A Case of Pediatric Cardiac Arrest – EM Reflections November 2021

Authored and Copyedited by Dr. Mandy Peach

Big thanks to Dr. Paul Page for leading this month’s discussions

All cases are imaginary but highlight important learning points.

Case

You are working a day shift at a tertiary hospital that sees both adult and pediatric patients. You receive dispatch for a 2 year-old female with potential sepsis. Parents report high fevers for 4 days and poor intake. EMS report a somnolent child, febrile and tachycardic. ETA of 5 minutes.

On arrival the child appears mottled and drowsy, paramedics have placed a non-rebreather and are supporting the airway. You rapidly complete an assessment while the patient is being placed on cardiorespiratory monitoring and nurses attempt access. The patient responds to voice with whimpers. A paramedic is performing a jaw thrust while another bags. Breathing is shallow and rapid. She is mottled with cool extremities and delayed capillary refill.

Vitals: BP 60 SBP, HR 160 sinus tachycardia, T 39.7 RR 50 O2 88% on 100% NRB.

Gulp. You ask the nurse to page the pediatrician on call as you are worried about this patient.

Pediatric vitals are interpreted by weight or age, but you don’t need a table to see that these vitals are abnormal and this kid is altered. Frankly, this patient is pre-arrest if intervention doesn’t take place soon.

Not so sick kid? Here’s a reminder of expected vitals per age¹.

Pediatric patients tend to compensate and compensate – until finally they don’t. Are there earlier signs of sepsis to be on alert for when assessing a patient¹?

• tachycardia out of proportion to fever – fever can give an expected increase in HR by 10 bpm,

• tachypnea – RR tends to increase by 5 breaths/min for every 1 deg over 38°C.

• poor perfusion – this can range from poor cap refill to altered level of consciousness.

When it’s later stages – it’s obvious. But sepsis doesn’t always have all these signs – a high suspicion is needed to recognize sepsis before it gets to critical stages.

What is the most concerning vital sign of our patient¹?

Hypotension – this is a late sign of sepsis and if untreated the patient will arrest.

You suspect this child has septic shock given the brief history and temperature. Currently, their airway is being well managed by paramedics who have added NC under the mask and with continued jaw thrust they have improved oxygen saturation – but this is temporary.

You want to initiate management for sepsis and potentially need to intubate this child.

But before any of that can occur you need IV access.

Nurses have attempted twice and failed – it’s been 2 minutes. What next?

Do not hesitate to move to intraosseous (IO). This child may imminently arrest. Fluid resuscitation and administration of antibiotics are vital. If you can’t obtain IV access in 60 secs – obtain IO¹

Preferred sites in pediatric patients (altered from EMdocs.net)²

Worried about hurting the child? Flush lidocaine through the IO – evidence suggests pain is more from infusions and medications through the IO than the insertion itself.¹

Have more time with a relatively stable patient? Consider using PoCUS to help obtain peripheral lines

You obtain IO access and immediately request fluids. You want them to run in as fast as possible, but the child is too small for a level 1 infuser. What’s your approach?

First, choose the fluid type. Normal saline or Ringer’s lactate is fine to start. 20cc/kg is the typically starting bolus over the first 5 minutes of resuscitation. This can be repeated twice more up to 60cc/kg in the first hour. For this patient, and any patient under 2, load a 30-60cc syringe with crystalloid and manually bolus.

Signs of fluid overload?

Hepatomegaly and crackles auscultated in the lungs

A better sign – pulmonary edema seen on PoCUS³.

Normal vs B lines

IO assess has been obtained in both tibia, a nurse is pushing fluid manually while another asked you what antibiotics you want drawn up.

What are the broad-spectrum antibiotics suggested by age¹?

You go back to reassess the patient’s airway. They are now satting 92% on 100% NRB + 5L NC. There is still some spontaneous whimpering. You estimate the GCS to be 9: E- 3 V- 2 M -4. This patient’s respiratory status is worsening and they have a low GCS. You feel they need intubation. Repeat vitals are obtained after first bolus.

BP 64 SBP, HR 158 sinus tach, T 39.8, RR 48 O2 as above.

Do you immediately intubate?

This patient is in profound shock, their catecholamine surge is deplete and any induction agents, even ketamine, would likely still worsen their hypotension and potentially precipitate arrest. If successfully intubated there is then the complication of increasing intrathoracic pressure – thus reducing blood flow back to the heart and decreasing cardiac output¹.

The principle of resuscitate before you intubate is especially true in this situation.

You order repeat bolus of fluid to be manually given while antibiotics are being infused in the other IO. A nurse has now achieved peripheral IV access.

You prepare drugs and airway equipment for RSI – you plan to intubate once fluid boluses are complete if vitals have improved.

What drugs will you use? What drugs would you avoid^5,6,7,8,9?

Avoiding worsening hypotension is key – ketamine is the drug of choice for sedation in children as it is considered hemodynamically neutral, but again expect drop in BP when the body is in shock. Ketamine also preserves airway reflexes and ventilatory drive.
Conversely propofol creates vasodilation and suppresses the myocardium – causing hypotension. It also can cause respiratory depression and apnea.

There is some evidence that etomidate is associated with less adverse events in septic patients, specifically hypotension. In one observational study in an adult population, ketamine was shown to be complicated by post-intubation hypotension more frequently when compared to etomidate.

In the pediatrics population etomidate for intubation in the ED setting has also been shown to be associated with minimal change in blood pressure – but this was a small, retrospective study. Currently etomidate is not recommended in patients < age 10 and more evidence is needed. One could also consider the potential for adrenal suppression post etomidate (etomidate inhibits functioning of an enzyme required to make cortisol, aldosterone and corticosterone). There are various studies – some in pediatric patients showing decreased plasma cortisol levels at 24 hours post etomidate. A similar effect was seen in other critically ill adult patients. The CORTICUS trial indicated a higher 28 day mortality in patients who received a single dose etomidate vs those that did not, regardless of being given exogeneous steroid.

For paralytics succinylcholine should be used cautiously in pediatric patients – it can precipitate hyperkalemia, bradycardia and even arrest. Rocuronium does have fewer side effects and contraindications, but it’s duration of action lasts approximately 50 mins – compared to approximately 6-10 minutes with succinylcholine. So strongly consider your choice – if you feel this is a ‘can’t intubate, can’t ventilate’ situation rocuronium is a dangerous choice.

You decide to go with ketamine and rocuronium and the drugs are being drawn up – what doses will you use?

In an adult population a safe choice in the shocked patient is to half the sedative and double the paralytic. The reason being even with ketamine you can get myocardial suppression and potential apnea.

For the paralytics use higher dose as the onset of action will be slower – double the dose.

For pediatric patients there is no evidence in the literature to support this practice, currently practice is to choose agents that have the least effect on hemodynamics – typically ketamine and rocuronium.

The RT is asking what size tube and airway equipment you would like.

Quick answer – Broslow tape. In this unstable patient this is the easiest way to get what you need without having to do any mental math. You request a cuffed tube – decreases the need  for ET tube changes⁴.

While airway equipment is being set up you move now to prepare the patient. How do you position this 2 year old^5,10?

Children have larger heads that naturally lies in flexion when supine. To align the mouth, larynx and trachea often the position has to be changed. You can roll up a towel to help with placement. As a rule of thumb:

Keeping a patient supine can also worsen hypoxemia as children have increased chest wall compliance and therefore increased work at baseline to maintain tidal volume. This can eventually lead to intrapulmonary shunting.

So although this patient doesn’t require additional positioning with a towel based on age we would still put the head of the bed up.

Someone asks if they can remove the additional oxygen mask or nasal cannula in preparation for intubation so it’s out of your way. Your response⁵?

No – pre-oxygenation is vital in the intubation of any patient, especially a child as they desaturate so quickly. In this 2 year old patient we expect a time of less than 4 minutes to desaturate to 90%. Children have much less surface area or ventilation channels as the alveoli continue to develop until the age of 8. In this patient with potential underlying respiratory illness there could be areas of atelectasis, worsening lung ventilation.

What other airway considerations are going through your head for a pediatric patient¹⁰?

Remember CHILD

For a great overall review see this infographic⁵

You are about to reassess the airway and obtain new vitals when the patient’s breathing changes to agonal and her whimpering has ceased. There is cardiac activity on the monitor, it be appears to be tachycardia with a widened QRS. Someone yells – check a pulse!

Do you need a pulse to initiate CPR in this patient?⁴

No – given the frequency of bradycardia and hypovolemia, pulse checks are not reliable. If apnea and unresponsive, initiate CPR.

At what rate should CPR be initiated in this patient⁴?

Use the encircling hands technique for infant CPR – it is shown to give better hemodynamics. Push hard (>1/3 AP diameter of chest) and fast (100-120 bpm), minimizing interruptions and allowing full recoil of the chest between compressions.

As this is an in-hospital cardiac arrest an LMA is immediately inserted to prevent interruption in compressions and to provide oxygenation.

Aim for 20-30 breaths/minute when an advanced airway is in place.

Out of hospital cardiac arrest⁴? Resuscitation with bag valve mask results in the same resuscitation outcomes as advanced airways -don’t underestimate the value of a good seal and a 2 person technique.

CPR is ongoing, an LMA has been inserted. The initial rhythm did not appear to be shockable. This is a PEA arrest.

What is your priority?

Determining the cause and in the meantime administering epinephrine – early administration within 5 minutes of non-shockable rhythms increases survival⁴.

You review your H’s and T’s.

You are pushing fluids for hypovolemia, the patient maintained oxygenation throughout with 2 sources of oxygen and had a normal oxygen saturation before arrest, the patient could be acidotic – but you are drawn to hypoglycemia. You rack your brain but can’t remember the glucose. You verbalize to the room, but no one knows if a glucose was done.

You quickly obtain one – 0.5.

You must correct glucose rapidly:

5cc/kg D10W IV push followed by an infusion of D10NS at 5cc/kg/hr (max at 250cc/hr)¹¹

After the correction of glucose and additional round of CPR you get ROSC.

Obtaining a glucose is VITAL in any pediatric patient – something you know but failed to recognize as you had an unstable patient in front of you.

ABC + DEFG = ABC and DON’T EVER FORGET GLUCOSE¹

What other metabolic abnormality must you consider¹?

Hypocalcemia is commonly seen in critically ill pediatric patients, even without clinical signs like seizure or arrythmia it is recommended to treat.

Calcium gluconate 10% 0.5-1 cc/kg slowly over 5 minutes (max of 20 cc)

You reassess the vitals and the patient is still hypotensive and tachycardic despite 3 boluses and fluid circulating throughout the arrest. The oxygen saturation is 100%. The RT is still bagging via LMA. Clinically they appear cool and mottled with pulses weaker distally.

The patient is in cold shock. What is the vasopressor of choice¹¹?

You initiate epinephrine at 0.05 mcg/kg/min IV and titrate up by 0.02 mcg/kg/min.

You assess cardiac function and lung fields via bedside ultrasound – the heart is hyperdynamic, lung fields are clear. You continue another bolus.

The patient’s GCS post arrest is back to 9. They are being easily bagged. You plan to wait until vitals have stabilized to switch out the tube.

At this point a pediatric attending arrives and you give an update.Immediately the staff begins verbalizing orders to the room for pressors, fluids and antibiotics. They begin questioning RT and direct them to intubate. The staff look to you for direction.

What do you do at this point?

This can be an uncomfortable situation to be in – this patient is still your patient; they are still unstable at this point and you have been guiding resuscitation. You have developed a sense of trust with your team and more than one leader can often lead to confusion.

You ask the attending to step out and together you review the management up to that point. This was a complex case with a lot of intervention. You discuss each medication given and the outcome. You make your suggestions on pressor support and fluid and reinforce what has been given. Together you are on the same page and go back in to reassess with the team.

It’s important to respectfully gain additional input from consultants and work together to ensure optimum care, but still realize that you are running the room. In other cases you may be at a loss for what to do and need guidance for what to do next – but again, once a plan is decided with your consultant it’s important that you verbalize to the room and give clear instruction to your team.

Overwhelmed and need to pass off? No problem – once you have help verbalize to the room that the consultant will now be leading resuscitation and stay nearby to assist and learn.

Lastly, what other medication should you consider if the patient’s hemodynamics or clinical picture do not improve¹?

Steroid – up to 25% of pediatric patients with septic shock have adrenal insufficiency. This may be from the infectious process itself, from previous steroid use or from primary adrenal insufficiency.

You administer hydrocortisone 2mg/kg IV.

What markers of a successful resuscitation will you look for¹?

• Capillary refill < two seconds
• Normal blood pressure
• Normal pulses with no differential betweencentral and peripheral pulses

• Warm extremities
• Urine output > 1 ml/kg/hr
• Normal mental status
• Normal lactate

The patient gets admitted to the ICU for Pneumococcal sepsis and after a prolonged admission does well.

Pediatric patients are scary – use the resources you have, verbalize your thought process to the room and ask for help. Continuously reassess 

ABC + DEFG = ABC and DON’T EVER FORGET GLUCOSE¹

References and further reading:

1. EM Cases Digest – Vol 2. Pediatric Emergencies. Chapter 2: Sepsis and septic shock. Helmon, A. Lloyd, T. 2016. Toronto, ON.
2. Image altered from http://www.emdocs.net/feelin-it-in-my-bones-a-review-of-intraosseous-access-in-the-emergency-department/
3. Images from https://www.thepocusatlas.com/
4. Highlights of the 2020 American Heart Association Guidelines for CPR and ECC
5. Tolmie, A 2021. PEM Pearls01: Pediatric Airway Differences. CanadiEM. Retrieved Jan 20, 2022 from https://canadiem.org/pem-pearls-01-pediatric-airway-differences/
6. Scheirer, O. 2018. CRACKCastE192 – Airway. CanadiEM. Retrieved Jan 20, 2022 from https://canadiem.org/crackcast-e192-airway-9th-edition/
7. Mohr NM, Pape SG, Runde D, Kaji AH, Walls RM, Brown CA 3rd. Etomidate Use Is Associated With Less Hypotension Than Ketamine for Emergency Department Sepsis Intubations: A NEAR Cohort Study. Acad Emerg Med. 2020 Nov;27(11):1140-1149. doi: 10.1111/acem.14070. Epub 2020 Jul 20. PMID: 32602974; PMCID: PMC8711033.
8. Guldner G, Schultz J, Sexton P, Fortner C, Richmond M. Etomidate for rapid-sequence intubation in young children: hemodynamic effects and adverse events. Acad Emerg Med. 2003 Feb;10(2):134-9. doi: 10.1111/j.1553-2712.2003.tb00030.x. PMID: 12574010.
9. Sprung CL, Annane D, Keh D, Moreno R, Singer M, Freivogel K, Weiss YG, Benbenishty J, Kalenka A, Forst H, Laterre PF, Reinhart K, Cuthbertson BH, Payen D, Briegel J; CORTICUS Study Group. Hydrocortisone therapy for patients with septic shock. N Engl J Med. 2008 Jan 10;358(2):111-24. doi: 10.1056/NEJMoa071366. PMID: 18184957.
10. Hsu, J. 2021. Tiny Tips: Pediatric Airway Anatomy Considerations CanadiEM. Retrieved Jan 20, 2022 from https://canadiem.org/tiny-tips-pediatric-airway-anatomy-considerations/
11. Pediatric Severe Sepsis Algorithm 2018. A PedsPac from Translating Emergency Knowledge for Kids (TREKK).