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 varies by age: 17% in adolescents, 13% in children, and 4.9% in infants. Poor outcomes may be attributable in part to the fact that many of these patients do not receive bystander cardiopulmonary resuscitation (CPR). The overall survival in pediatric patients with in-hospital cardiac arrests has increased from 9% to 41%. Of those who survive arrests, many suffer permanent brain injury. These improvements are believed to be attributable to earlier recognition and management of critical conditions, earlier CPR, the implementation of medical emergency teams with specialists trained in the acute resuscitation of pediatric patients using the PALS and APLS algorithms, and the use of extracorporeal cardiopulmary resuscitation (ECPR).
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
Normal ranges for heart rate are as follows
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Neonate: 90-205 beats per minute (BPM)
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1 week to 1 month: 90-180 BPM
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3 month to 2 years: 80-150 BPM
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2-10 years: 60-120 BPM
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10 years to adult: 50-100 BPM
Respiratory rate
Normal ranges for respiratory rate are as follows:
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Term infant: 30-50 breaths per minute (BPM)
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1 -6 months: 20-40 BPM
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6 months to 2 years: 20-30 BPM
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2-12 years: 16-24 BPM
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Adolescents: 12-20 BPM
Blood pressure
In children who 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 2020 PALS guidelines, hypotension is defined as a systolic blood pressure (note that these thresholds will overlap with normal values, including those of children who have systolic blood pressure lower than the 5th percentile for age):
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< 60 mm Hg in term newborns > 3kg (0-28 d), < 40 in Hg in preterm newborns < 1 kg
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< 70 mm Hg in infants (1-12 mo)
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< 70 mm Hg + (2 × age in years) in children 1-10 years
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< 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:
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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The Pediatric Assessment Triangle (PAT).
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Body-length tape.
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Code Cart (color-coded).
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CPR.
