Critical Alerts

• Pediatric arrest is usually respiratory: Hypoxia leads to bradycardia then arrest
• Ventilation is paramount: Oxygenation and ventilation often reverse bradycardia
• CPR ratio 15:2 for 2 rescuers, 30:2 for single rescuer: Different from adults
• Shockable rhythms (VF/pVT) are less common: But outcomes better when present
• Epinephrine every 3-5 min: 0.01 mg/kg IV/IO (0.1 mL/kg of 1:10,000)
• Defibrillation 2 J/kg → 4 J/kg → ≥4 J/kg: Max 10 J/kg or adult dose

Pediatric Age Definitions

Key Drug Doses

BLS Summary

Overview

Pediatric cardiac arrest differs from adult arrest in etiology (usually respiratory), rhythm (usually asystole/PEA), and management approach. Pediatric Advanced Life Support (PALS) provides the standardized approach. Prevention of arrest through early recognition and treatment of respiratory failure and shock is critical.

Classification

By Initial Rhythm:

By Etiology:

Epidemiology

• Out-of-hospital pediatric cardiac arrest survival: ~10-15%
• In-hospital pediatric cardiac arrest survival: ~40-50%
• Most common initial rhythm: Asystole/PEA (>80-90%)
• VF/pVT more common in: Congenital heart disease, witnessed arrest, adolescents

Etiology

Common Causes (H's and T's):

High-Risk for Arrest

ICU Admission

• All survivors of cardiac arrest
• ECMO candidacy evaluation
• Targeted temperature management
• Neuroprognostication

Declaration of Death

• After prolonged resuscitation without ROSC
• Consider duration, rhythm, underlying cause
• Family communication essential

Consider ECMO (Extracorporeal CPR)

• Reversible cause (e.g., myocarditis, hypothermia)
• Witnessed arrest with high-quality CPR
• ECMO-capable center
• Discuss early with team

For Family (Post-ROSC)

• "Your child's heart stopped and we performed CPR to restart it."
• "We are now focused on protecting the brain and supporting recovery."
• "We will monitor closely in the ICU and update you regularly."

For Family (After Death)

• Compassionate communication
• Offer chaplaincy, social work
• Consider organ donation if appropriate
• Discuss autopsy

Infants (<1 Year)

• Two-finger or two-thumb encircling technique for compressions
• Higher likelihood of respiratory etiology
• Use pediatric pads or attenuator for AED

Known Cardiac Disease

• Higher likelihood of VF/pVT
• May have pacemaker or ICD
• Contact cardiology early
• ECMO consideration

Drowning

• Prioritize oxygenation and ventilation
• Hypothermia may be protective—continue resuscitation
• Consider ECMO

Trauma

• Hemorrhage control is critical
• Blood transfusion early
• Tension pneumothorax, tamponade common
• Consider thoracotomy in select cases

Performance Indicators

Documentation Requirements

• Time of arrest, CPR start
• Rhythm at each check
• Epinephrine timing
• Xtine of shocks
• ROSC time (if achieved)
• Post-arrest care

Assessment Pearls

• Pediatric arrest is usually respiratory: Think hypoxia first
• HR &lt;60lt;60 with poor perfusion = start CPR: Don't wait for pulselessness
• Shockable rhythms are less common but better outcomes: Get AED/monitor early
• Check pulse in &lt;10lt;10 seconds: If unsure, start CPR
• Think H's and T's: Identify reversible causes

Treatment Pearls

• High-quality CPR saves lives: Push hard, push fast, minimize interruptions
• Ventilation is critical: Oxygenate and ventilate
• Epinephrine every 3-5 min: Don't skip doses
• Amiodarone for refractory VF/pVT: After epinephrine
• IO if no IV in 60-90 seconds: Fast and reliable
• Avoid hyperoxia post-ROSC: Titrate to SpO2 94-99%

Disposition Pearls

• All ROSC patients to ICU: Intensive monitoring
• Consider ECMO early: For reversible causes
• Family communication: Keep them informed
• Don't declare too early: Especially in hypothermia