Paediatric Resuscitation

Quick Reference

Critical Alerts

• Paediatric arrest is predominantly respiratory in origin: Hypoxia and respiratory failure lead to bradycardia and subsequent cardiac arrest in > 80% of cases [1,2]
• Initial 5 rescue breaths before CPR: Begin with ventilation to reverse hypoxia, unlike adult protocols [2,3]
• CPR ratio 15:2 for healthcare providers (2 rescuers): 30:2 for single rescuer or lay rescuers [1,2]
• Compression depth 1/3 anterior-posterior chest diameter: Approximately 4 cm (1.5 inches) for infants, 5 cm (2 inches) for children [1,2]
• Shockable rhythms (VF/pVT) are rare: Occur in 5-15% of paediatric arrests but have better survival when present [4,5]
• Adrenaline 10 mcg/kg IV/IO every 3-5 minutes: 0.1 mL/kg of 1:10,000 solution [1,2]
• Amiodarone 5 mg/kg for refractory VF/pVT: After second shock and adrenaline [1,6]
• Intraosseous access if IV fails within 60-90 seconds: Equally effective and faster than peripheral IV in arrest [7,8]

Paediatric Age Definitions for Resuscitation

Essential Drug Doses in Paediatric Cardiac Arrest

BLS Technique Summary

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Definition and Epidemiology

Overview

Paediatric cardiac arrest is a life-threatening emergency with fundamentally different aetiology, presenting rhythm, and management compared to adult cardiac arrest. The predominant mechanism is progressive respiratory failure leading to hypoxia, bradycardia, and eventual asystole or pulseless electrical activity (PEA), rather than the primary cardiac arrhythmias common in adults. [1,2,11]

Paediatric Advanced Life Support (PALS) provides the evidence-based framework for resuscitation, emphasizing early recognition of pre-arrest states, high-quality cardiopulmonary resuscitation (CPR), and systematic treatment of reversible causes. Prevention through early intervention in respiratory failure and shock is paramount. [1,2]

Classification of Paediatric Cardiac Arrest

By Initial Presenting Rhythm:

By Aetiology:

Epidemiology and Outcomes

Incidence:

• Out-of-hospital cardiac arrest (OHCA): 8-20 per 100,000 children per year in developed countries [11,12]
• In-hospital cardiac arrest (IHCA): 2-6% of paediatric intensive care unit (PICU) admissions [12]

Survival Rates [11,12,14]:

• OHCA: 3-16% survival to hospital discharge (median 8-10%)
• IHCA: 36-46% survival to hospital discharge (median 40%)
• Favourable neurological outcome (Pediatric Cerebral Performance Category 1-2): 60-70% of survivors

Factors Associated with Better Outcomes [4,5,11,12]:

• Witnessed arrest with immediate bystander CPR
• Shockable initial rhythm (VF/pVT)
• Short duration of CPR (less than 20 minutes)
• In-hospital arrest (monitored setting)
• Reversible aetiology (e.g., hypothermia, toxin)
• Availability of extracorporeal CPR (ECPR) for selected patients [15,16]

Factors Associated with Poor Outcomes [11,12]:

• Prolonged no-flow time (> 10 minutes without CPR)
• Asystole as initial or subsequent rhythm
• Need for > 2 doses of adrenaline
• Severe comorbidities
• Low end-tidal CO₂ (less than 10-15 mmHg) despite adequate CPR [17]

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Pathophysiology

The Paediatric Arrest Sequence: Respiratory to Cardiac

Unlike adults, paediatric cardiac arrest typically follows a progressive deterioration sequence [1,2,11,13]:

Stage 1: Respiratory Distress (Compensated)

• Increased work of breathing, tachypnoea, accessory muscle use
• Maintained oxygenation and ventilation through compensation
• Intervention at this stage prevents progression

Stage 2: Respiratory Failure (Decompensated)

• Inadequate oxygenation (hypoxaemia) and/or ventilation (hypercarbia)
• Altered mental status, decreased respiratory effort
• Cyanosis, gasping, or irregular breathing

Stage 3: Hypoxic Bradycardia

• Profound hypoxia leads to myocardial depression and vagal stimulation
• Heart rate less than 60 bpm with signs of poor perfusion
• Critical pre-arrest warning sign requiring immediate intervention [1,2]

Stage 4: Cardiac Arrest

• Asystole or PEA (> 80% of cases)
• Rarely VF/pVT in children (unless underlying cardiac disease)
• Cessation of effective circulation

Why Ventilation is Critical in Paediatric Resuscitation

The fundamental difference between paediatric and adult resuscitation is the primacy of oxygenation and ventilation [1,2,13]:

1. Respiratory aetiology dominates: 60-70% of arrests have respiratory cause [11,13]
2. Hypoxia precedes arrest: Providing oxygen can reverse bradycardia before progression to arrest
3. Initial 5 rescue breaths: Recommended before starting chest compressions to rapidly reverse hypoxia [2,3]
4. 15:2 compression-ventilation ratio: Higher proportion of ventilations than adult 30:2 ratio [1,2]
5. Bag-mask ventilation is effective: Advanced airway not immediately necessary if BVM effective [1,18]

Cardiac Arrest Without Respiratory Prodrome

Primary cardiac arrest (sudden collapse without respiratory phase) occurs in 5-15% of paediatric cases [4,5]:

High-Risk Conditions:

• Hypertrophic cardiomyopathy
• Long QT syndrome, Brugada syndrome, catecholaminergic polymorphic VT
• Congenital heart disease (especially post-operative)
• Anomalous coronary arteries
• Commotio cordis (blunt chest trauma during vulnerable period)
• Myocarditis

Key Feature: More likely to present with shockable rhythm (VF/pVT) requiring immediate defibrillation [4,5]

Cellular and Metabolic Consequences of Arrest

Ischaemia-Reperfusion Injury [19,20]:

1. No-flow phase: Complete cessation of oxygen delivery

   • Cellular ATP depletion within 5 minutes
   • Anaerobic metabolism → lactic acidosis
   • Failure of Na⁺/K⁺-ATPase → cellular oedema

2. Low-flow phase: CPR provides 10-30% of normal cardiac output

   • Partial oxygen delivery prevents complete cellular death
   • Quality of CPR determines degree of organ perfusion [10,17]

3. Reperfusion phase: Return of spontaneous circulation (ROSC)

   • Paradoxical generation of reactive oxygen species
   • Inflammatory cascade activation
   • Mitochondrial dysfunction
   • Post-cardiac arrest syndrome requiring intensive management [19,20]

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Clinical Presentation

Recognition of Pre-Arrest States

Early recognition and treatment of respiratory failure and shock prevents progression to cardiac arrest. [1,2,21]

Respiratory Distress/Failure Warning Signs:

Circulatory Failure (Shock) Warning Signs:

Critical Pre-Arrest Sign: Heart rate less than 60 bpm with poor perfusion in any infant or child requires immediate CPR [1,2]

Signs of Cardiac Arrest [1,2]

The diagnosis is clinical and must be made within 10 seconds:

1. Unresponsive: No response to voice or painful stimulation
2. No breathing or only gasping: Agonal respirations are not effective breathing
3. No pulse or pulse check uncertain:
   • Infant (less than 1 year): Brachial or femoral artery
   • Child (≥1 year): Carotid or femoral artery
   • If uncertain about pulse after 10 seconds → Start CPR [1,2]

Post-Arrest Recognition

Following ROSC, children remain at high risk for rearrest and require intensive monitoring [19,20]:

• Continuous cardiorespiratory monitoring
• Arterial blood pressure monitoring
• Neurological assessment (PICU or AVPU score)
• Temperature monitoring (avoid hyperthermia) [19,20,22]

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Red Flags

Immediate Life-Threatening Presentations

Rhythm-Specific Red Flags

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Investigations During Resuscitation

Point-of-Care Testing

While CPR continues, rapidly assess for reversible causes:

Bedside Glucose [1]:

• Hypoglycaemia (less than 2.8 mmol/L or less than 50 mg/dL) is a reversible cause
• Treat with 10% glucose 2-5 mL/kg IV/IO

Blood Gas Analysis (venous or arterial if available) [1]:

• Severe acidosis (pH less than 7.1): Consider sodium bicarbonate 1 mmol/kg
• Hyperkalaemia (K⁺ > 6.5 mmol/L): Calcium chloride 20 mg/kg, insulin-glucose, salbutamol
• Hypokalaemia (K⁺ less than 2.5 mmol/L): Potassium replacement (not during arrest; post-ROSC)
• Severe hypoxia despite ventilation: Check equipment, consider tension pneumothorax

Point-of-Care Ultrasound (POCUS) [1]:

• Cardiac: Assess for tamponade (diastolic collapse of right heart), cardiac activity in PEA
• Lung: Identify pneumothorax (absent lung sliding)
• Abdominal: Free fluid suggesting haemorrhage in trauma
• Vascular: Thrombus in IVC/femoral veins (massive PE)
• Timing: Brief pauses during rhythm checks; do not interrupt CPR for prolonged scanning

End-Tidal CO₂ (ETCO₂) Monitoring [1,17]:

• During CPR: ETCO₂ less than 10-15 mmHg suggests inadequate CPR quality or very low cardiac output
• Sudden rise in ETCO₂: May indicate ROSC
• Prognostic value: Persistently low ETCO₂ (less than 10 mmHg) associated with poor outcome [17]

Post-ROSC Investigations [19,20]

After achieving ROSC, comprehensive evaluation is essential:

Immediate Laboratory Studies:

• Arterial blood gas (oxygenation, ventilation, acid-base)
• Venous blood gas (lactate, ScvO₂)
• Electrolytes, calcium, magnesium, phosphate
• Full blood count, coagulation studies
• Liver function, renal function
• Cardiac biomarkers (troponin, NT-proBNP) if cardiac cause suspected
• Toxicology screen if appropriate

Imaging:

• Chest X-ray: Assess endotracheal tube position, lung pathology, cardiac silhouette
• Cranial CT/MRI: Not immediately post-arrest; delayed (24-72 hours) if neuroprognostication needed [19,20]
• Echocardiography: Assess cardiac function, structural abnormalities, fluid status
• CT chest/abdomen: If trauma suspected

Neurological Monitoring [19,20]:

• Continuous EEG: Detect non-convulsive seizures (common post-arrest)
• Amplitude-integrated EEG (aEEG): May provide early prognostic information
• Near-infrared spectroscopy (NIRS): Monitor cerebral oxygenation

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Management

Paediatric Basic Life Support (BLS) Algorithm

Step 1: Ensure Safety

• Ensure scene is safe for rescuer and child

Step 2: Check Responsiveness [1,2]

• Tap and shout: "Are you okay?"
• If unresponsive → Shout for help

Step 3: Activate Emergency Response [1,2]

• If alone with child:
  • Perform 5 cycles (2 minutes) of CPR before leaving to call for help
  • "Exception: If witnessed sudden collapse (likely VF), call for help first and get AED"
• If two rescuers: One starts CPR, other activates emergency response and retrieves AED/defibrillator

Step 4: Check Breathing and Pulse (Maximum 10 Seconds) [1,2]

• Breathing: Look for chest rise; if absent or only gasping → Not breathing
• Pulse:
  • "Infant: Brachial or femoral pulse"
  • "Child: Carotid or femoral pulse"
• If no pulse or uncertain → Proceed to CPR

Step 5: Begin CPR [1,2]

A. Initial 5 Rescue Breaths (if cardiac arrest; if isolated respiratory arrest, give continuous rescue breaths at 1 breath every 2-3 seconds) [2,3]:

1. Open airway (head tilt-chin lift; jaw thrust if trauma suspected)
2. Give 5 effective breaths (watch for chest rise)
3. If chest does not rise: Reposition airway, check for obstruction

B. Chest Compressions [1,2]:

C. Compression-Ventilation Ratio [1,2]:

• Healthcare providers with 2 rescuers: 15 compressions : 2 breaths
• Single rescuer or lay rescuer: 30 compressions : 2 breaths
• After advanced airway placement: Continuous compressions (100-120/min) + 1 breath every 2-3 seconds (no pauses for ventilation)

Step 6: Attach AED/Defibrillator as Soon as Available [1,2]:

• Use paediatric pads/attenuator if child less than 8 years or less than 25 kg (if available)
• If paediatric pads unavailable, use adult pads (do not delay defibrillation) [1,9]
• Follow AED prompts
• Minimize interruptions in chest compressions

Paediatric Advanced Life Support (PALS) Algorithm

Once advanced providers and equipment arrive:

Non-Shockable Rhythms (Asystole/PEA) [1,2]

Cycle Structure (Repeat Every 2 Minutes):

1. High-quality CPR × 2 minutes

   • 15:2 ratio if bag-mask ventilation
   • Continuous compressions if advanced airway
   • Minimize interruptions (less than 10 seconds)

2. Rhythm check at 2 minutes

   • Brief pause to assess rhythm
   • If still non-shockable, resume CPR immediately

3. Adrenaline (Epinephrine) IV/IO [1]:

   • Dose: 10 mcg/kg (0.1 mL/kg of 1:10,000 solution)
   • Timing: Give immediately upon obtaining IV/IO access, then every 3-5 minutes
   • Maximum single dose: 1 mg

4. Advanced airway [1,18]:

   • Endotracheal intubation or supraglottic airway (i-gel, LMA)
   • Confirm placement with ETCO₂ (target > 10-15 mmHg during CPR) [17]
   • Once placed: Continuous compressions + 1 breath every 2-3 seconds

5. Vascular access [1,7,8]:

   • Attempt IV access (if already present or easily obtainable)
   • If IV not achieved within 60-90 seconds → Intraosseous (IO) access [7,8]
   • IO sites: Proximal tibia (most common), distal femur, humeral head
   • All resuscitation drugs and fluids can be given via IO route

6. Identify and treat reversible causes (4 H's and 4 T's) [1]:

   • See detailed section below

Shockable Rhythms (VF/Pulseless VT) [1,2,9]

Initial Sequence:

1. First shock: 2 J/kg [1,9]

   • Ensure everyone clear ("I'm clear, you're clear, everyone clear")
   • Deliver shock
   • Resume CPR immediately (do not check rhythm or pulse)

2. CPR × 2 minutes

   • 15:2 compression-ventilation ratio
   • Establish IV/IO access during CPR
   • Prepare for next shock

3. Second shock: 4 J/kg [1,9]

   • Brief rhythm check
   • Deliver shock if VF/pVT persists
   • Resume CPR immediately

4. CPR × 2 minutes

   • Continue high-quality CPR

5. Adrenaline IV/IO [1]:

   • Give after 2nd shock: 10 mcg/kg (0.1 mL/kg of 1:10,000)
   • Repeat every 3-5 minutes (every other cycle)

6. Third shock: ≥4 J/kg [1,9]

   • Maximum 10 J/kg or adult dose (whichever is lower)
   • Resume CPR immediately

7. CPR × 2 minutes

8. Antiarrhythmic medication [1,6]:

   • Amiodarone 5 mg/kg IV/IO rapid bolus (max 300 mg for first dose)
   • Alternative: Lidocaine 1 mg/kg IV/IO
   • Give after 3rd shock (or earlier if refractory VF)
   • May repeat amiodarone (5 mg/kg) after 5th shock (max cumulative 15 mg/kg or 2 additional doses)

9. Continue cycles: Shock → CPR 2 min → Adrenaline (every other cycle) → Shock

   • Rhythm check every 2 minutes
   • If VF/pVT persists, escalate energy to maximum (10 J/kg or adult dose)
   • Treat reversible causes aggressively

Airway and Ventilation Management [1,18]

Bag-Mask Ventilation (Initial Approach):

• Size-appropriate equipment: Mask should cover mouth and nose without covering eyes or overlapping chin
• Bag size: 450-500 mL self-inflating bag for infants; 750-1000 mL for children
• Technique:
  • Two-person technique preferred (one person maintains seal and airway, second squeezes bag)
  • One-person technique: E-C clamp (thumb and index finger form "C" on mask, other three fingers form "E" to lift jaw)
• Rate: 1 breath every 2-3 seconds (20-30 breaths/min)
• Volume: Deliver breath over 1 second; watch for visible chest rise; avoid excessive volume (risk of gastric insufflation, aspiration, pneumothorax)
• Oxygen: Use 100% oxygen during cardiac arrest [1]

Adjuncts:

• Oropharyngeal airway (OPA): Size = distance from corner of mouth to angle of jaw; only if unconscious (risk of gagging/vomiting if conscious)
• Nasopharyngeal airway (NPA): Size = diameter of child's little finger; contraindicated in skull base fracture

Advanced Airway Indications [1,18]:

• Prolonged resuscitation expected
• Bag-mask ventilation ineffective despite optimal technique
• Need to protect airway (e.g., massive haemorrhage, vomitus)
• Need for higher ventilatory pressures (severe lung disease)

Endotracheal Intubation [1,18]:

Post-Intubation:

• Confirm placement: ETCO₂ waveform (gold standard), bilateral breath sounds, chest rise, absence of gastric insufflation [1]
• Secure tube: Tube holder or tape
• Chest X-ray: Confirm tube position (tip should be 1-2 cm above carina, approximately T2-T3 level)
• Ventilation strategy post-intubation during CPR [1]:
  • Continuous chest compressions (100-120/min)
  • 1 breath every 2-3 seconds (no synchronization with compressions)
  • Avoid hyperventilation (risk of decreased venous return, decreased coronary perfusion)

Supraglottic Airways (i-gel, LMA) [1]:

• Reasonable alternative to bag-mask or endotracheal intubation
• Faster to insert than ETT
• Size selection by weight (manufacturer guidelines)
• Confirm with ETCO₂

Vascular Access [1,7,8]

Priority Sequence:

1. Existing IV access: Use immediately if already in place
2. Peripheral IV: Attempt if experienced provider and likely to succeed within 60-90 seconds
3. Intraosseous (IO) access: If IV not rapidly obtained [7,8]

Intraosseous Access [7,8]:

• Indications: Any critically ill or arrested child when IV access cannot be rapidly obtained
• Sites:
  • "Proximal tibia (most common): 1-2 cm below tibial tuberosity on medial flat surface"
  • "Distal femur: 2-3 cm above lateral femoral condyle"
  • "Distal tibia: 1-2 cm above medial malleolus"
  • "Humeral head: (older children/adolescents)"
• Contraindications: Fracture in target bone, previous IO attempt in same bone within 24-48 hours, osteogenesis imperfecta, osteopetrosis
• Technique: Manual needle or powered driver (EZ-IO, BIG); advance until loss of resistance or "pop" felt
• Confirmation: Needle stands upright without support; can aspirate marrow (send for labs if needed); fluid flows freely
• Medications/fluids: All resuscitation drugs and fluids effective via IO (same doses as IV)
• Complications: Extravasation (most common), compartment syndrome, fracture, osteomyelitis (rare), fat embolism (rare)

Endotracheal Drug Administration (Only If IV/IO Unavailable):

• Only for adrenaline (epinephrine) [1]
• Dose: 10 times IV dose (100 mcg/kg = 0.1 mL/kg of 1:1,000 solution)
• Technique: Dilute in 5 mL normal saline, instill via catheter beyond ETT tip, follow with 5 breaths
• Not recommended for: Amiodarone, atropine, bicarbonate, calcium (unpredictable absorption)
• Strongly prefer IV/IO over ETT route [1]

Medications in Cardiac Arrest

Adrenaline (Epinephrine) [1]

Mechanism:

• α-adrenergic effects: Vasoconstriction increases aortic diastolic pressure → increased coronary and cerebral perfusion pressure during CPR
• β-adrenergic effects: Increased myocardial contractility and automaticity (may also increase myocardial oxygen consumption)

Dosing:

• IV/IO: 10 mcg/kg (0.1 mL/kg of 1:10,000 solution)
  • "Maximum single dose: 1 mg"
  • "Frequency: Every 3-5 minutes"
• ETT (if no IV/IO): 100 mcg/kg (0.1 mL/kg of 1:1,000 solution) – less preferred

Timing:

• Asystole/PEA: As soon as IV/IO access obtained, then every 3-5 minutes
• VF/pVT: After 2nd shock (i.e., during 2nd cycle), then every 3-5 minutes (every other shock cycle)

Evidence: No RCT demonstrates survival benefit to hospital discharge, but adrenaline increases ROSC rates [1]

Amiodarone [1,6]

Indications: Refractory VF/pulseless VT (shock-refractory)

Dosing:

• First dose: 5 mg/kg IV/IO rapid bolus (maximum 300 mg)
• Timing: After 3rd shock (or earlier if VF persists)
• Repeat doses: 5 mg/kg after 5th shock if VF persists (maximum cumulative dose 15 mg/kg or 2 additional doses)

Mechanism: Class III antiarrhythmic; prolongs action potential duration and refractory period; blocks potassium, sodium, and calcium channels

Administration: May dilute in 5% dextrose or give as undiluted bolus during arrest

Adverse effects: Hypotension (less concern during arrest), bradycardia

Lidocaine [1]

Indications: Alternative to amiodarone for refractory VF/pulseless VT (if amiodarone unavailable)

Dosing:

• IV/IO: 1 mg/kg bolus
• Repeat: 0.5-1 mg/kg every 5-10 minutes if VF persists (max cumulative 3 mg/kg)

Mechanism: Class IB antiarrhythmic; blocks sodium channels

Calcium [1]

Indications:

• Documented hypocalcaemia
• Hyperkalaemia (K⁺ > 6.5 mmol/L)
• Hypermagnesaemia
• Calcium channel blocker toxicity

Dosing:

• Calcium chloride 10%: 20 mg/kg (0.2 mL/kg) IV/IO slow push
• Repeat: May repeat every 10 minutes if indication persists

Not recommended: Routine use in cardiac arrest without specific indication (no evidence of benefit, potential harm)

Administration: Give slowly; ensure secure IV/IO (extravasation causes tissue necrosis); do not mix with bicarbonate (precipitates)

Sodium Bicarbonate [1]

Indications:

• Severe metabolic acidosis (pH less than 7.1) despite adequate ventilation
• Hyperkalaemia (K⁺ > 6.5 mmol/L)
• Tricyclic antidepressant overdose
• Prolonged arrest with adequate ventilation

Dosing:

• Sodium bicarbonate 8.4%: 1 mmol/kg (1 mL/kg) IV/IO slow push over 1-2 minutes
• Repeat: Based on blood gas results if available

Not recommended: Routine use in cardiac arrest (may worsen intracellular acidosis, cause hypernatraemia/hyperosmolality, left-shift oxyhaemoglobin curve)

Administration: Ensure adequate ventilation (bicarbonate generates CO₂); flush line before and after; do not mix with calcium or catecholamines

Glucose [1]

Indications:

• Documented hypoglycaemia (blood glucose less than 2.8 mmol/L or less than 50 mg/dL)
• Suspected hypoglycaemia when bedside glucose not immediately available (infants, known diabetes, malnourishment)

Dosing:

• Glucose 10%: 2-5 mL/kg IV/IO bolus
• Alternative: Glucose 25% (1-2 mL/kg) if 10% unavailable (preferred in neonates/infants)

Post-ROSC: Avoid hypoglycaemia and hyperglycaemia (both associated with worse neurological outcome) [19,20]

Magnesium Sulfate [1]

Indications:

• Torsades de pointes
• Documented hypomagnesaemia

Dosing:

• Magnesium sulfate 50%: 25-50 mg/kg (0.05-0.1 mL/kg) IV/IO over 1-2 minutes
• Maximum: 2 g per dose

Defibrillation [1,9]

Energy Dosing (Biphasic Defibrillators – Standard in Modern Practice):

Evidence: A 2024 systematic review found no significant difference in survival between initial energy doses of 2-4 J/kg vs. higher doses (5-9 J/kg), but higher doses may be reasonable for refractory VF/pVT [9]

Pad/Paddle Size and Placement [1]:

• Infants (less than 10 kg): Paediatric pads (4.5 cm diameter) if available; adult pads acceptable if paediatric pads unavailable
• Children > 10 kg and > 1 year: Adult pads (8-12 cm diameter) acceptable
• Placement:
  • "Standard (anterolateral): Right upper chest below clavicle, left lower chest lateral to nipple"
  • "Anteroposterior: Anterior left chest, posterior between scapulae (alternative if anterolateral difficult)"
• Ensure pads do not touch each other

Automated External Defibrillator (AED) [1,2]:

• Infants (less than 1 year): Manual defibrillator preferred; if unavailable, AED with paediatric dose attenuator acceptable; if no attenuator, adult AED acceptable (do not delay defibrillation)
• Children 1-8 years: AED with paediatric pads/attenuator preferred; adult AED acceptable if paediatric unavailable
• Children > 8 years: Adult AED appropriate

Defibrillation Technique [1]:

1. Confirm VF/pVT on monitor
2. Charge defibrillator while CPR continues
3. Ensure all personnel clear (visual and verbal confirmation: "I'm clear, you're clear, everyone clear")
4. Deliver shock
5. Immediately resume CPR (do not check rhythm or pulse) for 2 minutes
6. After 2 minutes CPR, briefly pause to check rhythm

Reversible Causes: The 4 H's and 4 T's [1]

Systematic evaluation and treatment of reversible causes is essential throughout resuscitation:

4 H's

4 T's

Extracorporeal CPR (ECPR) [15,16]

Definition: Initiation of extracorporeal membrane oxygenation (ECMO) during cardiac arrest to provide cardiopulmonary support while treating reversible causes.

Indications (Select Patients) [15,16]:

• In-hospital cardiac arrest (IHCA) with ongoing CPR
• Witnessed arrest with high-quality CPR initiated immediately
• Potentially reversible aetiology:
  • Myocarditis, cardiomyopathy
  • Post-cardiac surgery
  • Hypothermia
  • Drug toxicity (beta-blocker, calcium channel blocker, local anaesthetic)
  • Pulmonary embolism
• ECMO-capable centre with experienced team
• Favourable pre-arrest neurological status

Contraindications [15,16]:

• Prolonged no-flow time (> 5-10 minutes without CPR)
• Severe pre-existing neurological impairment
• Underlying condition incompatible with survival (e.g., lethal chromosomal abnormality)
• Contraindication to anticoagulation with active uncontrolled haemorrhage

Timing: Decision should be made early (ideally within 10-20 minutes of arrest) if ROSC not achieved with conventional CPR [15,16]

Outcomes [15,16]:

• Survival to hospital discharge: 30-40% in selected patients (highly variable by centre and patient selection)
• Better outcomes with: shorter duration of CPR before ECMO, witnessed arrest, initial shockable rhythm, reversible aetiology

Complications: Bleeding (most common), thromboembolism, limb ischaemia, infection, neurological injury

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Post-Resuscitation Care [19,20,22]

Return of spontaneous circulation (ROSC) is only the first step. Post-cardiac arrest syndrome requires intensive, protocolized care to optimize neurological recovery.

Post-Cardiac Arrest Syndrome Components [19,20]

1. Post-cardiac arrest brain injury: Primary (arrest) and secondary (reperfusion) injury; cerebral oedema, seizures
2. Post-cardiac arrest myocardial dysfunction: Transient myocardial stunning; may resolve within 48-72 hours
3. Systemic ischaemia-reperfusion response: Inflammatory cascade (similar to sepsis); multiorgan dysfunction
4. Persistent precipitating pathology: Underlying cause (e.g., sepsis, trauma, toxin) still present

Immediate Post-ROSC Management [1,19,20]

Airway and Ventilation:

• Goal: Normoxia and normocarbia
• SpO₂ target: 94-99% (avoid hyperoxia, which may worsen neurological outcome) [19,20]
• PaCO₂ target: 35-45 mmHg (4.7-6.0 kPa) – avoid hypocarbia (decreased cerebral blood flow) and hypercarbia (increased ICP) [19,20]
• Ventilator settings: Lung-protective strategy; tidal volume 5-8 mL/kg ideal body weight; adjust FiO₂ and ventilation to achieve targets
• Continuous ETCO₂ monitoring: Correlate with arterial blood gas

Haemodynamic Management:

• Goal: Adequate perfusion pressure and cardiac output
• Blood pressure target: Maintain MAP > 5th percentile for age (ideally > 50th percentile) [19,20]
  • "Age-specific MAP targets:"
    • Neonate: > 45-50 mmHg
    • Infant (1-12 months): > 50-55 mmHg
    • Child (1-10 years): > 55-65 mmHg
    • Adolescent (> 10 years): > 65-70 mmHg
• Monitoring:
  • Invasive arterial blood pressure (place arterial line early)
  • Central venous pressure (if central line placed)
  • Lactate, ScvO₂ (> 70%)
  • Urine output (> 1 mL/kg/hour)
  • Echocardiography (assess cardiac function)
• Fluid resuscitation: 10-20 mL/kg boluses crystalloid as needed for hypovolaemia; avoid excessive fluids if euvolaemic (risk pulmonary oedema, cerebral oedema)
• Vasoactive support:
  • "First-line: Adrenaline infusion 0.05-0.3 mcg/kg/min (inotropy + vasoconstriction)"
  • "Alternatives: Noradrenaline 0.05-0.5 mcg/kg/min (vasoconstriction), dopamine 5-20 mcg/kg/min, dobutamine 5-20 mcg/kg/min (inotropy)"
  • Titrate to MAP and perfusion targets

Temperature Management [19,20,22]:

• Avoid hyperthermia (temperature > 37.5°C): Strong evidence that fever worsens neurological outcome [19,20,22]
• Targeted Temperature Management (TTM):
  • "Normothermia (36-37.5°C): Recommended for all post-arrest children [19,20,22]"
  • "Therapeutic hypothermia (32-34°C): Controversial in children; adult data shows no benefit of hypothermia over normothermia, but some paediatric centres use for comatose patients [19,20,22]"
  • "Continuous temperature monitoring: Core temperature (oesophageal, rectal, or bladder probe)"
  • "Rewarming: If hypothermia used, rewarm slowly (0.25-0.5°C per hour) to avoid rebound hyperthermia, hypotension, electrolyte shifts"
• Shivering control: Sedation, neuromuscular blockade if necessary

Glucose Management [19,20]:

• Avoid hypoglycaemia (less than 2.8 mmol/L or less than 50 mg/dL): Associated with worse outcome
• Avoid severe hyperglycaemia (> 10-12 mmol/L or > 180-216 mg/dL): May worsen neurological outcome
• Target glucose: 4-10 mmol/L (72-180 mg/dL)
• Frequent monitoring: Every 1-2 hours initially

Seizure Management [19,20]:

• High incidence: 10-40% of children post-arrest have seizures (many subclinical)
• Continuous EEG monitoring: Strongly recommended for comatose patients (detect non-convulsive seizures)
• Treatment:
  • "First-line: Levetiracetam 20-60 mg/kg IV or lorazepam 0.1 mg/kg IV"
  • "Second-line: Phenytoin 20 mg/kg IV, phenobarbital 20 mg/kg IV"
  • "Refractory: Midazolam or propofol infusion, pentobarbital"
• Prophylactic antiepileptics: Not routinely recommended (no evidence of benefit)

Other Supportive Care:

• Sedation and analgesia: Optimize comfort; facilitate ventilator synchrony; reduce oxygen consumption
• Avoid factors that increase ICP: Head midline, head of bed elevated 30°, avoid hyperthermia, avoid hypotonic fluids
• Nutrition: Enteral nutrition when haemodynamically stable (typically post-ROSC day 1-2)
• Stress ulcer prophylaxis: H2-blocker or proton pump inhibitor
• Deep vein thrombosis prophylaxis: Sequential compression devices; consider anticoagulation if prolonged immobility and no contraindication

Neuroprognostication [19,20]

Timing: Should not be performed before 72 hours post-ROSC (ideally ≥5 days); avoid premature withdrawal of life-sustaining therapies

Multimodal Approach:

• Clinical examination: Brainstem reflexes, motor response; unreliable if sedated or hypothermic
• Imaging: MRI brain (diffusion-weighted imaging, ADC map) at 2-7 days; CT less sensitive
• Neurophysiology: EEG (background activity, reactivity, sleep-wake cycling); somatosensory evoked potentials (bilaterally absent N20 suggests poor outcome)
• Biomarkers: Neuron-specific enolase (NSE), S100B (limited paediatric data)

Validated Outcome Scores:

• Paediatric Cerebral Performance Category (PCPC): 1 = normal, 2 = mild disability, 3 = moderate disability, 4 = severe disability, 5 = coma/vegetative state, 6 = death
• Favourable outcome: PCPC 1-2 or PCPC score unchanged from baseline

Prognostic Factors:

• Poor prognostic indicators: Prolonged arrest (> 20 min), multiple doses of adrenaline (> 2), persistent asystole, very low ETCO₂ (less than 10 mmHg), severe brain injury on MRI, bilaterally absent cortical SSEP
• Favourable prognostic indicators: Short arrest duration (less than 10 min), IHCA with immediate CPR, shockable rhythm, rapid ROSC, good post-arrest neurological exam

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Disposition

PICU Admission [19,20]

All children with ROSC after cardiac arrest require PICU admission for:

• Continuous cardiorespiratory monitoring
• Mechanical ventilation management
• Haemodynamic support
• Targeted temperature management
• Continuous EEG monitoring
• Neuroprognostication
• Family support

Consideration for ECMO [15,16]

If cardiac arrest recurs or if refractory cardiogenic shock develops post-ROSC:

• Paediatric cardiology and cardiac surgery consultation
• ECMO candidacy assessment
• Transfer to ECMO-capable centre if not available on-site

Withdrawal of Life-Sustaining Therapies

Should not be performed prematurely (before 72 hours; ideally ≥5 days post-arrest) [19,20]

Considerations:

• Multimodal neuroprognostication
• Multidisciplinary team (intensivist, neurologist, palliative care, ethics)
• Family involvement and shared decision-making
• Cultural and religious considerations

Organ Donation

If prognosis deemed futile:

• Early discussion with organ procurement organization
• Compassionate approach with family
• Donation after circulatory death (DCD) or donation after brain death (DBD) may be possible

Bereavement Support

If child does not survive:

• Provide family with privacy and time with child
• Chaplaincy, social work, bereavement services
• Offer autopsy (may identify underlying genetic/metabolic cause)
• Follow-up with family (letter, phone call, clinic visit)

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Special Populations

Infants (less than 1 Year) [1,2]

Unique Considerations:

• Two-thumb encircling technique preferred for chest compressions if 2 rescuers (more effective than 2-finger technique)
• Higher likelihood of respiratory aetiology: SIDS, bronchiolitis, pneumonia, choking
• Brachial or femoral pulse check (carotid pulse difficult to palpate)
• Paediatric defibrillator pads/attenuator if available; adult AED acceptable if paediatric unavailable
• Intraosseous access: Proximal tibia preferred site

Common Causes:

• Sudden infant death syndrome (SIDS)
• Airway obstruction (choking, foreign body)
• Bronchiolitis, pneumonia
• Non-accidental trauma (abusive head trauma, suffocation)
• Congenital heart disease

Known Congenital Heart Disease [4,5]

Unique Considerations:

• Higher likelihood of VF/pVT, especially post-operative or with single-ventricle physiology
• Pacemaker or ICD may be present: Check for device; place pads/paddles at least 8 cm from device; reprogram device post-ROSC
• Consult paediatric cardiology early
• ECMO consideration: Many cardiac centres have ECPR protocols for post-operative patients
• Anatomy-specific considerations: Understand child's specific cardiac anatomy and surgical history (e.g., Fontan, Glenn, pulmonary atresia)

Management Pearls:

• Maintain preload (may be preload-dependent)
• Avoid excessive positive pressure ventilation (decreases venous return in Fontan/Glenn physiology)
• Consider cardiac tamponade in post-operative patients (emergency resternotomy may be needed)

Drowning [23]

Unique Considerations:

• Severe hypoxia is primary mechanism: Prioritize oxygenation and ventilation
• Initial 5 rescue breaths critical; may initiate in water if trained rescuer and safe
• Hypothermia may be present (especially cold water): Continue resuscitation during rewarming; "not dead until warm and dead"
• Aspiration of water: Fresh water (hypotonic) vs. salt water (hypertonic) distinction not clinically relevant
• Pulmonary oedema common: May require high PEEP, lung-protective ventilation
• Consider ECMO for refractory hypoxia or cardiac arrest with reversible cause [15,23]

Prognostic Factors [23]:

• Submersion duration: less than 5 minutes better prognosis
• Water temperature: Cold water may be neuroprotective
• Response to initial resuscitation: Rapid ROSC favourable
• Witnessed vs. unwitnessed: Witnessed better
• Bystander CPR: Critical for survival

2024 AHA/AAP Guideline Updates [23]:

• Rescue breaths should be initiated as soon as possible (even in water if safe)
• Standard resuscitation guidelines apply (initial breaths, then CPR)
• Routine cervical spine immobilization not recommended unless high-risk mechanism (diving, water slide)

Trauma [1]

Unique Considerations:

• Treat reversible causes aggressively:
  • "Haemorrhage: Blood transfusion (10-20 mL/kg packed RBCs); massive transfusion protocol (1:1:1 RBC:FFP:platelets); haemorrhage control (pressure, tourniquet, surgery)"
  • "Tension pneumothorax: Needle decompression, chest tube"
  • "Cardiac tamponade: Pericardiocentesis, thoracotomy"
• Damage control resuscitation: Permissive hypotension (if not head injury); avoid excessive crystalloid; early blood products
• Consider thoracotomy in penetrating trauma with witnessed arrest or signs of life in ED
• Avoid excessive hyperventilation if traumatic brain injury (decreases cerebral perfusion)

Poor Prognostic Indicators:

• Blunt trauma with prolonged arrest
• Severe traumatic brain injury with loss of brainstem reflexes
• Massive exsanguination

Pulseless Arrest with Ventricular Assist Device (VAD) or Pacemaker

VAD Patients:

• DO NOT perform chest compressions (risk of cannula dislodgement, bleeding)
• Check VAD function (flow, power, connections)
• Defibrillation safe (avoid paddles/pads directly over device)
• Emergency VAD troubleshooting per institutional protocol
• Immediate paediatric cardiology/cardiac surgery consultation

Pacemaker/ICD Patients:

• Chest compressions safe (continue as normal)
• Defibrillation safe; place pads/paddles ≥8 cm from device if possible
• Consider device malfunction as cause
• Reprogram device post-ROSC

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Quality Metrics and Debriefing [10,17]

High-Quality CPR Performance Indicators [1,10]

Real-Time Feedback Devices [10]

• CPR feedback devices (e.g., on defibrillator monitors) provide real-time data on compression depth, rate, recoil
• Use feedback to optimize CPR quality during resuscitation

Documentation Requirements

Critical Time Points:

• Time of arrest recognition
• Time CPR initiated
• Time advanced providers arrived
• Time of each rhythm check and rhythm observed
• Time and dose of each medication
• Time and energy of each defibrillation attempt
• Time of ROSC (if achieved) or termination of resuscitation
• Total CPR duration

Post-Event Debriefing [1]:

• Hot debrief (immediately after): Brief discussion of what went well and what could improve
• Cold debrief (within 24-48 hours): Structured multidisciplinary review; non-punitive; focus on systems improvement
• Benefits: Improves team performance, identifies system gaps, emotional support for team

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Key Clinical Pearls

Recognition Pearls

• Paediatric arrest is usually respiratory in origin: Think hypoxia first; early oxygenation/ventilation can prevent progression to arrest [1,11,13]
• HR less than 60 bpm with poor perfusion = cardiac arrest in children: Start CPR immediately; do not wait for pulselessness [1,2]
• Witnessed sudden collapse in adolescent = likely VF: Get defibrillator immediately [4,5]
• If unsure about pulse in 10 seconds, start CPR: False positive pulse check common; better to perform unnecessary CPR than delay when needed [1,2]

CPR Quality Pearls

• Push hard, push fast, allow full recoil, minimize interruptions: High-quality CPR is the foundation of successful resuscitation [1,10]
• Compression depth 1/3 AP diameter: Approximately 4 cm (1.5 inches) for infants, 5 cm (2 inches) for children [1,10]
• Two-thumb encircling technique for infant CPR (2 rescuers): More effective than two-finger technique [1,2]
• 15:2 compression-ventilation ratio for paediatric healthcare providers: Higher proportion of ventilations than adults (30:2) due to respiratory aetiology [1,2]
• Pause for rhythm checks less than 10 seconds: Longer pauses associated with decreased survival [10]
• ETCO₂ less than 10 mmHg during CPR is ominous: Suggests inadequate CPR or very poor cardiac output; optimize technique and consider ECPR [17]

Medication Pearls

• Adrenaline 10 mcg/kg (0.1 mL/kg of 1:10,000) every 3-5 min: Start after 2nd shock in VF/pVT; immediately in asystole/PEA [1]
• Amiodarone 5 mg/kg after 3rd shock for refractory VF/pVT: May repeat twice (max 15 mg/kg cumulative) [1,6]
• IO access if no IV in 60-90 seconds: Fast, effective, safe [7,8]
• Avoid routine calcium or bicarbonate: Only use for specific indications (hypocalcaemia, hyperkalaemia, severe acidosis) [1]

Defibrillation Pearls

• VF/pVT is rare in children (5-15%) but has better prognosis than asystole: Early defibrillation critical [4,5]
• Initial energy 2 J/kg, then 4 J/kg, then ≥4 J/kg (max 10 J/kg): Escalate energy for refractory VF [1,9]
• Resume CPR immediately after shock without checking rhythm: Minimize peri-shock pause [1]
• Adult AED acceptable for all ages if paediatric pads unavailable: Do not delay defibrillation [1,2]

Reversible Causes Pearls

• Always think H's and T's: Hypoxia most common in children; tension pneumothorax and tamponade in trauma/post-op; toxins in adolescents [1,11]
• Hypovolaemia requires 20 mL/kg boluses: May need multiple boluses; blood products if haemorrhage [1]
• Tension pneumothorax: immediate needle decompression: 2nd intercostal space MCL or 5th intercostal space AAL [1]

Post-ROSC Pearls

• Avoid hyperthermia: Fever (> 37.5°C) worsens neurological outcome; actively prevent/treat [19,20,22]
• Target normoxia (SpO₂ 94-99%) and normocarbia (PaCO₂ 35-45): Avoid extremes [19,20]
• Maintain MAP > 5th percentile for age: Use vasopressors early if needed [19,20]
• Continuous EEG for comatose patients: Detect non-convulsive seizures (common post-arrest) [19,20]
• Defer neuroprognostication until ≥72 hours (ideally ≥5 days): Avoid premature withdrawal of support [19,20]

Disposition Pearls

• All ROSC patients to PICU: Intensive monitoring, targeted temperature management, neuroprotective care [19,20]
• Consider ECPR early for reversible causes: Best outcomes when initiated within 20 minutes of arrest [15,16]
• Do not declare death prematurely in hypothermia or drowning: "Not dead until warm and dead" [23]
• Family communication is critical: Keep family informed; involve in shared decision-making; provide bereavement support if needed

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References

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