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SPECIAL ARTICLE |
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ABSTRACT |
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 TOP ABSTRACT INITIAL STEPS OF CPRDISTURBANCES IN CARDIAC RHYTHMAIRWAY AND VENTILATIONOXYGEN DURING...VASCULAR ACCESS AND DRUGS...POSTRESUSCITATION CAREPROGNOSISREFERENCESWORKSHEETS CITED |
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The COSTR document presents international consensus statements on the science of resuscitation. ILCOR member organizations are each publishing resuscitation guidelines that are consistent with the science in this consensus document, but they also take into consideration geographic, economic, and system differences in practice and the regional availability of medical devices and drugs. The American Heart Association (AHA) pediatric and the American Academy of Pediatrics/AHA neonatal sections of the resuscitation guidelines are reprinted in this issue of Pediatrics (see pages e978–e988).
The 2005 evidence evaluation process began shortly after publication of the 2000 International Guidelines for CPR and ECC. The process included topic identification, expert topic review, discussion and debate at 6 international meetings, further review, and debate within ILCOR member organizations and ultimate approval by the member organizations, an Editorial Board, and peer reviewers. The complete COSTR document was published simultaneously in Circulation (International Liaison Committee on Resuscitation. 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2005;112(suppl):73–90) and Resuscitation (International Liaison Committee on Resuscitation. 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2005;67:271–291).
Readers are encouraged to review the 2005 COSTR document in its entirety. It can be accessed through the CPR and ECC link at the AHA Web site: www.americanheart.org. The complete publication represents the largest evaluation of resuscitation literature ever published and contains electronic links to more detailed information about the international collaborative process.
To organize the evidence evaluation, ILCOR representatives established 6 task forces: basic life support, advanced life support, acute coronary syndromes, pediatric life support, neonatal life support, and an interdisciplinary task force to consider overlapping topics such as educational issues. The AHA established additional task forces on stroke and, in collaboration with the American Red Cross, a task force on first aid. Each task force identified topics requiring evaluation and appointed international experts to review them. A detailed worksheet template was created to help the experts document their literature review, evaluate studies, determine levels of evidence, develop treatment recommendations, and disclose conflicts of interest. Two evidence evaluation experts reviewed all worksheets and assisted the worksheet reviewers to ensure that the worksheets met a consistently high standard.
A total of 281 experts completed 403 worksheets on 275 topics, reviewing more than 22000 published studies. In December 2004 the evidence review and summary portions of the evidence evaluation worksheets, with worksheet author conflict of interest statements, were posted on the Internet at www.C2005.org, where readers can continue to access them. Journal advertisements and e-mails invited public comment.
Two hundred forty-nine worksheet authors (141 from the United States and 108 from 17 other countries) and additional invited experts and reviewers attended the 2005 International Consensus Conference for presentation, discussion, and debate of the evidence. All 380 participants at the conference received electronic copies of the worksheets. Internet access was available to all conference participants during the conference to facilitate real-time verification of the literature. Expert reviewers presented topics in plenary, concurrent, and poster conference sessions with strict adherence to a novel and rigorous conflict of interest process. Presenters and participants then debated the evidence, conclusions, and draft summary statements. Wording of science statements and treatment recommendations was refined after further review by ILCOR member organizations and the international editorial board. This format ensured that the final document represented a truly international consensus process.
The COSTR manuscript was ultimately approved by all ILCOR member organizations and by an international editorial board. The AHA Science Advisory and Coordinating Committee and the editor of Circulation obtained peer reviews of this document before it was accepted for publication.
The most important changes in recommendations for pediatric resuscitation since the last ILCOR review in 2000 include:
Some of the most important changes in recommendations for neonatal resuscitation since the last ILCOR review in 2000 include less emphasis on using 100% oxygen when initiating resuscitation, de-emphasis of the need for routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants born to mothers with meconium staining of amniotic fluid, proven value of occlusive wrapping of very low birth weight infants <28 weeks' gestation to reduce heat loss, preference for the IV versus the endotracheal route for epinephrine, and an increased emphasis on parental autonomy at the threshold of viability.
The scientific evidence supporting these recommendations is summarized in the neonatal document (see pages e978–e988).
Key Words: resuscitation • neonatal resuscitation • evidence-based medicine
Abbreviations: ILCOR—International Liaison Committee on Resuscitation • ECC—emergency cardiovascular care • SVT—supraventricular tachycardia • CPR—cardiopulmonary resuscitation • AED—automated external defibrillator • IV—intravenous • IO—intraosseous • LMA—laryngeal mask airway • EMS—emergency medical services • VF—ventricular fibrillation • LOE—level of evidence • VT—ventricular tachycardia • BVM—bag-valve-mask • EDD—esophageal detector device
The International Liaison Committee on Resuscitation (ILCOR) Pediatric Task Force included expert reviewers from Africa, Asia, Australia, Asia, Europe, North America, and South America. These experts reviewed 45 topics related to pediatric resuscitation. Topics were selected from previous recommendations (the emergency cardiovascular care [ECC] Guidelines 20001,2), emerging science, and newly identified issues. Some well-established topics without controversies or new evidence (eg, adenosine for the treatment of supraventricular tachycardia [SVT]) are not included in this document.
Evidence-based worksheets on some topics were prepared and discussed but are not included here because there was insufficient evidence (eg, fibrinolytics in cardiac arrest,W13 securing the endotracheal tube in children,W1 use of impedance threshold device in children,W2 sodium bicarbonate for prolonged resuscitation attemptsW34) or because no new evidence was found (eg, evaluation of capillary refill,W10 ventilation before naloxone,W18 delayed volume resuscitation in trauma,W17 use of hypertonic saline in shockW16).
The following is a summary of the most important changes in recommendations for pediatric resuscitation since the last ILCOR review in 2000.1,2 The scientific evidence supporting these recommendations is summarized in this document:
1 year of age. The ILCOR Pediatric Task Force reevaluated the definitions of newborn, infant, child, and adult. These definitions are somewhat arbitrary but are important because some recommendations for treatment differ according to patient size and the most likely etiology of arrest. The distinction between child and adult victims has been de-emphasized by the recommendation of a universal compression-ventilation ratio for lay rescuers and the same chest compression technique for lay rescuers of children and adults. Some differences in treatment recommendations remain between the newborn and infant and between an infant and child, but those differences are chiefly linked to resuscitation training and practice. They are noted below.
Identified knowledge gaps in pediatric resuscitation include
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INITIAL STEPS OF CPR |
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TOPABSTRACTINITIAL STEPS OF CPRDISTURBANCES IN CARDIAC RHYTHMAIRWAY AND VENTILATIONOXYGEN DURING...VASCULAR ACCESS AND DRUGS...POSTRESUSCITATION CAREPROGNOSISREFERENCESWORKSHEETS CITED |
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The pulse check was previously eliminated as an assessment for the lay rescuer. There is now evidence that health care professionals may take too long to check for a pulse and may not accurately determine the presence or absence of the pulse. This may lead to interruptions in chest compressions and affect the quality of CPR.
Experts reviewed the data on the technique of rescue breathing for infants and the 2-thumb-encircling hands versus 2-finger chest compression techniques for infants.
One of the most challenging topics debated during the 2005 Consensus Conference was the compression-ventilation ratio. The scientific evidence on which to base recommendations was sparse, and it was difficult to arrive at consensus. Evidence was presented that the ratio should be higher than 5:1, but the optimal ratio was not identified. The only data addressing a compression-ventilation ratio greater than 15:2 came from mathematical models. The experts acknowledged the educational benefit of simplifying training for lay rescuers (specifically 1-rescuer CPR) by adopting a single ratio for infants, children, and adults with the hope that simplification might increase the number of bystanders who will learn, remember, and perform CPR. On this basis experts agreed that this single compression-ventilation ratio should be 30:2. Health care providers will typically be experienced in CPR and practice it frequently. This group of experienced providers will learn 2-person CPR, and for them the recommended compression-ventilation ratio for 2 rescuers is 15:2.
Some laypeople are reluctant to perform mouth-to-mouth ventilation. For treatment of cardiac arrest in infants and children, chest compressions alone are better than no CPR but not as good as a combination of ventilations and compressions.
In the past 1-handed chest compressions were recommended for CPR in children. A review of the evidential basis for this recommendation was conducted. From an educational standpoint, we agree that it will simplify training to recommend a single technique for chest compressions for children and adults.
Activating EMS and Getting the AEDW4
Consensus on Science
Most cardiac arrests in children are caused by asphyxia (level of evidence [LOE] 4).3–6 Observational studies of non-VF arrests in children show an association between bystander CPR and intact neurologic outcome (LOE 4).6–8 Animal studies show that in asphyxial arrest, chest compressions plus ventilation CPR is superior to either chest compression-only CPR or ventilation-only CPR (LOE 6).9
Observational studies of children with VF report good (17–20%) rates of survival after early defibrillation (LOE 4).5,6,10 The merits of "call first" versus "call fast" CPR sequences have not been adequately studied in adults or children with cardiac arrest of asphyxial or VF etiologies. Three animal studies (LOE 6)9,11,12 show that even in prolonged VF, CPR increases the likelihood of successful defibrillation, and 7 adult human studies (LOE 7)13–19 document improved survival with the combination of CPR with minimal interruptions in chest compression and early defibrillation.
Treatment Recommendation
A period of immediate CPR before phoning EMS and getting the AED ("call fast") is indicated for most pediatric arrests because they are presumed to be asphyxial or prolonged. In a witnessed sudden collapse (eg, during an athletic event), the cause is more likely to be VF, and the lone rescuer should phone for professional help and get the AED (when available) before starting CPR and using the AED, if appropriate. Rescuers should perform CPR with minimal interruptions in chest compressions until attempted defibrillation.
In summary, the priorities for unwitnessed or nonsudden collapse in children are as follows:
The priorities for witnessed sudden collapse in children are as follows:
Pulse CheckW5A,W5B
Consensus on Science
Ten studies (LOE 220,21; LOE 422–26; LOE 527; LOE 628,29) show that lay rescuers23,25,30 and health care providers20,21,24,26–29 are often unable to accurately determine the presence of a pulse within 10 seconds. Two studies in infants (LOE 5)31,32 reported that rescuers rapidly detected cardiac activity by direct chest auscultation but were biased because they knew that the infants were healthy.
Treatment Recommendation
Lay rescuers should start chest compressions for an unresponsive infant or child who is not moving or breathing. Health care professionals may also check for a pulse but should proceed with CPR if they cannot feel a pulse within 10 seconds or are uncertain if a pulse is present.
Ventilations in InfantsW7A,W7B
Consensus on Science
One LOE 533 study and 10 LOE 734–43 reports assessed a mouth-to-nose ventilation technique for infants. The LOE 5 study33 is an anecdotal report of 3 infants ventilated with mouth-to-nose technique. The LOE 7 reports describe postmortem anatomy,34 physiology of nasal breathing,35–37 related breathing issues,38,39 and measurements of infants' faces compared with the measurement of adult mouths.40–43 There is great variation in these measurements, probably because of imprecise or inconsistent definitions.
Treatment Recommendation
There are no data to justify a change from the recommendation that the rescuer attempt mouth-to-mouth-and-nose ventilation for infants. Rescuers who have difficulty achieving a tight seal over the mouth and nose of an infant, however, may attempt either mouth-to-mouth or mouth-to-nose ventilation (LOE 5).33
Circumferential Versus 2-Finger Chest CompressionsW9A,W9B
Consensus on Science
Two manikin (LOE 6)44,45 and 2 animal (LOE 6)46,47 studies showed that the 2 thumb-encircling hands technique of chest compressions with circumferential thoracic squeeze produces higher coronary perfusion pressures and more consistently correct depth and force of compression than the 2-finger technique.
Case reports (LOE 5)48,49 of hemodynamic monitoring in infants receiving chest compressions showed higher systolic and diastolic arterial pressures in the 2-thumb-encircling hands technique compared with the 2-finger technique.
Treatment Recommendation
The 2 thumb-encircling hands chest compression technique with thoracic squeeze is the preferred technique for 2-rescuer infant CPR. The 2-finger technique is recommended for 1-rescuer infant CPR to facilitate rapid transition between compression and ventilation and to minimize interruptions in chest compressions. It remains an acceptable alternative method of chest compressions for 2 rescuers.
One- Versus 2-Hand Chest Compression TechniqueW276
Consensus on Science
There are no outcome studies that compare 1- versus 2-hand compressions of the chest in children. One (LOE 6)50 study reported higher pressures generated in child manikins using the 2-hand technique to compress over the lower part of the sternum to a depth of approximately one third the anterior-posterior diameter of the chest. Rescuers reported that this technique was easy to perform.
Treatment Recommendation
Both the 1- and 2-hand techniques for chest compressions in children are acceptable provided that rescuers compress over the lower part of the sternum to a depth of approximately one third the anterior-posterior diameter of the chest. To simplify education, rescuers can be taught the same technique (ie, 2-hand) for adult and child compressions.
Compression-Ventilation RatioW3A–W3C
Consensus on Science
There are insufficient data to identify an optimal compression-ventilation ratio for CPR in children. Manikin studies (LOE 6)51–54 have examined the feasibility of compression-ventilation ratios of 15:2 and 5:1. Lone rescuers cannot deliver the desired number of chest compressions per minute at a ratio of 5:1. A mathematical model (LOE 7)55 supports compression-ventilation ratios higher than 5:1 for infants and children.
Two animal (LOE 6)56,57 studies show that coronary perfusion pressure, a major determinant of success in resuscitation, declines with interruptions in chest compressions. In addition, once compressions are interrupted, several chest compressions are needed to restore coronary perfusion pressure. Frequent interruptions of chest compressions (eg, with a 5:1 compression-ventilation ratio) prolongs the duration of low coronary perfusion pressure. Long interruptions in chest compressions have been documented in manikin studies (LOE 6)58,59 and both in- and out-of-hospital adult CPR studies (LOE 7).60,61 These interruptions reduce the likelihood of a return of spontaneous circulation (LOE 7).62–64
Five animal (LOE 6)9,56,57,65,66 studies and 1 review (LOE 7)67 suggest that ventilations are relatively less important in victims with VF or pulseless ventricular tachycardia (VT) cardiac arrest than in victims with asphyxia-induced arrest. But even in asphyxial arrest, few ventilations are needed to maintain an adequate ventilation-perfusion ratio in the presence of the low cardiac output (and, consequently, low pulmonary blood flow) produced by chest compressions.
Treatment Recommendation
For ease of teaching and retention, a universal compression-ventilation ratio of 30:2 is recommended for the lone rescuer responding to infants (for neonates see Part 7: "Neonatal Resuscitation"), children, and adults. For health care providers performing 2-rescuer CPR, a compression-ventilation ratio of 15:2 is recommended. When an advanced airway is established (eg, a tracheal tube, esophageal-tracheal combitube [Combitube], or LMA), ventilations are given without interrupting chest compressions.
Some CPR Versus No CPRW8
Consensus on Science
Numerous reports (LOE 5)4,5,8,68–70 document survival of children after cardiac arrest when bystander CPR was provided. Bystander CPR in these reports included rescue breathing alone, chest compressions alone, or a combination of compressions and ventilations.
One prospective and 3 retrospective studies of adult VF (LOE 7)71–74 and numerous animal studies of VF cardiac arrest (LOE 6)56,57,66,75–79 document comparable long-term survival after chest compressions alone or chest compressions plus ventilations, and both techniques result in better outcomes compared with no CPR. In animals with asphyxial arrest (LOE 6),9 the more common mechanism of cardiac arrest in infants and children, best results are achieved with a combination of chest compressions and ventilations. But resuscitation with either ventilations only or chest compressions only is better than no CPR.
Treatment Recommendation
Bystander CPR is important for survival from cardiac arrest. Trained rescuers should be encouraged to provide both ventilations and chest compressions. If rescuers are reluctant to provide rescue breaths, however, they should be encouraged to perform chest compressions alone without interruption.
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DISTURBANCES IN CARDIAC RHYTHM |
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TOPABSTRACTINITIAL STEPS OF CPRDISTURBANCES IN CARDIAC RHYTHMAIRWAY AND VENTILATIONOXYGEN DURING...VASCULAR ACCESS AND DRUGS...POSTRESUSCITATION CAREPROGNOSISREFERENCESWORKSHEETS CITED |
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There is insufficient evidence to identify an optimal shock wave form, energy dose, and shock strategy (eg, fixed versus escalating shocks, 1 vs 3 stacked shocks) for defibrillation. The new recommendation for the sequence of defibrillation in children is based on extrapolated data from adult and animal studies with biphasic devices, data documenting the high rates of success for first shock conversion of VF with biphasic waveforms, and knowledge that interruption of chest compressions reduces coronary perfusion pressure. Thus, a 1-shock strategy may be preferable to the 3-shock sequence recommended in the ECC Guidelines 2000.2 For further details, see Part 3: "Defibrillation."
Many but not all AED algorithms have been shown to be sensitive and specific for recognizing shockable arrhythmias in children. A standard AED ("adult" AED with adult pad-cable system) can be used for children older than about 8 years of age and weighing more than about 25 kg. Many manufacturers now provide a method for attenuating the energy delivered to make the AED suitable for smaller children (eg, use of a pad-cable system or an AED with a key or switch to select a smaller dose).
Management of SVTs
If the child with SVT is hemodynamically stable, we recommend early consultation with a pediatric cardiologist or other physician with appropriate expertise. This recommendation is common for all of the SVT topics below.
Vagal Maneuvers for SVTW36
Consensus on Science
One prospective (LOE 3)80 and 9 observational studies (LOE 481; LOE 582,83; LOE 784–89) show that vagal maneuvers are somewhat effective in terminating SVT in children. There are reports of complications from carotid sinus massage and application of ice to the face to stimulate the diving reflex (LOE 5),90,91 but virtually none from the Valsalva maneuver.
Treatment Recommendation
The Valsalva maneuver and ice application to the face may be used to treat hemodynamically stable SVT in infants and children. When performed correctly, these maneuvers can be initiated quickly and safely and without altering subsequent therapies if they fail.
Amiodarone for Hemodynamically Stable SVTW38
Consensus on Science
One prospective (LOE 3)92 and 10 observational (LOE 5)93–102 studies show that amiodarone is effective for treating SVT in children. A limitation of this evidence is that most of the studies in children describe treatment for postoperative junctional ectopic tachycardia.
Treatment Recommendation
Amiodarone may be considered in the treatment of hemodynamically stable SVT refractory to vagal maneuvers and adenosine. Rare but significant acute side effects include bradycardia, hypotension, and polymorphic VT (LOE 5).103–105
Procainamide for Hemodynamically Stable SVTW37
Consensus on Science
Experience with procainamide in children is limited. Twelve LOE 5106–117 and 4 LOE 6118–121 observational studies show that procainamide can terminate SVT that is resistant to other drugs. Most of these reports include mixed adult-pediatric populations. Hypotension following procainamide infusion results from its vasodilator action rather than a negative inotropic effect (LOE 5122,123; LOE 6124).
Treatment Recommendation
Procainamide may be considered in the treatment of hemodynamically stable SVT refractory to vagal maneuvers and adenosine.
Management of Stable Wide-QRS Tachycardia
If a child with wide-QRS tachycardia is hemodynamically stable, early consultation with a pediatric cardiologist or other physician with appropriate expertise is recommended. In general, amiodarone and procainamide should not be administered together because their combination may increase risk of hypotension and ventricular arrhythmias.
AmiodaroneW39A,W39B,W40
Consensus on Science
One case series (LOE 5)125 suggests that wide-QRS tachycardia in children is more likely to be supraventricular than ventricular in origin. Two prospective studies (LOE 3)92,126 and 13 case series (LOE 5)93–102,127–129 show that amiodarone is effective for a wide variety of tachyarrhythmias in children. None of these reports specifically evaluate the role of amiodarone in the setting of a stable, unknown wide-complex tachycardia.
Treatment Recommendation
Wide-QRS tachycardia in children who are stable may be treated as SVT. If the diagnosis of VT is confirmed, amiodarone should be considered.
Procainamide for Stable VTW35
Consensus on Science
Twenty (LOE 5)106,115,123,130–146 and 2 LOE 6118,124 observational studies primarily in adults but including some children show that procainamide is effective in the treatment of stable VT.
Treatment Recommendation
Procainamide may be considered in the treatment of hemodynamically stable VT.
Management of Unstable VT
AmiodaroneW39A,W40
Consensus on Science
In small pediatric case series (LOE 3100; LOE 593,95,97,99,147–149) and extrapolation from animal (LOE 6)150,151 and adult (LOE 7)152–165 studies, amiodarone is safe and effective for hemodynamically unstable VT in children.
Treatment Recommendation
Synchronized cardioversion remains the treatment of choice for unstable VT. Amiodarone may be considered for treatment of hemodynamically unstable VT.
Pediatric Defibrillation
For additional information about consensus on science and treatment recommendations for defibrillation (eg, 1 vs 3 stacked shock sequences and sequence of CPR first versus defibrillation first), see Part 3: "Defibrillation."
Manual and Automated External DefibrillationW41A,W41B
Consensus on Science
The ideal energy dose for safe and effective defibrillation in children is unknown. Extrapolation from adult data (LOE 1166,167; LOE 2168–170) and pediatric animal studies (LOE 6)171–173 suggests that biphasic shocks are at least as effective as monophasic shocks and produce less postshock myocardial dysfunction. One LOE 5174 and 1 LOE 6171 study show that an initial monophasic or biphasic shock dose of 2 J/kg generally terminates pediatric VF. Two pediatric case series (LOE 5)171,175,176 report that doses >4 J/kg (up to 9 J/kg) have effectively defibrillated children <12 years of age, with negligible adverse effects.
In 5 animal studies (LOE 6)172,173,177–179 large (per kilogram) energy doses caused less myocardial damage in young hearts than in adult hearts. In 3 animal studies (LOE 6)173,179,180 and 1 small pediatric case series (LOE 5),176 a 50-J biphasic dose delivered through a pediatric pad-cable system terminated VF and resulted in survival. One piglet (13–26 kg) study (LOE 6)179 showed that pediatric biphasic AED shocks (50/75/86 J) terminated VF and caused less myocardial injury and better outcome than adult AED biphasic shocks (200/300/360 J).
Treatment Recommendation
The treatment of choice for pediatric VF/pulseless VT is prompt defibrillation, although the optimum dose is unknown. For manual defibrillation, we recommend an initial dose of 2 J/kg (biphasic or monophasic wave form). If this dose does not terminate VF, subsequent doses should be 4 J/kg.
For automated defibrillation, we recommend an initial pediatric attenuated dose for children 1 to 8 years of age and up to about 25 kg (55 lb) and 127 cm (50 in) in length. There is insufficient information to recommend for or against the use of an AED in infants <1 year of age. A variable dose manual defibrillator or an AED able to recognize pediatric shockable rhythms and equipped with dose attenuation are preferred; if such a defibrillator is not available, a standard AED with standard electrode pads may be used. A standard AED (without a dose attenuator) should be used for children 25 kg (about 8 years of age) and older adolescent and adult victims.
Management of Shock-Resistant VF/Pulseless VT
AmiodaroneW20,W21A,W21B
Consensus on Science
Evidence extrapolated from 3 (LOE 1) studies in adults (LOE 7 when applied to pediatrics)154,159,181 shows increased survival to hospital admission but not discharge when amiodarone is compared with placebo or lidocaine for shock-resistant VF. One study in children (LOE 3)100 showed effectiveness of amiodarone for life-threatening ventricular arrhythmias.
Treatment Recommendation
IV amiodarone can be considered as part of the treatment of shock-refractory or recurrent VT/VF.
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AIRWAY AND VENTILATION |
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The risks of tracheal tube misplacement, displacement, and obstruction are well recognized, and an evidence-based review led to a recommendation that proper tube placement and patency be monitored by exhaled CO2 throughout transport. A review also found that cuffed tracheal tubes could be used safely even in infants.
Following the return of spontaneous circulation from cardiac arrest, toxic oxygen byproducts (reactive oxygen species, free radicals) are produced that may damage cell membranes, proteins, and DNA (reperfusion injury). There are no clinical studies in children outside the newborn period comparing different concentrations of inspired oxygen during and immediately after resuscitation, and it is difficult to differentiate "sufficient" from "excessive" oxygen therapy.
BVM VentilationW6
Consensus on Science
One out-of-hospital pediatric prospective randomized controlled study (LOE 1)182 in an EMS system with short transport times showed that BVM ventilation compared with tracheal intubation resulted in equivalent survival to hospital discharge rates and neurologic outcome in children requiring airway control, including children with cardiac arrest and trauma.
One study in pediatric cardiac arrest (LOE 4)183 and 4 studies in children with trauma (LOE 3184,185; LOE 4186,187) found no advantage of tracheal intubation over BVM ventilation.
Treatment Recommendation
In the out-of-hospital setting with short transport times, BVM ventilation is the method of choice for children who require ventilatory support. When transport times are long, the relative benefit versus potential harm of tracheal intubation compared with BVM ventilation is uncertain. It is affected by the level of training and experience of the health care professional and the availability of exhaled CO2 monitoring during intubation and transport.
Advanced Airways
Advanced airways include the tracheal tube, the Combitube, and the LMA. Experts at the 2005 Consensus Conference reviewed the available evidence on use of the tracheal tube and LMA in infants and children. There were no data on use of the Combitube in this age group.
Cuffed Versus Uncuffed Tracheal TubesW11A,W11B
Consensus on Science
One randomized controlled trial (LOE 2),188 3 prospective cohort studies (LOE 3),189–191 and 1 cohort study (LOE 4)192 document no greater risk of complications for children <8 years of age when using cuffed tracheal tubes compared with uncuffed tubes in the operating room and intensive care unit.
Evidence from 1 randomized controlled trial (LOE 2)188 and 1 small, prospective controlled study (LOE 3)193 showed some advantage in cuffed over uncuffed tracheal tubes in children in the pediatric anesthesia and intensive care settings, respectively.
Treatment Recommendation
Cuffed tracheal tubes are as safe as uncuffed tubes for infants (except newborns) and children if rescuers use the correct tube size and cuff inflation pressure and verify tube position. Under certain circumstances (eg, poor lung compliance, high airway resistance, and large glottic air leak), cuffed tracheal tubes may be preferable.
LMAW26A,W26B
Consensus on Science
There are no studies examining the use of the LMA in children during cardiac arrest. Evidence extrapolated from pediatric anesthesia shows a higher rate of complications with LMAs in smaller children compared with LMA experience in adults. The complication rate decreases with increasing operator experience (LOE 7).194,195 Case reports document that the LMA can be helpful for management of the difficult airway.
Treatment Recommendation
There are insufficient data to support or refute a recommendation for the routine use of an LMA for children in cardiac arrest. The LMA may be an acceptable initial alternative airway adjunct for experienced providers during pediatric cardiac arrest when tracheal intubation is difficult to achieve.
Confirmation of Tube Placement
Exhaled CO2W25
Consensus on Science
Misplaced, displaced, or obstructed tracheal tubes are associated with a high risk of death. No single method of tracheal tube confirmation is always accurate and reliable. One study (LOE 3)196 showed that clinical assessment of tracheal tube position (observation of chest wall rise, mist in the tube, and auscultation of the chest) can be unreliable for distinguishing esophageal from tracheal intubation.
In 3 studies (LOE 5),197–199 when a perfusing cardiac rhythm was present in infants >2 kg and children, detection of exhaled CO2 using a colorimetric detector or capnometer had a high sensitivity and specificity for tracheal tube placement. In 1 study (LOE 5)198 during cardiac arrest, the sensitivity of exhaled CO2 detection for tracheal tube placement was 85% and specificity 100%. Both with a perfusing rhythm and during cardiac arrest, the presence of exhaled CO2 reliably indicates tracheal tube placement, but the absence of exhaled CO2 during cardiac arrest does not prove tracheal tube misplacement.
Treatment Recommendation
In all settings (ie, prehospital, emergency departments, intensive care units, operating rooms), confirmation of tracheal tube placement should be achieved using detection of exhaled CO2 in intubated infants and children with a perfusing cardiac rhythm. This may be accomplished using a colorimetric detector or capnometry. During cardiac arrest, if exhaled CO2 is not detected, tube position should be confirmed using direct laryngoscopy.
Esophageal Detector DeviceW23
Consensus on Science Statements
A study in the operating room (LOE 2)200 showed that the esophageal detector device (EDD) was highly sensitive and specific for correct tracheal tube placement in children weighing >20 kg with a perfusing cardiac rhythm. There have been no studies of the EDD in children during cardiac arrest. A pediatric animal study (LOE 6)201 showed only fair results with the EDD, but accuracy improved with use of a larger syringe device. The same animal study showed no difference when the tracheal tube cuff was either inflated or deflated.
Treatment Recommendation
The EDD may be considered for confirmation of tracheal tube placement in children weighing >20 kg.
Confirmation of Tracheal Tube Placement During TransportW24
Consensus on Science
Studies (LOE 1202; LOE 7203) have documented the high rate of inadvertent displacement of tracheal tubes during prehospital transport. There are no studies to evaluate the frequency of these events during intrahospital or interhospital transport.
Two studies (LOE 5)204,205 show that in the presence of a perfusing rhythm, exhaled CO2 detection or measurement can confirm tracheal tube position accurately during transport. In 2 animal studies (LOE 6),206,207 loss of exhaled CO2 detection indicated tracheal tube displacement more rapidly than pulse oximetry. On the basis of 1 case series (LOE 5),204 continuous use of colorimetric exhaled CO2 detectors may not be reliable for long (>30 minutes) transport duration.
Treatment Recommendation
We recommend monitoring tracheal tube placement and patency in infants and children with a perfusing rhythm by continuous measurement or frequent intermittent detection of exhaled CO2 during prehospital and intrahospital and interhospital transport.
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OXYGEN DURING RESUSCITATIONW14A,W14B |
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TOPABSTRACTINITIAL STEPS OF CPRDISTURBANCES IN CARDIAC RHYTHMAIRWAY AND VENTILATIONOXYGEN DURING...VASCULAR ACCESS AND DRUGS...POSTRESUSCITATION CAREPROGNOSISREFERENCESWORKSHEETS CITED |
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Treatment Recommendation
There is insufficient information to recommend for or against the use of any specific inspired oxygen concentration during and immediately after resuscitation from cardiac arrest. Until additional evidence is published, we support health care providers' use of 100% oxygen during resuscitation (when available). Once circulation is restored, providers should monitor oxygen saturation and wean inspired oxygen while ensuring adequate oxygen delivery.
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VASCULAR ACCESS AND DRUGS FOR CARDIAC ARREST |
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Routes of Drug Delivery
IO AccessW29
Consensus on Science
Two prospective randomized trials in adults and children (LOE 3)215,216 and 6 other studies (LOE 4217; LOE 5218–220; LOE 7221,222) document that IO access is safe and effective for fluid resuscitation, drug delivery, and blood sampling for laboratory evaluation.
Treatment Recommendation
We recommend establishing IO access if vascular access is not achieved rapidly in any infant or child for whom IV drugs or fluids are urgently required.
Drugs Given via Tracheal TubeW32
Consensus on Science
One study in children (LOE 2),223 5 studies in adults (LOE 2224–226; LOE 3227,228), and multiple animal studies (LOE 6)229–231 indicate that atropine, epinephrine, naloxone, lidocaine, and vasopressin are absorbed via the trachea. Administration of resuscitation drugs into the trachea results in lower blood concentrations than the same dose given intravascularly. Furthermore, animal studies (LOE 6)232–235 suggest that the lower epinephrine concentrations achieved when the drug is delivered by tracheal route may produce transient ß-adrenergic effects. These effects can be detrimental, causing hypotension, lower coronary artery perfusion pressure and flow, and reduced potential for return of spontaneous circulation.
Treatment Recommendation
Intravascular, including IO, injection of drugs is preferable to administration by the tracheal route. The recommended tracheal dose of atropine, epinephrine, or lidocaine is higher than the vascular dose and is as follows:
The optimal tracheal doses of naloxone or vasopressin have not been determined.
Drugs in Cardiac Arrest
Dose of Epinephrine for Cardiac ArrestW31A,W31B
Consensus on Science
In 4 pediatric studies (LOE 2236,237; LOE 4238,239) there was no improvement in survival rates and a trend toward worse neurologic outcome after administration of high-dose epinephrine for cardiac arrest. A prospective, randomized, controlled trial (LOE 2)236 comparing high-dose with standard-dose epinephrine for the second and subsequent ("rescue") doses in pediatric in-hospital cardiac arrest showed reduced 24-hour survival rates in the high-dose epinephrine group. In subgroup analysis, survival rates in asphyxia and sepsis were significantly worse with high-dose rescue epinephrine.
Treatment Recommendation
Children in cardiac arrest should be given 10 µg/kg of epinephrine as the first and subsequent intravascular doses. Routine use of high-dose (100 µg/kg) intravascular epinephrine is not recommended and may be harmful, particularly in asphyxia. High-dose epinephrine may be considered in exceptional circumstances (eg, ß-blocker overdose).
Vasopressin in Cardiac ArrestW19A,W19B
Consensus on Science
Based on a small series of children (LOE 5),240 vasopressin given after epinephrine may be associated with return of spontaneous circulation after prolonged cardiac arrest. Animal data (LOE 6)241,242 indicate that a combination of epinephrine and vasopressin may be beneficial. Adult data are inconsistent. Giving vasopressin after adult cardiac arrest (LOE 7)243–247 has produced improved short-term outcomes (eg, return of spontaneous circulation or survival to hospital admission) but no improvement in neurologically intact survival to hospital discharge when compared with epinephrine.
Treatment Recommendation
There is insufficient evidence to recommend for or against the routine use of vasopressin during cardiac arrest in children.
Magnesium in Cardiac ArrestW15
Consensus on Science
The relationship between serum magnesium concentrations and outcome of CPR was analyzed in 2 studies in adults (LOE 3248; LOE 4249) and 1 animal study (LOE 6).250 The first 2 studies indicated that a normal serum concentration of magnesium was associated with a higher rate of successful resuscitation, but it is unclear whether the association is causative. Six adult clinical studies (LOE 1251; LOE 2252–255; LOE 3256) and 1 study in an adult animal model (LOE 6)257 indicated no significant difference in any survival end point in patients who received magnesium before, during, or after CPR.
Treatment Recommendation
Magnesium should be given for hypomagnesemia and torsades de pointes VT, but there is insufficient evidence to recommend for or against its routine use in cardiac arrest.
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Ventilation: HyperventilationW27
Consensus on Science
One study in cardiac arrest patients (LOE 3)258 and extrapolation from 12 other studies (LOE 6259; LOE 2260; LOE 3261–267; LOE 4268; LOE 5269,270) suggest that hyperventilation may cause decreased venous return to the heart and cerebral ischemia and may be harmful in the comatose patient after cardiac arrest.
Treatment Recommendation
Hyperventilation after cardiac arrest may be harmful and should be avoided. The target of postresuscitation ventilation is normocapnia. Short periods of hyperventilation may be performed as a temporizing measure for the child with signs of impending cerebral herniation.
Temperature Control
Therapeutic HypothermiaW22B,W22C
Consensus on Science
Immediately after resuscitation from cardiac arrest, children often develop hypothermia followed by delayed hyperthermia (LOE 5).271 Hypothermia (32–34°C) may be beneficial to the injured brain. Although there are no pediatric studies of induced hypothermia after cardiac arrest, support for this treatment is extrapolated from
Treatment Recommendation
Induction of hypothermia (32–34°C) for 12 to 24 hours should be considered in children who remain comatose after resuscitation from cardiac arrest.
Treatment of HyperthermiaW22A,W22D
Consensus on Science
Two studies (LOE 5)271,279 show that fever is common after resuscitation from cardiac arrest, and 3 studies (LOE 7)280–282 show that it is associated with worse outcome. Animal studies suggest that fever causes a worse outcome. One study (LOE 6)283 shows that rats resuscitated from asphyxial cardiac arrest have a worse outcome if hyperthermia is induced within the first 24 hours of recovery. In rats with global ischemic brain injury (which produces endogenous fever), prevention of fever with a nonsteroidal antiinflammatory drug (NSAID) class of antipyretic attenuated neuronal damage (LOE 6).284,285
Treatment Recommendation
Health care providers should prevent hyperthermia and treat it aggressively in infants and children resuscitated from cardiac arrest.
Hemodynamic Support: Vasoactive DrugsW33A–W33D
Consensus on Science
Two studies in children (LOE 5),286,287 multiple studies in adults (LOE 7),288–290 and animal studies (LOE 6)291–293 indicate that myocardial dysfunction is common after resuscitation from cardiac arrest. Multiple animal studies (LOE 6)294–296 document consistent improvement in hemodynamics when selected vasoactive drugs are given in the post–cardiac arrest period. Evidence extrapolated from multiple adult and pediatric studies (LOE 7)297–302 of cardiovascular surgical patients with low cardiac output documents consistent improvement in hemodynamics when vasoactive drugs are titrated in the period after cardiopulmonary bypass.
Treatment Recommendation
Vasoactive drugs should be considered to improve hemodynamic status in the post–cardiac arrest phase. The choice, timing, and dose of specific vasoactive drugs must be individualized and guided by available monitoring data.
Blood Glucose Control: Treatment of Hypoglycemia and HyperglycemiaW30A–W30C
Consensus on Science
Adults with out-of-hospital cardiac arrest and elevated blood glucose on admission have poor neurologic and survival outcomes (LOE 7).303–308 In critically ill children, hypoglycemia (LOE 5)309 and hyperglycemia (LOE 5)310 are associated with poor outcome. It is unknown if the association of hyperglycemia with poor outcome after cardiac arrest is causative or an epiphenomenon related to the stress response.
In critically ill adult surgical patients (LOE 7),311 strict glucose control improves outcome, but there are currently insufficient data in children showing that the benefit of tight glucose control outweighs the risk of inadvertent hypoglycemia.
Several animal studies (LOE 6)312–316 and an adult clinical study (LOE 4)317 show poor outcome when glucose is given immediately before or during cardiac arrest. It is unknown if there is harm in giving glucose-containing maintenance fluids to children after cardiac arrest.
Hypoglycemia is an important consideration in pediatric resuscitation because
Treatment Recommendation
Health care providers should check glucose concentration during cardiac arrest and monitor it closely afterward with the goal of maintaining normoglycemia. Glucose-containing fluids are not indicated during CPR unless hypoglycemia is present (LOE 7).323
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PROGNOSIS |
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TOPABSTRACTINITIAL STEPS OF CPRDISTURBANCES IN CARDIAC RHYTHMAIRWAY AND VENTILATIONOXYGEN DURING...VASCULAR ACCESS AND DRUGS...POSTRESUSCITATION CAREPROGNOSISREFERENCESWORKSHEETS CITED |
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Predictors of Outcome in ChildrenW12B,W28
Consensus on Science
Multiple studies in adults have linked characteristics of the patient or of the cardiac arrest with prognosis following in-hospital or out-of-hospital cardiac arrest. Experience in children is more limited. Six pediatric studies (LOE 5)3,324–328 show that prolonged resuscitation is associated with a poor outcome. Although the likelihood of a good outcome is greater with short duration of CPR, 2 pediatric studies (LOE 3)328,329 reported good outcomes in some patients following 30 to 60 minutes of CPR in the inpatient setting when the arrests were witnessed and prompt and presumably excellent CPR was provided. Children with cardiac arrest associated with environmental hypothermia or immersion in icy water can have excellent outcomes despite >30 minutes of cardiac arrest (LOE 5).7,330
One large pediatric study (LOE 4)331 and several smaller studies (LOE 5)332–336 show that good outcome can be achieved when extracorporeal CPR is started after 30 to 90 minutes of refractory standard CPR for in-hospital cardiac arrests. The good outcomes were reported primarily in patients with isolated heart disease. These data show that 15 or 30 minutes of CPR does not define the limits of cardiac and cerebral viability.
Witnessed events, bystander CPR, and a short interval from collapse to arrival of EMS system personnel are important prognostic factors associated with improved outcome in adult resuscitation, and it seems reasonable to extrapolate these factors to children. At least 1 pediatric study (LOE 5)328 showed that the interval from collapse to initiation of CPR is a significant prognostic factor.
Children with prehospital cardiac arrest caused by blunt trauma337 and in-hospital cardiac arrest caused by septic shock329 rarely survive.
Treatment Recommendation
The rescuer should consider whether to discontinue resuscitative efforts after 15 to 20 minutes of CPR. Relevant considerations include the cause of the arrest, preexisting conditions, whether the arrest was witnessed, duration of untreated cardiac arrest ("no flow"), effectiveness and duration of CPR ("low flow"), prompt availability of extracorporeal life support for a reversible disease process, and associated special circumstances (eg, icy water drowning, toxic drug exposure).
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ACKNOWLEDGMENTS |
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Dianne L. Atkins, MD
Marc D. Berg, MD, FAAP
Robert A. Berg, MD
Adnan T. Bhutta
Dominique Biarent
Robert Bingham, MD
Dana Braner, MD
Renato Carrera, MD
Leon Chameides, MD
Ashraf Coovadia, MD
Allan de Caen, MD
Douglas S. Diekema, MD, MPH
Diana G. Fendya, RN, MSN (R)
Melinda L. Fiedor, MD
Richard T. Fiser, MD
Susan Fuchs, MD
Mike Gerardi, MD
William Hammill, MD
George W. Hatch, Jr, EdD, LP, EMT-P
Mary Fran Hazinski, RN, MSN
Robert W. Hickey, MD
John Kattwinkel, MD
Monica E. Kleinman, MD
Jesús López-Herce, MD
Peter Morley, MB, BS
Marilyn Morris
Vinay M. Nadkarni, MD
Jerry Nolan, MD
Jeffrey Perlman, MB, ChB
Lester T. Proctor, MD
Linda Quan, MD
Amelia Gorete Reis, PhD
Sam Richmond, MD
Antonio Rodriguez-Nuñez
Ricardo Samson, MD
Anthony J. Scalzo, MD
L.R. "Tres" Scherer III, MD
Stephen M. Schexnayder, MD
Charles L. Schleien, MD
Naoki Shimizu, MD, PhD
Paul M. Shore, MD
Vijay Srinivasan, MD
Edward R. Stapleton, EMT-P
James Tibballs, MD
Elise W. van der Jagt, MD, MPH
Arno Zaritsky, MD
David Zideman, MD
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FOOTNOTES |
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This report was copublished in Circulation. 2005;112:III-73–III-90; and Resuscitation. 2005;67:271–291.
The authors have indicated they have no financial relationships relevant to this article to disclose.
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REFERENCES |
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