Malik Al Rawahi

1. Resuscitation in Special Populations Malik Al-Rawahi

2. Objectives Resuscitation in Pediatric Population. Resuscitation in Pregnant Women.

3. Resuscitation in Pediatrics Pediatric Cardiac Arrest: Secondary to respiratory failure or arrest. Most Important Intervention: Oxygenation, ventilation.

4. Anatomy of the Pediatric Airway Relatively larger head and tongue. More anterior larynx. Narrowest part of the airway: cricoid cartilage. Long epiglottis (floppy, omega shaped). Easily compressed trachea.

5. Airway Evaluation Mallampatti Classification. Cormack and Lehane Grades.

6. Difficult pediatric airway Syndromes: Trisomy 21, Mucopolysaccharidoses, Pierre-Robin. Trauma to head and neck. Possible epiglotitis. Radiation therapy. Masses in the neck.

7. Airway Head-tilt/chin-lift. Big tongue; Forward jaw displacement critical. Avoid extreme hyperextension. With possible neck injury, jaw thrust.

8. Breathing Look-Listen-Feel. Limit to volume causing chest rise. Children usually underventilated. Use BVM only if proficient. Pedi BVM’s should not have pop-off valves. Do not use demand valve on children. Ventilate infants, children every 3 seconds.

10. 1 finger width below nipple line.

11. 1/2 - 1 inches.

13. Lower half of sternum.

14. 1 - 1.5 inches.

18. Narrow cricoid ring.

21. Endotracheal Intubation Confirm placement by: Seeing tube go through cords. Chest rise. Equal breath sounds. No sounds over epigastrium. CO2 in exhaled air.

22. Endotracheal Intubation Mark tube at corner of mouth. Avoid excessive head movement. Frequently reassess breath sounds. Ventilate to cause gentle chest rise.

24. Dilute with normal saline.

25. Stop compressions.

26. Inject through catheter passed beyond ETT.

28. Vascular Access, Scalp Veins No value in cardiac arrest. Useful in infants < 1 year.

29. Hand, Arm, Foot Veins 22 gauge catheter for smaller children. Restrain extremity before attempting. Incise overlying skin with 19 gauge needle.

32. Peripheral site cannot be obtained.

33. In two attempts, or

35. Osteogenesis imperfecta.

36. Osteoporosis.

38. 1 - 3 cm below knee.

42. Drug toxicity.

47. Look for treatable underlying cause.

54. Double ET dose.

55. Minimum dose: 0.1 mg to avoid paradoxical bradycardia.

56. Maximum single dose:

57. Child: 0.5 mg.

59. Ventilation.For bradycardia 2o to hypoxia/ischemia, preferred first drug is epinephrine.

60. Resuscitation in Pregnancy There are two patients, mother & fetus. The best hope of fetal survival is maternal survival. Consider the physiologic changes.

61. Physiologic Changes Compensate for increase metabolic demand. Prepare for blood loss at time of delivery. Alter presentation of injured women. Pregnant women is more vulnerable. Mask severity of injury.

62. Cardiovascular System Increase in cardiac output ( 20-30%) Increase in heart rate ( 10-15 b/min) Decrease in systolic and diastolic pressure (10-15) Increase in red blood cells and plasma (45%) Relative anemia. Increase to blood flow to uterus (up to 20%)

63. Respiratory System Increase in RR due to upward pressure of uterus. Increase in PCO2. Decrease in tidal volume.

64. GI System Delayed GI emptying. Movement of abdominal organs. Uterus is the largest abdominal organ.

65. Shock Body protect the mother: Uterine vasoconstriction 20-30%, decrease in blood flow to uterus. Loss of 30-35% of blood volume before developing hypotension, slow onset of signs and symptoms in mother. But fetus is vulnerable to mild hypotension.

66. Interventions to Prevent Arrest To treat the critically ill pregnant patient: Place her in left lateral position. Give 100% oxygen. IV access and give a fluid bolus. Consider reversible causes and identify any preexisting medical conditions.

67. Always ABC. Focus on maternal resuscitation. Remember that signs of shock are late. Evaluate and treat hypovolumia aggressively.

68. Resuscitation of the Pregnant Woman inCardiac Arrest Modifications of Basic Life Support GA>20 weeks, uterus press against the IVC & aorta. This can produce prearrest hypotension or shock and in the critically ill patient may precipitate arrest. Limits the effect of chest compressions.

69. Modifications of Basic Life Support Uterus may be shifted away from the IVC & aorta by placing in LUD or by pulling the uterus to the side. This may be accomplished manually or by placement of a rolled blanket or other object under the right hip and lumbar area.

70. Airway Hormonal changes promote insufficiency of the gastroesophageal sphincter. Apply continuous cricoid pressure during positive pressure ventilation for unconscious pregnant woman.

71. Airway Secure the airway early in resuscitation. Use an ETT 0.5 to 1 mm smaller in internal diameter.

72. Breathing Hypoxemia can develop rapidly because of decreased FRC & increased O2 demand. Ventilation volumes may need to be reduced because of elevated diaphragm.

73. Circulation Perform chest compressions higher, slightly above the center of the sternum. Vasopressor agents, including epinephrine & vasopressin, will decrease blood flow to the uterus.

74. Defibrillation Defibrillate using standard ACLS defibrillation doses. There is no evidence that shocks from a direct current defibrillator have adverse effects on the heart of the fetus. If fetal or uterine monitors in place, remove them before shocks.

75. Differential Diagnoses Same reversible causes of cardiac arrest that occur in nonpregnant. Providers should be familiar with pregnancy specific diseases & procedural complications. Use of abdominal US should be considered in detecting possible causes of the cardiac arrest.

76. Iatrogenic Overdose is possible in women with eclampsia. Administration of calcium gluconate is treatment of choice. It can be lifesaving.

77. Acute coronary syndromes Pregnant women may experience ACS. Fibrinolytics are relatively contraindicated, PCI is mangement of choice for STEMI.

78. Pre-eclampsia/eclampsia Pre-eclampsia/eclampsia develops after the 20th week of gestation. If untreated it may result in maternal and fetal morbidity & mortality.

79. Life-threatening PE & stroke Successful use of fibrinolytics for a massive, life-threatening PE & ischemic stroke have been reported.

80. Trauma and drug overdose Pregnant women are not exempt from the accidents & mental illnesses. Domestic violence also increases during pregnancy. Homicide & suicide are leading causes of mortality during pregnancy.

82. Emergency Cesarean Delivery forthe Pregnant Woman in Cardiac Arrest Delivery, relieving both the venous obstruction and aortic compression. It allows fast newborn resuscitation. Remember that you will lose both mother & infant if you cannot restore blood flow to the mother’s heart.

83. Decision Making for Emergency Cesarean Delivery Consider gestational age Fetal viability begins at approximately 24 to 25 weeks. Portable US, may aid in determination of gestational age & positioning.

84. Decision Making for Emergency Cesarean Delivery Gestational age less than 20 weeks Unlikely compromise maternal cardiac output. Gestational age approximately 20 to 23 weeks. Perform to enable successful resuscitation of the mother, not the survival of the delivered infant. Gestational age greater than 24 weeks. Perform to save the life of both the mother & infant.

85. Decision Making for Emergency Cesarean Delivery The following can increase the infant’s survival: Short interval between the mother’s arrest & the infant’s delivery. No sustained prearrest hypoxia in the mother. Minimal or no signs of fetal distress before the mother’s cardiac arrest. Aggressive & effective resuscitative efforts for the mother. Delivery to be performed in a medical center with a NICU.

86. Thank You