Recognizing Cardiac Arrest
Unlike cardiac arrest in adults, which is very common due to acute coronary syndrome, cardiac arrest in pediatrics is more commonly the consequence of respiratory failure or shock. Thus, cardiac arrest can often be avoided if respiratory failure or shock is successfully managed. Less than 10% of the time, cardiac arrest is the consequence of ventricular arrhythmia and occurs suddenly. It may be possible to identify a reversible cause of cardiac arrest and treat it quickly. The reversible causes are essentially the same in children and infants as they are in adults.
| RECOGNIZE CARDIOPULMONARY FAILURE | |
| The H’s | The T’s |
| Hypovolemia | Tension pneumothorax |
| Hypoxia | Tamponade |
| H+ (acidosis) | Toxins |
| Hypo/Hyperkalemia | Thrombosis (coronary) |
| Hypoglycemia | Thrombosis (pulmonary) |
| Hypothermia | Trauma (unrecognized) |
Table 21
| Reversible Causes Of Cardiac Arrest | |
| Airway | • May or may not be patent |
| Breathing | • Slow breathing • Ineffective breathing |
| Circulation | • Bradycardia and hypotension • Slow capillary refill • Weak central pulses (carotid) • No peripheral pulses (radial) • Skin mottling/cyanosis/coolness |
| Disability | • Decreased level of consciousness |
| Exposure | • Bleeding? • Hypothermia? • Trauma? |
Table 22
| Recognize Arrest Rhythms | |
| ASYSTOLE | |
| PULSELESS ELECTRICAL ACTIVITY (PEA) | |
| VENTRICULAR FIBRILLATION (V FiB) | |
| PULSELESS VENTRICULAR TACHYCARDIA (VTach) | |
Table 23
PULSELESS ELECTRICAL ACTIVITY AND ASYSTOLE
Pulseless electrical activity (PEA) and asystole are related cardiac rhythms in that they are both life-threatening and unshockable. Asystole is the absence of electrical or mechanical cardiac activity and is represented by a flat-line ECG. There may be subtle movement away from baseline (drifting flat-line), but there is no perceptible cardiac electrical activity. Make sure that a reading of asystole is not a technical error. Ensure that the cardiac leads are connected, gain is set appropriately, and the power is on. Check two different leads to confirm. PEA is one of any number of ECG waveforms (even sinus rhythm) but without a detectable pulse. PEA may include any pulseless waveform except VF, VT, or asystole. Asystole may be preceded by an agonal rhythm. An agonal rhythm is a waveform that is roughly similar to a normal waveform but occurs intermittently, slowly, and without a pulse.
- PEA and asystole are unshockable rhythms.
VENTRICULAR FIBRILLATION AND PULSELESS VENTRICULAR TACHYCARDIA
Ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) are life-threatening cardiac rhythms that result in ineffective ventricular contractions. VF is a rapid quivering of the ventricles instead of a forceful contraction. The ventricular motion of VF is not synchronized with atrial contractions. Pulseless VT occurs when the rapidly contracting ventricles are not pumping blood sufficiently to create a palpable pulse. In both VF and pulseless VT, victims are not receiving adequate perfusion. VF and pulseless VT are shockable rhythms.
- VF and pulseless VT are shockable rhythms.
Responding to Cardiac Arrest
The first management step in cardiac arrest is to begin high-quality CPR. (See BLS section of this handbook for details.)
Pediatric Cardiac Arrest Algorithm
Figure 16
CPR Quality
- Rate of 100 to 120 compressions per minute
- Compression depth: one-third diameter of chest (1.5 inches in infants (4 cm) and 2 inches in children (5 cm))
- Minimize interruptions
- Do not over ventilate
- Rotate compressor every two minutes
- If no advanced airway, 15:2 compression ventilation ratio
- If advanced airway, 20 to 30 breaths per minute with continuous chest compressions
Shock Energy
- First shock: 2 J/kg
- Second shock: 4 J/kg
- Subsequent shocks: ≥ 4 J/kg
- Maximum dose of the shock: 10 J/kg or adult dose
Return of Spontaneous Circulation
- Return of pulse and blood pressure
- Spontaneous arterial pressure waves with intra-arterial monitoring
Advanced Airway
- Supraglottic advanced airway or ET intubation
- Waveform capnography to confirm and monitor ET tube placement
- Once advanced airway in place, give one breath every 2 to 3 seconds (20 to 30 breaths per minute)
Drug Therapy
- Epinephrine IV/IO dose: 0.01 mg/kg (Repeat every 3 to 5 minutes; if no IO/IV access, may give an endotracheal dose of 0.1 mg/kg.)
- Amiodarone IV/IO dose: 5 mg/kg bolus during cardiac arrest (May repeat up to two times for refractory VF/pulseless VT.)
Reversible Causes
- Hypovolemia
- Hypoxia
- H+ (acidosis)
- Hypothermia
- Hypo-/hyperkalemia
- Hypoglycemia
- Tamponade, cardiac
- Toxins
- Tension pneumothorax
- Thrombosis, pulmonary
- Thrombosis, coronary
- Trauma