Cardiopulmonary Arrest in Children

Excerpt

Cardiopulmonary arrest in children refers to the cessation of cardiac mechanical activity, indicated by the absence of a palpable central pulse, unresponsiveness, and apnea. Although uncommon in pediatric populations, cardiopulmonary arrest is less likely to result from a primary cardiac cause. Early initiation of effective, high-quality cardiopulmonary resuscitation (CPR) improves survival outcomes. The American Heart Association (AHA) periodically updates its pediatric basic and advanced life support guidelines. Clinicians can acquire pediatric resuscitation principles through Pediatric Advanced Life Support (PALS) or Advanced Pediatric Life Support (APLS) courses. Pediatric arrest rhythms are classified as asystole, pulseless electrical activity (PEA), ventricular fibrillation, and pulseless ventricular tachycardia.

Regardless of etiology, early CPR combined with cardiac rhythm monitoring guides the appropriate pulseless arrest pathway. For pediatric patients in cardiac arrest, the recommended compression-to-ventilation ratio is 30:2 for a single healthcare provider and 15:2 for 2 providers. Management of asystole and PEA includes administration of epinephrine every 3 to 5 minutes at a dose of 0.01 mg/kg of the 1:10,000 solution. Although intravenous administration is preferred, epinephrine may also be delivered intraosseously or endotracheally. The endotracheal dose is 10 times higher, at 0.1 mg/kg. PEA typically results from an identifiable underlying cause, which PALS categorizes using the mnemonic "Hs and Ts."

The Hs include hypoxia, hypovolemia, hydrogen ion (acidosis), hypokalemia or hyperkalemia, hypothermia, and hypoglycemia. Among pediatric patients, hypoxia and hypovolemia represent the most frequent underlying causes. The Ts include toxins, tamponade (cardiac), tension pneumothorax, thromboembolic events, and trauma. Although commonly associated with PEA, the Hs and Ts should not be the sole considerations for determining the suitability of a candidate. In cases where return of spontaneous circulation (ROSC) is not achieved with initial management, other causes of cardiac arrest must be explored.

Ventricular fibrillation and pulseless ventricular tachycardia share core management principles, including early initiation of high-quality CPR and rapid identification of the presenting rhythm. Early access to a manual defibrillator or an automated external defibrillator (AED) significantly improves survival rates. In pediatric patients, the recommended defibrillation energy is 2 joules per kilogram (J/kg). The introduction of biphasic defibrillators has led to the removal of the 3-stacked-shock approach from current guidelines. Clinicians may refer to the algorithms below for detailed management steps.