Jesse Rideout, MD, MPH, FACEPTufts Medical Center, BostonAssistant Professor of Emergency Medicine

Pediatric Resuscitation

Objectives

• Identify challenges in pediatric resuscitation• Emphasize most pediatric cardiopulmonary arrests

as the terminal point of respiratory failure or shock. • Review basic airway management and advanced

airway management of respiratory distress• Review basic and advance management of shock• Outline updates to 2010 ILCOR for Pediatric and

Neonatal resuscitation guidelines• Demonstrate principles with case presentations to

emphasize key points

Challenges in Pediatric Resuscitation• It represents a rare event that is extremely

stressful for clinicians and family members• Little opportunity to perfect resuscitation

skills in real-life• Children are not simply little adults!

– Differences in anatomy, physiology and pathology

– Weight based dosing for medications, fluids and defibrillation

– Varying sizing and shapes for critical equipment depending on patient age

– Challenging vascular access

Pediatric Cardiopulmonary Arrest (CPA) • much rarer than in adults• rarely a sudden event• rarely a primary cardiac cause• most often represents the terminal event of

respiratory failure or shock.• Initial causes are diverse, depending on

pediatric age group. They include:– Trauma– Sepsis– Hypovolemia (diarrhea)– SIDS– Submersion/Near Drowning

Outcome from Cardiopulmonary Arrest (CPA) in Children is poor….

• Out-of-hospital CPA survival to hospital discharge– Overall survival: 6% – Most have poor neurological outcome

• Infants: 4% (likely because of SIDS)• Children: 10%• Adolescents: 13%

• Atkins DL, Everson-Stewart S, Sears GK, Daya M, Osmond MH, Warden CR, Berg RA. Epidemiology and outcomes from out-of-hospital cardiac arrest in children: the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest. Circulation. 2009;119:1484 –1491.

• In-hospital CPA survival to hospital discharge– Overall survival: 27%– Most have favorable neurological outcome

• Tibballs J, Kinney S. A prospective study of outcome of in-patient paediatric cardiopulmonary arrest. Resuscitation. 2006;71:310–318.

Causes of Pediatric Cardiopulmonary Arrest

Anticipating Cardiopulmonary Arrest

Progression Toward

Pediatric Cardiopulmonary ArrestMany Causes

(SIDS, Respiratory Infections, Sepsis, Trauma, Etc.)

Respiratory Failure Shock

CARDIOPULMONARY ARREST

DEATHCARDIOPULMONARY

RECOVERY

Good Neurological Outcome

Poor Neurological Outcome

Intervening Early:Recognizing Respiratory Distress

Respiratory Arrest

Respiratory Failure

Respiratory Distress

• Increase respiratory rate• Retractions• Nasal flaring• Head bobbing• Wheezing• Grunting• Rales• Stridor

• Mental status changes• Cyanosis• Apnea

EARLY

Signs

LATE

Signs

Intervening Early: Recognizing SHOCK

Cardiac Failure

Cardiac Distress

Cardiac Arrest

EARLY

Signs

• Increased heart rate• Poor capillary refill• Diminished peripheral pulses• Decreased urine output• Dry mucous membranes• No tears

• Mental status changes• Cyanosis• Apnea• Low blood pressure

LATE

Signs

Evaluation of Respiratory Status

Respiratory Rate (Dependent on age)

Respiratory Mechanics– Retractions,

Accessory Muscles use and Nasal Flaring

– Head Bobbing– Grunting– Stridor– Wheezing

Air Entry Chest Expansion Breath Sounds

Color

Cardiovascular Assessment

Heart rateBP Vol./strength of central pulsesPeripheral pulses Present/absent Volume/strengthSkin perfusion Cap.refill time Temperature Color Mottling

CNS perfusion Responsiveness (AVPU) Recognizes parents Muscle tone Pupil size Posturing

Vital Sign Variation

Age (years)

Respiratory Rate

(breaths/min)

Heart Rate (beats/min)

Newborn 60 160

Infant 40 150

Toddler 34 140

School Age 30 120

Teenage 16 100

The UPPER limits of respiratory rate and heart rate while awake:

The LOWER limit of systolic blood pressure:Newborn: 60 mm HgInfant: 70 mm Hg1-10 years: 70 mm Hg + (2 x Age in years)>10 years: 90 mm Hg

Broselow Tape

• A color coded, length based system• Drugs dosing and equipment are obtained

based on child’s length• Extremely useful for rapid estimates during a

pediatric resuscitation

Basic Airway Management

Case 1: 10 month-old boy is brought in by mother actively seizing, then becomes unresponsive and stops breathing

Basic Airway Management

• Basics of Pediatric Airway Management:– Position the head– Open the airway: jaw thrust – Clear the airway: Suction– Oxygenate– Consider Nasal or Oral Pharyngeal Airway– Bag-mask ventilation– Reassess

Basic Differences in the Pediatric Airway

Comparison of adult and pediatric airways.  (From Finucane BT: Principles of Airway Management. Philadelphia, FA Davis, 1988.)

Larger in proportion to the oral cavity than in the adultTongue

Epiglottis

Larynx

Narrower, shorter, omega-shaped

Higher in the neck (C3-C4) than in the adult (C5-C6); not only positioned more anteriorly in infants but positioned more cephalad

Cricoid More conically shaped in infants; narrowest portion is at the cricoid ring, whereas in the adult it is at the level of the vocal cords

Trachea Deviated posteriorly and downward (becomes anatomically similar to the adult between 8 and 10 years of age)

Head Occiput relatively large compared with the adults'Optimal intubating position is with shoulder roll to prevent neck flexion in the supine position

Differences between the pediatric and the adult airway

Differences in Pediatric and Adult Airway: Effect Of Edema

Poiseuille’s law

1mm of airway edema in the smaller infant airway will cause much greater resistance than in an adult

Basic Airway Management

• Position the head– The proportionately larger occiput of an infant

causes the head to flex on the neck which can obstruct the airway

– Elevating under the shoulders with a towel places the airway in better alignment for infants.

Basic Airway Management

• Open the Airway– The Tongue is the most common cause of

airway obstruction• Chin lift (avoid in suspected trauma)• JAW THRUST

– In a 2003 study by Bruppacher et al, the jaw-thrust was the most effective maneuver to overcome upper airway obstruction in children.

Airway Adjuncts

• Oropharyngeal Airway (OP)– Helps prevent tongue from obstructing

posterior pharynx – Potential use in unconscious patient– Cannot use in patients with intact gag reflex– SIZING: measure from corner of mouth to

angle of jaw– PLACEMENT: direct method vs rotation

method.

Airway Adjuncts

• Nasopharyngeal Airway (NP)– Unconscious or depressed mental status– SIZING: Measure from the tip of the nares to

the tragus of ear– CONTRAINDICATIONS: basilar skull fracture,

midface fractures, bleeding disorders– Relative contraindication: children < 1 year

old

Bag Mask Ventilation

• Know the steps– Size the mask

• Bridge of nose to cleft of chin– Select the bag

• adult, pediatric, small child/infant, neonatal– Connect to oxygen– EC-Clamp– **Control your RATE and VOLUME

Bag Mask Ventilation

• Most people over ventilate• Ventilation Rates: slower rates are best –

avoid too fast and too hard– Neonates: 30 breaths/min– Infants: 10-20 breaths/min– Children: 8-10 breaths/min

• The best predictor of effective ventilation is chest-rise.

• Physiological tidal volume is 6-8 mL/kg. With additional amount added for dead space of bag-mask the volume needed is ~ 10 mL/Kg

Ventilation during CPR

• AVOID BAGGING TOO FAST• Excessive ventilation is a very common

problem and has serious repercussions– In animal studies, it has shown to decrease

cerebral perfusion pressure, return of spontaneous circulation (ROSC) and survival

– Excessive ventilation increases intrathoracic pressure, impedes venous return, reduces cardiac output and cerebral and coronary blood flow

• **During CPR, ventilate 8-10 times per minute in infants and children

Basic Circulatory Management

Case 2: 16 month-old girl is taken to the ER withincreasing lethargy and dehydration with 5 days of profuse diarrhea and poor P.O.

Case 2:

• Assessment:– HR 170s, BP 60/palp, RR 40, Sat 93% Temp

37.6 C– Lethargic, diminished peripheral pulses,

delayed capillary refill, poor skin turgor

• Management:– Oxygen– Monitor (if available)– Finger stick glucose check: … 45 mg/dl (2.5

mmol/L)– Several attempts at intravenous access are

unsuccessful ...

Intraosseous Line

Best site of insertion: proximal tibia LANDMARK: 1cm medial to tibial tuberosity Various types of needles will work

16 gauge hypodermic needle spinal needle, bone marrow needle Hand-held electric operated (EZ-IO)

Intraosseous (IO)• Good literature to show that

IO is placed faster and with greater success than peripheral IV access in severely dehydrated children

• Studies of animals resuscitated from cardiac arrest have shown that whether drugs are delivered via peripheral intravenous, central line (IVC) or tibial IO, plasma epinephrine levels and physiological changes are equivalent

Andropoulos, J Peds, 1990, Orlowski, Am J DIs Child, 1990

time to placement0

20

40

60

80

100

120

140

129

68

PIV (n=30)

IO (n=30)

sec

Series10

10

20

30

40

50

60

70

80

90

100

67

100

PIV (n=30)

IO (n=30)

% success

Bannerjee, Indian Peds, 1994

Intraosseus (IO) lines

What can be transfused through an IO line?

ANSWER:Anything that can be transfused through

an intravenous line

Pediatric Fluid Management

• Fluid resuscitation– Isotonic crystalloid fluids: 20 mL/Kg over 10-

15min (repeat x1)• Normal Saline (or Lactated Ringers)

• Trauma (hypovolemic shock)– Isotonic crystalloid fluids x 2– Packed Red Blood Cells: 10 mL/Kg

• Maintenance IV fluids: "4-2-1" Rule:– For 0-10kg: 4 mL/kg/hr– For 10-20kg: + 2 mL/kg/hr– For >20kg: + 1 mL/kg/hr

Case 2: 16 month boy in shock

• While fluid resuscitating the child he decompensates further and becomes unresponsive and goes into cardiopulmonary arrest.

• The monitor shows a narrow complex tachycardia 220 (Pulseless electrical activity)

• …What are the next steps for optimal cardiopulmonary resuscitation ?

• …What’s new from 2010 ILCOR update?

PEDIATRIC RESUSCITATION 2010 UPDATE: ILCOR

• International Liaision Committee on Resuscitation (ILCOR)– October 2010– 277 Resuscitation topics reviewed over 36 months– 356 experts from 29 countries

• Forms the foundation for guidelines from:– Resuscitation Council of Asia– American Heart Association– Canadian Heart and Stroke Foundation– Australian Resuscitation Council– …others

2010 Guideline Changes to Pediatric Basic Life Support• CPR sequence has

changed from A-B-C (Airway-Breathing-Circulation) to C-A-B.– Start chest

compressions before ventilations

• Neonatal resuscitation continues to be A-B-C.

Why the change to C-A-B?

• Most victims of cardiac arrest are adults with v-fib or v-tach who need compressions immediately to support circulation

• Ventilation often delays initiation of chest compressions (by up to several minutes).

• Recommendations needed to be simple and algorithms were becoming too complex

• CPR is generally done poorly with excessive ventilations which can impede cardiac output

• When chest compressions are interrupted, coronary perfusion pressure declines rapidly

• Only 30% of pediatric CPA receive bystander CPR* • *Young KD, Seidel JS. Pediatric cardiopulmonary resuscitation: a collective review. Ann Emerg Med.

1999;33(2): 195–205

INFANT: Chest Compressions

• 1 Rescuer• Two-finger technique• Mid-sternal, one finger-

breadth below intra-mammary line.

• 2 Rescuers• Two-thumb-encircling

hands • Lower 1/3rd of mid-

sternum

“Push hard, push fast”: compress chest in infant 4cm – allow chest to recoil – at LEAST 100/min

Berg MD et al. Circulation 2010; 122:S862-S875

USE BRACHIAL OR FEMORAL ARTERY FOR PULSE CHECK

OLDER CHILD: Chest Compressions

“Push hard, push fast”: compress chest in infant 5cm – allow chest to recoil – at LEAST 100/min

Berg MD et al. Circulation 2010; 122:S862-S875

• In older children use the lower third of sternum

• Use one hand• Maintain continuous head-

tilt with hand on forehead• Feel for CAROTID artery

for pulse-check

Compression to Ventilation

• Healthcare providers: – ALONE 30:2– TWO OR MORE 15:2

• Breaths: 8-10/min– Avoid excessive ventilation

• Switch rescuers every 2 minutes to avoid fatigue when doing chest compressions

Circulation: DRUGS

• Routes for drugs in CPR– Intravenous (IV)– Intraosseous (IO)– Endotracheal (ET)

• L.E.A.N.– Lidocaine– Epinephrin– Atropine– Naloxone

• Unpredictable absorption• Dosed higher than IV/IO (Epi is 10x higher)

Drugs

• Epinephrine – IV/IO: 0.01 mg/kg (0.1mL/kg of 1:10,000) q3-5min– ET: 0.1 mg/kg (0.1mL/kg of 1:1,000)– IV drip: 0.1-1mcg/kg per minute IV/IO

• Adenosine– 0.1mg/kg IV/IO rapid push (max 6mg); second dose

0.2mg/kg IV/IO

• Amiodarone– 5mg/kg IV/IO bolus during cardiac arrest; repeat x2 for

VF/Pulseless VT.

• Atropine:– 0.02 mg/kg IV/IO (symptomatic bradycardia)

Electricity in Peds

• Shockable rhythms:– Ventricular Fibrillation– Pulseless, Ventricular Tachycardia

• Shock Energy for defibrillation– FIRST SHOCK: 2 Joules/kg– SECOND SHOCK: 4 Joules/kg

Case: 16 month old girl

• Pulseless Electrical Activity (PEA) Arrest– High quality CPR: 15:2 (compressions to

ventilations)– Epi 0.01 mg/kg IV/IO q3-5min– Address the REVERSIBLE CAUSES

Hypovolemia Tension pneumothorax

Hypoxia Tamponade, cardiac

Hydrogen ion (acidosis) Toxins

Hypoglycemia Thrombosis, pulmonary

Hypo-/hyperkalemia Thrombosis, coronary

Hypoglycemia: Dextrose

• <1 year: Dextrose 0.5-1 g/kg/dose.

5-10ml/kg of D10W

• 1-12 years: Dextrose 0.5-1 g/kg/dose

2-4 ml/kg/dose of D25W

• >12 years: Thiamine 100mg IV x 1

Dextrose 0.5-1 g/kg/dose

1-2 ml/kg/dose D50W

Advanced Airway Management

Case 3: 3 year old boy with cough, fevers and respiratorydistress.

Case 3:

• Assessment:– HR=165 BP=60/30 RR=45 Sat 91% T. =39 C– Tachypnic with intercostal retractions, sitting

forward, awake but depressed mental status, delayed capillary refill

– CXR with bilateral infiltrates

• Management:– Supplemental oxygen, intravenous fluid

boluses and IV antibiotics initially help, but patient continues to deteriorate

– Rapid sequence intubation (RSI) is considered

Pediatric Intubation

Failure to oxygenateFailure to ventilateFailure to protect the airwayAnticipation of worsening clinical

course

Indications

Rapid Sequence Intubation (RSI):7 Steps• Preparation:

– equipment selection; positioning (towel under shoulders for infants; towel under head for small children); a second ET tube ½ size smaller; rescue devise such as LMA

• Preoxygenation– 100% non-rebreather; avoid BVM if possible

• Pretreatment– Lidocaine (head trauma)– Atropine

• Paralysis with induction– Succynylcholine, rocuronium; Etomodate, Midazolam,

Ketamine, Thiopental• Protection and positioning• Placement of ET tube in trachea• Postintubation management

– Confirmation, CXR, secure tube

STEP 1: Preparation

• Selecting ET tube size– Use charts based on weight or length– Use length-based resuscitation tape

(Broselow)– Calculation of uncuffed ET tube size:

• For age > 1 year: (age/4) + 4• Premature infant: 2.5-3.0 mm• Newborn: 3.0-3.5 mm• Up to 6 months: 3.5 mm

Cuffed vs Uncuffed

• What about cuffed vs uncuffed ET tubes?– Rational for uncuffed: consideration that the

cuff causes pressure on the cricoid cartilage leading to pressure necrosis

– There is evidence that this may not be as significant as once considered.

– Conclusion in recommendations from American Heart Association: • Cuffed tubes may be preferred in certain

situations including poor lung compliance, high airway resistance, or large glottic air leak

– Use ½ size less for cuffed: (age in yrs/4) + 3.5

Blade Size

• Miller 0 – premature infant or small newborn• Miller 1 – normal newborn to 12 kg (2 years)• Miller 2 – 13 to 24 kg (7 years)• Miller 3 – 25 kg + (8 years +)• **Macintosh may be used after 2 years of

age• ** Miller 2 after age 2 (years)• **Too small a blade can get you into trouble

Miller Straight Blade Technique

Miller (straight) blade allows for easier lifting of the floppy epiglottis

Pretreatment

• Atropine: 0.02 mg/kg (min 0.1mg; max 0.5mg)– Rationale: used to blunt reflex bradycardia

associated with RSI– Incidence: “evidence indicates that the

incidence of reflex bradycardia in children undergoing RSI is much lower than previously thought” (Bean A, 2011)

– Hypoxia is a greater predictor of bradycardia

• Consider in infants < 1 yr and those children who receive a second dose of succinylcholine

Sedation / Induction Agents

• US National Emergency Airway Registry (NEAR) most common sedatives used in RSI in children– Etomidate (42%)– Thiopental (22%)– Midazolam (18%)– Ketamine (7%)

Sagarin MJ, et al: Pediatric Emerg Care 2002

Paralysis: Drugs Selection

• More physician preference• Succinylcholine: 2-3mg/kg

– Onset: faster– Duration: shorter– Adverse effects: more than Rocuronium

• Rocuronium: 1mg/kg– Onset: Slower – Duration: longer– Adverse effects: less than Succinylcholine

Difficult Airway in Pediatrics

• Need to anticipate this during initial assessment

• Have contingency plan if you can’t intubate• Supraglottic devices (e.g. Laryngeal mask

airway, LMA)

LMA

• Sizes 1-5– Use weight or length based system to

determine required size– Size and mL needed to inflate the cuff on the

side

• Placement:

Pediatric Advance Life Support (PALS): 2010 Algorithms

2010 ILCOR UPDATE:

Neonatal Resuscitation • Neonatal ventilation to compression ratio is

3:1– Per cycle there are 90 compressions with 30

ventilations

• Not necessary to do intrapartum suctioning (no improved outcomes)

• Vigorous newborns do not require endotracheal suctioning for meconium stained amniotic fluid

2010 ILCOR Update: Post Resuscitation Care

• Therapeutic Hypothermia: Children– Therapeutic hypothermia (32C to 34C) up to

72 hours may be considered in children with ROSC

– May be beneficial for adolescents with out-of-hospital witnessed V-fib arrest

2010 Update: Post Resuscitation Care Recommendations• Therapeutic Hypothermia: Neonatal

– Now several randomized controlled multicenter trials of induced hypothermia (33.5 C to 34.5 C) in newborns >36 weeks with moderate to severe hypoxic-ischemic encephalopathy showed improvement in neurodevelopmental disability at 18 month follow up for those cooled

– Treatment should be commence within 6 hours following birth, continuation for 72 hours, and slow rewarming over at least 4 hours

Conclusions

• Pediatric cardiopulmonary arrest is most often the terminal point of respiratory failure or shock and early intervention is critical

• Effective basic and advance airway management in pediatrics can often avoid or revert cardiopulmonary arrest

• Placing an Intraosseous line in a critically ill child without peripheral intravenous access is necessary

• Know your key weight based drugs, equipment selections, and fluids in peds

• Competence through deliberate practice with pediatric resuscitation and CPR should be stressed in emergency medicine training.