Pediatric cardiac arrest is a rare event.  Most pediatric cardiac arrests occur in children younger than one year of age, and 90% occur secondary to hypoxia due to respiratory failure. There are many rare causes of pediatric cardiac arrest including sudden infant death syndrome (SIDS), submersion or drowning, trauma, and sepsis.  In contrast to cardiac arrest in adults, cardiopulmonary arrest in infants and children is rarely a sudden event, and does not often result from a primary cardiac cause.  In cases of sudden collapse in older pediatric patients and patients with congenital heart disease, a primary cardiac cause should be considered.

• Prepare, in advance, any calculations that may be necessary to provide care for pediatric patients.  A Broselow tape, the BCEHS Handbook, and many other tools are available that can simplify this process.
• Recognize that in the majority of cases, respiratory failure is the primary cause of cardiac dysfunction.  Focus on adequate oxygenation and ventilation.
• Be aware that these are some of the most stressful types of prehospital events.  Pre-arrival planning, and effective crew resource management, are essential for ensuring an organized approach and high quality CPR.
• High quality CPR, appropriate ventilation, timely vascular access, and a moderate scene time (10 to 35 minutes) are proven elements that improve survival from cardiac arrest with good outcomes.
• Resuscitation and cardiac emergencies for neonates (<28 days of age) differ in approach than that for older patients.  See CPG M11 and CPG M13 for additional information.
• When an infant or child is found without a pulse, treatment should first be directed towards adequate ventilation and oxygenation, and maintenance of circulation by chest compression.
• Commotio cordis (cardiac concussion) refers to blunt, non-penetrating, precordial chest impact that causes arrhythmia or sudden death without evidence of cardiac injury.  It is from low-impact trauma, and significant signs of trauma are usually not found.

• Once oxygenation and high quality CPR have been established all infants and children in cardiac arrest should have a defibrillator attached to determine if a shockable rhythm is present.  If there is a history of blunt trauma to the chest, electrocution, or the patient has a cardiac history, oxygen and CPR are still the priority, but paramedics should apply the AED with greater urgency as these patients may be more likely to demonstrate a shockable rhythm.
• If ventricular fibrillation is demonstrated, defibrillation should be attempted as soon as possible.
• Rhythm analysis and defibrillation are appropriate for all pediatric cardiac arrests regardless of age.  A manual defibrillator is preferred for infants less than 1 year of age however if not available an AED with a pediatric attenuator is appropriate.
• An AED with a pediatric attenuator is preferred for children less than 8 years of age.  If neither a manual defibrillator nor an AED with pediatric attenuator is available, an AED without a dose attenuator may be used for any pediatric cardiac arrest.
• AEDs that deliver relatively high energy doses have been used in infants with minimal myocardial damage and good neurological outcomes
• For pulseless ventricular tachycardia, or ventricular fibrillation, an initial dose of 2 J/kg is indicated when using manual defibrillators.  If the initial shock fails and the patient is not hypothermic perform defibrillation at 4 J/kg.
• Drugs and advanced airways do not affect outcomes of pediatric cardiac arrest.  While still indicated, time and priorities should focus on high quality CPR, ventilation and defibrillation if indicated.  Do not stay on scene to justify intubating or providing drugs.
• For patients whose cardiac arrest is a result of traumatic injuries, rapid transport to a trauma center is the most important treatment.  En route management and early notification to a receiving facility are the major prehospital contributors to patient survival.  In penetrating trauma, particularly penetrating chest trauma, a small percentage of patients can survive a cardiac arrest with early emergency thoracotomy.  These are almost always patients who have demonstrated at least some signs of life in the prehospital setting.
• Needle decompression: in the setting of blunt traumatic cardiac arrest, bilateral needle decompression is appropriate any time the patient is in pulseless electrical activity.
  • Bilateral decompression is used because of the unreliable clinical examination in this patient subset
  • Assume a tension pneumothorax is present in all cases of cardiac arrest with penetrating chest trauma

All pediatric cardiac arrest patients with ROSC require emergency transport to hospital.  Pediatric patients with a prolonged pulseless condition should be discussed with CliniCall.  Non-viable or futile cases should also be discussed with CliniCall.

• Bystander CPR plus early defibrillation can more than double the rate of survival from out of hospital cardiac arrest.  As such, paramedics should perform full resuscitation in settings where first responder or bystander CPR has been initiated unless obvious signs of death are present.
• Although survival from asystole or pulseless electrical activity is rare, patients who receive immediate, high quality CPR occasionally survive.
• Asystole in cardiac arrest is usually an ominous prognostic sign indicating prolonged hypoperfusion and myocardial ischemia with deterioration to asystole from more treatable dysrhythmias.  Asystole must be confirmed in two or more leads.
• Pulseless electrical activity is evidence of organized electrical activity on the ECG without effective myocardial contraction.  Patients with wide complex PEA rhythms usually have poor survival and there are often indications of severe malfunction of the myocardium or cardiac conduction system.  There are numerous possible causes of PEA, some of which are amenable to pre-hospital treatment.  Paramedics should follow a step-wise approach to identifying and treating reversible causes of PEA.
• Special consideration must be given to hypothermic patients without a pulse.  As hypothermia progresses, the patient’s respiratory and heart rate slow significantly.  For this reason, breathing and pulse checks must be sufficiently long (60 seconds) to register very slow rates.
  • “Circum-rescue collapse” is a term that describes a death that occurs shortly before, during, or soon after rescue from exposure to a cold environment, usually cold water immersion.  It often presents as an apparently stable, conscious patient who suffers ventricular fibrillation and cardiac arrest shortly thereafter.
  • A patient with a core body temperature below 30°C will most likely develop arrhythmias with progression to ventricular fibrillation.
  • Medications are more slowly metabolized in hypothermic patients; toxic levels of medications may accumulate if normal dosing regimens are used, therefore, prolong repeat times to twice the normal interval and limit vasopressors to a maximum of 3 doses.
• The most common causes of traumatic cardiac arrest include:
  • Hypoxemia from airway obstruction and hypoventilation
  • Obstructive shock resulting from cardiac tamponade or pneumothorax
  • Hemorrhagic shock, from any source of major hemorrhage
  • Myocardial contusions cause dysrhythmias, perforation, valve rupture
  • Electrical shock produces a fall; ventricular fibrillation may also be present

General Cardiac Arrest Care

PEA / Asystole

Post-Cardiac Arrest Care

VF/VT-Pulseless (Shock Advised)