This document provides guidelines for managing pediatric cardiac arrest. It defines cardiac arrest and describes the main causes as respiratory failure, shock, or arrhythmia. Hypoxic/asphyxial arrest from respiratory failure or shock is more common than sudden cardiac arrest from arrhythmias. The treatment for cardiac arrest includes high-quality CPR, identifying and treating reversible causes, defibrillation if needed, advanced airway, medications like epinephrine, and post-cardiac arrest care. Special considerations are discussed for traumatic arrest, drowning, anaphylaxis, poisoning, and patients with congenital heart disease. Extracorporeal CPR may be considered for in-hospital arrests with existing ECMO capabilities.

1. PEDIATRIC ADVANCED
LIFE SUPPORT 2017
GUIDELINES- PART 2
DR. SAYED ISMAIL,MD
PROFESSOR AND CONSULTANT OF PEDIATRIC
ALSALAMA HOSPITAL

2. CARDIAC ARREST
PART 2

3. Definition of cardiac arrest
• Cardiac arrest is the cessation of blood circulation
resulting from absent cardiac mechanical activity
• Clinically the child is unresponsive , not breathing and no
pulse
• When circulation stop , tissue ischemia , organ damage
and death if not rapidly reversed

4. CARDIAC ARREST
• CAUSES
1. Respiratory failure
2. Shock
3. Arrhythmia ….. Give sudden collapse

5. Cardiac arrest
Respiratory
failure
Shock
Less
commonly
arrhythmia
PATHWAY OF PEDIATRIC CARDIAC ARREST
Sudden
Arrest
Hypoxic Arrest

6. Cardiac arrest in infant and children
• Pediatric cardiopulmonary arrest results from respiratory failure
or shock
• This form of arrest is called hypoxic /asphyxial arrest
• Respiratory failure or shock can be reversed if treated early
• If they progress to cardiac arrest the outlook is generally poor
• Ventricular arrhythmia cause 5-15% of pediatric cardiac arrest
• Survival rates from pediatric arrest is higher if arrest occurs in
hospital (43%) compared with out hospital (8%)

7. Respiratory failure and shock
Detect and treat Respiratory failure and shock
before the child deteriorates to cardiac arrest

8. Causes od sudden cardiac arrest
• Sudden cardiac arrest is less common in children than in adult
• Caused by sudden tachyarrhythmia ( VF Or pulseless VT )
• Predisposing conditions :
– Myocarditis (Muffled heart sounds ,Hepatomegaly,CHF)
– Hypertrophic cardiomyopathy
– Anomalous coronary artery
– Long QT syndrome
– Drug toxication
– Commotio cordis (sharp blow to chest )
– Familial Channelopathies

9. Prevention of cardiac arrest
• Primary prevention
– Screening for hypertrophic cardiomyopathy , and long QT
syndrome
– Treatment of myocarditis
– History of syncopes, seizures and unexplained death my
indicate familial Channelopathies
• Secondary prevention
– Prompt resuscitation and defibrillation (activate
emergency response , high quality CPR, and use of AED

10. Reversible causes of cardiac arrest ( 6 H and 5 T)
6-H 5-T
Hypovolemia Tension pneumothorax
hypoxia Tamponade (cardiac)
Hydrogen (acidosis ) Toxins
Hypoglycemia Thrombosis (Pulmonary)
Hypokalemia / hyperkalemia Thrombosis ( coronary )
Hypothermia

11. Cardiac Arrest
rhythms
1-Pulseless VT
2-VF
3-ASYSTOLE
4- PEA
see later
No pulse

12. Pulseless electrical activity
• Pulseless electrical activity means the situation when a patient is
unconscious because of cardiac arrest and pulseless. However, there is
organized electrical activity in the recorded ECG that is neither VT or VF
This is ECG record of a pulseless patient during cardiac tamponade.

13. Ventricular fibrillation
• It is random electrical activity. No organized rhythm
• Sometimes the amplitude of the waves is large (coarse VF),
while other times the amplitude is so small (fine VF)
• Incidence = 5-15% of cardiac arrest
Ventricular fibrillation (coarse)Ventricular fibrillation (fine)

14. Pulseless ventricular tachycardia
Types of ventricular tachycardia :
1- VT with pulse
2- VT without pulse = pVT
Monomorphic ventricular tachycardia
Organized wide QRS complexes

15. Torsades de pointes
• Torsades de pointes (TdP) is a specific form of polymorphic
ventricular tachycardia occurring in the context of QT prolongation; it
has a characteristic morphology in which the QRS complexes “twist”
around the isoelectric line.
• QRS complexes varying in amplitude, axis and duration.

16. Management
Of Cardiac
Arrest
Is commonest
arrhythmia
in children

17. High quality CPR
• Push fast 100-120 /min
• Push hard 4cm in infant 5 cm for child (1/3rd thorax depth)
• Allow complete chest recoil
• Minimize interruption
• Avoid excessive ventilation after advanced airway deliver 10
breaths /minute
• End tidal co2( petco2) keep more than 10-15mmhg
• if indwelling arterial catheter in place , use the wave form to
evaluate the chest compression
• Both the PET- CO2 and arterial waveform may be useful indicator
for ROSC

18. PALS to treat cardiac arrest my include :
1. Rhythm assessment, shock-able or not
2. Defibrillation
3. IV /IO access or endotracheal
4. Medications
5. intubation
6. Post cardiac arrest care

19. EPINEPHRIN
• Epinephrine is a potent α- and β-adrenergic stimulating .
• The α-adrenergic action increases systemic and pulmonary vascular
resistance, increasing both systolic and diastolic blood pressure. The
rise in diastolic blood pressure directly increases coronary perfusion
pressure, thereby increasing the likelihood of return of spontaneous
circulation.
• The β-adrenergic effect increases myocardial contractility and heart
rate and relaxes smooth muscle in the skeletal muscle vascular bed
and bronchi. Epinephrine also increases the vigor and intensity of
ventricular fibrillation, increasing the likelihood of successful
defibrillation.

20. • Dose of IV epinephrine is 0.1 mL/kg of a 1:10,000 solution (0.01
mg/kg), = 10 microgram /kg repeated every 3 to 5 minutes
Indications :
• In Cardiac arrest
• Time Of administration : after the 2nd shock
• REPEAT every 3 to 5 minutes , till presence pulse , to
avoid unnecessary epinephrine because it my induce
recurrent arrhythmia

21. CRP with advanced airway
• Once the advanced airway in place the CPR
sequence change from cyclic to continuous chest
compression
– One team give 100-120 compression
– Another give breath every 6 sec (10 breaths/min)
– Rotate every 2 min
– Check rhythm every 2 minutes

22. Pediatric cardiac arrest : special circumstances
1- cardiac arrest due to trauma
• Possible causes :
– Hypoxia due to airway obstruction
– Injury to vital structure e.g heart ,
aorta ..
– Severe brain injury with secondary
cardiovascular collapse
– Upper cervical spinal cord injury
with respiratory arrest
– Shock due to pneumothorax ,
cardiac tamponade or massive
hemorrhage

23. Basic and advanced life support are the same for traumatic
and nontraumatic cardiac arrest (CPR + ABCDE)
• CRP : according to cardiac arrest algorithm
– Perform high quality CPR
– Attach the monitor / defibrillator
• AIRWAY : use jaw thrust , minimize cervical motion
• BREATHING : consider needle decompression
• CIRCULATION
– establish IV/IO line , consider noncrossmatched O-ve blood
– vasopressor in spinal shock (hypotension and bradycardia )
– consider pericardiocentesis

24. Management of cardiac arrest due drowning ; SOME NOTES
1- CPR : of high quality , attach monitor /defibrillator , wipe the chest
if covered by water
2- AIRWAY , open , restrict the spine motion
3-BREATHING ; ventilate with bag – mask device with 100% o2
4- circulation
5- exposure : rewarm if the patient hypothermic
(CPR + ABCDE)

25. Management of cardiac arrest due to anaphylaxis
• CPR : according to cardiac arrest algorithm
• Airway : may need smaller ET tube
• Breathing
• Circulation : insert 2 IV /IO lines , give isotonic boluses as
needed to treat shock
• Administer epinephrine in same IV doses or via ET tube if
no IV/IO line
• Provide epinephrine infusion if hypotension
(CPR + ABCDE)

26. Treatment of , Cardiac
arrest due to poisons
• Follow cardiac arrest
algorithm
• Check glucose
• Treat the reversal
causes of arrest
• Early consultation to
poison center
Congenital heart
disease
• Follow cardiac arrest
algorithm
• Heparin if
ventriculopulmonary
shunt patency is a
concern
• Pediatric cardiac
consultation
(CPR + ABCDE assessment)

27. Extracorporeal CPR
• For inpatient cardiac arrest cases with existing ECMO
protocols , expertise and equipment
• Studies show improved survival to hospital discharge

28. • FOR PEDIATRIC RESPIRATORY
FAILURE ------- SEE PART 3 OF
PALS