Resuscitation in children

medical studies

1. Dr André Mwana N goie Resuscitation in children

2. Definition of resuscitation Is : an act or process of resuscitating someone or something: A medical : the act or an instance of reviving someone from apparent death or from unconsciousness . is : the act or an instance of restoring someone or something to an active or flourishing state

3. Age Definitions: What Defines an Infant, Child, and Adult? The age of the victim is currently the primary characteristic that guides decisions for application of resuscitation sequences and techniques . Discrimination on the basis of age alone is inadequate . Further, any single age delineation of the “child” versus the “adult” is arbitrary because there is no single parameter that separates the infant from the child from the adult. The following factors should be considered.

4. cont There is consensus that the age cut-off for infants should be at approximately 1 year. In general, cardiac compression can be accomplished using one hand for victims up to the age of approximately 8 years . However, variability in the size of the victim or the size and strength of the rescuer can require use of the two-handed “adult” compression technique for cardiac compression.

5. cont For instance, the chronically ill infant may be sufficiently small to enable compression using circular hand technique, and a 6- or 7-year-old may be too large for the one-hand compression technique. A small rescuer may need to use two hands to effectively compress the chest of a child victim.

6. cont The resuscitation of children differs from that of adults in a number of important ways. For example, the most common cause of primary cardiac arrest in adults is coronary artery disease, whereas respiratory failure and shock are more common causes among children and infants; hypoxemia, hypercapnia , and acidosis subsequently lead to bradycardia , hypotension, and secondary cardiac arrest in children.

7. cont After resuscitation, survival to discharge may be greater among children and adolescents than in infants or adults . The survival rate without devastating neurologic sequelae in children varies by age, ranging from 1% to 2% in infants and young children to 11% for adolescents in whom a shockable rhythm is more common; survival rates as high as 30% have been seen after sudden out-of-hospital witnessed ventricular fibrillation.

8. cont The best chance for a good outcome is to recognize impending respiratory failure or shock and intervene to prevent the development of cardiopulmonary arrest. Age-related differences are important considerations when treating children . An appropriate drug dose for a 6-month-old infant may be excessive for a 1-month-old newborn but inadequate for a 5-year-old child. Other aspects of resuscitation, such as endotracheal tube size, tidal volumes, cardiac compression rates, and respiratory rates, vary with a child's age.

9. cont Equipment selection and medication dosing are based on age and body weight. Valuable time can be lost in weight estimation, dosage calculations, and equipment selection. Emergency personnel must be able to find the proper equipment rapidly. Equipment can be stored on shelves or in drawers labeled by age and weight, or a system of color codes can be used in which color-coded shelves, carts, or equipment organizers correspond to specific length categories as illustrated in

10. The Physiology of Cardiopulmonary Resuscitation Outcomes after cardiac arrest remain poor more than a half a century after closed chest cardiopulmonary resuscitation (CPR) was first described. This review article is focused on recent insights into the physiology of blood flow to the heart and brain during CPR. Over the past 20 years, a greater understanding of heart–brain–lung interactions has resulted in novel resuscitation methods and technologies that significantly improve outcomes from cardiac arrest. This article highlights the importance of attention to CPR quality, recent approaches to regulate

11. cont intrathoracic pressure to improve cerebral and systemic perfusion, and ongoing research related to the ways to mitigate reperfusion injury during CPR. Taken together, these new approaches in adult and pediatric patients provide an innovative, physiologically based road map to increase survival and quality of life after cardiac arrest.

12. BASIC LIFE SUPPORT The American Heart Association Guidelines use the following age group delineations: newborn, 1 month or less in age; infant, 1 month to 1 year of age; and child, 1 year of age to the onset of puberty. As in adults, the priorities of resuscitation are airway, oxygenation, ventilation, and shock management.

13. Cont An important change in the 2010 American Heart Association Guidelines is the order of basic life support assessment . Instead of using ABC (airway, breathing, circulation) as a mnemonic, the American Heart Association recommends CAB, emphasizing the importance of chest compressions beginning as rapidly as possible

14. cont Reasons for this change in approach include the following: starting with chest compressions reduces the delay to the start of the first compression; all rescuers can start chest compressions immediately, because airway management requires manipulation and positioning of the patient; and simplifying the basic life support resuscitation approach is consistent for ...

15. cont Ideally the sequence of resuscitation should be determined by the most likely cause of the arrest. In the newly born infant this will be most likely related to respiratory failure . In the older infant and child it may be related to progression of respiratory failure, shock, or neurological dysfunction.

16. cont In general, pediatric pre hospital arrest has been characterized as hypoxic, hypercarbic arrest with respiratory arrest preceding asystolic cardiac arrest. Therefore , a focus on early ventilation and early CPR (rather than early emergency medical services [EMS] activation and/or defibrillation) appears to be warranted.

17. cont Early effective oxygenation and ventilation must be established as quickly as possible . Primary dysrhythmic cardiac arrest may occur and should particularly be considered in patients with underlying cardiac disease or history consistent with myocarditis.

18. Resuscitation Sequence/EMS Activation Local response intervals, dispatcher training, and EMS protocols may dictate the sequence of early life support interventions . In addition, the sequence of resuscitation actions must consider the most likely causes of arrest in the victim.

19. cont Respiratory failure and/or trauma may be the primary etiologies of cardiopulmonary arrest in victims aged 40 years or younger,68 with a relatively low incidence of primary ventricular fibrillation (VF). One critical issue in determining the sequence of interventions is whether the primary cause of arrest is due to a cardiac or respiratory etiology. The probability of successful resuscitation based on that etiology is another important unresolved resuscitation question

20. Determination of Responsiveness Unresponsiveness mandates assessment and support of airway and breathing. Infants and patients with suspected cervical spinal injury should not be shaken to assess responsiveness.

21. Airway Consensus continues to support use of the head tilt–chin lift or the jaw thrust (the jaw thrust especially when cervical spine instability or neck trauma is suspected) to open the airway . Other maneuvers, such as the tongue–jaw lift, may be considered if initial ventilation is unsuccessful despite repositioning of the head. The most common cause of airway obstruction in the unconscious pediatric victim is the tongue.

22. cont Although the use of a tongue–jaw lift and visual mouth inspection prior to ventilation of any unconscious infant may be considered if foreign body airway obstruction is strongly suspected, there are no data to support the delay of attempted ventilation in all victims.

23. cont Although the use of a tongue–jaw lift and visual mouth inspection prior to ventilation of any unconscious infant may be considered if foreign body airway obstruction is strongly suspected, there are no data to support the delay of attempted ventilation in all victims. CPR.

24. Breathing There is general consensus regarding the technique for rescue breathing for infants and children . The current recommendations for initial number of attempted breaths, however, vary from 2 to 5. There are no data to support any specific number of initial breaths. There was agreement that a minimum of 2 breaths be attempted . The rationale for attempting to deliver more than 2 initial ventilations includes the need to provide effective ventilation for pediatric victims based upon the likely hypoxic ,

25. cont hypercarbic etiology of arrest, suspected inability of the lay rescuer to establish effective ventilation with only 2 attempts, and clinical impressions that more than 2 breaths may be required to improve oxygenation and restore effective heart rate in the apneic, bradycardic infant.

26. cont Initial breaths should be delivered slowly, over 1.0 to 1.5 seconds, with a force sufficient to make the chest clearly rise. Care and attention to abdominal distention caused by insufflation of gas into the stomach should be recognized and avoided.

27. cont Consideration of the optimal method for delivering breaths to infants supports the current recommendation of mouth to mouth-and-nose ventilation for infants up to 1 year old. However , mouth-to-nose ventilation may be adequate in this population .

28. cont Consensus continues to support the emphasis on the provision of more ventilation (breaths per minute) for infants and children and more compressions per minute for adult victims . Current recommended ventilation rates are based on normal ventilatory rates for age, the need for coordination with chest compression, and the perceived practical ability of the rescuer to provide them . Ideal ventilation frequency during CPR is unknown.

29. Circulation There is a lack of specific pediatric data on the accuracy and time course for determining pulselessness of victims who are apneic and unresponsive. Several reports have documented the inability of lay rescuers and healthcare providers to reliably locate or count the pulse of the victim. The utility of the pulse check during pediatric CPR has been questioned.

30. cont Furthermore, the pulse check is difficult to teach to laypersons. It seems reasonable for healthcare providers to search for a pulse because it may be palpated by trained personnel, does not require sophisticated equipment, and there is no better alternative . However, resuscitative interventions should not be delayed beyond 10 seconds if a pulse is not confidently detected.

31. Chest Compression When to Start There is consensus that all pulseless patients and patients with heart rates too low to adequately perfuse vital organs warrant chest compressions. Because cardiac output in infancy and childhood is largely heart-rate dependent, profound bradycardia is usually considered an indication for cardiac compressions.

32. cont Location of Compression There is consensus for compression over the lower half of the sternum, taking care to avoid compression of the xiphoid. Depth Consensus supports recommendation of relative rather than absolute depth of compression ( eg , compress approximately one third of the depth of the chest rather than compress 4 to 5 cm). Effectiveness of compression should be assessed by the healthcare provider.

33. cont Methods of assessment include palpation of pulses, evaluation of end-tidal carbon dioxide, and analysis of arterial pressure waveform (if intra-arterial monitoring is in place ). Although it is recognized that pulses palpated during chest compression may reflect venous rather than arterial blood flow during CPR,36 pulse detection during CPR for healthcare providers remains the most universally practical “quick assessment” of chest compression efficacy.

34. cont Rate Consensus supports a rate of approximately 100 compressions per minute. With interposed ventilations, this will result in the actual delivery of <100 compressions to the patient in a 1-minute period.

35. Compression-to-Ventilation Ratio Ideal compression-ventilation ratios for infants and children are unknown. A single, universal compression-ventilation ratio for all ages and both BLS ( basics life support) and ALS interventions would be desirable from an educational standpoint. There currently is consensus among resuscitation councils for a compression-ventilation ratio of 3:1 for newborns and 5:1 for infants and children. The justification for this difference from adult guidelines includes the fact that respiratory problems are the most common etiology of pediatric arrest and therefore ventilation should be

36. cont emphasized, and physiological respiratory rates of infants and children are faster than those of adults . Although the actual number of delivered interventions is dependent on the amount of time the rescuer spends opening the airway and the effect of frequent airway repositioning on rescuer fatigue, there is insufficient evidence to justify changing the current recommendations for educational convenience at this time.

37. cont External chest compression must always be accompanied by rescue breathing in children. At the end of every compression cycle a rescue breath should be given . Interposition of compressions and ventilations is recommended to avoid simultaneous compression/ventilation.

38. Activation of the EMS System Ideally the sequence of resuscitation is determined by the etiology of the arrest . In pediatric arrest, dysrhythmias requiring defibrillation are relatively uncommon, and some data suggest that early bystander CPR is associated with improved survival.

39. cont However, it is impractical to teach the lay public different resuscitation sequences based on arrest etiology. The consensus recommendation is “phone fast” rather than “phone first” for young victims of cardiac arrest, but the appropriate age cut-off for this recommendation remains to be determined. Local EMS response intervals and the availability of dispatcher-guided CPR may override these considerations.

40. Recovery Position There is consensus that an ideal recovery position considers the following: etiology of the arrest and stability of the C-spine, risk for aspiration, attention to pressure points, ability to monitor adequacy of ventilation and perfusion, maintenance of a patent airway, and access to the patient for interventions.

41. Relief of Foreign-Body Airway Obstruction There are three suggested maneuvers to remove impacted foreign bodies: 1 back blows, chest thrusts, and abdominal thrusts . The sequences differ slightly among resuscitation councils, but published data do not convincingly support one technique sequence over another.

42. cont There is consensus that the lack of protection of the upper abdominal organs by the rib cage renders infants and newborns at risk for iatrogenic trauma from abdominal thrusts; therefore, abdominal thrusts are not recommended in infants and newborns . An additional practical consideration is that back blows should be delivered with the victim positioned head down, which may be physically difficult in older children. Suctioning is recommended for newborns rather than back blows or abdominal thrusts, which are potentially harmful to this age group.

43. cont IMMEDIATE MANAGEMENT – BASIC LIFE SUPPORT – CARDIOPULMONARY RESUSCITATION (CPR) Airway Clear the airway using the most appropriate measures: • Suction, in the case of vomitus, secretions or blood. • Manual clearance. Under direct vision insert your fingers into the pharynx and remove food, dentures or foreign bodies. Avoid “blind” finger sweeps. • Posture. Extend the head and lift the chin and jaws. • Insert a Guedel airway.

44. breathing Breathing Mouth-to-mouth respiration. Do this if there is no apparatus available to ventilate the patient, e.g. if the cardiac arrest occurs outside the hospital. Clear the airway as explained above. Extend the head and lift the jaw up. Kneel beside the patient's head. Take a deep breath. Pinch the patient's nose with your free hand. Apply your lips to the patient's mouth to provide a seal. Blow into the patient's chest. Note the rise and fall of the chest. Do this 12-15 times per minute. Allow approximately 1-2 seconds for inspiration and 3 seconds for expiration. In infants, mouth to nose breathing works well. Give only gentle puffs to avoid lung rupture.

45. disadv Disadvantages:  It is not a very pleasant procedure to carry out.  The patient is ventilated with expired gases which contain only 16% oxygen.  The rescuer tends to get "dizzy" after a few minutes because of low carbon dioxide. Mouth-to-mouth resuscitation cannot be carried out for long.

46. ventillation Ventilation using a bag, valve and mask. A non-rebreathing valve, self– inflating bag and mask may be used. This enables the patient to be ventilated more effectively. • Clear the airway completely, as described previously. • Make sure the chest moves every time the bag is squeezed. • An air-tight seal between the face and the mask is necessary to inflate the lungs. A self- inflating bag fills during expiration regardless of the seal and a one-way valve allows ventilation of the patient with 100% oxygen. A flow rate of 10L/min is necessary to remove carbon dioxide. (Endotracheal intubation is not an emergency measure. Ventilation can be quite effective using a mask and bag provided the rules are followed. Intubation can be postponed until someone experienced in intubation is available).

47. Vascular Access Vascular access for the arrested victim is needed for the delivery of resuscitative fluids and medications. However , establishment of adequate ventilation with BLS support of circulation is the first priority. The intravenous or intra osseous route for the delivery of medications is the preferred route , but the endotracheal route can be used in circumstances when vascular access is delayed. It is likely that drug delivery following endotracheal epinephrine administration may be lower than that delivered by the intravascular approach. Drug doses may need to be

48. cont increased accordingly, with attention to drug concentration, volume of vehicle, and delivery technique . There is consensus that the tibial intra osseous route is useful for vascular access, particularly for victims up to the age of 6 years . In the newly born, the umbilical vein is easy to find and frequently used for urgent vascular access.

49. Complications From CPR Reported complications from appropriately applied resuscitative techniques are rare in infants and children. The prevalence of significant adverse effects (rib fractures, pneumothorax, pneumoperitoneum , hemorrhage, retinal hemorrhages, from properly performed CPR appears to be much lower in children than in adults. In the most recent study,59 despite prolonged CPR by rescuers with variable resuscitation training skill levels, medically significant complications were documented in only 3% of patients. Therefore , there is consensus that chest compressions should be provided for children if the pulse is absent or critically slow or if the rescuer is uncertain if a pulse is present.

50. cont Efforts to resuscitate patients after cardiac arrest have preoccupied scientists and clinicians for decades.1,2 However, the majority of patients are never successfully resuscitated.1,3–5 Based on the published reports, the overall survival rates after cardiac arrest are grim, ranging from 1% to <20% for outof -hospital nontraumatic cardiac arrest and <40% for inhospital cardiac arrest.1,6 Of these, 10% to 50% have poor neurological function

51. cont 6 Of these, 10% to 50% have poor neurological function.1,7 Surprisingly, the physiologic principles that underlie the life-saving process of cardiopulmonary resuscitation (CPR) remain only partially understood and are often controversial.1,8 Some would argue that current approaches to cardiac arrest are fatally flawed, and that is why the overall survival rates have hovered around 7% for out-of-hospital cardiac arrest and <30% for in-hospital cardiac arrest nationwide for a half a century.9

52. cont Advantages • ECM can be performed by anyone • No equipment is required • No risk of infection • Ventilation is not interfered with. Dangers • Fractured ribs • Pneumothorax • Injury to liver Internal Cardiac Massage (ICM) This approach is rarely necessary but may be indicated: • When cardiac arrest occurs intra operatively, the chest or abdomen is already opened and the surgeon is present. • In trauma arrests, e.g. penetrating chest wounds, severe chest crush injuries, haemothorax . • If ECM is ineffective because of underlying pathology, e.g. pericardial tamponade , severe scoliosis

53. cont Mouth to mouth respiration and external cardiac massage (oval drawn on the sternum shows where pressure should be applied) Cardiac massage External cardiac massage (ECM) The heart is compressed between the sternum and the vertebral column. Technique The patient must lie on a rigid surface. The operator should stand or kneel beside the patient so that his shoulders are directly in line with his hands when placed on the patient's sternum.

54. cont FACTORS PRECIPITATING CARDIAC ARREST Hypoxia: inadequate inspired oxygen. Hypercarbia : hypoventilation from any cause, respiratory obstruction, severe lung disease, etc. Myocardial infarction Pulmonary embolism Haemorrhage leading to hypovolaemia .

55. drugs Drugs • Anaesthetic drugs may lead to cardiac arrest by causing:  Myocardial depression  Hypotension, due to peripheral venous pooling  Hypoxia or hypercarbia (which may be caused by central respiratory depressants or neuromuscular blocking agents)  Vagotonic action  Sympathetic stimulation. • Non- anaesthetic drugs  Large doses of digitalis or procainamide  Anaphylaxis to IV contrast used in X-ray studies. Vagal reflex mechanism: stimulation of organs e.g. dilatation of rectum, cervix, uterus, etc. in an awake or lightly anaesthetised patient.

56. cont Electric shock Electrolyte imbalance, especially potassium (K+) imbalance. Tension pneumothorax, cardiac tamponade Drowning Hypothermia Air embolism