2005 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) of Pediatric and Neonatal Patients: Pediatric Advanced Life Support (2006)

In contrast to adults, sudden cardiac arrest in children is uncommon, and cardiac arrest does not usually result from a primary cardiac cause.1 More often it is the terminal event of progressive respiratory failure or shock, also called an asphyxial arrest.Respiratory failure is characterized by inadequate ventilation or oxygenation. Anticipate respiratory failure and possible respiratory arrest if you see any of the following: Shock results from inadequate blood flow and oxygen delivery to meet tissue metabolic demands. Shock progresses over a continuum of severity, from a compensated to a decompensated state. Attempts to compensate include tachycardia and increased systemic vascular resistance (vasoconstriction) in an effort to maintain cardiac output and blood pressure. Although decompensation can occur rapidly, it is usually preceded by a period of inadequate end-organ perfusion.Signs of compensated shock include As compensatory mechanisms fail, signs of inadequate end-organ perfusion develop. In addition to the above, these signs include Signs of decompensated shock include the signs listed above plus hypotension. In the absence of blood pressure measurement, decompensated shock is indicated by the nondetectable distal pulses with weak central pulses in an infant or child with other signs and symptoms consistent with inadequate tissue oxygen delivery.The most common cause of shock is hypovolemia, one form of which is hemorrhagic shock. Distributive and cardiogenic shock are seen less often.Learn to integrate the signs of shock because no single sign confirms the diagnosis. For example: In compensated shock, blood pressure remains normal; it is low in decompensated shock. Hypotension is a systolic blood pressure less than the 5th percentile of normal for age, namely: Oropharyngeal and nasopharyngeal airways are adjuncts for maintaining an open airway. Oropharyngeal airways are used in unconscious victims (ie, with no gag reflex). Select the correct size: an oropharyngeal airway that is too small will not keep the tongue from obstructing the pharynx; one that is too large may obstruct the airway.Nasopharyngeal airways will be better tolerated than oral airways by patients who are not deeply unconscious. Small nasopharyngeal tubes (for infants) may be easily obstructed by secretions.There is insufficient evidence to recommend for or against the routine use of a laryngeal mask airway (LMA) during cardiac arrest (Class Indeterminate). When endotracheal intubation is not possible, the LMA is an acceptable adjunct for experienced providers (Class IIb; LOE 7),5 but it is associated with a higher incidence of complications in young children.6For information about the role of ventilation during CPR, see Part 11: “Pediatric Basic Life Support.”There are no studies comparing various concentrations of oxygen during resuscitation beyond the perinatal period. Use 100% oxygen during resuscitation (Class Indeterminate). Monitor the patient's oxygen level. When the patient is stable, wean the supplementary oxygen if the oxygen saturation is maintained.If the patient has a perfusing rhythm, monitor oxygen saturation continuously with a pulse oximeter because clinical recognition of hypoxemia is not reliable.7 Pulse oximetry, however, may be unreliable in a patient with poor peripheral perfusion.Bag-mask ventilation can be as effective as ventilation through an endotracheal tube for short periods and may be safer.8–11 In the prehospital setting ventilate and oxygenate infants and children with a bag-mask device, especially if transport time is short (Class IIa; LOE 18; 310; 49,11). Bag-mask ventilation requires training and periodic retraining on how to select a correct mask size, open the airway, make a tight seal between mask and face, ventilate, and assess effectiveness of ventilation (see Part 11: “Pediatric Basic Life Support”).Victims of cardiac arrest are frequently overventilated during resuscitation.12–14 Excessive ventilation increases intrathoracic pressure and impedes venous return, reducing cardiac output, cerebral blood flow, and coronary perfusion.13 Excessive ventilation also causes air trapping and barotrauma in patients with small-airway obstruction and increases the risk of stomach inflation, regurgitation, and aspiration.Minute ventilation is determined by the tidal volume and ventilation rate. Use only the force and tidal volume needed to make the chest rise visibly. During CPR for the patient with no advanced airway (eg, endotracheal tube, esophageal-tracheal combitube [Combitube], LMA) in place, ventilation rate is determined by the compression-ventilation ratio. Pause after 30 compressions (1 rescuer) or after 15 compressions (2 rescuers) to give 2 ventilations with mouth-to-mouth, mouth-to-mask, or bag-mask techniques. Give each breath over 1 second.If an advanced airway is in place during CPR (eg, endotracheal tube, Combitube, LMA), ventilate at a rate of 8 to 10 times per minute without pausing chest compressions. In the victim with a perfusing rhythm but absent or inadequate respiratory effort, give 12 to 20 breaths per minute. One way to achieve this rate with a ventilating bag is to use the mnemonic “squeeze-release-release” at a normal speaking rate.8,15A 2-person technique may be more effective than ventilation by a single rescuer if the patient has significant airway obstruction, poor lung compliance, or difficulty in creating a tight mask-to-face seal.16,17 One rescuer uses both hands to maintain an open airway with a jaw thrust and a tight mask-to-face seal while the other compresses the ventilation bag. Both rescuers should observe the victim's chest to ensure chest rise.Gastric inflation may interfere with effective ventilation18 and cause regurgitation. You can minimize gastric inflation by doing the following: Endotracheal intubation in infants and children requires special training because the pediatric airway anatomy differs from adult airway anatomy. Success and a low complication rate are related to the length of training, supervised experience in the operating room and in the field,23,24 adequate ongoing experience,25 and the use of rapid sequence intubation (RSI).23,26,27To facilitate emergency intubation and reduce the incidence of complications, skilled, experienced providers may use sedatives, neuromuscular blocking agents, and other medications to rapidly sedate and paralyze the victim.28 Use RSI only if you are trained and have experience using these medications and are proficient in the evaluation and management of the pediatric airway. If you use RSI you must have a secondary plan to manage the airway in the event that you cannot achieve intubation.In the in-hospital setting a cuffed endotracheal tube is as safe as an uncuffed tube for infants beyond the newborn period and in children.29–31 In certain circumstances (eg, poor lung compliance, high airway resistance, or a large glottic air leak) a cuffed tube may be preferable provided that attention is paid to endotracheal tube size, position, and cuff inflation pressure (Class IIa; LOE 230; 329,31). Keep cuff inflation pressure <20 cm H2O.32The internal diameter (ID) of the appropriate endotracheal tube for a child will roughly equal the size of that child's little finger, but this estimation may be difficult and unreliable.33,34 Several formulas such as the ones below allow estimation of proper endotracheal tube size (ID) for children 1 to 10 years of age, based on the child's age: \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \[\mathrm{uncuffed\ endotracheal\ tube\ size}\ (\mathrm{mm\ ID}){=}(\mathrm{age\ in\ years}/4){+}4\] \end{document} In general, during preparation for intubation using the above formula, providers should have the estimated tube size available, as well as uncuffed endotracheal tubes that have IDs that are 0.5 mm smaller and 0.5 mm larger than the size estimated ready at the bedside for use.The formula for estimation of a cuffed endotracheal tube size is as follows30: \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \[\mathrm{cuffed\ endotracheal\ tube\ size}\ (\mathrm{mm\ ID}){=}(\mathrm{age\ in\ years}/4){+}3\] \end{document} Endotracheal tube size, however, is more reliably based on a child's body length. Length-based resuscitation tapes are helpful for children up to approximately 35 kg.35There is a high risk that an endotracheal tube will be misplaced (ie, placed in the esophagus or in the pharynx above the vocal chords), displaced, or become obstructed,8,36 especially when the patient is moved.37 No single confirmation technique, including clinical signs38 or the presence of water vapor in the tube,39 is completely reliable, so providers must use both clinical assessment and confirmatory devices to verify proper tube placement immediately after intubation, during transport, and when the patient is moved (ie, from gurney to bed).Immediately after intubation and again after securing the tube, confirm correct tube position with the following techniques while you provide positive-pressure ventilation with a bag: After intubation secure the tube. There is insufficient evidence to recommend any one method (Class Indeterminate). After you secure the tube, maintain the patient's head in a neutral position; neck flexion pushes the tube farther into the airway, and extension pulls the tube out of the airway.42,43If an intubated patient's condition deteriorates, consider the following possibilities (DOPE): In infants and children with a perfusing rhythm, use a colorimetric detector or capnography to detect exhaled CO2 to confirm endotracheal tube position in the prehospital and in-hospital settings (Class IIa; LOE 544) and during intrahospital and interhospital transport (Class IIb; LOE 545). A color change or the presence of a capnography wave form confirms tube position in the trachea but does not rule out right main bronchus intubation. During cardiac arrest, if exhaled CO2 is not detected, confirm tube position with direct laryngoscopy (Class IIa; LOE 546–49; 650) because the absence of CO2 may be a reflection of low pulmonary blood flow.You may also detect a low end-tidal CO2 in the following circumstances: The self-inflating bulb (esophageal detector device) may be considered to confirm endotracheal tube placement in children weighing >20 kg with a perfusing rhythm (Class IIb; LOE 255,56). There are insufficient data to make a recommendation for or against its use in children during cardiac arrest (Class Indeterminate).Transtracheal catheter ventilation may be considered for support of oxygenation in the patient with severe airway obstruction if you cannot provide oxygen or ventilation any other way. Try transtracheal ventilation only if you are properly trained and have appropriate equipment.57A suction device with an adjustable suction regulator should be available. Use a maximum suction force of 80 to 120 mm Hg for suctioning the airway via an endotracheal tube.58 You will need higher suction pressures and large-bore noncollapsible suction tubing as well as semirigid pharyngeal tips to suction the mouth and pharynx.Advanced cardiovascular life support techniques are useless without effective circulation, which is supported by good chest compressions during cardiac arrest. Good chest compressions require an adequate compression rate (100 compressions per minute), an adequate compression depth (about one third to one half of the anterior-posterior diameter), full recoil of the chest after each compression, and minimal interruptions in compressions. Unfortunately, good compressions are not always performed for many reasons,14 including rescuer fatigue and long or frequent interruptions to secure the airway, check the heart rhythm, and move the that from the to the and the full of the support for effective chest compressions. In and life support use a are insufficient data to make a recommendation for or against the use of devices to the CPR, compression CPR, during resuscitation from cardiac arrest, and direct heart compression (Class Indeterminate). For information see Part and CPR for in-hospital cardiac arrest to resuscitation if the condition to cardiac arrest is or to heart if CPR has performed after no more than of cardiac arrest time without and if the is to rapidly oxygenation (Class IIb; LOE is possible after of CPR in or as as possible and monitor blood pressure. If the patient has an use the wave form to technique in the A of position or depth of compression can the wave is for medications and blood can be in infants and children during an can be easily the time you venous and if you cannot achieve In cardiac arrest is if no other is in is a and effective for the of medications and and it may be used for an blood during resuscitation (Class IIa; LOE You can blood and of and are to venous You can also blood for and and for and blood during cardiac but is after via the Use pressure or an to or rapid and each with a to into the central central more secure but central does not achieve higher or a more rapid than peripheral vascular or is but if you cannot vascular you can give such as and via the endotracheal endotracheal are with a of normal by If CPR is in chest compressions during of Although and may be by the endotracheal are no studies to support a (eg, and may the airway and should not be via the endotracheal of resuscitation into the trachea results in blood concentrations than the studies that the concentrations when the is by the endotracheal may can be coronary perfusion pressure and flow, and for of endotracheal of resuscitation is possible, or is because it will provide a more delivery and the setting a child's is often and experienced may not be to it with at various patient are helpful and have patients should have and emergency and an (eg, or normal to is no in using (eg, during Use with a to only (Class IIb; LOE There are insufficient data to make a recommendation for or against for shock associated with head or (Class causes a and that the has a because of its short higher may be for peripheral than central venous on and a may also be by and with a rapid to flow the central the period and and the blood pressure and as as the patient's clinical condition it should be to a patient with a pulse but may be rapidly to a patient with cardiac arrest or causes through its The of the is related to the rate and is less common with the form of the because complications may include heart and tachycardia Use when with such as may be long because the is up to is a that or and increases of may than may be in special circumstances (eg, or to of does not of cardiac In may provide than via a central venous catheter because of the risk of or with a peripheral venous of increases pressure and coronary perfusion a of through a secure into the central tissue and may result from tissue not with patients with a perfusing rhythm, causes tachycardia and may cause and have high and low and when blood concentrations during and after arrest and (Class IIb; LOE from and adult and but is not as effective as for (ie, of or to adult patients with to a shock and has to to patients with cardiac and and especially in patients with poor cardiac output and or is insufficient evidence to recommend for or against the routine of during cardiac arrest (Class is indicated for the of or for associated with long and may cause if the period of the and and is little clinical data on using in infants and while you monitor for of the and heart the if the to of or if Use when with such as routine of has not to of resuscitation (Class Indeterminate). After you have provided effective ventilation and chest compressions and you may consider for cardiac arrest (Class IIb; LOE may be used for of (see or special resuscitation cardiac arrest or severe shock, blood may not tissue and venous may tissue oxygen cause and the and cardiac is experience with the use of in pediatric and the results of its use in the of with cardiac arrest have There is insufficient evidence to make a recommendation for or against the routine use of during cardiac arrest (Class LOE from adult the the in the a victim CPR immediately supplementary oxygen if and for a or and with a are most common in asphyxial cardiac and are less and more to be in children with sudden arrest. If you are using an the rhythm if you are using an the device will you the rhythm is (ie, or rapid but it may not the in to of pediatric victims of cardiac and is in up to of pediatric in-hospital at during the The incidence increases with is the for (Class with an rate of to but in the of by to for each minute of arrest without CPR and The in is more when CPR is are or with or For information see Part and that for children at risk for and cardiac arrest (eg, emergency should have that are of that is appropriate for are When using a should be and are the or that will on the chest without about cm between the The size is The can be or not use or pressure on the placed over the right of the chest and the of the heart the of the over the place one on the of the chest to the of the and the other over the below the for effective and the for safe in infants and children are not to have and pediatric with on data from adult and pediatric to be at as effective as and less a or use a of 2 for the (Class IIa; LOE and for (Class can detect in children of and from with a high of and of the for and data have that can be and used in children 1 to 8 years of There are insufficient data to make a recommendation for or against using an in infants of (Class When using an for children about 1 to 8 years use a pediatric which the to a for children (Class IIb; LOE If an with a pediatric is not available, use a one with and for pediatric is that and for children and should use with both a high to pediatric and a pediatric following are is seen in patients with a long which may be or may result from with (eg, and or (eg, and (see or are of listed in the in the of the with a rapid of most common in infants and children in cardiac arrest are and is frequently is a sudden of cardiac output with an normal rhythm but without pulses and with poor as is more to be For and in the below to the in the pediatric advanced life support emergency of on its The in the below to the in the tachycardia are no with the arrest If pulses are and the patient has signs of weak ensure that the airway is ventilations if supplementary and an monitor or if the is or of a and the patient's clinical and and should you tachycardia from tachycardia If the rhythm is for and rhythm during to The of on the patient's of tachycardia with poor perfusion is in but may be with have the for consider an in pediatric children who are of resuscitation require because performed resuscitation is a cause of pediatric in pediatric resuscitation include failure to open and maintain the airway, failure to provide appropriate and failure to and internal a and if possible, transport a child with to a with pediatric following are special of with special may require emergency for (eg, obstruction of a failure of support (eg, of or to special For information about CPR see Part 11: “Pediatric Basic Life and providers should how to assess of the airway, the airway, and CPR using the airway in a child with a and providers should be to provide ventilation via the tube and verify effectiveness by chest If you cannot ventilate after suctioning the tube, If a tube is or If the airway is you may be to provide effective bag-mask ventilation through the and mouth while you or the with and resuscitation in addition to the coronary by chest and cardiac rhythm and is the most frequent for in the and and cause cardiovascular including heart of the and and a of of include of the of the and right and and of cause heart and cardiac and (eg, and may also the and the may cause and of are to secondary and the cause of and the patient to at a pediatric in an state. frequently because may supplementary oxygen you confirm adequate blood oxygenation and oxygen Monitor by pulse and ventilate the patient if is significant respiratory respiratory with or poor air If the patient is verify tube position, and In the blood 10 to 15 after the settings and make appropriate blood with end-tidal CO2 to of and with (eg, or and (eg, In neuromuscular blocking (eg, or with or or may ventilation and minimize the risk of tube however, will mask exhaled especially during transport and a gastric tube to and gastric monitor heart blood pressure direct if and oxygen clinical at the patient is Monitor output with an the after you have secure venous As a the following central venous or blood and of and A chest may you endotracheal tube position, heart size, and pulmonary is common after cardiac and pulmonary vascular resistance are increased in of may but each and must be to the patient (Class IIa; LOE because clinical is into a secure The of include and and and metabolic increased and per and systemic vascular and per cause is the to the may be preferable to in patients infants) with and decompensated to shock that is to and when systemic vascular resistance is low (Class IIb; LOE a of 2 to 20 per minute is Although has frequently to maintain blood flow or more data have to a from such higher per minute), cardiac but this may be in infants and in heart >20 per minute may result in has a on and it increases and usually peripheral vascular an to cardiac output and blood especially to poor is a and peripheral an to shock with low systemic vascular resistance or to increases cardiac output by vascular resistance If is related to poor consider using a of to reduce and an to and cardiac output with little on oxygen Use an for of with increased systemic or pulmonary vascular of may be because of the have a long with a long in a after the rate with and with In of if you the the may for of resuscitation is to secondary by to the following output per in infants and children or in may be by (eg, inadequate systemic or a of medications and the of medications by the you have should be provided by a trained in a pediatric such a as into the resuscitation as possible and with the should be trained and experienced in the of and and supervised by a pediatric emergency or pediatric The of transport and of the should be for each based on the by an Monitor exhaled CO2 colorimetric detector or during interhospital or intrahospital transport of intubated patients (Class to be during and providers of children are often about and with and emergency with no that at the of a one and during the of life is and in and most with not who during resuscitation have less and and more or often to but providers should the If the presence of to the should be to of the resuscitation must be to the presence of and one should be to and the of the are no of during resuscitation to when to CPR, and a short time from to of the of a In the children who resuscitation and absence of of after 2 of considered to but after in-hospital resuscitation has should be for infants and children with or or or a primary For on the of see Part on to the of to this by the following and