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Cardiac & Respiratory Arrest in Children

Feb 11 | 1:30 PM

Cardiopulmonary arrest is relatively rare in children, as compared to adults, and the causes were believed to be mainly respiratory. There has been a recent rise in the documentation of cardiac arrest in children during the past decades. Dr. Tamorish Kole, the Chief Functionary & Board Member of the Heart and Stroke Foundation of India, describes the treatment options for cardiopulmonary arrest in children.

[Music] good evening everyone netflix welcomes you to this session it's the second session in the rapid response club this is dr brushali from netflix today we have with us dr tamorish kohli he is an emergency medicine specialist he is the chief functionary and board member of heart and stroke foundation of india it's a subsidiary of american heart association he is also an alumnus of the international visitor leadership program which right now i came to know that you have to be nominated by the us government for this there's nothing you cannot apply for it so it's way more impressive he has also been the past president for the society for emergency medicine india the immediate past president of asian society for emergency medicine and chair of disaster medicine special interest group his interest areas are emergency care system development academic emergency medicine clinical governance trauma care and so on so sir i would like to welcome you on behalf of netflix and our doctors the attending doctors so today's presentation is a cardiac and respiratory arresting children and will take at least a half an hour to discuss certain things which we come across every day and and the way we have to treat the uh the kids if they are facing this complex problem now to begin with before even i i go to the guideline and especially for for the pediatric resuscitation resuscitation of kids it is very important that we prepare the place of resuscitation uh this is a department which i used to work until 2020 and i took special care you know to put every single equipments and and the medications in place uh to to prepare for proper resuscitation in case it is required and this place was built for both the adults and and kid so you can see uh the crash cards the monitor uh you know uh the ecg machines the ventilators and things like that so these are common to both adults and pediatrics station uh but when you talk of pediatric resuscitation we must be very familiar with the measurements and equipments and this is the first thing i would like to emphasize on uh which is very very important for outcome and ease of resuscitation for kids and the way we do it is uh we generally use length-based steps uh there are other methods also if you don't have uh length-based steps like cross-low steps uh to calculate the weight of the kids and then decide what kind of equipment will be required what kind of uh drugs required what will be the dosage of the drugs and and things like that uh so then the left of the screen is the brass laws tape this is again available in market uh if you don't have a brussels strip i highly recommend that you have a length-based tip or in case you you cannot have it you can have a web-based chart or length based chart based on the walls of the research station and this is basically i'm talking of you know hospital in ambulance also you can use the same thing the other thing is of course when you decide to use the brushless tape or a web-based tip you have to have proper size of equipments and you know the supplies uh according to the uh the color of the uh zone of the event and the kids and the medications as well so generally uh you know the adult resuscitation card which does not have so many of you know the drawers to say uh to to store it according to the brussels size or zone so instead you can simply you know have one two stacks of drawers and these are again very very cheaply available in the indian system and then level it according to the brussels size and store the equipment so that whenever there is an emergency you just measure the kit and open that particular uh drawer and you have all the equipments all the supplies so you don't need to you know uh go through the chart and the web-based system again again so this is again a very handy tips which is very very useful for for pediatric resuscitation now the the one thing which is again very important to understand that the the bra low step uh is more reliable in children of less than 10 kg and 10 to 18 kg groups but when it goes to the you know higher age uh as far as the indian kids are concerned the brussels team overestimate the weight of the kids so for indian kids more than 18 kg uh you please go through the weight-based resuscitation rather than using the brass low state now these are the brussels zones and when you measure it through the brussels steps you can very well find the you know the which zone that the kit falls and you have to measure from the toe to the head and depending on the zone you can get the approximate length and approximately of the kg and also if the edge is not known you can also have uh an estimate of the edge but it is also important that you keep one handy guide such as one displayed in the in this in the screen uh to consult whenever you need uh to consult for dosage and and the equipment size and things like that so uh [Music] uh the guidelines uh uh for reference uh in this case will be the american heart association uh 2020 guidelines we just got uh about this [Music] pediatric uh basic life support guidelines uh as well as pediatric advanced life support guideline and there is also a section of the new natural resuscitation guidelines so all the three guidelines are important and these are these were updated in 2020 uh there are other guidelines as well such as european uh research council guidelines and the mother of all guidelines is the ilcor reference which is internationally as a committee of on resuscitation and more or less all the guidelines are 90 the same only about five to ten percent they will be here and they're different so that doesn't make much difference and uh but important is to follow one set of guidelines and and try to memorize it and and go it over again uh in practice rather than consult a bits and pieces of guidelines and in case there is a doubt and hesitation hesitation on what to do in certain uh complex situation on pediatrician station don't hesitate to consult the consultant specialist uh on what to do uh in case of uh you know resuscitation scenarios now uh to start with the first thing we must remember is the pediatric chain of survival because the chain of survival is are the the sequence of steps which needs to need to be in place in order to in order to resuscitate a kid uh from the scene or from the from the uh hospital bed uh to complete recovery now uh there is uh there are two section of it one uh has to be followed in uh the uh inhospitable cardiac arrest and that and the down one is for outer vessel categorist and similarly there are adult chain of survival now the major difference and that's what the you know the first point to remember here in the chain of survival in pediatric versus adult days there is a section on early recognition and prevention in in hospital categorist in terms of uh when we talk of the pediatric chain of survival and in prevention uh in the outer hospital categorist in the chain of survival for out of hospital congress now what does this actually mean that means that you you take the preventive steps for example uh if you are if a kid has a risk of fall or if the giver has risk of drowning or there is a you know there is a risk of uh kid consuming uh small objects like foreign bodies and can can land into cardiac arrest that has to be corrected on the first place before even attempt a resuscitation and in this case the resuscitation would not be required if the prevention would have been in place so that's the first thing it has to be remembered the second thing is of course uh activation of emergency response and then high quality disappear and advanced resuscitation so these are the steps which are common between pediatric and adult and then uh just like adult the pediatric also you know there are set of actions which needs to be performed which will see a postcard request there are set of actions which needs to be performed and finally there is also emphasis on recovery because because the kid has to go back to his or her normal function post recovery so this complete set of you know treatment options or or the intervention options constitute the chain of survival so this has to be kept in mind whenever we are doing some resuscitation now uh the first thing is uh of course as a part of the community and the first responder uh the lay rescuers and in this case uh the first layer rescuers will be the the the parents uh if if they are not medical professionals they need to uh they need to learn uh the steps of of resuscitation and the the three common steps which needs to be taught to the parents and the caregivers and the and the family uh is uh first of all uh if they're witnessing a cardiac arrest or or a nearer situation they have to make sure the scene is safe and they can approach for resuscitation and and the next steps the second thing is of course the call for help uh and in this case it is very important to know the numbers and and the uh and the way to call for the local emergency response help system and how to call them and an idea on approximately how much time it will take for them to arrive and the third thing is in that period [Music] continue uh cpr the cardiopulmonary resuscitation skills now uh for late skewers uh there's only uh compression only cpr and the method is to for for child is to push in the middle of the chest at least one third of the chair stepped approximately two inches uh with one or two hands we will go through the two meters just a bit later and for infant it has to be pushing in the middle of the chest uh at least one third of the chest depth approximately one and a half inch uh with two fingers so that's the that's the method now uh for the last two years we are also in the in the inside the pandemic it is yet to be over so there is an additional additional direction uh which has been issued by by various resistance council that even if you are suspecting that that the kid is going it is reasonably safe to continue this hands-only cpr and this message must go uh to the parents and and the caregivers of the kids so that in kovit situation there is no change uh in the methods of providing the basic life support for kids for latest viewers uh the next thing is of course uh the the basic life support algorithm uh for for the healthcare professionals like doctors nurses paramedics what they should do and it starts in the same way but there is a you know is a difference between the number of rescuers so if there is a single rescuer and the victim is unresponsive of course the first step is to call for help and look for the signs of breathing for at least 10 seconds and if there is normal breathing but the patient has got a pulse uh we activate the uh uh activate the emergency response system and return to the uh return to the kid uh to see uh what can be done until the responder arrives but if there is uh the breathing help is not normal uh and is inadequate uh but the patient has pulse then we have to provide uh the rescue breathing which is one breath every three to five seconds or two to twenty breaths per minute and but if the patient is not uh breathing and it's only gasping and there is there is no pulse uh then then if the the arrest is witnessed that means you have seen that the kid is arrested in front of you uh you activate the emoji's responses to if not here is the difference that you you perform cpr for two minutes and then you you uh see whether the it is available and then go to the next step uh when you have more than one rescuer that means two or more rescuers uh then the uh then the uh the work shifts so one person can provide the breathing the other person can uh provide the cpr and one person can call for help and one person can and start cpr so things get distributed so uh depending on on the number of rescuers you you you devise the method and the interventions uh which is required to proceed for the pediatric bls and this is strictly for the healthcare providers lay rescue as i've just discussed before sorry i don't know whether why the pictures are not coming so there are two methods one is a two finger compression that means you use two fingers and uh put it in the middle of the chest and come and compression and right now while you are doing that make sure the hair is stabilized because uh if if if you are you have to have a solid compression and you need to stabilize the head so that that's the one advice if you're using this two finger compression technique uh the other method is of course uh two thumb encircling technique uh which is uh uh which is uh again used uh for the uh for the smaller kids uh where you encircle the chest and uh put your two fingers in the again in the middle of the chest and uh use the same compression technique in the same manner so depending on whichever you're comfortable you can use both the techniques uh for giving cpr uh the uh the next slide is is the most important part is actually the backbone of a pediatric cardiac arrest and what one should do and how it should uh you know it should be conducted uh well you have more than one people and there is a team which is acting uh to resuscitate the baby yes so this is uh the two finger technique and uh can you show the two thumbnail cycling technique as well yes yes i will yeah yes so this is basically for two rescuers when one person is using two thumb and cycling technique the other person is uh giving breath using a number back so this this is you know this is look like a very busy slide but this is what you need to have in your mind while it resuscitation the point i was trying to describe is when you are acting as a team and all of uh you know three four percent wants to do many things you have to have something called team dynamics that means you have to have a designated role who does what uh what comes first what comes second what can go simultaneously so these these things are taught in a typical you know training session uh while you are doing resuscitation uh training and this uh taking this training obtaining this training is is is a must according to me for every doctors regardless and every healthcare professional do that matter who are into the you know business of treating patients both adult and kids so this is very very important for every one of us uh to have that skill and have that knowledge on how to resist data baby now this this complete algorithm talks about starting cpr performing the bls actions and then coming to a very very important branch point using uh you know uh rhythm monitor that can be aed can read the rhythm and give you a instruction it is an automatic process or using a defibrillator where you yourself interpret the rhythm and decide whether you have to deliver a shock that is electrical energy using a defibrillator or the rhythm is uh not shockable now what are the shockable rhythms ventricular fibrillation and ventricular tachycardia with a weak pulse in in case of kids or no pulse and similarly when the systole which is a flat line on the monitor and any other rhythm without uh you know without a uh effective pulse is called pulseless electrical activity so two are shockable rhythms two are non shutter elements now if the rhythm is shockable you uh deliver the shock and then you perform this period of two minutes and then that you know cycle continues and if after uh you know the three shocks the rhythm still passes then you have to go to the trunks now there are several drugs uh which has to be used uh the first and foremost drug which has to be remembered is epinephrine which is used in all four scenarios so epinephrine is a common drug it can be given intravenous it can be given interest and uh the dosage are uh given i'm not going into the dosage uh the uh the next two drugs which you need to remember is emitter on or lidocaine both can be given for shockable rhythms and for non-surgical rhythms uh cpr cpr and rhythm check that cycle continues and then finally uh we go to a situation where we try to find out the reversible causes or the causes okay and in this process if you want to decide to put an advanced airway uh there are various options uh you can use a chuckle tube you can use a supraglottic airway so there are various options to bet and maintain the airway but one thing i would say that do not stop cpr and do not stop resuscitation just for sake of putting here that is a little later time we can we can appreciate and we can we can do that now the reversible causes which you need to remember uh and again which has to be differentiated at the end of uh this cycle are uh called five h and phi 5ts the 5hs are hyper hypopalaemia that means low volume hypoxia oxygen acidosis hypoglycemia high pore hyperkalemia hypothermia and for these uh tension pneumothorax cardiac component toxins uh then uh pulmonary thrombosis or coronary hormone so these are the five ages and five t's which has to be differentiated uh to to understand the cause and to successfully treat the reversible cause and sometimes uh many a times we actually find that you know we can get through the cause and if you correct it uh then the the hour there is always a return of spontaneous circulation so make an effort uh you know when you go through this cycle to start early uh you know going through these 5hs and 5ts and find out which one is actually the cause of cardiac arrest now two more things where you need to remember the type of defibrillator and the uh recommendation for defibrillator paddle size type and position so you must remember that using an ad in infant or children uh less than eight years of age use of a pediatric attenuator is recommended so that's special that additional device which needs to be the in place now for infants under the care of a chain health care provider provider manual defibrillation is recommended when the shock algorithm is identified now if the neither a manual defibrillator nor a ad is equipped with that this pediatric attenuator is available nad without the dose alternator may be used so if you have nothing at least you try to deliver some electrical energy so that is the principle and that is the level of recommendations uh in case you have to use a different method now regarding paddle size uh use the largest paddle of self-adhering electrodes that will feed to the child chest while still maintaining the good separation between the paddles and paddles with self-adhering pads may be considered an equally effective in delivering electricity depending on whatever you use but make sure there is a distance between the two pads and that's very important to remember now that's all about the pediatric cardiac arrest resuscitation but the things does not end here because ah as i mentioned earlier there is a checklist for pediatric post cardiac care which includes oxygenation and ventilation which includes hemodynamic monitoring uh targeted temperature management neuromonitoring measurement and management of electrolyte and glucose based disorders sedation and then of course the prognostication so if we need to understand the pediatric end point of visualization we need to remember that the pediatric endpoint of association does not end with the return of spontaneous circulation for all pediatric patients we need to ensure and prevent the treatment of hypotension hypertension hypocapnia hyperoxia which is again can be dangerous for kids hypoxia and children who do not gain consciousness post resuscitation consider target temperature management continuous eeg monitoring and delay prognosis decisions until 72 hours after return to normal temperature so these are the things which is a bit different from the adult post categorist care now finally uh we have come to the part of recovery and there are expectations of recovery uh in in terms of period in ultra short term period the expectation is of course early physical recovery uh monitoring for seizures and working on those things in the short term we expect the kid to gain the cognitive functions and ongoing improvement of daily activities in medium term improvement in memory return to work on baseline activities and long term is often of course improvement in anxiety depressions and things like that so pediatric cardiac list [Music] you know and recovery is a huge long-term process it does not end with the necessity return of spontaneous circulation it does not even end with the post-cardiac arrest care it does not even end at the end of the hospital stay it actually continues so referral to the appropriate specialist and follow-up uh is very very essential in terms of uh pediatrics station so what are the top 10 uh take home messages uh for pediatric association of course the first and foremost is high quality cardiopulmonic station is the foundation of resuscitation and as i just said that do not stop cpr please ensure high quality cpr and all other activities can wait uh when in in comparison to high quality cpr second a respiratory rate of 20 to 30 breaths per minute uh is new for infants and children who are receiving cpr been advanced in pace and receiving rescue breathing and have a pulse for patients with non-shockable rhythms the earlier epinephrine administration after cpr initiation is more likely patient is to survive so if the rhythm is shockable deliver shock first if rhythm is not shockable uh try to give adrenaline while the cpr is going on and then using cuffed endotracheal tube decreases the need for endotracheal tube changes so previously we were you know using uh uncuffed tube uh for uh for pediatric edge group but now uh the recommendation says we can use the cuff tube in fact the cuff tube decreases the need for inductive uh tube changes the routine use of required pressure which we are using uh you know uh in the beginning of uh you know a few years back uh is no more recommended it does not reduce the risk of regurgitation during backwards ventilation and may embed the success of integration so unless it is really not required for patient does not help for outer hospital categories back mass ventilation results in the same legislation outcome as advanced airway intervention so if somebody is resuscitating a kid out of hospital do not try you know try to put the tube if it is really not required you can safely continue with back mass ventilation and again record pressure which is no longer recommended as i just mentioned uh resuscitation does not end with rosc uh we need to have excellent post cardiac care we need to have uh a path for recovery so after discharge from the hospital category survivor can have physical cognitive emotional changes and especially for the kids who are in the growing age so um so planning uh and recovery from for those things are equally important uh then the uh return of spontaneous circulation and hospital discharge uh naloxone is actually used for opioids induced cardiac arrest uh opioid induced categorist is not very common in our country but in case you you are resuscitating our period peer-reduced categories that it can it is seen that naloxone can reverse cardiac arrest due to opioid reversals but there is no evidence that it benefits the patient in categories and finally fluid resuscitation in sepsis because many patients in sepsis can lead to respiratory arrest and cardiopulmonary arrest this is based on fluid resuscitation is now based on patient response and requires frequent assessment and pilots crystalloid unbalanced crystalloid colored fluids are all acceptable for safe season sagittarius but generally in most of our hospitals and designs departments we have crystalline solutions so do not shy away from using crystalline solution use whatever is available in the first place and then epinephrine or non-epinephrine infusion are used for fluid refractory septic shock so that should be used whenever that is indicated uh so what i did not cover today but uh this is the topic for further reading and if you have a future episodes we can cover these things uh which is again uh three very important topic pediatric bradycardia and tachycardia which may lead to a respiratory and cardiorespiratory arrest and children with special healthcare needs because there are children who had under who has septal defects uh whoever undergoes the uh cardiothoracic uh pediatric cardiothoracic surgery or who has undergone feeding tubes their resuscitation is a bit complicated so i'm not taking it uh uh for a lot of time but uh we'll cover it in in future episodes uh now all said and done as i mentioned uh several times during my lecture that this is a skill along along with the knowledge so you have to have a proper training session to have that skill now there are several training options which are available in this country uh there are training options from the american heart position itself there are training options from indian academy of pediatrics there are training options available in the colleges or in the hospitals you practice so uh and no training is superior and clear to another training uh the bottom line is you have to have a training and you have to have an active you know skill set uh to resuscitate a kid because if you don't practice and if you don't acquire the skill sets uh this knowledge whatever we discussed will all be useless and not be uh you will not be able to uh save lives especially in the kids which is a complex uh resuscitative scenarios uh so that's all from my side thank you very much for patient listening a very nice session so i must say all the points were explained properly and like you said we can have a next session wherein we can talk about the remaining points which we just summarized a bit i must say the session was quite self-explanatory so thanks for simplifying such a complex topic and i would also like to thank our audience for being the patient we have a comment that we require such more sessions so it's a one once more for you from our audience and uh i would say that you know uh as i said that this this skill set is required for everyone regardless whether we are doctor we are nurse or paramedic and more hands is always better yes and whenever in doubt you know we must involve the specialist without hesitation so these are the two important lessons uh which i would like to stress again and again um pediatric resuscitation is a complex uh resuscitation uh involvement of the specialist if they are available as early as possible is always better yes so we have one question so please elaborate about shockable and non-shockable rhythm okay so uh as i said uh when you connect a patient uh pediatric patient who is who is in cardiac arrest you will get a four types of rhythm so start with the simplest one where there is no movement you see a flat line so that is stone okay then the exactly opposite and that's a non-shockable rhythm uh the exactly opposite uh scenario is when you see the rhythm is absolute bizarre you you can't you know classify it anything so that's a typical ventricular fibrillation uh and then there is a regular rhythm uh without the loss of p wave and that is the ventricular tachycardia with a very weak pulse or without pulse so ventricular fibrillation and ventricular technique both are shockable written that means you have to use a d or difficulty to give electric shock to divert that rhythm because these with these rhythms the heart cannot pump the blood out of the uh you know system so effectively there is no pulse and anything else without a pulse in cardiac scenario is pulseless electrical activity and you know it's very important that you ask this question many a times we try to see the rhythm and say well this is you know some tachycardia going on and some something we don't need to use our brain when the patient is in cardiac arrest for for the treatment purpose all this other rhythm has to be grouped in pulseless electrical activity again pulseless electrical activity just like s is told the flat line is a non-shockable written that means you give epinephrine you do cpr and you use you search for reversible causes okay all right we have one more question uh what is the difference between aed and defibrillator a d is automated external defibrillator so if you have seen a defibrillator it is a device which can give shock but it has to be it is completely manual that means you have to see the rhythm you have to interpret by yourself and you decide the energy and you choose uh well is ad is automated external defibrillator that means you put the pad it will itself analyze it will use a vocal prompt and it will say you know you continue cpr while it analyze the rhythm and if the rhythm is shockable it will uh it will prompt you to press the you know shock button inside the aed and then it will deliver the shock so the only difference between the manual and this one is here you are not choosing the energy and you you don't need to interpret the aeds interpreting right right all right uh one more is what will be the correct line of treatment for stroke in a pediatric patient so stroke in a pediatric patient is not under the scope of uh you know resuscitation okay uh so just like adult stroke you you follow them you detect the stroke that's very important detection of stroke uh the one thing uh as a as a part of the initial assessment is to understand when the stroke happened and what can be done uh and then of course you have to consult the specialist and uh the most important thing which is to remember in the first you know half an hour or one hour whether these kind of patients present that these patients should not have uh hypoglycemia because hypoglycemia can mimic stroke okay so that is one collectible cause you have to be cautious about it well that's that was the question sir so i would like to thank you on behalf of netflix we surely hope to see you again you

BEING ATTENDED BY

Dr. Murtuza Zozwala & 752 others

SPEAKERS

dr. Tamorish  Kole

Dr. Tamorish Kole

Chief Functionary and Board Member of Heart and Stroke Foundation of India | Immediate Past President, Asian Society for Emergency Medicine

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dr. Tamorish  Kole

Dr. Tamorish Kole

Chief Functionary and Board Member of Heart a...

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