Basic life support in pediatrics

Basic life support (BLS) is the combination of maneuvers that identifies the child in cardiopulmonary arrest and initiates the substitution of respiratory and circulatory function, without the use of technical adjuncts, until the child can receive more advanced treatment. BLS includes a sequence of steps or maneuvers that should be performed sequentially: ensuring the safety of rescuer and child, assessing unconsciousness, calling for help, positioning the victim, opening the airway, assessing breathing, ventilating, assessing signs of circulation and/or central arterial pulse, performing chest compressions, activating the emergency medical service system, and checking the results of resuscitation. The most important changes in the new guidelines are the compression: ventilation ratio and the algorithm for relieving foreign body airway obstruction. A compression/ ventilation ratio of 30:2 will be recommended for lay rescuers of infants, children and adults. Health professionals will use a compression: ventilation ratio of 15:2 for infants and children. If the health professional is alone, he/she may also use a ratio of 30:2 to avoid fatigue. In the algorithm for relieving foreign body airway obstruction, when the child becomes unconscious, the maneuvers will be similar to the BLS sequence with chest compressions (functioning as a deobstruction procedure) and ventilation, with reassessment of the mouth every 2 min to check for a foreign body, and evaluation of breathing and the presence of vital signs. BLS maneuvers are easy to learn and can be performed by anyone with adequate training. Therefore, BLS should be taught to all citizens.     

Recognition of the child at risk of cardiopulmonary arrest

Early treatment is a major factor to improve the outcome of children at risk of cardiopulmonary arrest. That's why it is essential to recognize as soon as possible clinical signs that indicate a respiratory and/or circulatory dysfunction. Immediate systematic assessment and re-assessment of oxygenation, ventilation and organ perfusion status is one of the keys in the prevention of cardiorespiratory arrest in children. Health care staff must assure that a child with signs of acute respiratory and/or circulatory dysfunction is under constant surveillance by a person with ability to interpret signs, identify problems and to initiate emergency treatment, if needed. Respiratory assessment must include respiratory rate, signs of mechanical respiratory failure (nasal flaring, respiratory noises, paradoxical breathing, prolonged expiration) as well as skin-mucous colour. Cardiocirculatory failure assessment includes heart rate, blood pressure, peripheral perfusion (capillary refill time and temperature gradient), level of consciousness and urinary output. In a child with impending signs of cardio-respiratory failure, the priority is to warrant adequate ventilation and oxygenation. If, despite this treatment, there is no improvement in perfusion, treatment of circulatory failure with fluids and vasoactive drugs is necessary.     

Child with absent vital signs

The outcome of cardiopulmonary resuscitation in the child with absent vital signs is dismal. Best outcomes therefore should rely on early recognition and aggressive management of critical illness to interrupt deterioration to cardiorespiratory arrest. Moreover, resuscitation entails a spectrum of care starting with cardiopulmonary resuscitation at the site of injury through critical care and post resuscitation rehabilitation. The resources required to provide this level of care is not available in many parts of the world. Therefore, resuscitation skills should be taught to caregivers at a level which is congruent to their role in the continuum of care and the use of aggressive resuscitation needs to be tailored based on geography, risk to medical personnel, preservation of resources, transplantation issues and expected outcomes. In some cases, the most prudent decision may be not to attempt resuscitation of the child with absent vital signs.     

Cardiopulmonary resuscitation of a near-drowned child with a combination of epinephrine and vasopressin.

OBJECTIVE: To report a cardiopulmonary resuscitation attempt in a 20-month-old child employing a combination of vasopressin and epinephrine. DESIGN: Case report. SETTING: Out-of-hospital cardiopulmonary resuscitation. PATIENT: A 20-month-old child found in cardiac arrest after submersion. INTERVENTIONS AND RESULTS: Dispatcher-assisted basic life support was initiated immediately after pulling the child out of the water. The emergency medical service crew arrived approximately 6 mins later and found a hypothermic, cyanotic child in cardiocirculatory arrest. The first electrocardiogram showed sinus bradycardia. After intubation and administration of epinephrine and atropine with no effect, an intravenous bolus of 0.2 mg of epinephrine and 10 IU of vasopressin resulted in restoration of spontaneous circulation. The boy was flown to a hospital and was discharged 23 days later to a rehabilitation facility. He returned home 6 months after the accident, where further rehabilitation efforts are pending. CONCLUSION: Bystander cardiopulmonary resuscitation, early and aggressive advanced life support, rewarming, and the combination of intravenous epinephrine and vasopressin were associated with sustained return of spontaneous circulation following hypothermic submersion-associated cardiac arrest.     

Outcome of cardiopulmonary resuscitation in hospitalized African children

The outcome of cardiopulmonary resuscitation at the research ward of the Kenya Medical Research Institute is reviewed. The outcome for respiratory arrest was 15 per cent (95 per cent CI 6.6-27) to discharge, and worse for cardiorespiratory arrest with no survival. The illnesses leading to cardiopulmonary arrest and causes for the disappointing outcome are discussed.     

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.     

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.     

Initial pediatric trauma care and cardiopulmonary resuscitation

Accidents are a frequent cause of death in children older than 1 year. The most frequent causes of death by accident are traffic accidents, drowning, intentional injuries, burns, and falls. Cardiopulmonary resuscitation is one component of the set of actions needed to obtain initial stabilization of a child with serious trauma. In the first few minutes after the accident, cardiorespiratory arrest can occur due to airway obstruction or inadequate ventilation, massive blood loss or severe brain damage; cardiorespiratory arrest in this setting has a dismal outcome. When arrest occurs hours after trauma, it is usually caused by hypoxia, hypovolemia, hypothermia, intracranial hypertension, or electrolyte disturbances. The first response to trauma should include three objectives: to protect (scenario assessment and implementation of safety measures), to alert (activation of the emergency medical system) and to help (initial trauma care). Initial trauma care includes primary and secondary surveys. The primary survey involves several consecutive steps: A. airway and cervical spine stabilization, B. breathing, C. circulation and hemorrhage control, D. neurological dysfunction, and E. exposure. The secondary survey consists of assessment of the victim by means of anamnesis, sequential physical examination (from head to limbs) and complementary investigations. During emergency trauma care, specific procedures such as extrication and mobilization maneuvers, cervical spine control by means of bimanual immobilization, and cervical collar placement or helmet removal. If a cardiorespiratory arrest occurs during initial trauma care, resuscitation maneuvers must be immediately started with the specific adaptations indicated in children with trauma.     

Pediatric advanced life support

Advanced life support (ALS) includes all the procedures and maneuvers used to restore spontaneous circulation and breathing, thus minimizing brain injury. The fundamental steps of ALS are airway control with adjuncts, ventilation with 100% oxygen, vascular access and fluid and drug administration, and monitoring to diagnose and treat arrhythmias. Airway control can be achieved by means of oropharyngeal airway, endotracheal intubation, and alternative methods (laryngeal mask and cricothyroidotomy). Vascular access can be achieved by the peripheral venous, intraosseous, central venous, and tracheal routes. The most frequent rhythms found in children with cardiorespiratory arrest are nonshockable (asystole, severe bradycardia, pulseless electrical activity, and complete atrioventricular block). In these cases, adrenaline continues to be the essential drug. Currently, low adrenaline doses (0.01 mg/kg IV and 0.1 mg/kg intratracheal administration) are recommended throughout the resuscitation period. Amiodarone (5 mg/kg) is the drug of choice in cases of ventricular fibrillation refractory to electric shock. The treatment sequence for shockable rhythms (ventricular fibrillation and pulseless ventricular tachycardia) is one 4 J/kg electric shock, followed by cardiopulmonary resuscitation (chest compressions and ventilation) for 2 minutes with subsequent reassessment of the electrocardiographic rhythm. Adrenaline must be administered immediately before the third electric shock and subsequently every 3-5 minutes. Amiodarone must be administered immediately before the fourth shock.     

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.     

Monitoring the resuscitation of preterm infants in the delivery room using pulse oximetry

The first few minutes after birth are a critical time of adaptation of the newborn infant to extrauterine life. The adequacy of that adaptation has been evaluated by means of the summed Apgar score. In preterm infants, Apgar score may correlate less with adequacy of cardiopulmonary function because of developmental immaturity. Measurement of arterial oxygen saturation by means of pulse oximetry offers a physiologic, real time method of monitoring the progress of cardiopulmonary adaptation by which the clinician can evaluate the need for and success of resuscitative efforts. Four preterm infants are reported in whom pulse oximetry was useful in assessing the changes in oxygen saturation during resuscitation.     

影响儿童院内心肺复苏预后的因素分析

目的：探讨儿童院内心肺复苏(cardiopulmonary resuscitation,CPR)预后的影响因素。方法通过回顾性观察研究,对2012年1月至2014年10月我院发生的281例心肺复苏病例进行单因素分析,以自主循环恢复﹥20 min 作为近期复苏成功标准,分析心肺复苏预后的影响因素。结果纳入的281例患儿中,男∶女为1.34∶1,年龄1～191个月,其中自主循环恢复﹥20 min 共129例(45.9%),出院存活20例(8.8%)。性别、年龄、体重、呼吸心跳骤停(cardiopulmonary arrest,CPA)发生时间、CPA 初始心电图、pH 值、乳酸水平对心肺复苏预后无明显影响。基础疾病、CPA 发生地点、CPR 组织人员、通气方式、CPR 总时间、初期复苏时使用肾上腺素的次数、使用碳酸氢钠及血糖情况对复苏成功率有影响。结论目前 CPR 成功率及出院存活率仍较低。呼吸系统疾病成功率相对较高。CPR 时间﹥20 min、需要使用碳酸氢钠以及初期复苏中使用肾上腺素大于3次是影响 CPR 成功的不利因素。     

Emergency cardiopulmonary bypass for cardiac arrest refractory to pediatric advanced life support

We report the application of emergent cardiopulmonary bypass (CPB) for three pediatric patients in the cardiac catheterization laboratory with cardiac arrest who did not respond to conventional resuscitation efforts. All three patients had return of baseline prearrest rhythms within minutes of the initiation of artificial cardiopulmonary support and the return of spontaneous circulation upon weaning CPB. Two patients had normal neurologic outcomes despite an interval of over 30 minutes from arrest to CPB. The continued judicious application and study of this technology in a small subpopulation of pediatric cardiac arrest patients is warranted.     

What is the right dose of epinephrine?

OBJECTIVE: To review the findings and discuss implications of studies on high-dose epinephrine (0.1 mg/kg) during cardiopulmonary resuscitation in children. DESIGN: A critical appraisal of "A Comparison of High-Dose and Standard-Dose Epinephrine in Children with Cardiac Arrest" by Perondi et al. (N Engl J Med 2004; 350:1722-1730), with literature review. FINDINGS: Retrospective studies investigating the use of high-dose epinephrine during pediatric cardiopulmonary resuscitation demonstrate conflicting results with respect to return of spontaneous circulation and survival. The randomized controlled trial by Perondi et al. demonstrates decreased survival with the use of high-dose epinephrine and no difference in return of spontaneous circulation when compared with the standard dose. CONCLUSIONS: There is no benefit from the use of high-dose epinephrine in pediatric cardiopulmonary resuscitation. There is potential harm from such dosing. The cumulative evidence against the use of high-dose epinephrine during pediatric cardiopulmonary resuscitation is strong.     

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.     

EFFECT OF CONTINUOUS POSITIVE AIRWAY PRESSURE BREATHING ON CARDIORESPIRATORY FUNCTION IN INFANTS WITH RESPIRATORY DISTRESS SYNDROME

Abstract A method of investigating the cardiorespiratory responses to continuous positive airway pressure (CPAP) in infants with respiratory distress syndrome is described. All measurements were made immediately before and within five minutes of application or any change in level of CPAP. Ventilation was derived from a pneumo-tachograph and dynamic compliance calculated. We have also measured arterial pH, oxygen and carbon dioxide tensions, arterial blood pressure and central venous pressure. Arterial oxygen tension increased in association with a decrease in the alveolar-arterial oxygen gradient. No consistent changes occurred in pH or carbon dioxide tension. Heart rate and mean arterial blood pressure remained the same but the arterial pulse pressure narrowed and the increase in central venous pressure averaged 17% of the applied airway pressure. There were less variations in both tidal volumes and instantaneous respiratory rates with CPAP compared with spontaneous breathing without CPAP. The respiratory rate decreased, but there were no consistent changes in tidal volume, resulting in a lesser reduction of minute ventilation. Dynamic compliance decreased on CPAP. With correct use of CPAP, and improvement in oxygenation generally occurs without obvious adverse cardiorespiratory effects. CPAP must nevertheless be used cautiously and in conjunction with close monitoring; because when the appropriate pressures are exceeded, it is possible that both circulatory and ventilatory function might be severely compromised.     

Effect of continuous positive airway pressure breathing on cardiorespiratory function in infants with respiratory distress syndrome.

A method of investigating the cardiorespiratory responses to continuous positive airway presslre (CPAP) in infants with respiratory distress syndrome is described. All measurements were made immediately before and within five minutes of application or any change in level of CPAP. Ventilation was derived from a pneumotachograph and dynamic compliance calculated. We have also measured arterial pH, oxygen and carbon dioxide tensions, arterial blood pressure and central venous pressure. Arterial oxygen tension increased in association with a decrease in the alveolar-arterial oxygen gradient. No consistent changes occurred in pH or carbon dioxide tension. Heart rate and mean arterial blood pressure remained the same but the arterial pulse pressure narrowed and the increase in central venous pressure averaged 17% of the applied airway pressure. There were less variations in both tidal volumes and instantaneous respiratory rates with CPAP compared with spontaneous breathing without CPAP. The respiratory rate decreased, but there were no consistent changes in tidal volume, resulting in a lesser reduction of minute ventilation. Dynamic compliance decreased on CPAP. With correct use of CPAP, and improvement in oxygenation generally occurs without obvious adverse cardiorespiratory effects. CPAP must nevertheless be used cautiously and in conjunction with close monitoring; because when the appropriate pressures are exceeded, it is possible that both circulatory and ventilatory function might be severely compromised.     

Home monitoring following sudden infant death--report of the personal experiences of an anesthesist

An infant boy (brother of a SIDS victim) was followed up for the first 6 months of life by home cardiorespiratory monitoring. The case reports of both the two children are presented. Some of the problems arising after the subsequent pregnancy as there are selection of the kind of monitor, preparations for cardiopulmonary resuscitation and home situation are discussed. The personal decisions made in this context by the author are presented.     

Hypothermic cardiac arrest

After being lost for 16 hr, a 7-yr-old boy was admitted to the emergency Department (ED) in a severe hypothermic condition of 23.3 °C with cardiac arrest. Active rewarming was conducted with cardiopulmonary resuscitation (CPR). Sixty minutes after admission, return of spontaneous circulation was confirmed. Fever developed 14 hr after admission and continued for 9 days due to frostbite wound of both feet. This case report demonstrates successful resuscitation in severe hypothermic cardiac arrest with complete neurologic recovery in a 7-yr-old boy.