What is the immediate approach for pediatric patients requiring Advanced Cardiovascular Life Support (ACLS)?

Pediatric Advanced Cardiovascular Life Support (ACLS): Immediate Approach

Begin high-quality CPR immediately with chest compressions at a depth of at least one-third of the anterior-posterior chest diameter at 100-120 compressions per minute, using a 30:2 compression-to-ventilation ratio for single rescuers and 15:2 for two or more rescuers, while simultaneously activating the emergency response system and retrieving an AED. 1, 2, 3

Initial Assessment and Scene Safety

• Verify scene safety first before approaching the patient to avoid becoming a second victim 1, 2
• Check for responsiveness by shouting and tapping the child 1, 2
• Shout for nearby help immediately 1
• Activate the emergency response system via mobile device if appropriate, or have the second rescuer activate it while the first remains with the child 1

Simultaneous Breathing and Pulse Assessment

• Look for no breathing or only gasping while simultaneously checking for a pulse within 10 seconds 1, 2
• Do not perform prolonged pulse checks—if uncertain after 10 seconds, start CPR immediately 2
• If heart rate is less than 60 beats per minute with signs of poor perfusion, start CPR immediately even if a pulse is present 1, 3

High-Quality CPR Technique

Compression Parameters

• Compress at least one-third of the anterior-posterior diameter of the chest 3
• Maintain a rate of 100-120 compressions per minute 2, 3
• Allow complete chest recoil between compressions—incomplete recoil prevents full cardiac refilling and is a critical error 2
• Minimize interruptions in chest compressions, as continuous compressions are essential for survival 2

Compression-to-Ventilation Ratios

• Single rescuer: Use 30 compressions to 2 breaths (30:2) 1, 2, 3
• Two or more rescuers: Switch to 15 compressions to 2 breaths (15:2) when the second rescuer arrives 1, 2, 3

Ventilation Considerations

• Provide rescue breathing at 1 breath every 2-3 seconds (20-30 breaths per minute) if the child has a pulse but is not breathing normally 1
• In COVID-19 or suspected aerosol-generating situations, use HEPA filters with all ventilation devices 1
• Once an advanced airway is placed, give 1 breath every 6 seconds (10 breaths per minute) with continuous chest compressions 1

Early Defibrillation Strategy

• Retrieve the AED immediately (or have the second rescuer retrieve it) 1, 2
• For witnessed sudden collapse, activate emergency response and retrieve AED/defibrillator immediately before starting CPR 1
• For unwitnessed collapse, start CPR first, then retrieve AED after about 2 minutes if still alone 1
• Use the AED as soon as it becomes available—do not delay CPR to retrieve it, but apply immediately once present 1, 2

Rhythm Assessment and Shock Delivery

• Check rhythm to determine if shockable (ventricular fibrillation or pulseless ventricular tachycardia) 1, 2
• If shockable rhythm: Give 1 shock immediately, then resume CPR for 2 minutes before reassessing rhythm 1, 2
• If nonshockable rhythm: Resume CPR immediately for 2 minutes before reassessing rhythm 1, 2
• Check rhythm every 2 minutes during CPR 2

Advanced Life Support Interventions

Medication Administration

• Administer epinephrine every 3-5 minutes for all cardiac arrest rhythms 2
• Consider amiodarone or lidocaine for refractory ventricular fibrillation or pulseless ventricular tachycardia 2

Airway Management

• Use waveform capnography or capnometry to confirm and monitor endotracheal tube placement 1
• Consider supraglottic airway with HEPA filters to maximize chest compression fraction before endotracheal intubation 1
• Use the most experienced provider for intubation, as pediatric airways can be challenging 1

Critical Pitfalls to Avoid

• Do not delay CPR for any reason—delays worsen outcomes 3
• Do not provide inadequate compression depth or rate—compressions must be hard and fast to be effective 2
• Do not lean on the chest between compressions—this prevents adequate cardiac refilling 2
• Do not delay CPR to obtain a detailed history—the priority is immediate chest compressions 2
• Do not continue rescue breathing alone if heart rate drops below 60/min with poor perfusion—start full CPR immediately 3

Continuation of Resuscitation

• Continue CPR until advanced life support providers take over, the child starts to move, or the heart rate improves to >60/min with adequate perfusion 1, 3
• Reassess pulse every 2 minutes during rescue breathing or CPR 1