The Heart and Stroke guidelines help direct CPR rate, depth and compression-to-ventilation rates (as referenced in the recent TOTW: CPR Guidelines). However, there are other important nuances to know about for resuscitation in pediatrics. The below chart was created and disseminated with the changes to the ALS-PCS v5.0 and beyond, which highlights the age-related changes to the Newborn Resuscitation and Medical Cardiac Arrest Medical Directives.

These conventions apply for resuscitation when a patient is VSA, but also when a patient is in the pre-arrest state. Per the Pediatric Advanced Life Support section of the guidelines, If heart rate is <60 beats per minute with poor perfusion despite effective ventilation with oxygen, start CPR.

Example: A 9-year-old patient (who has not yet reached puberty) with HR of 45, who is mottled and cyanosed despite effective ventilation would be a candidate for CPR. If this same situation were to occur with a 16-year-old (who is going through or has gone through puberty), you would not start CPR.

NOTE: That the ACP Symptomatic Bradycardia Medical Directive carries indications for Age ≥ 18 years for Atropine, Transcutaneous Pacing and Dopamine. Therefore, a patch to the BHP would be required before initiating this management.

ALSO NOTE: Despite the fact CPR is indicated in a Child with HR <60 beats per minute with poor perfusion despite effective ventilation with oxygen, that Epinephrine is NOT indicated as the patient is not in cardiac arrest (in which case you cannot follow the Cardiac Medical Arrest Medical Directive).

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