Definition

Cardiorespiratory arrest occurs when both the heart and breathing stop. This condition disrupts the oxygen flow to the brain, which can lead to brain damage in just a few minutes. Without oxygen, organs and tissues in the body begin to die. The damage progresses quickly within 4 to 10 minutes after cardiorespiratory arrest, and if not addressed, it can result in death.

In children, cardiorespiratory arrest is most commonly caused by respiratory failure or airway blockages. Sudden cardiac arrest due to irregular heart rhythms is less common in children compared to adults, unless there are specific conditions such as severe chest injuries or congenital heart disease.

Prompt emergency response, including cardiopulmonary resuscitation (CPR) or the use of an automated external defibrillator (AED), can help restore the heart's normal rhythm and function.

Causes

The causes of cardiorespiratory arrest in children include respiratory problems, heart conditions, infections, and trauma or injury. Respiratory issues are the most frequent causes, such as respiratory infections, asthma, respiratory failure, choking or aspiration of foreign objects, and drowning.

Infections that can cause cardiorespiratory arrest include sepsis, a blood infection, and meningitis, an inflammation of the brain’s membranes. Heart-related causes include congenital heart defects, severe chest injuries, arrhythmias (irregular heart rhythms), and cardiomyopathy (heart muscle diseases). Trauma causes include blunt force head or chest injuries, drowning, and child abuse.

Other causes include Sudden Infant Death Syndrome (SIDS), which accounts for 42% of cases, and Sudden Unexpected Infant Death Syndrome (SUID). In infants, cardiorespiratory arrest is often due to lack of oxygen from causes like choking or drowning.

Risk Factor

Several factors increase the risk of cardiorespiratory arrest in children, including:

• Congenital heart disease
• Heart rhythm disorders, these are especially common after surgery to fix heart defects or in those with a weakened heart
• Rapid and abnormal heart rhythm
• Undiagnosed heart conditions
• Obesity and hypertension
• Exposure to drugs, toxins, infections, or illegal substances
• A severe blow to the chest, especially over the heart, can cause commotio cordis (a type of cardiac arrest)
• A history of heart disease, unexplained fainting or seizures, or sudden death before age 50 in the family can increase the risk.

Symptoms

In children experiencing cardiorespiratory arrest, key signs include respiratory failure, unresponsiveness to stimuli, and loss of consciousness. There may be minimal or no visible breathing, with the child possibly gasping for air. The pupils will not react to light and will be widely dilated. Seizures may also occur due to lack of oxygen.

Warning signs of sudden cardiac arrest are often present in 30-50% of cases, but they are frequently overlooked or misunderstood. These warning signs include:

• Chest pain or discomfort, especially with physical exertion

• Unexplained fainting, particularly if it happens repeatedly

• Seizures without an obvious cause

• Dizziness or feeling lightheaded

• A rapid or pounding heartbeat

• Excessive fatigue or shortness of breath

• Chest pain or changes in activity tolerance after a viral infection

• A history of heart murmurs that were unexplained

• A history of high blood pressure or heart treatment

• Restricted physical activity due to heart issues

Diagnosis

Given the urgent nature of the situation, the examination of symptoms and medical history is conducted quickly and efficiently. This process should be carried out alongside the evaluation of the airway, breathing, and blood circulation, as these are critical elements that need immediate attention.

A lack of oxygen can lead to low blood pressure, shortness of breath, and a slow heart rate, which can disrupt the heart’s electrical activity, eventually causing it to stop.

As the condition worsens, the patient becomes unresponsive, struggles with breathing, and may exhibit occasional gasping. The patient’s response to verbal or physical stimuli diminishes, and the pulse becomes difficult to detect in major blood vessels such as the neck or thighs. Blood flow in the capillaries, which can be checked using a capillary refill time test, is also impaired. Additionally, the pupils dilate and no longer respond to light.

To assess if any electrical activity remains in the heart, an electrocardiogram (ECG) is performed. To determine the cause of the cardiac arrest, laboratory tests such as blood gas analysis, lactate levels, electrolyte balance, glucose levels, and a complete blood count may be conducted. Radiological tests and core body temperature checks are also performed based on the suspected cause.

Management

A child cannot survive without oxygen for 8-10 minutes during cardiac arrest. Therefore, immediate cardiopulmonary resuscitation (CPR) is crucial to provide oxygen to the brain and other vital organs. CPR, or cardiopulmonary resuscitation, is a life-saving procedure used when both the heartbeat and breathing cease. It must be performed as soon as possible by the person who first encounters the patient for optimal results.

If you encounter a child or baby with an obstructed airway, the first step is to clear the airway. If the cause of the arrest is unclear, start CPR immediately.

Before initiating CPR, consider the following steps:

• Ensure the environment is safe.

• Check the child’s level of consciousness.

• If the child is unconscious, gently pat or shake the shoulder and loudly ask, "Are you okay?"

• If the child is unresponsive and no one is around, call for help by dialing the emergency number before starting CPR. If an Automated External Defibrillator (AED) is available, retrieve it.

• In cases where there are two rescuers, one should call the emergency number and retrieve the AED, while the other starts CPR.

• Once the AED is connected, it will assess the heart rhythm, deliver shocks as needed based on the AED’s instructions, and CPR should continue.

There are slight differences in CPR techniques depending on the age group of the child. For children older than one year, the procedure is similar to adult CPR. CPR typically involves three stages: compression, airway management, and breathing assistance. The compression stage helps restore blood circulation. The airway stage ensures the airway is clear, while the breathing stage provides oxygen to the patient. One complete cycle of CPR consists of both chest compressions and respiratory assistance.

Compression stage

• If you are alone and did not witness the child’s loss of consciousness, perform 5 cycles of CPR (about two minutes) before calling the emergency number and retrieving the AED.

• If you are alone and witnessed the loss of consciousness, call the emergency number, retrieve the AED, and then begin CPR. If there are two rescuers, one should call the emergency number and get the AED, while the other starts CPR.

• Position the child on their back on a flat, firm surface.

• In children older than 1 year and adolescents, use both palms stacked for chest compressions. If the child is small, use one hand. In infants under 1 year, use two fingers for compression.

• Chest compressions should be applied in the center of the chest, at the nipple line.

• For children older than 1 year, compress the chest to a depth of about 5 cm. In adolescents, the compression depth should range between 5 and 6 cm. In infants, compress the chest to a depth of 4 cm, using care.

• Perform chest compressions at a rate of 100-120 compressions per minute, while counting each compression aloud. If you are untrained, continue chest compressions until medical help arrives or the child regains consciousness. If you are trained, proceed to the airway and breathing stages.

Airway stage

• The goal of the airway stage is to clear the child’s airway.

• After performing 30 chest compressions, open the child’s airway using the head-tilt and chin-lift method.

• Place one hand on the child’s forehead and gently tilt the head back. With the other hand, lift the child’s chin to open the airway.

• Do not tilt the head if there is a suspected neck or head injury.

Breathing stage (rescue breathing)

• After opening the airway, proceed with rescue breathing.

• In children, pinch the child’s nostrils closed and cover their mouth with yours to provide 2 rescue breaths.

• In infants, cover both the baby’s mouth and nose with your mouth. Use gentle cheek muscle pressure to slowly blow air into the baby’s mouth.

• Ensure that the child’s chest rises during the breaths. If the chest does not rise after the first breath, repeat the head-tilt and chin-lift method to clear the airway.

• Avoid overinflating the lungs or blowing too forcefully.

• If the chest still does not rise, continue chest compressions.

• After performing 30 chest compressions, give 2 rescue breaths. If there are two rescuers, give 2 rescue breaths after every 15 chest compressions.

• If an AED is available, follow its instructions, deliver one shock, and continue CPR.

Continue CPR until the child regains consciousness or medical assistance arrives.

Complications

The primary complication of cardiorespiratory arrest is death due to the lack of oxygen supply to the body. However, CPR itself can cause complications, such as chest injuries, broken ribs, chest pain, or collapsed lungs.

Despite these potential side effects, performing CPR remains critical. The side effects of CPR can be addressed once the child’s life has been saved.

Prevention

Preventing cardiac arrest in children includes both primary and secondary prevention strategies.

Primary prevention

Primary prevention involves actions taken before an event occurs. To reduce the likelihood of sudden cardiac arrest, it is important to identify risk factors and provide early treatment. This includes screening children with known risk factors, family histories, or symptoms that could indicate heart issues. Early treatment might involve medications, lifestyle changes, or the use of defibrillators.

Secondary prevention

Secondary prevention focuses on preventing death after a child has experienced sudden cardiac arrest. This includes CPR, the use of AEDs, and possibly implantable defibrillators (ICDs).

When to See a Doctor?

If your child displays any of the warning signs or symptoms of cardiac arrest, seek medical help immediately or take the child to an emergency facility. If cardiac arrest occurs, perform CPR and call for medical assistance without delay.

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