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GUIDELINE UPDATE:
Pediatric advanced life support

Who should read this?

Any physician assistant who provides medical care to pediatric patients.

What’s new?

In 2005 and 2006, the American Heart Association revised the 2001 Pediatric Advanced Life Support guidelines.^1-4 The revisions were made because different approaches are needed to treat cardiovascular collapse in pediatric and adult populations. The principal mechanism for cardiovascular collapse in children is inadequate respiration or ventilation; in adults, the principal mechanism is primary cardiac failure.

The new recommendations do not imply that using the earlier guidelines constituted unsafe practice. Instead, code leaders may need to adapt the application of guidelines to unique circumstances, as it is now recognized that they will not apply to all rescuers and all victims in all situations. Important points include the following:

EMPHASIS ON EFFECTIVE CPR Effective CPR is crucial to a successful resuscitation. High quality CPR, defined as forceful, uninterrupted chest compressions allowing for full chest recoil, is emphasized by the phrase, push hard, push fast. A compression to ventilation ratio of 30:2 for lone providers and 15:2 for two-person resuscitation is recommended in infants and children, as in adults, to minimize interruptions in chest compressions. Central cyanosis and/or bradycardia are ominous signs. Bradycardia in the pediatric population may be a preterminal rhythm reflecting poor systemic perfusion. If ventilation and airway are secured and bradycardia persists, chest compressions should be administered to augment circulation.

DRUG ADMINISTRATION DURING CPR FOR PULSELESS ARREST Interruptions in CPR should be kept to the absolute minimum. If a drug is to be administered, it should be drawn up before beginning CPR and delivered directly after heart rhythm is checked. The recommended sequence is to defibrillate and then perform either 5 cycles of chest compressions and ventilations or continuous CPR for 2 minutes. Following that period, the presence of a perfusing rhythm is confirmed or discounted, and any drugs needed for the evolving situation are administered as CPR is resumed.

VASCULAR ACCESS PREFERRED The preferred route of drug administration has always been intravascular. The new guidelines re-emphasize that an intraosseous (IO) canula can provide access to marrow sinusoids for effective administration of drugs. By contrast, endotracheal drug administration is limited to a small number of drugs with questionable drug uptake and delivery. Because of this, optimal doses of medications for endotracheal administration are unknown or unreliable. Lidocaine, epinephrine, atropine, and naloxone may be administered at higher doses through an endotracheal tube in critical situations, such as when resuscitation efforts are prolonged; however, results are not predictable.

HIGH-DOSE EPINEPHRINE NOT RECOMMENDED High-dose epinephrine (0.1 mg/kg IV/IO) appears to be harmful with little demonstrated survival benefit based on randomized clinical trials and should be considered only under extraordinary circumstances, such as beta-blocker overdose. The recommendation stresses using the standard dose (0.01-0.03 mg/kg IV/IO) for the first and all subsequent doses.

AMIODARONE IS PREFERRED OVER LIDOCAINE In the presence of ventricular tachycardia (VT) or when attempting to prevent recurrent ventricular fibrillation (VF), amiodarone is recommended over lidocaine, as evidence shows lidocaine not to be beneficial.

HYPOTHERMIA OCCURRING AFTER RESUSCITATION Cooling comatose infants (32-34°C for 12-24 hours) may lessen the impact of hypoxic injury.

CAUTIONS FOR USE OF ADVANCED AIRWAY Advanced airway management should be handled only by trained, experienced providers. Ventilation with an Ambu-Bag and mask can provide effective oxygenation and should be used by those unskilled in advanced airway management.

CONFIRMATION OF ENDOTRACHEAL TUBE PLACEMENT The new guidelines stress the use of devices to supplement clinical judgment. Immediately following tube placement, or any time after the patient is moved, care must be taken to ensure the tube remains in the proper position. The new guidelines suggest that providers rely on a sound clinical impression augmented by colormetric or capnographic devices to ensure that CO₂ is detected in expired air. For children weighing 20 kg or more with perfusing rhythms, esophageal detection devises may be considered. Finally, any decline in cardiopulmonary status should immediately lead to confirmation of endotracheal tube.

USE OF CUFFED ENDOTRACHEAL TUBES Previous recommendations included the use of the uncuffed endotracheal tube in children. The new protocols allow the placement of a cuffed endotracheal tube (except in newborns), as long as the cuff pressure remains below 20 cm H₂O. The proper sizing of the tube is also crucial. The proper endotracheal tube size is obtained from Broselow Tape or by a calculation [cuffed endotracheal tube size (mm ID) = (age in years ÷ 4) + 3].

NEONATAL RESUSCITATION The major goal for the infant in the immediate postnatal period is establishment of effective and spontaneous respirations. Several issues discussed in the new guidelines are directly associated with problems encountered during this period. The compression-to-ventilation ratio in the neonatal setting is different than that for children and infants. A chest compression to ventilation ratio of 3:1 is recommended immediately following birth. If this fails to stimulate and sustain spontaneous respirations, ventilation assist devices with limited flow are recommended. An increase in heart rate serves as a reliable sign of effective ventilation. Supplemental oxygen should be administered in infants requiring positive pressure ventilation or when spontaneous respirations yield central cyanosis. Oxygen at a concentration of 100% may be initiated immediately; however, a short trial of lower oxygen concentrations or room air may yield improved heart rates and should be considered. Oxygen concentrations of 100% may be toxic to neonates, just as hypoxia leads to nervous system damage. Room air trials of less than 2 minutes should progress to oxygen supplementation if heart rate fails to increase or cyanosis fails to resolve.

In earlier guidelines, the presence of meconium in amniotic fluid raised concerns of meconium aspiration or airway compromise. New evidence has diminished those concerns, and the presence of meconium in the amnion does not necessitate routine suctioning in a vigorous newborn. Infants who are not clearly vigorous should still be suctioned, however.

What else is important?

It is important to recognize that bad outcomes cannot always be avoided. Providers should bear in mind that high mortalities are associated with critically low birth weight, low gestational age, and certain congenital anomalies. In conditions where mortality can be prevented and morbidities limited, providers should move quickly to correct respiratory and cardiovascular problems.

REFERENCES

The members and staff of CSAC include Anthony E. Brenneman, MPAS, PA-C; Alison C. Essary, MHPE, PA-C; Edward C. Hendrikson, PA-C; Lawrence M. Herman, MPA, PA-C; Marie-Michèle Léger, MPH, PA-C; Robert McNellis, MPH, PA-C; Daniel L. O'Donoghue, PhD, PA-C; and Eileen M. Van Dyke, MPS, PA-C. This article was written by Daniel L. O'Donoghue, PhD, PA-C, and edited by Sarah Zarbock, PA-C.

© 2007 Haymarket Media, Inc. and the American Academy of Physician Assistants. All rights reserved.
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