Pediatric Resuscitation Russian Field Hospital Nias Indonesia 405

Pediatric Resuscitation Russian Field Hospital Nias, Indonesia 4/05

Lecture Objectives The goal of this module: • Perform rapid cardiopulmonary assessment • Recognize signs of respiratory distress, respiratory failure, and shock

Progression of Respiratory Failure and Shock Various Conditions Respiratory failure Cardiopulmonary arrest Shock

Comparison of Survival 100% Survival rate 50% 0% Respiratory arrest Cardiopulmonary arrest

Rapid Cardiopulmonary Assessment 1. Evaluation of general appearance (mental status, tone, responsiveness) 2. Physical examination of airway, breathing, and circulation (ABCs) 3. Classification of physiologic status Rapid cardiopulmonary assessment should be accomplished in less than 30 seconds!

Pediatric Assessment Triangle

General Appearance

Evaluation of General Appearance • General color (“looks good” vs “looks bad”) • Mental status, responsiveness • Activity, movement, muscle tone • Age-appropriate response

Breathing Evaluation

Physical Examination: Airway • Clear • Maintainable • Not maintainable without intubation

Evaluating Respirations • Respiratory rate • Respiratory effort (work of breathing) • Breath sounds/air entry/tidal volume — STRIDOR (inspiration) — WHEEZE (expiration) • Skin color and pulse oximetry

Rapid Cardiopulmonary Assessment: Classification of Status • Respiratory distress: Increased work of breathing • Respiratory failure: Inadequate oxygenation or ventilation

Cardiovascular Assessment

Cardiovascular Variables Affecting Systemic Perfusion Preload Cardiac output Blood pressure Systemic vascular resistance Stroke volume Myocardial contractility Heart rate Afterload

Response to Shock Vascular resistance Percent of control 140 100 60 20 Cardiac output Compensated shock Blood pressure Decompensated shock

Decompensated Shock Compensatory mechanisms fail to maintain adequate cardiac output and blood pressure

Physical Examination: Circulation • Cardiovascular function — Heart rate — Pulses, capillary refill — Blood pressure • End-organ function/perfusion — Brain — Skin — Kidneys

Physical Examination: Circulation Typical Assessment Order: — Observe mental status — Feel for heart rate, pulse quality, skin temperature, capillary refill — Measure blood pressure — (Measure urine output later)

Physical Examination: Circulation Evaluation of responsiveness • A — Awake • V — responsive to Voice • P — responsive to Pain • U — Unresponsive

Heart Rates in Children Infant 85 220 300 Normal Compensating? SVT 60 Child 180 200 Normal Compensating? SVT

Physical Examination: Circulation • • • Evaluation of skin perfusion Temperature of extremities Capillary refill Color — Pink — Pale — Blue — Mottled

Palpation of Central and Distal Pulses

Capillary Refill Prolonged capillary refill (10 seconds) in a 3 -month-old with shock

Physical Examination: Circulation Estimate of Minimum Systolic Blood Pressure Age Minimum systolic blood pressure (5 th percentile) 0 to 1 month 60 mm Hg >1 month to 1 year 70 mm Hg 1 to 10 years of age 70 mm Hg + (2 age in years) >10 years of age 90 mm Hg

Minimum Systolic BP by age (5% of the range of normal)

Physical Examination: Circulation • Cardiovascular function — Heart rate — Pulses, capillary refill — Blood pressure • End-organ function/perfusion — Brain (Mental Status) — Skin (Capillary Refill Time) — Kidneys

Physical Examination: Circulation Evaluation of End-Organ Perfusion Kidneys • Urine Output — Normal: 1 to 2 m. L/kg per hour — Initial measurement of urine in bladder not helpful

Classification of Physiologic Status: Shock Early signs (compensated) — Increased heart rate — Poor systemic perfusion Late signs (decompensated) — Weak central pulses — Altered mental status — Hypotension

Septic Shock Is Different • Cardiac output may be variable • Perfusion may be high, normal, or low • Early signs of sepsis/septic shock include — Fever or hypothermia — Tachycardia and tachypnea — Leukocytosis, leukopenia, or increased bands

Special Situations: Trauma • Airway and Breathing problems are more common • • than Circulatory shock Use the ABC or assessment triangle approach plus — Airway + cervical spine immobilization — Breathing + pneumothorax management — Circulation + control of bleeding Identify and treat life-threatening injuries

Special Situations: Trauma Spinal Precautions? Pneumothorax? Bleeding control?

Special Situations: Toxicology • Airway obstruction, Breathing depression, and • • • Circulatory dysfunction may be present Use the ABC and assessment triangle approach, plus watch for — Airway: reduced airway protective mechanisms — Breathing: respiratory depression — Circulation: arrhythmias, hypotension, coronary ischemia Identify and treat reversible complications Administer antidotes

Special Situations: Toxicology Is the Patient Awake enough to maintain airway? Respiratory Effort and Rate? Arrythmias? Vascular Tone? Ischemia?

Classification of Physiologic Status: Cardiopulmonary Failure Cardiopulmonary failure produces signs of respiratory failure and shock: • Agonal respirations • Bradycardia • Cyanosis and poor perfusion

Classification of Cardiopulmonary Physiologic Status • Stable • Respiratory distress • Respiratory failure • Shock — Compensated — Decompensated • Cardiopulmonary failure

Rapid Cardiopulmonary Assessment: Summary • Evaluate general appearance • Assess ABCs • Classify physiologic status — Respiratory distress — Respiratory failure — Compensated shock — Decompensated shock — Cardiopulmonary failure • Begin management: support ABCs

Checkpoint • Rapidly perform assessment • Use the information to prioritize your resuscitation efforts • Remember the Pediatric Assessment Triangle as we practice cases

Rapid Cardiopulmonary Assessment Application A 3 -week-old infant arrives in the ED: • CC: Severe vomiting and diarrhea • Physical exam: Gasping respirations, bradycardia, cyanosis, and poor perfusion What ar the results of your RAPID ASSESSMENT? What is the PHYSIOLOGIC STATUS? What are the emergency interventions?

What is this Child’s Assessment?

Rapid Cardiopulmonary Assessment Application Case Progression • Response to intubation and ventilation with 100% oxygen: — Heart rate: 180 bpm — Blood pressure: 50 mm Hg systolic — Pink centrally, cyanotic peripherally — No peripheral pulses — No response to painful stimuli What is happening? What is next treatment step?

Rapid Cardiopulmonary Assessment Application: Response to Therapy • Vital signs improved

Pediatric Intubation Andrew Garrett, MD Division of Transport and Emergency Medicine

Goals • Review of some basic concepts of pediatric airway management • Introduce/review RSI in a stress-free environment • Have a chance to practice intubation skills later today

Review and Overview of Airway Management • Children at higher risk for hypoxia and respiratory failure: • Anatomic differences • Higher metabolic rate • Ambiguous symptoms of hypoxia • Head trauma is common in pediatrics • Limited practice of management skills

Airway Anatomic Differences (Extrathoracic) • Relatively larger tongue • Tongue placed superiorly (C 3 -4) • Angle of epiglottis angled away from larynx • Vocal folds can trap ET tube • Narrowest area at cricoid vs. glottis

Anatomy epiglottis True VC False VC cartilage trachea esophagus

Cricoid Cartilage

Airway Anatomic Differences (Intrathoracic) • Compliance of conducting airways at high flow rates • Fewer, smaller alveoli (< 8 yrs) • Smaller FRC (functional reserve) • Decreased diffusion • Metabolic Rate • 2 x adult oxygen consumption rate • Shorter tolerance of apnea

Can your patient be managed without intubation? • The A of the ABC’s • Chin lift • Jaw thrust • Suction • Oropharyngeal airway • Nasopharyngeal airway

Intubation Overview • Positioning • Choose the tube size • Choose the blade size and type • Insertion distance • Sedation • Paralysis • Equipment

Positioning the Patient • Alignment of the 3 axis • Oropharynx, Pharynx, Trachea P O T

Positioning thoughts • Don’t rush this part… • Be careful of cervical spine injury • Infant • Large occiput, gentle lift of shoulder • Use a folded towel • Adolescents and Adults • Extension of head on a towel support

Proper alignment for intubation (almost…)

Tube Size • Cuffed vs. Uncuffed (age cutoff ~8 yrs) • Remember pediatric airway anatomy • ( Age + 4 ) / 4 for > 1 year old • 3. 5 for newborn • 2. 5 for preemie (< 28 weeks) • 3 for in between

Choose your blade • Macintosh • Into the vallecula, lift the epiglottis from its foundation to visualize the trachea • Miller • Past the epiglottis, directly lift the epiglottis with traction to visualize

Macintosh vs. Miller Preemie 0 Neonate 0 <2 yrs 1 2 -6 yrs 1. 5 2 6 -12 yrs 2 3 >12 yrs 3

Insertion Distance • Guidelines: • < 4 kg • >4 kg weight (kg) + 6 * 3 x ET tube size • Distance to mandibular ridge • * usually a slightly high position

Confirmation of Placement • Auscultation • Capnography • Radiography • Visualization

The Technique of R. S. I. • Keep it simple, not stressful • In a nutshell: • What drug has been proven to increase the chance of successfully performing endotracheal intubation?

The Technique of R. S. I. • Keep it simple, not stressful • In a nutshell: • What drug has been proven to increase the chance of successfully performing endotracheal intubation? • A paralytic agent such as succinylcholine

The Technique of R. S. I. • Therefore, all RSI consists of is using a paralytic to increase the chance of being successful

The Technique of R. S. I. • Therefore, all RSI consists of is using a paralytic to increase the chance of being successful • The rest of the drugs are because we’re nice (but that’s optional!) – SEDATIVE

The Technique of R. S. I. • Therefore, all RSI consists of is using a paralytic to increase the chance of being successful • The rest of the drugs are because we’re nice (but that’s optional!) – SEDATIVE • Etomidate, benzos, propofol, etc. • Serves to make it a more pleasant experience • Don’t need to duplicate efforts

The Technique of R. S. I. • Therefore, all RSI consists of is using a paralytic to increase the chance of being successful • Or because we think they should help prevent a side effect

The Technique of R. S. I. • Therefore, all RSI consists of is using a paralytic to increase the chance of being successful • Or because we think they should help prevent a side effect – ATROPINE

The Technique of R. S. I. • Therefore, all RSI consists of is using a paralytic to increase the chance of being successful • Or because we think they should help prevent a side effect – ATROPINE • Dryer work environment • Heart rate stabilization

The Technique of R. S. I. • Therefore, all RSI consists of is using a paralytic to increase the chance of being successful • Or because we think they should help prevent a side effect – LIDOCAINE *

The Technique of R. S. I. • Therefore, all RSI consists of is using a paralytic to increase the chance of being successful • Or because we think they should help prevent a side effect – LIDOCAINE * • A bit questionable • May help prevent ICP increase

The Technique of R. S. I. • Don’t forget the basics though: • BVM skills • Positioning • Preparedness • Don’t rush, RSI is not a rescue airway technique, use BVM until you are ready

RSI: Rapid Sequence Intubation • “full stomach rule” in urgent intubations • Preoxygenation 1 -5 minutes with 100% • Utilize Sellick maneuver • Choreography of medications • Confidence of providers to adequately ventilate after medications are given. • Rule out airway compression from mass effect if paralysis is being considered.

Sedation • Fentanyl • Midazolam • Diazepam • Ketamine* 1 -2 mcg/kg IV 0. 1 mg/kg IV 0. 5 -2 mg/kg IV • * can be tripled for IM dosing

Paralysis • • Succinylcholine * • 5 to 10 min Rocuronium • mg/kg IV 0. 1 mg/kg IV ~1 -2 hours Vecuronium • 1 ~30 -45 minutes Pancuronium • 1 -2 mg/kg IV 0. 1 mg/kg IV ~30 minutes • * can be doubled for IM dosing

Plans B and C? • After deciding to undertake RSI • Make sure you have a backup/failed airway plan –LMA –Combitube –Fiberoptic, Bougie, Digital • The final option –Surgical airway • Percutaneous or Open

Equipment and Technique Take a moment to double check your equipment and medications before you start

The flow of things • Examination (esp. neuro status, etc. ) • Equipment checklist • Preoxygenate • Sedate, Paralyze, Intubate, Secure • Confirm placement • Continuous evaluation of placement

Tips from the Field: • Know the size and depth of the tube • Confirm placement with every move • Tape tape! • When in doubt, take it out and bag! • Don’t forget the CXR • Check your battery and bulb

Ready to Intubate? Ideal Reality! circumstances!

Circulation • After the RAPID ASSESSMENT is done • After BREATHING interventions are started • Priorities • STOP major bleeding • Get IV access – IV, IO, umbilical vein – We will review techniques

Circulation • Priorities • IV Fluids – Preload, afterload – Saline 20 m. L per kg – Give it fast – Repeat assessments and vital signs – Repeat if necessary – Consider blood?

IV Fluids Preload Cardiac output Blood pressure Systemic vascular resistance Stroke volume Myocardial contractility Heart rate Afterload

Cardiovascular Cases

Objectives • Differentiate shock from hypotension • Distinguish compensated from decompensated shock • Outline appropriate shock management • Identify and manage selected pediatric dysrhythmias

Shock and Hypotension • Shock is inadequate perfusion and oxygen delivery. • Hypotension is decreased systolic blood pressure. • Shock can occur with increased, decreased, or normal blood pressure.

Recognition of Shock Compensated: Decompensated: • Normal level of • Altered level of consciousness (ALOC) consciousness • Tachycardia • Profound tachycardia, or bradycardia • Normal or delayed perfusion • Delayed perfusion • Normal or increased BP • Hypotension

Management of Shock Interventions: • • • Open airway Provide supplemental oxygen Support ventilation Shock position Vascular access/fluid resuscitation Vasopressor support

9 -month-old infant • A 9 -month-old presents with 3 days of vomiting, diarrhea and poor oral intake.

9 -month-old infant Appearance Work of Breathing Agitated, makes eye contact No retractions or abnormal airway sounds Circulation to Skin Pale skin color

Initial Assessment • Airway - Open and maintainable • Breathing - RR 50 breaths/min, clear lungs, • • • good chest rise Circulation - HR 180 beats/min; cool, dry, pale skin; CRT 3 seconds Disability - AVPU=A Exposure - No sign of trauma, weight 8 kg

What is this child’s physiologic state? What are your treatment priorities?

• • Assessment: Compensated shock, likely due to hypovolemia with viral illness Treatment priorities: • Provide oxygen, as tolerated • Obtain IV access en route –Provide fluid resuscitation • 20 ml/kg of crystalloid, repeat as needed

• 160 ml normal saline infused • HR decreased to 140 beats/min • Patient alert and interactive, receiving second bolus on emergency department arrival

15 -month-old child • A previously healthy 15 -month-old child presents with 12 hours of fever, 1 hour of lethargy and a “purple” rash.

15 -month-old child Appearance Work of Breathing No eye contact, lies still with no spontaneous movement No retractions or abnormal airway sounds Circulation to Skin Pale skin color

Initial Assessment • • • Airway - Open Breathing - RR 60 breaths/min, poor chest rise Circulation - HR 70 beats/min; faint brachial pulse; warm skin; CRT 4 seconds; BP 50 mm Hg/palp Disability - AVPU=P Exposure - Purple rash, no sign of trauma, weight 10 kg

What is your assessment of this patient? What is her problem?

• This patient is in decompensated shock. What are your treatment and transport priorities for this patient?

Treatment Priorities • • • Begin BVM ventilation with 100% oxygen. Fluid resuscitation: • IV/IO access on scene • 20 ml/kg of crystalloid, repeat as needed en route Vasopressor therapy

Patient received 20 ml/kg (200 ml) with no change in level of consciousness, HR or BP. What are your treatment priorities now?

• Consider endotracheal intubation • Provide second 20 ml/kg fluid bolus • Vasopressor support

3 -year-old toddler • Toddler is found cyanotic and unresponsive • Child last seen 1 hour prior to discovery • Open bottle of blood pressure medicine found next to child

3 -year-old toddler Appearance No spontaneous activity; unresponsive Work of Breathing Gurgling breath sounds Circulation to Skin Cyanotic, mottled

Initial Assessment • Airway - Partial obstruction by tongue • Breathing - RR 15 breaths/min, poor air entry • Circulation - HR 30 beats/min; faint femoral • • pulse; CRT 3 seconds; BP 50/30 mm Hg Disability - AVPU=P Exposure - No sign of trauma

• The monitor shows the following rhythm. What are your treatment priorities for this patient?

Treatment Priorities • • • Open airway BVM ventilation/consider intubation Chest compressions IV/IO access on scene – Medications (epinephrine, atropine) – Possible antidote - naloxone – Fluid resuscitation Check glucose Rapid transport

• Patient’s heart rate improved to 70 beats/min with assisted ventilation. • Color, CRT and pulse quality improves. • After BVM, patient’s RR increases to 20 breaths/min, good chest rise • Rapid glucose check 100 mg/d. L

12 -month-old child • • • You arrive at the house of a 12 -month-old child. Mother states the child has a history of heart disease and has been fussy for the last 3 hours. Mother states the child weighs 10 kg.

12 -month-old child Appearance Alert but agitated Work of Breathing Mild retractions Circulation to Skin Lips and nailbeds blue

• On initial assessment, you note clear breath sounds, a RR of 60 breaths/min and a heart rate that is too rapid to count. What rhythm does the monitor show?

How can you distinguish SVT from sinus tachycardia? SVT Sinus Tachycardia

SVT versus Sinus Tachycardia SVT (Supraventricular Tachycardia) Sinus Tachycardia • Vague history of irritability, poor feeding • History of fever, vomiting/diarrhea, hemorrhage • Cardiac monitor: QRS complex narrow; R to R interval regular; no visible P waves • Cardiac monitor: QRS complex narrow; R to R interval varies; P waves present and upright • HR > 200 beats/min • HR < 220 beats/min

Treatment Priorities • • • Supplemental oxygen Obtain IV access Convert rhythm based on hemodynamic stability – Stable: vagal maneuvers or adenosine – Unstable: • IV /IO access obtained - adenosine • No IV/IO and unconscious - synchronized cardioversion

• Blow-by oxygen administered • IV started • Adenosine 0. 1 mg/kg (1 mg), given rapid IVP with 5 ml saline flush • Five seconds of asystole, followed by conversion to NSR

Conclusion • • • Cardiovascular compromise in children is often related to respiratory failure, hypovolemia, poisoning or sepsis. Management priorities for shock include airway management, oxygen and fluid resuscitation. Treat rhythm disturbances emergently only if signs of respiratory failure or shock are present.

Advanced Topics

Two Thumb–Encircling Hands Technique Preferred

Effective Bag-Mask Ventilation Is an Essential BLS Skill • • Use only the amount of force and tidal volume needed to make the chest rise Avoid excessive volume or pressure Increased inspiratory time may reduce gastric inflation Cricoid pressure may reduce gastric inflation Cricoid cartilage Occluded esophagus Cervical vertebrae

2 -Rescuer Bag-Mask Ventilation • • • One rescuer uses both hands to open the airway and maintain a tight mask-to-face seal The second rescuer compresses the manual resuscitator bag and may apply cricoid pressure if appropriate Both rescuers verify adequate chest expansion

Prehospital Tracheal Intubation vs Bag-Mask Ventilation • • Bag-mask ventilation may be as effective as intubation if transport time is short Tracheal intubation requires training and experience Confirmation of tracheal tube position strongly recommended Monitoring of quality improvement important

Complications of Prehospital Tracheal Intubation • • • Successful tracheal intubation rate: 57% Intubation attempts increased time at the scene by 2 to 3 minutes Unrecognized tube displacement or misplacement: 8% — Esophageal intubation: 2% — Unrecognized extubation: 6% — Esophageal intubation or unrecognized extubation fatal (for 14 of 15 patients) Gausche. JAMA. 2000; 283: 783.

Confirmation of Tracheal Tube Placement in Pediatric Advanced Life Support • Visualize tube through cords • Assess breath sounds, chest rise bilaterally • Secondary confirmation: — Oxygenation (oximetry) — Exhaled CO 2 (capnography)

Tube Confirmation • No single confirmation device or examination • • • technique is 100% reliable Detection of exhaled CO 2 is reliable in patients weighing >2 kg with a heart rate Exhaled CO 2 can be helpful in cardiac arrest Confirmation of tube position is particularly important after intubation and after any patient movement

Insertion of the Laryngeal Mask Airway in Children • • The LMA consists of a tube with a cuffed mask at the distal end. The LMA is blindly introduced into the pharynx until resistance is met; the cuff is then inflated and ventilation assessed.

Use of Laryngeal Mask Airway in Pediatric Advanced Life Support • Extensive experience with pediatric and adult patients in the operating room • An acceptable alternative to intubation of the unresponsive patient when the healthcare provider is trained • Contraindicated if gag reflex intact • Limited data outside the operating room (Class Indeterminate)

Intraosseous Needles Are Recommended for Patients >6 Years of Age • Successful use of intraosseous needles has been documented in older children and adolescents • Devices for adult use are commercially available • “No one should die because of lack of vascular access”

Drug Therapy for Cardiac Arrest • Epinephrine: the drug of choice — Initial IV/IO dose: 0. 01 mg/kg (tracheal: 0. 1 mg/kg) — Do not routinely use high-dose (1: 1, 000) epinephrine — Good at getting heart rates to return — Poor long term outcome

Resuscitation of the Newly Born Outside the Delivery Room • • • Priority: Establish effective ventilation Provide chest compressions if heart rate is <60 bpm despite adequate ventilation with 100% oxygen for 30 seconds If meconium is observed in amniotic fluid: — Deliver head and suction pharynx (all infants) — If infant is vigorous, no direct tracheal suctioning — If respirations are depressed or absent, poor tone, or HR <100 bpm, suction trachea directly

Potentially Reversible Causes of Arrest: 4 H’s • Hypoxemia • Hypovolemia • Hypothermia • Hyper-/hypokalemia and metabolic causes (eg, hypoglycemia)

Potentially Reversible Causes of Arrest: 4 T’s • Tamponade • Tension pneumothorax • Toxins/poisons/drugs • Thromboembolism (pulmonary)