II. Management: Approach
- ABC Management
- CPR until Defibrillator available
- Good quality Cardiac Compressions are critical for survival (ROSC)
- Consider 5 cycles CPR (2 min) before defibrillating
-
Defibrillation options (single shock)
- Manual Defibrillator
- First: 2-4 J/kg
- Subsequent: 4 J/kg
- Maximum: 10 J/kg or up to adult dose
- AED (age 1 year or older)
- Child system is preferred if available ages 1-8
- Manual Defibrillator
- Secure cardiopulmonary access
- See Cardiopulmonary Resuscitation
- Ventilate with 100% oxygen
- Endotracheal Intubation
- Obtain Intravenous Access
- Cycles
- Perform 5 cycles of CPR (15:2 if two providers) for total of 2 minutes
- Once Advanced Airway in place, give 8-10 breaths per minute (every 6-8 min) and compressions >100/minute asynchronously
- Re-evaluate rhythm with minimum interruption of Cardiac Compressions (<10 seconds)
- Organized Electrical activity: Check for pulse
- Non-shockable rhythm: See Other protocols
- Shockable rhythm: Defibrillate
- Ventricular Fibrillation
- Pulseless Ventricular Tachycardia (V. fib or V. Tach)
- Repeat Defibrillation as above after each cycle
- Call clear
- Compressions need not be interrupted if mechanical CPR device is in place
- Administer medications once IV or IO Access obtained (see below)
- Administer during Cardiac Compressions (between Defibrillations)
- Epinephrine (every 3-5 minutes)
- First dose after second Defibrillation
- IV/IO: 0.01 mg/kg (0.1 ml/kg of 1:10,000) up to 1 mg IV
- ET: 0.1 mg/kg (0.1 ml/kg of 1:10,000) up to 2.5 mg via ET
- Amiodarone (up to 3 doses)
- Dose: 5 mg/kg up to a maximum of 300 mg for a single dose
- First dose after the third Defibrillation
- May repeat up to 2 additional doses
- Adjunctive medications
- Magnesium Sulfate
- Dose: 25 to 50 mg/kg IV or IO
- Indications
- Polymorphic VT (Torsades de Pointes)
- Suspected Hypomagnesemia
- Magnesium Sulfate
- Perform 5 cycles of CPR (15:2 if two providers) for total of 2 minutes
III. Management: Post Return of Spontaneous Circulation (ROSC)
- Assess Vital Signs
- Support Airway and breathing
- Consider maintaining Antiarrhythmic medications
- Infusion of Antiarrhythmic that converted rhythm
- Discuss with pediatric cardiology
- Pursue definititive management of underlying cause
- Initiate Hypothermia protocol
- Improves longterm CNS recovery post-hypoxic event
IV. Management: Example
- Cycle 1
- Perform 5 cycles of CPR (15:2) for total of 2 minutes
- Obtain IV Access concurrent with CPR
- Rhythm check and Defibrillate 2 J/kg (Call 'clear' and <10 second cardiac compression interruption)
- Cycle 2
- Perform 5 cycles of CPR (15:2) for total of 2 minutes
- Place Advanced Airway concurrent with CPR
- Rhythm check and Defibrillate 4 J/kg (Call 'clear' and <10 second cardiac compression interruption)
- Cycle 3
- Perform CPR for 2 minutes (If Advanced Airway, give asynchronously 8-10 breaths per minute and >100 compressions/min)
- Administer Epinephrine 0.01 mg/kg IV up to 1 mg IV maximum
- Treat reversible cause (e.g. contact catheterization lab if Acute Coronary Syndrome suspected)
- With mechanical CPR device in place, inter-hospital transport is viable despite lack of ROSC
- Rhythm check and Defibrillate 4 J/kg (Call 'clear' and <10 second cardiac compression interruption)
- Cycle 4
- Perform CPR for 2 minutes
- Administer Amiodarone 5 mg/kg IV up to 300 mg IV maximum
- Rhythm check and Defibrillate 4 J/kg (Call 'clear' and <10 second cardiac compression interruption)
- Cycle 5
- Perform CPR for 2 minutes
- Administer Epinephrine 0.01 mg/kg IV up to 1 mg IV maximum
- Rhythm check and Defibrillate 4 J/kg (Call 'clear' and <10 second cardiac compression interruption)
- Cycle 6
- Perform CPR for 2 minutes
- Administer Amiodarone 5 mg/kg IV up to 300 mg IV maximum
- Rhythm check and Defibrillate 4 J/kg (Call 'clear' and <10 second cardiac compression interruption)
- Cycle 7: Perfusing rhythm obtained
- Check for pulse (confirm not Pulseless Electrical Activity)
- Amiodarone maintenance to prevent recurrent Arrhythmia
- Discuss indication and dosing with pediatric cardiology
- Initiate Induced Therapeutic Hypothermia protocol
- Discuss specific protocols with local experts
- Requires paralysis, sedation and Opioid Analgesics to prevent shivering