bubble_chart Overview

Cardiac and respiratory arrest is a common critical emergency in pediatrics. Cardiac arrest leads to cessation of brain oxygenation, resulting in respiratory arrest, while respiratory arrest causes hypoxia, leading to cardiac arrest. Clinically, these conditions always occur together and require immediate resuscitation with cardiopulmonary resuscitation (CPR); otherwise, systemic hypoxia will result in death. The incidence of cardiac and respiratory arrest in children is relatively higher than in adults. Based on the anatomical and physiological characteristics of children, resuscitation methods differ from those for adults. If timely and appropriate resuscitation is provided, the success rate is also higher than in adults.

bubble_chart Etiology

disease cause

1. Respiratory diseases rank first, including hypoxia, asphyxia, respiratory failure, various respiratory foreign bodies, pneumonia, laryngitis, tracheitis, pleural effusion, pneumothorax, etc.
2. Circulatory diseases rank first in adults but are less common in pediatrics, seen in various myocarditis, cardiomyopathy, pericarditis, cardiogenic shock, heart failure, arrhythmias such as conduction block, ventricular fibrillation, ventricular arrest, and cases where the heart rate suddenly drops below 30 beats per minute, which can be treated as cardiac arrest.
3. Digestive system diseases include severe dehydration, acidosis, hypokalemia, hyperkalemia, and electrolyte imbalances caused by enteritis, toxic dysentery, etc.
4. Central nervous system diseases include neonatal intracranial hemorrhage, various purulent meningitis, viral meningitis, encephalitis, and increased intracranial pressure caused by cerebral edema.
5. Drug poisoning diseases are more common in pediatrics due to accidental ingestion, such as digitalis, verapamil, quinidine, neostigmine, reserpine, etc. At the grassroots level, pesticide poisoning, especially organophosphorus poisoning, is more frequently seen.
6. Allergic reactions include penicillin, procaine, various serum preparations, and certain food allergies.
7. Medical accidents include sudden cardiac and respiratory arrest during lumbar puncture, pericardial puncture, ECG two-step test, cardiac catheterization, electrical cardioversion, cerebral and cardiac/renal angiography, hemodialysis, and anesthesia.
8. Accidental injuries include drowning, electric shock, traffic accidents, burns, massive hemorrhage, etc.
9. Sudden infant death syndrome and primary alveolar hypoventilation syndrome.

Pathophysiology

(1) Hypoxia: The cardiac conduction system is inhibited, causing various arrhythmias. It can lead to metabolic acidosis, electrolyte imbalances, and cerebral edema. (2) Carbon dioxide retention: Results in respiratory acidosis, also causing electrolyte imbalances and cerebral edema. (3) Sequence of cardiac and respiratory arrest: Clinically, respiratory arrest occurs more often first, as the respiratory center is more vulnerable, while the heart has intrinsic automaticity. (4) Cerebral hypoxia leads to hypoxic encephalopathy: Animal experiments show irreversible brain death after 3–5 minutes of cerebral hypoxia. Conditions vary and are not absolute; for example, newborn rats die after 25–30 minutes of cerebral hypoxia, while adult rats die in 3–4 minutes. Neonatal asphyxia lasting dozens of minutes is often successfully rescued, especially in pediatrics, where resuscitation should not be abandoned due to the "irreversible" concept of 4–6 minutes.

bubble_chart Diagnosis

(1) Cardiac arrest, disappearance of heart sounds, absence of carotid and femoral pulses. (2) Absence or weakening of thoracic respiratory movements. (3) Loss of consciousness, sometimes accompanied by unconsciousness or convulsions. (4) Pallor or cyanosis of the complexion. (5) Dilated pupils, absence of tendon reflexes. (6) No electrical activity on ECG, or presence of ventricular fibrillation, ventricular standstill, heart rate below 30 beats per minute; even with electrical activity, lack of pumping function is equivalent to cardiac arrest.

bubble_chart Treatment Measures

﹝Treatment﹞

Immediate rescue measures should be taken, establishing artificial respiration and artificial circulation. On-site rescue is preferred to minimize movement or transfer, avoiding delays in critical care. Only after respiration and circulation are established should the patient be transferred to a hospital.

1. Ensure airway patency by clearing secretions, vomitus, obstructions, or blood clots from the nasopharynx and oral cavity. Position the patient supine with the head slightly tilted back, the jaw lifted forward and upward, and the tongue slightly pulled forward to prevent airway obstruction and maintain patency.
2. Artificial Respiration (1) Mouth-to-mouth, mouth-to-nose, or mouth-to-mouth-and-nose ventilation should be administered at a rate of 20–30 breaths per minute for infants and 12–20 breaths per minute for children. The ratio of ventilation to cardiac compression should be
   1. 4–5:1, with an inspiration-to-expiration ratio of 1
   :2, ensuring visible chest rise. Avoid excessive force to prevent alveolar rupture, which may lead to mediastinal emphysema, subcutaneous emphysema, or pneumothorax. (2) If conditions permit, endotracheal intubation followed by oxygen delivery via a pressurized balloon or intermittent positive-pressure ventilation is recommended. Intubation should not exceed 48 hours. If the patient resumes spontaneous breathing, synchronize it with artificial respiration.
3. Cardiac Resuscitation (1) Precordial Thump: Most effective within the first minute of cardiac arrest. Strike the precordial area with the heel of the hand or a fist to stimulate cardiac restart. Avoid excessive force; do not perform on infants. Typically, 2–3 strikes are attempted; if ineffective, proceed to external chest compressions. (2) External Cardiac Compression: Effective compressions can achieve 30–40% of normal cardiac output, ensuring blood supply to the brain and heart to sustain life. Method: Place the patient supine on a hard surface. The rescuer uses the heel of the right hand to compress the sternum—lower third for older children, mid-sternum for infants. Compression depth: 3 cm for older children, 2 cm for infants. For neonates and small infants, compress the mid-sternum with the index and middle fingers or support the back with both palms and four fingers while compressing the mid-sternum with both thumbs. Compression rate: 60/min for school-aged children, 80/min for preschoolers, and 100/min for small infants and neonates. Compression-to-relaxation ratio: 1:1. Effective compressions result in pupil constriction, flushed complexion, and palpable carotid or femoral pulses during compression. Avoid excessive force to prevent rib fractures. If ineffective, consider internal cardiac massage, though rarely used in pediatrics.
4. Medication Administration
   (1) Cardiac Stimulants: May be administered intravenously or intracardially. (1) Epinephrine: Commonly used at 1‰ concentration—0.1–0.2 ml for neonates, 0.3–0.5 ml for infants, repeated every 3–5 minutes if necessary. (2) Atropine: 0.01–0.1 mg/kg per dose, intracardiac or IV. (3) Isoproterenol: 0.125–0.5 mg per dose, intracardiac. (4) A combination of epinephrine, isoproterenol, and atropine, each 1 mg, with dosage adjusted to 1/4–1/2 based on age, administered intracardially or IV, termed the "new triple." (5) 10% Calcium Gluconate: 50–100 mg/kg per dose, or 5% Calcium Chloride: 15–30 mg/kg per dose, mixed with 10 ml of 10% glucose for intracardiac or IV injection. (6) 5% Sodium Bicarbonate: 2 ml/kg per dose, IV.
   (2) Respiratory Stimulants: Administered IV or IM in addition to artificial respiration after respiratory arrest. (1) Central Respiratory Stimulants: Nikethamide, Scopolamine. (2) Reflex Respiratory Stimulants: Lobeline.
   (3) Correct Acidosis: Without correction, restoration of heartbeat and respiration is difficult. Administer 5% Sodium Bicarbonate initially at 1.5–2 ml/kg IV push, adjusting dosage based on subsequent blood gas analysis.
5. ECG Monitoring: Continuously monitor ECG during resuscitation to assess heartbeat restoration and arrhythmias, and take appropriate measures, including medications, electrical defibrillation, or pacing.
6. Post-resuscitation management After successful resuscitation from cardiac and respiratory arrest, timely intervention and maintenance of organ function are crucial for the brain, heart, lungs, kidneys, and other organs affected by hypoxia-induced damage and metabolic disturbances. Failure to address these issues may lead to recurrent cardiac and respiratory arrest, rendering subsequent resuscitation efforts futile.

(1) Maintain cardiac function and correct hypotension: (1) Commonly used agents include dopamine and metaraminol, administered intravenously to sustain blood pressure and pulse. If ineffective, norepinephrine may be added. (2) Cyclic adenosine monophosphate (cAMP) enhances myocardial contractility, improves stroke volume, and maintains blood pressure. (3) Hormones: Reduce myocardial edema, aid in restoring metabolic function, and improve myocardial contractility. Dexamethasone is often administered intravenously. (4) In cases of heart failure or arrhythmia, refer to the relevant sections for management.
(2) Maintain respiratory function: Due to brain hypoxia from respiratory arrest, the respiratory center is highly sensitive and prone to damage. To sustain spontaneous respiration, ensure adequate oxygen inhalation and administer respiratory stimulants intravenously. Additionally, maintain airway patency. For patients with unstable spontaneous respiration, tracheostomy and mechanical ventilation may be necessary.
(3) Prevention and treatment of hypoxic encephalopathy: Successful cardiopulmonary resuscitation does not merely entail the restoration of heartbeat and respiration but must also achieve the recovery of brain function, ensuring normal development in children without impairment to intelligence or motor skills and no residual sequelae. When respiration and heartbeat cease for 10 seconds, cerebral oxygen is depleted, leading to unconsciousness, followed by anaerobic metabolism. Glycogen is exhausted within 2–4 minutes, and ATP within 4–5 minutes, resulting in cerebral edema, injury, and petechial hemorrhage—collectively termed hypoxic encephalopathy. Early reversible edema may progress to irreversible cellular necrosis. Among survivors of cardiac and respiratory arrest, 20% suffer neurological damage, such as memory loss, epilepsy, or a vegetative state. To mitigate hypoxic encephalopathy: (1) Hypothermia: Apply ice packs to the head or use an ice cap to reduce cerebral metabolic rate and prevent neuronal injury. Initiate cooling as early as possible, typically maintaining a head temperature of 28°C and rectal temperature of 31–33°C. Combine with hibernation therapy for 3–5 days or until auditory and other responses reappear, followed by gradual rewarming. (2) Dehydration therapy: Administer 20% mannitol (1–2 g/kg per dose) intravenously, alternating with dexamethasone (0.5–1 mg/kg per dose) every 4–6 hours. (3) Promote cerebral metabolism: Use cytochrome C, coenzyme A, ATP, or a pre-mixed energy cocktail. Citicoline may also be employed. (4) Barbiturates: Administered during hypoxia to protect brain cells. (5) Hyperbaric oxygen therapy: Perform if facilities permit.
(4) Continue correcting acidosis and electrolyte imbalances.
(5) Prevent and treat renal failure: Following cardiac and respiratory arrest, renal hypoperfusion, hypoxia, and vasospasm may lead to tubular necrosis, manifesting clinically as oliguria or anuria. Manage as acute renal failure.
(6) Prevent and treat infections: During hypoxia-induced unconsciousness and resuscitation procedures, complications such as pneumonia or sepsis may arise. Timely prevention and treatment are essential.
Appendix

1. Common Technical Procedures in Pediatrics
   (1) Venipuncture
   1. Scalp vein puncture is most widely used in pediatrics, primarily for intravenous infusion and medication administration in infants and young children.

(1) The commonly used frontal vein is relatively thick, straight, and deep, making it easy to stabilize. Other veins such as the superficial temporal vein, supraorbital vein, posterior auricular vein, and occipital vein are easier to puncture but slightly more difficult to stabilize.
(2) It should be distinguished from the scalp artery: (1) The artery has a palpable pulse upon palpation, does not dilate significantly when the child cries, appears curved and light red, and causes surrounding tissue to turn white when fluid is injected, requiring greater pressure to infuse. (2) The vein has no palpable pulse, becomes noticeably congested when the child cries, appears branched and blue, allows smooth fluid infusion, and does not cause surrounding tissue to turn white.
(3) After selecting the vein, shave and disinfect the area routinely. Use a 5ml syringe to draw saline and expel air, then attach a 4½ to 5½ infusion needle. Insert the needle at a 30°–40° angle to the skin, then advance it parallel to the vein. Check for blood return by gently withdrawing the plunger or injecting a small amount of saline. If no swelling or pallor occurs around the needle, it indicates the needle is in the vein.
(4) Once the vein is confirmed, dry the surrounding skin and secure the needle with adhesive tape. Cross-fix the infusion tube connected to the needle with a long strip of tape, then coil and secure the plastic tubing.
2. Femoral Vein Puncture is mainly used for drawing venous blood from infants for various blood and biochemical tests.
(1) Place the child supine on the examination table with the legs flexed, thighs slightly externally rotated at a 45° angle to the body’s long axis, and a small pillow or sandbag under the thighs to expose the groin area.
(2) An assistant stands at the child’s head, using their elbows and forearms to stabilize the torso, and their hands to hold the thighs in place. Disinfect the groin area routinely. The operator wears gloves, places the left index finger below the groin to locate the pulsating femoral artery, and inserts the syringe vertically 0.5cm medial to the pulsation.
(3) Stabilize the syringe and needle with the right hand, while the left hand withdraws the plunger to check for blood return. If no blood is seen, slowly withdraw the needle while continuing to aspirate until blood appears, then stabilize the needle and draw the required blood volume. If unsuccessful, adjust the angle or depth slightly and try again.
(4) After drawing blood, apply pressure to the site with a sterile cotton ball and flex the thigh for 3–5 minutes to observe for local bleeding.
3. External Jugular Vein Puncture
(1) Place the child supine with a small pillow under the shoulders to let the head hang slightly off the table. An assistant stands beside the table, stabilizing the torso with their elbows and holding the head with both hands, turning the child’s face to one side to expose the external jugular vein.
(2) After routine disinfection, the operator stands at the child’s head and inserts the needle at the junction of the upper and middle third of the external jugular vein, following the direction of blood flow toward the heart. After entering the vein, withdraw the plunger to check for blood return. If no blood is seen, withdraw slowly while aspirating until blood appears, then stabilize the needle and draw the required blood volume.
(3) After needle removal, apply pressure to the puncture site with a sterile dry cotton ball for 3–5 minutes, avoiding excessive pressure to prevent carotid sinus reflex. If no bleeding occurs, lift the child upright to reduce venous pressure.
(2) Intravenous Drip

1. Common sites: Scalp, dorsum of the hand, dorsum of the foot, wrist, and ankle veins. For older children, the elbow vein may be used.
2. Prepare the required fluid beforehand, connect a disposable infusion set to the vent tube, attach the infusion needle, and tighten the infusion clamp.
3. After successful puncture and blood return, connect the fluid and secure it. Open the infusion clamp and observe whether the fluid flows smoothly and if there are any small air bubbles. Finally, adjust the drip rate to the child’s needs.
4. Regularly inspect for any dripping, backflow, local swelling, or liquid leakage due to loose connections.
5. Keep the infusion site clean to prevent contamination and avoid infection.

(3) Thoracentesis
Mainly used for extracting fluid from the thoracic cavity for diagnostic purposes, or for therapeutic purposes such as draining large amounts of fluid to relieve pressure, releasing large amounts of gas to decompress, extracting pus for irrigation, or injecting medications.

1. Position: Older children can straddle a chair, facing the backrest, with their arms resting on the top of the chair and their head and chest leaning on their arms. Younger children can rest their head and arms on a small table or straddle one of the assistant's thighs, with the assistant holding the child firmly to stabilize the torso and arms, exposing the puncture site.
2. Puncture site: Should be at the lowest point of dullness, typically at the 7th-8th intercostal space along the scapular line, the 7th intercostal space along the posterior axillary line, the 6th intercostal space along the midaxillary line, or the 5th intercostal space along the anterior axillary line. Prior to puncture, X-ray or ultrasound localization can also be used. For gas decompression, the 2nd intercostal space lateral to the midclavicular line is selected.
3. Puncture procedure: After localization, the skin is routinely disinfected. The operator wears gloves and drapes a sterile towel. After injecting 1% procaine for local anesthesia of the skin, subcutaneous tissue, and pleura, the rubber tube of the puncture needle is clamped with a hemostat. The skin at the puncture site is fixed with the left index finger and thumb, and the needle is slowly inserted along the upper edge of the lower rib with the right hand. A sudden loss of resistance indicates entry into the thoracic cavity. The syringe is then attached, and the hemostat is released to aspirate pleural fluid. After filling the syringe, the assistant clamps the rubber tube with a hemostat, removes the syringe, empties the fluid, and reattaches it for further aspiration. The amount of fluid extracted is determined by the condition, and samples are sent for testing and bacterial culture.
4. After fluid or gas extraction, if medication needs to be injected, it can be introduced into the thoracic cavity before removing the needle. The site is then disinfected, pressed with dry gauze, and secured with adhesive tape.
5. During the procedure, care must be taken to prevent the needle from slipping. If the child experiences severe coughing, fluid extraction should be stopped.

(4) Lumbar Puncture
Primarily used to obtain cerebrospinal fluid for diagnostic purposes, or less commonly for intrathecal medication or other specialized tests.

1. The child is placed in a lateral position. An assistant stands on the side facing the child's chest, placing the right hand behind the neck to hold the head and bend it toward the chest, while the left hand wraps around the popliteal fossa to bend the legs toward the abdomen, arching the back outward toward the operator. Older cooperative children can be instructed to hug their knees while lying on their side, keeping the back perpendicular to the table.
2. Site: Typically, the L3-L4 intervertebral space is selected as the puncture point. A line is drawn between the two iliac crests, and the L3-L4 interspinous space along this line is chosen. Adjacent lumbar spaces may also be used. In infants, the spinal cord ends lower, so the L4-L5 space is preferred to avoid spinal cord injury. Older children may use the L2-L3 space.
3. Procedure: The skin is routinely disinfected, and the operator wears gloves and drapes a sterile fenestrated towel. Except for unconscious patients and small infants, 1% procaine is injected into the skin, subcutaneous tissue, and interspinous ligament for anesthesia. The skin at the puncture site is fixed with the left index finger and thumb, and the lumbar puncture needle is held with the right hand and inserted vertically or slightly toward the child's head at the lower edge of the fixed spinous process. A loss of resistance indicates entry into the subarachnoid space. The stylet is removed, and cerebrospinal fluid flow is observed. If no fluid flows, the needle can be slightly rotated or the stylet reinserted to advance the needle further, especially during the first lumbar puncture, to avoid sudden advancement and potential blood vessel injury. When cerebrospinal fluid flows, pressure can be measured and samples collected. If pressure is high, fluid must be released slowly to prevent complications.
4. The stylet is reinserted, and the needle is removed. The site is disinfected and covered with sterile gauze, secured with adhesive tape. The child is instructed to lie flat for 4-6 hours to avoid cerebral herniation or post-puncture headache.

(5) Subdural Puncture
Suitable for infants with an open anterior fontanelle suspected of having subdural effusion, empyema, or hematoma for diagnosis or treatment.

1. The child's head is washed, and hair around the anterior fontanelle is shaved. The child is placed in a lateral position, wrapped in a sheet for stabilization, and the assistant holds the head firmly.
2. Routine skin disinfection of the head is performed, and the operator wears gloves and drapes a sterile fenestrated drape. The puncture site is at the outermost point of the lateral angle of the anterior fontanel. The skin is fixed with the left index finger and thumb, while a 7-8 gauge injection needle with a shorter bevel is used in the right hand to insert vertically 0.25–0.5 cm. When the resistance of the dura mater disappears and a sense of loss is felt, the subdural space is reached, and fluid can be seen flowing out. The amount sent for examination generally does not exceed 1 ml. If there is bloody, purulent, or yellow exudate, 15–20 ml can be slowly drained. For therapeutic purposes, fluid can also be drained from the other side.
3. After the procedure, remove the needle, disinfect, and apply pressure for 2-3 minutes to check for continued bleeding or cerebrospinal fluid leakage. Then cover with gauze and secure with adhesive tape.

(VI) Pericardiocentesis
Primarily used to extract fluid for testing to determine the nature of the disease when pericardial effusion is present. In cases of large effusion with cardiac tamponade symptoms, the purpose is decompression therapy. It is also used for purulent pericarditis to expel pus, perform irrigation, or administer medication.

1. The amount of effusion is determined based on X-ray, ultrasound, and physical examination of cardiac borders. Two common puncture sites are available for clinical selection: (1) Left thoracic puncture point: Located 2 cm medial to the left midclavicular line in the 5th intercostal space, within the cardiac dullness border. Insert the needle along the upper edge of the 6th rib, slowly advancing inward and backward toward the spine. (2) Subxiphoid puncture point: Positioned below the junction of the xiphoid process and the left costal margin, at a 45° angle to the chest wall, slowly advancing upward and backward to reach the base of the pericardium.
2. For older, cooperative children, a semi-recumbent position or sitting on a chair facing the operator is suitable. Infants can straddle the assistant's thigh, with the assistant securing the child. After marking the puncture site, disinfect the skin routinely. The operator wears gloves and places a sterile drape. Administer 1% procaine anesthesia, first intradermally, then subcutaneously and into the pericardial membrane. With the left index finger and thumb stabilizing the puncture site, the right hand holds the pericardial needle and advances slowly. A reduction in resistance or a "give" sensation indicates entry. Open the hemostat, attach a syringe, and aspirate for fluid. If a pulsation is felt, stop advancing. For drainage, repeat the process, then withdraw the needle, disinfect, cover with sterile gauze, and secure with tape.
3. During the procedure, advance the needle slowly and limit fluid extraction to 100 ml for testing. If the child appears pale, sweaty, or dyspneic, stop the puncture, lay the child flat, administer oxygen, or take other appropriate measures.

(VII) Bone Marrow Aspiration
Primarily used for diagnosing hematologic and related diseases, as well as detecting pathogens such as Rebing and malaria, or performing bone marrow culture for suspected bacterial infections. Common puncture sites in children include the iliac crest, lumbar spinous process, and tibia.

1. Anterior superior iliac spine puncture is suitable for children over 2 years old. The child lies supine or semi-lateral, stabilized by an assistant. The puncture site is the widest ridge of the iliac crest posterior to the anterior superior iliac spine. After routine skin disinfection, the operator wears gloves and places a sterile drape. Administer 1% procaine anesthesia, first intradermally, then subcutaneously to the bone membrane. Stabilize the skin with the left index finger and thumb, and hold the puncture needle (length fixed at 1-15 cm) with the right hand, inserting vertically. Upon contacting bone, advance with a rotating motion until a "give" sensation indicates entry into the marrow cavity. The needle should be fixed in the bone without wobbling. Remove the stylet, attach a dry syringe, and aspirate 0.2-0.3 ml of marrow. The child may feel pain during aspiration, so proceed quickly. After withdrawal, disinfect and apply pressure, cover with sterile gauze, and secure with tape. Immediately place the marrow on a slide, spread rapidly, and dry. The presence of small fat droplets confirms marrow extraction.
2. For lumbar spinous process puncture, position the child laterally or seated backward on a chair, similar to thoracentesis. Select the 2nd to 4th lumbar spinous processes. After routine disinfection and anesthesia, stabilize the skin with the left index finger and thumb, and insert the needle vertically. The rest of the procedure is the same as for iliac crest puncture.
3. Tibial puncture is safer, mainly for children under 2 years old. The child lies supine with legs slightly apart, a sandbag placed under the upper calf of the puncture side, and the assistant stabilizes the knee and ankle. Expose the upper 1/3 of the tibia, disinfect, and anesthetize. The puncture site is 1 cm below the tibial tuberosity on the anteromedial side. Insert vertically; the rest is the same as for iliac crest puncture.