Cardiopulmonary Arrest


Article Author:
Roy Vega


Article Editor:
Peter Edemekong


Editors In Chief:
Chaddie Doerr


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
6/4/2019 3:13:10 PM

Introduction

Unlike in adults, cardiopulmonary arrest in rare in children and less likely to be a primary cardiac event. Early onset of effective, high-quality CPR can improve survival. The American Heart Association periodically releases updates on pediatric, basic life support and pediatric, advanced life support. One can obtain the principles of pediatric resuscitation from enrolling in Pediatric Advanced Life Support courses (PALS), or Advanced Pediatric Life Support courses (APLS). Children in need of resuscitation can be divided into several categories that include pulseless arrest (which may be the result of asystole), pulseless electrical activity, or ventricular fibrillation/ventricular tachycardia without a pulse. [1][2] 

Regardless of the etiology, early initiation of CPR along with cardiac monitoring will determine which pulseless arrest pathway to follow. For a pediatric pulseless arrest, the compressions to breaths ratio are 30:2 for a sole healthcare provider and 15:2 for two healthcare providers. Subsequent management of patients with asystole and pulseless electrical activity include epinephrine administration every three to five minutes, as needed. The dose of epinephrine is 0.01 mg/kg of the 1:10,000 solution. One can administer epinephrine in multiple ways: intravenously, intraosseously, or endotracheally. The endotracheal dose is ten-fold higher at 0.1 mg/kg. Pulseless electrical activity is often secondary to an underlying cause. PALS teaches the Hs and Ts. [3][4][5]

The Hs are Hypoxia, Hypovolemia, Hydrogen ion (acidosis), Hypo/Hyperkalemia, Hypothermia, and Hypoglycemia. In pediatric patients, hypoxia and hypovolemia are the most common causes. The Ts include Toxins, Tamponade (cardiac) Tension pneumothorax, Thromboembolic event, and Trauma. Although the H's and T's are often associated with pulseless electrical activity, it is prudent to consider causes of cardiac arrest, especially if you fail to achieve a return of spontaneous circulation with your current management.

Ventricular fibrillation and pulseless ventricular tachycardia require similar initial principles, for example, early onset of CPR and early recognition of the rhythm. Quick access to a manual defibrillator or an Automated External Defibrillator (AED), can make the difference in survival. In pediatrics, the energy recommended for defibrillation is 2 J/kg. With the introduction of biphasic defibrillators, the practice of three stacked shocks had been removed from current recommendations. Please refer to the algorithms listed below.[6][7]

Etiology

There are numerous causes for cardiac arrest in children. They can be divided into several categories, which include respiratory, cardiac, infectious, and traumatic causes.[8]

Respiratory causes are the most common. There is considerable overlap between categories. Causes include respiratory infections such as pneumonia and bronchiolitis.

Other respiratory causes include asthma, apnea, aspiration, smoke inhalation, and drowning. Infectious causes also include sepsis and meningitis. Cardiac causes include congenital lesions, commotio cordis, arrhythmias, and cardiomyopathies. Traumatic causes include blunt trauma to the head or chest, ingestions, drowning, and child abuse. Other causes include Sudden Infant Death Syndrome (SIDS), and Sudden Unexpected Infant Death Syndrome (SUID). According to the Centers for Disease Control and Prevention (CDC), in 2015 there were approximately 3700 sudden unexpected deaths in the United States[9][10]

The majority of sudden death causes in young athletes were attributed to cardiovascular disease.

Epidemiology

Based on data from the American Heart Association (AHA), Emergency Medical Services assessed approximately 3628 out-of-hospital cardiac arrests involving individuals younger than 18 years of age. 

Survival to hospital discharge after EMS-treated, non-traumatic cardiac arrest among youth (younger than 18 years) is 5.4%. Nearly 6000 hospitalized children in the United States receive cardiopulmonary resuscitation (CPR) annually. 

Of the cardiovascular deaths that occurred in young athletes (younger than 18 years), 29% were black, 54% were high school students, and 82% were physically exerting themselves during competition or training.

According to data from the AHA, the outcome of unwitnessed cardiopulmonary arrest in infants and children is poor. Only 8.4% of pediatric patients who have out-of-hospital cardiac arrests survive to discharge, and most are neurologically impaired, while the in-hospital survival rate is 24% with a better neurological outcome. The best-reported outcomes have been in children who receive immediate high-quality cardiopulmonary resuscitation (resulting in ample ventilation and coronary artery perfusion), and in those with witnessed sudden arrest (presenting with ventricular rhythm disturbance) that responds to early defibrillation.[6]

History and Physical

Due to the patient's acute condition, a rapid review of the charted medical history may be the entire history available. Focus on noting abnormalities that may be causing the arrest.

The exam is limited to evaluation of the airway, breathing, and circulation during the initial arrest.

Evaluation

Since outcomes are poor post-arrest, priority is placed upon early recognition of pre-arrest states. Recognizing the signs of impending respiratory failure and shock of any etiology is paramount. The emergences of rapid response teams and early warning systems that have been incorporated into electronic medical record systems have helped. [3][5][8]

Treatment / Management

Preparation needs to occur before the patient’s arrival. This includes a code team, a resuscitation room, age appropriate equipment, and proper training in pediatric airway techniques and resuscitation. Code team assignments should occur before the patient’s arrival. Team members assigned to the following roles:[1][2][11]

  • A dedicated team leader
  • Airway management
  • Chest compression
  • Vascular access (intravenous or intraosseous)
  • Medication administration
  • History (from the family and pre-hospital personnel)
  • Family liaison (who can communicate with the family)
  • Recorder and timekeeper
  • Security officer (if available for crowd control)

It is not uncommon to perform several duties depending on staffing.

The Broselow system, a length-based resuscitation tape and/or code cart can assist in determining the proper medication doses and equipment sizes.

Pearls and Other Issues

A modified ABC’s approach can assist with code management: [11][12][13][3][14] 

ABCDE

A= Assign

A= Assess

A= Anticipate

A= Airway (with c-spine control if needed)

B = BLS (effective)

B = Broselow tape

C= CPR

C= Cardiac monitor

D= Disability

D=Drugs

D=Disposition

E= Exposure

E= Environment (temperature and crowd control)

In the adult population, the Universal Termination of Resuscitation guidelines have accurately predicted which patients with out-of-hospital cardiac arrest are less likely to have a return of spontaneous circulation.  In a study of 36,543 patients, researchers found that resuscitation should be terminated if, after at least four, two-minute intervals of cardiopulmonary resuscitation, three criteria are met

  1. Emergency Medical Services (EMS) did not witness the arrest
  2. There has been no return of spontaneous circulation
  3. No shocks were delivered. 

There are no reliable predictors of outcome during resuscitation to suggest when resuscitation efforts are futile. Factors that portend to a poor outcome are delays in bystander CPR, especially in an out-of-hospital cardiac arrest and with delays in activating the EMS system. Children with prolonged resuscitation efforts without the return of spontaneous circulation after two doses of epinephrine are unlikely to survive.

The value of end-tidal carbon dioxide (ETCO2) monitoring has emerged as more than just an adjunct to endotracheal tube placement and assessment of ventilation. Continuous end-tidal carbon dioxide monitoring has a role in the cardiac arrest. A return of spontaneous circulation may be detected sooner with end-tidal carbon dioxide monitoring compared to pulse checks. [15][11] 

Enhancing Healthcare Team Outcomes

The best results are obtained by an established rapid response team usually consisting of a nurse, respiratory therapist, and clinician working in a unified effort to resuscitate and stabilize the patient. [Level V]


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Cardiopulmonary Arrest - Questions

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Which of the following findings would indicate cardiopulmonary arrest?



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A 16-year-old boy was playing soccer and collapsed on the field. He arrives in your emergency department with high-quality CPR in progress. Paramedics report ventricular fibrillation on the monitor as initial rhythm. They have just administered epinephrine and circulated it for two minutes. What dose of energy is appropriate for subsequent shocks since initial shock in the field was ineffective?



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The code team arrives at the bedside of a 3-year-old child. CPR is in progress by a clinical resource nurse. Which piece of equipment will be the most useful to the code team in the resuscitative effort of this child?

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    Contributed by Tammy J. Toney-Butler, AS, RN, CEN, TCRN, CPEN
Attributed To: Contributed by Tammy J. Toney-Butler, AS, RN, CEN, TCRN, CPEN



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Pediatric arrest situations originate primarily from a respiratory origin. Which of the following interventions are paramount in the treatment of a sick child to prevent deterioration to an inevitable arrest?



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After the return of spontaneous circulation (ROSC), all attempts at normoxia should be the goal. What oxygen saturation reading helps us achieve this purpose?



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On the pediatric floor, a child goes into cardiac arrest. CPR is started. What artery will be palpated to assess the child's pulse during CPR? Select all that apply.



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High-quality cardiopulmonary resuscitation (CPR) is essential for achieving a positive outcome in a cardiopulmonary arrest. Which of the following contributes to high-quality CPR? Select all that apply.



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Cardiopulmonary Arrest - References

References

Epinephrine dosing interval and survival outcomes during pediatric in-hospital cardiac arrest., Hoyme DB,Patel SS,Samson RA,Raymond TT,Nadkarni VM,Gaies MG,Atkins DL,, Resuscitation, 2017 May 25     [PubMed]
Association Between Duration of Resuscitation and Favorable Outcome After Out-of-Hospital Cardiac Arrest: Implications for Prolonging or Terminating Resuscitation., Reynolds JC,Grunau BE,Rittenberger JC,Sawyer KN,Kurz MC,Callaway CW,, Circulation, 2016 Dec 20     [PubMed]
Initial end-tidal CO<sub>2</sub> partial pressure predicts outcomes of in-hospital cardiac arrest., Wang AY,Huang CH,Chang WT,Tsai MS,Wang CH,Chen WJ,, The American journal of emergency medicine, 2016 Dec     [PubMed]
Huang CH,Tsai MS,Ong HN,Chen W,Wang CH,Chang WT,Wang TD,Chen SC,Ma MH,Chen WJ, Association of hemodynamic variables with in-hospital mortality and favorable neurological outcomes in post-cardiac arrest care with targeted temperature management. Resuscitation. 2017 Nov;     [PubMed]
Lankster MA,Brasfield MS 3rd, Update on pediatric advanced life support guidelines. Critical care nursing clinics of North America. 2005 Mar;     [PubMed]
Duff JP,Topjian A,Berg MD,Chan M,Haskell SE,Joyner BL Jr,Lasa JJ,Ley SJ,Raymond TT,Sutton RM,Hazinski MF,Atkins DL, 2018 American Heart Association Focused Update on Pediatric Advanced Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2018 Dec 4;     [PubMed]
Soar J,Donnino MW,Maconochie I,Aickin R,Atkins DL,Andersen LW,Berg KM,Bingham R,Böttiger BW,Callaway CW,Couper K,Couto TB,de Caen AR,Deakin CD,Drennan IR,Guerguerian AM,Lavonas EJ,Meaney PA,Nadkarni VM,Neumar RW,Ng KC,Nicholson TC,Nuthall GA,Ohshimo S,O'Neil BJ,Ong GY,Paiva EF,Parr MJ,Reis AG,Reynolds JC,Ristagno G,Sandroni C,Schexnayder SM,Scholefield BR,Shimizu N,Tijssen JA,Van de Voorde P,Wang TL,Welsford M,Hazinski MF,Nolan JP,Morley PT, 2018 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary. Circulation. 2018 Dec 4;     [PubMed]
Berg RA,Reeder RW,Meert KL,Yates AR,Berger JT,Newth CJ,Carcillo JA,McQuillen PS,Harrison RE,Moler FW,Pollack MM,Carpenter TC,Notterman DA,Holubkov R,Dean JM,Nadkarni VM,Sutton RM, End-tidal carbon dioxide during pediatric in-hospital cardiopulmonary resuscitation. Resuscitation. 2018 Dec;     [PubMed]
Dhillon GS,Lasa JJ,Aggarwal V,Checchia PA,Bavare AC, Cardiac Arrest in the Pediatric Cardiac ICU: Is Medical Congenital Heart Disease a Predictor of Survival? Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. 2019 Mar;     [PubMed]
Hunt EA,Duval-Arnould JM,Bembea MM,Raymond T,Calhoun A,Atkins DL,Berg RA,Nadkarni VM,Donnino M,Andersen LW, Association Between Time to Defibrillation and Survival in Pediatric In-Hospital Cardiac Arrest With a First Documented Shockable Rhythm. JAMA network open. 2018 Sep 7;     [PubMed]
Andersen LW,Holmberg MJ,Granfeldt A,James LP,Caulley L, Cost-Effectiveness of Public Automated External Defibrillators. Resuscitation. 2019 Mar 26;     [PubMed]
Nakashima T,Noguchi T,Tahara Y,Nishimura K,Ogata S,Yasuda S,Onozuka D,Morimura N,Nagao K,Gaieski DF,Asai Y,Yokota H,Nara S,Hase M,Atsumi T,Sakamoto T, Patients With Refractory Out-of-Cardiac Arrest and Sustained Ventricular Fibrillation as Candidates for Extracorporeal Cardiopulmonary Resuscitation - Prospective Multi-Center Observational Study. Circulation journal : official journal of the Japanese Circulation Society. 2019 Mar 20;     [PubMed]
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