Key Points And Recommendations In Pediatric Advanced Life Support

• Class of recommendation (COR) is also called strength of recommendation. COR 1 is a strong recommendation (benefit is more and risk is less) also called a recommended guideline. COR 2a is moderate (the benefit is more than the risk)- it is a reasonable recommendation. COR 2b is weak (Benefit is more than risk but not so robust as the above two) -can be considered. COR 3 is no benefit (benefit is equal to risk); Hence not recommended, also written as 3NB. COR 3 is harm (Risk is more than the benefit)- Should not be performed, also called 3H.

Level Of Evidence (LOE)

• Level A is High-Quality Evidence. Level B- R: is Moderate from randomized (R) trials. (Randomised data is always better than non - randomized data). Level B- NR: is Moderate from non-randomized (NR) data Evidence. Level C- LD: Data with limitation of design (LD) or execution Evidence. Level C- EO: Consensus of expert opinion (EO) Evidence.

Pediatric Chains Of Survival

IHCA (In Hospital Cardiac Arrest) 

• 6 periodic changes can occur:  Early recognition and prevention of cardiac arrest, activation of emergency response, high-Quality CPR, advanced resuscitation means initial CPR is not working, Post -Cardiac Arrest care when the child is successfully resuscitated. Recovery includes rehabilitation and long-term neurological format.

OHCA (Out Of Hospital Cardiac Arrest) 

• High-Quality CPR, advanced resuscitation, post -cardiac arrest care and recovery (Except prevention)

Key Points And Recommendations In Pediatric Advanced Life Support (PALS)

Initiation Of CPR 

• Lay rescuers - the person who first attains the patient is a lay rescuer, not a medical professional. It should begin CPR for any unresponsive victim, not breathing normally, does not have signs of life, and does not check their pulse. Healthcare providers - check for a pulse for up to 10s as soon as definite pulses feel and begin compression unless a definite plus is felt. This is regarding the initiation of CPR. Initiate CPR with C-A-B (Compression - airway - breathing) rather than A-B-C

Components Of High-quality CPR

• In CPR, start chest compressions along with rescue breaths in cardiac arrest. If unable to give rescue breaths, compressions alone are to be given. The chest compression rate should be 100-120/min. Allow adequate chest recoil between 2 compressions. The compression depth should be at least 1/3rd the AP diameter of the chest. In infants, approximately 1.5 inches (4cm), and in children, 2 inches (5cm). Adult compression depth of 5- 6 cm post-puberty should not exceed 6 cm. A rhythm checks every 2 min every rhythm check should last for 10 sec. The child Should be given ventilation with 100% Oxygen.  When giving CPR with an advanced airway, give one breath every 2-3 sec, i.e., target a 20- 30 /min RR. Rates exceeding these may compromise hemodynamics.

Also Read: The Genetics of Down Syndrome

CPR Technique In Pediatric Advanced Life Support

• For Infants - Single rescuer:  Two fingers technique or 2 thumbs placed just below the intermammary line. Two rescuers:  Use the 2 thumb and encircling hands technique. For infants, if the rescuers cannot achieve an adequate depth, it may be reasonable to use the heel of 1 hand.  For children, it may be reasonable to use either a 1 or 2-hand technique to perform chest compressions.

Support Surfaces For CPR 

During in hospital cardiac arrest, activate the bed’s “CPR MODE “to increase mattress stiffness on soft surfaces when available. Use a backboard or a firm surface to give chest compressions if unavailable. OPENING THE AIRWAY – A special manoeuvre to use which depends on whether the cervical injury is suspected or not.    If no cervical   injury is suspected, the manoeuvre of choice would be the Head tilt - chin lift manoeuvre. In case of suspected cervical spine injury choice would be jaw thrust without head tilt. If it fails, use a head tilt-chin lift manoeuvre.

Advanced Airway Intervention In CPR 

• Bag and mask ventilation is reasonable compared with advanced airway interventions during cardiac arrest in out of hospital cardiac arrest.

Drug Administration During CPR 

• For paediatric patients in any setting, it is reasonable to administer epinephrine. IV/IO is preferable to endotracheal tube (ETT) administration.  The initial dose of epinephrine should be given within 5 minutes of starting chest compressions. It is reasonable for pediatric patients in any setting, it is reasonable to administer epinephrine every 3-5 min until ROSC (return of spontaneous circulation) is achieved. Either amiodarone or lidocaine may be used for shock-refractory VF/pVT (p- pulseless). Routine administration of sodium bicarbonate is not recommended in pediatric cardiac arrest without hyperkalaemia or sodium blockers like tricyclic antidepressants toxicity. Routine calcium administration is not recommended. For paediatric cardiac arrest without documented hypocalcaemia, calcium channel blocker overdose, hypermagnesemia, or hyperkalemia. Using the child’s body weight to calculate resuscitation drug doses while not exceeding the recommended dose for adults is recommended for resuscitation medication dosing.

Also Read : Pigmentary Disorders in Children

Management Of VF/PVT 

1. Energy Dose For Defibrillation 

Initial dose should be 2-4 J/kg and usually it is 2J/kg.  For refractory VF (ventricular fibrillation): 4 J/kg. Subsequently, doses 4J/kg and even higher can be used, but they should not exceed 10 J/kg or the maximum adult dose. 

2. Coordination Of Shock Therapy And Cpr

Perform CPR till the device is ready. Once ready, give a single shock, then immediately start CPR. Minimise interruptions of chest compressions. 

Type Of Defibrillator 

When using an AED on infants and children, preferably using a synchronizer is available.  For infants under the care of a trained healthcare provider, a manual defibrillator is recommended when a shockable rhythm is identified.  Use the largest paddles or self-adhering electrodes that will fit on the child's chest. Place them Antero-Lateral or Antero-Posteriorly. Both paddles and electrodes are equally effective. 

Assessment Of Resuscitation Quality 

If continuous invasive BP monitoring is available during cardiac arrest, use Diastolic BP to assess CPR Quality.  ETCO2 (end-tidal) monitoring may be considered to assess chest compression quality, but exact values in children are not yet determined.  If available, Use CPR feedback devices.  ECG may be considered to identify potentially treatable arrest causes, such as pericardial tamponade and inadequate ventricular filling. Still, the potential benefit should be weighed against the risks of interrupting chest compressions.

Post- Cardiac Arrest Care And Monitoring 

Targeted Temperature Monitoring

• For infants and children between 24hr and 18 yrs who remain comatose after out of hospital cardiac arrest or IHCA, use either targeted temperature monitoring 32- 34C followed by targeted temperature monitoring 36-37.5C or only targeted temperature monitoring 36 - 37.5C. Continuous core temperature monitoring is needed during targeted temperature monitoring.

Hemodynamic Monitoring And Ventilation

•  If available Continuous atrial pressure monitoring is given. After ROSC, use fluids /drugs to maintain SBP above the 5th percentile for age.  Wean O2 to target saturation O2 to 94-99%. If it is off O2, Target normoxemia and avoid hypo and hypercapnia, as both are associated with advanced neurological outcomes.

Neuromonitoring And Seizure Treatment

•  If available, continuous EEG monitoring for detecting non - convulsive Seizures following cardiac arrest in patients with persistent encephalopathy need to identify.  Recommended to treat clinical seizures after cardiac arrest. In the case of non-convulsive status epilepticus, it is reasonable to treat following cardiac arrest in consultation with experts.

Prognostication Following Cardiac Arrest 

• Performing an EEG 1 week after the post-arrest is 1 factor for prognostication. Consider multiple factors when predicting outcomes in infants and children who survive cardiac arrests.

Recovery 

• Survivors need evaluation for rehabilitation needs.  Refer survivors for ongoing neurological evaluation for at least the 1st year after cardiac arrest.  

Family Presence During Resuscitation 

• Whenever possible, provide family members with the option of begin present during the resuscitation of the infant or child (if the presence of family interrupts, they can be asked politely to leave).

Evaluation Of Sudden Unexplained Cardiac Arrest

• Consider autopsy and appropriate preservation of biological material for genetic analysis if the child does not survive.  If no causes are found on autopsy, refer to a healthcare provider or centre with expertise in inherited cardiac diseases and cardiac genetic counselling. For infants, children, and adolescents who survive, obtain a complete past medical and family history, review previous ECGs, and refer to a cardiologist. 

Resuscitation In Shock 

Septic Shock 

• In patients with septic shock, it is reasonable to administer fluid in 10 ml/kg or 20 ml/kg aliquots with frequent reassessment. Either isotonic crystalloids or colloids can be initial fluids.  Either balanced or unbalanced solutions can be effective. Providers should reassess after every fluid bolus for responsiveness and a sign of volume overloaded. Using either epinephrine or norepinephrine as an initial vasoactive infusion is reasonable for infants and children with fluid-refractory septic shocks. If epinephrine and norepinephrine are not available, then dopamine may be considered.

Cardiogenic Shock 

• Early expert consultation is needed, preferably cardiologist. Use epinephrine, dopamine, dobutamine (alone, cannot be used), or milrinone as an inotropic infusion.

Acute Traumatic Hemorrhagic Shock 

• To administer blood products (PRBC prefers whole blood transfusion when available) instead of crystalloid for ongoing volume resuscitation.

Also Read: Progeria- Pathogenesis, Clinical Features and Treatment

Treatment Of Respiratory Failure

Treatment Of Inadequate Breathing With A Pulse Present 

• Provide rescue breaths, 1 breath every 2 to 3s (20- 30 breaths/min)

Foreign Body Airway Obstruction

• If mild foreign body airway obstruction, allow the child to remove it by coughing, monitor. If severe foreign body airway obstruction is given Abdominal thrusts till either it is expelled, or the child becomes unresponsive. For infants with severe foreign body airway obstruction, deliver repeated cycles of 5 back blows (slaps) followed by 5 chest compression until the object is expelled or the victim becomes unresponsive. Once unresponsive, start CPR. Remove any visible FB while opening the airway, but no blind finger sweeps must be performed.

Opioid-related Respiratory And Cardiac Arrest 

• For patients in respiratory arrest, rescue breathing, or bag-mask ventilation should be maintained until spontaneous breathing returns. For a patient with suspected opioid overdose who has a definite pulse but no normal breathing or only gasping (i.e., a respiratory arrest), give life support and administer intramuscular or intranasal naloxone. For patients in cardiac arrest related to opioid intake, standard resuscitative measures should take priority over naloxone administration.

Intubation 

• Cricoid pressure during BMV (bag and mask ventilation) to prevent gastric insufflation.  Not recommended routine use of cricoid pressure during intubation. If used, discontinue cricoid pressure if it interferes with ease of intubation or ventilation. Choose cuffed over uncuffed ETTs 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 (in practice, it kept 15 to 18 as the max). Use atropine 0.02 mg/kg as a premedication to prevent bradycardia during an emergency for intubation with a high risk of bradycardia, e.g., succinylcholine use. In all settings, for infants and children with a perfusing rhythm, use exhaled CO2 detection (colorimetric detector or capnography) to confirm ETT placement.

Hope you found this blog helpful for your NEET SS General Pediatrics preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.