Sudden cardiac arrest due to a primary cardiac dysrhythmia is rare in children.¹ Unrecognized and progressive respiratory distress and shock are the most common etiologies of cardiopulmonary arrest (CPA) in children. The outcome for out-of-hospital CPA is poor, with only 4% to 13% of children surviving to hospital discharge.² The survival rate of in-hospital CPA is approximately 27% to 33%.^2,3 Early recognition of a child in respiratory distress and/or compensated shock is essential to prevent the progression to CPA.

The 2015 AHA CPR and Pediatric Advanced Life Support (PALS) guidelines continue to emphasize the importance of immediate high-quality basic life support by lay rescuers and by health care providers. The major change regarding the sequence of actions for CPR in the previous 2010 AHA guidelines was the “C-A-B” sequence, which stands for “compressions–airway–breathing.”⁴ This emphasis on initiating chest compressions before ventilations provides for more immediate perfusion to the heart and brain. Immediate chest compressions can be initiated much faster than opening the airway and providing ventilations. The delay in providing assisted ventilations when using C-A-B is approximately 18 seconds when the 30:2 compression-to-ventilation ratio is used, and shorter when the 15:2 compression-to-ventilation ratio is being used in infants and children.⁴

Table 21-1 lists the five essential components of high-quality chest compressions.⁶ The universal compression to ventilation ratio for one-rescuer CPR in any age victim is 30:2. When there are two health care providers performing CPR, the compression-to-ventilation ratio for infants and children (without signs of puberty) is 15:2. The effectiveness of CPR is measured by palpable pulses during cardiac compressions. Overzealous ventilations during CPR may be harmful by decreasing venous return to the heart and limiting cardiac output. The major points of emphasis in the 2015 PALS guidelines are noted in Table 21-2.

Although uncuffed endotracheal tubes (ETTs) have traditionally been used in pediatric patients, cuffed ETTs may be safely used in the hospital setting in children younger than 8 years (except for the newly born) under certain circumstances such as poor lung compliance, high airway resistance, or a large glottic leak.⁷ The cuff pressure must be monitored and kept <20 cm H₂O.

Although laryngeal mask airways (LMAs) have been extensively used by pediatric anesthesiologists in the operating room, there is currently insufficient evidence to recommend the routine use of LMAs in children during cardiac arrest.⁷ However, if a child in CPA cannot be adequately ventilated and oxygenated via bag-mask techniques and if intubation attempts have failed, an LMA can be used during CPR.

Once an advanced airway has been inserted, confirm proper tube placement and proper ventilation by clinical assessment and confirmatory devices. Check for adequate and symmetric rise and fall of the chest. The colorimetric CO₂ detector is commonly used to confirm tracheal intubation. There are several false positive and false negative conditions that may occur when using a colorimetric CO₂ detector device. During CPA, the lungs are poorly perfused, resulting in insufficient exhaled CO₂ to register on the detector despite correct tracheal intubation. Adult-sized CO₂ detectors used in infants might similarly be falsely negative. Children who have consumed carbonated beverages just prior to intubation may have enough carbon dioxide present in their stomachs to produce a color change during an esophageal intubation. Avoid this false positive condition by providing six ventilations prior to attaching a CO₂ detector device to check for the presence of exhaled carbon dioxide.

Following intubation during CPA, provide 10 ventilations per minute (or 1 ventilation every 6 seconds) while performing asynchronous continuous chest compressions at a rate of 100 to 120 compressions per minute.⁸ Excessive ventilations during CPR can impede venous return, potentially compromising cardiac output during CPR.⁹

During the resuscitation, the clinician must continuously reassess the adequacy of ventilations via the ETT. Clinical deterioration suggests ETT complications which can be quickly and systematically assessed via the “D-O-P-E” mnemonic.¹⁰

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  D = Dislodged or displaced ETT (esophageal intubation or right mainstem displacement)

  
  
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  O = Obstructed ETT (kinked tube or internal obstruction with blood, mucus, and/or emesis)

  
  
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  P = Pneumothorax (tension)

  
  
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  E = Equipment failure (disconnected tubing, too small ETT with air leak, and/or inadequate volume of ventilations)

Intravenous (IV) or intraosseous (IO) access is the preferred method of medication administration during any resuscitation. Although a few medications (i.e., “L-A-N-E” = lidocaine, atropine, naloxone, and epinephrine) can be administered via the ETT during a resuscitation, lower blood concentrations result when administered via the ETT, which may produce adverse transient β-effects (hypotension and lower coronary perfusion pressure).⁷ In infants and younger children, the preferred IO site is the flat-medial portion of the proximal tibia (i.e., 2–3 cm below the tibial tuberosity). Alternative sites for older children are the distal tibia (i.e., 2–3 cm proximal to the medial malleolus) or the proximal humerus.¹¹ Any medication that can be given via the IV route can also be administrated via the IO route in all ages.

ESTIMATION OF A CHILD’S WEIGHT FOR MEDICATION ADMINISTRATION

Difficulties encountered during a pediatric resuscitation include medication calculations, which are always based on a child’s weight, and selection of appropriate-size equipment (i.e., ETT, IV catheter sizes, chest tube sizes). Parent and physician weight estimations can be error prone. One quick method for estimating a child’s weight is based on the child’s age, and can be reviewed in Table 21-3.¹²

Length-based weight estimation tapes (i.e., Broselow tape) are recommended by PALS. They also calculate medication doses and device sizes, reducing the potential for errors. The validity of length-based tapes has been re-verified in studies.^13,14 A previous study claims that a length-based tape inaccurately estimated the actual weight in up to one-third of children.¹⁵ There are some weight estimate error concerns raised for obese and cachectic children. The addition of body habitus assessments to length-based systems has demonstrated more accurate weight estimations.¹⁶