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Pediatric Resuscitation

  • Author: James Stuart Booth, MD; Chief Editor: Ted Rosenkrantz, MD  more...
 
Updated: Apr 17, 2016
 

Background

Since the 1980s, significant advancements have been made in pediatric resuscitation training in the United States. In 1988, the American Heart Association (AHA) offered the first course in Pediatric Advanced Life Support (PALS). This course was designed for pediatric healthcare providers at all levels and taught basic approaches to pediatric cardiopulmonary arrest with a heavy emphasis on algorithms. In 1984, the American Academy of Pediatrics (AAP) and the American College of Emergency Physicians (ACEP) offered the first course in Advanced Pediatric Life Support (APLS). This course was designed to be more comprehensive and covered a spectrum of pediatric emergencies in addition to basic resuscitation. Over the last 20 years, these two programs have become the predominant courses required by hospitals across the United States for pediatric healthcare providers.

Overall survival to discharge in pediatric patients with an out-of-hospital cardiac arrest has remained low and relatively unchanged at 6%. These poor outcomes may be attributable in part to the fact that only one third to one half of these patients receives bystander cardiopulmonary resuscitation (CPR). Of those that survive out-of-hospital arrest, many suffer permanent brain injury. This is in contrast to the overall survival in pediatric patients with in-hospital cardiac arrests which has increased from 9% to 27%. This is believed to be attributable to earlier recognition and management of critical conditions, earlier CPR, and the implementation of medical emergency teams with specialists trained in the acute resuscitation of pediatric patients using the PALS and APLS algorisms.

In a pediatric resuscitation, understanding the anatomical differences from adults is paramount. They are most pronounced in children younger than 8 years.

Anatomy

The tongue is larger relative to the mouth and has a greater tendency to collapse and obstruct the airway. Tonsils are larger and may bleed with trauma. This makes blind nasotracheal intubation much more difficult in children. The epiglottis is larger, floppier, and more acutely angled, making it more likely to obstruct the view of the vocal cords during intubation. Because of this, a straight blade may be required. The larynx is higher, relative to adults. It is at C1 in infants, C3 in toddlers, and C6 in adults. It is also more anterior and more likely to collapse on inspiration. Avoid hyperextension of the neck and use a straight blade to help visualize the anatomy. The narrowest point of the airway in a child younger than 8 years is the cricoid cartilage, not the subglottic area. This makes correct tube size more important, especially if using an uncuffed tube. An infant's occiput is larger than an adult. For children younger than 2 years, a roll under the shoulders helps properly position theairway.For children older than 2 years, place a roll under the head to improve the view.

Pulses in an infant younger than 1 year should be palpated at the brachial artery on the medial aspect of the upper arm. For children older than 1 year, the neck should be long enough that the most accessible central artery will be the carotid. Infants have a lower functional residual capacity and higher oxygen consumption per minute giving them a greater tendency to become hypoxic.

In cases of airway edema, noxious stimuli may precipitate a respiratory arrest in a tenuous child. Keeping the child calm is extremely important in this situation. Because of their higher vagal tone, children are more prone to bradycardia with airway manipulation. Atropine may help blunt this effect (see Medications).

Normal vital signs vary by age. Basic guidelines are below:[1]

Heart rate

See the list below:

  • Neonate: 80-180 beats per minute (BPM)
  • 1 week to 1 month: 80-160 BPM
  • 3 month to 2 years: 80-150 BPM
  • 2-10 years: 75-110 BPM
  • 10 years to adult: 50-100 BPM

Respiratory rate

See the list below:

  • Term infant: 30-50 BPM
  • 1 -6 months: 20-40 BPM
  • 6 months to 2 years: 20-30 BPM
  • 2-12 years: 16-24 BPM
  • Adolescents: 12-20 BPM

Blood pressure

In children that require resuscitation, blood pressure may be normal. If the child appears ill, fluids and medications should not be delayed because the blood pressure remains normal. Hypotension in a child is often a sign of decompensated shock and reason for swift intervention. For the 2010 PALS guidelines, hypotension is defined as a systolic blood pressure:

  • < 60 mm Hg in term neonates (0-28 d)
  • < 70 mm Hg in infants (1-12 mo)
  • < 70 mm Hg + (2 × age in years) in children 1-10 years
  • < 90 mm Hg in children ≥10 years

Pediatric resuscitation is a broad topic. This article discusses basic principles in the recognition and management of pediatric cardiopulmonary arrest and its causes. For more information, see the following related topics:

Next

Indications

Respiratory failure and shock are the most common causes of cardiopulmonary arrest in the pediatric population. These tend to be progressive conditions in which a period of time is observed between the onset of illness and the clinical deterioration into full cardiopulmonary arrest. Consequently, the timely recognition and management of respiratory failure and shock are essential goals of pediatric resuscitation.

This is an important distinction from cardiopulmonary arrest in adults which is typically caused by cardiac dysrhythmias. Only 5-15% of pediatric in-hospital or out-of-hospital arrests are found to have ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) as the initial rhythm. That being said, pulseless VT and VF have also been shown to occur as frequently as 27% at some point during in-hospital resuscitations. Their management, along with the management of other cardiac dysrhythmias, pulseless electrical activity (PEA), and asystole are essential goals of pediatric resuscitation.

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Contributor Information and Disclosures
Author

James Stuart Booth, MD Emergency Physician, Assistant Professor, Assistant Medical Director, Department of Emergency Medicine, University of Alabama at Birmingham School of Medicine

James Stuart Booth, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Andrew R Edwards, MD, FACEP Associate Professor of Emergency Medicine, Vice-Chair for Education and Residency Program Director, Department of Emergency Medicine, University of Alabama at Birmingham School of Medicine; Medical Director, Jefferson County SWAT Team, Jefferson County Sheriff's Department

Andrew R Edwards, MD, FACEP is a member of the following medical societies: American College of Physicians, Society for Academic Emergency Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.

Arianna Shirk, MD Fellow in Pediatric Emergency Medicine, University of Alabama at Birmingham School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Ted Rosenkrantz, MD Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine

Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, Eastern Society for Pediatric Research, American Medical Association, Connecticut State Medical Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

References
  1. King C, Henretig FM, King BR. Textbook of Pediatric Emergency Procedures. Lippincott Williams & Wilkins; 2007.

  2. Kieboom JK, Verkade HJ, Burgerhof JG, Bierens JJ, Rheenen PF, Kneyber MC, et al. Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide retrospective cohort study. BMJ. 2015 Feb 10. 350:h418. [Medline].

  3. Brown T. Pediatric Drowning: Stop Resuscitation After 30 Minutes. Medscape Medical News. Available at http://www.medscape.com/viewarticle/839704. February 12, 2015; Accessed: April 18, 2016.

  4. Davidovic L, LaCovey D, Pitetti RD. Comparison of 1- versus 2-person bag-valve-mask techniques for manikin ventilation of infants and children. Ann Emerg Med. 2005 Jul. 46(1):37-42. [Medline].

  5. Jesudian MC, Harrison RR, Keenan RL, Maull KI. Bag-valve-mask ventilation; two rescuers are better than one: preliminary report. Crit Care Med. 1985 Feb. 13(2):122-3. [Medline].

  6. Newth CJ, Rachman B, Patel N, Hammer J. The use of cuffed versus uncuffed endotracheal tubes in pediatric intensive care. J Pediatr. 2004 Mar. 144(3):333-7. [Medline].

  7. Mongardon, N. Singer, M. Etomidate versus ketamine for sedation in acutely ill patients. The Lancet. 10 October 2009. 374:9697:1240.

  8. Mallory MD, Baxter AL, Yanosky DJ, Cravero JP,. Emergency physician-administered propofol sedation: a report on 25,433 sedations from the pediatric sedation research consortium. Ann Emerg Med. 2011 May. 57(5):462-8.e1. [Medline].

  9. Marsch SC, Steiner L, Bucher E, Pargger H, Schumann M, Aebi T, et al. Succinylcholine versus rocuronium for rapid sequence intubation in intensive care: a prospective, randomized controlled trial. Crit Care. 2011 Aug 16. 15(4):R199. [Medline].

  10. Lopez-Gil M, Brimacombe J, Alvarez M. Safety and efficacy of the laryngeal mask airway. A prospective survey of 1400 children. Anaesthesia. 1996 Oct. 51(10):969-72. [Medline].

  11. Carcillo, J, Wheeler, D. Shock. An Overview. Pediatric Critical Care Medicine: Basic Science and Clinical Evidence. London: 2007. 274-282.

  12. Popa C, Popa F, Grigorean VT, Onose G, Sandu AM, Popescu M. Vascular dysfunctions following spinal cord injury. J Med Life. 2010 Jul-Sep. 3(3):275-85. [Medline].

  13. Santry HP, Alam HB. Fluid resuscitation: past, present, and the future. Shock. 2010 Mar. 33(3):229-41. [Medline].

  14. Roberts I, Alderson P, Bunn F, Chinnock P, Ker K, Schierhout G. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2004 Oct 18. CD000567. [Medline].

  15. [Guideline] Kleinman ME, Chameides L, Schexnayder SM, Samson RA, Hazinski MF, Atkins DL. Part 14: pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2. 122(18 Suppl 3):S876-908. [Medline]. [Full Text].

  16. Matos RI, Watson RS, Nadkarni VM, Huang HH, Berg RA, Meaney PA. Duration of cardiopulmonary resuscitation and illness category impact survival and neurologic outcomes for in-hospital pediatric cardiac arrests. Circulation. 2013 Jan 29. 127(4):442-51. [Medline].

  17. [Guideline] Berg MD, Schexnayder SM, Chameides L, Terry M, Donoghue A, Hickey RW, et al. Part 13: pediatric basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2. 122(18 Suppl 3):S862-75. [Medline]. [Full Text].

  18. Dieckmann RA, Brownstein D, Gausche-Hill M. The pediatric assessment triangle: a novel approach for the rapid evaluation of children. Pediatr Emerg Care. 2010 Apr. 26(4):312-5. [Medline].

  19. Karpas A. The Evaluation And Management of Pediatric Cardiac Tachyarrhythmias: An Evidence-Based Approach. Pediatric Emergency Medicine Practice. June 2006. 3 (6):[Full Text].

  20. Section III: Resuscitation. Strange G, Ahrens W, Schafermeyer R, Wiebe R. Pediatric Emergency Medicine. 3rd. McGraw-Hill; 2009. chap 23-26.

  21. Spina L. Current Guidelines For Pediatric Advanced Life Support: The 2010 AHA Guidelines. EM Practice Guidelines Update. April 2011. [Full Text].

  22. [Guideline] Travers AH, Rea TD, Bobrow BJ, Edelson DP, Berg RA, Sayre MR. Part 4: CPR overview: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2. 122(18 Suppl 3):S676-84. [Medline]. [Full Text].

  23. William H. Resuscitation of Children. Tintinalli J et al (eds.). Tintinalli's Emergency Medicine: A Comprehensive Study. 7th. 2010. Chapter 15. [Full Text].

 
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The Pediatric Assessment Triangle (PAT).
Body-length tape.
Code Cart (color-coded).
CPR.
 
 
 
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