Priority Topic: Advanced Cardiac Life Support

Key Feature 9: In a pediatric resuscitation, use appropriate resources (ex: Braeslow tape, the patient’s weight) to determine the correct drug doses and tube sizes. 
Skill: Clinical Reasoning
Phase: Treatment

Two weeks into my pediatric emergency medicine rotation and I have yet to see a pediatric code. This is sort of a good thing. I hope I never have to see a pediatric cardiac arrest, and there's probably a good chance I never will considering I don't plan be a pediatric emergency physician. But should this unfortunate and rare situation arise, I need to be able to respond to try to save a life.

​While the A in ACLS stands for "Advanced," to a person taking this course they may just as well assume it stands for "Adult." This course does not address ACLS algorithms as pertains to children specifically, and there are many differences and as such there is a whole other course designed to teach the approach to pediatric resuscitation called Pediatric Advanced Life Support (PALS). While my program requires me to take ACLS, PALS is not an expectation. As part of the BLS course however, which is a prerequisite to the ACLS course, I do need to know the basics of providing emergency CPR to pediatric victims. I will share the elements of high quality CPR as outlined by the Emergency Handbook provided with the ACLS course, because they are important to be familiar with.

Not mentioned in this summary page, the artery that is checked for a pulse in an infant is the brachial artery, while in anyone older it is the carotid or femoral pulse. Other differences are rate of rescue breathing: In infants and children rescue breaths should be given every 3-5 second or about 12-20 breaths/min, which is much more than the frequency of rescue breaths given in an adults and adolescents at a rate of one breath ever 5-6 seconds or 10-12 breaths/min.

The Emergency Handbook provides an important message to be aware of in the beginning of the section on PALS (it does provide an overview of some basics, probably because they are still important to know about, aka why I am reviewing them). It states, "Primary cardiac arrest in children is much less common than in adults. Cardiac arrest in children typically results from progressive deterioration in respiratory or cardiovascular function. To prevent pediatric cardiac arrest, providers much detect and treat respiratory failure, respiratory arrest, and shock." In an adult who is not breathing but has a pulse, we would give rescue breaths but not perform chest compressions, whereas with a child, it is actually indicated to give chest compressions as well as support breathing if the pulse is 60 beats per minute or less. 

There are other differences, but I think I included the most basic and critical to know above with regards to the basics of CPR. Now when it comes to taking it to the next level, from providing basic life support (high-quality CPR) to advanced cardiac life support (which includes high-quality CPR plus more interventions), one of the main differences is the use of medications during resuscitation. Whenever medications are given in children, unlike adults, they are pretty much always dosed according to weight, which makes things slightly less streamlined but is critical to provide safe care. This is no different during pediatric resuscitation, although in the middle of an acute or impending cardiac arrest, if weight has not been measured already, it may need be estimated at first to give possibly life-sustaining medications. Given the low probability that I will be the first-responder to a pediatric cardiac arrest, it is unlikely that I will remember pediatric dosing of medications for the various ACLS algorithms. But I know where to look them up rapidly. That being said, I do think it is critical to know the dose of epinephrine, the medication that is given as soon as possible in a cardiac arrest and that is potentially life-saving: 0.01 mg/kg (of a 1:10,000 concentration of epinephrine). Just like in adults (although given at a dose of 1 mg regardless of weight), this dose can be repeated every 3-5 minutes during a cardiac arrest.

One last important and very useful element to know about for pediatric resuscitation is the Braeslow tape. This is a colour-coded resuscitation tape that provides an estimate of the different sizes of instruments, tubes, etc that may be needed during pediatric resuscitation protocols. Standard of care in emergency departments following ACLS guidelines will have supplies organized by colour to facilitate rapid selection of the most likely tools to resuscitate a child based on their size, which can save precious time during resuscitation. The pictures below show just how much simpler this is than having to go through and make decisions about each possible adjunct needed.