CASE OF THE MONTH - APRIL 2019
Paramedics are called to the home of a 2-year-old female with respiratory distress and apnea. The parents report that the girl has asthma and had been wheezing but the medication was not working. She was getting worse when they called 9-1-1. On arrival the child is unconscious, limp, and cyanotic.
The Pediatric Assessment Triangle shows abnormalities in all the arms (Appearance, Work of Breathing, and Circulation to the Skin).
Paramedics begin bag-mask ventilation (BMV). No pulses are palpated. Her rhythm strip is as shown:
What is the rhythm? What are the next steps in the management of this patient?
The rhythm is asystole, the most common presenting rhythm for children in cardiac arrest. About 80% of children present in asystole, 10-15% in pulseless electrical activity (PEA) and 5-9% in ventricular fibrillation or pulseless ventricular tachycardia. Only 4% of infants and 9% of children survive cardiac arrest. Many have neurological deficits if they recover, as the natural course of cardiac arrest is not a sudden arrest, but a slow decline in physiologic function to a point where compensatory mechanisms fail.
The most important initial intervention for a child in cardiac arrest is chest compressions. The hand encircling technique, as shown in this slide from the American Heart Association: Pediatric Advanced Life Support 2015 Guidelines, is recommended unless the rescuer’s hands cannot fit around the chest, then the adult technique should be performed, with the heal of the rescuer’s hand at the level of the nipples.
The ratio of compressions to ventilations are 15 compressions to 2 ventilations with BMV with two rescuers. If there is only one rescuer, the compression to ventilation ratio is 30:2.
Compressions should be delivered at a rate of 100-120 per minute (you can hum “Stayin’ Alive” to keep the appropriate pace of compressions). It is important to allow the thumbs to compress then achieve full recoil of the chest to allow for shifts in intrathoracic pressure which assists the pumping action of the circulation. Avoid hyperventilation – deliver ONLY 6-10 breaths per minute as too many ventilations decrease the blood flow to the heart. Ideally two rescuers would perform CPR on scene. Do not move the patient too quickly, but allow for establishment of adequate cardiopulmonary resuscitation. Per TP-1210P, Cardiac Arrest, Base Contact should be made, but not until CPR is well established.
The child measures 14 kg, Yellow on the length-based resuscitation tape. CPR is in progress and the Base has been contacted.
What is the next step in the management of this patient?
Epinephrine (0.1 mg/mL) concentration at 0.01 mg/kg as per MCG 1309 (0.14 mg or 1.4mL). This can be given IV or IO. If an IV cannot be rapidly established an IO can be placed in the proximal tibia. Note that the humeral site is not recommended for children. The Base confirms the dose and order a repeat dose of epinephrine in 3 to 5 minutes.
What are the “H’s and T’s”?
There are potential causes of pulseless electrical activity (PEA) arrest and possibly arrest with asystole that can be treated in the field. The table below illustrates several causes but in children, the overwhelming majority of cardiac arrest cases are caused by hypoxia and hypovolemia. Therefore, good CPR including appropriate ventilation (6-10 breaths per minute) may make the difference. One should also consider a fluid bolus, 20 mL/kg, based on history.
The other causes listed in the Table are rare causes. Potential causes that can be treated in the field include hypoxia, hypovolemia, hyperkalemia, hypothermia, toxins, and tension pneumothorax.
The closest Emergency Department Approved for Pediatrics (EDAP) is also a Pediatric Medical Center (PMC) with an ETA of 5 minutes.
Pediatric cardiac arrest is rare. When cardiac arrest in an infant or child happens, it is highly stressful for the family as well as the health care providers.
The key in management is rapid recognition and initiation of CPR including bag-mask ventilation and chest compressions.
- Respiratory failure is the most common cause of cardiac arrest in children, unlike adults for which atherosclerotic cardiac disease or ischemia is most common.
- The most common presenting rhythm for a child is asystole because this is a result of a long process during which compensatory mechanisms fail to maintain oxygenation and ventilation, then finally perfusion.
- CPR should be initiated rapidly once cardiac arrest is identified. The compression to ventilation ratio is 15 compressions to 2 ventilations with 2 rescuers; and 30 compressions to 2 ventilations with one rescuer.
- Epinephrine should be initiated after chest compressions and ventilation are established.
- Pediatric patients in medical cardiac arrest should be transported to the closest EDAP.
- These cases are very stressful for families and health care providers. One should take a moment post-resuscitation to reflect and understand that once a child has arrested, reanimation is difficult and may not occur. Understand that one’s role may shift from supporting the patient to supporting the family, and then each other.
The patient arrives at the EDAP/PMC and a team of physicians and nurses meets the paramedics and the patient, continuing resuscitative efforts for another 20 minutes. The parents are allowed to remain in the room during the resuscitation and a staff member is assigned to be with them to explain the process of care. The patient does not survive the resuscitation, and the family is allowed the time they need to be with their daughter at the time of death.
The staff including the paramedic crew take a moment to huddle following the resuscitation to commend their teamwork, and express sadness for the loss of a child.
- Duff JP, Topjian A, Berg MD, et al. American Heart Association Focused Update on Pediatric Advanced Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2018 Dec 4;138(23):e731-e739.
- De Caen AR, Berg MD, Chameides L, et al. Part 12: Pediatric Advanced Life Support:
2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015 Nov 3;132(18 Suppl 2):S526-42.
Translation in progress.....