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Knowledge of cardiopulmonary resuscitation among pediatric emergency staff

Vanessa Fernandes BertoloI; Cléa Dometilde Soares RodriguesII; Rita de Cássia Helú Mendonça Ribeiro III; Claudia Bernardi CesarinoIV; Lara Helk SouzaV

I RN, Specialist in Emergency Care, Faculdade de Medicina de São José do Rio Preto. State of São Paulo, Brazil. E-mail:
IIAdjunct Professor, General Nursing Department, Faculdade de Medicina de São José do Rio Preto. State of São Paulo, Brazil. E-mail:
III Adjunct Professor, General Nursing Department, Faculdade de Medicina de São José do Rio Preto. State of São Paulo, Brazil. E-mail:
IVAdjunct Professor, General Nursing Department, Faculdade de Medicina de São José do Rio Preto. State of São Paulo, Brazil. E-mail:
VProfessor, Specialist in Pediatrics, Management and Hospital Management. Collective Health Nursing and professional orientation Department, Faculdade de Medicina de São José do Rio Preto. State of São Paulo, Brazil. E-mail:




This descriptive, cross-sectional, quantitative study assessed pediatric emergency staff’s knowledge of the new guidelines for cardiopulmonary resuscitation. Data were collected by questionnaire, in September 2011, from the 45 participants: 6 physicians, 10 residents and 7 medical interns, 8 nurses, 1 technician and 13 nursing auxiliaries of the pediatric emergency department at a teaching hospital in São Paulo State, 71.1% of whom responded that they knew the new guidelines. The question most often answered correctly was the main cause of pediatric cardiopulmonary arrest and the least often, the depth for chest compressions. It was concluded that the results demonstrated the need for continuous education interventions to improve the practice of the cardiopulmonary resuscitation.

Keywords: Cardiopulmonary resuscitation; pediatrics; care; child.




Cardiorespiratory arrest (CRA) is an unexpected and life-threatening event. During care, the team needs speed, efficiency, technical-scientific knowledge and technical skills. In addition, appropriate infrastructure and harmonious and synchronized teamwork is needed, with a view to reestablishment, limitation of suffering, recovery and minimal sequelae for the patient.

Human beings have been dealing with these situations since early times, always attempting to find the best way to set standards for an effective end result. Outdated and precarious care to CRA victims show disordered situations of procedures aimed at reestablishing life1.

In view of the above, the objective in this study was to assess the pediatric emergency health team's knowledge about the New Cardiopulmonary Resuscitation Guidelines-2010.


In the last 50 years, studies have been developed and improved at large research centers for the purpose of enhanced compliance with CPR and cardiovascular emergencies2.

In pediatrics, CRA is one of the most severe situations and puts the child's life at great risk. It is defined as the interruption of cardiac and respiratory mechanical activities. The diagnostic suspicion is based on the child's visual aspect. Absence of pulse in the large arteries indicates circulatory arrest, while unconsciousness and apnea or agonic respiration indicates respiratory arrest3.

The final consequence of a prolonged deterioration of the respiratory and/or circulatory functions culminates in cardiac arrest, an event that is hardly unexpected. Examples of CRA increase respiratory failure due to airway obstruction, pneumonias, accidents or traumas, drowning, respiratory depression due to toxic agents, intracranial hypertension, convulsions, among others2. Primary CRA predominates when it derives from the postoperative phase of congenital cardiac disease or sudden death associated with cardiac arrhythmias3.

The 2010 Guidelines of the American Heart Association (AHA) for cardiorespiratory resuscitation (CRR) and emergency cardiovascular care (ECC) are based on a large-scale literature review about resuscitation and different debates and discussions with international experts in an assessment process of evidence. This involves hundreds of scientists and members of the AHA's ECC Committee and Subcommittees from all over the world who assess, discuss and debate on thousands of publications4.



A descriptive and cross-sectional study was undertaken at the pediatric emergency service of a large teaching hospital in the interior of the State of São Paulo, which is a referral institution for patients from the Northwest of the State of São Paulo.

The sample consisted of individuals who worked in all shifts at the pediatric emergency service in September 2011: physicians (6), medical residents and interns (10), nurses (8), nursing technician (1) and auxiliary nurses (13) and who agreed to participate in the study after signing the informed consent form.

The data collection instrument was a self-applied questionnaire, aimed at measuring the participants' knowledge level about the recommendations contained in the New Cardiopulmonary Resuscitation Guidelines, the Guidelines of the American Heart Association-2010. The questionnaire, elaborated by the research, was based on the guidelines and contained two open and 11 closed questions. A pilot study was undertaken with 3 emergency pediatric care professionals from another hospital to test and adapt the instrument in terms of clarity.

Approval for this study was obtained from the Research Ethics Committee at Faculdade de Medicina de São José do Rio Preto (FAMERP), under protocol 4375/2011. The collected data were grouped according to the study objectives, typed in an electronic Microsoft Excel worksheet, analyzed according to descriptive statistics and presented as figures.



Among the 45 (100%) participants, 13 (28.9%) were auxiliary nurses, 10 (22.2%) medical residents, eight (17.8%) nurses, seven (15.6%) medical interns (taking the fifth and sixth course year), 6 (13.3%) physicians and one (2.2%) nursing technician.

Most respondents were female - 40 (88.9%), had graduated between zero and five years earlier – 26 (57.8%) and had between zero and five years of professional experience - 27 (60%).

As regards these professionals' knowledge on the New Cardiopulmonary Resuscitation Guidelines in pediatrics, most interviewees demonstrated knowledge about these guidelines - 32 (71.1%). It should be highlighted that, among the 12 persons (26.7%) who did not know the new guidelines, six (50%) were still students.

When asked about the main cause of CRA in pediatrics, 35 (77.8%) answered respiratory failure, while ten (22.2%) answered cardiac failure and/or both. The early recognition of emergency situations that can lead to respiratory or circulatory failure and prevent CRA is the most important issue3.

Nevertheless, the study found that the health professionals do not determine the presence or absence of pulse in infants or children for certain. The palpation of a pulse or its absence is not reliable as the sole determinant of cardiac arrest and the need for thoracic compressions. If the victim does not respond, does not breathe normally and there are no vital signs, the rescuer should start CPR. In infants and children, without vital signs, health professionals should start CPR unless they can certainly palpate the pulse within 10 seconds5.

Concerning the start of CPR in basic life support (BLS), 29 (64.4%) answered that, in pediatric BLS, CPR should start with compressions; 16 (35.6%) answered opening the airways and applying two breaths before the thoracic compression and/or following the A - B - C- D (opening airways – rescue breaths – thoracic compressions - defibrillation).

According to the New Guidelines, CPR should start with high-quality thoracic compressions. The change enhances the rescue and prioritizes the circulation 4. Formerly, a lot of time was lost to open the airways, compromising the neurological system due to lack of blood in the tissues. The compressions are fundamental for the cardiopulmonary resuscitation. Most pediatric CRA is due to asphyxia and/or shock associated with hypoxemia and acidosis3.

The C-A-B-D approach was adopted for victims of all ages to increase the chance of people present to execute CPR. It should also be reminded that delas or interruptions in the thoracic compressions reduce survival-4.

The thoracic compression concept is only attractive because it is easier to teach than conventional CPR, and immediate thoracic compressions can have a beneficial effect on resuscitation after sudden cardiac arrest caused by ventricular fibrillation (VF) or ventricular tachycardia (VT) without pulse. Evidences based on studies undertaken outside the hospital environment showed higher survival rates for children with CPA of non-cardiac etiology (arrest due to asphyxia), with more favorable neurological results when they received CPR (thoracic compressions with rescue breathing) when compared to children who only received thoracic compression. Nevertheless, thoracic compression along was equally effective and better than no CPR in case of cardiac arrest due to cardiac causes. It is also noteworthy that the same study showed that more than 50% of the children with cardiac arrest outside the hospital environment did not receive any CPR6.

The study subjects were also asked about when thoracic compression is indicated. Among all participants, 22 (48.9%) answered – when the heart frequency is inferior to 60 bpm (beats per minute) and 23 (51.1%) – when there is no cardiac frequency. The other question, with a higher error rate, was related to the depth of the thoracic compressions, 16 (35.55%) answered compressing about one and a half inch (4 cm) in babies and two inches (5 cm) in children; and 29 (64.45%) answered compressing at least two-thirds of the anterior-posterior diameter of the chest and/or compressing with sufficient strength to depress it until approximately one-third or half of its anterior-posterior diameter.

The evidences from radiological chest studies of children suggest that obtaining compression until half of the anterior-posterior diameter may not be possible. Effective thoracic compressions demand that strength be applied and, according to new data, the depth of about one and a half inch (4 cm) is recommended for most babies and two inches (5 cm) for most children4. Evidences from anthropometric measures in research show that, in children, the chest can be compressed to one-third of the anterior-posterior chest diameter without causing damage to intra-thoracic organs7.

The question regarding the compression/ventilation ratio for babies (non-neonates) and children when involving two health professionals was assessed as follows: 23 (51.11%) answered 15:2, while 22 (48.89%) indicated 30:2. The current guidelines request the start of CPR with 30 compressions when the rescuer is acting alone or 15 compressions when involving two health professionals3,8.

In addition, 26 (57.78%) respondents correctly answered the question about the procedure seeing, listening and feeling whether the child is breathing; 14 (31.11%) answered it incorrectly and 5 (11.11%) did not answer it.

This procedure was removed from the breathing assessment sequence after airway opening. As a result of the New Guidelines, CPR will be executed if the baby or child does not answer and is not breathing, starting with compressions4.

When asked about defibrillation and the use of an automated external defibrillator (AED) in babies, 13 (28.89%) gave correct answers, 29 (64.44%) wrong answers and three (6.67%) did not answer. Among those who gave wrong answers, 10 are auxiliary nurses, six nurses, three medical students, seven residents and three physicians.

More recent case reports suggest that the AED can be safe and effective in babies. As survival requires defibrillation when rhythms that can be defibrillated are present during the CPR, the administration of a high-load shock is preferable to no shock at all. In babies, the use of a manual defibrillator is preferred over an AED. In case none is available, the ideal is to use an AED equipped with a pediatric load buffer. And, if none of both is available, the AED without buffer should be used. It is important to mention that evidence supporting the safe use of AED in babies remains limited 4.

As regards the use of capnography or colorimetry, the majority, 25 (55.56%) respondents, gave correct answers. In the literature, however, the individuals do not know what a capnograph is or its use. Capnography is a method that permits assessing the carbon dioxide level present in the expiration. That is possible due to the reading of a device called capnograph, based on a sensor placed in the expiration branch. The monitoring of the exhaled CO2 generally confirms the positioning of the endotracheal tube in the airway and can indicate the incorrect placement/dislocation of the tube faster than the monitoring of the oxy-hemoglobin saturation. It can be useful during CPR to assess and optimize the thoracic compressions7.

On the question about the expected percentage of inspired oxygen saturation after the return of spontaneous circulation, 28 (62.22%) respondents gave correct answers, 15 (33.33%) wrong answers and two (4.45%) did not answer.

Due to increasing evidence on the possible harmfulness of high exposure to oxygen, a new recommendation was added to hold the inspired oxygen (in case appropriate equipment is available) after the return of spontaneous circulation, to maintain the oxy-hemoglobin saturation at 94% or higher, but inferior to 100%, to limit the risk of hyperoxemia4. There is no sufficient evidence to recommend any concentration of specific inspired oxygen for ventilation during resuscitation after a cardiac arrest in babies and children.

When asked about the first measure to take when they are confronted with a child having a cardiopulmonary arrest and no pulse, many respondents - 19 (42%) – could not answer. In this group, 42% belongs to the nursing area - five auxiliaries, one technician and two nurses – and 58% to the medical area – five students, three residents and three physicians. For the purpose of a better prognosis, children having a cardiopulmonary arrest and no pulse should be monitored immediately3.

To conclude the analysis of the questionnaire applied, two essay questions remained for evaluation, the first of which asked the professionals to mention drugs that can be used during pediatric cardiorespiratory resuscitation.

It should be highlighted that 40 (88.88%) respondents cited adrenalin as the preferred drug, and 5 (11.11%) left the question open. Among the professionals who answered, 20 also mentioned sodium bicarbonate, nine atropine, 6 sodium gluconate, 5 naloxone and volume expanders.

In addition, amiodarone and glucose were mentioned. Amiodarone can be used for refractory shock treatment of recurrent VF/VT without pulse in babies and children; if amiodarone is unavailable, lidocaine can be considered7.

As regards the medication therapy in CPR, for infants and children with refractory supraventricular tachycardia (SVT) with a palpable pulse, the recommendations indicate adenosine as the preferred drug. Verapamil can be considered an alternative treatment in older children, but should not be used routinely in infants. Procainamide or amiodarone administered through slow IV perfusion with careful hemodynamic monitoring can also be considered for refractory SVT.

The selection of the drug to improve the hemodynamics should be adapted to each patient's physiology and adjusted according to the changes in the clinical condition7.

No new recommendations were made regarding the use of drugs during cardiac arrest and bradycardia9.

In infants and children, the appropriate dose of IV adrenalin is 10 mcg / kg per dose (0.01 mg / kg) for the first and for subsequent doses. The maximum single dose is 1 mg.

No randomized controlled trials have been performed in infants and children about the use of sodium bicarbonate as part of pediatric cardiac arrest management. A multicenter retrospective study at a pediatric hospital discovered that sodium bicarbonate, administered during cardiac arrest, was associated with reduced survival, even after controlling for age, sex and after documenting the first appearance of the heart rhythm. Therefore, the New Guidelines emphasize that sodium bicarbonate should not be used routinely in pediatric cardiac arrest and without specific indications10.

The routine use of calcium for infants and children with cardiorespiratory arrest is not recommended without hypocalcemia, blocker of calcium overdose channels, hypermagnesemia, or hyperkalemia. Epinephrine can be used for infants and children with bradycardia and bad perfusion that do not respond to ventilation and oxygenation. Atropine can be administered for bradycardia caused by increased vagal tonus or toxicity of cholinergic drugs. There is not sufficient evidence to support or reject the routine use of atropine for pediatric cardiac arrest. It is appropriate to monitor the blood glucose levels and avoid hypoglycemia, as well as sustained hyperglycemia after cardiac arrest7.

Concerning the most influential change the New Guidelines entailed for pediatrics, according to the health professionals: most of the respondents - 18 (40%) – mentioned the inversion in the care sequence from ABC to CABD. According to them, starting care with compressions, prioritizing the circulation, was the greatest adaptation. The change in the ventilation/perfusion index was also mentioned.

Only three (6.7%) inappropriate answers were observed. One of them indicated that the main change was related to the airway opening; another the improvement in care to children having a cardiopulmonary arrest and, finally, one answer indicated the treatment of children with multiple traumas. Twenty four (53.3%) people left this question unanswered.

A research on life support involving secondary school students also verified the lack of knowledge on the CPR steps. School education and training of multipliers are fundamental for damage reduction11.

A study of professionals working in CPR showed precariousness as a hampering factor, while the team's knowledge in CPR care appeared as a facilitator 12. These findings differ from the present study.



The following study limitations are highlighted: a single research field, the employees' difficult adherence to complete the questionnaire and the small sample size, which impede the generalization of the data.

These research results demonstrated that the new CPR Guidelines, launched in October 2010, were not implemented in practice, demanding permanent education interventions in the pediatric emergency health team for the purpose of effective CPR.



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Direitos autorais 2015 Vanessa Fernandes Bertolo, Cléa Dometilde Soares Rodrigues, Rita de Cássia Helú Mendonça Ribeiro, Claudia Bernardi Cesarino, Lara Helk Souza

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