PALS Provider: Course

Pediatric Cardiac Arrest Algorithm

Cardiac arrest in children is most often caused by respiratory failure or shock, not primary cardiac events as in adults. Early recognition, high-quality CPR, timely epinephrine administration, and defibrillation when indicated are essential for survival.

Goals of Management

  • Restore circulation and oxygenation quickly
  • Defibrillate promptly for shockable rhythms
  • Identify and treat reversible causes (H’s and T’s)

Recognition of Cardiac Arrest

  • Unresponsive
  • No normal breathing or only gasping
  • No pulse within 10 seconds

Immediately activate emergency response and begin CPR. Retrieve an AED or defibrillator if available.

Cardiac Arrest Algorithm

Step 1: Initiate High-Quality CPR
  • Single rescuer: 30:2 compressions to breaths
  • Two rescuers: 15:2 compressions to breaths
  • Infants: At least 1.5 inches (4 cm) compression depth
  • Children: At least 2 inches (5 cm) compression depth
  • Rate: 100–120 compressions per minute
  • Advanced airway: Continuous compressions, 1 breath every 2–3 seconds
Step 2: Establish Access & Administer Epinephrine
  • Use IV or IO access—do not delay CPR for placement
  • Epinephrine 1:10,000: 0.01 mg/kg IV/IO every 3–5 minutes
  • If IV/IO unavailable, consider ETT route at 0.1 mg/kg
Step 3: Analyze Rhythm & Defibrillate if Shockable

Use AED or ECG to determine rhythm type:

Shockable Rhythm: VF/pVT
  • 1st shock: 2 J/kg
  • 2nd shock: 4 J/kg
  • Subsequent: 4 J/kg, up to 10 J/kg or adult dose
  • Resume CPR immediately after shock
  • Medications: Epinephrine + Amiodarone (5 mg/kg) or Lidocaine (1 mg/kg)
Non-Shockable Rhythm: Asystole/PEA
  • Continue CPR, administer epinephrine every 3–5 minutes
  • Begin search for reversible causes
Step 4: Identify & Treat Reversible Causes (H’s and T’s)

H’s: Hypoxia, Hypovolemia, Hydrogen ion (acidosis), Hypo/Hyperkalemia, Hypothermia

T’s: Tension pneumothorax, Tamponade, Toxins, Thrombosis (PE or MI)

Quick Reference Table

Step Action Key Notes
1 Start CPR 30:2 or 15:2, compression depth 4–5 cm
2 Establish IV/IO Access Epinephrine 0.01 mg/kg every 3–5 min
3 Analyze Rhythm Shockable = defibrillate; Non-shockable = continue CPR
4 Defibrillation 2 J/kg → 4 J/kg → up to 10 J/kg
5 Treat Reversible Causes H’s and T’s checklist

Post-Resuscitation Care (ROSC)

  • Ensure SpO₂ >94% but avoid hyperoxia
  • Support ventilation as needed; intubate if indicated
  • Continue fluid resuscitation or initiate inotropes
  • Monitor for seizures and consider targeted temperature management (TTM)

When to Consider Terminating Resuscitation

  • Prolonged asystole with no signs of ROSC
  • Failure to identify a reversible cause
  • Team consensus with family support based on prognosis

Note: Pediatric patients may survive prolonged resuscitation with favorable outcomes. Use clinical judgment carefully.

Summary

  • Begin high-quality CPR immediately upon recognition
  • Epinephrine should not be delayed in non-shockable rhythms
  • Defibrillate immediately for VF/pVT
  • Always evaluate for and address reversible causes
  • Post-ROSC care is essential to survival and neurological recovery