Cardiac Arrest in Children - aetiology

There are two types of cardiac arrest in adults, and children.

Primary Cardiorespiratory Arrest: due to an underlying cardiac arrhythmia (eg VF or VT) is more frequent in adults. The onset is often acute and unpredictable. Immediate defibrillation is needed.

Secondary Cardiorespiratory Arrest is more common in children and is because the body can't deal with the underlying injury or illness.
The pre-terminal rhythm in children is often bradycardia which leads to asystole or PEA - non shockable rhythms.

The outcome from cardiorespiratory arrest in children is poor, especially if there is a prolonged duration. Compared to adults, children are physiologically different but like adults, early recognition of the seriously ill child can prevent sudden death.

Some conditions are more likely to affect children than adults, and more likely to cause their arrest:
Croup: remember a narrower tracheal tube than would normally be expected may be required.
Epiglottitis: you must keep the child calm until the airway is secure.
Bronchiolitis
Coma
Seizures
Anaphylaxis: give adrenaline as quickly as possible

Drowning, electrocution and hypothermia can also affect children, and cause cardio-respiratory arrest. In an arrest situation, the standard CPR algorithms should be followed.

Survival rates remain poor, with survival rates of 0 - 38% quoted in the literature.

Auto-injectors

Sometimes we prescribe patients auto-injectors. Sometimes they bring them with them. If we don't know how to use them it can be embarrassing - although it isn't an "official" skill to have.

There are three types of auto-injector available in the UK, and which one your patient has depend on local variations. Most of them have a similar method of using - "black to attack, and grey away". There are plenty of videos on how to use them, and a friendly pharmacist may have a trainer device to use.

Jext
These are the newest type of auto-injector available and are very simple to use.

Epipen
This is the type of auto-injector most people know. It is very similar to the jext device. In the epipen the needle does not retract so there is a chance of a needle stick after using the device. It is easy to use.

Anapen
An anapen is slightly more complicated to use as it has lots more safety devices in built. Anapens were subject to a voluntary recall in March 2012, so we should not be seeing many anapens in the community.
LITFL has a nice little summary here.

GEM Net Guidelines

If you haven't found CEM's Gemnet guidelines yet, they're worth a look at. They're evidence based, and look at every single bit of evidence around every aspect of each topic. This obviously takes a long time which is why they've not done many yet!



Above frame taken from: https://secure.collemergencymed.ac.uk/code/document.asp?id=5072

PV Card

If you haven't seen Michelle Lin's PV cards on Academic Medicine, you're missing out. These concise cards are fantastic and have lots of brilliant information and discussion.

The only problem with the PV cards is that they are American :( Otherwise they'd be perfect!




Above frame taken from: http://academiclifeinem.com/paucis-verbis-anaphylaxis/ 

(Comments disallowed on this page - please comment on original site)

Online Tutorials

There are quite a few places that offer free online tutorials if you are appropriately registered.

• Medline: Anaphylaxis Tutorial
  This is very American, but contains lots of good information. It is a useful overview of the clinical features, and the physiological features. 

• Doctors.org.uk Anaphylaxis Module
  This is a quick but effective case based tutorial on anaphylaxis. It includes a case from a child, and was a very useful over view.
  
  
• BMJ Learning
  There are no BMJ learning modules on anaphylaxis in children.
  
• Enlighten Me
  OSCE Assessment form - this is really useful as it emphasises what you need to know for each different "level" of knowledge.
  Case Study - a four year old with difficulty breathing needs your help...
  CEMPaedia - all about anaphylaxis
  Knowledge Bank - if it all goes wrong, what happens when your patient arrests? Mostly about big people - but a mention of a 16 year old.

Royal College of Paediatrics and Child Health

The RSPH has produced a guideline, which CEM has approved. Most of it doesn't affect us, as Emergency Providers - but it is again, a very useful summary that emphasises the importance of sending blood for tryptase levels.

I think most EDs complete most things here, except some of the educational facets of the guideline.

The guideline states we should:

• refer to an allergy clinic directly, via the GP using a local clinic or by checking the BSACI website
• provide a basic prevention and treatment package that includes:
•  basic avoidance advice based on the suspected trigger(s) 
• provision and training in the use of an adrenaline injector
• provide access to patient/parent/carer support group information

 Most emergency departments I know would admit a patient with a suspected anaphylactic reaction and assume that Paediatricians provided the above follow up.


Above frame from: http://www.rcpch.ac.uk/allergy/anaphylaxis.

Resus Council Guidelines

The resus council guidelines are what we should follow for every resuscitation. The guidelines are clear, and have a good summary of all the doses. They are very useful.

As you can see below, the resus council website has many good resources for anaphylaxis (adult and child).

• The anaphylaxis information including doses
• The Anaphylaxis slides - a ready made teaching session!
• The protocol
• Podcasts and discussion about anaphylaxis

Above frame from: http://www.resus.org.uk/indx/search.asp?zoom_sort=0&zoom_query=anaphylaxis&zoom_per_page=10&zoom_and=

Anaphylaxis

For all the blog posts written about anaphylaxis, please click here.

The CEM Curricular Guidelines are very clear about what you need to know about Anaphylaxis.It is difficult to separate adults from children.

I've made a summary of treatment, including the curricular knowledge. Please comment with any suggestions or additions:

For more anaphylaxis posts, start by looking here.