Chapter 3. Resuscitation of Children and Neonates

Children primarily develop cardiac arrest secondary to hypoxia from respiratory arrest or shock syndromes. Because of age and size differences among children, drug dosages, compression and respiratory rates, and equipment sizes differ considerably (Table 3-1).

Securing the Airway

The airway in infants and children is smaller, variable in size, and more anterior than that in the adult. The prominent occiput and relatively large tongue and epiglottis may lead to obstruction when the child is in the supine position.

Mild extension of the head in the sniffing position opens the airway. Chin lift or jaw thrust maneuvers may relieve obstruction of the airway related to the tongue. Oral airways are not commonly used in pediatrics but may be useful in the unconscious child who requires continuous jaw thrust or chin lift to maintain airway patency. Oral airways are inserted by direct visualization with a tongue blade.

A bag-valve-mask system is commonly used for ventilation. Minimum volume for ventilation bags for infants and children is 450 mL. The tidal volume necessary to ventilate children is 10 to 15 mL/kilogram. Observation of chest rise and auscultation of breath sounds will ensure adequate ventilation.

Endotracheal intubation usually is performed with a Miller straight blade with a properly sized tube. Resuscitation measuring tapes have been found to be the most accurate for determining tube size. The formula 16 plus age in years divided by 4 calculates approximate tube size. Uncuffed tubes are used in children up to 8 years.

Initiate ventilation at 20 breaths/min for infants, 15 breaths/min for young children, and 10 breaths/min for adolescents unless hyperventilation is required.

Rapid Sequence Intubation

Rapid sequence intubation is the administration of an intravenous (IV) induction agent with a neuromuscular blocking agent to facilitate endotracheal intubation.

1. Prepare equipment, medication, and personnel before initiation of RSI. Check equipment function.

2. Preoxygenate the patient with 100% oxygen.

3. In children, cricoid pressure can occlude the pliable trachea. Release cricoid pressure, if applied, if laryngoscopy and intubation are difficult.

4. Refer to Table 3-2 for specific induction and paralytic agents used in children.

5. Intubate the trachea, confirm proper placement, and secure the tube.

6. Atropine 0.02 milligram/kilogram (minimum dose, 0.1 milligram; maximum dose, 1 milligram) may be used for symptomatic reflex bradycardia.

Vascular Access

Airway management is paramount in pediatric arrest and should not be delayed while obtaining vascular access.

Try peripheral veins (antecubital, hand, foot, or scalp) first. Intraosseous access is also a quick, safe, and reliable route for administering fluids and resuscitation medications. The proximal tibia is the most commonly used site. If peripheral IV or IO is unsuccessful, percutaneous access of the femoral vein or saphenous vein cutdown may be attempted.

There are several manual and mechanical devices available for IO insertion. The insertion site is 1 to 3 cm below the anterior tibial tuberosity and in the middle of the anteromedial surface of the tibia. Using sterile technique, insert the device to penetrate the cortex. Then, remove the cannula from the needle, confirm needle placement by aspirating bone marrow or infusing 5 to 10 cc of saline, and secure the device.

Begin fluid resuscitation with rapid infusion of isotonic saline, 20 mL/kilogram IV bolus. Repeat as needed. If shock or hypotension persist after several boluses, consider initiating a pressor.

Drugs

Proper drug dosages in children require knowledge of the patient's weight. Use a length-based system when an exact weight is unavailable.

The rule of 6s may be used to quickly calculate continuous infusions of drugs such as dopamine and dobutamine. The calculation is 6 milligrams times weight in kilogram: fill to 100 mL with 5% dextrose in water. The infusion rate in mL per hour equals the micrograms per kilogram per min rate (ie, an infusion running at 1 mL/h = 1 microgram/kilogram/min, or 5 mL/h = 5 micrograms/kilogram/min).

Epinephrine is indicated in pulseless arrest and in hypoxia-induced bradycardia unresponsive to oxygenation and ventilation. The initial dose is 0.01 milligram/kilogram (0.1 mL/kilogram of 1:10,000 solution) IV/IO or 0.1 milligram/kilogram (0.1 mL/kilogram) of 1:1,000 solution by endotracheal route. Subsequent doses may be administered every 3 to 5 min as needed.

Consider sodium bicarbonate if ventilation, epinephrine, and chest compressions fail to correct acidosis.

Calcium may be useful in treating hyperkalemia, hypocalcemia, and calcium-channel blocker overdose. Calcium may be given as calcium chloride, 20 milligrams/kilogram (0.2 milligram/kilogram of 10% solution), or calcium gluconate, 60 to 100 milligrams/kilogram (0.6-1 milligram/kilogram of 10% solution), via IV or IO route.

Dysrhythmias

Dysrhythmias in infants and children are most often the result of respiratory insufficiency or hypoxia. Careful attention to oxygenation and ventilation, along with correction of hypoxia, acidosis, and fluid balance, are the cornerstones of dysrhythmia management in children.

Tables 3-3, 3-4, and 3-5 summarize electrical and drug therapies of unstable cardiac rhythms in children.

The most common rhythm seen in pediatric arrest is bradycardia leading to asystole. Oxygenation and ventilation will often correct this problem. Epinephrine may be useful if the child is unresponsive to this respiratory intervention.

The next most common dysrhythmia in children is narrow complex supraventricular tachycardia (SVT), with rates between 250 and 350 beats per min. On EKG, p waves are either absent or abnormal. It may be difficult to distinguish between a fast sinus tachycardia and SVT. The presence of normal p waves is strongly suggestive of sinus tachycardia rather than SVT. Young infants may have sinus tachycardia with rates faster than 200 beats/min. Patients with sinus tachycardia may have a history of fever, dehydration, or shock, while SVT is usually associated with a vague, nonspecific history.

Defibrillation and Cardioversion

Ventricular fibrillation and ventricular tachycardia are rare in children. When present, immediate defibrillation at 2 J/kilogram is recommended followed by 1 to 2 min of CPR (5 cycles of 15:2 compressions and ventilations) to restore coronary perfusion and improve oxygen delivery to the myocardium before additional attempts at defibrillation. If the first defibrillation attempt is unsuccessful, double the energy to 4 J/kilogram for each subsequent attempt.

Synchronized cardioversion, 0.5 J/kilogram, is used to treat other unstable tachydysrhythmias. Double the energy level to 1 J/kilogram, if the first attempt is unsuccessful.

Use the largest pads or paddles that still allow contact of the entire paddle with the chest wall. When using paddles, electrode cream or paste is used to prevent burns. One paddle is placed on the right of the sternum at the second intercostal space, and the other is placed at the left midclavicular line at the level of the xiphoid.

1. The first step in neonatal resuscitation is to maintain body temperature. Dry the infant and place on a radiant warmer. If available, place the limbs and torso of very-low-birth-weight newborns (<1500 grams) in specially developed polyethylene bags to help maintain normothermia.

2. Reserve immediate suctioning for babies who have obvious obstruction to spontaneous breathing or who require positive-pressure ventilation. If needed, suction the mouth and then the nose with a bulb syringe or mechanical suction device. Routine deep suctioning is not recommended as it may result in vagally induced bradycardia.

3. Aspiration of meconium-stained amniotic fluid may result in both morbidity and mortality. If the infant is vigorous after delivery, do not suction the mouth, nares, or airway. If the infant is depressed after delivery, perform direct tracheal suctioning using direct laryngoscopic visualization and an endotracheal tube fitted with a meconium-suctioning adapter. If attempted intubation is prolonged and unsuccessful, abandon further attempts and begin bag-mask ventilation if the heart rate is <100 beats/min.

4. Assess heart rate, respiratory effort, color, and activity quickly over the next 5 to 10 seconds. If the infant is apneic or the heart rate is slow (<100 beats/min), administer positive-pressure ventilation using bag-mask ventilation. For term babies, begin resuscitation with room air rather than 100% oxygen. Use pulse oximetry to guide the use of supplementary oxygen.

   If the baby is bradycardic (HR<60 beats/min) after 90 seconds of resuscitation with room air or with blended oxygen, increase the oxygen concentration to 100% until heart rate is normalized. Provide assisted ventilation at rates of 40 to 60 breaths/min. Begin with aninflation pressure of about 20 cm H2O. Pressures as high as 30 to 40 cm H2O may be required initially in some term infants if chest rise is inadequate and the baby is not responding. However, high inflation pressures may result in pneumothorax, especially in premature infants.

5. If no improvement is noted after 30 seconds of bag-mask ventilation or the infant's condition deteriorates further, perform endotracheal intubation and ventilation. CO2 detectors aid in determining whether the baby is properly intubated but color change is dependent on adequate circulation. Proper tube placement can also be determined by noting good chest rise, visualization of vapor steam in the endotracheal tube, and auscultation.

6. If the heart rate is still slower than 60 beats/min after intubation and assisted ventilation for 30 seconds, begin cardiac compressions at 90 chest compressions and 30 breaths each min (3:1 ratio). The '2 thumb-encircling hands' technique is preferred to the '2-finger' technique when performing chest compressions.

7. If there is still no improvement in heart rate, initiate drug therapy. Vascular access may be obtained peripherally or via the umbilical vein. The most expedient procedure in the neonate is to place a catheter in the umbilical vein and advance to 10 to 12 cm or until free flow of blood is seen in the catheter.

8. Push epinephrine, 0.01 to 0.03 milligram/kilogram of 1:10,000 solution IV, which equals 0.1 to 0.3 mL/kilogram, if the heart rate is still slower than 60 beats/min despite adequate ventilation and oxygenation. Repeat every 3 to 5 min if necessary. IV administration is preferred to intratracheal administration.

9. Initiate volume expansion with normal saline (or Type O/Rh negative blood, if available), 10 to 20 mL/kilogram, if hypovolemia is suspected on the basis of pallor, slow capillary refill time, weak pulses, and/or inadequate response to other measures.

10. Sodium bicarbonate during neonatal resuscitation remains controversial and is generally not administered during initial resuscitation. A dose of 1 mEq/kilogram of a 4.2% solution (0.5 mEq/mL) IV may be given if there is a significant metabolic acidosis; this therapy should be guided by blood gas values.

11. Naloxone is not recommended in the resuscitation for newborns with respiratory depression.