Paediatric Advanced Life Support
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Direct answer
Paediatric advanced life support is the structured algorithm for a child in cardiac arrest, separating shockable rhythms from non-shockable rhythms. Shockable rhythms are ventricular fibrillation and pulseless ventricular tachycardia, while asystole and pulseless electrical activity are non-shockable. Most paediatric arrests are respiratory in origin, so oxygenation, ventilation and the search for reversible causes sit at the centre of care, with adrenaline given every three to five minutes.
What you must remember
- Shockable rhythms: ventricular fibrillation and pulseless ventricular tachycardia, both treated with defibrillation.
- Non-shockable rhythms: asystole and pulseless electrical activity, managed with high-quality compressions, adrenaline and a search for reversible causes.
- Defibrillation energy: the first shock is 2 J/kg, the second 4 J/kg and later shocks at least 4 J/kg, not exceeding adult doses.
- Adrenaline: 0.01 mg/kg intravenously or intraosseously, maximum 1 mg, repeated every three to five minutes.
- Amiodarone: 5 mg/kg for shock-refractory ventricular fibrillation or pulseless ventricular tachycardia, maximum 300 mg.
- Reversible causes: hypoxia, hypovolaemia, acidosis, electrolyte disorders and hypothermia, plus tension pneumothorax, tamponade, toxins and thrombosis.
- Airway ventilation: with an advanced airway, about one breath every two to three seconds (20 to 30 per minute, AHA 2020) alongside continuous compressions.
A stepwise algorithm for paediatric cardiac arrest
The algorithm runs in cycles of about two minutes, with compressions interrupted only briefly for rhythm checks. Quality of compressions is treated as the most important intervention throughout.
- Confirm arrest and start CPR: check responsiveness, breathing and pulse, and begin compressions and ventilation when there is no pulse or breathing is inadequate.
- Attach the monitor: apply defibrillator pads or an ECG, and identify whether the rhythm is shockable or non-shockable.
- Shockable pathway: deliver a shock using the energy above, then resume compressions straight away for two minutes before the next rhythm check.
- Establish access and give adrenaline: obtain intravenous or intraosseous access, then give adrenaline every three to five minutes while CPR continues.
- Secure the airway: start with a bag-mask, then move to an advanced airway when a skilled rescuer is available, without interrupting compressions.
- Search for reversible causes: check systematically for hypoxia, hypovolaemia, electrolyte and acid-base disturbance, toxins and the thoracic causes while CPR continues.
Where the exam tries to catch you
Questions on this topic usually test drug doses, defibrillation energies and the rhythm pathway.
- Trap: giving adrenaline 0.1 mg/kg intravenously Correct: the intravenous or intraosseous dose is 0.01 mg/kg, and the higher 0.1 mg/kg figure is the endotracheal dose.
- Trap: using 4 J/kg as the first shock Correct: the first shock is 2 J/kg, with 4 J/kg for the second and later shocks.
- Trap: giving atropine routinely in asystole Correct: atropine is not a routine treatment for asystole, and reversible causes and quality CPR take priority.
- Trap: pausing compressions for long rhythm checks Correct: rhythm checks are kept brief, because interruptions reduce survival.
Frequently asked questions
What is the first defibrillation energy in paediatric advanced life support?
The first defibrillation energy in paediatric advanced life support is 2 J/kg for a shockable rhythm such as ventricular fibrillation. The second shock is given at 4 J/kg, and later shocks are at least 4 J/kg without exceeding adult maximum doses.
What is the intravenous dose of adrenaline in paediatric cardiac arrest?
The intravenous or intraosseous dose of adrenaline in paediatric cardiac arrest is 0.01 mg/kg, with a maximum single dose of 1 mg, repeated every three to five minutes. The endotracheal route needs a higher dose, so intravenous or intraosseous access is preferred when available.
When is amiodarone used in paediatric advanced life support?
Amiodarone is used in paediatric advanced life support for shock-refractory ventricular fibrillation or pulseless ventricular tachycardia, usually after the third shock. The dose is 5 mg/kg with a maximum of 300 mg, and it is given while compressions continue.
What are the reversible causes of paediatric cardiac arrest?
The reversible causes of paediatric cardiac arrest include hypoxia, hypovolaemia, acidosis, electrolyte disorders and hypothermia. Thoracic causes such as tension pneumothorax and tamponade, along with toxins and thrombosis, must also be looked for during resuscitation.