Ventricular Fibrillation Management in the Child

Aka: Ventricular Fibrillation Management in the Child

1. See Also
   1. Cardiopulmonary Resuscitation
   2. Reversible Causes of Cardiopulmonary Arrest (5H5T)
   3. Ventricular Fibrillation Management in the Adult
2. Management: Approach
   1. ABC Management
   2. CPR until Defibrillator available
      1. Good quality cardiac compressions are critical for survival (ROSC)
      2. Consider 5 cycles CPR (2 min) before defibrillating
   3. Defibrillation options (single shock)
      1. Manual Defibrillator
         1. First: 2 J/kg
         2. Subsequent: 4 J/kg
         3. Maximum: 10 J/kg or up to adult dose
      2. AED (age 1 year or older)
         1. Child system is preferred if available ages 1-8
   4. Secure cardiopulmonary access
      1. See Cardiopulmonary Resuscitation
      2. Ventilate with 100% oxygen
      3. Endotracheal Intubation
      4. Obtain Intravenous Access
   5. Cycles
      1. Perform 5 cycles of CPR (15:2 if two providers) for total of 2 minutes
         1. Once Advanced Airway in place, give 8-10 breaths per minute (every 6-8 min) and compressions >100/minute asynchronously
      2. Re-evaluate rhythm with minimum interruption of cardiac compressions (<10 seconds)
         1. Organized Electrical activity: Check for pulse
         2. Non-shockable rhythm: See Other protocols
            1. Asystole
            2. Pulseless Electrical Activity (PEA)
         3. Shockable rhythm: Defibrillate
            1. Ventricular Fibrillation
            2. Pulseless Ventricular Tachycardia (V. fib or V. Tach)
      3. Repeat Defibrillation as above after each cycle
         1. Call clear
         2. Compressions need not be interrupted if mechanical CPR device is in place
      4. Administer medications once IV or IO access obtained (see below)
         1. Administer during cardiac compressions (between Defibrillations)
         2. Epinephrine (every 3-5 minutes)
            1. First dose after second Defibrillation
            2. IV/IO: 0.01 mg/kg (0.1 ml/kg of 1:10,000) up to 1 mg IV
            3. ET: 0.1 mg/kg (0.1 ml/kg of 1:10,000) up to 2.5 mg via ET
         3. Amiodarone (up to 3 doses)
            1. Dose: 5 mg/kg up to a maximum of 300 mg for a single dose
            2. First dose after the third Defibrillation
            3. May repeat up to 2 additional doses
      5. Adjunctive medications
         1. Magnesium Sulfate
            1. Dose: 25 to 50 mg/kg IV or IO
            2. Indications
               1. Polymorphic VT (Torsades de Pointes)
               2. Suspected Hypomagnesemia
3. Management: Post Return of Spontaneous Circulation (ROSC)
   1. Assess Vital Signs
   2. Support Airway and breathing
   3. Consider maintaining Antiarrhythmic medications
      1. Infusion of Antiarrhythmic that converted rhythm
      2. Discuss with pediatric cardiology
   4. Pursue definititive management of underlying cause
      1. Reversible Causes of Cardiopulmonary Arrest (5H5T)
   5. Initiate Hypothermia protocol
      1. Improves longterm CNS recovery post-hypoxic event
4. Management: Example
   1. Cycle 1
      1. Perform 5 cycles of CPR (15:2) for total of 2 minutes
      2. Obtain IV Access concurrent with CPR
      3. Rhythm check and Defibrillate 2 J/kg (Call 'clear' and <10 second cardiac compression interruption)
   2. Cycle 2
      1. Perform 5 cycles of CPR (15:2) for total of 2 minutes
      2. Place Advanced Airway concurrent with CPR
      3. Rhythm check and Defibrillate 4 J/kg (Call 'clear' and <10 second cardiac compression interruption)
   3. Cycle 3
      1. Perform CPR for 2 minutes (If Advanced Airway, give asynchronously 8-10 breaths per minute and >100 compressions/min)
      2. Administer Epinephrine 0.01 mg/kg IV up to 1 mg IV maximum
      3. Treat reversible cause (e.g. contact catheterization lab if Acute Coronary Syndrome suspected)
         1. With mechanical CPR device in place, inter-hospital transport is viable despite lack of ROSC
      4. Rhythm check and Defibrillate 4 J/kg (Call 'clear' and <10 second cardiac compression interruption)
   4. Cycle 4
      1. Perform CPR for 2 minutes
      2. Administer Amiodarone 5 mg/kg IV up to 300 mg IV maximum
      3. Rhythm check and Defibrillate 4 J/kg (Call 'clear' and <10 second cardiac compression interruption)
   5. Cycle 5
      1. Perform CPR for 2 minutes
      2. Administer Epinephrine 0.01 mg/kg IV up to 1 mg IV maximum
      3. Rhythm check and Defibrillate 4 J/kg (Call 'clear' and <10 second cardiac compression interruption)
   6. Cycle 6
      1. Perform CPR for 2 minutes
      2. Administer Amiodarone 5 mg/kg IV up to 300 mg IV maximum
      3. Rhythm check and Defibrillate 4 J/kg (Call 'clear' and <10 second cardiac compression interruption)
   7. Cycle 7
      1. Check for pulse (confirm not Pulseless Electrical Activity)
      2. Amiodarone maintenance to prevent recurrent arrhythmia
         1. Discuss indication and dosing with pediatric cardiology
      3. Initiate Induced Therapeutic Hypothermia protocol
         1. Discuss specific protocols with local experts
         2. Requires paralysis, Sedation and OpioidAnalgesics to prevent shivering
5. References
   1. Pediatric Resucitation
      1. http://pediatrics.aappublications.org/content/126/5/e1361.full.html
      2. (2010) Pediatrics 126(5): e1361