Despite the use of cardiopulmonary resuscitation (CPR), mortality rates for out-of-hospital cardiac arrest are about 90% for infants and children. Mortality rates for in-hospital cardiac arrest for infants and children are about 65%. The mortality rate is 20 to 25% for respiratory arrest alone. Neurologic outcome is often severely compromised.
Pediatric resuscitation protocols are different for infants and children. Infant guidelines apply to those < 1 year of age, and child protocols are used from age 1 year up to a weight of 55 kg or the presence of signs of puberty (defined as appearance of breasts in females and axillary hair in males). Adult resuscitation protocols apply to children past the age of puberty or children weighing > 55 kg. About 50 to 65% of children requiring CPR are < 1 year; of these, most are < 6 months.
Neonatal resuscitation used in the immediate perinatal period is discussed elsewhere. About 6% of neonates require resuscitation at delivery; the incidence increases significantly if birth weight is < 1500 g.
Standardized outcome guidelines should be followed in reporting outcomes of CPR in children; eg, the modified Pittsburgh Outcome Categories Scale reflects cerebral and overall performance (see table Pediatric Cerebral Performance Category Scale).
Pediatric Cerebral Performance Category Scale*
Score | Category | Description |
|---|---|---|
1 | Normal | Age-appropriate level of functioning In preschool-aged children, appropriate development In school-aged children, attendance in regular classes |
2 | Mild disability | Can interact at an age-appropriate level Minor neurologic disease that is controlled and does not interfere with daily functioning (eg, seizure disorder) In preschool-aged children, possibly minor developmental delays, but with > 75% of all daily living developmental milestones above the 10th percentile In school-aged children, attendance in regular school but in a grade that is not appropriate for age or in the appropriate grade but failing because of cognitive difficulties |
3 | Moderate disability | Below age-appropriate functioning Neurologic disease that is not controlled and severely limits activities In preschool-aged children, most daily living developmental milestones below the 10th percentile In school-aged children, can do ADLs but attend special classes because of cognitive difficulties or a learning deficit |
4 | Severe disability | In preschool-aged children, ADLs milestones below the 10th percentile and excessive dependence on others for activities of daily living In school-aged children, possibly severe impairment that prevents school attendance and dependence on others for ADLs In preschool-aged and school-aged children, possibly abnormal motor movements, including nonpurposeful, decorticate, or decerebrate responses to pain |
5 | Coma or vegetative state | Unawareness |
6 | Death | ― |
* Worst level of performance for any single criterion is used for categorizing. Deficits are scored only if they result from a neurologic disorder. Assessments are based on medical records or an interview with the caretaker. | ||
Adapted from Fiser DH. Assessing the outcome of pediatric intensive care. J Pediatr 121(1):68-74, 1992. doi:10.1016/s0022-3476(05)82544-2 | ||
ADLs = activities of daily living. | ||
Standards and guidelines for CPR from the American Heart Association are followed (see table Child and Infant CPR Techniques for Health Care Practitioners). For protocol after an infant or child has collapsed with possible cardiac arrest, see figure Pediatric comprehensive emergency cardiac care.
Child and Infant CPR Techniques for Health Care Practitioners
Age Group | One-Rescuer CPR | Two-Rescuer CPR | Breath Size |
|---|---|---|---|
Children (1 year––puberty)* | 2 breaths (1 second each) after every 30 chest compressions at 100–120/minute | 2 breaths (1 second each) after every 15 chest compressions at 100–120/minute † | Small breaths (enough to make chest rise) |
Infants (< 1 year, excluding newborns) | 2 breaths (1 second each) after every 30 chest compressions at 100–120/minute | 2 breaths (1 second each) after every 15 chest compressions at 100–120/minute † | Only small puffs from the rescuer’s cheeks |
* Puberty is defined as the appearance of breasts in females and axillary hair in males. | |||
† Breaths are given without stopping chest compressions. | |||
After CPR has been started, defibrillation and identification of the underlying cardiac rhythm are done.
Pediatric comprehensive emergency cardiac care
* If an adequate number of trained personnel are available, patient assessment, CPR, and activation of the emergency response system should occur simultaneously. |
Based on the Comprehensive Emergency Cardiac Care Algorithm from the American Heart Association. |
Major Differences Between Pediatric and Adult CPR
Prearrest
Bradycardia in a distressed child is a sign of impending cardiac arrest. Neonates, infants, and young children are more likely to develop bradycardia caused by hypoxemia, whereas older children initially tend to have tachycardia. An infant or child with a heart rate < 60/minute and signs of poor perfusion that do not rise with ventilatory support should have cardiac compressions (see figure Chest compression). Bradycardia secondary to heart block is unusual.
Chest compressions
During chest compressions in infants and children (below the age of puberty or < 55 kg), the chest should be depressed one third of the anteroposterior diameter. This is about 4 to 5 cm. In adolescents or children > 55 kg, the recommended compression depth is the same as in adults, ie, 5 to 6 cm (see also chest compressions in adults).
Method of chest compression is also different in infants and children and is illustrated below. The rate of compression in infants and children is similar to that of adults at 100 to 120 compressions/minute.
Chest compression in infants and children
A: When 2 rescuers are present, side-by-side thumb placement for chest compressions is preferred for neonates and small infants whose chest can be encircled. Thumbs should overlap if used in very small neonates. B: Lone rescuers can use 2 fingers for infant compressions. Fingers should be maintained in the upright position during compression. For neonates, this technique results in too low a position, ie, at or below the xiphoid; the correct position is just below the nipple line. C: Hand position for chest compression for a child. (Adapted from American Heart Association: Standards and guidelines for CPR. Journal of the American Medical Association 268:2251–2281,1992. Copyright 1992, American Medical Association.) |
Drugs
ventricular fibrillation (VF) or pulseless ventricular tachycardia
Blood pressure
Blood pressure (BP) should be measured with an appropriate-sized cuff, but direct invasive arterial BP monitoring is mandatory in severely compromised children.
Because BP varies with age, an easy guideline to remember the lower limits of normal for systolic BP (< 5th percentile) by age is as follows:
< 1 month: 60 mm Hg
1 month to 1 year: 70 mm Hg
> 1 year: 70 + (2 × age in year)
Thus, in a 5-year-old child, hypotension would be defined by a BP of < 80 mm Hg (70 + [2 × 5]). Of significant importance is that children maintain BP longer because of stronger compensatory mechanisms (increased heart rate, increased systemic vascular resistance). Once hypotension occurs, cardiorespiratory arrest may rapidly follow. All effort should be made to start treatment when compensatory signs of shock (eg, increased heart rate, cool extremities, capillary refill > 2 seconds, poor peripheral pulses) are present but before hypotension develops.
Equipment and environment
Equipment size, drug dosage, and CPR parameters vary with patient age and weight (see tables CPR Techniques for Health Care Practitioners, Drugs for Resuscitation in Infants and Children, and Guide to Pediatric Resuscitation). Size-variable equipment includes defibrillator paddles or electrode pads, masks, ventilation bags, airways, laryngoscope blades, endotracheal tubes, and suction catheters. Weight should be measured rather than guessed; alternatively, commercially available measuring tapes that are calibrated to read standard patient weight based on body length can be used. Some tapes are printed with the recommended drug dose and equipment size for each weight. Dosages should be rounded down; eg, a 2 ½-year-old child should receive the dose for a 2-year-old child.
Drugs for Resuscitation in Infants and Children*
Drug † | Pediatric Dose | Comments |
|---|---|---|
0.1 mg/kg initially, then 0.2 mg/kg × 2 (maximum single dose 12 mg) | Rapid IV push is followed by flush. | |
For VF/pulseless VT: 5 mg/kg IV push over 2 minutes For perfusing VT: 5 mg/kg over 20–60 minutes, may repeat twice to a maximum of 15 mg/kg/day | — | |
0.02 mg/kg, repeat once in 3–5 minutes if needed, minimum dose 0.1 mg | Minimum dose is 0.1 mg. Maximum single dose is 0.5 mg. | |
20 mg/kg | 10% solution contains 100 mg/mL. | |
60–100 mg/kg | 10% solution contains 100 mg/mL. | |
2–5 mcg/kg/minute increasing as needed to maximum 20 mcg/kg/min | 500 mg in 250 mL 5% D/W gives 2000 mcg/mL. | |
2–5 mcg/kg/minute increasing as needed to maximum 20 mcg/kg/minute | 400 mg in 250 mL 5% D/W gives 1600 mcg/mL. | |
Bolus: 0.01 mg/kg repeated every 3–5 minutes as needed Infusion: 0.1–1.0 mcg/kg/minute | 8 mg in 250 mL 5% D/W gives 32 mcg/mL. | |
Glucose | 0.5–1 g/kg | Avoid high concentrations in infants and young children. 5% D/W: Give 10–20 mL/kg. 10% D/W: Give 5–10 mL/kg. 25% D/W: Give 2–4 mL/kg. For older children, use a large vein. |
1 mg/kg loading dose, then 20–50 mcg/kg/minute infusion | ||
Magnesium sulfate | 25–50 mg/kg given over 2–5 minutes to a maximum of 2 g | — |
0.1 mg/kg if patients are < 20 kg or <5 years | Repeat as needed. | |
Infusion: Starting with 0.05–0.1 mcg/kg/minute (maximum dose 2 mcg/kg/minute) | 8 mg in 250 mL 5% D/W gives 32 mcg/mL. | |
Infusion: 0.1–0.5 mcg/kg/minute | 10 mg in 250 mL 5% D/W gives 40 mcg/mL. | |
15 mg/kg over 30–60 minutes | Not recommended for pulseless arrest in children | |
1 mEq/kg | Infuse slowly and only when ventilation is adequate. 4.2% contains 0.5 mEq/mL; 8.4% contains 1 mEq/mL. | |
* For indications and use, see text. | ||
† IV or intraosseous. | ||
= ventricular fibrillation; VT = ventricular tachycardia. | ||
Guide to Pediatric Resuscitation—Mechanical Measures
Age (yr) | Term neonate | < 12 mo | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Weight, typical (kg) | 3.5 | < 10 | 10 | 12 | 14 | 16 | 18 | 20 | 22 | 25 | 28 | 30 | 35 | 40 | 45 | 50 | 55 | 60 | |
Compression techniques | Thumb compression, hands around chest (preferred) or 2 fingers | 1 hand | 2 hands | ||||||||||||||||
Airway size (Portex) in cm | 000 | 00 | 00 | 0 | 0 | 7 | 7 | 7 | 7 | 7 | 7 | 7 | 7 | 7 | 8 | 8 | 8 | 8 | |
3.5 | 5 | 5 | 6 | 6 | |||||||||||||||
Masks in Laerdal sizes or equivalent | Circular 0/1 | Rendell- Baker type # 1 | Rendell-Baker type # 2 | Dome cuff mask # 3 | Dome cuff mask # 4 | ||||||||||||||
Ventilation bag with reservoir for 100% O2 delivery | Infant 240 mL | Child 400–500 mL | Adult 1600 mL | ||||||||||||||||
Laryngoscope blade size | Miller 0 Straight blade | 1 | 1 | 1 | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | |
Straight blade (preferred) or curved blade | Curved or straight blade | ||||||||||||||||||
ETT size (Portex) in mm | 3 | 3.5 | 4 | 4.5 | 4.5 | 5 | 5 | 5.5 | 5.5 | 6 | 6 | 6 | 6 | 6.5 | 6.5 | 6.5 | 6.5 | 7 | |
Uncuffed | Uncuffed | Cuffed | |||||||||||||||||
Suction catheter | Direct oropharyngeal Through ETT | 10 F | Pediatric tonsil suction 8 Fr | Adult tonsil suction 10 Fr | |||||||||||||||
ETT =endotracheal tube; Fr = French. | |||||||||||||||||||
Courtesy of Dr. B. Paes and Dr. M. Sullivan, the Departments of Pediatrics and Medicine, St. Joseph’s Hospital, The Children’s Hospital, Hamilton Health Sciences Corporation, McMaster University, Hamilton, Ontario, Canada. | |||||||||||||||||||
Temperature management
Susceptibility to heat loss is greater in infants and children because of a large surface area relative to body mass and less subcutaneous tissue. A neutral external thermal environment is crucial during CPR and postresuscitation. Hypothermia with core temperature < 35° C makes resuscitation more difficult.
For comatose children resuscitated from in-hospital and out-of-hospital cardiac arrest, recent American Heart Association and American Association of Pediatrics guidelines advise therapeutic hypothermia (32 to 36° C) or normothermia (36 to 37.5° C—1, 2 ). Fever should be treated aggressively.
Airway and ventilation
Upper airway anatomy is different in children. The head is large with a small face, mandible, and external nares, and the neck is relatively short. The tongue is large relative to the mouth, and the larynx lies higher in the neck and is angled more anteriorly. The epiglottis is long, and the narrowest portion of the trachea is inferior to the vocal cords at the cricoid ring, allowing the use of uncuffed endotracheal tubes. In younger children, a straight laryngoscope blade generally allows better visualization of the vocal cords than a curved blade because the larynx is more anterior and the epiglottis is more floppy and redundant. Current available evidence does not support improved patient outcomes from advanced airway interventions as compared to bag-mask ventilation in infants and children during out-of-hospital cardiac arrest.
If there is no advanced airway in place in infants and children undergoing resuscitation, the recommended compression:ventilation ratio is 30:2 if only a single rescuer is present and 15:2 if more than one rescuer is present. This recommendation is in contrast to adults where the compression:ventilation ratio is always 30:2 and is independent of the number of rescuers.
With an advanced airway in place, the 2020 International Liaison Committee on Resuscitation (ILCOR) guidelines for pediatric cardiac arrest resuscitation advise a ventilation rate of 20 to 30 breaths per minute (with the faster rate in infants—2). However, this revised recommendation is based on a study of hospitalized patients and remains controversial in prehospital care. Many researchers of pediatric prehospital care continue to advise a ventilation rate of 10-breaths per minute.
Defibrillation
Ventricular fibrillation (VF) and pulseless ventricular tachycardiasee defibrillation in adults). The maximum recommended dose is 10 joules/kg or the maximum adult dose (200 joules for a biphasic defibrillator and 360 joules for a monophasic defibrillator).
Automated external defibrillators (AEDs) with adult cables may be used for children, but an AED with pediatric cables (maximum biphasic shock of 50 joules) is preferred for pediatric patients up to 8 years of age. Current guidelines recommend manual defibrillation if possible for pediatric patients, but an AED (with or without pediatric cables) can be used if a manual defibrillator is not immediately available (2). For pad placement, see defibrillation in adults.
Treatment references
1. Granfeldt A, Holmberg MJ, Nolan JP, Soar J, Andersen LW; International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force: Targeted temperature management in adult cardiac arrest: Systematic review and meta-analysis. Resuscitation 167:160–172, 2021. doi:10.1016/j.resuscitation.2021.08.040
2. Maconochie IK, Aickin R, Hazinski MF, et al: Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 156:A120–A155, 2020. doi:10.1016/j.resuscitation.2020.09.013
More Information
The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
American Heart Association 2020 CPR and ECC Guidelines: These guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) are based on the most recent review of resuscitation science, protocols, and education.
