Dhimitri Nikolla, DO
AHN Saint Vincent Hospital, Erie, PA
Pediatric cardiopulmonary arrest (PCA) is a rare event; it occurs out-of-hospital in about 8.04 per 100,000 person-years compared to 126.52 per 100,000 person-years in adults . As expected, the mortality is high; one study found one month survival of pediatric out-of-hospital cardiac arrest (OHCA) to be 10.5%, while another study found survival to discharge of pediatric in-hospital cardiac arrest (IHCA) to be 31.3% [2,3]. Achieving higher rates of survival is dependent on many factors in the chain of survival, but the performance of good quality cardiopulmonary resuscitation (CPR) has been shown to be directly associated with survival. In this article, we will define quality CPR in the pediatric patient, review some studies linking certain aspects of CPR with survival in PCA, and review some adjuncts to improve CPR performance.
When a PCA occurs, we often dedicate a tremendous amount of time and resources to give that child the best chance at survival. Despite this, the quality of CPR delivered in PCA is frequently poor even at a major pediatric hospital [4,5]. As seen in Tables 1 and 2, “Excellent CPR” for the pediatric patient is defined as CPR that meets the recommended targets for all the following variables: compression rate, depth, fraction, and residual leaning force . Despite professional training and the addition of real-time audiovisual feedback, “excellent CPR” occurs as little as 8% of the time . Recent changes in the American Heart Association (AHA) guidelines for pediatric CPR reflects the recent literature on these CPR performance variables and will hopefully translate into improved PCA outcomes.
Table 1 Definitions of Pediatric CPR Performance Variables 
|Compression Rate||Number of compressions per minute|
|Compression Depth||Depth of each compression|
|Compression Fraction||Percent of time during the resuscitation that compressions are taking place without interruption|
|Residual Leaning Force||Percent of compressions with more than 2.5kg of residual weight from leaning on the chest between compressions|
Table 2 Definition of “Excellent CPR” for the Pediatric Patient 
|Residual Leaning Force||<20%|
COMPRESSION RATE AND DEPTH:
The AHA has recently placed an upper limit on their recommended chest compression rate for pediatric CPR; the new recommendation is a rate of 100-120/min . Like many therapies in pediatric medicine, this recommendation was extrapolated from the adult literature. Idris, et al. found in their prospective, observational trial of 6,399 adults in OHCA that a compression rate of 100-120/min was associated with the highest survival to discharge. Surprisingly, higher rates were associated with worse survival to discharge, and about 25% of arrests had average compression rates ≥120/min. A possible explanation for this was that excessive compression rates were associated with reduced compression depths. In the compression rate category of 120-139/min, half of patients had depths <38mm .
Although the Idris, et al. study did not include children, a recent observational trial of 89 PCAs by Sutton, et al. found that average chest compression depths of ≥ 51mm were associated with improved 24-hour survival compared to depths <51mm . Since compression rates in simulated pediatric CPR can be too high up to 39% of the time, it is reasonable to place an upper limit on compression rates to preserve adequate compression depths since depth is associated with survival in PCA . However, compression depths that are too deep can also be harmful.
Hellevuo, et al. found in 170 adult patients who experienced IHCA that compression depths >6cm were associated with increased frequency of iatrogenic injuries. Injuries found included rib fractures, sternal fractures, hematoma or rupture of the myocardium, splenic injury, stomach injury, mediastinal bleeding, and pneumothorax . Although this study was conducted in adults, it is reasonable to assume that children would be at the same or greater risk of iatrogenic injury with these excessive depths. Therefore, the AHA placed an upper limit on their recommended chest compression depth for pediatric CPR. The new recommendations are depths of 4cm in infants, 5cm in children, and at least 5cm in adolescents but no greater than 6cm .
COMPRESSION-ONLY VS CONVENTIONAL:
Although compression-only CPR has been recommended for lay rescuers resuscitating adults, the AHA continues to recommend conventional CPR with compressions and ventilations for PCA [6,11]. Goto, et al. found in their observational study of 5009 pediatric OHCA a significantly greater one-month survival in pediatric patients who received conventional CPR compared to compression-only . Although the literature on this topic is limited to observational trials with many limitations and confounding variables, the findings are largely consistent across studies [2,12]. In addition, the majority of PCAs have a non-cardiac, likely pulmonary, etiology, compared to adults making conventional CPR with ventilations theoretically superior [2,6,12].
METRONOME AND FEEDBACK DEVICES:
While metronomes deliver signals to guide chest compressions and ventilations, feedback devices measure variables such as compression rate and depth, and simultaneously provide real-time feedback to the providers. Data on the use of metronomes and CPR feedback devices in PCA is limited. Adult studies have found improved quality of chest compressions, but no association with patient outcomes [13,14]. Zimmerman, et al., in their simulated pediatric CPR manikin study, found a significant improvement in the percentage of compressions with an adequate rate without a change in depth. This was primarily due to a reduction in the percentage of compressions that were too fast: 39% without the metronome to 21% with the metronome . Similarly, Sutton, et al. found a significant improvement in the percent of chest compressions at the target rate and the percent of time “excellent CPR” was delivered when a feedback device was used during eight pediatric IHCA .
Although these devices improved pediatric CPR performance variables, the quality of CPR is often still imperfect. It is unclear why, but several factors may impede metronome and feedback device efficacy including provider fatigue, distractions, and lack of training or familiarity with the devices [9,15]. Despite these limitations the AHA does recommend use of feedback devices in pediatric CPR when available .
Good quality CPR is essential to improve survival in PCA; however, the delivery of pediatric CPR is often poor quality. Recent literature associating new compression rate and depth targets with survival has prompted new AHA recommendations. Although studies are limited in PCA, metronomes and feedback devices are reasonable adjuncts to improve pediatric CPR quality, but their efficacy has limitations as well.
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