Cardiopulmonary resuscitation in children.

The management of the pulseless, nonbreathing pediatric patient continues to be a frustrating experience because mortality and morbidity are high. Improvement in outcome awaits a better understanding of the pathophysiology of organ ischemia and reperfusion injury. In the interim, early recognition and therapy of respiratory and circulatory failure are the only effective means to affect outcome. The approach to the pediatric cardiac arrest victim differs from the adult, because dysrhythmias rarely are the etiology of pediatric arrest. Instead, attention to securing the airway and provision of adequate ventilation are keys. Epinephrine is the most effective drug in this setting, and may be administered through an endotracheal tube as well as intravenously or intraosseously. The latter route provides a useful means of rapid vascular access in the pediatric victim less than 3 years of age. Sodium bicarbonate use has been discouraged and there are few indications for calcium, greatly simplifying the pharmacologic approach to the pediatric cardiac arrest patient. In those patients in whom a rhythm and pulse are restored, support of the circulation often is required. Dopamine or epinephrine are the catecholamines of choice in this setting. Ventricular arrhythmias are treated with defibrillation or cardioversion as appropriate. Infrequently, lidocaine or bretylium may be needed. Once the patient has been stabilized, further care is best delivered at a tertiary care center with a pediatric intensive care unit.