- Absence of effective mechanical cardiac activity
- In children, bradycardia is the most initial form of cardiac arrest in children, so provide oxygen.
- Asystole (confirm in 2 leads)
- Ventricular fibrillation (VF)
- Pulseless ventricular tachycardia (VT)
- Pulseless electrical activity (PEA)
- Consider possible reversible causes (6 Hs and 5 Ts):
GENERAL: signs of trauma?
SKIN: pallor, GI bleed?
EYES: pupil size, drug OD?
LUNGS: respiratory distress prior to collapse?
ARMS: dialysis shunt?
Reversible Causes (Hs & Ts)
- Hypovolemia – IV fluids and blood products.
- Hypoxia – Ventilation, Oxygen
- Hydrogen Ion – Sodium Bicarbonate, Hyperventilation
- Hyper (hypo) kalemia – Calcium chloride, insulin, glucose, sodium bicarbonate, sodium polystyrene sulfonate, dialysis
- Hypothermia – rewarming, oxygen, IV fluids
- Hypoglycemia – glucose
- Toxin (Drug Overdose) – drug screens, intubation, lavage, activated charcoal
- Tamponade (Cardiac) – pericardiocentesis
- Tension pneumothorax – needle decompression
- Thrombosis (coronary) – PCI, thrombolytics, oxygen, nitrogen, heparin, aspirin, morphine
- Thrombosis (pulmonary) – pulmonary arteriogram, surgical embolectomy, thrombolytics
- Trauma – volume infusion, intracranial pressure monitoring, bleeding control, surgical intervention
- Perform CPR: 100/min, allowing for chest wall recoil, with minimal interruptions
- Sequence should be:
- Rhythm check
- Resume CPR
- Shock/Meds (charge defibrillator and administer drugs during CPR)
Pulseless Electrical Activity
- Epinephrine: 1 mg IV q3–5min or
- Vasopressin 40 U IV single
Pediatric dose of Epinephrine: 0.01 mg/kg
Vasopressin is NOT recommended in children.
Torsades de pointes
- Magnesium sulfate: 1–2 g diluted in 10 mL D5W IV push
- Defibrillation – 150–200 J
If VT/VF is unresponsive to 2–3 shocks and the 1st dose of vasopressor consider Amiodarone.
Amiodarone is the drug preferred by the AHA. Dosing: 300 mg IV push followed by 2nd dose of 150 mg IV
Initial dose of 2 J/kg for the 1st attempt, followed by 4 J/kg for the next attempt. Increase energy with subsequent attempts, but do not exceed 10 J/kg or maximum adult dose.
Myocardial Infarction/Pulmonary Embolism (PE)
- Activase: 50 mg bolus over 2 minutes
- Repeat a second 50 mg bolus 15 minutes later if return of spontaneous circulation (ROSC) is not achieved.
- Heparin – systemic anticoagulation (eg, unfractionated heparin) should be administered with or shortly after administration of alteplase
- Initial: 80 units/kg bolus followed by…
- Continuous infusion of 18 units/kg/hour
- Adjust infusion rate to maintain target laboratory values based on institutional protocol