ILCOR, ARC & NZRC PAEDIATRIC RESUSCITATION RECOMMENDATIONS 2010 · 2018-08-17 · Australian...

Australian Resuscitation

Council

ILCOR, ARC & NZRC PAEDIATRIC

RESUSCITATION RECOMMENDATIONS

2010

Jim Tibballs

Resuscitation Officer, RCH

Convenor, Paediatric Sub-Committee,

Australian Resuscitation Council (ARC)

ARC Paediatric Representative

International Liaison Committee on Resuscitation (ILCOR)


Council

CONFLICT of INTEREST

• No financial

• Intellectual

• Member of ARC

• ILCOR delegate

• Co-author of some studies


Council

• Present some 2010 ILCOR recommendations

• Present rationale of a few changes

• Identify “departures” by ARC & NZRC (&ERC)

from ILCOR recommendations

• Identify some ARC & NZRC recommendations

not considered by ILCOR


Council 2010 ILCOR • 55 clinical subjects

• 20 new recommendations

• 7 “need to know” recommendations • Medical emergency team

• Starting CPR

• Pulse palpation

• Breaths vs no breaths

• Compression:ventilation ratios

• Infants and children

• Newborns outside delivery room

• Exhaled CO2 monitoring

• DC shock dose

• Oxygen

• Hypothermia


Council

ILCOR GUIDELINES published Oct-Nov 2010

<www,ilcor.org> Resuscitation 2010; 81: e213-e259 (Oct)

Circulation 2010; 122: S466-S515 (Oct)

Pediatrics 2010: 126(5):e1261-318 (Nov)

www.resus.org.au

paediatric guidelines

summary of changes to guidelines

JT 2011

http://www.resus.org.au/


Council Medical Emergency/Rapid Response

Team/Early Warning Scores

ILCOR

• Pediatric RRT or MET

systems may be

beneficial to reduce the

risk of respiratory and/or

cardiac arrest in

hospitalized pediatric

patients

ARC and NZRC

• All institutions … should

have a system which

enables staff at the

bedside to quickly

summon expert help to

assist in the management

of serious-illness.

Examples of such

systems are medical

emergency team (MET)

or rapid response team

(RRT) systems


Council

Chan PS, Jain, R. et. al.(2010) “Rapid Response Teams: a systematic review and meta-analysis.” Arch Intern Med. 170(1):18-26

Control Post Intervention Wt. RR (95% CI )

# pts Dths # Pts Dths

Results: Rate of Cardiopulmonary Arrest (↓ 38%)


Council Chan PS, Jain, R. et. al.(2010) “Rapid Response Teams: a systematic review and meta-analysis.” Arch Intern Med. 170(1):18-26

Results: Hospital Mortality Rate (↓21%)

Control Post Intervention Wt. RR (95% CI )

# pts Dths # Pts Dths


Council STARTING CPR

• If the victim is unresponsive and not

breathing normally (ILCOR – and there are

no signs of life)…

• … and if cannot palpate a pulse within 10

seconds with certainty, start CPR


Council

PULSE PALPATION (Resuscitation 2009; 80: 61. Resuscitation 2010; 81: 671)

• Accuracy 78% - all doctors and nurses

• Sensitivity 86% (diagnose CA correctly – BUT fail to diagnose CA 14%)

• Specificity 64% (exclude CA correctly – BUT diagnose CA incorrectly 36%)

• Average 15 seconds to exclude CA when truly absent

• Average 30 seconds to confirm CA when truly present

Experienced doctors correctly diagnose CA within 10 seconds


Council INITIAL BREATHS

ILCOR

2-5 (2005)

AHA

start ECC first

ARC & NZRC

Start ECC first

2 breaths first optional

ERC

5 breaths first

JT 2011

ILCOR 2010 Silent


Council

Shockable Non

Shockable

Shock (4 J/kg)

Return of

Spontaneous

Circulation ?

Post Resuscitation Care

CPR for 2 minutes

During CPR Airway adjuncts (LMA / ETT)

Oxygen

Waveform capnography

IV / IO access

Plan actions before interrupting

compressions

(e.g. charge manual defibrillator to 4

J/kg)

Drugs

Shockable

* Adrenaline 10 mcg/kg after 2nd

shock

(then every 2nd loop)

* Amiodarone 5mg/kg after 3rd shock

Non Shockable

* Adrenaline 10 mcg/kg immediately

(then every 2nd loop)

Consider and Correct Hypoxia

Hypovolaemia

Hyper / hypokalaemia / metabolic disorders

Hypothermia / hyperthermia

Tension pneumothorax

Tamponade

Toxins

Thrombosis (pulmonary / coronary)

Post Resuscitation Care Re-evaluate ABCDE

12 lead ECG

Treat precipitating causes

Re-evaluate oxygenation and ventilation

Temperature control (cool)

Advanced Life Support

for Infants and Children

December 2010

CPR for 2 minutes

Assess

Rhythm

Start CPR 15 compressions : 2 breaths

Minimise Interruptions

Attach Defibrillator / Monitor

Adrenaline 10 mcg/kg (immediately then every 2nd cycle)

JT 2011

Can give 2

breaths first


Council

COMPRESSION : VENTILATION RATIO

15:2

Why not 30:2 ratio for infants and

children? JT 2011


Council Why not 30:2 for paediatrics? • No human evidence

• Consensus with adult scientists NOT achieved. (Paediatricians not persuaded by animal cardiac arrest studies, mannekin studies and computer simulations)

• Rationale conjecture:

• Paediatric ventilation requirement greater than adult

• Hypoxic arrest, not sudden arrhythmia arrest, more common in paediatric practice

• In out-of-hospital paediatric cardiac arrest (Kitamura et al., Lancet 2010;

375: 1347)

• Survival from asphyxial cause better (7.2%) with standard CPR (7.2%) vs compression-only CPR (1.6%) vs no CPR (1.5%)

• Survival from cardiac cause same with standard CPR (9.9%) vs compression-only CPR (8.9%) vs no CPR (4.1%)

• 15:2 previously used for children (one-person rescue)

JT 2011


Council

Compression-ventilation ratios for

infants

JT 2011


Council Compression : ventilation ratio for infants (Term infants out of delivery area within first month)

At birth – 3:1

ILCOR

• In non-neonatal setting (eg

ED, PICU, prehospital) or with

cardiac aetiology regardless of

location:

• No ETT – prefer 15:2 over 3:1

• ETT – continuous compressions

no pauses for ventilations (15:2)

“ For use of training – use what is

commonly used in your

environment”

ARC & NZRC

• In ED, PICU, wards,

prehospital setting use 15:2

• With exception of newborns,

with cardiac aetiology

regardless of location:

• No ETT - 15:2

• ETT - continuous compressions

no pauses for ventilation 10/min


Council Ventilations after intubation

ILCOR

“reduce”

AHA 8-10/min (no circ)

12-20/min (circ)

ARC & NZRC 10/min

ERC

10-12/min

JT 2011

2010


Council

Compression : Ventilation ratio

after intubation

10:1

JT 2011


Council Compression – Ventilation Cycles

Basic CPR 30:2 (single rescuer)

2010 ILCOR

silent

AHA

5 in 2 min*

ARC & NZRC

5 in 2 min*

ERC

silent

• 75 compressions/minute

• 5 breaths/minute

JT 2011


Council Compression – Ventilation Cycles

Advanced CPR 15:2 (2 rescuers)

2010 ILCOR

silent

AHA

5 in 1 min* ARC & NZRC

5 in 1 min*

ERC

silent

• 75 compressions/minute

• 10 breaths/minute

JT 2011


Council

DC shock dose

JT 2011


Council

Dose of DC Shock

(Single shock strategy)

ILCOR CoSTR

2 - 4 J/kg

AHA

2 - 4 J/kg

ARC & NZRC

4 J/kg

ERC

4 J/kg

JT 2011


Council Biphasic DC shock for VF and pulseless VT Pediatr Crit Care Med 2011; 12: 14-20

0

20

40

60

80

100

120

140

160

180

200

220

0 10 20 30 40 50 60 70 80 90 100

Body weight (kg)

Jo

ule

s

ROSC

non-ROSC1J/kg

2J/kg

3J/kg4J/kg5J/kg

N=48

JT 2011

ROSC 50% if ≤2J/kg

ROSC if 3-5 J/kg


Council

Monitoring exhaled CO2

JT 2011


Council

1. To detect non-tracheal

intubation (standard of care)

2. Assess effectiveness of CPR

JT 2011


Council Monitoring end-tidal CO2

(PetCO2 )

ILCOR

• May guide effectiveness of

chest compressions. If

PetCO2 is < 15 mmHg,

improve chest compression

and reduce ventilation

• Cannot yet identify

threshold to stop CPR

ARC & NZRC

• Low PetCO2 may be due to

excessive positive

pressure ventilation or

inadequate chest

compressions or both


Council

End tidal C02 will rise as pulmonary blood

flow and overall cardiac output rises,

assuming that the amount of ventilation

(tidal volume and rate) does not change

Jin, CCM, 2000

Quantifying the effectiveness of CCs


Council Assessing effectiveness of CPR

Krep H, Mamier M, Breil

M, et al. Resuscitation.

2007;73(1):86.

JT 2011

No ROSC – low end-tidal CO2

ROSC – normal end-tidal CO2


Council

Partial pressure of end-tidal carbon dioxide successfully

predicts cardiopulmonary resuscitation in the field: a

prospective observational study. Kolar et al., Crit Care 2008; !2: R115

• 737 intubated cases out-of-hospital cardiac arrest

• After 20 minutes of CPR:

• 402 cases of ROSC when PetCO2 mean 33+/-9 mmHg

• 335 cases of non-ROSC when PetCO2 mean 7+/-2 mmHg

• PetCO2 <14 mmHg reliably predicts (100%) non-ROSC

• PetCO2 >14 mmHg reliably predicts (100%) ROSC


Council Oxygen

ILCOR

• Cannot specify oxygen

concentration during

resuscitation

• After resuscitation, titrate

oxygen concentration to

limit hyperoxemia

ARC & NZRC

• Use 100% oxygen initially

for resuscitation

• After resuscitation reduce

to yield PaO2 80-100

mmHg


Council Hypothermia

ILCOR

• Hypothermia (32-34

degrees) may be

considered for those

remaining comatose after

resuscitation

ARC & NZRC

• It is acceptable to induce

hypothermia (32-34

degrees) within 6 hours and

maintain up to 72 hours in

those remaining comatose

after resuscitation


Council

Principles of Guideline Formulation

Survival = Science x Education x Implementation

JT 2011


Council

... the debate will continue, especially

when data is lacking, after all …

“It’s not necessary to understand things in

order to argue about them ”

“Il n’est pas nécessaire de tenir les choses

pour en raisonner ” (Pierre Beaumarchais. Le Barbier de Séville)

http://en.wikipedia.org/wiki/Le_Barbier_de_S%C3%A9ville

ILCOR, ARC & NZRC PAEDIATRIC RESUSCITATION RECOMMENDATIONS 2010 · 2018-08-17 · Australian...

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Transcript of ILCOR, ARC & NZRC PAEDIATRIC RESUSCITATION RECOMMENDATIONS 2010 · 2018-08-17 · Australian...