Pediatric Cardiopulmonary Resuscitation

Introduction

The American Heart Association provides guidelines for cardiac arrest management in children, emphasizing the importance of high-quality CPR, early defibrillation, and systematic administration of medications 1, 2

The American Heart Association recommends administering epinephrine at 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration) IV/IO every 3-5 minutes with a maximum dose of 1 mg for a child undergoing CPR 3, 2
The American Heart Association suggests that high-dose epinephrine (0.1 mg/kg) provides no survival benefit and may be harmful, particularly in asphyxia-related arrests 3
Amiodarone may be used at a dose of 5 mg/kg IV/IO for refractory VF or pulseless VT, and may be repeated up to 3 total doses 2
Lidocaine may be used as an alternative to amiodarone at a loading dose of 1 mg/kg IV/IO 2
Sodium bicarbonate is not recommended for routine use in cardiac arrest, but may be indicated for hyperkalemia or sodium channel blocker toxicity, with a dose of 1 mEq/kg per dose IV/IO slowly 2, 3, 4
Calcium is not recommended for routine use in cardiac arrest, but may be indicated for documented hypocalcemia, calcium channel blocker overdose, hypermagnesemia, or hyperkalemia, with a dose of 20 mg/kg (0.2 mL/kg) calcium chloride IV/IO over 10-20 minutes, and a maximum dose of 2 g 2, 3, 4

The American Heart Association recommends ensuring high-quality CPR with a compression depth of at least 1/3 AP chest diameter, a rate of at least 100 compressions per minute, complete chest recoil between compressions, and minimal interruptions in chest compressions 3, 1, 5
Chest compressions should be performed at a depth of at least one-third of AP chest diameter (approximately 2 inches/5 cm), with a compression rate of 100-120/minute, and a compression-to-ventilation ratio of 15:2 (with two rescuers) or 30:2 (without advanced airway) 2, 1
Compressors should be changed every 2 minutes to avoid fatigue 2, 1
Allow complete chest recoil after each compression to ensure adequate venous return 5
Minimize interruptions in chest compressions to maintain coronary perfusion pressure, with a goal of less than 10 seconds 1, 5
Use quantitative waveform capnography to monitor CPR quality and detect return of spontaneous circulation (ROSC) 1, 6

The American Heart Association recommends defibrillating at 2 J/kg initially, then 4 J/kg for subsequent shocks, and resuming CPR immediately after shock delivery 3, 2
An AED should be used as soon as available, with manual defibrillation at 2-4 J/kg for the first shock, escalating to 4 J/kg for subsequent shocks if needed 2
CPR should be resumed immediately after shock for 2 minutes before rhythm check 2
For shockable rhythms (VF/pVT), the American Heart Association recommends delivering one shock (biphasic: 120-200J or manufacturer recommendation; monophasic: 360J), resuming CPR immediately after shock for 2 minutes before rhythm check, and not delaying CPR for rhythm check after shock 1, 6

The American Heart Association recommends searching for and treating reversible causes of cardiac arrest, including the "H's and T's" of cardiac arrest: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/Hyperkalemia, Hypothermia, Tension pneumothorax, Tamponade, Toxins, Thrombosis (pulmonary), and Thrombosis (coronary) 3, 1, 6
Identify and treat potential reversible causes of cardiac arrest, particularly those related to CCF, such as hypovolemia, hypoxia, acidosis, electrolyte abnormalities, tamponade, pulmonary thrombosis, and coronary thrombosis, as recommended by the American Heart Association 1
Continuous monitoring of vital signs is recommended, with a target mean arterial pressure (MAP) ≥65 mmHg, and monitoring of lactate clearance, as recommended by 7
Invasive hemodynamic monitoring may be considered in refractory shock, and fluid resuscitation with 30 mL/kg crystalloid within the first 3 hours is recommended, as suggested by the Society of Critical Care Medicine 7

Delaying epinephrine administration beyond 5 minutes, inadequate chest compression depth or allowing incomplete recoil, excessive interruptions in chest compressions, and failure to identify and treat reversible causes are common pitfalls in cardiac arrest management, as warned by 8
Delayed antibiotic administration, inadequate initial fluid resuscitation, failure to escalate to vasopressors when needed, and overlooking source control are common pitfalls in septic shock management, as noted by 9
Excessive tidal volumes, inadequate PEEP, excessive fluid administration after initial resuscitation, and inappropriate use of neuromuscular blockade are common pitfalls in ARDS management, as cautioned by 7