Pediatric Cardiac Arrest Algorithm

Shout for Help/Activate Emergency Response

1
Start CPR
 Give oxygen
 Attach monitor/defibrillator

Yes No
2 Rhythm shockable?
VF/VT 9 Asystole/PEA

3
Shock
4
CPR 2 min
 IO/IV access

No
Rhythm shockable?
Yes
5
Shock 10
6 CPR 2 min
CPR 2 min  IO/IV access
 Epinephrine every 3-5 min  Epinephrine every 3-5 min
 Consider advanced airway  Consider advanced airway

No Yes
Rhythm shockable? Rhythm shockable?
Yes
7 Shock No
8
11
CPR 2 min
CPR 2 min
 Amiodarone
 Treat reversible causes  Treat reversible causes

No Yes
Rhythm shockable?
12
 Asystole/PEA → 10 or 11
 Organizes rhythm → check pulse Go to
 Pulse present (ROSC) → post-cardiac arrest care 5 or 7
Doses/Details for the
Pediatric cardiac arrest Algorithm
CPR Quality Advanced Airway
 Push hard (≥ /3 of anterior-posterior
1
 Endotracheal intubation or supraglottic
diameter of chest) and fast (at least advanced airway
100/min) and allow complete chest recoil  Waveform capnography or capnometry to
 Minimize interruptions in compressions confirm and monitor ET tube placement
 Avoid excessive ventilation  Onece advanced airway in place, give 1
 Rotate compressor every 2 minutes breath every 6-8 seconds (8-10 breaths per
 If no advanced airway, 15:2 compression- minute).
ventilation ratio. If advanced airway, 8-10
breaths per minute with continous chest Return of Spontaneous
compressions Circulation (ROSC)
 Pulse and blood pressure
Shock Energy  Spontaneous waves with intra-arterial
For Defibrillation monitoring
First shock 2 J/kg,
second shock 4 J/kg, Reversible Causes
subsequent shocks ≥4 J/kg, - Hypovolemia
maximum 10 J/kg or adult dose. - Hypoxia
- Hydrogen ion (acidosis)
Drug Therapy - Hypoglycemia
 Epinephrine IO/IV Dose : - Hypo-/hyperkalemia
0.01 mg/kg (0.1 mL/kg of 1:10 000 - Hypothermia
concentration). Repeat every 3-5 minutes. - Tension pneumothorax
If no IO/IV access, may give endotracheal - Tamponade, cardiac
dose : - Toxins
0.1 mg/kg (0.1 mL/kg of 1:1000 - Thrombosis, pulmonary
concentration). - Thrombosis, coronary
 Amiodarone IO/IV Dose :
5 mg/kg bolus during cardiac arrest. May
repeat up to 2 times for refractory
VF/pulseless VT.
PALS Systematic Approach Algorithm

Initial Impression
(consciousness, breathing, color)

Is child unresponsive with no breathing or only gasping ?

Yes
No
Shout for Help/Activate
Emergency Response
(as appropriate
for setting)

Yes Open airway and begin

Is there
ventilation and oxygen
a pulse?
as available

No

Is the pulse <60/min

Yes No
with poor perfusion
despite oxygenation
and ventilation ?

If at any time you

Start CPR indentify cardiac arrest Evaluate
(C-A-B)  Primary assessment
 Secondary assessment
 Diagnostic tests

Go to
Pediatric Cardiac Arrest
Algorithm
Intervene Identify

After ROSC, begin

Evaluate-Identify-Intervene
sequence (right column)
Pediatric Bradycardia With a Pulse
And Poor Perfusion Algorithm

Identify and treat underlying cause

 Maintain patent airway; assist breathing as necessary
 Oxygen
 Cardiac monitor to identify rhythm; monitor blood pressure and oximetry
 IO/IV access
 12-Lead ECG if available; don’t delay therapy

No Cardiopulmonary Cardiaopulmonary
compromise Compromise
continues?  Hypotension
 Acutely altered
mental status
Yes
 Signs of shock

CPR if HR <60/min
with poor perfusion despite
oxygenation and ventilation

 Support ABCs
 Give oxygen No Bradycardia
 Observe
persists
 Consider expert
consultation

Yes
Doses/Details
 Epinephrine
 Atropine for increased vagal Epinephirine IO/IV Dose :
tone or primary AV block 0.01 mg/kg (0.1 mL/kg of
 Consider transthoracic 1 : 10 000 concentration).
pacing/transvenous pacing Repeatevery 3-5 minutes.
 Treat underlying causes If IO/IV access not
available but endotracheal
(ET) tube in place, may
give ET dose: 0.1 mg/kg
(0.1 mL/kg of 1 : 1000).

Atropine IO/IV Dose :

If pulseless arrest
0.02 mg/kg. May repeat
develops, go to Cardiac
once. Minimum dose 0.1
Arrest Algorithm
mg and maximum single
dose 0.5 mg.
Pediatric Tachycardia With a Pulse
and Poor Perfusion Algorithm
Identify and treat underlying cause Doses/Details
 Maintain patent airway; assist breathing as necessary Synchronized
 Oxygen Cardioversion :
Begin with 0.5-1 J/kg;
 Cardiac monitor to identify rhythm; monitor blood
if not effective,
pressure and oximetry
increase to 2 J/kg.
 IO/IV access Sedate if needed,but
 12-Lead ECG if available; don’t delay therapy don’t delay
cardioversion.
Narrow Wide Adenosine
(≤0.09 sec) Evaluate (>0.09 sec) IV/IO Dose :
QRS First dose:
duration 0.1 mg/kg rapid bolus
Evaluate rhythm (maximum: 6 mg).
with 12-lead ECG Second dose: 0.2
or monitor mg/kg rapid bolus
(maximum second
dose: 12 mg).
Amiodarone
Probable Probable Possible IV/IO Dose:
sinus supraventricular ventricular 5 mg/kg over
tachycardia tachycardia tachycardia 20-60 minutes
 Compatible  Compatible history or
history Procainamide
(vague, nonspecific);
IV/IO Dose:
consistent with history of abrupt
15 mg/kg over
known cause rate changes 30-60 minutes
 P waves  P waves absent/ Do not routinely
present/normal abnormal administer
 Variable R-R;  HR not variable amiodarone and
constant PR procainamide
 Infants :  Infants: rate usually together
rate usually ≥220/min
<220/min
 Children : rate  Children: rate Cardiopulmonary
usually <180/min usually ≥180/min compromise?
 Hypotension
No
 Acutely altered
mental status
 Signs of shock

Yes
Search for Consider Synchronized Consider
and vagal cardioversion adenosine
treat cause maneuvers if rhythm regular
(No delays) and QRS
monomorphic

Expert
 If IO/IV access present, give adenosine
consultation
OR
advised
 If IO/IV access not available, or if adenosine
 Amiodarone
ineffective, synchronized cardioversion
 Procainamide
PALS Postresuscitation Care
Management of Shock After ROSC Estimation of
Maintenance Fluid
Optimize Ventilation and Oxygenation
Requirements
 Titrate FIO2 to maintain oxyhemoglobin saturation
94%-99%; if possible, wean FIO2 if saturation is 100%  Infants <10 kg:
 Consider advanced airway placement and 4 mL/kg per hour
waveform capnography Example: for an 8-kg infant,
estimated maintenance
fluid rate
= 4mL/kg per hour x 8 kg
Assess for and *Possible = 32 mL per hour
treat Persistent Shock Contributing Factors  Children 10-20 kg:
 Identify, treat Hypovolemia 4 mL/kg per hour for the first
contributing Hypoxia 10 kg + 2 mL/kg per hour for
factors.* Hydrogen ion (acidosis) each kg above 10 kg
 Consider 20 mL/kg IV/IO Hypoglycemia Example: For a 15-kg child,
boluses of isotonic Hypo-/hyperkalemia estimated maintenance fluid
crystalloid. Consider Hypothermia rate
smaller boluses (eg, 10 Tension pneumothorax = (4 mL/kg per hour x 10 kg) +
mL/kg) if poor cardiac Tamponade, cardiac (2 mL/kg per hour x 5 kg)
function suspected. Toxins = 40 mL/hour + 10 mL/hour
 Consider the need for Thrombisis, pulmonary = 50 mL/hour
inotropic and/or Thrombosis, coronary  Children >20 kg: 4 mL/kg per
vasopressor support for Trauma hour for the first 10 kg + 2
fluid-refractory shock. mL/kg per hour for kg 11-20 +
1 mL/kg per hour for each kg
above 20 kg.
Example: for a 28-kg child,
estimated maintenance fluid
rate
Hypotensive Shock Normotensive Shock = (4 mL/kg per hour x 10 kg) +
 Epinephrine  Dobutamine (2 mL/kg per hour x 10 kg) +
 Dopamine  Dopamine (1 mL/kg per hour x 8 kg)
 Norepinephrine  Epinephrine = 40 mL/hour + 20 mL/hour +
 Milrinone 8 mL/hour
= 68 mL per hour
Following initial stabilization,
adjust the rate and composition
of intravenous fluids based on
the patient’s clinical condition
 Monitor for and treat agitation and siezures and state of hydration. In
 Monitor for and treat hypoglycemia general, provide a continuous
 Assess blood gas, serum electrolytes, calcium infusion of a dextrose-containing
 If patient remains comatose after resuscitation solution for infants. Avoid
from cardiac arrest, consider therapeutic hypotonic solutions in critically ill
hypothermia (32°C-34°C) children; for most patients use
 Consider consultation and patient transport to isotonic fluid such as normal
tertiary care center saline (0.9% NaCl) or lactated
Ringer’s solution with or without
dextrose, based on the child’s
clinical status.