Pediatric Cardiac Arrest Algorithm

1 Pediatric Cardiac Arrest Algorithm 1. CPR Quality Start CPR. Begin bag-mask ventilation and give oxygen Push hard ( of anteroposterior Attach monitor/defibrillator diameter of chest) and fast (100-120/min) and allow complete chest recoil Minimize interruptions in Yes No compressions Rhythm Change compressor every shockable? 2 minutes, or sooner if fatigued If no advanced airway, 15:2. 2 9 compression-ventilation ratio VF/pVT Asystole/PEA If advanced airway, provide continuous compressions and give a breath every 2-3 seconds Shock Energy for Defibrillation 3. Shock Epinephrine First shock 2 J/kg ASAP Second shock 4 J/kg 4 10 Subsequent shocks 4 J/kg, maximum 10 J/kg or adult dose CPR 2 min CPR 2 min IV/IO access IV/IO access Drug Therapy Epinephrine every 3-5 min Consider advanced Epinephrine IV/IO dose: mg/kg ( mL/kg of the airway and capnography mg/mL concentration).

2 No Max dose 1 mg. Rhythm Repeat every 3-5 minutes. shockable? If no IV/IO access, may give Yes endotracheal dose: mg/kg Yes Rhythm ( mL/kg of the 1 mg/mL. shockable? concentration). 5 Shock Amiodarone IV/IO dose: 5 mg/kg bolus during Cardiac Arrest . May repeat up to No 6 3 total doses for refractory CPR 2 min VF/pulseless VT. or Epinephrine every 3-5 min 11 Lidocaine IV/IO dose: . Consider advanced airway Initial: 1 mg/kg loading dose CPR 2 min Treat reversible causes Advanced Airway No Endotracheal intubation or Rhythm supraglottic advanced airway shockable? Waveform capnography or No Yes capnometry to confirm and Rhythm monitor ET tube placement Yes shockable? Shock reversible Causes 7. Hypovolemia 8 Hypoxia Hydrogen ion (acidosis). CPR 2 min Hypoglycemia Amiodarone or lidocaine Hypo-/hyperkalemia Treat reversible causes Hypothermia Tension pneumothorax Tamponade, Cardiac Toxins 12 Thrombosis, pulmonary If no signs of return of spontaneous Go to 7.

3 Thrombosis, coronary circulation (ROSC), go to 10. If ROSC, go to Post Cardiac Arrest Care checklist 2020 American Heart Association Pediatric Bradycardia With a Pulse Algorithm Patient with bradycardia Cardiopulmonary compromise? No Acutely altered mental status Signs of shock Hypotension Yes Assessment and support Support ABCs Maintain patent airway Consider oxygen Assist breathing with positive Observe pressure ventilation and oxygen 12-Lead ECG. as necessary Identify and treat Cardiac monitor to identify rhythm; underlying causes monitor pulse, BP, and oximetry Start CPR if HR <60/min despite oxygenation and ventilation. No Bradycardia persists? Yes Continue CPR if HR <60/min IV/IO access Epinephrine Doses/Details Atropine for increased vagal tone or primary AV block Epinephrine IV/IO dose: mg/kg ( mL/kg of the Consider transthoracic/ mg/mL concentration).

4 Transvenous pacing Repeat every 3-5 minutes. Identify and treat underlying If IV/IO access not available causes but endotracheal (ET) tube in place, may give ET dose: mg/kg ( mL/kg of the 1 mg/mL concentration). Atropine IV/IO dose: mg/kg. May repeat once. Yes Check pulse Minimum dose mg and every 2 minutes. maximum single dose mg. Pulse present? Possible Causes No Hypothermia Hypoxia Go to Pediatric Medications Cardiac Arrest Algorithm . 2020 American Heart Association Pediatric Tachycardia With a Pulse Algorithm Initial assessment and support Doses/Details Maintain patent airway; assist breathing as necessary Synchronized Administer oxygen cardioversion Cardiac monitor to identify rhythm; monitor pulse, Begin with J/kg;. blood pressure, and oximetry if not effective, increase IV/IO access to 2 J/kg.

5 Sedate if 12-Lead ECG if available needed, but don't delay cardioversion. Drug Therapy Probable sinus tachycardia if Adenosine IV/IO dose Evaluate rhythm P waves present/normal First dose: mg/kg with 12-lead ECG. Variable RR interval rapid bolus (maximum: or monitor. 6 mg). Infant rate usually <220/min Child rate usually <180/min Second dose: mg/kg rapid bolus (maximum second dose: 12 mg). Cardiopulmonary Search for compromise? and treat cause. Yes No Acutely altered mental status Signs of shock Hypotension Narrow Wide Narrow Wide ( sec) (> sec) ( sec) (> sec). Evaluate Evaluate QRS duration. QRS duration. Probable supraventricular Possible ventricular Probable supraventricular Possible ventricular tachycardia tachycardia tachycardia tachycardia P waves absent/abnormal P waves absent/abnormal RR interval not variable RR interval not variable Infant rate usually 220/min Infant rate usually 220/min Child rate usually 180/min Child rate usually 180/min History of abrupt rate change Synchronized History of abrupt rate change If rhythm is regular and cardioversion QRS monomorphic, Expert consultation consider adenosine.

6 Is advised before additional drug If IV/IO access is present, therapies. Consider give adenosine vagal maneuvers. or Expert consultation If IV/IO access is not is recommended. available, or if adenosine is ineffective, perform synchronized cardioversion If IV/IO access is present, give adenosine. 2020 American Heart Association Pediatric Basic Life Support Algorithm for Healthcare Providers 2 or More Rescuers Verify scene safety. Check for responsiveness. Shout for nearby help. First rescuer remains with the child. Second rescuer activates emergency response system and retrieves the AED and emergency equipment. Normal No normal breathing, Look for no breathing breathing, Provide rescue breathing, Monitor until pulse felt or only gasping and check pulse felt 1 breath every 2-3 seconds, emergency pulse (simultaneously).

7 Or about 20-30 breaths/min. responders arrive. Is pulse definitely felt Assess pulse rate for no within 10 seconds? more than 10 seconds. Yes HR <60/min No with signs of poor perfusion? No breathing or only gasping, pulse not felt Start CPR. Continue rescue breathing; check pulse about every 2 minutes. If no pulse, start CPR. Start CPR. First rescuer performs cycles of 30 compressions and 2 breaths. When second rescuer returns, perform cycles of 15 compressions and 2 breaths. Use AED as soon as it is available. Check rhythm. Shockable rhythm? Yes, No, shockable nonshockable Give 1 shock. Resume CPR Resume CPR immediately for immediately for 2 minutes 2 minutes (until prompted by AED. (until prompted by AED to allow to allow rhythm check). rhythm check).

8 Continue until ALS providers take Continue until ALS providers take over or the child starts to move. over or the child starts to move. 2020 American Heart Association Pediatric Basic Life Support Algorithm for Healthcare Providers Single Rescuer Verify scene safety. Check for responsiveness. Shout for nearby help. Activate the emergency response system via mobile device (if appropriate). Normal No normal Provide rescue breathing, breathing, breathing, 1 breath every 2-3 seconds, Look for no breathing or about 20-30 breaths/min. Monitor until pulse felt or only gasping and check pulse felt Assess pulse rate for no emergency pulse (simultaneously). more than 10 seconds. responders arrive. Is pulse definitely felt within 10 seconds? Yes HR <60/min No with signs of poor perfusion?

9 No breathing or only gasping, Start CPR. Continue rescue pulse not felt breathing; check pulse every 2. minutes. If no pulse, start CPR. Yes Activate emergency response Witnessed system (if not already done), sudden collapse? and retrieve AED/defibrillator. No Start CPR. 1 rescuer: Perform cycles of 30 compressions and 2 breaths. When second rescuer arrives, perform cycles of 15 compressions and 2 breaths. Use AED as soon as it is available. After about 2 minutes, if still alone, activate emergency response system and retrieve AED. (if not already done). Check rhythm. Shockable rhythm? Yes, No, shockable nonshockable Give 1 shock. Resume CPR Resume CPR immediately for immediately for 2 minutes 2 minutes (until prompted by AED. (until prompted by AED to allow to allow rhythm check).)

10 Rhythm check). Continue until ALS providers take Continue until ALS providers take over or the child starts to move. over or the child starts to move. 2020 American Heart Association PALS Systematic Approach Algorithm