What medications and equipment are recommended for a 3-year-old in cardiac arrest?

Medications and Equipment for a 3-Year-Old in Cardiac Arrest

For a 3-year-old in cardiac arrest, the essential medications include epinephrine (0.01 mg/kg IV/IO every 3-5 minutes), amiodarone (5 mg/kg IV/IO for shockable rhythms), and lidocaine (1 mg/kg IV/IO as an alternative), while required equipment includes an AED/defibrillator, bag-mask device, oxygen, IV/IO access supplies, and appropriately sized airway equipment. 1, 2

Essential Equipment

Airway Management

• Appropriately sized bag-mask device with oxygen reservoir
• Oxygen source and delivery equipment
• Oral and nasal airways (size 2-3 for a 3-year-old)
• Endotracheal tubes (cuffed 4.0-4.5 mm or uncuffed 4.5-5.0 mm)
• Laryngoscope with straight (Miller) and curved (Mac) blades (size 2)
• Supraglottic airway device (appropriate size for 3-year-old)
• Waveform capnography/capnometry device

Circulation Support

• Monitor/defibrillator with pediatric pads
• Backboard for CPR
• IV catheters (22-24 gauge)
• Intraosseous (IO) needle and insertion device
• Fluid administration sets
• Normal saline or Ringer's lactate solution

Critical Medications

First-Line Medications

• Epinephrine: 0.01 mg/kg (0.1 mL/kg of 0.1 mg/mL concentration)
  • Maximum dose: 1 mg
  • Route: IV/IO preferred
  • Frequency: Every 3-5 minutes
  • Alternative route: Endotracheal at 0.1 mg/kg (0.1 mL/kg of 1 mg/mL concentration) if no IV/IO access 1, 2

Antiarrhythmic Medications (for shockable rhythms)

• Amiodarone: 5 mg/kg IV/IO bolus
  • May repeat up to 3 total doses for refractory VF or pulseless VT 1, 2, 3
• Lidocaine: 1 mg/kg IV/IO loading dose (alternative to amiodarone) 1, 2

Additional Medications (as indicated)

• Sodium bicarbonate: Not for routine use, but may be considered for prolonged arrest or specific conditions
• Calcium: Not for routine use, but may be indicated for documented hypocalcemia, calcium channel blocker overdose, hypermagnesemia, or hyperkalemia 2

CPR Protocol for a 3-Year-Old

High-Quality CPR Parameters

• Compression depth: At least one-third of AP chest diameter (approximately 2 inches/5 cm)
• Compression rate: 100-120/minute
• Compression-to-ventilation ratio: 15:2 (with two rescuers)
• Allow complete chest recoil between compressions
• Minimize interruptions in compressions
• Change compressor every 2 minutes to avoid fatigue 1, 2

Defibrillation

• Use AED as soon as available
• For manual defibrillation: 2-4 J/kg for first shock, escalate to 4 J/kg for subsequent shocks if needed
• Resume CPR immediately after shock for 2 minutes before rhythm check 1, 2

Common Pitfalls to Avoid

• Delayed epinephrine administration: Administer within 5 minutes of arrest onset
• Inadequate compression depth: Ensure compressions are at least one-third of chest depth
• Excessive ventilation: Avoid over-ventilation which can increase intrathoracic pressure and reduce venous return
• Prolonged interruptions in compressions: Keep pauses under 10 seconds
• Failure to identify and treat reversible causes: Remember the H's and T's (Hypovolemia, Hypoxia, Hydrogen ion/acidosis, Hypo/Hyperkalemia, Hypothermia, Tension pneumothorax, Tamponade, Toxins, Thrombosis-pulmonary, Thrombosis-coronary) 2

Approach to Pediatric Cardiac Arrest

1. Recognition and Initial Actions

   • Check responsiveness
   • Call for help/activate emergency response system
   • Begin CPR immediately if no pulse or pulse <60 with poor perfusion
   • Get AED/defibrillator and emergency equipment

2. High-Quality CPR

   • Begin chest compressions (100-120/min)
   • Provide ventilations (15:2 ratio with two rescuers)
   • Attach monitor/defibrillator

3. Rhythm Assessment and Management

   • For shockable rhythm (VF/pVT): Deliver shock, resume CPR for 2 minutes, give epinephrine every 3-5 minutes, consider amiodarone or lidocaine
   • For non-shockable rhythm (asystole/PEA): Continue CPR, give epinephrine every 3-5 minutes

4. Advanced Airway Management

   • Consider placement of advanced airway after initial CPR cycles
   • Confirm placement with waveform capnography
   • After advanced airway placement: Provide continuous compressions with 1 breath every 2-3 seconds

5. Vascular Access

   • Establish IV/IO access as soon as possible
   • IO access is preferred if IV access is difficult or delayed

Pediatric cardiac arrest differs from adult cardiac arrest in that it's often secondary to respiratory failure or shock rather than a primary cardiac event. This makes early recognition, high-quality CPR, and appropriate ventilation particularly crucial for successful resuscitation 4.