Pediatric Resuscitation

Introduction

The etiology, pathophysiology, and outcomes from pediatric cardiopulmonary arrest are distinct from those seen in adults.¹ Cardiac arrest occurs much less frequently in children than it does in adults. While survival has improved dramatically over the past 20–30 years, several key factors such as prompt recognition, adherence to pediatric-specific resuscitation guidelines, and high-quality post-resuscitation care and monitoring affect the likelihood of a good quality of life after an arrest.¹ A critical intervention in pediatric nursing is recognizing the precipitating factors for cardiac arrest and intervening early to prevent it. If an arrest does occur, the child’s survival and an excellent post-arrest outcome are linked to nurses’ expert performance of pediatric-specific resuscitation interventions. The purpose of this article is to promote excellence in nurses’ early detection of deterioration, outline the latest evidence-based pediatric resuscitation nursing interventions, and describe the process of expert post-arrest nursing care that ensures the best possible patient outcome.

Discussion

Detecting Decompensation in Children

A review of the data across a pediatric safety collaborative suggests that 16% of in-hospital pediatric resuscitations are a result of failing to detect decompensation in a timely fashion and escalate care.² Detecting decompensation early in children is difficult, as children are often unable or willing to report their symptoms. Their physiology allows for a prolonged period of stable decompensation before a rapid decline occurs. Nurses are the primary providers of ongoing patient surveillance. Nurses collect subjective and objective assessment data, interpret and synthesize that data, and then determine potential interventions and threats to their patients’ health and safety. Therefore, it is not surprising that efforts to detect decompensation in children as early as possible focus on nursing surveillance and assessment.

Table 1 lists the typical clinical manifestations of decompensation found in children. Standardized early warning triggers and tools, such as the Pediatric Early Warning Score (PEWS) and its variants³, and the Rothman Index (RI)⁴ or other prediction algorithms exist to assist nurses and other caregivers identifying patients that are beginning to show signs of decompensation. The components of these standard tools are also noted in Table 1. While the PEWS requires an active assessment and input of a score by the nurse and the RI uses nursing data entered into the Electronic Medical Record (EMR) to generate its score, the goal of both tools is to translate subjective and objective nursing assessment data into a number that is meaningful to the care team and inspires action.

Table 1:

Clinical Signs of Decompensation and Early Warning / Trigger Tools

System	Sign	Early vs. Late Sign	Included in Tool or Trigger System
Neurologic	Change in Level of Consciousness / Behavior	Early	PEWS Rothman Index
	Fever / Temperature	Early	PEWS Rothman Index
	Pain	Late	PEWS
Respiratory	Respiratory Rate	Late	PEWS Rothman Index
	Work of Breathing	Early	Rothman Index
	Oxygen Saturation	Late	PEWS Rothman Index
	Receiving Oxygen Therapy	Late	PEWS Rothman Index
	Airway Clearance Problems	Early	PEWS Rothman Index
	Lab Results	Early	Rothman Index
Cardiac	Systolic Blood Pressure	Late	PEWS Rothman Index
	Pulses	Early	PEWS Rothman Index
	Capillary Refill Time	Early	PEWS Rothman Index
	ECG Rhythm	Late	Rothman Index
	Lab Results	Late	Rothman Index
Integumentary	Skin Color	Early	PEWS Rothman Index
Other Subjective Assessments	Staff Concern	Early	PEWS
	Family Concern	Early	PEWS

Note: “PEWS” denotes to the “original” PEWS score and its validated variants, such as the CHEWS, CCHEWS, etc.

A recent systematic review of the validity and effectiveness of the plethora of early warning systems and trigger tools suggests in general that they are very good at predicting transfers of patients to the intensive care unit, but that they often overestimate the child’s decompensation, which may lead to inappropriate transfers and alarm fatigue.⁵ Another potential issue with scoring tools is that nurses do not score the same patient the same way consistently.⁵ Most studies of the ability of these tools to effectively decrease mortality or cardiorespiratory arrest events have methodologic concerns, which limits their ability to demonstrate benefit.⁵ Evidence does suggest that these triggers and tools are appropriate and evidence-based additions to a comprehensive nursing surveillance plan that focuses on identifying the signs and symptoms of clinical decompensation in children as early as possible.

Identification of Acute Decompensation

Assessment Principles

Timely recognition and response to pediatric decompensation is vital to improve cardiac arrest outcomes. A standardized approach to rapid assessment and intervention is an essential component of most formal life support courses such as the American Heart Association’s (AHA) Pediatric Advanced Life Support (PALS). Throughout the assessment process, when a life-threatening problem is identified, appropriate interventions are initiated immediately. The first step in this standardized approach is a general observational assessment. The Pediatric Assessment Triangle (PAT) is a tool that was designed to standardize the rapid evaluation of infants and children for all levels of healthcare providers. It helps to establish the level of severity and prioritize the treatment needed. The PAT consists of three components: appearance, work of breathing, and circulation of the skin.⁶ A primary assessment, including vital signs, should follow the PAT. The primary assessment is a hands-on evaluation that focuses on the airway, breathing, circulation, disability, and exposure. The secondary assessment is performed next, including a focused history and detailed physical examination with ongoing reassessment.⁷ Table 2 presents a summary of the key clinical assessment findings in acute pediatric decompensation.

Table 2:

Key Clinical Assessment Findings for Acute Decompensation

Respiratory Distress	Increase in respiratory effort Tachypnea Accessory muscle use Retractions Abnormal airway sounds wheezing Stridor Change in level of consciousness
Respiratory Failure	Inadequate respiratory effort Apnea Bradypnea Hypoxemia despite supplemental oxygen Cyanosis Decreased level of consciousness Bradycardia
Shock	Signs of impaired perfusion Weak central pulses Diminished peripheral pulses Prolonged capillary refill Cool mottled skin Hypotension Tachycardia Oliguria Altered mental status
Cardiovascular Compromise or Cardiac Arrest	Changes in Heart Rate or Rhythm Tachycardia Bradycardia Arrhythmia Weak or absent pulse Hypotension Signs of shock Decreased level of consciousness Sudden collapse

Management Principles

Pediatric resuscitation management should follow evidence-based recommendations such as those outlined in the American Heart Association Pediatric Advanced Life Support (PALS) guidelines.⁷ The American Heart Association (AHA), in cooperation with the International Liaison Committee on Resuscitation (ILCOR), update these guidelines based on a continuous evidence evaluation process, and publish focused updates.

• High-Quality Cardiopulmonary Resuscitation (CPR) and Rapid Defibrillation

  • High-quality CPR is the cornerstone of pediatric resuscitation. Current American Heart Association guidelines emphasize the importance of rapid recognition of cardiac arrest, immediate initiation of high-quality chest compressions, and delivery of effective ventilations.⁸ In pediatric patients, this involves compressions that are 1/3 the anterior-posterior depth of the chest, at a rate of 100–120 compressions per minute and allow for good chest recoil.⁸ When providing CPR without an advanced airway, the ratio of compressions to ventilations for pediatric patients is 30:2 for single-rescuer and 15:2 when multiple rescuers are present.⁸ When performing CPR on infants and children with an advanced airway present, 1 breath should be delivered every 2–3 seconds while providing continuous compressions.⁸ When providing respirations, clinicians must avoid excessive ventilation, and ventilation volume should produce no more than visible chest rise.⁹
  • Defibrillation: Clinicians must initiate rapid defibrillation for ventricular fibrillation and pulseless ventricular tachycardia (VF/pVT) without delay. The shorter the duration of VF/pVT, the more likely the shock will result in a perfusing rhythm.⁸ Manual defibrillators are preferred to Automated External Defibrillators (AEDs) in infants and children because the energy dose can be titrated to the patient’s weight.⁸ In infants and children, the initial defibrillation dose is 2 joules/kg and 4–10 joules/kg for subsequent defibrillation attempts.⁸
  • Physiologic and quality monitoring during CPR: Although not required, when available, the team may utilize additional monitoring modalities to assess the quality of CPR. Arterial blood pressure monitoring may be beneficial for evaluating blood pressures achieved during resuscitation. End-tidal carbon dioxide monitoring may also indicate CPR’s effectiveness and the return of spontaneous circulation (ROSC).⁸ CPR feedback devices may also improve the quality of compressions performed.⁸

• Airway

Respiratory Distress

Prompt recognition and management of respiratory distress in children is essential, as respiratory distress can lead to respiratory arrest, which, if left untreated, can lead to cardiac arrest. Interventions to manage respiratory distress include general principles to ensure a patent airway and deliver oxygen as needed. Nurses may accomplish this by repositioning, suctioning, or administering supplemental oxygen via nasal cannula or face mask. When the cause of respiratory distress is identified (asthma, pneumonia, or croup, for example), children will require specific interventions based on the nature and severity of clinical symptoms.

Respiratory Failure

Since most pediatric cardiac arrests are caused by respiratory failure, airway management is a resuscitation priority. This may be accomplished by bag-mask ventilation (BMV) or placement of an advanced airway. When performed correctly, BMV may be as effective as ventilation through an advanced airway for short periods. During cardiac arrest, the benefits of an advanced airway include the ability to provide uninterrupted compressions, monitor CPR effectiveness/ROSC via end-tidal CO2 monitoring, and decrease aspiration risk. However, placement of an advanced airway in a pediatric patient requires specialized equipment and training. A recent systematic review of literature¹⁰ concluded that there is insufficient evidence to suggest improved survival to hospital discharge following placement of an advanced airway (tracheal tube or supraglottic airway) during cardiac arrest in children. The current recommendation of the 2019 American Heart Association Focused Update on Pediatric Advanced Life Support states that BMV is reasonable compared with advanced airway interventions in managing children during cardiac arrest in the out-of-hospital setting.¹¹ No recommendation was made for or against the use of an advanced airway for in-hospital cardiac arrest (IHCA) management.¹¹ The recommendations also note that the team should consider transport time, provider skill level, and equipment availability to select the most appropriate airway intervention. If BMV is ineffective despite proper techniques, more advanced airway interventions should be considered.¹¹

• Shock

Rapid identification and treatment of pediatric shock is a priority as untreated shock can progress to cardiac arrest. Shock is defined as a physiologic state characterized by inadequate tissue perfusion to meet metabolic demand and tissue oxygenation. Shock states can be classified by type of shock, including hypovolemic, cardiogenic, distributive, and obstructive. The most common type of pediatric shock is hypovolemic, including shock due to bleeding.⁸

Hypovolemic shock occurs due to decreased intravascular volume. This may be due to fluid losses from vomiting and diarrhea, burns, hemorrhage or inadequate fluid intake. Cardiogenic shock is a result of myocardial dysfunction and may be caused by congenital heart disease, cardiomyopathy, myocarditis or arrhythmia. Distributive shock occurs in states that result in decreased systemic vascular resistance that leads to inadequate blood flow. Septic shock, anaphylactic shock and neurogenic shock are all examples of distributive shock. Obstructive shock refers to conditions that impair flow of the blood to or from the heart, resulting in decreased cardiac output. Pericardial tamponade, tension pneumothorax and pulmonary embolism are all examples of obstructive shock⁷. Multiple types of shock may co-occur⁸ and it is important to identify the type of shock to direct treatment.

The severity of shock may be categorized as hypotensive or compensated (normal systolic blood pressure with inadequate tissue perfusion). In children, compensatory mechanisms such as tachycardia and vasoconstriction are often present. As compensatory mechanisms fail, patients may develop hypotension, decreased mental status and reduced urine output. Hypotension is a late sign of most types of shock and may indicate impending cardiac arrest.⁷

Treatment of shock includes supporting the airway, oxygenation, and ventilation, establishing vascular access, and providing fluid resuscitation while monitoring, reassessing, and providing medications as indicated to treat the underlying cause. Fluid resuscitation is a priority in treating most types of shock; however, clinicians must take caution to administer adequate volume while avoiding fluid overload. Generally, fluid resuscitation involves administering isotonic crystalloid as a 20mL/kg bolus administered over 5 to 20 minutes.⁷ Exceptions to this are 10–20mL/kg for septic shock and 5–10mL/kg over 10–20 minutes for cardiogenic shock⁷. Patients with signs of shock should be reassessed after each fluid bolus to assess fluid responsiveness and signs of volume overload.⁸

Management of cardiogenic shock differs from other types of shock. Rapid boluses or large volumes may worsen cardiac function and increase the risk of pulmonary edema. Cardiogenic shock is caused by myocardial dysfunction, so management should be directed at improving cardiac output by increasing the efficiency of ventricular ejection while minimizing myocardial demand.⁷ Some children with cardiogenic shock have a high preload and do not require additional fluid administration, while others may require cautious fluid administration to optimize preload. Fluid administration may include smaller fluid boluses of 5–10ml/kg administered over 10–20 minutes with close assessment and stopping the infusion if deterioration occurs. Afterload reduction is an effective way to increase stroke volume, but hypotensive patients may require fluid therapy and inotropic support to tolerate afterload reduction⁷. Vasodilators, inotropes and inodilators may be administered in cardiogenic shock to reduce peripheral vascular resistance and/or improve contractility⁷. In a normotensive child in cardiogenic shock with evidence of pulmonary edema, diuretics may be indicated. A pediatric critical care or pediatric cardiology specialist should be consulted to guide therapy for cardiogenic shock⁷.

Additional treatment of shock states must be initiated based on the identified type of shock. The Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children¹² outlines essential components for the management of patients in septic shock. Key elements of these guidelines include the prompt administration of antibiotics as soon as possible and within 1 hour of sepsis recognition and administration of vasoactive infusions in patients with signs of low perfusion despite fluid administration.¹²

• Vascular Access

During pediatric decompensation, vascular access is critical for the administration of medications and intravenous fluids. Pediatric vascular access can be challenging, especially in the setting of cardiac arrest or altered perfusion. When the team cannot rapidly obtain intravenous access, intraosseous (IO) cannulation can be a safe and reliable vascular access method in children and infants. When placed correctly, IO catheters can administer IV fluids, blood products, and medications. In certain circumstances, such as cardiac arrest, IO may be the initial vascular access attempted.⁷

• Estimating Patient Weight

In pediatric resuscitation, most medication doses and intravenous fluid volumes are weight-based. A team member should record an accurate weight in kilograms in the patient’s medical record.¹³ Pediatric patients may present in settings where a precise weight is unknown or unable to be obtained. When an exact weight cannot be obtained using traditional methods, height-based weight estimation tools such as the Broselow Pediatric Emergency Tape^™ are often used. The Broselow Pediatric Emergency Tape^™ is a standardized tape that is placed flat next to the patient, with one end aligned to the top of the head. When positioned next to the patient, the area on the tape adjacent to the heel is used to determine an estimated weight of the patient based on the height. This card also includes color-coded emergency medication dosing and equipment sizing based on the height estimate. Code carts and equipment storage can also be organized based on this color-coded system. Benefits include the ability to use the tape without interruption of resuscitation efforts and ease of use. Potential disadvantages of this method include the inability to factor in body habitus, especially in the obese patient population.¹⁴

• Medications and Supplies

A well-organized emergency supply cart with pediatric-specific equipment and medication dosing guides should be available in settings where pediatric patients are treated. Supplies must be available in sizes to accommodate pediatric patients treated in that area. Clinicians may use color-based coding systems to ensure proper equipment and correct medication dosing based on patient weight.¹³

During pediatric resuscitation, accurate drug administration is a critical skill that has the potential for error due to high stress and the need for weight-based calculations in the pediatric population. Standardized concentrations and medication dosing systems that minimize calculations may reduce the likelihood of medication errors.¹³ Comprehensive bedside medication dosing reference tools like those shown in Figures 1 & 2 containing information on drug dilution, preparation, and volume to administer are more likely to result in accurate drug administration.¹⁵

Figure 1:

Single Drug Reference Sheet with Multiple Patient Weights

Figure 2:

Specific Sheet for Each kg of Body Weight

Drugs administered during pediatric resuscitation will vary depending on circumstances, but epinephrine and antiarrhythmics are often administered in cardiac arrest. Epinephrine is administered to optimize cardiac perfusion and restore spontaneous circulation during cardiac arrest.⁸ Current recommendations state that it’s reasonable to administer epinephrine every 3–5 minutes during cardiac arrest, with the initial dose being given within 5 minutes of the start of chest compressions.⁸ For shock refractory ventricular fibrillation or ventricular tachycardia, Lidocaine or Amiodarone may be administered.⁸

• Team Dynamics and Communication

Pediatric resuscitation requires a multidisciplinary team of providers to work together to achieve optimal outcomes effectively. The team leader and all team members must establish clear roles and responsibilities, be aware of limitations, offer constructive interventions, and share information.⁷ Communication techniques such as closed-loop communication, speaking clearly and calmly, and displaying mutual respect⁷ must be demonstrated during pediatric resuscitation. One observational study by El-Shafy and colleagues¹⁶ found that the use of closed-loop communication can increase the speed and efficiency of task completion in the pediatric trauma resuscitation setting. Resuscitation teams should utilize simulation-based training programs in all settings where pediatric patients receive care.

• Extracorporeal Cardiopulmonary Resuscitation (ECPR)

ECPR refers to the rapid deployment of extracorporeal membrane oxygenation (ECMO) to support tissue perfusion when conventional CPR is not effective in achieving ROSC.¹⁷ In pediatrics, ECPR is used most frequently after postoperative in-hospital cardiac arrest (IHCA) associated with congenital heart disease and low cardiac output or arrhythmias.¹⁸ Current AHA recommendations state that ECPR may be considered for pediatric patients with cardiac diagnoses who have IHCA in settings with existing ECMO protocols, expertise, and equipment.⁸ There is insufficient evidence to suggest for or against the use of ECPR for pediatric patients experiencing out of hospital cardiac arrest (OHCA) or pediatric patients with noncardiac disease experiencing IHCA refractory to conventional CPR.⁸

• Cessation of Resuscitation

The decision to terminate the team’s resuscitation effort for a child is often complicated and challenging. Many factors are considered in the decision to terminate resuscitation. These may include medical factors, such as the duration of the arrest, resuscitation mechanics, cause of the arrest, patient prognosis, or non-medical considerations such as parent-related factors or provider beliefs.¹⁹ In children, there are no concrete guidelines on when to terminate resuscitative efforts, which may lead to increased uncertainty and distress for providers involved in the resuscitation.

Family Presence

Current research supports the option for families to be present at the bedside during pediatric resuscitation.^13,20–22 The American Academy of Pediatrics, American College of Emergency Physicians, American Association of Critical-Care Nurses, and Emergency Nurses Association all currently endorse family presence during resuscitation.²³ In pediatric resuscitation, benefits of family presence may include comfort to the patient, increased parental satisfaction, increased parental sense of control, and improved coping and acceptance of death.^20,24

When family members are present at the bedside during a resuscitation, a staff member not directly involved in the resuscitation efforts must be assigned the role of facilitator. The facilitator should remain with the family and act as a liaison between the family and the healthcare team.²⁰ All healthcare team members should be aware that the family is present and regular updates provided regarding interventions and ongoing care. Any behavior that is disruptive or obstructs care may warrant removal from the clinical area.²⁰ Families should also have the option to leave the bedside and return as needed.²⁰

Post Resuscitation Care and Monitoring

The goals of post resuscitative care include:

• Diagnose and treat the underlying cause of the arrest

• Minimize secondary injury to the heart and brain

• Support end-organ perfusion and functioning

After ROSC, the pediatric patient is at high risk for reperfusion injuries, secondary brain injuries, and ventricular arrhythmias from myocardial dysfunction and hypotension. This period requires a coordinated multidisciplinary approach where nurses play a crucial role, with particular attention paid to oxygenation and ventilation, hemodynamics, temperature and seizure control, and glucose and electrolytes management. Table 3 further describes general issues of concern, goals, interventions, and monitoring parameters for pediatric patients in the post resuscitative phase of care.

Table 3.

Post Resuscitation Concerns and Monitoring Parameters

Area of concern	Goals/interventions	Monitoring parameters
Oxygenation Hypoxemia Hyperoxemia	Deliver adequate oxygen (based on underlying condition) Minimize ongoing oxidative stress	Oxygen saturation (SpO2) Arterial blood gas (PaO2)
Ventilation Hyperventilation Hypoventilation	Normal ventilation, based on age and illness	Capnography/End-tidal CO2 Arterial blood gas (PaCO2) Chest radiograph
Cardiovascular support Hypotension Inadequate perfusion	Blood pressure >5th percentile for age Fluid resuscitation Inotropic agents* Vasopressors* Afterload reducers*	ECG monitoring NIRS monitoring Arterial blood pressure Central venous pressure (CVP) Central venous oxygen (SvO2) Serum lactate Urine output Echocardiogram
Temperature management Hyperthermia Hypothermia	Avoid hyperthermia (>38°C) Correct hypothermia (<32°C) Consider induced hypothermia (32°−34°C) or controlled normothermia (36° to 37.5°C), depending on the arrest etiology	Continuous core temperature monitoring (rectal, bladder, esophageal)
Neurologic support Seizures	Prevent, identify and treat seizures	EEG monitoring Brain imaging
Glucose/electrolyte management Hypoglycemia Hyperglycemia Metabolic derangement	Normalize blood sugar and electrolytes	Blood glucose Serum lactate Serum electrolytes Creatinine Complete blood count Coagulation profile

ECG – Electrocardiogram; EEG – Electroencephalography; NIRS – Near-Infrared Spectroscopy

^*The patient’s underlying cardiac function and pathology will help determine optimal drug therapy

Both hypoxia and hyperoxia have been associated with poor neurologic outcomes in children^25,26 because the brain does not tolerate ischemia, hyperemia, or edema, and clinicians should avoid these conditions. Inadequate or inappropriate ventilation can affect the brain. For example, hyperventilation with resultant hypocapnia can cause cerebral vasoconstriction and low perfusion, while hypercapnia may lead to cerebral vasodilation that contributes to increased intracranial pressure.

From a cardiovascular perspective, hypotensive shock is common after ROSC, as is myocardial stunning from increased production of inflammatory mediators and nitric oxide.^26,27 Arrhythmias, including bradycardia, can occur after ROSC. Early hypotension after successful resuscitation is associated with increased mortality.^26,28,29 Management strategies for hypotension include fluid resuscitation, and inotropic and vasopressor administration, with goals of adequate blood pressure (systolic blood pressure greater than the fifth percentile for age), adequate oxygen delivery, and evidence of sufficient blood flow to the heart, brain, and other organ systems.^8,30 When possible, clinicians should monitor the patient’s blood pressure continuously.

Hyperthermia is common after cardiac arrest and is associated with worse outcomes.³¹ Targeted temperature management (TTM) after cardiac arrest has received a great deal of attention in both pediatric and adult populations. Induced hypothermia is a strategy that maintains the patient’s temperature between 32 and 34 degrees Celsius. A second strategy, called controlled normothermia, has a temperature goal of 36 degrees to 37.5 degrees Celsius. The THAPCA-OH and THAPCA-IH randomized controlled trials sought to determine the effect of induced hypothermia versus controlled normothermia on neurologic outcome after pediatric cardiac arrest that occurred either in or out of the hospital^32,33 The results from these trials found no differences in neurologic outcome at one year and therefore, the evidence does not support one temperature management strategy over the other. For children who remain comatose after cardiac arrest, current recommendations are to aggressively prevent hyperthermia (>38 degrees Celsius) and severe hypothermia (<32 degrees Celsius) while maintaining the patient at either a targeted temperature of 32–34 degrees Celsius, followed by a temperature of 36 to 37.5 degrees Celsius, or only a targeted temperature of 36 to 37.5 degrees Celsius.⁸ Regardless of the temperature management strategy initiated, the nurse should continuously monitor the patient’s core temperature.⁸

There is little published evidence about interventional strategies for glucose control following pediatric cardiac arrest, and both hyper and hypoglycemia can be detrimental in the post resuscitative phase of care.³⁴ the patient’s blood sugar closely and derangements corrected. There are no recommendations to guide a specific serum glucose goal. Still, patients whose target is lower (80–100 mg/dL) are more likely to experience severe hypoglycemia (<40 mg/dL) than patients with a higher target of 150–180 mg/dL.³⁵ Additionally, a lower serum glucose target has not been shown to improve outcomes.³⁵ Metabolic derangements can occur both as a result of and as a cause of cardiac arrest and organ dysfunction. Serum electrolyte concentrations should be monitored and kept within appropriate limits.

Seizures can occur after ROSC, and they increase metabolic demand while contributing to increased intracranial pressure and secondary brain injury. Because of this, the etiology of any seizure should be evaluated and corrected, and the team should treat clinical seizures. Seizures may be subclinical and not detected unless the patient is monitored with continuous electroencephalography (cEEG).^26,36 Such monitoring as soon as possible for encephalopathic patients following ROSC and should remain in place for 24 to 48 hours.⁸ For patients undergoing hypothermia treatment, cEEG should be used until the patient has returned to normothermia for 24 hours.³⁷

Outcomes

Outcomes for children who require cardiopulmonary resuscitation can vary significantly along a continuum from full recovery to severe neurologic disability to death. The chances of survival and a meaningful recovery are better for in-hospital versus out-of-hospital arrest and unwitnessed arrest.^38,39 Other factors that are associated with poor outcomes are summarized in Box 1. For out-of-hospital arrests, those that are witnessed with early dispatcher-assisted bystander CPR, which has an initial shockable rhythm, and ROSC within 20 minutes can potentially improve outcomes.¹⁸

Box 1. Factors Associated with Poor Outcomes after Resuscitation.

• Out-of-hospital arrest

• Unwitnessed arrest

• Longer duration of Cardiopulmonary Resuscitation

• Cause of arrest (e.g., hypoxic injury, such as drowning)

• Pre-existing medical conditions

• Presence of a non-shockable rhythm

Avoiding the need for resuscitation in the first place is one key to improving patient outcomes. Clinicians can accomplish this with early identification that the patient is decompensating while initiating interventions to prevent arrest. In the inpatient setting, tools that can help identify patient decompensation, like the PEWS, are available.⁴⁰

From an outpatient perspective, an increasing number of medically-complex children living outside the hospital require technology such as tracheostomy tubes and home ventilation. These children are at risk for airway compromise that can lead to cardiac arrest. Parents and caregivers in the home need specialized training to recognize distress and initiate airway management interventions, such as suctioning and changing the tube, if there is concern for obstruction or decannulation.⁴¹ They should also be prepared to perform additional basic life support measures, like chest compressions, while awaiting help from emergency medical services (EMS). Local EMS should be informed when a child with specialized medical needs lives in their community. Additional strategies for emergency response in the home include having an emergency bag available with items such as a resuscitation bag and mask, extra tracheostomy tubes and obturators, and suction catheters.⁴²

Because pediatric resuscitation is a relatively rare event, team members do not have many opportunities to practice resuscitation skills in real-time. As such, multidisciplinary healthcare members need education and refresher training to maintain competency in basic and advanced life support skills. In addition to hands-on skills, team members should practice behavioral skills that enhance leadership and communication skills.⁴³ Modalities for resuscitation training include high-fidelity in situ simulation training and mock code training in the patient care environment.⁴⁴ Some devices provide real-time CPR feedback on compression rate and depth, which can improve CPR quality. However, the effect on patient outcomes is unknown. Evaluating team performance after resuscitation events with structured debriefings can identify areas for improvement.^45,46 Improved training experiences can translate to improved patient outcomes, although more research is needed in this area.^44,47,48 Family caregivers of medically-complex children also benefit from CPR training and high-fidelity simulation of tracheostomy and ventilator-related emergencies.⁴⁹

Summary

Preventing a cardiac arrest event in a child is the first and most crucial step in pediatric resuscitation. Most pediatric cardiac arrests result from respiratory failure and its resulting physiologic decompensation; therefore, nurses must be skilled at detecting and intervening when decompensation is present in children. Once an arrest occurs, adherence to the AHA’s PALS guidelines⁷ are essential along with attention to team dynamics, supporting weight-based dosing delivery using standardized bedside reference sheets, supporting family presence, and introducing ECMO when appropriate. Once the child has survived an arrest, post-resuscitation care includes monitoring oxygenation and ventilation, supporting normal hemodynamics, performing temperature and seizure control, and managing glucose and electrolytes in concert with the pediatric medical team is also critical. Children who experience a cardiopulmonary arrest will have the best possible outcome if their care team is well-trained and prepared, and evidence-based practices are followed. There are increasing numbers of medically complex children living in community settings; therefore, the care team must train parents and caregivers in basic life support. The emergency medical services in the area should also be aware of the child’s needs before an event occurs.

KEY POINTS.

1. The cause of pediatric cardiopulmonary arrest differs in etiology and pathophysiology from adults.

2. Early detection of clinical decompensation can prevent most pediatric cardiopulmonary arrest in children.

3. Pediatric resuscitation management should follow the American Heart Association’s Pediatric Advanced Life Support Recommendations.

4. Post-resuscitation nursing care includes monitoring oxygenation and ventilation, supporting hemodynamics, temperature and seizure control, and managing electrolytes.

5. Outcomes after cardiopulmonary arrest can be optimized by a clinician training regimen that includes basic and advanced life support skills, behavioral skills to enhance leadership and communication, and the use of high-fidelity clinical simulation training.

SYNOPSIS.

This article describes evidence-based nursing practices for detecting pediatric decompensation and prevention of cardiopulmonary arrest and outlines the process for effective and high-quality pediatric resuscitation and post-resuscitation care. Primary concepts include pediatric decompensation signs and symptoms, pediatric resuscitation essential practices, and post-resuscitation care, monitoring, and outcomes. Pediatric-specific considerations for family presence during resuscitation, ensuring good outcomes for medically complex children in community settings, and the role of targeted temperature management, continuous electroencephalography, and the use of extracorporeal membrane oxygenation in pediatric resuscitation are also discussed.