Update of CPR AHA Guidelines

Transcription

1 Update of CPR AHA Guidelines Donald Hal Shaffner Course objective is to have an updated understanding of the American Heart Association s treatment algorithms for the management of cardiac decompensation in the infant, child, and young adult. Pediatric Basic Life Support healthcare provider resuscitation interventions (PALS provider manual, page 71) Age Newly born Neonate Infant Child Older <12 hr <28d <12mo 1-8yr >8yr Phone fast fast fast fast first Pulse check umbilical brachial brachial carotid carotid Comp/vent ratio 3:1 5:1 5:1 5:1 5:1/15:2 Method encircle/2 finger encircle/2 finger encircle/2 finger one hand two hand Comp rate Depth 1/3 of chest 1/3-1/2 chest 1/3-1/2 chest 1/3-1/2 chest in *Comp = compression, vent = ventilation BLS updates Added newly born, newborn is treated like an infant Older than 8 years less likely to be respiratory etiology of decompensation and treated like adult Phone first > 8yrs or high risk of cardiac Phone fast < 8yrs or high risk of respiratory cause (submersion) No pulse check for lay person (10% wrong) Healthcare providers check brachial pulse -infants, carotid pulse -child Give ventilations simultaneous with 5th compression in intubated patient. Interrupt compressions as infrequently as possible Rate approximately 100 for everyone, depth 1/3 chest for pediatrics Access to the vasculature during CPR Largest vein that does not interfere with the resuscitation is preferable Flush each medication with 5-10 cc saline to move medications into central circulation, 20 cc for adult (0.25 cc/kg) IO sites continue to be proximal anterior tibia, distal femur, medial malleolus, and anterior superior iliac spine. New is that no longer limited to less than 6 years old patient, try distal radius, distal ulna in older children. IO can be used to draw blood samples Tracheal drugs delivered directly into ETT and no longer through catheter into ETT, follow with 1-5 cc of NS and 5 ventilations

2 Pediatric bradycardia algorithm (PALS provider manual, page 199) Bradycardia without compromise (poor perfusion, hypotension, respiratory difficulty, altered consciousness) may be observed and ABCs supported. With compromise Perform chest compressions if HR <60 for infants and children Epinephrine - IV/IO 0.01 mg/kg, ETT 0.1 mg/kg, repeat q 3-5 min Atropine 0.02 mg/kg, may repeat once Pacing transcutaneous, transesophageal, transvenous, transthoracic AHA mnemonic for potential causes of bradycardia - Hs and Ts Hypothermia Head injury Heart block Heart transplant Causes of bradycardia in the OR Sinus Heart block Digoxin Hypothermia Myocarditis Acidosis Cardiac surgery Hypotension Heart transplant Hypoglycemia Drugs Vagal stimulation Increased ICP Drugs Pediatric tachycardia poor perfusion (PALS provider manual, page 207) Tachycardia / poor perfusion differentiate sinus, supraventricular and ventricular tachycardia Probable sinus tachycardia normal p wave, variable with activity, <220 infants, < 180 child. Treat the cause of the sinus tachycardia. Probable SVT abnormal/absent p wave, rate doesn t vary, >220 infant, >180 child Vagal maneuvers ice, valsalva, carotid massage Immediate adenosine 0.1 mg/kg, max 6 mg, may double and repeat Immediate cardioversion J/kg, may increase to 2 J/kg Probable VT QRS >0.08 sec Immediate cardioversion J/kg Consider Amiodarone 5 mg/kg over min Or (not and) Procainamide or Lidocaine

3 AHA mnemonic for potential causes of tachycardia - Hs and Ts Hypovolemia Hyperthermia Hyper/hypokalemia Tamponade Tension pneumothorax Thromboembolism Pain Pediatric tachycardia adequate perfusion (PALS provider manual, page 209) Tachycardia / good perfusion Probable sinus tachycardia normal p wave, variable with activity, <220 infants, < 180 child. Treat the cause of the sinus tachycardia. Probable SVT Vagal maneuvers ice, valsalva, carotid massage Consider adenosine 0.1 mg/kg, max 6 mg Consider cardioversion J/kg Probable VT Consider Amiodarone 5 mg/kg over min Or (not and) Procainamide or Lidocaine Consider cardioversion J/kg Pediatric pulseless arrest algorithm (PALS provider manual, page 216) Pulseless Arrest VF/VT 2,2-4,4 J/kg Epinephrine - IV/IO 0.01 mg/kg, ETT 0.1 mg/kg, repeat q 3-5 min CPR sec 4 J/kg Amiodarone IV/VO 5 mg/kg bolus or Lidocaine, Mg CPR sec 4 J/kg Repeat CPR/drug/shock alternating presser and antiarrhythmic (may give 3 shocks in a row) PEA + Asystole Epinephrine - IV/IO 0.01 mg/kg, ETT 0.1 mg/kg, repeat q 3 min CPR 3 min

4 AHA mnemonic for potential causes of pulseless arrest - Hs and Ts Hypovolemia Hypothermia Hyper/hypokalemia Tamponade Tension pneumothorax Thromboembolism Other causes of pulseless arrest Congenital heart disease Cardiomyopathy Myocarditis Recreational drugs Tricyclic antidepressants Digoxin Cisapride and macrolide antibiotic Hypermagnesemia Hypocalcemia Hypoglycemia Monitoring the effectiveness of cardiopulmonary resuscitation efforts During CPR the retrograde transmission of pressure through veins may give the perception of the palpation of pulses in the adjacent artery and may not be a sign of forward flow. Other monitoring options Intensity of V-fib (uncommon in children) As poor flow duration increases, amplitude and frequency decrease, with better CPR, VF becomes coarser. Coronary perfusion press (need art line) Myocardial Perfusion Pressure (diastolic pressure) <15 mmhg = no Return of Spontaneous Circulation, 100 adults, Paradis, JAMA, 90. Mixed venous saturation (need central line) Mixed Venous O2 Saturation <30% = no ROSC, 100 adults, Rivers, Ann Emerg Med, 92. If not in VF, and don t have arterial line or central line you can use the ETCO2 monitor. Patients with single digit values for ETCO2 during compression have very little blood being circulated to the lungs (also heart and brain) and are unlikely to have return of spontaneous circulation (Sanders 89, Callahan 90, Bhende 95, Wayne 95).

5 The ETCO2 level during CPR is also useful for indicating spontaneous circulation has returned as there is a sudden increase in levels. This helps to decrease the number of times compressions have to be stopped to detect the return of a pulse. Post-resuscitation care of the victim of cardiac arrest Normo-ventilation not hyperventilation Avoid hyperthermia Hyperthermia is an independent predictor of poor outcome in head trauma, (JA Natale, Crit Care Med, 00) Iatrogenic fever worsens neurologic injury in rats resuscitated from asphyxial cardiac arrest (Hickey RA, Crit Care Med 03). Rewarming measures appear to facilitate the development of fever that could worsen brain injury (Hickey RW, Pediatrics 00). Hypothermia improves outcome for VF of cardiac etiology arrests in adults, (Bernard NEJM 02, HACASG NEJM 02), the effects of post arrest hypothermia remain unknown for children or with respiratory etiology of arrest. Manage post ischemic myocardial dysfunction (page 236 PALS provider manual) Hypotensive Epinephrine 0.1 to 1 ug/kg/min or Dopamine 20 ug/kg/min and Norepinephrine 0.1 to 2.0 ug/kg/min Normotensive Dobutamine 2 to 20 ug/kg/min or Dopamine 2 to 20 ug/kg/min or Epinephrine 0.05 to 0.3 ug/kg/min and Milrinone 0.5 to 0.75 ug/kg/min (can load with 50 to 75 ug/kg) Control glucose The most recent CPR guidelines were published in : Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Part 9: pediatric basic life support. Circulation Aug 22;102(8 Suppl):I Part 10: pediatric advanced life support. Circulation Aug 22;102(8 Suppl):I European Resuscitation Council. Part 9: pediatric basic life support. Resuscitation Aug 23;46(1-3): Part 10: pediatric advanced life support. Resuscitation Aug 23;46(1-3): Questions How are basic life support interventions different for infant, child and adult? Which four arrhythmias are considered in the pulseless cardiac arrest algorithm? How is their treatment organized? Which four methods are useful to determine the effectiveness of CPR? Which are available during most arrests? What are four general goals for the post-resuscitation care of the victim of cardiac arrest?