Cardiac Arrest

• Circulation of blood ceases due to absent or ineffective contractions of the heart.
• No pulse.
• No respiratory effort or occasional ineffective initial gasps.
• Lack of oxygen to the brain causes child to become unconscious.
• Cell death may progress to organ death and ultimately to the death of the child.
• Take no more than 10 seconds to try to palpate a pulse before beginning CPR.
• The primary cause of cardiac arrest in children is not due to a heart problem. It is usually due to respiratory failure or shock. This kind of cardiac arrest is referred to as a hypoxic/asphyxia arrest.
• Survival rates post arrests are impacted by location of the child when arrest occurs and the presenting rhythm.
• Sudden cardiac arrest from a ventricular arrhythmia causes approximately 5%-15% of pediatric cardiac arrests.
• The risk of sudden cardiac arrest increases among children who have underlying heart disease.
• The incidence of sudden cardiac arrest increases with age.
• Sudden cardiac arrest due to VFib or pulseless VTach should be considered if a child collapses.
• Most children who suffer a cardiac arrest die or suffer serious long-term complications.
• Caregivers must focus on early recognition, prevention, and management of illness and injuries, which may lead to cardiac arrest.
• The primary goal of treatment when treating pediatric cardiac arrest is the restoration of a spontaneous, perfusing heart rhythm: return of spontaneous circulation (ROSC).

Cardiac Arrest Etiologies

Hypoxic/Asphyxia (Respiratory) Arrest

• Most common type of pediatric cardiac arrest
• Result of tissue hypoxia and metabolic acidosiscaused by respiratory failure
• If one can intervene in respiratory distress and failure, one could avoid arrest

Shock

• Severe hypotension
• May rapidly deteriorate into cardiac arrest
• Reversal of cardiopulmonary failure may be difficult

Sudden Cardiac Arrest (SCA)

• Sudden onset of VFib or pulseless VTach
• May be precipitated by cardiac disease, drugs, or a blow to the chest
• Uncommon in children, but can occur

Types of Cardiac Arrest

• There are four types of arrest rhythms
• Ventricular fibrillation (VFib) and pulseless VTach
  • More common in older children and children who suffer from cardiac disease
  • Torsades de pointes is a form of VTach
  • VFib and pulseless VTach are “shockable rhythms,”primarily treated with unsynchronized cardioversion (“shock”)
• Asystole and PEA
  • The most common arrest rhythms in children under 12
  • Often preceded by slow, wide QRS complexes
  • The slow, wide complexes are often referred to as an agonal rhythm
  • Not considered “shockable” rhythms, primarily treated with drugs such as epinephrine

Asystole

Lack of cardiac electrical activity

ECG monitor demonstrates “flat line”

Pulseless Electrical Activity (PEA)

Any organized rhythm without a pulse, excludes VTach, VFib

Ventricular Tachycardia (Pulseless)

• Wide complex tachycardia, QRS >120 msec
• Monomorphic
• Regular

Ventricular Fibrillation (VFib)

• Wide complex
• Polymorphic: Can be coarse or fine
  • Fine VFib is important to differentiate because it can appear similar to asystole on monitor
  • Makes the difference between shockable and unshockable rhythm

Torsades de pointes

• Torsades de pointes (“twisting of the points”) is an unusual form of polymorphic ventricular tachycardia
• Patients will usually have a palpable pulse and be conscious
  • If there IS a pulse, it is NOT cardiac arrest – Treat with magnesium sulfate
  • If there is NO pulse, it IS cardiac arrest – Treat as cardiac arrest

Defibrillation – Manual Defibrillator and AED Use

• Out of hospital cardiac arrest is usually treated with an AED
• In-hospital cardiac arrest is usually treated with a manual defibrillator

AED Use

• Keep giving chest compressions until AED is ready to analyze (i.e., pads are in place)
• Place pads correctly and ensure that they are the appropriate size for the patient
• Sweat can interfere withadhesive of pads, dry the area
• ALWAYS CLEAR THE PATIENT BEFORE DELIVERING SHOCKS
  • Perform visual check to ensure no one is touching the patient before delivering shock
  • Announce, “Clear” before shocking
• An AED will automatically provide the right “dose” of electrical energy
• As soon as a shock is delivered, IMMEDIATELY resume CPR and give appropriate medications

Manual Defibrillator Use

• Keep giving chest compressions until defibrillator is ready to analyze (i.e., pads are in place)
• Place pads correctly and ensure that they are the appropriate size for the patient
  • Some manual defibrillators uses paddles instead of pads
• Sweat can interfere with conduction of electricity, dry the area if using pads
• ALWAYS CLEAR THE PATIENT BEFORE DELIVERING SHOCKS
  • Perform visual check to ensure no one is touching the patient before delivering shock
  • Announce, “Clear” before shocking
• Defibrillator energy
  • 2 J/kg first dose
  • 4 J/kg second dose
  • Subsequent doses may be higher, up to 10 J/kg or adult dose
• As soon as a shock is delivered, IMMEDIATELY resume CPR and give appropriate medications

Medications Used in Pulseless VTach/VFib

• Epinephrine (0.01 mg/kg IV/IO up to 1 mg) can be given after the second unsuccessful shock
  • The term “unsuccessful” means that there has NOT been return of spontaneous circulation (ROSC)
• Amiodarone OR lidocaine are equally effective in shock-resistant VFib/pulseless VTach
• Amiodarone can be given after the third unsuccessful shock
  • Give 5 mg/kg IV/IO first dose
  • May give up to 2 additional doses (2.2 g maximum in adolescents)
• Lidocaine can be given only if amiodarone is not available
  • Give 1 mg/kg IV/IO
• Magnesium sulfate is used to treat torsades de pointes
  • Loading dose: 25/50 mg/kg IV/IO diluted in D5W or normal saline, infuse over 5-20 min, max dose 2 g

Medications Used in Asystole/PEA

• Epinephrine (0.01 mg/kg IV/IO up to 1 mg per dose)
• Can be given every 3-5 minutes