In contrast to adults, cardiac arrest in infants and children does not usually result from a primary cardiac cause. More often it is the terminal result of progressive respiratory failure or shock, also called an asphyxial arrest. Asphyxia begins with a variable period of systemic hypoxemia, hypercapnea, and acidosis, progresses to bradycardia and hypotension, and culminates with cardiac arrest.1

Another mechanism of cardiac arrest, ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), is the initial cardiac rhythm in approximately 5% to 15% of pediatric in-hospital and out-of-hospital cardiac arrests;2,–,9 it is reported in up to 27% of pediatric in-hospital arrests at some point during the resuscitation.6 The incidence of VF/pulseless VT cardiac arrest rises with age.2,4 Increasing evidence suggests that sudden unexpected death in young people can be associated with genetic abnormalities in myocyte ion channels resulting in abnormalities in ion flow (see “Sudden Unexplained Deaths,” below).

Since 2010 marks the 50th anniversary of the introduction of cardiopulmonary resuscitation (CPR),10 it seems appropriate to review the progressive improvement in outcome of pediatric resuscitation from cardiac arrest. Survival from in-hospital cardiac arrest in infants and children in the 1980s was around 9%.11,12 Approximately 20 years later, that figure had increased to 17%,13,14 and by 2006, to 27%.15,–,17 In contrast to those favorable results from in-hospital cardiac arrest, overall survival to discharge from out-of-hospital cardiac arrest in infants and children has not changed substantially in 20 years and remains at about 6% (3% for infants and 9% for children and adolescents).7,9

It is unclear why the improvement in outcome from in-hospital cardiac arrest has occurred, although earlier recognition and management of at-risk patients on general inpatient units …

https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.110.971101

Part 14: Pediatric Advanced Life Support 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Background Discharging patients with acute myocardial infarction or unstable angina from the emergency department because of missed diagnoses can have dire consequences. We studied the incidence of, factors related to, and clinical outcomes of failure to hospitalize patients with acute cardiac ischemia. Methods We analyzed clinical data from a multicenter, prospective clinical trial of all patients with chest pain or other symptoms suggesting acute cardiac ischemia who presented to the emergency departments of 10 U.S. hospitals. Results Of 10,689 patients, 17 percent ultimately met the criteria for acute cardiac ischemia (8 percent had acute myocardial infarction and 9 percent had unstable angina), 6 percent had stable angina, 21 percent had other cardiac problems, and 55 percent had noncardiac problems. Among the 889 patients with acute myocardial infarction, 19 (2.1 percent) were mistakenly discharged from the emergency department (95 percent confidence interval, 1.1 to 3.1 percent); among the 966 patie...

https://www.nejm.org/doi/pdf/10.1056/NEJM200004203421603

Missed Diagnoses of Acute Cardiac Ischemia in the Emergency Department

Background Evaluation of patients with acute chest pain in emergency rooms is time-consuming and expensive, and it often results in uncertain diagnoses. We prospectively investigated the usefulness of bedside tests for the detection of cardiac troponin T and troponin I in the evaluation of patients with acute chest pain. Methods In 773 consecutive patients who had had acute chest pain for less than 12 hours without ST-segment elevation on their electrocardiograms, troponin T and troponin I status (positive or negative) was determined at least twice by sensitive, qualitative bedside tests based on the use of specific monoclonal antibodies. Testing was performed on arrival and four or more hours later so that one sample was taken at least six hours after the onset of pain. The troponin T results were made available to the treating physicians. Results Troponin T tests were positive in 123 patients (16 percent), and troponin I tests were positive in 171 patients (22 percent). Among 47 patients with evolving m...

Emergency Room Triage of Patients with Acute Chest Pain by Means of Rapid Testing for Cardiac Troponin T or Troponin I

ContextAlthough chest pain is widely considered a key symptom in the diagnosis
of myocardial infarction (MI), not all patients with MI present with chest
pain. The extent to which this phenomenon occurs is largely unknown.ObjectivesTo determine the frequency with which patients with MI present without
chest pain and to examine their subsequent management and outcome.DesignProspective observational study.Setting and PatientsA total of 434,877 patients with confirmed MI enrolled June 1994 to
March 1998 in the National Registry of Myocardial Infarction 2, which includes
1674 hospitals in the United States.Main Outcome MeasuresPrevalence of presentation without chest pain; clinical characteristics,
treatment, and mortality among MI patients without chest pain vs those with
chest pain.ResultsOf all patients diagnosed as having MI, 142,445 (33%) did not have chest
pain on presentation to the hospital. This group of MI patients was, on average,
7 years older than those with chest pain (74.2 vs 66.9 years), with a higher
proportion of women (49.0% vs 38.0%) and patients with diabetes mellitus (32.6%
vs 25.4%) or prior heart failure (26.4% vs 12.3%). Also, MI patients without
chest pain had a longer delay before hospital presentation (mean, 7.9 vs 5.3
hours), were less likely to be diagnosed as having confirmed MI at the time
of admission (22.2% vs 50.3%), and were less likely to receive thrombolysis
or primary angioplasty (25.3% vs 74.0%), aspirin (60.4% vs 84.5%), β-blockers
(28.0% vs 48.0%), or heparin (53.4% vs 83.2%). Myocardial infarction patients
without chest pain had a 23.3% in-hospital mortality rate compared with 9.3%
among patients with chest pain (adjusted odds ratio for mortality, 2.21 [95%
confidence interval, 2.17-2.26]).ConclusionsOur results suggest that patients without chest pain on presentation
represent a large segment of the MI population and are at increased risk for
delays in seeking medical attention, less aggressive treatments, and in-hospital
mortality.

https://jamanetwork.com/journals/jama/articlepdf/192825/JOC00166.pdf

Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain.

Basic life support (BLS) is the foundation for saving lives following cardiac arrest. Fundamental aspects of BLS include immediate recognition of sudden cardiac arrest (SCA) and activation of the emergency response system, early cardiopulmonary resuscitation ( CPR ), and rapid defibrillation with an automated external defibrillator ( AED) . Initial recognition and response to heart attack and stroke are also considered part of BLS. This section presents the 2010 adult BLS guidelines for lay rescuers and healthcare providers. Key changes and continued points of emphasis from the 2005 BLS Guidelines include the following: 

Despite important advances in prevention, SCA continues to be a leading cause of death in many parts of the world.1 SCA has many etiologies (ie, cardiac or noncardiac causes), circumstances (eg, witnessed or unwitnessed), and settings (eg, out-of-hospital or in-hospital). This heterogeneity suggests that a single …

Part 5: Adult Basic Life Support

In a prospective multicenter investigation of emergency room patients with acute chest pain, physicians admitted 96% of patients with acute myocardial infarction (AMI) and discharged 4%. Of 35 patients who were sent home with AMI, only 11 (31%) returned to the same hospital because of persistent symptoms. Compared with a control group of 105 randomly selected patients with AMI who were admitted from the emergency room, patients in whom AMI was missed were significantly younger, had less typical symptoms and were less likely to to have had prior AMI or angina or to have electrocardiographic evidence of ischemia or infarction not known to be old. Despite the less typical presentations of patients in whom AMI was missed, after controlling for age and sex, the short-term mortality rate was significantly higher among patients in whom AMI was missed but in whom it was detected through our follow-up procedures than in admitted AMI patients. As determined by independent reviewers, 49% of the missed AMIs could have been diagnosed through improved electrocardiographic reading skills or by admission of patients with recognized ischemic pain at rest or ischemic electrocardiographic changes not known to be old.

Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room.

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Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room.