cập nhật hồi sức cấp cứu nâng cao ở trẻ em, PGS TS BS PHÙNG NGUYỄN THẾ NGUYÊN

Nguyên nhân ngưng tim trong BV- 90% of pediatric cardiac arrest is  Asystole, or  Bradycardic PEA - Defibrillation seldom needed.?. CARDIAC ARREST: NON SHOCKABLE RHYTHM... CARDIAC ARR

CẬP NHẬT HỒI SỨC CẤP CỨU NÂNG CAO Ở TRẺ EM

PGS TS BS Phùng Nguyễn Thế Nguyên

HSCC- CĐ, BV NHI ĐỒNG 1 Giảng viên cao cấp- ĐH Y DƯỢC TP HCM

Mục tiêu

1 Trình bày lưu đồ hồi sức nâng cao?

2 Trình bày xử trí đường thở, thở và tuần hoàn nâng cao?

3 Cập nhật các vấn đề liên quan dùng

• Adrenalin

• Bicarbonate

• calcium

Nguyên nhân ngưng tim trong BV

- 90% of pediatric cardiac arrest is

 Asystole, or

 Bradycardic PEA

- Defibrillation seldom needed

PEA-Pulseless electrical activity

- Unpalpable pulse in the presence of organized cardiac

electrical activity

- Referred to as electromechanical dissociation (EMD)

- Raizes: 68% of monitored in-hospital deaths and 10%

of all in-hospital deaths

- Survival: 10-20%

- Điện tim bình thường tạo nên được mạch

Compression?

PEA

Tension pneumothorax

• Temponade (cardiac, lung)  Mass MI

• Thrombosis  Toxin (ức chế beta, calci)

• Hypovolumia  Hyperkalemia

• Hypoxia

• Mechanical hyperinflation

True-PEA

CARDIAC ARREST: NON SHOCKABLE RHYTHM

CARDIAC ARREST – SHOCKABLE RHYTHM

Airway

Oropharyngeal Airway

Nasopharyngeal Airway

Airway

1 Failure to oxygenate

2 Failure to ventilate

3 Failure to protect the airway

4 Anticipation of worsening clinical course

Indications

Endotracheal Tube (ET tube)

OXY ADMINISTRATION

- FiO2 100% trong thời gian Hồi sức không nguy hiểm

- Cho FiO2 cao

- Maintain SpO2 in the range of 94–98%

Objective:

- Maintain Gas Exchange

- Self-inflating Bag-Mask

 w/o reservoir 30-80% FiO2

 with reservoir 60-95% FiO2

Bag-Mask Ventilation

Proper area for mask

application

Breathing

Bag-Mask Ventilation

Breathing

Best Sign of Effective

Ventilation

Chest Rise

Cardiac Arrest: Non Shockable rhythm

Intraosseous Cannulation

 Vascular access required

 Peripheral site cannot be obtained

• In three attempts, or

• After 90 seconds

Indication

Intraosseous Cannulation

Intraosseous Cannulation

Đường truyền trong xương

 Dùng cho mọi lứa tuổi.

 Kim chích tủy xương:

• Trẻ em 1.5 cm

• Người lớn 2.5 cm

 Chỉ dùng trong 24 giờ

33

Intraosseous Cannulation

Incomplete penetration of the

bony cortex.

Penetration of the posterior cortex

Fluid escaping around the needle through the puncture site

Fluid leaking through a nearby previous cortical puncture site.

IO line Complication

Cardiac Arrest: Non Shockable rhythm

Compared to regular dose Epinephrine, high-dose

Epinephrine

1.Improves outcome.

2.Does not change outcome.

3.May worsen outcome.

Epinephrine: High vs Regular dose

- Prehospital epinephrine use and survival among patients

with out-of-hospital cardiac arrest, Nhật, 2005-2008, 15030

- Vasopressors are used to restore spontaneous

circulation by optimizing coronary perfusion and to help maintain cerebral perfusion

- Also cause intense vasoconstriction and increase

myocardial oxygen consumption, which might be detrimental

- 2015 Recommendation—New

 It is reasonable to administer epinephrine in

pediatric cardiac arrest

High dose of epinephrine

- Advantages

 “Improves myocardial and cerebral blood flow during CPR

more than standard-dose ”

 “May increase the incidence of initial ROSC”

David G Nichols “Rogers' Textbook of Pediatric Intensive Care”

- “Worsen post-resuscitation hemodynamic condition by

causing increased myocardial oxygen demand, ventricular ectopy, hypertension, and myocardial necrosis”

- “Do not improve survival and may be associated with a

worse neurologic outcome”

David G Nichols “Rogers' Textbook of Pediatric Intensive Care”

“High-dose epinephrine: in special circumstances of refractory

pediatric cardiac arrest (e.g., patient on high-dose epinephrine

infusion prior to cardiac arrest) and/or when continuous direct arterial blood pressure monitoring allows titration of the epinephrine dosage

to diastolic (decompression phase) with cautionly ”

David G Nichols “Rogers' Textbook of Pediatric Intensive Care”

- “Data from adult OHCA raise the possibility that any dose

of epinephrine during CPR might be harmful”

David G Nichols “Rogers' Textbook of Pediatric Intensive Care”

Fluid resuscitation

- 20 ml/kg bolus

 In settings with limited access to critical care

resources extreme caution.

- Either isotonic crystalloids or colloids can be

effective as the initial fluid choice for resuscitation

Atropin

- Chỉ dùng trong đặt NKQ mà có nguy cơ cao chậm

nhịp tim

 Dùng thuốc dãn cơ

All of the following are true regarding Atropine

1.It increases SA and AV conduction through muscuranic

antagonism.

2.At low doses, it has central and peripheral

parasympathomimetic actions which may lead to paradoxic vagotonic effects.

3.It does not cause fixed and dilated pupils during cardiac

arrest.

 In infants, cardiac contractility depends on

extracellular calcium influx since intracellular calcium is deficient.

 Hypocalcemia can present with cardiogenic shock!

 There is no role for the empiric use of calcium.

 Indications for use:

 Correct documented hypocalcemia.

 Antagonise hyperkalemia and hypermag.

 CCB toxicity.

Dose: CaCl2 10% (100 mg/ml) 20 mg/Kg IV

Sodium Bicarbonate

All of the following are true

1.NaHCO3 inactivates catecholamines.

2.NaHCO3 leads to increased CO2 production

and worsening acidosis.

3.No evidence shows an improvement in

outcome when NaCO3 in administration during resuscitation from cardiac arrest.

pH +0,14

During severe acidosis (pH less than 7.2)

- The heart is more susceptible to V-fib and other

arrhythmias

- Myocardial contractility is suppressed, hypotension

occurs, hepatic blood flow is reduced, and oxygen

delivery to tissue is impaired

BUT… Bicarbonate

1 Compromise CPR by reducing systemic vascular

resistance

2 Create extracellular alkalosis that will shift the

oxyhemoglobin saturation curve and inhibit oxygen release

3 Produce hypernatremia and therefore hypersmolarity

4 Produces excess CO2, which freely diffuses into

myocardial and cerebral cells and may paradoxically

contribute to intracellular acidosis

5 Exacerbate central venuous acidosis and may inactivate simultaneously administered catecholamines

Acidosis process

- Acidosis

 Developing 3 minutes

 Significant acidosis 18 minutes

 Regain normal ventilation and circulation quickly,

acidosis generally resolves within 60 minutes

- Two studies cited in the 2010 Guidelines demonstrated

increased ROSC, hospital admission and survival to hospital discharge associated with the use of bicarbonate

- The majority of studies showed no benefit or found no

relationship with poor outcomes.

Benefit of Sodium bicarbonate

Dose of NaHCO3

1 mEq/kg IV/ 10 phút

NaHCO3 (1 mEq/ml)

CARDIAC ARREST – SHOCKABLE RHYTHM

Amiodarone -Lidocaine

Consider….!

Thank you!