A. Most critical cardiac states in children are not due to primary cardiac problems but are secondary to respiratory, airway, metabolic, or infectious disorders.
B. Most standing orders for cardiac arrest states follow the adult orders. Refer to pediatric reference e.g., Broselow Tape, if assistance is needed with drug dosage calculations for pediatric patients.
C. Contact the medical control physician early when there is a question about the nature of a presumed cardiac emergency in children.
Standing Orders
1. Assess and support ABCs as needed, provide oxygen and attach monitor defibrillator.
2. If cardiorespiratory compromise (poor perfusion, hypotension, respiratory difficulty, altered level of consciousness):
a. Begin chest compressions
b. Intubate and assure adequate oxygenation and ventilation.
c. If despite oxygenation and ventilation heart rate <60 bpm in infant or child and poor systemic perfusion:
- Give EpinephrineIV/IO: 0.01 mg/kg (1:10,000, 0.1 mL/kg,) ET: 0.1 mg/kg (1:1000, 0.1 mL/kg). May repeat every 3 to 5 minutes at same dose.
- Atropine.02 mg/kg (minimum dose: 0.1 mg) may repeat once
- Contact a medical control physician for orders to consider pacing (see #4 below).
d. If pulseless arrest develops see appropriate protocol
3. If no cardiorespiratory compromise:
a. Support ABCs, observe and transport
After Obtaining Verbal Orders
4. Consider cardiac pacing.
See ALS algorithm for
Pediatric Bradycardia page 19.
Standing Orders
Assess and support ABCs, provide oxygen and ventilation, attach monitor/defibrillator. Evaluate rhythm:
1. Probable ventricular tachycardia - QRS duration wide for age (approximately > 0.08 sec)
After Obtaining Verbal Orders
a. Consider medications.
- Lidocaine1 mg/kg IV bolus (wide complex only)
b. Consider Cardioversion (energy rates as prescribed by current AHA ACLS guidelines e.g., 0.5 to 1.0 J/kg; may increase to 2 J/kg if initial dose ineffective) Use sedation if possible (midazolam0.1 mg/kg IV/IM, maximum: 4 mg)
2. Probable supraventricular tachycardia - QRS duration normal for age (approximately £ 0.08 sec)
After Obtaining Verbal Orders
a. Obtain 12-lead ECG if available.
b. Consider Valsalvamaneuver
c. Consider Adenosine0.1 mg/kg IV (maximum first dose: 6mg). May double and repeat dose once (maximum second dose 12 mg). Use rapid bolus technique.
d. Consider Cardioversion (energy rates as prescribed by current AHA ACLS guidelines e.g., 0.5 to 1.0 J/kg; may increase to 2 J/kg if initial dose ineffective) Use sedation if possible (midazolam0.1 mg/kg IV/IM, maximum: 4 mg)
3. Probable sinus tachycardia - QRS duration normal for age (approximately £ 0.08 sec)
After Obtaining Verbal Orders
a. Consider Normal Saline bolus 20 mL/kg IV/IO.
See ALS algorithm for Pediatric Tachycardia with Adequate Perfusion page 20.
Assess and support ABCs, provide oxygen and ventilation, attach monitor/defibrillator. Evaluate rhythm:
1. Probable ventricular tachycardia - QRS duration wide for age (approximately > 0.08 sec)
Standing Orders
a. Immediate cardioversion (energy rates as prescribed by current AHA ACLS guidelines e.g., 0.5 to 1.0 J/kg; may increase to 2 J/kg if initial dose ineffective) Consider sedation (midazolam,0.1 mg/kg IV/IM, maximum: 4 mg) but do not delay cardioversion
After Obtaining Verbal Orders
b. Consider alternative medications
- Lidocaine1 mg/kg IV bolus (wide complex only)
2. Probable supraventricular tachycardia - QRS duration normal for age (approximately £ 0.08 sec)
Standing Orders
a. Immediate cardioversion (energy rates as prescribed by current AHA ACLS guidelines e.g., 0.5 to 1.0 J/kg; may increase to 2 J/kg if initial dose ineffective) Consider sedation (midazolam0.1 mg/kg IV/IM, maximum: 4 mg) but do not delay cardioversion OR
b. Adenosine0.1 mg/kg rapid bolus IV/IO (maximum first dose: 6mg). May double and repeat dose once (maximum second dose 12 mg)
After Obtaining Verbal Orders
c. Consider alternative medications.
- Lidocaine1 mg/kg IV bolus (wide complex only)
3. Probable sinus tachycardia - QRS duration normal for age (approximately £ 0.08 sec)
Standing Orders
a. Consider Normal Saline bolus 20 mL/kg IV/IO.
b. Continue to assess and support ABCs, monitor, and provide oxygen and ventilation as necessary.
See ALS algorithm for Pediatric Tachycardia with Poor Perfusion page 21.
Standing Orders
1. Institute or continue CPR.
2. Assess and confirm Pulseless VT/VF then defibrillate up to 3 times (stacked), if necessary (energy rates as prescribed by current AHA ACLS guidelines; e.g., 2 J/kg, 2 to 4 J/kg, 4 J/kg).
3. Reassess rhythm, if defibrillation results in a change in rhythm proceed to the appropriate protocol. If rhythm remains unchanged or recurs continue this protocol.
4. Secure airway; confirm tube placement, effective ventilation and oxygenation.
5. Obtain IV access. If IV not possible, attempt IO access (if authorized). Transport early if no readily accessible IV/IO access.
Note: Refer to pediatric reference e.g., Broselow Tape, if assistance is needed with drug dosage calculations for pediatric patients.
6. Administer EpinephrineIV/IO: 0.01 mg/kg q. 3-5 min. (1:10,000; 0.1 mL/kg). ET: 0.1mg/kg (1:1000; 0.1 mL/kg)
7.
Defibrillate (energy rates as prescribed by current AHA ACLS guidelines
e.g., 4 J/kg) within 30-60 seconds.
- Pattern should be CPR-drug-shocks (stacked), repeat
8.
Lidocaine1 mg/kg bolus IV/IO OR
Contact medical control physician for further orders (see # 10-11 below).
9. Defibrillate (energy rates as prescribed by current AHA ACLS guidelines e.g. 4 J/kg) after each drug dose, within 30-60 seconds.
After Obtaining Verbal Orders
10. Consider: Magnesium25-50 mg/kg IV for torsades de pointes or hypomagnesemia (max. 2 g).
11. If no response, consider termination of resuscitative efforts.
See ALS algorithm for Pediatric Pulseless Arrest page 18.
Standing Orders
1. Institute or continue CPR.
2. Secure airway; confirm tube placement, effective ventilation and oxygenation.
3. Assess and confirm rhythm as Asystole or PEA
4. Obtain IV access. If IV not possible, attempt IO access (if authorized). Transport early if no readily accessible IV/IO access.
Note: Refer to pediatric reference e.g., Broselow Tape, if assistance is needed with drug dosage calculations for pediatric patients.
5. Administer EpinephrineIV/IO: 0.01 mg/kg q. 3-5 min. (1:10,000; 0.1 mL/kg). ET: 0.1mg/kg (1:1000; 0.1 mL/kg)
6. If PEA, review the most frequent causes and treat according to protocol if present:
· Hypovolemia – fluids, PCT
· Hypoxia – hyperventilate
· Hypothermia– re-warming (see Hypothermia protocol)
7. Contact medical control physician for further orders (see #8-10 below).
After Obtaining Verbal Orders
8. Consider alternative medications:
- Vasopressors
- Antiarrhythmics
- Buffers
9. Consider for:
· Acidosis - NaHCO
· Hyperkalemia - CaCl& NaHCO
· Tension pneumothorax - needle chest decompression
· Drug overdose - specific antidote
· Coronary thrombosis - 12 lead ECG
No specific pre-hospital treatment for:
· Hypokalemia
· Cardiac tamponade
· Pulmonary embolism
10. If no response, consider termination of resuscitative efforts.
See ALS algorithm for Pediatric Pulseless Arrest page 18.