Pediatric Cardiopulmonary
Resuscitation
Hany El-Zahaby
Ain Shams University
2011
Aim
“It is not a substitute for getting trained in Pediatric Life Support
Courses rather than providing theoretical background that will
help you having more solid information about different
aspects of pediatric life support”
Historical Background
Early 19th century: Neonates successfully resuscitated with mouth-tomouth resuscitation
In 1814, a description of the Rules of the Humane Society for recovering
drowned persons
Let one the mouth, and either nostril close
While through the other the bellows gently blows.
Thus the pure air with steady force convey,
To put the flaccid lungs again in play.
Should bellows not be found, or found too late,
Let some kind soul with willing mouth inflate;
Then downward, though but lightly, press the chest.
And let the inflated air be upward prest.
External cardiac massage was successfully conducted more than 100 years
ago in two children (ages 8 and 13 years) after circulatory arrest
precipitated by chloroform anesthesia.
In 1904, Crile described the effectiveness of external cardiac compressions in
maintaining the circulation of dogs.
1947: Beck and associates successfully internally defibrillated the human
heart.
1956: Zoll and colleagues performed the first successful external defibrillation
of a human heart.
1958: The National Academy of Sciences National Research Council
recommended mouth-to-mouth resuscitation with maximum backward tilt
of the head as the preferred technique for all individuals requiring
emergency artificial ventilation.
1960: External cardiac compression as a resuscitation technique was revived,
combined with artificial respirations.
Epidemiology and Outcome of In-hospital Pediatric
Cardiopulmonary Arrest
70%
60%
50%
40%
30%
20%
10%
0%
ICU
ER
Wards
OR/PACU
•
•
•
•
•
A 2006: National Registry of Cardiopulmonary Circulation registered 880 pediatric
events, excluding delivery room or neonatal intensive care unit.
The median age was 5.6 years.
The mean duration of cardiopulmonary resuscitation (CPR) for the children who survived
to hospital discharge was 27.3 minutes (median, 15 minutes).
27% percent of the children survived to hospital discharge.
58% of these with a good neurologic outcome.
Diagnosis of Cardiac Arrest
(10 Seconds)
Outside OR:
-absence of signs of life (response to stimuli, breathing,
movement).
-absence of pulse.
Inside OR:
-ECG will indicate nonperfusing rhythms such as VF or asystole.
-ETCO2 will decrease precipitously.
-Pulse oximeter will lose its regular waveform.
- absence of pulse.
Mechanics of CPR
ABC algorithm (Airway, Breathing, Circulation) with the
exception that the child with VF or pulseless VT should receive
electrical defibrillation without delay. CPR should be
conducted up until the earliest moment when the shock can
be delivered.
ABC: A-Airway
Bag-valve-mask (BVM) ventilation with proper head tilt-chin lift
and jaw thrust (avoid gastric insufflations).
Tracheal intubation ensures optimal control of the airway for
effective ventilation, multiple attempts at intubation by the
inexperienced operator may seriously compromise the child's
ability to recover. Auscultation of the is useful in verifying
endotracheal tube placement in children together with in-line
capnography.
ABC: B-Breathing
• Visible chest movement (F.B., bilateral tension pneumothorax)
• Avoid over-ventilation (decrease venous return, less than
normal minute ventilation to match less COP)
Ventilations/Compressions for All Ages
Respirations
Chest Compressions
Notes
BMV
2 /15
2/30 (single rescuer)
100/min
Aspirate stomach if
interferes with ventilation
ETT
8-10/min
100/min
Do not pause
compressions during
ventilation
ABC: C-Circulation
Chest-encircling method for cardiac
compressions in a neonate (<6M)
Infant chest compression: two-finger
technique
ABC: C-Circulation
Chest compression in small children
Chest compression in older children
ABC: C-Circulation
(1) ensuring adequate rate.
(2) ensuring adequate chest wall depression (one third to one half of the
anteroposterior chest diameter).
(3) releasing completely between compressions to allow full chest wall recoil.
(4) minimizing interruptions in chest compressions.
(5) ensuring that the child is on a sufficiently hard surface to allow effective
chest compressions.
In short, “push hard and push fast,” release completely, and don't interrupt
compressions unnecessarily.
Mechanisms of Blood Flow
Compliant Chest Wall
Cardiac pump
Thoracic pump
Defibrillation/Cardioversion
• Immediate management in children with VF or pulseless VT.
• Ventricular fibrillation is terminated due to simultaneous
depolarization and sustained contraction of a critical mass of
myocardium, which allows return of spontaneous coordinated
cardiac contractions, assuming the myocardium is well
oxygenated and the acid-base status is relatively normal.
Practical Aspects of Pediatric Defibrillation
• Correct paddle size:
The largest paddle size appropriate for the child should be used to
reduce the density of the current flow, which in turn reduces
myocardial damage (adult size>10kg).
• Paddle force (firmly applied).
• Paddle position:
One paddle is placed to the right of the upper sternum below the
clavicle, the other is positioned just caudad and to the left of the left
nipple. An alternative approach is to place one paddle anteriorly
over the left precordium and the other paddle posteriorly between
the scapulae.
• Gel pads interface not touching each other.
• Free flowing oxygen 1 meter away to avoid sparking, but keep
closed ventilator circuit connect ventilator on.
Acute cardiac dysfunction inside OR
• Open-Chest Defibrillation:
2 cm for infants, 4 cm for children, 5J in infants.
• Automated External Defibrillation:
Appropriate for use in children older than 1 year of age
with pediatric mode or with pediatric attenuator pads.
• Transcutaneous Cardiac Pacing
For temporary electrical cardiac pacing in children with
asystole or severe bradycardia due to defect in impulse
formation or conduction with preserved myocardial
function.
Vascular Access and Fluid Administration
• ‘’Early IV access is a key
factor for success’’.
• Intraosseous Access:
• IO needle, 16-18G
cannula, or 18G spinal
• 2cm below, 1cm medial
to tibial tuberosity.
• Complications:
osteomyelitis, fat or
bone marrow embolism
or compartment
syndrome.
Endotracheal Medication Administration
• Epinephrine, atropine, Lidocaine, and naloxone.
• Ionized medications such as sodium bicarbonate or calcium
chloride is not recommended by this route.
• 10% serum level of the IV route ► 10 times dose (0.1mg/kg)
for bradycardia or pulseless arrest with maximum volume of
5ml with each injection why?.
• Complication?
Monitoring During CPR
 Adequacy of bilateral chest expansion.
 Constantly reevaluate the depth of compression and the position
of the rescuer's hands in performing chest compressions by
palpation of a major artery.
 Pulse oximeter.
 ETCO2 reflects adequate CPR (transient ↓ after epinephrine)
 Direct diastolic arterial pressure ► coronary & cerebral
perfusion.
 Temperature: - hypothermic arrest ► continue CPR until 35◦.
 Peri-arrest hyperthermia should be aggressively treated to
improve outcome.
Medications Used During CPR
Epinephrine
Actions:
- α- adrenergic stimulation: ↑ PVR & SVR , ↑ SBP & DBP, ↑
coronary BF and likelihood of return of spontaneous
circulation.
- β-adrenergic stimulation: ↑ myocardial contractility & HR,
relaxes smooth muscle in the skeletal muscle vascular bed &
bronchi,↑ the vigor and intensity of ventricular fibrillation,
increasing the likelihood of successful defibrillation.
Medications Used During CPR
Epinephrine
Complications:
• Worsen myocardial ischemic injury.
• ↑oxygen demand.
• Post-resuscitative tachyarrhythmias, hypertension, pulmonary
edema.
• ↑ hypoxemia (increase alveolar dead space ventilation by
pulmonary BF redistribution).
• VC impairs reperfusion of kidneys & GIT.
‘’Routine use of large dose epinephrine in in-hospital pediatric
cardiac arrest should be avoided’’.
Medications Used During CPR
Atropine
• Parasympatholytic agent, increasing the sinus rate and
shortening atrioventricular node conduction time.
• Dose: 20µ/kg, with a minimum dose of 100µ (why?)
and a maximum dose of 2.0 mg.
• Route, IV, IO, ET, IM, SC.
• Onset: 30 seconds, peak 1-2 min after IV dose.
“Epinephrine is the drug of choice for asystole or severe
bradycardia with hypotension in pediatric CPR”
Medications Used During CPR
Vasopressin
• Because of the paucity of pediatric data, vasopressin is
considered Class Intermediate by the American Heart
Association in pediatric CPR although Class IIB for adults to
replace the second or third dose of epinephrine.
Medications Used During CPR
Sodium Bicarbonate
• The routine use of sodium bicarbonate during CPR remains
controversial, and it remains American Heart Association
Class Indeterminate.
Medications Used During CPR
Calcium
Indication:
Hypocalcemia, hyperkalemia, hypermagnesemia, and calcium
channel blocker overdose.
Doses:
Calcium chloride 20 mg/kg (maximum 0.5 to 1g).
Calcium gluconate 60 mg/kg (maximum 2 g).
Slowly through a large-bore, free-flowing intravenous line,
preferably a central venous line. When administered too
rapidly, calcium may cause bradycardia, heart block, or
ventricular standstill. Severe tissue necrosis occurs when
calcium infiltrates into subcutaneous tissue.
Medications Used During CPR
Glucose
• The administration of glucose during CPR should be restricted
to children with documented hypoglycemia because of the
possible detrimental effects of hyperglycemia on the brain
during or after ischemia
Medications Used During CPR
Amiodarone
• Amiodarone has now supplanted lidocaine as the first drug of
choice for medical management of shock-resistant ventricular
tachycardia and fibrillation.
α- adrenergic blocking ► VD & ↑ coronary BF
β- adrenergic blocking
CCB► ↓ A-V conduction
K+ channel blocking with tissue accumulation
Doses: life threatening arrhythmia 5mg/kg (over10 min) then 1020 mg/kg/day
Avoided in hypomagnesemia & electrolyte imbalance for fear of
“torsades de pointes”. Heart block (postoperative) with drugs
that prolong QT interval as inhalational anesthetics.
Lidocaine
Class IB antiarrhythmic ,↓ automaticity of ectopic focci in ventricles,
↓conduction & ↑effective refractory period in Perkinje fibers.
Normal cardiac and hepatic function, bolus of 1mg/kg of lidocaine followed by
a intravenous infusion at a rate of 20 -50μg/kg/min is given.
If the arrhythmia recurs, a second bolus at the same dose can be given.
In children with severe diminution of cardiac output, a bolus of no greater
than 0.75 mg/kg, followed by an infusion at the rate of 10 to 20
μg/kg/min, is administered.
In children with hepatic disease, dosages should be decreased by 50%.
Toxic effects of lidocaine occur when the serum concentration exceeds 7 to 8
μg/ml: seizures, psychosis, drowsiness, paresthesia, disorientation,
agitation, tinnitus, muscle spasms, and respiratory arrest.
Adjunctive CPR Techniques
Open-Chest CPR
• During and after thoracic surgery in ICU.
• Compared with closed-chest CPR, it generates greater cardiac
output and vital organ blood flow, with less elevation of
intrathoracic, right atrial, and intracranial pressure, resulting
in greater coronary and cerebral perfusion pressure and
greater myocardial and cerebral blood flow.
Adjunctive CPR Techniques
Extracorporeal Membrane Oxygenation
• In institutions with the ability to rapidly mobilize an
extracorporeal circuit, extracorporeal CPR should be
considered for refractory pediatric cardiac arrest when the
condition leading to arrest is reversible and when the period
of no flow (cardiac arrest without CPR) was brief. Survival with
a good neurologic outcome is possible after more than 50
minutes of CPR in selected children who were resuscitated via
extracorporeal CPR.
• Extracorporeal CPR should be reserved for children who have
effective CPR initiated immediately after cardiac arrest.
Adjunctive CPR Techniques
Active Compression-Decompression
• Negative-pressure “pull” on the thorax during the release
phase of chest compression using a hand-held suction device.
• Improve vascular pressures and minute ventilation during CPR
in animals and humans by enhancing venous return.
• Studies: Contradicting results.
• Complications: Fatal rib and sternal fractures.
Adjunctive CPR Techniques
Interposed Abdominal Compression
• IAC-CPR : The delivery of an abdominal compression during
the relaxation phase of chest compression.
1- Return venous blood to the chest during chest relaxation.
2- Increase intrathoracic pressure and augments the duty cycle
of chest compression.
3- Compress the aorta and return blood retrograde to the carotid
or coronary arteries.
• Human studies : increase in aortic pressure and coronary
perfusion pressure during IAC-CPR compared with
conventional CPR. The risk of injury to intra-abdominal organs
during IAC-CPR has not been evaluated.
Special Cardiac Arrest Situations
Hyperkalemia
• Diagnosis: history, progression of ECG changes, initial
laboratory results.
• Aim of treatment:
1-Antagonize the effects of hyperkalemia at the
myocardial cell membrane, increasing the threshold for
fibrillation by calcium chloride/gluconate.
2-Shift potassium from the extracellular to the
intracellular compartment by sodium bicarbonate and
hyperventilation, insulin with dextrose (0.1 unit/kg of
insulin with 2 ml/kg of dextrose 25%).
Special Cardiac Arrest Situations
Supraventricular Tachycardia
• It is a common arrhythmia in infants and children.
• If no circulatory compromise: vagal maneuver such as ice to
the face may be tried first before adenosine.
• The initial dose is 0.1 ► 0.2 ► 0.4 mg/kg given as a rapid
intravenous bolus (central Vs peripheral).
• In neonates, repeated doses of 0.05 mg/kg are given until
termination of the arrhythmia up to a maximum dose of 0.25
mg/kg.
• If circulatory compromise: immediate synchronized
cardioversion of 0.5 J/kg. If intravenous access is available,
adenosine can be administered as cardioversion is being
prepared (but not delayed).
Special Cardiac Arrest Situations
Pulseless Electrical Activity
• PEA: organized ECG activity, excluding ventricular tachycardia
and fibrillation, without clinical evidence of a palpable pulse
or myocardial contractions.
• Primary (cardiac) due to depletion of myocardial energy.
Drugs used to treat primary PEA are epinephrine, atropine,
calcium, and sodium bicarbonate.
Special Cardiac Arrest Situations
Pulseless Electrical Activity
4 H’s
4 T’s
Hypoxemia
Hypovolemia
Hypothermia
Tension pneumothorax
Tamponade (cardiac)
Thromboebolism
Hypoelectrolemia
Toxins (anesthetic overdose)
When the cause of PEA is unknown and the child does not
respond to medications, one should consider giving a fluid
bolus and inserting needles into the pleural space to rule out
pneumothorax and into the pericardial space to rule out
cardiac tamponade
Anaphylaxis
• Flushing, pallor, or urticaria, airway edema obstruction,
bronchospasm, and cardiovascular collapse.
• Severe anaphylaxis in situations of decreased endogenous
catecholamines as in children taking β blockers or receiving spinal or
epidural anesthesia.
• Resuscitation rests on reversing airway obstruction and
restoring intravascular volume and vascular tone.
• In the child with impending cardiac arrest, 0.01 mL/kg of
subcutaneous epinephrine (1 : 1000 concentration).
• Large volume fluid resuscitation of BSS.
• Diphenhydramine (Benadryl), 1 mg/kg.
• Methylprednisolone (Solu-Medrol), 2 mg/kg.
• Albuterol may help reverse bronchospasm.
• The airway should be secured early before being difficult to secure.
THANK YOU
• Continue resuscitation until:
• The child shows signs of life (normal
breathing, cough, movement or definite pulse
of greater than 60 min-1).
• Further qualified help arrives.
• You become exhausted.
Chest compression in children aged over 1
year:
„hƒn Place the heel of one hand over the lower
half of the sternum (as above).
„hƒn Lift the fingers to ensure that pressure is
not applied over the child’s ribs.
„hƒn Position yourself vertically above the
victim’s chest and, with your arm
straight, compress the sternum to depress it by
at least one-third of the
depth of the chest.
„hƒn In larger children, or for small rescuers,
this may be achieved most easily by
using both hands with the fingers interlocked.
• Chest compression in infants:
• The lone rescuer should compress the sternum with the tips of two
fingers.
• If there are two or more rescuers, use the encircling technique:
• o Place both thumbs flat, side by side, on the lower half of the
• sternum (as above), with the tips pointing towards the infant’s
• head.
• o Spread the rest of both hands, with the fingers together, to
• encircle the lower part of the infant’s rib cage with the tips of the
• fingers supporting the infant’s back.
• o Press down on the lower sternum with your two thumbs to
• depress it at least one-third of the depth of the infant’s chest.
For all children, compress the lower half of the sternum:
To avoid compressing the upper abdomen, locate the xiphisternum by
finding the angle where the lowest ribs join in the middle. Compress the
sternum one finger’s breadth above this.
Compression should be sufficient to depress the sternum by at least onethird
of the depth of the chest.
Don’t be afraid to push too hard. Push “hard and fast”.
Release the pressure completely, then repeat at a rate of 100 - 120 min-1
After 15 compressions, tilt the head, lift the chin, and give two effective
breaths.
Continue compressions and breaths in a ratio of 15:2.
• If you are confident that you can detect signs of a
circulation within 10 s:
• Continue rescue breathing, if necessary, until the child
starts breathing effectively on his own.
• Turn the child onto his side (into the recovery position) if he
starts breathing effectively but remains unconscious.
• If there are no signs of life, unless you are CERTAIN that
you can feel
• a definite pulse of greater than 60 min-1 within 10 s
• Start chest compression.
• Combine rescue breathing and chest compression.
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Assess the child’s circulation (signs of life):
Take no more than 10 s to:
Look for signs of life. These include any movement, coughing, or normal
breathing (not abnormal gasps or infrequent, irregular breaths).
If you check the pulse take no more than 10 s:
o In a child aged over 1 year – feel for the carotid pulse in the
neck.
o In an infant – feel for the brachial pulse on the inner aspect of the
upper arm.
o For both infants and children the femoral pulse in the groin (mid
way between the anterior superior iliac spine and the symphysis
pubis) can also be used.
For both infants and children, if you have difficulty
achieving an effective breath, the airway may be
obstructed:
• Open the child’s mouth and remove any visible
obstruction. Do not perform a blind finger sweep.
• Ensure that there is adequate head tilt and chin lift but
also that the neck is not over extended.
• If head tilt and chin lift has not opened the airway, try
the jaw thrust method.
• Make up to 5 attempts to achieve effective breaths. If
still unsuccessful, move on to chest compression.
Rescue breaths for an infant:
• Ensure a neutral position of the head (as an infant’s head is usually flexed
• when supine, this may require some extension) and apply chin lift.
• Take a breath and cover the mouth and nasal apertures of the infant with
• your mouth, making sure you have a good seal. If the nose and mouth
• cannot both be covered in the older infant, the rescuer may attempt to seal
• only the infant’s nose or mouth with his mouth (if the nose is used, close the
• lips to prevent air escape).
• Blow steadily into the infant’s mouth and nose over 1-1.5 s sufficient to
make
• the chest rise visibly.
• Maintain head position and chin lift, take your mouth away, and watch for
his
• chest to fall as air comes out.
• Take another breath and repeat this sequence four more times.
Rescue breaths for a child over 1 year:
Ensure head tilt and chin lift.
Pinch the soft part of his nose closed with the index finger and thumb of
your
hand on his forehead.
Open his mouth a little, but maintain the chin lift.
Take a breath and place your lips around his mouth, making sure that you
have a good seal.
Blow steadily into his mouth over about 1-1.5 s sufficient to make the
chest
rise visibly.
Maintaining head tilt and chin lift, take your mouth away and watch for his
chest to fall as air comes out.
Take another breath and repeat this sequence four more times. Identify
effectiveness by seeing that the child’s chest has risen and fallen in a
similar
fashion to the movement produced by a normal breath.
• 5A. If the child is breathing normally:
• Turn the child onto his side into the recovery position (see below).
• Send or go for help – call the relevant emergency number. Only
leave the child if no other way of obtaining help is possible.
• Check for continued normal breathing.
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5B. If the breathing is not normal or absent:
Carefully remove any obvious airway obstruction.
Give 5 initial rescue breaths.
While performing the rescue breaths note any gag or cough
response to your action. These responses, or their absence, will
form part of your assessment of ‘signs of life’, described below.
• In the first few minutes after cardiac arrest a
child may be taking infrequent, noisy gasps.
Do not confuse this with normal breathing.
Look, listen, and feel for no more than 10 s
before deciding – if you have any doubts
whether breathing is normal, act as if it is not
normal.
• 4. Keeping the airway open, look, listen, and
feel for normal breathing by
• putting your face close to the child’s face and
looking along the chest:
• Look for chest movements.
• Listen at the child’s nose and mouth for
breath sounds.
• Feel for air movement on your cheek.
• 3B. If the child does not respond:
• Shout for help.
• Turn the child onto his back and open the airway using head tilt and
chin lift:
• o Place your hand on his forehead and gently tilt his head back.
• o With your fingertip(s) under the point of the child’s chin, lift the
• chin. Do not push on the soft tissues under the chin as this may
• block the airway.
• o If you still have difficulty in opening the airway, try the jaw thrust
• method: place the first two fingers of each hand behind each side
• of the child’s mandible (jaw bone) and push the jaw forward.
• 1. Ensure the safety of rescuer and child.
• 2. Check the child’s responsiveness:
• Gently stimulate the child and ask loudly, ‘Are you all
right?’
• Do not shake infants, or children with suspected
cervical spine injuries.
• 3A. If the child responds by answering or moving:
• Leave the child in the position in which you find him
(provided he is not in further danger).
• Check his condition and get help if needed.
• Reassess him regularly.
Rescuers Taught the Adult BLS
Rescuers who have been taught adult BLS, and have no specific knowledge
of pediatric resuscitation, should use the adult sequence with the
following modifications :
-Give 5 initial rescue breaths before starting chest compression.
-If you are on your own, perform CPR for 1 min before going for help.
-Compress the chest by at least one-third of its depth.
- Use two fingers for an infant under 1 year; use one or two hands for a
child over 1 year as needed to achieve an adequate depth of compression.