More than 25% of children survive to hospital discharge after in-hospital cardiac arrests, and 5% to 10% survive after out-of-hospital cardiac arrests. This review of pediatric cardiopulmonary resuscitation addresses the epidemiology of pediatric cardiac arrests, mechanisms of coronary blood flow during cardiopulmonary resuscitation, the 4 phases of cardiac arrest resuscitation, appropriate interventions during each phase, special resuscitation circumstances, extracorporeal membrane oxygenation cardiopulmonary resuscitation, and quality of cardiopulmonary resuscitation. The key elements of pathophysiology that impact and match the timing, intensity, duration, and variability of the hypoxic-ischemic insult to evidence-based interventions are reviewed. Exciting discoveries in basic and applied-science laboratories are now relevant for specific subpopulations of pediatric cardiac arrest victims and circumstances (eg, ventricular fibrillation, neonates, congenital heart disease, extracorporeal cardiopulmonary resuscitation). Improving the quality of interventions is increasingly recognized as a key factor for improving outcomes. Evolving training strategies include simulation training, just-in-time and just-in-place training, and crisis-team training. The difficult issue of when to discontinue resuscitative efforts is addressed. Outcomes from pediatric cardiac arrests are improving. Advances in resuscitation science and state-of-the-art implementation techniques provide the opportunity for further improvement in outcomes among children after cardiac arrest.
Skip Nav Destination
Article navigation
November 2008
State-of-the-Art Review Article|
November 01 2008
Pediatric Cardiopulmonary Resuscitation: Advances in Science, Techniques, and Outcomes
Alexis A. Topjian, MD;
Alexis A. Topjian, MD
aDepartment of Anesthesia and Critical Care Medicine, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
Search for other works by this author on:
Robert A. Berg, MD;
Robert A. Berg, MD
aDepartment of Anesthesia and Critical Care Medicine, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
bDepartment of Pediatrics, University of Arizona College of Medicine, Tucson, Arizona
Search for other works by this author on:
Vinay M. Nadkarni, MD, MS
Vinay M. Nadkarni, MD, MS
aDepartment of Anesthesia and Critical Care Medicine, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
Search for other works by this author on:
Address correspondence to Alexis A. Topjian, MD, University of Pennsylvania School of Medicine, Critical Care and Pediatrics, Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104. E-mail: topjian@email.chop.edu
Pediatrics (2008) 122 (5): 1086–1098.
Article history
Accepted:
July 03 2008
Citation
Alexis A. Topjian, Robert A. Berg, Vinay M. Nadkarni; Pediatric Cardiopulmonary Resuscitation: Advances in Science, Techniques, and Outcomes. Pediatrics November 2008; 122 (5): 1086–1098. 10.1542/peds.2007-3313
Download citation file:
Sign in
Don't already have an account? Register
Pay-Per-View Access
$25.00
In 1958 Professor G S Dawes of Oxford wrote at the end of one of his numerous reports of animal investigations “It was concluded that the maintenance of the circulation is of primary importance in anoxia.” Even then there was evidence to support more emphasis of circulation and less on oxygenation. Dawes had previously described the recovery of a neonate after 40 minutes of complete anoxia. It is well recognised that the young brain can withstand hypoxia a lot better than the mature brain however even in the neonate 40 minutes of compete hypoxia has never been associated a normal outcome. These lambs were subjected to 40 minutes of complete anoxia by occlusion of the umbilical cord, which was then released allowing the placental circulation to recover. The lambs were never at risk of hypovlaemia as the compartment volumes and pulmonary circulation were unchanged from the fetal state. It was from these results that he was able to conclude that circulation was of primary importance.
Contrast this with the normal management of human birth, especially when asphyxia or hypoxia of the neonate is anticipated. The circulation may already be compromised by hypoxia. Hypoxia is commonly due to cord compression. This prevents the oxygenated blood returning from the placenta and results in congestion in the placenta and hypovolaemia in the fetus. Once the baby is born the compression will be released and the appropriate blood volume return to the neonate. Unfortunately this return of blood from the placenta is usually prevented by the rapid application of the cord clamp to enable the baby to be handed over to the pediatrician for cardio-pulmonary resuscitation. Ventilation of the lungs, the fall in pulmonary vascular resistance, and the filling of the pulmonary vascular tree simply aggravates the hypovolaemia. No amount of adjustment of the ratio of heart compression to ventilation can improve the cardiac output and cerebral circulation. By the time hypovolaemia is recognised and corrected permanent damage from a failure of circulation may have already occurred.
“Untying” the umbilical cord at birth may help to maintain the circulation of primary importance. If cardiac compression is necessary, the technique will not be compromised by hypovolaemia.
Reference
Dawes GS, Mott JC, Shelley HJ. The importance of cardiac glycogen for the maintenance of life in foetal lambs and new-born animals during anoxia. J Physiol (1959) 146,516-538
Conflict of Interest:
None declared