Pediatric Cardiopulmonary

Resuscitation
Hany El-Zahaby
Ain Shams University

2011

Aim
It is not a substitute for getting trained in Pediatric
Life Support Courses rather than providing
theoretical background that will help you having
more solid information about different aspects of
pediatric life support

Historical Background
Early 19th century: Neonates successfully resuscitated with
mouth-to-mouth resuscitation
In 1814, a description of the Rules of the Humane Society
for recovering drowned persons
Let one the mouth, and either nostril close
While through the other the bellows gently blows.
Thus the pure air with steady force convey,
To put the flaccid lungs again in play.
Should bellows not be found, or found too late,
Let some kind soul with willing mouth inflate;
Then downward, though but lightly, press the chest.
And let the inflated air be upward prest.

External cardiac massage was successfully conducted more

than 100 years ago in two children (ages 8 and 13 years)
after circulatory arrest precipitated by chloroform
anesthesia.
In 1904, Crile described the effectiveness of external cardiac
compressions in maintaining the circulation of dogs.
1947: Beck and associates successfully internally defibrillated
the human heart.
1956: Zoll and colleagues performed the first successful
external defibrillation of a human heart.
1958: The National Academy of Sciences National Research
Council recommended mouth-to-mouth resuscitation with
maximum backward tilt of the head as the preferred
technique for all individuals requiring emergency artificial
ventilation.
1960: External cardiac compression as a resuscitation
technique was revived, combined with artificial respirations.

Epidemiology and Outcome of In-hospital Pediatric

Cardiopulmonary Arrest
70%
60%
50%
40%
30%
20%
10%
0%

ICU
ER
Wards
OR/PACU

A 2006: National Registry of Cardiopulmonary Circulation registered

880 pediatric events, excluding delivery room or neonatal intensive
care unit.
The median age was 5.6 years.
The mean duration of cardiopulmonary resuscitation (CPR) for the
children who survived to hospital discharge was 27.3 minutes
(median, 15 minutes).
27% percent of the children survived to hospital discharge.
58% of these with a good neurologic outcome.

Diagnosis of Cardiac Arrest

(10 Seconds)
Outside OR:
-absence of signs of life (response to stimuli, breathing,
movement).
-absence of pulse.
Inside OR:
-ECG will indicate nonperfusing rhythms such as VF or
asystole.
-ETCO2 will decrease precipitously.
-Pulse oximeter will lose its regular waveform.
- absence of pulse.

Mechanics of CPR

ABC algorithm (Airway, Breathing, Circulation)

with the exception that the child with VF or
pulseless VT should receive electrical
defibrillation without delay. CPR should be
conducted up until the earliest moment when the
shock can be delivered.

ABC: A-Airway
Bag-valve-mask (BVM) ventilation with proper head
tilt-chin lift and jaw thrust (avoid gastric
insufflations).
Tracheal intubation ensures optimal control of the
airway for effective ventilation, multiple attempts
at intubation by the inexperienced operator may
seriously compromise the child's ability to
recover. Auscultation of the is useful in verifying
endotracheal tube placement in children together
with in-line capnography.

ABC: B-Breathing
Visible chest movement (F.B., bilateral tension
pneumothorax)
Avoid over-ventilation (decrease venous return,
less than normal minute ventilation to match less
COP)

Ventilations/Compressions for All Ages

Notes

Chest
Compressions

Respirations

Aspirate stomach if
interferes with
ventilation

100/min

2 /15
2/30 (single
rescuer)

BMV

Do not pause
compressions during
ventilation

100/min

8-10/min

ETT

ABC: C-Circulation

Chest-encircling method for

cardiac compressions in a
neonate (<6M)

Infant chest compression: twofinger technique

ABC: C-Circulation

Chest compression in small childrenChest compression in older children

ABC: C-Circulation
(1) ensuring adequate rate.
(2) ensuring adequate chest wall depression (one third to one
half of the anteroposterior chest diameter).
(3) releasing completely between compressions to allow full
chest wall recoil.
(4) minimizing interruptions in chest compressions.
(5) ensuring that the child is on a sufficiently hard surface to
allow effective chest compressions.

In short, push hard and push fast, release completely, and

don't interrupt compressions unnecessarily.

Mechanisms of Blood Flow

Compliant Chest Wall

Cardiac pump

Thoracic pump

Defibrillation/Cardioversion
Immediate management in children with VF or
pulseless VT.
Ventricular fibrillation is terminated due to
simultaneous depolarization and sustained
contraction of a critical mass of myocardium,
which allows return of spontaneous coordinated
cardiac contractions, assuming the myocardium is
well oxygenated and the acid-base status is
relatively normal.

Practical Aspects of Pediatric Defibrillation

Correct paddle size:
The largest paddle size appropriate for the child should
be used to reduce the density of the current flow, which
in turn reduces myocardial damage (adult size>10kg).
Paddle force (firmly applied).
Paddle position:
One paddle is placed to the right of the upper sternum
below the clavicle, the other is positioned just caudad
and to the left of the left nipple. An alternative approach
is to place one paddle anteriorly over the left precordium
and the other paddle posteriorly between the scapulae.
Gel pads interface not touching each other.
Free flowing oxygen 1 meter away to avoid sparking, but
keep closed ventilator circuit connect ventilator on.

Acute cardiac dysfunction inside OR

 Open-Chest Defibrillation:
2 cm for infants, 4 cm for children, 5J in infants.
Automated External Defibrillation:
Appropriate for use in children older than 1 year of
age with pediatric mode or with pediatric
attenuator pads.
Transcutaneous Cardiac Pacing

For temporary electrical cardiac pacing in children

with asystole or severe bradycardia due to defect in
impulse formation or conduction with preserved
myocardial function.

Vascular Access and Fluid Administration

Early IV access is a
key factor for
success.
Intraosseous Access:
IO needle, 16-18G
cannula, or 18G spinal
2cm below, 1cm
medial to tibial
tuberosity.
Complications:
osteomyelitis, fat or
bone marrow
embolism or
compartment
syndrome.

Endotracheal Medication Administration

Epinephrine, atropine, Lidocaine, and naloxone.
Ionized medications such as sodium bicarbonate
or calcium chloride is not recommended by this
route.
10% serum level of the IV route 10 times dose
(0.1mg/kg) for bradycardia or pulseless arrest
with maximum volume of 5ml with each injection
why?.
Complication?

Monitoring During CPR

Adequacy of bilateral chest expansion.
Constantly reevaluate the depth of compression
and the position of the rescuer's hands in
performing chest compressions by palpation of a
major artery.
Pulse oximeter.
ETCO2 reflects adequate CPR (transient after
epinephrine)
Direct diastolic arterial pressure coronary &
cerebral perfusion.
Temperature: - hypothermic arrest continue CPR
until 35.
Peri-arrest hyperthermia should be aggressively
treated to improve outcome.

Medications Used During CPR

Epinephrine
Actions:
- - adrenergic stimulation: PVR & SVR , SBP &
DBP, coronary BF and likelihood of return of
spontaneous circulation.
- -adrenergic stimulation: myocardial
contractility & HR, relaxes smooth muscle in the
skeletal muscle vascular bed & bronchi, the
vigor and intensity of ventricular fibrillation,
increasing the likelihood of successful
defibrillation.

Medications Used During CPR

Epinephrine
Complications:
Worsen myocardial ischemic injury.
oxygen demand.
Post-resuscitative tachyarrhythmias,
hypertension, pulmonary edema.
hypoxemia (increase alveolar dead space
ventilation by pulmonary BF redistribution).
VC impairs reperfusion of kidneys & GIT.
Routine use of large dose epinephrine in inhospital pediatric cardiac arrest should be
avoided.

Medications Used During CPR

Atropine
Parasympatholytic agent, increasing the sinus
rate and shortening atrioventricular node
conduction time.
Dose: 20/kg, with a minimum dose of 100
(why?) and a maximum dose of 2.0 mg.
Route, IV, IO, ET, IM, SC.
Onset: 30 seconds, peak 1-2 min after IV dose.

Epinephrine is the drug of choice for asystole or

severe bradycardia with hypotension in
pediatric CPR

Medications Used During CPR

Vasopressin

Because of the paucity of pediatric data,

vasopressin is considered Class Intermediate by
the American Heart Association in pediatric CPR
although Class IIB for adults to replace the second
or third dose of epinephrine.

Medications Used During CPR

Sodium Bicarbonate

The routine use of sodium bicarbonate during CPR

remains controversial, and it remains American
Heart Association Class Indeterminate.

Medications Used During CPR

Calcium
Indication:
Hypocalcemia, hyperkalemia, hypermagnesemia,
and calcium channel blocker overdose.
Doses:
Calcium chloride 20 mg/kg (maximum 0.5 to 1g).
Calcium gluconate 60 mg/kg (maximum 2 g).
Slowly through a large-bore, free-flowing
intravenous line, preferably a central venous line.
When administered too rapidly, calcium may
cause bradycardia, heart block, or ventricular
standstill. Severe tissue necrosis occurs when
calcium infiltrates into subcutaneous tissue.

Medications Used During CPR

Glucose
The administration of glucose during CPR should
be restricted to children with documented
hypoglycemia because of the possible
detrimental effects of hyperglycemia on the brain
during or after ischemia

Medications Used During CPR

Amiodarone
Amiodarone has now supplanted lidocaine as the first
drug of choice for medical management of shockresistant ventricular tachycardia and fibrillation.
- adrenergic blocking VD & coronary BF
- adrenergic blocking
CCB A-V conduction
K+ channel blocking with tissue accumulation
Doses: life threatening arrhythmia 5mg/kg (over10 min)
then 10-20 mg/kg/day
Avoided in hypomagnesemia & electrolyte imbalance for
fear of torsades de pointes. Heart block
(postoperative) with drugs that prolong QT interval as
inhalational anesthetics.

Lidocaine
Class IB antiarrhythmic , automaticity of ectopic focci in
ventricles, conduction & effective refractory period in
Perkinje fibers.
Normal cardiac and hepatic function, bolus of 1mg/kg of
lidocaine followed by a intravenous infusion at a rate of 20
-50g/kg/min is given.
If the arrhythmia recurs, a second bolus at the same dose can
be given.
In children with severe diminution of cardiac output, a bolus of
no greater than 0.75 mg/kg, followed by an infusion at the
rate of 10 to 20 g/kg/min, is administered.
In children with hepatic disease, dosages should be decreased
by 50%.
Toxic effects of lidocaine occur when the serum concentration
exceeds 7 to 8 g/ml: seizures, psychosis, drowsiness,
paresthesia, disorientation, agitation, tinnitus, muscle

Adjunctive CPR Techniques

Open-Chest CPR

During and after thoracic surgery in ICU.

Compared with closed-chest CPR, it generates
greater cardiac output and vital organ blood flow,
with less elevation of intrathoracic, right atrial,
and intracranial pressure, resulting in greater
coronary and cerebral perfusion pressure and
greater myocardial and cerebral blood flow.

Adjunctive CPR Techniques

Extracorporeal Membrane Oxygenation
In institutions with the ability to rapidly mobilize
an extracorporeal circuit, extracorporeal CPR
should be considered for refractory pediatric
cardiac arrest when the condition leading to arrest
is reversible and when the period of no flow
(cardiac arrest without CPR) was brief. Survival
with a good neurologic outcome is possible after
more than 50 minutes of CPR in selected children
who were resuscitated via extracorporeal CPR.
Extracorporeal CPR should be reserved for
children who have effective CPR initiated
immediately after cardiac arrest.

Adjunctive CPR Techniques

Active Compression-Decompression
Negative-pressure pull on the thorax during the
release phase of chest compression using a handheld suction device.
Improve vascular pressures and minute
ventilation during CPR in animals and humans by
enhancing venous return.
Studies: Contradicting results.
Complications: Fatal rib and sternal fractures.

Adjunctive CPR Techniques

Interposed Abdominal Compression
IAC-CPR : The delivery of an abdominal
compression during the relaxation phase of chest
compression.
1- Return venous blood to the chest during chest
relaxation.
2- Increase intrathoracic pressure and augments the
duty cycle of chest compression.
3- Compress the aorta and return blood retrograde
to the carotid or coronary arteries.
Human studies : increase in aortic pressure and
coronary perfusion pressure during IAC-CPR
compared with conventional CPR. The risk of
injury to intra-abdominal organs during IAC-CPR

Special Cardiac Arrest Situations

Hyperkalemia

Diagnosis: history, progression of ECG changes,

initial laboratory results.
Aim of treatment:
1-Antagonize the effects of hyperkalemia at the
myocardial cell membrane, increasing the
threshold for fibrillation by calcium
chloride/gluconate.
2-Shift potassium from the extracellular to the
intracellular compartment by sodium bicarbonate
and hyperventilation, insulin with dextrose (0.1
unit/kg of insulin with 2 ml/kg of dextrose 25%).

Special Cardiac Arrest Situations

Supraventricular Tachycardia
It is a common arrhythmia in infants and children.
If no circulatory compromise: vagal maneuver such
as ice to the face may be tried first before adenosine.
The initial dose is 0.1 0.2 0.4 mg/kg given as a
rapid intravenous bolus (central Vs peripheral).
In neonates, repeated doses of 0.05 mg/kg are given
until termination of the arrhythmia up to a maximum
dose of 0.25 mg/kg.
If circulatory compromise: immediate synchronized
cardioversion of 0.5 J/kg. If intravenous access is
available, adenosine can be administered as
cardioversion is being prepared (but not delayed).

Special Cardiac Arrest Situations

Pulseless Electrical Activity
PEA: organized ECG activity, excluding ventricular
tachycardia and fibrillation, without clinical
evidence of a palpable pulse or myocardial
contractions.
Primary (cardiac) due to depletion of myocardial
energy. Drugs used to treat primary PEA are
epinephrine, atropine, calcium, and sodium
bicarbonate.

Special Cardiac Arrest Situations

Pulseless Electrical Activity
Ts 4

Hs 4

Tension pneumothorax
Tamponade (cardiac)
Thromboebolism

Hypoxemia
Hypovolemia
Hypothermia

Toxins (anesthetic overdose)

Hypoelectrolemia

When the cause of PEA is unknown and the child

does not respond to medications, one should
consider giving a fluid bolus and inserting
needles into the pleural space to rule out
pneumothorax and into the pericardial space to
rule out cardiac tamponade

Anaphylaxis
Flushing, pallor, or urticaria, airway edema obstruction,
bronchospasm, and cardiovascular collapse.
Severe anaphylaxis in situations of decreased endogenous
catecholamines as in children taking blockers or receiving spinal
or epidural anesthesia.

Resuscitation rests on reversing airway obstruction and

restoring intravascular volume and vascular tone.
In the child with impending cardiac arrest, 0.01 mL/kg of
subcutaneous epinephrine (1 : 1000 concentration).
Large volume fluid resuscitation of BSS.
Diphenhydramine (Benadryl), 1 mg/kg.
Methylprednisolone (Solu-Medrol), 2 mg/kg.
Albuterol may help reverse bronchospasm.
The airway should be secured early before being difficult to secure.

THANK YOU

 Continue resuscitation until:

The child shows signs of life (normal
breathing, cough, movement or
definite pulse of greater than 60 min1).
Further qualified help arrives.
You become exhausted.

Chest compression in children

:aged over 1 year
hn Place the heel of one hand over
the lower half of the sternum (as
.above)
hn Lift the fingers to ensure that
pressure is not applied over the
.childs ribs
hn Position yourself vertically above
the victims chest and, with your arm
straight, compress the sternum to
depress it by at least one-third of the
.depth of the chest
hn In larger children, or for small
rescuers, this may be achieved most
easily by
using both hands with the fingers
.interlocked

 Chest compression in infants:

The lone rescuer should compress the sternum with the tips of
two fingers.
If there are two or more rescuers, use the encircling technique:
o Place both thumbs flat, side by side, on the lower half of the
sternum (as above), with the tips pointing towards the infants
head.
o Spread the rest of both hands, with the fingers together, to
encircle the lower part of the infants rib cage with the tips of
the
fingers supporting the infants back.
o Press down on the lower sternum with your two thumbs to
depress it at least one-third of the depth of the infants chest.

For all children, compress the lower half of the sternum:

To avoid compressing the upper abdomen, locate the
xiphisternum by
finding the angle where the lowest ribs join in the middle.
Compress the
sternum one fingers breadth above this.
Compression should be sufficient to depress the sternum by at
least onethird
of the depth of the chest.
Dont be afraid to push too hard. Push hard and fast.
Release the pressure completely, then repeat at a rate of 100 120 min-1
After 15 compressions, tilt the head, lift the chin, and give two
effective
breaths.
Continue compressions and breaths in a ratio of 15:2.

 If you are confident that you can detect signs of a

circulation within 10 s:
Continue rescue breathing, if necessary, until the child
starts breathing effectively on his own.
Turn the child onto his side (into the recovery position) if
he starts breathing effectively but remains unconscious.
If there are no signs of life, unless you are
CERTAIN that you can feel
a definite pulse of greater than 60 min-1 within
10 s
Start chest compression.
Combine rescue breathing and chest compression.

 Assess the childs circulation (signs of life):

Take no more than 10 s to:
Look for signs of life. These include any movement, coughing, or
normal
breathing (not abnormal gasps or infrequent, irregular breaths).
If you check the pulse take no more than 10 s:
o In a child aged over 1 year feel for the carotid pulse in the
neck.
o In an infant feel for the brachial pulse on the inner aspect
of the
upper arm.
o For both infants and children the femoral pulse in the groin (mid
way between the anterior superior iliac spine and the symphysis
pubis) can also be used.

For both infants and children, if you have difficulty

achieving an effective breath, the airway may be
obstructed:
Open the childs mouth and remove any visible
obstruction. Do not perform a blind finger sweep.
Ensure that there is adequate head tilt and chin lift
but also that the neck is not over extended.
If head tilt and chin lift has not opened the airway,
try the jaw thrust method.
Make up to 5 attempts to achieve effective breaths.
If still unsuccessful, move on to chest compression.

Rescue breaths for an infant:

Ensure a neutral position of the head (as an infants head is
usually flexed
when supine, this may require some extension) and apply
chin lift.
Take a breath and cover the mouth and nasal apertures of the
infant with
your mouth, making sure you have a good seal. If the nose
and mouth
cannot both be covered in the older infant, the rescuer may
attempt to seal
only the infants nose or mouth with his mouth (if the nose is
used, close the
lips to prevent air escape).
Blow steadily into the infants mouth and nose over 1-1.5 s
sufficient to make
the chest rise visibly.
Maintain head position and chin lift, take your mouth away,
and watch for his

Rescue breaths for a child over 1 year:

Ensure head tilt and chin lift.
Pinch the soft part of his nose closed with the index finger
and thumb of your
hand on his forehead.
Open his mouth a little, but maintain the chin lift.
Take a breath and place your lips around his mouth, making
sure that you
have a good seal.
Blow steadily into his mouth over about 1-1.5 s sufficient to
make the chest
rise visibly.
Maintaining head tilt and chin lift, take your mouth away
and watch for his
chest to fall as air comes out.
Take another breath and repeat this sequence four more
times. Identify
effectiveness by seeing that the childs chest has risen and
fallen in a similar

 5A. If the child is breathing normally:

Turn the child onto his side into the recovery position (see
below).
Send or go for help call the relevant emergency number. Only
leave the child if no other way of obtaining help is possible.
Check for continued normal breathing.

5B. If the breathing is not normal or absent:

Carefully remove any obvious airway obstruction.
Give 5 initial rescue breaths.
While performing the rescue breaths note any gag or cough
response to your action. These responses, or their absence, will
form part of your assessment of signs of life, described below.

 In the first few minutes after cardiac

arrest a child may be taking
infrequent, noisy gasps. Do not
confuse this with normal breathing.
Look, listen, and feel for no more
than 10 s before deciding if you
have any doubts whether
breathing is normal, act as if it is
not normal.

 4. Keeping the airway open,

look, listen, and feel for normal
breathing by
putting your face close to the
childs face and looking along
the chest:
Look for chest movements.
Listen at the childs nose and
mouth for breath sounds.
Feel for air movement on your

 3B. If the child does not respond:

Shout for help.
Turn the child onto his back and open the airway using head tilt
and chin lift:
o Place your hand on his forehead and gently tilt his head back.
o With your fingertip(s) under the point of the childs chin, lift the
chin. Do not push on the soft tissues under the chin as this may
block the airway.
o If you still have difficulty in opening the airway, try the jaw
thrust
method: place the first two fingers of each hand behind each side
of the childs mandible (jaw bone) and push the jaw forward.

 1. Ensure the safety of rescuer and child.

2. Check the childs responsiveness:
Gently stimulate the child and ask loudly, Are you all
right?
Do not shake infants, or children with suspected
cervical spine injuries.
3A. If the child responds by answering or moving:
Leave the child in the position in which you find him
(provided he is not in further danger).
Check his condition and get help if needed.
Reassess him regularly.

Rescuers Taught the Adult BLS

Rescuers who have been taught adult BLS, and have no
specific knowledge of pediatric resuscitation, should use the
adult sequence with the following modifications :
-Give 5 initial rescue breaths before starting chest
compression.
-If you are on your own, perform CPR for 1 min before going
for help.
-Compress the chest by at least one-third of its depth.
- Use two fingers for an infant under 1 year; use one or two
hands for a child over 1 year as needed to achieve an
adequate depth of compression.