Epidemiology of cardiac arrest and resuscitation in children

Education in pediatric basic and advanced life support

Curricula in pediatric resuscitation must be based on adult learning principles. The Pediatric Basic and Advanced Life Support Courses (PBLS, PALS) should use educational strategies fostering positive interactions between the instructor and learners and should take into consideration the learner's motivation for taking the course. Materials should be developed for a specific target audience; course design should be flexible to meet individual needs. The PBLS and PALS courses have different audiences. PBLS is targeted toward caretakers of children. This course will continue to emphasize primary injury prevention as the major strategy but also will give learners the knowledge and skills to perform CPR. To optimize retention of knowledge and skills, the course content must be simplified, and the sequencing of steps in basic life support must be modified. Health care providers caring for pediatric patients in acute care settings are the primary audience for the PALS course. This course already incorporates adult learning principles; only minor revisions are anticipated. Discussion of the trauma patient is limited in the PALS course; additional trauma education could be facilitated by the addition of a trauma module or by other educational courses. All aspects of the PBLS and PALS educational programs must be evaluated continually to determine whether learning objectives have been met and whether the teaching format is appropriate. The answers to evaluation questions will help determine the degree to which the American Heart Association is meeting its educational objectives and how to allocate resources for development and training.

Two-thumb versus two-finger chest compression during CRP in a swine infant model of cardiac arrest

STUDY OBJECTIVE

To test the hypothesis that two-thumb chest compression generates higher arterial and coronary perfusion pressures than the current American Heart Association-approved two-finger method.

DESIGN

Randomized, crossover experimental trial.

SETTING AND PARTICIPANTS

Animal laboratory experiment with seven swine of either sex weighing 9.4 kg (SD, 0.8 kg), representing infants less than 1 year old.

INTERVENTIONS

Animals were sedated with IM ketamine/xylazine, intubated with a 6.0 Hi-Lo endotracheal tube, anesthetized with alpha-chloralose, and paralyzed with pancuronium. ECG was monitored continuously. Left femoral arterial and Swan-Ganz catheters were placed. Cardiac arrest was induced with an IV bolus of KCl and verified by ECG and pressure tracings. Five American Heart Association-certified basic rescuers were randomly assigned to perform external chest compressions for one minute by either the currently recommended two-finger method or the two-thumb and thorax-squeeze method. After all five completed their first trial, rescuers crossed over to the other method for a second minute of compressions. Ventilation was performed with a bag-valve device, and no drugs were given during CPR. After three complete cycles, the fourth through sixth cycles of compressions were recorded. Every compression was analyzed for arterial systolic, diastolic, mean, and coronary perfusion pressures. One thousand fifty compressions were analyzed with repeated-measures analysis of variance and Scheffé multiple comparisons.

RESULTS

Systolic blood pressure, diastolic blood pressure, mean arterial pressure, and coronary perfusion pressure were all significantly higher (P < .001) with the two-thumb thoracic squeeze technique: systolic blood pressure, 59.4 versus 41.6 mm Hg; diastolic blood pressure, 21.8 versus 18.5 mm Hg; mean arterial pressure, 34.2 versus 26.1 mm Hg; and coronary perfusion pressure, 15.1 versus 12.2 mm Hg.

CONCLUSION

The two-thumb method of chest compression generates significantly higher arterial and coronary perfusion pressures than the two-finger method in this infant model of cardiac arrest.

Citizen response to cardiopulmonary emergencies

Since 1985, it has become apparent that the key to survival from adult sudden cardiac death is prompt defibrillation. Any delay from the time of collapse to the initial countershock will decrease the likelihood of survival. It also has been determined that CPR performed by lay rescuers is not begun promptly and, once started, often is performed for more than one minute before the emergency medical services (EMS) system is accessed, which significantly delays the time to defibrillation. In adults, therefore, the rescuer should phone first to activate the EMS system before performing CPR. In the pediatric population, respiratory arrests are far more common than cardiac arrests. Therefore, a rescuer should perform one minute of rescue support before activating the EMS system (a concept termed phone fast). It is recognized that this change is dependent upon a national EMS system that is still evolving. It is hoped that this change to phone first and phone fast will provide an impetus for rapid development of the EMS infrastructure.

The ethics of cardiopulmonary resuscitation. II. Medical logistics and the potential for good response

Mismatches between provision of paediatric cardiopulmonary resuscitation (CPR) and potential to benefit are examined. Deficiencies are most likely to occur in peripheral maternity units but futile CPR is more common in emergency departments where the child is unknown. Decision making in individual cases is best retained by the medical profession for the sake of the child and family. American style intervention by the legislature is likely to dissipate scarce resources and perhaps harm infants not capable of benefiting.

Paramedic intubation training in a pediatric operating room

The authors conducted a prospective study to assess the performance of paramedics with prior adult endotracheal intubation experience in pediatric intubation in the operating room of a teaching hospital. Nineteen paramedic students were observed attempting endotracheal intubation on a total of 57 anesthetized pediatric patients undergoing scheduled surgical procedures. The average age of patients was 5.1 years (range, 6 months to 15.2 years). Average duration of intubation attempts was 22.7 +/- 10.7 seconds, with a success rate on first attempt of 74%. Only minor complications occurred, and were limited to intubation attempts of greater than 45 seconds duration in four cases (6%), and patient oxygen saturation less than 90% in one case (2%). The study suggests that paramedics may be successfully incorporated into a hospital's clinical training program, and can receive closely supervised experience in pediatric endotracheal intubation without compromising patient care. Such training may increase the willingness of paramedics to attempt emergent prehospital endotracheal intubation of children, as well as increase their success with this potentially life-saving procedure.

The epidemiology of cardiac arrest in young adults

STUDY OBJECTIVE

To describe the epidemiology of cardiac arrest in young adults and to determine if there are characteristics unique to this group in terms of etiology, rhythm, and outcome.

DESIGN

Retrospective, case review.

SETTING

King County, Washington.

TYPE OF PARTICIPANTS

All out-of-hospital victims of cardiac arrest who received emergency aid.

MEASUREMENTS

The etiology, cardiac rhythm, and outcome were identified for each case.

MAIN RESULTS

During the 13-year period from 1976 to 1989, there were 8,054 cardiac arrests; 252 of these were among young adults 18 to 35 years of age. Of those 252 cases, 61 (24%) were caused by ischemic heart disease, and 60 (24%) were caused by overdose. Asystole was the most common rhythm (48%), followed by ventricular fibrillation or tachycardia (31%). Long-term survival following these rhythms was 4% and 28%, respectively. In terms of age, etiology, and rhythm, young adults appear to represent a transitional group between children and older adults. There were no unique characteristics specific to young adults. Long-term survival is dependent more on rhythm than on age.

CONCLUSION

In terms of age, etiology, and rhythm, young adults appear to represent a transitional group between children and older adults.

High risk pediatric emergency air transport

INTRODUCTION

Pediatric Emergency Air Transports (PEATs) at Massachusetts General Hospital, Boston, Massachusetts, were reviewed between November 1986 and December 1987. Severity of illness, complications, and outcome of PEATs were compared with ground transports. Factors associated with PEAT survival were identified.

METHODS

Severity of illness was measured using a modified Denver Patient Status Category (DPSC) method and the Therapeutic Intervention Scoring System (TISS). There were 35 PEATs (30 helicopter, five fixed-wing) and 96 ground transports.

RESULTS

Mean severity of illness for patients was greater in PEAT than for the ground transport (PEAT DPSC score=4.23+/-1.06 versus ground DPSC=3.57+/-0.89 [SD], p=.0005). The PEAT mortality was associated with a greater mean severity of illness (TISS survivors=19.1+/-11.4 versus non-survivors=44.3+/-9.5, p=.0001), but not with: the presence of an on-flight physician; transport delay; transport duration; age; sex; history of chronic illness; or intra-transport medical complications.

CONCLUSIONS

Compared to ground transports, PEATs were used for higher risk patients.

Advances in pediatric surgical critical care

The advances in pediatric intensive care outlined here point out the differences between children and adults that need to be considered when taking care of children with surgical diseases. In the past, advances in pediatric critical care have not kept pace with advances in adult care, but these and other new techniques have rapidly closed this gap in knowledge.

Controversies in cardiopulmonary resuscitation: pediatric considerations

This article addresses some therapeutic controversies concerning medications that may be needed during advanced pediatric life support (APLS) and the routes of administration that may be selected. The controversies that are discussed include the appropriateness and selection of various routes for drug administration during APLS; the determination of whether epinephrine hydrochloride is the adrenergic agent of choice for APLS and its appropriate dose; treatment of acidosis associated with a cardiopulmonary arrest; recommendations for atropine sulfate doses; and the role, if any, of calcium in APLS. Background information differentiating pediatric from adult cardiopulmonary arrest is presented to enable the reader to have a better understanding of the specific needs of children during this life-threatening emergency. The article also presents an overview of various drugs used for APLS and a table of their typically recommended doses and routes of administration.

Submersion in The Netherlands: prognostic indicators and results of resuscitation

STUDY OBJECTIVES

To analyze prognostic indicators and the outcome of resuscitation in submersion victims (drowning and near drowning).

DESIGN

Retrospective study.

SETTING

Intensive and Respiratory Care Unit. Between January 1, 1979, and December 31, 1985, 87 submersion victims were admitted. The files of 83 victims were available for statistical analysis. There were 66 male victims and 17 female victims; the average age was 31.4 +/- 25.8 years. There were ten salt water and 73 fresh water submersions.

MEASUREMENTS AND MAIN RESULTS

Predictors for better survival potentials were a young age, submersion of less than ten minutes, no signs of aspiration, and a central body temperature of less than 35 C at admission. We did not detect factors that accelerated a decrease in core body temperature at admission and assume that lethal hypoxia had preceded protective hypothermia in our submersion victims. The Orlowski score had a predictive value but at the same time we found nonindependent indicators in this score. Neurologic outcome in our patients, who were not treated according to a brain protection protocol, was not worse than the outcome published by authors who have used such a protocol. Thirty-three percent of the victims with a cardioventilatory arrest (15) and all victims with a ventilatory arrest (11) survived resuscitation and were discharged. Five nonarrest victims died due to late complications.

CONCLUSION

This study shows that no indicator at the rescue site and in the hospital is absolutely reliable with respect to death or survival.

Equipping and preparing the office for emergencies

It is the practitioner's responsibility to have a prepared office to aid the emergently ill child. Basic equipment and staff training are essential. The pediatrician and family practitioner are on the front lines of pediatric emergency care and, with minimal equipment and training, can serve a vital role in the initial stabilization of the critically ill child.

Nontraumatic prehospital cardiac arrest ages 1 to 39 years

Clinical and autopsy records were retrospectively reviewed for 105 patients between the ages of 1 and 39 years who came in to the emergency department with nontraumatic cardiac arrest. There were 65 male (62%) and 40 female patients (38%). Forty-eight percent of the patients were resuscitated. Long-term survival rate was 23%. The most common presenting rhythm was ventricular fibrillation (45%). Cardiac diseases constituted the most common cause of arrest (38%). Atherosclerotic coronary artery disease represented 50% of all cardiac causes. The second most common etiology was overdose or toxic exposure (21%). Witnessed arrest and an etiology of primary cardiac dysrhythmia for arrest were statistically significant factors related to favorable outcome. Asystole as the initial cardiac rhythm was a negative prognostic indicator. Age, sex, race, bystander cardiopulmonary resuscitation, and paramedic response time were not significant prognostic factors for long-term survival.

Prehospital countershock treatment of pediatric asystole

Prehospital care was retrospectively reviewed in 117 pulseless nonbreathing (PNB) pediatric patients (0 to 18 years of age) to determine the effects of immediate countershock treatment of asystole. Of 90 (77%) children with an initial rhythm of asystole, 49 (54%) received countershock treatment. Rhythm change occurred in ten (20%) of the asystolic children who received countershock treatment. Three of the countershocked asystolic children were successfully resuscitated, but none survived. Rhythm change occurred in nine (22%) of the asystolic children not countershocked. Six were successfully resuscitated, and one survived. The two groups (countershocked asystole v noncountershocked asystole) did not differ significantly in age, sex, witnessed arrest, witnessed arrest with bystander basic life support (BLS), prehospital endotracheal intubation, both intubation and vascular access success, or diagnosis. However, prehospital vascular access was successfully established in a significantly greater number of countershocked patients (P less than .05). The mean times to the scene, at the scene, and to the hospital for the countershocked v noncountershocked asystolic patients were 6.2, 23.8, and 6.1 v 5.9, 14.7 and 7.0 minutes. The mean time at the scene was significantly greater in the countershock group (P less than .001). The successful performance of prehospital endotracheal intubation was significantly associated with rhythm change (P less than .05). Patients age, witnessed arrest, witnessed arrest with bystander BLS, successful establishment of prehospital vascular access, diagnosis, and countershock treatment were not significantly associated with rhythm change. In conclusion, prehospital countershock treatment prolonged prehospital care time and was not associated with rhythm change in asystolic children. Therefore, prehospital countershock treatment of asystolic children is not recommended.

Endotracheal intubation of pediatric patients by paramedics

Although a number of studies have described endotracheal intubation of adult patients in the prehospital setting, there are few studies on prehospital endotracheal intubation of pediatric patients. The purposes of our study were to determine how frequently prehospital endotracheal intubation was used in pediatric cardiopulmonary arrests when a paramedic trained in endotracheal intubation was present, to determine the success rate and complications associated with the procedure in the field, and to compare resuscitation rates and outcome in patients with and without prehospital endotracheal intubation. Our retrospective study covered a 38-month period and included all prehospital victims of medical cardiopulmonary arrest under the age of 19 years. Data were collected from field assessment forms and validated by hospital charts, autopsy reports, coroner's reports, death certificates, and emergency medical services central dispatch logs. Of 63 victims of medical cardiorespiratory arrest, 42 had intubating paramedics present at the scene. Twenty-eight of 42 patients (66%) had endotracheal intubation attempted. Eighteen of 28 attempts (64%) were successful, associated with a major complication rate of 7% (two of 28) and a minor complication rate of 39% (11 of 28). In patients less than 1 year old, only six of 16 (38%) had endotracheal intubation attempted and only three of six (50%) attempts were successful. Of the 18 patients who were intubated successfully before arrival at the hospital, nine (50%) survived to hospital admission and one (6%) survived to discharge. The remainder died in the emergency department.(ABSTRACT TRUNCATED AT 250 WORDS)

Pre-CPR conditions and the final outcome of CPR. The Cerebral Resuscitation Study Group

Outcome of cardiac arrest (CA) is very much influenced by pre-CPR conditions. To assess the importance of these pre-CPR factors, an analysis of the Belgian CPCR registry was made according to some pre-CPR conditions. In this registry, several variables related to pre-arrest, arrest, CPR and post CPR period have been recorded in 4548 patients. The pre-CPR conditions studied were: age, witnessed event or not, pre-arrest health state, underlying disease, site of cardiac arrest, type of respiratory arrest and type of cardiac arrest. Age did not influence outcome significantly. The importance of witnessing is very significant. Severe pre-arrest disability reduces chances on long-term survival (LTS) to half and overall health status longterm survivors is clearly less. Intoxication and metabolic origin of CA have good prognosis (LTS, 21%). Trauma/exsanguination, drowning, SIDS and sepsis have bad prognosis (LTS, 1-3%). Cardiac (LTS, 12%) and respiratory (LTS, 14%) origin have similar outcome, although significant difference exists in occurrence of cerebral failure, suggesting that post-ischemic encephalopathy is more severe in respiratory than in cardiac origin. The most frequent site of CA, the home of the patient, has poor outcome results (LTS, 5%). Gasping is significantly related to successful outcome. In the out-of-hospital setting the type of CA was 25% VF (LTS, 77%), 65% asystole (LTS, 4%) and 10% EMD (LTS, 3%). Outcome of the subgroup out-of-hospital, witnessed, VF is comparable to other reports. This sub-group seems to us the most appropriate for clinical trials.

Pediatric intraosseous infusions: impact on vascular access time

A 1-year retrospective chart review was performed to evaluate the effect of intraosseous infusions (IO) on the time required to establish vascular access in pediatric patients requiring immediate vascular access for resuscitation. Eighty-one patients were identified, including 29 pulseless and non-breathing and 52 noncardiopulmonary arrest children, who required intravenous fluids or medication for resuscitation. Comparing the results with a previous review, the IO method effectively reduced the time needed to establish vascular access in the arrested group when standard techniques failed, particularly in the child less than 2 years old. The IO method was not used effectively in the non-arrest group, as evidenced by a significantly greater mean time required to establish vascular access. There were no significant complications related to the IO procedure. Nine (50%) of the patients receiving IO fluids or medication had clinical and/or laboratory evidence that these substances reached the central circulation. Early use of IO infusion in the resuscitation is recommended for not only the arrested patient, but also the critical nonarrested patient requiring immediate vascular access.

Intraosseous infusions by prehospital personnel in critically ill pediatric patients

A program to instruct ground and aeromedical prehospital emergency medical system providers in the intraosseous infusion technique was developed and implemented. Paramedics and flight nurses received training through lectures and performance of the procedure in several animal models. The records of attempts on 15 patients who subsequently received intraosseous infusions were then reviewed. An intraosseous infusion was successful in 12 of 15 attempts (80%), and all needles were placed in less than 30 seconds. Drugs administered included phenobarbitol, phenytoin, atropine, epinephrine, sodium bicarbonate, isoproterenol, and pancuronium. Observed complications were limited to minimal subcutaneous infiltration in three cases and slow infusion in another. No serious sequelae were noted, but most patients did not survive and the ability of this study to detect sequelae may be limited. These data suggest that intraosseous infusion is a safe and reliable technique in the prehospital setting. Research is needed to study this technique in more detail.

CPR in children

CPR has not been well studied in children and little is known about factors predictive of outcome. We conducted a study with three goals: longitudinal determination of demographic and laboratory data characterizing pediatric arrest victims; identification of factor(s) predictive of outcome; and determination of the prevalence of ionized hypocalcemia in pediatric arrest victims. All resuscitation efforts were documented during a one-year period in a 240-bed tertiary care children's hospital. Patients were classified into two groups--respiratory arrest (RA, requiring only assisted ventilation), and cardiac arrest (CA, absence of palpable cardiac activity requiring closed-chest CPR). Collected data and laboratory tests were analyzed using a step-wise discriminant analysis to determine which factors were predictive of outcome. There were 113 arrests in 93 children; 53 were CA victims and 40 were RA victims. CA had a high in-hospital mortality (90.6%) compared to RA (32.5%). The population was young (55% less than 1 year old) and 87% had at least one chronic underlying disease. No laboratory or demographic value was significantly associated with eventual outcome. The number of doses of epinephrine in CA victims, or bicarbonate in RA victims, was associated with eventual outcome. None of 31 CA victims receiving more than two doses of epinephrine survived to discharge. Low ionized calcium concentrations (less than 3.5 mg/dL) were identified in ten patients; septic shock was present in seven, and chronic renal failure in two.(ABSTRACT TRUNCATED AT 250 WORDS)

Prehospital care of the pulseless, nonbreathing pediatric patient

The performance of life-saving procedures by prehospital care personnel was reviewed in the cases of 114 pulseless, nonbreathing pediatric patients. Children 18 months to 18 years of age had a significantly greater chance of having prehospital endotracheal intubation and vascular access established compared to children younger than 18 months of age. For all patients, witnessed arrest and initial rhythm of ventricular fibrillation were significantly associated with survival. In the younger children, endotracheal intubation also was associated significantly with survival. Nine (8%) patients survived, and only three of the survivors were without neurologic sequelae. The number of neurologically intact survivors was too small to show a statistically significant association with these factors.

Epidemiology of pediatric prehospital care

Very few studies about prehospital care of pediatric emergencies have been published. With new interest in emergency care of the pediatric population demonstrated by the development of Pediatric Advanced Life Support and Advanced Pediatric Life Support, it is imperative to have data that define the different types of problems encountered in the prehospital care setting and their outcomes. Prehospital assessment forms were reviewed retrospectively over a consecutive 12-month period beginning August 1, 1983. Patients under 19 years of age were studied in a service area with a population of 557,700. A total of 3,184 forms were analyzed, representing approximately 10% of all ambulance runs. This contrasts sharply with the fact that the pediatric age group represents 32% of the population. The major users were the youngest and the oldest of the pediatric population. Of the cases, 54.4% were in the trauma category. The largest trauma group was motor vehicle accidents in the adolescent age group. Male patients predominated in the trauma cases. Medical disorders were the major reason for prehospital care in the very young. The demand for emergency medical services (EMS) occurred mainly during the summer months and on weekends. More than 50 percent of all EMS pediatric cases occurred during the hours of 1:00 PM to 9:00 PM. Advanced life support was associated with prolonged on-scene time and had a relatively low use and success rate in the younger pediatric population. Resuscitation of 23 cases of pediatric prehospital arrest resulted in no survivors to hospital discharge. The appropriateness of prolonged time spent on scene (mean of 18.3 minutes in 1,196 cases) for prehospital pediatric emergencies requires further evaluation.

Should the Mobile Intensive Care Unit respond to pediatric emergencies?

Between October 1982 and October 1985, the Mobile Intensive Care Unit (MICU) in Jerusalem responded to 625 pediatric emergencies, representing 5% of the total MICU case load. The most common medical problem was seizures, diagnosed in 205 cases (33%). The second most frequent group related to trauma (175 cases; 28%). There were 71 cases (11.4%) of cardiac arrest. Resuscitation was attempted in 37, but there were no long-term survivors. Almost all cardiac arrest patients were found in asystole, and most had antecedent serious medical problems. Compared with the adult population, children were less likely to require or benefit from an advanced level of prehospital care. When resources for advanced care are limited, priority should be given to adult emergencies.

Optimum position for external cardiac compression in infants and young children

Ninety-seven pediatric patients (age less than 17 years) undergoing routine upright chest roentgenograms in the posteroanterior projection and 90 children undergoing supine anteroposterior chest roentgenograms had lead markers placed at the suprasternal notch and xiphoid prior to taking the roentgenograms. The position of the geometric center of the cardiac silhouette in relation to the sternum was recorded as a percentage of the distance along the sternum. The heart lies under the lower one-third of the sternum (greater than 67%) in all cases at all ages. Ten pediatric patients (between 1 month and 3 years of age) who sustained cardiac arrest while in the Pediatric and Surgical Intensive Care Unit and who had arterial pressure monitoring lines already in place were monitored with a two- or four-channel strip-chart recorder during external cardiac compression (ECC) performed by staff members who were blinded from the results of the strip-chart recording. The ECC performers were instructed to perform ECC at either the midsternum at the level of the victim's nipples or at the lower one-third of the sternum 1.5 to 2 cm above the tip of the xiphoid, and then to switch on command. In every instance in which the patients served as their own controls (ECC performed at both the midsternum and lower one-third of the sternum in random sequence), the performance of ECC over the lower one-third of the sternum resulted in significantly better systolic and mean arterial blood pressures (P less than .001).(ABSTRACT TRUNCATED AT 250 WORDS)

Pathology of the lung in near-drowning

In order to study the initial pathological changes that occur in drowning, the authors developed an experimental model that closely simulates the actual changes in the nearly drowned patient. Adult male rabbits were anesthetized and intubated, and 6 ml/kg of fresh or salt water was instilled directly into the endotracheal tube. The animals were killed after 29 minutes, and the heart and lungs were then examined microscopically. The authors found that in the first 30 minutes, the brunt of the damage is borne by the vascular endothelium and not the alveolar cells.

Community hospital management of pediatric emergencies: implications for pediatric emergency medical services

The ability of emergency physicians in a general community hospital to manage pediatric patients was evaluated. Essential diagnostic and therapeutic procedures performed in the emergency department on pediatric patients transferred for admission to a tertiary care center were compared with those initially performed on the same patients by the pediatricians and residents of the tertiary care center. The overall care rendered by the emergency physicians correlated well with that of the referral center. Ninety one per cent of diagnostic studies and 96% of therapeutic interventions were performed in the emergency department. Implications for the care of seriously ill pediatric patients by emergency physicians and the role of community hospital emergency departments in pediatric emergency medical services (EMS) systems are discussed.

Advanced prehospital care for pediatric emergencies

During an 18-month study period, the mobile intensive care unit (MICU) in Jerusalem responded to 307 pediatric emergencies, representing 5% of the total MICU case load. The most common medical problems were seizures, diagnosed in 100 cases (32%), and conditions related to trauma, diagnosed in 77 cases (23%). Forty-one cases (13%) were cardiac arrests. Nineteen patients were pronounced dead with a resuscitation attempt; resuscitation was attempted in 22 patients. Four patients were stabilized for admission to the hospital, but there were no long-term survivors. Eighteen cardiac arrest patients (82%) were found in asystole, and most had previous serious medical problems. Based on our experience children are less likely to require or benefit from advanced levels of prehospital care compared to the adult population. When resources for advanced care are limited, priority should be given to adult emergencies.

Pancreatic injury associated with interposed abdominal compressions in pediatric cardiopulmonary resuscitation

A case in which conventional CPR was augmented with interposed abdominal compressions on a child is reported. Animal studies and electrical models of this new form of CPR have demonstrated improved hemodynamics without instance of intra-abdominal injury. In this case, intraperitoneal visceral injury was noticed in the form of blood within the stomach and small intestine and parenchymal hemorrhage within the pancreas. Similar pancreatic injury has not been reported with conventional pediatric CPR, and caution may have to be exercised if this form of CPR with interposed abdominal compressions is to be used on children.