Pediatric Pulseless Arrest

Runal ShahPGY-3KDAH

Introduction•Kids are not tiny adults !!

• Hypotension (SBP) as per age▫Neonates (0-28 days) = <60▫Infants (1-12 months) = <70▫Children (1-10yr) = <70 + (2 x age in years)▫Children > 10yr = < 90

Introduction• Pulseless Arrest is the end result of

progressive▫Respiratory failure▫Shock

• Termed as HYPOXIC-ISCHEMIC ARREST.

• Respiratory failure and shock can be reversible if identified and treated early, if they progress to cardiac arrest – outcome is generally poor.

• Sudden death in young people is associated with underlying cardiac conditions.

Cardiac Arrest• Hypoxic/Asphyxial

▫Most common▫End result of tissue

hypoxia & acidosis▫Caused by

progressive respiratory failure/ shock

• Sudden Cardiac Arrest▫Less common▫Ventricular

Fibrillation/ Pulseless VT

▫Cardiac causes –HOCMAnomalous coronaryLong QT/ channelopathyMyocarditisDrug toxicityCommotio cordis

Pathway to Cardiac ArrestRespiratory

Failure Shock

Cardiopulmonary Failure

Sudden Ventricular Arrhythmia

Hypoxic / Asphyxial Arrest

Sudden Cardiac Arrest

Recognition ofCardiopulmonary Failure

• Airway – ▫Possible upper airway

obstruction• Circulation –

▫Bradycardia▫Delayed CRT (>2

seconds)▫Weak central pulses▫Absent peripheral

pulses▫Cool extremities▫Mottled or cyanotic

skin

▫Hypotension• Breathing –

▫Bradypnoea▫Irregular, ineffective

respirations• Disability –

▫Decreased level of consciousness

• Exposure – ▫Assess for obvious

bleeding▫Hypo/ Hyperthermia

Arrest Rhythms• Asystole & PEA – the most common initial

rhythms seen in both in-hospital and out-of-hospital pediatric cardiac arrest, especially in children <12 years of age.

• Survival & outcome of patients with VF or pulseless VT as initial rhythm are better.

6H’s 6T’sHypovolemia Tension Pneumothorax

Hypoxia TamponadeHydrogen ion (Acidosis) Toxins

Hypoglycemia Thrombosis (Pulmonary)

Hypo / Hyperkalemia Thrombosis (Coronary)

Hypothermia Trauma

Arrest Rhythms• Asystole

▫Cardiac standstill without discernable electrical activity.

▫Straight (flat) line on the ECG.▫Confirm clinically! Can be a loose ECG lead.

• PEA▫Any organized electrical activity with no

palpable pulse.▫Very slow PEA – “Agonal rhythm”• Low or high amplitude T waves• Prolonged PR, QT interval• AV dissociation, CHB or ventricular complexes

without P waves

Arrest Rhythms• Ventricular fibrillation (VF)

▫No organized rhythm & no coordinated contractions.

▫VF may be preceded by a brief period of VT.▫Can occur in Teens during sports activities.▫Undiagnosed cardiac abnormality/ channelopathy.

• Pulselesss Ventricular Tachycardia▫ Organized wide QRS complexes.▫ Usually of a brief duration before it deteriorates into

VF.▫ Torsades de pointes : Polymorphic VT• Prolonged QT, Dyselectrolemia, Drug toxicity

Key BLS component of PALS

Pediatric Advanced Life Support

• High quality CPR▫Adequate compression rate (100-120

compressions/min)

▫An adequate compression depth ≥ 1/3 of the AP diameter of the chest or

approximately 1 ½ inches [4 cm] in infants, approximately 2 inches [5 cm] in children

▫Allowing complete recoil of the chest after each compression,

▫Minimizing interruptions in compressions avoiding excessive ventilation

Algorithm• Epinephrine –

▫IV/IO = 0.01 mg/kg bolus (1:10,000)

▫ET = 0.1 mg/kg bolus (1:1000)

• Defibrillation –▫Initial dose = 2-4

J/kg▫Subsequent doses

= 4 J/kg or higher

(Max 10 J/kg)

New updates (2015) of PALS• In specific settings, when treating pediatric

patients with febrile illnesses, the use of restrictive volumes of isotonic crystalloid leads to improved survival.▫ This contrasts with traditional thinking that routine

aggressive volume resuscitation is beneficial.

• Routine use of atropine as a premedication for emergency tracheal intubation in non-neonates, specifically to prevent arrhythmias, is controversial.▫ Also, there are data to suggest that there is no

minimum dose required for atropine for this indication.

• If invasive arterial blood pressure monitoring is already in place, it may be used to adjust CPR to achieve specific blood pressure targets for children in cardiac arrest.

• Amiodarone or Lidocaine is an acceptable antiarrhythmic agent for shock-refractory pediatric VF and pulselessVT in children.

• Epinephrine continues to be recommended as a vasopressor in pediatric cardiac arrest.

• For pediatric patients with cardiac diagnoses and IHCA in settings with existing extracorporeal membrane oxygenation protocols, ECPR may be considered.

• Fever should be avoided when caring for comatose children with ROSC after OHCA.▫ A large randomized trial of therapeutic

hypothermia for children with OHCA showed no difference in outcomes whether a period of moderate therapeutic hypothermia (with temperature maintained at 32°C to 34°C) or the strict maintenance of normothermia (with temperature maintained 36°C to 37.5°C) was provided.

• Several intra-arrest and post–cardiac arrest clinical variables were examined for prognostic significance.

• No single variable was identified to be sufficiently reliable to predict outcomes. Therefore, caretakers should consider multiple factors in trying to predict outcomes during cardiac arrest and in the post-ROSC setting.

• After ROSC, fluids and vasoactive infusions should be used to maintain a systolic blood pressure above the fifth percentile for age.

• After ROSC, normoxemia should be targeted. When the necessary equipment is available, oxygen administration should be weaned to target an oxyhemoglobin saturation of 94% to 99%.

• Hypoxemia should be strictly avoided. Ideally, oxygen should be titrated to a value appropriate to the specific patient condition. Likewise, after ROSC, the child’s PaCO2 should be targeted to a level appropriate to each patient’s condition. Exposure to severe hypercapnia or hypocapnia should be avoided.

• References:• Chameides L, Samson RA, Schexnayder SM, Hazinski MF.

Pediatric advanced life support provider manual. Dallas, TX: American Heart Association. 2011.

• Care EC. Part 12 : Pediatric Advanced Life Support. 2015;2015:1–74.

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