Prompt electrical defibrillation is indicated when ventricular fibrillation or pulseless ventricular tachycardia is noted (Table 38-5). CPR should continue until immediately before defibrillation and resume immediately afterward, minimizing interruptions in compressions. If a second attempt at defibrillation is necessary, it should be followed by a dose of epinephrine. Children failing two episodes of defibrillation may benefit from administration of amiodarone. Defibrillation should be distinguished from cardioversion of supraventricular tachycardias, which also may compromise cardiac output. Cardioversion requires a lower starting dose and synchronization of the discharge to the electrocardiogram to prevent discharging during a susceptible period, which may convert supraventricular tachycardia to ventricular tachycardia or fibrillation.
Place self-adhesive defibrillation pads or paddles with electrode gel at the apex of the heart and the upper right side of the chest
Notify all participating personnel before discharging paddles so that no one is in contact with patient or bed Begin with 2 J/kg; resume chest compressions immediately If unsuccessful, increase to 4 J/kg and repeat Higher energy levels may be considered, not to exceed 10 J/kg or the adult maximum dose
For symptomatic supraventricular tachycardia* or ventricular tachycardia with a pulse, synchronize signal with ECG Choose paddles, position pads, and notify personnel as above Begin with 0.5–1 J/kg If unsuccessful, use 2 J/kg
ECG, Electrocardiogram. *Consider adenosine first (see Table 38-4)
Table 38-4 Drug Doses for Cardiopulmonary Resuscitation DRUG INDICATION DOSE Adenosine Supraventricular tachycardia 0.1 mg/kg (maximum 6 mg); second dose: 0.2 mg/kg (maximum 12 mg)
Atropine Supraventricular or junctional 0.02 mg/kg (minimum dose 0.1 mg); up to 0.5 mg; higher doses needed in bradycardia organophosphate poisoning
Bicarbonate Hyperkalemia, some toxidromes 1 mEq/kg bolus; ensure adequate ventilation; monitor ABGs; can repeat every 10 min
Calcium chloride Hypocalcemia, calcium 20 mg/kg; maximum single dose 2 g; administer slowly channel blocker overdose, hypermagnesemia, hyperkalemia
Epinephrine Hypotension, chronotropy, 0.01 mg/kg IV/IO; 0.1 mg/kg ET; may repeat every 3–5 minutes; may promote inotropy arrhythmias
Fluid Hypovolemia, sepsis Administer crystalloid in 20 mL/kg boluses titrated to patient’s physiologic needs
Glucose Hypoglycemia Newborns: 5–10 mL/kg 10% dextrose; infants and children: 2–4 mL/kg 25% dextrose; adolescents: 1–2 mL/kg 50% dextrose
Data from 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 14: Pediatric Advanced Life Support, Circulation 122 [suppl 3]:S876-S908, 2010. ABG, Arterial blood gas; ET, endotracheal; IO, intraosseous; IV, intravenous; VF, ventricular fibrillation; VT, ventricular tachycardia.