Paediatric Advanced Life Support

Transcription

1 10 Paediatric Advanced Life Supprt Intrductin There is cncern that resuscitatin frm cardiac arrest is nt perfrmed as well as it might because the variatins in guidelines fr different age grups cause cnfusin t prviders, and therefre pr perfrmance. As in 2005, mst f the changes in paediatric guidelines fr 2010 have been made fr simplificatin and t minimise differences between adult and paediatric prtcls. It is hped that this will assist teaching and retentin. There remains a paucity f gd quality evidence n which t base the resuscitatin f infants and children. Mst cnclusins have had t be drawn frm extraplated adult studies and frm experimental wrk. In children, secndary cardipulmnary arrests, caused by either respiratry r circulatry failure, are mre frequent than primary arrests caused by arrhythmias. 276 S-called asphyxial arrests r respiratry arrests are als mre cmmn in yung adulthd (e.g. trauma, drwning, pisning). The utcme frm cardipulmnary arrests in children is pr 21 and identificatin f the antecedent stages f cardiac r respiratry failure is a pririty, as effective early interventin may be life-saving. The rder f assessment and interventin fr any seriusly ill r injured child fllws the ABCDE principles. A indicates airway (Ac fr airway and cervical spine stabilisatin fr the injured child). B indicates breathing. C indicates circulatin (with haemrrhage cntrl in injured child). D indicates disability (level f cnsciusness and neurlgical status). E indicates expsure t ensure full examinatin (whilst respecting dignity and temperature cnservatin). Interventins are made at each step f the assessment as abnrmalities are identified. The next step f the assessment is nt started until the preceding abnrmality has been managed and crrected if pssible. Summning a paediatric rapid respnse team r medical emergency team may reduce the risk f respiratry and/r cardiac arrest in hspitalised children utside the intensive care setting. 84 This team shuld include at least ne paediatric specialist and ne specialised nurse and shuld be called t evaluate a ptentially critically ill child wh is nt already in a paediatric intensive care unit (PICU) r paediatric emergency department (ED). 106 RESUSCITATION GUIDELINES 2010

2 Guideline changes Adrenaline is given after the third shck fr shckable rhythms and then during every alternate cycle (i.e. every 3-5 min during CPR). Adrenaline is still initially given as sn as vascular access is available in the nnshckable side f the algrithm. Amidarne is given after the third shck fr shckable rhythms. The dse is repeated after the fifth shck, if still in ventricular fibrillatin/pulseless VT (VF/VT). Bag-mask ventilatin remains the preferred methd fr achieving airway cntrl and ventilatin. If this fails, the laryngeal mask airway (r pssibly ther supraglttic airway device) is an acceptable alternative fr suitably trained prviders. Once spntaneus circulatin has been restred, delivered xygen shuld be titrated t limit the risk f hyperxaemia. CO 2 detectin (preferably with capngraphy) is even mre strngly encuraged, nt nly t cnfirm placement f tracheal tubes but als t aid decisin making during cardipulmnary resuscitatin (CPR) and management f ventilatin after return f spntaneus circulatin (ROSC). Pst-resuscitatin care shuld include cnsideratin f induced hypthermia. Sequence f actins 1. Establish basic life supprt (see paediatric BLS chapter). 2. Oxygenate, ventilate, and start chest cmpressin: Prvide psitive-pressure ventilatin with high-cncentratin inspired xygen. Prvide ventilatin initially by bag and mask. Ensure a patent airway by using an airway maneuvre as described in the paediatric basic life supprt chapter. If it can be perfrmed by a highly skilled peratr with minimal interruptin t chest cmpressins, the trachea shuld be intubated. This will bth cntrl the airway and enable chest cmpressin t be given cntinuusly, thus imprving crnary perfusin pressure. Take care t ensure that ventilatin remains effective when cntinuus chest cmpressins are started. Use a cmpressin rate f min -1 Once the child has been intubated and cmpressins are uninterrupted, use a ventilatin rate f apprximately min RESUSCITATION GUIDELINES 107

3 Paediatric Advanced Life Supprt Unrespnsive? Nt breathing r nly ccasinal gasps CPR (5 initial breaths then 15:2) Attach defibrillatr / mnitr Minimise interruptins Call resuscitatin team (1 min CPR first, if alne) Assess rhythm Shckable (VF / Pulseless VT) Nn-Shckable (PEA / Asystle) 1 Shck 4J / kg Return f spntaneus circulatin Immediately resume CPR fr 2 min Minimise interruptins Immediate pst cardiac arrest treatment Use ABCDE apprach Cntrlled xygenatin and ventilatin Investigatins Treat precipitating cause Temperature cntrl Therapeutic hypthermia? Immediately resume CPR fr 2 min Minimise interruptins During CPR Ensure high-quality CPR: rate, depth, recil Plan actins befre interrupting CPR Give xygen Vascular access (intravenus, intrasseus) Give adrenaline every 3-5 min Cnsider advanced airway and capngraphy Cntinuus chest cmpressins when advanced airway in place Crrect reversible causes Reversible Causes Hypxia Hypvlaemia Hyp- / hyperkalaemia / metablic Hypthermia Tensin pneumthrax Txins Tampnade - cardiac Thrmbemblism 108 RESUSCITATION GUIDELINES 2010

4 Sequence f actins (cntinued) 3. Attach a defibrillatr r mnitr: Assess and mnitr the cardiac rhythm. If using a defibrillatr, place ne defibrillatr pad r paddle n the chest wall just belw the right clavicle, and ne in the mid-axillary line. Pads r paddles fr children shuld be 8-12 cm in size, and 4.5 cm fr infants. In infants and small children it may be best t apply the pads r paddles t the frnt and back f the chest if they cannt be adequately separated in the standard psitins. If used, place mnitring electrdes in the cnventinal chest psitins. 4. Assess rhythm and check fr signs f life: Lk fr signs f life, which include respnsiveness, cughing, and nrmal breathing. Assess the rhythm n the mnitr: Nn-shckable (asystle r pulseless electrical activity (PEA)) OR Shckable (VF/VT). 5A. Nn-shckable (asystle r PEA): This is the mre cmmn finding in children. Perfrm cntinuus CPR: Cntinue t ventilate with high-cncentratin xygen. If ventilating with bag-mask give 15 chest cmpressins t 2 ventilatins. Use a cmpressin rate f min -1. If the patient is intubated, chest cmpressins can be cntinuus as lng as this des nt interfere with satisfactry ventilatin. Once the child has been intubated and cmpressins are uninterrupted use a ventilatin rate f apprximately min -1. Nte: Once there is ROSC, the ventilatin rate shuld be min -1. Measure exhaled CO 2 t mnitr ventilatin and ensure crrect tracheal tube placement. Give adrenaline: If venus r intrasseus (IO) access has been established, give adrenaline 10 mcg kg -1 (0.1 ml kg -1 f 1 in 10,000 slutin). If there is n circulatry access, attempt t btain IO access. If circulatry access is nt present, and cannt be btained quickly, but the patient has a tracheal tube in place, cnsider giving adrenaline 100 mcg kg -1 via the tracheal tube. This is the least satisfactry rute (see rutes f drug administratin). Cntinue CPR, nly pausing briefly every 2 min t check fr rhythm change RESUSCITATION GUIDELINES 109

5 Give adrenaline 10 mcg kg -1 every 3 t 5 min (i.e. every ther lp), while cntinuing t maintain effective chest cmpressin and ventilatin withut interruptin. Cnsider and crrect reversible causes: Hypxia Hypvlaemia Hyper/hypkalaemia (electrlyte disturbances) Hypthermia Tensin pneumthrax Txic/therapeutic disturbance Tampnade (cardiac) Thrmbemblism Cnsider the use f ther medicatins such as alkalising agents. 5B. Shckable (VF/VT) This is less cmmn in paediatric practice but may ccur as a secndary event and is likely when there has been a witnessed and sudden cllapse. It is cmmner in the intensive care unit and cardiac ward. Cntinue CPR until a defibrillatr is available. Defibrillate the heart: Charge the defibrillatr while anther rescuer cntinues chest cmpressins. Once the defibrillatr is charged, pause the chest cmpressins, quickly ensure that all rescuers are clear f the patient and then deliver the shck. This shuld be planned befre stpping cmpressins. Give 1 shck f 4 J kg -1 if using a manual defibrillatr. If using an AED fr a child f less than 8 years, deliver a paediatric-attenuated adult shck energy. If using an AED fr a child ver 8 years, use the adult shck energy. Resume CPR: Withut reassessing the rhythm r feeling fr a pulse, resume CPR immediately, starting with chest cmpressin. Cnsider and crrect reversible causes (4Hs and 4Ts). 110 RESUSCITATION GUIDELINES 2010

6 Cntinue CPR fr 2 min, then pause briefly t check the mnitr: If still VF/VT, give a secnd shck (with same energy level and strategy fr delivery as the first shck). Resume CPR: Withut reassessing the rhythm r feeling fr a pulse, resume CPR immediately, starting with chest cmpressin. Cntinue CPR fr 2 min, then pause briefly t check the mnitr: If still VF/VT, give a third shck (with same energy level and strategy fr delivery as the previus shck). Resume CPR: Withut reassessing the rhythm r feeling fr a pulse, resume CPR immediately, starting with chest cmpressin. Give adrenaline 10 mcg kg -1 and amidarne 5 mg kg -1 after the 3 rd shck, nce chest cmpressins have resumed. Repeat adrenaline every alternate cycle (i.e. every 3-5 min) until ROSC. Repeat amidarne 5 mg kg -1 ne further time, after the 5 th shck if still in a shckable rhythm. Cntinue giving shcks every 2 min, cntinuing cmpressins during charging f the defibrillatr and minimising the breaks in chest cmpressin as much as pssible. Nte: After each 2 min f uninterrupted CPR, pause briefly t assess the rhythm. If still VF/VT: Cntinue CPR with the shckable (VF/VT) sequence. If asystle: Cntinue CPR and switch t the nn-shckable (asystle r PEA) sequence as abve. If rganised electrical activity is seen, check fr signs f life and a pulse: If there is ROSC, cntinue pst-resuscitatin care. If there is n pulse (r a pulse rate f < 60 min -1 ), and there are n ther signs f life, cntinue CPR and cntinue as fr the nn-shckable sequence abve RESUSCITATION GUIDELINES 111

7 If defibrillatin was successful but VF/VT recurs, resume the CPR sequence and defibrillate. Give an amidarne blus (unless 2 dses have already been given) and start a cntinuus infusin. Imprtant nte Uninterrupted, gd-quality CPR is vital. Chest cmpressin and ventilatin shuld be interrupted nly fr defibrillatin. Chest cmpressin is tiring fr prviders. The team leader shuld cntinuusly assess and feed back n the quality f the cmpressins, and change the prviders every 2 min. Explanatry ntes Shckable rhythm sequence The change in timing f administratin f adrenaline and amidarne has been in respnse t the change in the adult algrithm. There is n evidence that the treatment f VF shuld differ fundamentally frm adult practice except that seeking and treating the reversible causes is particularly imprtant in children because arrhythmias are unlikely t be due t crnary artery disease. Shck energy level The ideal energy level fr safe and effective defibrillatin in children is unknwn. The recmmendatin f 2-4 J kg -1 in Guidelines 2000 was based n a single histrical study f effective utcmes. Extraplatin frm adult data and experimental studies shws that biphasic shcks are at least as effective as mnphasic shcks and prduce less pst-shck mycardial dysfunctin. Clinical studies have shwn that an initial mnphasic r biphasic shck level f 2 J kg -1 has a lw success rate in paediatric VF Paediatric case series have reprted that shck levels f mre than 4 J kg -1 (up t 9 J kg -1 ) have effectively defibrillated children less than 12 years f age with negligible adverse effects. In experimental studies, high energy levels cause less mycardial damage in yung hearts than in adult hearts. A single 4 J kg -1 shck strategy imprves first shck success rate and minimises interruptin in chest cmpressins. Tracheal tubes Recent studies cntinue t shw n greater risk f cmplicatins fr children less than 8 years when cuffed, rather than uncuffed, tracheal tubes are used in the perating rm and intensive care unit. Cuffed tracheal tubes are as safe as uncuffed tubes fr infants (except nenates) and children if rescuers use the crrect tube size and cuff inflatin pressure, and verify tube psitin. The use f cuffed tubes increases the chance f selecting the crrect size at the first attempt. Under certain circumstances (e.g. pr lung cmpliance, high airway resistance, and large glttic air leak) cuffed tracheal tubes may be preferable. 112 RESUSCITATION GUIDELINES 2010

8 Alternative airways Althugh bag-mask ventilatin remains the recmmended first line methd fr achieving airway cntrl and ventilatin in children, the LMA is an acceptable airway device fr prviders trained in its use. It is particularly helpful in airway bstructin caused by supraglttic airway abnrmalities r if bag-mask ventilatin is nt pssible. The LMA des nt ttally prtect the airway frm aspiratin f secretins, bld r stmach cntents, and therefre clse bservatin is required. Use f the LMA is assciated with a higher incidence f cmplicatins in small children cmpared with adults. Other supraglttic airway devices (e.g. laryngeal tube), which have been used successfully in children s anaesthesia, may als be useful, but there are few data n the use f these devices in paediatric emergencies. Capngraphy Mnitring end tidal CO 2 (ETCO 2 ) (preferably with capngraphy) reliably cnfirms tracheal tube placement in a child weighing mre than 2 kg with a perfusing rhythm, and its use is strngly recmmended after intubatin, and during transprt f an intubated child. The presence f a capngraphic wavefrm fr mre than fur ventilated breaths indicates that the tube is in the trachebrnchial tree, bth in the presence f a perfusing rhythm and during cardipulmnary arrest with CPR. Capngraphy des nt rule ut intubatin f a brnchus. The absence f exhaled CO 2 during CPR des nt guarantee tube misplacement because a lw r absent end tidal CO 2 may reflect lw r absent pulmnary bld flw. Capngraphy may als prvide infrmatin n the efficiency f chest cmpressins and a sudden rise in exhaled CO 2 can give an early indicatin f ROSC. Effrts shuld be made t imprve chest cmpressin quality if the ETCO 2 remains belw 2 kpa as this may indicate lw cardiac utput and pulmnary bld flw. Care must be taken when interpreting ETCO 2 values after the administratin f adrenaline r ther vascnstrictr drugs when there may be a transient decrease in values, r after the use f sdium bicarbnate when there may be a transient increase. Current evidence des nt supprt the use f a threshld ETCO 2 value as an indicatr fr stpping the resuscitatin attempt. Rutes f drug administratin Althugh atrpine, adrenaline, nalxne, lidcaine and vaspressin are absrbed frm the trachebrnchial tree, much lwer bld cncentratins result than if the same dse were given intravascularly. Cnversely, gd quality evidence in bth adults and children shw that intrasseus (IO) access is safe and effective and this rute is therefre far preferable t tracheal administratin, which shuld be used nly if there is n alternative. Semi-autmated devices fr inserting IO needles are available. Althugh there are few data t supprt their use in children during CPR, reprts f their use in ther circumstances have shwn them t be effective RESUSCITATION GUIDELINES 113

9 Drugs used in CPR Adrenaline This is an endgenus catechlamine with ptent alpha, beta 1, and beta 2 adrenergic actins. Althugh it is central t the treatment algrithms bth fr nn-shckable and shckable cardiac arrest rhythms, a prspective randmised adult study f the use f drugs (including adrenaline) in CPR shwed an imprvement in ROSC but nt in lngterm neurlgically intact survival. 144 Adrenaline induces vascnstrictin, increases crnary perfusin pressure, enhances the cntractile state f the heart, stimulates spntaneus cntractins, and increases the intensity f VF s increasing the likelihd f successful defibrillatin. The recmmended IV/IO dse f adrenaline in children is 10 mcg kg -1. Subsequent dses f adrenaline shuld, if needed, be given every 3-5 min. Higher dses f intravascular adrenaline shuld nt be used rutinely in children because this may wrsen utcme. Amidarne Amidarne is a membrane-stabilising anti-arrhythmic drug that increases the duratin f the actin ptential and refractry perid in atrial and ventricular mycardium. Atriventricular cnductin is als slwed, and a similar effect is seen in accessry pathways. Amidarne has a mild negative intrpic actin and causes peripheral vasdilatin thrugh nn-cmpetitive alpha-blcking effects. The hyptensin that ccurs with IV amidarne is related t the rate f delivery and is due mre t the slvent (Plysrbate 80 and benzyl alchl), which causes histamine release, than the drug itself. In the treatment f shckable rhythms, give an initial IV blus dse f amidarne 5 mg kg -1 after the third shck. Repeat the dse after the fifth shck if still in VF/VT. If defibrillatin was successful but VF/VT recurs, amidarne can be repeated (unless tw dses have already been injected) and a cntinuus infusin started. Amidarne can cause thrmbphlebitis when injected int a peripheral vein and, ideally, shuld be administered via a central vein. If central venus access is unavailable (likely at the time f cardiac arrest) and it has t be given peripherally, it shuld be flushed liberally with 0.9% sdium chlride r 5% glucse. Atrpine Atrpine is effective in increasing heart rate when bradycardia is caused by excessive vagal tne (e.g. after insertin f nasgastric tube). The dse is 20 mcg kg -1 and a minimum dse f 100 mcg shuld be given t avid a paradxical effect at lw dses. There is n evidence that atrpine has any benefit in asphyxial bradycardia r asystle and its rutine use has been remved frm the ALS algrithms. 114 RESUSCITATION GUIDELINES 2010

10 Magnesium This is a majr intracellular catin and serves as a cfactr in many enzymatic reactins. Magnesium treatment is indicated in children with dcumented hypmagnesemia r with plymrphic VT (trsade de pintes), regardless f cause. Calcium Calcium plays a vital rle in the cellular mechanisms underlying mycardial cntractin, but high plasma cncentratins achieved after injectin may be harmful t the ischaemic mycardium and may als impair cerebral recvery. The rutine administratin f calcium during cardiac arrest has been assciated with increased mrtality and it shuld be given nly when specifically indicated, fr example in hyperkalaemia, hypcalcaemia, and verdse f calcium-channel-blcking drugs. Sdium bicarbnate Cardiac arrest results in cmbined respiratry and metablic acidsis, caused by cessatin f pulmnary gas exchange, and the develpment f anaerbic cellular metablism respectively. The best treatment fr acidaemia in cardiac arrest is a cmbinatin f effective chest cmpressin and ventilatin (gd quality CPR). Administratin f sdium bicarbnate generates carbn dixide, which diffuses rapidly int the cells, exacerbating intracellular acidsis if it is nt rapidly cleared via the lungs. It als has the fllwing detrimental effects: It prduces a negative intrpic effect n an ischaemic mycardium. It presents a large, smtically active, sdium lad t an already cmprmised circulatin and brain. It prduces a shift t the left in the xygen dissciatin curve further inhibiting release f xygen t the tissues. The rutine use f sdium bicarbnate in cardiac arrest is nt recmmended. It may be cnsidered in prlnged arrest, and it has a specific rle in hyperkalaemia and the arrhythmias assciated with tricyclic antidepressant verdse. Fluids fr resuscitatin Hypvlaemia is a ptentially reversible cause f cardiac arrest. If hypvlaemia is suspected, infuse intravenus r intrasseus fluids rapidly (20 ml kg -1 bluses). In the initial stages f resuscitatin there are n clear advantages in using cllid slutins, whatever the aetilgy, s use istnic saline slutins fr initial vlume resuscitatin. D nt use dextrse-based slutins fr vlume replacement these will be redistributed rapidly away frm the intravascular space and will cause hypnatraemia 222, 232, 280 and hyperglycaemia, which may wrsen neurlgical utcme RESUSCITATION GUIDELINES 115

11 Pst-resuscitatin care Oxygen There is increasing evidence that hyperxaemia can be detrimental and studies in nenates suggest sme advantages in using rm air during initial resuscitatin (see Newbrn Life Supprt). 270 In the lder child there is n evidence fr any such advantages, s 100% xygen shuld be used fr initial resuscitatin. After ROSC, inspired xygen shuld be titrated, using pulse ximetry, t achieve an xygen saturatin f 94-98%. 281, 282 In situatins where disslved xygen plays an imprtant rle in xygen transprt such as smke inhalatin (carbn mnxide pisning) and severe anaemia, maintain a high inspired xygen (FiO 2 ). Therapeutic hypthermia Hypthermia is cmmn in the child fllwing cardipulmnary resuscitatin. 231 Central hypthermia (32-34 C) may be beneficial, whereas fever may be detrimental t the injured brain. Mild hypthermia has an acceptable safety prfile in adults and nenates and, althugh it has been shwn t imprve neurlgical utcme in adults after VF arrest, an bservatinal study neither supprts nr refutes the use f therapeutic hypthermia in paediatric cardiac arrest. 283 A child wh regains a spntaneus circulatin, but remains cmatse after cardipulmnary arrest, may benefit frm being cled t a cre temperature f C fr at least 24 h. The successfully resuscitated child with hypthermia and ROSC shuld nt be rewarmed actively unless the cre temperature is belw 32 C. Fllwing a perid f mild hypthermia, rewarm the child slwly at C h -1. Cmplicatins f mild therapeutic hypthermia include increased risk f infectin, cardivascular instability, cagulpathy, hyperglycaemia, and electrlyte abnrmalities such as hypphsphataemia and hypmagnesaemia. Hyperthermia is assciated with a prer utcme, 230, 284, 285 s infants and children with cre temperatures ver 37.5 C shuld be cled actively t a nrmal level. At the time f writing, there are nging, prspective, multicentre trials f therapeutic hypthermia in children fllwing in and ut-f-hspital cardiac arrest. (See the US Natinal Institutes f Heath Clinical Trials studies NCT and NCT ). The results frm these may change this advice. Bld glucse cntrl Nenatal, child and adult data shw that bth hyper- and hyp- glycaemia are assciated with pr utcme after cardipulmnary arrest but it is uncertain if this is causative r merely an assciatin. Plasma glucse cncentratins shuld be mnitred clsely in any ill r injured child, including after cardiac arrest. D nt give glucse-cntaining fluids during CPR except fr treatment f hypglycaemia. 116 RESUSCITATION GUIDELINES 2010

12 Hyper- and hyp- glycaemia shuld be avided fllwing ROSC but tight glucse cntrl has nt shwn survival benefits when cmpared with mderate glucse cntrl in adults and increased the risk f hypglycaemia in nenates, children and adults. Parental presence Many parents wuld like t be present during a resuscitatin attempt; they can see that everything pssible is being dne fr their child. Reprts shw that being at the side f the child is cmfrting t the parents r carers, and helps them t gain a realistic view f attempted resuscitatin and death. 286 Bereaved families wh have been present in the resuscitatin rm shw less anxiety and depressin several mnths after the death. Parental presence in the resuscitatin rm may als encurage healthcare prviders prfessinal behaviur and facilitate their understanding f the child in the cntext f his family. A dedicated staff member shuld be present with the parents at all times t explain the prcess in an empathetic and sympathetic manner. They can als ensure that the parents d nt interfere with the resuscitatin prcess r distract the resuscitatin team. If the presence f the parents is impeding the prgress f the resuscitatin, they shuld be gently asked t leave. When apprpriate, physical cntact with the child shuld be allwed. The resuscitatin team leader, nt the parents, will decide when t stp the resuscitatin effrt; this shuld be expressed with sensitivity and understanding. After the event, debriefing f the team shuld be cnducted, t express any cncerns and t allw the team t reflect n their clinical practice in a supprtive envirnment RESUSCITATION GUIDELINES 117