So my next topic is on cardiopulmonary resuscitation. And again, this is a summary of Dr. Ryan Morgan's presentation. Again, Dr. Morgan's an expert in cardiopulmonary resuscitation, is doing a lot of exciting work in this area. And therefore, he's the expert. And I'm just summarizing it for you all. Here are my disclosures. Just a little bit about epidemiology. Cardiac arrests in children are actually relatively rare events, but when things happen, it's not so good for the child. So it's really prevention is really the key for management of cardiac arrests. Cardiac arrests can happen anywhere, out of hospital and in hospital. I just put this up as a way of differentiating what might be different in out of hospital and in hospital cardiac arrests. Out of hospital cardiac arrests are relatively rare compared to in-hospital cardiac arrests. And that's the incidence per year from the American Heart Association Get With The Guidelines Registry. Out of hospital cardiac arrests are commonly in infants, as compared to older children. Out of hospital cardiac arrests can happen anywhere. But if you're in-hospital cardiac arrests often happen in monitored environments. And therefore, their survival is better because you have monitors, you have people to start resuscitation relatively quickly. Out of hospital cardiac arrests are largely related to respiratory arrests. And therefore, their presenting rhythms are often non-shockable rhythms. If you take out of hospital cardiac arrests into adults, then they often have shockable rhythms because those arrests are largely related to coronary artery disease or acute coronary syndromes. And they often present with ventricular fibrillation, ventricular tachycardia, compared to children who've had a respiratory event, have progressively become hypoxemic, and then have a non-shockable rhythm as their presenting rhythm. Many etiologies for cardiac arrests in children, respiratory failure, progressive shock seem to be the most common ones. And survival for cardiac arrests really depends on underlying conditions, reversible causes. So etiology of arrests, presenting rhythms. If somebody presents with ventricular tachycardia, ventricular fibrillation, the likelihood that you get ROSC is much higher compared to asystole or PEA. Quality of resuscitation is increasingly important. Duration of cardiopulmonary resuscitation before you receive ROSC. So everything that we do for managing cardiac arrests are to get that patient into return of spontaneous circulation as soon as we can. Post-arrest factors, and then increasingly use of ECMO to support cardiopulmonary resuscitation in certain situations have actually really helped improve some outcomes for children with cardiac arrests. What are the goals of cardiopulmonary resuscitation? The goals of cardiopulmonary resuscitation are really to provide temporary cardiac output whilst you're awaiting ROSC to happen. And to optimize condition for return of circulation, the most important thing that you can do is maximize coronary perfusion. And you maximize coronary perfusion by maintaining a good diastolic blood pressure. Remember, coronary arteries fill during diastole, and therefore diastolic filling will and therefore diastolic filling pressure is really the most important aspect of improving the ability to get ROSC. So maximizing coronary perfusion, so you're resuscitating based on that as your goal. You want to treat reversible causes. And in patients with ventricular fibrillation, early defibrillation's really important because that really improves survival in those patients. We've talked, AHA's spent a lot of time talking about or teaching high-quality CPR, the components of that are chest compression, appropriate depth, appropriate rate, the rate is 100 to 120, with minimal interruptions. Interruptions in CPR are a big no-no. Minimize interruptions, adequate depth, appropriate rate. Allow full chest recoil to fill your heart because if you're leaning on the chest, you're not gonna fill that heart. And therefore, allow full chest recoil. Excessive ventilation is bad, but no ventilation's also bad, especially in children, because the most common etiology for respiratory, for cardiac arrest is respiratory failure, and therefore you want appropriate ventilation and early defibrillation, as I previously mentioned. Early medication administration in patients with PA or ACEs, early use of epinephrine is associated with better outcomes. We all know basic life support, and I just put that up there. I just did my PALS last week, recertification of PALS last week. I just put that up there so that you don't have to go back to your PALS to answer a question in the test. So if you are a single rescuer and out of hospital, it's 30 to two is your chest compression to ventilation ratio, and if there are two rescuers, it's 15 to two. I previously mentioned the rate of chest compression should be 100 to 120, and the depth of chest compression is four centimeters for infants, or 1.5 inches, and five centimeters for children, which is two inches, and adults, actually. So four and five centimeters, just things to remember without having to go back to the book, if that could help with a lot of reading for tests. If you have a patient with ventricular fibrillation, the algorithm is early shock, so shock, shock, epi, shock, amiodarone. So shock, shock, epi, shock, amiodarone. So that's your ventricular tachycardia, ventricular fibrillation algorithm. If you have PEA, then you have a non-shockable rhythm and early use of epinephrine, so early onset of CPR, early administration of epinephrine, and look for the five H's and five T's to make sure that you've thought about all etiologies for cardiac arrest. Bradycardia is somehow a little bit more difficult. Bradycardia is defined as a heart rate less than 60, and if you come to my ICU, a heart rate less than 60 may not be that uncommon. But if you have a heart rate less than 60, but you're symptomatic, which means that you're in shock, then you really wanna start chest compressions as soon as you can, and the medication to use in those circumstances are epinephrine. You can use atropine, I believe it's recommended, for AV block. If you have somebody who's presenting in what looks like symptomatic bradycardia, but has AV block, the PALS algorithm recommends use of atropine. But I think I would rather use pacing to kind of get your patient through. So the ways you can pace patients in bradycardia are external defibrillator pads, or if you're in my ICU, we can quickly sink in a transvenous pacemaker wire, and then pace you through that. A few other things on pediatric advanced life support. The need for an advanced airway, there's no recommendation for intubating somebody without a hospital or in-hospital cardiac arrest. There's no studies to support or say no to it, so it's kind of up in the air. But increasingly, ventilator rates become something that people have talked about. Not ventilating a patient adequately is bad. Excessive ventilation is also bad. So in an intubated patient, the recommended rate of ventilation is 20 to 30. The dose of epinephrine is .01 milligrams per kilogram, and it's to be given every three to five minutes. Any delay in epinephrine, especially in PA and asystole, is associated with poor outcomes, so early epinephrine use is really important. And then there's other medications that we sometimes use, calcium and bicarb. In the cardiac intensive care unit, calcium is very commonly used because we use it as an inotrope. A lot of our patients have had blood transfusions, and therefore people think that they're hypocalcemic. But administering calcium in a patient who has a cardiac arrest is associated with poor outcomes, and therefore you should only use it if there are indications. And the indications for use of calcium in a cardiac arrest are hypocalcemia, hyperkalemia, or calcium channel blocker overdose. So those are the indications for calcium administration. I'm not so sure about bicarb, even though bicarb is not recommended. There are some circumstances where improving pH may actually be a good thing. So I'm not so sure, and there's definitely more work being done in the bicarb area, but I know that there are at least a couple of observational studies showing that calcium is associated with poor outcomes. And then the antiarrhythmics that we use are, in general, amiodarone and lidocaine, and there's no difference between the two. So five milligrams per kilogram of amiodarone or one milligram per kilogram of lidocaine for shock refractive ET or VF have similar outcomes. So that's kind of some medications. And then there's increasing emphasis on monitoring the adequacy of cardiopulmonary resuscitation, and that's largely been promoted by the use of a CPR coach whose only job is to make sure that you're compressing adequately, that you are being monitored adequately, and that you have some feedback so that you might improve the way you're performing cardiopulmonary resuscitation. The goal of cardiopulmonary resuscitation is to maintain a diastolic blood pressure of at least 25 in infants and 30 in children, or maintaining an entitled CO2 of more than 10 millimeters. I thought it was 15, but it's more than 10 millimeters of mercury because anything less than 10 means that you're not compressing adequately and it's associated with poor survival. And it's really important to debrief events to improve your system performance of cardiopulmonary resuscitation. There's a number of papers now to show that debriefing events is actually associated with better performance of CPR in healthcare systems. There's no recommendations for the use of extracorporeal life support. ECMO is recommended as part of resuscitation for refractory cardiac arrest in patients with a cardiac diagnosis who have in-hospital cardiac arrest in settings where you can mobilize ECMO relatively quickly. And it's largely experience-based, so the level of evidence for that is actually really quite low. Increasing emphasis on post-arrest care. We know that many patients after cardiac arrest get ROSC, but very few go home. So there's lots of patients who die in between. And one way of improving their outcomes is to be focused on post-resuscitation care. If you actually look at the literature, the number of patients who remain hypotensive after return of ROSC that then eventually leads to death is actually quite high. It's 20 to 30% of patients remain hypotensive after ROSC. So this post-arrest care is largely aimed at standardizing our approach to post-arrest care so that we provide the best opportunity for a patient who's had return of circulation to recover and survive. So the principles of post-arrest care is managing ischemic injury and ischemia reperfusion injury. And that largely affects the brain and your heart and end organs. It also emphasizes on treating an etiology of cardiac arrest so that that etiology doesn't continue to perpetuate low cardiac output syndrome or a second arrest. The paper by Alexis Topchan from CHOP is actually a really excellent read. And if you are interested in this field, I think it's a really good paper to read. So the components of post-arrest care is providing adequate monitoring. And adequate monitoring requires a continuous blood pressure monitoring, which is placing an arterial line, temperature, continuous temperature monitoring, and laboratory monitoring. The principles are to manage normal perfusion pressure, a normal systolic pressure greater than the fifth percentile for age. And for adults, it's a mean blood pressure of greater than 60 is what's recommended for post-arrest care. So whether you need to give them volume or use inotropes to maintain a perfusion pressure is really important. It's really important to avoid hyperthermia, to show that hypothermia is bad, especially for neurological outcomes. The recommendation between therapeutic hypothermia or targeted temperature management is equivocal. So you could use one of the two. And the recommendation is if you're doing 32 to 34, it's two days of 32 to 34, followed by three days of normothermia or five days of normothermia. And once you've maintained a patient with controlled temperature, then you allow the temperature to rise in a standardized, slow fashion. Normal oxygen saturations recommended is 94 to 99%. You don't want hyperoxia. Hyperoxia causes oxygen radical-related injury. So the saturations that they recommend is 94 to 99%. And if you come to my ICU, again, different bars for saturations. If normocarburea is really important, if you blow a patient's carbon dioxide down, then you're causing brain ischemia. If you allow carbon dioxide to be inadequate, then you may perpetuate increased cerebral blood flow and therefore cerebral edema. So you wanna have normocarburea in those patients. It's important to manage glucose. If patients have seizures, most centers now do 24-hour continuous EEG monitoring. Early management of seizures is really important. And then prognostication. Specific recommendations for prognostication as well. So in summary, Ryan's talk on cardiac arrest is really extremely well done and has lots of really good points. So please listen to that and use that. Pediatric cardiac arrest is common and it's associated with poor outcomes. The emphasis is really prevention of arrest. If you have a deteriorating patient, intervene early so that you can prevent the patient from arresting. Good quality CPR is really essential. The goal of CPR is to get ROSC and you get ROSC by maintaining coronary blood flow and therefore managing the diastolic blood pressure, good rate and depth of chest compressions is really important. Minimize interruptions. Know your pulse algorithms. Early defibrillation for VT, VF without a pulse is really important. And early use of epinephrine in patients who have PA or asystole. And then post-arrest care. And the principles of post-arrest care is maintaining a good perfusion pressure, targeted temperature management, invasive monitoring, treating seizures and making sure that all organs are well covered for your patient. That's my last talk. Thanks. Thank you.

CPR

cardiac arrest

children

defibrillation

post-arrest care