Paediatric cardiopulmonary arrest (CPA)

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2.1 Paediatric cardiopulmonary arrest (CPA)

Christopher Webber

1 Prevention is the link in the Chain of Survival key to decreasing the incidence of death from Out-of-Hospital Cardiac Arrest (OHCA)¹

2 Paediatric patients who sustain OHCA have similar survival to hospital discharge rates to adults who sustain OHCA.

3 CPA in children usually results from the development of progressive hypoxia and/or shock, which may be due to a myriad of causes.

4 The goal is to identify evolving hypoxia and shock early in seriously ill children and proactively instigate appropriate therapy to prevent the progression to cardiac arrest.

5 In contrast to adults, the most common arrest rhythm in children is non-VF/VT and is usually either asystole, pulseless electrical activity (PEA) or electromechanical dissociation (EMD).

6 Resuscitation organisations have developed guidelines for paediatric patients to include nuances of the newly-born, infant, young child and older child. Current recommendations simplify the differences in resuscitation approach between ages.

7 Allowing parents to be present and supported during the resuscitation of their child may be associated with a better long-term psychological outcome.

8 Unless CPA is associated with drug toxicity or some situations with profound hypothermia, neurologically intact survival is unlikely after 30 minutes of full CPR and several doses of adrenaline.

Epidemiology

Previous studies of paediatric Out-of-Hospital Cardiac Arrest (OHCA) have reported poor survival rates with severe neurological sequelae,^2,³ however more recent publications have challenged this reporting a similar rates of survival to hospital discharge as that of adults who sustain OHCA.^4,⁵

The incidence of out-of-hospital arrest is reported as ranging from 2.6 to 19.7 per year per 100 000 paediatric population (age < 18 years), in the region of 30% achieving return of spontaneous circulation (ROSC), 24% surviving to hospital admission, and 12% surviving to discharge.⁶

Less than 10% of paediatric OHCA victims have a shockable rhythm on arrival of the prehospital care providers.^4,⁵

Aetiology

The most common causes of cardiac arrest in children relate to the development of hypoxia and/or shock, the two pathways which, untreated, result in cardiopulmonary arrest. Shock is the clinical state of poor tissue perfusion. Thus, the primary organ systems involved are the respiratory and cardiovascular systems, and the central nervous system (CNS), which becomes compromised by hypoxia or decreased cerebral perfusion. Injury or diseases progressing to failure of these systems may then lead to cardiac arrest. CNS disorders, either with direct dysfunction or due to raised intracranial pressure, may cause respiratory arrest with the resulting hypoxia leading to cardiac arrest. The primary causes of cardiac arrest are heterogeneous and include trauma, sepsis, drug overdose, poisoning, immersion, critical respiratory illness and sudden infant death syndrome (SIDS). This list is by no means complete, and many other conditions may also progress to cardiac arrest.

Pathophysiology

Significant hypoxic and hypoperfusion insults to the myocardium are the common pathways that may progress to cardiac arrest in children. Hence, fluid or blood loss leading to shock, if left untreated, result in myocardial ischaemia and resultant cardiac arrest. Similarly, severe hypoxia also results in global myocardial dysfunction and subsequently cardiac arrest. Thus, preventive strategies must identify hypoxia and shock early and instigate appropriate management to improve oxygenation and organ perfusion, thereby preventing progress to cardiac arrest. Poisonings or ingestions may have a direct effect on the heart, causing an arrhythmia, coma, with subsequent respiratory arrest and hypoxia.

Outcome

Generally, the survival from respiratory arrest alone is much better than from cardiopulmonary arrest. Survival to discharge for children with respiratory arrest (pulse present) is around 75%, and of these up to 88% have a good neurological outcome. Reported survival rates from cardiac arrest in children have varied from 0% to 17%. Survival to discharge from hospital for paediatric OHCA is 7%^4,⁵ and 36% for in-hospital cardiac arrests.⁷ ‘Survival to discharge’ is a very crude marker of ‘success’ as it does not include a measure of neurological function. Proactive early resuscitation of the pre-arrest child is important in order to have the most impact on outcome.

Unfortunately, the perception of the public, and even doctors and nurses, is that the expected survival rate is higher than this. Lay rescuers, physicians and nurses estimate the survival rate for cardiopulmonary arrest in children as being 63%, 45% and 41% respectively (compared to 53%, 30% and 24% for adult cardiopulmonary arrest).⁸ Undoubtedly, fictional medical television programmes contribute to this bias, and even non-fictional medical programmes rarely show death as an outcome.

Differences compared to adults

When comparing children to adults in relation to cardiopulmonary arrest, there are several important differences. The aetiology of the event is usually different. Adults who collapse are more likely to have ventricular fibrillation or pulseless ventricular tachycardia, hence the time to defibrillation is the single greatest determinant of survival. Thus the ‘phone first’ principle that applies to adults is not applicable to most infants and children, in whom the response should be ‘phone fast’ (see Chapter 2.2 on Basic life support).

There are several anatomical and physical differences between children and adults. It is important to consider these differences in relation to the primary event leading to arrest and to the resuscitation techniques subsequently required (Table 2.1.1).

Difference in children Implication AIRWAY Prominent occiput tends to cause neck flexion Neck extension, into a neutral or sniffing position (slight extension), is required to optimise the airway for an infant or child respectively Mandible is relatively smaller More difficult intubation Tongue is relatively larger Tends to obstruct airway
More difficult intubation Larynx is more cephalad (located almost at base of tongue) More difficult intubation – tendency for inexperienced operator to insert laryngoscope blade into oesophagus Epiglottis is proportionally larger and more ‘floppy’ Intubation may require straight-bladed laryngoscope to lift epiglottis forward to allow visualisation of vocal cords Upper airways are more compliant (i.e. distensible) Tend to collapse during increased work of breathing BREATHING Chest wall more compliant (particularly the newborn infant and more so the preterm infant) Less efficient ventilation, when increased work of breathing
Earlier fatigue Greater dependence on diaphragm to generate tidal volume Distended stomach impairs ventilation
Importance of venting stomach with gastric tube CIRCULATION Maintains cardiac output and blood pressure by tachycardia initially Diagnose and treat shock before hypotension develops
Hypotension usually indicates late decompensation GENERAL Head has proportionally greater component of body surface area Loss of body heat during primary event or resuscitation
Greater chance of head injury Compliant chest wall allows transmission of energy to underlying organs, resulting in traumatic damage/rupture, rather than dissipation of energy Pulmonary, hepatic and splenic injury may occur without overlying rib fractures Development
Language
Motor development (fine and gross)
Social and cognitive development (including abstract thinking) Must be considered when interacting with the child and understanding injuries (accidental versus non-accidental) Parental and staff considerations Psychosocial issues
Presence of family during resuscitation
Staff pressure to continue resuscitation
Impact on staff from death of child

Development of resuscitation guidelines

In 1992 the American Heart Association guidelines for resuscitation were published. Subsequently representatives of seven resuscitation councils throughout the world, including the Australian Resuscitation Council, formed the International Liaison Committee on Resuscitation (ILCOR). ILCOR advisory statements were produced. A subcommittee on paediatric resuscitation with representation from the American Heart Association and other paediatric representatives from ILCOR (Paediatric Working Group) further developed guidelines for paediatric patients. This group attempted to evaluate the level of evidence for resuscitation recommendations. It was important to attempt to avoid confusion between adult, paediatric and neonatal algorithms and ultimately the International Guidelines 2000 were published. These were revised and published simultaneously in the journals Resuscitation and Circulation in 2005 and again in November 2010.⁹ The Australian Resuscitation Council (ARC) and New Zealand Resuscitation Council (NZRC) released updated guidelines in December 2010. For the first time, both Councils published identical guidelines on-line, with both Councils’ logos. Subsequently resuscitation courses, like the Advanced Paediatrics Life Support (APLS) course have been amended to be consistent with the international recommendations. APLS courses in Australia and New Zealand are consistent with ARC and NZRC recommendations.

Ethics of paediatric resuscitation

Presence of family

Over recent years, the benefit of allowing the family, mainly parents, into the resuscitation room during active resuscitation has become clearer. This practice has required a cultural change, and mandates appropriate and professional behaviour and language during resuscitation. Such practice should occur regardless of the presence of any ‘outside’ witnesses. It is a professional standard that all medical, nursing and other health professionals should aspire to and maintain. It is probably even more important that parents are offered the opportunity to witness the resuscitation, when the outcome is the death of their child.

In hindsight, parents who have witnessed the resuscitation of their child have valued this opportunity and despite the occasionally chaotic environment, common positive perceptions relate to the efforts made by staff. To achieve a positive (psychosocial) outcome, in relation to the presence of parents during resuscitation, the following issues should be considered:

• Parents being present during the resuscitation of their child should be regarded more as the norm than the exception.

• Parents should not be coerced into being present, but gentle encouragement and explanation by a senior member of staff is usually helpful.

• Senior members of staff engaged in resuscitation should not feel undue pressure as a result of the attendance of parents. Occasionally, however, it may be preferable for the parents to wait outside the immediate resuscitation area during challenging or visually disturbing procedures.

• Parents should have a dedicated support person, being a health professional, to remain with them throughout the resuscitation. The support person should obtain information from medical staff to keep the parents informed of their child’s progress and explain procedures to the parents.

• Touching and talking to their child is often important for the parents where this is feasible.

• Parents need to have a quiet room to retreat to, if necessary. Discussion with family should not occur in a busy emergency department corridor as it will negatively affect the family’s retention of information.

• Family requests and religious beliefs need to be respected.

• Obligations mandated by Coronial Law need to be explained with sensitivity.

• The emotional impact on all staff members when a child dies is considerable and this may be compounded by the distress of parents during and following the resuscitation.

• With any resuscitation, particularly those resulting in death, debriefing of staff is essential, as is organising the appropriate support and medical follow up of the parents.

Termination of resuscitative efforts

The decision to cease resuscitation efforts in a child in CPA is influenced by many factors. These include the total arrest time, clinical response to therapy, premorbid state of the child, potential for any reversible factors, likely neurological outcome, information from colleagues who care for a child with long-term medical problems and the parental wishes. In the initial stage of the arrested child arriving in the ED, these details should be rapidly established whilst resuscitation is continued in order to help guide subsequent management.

Termination of resuscitation in a newly born baby is likely to be appropriate if the baby remains in cardiorespiratory arrest at 15 minutes. Even after 10 minutes of documented asystole, survival without severe disability is unlikely.

For children in established cardiac arrest the overall outcome is poor. If the child requires adrenaline (epinephrine), and fails to respond to two doses, then survival is unlikely. Generally no longer than 30 minutes of advanced life support resuscitation is required to determine whether discontinuation of resuscitation is appropriate. Recurring/refractory VF or VT, toxic drug exposure or the presence of significant hypothermia in the setting of ice-cold immersion, are situations that may require more prolonged resuscitation efforts (see Chapter 22.2 on Drowning). Many children in cardiorespiratory arrest in Australia and New Zealand who are hypothermic, however, have lost body heat due to exposure, without spontaneous circulation after the arrest, and therefore this is unlikely to be neuroprotective.

Non-initiation of resuscitative efforts

Resuscitation should not be initiated if there are signs of prolonged death, like rigor mortis or post-mortem lividity. Children who are in a palliative phase of care should have an ‘end of life care plan’ that includes non-initiation of resuscitation should this have been previously determined by family and the child’s coordinating specialist. Children with complex and disabling conditions will occasionally have life-threatening events occur. If prior discussions between parents (and child if appropriate) and physicians have not included limitations of interventions or medical support, then it is difficult to avoid commencing resuscitation. Early and urgent consultation with the child’s primary physician is prudent in these situations. Physicians should not be coerced into undertaking care that they believe is morally wrong or fruitless.

There are specific situations in the newly born baby that may lead to the non-initiation of resuscitation, like extreme prematurity and congenital/chromosomal abnormalities not consistent with long-term survival. This issue is covered in Chapter 2.6 on neonatal resuscitation.

Consent

The philosophy of informed consent should be followed during any treatment, including resuscitation. The patient or the parents/guardian should have an explanation about the management (current and proposed), risks and potential outcomes. This may be limited during resuscitation but is the responsibility of the most senior physician involved with the child’s care at the time. The decision to stop resuscitative efforts in the emergency department setting due to a lack of return of spontaneous circulation is a medical decision. It is not a choice that is offered to the parents. The circumstances are completely different to the discussion with parents about ‘withdrawal of treatment’, which usually occurs in an intensive care unit in a child who is ventilated but has a spontaneous circulation.

Non-accidental injury

It is important that all healthcare providers involved with children should be aware of their statutory obligations under state or federal law regarding notification of suspicion of non-accidental injury or neglect. Awareness of development of the child, feasibility or compatibility of the history with clinical signs and any delay in presentation should be considered when assessing this possibility. Regardless of the outcome of the resuscitation, if there is a suspicion of abuse or neglect, appropriate notification should be made.

Organ donation

Organ donation is usually a consideration for staff when a child is in an intensive care unit and generally not in the emergency department. The only situation where it may be contemplated in the ED is when post-mortem organs (like corneas, heart valves) may be retrieved for this purpose. In cases mandating notification of the coroner, then permission is required prior to any organ harvesting. Liaison with the appropriate local donor coordinator is essential. A senior member of staff should have this discussion with the parents and occasionally the parents themselves raise the issue.

If resuscitation has resulted in the return of spontaneous circulation but with likely brain death, subsequent organ donation may be feasible. The determination of brain death would usually occur in an intensive care unit, as a repeat examination for brain death, after a period of time, is required. Consultation with and consideration of transfer to a paediatric intensive care unit is required. The focus in the emergency department at this point is the ongoing care of the child and support of the family.

Death certificates, notification to the coroner and other legal issues

Death in the ED is, by itself, not an indication to notify the death to the coroner. Coroners’ Acts vary from state to state and staff must be aware of their statutory obligations. Remember that if a death is to be notified to the coroner the body then becomes evidence and should be left intact at the termination of resuscitation. Common practices of taking hand/footprints, locks of hair, removing catheters and tubes must not occur or staff risk being held in contempt of court. Such mementos can be collected following the post-mortem examination. This usually requires liaison with staff in the forensic mortuary.

Some states have special processes in place for the management of sudden unexplained death in infancy (SUDI). Any sudden and unexplained death under 12 months of age warrants a detailed history as well as specific samples collected post-mortem to identify metabolic and genetic conditions. The Forensic Pathologist may need to have this drawn to their attention (e.g. see http://www.health.nsw.gov.au/policies/index.asp Search SUDI).

In the situation where a death does not require notification to the coroner, it must be clarified who can and will complete the death certificate, which includes the cause of death. Consultation with the primary physician involved with the long-term care of a child with chronic illness is obligatory. Medical staff need to be aware of other legal obligations, like the collection of blood alcohol specimens in pedestrian and vehicular accidents, but these would only be collected ante-mortem by hospital staff. These legal requirements vary between states.

1 Nolan J., Soar J., Eikeland H. The chain of survival. Resuscitation. 2006;71(3):270-271.

2 Schindler M.B., Bohn D., Cox P.N., et al. Outcome of out-of-hospital cardiac or respiratory arrest in children. N Engl J Med. 1996;335(20):1473-1479.

3 Young K.D., Gausche-Hill M., McClung C.D., et al. A prospective, population-based study of the epidemiology and outcome of out-of-hospital pediatric cardiopulmonary arrest. Pediatrics. 2004;114(1):157-164.

4 Atkins D.L., Everson-Stewart S., Sears G.K., et al. Epidemiology and outcomes from out-of-hospital cardiac arrest in children: the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest. Circulation. 2009;119(11):1484-1491.

5 Deasy C., Bernard S.A., Cameron P., et al. Epidemiology of paediatric out-of-hospital cardiac arrest in Melbourne, Australia. Resuscitation. 2010;81(9):1095-1100.

6 Donoghue A.J., Nadkarni V.M., Elliott M., Durbin D. Effect of hospital characteristics on outcomes from pediatric cardiopulmonary resuscitation: a report from the national registry of cardiopulmonary resuscitation. Pediatrics. 2006;118(3):995-1001.

7 Tibballs J., Kinney S. A prospective study of outcome of in-patient paediatric cardiopulmonary arrest. Resuscitation. 2006;71(3):310-318.

8 Brown K., Bocock J. Update on paediatric resuscitation. Emerg Med Clin North Am. 2002;20(1):1-26.

9 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science. Circulation 2010;122:18 Supplement and Resuscitation 2010;81 Supplement

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