Cardiopulmonary Resuscitation

Robert A. Berg

Katsuyuki Miyasaka

Antonio Rodríguez-Núñez

Mary Fran Hazinski

David Anthony Zideman

Vinay M. Nadkarni

KEY POINTS

Effective cardiopulmonary resuscitation (CPR) and advanced life support (ALS) targeted to the etiology, timing, intensity, and duration of the cardiac arrest can optimize the potential to restore an apparently dead child back to life.

Sudden arrhythmogenic (“electrical”) cardiac arrests are typically due to ventricular fibrillation (VF) or rapid ventricular tachycardia (VT) and respond to rapid electrical defibrillation.

Mechanical (“pump”) cardiomyopathic arrests are typically due to inadequate myocardial oxygen delivery from asphyxial, ischemic, metabolic, or pharmacologic problems, and usually require mechanical support (CPR) to restore perfusion.

Cardiac arrest has at least four phases: prearrest, no-flow (untreated cardiac arrest), low-flow (during CPR efforts), and postresuscitation. The interventions needed in each phase are specific to the phase of resuscitation.

Animal and human data indicate that well-performed CPR for children is quite effective and that high-quality basic life support (BLS) early is more important than ALS late.

Outcomes following pediatric out-of-hospital arrests appear to be worse than those following in-hospital arrests. Two common types of out-of-hospital cardiac arrests have especially poor outcomes: traumatic arrests and those associated with sudden infant death syndrome (SIDS).

The incidence of VF varies by setting and age. In special circumstances, such as tricyclic antidepressant overdose, hyperkalemia, cardiomyopathy, postcardiac surgery, and prolonged QT syndromes, VF is a more likely rhythm during cardiac arrest.

Defibrillation (termination of VF) is necessary for successful resuscitation from VF cardiac arrest. Defibrillation can result in asystole, pulseless electrical activity (PEA), or a perfusing rhythm. Successful defibrillation is achieved by attaining current flow adequate to depolarize a critical mass of myocardium.

One of the most common precipitating events for cardiac arrest in children is respiratory insufficiency. Adequate oxygen delivery to meet metabolic demands and removal of carbon dioxide are the goals of initial assisted ventilation.

Providing BLS with continuous effective chest compressions and minimal pauses and interruptions is generally the best way to provide circulation during cardiac arrest. In selected settings, particularly in the pediatric intensive care unit (PICU), goal-directed therapies targeted to hemodynamics are possible.

Targeted temperature management with close attention to avoid hypotension and hyperoxia is a promising goaldirected, postresuscitation therapy. However, benefits from these treatments deserve further rigorous study in infants, children, and adults.

Optimal treatment of postarrest myocardial dysfunction has not been rigorously established; it has been treated with various continuous inotropic/vasoactive agents in both children and adults.

Extracorporeal membrane oxygenation (ECMO) may provide optimized control of postresuscitation temperature and vital organ perfusion, and has been demonstrated to facilitate good outcomes in selected resuscitation circumstances. The concomitant administration of anticoagulants may optimize microcirculatory flow.

Despite evidence-based guidelines, extensive provider training, and provider credentialing in resuscitation medicine, the quality of CPR is typically poor. Slow compression rates, inadequate depth of compression, and substantial pauses are the norm. A focus on “push hard, push fast, minimize interruptions, allow full-chest recoil, and don’t overventilate” can markedly improve myocardial, cerebral, and systemic perfusion and improve outcomes.

Cardiopulmonary resuscitation (CPR), sometimes termed “cardiocerebral resuscitation,” delivers oxygen and blood to the vital organs (heart and brain). Life-sustaining CPR can temporarily support myocardial and cerebral blood flow and oxygen delivery during cardiac arrest or “near cardiac arrest,” such as very low-flow conditions associated with severe hypotension or hemodynamically compromising bradycardia. Most commonly, CPR is delivered very simply, by pushing hard and fast in the center of the chest. Chest compression, “closed-chest” or “open-chest,” can be delivered with or without assisted ventilation and/or supplemental oxygen. High-quality CPR can provide sufficient myocardial and cerebral blood flow to attain return of spontaneous circulation (ROSC) (e.g., defibrillation of VF) or can be a bridge to extracorporeal life support (ECLS

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