How Usual Resuscitative Maneuvers Can Kill Paediatric Cardiac Patients

HOW USUAL RESUSCITATIVE MANEUVERS CAN KILL PEDIATRIC CARDIAC PATIENTS

MICHELE DOMICO, MDCHILDREN’S HOSPITAL OF ORANGE COUNTY, CALIFORNIA

N O F I N A N C I A L D I S C L O S U R E S

O R A N G E C O U N T Y C A L I F O R N I A

O R A N G E C O U N T Y, C A L I F O R N I A

W H E N O X Y G E N A N D E P I N E P H R I N E M A K E T H E

S I T U AT I O N W O R S E

O X Y G E N D E C R E A S E S P V R E P I N E P H R I N E I N C R E A S E S S V R

BABY PRESENTS WITH MILD RESPIRATORY

DISTRESS AND POOR PERFUSION

SATURATIONS 75%

MORE OXYGEN MORE BETTER?

WHAT WENT WRONG?

H Y P O P L A S T I C L E F T H E A R T S Y N D R O M E

H Y P O P L A S T I C L E F T H E A R T S Y N D R O M E N O R W O O D P R O C E D U R E : S TA G E 1

B A L A N C I N G A C T B E T W E E N P U L M O N A RY A N D S Y S T E M I C VA S C U L A R R E S I S TA N C E

OXYGEN DECREASES PULMONARY VASCULAR

RESISTANCE

MORE BLOOD TO LUNGS

EPINEPHRINE INCREASES SVR

BLOOD FOLLOWS PATH OF LEAST RESISTANCE

MORE BLOOD FLOW TO LUNGS

H L H S S TA G E 1 G O I N G S O U T H

GO AHEAD AND INTUBATE ME

DO NOT “OVER-DO” THE BLOOD PRESSURE RESUSCITATION

LOW DOSE EPI (1/10th DOSE) OR INODILATOR

75% to 85%

W H E N I N T U B AT I O N A N D P O S I T I V E P R E S S U R E

V E N T I L AT I O N C A N A C T U A L LY D E C R E A S E

O X Y G E N AT I O N

D E C I S I O N T O I N T U B AT E

YOUR INTERVENTIONS MADE HIM WORSE

H Y P O P L A S T I C L E F T H E A R T S Y N D R O M E S TA G E 2 : G L E N N P R O C E D U R E

PULMONARY BLOOD FLOW IS DEPENDENT ON TWO THINGS:

INTRATHORACIC PRESSURE

BLOOD FLOW TO THE BRAIN

GLENN (STAGE 2) PHYSIOLOGY

I F Y O U M U S T I N T U B AT E A S TA G E 2 ( G L E N N ) : L O W E R P E E P A N D S L I G H T LY E L E VAT E D P C O 2

G I V E T H E M A L L T H E F I O 2 Y O U W A N T

W H E N D E F I B PA D D L E S B E C O M E

Y O U R E N E M Y

P E R F E C T I S T H E E N E M Y O F G O O D

H E A LT H Y 8 Y E A R O L D G I R L FAT I G U E , V O M I T I N G , “ H E A R T R A C I N G ”

A W A K E , TA L K I N G , P O O R D I S TA L P E R F U S I O N

DO NOT SHOCK

I N C I C U . M O R E H Y P O T E N S I V E . S T I L L A L E R T

LV EJECTION FRACTION 10%

C A R D I O V E R S I O N 1 J / K G V F I B A R R E S T > 6 0 M I N U T E S O N T O E C M O

A N O N Y M O U S E L E C T R O P H Y S I O L O G I S T

YOU ARE NOT A TRUE INTENSIVIST UNTIL YOU’VE TRIED TO SHOCK SINUS TACH

F E W HOURS A F T E R E C M O A N D L E F T A T R I A L D E C O M P R E S S I O N

D E - N O V O “ V TA C H ” I N H E A LT H Y C H I L D R E N I S M Y O C A R D I T I S U N T I L P R O V E N O T H E R W I S E

L E S S I N T E R V E N T I O N S T H E B E T T E R U N L E S S A N E C M O C I R C U I T I S N E A R B Y

N O R W O O D S TA G E 1 S I N G L E V E N T R I C L E PAT I E N T S S H O U L D H AV E S AT U R AT I O N S 7 5 - 8 5 % . D O N O T M A K E T H E M H I G H E R

I N C R E A S I N G S V R W I T H E P I C A N H A R M H L H S S TA G E 1 PAT I E N T S

S TA G E 2 ( G L E N N ) PAT I E N T S W I L L N O T O X Y G E N AT E W E L L W I T H H Y P E R V E N T I L AT I O N O R H I G H P E E P

D O N ’ T S H O C K T H E H E A LT H Y C H I L D W I T H P U L S AT I L E “ V TA C H ”

S U M M A R Y

M D O M I C O @ C H O C . O R G