Sandbox:Neepa Shah

Special situations

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Introduction- Pediatric BLS

Pediatric Basic Life Support is a life-saving skill comprising of high quality CPR (Cardiopulmonary Resuscitation) and Rescue Breadths with Artificial External Defibrillator (AED).

• Bystander CPR - Bystander resuscitation plays a key role in out of hospital CPR. A study by Maryam Y Naim et all found out communities, where bystander cardiopulmonary resuscitation is practiced, have better survival outcomes in children less than 18 years from out of hospital cardiac arrest.

• Two studies (Total children 781) concluded that about half of the Cardio-Respiratory arrests in children under 12 months occur outside the hospital.
• Good Prognostic Factor upon arrival at the emergency department-
  • The short interval between arrest and arrival at the hospital.
  • Less than 20 minutes of resuscitation in the emergency department.
  • Less than 2 doses of epinephrine.

Causes of Cardiopulmonary arrest in children.

• Ventricular Fibrillation
• Pulseless Ventricular tachycardia
• Children with preexisting cardiac disorders
  • Hypertrophic cardiomyopathy
  • Anomalous coronary artery (from the pulmonary artery)
  • Long QT syndrome
  • Myocarditis
• Drug intoxication (eg, tricyclic antidepressants, digoxin, cocaine)
• Commotio cordis

References

Basic Life Support Guidelines

• Pulse present but cannot breath.
• No Pulse and not breathing.

Survival benefits of early high-quality CPR

ALGORITHM

AHA GUIDELINES

Prognosis

The following tables provide the details of the different studies done to determine which factors during pediatric cardiac arrest resuscitation have a superior prognosis. OHCA - Out of hospital cardiac arrest. ROSC- Return of spontaneous circulation.

Summary of studies for OHCA to determine age as a prognostic factor

	Age <1 year compared to >1 year	Author	Study details
30- Day survival with good neurological outcome
	Good prognosis associated in children >1 year	Tetsuhisa Kitamura, MD	Study group - 5158 Children (RR -2.4; 95% CI,1.7-3.4)
30-Day survival in age >1 year	Good prognosis associated in children >1 year	Tetsuhisa Kitamura, MD	Study group- 5158 Children (RR- 1.5; 95% CI,1.3-1.8)
Survival to hospital discharge	Good prognosis associated in children >1 year	Dianne L. Atkins	Study group- 621 Children (RR- 2.7; 95% CI,1.3-5.7)
	Good prognosis associated in children >1 year	Kelly D. Young	Study group- 599 Children (RR- 1.3; 95% CI,0.8-2.1)
	Good prognosis associated in children >1 year	Moler, Frank W. MD	Study group- 138 Children (RR- 1.4; 95% CI,0.8-2.4)

Summary of studies for OHCA to determine shockable rhythm vs non-shockable rhythm as a prognostic factor

	Shockable rhythm vs non-Shockable rhythm	Author	Study details
30- Day survival with good neurological outcome	Good prognosis with shockable rhythm like VF	Tetsuhisa Kitamura, MD	Study group- 5170 Children (RR- 4.4; 95% CI,3.6-5.3)
30-Day survival	Good prognosis with shockable rhythm like VF	Tetsuhisa Kitamura, MD	Study group- 5170 Children (RR- 9.0; 95% CI,6.7-12.3)
Survival to hospital discharge	Good prognosis with shockable rhythm like VF	Dianne L. Atkins	Study group- 366 Children (RR- 4.0; 95% CI,1.8-8.9)
	Good prognosis with shockable rhythm like VF	Moler, Frank W. MD	Study group- 138 Children (RR- 2.7; 95% CI,1.3-5.6)

Variables with the good prognostic outcome

• Age >1 year
• Shockable rhythm like ventricular fibrillation
• Less duration of CPR
• Reactive pupil at 24 hours after ROSC
• Lower serum lactate levels at 0 to 12 hours after ROSC is associated with improved outcomes.

Changes made in the new AHA guidelines 2010,2015,2017,2019

According to the 2015 Pediatric BLS Guidelines, the following changes were made

Pediatric BLS algorithm for single and 2 or more rescuers

• For single rescuers start with 30 compressions followed by 2 rescue breaths.
• For 2 or more rescuers start with 15 compressions followed by 2 rescue breaths and then both rescuers should change the positions alternating between compressions and breathing every 2 minutes.

Change of order of A-B-C TO C-A-B

• A-B-C is airway, breathing, and compressions in that order. C-A-B is compression, airway, and breathing.
• This change was advised by the 2010 guidelines but in 2015 there is more evidence supporting this sequence of CPR.
• Evidence
  • Manikin studies in both adult and children shows a decrease in time to achieve the first chest compressions by following C-A-B compared to A-B-C.
  • The delay in getting to ventilation was of 6 seconds compared with the new C-A-B compared to A-B-C

Chest compression rate and depth

• Adult model for compression rate and depth is to be followed for pediatrics cases due to lack of evidence.
• More studies need to be found for the pediatric rate of compressions.
• A study by Sutton RM et al reported among 87 pediatric CPR of more than 8 years of age, found that compression depth greater than 51 mm for more than 60% of the compressions during 30-second epochs within the first 5 minutes was associated with improved 24-hour survival.

Compression-only (Hands-Only) CPR

• Adult BLS protocols advise for CPR-Only resuscitation to achieve more compressions.
• Pediatric cardiac arrest are majority due to asphyxia. Hence for children, it is advised to continue with CPR with rescue breaths.
• If the rescuer is not trained or is not able to give rescue breaths then CPR-Only resuscitation is advised.

2010

2015

2015

2017

3= this change was advised 2010 guidelines

4- evidence -

6- sutton -

5- evidence compression only CPR

General Consideration

• Performing a high-quality CPR based on the above guidelines can save a child's life and improve neurological outcomes.
• Every community should be encouraged to get BLS- trained to ensure any person is able to deliver high-quality CPR until the EMS arrives.

Limitations

• C-A-B sequence change from A-B-C
  • In order to accurately predict prognostic outcomes ROSC, survival to hospital admission, or survival to 180 days with the good neurologic outcome with respect to the C-A-B protocol there is a need for more pediatric clinical (human) studies in children as opposed to pediatric manikin studies.
• Chest compression depth
  • Pediatric studies for the chest compression depth has a small sample size and the age of children is above 14 years in the adolescent phase which does not provide data for children less than 14 years and infants.
  • The hospital data for OHCA is not available for the depth of compression on different surfaces.

AED (Automated external defibrillator)

• AED is a device that is useful in as it delivers shock and does not require the bystander or lay rescuer to recognize different types of heart rhythm.
• If you want to be trained in AED access this website by REDCROSS https://www.redcross.org/take-a-class/aed
• If a manual defibrillator is not available an AED automated external defibrillator is used.
• A study published by Ecker R et al concluded that older bystanders previously trained in AED are successfully able to deliver shock for ventricular fibrillation with dispatcher assistance.
• 2 minutes compression and ventilation cycle should be done before using the AED.
• If there are 2 bystanders send one person to get the AED and one person should start CPR immediately.
• A study by Dianne L.Atkinsa et all found the AED used in children less than 8 years of age is able to find both shockable rhythm with high sensitivity and high specificity.

Steps to use AED

• Follow the AED Prompt.
• Stop CPR when the AED is analyzing the rhythm and giving a shock.
• Resume compressions immediately after giving shock and minimize interruptions during compressions.
• Place the right pad of the AED on right below the clavicle.
• Place the left pad of the AED on the left chest lateral to the left breast.
• Other positions - Left pad is placed at the apex 5th Intercoastal space and the right pad placed on the left upper back.
• Keep the one-inch distance between the pads and the implantable device.
• Don't put the pads on a transdermal patch as it can burn the skin where the patch is placed.

Foreign Body Airway Obstruction(FBAO)

• Foreign Body Airway Obstruction(FBAO) also known as choking is blocking the airway which comprises of the pharynx and trachea. Children less than 3 years are at risk of choking due to the still-developing phase for swallowing and chewing. Parents, teachers should keep an eye for objects like coins, toys, balloons, and other food.
• A study by C S Harris et al concluded that one death due to choking occurred every 5 days the data was analyzed for infants and children from 0-9 years for a period of 3 years.
• The choking was associated with high risk in children less than 5 years of age due to meat products.
• Hot dog was the most common food identified along with hard candy, nuts.
• Airway obstruction - Steps to follow
  • If the airway obstruction is mild, where the child is able to respond wait for the child to clear it and monitor for signs of severe obstruction.
  • If the airway obstruction is severe, where the child will be silent quickly start the Heimlich maneuver or subdiaphragmatic abdominal thrust for children.
  • For infants do 5 back blows followed by 5 compressions as abdominal thrust can damage the liver.
  • If the child/infant becomes unresponsive start CPR immediately.
    • After 1 cycle which will be 30 compressions check the airway if the foreign body is visible remove it but if it's not visible or accessible do not probe blindly as the foreign body can be displaced which will further damage the oropharynx.
    • Give 2 rescue breaths after compressions and continue with compressions and ventilation cycle until the foreign body is out.

Special situations

Resuscitation in special circumstances

Child with a tracheostomy tube or stoma

• The caregiver (Parents, nurse, or teacher) should be trained in how to use the tracheostomy tube.
• If there is a cardiac arrest in a child with a tracheostomy start immediately CPR with compressions followed by ventilation of 2 rescue breaths.
• Ventilation
  • Give rescue breaths from mouth to a tracheostomy tube, if the chest does not rise to suction the tube, if still there is no chest rise then can give mouth to stoma ventilation or bag - mask ventilation if available.

Child with spinal trauma

• Steps to follow in a pediatric trauma case with cardiac arrest.
• Look for airway obstruction.
• If there is bleeding try to tie a tourniquet and apply external pressure.
• If spinal trauma is suspected try to avoid cervical spine movement.
  • In spinal trauma ventilation should be done with caution apply jaw thrust and do not tilt head.
  • If the jaw thrust is not successful then one rescuer would minimize the motion of the cervical spine and the other rescuer should attempt to give rescue breadth by head still and chin lift method.
  • To achieve a neutral position for a child while in supine posture a study by Nypaver M et all mentions that the back needs to be elevated in children less than 7 years.
  • In children less than 7 years its found that they have a disproportionately large head compared to their full bodies and when in a supine position the neck gets flexed.
    • To prevent cervical motion changes should be made to the backboard.
    • Changes like Raise the chest by putting a double mattress pad or use a recess for the occiput to lower the head.

Child drowning

• The rescuer should try to get the drowning child as soon as possible out of the water and start CPR after checking pulse and ventilation.
• If the rescuer has training in In water resuscitation start ventilation in water

Below is the IWR (In Water Resuscitation) guidelines

• Check if the child is breathing or conscious in the water.
  • If the child is breathing quickly swim back and get the child out of the water.
  • If the child is not breathing then give rescue breaths if spinal trauma is suspected then try to immobilize the spine while opening the airway and try to reach the shore as soon as possible.
  • If the distance to reach the shore is more than 5 minutes, try to give one more rescue breath 12-16 breaths/minute.

eckler -

atkinsa -

steps to add -

toys balloons -

harris

tracheostomy in the end

Nypaver -

Spinal trauma changes like raise the chest -

child drowning put it in every sentence -

iwr -

Migraine clinical features:

• Onset- Starts in the first decade of life, gradual in onset, crescendo pattern.
• Intensity- Moderate to severe.
• Presentation- Bilateral in young children, unilateral in adolescents.
• Frequency- 2-4 times/month
• Duration- 2-3 hours in young children, 48-72 hours in the adolescent.
• Character- Throbbing pulsating
• Aggravating factors- bright light, noise, strong food odor.
• Alleviating factors- Darkroom, cool compress, sleep.
• Family history is a strong indicator.

Migraine without aura criteria: At least 5 attacks fulfilling A to C: A. 4-72 hour duration of the headache. B. 2 of the following 4 -

1. Unilateral location
2. Pulsating character of pain
3. Moderate to severe intensity.
4. Aggravated by physical activity

C. Headache associated with nausea, vomiting, photophobia, and phonophobia.

Migraine with typical Aura. At least 2 attacks fulfilling criteria A to B: A. Aura can be visual, sensory, speech each fully reversible but no motor, brain stem, or retinal symptoms. B. At least 2 of the 4:

1. Aura symptom spreads gradually over 5 or more minutes.
2. Duration- Aura symptoms last 5-60 minutes.
3. At least one aura symptom is unilateral.
4. Aura is followed within 60 minutes by headache.

Migraine with Brain stem Aura: At least 2 attacks fulfilling criteria A to C. A. Aura consisting of visual, sensory, and or speech each fully reversible but no motor or retinal symptoms. B. At least 2 of the following brain stem symptoms

1. Dysarthria, vertigo, tinnitus, diplopia, ataxia, decreased level of consciousness.

C. At least 2 of the following 4

1. At least 1 aura symptom spreads over 5 minutes and 2 or more occur in succession.
2. Each individual aura lasts 5-60 minutes.
3. At least 1 aura is unilateral.
4. Aura is accompanied or followed within 60 minutes by headache.

Vesticular Migrane with vertigo:

• At least 5 episodes fulfilling criteria A, B, and C.

A. Current or past history of migraine with aura or migraine without aura. B. Vestibular symptoms of moderate to severe intensity lasting 5 minutes to 72 hour

Tension headache Duration - minutes to days, the variable can be all day (30 mins - 7 days) Alleviating factors- Tension headache decreases with sleep. Pain does not worsen with routine physical activity. Not associated with photophobia or phonophobia. Presentation- Episodic non-throbbing headache, constant pressure, bilateral pressing tightening in quality, mild to moderate intensity. Bilateral pressure tightness that waxes and wanes. Severity- Mild to moderate severity. Location - diffuse.

Criteria At least 10 episodes of headache fulfilling criteria A through C. Infrequent and frequent episodic subforms of TTH are distinguished as follows: Infrequent episodes - Headache occurring < 1 day /month on average <12 days per year. Frequent episode - Headache occurring on 1-14 days/ month on average for >3 months (>12 and <180 days/year). A. Headache lasting 30 min - 7 days B. 2 of the following 4

1. Bilateral location, pressing/tightening( non - pulsating) quality. Mild or moderate intensity. Not aggravated by routine physical activity such as walking or climbing stairs.

C. No nausea or vomiting, no more than one of photophobia or phonophobia.

Cluster Headache ❑ Duration - 5-15 minutes but may last 60 minutes. ❑ Location - Temporal or retro-orbital. ❑ Aggravating factors'- Headache worsens when lying down or resting. ❑ Frequency- Can occur every other day sometimes 8times/day. ❑ Location- Unilateral begins around the eye or temple. ❑ Onset- Pain begins quickly and reaches in a crescendo pattern within minutes. ❑ Duration- Can remain active for 30 minutes. ❑ Character- Deep continuous excruciating pain. ❑ Associated factors- Ipsilateral lacrimation, redness of the eye, stuffy nose, rhinorrhea, pallor, sweating, Horner syndrome, increased sensitivity to alcohol.

Diagnostic criteria: At least 5 attacks fulfilling criteria from A to C : A. Severe or very severe unilateral orbital, supraorbital/temporal pain lasting 15-180 minutes. B. Either or both :

1. One of the following: Conjunctival injection, lacrimation, nasal congestion, rhinorrhea, eyelid edema, forehead, and facial sweating, miosis/ptosis.
2. Sense of restlessness or agitation.

Cluster headache can be of 2 types :

❑ Episodic cluster headache Attacks fulfilling criteria for cluster headache occurring in bouts At least 2 cluster periods lasting from 7 days to 1 year(when untreated) and separated by pain free remission periods of 3 months. ❑  Chronic cluster headache Attacks fulfill the criteria for cluster headache. Attacks occurring without a remission period or with remission lasting less than 3 months for at least 1 year.

Neoplasm ❑ Location- Occipital ❑  Position- Recumbent, straining, Valsalva. ❑  Neurologic deficit- Ataxia, altered mental status, binocular horizontal diplopia. ❑  Presentation- Change in quality, severity, frequency, and pattern of headache. Nausea and vomiting between headache. Headache worst on first awakening in the morning. ❑  Neurologic exam - Complicated migraine, seizure or very brief aura, < 5-minute atypical aura ❑  Recent change in weight or vision- Pituitary tumor, Craniopharyngioma, idiopathic intracranial hypertension.

Diagnostic criteria — Proposed diagnostic criteria for headache attributed to intracranial neoplasm have been developed by the International Headache Society PMID: 29368949 For headache attributed directly to neoplasm, the diagnostic criteria are as follows:

1. Any headache fulfilling criterion 3 (below)

1. A space-occupying intracranial neoplasm has been demonstrated

1. Evidence of causation demonstrated by at least two of the following:

Headache has developed in temporal relation to the intracranial neoplasia or led to its discovery

Either or both of the following:

-Headache has significantly worsened in parallel with worsening of the neoplasm

-Headache has significantly improved in temporal relation to successful treatment of the neoplasm

Headache has at least one of the following four characteristics:

-Progressive

-Worse in the morning and/or when lying down

-Aggravated by Valsalva-like maneuvers

-Accompanied by nausea and/or vomiting

1. Not better accounted for by another International Classification of Headache Disorders, third edition (ICHD-3) diagnosis

Formal diagnostic criteria also exist in the ICHD-3 for headaches attributed to more specific tumors, including a colloid cyst of the third ventricle, carcinomatous meningitis, and pituitary adenoma.

Ulcerative colitis is a type of IBD (Inflammatory bowel disease) in which there is inflammation and ulceration of the colon and the rectum. {PMID 23386404}. The etiology of ulcerative colitis is unknown but the hypothesis up till now suggests it’s a multifactorial play between the dysregulated immune system, genetic alterations, and the colonic microbiota. {PMID 26600980}. Human colonic mucosa is maintained by a colonic epithelial barrier and the immune cells in the lamina. Immune dysregulation – The Th17 cells are helper T cells which play a critical role in regulating the immune system, these cells secrete IL-21, IL-22, IL-17, G-CSF. IL-12 is secreted by the APC(Antigen-presenting cells). IL-12 related molecule IL-23 is important in the maintenance of Th17 cells. Mutations in IL-23 is associated with IBD{PMID 17618837}. Genetic – a genome-wide association study identifies IL23R as an inflammatory bowel disease gene. { PMID 17068223 }. Microbiota – An increased amount of colonic sulfate-reducing bacteria has been found to play a role in ulcerative colitis. A higher concentration of toxic gas hydrogen sulfide interferes with beta-oxidation of N- butyrate by inhibiting short-chain acetyl CoA dehydrogenase enzyme, a short-chain FA. N- Butyrate helps supply nutrients to this epithelial barrier{PMID 9448181}. Standard treatment for ulcerative colitis depends on the extent of involvement and disease severity. The goal is to induce remission initially with medications, followed by the administration of maintenance medications to prevent a relapse. The criterion for emergent colectomy is a colonic perforation, life-threatening gastrointestinal hemorrhage, toxic megacolon, acute fulminant colitis refractory to medical treatment. The criteria for elective colectomy are those patients who have dysplastic polyps and long-lasting ulcerative colitis {PMID 19786761}.

In this case report, we analyzed 621,717 patients from 2007 to 2015 who are diagnosed with ulcerative colitis who underwent colectomy. We compiled this data from a large nationwide inpatient sample (NIS). Our goal for this retrospective case report is to find the data for colectomy in ulcerative colitis patients over a period of 9 years and highlight any differences in the incidence of change in colectomy rate, mortality, and the length of stay pre colectomy among different races, insurance types and geographical regions.

Ulcerative colitis was found to be most prevalent with 67.3% in white. Severe ulcerative colitis was prevalent in the African American population with Charlson index >5. Private insurance was the highest among Caucasians with 53.2% as compared to African Americans with 36.9% and Hispanics 38.9%. Medicaid was the highest among Hispanics with 24.6%, as compared to 24.1% in African Americans and 8.5% in Caucasians. 

Colectomy rate Our study analyzed data from 2007 to 2015 from the NIS database. We observed a downward trend in the rate of colectomy over the years. In 2007 the highest colectomy rate was identified 2.6% among the white race as compared to any other race which declined to 1.9% in 2015. In 2007 the lowest colectomy rate as compared to any other race was identified 1.9% among African – American population which declined to 1.3% which was also the lowest among all races in 2015. Medicaid was associated with a lower colectomy rate of 0.92(95%CI,0.86-0.98, P - 0.013) as compared to private insurance. Private insurance was the highest among Caucasians with 53.2% as compared to African Americans with 36.9% and Hispanics 38.9%. Medicaid was the highest among Hispanics with 24.6%, as compared to 24.1% in African Americans and 8.5% in Caucasians. The decrease rates of colectomy among African American and Hispanics can be explained by Medicaid being more common in among these races and more studies need to be done to address if there is an issue in getting the access of care in our case colectomy in patients with severe ulcerative colitis or if there is a lack of trust in the surgeon. The colectomy rate according to the region was observed to be fairly distributed equally all over the United States with the highest rate seen in 2007 in the west region 3.1% declining to 1.3% in 2015. The highest colectomy rate in 2015 was observed in mid-west with 2.4%. {PMID: 17162242}

The decline in the rate of colectomy among all races over a period of 9 years in our study can be explained by the introduction of purine metabolites like anti-TNF alpha drugs like infliximab in 2005. A study comparing the colectomy rates in the pre-infliximab era (2003-2006) to the post-infliximab era (2007-2010) identified a decrease in the rate of colectomy from 8.9% to 10%. (P = 0.03) {PMID – 24316950}. Another study analyzed that the decrease in the rate of colectomy coincided with an increase in the use of infliximab. {PMID – 231654}. A study analyzed patients with ulcerative colitis from 1997 to 2009 and identified there was no change in the rate of emergent colectomies with AAPC ( Average annual percent change) of 1.4%, 95% CI: 4.8% to 2.0% {PMID - 23165448}. Mortality rate There was a major decline in the mortality rate observed in patients with ulcerative colitis in our study from 5.3% in 2007 to 1.2% in 2015. The difference in mortality rate among ulcerative colitis patients post colectomy decreased from 4.7% in 2007 to 0.91% in 2015. Mortality in the Caucasian was observed to decrease over time with 5.54 % in 2007 to 0.78% in 2015. However, there is an increase in mortality rate observed in Hispanics from 5.63% in 2010 to 11.11 % in 2015. The mortality according to the race was higher in Hispanics compared to Caucasians with an odds ratio (95% CI) P-value 0.28.

The difference in mortality can be explained by African American and Hispanic races having more severe ulcerative colitis. The mortality rate ratio increases significantly as the Charlson Index burden increases. In our study we found severe ulcerative colitis with Charlson index >5 more prevalent in African Americans with 3.3%, 2.6% in Hispanic, and the lowest 2.2% in Caucasians. There is increased mortality observed in patients with Medicaid with reference to private insurance, the odds ratio of 1.16 (95% CI 0.96- 1.40), P-value 0.13. There is also increased mortality seen in patients on Medicare with reference to private insurance odds ratio 1.06 (0.94-1.19) with a P-value of 0.33. Patients diagnosed with ulcerative colitis with colectomy having Medicaid in a different study were found to have increased mortality which raises the issue of discussion about the access of healthcare to patients with ulcerative colitis. {PMID 17162242}. There was a change in mortality seen according to different regions with the highest mortality seen in the western United States as compared to the northeast with an odds ratio of 1.39 ( 1.23- 1.57) P-value < 0.0001. Poor prognostic factors associated with ulcerative colitis patients undergoing colectomies are older age, emergent or urgent admission for colectomy, higher Charlson index, Medicaid, or Medicare insurance. {PMID: 18242604 }. The IPAA (ileal pouch-anal anastomosis) is a more complex procedure and it is more difficult in patients with ulcerative colitis as they are on immunosuppressive medications. { PMID – 1824260 }. In our study, we observed more incidence of IPAA among African Americans with 2.8% incidence compared to other races like White ( 0.6%), Hispanic (0.6%), and (0.4%) in other races.

Length of stay We observed an increase in the length of stay(LOS) among Hispanic 7.8% as compared to African American 7.4% and Caucasian 5.9%. An increase in LOS was found to be among people with Medicaid insurance 7.8% as compared to Other insurance 7.4%, Medicare 5.9%, and Private insurance 5.7%. An increase of LOS was found to be in the western united states with 6.9% as compared to northeast 6.4%, south 6.2%, and midwest 5.2%. This increase in LOS among Hispanics, Medicaid insurance, and western united states needs to be studied as these specific groups might not be getting access to proper healthcare.