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Pediatric Emergency Planning and Resuscitation 

Pediatric Emergency Planning and Resuscitation
Author(s):

Shawn S. Jackson

and Richard D. Urman

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Introduction

Anesthesiologists are completing more and more cases outside the operating room (OR), a trend that is true for both pediatric and adult patients. Beyond the OR, anesthesiologists are frequently involved in the endoscopy suite, helping to provide sedation for the placement of peripherally inserted central catheter (PICC) lines or other bedside procedures and helping to ensure safe imaging studies in radiology. As the number of out-of-OR encounters involving the pediatric population increases, a focus on the prevention and management of emergency situations becomes even more important. As resources outside the OR can often be significantly more limited, careful planning and an understanding of resuscitation guidelines are critical for providers taking care of pediatric patients.

The newest American Heart Association (AHA) guidelines for cardiopulmonary resuscitation and emergency cardiovascular care focus on several key areas:

  • Prevention of pediatric arrests, including additional team-based training. Development and use of rapid response teams (RRTs) or medical emergency teams (METs).

  • A focus on high-quality cardiopulmonary resuscitation (CPR), starting with chest compressions and then including breaths.

  • Early access to advanced life support (ALS) care and algorithms

Prevention of Pediatric Arrest

Prevention of pediatric cardiopulmonary arrest has become a focal point of basic life support (BLS) and pediatric advanced life support (PALS) guidelines over the past 5-years.1,2 While a significant amount of research has focused on high-risk medical and surgical patients who are admitted to the hospital,3,4 many of these same principals and goals can be applied to the pediatric population outside the OR. Areas of emphasis for the prevention of pediatric arrests can be broadly divided into two main areas: first, stratifying and minimizing risk, especially with the increasing demand of out-of-OR sedation cases5; and second, developing and training with pediatric RRTs or METs that may respond to out-of-OR periarrest situations, as opposed to the more typical “anesthesia stat” encountered in the OR.

With regard to the prevention of pediatric arrest situations, several groups, including the American Society of Anesthesiologists (ASA) as well as the American Academy of Pediatrics, have published guidelines for use in establishing out-of-OR anesthesia and sedation practices. Several of the important guidelines include: consistent use of standard ASA monitors, even with minimal sedation cases; use of pre-sedation and pre-anesthesia checklists prior to administration of medications; and the development of algorithms for common periarrest situations (airway obstruction, laryngospasm, bradycardia).

The development of RRTs or METs has also proved to be an important part of addressing periarrest situations and preventing escalation to a full cardiopulmonary arrest.6 While the size and makeup of such pediatric emergency response teams would vary depending on the caseload and facility size and makeup, it is reasonable to establish a defined team to respond to pediatric out-of-OR emergencies and implement formal team-based training, when possible.

Pediatric Basic Life Support

The 2015 pediatric BLS algorithm (Figure A5.1) not only shares many similarities with previous versions but also includes some key differences. As in previous versions, the algorithm defines infants as those less than 1 year old and children as those between 1 year old and puberty. A major focus of the updated BLS protocol is to decrease the time between recognition of an emergency event and implementation of high-quality CPR. To decrease this amount of time, the AHA now recommends the CAB approach to CPR, whereby compressions are performed initially and then followed by airway and breathing. In addition, the previous recommendations to “look, listen, and feel” for breathing have also been eliminated, again to decrease the amount of time between recognition of an emergency and implementation of high-quality CPR.

Figure A5.1 2015 Basic Life Support Algorithm—2015 algorithm as published by the AHA.

Figure A5.1 2015 Basic Life Support Algorithm—2015 algorithm as published by the AHA.

(reprinted with permission.)

The pediatric BLS algorithm starts with recognition of an emergency situation. After ensuring that the environment is safe for a rescuer to intervene (scene safety), the emergency response system is activated, preferably by a bystander or second rescuer. If an automated external defibrillator (AED) is available on site, the person who activated the emergency response system should also retrieve the AED. After activation of the emergency response system, the patient should be assessed. The rescuer should assess for breathing while simultaneously checking for a pulse. This assessment should last no more than 10 seconds. If the patient is breathing normally and has a pulse, the patient should be closely monitored by the rescuer until additional resources arrive. If the patient has a pulse but is not breathing (or not breathing effectively), rescue breaths should be administered a rate of one breath every 3–5 seconds, or about 12–20 breaths per minute. If the patient is not breathing and does not have a pulse, CPR should begin immediately.

High-quality pediatric CPR begins with chest compressions and follows the CAB approach. While respiratory emergencies are by far the most common reason for cardiopulmonary arrest in the pediatric population, the AHA recommends starting with compressions to decrease the amount of time before effective CPR is initiated. For single-rescuer CPR in the pediatric population, a ratio of 30:2 (30 compressions followed by two breaths) should be utilized. If a second rescuer is available, a ratio of 15:2 should be employed (Table A5.1). Good chest compressions should be at a rate of 100–120 beats per minute. Compressions should take place at the lower half of the sternum, between the nipples, and be of sufficient force to depress the sternum one-third of the anterior-posterior (AP) distance. Adequate recoil of the sternum should be allowed to maximize circulation of blood throughout the body. Rescuers should remember to “push fast and push hard.” In infants, the current recommendations are to use the two-finger technique (usually the second and third digits) to provide chest compressions if one rescuer is available and the two-thumb–encircling hands technique if two or more rescuers are available. In children, the heel of one hand should be used with the second hand placed over the first.

Table A5.1. BLS Rescue Breathing and Chest Compression Guidelines

Rescue Breathing (No Compressions)

Chest Compression

Single-Rescuer CPR Ratio

Two-Rescuer CPR Ratio

Pediatric

12–20/min

One-third the anteroposterior dimension; 100–120 compressions/min

30:2 (compressions to breaths)

15:2 (compressions to breaths)

Adult

10–12/min

At least 2 inches. 100-120 compressions/min

30:2 (compressions to breaths)

30:2 (compressions to breaths)

Rescue breathing, whether used alone (for patients with a pulse) or as part of CPR, is a critical component of BLS. The pediatric airway differs in several ways from the adult, increasing the risk of obstruction. To help ensure adequate ventilation, rescuers should adopt the head tilt, chin lift maneuver or the jaw thrust, especially useful if there is concern for a traumatic injury to the cervical spine. The delivery of breaths is best accomplished using a bag-valve-mask (when two rescuers are available) connected to an oxygen reservoir. In the event only a single rescuer is available, mouth-to-mask or mouth-to-mouth resuscitation is also appropriate. Breaths should be delivered over the time period of 1 second and should be sufficient to see chest rise. If chest rise is not visualized, the airway should be repositioned as it may indicate signs of an airway obstruction. In an out-of-OR location, end-tidal CO2 is the gold standard for monitoring ventilation.

If an AED becomes available during CPR, it should be utilized at the earliest opportunity. While continuing appropriate cycles of compressions and breaths, the AED should be opened and the instructions (typically given by voice as soon as the AED is opened or turned on) followed. It is recommended to apply AED pads while compressions and breaths are going. CPR should only be interrupted once prompted by the AED that it is about to analyze the heart rhythm. For children or infants, it is preferable to use appropriate AED pads when they are available. However, the use of adult pads is acceptable if no alternative is available. If the AED analyzes the heart rhythm and determines that a shock is indicated, rescuers should clear the patient and deliver a shock. CPR should immediately begin after shock delivery. A pulse should be checked after approximately 2 minutes, an event that is typically prompted by the AED. If no shock is indicated and the patient still does not have a pulse, CPR should be continued until ALS providers arrive.

Pediatric Advanced Life Support

Pediatric advanced life support is a continuation of the principles and guidelines of BLS. In addition to these benefits, PALS adds additional team roles for a multifaceted approach to patient care. Some of these team roles include acting as a team leader, establishing intravenous/intraosseous access, providing chest compressions, administering medications, delivering ventilation and establishing advanced airway access, acting as the code recorder, and managing the defibrillator. These team members come together to deliver care as part of the PALS algorithm. To help achieve team goals, good team members use closed-loop communication, communicate with clear messages, and have clear roles/responsibilities.

The PALS guidelines are broken up into several different algorithms (Figure A5.2). The cardiac arrest algorithm is described in further detail. The most important part of the algorithm is high-quality CPR, discussed previously. While high-quality CPR is ongoing, the patient is attached to a cardiac monitor/defibrillator, and the rhythm is evaluated during a break in CPR (pulse check). The rhythm is categorized into a shockable rhythm, which includes ventricular fibrillation or pulseless ventricular tachycardia, or a nonshockable rhythm, which includes asystole or pulseless electrical activity (PEA).

Figure A5.2 2015 Pediatric Advanced Life Support (PALS) Algorithm—2015 algorithm as published by the AHA.

Figure A5.2 2015 Pediatric Advanced Life Support (PALS) Algorithm—2015 algorithm as published by the AHA.

(reprinted with permission.)

Shockable rhythms are treated with a combination of high-quality CPR, intravenous/intraosseous medications, and defibrillation. Early defibrillation is a critical component of this pathway. The recommended setting of defibrillation is weight based, with initial shocks at 2–4 J/kg and subsequent doses greater or equal to 4 J/kg. It is recommended not to exceed 10 J/kg (or the adult dose), even with refractory ventricular fibrillation or pulseless ventricular tachycardia. In addition to defibrillation, medications, including epinephrine 0.01 mg/kg every 3–5 minutes, can be administered. For refractory ventricular fibrillation and pulseless ventricular tachycardia, amiodarone 5 mg/kg and lidocaine 1 mg/kg should also be considered. Defibrillation should be repeated every 2 minutes during pulse checks provided the patient is still in a shockable rhythm.

Nonshockable rhythms are treated with a combination of high-quality CPR and intravenous/intraosseous medications. Unlike ventricular fibrillation and pulseless ventricular tachycardia, there is no role for defibrillation for asystole or PEA arrest. Epinephrine 0.01 mg/kg can be repeated every 3–5 minutes, and the patient should continuously be re-evaluated at pulse checks as the patient may develop a shockable rhythm while undergoing CPR.

In addition to high-quality CPR, medications, and defibrillation, PALS highlights the evaluation and treatment of reversible causes that may lead to cardiac arrest. The H’s and T’s are frequently used to help providers remember these causes and include hypovolemia, hypoxia, hyper- and hypokalemia, hypothermia, hydrogen ion (acidosis), hypoglycemia, toxins, tension pneumothorax, thrombosis (pulmonary or cardiac), and cardiac tamponade. The team leader and other team members should keep these reversible causes in mind and discuss them during code summaries to ensure one of these causes is not missed.

The placement of an advanced airway is also considered in PALS. An endotracheal tube or supraglottic airway is frequently employed during a pediatric arrest. Once an advanced airway has been placed, the 15:2 ratio utilized in CPR is replaced with continuous chest compressions and breaths delivered six gramatically (10 breaths per minute). In addition, an advanced airway provides the opportunity to monitor end-tidal CO2 (EtCO2). A target EtCO2 during effective CPR should exceed 15 mm Hg, and values less than this should encourage the team to focus on increasing the quality of CPR.

Summary

Pediatric resuscitation guidelines are a key aspect of reducing morbidity and mortality. This is equally, if not more, critical in an out-of-OR environment. The first step is to take measures to reduce and plan for pediatric periarrest situations, including reducing risk and establishing teams or responders who can quickly help in an emergency. Rapid implementation of effective BLS is critical, beginning with chest compressions and then delivering rescue breaths as part of the new emphasis on CAB instead of ABC when performing CPR. Activation of the emergency response and implementation of more advanced PALS protocols, including early defibrillation when indicated, are the next steps to improve outcomes. Overall, when these guidelines are taken together, outcomes can be improved, whether one is practicing in or out of the OR, on an inpatient unit, or outside of the hospital.

References

1. de Caen AR, Berg MD, Chameides L, et al. Pediatric advanced life support: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132: S526–S542. doi:10.1161/CIR.0000000000000266.Find this resource:

2. Atkins DL, Berger S, Duff JP, et al. Pediatric basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132:S519–S525. doi:10.1161/CIR.0000000000000265.Find this resource:

3. McLellan MC, Gauvreau K, Connor JA. Validation of the Cardiac Children’s Hospital Early Warning Score: an early warning scoring tool to prevent cardiopulmonary arrests in children with heart disease. Congenit Heart Dis. 2014;9(3):194–202. doi:10.1111/chd.12132.Find this resource:

4. Acker SN, Wathen B, Roosevelt GE, et al. Rapid response team activations in pediatric surgical patients. Eur J Pediatr Surg. 2016;(EFirst). doi:10.1055/s-0036-1593384.Find this resource:

    5. Coté CJ, Wilson S, American Academy of Pediatrics, American Academy of Pediatric Dentistry. Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures: update 2016. Pediatrics. 2016;138(1):e20161212. doi:10.1542/peds.2016-1212.Find this resource:

    6. Sharek PJ, Parast LM, Leong K, et al. Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a Children’s Hospital. JAMA. 2007;298(19):2267–2274. doi:10.1001/jama.298.19.2267.Find this resource:

    BLS, basic life support; CPR, cardiopulmonary resuscitation.Find this resource: