Paediatric Acute care Guidelines PMH Emergency Department

This refers to the period of time post return of spontaneous circulation and after resuscitation and prior to transfer for definitive care in a Paediatric Intensive Care Unit (PICU).

Background

  • After return of spontaneous circulation, post arrest patients should be admitted and managed in a Paediatric Intensive Care Unit (PICU).
  • Frequent clinical reassessment using the ABCD approach will detect deterioration or improvement in the patient’s condition.
  • The main goal of therapy is to maintain oxygenation and perfusion to vital organs to prevent secondary damage.

General

  • A child who is successfully resuscitated from cardiac arrest typically suffers from multiple organ system problems resulting from hypoxia and ischemia and subsequent reperfusion.
  • Management challenges of these children include acute lung injury (ALI, ARDS), post arrest myocardial dysfunction, hepatic and renal insufficiency, and neurologic injury.
  • Post resuscitation management aims to achieve and maintain homeostasis to minimise secondary organ damage and optimise recovery.
  • Management should be directed in a systematic (ABCD) approach 

Management

Initial management

Airway

Confirm adequate endotracheal tube size and position by checking:

    • For leaks
    • Symmetrical chest movement and air entry
    • Capnography (end tidal CO2)
    • Chest X Ray

Breathing

Ventilation settings should be maintained to keep:

    • Oxygen saturations > 95%
    • pH > 7.30
    • pCO2 35-40 mmHg

Circulation

Following resuscitation, patients will usually have poor cardiac output.

Ensure Adequate circulating volume

    • Adequate heart rate and rhythm
    • Adequate blood pressure and perfusion
    • Optimal oxygenation and ventilation
    • Normal pH, electrolytes and blood sugar

Manage with:

    • Fluid boluses
    • Inotrope infusions
    • Antiarrhythmics

Disability

Perform a rapid secondary survey including a brief neurological examination.

Minimise secondary brain injury:

    • Maintain oxygenation and normocapnia (not hyperventilation)
    • Optimise cerebral perfusion pressure (CPP) – optimise mean arterial pressure (MAP), may need to reduce intracranial pressure (ICP)
    • Normalise pH, electrolytes
    • Normoglycaemia (note: hyperglycaemia worsens cerebral outcome)

Reduce the metabolic requirements of the brain:

    • Sedation (morphine and midazolam infusion)
    • Pain control
    • Seizure control

Kidneys:

    • maximise renal perfusion and renal tubular patency

Optimise oxygenation and circulation:

    • Maintain urine output > 1 mL/kg/hour (use frusemide if necessary)

Coagulation disturbances result from hepatocellular damage and disseminated intravascular coagulation (DIC):

    • Replace clotting factors as necessary by giving FFP

Exposure

Evidence shows post arrest hypothermia (32 – 34°C) may improve neurological outcome in adults after VF arrest but there is insufficient data in paediatric arrests. However, current recommendations are if the core temperature is:

    • < 33°C then actively rewarm to 34°C
    • 34 – 37.5° C then no active warming, control shivering with sedation +/- paralysis
    • > 37.5°C commence active cooling

 

Further management

Monitoring

All post arrest patients should have the following monitoring prior to transfer to PICU:

  • ECG monitor
  • Pulse oximeter
  • Core temperature
  • Blood pressure
  • Urine output
  • Capnography
  • Regular blood gases

Consider:

  • Invasive blood pressure (arterial line)
  • Central venous pressure
  • Intracranial pressure monitoring

Follow up investigations

Post resuscitation investigations should include:

  • Chest X-Ray
  • Blood gases
  • Full blood count
  • Electrolytes, Urea, Creatinine
  • Blood Glucose
  • Coagulation profile
  • Group & Hold
  • 12 lead ECG

Medications

DRUG INDICATION DILUTION DOSE RANGE COMMENTS
Morphine
  • Analgesia
  • Sedation

1mg/kg
to make a combined total volume of
50ml of 5% dextrose
or
0.9% saline

1mL/hr = 20micrograms/kg/hour

10 – 40micrograms/kg/hour

Rate: 0.5 – 2 mL/hr

  • Opioid analgesic
  • No amnesia
  • Respiratory depression
  • Hepatic metabolism
  • Histamine mediated vasodilatation may cause hypotension
Midazolam
  • Sedation

2.5mg/kg
to make a combined total volume of 50mL of 5% dextrose
or
0.9% saline

1mL/hr = 50micrograms/kg/hour

50 – 200micrograms/kg/hour

Rate: 1 – 4 mL/hr

  • Benzodiazepine
  • Anxiolysis, amnesia, anticonvulsant
  • Good cardiovascular stability
  • Short half life
Adrenaline
  • Maintenance of adequate post-arrest perfusion in patients unresponsive to fluid resuscitation.
  • Symptomatic bradycardia not responding to oxygen and ventilation

0.15mg/kg
to make a combined total volume of
50mL of 5% dextrose
or
0.9% saline

1mL/hr = 0.05micrograms/kg/minute

0.05 – 0.5micrograms/kg/minute

Rate: 1 – 10 mL/hr

  • Inotrope, chronotrope
  • Vasodilator at low dose
  • Pressor at higher doses
  • Beware tachyarrhythmias and hypertension
  • Local tissue necrosis if extravasation occurs
Noradrenaline
  • Maintenance of adequate post-arrest perfusion in children with low systemic vascular resistance, not responding to fluid resuscitation (eg. Septic or anaphylactic shock)

0.15mg/kg
to make a combined total volume of  50mL of 5% dextrose
or
0.9% saline

1mL/hr = 0.05micrograms/kg/minute

0.05-0.5micrograms/kg/minute

Rate: 1 – 10 mL/hr

  • Vasopressor
  • Local tissue necrosis if extravasation occurs
  • Consider combining with low-dose dopamine to improve renal and splanchnic perfusion
Dopamine
  • Maintenance of adequate post-arrest perfusion in patients unresponsive to fluid resuscitation
  • Characterised by low systemic vascular resistance

15mg/kg
to make a combined total volume of 50mL of 5% dextrose
or
0.9% saline

1mL/hr = 5micrograms/kg/minute

5 – 20micrograms/kg/minute

Rate: 1 – 4 mL/hr

  • Inotrope, chronotrope
  • Renal and splanchnic vasodilator at low dose, pressor at high dose
  • Beware hypertension and tachyarrhythmias
  • Hypovolaemia should be corrected before using
  • Preferably via central line
Dobutamine
  • Inotropic support in normovolaemic patients following cardiac arrest due to a primary cardiac cause (eg. Myocarditis)

15mg/kg
to make a combined total volume of 50mL of 5% dextrose
or
0.9% saline

1mL/hr = 5micrograms/kg/minute

5 – 20micrograms/kg/minute

Rate: 1 – 4 mL/hr

  • Inotrope
  • Vasodilator (mild)
  • Dobutamine can be given through a peripheral lin

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