Bob Elling, MPA, EMT-P
(Part 5 of a 6-part series: CPR, ECC, and First Aid Guidelines: Version 2015)
Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality
A number of topics were addressed in the 2015 Guidelines on both pediatric basic and advanced life support and CPR quality that will be incorporated into updated protocols and procedures. Let’s take a closer look at the specifics here.
Components of High-Quality CPR: Chest Compression Rate and Depth
- To maximize simplicity in CPT training, in the absence of sufficient pediatric evidence, it is reasonable to use the adult chest compression rate of 100 to 120 compressions per minute for infants and children (Class IIa).
- Although the effectiveness of CPR feedback devices was not reviewed by this writing group, the consensus of the group is that the use of feedback devices likely helps the rescuer optimize adequate chest compression rate and depth, and we suggest their use when available (Class IIb).
- In pediatric patients (younger than 1 year), it is reasonable that rescuers provide chest compressions that depress the chest at least one third of the anterior–posterior diameter of the chest. This equates to approximately 1.5 inches (4 cm) in children (Class IIa). Once children have reached puberty, the recommended adult compression depth of at least 5 cm, but no more than 6 cm, is used for the adolescent of average adult size.
- Conventional CPR (rescue breathing and chest compressions) should be provided for pediatric cardiac arrest (Class I).
- The asphyxia nature of the majority of pediatric cardiac arrests necessitates ventilation as part of effective CPR. However, because compression-only CPR is effective in patients with a primary cardiac event, if rescuers are unwilling or unable to deliver breaths, we recommend rescuers perform compression-only CPR for infants and children in cardiac arrest (Class I).
Pediatric Advanced Life Support
Prearrest Care Updates
- Administration of an initial fluid bolus of 20 mL/kg to infants and children with shock is reasonable, including those with conditions such as severe sepsis (Class IIa) and malaria and dengue fever (Class IIb).
- When caring for children with severe febrile illness (such as those included in the FEAST trial) in settings with limited access to critical care resources (ie, mechanical ventilation and inotropic support), administration of bolus IV fluids should be undertaken with extreme caution because it may be harmful (Class IIb).
- Providers should reassess the patient after every fluid bolus (Class I).
- Either isotonic crystalloids or colloids can be effective as the initial fluid choice for resuscitation (Class IIa).
- The available evidence does not support the routine use of atropine prior to intubation of critically ill infants and children. It may be reasonable for practitioners to use atropine as a premedication in specific emergent intubations when there is a higher risk of bradycardia (eg, when giving succinylcholine as a neuromuscular blocker to facilitate intubation) (Class IIb).
- A dose of 0.02 mg/kg of atropine with no minimum dose may be considered when atropine is used as a premedication for emergency intubation (Class IIb).
Intra-arrest Care Updates
- ETCO2 monitoring may be considered to evaluate the quality of chest compressions, but specific values to guide therapy have not been established in children (Class IIb).
- It is reasonable to administer epinephrine in pediatric cardiac arrest (Class IIa).
- For shock-refractory VF/pVT, either amiodarone or lidocaine may be used (Class IIb).
- It is reasonable to use an initial dose of 2 to 4 J/kg of monophasic or biphasic energy for defibrillation (Class IIa), but for ease of teaching, an initial dose of 2 J/kg may be considered (Class IIb).
- For refractory VF, it is reasonable to increase the energy dose to 4 J/kg (Class IIa).
- For subsequent energy levels, a dose of 4 J/kg may be reasonable and higher energy levels may be considered, though not to exceed 10 J/kg or the adult maximum dose (Class IIb).
- For infants and children remaining comatose after OHCA, it is reasonable either to maintain 5 days of continuous normothermia (36 to 37.5°C) or to maintain 2 days of initial continuous hypothermia (32 to 34°C) followed by 3 days of continuous normothermia (Class IIa).
- Continuous measurement of temperature during this time period is recommended (Class I).
- Fever (temperature 38°C or higher) should be aggressively treated after ROSC (Class I).
- It may be reasonable for rescuers to target normoxemia after ROSC (Class IIb).
- It is reasonable for practitioners to target a Paco2 after ROSC that is appropriate to the specific patient condition, and to limit exposure to severe hypercapnia or hypocapnia (Class IIb).
The next section of this blog will cover the specifics of first aid. If you want to read all the details and background, take a look at the Supplement to Circulation, volume 132, number 18, supplement 2, November 3, 2015.
See you in the streets!