Ped's CPR CASE QUIZ

[WANTYNU]

The following was presented by a Dr. who works with our Critical Care Group.

A 10-year-old boy is in the PICU for evaluation of cardiomegaly. He was well until 1 week ago, when he had a flulike illness. Over the past 2 days, he has experienced shortness of breath when lying flat and dyspnea on exertion.

Laboratory studies have been ordered to evaluate for myocarditis and cardiomyopathy. Echocardiography shows globally diminished function but no structural defects.

Currently, the boy is receiving intravenous diuretics, an infusion of milrinone (0.5 mcg/kg per minute), and oxygen via nasal prongs. Suddenly, his arterial waveform flattens, and he becomes unresponsive.

The nurse calls for assistance and begins cardiopulmonary resuscitation (CPR) with bag-mask ventilation with supplemental oxygen.

Of the following, the MOST appropriate next step is to

A. administer 0.1 mg/kg epinephrine (1:1,000) intravenously

B. administer 0.01 mg/kg epinephrine (1:10,000) intravenously

C. attempt defibrillation with 2 J/kg

D. determine the cardiac rhythm

E. secure the airway with an endotracheal tube

Answer to follow.

Be Safe,

WANTYNU

[Fluffpaw38]

determine the rhythm and if its tachycardia/ventricular fib. then you shock.

[fiznat]

Definitely assess before we think about treating. Out of the choices I would like to know about the heart rhythm, but a full assessment is obviously in order. Is this patient actually pulseless? Is he aepnic? Is he completely unresponsive or is there a response to noxious stimuli? How well is he ventilating on his own vs with the BVM. Patent airway for now? Pupils, BGL, vital signs, etc, etc etc.

...Oh, and stop those meds for now.

[WANTYNU]

Definitely assess before we think about treating. ..... Is this patient actually pulseless? Is he aepnic? Is he completely unresponsive or is there a response to noxious stimuli? How well is he ventilating on his own vs with the BVM. Patent airway for now? Pupils, BGL, vital signs, etc, etc etc.

...Oh, and stop those meds for now.

"Suddenly, his arterial waveform flattens, and he becomes unresponsive. "

This means no cardiac output, No cardiac output = no breathing. So far treatment is appropriate, what is the MOST appropriate next step?

-w

[fiznat]

"Suddenly, his arterial waveform flattens, and he becomes unresponsive. "

This means no cardiac output, No cardiac output = no breathing. So far treatment is appropriate, what is the MOST appropriate next step?

No, it means only that the waveform is flat. We still need to check for a pulse and actually touch this patient to confirm that it is an arrest.

Given that it is a code though, I'd still like to check the rhythm before we start getting into the shock/meds routine. ...And like I said, shut those meds off. Milrinone has a well-known potential to instigate ventricular dysrhythmias.

[WANTYNU]

FYI at no point was any inference made that suggests the patient did not have a PE, in fact it is implied.

No, it means only that the waveform is flat. We still need to check for a pulse and actually touch this patient to confirm that it is an arrest.

Given that it is a code though, I'd still like to check the rhythm before we start getting into the shock/meds routine. ...And like I said, shut those meds off. Milrinone has a well-known potential to instigate ventricular dysrhythmias.

"Suddenly, his arterial waveform flattens, and he becomes unresponsive. "

This means no cardiac output, No cardiac output = no breathing. So far treatment is appropriate, what is the MOST appropriate next step?

I stand by this statement, I will not argue what a A line wave form reading from properly maintained and applied equipment means (this is assumed in the scenario).

Here is the answer,

-w

The following discussion is based on American Heart Association recommendations from 2005.

Recent reports of in-hospital CPR document survival rates of 27% in pediatric patients, with 65% of survivors having good neurologic function. In Nadkarni's recent study of in-hospital pediatric cardiac arrest, initial cardiac rhythm was associated with survival in logistic regression analysis. The child described in the vignette had a monitored arrest in the PICU with rescue breaths delivered. After starting 2-person CPR with 15 compressions followed by two breath cycles, optimally an automated external defibrillator (AED) should be applied using either paddles or self-adhering electrodes that fit on the chest wall without touching to assess cardiac rhythm and potentially intervene.

AEDs can detect and differentiate “shockable” from “nonshockable” rhythms in children with a high degree of sensitivity and specificity. Adult pads can be used for children who weigh more than 10 kg. Initially, 2 J/kg is recommended, followed by immediate resumption of CPR for five cycles prior to assessing response. Subsequent defibrillation is increased to 4 J/kg, again followed by prompt resumption of CPR and 0.01 mg/kg epinephrine intravenously or intraosseously. If ventricular fibrillation (VF) continues, amiodarone 5 mg/kg or lidocaine 1 mg/kg can be considered. Administration of magnesium sulfate (25 to 50 mg/kg, maximum of 2 g) should be considered for torsades de pointes.

Once sudden cardiac arrest occurs, prompt determination of presenting cardiac rhythm is key to potential survival. Asystole is the most common initial pulseless rhythm in pediatric arrest victims. Following initiation of CPR, epinephrine (0.01 mg/kg) should be administered for asystole. (VF) or pulseless ventricular tachycardia (VT) occurs as the first documented pulseless rhythm in approximately 14% of hospitalized children who have a cardiac arrest. The incidence of a “shockable” rhythm increases with age.

Defibrillation is the definitive treatment for VF, and survival rates decrease with delays in defibrillation. Survival for victims who suffer pulseless VT or VF is greater than for patients who have pulseless electrical activity or asystole as the first documented arrest rhythm. However, patients who develop VF or VT during ongoing CPR have significantly lower survival.

A randomized trial of high-dose epinephrine (0.1 mg/kg) compared with standard-dose (0.01 mg/kg) therapy in children who had cardiac arrest did not show any benefit and suggested that the high-dose therapy may worsen outcome. High-dose epinephrine is no longer recommended to treat cardiac arrest.

References:

Nadkarni VM, Larkin GL, Peberdy MA, et al. First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. JAMA. 2006;295:50-57. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/1639121...pt=AbstractPlus

Perondi MBM, Reis AG, Paiva EF, Nadkarni VM, Berg RA. A comparison of high-dose and standard-dose epinephrine in children with cardiac arrest. N Engl J Med. 2004;350:1722-1730. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/1510299...pt=AbstractPlus

Samson RA, Nadkarni VM, Meaney PA, Carey SM, Berg MD, Berg RA, American Heart Association National Registry of CPR Investigators. Outcomes of in-hospital ventricular fibrillation in children. N Engl J Med. 2006;354:2328-2339. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/1673826...pt=AbstractPlus

2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 12: Pediatric Advanced Life Support. Circulation. 2005;112:IV-167 – IV-187. Available at: http://circ.ahajournals.org/cgi/content/fu...24_suppl/IV-167

[fiznat]

Maybe I'm missing something here, but I'm not seeing anything that differs from the standard ACLS/PALS routine...?

Interesting that they suggest applying an AED to determine whether the rhythm is shockable or not. It might be just me, but I might assume that if we have arterial lines and cardioactive drugs running, we might also have the patient on a cardiac monitor as well, and would be capable of determining the rhythm ourselves without the AED.

As far as assuming pulselessness by looking at a monitor, you cannot do that ever... regardless of how well you might assume the equipment to be working. I guess its a silly argument though, so let's agree to disagree.

[WANTYNU]

Maybe I'm missing something here, .... As far as assuming pulselessness by looking at a monitor, .... I guess its a silly argument though, so let's agree to disagree.

This is my final post, as I stated I will not argue about reading from a piece of diagnostic equipment assumed for a scenario to be correctly calibrated, applied and working, that is a discussion without a point.

I don't agree, please research what an Arterial line is.

-w

[fiznat]

This is my final post, as I stated I will not argue about reading from a piece of diagnostic equipment assumed for a scenario to be correctly calibrated, applied and working, that is a discussion without a point.

I agree that there would be no point to THAT discussion. However, the original post says nothing about any assumptions that should be made about the equipment. You simply state "Suddenly, his arterial waveform flattens, and he becomes unresponsive." With as little information as there was there, I think it is prudent (as it most certainly is in real life!) to request a little more information. Don't get your feathers all ruffled, it wasn't an attack on you.

please research what an Arterial line is.

Okay buddy. :roll:

[ccmedoc]

No, it means only that the waveform is flat. We still need to check for a pulse and actually touch this patient to confirm that it is an arrest.

I agree with checking the patient. A-line waveforms can become flat from positional caths, clots, or kinked lines. Takes a few seconds to actually check the patient and is the prudent thing to do. Unresponsive does not=pulseless and apneic..right? Until the patient is found to be pulseless, the waveform is in fact..just flat :wink: