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Successful closed-chest cardiopulmonary resuscitation (CPR), the fundamental life-saving skill, was first reported in 1960, and the American Heart Association (AHA) has published pediatric and neonatal resuscitation guidelines since 1980. Although CPR has been widely taught to healthcare providers (HCPs) and the public, it is only recently that survival from cardiac arrest has improved. This improvement has occurred in association with an emphasis on teaching, monitoring, and improving CPR quality; widespread implementation of lay-rescuer CPR and automated external defibrillation (AED) programs; increased frequency of dispatcher-guided lay-rescuer CPR; and improvements in postcardiac arrest care, including targeted temperature management. Published studies from both out-of-hospital and in-hospital registries have provided additional information about the epidemiology, presentation, and outcome of pediatric cardiopulmonary arrest (CPA) at different ages and in different settings. The AHA Guidelines for Pediatric Basic Life Support (PBLS) and Pediatric Advanced Life Support (PALS) are now based on a continuous, structured international evidence-based review process. The reviews, sponsored by the AHA and the International Liaison Committee on Resuscitation (ILCOR), are posted on ILCOR’s Web site (http://www.ilcor.org./home/), in the Systematic Evidence Evaluation and Review System.
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Neonatal resuscitation guidelines are jointly created by the AHA and the American Academy of Pediatrics. These guidelines target resuscitation in the delivery room, emphasizing establishment of effective ventilation, because inadequate airway and ventilation are the most common problems requiring newborn resuscitation. Neonatal resuscitation guidelines are typically applied during the initial hospitalization of the newborn. The AHA infant Basic Life Support (BLS) and CPR guidelines typically apply to the infant after the initial hospitalization until 1 year of age. If a newborn remains hospitalized for treatment of heart disease, it is appropriate to apply infant CPR guidelines to provide a higher compression-to-ventilation ratio consistent with focus on establishment of adequate blood flow as well as oxygenation and ventilation. The AHA PBLS and CPR guidelines apply to children from 1 year of age to puberty. Adult BLS guidelines apply to adolescents. For ease of teaching and practice, providers in a unit such as a pediatric cardiovascular intensive care unit (ICU) may elect to apply the infant and child CPR guidelines to all patients in the unit.
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In 2010, the AHA recommended a change in the initial sequence of CPR from ABC (airway, breathing, circulation/compressions) to CAB (circulation/compressions, airway, breathing). This change was made because the initial steps of opening the airway and delivering breaths are relatively complicated and often created long delays to initiating chest compressions. Although support of airway, oxygenation, and ventilation is especially important during pediatric cardiac arrest, this change in sequence should delay ventilation only by a few seconds, and is designed to shorten the overall time to initiation of CPR for all victims of cardiac arrest.
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Every step in resuscitation is important, including treating prearrest conditions when possible; immediately identifying the arrest itself and providing high-quality CPR; and seamlessly integrating shock delivery with CPR when needed. Skilled, evidence- and protocol-supported postcardiac arrest care, including targeted temperature management is critical.
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PATHOGENESIS AND ETIOLOGY OF CARDIAC ARREST
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The causes and types of cardiac arrest during infancy and childhood vary by age and arrest location and will affect the priorities of resuscitation. In the past, much of the evidence used to characterize pediatric cardiac arrest was based on extrapolation from adult series; however, in recent years, several pediatric cardiac arrest registries have provided a wealth of information about many characteristics of pediatric CPA.
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Multiple large pediatric out-of-hospital cardiac arrest series have been published from registries such as the Cardiac Arrest Registry to Enhance Survival (CARES; https://mycares.net/), the Resuscitation Outcomes Consortium (ROC; https://roc.uwctc.org) registry, and the all-Japan Utstein Registry. In the United States, the Get with the Guidelines-Resuscitation (GWTG-R) registry, formerly the National Registry of Cardiopulmonary Resuscitation (http://www.heart.org/HEARTORG/Professional/GetWithTheGuidelines-Resuscitation/Get-With-The-Guidelines-Resuscitation_UCM_314496_SubHomePage.jsp) has published multiple pediatric series. These registries collect data based on the reporting templates known as the Utstein criteria. Publications from registries such as these contribute substantially to our knowledge of pediatric prearrest, arrest and postarrest conditions, further informing the emphasis of the AHA PBLS and PALS Guidelines.
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Asphyxial Versus Sudden Cardiac Arrest
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There are 2 major types of CPA: those that occur secondary to progression of respiratory failure or shock (so-called asphyxial or hypoxic arrest) and those that occur as an abrupt cessation of cardiac function, called sudden cardiac arrest (SCA). These types of CPA can be further identified by the terminal cardiac rhythm. Bradycardia and pulseless electrical activity (PEA) are the most common terminal rhythms associated with asphyxial arrest; these rhythms are called “nonshockable” because shock delivery is not indicated to treat the arrest. Pulseless ventricular tachycardia (pVT) and ventricular fibrillation (VF) are the terminal rhythms associated with SCA; these rhythms are known as “shockable” rhythms because shock delivery is required. The incidence of each type of CPA varies with the age and condition of the child, and with the location and circumstances of the arrest. Resuscitation priorities vary with arrest type, the number of rescuers, and the location of the arrest.
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At birth, approximately 5% to 10% of newborns require some resuscitation, ranging from simple stimulation or clearing of the airway to support of ventilation and occasionally to chest compressions. Most neonates in distress demonstrate bradycardia, and most will respond to the establishment of effective ventilation.
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Asphyxial arrest is the most common type of CPA in infants and children. However, this type of arrest can occur in patients of any age with conditions such as respiratory failure, trauma, drowning, drug overdose, poisonings, metabolic disorders, and shock. In the United States, the most common causes of infant death include congenital malformations, disorders related to prematurity, sudden unexpected infant death (including sudden infant death syndrome [SIDS], suffocation, and strangulation) and injury. Injuries are the most common causes of childhood and adolescent death. See also Chapters 113 and 116.
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The infant or child often develops bradycardia as a preterminal event after asphyxia arrest. Bradycardia in children may also result from vagal stimulation (eg, induced by suctioning or gagging), from other causes of hypoxia, or from heart block. In the minutes before an asphyxial or bradycardic arrest, oxygen delivery to the tissues is compromised by low arterial oxygen content, by inadequate blood flow, or both, and major organ ischemia is likely to be present even before the arrest occurs. Resuscitation requires conventional CPR because support of effective oxygenation and ventilation, and compressions are needed to support oxygen delivery.
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The infant or child with SCA has pVT/VF that causes the abrupt cessation of cardiac function. This type of cardiac arrest is most common in adults but is less common in children, particularly before adolescence. SCA has been reported in young athletes following a blow to the chest (commotio cordis) and in infants and children with genetic anomalies of impulse formation and conduction (eg, channelopathies such as prolonged QT syndrome), congenital heart disease, coronary artery abnormalities, cardiac inflammation, cardiomyopathy, and drug toxicity. Because arterial oxygen content is normal at the time of SCA, immediate support of blood flow with chest compressions may maintain oxygen delivery for the first few minutes of the arrest. However, beyond the first minutes of arrest, arterial oxygen content declines rapidly, so conventional CPR is needed.
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Characteristics of Out-of-Hospital Arrest
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Estimates of the incidence of asphyxial arrest versus SCA are based on extrapolation from mortality data collected by the Centers for Disease Control and Prevention and from published case series and registry data. In general, two-thirds of out-of-hospital pediatric cardiac arrests are asphyxial, about two-thirds of victims are infants who arrest at home, most are unwitnessed, and about half of the victims receive bystander CPR. These characteristics provide important information for exploring causes and prevention of CPR, targeting CPR education to parents and caregivers, and establishing resuscitation priorities for dispatcher-guided CPR.
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Cardiac arrest in schools, particularly among student athletes, has stimulated grassroots efforts to establish CPR and AED programs in schools. Extrapolation from voluntary US databases suggests that approximately 1 per 100,000 high school athletes suffers from SCA annually, with the incidence higher in males and lower in females, and lower among nonathletes. In the United States, more than half of the SCA deaths in athletes are attributed to hypertrophic cardiomyopathy, commotio cordis (a blow to the chest that triggers ventricular tachycardia or fibrillation), or coronary artery anomalies. Some athletes or children with arrhythmias such as those caused by channelopathies may have syncopal episodes prior to the cardiac arrest event. Vigorous exercise can trigger lethal ventricular arrhythmias; many episodes of SCA in athletes occur during sporting events and are witnessed.
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Characteristics of In-Hospital Arrest
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Publications from the nearly 10,000 pediatric arrests in the GWTG-R registry have enabled the characterization of in-hospital arrest in children. Most children with in-hospital cardiac arrest have prearrest respiratory insufficiency, shock, or congestive heart failure. The most common intermediate causes of arrest are hypotension, acute respiratory insufficiency, and arrhythmias. PEA or asystole is the terminal rhythm in two-thirds of the arrests. Of the children with initial pVT/VF, approximately half have a cardiac illness or surgical condition, and prearrest vasoactive infusions have been identified as proarrhythmic factors. Although pVT/VF is not a common initial arrest rhythm, VF is present at some time during resuscitation in approximately 25% of pediatric in-hospital arrests, so providers must be facile at integrating shock delivery with high-quality CPR.
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RESPIRATORY AND CARDIAC ARREST: CLINICAL MANIFESTATIONS
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Respiratory arrest is defined as the cessation of spontaneous respiratory activity in the presence of spontaneous circulation (palpable central pulses). The development of hypoxemia and tissue hypoxia will produce bradycardia and poor perfusion. Detection and immediate treatment of respiratory arrest and symptomatic bradycardia often prevent progression to CPA.
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Cardiopulmonary Arrest
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Cardiopulmonary arrest is defined as the cessation of effective cardiac mechanical function and systemic perfusion. The victim is unconscious/unresponsive, with apnea or agonal gasps and with no palpable central pulses. Agonal gasps may be mistaken for effective spontaneous breathing, delaying the identification of cardiac arrest. They are much more common in the first minutes of SCA but are uncommon in children with asphyxial cardiac arrest. Agonal gasps can increase pulmonary gas exchange if the airway is patent. Gasps can also enhance venous return and create some coronary and carotid perfusion during the first minutes of arrest.
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Once cardiac arrest develops, oxygen delivery ceases. Unless CPR is provided and spontaneous rhythm and perfusion are restored, the myocardium, brain, and all tissues will become progressively ischemic, and the likelihood of successful resuscitation diminishes with every passing minute. Generation of lactic acid, increased cell membrane permeability, production of free oxygen radicals, and activation of inflammatory mediators contribute to progressive organ and tissue destruction.
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Pulseless Electrical Activity and Asystole
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Pulseless electrical activity is a term used to describe cardiac electrical activity that fails to produce sufficient mechanical function to generate a palpable central pulse. Although this term could encompass agonal (eg, bradyasystolic) rhythms, it is typically reserved for patients with narrow QRS complexes that fail to produce a palpable pulse. Reversible causes of PEA in children include tension pneumothorax, cardiac tamponade, hypovolemia, and, rarely, pulmonary embolus. If PEA is not promptly treated, the rhythm will ultimately deteriorate to asystole.
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Asystole is the ultimate terminal rhythm, characterized by electrical silence. Asystole is likely to be present for any unwitnessed or prolonged arrest, and it is the most common rhythm reported in pediatric prehospital and in-hospital arrest. Although overall survival with asystole or PEA is poor, survival is higher among children than adults who present with these rhythms in in-hospital arrests.
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Ventricular Tachycardia and Fibrillation
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Just as in adults, children in cardiac arrest who present with pVT/VF in the out-of-hospital or in-hospital setting typically have higher survival rates than those presenting with PEA or asystole. Untreated pVT will rapidly progress to VF, so treatment of these rhythms is identical and the rhythms are considered together in treatment algorithms.
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During the first few minutes of VF, the amplitude of the VF will be high (so-called good VF), indicating that the myocardium initially has adequate oxygen and substrates. High-quality CPR can help maintain myocardial oxygenation and the amplitude and duration of VF (before it deteriorates to asystole). Rapid shock delivery is likely to result in elimination of the VF, enabling return of spontaneous cardiac rhythm and return of spontaneous circulation (ROSC). It is important to note that typically there is a delay between elimination of VF and ROSC, so CPR is needed until the shock can be delivered and after shock delivery until ROSC occurs.
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If the VF remains untreated (ie, no CPR or shock delivery) for several minutes after arrest, the VF amplitude will gradually decrease (so-called bad VF), indicating severe myocardial ischemia. At this point, shock delivery is less likely to eliminate the VF; multiple shocks may be required. Even if VF is eliminated, return of spontaneous rhythm and return of spontaneous cardiac rhythm are less likely.
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Untreated VF will ultimately progress to asystole. Once asystole is present, shock delivery will not be effective. High-quality CPR may result in the reappearance of VF (so-called secondary VF) that may respond to shock delivery, although the survival of patients who present with secondary VF is much lower than that of patients who present with VF as their initial rhythm.
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RESPIRATORY AND CARDIAC ARREST: MANAGEMENT
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Respiratory Arrest and Bradycardia
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The child with respiratory failure, shock, or respiratory arrest typically develops bradycardia with poor perfusion before developing pulseless arrest. If rescuers detect and treat respiratory arrest and bradycardia before the development of pulseless arrest, survival is typically 75% or higher in both out-of-hospital and in-hospital settings.
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Symptomatic bradycardia (ie, bradycardia with signs of poor perfusion) and respiratory arrest are both treated with support of airway, oxygenation, and ventilation through provision of bag-mask ventilation with oxygen. If the heart rate and perfusion improve but ventilation remains inadequate, mechanical ventilation is indicated. If the child’s heart rate remains at or below 60 beats per minute with signs of poor perfusion despite support of adequate oxygenation and ventilation, chest compressions are added to the bag-mask ventilation (ie, CPR is provided).
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When symptomatic bradycardia persists despite bag-mask ventilation and compressions, epinephrine is the drug of choice. Rescuers should consider using atropine for symptomatic bradycardia with increased vagal tone or when primary heart block is present. Cardiac pacing may also be needed.
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Opiate overdose has emerged as a common cause of death in young adults. If the lay first responder or HCP encounters a victim of respiratory arrest with suspected drug overdose, naloxone administration is added to interventions such as bag-mask ventilation and CPR as indicated.
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Cardiopulmonary Arrest
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Once cardiopulmonary arrest is present, immediate high-quality CPR is needed because CPR maintains a small but critical amount of blood flow (estimated at 10% to 33% of normal) and oxygen and substrate delivery to the heart, brain, and other organs. Performing CPR can prolong VF and can maintain or increase VF amplitude. This increases the window of opportunity for shock delivery and increases the likelihood that the shock delivery will be followed by return of spontaneous cardiac rhythm and ROSC.
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Cardiopulmonary Resuscitation Sequence
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The appropriate sequence for pediatric resuscitation is determined by the type and location of the arrest and the type of rescuers and equipment available. A lone HCP must choose a sequence of actions, while multiple rescuers are able to accomplish several resuscitation steps simultaneously.
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For the out-of-hospital arrest of a child or likely victim of asphyxial arrest, CPR focuses on initiation of high-quality conventional CPR. The lone HCP (with no nearby help or mobile phone) delivers about 5 cycles or about 2 minutes of CPR before leaving the victim to activate the emergency response system and retrieve an AED. The rescuer then returns to the victim to resume CPR and use the AED. If multiple bystanders are present during the out-of-hospital arrest, 1 rescuer remains with the victim to provide high-quality CPR while others activate the emergency response system and retrieve an AED.
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During an in-hospital arrest, multiple rescuers are generally present to accomplish many tasks at the same time. The first HCP to identify cardiac arrest calls for nearby help and initiates resuscitation. As additional rescuers arrive with equipment, they will perform tasks such as providing bag-mask ventilation, attaching the adhesive defibrillator electrode pads and operating the defibrillator, establishing vascular access, serving as an alternate compressor, recording the resuscitation events, and functioning as team leader.
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High-Quality Cardiopulmonary Resuscitation Technique
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The elements of high-quality CPR are compressions of adequate rate and depth, complete chest recoil after each compression, minimal number and duration of any interruptions in chest compressions, and avoidance of excessive ventilation.
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During CPR, the child should be placed supine on a firm, flat surface. A backboard is generally used as this surface.
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Chest Compressions of Adequate Rate and Depth
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Chest compressions create blood flow by increasing intrathoracic pressure and by directly compressing the heart. Myocardial blood flow is determined by the coronary perfusion pressure present between compressions. Coronary perfusion pressure is calculated as the difference between aortic end-diastolic pressure (during CPR, this is the aortic relaxation pressure) and the mean right atrial pressure; the mean CVP may be used as a surrogate for right atrial pressure. In adults with cardiac arrest, a coronary perfusion pressure greater than 15 mm Hg has been linked with ROSC. Although a similar threshold has not been established in children, if arterial and right atrial or central venous monitoring catheters are in place, rescuers should attempt to optimize coronary perfusion pressure by maximizing aortic relaxation pressure and minimizing right atrial and central venous pressure (see “Monitoring During Cardiopulmonary Resuscitation,” below).
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During CPR, blood flow, mean aortic relaxation pressure, and mean coronary perfusion pressure are increased by increasing the rate and force of chest compressions, and these variables are reduced when compressions are of either inadequate or excessive rate or inadequate depth. If the compression rate is too slow, blood flow generated by the compressions is inadequate. If the chest compression rate is too rapid, the depth of compressions may be compromised and chest recoil between compressions may be incomplete. The AHA-recommended chest compression rate for infants, children, and adults is 100 to 120 per minute.
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The sternum is depressed approximately one-third the depth of the chest in the newborn and at least one-third the depth of the chest (about 1.5 in, or 4 cm) in the infant. The lone rescuer uses 2 fingers to compress the newborn or infant sternum, just below the intermammary line. When 2 HCPs are delivering CPR to the newborn or infant, the compressor uses the 2-thumb-encircling hands chest compression technique. The compressor’s 2 thumbs are placed together on the sternum to depress the sternum (the thumbs can be placed side by side or they may overlap), while the fingers of both hands spread to encircle the thorax. The 2-thumb-encircling hands technique generates better coronary perfusion pressure and enables creation of more accurate depth of compression, and it may produce higher systolic and relaxation pressures with less rescuer fatigue than the 2-finger compression method.
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Chest compressions in the child 1 year of age to puberty may be accomplished with 1 or 2 hands, whichever allows compression of the lower third of the sternum to a depth of at least one-third the depth of the chest and about 2 inches (5 cm). For chest compressions in the adolescent (after puberty) the traditional adult 2-hand technique is used to compress over the lower third of the sternum to a depth of 2 to 2.4 inches (5–6 cm). While excessive compression depth in adults can cause injuries such as rib fractures, inadequate compression depth is the more common problem and clearly reduces blood flow, coronary perfusion pressure, ROSC, and even survival from cardiac arrest.
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Many CPR feedback devices are commercially available to provide visual and auditory indication and documentation of rate and depth of chest compressions and other resuscitation variables. These devices may be used for training and in actual resuscitations (see “Continuous Quality Improvement,” below).
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Complete Chest Recoil after Each Compression
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If rescuers fail to allow the chest wall to recoil completely after each compression, venous return to the heart is decreased, elevating right atrial pressure and reducingcoronary perfusion pressure. In addition, it prevents venous return to the heart and reduces the blood flow generated by the next compression. Rescuers who become fatigued while providing compressions are more likely to lean on the chest, failing to allow complete chest wall recoil. For this reason, during CPR, rescuers should rotate compressors about every 2 minutes (or more often if the compressor becomes fatigued or compression quality declines), and should monitor for and reduce leaning.
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Minimal Interruptions in Chest Compressions
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Aortic relaxation pressure and coronary perfusion pressure fall whenever chest compressions are interrupted (eg, when breaths are provided or when compressions are interrupted to check rhythm or deliver a shock). Frequent or prolonged interruptions in chest compressions reduce mean coronary perfusion pressure, ROSC, and survival. Interruptions should, therefore, be minimized during CPR and rescuers should monitor the frequency and duration of any interruptions and strive to reduce them. The chest-compression fraction (CCF) is the total CPR time spent delivering compressions. The CCF should be at least 60% of total CPR time and the resuscitation team should strive for a CCF goal exceeding 80% of total CPR time.
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Avoid Excessive Ventilation
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It is important to avoid excessive ventilation during CPR. When cardiac arrest is present, pulmonary blood flow, carbon dioxide delivery to the lungs, and oxygen uptake from the lungs are approximately 10% to 33% of normal, so victims need only a fraction of normal minute ventilation to match ventilation to perfusion during CPR. Excessive ventilation is harmful because it will reduce coronary perfusion pressure and blood flow during CPR. It will create positive intrathoracic pressure, reduce venous return to the heart, and reduce coronary perfusion and systemic and cerebral blood flow and survival.
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The optimal compression-to-ventilation ratio for pediatric resuscitation is unknown. For pediatric CPR, the AHA recommends a 30:2 compression-to-ventilation ratio for single rescuers and a 15:2 ratio for 2 or more rescuers. Once an advanced airway is placed, rescuers should no longer deliver cycles of compressions and breaths. Instead, the rescuer performing compressions should deliver continuous chest compressions, and the rescuer providing ventilation should deliver approximately 10 breaths per minute (1 breath every 6 seconds).
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Continuous Chest Compressions versus Conventional CPR
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Since 2008, the AHA has recommended Hands-Only/compression-only CPR for treatment of adult sudden witnessed cardiac arrest, particularly if the bystander is untrained or unwilling to provide mouth-to-mouth ventilation. The purpose of this recommendation was to increase the portion of victims of out-of-hospital cardiac arrest who receive some bystander CPR before the arrival of EMS providers. Because most pediatric cardiac arrest is asphyxial in origin, the AHA continues to recommend conventional CPR for infants and children with out-of-hospital cardiac arrest. This recommendation has been supported by pediatric data from out-of-hospital registries, with conventional CPR associated with higher survival than compression-only CPR, particularly in infants and particularly when asphyxial arrest is present.
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Advanced Cardiopulmonary Resuscitation Techniques
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Open-chest CPR can produce nearly normal blood flow but is impractical for most resuscitation situations. This technique is often used in the immediate postoperative period for pediatric cardiovascular surgical patients, when the chest is left open or the sternotomy can be opened quickly.
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Extracorporeal cardiopulmonary resuscitation (ECPR) is the use of extracorporeal membrane oxygenation (ECMO) during attempted resuscitation. Extracorporeal cardiopulmonary resuscitation has been successful for pediatric in-hospital resuscitation, particularly among children with heart disease (see Chapter 108). The timely implementation of ECMO may also be effective for preventing cardiac arrest among children with low cardiac output (eg, following cardiovascular surgery), septic shock, myocarditis, and cardiomyopathy.
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Monitoring during Cardiopulmonary Resuscitation
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Cardiopulmonary Resuscitation Feedback Devices
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Several elements of CPR quality may be monitored and recorded, with devices that provide visual and auditory signals. These feedback devices range from relatively simple accelerometers to more complicated feedback defibrillators. The thresholds provided on the defibrillator screens and in recordings are typically consistent with a minimum 2-inch (5-cm) depth of acceptable chest compressions. These feedback defibrillators can be used to monitor the ECG, shock delivery, depth and rate of compressions, frequency and volume of breaths, and frequency and duration of any interruptions in chest compressions. This information is critical for team debriefing following every arrest as well as to set goals and monitor progress for improving CPR quality and survival in any resuscitation system.
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Exhaled or End-Tidal Carbon Dioxide Tension
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Under normal conditions, the carbon dioxide tension in exhaled gas should be approximately equal to the carbon dioxide tension in both alveolar gas and pulmonary capillary blood. In very low flow states, if minute ventilation is fixed, the end-tidal carbon dioxide (CO2) pressure (PETCO2) will vary with cardiac output. When cardiac arrest develops, blood flow to the lungs stops, so the CO2 tension in the pulmonary capillaries, alveoli, and exhaled gas approaches zero. When effective chest compressions generate adequate pulmonary blood flow, the CO2 delivered to the lungs and the partial pressure of CO2 in exhaled gas should rise. ROSC is associated with a sharp and sustained rise in the PETCO2.
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In intubated adult victims of cardiac arrest, a PETCO2 less than 10 mm Hg despite 20 minutes of resuscitation is associated with very low survival. Although a similar threshold has not been identified in children, if the PETCO2 remains less than 10 mm Hg, providers should make additional efforts to optimize CPR quality. Waveform capnography should be used for these measurements rather than intermittent colorimetric exhaled CO2 monitors.
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Estimating Coronary Perfusion Pressure
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Most hospitalized children who develop cardiac arrest are in the ICU (rather than in the general care ward), and invasive monitoring catheters may already be in place. If an intra-arterial and a central venous or right atrial catheter are in place, the coronary perfusion pressure can be estimated by subtracting the right atrial or central venous pressure from the aortic relaxation pressure (it will appear as the aortic diastolic pressure). The CPR technique should be optimized to maximize the estimated coronary perfusion pressure.
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Because AED algorithms have been shown to be accurate in interpreting pediatric rhythms, the AHA recommends AED use for children ages 1 to 8 years in cardiac arrest, particularly for out-of-hospital arrest. Ideally, rescuers should use an AED with pediatric pads and a pediatric dose attenuator to deliver a shock dose appropriate for a small victim. However, if an AED with pediatric pads and dose attenuator is not available, rescuers should use an AED with adult pads. The pads should be placed according to the illustrations on the pads. They should not touch or overlap.
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When an infant requires defibrillation, the use of a manual defibrillator is preferred to the use of an AED, because the dose can be more closely adjusted. If a manual defibrillator is not available, an AED with pediatric pads and a pediatric dose attenuator should be used. If such an AED is not available, an adult AED (one that administers an adult dose through adult pads) should be used.
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When both pediatric and adult pads are available with the AED, it is important to use pediatric pads only for victims less than 8 years of age. If the pediatric pads are used for an older child, an adolescent, or an adult, they will likely attenuate the shock dose to one that is too small to eliminate VF in the larger victim.
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For in-hospital manual defibrillation, rescuers should use infant pads or paddles for attempting defibrillation in infants up to 1 year of age and should use larger pads or paddles for patients 1 year of age and older. Rescuers should use the pads recommended by the defibrillator manufacturer.
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Most commercially available defibrillators now use a biphasic waveform, while older defibrillators used a monophasic waveform. There are very limited data available regarding optimal manual biphasic waveform shock dose for defibrillation of children. In pediatric data from the GWTG-R in-hospital registry, an initial dose of 1 to 3 J/kg was associated with higher ROSC than a dose of more than 3 to 5 J/kg. The AHA recommends an initial shock of 2 J/kg. If the 2 J/kg initial dose fails to eliminate VF, rescuers should use a 4 J/kg dose for the second shock. For subsequent shocks, a dose of 4 J/kg is reasonable and a higher dose (up to a maximum of 10 J/kg) may be considered.
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More research regarding the optimal defibrillation dose is needed. In general, weight-based defibrillation dosing may not be optimal, because the dose or current delivered to the myocardium is influenced not only by paddle or pad size and energy dose but also by transthoracic impedance, and transthoracic impedance is not linearly related to body weight. In the future, current-based defibrillation would make more sense than energy-based defibrillation.
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Organization of Pediatric Resuscitation
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Resuscitation is organized around 2-minute periods of uninterrupted CPR. Once a defibrillator is attached, the rhythm is checked every 2 minutes and a shock is delivered if pVT/VF is present. When CPR is interrupted for shock delivery, rescuers should have the defibrillator charged and should deliver the shock within 10 seconds or less of the last chest compression, then should resume chest compressions immediately after shock delivery. Shock effectiveness (ie, likelihood of termination of VF and ultimate ROSC) decreases with every 10 seconds that elapse between the last compression and the shock delivery. When a shock eliminates VF, the most common rhythm for 30 to 60 seconds after shock delivery is asystole or PEA, so compressions are needed immediately after shock delivery.
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During resuscitation, the potential benefits of inserting an advanced airway should be weighed against the detrimental effects of the intubation attempt itself. Bag-mask ventilation for short periods may be as effective as ventilation through an advanced airway, but this form of ventilation requires training and frequent retraining. Inserting an advanced airway will enable delivery of uninterrupted chest compressions and may reduce gastric insufflation (and its attendant risks of regurgitation and aspiration), but it does require training and experience and will require interruption of chest compressions.
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During resuscitation, the most experienced provider should perform intubation, with careful preparation and coordination of rescuer activities to minimize interruptions in chest compressions. Once the advanced airway is inserted, rescuers should also confirm placement using clinical examination plus a device such as a quantitative waveform capnography. If waveform capnography is not available, a qualitative colorimetric exhaled carbon dioxide detector may be used after several positive pressure breaths have been given. If the child weighs more than 20 kg, rescuers may use esophageal detector devices to confirm tracheal tube placement. These devices use suction to determine the ease with which gas can be withdrawn from the tube; the esophagus collapses easily under suction, preventing gas withdrawal, but the trachea is rigid and allows easy withdrawal of gas. Rescuers should verify correct tube position when the patient is transported and, during postcardiac arrest care, whenever the intubated child suddenly deteriorates.
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Although no drug has been shown to increase survival from pediatric cardiac arrest, the use of vasoconstrictors has been shown to increase blood pressure and coronary and cerebral blood flow and return of spontaneous cardiac rhythm in animals. Drugs with beta-adrenergic effects also increase spontaneous myocardial depolarization and contractility. The AHA recommends administering a standard dose of intravenous (IV) epinephrine (0.01 mg/kg) every 3 to 5 minutes during cardiac arrest.
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During resuscitation, intravenous or intraosseous drug administration is preferable to endotracheal administration (see Chapter 100). Although lipid-soluble drugs can be administered by the endotracheal route, drug absorption is poor and unpredictable, and optimal drug doses for this route of administration are unknown. In fact, the lower blood concentrations of epinephrine resulting from endotracheal administration could produce undesirable vasodilatory β-2 adrenergic effects.
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Intravenous high-dose epinephrine (HDE) is no longer recommended for routine use in pediatric resuscitation, because it is associated with decreased survival and neurological outcomes. Although HDE can increase the return of spontaneous cardiac rhythm, it can also increase postcardiac arrest myocardial oxygen consumption, myocardial dysfunction, and hemodynamic instability.
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When shock-refractory VF is present, either amiodarone (5 mg/kg dose, to a maximum of 3 doses) or lidocaine (1 mg/kg dose) may be given as an antiarrhythmic. Because amiodarone can produce hypotension and arrhythmias, expert consultation is advised when the drug is considered for treatment of prearrest or postcardiac arrest arrhythmias.
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Magnesium administration is indicated for treating torsades de pointes and when hypomagnesemia is documented or strongly suspected. However, it is no longer used routinely during resuscitation.
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Termination of Resuscitation Efforts
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There are no intra-arrest factors that reliably predict poor resuscitation outcomes. In the out-of-hospital setting, age less than 1 year, unwitnessed arrest, no bystander CPR, and nonshockable rhythm on EMS arrival are associated with poor outcome. In the in-hospital setting, age greater than 1 year and longer duration of cardiac arrest have been associated with poor outcome. However, no single factor predicts outcome, and recent emphases on CPR quality, and improved postcardiac arrest care could all have a significant positive impact on CPR outcomes.
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Postcardiac Arrest Care
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Following ROSC, ischemic and reperfusion injuries can cause cardiorespiratory instability, perfusion abnormalities, and organ dysfunction. Reperfusion injury is characterized by calcium entry into cells, activation of inflammatory mediators, and cell death. This inflammatory response includes the development of endothelial injury, capillary leak, neutrophil activation, platelet aggregation, and increases in mediators such as tumor necrosis factor and interleukins. Increased production of free oxygen radicals and decreased production of nitric oxide can cause vasoconstriction and further ischemic injury. Hyperglycemia is common in children after an arrest, and both extreme hyperglycemia and hypoglycemia have been linked with increased mortality in children.
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Skilled postcardiac arrest care in adults has more than doubled neurologically intact survival to hospital discharge. Such care requires evidence-based and protocol-driven bundled care, including targeted temperature management and support of organ system function.
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Following ROSC, rescuers must begin targeted temperature management, optimize hemodynamic support, titrate inspired oxygen administration, and support of ventilation to maintain normoxemia (unless cyanotic heart disease is present) and partial pressure of carbon dioxide (PaCO2) appropriate for that patient, and support end-organ function. The use of protocols will support consistent care that can then be evaluated and modified as needed.
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Children often demonstrate a brief period of spontaneous hypothermia followed by the development of hyperthermia after cardiac arrest. While hyperthermia is associated with worse neurological outcome, the recent Therapeutic Hypothermia to Improve Survival After Cardiac Arrest in Pediatric Patients (THAPCA, see http://www.THAPCA.gov) clinical trials network failed to show any benefit of induced hypothermia when compared to normothermia after out-of-hospital cardiac arrest. Results following in-hospital cardiac arrest are anticipated soon. Thus, at present, it is appropriate to recommend controlled normothermia and avoidance of hyperthermia in this at-risk population.
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Continuous Quality Improvement
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Every resuscitation program or setting must develop a process of continuous quality improvement. This process requires measurement of CPR quality, monitoring and review of resuscitation outcomes and techniques, and frequent opportunities for retraining. If the resuscitation team is not measuring performance, they cannot hope to improve it.
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The availability of CPR courses for lay rescuers, including “CPR in schools” programs, can increase bystander CPR for out-of-hospital cardiac arrest. However, in addition to structured training programs, training opportunities must expand beyond the classroom. Opportunities to learn about CPR and to practice compressions are now offered to the lay public through kiosks in locations such as airports and through distribution of inflatable take-home manikins with instructions provided on a DVD.
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All EMS dispatchers should use protocols to enable them to rapidly identify a likely cardiac arrest and guide untrained rescuers to initiate CPR; their effectiveness must be evaluated by documenting time to cardiac arrest identification and time to CPR initiation as part of the EMS system of continuous quality improvement. Voluntary registration of bystanders willing to perform CPR has enabled a type of “crowd sourcing” that has been effective in summoning rescuers to the scene of an out-of-hospital arrest. Smartphone programs are also available to guide rescuers through the steps of CPR by pacing compressions to the correct rate and reminding rescuers of CPR sequences and steps. These and other innovations are needed to increase the likelihood and quality of bystander CPR.
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It is now clear that HCPs must regularly practice the skills and teamwork of resuscitation. However, the precise training duration and retraining interval needed to achieve and maintain resuscitation skills has not been established, and likely differs among HCPs who perform resuscitation frequently and those who rarely perform resuscitation. Providers need opportunities to refresh skills, particularly “just in time” training. Training with the use of realistic simulators holds promise to improve HCP skills and performance.
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Team debriefing immediately following an attempted resuscitation is essential to team improvement in subsequent resuscitations. Such debriefing requires objective and professional discussion of team performance and identification of opportunities for improvement.
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Ideally, successful treatment of prearrest conditions will prevent arrest or at least minimize potential organ ischemia before arrest ensues. In the in-hospital setting, a pediatric cardiac arrest outside of the ICU should be a rare event, and should trigger careful evaluation of the child’s prearrest care and remediation of any shortcomings in assessment or treatment. Although rapid response or medical emergency teams may reduce the incidence of non-ICU pediatric arrests, the published success rates of these teams have varied widely.
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