APatient is pulseless

i. Monitor shows asystole or pulseless electrical activity: Start chest compressions. Administer epinephrine via ET, IV, or IO route every 3-5 minutes.

ii. Monitor shows ventricular fibrillation or pulseless ventricular tachycardia: Defibrillate immediately (time should not be spent on ET intubation or IV or IO access), up to 3 times as needed. Start with 2 joules/kg, then 4 joules/kg, then 4 joules/kg. If no response, administer epinephrine via ET, IV, or IO route. Perform CPR. Defibrillate. If no response, administer antiarrhythmics (amiodarone, lidocaine, or magnesium) ET, IV, or IO. Perform CPR. Defibrillate.

b. Patient has slow pulse (< 60 beats/min) and shows severe cardiorespiratory compromise despite adequate oxygenation and ventilation.

i. Start chest compressions. Administer epinephrine via ET, IV, or IO route every 3-5 minutes.

ii. Consider atropine if primary AV block or increased vagal tone is suspected.

iii. Consider cardiac pacing.

c. Patient has rapid pulse and shows severe cardiorespiratory compromise despite adequate oxygenation and ventilation.

i. Monitor shows narrow complexes (probable supraventricular tachycardia): Perform cardioversion immediately with 0.5 joules/kg. Increase dose to 2 joules/kg if initial dose is ineffective, or administer adenosine IV or IO if immediately available.

ii. Monitor shows wide complexes (probable ventricular tachycardia): Perform cardioversion immediately with 0.5 joules/kg. Increase dose to 2 joules/kg if initial dose is ineffective. Consider antiarrhythmics (amiodarone, procainamide, lidocaine).

If patient is in shock, provide fluid boluses of 20 mL/kg of isotonic (NS or Ringer lactate) solution at least twice. Reassess patient after each fluid bolus. Consider infusion of inotrope if there is no or minimal improvement after second fluid bolus. Consider the 5 H's and 4 T's (see II, G, earlier). Involve consultants promptly for the following conditions: congenital or acquired heart disease, arrhythmias (cardiologist); injuries (trauma surgeon); head injury, and intracranial hypertension (neurosurgeon). Other actions a. Administer antidote when available for suspected toxins.

b. Provide empiric antimicrobial therapy for suspected sepsis or meningitis.

VI. Problem Case Diagnosis. The 4-month-old boy was unresponsive and apneic on arrival in the emergency department. He underwent ET intubation and received 100% oxygen but remained pulseless and asystolic. Cardiac compressions were initiated. IO access was obtained, and epinephrine was given every 3 minutes for a total of three times. Patient remained pulseless. Postmortem examination was consistent with sudden infant death syndrome.

VII. Teaching Pearl: Question. Among industrialized nations, what is the leading cause of death from the age of 6 months through young adulthood?

VIII. Teaching Pearl: Answer. Injury; therefore, injury prevention is the first link in the so-called pediatric chain of survival.

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