1 What is the incidence of pediatric cardiopulmonary arrests?

The estimates of incidence of pediatric cardiopulmonary arrests vary by location. In suburban King County, Washington, Eisenberg et al reported an annual pediatric cardiopulmonary arrest rate of 12.7 per 100,000 of the population younger than age 18 years. From rural community emergency departments, Thompson et al reported a range of 1.3 to 5.3 cardiopulmonary arrests per 10,000 of the population younger than age 5 years. Ronco et al estimated 63 cardiopulmonary arrests per 150,000 of the population younger than age 15 years in Birmingham, Alabama. Schoenfeld and Baker noted that 0.25% of patient visits to the emergency department of Children’s Hospital of Philadelphia involved management in the resuscitation room. A prospective study by Ong et al found an overall annual incidence of cardiopulmonary arrests of 59.7 per million children, with the highest incidence, 175 per million children, noted in the youngest age group (under 4 years).

Eisenberg M, Bergner L, Hallstrom A: Epidemiology of cardiac arrest and resuscitation in children. Ann Emerg Med 12:672–674, 1983.

Ong ME, Stiell I, Osmond MH, et al: Etiology of pediatric out-of-hospital cardiac arrest by coroner’s diagnosis. Resuscitation 68:335–342, 2006.

Ronco R, King W, Donley DK, et al: Outcome and cost at a children’s hospital following resuscitation for out-of-hospital cardiopulmonary arrest. Arch Pediatr Adolesc Med 149:210–214, 1995.

Schoenfeld PS, Baker MD: Management of cardiopulmonary and trauma resuscitation in the pediatric emergency department. Pediatrics 91:726–729, 1993.

Thompson JE, Bonner B, Lower GM Jr: Pediatric cardiopulmonary arrests in rural populations. Pediatrics 86:302–306, 1990.

2 Is the pathophysiology of cardiopulmonary arrest in children similar to that in adults?

No. cardiopulmonary arrests in children most commonly involve primary respiratory failure with subsequent cardiac arrest. Furthermore, cardiopulmonary arrests in children generally follow progressive deterioration and usually do not occur as sudden events. Exceptions to this statement include cases of sudden infant death syndrome (SIDS), major trauma, or certain primary cardiac events.

3 What are the common causes of cardiopulmonary arrest in children?

Common causes of cardiopulmonary arrest in children are numerous, but most fit into the classifications of respiratory, infectious, cardiovascular, traumatic, or central nervous system (CNS) diseases (Table 1-1). Respiratory diseases and SIDS together consistently account for one-third to two-thirds of all pediatric cardiopulmonary arrests in published series.

Table 1-1 Common Causes of Cardiopulmonary Arrest in Children

4 What is the typical age distribution of pediatric cardiopulmonary arrests?

Almost regardless of the underlying disease, the age distribution of cardiopulmonary arrest in children is skewed toward infancy. In published series of childhood cardiopulmonary arrests, 56% (range, 43–70%) of patients are younger than 1 year, 26% (range, 21–30%) are between 1 and 4 years of age, and 18% (range, 6–28%) are older than 4 years. For general emergency medicine practice settings, this finding is particularly important. Equipment and skills preparedness for this young age range are crucial to achieve best outcomes.

5 What are the outcomes of pediatric cardiopulmonary arrests?

In four reviews published since 1983, the survival rates for children experiencing isolated respiratory arrests ranged from 75% to 97%, while survival rates for children experiencing full cardiopulmonary arrests ranged from 4% to 16%. One recent comprehensive review of 41 articles on pediatric arrest found that of 5363 out-of-hospital pediatric arrests, only 12.1% of patients survived until discharge and only 4% were neurologically intact. Another study prospectively followed 474 patients having out-of-hospital pediatric cardiac arrest and found that only 1.9% survived to discharge. The poor prognosis of full cardiopulmonary arrests probably reflects the terminal nature of asystole, which is often preceded by prolonged respiratory insufficiency and its resultant long-standing tissue hypoxemia and acidosis. This is one reason why initial management is directed toward improvement of oxygenation and ventilation.

Donoghue AJ, Nadkarni V, Berg RA, et al: Out-of-hospital pediatric cardiac arrest: An epidemiologic review and assessment of current knowledge. Ann Emerg Med 46:512–522, 2005.

Kuisma M, Suominen P, Korpela R: Pediatric out-of-hospital cardiac arrests: Epidemiology and outcome. Resuscitation 30:141–150, 1995.

Lopez-Herce J, Garcia C, Dominguez P, et al: Outcome of out-of-hospital cardiorespiratory arrest in children. Pediatr Emerg Care 21:807–815, 2005.

Nadkarni VM, Larkin GL, Peberdy MA, et al: First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. JAMA 295:50–57, 2006.

Schindler MB, Bohn D, Cox PN, et al: Outcome of out-of-hospital cardiac or respiratory arrest in children. N Engl J Med 335:1473–1479, 1996.

6 What are some prognostic factors for pediatric cardiopulmonary arrests?

For out-of-hospital arrests, bystander or paramedic initiation resuscitation of witnessed arrest has repeatedly been found to improve survival by as much as fourfold compared to initial resuscitation by physicians after patient arrival at the hospital. Similarly, in eight reviews published since 1983, 96 of 542 (17.7%) children experiencing out-of-hospital cardiopulmonary arrest survived versus 137 of 342 (40%) experiencing in-hospital cardiopulmonary arrest.

Survival of patients presenting in ventricular fibrillation is much higher than among those in asystole, severe bradycardia, or pulseless electrical activity (PEA). Prolonged resuscitation over 20 minutes is often thought to be the strongest indicator of mortality. Trauma- and submersion injury–associated arrests are associated with better survival rates compared with isolated cardiac-origin arrests (21.9% and 22.7% versus 1.1%, respectively).

Scribano PV, Baker MD, Ludwig S: Factors influencing termination of resuscitative efforts in children: A comparison of pediatric emergency medicine and adult emergency medicine physicians. Pediatr Emerg Care 13:320–324, 1997.

7 Does the initial approach to childhood resuscitation differ from that for adults?

The initial approach to pediatric resuscitation is similar to that for adults: A (airway), B (breathing), C (circulation), D (drugs), E (exposure). Attention to proper positioning, oxygenation, and ventilation comes first, and drug therapy comes “last.” It is always advisable to preassign resuscitation duties to available staff. This eliminates confusion during the heat of the action. Care should always be taken to protect the cervical spine (and spinal cord) during resuscitation, especially during manipulation of the neck and jaw.

8 After establishing a clear chain of command and assigning specific duties to all members of the resuscitation team, what should the order of priorities be?

The order of priorities is:

9 What is the recommended way to establish a patent airway?

10 What is the recommended way to deliver supplemental oxygen to a child?

Supplemental oxygen can be delivered to a child by a variety of different means. For the sickest patient, oxygen should be delivered in the highest concentration and by the most direct method possible. Children who demonstrate spontaneous breathing might require less invasive means of administration of supplemental oxygen. Table 1-2 lists some different methods of oxygen delivery with their associated delivery capabilities.

Table 1-2 Methods of Oxygen Delivery and Their Delivery Capabilities

Children without adequate spontaneous breathing effort require mechanical support. Different bag-valve mask devices have different oxygen delivery capabilities. Self-inflating bag-valve devices are capable of delivering 60–90% oxygen, while non–self-inflating devices (anesthesia ventilation systems) deliver 100% oxygen to the patient. Endotracheal intubation offers the most secure and direct means of delivery of 100% oxygen to the patient.

Mondolfi AA, Greiner BM, Thompson JE, et al: Comparison of self-inflating bags with anesthesia bags for bag-mask ventilation in the pediatric emergency department. Pediatr Emerg Care 13:312–316, 1997.

11 Which children require intubation?

While the most obvious indication for endotracheal intubation is sustained apnea, a number of other indications exist. These include:

In many instances, bag-mask ventilation and bag–endotracheal tube ventilation are equally effective for the patient. In such circumstances, it is logical to employ the method that the rescuer is best able to deliver. A recent prospective study randomized the use of bag-mask ventilation and endotracheal intubation by paramedics in 830 out-of-hospital pediatric arrests. There was no difference in survival (30% versus 26%, respectively) or good neurologic outcome (23% versus 20%) between the two groups of children.

Gausche M, Lewis RJ, Stratton SJ, et al: Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: A controlled clinical trial. JAMA 283:783–790, 2000.

12 When selecting an endotracheal tube, what sizing guidelines are suggested?

There are a number of ways to ensure selection of properly sized endotracheal tubes (ETTs) for children. The most often cited is the following age-based formula:

Another “rule of thumb” is really a “rule of finger.” Research has demonstrated that the width of the child’s fifth fingernail is approximately equal to the outer width of the appropriately sized ETT. Most emergency physicians use uncuffed tubes for children younger than 10 years because in these patients, the anatomic narrowing at the level of the cricoid cartilage provides a natural “cuff.” However, in the in-hospital setting, a cuffed tube has been shown to be as safe as an uncuffed tube for infants beyond the newborn period. In some circumstances (e.g., poor lung compliance, high airway resistance, or a large glottic leak), a cuffed tube may be preferable.

American Heart Association: 2005 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 12: Pediatric Advanced Life Support. Circulation 112:167–187, 2005.

13 How can I determine if ETT placement is appropriate?

Proper depth for ETT insertion from the point of the patient’s central incisors can be estimated to be three times the internal diameter of the ETT. Measurement of end-tidal carbon dioxide using a colorimetric detector, observation for symmetric chest expansion, and auscultation for symmetric breath sounds can help to ensure proper placement. Confirmation of placement is probably best determined with a chest radiograph. Prior to an x-ray, the colorimetric detector offers a rapid bedside determination to detect CO₂ to confirm endotracheal tube placement (Fig. 1-1).

Figure 1-1 Colorimetric device. In infants and children with a perfusing rhythm, a purple color on the device indicates a problem, whereas a yellow color implies that the tube is in the trachea.

14 What are the best methods to assess a child’s circulatory status?

Assessment of a child’s circulatory status should always include appraisal of:

Always keep in mind that in the instance of acute blood loss, the protective mechanisms of increased heart rate and increased vascular resistance maintain a child’s blood pressure within a normal range in spite of losses as high as 25% of total body blood volume.

15 To whom and how should external cardiac compression be delivered?

Apply external cardiac compression to any child with ineffectual pulses. The optimal compression–ventilation ratio for two-rescuer cardiopulmonary resuscitation (CPR) is 15 to 2. It takes a number of compressions to raise coronary perfusion pressure, which drops with each pulse. Interruptions in chest compressions are associated with decreased rate of return of spontaneous circulation. It is currently recommended that in infants, compressions be applied evenly over the lower half of the sternum. The two thumb-encircling hands technique is preferred for two-rescuer CPR because it produces higher coronary perfusion pressure and more consistently results in appropriate depth of compression. For children and adolescents, compress the lower half of the sternum with the heel of one hand or with two hands, but do not press over the xiphoid process or ribs.

American Heart Association: 2005 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 11, Pediatric Basic Life Support. Circulation 112:1567–1166, 2005.

Plaisance P, Adnet F, Vicaut E, et al: Benefit of active compression-decompression cardiopulmonary resuscitation as a prehospital advanced cardiac life support: A randomized multicenter study. Circulation 95:955–961, 1997.

16 What are the golden rules of vascular access?

The messages are obvious. During resuscitation, procedures should be done by those most talented, and they should do what they do best. While it is better to have large-gauge vascular access for resuscitation, small-gauge vascular access is adequate to deliver medications and slower infusions of fluids.

17 What are the options for vascular access in children?

There are many options for vascular access in children. Depending on the situation at hand, some might not be as available or achievable as others. Conditions permitting, peripheral venous access is generally preferred over other means. Antecubital, hand, wrist, foot, and ankle veins are the most popular access sites. Saphenous veins in the ankle are deep but often accessible. External jugular veins are also reliably accessible but require difficult positioning of the child to be successful. Scalp veins are potential sites of access in infants but are located on a portion of the body that might be difficult to access while managing the patient’s airway.

Central access sites include bone marrow, femoral veins, and subclavian veins. Subclavian access should be attempted only by those skilled in the procedure. Intraosseous access should be considered early, especially in the case of apnea and pulselessness in an infant.

18 Why does intraosseous infusion work?

The bone marrow serves as a “stiff” vascular bed. It is composed of interconnected sinusoids that are fed and drained by veins that traverse the cortex of the bone and connect with the central circulation. Fluids infused anywhere into the marrow cavity enter these vascular channels and find their way to the central venous system. In animal models, transit times from the tibia to the heart are short (less than 60 seconds). Numerous medications and fluids have been shown to be effective when administered via this route.

19 What are the dos and don’ts surrounding intraosseous infusion?

Although there is no age limit for use of intraosseous infusion, it is easiest to accomplish in younger patients, whose bones are less calcified. Remember that intraosseous infusion was developed in the 1930s as a technique of vascular access in adults. Numerous studies using adult patients have demonstrated a cumulative 98% success rate. Preferred sites of intraosseous needle placement are the proximal tibia in children younger than 2 years and the distal tibia in those age 2 or older. The distal femur may also be used. Any IV fluid or medication can be safely and effectively administered via the intraosseous route. Rates of infusion are limited by needle gauge and length. When infusion is delivered with pressure, flow rates of saline through 20-G needles have been measured as high as 25 mL per minute.

Intraosseous needle placement is painful, and time-limited in its effectiveness. It should be reserved for emergency vascular access needs. Complications encountered most often include needle damage (bending or breaking), fluid extravasation at the needle entry site, and puncture through both sides of the bone. Intraosseous infusion will not succeed with bones that have breaks or holes in them because fluid will extravasate through these openings.

20 What role does drug therapy play in pediatric resuscitation?

Drug therapy during resuscitation is reserved for patients who do not respond adequately to the ABCs. Other than oxygen, most pediatric resuscitations require few drugs. Other useful chemical agents include:

Keep in mind that administration of any of these drugs should never be considered as a first line of management for any disorder. During resuscitation, drug therapy should always be preceded by another intervention. Oxygenation and ventilation are always the first priorities for any seriously ill child. Other appropriate supportive measures (e.g., chest compressions for pulselessness or fluid infusion for shock) should also precede administration of drugs during resuscitation.

21 What are the new recommendations regarding epinephrine administration during pediatric resuscitation?

Epinephrine dosing recommendations have undergone much debate recently. Reports have cited observations of “increased effectiveness” of high doses of epinephrine on cerebral resuscitation of children who sustained witnessed cardiopulmonary arrest. Other reports have demonstrated no increased effectiveness of higher doses. Pending the results of properly conducted prospective investigations of the issue, the American Heart Association and American Academy of Pediatrics, through their pediatric advanced life support (PALS) program, have issued recommendations for administration of epinephrine during management of asystole. Generally, with management of asystole in children, epinephrine should be used differently than if it were being administered to reverse bradycardia. However, in both situations, a dose-response method of epinephrine should be employed.

PALS recommendations for pulseless arrest (PES, asystole)

PALS recommendations for bradycardia

American Heart Association: 2005 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 12: Pediatric Advanced Life Support. Circulation 112:167–187, 2005.

Carpenter TC, Stenmark KR: High-dose epinephrine is not superior to standard-dose epinephrine in pediatric in-hospital cardiopulmonary arrest. Pediatrics 99:403–408, 1997.

22 Which resuscitation drugs are effective when given via an endotracheal tube?

There are four “traditional” resuscitation drugs that are effective when administered through the ETT. Those four are lidocaine, atropine, naloxone, and epinephrine. The acronym LANE is an easy way to remember them. Versed (midazolam) also is useful and is effective when administered endotracheally. Adding this drug to the list yields a different acronym: NAVEL. With the exception of epinephrine, endotracheal doses are the same as intravascular doses. All endotracheal doses of epinephrine should be a higher dose (0.1 mg/kg).

KEY POINTS: DRUGS THAT CAN BE GIVEN VIA THE ENDOTRACHEAL ROUTE

23 Are there minimum dosing requirements for any resuscitation drugs?

24 What are the recommendations for use of adenosine?

Adenosine is the drug of choice in the acute management of supraventricular tachycardia. It is a short-acting agent (half-life of approximately 10 seconds) that slows atrioventricular node conduction. The initial dose is 0.1 mg/kg, given as a rapid intravascular push with an immediate saline flush. If the drug is not given rapidly, its effectiveness is diminished. If the first dose is properly administered but ineffective, give a larger second dose of 0.2 mg/kg. Usual adult doses are 6 mg (first dose), followed by 12 mg (second dose). Expect that the first dose might be completely ineffective or only transiently effective. Administration of subsequent higher doses generally yields success.

Ros SP, Fisher EA, Bell TJ: Adenosine in the emergency management of supraventricular tachycardia. Pediatr Emerg Care 197:222–223, 1991.

25 Does calcium have any usefulness in pediatric resuscitations?

The American Heart Association does not recommend the routine use of calcium in pediatric cardiac arrest. While the use of calcium during resuscitation has declined considerably, there remain specific instances when it has significant value. Use calcium to remedy the following disorders:

When administered, calcium should be infused slowly. Rapid infusion results in severe bradycardia. Take care to avoid back-to-back infusion of calcium- and sodium bicarbonate– containing solutions. If mixed, these agents form calcium carbonate (chalk) in the IV tubing.

American Heart Association: 2005 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 12: Pediatric Advanced Life Support. Circulation 112:167–187, 2005.

26 Does sodium bicarbonate still have a role in pediatric resuscitations?

Sodium bicarbonate is not recommended for routine use in pediatric resuscitations. Although it is a useful agent for the reversal of documented metabolic acidosis, it is effective only in the presence of adequate ventilation. When bicarbonate combines with hydrogen, it forms a complex molecule that splits into carbon dioxide and water. The carbon dioxide has only one route of exit, the respiratory tract. Without effective ventilation, this by-product is not removed, and the buffering capacity of the bicarbonate is eliminated. A randomized, controlled trial found no benefit from sodium bicarbonate use in neonatal resuscitation. After provision of effective ventilation and chest compressions and administration of epinephrine, consider sodium bicarbonate for prolonged cardiac arrest.

American Heart Association: 2005 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 12: Pediatric Advanced Life Support. Circulation 112:167–187, 2005.

Lokesh L, Kumar P, Murki S, Narang A: A randomized controlled trial of sodium bicarbonate in neonatal resuscitation—effect on immediate outcome. Resuscitation 60:219–223, 2004.

27 Is there an easy method to calculate mixtures of constant infusions of drugs?

Several methods are used. Here is one easy method:

28 What role does defibrillation play in pediatric resuscitation?

Historically, pediatric resuscitation has focused on pulmonary etiologies; defibrillation is a relatively uncommon intervention in pediatric resuscitation. While asystole remains the most commonly observed arrhythmia during pediatric cardiac arrests, recent research indicates that ventricular fibrillation may occur much more frequently than originally thought. The National Registry of Cardiopulmonary Resuscitation, the largest inpatient pediatric cohort reported to date, found ventricular fibrillation occurred in 14% of pediatric arrests. In that study, pediatric patients with ventricular fibrillation had a higher survival rate (29%) than those with asystole (24%) or PEA (11%). A recent study of out-of-hospital pediatric arrests found ventricular fibrillation as the presenting rhythm in 17.6% of cases, with children older than 7 years of age having the highest incidence (38/141, 27.0%). Survival of patients with ventricular fibrillation was threefold greater (31.3% versus 10.7%) than in those without a shockable rhythm.

Smith BT, Rea TD, Eisenberg MS: Ventricular fibrillation in pediatric cardiac arrest. Acad Emerg Med 13:525–529, 2006.

29 How is defibrillation best accomplished?

As with any resuscitation, rhythm should be carefully checked after airway and breathing are established. Ventricular fibrillation should be carefully confirmed before defibrillation is attempted. Unmonitored defibrillation of a child is not recommended.

Defibrillation works by producing a mass polarization of myocardial cells with the intent of stimulating the return of a spontaneous sinus rhythm. Once ventricular fibrillation is diagnosed, prepare the patient for defibrillation and correct acidosis and hypoxemia. High-amplitude (coarse) fibrillation is more easily reversed than low-amplitude (fine) fibrillation. Administration of epinephrine can help coarsen fibrillation.

Defibrillation is most effective with use of the largest paddle that makes complete contact with the chest wall. Using the larger (8-cm diameter) paddle lowers the intrathoracic impedance and increases the effectiveness of the defibrillation current.

Take care to use an appropriate interface between the paddles and the chest wall. Electrode cream, paste, gel pads, or self-adhesive monitoring–defibrillation pads are preferred. Do not use saline-soaked gauze pads, ultrasound gel, alcohol pads, or bare paddles. Placement of the paste or pads must be meticulous, since electrical bridging across the surface of the chest results in ineffective defibrillation and, possibly, skin burns. When attempting defibrillation, guideline updates (2005) from the American Heart Association now state that immediate CPR should follow the delivery of one shock, rather than delivery of up to three shocks before CPR. These recommendations are based on the fact that the first shock eliminates ventricular fibrillation 85% of the time and studies have shown long delays typically occur between shocks when automated external defibrillators (AEDs) are used.

30 Are AEDs useful for children with sudden collapse?

PALS guidelines as of 2005 now recommend use of AEDs for children 1 year of age and older. Newer models of AEDs have been shown to be able to reliably recognize shockable rhythms in children. There is not enough evidence to recommend use of AEDs for children under 1 year of age (Class Indeterminate).

American Heart Association: 2005 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 12: Pediatric Advanced Life Support. Circulation 112:167–187, 2005.