Post resuscitation stabilization and transport

IAP ALS 2016

1 IAP-ALS Provider Module 2016

 CPR ---> ROSC
• Return of spontaneous circulation does not
translate automatically into survival, more so
intact survival
• ‘Post arrest care’ is a A bigger challenge and
responsibility

2 IAP-ALS Provider Module 2016

 Ischemia-reperfusion conundrum
Disruption of Impaired
BBB Cytokines coagulation

Endotoxin The
tolerance ISCHEMIA Oxygen free
Increased Result?
REPERFUSION radial formation
susceptibility to
infection
Increased
Increased vascular
Adrenal vascular endothelial
permeability growth factor
dysfunction

3 IAP-ALS Provider Module 2016

 PCAS-What exactly happens?

• Systemic ischemia/reperfusion response

• Brain injury
• Myocardial dysfunction
• Persistence of the precipitating cause of arrest

4 IAP-ALS Provider Module 2016

 Primary Goals

• Optimize & stabilize cardiopulmonary function

• Prevent secondary organ injury

• Identify & treat cause of illness

• Minimize risk of deterioration during transport

• Improve long-term, neurologically intact survival

5 IAP-ALS Provider Module 2016

 Components of post arrest care

• Ventilation and oxygenation

• Hemodynamic optimization
• Induction of therapeutic hypothermia
• Correction of metabolic derangements

ABCDE Approach
Post cardiac arrest bundle

6 IAP-ALS Provider Module 2016

 Phases
• First phase
– Continue to provide ALS for immediate life
threatening conditions
• Second phase
– Provide broader multi-organ supportive care
– Repeated primary assessments with secondary &
tertiary assessments

7 IAP-ALS Provider Module 2016

 Organ support & stabilization
•Parameter
ACTIONS O Initial Settings
2 by NRM.
• Respiratory ONGOING • GOALSASSESSMENT
•FiO2Intubate ifTitrate O2 sat to 94-99%
Infant 20-30/min; Childoxygenation
16-20/mim
• Cardiovascular Tube
rate
1. Maintain
•Respiratory
position,
potential patency,
Adolescent
adequate
8-12/min fixation
loss of airway protective reflexes
•TidalSpO <90% on(~100%
PaO2O2
>60 mmHg, SpaO2
• Neurological volume 6-8 ml/kg
Chest rise, abnormal breath sounds
2

94% -PaCO
99%)
•PIP Target normal
20-30 cm of (35H2O to 40) in previously
• Renal SpO
2
(Lowest level for optimal chest rise)
2 , ETCO2
normal2. lung;
Maintain
Avoidadequate ventilation &
hyperventilation
PEEP 3-5 cm of H2O
• Gastrointestinal •
(adjust to optimize oxygenation)
acceptable PaCO2& sedation for all
Chest X-rayand
Use NG tube / ABG Analgesia
• Hematological
Insp. time 0.5 – 1 seconds
responsive intubated patients

8 IAP-ALS Provider Module 2016

 Organ support & stabilization
• ONGOING ASSESSMENT
MAINTENANCE FLUIDS
 2 IV /GOALS
IO lines. Bolus 10-20 ml/kg isotonic
• Respiratory Intra- crystalloid
• Only
Frequently:
vascular
after
HR,Maintain
intravascular
No ECG adequate
rhythm,
volume
hypotonic/dextrose is
organ
BP,fluid
restored!
containing
• Cardiovascular • volume
 Considerperfusion
colloid, blood
Composition:
Pulse Initially
Pressure, SpO2, U/O
• Neurological • Isotonic 1. Management
fluid with
 Anticipate dextrose
Post-arrest of Shock:
Myocardial
• Renal Cardiac
• NIBP
KCL 10–20
dysfunction (PAMD) & consider vasoactive
often unreliable
mEq/L
agents to in
is added
Inability poorly
withoxygen
deliver K+ to
• Gastrointestinal monitoring
function  Treat hypotension aggressively, titrate
meet the metabolic demands
perfuse state - consider
volume & vasoactiveIBP
drugs
• Hematological • Fluid Rate4-2-1
Treat arrhythmia, if it is causing low BP
of vital organs
 4 X-ray: heart size, pulmonary
ml / kg / hrHigh FiO until adequate
For firstSpO
edema
10 -then
kg wttitrate
O2  2. Maintenance
2 fluids2
content
2 ml / kg + 40
Maintain
ml / hradequate
 Advanced monitoring ForHb10-20 kg
1 ml / kg + 60 ml / hr
Antipyretics For above 20 kg
Metabolic  Control agitation /pain with sedo-analgesia
demand (rule out hypoxemia, hypercarbia, poor perfusion
causing agitation)
9 IAP-ALS Provider
 Intubation Module
& ventilation 2016
to ↓ WOB
 Organ support & stabilization
Hypothermia : current evidence : AHA
HYPOTHERMIA AFTER ROSC
• Respiratory GOALS
2015 guidelines
• Cardiovascular • For
Do not actively
infants andrewarm
childrenif Temp >32 and <370C
remaining
 Maintain adequate brain perfusion
comatose after OHCA
Consider hypothermia either
if Comatose ,and normothermic.
• Neurological
• Maintain normothermia
 Treat raised (36-37.5) OR
• Renal Cooling improvesICP intact survival
• 2 days of initial continuous hypothermia
• Gastrointestinal Maintain
Adverse
(32-34) normoglycemia
effects
followed by normothermia
• Hematological • FEVER must
 arrhythmias, be avoided
pancreatitis,
Control temperature
coagulopathy, infection etc

• No evidence to supportshould
Therapeutic hypothermia hypothermia
be used by for
 Treat seizures aggressively &
IHCA
experienced units strictly according to the protocols

search and treat the cause

10 IAP-ALS Provider Module 2016

 Organ support & stabilization
GOAL
• Respiratory GOAL
Augment
Augmentrenal
renalperfusion
perfusion
• Cardiovascular MANAGEMENT
MANAGEMENT
• Neurological Avoid
Avoidnephrotoxic
nephrotoxicdrugs
drugsororadjust
adjustdoses
doses
• Renal IVIVpotassium
potassiumcautiously
cautiously
Restrict
Restrictfluids
fluidsif ifoliguria
oliguriadue
duetotointrinsic
intrinsicrenal
renalfailure
• Gastrointestinal failure
If Ifvolume
volumeoverload
overload&&normal
normalBPBP– –use
useloop
loopdiuretics
diuretics
• Hematological Treat
Treatacidosis
acidosisappropriately
appropriately
ONGOING ASSESSMENT
ASSESSMENT
U/O
U/Obybycatheter
catheter
Renal
Renalfunction
functiontests
tests

11 IAP-ALS Provider Module 2016

 Organ support & stabilization
GOALS
ONGOING ASSESSMENT
• Respiratory Restore & maintain organ function
Type & quantity of NG aspirate
• Cardiovascular Minimize risk of aspiration of gastric contents

• Neurological P/A: Abd. girth,

ACTIONS peristalsis
 stool
• Renal Gastricoutput
distention Place OG or NG tube
(sump tube rather than a single lumen tube)
• Gastrointestinal Investigations (Electrolytes, LFT)
 Ileus Large size OG/NG tube & aspirate regularly
• Hematological Restore & maintain electrolytes / fluid
 Hepatic failure Maintain euglycemia
Correct coagulation factor deficiencies if
bleeding

12 IAP-ALS Provider Module 2016

 Organ support & stabilization
• Respiratory ACTIONS:
GOALS
Blood Component Therapy:
• Cardiovascular Optimize oxygen carrying capacity and
1. PRBCs transfusion – (10ml/kg) if
• Neurological coagulation
hemorrhagic shock refractory to fluids
• Renal 2. ABO/Rh compatible Platelet Tx if indicated
ONGOING ASSESSMENT
• Gastrointestinal 3. FFP – (10 to 15 ml/kg) as indicated
Identify external/internal hemorrhage
• Hematological Assess skin / mucus membranes for pallor,
Vit- K for K dependent factor depletion
petechiae, bruising
Ensure normal iCa++ - a co-factor in coagulation
Hb / PCV
FFP uses citrate & rapid infusion may decrease iCa
Platelet count, PT, PTT, INR, D-dimer, FDP,
fibrinogen

13 IAP-ALS Provider Module 2016

 PCA: Outcome predictors
Determinants of prognosis : Multiple (AHA 2015)
• Pre – hospital cardiac arrest
• Prolonged resuscitation
• In hospital CA due to septic shock
• Interval between collapse to CPR
• Pre-hospital hypothermia
• Ice water drowning despite > 30 min of CA

14 IAP-ALS Provider Module 2016

 Transport
• Intra-hospital transport
• To Pediatric intensive care units (PICU)
– Improve survival of critically ill children
– Provides a spectrum of services for post
resuscitation patients
• Inter-hospital transport

15 IAP-ALS Provider Module 2016

 Transport Decisions
• Preparation for transport
• Mode of transport
• Transport team
• Communication
• Post-transport follow - up

16 IAP-ALS Provider Module 2016

 Transport Preparation
Advanced preparation Immediate preparation
• List of facilities providing • Documentation
– Consent
tertiary care with phone – Chart
nos. & alternative facilities – X-rays / lab investigations
– (give lab phone no. also)
• Local transport system and
their pediatric capabilities • Secure airway, fix ET / IV’s
• Periodic evaluation of •
transport vehicle • Stabilize C-spine and any other
fractures
• Equipment to be carried
• Administrative protocols • Anticipate need for blood product/
vasoactive drugs and supply it

17 IAP-ALS Provider Module 2016

 Transport Mode Options
Mode Advantages Disadvantages
•
Ground
Transport
transport
• Less expensive
in caregiver’s
• Spacious
• Traffic related delays
vehicle is NOT an
option •weather
(Ambulance) Operable in most
conditions
• Ease for procedure
Helicopter • Fast, rapid transport • Difficult to monitor / perform
over short / long distance procedures
• High cost
• Not pressurized
• Weather affects
Fixed wing • For long distance • Can land at controlled sites
aircraft • Monitoring & only
procedures easier to • Need to transfer to
perform ambulance

18 IAP-ALS Provider Module 2016

 Transport Team Considerations
Local EMS personnel

Medical personnel from referring hospital

Pediatric critical care team

• Pediatric capabilities of team

• Ability to manage extubation during transport
• Time for patient to reach PICU
• “Often best to wait for team experienced in pediatric
care even if it delays ” except when immediate surgery
needed (e.g. craniotomy for epidural hematoma)
19 IAP-ALS Provider Module 2016
 Transport Communication
• Physician to physician (and document it)
• Nurse to nurse
– Provide
• History
• Treatment given
• Current clinical status
• Latest change in clinical status
• To family
– Update about all interventions & studies
– Answer questions, clarify information & offer comfort

20 IAP-ALS Provider Module 2016

 Post - Transport Follow - up
• Provides important feedback that can improve
the performance of transport team/ referring
hospital

Referring Receiving
physician physician

21 IAP-ALS Provider Module 2016

 Summary
• Stabilize
– Reassess ABC’s
– Maintain ABC’s
– Assess Arrest Etiology

• Transport
– Deliver Patient And Patient Information In Optimal
Condition

22 IAP-ALS Provider Module 2016

 Thank you

23 IAP-ALS Provider Module 2016