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Patterson M. Pediatric Clinics of North America Vol 46 No 6 Dec 1999

Review: This is a complete review of CPR in children, beginning with pre hospital care. In children, the prognosis for survival of an arrest outside the hospital setting is dismal. Pre hospital care is a major focus of efforts to improve the outcome of CPR in children. Children who have arrest are less likely than adults to be have vascular access established, be intubated or even have intubation attempted. The LMA is mentioned and insertion technique illustrated although no data on its use in pediatric CPR is included. The use of automatic external defibrillators(AED) is discussed. There is some experience with these devices in children. One study reported that in the 20% of the pediatric arrest victims whose resuscitation included use of AED, survival was 38% with 17% having good outcomes. In contrast, children with PEA (pulseless electrical activity) in whom the AED was used only had a 4% survival. Most AEDs deliver a preset 200J with some models capable of delivering 100J or 200J. There is concern that the dose of electricity would be exceed the recommended 4J/kg in smaller children and possibly cause harm. Variations on traditional CPR such as active compression-decompression CPR, interposed abdominal compression are discussed in the section on restoration of circulation but data on effectiveness and safety in children are lacking.

High dose epinephrine is reviewed. Following the reports in the 1980s of improved survival in adults using epinephrine doses of between 0.1-0.2 mg/kg, a series of randomized trials of higher epinephrine doses did not show improvement in resumption of spontaneous circulation (ROSC) or improved rates of survival to hospital discharge. The retrospective studies of high dose epinephrine in pediatric patients did not show different rates of ROSC, neurologic outcome or survival. One randomized, prospective study in pediatrics was halted prior to completion due to changes in federal regulations. In this incomplete study, patients randomized to treatment with high dose epinephrine had higher rates of ROSC (25% vs 15%) and survival (9.5% vs 3.4%) but neither of these results were statistically significant due to the limited ample size (154 patients). On the other hand, there is no conclusive evidence that harm is caused by the use of high dose epinephrine in pediatric arrest victims.

There are no definitive guidelines regarding the length of time spent in efforts to resuscitate a child, although there is some evidence that the longer the resuscitation, the greater the likelihood of a poor outcome.

Comments: This paper, with 78 references, is a review of current knowledge of CPR in children. It is not a specific algorithm for the conduct of CPR, however. Newer therapies such as external defibrillators and high dose epinephrine are discussed as well as what information is available about prognosis. In hospital arrests are not specifically addressed, but the information presented is important to those of us who care for children.

Reviewed by: Thomas J. Mancuso, MD, FAAP
Childrens Hospital, Boston