1 Pediatric Advanced Life Support PALS 2000 Major changes Itai Shavit, MD

International Guidelines Revision Process: Science Review International evidence evaluation and guidelines conferences — More than 500 experts from more than 30 countries attended — More than 25,000 manuscripts reviewed Recommendations reviewed and revised by science subcommittees, international editorial board, and Circulation editorial board Guidelines endorsed by 6 international resuscitation councils

Class of Recommendation Class I:Definitely recommended (at least 1 prospective positive RCT) Class II: Acceptable and useful IIa:Good to very good evidence (Multiple studies, “ good methodology ”, no harm) IIb:Fair to good evidence Indeterminate: Preliminary evidence needs confirmation; no harm Class III: Not acceptable, may be harmful Class of recommendation reflects quality of evidence and not clinical preference

1 BASIC LIFE SUPPORT © 2001 American Heart Association

Compression-Ventilation Ratios A compression-ventilation ratio of 15:2 is now recommended for 1 or 2 rescuer CPR for older children (>8 y/o) and adults until the airway is secure. 15:2 ratio provides more compressions per minute and higher coronary artery perfusion pressure — appropriate for primary cardiac arrest Once the airway is secured, ventilations and compressions may be asynchronous.

Coronary Perfusion Pressure Improves With Sequential Compressions CPP at 5:1 ratio CPP at 15:2 ratio

Two Thumb – Encircling Hands Technique Preferred for Infant 2-Rescuer CPR by HCP

The 2 thumb-encircling hands technique is preferred for chest compressions when 2- rescuer CPR is performed by Health Care Providers. This technique is not recommended for lay rescuers or when chest compressions are done by the lone health care provider.

1 AIRWAY © 2001 American Heart Association

Securing the airway Role of prehospital tracheal intubation Secondary confirmation of tracheal tube placement strongly recommended Use of laryngeal mask airway acceptable

Laryngeal Mask Airway The LMA can be used to secure an airway in an unresponsive/unconscious patient

Use of Laryngeal Mask Airway in Pediatric Advanced Life Support Extensive experience with pediatric and adult patients in the operating room An acceptable alternative to intubation of the unresponsive patient when the healthcare provider is trained Contraindicated if gag reflex intact Limited data outside the operating room (Class Indeterminate)

Secondary Confirmation of Tracheal Tube Placement: Exhaled CO 2 in Patients With a Perfusing Rhythm Normal exhaled CO 2 should be approximately equal to PaCO 2 if airway is patent and unobstructed Normal CO 2 in esophagus is approximately zero Exhaled CO 2 detected from tube is sensitive and specific for tracheal tube placement if perfusing rhythm is present in patient weighing >2 kg

Purple: No exhaled CO 2 detected Yellow: Exhaled CO 2 detected Colorimetric Exhaled CO 2 Detector

1 BREATHING © 2001 American Heart Association

Prehospital Tracheal Intubation vs Bag-Mask Ventilation Bag-mask ventilation may be as effective as intubation if transport time is short Tracheal intubation requires training and experience

Prehospital Tracheal Intubation vs Bag-Mask Ventilation Effect of Out-of-Hospital Pediatric Endotracheal Intubation on Survival and Neurological Outcome A Controlled Clinical Trial Marianne Gausche, MD; Roger J. Lewis, MD, PhD; Samuel J. Stratton, MD, MPH; Bruce E. Haynes, MD; Carol S. Gunter, BSN, MPA; Suzanne M. Goodrich, RN, MSN; Pamela D. Poore, RN; Maureen D. McCollough, MD, MPH; Deborah P. Henderson, PhD, RN; Franklin D. Pratt, MD; James S. Seidel, MD, PhD JAMA. 2000;283:

Prehospital Tracheal Intubation vs Bag-Mask Ventilation C ompared the survival and neurological outcomes of pediatric patients treated with bag-valve-mask ventilation (BVM) with those of patients treated with BVM followed by ETI (rapid transport EMS system). Controlled clinical trial, , 830 p, <12 y/o, JAMA. 2000;283:

Prehospital Tracheal Intubation vs Bag-Mask Ventilation There was no significant difference in survival between the BVM and ETI groups (30% vs. 26%) or the rate of good neurological outcomes (23% vs. 20%). JAMA. 2000;283:

1 CIRCULATION © 2001 American Heart Association

Intraosseous Needles Are Recommended for Patients >6 Years of Age Access to circulation is critical. “No one should die because of lack of vascular access ” Successful use of intraosseous needles has been documented in older children and adolescents

1 RHYTHM DISTURBANCES

Potentially Reversible Causes of Arrest: 4 H ’ s Hypoxemia Hypovolemia Hypothermia Hyper-/hypokalemia and metabolic causes (eg, hypoglycemia)

Potentially Reversible Causes of Arrest: 4 T ’ s Tamponade Tension pneumothorax Toxins/poisons/drugs Thromboembolism (pulmonary)

Drug Therapy for Cardiac Arrest Epinephrine: the drug of choice — Initial IV/IO dose: 0.01 mg/kg (tracheal: 0.1 mg/kg) — High dose Adrenaline is De-emphasized. Routine use of high doses of epinephrine is not recommended but may be considered (IIb) for conditions such as sepsis, anaphylaxis, or  -blocker overdose Vasopressin: a potent vasoconstrictor — Adult clinical and animal cardiac arrest studies support use in adult refractory VF arrest — Asphyxial model: no benefit — No data in pediatric cardiac arrest (Indeterminate)

Vagal Maneuvers for Supraventricular Tachycardia Evidence supports use of vagal maneuvers to try to terminate supraventricular tachycardia, particularly in the stable patient (Class IIa) Can be performed while preparing for drug administration or cardioversion Maneuvers: — Apply ice water to the face of infants and young children (Note: Do not occlude airway.) — Older children may blow into occluded straw

Amiodarone Amiodarone can be used to treat both SVT and VT/VF. In particular for refrartory VF (patient not responds to 3 shocks, 1 dose of Adrenaline, and a 4 th shock (class indeterminate) Extrapolation from adult cardiac arrest and pediatric nonarrest data suggest a role in shock-resistant VF/pulseless VT

Amiodarone Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation. Kudenchuk PJ, Cobb LA, Copass MK, Cummins RO, Doherty AM, Fahrenbruch CE, Hallstrom AP, Murray WA, Olsufka M, Walsh T. N Engl J Med Sep 16; 341(12): 871-8

Amiodarone In patients with out-of-hospital cardiac arrest due to refractory ventricular arrhythmias, treatment with amiodarone resulted in a higher rate of survival to hospital admission. Whether this benefit extends to survival to discharge from the hospital merits further investigation. N Engl J Med Sep 16; 341(12): 871-8

Prehospital Use of AEDs for children

“ Shockable rhythms ” in children Recent data suggests that pediatric VF/pulseless VT at the pre-hospital setting is more common than previously thought When VF/pulseless VT is present, early defibrillation often improves survival

Effect of Time to Defibrillation on Survival From Witnessed VF Cardiac Arrest Cummins 1989

AHA new Recommendations (2003) for Prehospital Use of AEDs in Victims 1-8 Years of Age At the time of publication of ILCOR guidelines 2000, AEDs were not cleared by the FDA for use in young children. Children < 8 with VF have been “ orphans ” for electrical treatment at the pre-hospital setting. The new generation of AEDs are biphasic (less energy is delivered), and sensitive for detection of “ shockable ” rhythms in children and infants.

AHA new Recommendations (2003) for Prehospital Use of AEDs in Victims 1-8 Years of Age AEDs may now be used for children 1-8 y/o who have no signs of circulation. Ideally the device should deliver a pediatric dose. (the lone rescuer should always starts with 1 min of CPR before activating EMS or using AED)

1 Post resuscitation © 2001 American Heart Association

Postresuscitation Interventions Provide normal oxygenation, ventilation Monitor temperature — Treat/prevent hyperthermia — Tolerate/don ’ t correct mild hypothermia Anticipate, treat myocardial dysfunction Maintain normoglycemia (avoid hyperglycemia and hypoglycemia)