Paediatric Cardiac Arrest

Quick Answer

Critical: Paediatric cardiac arrest requires immediate high-quality CPR with emphasis on ventilation. Most paediatric arrests are hypoxic/asphyxial—oxygenation and ventilation are paramount. Shockable rhythms occur in only 10-20% of cases.

Survival depends on early recognition of pre-arrest states (bradycardia, respiratory failure), rapid initiation of BLS with effective ventilation, and prompt ALS with identification and treatment of reversible causes. Unlike adults, paediatric arrests rarely present with VF/VT—the majority are PEA or asystole secondary to respiratory failure, shock, or sepsis [1,2]. The Chain of Survival in children emphasises prevention, early recognition of respiratory failure and shock, immediate high-quality CPR with 5 initial rescue breaths, early defibrillation when indicated, and effective post-resuscitation care.

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ACEM Exam Focus

Primary Exam Relevance

• Physiology: Paediatric cardiovascular physiology (rate-dependent cardiac output, smaller cardiac reserve), oxygen consumption (higher metabolic rate 6-8 mL/kg/min), respiratory physiology (smaller airways, compliant chest wall, horizontal ribs)
• Pharmacology: Weight-based drug dosing, adrenaline pharmacology (alpha and beta effects), amiodarone class III antiarrhythmic mechanisms, catecholamine receptor distribution in children
• Anatomy: Paediatric airway anatomy (large occiput, anterior larynx at C3-4, narrow cricoid ring, epiglottis shape), chest wall compliance, vascular access sites, intraosseous anatomy

Fellowship Exam Relevance

• Written: SAQs on paediatric ALS algorithm, drug doses, reversible causes, post-arrest care, differences from adult algorithms
• OSCE: Resuscitation leadership station (paediatric arrest scenario), communication (breaking bad news to parents), procedural (IO insertion, intubation, defibrillation)
• Key domains tested: Medical Expert, Leader, Communicator, Professional

High-Yield Exam Topics

1. ANZCOR Guideline 12 algorithm differences from AHA
2. Weight-based drug calculations
3. 5 rescue breaths first in paediatric BLS
4. 15:2 compression ratio (2 rescuers)
5. 4 J/kg defibrillation for ALL shocks
6. Family presence during resuscitation
7. Post-ROSC targeted temperature management

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Key Points

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Age-Based Definitions

Weight Estimation

Broselow Tape: Gold standard for weight estimation and equipment sizing in emergencies [3].

APLS Formula (if no tape available):

• Infants under 12 months: Weight (kg) = (Age in months + 9) / 2
• Children 1-5 years: Weight (kg) = (Age in years × 2) + 8
• Children 6-12 years: Weight (kg) = (Age in years × 3) + 7

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Epidemiology

Age Distribution and Aetiology

Australian/NZ Specific Data

• Indigenous children have higher rates of sudden unexpected death in infancy (SUDI): 2-3× general population [9]
• Drowning is a leading cause of paediatric OHCA in Australia (35% of 1-4 year old deaths) [10]
• Remote/rural areas have prolonged EMS response times (median 15-30 min vs 8 min metro) affecting outcomes [11]
• Royal Flying Doctor Service retrieval times impact post-ROSC care access
• Higher rates of rheumatic heart disease in Indigenous populations

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Pathophysiology

Why Paediatric Arrests Differ from Adult

Cardiac Output = Heart Rate × Stroke Volume

In children, cardiac output is primarily rate-dependent because:

• Limited stroke volume reserve: Small ventricular size, immature myocardium with fewer contractile elements
• Rate-dependent cardiac output: Bradycardia causes significant output reduction (cannot compensate with increased SV)
• Higher baseline metabolic rate: 2-3× adult oxygen consumption per kg (6-8 mL/kg/min)
• Faster oxygen desaturation: Smaller FRC relative to body size, higher oxygen demand
• Compliant chest wall: Less effective respiratory mechanics, prone to fatigue

Arrest Aetiology Pathway (Asphyxial)

Respiratory Failure/Hypoxia → Tissue Hypoxia → Metabolic Acidosis
        ↓                           ↓                    ↓
   Bradycardia    ←    Myocardial Depression    ←    Myocardial Dysfunction
        ↓                                               ↓
Pulseless Electrical Activity (PEA) / Asystole    Shock / Circulatory Failure
        ↓
     Cardiac Arrest

Primary vs Secondary Arrest

Cellular Response to Arrest

Immediate Phase (0-5 minutes):

• Cessation of cardiac output
• Loss of consciousness within 10-20 seconds
• Anaerobic metabolism begins
• ATP depletion in neurons within 5 minutes
• Children tolerate hypoxia slightly better than adults (immature brain)

Intermediate Phase (5-15 minutes):

• Ischaemic cascade activation
• Cellular oedema from Na+/K+-ATPase failure
• Acidosis (pH drops 0.1 units/min)
• Calcium overload in neurons
• Free radical generation

Late Phase (greater than 15 minutes):

• Irreversible neuronal injury (especially hippocampus, cortex, basal ganglia)
• Multi-organ failure begins
• Coagulopathy development
• Systemic inflammatory response syndrome

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Recognition

Pre-Arrest Warning Signs

Paediatric Early Warning Scores (PEWS)

Use standardised scoring systems to identify deteriorating children:

• Respiratory rate, effort, oxygen requirement
• Heart rate, blood pressure, capillary refill
• Conscious state
• Trigger threshold for escalation

Confirming Cardiac Arrest

Paediatric Basic Life Support check (ARC/ANZCOR):

1. Danger: Check environment is safe
2. Response: Gently stimulate, call loudly
   • Infant: Flick soles of feet
   • Child: Tap shoulders, call name
3. Send for help: Call 000 / activate emergency response
4. Airway: Open airway (head tilt-chin lift; neutral position in infants)
5. Breathing: Look, listen, feel for 10 seconds
   • No normal breathing → Start CPR with 5 rescue breaths
6. Pulse check (healthcare providers only):
   • Infant: Brachial pulse (medial upper arm)
   • Child: Carotid or femoral pulse
   • Less than 10 seconds, if uncertain → Start CPR

Agonal Breathing Recognition

Agonal gasps are NOT normal breathing:

• Irregular, infrequent gasps
• Jaw movement without chest rise
• May persist for several minutes after arrest
• Treat as cardiac arrest

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ARC/ANZCOR Algorithm

Paediatric Basic Life Support (ANZCOR Guideline 6/10)

┌─────────────────────────────────────┐
│            DANGER                    │
│       Check for hazards             │
└─────────────────────────────────────┘
                 ↓
┌─────────────────────────────────────┐
│           RESPONSE                   │
│    Gently stimulate, shout          │
│    Infant: Flick soles of feet      │
└─────────────────────────────────────┘
                 ↓
┌─────────────────────────────────────┐
│       SEND FOR HELP                  │
│   Call 000 / Activate emergency     │
│   Request AED/defibrillator         │
└─────────────────────────────────────┘
                 ↓
┌─────────────────────────────────────┐
│           AIRWAY                     │
│   Infant: Neutral position          │
│   Child: Head tilt-chin lift        │
│   (Jaw thrust if c-spine concern)   │
└─────────────────────────────────────┘
                 ↓
┌─────────────────────────────────────┐
│          BREATHING                   │
│   Look, listen, feel (10 sec)       │
│   Not breathing normally?           │
│   ══════════════════════════════    │
│   ║  5 RESCUE BREATHS FIRST  ║      │
│   ══════════════════════════════    │
└─────────────────────────────────────┘
                 ↓
┌─────────────────────────────────────┐
│             CPR                      │
│   15 compressions : 2 breaths (2HCP)│
│   30:2 (single rescuer)             │
│   Rate: 100-120/min                 │
│   Depth: 1/3 AP diameter            │
└─────────────────────────────────────┘
                 ↓
┌─────────────────────────────────────┐
│        DEFIBRILLATION               │
│   Apply AED/defibrillator           │
│   Paediatric pads if under 8 years/below 25kg │
│   4 J/kg for manual defibrillator   │
└─────────────────────────────────────┘

Paediatric Advanced Life Support (ANZCOR Guideline 12)

┌─────────────────────────────────────────────────────────────┐
│                    CARDIAC ARREST                            │
│            Unresponsive, not breathing normally              │
└─────────────────────────────────────────────────────────────┘
                              ↓
┌─────────────────────────────────────────────────────────────┐
│                   START CPR                                  │
│   5 rescue breaths → 15:2 compressions:breaths              │
│   Attach monitor/defibrillator when available               │
│   Establish IV/IO access                                    │
└─────────────────────────────────────────────────────────────┘
                              ↓
┌─────────────────────────────────────────────────────────────┐
│                  RHYTHM CHECK                                │
│        Minimise interruptions (below 10 seconds)                  │
└─────────────────────────────────────────────────────────────┘
          ↓                                    ↓
┌─────────────────────┐            ┌─────────────────────┐
│   SHOCKABLE         │            │   NON-SHOCKABLE     │
│   VF / pulseless VT │            │   PEA / Asystole    │
└─────────────────────┘            └─────────────────────┘
          ↓                                    ↓
┌─────────────────────┐            ┌─────────────────────┐
│ SHOCK 4 J/kg        │            │ CPR 2 min           │
│ Resume CPR          │            │ IV/IO access        │
│ immediately for     │            │ ADRENALINE 10       │
│ 2 minutes           │            │ mcg/kg IMMEDIATELY  │
└─────────────────────┘            │ then every 3-5 min  │
          ↓                        └─────────────────────┘
   After 2 min CPR                          ↓
          ↓                        ┌─────────────────────┐
┌─────────────────────┐            │ RHYTHM CHECK        │
│ RHYTHM CHECK        │            │ after 2 min CPR     │
│ Still shockable?    │            │ Continue CPR cycle  │
└─────────────────────┘            └─────────────────────┘
          ↓
┌─────────────────────┐
│ SHOCK 4 J/kg        │
│ Continue CPR        │
│ After 3rd shock:    │
│ ▪ Adrenaline 10     │
│   mcg/kg            │
│ ▪ Amiodarone 5mg/kg │
└─────────────────────┘
          ↓
   Continue 2 min CPR cycles
   Adrenaline every 3-5 min
   Amiodarone 5mg/kg after 5th shock

══════════════════════════════════════════════════════════════
   THROUGHOUT: Consider and treat reversible causes (4Hs and 4Ts)
══════════════════════════════════════════════════════════════

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CPR Quality Metrics

Compression Parameters by Age

Why Two-Thumb Encircling Technique?

For infants with 2 rescuers, the two-thumb encircling technique is preferred:

• Generates higher blood pressure than 2-finger technique [12]
• Better hand positioning and consistency
• Allows deeper compressions
• Less rescuer fatigue
• Both thumbs on lower sternum, hands encircle chest

Ventilation Parameters

Quality Monitoring

End-tidal CO2 (EtCO2):

• Target over 10 mmHg during CPR (higher indicates better perfusion) [13]
• Sudden rise may indicate ROSC
• below 10 mmHg despite optimal CPR suggests poor prognosis

Other monitors:

• Pulse check: Only at rhythm check, below 10 seconds
• Arterial line (if present): Diastolic BP over 25 mmHg during CPR [14]
• POCUS: For rhythm check assessment

Rotation:

• Rotate compressors every 2 minutes
• Minimise transition time (below 5 seconds)

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Equipment Sizing

Broselow Tape Zones

The Broselow tape provides weight estimation and colour-coded equipment/drug dosing:

ETT Sizing Formulae (Cuffed Tubes)

Age-based formula:

• Internal diameter (mm) = (Age in years / 4) + 3.5
• Depth at lips (cm) = ID × 3

Other Equipment Sizing

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Reversible Causes

4 Hs

4 Ts

Electrolyte Disturbances

Hyperkalaemia (K+ greater than 6.5 mmol/L):

• ECG: Peaked T waves, wide QRS, sine wave, VF
• Treatment:
  • "Calcium chloride 10%: 0.2 mL/kg (20 mg/kg) slow IV"
  • "Sodium bicarbonate: 1-2 mmol/kg IV"
  • "Insulin + Dextrose: 0.1 unit/kg insulin with 2 mL/kg 10% dextrose"
  • "Salbutamol nebulised: 2.5-5 mg"

Hypokalaemia (K+ below 2.5 mmol/L):

• ECG: Flat T waves, prominent U waves, ST depression, VF
• Treatment: Potassium 0.5-1 mmol/kg IV over 1 hour (max rate 0.5 mmol/kg/hr)

Paediatric-Specific Causes

Common Toxins and Antidotes

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Medications

Adrenaline (Epinephrine)

Weight-based quick reference:

Amiodarone

Complete Drug Dosing Table

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Defibrillation

Energy Levels (ARC/ANZCOR)

Key ARC/ANZCOR Points:

• 4 J/kg for ALL shocks (unlike AHA which starts at 2 J/kg and escalates)
• Use paediatric attenuator/pads if under 8 years or below 25 kg
• Adult pads acceptable if paediatric not available—DO NOT delay defibrillation
• Monophasic or biphasic—same energy recommendation
• If using AED without paediatric mode, adult shocks are acceptable

Pad Placement

Defibrillator Checklist

1. Confirm VF/pVT on monitor
2. Continue CPR while charging
3. Select appropriate energy (4 J/kg)
4. Clear: "Stand clear, oxygen away"
5. Visual check all clear
6. Deliver shock
7. Immediately resume CPR (do not check rhythm)
8. Continue CPR for 2 minutes before rhythm check

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Airway Management

Bag-Valve-Mask (BVM) Ventilation

BVM is the mainstay of paediatric airway management during arrest—most children can be effectively ventilated with BVM.

Two-person technique: One person holds mask with two hands (E-C clamp both sides), second person squeezes bag. Improves seal and tidal volume delivery.

Advanced Airway Devices

ETT Sizing and Placement

Cuffed tubes are now preferred for all ages (ARC/ANZCOR 2021):

• Better seal, fewer reintubations
• Formula: ID = (Age/4) + 3.5
• Depth at lips: ID × 3

Confirmation of placement:

• Primary: Waveform capnography (EtCO2)
• Secondary: Chest rise, auscultation, SpO2 trend
• Definitive: CXR (post-stabilisation)

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Vascular Access

Priority Order (ARC/ANZCOR)

1. Intraosseous (IO): First-line if IV not immediately available (within 60 seconds)
2. Intravenous (IV): If rapid access possible (experienced operator, visible veins)
3. Endotracheal: NOT recommended for drug delivery in paediatric arrest

Intraosseous Access

IO needle sizes:

• Infants: 15-18G needle
• Children: 15-18G needle
• Use manual or powered device (EZ-IO)
• EZ-IO pink (PD) needle for 3-39 kg

IO drug delivery: All resuscitation drugs can be given IO. Follow with 5-10 mL saline flush.

IV Access Sites

• Antecubital fossa
• Dorsum of hand
• Saphenous vein at ankle
• Scalp veins (infants)
• Femoral vein (ultrasound-guided)
• External jugular

Do not delay resuscitation for IV access—proceed to IO if IV unsuccessful within 60 seconds.

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Post-Resuscitation Care

Immediate Post-ROSC (First 60 minutes)

Targeted Temperature Management (TTM)

ARC/ANZCOR 2021 recommendations:

For comatose children post-ROSC:

• Option 1: Maintain normothermia (36-37.5°C)
• Option 2: Mild hypothermia (32-34°C for 24-72 hours)
• Both options: Strict fever avoidance (over 37.5°C) for 72+ hours
• Rewarming: Slow (0.25°C/hour)

Evidence base [15,16]:

• THAPCA trials showed no difference between 33°C and 36.8°C
• Both groups had strict fever control
• Fever avoidance is the minimum standard

ICU Transfer Criteria

All post-ROSC paediatric patients require PICU/ICU admission for:

• Continuous monitoring (cardiac, respiratory, neurological)
• Mechanical ventilation as needed
• Targeted temperature management
• Neuroprognostication (defer over 72 hours)
• Investigation and treatment of underlying cause
• Family support

Organ-Specific Considerations

Neurological:

• EEG monitoring for seizures
• Avoid hyperthermia, hypoxia, hypotension
• Prognostication multimodal (clinical, EEG, imaging, biomarkers)

Cardiovascular:

• Post-arrest myocardial dysfunction common
• Inotropic support may be needed
• Serial echocardiography
• 12-lead ECG (exclude channelopathy)

Renal:

• Acute kidney injury common
• Avoid nephrotoxins
• Monitor urine output (target over 1 mL/kg/hr)

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Disposition

All ROSC Patients

• PICU admission mandatory
• No exceptions—100% require critical care monitoring
• Tertiary centre transfer if local PICU unavailable

Transfer Considerations

Termination of Resuscitation

Consider termination when:

• Asystole/PEA for over 30 minutes despite ALS
• No reversible cause identified
• EtCO2 persistently below 10 mmHg after 20 min of optimal CPR
• No shockable rhythm throughout
• Known terminal illness (age-appropriate goals of care)

Do NOT terminate if:

• Hypothermia (continue until core temp over 32°C)
• Toxin ingestion (may have prolonged but reversible cause)
• Intermittent ROSC
• Shockable rhythm present

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Special Circumstances

Drowning

Key points:

• Give 5 rescue breaths first (airway/oxygenation priority)
• Assume hypoxic arrest until proven otherwise
• Hypothermia common—continue CPR until core temp over 32°C [17]
• Do NOT attempt to drain water from lungs
• Consider cervical spine injury if diving/fall
• Prolonged resuscitation is warranted—children have survived over 60 min submersion with full neurological recovery when hypothermic

Trauma

Traumatic cardiac arrest:

• Treat hypovolaemia aggressively (most common reversible cause)
• Massive transfusion protocol: 1:1:1 ratio (RBC:FFP:platelets)
• Consider and treat tension pneumothorax, tamponade
• Resuscitative thoracotomy: Consider if penetrating trauma with signs of life within 15 min
• Blunt trauma thoracotomy rarely successful—focus on haemorrhage control
• Pelvic binder for pelvic fractures
• Control external haemorrhage

Anaphylaxis

• Adrenaline IM 10 mcg/kg (0.01 mg/kg) for anaphylaxis
• This is different from cardiac arrest IV dosing
• IM into lateral thigh
• Repeat every 5 min if no improvement
• Progress to IV adrenaline only if peri-arrest/arrest
• Fluid bolus 20 mL/kg
• Remove trigger if possible

Congenital Heart Disease

Post-operative patients:

• Consider tamponade (especially post-sternotomy)
• Arrhythmias common
• Residual lesions may cause haemodynamic compromise
• Involve paediatric cardiac surgical team
• Emergency re-sternotomy may be needed

Single ventricle physiology (Fontan, Glenn):

• Balanced circulation—avoid over-oxygenation in pre-Fontan
• Passive pulmonary blood flow—minimise positive pressure ventilation
• Avoid high PEEP
• Early involvement of paediatric cardiologist

ECMO/ECLS consideration:

• E-CPR (ECMO-CPR) may be appropriate for:
  • Refractory arrest in children with reversible cause
  • Post-cardiac surgery arrest
  • Hypothermic arrest
  • Myocarditis
• Requires ECMO-capable centre

Sepsis

• Most common cause of cardiac arrest in hospitalised children [18]
• Early recognition and aggressive resuscitation is key
• Fluid boluses 10-20 mL/kg (may need 40-60 mL/kg in first hour)
• Early antibiotics (within 1 hour of recognition)
• Inotropes for fluid-refractory shock (adrenaline or noradrenaline)
• Consider hydrocortisone for catecholamine-refractory shock

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Team Leadership and Communication

Roles in Paediatric Resuscitation

Closed-Loop Communication

Example:

• Leader: "Give adrenaline 100 micrograms IV now"
• Nurse: "Giving adrenaline 100 micrograms IV"
• Nurse: "Adrenaline 100 micrograms IV given"
• Leader: "Thank you, adrenaline confirmed. Time for next adrenaline is [time]"

Team Leader Responsibilities

1. Stand back from bedside to maintain situational awareness
2. Assign roles clearly at start and during resuscitation
3. Verbalise findings and decisions
4. Ask for input from team members
5. Ensure quality metrics are met
6. Consider reversible causes systematically
7. Communicate with family or delegate this role
8. Make disposition decisions (continue, ECMO, terminate)

Family Presence During Resuscitation

ARC/ANZCOR supports family presence [19]:

Benefits:

• Aids family coping and bereavement
• Reduces anxiety and facilitates acceptance
• Provides opportunity to say goodbye

Implementation:

• Assign dedicated staff member to support family
• Explain procedures in real-time using lay terms
• Allow family to be near (not in the way of resuscitation)
• Prepare family for possible outcome
• Respect family wishes if they decline to be present
• Continue professional resuscitation—family presence does not change care

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Indigenous Health Considerations

Important Note: Aboriginal, Torres Strait Islander, and Maori considerations:

Epidemiology:

• Higher rates of SUDI in Indigenous infants (2-3× general population) [9]
• Higher rates of rheumatic heart disease
• Increased prevalence of risk factors for cardiac disease

Barriers to Care:

• Remote community access challenges
• Delayed EMS response times
• Limited paediatric critical care access
• Language and cultural barriers to care

Cultural Considerations:

• Extended family involvement in decision-making (not just parents)
• Cultural protocols around death and dying (Sorry Business)
• Importance of Country/Place—may wish to return home
• Involve Aboriginal Liaison Officers / Maori Health Workers early

Communication:

• Use interpreters for non-English speaking families
• Aboriginal Health Workers for cultural translation
• Allow time for extended family consultation
• Respect cultural practices around deceased children
• Be aware of kinship structures (not just nuclear family)

Post-Mortem:

• Cultural concerns about post-mortem examination
• Explain requirement sensitively (coronial cases)
• Offer cultural and spiritual support

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Remote/Rural Considerations

Pre-Hospital

• Prolonged ambulance response times (15-60+ minutes)
• Community first responders may initiate BLS
• Telephone CPR instructions from 000
• AED availability in remote communities limited
• Volunteer ambulance officers may have limited paediatric experience

Limited Resource Setting

Modified approach when resources limited:

• Focus on high-quality BLS
• Use available equipment creatively
• Telemedicine support from paediatric specialists
• Do not delay treatment waiting for resources
• Consider earlier termination thresholds (discuss with retrieval)

Retrieval

Royal Flying Doctor Service (RFDS) / Paediatric Retrieval:

• Early notification critical (even during resuscitation)
• Paediatric retrieval teams for post-ROSC transport
• Fixed-wing vs rotary-wing depending on distance/time
• Mechanical CPR for ongoing arrest during transport (if available)
• Consider continuation of resuscitation during transport if reversible cause likely

Telemedicine:

• Video consultation with paediatric intensivists/emergency physicians
• Real-time guidance during resuscitation
• Assistance with drug calculations, algorithm adherence
• Decision support for termination

Aeromedical Considerations

• Altitude affects physiology (decreased partial pressure oxygen)
• Pressurised cabin for fixed-wing (typically 6,000-8,000 ft cabin altitude)
• Space limitations in aircraft
• Equipment must be secured for transport
• Communication with receiving hospital during transport

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Pitfalls and Pearls

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Viva Practice

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OSCE Scenarios

Station 1: Paediatric Cardiac Arrest Leadership

Format: Resuscitation leadership Time: 11 minutes Setting: ED resuscitation bay

Candidate Instructions:

An 18-month-old has been brought in by ambulance following a choking episode at home. The child is now in cardiac arrest. CPR is in progress. You are the team leader. Lead the resuscitation.

Resources Available:

• 2 nurses, 1 resident
• Full paediatric resuscitation equipment
• Defibrillator with paediatric pads
• Broselow tape available

Examiner Instructions:

• Child weight: 10 kg (use Broselow if candidate asks)
• Initial rhythm: Asystole
• After 4 minutes: Rhythm changes to PEA
• After 6 minutes: If foreign body consideration verbalised and laryngoscopy requested, FB found and removed
• After 8 minutes: ROSC if appropriate interventions performed

Expected Actions:

1. Assume team leader role with clear role allocation
2. Confirm cardiac arrest, assess rhythm (asystole)
3. Direct high-quality CPR (15:2, depth 4 cm for infant, 100-120/min)
4. Ensure 5 initial rescue breaths given
5. Establish IO access if IV delayed
6. Give adrenaline 10 mcg/kg (1 mL of 1:10,000 for 10 kg) immediately for non-shockable rhythm
7. Systematic consideration of reversible causes (mention foreign body as cause)
8. Request laryngoscopy/Magill forceps for FB removal
9. Closed-loop communication throughout
10. Appropriate post-ROSC management initiation

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators: Correct drug doses, consideration of foreign body, effective team leadership

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Station 2: Breaking Bad News - Paediatric Death

Format: Communication Time: 11 minutes Setting: Relatives room

Candidate Instructions:

You have been leading the resuscitation of a 3-year-old child who drowned in the family swimming pool. Despite 45 minutes of advanced life support, the child has not survived. The parents are waiting in the relatives room. Please inform them of their child's death.

Actor Brief:

• Parents of 3-year-old Thomas
• Mother was supervising when she briefly went inside to answer phone
• Initially hopeful, become extremely distressed
• Ask "Did he suffer?" / "Was he in pain?"
• Ask "Could we have done anything differently?"
• Father may become angry, blaming mother
• Want to see their child
• Mother is pregnant (8 months)

Expected Actions:

1. Introduce self, confirm identity of parents
2. Ensure private, quiet environment; sit at same level
3. Warning shot: "I'm afraid I have some very sad news"
4. Clear, unambiguous statement: "Despite our best efforts, Thomas has died"
5. Pause—allow silence and emotional reaction
6. Express genuine condolences
7. Answer questions honestly and compassionately:
   • "He would not have been aware" / "We ensured he was comfortable"
   • Address guilt sensitively: "Accidents happen very quickly..."
8. Acknowledge father's anger without escalating
9. Offer to see Thomas (prepare them for appearance)
10. Discuss next steps sensitively:
    • Police/coroner notification (required for drowning)
    • Support services available
11. Offer chaplain/cultural support
12. Consider impact on pregnant mother—additional support
13. Offer to contact other family members

Marking Criteria:

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Station 3: Procedural - Intraosseous Access

Format: Procedural skills Time: 8 minutes Setting: Simulation lab with manikin

Candidate Instructions:

A 2-year-old child (12 kg) is in cardiac arrest. Two attempts at peripheral IV access have failed. Please establish intraosseous access and administer the first dose of adrenaline.

Equipment Available:

• IO needles (manual and EZ-IO with paediatric needle)
• Antiseptic solution
• Syringes, saline flush
• Adrenaline 1:10,000
• Manikin with IO training leg

Expected Actions:

1. Confirm indication (cardiac arrest, failed IV)
2. Identify correct site (proximal tibia preferred)
3. Locate landmarks (1 cm below tibial tuberosity, flat medial surface)
4. Prepare equipment, don gloves
5. Clean site (if time permits)
6. Insert needle perpendicular to bone, advance until "give" felt
7. Remove stylet, confirm placement (aspiration, flush)
8. Calculate adrenaline dose: 10 mcg/kg = 120 mcg = 1.2 mL of 1:10,000
9. Administer adrenaline followed by saline flush

Marking Criteria:

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SAQ Practice

Question 1 (6 marks)

A 2-year-old child (weight 12 kg) is in cardiac arrest with asystole following a choking episode.

List 6 key components of appropriate paediatric advanced life support in this scenario.

Model Answer:

• High-quality CPR: 15:2 ratio, depth 4 cm (1/3 AP), rate 100-120/min (1 mark)
• 5 initial rescue breaths before starting compressions (1 mark)
• Establish IO or IV access within 60 seconds (1 mark)
• Adrenaline 10 mcg/kg (120 mcg = 1.2 mL of 1:10,000) given immediately for non-shockable rhythm, repeated every 3-5 min (1 mark)
• Consider and treat reversible causes—specifically foreign body airway obstruction (1 mark)
• Direct laryngoscopy and Magill forceps removal of foreign body if visualised (1 mark)

Examiner Notes:

• Accept: IO as first-line vascular access, mention of 4Hs/4Ts
• Do not accept: Adult doses, incorrect compression ratio (30:2 with 2 rescuers)

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Question 2 (8 marks)

Describe the differences between adult and paediatric cardiac arrest with respect to: a) Aetiology (2 marks) b) Initial rhythm (2 marks) c) CPR technique (2 marks) d) Drug dosing (2 marks)

Model Answer:

a) Aetiology:

• Adult: Primary cardiac causes (acute coronary syndrome, arrhythmia) in 60-80% (1 mark)
• Paediatric: Secondary to hypoxia/respiratory failure, sepsis, trauma in 80-90% (1 mark)

b) Initial rhythm:

• Adult: Shockable rhythms (VF/VT) common (40-50% of OHCA) (1 mark)
• Paediatric: Non-shockable rhythms (PEA/asystole) predominant (80-90%) (1 mark)

c) CPR technique:

• Adult: 30:2 ratio (all rescuers), 5-6 cm depth, 2 hands technique (1 mark)
• Paediatric: 15:2 ratio (2 rescuers), 1/3 AP diameter depth, 2 thumb-encircling (infants), 5 initial rescue breaths (1 mark)

d) Drug dosing:

• Adult: Fixed doses (adrenaline 1 mg, amiodarone 300/150 mg) (1 mark)
• Paediatric: Weight-based dosing (adrenaline 10 mcg/kg, amiodarone 5 mg/kg) (1 mark)

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Question 3 (6 marks)

A 5-year-old child achieves ROSC after 15 minutes of cardiac arrest following a near-drowning.

List 6 components of post-resuscitation care according to ARC/ANZCOR guidelines.

Model Answer:

• Maintain oxygenation SpO2 94-98%, avoid hyperoxia (1 mark)
• Maintain normocapnia PaCO2 35-45 mmHg, avoid hyperventilation (1 mark)
• Targeted temperature management: normothermia 36-37.5°C OR mild hypothermia 32-34°C; avoid fever (1 mark)
• Avoid and treat hypoglycaemia and hyperglycaemia (target 4-8 mmol/L) (1 mark)
• Treat seizures aggressively with anticonvulsants (1 mark)
• Transfer to PICU for ongoing monitoring, ventilatory support, and neuroprognostication (1 mark)

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Question 4 (8 marks)

A 10-month-old infant (8 kg) is in VF cardiac arrest.

a) What defibrillation energy would you use? (1 mark) b) Calculate the doses of adrenaline and amiodarone, including volumes (3 marks) c) When in the algorithm would you give each drug? (2 marks) d) What compression technique and ratio would you use with 2 healthcare providers? (2 marks)

Model Answer:

a) Defibrillation energy:

• 4 J/kg = 32 J for all shocks (1 mark)

b) Drug doses:

• Adrenaline: 10 mcg/kg = 80 mcg = 0.8 mL of 1:10,000 (1.5 marks)
• Amiodarone: 5 mg/kg = 40 mg (1.5 marks)

c) Timing:

• Adrenaline: After 3rd shock for shockable rhythm, then every 3-5 minutes (1 mark)
• Amiodarone: After 3rd shock (first dose), may repeat after 5th shock (1 mark)

d) CPR technique:

• Two-thumb encircling technique (1 mark)
• 15:2 compression:ventilation ratio (1 mark)

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Australian Guidelines

Key ANZCOR Guidelines

• Guideline 6: Compressions (paediatric modifications)
• Guideline 10: Basic Life Support for Infants
• Guideline 12: Paediatric Advanced Life Support
• Guideline 12.1: PALS in Special Circumstances
• Guideline 13.9: Drowning

Key Differences from AHA

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References

Guidelines

1. Australian Resuscitation Council. ANZCOR Guideline 12: Paediatric Advanced Life Support. Melbourne: ARC; 2021.
2. Australian Resuscitation Council. ANZCOR Guideline 6: Compressions. Melbourne: ARC; 2021.

Epidemiology

3. Atkins DL, Everson-Stewart S, Sears GK, et al. Epidemiology and outcomes from out-of-hospital cardiac arrest in children: the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest. Circulation. 2009;119(11):1484-1491. PMID: 19273724
4. Holmberg MJ, Wiberg S, Ross CE, et al. Trends in survival after pediatric in-hospital cardiac arrest in the United States. Circulation. 2019;140(17):1398-1408. PMID: 31545912
5. Moler FW, Meert K, Donaldson AE, et al. In-hospital versus out-of-hospital pediatric cardiac arrest: a multicenter cohort study. Crit Care Med. 2009;37(7):2259-2267. PMID: 19455024
6. Girotra S, Spertus JA, Li Y, et al. Survival trends in pediatric in-hospital cardiac arrests: an analysis from Get With the Guidelines-Resuscitation. Circ Cardiovasc Qual Outcomes. 2013;6(1):42-49. PMID: 23250980
7. Tijssen JA, Prince DK, Morrison LJ, et al. Time on the scene and interventions are associated with improved survival in pediatric out-of-hospital cardiac arrest. Resuscitation. 2015;94:1-7. PMID: 26073433
8. Donoghue AJ, Nadkarni V, Berg RA, et al. Out-of-hospital pediatric cardiac arrest: an epidemiologic review and assessment of current knowledge. Ann Emerg Med. 2005;46(6):512-522. PMID: 16308066

Australian/Indigenous Data

9. Shipstone RA, Young J, Kearney L. New approaches to prevent sudden unexpected deaths in infancy (SUDI) in high-risk Aboriginal and Torres Strait Islander families. J Paediatr Child Health. 2017;53(1):31-35. PMID: 27699930
10. Franklin RC, Peden AE, Hamilton EB, et al. The burden of unintentional drowning: global, regional and national estimates of mortality from the Global Burden of Disease 2017 Study. Inj Prev. 2020;26(Suppl 1):i83-i95. PMID: 32086363
11. Sladjana A, Niksik G, Goran M, Mihajlo J. Rural emergency services: are there really differences in outcomes? Int J Emerg Med. 2010;3(4):207-212. PMID: 21373289

CPR Quality

12. Christman C, Hemway RJ, Wyckoff MH, Perlman JM. The two-thumb is superior to the two-finger method for administering chest compressions in a manikin model of neonatal resuscitation. Arch Dis Child Fetal Neonatal Ed. 2011;96(2):F99-F101. PMID: 20847275
13. Sutton RM, Case E, Brown SP, et al. A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality--a report from the ROC Epistry-Cardiac Arrest. Resuscitation. 2015;93:150-157. PMID: 25917262
14. Berg RA, Sutton RM, Reeder RW, et al. Association between diastolic blood pressure during pediatric in-hospital cardiopulmonary resuscitation and survival. Circulation. 2018;137(17):1784-1795. PMID: 29459362

Targeted Temperature Management

15. Moler FW, Silverstein FS, Holubkov R, et al. Therapeutic hypothermia after in-hospital cardiac arrest in children. N Engl J Med. 2017;376(4):318-329. PMID: 28118559
16. Moler FW, Silverstein FS, Holubkov R, et al. Therapeutic hypothermia after out-of-hospital cardiac arrest in children. N Engl J Med. 2015;372(20):1898-1908. PMID: 25913022

Drowning

17. Quan L, Mack CD, Schiff MA. Association of water temperature and submersion duration and drowning outcome. Resuscitation. 2014;85(6):790-794. PMID: 24607869

Sepsis

18. Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020;46(Suppl 1):10-67. PMID: 32030529

Family Presence

19. Maxton FJC. Parental presence during resuscitation in the PICU: the parents' experience. J Clin Nurs. 2008;17(23):3168-3176. PMID: 19012785

Drug Therapy

20. Andersen LW, Berg KM, Saindon BZ, et al. Time to epinephrine and survival after pediatric in-hospital cardiac arrest. JAMA. 2015;314(8):802-810. PMID: 26305650
21. Goto Y, Funada A, Goto Y. Duration of prehospital cardiopulmonary resuscitation and favorable neurological outcomes for pediatric out-of-hospital cardiac arrests: a nationwide, population-based cohort study. Circulation. 2016;134(25):2046-2055. PMID: 27881562
22. Naim MY, Burke RV, McNally BF, et al. Association of bystander cardiopulmonary resuscitation with overall and neurologically favorable survival after pediatric out-of-hospital cardiac arrest in the United States. JAMA Pediatr. 2017;171(2):133-141. PMID: 27837587

Systematic Reviews

23. Maconochie IK, Aickin R, Hazinski MF, et al. Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020;142(16_suppl_1):S140-S184. PMID: 33084392
24. Topjian AA, Raymond TT, Atkins D, et al. Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16_suppl_2):S469-S523. PMID: 33081526
25. Scholefield BR, Silverstein FS, Telford R, et al. Therapeutic hypothermia after pediatric cardiac arrest: pooled randomized controlled trials. Resuscitation. 2018;133:101-107. PMID: 30300656

Paediatric-Specific Studies

26. Samson RA, Nadkarni VM, Meaney PA, et al. Outcomes of in-hospital ventricular fibrillation in children. N Engl J Med. 2006;354(22):2328-2339. PMID: 16738269
27. Meaney PA, Nadkarni VM, Cook EF, et al. Higher survival rates among younger patients after pediatric intensive care unit cardiac arrests. Pediatrics. 2006;118(6):2424-2433. PMID: 17142528
28. Reis AG, Nadkarni V, Perondi MB, et al. A prospective investigation into the epidemiology of in-hospital pediatric cardiopulmonary resuscitation using the international Utstein reporting style. Pediatrics. 2002;109(2):200-209. PMID: 11826196
29. Kurosawa H, Ikeyama T, Achuff P, et al. A randomized, controlled trial of in situ pediatric advanced life support recertification. Crit Care Med. 2014;42(3):610-618. PMID: 24231760
30. Hunt EA, Vera K, Diener-West M, et al. Delays and errors in cardiopulmonary resuscitation and defibrillation by pediatric residents during simulated cardiopulmonary arrests. Resuscitation. 2009;80(7):819-825. PMID: 19423209

Australian Studies

31. Deasy C, Bernard SA, Cameron P, et al. Epidemiology of paediatric out-of-hospital cardiac arrest in Melbourne, Australia. Resuscitation. 2010;81(9):1095-1100. PMID: 20541854
32. Tress EE, Kochanek PM, Saladino RA, Manole MD. Cardiac arrest in children. J Emerg Trauma Shock. 2010;3(3):267-272. PMID: 20930972
33. Nitta M, Iwami T, Kitamura T, et al. Age-specific differences in outcomes after out-of-hospital cardiac arrests. Pediatrics. 2011;128(4):e812-820. PMID: 21890829

Post-Arrest Care

34. Fink EL, Kochanek PM, Clark RS, Bell MJ. Fever control and application of hypothermia using intravenous cold saline. Pediatr Crit Care Med. 2012;13(1):80-84. PMID: 21666524
35. Doherty DR, Parshuram CS, Gaboury I, et al. Hypothermia therapy after pediatric cardiac arrest. Circulation. 2009;119(11):1492-1500. PMID: 19255345
36. Hickey RW, Kochanek PM, Ferimer H, et al. Hypothermia and hyperthermia in children after resuscitation from cardiac arrest. Pediatrics. 2000;106(1):118-122. PMID: 10878159

Drug Therapy Studies

37. Valdes SO, Donoghue AJ, Hoyme DB, et al. Outcomes associated with amiodarone and lidocaine in the treatment of in-hospital pediatric cardiac arrest with pulseless ventricular tachycardia or ventricular fibrillation. Resuscitation. 2014;85(3):381-386. PMID: 24263336
38. Raymond TT, Stromberg D, Stigall W, et al. Sodium bicarbonate use during in-hospital pediatric pulseless cardiac arrest. Resuscitation. 2015;89:106-113. PMID: 25619443
39. Hoyme DB, Patel SS, Engel ES, et al. Epinephrine dosing interval and survival outcomes during pediatric in-hospital cardiac arrest. Resuscitation. 2017;117:18-23. PMID: 28552785

Defibrillation Studies

40. Rossano JW, Quan L, Kenney MA, et al. Energy doses for treatment of out-of-hospital pediatric ventricular fibrillation. Resuscitation. 2006;70(1):80-89. PMID: 16757095
41. Tibballs J, Carter B, Kiraly NJ, et al. External and internal biphasic direct current shock doses for pediatric ventricular fibrillation and pulseless ventricular tachycardia. Pediatr Crit Care Med. 2011;12(1):14-20. PMID: 20495506
42. Rodriguez-Nunez A, Lopez-Herce J, del Castillo J, et al. Shockable rhythms and defibrillation during in-hospital pediatric cardiac arrest. Resuscitation. 2014;85(3):387-391. PMID: 24287328

Airway Management

43. Hansen M, Lambert W, Guise JM, et al. Out-of-hospital pediatric airway management in the United States. Resuscitation. 2015;90:104-110. PMID: 25725298
44. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA. 2000;283(6):783-790. PMID: 10683058
45. Ohashi-Fukuda N, Fukuda T, Doi K, Morimura N. Effect of prehospital advanced airway management for pediatric out-of-hospital cardiac arrest. Resuscitation. 2017;114:66-72. PMID: 28263794

Intraosseous Access

46. Voigt J, Waltzman M, Lottenberg L. Intraosseous vascular access for in-hospital emergency use: a systematic clinical review of the literature and analysis. Pediatr Emerg Care. 2012;28(2):185-199. PMID: 22307195
47. Anson JA. Vascular access in resuscitation: is there a role for the intraosseous route? Anesthesiology. 2014;120(4):1015-1031. PMID: 24608359

Prognostication

48. Fink EL, Berger RP, Clark RSB, et al. Serum biomarkers of brain injury after pediatric cardiac arrest. Crit Care Med. 2014;42(3):664-674. PMID: 24256671
49. Topjian AA, French B, Sutton RM, et al. Early postresuscitation hypotension is associated with increased mortality following pediatric cardiac arrest. Crit Care Med. 2014;42(6):1518-1523. PMID: 24561563

Indigenous Health

50. Shipstone RA, Young J. Safe sleeping close to caregiver: cultural context and advice for Indigenous families. J Paediatr Child Health. 2020;56(4):515-517. PMID: 32053247

Special Circumstances

51. Truhlář A, Deakin CD, Soar J, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation. 2015;95:148-201. PMID: 26477412
52. Young KD, Gausche-Hill M, McClung CD, Lewis RJ. A prospective, population-based study of the epidemiology and outcome of out-of-hospital pediatric cardiopulmonary arrest. Pediatrics. 2004;114(1):157-164. PMID: 15231922