PEDIATRIC BASIC LIFE SUPPORT (BLS)
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.
Most cardiac arrests in children are caused by progressive respiratory failure and circulatory collapse.
EPIDEMIOLOGY
Primary cardiac arrest is rather uncommon in children. It is most often asphyxial, resulting from respiratory failure or shock, or both.
Outcomes are generally poor: Out-of-hospital setting 5–12% survival; in-hospital setting about 27% survival.
The incidence of pediatric arrests is highest during infancy (age < 1) and approaches that observed in adults, but is lower among children and adolescents.
Survival to discharge is more common among children and adolescents than infants or adults.
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).
During childhood and adolescence, the leading cause of arrest is injury (intentional and unintentional).
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.
FATAL PEDIATRIC INJURIES
Most common causes of fatal pediatric injuries:
1. Motor vehicle injuries:
Nearly 50% of all pediatric injuries or deaths.
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:
Twenty percent of drowning victims who survive suffer permanent brain injury secondary to prolonged hypoxia.
Children younger than age 4 are at especially high risk.
Alcohol is often associated with adolescent drownings.
5. Burns:
Eighty percent of all fatalities occur from house fires (mostly from smoke inhalation).
Smoke detectors can reduce morbidity and mortality of house fires by 90%.
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:
Second leading cause of death in all adolescent males and the leading cause of death in African-American adolescents.
Two-thirds of American households have firearms; one-third have a handgun.
Motor vehicles are the leading cause of pediatric injuries.
BURNS
Upper extremities most frequent, followed by face and neck.
Pediatric considerations:
Larger body surface area-to-body mass ratio.
fluid loss greater fluid resuscitation requirement.
risk for hypothermia.
PATHOPHYSIOLOGY
Disruption of three functions of skin:
Regulation of heat loss.
Preservation of body fluids.
Barrier to infection.
EPIDEMIOLOGY
Occur commonly in toddlers, due to their curious nature and lack of understanding of danger.
CLASSIFICATION
Four criteria:
Depth:
First degree (eg, sunburn): Superficial. Only epidermis involved. Erythema, pain, and absence of blisters.
Second degree: Partial thickness. Epidermis and dermis involved, but dermal appendages spared. Red or mottled appearance with associated blisters. Painful.
Third degree: Full thickness. Destroys epidermis and all of the dermis. Painless, dry, and does not blanch.
Percentage of body surface area: Rule of nines—does not apply!
Head: 9% front, 9% back.
Chest, abdomen, and pelvis: 18% (genitals 1%).
Gluteals: 2.5% each.
Arms: 9% each (4.5% front and 4.5% back).
Legs: 14% each (7% front and 7% back).
Location:
Assess risk for disability.
Worse on face, eyes, ears, feet, perineum, or hands.
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).
TREATMENT
Airway, breathing, and circulation (ABCs) first!
Airway: Facial or neck burns, singed nose hair, hoarseness, or soot around mouth or nares may indicate inhalational injury. Assess for airway patency.
Breathing: Check arterial blood gases (ABGs) and check CO levels.
Circulation: IV fluid resuscitation.
Infants: > 10% of body surface area (BSA).
Children: > 15% BSA.
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.
Superficial and partial thickness:
Rapid and effective analgesia.
Cold compresses.
Antiseptic cleansing.
Debride open blisters.
Topical antibiotic (silver sulfadiazine).
Protect with bulky dressing.
Reexamine in 24 hr and serially after for healing and infection.
Full thickness or extensive partial thickness:
ABCs of trauma, especially airway.
Fluid and electrolyte replacement (as above).
Sedation and analgesia is usually necessary.
Clean and manage as above.
CRITERIA FOR ADMISSION/TRANSFER
Admit:
Two to five percent of full-thickness burn.
Five to ten percent of body surface.
Other considerations for admission:
Burns involving the face, hands, genitalia, perineum, or major joints.
Circumferential extremity burns.
High-voltage electrical burns.
Significant chemical burns.
Inhalation injury.
Suspicion of abuse or unsafe home environment.
Burn unit:
> 5% of full-thickness burn.
> 10% BSA.
BLS ALGORITHM
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.
Look for a rise and fall of the chest.
Listen for exhaled air.
Feel for exhaled air.
Provide two rescue breaths if no spontaneous breathing is present.
Infants (< 1 year old): Place mouth over infant’s mouth and nose, creating a seal.
Children (> 1 year old): Pinch nose and create mouth-to-mouth seal.
If the chest does not rise, or the breath does not go in easily, reposition the head and try again.
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
ABCs:
Airway
Breathing
Circulation
Infant Compressions
For < 1 year of age:
Single provider:
Place one hand on the head to maintain open airway for ventilation.
Place the two middle fingers of the other hand on the sternum one fingerbreadth below the nipple line to be used for chest compressions.
Chest compressions of 0.5–1 inch in depth at a rate of at least 100 per minute.
Coordinate compressions with pauses for ventilation at a ratio of 30:2.
Two providers:
Use hands encircling chest method with thumbs on sternum for chest compression.
Compression to ventilation ratio is 15:2.
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:
Place one hand on the head to maintain open airway for ventilation.
Place the heel of the other hand on the lower half of the sternum (take care to avoid the xiphoid).
Chest compressions of 1–1.5 inches in depth at a rate of 100 per minute.
Coordinate compressions with pauses for ventilation at a ratio of 30:2 for single provider and 15:2 for two providers.
High-quality cardiopulmonary resuscitation (CPR):
Push hard and fast (100/min).
Release completely (allow for full chest recoil).
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.
Foreign body airway obstruction should be considered in any child who suddenly demonstrates signs of respiratory distress, gagging, coughing, wheezing, or stridor.
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.
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.
Infant compressions: Hands encircling chest 0.5–1 inch depth, rate > 100/min, 15:2 ratio (two providers).
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.
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.
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
PEDIATRIC ADVANCED LIFE SUPPORT (PALS)
Goals: To provide rapid assessment and definitive management of the pediatric arrest situation using advanced airway management techniques, cardiac monitoring equipment, and pharmacologic therapy.
Respiratory problems are rather common among children, and respiratory arrest is the major cause of cardiac arrest in the pediatric population.
If respiratory arrest is treated before it progresses to cardiac arrest, survival is markedly improved.
If respiratory arrest progresses to pulseless cardiac arrest, the chances of survival are poor.
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
Infants are obligate nasal breathers.
Smaller airway.
Tongue occupies a greater percentage of the oropharynx.
Vocal cords are more superior and anterior.
The tonsils and adenoids are more prominent.
The epiglottis is larger and more floppy.
The tracheal rings are less rigid.
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.
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).
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
The earlier you detect respiratory distress or respiratory failure and start the appropriate therapy, the better chance the child has for a good outcome.
Respiratory distress hypoxemia (inadequate oxygenation) and/or hypercarbia.
Arterial oxygen content = (1.36 × Hgb concentratio× SaO2) + (0.003 × PaO2)
Hypoxemia is readily detected noninvasively with pulse oximetry monitoring.
Hypercarbia results from inadequate alveolar ventilation (ie, CO2 tension (PaCO2) in the blood.
Provide oxygen in the highest concentration available to any child experiencing respiratory difficulty (face tent, blow-by stream, mask, partial nonrebreather).
Suction secretions as needed (don’t forget the nose in infants).
Continually reassess for signs of decompensation; if a trend of worsening respiratory status is noted, assisted ventilation is required to prevent respiratory failure.
Upper airway obstruction: Predominantly during inspiration:
Tachypnea.
Retractions.
Stridor: Classic sign of upper airway obstruction.
Lower airway obstruction: Signs of obstruction:
Tachypnea.
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:
Airway: Open the airway.
Breathing: Support breathing using bag-valve-mask ventilation until definitive airway is established (ie, endotracheal intubation). Monitor oxygenation and end tidal CO2 (after intubation).
Circulation: Assess circulation, establish intravenous (IV) access, chest compressions if necessary.
Endotracheal Intubation
Endotracheal tube size: For children 1–10 yr:
Uncuffed endotracheal tube size (mm ID) = (age in years/4) + 4.
Cuffed endotracheal tube size (mm ID) = (age in years/4) + 3.
Cuffed tubes are generally safe for use in the hospital.
Keep cuff inflation pressure < 20 cm H2O.
Select and prepare all equipment prior to attempting intubation (make sure all are functioning well).
Laryngoscope blade (Figure 22-1): Size:
Infant: Miller (straight) 0.
Age < 1: Miller (straight) 1.
Age 1–5: Miller (straight) 2.
Age > 5: Mac (curved) 2 or Miller 2–3.
ETT size: Based on above formulas.
Confirm placement with end-tidal CO2 indicator.
Listen in both lung fields for equal breath sounds and confirm absent gastric insufflation.
If the intubated patient’s condition deteriorates, consider the following possibilities (DOPE):
Displacement of the tube from the trachea.
Obstruction of the tube.
Pneumothorax.
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
CANNULATION OF PERIPHERAL VEINS
Upper extremity:
Median cubital vein.
Cephalic vein (and tributaries in the dorsum of the hand).
Basilic vein.
Lower extremity:
Saphenous veins (especially great saphenous at the ankle).
Veins of the dorsal arch.
Median marginal veins.
Unpredictable drug absorption when drug administration via the ETT.
INTRAOSSEOUS CANNULATION
Rapid and reliable method to deliver fluids and drugs during resuscitation.
Preferred over ET route for the administration of drugs.
Temporary route (limit 24 hr).
Contraindications:
Open fracture at proposed insertion site.
Signs of skin infection at the insertion site.
Previous attempts at site.
During cardiopulmonary resuscitation (CPR), should be employed after three failed attempts to cannulate peripheral veins (or 90 sec).
Preferred site of insertion:
Proximal tibia: Two fingerbreadths below the tibial tuberosity.
Remember to insert needle at an angle pointing away from the growth plates.
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).
COMPLICATIONS
Rare (< 1%).
Extravasation compartment syndrome.
Infections cellulitis and osteomyelitis.
Fractures.
Injury to the epiphyseal growth plate.
CANNULATION OF CENTRAL VEINS
Complications (bleeding, infection, pneumothorax, etc.) are more common in the pediatric age group.
Central catheters should be used only when the benefit outweighs the risks (ie, when central venous pressures need to be monitored).
Catheters are inserted using the Seldinger (guidewire) technique.
Common sites include:
Femoral vein
Internal jugular vein
Subclavian vein
The worldwide leading cause of shock is hypovolemia.
Shock and Fluid Resuscitation
Shock is defined as inadequate oxygen delivery to the tissues and organs.
Shock can result from:
Inadequate blood volume or oxygen-carrying capacity (eg, hypovolemic/hemorrhagic shock).
Inappropriately distributed blood volume (distributive shock).
Impairment of heart contractility (cardiogenic shock).
Obstructive blood flow (obstructive shock).
All forms of shock require consideration of fluid administration during initial therapy.
Hypovolemia is the worldwide leading cause of shock (inadequate fluid intake plus diarrhea and vomiting can hypovolemic shock).
Septic shock, neurogenic shock, and anaphylactic shock are all characterized by vasodilation, capillary permeability, and third-space fluid loss that results in an intravascular hypovolemia. These are subcategories of distributive shock.
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.
The treatment goal for shock is to prevent end-organ injury and halt the progression to cardiopulmonary failure and cardiac arrest.
Initial fluid resuscitation:
Normal saline or lactated.
Ringer’s (isotonic).
ADMINISTRATION OF FLUID BOLUS
Initial bolus should be a rapid infusion of isotonic crystalloid of 20 mL/kg over 20 min.
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.
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).
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).
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.
CLASSIFICATION OF SHOCK (HEMORRHAGIC/HYPOVOLEMIC SHOCK)
Class I
0–15% volume loss.
Normal pulse.
Normal blood pressure.
Normal capillary refill.
Normal respiratory rate.
Urine output 1–2 mL/kg/hr.
Class II
15–30% volume loss.
Mild tachycardia.
Mildly blood pressure.
Mildly prolonged capillary refill.
Mild tachypnea.
Urine output 0.5–1.0 mL/kg/hr.
Class III
30–40% volume loss.
Tachycardia.
blood pressure.
Prolonged capillary refill.
Tachypnea.
Urine output 0.25–0.5 mL/kg/hr.
Class IV
> 40% volume loss.
Severely tachycardic, bradycardic, or absent pulse.
Very low blood pressure.
Greatly prolonged capillary refill.
Severe tachypnea.
Urine output 0 mL/kg/hr.
PRESSOR SUPPORT IN PEDIATRIC SHOCK
First, attempt multiple fluid boluses.
Try to identify and treat the underlying cause.
Choose pressor agent according to the type of shock present.
PHARMACOLOGIC AGENTS USED IN THE TREATMENT OF SHOCK
Inotropes:
Dopamine
Epinephrine
Dobutamine
Phosphodiesterase inhibitors:
Milrinone
Inamrinone
Vasodilators:
Nitroglycerine
Nitroprusside
Vasopressors:
Epinephrine
Norepinephrine
Dopamine
Vasopressin
HYPOVOLEMIC SHOCK
Multiple crystalloid boluses will be necessary (20 mL/kg bolus over 20 min, repeat PRN).
SEPTIC SHOCK
Multiple crystalloid boluses will be necessary (20 mL/kg bolus over 5–20 min, repeat PRN).
Consider dopamine 5–20 µg/kg/min if patient is normotensive.
Consider epinephrine 0.1–1.0 µg/kg/min if patient is hypotensive.
CARDIOGENIC SHOCK
Initial fluid bolus is usually necessary.
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.)
Consider epinephrine 0.1–1.0 µg/kg/min if the patient is hypotensive.
Cardiac Arrhythmias
Tachycardias.
Bradycardias.
No pulse: Asystole, pulseless electrical activity (PEA), ventricular fibrillation (VF), or pulseless ventricular tachycardia (VT).
TACHYARRHYTHMIAS
Sinus Tachycardia
Defined as a rate of sinus node discharge faster than normal for age.
Age-specific heart rates:
0–3 months (85–205 beats/min): Mean 140 tachycardia > 205.
3 months–2 yr (100–190 beats/min): Mean 130, tachycardia > 190.
2–10 yr (60–140 beats/min): Mean 80, tachycardia > 140.
> 10 yr (60–100 beats/min): Mean 75, tachycardia > 100.
Typically, a response to a need for cardiac output (compensatory tachycardia).
Common causes include fever, pain, anxiety, blood loss, sepsis, and shock.
Always assess and reassess ABCs.
Therapy entails treating the underlying cause.
Supraventricular Tachycardia (SVT)
SVT is rapid, very regular, often paroxysmal.
Often exceeds 220 bpm in infants, exceeds 180 bpm in children.
P waves are absent or indistinguishable.
QRS complex is typically narrow (< 0.08 sec).
SVT is most commonly caused by reentry mechanism.
SVT algorithm:
Assess ABCs, support as needed.
Administer 100% oxygen, ventilate as needed.
Document electrocardiogram (ECG)/rhythm tracing: Evaluate QRS—narrow ≤ 0.08 sec.
Establish IV or IO access:
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).
Synchronized cardioversion: 0.5 to 1 J/kg; if not effective to 2 J/kg (sedate if possible, but do not delay cardioversion).
If still in SVT: Obtain cardiology consult and consider administration of:
Amiodarone 5 mg/kg IV over 20–60 min or
Procainamide 15 mg/kg IV over 30–60 min. If patient becomes unstable at any time, proceed directly with synchronized cardioversion.
Management of SVT:
Stable: Vagal maneuvers and/or adenosine.
Unstable: Synchronized cardioversion.
Ventricular Tachycardia (VT) (with pulse)
Wide QRS complex (> 0.08 sec).
P waves not present.
Very uncommon in children.
Risk factors include prolonged QT syndrome, cardiac anomalies, drug ingestions, electrolyte abnormalities, underlying cardiac disease.
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, to 2 J/kg (sedate if possible, but do not delay cardioversion).
6. If still in VT: Call cardiology consult for administration of:
Amiodarone 5 mg/kg IV over 20–60 min or
Procainamide 15 mg/kg IV over 30–60 min.
7. Obtain cardiology consult as needed.
8. Identify and treat possible causes:
4Hs: Hypovolemia, Hypoxemia, Hypothermia, Hyper/hypokalemia.
4Ts: Tamponade, Tension pneumothorax, Toxins, Thromboembolism.
Ventricular tachycardia:
QRS wide
No P waves
Rare in children
BRADYARRHYTHMIAS
Age-specific heart rates:
0–3 months (85–205 beats/min); bradycardia < 85.
3 months–2 yr (100–190 beats/min); bradycardia < 100.
2–10 yr (60–140 beats/min); bradycardia < 60.
> 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.
If stable, continue to support ABCs, admit for observation.
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 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.
PULSELESS ARRHYTHMIAS
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)
PEA in children, while rare, usually occurs as a result of progressive respiratory and/or circulatory failure.
As with adult PEA, the differential diagnosis for pediatric PEA is essential to successful resuscitation.
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):
Hypovolemia (volume—normal saline infusion).
Hypoxia (oxygen, intubation, ventilation).
Hypothermia (warmed normal saline infusion).
Massive pulmonary embolism (heparin infusion, thrombolysis).
Acidosis (sodium bicarbonate).
Tension pneumothorax (needle decompression).
Cardiac tamponade (pericardiocentesis).
Hyperkalemia (insulin/glucose, calcium).
Drug overdose from TCAs, digoxin, β blockers, calcium channel blockers.
7. Epinephrine (every 3–5 min):
IV/IO 0.01 mg/kg (0.1 mL/kg of 1:10,000).
ETT 0.1 mg/kg (0.1 mL/kg of 1:1000).
Asystole
Most common pulseless rhythm in children.
Airway management and hyperventilation are the most important interventions.
Always confirm asystole in more than one lead and ensure that leads are properly connected.
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):
IV/IO 0.01 mg/kg (0.1 mL/kg of 1:10,000).
ETT 0.1 mg/kg (0.1 mL/kg of 1:1000).
7. Consider external pacing.
8. Search for reversible causes.
Note that atropine and bicarbonate are not part of the algorithm for asystole.
NEONATAL RESUSCITATION
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.
Birth asphyxia accounts for about 19% of the approximately 5 million neonatal deaths that occur each year worldwide.
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)?
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?
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?
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?
Healthy babies should have flexed extremities and be active.
Start CPR on neonate if pulse < 60.
Newborn Assessment
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.
Airway: Position the airway and suction any secretions (neck slightly extended in the “sniffing” position).
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).
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
Position
Suction
Stimulate cry
Warm and dry
Newborn Resuscitation
Assess every newborn (and give the appropriate support).
1. Delivery outside the delivery room.
2. ABCs—assess and support.
Airway (position and suction).
Breathing (stimulate to cry).
Circulation (heart rate and color).
Temperature (warm and dry).
3. Oxygen (100%).
4. Establish effective ventilation:
Bag-valve-mask.
Laryngeal mask airway (LMA) can be an effective alternative for establishing an airway when bag-valve-mask fails.
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
Ventilation rate: 40–60/min (room air or 100% oxygen, with titration to lowest level).
Compression rate: 120 events/min (90 compressions/30 ventilations/min).
Compression/ventilation ratio: 3:1.
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:
Strong respiratory efforts.
Good muscle tone.
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.
APGAR
See Gestation and Birth chapter.
If meconium is present during a delivery, aggressively suction hypopharynx as soon as head is delivered.