High Performance CPR, "Pediatric Pit Crew": A Step By Step Primer for Cardiac Arrest

Hey, this is Dr. Peter Entebbe, your medical director. Today I want to talk about pediatric cardiac arrest. We've done a really good job with adult cardiac arrest over these last couple years. Our Ross grades have gone through the roof. A tremendous job as well in pediatrics. And I want to make everyone understand that the adult arrest and the pediatric arrest, we should be treating exactly the same. Staying on scene, 20 minutes on scene, giving rounds of epi, performing an airway, speaking to families, getting closure. All these things are possible. You guys have done a great job. This video will go into that detail. Thank you, and I hope you enjoy the video. Foreign.

Let'S first talk about pre arrival. Before you enter the scene of a pediatric arrest, you have to be mentally ready.

Hey, listen, it's a seven year old. Looks like a drowning. If it's an actual cardiac arrest.

You'Re.

Gonna be airway, you'll be cpr. I'll be monitor and drilling. All right.

Since you're airway, your king's gonna be either a 2.5 or a 3, depending on what size is, but you can go either or. All right, defibrillation. The first one's at 50. The rest are at 115. 100. The rest, the epis are 2.5 MLS. And if they are in fib or they're in V tach, we'll do amiodro and it's 2.5ml as well. All right, I'm gonna drill them right when we get there.

You have to understand exactly what your role is, what you're going to do in the details of that. And, and most importantly, when you know that, to stay in your lane, that mindset of knowing exactly what you're going to do, knowing the dose of things, knowing equipment size is something that's so critical so that when you get in front of mom and dad and you're on the scene, that you actually stay on scene and you'll be present, you'll be focused, and you'll look like you know what you're doing, and people will enjoy watching you work. That's critical. Pre arrival is very important.

Now we're going to talk about placement of the gear during pit crew cardiac arrest when doing the research for putting together the pit crew cardiac arrest for the adult and the pediatric patient. We spoke to multiple different agencies around the country, and one of the things that they said was the most beneficial for orchestrating this in their organization was making sure that gear was placed the same every single time. This also sets up for success later On. As multiple units arrive on scene, it's easy for them to walk into the scene, see what's being done and see what's not being done, because the gear is going to be set up the same way on every single case.

So position number one is going to be your chest compressor. Your chest compressor is going to be set up on the same side. The pelican box is leaving room for whoever's working the monitor. You're going to place your hand in the center of the chest. You can put the middle of your hand across the nipple line. And then you're going to push hard and fast on the chest.

But you're also going to be allowing for proper recoil. So as far as depth goes, you're going to go about 2 inches, and we want to be anywhere from 100 to 120 beats per minute. There's also a feature on the LifePak 15 that's going to give you a metronome ventilate.

Jordan, what's going to tell you when to compress and when to ventilate your patient?

I wanted to talk to you about the science of chest compressions. Just like in the adult population, in pediatrics, chest compressions are critical. The depth and the rate are critical. So the rate is 100 times a minute. The depth, we're going 2 inches. And the recoil is critical. If you think about it, when you're ejecting blood out of the heart, when you're compressing, when you recoil, the blood is allowed to rush back into the heart and fill. So the next chest compression could have that same ejection volume. It's critical to actually keep that. Remember, the patient who's in cardiac arrest doesn't have the negative pressure to refill. All they're depending on is that recoil. And remember that with the rescue pod on there, it's causing a little bit extra negative pressure. Basically for the fact that you want to refill that right ventricle so that you can fill the heart back up upon ejection. So focus on bls, Focus on chest compressions. It is the most critical item for the pediatric arrest beyond the airway. Let's also mention about the Lucas. The Lucas is not really meant for pediatric patients unless that pediatric patient is big enough for them to fit in the Lucas. That's number one. Number two, the rescue pod. The rescue pod is meant for children at the age of one year and above. So do not use the rescue pod for children under the age of one.

Position. Number two is going to be responsible for working the LifePak 15. Now, there's a couple things that you need to know prior to actually getting next to the patient. One, which combo pad size are you going to use? Combo pad selection is very easy. You have two simple methods. One, you could look at the hand Tevy drug book and determine what size it is for the actual patient. Number two, you could look at the packaging the combo pads come in. If you look at the physio control packaging, it's clear on the pediatric pad. Any child that weighs 0-15 kg would use the pediatric pad. Anybody above 15 kg would use the adult combo pad. So if you're using the Hands Heavy drug guide, any child above the age of three requires an adult combo pad. Number two is what is your energy selection going to be? 40 joules, 50 joules? You have to have that number predetermined in your mind. That way, when you start to operate the machine, you go right to that designated joule setting. So after you turn this on, we're going to have you press the CPR feature and select Youth with an airway. And that's going to provide a metronome which is going to keep the chest compressor in sync during the cardiac arrest. Next, you're going to go ahead and pull out your combo pads. You're going to go ahead and place them on the child, and then you're going to charge the monitor to the appropriate predetermined setting. At that time, chest compressions will still be in progress. After the machine is fully charged, you're going to stop your chest compressor. You're going to look at the monitor and you're going to make the determination. Do you need to dump the charge or do you need to go ahead and press the defibrillation button? So now we're going to talk about the CPR metronome feature. So you're going to go ahead and press CPR and then you're going to scroll down to youth airway, because all of our patients are going to have a supraglottic airway in place. So you're going to go ahead and select youth airway, and it's going to prompt you to go ahead and do 10 compressions with the metronome. And approximately every six seconds, it's going to give you the ventilation cue for which the airway person would then deliver the breath. So now we're going to review the energy selection for the LifePak 15. So you're going to go ahead and determine what your predetermined joule setting, which for this case, we'll use 50 joules. You're going to go ahead and charge your monitor and then you're going to pause your chest compressor. As you pause the chest compressor, you've got to make the decision based upon the underlying rhythm whether we're going to apply the shock or we're going to dump the shock. If you forget how to dump the shock, it's very simple. By reading the bottom of the screen, it's going to say to cancel, push the speed dial in. Push in the speed dial and the joule setting will automatically be dumped. The last thing the LifePak 15 person is going to be responsible for is making sure the entitled CO2 filter line gets plugged in the machine for the airway person. So now I want to talk about a few procedural things that we need to consider during the post ROSC. The monitor person that's responsible for working the LifePak 15 has multiple things that they should be responsible for at this point. One, we need to make sure that the pulse oximeter cable is on the child's hands. Not only do we need to make sure it's on the child's hands, we need to make sure it's on the child's hand that actually does not have the blood pressure cuff on. So the blood pressure cuff and the pulse oximeter cable are not commonly used during the cardiac arrest. So these are two things that need to be applied in a timely fashion after we know that the child has ROSC. I just want to talk about what the number one indicator is for ROSC. It should be in tidal CO2. So you can see that we strategically place the monitor down by the feet of the patient. And the reason why we put it at the feet of the patient is because everybody should be able to have all eyes on the monitor at various different times throughout the call.

It looks like.

Spike to 60, you have a papal pulse.

So anytime you see a huge spiking box like waveform on the capnographic waveform or you see an increase in the capnometry number, then that should be a good indicator to you finish your two minute cycle that this child has a rosc.

Now I want to talk about the importance of the chest compressor and the person on the monitor. We know that, number one, just like in adults, the time to defibrillation is critical. So there should be the ability to get on this child and defibrillate as soon as possible if that child is in that rhythm. That's number one. Number two is the ability to work Together with that person on the monitor so that the peri shock pause is very minimal. Just like in the adult population, when we're actually increasing the pressure during chest compressions, we don't want to stop that pressure and we don't want it to go down too quickly. So if the person is stopping compressions, you actually defibrillate or you dump the shock and you're right back on the chest.

Everyone clear?

Just like we do in the adult population. The science is clear on this.

So now we're going to talk about position number three, the airway person. The first thing that we need to discuss is making sure the suction device makes it in on each and every one of these single calls. We know that this is something that doesn't go in the house or go next to the poolside on every single call. But during this situation, we have to be prepared and we have to make sure that this is there and. And it's right next to the patient's airway. The next thing that we need to discuss is the airway bag or backpack. It needs to be right next to you up by the airway, right next to the head, so it's easy to access to make sure that you apply everything that you need to do as quick as possible. So we're going to come in just like we would in an adult cardiac arrest. You're going to get your BVM out, you're going to hook it up to the oxygen, and you're going to go ahead and position the airway and you're going to deliver two big breaths. So you're going to give the two big breaths, you're going to push the blood out of the lung, and then you're going to go ahead and start your airway procedures. If the child's airway was covered in secretions or was a drowning case, it would be appropriate or applicable to actually suction the airway prior to performing the two big breaths. But that should almost be a simultaneous type thing. Quick suction, two big breaths followed by the suctioning. The next thing that we're going to discuss is the king airway. We know that what the appropriate size king airway is going to be, as well as how many mls of air. Now, we know that we're currently doing some eye gel research in the department, and it might be eye gel, so it doesn't matter. King airway, eye gel, lma, whatever it is, it needs to go in immediately. So you would go ahead and insert that device and you would inflate the cuff to the desired volume that's listed in the hand tevy book. Now after that, if it's above the age of one, you're going to go ahead and apply your rescue pod. On top of that, you're going to go ahead and turn on the light and it's going to match the metronome. The light's actually going to go off every six seconds and that's when you're going to provide the positive pressure ventilation. On top of the rescue pod would be your end tidal CO2. Now this is commonly messed up in the field. This goes on first and then they put the rescue pod on top. That's not how it's designed. The manufacturer's recommendations are clear on this. It goes rescue pod entitled CO2 filter line and then your BVM. Then you would go ahead and secure your device with either tape or an endolock and then you would go ahead and do the ventilations once every six seconds with the blinking light or the metronome. Another key point to remember in the post ROSC algorithm is to make sure that you remove the rescue pod.

Removing the rescue pod. Let's talk about the science behind the airway. In pediatrics we know that it's very typical that a child is in cardiac arrest because of an airway issue. So of course addressing the airway first and foremost is very important. Now a big issue that people often make is that they over ventilate. So especially with cardiac arrest, if you think about it, the amount of your end tidal number, the value in a typical cardiac arrest is low. And the only reason that you would have to bag more frequently is if a child is actually making that CO2. So as your end tidal goes up and your child develops rosc, your respiratory rate, your bagging rate will go up. But for cardiac arrest, there's no need to over ventilate, right? You can oxygenate someone very adequately with one breath every six seconds. There's no need to do more than that. The next thing I want to talk about, of critical importance is the end tidal CO2. We know that every time you're on a cardiac arrest, immediately along with placement of the airway, the supraglottic airway comes the end tidal monitor. And we all understand that a child who's in cardiac arrest will have a low end tidal. However, with good chest compressions, you should see that end tidal rise. So that end tidal CO2 monitor is of critical importance. The science is behind it and we need every single cardiac arrest to have that end tidal CO2 applied on top of the rescue pod as you see in the video here.

Now we're going to speak about position number four and position number four is going to be responsible for the medication box as well as performing the ez. So we know all cases isn't going to have six people or five people. It might only have two or three people. So if you're doing chest compressions, let's say you are position number one and you're only a two or three person rescue truck, you would actually, after your two minutes is up of doing chest compressions and you swap with the person that's actually working the monitor. Position number two, you would have the med box ready to go right there for you. So let's just say we're working this as a two person cardiac arrest or a three person cardiac arrest. Position number one is performing chest compressions. Position number two charges the monitor and then shocks or dumps the monitor. They would be able to reach over and go ahead and start spiking the bag and getting everything ready to go. At the two minute mark when they change chest compressors, this person would have the easy IO ready to go. We're going to do iOS in all of these cases. We're not going to waste time with an iv. And then we would go ahead and give our first round of EPI utilizing the hand heavy drug guide that should be found nearby your medication box. The only other consideration that you could have is if you had six people while the chest compressions are going on, while the monitor is being operated, while somebody's doing the actual airway, somebody could come in and solely focus just on the box. They could come right in, perform the IO and go ahead and have somebody administer the first round of epinephrine.

Before we talk about medications, I wanted to really stress that BLS is the most important item. There's a lot of controversy about epinephrine in the literature. But let's say this. We know from the literature that epinephrine, if it's going to work, will have to be given in the first 10 minutes from the time the child arrested. So let's take for example, if a child arrests and we have a six minute eta, that means that getting to the scene, airway, chest compressions, IO and the first dose of epinephrine has to happen very quickly. So epinephrine, although it shouldn't be the very first thing you think about with a cardiac arrest, it should happen immediately after the first BLS maneuvers have been started in the Pit crew approach.

Working these kids on scene, staying, doing the right thing, you're going to see that we're going to get ROSC much more frequently. And we have. The importance is, is that after ROSC is achieved, not to just stop and say, okay, we're good, because we're not. It's known that if a child post ROSC is hypotensive, the brain is not getting perfused. And although you have an alive child, you may have a neurologically devastated child. So it's of critical importance, right upon ROSC to do a set of vital signs, including obviously the heart rate. But blood pressure is of critical importance. So if the blood pressure is low, we can get fluids. But I also want you to consider, and you may see this reflected in our protocol in 2018, is to use push pressure EPI. It's the same type of epinephrine that we give for the severe anaphylactic child. It's where we take the EPI one to 10,000 and we make one to 100,000. You can use that to get the blood pressure up after rosc. That'll improve the circulation to the brain and it'll hopefully get us a positive neurologic intact outcome, which is what we're looking for.

One of the most important things for us as providers in the field is actually to get to closure. What does that mean? It means that after a patient has had a cardiac arrest and the family is struggling and the mother is crying, it's so important for us to understand what they're going through. It's important to understand what we're going through. But if you're performing at a high level, staying on scene and doing the right thing by the patient, then now you can get the closure mentally. And I would also like you to consider helping others get the closure as well. And so this is a tough skill to develop, but it's developed after expertise is achieved. And so I really ask you to stay on scene, do the right thing, and then talk to people, especially after the loss of a loved one, the loss of a child. They will remember what you tell them and what you do, and they will be thankful for you for doing that.

Thank you so much for taking the time to watch this training video. I do want to reiterate on a couple key tips. One, VLS is king. Make sure you guys are doing this appropriately and make sure that you're getting the interventions done as quick as possible. Number two is chest compressions. We know that the Lucas is not indicated for most children. So make sure you swap out your chest compressor after every two minutes. If there's no timer on scene to reiterate, when the two minutes is up, you can go by the ventilation person. So whoever's working the airway, they could count off at the 20 ventilation mark. That should give you the cue that the monitor should be charged and we should be swapping with position one and two and performing chest compressions. Good luck out there. Stay safe, and please utilize the tips that we provide in this video.