1. Pediatric Resuscitation: New Guidelines Update 2002 Arno Zaritsky, M.D.
©2000 American Heart Association 1

2. PBLS & PALS Guidelines
New guidelines published in August 22, 2000 addition of Circulation
NRP guidelines on Pediatrics web site: (September 2000)
Changes in new guidelines summarized in Currents: (Currents Newsletter)
PALS Instructors Manual December 2001 and Textbook published March 2002

3. Levels of Evidence Level 1 Large RCTs in humans
Level 2 Small RCTs in humans
Level 3 Prospective, non-randomized
Level 4 Historic controls, non-randomized
Level 5 Human case series
Level 6 Animal studies
Level 7 Rational extrapolation
Level 8 Rational conjecture (common sense)

4. Class of Recommendations
Class I: Proven safe and effective
Excellent evidence; LOE 1
Class IIa: Acceptable, useful
Good-to-very good evidence; LOE 2-4
Class IIb: Acceptable, useful
Fair-to-weak evidence; LOE 4-8
Class III: Unacceptable, harmful
Class Indeterminate: Inadequate data

5. PBLS: 1992-2000 Only 30% of kids receive bystander CPR
CPR: a complex psychomotor task
Difficult to teach, learn, remember, and perform
Often poorly performed
Pulse check

6. “For crying out loud, I was HIBERNATING!
…Don’t you guys ever take a pulse?

7. Pediatric Basic Life Support
Pulse check: time-consuming and unreliable
Lay rescuer: no pulse check (IIa)
Healthcare provider: check for “signs of circulation” (breathing, movement, response) and pulse ~10 secs

8. PULSE CHECK Accuracy in Identifying Cardiac Arrest
Rescuers take too long to decide if pulse present (median time: 24 sec; only 15% decided within 10 sec)
Sensitivity 90% to identify absent pulse (10% of victims in pulseless arrest would be “missed”)
Specificity 60% (40% of victims with pulse would receive compressions)
Overall error rate 35%

9. Compression-Ventilation Ratio
Consensus among resuscitation councils was to maintain age-specific rates:
Newly born 3:1
Children < 8 5:1
Children > 8 15:2
Note: do not need to maintain ratio once patient is intubated

10. Compression-Ventilation Ratio
Rationale for recommendation:
Respiratory problems are the most common cause of pediatric arrest
Physiologic respiratory rates in infants and children are faster than in adults
Adult compression rate important to maintain coronary perfusion pressure
Current providers are trained and accustomed to these ratios

11. Ventilation during CPR
The rescuer should use only the force and tidal volume necessary to cause the chest to rise visibly.
Larger tidal volumes recommended if ventilating with room air

12. Complications of Over-ventilation
Compromises cardiac output – positive pressure ventilation, auto-PEEP
Raises intrathoracic pressure
Risk of barotrauma
Distends stomach
Impedes ventilation
Increases risk of aspiration
Hyperventilation in head injured patient may be harmful

13. Goals of BVM Ventilation
Approximate normal ventilation and achieve physiological oxygen and carbon dioxide levels while minimizing risk of iatrogenic injury. [Class IIa]
Hyperventilate if signs of increased ICP

15. Chest Compressions
2-thumb, encircling hands preferred to 2-finger compression technique
(Class IIb, LOE 5)
Achieves higher peak systolic and coronary perfusion pressure
providers prefer this technique

16. “Thank heavens the plumber knows CPR!”

17. Pediatric Airway and Breathing
Best prehospital approach depends on training, skills, and situation
Endotracheal intubation (ETI): not Gold Standard in all circumstances
BVM: needs emphasis in training
may be preferable to ETI in prehospital setting with short transport time (IIa)

18. Pediatric ETI vs BVM in Prehospital Setting (Gausche JAMA 2000; 283:783)
No difference in overall survival
BVM: 123/404 (30%)
ETI: /416 (26%)
Odds ratio, 0.82 (95% CI, )
BVM better survival for respiratory arrest
BVM: 46/54 (85% survival)
ETI: /45 (61% survival)
OR, 0.27 (95% CI, )

19. Prehospital ETI problems
57% successful intubation rate
Longer time at scene (2-3 minutes)
2% esophageal intubation rate
6% unrecognized extubation rate
14/15 with esophageal intubation or unrecognized extubation DIED
Gausche JAMA 2000; 283:783

20. Align the oral (O), pharyngeal (P) and tracheal (T) planes:
Elevate the occiput and extend the head.
Looking from side, note the ear anterior to the shoulder—”sniffing rose” position.

21. Cricoid pressure reduces risk of aspiration
Only use in unconscious patient
Don’t distort trachea

22. Confirmation of ET Tube Placement
PALS emphasizes advanced airway management to prevent arrest
But, we should avoid morbidity/ mortality from this intervention
Who should perform prehospital ETI?
Is exhaled CO2 detection reliable in children and can its use increase safety of ETI?

23. Intubation Case
A 4-year old child with CP and a seizure disorder is found unresponsive at home and 911 is called
CPR is begun by family; EMS arrives and intubates child with a 5 mm ET tube
Breath sounds are heard bilaterally, but no air heard over stomach
Exhaled CO2 detector shows no color change
What would you do now?
What does this mean?

24. Intubation Case
Confirm placement of tracheal tube by direct visualization
Assure that proper closed chest compression is being performed

25. Exhaled CO2 Detection pH sensitive filter paper
Detects exhaled CO2 >0.5% (~4 torr)
Specific for correct tube placement when color changes
Increases airway resistance

26. Exhaled CO2 = 10 torr
PaCO2 = 25 torr
PvCO2 = 100 torr

27. Expired CO2
False negative: inadequate pulmonary blood flow or severe airway obstruction
Expired CO2 correlates with effectiveness of compression-induced cardiac output
Absent color change correlates with death in cardiac arrest
Transient decline in pulmonary blood flow following epinephrine
Massive pulmonary embolus
Pulmonary edema (ARDS)

28. Expired CO2
False positive: Contamination of device with secretions or drugs may cause fixed color change
Spontaneously breathing patient with tube in the posterior pharynx rather than trachea

29. Exhaled CO2 (yellow)
Normal (purple)

30. Conclusions: Confirmation of Tube Position
No single confirmation device or exam technique is 100% reliable under all circumstances
Expired CO2 detection is reliable in perfusing patient
Expired CO2 is specific, but not sensitive for tracheal position in cardiac arrest patient
Repeat confirmation after patient movement

32. Intraosseous access Expand to > 6 yo (Class IIa)
OK in neonates, if umbilical vessels not accessible (Class IIb)
Encourage IO without delay for cardiac arrest and decompensated shock

33. Drug and Equipment Selection
Broselow® tape based on 50% weight for length
Broselow tape used to estimate weight, calculate drugs and select ETT and other equipment

34. Broselow Resuscitation Tape

35. VF in kids VF is uncommon, but not rare
5-20% prehospital arrests (excluding SIDS)
Appropriate Rx is DEFIBRILLATION
New recommendations:
Emphasis on early cardiac rhythm analysis
Physicians responsible to notify at-risk families to learn CPR and “phone 1st”
AEDs may be used if > 8 yo (Indeterminate)

36. Drug therapy in cardiac arrest
Epinephrine is the drug of choice
Initial dose of 0.01 mg/kg
Data do not support subsequent high doses of epinephrine; may be considered (IIb), but not recommended. Consider in sepsis, beta-blocker overdose, etc.
Vasopressin: potent selective vasoconstrictor for skin, muscle, intestine and fat with relatively little effect on vessels in heart & brain
Clinical and animal studies are supportive
Asphyxial model: no benefit
Not recommended (Indeterminate)

37. Drug Therapy: Magnesium
Torsades de pointes ventricular tachycardia
Often related to drug toxicity
Acute asthma unresponsive to ß-adrenergic agonists
mg/kg slow IV infusion over minutes; max. dose 2 g
Monitor BP and HR
Side effect: hypotension and bradycardia

38. Anti-arrhythmic therapy
Refractory ventricular tachycardia or fibrillation
3 shocks, IV/IO epinephrine, 4th shock
Amiodarone (Indeterminate)
Lidocaine (Indeterminate)
High-dose epinephrine (Class IIb)
Vasopressin (Indeterminate)
Bretylium (Class III) – not recommended, high-risk of hypotension

39. Amiodarone
Complex pharmacology: highly lipid soluble; non-competitive inhibitor of SNS
VERY long half-life
Blocks outward K+ current  prolonged QT
Inhibits Na+ channels  slows conduction and prolongs QRS duration.
Use-dependent inhibition  works best at high rates
Useful in SVT, VT, JET, EAT and VF
Limited peds data, but based on adult data, considered drug of choice in shock-resistant VF/pulseless VT over lidocaine

40. Amiodarone FDA warning issued March 21, 2001
Plasticizer may be leached out during slow infusions – concerns about effects on male reproductive tract
“Gasping syndrome” – benzyl alcohol
Neonatal toxicity – gasping respirations, hypotension, bradycardia and cardiovascular collapse

41. Case
A 15-year old is brought to the ED by EMS after being found unresponsive in the bathroom
She had a fight with her boyfriend earlier in the day
She is noted to have occasional PVCs on the monitor with widened QRS complexes
Shortly after arrival she begins to seize
What do you want to do?

42. Toxicology (examples)
Tricyclic antidepressants:
Sodium bicarbonate (IIb)
Calcium-channel blocker overdose:
IV calcium (IIb)
Narcotics:
Naloxone (IIa)
Ventilation prior to naloxone (IIb)

43. Post-resuscitation care
Avoid routine hyperventilation (Class III)
Avoid rewarming unless core temp <33o C (Class IIb)
Treat hyperthermia with active cooling (Class IIa)
Post-resuscitation myocardial dysfunction is common: Rx it!!

44. Avoiding Hyperthermia
Worsens injury after hypoxic-ischemic insult (animals)
Extension of infarct size and worsening of outcome after ischemic stroke (adults)
Association of cerebral palsy with maternal infection/fever (neonates)

46. Initial Steps Provide warmth avoiding hyperthermia
Position, clear airway (as necessary)
tracheal suctioning for meconium
Dry, stimulate, reposition
Give O2 (as necessary)

47. Neonatal Resuscitation Room air vs. 100% Oxygen
If assisted ventilation is required, 100% oxygen should be delivered by positive pressure ventilation … If supplemental oxygen is not available, resuscitation of the newly born infant should be initiated with positive pressure ventilation and room air. [Indeterminate Class, level 2 evidence]

49. Meconium Aspiration (n=1051) (n=1043)
12 centers Intubate Expectant
(n=1051) (n=1043)
Overall (n=149) 74 (7.0%) 75 (7.2%)
MAS (n=62) 34 (3.2%) 28 (2.7%)
Other (N=87) 40 (3.8%) 47 (4.5%)
Wiswell Pediatrics 2000

50. Neonatal Resuscitation Meconium
Direct endotracheal suctioning is not necessary in vigorous infants with meconium-stained fluid. [Class I, level 1 evidence]
Direct endotracheal suctioning, using the endotracheal tube as a suction catheter, should be performed if the neonate is depressed (weak or absent respirations, poor tone, HR < 100 bpm).
Delay gastric aspiration until initial resuscitation is complete.
Best to suction airway on the perineum

51. Neonatal Resuscitation Volume expansion
Albumin and other colloids may increase mortality in critically ill patients. Also, more expensive.
Therefore, volume expansion may be accomplished with (1) isotonic crystalloid such as normal saline or Ringer’s lactate or (2) O-negative blood. [Class IIb, level 7 evidence]

52. Neonatal Resuscitation: Chest compressions
Begin if HR < 60 bpm despite adequate ventilation for 30 seconds
120 events per minute: 90 compressions:30 ventilations
Two-thumb encircling technique is preferred
Compress ~1/3 of AP diameter of chest

53. Neonatal Resuscitation: Post-resuscitation
Avoid and correct hyperthermia
Experimental data suggest benefit from induction of cerebral hypothermia but insufficient data (Class Indeterminate)

54. Avoiding Hyperthermia
Potentiation of injury after perinatal hypoxic-ischemic insult (animals)
Extension of infarct size and worsening of outcome after ischemic stroke (adults)
Association of cerebral palsy with maternal infection/fever (neonates)

55. Questions??

56. Neonatal Resuscitation Ethics
Non-initiation of resuscitation in the delivery room in infants with confirmed gestation < 23 weeks, birthweight < 400 grams, or with anencephaly or confirmed trisomy 13 or 18 may be appropriate. Current data support that resuscitation of these newborns is very unlikely to result in survival or survival without severe disability.
[Class IIb, level 5 evidence]

57. Neonatal Resuscitation Ethics
In cases of uncertain prognosis, including uncertain gestational age, a trial of therapy, non-initiation, or discontinuation of resuscitation remain options following assessment of the baby. Ongoing evaluation and discussion with the parents and the health care team should guide continuation vs. withdrawal of support.

58. Neonatal Resuscitation Ethics
Discontinuation may be appropriate after 15 minutes of absent heart rate despite complete and adequate resuscitation efforts.
Current data support that resuscitation of newborns after 10 minutes of asystole is very unlikely to result in survival or survival without severe disability.

59. Avoiding Hyperthermia
Hyperthermia should be avoided… because it is associated with perinatal respiratory depression (Class III, LOE 3).
Maternal fever and neonatal respiratory depression
Lieberman E, et al. Pediatrics 2000; 105:8
Perlman JM. Clin Pediatr 1999; 38:287

60. PALS: Airway & Ventilation
Bag—mask ventilation: increased emphasis
Selective endotracheal intubation
Confirmation of tracheal tube position