Tag Archives: APLS

Post-arrest hypothermia in children did not improve outcome

Many clinicians extrapolate adult research findings to paediatric patients because there’s no alternative, and until now we’ve had to do that with post-cardiac arrest therapeutic hypothermia after paediatric cardiac arrest.

However the THAPCA trial in the New England Journal of Medicine now provides child-specific data.

It was a multicentre trial in the US which included children between 2 days and 18 years of age, who had had an out-of-hospital cardiac arrest and remained comatose after return of circulation. They were randomised to therapeutic hypothermia (target temperature, 33.0°C) or therapeutic normothermia (target temperature, 36.8°C) within 6 hours after the return of circulation.

Therapeutic hypothermia, as compared with therapeutic normothermia, did not confer a significant benefit with respect to survival with good functional outcome at 1 year, and survival at 12 months did not differ significantly between the treatment groups.

These findings are similar to the adult TTM trial, although there are some interesting differences. In the paediatric study, the duration of temperature control was longer (120 hrs vs 36 hrs in the adult study), respiratory conditions were the predominant cause of paediatric cardiac arrest (72%), and there were only 8% shockable rhythms in the paediatric patients, compared with 80% in the adult study.

The full text is available here.

Therapeutic Hypothermia after Out-of-Hospital Cardiac Arrest in Children
N Engl J Med. 2015 Apr 25

Background: Therapeutic hypothermia is recommended for comatose adults after witnessed out-of-hospital cardiac arrest, but data about this intervention in children are limited.

Methods: We conducted this trial of two targeted temperature interventions at 38 children’s hospitals involving children who remained unconscious after out-of-hospital cardiac arrest. Within 6 hours after the return of circulation, comatose patients who were older than 2 days and younger than 18 years of age were randomly assigned to therapeutic hypothermia (target temperature, 33.0°C) or therapeutic normothermia (target temperature, 36.8°C). The primary efficacy outcome, survival at 12 months after cardiac arrest with a Vineland Adaptive Behavior Scales, second edition (VABS-II), score of 70 or higher (on a scale from 20 to 160, with higher scores indicating better function), was evaluated among patients with a VABS-II score of at least 70 before cardiac arrest.

Results: A total of 295 patients underwent randomization. Among the 260 patients with data that could be evaluated and who had a VABS-II score of at least 70 before cardiac arrest, there was no significant difference in the primary outcome between the hypothermia group and the normothermia group (20% vs. 12%; relative likelihood, 1.54; 95% confidence interval [CI], 0.86 to 2.76; P=0.14). Among all the patients with data that could be evaluated, the change in the VABS-II score from baseline to 12 months was not significantly different (P=0.13) and 1-year survival was similar (38% in the hypothermia group vs. 29% in the normothermia group; relative likelihood, 1.29; 95% CI, 0.93 to 1.79; P=0.13). The groups had similar incidences of infection and serious arrhythmias, as well as similar use of blood products and 28-day mortality.

Conclusions: In comatose children who survived out-of-hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia, did not confer a significant benefit in survival with a good functional outcome at 1 year.

Palpating neonatal tracheal tubes

infant-intubate-iconAfter neonatal intubation, the incidence of malposition of the tip of the tracheal tube is fairly high.

A technique was evaluated involving palpation of the tube tip in the suprasternal notch, which in this small study was superior to insertion length based on a weight-based nomogram.

The suprasternal notch was chosen because it anatomically corresponds to vertebral level T2, close to the optimal position at the mid-tracheal point. Correct position on the chest radiograph was defined as any position <0.5 cm above the interclavicular midpoint and more than 1 cm above the carina.

During tracheal tube placement, the tip was gently palpated in the suprasternal notch with the index or little finger of the left hand while holding the body of the tube with the fingers of the right hand. The tube tip was adjusted until the bevelled edge was just palpable in the the suprasternal notch.

Digital palpation of endotracheal tube tip as a method of confirming endotracheal tube position in neonates: an open-label, three-armed randomized controlled trial.
Paediatr Anaesth. 2013 Oct;23(10):934-9

OBJECTIVE: To compare the malposition rates of endotracheal tubes (ETTs) when the insertional length (IL) is determined by a weight-based nomogram versus when IL is determined by palpation of the ETT tip.

DESIGN: Open-label, randomized controlled trial (RCT).

SETTING: Level III neonatal intensive care unit (NICU).

SUBJECTS: All newborn babies admitted in NICU requiring intubation.

INTERVENTIONS: Subjects were randomly allocated to one of three groups, wherein IL was determined by (i) weight-based nomogram alone, (ii) weight-based nomogram combined with suprasternal palpation of ETT tip performed by specially trained neonatology fellows, or (iii) combination of weight-based and suprasternal methods by personnel not specially trained.

PRIMARY OUTCOME: Rate of malposition of ETT as judged on chest X-ray (CXR).

RESULTS: Fifty seven babies were randomized into group 1(n = 15), group 2 (n = 20), and group 3 (n = 22). The proportion of correct ETT placement was highest in group 2, being 66.7%, 83.3%, and 66.7% in groups 1 through 3, respectively (P value = 0.58). No complication was attributable to palpation technique.

CONCLUSION: Suprasternal palpation shows promise as a simple, safe, and teachable method of confirming ETT position in neonates.

Is 4 Joules per kg enough in kids?

glash-sim-paed-face-smResearchers from the Iberian-American Paediatric Cardiac Arrest Study Network challenge the evidence base behind defibrillation shock dose recommendations in children.

In a study of in-hospital pediatric cardiac arrest due to VT or VF, clinical outcome was not related to the cause or location of arrest, type of defibrillator and waveform, energy dose per shock, number of shocks, or cumulative energy dose, although there was a trend to better survival with higher doses per shock. 50% of children required more than the recommended 4J per kg and in over a quarter three or more shocks were needed to achieve defibrillation.


Shockable rhythms and defibrillation during in-hospital pediatric cardiac arrest
Resuscitation. 2014 Mar;85(3):387-91

OBJECTIVE: To analyze the results of cardiopulmonary resuscitation (CPR) that included defibrillation during in-hospital cardiac arrest (IH-CA) in children.

METHODS: A prospective multicenter, international, observational study on pediatric IH-CA in 12 European and Latin American countries, during 24 months. Data from 502 children between 1 month and 18 years were collected using the Utstein template. Patients with a shockable rhythm that was treated by electric shock(s) were included. The primary endpoint was survival at hospital discharge. Univariate logistic regression analysis was performed to find outcome factors.

RESULTS: Forty events in 37 children (mean age 48 months, IQR: 7-15 months) were analyzed. An underlying disease was present in 81.1% of cases and 24.3% had a previous CA. The main cause of arrest was a cardiac disease (56.8%). In 17 episodes (42.5%) ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) was the first documented rhythm, and in 23 (57.5%) it developed during CPR efforts. In 11 patients (27.5%) three or more shocks were needed to achieve defibrillation. Return of spontaneous circulation (ROSC) was obtained in 25 cases (62.5%), that was sustained in 20 (50.0%); however only 12 children (32.4%) survived to hospital discharge. Children with VF/pVT as first documented rhythm had better sustained ROSC (64.7% vs. 39.1%, p=0.046) and survival to hospital discharge rates (58.8% vs. 21.7%, p=0.02) than those with subsequent VF/pVT. Survival rate was inversely related to duration of CPR. Clinical outcome was not related to the cause or location of arrest, type of defibrillator and waveform, energy dose per shock, number of shocks, or cumulative energy dose, although there was a trend to better survival with higher doses per shock (25.0% with <2Jkg(-1), 43.4% with 2-4Jkg(-1) and 50.0% with >4Jkg(-1)) and worse with higher number of shocks and cumulative energy dose.

CONCLUSION: The termination of pediatric VF/pVT in the IH-CA setting is achieved in a low percentage of instances with one electrical shock at 4Jkg(-1). When VF/pVT is the first documented rhythm, the results of defibrillation are better than in the case of subsequent VF/pVT. No clear relationship between defibrillation protocol and ROSC or survival has been observed. The optimal pediatric defibrillation dose remains to be determined; therefore current resuscitation guidelines cannot be considered evidence-based, and additional research is needed.

ECMO for paediatric cardiac arrest

The Taiwanese are at it again with their extracorporeal life support. This time, they report their outcomes in children who received ECMO for in-hospital cardiac arrest. Interestingly, the patients with pure cardiac causes of cardiac arrest had a survival rate similar to patients with non-cardiac causes.

PURPOSE: The study aims to describe 11 years of experience with extracorporeal cardiopulmonary resuscitation (ECPR) for in-hospital paediatric cardiac arrest in a university affiliated tertiary care hospital.

METHODS: Paediatric patients who received extracorporeal membrane oxygenation (ECMO) during active extracorporeal cardiopulmonary resuscitation (ECPR) at our centre from 1999 to 2009 were included in this retrospective study. The results from three different cohorts (1999-2001, 2002-2005 and 2006-2009) were compared. Survival rates and neurological outcomes were analysed. Favourable neurological outcome was defined as paediatric cerebral performance categories (PCPC) 1, 2 and 3.

RESULTS: We identified 54 ECPR events. The survival rate to hospital discharge was 46% (25/54), and 21 (84%) of the survivors had favourable neurological outcomes. The duration of CPR was 39±17 min in the survivors and 52±45 min in the non-survivors (p=NS). The patients with pure cardiac causes of cardiac arrest had a survival rate similar to patients with non-cardiac causes (47% (18/38) vs. 44% (7/16), p=NS). The non-survivors had higher serum lactate levels prior to ECPR (13.4±6.4 vs. 8.8±5.1 mmol/L, p<0.01) and more renal failure after ECPR (66% (19/29) vs. 20% (5/25), p<0.01). The patients resuscitated between 2006 and 2009 had shorter durations of CPR (34±13 vs. 78±76 min, p=0.032) and higher rates of survival (55% (16/29) vs. 0% (0/8), p=0.017) than those resuscitated between 1999 and 2002.

CONCLUSIONS: In our single-centre experience with ECPR for paediatric in-hospital cardiac arrest, the duration of CPR has become shorter and outcomes have improved in recent years. Higher pre-ECPR lactate levels and the presence of post-ECPR renal failure were associated with increased mortality. The presence of non-cardiac causes of cardiac arrest did not preclude successful ECPR outcomes. The duration of CPR was not significantly associated with poor outcomes in this study.

Eleven years of experience with extracorporeal cardiopulmonary resuscitation for paediatric patients with in-hospital cardiac arrest
Resuscitation. 2012 Jun;83(6):710-4

Out-of hospital traumatic paediatric cardiac arrest

This small study on traumatic arrests in children1 refutes the “100% mortality from traumatic arrest” dogma that people still spout and gives information on the mechanisms associated with survival: drowning and strangulation were associated with greater rates of survival to hospital admission compared with blunt, penetrating, and other traumas. Overall, drowning had the greatest rate of survival to discharge (19.1%).

I would like to know the injuries sustained in non-survivors, to determine whether they were potentially treatable. Strikingly, in the list of prehospital procedures performed, there were NO attempts at pleural decompression, something that is standard in traumatic arrest protocols in prehospital services were I have worked.

It is interesting to compare these results with those of the London HEMS team2, who for traumatic paediatric arrest achieved 19/80 (23.8%) survival to discharged from the emergency department and 7/80 (8.75%) survival to hospital discharge. They also noted a large proportion of the survivors suffered hypoxic or asphyxial injuries, whereas those patients with hypovolaemic cardiac arrest did not survive.

OBJECTIVE:To determine the epidemiology and survival of pediatric out-of-hospital cardiac arrest (OHCA) secondary to trauma.

METHODS:The CanAm Pediatric Cardiac Arrest Study Group is a collaboration of researchers in the United States and Canada sharing a common goal to improve survival outcomes for pediatric cardiac arrest. This was a prospective, multicenter, observational study. Twelve months of consecutive data were collected from emergency medical services (EMS), fire, and inpatient records from 2000 to 2003 for all OHCAs secondary to trauma in patients aged ≤18 years in 36 urban and suburban communities supporting advanced life support (ALS) programs. Eligible patients were apneic and pulseless and received chest compressions in the field. The primary outcome was survival to discharge. Secondary measures included return of spontaneous circulation (ROSC), survival to hospital admission, and 24-hour survival.

RESULTS:The study included 123 patients. The median patient age was 7.3 years (interquartile range [IQR] 6.0-17.0). The patient population was 78.1% male and 59.0% African American, 20.5% Hispanic, and 15.7% white. Most cardiac arrests occurred in residential (47.1%) or street/highway (37.2%) locations. Initial recorded rhythms were asystole (59.3%), pulseless electrical activity (29.1%), and ventricular fibrillation/tachycardia (3.5%). The majority of cardiac arrests were unwitnessed (49.5%), and less than 20% of patients received chest compressions by bystanders. The median (IQR) call-to-arrival interval was 4.9 (3.1-6.5) minutes and the on-scene interval was 12.3 (8.4-18.3) minutes. Blunt and penetrating traumas were the most common mechanisms (34.2% and 25.2%, respectively) and were associated with poor survival to discharge (2.4% and 6.5%, respectively). For all OHCA patients, 19.5% experienced ROSC in the field, 9.8% survived the first 24 hours, and 5.7% survived to discharge. Survivors had triple the rate of bystander cardiopulmonary resuscitation (CPR) than nonsurvivors (42.9% vs. 15.2%). Unlike patients sustaining blunt trauma or strangulation/hanging, most post-cardiac arrest patients who survived the first 24 hours after penetrating trauma or drowning were discharged alive. Drowning (17.1% of cardiac arrests) had the highest survival-to-discharge rate (19.1%).

CONCLUSIONS:The overall survival rate for OHCA in children after trauma was low, but some trauma mechanisms are associated with better survival rates than others. Most OHCA in children is preventable, and education and prevention strategies should focus on those overrepresented populations and high-risk mechanisms to improve mortality.

1. Epidemiology of out-of hospital pediatric cardiac arrest due to trauma
Prehosp Emerg Care, 2012 vol. 16 (2) pp. 230-236

2. Outcome from paediatric cardiac arrest associated with trauma
Resuscitation. 2007 Oct;75(1):29-34

Caution with intraosseous adenosine

Two cases of failed cardioversion of SVT after tibial intraosseous administration of adenosine in infants are described in this month’s Pediatric Emergency Care. Both cases were subsequently cardioverted by intravenous adenosine. The maximum intraosseous dose given was 0.25 mg/kg. The successful IV doses were not higher than the IO doses.

It has been noted before that infants may require relatively higher doses of adenosine than children and that 0.2 mg/kg might even be considered a starting dose in infancy. I wonder if a bigger IO dose would have been effective, or whether a proximal humeral insertion site would make a difference. IO adenosine has been successfully used in infants and piglets.

This interesting case series provides a helpful caution in the management of paediatric SVT.

ABSTRACT: Supraventricular tachycardia (SVT) is a common tachyarrhythmia in the pediatric population that can necessitate immediate treatment. Adenosine has been well studied as a mainstay treatment, but the methods of adenosine administration have not been very well delineated. The intraosseous technique has presented itself as a possible method of administration. We describe 2 cases in which adenosine was administered through bone marrow infusion to convert SVT without success. The cases we describe show that intraosseous is not a reliable method of administering adenosine to stop SVT. Both patients presented with SVT refractory to vagal maneuvers and difficult intravenous placement. Intraosseous access was achieved, but administration of adenosine at increasing doses was unable to successfully convert the arrhythmia.

Intraosseous Infusion Is Unreliable for Adenosine Delivery in the Treatment of Supraventricular Tachycardia
Pediatr Emerg Care. 2012 Jan;28(1):47-8

A big brain saves a little one

Something I’ve been teaching for years – but never actually done – has been described in a case report from Oman.

A 2 year old child suffered a respiratory arrest due to an inhaled foreign body, which led to a bradyasystolic cardiac arrest. She was intubated by the resuscitation team who could not achieve any ventilation through the tube. The tube was removed and reinserted by an ‘expert’ (there is no mention of capnometry, for what it’s worth) and the same problem persisted.

The life-saving manouevre was to insert the tracheal tube further down into the right main bronchus and then withdraw to the trachea. This forced the obstructing object distally so that one-lung ventilation was then possible, resulting in return of spontaneous circulation and oxygen saturations in the mid-80’s. The object – a broken piece of plastic – was removed bronchoscopically and happily the child made an uneventful recovery.

Is this technique in your list of life-saving tricks? Hopefully, it is now.

A child is alive because a doctor was able to ‘think outside the guidelines’ in an incredibly high pressure situation. Rigid adherence to ACLS procedures here would have been futile. The guidelines save lives, but a few more can be saved when care can be individualised to the clinical situation by a thinking clinician.

Well done Dr Mishra and colleagues.

Sudden near-fatal tracheal aspiration of an undiagnosed nasal foreign body in a small child

Emerg Med Australas. 2011 Dec;23(6):776-8

[And here’s something else to consider if you have no airway equipment with you and your basic choking algorithm isn’t working]

Normal heart and respiratory rates in children

A large review has established normal ranges of heart rate and respiratory rate in children from birth to 18 years of age. Some of the results differed markedly from some existing ranges quoted, such as in the Advanced Paediatric Life Support Course.

BACKGROUND: Although heart rate and respiratory rate in children are measured routinely in acute settings, current reference ranges are not based on evidence. We aimed to derive new centile charts for these vital signs and to compare these centiles with existing international ranges.

METHODS: We searched Medline, Embase, CINAHL, and reference lists for studies that reported heart rate or respiratory rate of healthy children between birth and 18 years of age. We used non-parametric kernel regression to create centile charts for heart rate and respiratory rate in relation to age. We compared existing reference ranges with those derived from our centile charts.

FINDINGS: We identified 69 studies with heart rate data for 143,346 children and respiratory rate data for 3881 children. Our centile charts show decline in respiratory rate from birth to early adolescence, with the steepest fall apparent in infants under 2 years of age; decreasing from a median of 44 breaths per min at birth to 26 breaths per min at 2 years. Heart rate shows a small peak at age 1 month. Median heart rate increases from 127 beats per min at birth to a maximum of 145 beats per min at about 1 month, before decreasing to 113 beats per min by 2 years of age. Comparison of our centile charts with existing published reference ranges for heart rate and respiratory rate show striking disagreement, with limits from published ranges frequently exceeding the 99th and 1st centiles, or crossing the median.

INTERPRETATION: Our evidence-based centile charts for children from birth to 18 years should help clinicians to update clinical and resuscitation guidelines.

Normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: a systematic review of observational studies
Lancet. 2011 Mar 19;377(9770):1011-8

Infant CPR causing rib fractures

An increase in rib fractures was observed at autopsy in infants who had undergone CPR, which is temporally related to the introduction of guidelines stressing the hand-encircling two-thumb method of CPR and compression depths of 1/3 – 1/2 the anteroposterior diameter of the chest, which has been shown in previous studies to produce higher coronary perfusion pressures and more consistently correct depth and force of compression than the “two-finger” technique.

Previous posts here have reported a CT scan-based mathematical modelling study that suggested compressing to 1/3 anteroposterior chest wall diameter should provide a superior ejection fraction to 1/4 depth and should generate less risk for over-compression than 1/2 AP compression depth, and another post described a small case series of 6 PICU patients requiring CPR for cardiac arrest due to primary cardiac disease in which blood pressure as measured by an arterial line increased when the depth of chest compression was increased from one third to one half of the chest wall diameter (using the hand-encircling method).

What should we do about this? I think the take-home message is to be mindful of the risk of rib fractures and to avoid over-compression, but to follow the guidelines. Another valuable point was made by the authors:

“Regardless of the reason for the increased incidence, the possibility of CPR-related rib fractures needs to be seriously considered in the evaluation of any infant presenting with rib fractures, when there is a history of CPR, so as not to misinterpret the finding as evidence of non-accidental/inflicted injury.”

An infant NOT requiring CPR. And a happy doctor.

OBJECTIVE: A recent increase in the number of infants presenting at autopsy with rib fractures associated with cardio-pulmonary resuscitation (CPR) precipitated a study to determine whether such a phenomenon was related to recent revision of paediatric resuscitation guidelines.

METHODS: We conducted a review of autopsy reports from 1997 to 2008 on 571 infants who had CPR performed prior to death.

RESULTS: Analysis of the study population revealed CPR-related rib fractures in 19 infants (3.3%), 14 of whom died in the 2006-2008 period. The difference in annual frequency of CPR-related fractures between the periods before and after revision of paediatric CPR guidelines was statistically highly significant.

CONCLUSIONS: The findings indicate that CPR-associated rib fractures have become more frequent in infants since changes in CPR techniques were introduced in 2005. This has important implications for both clinicians and pathologists in their assessment of rib fractures in this patient population.

Increased incidence of CPR-related rib fractures in infants-Is it related to changes in CPR technique?
Resuscitation. 2011 May;82(5):545-8

Colorimetric CO2 detectors and newborns

Colorimetric CO2 detectors may fail to indicate successful tracheal tube placement in adults in certain circumstances, such as low cardiac output states, and waveform capnography is considered the gold standard. We now have data that demonstrate their inadequacy for neonatal intubation. Ideally, waveform devices should be used by all professionals who intubate patients – from paramedics to neonatologists.

AIM: Clinical assessment and end-tidal CO(2) (ETCO(2)) detectors are routinely used to verify endotracheal tube (ETT) placement. However, ETCO(2) detectors may mislead clinicians by failing to identify correct placement under a variety of conditions. A flow sensor measures gas flow in and out of an ETT. We reviewed video recordings of neonatal resuscitations to compare a colorimetric CO(2) detector (Pedi-Cap®) with flow sensor recordings for assessing ETT placement.
METHODS: We reviewed recordings of infants <32 weeks gestation born between February 2007 and January 2010. Airway pressures and gas flow were recorded with a respiratory function monitor. Video recording were used (i) to identify infants who were intubated in the delivery room and (ii) to observe colour change of the ETCO(2) detector. Flow sensor recordings were used to confirm whether the tube was in the trachea or not.
RESULTS: Of the 210 infants recorded, 44 infants were intubated in the delivery room. Data from 77 intubation attempts were analysed. In 35 intubations of 20 infants both a PediCap® and flow sensor were available for analysis. In 21 (60%) intubations, both methods correctly identified successful ETT placement and in 3 (9%) both indicated the ETT was not in the trachea. In the remaining 11 (31%) intubations the PediCap® failed to change colour despite the flow wave indicating correct ETT placement.
CONCLUSION: Colorimetric CO(2) detectors may mislead clinicians intubating very preterm infants in the delivery room. They may fail to change colour in spite of correct tube placement in up to one third of the cases.

Assessment of flow waves and colorimetric CO2 detector for endotracheal tube placement during neonatal resuscitation
Resuscitation. 2011 Mar;82(3):307-12