What is the initial joules (J) per kilogram used when defibrillating a pediatric patient?

From the Guidelines

The initial energy dose for defibrillation in pediatric patients is 2-4 joules per kilogram (J/kg) of body weight. When treating a pediatric patient in cardiac arrest with a shockable rhythm such as ventricular fibrillation or pulseless ventricular tachycardia, start with 2 J/kg for the first shock. If this is unsuccessful, subsequent shocks should be delivered at 4 J/kg. This lower initial energy dose is specifically tailored for children's smaller body size and cardiac mass compared to adults, as excessive energy could potentially damage the myocardium. It's essential to use pediatric pads for children under 8 years or 25 kg when available, as they deliver an appropriately reduced energy level. For infants under 1 year, manual defibrillators with dose adjustment capability are preferred. Weight-based dosing ensures appropriate energy delivery while minimizing the risk of myocardial damage, making accurate weight estimation or measurement crucial in emergency situations involving pediatric patients 1.

Key Considerations

• The initial dose of 2-4 J/kg is based on cohort studies showing low success in termination of VF in children with 2 J/kg 1.
• The recommendation for a single initial shock rather than stacked shocks is extrapolated from adult data showing that long pauses in chest compressions are associated with worse resuscitation outcomes 1.
• Pediatric pads or manual defibrillators with dose adjustment capability are preferred for children under 8 years or 25 kg, and for infants under 1 year, respectively 1.
• Accurate weight estimation or measurement is crucial in emergency situations involving pediatric patients to ensure appropriate energy delivery and minimize the risk of myocardial damage.

Energy Dosing

• Initial dose: 2-4 J/kg
• Subsequent doses: at least 4 J/kg, with higher energy levels considered if necessary, not to exceed 10 J/kg or the adult maximum dose 1.

From the Research

Initial Defibrillation Dose for Pediatric Patients

The initial joules per kilogram used when defibrillating a pediatric patient is a topic of ongoing research and debate.

• The American Heart Association (AHA) recommends an initial defibrillation dose of 2-4 J/kg for pediatric cardiac arrest with ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) 2.
• Some studies suggest that 2 J/kg may be an ineffective initial defibrillation dose, and higher doses such as 4 J/kg may be more effective 3, 4.
• However, other studies have found that doses other than 2 J/kg are associated with lower rates of survival to hospital discharge in pediatric patients with initial VF/pVT 2.
• The optimal pediatric defibrillation dose remains unknown, and further research is needed to determine the most effective dose 3, 5, 4.

Energy Dose Recommendations

• The International Liaison Committee on Resuscitation recommends an initial dose of 2-4 J/Kg, increased from 2 J/Kg 3.
• The European Resuscitation Council (ERC) advocates 4J/kg as the initial dose without escalation for subsequent shocks 3.
• The AHA recommends 2-4 J/Kg, increasing to ≥ 4 J/Kg with subsequent shocks up to adult dose 3, 2.

Historical Context

• Early studies suggested that an energy dose of 2 w-sec/kg (or approximately 1 w-sec/lb) is adequate to defibrillate most children weighing under 50 kg 6.
• However, more recent studies have raised questions about the effectiveness of this dose and the need for higher doses in certain situations 3, 2, 5, 4.