European Resuscitation Council Guidelines for Resuscitation 2005: Section 6. Paediatric life support
Introduction
The European Resuscitation Council (ERC) issued guidelines for paediatric life support (PLS) in 1994, 1998 and 2000.1, 2, 3, 4 The last edition was based on the International Consensus on Science published by the American Heart Association in collaboration with the International Liaison Committee on Resuscitation (ILCOR), undertaking a series of evidence-based evaluations of the science of resuscitation which culminated in the publication of the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care in August 2000.5, 6 This process was repeated in 2004/2005, and the resulting Consensus on Science and Treatment Recommendations were published simultaneously in Resuscitation, Circulation and Pediatrics in November 2005.7, 8 The PLS Working Party of the ERC has considered this document and the supporting scientific literature, and has recommended changes to the ERC PLS Guidelines. These are presented in this paper.
The approach to changes has been to alter the guidelines in response to convincing new scientific evidence and, where possible, to simplify them in order to assist teaching and retention. As before, there remains a paucity of good-quality evidence on paediatric resuscitation specifically and some conclusions have had to be drawn from animal work and extrapolated adult data.
The current guidelines have a strong focus on simplification based on the knowledge that many children receive no resuscitation at all because rescuers fear doing harm. This fear is fuelled by the knowledge that resuscitation guidelines for children are different. Consequently, a major area of study was the feasibility of applying the same guidance for all adults and children. Bystander resuscitation improves outcome significantly,9, 10 and there is good evidence from paediatric animal models that even doing chest compressions or expired air ventilation alone may be better than doing nothing at all.11 It follows that outcomes could be improved if bystanders, who would otherwise do nothing, were encouraged to begin resuscitation, even if they do not follow an algorithm targeted specifically at children. There are, however, distinct differences between the predominantly adult arrest of cardiac origin and asphyxial arrest, which is most common in children,12 so a separate paediatric algorithm is justified for those with a duty to respond to paediatric emergencies (usually healthcare professionals), who are also in a position to receive enhanced training.
The ILCOR treatment recommendation was that the compression:ventilation ratio should be based on whether one or more than one rescuers were present. ILCOR recommends that lay rescuers, who usually learn only single rescuer techniques, should be taught to use a ratio of 30 compressions to 2 ventilations, which is the same as the adult guidelines and enables anyone trained in BLS techniques to resuscitate children with minimal additional information. Two or more rescuers with a duty to respond should learn a different ratio (15:2), as this has been validated by animal and manikin studies.13, 14, 15, 16, 17 This latter group, who would normally be healthcare professionals, should receive enhanced training targeted specifically at the resuscitation of children. Although there are no data to support the superiority of any particular ratio in children, ratios of between 5:1 and 15:2 have been studied in manikins, and animal and mathematical models, and there is increasing evidence that the 5:1 ratio delivers an inadequate number of compressions.14, 18 There is certainly no justification for having two separate ratios for children aged greater or less than 8 years, so a single ratio of 15:2 for multiple rescuers with a duty to respond is a logical simplification.
It would certainly negate any benefit of simplicity if lay rescuers were taught a different ratio for use if there were two of them, but those with a duty to respond can use the 30:2 ratio if they are alone, particularly if they are not achieving an adequate number of compressions because of difficulty in the transition between ventilation and compression.
The adoption of single compression:ventilation ratios for children of all ages, together with the change in advice on the lower age limit for the use of automated external defibrillators (AEDs), renders the previous guideline division between children above and below 8 years of age unnecessary. The differences between adult and paediatric resuscitation are based largely on differing aetiology, as primary cardiac arrest is more common in adults whereas children usually suffer from secondary cardiac arrest. The onset of puberty, which is the physiological end of childhood, is the most logical landmark for the upper age limit for use of paediatric guidance. This has the advantage of being simple to determine, in contrast to an age limit in years, as age may be unknown at the start of resuscitation. Clearly, it is inappropriate and unnecessary to establish the onset of puberty formally; if rescuers believe the victim to be a child they should use the paediatric guidelines. If a misjudgement is made and the victim turns out to be a young adult, little harm will accrue, as studies of aetiology have shown that the paediatric pattern of arrest continues into early adulthood.19 An infant is a child under 1 year of age; a child is between 1 year and puberty. It is necessary to differentiate between infants and older children, as there are some important differences between these two groups.
The modification to age definitions enables a simplification of the advice on chest compression. Advice for determining the landmarks for infant compression is now the same as for older children, as there is evidence that the previous recommendation could result in compression over the upper abdomen.20 Infant compression technique remains the same: two-finger compression for single rescuers and two-thumb, encircling technique for two or more rescuers,21, 22, 23, 24, 25 but for older children there is no division between the one- or two-hand technique.26 The emphasis is on achieving an adequate depth of compression with minimal interruptions, using one or two hands according to rescuer preference.
Case reports published since International Guidelines 2000 have reported safe and successful use of AEDs in children less than 8 years of age.27, 28 Furthermore, recent studies have shown that AEDs are capable of identifying arrhythmias in children accurately and that, in particular, they are extremely unlikely to advise a shock inappropriately.29, 30 Consequently, advice on the use of AEDs has been revised to include all children aged greater than 1 year.31 Nevertheless, if there is any possibility that an AED may need to be used in children, the purchaser should check that the performance of the particular model has been tested against paediatric arrhythmias.
Many manufacturers now supply purpose-made paediatric pads or programmes, which typically attenuate the output of the machine to 50–75 J.32 These devices are recommended for children aged 1–8 years.33, 34 If no such system or manually adjustable machine is available, an unmodified adult AED may be used in children older than 1 year.35 There is currently insufficient evidence to support a recommendation for or against the use of AEDs in children aged less than 1 year.
The 2005 Consensus Conference treatment recommendation for paediatric ventricular fibrillation (VF) or paediatric pulseless ventricular tachycardia (VT) is to defibrillate promptly. In adult ALS, the recommendation is to give a single shock and then resume CPR immediately without checking for a pulse or reassessing the rhythm (see Section 3). As a consequence of this single-shock strategy, when using a monophasic defibrillator in adults a higher initial energy dose than used previously is recommended (360 J versus 200 J) (see Section 3). The ideal energy dose for safe and effective defibrillation in children is unknown, but animal models and small paediatric series show that doses larger than 4 J kg−1 defibrillate effectively with negligible side effects.27, 34, 36, 37 Biphasic shocks are at least as effective and produce less post-shock myocardial dysfunction than monophasic shocks.33, 34, 37, 38, 39, 40 For simplicity of sequence and consistency with adult BLS and ALS, we recommend a single-shock strategy using a non-escalating dose of 4 J kg−1 (monophasic or biphasic) for defibrillation in children.
The guidance for managing foreign-body airway obstruction (FBAO) in children has been simplified and brought into closer alignment to the adult sequence. These changes are discussed in detail at the end of this section.
In the following text the masculine includes the feminine and ‘child’ refers to both infants and children unless noted otherwise.
Section snippets
Sequence of action
Rescuers who have been taught adult BLS and have no specific knowledge of paediatric resuscitation may use the adult sequence, with the exception that they should perform 5 initial breaths followed by approximately 1 min of CPR before they go for help (Figure 6.1; also see adult BLS guideline).
The following sequence is to be observed by those with a duty to respond to paediatric emergencies (usually health professionals).
- 1.
Ensure the safety of rescuer and child.
- 2.
Check the child's responsiveness.
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Recovery position
An unconscious child whose airway is clear, and who is breathing spontaneously, should be turned on his side into the recovery position. There are several recovery positions; each has its advocates. There are important principles to be followed.
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Place the child in as near true lateral position as possible, with his mouth dependent to enable free drainage of fluid.
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The position should be stable. In an infant this may require the support of a small pillow or a rolled-up blanket placed behind the
Foreign-body airway obstruction (FBAO)
No new evidence on this subject was presented during the 2005 Consensus Conference. Back blows, chest thrusts and abdominal thrusts all increase intrathoracic pressure and can expel foreign bodies from the airway. In half of the episodes, more than one technique is needed to relieve the obstruction.41 There are no data to indicate which measure should be used first or in which order they should be applied. If one is unsuccessful, try the others in rotation until the object is cleared.
The
Prevention of cardiopulmonary arrest
In children, secondary cardiopulmonary arrests, caused by either circulatory or respiratory failure, are more frequent than primary arrests caused by arrhythmias.9, 12, 43, 44, 45, 46 So-called ‘asphyxial arrests’ or respiratory arrests are also more common in young adulthood (e.g., trauma, drowning, poisoning).47, 48 The outcome from cardiopulmonary arrests in children is poor; identification of the antecedent stages of cardiac or respiratory failure is a priority, as effective early
A and B
Open the airway and ensure adequate ventilation and oxygenation.
- •
Deliver high-flow oxygen.
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Achieving adequate ventilation and oxygenation may include the use of airway adjuncts, bag-mask ventilation (BMV), use of a laryngeal mask airway (LMA), securing a definitive airway by tracheal intubation and positive pressure ventilation.
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In rare, extreme circumstances, a surgical airway may be required.
C
Establish cardiac monitoring.
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Secure vascular access to the circulation. This may be via peripheral or
A B C
Commence and continue with basic life support (Figure 6.9).
A and B
Oxygenate and ventilate with BMV.
- •
Provide positive pressure ventilation with a high inspired oxygen concentration.
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Give five rescue breaths followed by external chest compression and positive pressure ventilation in the ratio of 15:2 (lone rescuer may use 30:2).
- •
Avoid rescuer fatigue by changing the rescuer performing chest compressions frequently.
- •
Establish cardiac monitoring.
C
Assess cardiac rhythm and signs of circulation (±check for a
Unstable arrhythmias
Check the central pulse of any child with an arrhythmia; if the pulse is absent, proceed to treating the child as being in cardiopulmonary arrest. If the child has a central pulse, evaluate his haemodynamic status. Whenever the haemodynamic status is compromised, the first steps are as follows.
- •
Open the airway.
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Assist ventilation and give oxygen.
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Attach ECG monitor or defibrillator and assess the cardiac rhythm.
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Evaluate if the rhythm is slow or fast for the child's age.
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Evaluate if the rhythm is
Post-arrest management
Myocardial dysfunction is common after cardiopulmonary resuscitation.215, 216 Vasoactive drugs may improve the child's post-arrest haemodynamic values, but the drugs must be titrated according to the clinical condition. They must be given continuously through an IV line.
Prognosis of cardiopulmonary arrest
There are no simple guidelines to determine when resuscitative efforts become futile. After 20 min of resuscitation, the team leader of the resuscitation team should consider whether or not to stop.187, 235, 236, 237, 238, 239 The relevant considerations in the decision to continue the resuscitation include the cause of arrest,45, 240 pre-existing conditions, whether the arrest was witnessed, the duration of untreated cardiopulmonary arrest (“no flow”), the effectiveness and duration of CPR
Parental presence
The majority of parents would like to be present during resuscitation and when any procedure is carried out on their child.245, 246, 247, 248, 249, 250, 251, 252, 253, 254, 255. Parents witnessing their child's resuscitation can see that everything possible has been attempted.256, 257, 258, 259, 260 Furthermore, they may have the opportunity to say goodbye to their child; allowing parents to be at the side of their child has been shown to help them gain a realistic view of the attempted
Preparation
Relatively few babies need any resuscitation at birth. Of those that do need help, the overwhelming majority will require only assisted lung aeration. A small minority may need a brief period of chest compressions in addition to lung aeration. Of 100,000 babies born in Sweden in 1 year, only 10 per 1000 (1%) babies weighing 2.5 kg or more appeared to need resuscitation at delivery.268 Of those babies receiving resuscitation, 8 per 1000 responded to mask inflation and only 2 per 1000 appeared to
Temperature control
Naked, wet, newborn babies cannot maintain their body temperature in a room that feels comfortably warm for adults. Compromised babies are particularly vulnerable.270 Exposure of the newborn to cold stress will lower arterial oxygen tension271 and increase metabolic acidosis.272 Prevent heat loss by
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protecting the baby from draughts
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keeping the delivery room warm
- •
drying the term baby immediately after delivery. Cover the head and body of the baby, apart from the face, with a warm towel to prevent
Initial assessment
The Apgar scoring system was not designed to identify prospectively babies needing resuscitation.273 Several studies have also suggested that it is highly subjective.274 However, components of the score, namely respiratory rate, heart rate and colour, if assessed rapidly, can identify babies needing resuscitation.275 Furthermore, repeated assessment of these components can indicate whether the baby is responding or whether further efforts are needed.
Newborn life support
Commence newborn life support (Figure 6.10) if assessment demonstrates that the baby has failed to establish adequate regular normal breathing, or has a heart rate of less than 100 beats min−1. Opening the airway and aerating the lungs is usually all that is necessary. Furthermore, more complex interventions will be futile unless these two first steps have been successfully completed.
Maintaining normal temperature in preterm infants
Significantly, preterm babies are likely to become hypothermic despite careful application of the traditional techniques for keeping them warm (drying, wrapping and placing under radiant heat).282 Several randomised controlled trials and observational studies have shown that placing preterm babies under radiant heat and then covering the babies with food-grade plastic wrapping, without drying them, significantly improves temperature on admission to intensive care compared with traditional
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