Background

APLS states that calcium should be administered during a paediatric cardiac arrest only when specifically indicated, for example, in cases of calcium channel blocker overdose, a rare occurrence in paediatrics. High dose insulin therapy in these cases is well documented in adult medicine, but is rarely used in paediatrics.

Objectives

We present the case of a 4 year old boy with Cockayne syndrome and hypertension, who developed nifedipine toxicity secondary to an acute kidney injury and 2.5mg/kg of nifedipine as a single dose. Cardiac arrest followed, requiring IV calcium gluconate (3 doses of 0.11mmol/kg) for return of spontaneous circulation (ROSC). There was ongoing, inotrope resistant, bradycardia following ROSC which was successfully was treated with high dose insulin therapy (1 unit/kg bolus then 1 unit/kg/hr infusion).

Methods

We additionally performed a systematic literature review of articles published prior to January 2019 using PubMed and Google Scholar (search terms: paediatric, calcium channel blocker, insulin). We identified articles which addressed the use of high dose insulin therapy in paediatric (under 16 years) calcium channel blocker toxicity.

Results

Few case reports of paediatric patients exist, those which do range in age between 5 months and 14 years.

Conclusion

There is growing evidence for the use of high dose insulin therapy in the management of calcium channel blocker toxicity in adult patients, with limited evidence in paediatrics. Additional clinical research and prospective clinical studies are needed to confirm the safety and efficacy of high dose insulin therapy in the paediatric population.

Background

Trauma related paediatric cardiopulmonary arrest (TRPCPA) is associated with high mortality and children that do survive often suffer from life changing morbidity. The decision of when to stop Cardiopulmonary Resuscitation (CPR) is always difficult and is often at the clinician’s discretion.

The European Resuscitation Council Guidelines for Resuscitation 2015 provides guidance on the cessation of CPR. The majority of these criteria are clear and objective. However, criterion 4 asks clinicians to define futility at a time when they may have limited clinical information and in what is often a time critical and highly emotive environment allowing for variation in practice.

Objectives

We aimed to review how objectively futility in TRPCPA is assessed and if it is defined well enough to aid clinician confidence in their decision making process.

Methods

We performed a systematic literature review of peer review articles published before January 2019. We identified articles that explored the futility or cessation of resuscitation in the context of TRPCPA.

Results

We reviewed 13 relevant articles identified from Embase, Medline, Pubmed, Cochrane and Google Scholar.

Conclusion

There is little evidence available to support clinicians in defining futility in the context of TRPCPA. The evidence that is available is generally of poor quality with studies containing low numbers, differing inclusion criteria and variable survival and morbidity outcomes. The only emerging objective marker of futility suggested is the presence or absence of fixed pupils but this requires significantly more robust research before it is implemented clinically.

Background

APLS states that calcium should be administered during a paediatric cardiac arrest only when specifically indicated, for example, in cases of calcium channel blocker overdose, a rare occurrence in paediatrics. High dose insulin therapy in these cases is well documented in adult medicine, but is rarely used in paediatrics.

Objectives

We present the case of a 4 year old boy with Cockayne syndrome and hypertension, who developed nifedipine toxicity secondary to an acute kidney injury and 2.5mg/kg of nifedipine as a single dose. Cardiac arrest followed, requiring IV calcium gluconate (3 doses of 0.11mmol/kg) for return of spontaneous circulation (ROSC). There was ongoing, inotrope resistant, bradycardia following ROSC which was successfully was treated with high dose insulin therapy (1 unit/kg bolus then 1 unit/kg/hr infusion).

Methods

We additionally performed a systematic literature review of articles published prior to January 2019 using PubMed and Google Scholar (search terms: paediatric, calcium channel blocker, insulin). We identified articles which addressed the use of high dose insulin therapy in paediatric (under 16 years) calcium channel blocker toxicity.

Results

Few case reports of paediatric patients exist, those which do range in age between 5 months and 14 years.

Conclusion

There is growing evidence for the use of high dose insulin therapy in the management of calcium channel blocker toxicity in adult patients, with limited evidence in paediatrics. Additional clinical research and prospective clinical studies are needed to confirm the safety and efficacy of high dose insulin therapy in the paediatric population.

Background

Trauma related paediatric cardiopulmonary arrest (TRPCPA) is associated with high mortality and children that do survive often suffer from life changing morbidity. The decision of when to stop Cardiopulmonary Resuscitation (CPR) is always difficult and is often at the clinician’s discretion.

The European Resuscitation Council Guidelines for Resuscitation 2015 provides guidance on the cessation of CPR. The majority of these criteria are clear and objective. However, criterion 4 asks clinicians to define futility at a time when they may have limited clinical information and in what is often a time critical and highly emotive environment allowing for variation in practice.

Objectives

We aimed to review how objectively futility in TRPCPA is assessed and if it is defined well enough to aid clinician confidence in their decision making process.

Methods

We performed a systematic literature review of peer review articles published before January 2019. We identified articles that explored the futility or cessation of resuscitation in the context of TRPCPA.

Results

We reviewed 13 relevant articles identified from Embase, Medline, Pubmed, Cochrane and Google Scholar.

Conclusion

There is little evidence available to support clinicians in defining futility in the context of TRPCPA. The evidence that is available is generally of poor quality with studies containing low numbers, differing inclusion criteria and variable survival and morbidity outcomes. The only emerging objective marker of futility suggested is the presence or absence of fixed pupils but this requires significantly more robust research before it is implemented clinically.