Pediatric Critical Care Mohammed El-Naggar
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Chapter Notes

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1Emergency Resuscitation
  • Cardiopulmonary Arrest
  • Cardiopulmonary Resuscitation
  • Neonatal Resuscitation
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Cardiopulmonary ArrestChapter 1

Cardiopulmonary arrest is the first and most urgent emergency in medicine. It is an emergency of only 5 minutes and unless adequate effective resuscitative measures are performed during this short period, irreversible damage of brain cells and even brain death will occur.
By definition, cardiopulmonary arrest is a sudden unexpected cessation of circulation and respiration in a patient who is unlikely to die and in whom the potentials for recovery are good. For such a patient, cardiopulmonary resuscitation is indicated. On the other hand, if the patient is suffering from a terminal illness as widespread malignancy or chronic advanced system failure, cessation of circulation and respiration do not necessitate any resuscitative measures.
 
CAUSES
Cardiopulmonary arrest can occur in any of the following situations:
  1. Acute critical illnesses: All patients with pediatric emergencies are susceptible because of the physiological instability. Patients with respiratory failure and circulatory failure are particularly more susceptible because of the resultant tissue hypoxia and acidosis. Primary cardiac disease is a rare cause of cardiac arrest in infants and children. This is different from the adult situation where cardiac arrest is often primary cardiac. The seven precipitating factors of cardiac arrest are (1) hypoxia, (2) shock, (3) acidosis, (4) electrolyte disturbance, (5) tension pneumothorax, (6) cardiac tamponade, and (7) hypothermia. These factors are called “the negative inotropes”.
  2. Stressful procedures: In patients with acute critical illnesses, some procedures as suctioning, chest physiotherapy, endotracheal intubation and lumbar puncture may precipitate cardiopulmonary arrest. Oxygenation prior to any of these 4techniques is important and careful observation during the technique is essential for early detection of signs of decompensation as bradycardia and slow respiration.
  3. Sudden withdrawal of support: In patients with acute critical illness, sudden withdrawal of support (as oxygen therapy or mechanical ventilation) may precipitate arrest. As a rule, any form of support should be withdrawn gradually.
 
DIAGNOSIS
Clinical manifestations of cardiopulmonary arrest can be divided into 2 stages; early signs of decompensation (or pre-arrest) and the actual cardiopulmonary arrest (see below). Physicians and nurses dealing with pediatric emergencies should be fully oriented with the early signs of decompensation. Discontinuation of any stressful procedure and oxygen administration may rapidly reverse these manifestations. Proper treatment of the causative disease is equally important.
In patients with cardiopulmonary arrest, urgent cardiopulmonary resuscitation is indicated. It is important to note that cardiac arrest usually occurs first in case of respiratory failure (myocardial hypoxia) and circulatory failure (myocardial ischemia). On the other hand, respiratory arrest usually occurs first in case of central neurological failure (due to severe respiratory depression).
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Figs 1.1A and B: (A) Pulse check in children (Feeling the carotid pulse) (B) Pulse check in infants (Feeling the brachial pulse)