Case Presentation:

Paramedics are dispatched to a private residence for a 12-year-old male with difficulty breathing. On arrival, paramedics find a minimally responsive, cyanotic patient with intermittent gasping breaths at the front door. The parents describe that the patient was sick with fever and upper respiratory symptoms for the last 3 days. He is generally healthy at baseline.

The pediatric assessment triangle can be used to determine a general impression of the patient’s underlying condition (MCG 1350). We know that this patient has abnormal appearance (minimally responsive) abnormal work of breathing (slow, gasping breaths), and abnormal circulation (cyanotic). With all three sides of the pediatric assessment triangle affected, the patient is in cardiopulmonary failure.

Immediate management steps for any pediatric patient, of any size, with cardiopulmonary failure include initiating airway maneuvers (MCG 1302) to include bag-mask-ventilation with high flow oxygen. Respiratory arrest is the most common cause of cardiopulmonary failure in pediatrics, so airway management is a top priority. If untreated, cardiopulmonary failure can progress to cardiac arrest. Initiate cardiac monitoring and vascular access.

While ventilation is performed, defibrillation pads should be placed since patients with cardiopulmonary failure per the PAT are likely to require chest compressions in their management. Initiate monitoring and assess vital signs.

His initial vital signs are HR 36, RR 4, SPO2 68% on RA.

He is longer than the length-based resuscitation tape.

This patient is in respiratory failure and also bradycardic. Initial provider impressions are Respiratory Arrest/Failure (RARF) and Cardiac Dysrhythmia (DYSR). The patient should be managed with TP-1237-P Respiratory Distress and TP-1212-P Cardiac Dysrhythmia – Bradycardia.

Even though the patient is longer than the length-based resuscitation tape, pediatric protocols apply because of his age. Pediatric patients in the prehospital setting are defined as “children 14 years of age or younger or, in the case that the age is unknown, the patient can be measured on the length-based resuscitation tape” (MCG 1350). This patient’s age is known, and he is ≤ 14 years old so he should be treated with pediatric protocols. Medication dosing will be the same as adult dosing due to his size.

It is critically important that immediate ventilation with high flow oxygen is performed because respiratory failure is the most common cause of bradycardia in pediatrics and hypoxia is a potential reversible cause of the patient’s cardiac dysrhythmia

There is no improvement in the patient’s bradycardia after one minute of bag-mask ventilation. Because the patient has persistent poor perfusion with ALOC, chest compressions are initiated and epinephrine administered per TP-1212-P Cardiac Dysrhythmia – Bradycardia. Base Contact is required for respiratory failure as well as symptomatic bradycardia. Normal Saline 20mL/kg IV rapid infusion is initiated for poor perfusion pending Base Contact.

This is a critically ill child in respiratory failure with a cardiac dysrhythmia and poor perfusion. The patient is likely peri-arrest. Base direction should focus on obtaining a brief clinical picture of the patient and initiating interventions per protocol for immediate resuscitation. The Base should ensure that airway management has been optimized. If there is any evidence of poor ventilation with bag-mask, consideration should be made for placing an advanced airway. For pediatric patients, chest compressions and epinephrine should be given for heart rates <60 bpm in patients with persistent poor perfusion and ALOC, even if they have a pulse. This differs from the adult bradycardia treatment protocol. Outcomes are better for bradycardic children who receive CPR prior to progressing to pulseless arrest1,2, so Base medical direction should confirm that chest compressions have been initiated. Once airway management, chest compressions and epinephrine have been administered, consider other contributing factors that may have led to bradycardia. This may include hypoxia, hypotension, hypoglycemia, and hypothermia. Identify and treat any of these underlying conditions. In addition, if there is suspected AV block or the patient does not improve after epinephrine, Atropine (0.1mg/mL) 0.02 mg/kg IV/IO push can be administered. Considerations can be made for TCP. Consider Base Physician consultation for further guidance.

The Base confirms airway management, chest compressions and epinephrine administration. An i-gel is placed to optimize oxygenation and ventilation. Base physician consultation recommends continued chest compressions, epinephrine every 3-5 minutes and transport to the PMC for cardiac dysrhythmia per Ref. No. 510. Paramedics initiate transport. Despite airway management, treatment of poor perfusion/hypovolemia with Normal Saline, and confirming hypoglycemia and hypothermia are not underlying causes, the patient goes into cardiac arrest en route to the PMC. The initial rhythm is PEA, then asystole.

High quality chest compressions should be continued. Another dose of Epinephrine (0.1mg/mL) 0.01mg/kg IV/IO is administered. Normal Saline is continued. Underlying causes are considered to include hypoxia, hypovolemia, hyperkalemia, hypothermia, toxins, and tension pneumothorax. Hypoxia and hypovolemia are common causes of non-shockable arrest in children, so airway management and volume resuscitation should remain high priorities.

Paramedics arrive at the PMC with the patient in cardiac arrest. In the Emergency Department cardiac arrest resuscitation continues. After a prolonged resuscitation, ROSC is achieved. The patient is admitted to the ICU with targeted temperature management and placed on ECMO due to refractory shock after cardiac arrest. The patient is discharged home after a 3-week hospital admission with continued outpatient rehabilitation.

      1. Pediatric patients are defined as children 14 years of age or younger. Even if they are longer than the length-based resuscitation tape, they should be treated according to pediatric protocols as treatment sometimes differs between children and adults. For patients longer than the length-based resuscitation tape, medication dosing will be the same as adults due to patient size.
      2. Chest compressions should be initiated for bradycardic children if poor perfusion is persistent and associated with ALOC despite ventilation with high flow oxygen. In this situation, with all three sides of the Pediatric Assessment Triangle abnormal, the patient is cardiopulmonary failure and should be treated as an impending cardiac arrest. Outcomes are better for bradycardic children who receive CPR prior to progressing to pulseless arrest.


  1. Khera R, Tang Y, Girotra S, Nadkarni VM, Link MS, Raymond TT, Guerguerian AM, Berg RA, Chan PS; on behalf of the American Heart Association’s Get With the Guidelines-Resuscitation Investigators. Pulselessness after initiation of cardiopulmonary resuscitation for bradycardia in hospitalized children. Circulation. 2019;140:370–378.
  2. Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16)S2: S469-S523

Author: Denise Whitfield, MD, MBA