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Keywords:
cardiopulmonary resuscitation;
C-A-B; chest compression; bag valve
mask; endotracheal tube; end-tidal
CO2; intraosseous; automatic
external defibrillator; dysrhythmia;
defibrillation; therapeutic hypothermia; termination of resuscitation
Department of Pediatrics, Division of
Emergency Medicine, Children's Hospital
at Montefiore/Albert Einstein College of
Medicine, Bronx, NY.
Reprint requests and correspondence:
Waseem Hafeez, MD, is to be contacted at
Department of Pediatrics, Division of
Emergency Medicine, Children's Hospital
at Montefiore/Albert Einstein College of
Medicine, 3315 Rochambeau Avenue,
Bronx, NY 10467. Lorraine Ronca, DO,
Theresa Maldonado, MD.
whafeez@montefiore.org (W. Hafeez),
lronca@montefiore.org (L.T. Ronca),
tmaldona@montefiore.org
(T.E. Maldonado)
1522-8401/$ - see front matter
2011 Elsevier Inc. All rights reserved.
Pediatric
Advanced Life
Support Update
for the
Emergency
Physician:
Review of 2010
Guideline
Changes
Waseem Hafeez, MD,
Lorraine T. Ronca, DO,
Theresa E. Maldonado, MD
PALS UPDATE FOR THE EMERGENCY PHYSICIAN / HAFEEZ, RONCA, AND MALDONADO VOL. 12, NO. 4 255
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PALS UPDATE FOR THE EMERGENCY PHYSICIAN / HAFEEZ, RONCA, AND MALDONADO VOL. 12, NO. 4 259
BVM Ventilation
Bag valve mask ventilation is an essential CPR
technique for health care providers. In apneic
patients and those in respiratory failure, the initial
method for ventilation is with a bag mask
apparatus, until all the appropriate equipment
and personnel for intubation are assembled. For
optimum airway alignment, the head should be
kept midline, with the auditory meatus in line with
the top of the anterior shoulder. The sniffing
position is achieved, in an older child, by placing a
folded towel under the head and elevating it, and
infants, by slightly extending the head with a pad
under the shoulders. Flexing or overextending the
neck may interfere with adequate ventilation by
kinking the airway. Provide ventilation using a
BVM device with an appropriate size face mask.
The proper size mask extends from the bridge of
the nose to the cleft of the chin. The minimum
volume for a bag in newborns, infants, and small
children is 450 to 500 mL, as smaller bags may not
deliver an effective tidal volume. 10 In adolescents,
an adult bag should be used. If only an adult bag is
available, ventilation of infants and children is
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Cricoid Pressure
There is insufficient evidence to recommend
routine cricoid pressure application to prevent
aspiration during endotracheal intubation in children. 23 Cricoid pressure is used to prevent gastric
inflation by the application of pressure on the
cricoid cartilage sufficient to occlude the esophagus
without compressing the airway lumen or moving
the cervical spine. However, cricoid pressure can
impede the placement of an ETT and does not
entirely prevent aspiration. Cricoid pressure may be
considered in an unresponsive patient, only if there
is a third health care provider available. 12
Oxygen
Oxygen delivery has a paradoxical effect on the
injured brain. Inadequate oxygenation may potentiate anoxic injury, whereas hyperoxemia after
ROSC from cardiac arrest enhances the oxidative
injury after ischemia reperfusion. 24 Until additional
information becomes available, current guidelines
recommend the use of 100% oxygen during resuscitation. Once circulation is restored, ensure adequate arterial oxygen content by titrating oxygen
administration to maintain the oxyhemoglobin
saturation between 94% and 99% because an oxygen
saturation of 100% may correspond to a PaO2
anywhere between 80 and 500 mm Hg. 12
PALS UPDATE FOR THE EMERGENCY PHYSICIAN / HAFEEZ, RONCA, AND MALDONADO VOL. 12, NO. 4 261
Vascular Access
When IV access is challenging or impossible, such
as in cardiac arrest or other emergent situations, do
not spend more than 90 seconds attempting
peripheral vascular access. The IO approach allows
for rapid, safe, and effective access for the administration of medications and fluids and should be
attempted immediately while other vascular sites
are sought. Intraosseous needle placement is no
longer restricted to children younger than 6 years,
and currently, various devices are available for all
age groups. 12 The primary site for IO insertion is the
proximal tibia. The Jamshidi IO needle (Baxter,
Deerfield, IL), the Cook IO needle (Cook Medical,
Inc, Bloomington, IN), and the newer EZ-IO system,
which consists of a small battery-powered driver,
are commercially available in sizes for infants,
children, and adults. 27 The insertion of EZ-IO
needle (Vidacare, Shavano Park, TX) is easier than
manually inserted needles because the power drill
does the all the work; however, extra precaution is
required because it is easy to overshoot the marrow
and through the other side. The FAST 1/FAST X
(Pying Medical Corporation, British Columbia,
Canada) sternal IO infusion system is designed to
safely penetrate into the manubrium. Adult and
adolescent patients (age, N12 years) have a manubrium thickness deep enough to make the procedure safe.
Dysrhythmia Management
An approach to pediatric dysrhythmia management is shown in the algorithm (Figure 1) and begins
with checking the patient's responsiveness and a
rapid pulse check. Unstable signs include altered
mental status and abnormal vital signs (temperature, heart rate, blood pressure, respiratory rate,
pulse oximeter). All patients require secure vascular
access, oxygen therapy, and cardiopulmonary monitoring. The goal of initial management is to restore
normal mental status, good oxygenation and perfusion, and adequate urine output. A 12-lead ECG
should be obtained to assess the rate, rhythm,
absence or presence of P wave, and whether there is
a widened QRS complex (N0.09 seconds).
Bradycardia
Patients with asymptomatic bradycardia have
adequate pulses, perfusion, and respirations, and
no emergency treatment is necessary. Continue
monitoring and proceed with a complete evaluation.
In patients with symptomatic bradycardia (heart
rate b60 beats/min with cardiovascular compromise), start chest compressions and support airway,
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CHECK PULSE
Check Rate
ABSENT
UNSTABLE SIGNS
Altered mental status
Hypotension
s/s Shock, Resp failure
CPR (5 cycles in 2 min)
<8yr: 15 compressions
>8yr: 30 compressions
HR >160 bpm
HR < 60 bpm
+ 2 breaths
STABLE
UNSTABLE
Check Rhythm
Initiate CPR
Epinephrine (1:10,000)
0.1 cc/kg IV q 3-5 min
Vagal/Primary AV block:
Atropine (0.02 mg/kg)
Min 0.1 mg
Max 0.5 mg child
1 mg adolescent
Consider Pacing
Check ABCs
100% O2
Monitor
Evaluate
Check QRS
NARROW
QRS 0.09
PRESENT
WIDE
QRS > 0.09
VT / VF
UNSTABLE
ABSENT
PEA/EMD
ASYSTOLE
Check P-wave
Epinephrine
ABNORMAL
OR ABSENT
NORMAL
Identify/Treat Causes:
Pneumothorax
Pericardial Tamponade
pH- Acidosis
Pulmonary Embolism
Poisons Drug OD
Hypoxemia
Hypovolemia
Hypoglycemia
Hypothermia
Hypo/hyperkalemia
VENTRICULAR TACHYCARDIA
STABLE:
Check ABCs / 100% O2 / IV access
Amiodarone 5 mg/kg (max 150 mg) IV in 20-60 min
or Lidocaine 1 mg/kg (max 100 mg) IV bolus
UNSTABLE:
Synchronized Cardioversion 0.5 - 2 J/kg
(max: Mono 100, 200, 300, 360 J / Biphasic 100, 200 J)
NO PULSE
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Narrow-Complex Tachycardia
(QRS 0.09 Seconds)
Patients with supraventricular tachycardia without hemodynamic compromise may respond to
vagal stimulation. In infants and young children,
apply ice to the face without pressure to the eyes or
occluding the airway. Older children may perform a
Valsalva maneuver by bearing down forcefully or
blowing through an occluded straw. If ineffective,
attempt pharmacologic cardioversion with adenosine (0.1 mg/kg; maximum dose, 6 mg) using the
2-syringe technique; give adenosine rapidly with
1 syringe and immediately flush with 5 to 10 mL of
normal saline with another syringe attached to a
stopcock. If necessary, adenosine may be repeated
at a dose of 0.2 mg/kg (maximum dose, 12 mg).
Verapamil (0.1-0.3 mg/kg) may be used as a secondline therapy, with pediatric cardiology consultation.
Use of verapamil in infants is not recommended
because it may cause myocardial depression,
hypotension, and potential cardiac arrest.
Wide-Complex Tachycardia
(QRS N0.09 Seconds)
QRS duration varies with age and is considered
prolonged if it is more than 90 milliseconds
(0.09 second) for a child younger than 4 years and
100 milliseconds or more (0.1 second) for a child
between the ages of 4 and 16 years. 28 The current
PALS guideline defines a QRS width more than
0.09 second as prolonged for the pediatric patient, a
change of 0.01 second from previous recommendations, which can only be detected by computer
interpretation of the ECG rhythm strip. 12
Ventricular tachycardia may be monomorphic
(identical QRS complexes originating from a single
focus) or polymorphic (torsade de pointesirregular rhythm, varying QRS waveform). Ventricular
fibrillation is a pulseless, grossly disorganized, rapid
ventricular rhythm that varies in interval and
morphology and may be difficult to distinguish
from rapid, polymorphic VT. The ED treatment of
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Pulseless ArrestAsystole/PEA
The treatment of asystole and PEA is to provide
high-quality chest compression and adequate ventilation and to maintain perfusion to vital organs.
Administer epinephrine 0.01 mg/kg IV/IO (0.1 ml/kg
of 1:10 000 solution), or if there is no vascular
access, administer ETT at 0.1 mg/kg (0.1 ml/kg of
1:1000 solution). The epinephrine dose can be
repeated every 3 to 5 minutes. There is no role in
PALS for the routine use of high-dose epinephrine,
atropine, calcium, or vasopressin in asystole. 12
During resuscitation, it is vital to identify and treat
the reversible cause of arrest: the 5 Hs (hypoxemia,
hypovolemia, hypothermia, hypoglycemia, hypokalemia/hyperkalemia) and the 5 Ps (pneumothorax,
pericardial tamponade, pHsevere acidosis, pulmonary embolism, poisonsdrug overdose). 12
Therapeutic Hypothermia
Cardiac arrest commonly contributes to the brain
injury caused by hypoxia and global ischemia.
Multiple mechanisms are involved in neuronal
damage, both by hypoxia-induced encephalopathy
and by reperfusion-induced cellular and tissue
Termination of Resuscitation
Currently, there are no reliable predictors of
outcome during resuscitation to guide when to
terminate in-hospital resuscitation efforts. Bystander CPR for witnessed collapse and a short interval
from collapse to arrival of EMS improves the
chances of survival. Children with prolonged resuscitation efforts without ROSC after 2 doses of
epinephrine were considered unlikely to survive;
however, intact survival after an unusually prolonged in-hospital resuscitation has been documented in children with VF or VT, drug toxicity, and
primary hypothermic insult. 32
CONCLUSION
Successful resuscitation requires a well-organized
team approach, with each member knowing his or
her preassigned responsibilities. 33 Pediatric-sized
equipment and precalculated weight-based medication dosing devices or the Broselow tape must be
available and organized for easy access. It is
imperative that the staff have training in PALS and
routinely practice mock pediatric resuscitations in
their unit. The most important determinant of
successful resuscitation is the maintenance of
adequate coronary artery and cerebral artery
perfusion. These can be achieved by implementing
the new guidelines of the AHA, by beginning
resuscitation with C-A-B. Resuscitation outcomes
in infants and children can be improved by
providing high-quality chest compressions combined with effective ventilations.
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REFERENCES
1. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest
cardiac massage. JAMA 1960;173:1064-7.
2. Nadkarni VM, Larkin GL, Peberdy MA, et al. First
documented rhythm and clinical outcome from in-hospital
cardiac arrest among children and adults. JAMA 2006;295:
50-7.
3. Meaney PA, Nadkarni VM, Kern KB, et al. Rhythms and
outcomes of adult in-hospital cardiac arrest. Crit Care Med
2010;38:101-8.
4. Atkins DL, Everson-Stewart S, Sears GK, et al. Epidemiology
and outcomes from out-of-hospital cardiac arrest in children:
the Resuscitation Outcomes Consortium EpistryCardiac
Arrest. Circulation 2009;119:1484-91.
5. Lopez-Herce J, Garcia C, Rodriguez-Nunez A, et al. Longterm outcome of paediatric cardiorespiratory arrest in Spain.
Resuscitation 2005;64:79-85.
6. Mogayzel C, Quan L, Graves JR, et al. Out-of-hospital
ventricular fibrillation in children and adolescents: causes
and outcomes. Ann Emerg Med 1995;25:484-91.
7. Kitamura T, Iwami T, Kawamura T, et al. Conventional and
chest-compression-only cardiopulmonary resuscitation by
bystanders for children who have out-of hospital cardiac
arrests: a prospective, nationwide, population-based cohort
study. Lancet 2010;375:1347-54.
8. Xu JQ, Kochanek KD, Murphy SL, et al. Deaths: final data for
2007. National vital statistics reports; vol 58 no 19. Hyattsville,
MD: National Center for Health Statistics; 2010.
9. Crewdson K, Lockey D, Davies G. Outcome from paediatric
cardiac arrest associated with trauma. Resuscitation 2007;
75:29-34.
10. Berg MD, Schexnayder SM, Chameides L, et al. 2010
American Heart Association guidelines for cardiopulmonary
resuscitation and emergency cardiovascular care science.
Part 13: pediatric basic life support: 2010 American Heart
Association guidelines for cardiopulmonary resuscitation
and emergency cardiovascular care. Circulation 2010;122:
S862-75.
11. Tibballs J, Russell P. Reliability of pulse palpation by
healthcare personnel to diagnose paediatric cardiac arrest.
Resuscitation 2009;80:61-4.
12. Kleinman ME, Chameides L, Schexnayder SM, et al. 2010
American Heart Association guidelines for cardiopulmonary
resuscitation and emergency cardiovascular care science.
Part 14: pediatric advanced life support: 2010 American
Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;
122:S876-908.
13. Paradis NA, Martin GB, Rivers EP, et al. Coronary perfusion
pressure and the return of spontaneous circulation in
human cardiopulmonary resuscitation. JAMA 1990;263:
1106-13.
14. Kolar M, Krizmaric M, Klemen P, et al. Partial pressure of endtidal carbon dioxide successful predicts cardiopulmonary
resuscitation in the field: a prospective observational study.
Crit Care 2008;12:1-13.
15. Smith KK, Gilcreast D, Pierce K. Evaluation of staff's retention
of ACLS and BLS skills. Resuscitation 2008;78:59-65.
16. Paradis NA, Martin GB, Goetting MG, et al. Simultaneous
aortic, jugular bulb, and right atrial pressures during
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
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