Residency · Residency · Emergency Medicine
Pediatric Cardiac Arrest: What Is Different and Why It Matters
Epidemiology and Etiology
Key Differences from Adult Arrest
The most important thing to understand about pediatric cardiac arrest is that it is fundamentally different from adult arrest in its cause. While adult cardiac arrest is typically a primary cardiac event, pediatric cardiac arrest is primarily respiratory in origin — it begins as an asphyxial arrest. The most common etiologies reflect this: respiratory failure, SIDS, drowning, sepsis, and trauma. Shockable rhythms (VF and pulseless VT) occur in only 5 to 15 percent of pediatric arrests, compared to 25 to 35 percent in adults. Survival to discharge is approximately 10 to 15 percent for out-of-hospital pediatric cardiac arrest and 35 to 45 percent for in-hospital arrest.
Age-Based Considerations
The etiology of arrest varies by age group. Neonatal arrest is most commonly caused by birth asphyxia, congenital anomalies, and prematurity. In infants, SIDS, respiratory infections, congenital heart disease, and non-accidental trauma predominate. In children, drowning, trauma, respiratory illness, and toxins are the leading causes. Adolescents begin to look more like adults, with arrhythmias, trauma, drug use, and congenital channelopathies becoming more prominent.
| Age Group | Common Etiologies |
|---|---|
| Neonates | Birth asphyxia, congenital anomalies, prematurity |
| Infants | SIDS, respiratory infections, congenital heart disease, non-accidental trauma |
| Children | Drowning, trauma, respiratory illness, toxins |
| Adolescents | Arrhythmias, trauma, drug use, congenital channelopathies |
BLS for Pediatric Patients
Compression Technique
The compression technique differs by age and number of rescuers. For infants under one year, the two-thumb encircling technique is preferred when two rescuers are available; with a single rescuer, the two-finger technique is used. For children from one year to puberty, a one- or two-hand technique is chosen based on the child's size. Compression depth should be at least one-third of the anteroposterior diameter of the chest — approximately 4 centimeters in infants and 5 centimeters in children. The rate is the same as for adults at 100 to 120 per minute. The compression-to-ventilation ratio is 15:2 with two rescuers and 30:2 with a single rescuer.
Ventilation Priority
Because the overwhelming majority of pediatric arrests are respiratory in origin, early effective ventilation is critical. Bag-mask ventilation should never be delayed in pursuit of intubation. In many cases of respiratory arrest — before it has deteriorated into cardiac arrest — adequate oxygenation and ventilation alone may be all that is needed to restore a perfusing rhythm.
PALS Algorithm
Non-Shockable Rhythms (PEA/Asystole)
For non-shockable rhythms, epinephrine is given at 0.01 mg/kg (which corresponds to 0.1 mL/kg of the 1:10,000 concentration) IV or IO every 3 to 5 minutes, with a maximum single dose of 1 mg. The focus should be on identifying and treating reversible causes using the H's and T's framework while maintaining high-quality CPR.
Shockable Rhythms (VF/pVT)
When a shockable rhythm is identified, the first shock is delivered at 2 J/kg, the second at 4 J/kg, and subsequent shocks at 4 J/kg or higher up to a maximum of 10 J/kg. Epinephrine is administered after the second shock and then every 3 to 5 minutes. Amiodarone at 5 mg/kg IV or IO (maximum 300 mg) or lidocaine at 1 mg/kg are the antiarrhythmic options.
| Intervention | Dose | Notes |
|---|---|---|
| Defibrillation — 1st shock | 2 J/kg | Monophasic or biphasic |
| Defibrillation — 2nd shock | 4 J/kg | — |
| Subsequent shocks | 4–10 J/kg | Maximum 10 J/kg |
| Epinephrine | 0.01 mg/kg (0.1 mL/kg of 1:10,000) IV/IO q3–5 min | Max single dose 1 mg |
| Amiodarone | 5 mg/kg IV/IO | Max 300 mg |
| Lidocaine | 1 mg/kg IV/IO | Alternative to amiodarone |
Weight-Based Dosing Under Pressure
Weight-based dosing during a pediatric resuscitation creates enormous potential for error. The Broselow tape is the standard tool for length-based weight estimation and provides pre-calculated doses that reduce cognitive load. Common errors include decimal point mistakes and confusion between epinephrine concentrations (1:1,000 versus 1:10,000). Pre-mixed syringes and color-coded systems can significantly reduce medication errors.
Vascular Access in Pediatric Arrest
Intraosseous (IO) Access
If IV access is not obtained rapidly — within 60 to 90 seconds — intraosseous access should be the next step. The proximal tibia is the preferred site in young children, with the distal tibia and distal femur as alternatives. IO access provides drug delivery equivalent to IV in cardiac arrest. Power drill devices such as the EZ-IO use a 15-gauge needle for children under 40 kg and a 25-gauge needle for neonates.
Peripheral IV Access
Peripheral IV access at the antecubital, saphenous, or hand veins can be attempted, but these sites are often difficult to access in hypovolemic, edematous, or very young children. IV access should never delay resuscitation when IO is available.
Endotracheal Drug Administration
The LEAN drugs — lidocaine, epinephrine, atropine, and naloxone — can be given via the endotracheal tube, but this route requires 2 to 10 times the IV dose and absorption is unreliable. IO or IV access is always preferred, and the endotracheal route should be considered only as a last resort.
Airway Management in Pediatric Arrest
Anatomic Differences
Several anatomic differences between pediatric and adult airways have direct implications for management. The larger occiput in infants causes neck flexion in the supine position, requiring padding under the shoulders rather than the head to achieve proper alignment. The tongue is proportionally larger relative to the oropharynx. The larynx is more anterior and cephalad (at the C3-C4 level versus C4-C6 in adults). The trachea is shorter, creating a higher risk of right mainstem intubation. In infants, the narrowest point of the airway is at the cricoid ring (subglottic), rather than at the vocal cords as in adults.
ETT Sizing
Cuffed endotracheal tubes are now preferred at all ages, sized using the formula (age/4) + 3.5. For uncuffed tubes in children under 2 years, the traditional formula is (age/4) + 4. The depth of insertion at the lip can be estimated as the ETT size multiplied by three. Placement must always be confirmed with continuous waveform capnography.
Extracorporeal CPR (ECPR)
Indications
ECPR is considered for refractory cardiac arrest in pediatric patients with a potentially reversible cause. Most evidence comes from in-hospital cardiac arrest at ECMO-capable centers, and the THAPCA trials demonstrated benefit in this setting. It requires institutional infrastructure, a trained team, and the capability for rapid cannulation.
Practical Considerations
ECPR is not available at most community emergency departments. Cannulation during ongoing CPR is technically challenging, and outcomes are best when ECPR is initiated within 30 to 60 minutes of arrest. Cardiac etiologies such as myocarditis and post-cardiac surgery arrest have better outcomes than non-cardiac causes.
Family Presence During Resuscitation
Evidence
Multiple studies have shown that the presence of family members does not interfere with resuscitation efforts. Families who witness the resuscitation have lower rates of PTSD and complicated grief. The AAP, AHA, and ENA all support offering family presence with a dedicated support person.
Implementation
A team member should be assigned to stay with the family, explain what is happening in plain language, and assess their tolerance of the situation. The resuscitation team should be prepared, and debriefing afterward is important. Families should never be forced to leave or forced to stay — cultural and individual preferences must be respected.
Post-Arrest Care in Children
The same principles that apply to adult post-arrest care apply to children: avoid hyperthermia, hyperoxia, hypocapnia, and hypotension. Temperature management calls for maintaining normothermia (36 to 37.5 degrees Celsius) or considering TTM at 32 to 34 degrees based on the THAPCA trials. Children are more prone to hypoglycemia than adults, so glucose should be monitored frequently. Neuroprognostication is even more uncertain in the pediatric population, and longer observation periods may be warranted before making definitive prognostic determinations.
<image>An anatomical comparison illustration showing pediatric versus adult airway anatomy in sagittal cross-section, side by side. The pediatric airway (left) highlights the large occiput causing neck flexion, the proportionally larger tongue, the higher and more anterior larynx at the C3-C4 level, the omega-shaped epiglottis, and the narrowest point at the cricoid ring. The adult airway (right) shows the larynx at C4-C6, the narrowest point at the vocal cords, and the longer trachea. Key differences are labeled with arrows and annotations.</image>
<image>A step-by-step visual guide showing intraosseous needle insertion in a pediatric patient. Four panels: (1) landmark identification showing the tibial tuberosity with a finger pointing 1-2 cm below and medial on the flat anteromedial tibial surface; (2) a power drill device (EZ-IO) positioned perpendicular to the bone with slight caudal angle; (3) the needle advanced through cortex with a "give" indicated; (4) confirmation by aspiration of marrow and flush with saline. The child's leg is shown with proper positioning and stabilization.</image>
<image>A color-coded Broselow tape infographic showing how length-based estimation maps to weight zones, with example drug doses for epinephrine, amiodarone, and defibrillation energy pre-calculated for each color zone. The tape is depicted stretched alongside a child's body from head to heel, with colored segments (gray, pink, red, purple, yellow, white, blue, orange, green) each listing the corresponding weight range and critical medication doses in mL and mg to reduce cognitive load during resuscitation.</image>
Clinical Pearls
The most critical concept in pediatric arrest is to think "respiratory first" — effective bag-mask ventilation is the highest-priority intervention, not chest compressions or medications. IO access should be placed within 60 to 90 seconds if IV access is not immediately available; wasting time on peripheral IV attempts during active arrest costs lives. Weight-based dosing errors are a leading cause of preventable harm in pediatric resuscitation, and a length-based tape or pre-calculated reference should always be used. Cuffed ETT tubes are now preferred at all ages, sized with the formula (age/4) + 3.5. Although shockable rhythms are uncommon in children, they must be identified quickly, so pads or leads should be applied immediately. Family presence during resuscitation is supported by evidence and should be offered with a dedicated support person. Post-arrest fever is harmful and normothermia should be maintained at minimum. Neonatal arrest follows a different algorithm entirely, with emphasis on warmth, stimulation, ventilation, and delayed cord clamping.
References
- Topjian AA, et al. 2020 AHA Pediatric Advanced Life Support Guidelines. Circulation. 2020;142(suppl 2).
- Moler FW, et al. THAPCA-IH Trial: Therapeutic hypothermia after in-hospital cardiac arrest in children. NEJM. 2017;376:318-329.
- Moler FW, et al. THAPCA-OH Trial: Therapeutic hypothermia after out-of-hospital cardiac arrest in children. NEJM. 2015;372:1898-1908.
- Jabre P, et al. Family presence during cardiopulmonary resuscitation. NEJM. 2013;368:1008-1018.
- Lasa JJ, et al. Extracorporeal CPR in pediatric cardiac arrest. Circulation. 2016;134:2374-2386.
