The effectiveness of Pediatric Advanced Life Support (PALS) is highly dependent on quality CPR and BLS
Photo credit: Photo by Dan Limmer
During the 50 years since the introduction of CPR and 30 years since the evolution of pediatric resuscitation, in-hospital pediatric patient survival has increased from 9% to 27%. Sadly, out-of-hospital cardiac arrest survival in infants and children has not improved.1 This red flag should send a signal to EMS providers that there is room for improvement in pediatric arrest management. When survival following ventricular fibrillation can approach 30% in children,2 the time has come to focus on what science says about pediatric arrest management and make an effort to improve our care. This month’s CE article focused on adult life support and CPR; this article dissects the science and updates for pediatric life support and looks specifically at how the updates impact the care EMS provides. Without a doubt, the most fundamental lesson for EMS is that the effectiveness of Pediatric Advanced Life Support (PALS) is highly dependent on quality CPR and BLS.
While quite a bit of research supports termination of adult resuscitation efforts, no research has been done on futility of pediatric CPR efforts, and no limits or end-points of resuscitation efforts have been documented or suggested.3 There is no good predictor of when to terminate efforts. Variables including length of CPR, age, number of epinephrine doses and cardiac rhythm all need to be considered.1 Unfortunately, the only framework or guideline for field termination of pediatric cardiac arrests is for children with special needs, such as a cardiac disease, ventilator dependency and long-term disabilities. The parents of these chronically ill children may have advance directives to drive their child’s care if they experience respiratory or cardiac arrest. When caring for these patients, ask about Do Not Resuscitate orders and work with the family or caregivers to respect their wishes about aggressive care.
One ethically sound idea is to allow family presence during resuscitation.1 Bringing the family in to observe resuscitation efforts is a class I intervention. It allows family to have some closure should efforts fail and to see that everything was done for their child, and it has been shown to decrease the anxiety and depression parents often feel after a child dies. When including family, try to designate a medical provider to stay with them and explain the different interventions being provided. This small effort can go far in helping people cope.1
The pediatric chain of survival, like the adult chain, has switched from a traditional ABC approach to CAB: chest compressions, airway, breathing/ventilation. The overall pediatric chain of survival is:
1) Injury prevention and safety
2) Early chest compressions and CPR
3) Early access to emergency care
4) Early PALS
5) Comprehensive post-arrest care.
It is well known that, unlike adults, in whom the majority of arrests are cardiac-based, asphyxia-induced cardiac arrest (primary respiratory problem) is much more common for pediatric patients. It makes sense to ensure a combination of ventilations and chest compressions (compressions-only CPR is not indicated in pediatric patients); however, because it is not known whether the ABC or CAB approach is superior for pediatric patients, to ease memory and teaching, the AHA adopted the same change for both patient populations.2
As in adult CPR, pulse checks will no longer be taught to lay rescuers. CPR will likely begin on patients presenting unresponsive and not breathing normally, even if they have a pulse. The AHA is recommending 9-1-1 dispatchers be trained to instruct callers to perform CPR on infants and children any time the caller cannot confirm the patient is breathing normally (class IIa).
Compressions-only CPR is reasonable for the adult population and is being taught to lay rescuers; however, research clearly shows that for pediatric patients, where the majority of arrests are respiratory-based, optimal resuscitation is a combination of ventilations and chest compressions (class I LOE B). There is a clear improved outcome when ventilations are provided with compressions.2 However, when a lay person is unwilling to provide mouth-to-mouth ventilations and does not have a barrier device, compressions-only CPR is better than no CPR. If compressions-only CPR is in progress when EMS arrives, transition to compression-and-ventilation CPR.
Healthcare Provider Pulse Checks
Several studies suggested that, in the middle of an emergency, healthcare providers can have difficulty detecting a pulse, even with adequate training. It is reasonable though, for professionals to take up to 10 seconds to check for a brachial pulse in infants, or a carotid or femoral pulse in children. If a pulse is not present or the provider is not positive the pulse is present, immediately begin CPR (class IIa).2 When a pulse is definitely felt, but it is less than 60 beats per minute, provide 12 to 20 artificial ventilations per minute, reassessing the pulse every 2 minutes (class IIa). If the pulse remains below 60, or there are signs of poor perfusion after 2 minutes of ventilations, begin chest compressions. Signs of poor perfusion include pallor, mottling, cyanosis and altered mental status.
While the ratio of compressions to ventilations did not change in 2010, there have been a few important changes to how compressions are performed. All age groups currently require a compression rate of at least 100 compressions per minute.2 The mantra of “push hard, push fast” is used to describe compressions. Push fast refers to the increased compression rate; push hard refers to the new compression depth. Compress the infant chest 1½" and the child’s chest 2". This new guideline is a class I recommendation that replaces old compression depths of ½" to 1" and 1"-1½" for infants and children, respectively. The hand positions and sequence for one- and two-provider CPR have not been altered; however, the two-thumb-encircling-hands technique has been found to produce better myocardial perfusion and more consistently results in appropriate compression depth and force. When capable, use this technique.
New emphasis has been placed on ensuring constant adequate compressions with minimized interruptions (class IIa). Complete all interventions possible while compressions are performed. When they must be interrupted, limit pauses to less than 10 seconds. To prevent rescuer fatigue that causes inadequate chest compressions, rotate compressors every two minutes. The limited research performed on using CPR feedback devices can be effective in the pediatric population, but there is not enough data yet to take a formal position. If your medical director endorses their use, that is OK, but no data clearly shows they are beneficial. Once an advanced airway is in place, perform constant compressions at a rate of at least 100 per minute with 6–8 breaths per minute interspersed.2
Airway and Ventilations
After beginning chest compressions on infants and children, open the airway with a head tilt-chin lift. The head tilt-chin lift is a class I LOE B intervention for all infants and children, both injured and non-injured. When there is high suspicion of a cervical spine injury, the jaw thrust is a class IIb alternative, but if it does not adequately open the airway, use a head tilt-chin lift.2 Place padding beneath the patient’s shoulders to help maintain an open airway. There have been no changes to the rate and volume of ventilations. Provide enough air to produce chest rise over about 1 second. Do not hyperventilate pediatric patients. For the professional rescuer, bag-valve mask ventilations are ideal; however, if there is difficulty making a good seal on the patient, mouth-to-mouth and mouth-to-nose ventilations are both class IIb alternatives.
Recommendations for rescue breathing have not changed. Continue to give one breath every 3 seconds and constantly reevaluate the patient. Also, the management of foreign body airway obstruction (choking) remains essentially the same. Perform abdominal thrusts or a combination of five chest compressions and back blows on children and infants respectively until choking is relieved or the patient becomes unresponsive. All unresponsive choking patients are managed with CPR without pulse checks until the airway is cleared.2
Barrier devices for mouth-to-mouth ventilations do nothing to reduce the already low risk of transmitting any infectious disease from patient to rescuer. Further, their use can actually increase airflow resistance.2 Still, they remain acceptable devices, particularly if they make someone willing to provide ventilations to a pediatric patient.
The BVM and the challenges to its proper use are well known to EMS. There are no significant changes in its recommended uses, but the importance of maintaining a proper seal and sizing a BVM are worth mentioning here. The easiest way to properly use a BVM is to have two rescuers—the first to maintain a seal and hold the airway open and the second to squeeze the bag. When this is not feasible, utilize the E-C technique, with three fingers lifting the jaw, and the thumb and index finger making a C around the mask to hold a tight seal. Air leakage around the side of the mask decreases the volume of air delivered to the patient.
BVMs come in several sizes, and it is essential to use the right-sized BVM for the right patient. Typical pediatric BVMs deliver 450–500 mL of air and will adequately ventilate most infants and children. Neonatal BVMs may not provide enough air to produce chest rise in infants and children and will inadequately ventilate them. On the other side, adult BVMs can deliver up to 1000 mL of air, which can easily lead to hyperventilation and cause barotrauma, decreased cardiac output, decreased coronary perfusion, and increased risk of aspiration. Hyperventilating pediatric patients is a class III intervention.2
Remember, it is perfectly OK to manage a child’s airway with a BVM. If there is sufficient chest rise with each breath, and there are no challenges maintaining an open airway, it may be reasonable to defer advanced airway placement until arrival at the ED. Good BVM management is a hallmark of EMS care, and it is better to transport a well-oxygenated patient with a BLS airway in place than to spend too long trying to place an advanced airway and successfully place it, only to find the patient has experienced a hypoxic brain injury.
Advanced providers can place an endotracheal (ET) tube during respiratory and cardiac arrest management. Remember, though, routine use of cricoid pressure during intubation is now a class III intervention, as it has been shown to lengthen the time required for intubation.1 When selecting an ET tube, consider using a cuffed tube (class IIa). Proper tube size is more frequently achieved, and there is a decreased rate of accidental extubation with cuffed ET tubes.1 Tube sizing has not changed. Following ET tube placement, constantly use multiple clinical assessments for monitoring tube placement, including: bilateral chest movement and breath sounds, absent gastric insufflation sounds, end-tidal CO2 (class I) and pulse oximetry if there is a spontaneous pulse.1 Esophageal detector devices are probably best avoided during cardiac arrest, as there are no data to show if they are or are not reliable indicators of tube placement.
Supplemental oxygen is indicated in most arrest situations. Traditionally, EMS uses 100% oxygen on pedatric patients without exception. Research is ongoing, and it is reasonable to use 100% oxygen during an arrest, but as soon as a pulse is restored, titrate oxygen down and use the minimum required to maintain a pulse oximetry of at least 94% (class IIb).
Laryngeal Mask Airway (LMA)
While several airway devices (King LT and Combitube) have been studied in the adult population, there is little to no research on their use in children. Some research has been done on the LMA, although even this research is limited. However, when the appropriate sizes are available and providers are properly trained, the LMA is a class IIa airway alternative when intubation is not possible.
There has been no change in the recommended 2 minutes of CPR prior to obtaining and placing an AED or defibrillator. Likewise, the energy used—2 joules per kilogram (J/kg) and then 4 J/kg—has not changed either.4 Interestingly, research has shown that up to 10 J/kg can be safely used on children without adverse effects; increasing the energy level is a class IIb recommendation.4
AEDs have been approved for years on children between ages 1–8, as long as a pediatric dose-attenuator system has been available (class IIa). The research now shows that adult pads can be safely used when pediatric pads are not available, as long as the pads are not touching each other.4 Additionally, AEDs may be used on infants under 1 year old when a manual defibrillator is not available (class IIb). Ideally, this would be with a set of pediatric pads, but if only adult pads are available, simply place them so the two pads do not touch.
IV Access and Medications
Rapid IV or IO access is important for medication administration. In children of all ages, IO access is just as rapid, safe and effective as IV access (class I).1 There are no recommendations among the various types of IO devices and needles, but keep a manual IO needle as a backup. Some mechanical devices are not approved for children younger than 6 months of age, as their use can cause the tibia to shatter, resulting in no access. A safe practice is to use a manually inserted needle on infants.
Drug dosages for use during a pediatric arrest have not changed since 2005; however, like adult arrests, some drug recommendations have changed. Amiodarone is now the preferred antiarrhythmic (class IIb), atropine has been removed from the asystole/PEA algorithm, and the routine use of sodium bicarbonate is now a class III intervention. Management of symptomatic tachycardia and bradycardia is beyond the scope of this article.
Compared to 2005, there are only minor, although very important, changes to resuscitation in these updates. The most important emphasis is on the assurance of constant high-quality CPR. The best chance of survival for any patient comes from keeping blood circulating. The de-emphasis on pulse checks, advanced airways and even medications signals the lifesaving importance of chest compressions. Remember “push hard, push fast” to give any patient in cardiac arrest the best opportunity for survival.
1. Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: Pediatric Advanced Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 122:S876–S908, 2010.
2. Berg MD, Schexnayder SM, Chameides L, et al. Part 13: Pediatric Basic Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 122:S862–S875, 2010.
3. Morrison LJ, Kierzek G, Diekema DS, et al. Part 3: Ethics: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 122:S665–S675, 2010.
4. Link MS, Atkins DL, Passman RS, et al. Part 6: Electrical Therapies: Automated External Defibrillators, Defibrillation, Cardioversion, and Pacing. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 122:S706–S719, 2010.
Kevin T. Collopy, BA, CCEMT-P, NREMT-P, WEMT, is an educator, e-learning content developer and author of numerous articles and textbook chapters. He is also a flight paramedic for Ministry Spirit Medical Transportation in central Wisconsin and a lead instructor for Wilderness Medical Associates. Contact him at firstname.lastname@example.org.