Cardiorespiratory arrest

I46.9

DESCRIPTION

Cardiorespiratory arrest in children usually follows a period of circulatory or respiratory insufficiency and less commonly is precipitated by a sudden cardiac event. It is, therefore, important to pre-empt cardiorespiratory arrest in children by recognising and urgently treating respiratory or circulatory compromise.

Cardiorespiratory arrest is diagnosed clinically in the unresponsive child who has no respiratory effort and/or in whom there is no palpable pulse and no signs of life, i.e. cough or spontaneous movement.

GENERAL AND SUPPORTIVE MEASURES

Always call for help immediately.

Ensure an open airway.

If there is still no respiration, then commence with artificial breathing using a self-inflating bag, with a reservoir and an appropriate mask. Connect the bag to a high flow oxygen source (15 L/minute). Movement of the chest in response to artificial breaths should be evident.

If there is inadequate chest movement with bag-valve-mask ventilation, re-assess airway patency. If necessary, place an appropriate sized endotracheal tube. In the event of an unexpected arrest or an arrest where there are no witnesses, consider foreign body obstruction. See Inhalation, foreign body .

Once effective breathing has been established, provide chest compressions at a rate of 100–120/minute for all children excluding neonates. Provide artificial breaths at a ratio of 15 compressions to 2 breaths in children (15:2).
Attach a cardiac monitor to the child and secure vascular access. If unable to insert an IV line, obtain intra-osseous access. See Intra-Osseous Infusion in Emergencies .

MEDICINE TREATMENT

Asystole or pulseless electrical activity (i.e. no palpable pulse even if normal electrical pattern (PEA))

  • Epinephrine (adrenaline) 1:10 000 , IV/ intra-osseous, 0.1 mL/kg. (Follow each dose with a small bolus of sodium chloride 0.9%.)
    • 0.1 mL of 1: 10 000 solution = 10 mcg.
    • Dilute a 1 mL ampoule of epinephrine (adrenaline) 1:1 000 in 9 mL of sodium chloride 0.9% or sterile water to make a 1:10 000 solution.

OR (Of unproven benefit, so only when no vascular access available)

  • Epinephrine (adrenaline) 1:1 000, endotracheal, undiluted 0.1 mL/kg down an endotracheal tube. (This is a higher dose due to the route of administration.)

Repeat the dose of epinephrine (adrenaline) every 4 minutes if asystole/PEA persists while CPR continues.
When an ECG sinus rhythm trace is present, continue CPR until an effective pulse and circulation is present.

If the arrest was preceded by circulatory shock:

  • Sodium chloride 0.9%, IV, 20 mL/kg as a bolus.

During the resuscitation consider if any of the following correctable conditions are present (and if present correct them):

  • Hypoxia.
  • Hypovolaemia.
  • Hyperkalaemia, hypokalaemia, hypocalcaemia.
  • Hypothermia.
  • Tension pneumothorax.
  • Tamponade (cardiac).
  • Toxins (e.g. tricyclic antidepressants).
  • Thrombo-embolic event.

Note:
There is no evidence to support the routine use of any of the following in cardiac arrest:

  • sodium bicarbonate,
  • calcium,
  • high dose IV epinephrine (adrenaline) (100 mcg/kg/dose).

Ventricular fibrillation or pulseless ventricular tachycardia

Proceed to immediate defibrillation, but during this process cardiorespiratory resuscitation (compressions and ventilation) must continue, except during the actual administration of each shock. Continue until adequate circulation can be demonstrated.
For pulseless ventricular tachycardia and ventricular fibrillation, the defibrillator should be set to asynchronous mode and 4 J/kg shocks administered.

Do not increase voltage, give 4 J/kg repeatedly, if needed.

After each shock continue CPR immediately for 2 minutes and only re-assess the ECG rhythm thereafter.
If ventricular tachycardia/fibrillation has reverted to sinus rhythm, stop shock cycle, but continue CPR until good stable circulation and adequate spontaneous breathing is evident.
If fibrillation/ventricular tachycardia is still present, give further shocks for 3 x 2-minute cycles of shocks.

Thereafter, if necessary, the 2-minute shock cycles should continue but, in addition, give the following after the 3rd shock:

  • Epinephrine (adrenaline) 1:10 000 , IV, 0.1 mL/kg and then repeat after every 2nd shock, i.e. every 4 minutes. (Follow each dose with a small bolus of sodium chloride 0.9%).
    • 0.1 mL of 1: 10 000 solution = 10 mcg.
    • Dilute a 1 mL ampoule of epinephrine (adrenaline) 1:1 000 in 9 mL of sodium chloride 0.9% or sterile water to make a 1:10 000 solution.

After the 3rd and 5th shocks, if normal rhythm has not returned:

  • Amiodarone, IV/IO, 5 mg/kg bolus.

Allow one minute of cardiopulmonary resuscitation between the administration of any medicine and a repeat cycle of shocks.

If ventricular fibrillation or pulseless ventricular tachycardia persists, consider the following (and if present correct):

  • Hypoxia.
  • Hypovolaemia
  • Hyperkalaemia, hypokalaemia, hypocalcaemia.
  • Hypothermia.
  • Tension pneumothorax.
  • Tamponade (cardiac).
  • Toxins (e.g. tricyclic antidepressants).
  • Thrombo-embolic event.

REFERRAL

  • To an intensive care unit after recovery from an arrest.