Peripheral venous access is notoriously difficult in small children. Central venous cannula insertion can be dangerous as well as difficult. Intra-osseous access may be life saving. If neither IV nor endotracheal access is available it is recommended that early intraosseous access is secured. This route, using a bone marrow needle in the proximal tibia is safe, simple and rapid to acquire and drugs, fluids and blood can be given by this route. Endotracheal drug administration has been advocated and adrenaline can be given in doses ten times greater than the initial IV dose by this route. In adults, the endotracheal route for adrenaline has been shown to be unreliable although this may not be the case in children. Endotracheal drugs should be passed through a fine suction catheter and then flushed with normal saline. Atropine, lidocaine, naloxone and diazepam can also be given via the endotracheal tube, but there are no recommended doses. Bicarbonate should not be given intratracheally.
Adrenaline should be given in doses of 0.01 mg/kg of 1:10 000 solution via the IV or intra-osseus route and 0.1 mg/kg of the 1:1000 solution via the endotracheal tube. It should be repeated at least every three minutes. Although the outcome for children in refractory asystole is dismal, and there may be a better long term outcome after high dose adrenaline (0.2 mg/kg) concerns about coronary vasoconstriction and post arrest hypertension resulted in recommendations that 0.1 mg/kg should be given as the second dose (Zideman 1994). Now caution is advised if a dose larger than 0.01 mg/kg is considered.
PAEDlÄTftlC ADVANCED LIFE SUPPORT
Since cardiac arrest in children may be the terminal event following a prolonged episode of hypoxia or hypovolaemia, bicarbonate may need to be given for a severe metabolic acidosis. The recommended dose is 1 mmol/kg by slow intravenous (preferably central) injections or via the intra-osseous route.
Since bradycardia and asystole in children is often secondary to hypoxia, ventilation with 100% oxygen is the recommended treatment and atropine is not included in the asystole algorithm. It may however be given if vagal overactivity was considered to be the precipitating cause of the arrest; the dose is 0.02 mg/kg IV with a minimum dose of 0.1 mg to avoid paradoxical bradycardia.
The usefulness of lidocaine in VF has been questioned. When indicated the recommended dose is 1 mg/kg IV. The effectiveness of bretylium in children is uncertain.
In suspected hypovolaemia with severe circulatory failure or EMD, 20 ml/kg of a crystalloid or colloid solution should be infused rapidly. Glucose administration should be avoided during cardiac arrest but is indicated for infants with proven hypoglycaemia.
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