The editors and current author would like to thank and acknowledge the significant contribution of the previous author of this chapter from the 2004 first edition Rodney B. Boychuk, MD and Alson S. Inaba, MD. This current third edition chapter is a revision and update of the original author’s work.
Paramedics are transporting a 5-month-old male infant with respiratory distress. During transport, he tires and stops breathing. Cardiopulmonary resuscitation (CPR) is initiated with ventilation via bag mask ventilation (BMV). On arrival at the emergency department, the patient is apneic and pulseless. Chest compressions are initiated and BMV is continued. The patient is intubated with an endotracheal tube (ETT). A colorimetric carbon dioxide capnometer detector device confirms proper tracheal tube placement.
Primary assessment findings: 1) Airway/breathing: Breath sounds are equal bilaterally, and there is good chest movement with ventilation. 2) Circulation: No pulse is palpable without chest compressions, and no heart sounds are heard. EKG monitor shows asystole. 3) VS: HR 0 on EKG, but 120 with chest compressions, RR 0 spontaneously, but 21 with bag ventilation via the ETT, BP 60/40 with chest compressions. Oxygen saturation shows a 60% saturation (and increasing) with chest compression pulsations.
Ventilation and chest compressions are continued. Epinephrine 0.5 mg of the 1:1,000 (1 mg/mL) solution is given down the ETT. An initial IV attempt is unsuccessful. A simultaneous intraosseous (IO) needle is drill-inserted into the proximal left tibia. The oxygen saturation is now 85% with chest compressions. Blood is obtained from the IO needle and is sent for several studies, including a rapid glucose check. The airway is reassessed. Ventilation and chest compressions are continued, and a second dose of epinephrine 0.05 mg is given into the IO needle 3 minutes after the initial ETT dose of epinephrine. The patient converts to a sinus bradycardia with a fair blood pressure. After a few minutes, chest compressions are stopped. The infant's heart rate is 120, he is breathing spontaneously, he is moving and coughing against the tracheal tube. The oxygen saturation is now 97% and a BP 73/45 is obtained. The resuscitation is a success.
When performing the initial assessment of a collapsed pediatric patient, the 2020 the American Heart Association Pediatric Advanced Life Support (PALS) guidelines (1) recommend the following series of steps. The assessment shouldn’t be delayed by more than 10 seconds in infants and children with no signs of life (1).
1) Determine the level of responsiveness.
2) Properly position the patient on a firm surface, maintaining cervical spine immobilization (in children with suspected head or cervical spine injury).
3) Assess and establish a patent airway.
4) Assure oxygenation.
5) Assure and establish ventilation (breathing) while protecting the cervical spine.
6) Assure adequate circulation.
7) Reassess.
8) Utilize appropriate drug therapy if required.
The following components should be practiced when performing pediatric CPR. (1)
1) High-Performance CPR (HP-CPR) includes the following components.
2) Ventilation:
3) Early administration of epinephrine in patients with a non-shockable rhythm, along with high-quality CPR, improves the outcomes.
4) Utilization of cuffed ETT reduces the need for ETT changes.
5) Routine use of cricoid pressure does not reduce the risk of regurgitation during bag-mask ventilation (BMV) and may reduce the intubation success rate.
6) The outcomes of out-of-hospital cardiac arrest (OHCA) with the use of BMV are comparable with the use of advanced airways (AA) such as ETTs.
7) Targeted temperature management, continuous electroencephalography (EEG) monitoring, prevention and/or treatment of hypotension, hyperoxia or hypoxia, and hypercapnia or hypocapnia are essential aspects of post-cardiac arrest care in unconscious children after the return of spontaneous circulation (ROSC).
8) The cardiac arrest care survivors may benefit from physical, cognitive, and emotional evaluations and appropriate support in the affected areas.
9) Naloxone can reverse respiratory arrest due to opioid overdose, but there is no evidence that it benefits patients in cardiac arrest.
10) Fluid resuscitation in sepsis should be guided based on patient response and frequent reassessment. Balanced crystalloid, unbalanced crystalloid, and colloid fluids are all acceptable for sepsis resuscitation. Epinephrine or norepinephrine infusions are used for fluid-refractory septic shock.
In the first decade of the 21st century, pediatric in-hospital cardiac arrest (IHCA) outcomes improved. This was largely due to the increased awareness of the need for high-quality cardiopulmonary resuscitation. In addition, there was increased emphasis on recognizing a deteriorating pediatric patient and moving them to an intensive care unit (ICU). Designated rapid response teams have become ubiquitous and their presence is associated with a decrease in the frequency of cardiac arrests and reducing mortality rates in patients who undergo CPR (3).
Recent reviews show that more than 15,000 children in the United States experience IHCA and receive cardiopulmonary resuscitation (CPR) each year. The age distribution of childhood cardiopulmonary arrest (CPA) is skewed toward infancy, with a median age of 1 to 2 years old and a mean of 3 to 5 years old. Survival rates of the initial event are as high as 80% to 90%, which has doubled in the last 20 years. However, more than half of patients do not survive to hospital discharge. Most cases of cardiac arrest are a result of respiratory failure or shock, and the most common initial rhythm is bradycardia with poor perfusion (50%). Unfortunately, 90% of pediatric patients do not present with a shockable rhythm (3).
Current efforts are focused on preventing CPA from occurring in this population. Some hospitals have pre-cardiac arrest systems that identify at-risk patients and ensure they are in appropriate units with adequate monitoring. Survival is increased with effective CPR, comprising high-quality chest compressions, early defibrillation, adequate ventilation, epinephrine delivery, and treating the underlying cause (3).
Ultimately, pediatric IHCA is a disease process with modifiable outcomes. The emphasis should be placed on preventing the initial event, providing high-quality CPR for the patient in CPA, and providing comprehensive post-cardiac arrest care (1-4).
The pathophysiology of CPA in children is different from that in adults. CPA in infants and children is most commonly in the setting of respiratory failure or shock with subsequent cardiac arrest. CPA in children is generally the end result of progressive deterioration and rarely occurs as a sudden event. Thus, it is vital to identify and manage respiratory distress in children and, therefore, prevent the deterioration into respiratory failure and subsequent CPA (1–6).
When assessing a pediatric patient in CPA, in addition to the initial treatment and CPR, a thorough history and physical exam are essential to identify the etiology and possible reversible causes.
Helpful history and physical exam items include age, recent illness, previous medical problems, current medications, recent trauma, time of day, location of the patient during CPA, access to toxins, medicines, poisons, access to potential foreign bodies, length of downtime, overall appearance (congenital defects), vital signs, tracheal deviation, subcutaneous air, pupillary response, evidence of trauma (including retinal hemorrhages), surgical scars (especially sternal, and scalp which suggest surgical heart disease and brain surgery respectively). Findings that suggest prolonged time since death include rigor mortis, dependent lividity, and corneal clouding.
There are significant differences between pediatric IHCA and out-of-hospital cardiac arrest (OHCA), mainly in the context of etiology. IHCA is often a result of shock or respiratory failure, whereas outpatient causes include drowning, sudden infant death syndrome, and sudden cardiac death from arrhythmias. OHCAs tend to have worse survival outcomes, and the focus for improving survival lies in prevention, bystander CPR, and basic life support (BLS) measures in the field. (6,7).
The more common dysrhythmias that one may be confronted with during a pediatric resuscitation include bradycardia, asystole, and pulseless electrical activity (PEA). Ventricular fibrillation and ventricular tachycardia are not very common in children but may be the presenting dysrhythmia in children with congenital heart diseases, genetically related arrhythmia, and adolescents secondary to various drug overdoses. The key focus in treating PEA and asystole is to hunt for reversible causes (8). The mnemonic used to recall the reversible etiologies of asystole and PEA are the 7 Hs and 5 Ts (7). 7 Hs: Hypovolemia (most common cause), hypoxia, hydrogen ion (acidosis), hypoglycemia, hypo/hyperkalemia, and hypothermia. 5 Ts: tension pneumothorax, tamponade (cardiac), toxins, thrombosis (pulmonary), and thrombosis (coronary).
Although the etiology of cardiopulmonary resuscitation (CPR) in children is different than in adults, the immediate goal is the same: to immediately reestablish effective cardiac output and delivery of oxygen to tissues using artificial ventilation, external chest compressions, the administration of pharmacologic agents, and the use of electricity (synchronized cardioversion or defibrillation), when applicable.
Early CPR: If no pulse or breathing is present, immediately start CPR. Start ventilation via BMV with 100% oxygen as soon as it is available and attach the patient to a monitor/defibrillator.
Airway and Ventilation:
The most common cause of upper airway obstruction in the unconscious child is posterior displacement of the tongue. This obstruction can be relieved by either a head tilt/chin lift or jaw-thrust maneuver by pulling the jaw forward into a sniffing position. Do not perform the head tilt/chin lift maneuver in children with potential cervical spine trauma. Foreign material or vomitus can also obstruct the airway. Therefore, open the mouth, inspect it, and suction it early and repeatedly. Consider the use of nasopharyngeal or oropharyngeal airways in selected patients. These types of airways should only be used in unconscious patients because the insertion of either a nasopharyngeal or oropharyngeal airway into a conscious patient will induce gagging and potential aspiration.
Children without adequate spontaneous breathing effort require positive pressure ventilatory support. The American Heart Association Emergency Cardiac Care 2020 guidelines recommend providing ventilations at a respiratory rate of 1 breath every 2-3 seconds (20-30 breaths per minute), as rates faster than this can compromise hemodynamics. If prolonged respiratory distress without adequate response to emergency BMV, the patient can be intubated with an ET tube. Cuffed ET tubes have improved capnography and ventilation and are now recommended when intubating pediatric patients (1-7).
Advanced Airway (AA): Current guidelines suggest similar survival and neurologic outcomes with bag-mask ventilation and endotracheal intubation (ETI) in OHCA. There was also no difference in outcomes when using supraglottic advanced airway (SGA) or ETI. There are not enough studies to support the timing for the use of AA. The overall goal of not using AA initially is to minimize the CPR interruption.
Waveform capnography or capnometry is used to confirm and monitor ET tube placement and the efficacy of cardiac output through chest compression.
Circulation:
Assuring adequate circulation includes not only the blood pressure but also the evaluation of the overall appearance, heart rate, the presence and strength of proximal vs. distal pulses, skin temperature and color, mucous membrane color, capillary refill time, and alertness/responsiveness (brain perfusion). With acute blood loss or any hypovolemic state, the protective/compensatory mechanisms of increasing the heart rate and increasing the systemic vascular resistance (poor perfusion with cool extremities) will maintain a child's systolic blood pressure within a normal range despite losses as high as 30% of the child's circulating blood volume. Once these protective homeostatic mechanisms are no longer able to compensate for the hypovolemic state, the child's systolic blood pressure will then abruptly decompensate to a pressure that is now hypotensive for age. This phenomenon highlights the importance of preventing hypotension by recognizing early signs of hypovolemia (tachycardia).
If circulation is inadequate (i.e., absent or ineffective pulses), external cardiac chest compressions should be started. After every step, reassess the patient. Pay attention to the ABCs, physical exam (e.g., chest excursion, heart rate, skin color, perfusion, etc.), and pulse oximetry or ancillary test results.
Defibrillation: If the rhythm is shockable (ventricular fibrillation or pulseless ventricular tachycardia), defibrillation (also called unsynchronized shock) is the essential element of treatment. The PALS algorithm for shockable rhythm in pediatric cardiac arrest is shock-shock-epinephrine-shock-amiodarone/lidocaine while you identify and treat Hs and Ts. IV magnesium sulfate should be considered in cases of Torsades de Pointes or hypomagnesemia.
After the initial dose of 2 J/kg, resume CPR immediately. After 2 minutes of CPR, reassess the patient and shock again at a rate of 4 J/kg if the rhythm is shockable. The subsequent shocks should be greater than or equal to 4 J/kg, maximum 10 J/kg, or maximum adult dose.
Although a complete discussion of all the pediatric dysrhythmia algorithms is well beyond the scope of this chapter, a summary of the key treatment points for the various pediatric dysrhythmias is listed in table 1 below. A consultation with a pediatric cardiologist should be obtained when possible and as time permits.
Table 1: Pediatric dysrhythmia treatments
| Asystole and PEA | Perform high-quality CPR, intubate, administer epinephrine, and search for reversible causes. Defibrillation or synchronized cardioversion is not recommended in this situation. |
|---|---|
| Bradycardia | Assure adequate oxygenation (since hypoxia is the most common etiology) and ventilation first; then consider epinephrine, atropine, and transcutaneous pacing. |
| Paroxysmal supraventricular tachycardia (PSVT) (hemodynamically stable) | Vagal maneuvers may be attempted first, then adenosine should be considered. |
| Unstable PSVT or refractory stable PSVT | Cardioversion |
| Ventricular tachycardia (VT) (hemodynamically stable) | Consider amiodarone or lidocaine or procainamide. |
| VT with a pulse | Cardioversion |
| VF or pulseless VT | Defibrillation |
| Torsades des points | Lidocaine, magnesium (for hypomagnesemia) |
Vascular access: The team should also obtain IV/IO (intraosseous) access. Early access is vital, and while IV access is preferred, if this cannot be obtained within a reasonable timeframe, IO access can be used. Any intravenous preparation (medication or fluid) can be given intraosseously, and blood (if available) from the IO needle can be used for many laboratory tests (12).
Drugs: In patients with cardiac arrest, epinephrine is given IV or IO at a dose of 0.01 mg/kg every 3-5 minutes, with a maximum dose of 1 mg. Recent studies have found that early epinephrine may increase survival to discharge rates (4). Epinephrine in CPR works by optimizing the coronary perfusion pressure and maintaining the cerebral perfusion pressure. Therefore, current recommendations are to administer the first dose of epinephrine within 3 to 5 minutes of the start of CPR. While the IV or IO routes for epinephrine are preferred, epinephrine can be given through an ETT at a dose of 0.1 mg/kg (10 times the IV/IO dose).
Some of the drugs utilized in pediatric resuscitation are noted here, but the entire list of resuscitation drugs is beyond the scope of this chapter. Epinephrine increases heart rate, contractility, and blood pressure. Atropine increases heart rate in cases associated with increased vagal tone. Amiodarone and lidocaine (antiarrhythmic agents) are used to convert ventricular fibrillation, pulseless ventricular tachycardia, or ventricular tachycardia with a pulse. Amiodarone can also be used for certain atrial tachydysrhythmias. Adenosine converts paroxysmal supraventricular tachycardia (PSVT).
The Broselow tape is a pediatric resuscitation tool that uses the length of the patient as a resuscitation guide, providing intubation and drug dosing recommendations for each length along the tape corresponding to the patient's length. This eliminates the need to estimate the patient's age and weight. This tape also includes precalculated emergency medications, airway and equipment sizes, and defibrillator shock doses. It can be used for pediatric patients up to 12 years old and 36 kg.
After the conclusion of CPR, when the pediatric patient is stabilized, the work is not finished. Post cardiac-arrest care plays an important role in increasing survival to discharge rates (13). Overall, post-resuscitation interventions include maintenance of normal ventilation (rather than hyperventilation), maintenance of normal temperature, glucose control, and management of post-ischemic myocardial dysfunction. To avoid hyperoxygenation, the FiO2 should be titrated to the goal SpO2 of 94% to 99% as hyperoxia can also cause damage and hyperemia. In addition, care should be taken to avoid hypercapnea and hypocapnea.
Facilities with successful post cardiac-arrest care focus on targeted-temperature management, optimizing hemodynamics, and effective ICU management (2). The goal of targeted-temperature management is to take active measures to keep the patient’s temperature in a specified range; for example, keep the patient’s temperature between 32 to 34 degrees C for 2 days followed by 36 to 37.5 degrees C for the next 3 days or 5 days of 36 to 37.5 degrees C. The specifics of targeted temperature management are beyond the scope of this chapter, but it is clear that the avoidance of fever is important to reduce metabolic demand (1). Lastly, post arrest cardiogenic shock and septic shock must be treated aggressively with fluid, inotropes and pressors (13,14).
Unfortunately, a common post-cardiac arrest complication is seizures which are often nonconvulsive and can only be seen with electroencephalography monitoring. The 2020 AHA guidelines recommend EEG monitoring when resources are available in post-cardiac arrest patients with persistent encephalopathy. Seizures should be treated accordingly, with consultations from pediatric neurologists if warranted (1-7).
In summary, cardiopulmonary arrest in children is typically secondary to respiratory distress leading to respiratory failure or shock. Prevention is the first step in reducing IHCA deaths by early recognition. Once recognized, early HP-CPR, early defibrillation, and early epinephrine can help increase survival to discharge rates. A CPR coach (someone assigned to monitoring and managing ongoing chest compressions) has also shown improved outcomes.(15) Finally, post-cardiac arrest care is vital for preventing further deterioration and increasing survival. Increased training at each step can improve readiness and increase the survival rates of pediatric cardiopulmonary arrests.
Questions
1. The most common cause of cardiopulmonary arrest in children is:
a. Acute myocardial infarction
b. Hemorrhagic shock
c. Nonaccidental trauma
d. Ventricular fibrillation
e. Hypoxia and respiratory failure
2. According to PALS, which of the following is not a common cause (Hs/Ts) of cardiopulmonary arrest:
a. Hypokalemia
b. Hypernatremia
c. Hypovolemia
d. Acidosis
e. Cardiac tamponade
3. The drug/treatment of choice for asystole in children is:
a. Atropine
b. Calcium chloride
c. Adenosine
d. Defibrillation
e. Epinephrine
4. A 12-year-old child comes to the ED pulseless. ECG reveals a wide complex tachycardia. Initial management should be:
a. Immediate defibrillation.
b. Immediate synchronized cardioversion.
c. Adenosine
d. Epinephrine
5. The most common cause of PEA in children is:
a. Tension pneumothorax
b. Metabolic acidosis
c. Non-accidental trauma
d. Hypovolemia
e. Hyperkalemia
6. The most common cause of bradycardia in children is:
a. Hypokalemia
b. Heart block
c. Hypoxemia
d. Toxic ingestions
d. Toxic ingestions
e. Myocarditis
References
1. Topjian AA, Raymond TT, Atkins D, et al. Pediatric Basic and Advanced Life Support Collaborators. Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16_suppl_2):S469-S523. doi: 10.1161/CIR.0000000000000901. Epub 2020 Oct 21. PMID: 33081526.
2. Meaney PA, Bobrow BJ, Mancini ME, et al, CPR Quality Summit Investigators, the American Heart Association Emergency Cardiovascular Care Committee, and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation. Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation. 2013;128(4):417-435. doi: 10.1161/CIR.0b013e31829d8654. Epub 2013 Jun 25. Erratum in: Circulation. 2013 Aug 20;128(8):e120. Erratum in: Circulation. 2013 Nov 12;128(20):e408. PMID: 23801105.
3. Morgan RW, Kirschen MP, Kilbaugh TJ, et al. Pediatric In-Hospital Cardiac Arrest and Cardiopulmonary Resuscitation in the United States: A Review. JAMA Pediatr. 2021;175(3):293-302. doi:10.1001/jamapediatrics.2020.5039
4. Randhawa MS, Revaiah VC, Jayashree M. AHA Pediatric Advanced Life Support Update 2020 — “More Breaths, Less Fluids, and a Focus on Recovery.” Indian Pediatr. 2021;58(3):273-278. doi:10.1007/s13312-021-2169-7
5. Vega RM, Kaur H, Edemekong PF. Cardiopulmonary Arrest In Children. In: StatPearls. StatPearls Publishing; 2022. Accessed April 10, 2022. http://www.ncbi.nlm.nih.gov/books/NBK436018/
6. Merchant RM, Topjian AA, Panchal AR, et al. Part 1: Executive Summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16_suppl_2):S337-S357. doi:10.1161/CIR.0000000000000918
7. American Academy of Pediatrics, American Heart Association. Pediatric Advanced Life Support: Provider Manual. American Heart Association; 2020.
8. Oliver TI, Sadiq U, Grossman SA. Pulseless Electrical Activity. In: StatPearls. StatPearls Publishing; 2022. Accessed April 16, 2022. http://www.ncbi.nlm.nih.gov/books/NBK513349/
9. Bachur RG, Shaw KN (eds). Fleisher and Ludwig’s Textbook of Pediatric Emergency Medicine, 8th edition. 2021, Wolters Kluwer, Philadelphia, PA.
10. Hoffman RJ, Wang VJ, Scarfone R, Godambe S, Nagler J. Fleisher and Ludwig’s 5-Minute Pediatric Emergency Medicine Consult. Wolters Kluwer; 2019. Accessed April 16, 2022. http://ebookcentral.proquest.com/lib/uhm/detail.action?docID=6372341
11. Weiss JN, Qu Z, Shivkumar K. Electrophysiology of Hypokalemia and Hyperkalemia. Circ Arrhythm Electrophysiol. 2017;10(3):e004667. doi:10.1161/CIRCEP.116.004667
12. Pediatric Intraosseous Access: Overview, Periprocedural Care, Technique. Published online December 10, 2021. Accessed April 10, 2022. https://emedicine.medscape.com/article/940993-overview#a2
13. Aaron SL, Vega RM, Hai O. Pediatric Post Resuscitation Management. In: StatPearls. StatPearls Publishing; 2022. Accessed April 10, 2022. http://www.ncbi.nlm.nih.gov/books/NBK441991/
14. Topjian AA, de Caen A, Wainwright MS, et al. Pediatric Post–Cardiac Arrest Care: A Scientific Statement From the American Heart Association. Circulation. 2019;140(6):e194-e233. doi:10.1161/CIR.0000000000000697
15. Nadkarni V, O’Halloran A, Wolfe H. Put Me in, Coach!...INSPIRE-ing Choreography of Cardiopulmonary Resuscitation*. Pediatric Critical Care Medicine 22(4):p 430-432, April 2021. | DOI: 10.1097/PCC.0000000000002645
Answers to questions
1.e, 2.b, 3.e, 4.a, 5.d, 6.c