Paediatric Cardiac Arrest

• In terms of aetiologies, the most common precipitants of cardiac arrest are:
• Hypoxia
• Dysrhythmia, especially bradycardia (often secondary to hypoxaemia)
• Hypotension, especially in those with congenital cardiac disease or due to major haemorrhage


• With respect to cardiac arrest rhythms;
• Non-shockable rhythms more common than shockable rhythms in children
• Asystole is the commonest rhythm overall
• VF or VT are much less common and usually due to congenital cardic disease, hyperkalaemia, hypothermia or sometimes poisoning (e.g. TCA overdose)

• Previous perioperative cardiac arrest in paediatric patients reported to occur in 1 in 1,900 anaesthetics with a mortality of 18%

• NAP7 contained 104 paediatric arrests, representing 12% of all perioperative arrests
• It gives an incidence of 1 in 3,724 (∽3 in 10,000) i.e. less common than previously quoted and similar to adults
• The highest incidence was in neonates (1 in 195) and infants (1 in 613), although over half of the patients in these cohorts had congenital cardiac disease, and the incidence falling with increasing age
• Survival to ROSC was 83% and at time of reporting the survival to discharge was 41% (with 33% still admitted and 26% mortality)

• Factors more common in those who experienced perioperative cardiac arrest included

• Most cardiac arrests were non-shockable
• Most frequent aetiologies in non-cardiac surgery
• Hypoxaemia (22%)
• Bradycardia (11%)
• Major haemorrhage (8%)


• Most frequent aetiologies in cardiac surgery
• Severe hypotension (16%)
• Cardiac tamponade (11%)


• 14% of cardiac arrests were airway related e.g. misplaced, obstructed or accidentally removed endotracheal tube
• This would then lead to hypoxia, bradycardia and cardiac arrest

W - Weight = (age + 4) x 2

E - Energy in cardiac arrest = 4J/kg

T - Tube (uncuffed) internal diameter = age/4 + 4
Depth of insertion = age/2 + 12cm

F - Fluids = 10-20ml/kg bolus

L - Lorazepam = 0.1mg/kg IV (max 4mg)

A - Adrenaline in cardiac arrest = 10μg/kg (0.1ml/kg of 1:10,000 [minijet] adrenaline)

G - Glucose = 2ml/kg 10% dextrose

• Atropine = 20μg/kg (min 100μg / max 600μg)
• Glycopyrrolate = 5μg/kg [max 200μg]


• Adrenaline for anaphylaxis = 1μg/kg


• Magnesium (e.g. Torsades) = 25 - 50mg/kg [max 2g]
• Calcium gluconate = 0.5ml/kg of a 10% solution
• Bicarbonate = 1ml/kg of an 8.4% solution

• For the most part, the paediatric cardiac arrest algorithm mirrors the adult one
• There are certain differences which one needs to be mindful of:

• 5 initial rescue breaths are recommended (absent in adults)
• CPR:ventilation ratio is 15:2 (30:2 in adults)
• Should start CPR for bradycardia <60bpm even if respiratory function adequate (not recommended in adults except in anaphylaxis)


• Once supraglottic device or ETT established the rate of ventilation depends on the age:
• Infant (<1yrs): 25bpm
• 1 - 8yrs: 20bpm
• 8 - 12yrs: 15bpm
• >12yrs: 10-12bpm as in adults


• Pulse checks should be brachial in infants, but carotid in older children as in adults


• Parental presence should be facilitated if desired; evidence suggests it helps them gain a realistic view of attempted resuscitation and death
• Bereaved families who have been present at the event show less anxiety and depression several months after the death

• Give 10μg/kg adrenaline IV or IO as soon as possible once non-shockable rhythm or bradycardia <60bpm has been identified
• Give adrenaline every 3-5mins thereafter

• Deliver 4J/kg shock as soon as shockable rhythm identified
• Give adrenaline 10μg/kg adrenaline IV or IO after the third shock, then every 3-5mins thereafter
• Give amiodarone 5mg/kg IV or IO after the third shock, with a repeat dose of 5mg/kg after the fifth shock
• Lidocaine 1mg/kg is an alternative to amiodarone
• Consider escalating energy levels after the sixth shock if still in a shockable rhythm and once expert help sought