Cardiopulmonary arrest in children..pptx

This PowerPoint presentation talks about the likely etiology, pathogenesis, clinical features, approach and management of cardiopulmonary arrest in pediatric population.

Cardiopulmonary arrest is the cessation of effective circulation and ventilation. BLS utilises cpr and cardiac defibrillation. PALS guidelines.

Evaluation includes quick assessment and guideline-based approach.
Techniques of CPR depending upon the age of the child.

1. Cardiopulmonary arrest in children Anushka Kalia Roll no. 25 Batch-2020 1

2. Case Scenario In the pediatric unit, 2-year-old Mina's condition rapidly deteriorated. Initially admitted for fever with cough, she began showing signs of respiratory distress, struggling to breathe and displaying cyanosis. Despite receiving supplemental oxygen, her condition continued to decline, and she became increasingly lethargic. Emily's pulse became non palpable, before she eventually became unresponsive. 2

3. Cardiopulmonary arrest (CPA) is the cessation of effective ventilation and circulation. It is also known as cardiac arrest or circulatory arrest. Etiology- Cardiac causes Coronary artery abnormalities: Anomalous coronary artery anatomy. Acute lesions (platelet aggregation, plaque fissuring, acute thrombosis) coronary artery spasm VHD Carditis: RHD, IE Inherited Disorders Early repolarization syndrome.   Brugada syndrome   Short QT syndrome. Long QT syndrome. Catecholaminergic polymorphic ventricular tachycardia   Heart Failure : EF< 35% Congenital disease : TOF Respiratory causes Airway obstruction :  Bronchospasm due to (pulmonary edema , pulmonary hemorrhage , and pneumonia) Severe asthma Pulmonary Embolism Respiratory Muscle Weakness :  due to spinal cord injury. Others- Sepsis Anaphylaxis Intracranial catastrophe (CVA, SAH) Trauma 3

4. Pathogenesis 4

5. Respiratory cause 5 Cardiac cause ↓ O2 to tissues Anaerobic metabolism ↓ATP  Na/k pump failure ↑Na inside cell Osmotic cell swelling Cell death Release of H+ and vasodilatory chemicals into circulation ↓Intravascular Volume Peripheral vasoconstriction Cool, pale skin ↓ core body temperature SNS activation  Catecholamine release Reflex vasoconstriction ↑activity of Ca+ pumps Prolonged action potential of cardiac cells Myocardial conduction delay ↑ K+ and H+ levels in blood Acidosis ↑Respiratory Rate (Dyspnoea) Cardiac instability Altered automaticity, conductivity, and excitability of heart Cardiac arrest

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7. The Resuscitation Team 7

8. BLS: Basic Life Support Basic Life Support (BLS) utilizes CPR and cardiac defibrillation when an Automated External Defibrillator(AED) is available. BLS is the life support method used when there is limited access to advanced interventions such as medications and monitoring devices. In general, BLS is performed until the emergency medical services (EMS) arrives to provide a higher level of care. 8

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10. BLS FOR CHILDREN (1 YEAR TO PUBERTY) ONE-RESCUER BLS FOR CHILDREN - If you are alone with a child, do the following: 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), yell for help. If someone responds, send the second person to call 911 and to get an 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 than 10 seconds . 10

11. 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 pulse rate is less than 60 beats per minute, you should begin CPR. This rate is too slow for a child. 5. After doing CPR for about two minutes (usually about ten cycles of 15 compressions and two breaths) and if help has not arrived, call EMS while staying with the child. The ILCOR emphasizes that cell phones are available everywhere now and most have a built-in speakerphone. Get an AED if you know where one is. 6. Use and follow AED prompts when available while continuing CPR until EMS arrives or until the child’s condition normalizes 11

12. TWO-RESCUER BLS FOR CHILDREN If you are not alone with a child, do the following: 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 911 and get an 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 than 10 seconds. 12

13. 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. 6. Use and follow AED prompts when available while continuing CPR until EMS arrives or until the child’s condition normalizes. 13

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15. One Rescuer BLS for Infants If you are alone with an infant, do the following: 1. Tap the bottom of their foot and talk loudly to the infant to determine if they are responsive. 2. If the infant does not respond, and they are not breathing (or if they are only gasping), yell for help. If someone responds, send the second person to call EMS and to get an AED. 3. Assess if they are breathing while feeling for the infant’s femoral or brachial pulse for no more than 10 seconds. 15

16. 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. To perform CPR on an infant do the following: a. Be sure the infant is face-up on a hard surface. b. Using two fingers, perform compressions in the center of the infant’s chest; do not press on the end of the sternum as this can cause injury to the infant. c. Compression depth should be about 1.5 inches (4 cm) and a rate of 100 to 120 per minute. 16

17. 5. After performing CPR for about two minutes (usually about ten cycles of 15 compressions and two breaths) if help has not arrived, call EMS while staying with the infant. The ILCOR emphasizes that cell phones are available everywhere now and most have a built-in speakerphone. Get an AED if you know where one is. 6. Use and follow AED prompts when available while continuing CPR until EMS arrives or until the infant’s condition normalizes. 17

18. Two Rescuer BLS for Infants If you are not alone with the infant, do the following: 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 911 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. 18

19. 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. 19

20. 6. Compressions should be approximately 1.5 inches (4 cm) deep and at a rate of 100 to 120 per minute . 7. Use and follow AED prompts when available while continuing CPR until EMS arrives or until the infant’s condition normalizes. 20

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22. Important Points Rate - 100-120 compressions/minute Depth - 1/3 rd of the AP diameter of chest Site - Lower 1/3 rd of sternum . Avoid Xiphoid process. Note - Allow full recoil of chest in between compressions. Compression: Ventilation ratio- 30:2 (in adults ) and 15:2 (in infants and children) 22

23. PALS: Paediatric Advanced Life Support When you find an unresponsive child or infant, it is often not possible to immediately deduce the etiology. You will want to act quickly, decisively, and apply interventions that fit the needs of the individual at that moment. In order to achieve this, PALS was designed for providers to take a comprehensive approach. Sequence followed- Assessment  Circulation  Airway  Breathing (CAB) as per 2015 update 2015 of Paediatric life support 23

24. Circulation Assessment of circulation in pediatrics involves more than checking the pulse and blood pressure. The color and temperature of the skin and mucous membranes can help to assess effective circulation. Pale or blue skin indicates poor tissue perfusion. Capillary refill time is also a useful assessment in pediatrics. Adequately, perfused skin will rapidly refill with blood after it is squeezed (e.g. by bending the tip of the finger at the nail bed). Inadequately perfused tissues will take longer than two seconds to respond. Abnormally, cool skin can also suggest poor circulation. 24

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27. Disability In PALS, disability refers to performing a rapid neurological assessment. A great deal of information can be gained from determining the level of consciousness on a four-level scale. Pupillary response to light is also a fast and useful way to assess neurological function. 27

28. Neurologic assessments include the AVPU (alert, voice, pain, unresponsive) response scale Glasgow Coma Scale (GCS). A specially-modified GCS is used for children and infants and takes developmental differences into account 28

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30. Exposure Exposure is classically most important when you are responding to a child or infant who may have experienced trauma; however, it has a place in all PALS evaluations. Exposure reminds the provider to look for signs of trauma, burns, fractures , and any other obvious sign that might provide a clue as to the cause of the current problem. Skin temperature and color can provide information about the child or infant’s cardiovascular system, tissue perfusion, and mechanism of injury. If time allows, the PALS provider can look for more subtle signs such as petechiae or bruising. Exposure also reminds the provider that children and infants lose core body temperature faster than adults do. Therefore, while it is important to evaluate the entire body, be sure to cover and warm the individual after the diagnostic survey. 30

31. Resuscitation Tools 31

32. Vascular Access Central venous lines provide secure access, rapid action, higher peak drug levels. m/c vein- Femoral Vein . Preferred access is the largest easily accessible vein, cannulating which does not require interruption of resuscitation. Alternative- Interosseous access. Site for IO access- Upper end of tibia, medial to tibial tuberosity. 32

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34. Bag and Mask Ventilation Preferred technique for emergency ventilation during initial steps of resuscitation. Volume of ventilation bag for term neonates, infants and children <8 years 450-500 mL. For preterm- 250 mL Self-inflating bag delivers room air unless connected to an oxygen source. Pediatric bag-valve device, without a reservoir, if connected to an oxygen inflow of 10 L/min, delivers 30-80 % of oxygen to the patient. With a reservoir, it may deliver 60-95% of oxygen, with an oxygen inflow of 15 L/ min 34

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36. Ventilation corrective steps (MR SOPA) Inadequate seal- Re-apply M ask Blocked airway- R eposition the Infant's head Blocked airway - Clear S ecretions by suction Blocked airway- Ventilate with mouth slightly O pen Inadequate pressure - Increase P ressure Consider A lternate airway- Blocked A irway(endotracheal tube) 36

37. Endotracheal Intubation Used properly, this is the most effective and reliable method of ventilation. Indications- Functional or anatomical airway obstruction Need for high peak inspiratory pressure or positive end expiratory pressure Lack of protective airway reflexes For prolonged duration cardiopulmonary resuscitation Inadequate neurological control over respiration (GCS <=8) 37

38. Size of ET tube= Age in years + 4 Depth of ET tube= 3* inner diameter of ET tube (in cm) In neonates, depth= Birth weight(kg) +6 In >=2 years, depth= Birth weight(kg) + 12 Cuff pressure- <20- 25 mm of water. Tube placement is confirmed by looking for symmetrical chest rise and auscultating for air entry on both sides. 4 2 38

39. Defibrillation It is an asynchronous depolarization of a critical mass of myocardium in order to terminate VF or pulseless VT. Criteria for AED Use: • No response after shaking and shouting. • Not breathing or ineffective breathing. • No carotid artery pulse detected. Larger size defibrillator paddles, 8 to 10 cm in diameter, are recommended in children weighing more than 10 kg. Smaller paddles are used in infants. One paddle is placed over the right side of the upper chest and the other over the apex of the heart Dosage of current- 2 J /kg, second dose of 4 J /kg and subsequent doses of >4 J /kg, to a maximum of 10 J /kg (adult dose). 39

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42. Cardiac Arrest 42 Start cardiopulmonary resuscitation (CPR) Bag and mask ventilation Attach monitor/defibrillator VF/ pVT Give electric shock CPR for 2 minutes. IV/IO access Give electric shock CPR for 2 minutes. Epinephrine every 3-5 minutes. Consider advanced airway Give electric shock CPR for 2 minutes. Amiodarone/ lignocaine Treat reversible cause Asystole/PEA Inj. Epinephrine CPR for 2 minutes IV/IO acces Epinephrine every 3-5 minutes Consider advanced airway CPR every 2 minutes Treat reversible cause Give electric shock. Follow shockable rhythm algorithm Rhythm shockable ? yes Rhythm shockable? yes Rhythm shockable? No Rhythm shockable? yes No No Yes No Check Rhythm

43. Pulseless electrical activity State of electrical activity observed on a monitor or ECG in absence of detectable cardiac activity. A preterminal state preceding asystole, representing the electrical activity of a hypoxic and acidotic myocardium Reversible causes of Electrochemical dissociation- 4Hs and 4Ts. 4Hs - severe hypovolemia, hypoxia, hypothermia and hyperkalaemia 4Ts - tension pneumothorax, toxins and drugs, pericardial tamponade, and pulmonary thromboembolism. 43

44. Post Arrest care Continuous BP monitoring- to maintain blood pressure above the 5th centile. Correction of hypoxia and hyperoxia. O2 saturation between 94 % to 99 % Body temperature- Normothermia (36-37.5°C) or Therapeutic hypothermia ( 32-34°C) Fluid therapy - initial fluid bolus of 20 mL/kg is recommended in shock . Volume expansion is best achieved with Plasmalyte , Ringer lactate or normal saline. Monitor and Treat Arrythmias 44

45. PALS Guidelines for Bradycardia General Guide for Pediatric Bradycardia: 0-3 years old: HR < 100 bpm 3-9 years old: HR < 60 bpm 9-16 years old: HR < 50 bpm Causes- Hypoxemia, hypothermia, hypotension, hypoglycemia Excessive vagal stimulation, raised intracranial pressure or brainstem compression, Sinus bradycardia, AV blocks may cause bradycardia 45

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47. References Ghai Essential Paediatrics https://acls-algorithms.com/pediatric-advanced-life-support/pals-bradycardia-algorithm/ https://cpr.heart.org/-/media/cpr-files/cpr-guidelines-files/algorithms/algorithmbls_ped_2_rescuers_200624.pdf https://www.ncbi.nlm.nih.gov/books/NBK563231 47

48. Thank you 48