Chapter 109: Resuscitation of Children

INTRODUCTION AND EPIDEMIOLOGY

The resuscitation of children differs from that of adults in a number of important ways. Respiratory failure and shock are more common causes of arrest among children and infants than adults; hypoxemia, hypercapnia, and acidosis subsequently lead to bradycardia, hypotension, and secondary cardiac arrest in children. Overall survival and neurologically favorable survival rates in children are 11.3% and 9.1%, respectively, in the United States.¹ Survival rates to discharge after resuscitation from cardiac arrest are greatest among perinatal children (25%) and adolescents (17.3%).² Infancy, unwitnessed arrest, and initial asystolic rhythm are associated with poor survival rates. The best chance for a good outcome is to recognize impending respiratory failure or shock and intervene to prevent the development of cardiopulmonary arrest.

Age-related differences are important considerations when treating children. An appropriate drug dose for a 6-month-old infant may be excessive for a 1-month-old newborn but inadequate for a 5-year-old child. Because other aspects of resuscitation, such as endotracheal tube size, tidal volumes, cardiac compression rates, and respiratory rates, vary with a child’s age, equipment selection and medication dosing require specific determination for each child. Valuable time cannot be lost in weight estimation, dosage calculations, and equipment selection. Equipment can be stored on shelves or in drawers labeled by age and weight, or a system of color codes can be used in which color-coded shelves, carts, or equipment organizers correspond to specific length categories, as illustrated in Figure 109-1.

BASIC LIFE SUPPORT

The American Heart Association guidelines use the following age group delineations: newborn, 1 month or less in age; infant, 1 month to 1 year of age; and child, 1 year of age to the onset of puberty.³ As in adults, the priorities of resuscitation are airway, oxygenation, ventilation, and shock management (Figure 109-2, A and B). Initial basic life support sequence can be initiated with either an airway-breathing-circulation sequence or a circulation-airway-breathing sequence, with circulation-airway-breathing achieving earlier chest compressions but airway-breathing-circulation achieving earlier ventilation.^3,4 To simplify the action sequence, the European Resuscitation Council recommends using the airway-breathing-circulation sequence for basic life support assessment but recommends starting with chest compressions if no pulse is present.⁵ The American Heart Association Guideline Update in 2015 recommends “initiating CPR with C-A-B [circulation-airway-breathing] over A-B-C [airway-breathing-circulation] sequence (Class IIb).”³ Cardiopulmonary arrest should be prevented whenever possible with prompt recognition of and intervention for compromised physiology.⁶ International consensus guidelines for basic life support procedures are listed in Table 109-1.