Protocol for VF or pulseless VT in paediatric ALS

Once VF or pulseless VT is identified

This is less common in paediatric practice but likely when there has been a witnessed and sudden collapse. It is commoner in the intensive care unit and cardiac ward

• Defibrillate the heart:

• give 1 shock of 4 per kilogram if using a manual defibrillator
• if using an AED for a child of 1-8 years, deliver a paediatricattenuated adult shock energy
• if using an AED for a child over 8 years, use the adult shock energy
• resume CPR:
  • without reassessing the rhythm or feeling for a pulse, resume CPR immediately, starting with chest compression
• continue CPR for 2 min
• pause briefly to check the monitor:
  • if still VF/VT, give a second shock at 4 J per kg if using a manual defibrillator, OR the adult shock energy for a child over 8 years using an AED, OR a paediatric-attenuated adult shock energy for a child between 1 year and 8 years
• resume CPR immediately after the second shock
• consider and correct reversible causes (see above: 4Hs and 4Ts)
  • hypoxia
  • hypovolaemia
  • hyper/hypokalaemia (electrolyte disturbances)
  • hypothermia
  • tension pneumothorax
  • tamponade
  • toxic/therapeutic disturbance
  • thromboembolism
• continue CPR for 2 min.
• pause briefly to check the monitor:
  • if still VF/VT:
    • give adrenaline 10 microgram per kg followed immediately by a (3rd) shock
    • resume CPR immediately and continue for 2 min
• pause briefly to check the monitor
  • if still VF/VT:
    • give an intravenous bolus of amiodarone 5 mg per kg and an immediate further (4th) shock
    • continue giving shocks every 2 min, minimising the breaks in chest compression as much as possible
    • give adrenaline immediately before every other shock (i.e. every 3-5 min) until return of spontaneous circulation (ROSC)
• Note: After each 2 min of uninterrupted CPR, pause briefly to assess the rhythm
  • if still VF/VT:
    • continue CPR with the shockable (VF/VT) sequence
  • if asystole:
    • continue CPR and switch to the non-shockable (asystole or pulseless electrical activity) sequence as above
  • if organised electrical activity is seen, check for a pulse:
    • if there is ROSC, continue post-resuscitation care
    • if there is no pulse, and there are no other signs of a circulation, give adrenaline 10 microgram per kg and continue CPR as for the non-shockable sequence (see linked item)

Reference:

1. Resuscitation Council (UK). Advanced Paediatric Life Support. Guidelines 2005.