1. Selected Pediatric Topics
Strive to Survive: Improving Cardiac Resuscitation
November 4,2016
Robert W. Hickey, M.D., FAAP, FAHA
Professor of Pediatrics
Professor of Clinical and Translational Science
Children’s Hospital of Pittsburgh of UPMC
University of Pittsburgh School of Medicine 1

2. Disclosures I have no relevant financial relationships to disclose
Past Chair of AHA-Peds Committee and AHA-ECC
Co-Chair of the International Guidelines Conference

4. Learning Objectives Important changes to the Guidelines
Impact of layperson CPR upon survival
Importance of respirations in pediatric CPR
What to do after the arrest

5. Learning Objectives Important changes to the Guidelines
Review of new literature led to upgrading or downgrading for some levels of evidence
BUT
the guidelines remain mostly unchanged
Emphasis remains on good CPR and CPR training

6. Learning Objectives
Impact of layperson CPR upon survival

7. Evidence Supporting Focus on CPR
CPR is important
Not enough people get CPR

8. Focus on CPR CPR is Important
Bystander CPR doubles survival of OOH arrest (peds and adults) !!!!!!!!
Donoghue et al. Annals Emerg Med 2005;46:512-22

9. ROSC = Return of Spontaneous Circulation
Collapse
Bystander CPR
ROSC
ROSC = Return of Spontaneous Circulation
EMS CPR
Visible in Studies

10. Bystander CPR resulting in
Collapse
Bystander CPR resulting in
ROSC = 41
All survived
EMS CPR=300
6 survived
Sirbaugh et al. Annals Emerg Med 1999;33:174-84

11. Hickey et al. Annals Emerg Med 1995;25:495-501
Collapse
Bystander CPR
ROSC
Selected pts=11
1 died
3 intubated
3 neuro consults
EMS CPR=43
5 survived
Hickey et al. Annals Emerg Med 1995;25:

12. Importance of CPR
Bystander CPR MORE THAN doubles survival of OOH arrest (peds and adults)

13. Not enough people get CPR
Focus on CPR
Not enough people get CPR
Only 1/3 of OOH cardiac arrest victims get CPR prior to EMS arrival (peds and adults)
Donoghue et al. Annals Emerg Med 2005;46:512-22

14. Not enough people who get CPR, get good CPR
Focus on CPR
Not enough people who get CPR, get good CPR
Too few chest compressions
Chest compressions are too weak
Too many ventilations
Too many interruptions

15. Solutions
CC only CPR (CCC)?

16. Advantages Less complicated to teach and perform Preserve CPP
Less fear of infectious disease
Less complicated to teach and perform
Preserve CPP
BUT, will it still work?

17. Lancet 2007;369:

18. Kitamura et al Lancet 2010;375:1347-1354

19. Favorable Neurologic Outcome at 30 Days
In 1-17 yo
No Bystander CPR
CC only
CC+V vs
CC Only
All Pts
34/1632
(2.1%)
20/538 (3.7%)
39/906 (4.3%)
Cardiac Cause
14/339 (4.1%)
14/158 (8.9%)
28/282 (9.9%)
1.2
( )
Non-Cardiac Cause
20/1293 (1.5%)
6/380 (1.6%)
45/624 (7.2%)
5.54
(2.5-17)

20. Arterial Blood Gas (after 7 min of CPR for VF)
7.41±.03
37±5
76±6*
* p<0.01 CC
7.49±.02
25±2
92±1*
CC+RB pH
pCO2
SaO2
…What is the explanation of this finding?
The best insight comes from the animal lab
ROSC EQUAL
Berg, Circulation 1997

21. Arterial Blood Gas (after 7 min of CPR-asphyxia)
SaO2
pCO2 pH
CC+RB
(15:2)
87±6**
45±8**
7.20±.02* CC
17±5
* p<0.001
97±5
7.01±.06
ROSC BETTER with RB
Berg, Circulation 1997

22. So, why teach CCC CPR?

23. For every 100 resuscitations in the out-of-hospital setting, 1
For every 100 resuscitations in the out-of-hospital setting, 1.6 will include a child

24. You could argue that we should teach RB for kids or for respiratory (but this complicates the message and may result in less retention and action)

25. Who should be taught CPR with ventilations?
Anyone likely to resuscitate a child
Life guards
School teachers
Baby sitters
To Review

26. Push Hard, Push Fast

27. Learning Objectives
What to do after the arrest

28. After the arrest What else Coroner CORE PCP Death Certificate
Help with grieving
Social workers
Personal space
Death packet (foot print; lock of hair, etc.)
See the back-up of patients
What else

29. After the arrest What else? ---be a detective (doctor) HPI PMH Fam Hx
Review previous records (EKGs?)

31. Post-Mortem Work N Engl J Med. 1999 Oct 7;341(15):1121-5.
Followed by case reports in SIDS, aborted SIDS, near drownings…

32. Case Report 19 yo woman Swimming laps in health club ACLS in field
found in 4 ft water
ACLS in field
QTc = 600 msec
Died in ICU 12 h later
Ackerman et al NEJM 1999;341:

33. Case Report Post-mortem section of myocardium
Molecular Diagnosis of the Inherited Long-QT Syndrome in a Woman who Died After Near Drowning
Case Report
Post-mortem section of myocardium
molecular genetic screening for mutations known to cause long-QT syndrome
discovered a novel mutation (9-bp deletion) in the KVLQT1 gene
Similar case report in a 10 yo near-drowning victim in Pediatrics 1999:101:
Schwartz et al ( NEJM 2000;343: ) describe a sodium channel gene mutation in an infant who nearly died of SIDS

34. Long QT syndrome (LQTS), short QT syndrome, WPW, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia (CPVT), arrhythmogenic right ventricular cardiomyopathy (ARVC)…

35. Three Questions
How many patients with sudden, unexpected death have a normal autopsy ?
How many of these patients will have a channelopathy?
Will a diagnosis of a channelopathy in the proband identify other family members at risk for sudden death?
The question, as with all case reports is---how common and how important is this?

36. Three Questions 14-35% (about 1/3rd)
How many patients with sudden, unexpected death will have a normal autopsy ?
14-35% (about 1/3rd)

37. Three Questions How many of these patients will have a channelopathy?
2-10% SIDS
14-20% young adults
(2,500/yr) in USA

38. Three Questions
Will a diagnosis of a channelopathy in the proband identify other family members at risk for sudden death?
22-35% of families

39. YOUR QUESTIONS (screening questions for family history of sudden death)
Has anybody in the family died unexpectedly
Has anybody died before 50 yo
Has anybody drowned
Has anybody died in a car accident
Is there a family history of seizures or “spells”

40. A two-year-old boy presents to the ED after a brief LOC
A two-year-old boy presents to the ED after a brief LOC. He has lost consciousness four times over a period of five months. Three of the episodes occurred when the child became upset. These episodes had previously been diagnosed as "breath-holding spells”.

41. Franklin WH, Hickey RW. Long QT syndrome. NEJM 1995; 333:355

42. Take Home Points Guidelines are mostly unchanged CPR is important
Not enough people get CPR (~1/3 of OOH)
Bystander CPR doubles survival from OOH arrest
Ventilations are important in pediatric CPR
Be a detective after the arrest