Paediatric resuscitation

Paediatric resuscitation

• 9yo and above get ALS but have lower rates of shockable rhythm
• Neonatal guidelines for newborns and first hours after birth
• Infant <1yo
• Young child aged 1-8
• Older child aged 9-14
• Initial cardiac rhythm often asystole or severe bradycardia
• VF initial rhythm in 10%
  • More likely if congenital cardiac disease, cardiotoxic agents, membrane channelopathies or during course of resuscitation

ALS

• Single rescuer and witnessed collapse – get help first then commence CPR
  • If encounter unwitnessed collapse, start CPR first then get help
• Start chest compressions if unresponsive and not breathing normally, pulse not palpable within 10 seconds or is <60/min
• CPR should commence with 2 rescue breaths in infants and children
• 2:15 ratio (unlike BLS 2:30)
• Same rate (100-120/min)
• Compression depth 1/3 of chest (same) = 4cm in infants, 5cm in children
• Two thumb technique preferred for infants
• One or two-handed technique for children
• Two-handed technique for older children >8yo
• IO if no IV within 60 seconds
• 10 breaths/min once intubated (if LMA continue to deliver during pauses (vs. adults 12/min after either LMA or ETT)
• Investigate for membrane channelopathies after sudden unanticipated cardiac arrest
• Do not recommend compression only CPR unless rescuer cannot/will not provide rescue breaths
• Insert NG or OG tube early after intubation

Paediatric resuscitation

• etCO2
  • No specific number for prognosis
  • Low CO2 during CPR may indicate treatable cause (PTX, hypovolaemia, tamponade)
  • High CO2 indicates hypoventilation
  • Adrenaline and other vasoconstrictors can reduce etCO2 for 1-2 minutes post-delivery
  • etCO2 of 10-15 despite 15-20min of ALS has strong association with inability to attain ROSC
• Drug dosing
  • In non-obese victims, can approximate weight from length/height
  • In obese victims, should use ideal body weight approximated from length/height (exception to this is suxamethonium)
  • Subsequent doses should be based on clinical effect and toxicity

Paediatric resuscitation

• Weight for age
  • Newborn = 3.5kg
  • 1 year = 10kg
  • 9 years and less = Age X 2 + 8
  • 10 years and over = age x 3.3kg
  • Can use height charts instead
• AED
  • Can use if over 8 years old
  • If under 8, preference is AED with paediatric attenuation but can use adult AED if only one available
  • Unknown safety if under 1yo but case report of effective use
  • Can still interpret rhythms effectively

Paediatric resuscitation – Drugs

• Drug delivery
  • Flush with N/S (or dextrose for amiodarone)
• Adrenaline
  • 10mcg/kg up to 1g after every 2^nd loop (immediately in non-shockable and after 2^nd failed shock in shockable)
  • Larger doses in beta-blocker poisoning
  • 100mcg/kg via ETT
  • Can give infusion 0.1-0.2mcg/kg/min
• Amiodarone
  • 5mg/kg IV/IO loading dose
  • Limited evidence that may improve rates of survival to hospital admission vs. lignocaine
  • Also useful for atrial tachycardia, resistant SVT, pulsatile VT, junctional ectopic tachycardia and wide-complex tachycardia
• Lignocaine
  • 1mg/kg IV/IO/ET
  • May increase rates of ROSC vs. amiodarone
• Can use either amiodarone or lignocaine for shock-resistant VF or pVT

Paediatric resuscitation – Drugs

• Atropine
  • Indicated for vagal hyperstimulation and cholinergic drug toxicity
  • Unclear if reduces incidence of bradycardia or cardiac arrest on intubation or if improves survival
    • Many practitioners have it available for paediatric intubation but pre-loading is not recommended
  • 20mcg/kg IV/IO or 30mcg/kg ETT
  • Bradycardia caused by hypoxaemia should be treated with ventilation and oxygenation but if resistant, add adrenaline
  • Severe bradycardia or bradycardia with hypotension should be treated with adrenaline

Paediatric resuscitation – Drugs

• Calcium
  • Utilised in hyperkalaemia, hypocalcaemia, hypermagnesaemia or CCB toxicity
  • Associated with worse outcome if used routinely
  • 0.15mmol/kg for CCB toxicity (= 0,2mL/kg of 10% calcium chloride or 0.7mL/kg of 10% calcium gluconate)
• Glucose
  • Normal 3-8mmol
  • Hypoglycaemia seen commonly in infants with critical illness
  • Hyperglycaemia associated with poorer outcomes
  • Treat hypoglycaemia with 0.25g/kg glucose IV or IO (e.g. 0.5mL/kg of 50% glucose via CVL) or 2.5mL/kg of 10% dextrose
  • Maintenance 5-8mg/kg/min

Paediatric resuscitation – Drugs

• Magnesium
  • Preferred treatment for torsades de pointes due to acquired or congenital prolonged QT
  • 0.1-0.2mmol/kg IV/IO followed by infusion of 0.3mmol/kg over 4 hours
• Potassium
  • Hypokalaemia
    • 0.03-0.07 mmol/kg slow injection over several minutes
    • If critical but not imminently life-threatening, 0.2-0.5mmol/kg/hour infusion
    • Need extreme caution and up to q30min repeat levels

Paediatric resuscitation – Drugs

• Procainamide
  • Effective for haemodynamically stable SVT and VT in children
  • 10-15mg/kg over 30-60min
• Sodium bicarbonate
  • Limited and unproven place
  • May exacerbate intracellular acidosis due to CO2 production
  • Also risks hypernatraemia, hyperosmolality and depressed myocardial function
  • May be useful in severe metabolic acidosis <7.1; prolonged arrest; hyperkalaemia and TCA overdose
  • 0.5-1mmol/kg IV or IO after adequate ventilation and chest compressions initiated

Paediatric resuscitation – Drugs

• Vasopressin
  • Unclear if beneficial
  • 0.5-0.8U/kg IV or IO bolus if used

Arrhythmia management

• Asystole or severe bradycardia
  • CPR if HR <60, abnormal breathing and unresponsive
  • Adrenaline 10mcg/IV bolus if unresponsive to initial CPR repeated every 4 minutes
  • Sodium bicarbonate 1mmol/kg IV/IO if prolonged arrest
  • Pacing may be effective but should not interfere with CPR

Arrhythmia management

• VF or pVT
  • If witnessed and monitored, defib first if within 20 seconds
    • Praecordial thump can also be considered in this setting
    • If within cardiac cath lab, ICU or cardiac ward post-surgery or other situations with defib already attached can do 3 stacked shocks
  • 4J/kg for biphasic or monophasic shocks followed by 2 min of CPR without waiting to re-assess rhythm
  • If fails, adrenaline 10mcg/kg IV or IO
  • Persistent or refractory treat with amiodarone 5mg/kg as a bolus or lignocaine 1mg/kg
  • Adrenaline every 2^nd cycle
  • If refractory consider sodium bicarbonate 1mmol/kg, magnesium 0.05-0.1mmol/kg and potassium chloride 0.05mmol/kg

Arrhythmia management

• PEA
  • Causes include intrinsic depressed myocardial contractility, hypoxaemia, hypovolaemia, hypo/hyperthermia, hyperkalaemia, hypocalcaemia, severe acidosis, tamponade, PE, tension PTX, toxins, CCB or air embolism
  • Adrenaline 10mcg/kg
  • If persistent, IV bolus of fluid and/or sodium bicarbonate 1mmol/kg
  • CXR, 12-lead and echo are all useful in determining underlying remediable cause

Arrhythmia management

• SVT
  • 220-300/min in infants; 180/min in children
  • QRS narrow <0.08s in most cases (hard to differentiate from sinus tachy)
  • HR in sinus tachycardia is variable vs. uniform sudden onset/offset in SVT
  • In both rhythms, a P wave may be discernable
  • If stable
    • Vagal
      • Infants and young children – iced-water bag on face or unilateral carotid massage
      • Older children – Unilateral carotid massage or blowing through narrow straw
      • Do not perform eyeball pressure
    • Adenosine
      • 0.1 to 0.2 to 0.3mg/kg sequentially (not to exceed 12mg)
    • Amiodarone 5mg/kg over 1 hour then 5mcg/kg/min infusion
    • Procainamide, digoxin, beta-blocker or CCB are alternatives
      • Procainamide 15mg/kg over 30-60min (risk of hypotension through vasodilation)
      • CCB should be avoided in infants and young children due to risk of hypotension and cardiac depression
  • If unstable/arrest
    • Synchronised DC cardioversion 0.5-1J/kg increased to 2J/kg if necessary
    • Overdrive pacing may also be effective

Arrhythmia management

• Pulsatile VT
  • Amiodarone 5mg/kg over 20-60min
  • Procainamide 15mg/kg over 30-60 min
  • Both prolong the QT and should not be used together
  • Synchronised DC cardioversion 0.5-2J/kg if unstable
• Polymorphic VT
  • MgSO4 0.1-0.2mmol/kg
  • If pulseless, treat as for pulseless VT
• Wide QRS SVT
  • Indistinguishable from VT in many cases
  • If stable, treat as for SVT
  • If unstable, regard as pulsatile VT and treat with synchronised DC cardioversion 0.5-2J/kg
  • If pulseless, regard as pulseless VT and performed unsynchronised defibrillation 4J/kg

Techniques

• 100% O2 until ROSC then target SpO2 94-98% (same as adults) or PaO2 80-100
• If cyanotic heart disease, target PaO2 40-50 and SpO2 75-85%
• LMA sizing
  • <5kg – Size 1
  • 5-10kg – Size 1.5
  • 10-20kg – Size 2
  • 20-30kg – Size 2.5
  • 30-50kg – Size 3
  • 50-70kg – Size 4
  • 70-100kg – Size 5
  • >100kg – Size 6

Techniques

• ET size
  • Uncuffed
    • Newborn 2-3kg = Size 3mm
    • Newborn >3kg = Size 3.5mm
    • Infant up to 6mo = Size 3.5-4mm
    • Infant 7mo to 1yo = Size 4mm
    • Over 1yo = Age (years)/4 + 4
  • Cuffed
    • Newborns >3kg and <1yo = 3mm
    • 1-2yo = 3.5mm
    • >2yo = Age in years /4  + 3.5

Techniques

• Insertion length for oral tubes
  • Newborn = 9cm from lips
  • 6mo infant = 11.5cm
  • 1 yo = 12cm
  • >1yo = Age in years /2 + 12cm
• Insertion length for nasal tubes
  • Newborn 11cm
  • 6 months 13cm
  • 1 year 14cm
  • >1yo = Age in years/2 + 15cm
• Need to measure when head NOT extended i.e. after placement

Techniques

• IO
  • Correct placement confirmed with aspiration of bone marrow or flushing without extravasation
  • Can use bone marrow for biochem and haematological investigations but NOT VBG
  • Can use any drug
• ET drugs
  • Adrenaline, atropine and lignocaine all can be delivered this way
  • Use water rather than saline as diluent
  • Volume 0.7mL in newborns, 1-2mL for infant, 2-5mL for small child and 5-10mL for large child

Post-RESUS care

• Supportive therapy to continue
• Maintain adequate BP and oxygenation appropriate for age and long-term comorbidity
  • Target at least 5^th centile for age BP
  • Target normocarbia
• Look for underlying cause
• Consider membrane channelopathy if sudden cardiac arrest
• Check for complications of CPR
  • CXR, echo, bloods, gas
• Continued monitoring of haemodynamics, ECG, SpO2, etCO2, glucose, temp and end-organ function
• Maintain normoglycaemia with care to avoid hypoglycaemia
• Maintain normothermia (36-37.5) or hypothermia (32-34)
  • Should institute TTM within 6 hours and continue for at least 24 hours and up to 72 hours in children who remain comatose after cardiac arrest
• Hyperthermia should be aggressively prevented and treated as associated with poorer outcomes

Prognosis

• Good prognostic indicators
  • Any shockable rhythm at any stage
  • IHCA age <1yo confers advantage
  • OOHCA age >1yo confers advantage
  • Drowning iced water or witnessed VF have better outcomes
    • Should continue resuscitation efforts longer in these settings
  • If respiratory arrest alone or in-hospital, better prognosis
• Duration of CPR is not a reliable indicator of outcomes
• Should use multiple indicators for prognostication
  • EEG within 7 days, somatosensory evoked potentials (SSEP) after 72 hours, biomarkers of neuronal damage repeatedly over 72 hours, computerised axonal tomography in first hours and MRI during first 6 days
  • May need to modify in setting of TTM, induced hypothermia, sedation

Cessation

• Combination of pre-arrest status, duration of arrest, response to resuscitation, reversible causes, duration and quality of CPR, likely outcome, opinions of experts, desires of parents and availability of ECMO
• In the absence of reversible causes, prolonged resuscitative efforts are rarely successful
• No legal obligation to persist indefinitely to try to save a life in this circumstance
• If deemed futile or not in child’s best interests, can cease treatment

Last Updated on October 13, 2020 by Andrew Crofton