PALS Course

Cardiopulmonary arrest or pediatric cardiac arrest occurs when there is abrupt loss of heart function and blood circulation is terminated due to abnormalities of the heart. Cardiac arrest is uncommon in children and is usually caused by prolonged respiratory distress, failure or shock. Children that have primary cardiac arrhythmias leading to cardiac arrest have very low survival rates so it is important to quickly recognize the problem and provide appropriate treatment. There are two examples of cardiac arrest that occur in children:

• Hypoxic/asphyxia arrest
• Sudden cardiac arrest

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Asphyxia is when there is a lack of oxygen to the body due to difficulty in breathing. Asphyxial arrest is the most common cause of cardiac arrest in children and is due to respiratory failure, shock and cardiopulmonary failure. Sudden cardiac arrest is uncommon in children and is seen by eh absence of cardiac and respiratory function or by arrest rhythm on the cardiac monitor. Cardiac arrest may be caused by the following problems:

• Hypertrophic cardiomyopathy
• Anomaly of the coronary artery
• Long QT syndrome
• Myocarditis
• Drug toxicity
• Trauma to the chest

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There are 4 examples of cardiac arrest in children:

• Asystole
• VF
• Pulseless VT
• Pulseless Electrical Activity (PEA)

Asystole

Asystole or flatline is associated with no cardiac electrical activity, no contraction of the cardiac muscle and no cardiac output. The first step is to ensure that it is an actual asystole and not an error due to improper connection of leads or no power in the unit. Some causes of asystole include:

• Hypothermia
• Sepsis
• Poisoning
• Drowning or being submerged for prolong period

Ventricular Fibrillation (VF)

Ventricular fibrillation (VF) is an arrhythmia, which can cause sudden cardiac arrest. During ventricular fibrillation there is disorganization of electrical activity in the heart and the heart has stopped pumping. VF is common in children and has the following causes:

VF does not have an identifiable ECG waveform. Earlier waveforms show a “coarse VF,” but after few minutes the waveforms are much smaller and show a “fine VF.”

Ventricular Tachycardia (VT)

Ventricular tachycardia (V-tach or VT) is a fast heart rhythm from the ventricles of the heart. VT can lead to VF and cause sudden death of the patient. A pulseless VT has no cardiac output causing no pulse and results in cardiac arrest. The causes of pulseless VT are:

Pulseless Electrical Activity (PEA)

Pulseless electrical activity (PEA) is lack of palpable pulse or cardiac contraction even with an organized cardiac electrical activity. PEA presents with prolong PR and QT intervals, AV dissociation or complete heart block.

PEA can be caused by many factors and are represented as H’s and T’s:

Management of Cardiac Arrest

The most important component in the management of cardiac arrest is activating the EMS and implementing high-quality CPR continuously, for infants compression depth is 1.5 inches, for children (1+ years) it’s 2 inches. There are different steps in order to treat a child with VT/VF and those with asystole or PEA.

Asystole/PEA

Upon recognizing the child with asystole or PEA immediately activating the EMS and start CPR with a ratio of 30 compressions to 2 breaths by the following:

• Open and support the airway
• Give oxygen and/or ventilation
• Start chest compressions with 100/min
• Attach a defibrillator for children over 1 years old
• Get vascular access
• Get labs
• Give epinephrine IV/IO 0.01 mg/kg and repat every 3 to 5 minutes
• Give 5 cycles of CPR
• Check rhythm to see if it is shockable or not and continue CPR

VF/VT

1. Upon recognizing the child with VF/VT immediately activating the EMS and start CPR with a ratio of 30 compressions to 2 breaths by the following:

   • Open and support the airway
   • Give oxygen and/or ventilation
   • Start chest compressions with 100/min
   • Attach a defibrillator for children over 1 years old
   • Get vascular access
   • Get labs
2. Give one shock at 2 J/kg for children over the age of 1 years and continue CPR
3. Give 5 cycles of CPR and check rhythm again
4. If persistent VF and VT give another shock at 4 J/kg for children over the age of 1 years and resume CPR while obtaining vascular access
5. Give epinehphrine IV/IO 0.01 mg/kg and repeat every 3 to 5 minutes
6. Give 5 cycles of CPR and check rhythm again
7. If persistent VF and VT give another shock at 4 J/kg for children over the age of 1 years and continue CPR
8. Give amiodarone 5 mg/kg IV/IO or lidocaine 1 mg/kg IV/IO. For Torsades give magnesium 25 to 50 mg/kg IV/IO Continue CPR

The following is the algorithm which shows the management of cardiac arrest of children: