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Updates
in Pediatrics Basic Life Support: An
Evidence-Based Review
*Salam
A. M.1,4,
Azzam S.B.2, Numan M.1, Al Haroob A.1,
**Al Musleh A.W.3,4 and *Gehani A.A.1,4
Departments of
Cardiology & Cardiovascular Surgery1,
Pediatrics2,
Accident & Emergency3
and Qatar Resuscitation Council4
Hamad Medical Corporation, Doha, Qatar
  Introduction:
The American Heart Association, together with representatives
from the International Liaison Committee on Resuscitation (ILCOR),
which is made up of leading resuscitation organizations from the Americas,
Europe, Southern Africa, Australia, and New Zealand, undertook a series of
evidence-based evaluations of the science of resuscitation which culminated
in the publication of ‘Guidelines 2000 for Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care’ in August 2000
(1,2). Experts from non-ILCOR
organizations from Asia and elsewhere also participated in drawing up the guidelines.
The Pediatric Life Support Working Party of the European Resuscitation Council (ERC) has considered this document and the supporting scientific literature and has recommended changes to the ERC Basic and Advanced Pediatric Life Support (PLS)
Guidelines(3,4). The Qatar Resuscitation Council (QRC) basically adopts these changes as endorsed by the ERC. In this article we present an evidence-based summary of these changes and conclude with areas of controversy that warrant further studies and research.
 Definitions:
An infant is a child under the age of one year. A child is aged between one and eight years. In the following text the masculine includes the feminine and ‘child’ refers to both infants and children unless specifically noted otherwise. Children over the age of eight years will still be subject to the same resuscitation sequence as for a younger child but may require adult techniques and ratios to attain effective chest compressions.
Guidelines
Classes:
Throughout these
Guidelines, the following definitions of classes
of
recommendations are used:
Class I: Recommendations
are always acceptable.
They are proven
safe and
definitely useful, and
they are
supported by excellent evidence
from at least
one prospective,
randomized
controlled clinical trial.
Class IIa: Recommendations
are considered
acceptable and useful
with good to
very good evidence
providing support. The weight
of evidence and
expert opinions
strongly favor these interventions.
Class IIb: Recommendations
are considered
acceptable and useful
with weak or
only fair evidence
providing support. The weight
of evidence and
expert opinion
are not strongly in favor of
the
intervention.
Class
III:
Refers to interventions that are unacceptable.
These interventions
lack any
evidence of benefit, and often the evidence
suggests
or confirms
harm.
Class Indeterminate: Refers
to an intervention
that is
promising, but
the evidence is insufficient in quantity
and/or quality
to support
a definitive class of recommendation.
The
Indeterminate Class
was added to
indicate interventions
that are
considered safe
and perhaps
effective and are recommended
by expert
consensus. However,
the available evidence supporting
the
recommendation is
either too weak or too limited at present
to make a
definite recommendation
based on the published data.
The approach to changes has been to alter the
guidelines in response to convincing new
scientific evidence and, where possible, to
simplify the guidelines in order to assist
teaching and retention. There is a paucity of
experimental evidence, both old and new, to inform
the development of guidelines for pediatric
resuscitation. Some alterations, therefore, have
been made in response to evidence from animal
work, studies in adults and to aid consistency
between adult and pediatric guidelines where this
was consistent with pediatric resuscitation needs.
Pediatric
Basic Life Support Guideline Changes:
Cardiopulmonary
resuscitation and life support in the pedia-tric
age group should be part
of a
community-wide Chain of Survival that links the
child to the
best hope of survival following emergencies. The
Chain of Survival
integrates education in prevention of
cardiopulmonary arrest,
Basic Life Support (BLS), early access to
Emergency Medical Service systems prepared for
children’s needs,
early and effective pediatric Advanced Life
Support (ALS), and pediatric post-resuscitation
and rehabilitative care
The changes in basic life support for infants
and children are as follows:
1. Determining
cardiac arrest by means of the pulse check: Lay
rescuers will no longer be taught or expected to
perform a pulse check to determine cardiac arrest
(Class IIa), although the need for a pulse check
will remain for healthcare providers. Both lay
rescuers and healthcare providers will be expected
to seek for ‘signs of a circulation’. Several
studies have made it clear that both lay rescuers
and health care providers are poor at determining
the presence or absence of a pulse. Poor
sensitivity and specificity of the pulse check
make it unreliable as the sole indicator for
starting chest compressions.
In addition most studies have
shown that even experienced healthcare providers
take longer than 10 seconds to determine the
presence or absence of the pulse(5-10).
2. Indications for starting
chest compressions: Chest compressions
should be started in the absence of a pulse, the
absence of ‘signs of circulation’ or if the
pulse is less than 60 at all ages in association
with poor perfusion. There is no experimental
evidence to indicate the ideal bradycardic rate at
which to start chest compressions so the rate of
less than 60 with signs of poor perfusion has been
chosen for all ages for ease of teaching and
retention. There is evidence that
‘inappropriate’, properly performed chest
compressions are very unlikely to cause harm to an
infant or child(11-12).
3. Technique for chest
compressions in the under one year old: If
two or more suitably trained providers are
available, a two thumb, chest-encircling technique
is the preferred method of chest compression in
infancy (Class IIb). Animal experiments and
anecdotal reports have shown that the two thumb,
chest encircling technique can produce better
coronary perfusion or a higher systolic pressure
during CPR than the two finger technique(13-14).
4. Rescue Breathing and
Bag-Mask Ventilation: Education in
bag-mask ventilation should be included in all BLS
curricula for the healthcare provider (Class IIa).
Bag-mask ventilation can
provide lifesaving support for infants and
children in both the out-of-hospital and
in-hospital settings and is a skill that BLS
providers should master (Class IIa).
5. Compression/Ventilation
ratio for over 8-year olds:
The CPR ratio will be 15:2 for any number of
rescuers in the over 8-year-old child (this
mirrors the adult CPR approach). For the under 8
years olds, the CPR ratio remains at 5:1 for any
number of rescuers (Class Indeterminate). Although
an increased number of chest compressions per
sequence improves coronary perfusion(15),
the 15:2 ratio decreases the amount of ventilation
provided compared to the 5:1 ratio. Respiratory
causes of cardiac arrest are especially important
in children. In addition, in view of their small
size and the need for only one hand for chest
compressions up to 8 years of age, more
compressions and ventilations can be given to
infants and small children using the 5:1 ratio so
this remains the recommended ratio for this group.
For larger children, however, the 15:2 ratio is
used both because of ease of use for the single
rescuer and to be consistent with adult guidelines
(Class Indeterminate).
6. Use of automated external
defibrillators (AEDs): AEDs may be
used in children over the age of 8 years, 25 kg or
over (Class IIb).
Below this age they may be used for rhythm
recognition (although in infants they may not be
accurate in identifying tachyarrhythmias) but the
defibrillation dose delivered cannot currently be
recommended(16-17).
7. ‘Phone first ’ for
children with heart disease: Although most
cardiac arrests in infants and children are
non-cardiac in origin, sudden collapse in an
infant or child with known heart disease is likely
to be arrhythmogenic in origin. Therefore rapid
access to a defibrillator is more likely to be
beneficial to this group of children as opposed to
immediate airway and breathing support with chest
compressions which is best for all other infants
and children.
8. Foreign body obstruction sequence for lay
providers in the unconscious infant or child: The
extremely complex skills sequence for lay
rescuer relief
of foreign-body
airway obstruction (FBAO) in the unconscious
victim has
been simplified (Class IIb). The sequence for the
conscious infant or child and the sequence for the
trained healthcare provider remain unchanged
(Class IIb).
Areas
of Overlap Within Adult and Pediatric Guidelines:
Note that recommendations will
overlap in areas where distinctions between
age cutoffs and target audiences are blurred.
Examples of overlapping
areas between adult, pediatric, and neonatal
recommendations include
Compression-ventilation ratios
of 15:2 versus 5:1 versus
3:1 and
2-finger versus 2 thumb–encircling hands versus
1-hand versus
2-hand compression technique
When to “phone
first” versus “phone fast”
Chest-compression rate of approximately
120 events per minute
for the newly born/neonate in the delivery
room versus at least
100 compressions per minute for BLS for
infants beyond the newly
born period and in the out-of-hospital
setting versus approximately
100 compressions per minute for
pediatric BLS.
Pulse check locations: carotid versus brachial
versus femoral
versus umbilical
Most of these overlapping areas are easily interpreted
in the context of
the training environment and target audience.
Areas
of Controversy:
Several areas of controversy
that require focused research have been
identified. They are as follows:
-
What is
the prevalence and time course for
presentation of VF
during
or after resuscitation?
-
Should resuscitation sequences
of interventions/algorithms
be taught
on the basis of the likelihood
of presenting rhythm (eg, bradycardia-asystole
most likely for
children) or reversible etiology (eg,
VF treated with
defibrillation
is most likely to be successfully resuscitated)?
-
How many
breaths should be initially attempted
after opening
the airway?
-
At what heart rate should
chest compressions be initiated?
-
What is the optimal depth
for chest compressions (one third
to one half depth of chest versus specified
number of inches
or centimeters)?
-
What sequence of interventions
for the choking
child is most appropriate:
back blows versus abdominal thrusts
versus chest thrusts?
-
What defibrillation dose,
type of waveform,
and number of defibrillation
shocks should be delivered after
medication has been provided
for VF in children?
-
Should visual
inspection of the mouth for a foreign
body precede ventilation
attempts in infants?
-
What is an optimal recovery
position for
infants and children?
-
Can a universal compression-ventilation
ratio be adopted (5:1
versus 10:2 versus 15:2) that can accommodate
all victims from
infancy to adulthood?
-
Is mouth-and-nose ventilation
a better method than maternal mouth-to-infant-mouth-and-nose
for ventilation of neonates and small
infants?
-
Can AEDs accurately
and reliably be used in pediatric patients?
Can AEDs provide
a single optimal defibrillation “dose”?
-
What are the frequency,
etiology, and outcome of CPR provided
by laypersons versus trained
providers in a variety of home, out-of-hospital,
and in-hospital
settings?
- What is the impact of implementing universal
resuscitation guidelines
on arrest
prevention, successful resuscitation, and
neurological performance
outcomes from potential or actual cardiopulmonary
arrest in
infants and children?
Conclusion:
Current
guidelines have been updated after extensive multinational
evidence-based review and discussion over several
years. Pediatric BLS guidelines detail specific
modifications of adult techniques necessary to address
anatomic, physiological, etiologic, and psychosocial
issues for infants and children. Areas of controversy
in current guidelines and unresolved issues provide
a potential for future research and studies.
References:
1.
American Heart Association in collaboration with the International
Liaison Committee on Resuscitation (ILCOR). Guidelines 2000 for
cardiopulmonary resuscitation and emergency cardiovascular care - an
international consensus on science. Resuscitation 2000; 46: 1-447.
2. American Heart
Association in collaboration with the International Liaison
Committee on Resuscitation (ILCOR). Guidelines 2000 for
cardiopulmonary resuscitation and emergency cardiovascular care. An
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I-1–I-384.
3. Phillips B,
Zideman D, Garcia-Castrillo L, Felix M, Shwarz- Schwierin U.
European Resuscitation Council Guidelines 2000 for Basic Paediatric
Life Support. A statement from the Pediatric Life Support Working
Group and approved by the Executive Committee of the European
Resuscitation Council. Resuscitation. 2001 Mar; 48(3): 223-9.
4. Phillips B,
Zideman D, Garcia-Castrillo L, Felix M, Shwarz- Schwierin V.
European Resuscitation Council Guidelines 2000 for Advanced
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European Resuscitation Council. Resuscitation. 2001 Mar; 48(3):
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S, Mandel LP, Brevik H, Tarnow J. The ability of health
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