Pediatric Cardiorespiratory Arrest and Resuscitation

Pediatric Cardiorespiratory Emergencies and Resuscitation

Cardiac Arrest and Cardiopulmonary Resuscitation Overview

• Cardiac arrest occurs when the heart fails as an effective pump, leading to the cessation of blood flow.
• Externally, the patient is unresponsive, apneic, and lacks a palpable pulse.
• Internally, this leads to tissue ischemia and organ failure due to the cessation of cardiac output and oxygen delivery.
• If not reversed rapidly, it results in deterioration of brain, heart, and other organ functions, making resuscitation and recovery impossible.

2020 American Heart Association (AHA) Guidelines

• The AHA Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care provide evidence-based recommendations.
• Initial guidelines were published in 1966 by an ad hoc CPR Committee of the Division of Medical Sciences, National Academy of Sciences—National Research Council in response to the need for standards and guidelines regarding training and response.

Statistics

• Emergency medical services respond to over 347,000 adults and more than 7,000 children (under 18 years) with out-of-hospital cardiac arrest (OHCA) each year in the United States.
• In-hospital cardiac arrest (IHCA) occurs in approximately 9.7 per 1000 adult cardiac arrests (approximately 292,000 events annually) and 2.7 pediatric events per 1000 hospitalizations.
• Approximately 1% of newly born infants in the United States require intensive resuscitative measures to restore cardiorespiratory function.

Causes of Out-of-Hospital Cardiac Arrest (OHCA)

• Sudden infant death syndrome (SIDS).
• Drowning.
• Foreign body aspiration.
• Poisoning or drug overdose.
• Trauma.

Chain of Survival

• Variation in survival rates is due to the strength of the Chain of Survival, which includes critical actions that must occur rapidly.
• A sixth link, recovery, has been added to emphasize the importance of recovery and survivorship for resuscitation outcomes.

Chains of Survival

• Adult Out-of-Hospital:
  • Activation of Emergency Response.
  • High-Quality CPR.
  • Defibrillation.
  • Advanced Resuscitation.
  • Post-Cardiac Arrest Care.
  • Recovery.
• Adult In-Hospital:
  • Early Recognition and Prevention.
  • Activation of Emergency Response.
  • High-Quality CPR.
  • Defibrillation.
  • Post-Cardiac Arrest Care.
  • Recovery.
• Pediatric Out-of-Hospital:
  • Prevention.
  • Activation of Emergency Response.
  • High-Quality CPR.
  • Advanced Resuscitation.
  • Post-Cardiac Arrest Care.
  • Recovery.
• Pediatric In-Hospital:
  • Early Recognition and Prevention.
  • Activation of Emergency Response.
  • High-Quality CPR.
  • Advanced Resuscitation.
  • Post-Cardiac Arrest Care.
  • Recovery.

Utstein Formula for Survival

• The 2020 AHA Guidelines are organized around this formula.

Pediatric BLS for Lay Rescuers

• Step 1: Ensure scene safety and check for responsiveness and normal breathing.
• Step 2: Shout for help.
  • If alone:
    • With a cell phone: Call 9-1-1, perform CPR (30 compressions and 2 breaths) for 5 cycles, then get an AED.
    • Without a cell phone: Perform CPR (30 compressions and 2 breaths) for 5 cycles, then call 9-1-1 and get an AED.
  • If help is available: Call 9-1-1 and start CPR while someone gets an AED.
• Step 3: Repeat cycles of 30 compressions and 2 breaths.
  • Child CPR: Push in the middle of the chest at least one-third of the chest depth or approximately 2 inches with 1 or 2 hands.
  • Infant CPR: Push in the middle of the chest at least one-third of the chest depth or approximately 1/2 inches with 2 fingers.
• Use the AED as soon as it arrives.
• Continue CPR until EMS arrives.

Assessment and Evaluation of Children with Cardiorespiratory Emergencies

• The first response is a rapid and systematic general assessment to identify immediate threats.
• If an emergency is identified, activate the emergency response system (EMS) immediately.
• Proceed through primary, secondary, and tertiary assessments based on the child’s condition, scene safety, and available resources.
• If a life-threatening problem is identified, pause the systematic assessment and prioritize targeted lifesaving interventions.

Recognition of Cardiac Arrest

• Pale or cyanotic appearance.
• Unresponsiveness.
• Apnea (absence of breathing).
• Pulselessness.

Pediatric BLS for Healthcare Providers - Single Rescuer

• Verify scene safety.
• Check for responsiveness.
• Shout for nearby help.
• Activate the emergency response system via mobile device (if appropriate).
• Look for no breathing or only gasping and check pulse (simultaneously).
• Assess if a pulse is definitely felt within 10 seconds.
  • If no normal breathing, but pulse felt: provide rescue breathing, 1 breath every 2-3 seconds, or about 20-30 breaths/min. Assess pulse rate for no more than 10 seconds.
    • If HR < 60/min with signs of poor perfusion, start CPR then continue rescue breathing; check pulse every 2 minutes. If no pulse, start CPR.
  • If no breathing or only gasping, and pulse not felt: Start CPR. Perform cycles of 30 compressions and 2 breaths. Use AED as soon as available. If still alone after about 2 minutes, activate emergency response system and retrieve AED (if not already done).
    • Check rhythm.
      • If shockable rhythm: give 1 shock. Resume CPR immediately for 2 minutes (until prompted by AED to allow rhythm check).
      • If nonshockable: Resume CPR immediately for 2 minutes (until prompted by AED to allow rhythm check).
• Continue until ALS providers take over or the child starts to move.
• Normal breathing, pulse felt: Monitor until emergency responders arrive.

Rescue Breathing

• Infant: The rescuer's mouth covers the infant's nose and mouth, creating a seal. One hand performs the head-tilt while the other hand lifts the infant's jaw.
• Child: The rescuer's mouth covers the child's mouth, creating a mouth-to-mouth seal. One hand maintains the head-tilt; the thumb and forefinger of the same hand are used to pinch the child's nose. The other hand lifts the child's jaw.

Compressions

• One rescuer CPR: Perform cycles of 30 compressions and 2 breaths.
• Two-rescuer CPR: Perform cycles of 15 compressions and 2 breaths.

Two-Rescuer BLS for Infants

1. Tap the bottom of their foot and talk loudly at the infant to determine if they are responsive
2. If the infant does not respond and is not breathing (or is only gasping), send the second rescuer to call for help and get an AED.
3. Assess if they are breathing while simultaneously feeling for the infant's brachial pulse for 5 but no more than 10 seconds.
4. If you cannot feel a pulse (or if you are unsure), begin CPR by doing 15 compressions followed by two breaths. If you can feel a pulse but the rate is less than 60 beats per minute, begin CPR. This rate is too slow for an infant
5. When the second rescuer returns, begin CPR by performing 15 compressions by one rescuer and two breaths by the second rescuer. If the second rescuer can fit their hands around the infant's chest, perform CPR using the two thumb-encircling hands method. Do not press on the bottom end of the sternum as this can cause injury to the infant.
6. Compressions should be approximately 1.5 inches ($4$ cm) deep and at a rate of 100 to 120 per minute.

Pediatric BLS for Healthcare Providers - Two or More Rescuers

• Verify scene safety.
• Check for responsiveness.
• Shout for nearby help.
• First rescuer remains with the child; second rescuer activates emergency response system and retrieves the AED and emergency equipment.
• Look for no breathing or only gasping and check pulse (simultaneously).
• Assess if pulse is definitely felt within 10 seconds.
  • If no normal breathing, but pulse felt: provide rescue breathing, 1 breath every 2-3 seconds, or about 20-30 breaths/min. Assess pulse rate for no more than 10 seconds.
    • If HR < 60/min with signs of poor perfusion, start CPR then Continue rescue breathing; check pulse about every 2 minutes. If no pulse, start CPR.
  • If no breathing or only gasping, pulse not felt: Start CPR - First rescuer performs cycles of 30 compressions and 2 breaths. When second rescuer returns, perform cycles of 15 compressions and 2 breaths. Use AED as soon as it is available.
    • Check rhythm.
      • If shockable rhythm: Give 1 shock. Resume CPR immediately for 2 minutes (until prompted by AED to allow rhythm check).
      • If nonshockable rhythm: Resume CPR immediately for 2 minutes (until prompted by AED to allow rhythm check).
• Continue until ALS providers take over or the child starts to move.
• Normal breathing, pulse felt: Monitor until emergency responders arrive.

Two-Rescuer BLS for Children

1. Tap their shoulder and talk loudly to the child to determine if they are responsive.
2. If the child does not respond and is not breathing (or is only gasping for breath), send the second rescuer to call for help and get an AED. State emergency, and state, "Bring AED."
3. Assess if they are breathing while feeling for the child's carotid pulse (on the side of the neck) or femoral pulse (on the inner thigh in the crease between their leg and groin) for no more
4. If you cannot feel a pulse (or if you are unsure), begin CPR by doing 15 compressions followed by two breaths. If you can feel a pulse but the rate is less than 60 beats per minute, begin CPR. This rate is too slow for a child.
5. When the second rescuer returns, begin CPR by performing 15 compressions by one rescuer and two breaths by the second rescuer. Always call for help. BLS is not an individual work, you need help.
6. Use and follow AED prompts when available while continuing CPR until EMS arrives or until the child's condition normalizes. Note: If patient is already normal after CPR without aid of AED, breathing and pulse is already present, position him/her in a side-lying position. Side-lying position encourages better circulation

Key Aspects of CPR

• Allow complete chest recoil after each compression to allow the heart to refill.
• Minimize interruptions in compressions (limit interruptions to less than 10 seconds).
• Give effective breaths that make the chest rise.
• Avoid excessive ventilation; chest compression is more critical than breaths.
• The goal of CPR is to provide critical blood flow to the heart and brain and to keep oxygenated blood circulating, delaying damage to vital organs and improving the chances of successful defibrillation.

Pediatric Cardiac Arrest Algorithm

1. Start CPR,begin bag-mask ventilation and give oxygen and attach monitor/defibrillator.
2. The algorithm splits depending on the rhythm. One side if VF/pVT (Ventricular Fibrillation/Pulseless Ventricular Tachycardia), the other Asystole/PEA (Pulseless Electrical Activity).
3. VF/PVT Pathway: Rhythm shockable? If yes, Shock. If no, go to Asystole/PEA Pathway.
4. Continue CPR for 2 minutes then give IV/IO access.
5. Rhythm shockable? If yes, Shock. If no, go to Asystole/PEA Pathway.
6. Perform CPR for 2 min while administering Epinephrine every 3-5 min and consider advanced airway.
7. Rhythm shockable? if yes, Shock. If no, go to the next step.
8. If the rhythm is not shockable, and if there are no signs of return of spontaneous circulation (ROSC), proceed to Asystole/PEA Pathway. If ROSC, proceed to Post-Cardiac Arrest Care checklist.
9. If performing CPR with defibrillation and epinephrine isnt working, think about doing Amiodarone or lidocaine and begin to treat reversible causes.
10. Asystole/PEA Pathway: CPR 2 min with IV/IO access
11. Administer epinephrine ASAP and every 3-5 min while considering advanced airway and capnography. Then continue CPR for 2 minutes.
12. Treat reversible causes, check if the rhythm is now shockable, if so shock. Go back to the start of algorithm if not

CPR Quality

• Push hard ( > 1/3 of anteroposterior diameter of chest) and fast (100-120/min), and allow complete chest recoil.
• Minimize interruptions in compressions.
• Change compressor every 2 minutes or sooner if fatigued.
• If no advanced airway, use a 15:2 compression-ventilation ratio.
• If advanced airway, provide continuous compressions and give a breath every 2-3 seconds.

Shock Energy for Defibrillation

• First shock: $2 J/kg$
• Second shock: $4 J/kg$
• Subsequent shocks: > $4 J/kg$, maximum $10 J/kg$ or adult dose.

Drug Therapy

• Epinephrine IV/IO dose: $0.01 mg/kg$ ($0.1 mL/kg$ of the $0.1 mg/mL$ concentration). Max dose $1 mg$. Repeat every 3-5 minutes. If no IV/IO access, give endotracheal dose: $0.1 mg/kg$ ($0.1 mL/kg$ of the $1 mg/mL$ concentration).
• Amiodarone IV/IO dose: $5 mg/kg$ bolus during cardiac arrest. May repeat up to 3 total doses for refractory VF/pulseless VT or Lidocaine IV/IO dose: Initial: $1 mg/kg$ loading dose

Advanced Airway

• Endotracheal intubation or supraglottic advanced airway.
• Waveform capnography or capnometry to confirm and monitor ET tube placement.

Reversible Causes

• Hypovolemia.
• Hypoxia.
• Hydrogen ion (acidosis).
• Hypoglycemia.
• Hypo-/hyperkalemia.
• Hypothermia.
• Tension pneumothorax.
• Tamponade, cardiac.
• Toxins.
• Thrombosis, pulmonary.
• Thrombosis, coronary.

Automated External Defibrillator (AED)

• A portable medical device used to treat sudden cardiac arrest by analyzing the heart's rhythm and delivering an electric shock if necessary.
• An AED can be used on children and infants as early as possible for the best chance of survival. Use pediatric pads if the person is less than eight years old or less than 55 pounds (25 kg).

AED Steps for Children and Infants

1. Retrieve the AED, open the case, and turn on the AED.
2. Expose the infant or child's chest. If wet, dry the chest. Remove any medication patches.
3. Open the pediatric AED pads. If unavailable, use adult pads, ensuring they do not touch. Peel off the backing.

• Check for a pacemaker or defibrillator; if present, do not apply patches over the device.

1. Apply pads to the chest for correct placement (follow the figure on the pads).
2. Ensure wires are attached to the AED box.
3. Move away from the person. Stop CPR and instruct others not to touch the person.
4. AED analyzes the rhythm.
5. If the message reads "Check Electrodes," ensure electrodes make good contact. If the message reads "Shock," then shock.
6. Resume CPR for two minutes.
7. Repeat the cycle.

Bag-Mask Ventilation (BVM) in Pediatrics

• A crucial skill for providing emergency respiratory support to infants and children who cannot breathe on their own.
• Uses a self-inflating bag connected to a face mask to deliver breaths.
• Often the first step in managing airway problems, especially before intubation.

Proper Use of BVM

• Proper fit: the mask should tightly cover the mouth and nose, but not the eyes. Use a clear mask to observe lip color and condensation.
• Two common types of bag-masks: self-inflating and flow-inflating.
• Self-inflating bags should be the first choice but not used in spontaneously breathing children/infants.
• Flow-inflating bags require more training to manage gas flow, mask seal, neck position, and tidal volume simultaneously.
• Minimum bag size: 450 mL for infants and young children; 1000 mL for older children.
• Proper ventilation is critical to avoid respiratory acidosis.

Types of Bag-Mask Devices

• Self-Inflating Bag
  • Advantages: Does not require gas source; pop-off valve helps avoid excessive PIP; predictable FiO2.
  • Disadvantages: Requires reservoir to achieve FiO2 = 90%-100%; inconsistent inspiratory time, PIP, PEEP.
• Flow-Inflating Bag
  • Advantages: N/A.
  • Disadvantages: Requires gas source to function; inconsistent inspiratory time, PIP, PEEP.

Ventricular Fibrillation/Pulseless Ventricular Tachycardia (VF/pVT)

• Chaotic electrical activity in the heart's ventricles, resulting in no effective pumping and no pulse.
• Lacks pattern or predictability on an ECG.
• Pulseless Ventricular Tachycardia (pVT): Rapid, organized heartbeat originating from the ventricles, but not forceful enough to produce a pulse.

Asystole and Pulseless Electrical Activity (PEA)

• Life-threatening, non-shockable cardiac rhythms requiring immediate intervention.
• Asystole: Complete cessation of electrical and mechanical activity in the heart, with no discernible electrical activity on an ECG (flatline).
• PEA: Organized or semi-organized electrical activity on the ECG without a palpable pulse.

Advanced Airway

• An advanced airway (supraglottic airway, laryngeal mask airway, or endotracheal tube) provides a more stable way of providing breaths and should, therefore, be inserted as early as possible in a resuscitation effort.
• Supraglottic airway devices prop open the oropharyngeal airway for unrestricted gas exchange but are not secure airways from aspiration.

Endotracheal Tube (ETT)

• A flexible plastic tube inserted into the trachea to maintain an open airway for breathing support.
• Commonly used during surgery or to assist patients with breathing problems.

Positioning Infants and Children for Airway Management

• Supine position: Infants' relatively large heads can cause neck flexion, compressing the upper airway.
• The classic sniffing position is an established standard across anesthesia practice.

Capnography

• A method of monitoring carbon dioxide (CO2) concentration in the respiratory gases, typically displayed as a waveform or numerical value.
• It's a non-invasive technique used to assess a patient's ventilation, perfusion, and metabolic status.

Uses of Capnography

• Verification of endotracheal tube placement.
• Ventilation monitoring.
• Early detection of apnea or severe airway obstruction.
• Assess pulmonary disease severity.
• Assess Cardiopulmonary Resuscitation (CPR) Quality.

Relationship of EtCO2 to PaCO2 in Normal Healthy Lungs

• EtCO2 is typically 0-5 mmHg less than PaCO2.
  • In adults and children: EtCO2 is 3-5 mmHg less than PaCO2.
  • In infants and small children: EtCO2 is 0-3 mmHg below PaCO2.

Recovery Position

• If normal breathing is present or resumes, place the unresponsive, injured person in the recovery position to ensure an open airway.
• Helps prevent blood and vomit from obstructing the airway or flowing into the lungs, minimizing the chance of aspiration.

Steps for Placing Someone in the Recovery Position

• Kneel beside the person, ensuring both legs are straight.
• Place the arm nearest to you at right angles to their body, with the elbow bent and palm facing upward.
• Bring the far arm across the person's chest and hold the back of their hand against the cheek nearest to you.
• Place your other hand under the leg farthest from you, just above the knee, or grab the pant leg of the person's clothing, and pull the knee up, keeping the foot on the ground.
• Keeping the person's hand pressed against their cheek, pull the far leg to roll them toward you and onto their side.
• Adjust the top leg to form 90-degree angles at both the hip and knee.
• Tilt back the person's head to ensure the airway remains open.
• Adjust their hand under their cheek, if necessary, to keep the head tilted.
• Check breathing regularly.

Recovery Position for an Infant

• Ensure the infant is facing the ground and provide support to their head with your hand to maintain an open airway. Remember to continuously assess their breathing status.
• If at any stage they do stop breathing, start CPR.

Components of Post-Cardiac Arrest Care

• Oxygenation and ventilation
  • Measure oxygenation and target normoxemia 94%-99% (or child's normal/appropriate oxygen saturation).
  • Measure and target PaCO2 appropriate to the patient's underlying condition and limit exposure to severe hypercapnia or hypocapnia.
• Hemodynamic monitoring
  • Set specific hemodynamic goals during post-cardiac arrest care and review daily.
  • Monitor with cardiac telemetry.
  • Monitor arterial blood pressure.
  • Check Monitor serum lactate, urine output, and central venous oxygen saturation to help guide therapies.
  • Use parenteral fluid bolus with or without inotropes or vasopressors to maintain a systolic blood pressure greater than the fifth percentile for age and sex.
• Targeted temperature management (TTM)
  • Measure and continuously monitor core temperature.
  • Prevent and treat fever immediately after arrest and during rewarming.
  • If patient is comatose apply TTM (32°C-34°C) followed by (36°C-37.5°C) or only TTM (36°C-37.5°C).
  • Prevent shivering.
  • Monitor blood pressure and treat hypotension during rewarming.
• Neuromonitoring
  • If patient has encephalopathy and resources are available, monitor with continuous electroencephalogram.
  • Treat seizures.
  • Consider early brain imaging to diagnose treatable causes of cardiac arrest.
• Electrolytes and glucose
  • Measure blood glucose and avoid hypoglycemia.
  • Maintain electrolytes within normal ranges to avoid possible life-threatening arrhythmias.
• Sedation
  • Treat with sedatives and anxiolytics.
• Prognosis
  • Always consider multiple modalities (clinical and other) over any single predictive factor.
  • Remember that assessments may be modified by TTM or induced hypothermia.
  • Consider electroencephalogram in conjunction with other factors within the first 7 days after cardiac arrest.
  • Consider neuroimaging such as magnetic resonance imaging during the first 7 days.