Protocol for asystole or pulseless electrical activity in paediatric ALS

Non-shockable (asystole or pulseless electrical activity): This is the more common finding in children

In this instance

• perform continuous CPR:
  • continue to ventilate with high-concentration oxygen
  • if ventilating with bag-mask give 15 chest compressions to 2 ventilations for all ages
  • if the patient is intubated, chest compressions can be continuous as long as this does not interfere with satisfactory ventilation
  • use a compression rate of 100 per min
  • once the child has been intubated and compressions are uninterrupted use a ventilation rate of approximately 10 per min

Note: Once there is return of spontaneous circulation (ROSC) the ventilation rate should be 12 - 20 per min. Measure exhaled CO2 to ensure correct tracheal tube placement

• give adrenaline:
  • if venous or intraosseous (IO) access has been established, give adrenaline 10 microgram per kg (0.1 ml per kg of 1 in 10,000 solution)
  • if there is no circulatory access, attempt to obtain IO access
  • if circulatory access is not present, and cannot be quickly obtained, but the patient has a tracheal tube in place, consider giving adrenaline 100 microgram per kg via the tracheal tube (1 ml per kg of 1 in 10,000 or 0.1 ml per kg of 1 in 1,000 solution). Using a tracheal tube is the least satisfactory route
• continue CPR
• repeat the cycle:
  • give adrenaline 10 microgram per kg every 3 to 5 min, (i.e. every other loop), while continuing to maintain effective chest compression and ventilation without interruption. Unless there are exceptional circumstances, the dose should be 10 microgram per kg again for this and subsequent doses
  • once the airway is protected by tracheal intubation, continue chest compression without pausing for ventilation. Provide ventilation at a rate of 10 per min and compression at 100 per min
  • when circulation is restored, ventilate the child at a rate of 12 - 20 breaths per min to achieve a normal pCO2, and monitor exhaled CO2
• consider and correct reversible causes (4H's and 4T's)
  • hypoxia
  • hypovolaemia
  • hyper/hypokalaemia (electrolyte disturbances)
  • hypothermia
  • tension pneumothorax
  • tamponade
  • toxic/therapeutic disturbance
  • thromboembolism
• consider the use of other medications such as alkalising agents.

Reference:

1. Resuscitation Council (UK). Advanced Paediatric Life Support. Guidelines 2005.