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Although the principles of cardiopulmonary resuscitation are the same in adults and children, the causes of cardiopulmonary arrest are usually different. Cardiopulmonary arrest in children is usually not due to a primary cardiac problem2. In addition, arrest rhythms are different. Outside-the-hospital ventricular fibrillation associated with coronary artery disease is the most common arrhythmia in adults1. The most common arrhythmias in children are asystole or bradyarrhythmias associated with respiratory failure and hypoxia or hypovolemic shock2,3.
The American Heart Association and the American Academy of Pediatrics have developed Pediatric Advanced Life Support (PALS) courses, which are excellent hands-on reviews of the recognition and management of cardiopulmonary failure in children. The emphasis is on recognition and aggressive intervention in the attempt to prevent cardiac arrest, since the prognosis of asystole in children is very poor. Physicians and others who work in emergency rooms and other settings where sick children are treated should take such a course. We have found that even experienced emergency physicians and pediatricians may find it helpful.
Brian Nolan, M.D.
George Zureikat, M.D.
Michigan State University College of Human Medicine
Flint, MI 48502
References
David A. Paulus, M.D.
University of Florida College of Medicine
Gainesville, FL 32610
References
C. Dennis Thron, M.D.
Dartmouth Medical School
Hanover, NH 03755
Daniel C. Wing, M.D.
Community Care Center
Lebanon, NH 03766
To the Editor: Drs. Nolan and Zureikat are certainly correct that my review dealt with the management of typical cardiopulmonary arrest in adults because, as I stated, "Sudden cardiac death outside the hospital is most often caused by ventricular fibrillation in patients with multivessel atherosclerotic coronary artery disease." Their comments about the causes of arrest in the pediatric population are well known and accepted. As an instructor in Pediatric Advanced Life Support, I heartily support their recommendation that physicians and nurses who are likely to encounter sick children be encouraged to take the course.
Dr. Paulus is indeed correct. In published studies, end-tidal measurements of carbon dioxide have been reported in units of concentration or partial pressure. This error occurred during the editing process. The volume of carbon dioxide may be more reflective of blood flow in the setting of changing or variable ventilatory tidal volume, as would be expected in cardiopulmonary resuscitation.
Dr. Thron's comments are interesting. With regard to increasing diastolic filling, Ditchey and Lindenfeld have shown that intravenous volume loading during cardiopulmonary resuscitation worsens the coronary perfusion pressure primarily by raising the right atrial pressure1. It is unlikely that passive leg raising would have a substantial effect on intraabdominal pressure. Our group evaluated the effect of raising intraabdominal pressure on perfusion pressures during cardiopulmonary resuscitation in a canine model. A thigh-fitting air-filled bladder inflated to 80 mm Hg had to be used to produce substantial hemodynamic changes2.
With respect to "plumber's helper" cardiopulmonary resuscitation, now referred to as the active compression-decompression technique, I would refer Dr. Wing and other interested readers to two recent articles3,4. This is clearly a promising technique in need of further study. A clinical, multicenter trial is currently in progress.
James T. Niemann, M.D.
Harbor-UCLA Medical Center
Torrance, CA 90509
References
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