No. 21

[PubMed]

Schindler MB, Bohn D, Cox PN, McCrindle BW, Jarvis A, Edmonds J, Barker G

Department of Critical Care Medicine, Hospital for Sick Children, University of Toronto, Canada.

BACKGROUND: Among adults who have a cardiac arrest outside the hospital, the survival rate is known to be poor. However, less information is available on out-of-hospital cardiac arrest among children. This study was performed to determine the survival rate among children after out-of-hospital cardiac arrest and to identify predictors of survival.

METHODS: We reviewed the records of 101 children (median age, two years) with apnea or no palpable pulse (or both) who presented to the emergency department at the Hospital for Sick Children in Toronto. The characteristics of the patients and the outcomes of illness were analyzed. We assessed the functional outcome of the survivors using the Pediatric Cerebral and Overall Performance Category scores.

RESULTS: Overall, there was a return of vital signs in 64 of the 101 patients; 15 survived to discharge from the hospital, and 13 were alive 12 months after discharge. Factors that predicted survival to hospital discharge included a short interval between the arrest and arrival at the hospital, a palpable pulse on presentation, a short duration of resuscitation in the emergency department, and the administration of fewer doses of epinephrine in the emergency department. No patients who required more than two doses of epinephrine or resuscitation for longer than 20 minutes in the emergency department survived to hospital discharge. The survivors who were neurologically normal after arrest had had a respiratory arrest only and were resuscitated within five minutes after arrival in the emergency department. Of the 80 patients who had had a cardiac arrest, only 6 survived to hospital discharge, and all had neurologic sequelae.

CONCLUSIONS: These results suggest that out-of-hospital cardiac arrest among children has a very poor prognosis, especially when efforts at resuscitation continue for longer than 20 minutes and require more than two doses of epinephrine.

Comments:

1. Comment in: N Engl J Med 1997 May 1;336(18):1325; discussion 1325-6

No. 22

[PubMed]

O'Rourke PP

Mortality and neurologic morbidity were evaluated in children who were successfully resuscitated after being brought to an emergency room with continued apnea and pulselessness. Of 34 patients studied from June 1981 through August 1984, 27 died during the initial hospitalization and seven (21%) survived until hospital discharge. Of the seven surviving children who were discharged to a chronic care facility, five remain in a vegetative state. Possible explanations for this high mortality and neurologic morbidity are discussed.

No. 23

[PubMed]

Torphy DE, Minter MG, Thompson BM

Ninety-one patients had cardiorespiratory arrest in a children's hospital emergency department over six years. Only five children survived, three with severe neurologic sequelae. The records of 40 other children in the same community resuscitated by paramedics, but taken to other hospitals, were reviewed and there were three survivors. The causes and outcomes of resuscitation of children are clearly different from those of adults. Cardiac disease and ventricular arrhythmias are uncommon. Neurologically intact survival was seen only in those children who received immediate resuscitation and responded promptly. Research in cerebral resuscitation at the cellular level is promising for the future. Prevention of some cardiorespiratory arrests through accident prevention and earlier recognition of serious infections is possible now.

No. 24

[PubMed]

http://www.americanheart.org/Scientific/statements/1995/199505.html

No. 25

[PubMed]

Nichols DG, Kettrick RG, Swedlow DB, Lee S, Passman R, Ludwig S

We evaluated 47 pediatric patients after cardiopulmonary arrest. Patients entered the study with the onset of advanced life support. We followed them until death, or discharge from the hospital, occurred. We identified three groups of patients: long-term survivors, who survived to discharge, short-term survivors, who survived longer than 24 hours after CPR but not until discharge, and nonsurvivors, who died within 24 hours of their arrest. All of the long-term surviving patients were discharged from the hospital without gross neurologic deficit attributable to the arrest or resuscitation effort. Twenty-seven (57%) children were successfully resuscitated. Eighteen (38%) were long term-survivors, while nine (19%) were short-term survivors. Favorable outcome is associated with the following factors: inhospital arrest, extreme bradycardia as the presenting arrhythmia, successful resuscitation with only ventilation, oxygen and closed chest massage, and a duration of CPR of less than 15 minutes. Age, sex, and race, as well as pupillary reaction and motor response at the onset of advanced life support, did not correlate with long-term survival.

No. 26

[PubMed]

Barzilay Z, Somekh E, Sagy M, Boichis H

Pediatric Intensive Care Unit, Chaim Sheba Medical Center, Tel Hashomer, Israel.

In order to identify factors that influence the outcome from cardiopulmonary resuscitation (CPR) in children, we studied 69 children (mean age 2.5 +/- 0.4 years) who were apneic and pulseless prior to resuscitation, and treated in the Pediatric Intensive Care Unit (PICU) following CPR. Immediate success (restoration of spontaneous circulation and normal sinus rhythm) was noted in 54 (78%) patients. Forty-one (59%) were short-term survivors (greater than 24 h), and ten (14.5%) became long-term survivors (five recovered well, three moderately disabled, and two severely disabled). Fifty-nine (85%) died. Outcome was positively influenced by: 1) CPR duration; when less than five min., 54% were long-term survivors compared to 5% of patients resuscitated for more than five min (p less than 0.001). 2) Number of epinephrine doses: 38% of 24 patients receiving one dose became long-term survivors versus 0% of 26 receiving more than one dose (p less than 0.001). 3) Location of arrest; Fifty percent of patients resuscitated in the operation suite or catherization laboratory survived long-term compared to only 8% resuscitated in the PICU (p less than 0.03). Age, sex, cardiac rhythm, as well as metabolic and acid-base variables during resuscitation, did not significantly affect the outcome. Overall good neurologic survival was rare.

No. 27

[PubMed]

No. 28

[PubMed]

Melker RJ

Current standards for ventilation during cardiopulmonary resuscitation are not supported by recent and ongoing investigation. This is particularly true in victims with an unprotected airway. Currently used flow rates and inspiratory times predispose to gastric insufflation and its complications. Potential changes and corrections that may benefit the victim of cardiac arrest are reviewed.

No. 29

[PubMed]

Melker RJ, Banner MJ

Current American Heart Association standards for ventilation during two-rescuer CPR recommend that a 0.8- to 1.2-L breath be delivered in 0.5 second after every fifth chest compression. Delivering a high-volume breath over a brief inspiratory time (TI) may lead to hypoventilation and gastric insufflation in victims with an unprotected airway. We reasoned that lengthening TI would lower peak inspiratory pressure and peak inspiratory flow rate, and thus improve lung inflation. To study this possibility, a mechanical model of the airway and upper gastrointestinal tract was designed. A ventilator delivering a sinusoidal wave form was used to simulate artificial ventilation. A 0.8-L breath was delivered at 0.5, 1.0, or 1.5 seconds at three lung compliances (CLs). Also, the effect of lengthening TI was studied with increased airway resistance. Lengthening TI improved lung inflation and decreased gastric insufflation at all CLs, but more so with normal CL than with decreased CL. This study demonstrates the need for evaluating alternative ventilatory patterns with longer TI during CPR.

No. 30

[PubMed]

Bowman FP, Menegazzi JJ, Check BD, Duckett TM

Center for Emergency Medicine of Western Pennsylvania, School of Medicine, University of Pittsburgh, USA.

STUDY OBJECTIVE: Unprotected airway ventilation models have been based on a lower esophageal sphincter (LES) pressure found in human beings under general anesthesia. Whether this assumption is applicable during cardiac arrest in human beings is unknown. We attempted to determine the effects of prolonged ventricular fibrillation (VF) on the tension of the LES in a swine model of cardiac arrest. DESIGN: Prospective experimental trial using 18 female mixed-breed domestic swine (mean weight, 21.9 +/- 2.0 kg). RESULTS: Animals were anesthetized, intubated, and fitted with instruments for the monitoring of LES pressure. LES tone was measured with a LECTRON 302 esophageal monitor (American Antec, Incorporated). VF was induced with a 3-second, 100 mA transthoracic shock and left untreated for 8 minutes; then resuscitation was attempted. LES tension was measured during the first 7 minutes of the arrest. If return of spontaneous circulation (ROSC) occurred, LES pressure was measured for 7 more minutes. The mean baseline LES pressure was 20.6 +/- 2.8 cm H2O. During minutes 1 through 7 of the arrest the LES tone (mean +/- SD) decreased from 18.0 +/- 3.0 to 3.3 +/- 4.2. ROSC occurred in 10 of the 18 trials. In the 7 minutes after ROSC, LES pressure increased from 4.7 +/- 3.8 to 9.8 +/- 3.0. CONCLUSION: This study demonstrated a rapid and severe decrease in LES tone during prolonged cardiac arrest. When ROSC occurred, LES tension increased quickly but did not return to baseline.

No. 31

[PubMed]

Tonkin SL, Davis SL, Gunn TR

New Zealand Cot Death Association, Auckland.

In infants under 6 months of age air normally enters the trachea by the nose because the tongue fills the oral cavity, and the oral route is open only when the infant is making muscular efforts such as crying or gasping. The present recommendation for infant resuscitation is for the resuscitator's mouth to cover the mouth and nose of the baby. We set out to test whether this recommendation is feasible. We measured the dimensions of the faces of 28 babies aged between 2 and 4 months (the age when resuscitation is most often needed) and of the mouths of 25 of their mothers. Only 2 mothers would have been able to cover with their mouths the nose and closed mouth of 2 babies (not their own). The mannequins often used to teach adults to resuscitate infants are misleading because they present a wide open mouth, thus implying that that is the preferred route. We recommend that the nasal route of air entry be taught to parents for resuscitation of babies who have stopped breathing.

Comments:

Comment in: Lancet 1995 Aug 5;346(8971):382
Nasal airway versus oral route for infant resuscitation.
Segedin E, Torrie J, Anderson B
Publication Types:Comment, Letter

No. 32

[PubMed]

No. 33

[PubMed]

Mather C, O'Kelly S

Shackleton Department of Anaesthetics, Southampton General Hospital.

In 554 anaesthetised patients, the times taken to separately palpate and identify each of the carotid, radial, brachial and femoral pulses were recorded. The patients were divided into three groups based on the form of airway management chosen (tracheal tube, facemask or laryngeal mask airway). Our results demonstrate that in the operating theatre environment the identification of the radial pulse is the most rapid and reliable; by 5 s, 98% and by 10 s, more than 99% of radial pulses were identified. The carotid pulse was not so easily identified, requiring 10 s to enable an identification rate of greater than 95%. The presence of a laryngeal mask airway or a tracheal tube did not hinder the identification of carotid pulse.

Publication Types: Clinical trial, Controlled clinical trial

No. 34

[PubMed]

Brearley S, Shearman CP, Simms MH

Department of Surgery, Selly Oak Hospital, Birmingham.

Fifty observers, including two fully trained vascular surgeons, were asked to determine the presence or absence of the femoral and distal pulses of four patients with peripheral vascular disease and one asymptomatic subject (50 pulses assessed). Pulses felt by both vascular surgeons were deemed to be palpable. Among the other observers, the sensitivity of palpation was 95% or over for the femoral pulse, but 33% to 60% for observers of varying experience feeling for the posterior tibial pulse. Up to 20% false-positive observations were reported. Disease was diagnosed in over 10% of examinations of healthy limbs and was missed in over 10% of symptomatic limbs. The accuracy of pulse palpation was strongly correlated with the systolic blood pressure in the underlying artery. Accuracy was greater among more experienced observers, suggesting that careful teaching of this skill is likely to be beneficial. Even so, pulse palpation alone is an unreliable physical sign and should only be used in combination with objective measurements as a guide to clinical management.

註．referenceのページ数が違うようです。

No. 35

[PubMed]

Connick M, Berg RA

Department of Pediatrics, Steele Memorial Children's Research Center, University of Arizona College of Medicine, Tucson.

(whole article) We describe the cases of two children with easily palpated femoral pulses during open-chest cardiac massage after aortic occlusion. These pulsations must have arisen from the femoral veins, implying that during CPR in children the usual anatomic landmarks for femoral venous access may be unreliable, and femoral pulsations do not necessarily reflect arterial flow. Femoral pulses may signify to-and-fro inferior vena caval flow that compromises venous return, adversely affecting cardiac output and the effectiveness of medication administration to the lower extremity.

PMID: 7978605, UI: 95069291

註．ここもrefereceのタイトルが少し違っていますね。 （during open-heart cardiac massageではなく，during open-chest cardiac massage が正しそうです）

No. 36

[PubMed]

Berg RA, Kern KB, Hilwig RW, Berg MD, Sanders AB, Otto CW, Ewy GA

Department of Pediatrics, Steele Memorial Children's Research Center, Tucson, Ariz, USA. rberg@aruba.ccit.arizona.edu

BACKGROUND: Mouth-to-mouth rescue breathing is a barrier to the performance of bystander cardiopulmonary resuscitation (CPR). We evaluated the need for assisted ventilation during simulated single-rescuer bystander CPR in a swine model of prehospital cardiac arrest.

METHODS AND RESULTS: Five minutes after ventricular fibrillation, swine were randomly assigned to 8 minutes of hand-bag-valve ventilation with 17% oxygen and 4% carbon dioxide plus chest compressions (CC + V), chest compressions only (CC), or no CPR (control group). Standard advanced life support was then provided. Animals successfully resuscitated received 1 hour of intensive care support and were observed for 24 hours. All 10 CC animals, 9 of the 10 CC + V animals, and 4 of the 6 control animals attained return of spontaneous circulation. Five of the 10 CC animals, 6 of the 10 CC + V animals, and none of the 6 control animals survived for 24 hours (CC versus controls, P = .058; CC + V versus controls, P < .03). All 24-hour survivors were normal or nearly normal neurologically.

CONCLUSIONS: In this model of prehospital single-rescuer bystander CPR, successful initial resuscitation, 24-hour survival, and neurological outcome were similar after chest compressions only or chest compressions plus assisted ventilation. Both techniques tended to improve outcome compared with no bystander CPR.

PMID: 9118534, UI: 97234036

No. 37

[PubMed]

Kyriacou DN, Arcinue EL, Peek C, Kraus JF

Olive View/UCLA Medical Center, Department of Emergency Medicine, Sylmar 91342.

STUDY OBJECTIVE. To determine the effect of immediate resuscitative efforts on the neurological outcome of children with submersion injury.

DESIGN. A case-control study was designed to determine if immediate resuscitation by rescuers or bystanders reduces the frequency of severe neurological damage or death in children with a documented submersion event. Logistic regression was used calculate an adjusted odds ratio.

PARTICIPANTS. The study group consisted of 166 children, aged zero to 14 years, having a submersion event during May 1984 through August 1992, and admitted through various emergency departments to Huntington Memorial Hospital in Pasadena, California.

MEASUREMENTS AND MAIN RESULTS. All study subjects had an observed and documented episode of apnea at the time of submersion. Outcomes were evaluated on the basis of neurological impairment or death. Exposure was verified from historical accounts of postsubmersion events provided by family, friends, and/or paramedical personnel. The study factors included age and gender, duration of submersion, hypothermia, presence of apnea, resuscitative efforts, and clinical outcome. Children with a good outcome were 4.75 (adjusted odds ratio (OR)) times more likely to have a history of immediate resuscitation than children with poor outcome (95% confidence interval: 3.44 < OR < 6.06, P = .0001). Various types of resuscitative efforts and potential confounding factors were also evaluated. CPR and mouth-to-mouth resuscitation were the most effective types for the prevention of death or severe anoxic encephalopathy.

CONCLUSION. Immediate resuscitation before the arrival of paramedical personnel is associated with a significantly better neurological outcome in children with submersion injury.

PMID: 8036063, UI: 94309960

No. 38

[PubMed]

Gillis J, Dickson D, Rieder M, Steward D, Edmonds J

We retrospectively reviewed the results of 42 cardiopulmonary arrests occurring over 1 yr in the general ward of a pediatric hospital. These data were compared to those of a similar study done 10 yr previously in the same institution. Patients were divided into those having pure respiratory arrest and those who also had cardiac arrest. In the most recent series, overall 6-month survival was 17%; however, only 9% of the cardiac arrest patients survived. Ten years previously, the survival rate from cardiac arrest was 11%. In both series, pure respiratory arrest had a significantly better outcome than cardiopulmonary arrest, and predictors of nonsurvival were a duration of arrest greater than 15 min and the administration of more than one iv bolus of epinephrine. During the more recent series, sepsis and upper airway problems produced fewer arrests. There was one neurologically damaged survivor in each study period. Our study confirms that the outcome of pediatric cardiac arrest is poor when arrest occurs in the hospital.

PMID: 3698612, UI: 86191328

No. 39

[PubMed]

Kissoon N, Peterson R, Murphy S, Gayle M, Ceithaml E, Harwood-Nuss A

Department of Pediatrics, University of Florida, Jacksonville.

OBJECTIVE: To compare the pH and PCO2 values determined from of simultaneously corrected samples of central venous and intraosseous blood during sequential changes in cardiac output. DESIGN: Prospective, descriptive study.

SETTING: An animal laboratory in a university medical center.

SUBJECTS: Fourteen mixed breed 4-wk-old piglets. INTERVENTIONS: Animals were anesthetized with ketamine hydrochloride and neuromuscular blockade was induced by the administration of pancuronium bromide. After endotracheal intubation and the institution of mechanical ventilation, a 4-Fr pulmonary artery catheter and a carotid artery cannula were inserted via a cutdown into the right neck of each piglet. A 16-gauge intraosseous needle was inserted into the anteromedial surface of the right tibia.

MEASUREMENTS AND MAIN RESULTS: Central venous and intraosseous blood gas samples were obtained simultaneously with thermodilution cardiac output measurements. Cardiac output measurements were as follows: during steady state (0.80 +/- 0.14 L/min), after volume loading of 15 mL/kg (1.00 +/- 0.25 L/min), after three successive bleeds of 15 mL/kg each at 30-min intervals (0.70 +/- 0.28, 0.54 +/- 0.22, and 0.43 +/- 0.16 L/min, respectively) and at exsanguination (unrecordable). Paired t-tests demonstrated no significant differences in pH and PCO2 values between intraosseous and central venous samples under all study conditions. Limits of agreement for difference in PCO2 between sites, within the range of cardiac outputs studied, were -12.86 to 11.38 torr (-1.71 to 1.46 kPa) and for pH were -0.09 to 0.15. CONCLUSIONS: Intraosseous blood samples can be obtained without difficulty even during extreme hypovolemia. The pH and PCO2 values of intraosseous and central venous blood samples were similar under all study conditions. Intraosseous blood may be a useful alternative to central venous blood to assess tissue acid-base status during hemorrhagic shock and other low-flow states.

PMID: 8205808, UI: 94265468

No. 40

[PubMed]

Kissoon N, Rosenberg H, Gloor J, Vidal R

Department of Pediatrics, University of Florida, Jacksonville.

OBJECTIVE: To compare the acid-base status of blood obtained from the tibial intraosseous site with that status obtained from a central venous site during stead- and low-flow states in a piglet model. DESIGN: A prospective, observational study.

SETTING: Animal laboratory at a university medical center.

SUBJECTS: Nine 2-day-old piglets.

INTERVENTIONS: Animals were anesthetized, intubated, and mechanically ventilated. A thermodilution pulmonary artery catheter was inserted via the right internal jugular vein and directed into the pulmonary artery. An arterial catheter was inserted into the right carotid artery and an intraosseous needle was inserted into the proximal tibial marrow cavity. Cardiorespiratory arrest was induced by discontinuation of ventilation. The animals were subsequently resuscitated by precordial compressions and ventilation. Blood samples were obtained from central venous and intraosseous sites during steady state and during resuscitation (low-flow state). RESULTS: No significant differences (p < .05) were found for pH, PCO2, and bicarbonate concentration when values that were obtained from the central venous and intraosseous sites were compared during steady- and low-flow states.

CONCLUSIONS: The acid-base status of intraosseous blood is similar to that status of central venous blood. Intraosseous blood gas values may be an acceptable alternative to central venous blood gas values in judging central acid-base status during cardiopulmonary resuscitation.