Paediatric Resuscitation Medicines

In children, cardiac arrest is usually the end of respiratory failure or shock, so oxygenation and ventilation come before drugs. High quality compressions (100 to 120/min, one third of the chest depth, 15 compressions to 2 breaths) and defibrillation for shockable rhythms matter more than any drug. Give drugs by the intravenous or intraosseous route.

Rhythms. Non-shockable (asystole, pulseless electrical activity) and shockable (ventricular fibrillation, pulseless ventricular tachycardia). Check the rhythm every 2 minutes.

• Adrenaline: 10 mcg/kg (0.1 mL/kg of 1 in 10,000, which is 100 mcg/mL) intravenously or intraosseously, maximum 1 mg, immediately in non-shockable rhythms and after the third shock in shockable rhythms, then every 3 to 5 minutes.
• Defibrillation: 4 J/kg (maximum 200 J for biphasic), one shock then 2 minutes of compressions.
• Amiodarone: 5 mg/kg (maximum 300 mg) intravenously or intraosseously after the third shock, with a second dose of 5 mg/kg after the fifth shock. Lidocaine 1 mg/kg is an alternative.
• Glucose: 2 mL/kg of 10% glucose for hypoglycaemia.
• Fluid: 10 mL/kg of 0.9% sodium chloride for hypovolaemia.
• Sodium bicarbonate 1 mmol/kg (1 mL/kg of 8.4%, diluted for infants) only for prolonged arrest with severe acidosis, hyperkalaemia or tricyclic poisoning.
• Calcium chloride 10%, 0.2 mL/kg intravenously over 5 to 10 minutes, only for hypocalcaemia, hyperkalaemia, magnesium excess and calcium channel blocker toxicity.
• Magnesium sulphate 25 to 50 mg/kg (maximum 2 g) for torsades de pointes or hypomagnesaemia.
• Atropine: not for routine use; 20 mcg/kg may be considered in bradycardia caused by vagal stimulation.

Neonatal resuscitation at birth: start with ventilation. Chest compressions at 3 to 1 ratio when heart rate is under 60/min after 30 seconds of effective ventilation. Adrenaline 10 to 30 mcg/kg intravenously (0.1 to 0.3 mL/kg of 1 in 10,000). Give 10 mL/kg of 0.9% sodium chloride for blood loss.

Dosing basis. Use the weight from a length tape or the age formula, and do not stop to weigh. Prepare doses in labelled syringes by weight band.

Reversible causes. Hypoxia, hypovolaemia, hypo- and hyperkalaemia, hypoglycaemia, hypothermia, tension pneumothorax, tamponade, toxins and thrombosis.

After return of circulation. Aim for SpO2 94 to 98%, normal carbon dioxide, normal glucose, avoid fever, and treat shock with fluids and adrenaline infusion 0.05 to 1 mcg/kg/min under specialist direction.

Special groups. Hypothermic children need continued resuscitation until rewarmed. In East Africa, resuscitation often begins with bag-mask ventilation in a district facility, and airway positioning and oxygen are the most effective measures.

Monitoring. End-tidal carbon dioxide, rhythm check every 2 minutes, glucose, blood gases and electrolytes after return of circulation.

Referral and escalation. Call for paediatric intensive care or senior help at the start. Transfer all children after return of circulation to intensive care.

Stopping. Consider stopping after 20 to 30 minutes of advanced life support without a return of circulation, unless a reversible cause is being treated, with the senior clinician and family informed.