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1. When evaluating the childs level of consciousness, breathing and color, note:
Level of consciousness Is the child awake and alert, irritable and crying or
unresponsive?
Breathing Is the childs respiratory pattern normal for his age, diminished or absent, or
extremely labored?
Color Is the childs color normal for his ethnicity, cyanotic or pale, or mottled?
1. Activate emergency medical services, call a pediatric code blue, obtain AED or defibrillator
2. Is the rhythm shockable?
Rhythm IS shockable (ventricular fibrillation or unstable ventricular tachycardia)
1. Administer shock at 2 Joules/kg
2. Administer high-quality CPR for 2 minutes
3. Check rhythm
If not shockable, move to asystole/PEA rhythm protocol
If shockable, continue
4. Administer shock at 4 Joules/kg
5. Administer epinephrine 0.01 mg/kg IV or 0.1 mg/kg per ETT every 3-5 minutes
6. Administer high-quality CPR for 2 minutes
7. Check rhythm
If not shockable, move to asystole/PEA rhythm protocol
If shockable, continue
8. Administer shock at >4 Joules/kg
9. Administer Amiodarone 5 mg/kg IV (repeat 2 times if needed) or lidocaine 1 mg/kg IV
10. Administer high-quality CPR for 2 minutes
11. Check rhythm
If not shockable, move to asystole/PEA rhythm protocol
If shockable, repeat steps 8-11
2. Administer Epinephrine 0.01 mg/kg IV or 0.1 mg/kg per ETT every 3-5 minutes
3. Check rhythm
If shockable, move to VF/VT rhythm protocol
If not shockable, continue
4. Administer high-quality CPR for 2 minutes
5. Check rhythm
If shockable, move to VF/VT rhythm protocol
If not shockable, continue
6. Administer Amiodarone 5 mg/kg IV (repeat 2 times if needed)
7. Administer high-quality CPR for 2 minutes
8. Check rhythm
If shockable, move to shockable rhythm protocol
If not shockable, continue CPR and medications
After successful resuscitation, the team must continue to manage the airway, ventilation, and
circulation and perform diagnostic testing. Post-resuscitation measures should include:
To meet these goals, rescuers should focus on respiratory, cardiovascular, neurologic, renal,
gastrointestinal, and hematologic systems. Administer oxygen as needed in order to maintain a
blood oxygenation level/saturation greater than 94% (based on pulse oximetry). If the precise
cause of the initial shock symptoms has not yet been identified, consider possible causes of
shock in the pediatric patient.
It is often helpful to remember the Hs and the Ts:
Hypovolemia
Hypoxia
(H+) Acidosis
Hypoglycemia
Hypo/Hyperkalemia
Hypothermia
Tension Pneumothorax
Toxins
Tamponade
Trauma
Thrombosis
Once the cause has been identified, provide definitive treatment as soon as possible. It will
usually also be necessary to provide additional fluid boluses. When needed, give crystalloid for
volume resuscitation. Monitor fluid resuscitation carefully.
Volume resuscitation may not be enough to maintain the childs blood pressure. In these cases,
you may consider adding pressors. One approach is to start with epinephrine, then move to
norepinephrine, then move to dopamine. Alternatively, some rescuers will begin with
dobutamine, then progress to dopamine, then try epinephrine followed by milrinone. The doses
of these cardiovascular agents are based on the size of the patient and then titrated to maintain an
effective blood pressure. These agents require an intensive care unit, an arterial line, and constant
monitoring. Diagnostic tests should be done at the same time as interventions.
For cardiac arrest outside of hospital, start and maintain targeted temperature management:
1. Bradycardia is diagnosed by manual testing or heart rate monitor Normal heart rates change
with age/size.
Age Category
Age Range
Newborn
0-3 months
Infant/Young child
4 months to 2 years
Child/School Age
2-10 years
Over 10 years
Hypoxia
Acidosis
Hyperkalemia
Hypothermia
Heart block
Toxins/Overdoses
Trauma
Acidosis Treated with increased ventilation; use sodium bicarbonate carefully if needed
Age Range
1 Day
4 Days
To 1 month
Systolic Blood
Pressure
60-76
67-84
73-94
Diastolic Blood
Pressure
30-45
35-53
36-56
Abnormally Low
Systolic Pressure
<60
<60
<70
Neonate
Neonate
Infant
Infant
1-3 months
78-103
44-65
<70
Infant
4-6 months
82-105
46-68
<70
Infant
7-12 months
67-104
20-60
PreSchool
2-6 years
70-106
25-65
School Age
7-14 years
79-115
38-78
Adolescent
15-18 years
93-131
45-85
8. If hypotensive,
Consider atropine 0.02 mg/kg (min dose = 0.1 mg; max dose = 0.5 mg); Repeat one time
if needed
1. Tachycardia is diagnosed by manual testing or heart rate monitor Normal heart rates
vary with age/size.
Age Category
Newborn
Age Range
0-3 months
Infant/Young child
4 months to 2 years
Child/School Age
2-10 years
Over 10 years
Vagal Maneuvers
Synchronized Cardioversion
Medications
50-100 Joules
120-200 Joules
100 Joules
Turn off the synchronized
mode and defibrillate
immediately
Age
Category
Neonate
Neonate
Infant
Infant
Infant
Infant
PreSchool
School
Age
Adolescen
t
Age
Range
1 Day
4 Days
To 1
month
1-3
months
4-6
months
7-12
months
2-6
years
7-14
years
15-18
years
Systolic Blood
Pressure
60-76
67-84
73-94
Diastolic Blood
Pressure
30-45
35-53
36-56
Abnormally Low
Systolic Pressure
<60
<60
<70
78-103
44-65
<70
82-105
46-68
<70
67-104
20-60
70-106
25-65
79-115
38-78
93-131
45-85
<70 + (age in
years x 2)
<70 + (age in
years x 2)
<70 + (age in
years x 2)
<90
1. Tachycardia is diagnosed by manual testing or heart rate monitor and the child
has poor perfusion Normal heart rates vary with age/size.
Age Category
Age Range
Normal Heart Rate
Newborn
0-3 months
80-205 per minute
Infant/Young child
4 months to 2 years
Child/School Age
2-10 years
Over 10 years
Age Category
Age Range
1 Day
4 Days
To 1 month
Systolic Blood
Pressure
60-76
67-84
73-94
Diastolic Blood
Pressure
30-45
35-53
36-56
Abnormally Low
Systolic Pressure
<60
<60
<70
Neonate
Neonate
Infant
Infant
1-3 months
78-103
44-65
<70
Infant
4-6 months
82-105
46-68
<70
Infant
7-12 months
67-104
20-60
PreSchool
2-6 years
70-106
25-65
School Age
7-14 years
79-115
38-78
Adolescent
15-18 years
93-131
45-85
Vagal Maneuvers
Synchronized Cardioversion
Medications
Supraventricular tachycardia
Cardioversion Rules
50-100 Joules
120-200 Joules
100 Joules
Stable
Age Category
Age Range
Newborn
0-3 months
Infant/Young child
Child/School Age
Older child/ Adolescent
4 months to 2 years
2-10 years
Over 10 years
1 Day
4 Days
To 1 month
1-3 months
4-6 months
Systolic Blood
Pressure
60-76
67-84
73-94
78-103
82-105
Diastolic Blood
Pressure
30-45
35-53
36-56
44-65
46-68
Infant
7-12 months
67-104
20-60
PreSchool
2-6 years
70-106
25-65
School Age
7-14 years
79-115
38-78
Adolescent
15-18 years
93-131
45-85
Age Category
Age Range
Neonate
Neonate
Infant
Infant
Infant
Abnormally Low
Systolic Pressure
<60
<60
<70
<70
<70
<70 + (age in years
x 2)
<70 + (age in years
x 2)
<70 + (age in years
x 2)
<90
1. Tachycardia is diagnosed by manual testing or heart rate monitor and the child has adequate
perfusion Normal heart rates vary with age/size.
Age Category
Newborn
Infant/Young child
Child/School Age
Older child/ Adolescent
Age Range
0-3 months
4 months to 2 years
2-10 years
Over 10 years
1 Day
4 Days
To 1 month
1-3 months
4-6 months
Systolic Blood
Pressure
60-76
67-84
73-94
78-103
82-105
Diastolic Blood
Pressure
30-45
35-53
36-56
44-65
46-68
Infant
7-12 months
67-104
20-60
PreSchool
2-6 years
70-106
25-65
School Age
7-14 years
79-115
38-78
Adolescent
15-18 years
93-131
45-85
Age Category
Age Range
Neonate
Neonate
Infant
Infant
Infant
Determine rhythm
Abnormally Low
Systolic Pressure
<60
<60
<70
<70
<70
<70 + (age in years
x 2)
<70 + (age in years
x 2)
<70 + (age in years
x 2)
<90
Possible SVT with QRS aberrancy Follow PALS Narrow QRS Tachycardia Adequate
Perfusion Algorithm and use the supraventricular rhythm pathway. Continue to reassess
vitals, cardiovascular status, and tissue perfusion. Be prepared to treat for ventricular
tachycardia/ventricular fibrillation.