Paediatric and neonatal cardiac arrest

By Alex Yartsev - 14/04/2017

Thus far, this issue has not arisen in the course of the CICM general fellowship exam. It would not be unexpected, however. Various other paediatric and neonatal topics have previously appeared, and though they have received fairly peripheral treatment even in the college model answers, we can expect that cardiopulmonary resuscitation is a topic with sufficient value to merit a detailed and thoughtful exploration.

For the disinterested adult intensivist, the best reference for paediatric resuscitation would have to be the canonic Chapter 113 from Oh's Manual (p. 1158), "Paediatric cardiopulmonary resuscitation" by James Tibballs. The recommendations made in that chapter are based on the 2010 ILCOR guidelines ( "Part 10: Pediatric Basic and Advanced Life Support"). As far as this author is aware, they have not been revised since this edition.

Unique aspects of paediatric cardiopulmonary resuscitation

Airways are smaller: for manual first responders, mouth to mouth-and-nose breaths are recommended.
Children typically arrest because of hypoxia or hypotension
You need not have a pulseless infant to start chest compressions; if they are bradycardic to below 60, CPR should commence.
In all sized children, the depth of compression is one-third of the AP diameter- but the technique changes: from
- "Two finger" technique for neonates, for single rescuers
- "Both thumbs" technique for neonates, for trained group rescuers (the hands encircle the chest)
- For young children, the heel of one hand may be used
For neonates, the rate of compressions is 120/min
Defibrillators need paediatric paddles for children who are smaller than 10kg (these are electrodes with 12-20 cm² area).
For haemodynamically unstable peri-arrest arrhythmias, the drugs are very similar to an adult selection, with the exception of verapamil. Calcium channel blockers like verapamil should not be used in infants or children, as they may induce cardiac depression and circulatory failure.

For the purpose of improving candidate recall under exam stress conditions, here are some paediatric resuscitation drug doses, derived from various tables in Oh's Manual as well as various forgotten sources lost in the course of this authors' haphazard referencing systems.

Paediatric and Neonatal Drug Doses
Drug	Dose	for 3kg neonate	for 10kg infant	For 20kg primary schooler
Defibrillation energy	4 J/kg	12 J	40 J	80 J
Adrenaline	10 mcg/kg	30 mcg	100 mcg	200 mcg
Amiodarone	5 mg/kg	15 mg	50 mg	100 mg
Glucose 50%	1 ml/kg	3 ml	10 ml	20 ml
Blood (PRBCs)	10ml/kg	30ml	100ml	200ml
Maximum replacement rates for commonly used electrolytes
Potassium	0.3 mmol/kg/hr	0.9 mmol/hr	3 mmol/hr	6 mmol/hr
Sodium (3% saline)	0.5 ml/kg/hr	1.5 ml/hr	5 ml/hr	10 ml/hr
Magnesium	0.4 mmol/kg/hr	1.2 mmol/hr	4 mmol/hr	8 mmol/hr
Calcium chloride 10%	0.2 ml/kg	0.6 ml	2 ml	4 ml

Endotracheal tube calculations:

Four formulae need to be recalled:

Uncuffed tube diameter: size (mm) = age (years) / 4 + 4
Cuffed tube diameter: size(mm) = age (years) / 4 + 3.5
Depth of insertion (cm) for ETT = age (years) / 2 + 12
Depth for a nasal tube (cm) = age (years) / 2 + 15

Circulatory access and volume resuscitation

In infants, scalp veins are fair go.
The umbilical vein can be used up to 1 week after birth.
Intraosseous access should be established as soon as it is clear that other forms of access are going to be too fiddly or too difficult.
Oh's Manual recommends the use of a 10ml syringe attached to a three-way tap as the best method of achieving rapid boluses of controlled volume.

References

Kleinman, Monica E., et al. "Part 10: Pediatric Basic and Advanced Life Support." Circulation 122.16 suppl 2 (2010): S466-S515.

Wyckoff, Myra H., et al. "Part 13: neonatal resuscitation." Circulation 132.18 suppl 2 (2015): S543-S560.

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