Pediatric defibrillation after cardiac arrest: initial response and outcome

Association between survival and number of shocks for pulseless ventricular arrhythmias during pediatric in-hospital cardiac arrest in a national registry

BACKGROUND

Annually 15,200 children suffer an in-hospital cardiac arrest (IHCA) in the US. Ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) is the initial rhythm in 10-15% of these arrests. We sought to evaluate the association of number of shocks and early dose escalation with survival for initial VF/pVT in pediatric IHCA.

METHODS

Using 2000-2020 data from the American Heart Association's (AHA) Get with the Guidelines®-Resuscitation (GWTG-R) registry, we identified children >48 hours of life and ≤18 years who had an IHCA from initial VF/pVT and received defibrillation.

RESULTS

There were 251 subjects (37.7%) who received a single shock and 415 subjects (62.3%) who received multiple shocks. Baseline and cardiac arrest characteristics did not differ between those who received a single shock versus multiple shocks except for duration of arrest and calendar year. The median first shock dose was consistent with AHA dosing recommendations and not different between those who received a single shock versus multiple shocks. Survival was improved for those who received a single shock compared to multiple shocks. However, no difference in survival was noted between those who received 2, 3, or ≥4 shocks. Of those receiving multiple shocks, no difference was observed with early dose escalation.

CONCLUSIONS

In pediatric IHCA, most patients with initial VF/pVT require more than one shock. No distinctions in patient or pre-arrest characteristics were identified between those who received a single shock versus multiple shocks. Subjects who received a single shock were more likely to survive to hospital discharge even after adjusting for duration of resuscitation.

Pediatric Cardiac Arrest and Resuscitation

Pediatric cardiac arrest in the emergency department is rare. We emphasize the importance of preparedness for pediatric cardiac arrest and offer strategies for the optimal recognition and care of patients in cardiac arrest and peri-arrest. This article focuses on both prevention of arrest and the key elements of pediatric resuscitation that have been shown to improve outcomes for children in cardiac arrest. Finally, we review changes to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care that were published in 2020.

Inappropriate Shock Delivery Is Common During Pediatric In-Hospital Cardiac Arrest

OBJECTIVES

To characterize inappropriate shock delivery during pediatric in-hospital cardiac arrest (IHCA).

DESIGN

Retrospective cohort study.

SETTING

An international pediatric cardiac arrest quality improvement collaborative Pediatric Resuscitation Quality [pediRES-Q].

PATIENTS

All IHCA events from 2015 to 2020 from the pediRES-Q Collaborative for which shock and electrocardiogram waveform data were available.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We analyzed 418 shocks delivered during 159 cardiac arrest events, with 381 shocks during 158 events at 28 sites remaining after excluding undecipherable rhythms. We classified shocks as: 1) appropriate (ventricular fibrillation [VF] or wide complex ≥ 150/min); 2) indeterminate (narrow complex ≥ 150/min or wide complex 100-149/min); or 3) inappropriate (asystole, sinus, narrow complex < 150/min, or wide complex < 100/min) based on the rhythm immediately preceding shock delivery. Of delivered shocks, 57% were delivered appropriately for VF or wide complex rhythms with a rate greater than or equal to 150/min. Thirteen percent were classified as indeterminate. Thirty percent were delivered inappropriately for asystole (6.8%), sinus (3.1%), narrow complex less than 150/min (11%), or wide complex less than 100/min (8.9%) rhythms. Eighty-eight percent of all shocks were delivered in ICUs or emergency departments, and 30% of those were delivered inappropriately.

CONCLUSIONS

The rate of inappropriate shock delivery for pediatric IHCA in this international cohort is at least 30%, with 23% delivered to an organized electrical rhythm, identifying opportunity for improvement in rhythm identification training.

Defibrillation in the Cardiac Arrest Patient

Defibrillation is one of the few interventions known to favorably impact survival in cardiac arrest. In witnessed arrest, survival improves with defibrillation as early as possible, whereas it may improve outcomes to administer high-quality chest compressions for 90 seconds before defibrillation in unwitnessed arrest. Minimizing pre-, peri-, and post-shock pauses has been shown to have mortality benefits. Refractory ventricular fibrillation has high mortality rates, and there is ongoing research into promising adjunctive treatment modalities. There remains no consensus on optimal pad positioning and defibrillation energy level, however, recent data suggest anteroposterior pad placement may be superior to anterolateral placement.

Factors associated with survival and neurologic outcome after in-hospital cardiac arrest in children: A cohort study

Aim

In-hospital paediatric cardiopulmonary resuscitation (CPR) survival has been improving in high-income countries. This study aimed to analyse factors associated with survival and neurological outcome after paediatric CPR in a middle-income country.

Methods

This observational study of in-hospital cardiac arrest using Utstein-style registry included patients <18 years old submitted to CPR between 2015 and 2020, at a high-complexity hospital. Outcomes were survival and neurological status assessed using Paediatric Cerebral Performance Categories score at prearrest, discharge, and after 180 days.

Results

Of 323 patients who underwent CPR, 108 (33.4%) survived to discharge and 93 (28.8%) after 180 days. In multivariable analysis, lower survival at discharge was associated with liver disease (OR 0.060, CI 0.007-0.510, p = 0.010); vasoactive drug infusion before cardiac arrest (OR 0.145, CI 0.065-0.325, p < 0.001); shock as the immediate cause (OR 0.183, CI 0.069-0.486, p = 0.001); resuscitation > 30 min (OR 0.070, CI 0.014-0.344, p = 0.001); and bicarbonate administration during CPR (OR 0.318, CI 0.130-0.780, p = 0.01). The same factors remained associated with lower survival after 180 days. Neurological outcome was analysed in the 93 survivors after 180 days following CPR. Prearrest neurological dysfunction was observed in 31.4%, and neurological prognosis was favourable in 79.7% at discharge and similar after 180 days.

Conclusion

In-hospital paediatric cardiac arrest patients with complex chronic conditions had lower survival associated with liver disease, shock as cause of cardiac arrest, vasoactive drug infusion before cardiac arrest, bicarbonate administration during CPR, and prolonged resuscitation. Most survivors had favourable neurological outcome.

Effectiveness of alternative shock strategies for out-of-hospital cardiac arrest: A systematic review

Aim

To determine the optimal first-shock energy level for biphasic defibrillation and whether fixed or escalating protocols for subsequent shocks are most effective.

Methods

We searched Medline, Embase, Cochrane CENTRAL, CINAHL, the Web of Science and national and international trial registry databases for papers published from database inception to January 2022. We reviewed reference lists of key papers to identify additional references. The population included adults sustaining non traumatic out-of-hospital cardiac arrest subject to attempted defibrillation. Studies of internal or monophasic defibrillation and studies other than randomised controlled trials or prospective cohorts were excluded. Two reviewers assessed study relevance. Data extraction and risk of bias assessment, using the ROBINS-I tool, were conducted by one reviewer and checked by a second reviewer. Data underwent intention-to-treat analysis.

Results

We identified no studies evaluating first shock energy. Only one study (n = 738) comparing fixed versus escalating energy met eligibility criteria: a prospective cohort analysis of a randomised controlled trial of manual versus mechanical CPR. High fixed (360 J) energy was compared with an escalating (200-200/300-360 J) strategy. Researchers found 27.5% (70/255) of patients in the escalating energy group and 27.61% (132/478) in the fixed high energy group survived to hospital discharge (unadjusted risk ratio 0.99, 95% CI 0.73, 1.23). Results were of very low certainty as the study was at serious risk of bias.

Conclusion

This systematic review did not identify an optimal first-shock energy for biphasic defibrillation. We identified no survival advantage at 30 days when comparing 360 J fixed with 200 J escalating strategy.

Epidemiology of pediatric cardiopulmonary resuscitation

OBJECTIVE

To analyze the main epidemiological aspects of prehospital and hospital pediatric cardiopulmonary resuscitation and the impact of scientific evidence on survival.

SOURCE OF DATA

This was a narrative review of the literature published at PubMed/MEDLINE until January 2019 including original and review articles, systematic reviews, meta-analyses, annals of congresses, and manual search of selected articles.

SYNTHESIS OF DATA

The prehospital and hospital settings have different characteristics and prognoses. Pediatric prehospital cardiopulmonary arrest has a three-fold lower survival rate than cardiopulmonary arrest in the hospital setting, occurring mostly at home and in children under 1year. Higher survival appears to be associated with age progression, shockable rhythm, emergency medical care, use of automatic external defibrillator, high-quality early life support, telephone dispatcher-assisted cardiopulmonary resuscitation, and is strongly associated with witnessed cardiopulmonary arrest. In the hospital setting, a higher incidence was observed in children under 1year of age, and mortality increased with age. Higher survival was observed with shorter cardiopulmonary resuscitation duration, occurrence on weekdays and during daytime, initial shockable rhythm, and previous monitoring. Despite the poor prognosis of pediatric cardiopulmonary resuscitation, an increase in survival has been observed in recent years, with good neurological prognosis in the hospital setting.

CONCLUSIONS

A great progress in the science of pediatric cardiopulmonary resuscitation has been observed, especially in developed countries. The recognition of the epidemiological aspects that influence cardiopulmonary resuscitation survival may direct efforts towards more effective actions; thus, studies in emerging and less favored countries remains a priority regarding the knowledge of local factors.

Cardiorespiratory arrest in children (out of hospital)

INTRODUCTION

Cardiorespiratory arrest outside hospital occurs in approximately 1/10,000 children per year in resource-rich countries, with two-thirds of arrests occurring in children under 18 months of age. Approximately 45% of cases have undetermined causes, including sudden infant death syndrome. Of the rest, 20% are caused by trauma, 10% by chronic disease, and 6% by pneumonia.

METHODS AND OUTCOMES

We conducted a systematic overview, aiming to answer the following clinical question: What are the effects of treatments for non-submersion out-of-hospital cardiorespiratory arrest in children? We searched: Medline, Embase, The Cochrane Library, and other important databases up to November 2014 (Clinical Evidence overviews are updated periodically; please check our website for the most up-to-date version of this overview).

RESULTS

At this update, searching of electronic databases retrieved 192 studies. After deduplication and removal of conference abstracts, 81 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 68 studies and the further review of 13 full publications. Of the 13 full articles evaluated, three systematic reviews were added at this update. We have also added eight studies to the Comment section. We performed a GRADE evaluation for three PICO combinations.

CONCLUSIONS

In this systematic overview, we categorised the efficacy for nine interventions based on information about the effectiveness and safety of airway management and ventilation (bag-mask ventilation and intubation), bystander cardiopulmonary resuscitation, direct-current cardiac shock, high dose and standard dose intravenous adrenaline (epinephrine), intravenous sodium bicarbonate, intubation versus bag-mask ventilation, targeted temperature management, and training parents to perform resuscitation.

The Use of Automated External Defibrillators in Infants: A Report From the American Red Cross Scientific Advisory Council

OBJECTIVE

Automated external defibrillators (AEDs) have been used successfully in many populations to improve survival for out-of-hospital cardiac arrest. While ventricular fibrillation and pulseless ventricular tachycardia are more prevalent in adults, these arrhythmias do occur in infants. The Scientific Advisory Council of the American Red Cross reviewed the literature on the use of AEDs in infants in order to make recommendations on use in the population.

METHODS

The Cochrane library and PubMed were searched for studies that included AEDs in infants, any external defibrillation in infants, and simulation studies of algorithms used by AEDs on pediatric arrhythmias.

RESULTS

There were 4 studies on the accuracy of AEDs in recognizing pediatric arrhythmias. Case reports (n = 2) demonstrated successful use of AED in infants, and a retrospective review (n = 1) of pediatric pads for AEDs included infants. Six studies addressed defibrillation dosages used. The algorithms used by AEDs had high sensitivity and specificity for pediatric arrhythmias and very rarely recommended a shock inappropriately. The energy doses delivered by AEDs were high, although in the range that have been used in out-of-hospital arrest. In addition, there are data to suggest that 2 to 4 J/kg may not be effective defibrillation doses for many children.

CONCLUSIONS

In the absence of prompt defibrillation for ventricular fibrillation or pulseless ventricular tachycardia, survival is unlikely. Automated external defibrillators should be used in infants with suspected cardiac arrest, if a manual defibrillator with a trained rescuer is not immediately available. Automated external defibrillators that attenuate the energy dose (eg, via application of pediatric pads) are recommended for infants. If an AED with pediatric pads is not available, the AED with adult pads should be used.

Structured performance assessment in three pediatric emergency scenarios: a validation study

OBJECTIVE

To develop and validate 3 performance evaluation checklists (PECs) for systematic performance assessment in 3 clinical scenarios: cardiopulmonary arrest, dyspnea with oxygen desaturation after intubation, and respiratory syncytial virus (RSV).

STUDY DESIGN

The 3 PECs were developed using an integrative approach and used to rate 50 training sessions in a simulator environment by different raters. Construct validity was tested by correlating the checklist scores with external constructs (ie, global rating, team experience level, and time to action). Further interrater reliability was tested for all 3 PECs.

RESULTS

The PECs for the desaturation and cardiopulmonary arrest scenarios were valid and reliable, whereas the PEC for RSV had limited validity and reliability.

CONCLUSION

For 2 pediatric emergencies, the PEC is a valid and reliable tool for systematic performance assessment. The unsatisfactory results for the PEC for RSV may be related to limitations of the simulation setting and require further investigation. Structured assessment of clinical performance can augment feedback on technical performance aspects and is essential for training purposes as well as for research. Only reliable and valid performance measures will allow medical educators to accurately evaluate the behavioral effects of training interventions and further enhance the quality of patient care.

Adrenaline, terlipressin, and corticoids versus adrenaline in the treatment of experimental pediatric asphyxial cardiac arrest

OBJECTIVE

To analyze if treatment with adrenaline (epinephrine) plus terlipressin plus corticoids achieves higher return of spontaneous circulation than adrenaline in an experimental infant animal model of asphyxial cardiac arrest.

DESIGN

Prospective randomized animal study.

SETTING

Experimental department in a University Hospital.

SUBJECTS

Forty-nine piglets were studied.

INTERVENTIONS

Cardiac arrest was induced by at least 10 minutes of removal of mechanical ventilation and was followed by manual external chest compressions and mechanical ventilation. After 3 minutes of resuscitation, piglets that did not achieve return of spontaneous circulation were randomized to two groups: adrenaline 0.02 mg kg every 3 minutes (20 animals) and adrenaline 0.02 mg kg every 3 minutes plus terlipressin 20 μg kg every 6 minutes plus hydrocortisone 30 mg kg one dose (22 animals). Resuscitation was discontinued when return of spontaneous circulation was achieved or after 24 minutes.

MEASUREMENT AND MAIN RESULTS

Return of spontaneous circulation was achieved in 14 piglets (28.5%), 14.2% with only cardiac massage and ventilation. Return of spontaneous circulation was achieved in 25% of piglets treated with adrenaline and in 9.1% of those treated with adrenaline plus terlipressin plus hydrocortisone (p = 0.167). Return of spontaneous circulation was achieved in 45.4% of animals with pulseless electric activity, 20% with asystole, and 0% with ventricular fibrillation (p = 0.037). Shorter duration of cardiac arrest, higher mean blood pressure and EtCO2 and lower PaCO2 before resuscitation, and higher mean blood pressure during resuscitation were associated with higher return of spontaneous circulation.

CONCLUSIONS

Treatment with adrenaline plus terlipressin plus corticoids does not achieve higher return of spontaneous circulation than that with adrenaline in an infant animal model of asphyxial cardiac arrest.

Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest

This multiorganizational literature review was undertaken to provide an evidence base for determining whether or not recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care, because the evidence suggests that either death or a poor outcome is inevitable.

Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest

This multiorganizational literature review was undertaken to provide an evidence base for determining whether recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care because the evidence suggests that either death or a poor outcome is inevitable.

Shockable rhythms and defibrillation during in-hospital pediatric cardiac arrest

OBJECTIVE

To analyze the results of cardiopulmonary resuscitation (CPR) that included defibrillation during in-hospital cardiac arrest (IH-CA) in children.

METHODS

A prospective multicenter, international, observational study on pediatric IH-CA in 12 European and Latin American countries, during 24 months. Data from 502 children between 1 month and 18 years were collected using the Utstein template. Patients with a shockable rhythm that was treated by electric shock(s) were included. The primary endpoint was survival at hospital discharge. Univariate logistic regression analysis was performed to find outcome factors.

RESULTS

Forty events in 37 children (mean age 48 months, IQR: 7-15 months) were analyzed. An underlying disease was present in 81.1% of cases and 24.3% had a previous CA. The main cause of arrest was a cardiac disease (56.8%). In 17 episodes (42.5%) ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) was the first documented rhythm, and in 23 (57.5%) it developed during CPR efforts. In 11 patients (27.5%) three or more shocks were needed to achieve defibrillation. Return of spontaneous circulation (ROSC) was obtained in 25 cases (62.5%), that was sustained in 20 (50.0%); however only 12 children (32.4%) survived to hospital discharge. Children with VF/pVT as first documented rhythm had better sustained ROSC (64.7% vs. 39.1%, p=0.046) and survival to hospital discharge rates (58.8% vs. 21.7%, p=0.02) than those with subsequent VF/pVT. Survival rate was inversely related to duration of CPR. Clinical outcome was not related to the cause or location of arrest, type of defibrillator and waveform, energy dose per shock, number of shocks, or cumulative energy dose, although there was a trend to better survival with higher doses per shock (25.0% with <2Jkg(-1), 43.4% with 2-4Jkg(-1) and 50.0% with >4Jkg(-1)) and worse with higher number of shocks and cumulative energy dose.

CONCLUSION

The termination of pediatric VF/pVT in the IH-CA setting is achieved in a low percentage of instances with one electrical shock at 4Jkg(-1). When VF/pVT is the first documented rhythm, the results of defibrillation are better than in the case of subsequent VF/pVT. No clear relationship between defibrillation protocol and ROSC or survival has been observed. The optimal pediatric defibrillation dose remains to be determined; therefore current resuscitation guidelines cannot be considered evidence-based, and additional research is needed.

Improving outcomes from out-of-hospital cardiac arrest in young children and adolescents

Out-of-hospital cardiac arrest (OHCA) is an unusual but devastating occurrence in a young person. Years of life-lost are substantial and long-term health care costs of survivors can be high. However, there have been noteworthy improvements in cardiopulmonary resuscitation (CPR) standards, out-of hospital care, and postcardiac arrest therapies that have resulted in a several-fold improvement in resuscitation outcomes. Recent interest and research in resuscitation of children has the promise of generating improvements in the outcomes of these patients. Integrated and coordinated care in the out-of-hospital and hospital settings are required. This article will review the epidemiology of OHCA, the 2010 CPR guidelines, and developments in public access defibrillation for children.

Update on cardiopulmonary resuscitation guidelines of interest to anesthesiologists

BACKGROUND AND OBJECTIVES

The new cardiopulmonary resuscitation (CPR) guidelines emphasize the importance of high-quality chest compressions and modify some routines. The objective of this report was to review the main changes in resuscitation practiced by anesthesiologists.

CONTENTS

The emphasis on high-quality chest compressions with adequate rate and depth allowing full recoil of the chest and with minimal interruptions is highlighted in this update. One should not take more than ten seconds checking the pulse before starting CPR. The universal relationship of 30:2 is maintained, modifying its order, initiating with chest compressions, followed by airways and breathing (C-A-B instead of A-B-C). The procedure "look, listen, and feel whether the patient is breathing" was removed from the algorithm, and the use of cricoid pressure during ventilations is not recommended any more. The rate of chest compressions was changed for at least one hundred per minute instead of approximately one hundred per minute, and its depth in adults was changed to 5 cm instead of the prior recommendation of 4 to 5 cm. The single shock is maintained, and it should be of 120 to 200 J when it is biphasic; and 360 J when it is monophasic. In advanced cardiac life support, the use of capnography and capnometry to confirm intubation and monitoring the quality of CPR is a formal recommendation. Atropine is no longer recommended for routine use in the treatment of pulseless electrical activity or asystole.

CONCLUSIONS

Updating the phases of the new CPR guidelines is important, and continuous learning is recommended. This will improve the quality of resuscitation and survival of patients in cardiac arrest.

Defibrillation in children

Defibrillation is the only effective treatment for ventricular fibrillation (VF). Optimal methods for defibrillation in children are derived and extrapolated from adult data. VF occurs as the initial rhythm in 8-20% of pediatric cardiac arrests. This has fostered a new interest in determining the optimal technique for pediatric defibrillation. This review will provide a brief background of the history of defibrillation and a review of the current literature on pediatric defibrillation. The literature search was performed through PubMed, using the MeSH headings of cardiopulmonary resuscitation, defibrillation and electric countershock. The authors’ personal bibliographic files were also searched. Only published articles were chosen. The recommended energy dose has been 2 J/kg for 30 years, but recent reports may indicate that higher dosages may be more effective and safe. In 2005, the European Resuscitation Council recommended 4 J/kg as the initial dose, without escalation for subsequent shocks. Automated external defibrillators are increasingly used for pediatric cardiac arrest, and available reports indicate high success rates. Additional research on pediatric defibrillation is critical in order to be able to provide an equivalent standard of care for children in cardiac arrest and improve outcomes.

External and internal biphasic direct current shock doses for pediatric ventricular fibrillation and pulseless ventricular tachycardia

OBJECTIVE

To determine energy dose and number of biphasic direct current shocks for pediatric ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT).

DESIGN

Observation of preshock and postshock rhythms, energy doses, and number of shocks.

SETTING

Pediatric hospital.

PATIENTS

Shockable ventricular dysrhythmias.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Forty-eight patients with VF or pulseless VT received external shock at 1.7 ± 0.8 (mean ± SD) J/kg. Return of spontaneous circulation (ROSC) occurred in 23 (48%) patients with 2.0 ± 1.0 J/kg, but 25 (52%) patients remained in VF after 1.5 ± 0.7 J/kg (p = .05). In 24 non-responding patients, additional 1-8 shocks (final dose, 2.8 ± 1.2 J/kg) achieved ROSC in 14 (58%) with 2.6 ± 1.1 J/kg but not in 10 (42%) with 3.2 ± 1.2 J/kg (not significant). Overall, 37 (77%) patients achieved ROSC with 2.2 ± 1.1 J/kg (range, 0.5-5.0 J/kg). Eight patients without ROSC recovered with cardiopulmonary bypass and internal direct current shock. At 13 subsequent episodes of VF or VT among eight patients, five achieved ROSC and survived. In combined first and subsequent resuscitative episodes, doses in the range of 2.5 to < 3 J/kg achieved most cases of ROSC. Survival for > 1 yr was seen in 28 (78%) of 36 patients with VF and seven (58%) of 11 patients with VT, with 35 (73%) overall. Lack of ROSC was associated with multiple shocks (p = .003). Repeated shocks with adhesive pads had significantly less impedance (p < .001). Pads in an anteroposterior position achieved highest ROSC rate. Internal shock for another 48 patients with VF or VT achieved ROSC in 28 (58%) patients with 0.7 ± 0.4 J/kg but not in 20 patients with 0.4 ± 0.3 J/kg (p = .01). Nineteen of the nonresponders who received additional internal 1-9 shocks at 0.6 ± 0.5 J/kg and one patient given extracorporeal membrane oxygenation all recovered, yielding 100% ROSC, but 1-yr survival tallied 43 (90%) patients.

CONCLUSIONS

The initial biphasic direct current external shock dose of 2 J/kg for VF or pulseless VT is inadequate. Appropriate doses for initial and subsequent shocks seem to be in the range of 3-5 J/kg. Multiple shocks do not favor ROSC. The dose for internal shock is 0.6-0.7 J/kg.

Effect of defibrillation energy dose during in-hospital pediatric cardiac arrest

OBJECTIVE

To examine the effectiveness of initial defibrillation attempts. We hypothesized that (1) an initial shock dose of 2 ± 10 J/kg would be less effective for terminating fibrillation than suggested in published historical data and (2) a 4 J/kg shock dose would be more effective.

PATIENTS AND METHODS

This was a National Registry of Cardiopulmonary Resuscitation prospective, multisite, observational study of in-hospital pediatric (aged ≤18 years) ventricular fibrillation or pulseless ventricular tachycardia cardiac arrests from 2000-2008. Termination of ventricular fibrillation or pulseless ventricular tachycardia and event survival after initial shocks of 2 J/kg were compared with historic controls and a 4 J/kg shock dose.

RESULTS

Of 266 children with 285 events, 173 of 285 (61%) survived the event and 61 of 266 (23%) survived to discharge. Termination of fibrillation after initial shock was achieved for 152 of 285 (53%) events. Termination of fibrillation with 2 ± 10 J/kg was much less frequent than that seen among historic control subjects (56% vs 91%; P < .001), but not different than 4 J/kg. Compared with 2 J/kg, an initial shock dose of 4 J/kg was associated with lower rates of return of spontaneous circulation (odds ratio: 0.41 [95% confidence interval: 0.21-0.81]) and event survival (odds ratio: 0.42 [95% confidence interval: 0.18-0.98]).

CONCLUSIONS

The currently recommended 2 J/kg initial shock dose for in-hospital cardiac arrest was substantially less effective than previously published. A higher initial shock dose (4 J/kg) was not associated with superior termination of ventricular fibrillation or pulseless ventricular tachycardia or improved survival rates. The optimal pediatric defibrillation dose remains unknown.

Cardiorespiratory arrest in children (out of hospital)

INTRODUCTION

Cardiorespiratory arrest outside hospital occurs in approximately 1/10,000 children a year in resource-rich countries, with two-thirds of arrests occurring in children under 18 months of age. Approximately 45% of cases have undetermined causes, including sudden infant death syndrome. Of the rest, 20% are caused by trauma, 10% by chronic disease, and 6% by pneumonia.

METHODS AND OUTCOMES

We conducted a systematic review aiming to answer the following clinical question: What are the effects of treatments for non-submersion out-of-hospital cardiorespiratory arrest in children? We searched: Medline, Embase, The Cochrane Library, and other important databases up to December 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 15 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: airway management and ventilation (bag-mask ventilation and intubation), bystander cardiopulmonary resuscitation, direct-current cardiac shock, hypothermia, intravenous sodium bicarbonate, standard dose of intravenous adrenaline (epinephrine), and training parents to perform resuscitation.

Part 10: Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

Note From the Writing Group: Throughout this article, the reader will notice combinations of superscripted letters and numbers (eg, “Family Presence During ResuscitationPeds-003”). These callouts are hyperlinked to evidence-based worksheets, which were used in the development of this article. An appendix of worksheets, applicable to this article, is located at the end of the text. The worksheets are available in PDF format and are open access.

Terlipressin versus adrenaline in an infant animal model of asphyxial cardiac arrest

PURPOSE

The objective of this study was to compare the efficacy of terlipressin versus adrenaline in an experimental infant animal model of asphyxial cardiac arrest (ACA).

DESIGN

Prospective randomised animal study.

SETTING

Laboratory research department of a university hospital.

METHODS

Seventy-one, 2-month-old, mechanically ventilated piglets were investigated. ACA was induced by removal of mechanical ventilation. Resuscitation was performed by means of manual external chest compressions and mechanical ventilation (CC + V). After 3 min of CC + V, return of spontaneous circulation (ROSC) was observed in 11 animals. The 60 piglets without ROSC were then randomised to the four study groups: adrenaline standard dose (Asd): 0.01 mg/kg/3 min; adrenaline high dose (Ahd): first dose (0.01 mg/kg) and subsequent doses (0.1 mg/kg/3 min); terlipressin (T): 20 microg/kg/6 min; and adrenaline standard dose plus terlipressin (Asd + T).

MEASUREMENTS AND RESULTS

The relationship between haemodynamic (heart rate, blood pressure, ECG rhythm, cardiac index), respiratory (end-tidal CO(2), blood gas analysis) and tissue perfusion (gastric intramucosal pH, central, cerebral and renal saturation) parameters and ROSC was analysed. ROSC was achieved in three piglets treated with Asd (20%), four treated with Ahd (26.7%), one treated with T (6.7%) and seven treated with Asd + T (46.7%) (P = 0.099). ROSC was achieved in 43.1% of animals with pulseless electrical activity, 30.4% with asystole and none with ventricular fibrillation (P = 0.0001).

CONCLUSION

In this infant animal model of cardiac arrest, there was a non-significant trend towards better outcome when terlipressin was combined with adrenaline compared with the use of adrenaline or terlipressin alone.

Post-cardiac arrest syndrome: Epidemiology, pathophysiology, treatment, and prognostication: A scientific statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke (Part 1)

AIM OF THE REVIEW

To review the epidemiology, pathophysiology, treatment and prognostication in relation to the post-cardiac arrest syndrome.

METHODS

Relevant articles were identified using PubMed, EMBASE and an American Heart Association EndNote master resuscitation reference library, supplemented by hand searches of key papers. Writing groups comprising international experts were assigned to each section. Drafts of the document were circulated to all authors for comment and amendment.

RESULTS

The 4 key components of post-cardiac arrest syndrome were identified as (1) post-cardiac arrest brain injury, (2) post-cardiac arrest myocardial dysfunction, (3) systemic ischaemia/reperfusion response, and (4) persistent precipitating pathology.

CONCLUSIONS

A growing body of knowledge suggests that the individual components of the postcardiac arrest syndrome are potentially treatable.

The approach to delayed resuscitation in paediatric cardiac arrest: A survey of paediatric intensivists in Canada

AIM

To determine how long a period of having had no cardiopulmonary-resuscitation (CPR) (delay time) is considered to result in subsequent futile efforts at resuscitation.

METHODS

In 2007 a survey was mailed to all 77 paediatric intensivists in Canada. Three scenarios of witnessed cardiac arrest were presented: out-of-hospital, in-hospital, and in-hospital with extracorporeal-CPR (E-CPR). Each scenario asked what delay time would make attempts at resuscitation futile for survival to hospital discharge, and for survival to hospital discharge in a better than vegetative state. Comparisons of median [inter-quartile range] used Wilcoxon-signed-rank or Friedman tests with Bonferroni corrections.

RESULTS

The response rate was 49/77 (64%). The delay time was significantly different between rhythms within all scenarios (p<.001); and was significantly shorter for survival than for better than vegetative survival (p<.006) except when E-CPR was to be used. The delay time was not significantly different between the in-hospital and out-of-hospital scenario with the same rhythms (p>.01). The delay time was significantly shorter in scenarios with asystole versus pulseless electrical activity with (p=.010) or without (p<.001) an arterial line with absent pulsation. In out-of-hospital arrest, the delay time for survival varied from 15 [10-20]min for asystole to 20 [15-20]min for pulseless electrical activity. In in-hospital scenarios, the delay time for survival varied from 10 [10-20]min for asystole, to 15 [10-20]min for most other rhythms.

CONCLUSION

A delay time of 15 [10-20] (range 5-30)min was considered futile for survival. This has implications for pronouncing death in donation after cardiac death.

Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke

AIM OF THE REVIEW

To review the epidemiology, pathophysiology, treatment and prognostication in relation to the post-cardiac arrest syndrome.

METHODS

Relevant articles were identified using PubMed, EMBASE and an American Heart Association EndNote master resuscitation reference library, supplemented by hand searches of key papers. Writing groups comprising international experts were assigned to each section. Drafts of the document were circulated to all authors for comment and amendment.

RESULTS

The 4 key components of post-cardiac arrest syndrome were identified as (1) post-cardiac arrest brain injury, (2) post-cardiac arrest myocardial dysfunction, (3) systemic ischaemia/reperfusion response, and (4) persistent precipitating pathology.

CONCLUSIONS

A growing body of knowledge suggests that the individual components of the post-cardiac arrest syndrome are potentially treatable.

Year in review 2006: Critical Care--Paediatrics

In 2006, paediatric intensive care-related subjects were discussed in a number of papers published in various journals, including Critical Care. Because they focused on the cardiovascular system and its support, we summarize them here. In particular, these papers highlighted the management of refractory septic shock, extracorporeal support, outcome markers in sepsis, and outcome after cardiac arrest.

Ventricular fibrillation and defibrillation

Cardiac arrest in children is not often due to a disturbance in rhythm that is amenable to electrical defibrillation, contrary to the situation in adults. When a shockable rhythm is present, defibrillation using an external electric shock applied at an early stage after pre-oxygenation and chest compressions is of proven efficacy. Success at conversion of ventricular fibrillation is dependent on the delay before delivering the shock and defibrillation efficiency, which is itself a function of thoracic impedance, energy dose and waveform.

Life-saving automated external defibrillation in a teenager: a case report

BACKGROUND

Adolescent sudden death during sport participation is commonly due to cardiac causes. Survival is more likely when an automated external defibrillator (AED) is used soon after collapse.

CASE PRESENTATION

We describe a case of sudden death in a 14 year old boy with two remarkable points, successful resuscitation at school using an AED and diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC). Bystander cardiopulmonary resuscitation (CPR) was immediately started by a witness and 5 minutes after the event the child was placed on an AED monitor that determined he was in a non shockable rhythm, therefore CPR was continued. Two minutes later, the AED monitor detected a shockable rhythm and recommended a shock, which was then administered. One minute after the shock, a palpable pulse was detected and the child began to breathe by himself. Four days after cardiac arrest, the boy was conversing and self-caring. Cardiac magnetic resonance imaging was suggestive of ARVC.

CONCLUSION

Ventricular fibrillation secondary to ARVC may be a devastating event and places young patients and athletes at high risk of sudden death. Immediate CPR and AED have been demonstrated to be lifesaving in such events. Therefore, we suggest that schools should have teachers skilled in CPR and accessible AEDs.

Lightning, sudden cardiac death, simulation and an automated external defibrillator: the perfect storm

This is a report of an 11-year-old boy who had sudden cardiac death after a lightning strike while playing lacrosse at summer camp. The camp staff had performed weekly drills to prepare for various medical emergencies and quickly activated their "Emergency Activation System". The child received immediate cardiopulmonary resuscitation (CPR) and was defibrillated with an automated defibrillator (AED) within 3 min of becoming pulseless and was ultimately resuscitated after being defibrillated three times. A community ambulance with a defibrillator on board did not arrive until several minutes after the on-site team had achieved return of spontaneous circulation. In this report, we describe the clinical course of this patient; briefly review lightning injuries, other causes of sudden cardiac death in children and use of AEDs. Finally, we review how simulation has been used in this case and others as a mechanism to ensure preparedness for medical emergencies. This child is alive and well today because of these well-trained camp counselors. Their system of using simulation to maintain emergency readiness serves as an example for lay and professional medical providers alike.