Part 12: Pediatric Advanced Life Support IV-17I TABLE 1. Medications for Pediatric Resuscitation and Arrhythmias Medication Dose Adenosine 0.1 mg/kg(maximum 6 mg) Monitor ecg Repeat: 0.2 mg/kg(maximum 12 mg) Rapid I/o bolus Amiodarone 5 mg/kg N/; repeat up to 15 mg/ Monitor ECG and blood pressure Maximum: 300 mg Adjust administration rate to urgency (give more slowly when perfusing rhythm present Use caution when administering with other drugs that olong OT (consider expert consultat Atropine 0.02 mg/kg I/o Higher doses may be used with organophosphate 0.03 mg/kg ET Repeat once if needed Minimum dose. Maximum single dose Child 0.5 mg Adolescent 1 mg Calcium chloride(10%) 20 mg/kg I/o (0.2 mL/kg) Adult dose: 5-10 mL 001mg/kg01 0000)M0 May repeat g 3-5 min 0.1mg/kg(0.1 000)ET Maximum dose 10 mg ET 0.5-1 g/kg IAO Bolus: 1 mg/kg I/o Infusion: 20-50 ug/kg per minute ET*: 2-3 mg Magnesium sulfate 25-50 mg/kg Nno over 10-20 min; faster in torsades Maximum dose: 2g Naloxone <5 y or s20 kg: 0.1 mg/kg I//ET Use lower doses to reverse respiratory depression ≥5yor>20kg:2 mg IV/O/E associated with therapeutic opioid use (1-15 ug/kg) Procainamide Monitor ECG and blood pressure Use caution when administering with other drugs that maximum dose 17 mg/kg prolong QT (consider expert consultation) 1 mEq/kg per dose N/O slowly After adequate ventilation I indicates intravenous; 10, intraosseous, and et, via endotracheal tube. *Flush with 5 mL of normal saline and follow with 5 ventilations or against hypertonic saline for shock associated with head Precautions injuries or hypovolemia( Class Indeterminate). 85,86 Monitor blood pressure and administer as slowly as the patients clinical condition allows; it should be administered Medications (See Table 1) slowly to a patient with a pulse but may be given rapidly to Adenosine a patient with cardiac arrest or ventricular fibrillation (VF) Adenosine causes a temporary atrioventricular(AV) nodal Amiodarone causes hypotension through its vasodilatory conduction block and interrupts reentry circuits that involve property. The severity of the hypotension is related to the the AV node. It has a wide safety margin because of its short infusion rate and is less common with the aqueous form of C A higher dose may be required for peripheral administra- Monitor the ecg because tion than central venous administration. 87, 88 Based on exper bradycardia, heart block, and torsades de pointes ventricular imental data89 and a case report, 90 adenosine may also be tachycardia (VT). Use extreme caution when administering given by 10 route. Administer adenosine and follow with a with another drug causing QT prolongation, such as procai rapid saline flush to promote flow toward the central amide. Consider obtaining expert consultation. Adverse ef- circulation fects may be long lasting because the half-life is days. 92 amiodarone Amiodarone slows AV conduction, prolongs the AV refrac- Atropine sulfate is a parasympatholytic drug that accelerates tory period and QT interval, and slows ventricular conduction Atropine (widens the Qrs). sinus or atrial pacemakers and increases AV conduction
or against hypertonic saline for shock associated with head injuries or hypovolemia (Class Indeterminate).85,86 Medications (See Table 1) Adenosine Adenosine causes a temporary atrioventricular (AV) nodal conduction block and interrupts reentry circuits that involve the AV node. It has a wide safety margin because of its short half-life. A higher dose may be required for peripheral administration than central venous administration.87,88 Based on experimental data89 and a case report,90 adenosine may also be given by IO route. Administer adenosine and follow with a rapid saline flush to promote flow toward the central circulation. Amiodarone Amiodarone slows AV conduction, prolongs the AV refractory period and QT interval, and slows ventricular conduction (widens the QRS). Precautions Monitor blood pressure and administer as slowly as the patient’s clinical condition allows; it should be administered slowly to a patient with a pulse but may be given rapidly to a patient with cardiac arrest or ventricular fibrillation (VF). Amiodarone causes hypotension through its vasodilatory property. The severity of the hypotension is related to the infusion rate and is less common with the aqueous form of amiodarone.91 Monitor the ECG because complications may include bradycardia, heart block, and torsades de pointes ventricular tachycardia (VT). Use extreme caution when administering with another drug causing QT prolongation, such as procainamide. Consider obtaining expert consultation. Adverse effects may be long lasting because the half-life is up to 40 days.92 Atropine Atropine sulfate is a parasympatholytic drug that accelerates sinus or atrial pacemakers and increases AV conduction. TABLE 1. Medications for Pediatric Resuscitation and Arrhythmias Medication Dose Remarks Adenosine 0.1 mg/kg (maximum 6 mg) Repeat: 0.2 mg/kg (maximum 12 mg) Monitor ECG Rapid IV/IO bolus Amiodarone 5 mg/kg IV/IO; repeat up to 15 mg/kg Maximum: 300 mg Monitor ECG and blood pressure Adjust administration rate to urgency (give more slowly when perfusing rhythm present) Use caution when administering with other drugs that prolong QT (consider expert consultation) Atropine 0.02 mg/kg IV/IO 0.03 mg/kg ET* Repeat once if needed Higher doses may be used with organophosphate poisoning Minimum dose: 0.1 mg Maximum single dose: Child 0.5 mg Adolescent 1 mg Calcium chloride (10%) 20 mg/kg IV/IO (0.2 mL/kg) Slowly Adult dose: 5–10 mL Epinephrine 0.01 mg/kg (0.1 mL/kg 1:10 000) IV/IO 0.1 mg/kg (0.1 mL/kg 1:1000) ET* Maximum dose: 1 mg IV/IO; 10 mg ET May repeat q 3–5 min Glucose 0.5–1 g/kg IV/IO D10W: 5–10 mL/kg D25W: 2–4 mL/kg D50W: 1–2 mL/kg Lidocaine Bolus: 1 mg/kg IV/IO Maximum dose: 100 mg Infusion: 20–50 g/kg per minute ET*: 2–3 mg Magnesium sulfate 25–50 mg/kg IV/IO over 10–20 min; faster in torsades Maximum dose: 2g Naloxone 5 y or 20 kg: 0.1 mg/kg IV/IO/ET* 5 y or 20 kg: 2 mg IV/IO/ET* Use lower doses to reverse respiratory depression associated with therapeutic opioid use (1–15 g/kg) Procainamide 15 mg/kg IV/IO over 30–60 min Adult dose: 20 mg/min IV infusion up to total maximum dose 17 mg/kg Monitor ECG and blood pressure Use caution when administering with other drugs that prolong QT (consider expert consultation) Sodium bicarbonate 1 mEq/kg per dose IV/IO slowly After adequate ventilation IV indicates intravenous; IO, intraosseous; and ET, via endotracheal tube. *Flush with 5 mL of normal saline and follow with 5 ventilations. Part 12: Pediatric Advanced Life Support IV-171
IV- 72 Circulation December 13. 2005 Precautions Procainamide Small doses of atropine(<0. I mg)may produce paradoxical Procainamide prolongs the refractory period of the atria and bradycardia. 93 Larger than recommended dose es ma ventricles and depresses conduction velocity quired in special circumstances(eg, organophosphate poi Precautions There is little clinical data on using procainamide in infants Calcium and children. 09, 110 Infuse procainamide very slowly while Routine administration of calcium does not improve outcome you monitor for hypotension, prolongation of the QT interval, of cardiac arrest. 95 In critically ill children, calcium chloride and heart block. Stop the infusion if the QRS widens to lay provide greater bioavailability than calcium gluconate.96 >50% of baseline or if hypotension develops Use extreme referably administer calcium chloride via a central venou caution when administering with another drug causing QT catheter because of the risk of sclerosis or infiltration with a prolongation, such as amiodarone. Consider obtaining expert peripheral venous line Epinephrine Sodium bicarbonate The a-adrenergic-mediated vasoconstriction of epinephrine The routine administration of sodium bicarbonate has not increases aortic diastolic pressure and thus coronary perfu- been shown to improve outcome of resuscitation(Class sion pressure, a critical determinant of successful Indeterminate). After you have provided effective ventilation resuscitation. 97.98 and chest compressions and administered epinephrine, you may consider sodium bicarbonate for prolonged cardiac arrest Precautio (Class IIb: LOE 6). Sodium bicarbonate administration may Administer all catecholamines through a secure line, prefer be used for treatment of some toxidrome(see"Toxicologic ably into the central circulation; local ischemia, tissue inJury, Emergencies, "below) or special resuscitation situations d ulceration may result from tissue infiltration. During cardiac arrest or severe shock, arterial blood ga Do not catecholamines with sodium bicarbonate analysis may not accurately reflect tissue and venous alkaline solutions inactivate them In patients with a perfusing rhythm, epinephrine causes tachycardia and may cause ventricular ectopy, tachyarrhythmias Precautions hypertension, and vasoconstriction. 9s Excessive sodium bicarbonate may impair tissue oxygen delivery I3: cause hypokalemia, hypocalcemia, hypernatre Glucose mia,and hyperosmolality. I5: decrease the vF threshold 6: Infants have high glucose requirements and low glycogen and impair cardiac function stores and develop hypoglycemia when energy requirements rise.100 Check blood glucose concentrations during and after vasopressin arrest and treat hypoglycemia promptly( Class Ilb: LOE 1 01 There is limited experience with the use of vasopressin in 7 [ most extrapolated from neonates and adult ICU studies]) pediatric patients, 7 and the results of its use in the treatment of adults with vf cardiac arrest have been inconsistent, 1l8-l2 Lidocaine There is insufficient evidence to make a recommendation for Lidocaine decreases automaticity and suppresses ventricular or against the routine use of vasopressin during cardiac arrest arrhythmias 02 but is not as effective as amiodarone for ( Class Indeterminate: LOE 57: 62,7-4[extrapolated improving intermediate outcomes (ie, return of spontaneous from adult literature)) circulation or survival to hospital admission) among adult patients with VF refractory to a shock and epinephrine. 03 Pulseless arrest Neither lidocaine nor amiodarone has been shown to improve In the text below, box numbers identify the corresponding survival to hospital discharge among patients with VF cardiac box in the algorithm(Figure 1.) If a victim becomes unresponsive(Box 1), start CPR immediately(with supplementary oxygen if available)and Precautions send for a defibrillator(manual or automated external defi- Lidocaine toxicity includes myocardial and circulatory de- brillator [AEDI). Asystole and bradycardia with a wide QRS pression, drowsiness, disorientation, muscle twitching, and seizures, especially in patients with poor cardiac output and and pulseless electrical activity(PEA) are less common[22 hepatic or renal failure. 104, 105 and more likely to be observed in children with sudden arrest. Magnesium If you are using an ECG monitor, determine the rhythm(Box There is insufficient evidence to recommend for or against 2); if you are using an AED, the device will tell you whether he routine administration of magnesium during cardiac arres the rhythm is"shockable"(ie, VF or rapid VT), but it may not Class Indeterminate). 106-108 Magnesium is indicated for the display the rhythm treatment of documented hypomagnesemia or for torsades de pointes(polymorphic VT associated with long QT interval). "Shockable Rhythm: VF/Pulseless VT (Box 3) Magnesium produces vasodilation and may cause hypoten- VF occurs in 5% to 15% of all pediatric victims of out-of sion if administered rapidly hospital cardiac arrest 23-125 and is reported in up to 20% of
Precautions Small doses of atropine (0.1 mg) may produce paradoxical bradycardia.93 Larger than recommended doses may be required in special circumstances (eg, organophosphate poisoning94 or exposure to nerve gas agents). Calcium Routine administration of calcium does not improve outcome of cardiac arrest.95 In critically ill children, calcium chloride may provide greater bioavailability than calcium gluconate.96 Preferably administer calcium chloride via a central venous catheter because of the risk of sclerosis or infiltration with a peripheral venous line. Epinephrine The -adrenergic-mediated vasoconstriction of epinephrine increases aortic diastolic pressure and thus coronary perfusion pressure, a critical determinant of successful resuscitation.97,98 Precautions Administer all catecholamines through a secure line, preferably into the central circulation; local ischemia, tissue injury, and ulceration may result from tissue infiltration. Do not mix catecholamines with sodium bicarbonate; alkaline solutions inactivate them. In patients with a perfusing rhythm, epinephrine causes tachycardia and may cause ventricular ectopy, tachyarrhythmias, hypertension, and vasoconstriction.99 Glucose Infants have high glucose requirements and low glycogen stores and develop hypoglycemia when energy requirements rise.100 Check blood glucose concentrations during and after arrest and treat hypoglycemia promptly (Class IIb; LOE 1101; 7 [most extrapolated from neonates and adult ICU studies]). Lidocaine Lidocaine decreases automaticity and suppresses ventricular arrhythmias102 but is not as effective as amiodarone for improving intermediate outcomes (ie, return of spontaneous circulation or survival to hospital admission) among adult patients with VF refractory to a shock and epinephrine.103 Neither lidocaine nor amiodarone has been shown to improve survival to hospital discharge among patients with VF cardiac arrest. Precautions Lidocaine toxicity includes myocardial and circulatory depression, drowsiness, disorientation, muscle twitching, and seizures, especially in patients with poor cardiac output and hepatic or renal failure.104,105 Magnesium There is insufficient evidence to recommend for or against the routine administration of magnesium during cardiac arrest (Class Indeterminate).106 –108 Magnesium is indicated for the treatment of documented hypomagnesemia or for torsades de pointes (polymorphic VT associated with long QT interval). Magnesium produces vasodilation and may cause hypotension if administered rapidly. Procainamide Procainamide prolongs the refractory period of the atria and ventricles and depresses conduction velocity. Precautions There is little clinical data on using procainamide in infants and children.109,110 Infuse procainamide very slowly while you monitor for hypotension, prolongation of the QT interval, and heart block. Stop the infusion if the QRS widens to 50% of baseline or if hypotension develops. Use extreme caution when administering with another drug causing QT prolongation, such as amiodarone. Consider obtaining expert consultation. Sodium Bicarbonate The routine administration of sodium bicarbonate has not been shown to improve outcome of resuscitation (Class Indeterminate). After you have provided effective ventilation and chest compressions and administered epinephrine, you may consider sodium bicarbonate for prolonged cardiac arrest (Class IIb; LOE 6). Sodium bicarbonate administration may be used for treatment of some toxidromes (see “Toxicologic Emergencies,” below) or special resuscitation situations. During cardiac arrest or severe shock, arterial blood gas analysis may not accurately reflect tissue and venous acidosis.111,112 Precautions Excessive sodium bicarbonate may impair tissue oxygen delivery113; cause hypokalemia, hypocalcemia, hypernatremia, and hyperosmolality114,115; decrease the VF threshold116; and impair cardiac function. Vasopressin There is limited experience with the use of vasopressin in pediatric patients,117 and the results of its use in the treatment of adults with VF cardiac arrest have been inconsistent.118 –121 There is insufficient evidence to make a recommendation for or against the routine use of vasopressin during cardiac arrest (Class Indeterminate; LOE 5117; 6121, 7118 –120 [extrapolated from adult literature]). Pulseless Arrest In the text below, box numbers identify the corresponding box in the algorithm (Figure 1.) If a victim becomes unresponsive (Box 1), start CPR immediately (with supplementary oxygen if available) and send for a defibrillator (manual or automated external defibrillator [AED]). Asystole and bradycardia with a wide QRS complex are most common in asphyxial cardiac arrest.1,23 VF and pulseless electrical activity (PEA) are less common122 and more likely to be observed in children with sudden arrest. If you are using an ECG monitor, determine the rhythm (Box 2); if you are using an AED, the device will tell you whether the rhythm is “shockable” (ie, VF or rapid VT), but it may not display the rhythm. “Shockable Rhythm”: VF/Pulseless VT (Box 3) VF occurs in 5% to 15% of all pediatric victims of out-ofhospital cardiac arrest123–125 and is reported in up to 20% of IV-172 Circulation December 13, 2005
Part 12: Pediatric Advanced Life Support Iv-173 PULSELESS ARREST BLS Algorithm: Continue CPR Attach monitor/defibrillator when available Check rhythm Shockable rhythm? VF/T Asystole/PEA Give 1 shock Manual: 2 J/kg me CPR immediately ediatric system if available Resume CPR immediately ndotracheal tube: 0. 1 mg/kg Repeat every 3 to 5 min Check rhythm Shockable rhythm? Shockable rhythm? Continue CPR while defibrillator f nual: 4 J/kg If electrical activity, check AED: >1 year of age pulse. If no pulse, go to Resume CPR immediately postresuscitation care (1:10000:0.1mL/kg Repeat every 3 to 5 minutes ve 5 cycles Check rhythm Shockable rhythm? During CPR Push hard and fast (100/min) Rotate co sors every 2 minutes Ensure full chest recoil Continue CPR while defibrillator Minimize interruptions in chest Search for and treat possible compressions contributing factors Give 1 shock One cycle of CPR: 15 compressions -Hypoxia AED: >1 year of age then 2 breaths: 5 Hydrogen ion (acidosis Avoid hyperventilation Consider antiarrhythmics Secure airway and confirm placement. (eg, amiodarone 5 mg/kg I/o or oxins lidocaine 1 mg/kg Iv/o After an advanced airway is placed. scuers no longer deliver"cycles torsades de pointe After 5 cycles of CPR' go to Box 5 above myth every 2 minut Figure 1. PALS Pulseless Arrest Algorithm pediatric in-hospital arrests at some point during the Defibrillators resuscitation. The incidence increases with age. 123, 125 De- Defibrillators are either manual or automated(AED), with fibrillation is the definitive treatment for VF(Class I) with monophasic or biphasic waveforms. For further informa an overall survival rate of 17% to 20%6.1 but in adults ion see Part lectrical Therapies: Automate the probability of survival declines by 7% to 10% for each Defibrillators, Defibrillation, Cardioversion, and Pacing. minute of arrest without cpr and defibrillation. 128 The Institutions that care for children at risk for arrhythmias decline in survival is more gradual when early CPR is and cardiac arrest (eg, hospitals, emergency departments) provided deally should have defibrillators available that are capable of
pediatric in-hospital arrests at some point during the resuscitation. The incidence increases with age.123,125 Defibrillation is the definitive treatment for VF (Class I) with an overall survival rate of 17% to 20%,125–127 but in adults the probability of survival declines by 7% to 10% for each minute of arrest without CPR and defibrillation.128 The decline in survival is more gradual when early CPR is provided. Defibrillators Defibrillators are either manual or automated (AED), with monophasic or biphasic waveforms. For further information see Part 5: “Electrical Therapies: Automated External Defibrillators, Defibrillation, Cardioversion, and Pacing.” Institutions that care for children at risk for arrhythmias and cardiac arrest (eg, hospitals, emergency departments) ideally should have defibrillators available that are capable of Figure 1. PALS Pulseless Arrest Algorithm. Part 12: Pediatric Advanced Life Support IV-173