Pediatric Cardiac Arrest Algorithm
Shout for Help/Activate Emergency Response
1
Start CPR
Give oxygen
Attach monitor/defibrillator
Yes No
2 Rhythm shockable?
VF/VT 9 Asystole/PEA
3
Shock
4
CPR 2 min
IO/IV access
No
Rhythm shockable?
Yes
5
Shock 10
6 CPR 2 min
CPR 2 min IO/IV access
Epinephrine every 3-5 min Epinephrine every 3-5 min
Consider advanced airway Consider advanced airway
No Yes
Rhythm shockable? Rhythm shockable?
Yes
7 Shock No
8
11
CPR 2 min
CPR 2 min
Amiodarone
Treat reversible causes Treat reversible causes
No Yes
Rhythm shockable?
12
Asystole/PEA → 10 or 11
Organizes rhythm → check pulse Go to
Pulse present (ROSC) → post-cardiac arrest care 5 or 7
Doses/Details for the
Pediatric cardiac arrest Algorithm
CPR Quality Advanced Airway
Push hard (≥ /3 of anterior-posterior
1
Endotracheal intubation or supraglottic
diameter of chest) and fast (at least advanced airway
100/min) and allow complete chest recoil Waveform capnography or capnometry to
Minimize interruptions in compressions confirm and monitor ET tube placement
Avoid excessive ventilation Onece advanced airway in place, give 1
Rotate compressor every 2 minutes breath every 6-8 seconds (8-10 breaths per
If no advanced airway, 15:2 compression- minute).
ventilation ratio. If advanced airway, 8-10
breaths per minute with continous chest Return of Spontaneous
compressions Circulation (ROSC)
Pulse and blood pressure
Shock Energy Spontaneous waves with intra-arterial
For Defibrillation monitoring
First shock 2 J/kg,
second shock 4 J/kg, Reversible Causes
subsequent shocks ≥4 J/kg, - Hypovolemia
maximum 10 J/kg or adult dose. - Hypoxia
- Hydrogen ion (acidosis)
Drug Therapy - Hypoglycemia
Epinephrine IO/IV Dose : - Hypo-/hyperkalemia
0.01 mg/kg (0.1 mL/kg of 1:10 000 - Hypothermia
concentration). Repeat every 3-5 minutes. - Tension pneumothorax
If no IO/IV access, may give endotracheal - Tamponade, cardiac
dose : - Toxins
0.1 mg/kg (0.1 mL/kg of 1:1000 - Thrombosis, pulmonary
concentration). - Thrombosis, coronary
Amiodarone IO/IV Dose :
5 mg/kg bolus during cardiac arrest. May
repeat up to 2 times for refractory
VF/pulseless VT.
PALS Systematic Approach Algorithm
Initial Impression
(consciousness, breathing, color)
Is child unresponsive with no breathing or only gasping ?
Yes
No
Shout for Help/Activate
Emergency Response
(as appropriate
for setting)
Yes Open airway and begin
Is there
ventilation and oxygen
a pulse?
as available
No
Is the pulse <60/min
Yes No
with poor perfusion
despite oxygenation
and ventilation ?
If at any time you
Start CPR indentify cardiac arrest Evaluate
(C-A-B) Primary assessment
Secondary assessment
Diagnostic tests
Go to
Pediatric Cardiac Arrest
Algorithm
Intervene Identify
After ROSC, begin
Evaluate-Identify-Intervene
sequence (right column)
Pediatric Bradycardia With a Pulse
And Poor Perfusion Algorithm
Identify and treat underlying cause
Maintain patent airway; assist breathing as necessary
Oxygen
Cardiac monitor to identify rhythm; monitor blood pressure and oximetry
IO/IV access
12-Lead ECG if available; don’t delay therapy
No Cardiopulmonary Cardiaopulmonary
compromise Compromise
continues? Hypotension
Acutely altered
mental status
Yes
Signs of shock
CPR if HR <60/min
with poor perfusion despite
oxygenation and ventilation
Support ABCs
Give oxygen No Bradycardia
Observe
persists
Consider expert
consultation
Yes
Doses/Details
Epinephrine
Atropine for increased vagal Epinephirine IO/IV Dose :
tone or primary AV block 0.01 mg/kg (0.1 mL/kg of
Consider transthoracic 1 : 10 000 concentration).
pacing/transvenous pacing Repeatevery 3-5 minutes.
Treat underlying causes If IO/IV access not
available but endotracheal
(ET) tube in place, may
give ET dose: 0.1 mg/kg
(0.1 mL/kg of 1 : 1000).
Atropine IO/IV Dose :
If pulseless arrest
0.02 mg/kg. May repeat
develops, go to Cardiac
once. Minimum dose 0.1
Arrest Algorithm
mg and maximum single
dose 0.5 mg.
Pediatric Tachycardia With a Pulse
and Poor Perfusion Algorithm
Identify and treat underlying cause Doses/Details
Maintain patent airway; assist breathing as necessary Synchronized
Oxygen Cardioversion :
Begin with 0.5-1 J/kg;
Cardiac monitor to identify rhythm; monitor blood
if not effective,
pressure and oximetry
increase to 2 J/kg.
IO/IV access Sedate if needed,but
12-Lead ECG if available; don’t delay therapy don’t delay
cardioversion.
Narrow Wide Adenosine
(≤0.09 sec) Evaluate (>0.09 sec) IV/IO Dose :
QRS First dose:
duration 0.1 mg/kg rapid bolus
Evaluate rhythm (maximum: 6 mg).
with 12-lead ECG Second dose: 0.2
or monitor mg/kg rapid bolus
(maximum second
dose: 12 mg).
Amiodarone
Probable Probable Possible IV/IO Dose:
sinus supraventricular ventricular 5 mg/kg over
tachycardia tachycardia tachycardia 20-60 minutes
Compatible Compatible history or
history Procainamide
(vague, nonspecific);
IV/IO Dose:
consistent with history of abrupt
15 mg/kg over
known cause rate changes 30-60 minutes
P waves P waves absent/ Do not routinely
present/normal abnormal administer
Variable R-R; HR not variable amiodarone and
constant PR procainamide
Infants : Infants: rate usually together
rate usually ≥220/min
<220/min
Children : rate Children: rate Cardiopulmonary
usually <180/min usually ≥180/min compromise?
Hypotension
No
Acutely altered
mental status
Signs of shock
Yes
Search for Consider Synchronized Consider
and vagal cardioversion adenosine
treat cause maneuvers if rhythm regular
(No delays) and QRS
monomorphic
Expert
If IO/IV access present, give adenosine
consultation
OR
advised
If IO/IV access not available, or if adenosine
Amiodarone
ineffective, synchronized cardioversion
Procainamide
PALS Postresuscitation Care
Management of Shock After ROSC Estimation of
Maintenance Fluid
Optimize Ventilation and Oxygenation
Requirements
Titrate FIO2 to maintain oxyhemoglobin saturation
94%-99%; if possible, wean FIO2 if saturation is 100% Infants <10 kg:
Consider advanced airway placement and 4 mL/kg per hour
waveform capnography Example: for an 8-kg infant,
estimated maintenance
fluid rate
= 4mL/kg per hour x 8 kg
Assess for and *Possible = 32 mL per hour
treat Persistent Shock Contributing Factors Children 10-20 kg:
Identify, treat Hypovolemia 4 mL/kg per hour for the first
contributing Hypoxia 10 kg + 2 mL/kg per hour for
factors.* Hydrogen ion (acidosis) each kg above 10 kg
Consider 20 mL/kg IV/IO Hypoglycemia Example: For a 15-kg child,
boluses of isotonic Hypo-/hyperkalemia estimated maintenance fluid
crystalloid. Consider Hypothermia rate
smaller boluses (eg, 10 Tension pneumothorax = (4 mL/kg per hour x 10 kg) +
mL/kg) if poor cardiac Tamponade, cardiac (2 mL/kg per hour x 5 kg)
function suspected. Toxins = 40 mL/hour + 10 mL/hour
Consider the need for Thrombisis, pulmonary = 50 mL/hour
inotropic and/or Thrombosis, coronary Children >20 kg: 4 mL/kg per
vasopressor support for Trauma hour for the first 10 kg + 2
fluid-refractory shock. mL/kg per hour for kg 11-20 +
1 mL/kg per hour for each kg
above 20 kg.
Example: for a 28-kg child,
estimated maintenance fluid
rate
Hypotensive Shock Normotensive Shock = (4 mL/kg per hour x 10 kg) +
Epinephrine Dobutamine (2 mL/kg per hour x 10 kg) +
Dopamine Dopamine (1 mL/kg per hour x 8 kg)
Norepinephrine Epinephrine = 40 mL/hour + 20 mL/hour +
Milrinone 8 mL/hour
= 68 mL per hour
Following initial stabilization,
adjust the rate and composition
of intravenous fluids based on
the patient’s clinical condition
Monitor for and treat agitation and siezures and state of hydration. In
Monitor for and treat hypoglycemia general, provide a continuous
Assess blood gas, serum electrolytes, calcium infusion of a dextrose-containing
If patient remains comatose after resuscitation solution for infants. Avoid
from cardiac arrest, consider therapeutic hypotonic solutions in critically ill
hypothermia (32°C-34°C) children; for most patients use
Consider consultation and patient transport to isotonic fluid such as normal
tertiary care center saline (0.9% NaCl) or lactated
Ringer’s solution with or without
dextrose, based on the child’s
clinical status.
