Part 14: Pediatric Advanced Life Support 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Monica E. Kleinman, Chair; Leon Chameides; Stephen M. Schexnayder; Ricardo A. Samson; Mary Fran Hazinski; Dianne L. Atkins; Marc D. Berg; Allan R. de Caen; Ericka L. Fink; Eugene B. Freid; Robert W. Hickey; Bradley S. Marino; Vinay M. Nadkarni; Lester T. Proctor; Faiqa A. Qureshi; Kennith Sartorelli; Alexis Topjian; Elise W. van der Jagt; Arno L. Zaritsky n contrast to adults, cardiac arrest in infants and children emergency response system for a deteriorating inpatient has Idoes not usually result from a primary cardiac cause. More been shown to significantly decrease the incidence of cardiac often it is the terminal result of progressive respiratory failure and respiratory arrests, as well as hospital mortality rates in or shock, also called an asphyxial arrest. Asphyxia begins some large children’s hospitals.18–21 Such teams, often con- with a variable period of systemic hypoxemia, hypercapnea, sisting of providers with expertise in assessment and initial and acidosis, progresses to bradycardia and hypotension, and management of acutely ill patients (critical-care nurses, culminates with cardiac arrest.1 respiratory therapists, and critical-care physicians), decreased Another mechanism of cardiac arrest, ventricular fibrilla- the number of cardiac and respiratory arrests by as much as tion (VF) or pulseless ventricular tachycardia (VT), is the 72%18 and hospital mortality by as much as 35% in institu- initial cardiac rhythm in approximately 5% to 15% of tions where the effect was studied.19 Although it is possible 2–9 pediatric in-hospital and out-of-hospital cardiac arrests; it that most of the impact is due to a decrease in respiratory is reported in up to 27% of pediatric in-hospital arrests at arrests, this cannot be confirmed by the available published 6 some point during the resuscitation. The incidence of VF/ data. Implementation of a pediatric MET/RRT may be 2,4 pulseless VT cardiac arrest rises with age. Increasing beneficial in facilities where children with high risk illnesses evidence suggests that sudden unexpected death in young Downloaded from http://ahajournals.org by on April 3, 2019 are present on general inpatient units (Class IIa, LOE B). people can be associated with genetic abnormalities in myo- Despite the improved outcome of in-hospital CPR, a cyte ion channels resulting in abnormalities in ion flow (see majority of children with in-hospital cardiac arrest and an “Sudden Unexplained Deaths,” below). even larger percentage of children with out-of-hospital car- Since 2010 marks the 50th anniversary of the introduction diac arrest do not survive, or they are severely incapacitated of cardiopulmonary resuscitation (CPR),10 it seems appropri- if they do. Several studies, discussed later in this document, ate to review the progressive improvement in outcome of showed that the presence of family members during resusci- pediatric resuscitation from cardiac arrest. Survival from in-hospital cardiac arrest in infants and children in the 1980s tation has helped them deal with the inevitable trauma and was around 9%.11,12 Approximately 20 years later, that figure grief following the death of a child. Therefore, whenever had increased to 17%,13,14 and by 2006, to 27%.15–17 In possible, provide family members with the option of being contrast to those favorable results from in-hospital cardiac present during resuscitation of an infant or child (Class I, arrest, overall survival to discharge from out-of-hospital LOE B). cardiac arrest in infants and children has not changed sub- stantially in 20 years and remains at about 6% (3% for infants BLS Considerations During PALS and 9% for children and adolescents).7,9 Pediatric advanced life support (PALS) usually takes place It is unclear why the improvement in outcome from in the setting of an organized response in an advanced in-hospital cardiac arrest has occurred, although earlier rec- healthcare environment. In these circumstances, multiple ognition and management of at-risk patients on general responders are rapidly mobilized and are capable of simulta- inpatient units and more aggressive implementation of neous coordinated action. Resuscitation teams may also evidence-based resuscitation guidelines may have played a have access to invasive patient monitoring that may role. Implementation of a formal pediatric medical emer- provide additional information during the performance of gency team (MET) or rapid response team (RRT) as part of an basic life support (BLS). The American Heart Association requests that this document be cited as follows: Kleinman ME, Chameides L, Schexnayder SM, Samson RA, Hazinski MF, Atkins DL, Berg MD, de Caen AR, Fink EL, Freid EB, Hickey RW, Marino BS, Nadkarni VM, Proctor LT, Qureshi FA, Sartorelli K, Topjian A, van der Jagt EW, Zaritsky AL. Part 14: pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S876–S908. (Circulation. 2010;122[suppl 3]:S876–S908.) © 2010 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.110.971101 S876 Kleinman et al Part 14: Pediatric Advanced Life Support S877 Simultaneous Actions ● An increased respiratory rate, particularly with signs of BLS (whether for a child or adult) is presented as a series of distress (eg, increased respiratory effort including nasal sequential events with the assumption that there is only one flaring, retractions, seesaw breathing, or grunting) responder, but PALS usually takes place in an environment ● An inadequate respiratory rate, effort, or chest excursion where many rescuers are rapidly mobilized and actions are (eg, diminished breath sounds or gasping), especially if performed simultaneously. The challenge is to organize the mental status is depressed rescuers into an efficient team. Important considerations for ● Cyanosis with abnormal breathing despite supplementary the greatest chance of a successful resuscitation from cardiac oxygen arrest include the following: Shock ● Chest compressions should be immediately started by one Shock results from inadequate blood flow and oxygen deliv- rescuer, while a second rescuer prepares to start ventila- ery to meet tissue metabolic demands. The most common tions with a bag and mask. Ventilation is extremely type of shock in children is hypovolemic, including shock due important in pediatrics because of the large percentage of to hemorrhage. Distributive, cardiogenic, and obstructive asphyxial arrests in which best results are obtained by a shock occur less frequently. Shock progresses over a contin- combination of chest compressions and ventilations.8 Un- uum of severity, from a compensated to a decompensated fortunately ventilations are sometimes delayed because state. Compensatory mechanisms include tachycardia and equipment (bag, mask, oxygen, airway) must be mobilized. increased systemic vascular resistance (vasoconstriction) in Chest compressions require only the hands of a willing an effort to maintain cardiac output and perfusion pressure rescuer. Therefore, start CPR with chest compressions respectively. Decompensation occurs when compensatory immediately, while a second rescuer prepares to provide mechanisms fail and results in hypotensive shock. ventilations (Class I, LOE C). ● The effectiveness of PALS is dependent on high-quality Typical signs of compensated shock include CPR, which requires an adequate compression rate (at least ● Tachycardia 100 compressions/min), an adequate compression depth (at ● Cool and pale distal extremities least one third of the AP diameter of the chest or approx- ● Prolonged (Ͼ2 seconds) capillary refill (despite warm 1 imately 1 ⁄2 inches [4 cm] in infants and approximately 2 ambient temperature) inches [5 cm] in children), allowing complete recoil of the ● Weak peripheral pulses compared with central pulses Downloaded from http://ahajournals.org by on April 3, 2019 chest after each compression, minimizing interruptions in ● Normal systolic blood pressure compressions, and avoiding excessive ventilation. Reasons for not performing high-quality CPR include rescuer inat- As compensatory mechanisms fail, signs of inadequate tention to detail, rescuer fatigue, and long or frequent end-organ perfusion develop. In addition to the above, these interruptions to secure the airway, check the heart rhythm, signs include and move the patient.22 Optimal chest compressions are best delivered with the victim on a firm surface.23,24 ● Depressed mental status ● While one rescuer performs chest compressions and an- ● Decreased urine output other performs ventilations, other rescuers should obtain a ● Metabolic acidosis monitor/defibrillator, establish vascular access, and calcu- ● Tachypnea late and prepare the anticipated medications. ● Weak central pulses ● Deterioration in color (eg, mottling, see below) Monitored Patients Many in-hospital patients, especially if they are in an ICU, are Decompensated shock is characterized by signs and symp- monitored and some have an advanced airway and are toms consistent with inadequate delivery of oxygen to tissues receiving mechanical ventilation. If the patient has an in- (pallor, peripheral cyanosis, tachypnea, mottling of the skin, dwelling arterial catheter, use the waveform as feedback to decreased urine output, metabolic