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SPECIAL ARTICLE |
Key Words: cardiopulmonary resuscitation
Abbreviations: LMA—laryngeal mask airway • RSI—rapid sequence intubation • ID—internal diameter • IV—intravenous • ECG—electrocardiographic • IO—intraosseous • AV—atrioventricular • VF—ventricular fibrillation • VT—ventricular tachycardia • AED—automated external defibrillator • PEA—pulseless electrical activity • PALS—pediatric advanced life support • SVT—supraventricular tachycardia
In contrast to adults, sudden cardiac arrest in children is uncommon, and cardiac arrest does not usually result from a primary cardiac cause.1 More often it is the terminal event of progressive respiratory failure or shock, also called an asphyxial arrest.
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RESPIRATORY FAILURE |
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SHOCK |
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Signs of compensated shock include
As compensatory mechanisms fail, signs of inadequate end-organ perfusion develop. In addition to the above, these signs include
Signs of decompensated shock include the signs listed above plus hypotension. In the absence of blood pressure measurement, decompensated shock is indicated by the nondetectable distal pulses with weak central pulses in an infant or child with other signs and symptoms consistent with inadequate tissue oxygen delivery.
The most common cause of shock is hypovolemia, one form of which is hemorrhagic shock. Distributive and cardiogenic shock are seen less often.
Learn to integrate the signs of shock because no single sign confirms the diagnosis. For example:
In compensated shock, blood pressure remains normal; it is low in decompensated shock. Hypotension is a systolic blood pressure less than the 5th percentile of normal for age, namely:
10 years of age |
AIRWAY |
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Nasopharyngeal airways will be better tolerated than oral airways by patients who are not deeply unconscious. Small nasopharyngeal tubes (for infants) may be easily obstructed by secretions.
Laryngeal Mask Airway
There is insufficient evidence to recommend for or against the routine use of a laryngeal mask airway (LMA) during cardiac arrest (Class Indeterminate). When endotracheal intubation is not possible, the LMA is an acceptable adjunct for experienced providers (Class IIb; LOE 7),5 but it is associated with a higher incidence of complications in young children.6
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BREATHING: OXYGENATION AND ASSISTED VENTILATION |
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Oxygen
There are no studies comparing various concentrations of oxygen during resuscitation beyond the perinatal period. Use 100% oxygen during resuscitation (Class Indeterminate). Monitor the patient's oxygen level. When the patient is stable, wean the supplementary oxygen if the oxygen saturation is maintained.
Pulse Oximetry
If the patient has a perfusing rhythm, monitor oxygen saturation continuously with a pulse oximeter because clinical recognition of hypoxemia is not reliable.7 Pulse oximetry, however, may be unreliable in a patient with poor peripheral perfusion.
Bag-Mask Ventilation
Bag-mask ventilation can be as effective as ventilation through an endotracheal tube for short periods and may be safer.8–11 In the prehospital setting ventilate and oxygenate infants and children with a bag-mask device, especially if transport time is short (Class IIa; LOE 18; 310; 49,11). Bag-mask ventilation requires training and periodic retraining on how to select a correct mask size, open the airway, make a tight seal between mask and face, ventilate, and assess effectiveness of ventilation (see Part 11: "Pediatric Basic Life Support").
Precautions
Victims of cardiac arrest are frequently overventilated during resuscitation.12–14 Excessive ventilation increases intrathoracic pressure and impedes venous return, reducing cardiac output, cerebral blood flow, and coronary perfusion.13 Excessive ventilation also causes air trapping and barotrauma in patients with small-airway obstruction and increases the risk of stomach inflation, regurgitation, and aspiration.
Minute ventilation is determined by the tidal volume and ventilation rate. Use only the force and tidal volume needed to make the chest rise visibly. During CPR for the patient with no advanced airway (eg, endotracheal tube, esophageal-tracheal combitube [Combitube], LMA) in place, ventilation rate is determined by the compression-ventilation ratio. Pause after 30 compressions (1 rescuer) or after 15 compressions (2 rescuers) to give 2 ventilations with mouth-to-mouth, mouth-to-mask, or bag-mask techniques. Give each breath over 1 second.
If an advanced airway is in place during CPR (eg, endotracheal tube, Combitube, LMA), ventilate at a rate of 8 to 10 times per minute without pausing chest compressions. In the victim with a perfusing rhythm but absent or inadequate respiratory effort, give 12 to 20 breaths per minute. One way to achieve this rate with a ventilating bag is to use the mnemonic "squeeze-release-release" at a normal speaking rate.8,15
Two-Person Bag-Mask Ventilation
A 2-person technique may be more effective than ventilation by a single rescuer if the patient has significant airway obstruction, poor lung compliance, or difficulty in creating a tight mask-to-face seal.16,17 One rescuer uses both hands to maintain an open airway with a jaw thrust and a tight mask-to-face seal while the other compresses the ventilation bag. Both rescuers should observe the victim's chest to ensure chest rise.
Gastric Inflation
Gastric inflation may interfere with effective ventilation18 and cause regurgitation. You can minimize gastric inflation by doing the following:
Ventilation Through an Endotracheal Tube
Endotracheal intubation in infants and children requires special training because the pediatric airway anatomy differs from adult airway anatomy. Success and a low complication rate are related to the length of training, supervised experience in the operating room and in the field,23,24 adequate ongoing experience,25 and the use of rapid sequence intubation (RSI).23,26,27
RSI
To facilitate emergency intubation and reduce the incidence of complications, skilled, experienced providers may use sedatives, neuromuscular blocking agents, and other medications to rapidly sedate and paralyze the victim.28 Use RSI only if you are trained and have experience using these medications and are proficient in the evaluation and management of the pediatric airway. If you use RSI you must have a secondary plan to manage the airway in the event that you cannot achieve intubation.
Cuffed Versus Uncuffed Tubes
In the in-hospital setting a cuffed endotracheal tube is as safe as an uncuffed tube for infants beyond the newborn period and in children.29–31 In certain circumstances (eg, poor lung compliance, high airway resistance, or a large glottic air leak) a cuffed tube may be preferable provided that attention is paid to endotracheal tube size, position, and cuff inflation pressure (Class IIa; LOE 230; 329,31). Keep cuff inflation pressure <20 cm H2O.32
Endotracheal Tube Size
The internal diameter (ID) of the appropriate endotracheal tube for a child will roughly equal the size of that child's little finger, but this estimation may be difficult and unreliable.33,34 Several formulas such as the ones below allow estimation of proper endotracheal tube size (ID) for children 1 to 10 years of age, based on the child's age:
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The formula for estimation of a cuffed endotracheal tube size is as follows30:
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Verification of Endotracheal Tube Placement
There is a high risk that an endotracheal tube will be misplaced (ie, placed in the esophagus or in the pharynx above the vocal chords), displaced, or become obstructed,8,36 especially when the patient is moved.37 No single confirmation technique, including clinical signs38 or the presence of water vapor in the tube,39 is completely reliable, so providers must use both clinical assessment and confirmatory devices to verify proper tube placement immediately after intubation, during transport, and when the patient is moved (ie, from gurney to bed).
Immediately after intubation and again after securing the tube, confirm correct tube position with the following techniques while you provide positive-pressure ventilation with a bag:
After intubation secure the tube. There is insufficient evidence to recommend any one method (Class Indeterminate). After you secure the tube, maintain the patient's head in a neutral position; neck flexion pushes the tube farther into the airway, and extension pulls the tube out of the airway.42,43
If an intubated patient's condition deteriorates, consider the following possibilities (DOPE):
Exhaled or End-Tidal CO2 Monitoring
In infants and children with a perfusing rhythm, use a colorimetric detector or capnography to detect exhaled CO2 to confirm endotracheal tube position in the prehospital and in-hospital settings (Class IIa; LOE 544) and during intrahospital and interhospital transport (Class IIb; LOE 545). A color change or the presence of a capnography wave form confirms tube position in the trachea but does not rule out right main bronchus intubation. During cardiac arrest, if exhaled CO2 is not detected, confirm tube position with direct laryngoscopy (Class IIa; LOE 546–49; 650) because the absence of CO2 may be a reflection of low pulmonary blood flow.
You may also detect a low end-tidal CO2 in the following circumstances:
Esophageal Detector Devices
The self-inflating bulb (esophageal detector device) may be considered to confirm endotracheal tube placement in children weighing >20 kg with a perfusing rhythm (Class IIb; LOE 255,56). There are insufficient data to make a recommendation for or against its use in children during cardiac arrest (Class Indeterminate).
Transtracheal Catheter Ventilation
Transtracheal catheter ventilation may be considered for support of oxygenation in the patient with severe airway obstruction if you cannot provide oxygen or ventilation any other way. Try transtracheal ventilation only if you are properly trained and have appropriate equipment.57
Suction Devices
A suction device with an adjustable suction regulator should be available. Use a maximum suction force of 80 to 120 mm Hg for suctioning the airway via an endotracheal tube.58 You will need higher suction pressures and large-bore noncollapsible suction tubing as well as semirigid pharyngeal tips to suction the mouth and pharynx.
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CIRCULATION |
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Backboard
A firm surface that extends from the shoulders to the waist and across the full width of the bed provides optimal support for effective chest compressions. In ambulances and mobile life support units, use a spine board.59,60
CPR Techniques and Adjuncts
There are insufficient data to make a recommendation for or against the use of mechanical devices to compress the sternum, active compression-decompression CPR, interposed abdominal compression CPR, pneumatic antishock garment during resuscitation from cardiac arrest, and open-chest direct heart compression (Class Indeterminate). For further information see Part 6: "CPR Techniques and Devices."
Extracorporeal Membrane Oxygenation
Consider extracorporeal CPR for in-hospital cardiac arrest refractory to initial resuscitation attempts if the condition leading to cardiac arrest is reversible or amenable to heart transplantation, if excellent conventional CPR has been performed after no more than several minutes of no-flow cardiac arrest (arrest time without CPR), and if the institution is able to rapidly perform extracorporeal membrane oxygenation (Class IIb; LOE 561,62). Long-term survival is possible even after >50 minutes of CPR in selected patients.61,62
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CARDIOVASCULAR MONITORING |
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VASCULAR ACCESS |
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IO Access
IO access is a rapid, safe, and effective route for the administration of medications and fluids,64,65 and it may be used for obtaining an initial blood sample during resuscitation (Class IIa; LOE 365,66). You can safely administer epinephrine, adenosine, fluids, blood products,64,66 and catecholamines.67 Onset of action and drug levels achieved are comparable to venous administration.68 You can also obtain blood specimens for type and crossmatch and for chemical and blood gas analysis even during cardiac arrest,69 but acid-base analysis is inaccurate after sodium bicarbonate administration via the IO cannula.70 Use manual pressure or an infusion pump to administer viscous drugs or rapid fluid boluses,71,72 and follow each medication with a saline flush to promote entry into the central circulation.
Venous Access
A central IV line provides more secure long-term access, but central drug administration does not achieve higher drug levels or a substantially more rapid response than peripheral administration.73
Endotracheal Drug Administration
Any vascular access, IO or IV, is preferable, but if you cannot establish vascular access, you can give lipid-soluble drugs such as lidocaine, epinephrine, atropine, and naloxone ("LEAN")74,75 via the endotracheal tube,76 although optimal endotracheal doses are unknown (Table 1). Flush with a minimum of 5 mL normal saline followed by 5 assisted manual ventilations.77 If CPR is in progress, stop chest compressions briefly during administration of medications. Although naloxone and vasopressin may be given by the endotracheal route, there are no human studies to support a specific dose. Non–lipid-soluble drugs (eg, sodium bicarbonate and calcium) may injure the airway and should not be administered via the endotracheal route.
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EMERGENCY FLUIDS AND MEDICATIONS |
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Fluids
Use an isotonic crystalloid solution (eg, lactated Ringer's solution or normal saline)80,81 to treat shock; there is no benefit in using colloid (eg, albumin) during initial resuscitation.82 Use bolus therapy with a glucose-containing solution to only treat documented hypoglycemia (Class IIb; LOE 283; 684). There are insufficient data to make a recommendation for or against hypertonic saline for shock associated with head injuries or hypovolemia (Class Indeterminate).85,86
Medications (See Table 1)
Adenosine
Adenosine causes a temporary atrioventricular (AV) nodal conduction block and interrupts reentry circuits that involve the AV node. It has a wide safety margin because of its short half-life.
A higher dose may be required for peripheral administration than central venous administration.87,88 Based on experimental data89 and a case report,90 adenosine may also be given by IO route. Administer adenosine and follow with a rapid saline flush to promote flow toward the central circulation.
Amiodarone
Amiodarone slows AV conduction, prolongs the AV refractory period and QT interval, and slows ventricular conduction (widens the QRS).
Precautions
Monitor blood pressure and administer as slowly as the patient's clinical condition allows; it should be administered slowly to a patient with a pulse but may be given rapidly to a patient with cardiac arrest or ventricular fibrillation (VF). Amiodarone causes hypotension through its vasodilatory property. The severity of the hypotension is related to the infusion rate and is less common with the aqueous form of amiodarone.91
Monitor the ECG because complications may include bradycardia, heart block, and torsades de pointes ventricular tachycardia (VT). Use extreme caution when administering with another drug causing QT prolongation, such as procainamide. Consider obtaining expert consultation. Adverse effects may be long lasting because the half-life is up to 40 days.92
Atropine
Atropine sulfate is a parasympatholytic drug that accelerates sinus or atrial pacemakers and increases AV conduction.
Precautions
Small doses of atropine (<0.1 mg) may produce paradoxical bradycardia.93 Larger than recommended doses may be required in special circumstances (eg, organophosphate poisoning94 or exposure to nerve gas agents).
Calcium
Routine administration of calcium does not improve outcome of cardiac arrest.95 In critically ill children, calcium chloride may provide greater bioavailability than calcium gluconate.96 Preferably administer calcium chloride via a central venous catheter because of the risk of sclerosis or infiltration with a peripheral venous line.
Epinephrine
The 
-adrenergic-mediated vasoconstriction of epinephrine increases aortic diastolic pressure and thus coronary perfusion pressure, a critical determinant of successful resuscitation.97,98
Precautions
Administer all catecholamines through a secure line, preferably into the central circulation; local ischemia, tissue injury, and ulceration may result from tissue infiltration.
Do not mix catecholamines with sodium bicarbonate; alkaline solutions inactivate them.
In patients with a perfusing rhythm, epinephrine causes tachycardia and may cause ventricular ectopy, tachyarrhythmias, hypertension, and vasoconstriction.99
Glucose
Infants have high glucose requirements and low glycogen stores and develop hypoglycemia when energy requirements rise.100 Check blood glucose concentrations during and after arrest and treat hypoglycemia promptly (Class IIb; LOE 1101; 7 [most extrapolated from neonates and adult ICU studies]).
Lidocaine
Lidocaine decreases automaticity and suppresses ventricular arrhythmias102 but is not as effective as amiodarone for improving intermediate outcomes (ie, return of spontaneous circulation or survival to hospital admission) among adult patients with VF refractory to a shock and epinephrine.103 Neither lidocaine nor amiodarone has been shown to improve survival to hospital discharge among patients with VF cardiac arrest.
Precautions
Lidocaine toxicity includes myocardial and circulatory depression, drowsiness, disorientation, muscle twitching, and seizures, especially in patients with poor cardiac output and hepatic or renal failure.104,105
Magnesium
There is insufficient evidence to recommend for or against the routine administration of magnesium during cardiac arrest (Class Indeterminate).106–108 Magnesium is indicated for the treatment of documented hypomagnesemia or for torsades de pointes (polymorphic VT associated with long QT interval). Magnesium produces vasodilation and may cause hypotension if administered rapidly.
Procainamide
Procainamide prolongs the refractory period of the atria and ventricles and depresses conduction velocity.
Precautions
There is little clinical data on using procainamide in infants and children.109,110 Infuse procainamide very slowly while you monitor for hypotension, prolongation of the QT interval, and heart block. Stop the infusion if the QRS widens to >50% of baseline or if hypotension develops. Use extreme caution when administering with another drug causing QT prolongation, such as amiodarone. Consider obtaining expert consultation.
Sodium Bicarbonate
The routine administration of sodium bicarbonate has not been shown to improve outcome of resuscitation (Class Indeterminate). After you have provided effective ventilation and chest compressions and administered epinephrine, you may consider sodium bicarbonate for prolonged cardiac arrest (Class IIb; LOE 6). Sodium bicarbonate administration may be used for treatment of some toxidromes (see "Toxicologic Emergencies" below) or special resuscitation situations.
During cardiac arrest or severe shock, arterial blood gas analysis may not accurately reflect tissue and venous acidosis.111,112
Precautions
Excessive sodium bicarbonate may impair tissue oxygen delivery113; cause hypokalemia, hypocalcemia, hypernatremia, and hyperosmolality114,115; decrease the VF threshold116; and impair cardiac function.
Vasopressin
There is limited experience with the use of vasopressin in pediatric patients,117 and the results of its use in the treatment of adults with VF cardiac arrest have been inconsistent.118–121 There is insufficient evidence to make a recommendation for or against the routine use of vasopressin during cardiac arrest (Class Indeterminate; LOE 5117; 6121; 7118–120 [extrapolated from adult literature]).
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PULSELESS ARREST |
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"Shockable Rhythm": VF/Pulseless VT (Box 3)
VF occurs in 5% to 15% of all pediatric victims of out-of-hospital cardiac arrest123–125 and is reported in up to 20% of pediatric in-hospital arrests at some point during the resuscitation. The incidence increases with age.123,125 Defibrillation is the definitive treatment for VF (Class I) with an overall survival rate of 17% to 20%,125–127 but in adults the probability of survival declines by 7% to 10% for each minute of arrest without CPR and defibrillation.128 The decline in survival is more gradual when early CPR is provided.
Defibrillators
Defibrillators are either manual or automated (AED), with monophasic or biphasic waveforms. For further information see Part 5: "Electrical Therapies: Automated External Defibrillators, Defibrillation, Cardioversion, and Pacing."
Institutions that care for children at risk for arrhythmias and cardiac arrest (eg, hospitals, emergency departments) ideally should have defibrillators available that are capable of energy adjustment that is appropriate for children. Many AED parameters are set automatically. When using a manual defibrillator, several elements should be considered, and they are highlighted below.
Paddle Size
Use the largest paddles or self-adhering electrodes129–131 that will fit on the chest wall without touching (leave about 3 cm between the paddles). The best paddle size is
Interface
The electrode-chest wall interface can be gel pads, electrode cream, paste, or self-adhesive monitoring-defibrillation pads. Do not use saline-soaked pads, ultrasound gel, bare paddles, or alcohol pads.
Paddle Position
Apply firm pressure on the paddles (manual) placed over the right side of the upper chest and the apex of the heart (to the left of the nipple over the left lower ribs). Alternatively place one electrode on the front of the chest just to the left of the sternum and the other over the upper back below the scapula.132
Energy Dose
The lowest energy dose for effective defibrillation and the upper limit for safe defibrillation in infants and children are not known. Energy doses >4 J/kg (up to 9 J/kg) have effectively defibrillated children133–135 and pediatric animal models136 with negligible adverse effects. Based on data from adult studies137,138 and pediatric animal models,139–141 biphasic shocks appear to be at least as effective as monophasic shocks and less harmful. With a manual defibrillator (monophasic or biphasic), use a dose of 2 J/kg for the first attempt (Class IIa; LOE 5142; 6136) and 4 J/kg for subsequent attempts (Class Indeterminate).
AEDs
Many AEDs can accurately detect VF in children of all ages143–145 and differentiate shockable from nonshockable rhythms with a high degree of sensitivity and specificity.143,144 Since publication of the "Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care," data have shown that AEDs can be safely and effectively used in children 1 to 8 years of age.143–146 There are insufficient data to make a recommendation for or against using an AED in infants <1 year of age (Class Indeterminate).146 When using an AED for children about 1 to 8 years old, use a pediatric attenuator system, which decreases the delivered energy to a dose suitable for children (Class IIb; LOE 5136; 6139,141). If an AED with a pediatric attenuating system is not available, use a standard AED, preferably one with sensitivity and specificity for pediatric shockable rhythms. It is recommended that systems and institutions caring for children and having AED programs should use AEDs with both a high specificity to recognize pediatric shockable rhythms and a pediatric attenuating system.
Defibrillation Sequence (Boxes 4, 5, 6, 7, 8)
The following are important considerations:
Torsades de Pointes
This polymorphic VT is seen in patients with a long QT interval, which may be congenital or may result from toxicity with type IA antiarrhythmics (eg, procainamide, quinidine, and disopyramide) or type III antiarrhythmics (eg, sotalol and amiodarone), tricyclic antidepressants (see below), digitalis, or drug interactions.155,156 These are examples of contributing factors listed in the green box in the algorithm.
Treatment
Regardless of the cause, treat torsades de pointes with a rapid (over several minutes) IV infusion of magnesium sulfate.
"Nonshockable Rhythm": Asystole/PEA (Box 9)
The most common ECG findings in infants and children in cardiac arrest are asystole and PEA. PEA is organized electrical activity—most commonly slow, wide QRS complexes—without palpable pulses. Less frequently there is a sudden impairment of cardiac output with an initially normal rhythm but without pulses and with poor perfusion. This subcategory (formerly known as electromechanical dissociation [EMD]) is more likely to be treatable. For asystole and PEA:
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BRADYCARDIA |
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TACHYCARDIA AND HEMODYNAMIC INSTABILITY |
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0.08 second (narrow-complex tachycardia) or >0.08 second (wide-complex tachycardia).
Narrow-Complex (0.08 Second) Tachycardia
Evaluation of a 12-lead ECG (box 3) and the patient's clinical presentation and history (boxes 4 and 5) should help you differentiate probable sinus tachycardia from probable supraventricular tachycardia (SVT). If the rhythm is sinus tachycardia, search for and treat reversible causes.
Probable SVT (Box 5)
Monitor rhythm during therapy to evaluate effect. The choice of therapy depends on the patient's degree of hemodynamic instability.
5 mL of normal saline with the other.
Wide-Complex (>0.08 Second) Tachycardia (Box 9)
Wide-complex tachycardia with poor perfusion is probably ventricular in origin but may be supraventricular with aberrancy.173
Tachycardia With Hemodynamic Stability
Because all arrhythmia therapies have the potential for serious adverse effects, consider consulting an expert in pediatric arrhythmias before treating children who are hemodynamically stable.
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SPECIAL RESUSCITATION SITUATIONS |
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The following are special aspects of trauma resuscitation:
Children With Special Health Care Needs
Children with special health care needs182–184 may require emergency care for their chronic conditions (eg, obstruction of a tracheostomy), failure of support technology (eg, ventilator failure), progression of their underlying disease, or events unrelated to those special needs.185 For additional information about CPR see Part 11: "Pediatric Basic Life Support."
Ventilation With a Tracheostomy or Stoma
Parents, school nurses, and home health care providers should know how to assess patency of the airway, clear the airway, and perform CPR using the artificial airway in a child with a tracheostomy.
Parents and providers should be able to provide ventilation via the tracheostomy tube and verify effectiveness by chest expansion. If you cannot ventilate after suctioning the tube, replace it. If a clean tube is unavailable, perform mouth-to-stoma or mask-to-stoma ventilations. If the upper airway is patent, you may be able to provide effective bag-mask ventilation through the nose and mouth while you or someone else occludes the tracheal stoma.
Toxicologic Emergencies
Overdose with cocaine, narcotics, tricyclic antidepressants, calcium channel blockers, and ß-adrenergic blockers poses some unique resuscitation problems in addition to the usual resuscitative measures.
Cocaine
Acute coronary syndrome, manifested by chest pain and cardiac rhythm disturbances (including VT and VF), is the most frequent
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RESPIRATORY FAILURE
SHOCK
