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Update on Paediatric
Lee Wallis
• there are new protocols for both basic and
advanced life support
• in general children arrest from hypoxia and / or
• early and effective treatment will prevent cardiac
arrest and dramatically improve the outcomes
that are possible
• highlights of the ILCOR recommendations 2005
for BLS and defibrillation
• particular issues for children
– as in the APLS guidelines
• actual algorithms for resuscitation
• additional issues
Highlights: lay (single)
• Airway opening only head tilt chin lift
• Simplification of instructions for rescue breaths
– 1 second
– Make the chest rise
• Elimination of lay rescuer training in rescue breathing
without chest compressions
• Elimination of lay rescuer assessment of signs of
circulation before beginning chest compressions
• 2 min of CPR before calling 112
Highlights: lay
• Recommendation of a single (universal)
compression-to ventilation ratio of 30:2 for single
rescuers of victims of all ages (except newborn
• Modification of the definition of “pediatric victim”
to preadolescent (prepubescent) victim for
application of pediatric BLS guidelines for
healthcare providers
Highlights: general
• Increased emphasis on the importance of
chest compressions
• Recommendation that EMS providers may
consider provision of about 5 cycles (or
about 2 minutes) of CPR before
defibrillation for unwitnessed arrest
• Recommendation that all rescue efforts be
performed in a way that minimizes interruption of
chest compressions
• Recommendation of only 1 shock followed
immediately by CPR (beginning with chest
compressions) instead of 3 stacked shocks for
treatment of shockable rhythms
Highlights: neonate
• Increased emphasis on the importance of
ventilation and de-emphasis on the
importance of using high concentrations of
oxygen for resuscitation of the newly born
issues for children:
age definitions
• infant – a child under one year
• child – between one year and puberty
– if you believe that the victim is a child, use the
paediatric guidelines
issues for children:
newborn resuscitation changes
• food grade plastic wrapping to maintain body
temperature in very pre-term babies
• attempts to aspirate meconium whilst the head is
on the perineum no longer recommended
• ventilation may start with air but oxygen added
quickly if a poor response
• adrenaline should be given intravascularly not
via the trachea
issues for children:
route of drug administration in ALS
• where possible give drugs intra-vascularly rather than
via the tracheal route –
– lower adrenaline concentrations may produce transient
hypotensive effects.
– dose of adrenaline in paediatric cardiac arrest is 10
micrograms/kg on every occasion.
issues for children:
endotracheal tubes
• either cuffed or uncuffed tracheal tubes
may be used during resuscitation of
infants and children in the hospital setting
– relevant when cardiac arrest is associated
with difficult to ventilate lungs.
number of defibrillating shocks
• one shock rather than three “stacked”
– VF
– pulseless VT
cardiac arrest algorithm
BLS and need for defibrillation
• clinical indication for EMS activation
before BLS by a lone rescuer include:
– witnessed sudden collapse with no apparent
preceding morbidity
– witnessed sudden collapse in a child with a
known cardiac condition and in the absence
of a known or suspected respiratory or
circulatory cause of arrest.
compression: ventilation ratios
• Five rescue breaths, to produce 2 effective
– may be added by lay rescuers
• 2 or more rescuers with a duty to respond use
15 compressions to 2 ventilations for all ages of
children (a single professional rescuer can use
either ratio)
• Lay (single) rescuers use the adult 30:2 ratio for
all ages
compression technique
• position:
– For all ages: compress the lower third of the sternum
• Find the lower third by measuring one finger’s breadth above the
angle of junction of ribs
• number of hands:
• in children: use one or two hands: whichever is required to
depress the sternum by approximately one third of the depth of
the chest
• In infants: two thumbs or two fingers
cardiac arrest algorithm
automated external defibrillators
• standard AED for children over 8 years
• paediatric pads or programmes to attenuate energy to
50-80 joules for children between 1 and 8 years
• If an attenuated machine is unavailable a standard AED
may be used for children over 1 year
• insufficient evidence to support a recommendation for or
against the use of an AED in children under 1 year
choking relief sequence
• simplified sequence based on if the child
has an effective or ineffective cough and if
they are conscious or unconscious.
Open airway
5 back blows
5 rescue breaths
5 chest/adbo
CPR check for FB
Assess and repeat
Support and
family presence
• in the absence of data documenting harm
and in light of data suggesting that it may
be helpful, offering select family members
the opportunity to be present during a
resuscitation seems reasonable and
ethical comments
• when to stop:
– In the past, children who underwent
prolonged resuscitation and absence of
ROSC after 2 doses of epinephrine were
considered unlikely to survive, but intact
survival …. been documented. Prolonged
efforts should be made for infants and
children with recurring or refractory VF or VT,
drug toxicity, or a primary hypothermic insult.
fluid resuscitation
• crystalloids
• volumes in trauma (where bleeding is not
• monitoring of adequacy of resuscitation
– central venous pressure
– beat to beat blood pressure variation
– central venous saturations
Summary of ALS guidelines