Cardiorespiratory arrest

Signs of shock, cyanosis, bradycaradia / tachycardia, apnoea or increasing tachypnoea are warning signs and an indication for urgent resuscitation. See MET call criteria

The majority of arrests in children are due to hypoxia, hypotension and acidosis. The most common dysrhythmias are severe bradycardia, pulseless electrical activity or asystole. Ventricular arrhythmias (Ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT))  are seen with pre-existing cardiac disease (cardiomyopathies, hereditary prolongation of QT interval, congenital heart disease), poisoning (eg. tricyclic antidepressants) and low voltage electrocution (less than 1000 volts), and may occur during resuscitation. SVT may cause shock in newborn infants.

Initial management

Assessment and Management of the airway and breathing are the initial priorities.

Call for help Dial 777 for MET call

Stimulate and assess response

Airway opening manoeuvers   Check breathing

Bag valve mask ventilation

Assess for pulse and signs of circulation

Assessment

A - Airway

• Position the head - neutral position (<1 year old), or sniffing position ( 1 year of age)
• Open airway - Head tilt and chin lift, or jaw thrust
• Use oropharyngeal airway if required.

B - Breathing

• Signs of respiratory inadequacy

If respiration is adequate, administer oxygen by facemask at 10 l/min.
Do not use self-inflating bags in spontaneously ventilating patients.They are designed to deliver O2 only if squeezed.

If the child is not breathing, commence artificial ventilation.

Artificial ventilation

• Select the appropriate sized resuscitator bag  
  • Infant up to 2 years - 500 ml bag
  • Child/adult > 2 years - 2 litre bag
• Select an appropriate sized mask.
• Obtain an airtight seal
• O2 flow rate of 10-15 l/min and attachment of a reservoir assembly will give nearly 100% O2. 
• An oropharyngeal airway will facilitate maintenance of the airway and bag and mask ventilation.
• Brief suction of the mouth and pharynx if needed, using a yankeur sucker under direct vision
• Ventilate to have normal chest rise and fall. Do not over ventilate
• Intubation should only be attempted by those credentialed and skilled to do so

Endotracheal intubation

Select the correct tube size:

Older than 1 year:  Tube size (mm) = (age in yr/4) + 4 
                            Length at lip (cm) = (age in yr/2) + 12

C - Circulation

If there are no signs of circulation, i.e. no pulse, slow pulse (<60) or you are not sure, commence external cardiac compression, and determine the cardiac rhythm - display the ECG

• Signs of circulatory inadequacy         

External cardiac compression

• DO NOT interrupt except for defibrillation.
• Place the child on a firm surface. If on a bed, place the cardiac massage board under the patient, not under the mattress
• Apply massage to the lower half of the sternum in all patients including newborns
• Compress sternum 1/3 the depth of the chest.
• Use the hand technique that allows you to achieve this - see examples pictures:
  • With large children use the "heel" of one hand with the other superimposed.
  • For small children use the heel of one hand
  • For infants use two fingers. 
  • For newborn infants the best technique is a two-handed hold in which both thumbs compress the sternum. 
• Gain IV or IO access as soon as possible - at least the second dose of adrenaline should be given via this route
• Frequent changes of personnel (every few minutes) is desirable
• During resuscitation do not stop to check for a pulse unless the ECG shows an organised rhythm.
• After DC  shock continue CPR for 2 minutes prior to checking rhythm.

During resuscitation

Correct treatable causes

• Hypoxaemia
• Hypovolaemia
• Hypo/hyperthermia
• Hypo/hyperkalaemia
• Tamponade
• Tension pneumothorax
• Toxins/poisons/drugs
• Thrombosis

Other drugs to consider

Atropine
for persistent asystole / bradycardia
(20mcg/kg) (min 100mcg, max 600mcg)

Lignocaine
Never give lignocaine after Amiodarone
Amiodarone is the preferred agent
Same indications as Amiodarone. Dose (1mg/kg) (0.1ml/kg of 1%)

Magnesium Sulphate
For hypomagnesaemia or for polymorphic VT (torsade de pointes)
50% solution: 0.05-0.1ml/kg (0.1-0.2mmol/kg) (max 2 g)
Infuse over 5 mins.

Sodium bicarbonate, calcium, and doses of adrenaline >10mcg/kg/dose have no place in routine resuscitation.

Other issues

Blood gas analysis

• It is not a priority in initial resuscitation attempts, and obtaining a sample should not distract from other resuscitation manoevres.
• Arterial (and to some extent venous) blood gas analysis can help determine degree of hypoxaemia, adequacy of ventilation, degree of acidosis, and presence of electrolyte abnormalities such as hyopmagnesaemia.

Post resuscitation care

• Ensure airway and breathing are managed effectively including intubation if not already performed. Do not extubate. Use adequate sedation and analgesia.
• Ventilate to normo carbia
• Circulation  - maintain adequate blood pressure with use of inotropes as needed. Monitor for further arrhythmias. 
• Aim for core temperature of 35 degrees (do not actively warm if core temp >32 degrees)
• Ongoing anti arrhythmic 
• Ensure normo glycaemia

See also

Withholding or Withdrawal of Life-Sustaining Treatment