Find information on medical topics, symptoms, drugs, procedures, news and more, written for the health care professional.

* This is a professional Version *

Cardiopulmonary Resuscitation in Infants and Children

by Robert E O'Connor, MD, MPH

Despite the use of CPR, mortality rates for cardiac arrest (see Cardiac Arrest) are 80 to 97% for infants and children. The mortality rate is almost 25% for respiratory arrest alone. Neurologic outcome is often severely compromised.

About 50 to 65% of children requiring CPR are < 1 yr; of these, most are < 6 mo. About 6% of neonates require resuscitation at delivery (see Neonatal Resuscitation); the incidence increases significantly if birth weight is < 1500 g.

Standardized outcome guidelines should be followed in reporting outcomes of CPR in children; eg, the modified Pittsburgh Outcome Categories Scale reflects cerebral and overall performance (see Pediatric Cerebral Performance Category Scale*).

Pediatric Cerebral Performance Category Scale*

Score

Category

Description

1

Normal

Age-appropriate level of functioning

In preschool-aged children, appropriate development

In school-aged children, attendance in regular classes

2

Mild disability

Can interact at an age-appropriate level

Minor neurologic disease that is controlled and does not interfere with daily functioning (eg, seizure disorder)

In preschool-aged children, possibly minor developmental delays, but with > 75% of all daily living developmental milestones above the 10th percentile

In school-aged children, attendance in regular school but in a grade that is not appropriate for age or in the appropriate grade but failing because of cognitive difficulties

3

Moderate disability

Below age-appropriate functioning

Neurologic disease that is not controlled and severely limits activities

In preschool-aged children, most daily living developmental milestones below the 10th percentile

In school-aged children, can do activities of daily living but attend special classes because of cognitive difficulties or a learning deficit

4

Severe disability

In preschool-aged children, activities of daily living milestones below the 10th percentile and excessive dependence on others for activities of daily living

In school-aged children, possibly severe impairment that prevents school attendance and dependence on others for activities of daily living

In preschool-aged and school-aged children, possibly abnormal motor movements, including nonpurposeful, decorticate, or decerebrate responses to pain

5

Coma or vegetative state

Unawareness

6

Death

*Worst level of performance for any single criterion is used for categorizing. Deficits are scored only if they result from a neurologic disorder. Assessments are based on medical records or an interview with the caretaker.

From Recommended guidelines for uniform reporting of pediatric advanced life support: The pediatric Utstein style; statement for health care professionals from the Task Force of the American Academy of Pediatrics, the American Heart Association, and the European Resuscitation Council; Pediatrics 96(4):765–779, 1995.

Standards and guidelines for CPR from the American Heart Association are followed (see see Figure: CPR Techniques for Health Care Practitioners). For protocol after a person has collapsed with possible cardiac arrest, see Overview and see Cardiopulmonary Resuscitation (CPR) in Adults : Circulation.

After CPR has been started, defibrillation (see Cardiopulmonary Resuscitation (CPR) in Adults : Defibrillation) and identification of the underlying cardiac rhythm (see Cardiopulmonary Resuscitation (CPR) in Adults : Monitor and IV) are done.

Major Differences Between Pediatric and Adult CPR

Prearrest

Bradycardia in a distressed child is a sign of impending cardiac arrest . Neonates, infants, and young children are more likely to develop bradycardia caused by hypoxemia, whereas older children initially tend to have tachycardia. An infant or child with a heart rate < 60/min and signs of poor perfusion that do not rise with ventilatory support should have cardiac compressions (see see Figure: Chest compression.). Bradycardia secondary to heart block is unusual.

Chest compression.

A: Side-by-side thumb placement for chest compressions is preferred for neonates and small infants whose chest can be encircled. Thumbs should overlap if used in very small neonates. B: Two fingers are used for infants. Fingers should be maintained in the upright position during compression. For neonates, this technique results in too low a position, ie, at or below the xiphoid; the correct position is just below the nipple line. C: Hand position for chest compression for a child. (Adapted from American Heart Association: Standards and guidelines for CPR. Journal of the American Medical Association 268:2251–2281,1992. Copyright 1992, American Medical Association.)

After adequate oxygenation and ventilation, epinephrine is the drug of choice (see First-line drugs).

BP should be measured with an appropriate-sized cuff, but direct invasive arterial BP monitoring is mandatory in severely compromised children.

Because BP varies with age, an easy guideline to remember the lower limits of normal for systolic BP (< 5th percentile) by age is as follows: < 1 mo, 60 mm Hg; 1 mo to 1 yr, 70 mm Hg; and > 1 yr, 70 + (2 × age in yr). Thus, in a 5-yr-old child, hypotension would be defined by a BP of < 80 mm Hg (70 + [2 × 5]). Of significant importance is that children maintain BP longer because of stronger compensatory mechanisms (increased heart rate, increased systemic vascular resistance). Once hypotension occurs, cardiorespiratory arrest may rapidly follow. All effort should be made to start treatment when compensatory signs of shock (eg, increased heart rate, cool extremities, capillary refill > 2 sec, poor peripheral pulses) are present but before hypotension develops.


Equipment and environment

Equipment size, drug dosage, and CPR parameters vary with patient age and weight (see CPR Techniques for Health Care Practitioners, see Table: Drugs for Resuscitation*, and see Table: Guide to Pediatric Resuscitation—Mechanical Measures). Size-variable equipment includes defibrillator paddles or electrode pads, masks, ventilation bags, airways, laryngoscope blades, endotracheal tubes, and suction catheters. Weight should be measured rather than guessed; alternatively, commercially available measuring tapes that are calibrated to read standard patient weight based on body length can be used. Some tapes are printed with the recommended drug dose and equipment size for each weight. Dosages should be rounded down; eg, a 2 ½-yr-old child should receive the dose for a 2-yr-old child.

Guide to Pediatric Resuscitation—Mechanical Measures

Age (yr)

Term neonate

< 12 mo

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

Weight (kg)

3.5

< 10

10

12

14

16

18

20

22

25

28

30

35

40

45

50

55

60

Ventilation rate/min (advanced airway)

Perfusing rhythm

30–60

20

20

12

Nonperfusing rhythm

8–10

Compression rate/min

120*

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

Compression/ventilation ratio (unprotected airway)

30:2 (1 rescuer)

15:2 (2 rescuers)

30:2

Compression techniques

Thumb compression, hands around chest (preferred) or 2 fingers

1 hand

2 hands

Airway size (Portex) in cm

000

00

00

0

0

7

7

7

7

7

7

7

7

7

8

8

8

8

3.5

5

5

6

6

Masks in Laerdal sizes or equivalent

Circular 0/1

Rendell- Baker type # 1

Rendell-Baker type # 2

Dome cuff mask # 3

Dome cuff mask # 4

Ventilation bag with reservoir for 100% O 2 delivery

Infant 240 mL

Child 400–500 mL

Adult 1600 mL

Laryngoscope blade size

Miller 0

Straight blade

1

1

1

2

2

2

2

2

2

2

3

3

3

3

3

3

3

Straight blade (preferred) or curved blade

Curved or straight blade

ETT size (Portex) in mm

3

3.5

4

4.5

4.5

5

5

5.5

5.5

6

6

6

6

6.5

6.5

6.5

6.5

7

Uncuffed

Uncuffed

Cuffed

Suction catheter

Direct oropharyngeal

Through ETT

10 F

Pediatric tonsil suction

8 Fr

Adult tonsil suction

10 Fr

Defibrillation (joules)

Dose (2 joules/kg)

Frequency

Maximum dose (4 joules/kg)

7      10

Pediatric paddles

20        20    30 30  30    50    50     50   50  70  70  70     100  100      200    200

Adult paddles

20

30

If no response, give maximum dose × 2

50           50       50     70     70     100 100  100           100    100    150      150      200     200   300   300

Cardioversion (joules)

Synchronized shock (0.5 joules/kg)

2

3

5

5

7

7

10

10

10

10

10

20

20

20

20

30

30

30

Frequency

Maximum dose (1 joule/kg)

5

5

10

10

Increase dose slowly at subsequent attempt to maximum

10      20     20    20   20    20     30    30      30      50      50   50  50 70

*Pause for ventilation

ETT = endotracheal tube; Fr = French.

Courtesy of Dr. B. Paes and Dr. M. Sullivan, the Departments of Pediatrics and Medicine, St. Joseph’s Hospital, The Children’s Hospital, Hamilton Health Sciences Corporation, McMaster University, Hamilton, Ontario, Canada.

Susceptibility to heat loss is greater in infants and children because of a large surface area relative to body mass and less subcutaneous tissue. A neutral external thermal environment is crucial during CPR and postresuscitation and may range from 36.5° C in a neonate to 35° C in a child. Hypothermia with core temperature < 35° C makes resuscitation more difficult (distinct from the beneficial effects of postresuscitation hypothermia Neurologic support).


Airway

Upper airway anatomy is different in children. The head is large with a small face, mandible, and external nares, and the neck is relatively short. The tongue is large relative to the mouth, and the larynx lies higher in the neck and is angled more anteriorly. The epiglottis is long, and the narrowest portion of the trachea is inferior to the vocal cords at the cricoid ring, allowing the use of uncuffed endotracheal tubes. In younger children, a straight laryngoscope blade generally allows better visualization of the vocal cords than a curved blade because the larynx is more anterior and the epiglottis is more floppy and redundant.


Rhythm disturbances

In asystole, atropine and pacing are not used.

VF and pulseless VT occur in only about 15 to 20% of cardiac arrests. Vasopressin is not indicated. When cardioversion is used, the absolute energy dose is less than that for adults; waveform can be biphasic (preferred) or monophasic (see Guide to Pediatric Resuscitation—Mechanical Measures). For either waveform, the recommended energy dose is 2 joules/kg for the first shock, increasing to 4 joules/kg for subsequent attempts (if necessary—see Cardiopulmonary Resuscitation (CPR) in Adults : Defibrillation).

Automated external defibrillators (AEDs) with adult cables may be used for children as young as 1 yr, but an AED with pediatric cables (maximum biphasic shock of 50 joules) is preferred for children between 1 yr and 8 yr. There is insufficient evidence to recommend for or against the use of AEDs in children < 1 yr. For pad placement, see Cardiopulmonary Resuscitation (CPR) in Adults : Defibrillation.


Resources In This Article

Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • ADRENALIN
  • ATROPEN
  • VASOSTRICT

* This is a professional Version *