24. Critical Care Pediatric Electrocardiography and Resuscitation
In the Pediatric Intensive Care Unit (PICU), continuous multi-lead electrocardiography is a critical window into acute myocardial perfusion, systemic oxygen delivery, and life-threatening arrest rhythms.
1. Pediatric Cardiac Arrest Rhythms & Resuscitation (PALS Protocols)
| Arrest Rhythm Category | Specific Rhythms | Immediate Resuscitation Action | Defibrillation Energy / Pharmacotherapy |
|---|---|---|---|
| Shockable Rhythms | 1. Ventricular Fibrillation (VF) 2. Pulseless Ventricular Tachycardia (pVT) | Immediate Defibrillation + High-Quality CPR ($100-120\text{ bpm}$, depth $1/3$ AP diameter). | Initial Shock: $2\text{ J/kg}$. Second Shock: $4\text{ J/kg}$. Subsequent: $\ge 4\text{ J/kg}$ (max $10\text{ J/kg}$). Epinephrine: $0.01\text{ mg/kg}$ IV/IO q3-5min. Amiodarone: $5\text{ mg/kg}$ IV/IO bolus. |
| Non-Shockable Rhythms | 1. Asystole 2. Pulseless Electrical Activity (PEA) | Immediate High-Quality CPR + Early Epinephrine + Treat Reversible Causes (H's & T's). | Epinephrine: $0.01\text{ mg/kg}$ IV/IO immediately. Zero Defibrillation. |
2. The Pediatric Reversible Causes Matrix (H's and T's)
- Hypovolemia: Sinus tachycardia, narrow QRS complexes $\to$ IV crystalloid boluses ($20\text{ mL/kg}$).
- Hypoxia: Severe progressive bradycardia leading to asystole $\to$ immediate airway control & ventilation.
- Hydrogen Ion (Acidosis): Widened QRS complexes $\to$ hyperventilation, IV Sodium Bicarbonate.
- Hyperkalemia / Hypokalemia: Sine wave / Torsades $\to$ Calcium gluconate, Insulin-Dextrose, KCl.
- Hypothermia: Osborn J waves, bradycardia $\to$ active internal and external rewarming.
- Tension Pneumothorax: Tracheal deviation, electromechanical dissociation $\to$ needle thoracostomy.
- Tamponade (Cardiac): Low voltage QRS, electrical alternans $\to$ emergency pericardiocentesis.
- Toxins: Wide QRS / prolonged QTc $\to$ specific antidotes (Sodium bicarbonate, DigiFab).