Pediatric Cardiac Arrest

Definition and epidemiology

Paediatric cardiac arrest is the cessation of effective cardiac mechanical activity, confirmed by unresponsiveness, absent or abnormal breathing, and no detectable central pulse within 10 seconds. Unlike adults, paediatric arrest is usually the end result of progressive respiratory failure or shock (an asphyxial mechanism) rather than a sudden primary arrhythmia. Consequently the presenting rhythm is most often non-shockable (asystole or pulseless electrical activity); ventricular fibrillation (VF) or pulseless VT account for a minority but rise with age and in certain settings (channelopathy, cardiomyopathy, post-cardiac-surgery). Out-of-hospital survival remains poor, but high-quality CPR and early reversal of cause meaningfully improve outcome, particularly for in-hospital arrest.

Clinical features

Many children show a recognisable pre-arrest deterioration — escalating tachypnoea, increasing work of breathing then bradypnoea, poor perfusion, bradycardia and altered consciousness. Recognising this trajectory and intervening early is the single biggest opportunity to prevent arrest. Established arrest is defined clinically by unresponsiveness, apnoea/agonal breathing and pulselessness.

Diagnosis

Diagnosis is clinical and must be rapid: check responsiveness, breathing and a central pulse simultaneously in ≤10 seconds, then start CPR. As soon as a monitor/defibrillator is available, determine whether the rhythm is shockable (VF/pulseless VT) or non-shockable (asystole/PEA) — this is the branch that drives every subsequent action.

See the full criteria: Pediatric Cardiac Arrest Algorithm

Red flags

• Pre-arrest signs: agonal/irregular breathing, bradycardia with poor perfusion, escalating shock
• Shockable rhythm (VF/pVT) — needs immediate defibrillation, not a drug, first
• A clearly reversible cause (the H’s and T’s) that is being missed during ongoing CPR
• Prolonged downtime with no high-quality CPR or no rhythm reassessment
• Special circumstances: hyperkalaemia, toxin ingestion, tamponade, tension pneumothorax, hypothermia

Management overview

The priority is uninterrupted, high-quality CPR with minimal pauses, plus rapid identification and correction of the cause.

1. High-quality CPR immediately: push hard and fast at the age-appropriate depth, allow full chest recoil, minimise interruptions, and rotate compressors; attach a monitor/defibrillator without delaying compressions.
2. Shockable (VF/pulseless VT): defibrillate as soon as charged, resume CPR at once, and escalate energy on subsequent shocks per the algorithm; give a vasopressor (epinephrine class) and, for refractory VF/pVT, an antiarrhythmic (amiodarone or lidocaine class) after shocks.
3. Non-shockable (asystole/PEA): continue CPR and give a vasopressor (epinephrine class) early, repeated at the algorithm interval; rhythm checks every 2 minutes.
4. Reversible causes — the H’s and T’s: Hypovolaemia, Hypoxia, Hydrogen ion (acidosis), Hypo/Hyperkalaemia, Hypoglycaemia, Hypothermia; Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (pulmonary/coronary). Treat each empirically where suspected.
5. Airway and access: effective ventilation/oxygenation, IV/IO access, and advanced airway when it does not compromise compression quality; capnography to gauge CPR quality and detect ROSC.
6. Post-ROSC: targeted temperature management, controlled oxygenation/ventilation, haemodynamic support and treatment of the precipitant, with transfer to paediatric intensive care.

Drug doses, energy levels and timing are weight- and age-specific — use a verified dosing reference and the resuscitation algorithm at the bedside.

References

• AHA PALS Guidelines 2020 — Pediatric Cardiac Arrest Algorithm
• AHA 2020 Guidelines for CPR and Emergency Cardiovascular Care (pediatric)
• IAP guidance on paediatric resuscitation

Decision support for qualified clinicians only — verify against current primary guidelines and your clinical judgement.