Paediatric basic and advanced life support — branching viva

Opening (candidate)

My immediate action is to confirm a shockable rhythm and defibrillate. The monitor shows ventricular fibrillation, so I would charge the defibrillator to 4 joules per kilogram — about 64 joules for a 16 kilogram child — deliver the shock, and resume chest compressions immediately for two minutes. I would ask the nurse to prepare adrenaline 10 micrograms per kilogram intraosseously for the third shock, and I would assign a team leader role, a scribe and a timer, and run the advanced life support loop. [1] [5]

Branch A — The defibrillation dose and the loop

Examiner: Walk me through the next two cycles. The rhythm remains in fibrillation after the first shock. [1]

Candidate: After two minutes of CPR I reassess the rhythm, which is still ventricular fibrillation, so I deliver a second shock at 4 joules per kilogram and resume compressions immediately. At the next cycle, after the third shock, I give adrenaline 10 micrograms per kilogram intraosseously — 0.1 mL per kilogram of the 1 in 10,000 solution — and amiodarone 5 mg per kilogram intraosseously, then resume CPR. Adrenaline is repeated every three to five minutes, and amiodarone can be repeated for refractory fibrillation. I reassess the rhythm every two minutes and shock if it remains fibrillating, while searching for and correcting the reversible causes. [1] [8]

Branch B — Why ventilation still matters in a shockable rhythm

Examiner: This child fibrillated. Is not ventilation irrelevant once you have a defibrillator? [4]

Candidate: No — ventilation matters in every paediatric arrest. Even a shockable rhythm in a child is more likely than an adult arrest to have an asphyxial or metabolic substrate, and the myocardium has been running without oxygen by the time we shock. Effective bag-mask ventilation at 15 to 2 keeps the lung oxygenated, supports the myocardium, and prevents the secondary hypoxic injury that turns a successful shock into a non-survivor. So I ventilate with the same care I compress with. [2] [4]

Branch C — High-quality CPR and minimising interruptions

Examiner: The compressor is tiring. What are your quality targets, and what do you do about fatigue? [4]

Candidate: The targets are a rate of 100 to 120 per minute, a depth of one third of the chest, full recoil, minimal interruptions to keep the compression fraction above 0.8, and avoidance of excessive ventilation. I watch the capnography as a live quality readout, and a falling end-tidal carbon dioxide tells me the compressions are degrading. I swap the compressor every two minutes, at the rhythm check, because fatigue silently erodes depth before anyone notices. [1] [4]

Branch D — Reversible causes

Examiner: The rhythm converts to asystole. What is your framework now? [5]

Candidate: Asystole is non-shockable, so I continue high-quality CPR and adrenaline every three to five minutes, and I run the four Hs and four Ts. Hypoxia is the commonest paediatric cause — I check the airway and the oxygen. Hypovolaemia — I consider a fluid bolus. Hypo- or hyperkalaemia — I send a blood gas. Hypothermia — I check the temperature. Tension pneumothorax — I listen to the chest. Tamponade — I consider it after surgery or trauma. Toxins — I take a history. Thrombosis — pulmonary or cardiac. I work through each against the history and the monitors. [1] [5]

Branch E — Post-arrest temperature management

Examiner: The child has return of spontaneous circulation and is comatose. What temperature do you target? [9]

Candidate: I maintain normothermia and actively avoid fever. The THAPCA trials showed that, unlike in adults, routine therapeutic hypothermia was not superior to normothermia for survival with good neurological outcome in comatose children after cardiac arrest. Hyperthermia in the first 24 hours is associated with worse neurological injury, so I treat any fever. I also target normoxia, saturations 94 to 99 per cent, and normocapnia guided by capnography, check the glucose, and arrange seizure surveillance with electroencephalography in the paediatric intensive care unit. [9] [10]

Close

Confirm the airway is secure and the haemodynamics are supported, hold normothermia, normoxia and normocapnia, surveil for seizures, and admit to the paediatric intensive care unit with early involvement of cardiology, neurology and toxicology as the cause dictates. Debrief the team, document the sequence, times, interventions and responses, and speak honestly and early with the family. [1] [9]