Continuing Education Activity

Unlike in adults, cardiopulmonary arrest in rare in children and less likely to be a primary cardiac event. Early onset of effective, high-quality CPR can improve survival. Children in need of resuscitation can be divided into several categories that include pulseless arrest (which may be the result of asystole), pulseless electrical activity, or ventricular fibrillation/ventricular tachycardia without a pulse. Regardless of the etiology, early initiation of CPR along with cardiac monitoring will determine which pulseless arrest pathway to follow. Subsequent management of patients with asystole and pulseless electrical activity include epinephrine administration every three to five minutes, as needed. This activity describes the role of health professionals working together to managing patient in cardiopulmonary arrest.

Objectives:

• Describe the evaluation of a patient who has survived a cardiac arrest.
• Summarize the treatment options for survivors of cardiac arrest.
• Review the causes of cardiac arrest.
• Summarize the role of health professionals working together to manage a patient in cardiopulmonary arrest.

Introduction

Unlike in adults, cardiopulmonary arrest in rare in children and less likely to be a primary cardiac event. Early onset of effective, high-quality CPR can improve survival. The American Heart Association periodically releases updates on pediatric, basic life support and pediatric, advanced life support. One can obtain the principles of pediatric resuscitation from enrolling in Pediatric Advanced Life Support courses (PALS), or Advanced Pediatric Life Support courses (APLS). Children in need of resuscitation can be divided into several categories that include pulseless arrest (which may be the result of asystole), pulseless electrical activity, or ventricular fibrillation/ventricular tachycardia without a pulse. [1][2] 

Regardless of the etiology, early initiation of CPR along with cardiac monitoring will determine which pulseless arrest pathway to follow. For a pediatric pulseless arrest, the compressions to breaths ratio are 30:2 for a sole healthcare provider and 15:2 for two healthcare providers. Subsequent management of patients with asystole and pulseless electrical activity include epinephrine administration every three to five minutes, as needed. The dose of epinephrine is 0.01 mg/kg of the 1:10,000 solution. One can administer epinephrine in multiple ways: intravenously, intraosseously, or endotracheally. The endotracheal dose is ten-fold higher at 0.1 mg/kg. Pulseless electrical activity is often secondary to an underlying cause. PALS teaches the Hs and Ts. [3][4][5]

The Hs are Hypoxia, Hypovolemia, Hydrogen ion (acidosis), Hypo/Hyperkalemia, Hypothermia, and Hypoglycemia. In pediatric patients, hypoxia and hypovolemia are the most common causes. The Ts include Toxins, Tamponade (cardiac) Tension pneumothorax, Thromboembolic event, and Trauma. Although the H's and T's are often associated with pulseless electrical activity, it is prudent to consider causes of cardiac arrest, especially if you fail to achieve a return of spontaneous circulation with your current management.

Ventricular fibrillation and pulseless ventricular tachycardia require similar initial principles, for example, early onset of CPR and early recognition of the rhythm. Quick access to a manual defibrillator or an Automated External Defibrillator (AED), can make the difference in survival. In pediatrics, the energy recommended for defibrillation is 2 J/kg. With the introduction of biphasic defibrillators, the practice of three stacked shocks had been removed from current recommendations. Please refer to the algorithms listed below.[6][7]

Etiology

There are numerous causes for cardiac arrest in children. They can be divided into several categories, which include respiratory, cardiac, infectious, and traumatic causes.[8]

Respiratory causes are the most common. There is considerable overlap between categories. Causes include respiratory infections such as pneumonia and bronchiolitis.

Other respiratory causes include asthma, apnea, aspiration, smoke inhalation, and drowning. Infectious causes also include sepsis and meningitis. Cardiac causes include congenital lesions, commotio cordis, arrhythmias, and cardiomyopathies. Traumatic causes include blunt trauma to the head or chest, ingestions, drowning, and child abuse. Other causes include Sudden Infant Death Syndrome (SIDS), and Sudden Unexpected Infant Death Syndrome (SUID). According to the Centers for Disease Control and Prevention (CDC), in 2015 there were approximately 3700 sudden unexpected deaths in the United States[9][10]

The majority of sudden death causes in young athletes were attributed to cardiovascular disease.

Epidemiology

Based on data from the American Heart Association (AHA), Emergency Medical Services assessed approximately 3628 out-of-hospital cardiac arrests involving individuals younger than 18 years of age. 

Survival to hospital discharge after EMS-treated, non-traumatic cardiac arrest among youth (younger than 18 years) is 5.4%. Nearly 6000 hospitalized children in the United States receive cardiopulmonary resuscitation (CPR) annually. 

Of the cardiovascular deaths that occurred in young athletes (younger than 18 years), 29% were black, 54% were high school students, and 82% were physically exerting themselves during competition or training.

According to data from the AHA, the outcome of unwitnessed cardiopulmonary arrest in infants and children is poor. Only 8.4% of pediatric patients who have out-of-hospital cardiac arrests survive to discharge, and most are neurologically impaired, while the in-hospital survival rate is 24% with a better neurological outcome. The best-reported outcomes have been in children who receive immediate high-quality cardiopulmonary resuscitation (resulting in ample ventilation and coronary artery perfusion), and in those with witnessed sudden arrest (presenting with ventricular rhythm disturbance) that responds to early defibrillation.[6]

History and Physical

Due to the patient's acute condition, a rapid review of the charted medical history may be the entire history available. Focus on noting abnormalities that may be causing the arrest.

The exam is limited to evaluation of the airway, breathing, and circulation during the initial arrest.

Evaluation

Since outcomes are poor post-arrest, priority is placed upon early recognition of pre-arrest states. Recognizing the signs of impending respiratory failure and shock of any etiology is paramount. The emergences of rapid response teams and early warning systems that have been incorporated into electronic medical record systems have helped. [3][5][8]

Treatment / Management

Preparation needs to occur before the patient’s arrival. This includes a code team, a resuscitation room, age appropriate equipment, and proper training in pediatric airway techniques and resuscitation. Code team assignments should occur before the patient’s arrival. Team members assigned to the following roles:[1][2][11]

• A dedicated team leader
• Airway management
• Chest compression
• Vascular access (intravenous or intraosseous)
• Medication administration
• History (from the family and pre-hospital personnel)
• Family liaison (who can communicate with the family)
• Recorder and timekeeper
• Security officer (if available for crowd control)

It is not uncommon to perform several duties depending on staffing.

The Broselow system, a length-based resuscitation tape and/or code cart can assist in determining the proper medication doses and equipment sizes.

Differential Diagnosis

• Angina pectoris

• Aortic stenosis

• Coronary artery atherosclerosis

• Dilated cardiomyopathy

• Ebstein anomaly

• Hypertrophic cardiomyopathy

• Myocardial infarction

• Tetralogy of Fallot

• Torsade de Pointes

• Ventricular fibrillation

Pearls and Other Issues

A modified ABC’s approach can assist with code management: [11][12][13][3][14] 

ABCDE

A= Assign

A= Assess

A= Anticipate

A= Airway (with c-spine control if needed)

B = BLS (effective)

B = Broselow tape

C= CPR

C= Cardiac monitor

D= Disability

D=Drugs

D=Disposition

E= Exposure

E= Environment (temperature and crowd control)

In the adult population, the Universal Termination of Resuscitation guidelines have accurately predicted which patients with out-of-hospital cardiac arrest are less likely to have a return of spontaneous circulation.  In a study of 36,543 patients, researchers found that resuscitation should be terminated if, after at least four, two-minute intervals of cardiopulmonary resuscitation, three criteria are met

1. Emergency Medical Services (EMS) did not witness the arrest
2. There has been no return of spontaneous circulation
3. No shocks were delivered. 

There are no reliable predictors of outcome during resuscitation to suggest when resuscitation efforts are futile. Factors that portend to a poor outcome are delays in bystander CPR, especially in an out-of-hospital cardiac arrest and with delays in activating the EMS system. Children with prolonged resuscitation efforts without the return of spontaneous circulation after two doses of epinephrine are unlikely to survive.

The value of end-tidal carbon dioxide (ETCO2) monitoring has emerged as more than just an adjunct to endotracheal tube placement and assessment of ventilation. Continuous end-tidal carbon dioxide monitoring has a role in the cardiac arrest. A return of spontaneous circulation may be detected sooner with end-tidal carbon dioxide monitoring compared to pulse checks. [15][11] 

Enhancing Healthcare Team Outcomes

The best results are obtained by an established rapid response team usually consisting of a nurse, respiratory therapist, and clinician working in a unified effort to resuscitate and stabilize the patient. [Level V]