Pediatric Resuscitation Technique

The initial approach to pediatric resuscitation begins with a general assessment of the child. This must be rapidly performed and can often be difficult when the child is critically ill. The goal of the general assessment is to quickly form an impression of the child's overall physiological state and to help answer one of the most basic questions in emergency medicine: "sick or not sick?"

The Pediatric Assessment Triangle (PAT) is considered to be an integral part of the general assessment of a sick child. It is used by PALS, APLS, Pediatric Education for Prehospital Professionals (PEPP), and the Emergency Nursing Pediatric Course (ENPC). The triangle is designed to be a quick and simple approach to evaluating a child based on visual and auditory clues. It is broken down into the following 3 elements:

• Appearance

• Work of breathing

• Circulation

  The Pediatric Assessment Triangle (PAT).

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These 3 elements are further broken down into certain characteristics that help the healthcare provider determine the child's level of severity as well as help identify the underlying physiological abnormality.

Appearance is assessed as follows:

• Tone

• Interactivity

• Consolability

• Look/gaze

• Speech/cry

Work of breathing assessment includes the following:

• Abnormal breath sounds

• Abnormal positioning

• Retractions

• Flaring

Circulation assessment includes the following:

• Pallor

• Mottling

• Cyanosis

• Bleeding

The visual and auditory clues of the pediatric assessment triangle allow the healthcare provider to quickly form a general impression of the child and make two determinations. First, the provider must determine if the child is "sick" or "not sick," which means determining whether the child has an apparent life-threatening condition or not. This determination prompts the provider to begin life-saving interventions immediately or continue with a systematic assessment of the child. Secondly, the pediatric assessment triangle helps determine the underlying physiological abnormality.

These abnormalities can be broken down into basic categories: respiratory distress, respiratory failure, compensated shock, decompensated shock, cardiopulmonary arrest, primary brain dysfunction, or other systemic abnormality. The general assessment is a critical starting point for pediatric resuscitation, and using the pediatric assessment triangle helps healthcare providers make timely decisions based on the overall appearance of the child.

Although the general assessment is considered a quick first impression, the primary assessment is a hands-on systematic approach to determining life-threatening abnormalities. The primary assessment has been traditionally taught using an ABCDE approach. This approach is discussed briefly below.

• A - Airway

• B - Breathing

• C - Circulation

• D - Disability

• E - Exposure

Airway

Assessment of the airway involves evaluating the patency of the upper airway by listening for breath sounds, watching for chest rise, and feeling the movement of air near the nose and mouth. Inspiratory stridor and snoring or absence of breath sounds despite inspiratory effort are signs that suggest upper airway obstruction. Specific management of an upper airway obstruction depends on the etiology of the obstruction but may include back blows, abdominal thrusts, removal of a foreign body, suctioning, head tilt-chin lift, jaw-thrust (if suspected cervical spine injury), airway adjuncts, and endotracheal intubation. Needle or surgical cricothyrotomy should only be considered when all other measures fail and as a last resort.  

Breathing

Assessment of breathing involves evaluation of the respiratory effort and whether the child is oxygenating and ventilating appropriately. Nasal flaring, chest retractions, and head bobbing are signs of increased respiratory effort. Grunting, wheezing, and crackles are findings that may help suggest certain types of pathology causing respiratory distress. Pulse oximetry is useful for determining how well a child is oxygenating in most circumstances; an oxygen saturation of 94% or more while breathing room air is typically considered within normal limits. Specific management depends on the particular respiratory pathology but may include supplemental oxygen, nebulized medications, bag-valve-mask ventilation, and endotracheal intubation.

Circulation

Assessment of circulation involves evaluating pulses, heart rate, blood pressure, skin color, skin temperature, and capillary refill time. These are all measures that help determine how well the body is perfusing. Likewise, decreased mental status and decreased urine output can help determine end-organ perfusion and function. Management of decreased or inadequate perfusion may include fluid resuscitation, vasopressors, and inotropes.

Disability

Assessment of disability involves quickly evaluating the child's neurologic status by checking pupil size and reactivity as well as using tools such as the AVPU Pediatric Response Scale or the Glasgow Coma Scale (GCS). The AVPU scale is a simple way to categorize the child's level of consciousness based on whether the child is alert (A), responds only to verbal (V), responds only to pain (P), or is completely unresponsive (U). The GCS is a 15-point score based on assessing the patient's eyes, verbal response, and motor response.

Exposure

Exposure is the final element of the primary assessment. It serves as a reminder to undress a critically ill child to help facilitate a focused physical exam. This is particularly important in the setting of trauma so additional injuries are not missed. Once undressed, care must be taken to prevent hypothermia with the use of blankets and warmers as needed.

As discussed more thoroughly in the section on Basic Life Support (BLS), the ABCDE approach of the primary assessment should be understood in the context of the latest 2020 AHA Guidelines for Pediatric Basic Life Support. ^[2] Earlier chest compressions during cardiopulmonary arrest are emphasized; consequently, the sequence of steps in CPR has been changed from airway, breathing/ventilations, chest compressions (ABC) to compressions, airway, and breathing/ventilations (CAB). The primary assessment should still involve the basic ABCDE approach but with the understanding that current guidelines recommend making a quicker determination of whether chest compressions should be initiated.

After completion of the primary assessment and initial management of any life-threatening abnormalities, a secondary assessment may be performed. This includes a more detailed physical exam. It also includes a focused history traditionally taught by the mnemonic SAMPLE:

• S - Signs and symptoms

• A - Allergies

• M - Medications

• P - Past medical history

• L - Last meal

• E - Events leading to current illness

The tertiary assessment involves diagnostic studies to help aid in the identification and severity of the child's condition. This may include laboratory studies such as a point-of-care blood glucose, an arterial blood gas, a CBC, a basic metabolic panel and a lactic acid level. Imaging studies also fall into the category of tertiary assessment and may include radiography, CT scanning, and ultrasonography.

The 2020 American Heart Association Guidelines for Pediatric Basic Life Support set the standard for the initial approach and management of a child in cardiopulmonary arrest. ^[2] The AHA guidelines discuss Basic Life Support (BLS) for both lay rescuers and healthcare providers. This article focuses more specifically on BLS for healthcare providers.

In conjunction with the implementation of BLS training programs across the United States, there have been other similar advances in public health initiatives for adults and children. "Public Access Defibrillation" (PAD) programs have been instituted across the United States. These programs provide access to early defibrillation which has been shown to increase the likelihood of survival from cardiac arrest. Automatic external defibrillators (AEDs) are now commonly found in many public locations, and many states now mandate the placement of AEDs in schools. Although sudden cardiac arrest is less common in the pediatric population, access to earlier defibrillation in the pediatric population is intended improve outcomes from cardiopulmonary arrest. The potential use of AEDs, in conjunction with high-quality CPR and activation of the emergency response system, is therefore an important part of the BLS algorithm.

Compressions, airway, breathing

One of the more notable changes in the 2010 AHA guidelines was the switch from the sequencing of airway, breathing, compressions (ABC) to compressions, airway, breathing (CAB). ^[3] This switch was made for several reasons. Quality chest compressions have been shown to improve outcomes and should be started as soon as possible. Airway positioning and rescue breaths can delay the initiation of chest compressions. This is particularly important in the adult population since most adult patients experience cardiopulmonary arrest secondary to a cardiac dysrhythmia rather than respiratory failure. Pediatric cardiopulmonary arrest, in contrast, is more commonly secondary to asphyxial cardiac arrest. The importance of respiratory support in the pediatric patient with cardiac arrest cannot be over emphasized. Despite this, the CAB sequencing is still recommended for children in the latest ACC/AHA guidelines to simplify the training process and increase the likelihood that CPR is promptly initiated.

BLS algorithm

If the child is unresponsive and not breathing, the healthcare provider should first send someone to activate the emergency response system and get an AED.

Healthcare providers trained to assess pediatric pulses should take no more than 10 seconds to feel for a pulse before initiating chest compressions. This is a subtle distinction from lay person BLS which instructs the immediate initiation of chest compressions if the child is unresponsive and not breathing.

If no pulse is observed, then chest compressions should be initiated at a rate of at least 100 per minute and at a depth of one third of the anteroposterior diameter of the chest. If a pulse is observed, rescue breaths should be initiated at a rate of 20-30 breaths per minute, or every 2-3 seconds. If the pulse remains below 60 BPM with evidence of poor perfusion despite adequate oxygenation and ventilation, chest compressions should be initiated. Pulse checks should occur every 2 minutes.

If CPR is initiated, the following recommendations for one-rescuer CPR versus two-rescuer CPR apply:

• One-rescuer CPR should cycle between 30 chest compressions and 2 breaths

• Two-rescuer CPR should cycle between 15 chest compressions and 2 breaths.

After 2 minutes of CPR, the emergency response system should be activated if not already done. CPR should then be continued until an AED is available. Once an AED arrives, it should be promptly connected to the patient, minimizing interruptions in CPR.

If the patient's rhythm is analyzed and determined to be a "shockable" rhythm, rescuers should clear the patient and deliver a shock. Chest compressions should be re-initiated immediately following the shock and should be continued for 2 minutes before another pulse check and rhythm analysis.

• If a "shockable" rhythm is detected, this cycle is repeated.

• If no shock is advised, chest compressions should be continued for 2 minutes.

• There should be a pulse check and rhythm analysis every two minutes until ALS providers arrive or the patient begins to move.

High quality CPR

The following are considered essential elements of high-quality CPR:

• Compression rate of 100-120/min

• Compression depth to at least one third of the anterior-posterior diameter of the chest (approximately 4 cm in infants and 5 cm in children)

• Complete chest recoil after each compression

• Minimized interruptions in chest compressions

• Avoidance of excessive ventilation

See the video below.

Foreign body

Do not attempt to dislodge a foreign body from a spontaneously breathing patient by giving abdominal thrusts or syrup of ipecac. This could change the position of a nonobstructive object and cause it to obstruct the airway. A plain radiograph can reveal an area of focal overinflation or an area of atelectasis, depending on the degree of obstruction; however, a negative radiograph finding does not exclude a foreign body. If an airway foreign body is visible on laryngoscopy in a patient with severe respiratory distress, Magill forceps may be used to grasp and remove the foreign body. Do not attempt blind finger sweeps. If an unconscious patient requires CPR, perform chest compressions, not abdominal thrusts.

Near drowning

Near drowning is a unique situation in resuscitation. All near drowning patients should be immediately placed on oxygen and C-spine precautions should be initiated if warranted by the patient's history. Any symptomatic patient should be admitted for observation. For resuscitation, intubation should be initiated if patient is altered or unable to protect the airway. Bagging with increased positive end-expiratory pressure (PEEP) and using albuterol to improve bronchospasm may be helpful in the initial resuscitation.

Favorable outcomes have occurred in patients resuscitated up to 30 minutes for warm water near drowning and 60 minutes in cold water. Resuscitation should continue until the patient is warm (32-35°C) unless a condition incompatible with life is also present. Chest radiography does not have predictive value in near drowning. Only if a patient is completely asymptomatic can they be discharged home after 4 hours of observation.

A study by Kieboom et al evaluated the outcome of 160 drowned children with cardiac arrest and hypothermia to determine distinct criteria for termination of cardiopulmonary resuscitation. The study found that resuscitation is likely to be unsuccessful for children in whom return of spontaneous circulation is not achieved within 30 minutes of advanced life support in seasons other than winter. ^{[4, 5]}

A more extensive discussion can be found in the article Near Drowning.

Overview

The 2020 American Heart Association Guidelines for Pediatric Advanced Life Support sets the standard for the management of pediatric resuscitation in a healthcare setting. ^[2]

Pediatric Advanced Life Support (PALS) is one of the most fundamental elements of pediatric resuscitation. Training in PALS is commonly a requirement for healthcare providers who are working in pediatric hospitals and emergency care settings. Similar to BLS, algorithms are a key component of PALS training and are designed to simplify and expedite recognition and treatment of life-threatening conditions. Unlike BLS, PALS typically involves a coordinated team of trained responders who are able to initiate several processes simultaneously.

Vascular access

Obtaining vascular access is a crucial component of PALS. Often, if access is not already established, a team member is designated to establish vascular access while other team members perform separate tasks such as chest compressions and ventilations.

Vascular access should be established as soon as possible. Initially, in the setting of cardiopulmonary arrest or decompensated shock, attempting peripheral intravenous (IV) access is acceptable but only for a short, limited time.

If a peripheral IV cannot be quickly established, then an intraosseous (IO) line should be placed by a trained provider. Bypassing attempts at IV access altogether and initially placing IO access to expedite care is also acceptable. IO access is fast, effective, safe, and any medications given intravenously may be used intraosseously. For further details concerning the intraosseous access, please see the Medscape Reference article Pediatric Intraosseous Cannulation.

A central venous line (CVL) is not recommended as a form of initial vascular access in an emergency. Although it may be beneficial after initial resuscitation, the placement of a CVL is time-consuming and could significantly delay management of life-threatening conditions.

If no form of vascular access can be obtained in a timely manner, then endotracheal drug administration is possible. Lidocaine, epinephrine, atropine and naloxone ("LEAN" mnemonic) may all be administered via an endotracheal tube. This route of administration is not preferred because absorption varies widely.

Airway management

Airway management is another crucial component of pediatric resuscitation. Healthcare providers must be knowledgeable concerning proper airway equipment and its use. For more information concerning airway management and equipment, please see the section below on Respiratory Failure.

Pulseless arrest

When cardiopulmonary arrest occurs in an advanced healthcare settings, such as an emergency room or pediatric hospital, a series of events are often quickly and simultaneously initiated.

When a child is found to be unresponsive and not breathing, several actions should be initiated and assigned to team members as they arrive:

• Call for help and activate the emergency response.

• Start chest compressions at a rate of at 100-120/min.

• Put the patient on supplemental oxygen and ventilate using a ratio of 15:2 (2-rescuer CPR) using a bag-valve-mask.

• Attach an ECG monitor and defibrillator pads.

• Establish vascular access.

Once the child is attached to the monitor or AED, the rhythm should be analyzed and determined to be shockable or nonshockable. Shockable rhythms include pulseless ventricular tachycardia or ventricular fibrillation. Nonshockable rhythms include pulseless electrical activity or asystole.

If the rhythm indicates ventricular tachycardia or ventricular fibrillation, then it is a "shockable" rhythm.

• The defibrillator should be charged to 2 J/kg, and a shock should be delivered as soon as possible once all team members are clear.

• Promptly restart CPR for an additional 2 minutes.

• Establish IV/IO access if not already done.

• After 2 minutes, recheck the rhythm.

If the rhythm is determined to be shockable again:

• The defibrillator should be charged to 4 J/kg and a shock should be delivered.

• Promptly restart CPR for an additional 2 minutes.

• Give epinephrine 0.01 mg/kg IV or IO. This may be repeated every 3-5 minutes.

• Consider endotracheal intubation or other advanced airway placement.

• Consider amiodarone 5 mg/kg IV/IO for refractory VF/pulseless VT (may repeat up to 2 times).

If the rhythm indicates pulseless activity or asystole, then it is a nonshockable rhythm.

• Continue CPR for an additional 2 minutes.

• Establish IV/IO access.

• Give epinephrine 0.01 mg/kg IV or IO as soon as possible (earlier administration is associated with increased survival).

• Consider endotracheal intubation or other advanced airway placement.  For out of hospital cardiac arrest, bag-mask ventilation results in the same resuscitation outcomes as advanced airway interventions in the field.

Once the patient is intubated, chest compressions and ventilations should work independently with the compressions at a continuous rate of 100-120/min and the ventilations at 8-10/min (every 6-8 s).

If a nonshockable rhythm persists, then reversible causes should be identified and treated if possible. The most common reversible causes are known as the "H's" and "T's," as follows:

• Hypovolemia

• Hypoxia

• Hypothermia

• Hydrogen ion (acidosis)

• Hypoglycemia

• Hypo-/Hyperkalemia

• Tension pneumothorax

• Tamponade, cardiac

• Toxins

• Thrombosis, pulmonary

• Thrombosis, coronary

The rhythm should be rechecked every 2 minutes. If an organized rhythm is observed, check a pulse. If a pulse is present, begin post‒cardiac arrest management.

Bradyarrhythmias

Emergent treatment is indicated for pediatric patients with hemodynamically unstable bradycardia. A bradyarrhythmia can be an ominous sign because it is the most common prearrest rhythm in the pediatric population. Hypoxia, from respiratory failure or sepsis, is the leading cause of unstable bradyarrhythmias in pediatrics. Similar to pulseless arrest, PALS uses an algorithmic approach to the recognition and management of these arrhythmias.

When a pediatric patient is found to be bradycardiac, quickly check for a pulse. If no pulse is found, proceed to the pulseless arrest algorithm. If a pulse is found, assess for signs of cardiopulmonary compromise. These signs include the following:

• Hypotension

• Acutely altered mental status

• Other signs of shock

If cardiopulmonary compromise is evident, the following immediate steps should be taken:

• Put the patient on supplemental oxygen and assist ventilations as needed.

• Attach cardiac monitoring, blood pressure cuff, pulse oximetry, and pacing pads.

• Establish vascular access (IV or IO if necessary).

• Get a 12-lead ECG for rhythm analysis if possible.

If the heart rate continues to be below 60/min and cardiopulmonary compromise is evident despite oxygenation and ventilation, then chest compressions should be initiated.

While the algorithm is being applied, attempt to identify and treat any underlying causes. This includes advanced airway placement if there is evidence of a primary respiratory disorder that is not improving with simple supplemental oxygen or bag-valve-mask (BVM) ventilation. Septic shock is another cause that should be addressed and appropriately treated. A 12-lead ECG should be obtained and analyzed for evidence of heart block, which can also be a cause of bradycardia particularly in heart disease. Similar to pulseless electrical activity arrest, consider the "H's" and "T's" when treating symptomatic bradycardia.

If bradycardia persists after 2 minutes of chest compressions, consider the following:

• Epinephrine - 0.01 mg/kg IV or IO

• Atropine - 0.02 mg/kg, not to exceed 0.5 mg/dose (for increased vagal tone or primary heart block)

• Transcutaneous or transvenous pacing

• Continue to identify and treat any underlying causes

If the bradycardia resolves, continue to support the ABCs, monitor the child, and consider expert consultation.

If the bradycardia evolves into pulseless arrest, proceed to the pulseless arrest algorithm.

Tachyarrhythmias

Emergent treatment is indicated for pediatric patients with hemodynamically unstable tachycardia. The most common types of tachycardia in the pediatric population include sinus tachycardia, supraventricular tachycardia and ventricular tachycardia. Distinguishing between these 3 types of tachycardia is important in successfully managing the patient's condition. As with other elements of PALS, an algorithmic approach is used for tachyarrhythmias in order to identify and manage the underlying etiology quickly and effectively.

If a pediatric patient is found to be unresponsive and not breathing in the context of tachycardia on the monitor, then proceed to the pulseless arrest algorithm. If the patient does have a pulse, evaluate for evidence of cardiopulmonary compromise, which include hypotension, acutely altered mental status, and signs of shock.

If cardiopulmonary compromise is evident, the following immediate steps should be taken:

• Put the patient on supplemental oxygen and assist ventilations as needed.

• Attach cardiac monitoring, blood pressure cuff, pulse oximetry, and defibrillator pads.

• Establish vascular access (IV or IO if necessary).

• Get a 12-lead ECG for rhythm analysis.

• Evaluate the ECG and determine if the QRS duration is narrow or wide.

If the QRS is narrow, determine whether sinus tachycardia or supraventricular tachycardia is more probable. Evidence supporting sinus tachycardia includes the presence of P waves, variable R-R intervals, and heart rate less than 180. Evidence supporting supraventricular tachycardia includes absences of P waves, no R-R variability, and a heart rate greater than 180.

The management of sinus tachycardia involves treating the underlying cause(s). Common causes of sinus tachycardia include hypovolemia, sepsis, fever, pain, hypoxia, and anemia. The history and physical exam can provide important information for narrowing the differential diagnosis.

The management of supraventricular tachycardia can be simplified into three basic steps:

1. While preparations are being made for chemical or electrical cardioversion, vagal maneuvers may be attempted to break the dysrhythmia. Vagal maneuvers may include application of an ice bag to the child's face or unilateral carotid massage in older children.

2. If vagal maneuvers are unsuccessful and the patient has IV or IO access, then chemical cardioversion with adenosine is indicated. Push adenosine 0.1 mg/kg (max dose 6 mg). If this is unsuccessful, the dose may be doubled with a maximum dose of 12 mg.

3. If chemical cardioversion is unsuccessful or not available, electrical cardioversion is indicated. If possible, sedate the patient beforehand but do not delay cardioversion. Deliver a synchronized shock at 0.5-1 J/kg. If this is not successful, increase the charge to 2 J/kg.

If chemical and electrical cardioversion continue to be unsuccessful, consider expert consultation for additional antiarrhythmics and rate-controlling recommendations.

If the QRS is wide on the initial ECG, ventricular tachycardia should be assumed. supraventricular tachycardia with aberrant conduction is a less common possibility.

• If a wide complex tachycardia is present with signs of cardiopulmonary compromise, synchronized cardioversion is indicated and should be delivered at 0.5-1 J/kg initially with an increase to 2 J/kg if initially unsuccessful.

• If a wide complex tachycardia with no signs of cardiopulmonary compromise is present, several other options should be considered. Adenosine may be empirically given for the possibility of supraventricular tachycardia with aberrancy. Amiodarone and procainamide may also be given in conjunction with expert consultation. Amiodarone is typically dosed at 5 mg/kg IV infused over 20-60 minutes. Procainamide is typically dosed at 15 mg/kg IV infused over 30-60 minutes.

Pediatric body-length tape

Pediatric body-length tape can be useful during resuscitation. Most medications, fluids, and equipment used for pediatric resuscitation are dependent on the patient's weight. Sometimes the patient's weight is known beforehand, but often it is not. Body-length tape can be used to quickly estimate the patient's weight and it often comes with precalculated doses and equipment sizes, which is helpful amid the coordination of a busy resuscitation. See the images below.

Blood glucose level

A blood glucose level should be quickly checked during resuscitations. Pediatric patients who are critically ill will often have hypoglycemia, which may contribute to the patient's clinical deterioration. Bedside point-of-care glucometers can be particularly helpful for this. Treatment typically consists of a dextrose-containing solution.

Naloxone

Naloxone can reverse respiratory arrest due to an opioid overdose, but there is not evidence that it beneftis patients in cardiac arrest.

This is a listing of medications commonly used in pediatric resuscitation with their dosing:

• Adenosine - 0.1 mg/kg IV/IO (not to exceed 6 mg for first dose), second dose 0.2 mg/kg (not to exceed 12 mg for second dose)

• Amiodarone - 5 mg/kg IV/IO, not to exceed 300 mg/dose; may repeat twice, not to exceed a cumulative dose of 15 mg/kg

• Atropine - 0.02 mg/kg IV/IO (minimum of 0.1 mg/dose, not to exceed 0.5 mg for single dose)

• Calcium chloride - 20 mg/kg (not to exceed 2 g for single dose)

• Epinephrine - 0.01 mg/kg (1:10,000 solution) IV/IO (not to exceed 1 mg)

• Glucose - 0.5-1 gram/kg IV/IO

  • Newborn - 5-10 mL/kg D10W

  • Infant/children - 2-4 mL/kg D25W

  • Adolescent - 1-2 mL/kg D50W

• Lidocaine - 1 mg/kg IV/IO (bolus)

• Magnesium sulfate - 25-50 mg/kg IV/IO (not to exceed 2 g/dose)

• Naloxone

  • < 5 years or ≤20 kg - 0.1 mg/kg IV/IO

  • ≥5 years or ≥20 kg - 2 mg IV/IO

• Procainamide - 15 mg/kg IV/IO

• Sodium bicarbonate - 1 mEq/kg/dose IV/IO

Basics of pediatric respiratory failure are covered in this article. For more detail, please see the Medscape Reference article Pediatric Respiratory Failure.

Respiratory failure is characterized by inadequate ventilation, insufficient oxygenation, or both. Tachypnea, tachycardia, and accessory muscle use may be signs of respiratory distress. Irregular breathing, bradycardia, a gradual decrease in respiratory rate, or cyanosis despite supplemental oxygen are all concerning signs for impending respiratory failure. Change in mental status can also be a sign of decreased end organ oxygenation and perfusion.

Ventilation with BVM

Rather than being used as an adjunct, bag-mask ventilation should be seen as an effective, possibly safer, alternative to endotracheal tube ventilation for short periods during pre-hospital resuscitation in children.

First, select the correct sized mask. The mask should cover the mouth and nose. Do not extend over the chin or put pressure on the eyes. Perform a head tilt, chin lift to open the airway. A rolled towel under the shoulders of children younger than 2 years and towel under the head of children aged 2-5 years may help to align the airway in the optimal position for intubation.

Two-handed (2-person) ventilation technique is preferable if at all possible to create a tight mask-to-face seal and observe for chest rise. ^{[6, 7]} Clinical practice guidelines on pediatric life support from the European Resuscitation Council also recommend 2-person bag-mask ventilation as the first-line method of ventilatory support. ^[8]

To assess for adequate bagging, consider the following:

• Watch for chest rise. Bagging too fast (>8-10 times a minute) or with too much pressure can lead air trapping and barotrauma in patients with small airways. It also increases the risk of stomach inflation, regurgitation, and aspiration.

• If ventilation is difficult, repositioning and suctioning may be the only corrective measures required.

• If it is still difficult, consider nasal and oral airways to help open the airway.

• Measure nasopharyngeal airway from the earlobe to the tip of the nose. It is contraindicated in cases of severe facial trauma. Lubricate and slide into place.

• Measure oral airway from the corner of the mouth to the earlobe or from the middle of the mouth to the angle of the mandible. Oral airways can only be inserted if the patient is unconscious. If they gag or cough, remove the oral airway immediately.

• Remember, bag-valve mask ventilation has not failed until you have 2 nasal airways, an oral airway, and are using a 2-person technique.

Endotracheal intubation

Emergent intubation may be required if a prolonged prehospital course or impending airway obstruction (eg, smoke inhalation or expanding neck hematoma) are present. Indications for intubation include failure to oxygenate with supplemental O₂, failure to ventilate and rising PaCO₂, severely increased work of breathing, decompensated shock, CNS depression, or rapid deterioration of Glasgow Coma Scale, severe neuromuscular weakness, or lack of airway protection.

Before administering drugs, make sure all equipment and accessories are available and working. The following is a commonly used mnemonic to remember the necessities for preintubation setup:

• U - Universal precautions

• S - Suctions

• O - Oxygen

• A - Airway equipment

• P - Pharmacy

• M - Monitoring

With pediatric patients, consider the following when choosing your equipment:

• Blades: A straight Miller blade may be preferable in younger children with floppy epiglottis. The curved Macintosh may be preferable in older children with stiff epiglottis.

• Tube: Cuffed endotracheal tubes should be used to intubate infants and children when available as cuffed ET tubes allow for pressure monitoring, adjustment of leaks, may prevent aspiration, and result in less need for tube changes. To select the proper size, use the following formula: 3.5 + (age/4) for a cuffed tube OR 4 + (age/4) for an uncuffed tube. Place at a depth (in cm) three times the size of the tube. For example, if a size 5.0 ET tube is used, a good estimation of the appropriate depth would be 15 cm. Alternatively, stop advancing the ET tube once the cuff passes the vocal cords, because children have a relatively short trachea before it branches to the bronchi. Have a Yankauer and Deep suction available. A patient weight‒appropriate end tidal CO₂ detector needs to be used for the detector to provide valid confirmation of proper ET tube placement. As always, good chest rise with application of positive pressure, auscultation over the chest for equal breath sounds, and absence of breath sounds in the stomach aid in the confirmation of appropriate ET tube placement. ^[9]

Medication

Premedication includes the following:

• Atropine (0.01 mg/kg/dose IV): This helps decrease secretions when using ketamine for induction. It may also blunt bradycardic response in children younger than 10 years when using succinylcholine for paralysis. Atropine should always be used in children younger than 5 years undergoing airway manipulation.

• Lidocaine (1.5 mg/kg/dose IV): Lidocaine may help in reactive airways disease. It may also be helpful in patients with head injuries.

• Fentanyl (1-3 mcg/kg/dose IV): Infants and toddlers are sensitive to respiratory depressant effect of fentanyl; this should be used with extreme caution. Do not use in patients with hypotension.

Hypnotics and sedatives are helpful and necessary if you need to intubate a child who is still awake and alert. Induction agents include the following:

• Ketamine (1-2 mg/kg/dose IV)

  • Onset - 45-60 seconds

  • Duration - 10-20 minutes

  • Pros - Has sympathomimetic actions and is a good drug to use in asthma and shock

  • Cons - Can increase secretions and should be paired with antisialagogue.

• Etomidate (0.2-0.4 mg/kg/dose IV) ^[10]

  • Onset - 5-15 seconds

  • Duration - 5-15 minutes

  • Pros - May maintain central perfusion pressure and may decrease intracranial pressure; good drug for isolated head injuries

  • Cons - May cause adrenal insufficiency and should not be used in patients with septic shock

• Propofol (1.5-3 mg/kg/dose IV) ^[11]

  • Onset - 15-45 seconds

  • Duration - 5-10 minutes

  • Pros - Reliable in its action; quick onset and short duration

  • Cons - Decreases blood pressure and central perfusion pressure

• Midazolam (0.3 mg/kg/dose IV)

  • Hypotension - 0.1 m/kg

  • Caution in shock

Paralytics should be used in combination with a sedative/hypnotic for an intubation and include the following: ^[12]

• Succinylcholine (1-2 mg/kg IV)

  • Onset - 30-60 seconds

  • Duration - 3-5 minutes

  • Pros - Has fast onset and is short-acting

  • Cons - Contraindicated in any child with an open eye injury, muscular dystrophy, or upper motor neuron disease (can cause muscle spasm or malignant hyperthermia); should not be used in burn and crush injuries because hyperkalemia is a possible complication; can also cause bradycardia or a prolonged blockade, especially with repeat dosing (Using Atropine as a premedication can help blunt this response.)

• Rocuronium (0.6-1.2 mg/kg IV)

  • Onset - 60-90 sec

  • Duration - 25-35 minutes

  • Pros - Has rapid onset

  • Cons - Has a long duration and is preferable when the patient is easy to ventilate and immediate ICU support is available

Laryngeal mask airway

An LMA is a supraglottic airway device originally developed for the operating room but is now used more often in emergency medicine and difficult airway settings. After failed intubation, the LMA can be used as a rescue device. In the case of the patient who cannot be intubated but can be ventilated, the LMA is a good alternative to continued BVM ventilation because LMA is easier to maintain over time and has been shown to decrease, although not eliminate, aspiration risk.

Choose appropriately sized mask, obtain water soluble lubricant, and prepare suction Deflate the cuff of the LMA completely against a flat surface.

Apply the lubricant to the posterior surface and slide the LMA along the hard palate toward the hypopharynx. When resistance is met, inflate the cuff.

If a patient cannot be intubated or ventilated, a surgical airway may be indicated. However, an LMA may be used as an adjunct to attempt ventilation while someone prepares for surgical intervention. ^[13]

This article covers basics in pediatric shock. For more detail, please see the Medscape Reference article Shock in Pediatrics.

Basics

Shock is defined as inadequate delivery of substrates and oxygen to meet the metabolic needs of the tissues. Infants and children have a remarkable ability to preserve their central blood pressure, attempting to protect their heart and brain in many forms of shock while critically reducing perfusion to the extremities, gut, kidneys, and other end organs. Although tachycardia maybe the result of stimuli, such as fever, pain, and agitation, it is still an early and specific finding in shock in children. ^[14]

Typical signs of compensated shock include the following:

• Tachycardia

• Cool and pale distal extremities

• Prolonged (>2 s) capillary refill (despite warm ambient temperature)

• Weak peripheral pulses compared with central pulses

• Normal systolic blood pressure

As compensatory mechanisms fail, signs of inadequate end-organ perfusion develop. In addition to the above, these signs include the following:

• Depressed mental status

• Decreased urine output

• Metabolic acidosis

• Tachypnea

• Weak central pulses

• Deterioration in color

Decompensated shock is characterized by signs and symptoms consistent with inadequate delivery of oxygen to tissues (pallor, peripheral cyanosis, tachypnea, mottling of the skin, decreased urine output, metabolic acidosis, depressed mental status), weak or absent peripheral pulses, weak central pulses, and hypotension.

Types of shock

Hypovolemic shock is a result of an absolute deficiency of intravascular blood volume either from blood loss (in trauma), from fluid loss (eg, gastroenteritis, diabetes insipidus, burns), inadequate fluid intake, or interstitial loss (eg, burns, nephrotic syndrome, ascites). It may be characterized by tachycardia, hypotension, weakened pulses, and delayed capillary refill.

Hemorrhagic shock is a type of hypovolemic shock characterized by rapid blood loss either into a body cavity or externally. Remember the head as a possible source of blood loss in infants.

Septic shock is a systemic inflammatory response triggered by the presence of infectious agents or their toxins that may be characterized by tachycardia, hypotension, and in the early phases bounding pulses, and flash capillary refill.

Neurogenic shock is a type of distributive shock that may be found in head and spinal injuries because of the loss of control of the sympathetic nervous system. It may be characterized by persistent bradycardia and refractory hypotension. ^[15]

Anaphylactic shock is a type of distributive shock that may result from exposure to certain medications, foods, blood products, or envenomation.

Cardiogenic shock is found when there is impairment of cardiac contractility. This leads to decreased stroke volume and cardiac output. Causes include congestive heart failure, congenital heart disease, cardiac tamponade, and ischemic heart disease (common in adults, rare in children), myocarditis, cardiomyopathy, cardiac tamponade, sepsis, and drug side effects. Presentation can vary, but it should be considered carefully in all patients presenting with signs of shock.

Treatment basics

Administration of isotonic crystalloid early is the most important intervention in children with signs and symptoms of shock. For initial fluid resuscitation in a child in shock, use an isotonic crystalloid solution (0.9% NaCl or Lactated Ringer solution). During initial resuscitation, colloid solution has not been shown to be beneficial and may be more difficult to rapidly obtain. ^[16]

Start with a bolus of 20 mL/kg of isotonic crystalloid (use 60 mL syringes to rapidly infuse) even if blood pressure is normal. Actively assess the patients’ response to the fluid and give additional boluses (20 mL/kg) if improvement is not seen.  Epinephrine or neuroepinephrine should be used for fluid-refractory shock, and steroids should be considered for vasoactive refractory shock per the 2020 surviving sepsis guidelines.

Insufficient evidence in infants and children is available to make a recommendation regarding the optimal timing or extent of volume resuscitation for children with hemorrhagic shock following trauma. However, in adults, especially in a multiple trauma patient, recommendations are to begin with isotonic fluids, but early administration of blood products as they become available has showed improved survival. ^[17]

For suspected septic shock, obtain blood cultures and give a broad spectrum antibiotic early in the course.

For neurogenic shock, stabilization of the C-spine, maintenance of mean arterial blood pressure of 85mmHg and timely detection and treatment of cardiac arrhythmias has been shown to improved long-term survivability. ^[15]

For suspected cardiogenic shock use fluids judiciously. They may need fluid, but give 5-10/kg slowly and watch for hemodynamic improvement or deterioration. If you have a child that you are treating for shock that is getting worse with fluid, consider cardiogenic shock as a possible cause. If the infant is younger than 3 weeks, their shock may be due to a closing ductus arteriosus in congenital heart disease. Prostaglandins are lifesaving in this case. Involve a pediatric cardiology subspecialist early.

Initial post-resuscitation care involves the basic principles of stabilization and disposition.

The goals of stabilization include preservation of neurologic function and prevention of end-organ damage.  Excellent post-cardiac arrest care is associated with improved outcomes. For children who do not regain consciousness, this includes targeted temperature management and continuous electroencephalography monitoring. For all children, the prevention and/or treatment of hypotension, hyperoxia or hypoxia, and hypercapnia or hypocapnia are important. Continual reassessment and maintaining cardiopulmonary support are crucial. Respiratory support may include ventilator management, chest radiography, and blood gases. Cardiovascular support may include securing IV access (eg, if IO access had been obtained initially), fluid resuscitation, and vasopressors and/or inotropes. If the cardiopulmonary arrest occurs in a hospital without the resources to resuscitate pediatric patients, it is the duty of the treating physician to make a clinical judgment concerning how much workup should be pursued at the expense of delaying the patient's transport to a pediatric tertiary care facility and whether the patient is stable enough for transfer.

One of the goals of disposition is knowing where the patient should be sent and how the patient should get there. This may involve arranging transport between hospitals if the patient's condition exceeds the abilities of the initial healthcare setting. If cardiopulmonary arrest occurs at a pediatric tertiary care facility, an emergency response team trained to resuscitate and transport patients to a receiving ICU may be involved.

Physicians need to use their clinical judgement to determine when to declare the end of a resuscitative effort.

Factors generally associated with poor outcome:

• Cardiopulmonary arrest lasting longer than 20 minutes

• No response to two doses of epinephrine

In the case of hypothermia, if electrical cardiac activity is evident, then resuscitation should be continued until the patient is warmed to 86ºF (30ºC). ^[18]

For in-hospital cardiac arrests, pediatric CPR for over 20 minutes generally has been considered futile. A study suggests that this 20-minute time point is not appropriate for all types of in-hospital cardiac arrests. For example, the study showed that medical cardiac and surgical cardiac patients after more than 35 minutes of CPR had survival rates of 21% and 25%, respectively, and favorable neurologic outcomes after more than 35 minutes of CPR in 13% and 17%, respectively. In contrast, only 10% of general medical patients had survival after more than 35 minutes of CPR and only 5% had favorable neurologic outcomes. ^[19]

In general, allow family members to be present during resuscitation efforts for infants and children. The family's presence during resuscitation may help psychologically with their grieving process in the case of a poor outcome. Try to delegate a member of the team to explain what is happening and answer the family's questions during the resuscitation. This task may be delegated in part to chaplains and social workers. ^[18]