PEDIA ADVANCE CARDIAC LIFE SUPPORT

NORMAL HEART ANATOMY AND PHYSIOLOGY

 The heart is a hollow muscle comprised of four chambers surrounded by

thick walls of tissue (septum).
 The atria are the two upper chambers, and the ventricles are the two lower
chambers.
 The left and right halves of the heart work together to pump blood throughout
the body.
 The right atrium (RA) and the right ventricle (RV) pump deoxygenated blood
to the lungs where it becomes oxygenated. This oxygen-rich blood returns to
the left atrium (LA) and then enters the left ventricle (LV).
 The LV is the main pump that delivers the newly oxygenated blood to the rest
of the body. Blood leaves the heart through a large vessel known as the
aorta. Valves between each pair of connected chambers prevent the
backflow of blood.
INTRODUCTION

Pediatric BLS refers to the provision of CPR, with no devices or with bag-mask
ventilation or barrier devices until advanced life support (ALS) can be provided.
The population addressed in this chapter includes infants from birth to 1 year of
age and children from 1 to 8 years of age.

B - BASIC
C - CARDIOPULMONARY
L - LIFE
S - SUPPORT

The phase of cardiopulmonary resuscitatio n (CPR) and emergency cardiac care

that either
1. prevents circulatory or respiratory arrest or insufficiency by prompt
recognition and early intervention or by early entry into the emergency care
system or both
2. externally supports the circulation and respiration of a patient in cardiac
arrest through CPR.
When cardiac or respiratory arrest occurs, basic life support (BLS) should be
initiated by anyone present who is familiar with CPR.
Basic Life Support (BLS) utilizes CPR and cardiac defibrillation when an
Automated External Defibrillator (AED) is available. BLS is the life
support method used when there is limited access to advanced
interventions such as medications and monitoring devices.
A – Advance ACLS - is the use of medical equipment to
C – Cardiac maintain breathing and circulation for the
L – Life Victim of a Cardiac Emergency
S - Support

Introduction
In contrast to adults, cardiac arrest in infants and children does not usually result from a
primary cardiac cause.
More often it is the terminal result of progressive respiratory failure or shock, also called an
asphyxial arrest. Asphyxia begins with a variable period of systemic hypoxemia, hypercapnea,
and acidosis, progresses to bradycardia and hypotension, and culminates with cardiac arrest.

Cardiac arrest caused by asphyxiation (lack of oxygen in blood)

Carbon dioxide accumulates in the lungs while oxygen in the lungs is depleted resulting in
cardiac arrest.

Causes: drowning, choking, airway obstruction, sepsis, shock

 ASPHYXIAL CARDIAC ARREST

One large pediatric study demonstrated that CPR with chest compression and mouth-to-
mouth rescue breathing is more effective than compression alone when the arrest was from a
noncardiac etiology

Ventilations are more important during resuscitation from asphysia-induced arrest, than during
resuscitation from VF or pulseless VT
SHOCK
Shock results from inadequate blood flow and oxygen delivery to meet tissue metabolic
demands.
The most common type of shock in children is hypovolemic, including shock due to
hemorrhage.
Distributive, cardiogenic, and obstructive shock occur less frequently.
Shock progresses over a continuum of severity, from a compensated to a decompensated
state.
Compensatory mechanisms include tachycardia and increased systemic vascular resistance
(vasoconstriction) in an effort to maintain cardiac output and perfusion pressure respectively.
Decompensation occurs when compensatory mechanisms fail and results in hypotensive
shock.

Typical signs of compensated shock include:

● Tachycardia
● Cool and pale distal extremities
● Prolonged (2 seconds) capillary refill (despite warm ambient temperature)
● Weak peripheral pulses compared with central pulses
● Normal systolic blood pressure As compensatory mechanisms fail, signs of inadequate end-
organ perfusion develop. In addition to the above, these signs include
● Depressed mental status
● Decreased urine output
● Metabolic acidosis
● Tachypnea
● Weak central pulses
● Deterioration in color

- Tachycardia is a common sign of shock, but it can also result from other causes, such
as pain, anxiety, and fever.
- Pulses are weak in hypovolemic and cardiogenic shock, but may be bounding in
anaphylactic, neurogenic, and septic shock.
- Blood pressure may be normal in a child with compensated shock but may decline
rapidly when the child decompensates.
PEDIATRIC CARDIAC ARREST

Pediatric cardiopulmonary arrest results when respiratory failure or shock is not identified and
treated in the early stages.

Early recognition and intervention prevents deterioration to cardiopulmonary arrest and

probable death.

Pediatric cardiac arrest is :

 Uncommon
 Rarely sudden cardiac arrest caused by primary
cardiac arrhythmias.
 Most often asphyxial, resulting from the
progression of respiratory failure or shock or
both.

Circulation
 Circulation reflects perfusion.
 Shock is a physiologic state where delivery of
oxygen and substrates are inadequate to meet
tissue metabolic needs.

Circulatory Assessment
 Heart rate is the most sensitive parameter for
determining perfusion and oxygenation in
children.
 Heart rate needs to be at least 60 beats per
minute to provide adequate perfusion.
 Heart rate greater than 140 beats per minute at
rest needs to be evaluated.
 Pulse quality reflects cardiac output.
 Capillary refill measures peripheral perfusion.
 Temperature and color of extremities proximal
versus distal.
Blood Pressure

 25 of blood volume must be lost before a drop in

blood pressure occurs.
 Minimal changes in blood pressure in children may
indicate shock.

ARRHYTHMIAS

- Bradycardia with pulse

- Tachycardia with pulses and adequate perfusion
- Pulseless arrest
 VF/VT
 Asystole
Defibrillators

Defibrillators are either manual or automated

(AED), with monophasic or biphasic
waveforms. AEDs in institutions caring for
children at risk for arrhythmias and cardiac
arrest (eg, hospitals, EDs) must be capable
of recognizing pediatric cardiac rhythms and
should ideally have a method of adjusting the
energy level for children.
 DEFIBRILLATION
Children with sudden witnessed collapse (eg, a child collapsing during an athletic event)
are likely to VF or pulseless VT and need immediate CPR and rapid defibrillation.

VF and pulseless VT are referred to as “shockable rhythms” because they respond to

electric shocks.

VT – ventricular tachycardia
VF – ventricular fibrillation

DEFIBRILLATION DOSING

The recommended first energy dose for defibrillation is 2 J/kg.

If second dose is required, it should be doubled to 4 J/kg.

AED with pediatric attenuator is preferred for children < 8 years of age.

DEFIBRILLATION SEQUENCE

1. Turn AED on
2. Follow the AED prompts
3. End CPR cycle (for analysis and shock)
4. Resume chest compressions immediately after the shock.
5. Minimize interruptions in chest compressions.
6. State CLEAR when giving the shock and have visual / verbal communication with any
other rescue personal

DEFIBRILLATOR GUIDELINES

AHA recommends that automatic external defibrillation be use in children with sudden
collapse or presumed cardiac arrest who are older than 8 years of age or more than 25 kg
and are 50 inches tall.

Electrical energy is delivered by a fixed amount range 150 to 200.

(2-4J/kg)
TACHYCARDIA WITH PULSES

- Supraventricular tachycardia

- History:
vague, non-specific, history of abrupt rate change

- P waves absent or normal

- HR not variable with activity

- Infants: rate > 220/min

- Children: rate > 180/min

BRADYCARDIA WITH POOR PERFUSION

•If pulse is less than 60 per minutes and there are signs of poor perfusion
• Pallor
• Mottling
• cyanosis

despite support of oxygenation and ventilation – start CHEST COMPRESSION

BRADYCARDIA
The most common dysrhythmia in the pediatric population. Etiology is usually hypoxemia

Initial management: ventilation and oxygenation.

If this does not work IV or IO epinephrine 0.01 mg / kg (1:10,000)

ET tube (not recommended)

0.1 mg / kg
PULSELESS ARREST

 Ventricular fibrillation / ventricular tachycardia

 Asystole

As soon as the child is found to be unresponsive with no breathing, call for help, send for a
defibrillator, and start CPR (with supplementary oxygen if available). Attach ECG monitor or
AED pads as soon as available. Throughout resuscitation, emphasis should be placed on
provision of high-quality CPR

While CPR is being given, determine the child’s cardiac rhythm from the ECG or, if you are
using an AED, the device will tell you whether the rhythm is “shockable” (eg VF or rapid
VT) or “not shockable” (eg, asystole or PEA). It may be necessary to temporarily interrupt
chest compressions to determine the child’s rhythm. Asystole and bradycardia with a wide
QRS are most common in asphyxial arrest.

VF and PEA are less common but VF is more likely to be present in older children with
sudden witnessed arrest.

MANAGEMENT
- Consider vagal maneuvers
- Establish vascular access
- Adenosine
 First dose 0.1 mg/kg IV (maximum of 6 mg)
 Second dose 0.2 mg/kg IV (maximum of 12 mg)

Synchronized cardioversion: 0.5 to 1 J / kg

ASYSTOLE     

- No Rhythm
- No rate
- No P wave
- No QRS comples
PULSELESS ARREST – ASYSTOLE

CAB: Start CPR

- Give oxygen when available

- Attach monitor / defibrillator
- Check rhythm / check pulse

- If asystole give epinephrine 0.01 mg / kg of 1:10,000

- Resume CPR may repeat epinephrine every 3-5 minutes until shockable rhythm is seen

PULSELESS ARREST – VF AND VT

- Start CAB
- Give oxygen
- Attach monitor / defibrillator
- Check rhythm: VF / VT
- Give one shock at 2 J/kg If still VF / VT
- Give 1 shock at 4 J/kg
- Give Epinephrine 0.01 mg/kg of 1:10,000
- Consider: amiodarone at 5 mg / kg

PALS DRUGS
 If CPR is in progress, stop chest compressions briefly, administer the medications, and follow
with a flush of at least 5 mL of normal saline and 5 consecutive positive-pressure ventilations.
Optimal endotracheal doses of medications are unknown; in general expert consensus
recommends doubling or tripling the dose of lidocaine, atropine or naloxone given via the ETT.
For epinephrine, a dose ten times the intravenous dose (0.1 mg/kg or 0.1 mL/kg of 1:1000
concentration) is recommended
EPINEPHRINE

Action: increase heart rate, peripheral vascular resistance and cardiac output; during CPR
increase myocardial and cerebral blood flow.

Dosing: 0.01 mg / kg 1: 10,0000

AMIODARONE

Used in atrial and ventricular antiarrhythmic

Action: slows AV nodal and ventricular conduction, increase the QT interval and may
cause vasodilation.

Dosing: IV/IO: 5 mg / kg bolus Used in pulseless arrest

 ADENOSINE

Drug of choice of symptomatic SVT

Action: blocks AV node conduction for a few seconds to interrupt AV node re-entry

Dosing

• First dose: 0.1 mg/kg max 6 mg

• Second dose: 0.2 mg/kg max 12 mg
• Used in tachycardia with pulses after synchronized cardioversion

POST- RESUSCITATION CARE

 Re-assessment of status is ongoing.
 Laboratory and radiologic information is obtained.
 Etiology of respiratory failure or shock is determined.
 Transfer to facility where child can get maximum care .