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 fingers 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.

choking
Assess Ineffective cough Effective cough Encourage coughing Support and assess continuously

Unconscious

Conscious

Open airway

5 back blows

5 rescue breaths

5 chest/adbo thrusts

CPR check for FB

Assess and repeat

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