Cardiac arrest and cardiopulmonary resuscitation in children

Diagnostic approach

• Assess the airway.
• Check for breathing.
• Check for a pulse.
• Attach a defibrillator to assess rhythm.
• Once CPR is established, assess for reversible causes (e.g., blood gas, POCUS).

Reversible causes

• Hypoxia
• Hypovolemia
• Hyperkalemia or hypokalemia
• Hypoglycemia
• Hydrogen ions (acidosis)
• Hypothermia
• Tension pneumothorax
• Tamponade
• Toxins
• Thrombosis (pulmonary or coronary)

Management checklist

• Activate emergency response (e.g., code blue).
• Initiate CPR in children.
• Attach AED or manual defibrillator.
• Assess the rhythm.
• Pediatric shockable rhythm (Vfib or pulseless VT)
• • Immediately defibrillate (2 J/kg).
  • Establish IV or IO access.
  • Continue management of shockable rhythm in children.
• Pediatric nonshockable rhythm (asystole or PEA)
• • Establish IV or IO access.
  • Administer epinephrine as soon as possible.
  • Continue management of nonshockable rhythms in children.
• Recheck rhythm and pulse every 2 minutes.
• Consider advanced airway placement and capnography.
• Assess for and treat reversible causes of pediatric cardiac arrest.

Cardiac arrest is the cessation of cardiac function and blood circulation, which manifests as apnea, pulselessness, and loss of consciousness. In children, cardiac arrest is commonly caused by profound hypoxia, but up to one-third of cases are due to an underlying cardiac condition. Cardiopulmonary resuscitation (CPR) is a lifesaving procedure that artificially maintains circulation and ventilation until cardiac function is restored. When cardiac arrest is suspected, basic life support (BLS) guides lay rescuers and the initial efforts of medical professionals. BLS involves assessment to confirm cardiac arrest, provision of CPR, and use of an automated defibillator (AED), if available. The pediatric BLS algorithm is used for infants and prepubertal children; it features more frequent rescue breaths to treat hypoxia. From puberty, adult BLS is recommended. Once trained providers and equipment arrive on scene, pediatric advanced life support (PALS) is provided to children of all ages. PALS includes additional measures (e.g., resuscitation medications, airway management) and identifying and treating reversible causes of cardiac arrest in children. After the return of spontaneous circulation (ROSC), comprehensive postresuscitation care in children is essential for good neurological and functional outcomes. This involves neuroprotective measures, hemodynamic support, critical care admission, monitoring for organ dysfunction, and treatment of underlying causes and complications.

For resuscitation of neonates at birth, see "Neonatal resuscitation." For infants in the first 28 days of life, either PALS or neonatal resuscitation algorithms may be used, depending on hospital protocol.

Epidemiology

• In-hospital cardiac arrest (IHCA) occurs in > 20,000 children each year; > 40% survive.
• Out-of-hospital cardiac arrest (OHCA) occurs in > 7000 children each year; 15–20% survive.
• Neurological outcomes are favorable in 47% of survivors.

Etiology

• Respiratory failure and shock are the most common causes of cardiac arrest in children.
• Progressive deterioration typically precedes cardiac arrest.
• Children with congenital heart disease may have a primary cardiac cause and an abrupt arrest.

Pediatric chain of survival

• Recognition and emergency activation
  • Identify and treat precipitating causes (e.g., respiratory failure) early.
  • Rapidly activate the emergency system.
• High-quality CPR
  • Initiate chest compressions.
  • Provide effective airway management and rescue breathing.
• Defibrillation of shockable rhythms
  • OHCA: Rapidly apply an AED.
  • IHCA: Use a defibrillator (manual or AED) as soon as a shockable rhythm is recognized.
• Advanced resuscitation
  • Obtain IV access or IO access.
  • Provide advanced respiratory support in pediatric ALS.
  • Administer inotropes and/or antiarrhythmics.
  • Assess for reversible causes.
• Postresuscitation care in children
  • Optimize oxygenation, ventilation, and hemodynamics.
  • Provide multifaceted neuroprognostication.
• Recovery and survivorship
  • Reassess survivors regularly in the first year for signs of complications.
  • Refer to specialist services (e.g., physiotherapy, speech and language therapy) as needed.

BLS vs. PALS in children ^[1]

BLS in children

• Provided by lay individuals and first responders to infants and prepubertal children.
  • Neonates at birth: Use the NLS algorithm.
  • Pubertal children: Use the adult BLS algorithm.
• Key components include:
  • Activation of emergency response
  • Provision of high-quality chest compressions
  • Airway opening maneuvers
  • Rescue breathing
  • AED application
• BLS should be replaced by PALS in children once trained responders and equipment arrive.

PALS ^[1]

• Provided by PALS-certified individuals to infants and children up to 18 years of age
• Key components of resuscitation include:
  • CPR in children
  • Defibrillation in children
  • Rhythm recognition in cardiac arrest
  • Use of epinephrine (plus antiarrhythmics for shockable rhythms)
  • Advanced airway management in children
  • Treatment of reversible causes of cardiac arrest in children
• Continue to provide comprehensive postresuscitation care in children, including:
  • Targeted temperature management in children
  • Blood pressure management
  • Oxygen therapy in children
  • Ventilatory support
  • Neurological monitoring
  • Neuroprognostication in children

The BLS algorithm for children guides trained individuals to assess an unresponsive infant or prepubertal child, recognize cardiac arrest, provide high-quality chest compressions, deliver ventilations, and use an AED. Use the adult BLS algorithm for children who have reached puberty (i.e., breast development in girls and growth of axillary hair in boys).

BLS algorithm for children

Scene safety assessment

• Check for fire, chemicals, toxins, and biohazards.
• Don PPE if there is concern for infectious and/or toxic exposure.
• Proceed with BLS once personal safety is confirmed.

Assessment of responsiveness

• Use verbal and tactile stimulation (e.g., tap and shout).
• Assume an unresponsive child with absent or abnormal breathing is in cardiac arrest.

Request for assistance

• Shout for help.
• Activate the emergency response (e.g., call 911, initiate a Code Blue).
• Request an AED or manual defibrillator.

Brief assessment (≤ 10 seconds)

• Observe for apnea or gasping respiration.
• Check for central pulse.
• Look for obvious signs of trauma.
• Normal breathing and pulse: Monitor until help arrives.
• Abnormal breathing, palpable pulse: Perform airway opening maneuvers, and provide rescue breathing as needed.
  • HR ≥ 60/minute after 2 minutes: Continue rescue breathing.
  • HR < 60/minute and perfusion appears poor after 2 minutes: Start CPR.
• Abnormal breathing and nonpalpable pulse: Start CPR.

Initiation of CPR

• One rescuer: Perform cycles of 30 chest compressions followed by 2 breaths.
• Two rescuers: Perform cycles of 15 chest compressions followed by 2 breaths.
• If only one rescuer is available, perform CPR for 2 minutes, then consider leaving to retrieve an AED or manual defibrillator.

Defibrillation

• Apply defibrillator pads as soon as they are available and assess the rhythm.
• If a shock is delivered, resume CPR for 2 minutes before rechecking the rhythm.
• Pause CPR briefly (< 10 seconds) every 2 minutes for a rhythm check and to allow for defibrillation.

Endpoints for CPR

• The child begins to move.
• PALS-trained professionals assume care of the child.

The BLS algorithm for children is designed for use in infants and prepubertal children. Once patients have reached puberty, use the adult BLS algorithm.

Pauses > 10 seconds before and after shock delivery are associated with decreased survival.

Shockable rhythms are rare in infants and young children; they are less frequent in adolescents than in adults.

Automated external defibrillator use in children

• Use an AED or defibrillator as soon as it is available.
• Use pediatric pads and a pediatric attenuator for children < 8 years of age or 25 kg in weight. ^[2]
• Consider using an AED without a pediatric attenuator if no alternative is available.
• Use the largest self-adhering pads or paddles that still allow 1–2 cm of separation.
• Pad position
  • Anteroposterior: one pad centered on the anterior chest, and one pad centered on the back
  • Anterolateral: one pad placed on the left chest between the sternum and the nipple, and one pad centered on the back

Special situations

Foreign body aspiration

• Mild obstruction: Encourage the child to clear the airway by coughing.
• Severe obstruction
  • Infant: Deliver five back blows followed by five chest thrusts; repeat until object expelled or infant unresponsive.
  • Child: Deliver five back blows followed by five abdominal thrusts; repeat until object expelled or child unresponsive.
• If the child becomes unresponsive, begin CPR with chest compressions.
• Remove the foreign body if it is observed in the mouth, but do not sweep the oropharynx blindly.
• See "Management of foreign body aspiration" for more details.

Avoid abdominal thrusts in infants due to the risk of abdominal organ injury.

The hand position for chest thrusts is the same as for one-hand chest compressions.

Opioid overdose

• Initiate CPR in children without delay, focusing on the airway and breathing.
• Administer an opioid antagonist (e.g., naloxone) if overdose is suspected. Available formulations include:
  • Intranasal naloxone
  • Naloxone for injection
• If opioid reversal is successful, admit to the hospital to monitor for recurrent CNS and/or respiratory depression.

Trauma

• Open the airway with jaw thrust, not head-tilt/chin-lift, if cervical spine injury is suspected.
• Avoid nasal pharyngeal airways in patients with facial trauma.

The following information is for infants and prepubertal children. For pubertal children, perform adult CPR.

Approach

• Immediately call for help and initiate CPR in unresponsive infants or children with abnormal breathing.
• Begin CPR with chest compressions.
• Open the airway and begin respiratory support as soon as possible.
• Minimize interruptions to CPR.
• Follow BLS or PALS algorithms, depending on training and equipment.

Cardiac arrest in children is most commonly caused by a respiratory condition.

Both chest compressions and ventilation are recommended for all causes of cardiac arrest.

Chest compressions in children

General principles for high-quality chest compressions

• Position the child on a firm surface if possible.
• Deliver compressions at a rate of 100–120/minute.
• Allow complete chest recoil after each compression.
• Do not pause compressions for > 10 seconds.

Infants

• Hand placement
  • One hand: Place the heel of one hand in the center of the chest just below the nipple line.
  • Two thumb encircling hands: Place both thumbs in the center of the chest, just below the nipple line.
• Depress the chest 4 cm with each compression.

The AHA no longer recommends two-finger compression of the sternum as studies have shown that it provides insufficient chest compression.

Children

• Hand placement
  • One hand: Place the heel of one hand in the center of the chest on the lower half of the sternum.
  • Two hands: Place the lower hand as above, with the second hand lying directly on top with fingers interlaced.
• Depress the chest 5 cm with each compression.

Two-hand chest compressions are generally more effective than one-hand compressions in children > 1 year.

Respiratory support for children during CPR

See "Airway management in children" for a more detailed approach.

General principles for high-quality respiratory support

• Perform airway opening maneuvers first.
  • Head-tilt/chin-lift: preferred in nontrauma settings
  • Jaw-thrust maneuver: preferred if cervical spine injury is suspected
• Known or suspected aspiration: See "Management of foreign body aspiration."
• Begin rescue breathing with bag-mask ventilation (BMV) if the child is pulseless, apneic, or has inadequate respiratory effort.
  • Attach the BMV to 100% oxygen.
  • Use basic airway adjuncts as needed (e.g., oropharyngeal airway, nasopharyngeal airway).
  • If equipment is not readily available (i.e., OHCA), provide mouth-to-mouth breaths (preferred) or compression-only CPR.
• Provide enough tidal volume to achieve a visible chest rise.
• Consider advanced airway placement if trained; see "Advanced respiratory support in pediatric ALS."

Continuous compression-only CPR is a reasonable alternative to mouth-to-mouth rescue breathing if the provider is uncomfortable administering rescue breaths.

Ventilation and oxygenation will be ineffective if the airway is not patent.

It is reasonable to continue effective BMV instead of attempting advanced airway placement during CPR. ^[1]

Compression to ventilation ratios in children

• Aim for 100–120 chest compressions per minute.
  • Advanced airway in place: Deliver continuous compressions.
  • No advanced airway in place: Interrupt compressions to deliver rescue breaths.
    • Single rescuer: 30 compressions followed by 2 breaths
    • Two rescuers: 15 compressions followed by 2 breaths
• Deliver 20–30 breaths a minute if there is:
  • An advanced airway in place
  • Respiratory arrest in a child with a pulse

Use adult CPR for children who have reached puberty, with a ratio of 30:2 for rescue breaths.

Avoid hyperventilation and hypoventilation in patients with cardiac arrest. ^[1]

Monitoring for effective CPR

Ensure good technique

• Compression rate: 100–120 compressions per minute
• Compression depth: 4 cm in infants and 5 cm in children
• Complete chest recoil between compressions.
• Breaths: visible equal chest rise when breaths are delivered

Consider advanced monitors

• CPR feedback devices: These devices improve chest compressions but have not been shown to improve ROSC or survival.
• End-tidal CO₂ (EtCO₂) ^[1]
  • Presence of EtCO₂ suggests adequate compressions and ventilations.
  • EtCO2 values may increase suddenly with ROSC.
  • There is no specific cut-off EtCO₂ value for ending resuscitation efforts.
• Arterial monitor: If the monitor is in place, aim for a target diastolic blood pressure of ≥ 25 mm Hg in infants or ≥ 30 mm Hg in children. ^[1]

PALS algorithm ^[1]

• Begin pediatric CPR.
• Provide initial respiratory support with BMV attached to 100% oxygen.
• Attach a defibrillator.
• Identify the rhythm in cardiac arrest and defibrillate as needed.
  • Shockable rhythms
    • Ventricular fibrillation
    • Pulseless ventricular tachycardia
  • Nonshockable rhythms
    • Asystole
    • Pulseless electrical activity
• Obtain IV access or IO access as quickly as possible.
• Continue management (e.g., defibrillation, medications) based on underlying rhythm. See:
  • Management of pediatric shockable rhythms
  • Management of pediatric nonshockable rhythms
• Consider placing an advanced airway.
• Assess for reversible causes of cardiac arrest in children.
• Designate a team member for continuous family support.
  • Offer the family the option to be present during resuscitation.
  • Ask the family to leave if their presence impedes resuscitation.
• Continue resuscitation until there are signs of ROSC or the decision to terminate pediatric CPR is made.

Use the Broselow tape in pediatric patients to rapidly determine medication dosages, equipment sizing, and defibrillator shock dosages. ^[1]

Do not administer medications through the endotracheal tube unless IV or IO access is not possible. ^[1]

Advanced respiratory support in pediatric ALS ^[1]

See "Airway management in children" for details.

• Placement of an advanced airway has benefits and risks.
  • Benefits
    • Allows uninterrupted chest compressions
    • May improve ventilation
    • Reduces the risk of aspiration
  • Risks
    • Placement interrupts chest compressions
    • Malpositioning or displacement can lead to catastrophic hypoxia
• Airway choice depends on expertise and patient location at the time of cardiac arrest.
  • OHCA: Consider continuing BMV without placing an advanced airway.
  • IHCA: Either BMV or an advanced airway is appropriate if an advanced airway can be placed swiftly, with minimal interruptions to compressions.
• When an advanced airway is in place, the target respiratory rate is 20–30 breaths per minute while providing continuous chest compressions.
• Verify correct advanced airway placement with EtCO₂.

Bag-mask ventilation provides adequate respiratory support for most patients. ^[1]

Avoid hyperventilation as it can reduce effective cardiac output. ^[1]

Shockable rhythms (Vfib or pulseless VT) are uncommon in children, but the proportion of cardiac arrests with shockable rhythms increases throughout childhood and adolescence. ^[1][4]

Algorithm for pediatric shockable rhythms ^[1]

• Defibrillate as soon as a shockable rhythm has been identified
• Repeat the following pattern as long as the rhythm remains shockable.
  • Immediately resume pediatric CPR for 2 minutes.
  • Check rhythm and pulse for ≤ 10 seconds after 2 minutes.
  • Defibrillate if the rhythm is still shockable.
• After the second defibrillation, administer epinephrine and repeat every 3–5 minutes.
• After the third defibrillation, consider amiodarone (off-label) OR lidocaine (off-label).
• If the rhythm converts to PEA or asystole during any pulse check, change to management of nonshockable rhythms in children.
• During CPR, identify and treat reversible causes of cardiac arrest in children.
• Continue resuscitation until there are signs of ROSC or the decision to terminate pediatric CPR is made.

Pediatric defibrillation

The following information relates to manual defibrillation; for automatic defibrillation, see "AED use in children."

• Use the largest self-adhering pads or paddles that still allow 1–2 cm of separation.
• Pad position
  • Anteroposterior: one pad centered on the anterior chest, and one pad centered on the back
  • Anterolateral: one pad placed on the left chest between the sternum and the nipple, and one pad centered on the back

Energy selection ^[1]

• Initial dose: 2 J/kg
• Second dose: 4 J/kg
• Subsequent doses: ≥ 4 J/kg; increase as needed up to 10 J/kg (maximum energy 200 J biphasic or 360 J monophasic).

• Continue pediatric CPR.
• Give epinephrine for pediatric cardiac arrest as soon as possible and repeat every 3–5 minutes.
• Every 2 minutes, check rhythm and pulse for ≤ 10 seconds.
  • Nonshockable rhythm persists: Resume CPR.
  • Shockable rhythm is identified: Immediately defibrillate and change to management of shockable rhythms in children.
• Search for reversible causes of cardiac arrest in children.
• Continue resuscitation until there are signs of ROSC or the decision to terminate pediatric CPR is made.

Overview ^[1]

• Use the Hs and Ts mnemonic to quickly review the common reversible causes of cardiac arrest.
• Review the patient's clinical history, examination findings, and bedside tests to identify underlying causes.

Do not administer calcium, sodium bicarbonate, or glucose unless there is clear evidence they are clinically indicated. ^[1][5]

Do not interrupt CPR or delay defibrillation to perform ultrasound examinations; using the subcostal view for FoCUS can minimize interference with chest compressions. ^[6][7]

Treatment of specific causes of cardiac arrest

The following etiologies may lead to cardiac arrest in children; see the respective articles for information on management.

• Anaphylaxis
• Asthma
• Congenital heart disease, cardiomyopathy (early use of ECPR in children may be beneficial)
• Drowning
• Electrical and lightning injuries
• Electrolyte abnormalities, e.g.:
  • Hyponatremia
  • Hypomagnesemia
  • Hypercalcemia
• Foreign body aspiration
• Heat-related injuries
• Venous air embolism, arterial air embolism

• Extracorporeal CPR (ECPR) is the initiation of venoarterial ECMO during refractory cardiac arrest or within 20 minutes of ROSC. ^[1]
• Consider ECPR for children with cardiac conditions, including myocarditis, who have an IHCA with potentially reversible causes. ^[1]
• Early ECPR or premeptive use of ECMO may improve survival of at-risk children with: ^[1]
  • Cardiomyopathy
  • Congenital heart disease
  • Pulmonary hypertension
• The benefit of ECPR for OHCA is unknown.

• Transition to postresuscitation care if there are signs of ROSC.
• Meticulous postresuscitation care is required to minimize hypoxic brain injury, which is a leading cause of morbidity after cardiac arrest in children. ^[1]

Targeted temperature management in children ^[1]

Targed temperture management (TTM) in comatose children following a cardiac arrest reduces central nervous system metabolic demands.

• Monitor core temperature continuously (e.g., rectal, bladder, esophageal).
• Proactively maintain core temperature ≤ 37.5° C (e.g., active cooling).
• Choose and maintain one of the following TTM protocols. ^[8][9]
  • 32–34° C for 5 days, then 36–37.5° C
  • 36–37.5° C after ROSC

Blood pressure management ^[1]

• Monitor arterial pressure continuously.
• Hypotension occurs in up to half of children following cardiac arrest and can worsen brain and myocardial injury.
  • Hypotension thresholds are typically defined as systolic blood pressure (SBP) < 5th percentile for age.
  • Estimated thresholds by age (mm Hg) ^[10][11]
    • Infants < 1 month: SBP < 60 mm Hg
    • Infants 1–12 months: SBP < 70 mm Hg
    • Children 1–10 years: SBP < 70 + (2 × age in years) mm Hg
    • Children > 10 years: SBP < 90 mm Hg
• Treat hypotension with fluids, inotropes, and/or vasopressors (e.g., epinephrine, dopamine, norepinephrine); aim for SBP and MAP > 10th percentile for age.

Respiratory management ^[1]

• Wean from 100% oxygen if possible.
• For children without significant underlying cardiac or respiratory disease, aim for the following:
  • SpO₂ of 94–99%
  • PaCO₂ in the normal range

Neurological monitoring ^[1]

Seizures occur in up to 30% of children post-cardiac arrest but may be clinically silent (i.e., nonconvulsant).

• Treat clinically apparent seizures.
• Consult with a specialist to determine the following:
  • Treatment for nonconvulsive status epilepticus
  • Need for continuous EEG monitoring (recommended in children with persistent encephalopathy ) ^[1]

Neuroprognostication in children ^[1]

Multiple physical examination findings and diagnostic study results are considered when predicting whether a neurological outcome will be favorable or unfavorable.

A prognosis is not usually given until ≥ 72 hours after a cardiac arrest because neuroprognostication is multimodal and requires multiple tests over several days. ^[1]

Evaluation of unexpected sudden cardiac arrest ^[1]

• Review past medical history and family history for:
  • Syncope
  • Seizures
  • Unexplained accidents
  • Family history of early or unexplained deaths
• Review previous ECG findings.
• Refer to a cardiologist with expertise in inherited disease.

Long-term care ^[1]

• Long-term neuropsychological impairments are common, even if the predicted outcome is favorable. ^[12]
  • Most common impairments: executive functioning, fine motor and visuomotor function, visual memory
  • IQ is typically unaffected
• Reassess survivors regularly during the first year and refer to services as needed, e.g.:
  • Physical therapy or occupational therapy
  • Speech-language pathologist
  • Psychiatry for treatment of anxiety and treatment of depression in children

• Some studies have shown survival with acceptable neurological outcomes after prolonged resuscitation in children (e.g., > 35 minutes). ^[13]
• Termination of resuscitation (TOR) protocols are commonly applied to adults but not children. ^[14]
• Factors associated with a lower chance of survival in children with cardiac arrest include: ^[15]
  • Unwitnessed arrest
  • Asystole
  • Cause other than drowning or electrocution
  • No sustained ROSC
• EtCO₂ alone is not a reliable indicator of futility. ^[1][16]
• Shared decision-making and consideration of all mitigating factors are recommended before TOR.
  • Continue resuscitation efforts until the family feels all appropriate measures have been taken.
  • Obtain specialist input when possible.

Unexpected deaths

• Consider forensic requirements (e.g., leave endotracheal tubes and lines in situ).
• A complete autopsy is recommended. ^[1]
• Further assessment for underlying cardiac causes includes: ^[1]
  • Postmortem genetic evaluation (unless autopsy identifies the cause)
  • Evaluation of first-degree relatives for inherited cardiac disease

All children

• Rapidly identify children who are deteriorating.
• Treat underlying causes of deterioration, e.g.: ^[1]
  • Hypoxia (see "Respiratory distress and failure in children")
  • Shock
  • Infection (see "Pediatric sepsis")
  • Arrhythmias
    • See "Life-threatening bradycardia in children."
    • See "Life-threatening tachycardia in children."
• Rapidly seek specialist assistance (e.g., PICU consult, pediatric rapid response team) for patients who are deteriorating.
• Consider premedication with atropine before endotracheal intubation to prevent bradycardia. ^[1]

Children with cardiac disease ^[1]

• Conditions that increase the risk of cardiac arrest
  • Myocarditis and cardiomyopathy
  • Congenital heart disease (e.g., single ventricle)
  • Acute decompensated pulmonary hypertension
• Management
  • Intervene early in at-risk children:
    • Obtain specialist guidance and transfer to the ICU or a regional pediatric cardiac center.
    • Optimize oxygenation and ventilation to prevent hypoxia and acidosis.
  • Consider early mechanical circulatory support, including ECMO, in deteriorating children.
  • Promptly treat cardiac complications (e.g., acute coronary syndrome, pericardial effusion and cardiac tamponade, arrhythmias) promptly.
  • Shunt-dependent congenital heart disease
    • Consider anticoagulation if shunt obstruction is suspected.
    • Consider vasoconstrictors to improve shunt perfusion.
  • Pulmonary hypertension
    • Consider inhaled nitric oxide or prostacyclin.
    • Consider inducing alkalosis until pulmonary vasodilators are available.

Underlying cardiac causes account for up to one-third of cardiac arrests in children. ^[17]

Overview ^[1][18]

• Bradycardia is a heart rate below the normal age-based range for a child (see "Normal vital signs at rest").
• May be asymptomatic or symptomatic
• Bradycardia is potentially life-threatening if there is evidence of hypoperfusion , risk of heart failure, and/or risk of pause-related tachyarythmia.
• Immediately assess infants and children with a heart rate < 60/minute as this may indicate impending cardiac arrest. ^[1]

Causes of pediatric bradycardia ^[1][18]

Sinus or junctional bradycardia

• Hypoxia
• Acidosis
• Hypothermia
• Electrolyte abnormalities (e.g., hypoglycemia, hyperkalemia, hypomagnesmia)
• Toxic ingestions (e.g., opioids, beta blockers)
• Increased intracranial pressure
• Increased vagal tone (e.g., secondary to breathholding or nasopharyngeal, rectal, or peritoneal stimulation)

Complete AV block

• Inherited AV block
• Long QT syndrome
• Infection (e.g., myocarditis, endocarditis, acute rheumatic fever, Rocky Mountain spotted fever)
• Metabolic (e.g., glycogen storage disorder)
• Muscular dystrophy

Management ^[1]

• No palpable pulse: Initiate PALS.
• Palpable pulse: Assess for evidence of hypoperfusion.
  • Hypotension
  • Altered mental status
  • Signs of shock
• Hypoperfusion present
  • Provide respiratory support.
  • Attach to a cardiac monitor.
  • Start CPR if heart rate remains < 60/minute despite respiratory support.
  • Establish IV access or IO access.
  • Administer atropine for increased vagal tone or primary AV block.
  • Administer epinephrine for persistent bradycardia with poor perfusion.
  • Identify and treat the underlying causes of pediatric bradycardia.
  • Consider transcutaneous pacing or transvenous pacing if symptoms persist.
• Adequate perfusion
  • Identify and treat underlying causes (e.g., hypoglycemia).
  • Consider oxygen therapy.
  • Consider ECG.
  • Monitor closely.

Definition ^[19][20]

• Tachycardia in children is defined as a heart rate higher than the normal age-based range for a child (see "Normal vital signs at rest").
• Tachycardia that causes hypoperfusion can be life-threatening.

Causes ^[1][20]

Narrow-complex tachycardia

• Common ^[20]
  • Sinus tachycardia (most common)
  • Atrioventricular nodal re-entrant tachycardia (AVNRT)
  • Atrioventricular reciprocating tachycardia (AVRT)
• Uncommon
  • Atrial flutter and atrial fibrillation
  • Ectopic atrial tachycardia
  • Junctional tachycardia

Wide-complex tachycardia

• SVT with aberrancy (most common)
• Antidromic AVRT
• Ventricular tachycardia

A normal QRS duration in children (typically < 90 ms) is lower than that for adults (< 120 ms). Therefore, lower QRS cutoffs are used to define narrow-complex tachycardia and wide-complex tachycardias in pediatric patients. ^[1]

Sinus tachycardia is the most common type of arrhythmia in children and often occurs in children with fever, anemia, and/or hypovolemia. ^[20]

Management ^[1]

Initial management

• Assess ABCs; start CPR in children if pulseless.
• Initiate airway opening maneuvers and respiratory support.
• Obtain IV access or IO access.
• Attach a cardiorespiratory monitor, and obtain an ECG if available.

Rhythm assessment

• Findings that suggest sinus tachycardia
  • P waves present and normal
  • Variable RR interval
  • HR < 220/minute in infants or < 180/minute in children
• Findings that suggest SVT
  • P waves absent or abnormal
  • Regular RR interval
  • History of sudden-onset tachycardia
  • HR ≥ 220/minute infants or ≥ 180/minute children

Assessment for signs of hemodynamic compromise

• Altered mental status
• Signs of shock
• Hypotension

Hemodynamic compromise occurs in only a minority of children with SVT. ^[1]

Management of sinus tachycardia ^[1]

• Investigate and treat the underlying cause.
• Antiarrhythmics or cardioversion are contraindicated and may cause harm.

Management of supraventricular tachycardia

• Hemodynamic compromise
  • Preferred: synchronized cardioversion ^[1]
    • First dose: 0.5–1 J/kg
    • Subsequent doses: 2 J/kg
  • Alternative: adenosine
  • Refractory SVT with cardiopulmonary compromise and no expert consultation available: Consider IV procainamide OR amiodarone OR sotalol.
• No hemodynamic compromise
  • Begin with vagal maneuvers.
  • Consider adenosine if vagal maneuvers are unsuccessful.
  • Obtain expert consultation before administering an additional antiarrhythmic agent.

Management of wide complex tachycardia

• Hemodynamic compromise
  • Synchronized cardioversion (treatment of choice) ^[1]
    • First dose: 0.5–1 J/kg
    • Subsequent doses: 2 J/kg
  • Obtain expert consultation.
• No hemodynamic compromise: In consultation with an expert, consider adenosine if the rhythm is regular and QRS is monomorphic.

Post-resuscitation management ^[20]

• Diagnostics
  • ECG
  • CBC
  • Serum electrolytes
  • Thyroid function tests
  • Echocardiogram
  • Additional tests based on clinical suspicion (e.g., toxicology screening, viral panel, cardiac enzymes)
• Disposition
  • Consult cardiology.
  • Admit patients for observation except for children > 1 year of age with resolved AVRT or AVNRT that did not cause hemodynamic compromise.