Abstract:

Important changes were introduced in

the 2010 American Heart Association
guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Cardiac arrest remains a
leading cause of death in many parts
of the world, and despite important
advances in medical science, the
outcome of cardiopulmonary arrest is
poor. The fundamental changes in the
American Heart Association 2010
guidelines include the new recommendation to begin resuscitation with
chest compression, airway, and
breathing. We will review and discuss
how to approach a successful pediatric resuscitation with the maintenance of adequate coronary artery
and cerebral artery perfusion and,
ultimately, how to improve outcomes
in infants and children.

Keywords:
cardiopulmonary resuscitation;
C-A-B; chest compression; bag valve
mask; endotracheal tube; end-tidal
CO2; intraosseous; automatic
external defibrillator; dysrhythmia;
defibrillation; therapeutic hypothermia; termination of resuscitation
Department of Pediatrics, Division of
Emergency Medicine, Children's Hospital
at Montefiore/Albert Einstein College of
Medicine, Bronx, NY.
Reprint requests and correspondence:
Waseem Hafeez, MD, is to be contacted at
Department of Pediatrics, Division of
Emergency Medicine, Children's Hospital
at Montefiore/Albert Einstein College of
Medicine, 3315 Rochambeau Avenue,
Bronx, NY 10467. Lorraine Ronca, DO,
Theresa Maldonado, MD.
whafeez@montefiore.org (W. Hafeez),
lronca@montefiore.org (L.T. Ronca),
tmaldona@montefiore.org
(T.E. Maldonado)
1522-8401/$ - see front matter
2011 Elsevier Inc. All rights reserved.

Pediatric
Advanced Life
Support Update
for the
Emergency
Physician:
Review of 2010
Guideline
Changes
Waseem Hafeez, MD,
Lorraine T. Ronca, DO,
Theresa E. Maldonado, MD

6-month-old female infant was brought into the

emergency department (ED) by her mother for respiratory distress. The patient had emesis and diarrhea for
the past day and was not breathing right since the
morning. The infant appeared very pale and was obtunded with
agonal respirations. Her fontanelle was sunken, and there was no
visible capillary refill. Her tone was limp. Her extremities were
cool, and a pulse could not be detected immediately.
Chest compressions were begun at a rate of 100/min, at a depth
of 1.5 in, using 2 thumbs with the hands encircling the chest.

PALS UPDATE FOR THE EMERGENCY PHYSICIAN / HAFEEZ, RONCA, AND MALDONADO VOL. 12, NO. 4 255

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Compressions were begun immediately because the patient

was unresponsive with abnormal breathing and no
detection of a pulse within 10 seconds. After 30
compressions were given, the airway was opened
with head tiltchin lift, and no spontaneous respirations were observed. Look, listen and feel has been
removed from the sequence.
Two breaths were delivered with a bag valve mask
(BVM) device, and good chest rise was observed.
Two effective breaths at 1 second per breath were
given with a 450-mL-sized bag connected to an
oxygen flow rate of 10 to 15 L/min. The compressionto-ventilation ratio was 15:2, as more than 2 rescuers were
present. For 1 cardiopulmonary resuscitation (CPR)
rescuer in all ages, a 30:2 ratio is recommended.
The patient was intubated with a 3.5-mm (internal diameter) cuffed endotracheal tube (ETT).
Cuffed tubes may be used in all ages. Cricoid pressure is
no longer recommended. Tube placement was confirmed by physical examination, auscultation, exhaled CO2 detector, and pulse oximeter. Ventilation
was provided at 8 to 10 breaths/min. Endotracheal
tube placement should be confirmed by capnography.
Breathing rate with an advanced airway is 8 to 10 breaths/
min in all ages.
Vascular access was not able to be obtained
within the first 90 seconds. An intraosseous (IO)
needle was inserted into the right tibia. Blood was
sent for analysis. Early IO placement is now recommended in all ages if intravascular (IV) access is not
available in less than 90 seconds.
Further history and physical examination revealed
the following: the patient has Bartter syndrome
(genetic renal disorder resulting in hyponatremic,
hypokalemic metabolic alkalosis) and receives potassium chloride (KCl) supplements, spironolactone,
indomethacin, and simethicone at home. She had a
gastrostomy tube in place and a Broviac catheter
inserted into the right chest. She was discharged
from the hospital 5 days ago for treatment of low
serum potassium. Upon discharge, the dose of KCl
was increased.
The cardiac monitor showed a wide-complex
ventricular tachycardia (VT) at a rate of 183/min,
and no pulse was palpated at the femoral artery. It was
determined that the patient was in pulseless VT.
While the defibrillator was charging, CPR was
continued. Defibrillation with a dose of 2 J/kg was
given, and CPR was immediately resumed. The
patient was still in pulseless VT, so a second
defibrillation dose was given at 4 J/kg followed by
epinephrine (0.1 mL/kg of 1:10 000 solution) at a dose
of 0.01 mg/kg, and CPR was continued. Cardiopulmonary resuscitation and defibrillation are critical in the
management of pulseless VT and ventricular fibrillation

(VF). High-dose epinephrine 1:1000 is not recommended for

IV or IO dosing, only for ETT delivery.
Because the patient did not revert to a perfusing
rhythm, defibrillation at 4 J/kg was delivered,
followed by amiodarone, 5 mg/kg. Another shock of
4 J/kg and 1 mg/kg of lidocaine was given while CPR
was continuously delivered except during delivery of
shocks. Recommended sequence for defibrillation is as
follows: CPR Y shock (2 J/kg) Y CPR Y shock (4 J/kg) Y
drug Y CPR Y shock (4 J/kg).
Laboratory analysis of blood revealed the following: for arterial blood gaspH 7.11, PCO2 46 mm Hg,
PO2 120 mm Hg, and HCO3 6 mEq/L, and for
serum chemistrysodium 144 mEq/L, potassium
13 mEq/L, CO2 6 mEq/L, glucose 194 mg/dL, blood
urea nitrogen 18 mg/dL, creatinine 0.9 mg/dL, and
calcium 6 mg/dL. A 12-lead electrocardiogram
(ECG) revealed VT with peaked T waves at a rate
of 183/min. Hyperkalemia was immediately treated
with calcium chloride, insulin, glucose, sodium
bicarbonate, furosemide, and Kayexalate. Identification and treatment of the underlying causes of any pulseless
electrical activity (PEA) are imperative. Five Hs and 5 Ps
are the most common causes: hypoxemia, hypovolemia,
hypoglycemia, hypothermia, hypokalemia/hyperkalemia,
pneumothorax, pericardial tamponade, pHsevere acidosis, pulmonary embolism, and poison overdose/toxicology.
The repeat potassium level was 6 mEq/L, and the
patient converted to normal sinus rhythm and
transferred to the pediatric intensive care unit for
further management. The pulse oximeter was maintained at 98% while she was in the ED. Arterial
oxyhemoglobin saturation was maintained at least 94% but
less than 100% to limit the risks of hyperoxemia.

PALS SCIENCE UPDATE 2010

This case highlights some important changes
that were introduced in the most recent recommendations in the 2010 American Heart Association
(AHA) guidelines for CPR and emergency cardiovascular care.
These changes mark the 50th anniversary of the
landmark 1960 recommendations when researchers
combined breaths and compressions to create CPR as
we know it today. In 1966, the AHA developed the first
CPR guidelines and has periodically updated its
recommendations based on research data and clinical
experience. 1 In 1992, the International Liaison
Committee on Resuscitation, an international consortium of the world's resuscitation councils, was formed
to periodically review the current resuscitation
literature and issue consensus treatment guidelines.
Despite important advances in medical science,
cardiac arrest remains a leading cause of death in

PALS UPDATE FOR THE EMERGENCY PHYSICIAN / HAFEEZ, RONCA, AND MALDONADO VOL. 12, NO. 4 257

many parts of the world. In the United States and

Canada, every year approximately 350 000 people
(almost half of them in-hospital) have cardiac arrest
and receive attempted resuscitation. 2 Approximately 25% of patients present with pulseless ventricular
arrhythmias and have a better outcome than those
who present with asystole or PEA. 3 The outcome of
unwitnessed cardiopulmonary arrest in infants and
children is poor. Infants are less likely to survive
out-of-hospital cardiac arrest than children or
adolescents. 4 Only 6% of pediatric patients who
have out-of-hospital cardiac arrest survive to discharge, and most are neurologically impaired,
whereas the in-hospital survival rate is 27% with a
better neurologic outcome. 2,4 Pulseless arrests
(PEA/asystole) have the poorest outcome, whereas
infants and children with a pulse but with poor
perfusion and bradycardia had the best survival
(64%) to discharge. For out-of-hospital respiratory
arrest and primary VF, bystander resuscitation has
had a substantial impact on survival with good
neurologic outcome. 5,6
A review of the evidence over the last few years
has revealed that rapid and effective CPR administered by a lay rescuer resulted in a successful return
of spontaneous circulation (ROSC) with neurologically intact survival in children after out-of-hospital
cardiac arrest. 7 The increased use of the automatic
external defibrillator (AED) in children with sudden
out-of-hospital witnessed arrest secondary to primary VF resulted in survival rates of 20% to 30%. 6
Individuals receiving bystander CPR were 4.5 times
more likely to survive and 3 times likely to leave the
hospital. Unfortunately, only one third to one half of
infants and children who have out-of-hospital cardiopulmonary arrest receive bystander CPR, and when
provided, CPR is frequently not begun promptly or
done well, even by health care professionals. 7 For
untrained rescuers, hands-only chest compression
CPR is now approved for the adult victim with sudden
collapse. All trained rescuers should provide chest
compressions and rescue breaths at a rate of 30:2. At
this time, there is insufficient evidence to recommend
hands-only CPR in children. 7

HIGHLIGHTS OF PEDIATRIC BASIC LIFE

SUPPORT (BLS) AND PALS
Pediatric Chain of Survival
The critical links in the pediatric cardiac arrest
chain of survival are as follows:
Injury prevention and safety
Early CPRchest compressions and ventilations

Rapid access to emergency medical services

911
Effective pediatric life support post-cardiac
arrest care
The leading causes of death in infants and children
are congenital malformations, complications of prematurity, sudden infant death syndrome, and
injury. 8 The back to sleep campaign has been
credited with decreasing mortality secondary to
sudden infant death syndrome. Motor vehicle crashes
are the most common cause of fatal childhood injuries
because the rate of survival from traumatic cardiac
arrest is rare. 9 Injuries related to accidental or
inflicted traumatic events can be prevented by
parental education and counseling, the use of
passenger safety seats and bicycle helmets, and
vigilance for nonaccidental trauma.

Check for Response

Look, listen, and feel for breathing has been
removed from the BLS algorithm. 10 In the new chest
compressions first sequence, breathing is briefly
checked as part of a check for cardiac arrest. If the
infant or child is unresponsive and not breathing,
health care providers may take up to 10 seconds to
attempt to feel for a pulse (brachial in an infant and
femoral in a child). If, within 10 seconds, the pulse is
not palpable, and the victim is unresponsive, not
breathing, or only gasping, perform CPR, beginning
with chest compressions. Studies show that lay
rescuers and many health care providers cannot
quickly and reliably determine the presence or
absence of a pulse in infants or children; thus, the
reliance on the presence of pulse check alone in
determining the need for CPR is minimized in the
2010 guidelines. 11

CPR Sequence Change From A-B-C to C-A-B

During the past 50 years, the primary emphasis
has been to begin resuscitation by the A-B-Cs, the
BLS sequence of airway assessment, assisting
breathing, and support of circulation. Most adult
victims have cardiac arrest as a result of VF or
pulseless VT, and the highest survival rates are
among patients of all ages who receive immediate
chest compression and early defibrillation. 6
The fundamental change in the AHA 2010 guidelines includes the new recommendation to begin
resuscitation with C-A-B (chest compression, airway,
and breathing). 12 The predominant factor in return
of circulation (ROSC) and survival in cardiac arrest
victims is the maintenance of adequate coronary
artery and cerebral artery perfusion. The most

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important concept in understanding the physiology

of CPR is the relationship of coronary artery
perfusion pressure (CPP) to myocardial blood flow
and resuscitation outcome. 13 Ideally, CPP measurement could be used to optimize chest compressions
and monitor CPR quality. A measurement of CPP or
arterial relaxation (diastolic) pressure is accurately
done using invasive arterial catheterization, which is
unlikely during the initial phase of CPR. Measurement of end-tidal carbon dioxide tension (PETCO2)
correlates with CPP and cerebral perfusion pressure
and is predictive of the outcomes of CPR. 14 It may be
used to monitor the effectiveness of chest compressions during CPR.
In persons with sudden cardiac arrest, the
bystander rescuer has traditionally been taught to
initiate the CPR sequence by opening the airway
(which involves head repositioning) and provide
breathing (which requires setting up ventilation
apparatus and obtaining a proper seal over the
mouth), the 2 most difficult and time-consuming
tasks for the rescuer, all of which delays the start of
CPR. Over the years, the A-B-C technique has been
entrenched into everyone so that the lay rescuer
who does not feel comfortable doing A (airway) and B
(breathing) is unlikely to go on to the C (compression) component. This would explain the reason why
so many persons with sudden cardiac arrest receive
no bystander CPR. By starting with chest compressions immediately, the most often-cited barriers to
performing CPR, A and B, are bypassed. The C-A-B
sequence is applicable for infants, children, and
adults alike. 10 This recommendation simplifies
training and provides consistency to a technique
that, for most rescuers, will be used only occasionally. These guidelines are supported by evidence that
suggests that participants across the board from
physicians to lay people often fail to master CPR
skills, with rapid deterioration of learned skills after
course completion. 15
Most cardiac arrests in infants and children are
primarily respiratory in origin, and resuscitation
outcome is best if chest compressions are combined
with ventilations. 7 The current recommendation is
to individualize the CPR sequence based on the
presumed etiology of the arrest. For in-hospital
pediatric arrests, health care providers are more
likely to work in teams and CPR sequences are often
performed simultaneously (chest compressions and
rescue breathing), so there is less relevance to
which intervention is performed first. During CPR
after cardiopulmonary arrest, cardiac output is
reduced to approximately 25% to 33% of normal,
so oxygen uptake from the lungs and CO2 delivery
to the lungs are also reduced. 16 Because both the

systemic and pulmonary perfusions are significantly

reduced during CPR, oxygen delivery to the heart
and brain is limited by blood flow rather than
by arterial oxygen content. During the first few
minutes of resuscitation, chest compressions are far
more important than rescue breaths, and normal
ventilation perfusion can be maintained with a
lower-minute ventilation. 17 Positive pressure ventilation could reduce CPR efficacy by interrupting
chest compressions and increasing intrathoracic
pressure, thus reducing coronary perfusion. Rescuers who opened the airway first took 30 critical
seconds longer to begin chest compressions, during
which time there is no coronary perfusion. By
changing the sequence to C-A-B, providing chest
compressions initially would rapidly restore adequate coronary and cerebral blood flow. The delay
in ventilation should be minimal, approximately
18 seconds, the time required to deliver the first
cycle of 30 chest compressions.

Chest CompressionPush Hard, Push Fast

The most important determinant of a successful
resuscitation is to provide high-quality chest compressions. To be effective, deliver effective chest
compressions on a firm surface. Components of
high-quality CPR include the following:
Push fast: perform chest compressions at a
rate of at least 100 compressions/min.
Push hard: for an infant, the chest should be
depressed at least one third the anteriorposterior diameter of the chest or approximately 1.5 in (4 cm). For children and
adolescents, depress the chest 2 in (5 cm).
Compression landmarks: in infants, the lone
rescuer should compress the sternum with
2 fingers, using the index and ring fingers
placed just below the intermammary line. 10
Push straight down, assuring that the compressions are smooth, not jerky. Avoid compression
over the xiphoid or ribs, which may damage
internal organs. When CPR is provided by
2 rescuers, the 2-thumb encircling-hands
technique is recommended. Place both the
thumbs together over the lower third of the
sternum and encircle the infant's chest with
both hands, spreading the fingers around the
thorax. 10 Forcefully compress the sternum
with the thumbs. There is no benefit in
squeezing the thorax at the time of chest
compression. The 2-thumb encircling-hands
technique is preferred over the 2-finger technique because it provides better force of
compression and produces higher CPP. 18 In

PALS UPDATE FOR THE EMERGENCY PHYSICIAN / HAFEEZ, RONCA, AND MALDONADO VOL. 12, NO. 4 259

children, compress the lower half of the

sternum with the heel of 1 or 2 hands. For
adolescents, compress the lower half of the
sternum with the heel of 2 hands. The long axis
of both heels should be placed parallel with the
long axis of the sternum, and rescuers should
straighten their arms and lock their elbows,
positioning their shoulders over their arms so
that body mass is added to the force of the
compressions.
Allow complete chest recoil: after each
compression, allowing the chest wall to recoil
completely permits the heart to refill with
blood and improves the blood flow to the body
during CPR. Incomplete chest wall recoil
during the decompression phase of CPR
increases intrathoracic pressure, which decreases venous return and mean arterial
pressure and significantly impairs coronary
and cerebral perfusion pressures. 19
Minimize interruptions of chest compressions: for the lone rescuer, a compressionto-ventilation ratio of 30:2 is recommended.
After giving 30 compressions, provide
2 breaths and immediately resume compressions, aiming to provide 5 cycles in about
2 minutes. When chest compressions are
interrupted, coronary perfusion pressure rapidly declines, which may require several chest
compressions to restore adequate coronary
pressure once compressions are resumed.
Frequent interruptions of chest compressions
should be avoided to reduce the duration of
low coronary perfusion pressure and flow.
Rotate the compressor role approximately
every 2 minutes: during pediatric CPR, rescuer
fatigue is common and can lead to inadequate
compression rate and depth, with deterioration
in quality, even when the rescuer denies feeling
fatigued. Because the quality of chest compressions may deteriorate within minutes, rescuers
should switch compression and ventilation
roles approximately every 5 cycles (about
2 minutes) to prevent compressor fatigue. To
minimize interruptions in chest compressions,
the switch should be anticipated by the
providers and accomplished as quickly as
possible, ideally in less than 5 seconds.

Airway and Breathing

Resuscitation outcomes in infants and children
are best if chest compressions are combined with
ventilations because of the higher percentage of
asphyxial arrests in the pediatric population. During

CPR, providers often deliver excessive ventilation

particularly when an advanced airway is in place. 20
Excessive ventilation increases intrathoracic pressure and impedes venous return, which decreases
cardiac output, cerebral blood flow, and coronary
perfusion. 21 For the single rescuer, a compressionto-ventilation ratio of 30:2 is recommended for all
ages, which provides more compressions per minute
and a higher CPP. For 2-rescuer infant and child
CPR, one provider should perform 15 chest compressions, whereas the second rescuer opens the
airway with a head tiltchin lift maneuver and
delivers 2 breaths. A compression-to-ventilation
ratio of 15:2 provides more ventilations per minute,
which is appropriate for most hypoxic, hypercarbic
pediatric arrests. One should use the jaw thrust
without head tilt to open the airway if there is
concern for spinal trauma. If the jaw thrust
is unsuccessful in opening the airway, protect the
C-spine and carefully use the head tiltchin lift
maneuver because maintaining a patent airway is
critical in providing adequate ventilation. Coordinate compressions with ventilations to avoid simultaneous delivery and minimize interruptions in
chest compressions. However, if the patient has an
ETT in place, deliver at least 100 chest compressions/min continuously without pauses for ventilations. Ventilation is provided by delivering 8 to
10 breaths/min (a breath every 6 to 8 seconds),
being careful to avoid excessive ventilation.

BVM Ventilation
Bag valve mask ventilation is an essential CPR
technique for health care providers. In apneic
patients and those in respiratory failure, the initial
method for ventilation is with a bag mask
apparatus, until all the appropriate equipment
and personnel for intubation are assembled. For
optimum airway alignment, the head should be
kept midline, with the auditory meatus in line with
the top of the anterior shoulder. The sniffing
position is achieved, in an older child, by placing a
folded towel under the head and elevating it, and
infants, by slightly extending the head with a pad
under the shoulders. Flexing or overextending the
neck may interfere with adequate ventilation by
kinking the airway. Provide ventilation using a
BVM device with an appropriate size face mask.
The proper size mask extends from the bridge of
the nose to the cleft of the chin. The minimum
volume for a bag in newborns, infants, and small
children is 450 to 500 mL, as smaller bags may not
deliver an effective tidal volume. 10 In adolescents,
an adult bag should be used. If only an adult bag is
available, ventilation of infants and children is

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possible using a proper size face mask and

administering only enough volume to cause the
chest to rise. Maintain an oxygen flow of 10 to
15 L/min into a reservoir attached to a pediatric
bag and at least 15 L/min in an adult bag.
Proper ventilation with a BVM device is achieved
in pediatric patients using the E-C clamp technique. 10 Hold the mask snugly to the face with the
left thumb and index finger forming a C. While
avoiding pressure to the eyes, apply downward
pressure over the mask to achieve a good seal. The
remaining 3 fingers of the left hand form an E and
are placed on the mandible to lift the jaw, avoiding
compression of the soft tissues of the neck. If CPR is
being provided, deliver the breaths at the end of
each cycle of chest compressions. An oral airway
(used in comatose patients with an absent gag
reflex) or nasopharyngeal airway (obtunded patients with an intact gag reflex) may help to
maintain a patent airway during BVM resuscitation.
Because positive pressure ventilation with a BVM
causes distention of the stomach, place a nasogastric tube to decompress air from the stomach to
minimize the risk of aspiration.

IntubationCuffed vs Uncuffed ETTs

Tracheal intubation is the best way to manage the
airway during CPR. Previously, cuffed ETTs were
only used in children older than 8 years; however,
newer high-volume, low-pressure cuffed tubes may
be used in children of all ages (except newborns). 12
The risk of complications in infants and children is
similar with cuffed and uncuffed tracheal tubes. 22
Patients in whom high mean airway pressures or
poor lung compliance is expected, such as those
with status asthmaticus, a cuffed ETT may be
preferable to an uncuffed tube, provided cuff
inflation pressure is kept less than 20 to 25 cm
H2O. 12 To select the correct tracheal tube size for
different ages, the following formulas may be used:
Uncuffed ETT = 4 plus age in years
4
Cuffed ETT = 3:5 plus age in years
4 . 12

Exhaled CO2 Detector

The new PALS guidelines recommend the use of
either a colorimetric detector or capnography to
confirm tracheal tube placement for neonates,
infants, and children with a perfusing cardiac
rhythm in all settings (eg, prehospital, ED, and
intensive care unit). 12 Immediately after cardiac
arrest, CO2 continues to be produced in the body,
but there is no CO2 delivery to the lungs. Continuous quantitative waveform capnography is a

reliable and rapid bedside method of confirming

ETT placement and for ongoing monitoring of ETT
placement and is recommended for intubated
patients throughout the periarrest period. Measurement of PETCO2 correlates with coronary and
cerebral perfusion pressures and is predictive of
the outcomes of CPR. 14 It may be used to help guide
therapy especially for monitoring cardiac output
and the effectiveness of chest compressions during
CPR or shock. As with many devices, there are
limitations that can affect results and interpretations. Values of PETCO2 decrease for a short time
after administration of epinephrine or other vasoconstrictive medications as a result of a reduced
pulmonary blood flow. Colorimetric CO2 detector
devices are reliable only with a perfusing rhythm.
False-positive readings due to contamination with
carbonated beverages in the stomach may be
minimized by administering 6 ventilations to clear
any residual CO2 from the trachea. In very small
infants (b2 kg), there may be insufficient volumes of
CO2 exhaled to produce a color change.

Cricoid Pressure
There is insufficient evidence to recommend
routine cricoid pressure application to prevent
aspiration during endotracheal intubation in children. 23 Cricoid pressure is used to prevent gastric
inflation by the application of pressure on the
cricoid cartilage sufficient to occlude the esophagus
without compressing the airway lumen or moving
the cervical spine. However, cricoid pressure can
impede the placement of an ETT and does not
entirely prevent aspiration. Cricoid pressure may be
considered in an unresponsive patient, only if there
is a third health care provider available. 12

Oxygen
Oxygen delivery has a paradoxical effect on the
injured brain. Inadequate oxygenation may potentiate anoxic injury, whereas hyperoxemia after
ROSC from cardiac arrest enhances the oxidative
injury after ischemia reperfusion. 24 Until additional
information becomes available, current guidelines
recommend the use of 100% oxygen during resuscitation. Once circulation is restored, ensure adequate arterial oxygen content by titrating oxygen
administration to maintain the oxyhemoglobin
saturation between 94% and 99% because an oxygen
saturation of 100% may correspond to a PaO2
anywhere between 80 and 500 mm Hg. 12

Laryngeal Mask Airway

The laryngeal mask airway (LMA) consists of a
tube attached to a mask rimmed with a soft

PALS UPDATE FOR THE EMERGENCY PHYSICIAN / HAFEEZ, RONCA, AND MALDONADO VOL. 12, NO. 4 261

inflatable cuff. When properly placed, the LMA

rests in the hypopharynx around the glottic
opening and directs air into the trachea. It is
used in patients with decreased airway reflexes
(ie, obtunded or comatose). Unlike a tracheal
tube, it will not prevent aspiration of gastric
contents into the trachea, making them unsuitable
for most emergent situations in infants and
children. LMA insertion is associated with a higher
incidence of complications in young children
compared with older children and adults. 25
There is insufficient evidence to recommend the
routine use of an LMA during cardiac arrest in
children. The LMA is an acceptable alternative
rescue device used by experienced providers when
bag mask ventilation and endotracheal intubation
are unsuccessful.

Rapid Sequence IntubationEtomidate

Contraindicated in Septic Shock
Rapid sequence intubation (RSI) involves the
sequential injection of preselected sedatives and
neuromuscular blocking agents to gain immediate
control of the airway. In the critically ill patient
with increased intracranial pressure or those who
may be hemodynamically unstable or uncooperative, attempting awake tracheal intubation is likely
to agitate the patient resulting in worsening
symptoms and increasing the risk of vomiting and
pulmonary aspiration. The goals of RSI are to
create ideal intubating conditions by attenuating
airway reflexes and to minimize elevations of
intracranial pressure while maintaining adequate
blood pressure. The patient is given a short-acting
sedative/analgesic (eg, etomidate, thiopental, midazolam, ketamine, fentanyl, or propofol) followed
immediately by a short-acting muscle relaxant (eg,
succinylcholine or rocuronium). The choice of
drug will depend on the clinical situation and
individual experience of the provider with these
agents. Patients in cardiac arrest or moribund
patients rarely require any medications to facilitate
intubation. The possibility of an unsuccessful
intubation should be anticipated, and preparations
for alternate airway management should be arranged before initiation of RSI. Etomidate is a
short-acting anesthetic that has minimal hemodynamic effects and decreases intracranial pressure;
it is a drug of choice for RSI in most clinical
situations in the ED. Etomidate should not be
routinely used in pediatric patients with evidence
of septic shock because even a single dose causes
adrenal suppression, which is associated with a
higher mortality rate in children. 26

Vascular Access
When IV access is challenging or impossible, such
as in cardiac arrest or other emergent situations, do
not spend more than 90 seconds attempting
peripheral vascular access. The IO approach allows
for rapid, safe, and effective access for the administration of medications and fluids and should be
attempted immediately while other vascular sites
are sought. Intraosseous needle placement is no
longer restricted to children younger than 6 years,
and currently, various devices are available for all
age groups. 12 The primary site for IO insertion is the
proximal tibia. The Jamshidi IO needle (Baxter,
Deerfield, IL), the Cook IO needle (Cook Medical,
Inc, Bloomington, IN), and the newer EZ-IO system,
which consists of a small battery-powered driver,
are commercially available in sizes for infants,
children, and adults. 27 The insertion of EZ-IO
needle (Vidacare, Shavano Park, TX) is easier than
manually inserted needles because the power drill
does the all the work; however, extra precaution is
required because it is easy to overshoot the marrow
and through the other side. The FAST 1/FAST X
(Pying Medical Corporation, British Columbia,
Canada) sternal IO infusion system is designed to
safely penetrate into the manubrium. Adult and
adolescent patients (age, N12 years) have a manubrium thickness deep enough to make the procedure safe.

Dysrhythmia Management
An approach to pediatric dysrhythmia management is shown in the algorithm (Figure 1) and begins
with checking the patient's responsiveness and a
rapid pulse check. Unstable signs include altered
mental status and abnormal vital signs (temperature, heart rate, blood pressure, respiratory rate,
pulse oximeter). All patients require secure vascular
access, oxygen therapy, and cardiopulmonary monitoring. The goal of initial management is to restore
normal mental status, good oxygenation and perfusion, and adequate urine output. A 12-lead ECG
should be obtained to assess the rate, rhythm,
absence or presence of P wave, and whether there is
a widened QRS complex (N0.09 seconds).

Bradycardia
Patients with asymptomatic bradycardia have
adequate pulses, perfusion, and respirations, and
no emergency treatment is necessary. Continue
monitoring and proceed with a complete evaluation.
In patients with symptomatic bradycardia (heart
rate b60 beats/min with cardiovascular compromise), start chest compressions and support airway,

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1. Assess Patient & Check Pulse

2. Calculate Rate
3. Analyze Rhythm: P-wave/QRS PRESENT
4. Treat Patient

CHECK PULSE

Check Rate

ABSENT

UNSTABLE SIGNS
Altered mental status
Hypotension
s/s Shock, Resp failure
CPR (5 cycles in 2 min)

<8yr: 15 compressions
>8yr: 30 compressions

HR >160 bpm

HR < 60 bpm

Check ABCs Start CPR

IV/IO Access
100% O2

+ 2 breaths

STABLE

UNSTABLE

Check Rhythm

Initiate CPR
Epinephrine (1:10,000)
0.1 cc/kg IV q 3-5 min
Vagal/Primary AV block:
Atropine (0.02 mg/kg)
Min 0.1 mg
Max 0.5 mg child
1 mg adolescent
Consider Pacing

Check ABCs
100% O2
Monitor
Evaluate

Check QRS

NARROW
QRS 0.09

PRESENT

WIDE
QRS > 0.09

VT / VF
UNSTABLE

ABSENT

PEA/EMD

ASYSTOLE

Check P-wave
Epinephrine

IV (1:10,000) 0.1 ml/kg IV q 3-5 min

ETT (1:1,000) 0.1 ml/kg

ABNORMAL
OR ABSENT

NORMAL

PROBABLE SINUS TACHYCARDIA

Infant <220 bpm ; child <180 bpm)

Identify and treat cause
PROBABLE SVT (infant >220 bpm; child >180 bpm)
STABLE:
Check ABCs
Give 100% O2
IV access
Vagal stimulation (no delay)
Adenosine: rapid push / large IV + 5-10 ml NS flush
First dose 0.1 mg/kg IV push (6 mg maximum)
repeat dose 0.2 mg/kg IV push (12 mg maximum)
Consider Synchronized Cardioversion
UNSTABLE:
Cardioversion 0.5 - 1 J/kg
(max: Mono 100, 200, 300, 360 J / Biphasic 100, 200 J)

Adapted from AHA 2010 Guidelines

Identify/Treat Causes:
Pneumothorax
Pericardial Tamponade
pH- Acidosis
Pulmonary Embolism
Poisons Drug OD

Hypoxemia
Hypovolemia
Hypoglycemia
Hypothermia
Hypo/hyperkalemia

PULSELESS VENTRICULAR TACH - FIBRILLATION

Continue CPR (while defibrillator charges)

Defibrillate X 1@2 J/kg (max 200 J mono/biphasic)
Defibrillate 4 J/kg (max mono 360 J / biphasic 200 J)
Epinephrine (1:10,000) 0.1 ml/kg IV q 3 - 5 min
Amiodarone 5 mg/kg (max 300 mg) IV bolus shock 4 J/kg
or Lidocaine 1 mg/kg (max 100 mg) IV bolus shock 4 J/kg
Torsades: Magnesium 25 - 50 mg/kg (2 G max)
Repeat sequence : CPR shock 4 J/kg drug CPR

VENTRICULAR TACHYCARDIA
STABLE:
Check ABCs / 100% O2 / IV access
Amiodarone 5 mg/kg (max 150 mg) IV in 20-60 min
or Lidocaine 1 mg/kg (max 100 mg) IV bolus
UNSTABLE:
Synchronized Cardioversion 0.5 - 2 J/kg
(max: Mono 100, 200, 300, 360 J / Biphasic 100, 200 J)

Figure 1. Pediatric dysrhythmia algorithm.

NO PULSE

PALS UPDATE FOR THE EMERGENCY PHYSICIAN / HAFEEZ, RONCA, AND MALDONADO VOL. 12, NO. 4 263

ventilation, and oxygenation. If bradycardia persists,

administer epinephrine 0.01 mg/kg (0.1 mL/kg of
1:10 000 solution). If bradycardia is caused by
increased vagal tone or primary atrioventricular
conduction block, administer atropine 0.02 mg/kg
(minimum dose, 0.1 mg; maximum dose, 0.5 mg in
child, 1 mg in adolescent). If the bradycardia is
caused by complete heart block or congenital or
acquired heart disease, consider emergent transcutaneous pacing. Pacing is typically not useful for
bradycardia caused by postarrest hypoxia or ischemic myocardial failure.

Narrow-Complex Tachycardia
(QRS 0.09 Seconds)
Patients with supraventricular tachycardia without hemodynamic compromise may respond to
vagal stimulation. In infants and young children,
apply ice to the face without pressure to the eyes or
occluding the airway. Older children may perform a
Valsalva maneuver by bearing down forcefully or
blowing through an occluded straw. If ineffective,
attempt pharmacologic cardioversion with adenosine (0.1 mg/kg; maximum dose, 6 mg) using the
2-syringe technique; give adenosine rapidly with
1 syringe and immediately flush with 5 to 10 mL of
normal saline with another syringe attached to a
stopcock. If necessary, adenosine may be repeated
at a dose of 0.2 mg/kg (maximum dose, 12 mg).
Verapamil (0.1-0.3 mg/kg) may be used as a secondline therapy, with pediatric cardiology consultation.
Use of verapamil in infants is not recommended
because it may cause myocardial depression,
hypotension, and potential cardiac arrest.

Wide-Complex Tachycardia
(QRS N0.09 Seconds)
QRS duration varies with age and is considered
prolonged if it is more than 90 milliseconds
(0.09 second) for a child younger than 4 years and
100 milliseconds or more (0.1 second) for a child
between the ages of 4 and 16 years. 28 The current
PALS guideline defines a QRS width more than
0.09 second as prolonged for the pediatric patient, a
change of 0.01 second from previous recommendations, which can only be detected by computer
interpretation of the ECG rhythm strip. 12
Ventricular tachycardia may be monomorphic
(identical QRS complexes originating from a single
focus) or polymorphic (torsade de pointesirregular rhythm, varying QRS waveform). Ventricular
fibrillation is a pulseless, grossly disorganized, rapid
ventricular rhythm that varies in interval and
morphology and may be difficult to distinguish
from rapid, polymorphic VT. The ED treatment of

acute VT depends on the clinical state of the patient.

Stable patients with monomorphic VT and normal
perfusion may be treated with either amiodarone
(5 mg/kg IV for 20-60 minutes) or procainamide
(15 mg/kg IV for 30-60 minutes), although not
simultaneously because both will prolong the QT
interval. 12 One must monitor the ECG and blood
pressure because these drugs may cause widening of
the QRS complex and hypotension. If the patient
does not respond or becomes hemodynamically
unstable, synchronized cardioversion is recommended using an initial dose of 0.5 to 1 J/kg,
increasing to 2 J/kg, if necessary.
At times, it may be difficult to differentiate
supraventricular tachycardia with aberrant conduction from VT. In such cases, adenosine may be
used, provided there are monomorphic QRS
complexes with a regular rhythm. Avoid using
adenosine in patients known to have WolffParkinson-White syndrome who present with a
wide-complex tachycardia.
Pulseless VT and polymorphic VT are treated
similar to VF with high-energy unsynchronized
shocks (defibrillation). Survival is better in primary
than in secondary VF, and the probability of survival
declines by 7% to 10% for each minute of arrest
without CPR and defibrillation. 29 In such patients,
begin high-quality CPR and deliver a single defibrillation dose of 2 J/kg, immediately resuming chest
compressions for about 2 minutes. On the next
rhythm check, if VF persists, give a second shock at
4 J/kg. If subsequent rhythm checks reveal VF,
administer epinephrine 0.01 mg/kg (0.1 mL/kg of
1:10 000 solution) followed by defibrillation at
4 J/kg. Other medications used to treat VF/VT
include amiodarone (5 mg/kg IV bolus) or lidocaine
(1 mg/kg), and for torsades de pointes, magnesium
sulfate (25-50 mg/kg) is indicated. 12 The goal is to
provide continuous CPR with minimal interruptions
between shock deliveries.
The resuscitation sequence should be as follows:
CPR (stop only to deliver shock) Y defibrillation
(2 J/kg) Y CPR Y defibrillation (4 J/kg) Y
medication Y CPR Y defibrillation (4 J/kg). In prior
AHA guidelines, 3 stacked shocks were delivered
based on the low first shock efficacy of monophasic
defibrillators and also to decrease transthoracic
impedance. Current biphasic defibrillators have
a high first shock efficacy. With these devices,
if one shock fails to eliminate VF, the incremental
benefit of another immediate shock is low. Resumption of CPR is likely to provide improved coronary
perfusion, which increases the likelihood of
a successful defibrillation with the delivery of
a subsequent shock. Another disadvantage of a

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3-shock sequence was the delay of 29 to 37 seconds

between delivery of the first shock and the beginning
of the first postshock chest compression, the period
during which there is no coronary perfusion.

Automatic External Defibrillator

Automated external defibrillators may be used for
children and adults with witnessed sudden arrest
who have no signs of circulation. 12 An AED can
accurately detect VF in children and can differentiate shockable from nonshockable rhythms
with a high degree of sensitivity and specificity. 30
Neither the lowest-energy dose for effective defibrillation nor the upper limit for safe defibrillation is
known in pediatric patients. Automatic external
defibrillators that deliver relatively high-energy
doses have been successfully used in infants in
cardiac arrest with no clear adverse effects and
achieved good neurologic outcomes. In infants and
children 1 to 8 years old (weight, 10-25 kg; length,
b50 in), use an AED with a pediatric attenuator
system, which decreases the delivered energy to a
dose suitable for children. In infants younger than 1
year, a manual defibrillator is preferred. 12 The
recommended first energy dose for defibrillation is 2
J/kg, and if a second dose is required, it should be
doubled to 4 J/kg. If a manual defibrillator is not
available, an AED with a dose attenuator may be
used in infants.

Pulseless ArrestAsystole/PEA
The treatment of asystole and PEA is to provide
high-quality chest compression and adequate ventilation and to maintain perfusion to vital organs.
Administer epinephrine 0.01 mg/kg IV/IO (0.1 ml/kg
of 1:10 000 solution), or if there is no vascular
access, administer ETT at 0.1 mg/kg (0.1 ml/kg of
1:1000 solution). The epinephrine dose can be
repeated every 3 to 5 minutes. There is no role in
PALS for the routine use of high-dose epinephrine,
atropine, calcium, or vasopressin in asystole. 12
During resuscitation, it is vital to identify and treat
the reversible cause of arrest: the 5 Hs (hypoxemia,
hypovolemia, hypothermia, hypoglycemia, hypokalemia/hyperkalemia) and the 5 Ps (pneumothorax,
pericardial tamponade, pHsevere acidosis, pulmonary embolism, poisonsdrug overdose). 12

Therapeutic Hypothermia
Cardiac arrest commonly contributes to the brain
injury caused by hypoxia and global ischemia.
Multiple mechanisms are involved in neuronal
damage, both by hypoxia-induced encephalopathy
and by reperfusion-induced cellular and tissue

injury. The neuroprotective role of hypothermia is

achieved by multiple mechanisms. It reduces the
metabolic oxygen utilization in the brain, decreasing cerebral electrical activity and minimizing free
radical formation, which is associated with reperfusion injury. The AHA has recommended the use of
induced hypothermia in comatose adult patients
with ROSC after out-of-hospital VF cardiac arrest. 12
Based on existing randomized controlled trials in
adults and newborns, the AHA recommends that
hypothermia therapy may be considered in children
who remain comatose after resuscitation from
cardiac arrest. 31 The ideal method and duration of
cooling and rewarming are not known. Cooling
should be initiated within 6 hours after ROSC, with
a hypothermia target of 32C to 34C (89.6F to
93.2F) for 12 to 24 hours. 12 Although there are
multiple methods for inducing hypothermia, no
single method has proved to be optimal.

Termination of Resuscitation
Currently, there are no reliable predictors of
outcome during resuscitation to guide when to
terminate in-hospital resuscitation efforts. Bystander CPR for witnessed collapse and a short interval
from collapse to arrival of EMS improves the
chances of survival. Children with prolonged resuscitation efforts without ROSC after 2 doses of
epinephrine were considered unlikely to survive;
however, intact survival after an unusually prolonged in-hospital resuscitation has been documented in children with VF or VT, drug toxicity, and
primary hypothermic insult. 32

CONCLUSION
Successful resuscitation requires a well-organized
team approach, with each member knowing his or
her preassigned responsibilities. 33 Pediatric-sized
equipment and precalculated weight-based medication dosing devices or the Broselow tape must be
available and organized for easy access. It is
imperative that the staff have training in PALS and
routinely practice mock pediatric resuscitations in
their unit. The most important determinant of
successful resuscitation is the maintenance of
adequate coronary artery and cerebral artery
perfusion. These can be achieved by implementing
the new guidelines of the AHA, by beginning
resuscitation with C-A-B. Resuscitation outcomes
in infants and children can be improved by
providing high-quality chest compressions combined with effective ventilations.

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