Ricardo A. Samson

Part 13: Pediatric Basic Life Support 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

In contrast to adults, cardiac arrest in infants and children does not usually result from a primary cardiac cause. More often it is the terminal result of progressive respiratory failure or shock, also called an asphyxial arrest. Asphyxia begins with a variable period of systemic hypoxemia, hypercapnea, and acidosis, progresses to bradycardia and hypotension, and culminates with cardiac arrest.1 Another mechanism of cardiac arrest, ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), is the initial cardiac rhythm in approximately 5% to 15% of pediatric in-hospital and out-of-hospital cardiac arrests;2,–,9 it is reported in up to 27% of pediatric in-hospital arrests at some point during the resuscitation.6 The incidence of VF/pulseless VT cardiac arrest rises with age.2,4 Increasing evidence suggests that sudden unexpected death in young people can be associated with genetic abnormalities in myocyte ion channels resulting in abnormalities in ion flow (see “Sudden Unexplained Deaths,” below). Since 2010 marks the 50th anniversary of the introduction of cardiopulmonary resuscitation (CPR),10 it seems appropriate to review the progressive improvement in outcome of pediatric resuscitation from cardiac arrest. Survival from in-hospital cardiac arrest in infants and children in the 1980s was around 9%.11,12 Approximately 20 years later, that figure had increased to 17%,13,14 and by 2006, to 27%.15,–,17 In contrast to those favorable results from in-hospital cardiac arrest, overall survival to discharge from out-of-hospital cardiac arrest in infants and children has not changed substantially in 20 years and remains at about 6% (3% for infants and 9% for children and adolescents).7,9 It is unclear why the improvement in outcome from in-hospital cardiac arrest has occurred, although earlier recognition and management of at-risk patients on general inpatient units …

Part 1: Executive Summary 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

The goal of therapy for bradycardia or tachycardia is to rapidly identify and treat patients who are hemodynamically unstable or symptomatic due to the arrhythmia. Drugs or, when appropriate, pacing may be used to control unstable or symptomatic bradycardia. Cardioversion or drugs or both may be used to control unstable or symptomatic tachycardia. ACLS providers should closely monitor stable patients pending expert consultation and should be prepared to aggressively treat those with evidence of decompensation.

2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: Pediatric advanced life support

This publication presents the 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of the pediatric patient and the 2005 American Academy of Pediatrics/AHA guidelines for CPR and ECC of the neonate. The guidelines are based on the evidence evaluation from the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, hosted by the American Heart Association in Dallas, Texas, January 23–30, 2005. The “2005 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care” contain recommendations designed to improve survival from sudden cardiac arrest and acute life-threatening cardiopulmonary problems. The evidence evaluation process that was the basis for these guidelines was accomplished in collaboration with the International Liaison Committee on Resuscitation (ILCOR). The ILCOR process is described in more detail in the “International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.” The recommendations in the “2005 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care” confirm the safety and effectiveness of many approaches, acknowledge that other approaches may not be optimal, and recommend new treatments that have undergone evidence evaluation. These new recommendations do not imply that care involving the use of earlier guidelines is unsafe. In addition, it is important to note that these guidelines will not apply to all rescuers and all victims in all situations. The leader of a resuscitation attempt may need to adapt application of the guidelines to unique circumstances. The following are the major pediatric advanced life support changes in the 2005 guidelines: There is further caution about the use of endotracheal tubes. Laryngeal mask airways are acceptable when used by experienced providers. Cuffed endotracheal tubes may be used in infants (except newborns) and children in in-hospital settings provided that cuff inflation pressure is kept <20 cm H2O. Confirmation of tube placement requires clinical assessment and assessment of exhaled carbon dioxide (CO2); esophageal detector devices may be considered for use in children weighing >20 kg who have a perfusing rhythm. Correct placement must be verified when the tube is inserted, during transport, and whenever the patient is moved. During CPR with an advanced airway in place, rescuers will no longer perform “cycles” of CPR. Instead, the rescuer performing chest compressions will perform them continuously at a rate of 100/minute without pauses for ventilation. The rescuer providing ventilation will deliver 8 to 10 breaths per minute (1 breath approximately every 6–8 seconds). Timing of 1 shock, CPR, and drug administration during pulseless arrest has changed and now is identical to that for advanced cardiac life support. Routine use of high-dose epinephrine is not recommended. Lidocaine is de-emphasized, but it can be used for treatment of ventricular fibrillation/pulseless ventricular tachycardia if amiodarone is not available. Induced hypothermia (32–34°C for 12–24 hours) may be considered if the child remains comatose after resuscitation. Indications for the use of inodilators are mentioned in the postresuscitation section. Termination of resuscitative efforts is discussed. It is noted that intact survival has been reported following prolonged resuscitation and absence of spontaneous circulation despite 2 doses of epinephrine. The following are the major neonatal resuscitation changes in the 2005 guidelines: Supplementary oxygen is recommended whenever positive-pressure ventilation is indicated for resuscitation; free-flow oxygen should be administered to infants who are breathing but have central cyanosis. Although the standard approach to resuscitation is to use 100% oxygen, it is reasonable to begin resuscitation with an oxygen concentration of less than 100% or to start with no supplementary oxygen (ie, start with room air). If the clinician begins resuscitation with room air, it is recommended that supplementary oxygen be available to use if there is no appreciable improvement within 90 seconds after birth. In situations where supplementary oxygen is not readily available, positive-pressure ventilation should be administered with room air. Current recommendations no longer advise routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants born to mothers with meconium staining of amniotic fluid. Endotracheal suctioning for infants who are not vigorous should be performed immediately after birth. A self-inflating bag, a flow-inflating bag, or a T-piece (a valved mechanical device designed to regulate pressure and limit flow) can be used to ventilate a newborn. An increase in heart rate is the primary sign of improved ventilation during resuscitation. Exhaled CO2 detection is the recommended primary technique to confirm correct endotracheal tube placement when a prompt increase in heart rate does not occur after intubation. The recommended intravenous (IV) epinephrine dose is 0.01 to 0.03 mg/kg per dose. Higher IV doses are not recommended, and IV administration is the preferred route. Although access is being obtained, administration of a higher dose (up to 0.1 mg/kg) through the endotracheal tube may be considered. It is possible to identify conditions associated with high mortality and poor outcome in which withholding resuscitative efforts may be considered reasonable, particularly when there has been the opportunity for parental agreement. The following guidelines must be interpreted according to current regional outcomes: When gestation, birth weight, or congenital anomalies are associated with almost certain early death and when unacceptably high morbidity is likely among the rare survivors, resuscitation is not indicated. Examples are provided in the guidelines. In conditions associated with a high rate of survival and acceptable morbidity, resuscitation is nearly always indicated. In conditions associated with uncertain prognosis in which survival is borderline, the morbidity rate is relatively high, and the anticipated burden to the child is high, parental desires concerning initiation of resuscitation should be supported. Infants without signs of life (no heartbeat and no respiratory effort) after 10 minutes of resuscitation show either a high mortality rate or severe neurodevelopmental disability. After 10 minutes of continuous and adequate resuscitative efforts, discontinuation of resuscitation may be justified if there are no signs of life.

Part 1: Executive Summary

Mary Fran Hazinski, Co-Chair*; Jerry P. Nolan, Co-Chair*; John E. Billi; Bernd W. Böttiger; Leo Bossaert; Allan R. de Caen; Charles D. Deakin; Saul Drajer; Brian Eigel; Robert W. Hickey; Ian Jacobs; Monica E. Kleinman; Walter Kloeck; Rudolph W. Koster; Swee Han Lim; Mary E. Mancini; William H. Montgomery; Peter T. Morley; Laurie J. Morrison; Vinay M. Nadkarni; Robert E. O’Connor; Kazuo Okada; Jeffrey M. Perlman; Michael R. Sayre; Michael Shuster; Jasmeet Soar; Kjetil Sunde; Andrew H. Travers; Jonathan Wyllie; David Zideman

Part 6: Electrical therapies: Automated external defibrillators, defibrillation, cardioversion, and pacing: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

The recommendations for electrical therapies described in this section are designed to improve survival from SCA and life-threatening arrhythmias. Whenever defibrillation is attempted, rescuers must coordinate high-quality CPR with defibrillation to minimize interruptions in chest compressions and to ensure immediate resumption of chest compressions after shock delivery. The high first-shock efficacy of newer biphasic defibrillators led to the recommendation of single shocks plus immediate CPR instead of 3-shock sequences that were recommended prior to 2005 to treat VF. Further data are needed to refine recommendations for energy levels for defibrillation and cardioversion using biphasic waveforms.

Part 1: Executive summary: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care

Publication of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) marks 49 years since the first CPR guidelines were published in 1966 by an Ad Hoc Committee on Cardiopulmonary Resuscitation established by the National Academy of Sciences of the National Research Council.1 Since that time, periodic revisions to the Guidelines have been published by the AHA in 1974,2 1980,3 1986,4 1992,5 2000,6 2005,7 2010,8 and now 2015. The 2010 AHA Guidelines for CPR and ECC provided a comprehensive review of evidence-based recommendations for resuscitation, ECC, and first aid. The 2015 AHA Guidelines Update for CPR and ECC focuses on topics with significant new science or ongoing controversy, and so serves as an update to the 2010 AHA Guidelines for CPR and ECC rather than a complete revision of the Guidelines. The purpose of this Executive Summary is to provide an overview of the new or revised recommendations contained in the 2015 Guidelines Update. This document does not contain extensive reference citations; the reader is referred to Parts 3 through 9 for more detailed review of the scientific evidence and the recommendations on which they are based. There have been several changes to the organization of the 2015 Guidelines Update compared with 2010. “Part 4: Systems of Care and Continuous Quality Improvement” is an important new Part that focuses on the integrated structures and processes that are necessary to create systems of care for both in-hospital and out-of-hospital resuscitation capable of measuring and improving quality and patient outcomes. This Part replaces the “CPR Overview” Part of the 2010 Guidelines. Another new Part of the 2015 Guidelines Update is “Part 14: Education,” which focuses on evidence-based recommendations to facilitate widespread, consistent, efficient and effective implementation …

Pediatric Advanced Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

For best survival and quality of life, pediatric basic life support (BLS) should be part of a community effort that includes prevention, early cardiopulmonary resuscitation (CPR), prompt access to the emergency response system, and rapid pediatric advanced life support (PALS), followed by integrated post–cardiac arrest care. These 5 links form the American Heart Association (AHA) pediatric Chain of Survival (Figure 1), the first 3 links of which constitute pediatric BLS. FIGURE 1. Pediatric Chain of Survival. Rapid and effective bystander CPR can be associated with successful return of spontaneous circulation (ROSC) and neurologically intact survival in children following out-of-hospital cardiac arrest.1,–,3 Bystander resuscitation may have the greatest impact for out-of-hospital respiratory arrest,4 because survival rates >70% have been reported with good neurologic outcome.5,6 Bystander resuscitation may also have substantial impact on survival from primary ventricular fibrillation (VF), because survival rates of 20% to 30% have been documented in children with sudden out-of-hospital witnessed VF.7 Overall about 6%8 of children who suffer an out-of-hospital cardiac arrest and 8% of those who receive prehospital emergency response resuscitation survive, but many suffer serious permanent brain injury as a result of their arrest.7,9,–,14 Out-of-hospital survival rates and neurological outcome can be improved with prompt bystander CPR,3,6,15,–,17 but only about one third to one half of infants and children who suffer cardiac arrest receive bystander CPR.3,9,12,18 Infants are less likely to survive out-of-hospital cardiac arrest (4%) than children (10%) or adolescents (13%), presumably because many infants included in the arrest figure are found dead after a substantial period of time, most from sudden infant death syndrome (SIDS).8 As in adults, survival is …

Part 12: Pediatric Advanced Life Support 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Over the past 13 years, survival to discharge from pediatric in-hospital cardiac arrest (IHCA) has markedly improved. From 2001 to 2013, rates of return of spontaneous circulation (ROSC) from IHCA increased significantly from 39% to 77%, and survival to hospital discharge improved from 24% to 36% to 43% (Girotra et al1 and personal communication with Paul Chan, MD, MSc, April 3, 2015). In a single center, implementation of an intensive care unit (ICU)–based interdisciplinary debriefing program improved survival with favorable neurologic outcome from 29% to 50%.2 Furthermore, new data show that prolonged cardiopulmonary resuscitation (CPR) is not futile: 12% of patients receiving CPR in IHCA for more than 35 minutes survived to discharge, and 60% of the survivors had a favorable neurologic outcome.3 This improvement in survival rate from IHCA can be attributed to multiple factors, including emphasis on high-quality CPR and advances in post-resuscitation care. Over the past decade, the percent of cardiac arrests occurring in an ICU setting has increased (87% to 91% in 2000 to 2003 to 94% to 96% in 2004 to 2010).4 While rates of survival from pulseless electrical activity and asystole have increased, there has been no change in survival rates from in-hospital ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT). Conversely, survival from out-of-hospital cardiac arrest (OHCA) has not improved as dramatically over the past 5 years. Data from 11 US and Canadian hospital emergency medical service systems (the Resuscitation Outcomes Consortium) during 2005 to 2007 showed age-dependent discharge survival rates of 3.3% for infants (less than 1 year), 9.1% for children (1 to 11 years), and 8.9% for adolescents (12 to 19 years).5 More recently published data (through 2012) from this network demonstrate 8.3% survival to hospital discharge across all age groups, with 10.5% survival for children …

Importance and Implementation of Training in Cardiopulmonary Resuscitation and Automated External Defibrillation in Schools: A Science Advisory From the American Heart Association

In 2003, the International Liaison Committee on Resuscitation published a consensus document on education in resuscitation that strongly recommended that “…instruction in CPR [cardiopulmonary resuscitation] be incorporated as a standard part of the school curriculum.”1 The next year the American Heart Association (AHA) recommended that schools “…establish a goal to train every teacher in CPR and first aid and train all students in CPR” as part of their preparation for a response to medical emergencies on campus.2 Since that time, there has been an increased interest in legislation that would mandate that school curricula include training in CPR or CPR and automated external defibrillation. Laws or curriculum content standards in 36 states (as of the 2009–2010 school year) now encourage the inclusion of CPR training programs in school curricula. The language in those laws and standards varies greatly, ranging from a suggestion that students “recognize” the steps of CPR to a requirement for certification in CPR. Not surprisingly, then, implementation is not uniform among states, even those whose laws or standards encourage CPR training in schools in the strongest language. This statement recommends that training in CPR and familiarization with automated external defibrillators (AEDs) should be required elements of secondary school curricula and provides the rationale for implementation of CPR training, as well as guidance in overcoming barriers to implementation. Sudden cardiac arrest is a leading cause of death in the United States and Canada. It is estimated that each year emergency medical services (EMS) personnel assess 294 851 (quasi-confidence intervals, 236 063 to 325 007) out-of-hospital cardiac arrests (OHCAs) in the United States. Survival, which is defined as being discharged alive from the hospital, varies widely by region (3.0% to 16.3%; median, 8.4%), but the overall average rate of survival to discharge from the hospital is estimated …

Use of Automated External Defibrillators for Children: An Update An Advisory Statement From the Pediatric Advanced Life Support Task Force, International Liaison Committee on Resuscitation

On the basis of the published evidence to date, the Pediatric Advanced Life Support (PALS) Task Force of the International Liaison Committee on Resuscitation (ILCOR) has made the following recommendation (October 2002): In addition: This statement expands and clarifies the 2000 ILCOR recommendations about the potential use of AEDs in children. The need for this update has become critical. A growing number of AEDs for adults are being placed in public access settings, and the use of AEDs by nontraditional responders is increasing. The likelihood for use of AEDs in smaller (<25 kg), younger (<8 years of age) patients is now a reality. This statement provides the rationale for development of AEDs, outlines questions about the efficacy and safety of AEDs used in smaller, younger children, and summarizes recent efforts to justify the use of existing or modified AEDs in smaller, younger children. ### Rationale for AED Use The primary determinant of survival from VF cardiac arrest is the time interval from collapse until defibrillation. Out-of-hospital defibrillation within the first …