Pediatric Cardiac Arrest: Old Evidence and New Guidelines

1
Pediatric Cardiac Arrest Old Evidence and New
Guidelines

• Tim Lynch, MD
• April, 2001

2
Resuscitation

• Reanimation (Fr)
• Resuscitare (L) the restoration of life of one
  apparently dead

3
Case Study

• A 5-year old girl is brought to your emergency
  department by paramedics after being found at
  home to be apneic, and pulseless. She has
  received only BVM ventilation and chest
  compressions en route.

4
Case Study Questions/Objectives

• Why do children arrest?
• What are the likely outcomes of these children?
• Whats your dose of epinephrine and why?
• What are these new agents and when do we use
  them?

5
Why do children arrest?

6
Pediatric cardiopulmonary resuscitation. A
review of 130 cases.Ludwig S et al Clin Pediatr
19842371-75

• Review of patients suffering cardiorespiratory
  arrest at Childrens Hospital of Philadelphia
  between 1976 and 1980 (ED, Medical, and Surgical
  Units)

7
Pediatric cardiopulmonary resuscitation. A
review of 130 cases.Ludwig S et al Clin Pediatr
19842371-75

• 130 arrests - 96 hospital and 34 EDs
• mean age of 2 and 65 less than 12 months

8
Pediatric cardiopulmonary resuscitation. A
review of 130 cases.Ludwig S et al Clin Pediatr
19842371-75

• ED (34 with 42 diagnoses)
• Respiratory (14)
• CNS (9)
• CVS (8)
• SIDS (6)
• DOA (4)
• rigor mortis, low temperature, asystole

9
Pediatric cardiopulmonary resuscitation. A
review of 130 cases.Ludwig S et al Clin Pediatr
19842371-75

• Respiratory (14)
• 4 pneumonia
• 3 aspiration
• 2 asthma
• 2 respiratory failure
• 1 epiglottitis
• 1 restrictive
• 1 RDS

10
Pediatric cardiopulmonary resuscitation. A
review of 130 cases.Ludwig S et al Clin Pediatr
19842371-75

• CNS (9)
• 6 trauma
• 2 seizure
• 1 hydrocephalus

11
Pediatric cardiopulmonary resuscitation. A
review of 130 cases.Ludwig S et al Clin Pediatr
19842371-75

• Cardiovascular (8)
• 4 CHD
• 2 sickle cell
• 1 CHF
• 1 hemophilia

12
Pediatric cardiopulmonary resuscitation. A
review of 130 cases.Ludwig S et al Clin Pediatr
19842371-75

• Hospitalized Patients (96 with 133 diagnoses)
• Respiratory (57)
• Cardiovascular (28)
• CNS (25)
• GI (7)
• Miscellaneous (16)

13
Pediatric cardiopulmonary resuscitation. A
review of 130 cases.Ludwig S et al Clin Pediatr
19842371-75

• Respiratory (57)
• 26 RDS/BPD - 1 epiglottitis
• 12 pneumonia - 1 choanal atresia
• 4 apnea - 1 pulm hemosidero
• 3 bronchiolitis - 1 botulism
• 3 aspiration
• 3 trach obstruction
• 2 respiratory failure

14
Pediatric cardiopulmonary resuscitation. A
review of 130 cases.Ludwig S et al Clin Pediatr
19842371-75

• CNS (25)
• 10 hydrocephalus
• 5 tumour
• 4 meningitis
• 2 seizure
• 2 anoxic encephalopathy
• 1 hemorrhage
• 1 microcephaly

15
Pediatric cardiopulmonary resuscitation. A
review of 130 cases.Ludwig S et al Clin Pediatr
19842371-75

• GI (7)
• 3 NEC
• 1 appendicitis
• 1 Hirschsprungs
• 1 TE Fistula
• 1 SBO

16
Pediatric cardiopulmonary resuscitation. A
review of 130 cases.Ludwig S et al Clin Pediatr
19842371-75

• Miscellaneous (16)
• 6 congenital (non-cardiac)
• 5 tumours (non-CNS)
• 2 genetic
• 1 drug ingestion
• 1 ITP
• 1 metabolic

17
What are the likely outcomes of these children?

18
Outcome of children who are apneic and pulseless
in the emergency roomORourke P, Crit Care Med
198614466-468

• To examine mortality and morbidity of patients
  successfully resuscitated after arriving
  pulseless and apneic
• 3-year retrospective chart review of patients
  admitted from the ED to ICU over 3 years in
  Childrens Hospital, Boston

19
Outcome of children who are apneic and pulseless
in the emergency roomORourke P, Crit Care Med
198614466-468

• 34 patients admitted to ICU post-resuscitation
• 27 died in the ICU
• 7 were discharged from the hospital

20
Patient Profiles
21
Etiology
22
The Resuscitation
23
Outcome of children who are apneic and pulseless
in the emergency roomORourke P, Crit Care Med
198614466-468

• 27 died in the ICU
• 7 due to cardiovascular instability
• 20 removed from life support diagnosed with brain
  death
• 7 discharged from the ICU to chronic care
• 4 were victims of near drowning
• 2 vegetative 1died secondary to obstructed trach
• 1 functioning at 9 mo level at age 4
• 2 with upper airway obstruction - both vegetative
• 1 with blunt chest trauma - vegetative

24
Results of inpatient pediatric resuscitationGilli
s, J et al. Crit Car Med 198614469-471

• Retrospective review of arrests at HSC over 1
  year
• outcomes at 6 months
• predictive accuracy of variables considered to
  influence survival

25
Results of inpatient pediatric resuscitationGilli
s, J et al. Crit Car Med 198614469-471

• Respiratory Arrest - cessation of breathing for
  longer than 1 minute without apparent loss of
  cardiac output
• Cardiac Arrest - apneic with no cardiac output
  (no recordable BP or femoral pulse)

26
Results of inpatient pediatric resuscitationGilli
s, J et al. Crit Car Med 198614469-471

• 42 attempted resuscitations (9 - respiratory 33
  - cardiac)
• 21 females and males mean age 5.5 y
• overall survival of 17 (9 cardiac arrests)
• 7 alive at 6 months - 1 with severe neurologic
  deficit

27
Results of inpatient pediatric resuscitationGilli
s, J et al. Crit Car Med 198614469-471
28
Results of inpatient pediatric resuscitationGilli
s, J et al. Crit Car Med 198614469-471
29
Results of inpatient pediatric resuscitationGilli
s, J et al. Crit Car Med 198614469-471

• All 33 with pre-existing cardiac disease had a
  cardiac arrest
• 30/33 with asystole
• 3/33 with intractable ventricular fibrillation

30
Results of inpatient pediatric resuscitationGilli
s, J et al. Crit Car Med 198614469-471
31
Results of inpatient pediatric resuscitationGilli
s, J et al. Crit Car Med 198614469-471
32
Results of inpatient pediatric resuscitationGilli
s, J et al. Crit Car Med 198614469-471

• Respiratory (4)
• 2 with hydrocephalus and blocked shunts
• 1 with lymphoma and 1 with cystic hygroma
• Cardiac (3)
• CCHD and arrythmia
• esophageal atresia and recurrent aspiration
• 3 yo girl with CCHD and pneumonia - arrested for
  12 min and received epi once
• spastic quadriplegia

33
Results of inpatient pediatric resuscitationGilli
s, J et al. Crit Car Med 198614469-471

• Respiratory arrests had better outcome
• predictors of non-survival
• gt 15 minutes of CPR
• administration of more than 1 dose of epi

34
Whats your dose of epinephrine and why?

35
High-dose epinephrine improves outcome from
pediatric cardiac arrestGoetting MG et al, Ann
Emerg Med 19912022-26

• Compared a prospectively treated high-dose
  epinephrine (HDE) study group with historical
  cohorts receiving conventional dose (SDE) with
  respect to the return of spontaneous circulation
  (ROSC)

36
High-dose epinephrine improves outcome from
pediatric cardiac arrestGoetting MG et al, Ann
Emerg Med 19912022-26

• 20 consecutive patients treated for cardiac arres
  who failed ROSC after 2 doses of SDE (0.01 mg/kg)
  five min apart were given HDE (o.2 mg/kg) in 110
  000 for infants and 11000 for older patients

37
High-dose epinephrine improves outcome from
pediatric cardiac arrestGoetting MG et al, Ann
Emerg Med 19912022-26

• Iv line was flushed after each dose
• atropine 0.01 mg/kg was given for bradycardia and
  asystole with each SDE
• sodium bicarbonate 1 mEq/kg was administered
  between each SDE
• all patients ventilated with 100 O2

38
High-dose epinephrine improves outcome from
pediatric cardiac arrestGoetting MG et al, Ann
Emerg Med 19912022-26

• ROSC was defined as
• a supraventricular rhythm with palpable pulses
  or
• an invasive systolic pressure greater than 60 mm
  Hg

39
High-dose epinephrine improves outcome from
pediatric cardiac arrestGoetting MG et al, Ann
Emerg Med 19912022-26

• historic controls -
• 20 consecutive children treated by the same
  author over 12 months
• with witnessed arrests,
• receiving ACLS within 5 min, and
• receiving more than 2 SDEs

40
High-dose epinephrine improves outcome from
pediatric cardiac arrestGoetting MG et al, Ann
Emerg Med 19912022-26

• 14 of HDE had ROSC within 5 minutes versus none
  of the controls (plt0.001)
• all 14 responded with sinus tachycardia for at
  least 15 min
• mild to moderate hypertension for 20 min in 8
• 10 placed on vasopressor drips

41
High-dose epinephrine improves outcome from
pediatric cardiac arrestGoetting MG et al, Ann
Emerg Med 19912022-26

• 14 survivors
• 8 survived to discharge
• 6 regained pre-arrest neurologic level
• 3 developmentally normal 6 - 17 mo later
  (pulmonary contusions, hypovolemia, septic shock)
• 3 regained severe pre-existing cognitive level
• 2 with global cortical damage

42
What are these new agents and when do we use them?

43
New Guidelines

• amiodarone
• procainamide
• lidocaine

44
Amiodarone

• Inhibits outward K current - prolongs QT
• Inhibits Na channels - slows and conduction
  (prolongs QRS)
• Non-competitive inhibitor of alpha- and
  beta-adrenergic receptors
• secondary to sympathetic block - vasodilatation
  and AV nodal suppression Non-competitive

45
Amiodarone

• Most commonly used for ectopic atrial tachycardia
  or junctional ectopic tachycardia post cardiac
  surgery
• 5 mg/kg loading infusion over minutes to 15
  mg/kg/day
• hypotension is the main adverse effect

46
Procainamide

• Sodium channel blocking agent - prolongs
  refractory period and depresses conduction
  velocity - prolonged QT and PR intervals
• effective for atrial fibrillation and flutter,
  SVT, JET, and perfusing VT

47
Procainamide

• Must be given by slow infusion to avoid heart
  block, myocardial depression, and prolonged QT
• 15 mg/kg over 30 to 60 min
• stop infusion if hypotension or QRS widens to gt
  50 of baseline

48
Lidocaine

• Not effective for ventricular arrhythmias in
  infants or children unless associated with focal
  myocardial ischemia
• may be considered in shock-resistant VF or
  pulseless VT
• 1 mg/kg bolus then 20 to 50 ug/kg/min

49
Pediatric Epinephrine Dosing
50
Epinephrine

• Alpha and beta-adrenergic properties
• Alpha-adrenergic vasoconstriction
• Increases aortic diastolic pressure and coronary
  perfusion

51
High Dose Epinephrine

• 10 to 20 times the standard dose
• A dangerous dose in one patient may be lifesaving
  in another
• Improved survival and neurological outcome
• Increased myocardial consumption and post arrest
  hyperadrenergic state

52
New Guidelines Epinephrine

• The conventional dose of epinephrine is
  recommended for second and subsequent doses
• Higher doses may be considered

53
New Guidelines Bradycardia

• Atropine is recommended in the treatment of
  symptomatic bradycardia caused by AV block or
  increased vagal tone

54
New Guidelines SVT

• Vagal maneuvers introduced
• Verapamil remains contraindicated in infants
• Amiodarone
• Procainamide

55
New Guidelines Stable VT

• Amiodarone
• Procainamide or lidocaine considered alternative
  agents

56
New Guidelines Pulseless VT/VF

• Defibrillation 2 J/kg, 4 J/kg, 4 J/kg
• Epinephrine
• Amiodarone

57
Amiodarone
58
Procainamide