Cardiopulmonary Resuscitation Overview
Cardiopulmonary arrest in infants and children is rarely a sudden event. The usual progression of arrest begins with hypoxia, hypercarbia, and acidosis resulting in respiratory failure, which eventually leads to asystolic cardiac arrest. Etiologies include sudden infant death syndrome (SIDS), respiratory disease, sepsis, major trauma, submersion, poisoning, metabolic/electrolyte imbalance, and congenital anomalies. In contrast, primary cardiac arrest is relatively rare in the pediatric age group and is most frequently caused by congenital heart disease, myocarditis, and chest trauma with myocardial injury. Although asystole and pulseless electrical activity (PEA) are the primary rhythms in pediatric cardiac arrest, patients with sudden cardiac arrest are likely to have ventricular tachycardia (VT) or ventricular fibrillation (VF).
The outcome of unwitnessed cardiopulmonary arrest in infants and children is poor. Less than 10% of pediatric patients who have out-of-hospital cardiac arrests survive to discharge and most are neurologically impaired. In contrast, about one-third of children with in-hospital cardiac arrest survive to hospital discharge, with a better neurological outcome.
Begin resuscitation with C-A-B: Chest compression, Airway and Breathing, as the key factor in return of spontaneous circulation (ROSC) and survival is the maintenance of adequate coronary artery and cerebral artery perfusion. This is best achieved by starting resuscitation with chest compressions. However, individualize the CPR sequence based upon the location of the arrest and the presumed etiology.
Emergency Department Priorities
To optimize outcome, it is essential to recognize early signs and symptoms of impending respiratory failure and circulatory shock prior to the development of full cardiopulmonary arrest. All equipment, supplies, and drugs must be available and organized for easy access. It is imperative that the staff have training in American Heart Association Pediatric Advanced Life Support (PALS), and routinely practice mock pediatric resuscitations. Pediatric Advanced Life Support utilizes a systematic approach to the assessment and treatment of seriously ill or injured pediatric patients.
In order to optimize care in a high-stress situation, use pre-calculated drug sheets or the Broselow tape, a height-based weight system for accurate dosing of resuscitation medication which also offers immediate access to pre-sized emergency equipment. In addition, develop and maintain a comprehensive plan to organize the resuscitation team (Figure 1.1). Assign a role to each team member: team leader, airway management, chest compressions, achieving vascular access, obtaining a history, medication administration, recorder, and runner. Identify a team leader early whose sole responsibility is to oversee the resuscitation and coordinate the team dynamics. Ideally, along with the physicians and nurses, a respiratory therapist and pharmacist will assist the team. Prepare the essential equipment needed for resuscitation in advance, using the mnemonic IMSOAPP (Table 1.1).
| I | IV fluids/IV catheter/intraosseous needle |
| M | Monitors: cardiorespiratory; pulse oximeter; blood pressure |
| S | Suction: tonsil tipped (Yankauer) and flexible catheters |
| O | 100% Oxygen source |
| A | Airway equipment |
| Bag-mask: different size masks | |
| Oral airway: nasopharyngeal and oral | |
| Laryngoscope with assorted blades: Miller, Macintosh | |
| Tracheal tube: cuffed and uncuffed, multiple sizes | |
| Stylet | |
| P | Pharmacy: medications, either a pre-calculated drug sheet or Broselow tape |
| P | Personnel: call a code, have resuscitation team available |
Rapid Cardiopulmonary Assessment
Quickly perform a primary evaluation, which focuses on the Appearance, Airway, Breathing and Circulatory (ABCs) status of the patient. This initial examination provides assessment of the patient’s acuity, and prioritizes the urgency and aggressiveness of intervention in response to the degree of physiologic compromise. Following stabilization of the ABCs, the secondary assessment includes a complete head-to-toe examination of the patient, while maintaining normothermia and normoglycemia.
Appearance
Assess the general appearance of the patient. Evaluate the activity level of the child, reaction to painful or unfamiliar stimuli, interaction with the caretaker, consolability, and the strength of cry, relative to the patient’s age.
Airway
Airway patency is particularly prone to early compromise in pediatric patients, as the airway diameter and length are smaller than in adults. Determine whether the airway is clear (no intervention required), maintainable with noninvasive intervention (positioning, suctioning, oropharyngeal or nasopharyngeal airway placement, bag-mask ventilation) or not maintainable without intubation.
Breathing
Ventilation and oxygenation are reflected in the work of breathing and can be quickly assessed by the mnemonic RACE:
Rate: age-dependent. Tachypnea is often the first sign of respiratory distress, but it may also be secondary to acidosis.
Air entry:
– listen to breath sounds in all areas: anterior and posterior chest, axillae
– a priority is to rule-out tension pneumothorax: absent breath sounds, tracheal deviation
– abnormal sounds: rales, rhonchi, wheezing.
Color
– pink, pallid, cyanotic, or mottled
– pulse oximetry: use the O2 saturation as the fifth vital sign.
Effort/mechanics:
– “Tripod” position, nasal flaring, grunting, stridor, head bobbing;
– Accessory muscle use: sternocleidomastoid prominence;
– Retractions: suprasternal, subcostal, intercostal.
The presence of abnormal clinical signs of breathing such as grunting, severe retractions, mottled color, use of accessory muscles, and cyanosis are precursors to impending respiratory failure.
Circulation
The circulatory status reflects the effectiveness of cardiac output as well as end-organ perfusion. The rapid assessment includes:
Cardiovascular function:
– heart rate: age-dependent
– central and peripheral pulses: compare the femoral, brachial, and radial pulses
– blood pressure: age-dependent; use the following guidelines to estimate the lowest acceptable (fifth percentile) systolic BP:
Newborn to 1 month = 60 mm Hg
1 month to 1 year = 70 mm Hg
1–10 years = 70 mm Hg + ( 2 × age in years)
>10 years = 90 mm Hg.
End-organ perfusion (systemic circulation):
– skin perfusion: capillary refill (<2 seconds normal), color, extremity temperature (relative to ambient temperature)
– renal perfusion: urinary output = 0.5–1 mL/kg/h (about 30 mL/h for an adolescent)
– CNS perfusion: mental status, level of consciousness, irritability, consolability, AVPU response:
- A
awake
- V
responsive to voice
- P
responsive to pain
- U
unresponsive.
- A
Tachycardia and tachypnea are early signs of cardiorespiratory compromise. Observe for central or peripheral cyanosis and feel the skin temperature and moisture. With the fingers at the level of the heart, apply pressure to the nail bed until it blanches, then release, timing the interval until the fingertip “pinks up.” Delayed capillary refill (>2 seconds), and cool, clammy extremities are clinical indicators of poor perfusion. A systolic blood pressure below the fifth percentile (measured with an appropriate-size cuff), loss of central pulses, oliguria, and altered level of consciousness are ominous signs of impending hypotensive/decompensated circulatory shock.
Initial Management
Immediate goals in the emergency department (ED) include supporting ventilation and organ perfusion. After a quick initial assessment, determine if the child is responsive and is breathing with a pulse. If the patient is unresponsive, not breathing or only gasping, without a pulse, immediately start CPR starting with chest compression, open and maintain the airway, support ventilation and perfusion, and identify and treat reversible causes (Table 1.2 and Figure 1.2).
Airway Management
Airway management is always the initial priority. To open the airway, first use simple maneuvers such as repositioning the head, suctioning secretions from the mouth, and placing an oropharyngeal or nasopharyngeal airway.
Head Tilt–Chin Lift
Open the airway using the head tilt–chin lift technique or jaw thrust maneuver. In an unresponsive child, perform the head tilt–chin lift maneuver by placing one hand on the patient’s forehead and gently tilting the head back into a neutral position. Curl the fingers of the other hand gently under the jaw near the chin, and lift the mandible upward to open the airway.
Jaw Thrust
In a known or suspected trauma victim, use the jaw thrust maneuver without head extension. Protect the cervical spine by providing manual in-line traction. Place one hand on each side of the patient’s head to hold it still, since immobilization devices may interfere with maintaining a patent airway. Perform the jaw thrust by keeping the head midline, placing the fingers at the angle of the jaw on both sides, and lifting the mandible upward and forward without extending the neck. If a jaw thrust does not open the airway, protect the C-spine and use a gentle head tilt–chin lift maneuver to open the airway, since maintaining airway patency is critical in providing adequate ventilation.
Suction Catheters
Suction secretions and blood from the nasal passages, oropharynx, and trachea with flexible suction catheters. These must be available in sizes small enough to pass through the smallest endotracheal tube (ETT). A 5 Fr catheter will pass through a 2.5 mm ETT (usually 2 × the ETT size). Large rigid tonsil tip catheters (Yankauer) have rounded tips which are less likely to injure the tonsils and are useful for clearing blood and particulate matter from the mouth and hypopharynx. Limit suctioning to less than ten seconds, while monitoring the pulse oximeter and heart rate, as vigorous suctioning may cause vagal stimulation resulting in bradycardia and hypoxia.
Oropharyngeal Airway
The oropharyngeal airway is an adjunct for ventilating an unresponsive patient with an absent gag reflex. It will keep the base of the tongue away from the posterior pharyngeal wall to maintain airway patency, and it will also serve as a bite block in intubated patients. Do not use in an awake patient as it can precipitate vomiting and laryngospasm.
An appropriately sized oral airway extends from the corner of the patient’s mouth to the angle of the jaw. Use a tongue depressor to push the tongue down, and insert the oropharyngeal airway with its curvature along the hard palate. In infants and children, avoid inserting an airway that is too large. Do not attempt to insert the airway in an inverted position and then rotate it 180°, as this technique may damage the palate and push the base of the tongue posteriorly, occluding the airway. The proximal part of the oral airway is firm and flat and is designed to be placed between the teeth to prevent biting (the tracheal tube or your finger). Tape the flange to the lips to prevent it from being dislodged.
Nasopharyngeal Airway
Use a nasopharyngeal airway in an obtunded patient with an intact gag reflex to prevent upper airway obstruction secondary to a floppy tongue. Estimate the size by measuring the distance from the tip of the nose to the tragus of the ear; the appropriately sized airway extends from the nostril to the base of the tongue without compressing the epiglottis. Lubricate the device and gently insert it along the floor of the nostril to avoid injuring the nasal mucosa or adenoids. A nasopharyngeal airway is contraindicated in a patient with a suspected basilar skull or nasal bone fracture.
Foreign Body Airway Obstruction
If choking or airway obstruction from a foreign body is suspected and the patient is awake and can speak, make no attempts to remove the object. Allow the patient to cough and clear the airway while observing for signs of complete obstruction (i.e., the victim is gagging, struggling to breathe, has high-pitched noise while breathing, is unable to make a sound, or is cyanotic). Remove the foreign body from the mouth only if it is visible. Do not perform blind finger sweeps in any age because the obstructing object may be pushed further into the pharynx and cause complete airway obstruction. If the patient deteriorates, use the following procedures, as summarized in Table 1.2.
Infants <1 Year of Age
Lay the infant prone over your thighs, with the head supported in a dependent position. Alternatively, hold the infant over your arm, in the prone position, supporting the head in your hand. Deliver five sharp back slaps, in rapid succession, between the baby’s scapulae. Turn the infant over and give five chest thrusts using two fingers on the mid-sternum, as in giving chest compressions. Look into the mouth to see if the foreign body is dislodged. Repeat these maneuvers until the object is expelled or the infant becomes unconscious. Do not perform abdominal thrusts in infants as there is risk of injury to the abdominal organs.
Unconscious Infant
First open the mouth wide by grasping the tongue and jaw, and look for the foreign body in the oral cavity. If an object is seen, remove it, but do not perform a blind finger sweep. If there is no improvement, begin cardiopulmonary resuscitation (CPR) providing five cycles (30 compressions and 2 breaths per cycle) over 2 min. If breaths cannot be delivered, reposition the head and try again, or proceed with advanced airway maneuvers until respirations have been restored.
Children >1 Year of Age to Adolescent
Use the Heimlich abdominal thrust maneuver in this age group. If the patient is awake, stand or kneel behind the child and position the heel of the hand in the midline of the epigastrium with the other hand on top of the first, then give a rapid series of separate and distinct upward thrusts. With each thrust use sufficient force to dislodge the foreign body. For a small child, the heel of one hand is sufficient, as overly vigorous abdominal thrusts may cause damage to internal organs. If the patient loses consciousness, lay the child supine on the floor, reposition the head, and attempt to visualize the object. Do not attempt a blind finger sweep. If the object is not visualized, begin CPR, providing five cycles for 2 min.
A foreign body may also be removed under direct visualization with a laryngoscope and Magill forceps. Consult an otolaryngologist to remove more distal tracheal or laryngeal foreign bodies via flexible bronchoscopy.
Oxygenation, Ventilation, and Intubation
Once the airway has been stabilized and the breathing assessed, the need for oxygenation and ventilation takes priority. Provide supplemental oxygen to all patients with respiratory distress. Reassess breathing effort by physical examination and pulse oximetry. The equipment for airway support is described below.
Nasal Cannula
Oxygen can be delivered by a low-flow or high-flow system. The actual oxygen concentration delivered by nasal cannula is unpredictable, so this method is appropriate only for a patient who requires minimal O2 supplementation. Low-flow oxygen is delivered by nasal cannula at rates of 1–4 L/min and provides O2 concentrations of 22–60%. However, flow rates >3 L/min are usually poorly tolerated by children, while flow rates >1–2 L/min may inadvertently administer positive pressure to newborns.
High-flow nasal cannula (HFNC) delivers an oxygen concentration of >60% at flow rates from 1–8 L/min in infants to 50–60 L/min in children and adults. Titrate the flow for additional inspiratory and expiratory pressure based on the patient’s work of breathing. High-flow nasal cannula uses a special device that warms and humidifies high flows of a combination of room air and oxygen. It can be used as an alternative to standard oxygen therapy or noninvasive positive pressure ventilation in a patient with acute hypoxemic respiratory distress without hypercapnia. Maximum deliverable flow rates vary by device manufacturer.
Simple O2 Mask
This is the most frequently used method for oxygen delivery in spontaneously breathing patients and it is more easily tolerated than nasal cannula. The actual O2 concentration that the patient receives is dependent on the flow rate and the patient’s ventilatory pattern, as room air enters through the ventilation holes on the sides of the mask. Oxygen flow rates of 6–10 L/min will deliver O2 concentrations of 35-60% and prevent rebreathing of exhaled CO2.
O2 Mask With Reservoir
A nonrebreather (NRB) mask is another form of high-flow delivery system which consists of a simple mask attached to a reservoir bag that is connected to an oxygen source. The NRB contains one-way valves at the exhalation ports to prevent the entrainment of room air, and a second valve at the reservoir bag to prevent the entry of exhaled gas back into the reservoir bag. The reservoir bag must be larger than the patient’s tidal volume (5–7 mL/kg) and remain inflated during inspiration. Oxygen concentrations up to 60% can be achieved in partial rebreathing systems, and >95% is possible if the oxygen flow rate is 10–15 L/min, and a good seal is maintained around the facemask.
Ventilation
For patients with respiratory failure, ventilate with a bag-mask apparatus until all the appropriate equipment and personnel for intubation are assembled. For optimum airway alignment, position the patient so that the auditory meatus is in line with the top of the anterior shoulder. Use the “sniffing” position in an older child by placing a folded towel under the head and elevating it. Due to a relatively larger head in an infant, keep the head midline and neck slightly extended with a pad under the shoulder. Flexing or overextending the neck may inadvertently obstruct the airway.
Adequate ventilation results in symmetric movement of the chest wall, with good breath sounds heard on auscultation. If the patient is making any respiratory effort, synchronize the delivered breaths with his or her efforts.
Bag-Mask
The most common system used to ventilate an apneic patient consists of a self-inflating bag (Ambu Bag), an O2 reservoir (corrugated tubing), and mask with a valve. These bags do not need a constant flow of O2 to refill. Using a reservoir with a supplemental oxygen flow rate of 10–15 L/min delivers 60–95% oxygen to the patient. Ensure that the corrugated tubing is pulled out to its full length to allow for the largest reservoir. If the bag has a pop-off valve set at 35–45 cm H2O, there must be a way to override it, since ventilatory pressure may be inadequate in patients with increased airway resistance or poor lung compliance.
Adequate ventilation requires an appropriate-size facemask, one that extends from the bridge of the nose to the cleft of the chin. The minimum volume for the bag in newborns, infants, and small children is 450–500 mL; use an adult bag (1000 mL or larger) for adolescents. If the only bags available are larger than the recommended size, ventilate infants and children by using the larger bag with a proper-size face mask and administering only enough volume to cause the chest to rise.
Use the E-C clamp technique to achieve proper ventilation with a bag-mask device. Hold the mask snugly to the face with the left thumb and index finger forming a “C.” Apply downward pressure over the mask to achieve a good seal, while avoiding pressure to the eyes. Place the remaining three fingers of the left hand, which form an “E,” on the mandible to lift the jaw, avoiding compression of the soft tissues of the neck. Using two hands to maintain the mask against the face (double E-C), while having a second provider compress the bag, will provide better ventilation than having a single provider perform bag-valve-mask alone.
Use a rate of 12–20 breaths per minute for an infant or child (Figure 1.2) (approximately one breath every 3–5 seconds). Squeeze the bag gently and deliver the breath over one second. Observe the chest rise, listen for breath sounds, and monitor the O2 saturation. Bagging too rapidly or using excessive pressure causes inflation of the stomach and barotrauma to the airways. If ventilation is difficult or breath sounds are unequal, reposition the head, suction the airway, switch to two-person bag-mask ventilation, and consider foreign body aspiration or pneumothorax. An oral or nasopharyngeal airway may help to maintain a patent airway during bag-mask resuscitation, and if the patient is ventilated for more than a few minutes, place a nasogastric tube to decompress air from the stomach to minimize the risk of aspiration from vomiting.
Intubation
Tracheal intubation is the best way to manage the airway during cardiopulmonary resuscitation. The indications for tracheal intubation include:
apnea
respiratory failure despite effective initial intervention
lack of airway protective reflexes (gag, cough)
complete airway obstruction unrelieved by foreign body airway obstruction maneuvers
CNS disorder (increased intracranial pressure, inadequate control of ventilation)
Before attempting intubation, ensure that all necessary supplies, medications, and personnel are available. All equipment must be available in various sizes along with spare laryngoscope handles, bulbs, and batteries. A Broselow tape, which accurately correlates weight with length (for patients <35 kg), gives precise sizes of airway equipment, as well as appropriate drug doses. “Straight blades” (Miller) are often easier to use than “curved blades” (Macintosh) in infants and young children. Estimate laryngoscope blade size by measuring the distance from the incisors to the angle of the mandible. If the patient is between sizes, use a blade that is larger and then pull back to visualize the cords. See Table 1.3 for the most popular age-appropriate blade sizes.
ETT Tubes
Estimate the tracheal tube size by matching the diameter of the endotracheal tube (ETT) to the width of the nail of the patient’s fifth finger or the diameter of the nares. Tracheal tube size for different age groups is listed in Table 1.4. Alternatively, use the following formulas, but always have available tracheal tubes 0.5 mm larger and smaller than the calculated size:
Previously, cuffed tracheal tubes were indicated only in children >8 years of age. Now, low-pressure cuffed tracheal tubes may be used in all ages (except newborns), provided the cuff inflation pressure is kept <20 cm H2O.
Prepare the tracheal tube with a stylet tip placed 1 cm from the distal end of the tube and bent in a gradual anterior curve at the distal third. The tip and cuff of the tube may be lubricated with viscous lidocaine or a water-soluble gel for easy passage.
Intubation Procedure
In an emergency situation, perform oral intubation, which is easier than nasal intubation. In general, use a straight Miller laryngoscope blade for pediatric intubations. Have a tonsil tipped suction (Yankauer) and an appropriately sized flexible suction catheter readily available. To intubate the patient, keep the head midline in the “sniffing” position. If cervical spine trauma is a concern, have an assistant maintain manual in-line stabilization during the intubation, avoiding traction or movement of the neck. Continuously monitor the heart rate and pulse oximeter throughout the procedure.
Place the thumb and index finger of the (gloved) right hand into the right side of the patient’s mouth. Place the index finger on the patient’s upper teeth and the thumb on the lower teeth, using the scissor technique to open the mouth as wide as possible. Hold the laryngoscope in the left hand and introduce the blade into the right edge of the mouth, sweeping the tongue toward the left and out of the line of vision. Position a straight blade under the epiglottis and place a curved blade into the vallecula. Lift by pulling the handle of the laryngoscope up and away at a 45° angle to the floor, in the direction of the long axis of the handle. If the blade is in too deep, slowly withdraw it until the glottis pops into view. Be careful not to tilt the handle or blade, which may risk breaking or damaging the teeth.
The routine use of cricoid pressure (Sellick maneuver) during tracheal intubation in cardiac arrest is not recommended, as it may not prevent aspiration, while potentially interfering with the delivery of positive pressure breaths.
Once the vocal cords are exposed, introduce the ETT from the right side of the mouth (not down the barrel of the blade). Advance the ETT until the cuff just passes beyond the vocal cords. Uncuffed tubes often have a mark at the distal end of the tube, which when placed at the level of the cords will position the distal tip in the mid-trachea. As an alternative, estimate the tube depth to be equal to 3 × ETT size. A proper-size ETT easily passes through the cords. If it meets resistance in the subglottic area, do not try to force it through. Rather, replace it with a smaller tube. Hold the tube securely against the upper teeth or gums and carefully withdraw the laryngoscope first, and then remove the stylet from the ETT. If the patient was intubated with a cuffed tube, inflate the cuff to a pressure of <20 cm H2O.
Confirming Position
Verify proper tube placement by listening for equal breath sounds and observing symmetrical rise of the chest. Confirm the presence of exhaled CO2 from the tracheal tube with either a colorimetric CO2 detector or capnography, and use a pulse oximeter to monitor oxygen saturation. Colorimetric devices are inaccurate if the patient does not have a perfusing rhythm (even with appropriate chest compressions) or the patient weighs <2 kg. Use continuous quantitative waveform capnography (PetCO2) to confirm correct placement of the ETT and to monitor intubated patients throughout the periarrest period. If breath sounds are louder over the stomach than the chest, or if it is unclear that the tube is in the trachea, remove the tracheal tube and ventilate by bag-mask. An audible air leak is expected with an uncuffed tube, but if there is a large air leak or none at all, the tube size may be inadequate; replace with an appropriately sized ETT. Secure the ETT to the patient’s face with tape or use a tracheal tube holder. Obtain a chest radiograph to confirm that the tip of the tube is opposite T2 (one fingerbreadth above the carina). Be aware that neck extension or head movement brings the tube higher, while neck flexion pushes the ETT deeper.
Complications
If the patient deteriorates after endotracheal intubation, use the mnemonic DOPE to reassess: Displacement of the tube into the esophagus or down the right mainstem bronchus; Obstruction of the tube with blood, secretions or kinking; Pneumothorax with decreased breath sounds and chest expansion on the affected side and deviation of trachea to the opposite side; or Equipment malfunction. If the patient is on a ventilator, disconnect and either attempt to ventilate with a bag or replace the ETT.
Rapid-Sequence Intubation
The goals of rapid-sequence intubation (RSI) are to create ideal intubating conditions by attenuating airway reflexes while minimizing elevations of intracranial pressure and maintaining adequate blood pressure. Rapid-sequence intubation is indicated for patients who require emergent tracheal intubation but are at high risk for pulmonary aspiration of gastric contents. Medications to facilitate intubation are rarely needed for patients who are moribund or in cardiac arrest, or for newborns within a few hours of delivery.
Anticipate the possibility of an unsuccessful intubation and prepare for alternate airway techniques before initiating sedation. Also, expect a difficult intubation and request help for patients with significant facial trauma, restricted neck extension, or if the tip of the uvula is not visible when the mouth is opened. Do not use sedation or muscle relaxation if there is any concern that bag-mask ventilation will be inadequate.
NEVER sedate or paralyze a patient whom you may not be able to ventilate!
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