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Appendix A

Resuscitation algorithms
Margarita Burmester
Royal Brompton Hospital, London, UK

Bradycardia algorithm (with a pulse and poor perfusion)

Commence BLS
Oxygenate
Ventilate as appropriate

No Severe Yes call resuscitation team


cardiorespiratory
compromise?
If HR < 60
CPR 15 chest compressions
2 ventilations
Until defibrillator/monitor attached

Observe
Support ABCs; give No Persistent symptomatic
oxygen if needed bradycardia?
Consider expert opinion
During CPR Yes
Ensure full chest recoil
Push hard and fast (100/min) Epinephrine (adrenaline)*
Minimize interruptions in chest IV/IO: 0.01 mg/kg max 1 mg
compressions (0.1 mL/kg) of 1:10 000
Secure airway if needed, confirm Endotracheal: 0.1 mg/kg
placement with end-tidal CO2 (0.1 mL/kg) of 1:1000
Give uninterrupted Repeat every 35 min
compressions when trachea
intubated (810 breaths/min )
Atropine
IV/IO: 0.02 mg/kg (min dose:
Treat possible causes
0.1 mg, max total dose for child:
Hypoxia
1 mg). May repeat 1
Hypovolemia
Endotracheal: 0.03 mg/kg
Hypo/hyperkalemia/metabolic
Hypothermia
Tension pneumothorax
Tamponade, cardiac Consider cardiac pacing
Toxins
Thromboembolism
Trauma If pulseless arrest develops go
to Pulseless arrest algorithm

*Give atropine rst if suspected increased vagal tone or primary AV (Adapted with permission from 2010 American Heart Association guidelines.
block. 2010 International Consensus on Cardiopulmonary Resuscitation and
ABCs, airway, breathing, circulation; BLS, basic life support; CPR, Emergency Cardiovascular Care Science with Treatment
cardiopulmonary resuscitation; HR, heart rate. Recommendations (COSTR).)

Pediatric Heart Disease: A Practical Guide, First Edition. Piers E. F. Daubeney, Michael L. Rigby, Koichiro Niwa, and Michael A. Gatzoulis.
2012 Blackwell Publishing Ltd. Published 2012 by Blackwell Publishing Ltd.

282
Resuscitation algorithms 283

Narrow complex tachycardia algorithm (with poor perfusion)

Support ABCs as needed


Oxygenate
Attach defibrillator/monitor

No
Pulse present? Pulseless arrest protocol

Yes

Narrow QRS (< 0.09 s) Evaluate Wide QRS (> 0.09 s)


12-lead EKG if practical
QRS duration

Probable supraventricular tachycardia Possible ventricular tachycardia or


Probable sinus tachycardia
Compatible history (vague, non-specific) supraventricular tachycardia
Compatible history with known cause
P waves absent/abnormal with aberrancy
P waves present/normal
HR not variable
Variable R-R; constant PR
Infants: rate usually 220 bpm
Infants: rate usually < 220 bpm
Children: rate usually 180 bpm
Children: rate usually < 180 bpm
Expert consultation advised

Search for and treat cause Vagal maneuvers (if no delays) Wide complex tachycardia algorithm

If IV access readily available give


adenosine 0.1 mg/kg IV (max first
If shocked dose 6 mg) by rapid bolus
patient and
delay in IV
access
Give adenosine* 0.2 mg/kg IV
During evaluation
(max second dose 12 mg)
Secure, verify airway when
possible
Consider expert opinion
Prepare for cardioversion Synchronized DC shock 0.51 J/Kg

Treat possible causes


Hypoxia Synchronized DC shock 2 J/Kg
Hypovolemia
Hypo/hyperkalemia/Metabolic
Hypothermia Expert consultation advised
Tension pneumothorax Amiodarone 5 mg/kg IV over 20
Tamponade, cardiac 60 min
Toxins OR (not together)
Thromboembolism Procainamide 15 mg/kg IV
Trauma over 3060 min

*European Resuscitation Council (ERC) 2010 Guidelines recommend a (Adapted with permission from 2010 American Heart Association
further third adenosine dose at 0.3 mg/kg followed by a fourth adenosine guidelines. 2010 International Consensus on Cardiopulmonary
dose at 0.40.5 mg/kg (max 12 mg) prior to cardioversion. Resuscitation and Emergency Cardiovascular Care
ABCs, airway, breathing, circulation; HR, heart rate. Science with Treatment Recommendations (COSTR).)
284 Appendices

Wide complex tachycardia algorithm

Support ABCs as needed


Oxygenate
Attach defibrillator/monitor

Pulse No
present Pulseless arrest algorithm

Yes

May attempt adenosine: 0.1 mg/kg


(max first dose 6 mg) by rapid bolus,
if it does not delay cardioversion
(in order to differentiate VT from
SVT with aberrant conduction)

No Yes
Patient
shocked?

Expert consultation advised Synchronized DC shock 0.51 J/Kg


Amiodarone 5 mg/kg IV
over 2060 min
OR (not together)
Procainamide 15 mg/kg IV
over 3060 min Synchronized DC shock 2 J/Kg

Expert consultation advised


Amiodarone 5 mg/kg IV over
2060 min (repeat 1 up to 15
mg/kg ; maximum 300 mg)
Identify and treat possible causes OR (not together)
Hypoxia Tension pneumothorax Procainamide 15 mg/kg IV
Hypovolemia Tamponade, cardiac over 3060 min
Hypo/hyperkalemia/Metabolic Toxins
Hypothermia Thromboembolism
Trauma

ABC, airway, breathing, circulation; SVT, supraventricular tachycardia; VT, ventricular tachycardia.
(Adapted with permission from 2010 American Heart Association guidelines. 2010 International Consensus on Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care Science with Treatment Recommendations (COSTR).)
Resuscitation algorithms 285

Pulseless arrest algorithm

Commence BLS
Oxygenate and ventilate

Call resuscitation team

CPR 15 chest compressions


2 ventilations until
defibrillator/monitor attached

Shockable Assess Non-shockable


VF/pulseless VT rhythm asystole/PEA

Manual shock 24 J/kg* or Resume CPR immediately


AED > 1 year of age
Use pediatric system if
available for 18 years of age During CPR Ventilate with high
Correct reversible causes concentration O2
2 min CPR, Intubate, high flow O2 Push hard and fast (100/min)
check monitor IV/IO access Minimize interruptions in chest
compressions Intubate
Manual shock 4 J/kg or Give uninterrupted compressions IV/IO access
AED > 1 year of age when trachea intubated (give 810
breaths/minute)
Confirm ETT placement with end Epinephrine
Epinephrine (adrenaline) tidal CO2 (adrenaline)
(immediately after shock)** Max dose epinephrine 1 mg IV/IO: 0.01 mg/kg
IV/IO: 0.01 mg/kg (0.1 mL/kg) (0.1 mL/kg) of 1:10 000
of 1:10 000 (max 1 mg) (max 1 mg)
Endotracheal : 0.1 mg/kg Endotracheal: 0.1 mg/kg
(0.1 mL/kg) of 1:1000 (0.1 mL/kg) of 1:1000
Repeat every 35 min Repeat every 35 min

2 min CPR, 4 min CPR Check monitor


check monitor every 2 min

Manual shock 4 J/kg or


AED > 1 year of age

Amiodarone 5 mg/kg IV/IO



over 2060 min (repeat 1 Reversible causes
up to 15 mg/kg ; maximum Hypoxia Tension pneumothorax
300 mg) If not available: Hypovolemia Tamponade, cardiac
Lidocaine 1 mg/kg IV/IO Hypo/hyperkalemia/Metabolic Toxins
Hypothermia Thromboembolism
Magnesium 2550 mg/kg IV/IO Consider alkalizing agents Trauma
for torsades de pointes

2 min CPR,
check monitor

*European Resuscitation Council (ERC) 2010 Guidelines recommend rst pulseless electrical activity; VF, ventricular brillation; VT, ventricular
shock to be 4 J/kg. tachycardia.
**ERC 2010 Guidelines recommend adrenaline immediately after third (Adapted with permission from 2010 American Heart Association
shock. guidelines. 2010 International Consensus on Cardiopulmonary
AED, automated external debrillator; BLS, basic life Resuscitation and Emergency Cardiovascular Care Science with Treatment
support; CPR, cardiopulmonary resuscitation; PEA, Recommendations (COSTR).)
286 Appendices

Hypercyanotic spell algorithm

Increase in R-L shunt


Hyperpnea Keep child calm with parent
(e.g. on shoulder)
Worsening cyanosis
Knee-to-chest position
Irritability
O2 unless this causes distress
Disappearance of murmur

Cyanosis
persists?

Morphine 0.1 mg/kg SC/IM OR


Buccal midazolam 200300 g/kg (max 5 mg)

No Cyanosis Yes
persists?

Observe and keep calm Continuous EKG and oxygen


Give oxygen if needed saturation monitoring, regular BP
Consider expert opinion Expert consultation advised

Site IV

Propranolol 0.5 mg/kg/dose PO 1020 mL/kg IV N/saline (preload)


TDS (gradually to 1.01.5
mg/kg/dose TDS) Continuous BP monitoring
Watch for hypotension and
hypoglycemia Esmolol 0.5 mg/kg IV over 1 min
then 0.050.5 mg/kg/min IV infusion
OR
Propranolol 0.150.25 mg/kg IV
Can repeat 1 in 15 min
Consider early surgery

Phenylephrine* to increase SVR


IV 520 g/kg/dose (slowly)
(IV infusion 0.10.5 g/kg/min)
Indicators of improved OR SC/IM 0.1 mg/kg
pulmonary blood flow
Decreased cyanosis
Cardiac murmur
Sodium bicarb 1 mEq/kg IV
becomes louder
Consider blood transfusion

Correct any underlying


cause/secondary problems, General anesthesia (consider
which may exacerbate episode, ketamine 13 mg/kg) and ventilation
e.g. cardiac arrhythmia,
hypothermia, hypoglycemia,
anemia
Urgent surgery required

*In UK may use metaraminol 0.01 mg/kg IV (continuous infusion at Cardiac Intensive Care. Philadelphia: Williams and Wilkins, 1998; Lieh-Lai
0.11 g/kg/min). M et al. Pediatric Acute Care, 2nd edn. Philadelphia: Williams and Wilkins,
BP, blood pressure; SVR, supraventricular rhythm. 2001.)
(Based on information from Park MK, The Pediatric Cardiology
Handbook, 3rd edn. Philadelphia: Mosby, 2003; Chang AC et al. Pediatric

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