Appendix A of pediatric respiratory arrest alone are better, with a
PEDIATRIC CARDIOPULMONARY highly signiﬁ cant.survival of 75%; however, a 25% mortality rate is still
RESUSCITATION Given that the outcomes of respiratory and cardiac
arrest are poor, a proactive approach is best:
Élise W. van der Jagt, MD, MPH 1. Identify children who are at risk for respiratory and
2. Institute treatments that prevent deterioration of
HISTORY 3. If respiratory or cardiac arrest occurs, treat thethe at-risk child.
An estimated 23,440 infants younger than 1 year old child expeditiously and effectively using evidence-
and 18,888 children between 1 and 19 years old died in based therapies.
the United States during 2012 from various causes. Until the mid-1980s, training was focused primarily
The mortality rate is clearly biphasic, with most deaths on the third step of this approach, the treatment of
occurring in the ﬁ rst year of life and then again in the pediatric patients who were in cardiac arrest. Cur-
15- to 19-year age group. Deaths of infants younger rently the preventive approach outlined in steps 1 and
than 1 year are the result primarily of congenital 2 is also recognized as having signiﬁ cant importance.
malformations (20%) and conditions relating to pre- Moreover, the AHA has emphasized the importance of
maturity and very low birth weight (18%). However, a community and serial approach to the signiﬁ cant
7% of deaths are the result of sudden infant death problem of cardiopulmonary arrests by advocating
syndrome, and 5% are caused by unintentional inju- for a concept called the Chain of Survival. Each link is
ries. In children older than 1 year, injuries are the lead- integrally related to the next, and only if all the links
ing cause of death. are accomplished will it be less likely that death and
Although children also die from acute cardiac dis- disability will occur from cardiac arrest. Because the
ease, including dysrhythmias and congenital heart major causes of pediatric cardiopulmonary arrest are
disease, the major causes of death are substantially not cardiac in origin, but are from injuries, sudden
different from the causes of adult cardiac arrest, in infant death syndrome, respiratory failure, sepsis,
which acute myocardial ischemia secondary to coro- neurologic diseases, and other illnesses, a separate
nary artery disease is the predominant cause. Such Pediatric Chain of Survival has been developed for
myocardial ischemia often results in an acute dys- the management of pediatric critical illness and injury.
rhythmia, usually ventricular ﬁ brillation or ventricu- It consists of prevention; early cardiopulmonary re-
lar tachycardia, and cardiac arrest. Unless children suscitation (CPR); prompt access to the emergency
suffer a traumatic death, reasons for cardiopulmo- response system; rapid pediatric advanced life sup-
nary arrest are more commonly related to respiratory port; and integrated post–cardiac arrest care.
failure, infection, shock, and metabolic and neuro-
logic events. Nevertheless, up to 17% of children with
out-of-hospital cardiac arrest have ventricular ﬁ ASSESSMENT bril-
lation, similar to the 5% recently described for pedi- Given the paramount importance of recognizing
atric in-hospital arrests. Thus, many of the efforts in children who are critically ill or injured before they
improving outcome for adults with cardiac arrest are deteriorate into respiratory or cardiac arrest, a rapid
also applicable to pediatric patients. systematic assessment is required, with due attention
Outcomes from pediatric cardiopulmonary arrest paid to possible respiratory and circulatory compro-
are generally poor. Survival to hospital discharge from mise. This process requires a rapid performance of
out-of-hospital arrest is less than 10%, with even those parts of the physical examination that pertain
fewer having intact neurologic function. Children who especially to the respiratory, circulatory (including car-
have sustained a cardiac arrest from a submersion diac and vascular systems), and neurologic systems.
injury have somewhat better outcomes, at 23% sur- The neurologic system is especially important in that
vival to hospital discharge and 6% with intact neu- failures of either or both respiratory and circulatory
rologic survival. However, based on the most recent systems will have an effect on neurologic function. The
data from the American Heart Association (AHA) AHA and the American Academy of Pediatrics (AAP)
“Get With the Guidelines: Resuscitation” (formerly have jointly developed an excellent systematic ap-
called the National Registry of Cardiopulmonary proach, which is included in their Pediatric Advanced
Resuscitation), a registry of adult and pediatric in- Life Support Course training materials, accessible via
hospital arrests, overall risk-adjusted survival in pedi- the AHA Web site (www.heart.org).
atric patients is 43%, a threefold increase in survival The components of this rapid, systematic evaluation
between 2000 and 2009. Asystole/pulseless electrical include an initial impression, a primary assessment
activity is the most common initial cardiac arrest using an A-B-C-D-E approach to rule out immediate,
rhythm (85%). Based on several studies, the outcomes life-threatening problems, a secondary assessment
Appendices APPENDIX A • Pediatric Cardiopulmonary Resuscitation 2995