European Resuscitation Council Guidelines for Resuscitation ... - CPR

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Resuscitation 81 (2010) 1364–138818 de 0ctubre de 2010 www.elsuapdetodos.comContents lists available at ScienceDirectResuscitationjournal homepage: www.elsevier.com/locate/resuscitationEuropean Resuscitation Council Guidelines for Resuscitation 2010Section 6. Paediatric life supportDominique Biarent a,∗ , Robert Bingham b , Christoph Eich c , Jesús López-Herce d ,Ian Maconochie e , Antonio Rodríguez-Núñez f , Thomas Rajka g , David Zideman ha Paediatric Intensive Care, Hôpital Universitaire des Enfants, 15 av JJ Crocq, Brussels, Belgiumb Great Ormond Street Hospital for Children, London, UKc Zentrum Anaesthesiologie, Rettungs- und Intensivmedizin, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, D-37075 Göttingen, Germanyd Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Complutense University of Madrid, Madrid, Spaine St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UKf University of Santiago de Compostela FEAS, Pediatric Emergency and Critical Care Division, Pediatric Area Hospital Clinico Universitario de Santiago de Compostela,15706 Santiago de Compostela, Spaing Oslo University Hospital, Kirkeveien, Oslo, Norwayh Imperial College Healthcare NHS Trust, London, UKIntroductionThese guidelines on paediatric life support are based on twomain principles: (1) the incidence of critical illness, particularlycardiopulmonary arrest, and injury in children is much lower thanin adults; (2) most paediatric emergencies are served primarily byproviders who are not paediatric specialists and who have limitedpaediatric emergency medical experience. Therefore, guidelines onpaediatric life support must incorporate the best available scientificevidence but must also be simple and feasible. Finally, internationalguidelines need to acknowledge the variation in national andlocal emergency medical infrastructures and allow flexibility whennecessary.The processThe European Resuscitation Council (ERC) published guidelinesfor paediatric life support (PLS) in 1994, 1998, 2000and 2005. 1–5 The latter two were based on the InternationalConsensus on Science published by the International Liaison Committeeon Resuscitation (ILCOR). 6–8 This process was repeated in2009/2010, and the resulting Consensus on Science with TreatmentRecommendations (CoSTR) was published simultaneously inResuscitation, Circulation and Pediatrics. 9,10 The PLS Working Partyof the ERC has developed the ERC PLS Guidelines based on the2010 CoSTR and supporting scientific literature. The guidelines forresuscitation of babies at birth are now covered in Section 7. 11Summary of changes since the 2005 GuidelinesGuideline changes have been made in response to convincingnew scientific evidence and to simplify teaching and retention.As before, there remains a paucity of good-quality evidence onpaediatric resuscitation. Therefore to facilitate and support disseminationand implementation of the PLS Guidelines, changes havebeen made only if there is new, high-level scientific evidence orto ensure consistency with the adult guidelines. The feasibility ofapplying the same guidance for all adults and children remainsa major topic of study. Major changes in these new guidelinesinclude:Recognition of cardiac arrestwww.elsuapdetodos.comHealthcare providers cannot reliably determine the presenceor absence of a pulse in less than 10 s in infants or children. 12,13Therefore pulse palpation cannot be the sole determinant of cardiacarrest and the need for chest compressions. If the victim isunresponsive, not breathing normally, and there are no signs of life,lay rescuers should begin CPR. Healthcare providers should look forsigns of life and if they are confident in the technique, they may addpulse palpation for diagnosing cardiac arrest and decide whetherthey should begin chest compressions or not. The decision to beginCPR must be taken in less than 10 s. According to the child’s age,carotid (children), brachial (infants) or femoral pulse (children andinfants) checks may be used. 14,15Compression ventilation ratios∗ Corresponding author.E-mail address: dominique.biarent@huderf.be (D. Biarent).The compression ventilation (CV) ratio used for children shouldbe based on whether one, or more than one rescuer is present. 16 Layrescuers, who usually learn only single-rescuer techniques, should0300-9572/$ – see front matter © 2010 European Resuscitation Council. Published by Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.resuscitation.2010.08.012
e taught to use a ratio of 30 compressions to 2 ventilations which isthe same as the adult guidelines and enables anyone trained in basiclife support (BLS) to resuscitate children with minimal additionalinformation. Rescuers with a duty to respond should learn and usea 15:2 CV ratio as this has been validated in animal and manikinstudies. 17–21 This latter group, who would normally be healthcareprofessionals, should receive enhanced training targeted specificallyat the resuscitation of children. For them, simplicity wouldbe lost if a different ratio was taught for the scenario when one ortwo or more rescuers were present. However, those with a duty torespond can use the 30:2 ratio if they are alone, particularly if theyare not achieving an adequate number of compressions becauseof difficulty in the transition between ventilation and compression.Ventilation remains a very important component of CPR inasphyxial arrests. 22 Rescuers who are unable or unwilling to providemouth-to-mouth ventilation should be encouraged to performat least compression-only CPR.CPR qualityThe compression technique for infants includes two-fingercompression for single rescuers and the two-thumb encirclingtechnique for two or more rescuers. 23–27 For older children, aone- or two-hand technique can be used, according to rescuerpreference. 28 The emphasis is on achieving an adequate depth ofcompression: at least 1/3 of the anterior-posterior chest diameterin all children (i.e., approximately 4 cm in infants and approximately5 cm in children). Subsequent complete release should alsobe emphasised. Chest compressions must be performed with minimalinterruptions to minimise no-flow time. For both infants andchildren, the compression rate should be at least 100 but not greaterthan 120 min −1 .DefibrillationAutomated external defibrillatorsCase reports indicate that automated external defibrillators(AEDs) are safe and successful when used in children older than1 year of age. 29,30 Automated external defibrillators are capable ofidentifying arrhythmias in children accurately; in particular, theyare extremely unlikely to advise a shock inappropriately. 31–33 Consequently,the use of AEDs is indicated in all children aged greaterthan 1 year. 34 Nevertheless, if there is any possibility that an AEDmay need to be used in children, the purchaser should check thatthe performance of the particular model has been tested againstpaediatric arrhythmias. Many manufacturers now supply purposemadepaediatric pads or software, which typically attenuate theoutput of the machine to 50–75 J 35 and these are recommendedfor children aged 1–8 years. 36,37 If an attenuated shock or a manuallyadjustable machine is not available, an unmodified adult AEDmay be used in children older than 1 year. 38 The evidence to supporta recommendation for the use of AEDs in children aged lessthan 1 year is limited to case reports. 39,40 The incidence of shockablerhythms in infants is very low except when they suffer fromcardiac disease. 41–43 In these rare cases, the risk/benefit ratio maybe favourable and use of an AED (preferably with dose attenuator)should be considered.Manual defibrillators18 de 0ctubre de 2010 www.elsuapdetodos.comD. Biarent et al. / Resuscitation 81 (2010) 1364–1388 1365The treatment recommendation for paediatric ventricular fibrillation(VF) or paediatric pulseless ventricular tachycardia (VT)remains immediate defibrillation. In adult advanced life support(ALS), the recommendation is to give a single shock and thenresume CPR immediately without checking for a pulse or reassessingthe rhythm (see Section 4). 44–47 To reduce the no-flowtime, chest compressions should be continued while applying andcharging the paddles or self-adhesive pads (if the size of the child’schest allows this). Chest compressions should be briefly pausedonce the defibrillator is charged to deliver the shock. The idealenergy dose for safe and effective defibrillation in children isunknown, but animal models and small paediatric case series showthat doses larger than 4 J kg −1 defibrillate effectively with negligibleside effects. 29,37,48,49 Clinical studies in children indicate that dosesof2Jkg −1 are insufficient in most cases. 13,42,50 Biphasic shocks areat least as effective and produce less post-shock myocardial dysfunctionthan monophasic shocks. 36,37,49,51–53Therefore, for simplicity and consistency with adult BLS andALS guidance, a single-shock strategy using a non-escalating doseof 4 J kg −1 (preferably biphasic but monophasic is acceptable) isrecommended for defibrillation in children. Use the largest sizepaddles or pads that fit on the infant or child’s chest in the anterolateralor antero-posterior position without the pads/paddlestouching each other. 13AirwayCuffed tracheal tubesCuffed tracheal tubes can be used safely in infants and youngchildren. The size should be selected by applying a validated formula.Cricoid pressureThe safety and value of using cricoid pressure during trachealintubation is not clear. Therefore, the application of cricoid pressureshould be modified or discontinued if it impedes ventilation or thespeed or ease of intubation.CapnometryMonitoring exhaled carbon dioxide (CO 2 ), ideally by capnography,is helpful to confirm correct tracheal tube position andrecommended during CPR to help assess and optimize its quality.Titration of oxygenBased on increasing evidence of potential harm from hyperoxaemiaafter cardiac arrest, once spontaneous circulation is restored,inspired oxygen should be titrated to limit the risk of hyperoxaemia.www.elsuapdetodos.comRapid response systemsImplementation of a rapid response system in a paediatric inpatientsetting may reduce rates of cardiac and respiratory arrestand in-hospital mortality.New topicsNew topics in the 2010 guidelines include channelopathies (i.e.,the importance of autopsy and subsequent family testing) andseveral new special circumstances: trauma, single ventricle preandpost-1st stage repair, post-Fontan circulation, and pulmonaryhypertension.TerminologyIn the following text the masculine includes the feminine andchild refers to both infants and children unless noted otherwise.
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