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).