Pediatric Basic and Advanced Life Support Guidelines


In late 2005, the Pediatrics Task Force of the International Liaison Committee on Resuscitation reviewed topics related to pediatrics resuscitation as well as addressed new issues and emerging science. The full pediatric basic life support (PBLS) and pediatrics advanced life support (PALS) guidelines can be accessed from the American Heart Association Web site at <www.circulationaha.org>. The present review by the Canadian Pediatric Society –Pediatric Emergency Medicine Section – highlights significant changes made to the recommendations for both PBLS and PALS guidelines for lay rescuers and health care providers. The new guidelines define infants as those younger than one year of age and define children as those one year of age until the onset of puberty. Neonatal resuscitation will not be discussed.


PBLS GUIDELINES: MAJOR CHANGES

Activating emergency medical services and retrieving the automated external defibrillator


A major change in the updated guidelines for the activation of emergency medical services (EMS) and the retrieval of an automated external defibrillator (AED) relate to their order relative to initiating cardiopulmonary resuscitation (CPR). In an unwitnessed or a non-sudden collapse, first responders are advised to initiate CPR immediately for five cycles (lasting approximately 2 min) before leaving to activate EMS and retrieve an AED (if lone care provider). In a witnessed sudden collapse, which evidence reveals is more likely to be related to a sudden pulseless arrhythmia, the lone responder is advised to activate EMS and retrieve an AED, before initiating CPR and attempting defibrillation.


Many AEDs are able to recognize shockable pediatric arrhythmias (wide complex tachycardia and ventricular fibrillation) and are equipped to deliver biphasic attenuated shocks that can be safely and effectively used in children older than one year of age. Therefore, the new recommendations for use of an AED apply to all children older than one year of age.


Breathing check

First responders are advised to open the airway using a head tilt or chin lift maneuver for all children and infants. Breathing effort is then assessed by sight, sound and touch for no more than 10 s. If the child or infant is not breathing, rescuers are advised to give two breaths, ensuring effective chest rise, before a pulse check.


Pulse check

Studies of both lay rescuers and health care providers reveal that both types of rescuers are often unable to accurately determine the presence of pulses within a 10 s period. Based on these studies, new recommendations state that lay rescuers should begin chest compressions on unresponsive infants and children who are not breathing after the initial two rescue breaths. By contrast, health care providers should attempt to find a pulse first and proceed to CPR if they cannot feel a pulse after 10 s of trying.


CPR (chest compressions and ventilation)

The most significant change in the 2005 resuscitation guidelines is the new emphasis placed on effective and adequate chest compressions. Several studies have shown that multiple chest compressions in sequence are needed to generate adequate coronary perfusion pressure, with any interruption in chest compressions resulting in inadequate coronary perfusion. In light of this, significant emphasis is placed on minimizing the interruption of chest compressions. The biggest change for children and infants is the compression-to-ventilation ratio. To simplify universal CPR skills retention, a universal compression-to-ventilation ratio of 30:2 is recommended for the lone rescuer. Rescuers should pause compressions when rescue breaths are given until there is an advanced airway in place. For two-rescuer CPR by health care providers, a compression-to-ventilation ratio of 15:2 is recommended. Once an advanced airway is established, chest compressions are no longer interrupted for ventilation and should be performed at a rate of at least 100 compressions/min. Hyperventilation has been shown to decrease venous return to the heart as well as decrease cerebral blood flow and coronary perfusion. In a pulseless patient, 8 breaths/min to 10 breaths/min should be given. In a patient with a pulse but no breath, 12 breaths/min to 20 breaths/min should be given. To ensure adequacy of compressions and avoid fatigue, the role of the chest compressor should be changed every 2 min.