346 Paediatric Emergencies
CARDIOPULMONARY RESUSCITATION(ii) Give adrenaline 10 g/kg i.v. or i.o. immediately in asystole or
pulseless electrical activity (PEA), or after the third shock in
ventricular fibrillation (VF)/pulseless ventricular tachycardia
(VT), then repeat every 3–5 min.
7 Defibrillation
See Figure 11.2 (p. 341).
(i) ‘Time to defibrillation’ is the main determinant of survival in the
shockable rhythms VF or pulseless VT. They are uncommon in
children, but increase with age.
(ii) Perform immediate defibrillation for VF and pulseless VT:
(a) place defibrillator pads or paddles one below the right
clavicle, and the other in the left axilla
(b) administer defibrillation with 4 J/kg biphasic, or with an
older monophasic device
(c) resume cardiopulmonary resuscitation (CPR) immediately
after each shock
(d) review rhythm every 2 min
(e) give further shocks at 4 J/kg if VF or pulseless VT persists.
8 Reversible causes
Identify and treat any reversible causes of cardiopulmonary arrest, the 4 Hs
and the 4 Ts, particularly hypoxia and hypovolaemia. Look for;
(i) Hypoxia, Hypovolaemia, Hyper/hypokalaemia, Hypothermia.
(ii) Tension pneumothorax, Toxins, Tamponade-cardiac,
Thromboembolism.
9 Heat loss
Remember sick infants and small children lose heat rapidly, so organize over-
head heating, warming blankets or an incubator as appropriate.
(i) Paradoxically, once a child regains a spontaneous circulation but
remains comatose after a period of CPR, he or she may benefit
from being cooled to a core temperature of 32–34°C for at least
24 h (see p. 12 for induced therapeutic hypothermia in adults).
10 Parents in the resuscitation room
Invite and encourage parents to be present in the resuscitation room, but a
member of the team must stay with them and explain the resuscitation process
with care and empathy:
(i) Parents can then witness that everything possible is being done to
help their child.
(ii) They have the opportunity to say goodbye to their child, if death
is inevitable:
(a) this facilitates the grieving process, and reduces parental
anxiety and the risk of subsequent depression.