“Pediatric Cardiac Arrest” by Robert Berg, MD for OPENPediatrics

“Pediatric Cardiac Arrest” by Robert Berg, MD for OPENPediatrics

Pediatric Cardiac Arrest by Dr. Robert Berg. Hello, I’m Bob Berg. I’m the Division Chief
of Critical Care Medicine at the Children’s Hospital of Philadelphia and I’ve been a career
investigator in cardiac arrest and resuscitation for both children and adults. What we’re going
to talk about in the next few minutes, is about pediatric cardiac arrest: a chance to
save a life. That may seem a little bit ironic of a title. Most of us get nervous, feel doom, feel gloom
when we hear about or see cardiac arrest in a child. But in fact, this is an opportunity,
I would like to convince you over the next hour, to save somebody’s life. I’m employed at the University of Pennsylvania,
I’ve been an AHA volunteer, but I want to be clear that this has nothing to do with
the American Heart Association or my previous roles as BLS or PALS committee chair, or have
anything to do with any of my grants. But I do have some serious intellectual conflicts
of interest after 25 years of being a cardiac arrest and CPR research scientist. So over
the next 50 minutes, what we plan on going over is number one, the history of cardiopulmonary
resuscitation with a focus on children. The epidemiology of pediatric CPR. And I’d
like to convince you that it’s not so rare and it’s not so dismal. We’ll talk a little
bit about CPR quality. Bottom line of it all is push hard and fast and allow full chest
recoil. We’ll talk a little bit about post-resuscitation
care, an important issue over the last 10 to 15 years. And then the hot, new stuff which
is duration of CPR and debriefing. Two exciting areas that are with recent information. History of Pediatric CPR. So in the mid 1950s, there was a problem of
people getting cardiac arrest because they bumped into high wires that were high voltage
in the United States. The former dean of the Johns Hopkins School of Engineering, Kouwenhoven,
got together with his young collaborators, Guy Knickerbocker and Jim Jude, and they had
a grant to look at defibrillation. At the time, defibrillators were the size of almost
a room and you had to bring the patient to the defibrillator rather than the defibrillator
to the patient, so they were trying to come up with new ideas. While they were working with this, they took
dogs, created a cardiac arrest, and when they took the paddles to get ready to shock the
dog, each time they squeezed on the paddle, they saw the arterial blood pressure rise.
And they pressed again, it rose again. And pressed again until they could– on a regular
basis, they looked at 100 animals and showed that they could keep adequate circulation
for as much as 30 minutes by squeezing on these paddles. And they called this new observation closed-chest
massage. Jim Jude was a cardiothoracic surgery fellow at Johns Hopkins, and they had a patient
in the PACU– which, at that time, was the hallway at Johns Hopkins in the 1950s– who
had a cardiac arrest. And he did the same thing he did on the animals, but instead of
squeezing from the sides, he put his hands on the chest and did the same sort of forceful
compressions which was called in that article closed-chest massage. But really was a quite
vigorous act of compression. And the first woman survived and went home.
They, in fact, in total did it on 20 patients all of whom had asphyxia in the operating
room. 20 of 20 of them survived the cardiac arrest, and 14 of the 20 were long-term survivors,
which is still the best outcome of any cardiac arrest study ever before or after that’s had
that many patients in it. Importantly, the next article that they are published by Jude,
Kouwenhoven, and Knickerbocker was in 1961. And you can see in this picture here were
the kinds of blood pressures that they attained with the CPR that they were providing was
nowhere near what you would expect from something as benign sounding as cardiac massage. You
can see here that on this 39-year-old man, the blood pressure was 150/40. In this 60-year-old
man, it was approximately 110/40. To get those kinds of pressures required very vigorous
CPR. In that same article, a third picture that
they showed was the arterial blood pressure in an 8-year-old post-op cardiac surgery,
and we have blood pressures of 110/30 during CPR. This was vigorous, aggressive chest compressions.
As one of the parents once told me after CPR was done on their child in our intensive care
unit, that wasn’t just compressions. That was a violent act. And thank you very much
for doing it because you brought my child back to life. At the same time in Baltimore, over at Baltimore
City Hospital, the young Peter Safran was showing a novel idea about how to provide
mouth-to-mouth resuscitation. The A and B of the A, Bs, and Cs of CPR were discovered
at this time. They were concerned at the time about how to give adequate ventilation. The
As and Bs and Cs, the airway and breathing of Peter Safran, and the circulation that
was put together by Kouwenhoven et al were put together with the modern ABCs of CPR. About 25 years later, Dave Nichols and others
at the Children’s Hospital of Philadelphia – where I’m now at – took a look at what happened
during those 20 years when they did CPR in their hospital. And they showed 18 children
that had asystole. 2 of the 18, about 10% survived to discharge, and none of them survived
after more than 2 doses of epinephrine. A young Vinay Nadkarni then similarly did a
study at National Children’s Hospital in DC showing that 53 pulseless arrests occurred
in these children. And again, 5 out of 53, or about 10%, survived
to discharge from the hospital. And again, none of them survived if they needed more
than 2 dose of epi. And none of them survived when CPR was greater than 10 minutes. And
from these 2 studies came the concept that outcomes from cardiac arrest in children were
quite poor. Preventing it was better than treating it. And here’s the next slide that comes from
the initial PALS course, the Pediatric Advanced Life Support Course of the American Heart
Association, looking at the outcome of respiratory versus cardiopulmonary arrest in children
showing that the survival rate was excellent if it was a respiratory rate arrest, but if
you wait until it’s a cardiopulmonary arrest and the heart stops, outcomes were really
terrible. So the original courses focused on diagnosis of treatment and treatment of
respiratory failure and shock, and prevention of cardiopulmonary arrest. And really didn’t
spend much time on cardiopulmonary arrest because it was considered a rare event with
dismal outcomes. Epidemiology of Pediatric CPR. I’m going to give you a little bit of epidemiologic
data that I hope will convince you that those assumptions weren’t quite true. First of all,
I’m going to give you information from the National Heart, Lung, and Blood Institute
and the Canadian equivalent on the Resuscitation Outcome Consortium, which provides EMS, out-of-hospital
cardiac arrest information epidemiology on a population, initially, of 21 million, and
now 23 million. And you can see the various centers that were involved. And the first pediatric study to come out
of this– we showed Diane Atkins and some others of us looked at population-based incidents
from out-of-hospital cardiac arrest and showed that for under one year of age, the incidence
was relatively similar to that in adults. It was about one order of magnitude less common
than kids that were one year to 19 years of age. Now, of course, there are many, many, many
more adults than there are kids less than 1 year of age. So it’s much more common to
have an out-of-hospital cardiac arrest in an adult. But in any given year, it was about
the same instance in kids under a year of age as it was in adults. So is it rare? Well, if you take that data
when it was gathered and you look at the number of children with cardiac arrest and the number
of months and the population of the United States, that would estimate that somewhere
around 5,000 children in the United States each year would have a cardiac arrest. And
there are many diseases we take care of in our intensive care units that are much less
common than 5,000 per year. So it’s not so rare, in fact. How about is it dismal? As this slide shows
from that same data, the kids 1 to 19 years of age had about a 9% survival compared to
adults with a 4.5% survival. And across the whole board, children have much better survival
rates than adults. One thing I would like to emphasize is the
under 1 year of age kids– probably about 1/3 of them had sudden infant death syndrome,
although the study did not have adequate information about that because of the nature of the study.
Nearly every other study shows about 1/3 to 1/2 of the patients with out-of-hospital cardiac
arrest in the first year of life are due to SIDS. And those patients frequently wake up
in the morning, and they’ve been dead all night long. So it’s not surprising their outcome
is poor. If you take them out, the survival rate under a year of age is pretty close to
that for those that are adults. And between 1 in 19 is much better. In this slide we look in Japan with very similar
data showing, again, with almost 1,000 patients, it almost looks like identical data. 9% survival
in the 5 to 12-year-old range. And overall, kids had a 50% higher survival rate than adults.
And a favorable neurological outcome rate was also higher among children than adults.
So nobody is saying that we shouldn’t be doing CPR on adults. And yet some people have said
in the past we shouldn’t do it on children when, in fact, their outcomes are better. More recent data from the PECARN network,
the Pediatric Emergency Care Research Network in the United States– they looked at 138
children from 15 sites– about 20% were at our hospital, Children’s Hospital in Philadelphia–
that had one minute of chest compressions and then had return of circulation for at
least 10 minutes. 38% of them survived to discharge. Those are the ones that made it
to you. Remember, a lot of them didn’t survive to get to your hospital. But of those that
had that much return of spontaneous circulation, most of whom came to intensive care units,
56% have favorable neurological outcomes. But importantly, 1/3 of them had severe disabilities. How about in the PICU? So I’m an intensive
care doctor, and Tony Slonim and Murray Pollack showed in the mid-1990s that almost 2% of
PICU admissions in 32 PICUs in the United States, the patient had at least two minutes
of CPR. Looking at Adrian Randolph’s data looking at the frequency of admissions to
intensive care units in the United States, somewhere in the range of 5,000 to 10,000
PICU CPR events happen every year. So PICU CPR is at least as common as CPR out of hospital.
It’s an important problem. It’s not rare. This has been repeated last year by us in
the Collaborative Pediatric Critical Care Research Network of the NIH. In our PICU CPR,
the Pediatric Intensive Care Quality CPR pilot data, we showed, again, that about 1.5% of
the PICU admissions in the year 2012 at these major institutions ended up having cardiac
arrest. So somewhere around 1 in 50 to 1 in 70 kids that are admitted to an intensive
care unit end up having CPR provided to them. This is not a rare event. The next thing I’d like to show you, a little
data, is national data from the American Heart Association from the Get With the Guidelines
Resuscitation Database. This includes over 500 hospitals and more than 200,000 adult
and pediatric cardiac arrests. And the pediatric arrests are just under 10,000. In the first
of these studies from this– again, by Vinay Nadkarni and others of us– showed that of
the first almost 1,000 kids to have a cardiac arrest, 60% had return of spontaneous circulation.
We were able to bring them back, at least initially. Almost half of them did not survive
the first 24 hours. And 27%, or less than half of them, survived to hospital discharge. But those who did survive to hospital discharge,
81% had a relatively favorable neurological outcome. That is they were walking and talking.
So unlike the out-of-hospital cardiac arrest, which had a substantial number of patients
who were devastated and relatively few– only about half of them that had favorable neurological
outcomes– it’s up to 80% for in-hospitals in this study. And it’s important to know
that the immediate cause of death in these studies from pediatric and adult in-house
cardiac arrest, about half are due to respiratory insufficiency acutely and half are due to
hypotension. And if you look at these numbers, you’ll see that they add up to more than 100%,
because many patients have both. Most importantly, the children have much better
outcomes than adults. 27% of children survived hospital discharge versus 18% of adults, and
with an adjusted odds ratio of 2.3, because children were much less likely to have VF
and VT and had other adverse factors. These are absolute numbers, and they ignore the
very important issue about potential years of life gained. A pediatric survivor of a
cardiac arrest has a much greater opportunity to live many, many more years. So I’d like to say pediatric resuscitation–
it’s worth the effort. CPR Quality. When I talk about cardiac arrest,
I like to think about four phases. I like to think about the pre-arrest phase, and there’s
a certain set of things we can do to prevent cardiac arrest; the no flow phase, when there’s
untreated arrest and what we should do then; the low flow phase, or what Peter Safar–
one of the fathers of modern CPR– would called the trickle flow CPR, where we just get some
flow with CPR but not enough; and then the post-resuscitation phase, what happens afterwards
the focus of the last 10 years that really has had us reenergize and rethink about what
we can do for cardiac arrests. So first of all, the pre-arrest phase. Simple.
Prompt diagnosis and treatment of respiratory failure and shock should be able to prevent
cardiac arrest. In motor vehicle accidents, you can help by having kids in their seat
belts so that they don’t have a cardiac arrest. And there’s a whole host of things that we
can do in other settings. It’s the focus of the PALS course. It’s the focus of the whole
movement for medical emergency teams or rapid response teams. Studies from Stanford and
from Melbourne show that we can have fewer deaths and fewer non-ICU codes by having these
medical emergency teams. The second, and no small issue, is that we
should monitor critically ill children. In fact, the bottom part of this slide I showed
about 15 years ago at a major conference and people were ready to throw me off the stage.
I said a non-ICU pediatric cardiac arrest is a sentinel event, a potentially avoidable
medical error. And people in the audience thought I was some sort of crazy loon. But
in fact, as you know now, in the United States with the Children’s Healthcare Association,
CHA, we now believe that non-ICU pediatric cardiac arrest should be avoided. And as this slide shows, recent data from
Get With The Guidelines-Resuscitation shows that in the latter half of the last decade,
95% of the cardiac arrests in ICUs and wards happen in ICU. We have effectively moved from
less than 90% up to 95% of those arrests are happening in the ICU because we’ve been able
to move the patients earlier. And most importantly, that’s resulted in better outcomes, a higher
rate of return of spontaneous circulation and survivor with favorable neurological outcomes.
And that’ll be coming in press in Critical Care Medicine soon. So that’s the pre-arrest phase. How about
the no flow phase? Bottom line of that is do something. Push hard, push fast, allow
full chest recoil, minimize interruptions, and don’t overventilate. In hospitals, get
the patient to the ICU before, where they can be monitored for cardiac arrest and treated
promptly instead of having a prolonged period. That sounds trivial but an important issue
for out of hospital cardiac arrest is only about a third of kids that have out of hospital
cardiac arrest have bystander CPR. It is unbelievable that some people– there’s a call to EMS,
6 to 12 minutes later the emergency medical system arrives, they do CPR, and some of them
survive. The truth of the matter is, that prolonged no flow state is a terrible factor
leading to death. Low flow phase CPR. Chest compressions provide
the entire cardiac output. The stroke volume depends on pushing hard, the heart rate depends
on how fast you push it. How good can we be in CPR? The data aren’t perfectly clear in
kids, but in our animal models we can show that a cardiac output in pediatric animal
models can be 10% to 25% of normal with CPR. That means that the blood flow is about 10%
to 25% of normal and that normal ventilation isn’t necessary. We can ventilate a little
bit lower than that because blood flow is only 10% to 25% of normal. So we have a tendency
to want to bag real fast and breathe real fast when it’s really not necessary. And in fact, a very high intrathoracic pressure
from rapid rates of ventilation can result in high intrathoracic pressure and impede
blood return to the chest. Interestingly, myocardial and cerebral blood flow can be
greater than 50% of normal sinus rhythm during CPR. How can that be so big? Well, you get
vasoconstriction elsewhere and your blood flow is predominately to the heart and to
the brain. And you can get actually quite good flow, which is why we can have so many
good outcomes. One of my colleagues at the University of
Arizona, Art Sanders, an emergency medicine specialist, showed in 1984 the coronary perfusion
pressure, that is, the aortic diastolic pressure minus the right atrial pressure during CPR,
is the critically important determinant of successful CPR. It turns out that when you
push on the chest, you squeeze on the myocardium. When it gets squeezed on, the microvasculature
has a very high resistance and nothing flows through from the epicardium into the heart.
And we’ve done some studies with Doppler showing minimal flow during the compression phase. Karl Kern, another one of my associates when
I was at the University of Arizona, an interventional cardiologist, showed very nicely that coronary
perfusion or myocardium perfusion was a predictor of 24-hour survival as well. When the coronary
perfusion pressure was less than 20 at 10 minutes of CPR, 96% of the animals could not
attain returned spontaneous circulation. So having a high enough pressure is critical
to perfuse those hearts. And then the limited data we have in humans
is Norm Paradis showing in a really astounding set of studies that were done at Henry Ford
Hospital in Detroit, Michigan that patients came in with CPR, they put in arterial catheters
in the emergency department, he and Manny Rivers and others, and where they measured
the coronary perfusion pressure and there was a dose response curve as shown in this
slide. If the CPP was less than 15, none of them had returned spontaneous circulation.
Half of them did when it was 15 to 25 and 80% did what it was greater than 25. So there’s
a dose response curve of pressure to flow to outcome. This is the classic curve, this from one of
our animal experiments from a little more than a decade ago. And in the pink is the
arterial waveforms and in the yellow is the right atrial wave forms. And you can see that
the bottom of the pink to the bottom of the yellow is the coronary perfusion pressure
or the pressure at the end of relaxation. And you can see that each time we stop to
give two breaths, the aorta empties out to the periphery, the aortic diastolic pressure
drops, and it takes a while for it to build back up. So what we learned is, interrupting
compressions has a lot of adverse effects. First and foremost, it decreases the frequency
of your compressions, that drops your cardiac output by dropping the heart rate. There’s
a decrement in aortic diastolic pressure. There’s lower left ventricular myocardial
blood flow, we measured that as well and it resulted in worse outcomes. So the bottom
line is, minimize interruptions. So Philips and Laerdal made this defibrillator
that you can work that had associated with it a chest compression sensor that has an
accelerometer in it. With it you can measure the chest compression rate, depth, force,
and residual leaning. My colleagues at Children’s Hospital Philadelphia, Bobby Sutton and Vinay
Nadkarni decided in 2006 to start measuring CPR quality of CHOP and for those two year
periods you can see that a very high percentage of the children did not get the rate that
you wanted. That’s 43% did not get the rate wanted, 36% did not get the depth that we
were trying for, and 36% did not get the absence of leaning on the chest that we were hoping
for. Or said in the other way, only about 60% got each of the correct rate depth and
absence of leaning that we were expecting. It was written in that article by Bobby and
Vinay that this was terrible CPR and that they have long way to go to get better. But
the truth of the matter is, it was the best quality CPR study that had been published
at that point. They had better quality than any of the adult studies that have been published. And interestingly, just published in 2013,
our group has looked at whether when we push down a third to half of the chest compression
depth do we get that aortic diastolic pressure of 30, which will give us a coronary perfusion
pressure around 20, just like we said we needed in the animals. And lo and behold, luckily,
pushing down that far was about the right amount to get adequate pressures that would
predict that you’d have better outcomes. We’ll get back to that more in a little bit. Vinay Nadkarni came up with this brilliant
idea at CHOP to look at a mobile cart with a mannequin to provide 30 to 90 seconds of
insight to CPR practice with feedback to optimize CPR skills. So you can see this mannequin
with the force transducer on them, and you can see the cart that would go by the bedside.
They would ask the five sickest kids in the unit, they would come on over and the CPR
group goes over to the nurse by the bedside and has them practice 30 to 90 seconds of
CPR. Will that make any difference? It turns out, surprisingly to me, that highly refreshed
teams, that is, teams that have at least two providers that had had refreshments just 30
to 60 to 90 seconds of CPR practice within the last four months, the frequency of chest
compressions of adequate depth went from 70% up to 88%. So practice improves your performance. None
of us would think about taking a ball and throwing it someplace once every two years
and then think we could throw the ball across the plate well. Or kick a soccer ball into
a net once and then two years later, be able to perform well at the most important time
to perform in the world. Yet somehow, we think that we can do CPR once every two years and
be able to perform well. Instead of four hours of CPR once every two years, just doing every
few months 30 to 90 seconds is enough to make a big difference in outcome. No surprise to
any of us. Also published in 2013, Bobby Sutton showed
that– and our whole group– that adequate blood pressure is dependent added with chest
compression, rate, and depth. And you can see that if you did the rate greater than
100 and the depth greater than 38 millimeters, your chance of having a systolic blood pressure
above 80, what they showed that they could do in 1960 and had those excellent outcomes,
was two-fold more likely. And the diastolic pressure greater than 30, the kind that will
get you a coronary perfusion above 20, was 1.5 times more likely. So adequate blood pressure
is due, in fact, dependant adequate chest compression rate and depth in our pediatric
ICUs. And what we did is we did a study looking
at a pediatric model to see if there was any effective leaning, and we looked at the pressures
during CPR. And we took a look at a group of animals that had no leaning and then one
that had 10% leaning and 20% leaning, and as you look at the pressures, they’re not
very much different. The coronary perfusion pressure dropped from 22 to 19 to 17. But
those low numbers seem to be unlikely to make a difference. However, in the low flow state of CPR, slight
differences in pressures make huge differences in flow. So as this slide shows, myocardial
blood flow dropped by almost a half and cardiac index dropped by almost a half. How common
does leaning occur? Well, leaning of greater than 2.5 kilograms, which was more than about
20% in most of these children, occurred in 13% of the chest compressions. So leaning
is common and leaning has adverse effects. Do we have the right goals? Should the goals
be based on mechanics, go in depth, or go rate? Or should it be based on hemodynamics,
blood pressures, like we do with anything else we do in medicine? We would look at–
we certainly wouldn’t go in the operating room and say, the chest should move by this
amount when we ventilate. We’d look at the end-tidal CO2. We certainly wouldn’t say,
I should give you this amount of epinephrine. I’d look at the blood pressure. So should
we be looking at hemodynamics? This study in resuscitation, again by Bobby
Sutton and our group of investigators at CHOP, showed that when we switch from a guideline
directed, depth directed CPR with giving epinephrine every four minutes as per the guidelines,
that the outcomes were not nearly as good as when we did it by hemodynamic goal directing.
We took a swine model, we gave them seven minutes of asphyxia, clamped the tube. Then
we did 10 minutes of CPR and we either gave what we call realistic, which was the depth
that is typically measured in hospitals, or the 2010 goals, a deeper, the greater than
50 millimeters. And we gave the epinephrine whether they needed it or not every four minutes. And we compared that to hemodynamic goals,
which was we didn’t give the epi if it wasn’t needed because the blood pressures were high
enough. And if the blood pressures dropped down, we gave more frequent epi until we got
it up there. The two groups got approximately the same amount of epinephrine and the survival
rate, as you can see, was dramatically better with hemodynamic goals than with the standard
system that we use without paying attention to flow. Good pediatric advanced life support begins
with good basic life support. Push hard, push fast, allow the chest to recoil– that is,
don’t lean– and minimize your interruptions and that will get you the best outcome from
children in cardiac arrest. So you all know this algorithm from the American Heart Association,
CPR again in the center of it is push hard, push fast, don’t interrupt, breathe slowly,
and seek reversible causes. And if you’re doing an electrocardiogram and you see VF/VT
we shock. If that doesn’t work, we give epinephrine. We keep doing compressions and then we shock
again. And then we can use anti-arrhythmic. If on the other hand, there is no VF or VT,
we give epinephrine and we do CPR for two minutes and we continue to seek reversible
causes and provide CPR. So in the past we taught CPR by a series of
boxes that made it look like one person was providing care and just going from step to
step. But in fact, that’s not how we work in medicine. We work as an integrated team
and there’s multiple players at once. It’s sort of like thinking of a football game or
a basketball game as each. The ball gets thrown to one person and there’s nobody else on the
court, and then it gets passed to another person and there’s nobody else on the court. That’s not how it works. There’s a team working.
An integrated team can give a simultaneous, choreographed approach. The first rescuer
who has his hands available can start doing chest compressions instead of having the first
box say, you know, him breathing and running around looking for a bag and mask. The next
rescuers simultaneously can be one person getting the rhythm detection and getting a
defibrillator while another person is getting a bag mask for ventilation. Back to our earlier study from the NRCPR,
that’s now called Get With The Guidelines-Resuscitation, we looked at almost 1,000 kids. 60% have return
of spontaneous circulation. 24 hours later, almost half of them were no longer alive.
And by discharge, there was 27% survival. Remember these numbers. This is just one decade
ago. Yet now we knew there was a drop off one decade ago and we knew that before then.
And finally in the year 2008, the American Heart Association published the post-cardiac
arrest syndrome, the whole concept that a lot of things happened post-arrest and there’s
things we can do about it. The first of those things that we could do
about it that was published in 2002 where these two articles in the New England Journal
of Medicine, showing that mild therapeutic hypothermia can improve outcomes after cardiac
arrest, both in Europe in the HACA study and by Steve Bernard in Melbourne. And everybody
says that mild therapeutic hypothermia improved neuro outcome, but actually, as you see this
slide, it improves survival and neuro outcome by about the same amount and was quite effective.
However, what most people don’t know from that study is that hypertension occurred in
over half of the patients in the HACA study, and that more than half of the patients in
Bernard’s study received epinephrine for hemodynamic support. Myocardial dysfunction and hemodynamic
dysfunction during cardiac arrest are the norm. This is a study published by our group in
Arizona in 1996 that for the first time looked at cardiac output, along with the same year
a study by Max Harry Weil and Tang, and as you can see from the graph here that the cardiac
output drops by almost a half within 30 minutes, stays down during that day, and comes back
up the next day. Very similar to post-pump myocardial dysfunction and very similar to
substance associated myocardial dysfunction. It’s a myocardial stunning. It’s reversible
myocardial depression without concomitant myocardial ischemia. There’s LV systolic and
diastolic dysfunction. There’s right ventricular systolic and diastolic dysfunction. And there’s
activation of pro-inflammatory cytokines. Virtually every cytokine that’s been shown
to be abnormal post-pump or associated with the systemic inflammatory response has also
been shown in the post-cardiac arrest. In fact, some people refer to it as a sepsis-like
syndrome. Karl Kern and my other colleagues at the University
of Arizona showed that we could obviate that by treating with dobutamine, and you can see
from this slide that you can prevent the drop in cardiac output, in this case, left ventricular
ejection fracture, by giving dobutamine. And there been multiple other ways to approach
it. Soon after this was studied, Ivan Laurent in Paris gathered data on hospital cardiac
arrests patients in Paris and showed that over half the adults needed vasoactive drips
for hypertension in the first 24 hours after the cardiac arrest. Frank Muller showed in the P current study
that I mentioned before that 70% of kids after out of hospital cardiac arrest were put on
vasoactive drips because of hemodynamic dysfunction. So how do you treat it? Well, most of us treat
with catecholamines, although there’s no controlled trials, dobutamine, epinephrine, dopamine,
or norepinephrine have all been used. Any animal studies have shown Milrinone and Levosimendan
as successful agents. The bottom line is keep up the blood pressure. Don’t let the blood
pressure drop in somebody as a second insult to both the heart and the brain. Post-Resuscitation Care. I’m going to switch gears a little bit and
talk about post-resuscitation care, as a whole. What do we know? We know that we avoid hyperthermia.
We know that we should monitor temperature and treat fever aggressively. We should consider induced hypothermia. And
that is 32 to 34 degrees, for 24 to 72 hours. But there’s, for those of us in pediatric,
the THAPCA study’s on right now. And maybe that’s the right thing to do, and maybe not. It should be noted that even though the previous
studies showed that hypothermia was better than the control group the control group were
all hyperthermic. And some people would argue that if we just brought the temperature down,
we would have gotten all the gain without any adverse effects. And most importantly, I hope that I’ve emphasized
that myocardial dysfunction is common after cardiac arrest. It’s virtually the norm. Make
sure you treat that with fluids appropriately and with vasoactive agents. The next slide shows the picture of Alexis
Topjian, one of the young faculty members at the Children’s Hospital of Philadelphia.
And she’s looked at seizures during hypothermia. And she’s showed that with long-term, continuous
EEG monitoring of these patients that came in after cardiac arrest, that almost half
of them had seizures. They were mostly non-convulsive. And it especially
occurred during rewarming. This has been repeated at Toronto Sick Children’s and at other places.
And about 1/3 of the patients had status epilepticus. And that 1/3 that had status epilepticus had
the worst outcomes. What we don’t know yet is if active treatment could have prevented
that status epilepticus earlier in the seizures, and ended up with better outcomes. So I’m going to switch gears one more time
and talk a little bit about something that’s been very exciting for the last decade, that
many of us use at our institutions– ECMO-CPR. There were studies in Pittsburgh, Boston,
and others showing small groups of patients– seven, eight, nine patients– that were put
on ECMO during CPR and survived. The first large study was presented from the
Children’s Hospital of Philadelphia, looking at 66 children over seven years, approximately
1/3 of the total ECMO at the Children’s Hospital of Philadelphia. 1/3 of them survived a hospital
discharge, despite a median duration of CPR of 50 minutes. Nobody could imagine it could be true. It’s
important that the investigator said that there was a brief no flow period. They started
CPR immediately in the ICUs. There was excellent CPR during the low flow, although none of
them measured it. And unlike patients not on ECMO, when you’re
on ECMO, you can control the post-resuscitation temperature and blood flow. So it was optimal
post-resuscitation phase. This brought a new paradigm in 2004. Cardiac
arrest, or CPR duration, does not necessarily determine futility. The concept of 10 minutes
or two doses of epi was totally thrown out. That study was from the Children’s Hospital
of Philadelphia. It’s been repeated by the people in Boston Children’s Hospital, by Toronto
SickKids, and at Great Ormond Street. And all four places have shown virtually identical
findings, in fact, so much so it’s striking. New Topics: Duration and Debriefing. I’m going to talk for the last little bit
about two really new, striking, provocative findings. So the first one is about CPR duration.
About three months, ago there was an article by Zach Goldberger and some of the rest of
us from the Get With The Guidelines Resuscitation showing that adults could have CPR for more
than 25 minutes and have 9% of them survive to discharge. An amazing study. I’m not going to go into
much detail about that, but this month, in January of 2013, we have an article also in
Pediatrics showing that the adjusted probability of survival, if you needed CPR for one to
15 minutes, is now 41%. It is a chance to save a life. But more amazing is that if your CPR was more
than 35 minutes, 12% survived. Now this is a biased sample, I’m sure, looking at what
positions and providers did in hospitals all over the United States. And many of the patients
that died, the provider stopped CPR before 35 minutes. Among those that they continued
to do CPR for 35 minutes, among that biased sample that providers thought had a chance,
12% survived, a number that none of us ever believed was possible. Just a striking is among those survivors,
favorable neurological outcomes occurred in the majority of them in both groups, and they
were not statistically significant. So prolonged CPR can result in survival, and survival with
good neurological outcomes. What’s most amazing about this is it sort
of confuses us about what’s right. When’s the right time to stop? That’s why these findings
in adults– I got to the front page of The New York Times– the idea about how long do
you try is an important issue for physicians and for the public alike about what does it
take to save my life? And the scary idea about if you go too long, have you kept somebody
alive that has severe neurological deficits? In both the pediatric and adults’ trials,
it looks like you’ve not had a large price to be paid in terms of bad neurological outcomes
if you could survive. But we’re just at the beginning. We don’t know what the right thing
is to do. And nobody knows the right answer of how long do you do. This slide is looking at, first adults, and
then kids in Get With The Guidelines among hospitals that have been in this Get With
The Guidelines quality improvement regimen, where they keep data about how well they’ve
been doing in their hospital. Hospitals have been in this for the last decade. You can see that the survival rate from VF
and VT among adults increased from 28% to 40%, and for asyst and PEA increased from
6% to almost 15%. That’s a 4% adjusted rate of improvement per year over the last decade.
This is the first study since the original description in the 1960s showing that we’re
improving outcomes with CPR at places that are paying attention to what they’re doing. Again, in Pediatrics, by Girotra et al, we
showed among 1,000 children who had CPR provided during the last decade, the risk adjusted
survival increased from 14% to 43%, an adjusted rate of improvement of 1.08 or 8% per year.
So again, outcomes are improving, both in adults and children. And then I’m going to say one more thing that’s
sort of an area of just new and stunning results. Remember I showed you that puck they put in
the chest, and they give you feedback about how well you push. On that puck there’s actually
audio and visual feedback to tell you how hard to push and how to optimize your CPR.
And when people turn on and turn off that feedback, the outcomes and the processes only
improve a very little bit. Some of the investigators in adult medicine,
particularly Donna Edelson at the University of Chicago and Ben Abella at the University
of Pennsylvania, showed that by debriefing, by showing people afterwards what their blood
pressures and compression rates and compression depths were like, and debriefing people after
cardiac arrest, that the system improved over time. But it was relatively subtle. But it
was much, much more impressive than the changes that happened with direct feedback during
the chaotic event of CPR. At the Children’s Hospital of Philadelphia
we tried something different. In the year 2008, they decided to look at 18 months before
they did debriefing, and then start doing a different kind of debriefing at the Children’s
Hospital of Philadelphia. In our case, we decided rather than debrief individuals, we
were going to do it as a whole team so all the nurses and all the Fellows could be in
the room and learn about how the last CPR event, in a non-confrontational, open communication,
transparent way to look at how we can improve our care. What was most striking is you’d see a picture
and you’d see that there’s a flat wave, and there’s no compressions done for 10 seconds.
Everybody in the room said, oh my god. I was there. How did that happen? And they nevet
let it happen again. So you can see from this slide that pre-debrief
and post-debrief, the rate of return of spontaneous circulation increased by 10% and the rate
of survival after hospital discharge went from 31% to 51%, and the rate of survival
with good neurological outcome improved from 27% to 48%, numbers that none of us truly
believed were possible in these 120 CPR events. What was the mechanism of that? Well, remember
in the beginning when we showed you those slides that only about 60% of the time did
we do the right depth and the right rate, and avoid leaning? In 2008 to 2010, before
we did debriefing, we’d already increased that up to 70% and 80% doing good CPR, as
opposed to the 60%. After debriefing, we increased that up to the 90% range. So no surprise that if you improve the quality
of CPR, you get better profusion of your heart and your brain and the outcomes are better. So in conclusion, I hope that I’ve said to
you that pediatric cardiac arrests are not so rare, they’re not so dismal, and increasingly
they’re a chance to save a life, particularly if the CPR has been done in an intensive care
unit. Then for pre-arrest, prevent the cardiac arrest.
Recognize respiratory failure and shock. Put people in seat belts. Avoid poisons. Once you do have a cardiac arrest, don’t have
no-flow phase. Immediately just do it. Push hard, push fast, avoid interruptions, and
don’t lean. And in the post-arrest period, manage left ventricular dysfunction. Diagnose
and manage seizures or myocardial dysfunction. Prevent hyperthermia, and perhaps consider
hypothermia. This data that we have right now is a beginning
to a new future where we can save more lives. And I’d like to have my last slide show that
we should be thinking the future, should ward events that are now uncommon, should they
become a no-no? Should they be a circumstance where, in the United States, a no-no means
if that happens, you’re not going to get paid for it because that’s not acceptable outcomes.
Are we really ready for a time like that? Maybe. In-hospital cardiac arrest survival rates
are improving, but there’s got to be a limit. What is that limit? Let’s find out what that
limit is, and who are the right people to be providing CPR for, and for how long. The duration of CPR. This is just the big,
new– it’s new as can be, and nobody really knows what to do with it. 12% survived after
more than 35 minutes of CPR. None of us imagined that was possible. When should we stop? Does that mean we should
go more than 35 minutes with everybody? I don’t think so. But what are the characteristics
that helped those doctors decide that their patients had a better chance? And don’t forget,
12% survival meant that 88% did not survive. So going along doesn’t promise you anything,
but stopping early promises you that those patients could not survive. And finally, and last, debriefing is good.
And I want to thank all the Children’s Hospital of Philadelphia and Penn Investigators on
this slide. It truly does take a village to make a difference. Please help us improve the content by providing
us with some feedback.

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About the Author: Sam Caldwell


  1. Good program! Great quote at about 9:50 "These kids wake up in the morning after having been dead all night long"!

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