A case-based update of PALS: Paediatric basic and advanced life-support guidelines

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In October 2010, the Heart and Stroke Foundation of Canada and the American Heart Association released new guidelines for cardiopulmonary resuscitation (CPR) ^[1][2]. These guidelines were updated in November 2015 ^[3][4], based on an extensive, evidence-based review of the resuscitation literature conducted by the International Liaison Committee on Resuscitation ^[5]. This article highlights changes in the 2010 guidelines, with focus on the 2015 updates. The neonatal guidelines were reviewed separately in 2017 ^[2].  Access to the complete guidelines and the International Liaison Committee on Resuscitation consensus on science and treatment recommendations is available online at: circ.ahajournals.org/content/vol122/18_suppl_3/, circ.ahajournals.org/content/vol132/16_suppl_2/, circ.ahajournals.org/content/vol132/18_suppl_1/ and eccguidelines.heart.org.

Case 1: Asystolic cardiac arrest ^[1][3][5][6]

A two-month-old girl presents to the emergency room with vomiting and dehydration. On assessment, the nurse determines that the infant is cyanotic and unresponsive. The infant is not breathing and has no pulse.

Compressions, airway, breathing: The new priority in initiating CPR

Previous CPR guidelines have recommended an airway, breathing, compression approach to victims of cardiac arrest. However, the 2010 guidelines and 2015 update recommend that rescuers start with chest compressions first. For in-hospital arrest, these roles can be performed by health care providers (HCPs) concurrently, with a focus on initiating chest compressions immediately, while another rescuer prepares to open the airway and provide ventilation. This approach avoids the delay in providing chest compressions that often occurs while rescuers set up and administer bag-mask ventilation. The recommended compression to ventilation ratio is unchanged at 30:2 for single-rescuer CPR and 15:2 for two-rescuer CPR. If an advanced airway is in place, compressions should be provided continuously (at a rate of 100 to 120 compressions/min) without pausing for rescue breaths (8 to 10 ventilations/min).

What are the guidelines regarding the performance of chest compressions?

Chest compressions should be provided at an optimal compression depth of at least one-third of the anterior-posterior diameter of the chest (approximately 4 cm in infants and 5 cm in children). Chest compression depth in adolescents should be at least 5 cm but no greater than 6 cm. Rescuers providing compressions should allow for full recoil, minimize interruptions, avoid excessive ventilation and rotate the compressor role every 2 min. Rescuers should allow for no more than a 5 s pause for compressor switches and limit pulse checks to a maximum of 10 s.

Is hands-only (compression-only) CPR appropriate for infants and children?

Paediatric cardiac arrest is primarily asphyxial in nature; therefore, ventilation is critical for the resuscitation of infants and children. The 2015 update strongly reaffirms that compressions and ventilation are needed for paediatric basic life support in both single-rescuer and ­two-rescuer CPR. However, if rescuers are unable or unwilling to deliver breaths, compression-only CPR should be performed.

Case 2: Ventricular fibrillation ^[1]-[5]

An asymptomatic six-year-old boy with a family history of sudden death is being evaluated in the cardiology clinic. While visiting the hospital cafeteria, he suddenly collapses, becomes unresponsive and has only gasping respirations.

How should a rescuer decide whether CPR is necessary?

The 2010 guidelines have eliminated “look, listen and feel” as part of the CPR sequence. Lay rescuers should assess the victim for responsiveness and determine whether the patient is breathing normally. If the patient is unresponsive and apneic (or only gasping), the rescuer should initiate CPR immediately.

HCPs may additionally check for a pulse (brachial in an infant, and carotid or femoral in a child), but this may be unreliable. Therefore, a pulse check should be limited to no more than 10 s, and CPR should be initiated if no pulse is palpated or if the HCP is unsure of its presence.

Can automated external defibrillators be used for infants in cardiac arrest?

Automated external defibrillators (AEDs) can be used for infants and children. However, the recommended method of defibrillation for infants is manual defibrillation. If a manual defibrillator is not available, an AED with a paediatric dose attenuator is preferred (up to 25 kg or eight years of age). A standard adult AED without a dose attenuator can be used if this is not available.

What is the optimal shock dose for defibrillation?

The 2010 guidelines suggest an initial shock dose of 2 J/kg to 4 J/kg. The 2015 update reaffirms this initial shock dose but does not make a recommendation regarding second and subsequent defibrillation doses.

What is the optimal medication if the rhythm is refractory to shock?

Amiodarone or lidocaine may be used for the treatment of shock-refractory ventricular fibrillation or pulseless ventricular tachycardia.

Should vasopressors be administered during cardiac arrest?

The 2015 update states that it is reasonable for providers to use standard-dose epinephrine.

Are there any other treatments that should be considered for cardiac arrest?

ECPR (CPR with extracorporeal membrane oxygenation (ECMO)) may be considered for infants and children with known cardiac diagnoses who experience in-hospital cardiac arrest, providing expertise, resources, and systems are in place to provide this therapy.

The patient is successfully resuscitated from the cardiac arrest event. Are there any post-arrest care issues that need to be considered?

Hyperoxemia can be harmful because it enhances the oxidative injury during reperfusion (following ischemia). Postarrest, oxygen therapy should be titrated to maintain an oxygen saturation of between 94% and 99%, as a saturation of 100% corresponds to a partial pressure of oxygen in arterial blood of between 80 mmHg and 500 mmHg. The 2015 update supports a target of normoxemia and makes no recommendations regarding ventilation. The update also supports using  parenteral fluids and/or inotropes or vasopressors to maintain a systolic blood pressure greater than the fifth percentile for age. Therapeutic hypothermia at a temperature of 32°C to 34°C for 2 days, followed by 3 days of normothermia at 36°C to 37.5°C or 5 days of continuous normothermia, is reasonable for children who remain comatose after resuscitation from cardiac arrest. Hyperthermia should be avoided. Pharmacological seizure prophylaxis should not be used routinely, but clinical seizures should be treated. Electroencephalography (EEG) should be obtained within the first 7 days after cardiac arrest, because readings may help in prognosticating neurologic outcome at the time of discharge. EEG readings should not used in isolation, however, because no single variable has been identified to reliably predict outcome. Expert consultation should be considered to help guide post-arrest therapy.

Case 3: Wide-complex tachycardia ^[2]

A 10-year-old obese girl presents with a stable wide-complex tachycardia at 180 beats/min.

What is the appropriate next step in managing this patient?

The definition of wide-complex tachycardia has been changed to a QRS interval of greater than 0.09 s. Because this wide-complex rhythm can be ventricular or supraventricular in origin, adenosine can be used in stable patients to distinguish between the two. It should only be used for regular, monomorphic QRS rhythms and should be avoided if a patient with known Wolff-Parkinson-White syndrome presents with wide-complex tachycardia.

How should medication doses be calculated in obese children?

Doses for resuscitation medications in children should be based on the actual patient weight rather than the ideal body weight, up to the adult maximum. Length-based tapes with pre-calculated doses should be used if the weight is not known because they are more accurate than age-based or observer-based methods to predict the patient’s weight.

Case 4: Septic shock ^[2][4][5]

A previously healthy two-year-old boy presents to the emergency room with a four-day history of high fever and lethargy. On examination, the child is tachycardic, hypotensive and poorly responsive.

Which fluid is best for septic shock – colloid or crystalloid?

There are no clinically important differences in outcomes when comparing children in septic shock treated with colloid versus crystalloid fluid. The guidelines continue to recommend a bolus of crystalloid solution (eg, normal saline) as the initial choice for resuscitation fluid.

For paediatric patients in septic shock, how much fluid should be administered, and how fast?

Infants and children with severe sepsis and septic shock should receive an initial fluid bolus of 20 mL/kg of isotonic crystalloid, followed by regular, frequent reassessment. In some scenarios, such as resource-limited settings with little or no ability to provide critical care, the use of restrictive volumes of isotonic crystalloid may be associated with improved survival. Infants and children with febrile illness who are not in compensated or uncompensated shock should not routinely receive a bolus of fluid, but rather should be reassessed to identify deterioration early as well as need for further observation or treatment.

Should atropine be administered routinely as a premedication for emergency endotracheal intubation in non-neonates?

The practice of routinely administering atropine as a premedication for emergency endotracheal intubation is controversial, but reasonable in situations with a higher risk of bradycardia. There are data to suggest there is no minimum dose of atropine required when it is used for this indication.

Should etomidate be used as the sedative during the rapid sequence intubation of a child in septic shock?

Etomidate is a sedative agent with minimal adverse hemodynamic effects. However, etomidate should not be used routinely in paediatric patients with suspected septic shock because adrenal suppression has been documented after its use in children and adults, and administration is associated with higher mortality rates.

What is the optimal endotracheal tube size?

Both cuffed or uncuffed tubes are acceptable for intubating infants and children. However, in certain settings, the use of cuffed endotracheal tubes may help to decrease the risk of aspiration and reduce the need for reintubation. For cuffed tubes, a 3.0 mm internal diameter (ID) tube should be used to intubate an infant younger than one year of age and a 3.5 mm ID tube should be used for patients one to two years of age. After two years of age, the cuffed tube size can be estimated using the following formula:

Cuffed endotracheal tube ID (mm) = 3.5 + (age/4)

For uncuffed tubes, select a tube size with an ID that is 0.5 mm larger than what is recommended for cuffed tubes for that age.

Is cricoid pressure recommended during intubation?

There is insufficient evidence to recommend the routine use of cricoid pressure to prevent aspiration during intubation because it may interfere with the speed or ease of intubation.

What else is new in the guidelines?

The 2010 guidelines also provide management recommendations for infants and children with congenital heart disease (single-­ventricle physiology and pulmonary hypertension), along with guidance on how to explore the potential cause of sudden, unexplained deaths. For details, refer to the complete guidelines document.

The 2015 update indicates that when invasive arterial blood pressure monitoring is already in place, it may be used to adjust CPR to achieve specific blood pressure targets for children in cardiac arrest. Capnography can be used during paediatric cardiac arrest to confirm endotracheal tube placement and to monitor for return of spontaneous circulation (ROSC) and CPR quality.

Future directions: Education and implementation ^[1]-[7]

Out-of-hospital cardiac arrest survival remains poor. Bystander CPR is a major determinant of victim outcome but, unfortunately, most bystanders do not act, commonly citing panic or fear of harming the patient as their reason. CPR training may help overcome this problem and improve bystander response rates. Short 20 min to 30 min video-based self-instruction kits for basic life support (such as the Heart and Stroke Foundation of Canada’s CPR Anytime Family & Friends kit) have demonstrated equivalent learning outcomes compared with longer instructor-led courses. This training format might be one method to increase the number of bystanders willing to respond, ultimately improving outcomes from cardiac arrest.

Survival from in-hospital cardiac arrests has improved dramatically over the past 25 years, but three-quarters of all ­in-hospital paediatric cardiac arrest victims still die. The etiology for most cardiac arrests in children remains asphyxial; thus, recognition of patients at risk and prevention of deterioration remain priorities. Implementating medical emergency teams and/or rapid response systems must always be considered in institutions with adequate resources, but it is even more important that health care team members are able to recognize and intervene when paediatric patients are deteriorating. There is insufficient evidence to recommend the implementation of Paediatric Early Warning Scores (PEWS) in hospitals caring for paediatric patients. Paediatric institutions require, at minimum, a continuous quality improvement process that systematically monitors cardiac arrests, resuscitation care and outcomes. The cycle of measurement, benchmarking, feedback and change is fundamental in narrowing the gap between ideal and actual performance.

Current resuscitation courses, such as Paediatric Advanced Life Support (PALS) and the Neonatal Resuscitation Program, are adopting new educational methods to improve long-term retention of knowledge and skills. Methods, such as team training with realistic patient simulators, debriefing with standardized scripts and video-based learning with a ‘practice while watching’ approach, may help to consolidate learning and, ultimately, lead to improved patient outcomes from cardiac arrest.

Acknowledgements

The principal authors thank Dr. Allan de Caen for his expert review of this manuscript.

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ACUTE CARE COMMITTEE

Members: Adam Cheng MD; Catherine Farrell MD; Jeremy Friedman MD; Marie Gauthier MD (Board Representative); Angelo Mikrogianakis MD (Chair); Oliva Ortiz-Alvarez MD
Liaisons: Laurel Chauvin-Kimoff MD, Paediatric Emergency Medicine Section, Canadian Paediatric Society; Jennifer Walton MD, Hospital Paediatrics Section, Canadian Paediatric Society
Consultant: Claudette Bardin MD
Principal authors: A Cheng MD; F Bhanji MD
Updated by: Kristina Krmpotic MD

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References

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Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.