Disclosures Unlearning – a new challenge


Disclosures Unlearning – a new challenge


Concepts and Controversies in

Pediatric CPR

Arno Zaritsky, MD

Children’s Hospital of The King’s

Daughters; Norfolk, VA


• I am a non-compensated consultant on the

Broselow-Luten color-coded dosing system

• I chair the DSMB for the NIH-funded trial of

Therapeutic Hypothermia After Pediatric Cardiac

Arrest (THAPCA)

• Note that some treatments (eg, therapeutic

hypothermia & amiodarone for pediatric cardiac

arrest) in AHA Guidelines are not yet approved by

the FDA

Unlearning a new


• Introducing new guidelines every 5 years requires

that you must “unlearn” something that you learned

• Learning something new is easy

Unlearning requires that you alter your current

knowledge and deal with conflicts between new and

old information

• Our brains are not like a computer hard drive

Unlearning is hard work!

Johnson, C. Unlearning, BMJ 2005; 331:703



A concerted attempt to separate

A,B and C!


CPR Sequence

• Change:

• From A-B-C to C-A-B

• Initiate chest compressions

before ventilations

• Why?

• Goal: To reduce delay to

CPR, sequence begins with

skill that everyone can


• Opening airway and

delivering rescue breaths

most difficult procedure for


• Standardize training

© 2010 American Heart Association. All rights reserved.

Pediatric Basic Life Support

• C-A-B rather than A-B-C sequence

• Traditional CPR (compressions and ventilations) by

bystanders associated with higher survival than chest

compressions alone (see Lancet 2010; 375:1347)

• Unknown if it makes a difference if sequence begins

with ventilations (ABC) or compressions (CAB)

• C-A-B recommended to simplify training

• Doing 30 compressions should delay ventilations by 18

secs or less, esp. if 2 rescuers



Pediatric Advanced Life

Support (PALS)

• Foundation of successful PALS is high quality BLS

change to C-A-B.

• Traditional cardiac arrest algorithm simplified with

emphasis on the importance of high-quality CPR.

• Role of medications questioned

• Increased emphasis on continuous waveform

capnography to

• verify endotracheal tube placement

• optimize CPR quality and detect ROSC

Quality of CPR During In-

Hospital Cardiac Arrest

‣ Case series n=67

‣ U of Chicago

‣ Chest compressions were too slow

‣ 38% of compressions were too shallow

‣ Ventilation rates were too high (>20/min

in 61%)

‣ 24% of time with no compressions

Abella B, JAMA 2005; 293:305-310

Milander M, Arch 8 Int Med 1995

Chest Compressions

Aufderheide T, et al. Incomplete

chest wall decompression.

Resuscitation 2005; 64:353-62.

Yannopoulos D, et al. Resuscitation

2005; 64:363-72.



Interruptions kill: The CPP story

Aortic diastolic


Coronary perfusion pressure = Ao Diastolic RA pressure

Sarver Heart Center Resuscitation Research Team

Chest Compressions


• Without effective chest compressions

• Oxygen flow to brain stops

• Oxygen flow to heart stops

• Drugs go nowhere.

• Important to relax chest pressure completely no


• Minimize interruptions in chest compressions

Direct Compression

Kao P‐C, et al. Pediatrics 2009; 124:49‐55



Compression Depth

• Currently recommend compressing

at least 1/3 A-P diameter

• In most infants, compression depth of 3.8 cm achieves at

least 1/3 A-P diameter

• How do you teach this?

• Devices can provide feedback, but movement of

bed/mattress affect reading; recent data suggest that

up to 40% of compression depth is from mattress


Sutton RM et al. Resuscitation 2009; 80:1137-41; Braga MS et al.

Pediatrics 2009; 124:e69-e74; Kao P-C et al. Pediatrics 2009; 124:49-55


Effective chest compressions

‣ “Push Hard and Push Fast” at 100/min

‣ Is faster better?

‣ Allow chest to recoil

‣ Limit chest compression interruptions

‣ Use 30:2 C:V ratio for single rescuer and 15:2 C:V

ratio for two rescuers

Staying Alive


Adverse Effects of


• Noted high ventilation

rates by EMS providers


Review of 68 peds sim codes

• Study







rate of

40.6 ± 11.8 bpm.


For isolated




arrest, mean

rate was on 44 mean ± 13.9 bpm.

intrathoracic pressure




2011; 128:e1195‐1200

perfusion pressure

(CPP) and survival

• 9 pigs/group studied

Aufderheide TP, Sigurdsson G, Pirrallo RG, et

al. Hyperventilation-Induced Hypotension

During Cardiopulmonary Resuscitation.

Circulation 2004; 109:1960-5



Tidal Volume and

Ventilation Rate

Review of 68 peds sim codes

showed mean ventilation rate of

40.6 ± 11.8 bpm.

For isolated respiratory arrest, mean

rate was 44 ± 13.9 bpm.

Pediatrics 2011; 128:e1195‐1200


Intubation: Cricoid Pressure

• Recent data show that

modest pressure can distort

the pediatric and adult


• No data show that cricoid

pressure effectively

prevents aspiration

• If used, abandon if

ventilation or visualization is


Walker RWM, et al. Br J Anaesth 2010;


Ellis DY, et al. Ann Emerg Med 2007;


Cuffed vs. Uncuffed ET


• Traditionally, uncuffed tubes are used in children


Cuffed vs. Uncuffed ET


• Cuffed tubes are safe, when used


• Monitor cuff pressure keep

< 20-25 cm H2O

• Formula: 3.5+(age/4) for children

>2 yrs of age

• 3.0-3.5 mm < one year

• 3.5 4.0 mm for one-two years old

• Length-based estimate is superior

to age-based estimate

Waveform Capnography

• Change:

• Quantitative waveform capnography is the most reliable

method to confirm and monitor correct ET tube placement.

• Why:

• Unacceptably high incidence of unrecognized ET tube

misplacement or displacement.

• Capnography has high sensitivity and specificity to identify

correct endotracheal tube placement in cardiac arrest.

• Can be used for monitoring CPR quality and detecting


ACLS & PALS: Waveform


• After intubation, exhaled carbon dioxide is detected,

confirming tracheal tube placement.

• Highest value at end-expiration.



Exhaled CO 2 =

10-15 torr

PaCO 2 = 25 torr

PvCO 2 = 100 torr

Under steady state

conditions (constant

minute ventilation), ETCO 2

is determined by VCO 2 ,

effective pulmonary blood

flow and physiologic dead


• Animal data consistently

show a relationship

between ETCO 2 and

cardiac output, provided

minute ventilation is

relatively constant

• In children with increased

RL shunts that reduces

pulmonary blood flow

ETCO 2 will fall

Animated GIF from www.capnography.com

Physiologic Monitoring

During CPR

Adult data show that failure to achieve ETCO 2 >10 to 15 mmHg

is associated with failure to achieve ROSC. Monitoring ETCO 2

during CPR may help to guide quality of CPR and substitute for

need to pause to conduct pulse checks



Witnessed collapse

outside store and CPR

started by 2 firefighters

who saw arrest.

At 34 mins ETCO2

was in low 30’s and

maintained there

during CPR so

rescuers continued


He received a total of

12 shocks and came

out of VF after

amiodarone. Had good

neurologic outcome.

WSJ May 17, 2011

© 2010 American Heart Association. All rights reserved.


of ≤1.9 kPa (14.3 mmHg) measured at 20 mins after

the initiation of ALS for cardiac arrest accurately predicts death in

adult OOH cardiac arrest.

For ROSC, the sensitivity, specificity, PPV and NPV were all

100% using this threshold at 20 mins.


> 1.9 kPa (14.3 mmHg) 402 0

≤ 1.9 kPa 0 335

Initial ETCO 2 is higher with asphyxial versus cardiac arrests.

ETCO 2 decreases transiently after epinephrine and increases

transiently after sodium bicarbonate

Kolar M, et al. Crit Care 2008; 12:R115

© 2010 American Heart Association. All rights reserved.



Defibrillation Dose

• Optimal energy dose is unknown; data from NRCPR

found low first shock success rate for 2 and 4 J/kg

(53%) in-hospital*

• Lower success with 4 J/kg, but may be selection bias

• Biphasic energy (up to 10 J/kg) safer than

monophasic doses in animal models

• Manual defibrillator preferred; use AED in children if

that is all you have

• Note: primary VF/VT has good outcome; secondary

VF/VT associated with poor outcome

*Meaney PA, et al. Pediatrics 2011; 127:e16-e23

Olasveengen, T. M., K. Sunde, et al. "Intravenous Drug

Administration During Out‐of‐Hospital Cardiac Arrest: A

Randomized Trial." JAMA 2009; 302:2222‐9.

• Prospective RCT of non-traumatic CA over 5 years in

Oslo, Norway

• Resuscitation attempted in 1183; 418 in ACLS with IV

access vs 433 without IV access

• Survival to discharge: 10.5% vs 9.2% (p=.61);

w/favorable neuro outcome (9.8% vs 8.1%)

• ROSC w/hospital admission was 32% w/IV

access vs 21% without IV meds (p



• Calcium not recommended for pediatric cardiac

arrest except for documented hypocalcemia, CCB

toxicity, hyperMg, hyperkalemia

• Adenosine recommended as safe and potentially

effective for treatment and diagnosis in initial

management of undifferentiated regular

monomorphic wide-complex tachycardia.

• Use actual body weight or body length tape to

calculate doses. Do not exceed adult dose

• Epinephrine dose and indications unchanged—

more data against high-dose epinephrine.

Drug therapy in cardiac


• In children, epinephrine remains the drug of choice

• Initial dose of 0.01 mg/kg

• Data do not support subsequent high doses of epinephrine;

may be considered, but not recommended.

• Consider in sepsis, ß-blocker overdose, other conditions

characterized by poor catecholamine responsiveness

NEJM 2004; 350:1722-30


High‐dose epinephrine vs. standard dose for

in‐hospital pediatric cardiac arrest

Perondi M, et al. NEJM 2004; 350:1722-30

• n=68 (34 each)

• In-hospital, blinded RCT

• HDE rescue did not

improve ROSC (20/34

vs 21/34)

• HDE resulted in worse

24-hour survival








20.5 *



10 3




1/34 HDE vs. 7/34 SDE survived >24 hours







• Atropine: Not routinely recommended in PEA;

only for hemodynamically significant bradycardia

due to increased vagal tone or AV block

• Consider epinephrine or pacing

• Sodium bicarbonate: Not routinely recommended

during CPR. Use for hyperkalemia (but glucoseinsulin

better) and TCA overdose

• GWTG analysis - use of NaHCO 3 associated with

increased mortality submitted for publication to


Morley PT. Drugs during CPR. Curr Opinion Crit Care 2011; 17:214‐8


• Long used in cardiac arrest—important for cardiac


• Extracellular concentration is 10,000 fold higher than

intracellular concentration!

• Increased intracellular Ca mediates final pathway for

cell death

• Calcium use was associated with increased mortality*

• Used in 45% of 1477 in-hospital arrests; use associated

with ICU location, prolonged arrest and use of other

ALS medications

• Indicated for hypocalcemia, CCB overdose,

hyperkalemia and hypermagnesemia

• Ca gluconate is as effective as Ca Chloride; gluconate

preferred for peripheral venous administration


et al. Pediatrics 2008; 121:e1144-51


• Other than anecdotal reports, there are no data on its

use in pediatric arrest

• NRCPR data reported that its use was associated with

increased mortality*

• Selection bias and only used in 4.9% of cases (64

cases), mostly PICU in large children’s hospitals

• Vasopressin may be useful in vasodilated,

catecholamine-refractory states (eg, sepsis,

occasionally after CPB)

• Optimal bolus dose is unknown 40 IU used in

adults so 0.5 1 U/kg has been used in children

*Duncan JM, et al. Ped Crit Care Med 2009; 10:191




Miscellaneous Medications

• Amiodarone is highly effective for both

ventricular and supraventricular arrhythmias

• Complex pharmacology with very long half-life

• Avoid if prolonged QT or giving other drugs that

prolong QT interval

• May cause severe hypotension with rapid IV admin

• Naloxone doses are different based on indication:

• Use 0.1 mg/kg (100 mcg/kg) for intentional opioid


• Use 0.001 0.005 mg/kg (1 5 mcg/kg) to antagonize

respiratory depression due to too much narcotic

• Etomidate not recommended if evidence of


Pediatric Resuscitation

• Revised pediatric chain of survival

• New post-arrest care link

© 2010 American Heart Association. All rights reserved.

Post-resuscitation care

• Myocardial dysfunction is common after cardiac

arrest. Vasoactive agents may improve

hemodynamics, but drug selection must be tailored to

the patient because clinical response is variable.

‣ Some post-arrest patients develop a SIRS (sepsis-like)

clinical picture; others have cardiogenic shock

‣ Vasoactive therapy should be based on patient’s

hemodynamic state and desired goals

‣ But, don’t know best method of monitoring

cardiovascular function or the optimal hemodynamic

goals used to monitor and titrate therapy

‣ No specific MAP goal; may want afterload reduction to

improve cardiac output




Post-resuscitation care

• Fluid may be required to compensate for altered

capillary permeability, reduced vascular tone and

SIRS response

• 3 L of iced NS or RL tolerated in post-ROSC adults

• Like sepsis, may benefit from monitoring venous

oxygen saturation (central) if available

• Evaluate arterial venous oxygen content difference

• Monitor lactate clearance

• Maintain adequate MAP; some data suggests

benefit from increased MAP early post arrest

• Consider ECHO to objectively assess cardiac fx

Post-resuscitation care

Postresuscitation Care Bundle of Interventions

‣ Do not routinely hyperventilate impairs venous

return and may reduce cerebral blood flow

‣ Avoid hyperthermia!

‣ Monitor temperature and treat fever aggressively

‣ Monitor glucose attempt to maintain “normal”

glucose concentration

‣ No data to support avoiding glucose in IV fluids

‣ Tight glucose control associated with much higher risk

of significant hypoglycemia and increased ICU


‣ Consider induced hypothermia (32 o C to 34 o C) for

patients comatose after resuscitation from cardiac

arrest. 41

Post-resuscitation care

Postresuscitation Care Bundle of Interventions

‣ Bicarbonate for correction of acidosis is it valuable?

‣ Be sure ventilation is adequate

‣ Monitor urine output, but beware of hyperglycemiainduced

diuresis and high-output renal failure

‣ At risk for seizures may be subclinical, so have

low threshold for EEG, treatment

‣ Prophylactic anticonvulsants?

‣ Prognostication difficult immediately post arrest

and not reliable if patient receives therapeutic


Morrison LJ, et al. Strategies for improving survival after in‐hospital cardiac arrest in

the United States: 2013 Consensus Recommendations. Circulation 2013; 127:1538




Pediatric Advanced Life Support

• Ventilate with 100% Oxygen during CPR, but post-

ROSC: titrate oxygen to limit hyperoxemia. Adjust FIO2

to maintain sats >94% but



• Many resuscitation systems and communities have

documented improved survival from cardiac arrest when

high quality CPR is emphasized push fast, push deep,

minimize interruptions and no leaning!

• C-A-B sequence is a major change in training requires


• New emphasis on use of continuous wave capnography

to monitor endotracheal tube position and quality of CPR

• Epinephrine and amiodarone are only drugs with data

supporting their use, although epi is controversial

• Victims require excellent postcardiac arrest care by

organized, integrated teams.


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