Current Pediatric Reviews - Volume 9, Issue 2, 2013

Advances in resuscitation science have improved pediatric cardiac arrest outcomes substantially over the past 25 years. The performance of high-quality cardiopulmonary resuscitation (CPR) has been highlighted as an important determinant of survival of both adult and pediatric cardiac arrest. In short, performance of high quality Basic Life Support (BLS) saves childrens’ lives. This article will focus specifically on cardiopulmonary resuscitation “technique” for infants and children. In concert with the International Liaison Committee on Resuscitation (ILCOR) and the American Heart Association (AHA), the available scientific evidence supporting current resuscitation guidelines for hand position, chest compression rate and depth, minimizing interruptions, and full chest recoil will be discussed. Important changes will be highlighted, such as the increasing emphasis on early and effective high quality chest compressions even for pediatric victims, exemplified in the acronym change from Airway-Breathing-Circulation, or ABC, to Circulation-Airway-Breathing, or CAB. Exciting technological advances that have been shown to successfully monitor / improve CPR technique will also be presented. And while the foundation of CPR guidelines is evidence-based, resuscitation scientists should be challenged to focus future efforts towards several questions that remain unanswered. In the end, all providers – trained and untrained – should be encouraged to recognize and immediately DO SOMETHING when a child has no signs of life, most importantly and simply: “PUSH HARD and PUSH FAST!”.

In children, ventilation management is essential before, during, and after cardiopulmonary resuscitation (CPR). In the pre-arrest phase, interventions must focus on the prevention of cardiopulmonary arrest. During CPR, the objective is to match ventilation with perfusion, because much less ventilation is necessary for adequate gas exchange and evidences indicate that overventilation is common and can compromise venous return, cardiac output and outcome. Hypoventilation, hypoxemia and hyperoxemia must be also avoided. Self-inflating bags connected to a face mask or an endotracheal tube are the preferred devices to deliver oxygen and positive pressure ventilation during respiratory or cardiac arrest in children. Following return of spontaneous circulation (ROSC) a complex and global process of reperfusion injury occurs; therefore, intensive monitoring and goal directed respiratory therapy should be the standard of care. New studies and evidences are needed to define the optimal ventilation procedures and strategies in pediatric CPR.

Good airway management is fundamental to pediatric resuscitation. This review focuses on the anatomy of the infant and child airway, together with techniques and equipment required to open and maintain a child’s airway in an emergency. Much of the knowledge has been available for many years but newer imaging techniques are allowing more accurate assessment of the child’s airway anatomy and, in some cases, challenging traditional assumptions. In addition, recent technologies are facilitating the development of equipment, such as supra-glottic airway devices, cuffed tracheal tubes and video laryngoscopes that have the potential to simplify pediatric airway management. In some cases, this may bring the provision of safer definitive airway management into the hands of non-specialists, which will, in turn, allow the delivery of earlier and better care to the sick child. Such techniques are best used together with accurate monitoring to confirm the effectiveness of any intervention. In airway management, the use of expired carbon dioxide monitoring provides absolute confirmation that pulmonary ventilation is occurring and, when used together with the techniques and equipment described above, will reduce the potential for error and increase safety and survival.

Although sustained return of spontaneous circulation (ROSC) can be initially established after resuscitation in children, many of the children do not survive to discharge because they developped a post cardiac arrest syndrome. The post-cardiac arrest syndrome includes systemic ischaemia/reperfusion response, post-cardiac arrest brain injury, postcardiac arrest myocardial dysfunction, and persistent precipitating pathology. The main cause of death after ROSC in children is brain injury. Physiopathology and management are reviewed in regards of pediatric specificities. Management according to ABCDE includes airway and ventilation management, oxygen therapy, hemodynamic management with early goal directed therapy and protection of the brain against secondary injury by therapeutic hypothermia, management of seizures and control of glycemia.

Infants and children have historically received a weight-based escalating defibrillation dose, commencing at 2J/kg. Researchers are increasingly suggesting that 2J/kg maybe an ineffective initial defibrillation dose. However without a definitive study there has been hesitancy to modify this initial dose. The International Liaison Committee on Resuscitation made a recommendation in 2010 of an initial dose of 2–4 J/Kg, increased from 2 J/Kg. The American Heart Association and the European Resuscitation Councils now have different initial dosing recommendations for children. The ERC advocates 4J/kg as the initial dose without escalation for subsequent shocks, while the AHA recommends 2–4 J/Kg, increasing to ≥ 4 J/Kg with subsequent shocks up to adult dose. The difficulty of finding a dose based on robust evidence continues to provide a stimulus for research to better define the best defibrillation energy dose for children.

Resuscitation of the newly born baby is among the most important and commonly performed interventions worldwide. Different approaches have been used for thousands of years depending upon both fashion and the scientific understanding at the time. Artificial respiration and an “ABC” approach has been the mainstay of delivery room resuscitation for about the last 50 years. Over the last 15 years an international collaboration has evaluated the available evidence and published conclusions upon which to base guidelines [1]. Whilst a major step forward, this process has also revealed the lack of evidence for some well established practices. This review will cover some of the historical background as well as the most modern interpretation of the evidence guiding resuscitation at birth in a number of key areas. However, it will also highlight other areas for which further evidence is needed to guide practice. More newborn resuscitation-based research has taken place in the last 10 years, however, it is still true that “There can be few areas of medicine where the potential benefit is so great but which have been subjected to so little evaluation”[2].

Neonates and infants with functional single ventricle anatomy face nearly certain early mortality without cardiac transplantation or successive palliation through a pathway of staged interventions. Patients with single ventricle variants typically have multiple hospitalizations and high incidence of cardiac arrest. Few studies have directly addressed the physiology, pharmacology, techniques or outcomes of resuscitation of this high-risk group. The unique challenge posed by resuscitation of this patient group was recently recognized within the 2010 International Liaison Committee on Resuscitation consensus statement, where, for the first time, two worksheets were devoted exclusively to the resuscitation of the single ventricle patient before and after S1P and those patients with bidirectional Glenn/hemi-Fontan and Fontan physiology. This article will review the consensus on science, treatment recommendations, and areas of uncertainty in the resuscitation of the infants and children with single ventricle physiology during each stage of surgical repair.

During the past 10-15 years it has become evident that in spite of the sophistication of medicine, hospitalized patients frequently experience cardiac arrests from which the majority do not survive. A substantial number of these arrests occur on general inpatient units where patients begin to deteriorate but there is a failure of timely recognition so that appropriate intervention can be instituted before the arrest takes place. Much work has been done to determine how survival from adult in-hospital cardiac arrests can be improved by (1) teaching health care providers about resuscitation management using a team approach and (2) more recently, by developing rapid response systems to recognize deteriorating patients early and intervening to prevent the cardiac arrest. The purpose of this review is to outline what is known about the use and organization of resuscitation teams (code teams) and rapid response systems as they apply to pediatric patients. Effort has been made to include the most current pediatric science available as a basis for encouraging the ongoing implementation of hospital team-based systems which appear to be able to improve the outcomes of pediatric in-hospital cardiac and respiratory arrests. Practical suggestions, implementation strategies, potential barriers, and ways to integrate pediatric code teams and rapid response systems into the quality and safety fabric of the hospital are provided.

Sudden death is a rare event, particularly in the young. A traditional comprehensive autopsy often reveals diseases that were not recognized prior to death. For a significant proportion of sudden deaths in the young, there is no clear etiology following autopsy. These unexplained sudden deaths are often secondary to primary arrhythmogenic diseases, where there is a defect in the structure or function of the channels that regulate the ion movement responsible for the electrical activation of the heart. As a group, these diseases are known as channelopathies. Channelopathies are often secondary to genetic mutations which may be inherited and place surviving relatives at risk. While these conditions cannot be detected by the traditional comprehensive autopsy, there is increasing evidence that they may be detected by molecular genetic analysis using blood or tissue from the deceased individual. There is no conclusive evidence to show the benefit of systematic screening for channelopathies in sudden unexplained death; however, there is increasing circumstantial evidence supporting the practice. There is currently insufficient infrastructure for the systematic implementation of such a screening program, including insufficient financial resources. While no clear legal obligation exists, there is a moral obligation to inform surviving family members of their potential risk. Strong consideration should be given to augmenting the traditional autopsy with a molecular analysis in the presence of unexplained sudden death in the young.

The optimal approach for teaching and maintaining competency in cardiopulmonary resuscitation (CPR) remains unclear. Basic CPR competency is a foudational skill in both basic and advanced life support training and ample data supports the need to improve ongoing maintenance of competency. Many out-of-hospital cardiac arrest victims do not receive CPR before the arrival of professional rescuers. Video-based instruction effectively trains students more quickly than traditional classroom based courses and evidence suggests ongoing refresher training benefits skill retention. Real time feedback devices improve CPR quality in both training and actual resuscitation events. High fidelity simulation may improve competency in advanced life support training scenarios.