Pediatric Advanced Life Support (PALS) - UpToDate PDF

8/27/2017 Pediatric advanced life support (PALS) - UpToDate
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Pediatricadvancedlifesupport(PALS)
Authors: EricFleegler,MD,MPH,MonicaKleinman,MD
SectionEditor: SusanBTorrey,MD
DeputyEditor: JamesFWiley,II,MD,MPH
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Jul2017.|Thistopiclastupdated:Mar22,2017.
INTRODUCTIONThistopicwilldiscusstheadvancedcomponentsofrecognitionandtreatmentofrespiratory
failure,shock,cardiopulmonaryfailure,andcardiacarrhythmiasinchildren.
Basiclifesupportinchildrenandguidelinesforcardiacresuscitationinadultsarediscussedseparately.(See
"Pediatricbasiclifesupportforhealthcareproviders"and"Advancedcardiaclifesupport(ACLS)inadults".)
BACKGROUNDTheAmericanHeartAssociation(AHA)PALSprogramprovidesastructuredapproachtothe
assessmentandtreatmentofthecriticallyillpediatricpatient[1,2].TheAHAguidelinesforpediatricresuscitation
wereupdatedin2015toreflectadvancesandresearchinclinicalcareusingnewevidencefromavarietyof
sourcesrangingfromlargeclinicaltrialstoanimalmodels.
ThePALScontentincludes:
Overviewofassessment
Recognitionandmanagementofrespiratorydistressandfailure
Recognitionandmanagementofshock
Recognitionandmanagementofcardiacarrhythmias
Recognitionandmanagementofcardiacarrest
Postresuscitationmanagementofpatientswithpulmonaryandcardiacarrest
Reviewofpharmacology
Theclinicianshouldprimarilyfocusonpreventionofcardiopulmonaryfailurethroughearlyrecognitionand
managementofrespiratorydistress,respiratoryfailure,andshockthatcanleadtocardiacarrestfromhypoxia,
acidosis,andischemia.
ASSESSMENTTheassessmentofrespiratorydistressandcirculatorycompromiseinchildren,includingthe
commonfindings,iscoveredingreaterdetailseparately.(See"Initialassessmentandstabilizationofchildren
withrespiratoryorcirculatorycompromise".)
PALSusesanassessmentmodelthatfacilitatesrapidevaluationandinterventionforlifethreateningconditions.
Ininfantsandchildren,mostcardiacarrestsresultfromprogressiverespiratoryfailureand/orshock,andoneof
theaimsofthisrapidassessmentmodelistopreventprogressiontocardiacarrest.
Theevaluationincludes:
Initialimpression(briefvisualandauditoryobservationofchild'soverallappearance,workofbreathing,
circulation)(see"Initialassessmentandstabilizationofchildrenwithrespiratoryorcirculatorycompromise",
sectionon'Pediatricassessmenttriangle')
https://www.uptodate.com.aure.unab.edu.co/contents/pediatric-advanced-life-support-pals/print?source=search_result&search=Pediatric%20advanced%20life%20su 1/49
PrimaryassessmentTheclinicianshouldinrapidsequenceassess:
Airway(patent,patentwithmaneuvers/adjuncts,partiallyorcompletelyobstructed)
Breathing(respiratoryrate,effort,tidalvolume,lungsounds,pulseoximetry)
Circulation(skincolorandtemperature,heartrateandrhythm,bloodpressure,peripheralandcentral
pulses,capillaryrefilltime)
Disability
AVPUpediatricresponsescale:Alert,Voice,Pain,Unresponsive
Pupillaryresponsetolight
Presenceofhypoglycemia(rapidbedsideglucoseorresponsetoempiricadministrationof
dextrose)
GlasgowComaScale:EyeOpening,VerbalResponse,MotorResponse(table1)(fortrauma
patients)
Exposure(feverorhypothermia,skinfindings,evidenceoftrauma)
SecondaryassessmentThisportionoftheevaluationincludesathoroughheadtotoephysical
examination,aswellasafocusedmedicalhistorythatconsistsofthe"SAMPLE"history:
S:Signsandsymptoms
A:Allergies
M:Medications
P:Pastmedicalhistory
L:Lastmeal
E:Eventsleadingtocurrentillness
TertiaryassessmentInjuryandinfectionarecommoncausesoflifethreateningillnessinchildren.Thus,
ancillarystudiesarefrequentlydirectedtowardsidentifyingtheextentoftraumaoraninfectiousfocus.(See
"Traumamanagement:Approachtotheunstablechild",sectionon'Adjunctstotheprimarysurvey'and
"Traumamanagement:Approachtotheunstablechild",sectionon'Adjunctstothesecondarysurvey'and
"Initialevaluationofshockinchildren",sectionon'Evaluation'and"Approachtotheillappearinginfant
(youngerthan90daysofage)",sectionon'Ancillarystudiesforinfectiousetiologies'.)
RespiratorydistressandfailureRecognitionandtreatmentofrespiratoryconditionsamenabletosimple
measures(eg,supplementaloxygenorinhaledbronchodilators)aremajorgoalsofPALS[3].Theclinicianmay
alsohavetotreatrapidlyprogressiveconditionsandintervenewithadvancedtherapiestoavoidcardiopulmonary
arrestinpatientswithrespiratoryfailure.Earlydetectionandtreatmentimproveoveralloutcome.
Therearemanycausesofacuterespiratorycompromiseinchildren(table2).Theclinicianshouldstriveto
categorizerespiratorydistressorfailureintooneormoreofthefollowing[3](see"Acuterespiratorydistressin
children:Emergencyevaluationandinitialstabilization"):
Upperairwayobstruction(eg,croup,epiglottitis)
Lowerairwayobstruction(eg,bronchiolitis,statusasthmaticus)
Lungtissue(parenchymal)disease(eg,bronchopneumonia)
Disorderedcontrolofbreathing(eg,seizure,coma,muscleweakness)
Initialmanagementsupportsairway,breathing,andcirculation:
AirwayKeystepsinbasicairwaymanagementinclude(see"Basicairwaymanagementinchildren"):
Provide100percentinspiredoxygen
Allowchildtoassumepositionofcomfortormanuallyopenairway
Clearairway(suction)
Insertanairwayadjunctifconsciousnessisimpaired(eg,nasopharyngealairwayor,ifgagreflex
absent,oropharyngealairway)
BreathingTheclinicianshould:
Assistventilationmanuallyinpatientsnotrespondingtobasicairwaymaneuversorwithinadequateor
ineffectiverespiratoryeffort
Monitoroxygenationbypulseoximetry
Monitorventilationbyendtidalcarbondioxide(EtCO2)ifavailable
Administermedicationsasneeded(eg,albuterol,epinephrine)
Inpreparationforintubation,100percentoxygenshouldbeappliedvianonrebreathermaskorotherhigh
concentrationdevice.Ifthepatienthasevidenceofrespiratoryfailure,positivepressureventilationshouldbe
initiatedwithabagvalvemaskorflowinflatingdevicetooxygenateandimproveventilation.(See"Basic
airwaymanagementinchildren".)
Childrenwhocannotmaintaintheirairway,oxygenation,orventilatoryrequirementsshouldundergo
placementofanartificialairway,usuallyviaendotrachealintubationandlesscommonlywithalaryngeal
maskairwayoralternativedevice.Certainpopulationsofpatientswithupperairwayobstructionand/or
respiratoryfailuremayrespondtononinvasiveventilation(CPAPorBiPAP)ifairwayreflexesarepreserved.
Arapidoverviewdescribesthestepsinperformingrapidsequenceintubation(table3).(See"Noninvasive
ventilationforacuteandimpendingrespiratoryfailureinchildren"and"Emergencyendotrachealintubationin
children"and"Rapidsequenceintubation(RSI)outsidetheoperatingroominchildren:Approach".)
CirculationKeyinterventionsconsistofmonitoringheartrateandrhythmandestablishingvascular
accesstoprovidevolumeadministrationand/ormedicationsforresuscitation.(See"Vascular(venous)
accessforpediatricresuscitationandotherpediatricemergencies".)
ShockThegoalistorecognizeandcategorizethetypeofshockinordertoprioritizetreatmentoptions
(algorithm1).Earlytreatmentofshockmaypreventtheprogressiontocardiopulmonaryfailure(algorithm2).The
managementofshockisdiscussedseparately.(See"Initialmanagementofshockinchildren"and"Septicshock:
Rapidrecognitionandinitialresuscitationinchildren".)
Shockmayoccurwithnormal,increased,ordecreasedsystolicbloodpressure.Shockinchildrenisusually
relatedtolowcardiacoutput,butsomepatientsmayhavehighcardiacoutput,suchaswithsepsisorsevere
anemia.(See"Initialevaluationofshockinchildren".)
Shockseverityisusuallycategorizedbyitseffectonsystolicbloodpressure[3]:
CompensatedshockCompensatedshockoccurswhencompensatorymechanisms(including
tachycardia,increasedsystemicvascularresistance,increasedinotropy,andincreasedvenoustone)
maintainasystolicbloodpressurewithinanormalrange.Thecalculatorsprovidethepercentileofblood
pressurebyheightforboys,age2to17years(calculator1)andgirls,age2to17years(calculator2).
Hypotensiveshock(ordecompensatedshock)Hypotensiveshockoccurswhencompensatory
mechanismsfailtomaintainsystolicbloodpressure.
Thedefinitionofhypotensionvariesbyage[3]:
Interminfants0to1monthofage,systolicpressure<60mmHg
Forinfants1to12monthsofage,hypotensionisdefinedbysystolicpressure<70mmHg
Inchildren1to10yearsofage,hypotensionisdefinedas:
Systolicpressure(5thpercentile)<(70mmHg+[child'sageinyearsx2])
Inchildrenover10yearsofage,systolicbloodpressure<90mmHg
Hypotensiveshockmayrapidlyprogresstocardiopulmonaryfailure.
ShockcategorizationTherearefourmajorcategoriesofshock[3](see"Initialevaluationofshockin
children"):
HypovolemicshockHypovolemicshockischaracterizedbyinadequatecirculatingbloodvolume.
Commoncausesoffluidlossincludediarrhea,hemorrhage(internalandexternal),vomiting,inadequate
fluidintake,osmoticdiuresis(eg,diabeticketoacidosis),thirdspacelosses,andburns.
DistributiveshockDistributiveshockdescribesinappropriatelydistributedbloodvolumetypically
associatedwithdecreasedsystemicvascularresistance.Commoncausesincludesepticshock,
anaphylacticshock,andneurogenicshock(eg,headinjury,spinalinjury).
CardiogenicshockCardiogenicshockreferstoimpairmentofheartcontractility.Commoncauses
includecongenitalheartdisease,myocarditis,cardiomyopathy,arrhythmias,sepsis,poisoningordrug
toxicity,andmyocardialinjury(trauma).
ObstructiveshockInthisformofshock,hypotensionarisesfromobstructedbloodflowtotheheart
orgreatvessels.Commoncausesincludecardiactamponade,tensionpneumothorax,ductaldependent
congenitalheartlesions,andmassivepulmonaryembolism.
Anygivenpatientmaysufferfrommorethanonetypeofshock.Forexample,achildinsepticshock
maydevelophypovolemiaduringtheprodromephase,distributiveshockduringtheearlyphaseof
sepsis,andcardiogenicshocklaterinthecourse.
CardiopulmonaryfailureRespiratoryfailureandhypotensiveshockarethemostcommonconditions
precedingcardiacarrest.
Causesofrespiratoryfailureinclude:
Upperairwayobstruction(choking,infection)
Lowerairwayobstruction(asthma,foreignbodyaspiration)
Parenchymaldisease(pneumonia,acutepulmonaryedema)
Disorderedcontrolofbreathing(coma,toxicingestion,statusepilepticus)
Causesofhypotensiveshockinclude:
Hypovolemia(dehydration,hemorrhage)
Cardiacfailure(eg,duetomyocarditisorvalvulardisease)
Distributiveshock(septic,neurogenic)
Metabolic/electrolytedisturbances
Acutemyocardialinfarction/ischemia
Toxicologicingestions
Pulmonaryembolism
Thefollowingphysicalfindingsoftenprecedecardiopulmonaryfailure:
AirwayStridor,stertor,drooling,and/orsevereretractions
BreathingBradypnea,irregular,ineffectiverespiration,gasping,and/orcyanosis
CirculationBradycardia,capillaryrefill>5seconds,weakcentralpulses,noperipheralpulses,
hypotension,coolextremities,and/ormottled/cyanoticskin
DisabilityDiminishedlevelofconsciousness
Thepatientincardiopulmonaryfailurewillprogressrapidlytocardiacarrestwithoutaggressiveintervention.
Positivepressureventilationswith100percentinspiredoxygen,chestcompressionsforheartrate<60beatsper
minuteinpatientswithpoorperfusion,andadministrationofintravenousfluidsandmedicationstailoredtotreat
theunderlyingcauseareindicated.(See"Basicairwaymanagementinchildren"and"Pediatricbasiclifesupport
forhealthcareproviders".)
HeartrateandrhythmInchildren,theheartrateisclassifiedasbradycardia,tachycardia,andpulseless
arrest.Interpretationofthecardiacrhythmrequiresknowledgeofthechild'stypicalheartrate(table4)and
baselinerhythmaswellaslevelofactivityandclinicalcondition.
BradycardiaBradyarrhythmiasarecommonprearrestrhythmsinchildrenandareoftenduetohypoxia.
Bradycardiawithsymptomsofshock(eg,poorsystemicperfusion,hypotension,alteredconsciousness)requires
urgenttreatmenttopreventcardiacarrest(algorithm3).(See'Bradycardiaalgorithm'below.)
Bradycardiaisdefinedasaheartratethatisslowcomparedwithnormalheartratesforthepatient'sage(table4)
[3].
Primarybradycardiaistheresultofcongenitalandacquiredheartconditionsthatdirectlyslowthespontaneous
depolarizationrateoftheheart'spacemakerorslowconductionthroughtheheart'sconductionsystem.
Secondarybradycardiaistheresultofconditionsthatalterthenormalfunctionoftheheart,includinghypoxia,
acidosis,hypotension,hypothermia,anddrugeffects.
SignsandsymptomsPathologicbradycardiafrequentlycausesachangeinthelevelofconsciousness,
lightheadedness,dizziness,syncope,orfatigue.Shockassociatedwithbradycardiacanmanifestwith
hypotension,poorendorganperfusion,alteredconsciousness,and/orsuddencollapse.
Electrocardiogram(ECG)findingsassociatedwithbradycardiainclude(see"Bradycardiainchildren"):
Slowheartraterelativetonormalrates(table4)
Pwavesthatmayormaynotbevisible
QRScomplexthatisnarrow(electricalconductionarisingfromtheatriumorhighnodalarea)orwide
(electricalconductionfromlownodalorventricularregion)
PwaveandQRScomplexmaybeunrelated(ie,atrioventriculardissociation)orhaveanabnormally
longperiodbetweenthem(atrioventricularblock)
Typicalbradyarrhythmiasinclude:
SinusbradycardiaSinusbradycardiaiscommonlyanincidentalfindinginhealthychildrenasanormal
consequenceofreducedmetabolicdemand(sleep,rest)orincreasedstrokevolume(wellconditioned
athlete)(waveform1).Pathologiccausesincludehypoxia,hypothermia,poisoning,electrolytedisorders,
infection,sleepapnea,drugeffects,hypoglycemia,hypothyroidism,andincreasedintracranialpressure.
(See"Bradycardiainchildren",sectionon'Sinusbradycardia'.)
AtrioventricularblockAtrioventricular(AV)blockisdefinedasadelayorinterruptioninthetransmission
ofanatrialimpulsetotheventriclesduetoananatomicalorfunctionalimpairmentintheconductionsystem.
Heartblockiscategorizedintothreetypes:
FirstdegreeFirstdegreeAVblockischaracterizedbyaprolongedPRintervalforagecausedby
slowconductionthroughtheAVnodewithoutmissedventricularbeats(waveform2).Ofnote,first
degreeAVblockdoesnotcausebradycardia.Ingeneral,thenormalPRintervalsare:70to170msecin
newborns,and80to200msecinyoungchildrenandadults.(See"Bradycardiainchildren",sectionon
'FirstdegreeAVblock'.)
SeconddegreeInseconddegreeAVblock,theorganizedatrialimpulsefailstobeconductedtothe
ventricleina1:1ratio.TherearetwotypesofseconddegreeAVblock(see"Bradycardiainchildren",
sectionon'SeconddegreeAVblock'):
MobitztypeI(Wenckebachphenomenon)OnECG,thereisprogressiveprolongationofthe
PRintervaluntilaPwavefailstobeconducted(waveform3).Theblockislocatedatthelevelof
theAVnodeandisusuallynotassociatedwithothersignificantconductionsystemdiseaseor
symptoms.
MobitztypeIIThisblockoccursbelowtheAVnodeandhasconsistentinhibitionofaspecific
proportionofatrialimpulses,usuallywitha2:1atrialtoventricularrate(waveform4).Ithasaless
predictablecourseandfrequentlyprogressestocompleteheartblock.
ThirddegreeInthirddegreeAVblock,alsoreferredtoascompleteheartblock,thereiscomplete
failureoftheatrialimpulsetobeconductedtotheventricles(waveform5).Theatrialandventricular
activityisindependentofoneanother.Theventricularescaperhythmthatisgeneratedisdictatedbythe
locationoftheblock.Itisusuallyslowerthanthelowerlimitsofnormalforage,resultinginclinically
significantbradycardia.(See"Bradycardiainchildren",sectionon'ThirddegreeAVblock'.)
TachycardiaRelativetachycardiaisaheartratethatistoofastforthechild'sage,levelofactivity,and
clinicalcondition(table4).Inchildren,sinustachycardiausuallyrepresentshypovolemia,fever,physiologic
responsetostressorfear,ordrugeffect(suchaswithbetaagonists).(See"Approachtothechildwith
tachycardia".)
Tachyarrhythmiasarefastabnormalrhythmsoriginatingintheatriaortheventricles.Certainarrhythmias,such
assupraventriculartachycardiaandventriculartachycardia,canleadtoshockandcardiacarrest.Unstable
rhythmsleadtopoortissueperfusionwithafallincardiacoutput,poorcoronaryarteryperfusion,andincreased
myocardialoxygendemand,whichcanallleadtocardiogenicshock.
Signsandsymptomsinchildrenwithtachycardiaareoftennonspecificandvarybyage.Theymayinclude
palpitations,lightheadedness,dizziness,fatigueandsyncope.Ininfants,prolongedtachycardiamaycausepoor
feeding,tachypnea,andirritabilitywithsignsofheartfailure.(See"Approachtothechildwithpalpitations"and
"Emergentevaluationofsyncopeinchildrenandadolescents".)
ImportantECGfindingsinclude:
Heartratethatisfastcomparedwithnormalrates(table4)
Pwavesthatmayormaynotbevisible
QRSintervalthatisnarroworwide
Treatmentprioritiesinmanagingtachycardiasrelyonwhetherhemodynamicinstabilityispresentand
differentiatingbetweentachycardiawithnarrowQRScomplex(sinustachycardia,supraventriculartachycardia,
atrialflutter)andwideQRScomplextachycardias(ventriculartachycardia,supraventriculartachycardiawith
aberrantintraventricularconduction)(algorithm4):
SinustachycardiaSinustachycardiaischaracterizedbyarateofsinusnodedischargethatisfasterthan
normalforthepatient'sage(table4).Thisrhythmusuallyrepresentsthebody'sincreasedneedforcardiac
outputoroxygendelivery.Theheartrateisnotfixedandvarieswithotherfactors,includingfever,stress,
andlevelofactivity.Causesincludetissuehypoxia,hypovolemia,fever,metabolicstress,injury,pain,
anxiety,toxins/poisons/drugs,andanemia.Lesscommoncausesincludecardiactamponade,tension
pneumothorax,andthromboembolism.(See"Approachtothechildwithtachycardia".)
TypicalECGfindingsinpatientswithsinustachycardiainclude:
Heartrateisusually<220/minininfants,<180/mininchildren,andexhibitsbeattobeatvariabilityin
rate.
Pwavesarepresentwithnormalappearance.
PRintervalisconstantandexhibitsanormaldurationforage.
RRintervalisvariable.
QRScomplexisnarrow.
SupraventriculartachycardiaSupraventriculartachycardia(SVT)canbedefinedasanabnormallyrapid
heartrhythmoriginatingabovetheventricles,often(butnotalways)withanarrowQRScomplexit
conventionallyexcludesatrialflutterandatrialfibrillation.ThetwomostcommonformsofSVTinchildrenare
atrioventricularreentranttachycardia(AVRT),includingtheWolffParkinsonWhite(WPW)syndrome
(waveform6),andatrioventricularnodalreentranttachycardia(AVNRT).
SignsandsymptomsSVTtypicallyhasanabruptonsetandintermittentpresentation.Signsand
symptomsininfantsincludepoorfeeding,tachypnea,irritability,increasedsleepiness,diaphoresis,
pallor,and/orvomiting.Olderchildrenmayhavepalpitations,shortnessofbreath,chestpain/discomfort,
dizziness,lightheadedness,and/orfainting.InfantsandchildrenwithprolongedSVTmaydisplayclinical
findingsofheartfailure.(See"Supraventriculartachycardiainchildren:AVreentranttachycardia
(includingWPW)andAVnodalreentranttachycardia",sectionon'Clinicalfeatures'.)
TypicalECGfindingsinpatientswithSVTinclude[3]:
Heartratethatisusually>220/minininfants,>180/mininchildren,andhasnoorminimalbeatto
beatvariability.
Pwavesareabsentorabnormal.
PRintervalmaynotbepresentorshortPRintervalwithectopicatrialtachycardia.
RRintervalisusuallyconstant.
QRSisusuallynarrow.Conductiondelayalongtheventricularsystemmayleadtoanappearance
ofwidecomplextachycardia,knownasSVTwithaberrantconduction.
VentriculartachycardiaVentriculartachycardia(VT)originatesfromtheventricularmyocardiumor
PurkinjecellsbelowthebifurcationofthebundleofHis(waveform7).VTmaypresentwithorwithoutpulses.
VTisassociatedwithsuddencardiacdeath.Asaresult,patientswhodevelopVTorareatriskfor
developingVTmustbeidentified,evaluated,andtreated,ifnecessary.
VTwithpulsescanvaryinratefromnearnormalto>200beatsperminute.Fasterratescancompromise
strokevolumeandcardiacoutputleadingtopulselessVTorventricularfibrillation(VF).CausesofVT
includeunderlyingheartdiseaseorcardiacsurgery,prolongedQTsyndromeorotherchannelopathies,or
myocarditis/cardiomyopathy.Othercausesincludehyperkalemiaandtoxicingestions(eg,tricyclic
antidepressants,cocaine)(table5).
FindingsofventriculartachycardiaonECGinclude(waveform7):
Ventricularrateis>120beatsperminuteandregular.
Pwavesareoftennotidentifiable,mayhaveAVdissociation,ormayhaveretrogradedepolarization.
QRSistypicallywide(>0.09seconds).
TwavesareoftenoppositeinpolarityfromtheQRScomplex.
Ventricularfibrillation,causesofwidecomplexQRS,andtreatmentofpulselessarrestarediscussed
separately.(See'Pulselessarrest'belowand"CausesofwideQRScomplextachycardiainchildren",section
on'Ventriculartachycardia'and'Pulselessarrestalgorithm'below.)
PulselessarrestPulselessarrestreferstothecessationofbloodcirculationcausedbyabsentor
ineffectivecardiacmechanicalactivity.Mostpediatriccardiacarrestsarehypoxic/asphyxialarreststhatresult
fromaprogressionofrespiratorydistress,respiratoryfailure,orshockratherthanfromprimarycardiac
arrhythmias("suddencardiacarrest").
Childrenwithpulselessarrestappearapneicordisplayafewagonalgasps.Theyhavenopalpablepulses,and
areunresponsive.
Thearrestrhythmsconsistof:
Shockablerhythms:
VentricularfibrillationVentricularfibrillationischaracterizedbynoorganizedrhythmandno
coordinatedcontractions(waveform8).Electricalactivityischaotic.Causesoverlapwithetiologiesof
ventriculartachycardia,includinghyperkalemia,congenitaloracquiredheartdisease,toxicexposures,
electricalorlightningshocks,andsubmersion.
PulselessventriculartachycardiaPulselessVTisacardiacarrestofventricularorigincharacterized
byorganized,wideQRScomplexes(waveform7).AnycauseofVTwithpulsescanleadtopulseless
VT.(See'Tachycardia'above.)
TorsadesdepointesTorsadesdepointesorpolymorphicVTdisplaysaQRScomplexthatchanges
inpolarityandamplitude,appearingtorotatearoundtheECGisoelectricline(translation:"twistingofthe
points")(waveform9).ThisarrhythmiaisassociatedwithmarkedlyprolongedQTcintervalfrom
congenitalconditions(longQTsyndrome),drugtoxicity(antiarrhythmicdrugs,tricyclicantidepressants,
calciumchannelblockers,phenothiazine),andelectrolytedisturbances(eg,hypomagnesemiaarising
fromanorexianervosa).Ventriculartachycardia,includingtorsadesdepointes,candeteriorateinto
ventricularfibrillation.
AsystoleChildrenwithasystolehavecardiacstandstillwithnodiscernibleelectricalactivity(waveform8).
Themostcommoncauseisrespiratoryfailureprogressingtocriticalhypoxemia,bradycardia,andthen
cardiacstandstill.Underlyingconditionsincludeairwayobstruction,pneumonia,submersion,hypothermia,
sepsis,andpoisoning(eg,carbonmonoxidepoisoning,sedativehypnotics)leadingtohypoxiaandacidosis.
PulselesselectricalactivityPulselesselectricalactivity(PEA)consistsofanyorganizedelectricalactivity
observedonECGinapatientwithnocentralpalpablepulse.ReversibleconditionsmayunderliePEA,
including:
Hypovolemia
Hypoxia
Hydrogenion(acidosis)
Hypo/hyperkalemia
Hypoglycemia
Hypothermia
Toxins
Tamponade,cardiac
Tensionpneumothorax
Thrombosis(coronaryorpulmonary)
Trauma
ThesecanberememberedastheH'sandT'sofPEA[3].
RESUSCITATIONGUIDELINESTheapproachpresentedhereisbaseduponthe2010international
resuscitationguidelinesdevelopedbytheInternationalLiaisonCommitteeonResuscitation(ILCOR)andusedas
thebasisfortheAmericanHeartAssociation(AJA)GuidelinesonCardiopulmonaryResuscitationand
EmergencyCardiovascularCare[46].In2015,boththeILCORconsensusonscienceandtheAHAGuidelines
representupdatesratherthanacomprehensivereviewofallrecommendations.Forthe2015AHA/ILCOR
update,thealgorithmforpediatriccardiacarrestwasrevisedbuttheguidelinesforbradyarrhythmiasand
tachyarrhythmiasremainedunchanged[1,2].
BradycardiaalgorithmThemanagementofbradycardiafocuseson(algorithm3):
Reestablishingoroptimizingoxygenationandventilation(see"Basicairwaymanagementinchildren")
Supportingcirculationwithchestcompressionsforpatientswithpoorperfusionandaheartrate<60beats
perminute
Usingmedications(ie,epinephrineoratropine)toincreaseheartrateandcardiacoutput
Ifthesemeasuresfail,transcutaneouspacingcanbeattemptedhowever,thesamefactorsthatareproducing
refractorybradycardia(eg,hypoxia,hypothermia,electrolytedisturbance,ordrugoverdose)mayprevent
effectiveelectricalcapture.(See"Bradycardiainchildren",sectionon'Poorperfusion'.)
TachycardiaalgorithmThemanagementofsinustachycardiafocusesontreatmentoftheunderlying
physiologicderangementandislargelysupportive.
ThemanagementoftachyarrhythmiasthatarenotsinusinoriginisguidedbytheappearanceoftheQRS
complex,andbythepatient'sstatus,whetherunstableorstable(algorithm4):
UnstablePatientswithapulseandeithernarroworwidecomplextachycardiawhohavesignificantly
impairedconsciousnessandhypotensiveshockshouldbetreatedwithsynchronizedcardioversion(initial
dose:0.5to1J/kg)(algorithm4).(See"Defibrillationandcardioversioninchildren(includingautomated
externaldefibrillation)",sectionon'Methods:Manualdefibrillatoruse'.)
StableForpatientswhoarementatingandnothypotensive,treatmentisdeterminedbytheQRScomplex:
NarrowQRS(0.09seconds)Fornarrowcomplextachycardiasuggestiveofsupraventricular
tachycardia(SVT),vagalmaneuversmaybeattemptedwhilepreparingformedicationadministration.
Appropriatevagalmaneuversincludeapplicationoficetothefaceor,inacooperativechild,aValsalva
maneuverbybearingdownorblowingintoanoccludedstraw.
ThefirstrecommendedmedicationforSVTisadenosine,0.1mg/kg(maximumdose6mg)administered
rapidlyIV/IOandfollowedbyarapidsalineflush(table6).(See"Managementofsupraventricular
tachycardiainchildren",sectionon'Antiarrhythmictherapy'.)
WideQRS(>0.09seconds)Ifthewidecomplexrhythmismonomorphicandregular,itisacceptable
toadministeradoseofadenosinetodetermineiftherhythmisactuallysupraventriculartachycardiawith
aberrantconduction.
Antiarrhythmictherapyofwidecomplextachycardiainvolvesagentswithsignificantsideeffects(eg,
amiodaroneorprocainamide)andconsultationwithapediatriccardiologyspecialistisstrongly
recommended.(See"ManagementandevaluationofwideQRScomplextachycardiainchildren",
sectionon'Management'.)
PulselessarrestalgorithmTreatmentofapediatriccardiacarrestisprovidedinthe2015PediatricCardiac
ArrestAlgorithmandsummarizedbelow[1,2].Theepidemiologyofcardiacarrestinchildrenisdiscussed
separately.(See"Pediatricbasiclifesupportforhealthcareproviders",sectionon'Epidemiologyandsurvival'.)
StartCPRThefirststepistoinitiatecardiopulmonaryresuscitationaccordingtothealgorithmsavailable
here(onerescuer)andhere(twoormorerescuers)[7,8].(See"Pediatricbasiclifesupportforhealthcare
providers",sectionon'Basiclifesupportalgorithms'.)
Forhighlyeffectivechestcompressions,theindividualperformingthecompressionsneedstopushatan
adequaterateanddepth,avoidleaningonthechest(allowfullrecoil),andminimizeinterruptionsinchest
compressions.Thepersonperformingchestcompressionsshouldberotatedapproximatelyeverytwominutes,
regardlessofwhetherhe/shefeelscapableofcontinuing.
Theclinicianshouldonlyinterruptcompressionsforrhythmcheckattheappropriatelydefinedintervals,shock
delivery,andforinsertionofbreathsforpatientswithoutasecureairwayataratioof30compressionsto2
ventilations(onerescuerorageorpubertyandolder)or15compressionstotwoventilations(tworescuersand
infantsandchildren).Oncethepatientsairwayissecuredbyendotrachealintubation,performcontinuouschest
compressionsandventilateatarateof8to10breaths/minute(approximatelyonebreatheverysixseconds).
InfantsandchildrenshouldreceivebothchestcompressionsandventilationsratherthancompressiononlyCPR
baseduponlargepopulationstudiesdemonstratingimprovedsurvivalandneurologicoutcome.(See"Pediatric
basiclifesupportforhealthcareproviders",sectionon'Chestcompressions'and"Pediatricbasiclifesupportfor
healthcareproviders",sectionon'ConventionalversuscompressiononlyCPR'.)
ShockablerhythmPatientswithventricularfibrillation(VF)orpulselessventriculartachycardia(pVT)
shouldreceiveimmediateCPRanddefibrillationat2J/kgassoonasadeviceisavailable(2015Pediatric
https://www.uptodate.com.aure.unab.edu.co/contents/pediatric-advanced-life-support-pals/print?source=search_result&search=Pediatric%20advanced%20life%20s 10/49
CardiacArrestAlgorithm).Afterdeliveringtheshock,performapproximatelytwominutesofCPR(10cyclesfor
twopersonCPRor5cyclesforonepersonCPR)beforecheckingtherhythm[1,2].
Iftherhythmhasnotconvertedwithdefibrillation,thepatientshouldreceivearepeateddefibrillationatahigher
dose(4J/kg)followedbyadditionalcyclesofCPRasdescribedabove[1,2].Subsequentdefibrillationsshouldbe
providedataminimumof4J/kg,upto10J/kgortheadultenergydose(typically120to200Jforabiphasic
defibrillatorand360Jforamonophasicdefibrillator).
Althoughmanualdefibrillatorsoperatedbyadvancedlifesupportprovidersorautomatedexternaldefibrillators
withpediatricattenuatingdevicesarepreferredforuseininfantsandchildren,automatedexternaldefibrillators
withoutpediatricattenuatingdevicesmaybeusediftheyaretheonlyoptionavailable.(See"Pediatricbasiclife
supportforhealthcareproviders",sectionon'Automatedexternaldefibrillator'and"Defibrillationand
cardioversioninchildren(includingautomatedexternaldefibrillation)",sectionon'Methods:Manualdefibrillator
use'.)
PersistentVForpVTrequirestheadditionofmedicationssuchasparenteralepinephrineeverythreetofive
minutesandantiarrhythmictherapy(eg,amiodaroneorlidocaineforVForpVTasshowninthe2015Pediatric
CardiacArrestAlgorithm)ormagnesiumsulfatefortorsadesdepointes[1,2].Whengivingmedications,theIOor
IVrouteisalwayspreferredtoadministrationthroughtheendotrachealtube.Attemptsatvascularorintraosseous
accessshouldnotinterruptchestcompressions.DuringCPR,intraosseousaccessmaybepursuedinitially,or
simultaneouslywithperipheralvascularaccess.(See"Intraosseousinfusion"and"Vascular(venous)accessfor
pediatricresuscitationandotherpediatricemergencies",sectionon'Generalapproach'.)
Drugdosesareasfollows(table6)[1,2]:
EpinephrineTheIV/IOdoseofepinephrineis0.01mg/kg(0.1mL/kgofthe0.1mg/mLconcentration[ratio
1:10,000])giveneverythreetofiveminutesmaximumsingledose:1mg(10mL).Whenepinephrineis
administeredviaendotrachealtube,usea10foldhigherdoseor0.1mg/kg(0.1mL/kgofthe1mg/mL
concentration[ratio1:1000])everythreetofiveminutes.(See"Primarydrugsinpediatricresuscitation",
sectionon'Epinephrine'.)
AmiodaroneTheinitialIV/IOdoseofamiodaroneis5mg/kg(maximumsingledose300mg).The5mg/kg
(maximum300mg)dosecanberepeatedtwice.(See"Primarydrugsinpediatricresuscitation",sectionon
'Amiodarone'.)
LidocaineTheinitialIV/IObolusdoseoflidocaineis1mg/kg.Thismaybefollowedbyaninfusionof20to
50mcg/kg/min.Thebolusdoseshouldberepeatedifthelidocaineinfusionisstartedmorethan15minutes
aftertheinitialbolus.Althoughlidocainecanbegiventhroughtheendotrachealtube,theoptimaldoseis
unknown.Anincreaseoftwotothreefoldissuggested.(See"Primarydrugsinpediatricresuscitation",
sectionon'Lidocaine'and"Primarydrugsinpediatricresuscitation",sectionon'Endotrachealdrug
administration'.)
MagnesiumsulfateTheIV/IOdoseis25to50mg/kg(maximumdose2g)givenasaninfusionof
magnesiumsulfatedilutedina5percentdextrosesolution(D5W)toaconcentrationof20percentorless
and,inanarrestedpatient,infusedoveronetotwominutes.(See"Primarydrugsinpediatricresuscitation",
sectionon'Magnesiumsulfate'.)
ResuscitationmedicationsgiventhroughanIOorperipheralIVshouldbefollowedwitha5to10mLflushof
normalsalinetomovethedrugfromtheperipheraltothecentralcirculation.
AsystoleorpulselesselectricalactivityPatientswithasystoleorpulselesselectricalactivityshould
receivecardiopulmonaryresuscitationandepinephrineassoonaspossibleafterarrest(2015PediatricCardiac
ArrestAlgorithm)[1,2].
Duringthecourseoftheresuscitation,theclinicianshouldevaluateforandtreatunderlyingcauses(H'sandT's)
forthepulselessarrest[1,2].Whengivingmedications,theIOorIVrouteisalwayspreferredtoadministration
throughtheendotrachealtube.AttemptsatvascularorintraosseousaccessshouldNOTinterruptchest
compressions.DuringCPR,intraosseousaccessmaybepursuedinitially,orsimultaneouslywithperipheral
vascularaccess.(See"Vascular(venous)accessforpediatricresuscitationandotherpediatricemergencies",
sectionon'Generalapproach'.)
TheIV/IOdoseofepinephrineis0.01mg/kg(0.1mL/kgofthe0.1mg/mLconcentration[ratio1:10,000])given
everythreetofiveminutesmaximumsingledose:1mg(10mL).EpinephrinegiventhroughanIOorperipheral
IVshouldbefollowedwitha5to10mLflushofnormalsalinetomovethedrugfromtheperipheraltothecentral
circulation.IV/IOadministrationisstronglypreferredtoendotracheal(ET)administration.Whenepinephrineis
administeredviaETtube,thedoseshouldbeincreased10foldto0.1mg/kg(0.1mL/kgofthe1mg/mL
concentration[ratio1:1000])everythreetofiveminutes.(See"Primarydrugsinpediatricresuscitation",section
on'Epinephrine'and"Primarydrugsinpediatricresuscitation",sectionon'Endotrachealdrugadministration'.)
Amongchildrenwhoarrestinaninpatientsettingandwhodonothaverapidreturnofspontaneouscirculation
withinitiationofbasiclifesupport,timelyadministrationofepinephrineisassociatedwithimprovedsurvival.As
anexample,inaretrospectivereviewofregistrydataon1558childrenwithinpatientarrestandadocumented
nonshockableinitialrhythm,themediantimetothefirstdoseofepinephrinewasoneminute[9,10].Adjusted
survivaltodischargewasseeninupto37percentofpatientsreceivingepinephrineoneminuteorlessafter
arrestanddecreased5percentforeveryadditionalminutedelayinepinephrineadministration.Survivalwith
favorableneurologicoutcomeatdischargeoccurredinapproximately16percentofpatientsandalsodecreased
5percentforeveryadditionalminuteofdelayinepinephrineadministrationbaseduponadjustedanalysis.
MonitoringGiventheimportanceofhighqualitychestcompressions,techniquestomeasureandmonitor
CPRperformancehavebeendeveloped.Feedbackdevicesforpediatricpatientsarenotwidelyavailable,and
therearenostudiesevaluatingtheeffectoftheiruseonoutcome.(See"Pediatricbasiclifesupportforhealth
careproviders",sectionon'Chestcompressions'.)
Inadults,endtidalcarbondioxide(EtCO2)measurementsfromcontinuouswaveformcapnographyalso
accuratelyreflectcardiacoutputandcerebralperfusionpressure,andthereforethequalityofCPR.Adeclinein
EtCO2duringresuscitationmayindicateinadequateeffectivenessofcompressions,dislodgementofan
endotrachealtube,ordisruptionofpulmonarybloodflow(eg,massivepulmonaryembolus).WhetherEtCO2has
similarabilitytoidentifythequalityofCPRduringpediatricresuscitationsandspecificvaluestoguidetherapy
havenotbeenestablished[1,2].(See"Advancedcardiaclifesupport(ACLS)inadults",sectionon'Monitoring'
and"Carbondioxidemonitoring(capnography)",sectionon'EffectivenessofCPR'.)
InpediatricpatientswithadecliningEtCO2,effortstoimprovethequalityofcompressionsandtoavoidexcessive
ventilationareappropriate.Thus,inadditiontomonitoringrateandclinicaleffectivenessofventilation,weuse
EtCO2measurementsfromcontinuouswaveformcapnographywheneverpossibleduringpediatriccardiacarrest.
Sudden,sustainedincreasesinEtCO2duringCPRareassociatedwithareturnofspontaneouscirculation
(ROSC).(See"Carbondioxidemonitoring(capnography)",sectionon'Returnofspontaneouscirculation'.)
Inadults,measurementsofarterialrelaxationprovideareasonableapproximationofcoronaryperfusion
pressure.DuringCPR,areasonablegoalistomaintainthearterialrelaxation(or"diastole")pressureabove20
mmHg.Similarly,inadultpatients,centralvenousoxygensaturation(SCVO2)providesinformationaboutoxygen
deliveryandcardiacoutput.DuringCPR,areasonablegoalistomaintainSCVO2above30percent(see
"Advancedcardiaclifesupport(ACLS)inadults",sectionon'Monitoring').Datafromotherphysiologicmonitors
arelesslikelytobeavailableinchildrenwithpulselessarrest,butmeasurementsobtainedfromarterialand
centralvenouscatheterscanprovideusefulfeedbackaboutthequalityofCPRandthepresenceofROSC.
However,specifictargetsforbloodpressureorSCVO2havenotbeenestablishedinchildrenduringcardiac
arrest[1,2].
Extracorporealmembraneoxygenation(ECMO)withCPRExtracorporealmembraneoxygenationwith
CPR(ECPR)forinfantsandchildrenwithinpatienthospitalcardiacarrestsisusedinapproximately1percentof
arrestsandhasnotbeenassociatedwithoverallbenefitwhencomparedwithconventionalCPRinmoststudies
[1,2,11].Otherobservationalstudiesindicateimprovedoutcomesonlyforpatientswithunderlyingcardiac
diseases(eg,cardiomyopathy,myocarditis,orcongenitalcardiacanomalies)[1214].Forsuchpatients,intact
survivalapproaching50percenthasbeendescribed[13].Furthermore,intactsurvivalhasoccurredevenafter
prolongedperiodsofchestcompressions(>60minutes)inthesepatients.
Inonemulticenterprospectivecohortstudyof3756childrenwithinpatientcardiacarrests,ECPRwasassociated
withoverallincreasedratesofsurvivaltodischargeandfavorableneurologicoutcomesonadjustedanalysis[15].
However,thestudypooledpatientswithcardiacandnoncardiacetiologieseventhoughECPRwasmuchmore
likelytobeusedinsurgicalcardiacpatients.Whenthesegroupswereanalyzedseparately,onlythecardiac
patientshadstatisticallysignificantimprovedoutcomes.
Thus,useofECPRinsettingswithexistingECMOprotocols,expertise,andequipmentmaybebeneficialfor
selectedpatientswhofailconventionalCPRafterinpatientcardiacarrest.Ourapproachistoprepareforpossible
ECPRafterapproximately10minutesoffailedconventionalresuscitationinpatientswithconditionsthatmaybe
reversibleafteraperiodofECPR(eg,myocarditis,pulmonaryorairembolus,suddenarrestaftercardiacsurgery,
poisoning,orprimaryhypothermicarrest)orwhoarecandidatesfortheuseofECPRasabridgetotherapies
suchascardiactransplantation.
TerminationofresuscitationAlthoughcertainfactorsareassociatedwithbetterorworseoutcomesafter
cardiacarrestininfantsandchildren,nosinglefactorisreliableenoughtoaccuratelyguidewhethertermination
effortsshouldceaseorcontinue[1,2].
Thus,thedecisiontoterminateresuscitationshouldbeindividualizedandmultiplefactorsconsideredincluding:
Durationofcardiacarrest,includingwhenthepatientwasdiscoveredrelativetoinitialpresentation(eg,
patientswithsuddenInfantDeathSyndromewhoarefoundwithevidenceoflividitywouldhaveCPR
discontinuedearlierthanpatientswithinhospitalarrests)
Presentingrhythm(eg,shockableversusasystoleorpulselesselectricalactivity)
Underlyingdiseaseorcause,ifknown(eg,cardiacdisease,trauma,respiratoryfailure,orsepsis)
Settingandavailableresources
Donotresuscitatestatus
Intactsurvivalafterprolongedresuscitation(>30minutes)hasoccurredinpatientswiththefollowingconditions
[3]:
Poisoning
Primaryhypothermicarrest(see"Hypothermiainchildren:Management",sectionon'Nonperfusingcardiac
rhythms')
PatientswithcardiacdiseaseresuscitatedwithECPR(see'Extracorporealmembraneoxygenation(ECMO)
withCPR'above)
EarlypostresuscitationmanagementTheearlypostresuscitationperiodinvolvesthetimesoonafterreturn
ofspontaneouscirculationorrecoveryfromcirculatoryorrespiratoryfailure.Duringthistime,theclinicianmust
continuetotreattheunderlyingcauseofthelifethreateningeventandmonitorforcommonrespiratoryor
circulatoryproblemsthatmaycausesecondarymorbidityordeath.
MaintainairwayAllintubatedchildrenrequirecontinuedassessmenttoensureproperendotrachealtube
positioning,continuousmonitoringofoxygenation(pulseoximetry),andongoingmonitoringofventilation(eg,
continuousEtCO2monitoring,ifavailable,and/orintermittentbloodgasassessment).Insertionofagastrictube
helpstoreducegastricdistensionandmaypreventvomiting.
Thecausesofsuddendecompensationinachildwhohasbeensuccessfullyintubatedwithanartificialairwayis
describedbythemnemonic"DOPE"[3]:
D:Dislodgedordisplacedendotrachealtube(rightmainstemoresophageallocation)
O:Obstructedendotrachealtube(eg,mucousplug,kinkedendotrachealtube)
P:Pneumothorax
E:Equipmentfailure(eg,ventilatormalfunction,oxygendisconnectedoroff)
AvoidlowandhigharterialoxygenOncereturnofspontaneouscirculationhasbeenachieved,the
clinicianshouldtitrateinspiredoxygentomaintainpulseoximetrybetween94and99percenttoavoidhypoor
hyperoxemia[1,2,6,16].
Smallobservationalstudieshavefailedtoshowanassociationbetweenarterialoxygenationandmortalityin
resuscitatedchildren[1719].However,inonelarge,retrospective,multicenterobservationalpediatricstudyof
1875infantsandchildrenwhosurvivedtopediatricintensivecareunit(PICU)admission,multivariateanalysis
showedthatbothhypoxemia(PaO2<60mmHg)andhyperoxemia(PaO2300mmHg)independentlyand
significantlyincreasedtheestimatedriskofdeathby90and25percent,respectively[16].Overallmortalityprior
toPICUdischargewas39percentinthisstudy.
MonitorventilationThe2015internationalresuscitationguidelinesprovidearecommendationthatPaCO2
afterreturnofspontaneouscirculationmaybetargetedbaseduponthepatient'sspecificconditionandthat
exposuretoseverehypocapnia(PaCO2<30mmHg)orhypercapnia(PaCO2>50mmHg)shouldbelimited[1,2].
Inoneprospective,multicenterobservationalstudyof223infantsandchildrenwhosustainedaninhospital
arrest,hypoorhypercapniauponreturnofspontaneouscirculationwasassociatedwithamortalityof50or59
percent,respectively,comparedwith33percentmortalityifthePaCO2was30to50mmHg[17].
Hypocapniashouldalsobeavoidedsinceindirectevidencesuggeststhathyperventilationmaycausecerebral
ischemiainpediatricpatientswithseverebraininjury.(See"Severetraumaticbraininjuryinchildren:Initial
evaluationandmanagement",sectionon'Ventilation'.)
AvoidrecurrentshockThe2015internationalguidelinesrecommendthatparenteralfluidsandvasoactive
medicationsbeusedtomaintainthesystolicbloodpressure>5thpercentileforage[1,2].Hypotensionafter
ROSCisassociatedwithdecreasedsurvivaltohospitaldischarge[2022]and,forinfantsandchildrenwithan
inpatientarrest,decreasedsurvivalwithfavorableneurologicoutcome[20].
Afterreturnofspontaneouscirculation(ROSC)inachild,circulatoryinstabilitymayrecurastheresultofongoing
fluidloss,decreasedcardiacfunction,and/orharmfulalterationsinsystemicvascularresistance.Recurrent
shockshouldbemanagedaccordingtophysiologicendpoints(eg,skinperfusion,qualityofpulses,blood
pressure,urineoutputandmentalstatus).Ofnote,cardiogenicshockoccursfrequentlyinsurvivorsofcardiac
arrest.Ifhypovolemiaissuspectedinapatientwithcardiogenicshock,theclinicianshouldcarefullyinfuse5to
10mL/kgofisotonicfluids(eg,normalsalineorRinger'slactate)over10to20minutesfollowedbyreevaluation
ofendpoints(algorithm2).(See"Initialmanagementofshockinchildren",sectionon'Fluidadministration'.)
MaintainnormalbloodglucoseTheclinicianshouldmonitorbloodglucoselevelsandpromptlytreat
hypoglycemia.(See"Approachtohypoglycemiaininfantsandchildren",sectionon'Immediatemanagement'.)
Sustainedhyperglycemia(bloodglucose>180mg/dL[10mmol/L])isassociatedwithhighermortalityincritically
illchildrenandshouldbeavoided[23,24].Evidenceindicatesthatbloodglucoseshouldbemaintainedbelowthis
threshold,buttheroleof"tightcontrol"thatusesinsulintoachieveaspecifiedbloodglucoserangeisofuncertain
valueinchildrenaftercardiacarrest[6].Ifperformed,tightglucosecontrolrequiresclosemonitoringofblood
glucoseandavoidanceofhypoglycemia.Intensiveinsulintherapyinadultstomaintainabloodglucoserangeof
80to110mg/dL(4.4to6.1mmol/L)increasestheriskofhypoglycemiawithoutdemonstratedbenefit.(See
"Glycemiccontrolandintensiveinsulintherapyincriticalillness",sectionon'Generalapproach'.)
EEGmonitoringBaseduponsmallobservationalstudies,seizuresarecommonfollowingresuscitation
frompediatriccardiacarrestoccurringinapproximately33to50percentofpatients[2527].Nonconvulsivestatus
epilepticushasalsobeendescribedandmayaffectasignificantproportionofpatients.Asanexample,
nonconvulsivestatusepilepticuswasfoundaftercardiacarrestin6of19childreninoneseries[25].Forthis
reason,infantsandchildrenwhoremaincomatoseaftercardiacarrestshouldhaveelectroencephalogram(EEG)
evaluationforthepresenceofseizures,withpromptmanagementtoreducetheriskofworseningneurologic
injury.
Themanagementofnonconvulsiveandconvulsivestatusepilepticusarediscussedseparately.(See
"Nonconvulsivestatusepilepticus",sectionon'Treatment'and"Managementofconvulsivestatusepilepticusin
children".)
InformationfrompostarrestEEGmonitoringshouldnotbeusedasthesolecriterionforprognostication
followingpediatriccardiacarrest.
TargetedtemperaturemanagementTargetedtemperaturemanagementdescribesmeasurestokeep
corebodytemperatureinapredefinedrangeafterresuscitation.Inourinstitution,weuseatargetcorebody
temperatureof36to37.5Cwiththegoalofavoidingfever(temperature>38C)inchildrenfollowingcardiac
arrest.Basedupontheavailableevidenceandinternationalresuscitationguidelines,itisreasonabletoeither
providefivedaysofnormothermia(temperature36to37.5C),ortoprovidetwodaysoftherapeutichypothermia
followedbythreedaysofcontinuousnormothermiaforcomatoseinfantsandchildrenafteranoutofhospital
cardiacarrest[1,2].Regardlessoftheapproachchosen,fever(T>38C)shouldbestrictlyavoided.
Elevatedtemperaturefollowingresuscitationisassociatedwithworseoutcomesinneonatesandadultpatients
andispresumedtobeharmfulinchildrenaswellalthoughthereisnodirectevidenceinthispopulation[28].
Feveriscommoninchildrenafterresuscitationfromcardiacarrestthus,definingthetargetrangefor
temperatureandcarefulcoretemperaturemonitoringareindicated.Promptavailabilityandanticipatoryuseof
coolingblanketsandantipyreticsareroutineinourpractice.
Therapeutichypothermiatomaintaincorebodytemperaturebelownormal(typically32to34C)hasbeen
evaluatedinchildrenbaseduponevidenceforimprovedneurologicoutcomeinneonatesandselectedadults.
Forchildrenresuscitatedfromoutofhospitalcardiacarrest,therapeutichypothermiahasnotshownimproved
outcomesasfollows(see"Clinicalfeatures,diagnosis,andtreatmentofneonatalencephalopathy",sectionon
'Therapeutichypothermia'and"Postcardiacarrestmanagementinadults",sectionon'Targetedtemperature
management(TTM)andtherapeutichypothermia(TH)'):
Inamulticentertrialinvolvingchildrenwhowereresuscitatedfromanoutofhospitalcardiacarrest,260
patients(48hoursto18yearsofage)wererandomizedtoeithertherapeutichypothermiawithatargetcore
bodytemperatureof33Cortherapeuticnormothermiatomaintainatargettemperatureof36.8C.Oneyear
survivalwithgoodneurologicfunctionwasnotsignificantlydifferentinpatientsundergoingtherapeutic
hypothermiacomparedwiththerapeuticnormothermia(20versus12percent,respectively,relativelikelihood
1.54,95%CI0.862.76)[28].Thegroupsalsodidnotsignificantlydifferwithrespecttoincidenceofadverse
effectsincludinginfectionsorseriousarrhythmiasand28daymortality.Similarly,theseinvestigators,using
thesamemethodology,foundnobenefitoftherapeutichypothermiacomparedwiththerapeutic
normothermiain329childrenresuscitatedfrominhospitalcardiacarrest[29].Thistrialwasstoppedearlyfor
futility.
Ofnote,thenumberofpatientsrandomizedinbothtrialswasinsufficienttoexcludeanimportantbenefitor
harmfromtherapeutichypothermiaandfurtherstudymaybewarranted.Thelackofbenefitfrom
hypothermiamayberelatedtoimprovedoutcomesinthecontrolgroupsofthesetwotrials,bothofwhom
receivedactivecontrollednormothermiawhichmayalsobebeneficialinpatientswithcardiacarrest.
Severalobservationalstudieshaveshownnobenefitfortherapeutichypothermiaafteroutofhospital
cardiacarrestinchildren[28,3032]whileonesmallretrospectiveseriesshowedimprovedsurvival[33].
Takentogether,availableevidencesuggeststhattemperaturemanagementinchildrenaftercardiacarrestshould
includemeasurestoavoidfeverandmaintaincorebodytemperatureatornearnormal.Furtherstudies,are
neededtoestablishtheoptimaltemperaturetargetanddurationoftargetedtemperaturemanagement.
TransfertoapediatriccenterIfthechildisnotbeingtreatedinacenterwithpediatricemergencyand
criticalcareexpertise,thechildshouldbestabilizedandrapidlytransferredfordefinitivecareataregional
pediatriccenter.Criticallyillorinjuredchildrentypicallybenefitfromtransportbyateamwithpediatricexpertise
andadvancedpediatrictreatmentcapability,althoughinsomeisolatedcases(eg,expandingepiduralhematoma)
morerapidtransportbyanimmediatelyavailablenonpediatricteammaybeadvantageous.(See"Prehospital
pediatricsandemergencymedicalservices(EMS)",sectionon'Interfacilitytransport'.)
Priortotransfer,theclinicianresponsibleforthechild'scareatthetransferringhospitalshouldspeakdirectlyto
theclinicianwhowillbetakingchargeofthepatientatthereceivinghospital.Alldocumentationofcare(eg,
medicalchart,medicationadministrationrecord,laboratoryresults,copiesofancillarystudies[radiographs,
ECGs])shouldbesentwiththepatient.(See"Prehospitalpediatricsandemergencymedicalservices(EMS)",
sectionon'Interfacilitytransport'.)
RapidresponseteamsArapidresponseteam(RRT),alsoknownasamedicalemergencyteam(MET),
consistsofpersonnelfrommedical,nursingand/orrespiratorytherapywhohavecriticalcaretrainingandare
available24hoursperday,sevendaysaweekforevaluationandtreatmentofpatientswhoshowsignsofclinical
deteriorationandarelocatedinnoncriticalcaresettings(eg,medicalorsurgicalinpatientwards.Implementation
ofaRRThasbeenpromotedasamajorstrategyforimprovingpatientsafetyinhospitals[34].Infantsand
childrenwithhighriskconditionswhoaremanagedongeneralinpatientunitsmaybenefitfromrapidresponse
teamsthatcanprovidepromptassessmentandmanagementifclinicaldeteriorationoccursalthoughresultsfrom
largestudiesarenotconsistent[1,2,3538]:
Ametaanalysisoffivepediatricprospectiveobservationalstudieswithatotalof347,618patientadmissions
foundthatimplementationofaRRTwasassociatedwithasignificantreductionindeathsfromcardiacarrest
whencomparedtohistoricalcontrolperiods(0.05versus0.17percent,relativerisk[RR]0.6,95%CI0.50.8)
[35].However,decreasedmortalityafterimplementationofaRRTwasnotfoundinallstudies.
Acohortstudyof29,294patientadmissions(7257admissionsafterinstitutionofaRRT)thatwasincludedin
themetaanalysiscomparedhospitalwidemortalityratesandratesofrespiratoryandcardiopulmonary
arrestsoutsideoftheintensivecareunitbeforeandafterimplementationofanRRTina264bed
freestandingchildren'shospital[36].Majorfindingsincluded:
Themeanmonthlymortalityratedecreasedfrom1.0to0.8deathsper100discharges(18percent
decrease,95%CI530percent).
Themeanmonthlycoderate(respiratoryorcardiopulmonaryarrest)decreasedfrom2.5to0.7codes
per1000patientadmissions(RR0.3,95%CI0.10.7).Apossibleexplanationforthisfindingisthat
earlyactivationoftheRRTinacriticallyillpatientmighthavepreventedcodes.
Over18months,theRRTwasactivated143times,mostcommonlyforrespiratorydistress,
hypotension,hypoxemia,alteredmentalstatus,andtachycardia.ThemostcommonactionsbytheRRT
wererespiratorysupport,fluidresuscitation,airwaymanagement,andtransfertotheintensivecareunit.
Amulticenter,prospectiveobservationalstudyoftheimplementationofaclinicianledpediatricRRTinfour
pediatricacademiccentersfoundthatinitiationofanRRTwasassociatedwithasignificantreductionin
pediatricintensivecareunitmortalityrateafterreadmissionfromamedicalorsurgicalunit(0.3to0.1deaths
per1000hospitaladmissions)butnosignificantdeclineintherateofcardiopulmonaryarrests[37].
However,theseobservationsdonotprovethattheRRTwasresponsiblefortheimprovementinoutcomes.
Supportforthisconcerncomesfromanobservationalstudyinachildren'shospitalthatdidnotimplementan
RRTbutalsofoundasignificantreductioninmortalityoverthesametimeperiodinwhichotherpediatriccenters
reporteddecreasedmortalityinassociationwithRRTimplementation[38].
Thus,thebenefitofanRRTisnotconsistentacrossallsettings,anditispossiblethatexplanationsotherthan
theRRTmayberesponsibleforatleastpartofthebenefit.Inaddition,thequalityandgeneralizabilityofthe
evidencedescribingtheeffectivenessofimplementingRRTsislimitedbyfeaturessuchasbeforeandafter
observationdesign,selectionofprimaryandsecondaryoutcomemeasures,andvariedindicationsforRRT
activation.Inaddition,becausethemortalityfollowingpediatricintensivecareunit(PICU)admissionistypically
low,itsutilityasanoutcomemeasuremaybelimited.Finally,thesystemsbeingstudiedarecomplex,makingit
difficulttoidentifyconfoundingfactorssuchaschangesinseculartrendsorindirectbenefitsderivedfromthe
RRTimplementation.However,institutionsmaychoosetoimplementandmaintainRRTsbasedupontheirown
safetypriorities.
FamilypresenceduringresuscitationObservationalstudiesindicatethatcaretakersshouldbegiventhe
optionofbeingpresentduringtheinhospitalresuscitationoftheirchild[6].
Keyfindingsinclude:
Mostparentswanttheopportunitytoremainwiththeirchildduringresuscitation[6]andbelieveitistheirright
[39].
Caretakerspresentduringtheresuscitationofafamilymemberfrequentlyreportedthattheirpresence
duringtheresuscitationwasbeneficialtothepatient[3941].
Twothirdsofcaretakerspresentduringtheresuscitationofachildwhodiedreportedthattheirpresence
helpedwiththeiradjustmenttothedeathandthegrievingprocess[41].
Studiesofhospitalpersonnelsuggestthatthepresenceofafamilymember,inmostinstances,wasnot
stressfultostaffanddidnotnegativelyimpactstaffperformance[39,40,42].
Whenfamilymembersarepresentduringapediatricresuscitation,astaffmemberwithclinicalknowledge,
empathy,andstronginterpersonalskillsshouldbepresentwiththemtoprovidesupportandanswerquestions.
Intherareinstancethatfamilypresenceisdisruptivetoteamresuscitationefforts,thefamilymembersshouldbe
respectfullyaskedtoleave.
SUMMARYANDRECOMMENDATIONS
TheprincipalaimforPediatricAdvancedLifeSupport(PALS)istopreventcardiopulmonaryfailureand
arrestthroughearlyrecognitionandmanagementofrespiratorydistress,respiratoryfailure,andshock.(See
'Assessment'aboveand"Initialassessmentandstabilizationofchildrenwithrespiratoryorcirculatory
compromise".)
Amajorgoalofpediatricadvancedlifesupportistorecognizeandtreatrespiratoryconditionsamenableto
simplemeasures(eg,supplementaloxygen,inhaledalbuterol)(table2).Theclinicianmayalsohavetotreat
rapidlyprogressiveconditionsandintervenewithadvancedtherapiestoavoidcardiopulmonaryarrestin
patientswithrespiratoryfailure.Earlydetectionandtreatmentimproveoveralloutcome.(See'Respiratory
distressandfailure'above.)
Keystepsinbasicairwaymanagementinclude(see'Respiratorydistressandfailure'above):
Provide100percentinspiredoxygen
Allowchildtoassumepositionofcomfortormanuallyopenairway
Clearairway(suction)
Insertanairwayadjunctifconsciousnessisimpaired(eg,nasopharyngealairwayor,ifgagreflex
absent,oropharyngealairway)
Theclinicianshouldassistventilationmanuallyinpatientsnotrespondingtobasicairwaymaneuvers,
monitoroxygenationbypulseoximetry,monitorventilationbyendtidalcarbondioxide(EtCO2)ifavailable,
andadministermedicationsasneeded(eg,albuterolorracemicepinephrine).Inpreparationforintubation,
thepatientshouldreceive100percentoxygenviaahighconcentrationmask,orifindicated,positive
pressureventilationwithabagvalvemasktopreoxygenateandimproveventilation.(See'Respiratory
distressandfailure'above.)
Childrenwhocannotmaintainaneffectiveairway,oxygenation,orventilationshouldreceivenoninvasive
ventilation(NIV)orundergoendotrachealintubation.Arapidoverviewprovidesthestepsinperformingrapid
sequenceintubation(table3).InitiationofNIVisdiscussedseparately.(See"Rapidsequenceintubation
(RSI)outsidetheoperatingroominchildren:Approach"and"Noninvasiveventilationforacuteand
impendingrespiratoryfailureinchildren".)
Propertreatmentofshockinchildrenrequiresthecliniciantorecognizeandeventuallycategorizethetypeof
shockinordertoprioritizetreatmentoptions(algorithm1).Earlytreatmentofshockmaypreventthe
progressiontocardiopulmonaryfailure(algorithm2).(See"Initialevaluationofshockinchildren"and"Initial
managementofshockinchildren"and'Shock'above.)
Wesuggestthattreatmentofbradycardia(algorithm3),tachycardia(algorithm4),andpulselessarrest2015
PediatricCardiacArrestAlgorithmbemanagedaccordingtothe2010(bradycardiaandtachycardia)and
2015(pulselessarrest)AmericanHeartAssociation(AHA)andInternalLiaisonCommitteeonResuscitation
(ILCOR)guidelines(Grade2C).(See'Bradycardiaalgorithm'aboveand'Tachycardiaalgorithm'aboveand
'Pulselessarrestalgorithm'above.)
Keymeasuresafterresuscitationareasfollows(see'Earlypostresuscitationmanagement'above):
Continuespecificmanagementoftheunderlyingcauseofthelifethreateningevent
Titrateinspiredoxygentomaintainpulseoximetrybetween94and99percent
Inintubatedpatients,ensureproperendotrachealtubepositionandongoingmonitoringofventilation
Avoidrecurrentshockandhypotension(bloodpressure<5thpercentileforage)byadministering
parenteralfluidsandvasoactivemedicationsasneededandaccordingtophysiologicendpointsand
cardiacfunction
Avoidhypoglycemiawhilemaintainingbloodglucose<180mg/dL(10mmol/L)
Monitorforandtreatseizuresaggressivelyiftheyoccur
Preventelevatedcorebodytemperatureusingcoolingmeasures,asneeded
Ifthechildisnotbeingtreatedinacenterwithpediatricemergencyandcriticalcareexpertise,thechild
shouldbestabilizedandrapidlytransferredfordefinitivecareataregionalpediatriccenter.(See'Early
postresuscitationmanagement'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
REFERENCES
1.AmericanHeartAssociation.WebbasedIntegratedGuidelinesforCardiopulmonaryandEmergencyCardio
vascularCarePart12.Pediatricadvancedlifesupport.https://eccguidelines.heart.org/index.php/circulatio
n/cpreccguidelines2/part12pediatricadvancedlifesupport/(AccessedonNovember10,2015).
2.deCaenAR,BergMD,ChameidesL,etal.Part12:PediatricAdvancedLifeSupport:2015AmericanHeart
AssociationGuidelinesUpdateforCardiopulmonaryResuscitationandEmergencyCardiovascularCare.
Circulation2015132:S526.
3.PediatricAdvancedLifeSupportProviderManual,ChameidesL,SamsonRA,SchexnayderSM,Hazinski
MF(Eds),AmericanHeartAssociation,Dallas2012.
4.KleinmanME,deCaenAR,ChameidesL,etal.Pediatricbasicandadvancedlifesupport:2010
InternationalConsensusonCardiopulmonaryResuscitationandEmergencyCardiovascularCareScience
withTreatmentRecommendations.Pediatrics2010126:e1261.
5.KleinmanME,deCaenAR,ChameidesL,etal.Part10:Pediatricbasicandadvancedlifesupport:2010
InternationalConsensusonCardiopulmonaryResuscitationandEmergencyCardiovascularCareScience
WithTreatmentRecommendations.Circulation2010122:S466.
6.KleinmanME,ChameidesL,SchexnayderSM,etal.Part14:pediatricadvancedlifesupport:2010
AmericanHeartAssociationGuidelinesforCardiopulmonaryResuscitationandEmergencyCardiovascular
Care.Circulation2010122:S876.
7.AmericanHeartAssociation.WebbasedIntegratedGuidelinesforCardiopulmonaryResuscitationandEme
rgencyCardiovascularCarePart11:PediatricBasicLifeSupportandCardiopulmonaryResuscitationQua
lity.ECCguidelines.heart.org(AccessedonOctober15,2015).
8.AtkinsDL,BergerS,DuffJP,etal.Part11:PediatricBasicLifeSupportandCardiopulmonaryResuscitation
Quality:2015AmericanHeartAssociationGuidelinesUpdateforCardiopulmonaryResuscitationand
EmergencyCardiovascularCare.Circulation2015132:S519.
9.AndersenLW,BergKM,SaindonBZ,etal.TimetoEpinephrineandSurvivalAfterPediatricInHospital
CardiacArrest.JAMA2015314:802.
10.TaskerRC,RandolphAG.PediatricPulselessArrestWith"Nonshockable"Rhythm:DoesFasterTimeto
EpinephrineImproveOutcome?JAMA2015314:776.
11.LowryAW,MoralesDL,GravesDE,etal.Characterizationofextracorporealmembraneoxygenationfor
pediatriccardiacarrestintheUnitedStates:analysisofthekids'inpatientdatabase.PediatrCardiol2013
34:1422.
12.OrtmannL,ProdhanP,GossettJ,etal.Outcomesafterinhospitalcardiacarrestinchildrenwithcardiac
disease:areportfromGetWiththeGuidelinesResuscitation.Circulation2011124:2329.
13.MorrisMC,WernovskyG,NadkarniVM.Survivaloutcomesafterextracorporealcardiopulmonary
resuscitationinstitutedduringactivechestcompressionsfollowingrefractoryinhospitalpediatriccardiac
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14.RaymondTT,CunnynghamCB,ThompsonMT,etal.Outcomesamongneonates,infants,andchildren
afterextracorporealcardiopulmonaryresuscitationforrefractoryinhospitalpediatriccardiacarrest:areport
fromtheNationalRegistryofCardiopulmonaryResuscitation.PediatrCritCareMed201011:362.
15.LasaJJ,RogersRS,LocalioR,etal.ExtracorporealCardiopulmonaryResuscitation(ECPR)During
PediatricInHospitalCardiopulmonaryArrestIsAssociatedWithImprovedSurvivaltoDischarge:AReport
fromtheAmericanHeartAssociation'sGetWithTheGuidelinesResuscitation(GWTGR)Registry.
Circulation2016133:165.
16.FergusonLP,DurwardA,TibbySM.Relationshipbetweenarterialpartialoxygenpressureafter
resuscitationfromcardiacarrestandmortalityinchildren.Circulation2012126:335.
17.DelCastilloJ,LpezHerceJ,MatamorosM,etal.Hyperoxia,hypocapniaandhypercapniaasoutcome
factorsaftercardiacarrestinchildren.Resuscitation201283:1456.
18.GuerraWallaceMM,CaseyFL3rd,BellMJ,etal.Hyperoxiaandhypoxiainchildrenresuscitatedfrom
cardiacarrest.PediatrCritCareMed201314:e143.
19.BennettKS,ClarkAE,MeertKL,etal.Earlyoxygenationandventilationmeasurementsafterpediatric
cardiacarrest:lackofassociationwithoutcome.CritCareMed201341:1534.
20.TopjianAA,FrenchB,SuttonRM,etal.Earlypostresuscitationhypotensionisassociatedwithincreased
mortalityfollowingpediatriccardiacarrest.CritCareMed201442:1518.
21.LinYR,LiCJ,WuTK,etal.Postresuscitativeclinicalfeaturesinthefirsthourafterachievingsustained
ROSCpredictthedurationofsurvivalinchildrenwithnontraumaticoutofhospitalcardiacarrest.
Resuscitation201081:410.
22.LinYR,WuHP,ChenWL,etal.Predictorsofsurvivalandneurologicoutcomesinchildrenwithtraumatic
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75:439.
23.SrinivasanV,SpinellaPC,DrottHR,etal.Associationoftiming,duration,andintensityofhyperglycemia
withintensivecareunitmortalityincriticallyillchildren.PediatrCritCareMed20045:329.
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incriticallyillchildren"byFaustinoandApkon(JPediatr2005146:3034).PediatrCritCareMed2007
8:482.
25.AbendNS,TopjianA,IchordR,etal.Electroencephalographicmonitoringduringhypothermiaafterpediatric
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26.KirkhamF.Cardiacarrestandpostresuscitationofthebrain.EurJPaediatrNeurol201115:379.
27.ConstantinouJE,GillisJ,OuvrierRA,RahillyPM.Hypoxicischaemicencephalopathyafternearmiss
suddeninfantdeathsyndrome.ArchDisChild198964:703.
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29.MolerFW,SilversteinFS,HolubkovR,etal.TherapeuticHypothermiaafterInHospitalCardiacArrestin
Children.NEnglJMed2017376:318.
30.FinkEL,ClarkRS,KochanekPM,etal.Atertiarycarecenter'sexperiencewiththerapeutichypothermia
afterpediatriccardiacarrest.PediatrCritCareMed201011:66.
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2009119:1492.
32.ChangI,KwakYH,ShinSD,etal.Therapeutichypothermiaandoutcomesinpaediatricoutofhospital
cardiacarrest:Anationwideobservationalstudy.Resuscitation2016105:8.
33.LinJJ,HsiaSH,WangHS,etal.Therapeutichypothermiaassociatedwithincreasedsurvivalafter
resuscitationinchildren.PediatrNeurol201348:285.
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deadlineforimprovinghealthcarequality.JAMA2006295:324.
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proceduresinapediatricemergencydepartment.JEmergNurs200632:225.
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resuscitation:evaluatingaclinicalpracticechange.AmJRespirCritCareMed2012186:1133.
Topic6392Version33.0
GRAPHICS
GlasgowComaScaleandPediatricGlasgowComaScale
GlasgowComa
Sign PediatricGlasgowComaScale [2] Score
Scale [1]
Eye Spontaneous Spontaneous 4

opening
Tocommand Tosound 3
Topain Topain 2
None None 1
Verbal Oriented Ageappropriatevocalization,smile,ororientationtosound,interacts 5

response (coos,babbles),followsobjects
Confused,disoriented Cries,irritable 4
Inappropriatewords Criestopain 3
Incomprehensible Moanstopain 2
sounds
None None 1
Motor Obeyscommands Spontaneousmovements(obeysverbalcommand) 6

response
Localizespain Withdrawstotouch(localizespain) 5
Withdraws Withdrawstopain 4
Abnormalflexionto Abnormalflexiontopain(decorticateposture) 3
pain
Abnormalextensionto Abnormalextensiontopain(decerebrateposture) 2
pain
None None 1
Besttotalscore 15
TheGlasgowComaScale(GCS)isscoredbetween3and15,3beingtheworst,and15thebest.Itiscomposedof
threeparameters:besteyeresponse(E),bestverbalresponse(V),andbestmotorresponse(M).Thecomponentsof
theGCSshouldberecordedindividuallyforexample,E2V3M4resultsinaGCSof9.Ascoreof13orhighercorrelates
withmildbraininjuryascoreof9to12correlateswithmoderateinjuryandascoreof8orlessrepresentssevere
braininjury.ThepediatricGlasgowcomascale(PGCS)wasvalidatedinchildrentwoyearsofageoryounger.
Datafrom:
1.TeasdaleG,JennettB.Assessmentofcomaandimpairedconsciousness.Apracticalscale.Lancet19742:81.
2.HolmesJF,PalchakMJ,MacFarlaneT,KuppermannN.PerformanceofthepediatricGlasgowcomascaleinchildrenwith
bluntheadtrauma.AcadEmergMed200512:814.
Graphic59662Version11.0
Causesofacuterespiratorydistressinchildren
Respiratorytract
Infection
Uvulitis
Epiglottitis*
Retropharyngealabscess
Peritonsillarabscess
Croup
Tracheitis
Bronchiolitis
Pneumonia
Asthma
Anaphylaxis*
Foreignbody(upperairway*,lowerairway,esophagus)
Airwayanomalies(eg,laryngomalacia,laryngospasm,tracheoesophagealfistula,trachealstenosis,trachealringorsling)
Biologicorchemicalweapons*(eg,anthrax,tularemia,phosgene,nitrogenmustard,nerveagents,ricin)
Chestwalltraumaorabnormalities(eg,flailchest*,openpneumothorax*,thoracicdystrophy)
Thoraciccavitytraumaorconditions(eg,pneumothorax*,hemothorax*,pleuraleffusion,empyema,mediastinalmass)
Pulmonarytraumaorconditions(contusion,embolism,hemorrhage)
Smokeinhalation*
Chemicalagentexposures*(eg,phosgene,chlorine,cyanide)
Submersioninjury(neardrowning)*
Cardiovascular
Congenitalheartdisease*
Acutedecompensatedheartfailure*
Myocarditis*
Pericarditis
Arrhythmia*
Shock*
Cardiactamponade*
Myocardialinfarction*
Nervoussystem
Depressedventilation*(eg,ingestion,CNStrauma,seizures,orCNSinfection)
Hypotonia*(conditionscausingpoorairwayorrespiratorymuscletoneandineffectiverespiratoryeffort)
Pulmonaryaspirationduetolossofairwayprotectivereflexes
Gastrointestinal
Hypoventilationduetoabdominalpainordistention(eg,intraabdominaltrauma,smallbowelobstruction,bowel
perforation)
Gastroesophagealrefluxwithpulmonaryaspiration
Metabolicandendocrinediseases
Metabolicacidosis(eg,diabeticketoacidosis,severedehydration,sepsis,toxicingestions,inbornerrorsofmetabolism)
Hyperthyroidism
Hypothyroidism
Hyperammonemia
Hypocalcemia(laryngospasm)
Hematologic
DecreasedO 2 carryingcapacity(eg,acutesevereanemiafromhemolysis,methemoglobinemia,carbonmonoxide
poisoning)
Acutechestsyndrome(patientswithsicklecelldisease)*
*Conditionthatcanbeimmediatelylifethreatening.
CNS:centralnervoussystemO2:oxygen.
Rapidoverviewofrapidsequenceintubationinchildren
Preparation:Utilizeanactivechecklistto:
Beginpreoxygenationasdescribedbelow.
Identifyconditionsthatwillaffectchoiceofmedications(eg,increasedintracranialpressure,septicshock,
bronchospasm,statusepilepticus,or,ifsuccinylcholineuseisplanned,absolutecontraindicationsforitsuseaslisted
below).
Identifyconditionsthatwillpredictdifficultintubationorbagmaskventilation(eg,smallchin,inabilitytofullyopen
themouth,upperairwaytrauma,orinfection).
Assembleequipmentandcheckforfunction.
Developcontingencyplanforfailedintubation(refertoUpToDatetopicsondevicesfordifficultendotracheal
intubation).
Preoxygenation
Beginpreoxygenationassoonasrapidsequenceintubationispotentiallyneeded:
Spontaneouslybreathing:100%FiO 2 (7L/minoxygenflow)bynonrebreathermaskfor3minutes
Apneicorinadequatebreathing:Bagmaskventilationwithsmalltidalbreathsusing100%FiO 2
Duringinductionandparalysis,apneicoxygenationvianasalcannulaatflowrateof1L/kg/min(maximumflow
15L/min)maybeprovided
Administeroxygenatthehighestconcentrationavailable.
Pretreatment(optional)
Atropine:Althoughnotroutinelyrecommended,manyexpertssuggestatropineaspretreatmentfor:
Children1year
Childreninshock
Children<5yearsreceivingsuccinylcholine
Olderchildrenreceivingaseconddoseofsuccinylcholine
Dose:0.02mg/kgIVwithoutaminimumdose(maximumsingledose0.5mgifnoIVaccess,canbegivenIM).
Fentanyl:Optionalforincreasedintracranialpressureinpatientswithnormalorelevatedbloodpressure.Dose:1to3
mcg/kggivenover30to60secondstoavoidrespiratorydepressionandchestwallrigidity.Give3minutesbefore
inductionagentisadministered.
Lidocaine:Optionalforincreasedintracranialpressure(notrecommendedforpretreatmentinchildrenbysomeairway
experts).Dose:1to2mg/kgIV(maximumdose200mg).Give2to3minutesbeforeintubation.
Sedation
Etomidate:
Safewithhemodynamicinstability,neuroprotective,transientadrenalcorticosuppression.Donotuseroutinelyin
patientswithsepticshock.
Dose:0.3mg/kgIV.
Ketamine:
Safewithhemodynamicinstabilityifpatientisnotcatecholaminedepleted.Useinpatientswithbronchospasmand
septicshock.Usewithcautioninhypertensivepatientswithincreasedintracranialpressure.
Dose:1to2mg/kgIV(ifnoIVaccess,canbegivenIMdose:3to7mg/kg).
Propofol:
Causeshypotension.Mayuseinhemodynamicallystablepatientswithstatusepilepticus.
Dose1to1.5mg/kgIV.
Midazolam:
Mayuseinhemodynamicallystablepatientswithstatusepilepticus.Timetoclinicaleffectislonger,inconsistently
inducesunconsciousness.Maycausehemodynamicinstabilityatdosesrequiredforsedation.
Dose:0.2to0.3mg/kgIV(maximumdose10mg,onsetofeffectrequires2to3minutes).
Fentanyl:
Optionalforcardiogenicshockorcatecholaminedepletedshock(eg,persistenthypotensiondespitevasopressor
therapy).Limitedevidenceinchildren.
Dose1to5mcg/kgtitratedtoeffect.Startatlowerendofrangeinhypotensivepatients.Giveover30to60
secondstoavoidrespiratorydepressionorchestwallrigidity.
Thiopental:
Neuroprotective.Donotusewithhemodynamicinstability.
Dose:3to5mg/kgIV.*
Paralytic
Rocuronium:
Useforchildrenwithcontraindicationforsuccinylcholineorasprimaryparalyticifsugammadexisimmediately
available.
Dose:1mg/kgIV.
Succinycholine:
Donotusewithextensivecrushinjurywithrhabdomyolysis,chronicskeletalmuscledisease(eg,Beckermuscular
dystrophy)ordenervatingneuromusculardisease(eg,cerebralpalsywithparalysis)48to72hoursafterburn,
multipletrauma,ordenervatinginjurypatientswithhistoryormalignanthyperthermiaorpreexisting
hyperkalemia.
Dose:Infantsandchildren2years:2mg/kgIV,olderchildrenandadolescents:1to1.5mg/kgIV(ifIVaccess
unobtainable,canbegivenIM,dose:3to5mg/kg).
Protectionandpositioning
Maintainmanualcervicalspineimmobilizationduringintubationinthetraumapatient.
Ifcervicalspineinjuryisnotpotentiallypresent,putthepatientinthe"sniffingposition"(ie,headforwardsothatthe
externalauditorycanalisanteriortotheshoulderandthenoseandmouthpointtotheceiling).
Utilizeexternallaryngealmanipulationor,ininfants,gentlecricoidpressuretooptimizetheviewoftheglottisduring
directlaryngoscopyiftheinitialviewissuboptimalorinadequatedespitecorrectlaryngoscopebladepositioning.
Positioning,withplacement
ConfirmtrachealtubeplacementwithendtidalCO 2 detectionandauscultation.
Postintubationmanagement
Obtainachestradiographtoconfirmthedepthoftrachealtubeinsertion.
Provideongoingsedation(eg,midazolam),analgesia(eg,fentanyl1mcg/kg),and,ifindicated,paralysis.
IfIVaccessunobtainable,intraosseousadministrationofdrugslistedisanacceptablealternative.
IM:intramuscularlyIV:intravenously.
*Notavailableinmanycountries,includingtheUnitedStatesandCanada.
Sugammadexinadoseof16mg/kgcanprovideimmediatereversalofparalysiswhengivenapproximately3minutesafter
asingledoseofrocuronium.Vecuroniummaybeusedinchildrenwithcontraindicationstosuccinylcholineandwhen
rocuroniumisnotavailable.Suggesteddoseforrapidsequenceintubation:0.15to0.2mg/kg.Patientsmayexperience
prolongedandunpredictabledurationofparalysisatthisdose.
Defasciculatingagents(eg,rocuroniumorvecuroniumatonetenthoftheparalyzingdose)arenotroutinelyrecommended
forchildrenreceivingsuccinylcholine.
Bimanuallaryngoscopy,alsocalledexternallaryngealmanipulation(ELM),entailsmanipulatingthethyroidcartilageor
hyoidbonewiththerighthandduringlaryngoscopyinordertoimprovetheviewoftheglottis.Foradescriptionofhowto
performELM,refertotopicsonemergencyendotrachealintubationinchildrenandrapidsequenceintubationinchildren.
Ifdecompensationoccursaftersuccessfulintubation,usetheDOPEmnemonictofindthecause:
D:Dislodgementofthetube(rightmainstemoresophageal)
O:Obstructionoftube
P:Pneumothorax
E:Equipmentfailure(ventilatormalfunction,oxygendisconnectedornoton)
Approachtotheclassificationofundifferentiatedshockin
children
Initialmanagementofshockinchildren
DKA:diabeticketoacidosis.
*Forpossiblecardiogenicshockwithhypovolemia,give5to10mL/kgofisotonicfluids(eg,normalsalineor
Ringerslactate),infusedover10to20minutes.Evaluatetargetendpointsandslowlygiveanother5to10
mL/kgiftherehasbeenimprovementornochange.Forpatientswithdiabeticketoacidosis,give10mL/kgof
isotonicfluidsoveronehour.
Suchasinotropesorvasodilators.Fornewborns,prostaglandinE 1 .
ForpatientswithDKAwhodonotimprovewith20mL/kg,lookforanothercauseofshockbefore
administeringadditionalcrystalloid.Forpossiblecardiogenicshock,slowlygiveanother5to10mL/kgifthere
hasbeenimprovementornochange.
Dopamineifnormotensive,norepinephrineifhypotensiveandvasodilated,andepinephrineifhypotensive
andvasoconstricted.
Adaptedfrom:CarcilloJA,FieldsAI.Clinicalpracticeparametersforhemodynamicsupportofpediatricand
neonatalpatientsinsepticshock.CritCareMed200230:1365.
Pediatricrespiratoryrateandheartratebyage*
Respiratoryrate Heartrate
Agegroup Median Median
(1st99thpercentile) (1st99thpercentile)
0to3months 43(2566) 143(107181)termnewbornatbirth:127

(90164)
3to6months 41(2464) 140(104175)
6to9months 39(2361) 134(98168)
9to12months 37(2258) 128(93161)
12to18months 35(2153) 123(88156)
18to24months 31(1946) 116(82149)
2to3years 28(1838) 110(76142)
3to4years 25(1733) 104(70136)
4to6years 23(1729) 98(65131)
6to8years 21(1627) 91(59123)
8to12years 19(1425) 84(52115)
12to15years 18(1223) 78(47108)
15to18years 16(1122) 73(43104)
*Therespiratoryandheartratesprovidedarebaseduponmeasurementsinawake,healthyinfantsandchildrenatrest.Many
clinicalfindingsbesidestheactualvitalsignmeasurementmustbetakenintoaccountwhendeterminingwhetheraspecific
vitalsignisnormalinanindividualpatient.Valuesforheartrateorrespiratoryratethatfallwithinnormallimitsforagemay
stillrepresentabnormalfindingsthatarecausedbyunderlyingdiseaseinaparticularinfantorchild.
Datafrom:FlemingS,ThompsonM,StevensR,etal.Normalrangesofheartrateandrespiratoryrateinchildrenfrombirthto
18yearsofage:asystematicreviewofobservationalstudies.Lancet2011377:1011.
Pediatricbradycardiaalgorithm(withapulseandpoorperfusion)
PALS:pediatricadvancedlifesupportCPR:cardiopulmonaryresuscitationIO:intraosseousIV:
intravenousHR:heartrateAV:atrioventricularABCs:airway,breathing,circulation.
Reprintedwithpermission.PediatricAdvancedLifeSupport:2010.AmericanHeartAssociation
GuidelinesforCardiopulmonaryResuscitationandEmergencyCardiovascularCare.2010
AmericanHeartAssociation,Inc.Thisalgorithmremainsunchangedinthe2015update.
Singleleadelectrocardiogram(ECG)showingsinusbradycardia
Markedsinusbradycardiaatarateof25to30beats/min.ThenormalPwaves(uprightinlead
II)andPRintervalareconsistentwithasinusmechanismwithnormalatrioventricular(AV)
conduction.
CourtesyofAryGoldberger,MD.
Normalrhythmstrip
NormalrhythmstripinleadII.ThePRintervalis0.15secandtheQRS
durationis0.08sec.BoththePandTwavesareupright.
CourtesyofMortonFArnsdorf,MD.
Singleleadelectrocardiogram(ECG)showingfirst
degreeatrioventricular(AV)blockI
ElectrocardiogramofleadIIshowingnormalsinusrhythm,firstdegree
atrioventricularblockwithaprolongedPRintervalof0.30sec,andaQRS
complexofnormalduration.ThetallPwavesandPwavedurationof
approximately0.12secsuggestconcurrentrightatrialenlargement.
CourtesyofMortonArnsdorf,MD.
Normalrhythmstrip
Electrocardiogram(ECG)showingMobitztypeI
(Wenckebach)Atrioventricular(AV)block
Singleleadelectrocardiogram(ECG)showingMobitztypeI(Wenckebach)
seconddegreeAVblockwith5:4conduction.Thecharacteristicsofthis
arrhythmiainclude:aprogressivelyincreasingPRintervaluntilaPwaveisnot
conducted(arrow)aprogressivedecreaseintheincrementinthePRintervala
progressivedecreaseintheRRintervalandtheRRintervalthatincludesthe
droppedbeat(0.96sec)islessthantwicetheRRintervalbetweenconducted
beats(0.53to0.57sec).
CourtesyofMortonArnsdorf,MD.
Normalrhythmstrip
IIECGofmobitzIIseconddegreeheartblock
TheleadIIrhythmstripshowsfoursinusbeatswithPwavefollowedbyaQRScomplexthe
fifthPwaveisnotfollowedbyaQRScomplexandrepresentsseconddegreeheartblock.There
isnochangeinthePRintervalpriortooraftertheblockedPwaveandthusthisisMobitzII
seconddegreeheartblock.Asecondepisodeofseconddegreeheartblockcanbeseenafter
theseventhQRScomplex.
ReproducedwithpermissionbySamuelLevy,MD.
Thirddegree(complete)atrioventricularblockwithnarrowQRS
escaperhythm
ThePwavesarecompletelydissociatedfromtheQRScomplexes.TheQRScomplexesare
narrow,indicatingajunctionalescaperhythm.Theatrialandventricularratesarestable
theformerisfasterthanthelatter.
Normalrhythmstrip
Pediatrictachycardiaalgorithm(withapulseandpoorperfusion)
PALS:pediatricadvancedlifesupportIO:intraosseousIV:intravenousECG:electrocardiogramHR:heartrate.
*Vagalmanuevers:Ininfantsoryoungchildren,placeaplasticbagfilledwithiceandcoldwateroverthefacefor15
to30secondsorstimulatetherectumwithathermometer.Inolderchildren,encouragebearingdown(Valsalva
maneuver)for15to20seconds.Carotidmassageandorbitalpressureshouldnotbeperformedinchildren.
Reprintedwithpermission.PediatricAdvancedLifeSupport:2010.AmericanHeartAssociationGuidelinesfor
CardiopulmonaryResuscitationandEmergencyCardiovascularCare.2010AmericanHeartAssociation,Inc.This
algorithmremainsunchangedinthe2015update.
AVreentranttachycardia
AVreentranttachycardiabreakingtosinusrhythmwithWolffParkinsonWhite
syndrome.
Singleleadelectrocardiogram(ECG)showingmonomorphic
ventriculartachycardia
Threeormoresuccessiveventricularbeatsaredefinedasventriculartachycardia(VT).
ThisVTismonomorphicsincealloftheQRScomplexeshaveanidenticalappearance.
AlthoughthePwavesarenotdistinct,theycanbeseenalteringtheQRScomplexand
STTwavesinanirregularfashion,indicatingtheabsenceofarelationshipbetween
thePwavesandtheQRScomplexesie,AVdissociationispresent.
AV:atrioventricular.
Normalrhythmstrip
Drugandtoxininducedelectrocardiographicabnormalities
Bradycardia/AV Supraventricular Ventricular QRSandQTinterval

blockade tachycardia tachycardia prolongation
Betablockers Sympathomimetics Sympathomimetics Antidepressants
Calciumchannelblockers Amphetamines Cocaine Antipsychotics

Cocaine Amphetamines
Cardiacglycosides Antihistamines
Theophylline Theophylline
Digoxin Diphenhydramine
Caffeine Antidepressants
Digitoxin Astemizole
Methylphenidate TCAs
Redsquill Terfenadine
Ephedrine
Digitalislanata Antipsychotics Antiarrhythmics
Pseudoephedrine
Digitalispurpurea Phenothiazines Quinidine
Albuterol
Bufotenin Chlorinatedhydrocarbons Disopyramide
Dobutamine
Oleander Chloralhydrate Procainamide
Epinephrine
Alphaadrenergicagonists Solvents Propafenone
Dopamine
Phenylpropanolamine Fluoride Flecainide,encainide
Anticholinergics
Clonidine Amiodarone
Antihistamines
Cardiacglycosides
Imidazolines Calciumchannelblockers
TCAs Potassium (rare)
Cholinergics
Phenothiazines Betablockers(rare)
Organophosphates
Clozapine
Propoxyphene
Carbamates
Atropine
Opioids Organophosphate
Scopolamine
insecticides
Sedativehypnotics Thyroidhormone
Antimicrobials
Magnesium Cellularasphyxiants
Amantadine
Carbonmonoxide Azithromycin
Drugwithdrawalstates Chloroquine
Erythromycin
Pentamidine
Quinine
Quinolones(eg,
ciprofloxacin)
Arsenic
Thallium
Fluoride
Citrate
Lithium
Continuouselectrocardigraphic(ECG)stripduringanepisodeof
ventricularfibrillation(VF)thatprogressestofineVFandthen
asystole
Attheonsetofventricularfibrillation(VF),theQRScomplexesareregular,widened,andof
tallamplitude,suggestingamoreorganizedventriculartachyarrhythmia.Overabriefperiod
oftime,therhythmbecomesmoredisorganizedwithhighamplitudefibrillatorywavesthis
iscoarseVF.Afteralongerperiodoftime,thefibrillatorywavesbecomefine,culminatingin
asystole.
Singleleadelectrocardiogram(ECG)showingtorsades
depointes
Thisisanatypical,rapid,andbizarreformofventriculartachycardiathatis
characterizedbyacontinuouslychangingaxisofpolymorphicQRS
morphologies.
Pharmacologicagentsforpediatricadvancedlifesupport
Agent Indications Dose
Adenosine* Supraventriculartachycardia(SVT) Initialdose0.1mg/kg(children>50kg

receive6mg)givenasrapidIVorIOpush
closesttocentralcirculationfollow
immediatelywith5mLsalineflush(10to
20mLsalineflushforlargerchildor
adolescent)
Ifnotresponsivein2minutes,givesecond
doseof0.2mg/kg(children>50kgreceive
12mg)followimmediatelywith5mLsaline
flushifnotresponsiveafteradditional2
minutes,givethirddoseof0.3mg/kg
(maximum12mg)followimmediatelywith
5mLsalineflush
Amiodarone Pulselessventriculararrhythmiasnot Cardiacarrest:5mg/kgrapidIVorIO

responsivetoCPR,defibrillation,and bolus(maximumdose300mg)may
epinephrine repeat5mg/kgdosetwotimesuptoa
Stableventriculartachycardia maximumof15mg/kg
Perfusingpatient:5mg/kgIVorIO
SVTrefractorytoadenosine
(maximumdose300mg)diluteto2
mg/mLorlessandinfuseover20to60
minutesmayrepeat5mg/kgdosetwo
timesuptoamaximumof15mg/kgduring
acutetreatment
Atropine Vagallymediatedbradycardia 0.02mg/kgIVorIO(minimum0.1mg ,

Primaryatrioventricularblock maximumsingledose0.5mgforchildor1
mgforadolescent)mayrepeatoncein3
Bradycardianotresponsivetooxygen,airway
to5minutes
support,andepinephrineadministration
Maximumtotaldose1mg(child)or2mg
Preventionofbradycardiaduringendotracheal (adolescent)
intubationforchildren<1yearofage,children
OnlyifIVandIOnotavailable,maygive
15yearsofagereceivingsuccinylcholine,and
viaendotrachealtube(ET)0.04to0.06
childrenover5yearsofagereceivingasecond
mg/kgdilutedwith3to5mLsalinerepeat
doseofsuccinylcholine
onceifneeded(IVorIOarepreferred)
Calciumchloride Hypocalcemia Cardiacarrest:20mg/kggivenas0.2

Hypermagnesemia mL/kgof10%calciumchloridesolution,
maximum2g(20mL,14mmol)perdose
Hyperkalemia
diluteinanequalamountofD5WorNS
Calciumchannelblocker(CCB)overdose andgiveslowIVorIOpushrepeatin10
minutesifneeded
Perfusingpatient:10to20mg/kggiven
as0.1to0.2mL/kgof10%calcium
chloridesolution,maximum2g(20mL,14
mmol)perdosediluteinanequalamount
ofD5WorNSandgiveIVorIOover5to
10minutes(forinitialstabilizationinCCB
overdoseorseveresymptomatic
hyperkalemia)ordilutein10to50mL
D5WorNSandgiveIVorIOover10to20
minutesinperfusingpatientwithsevere
symptomatichypocalcemia(eg,tetany,
carpopedalspasm,orseizure)mayrepeat
in10minutesifneeded
Conversions:10%calciumchloride=100
mg/mLcalciumchloride=27.3mg/mL
elementalcalcium=0.68mmol/mLcalcium
Peripheraladministrationofcalcium
chlorideisnotrecommended
Formsprecipitatewithsodiumbicarbonate,
donotcoinfuse
Calciumgluconate Hypocalcemia Cardiacarrest:60mg/kggivenas

Hypermagnesemia 0.6mL/kgof10%calciumgluconate
solution,maximum3g(30mL,7mmol)
Hyperkalemia
perdosediluteinanequalamountofD5W
Calciumchannelblocker(CCB)overdose orNSandgiveslowIVorIOpush
(Alternatetocalciumchlorideforperfusing repeatin10minutesifneeded.Calcium
patientprovidesslowercorrectionofionized chloridepreferredifavailableandpatient
calciumconcentrationbutlesslikelytocause hascentralvenousaccess.
tissueinjurywhengivenbyperipheralIV) Perfusingpatient:60mg/kggivenas0.6
mL/kgof10%calciumgluconatesolution,
maximum2g(20mL,4.5mmol)perdose
diluteinanequalamountofD5WorNS
andgiveIVorIOover5to10minutesfor
initialstabilizationinCCBoverdoseor
severesymptomatichyperkalemia,may
repeatifneededorfollowbycontinuous
infusion(CCBoverdose)ordilutein10to
50mLD5WorNSandgiveIVorIOover
10to20minutesinperfusingpatientwith
severesymptomatichypocalcemia(eg,
tetany,carpopedalspasm,orseizures)
mayrepeatin10minutesifneeded
Conversions:10%calciumgluconate=100
mg/mLcalciumgluconate=9.3mg/mL
elementalcalcium=0.23mmol/mLcalcium
Formsprecipitatewithsodiumbicarbonate,
donotcoinfuse
Epinephrine Asystole 0.01mg/kgIVorIOgivenas0.1mL/kg

Pulselesselectricalactivity usingthe0.1mg/mL(1:10,000)solution
upto1mgperdose
Pulselessventriculararrhythmiasnot
Repeatevery3to5minutesasneeded
responsivetoinitialdefibrillation
notcompatiblewithsodiumbicarbonate
Bradycardianotresponsivetooxygenand
OnlyifIVandIOarenotavailable,may
supportofairwayandbreathing
giveendotracheal(ET)0.1mg/kgas0.1
mL/kgusingthe1mg/mL(1:1000)
solutionupto2.5mgperdosedilutedto3
to5mLwithsalinerepeatevery3to5
minutesasneeded(IVorIOarepreferred)
Examplesofepinephrineinfusionfor
refractoryanaphylaxis(perfusingpatient)
areprovidedasseparatetablesin
UpToDate
Glucose(dextrose) Documentedbloodglucose40mg/dL(2.2 0.5to1g/kg,IVorIO,asfollows:

mmol/L) Infantsandchildren<5years:5to10
mL/kgof10%dextrosesolution
Children5years:2to4mL/kgof25%
dextrosesolution(preferred)or1to2
mL/kgof50%dextrosesolution
Lidocaine Pulselessventriculararrhythmiasnot 1mg/kgrapidIVorIObolus

responsivetoCPR,defibrillation,and
epinephrine Followtheboluswithaninfusionof20
to50mcg/kg/minute.Ifthestart
oftheinfusionwillbedelayed
longerthan15minutes,thena
secondIVorIObolusdoseof1
mg/kgissuggested
OnlyifIVandIOnotavailable,maygive
viaendotrachealtube(ET)2to3mg/kg,
flushwith5mLNSandfollowwith5
assistedmanualventilations(IVandIOare
preferred)
Magnesiumsulfate Polymorphicventriculartachycardia(torsades Cardiacarrest(pulselesstorsades):25to

depointes) 50mg/kggivenas0.05to0.1mL/kgof
Documentedhypomagnesemia 50%magnesiumsulfatesolutionupto
maximum2g(4mL)perdosedilutein10
mLD5W,giveIVorIOover1to2
minutes
Perfusingpatient(torsades,
hypomagnesemia,statusasthmaticus) :
Samedoseasforcardiacarrest,except
dilutedosein10to50mLD5WorNSand
infuseover15minutes(maximum150mg
perminute)
Conversions:50%magnesiumsulfate=
500mg/mLmagnesiumsulfate=2
mmol/mLmagnesium
Oxygen Allinfantsandchildrenoutsideoftheneonatal 100%initialdosevianonrebreathingface

period maskorbagmaskventilation,weanas
clinicallyindicated
Procainamide** Stableventriculartachycardia Loadingdose:

SVTinpatientswithWPWsyndromeor Infantsandchildren<1year:7to10
refractorytoadenosine mg/kgIVorIOover30to60minutes
Children1year:15mg/kgIVorIO
over30to60minutes
Maximum:500mgin30minutes
Followloadingdosewithacontinuous
infusionat40to50mcg/kgperminute
(maximum2g/24hours)andobtain
plasmalevels4hoursafterloadingdose
Sodium Hyperkalemia Infants<6months:1mEq/kgIVorIO

bicarbonate Poisoningbysodiumchannelblockingagents givenas2mL/kgof4.2%solution
(eg,cyclicantidepressants,typeIa Infants6monthsandchildren:1mEq/kg
antiarrhythmicagents)withprolongationof IVorIOgivenas1mL/kgof8.4%solution
QRSinterval(>0.1msec) Maximumsingledose50mEq(child)to
Prolongedcardiacarrestwithdocumented 100mEq(adolescent)
severemetabolicacidosis(routineusein 0.5mEq/kgsubsequentdosesafter10
resuscitationisNOTrecommended) minutesgivenas:
Child:0.5mL/kgof8.4%solution
Shockwithdocumentedmetabolicacidosis
Infantsunder6months:1mL/kgof
4.2%solution
Formsprecipitatewithcalciumandcan
inactivateepinephrine,donotcoinfuse
RecommendationsinthistablearegenerallyconsistentwithPediatricAdvancedLifeSupport(PALS)guidelinesand
AmericanAcademyofPediatrics(AAP)guidance [1,2].Detailconcerningdilutionandadministrationofemergencydrugs
arebaseduponrecommendationsusedatexperiencedpediatriccenters.Protocolsvary.Foradditionaldetail,referto
theindividualdrugmonographsprovidedbyLexicompthatareincludedwithUpToDate.
IV:intravenousIO:intraosseousET:endotracheallyCCB:calciumchannelblocker.
*MaycauseatrialfibrillationwithprogressiontoventricularfibrillationinchildrenwithWolffParkinsonWhitesyndrome.Avoid
inchildrenwithwidecomplextachycardiabecauseseverehemodynamicdeteriorationmayoccurinpatientswithventricular
tachycardia.Earlyconsultationwithpediatriccardiologistisrecommended.
AmiodaroneshouldnotbeadministeredwithotherdrugsthatmaycauseQTprolongation(eg,procainamide)without
cardiologyconsultationortopatientswithcongenitallongQTsyndrome.Cardiologyconsultisrecommendedpriortousewhen
patienthasaperfusingrhythm.
Aweightbaseddoseof0.02mg/kgatropineisusedbysomeexpertsforinfantsandsmallchildrenweighinglessthan5kg.
(RefertoUpToDatetopicsonpediatricresuscitationdrugs.)
Patientswithpoisoningfromcholinesteraseinhibitingagentsmayrequiremuchhigherdosesofatropinetodrybronchial
secretions.(RefertoUpToDatetopicsonorganophosphateandcarbamatepoisoning.)
Rapidadministrationcancausebradycardiaorasystole.Calciumchlorideshouldbegiventhroughcentralvenousor
intraosseousaccess,ifpossibletoavoidpotentialtissuenecrosisorsloughingintheeventofextravasation.
Caremustbetakentousethecorrectconcentration:0.1mg/mL(1:10,000)forIV/IOversus1mg/mL(1:1000)viaET.
Routineadministrationofglucosewithoutevaluationoftheserumglucoseisnotrecommended.Empirictreatmentwith
glucosemaybeappropriateifbedsideglucosedeterminationisnotavailableandtheinfantorchildhassymptomsof
hypoglycemiaorisatriskfordevelopinghypoglycemia.Lowerdosesofglucose(eg,0.25g/kgor2.5mL/kgof10percent
dextrosesolution)havebeenproposedbysomeexpertstoavoidosmoticdiuresis.(RefertoUpToDatetopicsonhypoglycemia
ininfantsandchildren.)
Rapidinfusionsofmagnesiumsulfateinperfusingpatientsareassociatedwithhypotensionandasystole.
**MaybeusedsafelyinchildrenwithWolffParkinsonWhitesyndrome.Shouldnotbeusedinpatientswhohavereceived
otherdrugsthatprolongtheQTinterval(eg,amiodarone)withoutcardiologyconsultationorinpatientswithcongenital
prolongedQTsyndrome.
Sodiumbicarbonateshouldonlybeadministeredtochildrenwithadequateventilation.Flushwellwithnormalsalinebefore
andafteradministrationtoavoidalkalineinactivationofepinephrineorprecipitationwithcalciumcontainingsolutions.
CourtesyofPamelaBailey,MDandSusanBTorrey,MDwithadditionaldatafrom:
1.KleinmanME,ChameidesL,SchexnayderSM,etal.Part14:PediatricAdvancedLifeSupport(PALS):2010American
HeartAssociationGuidelinesforCardiopulmonaryResuscitationandEmergencyCardiovascularCare.Circulation2010
122(18Suppl3):S876asupdatedbydeCaenA,BergM,ChameidesLetal.Part12:PediatricAdvancedLifeSupport
(PALS):2015AmericanHeartAssociationGuidelinesforCardiopulmonaryResuscitationandEmergencyCardiovascular
Care.Circulation2015132(suppl2):S526.
2.HegenbarthMA.PreparingforPediatricEmergencies:DrugstoConsider.Pediatrics2008121:433.
Contributor Disclosures
Eric Fleegler, MD, MPH Nothing to disclose Monica Kleinman, MD Consultant/Advisory Boards: American
Heart Association [Pediatric resuscitation (Pediatric advanced life support training materials)]. Susan B Torrey,
MD Nothing to disclose James F Wiley, II, MD, MPH Nothing to disclose
Contributor disclosures are reviewed for conicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform to
UpToDate standards of evidence.
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8/27/2017 Pediatric advanced life support (PALS) - UpToDate

Eye Spontaneous Spontaneous 4

Verbal Oriented Ageappropriatevocalization,smile,ororientationtosound,interacts 5

Motor Obeyscommands Spontaneousmovements(obeysverbalcommand) 6

0to3months 43(2566) 143(107181)termnewbornatbirth:127

3to6months 41(2464) 140(104175)

6to9months 39(2361) 134(98168)

9to12months 37(2258) 128(93161)

12to18months 35(2153) 123(88156)

18to24months 31(1946) 116(82149)

2to3years 28(1838) 110(76142)

3to4years 25(1733) 104(70136)

4to6years 23(1729) 98(65131)

6to8years 21(1627) 91(59123)

8to12years 19(1425) 84(52115)

12to15years 18(1223) 78(47108)

15to18years 16(1122) 73(43104)

Bradycardia/AV Supraventricular Ventricular QRSandQTinterval

Calciumchannelblockers Amphetamines Cocaine Antipsychotics

Agent Indications Dose

Adenosine* Supraventriculartachycardia(SVT) Initialdose0.1mg/kg(children>50kg

Amiodarone Pulselessventriculararrhythmiasnot Cardiacarrest:5mg/kgrapidIVorIO

Atropine Vagallymediatedbradycardia 0.02mg/kgIVorIO(minimum0.1mg ,

Calciumchloride Hypocalcemia Cardiacarrest:20mg/kggivenas0.2

Calciumgluconate Hypocalcemia Cardiacarrest:60mg/kggivenas

Epinephrine Asystole 0.01mg/kgIVorIOgivenas0.1mL/kg

Glucose(dextrose) Documentedbloodglucose40mg/dL(2.2 0.5to1g/kg,IVorIO,asfollows:

Lidocaine Pulselessventriculararrhythmiasnot 1mg/kgrapidIVorIObolus

Magnesiumsulfate Polymorphicventriculartachycardia(torsades Cardiacarrest(pulselesstorsades):25to

Oxygen Allinfantsandchildrenoutsideoftheneonatal 100%initialdosevianonrebreathingface

Procainamide** Stableventriculartachycardia Loadingdose:

Sodium Hyperkalemia Infants<6months:1mEq/kgIVorIO

Conict of interest policy

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