Signs and Symptoms
History
- Obtaining a history should not delay the primary assessment of a child in extremis or cardiopulmonary arrest
- When appropriate, obtain a SAMPLE history from caregivers and prehospital providers including signs and symptoms, allergies, medications, past medical and surgical history, last meal and menses, and preceding events
Physical Exam
- Cardiopulmonary arrest: Absence of pulse (femoral/brachial for infants), respiratory effort, and responsiveness: Initiate CPR and follow the Pediatric Advanced Life Support/American Heart Association (PALS/AHA) algorithm (see Treatment)
- Pediatric assessment triangle (PAT):
- Quickly identify respiratory or circulatory compromise
- Appearance (tone, interactiveness, consolability, look/gaze, speech/cry)
- Work of breathing (airway sounds, positioning, accessory muscle use)
- Circulation (pallor, cyanosis, cap refill, cool skin)
- If PAT abnormal, proceed with concurrent primary assessment (ABCDE) and treatment
- If PAT normal, proceed with secondary/head-to-toe assessment
- Primary assessment (ABCDE) and treatment should occur simultaneously
- Airway:
- Assess for pooling of secretions, obstruction, ability to speak or cry
- Treat with chin lift, jaw thrust, suction, placement of a nasopharyngeal or oropharyngeal airway as indicated by clinical picture
- Proceed to endotracheal intubation if corrective steps unsuccessful
- Breathing:
- Assess for respiratory rate, work of breathing, positioning, breath sounds, grunting, nasal flaring, retractions, stridor, oxygen saturation, consider EtCO2monitoring
- Treat with oxygen via nasal cannula or nonrebreather mask for saturations <95% or impending respiratory failure, bag-valve-mask ventilation for ventilatory support, needle/tube thoracostomy for pneumothorax, albuterol for bronchospasm, inhaled epinephrine for suspected croup. Proceed to endotracheal intubation if interventions unsuccessful
- Circulation:
- Assess for evidence of hypoperfusion and shock: Delayed capillary refill, pallor, cool/mottled extremities, diminished peripheral pulses, hypotension (<70 + age × 2), tachy/bradycardia; establish IV/IO access
- Bedside US may quickly identify pericardial effusion/tamponade, large-volume intraperitoneal free fluid, pneumothorax, collapsed IVC, right heart stain or structural cardiac abnormalities, assisting management
- Treat with 20 mL/kg crystalloid bolus and repeat as needed (10 mL/kg if undifferentiated or any concerns for cardiac etiology), pRBCs 10 mL/kg if hemorrhagic shock suspected, vasopressors if fluid refractory, chemical, or electrical cardioversion for tachydysrhythmias
- Disability:
- Assess for level of consciousness using pediatric GCS or AVPU, pupil size and reactivity, seizure-like activity and extremity movement, and tone; check fingerstick glucose
- Treat suspected increased ICP/impending herniation with head of bed to 30 degrees, give hypertonic saline or mannitol, temporarily hyperventilate, and avoid hypotension and hypoxia; correct hypoglycemia; treat ongoing seizure activity with benzodiazepines
- Exposure:
- Undress to assess completely then cover to maintain normothermia
- Secondary assessment: A comprehensive head-to-toe physical exam
Essential Workup
- Obtain a weight (kg) for proper equipment size and dosing; If actual weight measurement or parental estimation is not possible, use a length- or age-based estimation
- Frequent vital signs and cardiorespiratory monitoring
- Fingerstick glucose
- Pregnancy test for adolescent females
- Further labs and radiographic workup should be determined by a thorough history, physical exam, and differential diagnosis
Diagnostic Tests & Interpretation
Lab
- Lab evaluation should be determined by the clinical presentation and may include:
- CBC, electrolytes, liver function tests, and venous blood gas if critically ill
- Type and screen/cross-match for patients who may require a blood transfusion
- Sepsis evaluation including lactate, blood cultures, urinalysis and urine culture, CSF cell count/Gram stain and culture, and stool studies (blood, WBCs, specific pathogen testing) if indicated
- Coagulation studies only necessary if patient is taking anticoagulants, has a known coagulopathy, or if there is concern for DIC
- BNP and troponin if there is concern for ischemia, myocarditis, or congestive heart failure
- Send extra red-top blood tube (if concerned for metabolic disorder/inborn error) or fourth CSF tube to be held for future studies
- Toxicologic testing, if indicated
Imaging
- Imaging and ancillary testing should be determined by the clinical presentation and may include:
- CXR for infection, pneumothorax, and cardiac size
- Cervical spine and trauma studies as indicated
- CT head for hemorrhage or mass
- CT abdomen/pelvis for hemorrhage or intra-abdominal infection
Diagnostic Procedures/Surgery
- ECG for tachy/bradydysrhythmia or evidence of structural heart disease
- EEG if concerns for status epilepticus
- Echocardiogram for structural heart disease
Differential Diagnosis
- Respiratory failure:
- Upper airway obstruction: Croup, epiglottitis, peritonsillar or retropharyngeal abscess, foreign body, tracheitis, congenital abnormalities
- Lower tract/parenchymal disease: Asthma, pneumonia, bronchiolitis, foreign body, cystic fibrosis, thoracic trauma, drowning, pulmonary edema
- Shock:
- Hypovolemic: Hemorrhage, diarrhea, inadequate intake, osmotic diuresis/DKA, third-spacing, burns
- Distributive: Sepsis, anaphylaxis, neurogenic shock
- Cardiogenic: Myocarditis, congenital heart disease, cardiomyopathy, drug toxicity, arrhythmia, sepsis
- Obstructive: Cardiac tamponade, tension pneumothorax, PE, congenital heart disease
- Shock categories often overlap, particularly in cases of sepsis, metabolic derangements, and endocrine disorders
- CNS disease, SIDS/SUID/BRUE/ALTE/ASSB, overdose, etc.
- Consider nonaccidental trauma when history is inconsistent with the illness or pattern of injury
ED Treatment/Procedures
- Cardiopulmonary arrest: Initiate CPR and follow the PALS/AHA algorithm:
- Compressions-airway-breathing:
- Compression-only and compression-first CPR is controversial in children; in the ED, compressions and ventilation should be initiated simultaneously
- 15:2 compression to ventilation ratio for infants and prepubertal children until an advanced airway is in place
- 100-120 compressions per minute on a firm surface
- Infants - encircle the chest with both hand s and compress the lower sternum with two thumbs (1.5-in depth); Children - traditional, two-hand technique (2-in depth)
- Bag-valve-mask or supraglottic airway ventilation should be used until endotracheal intubation is possible and continued if endotracheal intubation is unsuccessful to avoid prolonged interruptions in compressions
- Defibrillation:
- Quickly identify pulseless ventricular tachycardia or ventricular fibrillation (VT/VF)
- Perform high-quality compressions until defibrillator appropriately attached and charged, deliver shock as soon as possible, do not delay in establishing an airway
- When available, use pediatric pads for children <8 yr
- Anteroposterior and anterolateral positioning are equivalent if using adult pads, to avoid contact between pads
- 2 J/kg for first attempt, 4 J/kg for second, and 10 J/kg for third and subsequent attempts
- Medications (see Medication for dosing):
- Epinephrine for all rhythms
- Amiodarone or lidocaine for VT/VF
- Magnesium for Torsade de pointes
- Dextrose for hypoglycemia
- Consider sodium bicarbonate for hyperkalemia or tricyclic antidepressant poisoning
- Consider calcium chloride for hyperkalemia, hypocalcemia, or calcium channel blocker overdose
- Postarrest care:
- Avoid hypotension with norepinephrine; add dobutamine for suspected cardiogenic shock
- Optimize ventilator settings to achieve normal oxygen saturation (target 94%) and carbon dioxide levels (target PaCO2 35-45 mm Hg)
- Avoid hyperthermia; no difference in outcomes between target temperature of 33 or 36°C
- Family should be given the option of being present during their child's resuscitation
- Abnormal pediatric assessment triangle (respiratory or circulatory insufficiency): Life and limb-saving interventions to be performed during the primary assessment are listed above:
- Initial management steps should include obtaining an actual or estimated weight (kg), cardiopulmonary monitoring, basic airway maneuvers/adjuncts, administration of oxygen for hypoxia or impending respiratory failure, obtaining IV/IO access, and fluid administration if indicated
- Respiratory failure: Trial of humidified, heated, high-flow nasal cannula oxygen or continuous positive airway pressure in the appropriate patient; if unsuccessful or poor cand idate, proceed to endotracheal intubation:
- Rapid sequence intubation with etomidate or ketamine and succinylcholine or rocuronium
- Atropine pretreatment is not necessary to prevent vagal response to laryngoscopy; should be given for pre-existing or periprocedural bradycardia
- Endotracheal tube (ETT) size: Age/4 + 3.5 (cuffed), age/4 + 4 (uncuffed); cuffed ETT (cETT) safe for all ages, uETT <1 yr only
- Miller/Mac 1 for 0-2 yr, Miller/Mac 2 for 2-8 yr, Miller/Mac 3 for 8+ yr
- Insertion depth: 3× uETT size (cm)
- If endotracheal intubation unsuccessful, continue bag-valve-mask ventilation and place a supraglottic airway device
- Perform needle cricothyrotomy if unable to intubate and unable to ventilate
- Shock:
- Distributive: 20 mL/kg NS/LR fluid bolus × 2-3, start norepinephrine if fluid refractory “warm shock,” epinephrine if fluid refractory “cold shock,” hydrocortisone for known or suspected adrenal insufficiency, epinephrine for anaphylaxis
- Cardiogenic: Start norepinephrine, add dobutamine if needed for ionotropic support, synchronized cardioversion (0.5-2 J/kg) for unstable tachydysrhythmias, epinephrine and pacing for unstable bradycardia
- Obstructive: Needle decompression of tension pneumothorax, pericardiocentesis for tamponade, thrombolysis for pulmonary embolism
- Hypovolemic: Volume expansion with 20 mL/kg of NS/LR or 10 mL/kg of pRBC boluses and repeat as needed
Medication
- Given IV/IO unless otherwise indicated
- Adenosine 0.1 mg/kg (max 6 mg) rapid push; 0.2 mg/kg (max 12 mg) second dose (IO ineffective)
- Amiodarone 5 mg/kg (max 300 mg) bolus for VT/VF, over 30 min for SVT/VT with pulse
- Atropine 0.02 mg/kg (min 0.1 mg, max 0.5 mg) IV
- Calcium chloride 20 mg/kg (max 1 mg)
- Cardioversion, synchronized 0.5-2 J/kg
- Defibrillation 2 J/kg, then 4-10 J/kg
- Dextrose: 1 mL/kg D50; 2 mL/kg D25; 5 mL/kg D10
- Dopamine 5-20 mcg/kg/min
- Dobutamine 5-20 mcg/kg/min
- Epinephrine 0.01 mg/kg 1:10,000 (max 1 mg) q3-5min; if no IV/IO can give 0.1 mg/kg 1:1000 via ETT; for anaphylaxis 0.01 mg/kg IM 1:1,000 (max 0.5 mg)
- Epinephrine 0.1-1 mcg/kg/min
- Etomidate 0.3 mg/kg
- Hydrocortisone 25 mg (for CAH)
- Ketamine 2 mg/kg, 4 mg/kg IM
- Lidocaine 1 mg/kg (max 150 mg)
- Magnesium 50 mg/kg (max 2 g)
- Mannitol 0.5-1 g/kg
- Milrinone 50 mcg/kg load over 30 min, then 0.25-0.75 mcg/kg/min
- Naloxone 0.1 mg/kg
- Norepinephrine 0.05-2 mcg/kg/min
- Normal saline/lactated Ringer's 20 mL/kg
- Packed red blood cells (pRBC) 10 mL/kg
- PGE1 0.1 mcg/kg/min
- Procainamide 15 mg/kg (max 1 g over 30 min)
- Propofol 2 mg/kg
- Rocuronium 1.2 mg/kg
- Sodium bicarbonate 1 mEq/kg
- 3% NaCl 5 mL/kg
- Succinylcholine 1.5 mg/kg
Disposition
Admission Criteria
Survivors of cardiopulmonary arrest, children with respiratory failure or insufficiency, and children with ongoing shock should be managed by pediatric critical care clinicians. Transfer, if needed
Discharge Criteria
Patients with a rapidly resolved cause of pulmonary or circulatory compromise that was not life-threatening and is not expected to recur (e.g., hypovolemia or anaphylaxis) may be considered for discharge following a prolonged period of observation
Follow-up Recommendations
- Discharged patients should have immediate primary care follow-up. All families need support
- Provide CPR training resources for caregivers
- Educate patients and /or caregivers about self-administration of epinephrine for anaphylaxis