Paediatric resus update 2021

2021 Resuscitation Council UK Guidance: What’s new in paediatrics?

Cite this article as:
Anandi Singh, Jilly Boden and Vicki Currie. 2021 Resuscitation Council UK Guidance: What’s new in paediatrics?, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.33450

You are working in Paeds ED. The alert phone rings for a 2-year-old boy coming in a cardiac arrest. You hear some colleagues talking about Plasmalyte, capnography, and reduced respiration rates. Don’t panic! You had heard somebody mention that there were new resuscitation guidelines out though you’ve not read them yet. How much could have really changed?

Let’s take a step back. Where do these resus guidelines come from?

The Resuscitation Council UK recently issued their 2021 guidelines. They are tailored to UK clinical practice and derived from the European Resuscitation Council (ERC) 2021 Guidelines. The International Liaison Committee on Resuscitation (ILCOR) is responsible for the International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations (CoSTR). This consensus document is then used by international member organisations to develop guidelines. They are updated roughly every five years. CoSTR 2020 formed the ERC 2021 guidance.

The guideline development process utilised systematic reviews, scoping reviews, evidence updates and engagement from worldwide stakeholders (including members of the public and cardiac arrest survivors).

The 2021 Resuscitation Council UK Guidance covers both adult and paediatric basic and advanced life support. We have reviewed the corpus of generic guidance, some key additions and the main changes to both paediatric and neonatal life support algorithms.

The new guidelines do not specifically include the management of arrest secondary to COVID-19. You can be find them at https://www.resus.org.uk/covid-19-resources.

Epidemiology of Paediatric Cardiac Arrest

Epidemiology of paediatric cardiac arrest

Changes in paediatric resuscitation

Paediatric Basic Life Support

There are a few minor changes in 2021 to the paediatric BLS guidelines. They all apply to children up to 18 years of age (except for newborns).

Initial Assessment

Assess for signs of life simultaneously with the delivery of rescue breaths. If there are no signs of life, start chest compressions immediately after initial rescue breaths (you do not need to pause here).

Deliver five rescue breaths followed by ventilation breaths with compressions at a ratio of 15:2.

Emphasis on achieving high quality CPR

We should use mobile phones on loudspeaker for dispatcher guidance on how to deliver CPR or to summon emergency medical services (EMS) without leaving the victim.

Whilst the majority of paediatric cardiac arrests are respiratory in nature, effective chest compressions still play their part. Do these on a firm surface( so not a bed) and to a depth of at least one third the anterior-posterior diameter of the chest (or by 4cm in an infant and 5cm in a child). The rate remains at a rate of 100-120/min. The chest needs to fully recoil after each compression and around 80% of the CPR cycle should be composed of compressions.

Airway

The Resus Council recommend cuffed endotracheal tubes in children, if intubation is needed, and uncuffed tubes in neonates (Ed. note-we’ll look at this another day). Monitor this cuff pressures and try to keep it below 20mmHg.

Breathing

Target oxygen saturations (SpO2) of 94-98% with as little supplemental oxygen as possible. Avoid giving pre-emptive oxygen therapy without signs of hypoxemia or shock and try to avoid readings of up to 100% – unless in situations such as carbon monoxide poisoning. Hyperoxia appears to be almost as harmful as hypoxia.

High-flow nasal cannula oxygen (HFNC) or continuous positive airway pressure (CPAP)/non-invasive ventilation (NIV) support should be considered in children that have adeqaute respiratory drive but are not responding to low-flow oxygen. Bag-mask ventilation (BMV) is recommended in children with inadequate respiratory drive. If oxygenation/ventilation doesn’t improve, or ventilation may be ongoing, it is time for more advanced airway techniques – supraglottic airway devices (SGA) or endotracheal intubation.

Changes to paediatric resuscitation guidelines

Monitor capnography

End-Tidal CO2 monitoring is the gold standard, whether using an SGA or bag-valve-mask ventilation. Waveform capnography can reliably confirm tracheal tube placement when has a perfusing rhythm, as long as they are over two kilos in weight. There is a reasonable correlation between ETCO2 and PaCO2 but the guidelines do not go so far as suggesting a threshold ETCO2 or PaCO2 for stopping the resuscitation attempt.

What can the ETCO2 waveform tell us in resuscitation?

Use of end-tidal in paediatric resus

Circulation

No single finding can reliably identify the severity of circulatory failure. We still need to reassess frequently and after every intervention. This can be done by monitoring mean arterial blood pressure, trends in lactate, urine output and, if competent, ultrasound findings.

Vascular Access

Peripheral intravenous (IV) lines are the first choice for vascular access but it’s just two attempts and you are out. Then it is time to move on.

Intraosseous (IO) access is the primary rescue alternative. Remember it can be painful so give proper intraosseous analgesia before giving the first fluid bolus in every (awake) child.

A balanced approach to fluids

In children with shock, use a 10 mL/kg fluid bolus repeated up to 40-60 mls/kg.

How much should we give? There is an emphasis on smaller volumes with careful reassessment after each bolus to enable early identification of signs and symptoms of fluid overload. These include hepatomegaly, bilateral basal lung crackles, and jugular venous distention. Current evidence shows that a restrictive approach to fluid therapy is at least as effective as larger volumes.

In children with shock secondary to haemorrhage, we need to keep crystalloid boluses to a minimum (max 20mls/kg). Early use of blood products is the way to go in children who present with severe trauma.

Having decided to give fluid, what should we give? Balanced isotonic crystalloids (e.g. Plasmalyte) are the first choice with 0.9% sodium chloride being an acceptable alternative. Saline can induce hyperchloremic acidosis and may be associated with a worse outcome. The evidence for Hartmanns/Ringer’s lactate is still limited and shows ‘no more than a trend’ (?) towards a better outcome – so this is still left a bit unclear… Don’t use dextrose-based solutions for volume replacement – these will be redistributed rapidly away from the intravascular space and will cause hyponatremia and hyperglycaemia which may worsen neurological outcome.

Consider using permissive hypotension (mean arterial blood pressure (MAP) at 5th percentile for age) in traumatic injury. Be mindful that It is contraindicated in children with traumatic brain injury. You need to maintain a reasonable cerebral perfusion pressure. The Resus Council UK guidelines recommend giving tranexamic acid (TXA) to all children requiring transfusion after severe trauma and/or significant haemorrhage, as long as it is within three hours of injury

Vasoactive drugs need to be started early In children with persistent decompensated circulatory failure. Noradrenaline or adrenaline are recommended as first-line agents. Vasoactive drug choice may be directed by individual patient circumstances once more detailed information about the pathophysiology is available..

Dopamine is no longer recommended but can be used if adrenaline and noradrenaline are not available.

Cardiac Arrest in Special Circumstances

Specific approach to CPR needed during specific conditions such as cardiac surgery, neurosurgery, trauma, drowning, sepsis, and pulmonary hypertension. However, there are no major changes to any of these guidelines.

When managing traumatic cardiac arrest we need to fix the reversible causes.

Traumatic cardiac arrest guidelines

We need to start simultaneous chest compressions whilst treating these causes. This trumps adrenaline use. Though exceedingly rare we should think about thoracotomy in paediatric TCA patients with penetrating trauma with or without signs of life on ED arrival.

Extracorporeal Life Support (ECLS)

Extracorporeal cardiopulmonary resuscitation (E-CPR) is the implementation of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in a patient with refractory cardiac arrest. E-CPR should only be considered if it is readily available and there is a (presumed) reversible cause.

For specific subgroups of children with decompensated cardiorespiratory failure (e.g. severe refractory septic shock or cardiomyopathy or myocarditis and refractory low cardiac output), the pre-arrest use of ECLS can be lifesaving and provide end-organ support, preventing cardiac arrest.

Post-cardiac arrest care

Avoid hypoxia, hypotension and fever in children and infants who have a return of spontaneous circulation (ROSC) following cardiac arrest. Targeted temperature management of children post-ROSC should comprise active treatment with either normothermia or mild hypothermia and continuous invasive temperature monitoring.

Changes in adult resuscitation guidance

Are you curious about the big people?

For the adults, there are no major changes in ADULT BLS/ ALS 2021 guidelines. The guide states that a child is any person up to 18 years – in terms of when we switch from paediatric to adult algorithm. If the child looks like a child, we use the paediatric algorithm. If it turns out that your patient looks more youthful than they actually are then little harm will ensue. They also recommend a stepwise approach to airway management. The expert consensus is that: providers with a high first-pass success rate should perform tracheal intubation.

The use of adrenaline is controversial. We don’t have great evidence for either the dosing or the timing of doses. A large trial in the UK (PARAMEDIC 3, expected Autumn 2021) will look in more detail at the timing of adrenaline and the potential benefits of an IO first approach.

There is a greater emphasis on POCUS and ECMO. This reflects the increasing evidence as a rescue therapy in certain adult patients in cardiac arrest. There is an increasing role of point-of-care ultrasound (POCUS) in peri-arrest care for diagnosis, but it requires a skilled operator, and the need to minimise interruptions during chest compression.

As with the paediatric population: there is a greater recognition that patients with both in- and out-of-hospital cardiac arrest have premonitory signs, and that many of these arrests may be preventable.

What else is in the guidance?

Health inequality (HI) and it’s impact on cardiac arrest outcome

There is vast inequality in the incidence of cardiac arrest, use of bystander CPR and the distribution of public access defibrillators. Deprived areas, and areas with a greater proportion of residents from minority ethnic backgrounds, have a higher incidence of cardiac arrest, lower incidence of bystander CPR and lower access to public access defibrillators. This needs further discussion and research. Teaching CPR to children in all schools would be a way of improving some of these inequalities.

Improving education and systems can save (more) lives

50% of out-of-hospital cardiac arrests (OHCAs) are witnessed. Bystanders perform CPR in 70% of these. Public education is crucial in saving lives. In 2018, 59% of members of the public in the UK reported having received training in CPR and 19% in how to use an automated external defibrillator (AED).

In 2019, over 291,000 people in the UK were trained in CPR as part of World Restart a Heart Day. Teaching the essential core skills in resuscitation will improve patient survival.

How to get better at paediatric resus

Technology-enhanced education, as well as simulation, can be used to improve teaching and engage learners. Social media and smartphone apps can be used to engage the community. A new section has been added to the guidance named ’Systems Saving Lives’ with the intended audience being governments, managers in health and education systems, health care professionals, teachers, students and members of the public. By emphasising the importance of the connections along the Chain of Survival, we can improve the performance of resuscitation systems.

4 Key areas that have been highlighted are:

What's new in paediatric resus guidelines

Ethics

Another key area in the new guidelines is around integrating decisions about CPR in advanced treatment plans (e.g. Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) process). The guideline highlights the need for communication strategies and interventions to support discussions with patients and their family around resuscitation.

What might we see in the next revision…

  • Could IO become the first choice route of adrenaline?
  • Will we still be using adrenaline in all arrest situations?
  • Will (ab)normal saline be removed entirely?
  • Will we have more concrete evidence on using Hartmann’s/ Ringer’s Lactate in resuscitation fluids?
  • Will we have more information on the barriers and motivators to bystander CPR and AED use in respect of ethnic, socio-economic, cultural and educational background?

Selected references for the updated Resuscitation Council UK guidelines

Resuscitation Council UK Guidelines 2021 https://www.resus.org.uk/library/2021-resuscitation-guidelines

Madar Jet al European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth (2021). https://doi.org/10.1016/j.resuscitation.2021.02.014 ERC Guidelines 2021: https://cprguidelines.eu/

Wyckoff MH, ET AL. Neonatal Life Support Collaborators. Neonatal Life Support 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2020 Nov;156:A156-A187.  https://doi.org/10.1016/j.resuscitation.2020.09.015 Epub 2020 Oct 21. PMID: 3309891

Chest compressions in traumatic cardiac arrest

Cite this article as:
Karl Kavanagh and Nuala Quinn. Chest compressions in traumatic cardiac arrest, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31093

Traumatic cardiac arrest (TCA) is an infrequent event in paediatrics, and a cause of significant stress in the busy trauma resuscitation room. Outcomes are similar in both paediatric and adult arrests, with poor survival rates in both. There are now international guidelines on the management of traumatic cardiac arrest. A traumatic cardiac arrest (TCA) is traumatic not just for patients but also for staff and all those involved. The guidelines were published in 2016, however, the role of chest compressions is still a source of confusion for medical and nursing staff alike. Advanced Paediatric Life Support algorithms and supporting medical evidence have correctly engrained chest compressions into medical management of life threats. However, there is a paucity of studies examining trauma-induced hypovolaemic arrests to base the decision to change the “normal practice”. It is counter-intuitive for medical staff to not start compressions when an arrest is presented to you and withholding them inevitably leads to the question “Well, what can I do then?”.

Haemorrhage is one of the three common causes of early preventable death in trauma. This paper, from Sarah Watts et al, sought to determine whether compressions are beneficial and with what fluid the patient should be resuscitated with (if at all). Of course there are ethical and practical issues with a prospective randomised control study involving children as the subjects. Instead, this animal study is a helpful surrogate for analysis of the question surrounding the role of chest compressions in haemorrhage-induced traumatic cardiac arrest.

Disclaimer: not suitable for vegetarians!

Watts S, Smith JE, Gwyther R and Kirkman E. Closed chest compressions reduce survival in an animal model of haemorrhage-induced traumatic cardiac arrest. Resuscitation. 2019; 140:37-42. Doi: 10.1016/j.resuscitation.2019.04.048

PICO image

Population

39 pigs were enrolled and treated as per UK Animals (Scientific Procedures) Act 1986 ethics standards. The baseline data of all animals involved were within normal ranges and differences between them was not clinically significant. Each subjects’ vital signs were invasively monitored throughout the study.

Intervention

There were 5 phases through which all participants/subjects went.

  • Injury phase
  • Shock phase
  • TCA phase
  • Resuscitation phase
  • Post-resuscitation phase

Each subject was anaesthetised and the same injury was reproduced in each. Subjects were allowed to exsanguinate in a controlled pattern. Once terminal hypovolaemia was declared, three rounds of resuscitation were commenced. After resuscitation, subjects were categorised according to MAP and Study End was defined as 15 minutes after the end of the third resuscitation cycle.

Patients were blindly randomised into 5 different groups:

  1. Closed chest compressions(CCC)
  2. Whole blood (WB)
  3. 0.9% Saline (NaCl)
  4. WB+ CCC
  5. NaCl+ CCC

Outcome

The primary outcome was achievement of ROSC at study end.

Secondary outcomes were differences in survival and attainment and maintenance of ROSC during the resuscitation and post-resuscitation phases.

Results

To summarise the numerous results:

  1. All the subjects in compressions only group died.
  2. All the subjects that received whole blood only survived.
  3. Resuscitation with blood had improved outcomes over normal saline.
  4. Addition of compressions had a detrimental effect on fluid resuscitation.
  5. Subjects that received any combination of CCC showed a more significant metabolic acidosis, reflecting increased tissue ischaemia.
  6. In the group that received both CCC and WB, 5 of 8 subjects achieved partial ROSC (MAP 20-50mmHg). Once partial ROSC was ascertained, CCC’s ceased and fluid resuscitation alone was continued. This led to the subjects improving to such a degree that there was no longer a difference between this group and that resuscitated by WB alone from the beginning.
  7. All results can be attributed to the groups’ interventions as confounding variables were minimised and the initial injury reproduced in each case.

Discussion

While this is a small population study, it has become a sentinel paper as it demonstrates clear evidence that chest compressions in a TCA are detrimental and that our reflexive management of medical arrests is not transferable. We need to shift our focus to optimising fluid resuscitation. It shows a clinically relevant outcome that is internationally applicable. It is important to note that it was terminal hypovolaemia, not true cardiac arrest with no output, which was being measured. However terminal hypovolaemia is an imminent precursor of cardiac arrest.

Reflections from Nuala Quinn

I have listened to Dr Sarah Watts present this paper and listening to her reinforced my opinion that this paper is superb. It challenges the dogma and forces us to push beyond traditional management strategies in what is arguably the most stressful paediatric emergency: major trauma.

Closed chest compressions are a mainstay of medical management. They are firmly embedded in resuscitation culture and indeed have become a mainstay of civilian culture. When healthcare practitioners hear the word “arrest” they automatically move into the “chest compressions” mindset. However medical cardiac arrest and traumatic cardiac arrest are two completely different entities with ensuing separate management. Anecdotally it is difficult to separate the two and advising a team that no-one needs to do chest compressions in an arrest causes anxiety and confusion. This happened only recently in our department where advising one of our staff that we didn’t need to do chest compressions as a priority was met with “but it says in APLS so we need to do them”. 

So how do we get around this? In my mind we do this in two ways: 

Firstly, we use and promote the life-saving bundle of interventions for TCA and keep it as a completely separate entity. When leading a TCA, as the pre-brief I will usually start with This is a Traumatic Cardiac Arrest which will need the bundle of life-saving interventions before anything else”. I write the bundle of life-saving interventions on the adjacent whiteboard and assign specific people to them. I focus on the bundle, rather than ABCDE. Focusing the team on the bundle, rather than the “arrest” per se, helps to separate the medical arrest from the traumatic arrest. 

Nuala's priorities for traumatic cardiac arrests
Team priorities in a traumatic cardiac arrest

I follow the PERUKI guideline which can be found here. The bundle needs to be prioritised over chest compressions and defibrillation. For revision, here is the bundle:

Secondly, we use the evidence and this is where papers like Watts et al come in. Evidence is fluid, it changes all the time. It takes years for resuscitation courses and bodies to update manuals and so it is our responsibility to use emerging evidence and use it sensibly and progressively. Watts’ paper helps me to educate and challenge dogma, particularly with compressions and saline resuscitation. Again, anecdotally the practice of giving saline as the initial resuscitation fluid in trauma exists.  We seem to be hesitant to give blood immediately, with view that to try with saline first is better, to not waste blood. The literature is now abound with papers describing the deleterious effects of saline in trauma, particularly with regard to its dilutional effects and role in worsening trauma coagulopathy. Again, this paper supports the choice of whole blood over saline and is in keeping with the life-saving bundle.  This paper cements for me, the reasons for the importance of the life-saving bundle before anything else and should empower us to make better decisions in the trauma reception and resuscitation:

Should we just give a saline bolus first?

Should we just get someone to do chest compressions as they have no pulse?

The answer here should always be no, and this paper is evidence to support that. The TCA algorithms are almost exactly the same, between adults and paediatrics and in institutions all over the world. This has really helped to standardize the management of TCA and have people trust the bundle, rather than revert back to what feels safe for them (compressions and saline in most instances). 

As to our case above, I wasn’t team-leading and with 10min to the patient’s arrival, didn’t want to push the issue, so the plan for compressions went ahead and the role was assigned. However, at the end of the trauma resuscitation, I realised that the chest compressions hadn’t actually been performed. So in that clinician’s subconscious, there was an understanding and mutual trust in the process of changing and progressing how we better manage traumatic cardiac arrest. Watts and PERUKI are leading the way. It is up to us to follow them.

Selected references

Watts S, Smith JE, Gwyther R and Kirkman E. Closed chest compressions reduce survival in an animal model of haemorrhage-induced traumatic cardiac arrest. Resuscitation. 2019; 140:37-42. Doi: 10.1016/j.resuscitation.2019.04.048

Rickard AC, Vassallo J, Nutbeam T, Lyttle MD, Maconochie IK, Enki DG, et al. Paediatric traumatic cardiac arrest: a Delphi study to establish consensus on definition and management. Emerg Med J. 2018;35(7):434-9.

Vassallo J, Nutbeam T, Rickard AC, Lyttle MD, Scholefield B, Maconochie IK, et al. Paediatric traumatic cardiac arrest: the development of an algorithm to guide recognition, management and decisions to terminate resuscitation. Emerg Med J. 2018;35(11):669-74.

(ANZCOR) AaNZCoR. Australian Resuscitation Council Guidelines 2016 [Available from: https://resus.org.au/guidelines/.]

Virtual Reality: Camilla Sorensen at DFTB19

Cite this article as:
Team DFTB. Virtual Reality: Camilla Sorensen at DFTB19, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.21504

Imagine a world where you could teach CPR from a thousand miles away, a world where you can guide clinicians on the other side of the world. In this groundbreaking talk from DFTB19 Camilla Sørensen tackles another side of virtual reality. This one involves the clinician as power user.

 

 

©Ian Summers

(Editor’s note – I was so excited when I watched this talk that I promptly bought myself a VR headset)

 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

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