Resuscitation

In infants and children, cardiac arrest is not usually caused by primary cardiac pathology, as it is in adults. Although primary cardiac disease accounts for approximately 13% of pediatric arrests, pediatric cardiopulmonary arrest is more commonly the result of respiratory failure, which in turn leads to secondary (asphyxia) arrest.

This section covers the following topics:

• Resuscitation Algorithms

• Pediatric Bradycardia with a Pulse and Poor Perfusion

• Tachycardia with a Pulse and Poor Perfusion

• Pulseless Arrest

To improve outcomes of pediatric resuscitation from cardiac arrest, the American Heart Association (AHA) developed age-specific cardiopulmonary resuscitation (CPR) guidelines and pediatric advanced life support (PALS) algorithms in 2010, which were revised and updated in 2015 and again in 2020. Evidence suggests that family presence during pediatric resuscitation can help family members process the trauma of the event, regardless of outcome.

Resuscitation Algorithms

In accordance with the PALS algorithm, pediatric CPR is usually performed in an advanced health care environment in which multiple rescuers perform several actions simultaneously. These actions include the rapid assessment of a child’s airway, breathing, and circulation (ABCs). Research from the AHA has demonstrated that the following quality measures must be met to maximize the chances of a child’s postarrest survival:

• airway and circulation should be addressed concurrently (given the high proportion of asphyxia arrests in children):

  • simultaneous initiation of immediate chest compressions (where indicated) and initial airway management, including application of supplemental oxygen or bag-mask ventilation and preparation for an advanced airway as needed

  • pulse-check locations:

    • infants aged <12 months: brachial artery

    • children aged >1 year: femoral or carotid arteries

• high-quality CPR:

  • between 100 and 120 compressions per minute

  • adequate compression depth (one-third of the anteroposterior diameter of the child’s chest)

    • infants: approximately 1.5 inches

    • children: approximately 2 inches

  • allowance for complete recoil of the chest between compressions

  • delivery of compressions on a firm surface (e.g., backboard)

• compression-to-ventilation ratio (without an advanced airway):

  • single rescuer: 30 compressions to 2 breaths

  • two rescuers: 15 compressions to 2 breaths

  • one breath every 2 to 3 seconds (20-30 breaths per minute)

• obtain monitor/defibrillator, establish vascular access, prepare to administer anticipated medications

Bradycardia with a Pulse and Poor Perfusion

Although normal heart rate varies with age, bradycardia is generally accepted as a heart rate <60 beats per minute outside of the neonatal period. Signs and symptoms of poor perfusion include pallor, cyanosis, prolonged capillary refill, and depressed mental status.

Etiology:

• most often results from impending or existing respiratory failure

• nonrespiratory causes: heart block, increased intracranial pressure, hypoglycemia, hypercalcemia, drug effect, increased parasympathetic tone, hypothermia, post-heart transplant bradycardia

(Reprinted with permission. 2020 American Heart Association Guidelines for CPR & ECC, Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. ©2020 American Heart Association, Inc.)

Tachycardia with a Pulse and Poor Perfusion

In the pediatric population, the definition of tachycardia varies by age. A 2011 review of observational studies established normal heart-rate percentiles by age group. Generally, tachycardia is considered to be a persistent heart rate >90th percentile for age. In a 2015 study, researchers derived reference values for heart rate by age and body temperature in hospitalized children and compared those values to reference values in children in primary care and in the emergency department (ED).

• sinus tachycardia

  • etiology: hypoxemia, hypovolemia, hyperthermia, metabolic abnormalities, and pain/anxiety and shock

  • management: treat reversible causes (e.g., volume expansion, antipyretic)

• supraventricular tachycardia (SVT)

  • etiology: most commonly due to accessory reentry pathways

  • management:

    • vagal maneuvers: knee to chest, forceful blowing on an obstructed straw, ice to face, rectal stimulation (infants)

    • medication administration, cardioversion, or both when vagal maneuvers are unsuccessful (see algorithm)

      • adenosine: pushed as rapidly as possible in an intravenous (IV) site close to the heart (e.g., right-antecubital vein), given adenosine’s short half-life (<1 minute)

• ventricular tachycardia (VT)

  • etiology: prolonged QT syndrome, structural heart disease, myocarditis, cardiomyopathy, and poisonings/drug effects

  • management: medication administration, cardioversion, or both (see algorithm)

(Reprinted with permission. 2020 American Heart Association Guidelines for CPR & ECC, Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. ©2020 American Heart Association, Inc.)

Pulseless Arrest

• asystole/pulseless electrical activity (PEA): asystole and any other “nonshockable” rhythms without palpable pulses; PEA has organized electrical activity — most commonly slow, wide QRS complexes, but no pulse

  • management: CPR, early epinephrine administration and treatment of reversible causes (see algorithm)

• ventricular fibrillation (VF)/pulseless VT: “shockable” rhythms; VF has irregular unformed QRS complexes of varying amplitudes without any identifiable P waves; pulseless VT is a wide QRS complex tachycardia without a pulse

  • management: immediate defibrillation per the algorithm below

• torsades de pointes: polymorphic VT associated with a long QT interval; can degenerate into VF

  • etiology:

    • congenital (e.g., Brugada syndrome)

    • medication toxicity:

      • class IA antiarrhythmic (procainamide, quinidine)

      • class III antiarrhythmic (sotalol, amiodarone)

      • tricyclic antidepressants

      • digitalis

      • multidrug interactions

    • metabolic derangement (e.g., hypokalemia, hypomagnesemia)

  • management:

    • rapid IV infusion of magnesium sulfate

    • defibrillation per VF algorithm if torsade degenerates

(Reprinted with permission. 2020 American Heart Association Guidelines for CPR & ECC, Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. ©2020 American Heart Association, Inc.)