1. Description of the problem
What every clinician needs to know
Pediatric cardiopulmonary arrest is characterized by unresponsiveness and lack of normal breathing (with only an occasional gasp), and is most often the end result of apnea or respiratory failure leading to bradycardia and then pulseless electrical activity or asystole.
Hypoxia and ischemia (asphyxia) progresses rapidly over 4 to 10 minutes.
Sudden cardiac arrest from arrhythmia (ventricular fibrillation/tachycardia) is much less common in children than adults, except for special resuscitation circumstances such as commotio cordis (sudden forceful blow to chest) or congenital heart disease or prolonged QTc interval.
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Infant and newly born cardiac arrest is almost always a result of respiratory failure or airway obstruction, with SIDS being the most common cause of death in children under 6 months of age.
Instruction
Clinical features
Apnea, unresponsiveness, Lack of response to verbal or physical stimuli characterize pediatric cardiac arrest. Other than an occasional gasp, there is rarely respiratory effort. Pupils are usually fixed and dilated maximally, and myoclonic jerks or seizures can be seen with hypoxia before or immediately after return of spontaneous circulation.
In the out-of-hospital environment, most pediatric cardiac arrest occurs in or around the home, with about 30% bystander CPR rates. With the advent of rapid response teams in the hospital, almost 90% of pediatric cardiac arrests occur in the ICU environment.
Key management points
All pediatric pulseless cardiac arrest victims should receive AT LEAST excellent chest compressions to circulate blood, however rescue breathing by laypersons or health care providers remains an important part of resuscitation of infants and children.
Pediatric animal (piglets) and human registry data (Japan) suggest that rescue breathing as part of CPR provided by first responders/bystanders for out-of-hospital pediatric cardiac arrest is important, with both rescue breathing and chest compressions being important when the arrest etiology is not of obvious cardiac cause (e.g. about 70% of pediatric out-of-hospital arrests).
The same principles as for adults (push hard > 5 cm, push fast > 100/minute, allow full chest recoil, minimize interruptions in chest compressions, and don’t overventilate > 12/minute) apply to children.
Just as for adults, quality of CPR is often not optimal, and good quality CPR (deep, fast, full release, minimal interruptions, not overventilated) is associated with improved outcomes following CPR.
Rapid recognition and shock delivery for shockable ECG rhythms (VF/VT) are essential, with a starting energy dose of 2-4 J/kg. If there is no response to the basic C-A-B approach, seek and treat reversible causes of cardiac arrest.
2. Emergency Management
Emergency management steps
First, establish unresponsiveness and lack of effective breathing. If pediatric cardiac arrest is established or strongly suspected, DO NOT DELAY. Shout for help and start CPR with chest compressions in the center of the chest, at a compression to ventilation ratio of 30 compressions followed by two quick breaths.
Laypersons should not delay chest compressions to check for a pulse, as it is unreliable and often misleading. Health care professionals should not delay chest compressions for any longer than 10 seconds for a pulse check, and then should deliver hard (> 5 cm), fast (> 100/min), minimally interrupted, fully released chest compressions.
Ventilation should be provided at 10 to 12 breaths per minute, with attention to avoid overventilation.
If an AED or monitor is available, assess for a shockable rhythm (VF/VT) and defibrillate with 2 joules per kg as an initial dose, followed by doubling to 4 joules per kg if unsuccessful. If the rhythm is shockable, continue with 2 minute cycles of chest compressions, followed by a single shock.
Consider giving epinephrine every 3 to 5 minutes, and if VF/VT persists, consider amiodarone 5 mg/kg IV or IO, followed by circulating the drug with CPR and then a shock to defibrillate.
Alternative medications include lidocaine or vasopressin, but amiodarone is preferred.
If the rhythm is not shockable, then continue excellent CPR with the addition of epinephrine 10 micrograms/kg IV/IO every 3 to 5 minutes. Higher doses of epinephrine have not been shown to be helpful, and are potentially harmful.
Titrate the CPR quality (depth, rate, full release, ventilation) to target a diastolic BP of 30 mm Hg, and an end-tidal CO2 of > 15 mm Hg. End-tidal CO2 is often reflective of quality of CPR (e.g. correlated to pulmonary blood flow), and thus can provide a goal-directed target. These targets have been associated with improved return of spontaneous circulation in animals and adults.
If the cardiac arrest victim is refractory to these basic treatments, seek and treat reversible causes of cardiac arrest, including: hypothermia, acidosis, hyperkalemia, pulmonary embolism, pneumothorax, pericardial tamponade, and hypovolemia.
Management points not to be missed
Push hard (at least 1/3 the anterior-posterior diameter of the child’s chest, about 5 cm in a child under 8 years of age, and about 4 cm in an infant from newborn to 1 year of age). Push fast, at least 100-120 times per minute for all ages.
Minimize interruptions to less than 10 seconds at any time.
Allow full chest recoil without “leaning” in between compressions. Leaning with a force of as little as 2.5 kg force can impede venous return, elevate right atrial pressure, and decrease coronary perfusion pressure.
Don’t overventilate: approximately 12/minute in children and approximately 20/minute for infants.
If it is a shockable rhythm, consider 2 J/kg dose in either anterior-apical pad position or anterior-posterior position. If the rhythm is VF/VT, deliver an AED shock even if pediatric attenuated pads are not available. Note that the LD100 for a shockable rhythm is actually no shock at all.
No ALS drug has been shown to improve survival to hospital discharge and beyond. Although epinephrine is recommended as the drug of choice, it has not been confirmed in RCT testing.
Therapeutic hypothermia after pediatric cardiac arrest is under study at this time. There is equipoise for institution of cooling after cardiac arrest.
Drugs and dosages
As above, no ALS drug has been documented to improve survival to hospital discharge.
Epinephrine 10 mcg/kg/dose via IV or IO access (endotracheal administration is not routinely recommended)
Amiodarone for refractory VF/VT at 5 mg/ktg/dose via IV or IO access.
Other medications for specific special resuscitation circumstances may be appropriate, such as for hyperkalemia: calcium, bicarbonate, glucose, insulin, Kayexalate, hyperventilation.
3. Diagnosis
Establishing the diagnosis
Cardiopulmonary arrest in children is usually the end result of respiratory failure and/or shock.
Hypoxia and ischemia lead to hypotension, apnea, and bradycardia with poor perfusion most often resulting in PEA (Pulseless Electrical Activity) or asystole.
The patient transitions to unresponsiveness, lack of breathing other than occasional gasp, and lack of response to verbal or physical stimuli. Pulses are difficult to palpate in carotid, brachial or femoral locations centrally, and capillary refill is markedly delayed > 3 seconds. The pupils become dilated and fixed.
Diagnostic approach
One should seek and treat reversible causes.
Start chest compressions, call for help and rapidly determine if there is a shockable rhythm. If not shockable, then continue CPR, order epinephrine and seek treatable causes such as toxins (antidotes), electrolyte imbalances, physical impediments to cardiac refill (pneumothorax, pericardial tamponade), hypothermia, or pulmonary embolism.
If a reversible cause is identified, consideration for ECMO (E-CPR) should be considered in centers where rapid deployment ECMO is available.
Diagnostic tests
Usually a blood gas, lactate, electrolytes, glucose, complete blood count, magnesium, calcium, and core temperature, and chest radiograph are appropriate.
Pathophysiology
Good quality manual pediatric CPR (hard, fast, minimally interrupted, not over-ventilated) usually provides approximately 1/3 of the normal cardiac output. For this reason, ventilation does not have to be vigorous. Over-ventilation pressurizes the chest, decreases venous return, raises intrathoracic pressure and decreases coronary perfusion pressure.
Exhaled CO2 of > 15 mm Hg usually indicates good pulmonary blood flow with CPR and translates to good systemic flow and coronary perfusion pressure of > 25 mm Hg (associated with ROSC).
If the diastolic blood pressure is low and cannot improve to >30 mm Hg with adjustment of quality of CPR, a vasopressor (such as epinephrine) can help to achieve these goal directed parameters. On the downside, overconstriction of peripheral or lung microvessels may cause further local ischemia and hypoperfusion of vital tissues and organs.
Cumulative higher doses of epinephrine have been associated with worse survival and neurologic outcome, however the causative relationship has not been definitively proven.
Epidemiology
Generally hypoxia and ischemia caused by respiratory distress/failure is the primary cause of cardiac arrest in infants and children.
In the USA, more than 4,000 children per year are estimated to arrest out of hospital with a 7 to 10% survival rate and more than 4,000 children per year are estimated to arrest in-hospital with a survival rate of approximately 23 to 30%.
Special considerations for nursing and allied health professionals.
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What's the evidence?
(Provides evidence evaluation worksheets and discussion for key topics involving pediatric resuscitation diagnosis, treatment, drugs, equipment, and techniques. Updated in October 2010. Revises every 5 years. Provides rationale for C-A-B vs A-B-C approach.)
(Full recommendations for diagnosis, treatment, drugs, equipment, and techniques. Updated October 2010 by Pediatric Subcommittee of the American Heart Association.)
(Evidence from the Japanese National Registry that contemporary cardiac arrest and resuscitation out of hospital process and outcomes are age-specific, and that respiratory causes are more common than presumed cardiac causes for children.)
(Evidence from the AHA National Registry of CPR (get with the Guidelines-Resuscitation) that process and outcomes of care for children with underlying cyanotic and acyanotic heart disease are different than previously reported for the general population.)
(Novel booster training including short and frequent refresher training can improve quality of resuscitation process of care. The addition of real-time feedback further improves CPR quality.)
(Key manuscript that describes the benefit of rescue breathing as a component of pediatric CPR when provided across a large country registry. Of note, for presumed cardiac etiology, CC only and CC with rescue breathing were not significantly different, and both were better than no bystander CPR. For those without presumed cardiac etiology, CC with rescue breathing was significantly better than either CC only or no CPR.)
(Key manuscript from AHA national registry of CPR (get with the Guidelines-Resuscitation) that describes the better outcomes associated with CPR started during bradycardia with poor perfusion (instead of for pulseless cardiac arrest), even when correcting for other known and potentially confounding factors.)
(First manuscript to describe the landscape of CPR quality in a single PICU, and the association with better quality CPR (deep, fast, non-interrupted) with hemodynamics and outcomes.)
(Comparison of out of hospital vs. in-hospital cardiac arrest etiologies, process of care and outcomes as a prelude to a study of therapeutic hypothermia for pediatric cardiac arrest.)
(Summary of special resuscitation circumstances to consider in resuscitation of children with congenital heart disease.)
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