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