Despite the use of cardiopulmonary resuscitation (CPR), mortality rates for out-of-hospital cardiac arrest are about 90% for infants and children. Mortality rates for in-hospital cardiac arrest for infants and children are about 65%. The mortality rate is 20 to 25% for respiratory arrest alone. Neurologic outcome is often severely compromised.
Pediatric resuscitation protocols are different for infants and children. Infant guidelines apply to those < 1 year of age, and child protocols are used from age 1 year up to a weight of 55 kg or the presence of signs of puberty (defined as appearance of breasts in females and axillary hair in males). Adult resuscitation protocols apply to children past the age of puberty or children weighing > 55 kg. About 50 to 65% of children requiring CPR are < 1 year; of these, most are < 6 months.
Neonatal resuscitation used in the immediate perinatal period is discussed elsewhere. About 6% of neonates require resuscitation at delivery; the incidence increases significantly if birth weight is < 1500 g.
Standardized outcome guidelines should be followed in reporting outcomes of CPR in children; eg, the modified Pittsburgh Outcome Categories Scale reflects cerebral and overall performance (see table Pediatric Cerebral Performance Category Scale).
Standards and guidelines for CPR from the American Heart association are followed (see table Child and Infant CPR Techniques for Health Care Practitioners). For protocol after an infant or child has collapsed with possible cardiac arrest, see figure Pediatric comprehensive emergency cardiac care.
After CPR has been started, defibrillation and identification of the underlying cardiac rhythm are done.
Pediatric comprehensive emergency cardiac care
* If an adequate number of trained personnel are available, patient assessment, CPR, and activation of the emergency response system should occur simultaneously. |
Based on the Comprehensive Emergency Cardiac Care Algorithm from the American Heart Association. |
Major Differences Between Pediatric and Adult CPR
Prearrest
Bradycardia in a distressed child is a sign of impending cardiac arrest. Neonates, infants, and young children are more likely to develop bradycardia caused by hypoxemia, whereas older children initially tend to have tachycardia. An infant or child with a heart rate < 60/minute and signs of poor perfusion that do not rise with ventilatory support should have cardiac compressions (see figure Chest compression). Bradycardia secondary to heart block is unusual.
Chest compressions
During chest compressions in infants and children (below the age of puberty or < 55 kg), the chest should be depressed one third of the anteroposterior diameter. This is about 4 to 5 cm. In adolescents or children > 55 kg, the recommended compression depth is the same as in adults, ie, 5 to 6 cm (see also chest compressions in adults).
Method of chest compression is also different in infants and children and is illustrated below. The rate of compression in infants and children is similar to that of adults at 100 to 120 compressions/minute.
Chest compression in infants and children
A: When 2 rescuers are present, side-by-side thumb placement for chest compressions is preferred for neonates and small infants whose chest can be encircled. Thumbs should overlap if used in very small neonates. B: Lone rescuers can use 2 fingers for infant compressions. Fingers should be maintained in the upright position during compression. For neonates, this technique results in too low a position, ie, at or below the xiphoid; the correct position is just below the nipple line. C: Hand position for chest compression for a child. (Adapted from American Heart Association: Standards and guidelines for CPR. Journal of the American Medical Association 268:2251–2281,1992. Copyright 1992, American Medical Association.) |
Drugs
ventricular fibrillation (VF) or pulseless ventricular tachycardia
Blood pressure
Blood pressure (BP) should be measured with an appropriate-sized cuff, but direct invasive arterial BP monitoring is mandatory in severely compromised children.
Because BP varies with age, an easy guideline to remember the lower limits of normal for systolic BP (< 5th percentile) by age is as follows:
< 1 month: 60 mm Hg
1 month to 1 year: 70 mm Hg
> 1 year: 70 + (2 × age in year)
Thus, in a 5-year-old child, hypotension would be defined by a BP of < 80 mm Hg (70 + [2 × 5]). Of significant importance is that children maintain BP longer because of stronger compensatory mechanisms (increased heart rate, increased systemic vascular resistance). Once hypotension occurs, cardiorespiratory arrest may rapidly follow. All effort should be made to start treatment when compensatory signs of shock (eg, increased heart rate, cool extremities, capillary refill > 2 seconds, poor peripheral pulses) are present but before hypotension develops.
Equipment and environment
Equipment size, drug dosage, and CPR parameters vary with patient age and weight (see tables CPR Techniques for Health Care Practitioners, Drugs for Resuscitation in Infants and Children, and Guide to Pediatric Resuscitation). Size-variable equipment includes defibrillator paddles or electrode pads, masks, ventilation bags, airways, laryngoscope blades, endotracheal tubes, and suction catheters. Weight should be measured rather than guessed; alternatively, commercially available measuring tapes that are calibrated to read standard patient weight based on body length can be used. Some tapes are printed with the recommended drug dose and equipment size for each weight. Dosages should be rounded down; eg, a 2 ½-year-old child should receive the dose for a 2-year-old child.
Temperature management
Susceptibility to heat loss is greater in infants and children because of a large surface area relative to body mass and less subcutaneous tissue. A neutral external thermal environment is crucial during CPR and postresuscitation. Hypothermia with core temperature < 35° C makes resuscitation more difficult.
For comatose children resuscitated from in-hospital and out-of-hospital cardiac arrest, recent American Heart Association and American Association of Pediatrics guidelines advise therapeutic hypothermia (32 to 36° C) or normothermia (36 to 37.5° C—1, 2 ). Fever should be treated aggressively.
Airway and ventilation
Upper airway anatomy is different in children. The head is large with a small face, mandible, and external nares, and the neck is relatively short. The tongue is large relative to the mouth, and the larynx lies higher in the neck and is angled more anteriorly. The epiglottis is long, and the narrowest portion of the trachea is inferior to the vocal cords at the cricoid ring, allowing the use of uncuffed endotracheal tubes. In younger children, a straight laryngoscope blade generally allows better visualization of the vocal cords than a curved blade because the larynx is more anterior and the epiglottis is more floppy and redundant. Current available evidence does not support improved patient outcomes from advanced airway interventions as compared to bag-mask ventilation in infants and children during out-of-hospital cardiac arrest.
If there is no advanced airway in place in infants and children undergoing resuscitation, the recommended compression:ventilation ratio is 30:2 if only a single rescuer is present and 15:2 if more than one rescuer is present. This recommendation is in contrast to adults where the compression:ventilation ratio is always 30:2 and is independent of the number of rescuers.
With an advanced airway in place, the 2020 International Liaison Committee on Resuscitation (ILCOR) guidelines for pediatric cardiac arrest resuscitation advise a ventilation rate of 20 to 30 breaths per minute (with the faster rate in infants—2). However, this revised recommendation is based on a study of hospitalized patients and remains controversial in prehospital care. Many researchers of pediatric prehospital care continue to advise a ventilation rate of 10-breaths per minute.
Defibrillation
Ventricular fibrillation (VF) and pulseless ventricular tachycardiasee defibrillation in adults). The maximum recommended dose is 10 joules/kg or the maximum adult dose (200 joules for a biphasic defibrillator and 360 joules for a monophasic defibrillator).
Automated external defibrillators (AEDs) with adult cables may be used for children, but an AED with pediatric cables (maximum biphasic shock of 50 joules) is preferred for pediatric patients up to 8 years of age. Current guidelines recommend manual defibrillation if possible for pediatric patients, but an AED (with or without pediatric cables) can be used if a manual defibrillator is not immediately available (2). For pad placement, see defibrillation in adults.
Treatment references
1. Granfeldt A, Holmberg MJ, Nolan JP, Soar J, Andersen LW; International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force: Targeted temperature management in adult cardiac arrest: Systematic review and meta-analysis. Resuscitation 167:160–172, 2021. doi:10.1016/j.resuscitation.2021.08.040
2. Maconochie IK, Aickin R, Hazinski MF, et al: Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 156:A120–A155, 2020. doi:10.1016/j.resuscitation.2020.09.013
More Information
The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
American Heart Association 2020 CPR and ECC Guidelines: These guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) are based on the most recent review of resuscitation science, protocols, and education.
