Part 10: Pediatric Advanced Life Support
2000; Lippincott Williams & Wilkins; Volume: 102; Issue: suppl_1 Linguagem: Inglês
10.1161/circ.102.suppl_1.i-291
ISSN1524-4539
Tópico(s)Neuroscience of respiration and sleep
ResumoHomeCirculationVol. 102, No. suppl_1Part 10: Pediatric Advanced Life Support Free AccessOtherPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessOtherPDF/EPUBPart 10: Pediatric Advanced Life Support Originally published22 Aug 2000https://doi.org/10.1161/circ.102.suppl_1.I-291Circulation. 2000;102:I-291–I-342Major Guidelines ChangesInternational TerminologyIn the preparation of these guidelines, we recognized that certain terms that are commonplace in the United States are uncommon internationally and vice versa. Because these are international guidelines, efforts were made to use terms consistently throughout. To avoid confusion, the reader should note the use of the following terms: Tracheal tube—commonly called an endotracheal tube. Note that a tracheal tube may be incorrectly placed in the esophagus, so the term does not mean a correctly positioned tube in the trachea. Moreover, a tracheostomy tube is not the same as a tracheal tube as used in these guidelines, even though both tubes are placed in the trachea. The procedure of placing a tracheal tube is still called endotracheal intubation.Manual resuscitator—refers to a bag-valve device used to provide mask, tracheal tube, or tracheostomy tube ventilation to a victim. A manual resuscitator may be self-inflating or flow-inflating (ie, an anesthesia manual resuscitator).Exhaled CO2detection—refers to detection of carbon dioxide in exhaled gas. End-tidal CO2 monitors are a subset of exhaled CO2 detectors, but they specifically detect and measure the quantity of CO2 at the end of exhalation. Capnography graphically displays the change in exhaled CO2 over time, whereas exhaled CO2 detectors often are colorimetric systems designed to detect any CO2 during exhalation and not just at the end of expiration.Defibrillation—although commonly used interchangeably with "shocks," defibrillation is the untimed (asynchronous) depolarization of the myocardium that successfully terminates ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). Thus, shocks are administered to victims in an attempt to achieve defibrillation.Epidemiology and Recognition of Shock and Respiratory FailureWe emphasize the need for better data regarding the epidemiology and treatment of pediatric cardiopulmonary arrest. There is a critical need for identification, tracking, and reporting of key resuscitation interventions and their relationship to various outcome measures, such as return of spontaneous circulation, survival, and neurological outcome. Published reports of resuscitation outcome are essential to provide data in future guideline reviews. Data collection efforts should use consistent terminology and record important time intervals. Critical elements for data collection have been described by an international consensus process called the Pediatric Utstein Guidelines for Reporting Outcome of Pediatric Cardiopulmonary Arrest.1An age-defined sequence of "phone fast" resuscitation is still appropriate for treatment of out-of-hospital arrest in infants and children, but a "phone first" approach to resuscitation from sudden collapse should be used for children at high risk for arrhythmias.Support of VentilationThe method of advanced airway support (endotracheal intubation versus laryngeal mask versus bag-mask) provided to the patient should be selected on the basis of the training and skill level of providers in a given advanced life support (ALS) system and on the arrest characteristics and circumstances (eg, transport time and perhaps the cause of the arrest).Proficiency in the skill of bag-mask ventilation is mandatory for anyone providing ALS in prehospital and in-hospital settings (Class IIa).Secondary confirmation of proper tracheal tube placement is required for patients with a perfusing rhythm by capnography or exhaled CO2 detection immediately after intubation and during transport (Class IIa). We strongly encourage the use of exhaled or end-tidal CO2 detection. It is extremely reliable in a spontaneously perfusing victim (Class IIa), although it has lower specificity in the cardiac arrest victim (Class IIb). Adequate oxygenation should also be confirmed in a victim with a perfusing rhythm using pulse oximetry.Fluid TherapyRescuers should increase attention to early vascular access, including immediate intraosseous access for victims of cardiac arrest, and extend the use of intraosseous techniques to victims >6 years old.MedicationsThere is renewed emphasis on the need to identify and treat reversible causes of cardiac arrest and symptomatic arrhythmias, such as toxic drug overdose or electrolyte abnormalities.For cardiac arrest victims, we provide specific drug selection and dose recommendations but acknowledge the lack of adequate data to make such recommendations on the basis of firm evidence. For example, data supporting the use of high-dose epinephrine and the use of vasopressin in cardiac arrest is inadequate to allow firm recommendations (for further details, see the following section, "Drugs Used for Cardiac Arrest and Resuscitation").Treatment of ArrhythmiasWe introduce vagal maneuvers into the treatment algorithm for supraventricular tachycardia.We introduce the drug amiodarone into the treatment algorithms for pediatric VT and shock-refractory VF.Automated external defibrillators (AEDs) may be used in the treatment of children ≥8 years of age (approximately >25 kg body weight) in cardiac arrest in the prehospital setting.Postarrest StabilizationWe place increased emphasis on postresuscitation interventions that may influence neurological survival, which include maintenance of normal ventilation rather than hyperventilation (Class IIa) in most victims, control of temperature (avoid hyperthermia), management of post-ischemic myocardial dysfunction, and glucose control.Education and TrainingSimplification of education and reinforcement of skill acquisition and core competencies are essential in all American Heart Association courses. See also, in "Part 9: Pediatric Basic Life Support," Education and Training and Introduction.IntroductionIn contrast to cardiac arrest in adults, cardiopulmonary arrest in infants and children is rarely a sudden event and does not often result from a primary cardiac cause.2 In adults, cardiopulmonary arrest is usually sudden and is primarily cardiac in origin; approximately 250 000 adults die annually of sudden cardiac arrest in the United States alone. Consequently, much of the research and training in adult cardiac resuscitation focuses on the identification and treatment of VF in the out-of-hospital setting, since this rhythm is the most amenable to effective therapy. Factors associated with increased survival after adult cardiopulmonary arrest include bystander CPR (relative odds of survival, 2.6; 95% confidence interval, 2.0 to 3.4)34 and short interval to defibrillation.56Cardiopulmonary (ie, cardiac) arrest in children is much less common than cardiac arrest in adults. When it does occur, pediatric cardiac arrest frequently represents the terminal event of progressive shock or respiratory failure. Causes of pediatric cardiac arrest are heterogeneous, including sudden infant death syndrome (SIDS), submersion/near-drowning, trauma, and sepsis. The progression from shock or respiratory failure to cardiac arrest associated with each of these causes may vary, making research or outcome reporting difficult, since there is not a "typical" type of cardiac arrest.The cause of cardiac arrest also varies with age, the underlying health of the child, and the location of the event. In the out-of-hospital location, conditions such as trauma, SIDS, drowning, poisoning, choking, severe asthma, and pneumonia represent the most common causes of arrest. In the hospital, common causes of cardiac arrest include sepsis, respiratory failure, drug toxicity, metabolic disorders, and arrhythmias. These in-hospital causes often complicate an underlying condition. The Emergency Department represents a transition from the out-of-hospital to the hospital location. In the Emergency Department, cardiac arrest may be seen in children with underlying conditions typical for the hospital setting and in children with conditions seen more often in the out-of-hospital setting.Throughout infancy and childhood, most out-of-hospital cardiac arrest occurs in or around the home. Beyond 6 months of age, trauma is the predominant cause of death.Pediatric advanced life support (PALS) refers to the assessment and support of pulmonary and circulatory function in the period before an arrest and during and after an arrest. Consistent with the Chain of Survival (Figure 1), PALS should focus on prevention of the causes of arrest (SIDS, injury, and choking) and on early detection and rapid treatment of cardiopulmonary compromise and arrest in the critically ill or injured child. The components of PALS are similar in many respects to those of adult ACLS and includeBasic life supportUse of adjunctive equipment and special techniques to establish and maintain effective oxygenation, ventilation and perfusionClinical and ECG monitoring and arrhythmia detectionEstablishment and maintenance of vascular accessIdentification and treatment of reversible causes of cardiopulmonary arrestTherapies for emergency treatment of patients with cardiac and respiratory arrestTreatment of patients with trauma, shock, respiratory failure, or other prearrest conditionsBecause the etiology of cardiopulmonary emergencies and the available treatments and approaches may not be the same in out-of-hospital and hospital settings, these guidelines will highlight evaluation and treatment approaches that are recommended for each setting when appropriate.These guidelines are based on clinical and experimental evidence of varying quality and quantity. Information on the strength of the scientific data leading to each new recommendation is provided. (For more information on the evidence evaluation process, see Reference 7 .) Classes are defined fully in "Part 1: Introduction."Ideally, treatments of choice are supported by excellent evidence and are Class I recommendations. Unfortunately the quality of published data on cardiac arrest and resuscitation, especially for children, usually dictates that consensus treatments included in the guidelines are Class IIa or IIb.PALS for Children With Special NeedsChildren with special healthcare needs have chronic physical, developmental, behavioral, or emotional conditions and also require health and related services of a type or amount not usually required by other children.8910 These children may require emergency care for acute, life-threatening complications that are unique to their chronic conditions, such as obstruction of a tracheostomy, failure of support technology (eg, ventilator failure), or progression of underlying respiratory failure or neurological disease. Approximately half of the EMS responses for children with special healthcare needs, however, are unrelated to those special needs.11 Many involve traditional causes of EMS calls, such as trauma,11 that require no treatment beyond the normal EMS standard of care.Emergency care of children with special healthcare needs can be complicated by lack of specific medical information about the child's baseline condition, plan of medical care, current medications, and any "Do Not Attempt Resuscitation" orders. Certainly the best source of information about a chronically ill child is a concerned and compassionate person who cares for the child on a daily basis. If that person is unavailable or incapacitated (eg, after an automobile crash), some means is needed to access important information. A wide variety of methods have been developed to make this information immediately accessible, including the use of standard forms, containers kept in a standard place in the home (eg, the refrigerator), window stickers for the home, wallet cards, and medical alert bracelets. No one method of information communication has yet proved to be superior. A standardized form, the Emergency Information Form (EIF), was developed by the American Academy of Pediatrics and the American College of Emergency Physicians,10 to be completed by the child's primary physician for use by EMS personnel and hospitals. This form is available electronically (http://www.pediatrics.org/cgi/content/full/104/4/e53). Parents and child-care providers should be encouraged to keep copies of essential medical information at home, with the child, and at the child's school or child-care facility. School nurses should have copies of these forms and should be familiar with signs of deterioration in the child and any existing "Do Not Attempt Resuscitation" orders.1112If decisions are made by the physician, parents, and child (as appropriate) to limit resuscitative efforts or to withhold attempts at resuscitation, a physician order indicating the limits of resuscitative efforts must be written for use in the in-hospital setting, and in most countries a separate order must be written for the out-of-hospital setting. Legal issues and regulations vary from country to country and within the United States from state to state regarding requirements for these out-of-hospital "No CPR Directives." It is always important for a family to inform their local EMS system when such directives are established for out-of-hospital care. For further information about ethical issues of resuscitation, see also "Part 2: Ethical Aspects of CPR and ECC."Whenever a child with a chronic or life-threatening condition is discharged from the hospital, parents, school nurses, and any home healthcare providers should be informed about possible causes of deterioration or complications that the child may experience and anticipated signs of deterioration. They should receive specific instructions about CPR and other interventions the child may require and instructions about whom to contact and why.12If the child has a tracheostomy, anyone responsible for the child's care (including parents, school nurses, and home healthcare providers) should be taught to assess that the airway is patent, how to clear the airway, and how to provide CPR using the artificial airway. If CPR is required, rescue breathing and bag-mask ventilation are performed through the tracheostomy tube. As with any form of rescue breathing, the key sign of effective ventilation is adequate bilateral chest expansion. If the tracheostomy tube becomes obstructed and it is impossible to provide ventilation through it even after attempts to clear the tube with suctioning, remove and replace the tube. If a clean tube is unavailable, ventilation can be provided using mouth-to-stoma ventilation until an artificial airway can be placed through the stoma. Alternatively, if the upper airway is patent, it may be possible to provide effective conventional bag-mask ventilation through the nose and mouth while occluding the superficial tracheal stoma site.International PALS GuidelinesFollowing the implementation of the 1992 guidelines,13 the major international resuscitation councils (International Liaison Committee on Resuscitation [ILCOR]) participated in the development of advisory statements reflecting consensus recommendations based on existing resuscitation guidelines, practical experience, and informal interpretation and debate of an international resuscitation database.1415 A high degree of uniformity exists in current guidelines created by the major resuscitation councils for resuscitation of the newly born, neonates, infants, and young children. Controversies arise mostly from local and regional preferences or customs, training networks, and differences in availability of equipment and medication rather than from differences in interpretation of scientific evidence.To develop this International Guidelines 2000 document on PALS, the Subcommittee on Pediatric Resuscitation of the AHA and other members of ILCOR identified issues or new developments worthy of further in-depth evaluation. From this list, areas of active research and evolving controversy were identified; evidence-based evaluation of each of these areas was conducted and debated, culminating in assignment of consensus-defined "levels of evidence" for specific guidelines questions. After identification and careful review of this evidence, the Pediatric Working Group of ILCOR updated the PALS guidelines, assigned classes of recommendations where possible, and objectively attempted to link the class of recommendation to the identified level of evidence. During these discussions the authors recognized the need to make recommendations for important interventions and treatment even when the only level of evidence was poor or absent. In the absence of specific pediatric data (outcome validity), recommendations were made or supported on the basis of common sense (face validity) or ease of teaching or skill retention (construct validity).To reduce confusion and simplify education, whenever possible and appropriate, PALS recommendations are consistent with the adult BLS and ACLS algorithms and guidelines. Areas of departure from the adult algorithms and interventions are noted, and the rationale is explained in the text. Ultimately the practicality of implementing recommendations must be considered in the context of local resources (technology and personnel) and customs. No resuscitation protocol or guideline can be expected to appropriately anticipate all potential scenarios. Rather, these guidelines and treatment algorithms serve as a guiding template that will provide most critically ill children with appropriate support while thoughtful and appropriate etiology-based interventions are assembled and implemented.Age Definitions: What Defines an Infant, Child, and Adult?Definition of Newly Born, Neonate, Infant, and ChildThe term "neonate" refers to infants in the first 28 days (month) of life.16 In AHA ECC and ILCOR publications, the term "newly born" refers specifically to the neonate in the first minutes to hours following birth. This term is used to focus resuscitation knowledge and training on the time immediately after birth and during the first hours of life. Newly born is designed to emphasize those first hours of life, separate from the first month of life. The term "infant" includes the neonatal period and extends to the age of 1 year (12 months). For the purposes of these guidelines, the term "child" refers to the age group from 1 year to 8 years.Pediatric BLS and ALS interventions tend to blur at the margins of age because there is no single anatomic, physiological, or management characteristic that is consistently different in the infant versus the child versus the adult victim of cardiac arrest. Furthermore, new technologies such as AEDs and the availability of airway and vascular access adjuncts that can be implemented with a minimum of advanced training create the need to reexamine previous recommendations for therapies based on age.AnatomyBy consensus, the age cutoff for infants is 1 year. Note, however, that this definition is not based on specific anatomic or physiological differences between infants and children. For example, the differences between an 11-month-old "infant" and an 18-month-old "child" are smaller than the differences in anatomy and physiology between an 11-month-old and a 1-week-old infant. Historically the use of the term child was limited to ages 1 to 8 years for purposes of BLS education; cardiac compression can be done with 1 hand for victims up to the age of approximately 8 years. However, variability in the size of the victim or the size and strength of the rescuer can require use of the 2-handed adult compression technique for cardiac compression in younger children. For instance, a chronically ill 11-month-old infant may be sufficiently small to enable compression using the 2 thumb–encircling hands technique, and a 6- or 7-year-old may be too large for the 1-hand compression technique.Further anatomic differences are noted in the airway of the child versus the adult. The narrowest portion of the airway in the child is at the level of the cricoid cartilage; in older children and adults the narrowest portion is at the level of the glottic opening. Moreover, the loose areolar tissue in the subglottic space allows for a natural seal without a cuffed tube in most children. Finally, attempting to squeeze a tube through the narrowed area of the cricoid cartilage increases the risk of subglottic stenosis. These anatomic differences and risk of complications led to the recommendation to use uncuffed tracheal tubes in children <8 years of age.13PhysiologyRespiratory and cardiac physiology evolves throughout infancy and childhood. In the newly born, for example, fluid-filled alveoli may require higher initial ventilation pressures than subsequent rescue breathing. In infants and children, lung inspiratory and expiratory time constants for alveolar filling and emptying may need to be adjusted according to both anatomic and physiological development. For example, the child with respiratory failure secondary to asthma clearly will require a different approach for mechanical ventilation support than a neonate with alveolar collapse caused by respiratory distress syndrome.EpidemiologyIdeally the sequence of resuscitation should be tailored to the most likely cause of the arrest, but this increases the complexity of BLS and ALS education. For lay rescuers, CPR instruction must remain simple. Retention of current CPR skills and knowledge is now suboptimal, and more complex instruction is more difficult to teach, learn, remember, and perform. In the newly born infant, respiratory failure is the most common cause of cardiopulmonary deterioration and arrest. In the older infant and child, arrest may be related to progression of respiratory failure, shock, or neurological dysfunction. In general, pediatric out-of-hospital arrest is characterized by a progression from hypoxia and hypercarbia to respiratory arrest and bradycardia and then to asystolic cardiac arrest.21718 Therefore, a focus on immediate ventilation and compressions, rather than the "adult" approach of immediate EMS activation or defibrillation, appears to be warranted. In this age group, early effective ventilation and oxygenation must be established as quickly as possible.In some circumstances primary arrhythmic cardiac arrest is more likely than respiratory arrest, and the lay rescuer may be instructed to activate the EMS system first (eg, children with underlying cardiac disease or a history of arrhythmias). If a previously well child experiences a sudden witnessed collapse, this suggests a previously undetected cardiac disorder, and immediate activation of the EMS system may be beneficial. Children with sudden collapse may have a prolonged-QT syndrome, hypertrophic cardiomyopathy, or drug-induced cardiac arrest192021 ; the latter is more likely in the adolescent age group, related to a drug overdose.For optimal patient outcomes, all of the links of the Chain of Survival must be strong. Unfortunately the rate of bystander CPR is disappointing; bystander CPR is provided for only approximately 30% of out-of-hospital pediatric arrests.217 A low rate of bystander CPR may mask improvements in the structure and function of the EMS system, since data in adults suggests a much worse outcome when bystander CPR is not provided.356 Because all the links are connected, it is difficult to evaluate components of single links such as the optimal method of EMS system activation or the effect of specific EMS interventions.In addition, local EMS response intervals, dispatcher training, and EMS protocols may dictate the most appropriate sequence of EMS activation and early life support interventions. For example, providing 1 minute of CPR is recommended in pediatric out-of-hospital arrest before activation of the EMS system.13 Rather than using a uniform approach, however, perhaps the activation of the EMS system and the sequence of BLS support for out-of-hospital arrest should be based on the cause of arrest (ie, the cause of arrest could be separated into cardiac versus respiratory origin by lay rescuers). The increased educational complexity limits this approach, however. As noted above, if a cardiac cause is suspected on the basis of event circumstances, then immediate EMS activation may be more important than providing 1 minute of CPR. Once EMS providers arrive, early use of AEDs in children ≥8 years of age may help to better identify initial rhythms and rapidly treat children with a more favorable arrest rhythm (ie, VF or pulseless VT).2Although recommending an etiology-based resuscitation sequence for lay rescuers may be more medically appropriate in certain circumstances, it is more complex and therefore harder to teach, learn, and remember. Consequently, after much deliberation and debate, we continue to recommend the same approach as stated in the 1992 guidelines13 : phone first for adults and phone fast for children. Nevertheless, it is the responsibility of the healthcare provider to identify and train caretakers to call first when a child with a high risk of a primary cardiac event is identified. It is also appropriate to teach more knowledgeable providers to "call first" for a likely arrhythmic cardiac arrest (eg, sudden collapse at any age) and to "call fast" in other circumstances (eg, trauma, a submersion event, or an apparent choking event).Recognition of Respiratory Failure and ShockSurvival after cardiac arrest in children averages 7% to 11%, with most survivors neurologically impaired. For this reason we emphasize early recognition and treatment of respiratory failure and shock to prevent an arrest from occurring. To clarify terminology we use the following Pediatric Utstein Style1 definitions: "respiratory arrest" is defined as the absence of respirations (ie, apnea) with detectable cardiac activity. This should be distinguished from respiratory compromise leading to assisted ventilation. In the latter, the patient may have respiratory distress with increased effort or inadequate respiratory effort with no distress. Cardiac arrest is the cessation of cardiac mechanical activity, determined by the inability to palpate a central pulse, unresponsiveness, and apnea (ie, no signs of circulation or life).Deterioration in respiratory function or imminent respiratory arrest should be anticipated in infants or children who demonstrate any of the following signs: an increased respiratory rate, particularly if accompanied by signs of distress and increased respiratory effort; inadequate respiratory rate, effort, or chest excursion; diminished peripheral breath sounds; gasping or grunting respirations; decreased level of consciousness or response to pain; poor skeletal muscle tone; or cyanosis."Respiratory failure" is a clinical state characterized by inadequate oxygenation, ventilation, or both. Strict criteria for respiratory failure are difficult to define because the baseline oxygenation or ventilation of an individual infant or child may be abnormal. For example, an infant with cyanotic congenital heart disease would not be in respiratory failure on the basis of an oxygen saturation of 60%, whereas that would be an appropriate criterion in a child with normal cardiopulmonary physiology. Respiratory failure may be functionally characterized as a clinical state that requires intervention to prevent respiratory or cardiac arrest."Shock" is a clinical state in which blood flow and delivery of tissue nutrients do not meet tissue metabolic demand. Shock may occur with increased, normal, or decreased cardiac output or blood pressure. Since shock represents a continuum of severity, it is further characterized as being compensated or decompensated. "Decompensated shock" is defined as a clinical state of tissue perfusion that is inadequate to meet metabolic demand and hypotension (ie, a systolic blood pressure [SBP] less than the 5th percentile for age). The definition of hypotension in preterm neonates depends on the newborn's weight and gestational age.For the PALS guidelines, hypotension is characterized by the following:For term neonates (0 to 28 days of age), SBP <60 mm HgFor infants from 1 month to 12 months, SBP 1 year to 10 years, SBP <70+(2×age in years)Beyond 10 years, hypotension is defined as an SBP <90 mm HgNote that these blood pressure thresholds will overlap with normal values, including the 5% of normal children who have an SBP lower than the 5th percentile for age.Early (ie, compensated) shock is shock without hypotension (ie, shock with a "normal" blood pressure). Compensated shock is detected by evaluation of heart rate, presence and volume (strength) of peripheral pulses, and adequacy of end-organ perfusion. The latter includes assessment of mental status, capillary refill, skin temperature, and when available, monitoring urine output and determining the presence and magnitude of metabolic acidosis on laboratory evaluation.Cardiac output is the product of heart rate and stroke volume. If stroke volume is compromised for any reason, tachycardia is a common physiological response in an attempt to maintain cardiac output. Therefore, sustained sinus tachycardia (ST) in the absence of known causes such as fever or pain may be an early sign of cardiovascular compromise. Bradycardia, on the other hand, may be a preterminal cardiac rhythm indicative of advanced shock, and it is often associated with hypotension. When cardiac output and systemic perfusion are compromised, the volume (strength or quality) of peripheral pulses is decreased, capillary refill time may be prolonged, and skin temperature is often cool despite a warm ambient
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