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Resuscitation, Pediatric, Emergency Medicine

Basics

Description

- History from caregivers/parents of onset, progression, inciting, contributing, or predisposing trauma/exposure/conditions, associated findings, past medical history, family history, medications, ingestions - History of preceding events from pre-hospital personnel - Respiratory failure: - Tachypnea - Slow, irregular breathing pattern prearrest - Decreased or absent breath sounds; inadequate ventilation - Retractions, accessory muscle use, expiratory grunting, nasal flaring - Mottled skin, cyanosis - Altered level of consciousness: Irritability, agitation, lethargy, weak or absent cry, decreased response to pain - Weak or absent cough or gag reflex - Most common presenting condition

- Late shock (uncompensated): - Tachycardia, tachypnea, prearrest bradycardia - Hypotension, weak peripheral pulses - Mottled, pale, cool extremities with markedly decreased capillary refill - Poor muscle tone - Decreased urine output progressing to anuria - Decreased LOC, seizures, coma - Fever or hypothermia in septic shock

- Respiratory: - Upper airway obstruction: Croup, epiglottitis, peritonsillar or retropharyngeal abscess, FB, tracheitis, congenital abnormalities - Lower airway obstruction: Asthma, pneumonia, bronchiolitis, FB, cystic fibrosis - Thoracic trauma, near drowning

- Rapid-sequence intubation: - Preoxygenate - Pretreatment: Atropine to prevent bradycardia, lidocaine if head injury - Induction agents: Midazolam, thiopental, etomidate (avoid in septic shock), ketamine - Paralytics: Rocuronium, vecuronium, pancuronium, succinylcholine - Position of endotracheal tube (ETT) at lips (cm) = 3 times diameter of tube (mm) - Postintubation: Confirm placement with continuous end-tidal CO2 monitoring

- Circulation: - Obtain IV, intraosseous (IO), or central access - Resuscitate with 0.9% NS or LR bolus at 20 mL/kg; repeat if necessary - Control obvious bleeding sources: Apply direct pressure; elevate. - Consider transfusion of packed RBCs after crystalloid replacement in trauma. - Use pressors early; peripheral use OK - Dopamine preferred 1st line; if refractory, norepinephrine (warm shock) or epinephrine (cold shock)

- Antiarrhythmic agents: - Adenosine: 0.1 mg/kg (max. 6 mg) IV rapid push; 2nd dose 0.2 mg/kg (max. 12 mg). - Amiodarone: 5 mg/kg IV, max. dose 300 mg. Give as bolus for pulseless VF/VT, load over 20 " 60 min for SVT/VT. - Lidocaine: For VF or pulseless VT: 1 mg/kg IV bolus, 20 " 50 ug/kg/min IV infusion - Magnesium sulfate: 25 " 50 mg/kg (max. 2 g) for pulseless VT with torsades de pointes - Procainamide: 15 mg/kg IV over 30 " 60 min

- Inotropes and pressors: - Dobutamine: 2 " 20 ug/kg/min IV - Dopamine: 2 " 20 ug/kg/min IV - Inamrinone: Load 0.75 " 1 mg/kg IV over 5 min; maintenance 5 " 10 mcg/kg/min - Milrinone: Load 50 ug/kg IV over 10 " 60 min; maintenance 0.25 " 0.75 ug/kg/min - Norepinephrine: 0.1 " 2 ug/kg/min IV

- Other agents: - Albuterol: For asthma or anaphylaxis, multidose inhaler 4 " 8 puffs q20min or nebulizer 2.5 mg/dose (5 mg/dose if >20 kg) q20min; severe symptoms: 0.5 mg/kg/h by nebulizer (max. 20 mg/h) - Alprostadil: 0.05 " 0.1 ug/kg/min IV for ductal-dependent congenital heart disease - Calcium chloride: 20 mg/kg slow IV push in hypocalcemia, hyperkalemia, Ca channel blocker overdose - Dexamethasone: 0.6 mg/kg IV (max. 16 mg) for severe croup or asthma - Dextrose: 0.5 " 1 g/kg IV. D25W 2 " 4 mL/kg or D10W 5 " 10 mL/kg. - Diphenhydramine: 1 " 2 mg/kg IV q4 " 6 hr - Ipratropium: 250 " 500 mcg q20min 3 - Naloxone: 0.1 mg/kg IV q2min (max. 2 mg) - Sodium bicarbonate: 1 mEq/kg IV - Terbutaline: 10 mcg/kg SC q10 " 15min or 0.1 " 10 mg/kg/min IV for status asthmaticus

Emergent treatment of pediatric patients with imminent or ongoing respiratory or circulatory failure

Etiology

  • Respiratory failure
  • Early shock (compensated)
  • Late shock (uncompensated)
  • Cardiopulmonary arrest
  • Respiratory and/or circulatory failure leads to tissue hypoxia, acidosis, and cell death.
  • Multisystem organ failure subsequently develops.

Diagnosis

Signs and Symptoms

History

  • History from caregivers/parents of onset, progression, inciting, contributing, or predisposing trauma/exposure/conditions, associated findings, past medical history, family history, medications, ingestions
  • History of preceding events from pre-hospital personnel
  • Respiratory failure:TachypneaSlow, irregular breathing pattern prearrestDecreased or absent breath sounds; inadequate ventilationRetractions, accessory muscle use, expiratory grunting, nasal flaringMottled skin, cyanosisAltered level of consciousness: Irritability, agitation, lethargy, weak or absent cry, decreased response to painWeak or absent cough or gag reflexMost common presenting condition
  • Early shock (compensated):Vital signs initially compensatedOrthostatic changes or isolated tachycardiaSlightly delayed cap refill (>2 sec)Warm, dry skin in early septic shock
  • Late shock (uncompensated):Tachycardia, tachypnea, prearrest bradycardiaHypotension, weak peripheral pulsesMottled, pale, cool extremities with markedly decreased capillary refillPoor muscle toneDecreased urine output progressing to anuriaDecreased LOC, seizures, comaFever or hypothermia in septic shock
  • Cardiopulmonary arrest:Final common pathway of progressive deterioration of respiratory and circulatory function

Physical Exam

  • Airway assessment:Look, listen, feel for air movement, breath sounds, and chest movement. Observe for stridor or signs of obstruction.
  • Breathing assessment:Respiratory rate: Tachypnea or slow/irregular pattern (more ominous)Respiratory effort: Note grunting, nasal flaring, head bobbing, retractions, stridor.Pulse oximetry reflects hemoglobin oxygen saturation, not necessarily oxygen delivery.Auscultation: Assess for wheezing, rales, diminished breath sounds.
  • Circulatory assessment:Pulse: Tachycardia or bradycardia (more ominous); orthostatic changes noted easily.BP: Typical SBP in children is 90mm Hg plus twice the age (yrs). Hypotension is a late finding; widened pulse pressure in early septic shock.Peripheral pulse presence and strength (correlates better than BP)Capillary refill: Delayed >2 sec with poor perfusionSkin: Mottled, pale, or cyanotic
  • Mental status assessment:Decreased responsiveness, irritability, confusion, agitation, poor muscle tone, sluggish pupillary response, posturing.
  • Complete set of vital signs including rectal temperature, oximetry, and orthostatics when appropriate

Essential Workup

  • ABCDE evaluation:Airway: Assess ability to speak/cry; assess for air movement. Assess for stridor or trauma.Breathing: Observe for nasal flaring, grunting, head bobbing, retractions, tracheal deviation, chest injury or pneumothorax; auscultate, apply oxygen.Circulation: Evaluate for pulses, capillary refill, mottling, cyanosis.Disability: Determine mental status with alert/verbal/painful/unresponsive (AVPU) scale or Glasgow Coma Scale. Assess for neurologic deficits; check stat glucose.Exposure/environment: Fully expose for skeletal survey. Prevent hypothermia.

Diagnosis Tests & Interpretation

Lab

  • Workup directed by history, assessment of (ABCs), and differential diagnosis
  • Arterial blood gas with oximetry to assess oxygenation, ventilation, acid " base status
  • Glucose, electrolytes
  • Other metabolic/toxicology tests as indicated
  • Sepsis evaluation including lumbar puncture, urine and blood cultures as indicated

Imaging

  • CXR to evaluate pulmonary or cardiac sources
  • Lateral decubitus, inspiratory/expiratory film, or laryngoscopy/bronchoscopy if foreign body (FB) suspected
  • ECG
  • Echocardiogram
  • Cervical spine, other trauma films as indicated
  • CT brain for trauma or abnormal neuro exam
  • US as indicated

Differential Diagnosis

  • Respiratory:Upper airway obstruction: Croup, epiglottitis, peritonsillar or retropharyngeal abscess, FB, tracheitis, congenital abnormalitiesLower airway obstruction: Asthma, pneumonia, bronchiolitis, FB, cystic fibrosisThoracic trauma, near drowning
  • Hypovolemia: Trauma/hemorrhage, diarrhea/vomiting, burns
  • Cardiovascular: Congenital/acquired heart disease, myocarditis, pericarditis, CHF, dysrhythmias
  • Infectious: Sepsis, meningitis, gastroenteritis, peritonitis, pyelonephritis
  • CNS: Status epilepticus, epidural/subdural hematoma
  • Metabolic: DKA, hypoglycemia, hypernatremia, hypo/hyperkalemia, acidosis
  • Toxicologic: CO poisoning, cardiotoxic agents
  • Near sudden infant death syndrome/apparent life-threatening event
  • Consider child abuse when history is inconsistent with the illness or pattern of injury.

Treatment

Pre-Hospital

  • Stabilize ABCs; monitor.
  • Avoid prolonged on-scene times
  • Gather pertinent history from family/bystanders
  • Recognize respiratory or circulatory failure; intervene early.
  • Recognize impending arrest; support ABCs
  • Automated external defibrillator for ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) in children ≥1 yr.
  • Early ED notification to allow preparation

Initial Stabilization/Therapy

  • Early recognition and stabilization of shock
  • Glucose, IV, oxygen, cardiac monitoring
  • Diagnose and treat immediate life-threats
  • Employ Broselow Pediatric Emergency Tape for appropriate drug doses and equipment.

Ed Treatment/Procedures

  • Airway:Secure 1st in every resuscitation.Employ head tilt/chin lift or modified jaw thrust (if trauma suspected).Clear secretions and blood with suction.Temporary stabilization with oral or nasal airway, bag-valve mask assistanceIntubation as necessary using appropriate tube size ([16 + age in years]/4) or size similar to patients little finger or nares
  • Rapid-sequence intubation:PreoxygenatePretreatment: Atropine to prevent bradycardia, lidocaine if head injuryInduction agents: Midazolam, thiopental, etomidate (avoid in septic shock), ketamineParalytics: Rocuronium, vecuronium, pancuronium, succinylcholinePosition of endotracheal tube (ETT) at lips (cm) = 3 times diameter of tube (mm)Postintubation: Confirm placement with continuous end-tidal CO2 monitoring
  • Breathing:Oxygenate with supplemental O2, nonrebreather mask; assist ventilation with bag-valve mask or control ventilation if intubation performed.Treat conditions that limit ability to oxygenate/ventilate: Pneumothorax, hemothorax, cardiac tamponade, circumferential burns.
  • Circulation:Obtain IV, intraosseous (IO), or central accessResuscitate with 0.9% NS or LR bolus at 20 mL/kg; repeat if necessaryControl obvious bleeding sources: Apply direct pressure; elevate.Consider transfusion of packed RBCs after crystalloid replacement in trauma.Use pressors early; peripheral use OKDopamine preferred 1st line; if refractory, norepinephrine (warm shock) or epinephrine (cold shock)
  • Cardiopulmonary resuscitation:Provide blood flow to vital organs while restoring spontaneous circulationInfant <1 yr: Check brachial/femoral pulseChild 1 " 8 yr: Check carotid pulse
  • Cardiac dysrhythmias:Often due to respiratory/metabolic processTreat dysrhythmias per PALS algorithms.Unstable tachydysrhythmias may require adenosine, amiodarone, procainamide, cardioversion, or defibrillation.Unstable bradydysrhythmias may require atropine, epinephrine, or pacing.Pulseless rhythms: VF, pulseless VT, pulseless electrical activity, asystole may require defibrillation, epinephrine, amiodarone, lidocaine.

Medication

  • 1st or loading dose unless otherwise noted
  • All IV doses may be given IO if necessary
  • LEAN (lidocaine, epinephrine, atropine, naloxone) may be given by endotracheal route
  • Epinephrine: Multiple uses:Pulseless arrest/symptomatic bradycardia: 0.01 mg/kg 1:10,000 IV q3 " 5min (max. 1 mg) or 0.1 mg/kg 1:1,000 ETT q3 " 5minAsthma: 0.01 mg/kg 1:1,000 SC q15minAnaphylaxis: 0.01 mg/kg 1:1,000 IM in thigh q15min (max. 0.3 mg); if hypotensive, 0.01 mg/kg 1:10,000 IV q3 " 5min (max. 1 mg)Shock/hypotension: 0.1 " 1 mcg/kg/min IVToxins/overdose: 0.01 mg/kg 1:10,000 IV; may repeat to max. 0.1 mg/kg 1:1,000 IV.
  • Rapid-sequence intubationPretreatment:Atropine: 0.02 mg/kg IV (min. 0.1 mg)Lidocaine: 1 " 2 mg/kg IVInduction:Etomidate: 0.3 mg/kg IVKetamine: 1 " 1.5 mg/kg IV; 4 " 5 mg/kg IMMidazolam: 0.1 " 0.2 mg/kg IVThiopental: 3 " 5 mg/kg IVParalytics:Succinylcholine: 1 " 2 mg/kg IVRocuronium: 0.6 " 1.2 mg/kg IVVecuronium: 0.1 " 0.2 mg/kg IVPancuronium: 0.1 mg/kg IV
  • Antiarrhythmic agents:Adenosine: 0.1 mg/kg (max. 6 mg) IV rapid push; 2nd dose 0.2 mg/kg (max. 12 mg).Amiodarone: 5 mg/kg IV, max. dose 300 mg. Give as bolus for pulseless VF/VT, load over 20 " 60 min for SVT/VT.Lidocaine: For VF or pulseless VT: 1 mg/kg IV bolus, 20 " 50 ug/kg/min IV infusionMagnesium sulfate: 25 " 50 mg/kg (max. 2 g) for pulseless VT with torsades de pointesProcainamide: 15 mg/kg IV over 30 " 60 min
  • Inotropes and pressors:Dobutamine: 2 " 20 ug/kg/min IVDopamine: 2 " 20 ug/kg/min IVInamrinone: Load 0.75 " 1 mg/kg IV over 5 min; maintenance 5 " 10 mcg/kg/minMilrinone: Load 50 ug/kg IV over 10 " 60 min; maintenance 0.25 " 0.75 ug/kg/minNorepinephrine: 0.1 " 2 ug/kg/min IV
  • Other agents:Albuterol: For asthma or anaphylaxis, multidose inhaler 4 " 8 puffs q20min or nebulizer 2.5 mg/dose (5 mg/dose if >20 kg) q20min; severe symptoms: 0.5 mg/kg/h by nebulizer (max. 20 mg/h)Alprostadil: 0.05 " 0.1 ug/kg/min IV for ductal-dependent congenital heart diseaseCalcium chloride: 20 mg/kg slow IV push in hypocalcemia, hyperkalemia, Ca channel blocker overdoseDexamethasone: 0.6 mg/kg IV (max. 16 mg) for severe croup or asthmaDextrose: 0.5 " 1 g/kg IV. D25W 2 " 4 mL/kg or D10W 5 " 10 mL/kg.Diphenhydramine: 1 " 2 mg/kg IV q4 " 6 hrIpratropium: 250 " 500 mcg q20min 3Naloxone: 0.1 mg/kg IV q2min (max. 2 mg)Sodium bicarbonate: 1 mEq/kg IVTerbutaline: 10 mcg/kg SC q10 " 15min or 0.1 " 10 mg/kg/min IV for status asthmaticus
  • Cardioversion: 0.5 " 1 J/kg, increase to 2 J/kg
  • Defibrillation: 2 J/kg, increase to 4 J/kg

Follow-Up

Disposition

Admission Criteria

  • All patients with impending or ongoing respiratory or cardiovascular compromise
  • Survivors of cardiopulmonary arrest require continuous monitoring for decompensation postresuscitation in an ICU setting.
  • Consider transfer to pediatric critical care center.

Discharge Criteria

Patients with mild dehydration who respond to fluid resuscitation without signs of hemodynamic instability may be considered for discharge.

Discharge Criteria

  • Consultation as appropriate depending on specific etiology
  • Involve authorities if abuse is suspected.

Follow-Up Recommendations

  • Educate patients, parents, and caregivers regarding household products and toxins
  • Educate patients about self-administration of epinephrine in anaphylaxis (if age appropriate).

Pearls and Pitfalls

  • Empiric treatment is often necessary.
  • Be vigilant for signs of early sepsis in children.
  • Consider abuse if history contradicts exam
  • Early recognition and stabilization

Additional Reading

  • Brierley J, Carcillo JA, Choong K, et al. Clinical practice parameters for hemodynamic support of pediatrics and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med. 2009;37(2):666 " 688.
  • Fuchs S. Cardiopulmonary resuscitation and pediatric advanced life support update for the emergency physician. Pediatr Emerg Care. 2008;24(8):561 " 565.
  • International Liaison Committee on Resuscitation. The International Liaison Committee on Resuscitation (ILCOR) consensus on science with treatment recommendations for pediatric and neonatal patients: Pediatric basic and advanced life support. Pediatrics. 2006;117(5):e955 " e977.
  • Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: Pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S876 " S908.
  • Ralston M, Hazinski MF, Zaritsky AL, et al. Pediatric Advanced Life Support. Dallas, TX: American Heart Association; 2006.

Codes

ICD9

  • 427.5 Cardiac arrest
  • 518.81 Acute respiratory failure
  • 785.50 Shock, unspecified

ICD10

  • I46.9 Cardiac arrest, cause unspecified
  • J96.00 Acute respiratory failure, unsp w hypoxia or hypercapnia
  • R57.9 Shock, unspecified

SNOMED

  • 409622000 Respiratory failure (disorder)
  • 439569004 Resuscitation (procedure)
  • 410430005 Cardiorespiratory arrest (disorder)
  • 27942005 shock (disorder)