Levels of Evidence (LOE) (1-8) are defined at the end of the "Major Recommendations" field.
Initial Steps of Cardiopulmonary Resuscitation (CPR)
Activating Emergency Medical Services and Getting the Automated External Defibrillator (AED)
A period of immediate CPR before phoning emergency medical services (EMS) and getting the AED ("call fast") is indicated for most pediatric arrests because they are presumed to be asphyxial or prolonged. In a witnessed sudden collapse (e.g., during an athletic event), the cause is more likely to be ventricular fibrillation (VF), and the lone rescuer should phone for professional help and get the AED (when available) before starting CPR and using the AED, if appropriate. Rescuers should perform CPR with minimal interruptions in chest compressions until attempted defibrillation.
In summary, the priorities for unwitnessed or nonsudden collapse in children are as follows:
- Start CPR immediately.
- Activate EMS/get the AED.
The priorities for witnessed sudden collapse in children are as follows:
- Activate EMS/get the AED.
- Start CPR.
- Attempt defibrillation.
Pulse Check
Lay rescuers should start chest compressions for an unresponsive infant or child who is not moving or breathing. Healthcare professionals may also check for a pulse but should proceed with CPR if they cannot feel a pulse within 10 seconds or are uncertain if a pulse is present.
Ventilations in Infants
There is no data to justify a change from the recommendation that the rescuer attempt mouth-to-mouth-and-nose ventilation for infants. Rescuers who have difficulty achieving a tight seal over the mouth and nose of an infant, however, may attempt either mouth-to-mouth or mouth-to-nose ventilation (LOE 5) (Tonkin & Gunn, 2001).
Circumferential Versus 2-Finger Chest Compressions
The 2 thumb-encircling hands chest compression technique with thoracic squeeze is the preferred technique for 2-rescuer infant CPR. The 2-finger technique is recommended for 1-rescuer infant CPR to facilitate rapid transition between compression and ventilation and to minimize interruptions in chest compressions. It remains an acceptable alternative method of chest compressions for 2 rescuers.
One- Versus 2-Hand Chest Compression Technique
Both the 1- and 2-hand techniques for chest compressions in children are acceptable provided that rescuers compress over the lower part of the sternum to a depth of approximately one third the anterior-posterior diameter of the chest. To simplify education, rescuers can be taught the same technique (i.e., 2-hand) for adult and child compressions.
Compression-Ventilation Ratio
For ease of teaching and retention, a universal compression ventilation ratio of 30:2 is recommended for the lone rescuer responding to infants (for neonates see National Guideline Clearinghouse summary of American Heart Association guideline Neonatal Resuscitation), children, and adults. For healthcare providers performing 2-rescuer CPR, a compression-ventilation ratio of 15:2 is recommended. When an advanced airway is established (e.g., a tracheal tube, esophageal-tracheal combitube [Combitube], or laryngeal mask airway [LMA]), ventilations are given without interrupting chest compressions.
Some CPR Versus No CPR
Bystander CPR is important for survival from cardiac arrest. Trained rescuers should be encouraged to provide both ventilations and chest compressions. If rescuers are reluctant to provide rescue breaths, however, they should be encouraged to perform chest compressions alone without interruption.
Disturbances in Cardiac Rhythm
Management of Supraventricular Tachycardias
If the child with supraventricular tachycardia (SVT) is hemodynamically stable, the Task Force members recommend early consultation with a pediatric cardiologist or other physician with appropriate expertise. This recommendation is common for all of the SVT topics below.
Vagal Maneuvers for SVT
The Valsalva maneuver and ice application to the face may be used to treat hemodynamically stable SVT in infants and children. When performed correctly, these maneuvers can be initiated quickly and safely and without altering subsequent therapies if they fail.
Amiodarone for Hemodynamically Stable SVT
Amiodarone may be considered in the treatment of hemodynamically stable SVT refractory to vagal maneuvers and adenosine. Rare but significant acute side effects include bradycardia, hypotension, and polymorphic ventricular tachycardia (VT) (LOE 5) (Yap, Hoomtje, & Sreeram, 2000; Daniels et al., 1998; Gandy, Wonko, & Kantoch, 1998).
Procainamide for Hemodynamically Stable SVT
Procainamide may be considered in the treatment of hemodynamically stable SVT refractory to vagal maneuvers and adenosine.
Management of Stable Wide-QRS Tachycardia
If a child with wide-QRS tachycardia is hemodynamically stable, early consultation with a pediatric cardiologist or other physician with appropriate expertise is recommended. In general, amiodarone and procainamide should not be administered together because their combination may increase risk of hypotension and ventricular arrhythmias.
Amiodarone
Wide-QRS tachycardia in children who are stable may be treated as SVT. If the diagnosis of VT is confirmed, amiodarone should be considered.
Procainamide for Stable VT
Procainamide may be considered in the treatment of hemodynamically stable VT.
Management of Unstable VT
Amiodarone
Synchronized cardioversion remains the treatment of choice for unstable VT. Amiodarone may be considered for treatment of hemodynamically unstable VT.
Pediatric Defibrillation
For additional information about consensus on science and treatment recommendations for defibrillation (e.g., 1 versus 3 stacked shock sequences and sequence of CPR first versus defibrillation first), see the NGC summary of the AHA guideline Defibrillation.
Manual and Automated External Defibrillation
The treatment of choice for pediatric VF/pulseless VT is prompt defibrillation, although the optimum dose is unknown. For manual defibrillation, the Task Force members recommend an initial dose of 2 J/kg (biphasic or monophasic waveform). If this dose does not terminate VF, subsequent doses should be 4 J/kg.
For automated defibrillation, the Task Force members recommend an initial pediatric attenuated dose for children 1 to 8 years of age and up to about 25 kg (55 pounds) and 127 cm (50 inches) in length. There is insufficient information to recommend for or against the use of an AED in infants <1 year of age. A variable dose manual defibrillator or an AED able to recognize pediatric shockable rhythms and equipped with dose attenuation are preferred; if such a defibrillator is not available, a standard AED with standard electrode pads may be used. A standard AED (without a dose attenuator) should be used for children
>25 kg (about 8 years of age) and older adolescent and adult victims.
Management of Shock-Resistant VF/Pulseless VT
Amiodarone
Intravenous (IV) amiodarone can be considered as part of the treatment of shock-refractory or recurrent VT/VF.
Airway and Ventilation
Bag-Valve-Mask (BVM) Ventilation
In the out-of-hospital setting with short transport times, BVM ventilation is the method of choice for children who require ventilatory support. When transport times are long, the relative benefit versus potential harm of tracheal intubation compared with BVM ventilation is uncertain. It is affected by the level of training and experience of the healthcare professional and the availability of exhaled carbon dioxide (CO2) monitoring during intubation and transport.
Advanced Airways
Cuffed Versus Uncuffed Tracheal Tubes
Cuffed tracheal tubes are as safe as uncuffed tubes for infants (except newborns) and children if rescuers use the correct tube size and cuff inflation pressure and verify tube position. Under certain circumstances (e.g., poor lung compliance, high airway resistance, and large glottic air leak), cuffed tracheal tubes may be preferable.
Laryngeal Mask Airway (LMA)
There is insufficient data to support or refute a recommendation for the routine use of an LMA for children in cardiac arrest. The LMA may be an acceptable initial alternative airway adjunct for experienced providers during pediatric cardiac arrest when tracheal intubation is difficult to achieve.
Confirmation of Tube Placement
Exhaled CO2
In all settings (i.e., prehospital, emergency departments, intensive care units, operating rooms), confirmation of tracheal tube placement should be achieved using detection of exhaled CO2 in intubated infants and children with a perfusing cardiac rhythm. This may be accomplished using a colorimetric detector or capnometry. During cardiac arrest, if exhaled CO2 is not detected, tube position should be confirmed using direct laryngoscopy.
Esophageal Detector Device
The esophageal detector device may be considered for confirmation of tracheal tube placement in children weighing >20 kg.
Confirmation of Tracheal Tube Placement During Transport
The Task Force members recommend monitoring tracheal tube placement and patency in infants and children with a perfusing rhythm by continuous measurement or frequent intermittent detection of exhaled CO2 during prehospital and intra- and interhospital transport.
Oxygen
Oxygen During Resuscitation
There is insufficient information to recommend for or against the use of any specific inspired oxygen concentration during and immediately after resuscitation from cardiac arrest. Until additional evidence is published, the Task Force members support healthcare providers' use of 100% oxygen during resuscitation (when available). Once circulation is restored, providers should monitor oxygen saturation and wean inspired oxygen while ensuring adequate oxygen delivery.
Vascular Access and Drugs for Cardiac Arrest
Routes of Drug Delivery
Intraosseous (IO) Access
The Task Force members recommend establishing IO access if vascular access is not achieved rapidly in any infant or child for whom IV drugs or fluids are urgently required.
Drugs Given via Tracheal Tube
Intravascular, including IO, injection of drugs is preferable to administration by the tracheal route. The recommended tracheal dose of atropine, epinephrine, or lidocaine is higher than the vascular dose and is as follows:
- Epinephrine 0.1 mg/kg (multiple LOE 6 studies)
- Lidocaine 2 to 3 mg/kg (LOE 3) (Hahnel et al., 1990) and multiple LOE 6 studies
- Atropine 0.03 mg/kg (LOE 2) (Lee et al., 1989)
The optimal tracheal doses of naloxone or vasopressin have not been determined.
Drugs in Cardiac Arrest
Dose of Epinephrine for Cardiac Arrest
Children in cardiac arrest should be given 10 micrograms/kg of epinephrine as the first and subsequent intravascular doses. Routine use of high-dose (100 micrograms/kg) intravascular epinephrine is not recommended and may be harmful, particularly in asphyxia. High-dose epinephrine may be considered in exceptional circumstances (e.g., beta-blocker overdose).
Vasopressin in Cardiac Arrest
There is insufficient evidence to recommend for or against the routine use of vasopressin during cardiac arrest in children.
Magnesium in Cardiac Arrest
Magnesium should be given for hypomagnesemia and torsades de pointes VT, but there is insufficient evidence to recommend for or against its routine use in cardiac arrest.
Postresuscitation Care
Ventilation
Hyperventilation
Hyperventilation after cardiac arrest may be harmful and should be avoided. The target of postresuscitation ventilation is normocapnia. Short periods of hyperventilation may be performed as a temporizing measure for the child with signs of impending cerebral herniation.
Temperature Control
Therapeutic Hypothermia
Induction of hypothermia (32 degrees C to 34 degrees C) for 12 to 24 hours should be considered in children who remain comatose after resuscitation from cardiac arrest.
Treatment of Hyperthermia
Healthcare providers should prevent hyperthermia and treat it aggressively in infants and children resuscitated from cardiac arrest.
Hemodynamic Support
Vasoactive Drugs
Vasoactive drugs should be considered to improve hemodynamic status in the post-cardiac arrest phase. The choice, timing, and dose of specific vasoactive drugs must be individualized and guided by available monitoring data.
Blood Glucose Control
Treatment of Hypoglycemia and Hyperglycemia
Healthcare providers should check glucose concentration during cardiac arrest and monitor it closely afterward with the goal of maintaining normoglycemia. Glucose-containing fluids are not indicated during CPR unless hypoglycemia is present (LOE 7) (Longstreth et al., 1986).
Prognosis
Predictors of Outcome in Children
The rescuer should consider whether to discontinue resuscitative efforts after 15 to 20 minutes of CPR. Relevant considerations include the cause of the arrest, preexisting conditions, whether the arrest was witnessed, duration of untreated cardiac arrest ("no flow"), effectiveness and duration of CPR ("low flow"), prompt availability of extracorporeal life support for a reversible disease process, and associated special circumstances (e.g., icy water drowning, toxic drug exposure).
Definitions:
Levels of Evidence
Level 1: Randomized clinical trials or meta-analyses of multiple clinical trials with substantial treatment effects
Level 2: Randomized clinical trials with smaller or less significant treatment effects
Level 3: Prospective, controlled, nonrandomized cohort studies
Level 4: Historic, nonrandomized cohort or case-control studies
Level 5: Case series; patients compiled in serial fashion, control group lacking
Level 6: Animal studies or mechanical model studies
Level 7: Extrapolations from existing data collected for other purposes, theoretical analyses
Level 8: Rational conjecture (common sense); common practices accepted before evidence-based guidelines
