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Pediatric Resuscitation

Learning Objectives

For pediatric residents on cardiology rotation

Core Knowledge & Clinical Reasoning

  • [ ] Apply PALS cardiac arrest algorithms distinguishing shockable from non-shockable rhythms
  • [ ] Analyze H's and T's systematically during resuscitation to identify reversible causes
  • [ ] Know key differences between pediatric and adult resuscitation
  • [ ] Understand when epinephrine should be given (ASAP for non-shockable; after 2nd shock for shockable)

Acute Management (Resident Scope)

  • [ ] Perform high-quality CPR with appropriate rate (100-120/min) and depth (1/3 AP diameter)
  • [ ] Minimize CPR interruptions (<10 seconds for pulse/rhythm checks)
  • [ ] Determine appropriate defibrillation energy (2 J/kg → 4 J/kg)
  • [ ] Know epinephrine dosing: 0.01 mg/kg IV/IO every 3-5 minutes

Special Populations

  • [ ] Modify resuscitation approach for CHD populations (Fontan, single ventricle, PH)
  • [ ] Recognize that Fontan patients require aggressive volume and are difficult to resuscitate

Communication & Counseling

  • [ ] Lead resuscitation team with clear communication and role assignment
  • [ ] Counsel families during and after resuscitation events with honesty and compassion
  • [ ] Facilitate family presence during resuscitation when appropriate

Systems-Based Practice

  • [ ] Participate in resuscitation quality improvement (debriefing, mock codes)
  • [ ] Ensure appropriate documentation and family follow-up after cardiac arrest

Key Guidelines

2025 AHA/AAP Pediatric Advanced Life Support Guidelines Circulation. 2025 - Part 8: PALS First guidelines co-developed equally by AHA and AAP

2025 AHA/AAP Pediatric Basic Life Support Guidelines Circulation. 2025 - Part 6: PBLS

2025 Key Updates

What's New in 2025 PALS

  • Physiology-directed resuscitation: Target DBP ≥25 mmHg (infants) or ≥30 mmHg (children) if arterial line present
  • CPR quality: Minimize interruptions to <10 seconds
  • Epinephrine timing: Give ASAP for non-shockable rhythms (associated with better outcomes)
  • Infant compressions: Two-thumb encircling technique OR heel of one hand if cannot encircle chest
  • FBAO: Back blows (5) alternating with abdominal thrusts (5) for children with severe obstruction

Pediatric BLS Key Points

Compression-Ventilation Ratio

  • Single rescuer: 30:2
  • Two rescuers: 15:2

Compression Depth

  • Infants: At least 1.5 inches (4 cm)
  • Children: At least 2 inches (5 cm)
  • Allow full chest recoil

Compression Rate

  • 100-120 compressions/minute
  • Same as adults

Pediatric Chain of Survival

  1. Prevention
  2. Early recognition and activation
  3. High-quality CPR
  4. Advanced resuscitation
  5. Post-arrest care
  6. Recovery

PALS Cardiac Arrest Algorithm (2025)

Shockable Rhythms (VF/pVT)

  1. High-quality CPR while defibrillator charges
  2. Shock 2 J/kg → Resume CPR immediately × 2 min
  3. Shock 4 J/kg → Resume CPR × 2 min → Epinephrine 0.01 mg/kg
  4. Shock 4 J/kg → Resume CPR × 2 min → Antiarrhythmic
  5. Amiodarone 5 mg/kg IV/IO, OR
  6. Lidocaine 1 mg/kg IV/IO
  7. Continue: Shock → CPR → Epinephrine (every 3-5 min)

2025 Note: Epinephrine given after 2nd shock for shockable rhythms. Rapid defibrillation remains priority.

Non-Shockable Rhythms (Asystole/PEA)

  1. High-quality CPR
  2. Epinephrine 0.01 mg/kg IV/IO as soon as possible ← KEY 2025 UPDATE
  3. Continue epinephrine every 3-5 minutes
  4. Search for reversible causes (H's and T's)

2025 Update: For non-shockable rhythms, administering epinephrine ASAP is associated with improved outcomes.

H's and T's

H's: - Hypovolemia - Hypoxia - Hydrogen ion (acidosis) - Hypoglycemia - Hypo/hyperkalemia - Hypothermia

T's: - Tension pneumothorax - Tamponade (cardiac) - Toxins - Thrombosis (pulmonary/coronary)

Special Circumstances: CHD

Single Ventricle Physiology

  • Unique pathophysiology requires modified approach
  • May need higher FiO2 or different ventilation strategy
  • Baseline saturations vary widely

Pulmonary Hypertension

  • Avoid hypoxia, acidosis, hypothermia (worsen PH)
  • Consider inhaled nitric oxide
  • May need higher doses of vasopressors
  • ECMO consideration early

Fontan Circulation

  • Dependent on venous return
  • Aggressive volume resuscitation critical
  • Avoid positive pressure ventilation if possible
  • Very difficult to resuscitate

Post-Arrest Care

Targeted Temperature Management

  • Maintain normothermia (36-37.5°C)
  • Avoid hyperthermia
  • Consider therapeutic hypothermia in specific cases

Hemodynamic Support

  • Target normal blood pressure
  • Avoid hypo- and hypertension
  • Vasoactive support as needed

Neuroprotection

  • Avoid hypoglycemia and hyperglycemia
  • Avoid hyperthermia
  • Control seizures

Physiology-Directed Resuscitation (2025)

New in 2025: When invasive arterial monitoring is available during CPR:

Age Target DBP During CPR
Infants ≥25 mmHg
Children ≥30 mmHg
  • Provides real-time feedback on CPR quality
  • DBP reflects coronary perfusion pressure
  • Adjust compressions to achieve targets

Board Pearls

Pearl: Pediatric compression-ventilation ratio: 15:2 with two rescuers

Single rescuer uses 30:2 (same as adult)

Pearl: 2025 update - Epinephrine timing matters

Non-shockable: Give ASAP. Shockable: Give after 2nd shock

Pearl: First shock: 2 J/kg; subsequent shocks: 4 J/kg

Minimize pause for shock delivery (<10 sec interruption)

Pearl: Physiology-directed CPR targets (if arterial line present)

Target DBP ≥25 mmHg (infant) or ≥30 mmHg (child) during compressions

Pearl: Fontan resuscitation is very difficult

Dependent on passive venous return; needs aggressive volume, avoid positive pressure if possible

Self-Assessment

Q1: An 8-year-old in cardiac arrest is found to be in VF. After 2 shocks and 2 rounds of CPR, what medication should be given?

Answer **Answer**: Epinephrine 0.01 mg/kg IV/IO **Rationale**: For VF/pVT, epinephrine is given after the 2nd shock. Antiarrhythmics (amiodarone or lidocaine) are considered after the 3rd shock if VF/pVT persists.

References

  • 2025 AHA/AAP Pediatric Advanced Life Support Guidelines. Circulation. 2025. Part 8: PALS
  • 2025 AHA/AAP Pediatric Basic Life Support Guidelines. Circulation. 2025. Part 6: PBLS
  • Topjian AA, et al. Pediatric Basic and Advanced Life Support Collaborators. Circulation. 2025