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The cerebral function monitor (CFM) (Devices Unlimited) is a single-channel, bipolar ECG device modified for continuous recording of cortical electrical activity. We have found the CFM useful in the Pediatric Intensive Care Unit (PICU), particularly in seizure patients, patients with increased intracranial pressure, and after cardiorespiratory arrest. The device and our experience with its use in the PICU are described in this paper.

A model of spontaneous lactic acidosis was developed in alloxan diabetic rabbits by infusing intravenously β-hydroxybutyric acid followed by a continuous infusion of NaHCO 3 . In half of the animals, the arterial lactate/pyruvate ratio rose from 2.5 m M 0.19 m M to 20.4 m M 0.28 m M , and arterial pH fell to 7.16. In animals with lactic acidosis, the calculated ratio in blood of NAD NADH was 1437 ± 230, versus a normal value of 6754 ± 1250. Both arterial po 2 and blood pressure were normal. Continued infusion of NaHCO 3 led to increased blood lactate levels, with cardiorespiratory arrest in 36% of animals. Lactic acidosis did not develop in normal rabbits who were similarly treated. It is concluded that spontaneous lactic acidosis can be produced in diabetic, but not in normal, rabbits by infusion of β-hydroxybutric acid followed by infusion of NaHCO 3 .

A survey of cardiopulmonary resuscitations (CPR) done in a large general hospital over a 6 month period gave the result previously obtained by other workers-namely, that the long-term survival rate of patients receiving CPR in general wards is poor. The reason is that a high proportion of the patients undergoing CPR have a very poor prognosis to begin with. Those who do respond to CPR usually die fairly soon afterwards, while still in intensive care and having used up much of the hospital's resources. The suitability of patients for CPR should be considered and a decision should be made beforehand as to whether CPR is to be instituted when a cardiorespiratory arrest occurs.

Twelve cardiorespiratory arrests in eight young diabetics with severe autonomic neuropathy are reported. Only one patient died at the time, but two others subsequently died suddenly at home. There was no evidence of myocardial infarction, cardiac arrhythmia, or hypoglycaemia at the time of arrest. In most of the episodes there was some interference with respiration, either by anaesthesia, drugs, or bronchopneumonia. Five of the episodes occurred during or immediately after anaesthesia. It is suggested that the arrests were caused by defective respiratory rather than cardiovascular reflexes. Cardiorespiratory arrest appears to be a specific feature of diabetic autonomic neuropathy and may contribute to the mortality of this condition.

Recent studies in swine have shown that larger doses of epinephrine than those currently employed for cardiopulmonary resuscitation (CPR) significantly improve regional myocardial blood flow following prolonged cardiac arrest. The dose-response effect of a pure alpha-adrenergic agonist, methoxamine, on regional myocardial blood flow has not been investigated in this setting. This study compared the effect of high-dose epinephrine with graded doses of methoxamine on regional myocardial blood flow, oxygen delivery/utilization, and defibrillation rates during CPR. Twenty swine were instrumented for regional myocardial blood flow measurements using radiolabeled tracer microspheres. Measurements of regional myocardial blood flow, oxygen delivery, and oxygen consumption were made during normal sinus rhythm. Ventricular fibrillation was then induced. Following 10 minutes of ventricular fibrillation, CPR was initiated with a pneumatic compressor. Regional myocardial blood flow, oxygen delivery, and oxygen consumption were then measured during CPR. Following 3 minutes of CPR, the swine were allocated to one of four treatment groups (five per group): group I, epinephrine 0.2 mg/kg; group II, methoxamine 0.1 mg/kg; group III, methoxamine 1.0 mg/kg; and group IV, methoxamine 10.0 mg/kg. One minute after drug administration, regional myocardial blood flow, oxygen delivery, and oxygen consumption measurements again were made. Three and one half minutes after drug administration, defibrillation was attempted. Regional myocardial blood flow following drug administration was compared using an analysis of covariance. Epinephrine (0.2 mg/kg) significantly improved myocardial blood flow (P less than .002) for all tissues examined compared with all doses of methoxamine.(ABSTRACT TRUNCATED AT 250 WORDS)

Patients successfully resuscitated from cardiorespiratory arrest endure anoxic and ischaemic insult of the central nervous system. The extent of brain damage determines the chances and qualitiy of survival of those patients whose hemodynamic state can be restored. Anoxic neuronal lesions occur predominantly in the cerebral and cerebellar cortex because neurons in those areas are more sensitive to anoxia. This selective vulnerability of neurons to anoxia and relative sparing of brainstem structures is probably the reason why the vegetative state more frequently follows anoxia than any other cause of nontraumatic coma [6]. The prognosis of patients in vegetative state with spontaneous eye epening, normal brainstem reflexes but without cognition is difficult to ascertain within the first days of coma [2]. Thus in contrast to brain death, a widely accepted criterion of death in medical, legal and public opinion today many medical, judicial and moral questions concerning the vegetative state remain unsolved.

Diabetes insipidus following cardiac arrest and hypoxemic encephalopathy occurred in two patients. In both, severe hypoxemic brain damage was followed within three days by clinical and laboratory features of diabetes insipidus, which were corrected by administration of exogenous vasopressin. Hypothalamic injury resulting in diabetes insipidus should be considered in the differential diagnosis of polyuria and dehydration occurring in critically ill patients who have suffered cardiorespiratory arrest. ( JAMA 238:620-621, 1977)

The organization of the Resuscitation Service for cardiorespiratory arrest in two major hospitals in Bristol is described. The results of resuscitation attempts in 258 calls over two separate periods are analysed and some guidance is given, of the prognosis in certain conditions. Special emphasis is laid on the proper selection of patients who should not be resuscitated. The problems and deficiencies of the service are scrutinized and the measures taken to reduce them are reported. This objective assessment of our Resuscitation Service has resulted in an increased survival rate.

BackgroundCardiorespiratory arrest (CRA) is a rare event in childhood. Our objective was to determine the characteristics of paediatric CRA and the immediate results of cardiopulmonary resuscitation (CPR) in Galicia, a community with a very scattered population.MethodsAll children (aged from newborn to 16 years old) who suffered an out-of-hospital CRA in Galicia and were assisted by the Public Foundation Medical Emergencies of Galicia-061 staff, from June 2002 to February 2005, were included in the study. Data were prospectively recorded following the Utstein's style guidelines.ResultsThirty-one cases were analyzed (3.4 CRA annual cases per 100.000 paediatric population). The arrest was respiratory in 16.1% and cardiac in 83.9% of cases. CRA occurred at home in 58.1% of instances. Time CRA to initiation of CPR was shorter than 10 minutes in 32.2% and longer than 20 minutes in 29.0% of cases. 22.6% of children received bystander CPR. The first recorded rhythm was asystole in 67.7% of cases. Bag-mask ventilation was used in 67.7% and in 83.8% oro-tracheal intubation was done. A peripheral venous access was achieved in 67.7% and intraosseous access was used in 16.1% of patients. 93.5% of children were treated with adrenaline. After initial CPR, sustained restoration of spontaneous circulation was achieved in 38.7% of cases. Six children (19.4%) survived until hospital discharge. Four of 5 children with respiratory arrest survived, whereas only 2 of 26 children with cardiac arrest survived until hospital discharge.ConclusionDespite the handicap of a highly disseminated population, paediatric CRA characteristics and CPR results in Galicia are comparable to references from other communities. Programs to increase bystander CPR, equip laypeople with basic CPR skills and to update life support knowledge of health staff are needed to improve outcomes.

Um lactente de 37 dias de vida, do sexo masculino, previamente higido e sem intercorrencias durante periodo perinatal, foi admitido em unidade de terapia intensiva pediatrica com insuficiencia ventilatoria aguda devido a bronquiolite viral pelo virus sincicial respiratorio. Foi submetido a intubacao traqueal por deterioracao clinica, sendo realizada sequencia rapida de intubacao com fentanil, cetamina e succinilcolina. Durante o procedimento, apresentou tosse, rigidez toracica, diminuicao da ausculta pulmonar e ma perfusao tecidual. Persistiu com piora clinica, culminando com parada cardiorrespiratoria [...]

A case of status asthmaticus was associated with cardiorespiratory arrest, illustrating rarely reported complications of ventilatory therapy including tension pneumomediastinum and coronary air embolization. Proposed pathophysiologic mechanisms and recommendations for surgical management are discussed.

A volunteer participating in a study of eproxindine, a new antiarrhythmic agent, had a sudden cardiorespiratory arrest and died. Subsequently it became known that he had received a depot injection of flupenthixol on the day before his death; an interaction between these two drugs seems likely. This incident illustrates that it is impossible to guarantee absolute safety in volunteer studies if details of medical history are witheld.

This case report describes cardiorespiratory arrest which occurred in a 38-year-old man immediately after a mobilization procedure of the cervical spine without anaesthesia.

Sudden infant death syndrome (SIDS) is recognized as the largest single cause of death in infants between 1 week and 1 year of age in the U.S., accounting for the unexpected deaths of approximately 10,000 previously well infants annually. 1 Infants who survive episodes of respiratory or cardiorespiratory arrest have been described as having aborted, or "near-miss," SIDS events, which are generally presumed to represent a variant of true SIDS. 2 Although "near-miss" occurrences may be repetitive, death rarely occurs in infancy. 2–3 However, the long-term significance of aborted SIDS events and the risk for subsequent catastrophe in these children is not known. The following case of an apparently healthy young girl with a history of "nearmiss" SIDS at age 6 weeks who died suddenly and unexpectedly in her sleep 12 years later may reflect an important and unappreciated aspect of the natural history of SIDS.

To the Editor.— InThe Journal'seditorial (240:1755, 1978) on cardiorespiratory arrest in diabetic autonomic neuropathy, Samuel Vaisrub, MD, reviews recent reports that postulate a primarily respiratory, rather than cardiac, mechanism to account for these episodes. This conclusion was based on the fact that most of the arrests occurred in association with factors that interfere with normal respiration. A majority of the patients whose cases were reported, however, were pulseless as well as apneic. This and the suddenness of the failure bespeak against a purely respiratory mechanism. An alternative explanation has been subsequently proposed, based on an additional case that displayed marked vagal hyperexcitability in response to tracheal suction. 1 In diabetic autonomic neuropathy, the loss of restraining influences from the sympathetic system may cause an exaggerated vagal reaction to impulses arising from the tracheobronchial tree (ie, suction, severe cough) and result in an idioventricular cardiac rhythm. On cessation of

When resuscitating a patient who suddenly became breathless and pulseless, the physician generally assumes that the cardiorespiratory arrest was precipitated by serious heart disease. In the vast majority of cases, the assumption will prove to be correct. The ECG or, if resuscitation fails, the autopsy will disclose evidences of underlying pathology in the myocardium, the coronary vasculature, or the conducting system. Occasionally, however, no such pathology will be found. Classic examples are crib deaths and "near deaths," which still defy explanation. Whatever their cause, no cardiac lesions serious enough to account for the sudden death have been found in the stricken infants. Recently, a variant of cardiorespiratory arrest that could not be accounted for by a cardiac lesion has been described by several observers. Lloyd-Mostyn and Watkins 1 reported unexplained cardiorespiratory arrests in two diabetic patients with autonomic neuropathy. In a later and more extensive study, Page and Watkins 2

• Ninety-one patients had cardiorespiratory arrest in a children's hospital emergency department over six years. Only five children survived, three with severe neurologic sequelae. The records of 40 other children in the same community resuscitated by paramedics, but taken to other hospitals, were reviewed and there were three survivors. The causes and outcomes of resuscitation of children are clearly different from those of adults. Cardiac disease and ventricular arrhythmias are uncommon. Neurologically intact survival was seen only in those children who received immediate resuscitation and responded promptly. Research in cerebral resuscitation at the cellular level is promising for the future. Prevention of some cardiorespiratory arrests through accident prevention and earlier recognition of serious infections is possible now. ( AJDC 1984;138:1099-1102)

• To study the outcome of cardiopulmonary resuscitation (CPR) in patients with acquired immunodeficiency syndrome (AIDS), data on CPR in hospitalized patients were collected prospectively during a one-year study period. Of 43 consecutive patients with AIDS who underwent CPR, 23% were revived in the initial attempt, whereas of 293 patients with other diseases 42% were revived. One (2.3%) of 43 patients with AIDS survived until hospital discharge, and his arrest was iatrogenic, as opposed to 19 (6.5%) of 293 patients with diseases other than AIDS. A respiratory mechanism for the arrest was significantly more common in patients with AIDS. The duration of the unsuccessful attempt did not vary significantly; a higher number of temporary pacemakers was used in patients with diseases other than AIDS indicating a more invasive approach. Survival until hospital discharge is minimal in our series of patients with AIDS, undergoing CPR. We recommend that informative discussions take place early in the course of the disease to provide patients with a better understanding of the available options in case of cardiorespiratory arrest. ( Arch Intern Med 1988;148:2602-2605)

ON AN Eastern Airlines flight to Atlanta from Los Angeles recently, a passenger who was a diabetic had a seizure. Despite the fact that there were three physicians aboard the plane the passenger could not be treated, because there was no supportive medical equipment on board. "The patient in question had taken his morning insulin and had not eaten lunch. The resulting low blood sugar produced a grand mal seizure," says Michael Diamant, MD, of Santa Barbara, Calif, one of the physicians aboard that flight. In another instance, on a flight from Boston to New York City, a physician was asked to provide medical assistance to a passenger in cardiorespiratory arrest. The physician, James S. Liljestrand, MD, of Braintree, Mass, discovered that there was no medical equipment—not even a stethoscope— or medication available on board. In a third case, Marvin A. Epstein, MD, of Walnut Creek, Calif, was flying to

• New instruments and techniques have refined the art of extracting aspirated foreign bodies from children. During a five-year period at the University of New Mexico, Albuquerque, bronchoscopic extractions were successful in 40 of 41 children (98%). The extractions were performed with the patient under general anesthesia, using a pediatric ventilating bronchoscope that contained the Hopkins rod-lens system. Two methods of extraction were used, depending on the shape of the foreign object: the Fogarty balloon technique for spherical objects, and the forceps technique for flat objects. Using these techniques, most foreign bodies (80%) were removed on the first or second pass of the bronchoscope. Because bronchoscopic extraction is a delicate procedure and carries a risk of cardiorespiratory arrest, it should be performed by endoscopists and anesthesiologists who are skilled with this procedure in children. ( Am J Dis Child 1982;136:924-927)

• Three cases of subarachnoid hemorrhage (SAH) due to ruptured developmental (berry) aneurysm are reported. Two patients presented with cardiac arrest and were successfully resuscitated, but the diagnosis of SAH was delayed and this most likely influenced poor final outcome. The third patient presented with irreversible respiratory arrest. The possible mechanisms responsible for SAH-triggered cardiac arrhythmia and/or respiratory arrest are discussed. Absence of previous cardiac history, persistent headache, focal neurologic findings (especially papilledema or subhyaloid hemorrhages) should warn the clinician of the possibility of SAH and warrant further neurologic investigation. ( Arch Intern Med 1987;147:1661-1662)

MANAGEMENT decisions in medicine, even those involving preservation of life, are profoundly personal. They are like gloves to be fit to a particular hand. For this reason, age-old wisdom has urged that decision making in health care, if it is to remain truly human and in the patient's best interest, should be controlled within the patient-family-physician relationship, always maintaining the right of appeal against potential abuses, of course. Three rather impersonal factors (high technology, cost-containment considerations, and public entities such as the law and the courts) are becoming increasingly influential in medical treatment. Impersonal forces tend to preprogram treatment and are thus a threat to all of us. That is why I see a very ominous drift in the recent New York appellate court resolution of the Fox case. On Oct 2, 1979, Brother Joseph Charles Fox, an 83-year-old member of the Society of Mary, suffered severe cardiorespiratory arrest during

The withdrawal of all nourishment and hydration from a patient who had suffered severe brain damage as a result of a cardiorespiratory arrest was recently held by a Californian court of appeal not to constitute an unlawful killing. The possible implications of this decision, both at common law and under the various criminal codes in Australia, are considered.