Update on Paediatric resuscitation

Lee Wallis

introduction

• there are new protocols for both basic and advanced life support

• in general children arrest from hypoxia and / or shock

• early and effective treatment will prevent cardiac arrest and dramatically improve the outcomes that are possible

introduction

• highlights of the ILCOR recommendations 2005 for BLS and defibrillation

• particular issues for children– as in the APLS guidelines

• actual algorithms for resuscitation

• additional issues

Highlights: lay (single)• Airway opening only head tilt chin lift• Simplification of instructions for rescue breaths

– 1 second– Make the chest rise

• Elimination of lay rescuer training in rescue breathing without chest compressions

• Elimination of lay rescuer assessment of signs of circulation before beginning chest compressions

• 2 min of CPR before calling 112

Highlights: lay

• Recommendation of a single (universal) compression-to ventilation ratio of 30:2 for single rescuers of victims of all ages (except newborn infants)

• Modification of the definition of “pediatric victim” to preadolescent (prepubescent) victim for application of pediatric BLS guidelines for healthcare providers

Highlights: general

• Increased emphasis on the importance of chest compressions

• Recommendation that EMS providers may consider provision of about 5 cycles (or about 2 minutes) of CPR before defibrillation for unwitnessed arrest

highlights

• Recommendation that all rescue efforts be performed in a way that minimizes interruption of chest compressions

• Recommendation of only 1 shock followed immediately by CPR (beginning with chest compressions) instead of 3 stacked shocks for treatment of shockable rhythms

Highlights: neonate

• Increased emphasis on the importance of ventilation and de-emphasis on the importance of using high concentrations of oxygen for resuscitation of the newly born infant

issues for children: age definitions

• infant – a child under one year

• child – between one year and puberty – if you believe that the victim is a child, use the

paediatric guidelines

issues for children:newborn resuscitation changes

• food grade plastic wrapping to maintain body temperature in very pre-term babies

• attempts to aspirate meconium whilst the head is on the perineum no longer recommended

• ventilation may start with air but oxygen added quickly if a poor response

• adrenaline should be given intravascularly not via the trachea

issues for children:route of drug administration in ALS

• where possible give drugs intra-vascularly rather than via the tracheal route –

– lower adrenaline concentrations may produce transient hypotensive effects.

– dose of adrenaline in paediatric cardiac arrest is 10 micrograms/kg on every occasion.

issues for children:endotracheal tubes

• either cuffed or uncuffed tracheal tubes may be used during resuscitation of infants and children in the hospital setting

– relevant when cardiac arrest is associated with difficult to ventilate lungs.

number of defibrillating shocks

• one shock rather than three “stacked” shocks – VF– pulseless VT

cardiac arrest algorithm

BLS and need for defibrillation

• clinical indication for EMS activation before BLS by a lone rescuer include:– witnessed sudden collapse with no apparent

preceding morbidity

– witnessed sudden collapse in a child with a known cardiac condition and in the absence of a known or suspected respiratory or circulatory cause of arrest.

compression: ventilation ratios

• Five rescue breaths, to produce 2 effective– may be added by lay rescuers

• 2 or more rescuers with a duty to respond use 15 compressions to 2 ventilations for all ages of children (a single professional rescuer can use either ratio)

• Lay (single) rescuers use the adult 30:2 ratio for all ages

compression technique

• position:– For all ages: compress the lower third of the sternum

• Find the lower third by measuring one finger’s breadth above the angle of junction of ribs

• number of hands:• in children: use one or two hands: whichever is required to

depress the sternum by approximately one third of the depth of the chest

• In infants: two thumbs or two fingers

cardiac arrest algorithm

automated external defibrillators

• standard AED for children over 8 years

• paediatric pads or programmes to attenuate energy to 50-80 joules for children between 1 and 8 years

• If an attenuated machine is unavailable a standard AED may be used for children over 1 year

• insufficient evidence to support a recommendation for or against the use of an AED in children under 1 year

choking relief sequence

• simplified sequence based on if the child has an effective or ineffective cough and if they are conscious or unconscious.

Assess

Ineffectivecough

Effectivecough

Unconscious Conscious

Open airway 5 back blows

5 rescue breaths

CPR check for FB

5 chest/adbothrusts

Assess and repeat

Encouragecoughing

Support andassess

continuously

choking

family presence

• in the absence of data documenting harm and in light of data suggesting that it may be helpful, offering select family members the opportunity to be present during a resuscitation seems reasonable and desirable

ethical comments

• when to stop:– In the past, children who underwent

prolonged resuscitation and absence of ROSC after 2 doses of epinephrine were considered unlikely to survive, but intact survival …. been documented. Prolonged efforts should be made for infants and children with recurring or refractory VF or VT, drug toxicity, or a primary hypothermic insult.

fluid resuscitation

• crystalloids

• volumes in trauma (where bleeding is not controlled)

• monitoring of adequacy of resuscitation– central venous pressure– beat to beat blood pressure variation– central venous saturations

Summary of ALS guidelines