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.
Prepare equipment, medication, and personnel before initiation of RSI. Check equipment function.
Preoxygenate the patient with 100% oxygen.
In children, cricoid pressure can occlude the pliable trachea. Release cricoid pressure, if applied, if laryngoscopy and intubation are difficult.
Refer to Table 3-2 for specific induction and paralytic agents used in children.
Intubate the trachea, confirm proper placement, and secure the tube.
Atropine 0.02 milligram/kilogram (minimum dose, 0.1 milligram; maximum dose, 1 milligram) may be used for symptomatic reflex bradycardia.
Table 3-2 Common Rapid-Sequence Intubation Medications in Children* ||Download (.pdf)
Table 3-2 Common Rapid-Sequence Intubation Medications in Children*
| Etomidate||0.3 milligram/kilogram||Preserves hemodynamic stability; may suppress adrenal axis even in a single dose; short acting, requires anxiolysis or analgesia after intubation|
| Ketamine||1–2 milligrams/kilogram||Bronchodilator, preserves respiratory drive, cardiovascular stimulant; drug of choice for intubation for asthma|
| Propofol||1–2 milligrams/kilogram||Rapid push, higher dose in infants, may cause hypotension; short acting, requires ongoing anxiolysis or analgesia after intubation|
| Rocuronium||1 milligram/kilogram||Nondepolarizing agent; longer duration than succinylcholine|
< kilograms: 1.5–2.0 milligrams/kilogram
>10 kilograms: 1.0–1.5 milligrams/kilogram
|Shorter duration than rocuronium; better intubating conditions at 60 s; may cause bradycardia in children and hyperkalemic cardiac arrest in children with undiagnosed neuromuscular disease|
| Midazolam||0.1 milligram/kilogram||Short-acting sedative|
| Lorazepam||0.1 milligram/kilogram||Longer-acting sedative|
| Fentanyl||1–2 micrograms/kilogram||Short-acting analgesic; preserves hemodynamic stability|
| Morphine||0.1–0.2 milligram/kilogram||Longer-acting analgesic; may cause histamine release|
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.
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 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.
Table 3-3 Treatment of Pediatric Bradycardia ||Download (.pdf)
Table 3-3 Treatment of Pediatric Bradycardia
|1. If bradycardia causing cardiorespiratory compromise:|
| a. Provide oxygen and/or ventilation as necessary.|
| b. If heart rate remains bradycardic (<60) with poor perfusion, begin CPR.|
|2. If symptomatic bradycardia persists, administer epinephrine 0.01 milligram/kilogram (0.1 mL/kilogram of 1:10,000 concentration) IV/IO and repeat every 3 to 5 min as necessary. ET epinephrine 0.1 milligram/kilogram (0.1 mL of 1:1000 concentration) may be used if IV access is unavailable. If bradycardia is due to increased vagal tone or primary AV conduction block, give atropine: 0.02 milligram/kilogram (minimum dose, 0.1 milligram; maximum dose, 1 milligram); may repeat.|
|3. Consider emergency pacing in patients with complete heart block or sinus node dysfunction unresponsive to oxygenation, ventilation, chest compressions, and medications.|
|4. Identify and treat the underlying cause.|
Table 3-4 Treatment of Pediatric Pulseless Arrest ||Download (.pdf)
Table 3-4 Treatment of Pediatric Pulseless Arrest
|1. Initiate BLS; CPR; administer oxygen, attach monitor/defibrillator if available. If after any of the steps below the rhythm becomes stable, begin post-resuscitation efforts.|
|2. If rhythm is shockable, ie, ventricular fibrillation (VF) or ventricular tachycardia (VT):|
| a. Defibrillate once w/ 2 J/kilogram; may use pediatric AED if > 1 y/o (1-8 year olds); Check rhythm.|
| b. If unstable cardiac rhythm persists, resume CPR for 5 cycles. Interrupt only to administer 4 J/kilogram (may use pediatric AED) for VF/VT. Give epinephrine 0.01 milligram/kilogram (0.1 mL of 1:10,000 concentration) IV/IO and repeat every 3-5 min as necessary. ET epinephrine 0.1 milligram/kilogram (0.1 mL of 1:1000 concentration) may be used if IV access is unavailable. Check rhythm.|
| c. If unstable cardiac rhythm persists, resume CPR for 5 cycles. Interrupt only to administer 4 J/kilogram (may use pediatric AED) for VF/VT. Consider amiodarone 5 milligrams/kilogram IV/IO, lidocaine 1 milligram/kilogram IV/IO, magnesium 25-50 milligrams/kilogram IV/IO. Treat reversible causes. Check rhythm.|
| d. Repeat steps b and c until stable rhythm or decision to discontinue resuscitation.|
|3. If rhythm is not shockable, ie asystole:|
| a. Resume CPR. Give epinephrine 0.01 milligram/kilogram (0.1 mL of 1:10,000 concentration) IV/IO and repeat every 3-5 min as necessary. ET epinephrine 0.1 milligram/kilogram (0.1 mL of 1:1000 concentration) may be used if IV access is unavailable. Check rhythm.|
| b. If asystole persists, repeat step above until a treatable rhythm develops or decision to discontinue resuscitation.|
Table 3-5 Treatment of Pediatric Tachycardia with Poor Perfusion ||Download (.pdf)
Table 3-5 Treatment of Pediatric Tachycardia with Poor Perfusion
|Provide oxygen and ventilation as necessary. Attach monitor/defibrillator if available; perform ECG and evaluate QRS duration.|
|NARROW COMPLEX QRS (>0.09 sec)|
| a. Identify and treat underlying cause.|
| b. ECG reveals normal P waves, variable R-R intervals, constant P-R intervals; infant rate usually <220 bpm; child rate usually <180 bpm)|
| a. Try vagal maneuvers first; if unsuccessful, administer adenosine, 0.1 milligram/kilogram (maximum, 6 milligrams) by rapid IV push; if unsuccessful, double dose to 0.2 milligram/kilogram (maximum, 12 milligrams).|
| b. Another option is synchronized cardioversion, 0.5-1 J/kilogram. If unsuccessful, double to 1-2 J/kilogram. Sedate patient, if possible.|
| c. EKG reveals absent/abnormal P waves, HR not variable (infant rate usually >220 bpm; child rate usually >180 bpm)|
|WIDE COMPLEX QRS(≥0.09 sec)|
| 1. Perform synchronized cardioversion, 0.5-1 J/kilogram. Sedate if possible. Consider giving adenosine if electrical cardioversion is not delayed.|
| 2. Other options include amiodarone, 5 milligrams/kilogram IV over 20-60 min or procainamide, 15 milligrams/kilogram IV over 30-60 min.|
| 3. Expert consultation is advised.|
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.