Automated External Defibrillators and Secondary Prevention of Sudden Cardiac Death Among Children and Adolescents

Sudden cardiac death is devastating at any age, but it is especially so among children and adolescents. This report discusses the outcomes for patients with out-of-hospital cardiac arrest (OHCA) and describes public access defibrillation programs in general and those directed at children and adolescents. In addition, the relatively new concept of cardiopulmonary resuscitation (CPR)–automated external defibrillator (AED) programs directed at schools is discussed. Although limited data are available, some of the preliminary data suggest improved OHCA outcomes associated with CPR-AED programs implemented in schools. These early data provide hope for the future potential reduction in the incidence of sudden cardiac deaths in the school setting, not only among children and adolescents, but also among adults.     

Ventricular fibrillation and the use of automated external defibrillators on children

The use of automated external defibrillators (AEDs) has been advocated in recent years as one part of the chain of survival to improve outcomes for adult cardiac arrest victims. When AEDs first entered the market, they had not been tested for pediatric usage and rhythm interpretation. In addition, the presumption was that children do not experience ventricular fibrillation, so they would not benefit from the use of AEDs. Recent literature has shown that children do experience ventricular fibrillation, which has a better outcome than do other cardiac arrest rhythms. At the same time, the arrhythmia software on AEDs has become more extensive and validated for children, and attenuation devices have become available to downregulate the energy delivered by AEDs to allow their use on children. Pediatricians are now being asked whether AED programs should be implemented, and where they are being implemented, pediatricians are being asked to provide guidance on the use of them on children. As AED programs expand, pediatricians must advocate on behalf of children so that their needs are accounted for. For pediatricians to be able to provide guidance and ensure that children are included in AED programs, it is important for pediatricians to know how AEDs work, be up-to-date on the literature regarding pediatric fibrillation and energy delivery, and understand the role of AEDs as life-saving interventions for children.     

Relación entre el estado de gravedad previo y el pronóstico de la parada cardiaca intrahospitalaria

ObjectivesTo analyze the relationship between previous severity of illness, lactic acid, creatinine and inotropic index with mortality of in-hospital cardiac arrest (CA) in children, and the value of a prognostic index designed for adults.MethodsThe study included total of 44 children aged from 1 month to 18 years old who suffered a cardiac arrest while in hospital. The relationship between previous severity of illness scores (PRIMS and PELOD), lactic acid, creatinine, treatment with vasoactive drugs, inotropic index with return of spontaneous circulation and survival at hospital discharge was analyzed.ResultsThe large majority (90.3%) of patients had a return of spontaneous circulation, and 59% survived at hospital discharge. More than two-thirds (68.2%) were treated with inotropic drugs at the time of the CA. The patients who died had a higher lactic acid before the CA (3.4 mmol/L) than survivors (1.4 mmol/L), P=.04. There were no significant differences in PRIMS, PELOD, creatinine, inotropic drugs, and inotropic index before CA between patients who died and survivors.ConclusionA high lactic acid previous to cardiac arrest could be a prognostic factor of in-hospital cardiac arrest in children.     

Automated external defibrillators: safety and efficacy in children and adolescents

Although children do not suffer from ventricular fibrillation (VF) as frequently as adults, it does occur in 10% to 20% of pediatric cardiac arrests. The technology is available to recognize and treat ventricular fibrillation in children as quickly as we can for adults. This article discusses the evidence to support automated external defibrillator use in young children. As this technology gains increased acceptance, resuscitation rates and outcomes for VF in children should approach those that are seen in adults.     

Role of pediatricians in advocating life support training courses for parents and the public

Available literature suggests a need for both initial cardiopulmonary resuscitation basic life support training and refresher courses for parents and the public as well as health care professionals. The promotion of basic life support training courses that establish a pediatric chain of survival spanning from prevention of cardiac arrest and trauma to rehabilitative and follow-up care for victims of cardiopulmonary arrest is advocated in this policy statement and is the focus of an accompanying technical report. Immediate bystander cardiopulmonary resuscitation for victims of cardiac arrest improves survival for out-of-hospital cardiac arrest. Pediatricians will improve the chance of survival of children and adults who experience cardiac arrest by advocating for cardiopulmonary resuscitation training and participating in basic life support training courses as participants and instructors.     

Automatic external defibrillation in a 6 year old.

A case is reported in which an automatic external defibrillator (AED) was used during the successful resuscitation of a 6 year old child in out-of-hospital cardiac arrest, despite the fact that these devices are not recommended in children under 8 years. The interpretation of resuscitation protocols is discussed and new developments in this area reported.     

Automatic external defibrillation in a 6 year old

A case is reported in which an automatic external defibrillator (AED) was used during the successful resuscitation of a 6 year old child in out-of-hospital cardiac arrest, despite the fact that these devices are not recommended in children under 8 years. The interpretation of resuscitation protocols is discussed and new developments in this area reported.     

Basic and advanced paediatric cardiopulmonary resuscitation - guidelines of the Australian and New Zealand Resuscitation Councils 2010

Guidelines for basic and advanced paediatric cardiopulmonary resuscitation (CPR) have been revised by Australian and New Zealand Resuscitation Councils. Changes encourage CPR out-of-hospital and aim to improve the quality of CPR in-hospital. Features of basic CPR include: omission of abdominal thrusts for foreign body airway obstruction; commencement with chest compression followed by ventilation in a ratio of 30:2 or compression-only CPR if the rescuer is unwilling/unable to give expired-air breathing when the victim is 'unresponsive and not breathing normally'. Use of automated external defibrillators is encouraged. Features of advanced CPR include: prevention of cardiac arrest by rapid response systems; restriction of pulse palpation to 10 s to diagnosis cardiac arrest; affirmation of 15:2 compression-ventilation ratio for children and for infants other than newly born; initial bag-mask ventilation before tracheal intubation; a single direct current shock of 4 J/kg for ventricular fibrillation (VF) and pulseless ventricular tachycardia followed by immediate resumption of CPR for 2 min without analysis of cardiac rhythm and avoidance of unnecessary interruption of continuous external cardiac compressions. Monitoring of exhaled carbon dioxide is recommended to detect non-tracheal intubation, assess quality of CPR, and to help match ventilation to reduced cardiac output. The intraosseous route is recommended if immediate intravenous access is impossible. Amiodarone is strongly favoured over lignocaine for refractory VF and adrenaline over atropine for severe bradycardia, asystole and pulseless electrical activity. Family presence at resuscitation is encouraged. Therapeutic hypothermia is acceptable after resuscitation to improve neurological outcome. Extracorporeal circulatory support for in-hospital cardiac arrest may be used in equipped centres.     

Cardiac arrest and post resuscitation of the brain

Primary out-of-hospital cardiac arrest in childhood is rare but survival is a little better for children than for adults, although the prognosis for infants is very poor. Hypoxic-ischaemic encephalopathy after in-hospital cardiac arrest in children undergoing complicated treatment for previously untreatable conditions is now a common problem and is probably increasing. An additional ischaemic insult worsens the prognosis for other encephalopathies, such as that occurring after accidental or non-accidental head injury. For near-drowning, the prognosis is often good, provided that cardiopulmonary resuscitation (CPR) is commenced immediately, and the child gasps within 40 minutes of rescue and regains consciousness soon afterwards. The prognosis is much worse for the nearly drowned child admitted to casualty or the emergency room deeply unconscious with fixed dilated pupils, requiring continuing CPR and with an arterial pH <7, especially if there is little recovery by the time of admission to the intensive care unit. The use of adrenaline, sodium bicarbonate and calcium appears to worsen prognosis. Neurophysiology, specifically serial electroencephalography and evoked potentials, is the most useful tool prognostically, although neuroimaging and biomarkers may play a role. In a series of 89 patients studied after cardiac arrest in three London centres between 1982 and 1985, 39% recovered consciousness within one month. Twenty seven percent died a cardiac death whilst in coma, and the outcome in the remainder was either brain death or vegetative state. EEG and initial pH were the best predictors of outcome in this study. Seizures affected one third and were associated with deterioration and worse outcome. The advent of extracorporeal membrane oxygenation (ECMO) and the positive results of hypothermia trials in neonates and adults have rekindled interest in timely management of this important group of patients.     

儿童心脏骤停的预后及影响因素

儿童心脏骤停是临床上最危急的情况之一,对生命造成严重威胁.随着心肺复苏及高级生命支持技术的进步,儿童心脏骤停的存活率较以前升高,但很多存活者遗留神经系统后遗症.儿童院外心脏骤停与院内心脏骤停的疾病原因不同,其预后和影响因素也不尽相同.儿童心脏骤停死亡危险因素有癌症、肝功能不全、急性肾功能衰竭和脓毒症/全身炎症反应综合征等,心肺复苏作为心脏骤停的主要急救手段,是影响心脏骤停儿童存活率的主要因素之一.     

Sudden Unexplained Cardiac Arrest in Apparently Healthy Children: A Single-Center Experience

This study aimed to determine the causes of sudden cardiac arrest (SCA) in apparently healthy children at a single center in the era of primary prevention (screening questionnaire [SQ]) and secondary prevention (automated external defibrillator [AED] and the automated implantable cardioverter defibrillator [AICD]). Any child 0 to 18 years of age without prior known disease, except for attention deficit disorder, who underwent out-of-the hospital cardiopulmonary resuscitation was included in the study as a SCA subject. A retrospective chart review was used to evaluate the efficacy of the SQ, electrocardiogram (ECG), chest roentgenogram (CXR), and echocardiogram. The findings showed that for 44 of 6,656 children admitted to intensive care with SCA, an AED was used for 39 %, an AICD was placed in 18 %,and survival to hospital discharge was 50 %. The etiology for SCA was identified in 57 % of the cases, mostly in those older than 1 year, and the majority of these had a cardiac etiology (50 %), whereas 7 % had rupture of an arteriovenous malformation. Stimulant medication use was seen in 11 % of the SCA subjects. In the best-case scenario of hypothesized primary prevention, a prior SQ, CXR, ECG, or echocardiogram may have detected respectively 18, 9, 23 and 16 % of the at-risk cases, and 32 % of the cases may have been detected with ECG and SQ together. Based on a historical control cohort, a positive ECG was significantly higher in the children with SCA (p = 0.014). An ECG together with a screening SQ may be more effective in identifying children potentially at risk for SCA than an SQ alone.     

Pediatric victims involved in urban fires in Paris and its suburbs: Epidemiology,prehospital care,and lessons learned

AimThe literature includes few reports on the prehospital care of pediatric casualties of urban house fires. Here we aimed to describe the epidemiology of pediatric fire victims, focusing on their injuries, prehospital care, and survival.MethodsThis retrospective study included children under 15 years of age who were victims of urban house fires and who received care from prehospital medical teams. The variables analyzed included epidemiology, specific care provided by prehospital emergency services, the number of cardiac arrests, and survival rates.ResultsOver the 15-month study period, 365 house fires required the presence of at least one prehospital medical team. Casualties of these fires included 121 pediatric victims (median age, 4 years [interquartile range: 2–9 years]). All children were initially treated by a prehospital medical team that was not specialized in pediatrics. Six children (4.9%) received secondary treatment from a pediatric support team. Of the 121 children, 114 (94.2%) suffered from smoke inhalation and seven (5.8%) from burns. Two patients who were in cardiac arrest at their initial medical care did not survive.ConclusionPediatric fire casualties were initially managed by prehospital medical teams that were not specialized in pediatrics. As in adults, the main injuries were secondary to smoke inhalation, but this has increased toxicity in children. Prehospital teams not specialized in pediatrics can optimize their practice via the sharing of experiences, team training, and cognitive aid checklist for pediatric fire victims.     

Review of resuscitation physiology in children

More than one quarter of children survive to hospital discharge after in-hospital cardiac arrests, and 5–10% of children survive to hospital discharge after out-of-hospital cardiac arrests. Cardio-pulmonary resuscitation (CPR) differs in children from adults. Following the Airway, Breathing, Circulation format, this article reviews the physiology of paediatric cardio-pulmonary resuscitation. It addresses the appropriate interventions during CPR, mechanisms of action of commonly used drugs and special resuscitation circumstances: premature and newly born infants, traumatic cardiac arrest, and ECMO (Extracorporeal Membrane Oxygenation). New exciting discoveries in resuscitation science postulate that the key factor in improving outcomes of paediatric cardiac arrest is improving the quality of interventions. A thorough understanding of the physiology underpinning CPR is helpful in ensuring optimal delivery of CPR in children and improving clinical outcomes.     

儿童心肺复苏预后相关因素的研究进展

儿童心跳呼吸骤停是临床上最危急的情况之一,对生命造成严重威胁.随着医疗技术的进步,儿童心跳呼吸骤停后,自主循环恢复率不断提高.但是由于机体长时间的缺血缺氧,容易导致多脏器功能不全或衰竭,患儿长期存活率并不高,远期预后不佳.因此,如何使心肺复苏更为有效是目前研究的热点.该文就影响复苏效果的相关因素进行综述,以期为儿童心跳呼吸骤停的治疗提供参考.     

Survival outcomes after extracorporeal cardiopulmonary resuscitation instituted during active chest compressions following refractory in-hospital pediatric cardiac arrest.

OBJECTIVE: To report survival outcomes and to identify factors associated with survival following extracorporeal cardiopulmonary resuscitation for in-hospital pediatric cardiac arrest. DESIGN: Retrospective chart review, consecutive case series. MAIN OUTCOME MEASURE: Survival to hospital discharge. RESULTS: During a 7-yr study period, there were 66 cardiac arrest events in 64 patients in which a child was cannulated for extracorporeal membrane oxygenation during active cardiopulmonary resuscitation with chest compressions. A total of 33 of 66 events (50%) resulted in the child being decannulated and surviving at least 24 hrs; 21 of 64 (33%) children undergoing extracorporeal cardiopulmonary resuscitation survived to hospital discharge. A total of 19 of 43 children with isolated heart disease compared with two of 21 children with other medical conditions survived to hospital discharge (p <.01). Pediatric Cerebral Performance Category and Pediatric Overall Performance Category were determined for survivors >2 months old. Five of ten extracorporeal cardiopulmonary resuscitation survivors >2 months old had no change in Pediatric Cerebral Performance Category or Pediatric Overall Performance Category compared with admission. Three of six extracorporeal cardiopulmonary resuscitation patients who survived after receiving >60 mins of chest compressions before extracorporeal cardiopulmonary resuscitation had grossly intact neurologic function. During a 2-yr period in the same hospital, no patient who received >30 mins of cardiopulmonary resuscitation without extracorporeal cardiopulmonary resuscitation survived. In this case series, age, weight, or duration of chest compressions before extracorporeal cardiopulmonary resuscitation did not correlate with survival. CONCLUSIONS: Extracorporeal cardiopulmonary resuscitation can be used to successfully resuscitate selected children following refractory in-hospital cardiac arrest, and can be implemented during active cardiopulmonary resuscitation. Intact neurologic survival can sometimes be achieved, even when the duration of in-hospital cardiopulmonary resuscitation is prolonged. In this series, children with isolated heart disease were more likely to survive following extracorporeal cardiopulmonary resuscitation than were children with other medical conditions.     

Retrospective analysis of the prognostic value of electroencephalography patterns obtained in pediatric in-hospital cardiac arrest survivors during three years.

OBJECTIVE: To test the hypothesis that electroencephalography has prognostic value in children after in-hospital cardiac arrest. DESIGN: Single-center, retrospective chart review. SETTING: Urban tertiary care children's hospital, January 2001 to July 2004. PATIENTS: Thirty-four consecutive children were identified from a registry of all patients resuscitated for cardiac arrest. Inclusion criteria were age >44 wks postmenstrual age to 18 yrs, survival after in-hospital cardiac arrest >24 hrs, and undergoing electroencephalography within 7 days after the cardiac arrest. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Prearrest, event, cardiopulmonary resuscitation, and postresuscitation variables were collected. Neurologic outcome was assessed by Pediatric Cerebral Performance Category (PCPC). Prearrest PCPC was estimated from chart review. Change in PCPC >1 or death between prearrest and time of hospital discharge was defined as poor neurologic outcome. Experts blinded to PCPC outcomes scored electroencephalographs from 1 (normal) to 5 (isoelectric). Sensitivity/specificity analysis and receiver operating characteristic curve were developed with each electroencephalography grade cutoff. Of 184 consecutive patients who had cardiac arrests in our registry, 107 survived >24 hrs, and 83 met study criteria. Thirty-four patients had electroencephalography within the first 7 days after the cardiac arrest. Among those, 16 (47%) patients had good neurologic outcome defined as no change in PCPC, and 18 (53%) died or had poor neurologic outcome. Univariate analysis showed that a higher electroencephalography score performed within 7 days was associated with poor neurologic outcome (p < .05). Positive predictive value of electroencephalography grade 4-5 for poor neurologic outcome was 90%, and negative predictive value of electroencephalography grade 1-2 for poor neurologic outcome was 91%. CONCLUSIONS: In a single-center consecutive case series, electroencephalography background patterns during the initial 7 days after in-hospital cardiac arrest were associated with neurologic outcome in children.     

Antiepileptic drug withdrawal in childhood epilepsy: What are the risk factors associated with seizure relapse?

BackgroundIn recent years, several studies have been conducted to determine the risk of relapse after antiepileptic drug (AED) withdrawal: there is no general agreement on criteria that can predict safe discontinuation or seizure recurrence.AimsTo evaluate prospectively the relapse rate of epilepsy associated to AED withdrawal in epileptic children and to determine the risk factors of seizure recurrence.MethodsOne hundred-sixty-eight children with epilepsy who were seizure-free for at least 2 years were enrolled and all children were proposed to stop AED treatment and were followed. In all children electroencephalograms (EEGs) were performed before the withdrawal of AEDs and after discontinuation of the treatment.ResultsA total of 48 (28.6%) children relapsed; half of these patients relapsed while reducing the AED dose and the other half after the AED was withdrawn; after 2 years without AEDs, the risk of relapse was very low. Data evaluated by multivariable analysis showed that the children receiving polytherapy before AED withdrawal, having a history of febrile seizures and suffering from multiple seizure types relapsed more frequently. The presence of abnormal post-withdrawal EEG recordings was associated with a higher risk of seizure recurrence.ConclusionsEpileptic children, after a seizure-free period of 2 years, have a low risk of seizure recurrence. The potential risk factors of relapse, are multiple seizure types previous polytherapy, history of febrile seizures and abnormalities in post-withdrawal EEG.     

Airwaymanagement bei Kindern in Notfallsituationen

In babies and toddlers, most emergencies that necessitate resuscitation attempts are respiratory in origin. This is in contrast to emergencies in adults, in which circulatory failure with low output is often present, as it is for examplein dysrhthmia following cardiac infarct, and the treatment is fundamentally different from that in a paediatric emergency. In paediatric emergencies correction of the respiratory disturbance is often enough to deal with the acute risk situation. In general, particular attention should be paid to making certain the airway stays open. The airway is smaller in children than in adults. In view of the frequent respiratory infections children are exposed to they are often swollen and can therefore themselves be the actual cause of a life-threatening situation not only when foreign bodies have been aspirated, but also in cases of epiglottitis and pseudocroup. Since a cardiovascular arrest often occurs as the result of respiratory hypoxia in children, its prognosis is serious. In adults the organs are initially still adequately oxygenated when a dysrhythmia occurs or in the presence of other cardiovascular diseases. In children the cardiac arrest comes about as the result of preceding hypoxia of all tissues, so that particularly rapid action is essential. It is the object of any airway management to ensure an adequate oxygen supply and prevention of aspiration, but preparations must also be made for intratracheal administration of emergency medications.     

Antiepileptic drug-induced osteopenia in ambulatory epileptic children receiving a standard vitamin D3 supplement

Dual energy X-ray absorptiometry (DEXA) is a non-invasive, rapid, accurate and highly reproducible method for the assessment of antiepileptic drug (AED)-induced osteopenia in epileptic children. In this study, we investigated bone mineral density (BMD) using DEXA in 56 epileptic children receiving long-term AED treatment for at least 2 years. All children received AED monotherapy or polytherapy plus a standard vitamin D3 supplement (400 U/day). BMD measurements were made from lumbar spine (L2-L4) regions. Age- and sex-specific BMD SD scores were calculated for each child. Osteopenia was defined as SD scores less than -1.5. There was no significant difference in mean BMD values between epileptic children receiving monotherapy or polytherapy. The results were also compared to the age- and sex-specific BMD SD scores obtained from healthy Turkish children. Only three patients (5%) receiving AED therapy had a BMD SD score less than -1.5. This rate is relatively lower than the rates of previous studies conducted on ambulatory children on long-term AED treatment without vitamin D3 supplementation.     

Serum lipid profile in children receiving anti-epileptic drug monotherapy: is it atherogenic?

The effect of anti-epileptic drugs (AEDs) on serum lipid profile is controversial in children as well as in adults. We longitudinally studied serum lipid profile in 34 newly diagnosed epileptic children receiving AED monotherapy with valproic acid (VPA), carbamazepine (CBZ) or phenobarbital (PB). Serum levels of total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides (TGs), apolipoprotein Al (Apo A1) and apolipoprotein B (Apo B) were measured at baseline and after 2 years of AED monotherapy. Atherosclerotic indices of TC/ HDL-C and Apo A1/Apo B ratios were calculated. Although there were some alterations in serum lipid profile with AED without statistical significance, the atherosclerotic indices of TC/HDL-C and Apo A1/Apo B ratios did not change significantly after 2 years of monotherapy. Only serum TGs levels significantly decreased with VPA monotherapy. These data suggest that 2 years AED monotherapy with VPA, CBZ or PB did not cause a significant level of concern for an atherogenic effect in children with epilepsy.