A-B-C: The mnemonic for airway – breathing – compressions, the CPR sequence used when resuscitating a patient afterdrowning. When assessing the patient, it refers to airway – breathing – circulation.

abdominal thrusts: The procedure used to help clear an upper airway obstruction in a choking individual who is awake but unable to make sounds  

acid-base balance: The balance of acid and alkaline compounds; measured on the pH scale, an increase in acids causes a decrease in pH; an increase in alkaline compounds causes an increase in pH. The lungs and kidneys are the primary organs that work to establish acid-base balance. See respiratory acidosis, metabolic acidosis, respiratory acidosis, and respiratory alkalosis.

acrocyanosis: A bluish or purplish discoloration of the hands, feet, and distal parts of the face caused by disruptions in circulation; this condition is typically caused by decreased oxygenation to the tissues.

acute respiratory distress syndrome (ARDS): This disorder occurs when fluid builds up in the alveoli, causing the lungs not to receive enough air. In the pediatric population, it is often caused by sepsis, inhalation of substances, and severe pneumonia. With the decreased oxygen levels, less oxygen from the lungs moves into the blood, and thus less oxygen is available on the cellular level. The most common symptom is severe shortness of breath accompanied by a rapid respiratory rate and hypotension.

adenosine: Medication used as a second-line treatment for supraventricular tachycardia when vagal maneuvers have not stopped the arrhythmia; side effects include shortness of breath and hypotension.

afterload: The pressure needed by the heart to eject blood during systole. This measurement is influenced by the aortic pressure of the left ventricle and pulmonary artery pressure of the right ventricle. When afterload increases, the cardiac output decreases.

agonal gasps (agonal respirations): An abnormal respiratory pattern characterized by gasping or struggling to breathe due to a decrease in the oxygen circulating in the blood

airway obstruction: A partial or complete blockage of any of the breathing passages that lead to the lungs. Airway obstruction is usually classified as an upper or lower obstruction and can have mechanical or disease-specific causes.

airway resistance: The opposition to airflow due to friction in the airway. When airways are obstructed in the pediatric population, airway resistance increases. As lungs inflate, airway resistance typically decreases.

alternative airway: An adjunct often used to ensure the newborn is adequately ventilated. In neonates, the alternative airways typically used include the endotracheal tube and laryngeal mask.

amiodarone: Medication used to control arrhythmias, including ventricular tachycardia and fibrillation, supraventricular tachycardia, wide complex tachycardia, and atrial fibrillation. Common side effects include toxicity, visual changes, pneumonitis, and gastrointestinal symptoms.

analgesia: The loss of pain sensation from a therapeutic disruption of the neural pathways between the sensory organ and the brain  

anaphylactic shock: A type of distributive shock typically caused by an allergic reaction to an allergen present in the environment. As the body recognizes the allergen as “foreign,” histamines are released, causing vasodilation throughout the body. Signs include an increased respiratory rate, widening pulse pressure, increased heart rate, decreased urine output, and altered level of consciousness.

anaphylaxis: A serious allergic reaction to an allergen that can be deadly if not treated. Symptoms include rash, tongue or throat swelling, shortness of breath, nausea, vomiting, and hypotension. The allergen can be food, medication, an insect bite or sting, or another environmental cause.

apnea: A temporary cessation of breathing that results in no movement of air into or out of the lungs  

arrhythmia: A medical condition in which the heart beats in an abnormal rhythm. In the infant, PEA and bradycardia are the most common arrhythmias.

arterial blood gas (ABG): The measurement of pH, pCO2, pO2, and HCO3 in an arterial blood sample. Normal values in the pediatric population after the first few days of life closely mimic the range of normal adult values: pH = 7.35–7.45; PaCO2 = 27–41 mm Hg; PaO2 = 80–100 mm Hg; and HCO3 = 19–27 mmol/L.

asphyxiation: Suffocation or oxygen deprivation that may lead to death.

aspiration pneumonitis: Caused by aspiration of food, stomach acid, or liquids into the lungs, this condition causes bacteria to be transported into the lungs. If the aspirant is not cleared out of the lungs, pneumonitis and pneumonia can result. Signs and symptoms may include shortness of breath, cough and wheezing, chest pain, difficulty swallowing, fever, and cyanosis.

asthma: A common disease in the pediatric population that involves airway inflammation and airway obstruction due to bronchial hyperresponsiveness. Symptoms include cough, wheezing, chest tightness, croupy cough, and shortness of breath. Diagnosis is clinical with the addition of a chest X-ray, spirometry, and pulse oximetry as needed to exclude other forms of illness that result in hypoxemia. 

asystole: Also called cardiac standstill or flatline. In this state, the heart has stopped beating, and the patient has no cardiac output or heart muscle activity.

atelectasis: Partial or complete collapse of the air sacs when they don’t expand properly, usually caused by a blockage of air.

atrial flutter: An arrhythmia that includes various forms of atrial tachycardia and may often display a second-degree heart block as the atrial rate becomes very rapid. This rhythm is rare in pediatric patients unless the child has pre-existing congenital heart disease. In the pediatric population, this rhythm can be treated with medication, cardiac pacing, or cardioversion. In rare recurrent cases, ablation therapy or surgical procedures may be necessary.

atrioventricular (AV) block: An impairment of electrical impulses from the cardiac atria to the ventricles typically caused by a block at the atrioventricular junction. The condition can be further classified as first, second, or third degree.

automatic external defibrillator (AED): A portable device that evaluates the heart rhythm and delivers an appropriate electrical shock to the heart when a shockable rhythm is detected

autonomy: The ethical principle that the provider must respect an individual’s right to make choices. For the pediatric population, autonomy resides in the parent(s) of the child.

AVPU Pediatric Response Scale: A system used to evaluate an individual’s responsiveness quickly. The mnemonic stands for: alert (fully awake and alert), voice (responds to voice commands), pain (responds only to pain), unresponsive (does not respond to voice or pain).

beneficence: The ethical principle that the provider must act for the benefit of the patient. For the pediatric population, autonomy resides in the parent(s) of the child.

brachial artery: The main artery of the upper arm; it is one of the easiest arteries from which to assess a pulse in the pediatric population.

bradycardia: An abnormally slow heart rate for the individual’s age. In the neonate, a sustained rate < 100 bpm is considered bradycardia.

bronchiolitis: A viral respiratory disease in which the bronchioles are inflamed and infected. This condition can cause increased work of breathing and restriction of breathing.

C-A-B sequence: The current and preferred CPR sequence that teaches chest compressions, airway management, and breathing. The rationale for this order is that the individual cannot survive without circulation but can survive for a short time without additional oxygen entering the circulation.

calcium: The most abundant mineral in the body, calcium is required for cardiac contraction and vasodilation. Typically, calcium levels are held relatively constant as the body can readily pull calcium from the bones.

capillary refill time: The time it takes for color to return to a capillary bed after pressure is applied. In newborns and younger children, the pressure is often applied to the sternum for several seconds. Normal capillary refill time in the neonate is < 3 seconds; in adults and older children, the normal time is < 2 seconds.

carbon dioxide detector: A device used to detect the amount of carbon dioxide

carbon dioxide: Often represented as CO2, a colorless gas that is a by-product of respiration that occurs during normal expiration

cardiac arrest: The sudden cessation of heart function. In the neonatal population, a cardiac arrest is rarely a primary event but usually the result of deteriorating respiratory function, leading to respiratory failure and cardiac arrest. This condition is often called cardiopulmonary arrest or failure.

cardiac output: The volume of blood pumped by the ventricle each minute. Normally, this is calculated as heart rate x stroke volume. The pediatric population has a higher normal cardiac output than adults, usually as a result of the higher baseline heart rate.

cardiac tamponade: A serious but rare condition in which the heart is compressed due to fluid accumulation in the pericardial sac around the heart. The cause is usually chest trauma. Symptoms include restlessness, decreased level of consciousness, tachypnea, and sharp chest pain. Treatment will include a pericardial tap and management of blood pressure.

cardiogenic shock: Typically caused by a myocardial infarction that damages the heart muscle.  Consequently, the heart cannot pump effectively, and cardiac output decreases. As that occurs, the cells do not receive enough oxygen. Signs include increased respiratory rate, narrowing pulse pressure, increased pulse rate but reduced quality, decreased urine output, and delayed capillary refill.  

central cyanosis: Bluish or purplish discoloration of the lips and mucous membranes. Although it can be caused by certain congenital deformities, it is most often the result of decreased oxygen in the blood.

chemical pneumonitis: Inflammation of the lungs due to inhalation or aspiration of chemical irritants

closed-loop communication: A communication technique that involves the sender sending a message that is repeated back by the receiver. If the response message from the receiver is correct, the original sender returns with a “yes” message.  

coagulopathy: Impaired clotting of the blood.

commotio cordis: Refers to a death caused by an arrhythmia due to nonpenetrating chest wall impact. This is typically seen in young athletes who are struck in the chest by balls, pucks, or other sports equipment.

compression-ventilation ratio: Refers to the number of chest compressions and breaths during cardiopulmonary resuscitation. For single-rescuer situations, the ratio is 30 compressions for 2 ventilations for all ages. When two rescuers are available, the compression-ventilation ratio remains at 30 to 2 for adults but changes to 15 compressions to 2 ventilations for the pediatric population.

congenital heart disease: An abnormality or structural defect in the heart that is present before birth due to developmental abnormalities; may result in arrhythmias, cyanosis, respiratory problems, or fatigue

congestive heart failure (CHF): Characterized by severe shortness of breath, irregular heartbeat, and fatigue, CHF in adults is a heart disease often caused by coronary artery disease that leads to damage to muscles of the heart. While relatively uncommon in the pediatric population, CHF is most often caused by cardiomyopathy or congenital cardiac malformations.

continuous positive airway pressure (CPAP): A form of ventilation that applies continuous air pressure throughout the respiratory cycle to keep the airways open; typically used in individuals who can breathe on their own

coronary arteries: The blood vessels that supply blood to the myocardium. The two large coronary arteries are the left main and the right coronary arteries. The left main further divides into the left anterior descending artery, supplying blood to the left ventricle and atrium, and the circumflex artery that circles the heart and supplies blood to the outside and back of the heart.  

cricothyrotomy: An emergency procedure to establish an airway when a patent airway cannot be achieved by positioning or placement of an adjunct airway. Typically, the cricothyrotomy is only performed when the airway is completely obstructed or when a facial injury prevents the provider from establishing an airway.

croup: A viral infection of the respiratory tract that results in the narrowing of the child’s trachea. This narrowing obstructs the airway and decreases the amount of air that can be inhaled, increases the work of breathing, and results in the typical barking cough and hoarseness characteristic of the disease.  

crystalloid fluids: Fluids that are isotonic and can easily pass through semipermeable membranes. In infants, the most used crystalloids are normal saline with a concentration of 0.9% sodium chloride and lactated Ringer solution. If large volumes of fluids are required for replacement, lactated Ringer solution is often the fluid of choice.

cyanosis: A bluish or purplish discoloration of the skin due to decreased oxygen in the blood; see acrocyanosis and central cyanosis

defibrillation: The definitive treatment for ventricular tachycardia or fibrillation that consists of delivering an unsynchronized shock to the cardiac muscle using a defibrillator

diabetic ketoacidosis: One of the types of metabolic acidosis caused by a buildup of ketone bodies due to poorly controlled diabetes. Ketone bodies build up as the body burns fat instead of sugar due to the inability of the body to process sugars. Symptoms include polyuria, polydipsia, elevated blood glucose, ketonuria, nausea, vomiting, tachypnea, confusion, fruity-smelling breath, and dry mucous membranes.

disordered control of breathing: The abnormal breathing patterns typically caused by neurologic disorders or infections, brain disorders, or central nervous system infections. One of the most common symptoms other than irregular respiratory rate is a decreased level of consciousness.

distributive shock: Classification of shock that includes septic, anaphylactic, and neurogenic shock. Signs include an elevated respiratory rate, widening pulse pressure, increased heart rate, decreased urine output, and altered level of consciousness.

dopamine: A vasopressor commonly indicated for cardiogenic or distributive shock. Dopamine will increase the child’s systemic vascular resistance, heart rate, and cardiac contractility.

DOPE: Mnemonic to be used to remind the team of possible causes of respiratory deterioration after intubation (displaced ET tube, obstructed ET tube, pneumothorax, equipment failure).

ductal-dependent lesions: Cardiac abnormalities that are typically congenital and may affect pulmonary or systemic blood flow. These lesions may present with signs of pulmonary edema and congestive heart failure. The child’s skin will be cool, the level of consciousness may be altered, and respiratory effort may be inadequate.

ductus arteriosus: In the fetus, this is one of two shunts that allows blood to bypass the fluid-filled fetal pulmonary circulation. It is a blood vessel connecting the pulmonary artery to the descending aorta. Normally, this structure closes at birth. When it does not close, the condition called patent ductus arteriosus occurs with a resulting left-to-right shunt, which leads to pulmonary hypertension and cardiac arrhythmias.

E-C technique: A one-handed technique for holding a face mask on the child during ventilation. In this technique, the thumb and index finger form a “C” over the top and bottom of the mask and the other three fingers form an E by holding the child’s mandible.

echocardiogram: A noninvasive ultrasound test that evaluates the heart muscle and valves

edema: The abnormal collection of fluid in soft tissues resulting in swelling. In adults, it usually appears in the lower extremities. In the fetus, edema in fetal compartments (abdominal, pleural, or pericardial) is a severe condition that can be fatal.

ejection fraction (EF): A measurement of the amount of blood being pumped by the heart with each contraction. EF is typically expressed as a percentage, with normal being between 55% and 70%. Lower than normal EF measurements may be indicative of heart failure.

electrocardiogram (ECG): A noninvasive recording of the heart’s electrical activity in which electrodes are placed in specific locations on the patient’s skin to record activity in all areas of the heart

End-tidal carbon dioxide: Used to determine the adequacy of CPR, end-tidal CO2 is a noninvasive measurement of exhaled carbon dioxide through a capnograph. If the measurement is less than 10 mm Hg, blood flow to the lungs is decreased, and the team should assume that compressions or airway management are not optimal.

endotracheal intubation: Also called tracheal intubation; the placement of a plastic tube into the trachea to keep the individual’s airway open and provide ventilation as well as a means for administering epinephrine during resuscitation. In the infant, endotracheal intubation is always done through the mouth.  

epiglottis: An elastic cartilage shaped like a flap that overlies the glottis

epinephrine: A naturally occurring hormone that aids in regulating the sympathetic autonomic nervous system. As a powerful vasopressor, epinephrine (or adrenaline) increases blood pressure, heart rate, and cardiac output. In resuscitation, epinephrine is used as a cardiac stimulant to treat persistent bradycardia.

ET tube: A plastic tube that is used in the endotracheal intubation procedure to keep the airway patent

extracorporeal cardiopulmonary resuscitation: Known by different names (ECLS and ECMO), this is a type of mechanical circulatory support for children with cardiogenic shock that is not responsive to medical treatment. These technologies provide temporary support for cardiac output and oxygenation until definitive treatment is established.

femoral artery: The artery that supplies blood to the leg. The femoral artery pulse in the groin is one of the best to use during pediatric resuscitation.

flow-inflating bag: One of the two types of manual ventilation bags; the flow-inflating bag requires a constant flow of air into the bag. This bag is an excellent choice for neonates since the provider can maintain fine control of tidal volume. Also, see self-inflating bag.

flowmeter: An instrument that measures and regulates the rate of flow of oxygen or other compressed gasses  

fluid resuscitation: Fluids administered to restore intravascular volume and increase perfusion to the tissues. For the pediatric population, fluid administration volume is dependent on the type of shock. For hypovolemic shock, the fluid should be administered at 20 mL/kg over 5–10 minutes. For cardiogenic shock or poisoning, the volume should be 5–10 mL/kg over 10–20 minutes. For DKA, the volume should be 10–20 mL/kg over approximately 60 minutes.

foreign-body obstruction (FBO): Obstruction of the upper airway due to aspiration of food or small objects. Particularly in the pediatric population, this type of obstruction should be considered when there is inspiratory stridor, tachypnea, or increased inspiratory effort.

functional residual capacity (FRC): The amount of air left in the lungs at the end of passive expiration. During passive expiration, the lungs and chest wall are in equilibrium, and there is no pressure on the respiratory muscles. The air remaining in the lungs makes it easier to fill them with the next inspiration. If inhalation and exhalation are not in balance, the neonate will have decreased ability to absorb oxygen or remove carbon dioxide.

gasping: Abnormal respiratory effort in which the individual attempts to inhale or exhale with quick, ineffective breaths. The clinician should immediately intervene to provide effective ventilation.

Glasgow Coma Scale (GCS): A method for evaluating level of consciousness to determine the severity of a head injury using eye-opening, best verbal response, and best motor response. Mild = 13–15; moderate = 9–12; severe = 3–8. The team must understand the modifications necessary for evaluating the child and infant.

glottis: An opening of the larynx, a passageway into the trachea

grunting: Breath sounds that typically indicate upper airway obstruction; it sounds as though the child is grunting with each respiratory effort

head tilt-chin lift maneuver: Technique for opening the airway in which the child’s head is tilted and chin is lifted, so the head is in the “sniffing” position. This technique should NOT be used if there is a suspected cervical spine injury.

hematocrit: Also known as packed cell volume or erythrocyte volume fraction, it is the volume percentage of red blood cells in the blood. In the neonate, the normal range is between 55% and 68%.  

hemorrhagic shock: One of the types of hypovolemic shock. Loss of body fluids from bleeding, trauma, surgery, dehydration, or burns can result in blood pressure decreases, and the delivery of blood and oxygen to the body’s cells is reduced.

hemoglobin: The protein in the red blood cell that carries blood away from the heart and carbon dioxide back to the lungs. The normal ranges are as follows:

• Newborn: 14–24 g/dL 
• 2–6 months: 12–20 g/dL 
• 6–12 months: 9.5–14 g/dL 
• 2–6 years: 12.5 g/dL 
• 6–12 years: 13.5 g/dL. 
• After the age of 12: 14–14.5 g/dL.

hemothorax: The accumulation of blood in the space between the lung and the inner wall of the chest (the pleural cavity).

hepatomegaly: Enlargement of the liver due to infection, metabolic disorder, or tumor. Signs and symptoms can include heartburn, nausea, vomiting, jaundice, and abnormal liver function tests.

high-quality CPR: High-quality CPR refers to the current American Heart Association recommendations for providing a compression rate of at least 100 per minute for all ages and a compression depth of at least 2 inches for adults and a depth of at least one-third of the anterior-posterior diameter of the chest for infants and children (usually 1.5–2 inches).

hypercapnia: An abnormally high carbon dioxide level in the blood caused by the retention of carbon dioxide. The body’s normal mechanism for this condition is to increase the respiratory rate.

hypercarbia: Greater than normal carbon dioxide levels in the blood resulting in respiratory alkalosis; usually caused by hypoventilation

hyperglycemia: A higher than normal level of sugar in the blood; see diabetic ketoacidosis

hyperkalemia: A higher than normal potassium level in the blood. The normal neonatal potassium level is 4.1–5.3 mmol/L. Hyperkalemia is a normal variation in extremely premature infants.

hyperoxia: A condition in which there is a higher than normal oxygen content in the blood and other tissues

hyperthermia: A higher than normal body temperature. Normal neonatal temperature is 97.7–99.5°F (36.5–37.5°C).

hypertrophic cardiomyopathy: Thickening of the myocardium, resulting in less effective heart pumping and decreased cardiac output; typically, the result of a genetic disorder

hypocalcemia: A lower than normal calcium level defined as <7 mg/dL.

hypocapnia: A lower than normal carbon dioxide level in the blood, resulting in respiratory alkalosis. Usually caused by hyperventilation, it can lead to tetany, dizziness, and confusion.

hypoglycemia: A lower than normal blood glucose level; in the neonate, it is defined as < 30 mg/dL in the first 24 hours after delivery.

hyponatremia: A lower than normal sodium level defined as serum sodium < 130 mg/dL. Typically, sodium levels are not treated in the first 24 hours after delivery, particularly in premature infants. 

hypotension: A lower than normal blood pressure. In the neonate, hypotension is a clinical condition caused by low arterial blood pressure that affects organ perfusion. Typically, severe hypotension is treated with the IV administration of fluid or blood.

hypothermia: A lower than normal body temperature. Normal neonatal temperature is 97.7–99.5°F (36.5–37.5°C).

hypovolemia: A lower than normal blood volume. Normal neonatal blood volume is approximately 80–85 mL/kg of body weight. Hypovolemia in neonates is typically caused by blood loss before and during labor and delivery.

hypovolemic shock: Low-volume shock usually caused by fluid loss from nausea, vomiting, infections, or electrolyte imbalance. As fluids decrease in the body, the heart must work harder and beat faster to maintain cardiac output.

hypoxemia: Abnormally low level of oxygen in arterial blood most often caused by respiratory disorders or obstruction

hypoxia: Inadequate oxygen supply to meet the metabolic demands of the individual at the tissue level. Causes of hypoxia can include pulmonary disease, congenital heart disease, airway obstruction, and sepsis. Hypoxia will often lead to hyperventilation.  

intracranial pressure (ICP): The pressure inside the cranial vault that compresses the brain and cerebrospinal fluid. Normal pressure is 7–15 mm Hg for an adult at rest. For the pediatric population, the normal pressure is 9–21 mm Hg.

inspiratory time: The time of the inhalation phase of the repiratory cycle. In a ventilated individual, it is the amount of time to deliver the tidal volume to the lung.  

intraosseous (IO) access: Circulatory access through the bone marrow when the umbilical vein or other IV access is not readily available. In the case of cardiac arrest, IO access is a quick and easy way to establish circulatory access. IO is contraindicated if there is a long-bone fracture in the extremity.  

intravenous (IV) access: Circulatory access through a vein. Due to the small size of the veins in a neonate, this route is less commonly used than IO or umbilical vein access.

invasive arterial blood pressure (IBP): IBP monitoring measures the arterial blood pressure by inserting an arterial line into an accessible artery.

jaw-thrust maneuver: Technique for opening the airway of a patient when a cervical spine injury is possible. The provider pushes the lower jaw forward while maintaining the neck in a neutral position.  

justice: The ethical principle that the provider must treat patients and families truthfully and fairly. For the pediatric population, autonomy resides in the parent(s) of the child.

lactic acidosis: A type of metabolic acidosis; can be caused by hypoglycemia, hypoxia, seizures, kidney disease, certain poisonings, and prolonged dehydration. Any of these disorders can cause the blood pH to be lower than normal.

laryngeal mask airway (LMA): A supraglottic airway that keeps the individual’s airway open. Easier to insert than an endotracheal tube, the laryngeal mask helps ensure an airtight seal on top of the glottis.

laryngoscope: A type of endoscope used to visualize the larynx. In the neonatal population, the laryngoscope is typically a rigid instrument equipped with a light that illuminates the vocal cords.

larynx: An anatomical segment that connects the pharynx and the trachea

left-to-right shunt: A condition that results when blood from the left side of the heart enters the right side of the heart due to a ventricular or atrial septal defect; more common than the right-to-left shunt

lidocaine: An antiarrhythmic medication indicated for ventricular fibrillation or pulseless ventricular tachycardia, wide-complex tachycardia with pulses, and rapid sequence intubation. Lidocaine decreases the automaticity of the cardiac fibers and decreases intracranial pressure.

lower airway obstruction: Obstruction of the bronchi and bronchioles in the chest cavity. In the pediatric population, lower airway obstruction is typically caused by asthma or bronchiolitis.

lung compliance: The change in lung volume as a result of pressure in the lung. If compliance is high, lung volumes are large with a small amount of pressure. With low lung compliance, the pediatric patient must expend more energy to inflate the lungs. Decreased lung compliance can be overcome with increased positive airway pressure through mechanical ventilation.

lung tissue disease: Sometimes referred to as parenchymal lung disease, this classification of cause of respiratory distress includes diseases such as pneumonia, pulmonary edema, and acute respiratory distress syndrome. The team should understand that higher pressures will be required to provide adequate ventilation for children with lung tissue disease.

magnesium sulfate: A bronchodilator and electrolyte replacement medication indicated for refractory asthma, torsades de pointes, and low magnesium levels; relaxes smooth muscle and acts as antiarrhythmic

mainstem bronchus: The major air passageways leading to the right and left lungs

metabolic acidosis: When the kidneys cannot remove acids, body fluids become acidodic. In the pediatric population, the most common type is diabetic ketoacidosis. Severe and long-lasting diarrhea can cause the loss of too much sodium bicarbonate, leading to acidosis. Finally, lactic acidosis can be caused by hypoglycemia, hypoxia, seizures, kidney disease, certain poisonings, and prolonged dehydration.  

metabolic alkalosis: When the blood has high levels of bicarbonate and the kidneys cannot excrete the excess, the blood pH increases. Metabolic alkalosis is typically due to decreased oxygenation, fever, lung disease, and high altitude. Symptoms include muscle spasms and tremors, nausea, vomiting, tingling, and confusion. 

myocarditis: Inflammation of the middle layer (myocardium) of the heart. In the pediatric population, a viral infection is the most common cause of myocarditis.

myocardium: The thick, middle layer of the heart wall that contains primarily contractile muscle cells

nasopharyngeal airway (NPA): An airway adjunct used in the management of less severe cases of airway obstruction. The NPA is inserted through the nose and to the base of the tongue to prevent the tongue from covering the epiglottis.

nasopharynx: The upper part of the throat behind the nose and above the soft palate  

neurogenic shock: Injury to the brain or spinal cord that results in impaired neural transmission. Blood vessels become dilated, and blood pressure decreases. Signs include an increased respiratory rate, widening pulse pressure, increased heart rate, reduced urine output, and altered level of consciousness.

nonmaleficence: The ethical principle that the provider must avoid doing harm. For the pediatric population, autonomy resides in the parent(s) of the child.

nonshockable rhythms: Cardiac arrhythmias that will not respond to cardioversion or defibrillation. The two rhythms include PEA and asystole and are considered nonshockable since they do not have an electrically identifiable spike.

norepinephrine: A vasopressor indicated for the treatment of hypotensive shock that is not responsive to fluid resuscitation  

normothermia: A normal temperature. For a newborn, the normal range is 97.7–99.5°F (36.5–37.5°C).

obstructive shock: The type of shock caused by ductal-dependent lesions, tension pneumothorax, cardiac tamponade, and pulmonary embolism. Signs include increased respiratory rate and work of breathing, narrowing pulse pressure, cool and pale skin, and irritability.

oropharyngeal airway: An airway adjunct used to maintain an open airway by preventing the tongue from falling back over the epiglottis and causing airway obstruction

oxygen blender: A device that mixes oxygen with compressed air, allowing the clinician to deliver oxygen concentrations of < 100% but higher than room air (21%)

oxygen saturation: The percentage of oxygen-rich hemoglobin relative to the total hemoglobin. At the time of birth, all infants will have an oxygen saturation < 70%. Within the first 10 minutes, the normal neonate’s oxygen saturation should be 85–95%. Normal for a child and adult will be > 94% when breathing room air.

oxygen: The chemical element that is often specified as O2. Room air contains approximately 21% oxygen at sea level. Recommendations are to begin resuscitation at room air and then titrate based on pulse oximetry.

peak expiratory flow rate (PEFR): Measures the patient’s maximum speed of expiration. PEFR is measured using a peak flow meter. This measurement is most reliable in individuals who understand the measurement process and is less useful in young children. The normal PEFR is based on gender, age, and height.

peak inspiratory pressure (PIP): The highest pressure in the lungs during the inspiratory phase. Studies have shown that infants who require high peak inspiratory pressures during mechanical ventilation are more likely to die of respiratory causes subsequently.

Pediatric Assessment Triangle (PAT): The 2006 version of the PALS course included a pediatric assessment triangle that was a tool used to evaluate the child’s clinical condition. The three pieces of this triangle included: work of breathing, skin circulation, and appearance. In the most current PALS course, this has been replaced by the concept of the initial assessment.

peripheral cyanosis: Blue or purple discoloration of the hands and feet. Normal in the neonate, it is a sign of decreased oxygenation in the older individual.

peripheral edema: Swelling of the hands or lower part of the legs.

permissive hypoxemia: The concept of allowing lower than normal arterial blood oxygen levels in order to prevent the risks of high oxygen therapy  

petechiae: Round, pinpoint red or purple spots seen on the skin caused by superficial capillary bleeding.

pleural effusion: An abnormal collection of fluid in the pleural space. Although relatively uncommon in the neonate, the disorder can be caused by heart failure. In the neonatal population, the most common complication is respiratory failure.

pneumonia: Although relatively uncommon in the neonate, pneumonia is typically part of sepsis syndrome, is a very serious condition, and must be treated aggressively with antibiotics and fluids.

pneumothorax: A condition in which a lung is partially or completely collapsed. In the neonatal population, this is typically a complication of a premature birth since the infant does not have enough surfactant to help the lungs remain inflated. Another common cause in all age groups is the over-inflation of the lungs from aggressive ventilation that causes the alveoli to rupture.

polycythemia: An increased number of red blood cells in the body.

positive end-expiratory pressure (PEEP): A form of ventilation that applies air pressure at the end of exhalation in the respiratory cycle to keep airways from collapsing during the resting phase  

positive pressure ventilation (PPV): Technique of artificial respiration using a mechanical ventilator to force air into the patient’s lungs. PPV is used when spontaneous breathing is either inadequate or absent. PPV is administered through a tube to expand the lungs. When the ventilator breath stops, passive recoil of the chest occurs, causing exhalation. PPV is accomplished by volume-cycled ventilators (those that terminate the inspiration at a preset volume), pressure-cycled ventilators (those that terminate the inspiration at a preset pressure), or time-cycled ventilators (those that terminate the inspiration at a preset time).  

preload: The amount the ventricles stretch by end-diastole before they contract and begin the next cardiac cycle

primary assessment: Includes assessment of airway-breathing-circulation-disability-exposure approach (ABCDE) to evaluate the respiratory, cardiac, and neurologic functioning of the patient, including taking the patient’s vital signs

procainamide: An antiarrhythmic medication indicated for the treatment of supraventricular tachycardia, atrial flutter, or ventricular tachycardia with palpable pulses; increases the refractory period and decreases the excitability of cardiac muscles. Because of the risk of hypotension, expert consultation should be obtained before administration in children.

pulmonary embolism (PE): Mechanical blockage of a blood vessel in the lungs by a clot, leading to chest pain, cough, and shortness of breath. A PE can result in obstructive shock leading to low cardiac output, decreased tissue perfusion, and an increase in systemic vascular resistance to compensate for the other issues.

pulmonary hypertension: Increased blood pressure in the arteries of the lungs resulting in shortness of breath, fatigue, extremity swelling, tachycardia, and syncope; in infants, usually caused by the failure of normal shunts to close at the time of birth

pulse oximetry: The measurement of oxygen through the skin. Pulse oximetry should always be available and utilized when resuscitation is anticipated or when supplementary oxygen or PPV is administered after birth. Studies show that there is no benefit to resuscitation with high oxygen concentrations (> 65%) as compared to low concentrations (21–30%).

pulseless electrical activity (PEA): A common arrhythmia during resuscitation in which the cardiac monitor shows electrical activity without palpable pulses. In this situation, defibrillation is not the treatment of choice. Instead, the team must continue CPR and quickly identify the cause of the arrest from the Hs and Ts. The most common cause of PEA in the pediatric population is hypoxemia.

pulseless ventricular tachycardia: A life-threatening cardiac arrhythmia characterized by a rate >180 bpm, wide QRS complexes, the lack of palpable pulse, and a rhythm that originates in the ventricles rather than the atrial node

pulsus paradoxus: A decrease in systolic blood pressure during inspiration. Although there can be a normal decrease during inspiration, the fall is generally 10 mm Hg or less. A decrease greater than 10 mm Hg is referred to as pulsus paradoxus.

purpura: Purple areas of discoloration that appear on the skin due to small vessel hemorrhage. They are usually between 4 and 10 mm in size.

rales: High-pitched sounds heard on auscultation of the lungs, may also be referred to as crackles. 

red blood cells (RBCs): The component of blood that contains hemoglobin and iron, the elements that are essential for carrying oxygen and carbon dioxide to and from the cells. Produced by the bone marrow, the life expectancy of a red blood cell is approximately 120 days. Anemia in newborns is seen as low hemoglobin and hematocrit and abnormal reticulocyte count (percent of immature red blood cells in the blood).

respiratory acidosis: When the lungs cannot remove carbon dioxide, body fluids become acidic resulting in respiratory acidosis. In the pediatric population, this disorder is most often caused by chest injuries or chronic lung or airway disease. Symptoms include shortness of breath and confusion.

respiratory alkalosis: When there are low levels of carbon dioxide in the blood, the blood pH increases. Respiratory alkalosis is typically due to decreased oxygenation, fever, lung disease, and high altitude. Symptoms include muscle spasms and tremors, nausea, vomiting, tingling, and confusion. 

respiratory distress: Respiratory distress is often seen in the premature neonate. The primary cause is poor lung development and a lack of surfactant. Without surfactant, the alveoli deflate and are increasingly hard to inflate. Although uncommon in term infants after 39 weeks gestation, respiratory distress in this population is commonly due to congenital abnormalities, very rapid labor, or problems during delivery that reduce blood flow to the infant. In older children, airway obstruction is often the cause of this disorder.

respiratory failure: Occurs when the gas exchange between air and blood cannot match the metabolic demands of the body. Respiratory failure is the most common cause of morbidity and mortality in the pediatric population. Signs and symptoms of impending respiratory failure include bradypnea or tachypnea, tachycardia or bradycardia, hypertension, stridor, diminished breath sounds, paradoxical chest wall movement, wheezing, and use of accessory muscles during respiration.

return of spontaneous circulation (ROSC): The return of cardiac and significant respiratory effort after a cardiac arrest event. Signs of ROSC include palpable pulses, spontaneous movement, respiratory effort, and blood pressure that can be measured.

right-to-left shunt: A cardiac defect that causes deoxygenated blood from the right side of the heart to pass into the left side without going through the pulmonary circulation to pick up more oxygen. This shunt causes hypoxemia that creates the characteristic bluish discoloration of the skin.

Robin sequence: A congenital abnormality marked by an underdeveloped mandible. The abnormality causes the tongue of the newborn to obstruct the pharynx.  

SAMPLE: A mnemonic used during resuscitation to remind the team of further questions to consider before, during, and after resuscitation. The letters stand for signs/symptoms, allergies, medications, past medical history, last meal, and events leading up to the precipitating event.

secondary assessment: Includes a history of the present illness and a focused physical assessment based on the child’s current condition

seesaw respirations: A breathing pattern in which the abdomen lifts and the chest caves in during inspiration most often due to severe airway obstruction.

self-inflating bag: One of the two types of manual ventilation bag. The self-inflating bag refills itself when the provider stops squeezing the bag (see also flow-inflating bag).

sepsis: A potentially fatal response to infection that, without treatment, will lead to organ failure and death. The Sepsis Alliance defines the TIME acronym to remember potential signs and symptoms: temperature (although fever is not always apparent), infection, mental decline, extremely ill.

septic shock: Caused by an overwhelming systemic infection in the body, this disorder leads to decreased blood flow to cells, elevated temperature, and often hypotension.

shock: A life-threatening medical condition characterized by tachypnea, cool skin, rapid and weak pulse, dizziness, faintness, and, ultimately, hypotension. It is categorized as compensated or decompensated and typed as anaphylactic, cardiogenic, distributive, hemorrhagic, hypovolemic, and septic.

shockable rhythms: An arrhythmia that can be interrupted by electrical shock. The two rhythms are VF and pulseless VT.

sinus tachycardia: A rhythm that originates in the atria but has a faster than expected heart rate for the patient’s age.

sodium bicarbonate: An electrolyte that acts as an alkalinizing agent. Although less commonly used in resuscitation than in the past, sodium bicarbonate continues to be indicated for very severe metabolic acidosis, certain poisonings, and hyperkalemia.

status asthmaticus: Severe and prolonged  asthma attack that does not respond to therapy.

stridor: High-pitched, noisy breathing that occurs when airways are narrow or obstructed. Common in pediatric patients with croup or foreign-body aspiration and obstruction of the upper airways.

stroke volume: The volume of blood pumped out of the left ventricle with each cardiac contraction  

suction equipment: Including the catheter and machine, suction equipment is used to clear the airway of secretions. A bulb syringe might be used to perform initial suctioning of the newborn.  

sudden unexpected infant death (SUID): The unexpected and suddent death of an infant < 12 months of age. There are many possible causes that fit into this category, including suffocation, SIDS, metabolic conditions, infection, toxin ingestion, arrthythmias, and trauma.

supraventricular tachycardia (SVT): A fast heart rhythm that originates above the ventricles. Signs and symptoms of SVT include chest pain, diaphoresis, shortness of breath, and dizziness.

synchronized cardioversion: Treatment for specific arrhythmias in which a low-energy shock is timed to be delivered at a point in the QRS complex when the rhythm is in the refractory period. The purpose is to restore normal cardiac activity and convert atrial fibrillation, atrial flutter, atrial tachycardia, and supraventricular tachycardia when medications have not been successful.

systemic vascular resistance (SVR): The force placed on the blood circulating within the body as determined by the blood viscosity and the length and diameter of blood vessels.

tachycardia: An abnormally high heart rate. In the newborn, the heart rate normally varies with activity. A faster than normal heart rate in the neonate can be caused by infection, illness, fever, and medications.

tachypnea: An abnormally high respiratory rate (typically > 30–60 breaths per minute in the newborn). A frequent finding in the premature infant, it is also common in neonates born by cesarean section or to a mother with diabetes. When sustained, tachypnea can be a sign of impending respiratory failure in all age groups, so it should be monitored and treated.

Targeted temperature management (TTM): A treatment involving lowering the core temperature using cooling devices. It is typically used for patients who do not regain consciousness after cardiac arrest to improve brain function and survival. It reduces metabolic demand and shunts blood from the periphery to the vital organs (brain, heart, and lungs). The temperature is usually lowered to 89–93°F (32–34°C) and maintained for up to 24 hours.

thoracentesis: A procedure in which a catheter is inserted into the pleural space as a method of removing air or fluid inside the thoracic cavity

thyroid cartilage: A thick protective cartilage surrounding the larynx

torsades de pointes: A cardiac arrhythmia often described as a polymorphic ventricular tachycardia and is characterized by a twisting of the QRS complexes around the isoelectric line on ECG. The danger of this arrhythmia is that it can degenerate into ventricular tachycardia or ventricular fibrillation and can result in sudden cardiac death.

trachea: The segment of the airway between the larynx and the carina

transthoracic pacing: The regulation of the heart rate by an artificial pacemaker with electrodes that are attached to the external chest wall

uncal herniation: Brain herniation resulting from increased intracranial pressure. Signs and symptoms include pupillary changes, ptosis, altered mental status, and contralateral hemiparesis.

upper airway obstruction: A blockage of the trachea, larynx, or throat that impairs air movement into the lungs. In the pediatric population, this is often due to foreign-body aspiration, anaphylaxis, or croup.

vagal maneuvers: Techniques to slow supraventricular tachycardic rhythms. Bearing down as if having a bowel movement, carotid massage, and immersing the face in ice water are common vagal maneuvers that may slow rapid rhythms.

vallecula: A pouch located at the base of the tongue and the epiglottis

Valsalva maneuver: The technique of exhaling forcefully against a closed nose and mouth; it may be successful in slowing a tachycardic cardiac rhythm.

vascular resistance: The resistance of blood flow through vessels in the circulatory system. When in the peripheral circulation, this resistance is known as systemic vascular resistance (SVR). In the lungs, it is termed pulmonary vascular resistance (PVR).

vasoactive agents: Medications that increase myocardial contractility or cause vasoconstriction, which increases systemic vascular resistance. Common medications in this class include adrenaline, dobutamine, and ephedrine.

ventilation-perfusion mismatch: The ventilation-perfusion ratio assesses the adequacy of the respiratory process. When there is a mismatch, it is an indication that either the lungs are receiving oxygen with no blood flow or blood flow with no oxygen, leading to hypoxia of the tissues.

ventricular fibrillation (VF): A cardiac arrhythmia characterized by fibrillation of the ventricles instead of effective contractions. In the pediatric population, this arrhythmia is uncommon and occurs mostly in the context of preexisting cardiomyopathy.

vocal cords: Made up of two membranous tissues at opposite locations that project medially from the walls of the larynx, the vocal cords form a slit across the glottis. Their edges vibrate when an airstream passes through, causing modulation to produce the voice.

volume expanders: When fluid or blood losses are known or suspected, and the neonate is symptomatic, volume expanders can be used to increase circulatory volume. Isotonic crystalloid solutions or blood products are the most used products for volume expansion.

work of breathing: The energy required to inhale and exhale. The calculation is typically measured as joules/liter or joules/minute. In a normal resting individual, approximately 3% of total energy is consumed during the process of breathing. The calculation is work of breathing = pressure x volume. If either of these factors increases, the work of breathing also increases.