This practice guideline contains changes related to COVID-19.
Pediatric cardiac arrest is a rare event. Most pediatric cardiac arrests occur in children younger than one year of age and 90% occur secondary to hypoxia due to respiratory failure. There are many rare causes of pediatric cardiac arrest including sudden infant death syndrome (SIDS), submersion or drowning, trauma, and sepsis. In contrast to cardiac arrest in adults, cardiopulmonary arrest in infants and children is rarely a sudden event and does not often result from a primary cardiac cause. In cases of sudden collapse in older pediatric patients and patients with congenital heart disease, a primary cardiac cause should be considered.
Chest compressions and ventilations should be provided at a ratio of 15:2, with pauses to allow for ventilation. Where available, a pediatric iGel may be a preferable airway management strategy if sufficient face-mask seal is difficult to obtain or maintain. Endotracheal intubation should not be performed in pediatric patients who do not show signs of puberty, generally those less than 12 years old. Direct laryngoscopy is permitted in pediatric patients ONLY for the removal of foreign body airway obstruction. Initiate appropriate resuscitation on scene (airway management/ventilations, chest compressions, and defibrillation as required) and then consider expedited conveyance to an appropriate hospital.
Paramedics and EMRs/FRs are required to wear airborne PPE (EHFR/N95, face shield, gown, gloves) before initiating CPR and resuscitation. A surgical mask should be placed over the patient’s face before initiating CPR. Defibrillation, when indicated, should be administered as early as possible. If required, the airway should be managed using an iGel with a viral filter pre-connected before insertion or 2-person bag-valve-mask ventilation using a viral filter and a tight mask seal.
Prepare, in advance, any calculations that may be necessary to provide care for pediatric patients. A Broselow tape, the BCEHS Handbook, and many other tools are available that can simplify this process.
Recognize that in the majority of cases, respiratory failure is the primary cause of cardiac dysfunction. Focus on adequate oxygenation and ventilation.
Be aware that these are some of the most stressful types of out-of-hospital events. Pre-arrival planning and effective crew resource management are essential for ensuring an organized approach and high quality CPR.
High quality CPR, appropriate ventilation, timely vascular access, and a moderate scene time (10 to 35 minutes) are proven elements that improve survival from cardiac arrest with good outcomes.
Resuscitation and cardiac emergencies for neonates (< 28 days of age) differ in approach than that for older patients. See CPG M11 and CPG M13 for additional information.
When an infant or child is found without a pulse, treatment should first be directed towards adequate ventilations and oxygenation, and maintenance of circulation by chest compressions.
Commotio cordis (cardiac concussion) refers to blunt, non-penetrating, precordial chest impact that causes arrhythmia or sudden death without evidence of cardiac injury. It is from low-impact trauma and significant signs of trauma are usually not found.
Additional Treatment Information
Once oxygenation and high quality CPR have been established, all infants and children in cardiac arrest should have a defibrillator attached to determine if a shockable rhythm is present. If there is a history of blunt trauma to the chest, electrocution, or the patient has a cardiac history, oxygen and CPR are still the priority, but paramedics and EMRs/FRs should apply the AED with greater urgency as these patients may be more likely to demonstrate a shockable rhythm.
If ventricular fibrillation is demonstrated, defibrillation should be attempted as soon as possible.
Rhythm analysis and defibrillation are appropriate for all pediatric cardiac arrests, regardless of age. A manual defibrillator is preferred for infants < 1 year of age. However, if not available, an AED with a pediatric attenuator is appropriate.
An AED with a pediatric attenuator is preferred for children < 8 years of age. If neither a manual defibrillator nor an AED with pediatric attenuator is available, an AED without a dose attenuator may be used for any pediatric cardiac arrest.
AEDs that deliver relatively high energy doses have been used in infants with minimal myocardial damage and good neurological outcomes.
For pulseless ventricular tachycardia, or ventricular fibrillation, an initial dose of 2 J/kg is indicated when using manual defibrillators. If the initial shock fails and the patient is not hypothermic, perform following defibrillations at 4 J/kg.
Drugs and advanced airways do not affect outcomes of pediatric cardiac arrest. While still indicated, time and priorities should focus on high quality CPR, ventilation, and defibrillation if indicated. Do not stay on scene to justify intubating or providing drugs.
For patients whose cardiac arrest is a result of traumatic injuries, rapid conveyance to a trauma centre is the most important treatment. En route management and early notification to a receiving facility are the major out-of-hospital contributors to patient survival. In penetrating trauma, particularly penetrating chest trauma, a small percentage of patients can survive a cardiac arrest with early emergency thoracotomy. These are almost always patients who have demonstrated at least some signs of life in the out-of-hospital setting.
Needle decompression: in the setting of blunt traumatic cardiac arrest, bilateral needle decompression is appropriate any time the patient is in pulseless electrical activity.
Bilateral decompression is used because of the unreliable clinical examination in this patient subset
Assume a tension pneumothorax is present in all cases of cardiac arrest with penetrating chest trauma
Out-of-hospital needle thoracentesis should be considered an AGMP. Although this is a low occurrence procedure, it does potentially expose the paramedic to an increased risk of exposure. If this procedure is needed, crews are required to use airborne PPE including face-shield, EHFR/N95 mask, gown, and gloves.
All pediatric cardiac arrest patients with ROSC require emergency conveyance to hospital. Pediatric patients with a prolonged pulseless condition should be discussed with CliniCall. Non-viable or futile cases should also be discussed with CliniCall.
Bystander CPR, plus early defibrillation, can more than double the rate of survival from out-of-hospital cardiac arrest. As such, paramedics and EMRs should carry out a full resuscitation in settings where first responder or bystander CPR has been initiated, unless obvious signs of death are present.
Although survival from asystole or pulseless electrical activity is rare, patients who receive immediate, high quality CPR occasionally survive.
Asystole in cardiac arrest is usually an ominous prognostic sign indicating prolonged hypoperfusion and myocardial ischemia with deterioration to asystole from more treatable dysrhythmias. Asystole must be confirmed in two or more leads.
Pulseless electrical activity (PEA) is evidence of organized electrical activity on the ECG without effective myocardial contraction. Patients with wide complex PEA rhythms usually have poor survival and there are often indications of severe malfunction of the myocardium or cardiac conduction system. There are numerous possible causes of PEA, some of which are amenable to out-of-hospital treatment. Paramedics (and EMRs where applicable) should follow a step-wise approach to identifying and treating reversible causes of PEA.
Special consideration must be given to hypothermic patients without a pulse. As hypothermia progresses, the patient’s respiratory and heart rate slow significantly. For this reason, breathing and pulse checks must be sufficiently long (60 seconds) to register very slow rates.
“Circum-rescue collapse” is a term that describes a death that occurs shortly before, during, or soon after rescue from exposure to a cold environment, usually cold water immersion; it often presents as an apparently stable, conscious patient who suffers ventricular fibrillation and cardiac arrest shortly thereafter
A patient with a core body temperature < 30°C will most likely develop arrhythmias with progression to ventricular fibrillation
Medications are more slowly metabolized in hypothermic patients; limit vasopressors to a maximum of 3 doses; refer to → I01: Hypothermia for additional information
The most common causes of traumatic cardiac arrest include:
Hypoxemia from airway obstruction and hypoventilation
Obstructive shock resulting from cardiac tamponade or pneumothorax
Hemorrhagic shock from any source of major hemorrhage
Myocardial contusions cause dysrhythmias, perforation, and valve rupture
Electrical shock produces a fall; ventricular fibrillation may also be present
First Responder (FR) Interventions
Ensure high performance CPR and appropriate ventilation; chest compressions and ventilations should be provided at a ratio of 15:2 with pauses to allow for ventilation
Most pediatric airways can be effectively managed with proper positioning and an OPA/NPA (as per license level) and BVM without any requirements for further airway interventions. The gold standard for airway management is a self-maintained airway. Two-person bag-valve mask, with a viral filter attached and a tight seal, is the preferred technique for airway management in pediatric resuscitation and is reasonable compared with advanced airway interventions (endotracheal intubation or supraglottic airway) in the management of pediatrics during a cardiac arrest in the out-of-hospital setting.
Low mechanism blunt trauma: CPR according to medical guidelines
Penetrating trauma or high mechanism blunt trauma:
Immediately prepare for rapid conveyance and CPR
Control life threatening bleeding while facilitating conveyance
Direct pressure to sites of obvious ongoing blood loss
Rapid application of tight tourniquet for catastrophic extremity injury with ongoing large volume blood loss
Primary Care Paramedic (PCP) Interventions
Warning: primary care paramedics equipped with lifepak 15 monitor/defibrillators (LP15) must use an LP1000 AED when managing a pediatric cardiac arrest. Use of the LP15 in children under the age of 12 can result in electrical arcing, severe patient burns, and a significant fire hazard.
Bradycardia with poor cardiac output requires chest compressions if the heart rate is < 60 and signs of poor perfusion are present; signs of poor perfusion include cyanosis, mottling, decreased level of consciousness, and lethargy
Out-of-hospital needle thoracentesis should be considered AGMP. Although this is a low occurrence procedure, it does potentially expose the paramedic to an increased risk of exposure. If this procedure is needed, crews are directed to proceed with airborne PPE including face-shield, EHFR/N95 mask, gown, and gloves.
Critical Care Paramedic (CCP) Interventions
Aggressive fluid replacement including blood products for suspected hemorrhagic shock
Aggressive re-warming if hypothermia present and suspected to be primary cause of presentation
Ultranosonography to assess pneumothorax, tamponade, and cardiac contractility