Every 5 years, the American Heart Association (AHA) revises the recommendations, or Guidelines, for Emergency Cardiovascular Care (ECC), including CPR. Here is a summary of some of the key issues and major changes for Pediatric Basic and Advanced Life Support. These were released on October 21, 2020, and will be implemented into AHA classes over the next few months.
Pediatric Basic and Advanced Life Support
- >20,000 infants and children have a cardiac arrest each year in the United States.
- Algorithms and visual aids revised with best science and improved clarity.
- Assisted ventilation rate increased to 1 breath every 2 to 3 seconds (20-30 breaths per minute) for all pediatric resuscitation scenarios.
- Cuffed ETTs reduce air leak and the need for tube exchanges for patients of any age who require intubation.
- The routine use of cricoid pressure during intubation is not recommended.
- Epinephrine should be administered as early as possible, ideally within 5 minutes of the start of cardiac arrest from a non shockable rhythm (asystole and PEA).
- For patients with arterial lines in place, using feedback from continuous measurement of arterial blood pressure may improve CPR quality.
- After ROSC, patients should be evaluated for seizures; status epilepticus and any convulsive seizures should be treated.
Patients should have assessment and support for their physical, cognitive, and psychosocial needs.
- A titrated approach to fluid management, with epinephrine or norepinephrine infusions if vasopressors are needed, is appropriate for septic shock.
- Balanced blood component resuscitation is reasonable for infants and children with hemorrhagic shock.
- Opioid overdose management includes CPR and timely administration of naloxone by either lay rescuers or trained rescuers.
- Children with acute myocarditis who have arrhythmias, heart block, ST-segment changes, or low cardiac output are at high risk of cardiac arrest. - Early transfer to an intensive care unit is important, and some patients may require mechanical circulatory support or extracorporeal life support (ECLS).
- Infants and children with congenital heart disease and single ventricle physiology who are in the process of staged reconstruction require special considerations in PALS management.
- Management of pulmonary hypertension may include the use of inhaled nitric oxide, prostacyclin, analgesia, sedation, neuromuscular blockade, the induction of alkalosis, or rescue therapy with ECLS.
Algorithms and Visual Aids
- New pediatric Chain of Survival for IHCA in infants, children, and adolescents.
- A sixth link, Recovery, added to pediatric OHCA Chain of Survival and is included in the new pediatric IHCA Chain of Survival.
- The Pediatric Cardiac Arrest Algorithm and the Pediatric Bradycardia With a Pulse Algorithm have been updated.
- The single Pediatric Tachycardia With a Pulse Algorithm covers both narrow- and wide-complex tachycardias in pediatric patients.
- Two new Opioid-Associated Emergency Algorithms added.
- A new checklist is provided for pediatric post–cardiac arrest care.
AHA Chains of Survival for pediatric IHCA and OHCA
AHA Pediatric Basic Life Support Algorithm for Single Rescuer
AHA Pediatric Basic Life Support Algorithm for Multiple Rescuers
AHA Pediatric Cardiac Arrest Algorithm
AHA Pediatric Post–Cardiac Arrest Care Checklist
AHA Pediatric Bradycardia With a Pulse Algorithm
AHA Pediatric Tachycardia With a Pulse Algorithm
Major New and Updated Recommendations
- For infants and children with a pulse but no or inadequate respiratory effort, give 1 breath every 2 to 3 seconds (20-30 breaths/min).
Ventilation Rate During CPR With an Advanced Airway
- When performing CPR in infants and children with an advanced airway, target a respiratory rate range of 1 breath every 2 to 3 seconds (20-30/min), accounting for age and clinical condition. Rates exceeding these recommendations may compromise hemodynamics.
- Higher ventilation rates (at least 30/min in infants [younger than 1 year] and at least 25/min in children) are associated with improved rates of ROSC and survival in pediatric IHCA.
- Cuffed ETTs preferred over uncuffed for intubating infants and children.
- When a cuffed ETT is used, attention should be paid to ETT size, position, and cuff inflation pressure (usually <20-25 cm H2O).
- Several studies and systematic reviews support the safety of cuffed ETTs and demonstrate decreased need for tube changes and reintubation.
- Cuffed tubes may decrease the risk of aspiration.
Cricoid Pressure During Intubation
- Use of cricoid pressure is not recommended during endotracheal intubation of pediatric patients.
- Use of cricoid pressure reduces intubation success rates and does not reduce the rate of regurgitation.
Emphasis on Early Epinephrine Administration
- Administer the initial dose of epinephrine within 5 minutes from the start of chest compressions.
- A study of children (IHCA) who received epinephrine for an initial asystole or PEA demonstrated that, for every minute of delay in administration of epinephrine, there was a significant decrease in ROSC, survival at 24 hours, survival to discharge, and survival with favorable neurological outcome.
- Patients who received epinephrine within 5 minutes of CPR initiation compared with those who received epinephrine more than 5 minutes after CPR initiation were more likely to survive to discharge.
Invasive Blood Pressure Monitoring to Assess CPR Quality
- Continuous IABP monitoring in place at the time of cardiac arrest, it is reasonable for providers to use diastolic blood pressure to assess CPR quality.
- Providing high-quality chest compressions is critical to successful resuscitation.
- A new study shows that rates of survival with favorable neurologic outcome were improved if the diastolic blood pressure was at least 25 mm Hg in infants and at least 30 mm Hg in children.
Detecting and Treating Seizures After ROSC
- Continuous EEG monitoring is recommended for the detection of seizures following cardiac arrest in patients with persistent encephalopathy.
- It is recommended to treat clinical seizures following cardiac arrest.
- It is reasonable to treat nonconvulsive status epilepticus following cardiac arrest in consultation with experts.
Evaluation and Support for Cardiac Arrest Survivors
- Pediatric cardiac arrest survivors should be evaluated for rehabilitation services.
- Refer pediatric cardiac arrest survivors for ongoing neurologic evaluation for at least the first year after cardiac arrest.
Septic Shock Fluid Boluses
- Septic shock patients: administer fluid in 10 or 20 mL/kg boluses with frequent reassessment.
Choice of Vasopressor
- In infants and children with fluid-refractory septic shock, use either epinephrine or norepinephrine as an initial vasoactive infusion. If epinephrine or norepinephrine are unavailable, dopamine may be considered.
- For infants and children with septic shock unresponsive to fluids and requiring vasoactive support, consider stress-dose corticosteroids.
- Fluids remain the mainstay of initial therapy for infants and children in shock, especially in hypovolemic and septic shock, but fluid overload can lead to increased morbidity.
- In recent trials of patients with septic shock, those who received higher fluid volumes or faster fluid resuscitation were more likely to develop clinically significant fluid overload and require mechanical ventilation.
- Among infants and children with hypotensive hemorrhagic shock following trauma, it is reasonable to administer blood products, when available, instead of crystalloid for ongoing volume resuscitation.
- For patients in respiratory arrest, rescue breathing or bag-mask ventilation should be maintained until spontaneous breathing returns, and standard life support measures should continue if ROSC does not occur.
- For a patient with suspected opioid overdose who has a definite pulse but no normal breathing or only gasping (ie, a respiratory arrest), in addition to providing standard PBLS or PALS, it is reasonable for responders to administer IM or IN naloxone.
- For patients known or suspected to be in cardiac arrest, in the absence of a proven benefit from the use of naloxone, standard resuscitative measures should take priority over naloxone administration, with a focus on high-quality CPR.
- The opioid epidemic has not spared children. In the United States in 2018, opioid overdose caused 65 deaths in children younger than 15 years and 3618 deaths in people 15 to 24 years old, and many more children required resuscitation.
- These recommendations are identical for adults and children, except that compression-ventilation CPR is recommended for all pediatric victims of suspected cardiac arrest.
- Naloxone can be administered by trained providers, laypersons with training, and untrained laypersons.
- Given the high risk of cardiac arrest in children with acute myocarditis with arrhythmias, heart block, ST-segment changes, and/or low cardiac output, early consideration of transfer to ICU monitoring and therapy is recommended.
- For children with myocarditis or cardiomyopathy and refractory low cardiac output, pre arrest use of ECLS or mechanical circulatory support can be beneficial to provide end-organ support and prevent cardiac arrest.
- Given the challenges to successful resuscitation of children with myocarditis and cardiomyopathy, once cardiac arrest occurs, early consideration of extracorporeal CPR may be beneficial.
- Although myocarditis accounts for about 2% of sudden cardiovascular deaths in infants, 5% of sudden cardiovascular deaths in children, and 6% to 20% of sudden cardiac death in athletes, previous PALS guidelines did not contain specific recommendations for management.
Pulmonary Hypertension (PH)
- Inhaled nitric oxide or prostacyclin should be used as the initial therapy to treat PH crisis or acute right-sided heart failure secondary to increased pulmonary vascular resistance.
- Provide careful respiratory management and monitoring to avoid hypoxia and acidosis in the postoperative care of the child with PH.
- For pediatric patients who are at high risk for PH crises, provide adequate analgesics, sedatives, and neuromuscular blocking agents.
- For the initial treatment of PH crises, oxygen administration and induction of alkalosis through hyperventilation or alkali administration can be useful while pulmonary-specific vasodilators are administered.
- For children who develop refractory PH, including low cardiac output or profound respiratory failure despite optimal medical therapy, ECLS may be considered.
For more information about the 2020 AHA Guidelines, please review our other blogs or visit https://professional.heart.org/en/science-news/2020-aha-guidelines-for-cpr-and-ecc.