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: