Paediatrics chapters
Paediatric basic and advanced life support
How to recognise a child heading for cardiorespiratory arrest, the ABCDE assessment, chest compressions and airway opening, choking manoeuvres, and the advanced steps: intraosseous access, adrenaline and other drug doses, defibrillation and post-arrest care.
- Children usually arrest from hypoxia after respiratory failure or shock, not from a primary heart rhythm problem, so early recognition of the seriously ill child (ABCDE, AVPU, perfusion) saves most lives; outcome after arrest is poor.
- Start chest compressions if there is no pulse or the heart rate is below 60/min with poor perfusion: hard, flat surface, depth one third to one half of the chest, rate at least 100/min (Nelson), full recoil, and ventilate with a bag and mask with 100% oxygen.
- Give adrenaline 0.01 mg/kg IV or IO (as 1:10,000 solution) every 3-5 minutes; for VF or pulseless VT, shock at 2 J/kg, then 4 J/kg, and consider amiodarone 5 mg/kg; check glucose; bicarbonate and calcium are not routine.
On this page
Overview
In children, cardiac arrest is usually the end of a long slide: respiratory failure or shock causes hypoxia and acidosis, the heart slows (bradycardia) and finally stops (asystole or pulseless electrical activity). A primary heart rhythm problem such as ventricular fibrillation is less common than in adults. Survival after arrest is poor (Nelson: about 6% after out-of-hospital and about 27% after in-hospital arrest, many with brain damage), so the real skill is to recognise and treat the seriously ill child early.
Recognising the seriously ill child
Rapid ABCDE assessment
| Step | What to check |
|---|---|
| A: Airway | Is it open and maintainable on its own, with positioning and suction, or does it need help? Stridor? Protect the cervical spine in trauma |
| B: Breathing | Rate, work of breathing (recession, grunting, nasal flaring, accessory muscles), air entry, wheeze, colour, pulse oximetry |
| C: Circulation | Heart rate, central and peripheral pulses, capillary refill, skin temperature and colour, mottling, blood pressure |
| D: Disability | AVPU (is the child Alert, reacting to Voice, reacting only to Pain, or Unresponsive?), pupils, posture; check blood glucose |
| E: Exposure | Undress to look for rash, injury, bleeding; prevent heat loss |
Warning signs that resuscitation may be needed
- Brain: lethargy, agitation, confusion, falling level of consciousness.
- Breathing: apnoea, grunting, nasal flaring, stridor, severe distress, or slow tired breathing in a sick child.
- Circulation: bradycardia or marked tachycardia, weak pulses, poor capillary refill, hypotension.
- Skin: mottling, pallor, cyanosis, sweating.
Respiratory failure is the commonest cause of sudden deterioration in children. In shock, tachycardia and poor perfusion come first; hypotension appears late.
Bradycardia in a hypoxic, sick child is a pre-arrest sign, not reassurance. Give oxygen and ventilate.
Basic life support
Order of actions
- Make sure the scene is safe; check response; shout for help.
- Open the airway and check breathing; check for signs of circulation and a central pulse.
- Start chest compressions if there is no pulse, or the heart rate is below 60/min with signs of poor perfusion, even if a pulse is felt.
- Give rescue breaths (bag and mask with oxygen when available) and continue CPR.
Since the 2010 resuscitation guidelines quoted in Nelson, compressions are started first (C-A-B) while a second rescuer prepares to ventilate. Ventilation remains very important in children because most arrests are respiratory in origin.
Chest compressions
- Child supine on a firm, flat surface.
- Depth: about one third to one half of the front-to-back depth of the chest.
- Rate: at least 100 per minute (Nelson).
- Allow full recoil after each compression; keep interruptions short.
- Once an advanced airway (tracheal tube) is in place, compressions continue without pausing for breaths, with about 8-10 breaths per minute.
The ratio of compressions to breaths before an advanced airway is placed is set by the current resuscitation guideline (it differs for one and two rescuers). Resuscitation guidelines are revised every few years, so learn the version in use at your hospital.
Opening the airway
- Loss of muscle tone lets the tongue and jaw fall back against the pharynx.
- Head tilt-chin lift when there is no risk of neck injury.
- Jaw thrust if a head or neck injury is possible.
- Suction secretions or vomit; consider an oropharyngeal airway.
Breathing
- Bag-mask ventilation with 100% oxygen is as effective as intubation for short periods.
- Give only enough volume to make the chest rise; avoid hyperventilation.
- Oxygenation matters more than correcting the respiratory acidosis.
- Rate with a perfusing rhythm: about 12-20 breaths per minute (Nelson).
Choking (foreign body airway obstruction)
- If the child can cough, cry, breathe or speak, do not interfere: encourage coughing, which is more effective than any manoeuvre, and watch closely.
- If the cough becomes ineffective or the child is unresponsive:
| Age | Manoeuvre |
|---|---|
| Infant under 1 year | Back blows alternating with chest thrusts |
| Child over 1 year | Abdominal thrusts (Heimlich manoeuvre), with back blows as needed |
- No abdominal thrusts under 1 year: risk of perforating an abdominal organ.
- If these fail, advanced airway measures bypass the obstruction until the object is removed: needle or surgical cricothyrotomy, rigid bronchoscopy, rarely open bronchotomy.
Infant: back blows plus chest thrusts. Older child: abdominal thrusts.
Prevention of choking
- No small toys, nuts, hard beans or raw vegetables for young children; cut food into small pieces.
- No eating while running or playing; no coins in the mouth.
- Parents should learn basic CPR.
Advanced life support
Airway and intubation
- Intubate if skilled staff and equipment are available, after pre-oxygenation with bag and mask.
- Tube size: 4 + (age in years ÷ 4), or about the width of the child's little finger (Nelson).
- Confirm position clinically (equal chest movement and breath sounds) and with end-tidal CO2.
- If an intubated child deteriorates, think DOPE: Displacement, Obstruction, Pneumothorax, Equipment failure.
A 4-year-old child weighing 16 kg
Tube size = 4 + (4 ÷ 4) = 5
Adrenaline = 0.01 mg/kg × 16 = 0.16 mg = 1.6 mL of 1:10,000
First shock for VF = 2 J/kg × 16 = 32 J; next shock = 4 J/kg × 16 = 64 J
Amiodarone = 5 mg/kg × 16 = 80 mg
Vascular access
- If an IV line cannot be placed quickly, use the intraosseous (IO) route; all resuscitation drugs and fluids can be given IO.
- Some drugs can be given down the tracheal tube if there is no other route (for example adrenaline, atropine, naloxone), at higher doses.
Drugs in paediatric resuscitation (Nelson)
| Drug | Use | Dose |
|---|---|---|
| Adrenaline | Asystole, PEA, VF after shocks; the main arrest drug | 0.01 mg/kg by IV or IO route (as 1:10,000, that is 0.1 mL/kg), every 3-5 minutes; 0.1 mg/kg via tracheal tube; no benefit from high doses |
| Amiodarone | Shock-resistant VF or pulseless VT | 5 mg/kg, may repeat up to 15 mg/kg |
| Adenosine | Supraventricular tachycardia | 0.1 mg/kg (max 6 mg), then 0.2 mg/kg (max 12 mg) |
| Atropine | Vagal or junctional bradycardia | 0.02 mg/kg (minimum 0.1 mg) |
| Lignocaine | VT (alternative) | 1 mg/kg bolus |
| Fluid | Hypovolaemia, sepsis | 20 mL/kg isotonic crystalloid bolus, repeated as needed |
| Glucose | Hypoglycaemia (common in sick infants) | Infants and children: 2-4 mL/kg of 25% dextrose (newborns 10% dextrose) |
| Sodium bicarbonate | Not routine; hyperkalaemia, tricyclic overdose | 1 mEq/kg, only with good ventilation |
| Calcium | Not routine; hypocalcaemia, hyperkalaemia, hypermagnesaemia, calcium channel blocker overdose | Calcium chloride 20 mg/kg |
Adrenaline is the mainstay of drug treatment in arrest. Its alpha effect raises vascular resistance and coronary perfusion. Use the standard dose each time.
Routine sodium bicarbonate and calcium are not recommended in arrest. Bicarbonate can cause hypernatraemia, alkalosis (oxygen release to tissues falls), low ionised calcium and worse cardiac function.
Shockable versus non-shockable rhythms
| Rhythm | Treatment |
|---|---|
| Asystole, pulseless electrical activity (the usual end-point of hypoxic arrest) | CPR + adrenaline every 3-5 minutes; look for reversible causes |
| Ventricular fibrillation, pulseless VT | Defibrillate; CPR between shocks; adrenaline after the second shock; amiodarone if two shocks fail |
Defibrillation and cardioversion
| Setting | Energy |
|---|---|
| Defibrillation (VF, pulseless VT) | 2 J/kg first, then 4 J/kg; higher doses up to 10 J/kg or the adult dose may be considered |
| Synchronised cardioversion (SVT or VT with a pulse) | 0.5-1 J/kg, then 2 J/kg; sedate if possible; try adenosine first for SVT |
- Infant pads or paddles for children under 10 kg; adult size above 10 kg.
- Pads at the apex and the upper right chest.
- Warn everyone to stand clear; restart compressions immediately after each shock.
"Two, then four": 2 J/kg, then 4 J/kg for shockable rhythms.
After return of circulation
Hypoxia and poor perfusion damage many organs, so post-arrest care aims to protect them:
| Organ | Possible damage |
|---|---|
| Brain | Seizures, cerebral oedema, infarction, SIADH or diabetes insipidus |
| Heart and lungs | Heart failure; ARDS, pulmonary hypertension |
| Kidney | Acute tubular or cortical necrosis |
| Liver and gut | Hepatic necrosis; gastric ulceration |
| Blood | DIC |
- Keep oxygenation and ventilation normal; avoid hyperventilation.
- Support blood pressure with fluids and inotropes (adrenaline, noradrenaline, dopamine, dobutamine depending on the type of shock).
- Correct glucose and electrolytes; treat seizures; monitor in intensive care.
Shock: early treatment that prevents arrest
- Give oxygen and a 10-20 mL/kg bolus of isotonic crystalloid (normal saline or Ringer lactate) under monitoring; repeat until circulation recovers.
- If bleeding is the cause, give blood.
- If the heart rate rises and blood pressure falls during fluid boluses, the heart may be failing (cardiogenic shock): stop fluid and support the heart.
- If fluids are not enough, start vasoactive drugs.
Special situations
- Neonatal resuscitation follows its own algorithm (covered in the neonatology chapters).
- Drowning: begin CPR at once; give warmed fluids and rewarm a hypothermic child; treat associated neck injury.
- Anaphylaxis: IM adrenaline first (see the anaphylaxis chapter).
- Poisoning: specific antidotes (for example bicarbonate for tricyclics, atropine for organophosphates).
Expect: secondary (hypoxic) arrest as the usual mechanism in children; bradycardia and hypotension as late signs; when to start compressions (no pulse or heart rate under 60 with poor perfusion); compression depth and rate; head tilt-chin lift versus jaw thrust; choking management by age; tube size formula; intraosseous access; adrenaline 0.01 mg/kg of 1:10,000 every 3-5 minutes; amiodarone 5 mg/kg; adenosine 0.1 mg/kg for SVT; atropine 0.02 mg/kg; defibrillation 2 then 4 J/kg; cardioversion 0.5-1 J/kg; no routine bicarbonate or calcium; check glucose.
Quick revision
- Children arrest from hypoxia: bradycardia, then asystole or PEA.
- ABCDE, AVPU, capillary refill; check glucose early.
- Compress if no pulse or heart rate under 60 with poor perfusion; depth one third to one half; at least 100/min.
- Head tilt-chin lift; jaw thrust in neck injury; 100% oxygen; avoid hyperventilation.
- Choking: infant back blows and chest thrusts; older child abdominal thrusts.
- Tube size 4 + age/4; IO if no IV; DOPE if the intubated child worsens.
- Adrenaline 0.01 mg/kg by IV or IO route every 3-5 minutes; 0.1 mg/kg via tube.
- VF/pulseless VT: 2 J/kg, then 4 J/kg; amiodarone 5 mg/kg.
- No routine bicarbonate or calcium.
Written by The House Job from standard references (Basis of Paediatrics by Pervez Akbar; Nelson Essentials of Paediatrics).
FAQ
Why are children's arrests different from adults'?
Most adult arrests are sudden heart rhythm problems, while most children arrest after a period of hypoxia from breathing failure or shock. This is why airway, oxygen and ventilation are so important in children.
When do you start chest compressions in a child who still has a pulse?
When the heart rate is below 60 per minute and the child shows signs of poor perfusion despite oxygen and ventilation.
What strength of adrenaline is used in cardiac arrest?
The 1:10,000 solution intravenously or intraosseously: 0.1 mL/kg, which gives 0.01 mg/kg. The 1:1000 strength is used for intramuscular injection in anaphylaxis. The tracheal dose is higher (0.1 mg/kg, Nelson).
Why are abdominal thrusts avoided in infants?
In infants, abdominal thrusts can perforate or rupture an abdominal organ. Back blows and chest thrusts are used instead under 1 year.