Outcome following cardiopulmonary arrest

This article summarizes the current state of outcomes and outcome predictors following pediatric cardiopulmonary arrest with special emphasis on neurologic outcome. The authors briefly describe the factors associated with outcome and review clinical signs, electrophysiology, neuroimaging, and biomarkers used to predict outcome after cardiopulmonary arrest. Although clinical signs, imaging, and somatosensory evoked potentials are best associated with outcome, there are limited data to guide clinicians. Combinations of these predictors will most likely improve outcome prediction, but large-scale outcome studies are needed to better define these predictors.     

Identifying children at risk for cardiorespiratory arrest

Cardiorespiratory arrest in children with severe disease does not usually present suddenly or unexpectedly but is often the result of a progressive deterioration of respiratory and/or circulatory function. Before failure of these functions occurs, there is a series of clinical signs that serve as a warning. Health professionals should not only evaluate clinical signs of respiratory and/or circulatory insufficiency but should also be able to identify these warning signs as early as possible, preferably in the compensation phase, given that the possibility that this process can be reversed by therapeutic measures decreases as the process progresses.     

Out-of-hospital cardiopulmonary arrest in children with croup

Viral laryngotracheobronchitis is a ubiquitous infectious process that has not caused significant mortality in the past 20 years. Bacterial tracheitis and pneumonia can complicate viral laryngotracheobronchitis and markedly increase the risk of bad outcome. Even uncomplicated, properly managed, viral laryngotracheobronchitis can occasionally result in death, particularly in the infant age group.     

Secondary pseudohypoaldosteronism causing cardiopulmonary arrest and cholelithiasis

A 4‐month‐old boy presented with cardiopulmonary arrest on arrival after a brief period of lethargy. Laboratory examination indicated severe hyperkalemia, hyponatremia, metabolic acidosis, and slightly elevated C‐reactive protein. Whole body computed tomography identified left‐dominant hydronephrosis, hydroureter and cholelithiasis. Despite cardiac arrest >30 min, he was successfully resuscitated and treated with therapeutic hypothermia. Escherichia coli was detected on urine culture. Renal ultrasound showed bilateral hydronephrosis, grade II in the right and grade IV in the left. Retrospective analysis of the blood sample at admission indicated a high level of aldosterone. The patient recovered almost fully with no electrolyte imbalance and normal plasma renin and aldosterone, leading to the diagnosis of secondary pseudohypoaldosteronism associated with bilateral infected hydronephrosis. In this case, cholelithiasis, which may account for chronic dehydration, was a diagnostic clue in the absence of information of pre‐existing situations.     

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.     

Recognizing a child at increased risk of abuse.

Data from two studies are presented. Both highlight characteristics which help identify children at increased risk of child abuse. The first study demonstrates that the abused child when compared with unharmed children in the same family is more likely to have been the product of an abnormal pregnancy, labor, delivery and neonatal period. He is more likely to have been separated from his mother and to have been ill in the first year of life. His mother too is more likely to have been sick during that year. The second study shows that it is possible to identify 'at risk' families around the time the baby is born. When compared with controls, five factors are more common: mother aged under 20 at birth of first child, evidence of emotional disturbance, referral to the social worker, admission of baby to special care nursery, and early concern over mothering.     

Extracorporeal cardiopulmonary resuscitation in refractory pediatric cardiac arrest

The purpose of this article is to discuss the indications for extracorporeal cardiopulmonary resuscitation (ECPR), physiologic and mechanical issues that arise in patients managed with ECPR, and optimal patient selection for ECPR. ECPR can provide very good outcomes for some children who, in all likelihood, would otherwise have died. Having the capability to routinely offer ECPR represents an enormous institutional commitment of people and resources. For ECPR to be successful, it must be rapidly deployed, patients must be selected with care, and consistently excellent conventional CPR must take place while awaiting ECPR.     

纳洛酮对缺氧型心跳呼吸骤停复苏影响的实验研究

目的　研究纳洛酮 (Nal)在缺氧型心跳呼吸骤停小猪模型复苏中对心、肺、脑的作用。方法　将 2 7只小猪随机分成Nal 1、Nal 2组和对照组。夹闭气管插管制成缺氧型心跳呼吸骤停模型 ,自主循环恢复者给予不同剂量Nal ,对照组给生理盐水 ;自主呼吸恢复者监护 2h (监护期 ) ,继续观察至心跳骤停后 2 4h ,监测动脉血气、平均动脉压、心肌钙蛋白I(cTnI)、肿瘤坏死因子α(TNFα)、β 内啡肽(β EP)及心跳骤停后 4h、2 4h神经系统评分。 结果　三组自气管插管夹闭至大动脉搏动消失至心跳骤停至自主循环恢复时间均相近 ,Nal 1、Nal 2组自主循环恢复至自主呼吸恢复时间分别为(9.2± 2 .7)、(10 .7± 4.6 )min ,与对照组的 (2 2 .8± 7.6 )min相比 ,差异有非常显著意义 (P <0 .0 1) ;Nal 1、Nal 2组和对照组存活小猪心跳骤停后 4h神经系统评分分别为 0～ 16 0 (M 0 )、70～ 12 5 (M 10 0 )、115～ 310 (M 2 15 )分 (三组比较 ,P >0 .0 5 ) ,2 4h神经系统评分分别为 0～ 2 0 (M 0 )、0～ 35 (M 2 7.5 )、40～ 310 (M 117.5 )分 (P <0 .0 0 9) ;三组麻醉后至自主循环恢复各点cTnI值均逐渐升高 ,但差异无显著性 ;两Nal组存活者给予Nal后监护期cTnI值下降 ,对照组上升 ;监护期平均动脉压较高 (P <0 .0 5 )、β EP值较高     

Myopathy and neurogenic muscular atrophy in unexpected cardiopulmonary arrest

Background: Neuromuscular disorders can be the cause of sudden death of infants because of their weakness and gastroesophageal reflux (GER). Methods: Muscle biopsy and genetic studies were performed by usual method. Results: In this report four cases of infants with neuromuscular disorders (two cases of congenital myopathy and two cases of spinal muscular atrophy) who had unexpected cardiopulmonary arrest on arrival (CPAOA) are presented. Two of the cases did not show any symptoms, such as muscle weakness prior to CPAOA. The diagnosis was based on the results of the muscle biopsy and genetic examination. Conclusion: These results suggest that sudden infant death caused by neuromuscular disorders should be considered.     

大剂量肾上腺素对于儿童心肺复苏的Meta分析

目的评价大剂量肾上腺素对比标准剂量肾上腺素用于儿童心肺复苏的疗效。方法计算机检索Medline（1966至2006年）、Embase（1974至2006年）、Cochrane图书馆2006年第三期、中国生物医学文献光盘数据库（CBM）（1998至2006年）、中文学术期刊全文数据库（1994至2006年）。按纳入排除标准纳入合格的随机对照研究并对其进行质量评价,Meta分析采用Rev Man4．2．7软件进行。结果共纳入4篇研究包括360例,Meta分析结果表明大剂量肾上腺素与标准剂量的肾上腺素相比用于儿童的心肺复苏在自主循环恢复、24h存活率、出院存活率、神经系统后遗症方面无统计学意义,其RR值和95％CI分别为1．28（0．93,1．77）、1．40（0．43,4．55）、1．78（0．42,7．50）、0．72（0．43,1．19）。结论儿童在进行同等心肺复苏条件下,尚不能认为大剂量的肾上腺素可以增加自主循环恢复率、24h存活率、出院存活率和减少神经系统后遗症。     

Identification during the postpartum period of infants who are at high risk of child maltreatment

To determine whether clinicians correctly identify newborn infants who are at high risk of child maltreatment, we examined the outcomes of high-risk and non-high-risk children. Infants who were born at Yale-New Haven Hospital from 1979 to 1981 and who were referred by clinicians during the postpartum period to the hospital's child abuse registry because they were considered at high risk of child abuse or neglect became the high-risk group. For each high-risk infant, a comparison infant was selected and matched according to date of birth, gender, race, and method of payment for the hospitalization. For both groups, the occurrence of maltreatment was ascertained by reviewing the medical records until the child's fourth birthday. Each injury for which medical care was sought was classified into one of seven categories (from definite child abuse to accident) by a pediatrician who was unaware of the child's risk status. Information also was recorded about nonorganic failure to thrive and changes in the child's caretaker. Maltreatment (defined as abuse or neglect) occurred more frequently in the high-risk group than the comparison group (adjusted matched odds ratio = 4.3; 95% confidence interval = 1.41, 6.93; p less than 0.001), as did poor weight gain from a nonorganic cause (matched odds ratio = 7.0; 95% confidence interval = 1.59, 30.79; p less than 0.01) and changes in the child's caretaker (matched odds ratio = 9.0; 95% confidence interval = 3.80; 20.55; p less than 0.001). We conclude that as early as the postpartum period, clinicians can identify some families who are at high risk of maltreatment and other major adverse outcomes resulting from poor parenting.     

以严重低血糖、反复呼吸心跳骤停为主症的甲状腺低功一例

患儿,男,52 d,因呛奶5 h,心跳、呼吸停止复苏后2 h入院。患儿5 h前吃奶后呛奶,随后面色青紫,呼吸不规则,拍背后面色及呼吸好转。1 h后又面色青紫,呼吸微弱,大汗淋漓,随后呼吸心跳停止,在外院经气管插管,未吸出奶汁,胸外心脏按压,静推肾上腺素、阿托品、碳酸氢钠等抢救后心跳呼吸逐渐恢复。入院时查体:神志清,反应迟钝,面色稍苍白,四肢冰凉,可见花纹,毛细血管再充盈时间5~6 s,自主呼吸30次/min,无吸气三凹征,双肺呼吸音清,未闻及音,心率118次/min、心律齐、心音低钝、无杂音,腹胀明显、叩诊鼓音,四肢肌张力稍低,膝反射正常,病理征未引出。辅…     

Cardiac arrest in children. Causes and future after cardiopulmonary resuscitation

A 24 months retrospective study was carried out to investigate 133 patients with an unexpected cardiorespiratory arrest (CRA). Cardiopulmonary resuscitation (CPR) was undertaken in all cases. 96 patients suffered CRA outside of hospital, 11 patients in the wards of the hospital, and 26 in the pediatric intensive care unit (PICU). Sixty children (44%) responded to initial resuscitation and 20 patients (15%) survived after discharge, 12 (9%) of them with a good neurologic outcome. The best results were obtained in patients with an CRA in the PICU. The results of this study suggest that survival among resuscitated children is not better than that among adults, but can be improved with early recognition and monitoring of children at risk.