PEDIATRIC CARDIAC ARREST ALGORITHM (PALS GUIDELINES)
Cardiac arrest in children is most commonly caused by respiratory failure and shock rather than primary cardiac causes (as seen in adults). Immediate, high-quality CPR, early epinephrine administration, and defibrillation (if indicated) are critical for survival.
Key Goals of Pediatric Cardiac Arrest Management:
Restore circulation and oxygenation as quickly as possible. Deliver defibrillation promptly for shockable rhythms. Identify and treat reversible causes (H’s and T’s).
RECOGNITION OF PEDIATRIC CARDIAC ARREST
A child in cardiac arrest will present with:
- Unresponsiveness.
- No normal breathing or only gasping.
- No palpable pulse (check for ≤10 seconds).
Confirm Arrest and Call for Help: Activate emergency response system and get an AED/defibrillator. Begin immediate, high-quality CPR.
PEDIATRIC CARDIAC ARREST ALGORITHM
Step 1: Initiate High-Quality CPR Immediately
Start CPR as soon as cardiac arrest is confirmed.
- Compression-to-Ventilation Ratio: Single rescuer: 30:2 (compressions: breaths) Two rescuers: 15:2 (compressions: breaths)
- Compression Depth: Infants (<1 year): At least 1.5 inches (4 cm) Children (>1 year): At least 2 inches (5 cm)
- Compression Rate: 100-120 compressions per minute.
- Minimize Interruptions: <10 seconds per pause for defibrillation or interventions.
If advanced airway is placed (ETT/LMA):
- Provide continuous compressions with 1 breath every 2-3 seconds (20-30 breaths per minute).
Step 2: Establish Vascular Access and Administer Epinephrine
IV or IO Access (whichever is faster) – Do not delay CPR while attempting IV placement. Epinephrine (1:10,000) 0.01 mg/kg IV/IO every 3-5 minutes. If no IV/IO access available, administer epinephrine via ETT (0.1 mg/kg).
Epinephrine is critical for improving perfusion—administer as soon as IV/IO access is established!
Step 3: Determine Rhythm and Deliver Defibrillation (if Shockable)
Assess rhythm on ECG/AED and determine if it is shockable or non-shockable.
Shockable Rhythms (VF/pVT) → DEFIBRILLATE ASAP
First shock: 2 J/kg Second shock: 4 J/kg Subsequent shocks: 4 J/kg (up to 10 J/kg or adult dose). Resume CPR immediately after each shock (do not delay).
Medications for Shockable Rhythms:
- Epinephrine (0.01 mg/kg IV/IO every 3-5 min) – improves circulation.
- Amiodarone (5 mg/kg IV/IO, max 300 mg dose) OR Lidocaine (1 mg/kg IV/IO) – for refractory VF/pVT.
Non-Shockable Rhythms (Asystole/PEA) → CONTINUE CPR & EPI
DO NOT DEFIBRILLATE. Continue high-quality CPR. Epinephrine (0.01 mg/kg IV/IO every 3-5 min). Identify and treat reversible causes (H’s & T’s).
Step 4: Identify and Treat Reversible Causes (H’s and T’s)
Many cases of pediatric cardiac arrest have an underlying reversible cause that, when corrected, can restore circulation.
The H’s (Common Causes of Hypoxia-Related Arrest)
Hypoxia → Give oxygen, assist ventilation. Hypovolemia → Give fluids (20 mL/kg boluses NS/LR). Hydrogen ion excess (Acidosis) → Consider sodium bicarbonate in prolonged arrest. Hyperkalemia/Hypokalemia → Correct electrolytes (Calcium, Dextrose/Insulin for hyperK). Hypothermia → Rewarm patient.
The T’s (Common Reversible Cardiac Causes)
Tension pneumothorax → Needle decompression. Tamponade (Cardiac) → Pericardiocentesis. Toxins (Drug overdose, poisoning) → Administer antidote (e.g., naloxone for opioids). Thrombosis (Pulmonary or Coronary) → Thrombolysis or advanced interventions (ECMO).
If a reversible cause is found, address it immediately while continuing CPR.
QUICK REFERENCE: PEDIATRIC CARDIAC ARREST MANAGEMENT
| Step | Action | Key Considerations |
|---|---|---|
| 1 | Start CPR Immediately | 30:2 (1 rescuer), 15:2 (2 rescuers), depth: 1.5-2 inches |
| 2 | Establish IV/IO Access | Administer Epinephrine (0.01 mg/kg IV/IO q3-5 min) |
| 3 | Analyze Rhythm | Defibrillate VF/pVT, continue CPR for asystole/PEA |
| 4 | Shockable? (VF/pVT) | Give 2 J/kg → 4 J/kg → max 10 J/kg |
| 5 | Non-Shockable? (Asystole/PEA) | Continue CPR, Epinephrine, identify causes |
| 6 | Identify & Treat Reversible Causes | Check H’s & T’s (Hypoxia, Hypovolemia, Tamponade, etc.) |
POST-RESUSCITATION CARE (Return of Spontaneous Circulation – ROSC)
If circulation returns, focus on stabilizing the patient.
Optimize Ventilation & Oxygenation:
- Maintain SpO₂ >94% but avoid hyperoxia.
- Intubation may be required for airway protection.
Hemodynamic Support:
- Fluid resuscitation for persistent shock.
- Consider inotropes (dopamine, epinephrine) for poor perfusion.
Neurological Monitoring:
- Monitor for seizures, post-arrest brain injury.
- Consider targeted temperature management (TTM) to prevent brain damage.
WHEN TO CONSIDER TERMINATION OF RESUSCITATION?
Resuscitation should continue unless:
- Prolonged asystole despite high-quality CPR and interventions.
- No reversible cause is found after extensive efforts.
- Decision is made with family and medical team based on prognosis.
Pediatric patients can have good outcomes even after prolonged resuscitation—decisions should be individualized.
SUMMARY: WHY TIMELY INTERVENTION MATTERS
High-quality CPR is the foundation of pediatric cardiac arrest survival. Epinephrine should be given as early as possible in non-shockable rhythms. Shockable rhythms (VF/pVT) require immediate defibrillation. Identifying reversible causes (H’s & T’s) can dramatically improve outcomes. Post-resuscitation care is critical for long-term survival and neurological recovery.
Takeaway: In pediatric cardiac arrest, every second counts—immediate, effective interventions can save lives.