PEDIATRIC AND NEONATAL RESUSCITATION

Kristen JohnsonAdam Oster

Objectives

Highlight differences between pediatric and adult cardiac arrest regarding Etiology Outcomes

Practice the basics of pediatric resuscitation through a variety of cases

Provide numbers and tips to help in a crunch

Review controversial areas of resuscitation

Not little adults?

Newly Born – in delivery room, including first few hours of life

Newborn – delivery until discharge from hospital/NICU

Infant – initial discharge from hospital until 12 months

Child – 1 year old until adolescence (signs of puberty)

Adult – adolescent (signs of puberty) and older

80% 20%

HypoxemiaHypercapnea

Acidosis

BradycardiaHypotension

Airway intervention saves 90%

IV access saves 9%

Drugs save 1%

Etiology

Out of Hospital Trauma (1/3)

Blunt trauma Drowning Fire Residential accidents Strangulation

Medical (2/3) SIDS Respiratory

Disease Cardiac

disease/arrhythmia CNS disease Toxins Sepsis Metabolic

Gerein et al. Acad Emerg Med 2006Young et al. Pediatrics 2004

Incidence of Out of Hospital Cardiac Arrest

Atkins et al. Circulation 2009

Survival Following Out of Hospital Cardiac Arrest

Infants3.3%NNT = 29

Children9.1%NNT = 10

Adolescents8.9%NNT = 8

Adults4.5%NNT = 13

Atkins et al. Circulation 2009

VF arrests

Occurs in 5% of infants/children15% of adolescents

Survival in VF (20%) >> than PEA/asystole (5%)

Mortality increases by 7-10% per minute of delay to defibrillationAtkins et al. Circulation 2009

Predictors of increased survival Peri-arrest

Witnessed arrest* Weekend arrest Rhythm other than

asystole No atropine or

HCO3 Fewer epi doses Shorter duration of

CPR Drowning/

submersion* or asphyxial arrest

Post-arrest Absence of

pressors/inotropes Greater lowest pH Low lactate Lower maximum

glucose N pupilllary

responses Higher lowest

temperatureMoler et al. Crit Care Med 2011*Donaghue et al. Ann Emerg Med 2005

Unresponsive in crib this morning

To cuff or not to cuff….

Higher likelihood of correct selection of tube size

No greater risk of post-extubation stridor

May decrease risk of aspiration

Beneficial when high ventilation pressures requiredNewth et al. J Pediatr 2004Weiss et al. Br J Anaesth 2009

Any role for intratracheal epi?Maybe Probably Not

Is there a role for high dose epinephrine?

“Less is more…”

“There is no survival benefit from high dose epinephrine, and it may be harmful, particularly

in asphyxia.”Dieckmann et al. Pediatrics 1995Carpenter et al. Pediatrics 1997Perondi et al. NEJM 2004Patterson et al. Pediatr Emerg Care 2005

Family presence during resuscitationPatient perspective• ???

Family perspective•overwhelmingly positive

Clinician perspective• mixed thoughts

Families should be allowed in the resuscitation room.Families Clinicians

Majority want to be present

Most do not regret their decision to be present

Positive trend in psychological health Less anxiety/depression Fewer disturbing

memories Eased grief

Family presence does not delay or interfere with care

Procedural performance is not affected Some have performance

anxiety Some have medical-legal

concerns

Nurses > Physicians > Trainees in willingness to include familiesTinsley et al. Pediatrics 2008

???When to call it???

Young et al. Pediatrics 2004Moler et al. Crit Care Med 2011Raymond et al. Pediatr Crit Care Med 2010Morris et al. Pediatr Crit Care Med 2004

>3 doses of epinephrine > 30 minutes of CPR in ED

Exceptions:Primary cardiac disease and

ECMO availableHypothermiaSuspected toxicologic cause

Called STAT overhead

18 month old Unwell for 3-4 days

FeverCough

resp distress

Should we cool our patient?

Adults

Neonates

Pediatrics ?

Fink et al. Pediatr Crit Care Med 2010Doherty et al. Circulation 2009

7 year old girl

Unwell for 1 weekFlu-like illness

Low grade fever

What is the best energy dose for defibrillation?

2 J/kg likely too low

3-5 J/kg may be better

No more than 10 J/kg

PALS = 2 - 4 J/kg with 4 J/kg for subsequent shocks

Anterior-posterior position

likely better than

Anterior-lateral position

Tibballs et al. Pediatr Crit Care Med 2011

Calcium associated with worse outcomes

Survival21% vs. 44%

Favorable neuro outcome15% vs. 35%

Exceptionselectrolyte abnormalitiestoxicological abnormality

Srinivasan et al. Pediatrics 2008

Bicarbonate not indicated in routine resuscitation Meert et al. 2009

Multi-center cohort study that found HCO3 administration associated with increased mortality

Lokesh et al. 2004 RCT showing no survival benefit in

neonates resuscitated with bicarbonate

17 year old brought in from drug house

Abdominal painThinks may be pregnant

10% of newborns will require some assistance after birth

<1% require extensive measures

<0.1% require chest compressions

< 23 weeks GA

Anencephaly

Known trisomy 13

Birth weight <400g

Begin resuscitationwith room air

<29 wk GACover with plastic

M reapply MaskR Reposition head

S Suction mouth and noseO Open mouthP increase PressureA Alternate airway

Time Saturation

1 min 60-65%

3 min 70-75%

5 min 80-85%

10 min

85-95%

Compression:Breath ratio=

3:1

Terminate after 10 minutes of good CPR

THANKS