Epidemiology

Cardiac arrest in children most commonly stems from respiratory pathology, with pneumonia, asthma, bronchiolitis, and aspiration accounting for the most common causes. In pediatric in-hospital and out-of-hospital arrests, only 5% to 15% of patients will have pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF). Although survival rates after in-hospital arrest have increased from 9% in the 1980s to 27% in 2006, the survival rate after out-of-hospital arrest has remained relatively constant at 6%.

Results from studies of pediatric in-patient cardiac arrest have shown that patients with VF or pulseless VT have a 34% survival rate to discharge whereas patients with pulseless electrical activity have a 38% survival rate. The worst outcomes occur in children with asystole, with only 24% of these children surviving to hospital discharge. Infants and children with a pulse but poor perfusion and bradycardia who require cardiopulmonary resuscitation (CPR) have the best survival to discharge (64%), thus suggesting that early intervention to prevent full cardiopulmonary arrest portends the best outcomes.

Basic Principles of Cardiopulmonary Resuscitation

Single-rescuer CPR providers should institute emergency medical service treatment after 1 minute of rescue breathing and compressions if the patient is younger than 8 years because the underlying cause is more likely to be respiratory than cardiac in this population. The American Heart Association (AHA) recommends “push hard and push fast” with compressions. Infants and children should have a compression rate of at least 100 per minute. In single-rescuer CPR, the compression-to-ventilation ratio should be 30 : 2. For health care providers or responders trained in CPR, the ratio is 15 : 2. In newborns, the compression-to-ventilation ratio should be 3 : 1. According to the pediatric advanced life support (PALS) guidelines, adequate compression depth is approximately one third to one half the anterior-posterior diameter of the patient’s chest—4 cm in infants and 5 cm in children. In infants, the two-thumb method is preferred over the finger method for compressions. For optimal compressions, full recoil of the chest should take place after each compression, with a firm surface behind the victim.

The effectiveness of CPR is best judged by the presence of a femoral pulse with corresponding chest compressions. Interruptions in compressions have been shown to decrease the rate of return to spontaneous circulation and should be limited to less than 10 seconds for interventions such as placement of an advanced airway or defibrillation. Rhythm checks should be performed every 2 minutes (every five cycles of CPR). Once an advanced airway is in place, compressions and breaths should be performed continuously without interruption. Because of rescuer fatigue and the importance of proper compressions, it is ideal for the person performing compressions to be rotated every 2 minutes.

Foreign body removal maneuvers consist of a sequence of five back blows and five chest thrusts for infants and the Heimlich maneuver for children (Fig. 13.1). Blind finger sweeps should not be performed in children because a partial obstruction can be turned into a full obstruction if the foreign body is pushed further into the airway. Because of the pliability of the esophageal wall, foreign bodies in the esophagus can impinge on the trachea and result in airway obstruction. If the foreign body cannot be removed with basic life support maneuvers and the patient decompensates, the clinician can attempt to remove any visible foreign body with Magill forceps. Intubation may be required, and it may be possible to push the foreign body into a mainstem bronchus, most commonly on the right side. If this maneuver fails and the patient cannot be intubated, the last resort is either needle cricothyrotomy or a surgical airway. In a stable patient, bronchoscopy with maintenance of the patient’s position of comfort is the treatment of choice.

Fig. 13.1 Foreign body removal techniques in infants and children.

Airway Management

Airway management in children can be anxiety provoking; the same preparation guidelines outlined in Chapter 1 should be followed. Signs of respiratory failure include an increased or decreased respiratory rate, nasal flaring, grunting, retractions, cyanosis, apnea, or altered mental status. Hypoxia, compromised airway protection, altered mental status, and impending respiratory failure are common indications for pediatric airway intervention. Because most pediatric cardiac arrests are secondary to respiratory failure, early airway intervention is crucial.

Anatomy

The pediatric airway differs significantly from the adult airway (Box 13.1), and some special techniques are helpful when intubating a child. An oral or nasal airway can assist in maintaining airway patency. Because of the large occiput in a young child, typically those younger than 1 year, a towel roll placed beneath the patient’s shoulders often improves airway alignment. To visualize the very anterior pediatric airway, the operator must look up during intubation and may need to squat or raise the bed for adequate viewing. To see the glottic opening, a straight blade is recommended to lift up an infant’s floppy omega-shaped epiglottis. Because of infants’ small mouths, an assistant may need to pull the baby’s cheek to the side to allow passage of the laryngoscope and endotracheal tube.^1,2

Rapid-Sequence Intubation in Children

The intubating time line and drugs of choice are listed in Tables 13.1 and 13.2. Postintubation assessment includes confirmation that the endotracheal tube is in correct position. First listen over the stomach and then over the axillae for breath sounds. A confirmatory device such as an end-tidal carbon dioxide monitor, a carbon dioxide chart (e.g., Pedi-Cap, which should change from purple to yellow with proper tube placement), or an esophageal detector should be used.^3,4 A nasogastric or orogastric tube should also be placed as soon as possible because any amount of gastric distention can make ventilation and oxygenation of a child difficult. A rough rule of thumb for nasogastric and orogastric tube size is two times the endotracheal tube size.

Table 13.1 Paralytic Agents Commonly Used for Intubation in Children*

Table 13.2 Induction Agents for Intubation in Children

Principles of Endotracheal Intubation

Recommended endotracheal tube sizes are listed in Box 13.2. With the advent of high-volume, low-pressure cuffed endotracheal tubes, the dictum of using only uncuffed endotracheal tubes in children younger than 8 years has changed. It is not only acceptable but at times preferable (high peak pressure) to use a cuffed endotracheal tube in children. For an approximate guide to tube size, use 4 + (age ÷ 4) for uncuffed tubes and 3.5 + (age ÷ 4) for cuffed tubes. Cuff inflation pressure should be kept less than 20 to 25 cm H₂O. Cuffed endotracheal tubes are not recommended for use in neonates.^5,6

Box 13.2 Ways of Choosing Endotracheal Tube Size

1. Estimate size according to the patient’s age:

– Newborns, 3.0 mm, or in large newborn, 3.5 mm

– Up to 6 months, 3.5 to 4.0 mm

– 1 year, 4.0 to 4.5 mm

– Older than 1 year:

– Uncuffed tube: 4 + (age ÷ 4)

– Cuffed tube: 3.5 + (age ÷ 4). Cuffed tubes should not be used in neonates

2. Use a length-based resuscitation tape, such as the Broselow-Luten

3. Estimate according to the patient’s finger:

– The width of the child’s little fingernail is used to estimate the internal diameter of the endotracheal tube

– The width of the child’s little finger is equal to the width of the whole endotracheal tube

Table 13.4 summarizes the procedure for rapid-sequence intubation in children.

Table 13.4 Procedure for Rapid-Sequence Intubation in Children

Time to intubation 5 min	Start preoxygenation
Time to intubation 3 min	Give any premedication (atropine, lidocaine)
Intubation time	Push induction and paralytic agents
After the patient is relaxed	Intubate:
	Apply cricoid pressure
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