Paediatric cardiac arrest (AHA/AAP 2025), bradycardia and SVT, weight estimation and the core resuscitation doses — with worked examples for a 10 kg and 20 kg child.
At the bedside
Timed steps- 1
Recognise and start CPR
0 sUnresponsive, not breathing normally, no definite pulse within 10 s (or HR <60/min with poor perfusion despite oxygenation and ventilation) → start CPR. Push hard and fast: 100–120/min, depth at least one-third of the AP chest diameter (~4 cm infant, ~5 cm child), full recoil, minimal interruptions. Two rescuers: 15:2.
- 2
Attach monitor/defibrillator; check rhythm
0–1 minShockable (VF/pVT) → shock 2 J/kg (2–4 J/kg acceptable), resume CPR immediately for 2 min. Non-shockable (asystole/PEA) → adrenaline as soon as possible.
- 3
IV or IO access
ASAPRapid IV or IO — choose whichever is fastest; IO in the proximal tibia if IV is not quick. Endotracheal drug route is a last resort.
- 4
Adrenaline
Every 3–5 min0.01 mg/kg IV/IO (0.1 mL/kg of 0.1 mg/mL), max 1 mg. Non-shockable: give as early as possible. Shockable: after 2 shocks, or earlier only if defibrillation is not possible.
- 5
Escalate shocks and antiarrhythmic
Shock 2+Second shock 4 J/kg; subsequent ≥4 J/kg up to 10 J/kg or adult maximum. Refractory VF/pVT: amiodarone 5 mg/kg (max 300 mg) or lidocaine 1 mg/kg.
- 6
Airway and ventilation
ThroughoutBag-mask ventilation is acceptable; with an advanced airway give 1 breath every 2–3 s (20–30/min) with continuous compressions; avoid hyperventilation. Use waveform capnography.
- 7
Treat reversible causes
ThroughoutHypoxia (commonest), hypovolaemia, hydrogen ion (acidosis), hypo/hyperkalaemia, hypoglycaemia, hypothermia; tension pneumothorax, tamponade, toxins, thrombosis. Check glucose in every arrest.
- 8
Post-arrest care
ROSCAvoid fever (>37.5 °C) in comatose children; keep systolic and mean BP above the 10th percentile for age; normoxia (SpO₂ 94–99%) and normocapnia; EEG monitoring if available; multimodal prognostication, not a single test.
Cardiac arrest
Adrenaline (epinephrine) — paediatric
- Dose
- 0.01 mg/kg (0.1 mL/kg of 0.1 mg/mL), max 1 mg, every 3–5 min
- Range
- 0.01–0.01 mg/kg
- Worked example
- 10 kg: 0.1 mg = 1 mL of 0.1 mg/mL. 20 kg: 0.2 mg = 2 mL.
Shock-refractory VF/pVT
Amiodarone — paediatric
- Dose
- 5 mg/kg (max 300 mg); repeat to total 15 mg/kg
- Worked example
- 20 kg: 100 mg (2 mL of 150 mg/3 mL).
Shock-refractory VF/pVT (alternative)
Lidocaine (lignocaine) — paediatric
- Dose
- 1 mg/kg
- Worked example
- 20 kg: 20 mg = 1 mL of 2%.
SVT with a pulse
Adenosine — paediatric
- Dose
- 0.1 mg/kg (max 6 mg), then 0.2 mg/kg (max 12 mg)
- Worked example
- 10 kg: 1 mg (0.33 mL of 3 mg/mL), then 2 mg.
Vagal bradycardia / AV block
Atropine — paediatric
- Dose
- 0.02 mg/kg (max single dose 0.5 mg)
- Worked example
- 10 kg: 0.2 mg = 0.33 mL of 0.6 mg/mL.
Hypoglycaemia
Dextrose 10% — paediatric
- Dose
- 2–5 mL/kg of 10% dextrose
- Worked example
- 10 kg: 20–50 mL D10.
Estimating weight (when it cannot be measured)
| Age | Formula (APLS-style) | Example |
|---|---|---|
| 0–12 months | (0.5 × age in months) + 4 | 6 months ≈ 7 kg |
| 1–5 years | (2 × age in years) + 8 | 3 years ≈ 14 kg |
| 6–12 years | (3 × age in years) + 7 | 8 years ≈ 31 kg |
Length-based tapes (Broselow, PAWPER) are acceptable; age formulas are inaccurate and may overestimate weight in undernourished Indian children — use actual weight whenever possible and never exceed adult doses.
Electrical therapy doses
| Situation | Energy |
|---|---|
| VF/pulseless VT — first shock | 2 J/kg (2–4 J/kg) |
| Second shock | 4 J/kg |
| Subsequent shocks | ≥4 J/kg, max 10 J/kg or adult dose |
| Synchronised cardioversion (SVT/VT with pulse) | 0.5–1 J/kg, then 2 J/kg |
Quick reference: 10 kg and 20 kg child
| Drug/item | Dose per kg | 10 kg | 20 kg |
|---|---|---|---|
| Adrenaline (arrest) 0.1 mg/mL | 0.01 mg/kg | 0.1 mg (1 mL) | 0.2 mg (2 mL) |
| Amiodarone | 5 mg/kg | 50 mg | 100 mg |
| Adenosine (1st) | 0.1 mg/kg | 1 mg | 2 mg |
| Atropine | 0.02 mg/kg | 0.2 mg | 0.4 mg |
| Dextrose 10% | 2–5 mL/kg | 20–50 mL | 40–100 mL |
| Fluid bolus | 10–20 mL/kg | 100–200 mL | 200–400 mL |
| Defibrillation | 2 → 4 J/kg | 20 → 40 J | 40 → 80 J |
Always confirm weight and concentration; never exceed adult doses.
Approximate normal vital signs and hypotension
| Age | Heart rate (/min) | Resp rate (/min) | Hypotension (systolic) |
|---|---|---|---|
| Infant (<1 y) | 110–160 | 30–40 | <70 mmHg |
| 1–2 y | 100–150 | 25–35 | <70 + (2 × age) mmHg |
| 2–5 y | 95–140 | 25–30 | <70 + (2 × age) mmHg |
| 5–12 y | 80–120 | 20–25 | <70 + (2 × age) mmHg (to age 10); <90 after |
| >12 y | 60–100 | 15–20 | <90 mmHg |
Heart and respiratory rate ranges are approximate APLS-style values; hypotension thresholds from PALS.
References
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Paediatric cardiac arrest (AHA/AAP 2025)
Step 1 of ~7
Simplified pulseless arrest algorithm for infants and children.
Start CPR 15:2, give oxygen, attach monitor/defibrillator
Based on Lasa JJ, Dhillon GS, Duff JP, et al. Educational use; follow local protocol.
Pathophysiology
Paediatric arrest is usually the end of progressive hypoxia or shock (asphyxial arrest), which is why the commonest initial rhythms are bradycardia, PEA and asystole. Children have a higher metabolic rate, smaller functional residual capacity and desaturate quickly; good-quality ventilation and early adrenaline (coronary perfusion via alpha-1 vasoconstriction) are central.
Evidence
AHA/AAP 2025 PALS — key changes and reaffirmations
- Early adrenaline for initial non-shockable rhythms is associated with better outcomes (COR 2a).
- For shockable rhythms, defibrillation is the priority; adrenaline after 2 shocks or sooner only if defibrillation is not possible.
- With an arterial line, diastolic BP ≥25 mmHg (infants) and ≥30 mmHg (≥1 year) are included as CPR-quality targets.
- With an advanced airway, ventilate 20–30 breaths/min (1 breath every 2–3 s).
- Initial defibrillation 2–4 J/kg (2 J/kg for ease of teaching), then 4 J/kg, up to 10 J/kg or adult maximum.
- Routine sodium bicarbonate and calcium are not recommended.
- After ROSC: prevent fever (>37.5 °C) in comatose children; keep SBP/MAP above the 10th centile for age.
- Weight-based dosing should not exceed adult doses; length-based tapes are acceptable when weight is unknown.
- IV sotalol is a new option for refractory SVT with compromise when expert help is unavailable.
Controversies
- Optimal adrenaline interval (observational data conflict).
- Amiodarone vs lidocaine for refractory VF — no clear difference in survival.
- Age formulas vs length-based tapes in children with malnutrition or obesity.
🇮🇳 India notes
- Weight-for-age formulas derived in Western children often overestimate weight in undernourished Indian children; weigh the child or use a length tape, and use actual weight for dosing.
- Keep a pre-calculated paediatric resuscitation chart (by weight band) on every emergency trolley — mixing errors with 1 mg/mL adrenaline ampoules are common.
- IO needles may not be stocked in smaller hospitals: an 18G spinal or bone-marrow needle is a recognised improvisation in the proximal tibia when nothing else is available.
- Common Indian precipitants: severe dehydration from diarrhoea, pneumonia, dengue shock, scorpion sting myocarditis, OP poisoning, drowning.
References
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Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.