PALS | Pedi Cardiac Arrest Extended

80/20 Summary: Pediatric Cardiac Arrest Recognition & Management

1. Core Pathways & Immediate Recognition (High-Impact 20%)

• Pathways to Arrest: Most pediatric cardiac arrests stem from progressive hypoxic/asphyxial respiratory failure or shock rather than sudden cardiac collapse[1][2]. Out-of-hospital arrest (OHCA) survival is ~8%, whereas in-hospital (IHCA) survival reaches ~43%[1][3].
• Immediate Recognition: Identify unresponsiveness, absent/agonal breathing, and absence of a central pulse assessed in ≤10 seconds[4][5]. Begin CPR immediately within 10 seconds if uncertain[1][5].

2. High-Quality CPR & Airway Management

• Sequence & Ratios: Use C-A-B[6]. Without an advanced airway, compression-to-ventilation ratio is 30:2 (1 rescuer) and 15:2 (2+ rescuers)[7]. With an advanced airway, give continuous compressions at 100–120/min with 1 breath every 6 seconds (10 breaths/min)[7][8].
• Compression Technique: Rate is 100–120/min[7]. Depth is at least 1/3 chest AP diameter (~1.5 in / 4 cm in infants; ~2 in / 5 cm in children)[7]. Allow full recoil and limit chest compression pauses to <10 seconds[7][9]. Rotate compressors every 2 minutes[8][10].
• CPR Monitoring: PETCO₂ goal is >10–15 mmHg; a jump to >40 mmHg indicates Return of Spontaneous Circulation (ROSC)[9][11].

3. Cardiac Arrest Algorithms & Electrical Therapy

• Nonshockable Rhythms (Asystole / PEA): Most common initial pediatric arrest rhythms (~85–95%)[3][5]. Pathway: Start CPR → Give Epinephrine ASAP → Reassess rhythm every 2 minutes → Treat reversible H's & T's[12].
• Shockable Rhythms (VF / pVT): Occurs in 5–15% initially[3]. Pathway: Deliver 1st shock at 2 J/kg → CPR 2 min → Recheck rhythm → If persistent, 2nd shock at 4 J/kg + Epinephrine → CPR 2 min → 3rd shock (≥4 J/kg, max 10 J/kg) + Amiodarone or Lidocaine[10].
• Paddle Sizes: Adult paddles (8–13 cm) for >10 kg (≥1 yr); infant paddles (4.5 cm) for <10 kg (<1 yr)[16].

4. Critical Resuscitation Medications

• Epinephrine: Dose is 0.01 mg/kg (0.1 mL/kg of 0.1 mg/mL) IV/IO every 3–5 minutes[12][17]. ET dose is 0.1 mg/kg[12][17].
• Amiodarone: 5 mg/kg IV/IO bolus (max 300 mg) for refractory VF/pVT, repeatable up to 2 times[12][15].
• Lidocaine: 1 mg/kg IV/IO loading dose[12][15].
• Magnesium Sulfate: 25–50 mg/kg (max 2 g) for Torsades de Pointes or hypomagnesemia[15][18].
• Vascular Access Order: IV → IO (obtain within 30–60 sec) → Endotracheal (ET) as last resort[19][20].

5. Reversible Causes (H's and T's)

• H's: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypoglycemia, Hypo-/Hyperkalemia, Hypothermia[4][21].
• T's: Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (pulmonary), Thrombosis (coronary)[4][21].