Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

2020 ACLS Repeats the Mistakes of 2015 ACLS



The International Liaison Committee on Resuscitation (ILCOR) has updated the ACLS (Advanced Cardiac Life Support) recommendations by making excuses for the evidence.


We have been using epinephrine for 50 years without evidence of improved outcomes that matter to patients.


A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest (Paramedic2) shows that epinephrine does not improve outcomes for prehospital patients.


In conclusion, in this randomized trial involving patients with out-of-hospital cardiac arrest, the use of epinephrine resulted in a significantly higher rate of survival at 30 days than the use of placebo, but there was no significant between-group difference in the rate of a favorable neurologic outcome because more survivors had severe neurologic impairment in the epinephrine group.


Rather than limit treatments to those with high quality evidence that they improve outcomes that matter to patients, the recommendation is to keep giving epinephrine, because eventually someone might provide something – anything – to support epinephrine.


What about amiodarone?


Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest (ALPS) showed that amiodarone also does not improve outcomes.


Conclusions Overall, neither amiodarone nor lidocaine resulted in a significantly higher rate of survival or favorable neurologic outcome than the rate with placebo among patients with out-of-hospital cardiac arrest due to initial shock-refractory ventricular fibrillation or pulseless ventricular tachycardia.


If amiodarone was mentioned, I missed it. Both epinephrine and amiodarone had large placebo-controlled research results released showing that the outcomes are worse with epinephrine and worse with amiodarone.


There is still no evidence that any ventilation produces better outcomes than compression-only resuscitation, but it looks like the intervention will continue to be recommended.


In the absence of evidence of benefit, inadequately tested interventions should be avoided.


The goal is to protect the patients, not to protect the interventions.



Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19 – April 9, 2020

All of the revised guidelines are at the end.

Treatment of cardiac arrest in the time of a pandemic requires changes to the ACLS (Advanced Cardiac Life Support), PALS (Pediatric Advanced Life Support), and NRP (Neonatal Resuscitation Program) guidelines. These were written specifically for COVID-19, but would apply just as well to any other pandemic with the possibility of aerosolized respiratory transmission.

Who is making these recommendation?

From the Emergency Cardiovascular Care Committee and Get With the Guidelines®-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nurses and National EMS Physicians[1]

Why are these recommendations being made?

Hypoxemic respiratory failure secondary to acute respiratory distress syndrome (ARDS), myocardial injury, ventricular arrhythmias, and shock are common among critically ill patients and predispose them to cardiac arrest,5-8 as do some of the proposed treatments, such as hydroxychloroquine and azithromycin, which can prolong the QT.9 With infections currently growing exponentially in the United States and internationally, the percentage of cardiac arrests with COVID-19 is likely to increase.

Healthcare workers are already the highest risk profession for contracting the disease.10 This risk is compounded by worldwide shortages of personal protective equipment (PPE). Resuscitations carry added risk to healthcare workers for many reasons. First, the administration of CPR involves performing numerous aerosol-generating procedures, including chest compressions, positive pressure ventilation, and establishment of an advanced airway. During those procedures, viral particles can remain suspended in the air with a half-life of approximately 1 hour and be inhaled by those nearby.11 Second, resuscitation efforts require numerous providers to work in close proximity to one another and the patient. Finally, these are high-stress emergent events in which the immediate needs of the patient requiring resuscitation may result in lapses in infection-control practices.[1]

Will the changes decrease chances of successful resuscitation?

Yes. That is unavoidable, but DNRs (Do Not Resuscitate orders) and POLSTs (Physicians Orders for Life Sustaining Treatment) also decrease the chances of successful resuscitation. These changes are still the right thing to do.

How do these changes decrease the chances of successful resuscitation?

There is more focus on successful intubation – at the expense of continuous chest compressions. Chest compressions definitely improve outcomes, while there is no evidence that intubation improves outcomes – and there is evidence that intubation decreases successful resuscitation.

Prioritize oxygenation and ventilation strategies with lower aerosolization risk

● Use a HEPA filter, if available, for all ventilation
● Intubate early with a cuffed tube, if possible, and connect to mechanical ventilator, when able
● Engage the intubator with highest chance of first-pass success
● Pause chest compressions to intubate
● Consider use of video laryngoscopy, if available
● Before intubation, use a bag-mask device (or T-piece in neonates) with a HEPA filter and a
tight seal
● For adults, consider passive oxygenation with nonrebreathing face mask as alternative to bagmask device for short duration
● If intubation delayed, consider supraglottic airway
● Minimize closed circuit disconnections[1]

The AHA is now telling us to stop compressions to help minimize the number of intubation attempts, but not because intubation is going to improve outcomes for the patient. This is to protect everyone near the patient from aerosolized infectious material. An endotracheal tube with a HEPA filter is not an absolute protection, but intubation with a HEPA filter is probably best at preventing spread of aerosolized infectious material than other methods of ventilation and probably even better than passive ventilation (compression only resuscitation with a mask over the patient’s mouth).

Because our patients will now have a lower chance of a good outcome (being resuscitated with good brain function), we should also be more selective about whom we attempt to resuscitate. Too many of us have only been going through the motions, because we have refused to recognize futility, or our medical directors have refused to let us recognize futility.

Even though this lower chance of a good outcome is still better than before we focused on chest compressions, more patients should not have resuscitation attempted.

Consider resuscitation appropriateness

● Address goals of care
● Adopt policies to guide determination, taking into account patient risk factors for survival [1]

The other import consideration is the transport of family members.


o Family members and other contacts of patients with suspected or confirmed COVID-19 should not ride in the transport vehicle.
o If return of spontaneous circulation (ROSC) has not been achieved after appropriate resuscitation efforts in the field, consider not transferring to hospital given the low likelihood of survival for the patient,17 balanced against the added risk of additional exposure to prehospital and hospital providers.[1]

Unfortunately, footnote 17 is to page 16 of CARES (the Cardiac Arrest Registry to Enhance Survival), which is about using CARES in Ohio. I suspect that this was meant to refer to something else, so the wrong citation was provided in the rush to get new guidelines on line quickly.

17. CARES: Cardiac Arrest Registry to Enhance Survival. 2018 Annual Report.


Below are all of the new AHA algorithms (they are also available in PDF format at

AHA – COVID-19 Recommendations – BLS Healthcare Provider Adult Cardiac Arrest Algorithm [1]

Click on the image for full size.

AHA – COVID-19 Recommendations – ACLS Cardiac Arrest Algorithm [1]

Click on the image for full size.

AHA – COVID-19 Recommendations – BLS Healthcare Provider Pediatric Cardiac Arrest Algorithm for 2 or More Rescuers [1]

Click on the image for full size.

AHA – COVID-19 Recommendations – BLS Healthcare Provider Pediatric Cardiac Arrest Algorithm for the Single Rescuer [1]

Click on the image for full size.

AHA – COVID-19 Recommendations – PALS Pediatric Cardiac Arrest Algorithm [1]

Click on the image for full size.


[1] Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With the Guidelines®-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nurses and National EMS Physicians.
Edelson DP, Sasson C, Chan PS, Atkins DL, Aziz K, Becker LB, Berg RA, Bradley SM, Brooks SC, Cheng A, Escobedo M, Flores GE, Girotra S, Hsu A, Kamath-Rayne BD, Lee HC, Lehotzky RE, Mancini ME, Merchant RM, Nadkarni VM, Panchal AR, Peberdy MAR, Raymond TT, Walsh B, Wang DS, Zelop CM, Topjian A.
Circulation. 2020 Apr 9. doi: 10.1161/CIRCULATIONAHA.120.047463. [Epub ahead of print]
PMID: 32270695

Free Full Text from the American Heart Association in PDF format

This page is the abstract from the American Heart Association. It has a tab for PDF/EPUB, but the link only provides the PDF link above.


Pedi-U – Summertime Fun and Illness and Death

On this Pedi-U podcast, Dr. Lou Romig, Dr. Peter Antevy, Chris Cebollero, Russell Stine, Kyle David Bates, and I discuss pediatric heat emergencies.[1]

How much of a problem are heat emergencies? Can’t we just give them a Gatorade and have them sit in the shade and cool off? If the price of oil were increasing as quickly as the death rate from heat emergencies is increasing, we would see politicians grandstanding about special investigations into speculators and manipulation and there would be lynch mobs.

OK, we do have that with the price of oil. But there is a similar increases in the deaths of children, but there does not appear to be any similar effort to try to stop this continuing increase in the heat-related deaths of children?




Nationally, an estimated 54,983 (95% CI=39995, 69970) patients were treated in U.S. emergency departments for exertional heat-related injuries from 1997 to 2006. The number of exertional heat-related injuries increased significantly from 3192 in 1997 to 7452 in 2006 (p=0.002), representing a 133.5% increase. The overall exertional heat-related injury rate per 100,000 U.S. population more than doubled from 1.2 in 1997 to 2.5 in 2006 (p=0.005).[2]

Go listen to the podcast.

Patients aged ≤19 years accounted for the largest proportion of exertional heat-related injuries (47.6%).[2]

This is definitely an important pediatric care problem.

The majority of exertional heat-related injuries were associated with performing a sport or exercising (75.5%) and yard work (11.0%).[2]

EHI (Exertional Heat-related Injuries) suggests some sort of physical activity and we tend to assume that this is some extreme exertion. That is a mistake.

We need to consider the environment and the physical condition of the person exposed to that environment.

If a child is left in a car seat in the back of a car, is that child at high risk for Exertional Heat-related Injuries?


If you disagree, I assume that you do not have any children. Try to get a child to sit still when you strap the child into a car seat. We need to distract the child from the restraint. The same would be true for adults, if we were to strap them into car seats of the style used for children.

The child is in a warm environment. That environment is rapidly becoming hot, then extremely hot.

Sitting in the sun for only 10 minutes, the time it takes to get a cup of coffee at Starbucks, we can expect the temperature will rise by about 20 degrees. If it is in the 80s, with a nice comfortable breeze, the temperature in the car will rise to over 100 degrees in 10 minutes. We are comfortable outside of the car, but the child is trapped inside the car inside the oven where we left him/her to baking.

This child is no Thanksgiving turkey, where we are worried about cooking to the proper temperature to kill off salmonella. This is just a family member, who will be dead long before any salmonella would.

Oh, but I cracked the window to let the heat out.

Save that pathetic epitaph for someone more gullible than me.

“Cracking” the windows had little effect[3]

The child is uncomfortable.

Uncomfortable people squirm and try to get away from what is making them uncomfortable.

This is exertion.

The child will keep trying this until the child is exhausted. Physical activity to the point of exhaustion is what is happening. go run a marathon in this kind of heat. That is the kind of activity that this child is engaging in – right up until collapse.

This is exertion.

Children’s thermoregulatory systems are not as efficient as an adult’s and their body temperatures warm at a rate 3 to 5 times faster than an adult’s.[3]

So, not only are these children less capable of dealing with heat, but we are putting them in an environment that magnifies the heat they are exposed to.

Children that have died from vehicular hyperthermia in the United States (1998-2010) have ranged in age from 5 days to 14 years. More than half of the deaths are children under 2 years of age.[3]

But –

There is some good news.

The majority of patients (90.4%) were treated and released from the emergency department.[2]

If we cannot prevent the heat stroke (or whatever degree of illness), then many do seem to be able to be safely discharged from the emergency department.

This is not like discharging a patient from the trauma center the same day.


With heat emergencies, this does NOT mean that there was no real emergency.


This just means that children can recover quickly with prompt and aggressive treatment.

Go listen to the podcast.


Read the Fact Sheet.


[1] Summertime Fun! Episode 9
Podcast with learning objectives

[2] Exertional heat-related injuries treated in emergency departments in the U.S., 1997-2006.
Nelson NG, Collins CL, Comstock RD, McKenzie LB.
Am J Prev Med. 2011 Jan;40(1):54-60.
PMID: 21146768 [PubMed – indexed for MEDLINE]

Free Full Text PDF Download from Prepared Patient Forum

[3] Hyperthermia Deaths of Children in Vehicles
by Jan Null, CCM
Department of Geosciences, SFSU
Updated June 13, 2011
Fact Sheet


A Comment on A Pediatric Bag Separate From the Adult Gear

In reply to 9-ECHO-1 and to my post A Pediatric Bag Separate From the Adult Gear, was this comment from jim emt-p.

You all have made good points but you can not carry everything you could possibly need in one bag unless its the size of a truck.

Possibly need or practically need?

If we find that we need much more than is in the truck, we can call for help. We are supposed to do so early, to anticipate our needs, rather than wait until they are unavoidable and then panic, but there are some who do seem to love to create these panic situations. These are the adrenaline junkies. I am more of a relaxation junkie. I want to show up and calm everyone down, not make everything worse. I am not suggesting that jim emt-p is different from me, just pointing out that this is the SOP for some people.

There is a standard set of pediatric gear that is carried.

Airway gear that includes one, or more, pediatric laryngoscope handles. Redundancy is good, but we already should have at least one adult laryngoscope handle. If I have to give up one type of handle, I would give up the adult handle.

We tend to want to use the handle as a lever, to pull back on it like a slot machine arm. This is not good.

Using the adult laryngoscope handle with a pediatric laryngoscope blade might encourage us to apply adult leverage to the airway, even though we should not be using the laryngoscope as a lever. I would rather have people being more gentle with the adult airway, than more forceful with the pediatric airway. We tend to apply too much force to the adult airway to make up for not applying enough skill and understanding of the airway anatomy.

I would be comfortable with one adult and one pediatric laryngoscope handle in the intubation kit. If a second extra handle is needed, we can save weight by making it another pediatric handle. This might get some of us to understand what parts of our equipment are interchangeable.

Also in the airway kit would be a bunch of little OPAs (OroPharyngeal Airways) and NPAs (NasoPharyngeal Airways). They don’t take up much room and they weigh almost nothing.

We have a first in bag that has O2, trauma supplies, airway kit adult and pedi, AED, and BVM,

I would refer to that as an oxygen bag or an airway bag. Trauma supplies are similar to pediatric supplies. Both are light. So a bunch of bandages can make anything a trauma bag.

What about IVs?

Any time I am thinking about IVs with a trauma patient, I am considering giving medications, so I would want the rest of my drugs and not just an airway bag. Trauma patients tend to have a lot of pain. We can safely manage pain with a variety of medications.

then we have a med bag with all meds and IV supplies and a pedi wheel

I do not see the benefit of a pedi wheel.

Estimating Weight
In the out-of-hospital setting, a child’s weight is often unknown, and even experienced personnel may not be able to estimate it accurately.74 Tapes with precalculated doses printed at various patient lengths have been clinically validated74,77,95 and are more accurate than age-based or observer (parent or provider) estimate-based methods in the prediction of body weight.70–77 Body habitus may also be an important consideration.70,72,78,79

Unless we have an accurate weight, we are basing our calculation on a number that is probably wrong. GIGO Garbage In = Garbage Out. If it is important to calculate the dose correctly, and the child’s weight is an important part of that calculation, then the best way to come up with an accurate dose is to avoid entering a guess into the calculation. A length-based resuscitation tape is the recommended way to do that and I agree with that recommendation.

Endotracheal Tube Size
Length-based resuscitation tapes are helpful and more accurate than age-based formula estimates of endotracheal tube size for children up to approximately 35 kg,77,95,96 even for children with short stature.97

and we have a pedi bag. It is geared with equipment that is for pedis infants and neonate pt only. We have an OB kit in this bag also because most people forget that a preg. female can turn into multiple pts real quick.

How much of that pediatric gear is just duplicating adult gear and how much is unique pediatric gear that takes up significant space?

Very little extra space is needed for the pediatric gear. The pediatric gear takes up about the same amount of space as the OB (OBstetrical) kit. Not enough to need a separate bag.

We can work with 2 bags but three is a lot better.

That can be just a matter of personal preference, if we bring all of the bags with us on every call. The problem is that some people do not bring all of the ALS gear on every call. When working out of a fly car, that means that we cannot even go back to the car to get the gear until after we are returned to the scene, which may be several calls later. Some of these calls may be pediatric calls and if that pediatric gear is still in the fly car, what do we do for our pediatric patient with nothing but adult gear?

But I do agree that airway kits should cover all ages and med bags cover all ages.

If we already have most of the pediatric equipment with us, why not add the little bit of pediatric equipment that is not airway?

Even the IO (IntraOsseous) needles/gun are now part of the adult equipment. That leaves the pediatric doses of bicarb and dextrose, which we can make on out own out of the adult containers by eliminating half of the contents and replacing with saline out of an IV bag. Instant half strength medication. Not instant, but not that much longer. If i cannot measure half of a pre-filled syringe, than I should not be giving medications to any pediatric patients.

Now that said to help keep from getting caught in a bad situations, expect the worst on every run.

I agree.


[1] Estimating Weight
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 14: Pediatric Advanced Life Support
Emergency Fluids and Medications
Free Full Text from AHA with link to Free Full Text PDF

[2] Endotracheal Tube Size
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 14: Pediatric Advanced Life Support
BLS Considerations During PALS
Free Full Text from AHA with link to Free Full Text PDF

Schools and Asthma/Anaphylaxis

The Asthma and Allergy Foundation of America (AAFA) has recently released its report on school health policies,[1] specifically focusing on asthma and anaphylaxis. Anaphylaxis is the fancy word for life threatening allergic reaction. Not the rash. Not the itching. Not the minor complaints.

Life threatening.

Dramatically lower blood pressure and/or significant difficulty breathing. These may never have happened before in this person. My favorite questions to ask are:

1. Has this ever happened before.

2. If so, what happened then?

3. What seemed to help?

4. What didn’t seem to help?

5. How does this feel compared to previous episodes? Better? Worse?

One of the nice things about anaphylaxis is that you can usually diagnose it from across the room. This is not a subtle presentation.

Their report shows a lot of good information about how schools are handling the ability of children to treat themselves. There is no good reason for a child to have to wait for a teacher to determine that they are sick enough to go to the school nurse to get their EpiPen.[2] What if the school nurse is not available? On 911 calls there is often no school nurse on the premises, since the nurse may be assigned to cover several schools at the same time.

This change in the approach to self-medication by children with chronic, but potentially life threatening, illnesses is a good thing.

I responded to a middle school that did not allow children to carry their medication. A child was having a severe asthma attack. Fortunately, the school nurse was authorized to administer an EpiPen injection. When I arrived, he was looking as if he was ready to stop breathing. Uh oh! The number one get your BVM and intubation kit out indicator. The school nurse had just given him an injection from a pediatric EpiPen (or EpiPen Jr). He was stating that he felt that his breathing was improving. Time to reassess and provide some oxygen and decide between albuterol and benign neglect. If I remember correctly, he received benign neglect, since his breathing was good. He actually was soon complaining more about the side effects, than the respiratory distress. Respiratory distress that almost ended with him intubated, or even in cardiac arrest. The difference can be just a matter of a couple of minutes. And some epinephrine.

Photo credit

Here is a video on using an EpiPen. I looked at a bunch of videos. Most had something good about them, but none were great. This seemed like the best one.

EpiPen now appear to be sold in packs of 2, so that you have another on hand if the anaphylaxis or asthma does not respond to one dose, or if EMS is not readily available.

Here are a couple of other descriptions of the use of EpiPens in life threatening situations. The CNN article states that it is only for anaphylaxis. No. An EpiPen is appropriate for severe asthma, too. Of course, I have pointed out that CNN needs a medical correspondent, who does a responsible job of vetting medical news, or even responding to complaints about completely false information. The LA Times article is by a professor of medicine.[3] The CNN article does not list any medical qualifications.[4] Why include the CNN article? Stories help us to understand what presentations might be like, to anticipate variations in these emergencies.

I have been dispatched to plenty of patients, who had used EpiPens. I have not yet had to treat any of them. Sometimes medical command insists that the patient receive diphenhydramine (Benadryl) and/or fluids, but not because the patient needs it, because it is in the protocol.

There is also a video about FDNY BLS ambulances finally being issued EpiPens.[5] This should not be news. Fire Commissioner Nicholas Scoppetta demonstrates a horrible lack of understanding of math. He states:

At a price tag of more than $96,000, Scoppetta says it will be money well spent.

“This is a terrific investment. If you save the life of one child who goes into shock, it pays for itself 1,000 times over,” said Scoppetta.

One life = $96,000 a thousand times over? Easy math. That is $96 million per save. 2 full time EMTs combined make less in a year than the cost of the whole program $96 thousand.

At a price of $96 million per life saved, even NYC would not be able to afford to keep this program running. Or, this might explain why their resuscitation rate is so low./


1 2009 State Honor Roll
Annual Report of State Asthma and Allergy Policies for Schools
– Updated Report Features New “Honorable Mention” States that Made Progress in 2009
The Asthma and Allergy Foundation of America (AAFA)
Web Page with links to plenty of resources.

2 EpiPen® and EpiPen® Jr (0.3 and 0.15 mg epinephrine) Auto-Injectors
Web page.

3 The highly allergic should keep an epinephrine shot close by
For some, a bee sting can be fatal, so learning to self-administer the injections — and having one on hand when traveling — can be a life saver.
Los Angeles Times
In Practice
By Claire Panosian Dunavan
September 7, 2009

4 Allergy injectors are ‘liberating and daunting’
By Elizabeth Landau
updated 9:11 a.m. EDT, Fri September 4, 2009

5 All FDNY Life Support Units To Carry Epi Pens
04/04/2009 01:11 PM
By: NY1 News
Article and Video


Not Successful Resuscitation

Here is another Normal Sinus Rhythm post. The topic this week is kids, so it should be interesting what different people write about, since this is one of the few calls that almost everyone in EMS dreads. Read the rest of the NSR Blog posts at NSR Week 7.

EE at Backboards and Band-Aids writes the messenger.

Her posts are usually very brief. Here she shows that she really knows how to write when she has a little more to communicate.

Telling someone that a loved one – spouse/parent/child/fiance/. . . – is dead is very difficult to do. I prefer to be the one to tell people, not because I do it so well, but because I have seen it done so badly.

I have always hated the phrase, “I’m sorry for your loss.” It sounds like a Hallmark card for a stranger you’ve never met. What happened? “Passed on,” “Sorry for my loss,” “No longer in pain,” “No longer with us,”. . . . We ask too much of the family member when we provide vague descriptions of what is going on. Unless we use the words “is dead,” or “has died,” we aren’t helping them to recognize what has happened. These are attempts to say the right thing, but they just seems so far from adequate, at least to me.

That does not mean that we rush to say, “She’s dead. Gotta go,” and leave. That is not at all the right approach.

I prefer to lead them to recognize death themselves. A more gradual approach, but I am not in a rush to get back in service. I just acquired a bunch of potential patients, who may not need anything medical from me. They may need someone to yell at, someone to hold, someone to just be a connection to reality in this unreal time. Until someone they feel more comfortable with shows up. No. I do not remove family from the room, unless they are interfering with care, which is extremely rare.

We are performing CPR. One hand compressions on the center of the sternum (breast bone), about 1/3 the depth of the chest. At least 100 per minute as the compression rate. Compressions on a child, you will probably be compressing too quickly, but try to get an idea of the rate. Compressions should produce a femoral pulse (felt by someone else), so if not maybe that is a clue about a reversible cause of cardiac arrest, or you aren’t compressing deeply enough, possibly out of fear of hurting the child. The child will let you know if you are causing physical pain, but that is not going to happen with a properly assessed cardiac arrest. Too deeply would be where you feel the sternum hitting the spine. Until the tube is in place, compressions are paused after every 15 compressions for 2 breaths. After the tube is in placed and confirmed to be in the right place, there is no reason to pause for breaths, just every couple of minutes for reassessment and/or defibrillation.

What does that mean to the family? They see it on TV and frequently the person on the receiving end of CPR survives. This is not typical, but appears to be more common with switching to compression only CPR.

So, we are performing CPR, after we obtain relevant medical information, we can explain why we do CPR.

This is part of the way through the treatment of the cardiac arrest (and cardiac arrest is not a term that is helpful for family).

RM – “Her heart is not beating on it’s own, so we are trying to keep blood moving to her brain and heart.”

Mom – “She was just in Emergency this morning and the doctor said she was fine.” (This is information we already knew, but it is her attempt to deny what is happening.)

RM – “She is not breathing on her own, so we are trying to keep some air moving to her lungs.”

Mom makes more statements of not comprehending what is happening.

The police want to talk with her because this is unusual. An otherwise healthy 7 year old, who attends a regular school, has no medical history, and was seen in the ED less than 12 hours ago. This child should not be dead. All medications in the home have been accounted for, she has not been out of the sight of her mother since going to the ED for a high fever, with weakness, nausea, and decreased appetite.

While Mom is talking with the police, I contact medical command at the ED where she was seen. The doctor who saw her has gone for the day and nobody there knows anything about her. I explain that the patient has no history prior to today/late last night and that when we arrived she was asystolic (flat line, no electrical activity of any kind in the heart), pulseless (no pulse), and apneic (no breathing). We follow the standard asystole treatments and there is no indication that she has any of the potentially reversible causes of cardiac arrest (the doctor is able to pull up her labs on the computer and everything is normal, including her potassium – hypokalemia, or low potassium, is one of the reversible causes of asystole; vomiting could cause this, but she has not been vomiting, nor has she been taking much in). The potentially reversible causes are listed at the end of the post.

Her blood sugar was very low, so some D25W (25% Dextrose in Water or concentrated sugar water) is given through an IV. Aspirate a little bit (pull back with the syringe to make sure blood returns, so that we are confident that the IV is in the vein and not leaking), push about 5 ml, look for signs of infiltration (a bulge under the skin that indicates the fluid is leaking out of the vein and under the skin), aspirate again, push D25W again, and repeat until 1 g/kg is in. Or use a length based resuscitation tape, which I wrote about in More Bad Airway Instruction. And everybody dead gets epi, so 0.01 mg/kg epinephrine, and repeat epinephrine every 3 – 5 minutes. Atropine would be appropriate – if she were an adult, but she is not.

I never get another chance to let her come to the realization her daughter has died, but it is unlikely she would, no matter how much time I spent trying to get her to see something she can’t yet accept.

We exhaust the asystole algorithm and medical command says to cease efforts. She had been febrile in the ED, but is cool to the touch when we arrive, not cold, just not really warm either. Mom never really does seem to understand what has happened, still keeps expecting her daughter to meet her, sick, but recovering, in the ED. Not an example of when I was able to persuade a family member to recognize the futility of a resuscitation attempt, but children are different. How do we react to the death of a child? Would we react any more logically if it were our child, or little brother/sister?

The potentially reversible causes of cardiac arrest use 5 H’s and 5 T’s to help remember them [this is how PALS (Pediatric Advanced Life Support) teaches memorizing this].



Hydrogen ion (Acidosis).




Toxins (Drugs).

Tamponade, cardiac.

Tension pneumothorax.

Thrombosis (coronary or pulmonary – AMI or PE).


This list is supposed to make it easier to remember the potentially reversible causes when under stress. I recommend memorizing them in a way that works for you. The H and T list does not work for me. Once I get up to three or more items, it becomes hard to remember how many I have covered. I also recommend carrying a cheat sheet that includes cardiac arrest algorithms, especially pediatric, until you feel that you have run enough of these codes, without errors, that you no longer need the cheat sheet.

I have changed this from what I originally wrote. My, borrowed from Jeff B of JB on the Rocks, mnemonic (memory aid) for the potentially reversible causes of cardiac arrest is now two words – COLD PATCHeD. There are others, but this is what I intend to use from now on – at least until somebody convinces me that there is a better mnemonic. Find what works for you, modify it as necessary, and use it regularly. Teaching helps to drill this into my head.

C – COLD reminds you that the C is for hypothermia – being very cold, sometimes we forget the obvious in resuscitation attempts, so it doesn’t hurt to put extra reminders in a mnemonic.

O – Oxygen deficit or hypoxia.

L – Lytes. This works better as a mnemonic for the in hospital crowd, but there is nothing wrong with getting EMS to think more about electroLytes. Hypokalemia and Hyperkalemia – too little and too much potassium.

D – Drugs (OverDose, poison, wrong drug, wrong dose, . . .).

P – PE (Pulmonary Embolus).

A – Acidosis and AMI (Acute Myocardial Infarction).

T – Tension Pneumothorax.

C – Cardiac Tamponade.

H – Here it is now much less confusing, only 2 Hypos.

HypoVolemia and HypoGlycemia.

e – Everybody dead gets Epi. Just a reminder to continue CPR and other treatments – don’t forget the basics.

D – Distributive Shock.

I will have to write a post on why these categories matter, what the treatments are, and other ways to approach them, rather than the order of the mnemonic. This is a lot for one post and a not at all cheerful one.

All of the treatments listed are following the current recommendations of the AHA (American Heart Association) . These are links to the free full text of all of the current AHA guidelines.

Circulation, Volume 112, Issue 24 Supplement; December 13, 2005.

Part 11: Pediatric Basic Life Support.

Part 12: Pediatric Advanced Life Support.

Figure 1. PALS Pulseless Arrest Algorithm image.

TABLE 1. Medications for Pediatric Resuscitation and Arrhythmias.


A Pediatric Bag Separate From the Adult Gear


Why do some squads carry their ALS pediatric gear in a separate bag?

Most claim that kids are special and need their own special bag for their own special equipment. They do need special equipment, but it doesn’t need to be stored separately, unless you want to find out how to try to force adult equipment into a small child or infant. This will not go smoothly.

Kids are not just little adults, but the best way to deal with this is to train, get experience treating children, focus on the basics, and have the pediatric equipment available when bad things happen unexpectedly.

But some squads carry all of their ALS pediatric gear in a separate bag.

The pediatric endotracheal tubes, pediatric laryngoscope blades, IO (IntraOsseous) needles, meconium aspirator, and the length based resuscitation tape[1] weigh about a pound.

There is no good reason to separate airway equipment intothe stuff you have when you need it and the stuff that you left in the truck.

What about pediatric dextrose and pediatric bicarb?

You can take an adult syringe (50 ml) of either drug and squirt half out, from a bag of saline draw up enough to return the volume to 50 ml. Tada! Half strength dextrose or half strength bicarb. You can administer this the way the length based resuscitation tape directs for D25W and for 4.2 % Sodium Bicarbonate (adult concentration is 8.4%).

You don’t even need to be good at math to do this. Waste half of the syringe. Refill the part you wasted with saline from an unused IV bag of normal saline (0.9 % saline in water).

What about the difference in cost? The adult syringe contains so much more than the pediatric syringe. You must be wasting a lot of money.

The adult 50 ml syringes cost about the same amount as the pediatric 10 ml syringes. There is extra cost for the IV bag, but you can have that bag running into the child and then there is no extra cost. Or were you planning on giving these very slow IV push, with intermittent aspiration to assure patency, drugs without an IV present?

But the syringe is so much bigger and the markings are much less accurate.

You can clean the plunger with alcohol and use a 10 ml syringe with a needle to draw the amount you need out of the 50 ml syringe. Or you can give a little less than the indicated dose – you can always give more.

So, why do some squads carry all of their ALS pediatric gear in a separate bag?

“Kids are easy to take care of and they can wait until we get to the truck to do that stuff.”

“Carry almost an extra pound? Are you trying to kill ME?”

“I’m so good, I can get away with anything.”

“It’s all in how you document it.”

“We know what we need because dispatch tells us.”

“Like medical command is going to find out?”

So, the 60 year old difficulty breathing patient really is 6 years old and somebody made a mistake about the age, that never happens?

The unknown adult emergency would never really turn out to be a child?

Or, you work in a fly car system and the burned out idiot you relieve never brings the pediatric gear on adult emergencies. When you meet that medic at the hospital, he never has the pediatric bag. Why would he need to? You are protected by a magic force field that prevents you from receiving pediatric calls until you get back to the truck.

Every time you put pediatric gear in the “adult” bag, burned out idiot removes it. Management refuses to act. Nobody at the hospital thinks it is worth doing anything about.

The good news was that the little kid already had extensive rigor mortis.

Updated footnote 02-27-11.


[1] I wrote about the length based resuscitation tape here, and not yet about the rest:

More Bad Airway Instruction.


More Bad Airway Instruction.

Entertainment from PALS (Pediatric Advanced Life Support) classes?

How about pediatric intubation?

Kids are pretty scary, especially when they are really sick.

Then the idea of doing math while preparing to intubate a child is less than appealing to you?

Absolutely. Why would I want to do that?

Well, the PALS teaching includes using a formula:


Endotracheal Tube Size

The internal diameter of the appropriate endotracheal tube for a child will roughly equal the size of that child’s little finger, but this estimation may be difficult and unreliable.33,34 Several formulas such as the ones below allow estimation of proper endotracheal tube size (ID, internal diameter) for children 1 to 10 years of age, based on the child’s age:

Uncuffed endotracheal tube size (mm ID) =(age in years/4) + 4

In general, during preparation for intubation using the above formula, providers should have the estimated tube size available, as well as uncuffed endotracheal tubes that have internal diameters that are 0.5 mm smaller and 0.5 mm larger than the size estimated ready at the bedside for use.

The formula for estimation of a cuffed endotracheal tube size is as follows30:

Cuffed endotracheal tube size (mm ID) = (age in years/4) + 3 [1]


They include at least one test question to stress the importance of this.

Then in the last sentence in that section – the only sentence I did not include above – they write:

Endotracheal tube size, however, is more reliably based on a child’s body length. Length-based resuscitation tapes are helpful for children up to approximately 35 kg.35 [1]


I still get people arguing with me that the formula is more accurate than the length-based tape. They argue that the child’s airway grows at a rate determined by the formula, regardless of how quickly the rest of the body grows. The tape accounts for this difference, the formula caters to fools.

What is a length-based resuscitation tape?


This image is from the FDA Patient Safety News from October 2004 a bit more than half way down the page.[2]

You need to get a length-based resuscitation tape (Broselow or generic), become familiar with the tape, become familiar with the information that is on the tape, and use the tape a few times to feel comfortable with it.

This is a way to avoid having people calculate formulas or guess at weights when dealing with unstable children. Most doctors don’t calculate well under these circumstances. The same is true for nurses, medics, and even mathematicians. It is a very bad idea to avoid using something that simply and more accurately arrives at the answer.

Except when intubating during PALS.


Maybe they needed to get another multiple choice question for the test. Why try to explain dangerous foolishness?

Looking at the tape, you can see the Red to Head attempt to avoid confusion can be confusing in itself. There is a red section of the tape for 8 – 9 kg patients.

Nobody would make that mistake.

Nobody properly trained and supervised by competent people would, but the FDA does not look at things that way. Instead they try to require a fool proof tool. Only a fool would do that. Nobody has made the FDA fool proof.

Dr. Deborah Peel must love them, since they approach things the same way.[3],[4]

Here is what the FDA wrote:

Determining the dose of medication to give a child in an emergency can be a challenge. In most cases the dose is based on the child’s weight, and this can be very difficult to estimate. Even parents can be far off the mark when they’re asked their child’s weight. And even if the estimate is accurate, there’s the added chore of looking up the dose for a child of that weight.

Some clinicians avoid these difficulties by using a Broselow Tape, which measures the child from head to toe and uses this measurement to estimate the child’s weight, and thus the dose. The tape is divided into color-coded segments based on the child’s length, and each of the colored segments shows the approximate weight for that length child, along with the dose for commonly used emergency drugs for children of that weight. [2]


Here is one of the problems. They act as if the only way to measure the child is to start at the head and stretch the tape down to the feet. Would it be wrong, or unanticipated, to start at the fee and move to the head? What part of the body would a podiatrist start at?

The only thing that matters, whether you start at the feet or start at the head, is that the bright red/orange color on one end of the tape is the starting point. Starting at the other end of the tape is wrong – you will be using a different measurement.

You can use this tape for finding the dose of common resuscitation drugs and for finding the size of various pediatric equipment, such as an endotracheal tube.

But errors are often made using Broselow tapes. In a recent Medication Safety Alert, the Institute for Safe Medication Practices notes that the tapes can be placed alongside the child upside down, which would give the wrong length for the child and thus the wrong dose.[2]


It does not matter if the tape is “right side up,” what matters is that you start from the bright red/orange color on one end of the tape. The other end of the tape does not have this. It gets worse.

ISMP also says that the 1998 edition of the tape can be confusing in several respects, and that some of these problems were corrected in the newer 2002 version. They also point out that errors can occur if physicians wrongly assume that the listing of drugs on the tape means that they’re to be given in sequence. [2]


If you are a doctor and you don’t know anything about resuscitation get out of the way of the people who do. No amount of fool proofing will work for you. You are a danger to everyone else present. The same is true for nurses and medics who don’t know what they are doing.

If you do not know what medications to give, don’t give any medications.

If you are giving medications in the order that they are listed on the tape you are a dangerous idiot and should be bundled up and sent to Osama bin Laden as a Hanukkah present for him to torture.


I do what I can.

Of course, if you do not know the difference between the 8 – 9 kg section of the tape and the part marked MEASURE FROM THIS END, you probably don’t know what medication to give, when to give a medication, or why to give a medication.

Here are some of the measures ISMP recommends to prevent errors when using Broselow tape.

First, replace outdated Broselow tapes with the most recent edition, issued in 2002.

To prevent using the tapes upside down, hang them with the red arrow that says “Measure from this end” at the top. Teach staff to remember “RED TO HEAD” when placing the tape alongside the child’s body. [2]


And they repeat their misleading suggestion.

And if the tape is laminated in plastic, be sure the plastic doesn’t extend beyond the red arrow, which could change the measurement starting point.

For in-service training on how to properly use Broselow tapes, the Duke University Medical Center has a comprehensive programmed instruction course under its program for enhancing pediatric safety. [2]


A comprehensive programmed instruction course?

Give them the tape, let the doctors, nurses, and medics ask questions. Let them use the tape. Correct them when they make mistakes. As long as they do not resemble 2 monkeys with a football, things are pretty good.

Or is that too comprehensive for such a fine medical and educational institution.

Duke did a study that found that morphine is bad for chest pain, suggested that only NTG (nitroglycerin) should be used for the chest pain. Meanwhile, other researchers at Duke are trying to show that NTG is bad for chest pain. Does anyone at Duke communicate?

More on length based resuscitation tapes here:

A Pediatric Bag Separate From the Adult Gear

Weight based tube size here:

Bariatric Endotracheal Tubes for Adults?


[1] Endotracheal Tube Size
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 12: Pediatric Advanced Life Support
Breathing: Oxygenation and Assisted Ventilation
Free Full Text from Circulation

[2] FDA Patient Safety News from October 2004
Archived FDA Patient Safety News
Link to PDF of archived printed information from October 2004 that does not include the image in its current form.

[3] Deborah Peel is the antidote to HIPAA
Mon, 17 Mar 2008
Rogue Medic

[4] Calling Dr. Deborah Peel – Anyone Home?
Wed, 26 Mar 2008
Rogue Medic