Chapter 20: Cardiopulmonary Resuscitation

High-Yield Facts

• The code leader must ensure high-quality cardiopulmonary resuscitation (CPR) be integrated into advanced life-support measures in order to ensure a good outcome during resuscitation.

• Chest compressions should be initiated before ventilations in order to immediately provide blood flow to the heart and brain (2010 AHA C-A-B recommendations).

• When two or more health care providers are performing CPR in an infant or child, the correct compression-to-ventilation ratio is 15:2 (15 compressions followed by 2 ventilations). In all other circumstances, the ratio is 30:2.

• Two-minute cycles of CPR should be performed before stopping compressions to reassess the child.

• Automated external defibrillators (AEDs) can now be safely and effectively used in infants and children of all ages. If possible use a pediatric attenuator device for children weighing less than 25 kg.

• Ventricular fibrillation and pulseless ventricular tachycardia are treated with single shocks followed immediately by 2-minute cycles of CPR in order to maintain myocardial perfusion after each defibrillation.

• Length-based tapes facilitate medication dosing and device size selection.

• Intraosseous (IO) lines can be used in any age for an IV medication.

• IV or IO medication administration is preferred over the endotracheal route.

• Pulseless electrical activity (PEA) requires the identification and correction of reversible causes, the most common of which is hypovolemia. Consider a rapid fluid bolus in any child presenting in a PEA rhythm.

• The quality of chest compressions can be monitored with continuous monitoring of end-tidal CO₂. Less than 10 to 15 mm Hg may indicate low cardiac output during CPR, whereas >10 to 15 mm Hg suggests effective chest compressions during CPR. An abrupt rise in end-tidal CO₂ (ETCO₂) during chest compressions may suggest the return of spontaneous circulation.

• After the return of spontaneous circulation, avoid the risk of hyperoxia reperfusion injury. Titrate the oxygen FiO₂ administration to maintain oxygen saturations of 94% to 99%.

Sudden cardiac arrest due to a primary cardiac dysrhythmia is rare in children.¹ Unrecognized and progressive respiratory distress and shock are the most common etiologies of cardiopulmonary arrest (CPA) in children. The outcome for out-of-hospital CPA is poor with only 4% to 13% of children surviving to hospital discharge.² The survival rate of in-hospital CPA is approximately 27% to 33%.^2,3 Early recognition of a child in respiratory distress and/or compensated shock (Chapters 17,18,19) is essential to prevent the progression to CPA.

The Importance of Incorporating High-Quality Basic Life Support into Advanced Life-Support Measures

The 2010 AHA CPR and PALS guidelines continue to emphasize the importance of high-quality cardiopulmonary resuscitation (CPR) by lay rescuers and by health care providers. The major change regarding the sequence of actions for CPR in the 2010 AHA guidelines is the “C-A-B” sequence, which stands for “compressions–airway–breathing.”⁴ This new emphasis on initiating chest compressions before ventilations provides for more immediate perfusion to the heart ...