Learning objectives.
By reading this article you should be able to:
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Discuss the evidence behind the resuscitation guidelines
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Apply current paediatric resuscitation guidelines in clinical practice.
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Recognise that focused post resuscitation care is critical for preventing further brain injury.
Key points.
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Do not interrupt chest compressions during resuscitation unless absolutely necessary.
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Do not be afraid to push hard when performing chest compressions, rib fractures are uncommon in children.
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Automated external defibrillators can be used for children.
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Use intraosseous access if i.v. access is difficult.
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Parental presence at resuscitation should be accommodated if requested.
Paediatric resuscitation was last reviewed in this journal in 2002. The European paediatric resuscitation guidelines 2000 have since undergone a number of sequential changes, during updates in 2005, 2010, and 2015. During this time, survival to return of spontaneous circulation (ROSC) has increased to 77% and survival to hospital discharge to 44%, for in-hospital cardiac arrests.1 This article will review the current (2015) guidelines for healthcare professionals.2 It will also highlight evidence behind key changes undertaken since the year 2000.
Guidelines on paediatric life support are based on three main principles:
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(i)
the incidence of critical illness, particularly cardiopulmonary arrest, and injury in children is much lower than in adults;
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(ii)
the illnesses and pathophysiological responses of paediatric patients often differ from those seen in adults;
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(iii)
many paediatric emergencies are managed primarily by providers who are not paediatric specialists and who have limited paediatric emergency medical experience.
Therefore, guidelines on paediatric life support must incorporate the best available scientific evidence, but must also be simple and feasible.
Basic life support and automated external defibrillation
The majority of paediatric cardiorespiratory arrests are not caused by primary cardiac problems but are secondary to other causes, mostly respiratory insufficiency; hence the order of delivering the resuscitation sequence: airway (A), breathing (B), and circulation (C).
Rescuers should assess the responsiveness of a child. If unresponsive they should shout for help, place the child on their back, and open the airway with a head tilt chin lift or jaw thrust. Once the airway is opened, if breathing is deemed inadequate, any visible obstruction should be removed and five rescue breaths should be delivered. If there are no signs of life (e.g. no response to rescue breaths) chest compressions should be commenced. If alone, perform cardiopulmonary resuscitation (CPR) for 1 min before going for help. Feeling for a pulse is NOT a reliable way to determine if there is an effective or inadequate circulation. The decision to start CPR should take less than 10 s from starting the initial assessment of the child's circulatory status and if there is still doubt after that time, start CPR. The algorithm for basic life support (BLS) is given in Figure 1.
Fig 1.
Algorithm for paediatric basic life support. Reproduced with kind permission of the Resuscitation Council (UK).
Compression ventilation ratio
Optimal compression to ventilation ratios are lower for professional rescuers, who take less time to deliver a rescue breath, than for lay rescuers, who interrupt chest compressions for longer to perform ventilations.3 The 2015 guidelines recommend delivering a breath over about 1 s, to coincide with adult practice.
The asphyxial origin of most paediatric cardiac arrests necessitates ventilation as part of effective CPR in children. Ideal compression to ventilation ratios in CPR should be smaller for children than for adults and gradually increase as a function of body weight, so ideally compression ventilation ratios should change according to weight.4 However, this is clearly impractical, so the recommended compression ventilation ratio of 15:2 for healthcare professionals represents a compromise, balancing optimal organ perfusion with the delivery of simple feasible resuscitation practice.
Hyperventilation must also be avoided during CPR, particularly after tracheal intubation. Hyperventilation results in positive intrathoracic pressure, which reduces venous return to the thorax and also reduces cerebral and coronary perfusion pressures. As pulmonary blood supply is very low during external cardiac compression, it is not possible to control arterial CO2 concentrations with positive pressure ventilation. The purpose of ventilation during CPR is simply to supply oxygen to the alveoli and this only requires intermittent expansion of the lung with a high concentration of oxygen. A respiratory rate of 10–12 bpm is recommended for all ages.
Chest compression quality
Fear of doing harm can often lead to inadequate chest compressions, yet studies have shown that rib fractures caused by CPR are uncommon in children.5 Compress the chest by at least one-third of its depth, approximately 4 cm for an infant and approximately 5 cm for an older child.6 In a child more than 1 yr, use one or two hands in order to achieve an adequate depth of compression. The compression rate should be 100–120 min−1. In an infant under 1 yr of age, single rescuers should use two fingers for chest compression, but if there is more than one rescuer, an encircling technique using both hands around the chest and compressing the sternum with both thumbs produces better arterial pressures. For all compression techniques, it is important to let the chest fully expand after the compression. Incomplete recoil results in impaired cardiovascular function because of reduced venous return to the thorax, which results in decreased cardiac output, myocardial, and cerebral perfusion. Complete recoil is achieved by releasing all pressure from the chest at the end of each compression (without removing the hands from the chest wall) and not leaning on the chest during the relaxation phase.
Automated external defibrillators
Automated external defibrillators (AEDs) can recognise the cardiac rhythm in paediatric cardiac arrest with high sensitivity and specificity.7 Current guidance reflects this and recommends continuing CPR uninterrupted until the AED is available. Upon its arrival, attach the AED and follow its instructions. For 1–8 yr olds, use purpose-made attenuated pads if available. If these are not available, you should still deliver a shock if advised.
AEDs are pre-set for all variables including the energy dose. Concerns regarding myocardial damage resulting from delivery of adult energy doses via AEDs to children, should not prevent AED use in children. An animal study estimated that the amount of energy required to kill 50% of its test population (lethal dose in 50% or LD50) is 470 J kg−1.8 Conversely, not delivering a shock results in certain death if the patient has ventricular fibrillation (VF).
Advanced life support
The paediatric advanced life support (PALS) algorithm should be used by healthcare professionals trained in PALS techniques (Fig. 2). Many of its features are now common with adult practice. If cardiac arrest is suspected, the paediatric resuscitation team should be called, with the exact location made explicit. Meanwhile, good quality CPR is commenced while self-adhesive monitoring and defibrillation pads are applied to allow rapid assessment of rhythm. The treatment algorithm has two branches, the shockable and the non-shockable pathway, depending on whether defibrillation is indicated. Interventions such as high quality chest compressions with minimal interruptions, securing the airway, vascular access, and seeking reversible causes are common to both groups.
Fig 2.
Algorithm for paediatric advanced life support. Reproduced with kind permission of the Resuscitation Council (UK).
Shockable rhythms
Primary VF occurs in 3.8–19% of cardiopulmonary arrests in children. The incidence of VF or pulseless ventricular tachycardia (pVT) increases as age increases.9 The primary determinant of survival is time to defibrillation.
For shockable rhythms, attempt defibrillation immediately at 4 J kg−1. Charge the defibrillator whilst continuing chest compressions. At this time, the rest of the team (excluding the individual performing chest compressions) are instructed to stand clear and the oxygen delivery device removed if not a closed circuit. Only when the defibrillator is charged should compressions cease, the person delivering chest compressions warned to stand clear, and the shock delivered. Chest compressions should be resumed immediately without reassessing rhythm or feeling for a pulse. After 2 min, check briefly the cardiac rhythm on the monitor and deliver a second shock (4 J kg−1) if still in VF/pVT. Continue CPR for 2 min as soon as possible without reassessing the rhythm. Pause briefly to assess the rhythm after a further 2 min and deliver a third shock at 4 J kg−1 if still in VF/pVT. Administer adrenaline 10 μg kg−1 and amiodarone 5 mg kg−1 after the third shock once CPR has been resumed. Repeat adrenaline administration every alternate cycle (i.e. every 3–5 min during CPR). Give a second dose of amiodarone 5 mg kg−1 if still in VF/pVT after the fifth shock.10
Although amiodarone is the usual first line antiarrhythmic, lidocaine may be used as an alternative. If the child remains in VF/pVT, continue to alternate shocks of 4 J kg−1 with 2 min of CPR. If defibrillation has been successful but VF/pVT recurs, resume CPR, repeat the previously given antiarrhythmic, and defibrillate again at the energy level that was effective previously.
If signs of life become evident, check the monitor for an organised rhythm; if this is present, continue ventilation until full return of spontaneous breathing, re-evaluate for signs of life and a central pulse, and assess the haemodynamics of the child (return of consciousness, peripheral perfusion, blood pressure).
Defibrillation
Defibrillators are either automated or manually operated, and may be capable of delivering either monophasic or biphasic shocks. Manual defibrillators capable of delivering the full energy requirements from neonates upwards must be available within hospitals and in other healthcare facilities caring for children at risk of cardiopulmonary arrest.
Pad/paddle size for defibrillation
Select the largest possible available paddles to provide good contact with the chest wall. Recommended sizes are: 4.5 cm diameter for infants and children weighing <10 kg and 8–12 cm diameter for children weighing >10 kg (older than 1 yr). To decrease skin and thoracic impedance, an electrically conducting interface is required between the skin and the paddles. Purpose made self-adhesive defibrillation electrodes are very effective and are strongly recommended for maximal delivery of the energy, they also facilitate continuous good quality CPR.
Position of the pads/paddles
Apply the pads to the bare chest in the antero-lateral position, one pad placed below the right clavicle and the other in the left axilla. If the pads are too large and there is a danger of charge arcing between them, one should be placed on the upper back, below the left scapula, and the other on the front, to the left of the sternum. This is known as the antero-posterior position and is also acceptable.
Energy doses for children
The ideal energy dose for safe and effective defibrillation is unknown. Biphasic shocks are at least as effective and produce less post-shock myocardial dysfunction than monophasic shocks.11 Animal models show better results with paediatric doses of 3–4 J kg−1 than with lower doses,12 or adult doses,13 but there are no data to support a different strategy to the current one of an initial dose of 2–4 J kg−1. In Europe, for the sake of simplicity, we continue to recommend 4 J kg−1 for initial and subsequent defibrillation.
Non-shockable rhythms
The most common ECG patterns in infants, children, and adolescents with cardiopulmonary arrest are asystole and pulseless electrical activity (PEA). PEA is characterised by electrical activity on the ECG and absent pulses. It commonly follows a period of hypoxia. A period of immediate CPR is therefore recommended in this age group before searching for an AED or manual defibrillator, unless staff are available to do both, as its immediate availability will not improve the outcome of a respiratory arrest. In non-shockable rhythms, good quality CPR is the most important intervention. In addition, give adrenaline i.v. or intraosseously (10 μg kg−1) and repeat every 3–5 min (every 2nd cycle).
Monitoring
Appropriate clinical monitoring must be instituted as early as possible. In addition to ECG, pulse oximetry, blood pressure, and clinical signs, this includes:
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(i)
end-tidal capnography
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(ii)
CPR feedback devices
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(iii)
venous, arterial or capillary blood sampling
Both capnography and CPR feedback devices can be effective in guiding CPR. Studies have shown that feedback on rate and depth of compression, and allowing full recoil after a compression, improve provider's compliance with guideline recommendations.14 Capnography reflects pulmonary blood flow and therefore cardiac output during CPR. It has been suggested that this can be a useful guide to both CPR performance and in prognostication.15
Reversible causes
During CPR, reversible causes for which there is specific treatment should be identified and treated. They are divided into two groups of four and are included in the ALS algorithm represented by the four H's and four T's:
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(i)
Hypoxia
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(ii)
Hypovolaemia
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(iii)
Hyper/hypokalaemia, metabolic
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(iv)
Hypothermia
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(v)
Thrombosis (coronary or pulmonary)
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(vi)
Tension pneumothorax
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(vii)
Tamponade (cardiac)
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(viii)
Toxic/therapeutic disturbances
In children, it is important to remember that hypoxia and hypovolaemia have the highest prevalence in critically ill or injured children, and that electrolyte disturbances and toxicity are common causes of arrhythmia.
Airway management
Open the airway by using BLS techniques. Oro-pharyngeal and nasopharyngeal airways adjuncts can help maintain the airway.
Although bag mask ventilation (BMV) remains the recommended first line method for achieving airway control and ventilation in children, supraglottic airway devices may assist providers trained in their use. They may be particularly helpful in airway obstruction caused by supraglottic airway abnormalities, or if BMV ventilation is difficult or not possible.
Tracheal intubation is the most secure and effective way to establish and maintain the airway, prevent gastric distension, protect the lungs against pulmonary aspiration, enable optimal control of the airway pressure, and provide PEEP. The oral route for tracheal intubation is preferable during resuscitation.
Uncuffed tracheal tubes have been used traditionally in children up to 8 yr of age, but cuffed tubes may offer advantages in certain circumstances such as facial burns. Cuffed tubes also make it more likely that the correct tube size will be chosen on the first attempt.16 The correctly sized cuffed tracheal tube is as safe and effective as an uncuffed tube for resuscitation of infants and children, provided cuff pressures are monitored and controlled.
I.V. access and drugs
Vascular access is essential to enable drugs and fluids to be given, and blood samples obtained. Venous access can be difficult to establish during resuscitation of an infant or child. If attempts at establishing i.v. access are unsuccessful after 1 min, insert an intraosseous needle instead.
Post resuscitation care
After ROSC, the main goals are to prevent further brain injury and myocardial dysfunction, to treat the systemic ischaemia/reperfusion response, and any persistent precipitating pathology.
Evidence from animal studies and neonates, suggests that reperfusion injury from toxic oxygen radicles is possible if uncontrolled hyperoxia is tolerated. It is therefore recommended that inspired oxygen concentrations are titrated to maintain oxygen saturations in the mid to high 90s once ROSC is achieved.
Parenteral fluids and vasoactive drugs may improve the child's post-arrest cardiovascular status and should be titrated to maintain systolic blood pressure of at least >5th centile for the age.17
Recently, the therapeutic hypothermia after paediatric cardiac arrest (THAPCA) in-hospital study showed that both hypothermia (32–34°C) and controlled normothermia (36–37.5°C) could be used in children who remain comatose after cardiac arrest. Hyperthermia is potentially harmful and should be actively avoided.18 After ROSC, a strict control of the temperature must be maintained to avoid hyperthermia (>37.5°C) and severe hypothermia (<32°C).
Most parents want to be present at the resuscitation of their child. There is evidence to suggest this can be managed without being disruptive or stressful for staff.19 Some parents believe their presence is beneficial for the child. Family presence at their child's death can aid adjustment and improve the grieving process.20
The 2015 guidelines recommend that when parents are in the resuscitation room, a member of the resuscitation team should be allocated to them and explain the process in an empathetic manner, ensuring that they do not interfere with or distract the resuscitation process. If the presence of the relatives is impeding the progress of the resuscitation, they should be asked sensitively to leave. When appropriate, physical contact with the child should be allowed and, wherever possible, the parents should be allowed to be with their dying child at the final moments.
The leader of the resuscitation team, not the parents, will decide when to stop the resuscitation; this should be expressed with sensitivity and understanding. After the event, the team should be debriefed, to enable any concerns to be expressed and for the team to reflect on their clinical practice in a supportive environment.
Declaration of interest
None declared.
MCQs
The associated MCQs (to support CME/CPD activity) can be accessed at www.bjaed.org/cme/home by subscribers to BJA Education.
Biographies
Bob Bingham FRCA is a Consultant Paediatric Anaesthestist at Great Ormond Street Hospital for Children.
Usman Ali FRCA is a Fellow in Paediatric Anaesthesia at Great Ormond Street Hospital for Children.
Matrix codes: 1B04, 2D01, 3D00
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