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.     

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.     

Audit of paediatric cardiopulmonary resuscitation.

The causes and outcome of cardiopulmonary arrests were studied in a paediatric hospital over a 12 month period. Forty five resuscitation attempts were made involving 41 children and one adult. Twenty eight (68%) of the children were under 1 year of age and 10 (24%) were neonates. Twenty one (47%) arrests were primarily respiratory and 11 (24%) primarily cardiac in origin. Eighty two per cent of the respiratory arrests had an initially successful outcome, compared with 36% of the cardiac arrests. Overall 70% of cardiopulmonary resuscitation attempts were initially successful. There were no survivors from resuscitation attempts longer than 30 minutes. At 12 months after cardiopulmonary resuscitation 15 (37%) of the children were still alive. The 11 children who had been neurologically normal before the arrest showed no evidence of neurological damage after successful cardiopulmonary resuscitation.     

Future directions in cardiocerebral resuscitation

Outcomes from pediatric cardiac arrest and cardiopulmonary resuscitation (CPR) seem to be incrementally improving. The past 2 decades have brought advances in the understanding of the pathophysiology of cardiac arrest and ventricular fibrillation, better treatment strategies, and a more robust standard for CPR epidemiology and research reporting. The evolution of practice based on an improved understanding of the pathophysiology and timing, intensity, duration, and variability of the hypoxic-ischemic insult should lead to goal-directed therapy gated to the phase of cardiac arrest and the postarrest period encountered. By strategically focusing therapies to specific phases of cardiac arrest and resuscitation and to the evolving pathophysiology and by implementing evidence-based practice, there is great promise that critical care interventions can lead the way to more successful cardiopulmonary and cerebral resuscitation in children.     

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.     

Current and future therapies of pediatric cardiopulmonary arrest

Objective  To review contemporary guidelines and therapies for pediatric cardiac arrest and discuss potential novel therapies. Methods  Key articles and guidelines in the field were reviewed along with recent publications in the fields of neurointensive care and neuroscience germane to cerebral resuscitation. Results  A total of 45 articles were reviewed. The majority of arrests in the pediatric population are asphyxial in origin-which differs importantly from the adult population. The International Consensus on CPR guidelines are discussed, including good quality CPR, chest compressions without interruptions, resuscitation with 100% oxygen and subsequent titration of oxygen to normal oxygen saturations, correct dose of epinephrine, and use of hypothermia in the first 12–24 hours. Novel therapies that showed success in animal studies, such as hypertensive reperfusion, thrombolytics, hemodilution and extracorporeal CPR are also discussed. Conclusion  With only 30% return of spontaneous circulation, 12% survival to hospital discharge and 4% intact neurologic survival, pediatric cardiac arrest remains an area of intense research for therapies to improve its outcomes. In addition to the rapid implementation of basic and advanced life support interventions, new therapies that may have value include mild hypothermia, extracorporeal support, promotion of cerebral blood flow and other more novel therapies targeting oxidative stress, excitotoxicity, neuronal death, and rehabilitation.     

Pediatric cardiopulmonar resuscitation

OBJECTIVE: To present the main aspects of pediatric cardiopulmonary resuscitation.METHOD: The articles on pediatric cardiorespiratory arrest and cardiopulmonary resuscitation were revised, by Medline and Lilacs systems. Books and dissertations were also analyzed. Only the most important articles were included in this review.RESULTS: The relevant aspects related to diagnosis and epidemiology of pediatric cardiac arrest were described. The sequence of actions on cardiopulmonary resuscitation were emphasized. The basic and advanced life support techniques were described and the age differences were highlighted.CONCLUSION: The knowledge of the content of this review provides more effectiveness to cardiopulmonary resuscitation. The anoxic period of time of children in cardiac arrest can be reduced and a better prognosis can be thus achieved.     

Results of cardiopulmonary resuscitation in children

We retrospectively evaluated the outcome from cardiopulmonary resuscitation (CPR) in 149 children of all age groups. Only 7 children experienced ventricular fibrillation. 47 children (31.5%) died immediately. Further 47 children died within 24 hours of their arrest, 24 (16.1%) survived longer than 24 hours after CPR but not until discharge. Only 31 children (20.8%) survived to discharge, 5 with severe neurologic sequelae, attributable to the arrest or resuscitation efforts. Cardiopulmonary arrests in the Pediatric Intensive Care Unit carried the worst prognosis. Better results were obtained out-of-hospital, in the OR or on the pediatric floor. Long-term survival rate did not correlate with age, or type of administered catecholamine. None of the children receiving calcium survived. This large study confirms the poor outcome of CPR in children.     

CPR-why the new emphasis?

The importance of high quality, prompt cardiopulmonary resuscitation (CPR) for patients in cardiac arrest is receiving new attention and emphasis. This extends to CPR for children. In this article, the authors examine the differences in pediatric anatomy and the mechanisms of blood flow during CPR. Additionally, new evidence on the frequent poor performance of CPR and mechanisms to improve it are presented.     

Outcome of cardiopulmonary resuscitation in children

A study was undertaken in order to identify factors correlated with the outcome of pediatric cardiopulmonary resuscitation (CPR). A total of 35 children who experienced a total of 41 cardiopulmonary arrests were included. Sixteen of 41 patients (39%) could not be resuscitated; 16/41 (39%) were resuscitated temporarily but did not survive to discharge; 9/41 (22%) survived to discharge. Patients arresting outside the hospital who received early basic CPR at the scene were significantly more likely to be resuscitated, at least temporarily, than those who did not (8/8 vs 5/11; P = 0.02). A statistically significant difference in outcome was also demonstrated between patients with an initial arterial blood pH greater than 7.0 and those with an initial arterial blood pH less than 7.0 (P less than 0.05). We conclude that an initial arterial blood pH less than 7.0 predicts a poor outcome from cardiopulmonary arrest in children. Access to early basic CPR may improve the initial pH and the ability of the patient to be resuscitated.     

Current methods of training residents to manage pediatric cardiopulmonary arrests

Pediatric residency training programs were surveyed to assess current methods of educating house staff to manage pediatric cardiopulmonary resuscitations. Of the 155 programs responding, 96% provide Basic Life Support training, while 79% offer Advanced Cardiac Life Support training, but only 30% provide ongoing education in the form of mock arrests. In general, the availability of the various forms of resuscitation management instruction was not related to either program size or institution needs. The system of training pediatric residents to manage pediatric cardiopulmonary resuscitations at The Johns Hopkins Hospital is outlined.     

In-hospital pediatric cardiac arrest

The understanding of the incidence, epidemiology, etiology, and pathophysiology of pediatric cardiac arrest has evolved greatly in the past two decades. This includes recognition that cardiopulmonary resuscitation delays in cardiac arrest are especially injurious, ventricular arrhythmias are not as uncommon in children as previously believed, and four distinct phases of cardiac arrest can be delineated. Performance of, and technologic advances in, the treatment of cardiac arrest make this an exciting time in the field.     

Das ABC des lebensbedrohlichen Kindernotfalls

Resuscitation is extremely rare in pediatric practice. It is far more likely that a pediatrician will be confronted with an infant or child with a life-threatening illness of unclear etiology. Both the recognition of critical illness and implementation of rapid, effective intervention to reverse hypoxia and hemodynamic instability can prevent further deterioration and markedly improve the prognosis. Prompt intervention can possibly help avoid a situation in which resuscitation is necessary. When faced with a child in cardiopulmonary arrest, meticulous attention to basic life support has highest priority. Acute life-threatening emergencies in children involve a high cognitive load for providers and standardised algorithms promote a systematic approach. Periodic training in both medical management and non-technical skills such as communication, teamwork and use of resources plays a key role in effectively improving the quality of care in critically ill children.     

中国儿童重症监护病房体外膜肺氧合技术应用现状调查

目的：了解中国PICU体外膜肺氧合( ECMO)技术开展及ECMO疗效情况。方法采用问卷调查方式,2015年3月至2015年8月对全国三级甲等医院PICU进行调查。结果共调查了38家儿童医院或综合医院的PICU,其中儿童医院28家,综合医院10家。10家医院的PICU拥有12台ECMO设备;能开展ECMO技术的单位6家,准备开展ECMO技术的单位14家;接受过ECMO培训的医院8家。共有63例患儿在 PICU 内接受非开胸 ECMO 治疗,成功撤离 ECMO 者49例,有效率77.8％;36例存活,存活率57.1％。儿童患者(大于28 d)51例,其中呼吸系统疾病21例,心脏疾病28例,心肺衰竭2例;存活出院31例,存活率60.8％。新生儿患者12例,呼吸系统疾病10例,心脏疾病2例,存活出院5例,存活率41.7％。结论国内儿科领域ECMO技术尚处于起步阶段,且发展不均衡,整体上存活率低于国际水平,今后需要进一步增加ECMO技术在儿科领域应用的临床实践,提高国内危重患儿的救治水平。     

Novedades en las recomendaciones de reanimación cardiopulmonar pediátrica

Cardiac arrest has a high mortality in children. To improve the performance of cardiopulmonary resuscitation, it is essential to disseminate the international recommendations and the training of health professionals and the general population in resuscitation.This article summarises the 2015 European Paediatric Cardiopulmonary Resuscitation recommendations, which are based on a review of the advances in cardiopulmonary resuscitation and consensus in the science and treatment by the International Council on Resuscitation. The Spanish Paediatric Cardiopulmonary Resuscitation recommendations, developed by the Spanish Group of Paediatric and Neonatal Resuscitation, are an adaptation of the European recommendations, and will be used for training health professionals and the general population in resuscitation.This article highlights the main changes from the previous 2010 recommendations on prevention of cardiac arrest, the diagnosis of cardiac arrest, basic life support, advanced life support and post-resuscitation care, as well as reviewing the algorithms of treatment of basic life support, obstruction of the airway and advanced life support.     

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.     

Outcome and predictors of outcome in pediatric submersion victims receiving prehospital care in King County, Washington

Predictors of outcome in pediatric submersion victims treated by Seattle and King County's prehospital emergency services were studied. Victims less than 20 years old were identified from hospital admissions and paramedic and medical examiners' reports. The proportion of fatal or severe outcomes in patients were compared with various risk factors. Of 135 patients, 45 died and 5 had severe neurologic impairment. A subset of 38 victims found in cardiopulmonary arrest had a 32% survival rate, with 67% of survivors unimpaired or only mildly impaired. The two risk factors that occurred most commonly in victims who died or were severely impaired were submersion duration greater than 9 minutes (28 patients) and cardiopulmonary resuscitation duration longer than 25 minutes (20 patients). Both factors were ascertained in the prehospital phase of care. Submersion duration was associated with a steadily increasing risk of severe or fatal outcomes: 10% risk (7/67) for 0 to 5 minutes, 56% risk (5/9) for 6 to 9 minutes, 88% risk (21/25) for 10 to 25 minutes, 100% risk (4/4) for greater than 25 minutes. None of 20 children receiving greater than 25 minutes of cardiopulmonary resuscitation escaped death or severe neurologic impairment. Our rates for saving all victims, particularly victims in cardiopulmonary arrest, are considerably higher than has been reported before the children. Prompt prehospital advanced cardiac life support is the most effective means of medical intervention for the pediatric submersion victim. Prehospital information provided the most valuable predictors of outcome.     

Pediatric cardiopulmonary resuscitation: State at the art

Prognosis for pediatric cardiopulmonary is currently bleak. Tyre are main gaps ill our knowledge regarding optimal prevention and treatment of pediatric arrest. This article will review our current knowledge in pediatric cardiopulmonary resuscitation, identify gaps in our knowledge, and discuss recent changes in guidelines for pediatric basic and advanced cardiac life support.