Paediatric advanced life support

Advanced life support aims to maintain perfusion of the heart and brain in the context of a pulseless child, in whom basic life support is being carried out.

As with basic life support, attention should be paid to the areas of airway, breathing and circulation. In maintaing the latter drugs and cardioversion may be appropriate.

This section of GPnotebook provides a summary of aspects of paediatric advanced life support (ALS). The up-to-date guidelines concerning paediatric ALS must be consulted and can be accessed on the UK Resuscitation Council website www.resus.org.uk.

Some important changes in the 2010 update of the paediatric ALS guidelines were:

• adrenaline is given after the third shock for shockable rhythms and then during every alternate cycle (i.e. every 3-5 min during CPR). Adrenaline is still initially given as soon as vascular access is available in the nonshockable side of the algorithm.
• amiodarone is given after the third shock for shockable rhythms. The dose is repeated after the fifth shock, if still in ventricular fibrillation/pulseless VT (VF/VT).
• bag-mask ventilation remains the preferred method for achieving airway control and ventilation. If this fails, the laryngeal mask airway (or possibly other supraglottic airway device) is an acceptable alternative for suitably trained providers.
• once spontaneous circulation has been restored, delivered oxygen should be titrated to limit the risk of hyperoxaemia.
• CO2 detection (preferably with capnography) is even more strongly encouraged, not only to confirm placement of tracheal tubes but also to aid decision making during cardiopulmonary resuscitation (CPR) and management of ventilation after return of spontaneous circulation (ROSC).
• post-resuscitation care should include consideration of induced hypothermia.

Sequence of actions

1. Establish basic life support.

2. Oxygenate, ventilate, and start chest compression:

• provide positive-pressure ventilation with high-concentration inspired oxygen.
• provide ventilation initially by bag and mask. Ensure a patent airway by using an airway manoeuvre.
• if it can be performed by a highly skilled operator with minimal interruption to chest compressions, the trachea should be intubated. This will both control the airway and enable chest compression to be given continuously, thus improving coronary perfusion pressure.
• take care to ensure that ventilation remains effective when continuous chest compressions are started.
• use a compression rate of 100 - 120 min-1
• once the child has been intubated and compressions are uninterrupted, use a ventilation rate of approximately 10 - 12 min-1.

3. Attach a defibrillator or monitor:

• assess and monitor the cardiac rhythm.
• if using a defibrillator, place one defibrillator pad or paddle on the chest wall just below the right clavicle, and one in the mid-axillary line.
• pads or paddles for children should be 8 - 12 cm in size, and 4.5 cm for infants. In infants and small children it may be best to apply the pads or paddles to the front and back of the chest if they cannot be adequately separated in the standard positions.
• if used, place monitoring electrodes in the conventional chest positions.

4. Assess rhythm and check for signs of life:

• look for signs of life, which include responsiveness, coughing, and normal breathing.
• assess the rhythm on the monitor:
  • non-shockable (asystole or pulseless electrical activity (PEA)) OR
  • shockable (VF/VT).

5A. Non-shockable (asystole or PEA):

This is the more common finding in children.

• perform continuous CPR:
  • continue to ventilate with high-concentration oxygen.
  • if ventilating with bag-mask give 15 chest compressions to 2 ventilations.
  • use a compression rate of 100 - 120 min-1.
  • if the patient is intubated, chest compressions can be continuous as long as this does not interfere with satisfactory ventilation.
  • once the child has been intubated and compressions are uninterrupted use a ventilation rate of approximately 10 - 12 min-1.

Note: Once there is ROSC, the ventilation rate should be 12 - 20 min-1. Measure exhaled CO2 to monitor ventilation and ensure correct tracheal tube placement.

• give adrenaline:
  • if venous or intraosseous (IO) access has been established, give adrenaline 10 mcg kg-1 (0.1 ml kg-1 of 1 in 10,000 solution).
  • if there is no circulatory access, attempt to obtain IO access.
  • if circulatory access is not present, and cannot be obtained quickly, but the patient has a tracheal tube in place, consider giving adrenaline 100 mcg kg-1 via the tracheal tube. This is the least satisfactory route.
• continue CPR, only pausing briefly every 2 min to check for rhythm change.
• give adrenaline 10 mcg kg-1 every 3 to 5 min (i.e. every other loop), while continuing to maintain effective chest compression and ventilation without interruption.

Consider and correct reversible causes:

• Hypoxia
• Hypovolaemia
• Hyper/hypokalaemia (electrolyte disturbances)
• Hypothermia
• Tension pneumothorax
• Toxic/therapeutic disturbance
• Tamponade (cardiac)
• Thromboembolism

Consider the use of other medications such as alkalising agents.

5B. Shockable (VF/VT)
This is less common in paediatric practice but may occur as a secondary event and is likely when there has been a witnessed and sudden collapse. It is commoner in the intensive care unit and cardiac ward.

• Continue CPR until a defibrillator is available.
• Defibrillate the heart:
  • charge the defibrillator while another rescuer continues chest compressions.
  • once the defibrillator is charged, pause the chest compressions, quickly ensure that all rescuers are clear of the patient and then deliver the shock. This should be planned before stopping compressions.
  • give 1 shock of 4 J kg-1 if using a manual defibrillator.
  • if using an AED for a child of less than 8 years, deliver a paediatric-attenuated adult shock energy.
  • if using an AED for a child over 8 years, use the adult shock energy.
• Resume CPR:
  • without reassessing the rhythm or feeling for a pulse, resume CPR immediately, starting with chest compression.
  • consider and correct reversible causes (4Hs and 4Ts).
• Continue CPR for 2 min, then pause briefly to check the monitor:
  • if still VF/VT, give a second shock (with same energy level and strategy for delivery as the first shock).
• Resume CPR:
  • without reassessing the rhythm or feeling for a pulse, resume CPR immediately, starting with chest compression.
• Continue CPR for 2 min, then pause briefly to check the monitor:
• If still VF/VT, give a third shock (with same energy level and strategy for delivery as the previous shock).
• Resume CPR:
  • without reassessing the rhythm or feeling for a pulse, resume CPR immediately, starting with chest compression.
  • give adrenaline 10 mcg kg-1 and amiodarone 5 mg kg-1 after the 3rd shock, once chest compressions have resumed.
  • repeat adrenaline every alternate cycle (i.e. every 3-5 min) until ROSC.
  • repeat amiodarone 5 mg kg-1 one further time, after the 5th shock if still in a shockable rhythm.

Continue giving shocks every 2 min, continuing compressions during charging of the defibrillator and minimising the breaks in chest compression as much as possible.
Note: After each 2 min of uninterrupted CPR, pause briefly to assess the rhythm.

• if still VF/VT:
  • continue CPR with the shockable (VF/VT) sequence.
• if asystole:
  • continue CPR and switch to the non-shockable (asystole or PEA) sequence.
• if organised electrical activity is seen, check for signs of life and a pulse:
  • if there is ROSC, continue post-resuscitation care.
  • if there is no pulse (or a pulse rate of < 60 min-1), and there are no other signs of life, continue CPR and continue as for the non-shockable sequence above.

If defibrillation was successful but VF/VT recurs, resume the CPR sequence and defibrillate. Give an amiodarone bolus (unless 2 doses have already been given) and start a continuous infusion.

Reference:

1. Resuscitation Council (UK). Resuscitation Guidelines 2010.