MANAGEMENT OF PEDIATRIC CARDIAC ARREST

MANAGEMENT OF PEDIATRIC CARDIAC ARREST

By Dr. Kheng Chheng

I- INTRODUCTION

In contrast to adults, cardiac arrest in infants and children does not usually result from a primary cardiac cause. More often it is the terminal result of progressive respiratory failure or shock, also called an asphyxia arrest

Cardiac arrest has occurred when there is no effective cardiac output. Before any specific treatment is started, effective basic life support must be established (see BLS guideline).

II- SEQUENCE OF ACTIONS IN CARDIAC ARREST

1. Start basic life support (see pediatric BLS guideline)


2. Oxygenate, ventilate, and start chest compression:

      Provide ventilation initially by bag and mask with high oxygen concentration. Ensure  patent airway by using an airway maneuver as described in the pediatric basic life support guideline.

     Ensure that ventilation remains effective when continuous chest compressions are  started.

       If airway cannot be well secured, intubation should be performed. This will both control the airway and enable chest compression to be given continuously, thus improving coronary perfusion pressure.

      Once the child has been intubated and compressions are uninterrupted, use a       ventilation rate of approximately 12 per minute.

3. Attach to monitor or defibrillator: assess the cardiac rhythm to identify shockable or non-shockable rhythm.

         i. Non-shockable rhythm (Asystole/PEA): more common finding in children.

             a) Perform continuous CPR:
                  Continue to ventilate with high-concentration oxygen.
                  15 compressions to 2 ventilations (15:2)
                  Use a compression rate of 100/min
                  Once the child has been intubated and compressions are uninterrupted use a ventilation rate of approximately 12/min

             b) Give Adrenaline
                 If venous or intraosseous (IO) access has been established, give Adrenaline 0.1 ml/kg of 1:10 000 solution
                 If circulatory access is not present, and cannot be obtained quickly, but the patient has a tracheal tube in place, consider giving Adrenaline 1 ml/kg of 1:10 000 solution via the tracheal tube.
                 Give Adrenaline every 3 minutes

            c) Continue CPR, only pausing briefly every 2 min to check for rhythm change

            d) Consider and correct reversible causes (4H 4T):
                Hypoxia
                Hypervolemia
                Hyper/hypokalemia
                Hypothermia
                Tension pneumothorax
                Toxic/therapeutic disturbance
                Tamponade (cardiac)
                Thromboembolism

            e) Consider the use of other medications such as alkalizing agents (Sodium Bicarbonate 1mmol/kg) slow iv in case of:
                prolonged resuscitation
                known or suspected hyperkaliemia
                Tricyclics antidepressant overdose

Note that:
               Bicarbonate must not be given in the same intravenous line as calcium because precipitation will occur.
               Sodium bicarbonate inactivates Adrenaline and dopamine, so the line must be flushed with saline if these drugs are subsequently given.

               Bicarbonate must not given by intratracheal route

        ii. Shockable rhythm (VF/VT): less common in pediatric cardiac arrest.

          a) Continue CPR until a defibrillator is available.
          b) Defibrillate the heart:
               Give 1 shock of 4J/kg

          c) Resume CPR:
               Without reassessing the rhythm or feeling for a pulse, resume CPR immediately, starting with chest compression.
               Continue CPR for 2 min, then pause briefly to check the monitor:
                       If still VF/VT, give a second shock of 4J/kg
                       Without reassessing the rhythm or feeling for a pulse, resume CPR immediately, starting with chest compression. Consider about reversible causes (4H 4T).
               Give Adrenaline 0.1 ml/kg (1:10 000) iv or IO after the 2nd shock, once chest compressions have resumed.
               Repeat Adrenaline every 3 minutes until ROSC.
               Give Amiodarone 5 mg/kg after 3rd shock and one more time after the 5th shock if still in a shockable rhythm.
               Continue giving shocks every 2 min, continuing compressions and minimizing the breaks in chest compression as much as possible.
               Note: After each 2 min of uninterrupted CPR, pause briefly to assess the rhythm.
               If still VF/VT: Continue CPR with the shockable (VF/VT) sequence.
               If asystole: Continue CPR and switch to the non-shockable (asystole or PEA) sequence as above.
               If organized electrical activity is seen, check for signs of life and a pulse:
                          If there is ROSC, continue post-resuscitation care.
                          If there is no pulse (or a pulse rate of < 60/min), and there are no other signs of life, continue CPR and continue as for the non-shockable sequence above.

III- WHEN TO STOP RESUSCITATION

Resuscitation efforts are unlikely to be successful and cessation can be considered if there is no return of spontaneous circulation at any time with up to 20 minutes of cumulative life support and in the absence of recurring or refractory VF/VT. Exceptions are patients with a history of poisoning or hypothermia in whom prolonged attempts may occasionally be successful.

IV- PARENTAL PRESENCE

Family members should be offered the opportunity to be present during the resuscitation of their child. The presence of parents at the child’s side during resuscitation enables them to gain realistic understanding of the efforts made to save their child and they may show less anxiety and depression afterward.

Important points:
 A staff member must be with the parents to support and explain the events to them.

 The team leader, not the parents, decides when it is appropriate to stop the resuscitation. If the presence of the parents is impeding the progress of the resuscitation, they should be asked to leave.




REFERENCES
1. Advanced Pediatric Life Support: The Practical Approach 5th Edition (April 2011) by Advanced Life Support Group.
2. Pediatric Advanced Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
3. Pediatric Advanced Life Support: 2010 Resuscitation Council, UK
4. European Resuscitation Council Guidelines for Resuscitation 2010 Section 6. Pediatric Life Support

Thanks