Despite our best efforts, some patients cannot be resuscitated. The decision to terminate efforts at saving a life can be a difficult one. Many factors need to be considered, including time to the initia- tion of CPR, time to defibrillation, co-morbid dis- ease, age of the patient, initial rhythm, quality of life prior to the arrest, and expected quality of life if resuscitated. The most important prognostic factor is the duration of cardiac arrest. The chance of being discharged from the hospital alive and
Cardiopulmonary and cerebral resuscitation
neurologically intact diminishes as resuscitation time increases. Available scientific studies have shown that prolonged resuscitation efforts are unlikely to be successful if there is no return of spontaneous circulation at any time during 30 minutes of cumulative ACLS. Reversible causes of cardiac arrest such as drug overdose, electrolyte abnormalities, or profound hypothermia should be taken into account when considering termina- tion of efforts. Treatment of these causes may improve the efficacy of the resuscitation effort and the patient’s chances of survival.
Hypothermia (core body temperature of 30°C/86°F) is associated with marked depres- sion of cerebral blood flow, oxygen requirement, cardiac output, and arterial pressure. Hypo- thermia may exert a protective effect on the brain and other organs in cardiac arrest. Although rare, full resuscitation with intact neurologic recovery may be possible after prolonged hypothermic car- diac arrest. Research is ongoing to determine the role of induced hypothermia in cardiac arrest.
When all Basic Life Support (BLS) or ACLS measures have been reasonably attempted and the likelihood of survival is minimal, resuscita- tion efforts should be discontinued. Informing family members of the death of a loved one is a very difficult responsibility faced by emergency physicians. Prior to such a disclosure, family members should be gathered in a quiet and pri- vate area. Social service personnel and nursing
staff should be asked to assist. It is best to be honest and straightforward using language that is appropriate for the family’s education level and culture. Briefly relate the circumstances regarding the resuscitation efforts ending with the news that their loved one is dead. Avoid terminology such as “passed away” or “is gone,” which may lead to confusion. Family will often want to know what, if anything, they could have done to change the outcome. It is important to reassure them that they did nothing wrong if this is appro- priate. Enlist the support of social services, clergy, or other culturally-appropriate personnel to assist you with some of the associated issues, such as autopsy, organ donation, and viewing the body.
Express your sympathy and make sure that there is reasonable social support before leaving.
Special patients
The evaluation and treatment of cardio- pulmonary arrest is particularly challenging in the pediatric population. Unlike adults, pediatric cardiac arrests are most commonly the result of respiratory causes. Reduced familiarity with pro- cedures as well as anatomic issues (i.e., decreased size of structures) make definitive airway man- agement and vascular access more challenging in pediatric patients. In addition, psychosocial issues are generally more complex in these patients.
Neonatal Advanced Life Support (NALS), Pediatric
Temperature (warm and dry) Airway (position and suction) Breathing (stimulate to cry) Circulation (heart rate and color)
Assess baby’s response to birth Keep baby warm
Position, clear airway, stimulate to breathe by drying, and give oxygen (as necessary)
Establish effective ventilation
• Bag and mask
• Tracheal intubation Provide chest compressions Administer medications Needed less
frequently
Rarely needed by newborns Always needed
by newborns Assess and
support
Figure 3.6
Neonatal resuscitation inverted pyramid. Reproduced with permission, PALS Provider Manual, © 2002, Copyright American Heart Association.
Cardiopulmonary and cerebral resuscitation Advanced Life Support (PALS), and Advanced
Pediatric Life Support (APLS) courses exist to teach these differences. The cardiopulmonary arrest algorithms are similar between children and adults, although the energy of defibrillation and medica- tion dosing are weight-based. The Broselow tape which bases a neonate’s or child’s weight on the length is an essential piece of equipment for pedia- tric resuscitation. It has the appropriate medica- tion doses, equipment sizes, and defibrillation energies listed for the appropriate length (weight), and is color coded. Many EDs arrange the pedia- tric resuscitation equipment by these colors, in order to make the appropriate equipment more readily accessible during resuscitation.
The algorithms for neonatal and pediatric resuscitations are included (Figures 3.6–3.9).
Detailed discussions of these scenarios are beyond the scope of this chapter. There no longer seems to be controversy regarding parents or family mem- bers witnessing resuscitation attempts. This offers family members the chance to see the health care team doing their best under difficult circum- stances, and affords family members the opportu- nity to more readily accept any outcomes. Again, support staff should be made available during these difficult situations. It is recommended that debriefing opportunities for the emergency health care team be arranged in a timely manner, for as many providers as possible. These are best lead by
Is bradycardia causing severe cardio- respiratory compromise?
(Poor perfusion, hypotension, respiratory difficulty, altered consciousness)
No Yes
Perform chest compressions if despite oxygenation and ventilation:
Epinephrine*
• IV/IO: 0.01 mg/kg (1 : 10,000; 0.1 ml/kg)
• Tracheal tube: 0.1 mg/kg (1 : 1000; 0.1 ml/kg)
• May repeat every 3–5 minutes at the same dose
• Observe
• Support ABCs
• Consider transfer or transport to ALS facility
During CPR Attempt/verify
• Tracheal intubation and vascular access
Check
• Electrode position and contact
• Paddle position and contact
• Pacer position and contact Give
• Epinephrine every 3–5 minutes and consider alternate medications:
epinephrine or dopamine infusions Identify and treat possible causes
• Hypoxemia
• Hypothermia
• Head injury
• Heart block
• Heart transplant (special situation)
• Toxins/poisons/drugs
• Heart rate 60/minutes in infant or child and poor systemic perfusion
Atropine* 0.02 mg/kg (minimum dose: 0.1 mg)
• May be repeated once
Consider cardiac pacing
If pulseless arrest develops, see Pulseless arrest algorithm
• BLS algorithm: Assess and support ABCs as needed
• Provide oxygen
• Attach monitor/defibrillator
*Give atropine first for bradycardia due to suspected increased vagal tone or primary AV block.
Figure 3.7
Pediatric Advanced Life Support pulseless arrest. CPR: cardiopulmonary resuscitation; ALS: Advanced Life Support; BLS: Basic Life Support; IO: intraosseous. Reproduced with permission, PALS Provider Manual,
© 2002, Copyright American Heart Association.
Cardiopulmonary and cerebral resuscitation
• BLS algorithm: Assess and support ABCs as needed
• Provide oxygen
• Attach monitor/defibrillator
Continue CPR up to 3 minutes Assess rhythm (ECG)
VF/VT
Not VF/VT (includes PEA and asystole)
Attempt defibrillation
• Up to three times if needed
• Initially 2 J/kg, 2–4 J/kg, 4 J/kg*
Attempt defibrillation with 4 J/kg* within 30–60 seconds after each medication
• Pattern should be drug – CPR–shock (repeat) or drug–CPR–shock–shock–
shock (repeat)
Attempt defibrillation with 4 J/kg* within 30–60 seconds after each medication
• Pattern should be drug–
CPR–shock (repeat) or drug–CPR–shock–shock–
shock (repeat) Antiarrhythmic
• Amiodarone: 5 mg/kg bolus IV/IO or
• Lidocaine: 1 mg/kg bolus IV/IO/TT or
• Magnesium: 25 –50 mg/kg IV/IO for torsades de pointes or hypomag- nesemia (maximum: 2 g)
* Alternative waveforms and higher doses are class indeterminate for children.
Epinephrine
• IV/IO: 0.01 mg/kg (1 : 10,000; 0.1 ml/kg)
• Tracheal tube 0.1 mg/kg (1 : 1000; 0.1 ml/kg) During CPR
Attempt/verify
• Tracheal intubation and vascular access
Check
• Electrode position and contact
• Paddle position and contact Give
• Epinephrine every 3–5 minutes (consider higher doses for second and subsequent doses)
Consider alternative medications
• Vasopressors
• Antiarrhythmics (see box at left)
• Buffers
Identify and treat causes
• Hypoxemia
• Hypovolemia
• Hypothermia
• Hyper/hypokalemia and metabolic disorders
• Tamponade
• Tension pneumothorax
• Toxins/poisons/drugs
• Thromboembolism Epinephrine
• IV/IO: 0.01 mg/kg (1 : 10,000; 0.1 ml/kg)
• Tracheal tube: 0.1 mg/kg (1 : 1000; 0.1 ml/kg)
Figure 3.8
Pediatric Advanced Life Support bradycardia. CPR: cardiopulmonary resuscitation; VF: ventricular fibrillation;
VT: ventricular tachycardia; IO: intraosseous; PEA: pulseless electrical activity; TT: Tracheal tube; BLS: Basic Life Support. Reproduced with permission, PALS Provider Manual, © 2002, Copyright American Heart Association.
Cardiopulmonary and cerebral resuscitation
• BLS algorithm: Assess, support ABCs
• Initiate CPR
• See pulseless arrest algorithm • Pulse present?
Evaluate the tachycardia
Evaluate the tachycardia During evaluation Identify and treat
possible causes
• Provide oxygen and ventilation as needed
• Attach monitor/defibrillator
Consider vagal maneuvers (no delays)
• Provide oxygen and ventilation as needed
• Support ABCs
• Confirm continuous monitor/pacer attached
• Consider expert consultation
• Prepare for cardioversion (consider sedation)
• Hypoxemia
• Hypovolemia
• Hyperthermia
• Hyper/hypokalemia and metabolic disorders
• Tamponade
• Tension pneumothorax
• Toxins/poisons/drugs
• Thromboembolism
• Pain
• 12-lead ECG if practical
• Evaluate QRS duration Yes
QRS duration wide for age (approximately 0.08 seconds) No
QRS duration normal for age (approximately 0.08 seconds)
Probable sinus tachycardia
• History compatible
• P waves present/normal
• HR often varies with activity
• Variable RR with constant PR
• Infants: rate usually 220 bpm
• Children: rate usually 180 bpm
Probable ventricular tachycardia
• Immediate cardioversion 0.5–1 J/kg
(consider sedation, do not delay cardioversion)
Immediate cardioversion or Immediate IV/IO adenosine
• Attempt cardioversion with 0.5–1 J/kg (may increase to 2 J/kg if initial dose is ineffective)
• Use sedation if possible
• Sedation must not delay cardioversion
• Adenosine: Use if IV access is immediately available
• Dose: Adenosine 0.1 mg/kg IV/IO (maximum first dose: 6 mg)
• May double and repeat dose once (maximum second dose: 12 mg)
• Technique: Use rapid bolus technique
Consider alternative medications
• Amiodarone 5 mg/kg IV over 20–60 minutes
or
• Procainamide 15 mg/kg IV over 30–60 minutes (do not routinely administer amiodarone and procainamide together)
or
• Lidocaine 1 mg/kg IV bolus (wide-complex only)
• Consult pediatric cardiologist
• 12-lead ECG Probable supraventricular
tachycardia
• History incompatible with ST
• P waves absent/abnormal
• HR not variable with activity
• Abrupt rate changes
• Infants: rate usually 220 bpm
• Children: rate usually 180 bpm
Figure 3.9
Pediatric Advanced Life Support tachycardia poor perfusion. CPR: cardiopulmonary resuscitation; HR: heart rate;
ST: sinus tachycardia; RR: R-R interval; PR: P-R interval; IO: intraosseous; BLS: Basic Life Support. Reproduced with permission, PALS Provider Manual, © 2002, Copyright American Heart Association.
Cardiopulmonary and cerebral resuscitation
personnel specifically trained in psychology, psychiatry, or critical debriefing.