Part 14: Pediatric Advanced Life Support : 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Monica E. Kleinman, Leon Chameides, Stephen M. Schexnayder, Ricardo A. Samson, Mary Fran Hazinski, Dianne L. Atkins, Marc D. Berg, Allan R. de Caen, Ericka L. Fink, Eugene B. Freid, Robert W. Hickey, Bradley S. Marino, Vinay M. Nadkarni, Lester T. Proctor, Faiqa A. Qureshi, Kennith Sartorelli, Alexis Topjian, Elise W. van der Jagt and Arno L. Zaritsky Circulation 2010, 122:S876-S908 doi: 10.1161/CIRCULATIONAHA.110.971101 Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX 72514 Copyright © 2010 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/content/122/18_suppl_3/S876 Subscriptions: Information about subscribing to Circulation is online at http://circ.ahajournals.org//subscriptions/ Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, a division of Wolters Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-2436. Phone: 410-528-4050. Fax: 410-528-8550. E-mail: [email protected] Reprints: Information about reprints can be found online at http://www.lww.com/reprints Downloaded from http://circ.ahajournals.org/ by guest on March 6, 2012 Part 14: Pediatric Advanced Life Support 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Monica E. Kleinman, Chair; Leon Chameides; Stephen M. Schexnayder; Ricardo A. Samson; Mary Fran Hazinski; Dianne L. Atkins; Marc D. Berg; Allan R. de Caen; Ericka L. Fink; Eugene B. Freid; Robert W. Hickey; Bradley S. Marino; Vinay M. Nadkarni; Lester T. Proctor; Faiqa A. Qureshi; Kennith Sartorelli; Alexis Topjian; Elise W. van der Jagt; Arno L. Zaritsky In contrast to adults, cardiac arrest in infants and children emergency response system for a deteriorating inpatient has doesnotusuallyresultfromaprimarycardiaccause.More beenshowntosignificantlydecreasetheincidenceofcardiac oftenitistheterminalresultofprogressiverespiratoryfailure and respiratory arrests, as well as hospital mortality rates in or shock, also called an asphyxial arrest. Asphyxia begins some large children’s hospitals.18–21 Such teams, often con- with a variable period of systemic hypoxemia, hypercapnea, sisting of providers with expertise in assessment and initial andacidosis,progressestobradycardiaandhypotension,and management of acutely ill patients (critical-care nurses, culminates with cardiac arrest.1 respiratorytherapists,andcritical-carephysicians),decreased Another mechanism of cardiac arrest, ventricular fibrilla- the number of cardiac and respiratory arrests by as much as tion (VF) or pulseless ventricular tachycardia (VT), is the 72%18 and hospital mortality by as much as 35% in institu- initial cardiac rhythm in approximately 5% to 15% of tions where the effect was studied.19 Although it is possible pediatric in-hospital and out-of-hospital cardiac arrests;2–9 it that most of the impact is due to a decrease in respiratory is reported in up to 27% of pediatric in-hospital arrests at arrests, this cannot be confirmed by the available published some point during the resuscitation.6 The incidence of VF/ data. Implementation of a pediatric MET/RRT may be pulseless VT cardiac arrest rises with age.2,4 Increasing beneficialinfacilitieswherechildrenwithhighriskillnesses evidence suggests that sudden unexpected death in young are present on general inpatient units (Class IIa, LOE B). people can be associated with genetic abnormalities in myo- Despite the improved outcome of in-hospital CPR, a cyte ion channels resulting in abnormalities in ion flow (see majority of children with in-hospital cardiac arrest and an “Sudden Unexplained Deaths,” below). even larger percentage of children with out-of-hospital car- Since2010marksthe50thanniversaryoftheintroduction diac arrest do not survive, or they are severely incapacitated ofcardiopulmonaryresuscitation(CPR),10itseemsappropri- if they do. Several studies, discussed later in this document, ate to review the progressive improvement in outcome of showed that the presence of family members during resusci- pediatric resuscitation from cardiac arrest. Survival from tation has helped them deal with the inevitable trauma and in-hospitalcardiacarrestininfantsandchildreninthe1980s grief following the death of a child. Therefore, whenever wasaround9%.11,12Approximately20yearslater,thatfigure possible, provide family members with the option of being had increased to 17%,13,14 and by 2006, to 27%.15–17 In present during resuscitation of an infant or child (Class I, contrast to those favorable results from in-hospital cardiac LOE B). arrest, overall survival to discharge from out-of-hospital cardiac arrest in infants and children has not changed sub- BLS Considerations During PALS stantiallyin20yearsandremainsatabout6%(3%forinfants and 9% for children and adolescents).7,9 Pediatricadvancedlifesupport(PALS)usuallytakesplace It is unclear why the improvement in outcome from in the setting of an organized response in an advanced in-hospital cardiac arrest has occurred, although earlier rec- healthcare environment. In these circumstances, multiple ognition and management of at-risk patients on general respondersarerapidlymobilizedandarecapableofsimulta- inpatient units and more aggressive implementation of neous coordinated action. Resuscitation teams may also evidence-based resuscitation guidelines may have played a have access to invasive patient monitoring that may role. Implementation of a formal pediatric medical emer- provide additional information during the performance of gencyteam(MET)orrapidresponseteam(RRT)aspartofan basic life support (BLS). TheAmericanHeartAssociationrequeststhatthisdocumentbecitedasfollows:KleinmanME,ChameidesL,SchexnayderSM,SamsonRA,Hazinski MF,AtkinsDL,BergMD,deCaenAR,FinkEL,FreidEB,HickeyRW,MarinoBS,NadkarniVM,ProctorLT,QureshiFA,SartorelliK,TopjianA, vanderJagtEW,ZaritskyAL.Part14:pediatricadvancedlifesupport:2010AmericanHeartAssociationGuidelinesforCardiopulmonaryResuscitation andEmergencyCardiovascularCare.Circulation.2010;122(suppl3):S876–S908. (Circulation.2010;122[suppl3]:S876–S908.) ©2010AmericanHeartAssociation,Inc. Circulationisavailableathttp://circ.ahajournals.org DOI:10.1161/CIRCULATIONAHA.110.971101 Downloaded from http://circ.ahajoSu8r7na6ls.org/ by guest on March 6, 2012 Kleinman et al Part 14: Pediatric Advanced Life Support S877 Simultaneous Actions ● An increased respiratory rate, particularly with signs of BLS(whetherforachildoradult)ispresentedasaseriesof distress (eg, increased respiratory effort including nasal sequential events with the assumption that there is only one flaring, retractions, seesaw breathing, or grunting) responder, but PALS usually takes place in an environment ● An inadequate respiratory rate, effort, or chest excursion where many rescuers are rapidly mobilized and actions are (eg, diminished breath sounds or gasping), especially if performed simultaneously. The challenge is to organize the mental status is depressed rescuers into an efficient team. Important considerations for ● Cyanosis with abnormal breathing despite supplementary thegreatestchanceofasuccessfulresuscitationfromcardiac oxygen arrest include the following: Shock ● Chest compressions should be immediately started by one Shockresultsfrominadequatebloodflowandoxygendeliv- rescuer, while a second rescuer prepares to start ventila- ery to meet tissue metabolic demands. The most common tions with a bag and mask. Ventilation is extremely typeofshockinchildrenishypovolemic,includingshockdue important in pediatrics because of the large percentage of to hemorrhage. Distributive, cardiogenic, and obstructive asphyxial arrests in which best results are obtained by a shockoccurlessfrequently.Shockprogressesoveracontin- combination of chest compressions and ventilations.8 Un- uum of severity, from a compensated to a decompensated fortunately ventilations are sometimes delayed because state. Compensatory mechanisms include tachycardia and equipment(bag,mask,oxygen,airway)mustbemobilized. increased systemic vascular resistance (vasoconstriction) in Chest compressions require only the hands of a willing an effort to maintain cardiac output and perfusion pressure rescuer. Therefore, start CPR with chest compressions respectively. Decompensation occurs when compensatory immediately, while a second rescuer prepares to provide mechanisms fail and results in hypotensive shock. ventilations (Class I, LOE C). Typical signs of compensated shock include ● The effectiveness of PALS is dependent on high-quality CPR,whichrequiresanadequatecompressionrate(atleast ● Tachycardia 100compressions/min),anadequatecompressiondepth(at ● Cool and pale distal extremities least one third of the AP diameter of the chest or approx- ● Prolonged ((cid:1)2 seconds) capillary refill (despite warm imately 1 1⁄2 inches [4 cm] in infants and approximately 2 ambient temperature) inches[5cm]inchildren),allowingcompleterecoilofthe ● Weak peripheral pulses compared with central pulses chest after each compression, minimizing interruptions in ● Normal systolic blood pressure compressions,andavoidingexcessiveventilation.Reasons for not performing high-quality CPR include rescuer inat- As compensatory mechanisms fail, signs of inadequate tention to detail, rescuer fatigue, and long or frequent end-organ perfusion develop. In addition to the above, these interruptionstosecuretheairway,checktheheartrhythm, signs include and move the patient.22 Optimal chest compressions are best delivered with the victim on a firm surface.23,24 ● Depressed mental status ● While one rescuer performs chest compressions and an- ● Decreased urine output otherperformsventilations,otherrescuersshouldobtaina ● Metabolic acidosis monitor/defibrillator, establish vascular access, and calcu- ● Tachypnea late and prepare the anticipated medications. ● Weak central pulses ● Deterioration in color (eg, mottling, see below) Monitored Patients Manyin-hospitalpatients,especiallyiftheyareinanICU,are Decompensatedshockischaracterizedbysignsandsymp- monitored and some have an advanced airway and are tomsconsistentwithinadequatedeliveryofoxygentotissues receiving mechanical ventilation. If the patient has an in- (pallor, peripheral cyanosis, tachypnea, mottling of the skin, dwelling arterial catheter, use the waveform as feedback to decreasedurineoutput,metabolicacidosis,depressedmental evaluatehandpositionandchestcompressiondepth.Aminor status),weakorabsentperipheralpulses,weakcentralpulses, adjustment of hand position or depth of compression can and hypotension. significantlyimprovetheamplitudeofthearterialwaveform, Learntointegratethesignsofshockbecausenosinglesign reflecting better chest compression-induced stroke volume. confirms the diagnosis. For example: Thearterialwaveformmayalsobeusefulinidentificationof ● Capillary refill time alone is not a good indicator of return of spontaneous circulation (ROSC). If the patient’s circulatoryvolume,butacapillaryrefilltime(cid:1)2secondsis end-tidalCO2(PETCO2)isbeingmonitored,itcanbeusedto ausefulindicatorofmoderatedehydrationwhencombined evaluatethequalityofchestcompressions;itcanalsoprovide an indication of ROSC (see below). with decreased urine output, absent tears, dry mucous membranes,andagenerallyillappearance.Capillaryrefill Respiratory Failure time is influenced by ambient temperature,25 site, and age Respiratoryfailureischaracterizedbyinadequateventilation, and its interpretation can be influenced by lighting.26 insufficientoxygenation,orboth.Anticipaterespiratoryfail- ● Tachycardia is a common sign of shock, but it can also ure if any of the following signs is present: result from other causes, such as pain, anxiety, and fever. Downloaded from http://circ.ahajournals.org/ by guest on March 6, 2012 S878 Circulation November 2, 2010 ● Pulsesareweakinhypovolemicandcardiogenicshock,but may correspond to a PaO anywhere between (cid:5)80 and 2 may be bounding in anaphylactic, neurogenic, and septic 500mmHg,ingeneralitisappropriatetoweantheFIO2when shock. saturation is 100%, provided the oxyhemoglobin saturation ● Bloodpressuremaybenormalinachildwithcompensated canbemaintained(cid:1)94%(ClassIIb,LOEC).Rememberthat shock but may decline rapidly when the child decompen- adequateoxygendeliveryrequiresnotonlyadequatearterial sates.Liketheothersigns,hypotensionmustbeinterpreted oxyhemoglobin saturation but also adequate hemoglobin within the context of the entire clinical picture. concentration and cardiac output. Thereareseveralsourcesofdatathatuselargepopulations Pulse Oximetry to identify the 5th percentile for systolic blood pressure at Ifthepatienthasaperfusingrhythm,monitoroxyhemoglobin various ages.27,28 For purposes of these guidelines, hypoten- saturation continuously with a pulse oximeter because clini- sion is defined as a systolic blood pressure: calrecognitionofhypoxemiaisnotreliable.44Pulseoximetry may,however,alsobeunreliableinpatientswithpoorperipheral ● (cid:2)60 mm Hg in term neonates (0 to 28 days) perfusion,carbonmonoxidepoisoning,ormethemoglobinemia. ● (cid:2)70 mm Hg in infants (1 month to 12 months) ● (cid:2)70mmHg(cid:3)(2(cid:4)ageinyears)inchildren1to10years Bag-Mask Ventilation ● (cid:2)90 mm Hg in children (cid:1)10 years of age Bag-mask ventilation can be as effective, and may be safer, than endotracheal tube ventilation for short periods during Airway out-of-hospital resuscitation.45–52 In the prehospital setting it Oropharyngeal and Nasopharyngeal Airways isreasonabletoventilateandoxygenateinfantsandchildren Oropharyngealandnasopharyngealairwayshelpmaintainan with a bag-mask device, especially if transport time is short openairwaybydisplacingthetongueorsoftpalatefromthe (Class IIa, LOE B). Bag-mask ventilation requires training pharyngeal air passages. Oropharyngeal airways are used in and periodic retraining in selecting a correct mask size, main- unresponsive victims who do not have a gag reflex. Make taininganopenairway,providingatightsealbetweenmaskand suretoselectthecorrectsize:anoropharyngealairwaythatis face, providing ventilation, and assessing effectiveness of ven- too small may push the base of the tongue farther into the tilation(seePart13,“PediatricBasicLifeSupport”). airway; one that is too large may obstruct the airway. Nasopharyngeal airways can be used in children who do Precautions Useonlytheforceandtidalvolumeneededtojustmakethe have a gag reflex. Pay careful attention to proper diameter chestrisevisibly(ClassI,LOEC);avoiddeliveringexcessive andlength.Anasopharyngealairwaythatistooshortmaynot ventilationduringcardiacarrest(ClassIII,LOEC).Evidence maintain an open airway, while one that is too long may showsthatcardiacarrestvictimsfrequentlyreceiveexcessive obstruct it. A small-diameter nasopharyngeal airway may be ventilation.22,53–55Excessiveventilationduringcardiacarrest obstructed easily by secretions. It may therefore require increases intrathoracic pressure, which impedes venous re- frequent suctioning. turn,thusreducingcardiacoutputandcerebralandcoronary Laryngeal Mask Airway (LMA) blood flow. These effects will reduce the likelihood of Although several supraglottic devices have been used in ROSC.54 In addition, excessive ventilation may cause air children, clinical studies of devices other than the LMA in trapping and barotrauma in patients with small airway ob- pediatricpatientsarelimited.Whenbag-maskventilation(see struction. It also increases the risk of stomach inflation, “Bag-Mask Ventilation,” below) is unsuccessful and when regurgitation, and aspiration. endotracheal intubation is not possible, the LMA is accept- If the infant or child is not intubated, pause after 30 chest ablewhenusedbyexperiencedproviderstoprovideapatent compressions (1 rescuer) or after 15 chest compressions (2 airwayandsupportventilation(ClassIIa,LOEC).29–37LMA rescuers) to give 2 ventilations (mouth-to-mouth, mouth-to- insertion is associated with a higher incidence of complica- mask, or bag-mask). Deliver each breath with an inspiratory tions in young children compared with older children and time of approximately 1 second. If the infant or child is adults.38–43 intubated, ventilate at a rate of about 1 breath every 6 to 8 seconds(8to10timesperminute)withoutinterruptingchest Oxygen compressions (Class I, LOE C). It may be reasonable to do It is reasonable to ventilate with 100% oxygen during CPR the same if an LMA is in place (Class IIb, LOE C). because there is insufficient information on the optimal In the victim with a perfusing rhythm but absent or inspired oxygen concentration (Class IIa, LOE C). Once the inadequate respiratory effort, give 1 breath every 3 to 5 circulationisrestored,monitorsystemicoxygensaturation.It seconds (12 to 20 breaths per minute), using the higher rate may be reasonable, when the appropriate equipment is for the younger child (Class I, LOE C). One way to achieve available, to titrate oxygen administration to maintain the that rate with a ventilating bag is to use the mnemonic oxyhemoglobin saturation (cid:1)94%. Provided appropriate “squeeze-release-release” at a normal speaking rate.45,56 equipment is available, once ROSC is achieved, adjust the FIO2 to the minimum concentration needed to achieve an Two-Person Bag-Mask Ventilation arterialoxyhemoglobinsaturationatleast94%,withthegoal A 2-person ventilation technique may be preferable when of avoiding hyperoxia while ensuring adequate oxygen de- personnel are available and may be more effective than livery. Since an arterial oxyhemoglobin saturation of 100% ventilation by a single rescuer if the patient has significant Downloaded from http://circ.ahajournals.org/ by guest on March 6, 2012 Kleinman et al Part 14: Pediatric Advanced Life Support S879 airwayobstruction,poorlungcompliance,ortherescuerhas Cuffed Versus Uncuffed Endotracheal Tubes difficulty in creating a tight mask-to-face seal.57,58 One Both cuffed and uncuffed endotracheal tubes are acceptable rescuer uses both hands to maintain an open airway with a forintubatinginfantsandchildren(ClassIIa,LOEC).Inthe jaw thrust and a tight mask-to-face seal while the other operatingroom,cuffedendotrachealtubesareassociatedwith compressestheventilationbag.Bothrescuersshouldobserve a higher likelihood of correct selection of tube size, thus the victim’s chest to ensure chest rise. achievingalowerreintubationratewithnoincreasedriskof perioperativecomplications.88–90Inintensivecaresettingsthe Gastric Inflation risk of complications in infants and in children is no greater Gastricinflationmayinterferewitheffectiveventilation59and with cuffed tubes than with noncuffed tubes.91–93 Cuffed cause regurgitation, aspiration of stomach contents, and endotracheal tubes may decrease the risk of aspiration.94 If further ventilatory compromise. The risk of gastric inflation cuffed endotracheal tubes are used, cuff inflating pressure can be decreased by shouldbemonitoredandlimitedaccordingtomanufacturer’s instruction (usually less than 20 to 25 cm H O). ● Avoidingexcessivepeakinspiratorypressuresbyventilat- 2 In certain circumstances (eg, poor lung compliance, high ing slowly and giving only enough tidal volume to just airway resistance, or a large glottic air leak) a cuffed achieve visible chest rise.45 endotracheal tube may be preferable to an uncuffed tube, ● Applying cricoid pressure in an unresponsive victim to provided that attention is paid to endotracheal tube size, reduce air entry into the stomach (Class IIa, LOE B).60–62 position,andcuffinflationpressure(ClassIIa,LOEB).88,91,92 Thismayrequireathirdrescuerifcricoidpressurecannot be applied by the rescuer who is securing the bag to the Endotracheal Tube Size face.Avoidexcessivecricoidpressuresoasnottoobstruct Length-based resuscitation tapes are helpful and more accu- the trachea (Class III, LOE B).63 rate than age-based formula estimates of endotracheal tube ● Passing a nasogastric or orogastric tube to relieve gastric size for children up to approximately 35 kg,77,95,96 even for inflation, especially if oxygenation and ventilation are children with short stature.97 compromised. Pass the tube after intubation because a In preparation for intubation with either a cuffed or an gastric tube interferes with gastroesophageal sphincter uncuffedendotrachealtube,confirmthattubeswithaninternal function, allowing regurgitation during intubation. If a diameter (ID) 0.5 mm smaller and 0.5 mm larger than the gastrostomy tube is present, vent it during bag-mask estimated size are available. During intubation, if the endotra- ventilation to allow gastric decompression. chealtubemeetsresistance,placeatube0.5mmsmallerinstead. Ventilation With an Endotracheal Tube Following intubation, if there is a large glottic air leak that Endotracheal intubation in infants and children requires interfereswithoxygenationorventilation,considerreplacingthe specialtrainingbecausethepediatricairwayanatomydiffers tubewithonethatis0.5mmlarger,orplaceacuffedtubeofthe from that of the adult. The likelihood of successful endotra- same size if an uncuffed tube was used originally. Note that chealtubeplacementwithminimalcomplicationsisrelatedto replacementofafunctionalendotrachealtubeisassociatedwith thelengthoftraining,supervisedexperienceintheoperating risk; the procedure should be undertaken in an appropriate roomandinthefield,64,65adequateongoingexperience,66and settingbyexperiencedpersonnel. use of rapid sequence intubation (RSI).67,68 If an uncuffed endotracheal tube is used for emergency intubation,itisreasonabletoselecta3.5-mmIDtubeforinfants Rapid Sequence Intubation (RSI) uptooneyearofageanda4.0-mmIDtubeforpatientsbetween To facilitate emergency intubation and reduce the incidence 1 and 2 years of age. After age 2, uncuffed endotracheal tube of complications, skilled, experienced providers may use sizecanbeestimatedbythefollowingformula: sedatives,neuromuscularblockingagents,andothermedica- UncuffedendotrachealtubeID(mm)(cid:6)4(cid:3)(age/4) tions to rapidly sedate and neuromuscularly block the pedi- atric patient.69 Ifacuffedtubeisusedforemergencyintubationofaninfant UseRSIonlyifyouaretrained,andhaveexperienceusing lessthan1yearofage,itisreasonabletoselecta3.0mmID these medications and are proficient in the evaluation and tube. For children between 1 and 2 years of age, it is managementofthepediatricairway.IfyouuseRSIyoumust reasonabletouseacuffedendotrachealtubewithaninternal haveasecondaryplantomanagetheairwayintheeventthat diameterof3.5mm(ClassIIa,LOEB).89,98–100Afterage2it you cannot achieve intubation. isreasonabletoestimatetubesizewiththefollowingformula Actual body weight, rather than ideal body weight, (Class IIa, LOE B:89,98–101): shouldbeusedforsomenon-resuscitationmedications(eg, succinylcholine).70–85 CuffedendotrachealtubeID(mm)(cid:6)3.5(cid:3)(age/4) Cricoid Pressure During Intubation Verification of Endotracheal Tube Placement There is insufficient evidence to recommend routine cricoid There is a risk of endotracheal tube misplacement (ie, in the pressureapplicationtopreventaspirationduringendotracheal esophagus,thepharynxabovethevocalcords,oramainstem intubation in children. Do not continue cricoid pressure if it bronchus) and an ongoing risk of displacement or obstruc- interferes with ventilation or the speed or ease of intubation tion,45,102 especially during patient transport.103 Since no (Class III, LOE C).86,87 single confirmation technique, including clinical signs104 or Downloaded from http://circ.ahajournals.org/ by guest on March 6, 2012 S880 Circulation November 2, 2010 the presence of water vapor in the tube,105 is completely a consistent color rather than a breath-to-breath color reliable, use both clinical assessment and confirmatory de- change may be seen. vices to verify proper tube placement immediately after ● An intravenous (IV) bolus of epinephrine121 may tran- intubation,againaftersecuringtheendotrachealtube,during siently reduce pulmonary blood flow and exhaled CO 2 transport, and each time the patient is moved (eg, from below the limits of detection.120 gurney to bed) (Class I, LOE B). ● Severe airway obstruction (eg, status asthmaticus) and Thefollowingaremethodsforconfirmingcorrectposition: pulmonary edema may impair CO elimination below the 2 limits of detection.120,122–124 ● Look for bilateral chest movement and listen for equal ● A large glottic air leak may reduce exhaled tidal volume breath sounds over both lung fields, especially over the through the tube and dilute CO concentration. axillae. 2 ● Listen for gastric insufflation sounds over the stomach. Esophageal Detector Device (EDD) They should not be present if the tube is in the trachea.104 Ifcapnographyisnotavailable,anesophagealdetectordevice ● Check for exhaled CO2 (see “Exhaled or End-Tidal CO2 (EDD) may be considered to confirm endotracheal tube Monitoring,” below). placement in children weighing (cid:1)20 kg with a perfusing ● If there is a perfusing rhythm, check oxyhemoglobin rhythm(ClassIIb,LOEB),125,126butthedataareinsufficient saturationwithapulseoximeter.Rememberthatfollowing to make a recommendation for or against its use in children hyperoxygenation, the oxyhemoglobin saturation detected during cardiac arrest. bypulseoximetrymaynotdeclineforaslongas3minutes even without effective ventilation.106,107 Transtracheal Catheter Oxygenation ● Ifyouarestilluncertain,performdirectlaryngoscopyand and Ventilation visualize the endotracheal tube to confirm that it lies Transtracheal catheter oxygenation and ventilation may be between the vocal cords. consideredforpatientswithsevereairwayobstructionabove ● Inhospitalsettings,performachestx-raytoverifythatthe the level of the cricoid cartilage if standard methods to tubeisnotinabronchusandtoidentifyproperpositionin manage the airway are unsuccessful. Note that transtracheal the midtrachea. ventilation primarily supports oxygenation as tidal volumes are usually too small to effectively remove carbon dioxide. After intubation, secure the tube; there is insufficient This technique is intended for temporary use while a more evidencetorecommendanysinglemethod.Aftersecuringthe effective airway is obtained. Attempt this procedure only tube, maintain the patient’s head in a neutral position; neck after proper training and with appropriate equipment (Class flexion may push the tube farther into the airway, and IIb, LOE C).127 extension may pull the tube out of the airway.108,109 Ifanintubatedpatient’sconditiondeteriorates,considerthe Suction Devices following possibilities (mnemonic DOPE): A properly sized suction device with an adjustable suction regulator should be available. Do not insert the suction ● Displacement of the tube catheter beyond the end of the endotracheal tube to avoid ● Obstruction of the tube injuringthemucosa.Useamaximumsuctionforceof-80to ● Pneumothorax -120 mm Hg for suctioning the airway via an endotracheal ● Equipment failure tube. Higher suction pressures applied through large-bore Exhaled or End-Tidal CO Monitoring noncollapsible suction tubing and semirigid pharyngeal tips 2 When available, exhaled CO detection (capnography or are used to suction the mouth and pharynx. 2 colorimetry)isrecommendedasconfirmationoftrachealtube CPR Guidelines for Newborns With Cardiac position for neonates, infants, and children with a perfusing Arrest of Cardiac Origin cardiac rhythm in all settings (eg, prehospital, emergency Recommendationsforinfantsdifferfromthoseforthenewly department [ED], ICU, ward, operating room) (Class I, born(ie,inthedeliveryroomandduringthefirsthoursafter LOEC)110–114andduringintrahospitalorinterhospitaltrans- birth)andnewborns(duringtheirinitialhospitalizationandin port(ClassIIb,LOEC).115,116Rememberthatacolorchange the NICU). The compression-to-ventilation ratio differs or the presence of a capnography waveform confirms tube (newly born and newborns – 3:1; infant two rescuer - 15:2) position in the airway but does not rule out right mainstem and how to provide ventilations in the presence of an bronchusintubation.Duringcardiacarrest,ifexhaledCO is 2 advanced airway differs (newly born and newborns – pause not detected, confirm tube position with direct laryngoscopy after 3 compressions; infants – no pauses for ventilations). (ClassIIa,LOEC)110,117–120becausetheabsenceofCO may 2 This presents a dilemma for healthcare providers who may reflect very low pulmonary blood flow rather than tube also care for newborns outside the NICU. Because there are misplacement. nodefinitivescientificdatatohelpresolvethisdilemma,for Confirmationofendotrachealtubepositionbycolorimetric ease of training we recommend that newborns (intubated or end-tidal CO detector may be altered by the following: 2 not) who require CPR in the newborn nursery or NICU ● If the detector is contaminated with gastric contents or receiveCPRusingthesametechniqueasforthenewlyborn acidicdrugs(eg,endotracheallyadministeredepinephrine), inthedeliveryroom(ie,3:1compression-to-ventilationratio Downloaded from http://circ.ahajournals.org/ by guest on March 6, 2012 Kleinman et al Part 14: Pediatric Advanced Life Support S881 withapauseforventilation).NewbornswhorequireCPRin check. PETCO2 must be interpreted with caution for 1 to 2 other settings (eg, prehospital, ED, pediatric intensive care minutesafteradministrationofepinephrineorothervasocon- unit [PICU], etc.), should receive CPR according to infant strictivemedicationsbecausethesemedicationsmaydecrease guidelines:2rescuersprovidecontinuouschestcompressions the end-tidal CO level by reducing pulmonary blood flow. 2 with asynchronous ventilations if an advanced airway is in place and a 15:2 ventilation-to-compression ratio if no ad- Vascular Access vancedairwayisinplace(ClassIIb,LOEC).Itisreasonable Vascular access is essential for administering medications to resuscitate newborns with a primary cardiac etiology of and drawing blood samples. Obtaining peripheral venous arrest, regardless of location, according to infant guidelines, access can be challenging in infants and children during an withemphasisonchestcompressions(ClassIIa,LOEC).For emergency; intraosseous (IO) access can be quickly estab- further information, please refer to Part 13, “Pediatric Basic lished with minimal complications by providers with varied Life Support,” and Part 15, “Neonatal Resuscitation.” levels of training.172–179 Limit the time spent attempting to establishperipheralvenousaccessinacriticallyillorinjured Extracorporeal Life Support (ECLS) child.180 Extracorporeal life support (ECLS) is a modified form of cardiopulmonary bypass used to provide prolonged delivery Intraosseous (IO) Access ofoxygentotissues.ConsiderearlyactivationofECLSfora IOaccessisarapid,safe,effective,andacceptableroutefor cardiacarrestthatoccursinahighlysupervisedenvironment, vascular access in children,172–179,181 and it is useful as the such as an ICU, with the clinical protocols in place and the initial vascular access in cases of cardiac arrest (Class I, expertiseandequipmentavailabletoinitiateitrapidly.ECLS LOE C). All intravenous medications can be administered should be considered only for children in cardiac arrest intraosseously, including epinephrine, adenosine, fluids, refractory to standard resuscitation attempts, with a poten- blood products,182,183 and catecholamines.184 Onset of action tially reversible cause of arrest (Class IIa, LOE C).128–154 and drug levels for most drugs are comparable to venous When ECLS is employed during cardiac arrest, outcome for administration.185 IO access can be used to obtain blood children with underlying cardiac disease is better than the samples for analysis including for type and cross match and outcomeforchildrenwithnoncardiacdisease.Withunderly- blood gases during CPR,186 but acid-base analysis is inaccu- ing cardiac disease, long-term survival when ECLS is initi- rate after sodium bicarbonate administration via the IO atedinacritical-caresettinghasbeenreportedevenafter(cid:1)50 cannula.187 Use manual pressure or an infusion pump to minutes of standard CPR.128,129,139,147 administer viscous drugs or rapid fluid boluses;188,189 follow each medication with a saline flush to promote entry into the Monitoring centralcirculation. Electrocardiography Venous Access Monitor cardiac rhythm as soon as possible so both normal Peripheral IV access is acceptable during resuscitation if it and abnormal cardiac rhythms are identified and followed. can be placed rapidly, but placement may be difficult in a Continuous monitoring is helpful in tracking responses to critically ill child. Although a central venous catheter can treatment and changes in clinical condition. providemoresecurelong-termaccess,itsplacementrequires Echocardiography training and experience, and the procedure can be time- Thereisinsufficientevidencefororagainsttheroutineuseof consuming. Therefore central venous access is not recom- echocardiographyinpediatriccardiacarrest.Whenappropri- mended as the initial route of vascular access during an ately trained personnel are available, echocardiography may emergency.Ifbothcentralandperipheralaccessesareavail- be considered to identify patients with potentially treatable able,administermedicationsintothecentralcirculationsince causes of the arrest, particularly pericardial tamponade and some medications (eg, adenosine) are more effective when inadequate ventricular filling (Class IIb, LOE C).155–162 Mini- administered closer to the heart, and others (eg, calcium, mizeinterruptionofCPRwhileperformingechocardiography. amiodarone, procainamide, sympathomimetics) may be irri- tating when infused into a peripheral vein. The length of a End-Tidal CO (PETCO ) centralcathetercancontributetoincreasedresistance,makingit 2 2 Continuouscapnographyorcapnometrymonitoring,ifavail- more difficult to push boluses of fluid rapidly through a able, may be beneficial during CPR, to help guide therapy, multilumencentralthanaperipheralcatheter. especiallytheeffectivenessofchestcompressions(ClassIIa, LOEC).Animalandadultstudiesshowastrongcorrelation Endotracheal Drug Administration betweenPETCO2andinterventionsthatincreasecardiacoutput Vascular access (IO or IV) is the preferred method for drug during CPR or shock.53,163–169 If the PETCO2 is consistently delivery during CPR, but if it is not possible, lipid-soluble (cid:2)10 to 15 mm Hg, focus efforts on improving chest com- drugs,suchaslidocaine,epinephrine,atropine,andnaloxone pressions and make sure that the victim does not receive (mnemonic“LEAN”)190,191canbeadministeredviaanendo- excessiveventilation.AnabruptandsustainedriseinPETCO2 tracheal tube.192 However, the effects may not be uniform inadults170,171andanimals110isobservedjustpriortoclinical with tracheal as compared with intravenous administration. identification of ROSC, so use of PETCO2 may spare the One study of children in cardiac arrest193 demonstrated rescuer from interrupting chest compressions for a pulse similarROSCandsurvivalratesregardlessofthemethodof Downloaded from http://circ.ahajournals.org/ by guest on March 6, 2012 S882 Circulation November 2, 2010 Table1. MedicationsforPediatricResuscitation Medication Dose Remarks Adenosine 0.1mg/kg(maximum6mg) MonitorECG Seconddose:0.2mg/kg(maximum12mg) RapidIV/IOboluswithflush Amiodarone 5mg/kgIV/IO;mayrepeattwiceupto15mg/kg MonitorECGandbloodpressure;adjustadministrationratetourgency Maximumsingledose300mg (IVpushduringcardiacarrest,moreslowly–over20–60minuteswith perfusingrhythm).Expertconsultationstronglyrecommendedpriorto usewhenpatienthasaperfusingrhythm UsecautionwhenadministeringwithotherdrugsthatprolongQT (obtainexpertconsultation) Atropine 0.02mg/kgIV/IO Higherdosesmaybeusedwithorganophosphatepoisoning 0.04–0.06mg/kgET* Repeatonceifneeded Minimumdose:0.1mg Maximumsingledose: 0.5mg CalciumChloride 20mg/kgIV/IO(0.2mL/kg) Administerslowly (10%) Maximumsingledose2g Epinephrine 0.01mg/kg(0.1mL/kg1:10,000)IV/IO Mayrepeatevery3–5minutes 0.1mg/kg(0.1mL/kg1:1000)ET* Maximumdose1mgIV/IO;2.5mgET Glucose 0.5–1g/kgIV/IO Newborn:5–10mL/kgD W 10 InfantsandChildren:2–4mL/kgD W 25 Adolescents:1–2mL/kgD W 50 Lidocaine Bolus:1mg/kgIV/IO Infusion:20–50mcg/kg/minute MagnesiumSulfate 25–50mg/kgIV/IOover10–20minutes,fasterin torsadesdepointes Maximumdose2g Naloxone FullReversal: Uselowerdosestoreverserespiratorydepressionassociatedwith (cid:2)5yor(cid:3)20kg:0.1mg/kgIV/IO/ET* therapeuticopioiduse(1–5mcg/kgtitratetoeffect) (cid:1)5yor(cid:1)20kg:2mgIV/IO/ET* Procainamide 15mg/kgIV/IO MonitorECGandbloodpressure; AdultDose:20mg/minIVinfusiontototalmaximum Giveslowly–over30–60minutes.Usecautionwhenadministering doseof17mg/kg withotherdrugsthatprolongQT(obtainexpertconsultation) Sodium 1mEq/kgperdoseIV/IOslowly Afteradequateventilation bicarbonate IVindicatesintravenous;IO,intraosseous;andET,viaendotrachealtube. *Flushwith5mLofnormalsalineandfollowwith5ventilations. drug delivery, while three studies of adults in cardiac ar- when the drug is delivered by the endotracheal route may rest194–196 demonstrated reduced ROSC and survival to hos- produce predominant transient peripheral (cid:2)-adrenergic va- 2 pital discharge with tracheal administration of epinephrine sodilatingeffects.Theseeffectscanbedetrimental,andcause compared to vascular delivery. If CPR is in progress, stop hypotension, lower coronary artery perfusion pressure and chest compressions briefly, administer the medications, and flow, and a reduced potential for ROSC. follow with a flush of at least 5 mL of normal saline and 5 Non-lipid-soluble drugs (eg, sodium bicarbonate and cal- consecutive positive-pressure ventilations.197 Optimal endo- cium)mayinjuretheairway;theyshouldnotbeadministered trachealdosesofmedicationsareunknown;ingeneralexpert via the endotracheal route. consensus recommends doubling or tripling the dose of lidocaine, atropine or naloxone given via the ETT. For Emergency Fluids and Medications epinephrine,adosetentimestheintravenousdose(0.1mg/kg or 0.1 mL/kg of 1:1000 concentration) is recommended (see Estimating Weight Table 1). In the out-of-hospital setting, a child’s weight is often The effectiveness of endotracheal epinephrine during car- unknown,andevenexperiencedpersonnelmaynotbeableto diac arrest is controversial. Some studies showed it to be as estimate it accurately.74 Tapes with precalculated doses effectiveasvascularadministration193,198,199whileotherstud- printed at various patient lengths have been clinically vali- ies have not found it to be as effective.194–196,200 Animal dated74,77,95andaremoreaccuratethanage-basedorobserver studies201–206 suggested that a higher dose of epinephrine is (parentorprovider)estimate-basedmethodsintheprediction required for endotracheal than for intravascular administra- of body weight.70–77 Body habitus may also be an important tion because the lower epinephrine concentrations achieved consideration.70,72,78,79 Downloaded from http://circ.ahajournals.org/ by guest on March 6, 2012 Kleinman et al Part 14: Pediatric Advanced Life Support S883 Medication Dose Calculation Atropine To calculate the dose of resuscitation medications, use the Atropinesulfateisaparasympatholyticdrugthataccelerates child’sweightifitisknown.Ifthechild’sweightisunknown, sinus or atrial pacemakers and increases the speed of AV it is reasonable to use a body length tape with precalculated conduction. doses (Class IIa, LOE C).70–77 Precautions Itisunclearifanadjustmentinthecalculationofresusci- Smalldosesofatropine((cid:2)0.1mg)mayproduceparadoxical tation medications is needed in obese children. Use of the bradycardia because of its central effect.208 Larger than actual body weight in calculation of drug doses in obese recommended doses may be required in special circum- patients may result in potentially toxic doses. Length-based stancessuchasorganophosphatepoisoning209orexposureto tapesestimatethe50thpercentileweightforlength(ie,ideal nerve gas agents. body weight), which may, theoretically, result in inadequate doses of some medications in obese patients. Despite these Calcium theoretical considerations, there are no data regarding the Calcium administration is not recommended for pediatric car- safety or efficacy of adjusting the doses of resuscitation diopulmonary arrest in the absence of documented hypocalce- medications in obese patients. Therefore, regardless of the mia, calcium channel blocker overdose, hypermagnesemia, or patient’s habitus, use the actual body weight for calculating hyperkalemia (Class III, LOE B). Routine calcium administra- initialresuscitationdrugdosesoruseabodylengthtapewith tion in cardiac arrest provides no benefit210–221 and may be precalculated doses (Class IIb, LOE C). harmful.210–212 For subsequent doses of resuscitation drugs in both non- Ifcalciumadministrationisindicatedduringcardiacarrest, obese and obese patients, expert providers may consider eithercalciumchlorideorcalciumgluconatemaybeconsid- adjusting doses to achieve the desired therapeutic effect. In ered.Hepaticdysfunctiondoesnotappeartoaltertheability general, the dose administered to a child should not exceed of calcium gluconate to raise serum calcium levels.222 In the standard dose recommended for adult patients. critically ill children, calcium chloride may be preferred because it results in a greater increase in ionized calcium Medications (See Table 1) during the treatment of hypocalcemia.222A In the nonarrest Adenosine setting, if the only venous access is peripheral, calcium Adenosine causes a temporary atrioventricular (AV) nodal gluconateisrecommendedbecauseithasalowerosmolality conduction block and interrupts reentry circuits that involve than calcium chloride and is therefore less irritating to the theAVnode.Thedrughasawidesafetymarginbecauseof vein. itsshorthalf-life.AdenosineshouldbegivenonlyIVorIO, Epinephrine followed by a rapid saline flush to promote drug delivery to The (cid:4)-adrenergic-mediated vasoconstriction of epinephrine thecentralcirculation.IfadenosineisgivenIV,itshouldbe increases aortic diastolic pressure and thus coronary perfu- administered as close to the heart as possible. (See also sion pressure, a critical determinant of successful resuscita- “Arrhythmia.”) tionfromcardiacarrest.223,224Atlowdoses,the(cid:2)-adrenergic Amiodarone effects may predominate, leading to decreased systemic Amiodarone slows AV conduction, prolongs the AV refrac- vascular resistance; in the doses used during cardiac arrest, toryperiodandQTinterval,andslowsventricularconduction the vasoconstrictive (cid:4)-effects predominate. (widens the QRS). Expert consultation is strongly recom- Precautions mended prior to administration of amiodarone to a pediatric patient with a perfusing rhythm. (See also “Arrhythmia.”) ● Donotadministercatecholaminesandsodiumbicarbonate simultaneously through an IV catheter or tubing because Precautions alkaline solutions such as the bicarbonate inactivate the Monitorbloodpressureandelectrocardiograph(ECG)during catecholamines. intravenousadministrationofamiodarone.Ifthepatienthasa ● In patients with a perfusing rhythm, epinephrine causes perfusing rhythm, administer the drug as slowly (over 20 to tachycardia; it may also cause ventricular ectopy, 60 minutes) as the patient’s clinical condition allows; if the tachyarrhythmias,vasoconstriction,andhypertension. patientisinVF/pulselessVT,givethedrugasarapidbolus. Amiodarone causes hypotension through its vasodilatory Glucose property, and the severity is related to the infusion rate; Because infants have a relatively high glucose requirement hypotension is less common with the aqueous form of and low glycogen stores, they may develop hypoglycemia amiodarone.207 Decrease the infusion rate if there is prolon- when energy requirements rise.225 Check blood glucose gation of the QT interval or heart block; stop the infusion if concentrationduringtheresuscitationandtreathypoglycemia the QRS widens to (cid:1)50% of baseline or hypotension devel- promptly (Class I, LOE C).226 ops. Other potential complications of amiodarone include bradycardia and torsades de pointes ventricular tachycardia. Lidocaine Amiodarone should not be administered together with an- Lidocaine decreases automaticity and suppresses ventricular other drug that causes QT prolongation, such as procain- arrhythmias,227 but is not as effective as amiodarone for amide, without expert consultation. improving ROSC or survival to hospital admission among Downloaded from http://circ.ahajournals.org/ by guest on March 6, 2012 S884 Circulation November 2, 2010 adult patients with VF refractory to shocks and epineph- ROSC, and a trend toward lower 24-hour and discharge rine.228Neitherlidocainenoramiodaronehasbeenshownto survival.250Apreponderanceofcontrolledtrialsinadultsdo improve survival to hospital discharge. not demonstrate a benefit.251–256 Precautions Pulseless Arrest Lidocaine toxicity includes myocardial and circulatory de- In the text below, box numbers identify the corresponding pression, drowsiness, disorientation, muscle twitching, and step in the algorithm (Figure 1). seizures, especially in patients with poor cardiac output and hepatic or renal failure.229,230 ● (Step 1) As soon as the child is found to be unresponsive with no breathing, call for help, send for a defibrillator Magnesium (manual or AED), and start CPR (with supplementary Magnesium is indicated for the treatment of documented oxygenifavailable).AttachECGmonitororAEDpadsas hypomagnesemiaorfortorsadesdepointes(polymorphicVT soon as available. Throughout resuscitation, emphasis associated with long QT interval). There is insufficient should be placed on provision of high-quality CPR (pro- evidence to recommend for or against the routine adminis- viding chest compressions of adequate rate and depth, tration of magnesium during cardiac arrest.231–233 allowing complete chest recoil after each compression, minimizing interruptions in compressions and avoiding Precautions excessive ventilation). Magnesium produces vasodilation and may cause hypoten- ● While CPR is being given, determine the child’s cardiac sion if administered rapidly. rhythm from the ECG or, if you are using an AED, the devicewilltellyouwhethertherhythmis“shockable”(eg, Procainamide VForrapidVT)or“notshockable”(eg,asystoleorPEA). Procainamide prolongs the refractory period of the atria and Itmaybenecessarytotemporarilyinterruptchestcompres- ventricles and depresses conduction velocity. sionstodeterminethechild’srhythm.Asystoleandbrady- Precautions cardia with a wide QRS are most common in asphyxial Thereislimitedclinicaldataonusingprocainamideininfants arrest.1 VF and PEA are less common13 but VF is more andchildren.234–236Infuseprocainamideveryslowly(over30 likelytobepresentinolderchildrenwithsuddenwitnessed to60minutes)whilemonitoringtheECGandbloodpressure. arrest. Decrease the infusion rate if there is prolongation of the QT interval, or heart block; stop the infusion if the QRS widens “Nonshockable Rhythm”: Asystole/PEA (Step 9) to (cid:1)50% of baseline or hypotension develops. Do not PEAisanorganizedelectricactivity—mostcommonlyslow, administer together with another drug causing QT prolonga- wide QRS complexes—without palpable pulses. Less fre- tion, such as amiodarone, without expert consultation. Prior quently there is a sudden impairment of cardiac output with tousingprocainamideforahemodynamicallystablepatient, an initially normal rhythm but without pulses and with poor expert consultation is strongly recommended. perfusion. This subcategory, formerly known as electrome- chanical dissociation (EMD), may be more reversible than Sodium Bicarbonate asystole. For asystole and PEA: Routine administration of sodium bicarbonate is not recom- ● (Step10)ContinueCPRwithasfewinterruptionsinchest mendedincardiacarrest(ClassIII,LOEB).212,237,238Sodium compressionsaspossible.Asecondrescuerobtainsvascu- bicarbonate may be administered for treatment of some laraccessanddeliversepinephrine,0.01mg/kg(0.1mL/kg toxidromes (see “Toxicological Emergencies,” below) or of 1:10000 solution) maximum of 1 mg (10 mL), while special resuscitation situations such as hyperkalemic cardiac CPR is continued. The same epinephrine dose is repeated arrest. every3to5minutes(ClassI,LOEB).Thereisnosurvival Precautions benefitfromhigh-doseepinephrine,anditmaybeharmful, During cardiac arrest or severe shock, arterial blood gas particularly in asphyxia (Class III, LOE B).257–261 High- analysis may not accurately reflect tissue and venous acido- doseepinephrinemaybeconsideredinexceptionalcircum- sis.239,240 Excessive sodium bicarbonate may impair tissue stances, such as (cid:2)-blocker overdose (Class IIb, LOE C). oxygen delivery;241 cause hypokalemia, hypocalcemia, hy- ● Onceanadvancedairwayisinplace,1rescuershouldgive pernatremia, and hyperosmolality;242,243 decrease the VF continuouschestcompressionsatarateofatleast100per threshold;244 and impair cardiac function. minute without pause for ventilation. The second rescuer delivers ventilations at a rate of 1 breath every 6 to 8 Vasopressin seconds (about 8 to 10 breaths per minute). Rotate the Thereisinsufficientevidencetomakearecommendationfor compressorroleapproximatelyevery2minutestoprevent oragainsttheroutineuseofvasopressinduringcardiacarrest. compressorfatigueanddeteriorationinqualityandrateof Pediatric245–247 and adult248,249 case series/reports suggested chest compressions. Check rhythm every 2 minutes with that vasopressin245 or its long-acting analog, terlipres- minimalinterruptionsinchestcompressions.Iftherhythm sin,246,247 may be effective in refractory cardiac arrest when is “nonshockable” continue with cycles of CPR and epi- standard therapy fails. A large pediatric NRCPR case series, nephrineadministrationuntilthereisevidenceofROSCor however,suggestedthatvasopressinisassociatedwithlower youdecidetoterminatetheeffort.Ifatanytimetherhythm Downloaded from http://circ.ahajournals.org/ by guest on March 6, 2012