First Aid for the Pediatrics Clerkship, 3 Ed.

Pediatric Life Support




Image The great majority of pediatric cardiopulmonary arrests outside the hospital setting occur with parents or their surrogates (ie, teachers, coaches, day care workers, babysitters) nearby. BLS courses should be particularly targeted toward these individuals.

Image Most cardiac arrests in children are caused by progressive respiratory failure and circulatory collapse.


Image Primary cardiac arrest is rather uncommon in children. It is most often asphyxial, resulting from respiratory failure or shock, or both.

Image Outcomes are generally poor: Out-of-hospital setting 5–12% survival; in-hospital setting about 27% survival.

Image The incidence of pediatric arrests is highest during infancy (age < 1) and approaches that observed in adults, but is lower among children and adolescents.

Image Survival to discharge is more common among children and adolescents than infants or adults.

Image During infancy, the leading causes of arrest are injuries (intentional and unintentional), respiratory diseases, airway obstruction (eg, foreign body aspiration), sepsis, drowning, and sudden infant death syndrome (SIDS).

Image During childhood and adolescence, the leading cause of arrest is injury (intentional and unintentional).

Image Injuries should be viewed as preventable (not accidents), and education about injury prevention is an important aspect of pediatric BLS.


Injury is the leading cause of pediatric arrest in children over age 1 yr.


Most common causes of fatal pediatric injuries:

1. Motor vehicle injuries:

Image Nearly 50% of all pediatric injuries or deaths.

Image Risk factors include misuse of child seat restraints, seat belts, and air-bags; adolescent drivers; and intoxicated drivers.

2. Pedestrian injuries: Leading cause of injury in ages 5–9.

3. Bicycle injuries: Helmets reduce morbidity of head and brain injuries by 85–90%.

4. Drownings:

Image Twenty percent of drowning victims who survive suffer permanent brain injury secondary to prolonged hypoxia.

Image Children younger than age 4 are at especially high risk.

Image Alcohol is often associated with adolescent drownings.

5. Burns:

Image Eighty percent of all fatalities occur from house fires (mostly from smoke inhalation).

Image Smoke detectors can reduce morbidity and mortality of house fires by 90%.

Image Contact burns, electrical burns, and scaldings most often affect children below the age of 4.


Remember, injury in children is not always an accident.

6. Firearms:

Image Second leading cause of death in all adolescent males and the leading cause of death in African-American adolescents.

Image Two-thirds of American households have firearms; one-third have a handgun.


Motor vehicles are the leading cause of pediatric injuries.


Image Upper extremities most frequent, followed by face and neck.

Image Pediatric considerations:

Image Larger body surface area-to-body mass ratio.

Image Image fluid loss Image greater fluid resuscitation requirement.

Image Image risk for hypothermia.


Disruption of three functions of skin:

Image Regulation of heat loss.

Image Preservation of body fluids.

Image Barrier to infection.


Occur commonly in toddlers, due to their curious nature and lack of understanding of danger.


Four criteria:

Image Depth:

Image First degree (eg, sunburn): Superficial. Only epidermis involved. Erythema, pain, and absence of blisters.

Image Second degree: Partial thickness. Epidermis and dermis involved, but dermal appendages spared. Red or mottled appearance with associated blisters. Painful.

Image Third degree: Full thickness. Destroys epidermis and all of the dermis. Painless, dry, and does not blanch.

Image Percentage of body surface area: Rule of nines—does not apply!

Image Head: 9% front, 9% back.

Image Chest, abdomen, and pelvis: 18% (genitals 1%).

Image Gluteals: 2.5% each.

Image Arms: 9% each (4.5% front and 4.5% back).

Image Legs: 14% each (7% front and 7% back).

Image Location:

Image Assess risk for disability.

Image Worse on face, eyes, ears, feet, perineum, or hands.

Image Association with other injuries.


Burns indicating abuse generally do not have a splash pattern, but more linear (eg, placing a child in a hot bath).


Image Airway, breathing, and circulation (ABCs) first!

Image Airway: Facial or neck burns, singed nose hair, hoarseness, or soot around mouth or nares may indicate inhalational injury. Assess for airway patency.

Image Breathing: Check arterial blood gases (ABGs) and check CO levels.

Image Circulation: IV fluid resuscitation.

Image Infants: > 10% of body surface area (BSA).

Image Children: > 15% BSA.

Image IV/IO access and the Parkland Formula:

Parkland formula = [wt kg × % burn × 4 mL/kg] + maintenance fluid requirements

Administer one-half over first 8 hr and remainder over next 16 hr.

Image Superficial and partial thickness:

Image Rapid and effective analgesia.

Image Cold compresses.

Image Antiseptic cleansing.

Image Debride open blisters.

Image Topical antibiotic (silver sulfadiazine).

Image Protect with bulky dressing.

Image Reexamine in 24 hr and serially after for healing and infection.

Image Full thickness or extensive partial thickness:

Image ABCs of trauma, especially airway.

Image Fluid and electrolyte replacement (as above).

Image Sedation and analgesia is usually necessary.

Image Clean and manage as above.


Image Admit:

Image Two to five percent of full-thickness burn.

Image Five to ten percent of body surface.

Image Other considerations for admission:

Image Burns involving the face, hands, genitalia, perineum, or major joints.

Image Circumferential extremity burns.

Image High-voltage electrical burns.

Image Significant chemical burns.

Image Inhalation injury.

Image Suspicion of abuse or unsafe home environment.

Image Burn unit:

Image > 5% of full-thickness burn.

Image > 10% BSA.


1.     Determine unresponsiveness: Stimulate and check for responsiveness.

2.     If unresponsive, shout for help (send someone to phone 911) and get automatic external defibrillator (AED). If lone provider: for sudden collapse, phone 911 and get AED. First, the airway is assessed, then breathing, and finally circulation. If there is an abnormality at any step of this ABC assessment, intervention must be initiated to stabilize the patient.

3.     Airway (open and assess): Head tilt–chin lift maneuver or jaw thrust maneuver (if cervical spine injury is suspected).

4.     Breathing: Look, listen, and feel.

Image Look for a rise and fall of the chest.

Image Listen for exhaled air.

Image Feel for exhaled air.

Image Provide two rescue breaths if no spontaneous breathing is present.

Image Infants (< 1 year old): Place mouth over infant’s mouth and nose, creating a seal.

Image Children (> 1 year old): Pinch nose and create mouth-to-mouth seal.

Image If the chest does not rise, or the breath does not go in easily, reposition the head and try again.

Image If no response, check pulse (brachial artery or femoral): Definite pulse within 10 sec check, give one breath every 6–8 sec and check pulse every 2 min. If no pulse, proceed to Circulation.


BLS: Determine unresponsiveness, call for help, and remember your





Infant Compressions

For < 1 year of age:

Image Single provider:

Image Place one hand on the head to maintain open airway for ventilation.

Image Place the two middle fingers of the other hand on the sternum one fingerbreadth below the nipple line to be used for chest compressions.

Image Chest compressions of 0.5–1 inch in depth at a rate of at least 100 per minute.

Image Coordinate compressions with pauses for ventilation at a ratio of 30:2.

Image Two providers:

Image Use hands encircling chest method with thumbs on sternum for chest compression.

Image Compression to ventilation ratio is 15:2.

Image One minute of BLS is provided to children before activating the Emergency Medical Services (EMS) system, because most cardiopulmonary arrest in children is caused by the development of hypoxemia, and 1 min of ventilatory and circulatory support may delay or prevent the development of cardiac arrest.

Child Compressions

Chest compressions should be initiated if heart rate is < 60 beats/min. For child age 1 to puberty:

Image Place one hand on the head to maintain open airway for ventilation.

Image Place the heel of the other hand on the lower half of the sternum (take care to avoid the xiphoid).

Image Chest compressions of 1–1.5 inches in depth at a rate of 100 per minute.

Image Coordinate compressions with pauses for ventilation at a ratio of 30:2 for single provider and 15:2 for two providers.

Image High-quality cardiopulmonary resuscitation (CPR):

Image Push hard and fast (100/min).

Image Release completely (allow for full chest recoil).

Image Minimize interruptions during compressions (< 10 sec).


Improper opening of the airway is the most common cause of ineffective rescue breaths.

Foreign Body Airway Obstruction


A 2-year-old boy is found unresponsive on the floor of his bedroom. He was last seen by his mother playing with building blocks. She states she only left the child alone for a few minutes while she went to use the bathroom. When EMS arrives, they find a cyanotic infant, unresponsive, not breathing. Pulses are palpable with a heart rate of 137. What are the initial and critical actions that must be taken?

In this case, foreign body aspiration is highly suspicious. This patient is unconscious, so a Heimlich maneuver should not be attempted. The victim should be placed supine, then the airway is opened with head-tilt chin-lift; if you see the object, attempt a finger sweep to remove it. Attempt rescue breathing. If unsuccessful, reposition head and attempt rescue breathing. If still unsuccessful, straddle the victim, placing the heel of one hand on the child’s abdomen in the midline just above the umbilicus (avoiding the xiphoid). Place the other hand on top of the first and deliver five quick inward and upward thrusts. Repeat this maneuver until ventilation is successful.

Image Foreign body airway obstruction should be considered in any child who suddenly demonstrates signs of respiratory distress, gagging, coughing, wheezing, or stridor.

Image These symptoms of airway obstruction can also be caused by infection. Infectious etiologies of airway obstruction are pediatric emergencies and should be suspected if fever, congestion, hoarseness, drooling, lethargy, or atony are present.

Image If an infectious cause of airway obstruction is being entertained, the child must be transported immediately to the nearest hospital capable of emergent pediatric intubation.

Image Infant compressions: Hands encircling chest 0.5–1 inch depth, rate > 100/min, 15:2 ratio (two providers).

Image Child compressions: Heel of palm 1–1.5 inch depth, rate 100/min, 15:2 ratio (two providers).

Infant Airway Obstruction (< 1 Year of Age)

Back blows and chest thrusts:

1.     Activate EMS.

2.     Hold the choking infant in one arm, with the infant face down, firmly holding the jaw and allowing the body to rest on your forearm.

3.     Deliver five back blows using the heel of your free hand directly between the infant’s shoulder blades.

4.     If no improvement, turn the infant over to the face-up position, maintaining support of the head and neck.

5.     Deliver five quick chest thrusts using the same technique as for infant chest compressions.

6.     Repeat above steps, alternating back blows and chest thrusts, until object is removed or the child loses consciousness.


Ninety percent of foreign body deaths are children under age 5; two-thirds of these are infants.

Child Airway Obstruction (> 1 Year of Age)


Airway obstruction caused by infection requires immediate transport to the hospital.

Image Heimlich maneuver—if conscious:

1.     Ask patient if she is choking and if she can speak.

2.     If not, tell patient you are going to help her and activate EMS.

3.     Stand behind the conscious victim, and wrap your arms around the abdomen.

4.     Place the thumb of one fist in the midline of the abdomen just above the umbilicus (well below the xiphoid).

5.     Grasp the fist with the other hand and deliver quick thrusts inward and upward.

6.     Continue until object is expelled or victim becomes unconscious.


Infant airway obstruction = back blows + chest thrusts.

Image If the victim becomes unconscious (witnessed):

1.     Place victim supine.

2.     Open the airway with head-tilt chin-lift; if you see the object, attempt a finger sweep to remove it.

3.     Attempt rescue breathing.

4.     If unsuccessful, reposition head and attempt rescue breathing.

5.     If still unsuccessful, straddle the victim, placing the heel of one hand on the child’s abdomen in the midline just above the umbilicus (avoiding the xiphoid).

6.     Place the other hand on top of the first and deliver five quick inward and upward thrusts.

7.     Repeat steps 2–6 until ventilation is successful or EMS arrives and takes over.


Child (> 1 year of age) airway obstruction = Heimlich maneuver


Image Goals: To provide rapid assessment and definitive management of the pediatric arrest situation using advanced airway management techniques, cardiac monitoring equipment, and pharmacologic therapy.

Image Respiratory problems are rather common among children, and respiratory arrest is the major cause of cardiac arrest in the pediatric population.

Image If respiratory arrest is treated before it progresses to cardiac arrest, survival is markedly improved.

Image If respiratory arrest progresses to pulseless cardiac arrest, the chances of survival are poor.

Image Early recognition of respiratory failure and effective management of respiratory problems are key elements taught in PALS.


Poiseuille’s equation: Resistance (airway) × 1/r4

Anatomic Differences in the Pediatric Airway

Image Infants are obligate nasal breathers.

Image Smaller airway.

Image Tongue occupies a greater percentage of the oropharynx.

Image Vocal cords are more superior and anterior.

Image The tonsils and adenoids are more prominent.

Image The epiglottis is larger and more floppy.

Image The tracheal rings are less rigid.

Image The narrowest part of the airway is just below the vocal cords at the nondistensible cricoid cartilage; endotracheal tube (ETT) size is thus determined by the size of this opening.

Image Smaller amounts of vocal cord edema can drastically reduce the diameter of the airway (resistance is inversely proportional to the fourth power of the radius).

Image The angle between the base of the tongue and the glottis is more acute.


Straight laryngoscope blades are more effective to visualize the pediatric airway. Used to “pick up” epiglottis.

Pediatric Respiratory Distress

Image The earlier you detect respiratory distress or respiratory failure and start the appropriate therapy, the better chance the child has for a good outcome.

Image Respiratory distress Image hypoxemia (inadequate oxygenation) and/or hypercarbia.

Arterial oxygen content = (1.36 × Hgb concentratio× SaO2) + (0.003 × PaO2)

Image Hypoxemia is readily detected noninvasively with pulse oximetry monitoring.

Image Hypercarbia results from inadequate alveolar ventilation (ie, Image CO2 tension (PaCO2) in the blood.

Image Provide oxygen in the highest concentration available to any child experiencing respiratory difficulty (face tent, blow-by stream, mask, partial nonrebreather).

Image Suction secretions as needed (don’t forget the nose in infants).

Image Continually reassess for signs of decompensation; if a trend of worsening respiratory status is noted, assisted ventilation is required to prevent respiratory failure.

Image Upper airway obstruction: Predominantly during inspiration:

Image Tachypnea.

Image Retractions.

Image Stridor: Classic sign of upper airway obstruction.

Image Lower airway obstruction: Signs of obstruction:

Image Tachypnea.

Image Wheezing: Most common, generally expiratory.

Management of Respiratory Failure and Pediatric Intubation

Timing is everything! If respiratory function is restored promptly, neurologically intact survival is likely:

Image Airway: Open the airway.

Image Breathing: Support breathing using bag-valve-mask ventilation until definitive airway is established (ie, endotracheal intubation). Monitor oxygenation and end tidal CO2 (after intubation).

Image Circulation: Assess circulation, establish intravenous (IV) access, chest compressions if necessary.

Endotracheal Intubation

Image Endotracheal tube size: For children 1–10 yr:

Image Uncuffed endotracheal tube size (mm ID) = (age in years/4) + 4.

Image Cuffed endotracheal tube size (mm ID) = (age in years/4) + 3.

Image Cuffed tubes are generally safe for use in the hospital.

Image Keep cuff inflation pressure < 20 cm H2O.

Image Select and prepare all equipment prior to attempting intubation (make sure all are functioning well).

Image Laryngoscope blade (Figure 22-1): Size:

Image Infant: Miller (straight) 0.

Image Age < 1: Miller (straight) 1.

Image Age 1–5: Miller (straight) 2.

Image Age > 5: Mac (curved) 2 or Miller 2–3.

Image ETT size: Based on above formulas.

Image Confirm placement with end-tidal CO2 indicator.

Image Listen in both lung fields for equal breath sounds and confirm absent gastric insufflation.

Image If the intubated patient’s condition deteriorates, consider the following possibilities (DOPE):

Image Displacement of the tube from the trachea.

Image Obstruction of the tube.

Image Pneumothorax.

Image Equipment failure.


FIGURE 22-1. Two common types of laryngoscope blades: Macintosh and Miller blades.

(Reproduced, with permissionm, from Lalwani AK. Current Diagnosis & Treatment in Otolaryngology – Head & Neck Surgery. New York: McGraw-Hill, 2004: 1700).

Vascular Access


Image Upper extremity:

Image Median cubital vein.

Image Cephalic vein (and tributaries in the dorsum of the hand).

Image Basilic vein.

Image Lower extremity:

Image Saphenous veins (especially great saphenous at the ankle).

Image Veins of the dorsal arch.

Image Median marginal veins.


Unpredictable drug absorption when drug administration via the ETT.


Image Rapid and reliable method to deliver fluids and drugs during resuscitation.

Image Preferred over ET route for the administration of drugs.

Image Temporary route (limit 24 hr).

Image Contraindications:

Image Open fracture at proposed insertion site.

Image Signs of skin infection at the insertion site.

Image Previous attempts at site.

Image During cardiopulmonary resuscitation (CPR), should be employed after three failed attempts to cannulate peripheral veins (or 90 sec).

Image Preferred site of insertion:

Image Proximal tibia: Two fingerbreadths below the tibial tuberosity.

Image Remember to insert needle at an angle pointing away from the growth plates.

Image Can safely administer fluids, blood products, and drugs. (Anything that can be given via central line can be given by intraosseous route).


LEAN: Lidocaine, epinephrine, atropine, and naloxone (can be administered via ET route if vascular access is not available).


Image Rare (< 1%).

Image Extravasation Image compartment syndrome.

Image Infections Image cellulitis and osteomyelitis.

Image Fractures.

Image Injury to the epiphyseal growth plate.


Image Complications (bleeding, infection, pneumothorax, etc.) are more common in the pediatric age group.

Image Central catheters should be used only when the benefit outweighs the risks (ie, when central venous pressures need to be monitored).

Image Catheters are inserted using the Seldinger (guidewire) technique.

Image Common sites include:

Image Femoral vein

Image Internal jugular vein

Image Subclavian vein


The worldwide leading cause of shock is hypovolemia.

Shock and Fluid Resuscitation

Image Shock is defined as inadequate oxygen delivery to the tissues and organs.

Image Shock can result from:

Image Inadequate blood volume or oxygen-carrying capacity (eg, hypovolemic/hemorrhagic shock).

Image Inappropriately distributed blood volume (distributive shock).

Image Impairment of heart contractility (cardiogenic shock).

Image Obstructive blood flow (obstructive shock).

Image All forms of shock require consideration of fluid administration during initial therapy.

Image Hypovolemia is the worldwide leading cause of shock (inadequate fluid intake plus diarrhea and vomiting can Image hypovolemic shock).

Image Septic shock, neurogenic shock, and anaphylactic shock are all characterized by vasodilation, Image capillary permeability, and third-space fluid loss that results in an intravascular hypovolemia. These are subcategories of distributive shock.

Image Cardiogenic shock may even require initial fluid administration before the initiation of inotropic and chronotropic agents (“you must fill the tank before starting the engine”). Judicious use of fluids mandatory to avoid causing pulmonary edema.

Image The treatment goal for shock is to prevent end-organ injury and halt the progression to cardiopulmonary failure and cardiac arrest.

Image Initial fluid resuscitation:

Image Normal saline or lactated.

Image Ringer’s (isotonic).


Image Initial bolus should be a rapid infusion of isotonic crystalloid of 20 mL/kg over 20 min.

Image Reassess after initial bolus by looking at response in heart rate, capillary refill, level of consciousness, and most importantly urinary output. Aim for a urinary output of 0.5–1 cc/kg/hr.

Image Remember that only about 25% of crystalloid will remain in the intravascular space; thus, you may need to administer three times the estimated fluid loss (3:1 rule).

Image Blood is the preferred fluid replacement for trauma victims demonstrating persistent hypovolemic shock after two to three boluses of crystalloid (ie, 40–60 mL/kg).

Image Maintenance fluids are given by the 4,2,1 formula: 4 mL/kg/hr for the first 10 kg + 2 mL/kg/hr for the second 10 kg + 1 mL/kg/hr for every 1 kg above 20.


3:1 Rule

May need to administer three times estimated fluid loss.


Class I

Image 0–15% volume loss.

Image Normal pulse.

Image Normal blood pressure.

Image Normal capillary refill.

Image Normal respiratory rate.

Image Urine output 1–2 mL/kg/hr.

Class II

Image 15–30% volume loss.

Image Mild tachycardia.

Image Mildly Image blood pressure.

Image Mildly prolonged capillary refill.

Image Mild tachypnea.

Image Urine output 0.5–1.0 mL/kg/hr.

Class III

Image 30–40% volume loss.

Image Tachycardia.

Image Image blood pressure.

Image Prolonged capillary refill.

Image Tachypnea.

Image Urine output 0.25–0.5 mL/kg/hr.

Class IV

Image > 40% volume loss.

Image Severely tachycardic, bradycardic, or absent pulse.

Image Very low blood pressure.

Image Greatly prolonged capillary refill.

Image Severe tachypnea.

Image Urine output 0 mL/kg/hr.


Image First, attempt multiple fluid boluses.

Image Try to identify and treat the underlying cause.

Image Choose pressor agent according to the type of shock present.


Image Inotropes:

Image Dopamine

Image Epinephrine

Image Dobutamine

Image Phosphodiesterase inhibitors:

Image Milrinone

Image Inamrinone

Image Vasodilators:

Image Nitroglycerine

Image Nitroprusside

Image Vasopressors:

Image Epinephrine

Image Norepinephrine

Image Dopamine

Image Vasopressin


Multiple crystalloid boluses will be necessary (20 mL/kg bolus over 20 min, repeat PRN).


Multiple crystalloid boluses will be necessary (20 mL/kg bolus over 5–20 min, repeat PRN).

Image Consider dopamine 5–20 µg/kg/min if patient is normotensive.

Image Consider epinephrine 0.1–1.0 µg/kg/min if patient is hypotensive.


Image Initial fluid bolus is usually necessary.

Image Consider dobutamine 5–20 µg/kg/min if patient is normotensive. (Note: Dobutamine may not be effective in infants and young children due to lack of stroke volume response.)

Image Consider epinephrine 0.1–1.0 µg/kg/min if the patient is hypotensive.

Cardiac Arrhythmias

Image Tachycardias.

Image Bradycardias.

Image No pulse: Asystole, pulseless electrical activity (PEA), ventricular fibrillation (VF), or pulseless ventricular tachycardia (VT).


Sinus Tachycardia

Image Defined as a rate of sinus node discharge faster than normal for age.

Image Age-specific heart rates:

Image 0–3 months (85–205 beats/min): Mean 140 tachycardia > 205.

Image 3 months–2 yr (100–190 beats/min): Mean 130, tachycardia > 190.

Image 2–10 yr (60–140 beats/min): Mean 80, tachycardia > 140.

Image > 10 yr (60–100 beats/min): Mean 75, tachycardia > 100.

Image Typically, a response to a need for Image cardiac output (compensatory tachycardia).

Image Common causes include fever, pain, anxiety, blood loss, sepsis, and shock.

Image Always assess and reassess ABCs.

Image Therapy entails treating the underlying cause.

Supraventricular Tachycardia (SVT)

Image SVT is rapid, very regular, often paroxysmal.

Image Often exceeds 220 bpm in infants, exceeds 180 bpm in children.

Image P waves are absent or indistinguishable.

Image QRS complex is typically narrow (< 0.08 sec).

Image SVT is most commonly caused by reentry mechanism.

Image SVT algorithm:

Image Assess ABCs, support as needed.

Image Administer 100% oxygen, ventilate as needed.

Image Document electrocardiogram (ECG)/rhythm tracing: Evaluate QRS—narrow ≤ 0.08 sec.

Image Establish IV or IO access:

Image Adenosine 0.1 mg/kg rapid intravenous push, immediately followed by 5 mL of saline flush (maximum dose: 6 mg in children and 12 mg in adolescents).

Image Synchronized cardioversion: 0.5 to 1 J/kg; if not effective Image to 2 J/kg (sedate if possible, but do not delay cardioversion).

Image If still in SVT: Obtain cardiology consult and consider administration of:

Image Amiodarone 5 mg/kg IV over 20–60 min or

Image Procainamide 15 mg/kg IV over 30–60 min. If patient becomes unstable at any time, proceed directly with synchronized cardioversion.

Image Management of SVT:

Image Stable: Vagal maneuvers and/or adenosine.

Image Unstable: Synchronized cardioversion.

Ventricular Tachycardia (VT) (with pulse)

Image Wide QRS complex (> 0.08 sec).

Image P waves not present.

Image Very uncommon in children.

Image Risk factors include prolonged QT syndrome, cardiac anomalies, drug ingestions, electrolyte abnormalities, underlying cardiac disease.

Image VT algorithm:

1. Assess ABCs, support as needed.

2. Administer 100% oxygen, ventilate as needed.

3. Document electrocardiogram (ECG)/rhythm tracing (wide QRS ≥ 0.08 sec).

4. Establish IV or IO access or

5. Synchronized cardioversion: 0.5–1 J/kg; if not effective, Image to 2 J/kg (sedate if possible, but do not delay cardioversion).

6. If still in VT: Call cardiology consult for administration of:

Image Amiodarone 5 mg/kg IV over 20–60 min or

Image Procainamide 15 mg/kg IV over 30–60 min.

7. Obtain cardiology consult as needed.

8. Identify and treat possible causes:

Image 4Hs: Hypovolemia, Hypoxemia, Hypothermia, Hyper/hypokalemia.

Image 4Ts: Tamponade, Tension pneumothorax, Toxins, Thromboembolism.


Ventricular tachycardia:

Image QRS wide

Image No P waves

Image Rare in children


Image Age-specific heart rates:

Image 0–3 months (85–205 beats/min); bradycardia < 85.

Image 3 months–2 yr (100–190 beats/min); bradycardia < 100.

Image 2–10 yr (60–140 beats/min); bradycardia < 60.

Image > 10 yr (60–100 beats/min); bradycardia < 60

Bradycardia Algorithm.

1.     Assess ABCs, support.

2.     Administer 100% oxygen, ventilate, prepare to intubate.

3.     Establish IV/IO access.

4.     Cardiac monitor, pulse oximetry, blood pressure cuff.

5.     Reassess ABCs.

Image If stable, continue to support ABCs, admit for observation.

Image If unstable (poor perfusion, hypotension, heart rate < 60, continued hypoxia despite 100% oxygen administration):

1.     Begin chest compressions if still persistent bradycardia.

2.     Give epinephrine 0.01 mg/kg (1:10,000, 0.1 mL/kg) IV/IO, or via ETT 0.1 mg/kg (1:1,000, 0.1 mL/kg). Repeat every 3–5 min.

3.     If Image vagal tone or primary AV block, give atropine 0.02 mg/kg IVP. Min dose: 0.1 mg. Max dose: 0.02 mg/kg to maximum of 1.0 mg via ETT dose: Two to three times dose in 5 mL normal saline.

4.     Consider external pacing.



A 6-year-old girl with a past medical history of asthma is brought to your ED by EMS in respiratory distress. Her vital signs are heart rate 120, BP 90/50, RR 26, O2 93% on facemask. Per EMS, the child had been wheezing all morning, and the mother had tried several nebulizer treatments without relief. The mother called 911 when her child seemed to become in more distress. While performing your primary survey the patient becomes unresponsive, the monitor shows v-fib. What are the initial and critical actions that must be taken?

Here the patient is going into cardiac failure/arrest secondary to respiratory distress. The first step is to palpate for a pulse. This patient has ventricular fibrillation, which is a shockable rhythm.

Ventricular Fibrillation (VF)/Pulseless VT1.

1.     Assess ABCs.

2.     Continue CPR for 2 min.

3.     Confirm rhythm in more than one lead. Is rhythm shockable?

4.     Intubate and hyperventilate with 100% oxygen.

5.     IV/IO access (do not delay defibrillation for access).

6.     If shockable rhythm, defibrillat × 1 with 2 J/kg).

7.     Restart CPR for 2 min.

8.     Give another shock, 4 J/kg; give epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,000) IV/IO or ETT 0.1 mg/kg (0.1 mL/kg of 1:1000).

9.     Restart CPR for 2 min.

10. Give another shock 4 J/kg; consider giving antiarrhythmics: Lidocaine 1 mg/kg IV/IO/ETT or amiodarone 5 mg/kg bolus IV/IO.

11. Consider magnesium 25 to 50 mg/kg IV/IO for Torsades de pointes (max dose: 2 g).

12. Identify and treat possible causes (4Hs and 4Ts).

Pulseless Electrical Activity (PEA)

Image PEA in children, while rare, usually occurs as a result of progressive respiratory and/or circulatory failure.

Image As with adult PEA, the differential diagnosis for pediatric PEA is essential to successful resuscitation.

Image PEA algorithm:

1.     Assess ABCs.

2.     Continue CPR.

3.     Confirm rhythm in more than one lead.

4.     Intubate and hyperventilate with 100% oxygen.

5.     IV/IO access.

6.     Consider possible causes of PEA (and specific treatments):

Image Hypovolemia (volume—normal saline infusion).

Image Hypoxia (oxygen, intubation, ventilation).

Image Hypothermia (warmed normal saline infusion).

Image Massive pulmonary embolism (heparin infusion, thrombolysis).

Image Acidosis (sodium bicarbonate).

Image Tension pneumothorax (needle decompression).

Image Cardiac tamponade (pericardiocentesis).

Image Hyperkalemia (insulin/glucose, calcium).

Image Drug overdose from TCAs, digoxin, β blockers, calcium channel blockers.

7. Epinephrine (every 3–5 min):

Image IV/IO 0.01 mg/kg (0.1 mL/kg of 1:10,000).

Image ETT 0.1 mg/kg (0.1 mL/kg of 1:1000).


Image Most common pulseless rhythm in children.

Image Airway management and hyperventilation are the most important interventions.

Image Always confirm asystole in more than one lead and ensure that leads are properly connected.

Image Asystole algorithm:

1.     ABCs.

2.     CPR.

3.     Confirm rhythm in more than one lead.

4.     Intubate and hyperventilate with 100% oxygen.

5.     IV/IO access.

6.     Epinephrine (every 3–5 min):

Image IV/IO 0.01 mg/kg (0.1 mL/kg of 1:10,000).

Image ETT 0.1 mg/kg (0.1 mL/kg of 1:1000).

7. Consider external pacing.

8. Search for reversible causes.

Image Note that atropine and bicarbonate are not part of the algorithm for asystole.


Image Newborn resuscitation ideally should be performed in the delivery room, neonatal intensive care unit (NICU), or other unit with personnel experienced with treating newborns and equipment appropriate for the task.

Image Birth asphyxia accounts for about 19% of the approximately 5 million neonatal deaths that occur each year worldwide.

Image Approximately 10% of newborns require some assistance to begin breathing at birth; about 1% need extensive resuscitative measures to survive.

Preassessment and Triage

Always ask the following questions when treating a new born baby:

1. Was the baby born at term (ie, how many weeks’ gestation)?

Image Premature babies are at higher risk for intubation and resuscitation, especially if their respiratory system is not fully developed and functional.

2. Was the amniotic fluid clear?

Image Meconium in the amniotic fluid is a sign of a stressed birth, and the baby, if not vigorous, will need to be intubated.


Suction newborn airway aggressively.

3. Is the baby breathing or crying?

Image Note: Gasping usually indicates a significant problem and requires the same intervention as no respiratory efforts at all (apnea).

4. Is there good muscle tone?

Image Healthy babies should have flexed extremities and be active.


Start CPR on neonate if pulse < 60.

Newborn Assessment

Image Temperature: Neonatal hypothermia can be associated with neonatal respiratory depression. Upon delivery, warming and drying with a towel or blanket is often adequate to stimulate breathing in a newborn.

Image Airway: Position the airway and suction any secretions (neck slightly extended in the “sniffing” position).

Image Breathing: Observe chest rise and fall, give 100% oxygen if necessary, initiate adequate bag-valve-mask ventilation if necessary (ie, heart rate < 100 beats/min and unresponsiveness; absent or depressed respirations).

Image Circulation: Assess heart rate and color, provide chest compressions as necessary (if heart rate absent, if heart rate < 60 despite 30 sec of assisted ventilation).


Newborn ABCs

Image Position

Image Suction

Image Stimulate cry

Image Warm and dry

Newborn Resuscitation

Assess every newborn (and give the appropriate support).

1. Delivery outside the delivery room.

2. ABCs—assess and support.

Image Airway (position and suction).

Image Breathing (stimulate to cry).

Image Circulation (heart rate and color).

Image Temperature (warm and dry).

3. Oxygen (100%).

4. Establish effective ventilation:

Image Bag-valve-mask.

Image Laryngeal mask airway (LMA) can be an effective alternative for establishing an airway when bag-valve-mask fails.

Image Endotracheal intubation (only by trained rescuer competent in neonatal intubations).

5. Chest compressions if pulse < 60 beats/min, despite 30 sec of effective positive-pressure ventilation. Place two hands around infant’s chest with thumbs on sternum in the nipple line. Compress to one-third the anterior-posterior diameter.

6. Medications as dictated by the situation.


Neonatal Resuscitation

Image Ventilation rate: 40–60/min (room air or 100% oxygen, with titration to lowest level).

Image Compression rate: 120 events/min (90 compressions/30 ventilations/min).

Image Compression/ventilation ratio: 3:1.

Image Note: The two-finger compression technique is also acceptable.

Meconium Deliveries

1. Deliver head.

2. Aggressively suction hypopharynx while infant is still in birth canal.

3. Complete delivery of infant.

4. Assess temperature and ABCs. If the infant is active and vigorous, continue supportive measures. If any signs of distress (absent or depressed respirations, heart rate < 100, poor muscle tone), proceed with algorithm.

5. Direct tracheal suctioning either following endotracheal intubation or by using ETT as suction catheter.

6. Decision to intubate and perform tracheal suctioning depends on whether the newborn infant is vigorous. Current neonatal resuscitation guidelines define an infant as vigorous if he or she has:

Image Strong respiratory efforts.

Image Good muscle tone.

Image Heart rate more than 100 beats/min.

In a vigorous and active infant, there is generally no need for tracheal suctioning. In a nonvigorous and depressed infant, drying and stimulation should be delayed. Perform direct laryngoscopy and suction the mouth and hypopharynx, followed by intubation and then applying suction (∼100 mmHg) directly to the ETT. A nonvigorous and depressed infant has a low threshold for intubation and direct tracheal suctioning in the presence of thick meconium.


See Gestation and Birth chapter.


If meconium is present during a delivery, aggressively suction hypopharynx as soon as head is delivered.


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