1. Cardiovascular Emergencies
Serious cardiovascular emergencies in children are uncommon in the out-of-hospital setting. Pediatric cardiovascular emergencies may be the result of volume loss, vascular instability, cardiac failure, output obstruction, or a combination of any or all of these. Regardless of the type of cardiovascular emergency, early recognition and management can reduce the likelihood of serious morbidity or mortality.

2. Objectives
Understand the causes and management priorities of bradycardia in children.
Identify risk factors for serious causes of syncope in children.
Describe the resuscitation and stabilization of a child presenting with cardiopulmonary failure.
List the strategies for prevention of submersion injuries in infants and children.
Read the slide.

3. Case Presentation
You are called to a suburban home for toddler found submerged in backyard pool.
A sobbing mother is performing CPR on 15-month-old girl on pool deck.
As you take over resuscitation, the mother tells you, “The phone rang; I was only gone for 5 minutes!”
Read the slide.
Ask this question: “What is your first response?
Quickly perform the PAT. In this patient, it will consist of checking for the presence or absence of spontaneous respiratory efforts and taking over the resuscitation from the caregiver.

4. General Assessment: PAT
Appearance
Unconscious, unresponsive;
poor muscle tone
Work of Breathing
No spontaneous respirations
Read the slide.
PAT:
Appearance: no spontaneous movements and poor muscle tone.
Breathing: no chest movement, no spontaneous respiratory effort.
Circulation: peripheral and central cyanosis suggesting circulatory compromise.
Circulation to Skin
Ashen, cyanosis of hands and lips
What is your general impression?

5. General Impression and Management Priorities
Sick: respiratory arrest; possible cardiorespiratory failure
Unresponsive, apneic, abnormal circulation to skin
Physiologic problem: global hypoxemic–ischemic event
Immediate management:
Start oxygenation and ventilation while assessing for spontaneous circulation.
She needs immediate resuscitative support.
She is definitely in respiratory arrest and may be in cardiopulmonary arrest as well. Further assessment of heart rate and pulse quality will determine the precise physiologic problem.
Ventilatory support must be initiated immediately while continuing the assessment of circulation.

6. Initial Assessment: ABCDEs
Airway — patent
Breathing —good air movement with bag-mask ventilation; wet crackles on auscultation
Circulation — HR 20; femoral pulse barely palpable; capillary refill > 5 seconds; BP not obtained
Disability — pupils dilated, sluggishly reactive; unresponsive to pain
Exposure — no bruises, no signs of injury
What is your overall assessment?
Read the slide.

7. Case Progression Cardiopulmonary failure due to hypoxemia.
Chest compressions are indicated for HR < 60.
No evidence of associated injuries.
Consider spinal injury.
Less likely in toddler submersion than with adolescent diving injury.
Consider nonaccidental trauma.
No “red flags”
What are your management priorities?
Although a cervical spine injury would be unusual in an accidental toddler pool drowning, spinal stabilization should be part of airway management pending further evaluation.
Central pulses are weak but palpable, with profound bradycardia confirmed on auscultation. Cardiac output at this rate is insufficient to support core perfusion. Continue compressions to support circulation.
NOTE: The only exception to this is when there is severe hypothermia (e.g., a child falls through the ice and is submerged in the water).

8. Management Priorities
BLS:
Place on spine board.
Open airway; begin bag-mask ventilations, 100% 02.
Perform chest compressions.
Dry to prevent further heat loss/hypothermia.
ALS:
IV access, consider endotracheal intubation.
Epinephrine, 0.01 mg/kg IV/IO, or 0.1 mg/kg by endotracheal tube; repeat every 3–5 minutes.
Profound bradycardia in a child—especially in a setting like this one—is most commonly due to hypoxemia, rather than a primary cardiac event. Initial treatment is therefore focused on restoring adequate oxygenation and ventilation. Epinephrine is the drug of choice for the treatment of symptomatic bradycardia if heart rate does not quickly respond to assisted ventilation with supplemental oxygen.
Ask this question: “Do you want to stay or go?”

9. Transport Decision: Stay or Go?
BLS:
Rapid transport to nearest appropriate ED.
Continuous reassessment for return of pulse and circulation en route.
ALS:
Transport after airway/ventilation is secure, IV/IO access is established, and the first dose of epinephrine is given.
Do not delay transport if vascular access fails.
BLS: after cardiac compressions and ventilatory support are established, rapid transport to the nearest ED is appropriate.
ALS: the decisions to perform endotracheal intubation before transport is dependent on the adequacy of bag-mask ventilations, the transport time, and the comfort level of the care provider in performing intubation on a toddler. Vascular access should be attempted, but do not delay transport if there is difficulty obtaining IV or IO access.
For both BLS and ALS providers, close monitoring during transport is important to identify the return of adequate circulation.

10. Key Concepts: Bradycardia
Treatable causes of bradycardia with poor perfusion:
Hypoxemia
Hypothermia
Hypovolemia
Heart block
Toxins, poisoning, drugs
Tampondae, cardiac
Tension pneumothorax
Trauma (Head injury)
Because this patient was found submerged, hypoxemia is the most likely cause of her bradycardia. Hypoxemia is the most common cause of symptomatic bradycardia and cardiac arrest in children.
Hypothermia should be considered if the patient was pulled from cold water. Attention to keeping the infant warm and in a neutral thermal environment during resuscitation and transport is critical. Wet clothing should be removed and the skin kept dry and warm during transport.
Although there are no signs of trauma, this was an unwitnessed event, and head injury should be considered. Other possible traumatic causes include tension pneumothorax and hypovolemia.
Bradycardia from a heart block is rare in children without underlying heart disease, but a rhythm strip should be examined for evidence of block.
The presence of a heart block would be an indication for use of atropine. When in doubt, there is no harm in giving atropine at 0.02 mg/kg IV/IO (may repeat once), but atropine would not be expected to improve heart rate or cardiac output in a patient with bradycardia due to hypoxemia. [ET dose is 0.03 mg/kg; flush with 5 mL of saline and follow with five ventilations.]

11. Key Concepts: Bradycardia with Submersion Event
Bradycardia in near-drowning reflects significant hypoxia and myocardial ischemia.
The brain and other vital organs may also have suffered ischemic injury.
Rapid support of ventilation and oxygenation will reduce the risk of secondary injury.
The drug of choice is oxygen, followed by epinephrine.
Prolonged submersion results in a global hypxic–ischemic insult, with potential for multiorgan system failure.
Bradycardia reflects cardiac ischemia and can be considered a prearrest rhythm. The outcome is poor if the patient is asystolic on arrival of EMS.
Immediate oxygenation and ventilation will give the infant the best chance for a good outcome.
Consider atropine if the heart rate does not respond to adequate compressions and epinephrine.
Cardiac pacing is not an effective treatment for bradycardia caused by hypoxemia.

12. Key Concepts: Drowning Prevention
Pool drowning prevention:
Close supervision
Four-sided pool fence
Self-locking gate
Pool alarms
Open water drowning prevention:
Supervision of all age groups.
Use of personal floatation devices.
Educate teens about dangers of alcohol and water sports.
Risk awareness, as toddler drownings may occur in shallow water.
Toddler drowning is a predictable and preventable event.
Supervision is an important strategy to prevent submersion injuries, and toddlers should never be left alone near a pool, lake, or even the bathtub. However, relying on caretakers for constant vigilance is not the most effective injury prevention strategy.
Many locales have laws that require fences and self-locking gates around home pools — this takes the “human factor” out of prevention.
Risk factors for adolescent drowning are different and mirror those of young adults. Head injury due to diving and drowning due to intoxication while boating or swimming come into play in this age group.
Awareness of risk is critical — a toddler can drown in a 5-gallon bucket or in the bathtub. Supervision and environmental mitigation can help to prevent these senseless deaths.

13. Key Concepts: Injury Prevention
Multiple strategies are necessary for an effective injury prevention program.
Passive strategies
Legislative action
Enforcement of laws
Education
A variety of strategies are necessary for a successful injury prevention program. Interventions that do not rely on individual motivation tend to have the greatest impact.
Passive strategies “force” the “risk-taking” individual to be protected from injury.
A good example is four-sided fencing and self-locking gates around home pools.
Airbags are another design intervention that saves lives.
Legislation can be a powerful tool for motivating behavioral change to prevent injury.
Laws mandating use of automobile seatbelts, car booster seats, bike helmets, or personal floatation devices in small watercraft send a powerful message.
Legislation is ineffective unless there is enforcement.
Although some will comply with a law simply because it is on the books, a fear of citations will bring along many stragglers!
Education alone, because it relies on individual motivation, is a relatively weak injury-prevention strategy. Still, in combination with other initiatives, it is an important part of an injury prevention campaign.
Prehospital providers can be effective advocates for injury prevention. Your credibility in the community and first-hand experience in dealing with preventable injuries and deaths equip you for a leadership role when safety initiatives are being promoted.

14. Case Progression
Oxygen provided by bag-mask device, compressions continued.
After 30 seconds, the heart rate increases to 80 per minute and compressions are discontinued.
After 1 minute, the heart rate is 120 per minute; spontaneous respirations return.
Read the slide.

15. Case Progression En route: Supplemental oxygen is delivered by mask.
Blankets are applied to prevent heat loss.
Even in warm water drowning, children — with their high body surface area to mass ratio — lose a tremendous amount of heat. The rate of heat loss in water is 32 times that in air. Most near-drowning victims will experience some degree of hypothermia. Attention to the prevention of heat loss is an important transport consideration. If you are not sweating, the ambulance is not warm enough!

16. ED Course
In the ED:
The child shows progressive improvement in level of consciousness, asking for her mommy.
She remains hemodynamically stable.
SaO2 is 94% on 100 % O2, and chest X-ray shows diffuse infiltrates.
She is admitted to the pediatric intensive care unit and transferred to a ward the next morning.
Diagnosis: near drowning; pulmonary edema
Outcome: weaned from oxygen on day 2; home on day 4 with normal neurologic exam.
A near-drowning victim who is successfully resuscitated in the field has an excellent chance of a good outcome.
Children whose mental status returns to baseline in the field or in the ED are unlikely to develop late neurologic complications. However, late pulmonary complications can occur.

17. Summary
Submersion results in hypoxia, leading to bradycardia, tissue ischemic injury, and eventually, cardiac arrest.
Early oxygenation and ventilation are the most effective ways to restore spontaneous circulation.
Prehospital management is a major determinant of outcome in children with submersion injury.
Submersion injuries are predictable — prevention is the best treatment!
Read slide and review important concepts.
The duration of submersion and time to return of spontaneous circulation are key determinants of outcome in a pediatric submersion victim.
The brain is very sensitive to hypoxia, and neurologic sequelae are the most frequent and serious complications of near drowning.
Early, effective oxygenation and ventilation are the treatments most likely to lead to a successful resuscitation and a good long-term prognosis.
The best treatment of drowning is prevention.

18. Case Presentation
You are dispatched to a middle-school athletic field for a child with loss of consciousness.
A 13-year-old boy is lying on the grass, receiving CPR by his coach.
The coach tells you that the child collapsed while running for a ball, and that “this has happened before.”
What is the first thing you will do on arrival?
Read the slide.
Ask the group, “What is the first thing you will do on arrival?”

19. General Assessment: PAT
Work of Breathing
No spontaneous respirations
Appearance
Unresponsive
Review the PAT.
This adolescent is unresponsive with no ventilatory efforts and has pale, cyanotic skin.
Ask the question, “What is your general impression?”
Circulation to Skin
Pale, cyanotic
What is your general impression?

20. General Impression and Management Priorities
Sick: cardiopulmonary failure
Scenario suggests primary cardiac event.
Management:
BLS: apply AED.
ALS: “quick look” on monitor/defibrillator.
Read the slide.

21. Initial Assessment: ABCDEs
Since this was a witnessed collapse, attach the AED as soon as available.
Airway: patent
Breathing: no chest movement
Circulation: absent pulses, no heart sounds; shockable rhythm on AED, ventricular fibrillation (VF) on monitor
Disability: unresponsive to pain
Exposure: no bruising or signs of injury
What is your overall assessment?
If this was an unwitnessed arrest, begin CPR for 2 minutes (five cycles) before AED rhythm analysis.

22. Case Progression VF cardiac arrest Possible mechanisms:
Primary cardiac disease
Trauma (direct blow to precordium)
Toxin/drugs
What are your management priorities?
Primary cardiac arrest is uncommon in the pediatric population. In most situations, cardiac arrest in children is the result of severe hypoxemia or shock.
Only about 10% of children in whom a terminal rhythm is recorded are in VF.

23. Management Priorities
BLS:
Establish absence of respirations, pulse.
Turn on AED.
Attach AED electrode pads.
Analyze rhythm.
Shock if advised, then resume CPR immediately for five cycles (2 minutes).
If no shock is advised, resume CPR for five cycles (2 minutes).
Check for signs of circulation and rhythm every 2 minutes and repeat sequence from analyze rhythm.
Read the slide.

24. Management Priorities
ALS: BLS priorities plus:
Place on monitor, check rhythm.
Defibrillate.
2 joules/kg
Resume CPR for five cycles (2 minutes), check rhythm; if VF, defibrillate with 4 joules/kg.
Resume CPR immediately.
Intubate, secure airway (optional).
Obtain vascular access.
Epinephrine 0.01 mg/kg (1:10,000) IV or 0.1 mg/kg ETT (1:1000); repeat every 3-5 minutes.
After five cycles (2 minutes); check rhythm. If shockable:
Defibrillate (4 joules/kg).
Consider antiarrhythmic.
Lidocaine 1mg/kg IV/IO/ET
Amiodarone 5 mg/kg IV/IO
ALS providers may recognize VF on the AED or on a monitor-defibrillator. Standard cardiac resuscitation protocols should be followed, regardless of age.
Defibrillate with AED or with up to three successive shocks at 2 joules/kg.
If VF persists, give epinephrine IV/IO at 0.01 mg/kg (0.1 mL/kg of 1:10,000) or 0.1 mg/kg via ET tube (0.1 mL/kg of 1:1,000).
After epinephrine is given, resume CPR for five cycles (2 minutes); check rhythm and if shockable, defibrillate at 4 joules/kg.
If VF still persists, consider antiarrhythmics.
Lidocaine at 1 mg/kg bolus IV/IO/ET
Amiodarone at 5 mg/kg bolus IV/IO
Consider magnesium 25 to 50 mg/kg (maximum 2 g) for torsades de pointes.

25. Transport Decision: Stay or Go?
Stay on scene and treat until a pulse is established or the child is asystolic.
As in adults, the outcome is strongly linked to resuscitation in the field.
Survival statistics are poor for a child brought to the ED in asystole.
Cardiac arrest is one situation where the potential benefits of on scene treatment clearly outweigh the potential risks of prolonged scene time.

26. Key Concepts: Ventricular Fibrillation
Airway management and correction of hypoxia while making rhythm diagnosis is critical.
Although pediatric VF is uncommon, early recognition and treatment improve the chance of successful resuscitation.
Early defibrillation increases the survival rate.
Increased availability and use of AEDs in community can improve outcomes for both pediatric and adult VF victims.
Ventricular fibrillation is an uncommon arrest rhythm in in children with no history of heart disease.
Studies have reported VF in 3% to 20% of pediatric and adolescent cardiac arrest victims, with the highest incidence in teens.
The age of the pediatric patient, the cause of arrest, the time to EMS response, and the presence or absence of bystander CPR all impact VF rates in different studies.
Although early defibrillation is the cornerstone of treatment of VF, hypoxia must also be corrected. Once initial shocks have been delivered, attend to airway and ventilation.
Bystander CPR is associated with improved survival for VF, and the increasing availability and use of AED’s in the community should lead to further improvements in outcome.
With regard to AED use in children, the American Heart Association recommends the following:
“Automated external defibrillators (AEDs) may be used for children 1 to 8 years of age who have no signs of circulation. Ideally, the device should deliver a pediatric dose. The arrhythmia detection algorithm used in the device should demonstrate high specificity for pediatric shockable rhythms; that is, it will not recommend delivery of a shock for nonshockable rhythms.”
Currently, there is insufficient evidence to support a recommendation for or against the use of AEDs in children less than 1 year of age.
For a lone rescuer responding to a child without signs of circulation the recommendation is based on whether the collapse is witnessed or not. For a witnessed collapse, phone (and get the AED). If the collapse is not witnessed, open airway, check breathing, begin CPR (30 compressions : 2 breaths) then call
Defibrillation is recommended for documented ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT).

27. Key Concepts: High-risk Groups/Causes for VF
Cardiomyopathies
Coronary artery abnormalities:
Post-Kawasaki disease aneurysms, thrombi
Congenital anomalies
Direct blow to chest
Dysrhythmia syndromes
Cardiomyopathies — congenital or acquired — are the most common cause of sudden death in young athletes and children. There are many causes of cardiomyopathy, including familial, metabolic problems, drugs, toxins, and infection.
The most common cause of acquired heart disease in children is Kawasaki Disease, which causes coronary aneurysms and thrombosis. More than 20% cases of Kawasaki disease may go unrecognized in the acute phase, presenting later with chest pain, syncope, and dysrhythmia, including VF.
A direct blow to the chest can cause an electrical impulse that can, in rare instances, cause VF (commotio cordis).
Long QTc syndrome is a hereditary cause of often fatal dysrhythmia.

28. Key Concept: Identifying Cardiac Syncope
Most fainting spells are benign, but “red flags” can identify serious cardiac causes.
Was the episode associated with chest pain?
Was there a brief or absent aura?
Were there palpitations prior to fainting?
Did it occur during exercise?
Is there a family history of sudden death?
Fainting spells are common and often result in an EMS call for help. Most are benign and due to orthostatic changes, or vagal response.
Cardiac causes of syncope, even when there is a quick return to normal mental status, require immediate medical attention. A dysrhythmia may be transient and convert to normal sinus rhythm (NSR) without treatment.

29. Case Progression At scene:
Rescue breathing and cardiac compressions started.
AED shows VF — converted to NSR on second shock.
Vascular access obtained
En route:
Lidocaine bolus 1 mg/kg IV and then 20 micrograms/kg/min infusion or bolus every 15 minutes
Continues in sinus rhythm
Read the slide.

30. ED Course In the ED: Lead 2 rhythm strip shows QTc = 0.52
The mother arrives and reports three prior brief episodes of exercise-associated syncope; sudden death at the age of 28 in uncle.
Outcome: child diagnosed with long QTc syndrome. A pacemaker is placed. The patient is discharged neurologically intact 5 days later.
Long QTc syndrome is characterized by a sudden loss of consciousness during stress or exercise and can lead to cardiac sudden death. A history of sudden death at a young age in a family member may be a tip-off.

31. Summary Most episodes of syncope in children are benign.
Ventricular fibrillation is a rare cause of loss of consciousness in pediatrics.
Early recognition of VF and defibrillation improve survival rates.
When VF is diagnosed, standard cardiac resuscitation protocols should be followed, regardless of the age of the patient.
Read the slide.

32. Summary
The primary cause of cardiopulmonary arrest in children is severe hypoxia associated with respiratory failure.
Asystole or profound bradycardia is the most common arrest rhythm on EMS arrival.
Rapid intervention and return of vital signs in the field are associated with good outcome.
Patients with ventricular fibrillation who have return of sinus rhythm have good survival rates.
Children with asystole as the presenting rhythm on scene rarely survive.
Review the slide and emphasize that most arrests in children are a result of respiratory arrest, and resulting hypoxia, not of primary cardiac etiology as in adults.
When unstable cardiac ventricular dysrhythmias occur, rapid treatment improves survival.