- Email: [email protected]
Pediatric Cardiopulmonary Resuscitation: A Collective Review
PEDIATRICS/REVIEW
Pediatric Cardiopulmonary Resuscitation: A Collective Review From the Departments of Emergency Medicine and Pediatrics, HarborUCLA Medical Center, University of California Los Angeles School of Medicine, Torrance, Torrance, CA.
Kelly D Young, MD James S Seidel, MD, PhD
Received for publication July 24, 1998. Revision received October 23, 1998. Accepted for publication November 5, 1998. Address for reprints: James S Seidel, MD, PhD, Harbor-UCLA Medical Center, Department of General and Emergency Pediatrics, 1000 West Carson Street, Box 21, Torrance, CA 90509; 310-222-3506, fax 310-782-1763; E-mail [email protected] or [email protected]. Copyright © 1999 by the American College of Emergency Physicians.
See editorial, p. 214. Little information is available about the effects of CPR in children, although it is known that the outcomes are dismal. Examples of unanswered questions include which advanced life support (ALS) procedures should be performed outof-hospital, whether high-dose epinephrine improves survival, and the true prevalence of ventricular fibrillation as a presenting rhythm. Children differ from adults as to the cause and pathophysiology of cardiopulmonary arrest, but prehospital EMS and hospital resuscitation teams were initially designed for the care of adults. Because pediatric cardiopulmonary arrest is rare, prospective data are difficult to gather, and there are few large published studies. The purpose of this collective review was to review the current body of knowledge regarding survival rates and outcomes in pediatric CPR and, based on this review, to outline a course for future research. [Young KD, Seidel JS: Pediatric cardiopulmonary resuscitation: A collective review. Ann Emerg Med February 1999;33:195-205.]
0196-0644/99/$8.00 + 0 47/1/95657
METHODS
Articles published between 1970 and February 1997 in US and foreign peer-reviewed journals were identified by MEDLINE searches for the keywords “cardiopulmonary resuscitation (CPR),” “cardiac arrest,” and “heart arrest” (Figure). Additional searches with the related keywords “endotracheal intubation,” “drowning,” “epinephrine,” “ventricular fibrillation,” and “asystole” were performed to identify more articles reporting on pediatric patients who received CPR. Titles and abstracts of articles were reviewed to exclude articles that did not report survival rates for pediatric, human patients in cardiac or respiratory arrest. A manual search of the bibliographies of all citations identified and of several review articles on pediatric CPR was conducted to locate previously unidentified articles.
FEBRUARY 1999
33:2
ANNALS OF EMERGENCY MEDICINE
1 9 5
PEDIATRIC CPR Young & Seidel
All published studies and abstracts were considered for inclusion. Articles reporting on both adults and children were included if sufficient data for pediatric patients could be extracted. Also included were articles reporting on subsets of pediatric CPR patients, such as drowning patients or children receiving particular ALS treatments (eg, highdose epinephrine). If an author reported on the same group of patients in more than 1 article, the article with the most complete information was selected for review. If different authors reported separately on patients from the same population database, the article with the largest number of patients and most complete information was included. If an author included information on some patients in whom CPR was not attempted (ie, who were declared dead without attempted resuscitation or had a do-not-resuscitate order), the article was included but these patients were excluded from data analysis. From each article we abstracted the case definition (specifically, whether the patients were in cardiac arrest,
respiratory arrest, or either), outcome rates, and outcome measures used (return of spontaneous circulation [ROSC], survival to hospital admission, survival to hospital discharge, survival for a specified length of time, and neurologic function of survivors). Because of the wide variability in outcome measures reported, we combined ROSC and survival to hospital admission as the outcome category “ROSC,” survival to hospital discharge or survival for a specified length of time (1 to 12 months) as the outcome category “survival to discharge,” and survival with normal or prearrest neurologic function or with mild disabilities as the neurologic outcome category “good outcome.” When the information was available, cardiac arrest patients with specific characteristics were separated and outcome rates for these subgroups were recorded. Subgroups included patients with out-of-hospital versus inpatient arrest, patients with specific diagnoses, patients whose arrest was witnessed, patients who received bystander
Figure.
Methods for identification of articles.
MEDLINE search for cardiopulmonary resuscitation (CPR), cardiac arrest, heart arrest, drowning, epinephrine, endotracheal intubation, ventricular fibrillation, asystole
Hand search bibliographies of articles identified by other sources
Hand search bibliographies of review articles on pediatric CPR
Review titles and abstracts to include only articles reporting survival data on pediatric, human patients in cardiac or respiratory arrest
46 pediatric articles identified
Exclude 5 reported in greater detail in another article
20 pediatric and adult articles identified
2 pediatric abstracts identified
36
Exclude 5 for same patients reported by other authors
Exclude 14 for data on pediatric patients not extractable
2
6 44 total articles
1 9 6
ANNALS OF EMERGENCY MEDICINE
33:2 FEBRUARY 1999
PEDIATRIC CPR Young & Seidel
CPR, and patients grouped by initial recorded rhythm. Available data on the correlation of epinephrine dosage and CPR duration with survival and on comparative survival rates for adults were also examined. R E S U LT S
Forty-six studies with survival data on pediatric patients who received CPR were identified (Figure). Five studies were excluded because the data were reported in greater detail in another article by the same authors, leaving 41 articles.1-41 Data from 5 articles overlapped with data reported in 2 other articles6,48 and were not included in the main analysis, although some data regarding subgroups of patients (eg, near-drowning patients) were used. These 5 articles were retained in the bibliography for reference.3,4,25,27,34 Two pediatric abstracts were identified.42,43 An additional 20 studies with survival data on both pediatric and adult arrest patients were identified. Thirteen of these were excluded because separate data on the pediatric patients could not be extracted, and 1 was excluded because it reported on only 8 pediatric patients, all aged 10 to 19 years; 6 studies remained.44-49 Therefore, 44 studies reporting on a total of 3,094 patients were analyzed (Table 1). Ten studies were prospective, 2,5,8,13,16,17,26,30,36,47 2 of which used additional retrospective data, 2,26 and the remainder were retrospective. Only 8 studies included more than 100 patients 1,6,7,19,22,23,41,48 ; 5 of these reported solely on patients with full cardiopulmonary arrest. 6,19,22,23,48 Ten studies reported on all the pediatric cardiopulmonary arrests in a city or county’s population 2,11,15,19,21,22,24,37,40,48 ; the remainder were based in a single hospital, most often a children’s hospital. Geographic locations included all parts of the United States, Canada, Japan, Australia, Israel, Netherlands, United Kingdom, Finland, and Germany. Most of the studies were performed in urban areas, 1 was solely rural, 24 and a few were a mixture. The term “arrest” (cardiac or respiratory) was defined in 33 studies (75%). Definitions varied widely, with the most common being “apneic and pulseless.” Studies that did not define arrest often considered all resuscitations or calls for the code team. The term “pediatric” or “child” was defined in 20 studies (45%), and the definition ranged from “less than 14 years old” to “less than 21 years old.” The most common inclusion criterion used was presence of the patient in a children’s hospital. One study using this criterion included a 34-year-old patient with Down’s syndrome and congenital heart disease.39
FEBRUARY 1999
33:2
ANNALS OF EMERGENCY MEDICINE
Fourteen different outcomes were reported, ranging from “initial success” to “alive at 1 year.” The most common outcome reported (29 studies [66%]) was “survival to hospital discharge.” Most studies gave some indication of the neurologic outcome of survivors, but follow-up was often incomplete and specific disabilities were rarely documented. Neurologic outcome variables ranged from “normal” to “without gross deficits,” “severe sequelae,” and “prearrest function.” One study defined a good outcome as “symmetric and purposeful movement, either spontaneously or in response to a noxious stimulus.”16 Only 4 studies used standardized outcome measures: Glasgow Outcome Scale,20 1; Bloom Classification system,40 1; and Pediatric Cerebral Performance Categories (PCPC),41,42 2. When patients with cardiac arrest were specifically described, 56% (790/1,407) were younger than 1 year of age, and 62% (740/1,197) were boys. Out-of-hospital cardiac arrest was witnessed in 31% of reported cases (222/713), and bystander CPR was given in 30% (153/509). Initial ECG rhythm was recorded for 1,420 cardiac arrest patients; 73% were in bradyasystole or had pulseless electrical activity, and 10% were in ventricular fibrillation or pulseless ventricular tachycardia (VF/VT). Calculation of outcome percentages was confounded by lack of reported outcomes for some patients. Tables 2 and 3 give absolute numbers and percentages for the outcomes “survival to hospital discharge or for a specified length of time” and “good neurologic outcome” for various subgroups of patients. Overall, ROSC or admission to hospital was reported for 56% of patients, and survival to discharge or for a specified length of time was reported for 98%. Neurologic outcome was reported in only 41% (280/685) of survivors. The percentage of survivors with good neurologic outcome could not be reliably estimated owing to the low overall number of survivors, lack of documentation of neurologic outcome, and lack of a uniform definition of good neurologic outcome. The hospital discharge rate, when it was reported, was 13% (306/2,349) for patients with cardiac arrest. Neurologic outcome was assessed for 65% (199/306) of these survivors, and 62% (124/199) of those assessed had a good outcome. Of the patients with respiratory arrest (pulse present), 75% (117/157) were discharged, 48% (56/117) had neurologic outcome assessed, and 88% (49/56) of those assessed had a good outcome. Survival to discharge was 8.4% (132/1,568) for patients with out-of-hospital cardiac arrest, compared with 24% (129/544) for inpatients. When the cause of cardiac arrest was reported, 26% (38/145) of near-drowning patients, 4% (9/207) of trauma
1 9 7
PEDIATRIC CPR Young & Seidel
Table 1.
Bibliography of literature reviewed. Reference No. and Type*
Authors (Date)
Location
Event Location
No. of Patients
Definition of Child
Definition of Arrest
Outcome and %‡
1
Ehrlich et al (1974)
Brooklyn, NY
Inpatient
239
Pediatric floor
Major pulses absent, inaudible/slow heart sounds, cyanosis/extreme pallor, and absent/inadequate respiration
ROSC, 78; discharged, 47
2 (Pr)
Friesen et al (1982)
Manitoba, Canada
All areas
66
30 d–16 y
Lack of a central arterial pulse
Discharged, 9
3† (Pr)
Lewis et al (1983)
Milwaukee, WI
All areas
74
Children’s hospital
RA: no spontaneous ventilation; CA: no cardiac output
Survived (CA), 28 (17)
4†
Eisenberg et al (1983)
King County, WA
Out
119
<18 y
No pulse or BP
Discharged, 7
5 (P)
Rosenberg (1984)
Detroit, MI
Out/ED
26
Children’s hospital
No palpable or auscultable pulse
Survival, 15
6
Torphy et al (1984)
Milwaukee, WI
Out/ED
139
<14 y
Apneic and pulseless
Discharged, 5.5
7
Ludwig et al (1984)
Philadelphia, PA
ED/Inpatient
130
Children’s hospital
Code team called (special care units excluded)
Subsequent survival, 55
8 (P)
Wark and Overton (1984)
Sydney, Australia
Inpatient
49
Children’s hospital
Absent pulses, extremely low heart sounds, cyanosis or extreme pallor, and absent/ inadequate ventilation
Responded initially, 66; discharged, 42
9
Horimoto et al (1985)
Shizuoka, Japan
Inpatient
43
Children’s hospital
Emergency call for resuscitation
Discharged, 21
10
Von Seggern et al (1986)
Minneapolis, MN
PICU
81
PICU
Sudden deterioration requiring chest compressions and/or emergency drug administration
Initial success, 64; survived 24 h, 48; Discharged from PICU, 31
11
Applebaum and Slater Jerusalem, Israel (1986)
Out
37
<15 y
Pulseless
Long-term survivor, 0
12
O’Rourke (1986)
Boston, MA
Out
34
Children’s hospital
Apneic and pulseless
Discharged, 21
13 (P)
Nichols et al (1986)
Philadelphia, PA
All areas
47
Children’s hospital
Cyanosis and coma after sudden cessation of breathing and/or pulsation in the large arteries or heart
Successfully resuscitated, 57; long-term survivor, 38
14
Gillis et al (1986)
Toronto, Canada
Inpatient
42
Children’s hospital
CA: apnea and no recordable BP or palpable femoral pulse; RA: cessation of breathing >1 min
6-mo survival (CA), 17 (9)
15
Tsai and Kallsen (1987)
Fresno, CA
Out
23
<19 y
CA patients a subgroup, not specifically defined
Discharged, 0
Abs, abstract; Out, out-of-hospital; PICU, pediatric intensive care unit; RA, respiratory arrest; CA, cardiac arrest; BP, blood pressure; ROSV, return of spontaneous ventilation. *All studies are retrospective except those marked P (prospective), Pr (prospective with additional data gathered retrospectively), or P/R (prospective patients with retrospective [historical] controls). †Article not included in the data analysis. ‡Outcome percentages in parentheses are for the subset of cardiac arrest patients only. (continued)
1 9 8
ANNALS OF EMERGENCY MEDICINE
33:2 FEBRUARY 1999
PEDIATRIC CPR Young & Seidel
Table 1. (continued)
Bibliography of literature reviewed. Reference No. and Type*
Authors (Date)
Location
Event Location
No. of Patients
16 (P)
Davies et al (1987)
Atlanta, GA
Inpatient
67
17 (P)
Zaritsky et al (1987)
Washington, DC
All areas
93
18
Fiser and Wrape (1987)
Little Rock, AR
All areas
35
19
Losek et al (1987)
Milwaukee, WI
Out
20
Barzilay et al (1988)
Tel Aviv, Israel
21
Aijian et al (1989)
22
Definition of Child
Definition of Arrest
Outcome and %‡
Children’s hospital
Need for external or internal cardiac compressions
Discharged, 37
Children’s hospital
CA: absent palpable cardiac activity and pulse; RA: no ventilatory effort, requiring basic and advanced life support
Successful resuscitation, 72 (51); discharged (CA), 34 (9)
Children’s hospital
Apneic and pulseless
Resuscitated temporarily, 61; discharged, 22
114
<18 y
Apneic and pulseless
Discharged, 8
Inpatient
69
PICU
Apneic and pulseless
ROSC, 78; discharged, 14.5
Fresno, CA
Out
42
<19 y
Apneic and pulseless
Admitted, 36; survivor, 5
Losek et al (1989)
Milwaukee, WI
Out
117
<18 y
Apneic and pulseless
Admitted, 14; discharged, 2
23
Stopfkuchen et al (1989)
Germany
All areas
149
None
Received CPR
Discharged, 21
24
Thompson et al (1990)
Midwest USA
Out
95
<18 y
RA: no spontaneous ventilation; CA: no palpable pulse or absent ECG cardiac activity
Alive (CA), 25 (4.3)
25†
Quan et al (1990)
King County, WA
Out
38
<20 y
Apneic, no BP, and pulse <40
Survived, 32
26 (P/R)
Goetting and Paradis (1991)
Detroit, MI
Inpatient
40
None
“Cardiac arrest”
ROSC, 35; discharged, 20
27† (P/R) Quan et al (1992)
King County, WA
Out
19
<20 y
Asystole or pulseless idioventricular rhythm
Survived, 10
28
Bos et al (1992)
Rotterdam, Netherlands PICU
34
Children’s hospital
Apnea and bradycardia, underwent CPR
Survivor, 9
29
Schoenfeld and Baker Philadelphia, PA (1993)
Out
58
Children’s hospital
Apneic and pulseless
Survived, 10
30 (P)
Innes et al (1993)
Liverpool, United Kingdom
All areas
41
Children’s hospital
Crash team called, required resuscitation
Initially successful, 69; alive at 1 mo, 49; alive at 12 mo, 37
31
Sheikh and Brogan (1994)
Sacramento, CA
Out
27
None
Traumatic cardiac arrest
ROSC, 18; discharged, 0
32
Hazinski et al (1994)
Nashville, TN
Out
30
<16 y
Pulseless (absent femoral or carotid pulse) regardless of ECG rhythm
Admitted or to operating room, 23; discharged, 0
(continued)
FEBRUARY 1999
33:2
ANNALS OF EMERGENCY MEDICINE
1 9 9
PEDIATRIC CPR Young & Seidel
Table 1. (continued)
Bibliography of literature reviewed. Reference No. and Type*
Authors (Date)
Location
Event Location
No. of Patients
Definition of Child
Definition of Arrest
Outcome and %‡
33
Kyriacou et al (1994)
Pasadena, CA
Out
33
<14 y
CA patients a subgroup, not specifically defined
Survived, 36
34†
Mogayzel et al (1995)
King County, WA
Out
157
<20 y
Apneic and pulseless
ROSC, 25; discharged, 9.5
35
Ronco et al (1995)
Birmingham, AL
Out
63
<15 y
Apneic and pulseless
Admitted, 29; discharged, 9.5
36 (P)
Bhende and Thompson Pittsburgh, PA (1995)
All areas
40
Children’s hospital
Cardiopulmonary arrest, undergoing CPR
Admitted, 35; discharged, 5
37
Dieckmann and Vardis San Francisco, CA (1995)
Out
65
<18 y
Apneic and pulseless, unresponsive
ROSC/admitted, 5; discharged, 3
38
Hickey et al (1995)
Columbus, OH
Out
95
Children’s hospital
Apneic and pulseless
Discharged, 26
39
Teach et al (1995)
Boston, MA
ED
30
Children’s hospital
CA: no effective ventilation for 20 s and no pulse or BP; RA: no effective ventilation for 20 s necessitating physician intervention
ROSV/ROSC (CA), 73 73 (50); discharged from ED (CA), 70 (44); discharged (CA), 50 (19)
40
Kuisma et al (1995)
Helsinski, Finland
Out
34
<16 y
Apneic and pulseless
Discharged, 14.7
41
Schindler et al (1996)
Toronto, Canada
Out
101
Children’s hospital
Apneic or pulseless or both
Discharged, 15
42 (Abs) Pickert et al (1994)
Little Rock, AR
Inpatient
92
1 mo–18 y
Received CPR, defined as chest compressions, pharmacologic resuscitation, and assisted ventilation
Alive at 1 y, 10
43 (Abs) Walsh et al (1994)
Albany, NY
Out
22
PICU
Chest compressions and controlled Discharged, 0 ventilation
44
DeBard (1981)
Dayton, OH
All areas
41
0–19 y
Need for CPR due to sudden RA and/or CA
45
Clinton et al (1984)
Minneapolis, MN
Out
14
1–20 y
Apneic and pulseless, unresponsive Discharged, 7
46
Hendrick et al (1990)
Nijmegen, Netherlands
Inpatient
18
<18 y
Total absence of signs of functional Initial success, 72; respiration, circulation, or both discharged, 33
47 (P)
Tunstall-Pedoe et al (1992)
United Kingdom
Inpatient
84
0–14 y
Attempted CPR, exclude false alarms and recurrences
Survival through arrest, 27; discharged, 20
48
Safranek et al (1992)
King County, WA
Out
353
<18 y
Lack of pulse and BP
Long-term survival, 8.5
49
Schwenzer et al (1993)
Charlottesville, VA
Inpatient
42
0–18 y
Any of these: absent pulse, asystole, Discharged, 49 ventricular fibrillation, electromechanical dissociation, apnea
CPR success, 55
Abs, abstract; Out, out-of-hospital; PICU, pediatric intensive care unit; RA, respiratory arrest; CA, cardiac arrest; BP, blood pressure; ROSV, return of spontaneous ventilation. *All studies are retrospective except those marked P (prospective), Pr (prospective with additional data gathered retrospectively), or P/R (prospective patients with retrospective [historical] controls). †Article not included in the data analysis. ‡Outcome percentages in parentheses are for the subset of cardiac arrest patients only.
2 0 0
ANNALS OF EMERGENCY MEDICINE
33:2 FEBRUARY 1999
PEDIATRIC CPR Young & Seidel
patients, and .2% (1/433) of patients with sudden infant death syndrome (SIDS) survived to hospital discharge (see Table 2). Neurologic outcome was reported for 37 of the 38 near-drowning survivors, and 41% (15/37) had good outcome (3 normal, 12 mild deficits; see Table 3). Age and survival were reported for 332 cardiac arrest patients; 6% (19/332) of those younger than 1 year of age survived to discharge, compared with the overall rate of 13%. When reported, out-of-hospital cardiac arrest patients whose arrests were witnessed had a 19% hospital discharge rate (28/150) and those who received bystander CPR had a rate of 26% (20/76), compared with the overall rate for out-of-hospital cardiac arrest of 8.4%. Only 5% (39/802) of cardiac arrest patients whose initial recorded rhythm was asystole survived to discharge, compared with 30% (29/97) of patients in VF/VT. Several studies documented epinephrine dosing as related to outcome. In 4 studies with a total of 198 cardiac arrest patients, no patient who received more than 2 doses of standard-dose epinephrine survived,13,17,26,41 and in 3 studies with a total of 158 patients, no patient who received more than 1 dose survived.14,20,38 Improved ROSC and survival to hospital discharge with high-dose epinephrine given for the third epinephrine dose was reported in 1 study,26 whereas others showed no benefit with high-dose epinephrine.35,37 Twelve studies correlated duration of CPR and outcome. Eight reports with a total of 347 patients noted that continuing CPR longer than 20 to 30 minutes in normothermic pat-
ients did not produce additional survivors.5,14,16,30,35,40,41,46 Four other articles noted that the majority of survivors underwent CPR for 15 minutes or less.12,13,17,20 In 2 studies, the cardiac arrest survival rate in children was compared with the rate in adults for the same time period, geographic area, and EMS system. Adults had a higher rate of long-term survival in both studies (12.3% versus 0%11 and 17% versus 8.5%48). One study documented VF/VT as the initial recorded rhythm in 6% of patients younger than 18 years of age, compared with 31% of 18to 35-year-olds and 46% of those older than 35 years.48
Table 2.
Table 3.
Summary of available data on survival to hospital discharge or for a specified period of time.
Patient Subgroup
No. Identifiable Patients in Subgroup
No. Patients for Whom Outcome Data Are Reported
3,094 216 2,385 1,587 631 179 492 244 93 118 151 790 222 153 1,036 142
3,072 157 2,349 1,568 544 161 433 207 65 118 145 332 150 76 802 97
All patients Respiratory arrest Cardiac arrest Out-of-hospital Inpatient ICU SIDS Trauma Sepsis Cardiac diagnosis Drowning Age <1 y Witnessed Lay CPR given Asystole VF/VT
FEBRUARY 1999
33:2
ANNALS OF EMERGENCY MEDICINE
No. (%) Achieving Survival or Discharge 685 (22) 117 (75) 306 (13) 132 (8.4) 129 (24) 33 (20) 1 (.2) 9 (4) 0 (0) 13 (11) 38 (26) 19 (6) 28 (19) 20 (26) 39 (5) 29 (30)
DISCUSSION
There are still large gaps in our knowledge of pediatric CPR. Guidelines for pediatric ALS were not developed by the American Heart Association Emergency Cardiac Care Committee until 1986,50 and they have since been revised once, in 1992.51 This review of the literature demonstrates a poor survival rate for pediatric cardiac arrest patients, a rate that has not improved in the last decade. Because pediatric arrest is an uncommon event, prospective data are difficult to gather, and most research in pediatric CPR consists of small, retrospective series that do not use standardized definitions or outcome measures. Although the data reviewed are flawed by lack of uniformity, some conclusions can be drawn, and it is essential to collate the current body of knowledge so as to guide future research priorities.
Summary of available data on survivors with good neurologic outcome.
Patient Subgroup All patients Respiratory arrest Cardiac arrest Out-of-hospital Inpatient ICU SIDS Trauma Sepsis Cardiac diagnosis Drowning Age <1 y Witnessed Lay CPR given Asystole VF/VT
No. Identifiable Patients in Subgroup
No. Patients for Whom Outcome Data Are Reported
No. (%) With Good Neurologic Outcome
685 117 306 132 129 33 1 9 0 13 38 19 28 20 39 29
280 56 199 68 77 3 1 7 — 2 37 3 10 4 16 21
195 (70) 49 (88) 124 (62) 28 (41) 60 (78) 1 (33) 1 (100) 3 (43) — 2 (100) 15 (41) 1 (33) 2 (20) 2 (50) 6 (37) 10 (47)
2 0 1
PEDIATRIC CPR Young & Seidel
Reported studies show wide variation in case definitions and outcome measures. A quarter of the studies reviewed did not use an explicit definition of “arrest.” Current studies cannot be compared or combined for meta-analysis because of this lack of uniform reporting. In October 1995, international guidelines for uniform reporting and case definitions for pediatric ALS research were published. 52-55 These guidelines were designated “the pediatric Utstein style” in homage to similar guidelines for adult cardiac arrest data that were developed by an international task force that first met at the historic Utstein Abbey in Norway and were published in 1991.56 Studies on CPR could be improved and made comparable if the pediatric Utstein definitions were used to report research results. Researchers should include only patients meeting the case definitions outlined in those guidelines. “Cardiac arrest” is defined there as cessation of cardiac mechanical activity, determined by inability to palpate a central pulse, unresponsiveness, and apnea. “Respiratory arrest” is defined as apnea with cardiac activity detectable as a palpable pulse. In children, arrest is usually the result of progressive deterioration in respiratory or circulatory function, in contrast to the sudden cardiac arrest commonly seen in adults. In the studies reviewed, patients in respiratory arrest who had not yet deteriorated into cardiac arrest had a 75% hospital discharge rate, with 88% achieving good outcome. Research focused on recognition of early signs of impending arrest and interventions to prevent further deterioration would be more likely to improve outcomes than would research on cardiac arrest. The pediatric Utstein definitions include 2 additional groups of patients to be studied: those with respiratory compromise leading to assisted ventilation (not respiratory arrest), and those with bradycardia or poor perfusion for which basic CPR is given (ie, shock). Data would be more meaningful if researchers excluded, or reported separately on, patients for whom resuscitation was not attempted, including patients pronounced dead before arrival at the hospital, patients with do-not-resuscitate orders, and patients declared dead on arrival. Inclusionof such patients can significantly affect rate calculations for survival and therefore can bias research in treatment interventions.57,58 The pediatric Utstein guidelines recommend that, when multiple arrests occur in a single patient, only the index event should be reported. In the future, researchers must use uniform outcome measures. Fourteen different outcomes were reported in the studies we reviewed, making comparisons difficult. The pediatric Utstein guidelines recommend that the following outcomes be reported: ROSC never achieved, any
2 0 2
ROSC, sustained ROSC (longer than 20 minutes), return of spontaneous ventilation for respiratory arrest patients, admission to hospital, death in hospital (total, within 24 hours, and between 1 and 7 days), and discharge alive from hospital. As a minimum, the number of patients discharged alive from the hospital should be reported. Reports of ROSC alone are unacceptable because many patients achieve ROSC but do not survive to hospital discharge. Good neurologic outcome, not merely survival, is the optimal outcome. In this review, neurologic outcome was reported in only 41% of survivors. The small number of patients that could be included in Table 3 demonstrates that little is currently known about the neurologic outcome of survivors. Use of a standard neurologic outcome measure and reporting of neurologic outcome for all survivors would allow for comparisons of treatment modalities. As a minimum, the pediatric Utstein guidelines recommend reporting neurologic status at hospital discharge using the Pediatric Overall Performance Categories (POPC) and the PCPC.59 Because neurologic outcome improves gradually after an arrest event, they also recommend that researchers report neurologic outcome on follow-up at 1 year after the reported event. Standardization of the time of the follow-up examination is important, because outcomes reported for patients in the current literature at the common times of 1, 6, or 12 months cannot be compared. Neurologic deficits may be subtle,60,61 and development and standardization of a neurologic outcome scale with finer gradations of outcome than those provided by the POPC and PCPC may be useful.62 Lack of definition of “child,” as seen in the majority of the studies reviewed, presents further difficulties in comparing pediatric CPR studies. Gathering of retrospective data is often limited by the use of arbitrary age cutoffs for triage by individual EMS systems.63 The pediatric Utstein guidelines recommend stratification of results by the following age groups: 0 to 12 months, 1 to 4 years (preschool), 5 to 12 years (child), and 13 to 21 years (adolescent). Newborns in the first day of life and neonatal ICU patients should be studied separately. Children younger than 1 year of age consistently accounted for about half of pediatric cardiac arrest patients in the studies reviewed. Infants clearly have a higher rate of asystole and a lower survival rate. Pediatric emergency cardiac care protocols based on current CPR research may not be appropriate for the older child, and less so for the adolescent. It has been shown that the epidemiology of CPR in young adults is intermediate between those of children and of older adults.48 Similarly, adolescent arrest patients may respond to treatment protocols developed for adults better
ANNALS OF EMERGENCY MEDICINE
33:2 FEBRUARY 1999
PEDIATRIC CPR Young & Seidel
than to those developed for “children.” Further research elucidating the differences among the pediatric Utstein age stratification groups is needed. There is more to be learned about the frequency and outcome of pediatric VF/VT. The overall frequency of VF/VT as the initial recorded rhythm in patients with cardiac arrest was 10%. Other studies have found rates ranging from 6%48,64 to 19%.34 The study with a 19% rate excluded SIDS patients; if these patients had been included, the VF/VT rate would have been 11.4%. Therefore, 10% is probably close to the true rate when SIDS patients are included. The higher survival rate for adult patients with cardiac arrest is probably a result of differences in presenting rhythm. Up to 80% of out-of-hospital adult cardiac arrest patients demonstrate VF/VT,65 and early-defibrillation EMS protocols have improved survival.66 Current recommendations in pediatric patients do not emphasize early defibrillation because VF/VT is much less common in these patients. However, the smaller percentage of patients in VF/VT must be balanced with their improved survival67; our review showed that 30% of VF/VT patients survived to hospital discharge, compared with 5% of asystolic patients. An increased tendency to develop VF/VT after the newborn period, and in older versus younger children, has been shown.64,68 Perhaps a subgroup (eg, patients >1 year of age) can be identified who would benefit from EMS protocols emphasizing early defibrillation. Survival rate, rate of VF/VT, and rate of witnessed arrest may all be related. Children may have more unwitnessed arrests and longer times in arrest before discovery, degenerating from tachycardia to bradyasystole by the time they are discovered. Our review showed improved survival for children with witnessed arrest and for children receiving bystander CPR. Children and adults with witnessed arrests have similar survival rates (15%).4 Whether the 2 groups also have the same rate of VF/VT as presenting rhythm is unknown. In a study documenting the terminal rhythms of 100 pediatric patients, 22 had VF/VT, and 16 of these 22 patients had bradycardic/asystolic arrest as the final electrical event.68 Therefore, although children appear to have VF/VT as a terminal rhythm much less often than bradyasystole, VF/VT may precede bradyasystole in some and may represent a “window of opportunity” for bystander CPR and defibrillation. Research is needed to determine whether increased parent and caretaker knowledge of CPR and shortened time to defibrillation (eg, with the use of automated external defibrillators) leads to improved outcomes. Analysis of the CPR literature appears to demonstrate that there are large differences in survival based on cause of
FEBRUARY 1999
33:2
ANNALS OF EMERGENCY MEDICINE
arrest. However, because of the small numbers of patients for whom both cause and survival are reported, current data are inadequate to draw firm conclusions. The data show that patients with SIDS, trauma, or sepsis have poor survival rates, and those with submersion injury have better survival but often sustain residual deficits. Data showing differences in survival by age are confounded by cause; for example, infant cardiac arrests are predominantly patients with SIDS. Further research separating the effects of age and cause is needed. One question is whether specific diagnoses (eg, congenital heart disease) or certain age groups are more likely to be associated with VF/VT. Ethical issues in pediatric CPR, such as discontinuation of resuscitative efforts and organ donation, are important topics.69 Guidelines for termination of CPR and for not beginning CPR are needed. The current data strongly suggest that need for multiple epinephrine doses or for CPR longer than 30 minutes in a normothermic patient are indicators of poor outcome. Further data are needed to identify and validate such indicators. Most of the literature reviewed was not population based. Results from studies involving a single hospital cannot be generalized to the entire population and therefore are not useful in developing treatment protocols. Population-based data are more difficult to gather than data from a single hospital but must be the priority in CPR research. Almost all of the literature reviewed consists of case series in urban areas. Protocols developed and based on current research may not be applicable in rural areas, where arrest causes and resources for treatment differ greatly. 70,71 There is currently minimal research in pediatric CPR in rural areas. In summary, we can draw several conclusions from this review of the current pediatric CPR literature. Overall survival after cardiac arrest is poor at 13%, with patients arresting out-of-hospital faring worse than inpatients (8.4% versus 24% survival). Children younger than 1 year of age make up about half of cardiac arrest patients; as a group, they demonstrate a higher rate of asystole and a poorer survival rate (6%). The rate of VF/VT in pediatric cardiac arrest patients is about 10%; these patients have a much higher survival rate than do bradyasystolic patients (30% versus 5%). Approximately one third of pediatric arrests are witnessed, and one third of patients receive bystander CPR; these patients have improved outcomes compared with those whose arrest is unwitnessed and who do not receive bystander CPR. Patients in pure respiratory arrest have a much better survival rate than those with cardiac arrest. Our efforts may be better spent in preventing these patients from degenerating into cardiac arrest. Finally, CPR duration longer than 30 minutes and admin-
2 0 3
PEDIATRIC CPR Young & Seidel
istration of more than 2 doses of epinephrine are indicators of poor outcome. There remain gaps in our knowledge of pediatric CPR that are not well addressed by the current literature. 72 EMS systems and emergency departments have been shown to be inadequately prepared for the pediatric patient.73-75 What changes can be made in EMS systems to benefit such patients? What procedures should be attempted by out-of-hospital rescuers, and will such attempts result in improved outcomes? Does the presence of arrest teams designed to respond to ED and inpatient pediatric cardiac arrests improve survival? Who should be included in these teams? What training and equipment specific to pediatric arrests should be required? Finally, emphasis must be placed on improved neurologic outcome in addition to survival. How can we increase cerebral blood flow during CPR (brain resuscitation)? Do treatment interventions such as high-dose epinephrine improve neurologic outcome as well as ROSC and survival? We have much still to learn about pediatric CPR. Poor outcomes may be improved by research and subsequent improvements in emergency care and resuscitation techniques specific for children. Research in prevention of progression from prearrest states to arrest may be more beneficial than research in CPR itself. Current data consist mostly of small, retrospective case series based in a single hospital. Meta-analysis of these small series cannot be performed owing to lack of uniformity in case definitions and outcomes reported. Large, multicenter, prospective studies are needed to test interventions and improve outcomes. Future research should be population-based; should use the case definitions, age groups, and outcomes specified in the pediatric Utstein guidelines; and should report on neurologic outcome as well as survival.
9. Horimoto Y, Yoshizawa M, Atsushi O, et al: Five years experience of cardiopulmonary resuscitation in a children’s hospital. Resuscitation 1985;13:47-55. 10. Von Seggern K, Egar M, Fuhrman BP: Cardiopulmonary resuscitation in a pediatric ICU. Crit Care Med 1986;14:275-277. 11. Applebaum D, Slater PE: Should the mobile intensive care unit respond to pediatric emergencies? Clin Pediatr 1986;25:620-623. 12. O’Rourke PP: Outcome of children who are apneic and pulseless in the emergency room. Crit Care Med 1986;14:466-468. 13. Nichols DG, Kettrick RG, Swedlow DB, et al: Factors influencing outcome of cardiopulmonary resuscitation in children. Pediatr Emerg Care 1986;2:1-5. 14. Gillis J, Dickson D, Rieder M, et al: Results of inpatient pediatric resuscitation. Crit Care Med 1986;14:469-471. 15. Tsai A, Kallsen G: Epidemiology of pediatric prehospital care. Ann Emerg Med 1987;16:284292. 16. Davies CR, Carrigan T, Wright JA, et al: Neurologic outcome following pediatric resuscitation. J Neurosci Nurs 1987;19:205-210. 17. Zaritsky A, Nadkarni V, Getson P, et al: CPR in children. Ann Emerg Med 1987;16:11071111. 18. Fiser DH, Wrape V: Outcome of cardiopulmonary resuscitation in children. Pediatr Emerg Care 1987;3:235-238. 19. Losek JD, Hennes H, Glaeser P, et al: Out-of-hospital care of the pulseless nonbreathing pediatric patient. Am J Emerg Med 1987;5:370-374. 20. Barzilay Z, Somekh E, Sagy M, et al: Pediatric cardiopulmonary resuscitation outcome. J Med 1988;19:229-241. 21. Aijian P, Tsai A, Knopp R, et al: Endotracheal intubation of pediatric patients by paramedics. Ann Emerg Med 1989;18:489-494. 22. Losek JD, Hennes H, Glaeser PW, et al: Prehospital countershock treatment of pediatric asystole. Am J Emerg Med 1980;7:571-575. 23. Stopfkuchen H, Stein G, Queisser-Luft A, et al: Ergebnisse der kardiopulmonalen reanimation im kindesalter. Klin Padiatr 1989;201:373-376. 24. Thompson JE, Bonner B, Lower GM: Pediatric cardiopulmonary arrests in rural populations. Pediatrics 1990;86:302-306. 25. Quan L, Wentz KR, Gore EJ, et al: Outcome and predictors of outcome in pediatric submersion victims receiving out-of-hospital care in King county, Washington. Pediatrics 1990;86:586593. 26. Goetting MG, Paradis NA: High-dose epinephrine improves outcome from pediatric cardiac arrest. Ann Emerg Med 1991;20:22-26. 27. Quan L, Graves JR, Kinder DR, et al: Transcutaneous cardiac pacing in the treatment of outof-hospital pediatric cardiac arrests. Ann Emerg Med 1992;21:905-909.
REFERENCES
28. Bos AP, Polman A, van der Voort E, et al: Cardiopulmonary resuscitation in paediatric intensive care patients. Intensive Care Med 1992;18:109-111.
1. Ehrlich R, Emmett SM, Rodriquez-Torres RO: Pediatric cardiac resuscitation team: A 6 year study. J Pediatr 1974;84:152-155.
29. Schoenfeld PS, Baker MD: Management of cardiopulmonary and trauma resuscitation in the pediatric emergency department. Pediatrics 1993;91:726-729.
2. Friesen RM, Duncan P, Tweed WA, et al: Appraisal of pediatric cardiopulmonary resuscitation. Can Med Assoc J 1982;126:1055-1058.
30. Innes PA, Summers CA, Boyd IM, et al: Audit of paediatric cardiopulmonary resuscitation. Arch Dis Child 1993;68:487-491.
3. Lewis JK, Minter MG, Eshelman SJ, et al: Outcome of pediatric resuscitation. Ann Emerg Med 1983;12:297-299.
31. Sheikh A, Brogan T: Outcome and cost of open- and closed-chest cardiopulmonary resuscitation in pediatric cardiac arrests. Pediatrics 1994;93:392-398.
4. Eisenberg M, Bergner L, Hallstrom A: Epidemiology of cardiac arrest and resuscitation in children. Ann Emerg Med 1983;12:672-674.
32. Hazinski MF, Chahine AA, Holcomb GW, et al: Outcome of cardiovascular collapse in pediatric blunt trauma. Ann Emerg Med 1994;23:1229-1235.
5. Rosenberg NM: Pediatric cardiopulmonary arrest in the emergency department. Am J Emerg Med 1984;2:497-499.
33. Kyriacou DN, Arcinue EL, Peek C, et al: Effect of immediate resuscitation on children with submersion injury. Pediatrics 1994;94:137-142.
6. Torphy DE, Minter MG, Thompson BM: Cardiorespiratory arrest and resuscitation of children. Am J Dis Child 1984;138:1099-1102.
34. Mogayzel C, Quan L, Graves JR, et al: Out-of-hospital ventricular fibrillation in children and adolescents: causes and outcomes. Ann Emerg Med 1995;25:484-491.
7. Ludwig S, Kettrick RG, Parker M: Pediatric cardiopulmonary resuscitation. Clin Pediatr 1984;23:71-75.
35. 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 1995;149:210-214.
8. Wark H, Overton JH: A paediatric “cardiac arrest” survey. Br J Anaesth 1984;56:1271-1274.
2 0 4
ANNALS OF EMERGENCY MEDICINE
33:2 FEBRUARY 1999
PEDIATRIC CPR Young & Seidel
36. Bhende MS, Thompson AE: Evaluation of an end-tidal CO2 detector during pediatric cardiopulmonary resuscitation. Pediatrics 1995;95:395-399. 37. Dieckmann RA, Vardis R: High-dose epinephrine in pediatric out-of-hospital cardiopulmonary arrest. Pediatrics 1995;95:901-913. 38. Hickey RW, Cohen DM, Strausbaugh S, et al: Pediatric patients requiring CPR in the prehospital setting. Ann Emerg Med 1995;25:495-501. 39. Teach SJ, Moore PE, Fleisher GR: Death and resuscitation in the pediatric emergency department. Ann Emerg Med 1995;25:799-803. 40. Kuisma M, Suominen P, Korpela R: Paediatric out-of-hospital cardiac arrests: Epidemiology and outcome. Resuscitation 1995;30:141-150. 41. Schindler MB, Bohn D, Cox PN, et al: Outcome of out-of-hospital cardiac or respiratory arrest in children. N Engl J Med 1996;335:1473-1479. 42. Pickert CB, Torres A, Firestone J, et al: Outcome of in-hospital pediatric cardiopulmonary arrest [abstract]. Crit Care Med 1994;22:A161. 43. Walsh RF, Sanchez JL, Edge WE, et al: Outcome of pre-hospital CPR in the pediatric trauma patient [abstract]. Crit Care Med 1994;22:A162. 44. DeBard ML: Cardiopulmonary resuscitation: Analysis of six years’ experience and review of the literature. Ann Emerg Med 1981;10:408-416. 45. Clinton JE, McGill J, Irwin G, et al: Cardiac arrest under age 40: Etiology and prognosis. Ann Emerg Med 1984;13:1011-1015. 46. Hendrick JM, Pijls NH, van der Werf T, et al: Cardiopulmonary resuscitation on the general ward: No category of patients should be excluded in advance. Resuscitation 1990;20:163-171.
62. Okada PJ, Raroque SS, Young KD, et al: Validation of a practical research instrument for the measurement of neurologic outcome in infants and children [abstract]. Acad Emerg Med 1997;4:370-371. 63. Seidel JS: Emergency medical services and the adolescent patient. J Adolesc Health 1991;12:95-100. 64. Appleton GO, Cummins RO, Larson MP, et al: CPR and the single rescuer: At what age should you “call first” rather than “call fast”? Ann Emerg Med 1995;25:492-494. 65. Montgomery WH, Brown DD, Hazinski MF, et al: Citizen response to cardiopulmonary emergencies. Ann Emerg Med 1993;22:428-434. 66. Eisenberg MS, Copass MK, Hallstrom AP, et al: Treatment of out-of-hospital cardiac arrests with rapid defibrillation by emergency medical technicians. N Engl J Med 1980;302:1379-1383. 67. Hazinski MF: Is pediatric resuscitation unique? Relative merits of early CPR and ventilation versus early defibrillation for young victims of cardiac arrest. Ann Emerg Med 1995;25:540-543. 68. Walsh CK, Krongrad E: Terminal cardiac electrical activity in pediatric patients. Am J Cardiol 1983;51:557-561. 69. Landwirth J: Ethical issues in pediatric and neonatal resuscitation. Ann Emerg Med 1993;22:502-507. 70. Gausche M, Seidel JS, Henderson DP, et al: Pediatric deaths and emergency medical services (EMS) in urban and rural areas. Pediatr Emerg Care 1989;5:158-162. 71. Seidel JS: EMS-C in urban and rural areas: The California experience, in Haller JA Jr (ed): Emergency medical services for children: Report of the 97th Ross Conference on Pediatric Research. Columbus, Ohio: Ross Laboratories, 1989:22-33. 72. Chameides L: CPR challenges in pediatrics. Ann Emerg Med 1993;22:388-392.
47. Tunstall-Pedoe H, Bailey L, Charmberlain DA, et al: Survey of 3765 cardiopulmonary resuscitations in British hospitals (the BRESUS study): Methods and overall results. BMJ 1992;304:1347-1351.
73. Seidel JS, Hornbein M, Yoshiyama K, et al: Emergency medical services and the pediatric patient: Are the needs being met? Pediatrics 1984;73:769-772.
48. Safranek DJ, Eisenberg MS, Larsen MP: The epidemiology of cardiac arrest in young adults. Ann Emerg Med 1992;21:1102-1106.
74. Seidel JS: Emergency medical services and the pediatric patient: Are the needs being met? II: Training and equipping emergency medical services providers for pediatric emergencies. Pediatrics 1986;78:808-812.
49. Schwenzer KJ, Smith WT, Durbin CG: Selective application of cardiopulmonary resuscitation improves survival rates. Anesth Analg 1993;76:478-484.
75. Zaritsky A, French JP, Schafermeyer R, et al: A statewide evaluation of pediatric prehospital and hospital emergency services. Arch Pediatr Adolesc Med 1994;148:76-81.
50. Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). JAMA 1986;255:2961-2968. 51. Emergency Cardiac Care Committee and Subcommittees, American Heart Association: Guidelines for cardiopulmonary resuscitation and emergency cardiac care: VI. JAMA 1992;268:2262-2275. 52. Zaritsky A, Nadkarni V, Hazinski MF, et al: Recommended guidelines for uniform reporting of pediatric advanced life support: The pediatric Utstein style. Ann Emerg Med 1995;26:487503. 53. Zaritsky A, Nadkarni V, Hazinski MF, et al: Recommended guidelines for uniform reporting of pediatric advanced life support: The pediatric Utstein style. Circulation 1995;92:2006-2020. 54. Zaritsky A, Nadkarni V, Hazinski MF, et al: Recommended guidelines for uniform reporting of pediatric advanced life support: The pediatric Utstein style. Pediatrics 1995;96:765-779. 55. Zaritsky A, Nadkarni V, Hazinski MF, et al: Recommended guidelines for uniform reporting of pediatric advanced life support: The pediatric Utstein style. Resuscitation 1995;30:95-115. 56. Cummins RO, Chamberlain DA, Abramson NS, et al: Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: The Utstein style. Task force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council. Ann Emerg Med 1991;20:861874. 57. Eisenberg MS, Cummins RO, Larsen MP: Numerators, denominators, and survival rates: Reporting survival from out-of-hospital cardiac arrest. Am J Emerg Med 1991;9:544-546. 58. Valenzuela TD, Spaite DW, Meislin HW, et al. Case and survival definitions in out-of-hospital cardiac arrest: Effect on survival rate calculation. JAMA 1992;267:272-274. 59. Fiser DH: Assessing the outcome of pediatric intensive care. J Pediatr 1992;121:68-74. 60. Morris RD, Krawiecki NS, Wright JA, et al: Neuropsychological, academic and adaptive functioning in children who survive in-hospital cardiac arrest and resuscitation. J Learn Disabil 1993;26:46-51. 61. Longstreth WT, Dikmen SS: Outcomes after cardiac arrest. Ann Emerg Med 1993;22:64-69.
FEBRUARY 1999
33:2
ANNALS OF EMERGENCY MEDICINE
2 0 5
Pediatric Cardiopulmonary Resuscitation: A Collective Review From the Departments of Emergency Medicine and Pediatrics, HarborUCLA Medical Center, University of California Los Angeles School of Medicine, Torrance, Torrance, CA.
Kelly D Young, MD James S Seidel, MD, PhD
Received for publication July 24, 1998. Revision received October 23, 1998. Accepted for publication November 5, 1998. Address for reprints: James S Seidel, MD, PhD, Harbor-UCLA Medical Center, Department of General and Emergency Pediatrics, 1000 West Carson Street, Box 21, Torrance, CA 90509; 310-222-3506, fax 310-782-1763; E-mail [email protected] or [email protected]. Copyright © 1999 by the American College of Emergency Physicians.
See editorial, p. 214. Little information is available about the effects of CPR in children, although it is known that the outcomes are dismal. Examples of unanswered questions include which advanced life support (ALS) procedures should be performed outof-hospital, whether high-dose epinephrine improves survival, and the true prevalence of ventricular fibrillation as a presenting rhythm. Children differ from adults as to the cause and pathophysiology of cardiopulmonary arrest, but prehospital EMS and hospital resuscitation teams were initially designed for the care of adults. Because pediatric cardiopulmonary arrest is rare, prospective data are difficult to gather, and there are few large published studies. The purpose of this collective review was to review the current body of knowledge regarding survival rates and outcomes in pediatric CPR and, based on this review, to outline a course for future research. [Young KD, Seidel JS: Pediatric cardiopulmonary resuscitation: A collective review. Ann Emerg Med February 1999;33:195-205.]
0196-0644/99/$8.00 + 0 47/1/95657
METHODS
Articles published between 1970 and February 1997 in US and foreign peer-reviewed journals were identified by MEDLINE searches for the keywords “cardiopulmonary resuscitation (CPR),” “cardiac arrest,” and “heart arrest” (Figure). Additional searches with the related keywords “endotracheal intubation,” “drowning,” “epinephrine,” “ventricular fibrillation,” and “asystole” were performed to identify more articles reporting on pediatric patients who received CPR. Titles and abstracts of articles were reviewed to exclude articles that did not report survival rates for pediatric, human patients in cardiac or respiratory arrest. A manual search of the bibliographies of all citations identified and of several review articles on pediatric CPR was conducted to locate previously unidentified articles.
FEBRUARY 1999
33:2
ANNALS OF EMERGENCY MEDICINE
1 9 5
PEDIATRIC CPR Young & Seidel
All published studies and abstracts were considered for inclusion. Articles reporting on both adults and children were included if sufficient data for pediatric patients could be extracted. Also included were articles reporting on subsets of pediatric CPR patients, such as drowning patients or children receiving particular ALS treatments (eg, highdose epinephrine). If an author reported on the same group of patients in more than 1 article, the article with the most complete information was selected for review. If different authors reported separately on patients from the same population database, the article with the largest number of patients and most complete information was included. If an author included information on some patients in whom CPR was not attempted (ie, who were declared dead without attempted resuscitation or had a do-not-resuscitate order), the article was included but these patients were excluded from data analysis. From each article we abstracted the case definition (specifically, whether the patients were in cardiac arrest,
respiratory arrest, or either), outcome rates, and outcome measures used (return of spontaneous circulation [ROSC], survival to hospital admission, survival to hospital discharge, survival for a specified length of time, and neurologic function of survivors). Because of the wide variability in outcome measures reported, we combined ROSC and survival to hospital admission as the outcome category “ROSC,” survival to hospital discharge or survival for a specified length of time (1 to 12 months) as the outcome category “survival to discharge,” and survival with normal or prearrest neurologic function or with mild disabilities as the neurologic outcome category “good outcome.” When the information was available, cardiac arrest patients with specific characteristics were separated and outcome rates for these subgroups were recorded. Subgroups included patients with out-of-hospital versus inpatient arrest, patients with specific diagnoses, patients whose arrest was witnessed, patients who received bystander
Figure.
Methods for identification of articles.
MEDLINE search for cardiopulmonary resuscitation (CPR), cardiac arrest, heart arrest, drowning, epinephrine, endotracheal intubation, ventricular fibrillation, asystole
Hand search bibliographies of articles identified by other sources
Hand search bibliographies of review articles on pediatric CPR
Review titles and abstracts to include only articles reporting survival data on pediatric, human patients in cardiac or respiratory arrest
46 pediatric articles identified
Exclude 5 reported in greater detail in another article
20 pediatric and adult articles identified
2 pediatric abstracts identified
36
Exclude 5 for same patients reported by other authors
Exclude 14 for data on pediatric patients not extractable
2
6 44 total articles
1 9 6
ANNALS OF EMERGENCY MEDICINE
33:2 FEBRUARY 1999
PEDIATRIC CPR Young & Seidel
CPR, and patients grouped by initial recorded rhythm. Available data on the correlation of epinephrine dosage and CPR duration with survival and on comparative survival rates for adults were also examined. R E S U LT S
Forty-six studies with survival data on pediatric patients who received CPR were identified (Figure). Five studies were excluded because the data were reported in greater detail in another article by the same authors, leaving 41 articles.1-41 Data from 5 articles overlapped with data reported in 2 other articles6,48 and were not included in the main analysis, although some data regarding subgroups of patients (eg, near-drowning patients) were used. These 5 articles were retained in the bibliography for reference.3,4,25,27,34 Two pediatric abstracts were identified.42,43 An additional 20 studies with survival data on both pediatric and adult arrest patients were identified. Thirteen of these were excluded because separate data on the pediatric patients could not be extracted, and 1 was excluded because it reported on only 8 pediatric patients, all aged 10 to 19 years; 6 studies remained.44-49 Therefore, 44 studies reporting on a total of 3,094 patients were analyzed (Table 1). Ten studies were prospective, 2,5,8,13,16,17,26,30,36,47 2 of which used additional retrospective data, 2,26 and the remainder were retrospective. Only 8 studies included more than 100 patients 1,6,7,19,22,23,41,48 ; 5 of these reported solely on patients with full cardiopulmonary arrest. 6,19,22,23,48 Ten studies reported on all the pediatric cardiopulmonary arrests in a city or county’s population 2,11,15,19,21,22,24,37,40,48 ; the remainder were based in a single hospital, most often a children’s hospital. Geographic locations included all parts of the United States, Canada, Japan, Australia, Israel, Netherlands, United Kingdom, Finland, and Germany. Most of the studies were performed in urban areas, 1 was solely rural, 24 and a few were a mixture. The term “arrest” (cardiac or respiratory) was defined in 33 studies (75%). Definitions varied widely, with the most common being “apneic and pulseless.” Studies that did not define arrest often considered all resuscitations or calls for the code team. The term “pediatric” or “child” was defined in 20 studies (45%), and the definition ranged from “less than 14 years old” to “less than 21 years old.” The most common inclusion criterion used was presence of the patient in a children’s hospital. One study using this criterion included a 34-year-old patient with Down’s syndrome and congenital heart disease.39
FEBRUARY 1999
33:2
ANNALS OF EMERGENCY MEDICINE
Fourteen different outcomes were reported, ranging from “initial success” to “alive at 1 year.” The most common outcome reported (29 studies [66%]) was “survival to hospital discharge.” Most studies gave some indication of the neurologic outcome of survivors, but follow-up was often incomplete and specific disabilities were rarely documented. Neurologic outcome variables ranged from “normal” to “without gross deficits,” “severe sequelae,” and “prearrest function.” One study defined a good outcome as “symmetric and purposeful movement, either spontaneously or in response to a noxious stimulus.”16 Only 4 studies used standardized outcome measures: Glasgow Outcome Scale,20 1; Bloom Classification system,40 1; and Pediatric Cerebral Performance Categories (PCPC),41,42 2. When patients with cardiac arrest were specifically described, 56% (790/1,407) were younger than 1 year of age, and 62% (740/1,197) were boys. Out-of-hospital cardiac arrest was witnessed in 31% of reported cases (222/713), and bystander CPR was given in 30% (153/509). Initial ECG rhythm was recorded for 1,420 cardiac arrest patients; 73% were in bradyasystole or had pulseless electrical activity, and 10% were in ventricular fibrillation or pulseless ventricular tachycardia (VF/VT). Calculation of outcome percentages was confounded by lack of reported outcomes for some patients. Tables 2 and 3 give absolute numbers and percentages for the outcomes “survival to hospital discharge or for a specified length of time” and “good neurologic outcome” for various subgroups of patients. Overall, ROSC or admission to hospital was reported for 56% of patients, and survival to discharge or for a specified length of time was reported for 98%. Neurologic outcome was reported in only 41% (280/685) of survivors. The percentage of survivors with good neurologic outcome could not be reliably estimated owing to the low overall number of survivors, lack of documentation of neurologic outcome, and lack of a uniform definition of good neurologic outcome. The hospital discharge rate, when it was reported, was 13% (306/2,349) for patients with cardiac arrest. Neurologic outcome was assessed for 65% (199/306) of these survivors, and 62% (124/199) of those assessed had a good outcome. Of the patients with respiratory arrest (pulse present), 75% (117/157) were discharged, 48% (56/117) had neurologic outcome assessed, and 88% (49/56) of those assessed had a good outcome. Survival to discharge was 8.4% (132/1,568) for patients with out-of-hospital cardiac arrest, compared with 24% (129/544) for inpatients. When the cause of cardiac arrest was reported, 26% (38/145) of near-drowning patients, 4% (9/207) of trauma
1 9 7
PEDIATRIC CPR Young & Seidel
Table 1.
Bibliography of literature reviewed. Reference No. and Type*
Authors (Date)
Location
Event Location
No. of Patients
Definition of Child
Definition of Arrest
Outcome and %‡
1
Ehrlich et al (1974)
Brooklyn, NY
Inpatient
239
Pediatric floor
Major pulses absent, inaudible/slow heart sounds, cyanosis/extreme pallor, and absent/inadequate respiration
ROSC, 78; discharged, 47
2 (Pr)
Friesen et al (1982)
Manitoba, Canada
All areas
66
30 d–16 y
Lack of a central arterial pulse
Discharged, 9
3† (Pr)
Lewis et al (1983)
Milwaukee, WI
All areas
74
Children’s hospital
RA: no spontaneous ventilation; CA: no cardiac output
Survived (CA), 28 (17)
4†
Eisenberg et al (1983)
King County, WA
Out
119
<18 y
No pulse or BP
Discharged, 7
5 (P)
Rosenberg (1984)
Detroit, MI
Out/ED
26
Children’s hospital
No palpable or auscultable pulse
Survival, 15
6
Torphy et al (1984)
Milwaukee, WI
Out/ED
139
<14 y
Apneic and pulseless
Discharged, 5.5
7
Ludwig et al (1984)
Philadelphia, PA
ED/Inpatient
130
Children’s hospital
Code team called (special care units excluded)
Subsequent survival, 55
8 (P)
Wark and Overton (1984)
Sydney, Australia
Inpatient
49
Children’s hospital
Absent pulses, extremely low heart sounds, cyanosis or extreme pallor, and absent/ inadequate ventilation
Responded initially, 66; discharged, 42
9
Horimoto et al (1985)
Shizuoka, Japan
Inpatient
43
Children’s hospital
Emergency call for resuscitation
Discharged, 21
10
Von Seggern et al (1986)
Minneapolis, MN
PICU
81
PICU
Sudden deterioration requiring chest compressions and/or emergency drug administration
Initial success, 64; survived 24 h, 48; Discharged from PICU, 31
11
Applebaum and Slater Jerusalem, Israel (1986)
Out
37
<15 y
Pulseless
Long-term survivor, 0
12
O’Rourke (1986)
Boston, MA
Out
34
Children’s hospital
Apneic and pulseless
Discharged, 21
13 (P)
Nichols et al (1986)
Philadelphia, PA
All areas
47
Children’s hospital
Cyanosis and coma after sudden cessation of breathing and/or pulsation in the large arteries or heart
Successfully resuscitated, 57; long-term survivor, 38
14
Gillis et al (1986)
Toronto, Canada
Inpatient
42
Children’s hospital
CA: apnea and no recordable BP or palpable femoral pulse; RA: cessation of breathing >1 min
6-mo survival (CA), 17 (9)
15
Tsai and Kallsen (1987)
Fresno, CA
Out
23
<19 y
CA patients a subgroup, not specifically defined
Discharged, 0
Abs, abstract; Out, out-of-hospital; PICU, pediatric intensive care unit; RA, respiratory arrest; CA, cardiac arrest; BP, blood pressure; ROSV, return of spontaneous ventilation. *All studies are retrospective except those marked P (prospective), Pr (prospective with additional data gathered retrospectively), or P/R (prospective patients with retrospective [historical] controls). †Article not included in the data analysis. ‡Outcome percentages in parentheses are for the subset of cardiac arrest patients only. (continued)
1 9 8
ANNALS OF EMERGENCY MEDICINE
33:2 FEBRUARY 1999
PEDIATRIC CPR Young & Seidel
Table 1. (continued)
Bibliography of literature reviewed. Reference No. and Type*
Authors (Date)
Location
Event Location
No. of Patients
16 (P)
Davies et al (1987)
Atlanta, GA
Inpatient
67
17 (P)
Zaritsky et al (1987)
Washington, DC
All areas
93
18
Fiser and Wrape (1987)
Little Rock, AR
All areas
35
19
Losek et al (1987)
Milwaukee, WI
Out
20
Barzilay et al (1988)
Tel Aviv, Israel
21
Aijian et al (1989)
22
Definition of Child
Definition of Arrest
Outcome and %‡
Children’s hospital
Need for external or internal cardiac compressions
Discharged, 37
Children’s hospital
CA: absent palpable cardiac activity and pulse; RA: no ventilatory effort, requiring basic and advanced life support
Successful resuscitation, 72 (51); discharged (CA), 34 (9)
Children’s hospital
Apneic and pulseless
Resuscitated temporarily, 61; discharged, 22
114
<18 y
Apneic and pulseless
Discharged, 8
Inpatient
69
PICU
Apneic and pulseless
ROSC, 78; discharged, 14.5
Fresno, CA
Out
42
<19 y
Apneic and pulseless
Admitted, 36; survivor, 5
Losek et al (1989)
Milwaukee, WI
Out
117
<18 y
Apneic and pulseless
Admitted, 14; discharged, 2
23
Stopfkuchen et al (1989)
Germany
All areas
149
None
Received CPR
Discharged, 21
24
Thompson et al (1990)
Midwest USA
Out
95
<18 y
RA: no spontaneous ventilation; CA: no palpable pulse or absent ECG cardiac activity
Alive (CA), 25 (4.3)
25†
Quan et al (1990)
King County, WA
Out
38
<20 y
Apneic, no BP, and pulse <40
Survived, 32
26 (P/R)
Goetting and Paradis (1991)
Detroit, MI
Inpatient
40
None
“Cardiac arrest”
ROSC, 35; discharged, 20
27† (P/R) Quan et al (1992)
King County, WA
Out
19
<20 y
Asystole or pulseless idioventricular rhythm
Survived, 10
28
Bos et al (1992)
Rotterdam, Netherlands PICU
34
Children’s hospital
Apnea and bradycardia, underwent CPR
Survivor, 9
29
Schoenfeld and Baker Philadelphia, PA (1993)
Out
58
Children’s hospital
Apneic and pulseless
Survived, 10
30 (P)
Innes et al (1993)
Liverpool, United Kingdom
All areas
41
Children’s hospital
Crash team called, required resuscitation
Initially successful, 69; alive at 1 mo, 49; alive at 12 mo, 37
31
Sheikh and Brogan (1994)
Sacramento, CA
Out
27
None
Traumatic cardiac arrest
ROSC, 18; discharged, 0
32
Hazinski et al (1994)
Nashville, TN
Out
30
<16 y
Pulseless (absent femoral or carotid pulse) regardless of ECG rhythm
Admitted or to operating room, 23; discharged, 0
(continued)
FEBRUARY 1999
33:2
ANNALS OF EMERGENCY MEDICINE
1 9 9
PEDIATRIC CPR Young & Seidel
Table 1. (continued)
Bibliography of literature reviewed. Reference No. and Type*
Authors (Date)
Location
Event Location
No. of Patients
Definition of Child
Definition of Arrest
Outcome and %‡
33
Kyriacou et al (1994)
Pasadena, CA
Out
33
<14 y
CA patients a subgroup, not specifically defined
Survived, 36
34†
Mogayzel et al (1995)
King County, WA
Out
157
<20 y
Apneic and pulseless
ROSC, 25; discharged, 9.5
35
Ronco et al (1995)
Birmingham, AL
Out
63
<15 y
Apneic and pulseless
Admitted, 29; discharged, 9.5
36 (P)
Bhende and Thompson Pittsburgh, PA (1995)
All areas
40
Children’s hospital
Cardiopulmonary arrest, undergoing CPR
Admitted, 35; discharged, 5
37
Dieckmann and Vardis San Francisco, CA (1995)
Out
65
<18 y
Apneic and pulseless, unresponsive
ROSC/admitted, 5; discharged, 3
38
Hickey et al (1995)
Columbus, OH
Out
95
Children’s hospital
Apneic and pulseless
Discharged, 26
39
Teach et al (1995)
Boston, MA
ED
30
Children’s hospital
CA: no effective ventilation for 20 s and no pulse or BP; RA: no effective ventilation for 20 s necessitating physician intervention
ROSV/ROSC (CA), 73 73 (50); discharged from ED (CA), 70 (44); discharged (CA), 50 (19)
40
Kuisma et al (1995)
Helsinski, Finland
Out
34
<16 y
Apneic and pulseless
Discharged, 14.7
41
Schindler et al (1996)
Toronto, Canada
Out
101
Children’s hospital
Apneic or pulseless or both
Discharged, 15
42 (Abs) Pickert et al (1994)
Little Rock, AR
Inpatient
92
1 mo–18 y
Received CPR, defined as chest compressions, pharmacologic resuscitation, and assisted ventilation
Alive at 1 y, 10
43 (Abs) Walsh et al (1994)
Albany, NY
Out
22
PICU
Chest compressions and controlled Discharged, 0 ventilation
44
DeBard (1981)
Dayton, OH
All areas
41
0–19 y
Need for CPR due to sudden RA and/or CA
45
Clinton et al (1984)
Minneapolis, MN
Out
14
1–20 y
Apneic and pulseless, unresponsive Discharged, 7
46
Hendrick et al (1990)
Nijmegen, Netherlands
Inpatient
18
<18 y
Total absence of signs of functional Initial success, 72; respiration, circulation, or both discharged, 33
47 (P)
Tunstall-Pedoe et al (1992)
United Kingdom
Inpatient
84
0–14 y
Attempted CPR, exclude false alarms and recurrences
Survival through arrest, 27; discharged, 20
48
Safranek et al (1992)
King County, WA
Out
353
<18 y
Lack of pulse and BP
Long-term survival, 8.5
49
Schwenzer et al (1993)
Charlottesville, VA
Inpatient
42
0–18 y
Any of these: absent pulse, asystole, Discharged, 49 ventricular fibrillation, electromechanical dissociation, apnea
CPR success, 55
Abs, abstract; Out, out-of-hospital; PICU, pediatric intensive care unit; RA, respiratory arrest; CA, cardiac arrest; BP, blood pressure; ROSV, return of spontaneous ventilation. *All studies are retrospective except those marked P (prospective), Pr (prospective with additional data gathered retrospectively), or P/R (prospective patients with retrospective [historical] controls). †Article not included in the data analysis. ‡Outcome percentages in parentheses are for the subset of cardiac arrest patients only.
2 0 0
ANNALS OF EMERGENCY MEDICINE
33:2 FEBRUARY 1999
PEDIATRIC CPR Young & Seidel
patients, and .2% (1/433) of patients with sudden infant death syndrome (SIDS) survived to hospital discharge (see Table 2). Neurologic outcome was reported for 37 of the 38 near-drowning survivors, and 41% (15/37) had good outcome (3 normal, 12 mild deficits; see Table 3). Age and survival were reported for 332 cardiac arrest patients; 6% (19/332) of those younger than 1 year of age survived to discharge, compared with the overall rate of 13%. When reported, out-of-hospital cardiac arrest patients whose arrests were witnessed had a 19% hospital discharge rate (28/150) and those who received bystander CPR had a rate of 26% (20/76), compared with the overall rate for out-of-hospital cardiac arrest of 8.4%. Only 5% (39/802) of cardiac arrest patients whose initial recorded rhythm was asystole survived to discharge, compared with 30% (29/97) of patients in VF/VT. Several studies documented epinephrine dosing as related to outcome. In 4 studies with a total of 198 cardiac arrest patients, no patient who received more than 2 doses of standard-dose epinephrine survived,13,17,26,41 and in 3 studies with a total of 158 patients, no patient who received more than 1 dose survived.14,20,38 Improved ROSC and survival to hospital discharge with high-dose epinephrine given for the third epinephrine dose was reported in 1 study,26 whereas others showed no benefit with high-dose epinephrine.35,37 Twelve studies correlated duration of CPR and outcome. Eight reports with a total of 347 patients noted that continuing CPR longer than 20 to 30 minutes in normothermic pat-
ients did not produce additional survivors.5,14,16,30,35,40,41,46 Four other articles noted that the majority of survivors underwent CPR for 15 minutes or less.12,13,17,20 In 2 studies, the cardiac arrest survival rate in children was compared with the rate in adults for the same time period, geographic area, and EMS system. Adults had a higher rate of long-term survival in both studies (12.3% versus 0%11 and 17% versus 8.5%48). One study documented VF/VT as the initial recorded rhythm in 6% of patients younger than 18 years of age, compared with 31% of 18to 35-year-olds and 46% of those older than 35 years.48
Table 2.
Table 3.
Summary of available data on survival to hospital discharge or for a specified period of time.
Patient Subgroup
No. Identifiable Patients in Subgroup
No. Patients for Whom Outcome Data Are Reported
3,094 216 2,385 1,587 631 179 492 244 93 118 151 790 222 153 1,036 142
3,072 157 2,349 1,568 544 161 433 207 65 118 145 332 150 76 802 97
All patients Respiratory arrest Cardiac arrest Out-of-hospital Inpatient ICU SIDS Trauma Sepsis Cardiac diagnosis Drowning Age <1 y Witnessed Lay CPR given Asystole VF/VT
FEBRUARY 1999
33:2
ANNALS OF EMERGENCY MEDICINE
No. (%) Achieving Survival or Discharge 685 (22) 117 (75) 306 (13) 132 (8.4) 129 (24) 33 (20) 1 (.2) 9 (4) 0 (0) 13 (11) 38 (26) 19 (6) 28 (19) 20 (26) 39 (5) 29 (30)
DISCUSSION
There are still large gaps in our knowledge of pediatric CPR. Guidelines for pediatric ALS were not developed by the American Heart Association Emergency Cardiac Care Committee until 1986,50 and they have since been revised once, in 1992.51 This review of the literature demonstrates a poor survival rate for pediatric cardiac arrest patients, a rate that has not improved in the last decade. Because pediatric arrest is an uncommon event, prospective data are difficult to gather, and most research in pediatric CPR consists of small, retrospective series that do not use standardized definitions or outcome measures. Although the data reviewed are flawed by lack of uniformity, some conclusions can be drawn, and it is essential to collate the current body of knowledge so as to guide future research priorities.
Summary of available data on survivors with good neurologic outcome.
Patient Subgroup All patients Respiratory arrest Cardiac arrest Out-of-hospital Inpatient ICU SIDS Trauma Sepsis Cardiac diagnosis Drowning Age <1 y Witnessed Lay CPR given Asystole VF/VT
No. Identifiable Patients in Subgroup
No. Patients for Whom Outcome Data Are Reported
No. (%) With Good Neurologic Outcome
685 117 306 132 129 33 1 9 0 13 38 19 28 20 39 29
280 56 199 68 77 3 1 7 — 2 37 3 10 4 16 21
195 (70) 49 (88) 124 (62) 28 (41) 60 (78) 1 (33) 1 (100) 3 (43) — 2 (100) 15 (41) 1 (33) 2 (20) 2 (50) 6 (37) 10 (47)
2 0 1
PEDIATRIC CPR Young & Seidel
Reported studies show wide variation in case definitions and outcome measures. A quarter of the studies reviewed did not use an explicit definition of “arrest.” Current studies cannot be compared or combined for meta-analysis because of this lack of uniform reporting. In October 1995, international guidelines for uniform reporting and case definitions for pediatric ALS research were published. 52-55 These guidelines were designated “the pediatric Utstein style” in homage to similar guidelines for adult cardiac arrest data that were developed by an international task force that first met at the historic Utstein Abbey in Norway and were published in 1991.56 Studies on CPR could be improved and made comparable if the pediatric Utstein definitions were used to report research results. Researchers should include only patients meeting the case definitions outlined in those guidelines. “Cardiac arrest” is defined there as cessation of cardiac mechanical activity, determined by inability to palpate a central pulse, unresponsiveness, and apnea. “Respiratory arrest” is defined as apnea with cardiac activity detectable as a palpable pulse. In children, arrest is usually the result of progressive deterioration in respiratory or circulatory function, in contrast to the sudden cardiac arrest commonly seen in adults. In the studies reviewed, patients in respiratory arrest who had not yet deteriorated into cardiac arrest had a 75% hospital discharge rate, with 88% achieving good outcome. Research focused on recognition of early signs of impending arrest and interventions to prevent further deterioration would be more likely to improve outcomes than would research on cardiac arrest. The pediatric Utstein definitions include 2 additional groups of patients to be studied: those with respiratory compromise leading to assisted ventilation (not respiratory arrest), and those with bradycardia or poor perfusion for which basic CPR is given (ie, shock). Data would be more meaningful if researchers excluded, or reported separately on, patients for whom resuscitation was not attempted, including patients pronounced dead before arrival at the hospital, patients with do-not-resuscitate orders, and patients declared dead on arrival. Inclusionof such patients can significantly affect rate calculations for survival and therefore can bias research in treatment interventions.57,58 The pediatric Utstein guidelines recommend that, when multiple arrests occur in a single patient, only the index event should be reported. In the future, researchers must use uniform outcome measures. Fourteen different outcomes were reported in the studies we reviewed, making comparisons difficult. The pediatric Utstein guidelines recommend that the following outcomes be reported: ROSC never achieved, any
2 0 2
ROSC, sustained ROSC (longer than 20 minutes), return of spontaneous ventilation for respiratory arrest patients, admission to hospital, death in hospital (total, within 24 hours, and between 1 and 7 days), and discharge alive from hospital. As a minimum, the number of patients discharged alive from the hospital should be reported. Reports of ROSC alone are unacceptable because many patients achieve ROSC but do not survive to hospital discharge. Good neurologic outcome, not merely survival, is the optimal outcome. In this review, neurologic outcome was reported in only 41% of survivors. The small number of patients that could be included in Table 3 demonstrates that little is currently known about the neurologic outcome of survivors. Use of a standard neurologic outcome measure and reporting of neurologic outcome for all survivors would allow for comparisons of treatment modalities. As a minimum, the pediatric Utstein guidelines recommend reporting neurologic status at hospital discharge using the Pediatric Overall Performance Categories (POPC) and the PCPC.59 Because neurologic outcome improves gradually after an arrest event, they also recommend that researchers report neurologic outcome on follow-up at 1 year after the reported event. Standardization of the time of the follow-up examination is important, because outcomes reported for patients in the current literature at the common times of 1, 6, or 12 months cannot be compared. Neurologic deficits may be subtle,60,61 and development and standardization of a neurologic outcome scale with finer gradations of outcome than those provided by the POPC and PCPC may be useful.62 Lack of definition of “child,” as seen in the majority of the studies reviewed, presents further difficulties in comparing pediatric CPR studies. Gathering of retrospective data is often limited by the use of arbitrary age cutoffs for triage by individual EMS systems.63 The pediatric Utstein guidelines recommend stratification of results by the following age groups: 0 to 12 months, 1 to 4 years (preschool), 5 to 12 years (child), and 13 to 21 years (adolescent). Newborns in the first day of life and neonatal ICU patients should be studied separately. Children younger than 1 year of age consistently accounted for about half of pediatric cardiac arrest patients in the studies reviewed. Infants clearly have a higher rate of asystole and a lower survival rate. Pediatric emergency cardiac care protocols based on current CPR research may not be appropriate for the older child, and less so for the adolescent. It has been shown that the epidemiology of CPR in young adults is intermediate between those of children and of older adults.48 Similarly, adolescent arrest patients may respond to treatment protocols developed for adults better
ANNALS OF EMERGENCY MEDICINE
33:2 FEBRUARY 1999
PEDIATRIC CPR Young & Seidel
than to those developed for “children.” Further research elucidating the differences among the pediatric Utstein age stratification groups is needed. There is more to be learned about the frequency and outcome of pediatric VF/VT. The overall frequency of VF/VT as the initial recorded rhythm in patients with cardiac arrest was 10%. Other studies have found rates ranging from 6%48,64 to 19%.34 The study with a 19% rate excluded SIDS patients; if these patients had been included, the VF/VT rate would have been 11.4%. Therefore, 10% is probably close to the true rate when SIDS patients are included. The higher survival rate for adult patients with cardiac arrest is probably a result of differences in presenting rhythm. Up to 80% of out-of-hospital adult cardiac arrest patients demonstrate VF/VT,65 and early-defibrillation EMS protocols have improved survival.66 Current recommendations in pediatric patients do not emphasize early defibrillation because VF/VT is much less common in these patients. However, the smaller percentage of patients in VF/VT must be balanced with their improved survival67; our review showed that 30% of VF/VT patients survived to hospital discharge, compared with 5% of asystolic patients. An increased tendency to develop VF/VT after the newborn period, and in older versus younger children, has been shown.64,68 Perhaps a subgroup (eg, patients >1 year of age) can be identified who would benefit from EMS protocols emphasizing early defibrillation. Survival rate, rate of VF/VT, and rate of witnessed arrest may all be related. Children may have more unwitnessed arrests and longer times in arrest before discovery, degenerating from tachycardia to bradyasystole by the time they are discovered. Our review showed improved survival for children with witnessed arrest and for children receiving bystander CPR. Children and adults with witnessed arrests have similar survival rates (15%).4 Whether the 2 groups also have the same rate of VF/VT as presenting rhythm is unknown. In a study documenting the terminal rhythms of 100 pediatric patients, 22 had VF/VT, and 16 of these 22 patients had bradycardic/asystolic arrest as the final electrical event.68 Therefore, although children appear to have VF/VT as a terminal rhythm much less often than bradyasystole, VF/VT may precede bradyasystole in some and may represent a “window of opportunity” for bystander CPR and defibrillation. Research is needed to determine whether increased parent and caretaker knowledge of CPR and shortened time to defibrillation (eg, with the use of automated external defibrillators) leads to improved outcomes. Analysis of the CPR literature appears to demonstrate that there are large differences in survival based on cause of
FEBRUARY 1999
33:2
ANNALS OF EMERGENCY MEDICINE
arrest. However, because of the small numbers of patients for whom both cause and survival are reported, current data are inadequate to draw firm conclusions. The data show that patients with SIDS, trauma, or sepsis have poor survival rates, and those with submersion injury have better survival but often sustain residual deficits. Data showing differences in survival by age are confounded by cause; for example, infant cardiac arrests are predominantly patients with SIDS. Further research separating the effects of age and cause is needed. One question is whether specific diagnoses (eg, congenital heart disease) or certain age groups are more likely to be associated with VF/VT. Ethical issues in pediatric CPR, such as discontinuation of resuscitative efforts and organ donation, are important topics.69 Guidelines for termination of CPR and for not beginning CPR are needed. The current data strongly suggest that need for multiple epinephrine doses or for CPR longer than 30 minutes in a normothermic patient are indicators of poor outcome. Further data are needed to identify and validate such indicators. Most of the literature reviewed was not population based. Results from studies involving a single hospital cannot be generalized to the entire population and therefore are not useful in developing treatment protocols. Population-based data are more difficult to gather than data from a single hospital but must be the priority in CPR research. Almost all of the literature reviewed consists of case series in urban areas. Protocols developed and based on current research may not be applicable in rural areas, where arrest causes and resources for treatment differ greatly. 70,71 There is currently minimal research in pediatric CPR in rural areas. In summary, we can draw several conclusions from this review of the current pediatric CPR literature. Overall survival after cardiac arrest is poor at 13%, with patients arresting out-of-hospital faring worse than inpatients (8.4% versus 24% survival). Children younger than 1 year of age make up about half of cardiac arrest patients; as a group, they demonstrate a higher rate of asystole and a poorer survival rate (6%). The rate of VF/VT in pediatric cardiac arrest patients is about 10%; these patients have a much higher survival rate than do bradyasystolic patients (30% versus 5%). Approximately one third of pediatric arrests are witnessed, and one third of patients receive bystander CPR; these patients have improved outcomes compared with those whose arrest is unwitnessed and who do not receive bystander CPR. Patients in pure respiratory arrest have a much better survival rate than those with cardiac arrest. Our efforts may be better spent in preventing these patients from degenerating into cardiac arrest. Finally, CPR duration longer than 30 minutes and admin-
2 0 3
PEDIATRIC CPR Young & Seidel
istration of more than 2 doses of epinephrine are indicators of poor outcome. There remain gaps in our knowledge of pediatric CPR that are not well addressed by the current literature. 72 EMS systems and emergency departments have been shown to be inadequately prepared for the pediatric patient.73-75 What changes can be made in EMS systems to benefit such patients? What procedures should be attempted by out-of-hospital rescuers, and will such attempts result in improved outcomes? Does the presence of arrest teams designed to respond to ED and inpatient pediatric cardiac arrests improve survival? Who should be included in these teams? What training and equipment specific to pediatric arrests should be required? Finally, emphasis must be placed on improved neurologic outcome in addition to survival. How can we increase cerebral blood flow during CPR (brain resuscitation)? Do treatment interventions such as high-dose epinephrine improve neurologic outcome as well as ROSC and survival? We have much still to learn about pediatric CPR. Poor outcomes may be improved by research and subsequent improvements in emergency care and resuscitation techniques specific for children. Research in prevention of progression from prearrest states to arrest may be more beneficial than research in CPR itself. Current data consist mostly of small, retrospective case series based in a single hospital. Meta-analysis of these small series cannot be performed owing to lack of uniformity in case definitions and outcomes reported. Large, multicenter, prospective studies are needed to test interventions and improve outcomes. Future research should be population-based; should use the case definitions, age groups, and outcomes specified in the pediatric Utstein guidelines; and should report on neurologic outcome as well as survival.
9. Horimoto Y, Yoshizawa M, Atsushi O, et al: Five years experience of cardiopulmonary resuscitation in a children’s hospital. Resuscitation 1985;13:47-55. 10. Von Seggern K, Egar M, Fuhrman BP: Cardiopulmonary resuscitation in a pediatric ICU. Crit Care Med 1986;14:275-277. 11. Applebaum D, Slater PE: Should the mobile intensive care unit respond to pediatric emergencies? Clin Pediatr 1986;25:620-623. 12. O’Rourke PP: Outcome of children who are apneic and pulseless in the emergency room. Crit Care Med 1986;14:466-468. 13. Nichols DG, Kettrick RG, Swedlow DB, et al: Factors influencing outcome of cardiopulmonary resuscitation in children. Pediatr Emerg Care 1986;2:1-5. 14. Gillis J, Dickson D, Rieder M, et al: Results of inpatient pediatric resuscitation. Crit Care Med 1986;14:469-471. 15. Tsai A, Kallsen G: Epidemiology of pediatric prehospital care. Ann Emerg Med 1987;16:284292. 16. Davies CR, Carrigan T, Wright JA, et al: Neurologic outcome following pediatric resuscitation. J Neurosci Nurs 1987;19:205-210. 17. Zaritsky A, Nadkarni V, Getson P, et al: CPR in children. Ann Emerg Med 1987;16:11071111. 18. Fiser DH, Wrape V: Outcome of cardiopulmonary resuscitation in children. Pediatr Emerg Care 1987;3:235-238. 19. Losek JD, Hennes H, Glaeser P, et al: Out-of-hospital care of the pulseless nonbreathing pediatric patient. Am J Emerg Med 1987;5:370-374. 20. Barzilay Z, Somekh E, Sagy M, et al: Pediatric cardiopulmonary resuscitation outcome. J Med 1988;19:229-241. 21. Aijian P, Tsai A, Knopp R, et al: Endotracheal intubation of pediatric patients by paramedics. Ann Emerg Med 1989;18:489-494. 22. Losek JD, Hennes H, Glaeser PW, et al: Prehospital countershock treatment of pediatric asystole. Am J Emerg Med 1980;7:571-575. 23. Stopfkuchen H, Stein G, Queisser-Luft A, et al: Ergebnisse der kardiopulmonalen reanimation im kindesalter. Klin Padiatr 1989;201:373-376. 24. Thompson JE, Bonner B, Lower GM: Pediatric cardiopulmonary arrests in rural populations. Pediatrics 1990;86:302-306. 25. Quan L, Wentz KR, Gore EJ, et al: Outcome and predictors of outcome in pediatric submersion victims receiving out-of-hospital care in King county, Washington. Pediatrics 1990;86:586593. 26. Goetting MG, Paradis NA: High-dose epinephrine improves outcome from pediatric cardiac arrest. Ann Emerg Med 1991;20:22-26. 27. Quan L, Graves JR, Kinder DR, et al: Transcutaneous cardiac pacing in the treatment of outof-hospital pediatric cardiac arrests. Ann Emerg Med 1992;21:905-909.
REFERENCES
28. Bos AP, Polman A, van der Voort E, et al: Cardiopulmonary resuscitation in paediatric intensive care patients. Intensive Care Med 1992;18:109-111.
1. Ehrlich R, Emmett SM, Rodriquez-Torres RO: Pediatric cardiac resuscitation team: A 6 year study. J Pediatr 1974;84:152-155.
29. Schoenfeld PS, Baker MD: Management of cardiopulmonary and trauma resuscitation in the pediatric emergency department. Pediatrics 1993;91:726-729.
2. Friesen RM, Duncan P, Tweed WA, et al: Appraisal of pediatric cardiopulmonary resuscitation. Can Med Assoc J 1982;126:1055-1058.
30. Innes PA, Summers CA, Boyd IM, et al: Audit of paediatric cardiopulmonary resuscitation. Arch Dis Child 1993;68:487-491.
3. Lewis JK, Minter MG, Eshelman SJ, et al: Outcome of pediatric resuscitation. Ann Emerg Med 1983;12:297-299.
31. Sheikh A, Brogan T: Outcome and cost of open- and closed-chest cardiopulmonary resuscitation in pediatric cardiac arrests. Pediatrics 1994;93:392-398.
4. Eisenberg M, Bergner L, Hallstrom A: Epidemiology of cardiac arrest and resuscitation in children. Ann Emerg Med 1983;12:672-674.
32. Hazinski MF, Chahine AA, Holcomb GW, et al: Outcome of cardiovascular collapse in pediatric blunt trauma. Ann Emerg Med 1994;23:1229-1235.
5. Rosenberg NM: Pediatric cardiopulmonary arrest in the emergency department. Am J Emerg Med 1984;2:497-499.
33. Kyriacou DN, Arcinue EL, Peek C, et al: Effect of immediate resuscitation on children with submersion injury. Pediatrics 1994;94:137-142.
6. Torphy DE, Minter MG, Thompson BM: Cardiorespiratory arrest and resuscitation of children. Am J Dis Child 1984;138:1099-1102.
34. Mogayzel C, Quan L, Graves JR, et al: Out-of-hospital ventricular fibrillation in children and adolescents: causes and outcomes. Ann Emerg Med 1995;25:484-491.
7. Ludwig S, Kettrick RG, Parker M: Pediatric cardiopulmonary resuscitation. Clin Pediatr 1984;23:71-75.
35. 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 1995;149:210-214.
8. Wark H, Overton JH: A paediatric “cardiac arrest” survey. Br J Anaesth 1984;56:1271-1274.
2 0 4
ANNALS OF EMERGENCY MEDICINE
33:2 FEBRUARY 1999
PEDIATRIC CPR Young & Seidel
36. Bhende MS, Thompson AE: Evaluation of an end-tidal CO2 detector during pediatric cardiopulmonary resuscitation. Pediatrics 1995;95:395-399. 37. Dieckmann RA, Vardis R: High-dose epinephrine in pediatric out-of-hospital cardiopulmonary arrest. Pediatrics 1995;95:901-913. 38. Hickey RW, Cohen DM, Strausbaugh S, et al: Pediatric patients requiring CPR in the prehospital setting. Ann Emerg Med 1995;25:495-501. 39. Teach SJ, Moore PE, Fleisher GR: Death and resuscitation in the pediatric emergency department. Ann Emerg Med 1995;25:799-803. 40. Kuisma M, Suominen P, Korpela R: Paediatric out-of-hospital cardiac arrests: Epidemiology and outcome. Resuscitation 1995;30:141-150. 41. Schindler MB, Bohn D, Cox PN, et al: Outcome of out-of-hospital cardiac or respiratory arrest in children. N Engl J Med 1996;335:1473-1479. 42. Pickert CB, Torres A, Firestone J, et al: Outcome of in-hospital pediatric cardiopulmonary arrest [abstract]. Crit Care Med 1994;22:A161. 43. Walsh RF, Sanchez JL, Edge WE, et al: Outcome of pre-hospital CPR in the pediatric trauma patient [abstract]. Crit Care Med 1994;22:A162. 44. DeBard ML: Cardiopulmonary resuscitation: Analysis of six years’ experience and review of the literature. Ann Emerg Med 1981;10:408-416. 45. Clinton JE, McGill J, Irwin G, et al: Cardiac arrest under age 40: Etiology and prognosis. Ann Emerg Med 1984;13:1011-1015. 46. Hendrick JM, Pijls NH, van der Werf T, et al: Cardiopulmonary resuscitation on the general ward: No category of patients should be excluded in advance. Resuscitation 1990;20:163-171.
62. Okada PJ, Raroque SS, Young KD, et al: Validation of a practical research instrument for the measurement of neurologic outcome in infants and children [abstract]. Acad Emerg Med 1997;4:370-371. 63. Seidel JS: Emergency medical services and the adolescent patient. J Adolesc Health 1991;12:95-100. 64. Appleton GO, Cummins RO, Larson MP, et al: CPR and the single rescuer: At what age should you “call first” rather than “call fast”? Ann Emerg Med 1995;25:492-494. 65. Montgomery WH, Brown DD, Hazinski MF, et al: Citizen response to cardiopulmonary emergencies. Ann Emerg Med 1993;22:428-434. 66. Eisenberg MS, Copass MK, Hallstrom AP, et al: Treatment of out-of-hospital cardiac arrests with rapid defibrillation by emergency medical technicians. N Engl J Med 1980;302:1379-1383. 67. Hazinski MF: Is pediatric resuscitation unique? Relative merits of early CPR and ventilation versus early defibrillation for young victims of cardiac arrest. Ann Emerg Med 1995;25:540-543. 68. Walsh CK, Krongrad E: Terminal cardiac electrical activity in pediatric patients. Am J Cardiol 1983;51:557-561. 69. Landwirth J: Ethical issues in pediatric and neonatal resuscitation. Ann Emerg Med 1993;22:502-507. 70. Gausche M, Seidel JS, Henderson DP, et al: Pediatric deaths and emergency medical services (EMS) in urban and rural areas. Pediatr Emerg Care 1989;5:158-162. 71. Seidel JS: EMS-C in urban and rural areas: The California experience, in Haller JA Jr (ed): Emergency medical services for children: Report of the 97th Ross Conference on Pediatric Research. Columbus, Ohio: Ross Laboratories, 1989:22-33. 72. Chameides L: CPR challenges in pediatrics. Ann Emerg Med 1993;22:388-392.
47. Tunstall-Pedoe H, Bailey L, Charmberlain DA, et al: Survey of 3765 cardiopulmonary resuscitations in British hospitals (the BRESUS study): Methods and overall results. BMJ 1992;304:1347-1351.
73. Seidel JS, Hornbein M, Yoshiyama K, et al: Emergency medical services and the pediatric patient: Are the needs being met? Pediatrics 1984;73:769-772.
48. Safranek DJ, Eisenberg MS, Larsen MP: The epidemiology of cardiac arrest in young adults. Ann Emerg Med 1992;21:1102-1106.
74. Seidel JS: Emergency medical services and the pediatric patient: Are the needs being met? II: Training and equipping emergency medical services providers for pediatric emergencies. Pediatrics 1986;78:808-812.
49. Schwenzer KJ, Smith WT, Durbin CG: Selective application of cardiopulmonary resuscitation improves survival rates. Anesth Analg 1993;76:478-484.
75. Zaritsky A, French JP, Schafermeyer R, et al: A statewide evaluation of pediatric prehospital and hospital emergency services. Arch Pediatr Adolesc Med 1994;148:76-81.
50. Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). JAMA 1986;255:2961-2968. 51. Emergency Cardiac Care Committee and Subcommittees, American Heart Association: Guidelines for cardiopulmonary resuscitation and emergency cardiac care: VI. JAMA 1992;268:2262-2275. 52. Zaritsky A, Nadkarni V, Hazinski MF, et al: Recommended guidelines for uniform reporting of pediatric advanced life support: The pediatric Utstein style. Ann Emerg Med 1995;26:487503. 53. Zaritsky A, Nadkarni V, Hazinski MF, et al: Recommended guidelines for uniform reporting of pediatric advanced life support: The pediatric Utstein style. Circulation 1995;92:2006-2020. 54. Zaritsky A, Nadkarni V, Hazinski MF, et al: Recommended guidelines for uniform reporting of pediatric advanced life support: The pediatric Utstein style. Pediatrics 1995;96:765-779. 55. Zaritsky A, Nadkarni V, Hazinski MF, et al: Recommended guidelines for uniform reporting of pediatric advanced life support: The pediatric Utstein style. Resuscitation 1995;30:95-115. 56. Cummins RO, Chamberlain DA, Abramson NS, et al: Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: The Utstein style. Task force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council. Ann Emerg Med 1991;20:861874. 57. Eisenberg MS, Cummins RO, Larsen MP: Numerators, denominators, and survival rates: Reporting survival from out-of-hospital cardiac arrest. Am J Emerg Med 1991;9:544-546. 58. Valenzuela TD, Spaite DW, Meislin HW, et al. Case and survival definitions in out-of-hospital cardiac arrest: Effect on survival rate calculation. JAMA 1992;267:272-274. 59. Fiser DH: Assessing the outcome of pediatric intensive care. J Pediatr 1992;121:68-74. 60. Morris RD, Krawiecki NS, Wright JA, et al: Neuropsychological, academic and adaptive functioning in children who survive in-hospital cardiac arrest and resuscitation. J Learn Disabil 1993;26:46-51. 61. Longstreth WT, Dikmen SS: Outcomes after cardiac arrest. Ann Emerg Med 1993;22:64-69.
FEBRUARY 1999
33:2
ANNALS OF EMERGENCY MEDICINE
2 0 5