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Pediatric cardiopulmonary resuscitation: State at the art
Pediatric Cardiopulmo Resuscitation: State oftheArt By Kelly D. Young,MD TORRANCE, CALIFORNIA
T
HE PEDIATRIC CHAIN of survival describes the critical links of prevention, early cardiopulmonary resuscitation (CPR), early Emergency Medical Services (EMS) activation, and early advanced life support (ALS) to improve survival in pediatric cardiopulmonary arrest. l Postresuscitation stabilization and definitive pediatric critical care are important additional links. Unfortunately, although the following scenario illustrates the ideal state of the art with all the links in place, the current reality of pediatric CPR is far inferior. Survival rates to hospital discharge are dismal: 13% overall and 8% for out-of-hospital arrests.2
CaseScenario A 4-year-old boy suddenly collapses in the presence of his mother and father at home. Both parents have been trained in basic life support (BLS). His mother begins CPR while his father activates the EMS system by calling 911. ALS-capable prehospital providers arrive within 4 minutes. They begin bag-valve-mask ventilation and find the patient to be in ventricular fibrillation. The patient undergoes defibrillation and achieves return of spontaneous circulation (ROSC). He is transported to an emergency department which has met guidelines for staff training and equipment for pediatric emergencies, is stabilized there, and is then transferred to a specialized pediatric critical care facility. He is diagnosed with cardiomyopathy, optimized medically, and discharged home neurologically intact.
CurrentKnowledge A collective review was published in 1999 of all the case series published to date on pediatric cardiopulmonary arrest.2 A total of 80
CARDIOPULMONARYRiSUSClTATlON / KELLY D. YOUNG
CARDIOPULMONARYRESUSCITATION/ KELLY D. YOUNG
3,094 patients in 44 studies were reviewed. More than half (56%) of the patients were less than 1 year old, and 62% were male. There was an overall rate of survival to hospital discharge of 13%, with 24% of inpatient arrest victims and only 8.4% of out-ofhospital patients surviving. Pediatric cardiopulmonary arrest, unlike adult cardiopulmonary arrest, is usually noncardiac in etiology and less sudden in onset. Patients who were in respiratory arrest alone (ie, had a pulse) on presentation for medical care had a 75% survival rate. Therefore, emphasis should be placed on early recognition and management of the pediatric patient in respiratory failure, preventing progression to cardiopulmonary arrest. Patients whose arrests were witnessed and who received citizen CPR had a higher survival rate. Of all out-of-hospital arrests, 31% were witnessed, and these patients had a 19% survival rate compared with the overall survival rate of 8.4% for out-ofhospital arrest patients. In the studies for which citizen CPR was reported, 30% of the patients received citizen CPR, and 26% of these patients survived. Initial cardiac rhythm was also strongly associated with survival. Most patients (73%) had a bradyasystolic rhythm and only 5% survived. Ten percent of the children had ventricular fibrillation or pulseless ventricular tachycardia (VFNT), and 30% of these children survived. Whether an arrest is witnessed, whether citizen CPR is performed, and initial rhythm may all be interrelated. Children whose arrests are witnessed may be more likely to be in VFNT and thus have a higher survival rate. Unwitnessed arrest patients may be more likely to have degenerated from VFNT into a bradyasystolic rhythm. Citizen CPR may lengthen the duration of VFNT before degeneration into a bradyasystolic rhythm. As a prognostic factor, age is also confounded by initial rhythm. Out-of-hospital arrest patients under 1 year of age were less likely to be in VFNT and had only a 6% survival rate. When adults and children from the same period, geographic area, and EMS system were studied, adults were more likely to be in VFNT and had a significantly higher survival rate.3*4 Guidelines for termination of CPR are desirable to conserve resources and avoid prolonging futile resuscitations. No patient given more than 2 doses of epinephrine and no patient undergoing CPR longer than 20 to 30 minutes after hospital arrival survived to hospital discharge.2 Our current knowledge base is limited by the lack of quality data. Most research in pediatric CPR has consisted of small, retrospective, single-hospital, rather than population-based, case series that
81
do not use standardized definitions or outcome measures. To improve the quality of pediatric CPR data reported, guidelines for uniform reporting and case definitions (the “pediatric Utstein style”) were published in 1995.5 These guidelines parallel similar guidelines for adult cardiac arrest data that were developed by an international task force that first met at the Utstein Abbey in Norway and were published in 1991.6 Using the Utstein guidelines, Sirbaugh et al7 published a prospective, population-based case series of 300 apneic and pulseless children treated by EMS personnel during a 3.5year period. Of the children, 54% were less than 1 year old, and 60% were male. Only 6 children (2%) survived to hospital discharge; 5 were neurologically devastated. All 6 survivors had ROSC at the scene and did not require any epinephrine. Although 72% of the arrests occurred at home and 60% of patients had family members present, only 26% received citizen CPR. Of the patients, 83% were in asystole, 12% had pulseless electrical activity, and only 4% were in VFNT. The low number of survivors made it difficult to draw meaningful conclusions about associations between risk factors or protective factors and survival. The only factor significantly associated with survival was onscene ROSC. In summary, more than half of pediatric cardiopulmonary arrests occur in children less than 1 year old, and there is a slight male predominance (60%). Out-of-hospital arrest survival is poor (8% or less), whereas inpatient arrest survival is better (24%). Factors associated with improved survival include witnessed arrest, citizen CPR, and VFNT rhythm. Patients requiring multiple doses of epinephrine or prolonged resuscitation are unlikely to survive. Early recognition of pediatric patients in respiratory failure or shock and the prevention of progression to cardiac arrest deserves special emphasis.
CurrentGapsin Our Knowledge Although it has been 14 years since guidelines for pediatric ALS were first developed by the American Heart Association Emergency Cardiac Care Committee,5 large gaps remain in our knowledge base. Meta-analysis of current data is difficult because of the lack of uniformity in case definitions and outcomes reported. Pediatric CPR research is challenging to perform. Pediatric cardiopulmonary arrests are infrequent, requiring multicenter trials. Although retrospective studies are significantly limited by missing data, prospective studies require a
82
CARDIOPULMONARYRESUSCITATION/ KELLY D. YOUNG
large time commitment on the part of investigators. Informed consent is rarely obtainable before intervention because of the critical nature of the patients. The Department of Health and Human Services and the Food and Drug Administration endorsed a rule for the waiver of informed consent in resuscitation research.9 However, the rule’s requirements for consultation with community representatives are difficult to implement. Despite the many barriers to performing quality pediatric CPR research, large, multicenter, population-based, prospective studies using the case definitions and outcomes specified by the Utstein guidelines are needed to test interventions, with the goal of improving both survival and neurologic outcome of survivors A recently published controlled clinical trial comparing bag-valve-mask ventilation and endotracheal intubation for out-of-hospital management of pediatric patients requiring respiratory assistance is a good example of the type of research that is needed.10 In this population-based study carried out in Los Angeles and Orange Counties, California, 830 pediatric patients requiring airway assistance were randomized to bag-valve-mask ventilation on odd days and endotracheal intubation on even days. The study involved the cooperation of 56 paramedic provider agencies and 115 receiving hospitals. Strict inclusion criteria and case definitions of subgroups were prospectively defined, and the primary outcomes of survival to hospital discharge and neurologic status at discharge were clearly identified. The investigators found no significant difference in survival or neurologic outcome between the two groups. The results of this study provide useful information for EMS policymakers and paramedic educators. Many issues and areas of controversy in pediatric CPR require additional research. A partial list of those identified by the International Liaison Committee on Resuscitation are: (1) The prevalence and time course for presentation of VF/VT; (2) whether resuscitation measures should vary according to presumed initial rhythm; (3) the optimal methods, rates, and ratio for assisted ventilation and chest compressions; (4) the optimal methods for defibrillation and the use of automatic external defibrillators in children; (5) the frequency of citizen CPR and its impact on outcome; (6) the impact of resuscitation guidelines on prevention, successful resuscitation, and outcomes in pediatric CPR, (7) training of out-of-hospital providers on what ALS procedures they should provide; (8) what equipment, training, and staffing should be required of receiving facilities; and (9) use of high-dose epi-
nephrine, cerebral cooling, and other drugs or techniques to improve survival and neurologic outcome.
RecentGuidelineChanges for PediatricBLS and ALS Updated guidelines for pediatric BLS and ALS were published in August 2000.iJ1 BLS guidelines still recommend that the lone rescuer provide 1 minute of CPR before activating EMS (“phone fast”) for pediatric arrest patients. This is in contrast to the “phone first” recommendations for adult patients, which recognize the importance of early EMS arrival and defibrillation for improved survival. For the subgroup of pediatric patients at high risk of VFNT, such as drowning victims, children with sudden witnessed collapses (especially those older than 8 years), and patients with a traumatic or toxicologic etiology for their arrest, the guidelines state that a “phone first” approach may be more appropriate. The revised guidelines emphasize checking for signs of circulation (ie, normal breathing, movement, coughing in response to rescue breaths) rather than checking for a pulse. Identification of a pulse is frequently inaccurate and takes too long for the lay provider. Healthcare providers should still check for a pulse and should initiate chest compressions for a pulse less than 60 bpm. Also, for infants, the 2-thumbs encircling the thorax method of chest compressions is preferred over the 2-fingers method. Alternative compression techniques have shown some promising results in adults, but have not been studied in children. Finally, automatic external defibrillators are recommended for use in children over age 8 years or 25 kg when available. The dose delivered is too high for smaller children. The updated pediatric ALS guidelines state that whether bag-valve-mask (BVM) or endotracheal intubation is used depends on the skill and training of the out-of-hospital providers. However, citing the study by Gausche et al10 emphasis is placed on training in effective BVM for all providers. Use of end-tidal carbon dioxide detectors for confirmation of endotracheal tube placement is recommended, and laryngeal mask airway use for patients who are not treatable by standard techniques is mentioned, although clinical data are currently limited. The guidelines emphasize early vascular access and state that intraosseous access should be established if intravenous access cannot be rapidly attained, even in children older than age 6 years. The revised guidelines, like their adult counter-
CARDIOPULMONARYRESUSCITATION/ KELLY D. YOUNG
parts, add amiodarone to the algorithm for VF/VT, and remove bretylium. Emphasis is placed on identifying treatable underlying causes of the arrest/ arrhythmia, using the mnemonic 4 H’s (hypovolemia, hypoxia, hypothermia, hyperkalemia, and other metabolic disorders) and 4 T’s (tension pneumothorax, tamponade, toxins, and primary thromboembolus). Vagal maneuvers (ice water to the face, Valsalva maneuvers such as blowing on a straw, and carotid massage) have been added as an option in the hemodynamically stable patient with supraventricular tachycardia. The guidelines for postarrest stabilization emphasize measures to improve neurologic outcome. Ventilation should be adequate but hyperventilation should be avoided, because lowered pC0, leads to cerebral vasoconstriction. Frequent reassessment and arterial blood gas analysis are important. Avoid hyperthermia and do not actively rewarm the patient unless the temperature is below 33°C. Glucose monitoring is also important, both for recognition of hypoglycemia and to avoid hyperglycemia. Hyperthermia and hyperglycemia have been associated with worsened neurologic outcomes. Myocardial function should be closely monitored, and circulation optimized with pressors as needed. Updated guidelines for neonatal resuscitation state that personnel capable of neonatal resuscitation should be present at every delivery. Suctioning for thick meconium with endotracheal intubation is recommended only for babies with absent or depressed respirations, heart rate less than 100 bpm, or poor muscle tone. Like pediatric patients, emphasis is placed on adequate ventilation and use of an end-tidal CO, detector for confirmation of endotracheal tube placement. Laryngeal mask airway and intraosseous access are listed as alternatives for newborns when standard airway management and vascular access techniques are unsuccessful. Again, the 2-thumbs encircling the thorax method of chest compressions is preferred. High-dose epinephrine is not recommended, because of an increased risk of intracranial hemorrhage. The 2000 guidelines state that children failing to achieve ROSC after at least 2 doses of epinephrine and CPR longer than 30 minutes are unlikely to survive. Unless there is recurring or refractory VF/ VT, a history of a toxic drug exposure, or a primary hypothermic insult, it is appropriate to discontinue resuscitation efforts. Recent research supports family member presence at resuscitations.12J3 Parents generally prefer to be present if given the option, and in the event of
their child’s death, parents may experience ier adjustment period.
83
an eas-
Prevention Although research and guidelines emphasize BLS, ALS, and postresuscitation interventions, prevention remains a critical, if not the most crucial, link in improving pediatric cardiopulmonary arrest survival. Citizen CPR has been shown to improve survival rates, yet less than one third of pediatric arrest patients receive citizen CPR. Parents, grandparents, older siblings, teachers, babysitters, and other care providers should be encouraged to learn pediatric BLS. Parents, physicians, and nurses caring for children must also be trained to recognize impending respiratory failure or shock before progression to cardiopulmonary arrest. Anticipatory guidance for parents on injury prevention (eg, water safety, car seat usage, bicycle helmet usage, drug and toxic substance storage) also play a key role in prevention. Special-needs children should carry a copy of the emergency information form developed by the American Academy of Pediatrics and the American College of Emergency Physicians. This form is available on the Internet (http:// www. pediatrics. org/cgi/conteniY~ll/lO4/4/e53) .I4
Summary Pediatric cardiopulmonary arrest carries a very poor prognosis that has not improved over the last few decades. Many unanswered questions remain regarding pediatric CPR and how best to improve survival and neurologic outcome. High-quality research is needed to resolve these issues. This research should consist of population-based, prospective studies using the case definitions and outcomes specified by the Utstein guidelines. Prevention as a critical link in the chain of survival deserves special emphasis and attention.
References 1. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: Pediatric Advanced Life Support. Circulation 102:1291-1342, 2000 (suPP I). 2. Young KD, Seidel JS: Pediatric cardiopulmonary resuscitation: A collective review. Ann Emerg Med 33: 195205, 1999. 3. Applebaum D, Slater PE: Should the mobile intensive care unit respond to pediatric emergencies? Clin Pediatr 25:620-623, 1986.
84
CARDIOPULMONARYRESUSCITATIONI KELLY D. YOUNG
4. Safranek DJ, Eisenberg MS, Larsen MP: The epidemiology of cardiac arrest in young adults. Ann Emerg Med 21:1102-1106, 1992. 5. Zaritsky A, Nadkarni V, Hazinski MF, et al: Recommended guidelines for uniform reporting of pediatric advanced life support: The pediatric Utstein style. Circulation 92:2006-2020, 199.5. 6. 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 20:861-874, 1991. 7. Sirbaugh PE, Pepe PE, Shook JE, et al: A prospective, population-based study of the demographics, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest. Ann Emerg Med 33: 174-184, 1999. 8. Standards and Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC). JAMA 2552961-2968, 1986. 9. Biros MH, Lewis RJ, Olson CM, et al: Informed consent in emergency research: Consensus statement
from the coalition conferences of acute resuscitation and critical care researchers. JAMA 273:1283-1287, 1995. 10. Gausche M, Lewis RJ, Stratton SJ, et al: Effect of out-of-hospital pediatric endotracheal intubation on survival and neurologic outcome: A controlled clinical trial. JAMA 283:783-790, 2000. 11. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 9: Pediatric basic life support. Circulation 102:1253-1290, 2000 (supp I). 12. Boie ET, Moore GP, Brummett C, et al: Do parents want to be present during invasive procedures performed on their children in the emergency Department? A survey of 400 parents. Ann Emerg Med 34:7074, 1999. 13. Robinson SM, Mackenzie-Ross S, Campbell Hewson CL, et al: Psychological effect of witnessed resuscitation on bereaved relatives. Lancet 352:614-617, 1998. 14. Committee on Pediatric Emergency Medicine, American Academy of Pediatrics: Emergency preparedness for children with special health care needs. Pediatrics 104:eS3, 1999.
T
HE PEDIATRIC CHAIN of survival describes the critical links of prevention, early cardiopulmonary resuscitation (CPR), early Emergency Medical Services (EMS) activation, and early advanced life support (ALS) to improve survival in pediatric cardiopulmonary arrest. l Postresuscitation stabilization and definitive pediatric critical care are important additional links. Unfortunately, although the following scenario illustrates the ideal state of the art with all the links in place, the current reality of pediatric CPR is far inferior. Survival rates to hospital discharge are dismal: 13% overall and 8% for out-of-hospital arrests.2
CaseScenario A 4-year-old boy suddenly collapses in the presence of his mother and father at home. Both parents have been trained in basic life support (BLS). His mother begins CPR while his father activates the EMS system by calling 911. ALS-capable prehospital providers arrive within 4 minutes. They begin bag-valve-mask ventilation and find the patient to be in ventricular fibrillation. The patient undergoes defibrillation and achieves return of spontaneous circulation (ROSC). He is transported to an emergency department which has met guidelines for staff training and equipment for pediatric emergencies, is stabilized there, and is then transferred to a specialized pediatric critical care facility. He is diagnosed with cardiomyopathy, optimized medically, and discharged home neurologically intact.
CurrentKnowledge A collective review was published in 1999 of all the case series published to date on pediatric cardiopulmonary arrest.2 A total of 80
CARDIOPULMONARYRiSUSClTATlON / KELLY D. YOUNG
CARDIOPULMONARYRESUSCITATION/ KELLY D. YOUNG
3,094 patients in 44 studies were reviewed. More than half (56%) of the patients were less than 1 year old, and 62% were male. There was an overall rate of survival to hospital discharge of 13%, with 24% of inpatient arrest victims and only 8.4% of out-ofhospital patients surviving. Pediatric cardiopulmonary arrest, unlike adult cardiopulmonary arrest, is usually noncardiac in etiology and less sudden in onset. Patients who were in respiratory arrest alone (ie, had a pulse) on presentation for medical care had a 75% survival rate. Therefore, emphasis should be placed on early recognition and management of the pediatric patient in respiratory failure, preventing progression to cardiopulmonary arrest. Patients whose arrests were witnessed and who received citizen CPR had a higher survival rate. Of all out-of-hospital arrests, 31% were witnessed, and these patients had a 19% survival rate compared with the overall survival rate of 8.4% for out-ofhospital arrest patients. In the studies for which citizen CPR was reported, 30% of the patients received citizen CPR, and 26% of these patients survived. Initial cardiac rhythm was also strongly associated with survival. Most patients (73%) had a bradyasystolic rhythm and only 5% survived. Ten percent of the children had ventricular fibrillation or pulseless ventricular tachycardia (VFNT), and 30% of these children survived. Whether an arrest is witnessed, whether citizen CPR is performed, and initial rhythm may all be interrelated. Children whose arrests are witnessed may be more likely to be in VFNT and thus have a higher survival rate. Unwitnessed arrest patients may be more likely to have degenerated from VFNT into a bradyasystolic rhythm. Citizen CPR may lengthen the duration of VFNT before degeneration into a bradyasystolic rhythm. As a prognostic factor, age is also confounded by initial rhythm. Out-of-hospital arrest patients under 1 year of age were less likely to be in VFNT and had only a 6% survival rate. When adults and children from the same period, geographic area, and EMS system were studied, adults were more likely to be in VFNT and had a significantly higher survival rate.3*4 Guidelines for termination of CPR are desirable to conserve resources and avoid prolonging futile resuscitations. No patient given more than 2 doses of epinephrine and no patient undergoing CPR longer than 20 to 30 minutes after hospital arrival survived to hospital discharge.2 Our current knowledge base is limited by the lack of quality data. Most research in pediatric CPR has consisted of small, retrospective, single-hospital, rather than population-based, case series that
81
do not use standardized definitions or outcome measures. To improve the quality of pediatric CPR data reported, guidelines for uniform reporting and case definitions (the “pediatric Utstein style”) were published in 1995.5 These guidelines parallel similar guidelines for adult cardiac arrest data that were developed by an international task force that first met at the Utstein Abbey in Norway and were published in 1991.6 Using the Utstein guidelines, Sirbaugh et al7 published a prospective, population-based case series of 300 apneic and pulseless children treated by EMS personnel during a 3.5year period. Of the children, 54% were less than 1 year old, and 60% were male. Only 6 children (2%) survived to hospital discharge; 5 were neurologically devastated. All 6 survivors had ROSC at the scene and did not require any epinephrine. Although 72% of the arrests occurred at home and 60% of patients had family members present, only 26% received citizen CPR. Of the patients, 83% were in asystole, 12% had pulseless electrical activity, and only 4% were in VFNT. The low number of survivors made it difficult to draw meaningful conclusions about associations between risk factors or protective factors and survival. The only factor significantly associated with survival was onscene ROSC. In summary, more than half of pediatric cardiopulmonary arrests occur in children less than 1 year old, and there is a slight male predominance (60%). Out-of-hospital arrest survival is poor (8% or less), whereas inpatient arrest survival is better (24%). Factors associated with improved survival include witnessed arrest, citizen CPR, and VFNT rhythm. Patients requiring multiple doses of epinephrine or prolonged resuscitation are unlikely to survive. Early recognition of pediatric patients in respiratory failure or shock and the prevention of progression to cardiac arrest deserves special emphasis.
CurrentGapsin Our Knowledge Although it has been 14 years since guidelines for pediatric ALS were first developed by the American Heart Association Emergency Cardiac Care Committee,5 large gaps remain in our knowledge base. Meta-analysis of current data is difficult because of the lack of uniformity in case definitions and outcomes reported. Pediatric CPR research is challenging to perform. Pediatric cardiopulmonary arrests are infrequent, requiring multicenter trials. Although retrospective studies are significantly limited by missing data, prospective studies require a
82
CARDIOPULMONARYRESUSCITATION/ KELLY D. YOUNG
large time commitment on the part of investigators. Informed consent is rarely obtainable before intervention because of the critical nature of the patients. The Department of Health and Human Services and the Food and Drug Administration endorsed a rule for the waiver of informed consent in resuscitation research.9 However, the rule’s requirements for consultation with community representatives are difficult to implement. Despite the many barriers to performing quality pediatric CPR research, large, multicenter, population-based, prospective studies using the case definitions and outcomes specified by the Utstein guidelines are needed to test interventions, with the goal of improving both survival and neurologic outcome of survivors A recently published controlled clinical trial comparing bag-valve-mask ventilation and endotracheal intubation for out-of-hospital management of pediatric patients requiring respiratory assistance is a good example of the type of research that is needed.10 In this population-based study carried out in Los Angeles and Orange Counties, California, 830 pediatric patients requiring airway assistance were randomized to bag-valve-mask ventilation on odd days and endotracheal intubation on even days. The study involved the cooperation of 56 paramedic provider agencies and 115 receiving hospitals. Strict inclusion criteria and case definitions of subgroups were prospectively defined, and the primary outcomes of survival to hospital discharge and neurologic status at discharge were clearly identified. The investigators found no significant difference in survival or neurologic outcome between the two groups. The results of this study provide useful information for EMS policymakers and paramedic educators. Many issues and areas of controversy in pediatric CPR require additional research. A partial list of those identified by the International Liaison Committee on Resuscitation are: (1) The prevalence and time course for presentation of VF/VT; (2) whether resuscitation measures should vary according to presumed initial rhythm; (3) the optimal methods, rates, and ratio for assisted ventilation and chest compressions; (4) the optimal methods for defibrillation and the use of automatic external defibrillators in children; (5) the frequency of citizen CPR and its impact on outcome; (6) the impact of resuscitation guidelines on prevention, successful resuscitation, and outcomes in pediatric CPR, (7) training of out-of-hospital providers on what ALS procedures they should provide; (8) what equipment, training, and staffing should be required of receiving facilities; and (9) use of high-dose epi-
nephrine, cerebral cooling, and other drugs or techniques to improve survival and neurologic outcome.
RecentGuidelineChanges for PediatricBLS and ALS Updated guidelines for pediatric BLS and ALS were published in August 2000.iJ1 BLS guidelines still recommend that the lone rescuer provide 1 minute of CPR before activating EMS (“phone fast”) for pediatric arrest patients. This is in contrast to the “phone first” recommendations for adult patients, which recognize the importance of early EMS arrival and defibrillation for improved survival. For the subgroup of pediatric patients at high risk of VFNT, such as drowning victims, children with sudden witnessed collapses (especially those older than 8 years), and patients with a traumatic or toxicologic etiology for their arrest, the guidelines state that a “phone first” approach may be more appropriate. The revised guidelines emphasize checking for signs of circulation (ie, normal breathing, movement, coughing in response to rescue breaths) rather than checking for a pulse. Identification of a pulse is frequently inaccurate and takes too long for the lay provider. Healthcare providers should still check for a pulse and should initiate chest compressions for a pulse less than 60 bpm. Also, for infants, the 2-thumbs encircling the thorax method of chest compressions is preferred over the 2-fingers method. Alternative compression techniques have shown some promising results in adults, but have not been studied in children. Finally, automatic external defibrillators are recommended for use in children over age 8 years or 25 kg when available. The dose delivered is too high for smaller children. The updated pediatric ALS guidelines state that whether bag-valve-mask (BVM) or endotracheal intubation is used depends on the skill and training of the out-of-hospital providers. However, citing the study by Gausche et al10 emphasis is placed on training in effective BVM for all providers. Use of end-tidal carbon dioxide detectors for confirmation of endotracheal tube placement is recommended, and laryngeal mask airway use for patients who are not treatable by standard techniques is mentioned, although clinical data are currently limited. The guidelines emphasize early vascular access and state that intraosseous access should be established if intravenous access cannot be rapidly attained, even in children older than age 6 years. The revised guidelines, like their adult counter-
CARDIOPULMONARYRESUSCITATION/ KELLY D. YOUNG
parts, add amiodarone to the algorithm for VF/VT, and remove bretylium. Emphasis is placed on identifying treatable underlying causes of the arrest/ arrhythmia, using the mnemonic 4 H’s (hypovolemia, hypoxia, hypothermia, hyperkalemia, and other metabolic disorders) and 4 T’s (tension pneumothorax, tamponade, toxins, and primary thromboembolus). Vagal maneuvers (ice water to the face, Valsalva maneuvers such as blowing on a straw, and carotid massage) have been added as an option in the hemodynamically stable patient with supraventricular tachycardia. The guidelines for postarrest stabilization emphasize measures to improve neurologic outcome. Ventilation should be adequate but hyperventilation should be avoided, because lowered pC0, leads to cerebral vasoconstriction. Frequent reassessment and arterial blood gas analysis are important. Avoid hyperthermia and do not actively rewarm the patient unless the temperature is below 33°C. Glucose monitoring is also important, both for recognition of hypoglycemia and to avoid hyperglycemia. Hyperthermia and hyperglycemia have been associated with worsened neurologic outcomes. Myocardial function should be closely monitored, and circulation optimized with pressors as needed. Updated guidelines for neonatal resuscitation state that personnel capable of neonatal resuscitation should be present at every delivery. Suctioning for thick meconium with endotracheal intubation is recommended only for babies with absent or depressed respirations, heart rate less than 100 bpm, or poor muscle tone. Like pediatric patients, emphasis is placed on adequate ventilation and use of an end-tidal CO, detector for confirmation of endotracheal tube placement. Laryngeal mask airway and intraosseous access are listed as alternatives for newborns when standard airway management and vascular access techniques are unsuccessful. Again, the 2-thumbs encircling the thorax method of chest compressions is preferred. High-dose epinephrine is not recommended, because of an increased risk of intracranial hemorrhage. The 2000 guidelines state that children failing to achieve ROSC after at least 2 doses of epinephrine and CPR longer than 30 minutes are unlikely to survive. Unless there is recurring or refractory VF/ VT, a history of a toxic drug exposure, or a primary hypothermic insult, it is appropriate to discontinue resuscitation efforts. Recent research supports family member presence at resuscitations.12J3 Parents generally prefer to be present if given the option, and in the event of
their child’s death, parents may experience ier adjustment period.
83
an eas-
Prevention Although research and guidelines emphasize BLS, ALS, and postresuscitation interventions, prevention remains a critical, if not the most crucial, link in improving pediatric cardiopulmonary arrest survival. Citizen CPR has been shown to improve survival rates, yet less than one third of pediatric arrest patients receive citizen CPR. Parents, grandparents, older siblings, teachers, babysitters, and other care providers should be encouraged to learn pediatric BLS. Parents, physicians, and nurses caring for children must also be trained to recognize impending respiratory failure or shock before progression to cardiopulmonary arrest. Anticipatory guidance for parents on injury prevention (eg, water safety, car seat usage, bicycle helmet usage, drug and toxic substance storage) also play a key role in prevention. Special-needs children should carry a copy of the emergency information form developed by the American Academy of Pediatrics and the American College of Emergency Physicians. This form is available on the Internet (http:// www. pediatrics. org/cgi/conteniY~ll/lO4/4/e53) .I4
Summary Pediatric cardiopulmonary arrest carries a very poor prognosis that has not improved over the last few decades. Many unanswered questions remain regarding pediatric CPR and how best to improve survival and neurologic outcome. High-quality research is needed to resolve these issues. This research should consist of population-based, prospective studies using the case definitions and outcomes specified by the Utstein guidelines. Prevention as a critical link in the chain of survival deserves special emphasis and attention.
References 1. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: Pediatric Advanced Life Support. Circulation 102:1291-1342, 2000 (suPP I). 2. Young KD, Seidel JS: Pediatric cardiopulmonary resuscitation: A collective review. Ann Emerg Med 33: 195205, 1999. 3. Applebaum D, Slater PE: Should the mobile intensive care unit respond to pediatric emergencies? Clin Pediatr 25:620-623, 1986.
84
CARDIOPULMONARYRESUSCITATIONI KELLY D. YOUNG
4. Safranek DJ, Eisenberg MS, Larsen MP: The epidemiology of cardiac arrest in young adults. Ann Emerg Med 21:1102-1106, 1992. 5. Zaritsky A, Nadkarni V, Hazinski MF, et al: Recommended guidelines for uniform reporting of pediatric advanced life support: The pediatric Utstein style. Circulation 92:2006-2020, 199.5. 6. 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 20:861-874, 1991. 7. Sirbaugh PE, Pepe PE, Shook JE, et al: A prospective, population-based study of the demographics, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest. Ann Emerg Med 33: 174-184, 1999. 8. Standards and Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC). JAMA 2552961-2968, 1986. 9. Biros MH, Lewis RJ, Olson CM, et al: Informed consent in emergency research: Consensus statement
from the coalition conferences of acute resuscitation and critical care researchers. JAMA 273:1283-1287, 1995. 10. Gausche M, Lewis RJ, Stratton SJ, et al: Effect of out-of-hospital pediatric endotracheal intubation on survival and neurologic outcome: A controlled clinical trial. JAMA 283:783-790, 2000. 11. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 9: Pediatric basic life support. Circulation 102:1253-1290, 2000 (supp I). 12. Boie ET, Moore GP, Brummett C, et al: Do parents want to be present during invasive procedures performed on their children in the emergency Department? A survey of 400 parents. Ann Emerg Med 34:7074, 1999. 13. Robinson SM, Mackenzie-Ross S, Campbell Hewson CL, et al: Psychological effect of witnessed resuscitation on bereaved relatives. Lancet 352:614-617, 1998. 14. Committee on Pediatric Emergency Medicine, American Academy of Pediatrics: Emergency preparedness for children with special health care needs. Pediatrics 104:eS3, 1999.