Characteristics and outcome of cardiorespiratory arrest in children

OBJECTIVE: To analyse the present day characteristics and outcome of cardio-respiratory arrest in children in Spain. DESIGN: An 18-month prospective, multicentre study analysing out-of-hospital and in-hospital cardio-respiratory arrest in children. Patients and methods: Two hundred and eighty-three children between 7 days and 17 years of age with cardio-respiratory arrest. Data were recorded according to the Utstein style. The outcome variables were the sustained return of spontaneous circulation (initial survival), and survival at 1 year (final survival). Three hundred and eleven cardio-respiratory arrest episodes, composed of 70 respiratory arrests and 241 cardiac arrests in 283 children were studied. Accidents were the most frequent cause of out-of-hospital arrest (40%), and cardiac disease was the leading cause (31%) of in-hospital arrest. Initial survival was 60.2% and 1 year survival was 33.2%. The final survival was higher in patients with respiratory arrest (70%) than in patients with cardiac arrest (21.1%) (P <0.0001). Although many individual factors correlated with mortality, multivariate logistic regression revealed that the best indicator of mortality was a duration of cardiopulmonary resuscitation of over 20 min (odds ratio: 10.35; 95% CI 4.59-23.32). CONCLUSIONS: In Spain, the present mortality from cardio-respiratory arrest in children remains high. Survival after respiratory arrest is significantly higher than after cardiac arrest. The duration of cardiopulmonary resuscitation attempt is the best indicator of mortality of cardio-respiratory arrest in children.     

Analysis of a 2-year-old resuscitation service

The results of attempted resuscitation of 561 patients with cardiac or respiratory arrest are reported. A one-way speech, multiple-call system, and two mobile resuscitation trolleys were used. Most of the patients were between 50 and 80 years of age. Threequarters of the patients presented with cardiac arrest which manifested as asystole almost twice as often as ventricular fibrillation. The commonest causes of arrest were acute myocardial infarction, unknown causes, cardiac failure, recent surgery, and respiratory arrest. Autopsies were obtained in one-third of patients who died. Most calls were between 10.00 hours and 22.00 hours and came from the medical wards. The initial method of assisted ventilation was by endotracheal tube and Ambu-bag in almost one-half of the patients, face mask and Ambu-bag in one-quarter and mouth-to-mouth or mouthto-nose in only one-tenth. A spontaneous electrocardiogram and/or pulse was restored in approximately one-third of patients, spontaneous breathing in 22%, and consciousness in 9%, and 18% returned to their pre-arrest status. Successful resuscitation was achieved in 25% but only 8% survived to leave hospital. Patients with respiratory arrest fared more than twice as well as those with cardiac arrest.The factors relating to successful resuscitation are discussed.     

Characteristics and outcome of cardiopulmonary resuscitation in hospitalised African children

ObjectiveTo review the characteristics and outcome of cardiopulmonary resuscitation in children at a rural hospital in Kenya.Patients and methodAll children aged 0–14 years who experienced ≥1 episode of respiratory or cardiopulmonary arrest during April 2002–2004 were prospectively identified. Demographic variables, cause of hospitalisation, type and duration of arrest, resuscitation measures taken and outcomes were determined.Results114 children experienced at least one episode of respiratory arrest (RA) or cardiopulmonary arrest (CPA). Cardiopulmonary resuscitation (CPR) was performed on all children. “Do not resuscitate order” (DNR) was given in 15 patients after initial resuscitation. Eighty two patients (72%) had RA and 32 (28%) had CPA. 25/82 (30%) patients with RA survived initial CPR compared to 5/32 (16%) with CPA. Survival at discharge was 22% (18/82) in children who had RA while no one with CPA survived at discharge. The leading underlying diseases were severe malaria, septicaemia and severe malnutrition. Prolonged resuscitation beyond 15 min and receiving adrenaline [epinephrine] (at least one dose of 10 μg/kg IV) were predictive of poor final outcome.ConclusionCardiopulmonary arrest after admission has a very poor prognosis in our hospital. Infectious diseases are the main underlying causes of arrest. If a child fails to respond to the basic tenements of PALS within 15 min then it is unlikely that further efforts to sustain life will be fruitful in hospitals where ventilation facilities are not present.     

First report of an experimental study in dogs of cerebrocardiopulmonary resuscitation (CCPR)

Since 1974, we have used the method of brain cooling by intracarotid hypothermic infusion combined with cardiopulmonary resuscitation (CPR) and called it “cerebrocardiopulmonary resuscitation” (CCPR). This paper reports further studies of clinical significance.Cardiac arrest was experimentally produced in dogs by the inhalation of pure nitrous oxide during spontaneous respiration. Five minutes after cardiac arrest, CPR was performed at the same time as an intracarotid infusion of cold medium which was composed of equal quantities of low molecular dextran and 20% of mannitol to which was added methylprednisolone and heparin. The temperature of the cold medium was 5°C, 15°C or 25°C. An average of 200 ml of cold medium was infused into the common carotid artery at an infusion pressure of 110–170 mmHg for a period of 2–3 min. The same procedure was repeated 15 min after cardiac arrest.Investigations as to clinical measurements, hemodynamics, cerebral oxygen availability and cerebral mitochondrial respiratory activity during the period up to 180 min after cardiac arrest have been made by the authors.The best values of oxygen availability, respiratory control ratios (RCR) and ADP/O ratios were attained 30 min after resuscitation in the groups in which cold medium at 5°C was infused. Better results were attained 180 min after resuscitation in the groups in which cold medium at 15°C was infused. The mitochondrial respiratory activities 30 min after resuscitation were fairly high in the groups in which moderate hypothermia with a cerebral temperature of 25°C was applied for 30 min, but they decreased 180 min after resuscitation. They were slightly worse 30 min after resuscitation in the groups to which mild hypothermia with a cerebral temperature of 30°C was applied for 30 min and cold medium of 15°C temperature was infused than they were in those groups in which a cold medium at 5°C temperature was infused, but better results were obtained 180 min after resuscitation.A comparison was made of post-resuscitation behaviour 50 h after resuscitation between the CPR group and CCPR group. The effectiveness of the treatment of the latter group was proved.     

Cardiac arrest during surgery and ventilation in the prone position: a case report and systematic review.

We present a case report of successful resuscitation following cardiac arrest in a patient undergoing surgery in the prone position. A systematic review of the literature identified 22 further cases. Risk factors for intra-operative cardiac arrest in patients in the prone position include: cardiac abnormalities in patients undergoing major spinal surgery, hypovolaemia, air embolism, wound irrigation with hydrogen peroxide, poor positioning and occluded venous return. Cardiac arrest is also a risk in the increasing number of patients with acute respiratory distress syndrome ventilated in the prone position. Management of prone cardiac arrest may be improved by identification of high-risk patients, careful patient positioning, use of invasive monitoring and placement of self-adhesive defibrillator paddles. Suitable techniques for cardiopulmonary resuscitation including methods for chest compression, defibrillation and the management of air embolism are discussed.     

Do we hyperventilate cardiac arrest patients?

INTRODUCTION: Hyperventilation during cardiopulmonary resuscitation is detrimental to survival. Several clinical studies of ventilation during hospital and out-of-hospital cardiac arrest have demonstrated respiratory rates far in excess of the 10 min(-1) recommended by the ERC. We observed detailed ventilation variables prospectively during manual ventilation of 12 cardiac arrest patients treated in the emergency department of a UK Hospital. METHODS: Adult cardiac arrest patients were treated according to ERC guidelines. Ventilation was provided using a self-inflating bag. A COSMOplus monitor (Respironics Inc.) was inserted into the ventilation circuit at the beginning of the resuscitation from which ventilation data were downloaded to a laptop. RESULTS: Data were collected from 12 patients (7 male; age 47-82 years). The maximum respiratory rate was 9-41 breaths per minute (median 26). The median tidal volume was 619 ml (374-923 ml) and the median respiratory rate was 21 min(-1) (7-37 min(-1)). The corresponding median minute volume was 13.0 l/min (4.6-21.3 min(-1)). Median peak inspiratory pressures were 60.6 cmH(2)O (range 46-106). Airway pressure was positive for 95.3% of the respiratory cycle (range 87.9-100%). CONCLUSIONS: Hyperventilation was common, mostly through high respiratory rates rather than excessive tidal volumes. This is the first study to document tidal volumes and airway pressures during resuscitation. The persistently high airway pressures are likely to have a detrimental effect on blood flow during CPR. Guidelines on respiratory rates are well known, but it would appear that in practice they are not being observed.     

Tension pneumoperitoneum.

Tension pneumoperitoneum developing in a middle aged asthmatic male during resuscitation after a respiratory arrest is reported. This was associated with bilateral tension pneumothorax and caused severe respiratory embarrassment which was relieved by needle decompression, after decompression of the pneumothoraces. The chest is not the only body cavity that can contain air under tension.     

Experience with ketamine and sodium pentobarbital as anesthetics in a rat model of cardiac arrest and resuscitation

We review 7 years experience with the chest compression model of cardiac arrest and resuscitation, comparing two different anesthetics. Ketamine stimulates cardiac function and only mildly depresses respiration; of the two it provides easier resuscitation. However, ketamine severely depresses brain protein synthesis; in studies using this measure ketamine is unsuitable and another agent must be used. Sodium pentobarbital mildly depresses brain protein synthesis, but depresses both cardiac and respiratory function, making resuscitation more difficult. Use of alternate chest/abdominal pumping (Babbs resuscitation technique), with judicious use of intra-cardiac epinephrine (adrenaline), made resuscitation reliable under sodium pentobarbital as well.     

Outcomes for in-hospital cardiac arrest for COVID-19 patients at a rural hospital in Southern California

BackgroundIn-hospital cardiac arrest (IHCA) carries a high mortality and providing resuscitation to COVID-19 patients presents additional challenges for emergency physicians. Our objective was to describe outcomes of COVID-19 patients suffering IHCA at a rural hospital in Southern California.MethodsSingle-center retrospective observational study. A hospital registry of COVID-19 patients was queried for all patients who suffered IHCA and received cardiopulmonary resuscitation (CPR) between May 1st and July 31st, 2020. A manual chart review was performed to obtain patient demographics, oxygen requirement prior to cardiac arrest (CA), details of the resuscitation including presence of an emergency physician, and final disposition.ResultsTwenty-one patients were identified, most of whom were Hispanic, male, and aged 50–70. The most common medical comorbidities were diabetes and hypertension. Most patients suffered respiratory arrest, with an initial rhythm of pulseless electrical activity or asystole. Return of spontaneous circulation (ROSC) was achieved in 3/9 patients already receiving mechanical ventilation, but all 3 expired within the following 24 h. ROSC was achieved in 10/12 patients not already intubated, though most also expired within a few days. The only 2 patients who survived to discharge suffered respiratory arrest after their oxygen delivery device dislodged.ConclusionAt a small rural hospital with limited resources and a predominantly Hispanic population, cardiac arrest in a COVID-19 patient portends an extremely poor prognosis. A better appreciation of these outcomes should help inform emergency providers and patients when discussing code status and attempts at resuscitation, particularly in resource limited settings.     

Prediction of outcome after resuscitation in a case of electrocution

Electrical shocks commonly cause widespread acute and delayed tissue damage. Cardiac arrythmias and respiratory arrest are the most life-threatening complications in the acute phase. Prediction of outcome after cardiopulmonary resuscitation is usually based on neurological findings compatible with anoxic encephalopathy. This report describes a case of electrocution followed by cardiopulmonary resuscitation. Although neurological signs on admission pointed towards severe brain injury, the patient fully recovered and was able to resume the level of cognitive functioning prior to the accident. Received: 25 April 1997 Accepted: 4 December 1997     

Advances in airway management

Emergency ventilation is an essential component of basic life support. Respiratory emergencies occur far more frequently than cardiac arrest and, if not treated promptly and effectively, may lead to cardiac arrest. Many respiratory emergencies require assisted ventilation to prevent the occurrence of hypoxemia, hypercarbia, and cardiac decompensation. Emergency assisted ventilation is often difficult to perform and is associated with several adverse complications, such as gastric inflation, regurgitation, and pulmonary aspiration. The American Heart Association sponsored conferences in 1999 and 2000 to review and revise guidelines for cardiopulmonary resuscitation. This article reviews the science behind guideline changes related to pulmonary resuscitation and discusses recent advances in emergency airway management, focusing on noninvasive techniques for ventilation (mouth-to-mouth ventilation, bag-mask ventilation) and alternative airway devices (laryngeal mask airway, the Combitube).     

Ventricular fibrillation in a 2-month-old infant: a pediatric case study and review of lessons learned

The best way to deal with pediatric patients in cardiac arrest is to be prepared. We often acknowledge that children may experience V fib, but we do not truly take to heart that those events with "less than 10% chance of occurrence" can happen to us. From this case, the pediatric resuscitation team concluded that it is necessary to be prepared for all possible cardiac arrest situations. I know that our ED staff is more prepared now that this unusual situation has happened to us. I hope that others will also reassess their hospital's ability to handle a pediatric arrest that is not related to a primary respiratory event.     

Short-term health system costs of paediatric in-hospital acute life-threatening events including cardiac arrest

ObjectivesAcute life-threatening events in children are medical emergencies requiring immediate intervention. They can be due to cardiac arrest, respiratory arrest or another cause of sudden compromise for example, choking. Internationally, hospital systems are being introduced to reduce preventable acute life-threatening events and, despite having significant resource implications, have not yet been subject to economic analysis. This study presents the additional short-term health service costs of in-hospital acute life-threatening events to inform a cost-effectiveness analysis of prevention strategies.MethodologyPatient level costs (GB pounds, price year 2005), in excess of baseline costs, were collected from a short-term NHS perspective. The cost per survivor to hospital discharge included the cost of the cardiopulmonary resuscitation attempt, resuscitation preparedness, and the cost of in-hospital post-resuscitation care. Acute life-threatening events calls were classified into two groups: cardiac arrest, and respiratory arrest and other acute life threatening events. Outcomes from these groups were compared to a similar group of unplanned Paediatric Intensive Care (PIC) admissions. All survival and length of stay outcomes were calculated for the first episode.ResultsThe survival to hospital discharge was 64.4% (65/101), (95% Confidence Intervals 55.02, 73.70) for all acute life-threatening event calls, and 41.3% (12/29), (95% Confidence Intervals 23.45, 59.31) for cardiac arrest. The mean cost of the resuscitation attempt was £3664 for all acute life-threatening event calls, and £3884 for cardiac arrest. The annual cost of cardiopulmonary resuscitation preparedness was £181,565.The mean cost of the post-event length of stay in hospital was £22,562 for cardiac arrest, £26,335 for other acute life-threatening events, and £26,138 for urgent PIC admissions. The cost per survivor to hospital discharge was £53,289.ConclusionThe short-term costs of paediatric in-hospital acute life-threatening events, including cardiac arrest, from an NHS perspective, are more expensive than those reported for adults, but similar to other life saving treatments. This new information will serve to improve efficiency in the current resuscitation programme and contribute to cost-effectiveness analysis of prevention strategies.     

影响心肺复苏成功因素的临床分析

目的 探讨影响心肺复苏预后的相关因素,为治疗提供依据.方法 回顾分析急诊抢救室、急诊重症医学科(EICU)2007-01-2010-09心肺复苏患者150例,将150例患者分为复苏失败组(A组)、复苏成功组(B组)和存活出院组(C组),比较分析三组患者的年龄、合并疾病、骤停时间、抢救时间、存活时间及APACHEⅡ评分,结果 与A组比较,B组和C组年龄、骤停时间、抢救时间差异有统计学意义(P＜0.05),但两组间差异不明显;与A组和B组比较,C组存活时间、APACHEⅡ评分差异有统计学意义(P＜0.01);三组患者均合并多种疾病,而以合并循环系统和呼吸系统疾病为首位.结论 年龄是复苏成功的重要因素,合并循环系统和呼吸系统疾病是心搏骤停高危因素,骤停时间是复苏成功的关键,脑复苏成功是存活出院的最重要因素,APACHEⅡ评分能评估心肺复苏的预后.     

Management of cardiopulmonary arrest in the rehabilitation setting.

Life-threatening cardiac and respiratory arrests are stressful emergency situations. Nurses may be anxious and unsure of what needs to be done if their roles are not clearly defined. This article describes a system one rehabilitation hospital uses when responding to arrests, reviews the steps in basic cardiopulmonary resuscitation, and presents an algorithm of a cardiopulmonary arrest.     

颅脑降温仪在心肺脑复苏中的应用时机及护理

目的:探讨颅脑降温监护治疗仪在心肺脑复苏(CPCR)中的应用时机及护理方法。方法:将确定心跳和呼吸停止时间在6 min内、经心肺复苏(CPR)术后自主循环恢复并能维持24 h以上的68名复苏患者随机分为A组和B组各34例,A组患者在实施常规CPR同时,2 min内即用颅脑降温监护仪进行亚低温治疗;B组患者经CPR、在自主循环恢复后再用颅脑降温监护治疗仪进行亚低温治疗。两组均在2～4 h内使体表温度降至32～34℃,持续12～24 h。比较两组自主呼吸恢复情况、意识恢复(GCS评分)情况。结果:两组患者自主呼吸恢复人数及恢复时间比较,差异有统计学意义(P<0.05);24 h、48 h时、72 h内意识恢复(GCS评分)情况比较,差异有统计学意义(P<0.05)。结论:颅脑降温监护治疗仪实施越早越好,最好在实施常规基础生命支持(BLS)和高级生命支持(ACLS)同时开始,并配合高质量CPCR技术及精心护理,可有效提高脑复苏成功率。     

The epidemiology and resuscitation effects of cardiopulmonary arrest among hospitalized children and adolescents in Beijing: An observational study

Aim

To investigate the epidemiology and resuscitation effects of cardiopulmonary arrest among hospitalized children and adolescents in Beijing.

Methods

A prospective multicentre study was conducted in four hospitals in urban/suburban areas of Beijing. Patients aged 1 month–18 years with cardiopulmonary arrest and received cardiopulmonary resuscitation (CPR) who were consecutively hospitalised during the study period (1 September 2008–31 December 2010) were enrolled. Data was collected and analyzed using the “in-hospital Utstein style”. Neurological outcome was assessed with the pediatric cerebral performance category (PCPC) among patients who survived.

Result

201 of 108,673 hospitalized patients (0.18%) had cardiopulmonary arrest during their hospitalization. Of these, 174 patients underwent CPR. The most common causes of cardiopulmonary arrest were the diseases of respiratory system (29.3%) and circulatory system (19.0%). The most common initial rhythm was bradycardia (72.4%). About 108 patients (62.1%) had restoration of spontaneous circulation (ROSC). Forty-nine patients (28.2%) survived to hospital discharge, 25 (14.5%) survived 6 months post discharge, and 21 (12.1%) survived 1 year post discharge. Out of the 21 patients who survived 1 year after hospital discharge, 18 had good neurological outcome. Multivariate logistic regression analysis showed age, duration of CPR and endotracheal intubation performed before cardiopulmonary arrest were independent factors of cardiopulmonary resuscitation effect.

Conclusion

The prevalence of in-hospital cardiopulmonary arrest in children and adolescents is low. The long-term result of children and adolescents survived from cardiopulmonary resuscitation is quite good. Age, CPR duration and endotracheal intubation performed before cardiopulmonary arrest were independent factors of cardiopulmonary resuscitation effect.     

Efficacy of long duration resuscitation and magnesium sulphate treatment in amitriptyline poisoning.

A single dose of cyclic antidepressants leads to death in childhood. Myocardial depression and ventricular arrhythmia are the severe side effects in cyclic antidepressant overdose. A 23-month-old boy was brought to hospital because 36 mg/kg of amitriptyline had been taken. Cardiopulmonary resuscitation was applied for 70 minutes due to cardiac and respiratory arrest. Circulation was restored after resuscitative efforts. However, ventricular tachycardia was detected which did not respond to lidocaine, bicarbonate and cardioversion treatment. Magnesium sulphate treatment was started and cardiac rhythm normalized. No side effects were observed. The duration of resuscitation should be extended in cases of cardiopulmonary arrest secondary to tricyclic antidepressants intoxication. It should be continued at least for 1 hour. Magnesium sulphate was found to be extremely effective in a case of amitriptyline intoxication refractory to treatment.     

Cardiopulmonary resuscitation standards for clinical practice and training in the UK

The Royal College of Anaesthetists, the Royal College of Physicians, the Intensive Care Society and the Resuscitation Council (UK) have published new resuscitation standards. The document provides advice to UK healthcare organisations, resuscitation committees and resuscitation officers on all aspects of the resuscitation service. It includes sections on resuscitation training, resuscitation equipment, the cardiac arrest team, cardiac arrest prevention, patient transfer, post resuscitation care, audit and research. The document makes several recommendations. Healthcare institutions should have, or be represented on, a resuscitation committee that is responsible for all resuscitation issues. Every institution should have at least one resuscitation officer responsible for teaching and conducting training in resuscitation techniques. Staff with patient contact should be given regular resuscitation training appropriate to their expected abilities and roles. Clinical staff should receive regular training in the recognition of patients at risk of cardiopulmonary arrest and the measures required for the prevention of cardiopulmonary arrest. Healthcare institutions admitting acutely ill patients should have a resuscitation team, or its equivalent, available at all times. Clear guidelines should be available indicating how and when to call for the resuscitation team. Cardiopulmonary arrest should be managed according to current national guidelines. Resuscitation equipment should be available throughout the institution for clinical use and for training. The practice of resuscitation should be audited to maintain and improve standards of care. A do not attempt resuscitation (DNAR) policy should be compiled, communicated to relevant members of staff, used and audited regularly. Funding must be provided to support an effective resuscitation service.     

Historical perspectives on anesthetic-related cardiac arrest and resuscitation

Contemporary interest in resuscitation was historically related to anesthetic death. Primitive techniques of anesthetic administration, loss of airway control, and psychologically influenced sudden death contributed to unanticipated respiratory and cardiac arrest. Airway obstruction has remained the principal factor in asphyxial death, necessitating crucial preservation of respiratory function during induction of anesthesia. Early, disorganized overdose and arrest interventions included: application of cold water, manual artificial respiration, heat, friction and galvanic battery application. Cardiopulmonary resuscitation, after years of research and experimentation became an integrated plan of attack: mouth-to-mouth ventilation and maneuvers eliminating pharyngeal obstruction were proven effective; internal and external cardiac massage was incorporated and definitive drug therapy began with epinephrine, strychnine, caffeine, carbon dioxide, amyl nitrate, coramine, metrazol and procaine. Defibrillation proved electricity converted ventricular fibrillation to normal sinus rhythm. Significant lethality still occurs from anesthetic-induced cardiac arrest, despite technological advances. Causes of operating room cardiac arrests are numerous and include sudden death syndrome. Constant vigilance distinguishes variable patient response. Immediate recognition and coordinated intervention assures success.