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; American Academy of Pediatrics; Volume: 117; Issue: 5 Linguagem: Inglês
10.1542/peds.2006-0346
ISSN1098-4275
Tópico(s)Respiratory Support and Mechanisms
ResumoIn 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 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 patient.A firm surface that extends from the shoulders to the waist and across the full width of the bed provides optimal support for effective chest compressions. In ambulances and mobile life support units, use a spine board.59,60There are insufficient data to make a recommendation for or against the use of mechanical devices to compress the sternum, active compression-decompression CPR, interposed abdominal compression CPR, pneumatic antishock garment during resuscitation from cardiac arrest, and open-chest direct heart compression (Class Indeterminate). For further information see Part 6: “CPR Techniques and Devices.”Consider extracorporeal CPR for in-hospital cardiac arrest refractory to initial resuscitation attempts if the condition leading to cardiac arrest is reversible or amenable to heart transplantation, if excellent conventional CPR has been performed after no more than several minutes of no-flow cardiac arrest (arrest time without CPR), and if the institution is able to rapidly perform extracorporeal membrane oxygenation (Class IIb; LOE 561,62). Long-term survival is possible even after >50 minutes of CPR in selected patients.61,62Attach electrocardiographic (ECG) monitoring leads or defibrillator pads as soon as possible and monitor blood pressure. If the patient has an indwelling arterial catheter, use the wave form to guide your technique in compressing the chest. A minor adjustment of your hand position or depth of compression can significantly improve the wave form.Vascular access is essential for administering medications and drawing blood samples. Venous access can be challenging in infants and children during an emergency, whereas intraosseous (IO) access can be easily achieved. Limit the time you attempt venous access,63 and if you cannot achieve reliable access quickly, establish IO access. In cardiac arrest immediate IO access is recommended if no other IV access is already in place.IO access is a rapid, safe, and effective route for the administration of medications and fluids,64,65 and it may be used for obtaining an initial blood sample during resuscitation (Class IIa; LOE 365,66). You can safely administer epinephrine, adenosine, fluids, blood products,64,66 and catecholamines.67 Onset of action and drug levels achieved are comparable to venous administration.68 You can also obtain blood specimens for type and crossmatch and for chemical and blood gas analysis even during cardiac arrest,69 but acid-base analysis is inaccurate after sodium bicarbonate administration via the IO cannula.70 Use manual pressure or an infusion pump to administer viscous drugs or rapid fluid boluses,71,72 and follow each medication with a saline flush to promote entry into the central circulation.A central IV line provides more secure long-term access, but central drug administration does not achieve higher drug levels or a substantially more rapid response than peripheral administration.73Any vascular access, IO or IV, is preferable, but if you cannot establish vascular access, you can give lipid-soluble drugs such as lidocaine, epinephrine, atropine, and naloxone (“LEAN”)74,75 via the endotracheal tube,76 although optimal endotracheal doses are unknown (Table 1). Flush with a minimum of 5 mL normal saline followed by 5 assisted manual ventilations.77 If CPR is in progress, stop chest compressions briefly during administration of medications. Although naloxone and vasopressin may be given by the endotracheal route, there are no human studies to support a specific dose. Non–lipid-soluble drugs (eg, sodium bicarbonate and calcium) may injure the airway and should not be administered via the endotracheal route.Administration of resuscitation drugs into the trachea results in lower blood concentrations than the same dose given intravascularly. Furthermore, recent animal studies suggest that the lower epinephrine concentrations achieved when the drug is delivered by the endotracheal route may produce transient β-adrenergic effects. These effects can be detrimental, causing hypotension, lower coronary artery perfusion pressure and flow, and reduced potential for return of spontaneous circulation. Thus, although endotracheal administration of some resuscitation drugs is possible, IV or IO drug administration is preferred because it will provide a more predictable drug delivery and pharmacologic effect.In the out-of-hospital setting a child's weight is often unknown, and even experienced personnel may not be able to estimate it accurately.78 Tapes with precalculated doses printed at various patient lengths are helpful and have been clinically validated.35,78,79 Hospitalized patients should have weights and precalculated emergency drug doses recorded and readily available.Use an isotonic crystalloid solution (eg, lactated Ringer's solution or normal saline)80,81 to treat shock; there is no benefit in using colloid (eg, albumin) during initial resuscitation.82 Use bolus therapy with a glucose-containing solution to only treat documented hypoglycemia (Class IIb; LOE 283; 684). There are insufficient data to make a recommendation for or against hypertonic saline for shock associated with head injuries or hypovolemia (Class Indeterminate).85,86Adenosine causes a temporary atrioventricular (AV) nodal conduction block and interrupts reentry circuits that involve the AV node. It has a wide safety margin because of its short half-life.A higher dose may be required for peripheral administration than central venous administration.87,88 Based on experimental data89 and a case report,90 adenosine may also be given by IO route. Administer adenosine and follow with a rapid saline flush to promote flow toward the central circulation.Amiodarone slows AV conduction, prolongs the AV refractory period and QT interval, and slows ventricular conduction (widens the QRS).Monitor blood pressure and administer as slowly as the patient's clinical condition allows; it should be administered slowly to a patient with a pulse but may be given rapidly to a patient with cardiac arrest or ventricular fibrillation (VF). Amiodarone causes hypotension through its vasodilatory property. The severity of the hypotension is related to the infusion rate and is less common with the aqueous form of amiodarone.91Monitor the ECG because complications may include bradycardia, heart block, and torsades de pointes ventricular tachycardia (VT). Use extreme caution when administering with another drug causing QT prolongation, such as procainamide. Consider obtaining expert consultation. Adverse effects may be long lasting because the half-life is up to 40 days.92Atropine sulfate is a parasympatholytic drug that accelerates sinus or atrial pacemakers and increases AV conduction.Small doses of atropine ( 50% of baseline or if hypotension develops. Use extreme caution when administering with another drug causing QT prolongation, such as amiodarone. Consider obtaining expert consultation.The routine administration of sodium bicarbonate has not been shown to improve outcome of resuscitation (Class Indeterminate). After you have provided effective ventilation and chest compressions and administered epinephrine, you may consider sodium bicarbonate for prolonged cardiac arrest (Class IIb; LOE 6). Sodium bicarbonate administration may be used for treatment of some toxidromes (see “Toxicologic Emergencies” below) or special resuscitation situations.During cardiac arrest or severe shock, arterial blood gas analysis may not accurately reflect tissue and venous acidosis.111,112Excessive sodium bicarbonate may impair tissue oxygen delivery113; cause hypokalemia, hypocalcemia, hypernatremia, and hyperosmolality114,115; decrease the VF threshold116; and impair cardiac function.There is limited experience with the use of vasopressin in pediatric patients,117 and the results of its use in the treatment of adults with VF cardiac arrest have been inconsistent.118–121 There is insufficient evidence to make a recommendation for or against the routine use of vasopressin during cardiac arrest (Class Indeterminate; LOE 5117; 6121; 7118–120 [extrapolated from adult literature]).In the text below, box numbers identify the corresponding box in the algorithm (Fig 1.)If a victim becomes unresponsive (box 1), start CPR immediately (with supplementary oxygen if available) and send for a defibrillator (manual or automated external defibrillator [AED]). Asystole and bradycardia with a wide QRS complex are most common in asphyxial cardiac arrest.1,23 VF and pulseless electrical activity (PEA) are less common122 and more likely to be observed in children with sudden arrest. If you are using an ECG monitor, determine the rhythm (box 2); if you are using an AED, the device will tell you whether the rhythm is “shockable” (ie, VF or rapid VT), but it may not display the rhythm.VF occurs in 5% to 15% of all pediatric victims of out-of-hospital cardiac arrest123–125 and is reported in up to 20% of pediatric in-hospital arrests at some point during the resuscitation. The incidence increases with age.123,125 Defibrillation is the definitive treatment for VF (Class I) with an overall survival rate of 17% to 20%,125–127 but in adults the probability of survival declines by 7% to 10% for each minute of arrest without CPR and defibrillation.128 The decline in survival is more gradual when early CPR is provided.Defibrillators are either manual or automated (AED), with monophasic or biphasic waveforms. For further information see Part 5: “Electrical Therapies: Automated External Defibrillators, Defibrillation, Cardioversion, and Pacing.”Institutions that care for children at risk for arrhythmias and cardiac arrest (eg, hospitals, emergency departments) ideally should have defibrillators available that are capable of energy adjustment that is appropriate for children. Many AED parameters are set automatically. When using a manual defibrillator, several elements should be considered, and they are highlighted below.Use the largest paddles or self-adhering electrodes129–131 that will fit on the chest wall without touching (leave about 3 cm between the paddles). The best paddle size is The electrode-chest wall interface can be gel pads, electrode cream, paste, or self-adhesive monitoring-defibrillation pads. Do not use saline-soaked pads, ultrasound gel, bare paddles, or alcohol pads.Apply firm pressure on the paddles (manual) placed over the right side of the upper chest and the apex of the heart (to the left of the nipple over the left lower ribs). Alternatively place one electrode on the front of the chest just to the left of the sternum and the other over the upper back below the scapula.132The lowest energy dose for effective defibrillation and the upper limit for safe defibrillation in infants and children are not known. Energy doses >4 J/kg (up to 9 J/kg) have effectively defibrillated children133–135 and pediatric animal models136 with negligible adverse effects. Based on data from adult studies137,138 and pediatric animal models,139–141 biphasic shocks appear to be at least as effective as monophasic shocks and less harmful. With a manual defibrillator (monophasic or biphasic), use a dose of 2 J/kg for the first attempt (Class IIa; LOE 5142; 6136) and 4 J/kg for subsequent attempts (Class Indeterminate).Many AEDs can accurately detect VF in children of all ages143–145 and differentiate shockable from nonshockable rhythms with a high degree of sensitivity and specificity.143,144 Since publication of the “Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care,” data have shown that AEDs can be safely and effectively used in children 1 to 8 years of age.143–146 There are insufficient data to make a recommendation for or against using an AED in infants 0.08 second (wide-complex tachycardia).Evaluation of a 12-lead ECG (box 3) and the patient's clinical presentation and history (boxes 4 and 5) should help you differentiate probable sinus tachycardia from probable supraventricular tachycardia (SVT). If the rhythm is sinus tachycardia, search for and treat reversible causes.Monitor rhythm during therapy to evaluate effect. The choice of therapy depends on the patient's degree of hemodynamic instability. Wide-complex tachycardia with poor perfusion is probably ventricular in origin but may be supraventricular with aberrancy.173Because all arrhythmia therapies have the potential for serious adverse effects, consider consulting an expert in pediatric arrhythmias before treating children who are hemodynamically stable. Some aspects of trauma resuscitation require emphasis because improperly performed resuscitation is a major cause of preventable pediatric death.174 Common errors in pediatric trauma resuscitation include
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