Pediatric Pit Crew / High Performance CPR

A reader asks, “Does your Pit Crew CPR process work for pediatrics?” (See video on Vimeo).

The answer is yes (with some minor modifications).

Some things to keep in mind:

Pediatric cardiac arrest is more likely to be respiratory or asphyxial so there is less emphasis on “patient’s side to first shock” as the arrest rhythm is more likely to be brady/asystole/PEA.

However, this rule is not absolute! Hopefully you will know something about the history of the arrest on your arrival. There’s a big difference between a child fished out from the bottom of a swimming pool and a child who was hit in the chest by a baseball.

In addition, for the pediatric population we should start chest compressions when the heart rate drops below 60 and there are signs of poor perfusion despite ventilation with oxygen.

Evidence shows that EMS tends to “load and go” with kids, especially infants, they frequently do not receive epinephrine in a timely manner, and outcomes are generally poor.

survival by age and scene time vs survival

At a minimum we should establish effective airway, breathing, and circulation; initiate IV or IO access, and get the first dose of epinephrine on board prior to moving the patient even if the patient is a baby (which is statistically likely).

Consider: A, B, C, D, E

  • A: Airway
  • B: Breathing
  • C: Circulation
  • D: Drill (IO)
  • E: Epinephrine

Phase 1: Initiate compressions and ventilations

  • Confirm the patient is pulseless or peri-arrest
  • Start continuous chest compressions at the appropriate rate, depth, and recoil
  • Deploy the appropriately sized BVM
  • Attach the capnography circuit between the mask and bag
  • Attach the other end of the capnography circuit to the cardiac monitor
  • Turn on the oxygen
  • Attach the BVM to oxygen and set for 15 LPM
  • Insert an appropriately sized OPA
    • 40 mm: premie or newborn
    • 50 mm: < 1 year old
    • 60 mm: 1-4 years old
    • 70 mm: 5-6 years old
    • 80 mm: 7-9 years old
  • Switch from continuous chest compressions to 15:2
  • Make note of the initial ETCO2 reading
  • Note: You have just implemented the most important evidence-based therapies

Phase 2: Attach defib pads, measure child if necessary, shock as needed

  • Expertly performed BLS should already be ongoing at 15:2
  • Deploy and test the suction unit
  • Power on the cardiac monitor and select the cardiac arrest picklist (or set the monitor to pediatric mode)
  • Deploy the cables and attach the defib pads
  • Note: According to the ECC Guidelines children > 10 kg (> 1 year old) get the adult defib pads
  • Coordinate the application of the pads with the rescuer on chest compressions
  • Tip: You should know if the rhythm is shockable after the application of the second pad (unlikely if asphyxial arrest)
  • Measure the child with the Handtevy tape only if necessary — otherwise make note of the child’s age
  • If the rhythm is shockable charge the capacitor at 2 J/kg without interrupting chest compressions
  • Once the defibrillator is charged, announce “Stop CPR”
  • The rescuer on chest compressions should “hover” to indicate they are clear
  • Note: “I’m clear, you’re clear, we’re all clear” is no longer deemed necessary
  • Push the shock button
  • Resume immediate post-shock compressions
  • Subsequent shocks should be administered at 4 J/kg
  • After 2 minutes of expertly performed BLS reassess heart rhythm and pulse

Phase 3: Initiate IV/IO access, give epinephrine, and consider advanced airway

  • Continue expertly performed BLS
  • Initiate IV/IO access (proximal humerus preferred)
  • Provide first does of epinephrine (use the Handtevy method)
  • Repeat every 3-5 minutes until ROSC
  • Advanced airway management is acceptable but should not significantly interfere with expertly performed BLS
  • Once an advanced airway is in place deliver asynchronous ventilations every 6 seconds (that’s slow)
  • Avoid hyperventilation!
  • Consider and treat reversible causes (Hs and Ts)

Pediatric Airways Final
Phase 4: Post-resuscitation care

  • Once ROSC is identified (sudden rise in ETCO2, organized rhythm on the monitor, verified with pulse check)
  • Continue ventilating every 3-5 seconds
  • Attach pulse oximetry and maintain SpO2 at 96-99%
  • Avoid hyperventilation!
  • Obtain blood pressure
  • Remove any wet clothing
  • Obtain baseline temperature
  • Perform mini-neuro exam (Can the patient follow commands?)
  • Check oxygen and re-evaluate airway
  • Safely convey the patient to the hospital
  • Whenever possible transport parents with the child

See also:

Adult Pit Crew CPR – The Explicit Details

Handtevy Pediatric Emergency Standards

EMS 12-Lead podcast Episode #8: Jim Broselow, M.D. and the Artemis Pediatric Initiative

2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science – Part 14: Pediatric Advanced Life Support

Airway Challenges in Children by Dr. Brent Myers (highly recommended)

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