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PEDIATRIC CARDIAC ARREST

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In contrast to cardiopulmonary arrest in adults, most incidences of cardiopulmonary arrest in children are preceded by respiratory failure including hypoxia and hypercarbia. A number of conditions can lead to respiratory failure followed by cardiac arrest, including sepsis, respiratory disease, submersion, trauma, electrolyte and metabolic abnormalities, and sudden infant death syndrome (SIDS). Although the conditions represent the minority of incidences, spontaneous cardiac arrests with initial rhythms of ventricular fibrillation (VF) and ventricular tachycardia (VT) not preceded by any apparent illness also can occur.

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Unfortunately, pediatric victims of cardiac arrest have low survival rates. Although survival rates from in-hospital ­cardiac arrest has increased from 9 to 27% over the past 30 years, no increase has been shown in survival rate from out-of-hospital cardiac arrest with survival stagnating at 6%. Possible reasons for hospital-based increase in survival include rapid recognition of pediatric cardiac arrest, rapid response teams, and availability of pediatric specialists to give immediate care to critically ill children whereas out-of-­hospital arrests lack these advantages. Although cardiopulmonary resuscitation (CPR) increases survival rate, fewer than 50% of pediatric cardiac arrest patients receive bystander CPR.

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Nothing causes greater concern, fear, and anxiety in a clinician than a major pediatric resuscitation. The successful art of caring for children in cardiac arrest requires a calm and organized team approach. The advent of standardized resuscitation guidelines in the 1980s has aided clinicians in providing the best possible care to critically ill children, and mastery of pediatric advanced life support (PALS) guidelines is important for optimal care of the arresting child. Although PALS is a standard to guide care, resuscitative efforts can go beyond it, including the use of ultrasound, quantitative calorimetric monitoring, and continuous CPR.

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Additionally, to optimize outcomes it is vital to recognize signs of shock and respiratory failure early on, before cardiopulmonary arrest occurs. It is also important to have a good understanding of the conditions that can lead up to cardiopulmonary arrest. In many patients, prompt treatment of reversible causes and early resuscitation when indicated will avert impending arrest.

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APNEIC/PULSELESS CHILD

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Once a child is recognized to be pulseless and/or apneic, PALS algorithms are instituted. A variety of advanced airway management techniques may be used to achieve oxygenation and ventilation. Cardiopulmonary resuscitation should be instituted for all pulseless rhythms or bradycardic infants with aims at circulating blood. Rhythm analysis and electrical stabilization is a priority with a final goal of perfusing oxygenated blood to vital organs, thereby reducing ischemic damage and preserving vital organ function. Actions that are listed in series on PALS algorithms are often performed in parallel by the resuscitating team but directed in a stepwise fashion.

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ADJUNCTIVE GUIDES THAT REDUCE ERROR

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Adult resuscitation medications have prefilled dosed syringes that reduce medication errors; however, pediatric drugs must be calculated in mg/kg to be dosed correctly. A number of ...

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