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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 Perinatal Problems: 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 Table 3: Cardiac Arrest: Pediatric Cerebral Performance Category Scale* ).
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Table 3
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| Pediatric Cerebral Performance Category Scale* |
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Score
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Category
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Description
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1
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Normal
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Age-appropriate level of functioning
In preschool-aged children, appropriate development
In school-aged children, attendance in regular classes
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2
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Mild disability
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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
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3
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Moderate disability
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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
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4
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Severe disability
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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
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5
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Coma or vegetative state
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Unawareness
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6
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Death
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―
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*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.
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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.
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Standards and guidelines for CPR from the American Heart Association are followed (see Fig. 1: Cardiac Arrest: CPR Techniques for Health Care Practitioners). For protocol after a person has collapsed with possible cardiac arrest, see Cardiac Arrest: Overview and see Cardiac Arrest: Circulation.
After CPR has been started, defibrillation (see Cardiac Arrest: Defibrillation) and identification of the underlying cardiac rhythm (see Cardiac Arrest: 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 Fig. 2: Cardiac Arrest: Chest compression. ). Bradycardia secondary to heart block is unusual.
After adequate oxygenation and ventilation, epinephrine is the drug of choice (see Cardiac Arrest: 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 Table 1: Cardiac Arrest: CPR Techniques for Health Care Practitioners, Table 2: Cardiac Arrest: Drugs for Resuscitation*, and Table 4: Cardiac Arrest: 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.
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Table 4
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| Guide to Pediatric Resuscitation—Mechanical Measures |
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Age (yr)
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Term neonate
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< 12 mo
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1
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2
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3
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4
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5
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6
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7
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8
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9
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10
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11
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12
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13
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14
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15
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16
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Weight (kg)
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3.5
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< 10
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10
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12
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14
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16
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18
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20
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22
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25
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28
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30
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35
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40
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45
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50
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55
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60
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Ventilation rate/min (advanced airway)
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Perfusing rhythm
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30–60
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20
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20
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12
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Nonperfusing rhythm
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8–10
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Compression rate/min
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120*
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100
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100
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100
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100
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100
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100
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100
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100
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100
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100
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100
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100
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100
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100
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100
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100
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100
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Compression/ventilation ratio (unprotected airway)
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30:2 (1 rescuer)
15:2 (2 rescuers)
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30:2
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Compression techniques
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Thumb compression, hands around chest (preferred) or 2 fingers
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1 hand
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2 hands
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Airway size (Portex) in cm
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000
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00
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00
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0
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0
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7
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7
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7
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7
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7
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7
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7
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7
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7
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8
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8
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8
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8
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3.5
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5
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5
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6
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6
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Masks in Laerdal sizes or equivalent
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Circular 0/1
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Rendell- Baker type # 1
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Rendell-Baker type # 2
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Dome cuff mask # 3
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Dome cuff mask # 4
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Ventilation bag with reservoir for 100% O2 delivery
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Infant 240 mL
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Child 400–500 mL
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Adult 1600 mL
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Laryngoscope blade size
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Miller 0
Straight blade
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1
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1
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1
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2
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2
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2
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2
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2
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2
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2
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3
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3
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3
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3
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3
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3
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3
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Straight blade (preferred) or curved blade
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Curved or straight blade
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ETT size (Portex) in mm
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3
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3.5
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4
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4.5
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4.5
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5
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5
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5.5
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5.5
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6
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6
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6
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6
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6.5
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6.5
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6.5
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6.5
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7
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Uncuffed
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Uncuffed
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Cuffed
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Suction catheter
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Direct oropharyngeal
Through ETT
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10 F
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Pediatric tonsil suction
8 Fr
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Adult tonsil suction
10 Fr
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Defibrillation (joules)
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Dose (2 joules/kg)
Frequency
Maximum dose (4 joules/kg)
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7 10
Pediatric paddles
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20 20 3030 30 50 50 50 50 70 70 70 100 100 200 200
Adult paddles
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20
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30
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If no response, give maximum dose × 2
50 50 50 70 70 100 100 100 100 100 150 150 200 200 300 300
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Cardioversion (joules)
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Synchronized shock (0.5 joules/kg)
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2
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3
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5
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5
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7
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7
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10
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10
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10
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10
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10
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20
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20
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20
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20
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30
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30
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30
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Frequency
Maximum dose (1 joule/kg)
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5
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5
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10
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10
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Increase dose slowly at subsequent attempt to maximum
10 20 20 20 20 20 30 30 30 50 50 50 5070
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*Pause for ventilation
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ETT = endotracheal tube; Fr = French.
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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.
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 Clinical Calculator
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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 discussed in Cardiac Arrest: 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 Table 4: Cardiac Arrest: 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 Cardiac Arrest: 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 Cardiac Arrest: Defibrillation.
Last full review/revision February 2013 by Robert E O'Connor, MD, MPH
Content last modified March 2013
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