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Paediatric Clinical Guideline
Emergency: 1.1 Cardiopulmonary Resuscitation
Short Title:
Cardiopulmonary Resuscitation
Full Title:
Date of production/Last revision:
Guideline for the management of cardiopulmonary resuscitation in children
and young people
January 2007
Explicit definition of patient group
to which it applies:
This guideline applies to all children and young people under the age of 19
years.
Name of contact author
Dr Gillian Body, Paediatric SpR
Dr Stephanie Smith, Consultant Paediatrician
Ext: 64042
January 2009
Revision Date
This guideline has been registered with the Trust. However, clinical guidelines are 'guidelines' only. The interpretation
and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a
senior colleague or expert. Caution is advised when using guidelines after the review date.
Cardiopulmonary Resuscitation
In the event of Cardiac Arrest, call 2222, give location, and ask for the Paediatric Arrest
Team.
Cardiac arrest has occurred when there are no palpable central pulses. Effective basic life
support must be established before any specific therapy is started.
In children cardiac arrest is a rare event, and usually the result of prolonged hypoxia. This is
different from adults where cardiac arrest is usually due to a primary cardiac problem.
Scope of the Guideline
This guideline outlines the advanced management of cardiac arrest in children. It is assumed
that cardiac arrest has been confirmed, and Basic life support is in progress. BLS is outlined
at the end of this document.
Before the Child Arrives
It is best to be prepared, if possible.
 Try to obtain basic information from ambulance crew – age or weight, time of arrest,
any drugs and treatment given in transit.
 Assemble your team and assign roles, including allocating a team leader.
o You may need to limit the number of people involved in the immediate area.
o Allocate a member of staff to be with the parents if they wish to be present during
resuscitation. (It is accepted good practice for parents/guardians to be present in
the resuscitation room; however they should have a member of staff with them.)
o A scribe is an important role – documenting timing and treatments.
o Inform the Consultant on call.
 Consider any known resuscitation or end of life plans
 Calculate drug doses, (eg Adrenaline) in advance if possible.
o If fluids are likely to be needed, start drawing them up in advance as it is a time
consuming process.
o Other drugs can be calculated depending on the history you obtain, (eg IV
salbutamol for an asthmatic who has arrested).
Gillian Body
Page 1 of 12
January 2007
Paediatric Clinical Guideline
Emergency: 1.1 Cardiopulmonary Resuscitation
Broselow tapes and kits are available in some clinical areas to assist in the cardiac arrest
situation. The child’s weight can be estimated using these tapes, or by using the formula;
Weight (kg) = (Age in years + 4) x 2
Be prepared to adjust this dose once the child arrives. Not all children follow the formula!
If the child is admitted as a child on the Paediatric wards – they should be treated as a child,
and Paediatric resuscitation algorithms followed.
Management of cardiac arrest follows ABC;
Airway
Breathing
Circulation
The airway, breathing and circulation must be assessed in this order and problems addressed
as they are recognised.
ONCE CARDIAC ARREST IS CONFIRMED, THE PATIENT SHOULD RECEIVE GOOD,
EFFECTIVE, CONTINUOUS BASIC LIFE SUPPORT.
Basic life support is detailed at the end of this guideline. BLS should be in progress before
any drug treatment is given. Whilst BLS is ongoing a monitor should be attached to establish
the arrest rhythm.
Gillian Body
Page 2 of 12
January 2007
Paediatric Clinical Guideline
Emergency: 1.1 Cardiopulmonary Resuscitation
Cardiac Arrest Rhythms and Management
This guideline will outline the management of two different Arrest protocols
1.
2.
Asystole and Pulseless Electrical Activity (PEA)
Ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT)
Cardiac Arrest
confirmed
Good BLS in progress
Attach monitor
VF
Pulseless VT
Gillian Body
Determine arrest
rhythm
Page 3 of 12
PEA
Aystole
January 2007
Paediatric Clinical Guideline
Emergency: 1.1 Cardiopulmonary Resuscitation
Asystole
This is the most common arrest rhythm in children, and is the response of the young heart to
prolonged severe hypoxia and acidosis. The ECG/monitor appearance of asystole is an
almost straight line, with occasional p waves seen. Check that there are no loose connections
and turn up the gain on the ECG monitor.
Pulseless Electrical Activity (P E A)
This is an impalpable pulse in the presence on the monitor, of a rhythm that should produce a
pulse. The most common cause in children is profound shock.
(Note: the term Electro-mechanical dissociation (EMD) is sometimes used interchangeably,
although strictly this refers to a specific situation in adults with coronary disease)
Both ASYSTOLE and PEA follow the same algorithm which is outlined on the following
page.
Before the administration of any drug the patient must be receiving continuous and
effective basic life support
NOTES: (notes relate to the numbers on the algorithm on the next page)
1. Intubation will protect the airway, but attempts to intubate should not delay good BLS.
Effective ventilation can be maintained using a bag-valve-mask system. Once intubated,
cardiac compressions should be continuous, unless doing so prevents effective
ventilation.
IV access can be attempted, but if not successful quickly – intraosseous is the preferred
route of drug administration. The tracheal route is not recommended.
2. Adrenaline should be given by IV or IO route, followed by saline flush. Doses should be
repeated every 3-5 minutes.
A monitor check is performed every 2 minutes, and a pulse check performed if there is
any change in rhythm. Giving the adrenaline before every second pulse check, means it
is given, in effect, every 4 minutes.
3. The four Hs and 4 Ts are some of the reversible causes of arrest, and should all be
considered whilst resuscitation continues. These are outlined in the following table.
Alkalising agents, (Sodium Bicarbonate: 1 mmol/kg = 1 ml/kg of an 8.4% solution), can
be considered in children with prolonged arrest / TCA overdose / hyperkalaemia.
Gillian Body
Page 4 of 12
January 2007
Paediatric Clinical Guideline
Emergency: 1.1 Cardiopulmonary Resuscitation
Good effective BLS
Ventilate with high flow
oxygen
Intubate
Obtain IV or IO access
Adrenaline IV or IO
10 mcg/kg
0.1ml/kg of 1:10,000
1
2
Check monitor every 2
minutes
4 minutes CPR
Consider 4 Hs and 4 Ts
Consider alkalising agents and repeat as needed
3
Algorithm for asystole and PEA
4 Hs and 4 Ts
Hypoxia
Hypovolaemia
Hyper/Hypokalaemia/metabolic
Hypothermia
Particular relevance in
asystole
Yes
Yes
Cardiac Tamponade
Tension pneumothorax
Toxins
Thrombo-embolic events
Gillian Body
Particular relevance in
PEA
Yes
Yes (low Ca)
Yes
Yes
Yes
Yes
Page 5 of 12
January 2007
Paediatric Clinical Guideline
Emergency: 1.1 Cardiopulmonary Resuscitation
Ventricular Fibrillation
This arrhythmia is uncommon in children but may occur in hypothermia, tricyclic
antidepressant poisoning, and in the presence of pre-existing cardiac disease.
Pulseless Ventricular Tachycardia
This is also an uncommon rhythm in children, but may occur in similar situations to ventricular
fibrillation. (Note: pulsed VT is treated differently).
Gillian Body
Page 6 of 12
January 2007
Paediatric Clinical Guideline
Emergency: 1.1 Cardiopulmonary Resuscitation
1
DC shock 4J/kg
3
2 mins CPR
Check monitor
Intubate. High flow O2
Obtain IV/IO access
2
DC shock 4J/kg
2 mins CPR
Check monitor
Intubate. High flow O2
Obtain IV/IO access
Adrenaline 10mcg/kg
then
DC shock 4J/kg
4
2 mins CPR
Check monitor
Amiodarone 5mg/kg
then
DC shock 4J/kg
5
2 mins CPR
Check monitor
Adrenaline 10mcg/kg
then
DC shock 4J/kg
6
2 mins CPR
Check monitor
2 mins CPR
Check monitor
DC shock 4J/kg
7
Consider 4 Hs and 4 Ts
Consider alkalising agents and repeat as needed
Algorithm for VF and pulseless VT
Gillian Body
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Paediatric Clinical Guideline
Emergency: 1.1 Cardiopulmonary Resuscitation
NOTES: (notes relate to numbers on algorithm)
1. and 2. Defibrillation is the first action, as it is defibrillation that will restore the heart to a
sinus rhythm. It is likely, however, that in an unmonitored patient, BLS will be in progress
while the rhythm is being determined. Shocks are given as single shocks at 4J/kg. CPR
for 2 minutes is continued immediately, and then the monitor checked, (with a brief pause
in compressions) before the next shock. A single shock should be given every 2 minutes.
Cardiac compressions should be interrupted for as little time as possible.
3. Intubation will protect the airway, but attempts to intubate should not delay good BLS or
defibrillation. Effective ventilation can be maintained using a bag-valve-mask system.
Once intubated, cardiac compressions should be continuous, unless doing so prevents
effective ventilation.
IV access can be attempted, but if not successful quickly – intraosseous is the preferred
route of drug administration. The tracheal route is not recommended.
4. Adrenaline is given immediately before the 3rd shock, after the monitor check that
confirms there is no change in rhythm. As the shock comes immediately after this, the
adrenaline will not be circulated until CPR resumes after the shock. The adrenaline is to
support coronary and cerebral perfusion.
5. Amiodarone is the anti-arrhythmic drug of choice in shock resistant VF. It aims to keep
the heart in a sinus rhythm once the shock has been successful. Lignocaine (Lidocaine)
can be used if Amiodarone is not available.
6. The cycle of shocks every 2 minutes after a monitor check should continue, with
Adrenaline given every 4 minutes (alternate shocks). A pulse check should be done if a
change in rhythm is seen that is compatible with a perfusing rhythm. If there is a change
in rhythm, then resuscitation should follow the appropriate algorithm.
7. The four Hs and 4 Ts are some of the reversible causes of arrest, and should all be
considered whilst resuscitation continues. These are outlined in the table below.
Particular attention should be paid to those which are more common in VF or pulseless
VT. Hypothermic patients below 320C should be actively warmed, and the number of
shocks
reduced
until
the
patient
is
warmer.
Alkalising agents, (Sodium Bicarbonate: 1 mmol/kg = 1 ml/kg of an 8.4% solution),
be considered in children with prolonged arrest / TCA overdose / hyperkalaemia.
can
Particular relevance in
VF/pulseless VT
4 Hs and 4 Ts
Hypoxia
Hypovolaemia
Hyper/Hypokalaemia/metabolic
Hypothermia
Yes
Yes
Cardiac Tamponade
Tension pneumothorax
Toxins
Yes
Thrombo-embolic events
Gillian Body
Page 8 of 12
January 2007
Paediatric Clinical Guideline
Emergency: 1.1 Cardiopulmonary Resuscitation
If resuscitation is unsuccessful
1. Ensure that all team members present are happy to stop the resuscitation attempt.
Special consideration needs to be given to children who are hypothermic (prolonged
period outside / drowning), as resuscitation may need to continue until the child has a
normal body temperature.
2. Spend time with the relatives and ensure they are being supported by a member of staff.
3. Inform the GP and all other relevant parties
4. If appropriate refer to the:
 Sudden Unexpected Death guideline
 Care of the Next Infant (CONI) guideline
If resuscitation is successful
1. Assessment of ABCD should be made. The airway may need to be protected by
controlled intubation if not already done.
2. Post resuscitation care should be discussed with the consultant on call for PICU. Some
children will remain intubated and ventilated and need inotropic support.
3. Attention should be paid to electrolytes, glucose and temperature control.
4. Further evidence of the cause of the arrest should be sought if this is not yet determined.
Non-Accidental Injury should be considered.
5. If appropriate refer to the
 Acute Life Threatening Event guideline.
Gillian Body
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January 2007
Paediatric Clinical Guideline
Emergency: 1.1 Cardiopulmonary Resuscitation
Basic Life Support
SAFE
Shout for Help
Approach with Care
Free from Danger
Evaluate ABC
Infant
Neutral position
SAFE
Approach
Are you alright?
Airway Opening
Manoeuvres
Head tilt, chin lift
Jaw thrust
Child
Sniffing position
Look, listen, feel for 10 seconds
5 rescue breaths
Brachial/femoral
Two fingers,
compress to
between 1/3 and ½
depth of chest
Check for pulse/signs of circulation
Carotid Pulse
15:2 Compressions/ventilation
Heel of 1 or 2
hands, compress
to between 1/3 and
½ depth of chest
Ensure help on the way.
Call 999/2222
Gillian Body
Page 10 of 12
January 2007
Paediatric Clinical Guideline
Emergency: 1.1 Cardiopulmonary Resuscitation
Notes




An ‘infant’ is under 1 year of age, and a ‘child’ from 1yr to ‘puberty’. For this guideline this
includes all those children over 1 yr admitted to the paediatric wards.
The landmark for compressions is one finger breadth above the xiphisternum in all ages.
The rate of compressions is 100 per minute. With pauses for ventilation less than 100 will
be achieved, however the rate should be maintained.
Compressions should commence if no pulse, no signs of circulation, or a pulse less than
60 in a shocked child with circulatory compromise.
Airway Adjuncts and Intubation
Oropharyngeal airways (Guedel):
A suitable sized Guedel airway reaches from the centre of the incisors to the angle of the
mandible when laid on the face concave side up. In infants and small children the airway
should be inserted the “correct” way up, under direct vision, using a tongue depressor or
laryngoscope to avoid soft tissue trauma.
Nasopharyngeal Tubes
A suitable size tube reaches from the tip of the nose to the tragus of the ear. The diameter
should be that which snugly fits in the child’s nostril –this is approximately the size of their
little finger, or can be estimated using the formula below.
Intubation
Children frequently require endotracheal intubation during cardiac arrest. Uncuffed or cuffed
tubes can be used. A change in tube size (or to a cuffed tube) may be needed if there is
difficulty ventilating the intubated child.
The appropriate size of an endotracheal tube is estimated using the following formula;
Endotracheal tube size
Internal diameter (mm) = (Age/4) + 4
Length (cm) = (Age/2) + 12 for an oral tube
Length (cm) = (Age/2) + 15 for a nasal tube
These formulae are appropriate for ages over 1 year. Neonates usually require a tube of
internal diameter 3-3.5 mm. Another useful guide is to use a tube of the same diameter as the
child’s little finger, or a size that will just fit into the nostril.
Gillian Body
Page 11 of 12
January 2007
Paediatric Clinical Guideline
Emergency: 1.1 Cardiopulmonary Resuscitation
Title
Cardio-Respiratory Arrest
Guideline Number
1.1
Version
Final
Distribution
All wards QMC and CHN
Author
Dr Gillian Body
Paediatric Specialist Registrar
Dr Stephanie Smith
Consultant Emergency Paediatrician
Document Derivation
APLS Manual 4th Ed
ILCOR Update 2005
First Issued
Review Date
January 2009
Latest Version Date
January 2007
Ratified By
Paediatric Clinical Guidelines Meeting
Date
January 2007
Audit
Amendments
Gillian Body
Induction Programme
Page 12 of 12
January 2007