The most challenging scenario you can ever face is resuscitation of pediatric population in your ED, high level of stress is involved, so going systematic will make your work easy. The new PALS guidelines by AHA is quoted d here.

1. Pediatric Pulseless Arrest
Runal Shah
PGY-3
KDAH

2. Introduction
• Kids are not tiny adults !!
• Hypotension (SBP) as per age
▫ Neonates (0-28 days) = <60
▫ Infants (1-12 months) = <70
▫ Children (1-10yr) = <70 + (2 x age in years)
▫ Children > 10yr = < 90

3. Introduction
• Pulseless Arrest is the end result of progressive
▫ Respiratory failure
▫ Shock
• Termed as HYPOXIC-ISCHEMIC ARREST.
• Respiratory failure and shock can be reversible if
identified and treated early, if they progress to cardiac
arrest – outcome is generally poor.
• Sudden death in young people is associated with
underlying cardiac conditions.

4. Cardiac Arrest
• Hypoxic/Asphyxial
▫ Most common
▫ End result of tissue
hypoxia & acidosis
▫ Caused by progressive
respiratory failure/
shock
• Sudden Cardiac Arrest
▫ Less common
▫ Ventricular Fibrillation/
Pulseless VT
▫ Cardiac causes –
HOCM
Anomalous coronary
Long QT/
channelopathy
Myocarditis
Drug toxicity
Commotio cordis

5. Pathway to Cardiac Arrest
Respiratory
Failure
Shock
Cardiopulmonary
Failure
Sudden Ventricular
Arrhythmia
Hypoxic / Asphyxial
Arrest
Sudden Cardiac Arrest

6. Recognition of
Cardiopulmonary Failure
• Airway –
▫ Possible upper airway
obstruction
• Circulation –
▫ Bradycardia
▫ Delayed CRT (>2
seconds)
▫ Weak central pulses
▫ Absent peripheral pulses
▫ Cool extremities
▫ Mottled or cyanotic skin
▫ Hypotension
• Breathing –
▫ Bradypnoea
▫ Irregular, ineffective
respirations
• Disability –
▫ Decreased level of
consciousness
• Exposure –
▫ Assess for obvious
bleeding
▫ Hypo/ Hyperthermia

7. Arrest Rhythms
• Asystole & PEA – the most common initial rhythms seen
in both in-hospital and out-of-hospital pediatric cardiac
arrest, especially in children <12 years of age.
• Survival & outcome of patients with VF or pulseless VT
as initial rhythm are better.
6H’s 6T’s
Hypovolemia Tension Pneumothorax
Hypoxia Tamponade
Hydrogen ion (Acidosis) Toxins
Hypoglycemia Thrombosis (Pulmonary)
Hypo / Hyperkalemia Thrombosis (Coronary)
Hypothermia Trauma

8. Arrest Rhythms
• Asystole
▫ Cardiac standstill without discernable electrical
activity.
▫ Straight (flat) line on the ECG.
▫ Confirm clinically! Can be a loose ECG lead.
• PEA
▫ Any organized electrical activity with no palpable
pulse.
▫ Very slow PEA – “Agonal rhythm”
• Low or high amplitude T waves
• Prolonged PR, QT interval
• AV dissociation, CHB or ventricular complexes
without P waves

9. Arrest Rhythms
• Ventricular fibrillation (VF)
▫ No organized rhythm & no coordinated contractions.
▫ VF may be preceded by a brief period of VT.
▫ Can occur in Teens during sports activities.
▫ Undiagnosed cardiac abnormality/ channelopathy.
• Pulselesss Ventricular Tachycardia
▫ Organized wide QRS complexes.
▫ Usually of a brief duration before it deteriorates into VF.
▫ Torsades de pointes : Polymorphic VT
• Prolonged QT, Dyselectrolemia, Drug toxicity

10. Key BLS
component
of PALS

11. Pediatric Advanced Life Support
• High quality CPR
▫ Adequate compression rate (100-120
compressions/min)
▫ An adequate compression depth
≥ 1/3 of the AP diameter of the chest or approximately
1 ½ inches [4 cm] in infants, approximately 2 inches
[5 cm] in children
▫ Allowing complete recoil of the chest after each
compression,
▫ Minimizing interruptions in compressions avoiding
excessive ventilation

13. Algorithm
• Epinephrine –
▫ IV/IO = 0.01
mg/kg bolus
(1:10,000)
▫ ET = 0.1 mg/kg
bolus (1:1000)
• Defibrillation –
▫ Initial dose = 2-4
J/kg
▫ Subsequent doses
= 4 J/kg or higher
(Max 10 J/kg)

14. New updates (2015) of PALS
• In specific settings, when treating pediatric patients with
febrile illnesses, the use of restrictive volumes of isotonic
crystalloid leads to improved survival.
▫ This contrasts with traditional thinking that routine
aggressive volume resuscitation is beneficial.
• Routine use of atropine as a premedication for
emergency tracheal intubation in non-neonates,
specifically to prevent arrhythmias, is controversial.
▫ Also, there are data to suggest that there is no minimum
dose required for atropine for this indication.

15. • If invasive arterial blood pressure monitoring is already
in place, it may be used to adjust CPR to achieve specific
blood pressure targets for children in cardiac arrest.
• Amiodarone or Lidocaine is an acceptable
antiarrhythmic agent for shock-refractory pediatric VF
and pulselessVT in children.
• Epinephrine continues to be recommended as a
vasopressor in pediatric cardiac arrest.
• For pediatric patients with cardiac diagnoses and IHCA
in settings with existing extracorporeal membrane
oxygenation protocols, ECPR may be considered.

16. • Fever should be avoided when caring for comatose
children with ROSC after OHCA.
▫ A large randomized trial of therapeutic hypothermia for
children with OHCA showed no difference in outcomes
whether a period of moderate therapeutic hypothermia
(with temperature maintained at 32°C to 34°C) or the strict
maintenance of normothermia (with temperature
maintained 36°C to 37.5°C) was provided.
• Several intra-arrest and post–cardiac arrest clinical
variables were examined for prognostic significance.
• No single variable was identified to be sufficiently
reliable to predict outcomes. Therefore, caretakers
should consider multiple factors in trying to predict
outcomes during cardiac arrest and in the post-ROSC
setting.

17. • After ROSC, fluids and vasoactive infusions should be
used to maintain a systolic blood pressure above the fifth
percentile for age.
• After ROSC, normoxemia should be targeted. When the
necessary equipment is available, oxygen administration
should be weaned to target an oxyhemoglobin saturation
of 94% to 99%.
• Hypoxemia should be strictly avoided. Ideally, oxygen
should be titrated to a value appropriate to the specific
patient condition. Likewise, after ROSC, the child’s
PaCO2 should be targeted to a level appropriate to each
patient’s condition. Exposure to severe hypercapnia or
hypocapnia should be avoided.

18. • References:
• Chameides L, Samson RA, Schexnayder SM, Hazinski MF. Pediatric
advanced life support provider manual. Dallas, TX: American Heart
Association. 2011.
• Care EC. Part 12 : Pediatric Advanced Life Support. 2015;2015:1–74.