Leading a paediatric arrest — OSCE

Station brief (8–10 minutes)

A 4-year-old weighing approximately 16 kilograms is brought to the emergency department by ambulance after collapsing at home. Cardiopulmonary resuscitation is in progress. On arrival the child is unresponsive, and the monitor shows ventricular fibrillation. Intraosseous access is in place. You are the registrar leading the resuscitation, with a skilled nurse and a junior doctor present. Demonstrate the advanced life support loop, state the correct shock and drug doses, search for reversible causes, and outline post-arrest care. Name the source for each threshold. [1] [5]

Tasks for the candidate

1. Confirm the rhythm and deliver the correct first shock, stating the dose and pad placement. [1]
2. Run the two-minute loop: rhythm check, second and third shocks, adrenaline and antiarrhythmic dosing. [1] [8]
3. State the high-quality CPR targets and how you would manage compressor fatigue. [4]
4. Search for and correct the reversible causes using the four Hs and four Ts framework. [5]
5. Outline the post-arrest temperature, oxygen and carbon dioxide strategy, citing the trial evidence. [9]

Expected performance

Must hit. Identifies ventricular fibrillation as a shockable rhythm and delivers the first shock at 4 joules per kilogram (about 64 joules for 16 kg) using paediatric pads in an anterolateral position, resuming compressions immediately. Runs the two-minute loop: reassesses rhythm, delivers a second shock at 4 J per kg, and after the third shock gives adrenaline 10 micrograms per kilogram intraosseously (0.1 mL per kg of the 1 in 10,000 solution, repeated every 3 to 5 minutes) and amiodarone 5 mg per kilogram. States the CPR targets of 100 to 120 per minute, one third chest depth, full recoil and minimal interruptions, and swaps the compressor every two minutes. Works through the four Hs and four Ts. After return of spontaneous circulation, states that routine hypothermia is not superior to normothermia in children per THAPCA, so maintains normothermia, avoids fever, and targets normoxia and normocapnia. [1] [5]

Merit. Names the AHA 2020, ERC 2021 and ANZCOR sources explicitly; uses capnography as a live quality readout and as an early sign of return of spontaneous circulation; explains physiologically why ventilation still matters in a shockable paediatric rhythm; places the intraosseous needle early rather than chasing intravenous access; and explains why high-dose adrenaline and the endotracheal adrenaline route are no longer recommended. [1] [8]

Fail. Shocks at the wrong dose (for example 2 J per kg or a fixed adult dose); pauses compressions for a slow rhythm check or intubation; gives adrenaline at the wrong concentration or by the endotracheal route; omits the antiarrhythmic after the third shock; cannot name any reversible cause; or recommends routine therapeutic hypothermia in a child after arrest. [1] [9]

Sample candidate structure

"The monitor shows ventricular fibrillation, which is shockable. I would deliver the first shock at 4 joules per kilogram — that is about 64 joules for this 16 kilogram child — using paediatric pads below the right clavicle and below the left nipple in the mid-axillary line, then resume compressions immediately for two minutes. At the rhythm check, if it is still fibrillating, I would give a second shock at 4 J per kg and resume CPR. After the third shock I would give adrenaline 10 micrograms per kilogram intraosseously — 0.1 mL per kg of the 1 in 10,000 solution — repeated every three to five minutes, and amiodarone 5 mg per kg. I would run the four Hs and four Ts at each cycle, monitor the capnography for quality and for a rising trace that signals return of spontaneous circulation, and swap the compressor every two minutes. Once circulation returns, I would maintain normothermia and avoid fever, because the THAPCA trials did not show hypothermia superior to normothermia in children, target normoxia and normocapnia, check the glucose, and admit to the paediatric intensive care unit." [1] [9]