What is the incidence of cardiopulmonary arrest in children in developed countries?
1-20 per 100,000 children per year
In which children do the majority of cases of cardiopulmonary occur in?
Children under 1
How does the cause of cardiopulmonary arrest differ in children compared to adults?
In adults, it is often due to primary cardiac disease, which occurs with near-normal function of circulatory and respiratory system until moment of arrest. In children, most occur secondary to hypoxia due to respiratory failure or circulatory failure
What are the most common causes of circulatory failure leading to cardiopulmonary arrest in children?
Fluid loss or fluid maldistribution
What is the result of most cases of cardiopulmonary arrest in children being secondary to respiratory or circulatory failure?
End organ damage is often already present at the time of cardiac arrest, and is responsible for their prognosis
In what % of children is there a cardiac cause for cardiopulmonary arrest?
30%
Give 3 cardiac causes of cardiopulmonary arrest?
- Congenital heart disease
- Cardiomyopathy
- Channelopathies
What is the result of survival from complex congenital heart disease improving?
Cardiopulmonary arrest in children is becoming more common
What might unrecognised cardiomyopathy or channelopathies cause?
Sudden unexpected ventricular fibrillation or pulseless VT
What should be done following an unexpected cardiac arrest or VT/VF arrest?
Referral to paediatric cardiologist
Family should also be referred
Why is it important to make a referral to a paediatric cardiologist after unexpected or VT/VF arrest?
Identifiable cause may be found following detailed investigations, and treatment can be given
What might be included in investigations for unexpected or VT/VF arrest?
- Genetic studies
- Pharmacological provocation tests
Why should the family also be referred to a paediatric cardiologist in unexpected or VT/VF arrest?
They may also be at risk of sudden death
What is achieved in CPR?
Delaying cell damage and death in the heart and brain by facilitating partial flow of oxygenated bloods to these organs
What is the purpose of CPR?
To provide a window of opportunity to restore breathing and spontaneous blood circulation
What does CPR consist of?
Chest compressions and breaths
What is the ratio of chest compressions to breaths in children?
15:2 (except in newborns, when 3:1 ratio required)
What is the best compression rate for CPR?
100-120 per minute
What is the recommended depth of compression?
1/3 of depth of chest
Why is it important that there is minimal interruption of chest compressions?
As coronary perfusion pressure has been shown to be greater with prolonged continuous compressions
How do the outcomes from bystander CPR compare in children to adults?
In adults, improves survival even if compression only. In children, doesn’t improve survival if compression only
Why doesn’t compression only bystander CPR improve survival in children?
Most out-of-hospital cardiac arrests are hypoxic in origin, and so rescue ventilation is important
What is prolonged resuscitation generally associated with?
Bad neurological outcome
What has a recent study into prolonged CPR in adults shown?
Neurological outcome is not directly correlated to duration of CPR
What is the result of it being shown that neurological outcome is not directly correlated with duration of CPR in adults?
Resuscitation Council does not recommend a specific duration for CPR, and instead clinicians should determine duration on case-by-case basis
When might prolonged resuscitation be appropriate?
When there is potential for a reversible cause
Does prolonged resuscitation in children have the same outcomes as in adults?
No they are worse
What improves the outcomes of prolonged resuscitation in children?
- Profound hypothermia (<30C)
- Intermittent return of spontaneous circulation
When is survival rate with prolonged resuscitation in children?
After 20-30 minutes
What is true of survivors of prolonged resuscitation in children?
They are likely to have significant neurological deficits
Where are there cases of survival from prolonged resuscitation with reasonable outcome?
In cardiac centres with ECMO
What might children have following return of circulation?
Significant multi-organ dysfunction
Where should children be taken after return of circulation?
Intensive care
What does post-resuscitation care focus on?
- Achieving and maintaining homeostasis, in order to optimise multi-organ recovery
- Initiating investigation of underlying cause
- Treating any identifiable cause
Why is it important to manage oxygenation carefully in post-resus care?
There is increasing evidence that hyperoxaemia can be detrimental
Why might hypoxaemia be detrimental?
Excessive tissue oxygen concentrations may increase the production of oxygen free radicals, which damage mitochondria and so may compound neuronal damage
What % oxygen is used during resuscitation beyond the neonatal period?
100%
What should be done with oxygen after return of spontaneous circulation?
Inspired oxygen should be titrated to achieve oxygen saturations of 94-98%
What is the role of therapeutic hypothermia post cardiac arrest in children?
Remains unclear, but current guidelines suggest therapeutic cooling to 32-36 degrees for at least 24 hours
Why should hyperthermia be avoided post-resuscitation?
Increased core temperature increases metabolic demand by 10-13% for each degree centigrade above normal
How should hyperthermia be treated if it occurs post-resuscitation?
Active cooling to achieve normal core temperature
Why should shivering be avoided post-resuscitation?
Increases metabolic demand
What may be needed post-resuscitation to prevent shivering?
Sedation and neuromuscular blockade
When has therapeutic hypothermia been shown to improve neurological outcome in children?
In newborns with hypoxic-ischaemic encephalopathy
In what age groups are abnormal blood glucose levels associated with poor outcome following cardiorespiratory arrest?
All age groups
Is abnormal blood glucose levels being associated with poor outcome post-arrest a causative or associated factor?
Unknown
How should glucose levels be managed following the return of spontaneous circulation?
Plasma glucose levels should be monitored, and hypo/hyperglycaemia avoided
Is tight glucose control recommended post-resus?
No
Why is tight glucose control not recommended post-resus?
It increases the risk of hypoglycaemia without any survival benefit
What is the survival rate for respiratory arrest without cessation of circulation?
More than 2/3
When do the majority of children with respiratory arrest without circulatory arrest survive?
If they get to PICU
What % of children who have respiratory arrest without circulatory arrest who get to PICU have a good neurological outcome?
90%
What proportion of children with cardiopulmonary arrest get to PICU?
1/3
What proportion of children with cardiopulmonary arrest who get to PICU survive to discharge?
1/3
What % of children who survive cardiopulmonary arrest have moderate to severe neurological deficit?
90%
