Update on Paediatric resuscitation

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Update on Paediatric resuscitation

• Lee Wallis

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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

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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

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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

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Highlights lay

• Recommendation of a single (universal)
  compression-to ventilation ratio of 302 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

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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

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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

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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

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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

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issues for childrennewborn 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

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issues for childrenroute 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.

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issues for childrenendotracheal 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.

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number of defibrillating shocks

• one shock rather than three stacked shocks
• VF
• pulseless VT

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cardiac arrest algorithm
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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.

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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 302 ratio
  for all ages

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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

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cardiac arrest algorithm
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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

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choking relief sequence

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

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choking
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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

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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.

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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

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Summary of ALS guidelines
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