#smaccMINI – Paediatric Resuscitation Update at #smaccDUB

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ILCOR published resuscitation updates in 2015 and I’m sure many of you have already familiarised yourselves with the changes. At smaccMINI I took the paediatric critical care workshop delegates through a whirlwind review of the major changes to paediatric resuscitation and a slightly more leisurely review of what to do when neonates appear with little or no warning 🙂

I would strongly recommend you take the time to look over the two guidelines as the summary of changes doesn’t quite capture the full story and reads a little out of context.

Children/Infants

Babies at Birth

Children & Infants

3 (2)Firstly, we are still following the A-B-C approach when it comes to resuscitating children and infants.

In the context of basic life support, compression-only CPR is acceptable if you are not trained in resuscitation but including ventilatory support is preferable (so healthcare professionals, no compression only CPR for you!)

Airway

It’s now standard to use cuffed tubes from 1yr onwards as long as we are mindful of cuff pressure <25cm H2O. When intubating it’s important to confirm ETT placement and there are a number of ways to do this;

  • See the tube pass through cords
  • EtCO2 (capnography>capnometer>colorimeter)
  • Chest rise symmetrically
  • Misting of tube
  • Absence of gastric distension (delayed)
  • Auscultation (axillae: breath sounds not heard over stomach)
  • Improvement in SpO2 with ventilation (delayed)
  • Improvement in HR with ventilation (delayed)

In babies weighing <2kg note that the colorimeter/capnometer may not work!

Absent CO2 does not exclude correct tube placement as it may reflect poor pulmonary flow (auscultate to assess) but consider oesophageal intubation in this instance.

Breathing

Ventilation breaths delivered as part of resuscitation should have a duration of 1 second per breath. As previously, we should resuscitate with a ratio of 2 breaths:15 compressions.

We should be using 100% oxygen for resuscitation then target SpO2 94-98% if return of spontaneous circulation (ROSC) is achieved.

Once a patient in cardiac arrest is intubated, ventilate at 10/min increasing to 12-14/min after ROSC.

Problems ventilating? Consider DOPES

  • Displacement (of ETT)
  • Obstruction
  • Pneumothorax
  • Equipment failure
  • Stomach (have a very low threshold for gastric decompression)

Circulation

In absence of signs of life, we should begin CPR unless certain we can feel a pulse – it’s appropriate to consider echo if available but not to delay CPR in order to do this.

Chest compressions should depress the chest 1/3 of the AP diameter – 4cm for an infant, 5cm for a child.

Shockable rhythms are rare, even in hospital (3.8-19%) so CPR should be prioritised and established before searching for a defib. The optimum dose for cardioversion is unknown but by consensus in Europe we are continuing to use 4j/kg for a biphasic defibrillator in shockable cardiac arrest rhythms. Be sure to apply pads firmly (in the left axilla and below right clavicle, or AP positioning); hands-on charging is advocated in the new guidelines in parallel with adult practice.

If you have access to ECMO services this should be considered if the cause is potentially reversible (especially for cardiac patients).

Caution regarding fluid bolus administration is advised for the resuscitation of children who are febrile but not shocked however even if the blood pressure is normal, in the presence of signs of inadequate systemic perfusion 20ml/kg isotonic crystalloid should be given as a bolus with reassessment after this and between subsequent boluses. There is growing evidence, say the guidelines, for balanced crystalloid use in place of normal saline. Avoid glucose containing solutions unless the child is hypoglycaemic.

For blood loss in major trauma, consider limited crystalloids and activate local massive transfusion protocol; consider thoracotomy for penetrating trauma.

What should you do after achieving return of spontaneous circulation (ROSC)?

The new guidelines contain lots of info on targets for physiological parameters but the bottom line is aim for normality:

  • Target SBP >5th centile for age
  • Aim for normoxaemia
  • ?Aim for normocapnia
  • Avoid hyperthermia (>37.5) (following the THAPCA trial) and severe hypothermia (<32)
  • Avoid hyper and hypoglycaemia but without rigid control

What about when resuscitation has been unsuccessful?

There is no single predictor of when to stop attempting resuscitation.

If the team is heading towards discontinuing resuscitation attempts, the guidelines remind us to consider family presence – and, if family are to be present, allocate a specific member of staff to liaise with them, explain proceedings and answer questions. Physical contact with the child should not be deterred (as long as it is safe and appropriate to do so) and where possible and in alignment with the family’s wishes their presence at the time of cessation of resuscitation (the child’s time of death) should be encouraged.

The responsibility for a decision to stop attempting resuscitation falls with the leader of team (rather than the family) but they should communicate this and explain the decision with sensitivity and understanding.

Debrief is recommended for staff involved with ongoing support for the child’s family.

Neonatal Transition and Resuscitation

15YIKES!

I know, newborns can be very scary. I spent a bit more time talking about this over general paediatric life support because I think this is an area where non-paediatricians feel very uncomfortable on the whole (versus PLS and APLS which we are exposed to more regularly). It is unusual for ED and critical care doctors to come into contact with freshly born neonates at all, let alone those requiring resuscitation. I can forsee two circumstances where this might happen:

  1. Someone delivers following spontaneous labour, unexpectedly in front of you (either in the ED or prehospital environment or perhaps on the street), which will most likely be a near-term or term delivery
  2. A peri-mortem caesarian section as a part of the resuscitation of a pregnant woman of >20 weeks’ gestation – we aren’t delivering the baby for the baby’s sake but it may justifiably require resuscitation too. If you’re not familiar with peri-mortem caesarian section (AKA resuscitative hysterotomy) as a life-saving procedure, check out the link at the start of this sentence or these resources over at EMCrit and PHARM.

If you find yourself in either of these situations the likelihood is one of your first steps will be to summon experienced neonatal resuscitation help but you still need to know what to do until that help arrives! You may not know the exact gestation of the baby in either scenario but a combination of assessing the pregnant uterus (reasonable to accept you won’t have time to find a tape measure but remember you can assume that once the fundus reaches the umbilicus gestation is 20/40 and by 38/40 it sits at the xiphisternum) or the size (weight) of the baby itself (you can usually tell an extremely preterm baby as they are very small! Normal birth weight is around 3kg at term).

So there are three possible broad states that the baby will be in when it is delivered to you.

28 Baby Scenario 1:

Vigorous crying, good tone, HR>100, pink/blue.

These babies are sometimes a little blue around the edges but with a good cry they pink up very quickly. For these babies, delayed cord clamping should be considered.

There are a number of proposed advantages to delayed cord clamping: improvement in iron status for next 3-6/12, reduced transfusion needs in the preterm infant, improved stability of blood pressure and heart rate during the neonatal period, possible reduction in interventricular haemorrhageperiventricular leukomalacia (these things are both potentially BAD) and late onset sepsis HOWEVER babies needing resuscitation have been excluded from all studies on delayed cord clamping so we need to employ a little common sense.

If no resuscitation is required, cord clamping can be delayed for 1min (there’s no need to milk the cord). You can dry and wrap the baby, hand him/her to mum for skin-to-skin or breast feeding (assuming that mum is in a fit state to receive her newborn) and remember to keep the baby warm (a clean dry towel may be sufficient).

29Baby Scenario 2:

Inadequate breathing/apnoea, normal/reduced tone, HR<100, blue.

These babies don’t require “resuscitation” per se but instead something we are now to call “assisted transition” to life outside the uterus. They are usually blue around the edges and may have a low heart rate, but they usually improve rapidly with drying and wrapping followed by mask inflation breaths, although some may require subsequent ventilation breaths too (see below). Don’t delay cord clamping in these babies – get them dry, warm and breathing.

30Baby Scenario 3:

Inadequate breathing/apnoea, floppy, low/undetectable HR, pale.

Don’t panic. This is actually relatively rare – only around 1-2 per 1000 births requires resuscitation as we are about to describe it.

As previously we want to dry and wrap the baby and begin to resuscitate – airway first, then inflation, then ventilation. These babies may also need some chest compressions and a very small number receive drugs.

Let’s Resuscitate!

So most of these babies needing help with transition or resuscitation will improve if you get the airway and ventilation right. For that reason the approach isn’t quite so much A-B-C as A-B, A-B-C – it’s all about the breaths.

We are going to make a rapid assessment of five things: breathing, tone, colour, heart rate and activity. Your best tools, apart from your visual and clinical assessment, are neonatal/paediatric/small ECG leads and neonatal/paediatric SpO2 monitoring (on the right hand – more on this below) so think about getting someone to get these out early.

HOWEVER it’s important that we still do three key things at the start – dry, wrap and start the clock. Timings matter.

Airway

After drying and wrapping, positioning is important – neonates should be positioned with the head in a neutral position – you might need a 2cm towel under the baby’s shoulder to maintain positioning and sometimes a jaw thrust or oropharyngeal airway is required too.

We used to routinely suction intrapartum and intubate for thick meconium staining but this is no longer deemed necessary. Only suction if there is thick meconium in a non-vigorous baby or if the airway appears obstructed (with meconium, blood etc) – remember to be gentle as suction can provoke laryngeal spasm or stimulate vagal tone leading to profound reflexive bradycardia.

Emphasis should be on achieving adequate ventilation in the first minute of life if the baby isn’t breathing – don’t delay this any further than is absolutely necessary.

Breathing

The first five breaths delivered are inflation breaths, designed to squeeze fluid from the lungs into the systemic circulation. They are longer, slower breaths than the normal breaths you might use in resuscitation of a child – your aim is to maintain initial inflation pressure for 2-3secs at a pressure of 15-30cmH2O (aim for 30cmH2O for term babies and 20-25cmH2O for preterm).

Ensure that the chest is rising. Effective inflation breaths may well see the heart rate rise within 30s – and this is key, so ask an assistant to apply neonatal (or cut adult) ECG monitoring.

For term babies we would start resuscitation in air (21%). If the baby’s heart rate is not improving, gradually increase FiO2 with preductal SpO2 monitoring (use a neonatal sats probe on the right hand as the left hand may or may not be pre-ductal – a neonatal probe obtains reading from 90% of normal term births, 80% preterm and 80-90% of those requiring resuscitation).

For preterm babies (<35/40): start low (21-30%) and titrate to achieve pre-ductal SpO2 at approx 25th percentile for healthy term babies after birth. Remember, SpO2 in utero sits at around 60% and increases to 90% within 10mins of birth. The 25th percentile corresponds to  SpO2 40% at birth and 80% at 10min (approx.) at sea level.

If the inflation breaths don’t trigger spontaneous ventilation we need to move to ventilation breaths which are shorter in duration (1second each).  If the baby remains apnoeic requiring positive pressure ventilation, use PEEP at 5cmH2O.

The guideline suggests that a T-piece achieves target tidal volume, inflation pressure and inspiratory time better in mechanical models than other methods but you can use a self-inflating or flow inflating bag in a crisis – whatever is available (in a small size please!).

Airway (Again)

Consider intubation if you are suctioning to remove presumed tracheal blockage; there is prolonged bag-valve-mask ventilation despite corrected mask technique and head positioning; if chest compressions will be being performed (ventilation may be compromised by compressions and we want to prioritise good ventilation) or in certain special circumstances  you probably aren’t going to even think about (diaphragmatic hernia).

We can consider an LMA as an alternative after 34/40 gestation or for babies >2kg in weight – if you have a small enough LMA available to you.

Breathing (Again)

Aetiology of conditions requiring neonatal resuscitation dictate that there’s no point in starting compressions before inflation breaths have been adequately achieved, so make sure if you haven’t been able to ventilate until now (when you’ve secured the airway), those five inflation breaths are delivered – then move on to…

Circulation

As with paediatric resuscitation we are going to give compressions if the heart rate remains <60/min despite adequate ventilation.

The hand encircling technique is recommended with thumbs adjacent: overlapping thumb positioning has been shown to be more effective but more likely to cause fatigue.

Unlike paediatric resuscitation, we are undertaking 1 breath: 3 compressions at a rate of 120 events (breaths and compressions) per minute. Remember to check the heart rate at 30s and periodically afterwards.

Since we have already tried to improve output with optimal ventilation using low O2 it’s now reasonable to increase FiO2.

Drugs are rarely indicated; if CPR hasn’t brought HR>60/min you might consider adrenaline for which we use the same dosing as in paediatric arrest (0.1ml/kg of 1:10,000). The preferred route is via an umbilical venous catheter (remember: 2 arteries, one vein). IV/IO are options if you can obtain access that way but the endotracheal route is no longer recommended.

Bicarbonate is not recommended for brief CPR. If there is blood loss/shock, consider volume: irradiated, leucocyte depleted O-ve blood can be used as first line, or consider isotonic crystalloid (10ml/kg initially) but this is RARELY needed, especially if preterm.

What should you do after achieving return of spontaneous circulation (ROSC)?

Hopefully your help has arrived because babies who have needed this much help need to be observed in the NICU. Just like following infant/paediatric ROSC we want to keep most parameters normal (the best evidence is for normal glucose but that evidence isn’t very good!)

The big difference is that we consider therapeutic hypothermia for term or near term infants with developing HIE. You might want to listen to Phil Hyde and Greg Kelly slug it out over the logic of cooling kids at smaccUS.

What about when resuscitation has been unsuccessful?

Neonatal resuscitation situations are about the only ones where there is clear guidance about when to stop attempting resuscitation: if you have attempted for 10mins or more with no heart rate recorded at any point, the guidance suggests this is an appropriate time to discontinue. However if you have a persistently low heart rate (<60/min), the situation is less clear and you probably need to engage whatever expert help you can get hold of.

There are also clear circumstances where withholding resuscitation attempts altogether is deemed appropriate: the guidelines suggest extreme prematurity (defined as <23/40), extremely low birth weight (defined as <400g), or birth abnormalities incompatible with life as reasons to withhold initial resuscitation (anencephaly is probably the only diagnosis you are going to be able to make in these circumstances with an unexpected delivery).

Communication throughout resuscitation

Communication really matters in this situation. Our aim should be to give baby to mum ASAP, weighed against the baby’s needs for resuscitation. If resuscitation is required, it’s essential to inform parents of procedures performed and why they were required and just like for paediatric resuscitations we should do our utmost to support parents who wish to be present at the bedside.

Again it is helpful to brief and debrief staff and to remember the need to support the parents beyond the immediate transition/resuscitation period (they may, for example, need counselling even if the resuscitation achieved ROSC successfully).

Putting it all together

There’s a nice algorithm to explain this process in a visual way that you can download in poster format here for free.

Further Resources

European Resuscitation Council Guidelines 2015: Children/Infants

European Resuscitation Council Guidelines 2015: Babies at Birth

All the ILCOR Guidance updates over at First10EM

First10EM’s updated Neonatal Resus Guideline

Summary of the draft version of the ILCOR guidelines over at DFTB (caution – some of these elements don’t seem to appear in the final guideline)

 

Nat

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