General Approach to All Pediatric Patients

Cardiac Arrest / Non-traumatic - Pediatric

Airway management by BVM is sufficient in the pediatric arrest patient. A single attempt at intubation or laryngeal tube placement can be made if time allows. Do not prolong transport or scene time to attempt invasive airway placement.

Basic Life Support

  • Establish responsiveness
  • If trauma suspected, stabilize spine
  • Confirm apnea and pulselessness and administer CPR
  • Apply AED as soon as available for ≥ 8 years old
  • For children ≤ 8 years old use pediatric AED cables/electrodes if available
    • As a last resort in a child ≤ 8 years old in cardiac arrest, apply AED with any available cables/electrodes

Advanced Life Support

  • Full Pediatric ALS Assessment and Treatment
  • Determine cardiac rhythm and refer to appropriate protocol for further management actions
  • Check blood glucose and treat glucose < 70 mg/dl
    • D10W at 5 ml/kg for children < 1 year old (max 40 ml)
    • D25W at 2 ml/kg for children 1-8 years old (max 50 ml)
    • D50W at 1 ml/kg for children ≥ 9 years old (max 50 ml)
  • Due to the child’s critical condition, initiate transport without delay

Pediatric Cardiac Arrest Flowchart

Asystole and Pulseless Electrical Activity

Advanced Life Support

  • Follow Cardiac Arrest/Nontraumatic-Pediatric protocol
  • Confirm the presence of Asystole in two leads
  • Minimize any interruptions in compressions
  • Using the most readily available route, administer (during CPR)
    • Epinephrine (1:10,000) 0.01 mg/kg IV/IO every 3-5 min during arrest
      OR, if no IV/IO
    • Epinephrine (1:1,000) 0.1 mg/kg (Max. of 2.5 mg) diluted in 5 ml of NaCl via endotracheal tube; give 5 manual ventilations after drug administered
  • Treat any suspected contributing factors:
    • If hypovolemic, administer 0.9% NaCl 20 ml/kg IV/IO bolus, may repeat X 2 (to a maximum total of 60ml/kg)
    • If hypoxic, secure airway and assist ventilation
      • BVM is sufficient to address hypoxia and assist ventilation
    • If hypothermic, rewarm
    • If hyperkalemia suspected (history of renal failure/dialysis):
      • Calcium chloride (10%), 20 mg/kg IV (Max individual dose 1g)
      • Sodium Bicarbonate 1 mEq/kg IV
    • If toxin ingestion, see specific toxin section
    • Assess for tension pneumothorax:
      • Unilateral decreased or absent lung sounds (may see tracheal deviation away from collapsed lung field)
      • Evidence of hemodynamic compromise
      • If tension pneumothorax suspected due to history or condition perform pleural decompression at 2nd intercostal space, mid-clavicular line

Ventricular Fibrillation or Pulseless Ventricular Tachycardia

Advanced Life Support

  • Follow Cardiac Arrest/Nontraumatic-Pediatric protocol
  • Confirm the presence of ventricular fibrillation/pulseless ventricular tachycardia
  • Defibrillate for persistent VF or pulseless VT:
    • Defibrillate at 2 J/kg (maximum 200 J)
    • Continue CPR immediately after shock (do not stop to check pulse or rhythm)
    • Call first defibrillation time to dispatch (if not done above)
  • Analyze rhythm after 2 minutes of good CPR; If VF/VT persists:
    • Defibrillate at 4 J/kg (maximum 360 J)
    • Continue CPR immediately after shock (do not stop to check pulse or rhythm)
    • Epinephrine (1:10,000) 0.01 mg/kg IV/IO every 3-5 min during arrest
      OR, if no IV/IO
    • Epinephrine (1:1,000) 0.1 mg/kg (Max. of 2.5 mg) diluted in 5 ml of NaCl via endotracheal tube; give 5 manual ventilations after drug administered
  • Analyze rhythm after 2 minutes of good CPR; If VF/VT persists:
    • Defibrillate at 10 J/kg (maximum 360 J)
      • All subsequent shocks at 10J/kg (maximum 360 J)
    • Continue CPR immediately after shock (do not stop to check pulse or rhythm)
    • Amiodarone 5 mg/kg IV/IO bolus (maximum individual dose 300 mg)
      • For persistent VF/VT repeat Amiodarone 5 mg/kg IV/IO bolus on second and third round (maximum total dose 15mg/kg)
  • Continue cycle of CPR & Drug→Rhythm Check→CPR→Shock→CPR and Drug→Rhythm Check→CPR→Shock as needed
  • Magnesium 50 mg/kg IV/IO over 1-2 minutes for suspected torsades de pointes