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Part 14: Pediatric Advanced Life Support

2010; Lippincott Williams & Wilkins; Volume: 122; Issue: 18_suppl_3 Linguagem: Inglês

10.1161/circulationaha.110.971101

1524-4539

Monica E. Kleinman, Leon Chameides, Stephen M. Schexnayder, Ricardo A. Samson, Mary Fran Hazinski, Dianne L. Atkins, Marc Berg, Allan R. de Caen, Ericka L. Fink, Eugene B. Freid, Robert W. Hickey, Bradley S. Marino, Vinay Nadkarni, Lester T. Proctor, Faiqa Qureshi, Kennith H. Sartorelli, Alexis A. Topjian, Élise W. van der Jagt, Arno Zaritsky,

Family and Patient Care in Intensive Care Units

HomeCirculationVol. 122, No. 18_suppl_3Part 14: Pediatric Advanced Life Support Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBPart 14: Pediatric Advanced Life Support2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Monica E. Kleinman, 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 and Arno L. Zaritsky Monica E. KleinmanMonica E. Kleinman , Leon ChameidesLeon Chameides , Stephen M. SchexnayderStephen M. Schexnayder , Ricardo A. SamsonRicardo A. Samson , Mary Fran HazinskiMary Fran Hazinski , Dianne L. AtkinsDianne L. Atkins , Marc D. BergMarc D. Berg , Allan R. de CaenAllan R. de Caen , Ericka L. FinkEricka L. Fink , Eugene B. FreidEugene B. Freid , Robert W. HickeyRobert W. Hickey , Bradley S. MarinoBradley S. Marino , Vinay M. NadkarniVinay M. Nadkarni , Lester T. ProctorLester T. Proctor , Faiqa A. QureshiFaiqa A. Qureshi , Kennith SartorelliKennith Sartorelli , Alexis TopjianAlexis Topjian , Elise W. van der JagtElise W. van der Jagt and Arno L. ZaritskyArno L. Zaritsky Originally published2 Nov 2010https://doi.org/10.1161/CIRCULATIONAHA.110.971101Circulation. 2010;122:S876–S908In contrast to adults, cardiac arrest in infants and children does not usually result from a primary cardiac cause. More often it is the terminal result of progressive respiratory failure or shock, also called an asphyxial arrest. Asphyxia begins with a variable period of systemic hypoxemia, hypercapnea, and acidosis, progresses to bradycardia and hypotension, and culminates with cardiac arrest.1Another mechanism of cardiac arrest, ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), is the initial cardiac rhythm in approximately 5% to 15% of pediatric in-hospital and out-of-hospital cardiac arrests;2–9 it is reported in up to 27% of pediatric in-hospital arrests at some point during the resuscitation.6 The incidence of VF/pulseless VT cardiac arrest rises with age.2,4 Increasing evidence suggests that sudden unexpected death in young people can be associated with genetic abnormalities in myocyte ion channels resulting in abnormalities in ion flow (see "Sudden Unexplained Deaths," below).Since 2010 marks the 50th anniversary of the introduction of cardiopulmonary resuscitation (CPR),10 it seems appropriate to review the progressive improvement in outcome of pediatric resuscitation from cardiac arrest. Survival from in-hospital cardiac arrest in infants and children in the 1980s was around 9%.11,12 Approximately 20 years later, that figure had increased to 17%,13,14 and by 2006, to 27%.15–17 In contrast to those favorable results from in-hospital cardiac arrest, overall survival to discharge from out-of-hospital cardiac arrest in infants and children has not changed substantially in 20 years and remains at about 6% (3% for infants and 9% for children and adolescents).7,9It is unclear why the improvement in outcome from in-hospital cardiac arrest has occurred, although earlier recognition and management of at-risk patients on general inpatient units and more aggressive implementation of evidence-based resuscitation guidelines may have played a role. Implementation of a formal pediatric medical emergency team (MET) or rapid response team (RRT) as part of an emergency response system for a deteriorating inpatient has been shown to significantly decrease the incidence of cardiac and respiratory arrests, as well as hospital mortality rates in some large children's hospitals.18–21 Such teams, often consisting of providers with expertise in assessment and initial management of acutely ill patients (critical-care nurses, respiratory therapists, and critical-care physicians), decreased the number of cardiac and respiratory arrests by as much as 72%18 and hospital mortality by as much as 35% in institutions where the effect was studied.19 Although it is possible that most of the impact is due to a decrease in respiratory arrests, this cannot be confirmed by the available published data. Implementation of a pediatric MET/RRT may be beneficial in facilities where children with high risk illnesses are present on general inpatient units (Class IIa, LOE B).Despite the improved outcome of in-hospital CPR, a majority of children with in-hospital cardiac arrest and an even larger percentage of children with out-of-hospital cardiac arrest do not survive, or they are severely incapacitated if they do. Several studies, discussed later in this document, showed that the presence of family members during resuscitation has helped them deal with the inevitable trauma and grief following the death of a child. Therefore, whenever possible, provide family members with the option of being present during resuscitation of an infant or child (Class I, LOE B).BLS Considerations During PALSPediatric advanced life support (PALS) usually takes place in the setting of an organized response in an advanced healthcare environment. In these circumstances, multiple responders are rapidly mobilized and are capable of simultaneous coordinated action. Resuscitation teams may also have access to invasive patient monitoring that may provide additional information during the performance of basic life support (BLS).Simultaneous ActionsBLS (whether for a child or adult) is presented as a series of sequential events with the assumption that there is only one responder, but PALS usually takes place in an environment where many rescuers are rapidly mobilized and actions are performed simultaneously. The challenge is to organize the rescuers into an efficient team. Important considerations for the greatest chance of a successful resuscitation from cardiac arrest include the following: Chest compressions should be immediately started by one rescuer, while a second rescuer prepares to start ventilations with a bag and mask. Ventilation is extremely important in pediatrics because of the large percentage of asphyxial arrests in which best results are obtained by a combination of chest compressions and ventilations.8 Unfortunately ventilations are sometimes delayed because equipment (bag, mask, oxygen, airway) must be mobilized. Chest compressions require only the hands of a willing rescuer. Therefore, start CPR with chest compressions immediately, while a second rescuer prepares to provide ventilations (Class I, LOE C).The effectiveness of PALS is dependent on high-quality CPR, which requires an adequate compression rate (at least 100 compressions/min), an adequate compression depth (at least one third of the AP diameter of the chest or approximately 1 ½ inches [4 cm] in infants and approximately 2 inches [5 cm] in children), allowing complete recoil of the chest after each compression, minimizing interruptions in compressions, and avoiding excessive ventilation. Reasons for not performing high-quality CPR include rescuer inattention to detail, rescuer fatigue, and long or frequent interruptions to secure the airway, check the heart rhythm, and move the patient.22 Optimal chest compressions are best delivered with the victim on a firm surface.23,24While one rescuer performs chest compressions and another performs ventilations, other rescuers should obtain a monitor/defibrillator, establish vascular access, and calculate and prepare the anticipated medications.Monitored PatientsMany in-hospital patients, especially if they are in an ICU, are monitored and some have an advanced airway and are receiving mechanical ventilation. If the patient has an indwelling arterial catheter, use the waveform as feedback to evaluate hand position and chest compression depth. A minor adjustment of hand position or depth of compression can significantly improve the amplitude of the arterial waveform, reflecting better chest compression-induced stroke volume. The arterial waveform may also be useful in identification of return of spontaneous circulation (ROSC). If the patient's end-tidal CO2 (Petco2) is being monitored, it can be used to evaluate the quality of chest compressions; it can also provide an indication of ROSC (see below).Respiratory FailureRespiratory failure is characterized by inadequate ventilation, insufficient oxygenation, or both. Anticipate respiratory failure if any of the following signs is present: An increased respiratory rate, particularly with signs of distress (eg, increased respiratory effort including nasal flaring, retractions, seesaw breathing, or grunting)An inadequate respiratory rate, effort, or chest excursion (eg, diminished breath sounds or gasping), especially if mental status is depressedCyanosis with abnormal breathing despite supplementary oxygenShockShock results from inadequate blood flow and oxygen delivery to meet tissue metabolic demands. The most common type of shock in children is hypovolemic, including shock due to hemorrhage. Distributive, cardiogenic, and obstructive shock occur less frequently. Shock progresses over a continuum of severity, from a compensated to a decompensated state. Compensatory mechanisms include tachycardia and increased systemic vascular resistance (vasoconstriction) in an effort to maintain cardiac output and perfusion pressure respectively. Decompensation occurs when compensatory mechanisms fail and results in hypotensive shock.Typical signs of compensated shock include TachycardiaCool and pale distal extremitiesProlonged (>2 seconds) capillary refill (despite warm ambient temperature)Weak peripheral pulses compared with central pulsesNormal systolic blood pressureAs compensatory mechanisms fail, signs of inadequate end-organ perfusion develop. In addition to the above, these signs include Depressed mental statusDecreased urine outputMetabolic acidosisTachypneaWeak central pulsesDeterioration in color (eg, mottling, see below)Decompensated shock is characterized by signs and symptoms consistent with inadequate delivery of oxygen to tissues (pallor, peripheral cyanosis, tachypnea, mottling of the skin, decreased urine output, metabolic acidosis, depressed mental status), weak or absent peripheral pulses, weak central pulses, and hypotension.Learn to integrate the signs of shock because no single sign confirms the diagnosis. For example: Capillary refill time alone is not a good indicator of circulatory volume, but a capillary refill time >2 seconds is a useful indicator of moderate dehydration when combined with decreased urine output, absent tears, dry mucous membranes, and a generally ill appearance. Capillary refill time is influenced by ambient temperature,25 site, and age and its interpretation can be influenced by lighting.26Tachycardia is a common sign of shock, but it can also result from other causes, such as pain, anxiety, and fever.Pulses are weak in hypovolemic and cardiogenic shock, but may be bounding in anaphylactic, neurogenic, and septic shock.Blood pressure may be normal in a child with compensated shock but may decline rapidly when the child decompensates. Like the other signs, hypotension must be interpreted within the context of the entire clinical picture.There are several sources of data that use large populations to identify the 5th percentile for systolic blood pressure at various ages.27,28 For purposes of these guidelines, hypotension is defined as a systolic blood pressure: <60 mm Hg in term neonates (0 to 28 days)<70 mm Hg in infants (1 month to 12 months)<70 mm Hg + (2 × age in years) in children 1 to 10 years 20 kg with a perfusing rhythm (Class IIb, LOE B),125,126 but the data are insufficient to make a recommendation for or against its use in children during cardiac arrest.Transtracheal Catheter Oxygenation and VentilationTranstracheal catheter oxygenation and ventilation may be considered for patients with severe airway obstruction above the level of the cricoid cartilage if standard methods to manage the airway are unsuccessful. Note that transtracheal ventilation primarily supports oxygenation as tidal volumes are usually too small to effectively remove carbon dioxide. This technique is intended for temporary use while a more effective airway is obtained. Attempt this procedure only after proper training and with appropriate equipment (Class IIb, LOE C).127Suction DevicesA properly sized suction device with an adjustable suction regulator should be available. Do not insert the suction catheter beyond the end of the endotracheal tube to avoid injuring the mucosa. Use a maximum suction force of -80 to -120 mm Hg for suctioning the airway via an endotracheal tube. Higher suction pressures applied through large-bore noncollapsible suction tubing and semirigid pharyngeal tips are used to suction the mouth and pharynx.CPR Guidelines for Newborns With Cardiac Arrest of Cardiac OriginRecommendations for infants differ from those for the newly born (ie, in the delivery room and during the first hours after birth) and newborns (during their initial hospitalization and in the NICU). The compression-to-ventilation ratio differs (newly born and newborns – 3:1; infant two rescuer - 15:2) and how to provide ventilations in the presence of an advanced airway differs (newly born and newborns – pause after 3 compressions; infants – no pauses for ventilations). This presents a dilemma for healthcare providers who may also care for newborns outside the NICU. Because there are no definitive scientific data to help resolve this dilemma, for ease of training we recommend that newborns (intubated or not) who require CPR in the newborn nursery or NICU receive CPR using the same technique as for the newly born in the delivery room (ie, 3:1 compression-to-ventilation ratio with a pause for ventilation). Newborns who require CPR in other settings (eg, prehospital, ED, pediatric intensive care unit [PICU], etc.), should receive CPR according to infant guidelines: 2 rescuers provide continuous chest compressions with asynchronous ventilations if an advanced airway is in place and a 15:2 ventilation-to-compression ratio if no advanced airway is in place (Class IIb, LOE C). It is reasonable to resuscitate newborns with a primary cardiac etiology of arrest, regardless of location, according to infant guidelines, with emphasis on chest compressions (Class IIa, LOE C). For further information, please refer to Part 13, "Pediatric Basic Life Support," and Part 15, "Neonatal Resuscitation."Extracorporeal Life Support (ECLS)Extracorporeal life support (ECLS) is a modified form of cardiopulmonary bypass used to provide prolonged delivery of oxygen to tissues. Consider early activation of ECLS for a cardiac arrest that occurs in a highly supervised environment, such as an ICU, with the clinical protocols in place and the expertise and equipment available to initiate it rapidly. ECLS should be considered only for children in cardiac arrest refractory to standard resuscitation attempts, with a potentially reversible cause of arrest (Class IIa, LOE C).128–154 When ECLS is employed during cardiac arrest, out