Cardiopulmonary Resuscitation (CPR) in Infants and Children
Despite the use of 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 apply to infants < 1 year of age and children up to the age of puberty (defined as appearance of breasts in females and axillary hair in males) or children weighing < 55 kg. Adult resuscitation protocols apply to children past the age of puberty or children weighing > 55 kg. Neonatal resuscitation is discussed elsewhere.
About 50 to 65% of children requiring cardiopulmonary resuscitation (CPR) are < 1 year; of these, most are < 6 months. 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).
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.
Child and Infant CPR Techniques for Health Care Practitioners
Pediatric comprehensive emergency cardiac care
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.
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 (1.5 to 2 in). In adolescents or children > 55 kg, the recommended compression depth is the same as in adults, ie, 5 to 6 cm (2 to 2.5 in).
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
After adequate oxygenation and ventilation, epinephrine is the drug of choice (see First-line drugs). Epinephrine dose is 0.01 mg/kg IV, which can be repeated every 3 to 5 minutes.
Amiodarone 5 mg/kg IV bolus can be given if defibrillation is unsuccessful after epinephrine. It may be repeated up to 2 times for refractory ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). If amiodarone is not available, lidocaine may be given at a loading dose of 1 mg/kg IV followed by a maintenance infusion of 20 to 50 mcg/kg/minute. Neither amiodarone nor lidocaine have been shown to improve survival to hospital discharge.
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:
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 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.
Drugs for Resuscitation in Infants and Children*
Guide to Pediatric Resuscitation—Mechanical Measures
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, there is no evidence that therapeutic hypothermia is beneficial. In comatose children resuscitated from cardiac arrest, therapeutic normothermia (36° C to 37.5° C) should be pursued (1, 2) and fever should be treated aggressively.
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.
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, 1 breath is given every 6 seconds (10 breaths/minutes) for infants, children, and adults.
In asystole, atropine and pacing are not used.
VF and pulseless VT occur in only about 15 to 20% of cardiac arrests. Vasopressin is not indicated. When defibrillation is used, the absolute energy dose is less than that for adults; waveform can be biphasic (preferred) or monophasic. For either waveform, the recommended energy dose is 2 joules/kg for the first shock, increasing to 4 joules/kg for subsequent attempts (if necessary—see 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 as young as 1 year, but an AED with pediatric cables (maximum biphasic shock of 50 joules) is preferred for children between 1 year and 8 years. There is insufficient evidence to recommend for or against the use of AEDs in children < 1 year. For pad placement, see defibrillation in adults.
1. Moler FW, Silverstein FS, Holubkov R, et al: Therapeutic hypothermia after in-hospital cardiac arrest in children. N Engl J Med 376:318–332, 2017. doi: 10.1056/NEJMoa1610493
2. Moler FW, Silverstein FS, Holubkov R, et al: Therapeutic hypothermia after out-of-hospital cardiac arrest in children. N Engl J Med 372:1898–1908, 2015. doi: 10.1056/NEJMoa1411480