Basic and advanced paediatric cardiopulmonary resuscitation - guidelines of the Australian and New Zealand Resuscitation Councils 2010

Guidelines for basic and advanced paediatric cardiopulmonary resuscitation (CPR) have been revised by Australian and New Zealand Resuscitation Councils. Changes encourage CPR out-of-hospital and aim to improve the quality of CPR in-hospital. Features of basic CPR include: omission of abdominal thrusts for foreign body airway obstruction; commencement with chest compression followed by ventilation in a ratio of 30:2 or compression-only CPR if the rescuer is unwilling/unable to give expired-air breathing when the victim is 'unresponsive and not breathing normally'. Use of automated external defibrillators is encouraged. Features of advanced CPR include: prevention of cardiac arrest by rapid response systems; restriction of pulse palpation to 10 s to diagnosis cardiac arrest; affirmation of 15:2 compression-ventilation ratio for children and for infants other than newly born; initial bag-mask ventilation before tracheal intubation; a single direct current shock of 4 J/kg for ventricular fibrillation (VF) and pulseless ventricular tachycardia followed by immediate resumption of CPR for 2 min without analysis of cardiac rhythm and avoidance of unnecessary interruption of continuous external cardiac compressions. Monitoring of exhaled carbon dioxide is recommended to detect non-tracheal intubation, assess quality of CPR, and to help match ventilation to reduced cardiac output. The intraosseous route is recommended if immediate intravenous access is impossible. Amiodarone is strongly favoured over lignocaine for refractory VF and adrenaline over atropine for severe bradycardia, asystole and pulseless electrical activity. Family presence at resuscitation is encouraged. Therapeutic hypothermia is acceptable after resuscitation to improve neurological outcome. Extracorporeal circulatory support for in-hospital cardiac arrest may be used in equipped centres.     

Pediatric Cardiopulmonary Resuscitation and Stabilization

Cardiopulmonary arrest refers to cessation of clinically detectable cardiac activity. In children, it usually results from progression of shock, respiratory failure or cardiac dysrhythmia. Early recognition and timely interventions in above group of patients is the key to prevent progression to cardiac arrest. The goal of resuscitation is to urgently re-establish oxygenation of vital organs by attention to Airway, Breathing and Circulation. Measures to restore airway patency include positioning, suctioning, continuous positive airway pressure, relieving a foreign-body airway obstruction and, endotracheal intubation, tracheotomy or laryngeal mask airway. Breathing is supported with O₂ and if needed, bag-mask ventilation, or endotracheal intubation and ventilation. Patients with absent or feeble central pulse are given cardiac compressions (CPR) at a rate of 100/ min synchronized with ventilation. In sudden witnessed collapse, immediate defibrillation is warranted, followed by CPR and administration of drugs. In unwitnessed collapse, CPR is performed for five cycles or 2 min before defibrillation. In patients with shock, a venous or an intraosseous access is rapidly established to administer 20 ml/kg saline bolus. Supraventricular tachycardia is treated with vagal maneuvers and adenosine, if the patient is stable and with synchronized cardioversion, if unstable. Ventricular tachycardia is treated with amiodarone or lidocaine, if stable, and cardioversion if unstable or if drugs fail. Ventricular fibrillation needs defibrillation. Aggressive supportive care is needed during the post-resuscitation phase. There is no definite marker to determine futility of CPR. Short duration of arrest, early initiation of CPR, hypothermia as the cause of arrest, and in-hospital arrest have better prognosis.     

New Australian Neonatal Resuscitation Guidelines

New Australian Neonatal Resuscitation Guidelines highlight the recent advances in neonatal resuscitation. Resuscitation should start with air and only use oxygen if the infant does not respond. CPAP and PEEP should be considered for premature infants with meconium stained liquor. Sucking out the mouth and nose is not necessary. Infants less than 28 weeks gestation should be placed in a polyethylene bag or wrap to keep warm. Chest compressions, when required, remain at 3:1 inflation. The endotracheal tube position must be verified with a carbon dioxide detector.     

2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: pediatric basic life support

This publication presents the 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of the pediatric patient and the 2005 American Academy of Pediatrics/AHA guidelines for CPR and ECC of the neonate. The guidelines are based on the evidence evaluation from the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, hosted by the American Heart Association in Dallas, Texas, January 23-30, 2005. The "2005 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care" contain recommendations designed to improve survival from sudden cardiac arrest and acute life-threatening cardiopulmonary problems. The evidence evaluation process that was the basis for these guidelines was accomplished in collaboration with the International Liaison Committee on Resuscitation (ILCOR). The ILCOR process is described in more detail in the "International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations." The recommendations in the "2005 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care" confirm the safety and effectiveness of many approaches, acknowledge that other approaches may not be optimal, and recommend new treatments that have undergone evidence evaluation. These new recommendations do not imply that care involving the use of earlier guidelines is unsafe. In addition, it is important to note that these guidelines will not apply to all rescuers and all victims in all situations. The leader of a resuscitation attempt may need to adapt application of the guidelines to unique circumstances. The following are the major pediatric advanced life support changes in the 2005 guidelines: There is further caution about the use of endotracheal tubes. Laryngeal mask airways are acceptable when used by experienced providers. Cuffed endotracheal tubes may be used in infants (except newborns) and children in in-hospital settings provided that cuff inflation pressure is kept <20 cm H2O. Confirmation of tube placement requires clinical assessment and assessment of exhaled carbon dioxide (CO2); esophageal detector devices may be considered for use in children weighing >20 kg who have a perfusing rhythm. Correct placement must be verified when the tube is inserted, during transport, and whenever the patient is moved. During CPR with an advanced airway in place, rescuers will no longer perform "cycles" of CPR. Instead, the rescuer performing chest compressions will perform them continuously at a rate of 100/minute without pauses for ventilation. The rescuer providing ventilation will deliver 8 to 10 breaths per minute (1 breath approximately every 6-8 seconds). Timing of 1 shock, CPR, and drug administration during pulseless arrest has changed and now is identical to that for advanced cardiac life support. Routine use of high-dose epinephrine is not recommended. Lidocaine is de-emphasized, but it can be used for treatment of ventricular fibrillation/pulseless ventricular tachycardia if amiodarone is not available. Induced hypothermia (32-34 degrees C for 12-24 hours) may be considered if the child remains comatose after resuscitation. Indications for the use of inodilators are mentioned in the postresuscitation section. Termination of resuscitative efforts is discussed. It is noted that intact survival has been reported following prolonged resuscitation and absence of spontaneous circulation despite 2 doses of epinephrine. The following are the major neonatal resuscitation changes in the 2005 guidelines: Supplementary oxygen is recommended whenever positive-pressure ventilation is indicated for resuscitation; free-flow oxygen should be administered to infants who are breathing but have central cyanosis. Although the standard approach to resuscitation is to use 100% oxygen, it is reasonable to begin resuscitation with an oxygen concentration of less than 100% or to start with no supplementary oxygen (ie, start with room air). If the clinician begins resuscitation with room air, it is recommended that supplementary oxygen be available to use if there is no appreciable improvement within 90 seconds after birth. In situations where supplementary oxygen is not readily available, positive-pressure ventilation should be administered with room air. Current recommendations no longer advise routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants born to mothers with meconium staining of amniotic fluid. Endotracheal suctioning for infants who are not vigorous should be performed immediately after birth. A self-inflating bag, a flow-inflating bag, or a T-piece (a valved mechanical device designed to regulate pressure and limit flow) can be used to ventilate a newborn. An increase in heart rate is the primary sign of improved ventilation during resuscitation. Exhaled CO2 detection is the recommended primary technique to confirm correct endotracheal tube placement when a prompt increase in heart rate does not occur after intubation. The recommended intravenous (IV) epinephrine dose is 0.01 to 0.03 mg/kg per dose. Higher IV doses are not recommended, and IV administration is the preferred route. Although access is being obtained, administration of a higher dose (up to 0.1 mg/kg) through the endotracheal tube may be considered. It is possible to identify conditions associated with high mortality and poor outcome in which withholding resuscitative efforts may be considered reasonable, particularly when there has been the opportunity for parental agreement. The following guidelines must be interpreted according to current regional outcomes: When gestation, birth weight, or congenital anomalies are associated with almost certain early death and when unacceptably high morbidity is likely among the rare survivors, resuscitation is not indicated. Examples are provided in the guidelines. In conditions associated with a high rate of survival and acceptable morbidity, resuscitation is nearly always indicated. In conditions associated with uncertain prognosis in which survival is borderline, the morbidity rate is relatively high, and the anticipated burden to the child is high, parental desires concerning initiation of resuscitation should be supported. Infants without signs of life (no heartbeat and no respiratory effort) after 10 minutes of resuscitation show either a high mortality rate or severe neurodevelopmental disability. After 10 minutes of continuous and adequate resuscitative efforts, discontinuation of resuscitation may be justified if there are no signs of life.     

PALS update 2005

Many of the changes in BLS recommended in 2005 Guidelines are designed to simplify CPR recommenda-tions, increase the number and quality of chest compressions delivered, and increase the number of uninterrupted chest compressions. The recommendations for compressions have been summarized as, Push harder, push faster, allow the chest to fully recoil, and stop only to use a bag mask to ventilate the patient, analyze the rhythm, deliver a shock or intubate. When such an interruption to compressions occurs, keep the length of that interruption to an absolute minimum. For lay rescuers, a single compression-ventilation ratio (30:2) for all age groups greatly simplifies the instructions for performing CPR. Recommendation of 1 Shock plus Immediate CPR for Attempted Defibrillation for cardiac arrest associated with VF or pulseless VT. Rescuers should not interrupt chest compressions to check circulation until about 5 cycles or approximately 2 minutes of CPR have been provided after the shock. The changes are designed to minimize interruptions in chest compressions. For Neonatal resuscitation, additional evidence was available about the use of oxygen versus room air for resuscitation, the need for clearing the airway of meconium, methods of assisting ventilation, techniques for confirming endotracheal tube placement, and use of the laryngeal mask airway (LMA).     

Australian and New Zealand Committee on Resuscitation Neonatal Resuscitation guidelines 2016

New Australian and New Zealand Neonatal Resuscitation guidelines reflect recent advances in neonatal resuscitation science, as critically appraised by the International Liaison Committee on Resuscitation. Substantial changes since the 2010 guidelines include: (i) updates to the Newborn Resuscitation Flowchart to include a greater emphasis on maintaining normal body temperature, and to emphasise the importance of beginning assisted ventilation by 1 min in infants who have absent or ineffective spontaneous breathing; (ii) updates to the physiology of the normal perinatal transition that resuscitation is trying to restore; (iii) recommendations for more frequent reinforcement of training, and for structured feedback for resuscitation training instructors; (iv) new guidance in relation to the timing of cord clamping for preterm newborn infants; (v) recommendation to monitor body temperature on admission to newborn units as a resuscitation quality indicator; (vi) suggestion to consider electrocardiographic (ECG) monitoring (as an adjunct to oximetry) to obtain more rapid and accurate estimation of heart rate during resuscitation; (vii) removal of previous suggestions to intubate meconium‐exposed, non‐vigorous term infants to suction the trachea; and (viii) suggestion to establish vascular access to enable administration of intravenous adrenaline (epinephrine) as soon as chest compressions are deemed to be needed.     

Neonatal resuscitation

At birth approximately 10 % of term or near-term neonates require initial stabilization maneuvers to establish a cry or regular breathing, maintain a heart rate greater than 100 beats per minute (bpm), and good color and muscular tone. About 1 % requires ventilation and very few infants receive chest compressions or medication. However, birth asphyxia is a worldwide problem and can lead to death or serious sequelae. Recently, the European Resuscitation Council (ERC) and the International Liaison Committee on Resuscitation (ILCOR) published new guidelines on resuscitation at birth. These guidelines review specific questions such as the use of air or 100 % oxygen in the delivery room, dose and routes of adrenaline delivery, the peripartum management of meconium-stained amniotic fluid, and temperature control. Assisted ventilation in preterm infants is briefly described. New devices to improve the care of newborn infants, such as the laryngeal mask airway or CO2 detectors to confirm tracheal tube placement, are also discussed. Significant changes have occurred in some practices and are included in this document.     

Drugs in the delivery room

The need for cardiopulmonary resuscitation in newborns is quite rare, as most non-vigorous infants respond well to effective ventilation. For the minority of babies who do not respond to adequate ventilation, chest compressions are necessary using the preferred two thumb technique. Since effective ventilation remains a key component to successful resuscitation, chest compressions are coordinated with ventilations in a 3:1 ratio. If despite adequate ventilation and compressions, the heart rate remains below 60 beats per minute, epinephrine is indicated. The intravenous route is preferred over the endotracheal route and the recommended dose of epinephrine is 0.01–0.03 mg/kg. This can be repeated every 3–5 min until return of spontaneous circulation is achieved. In rare instances, when there is no response to these above measures and in infants who show evidence of significant hypovolemia, volume replacement should be considered.     

Favourable neurological outcomes following delivery room cardiopulmonary resuscitation of infants < or = 750 g at birth

OBJECTIVE: To study short- and long-term outcomes of infants < or = 750 g birthweight who received cardiopulmonary resuscitation (CPR) in the delivery room. METHODOLOGY: A retrospective analysis of all inborn live births < or = 750 g birthweight from 1990 to 1996. Cardiopulmonary resuscitation was defined as positive pressure ventilation via an endotracheal tube and chest compressions. Univeriate analysis were conducted comparing patients according to the use of CPR or positive pressure ventilation alone. RESULTS: Cardiopulmonary resuscitation was administered to 16 infants: four received chest compressions only and 12 also received adrenaline. Cardiopulmonary resuscitation recipients had significantly lower Apgar scores at both 1 and 5 min, and had delayed onset of spontaneous respiration (P < 0.01). Seven patients died, and eight of nine survivors were free of major neurodevelopmental abnormalities at follow up. All CPR recipients with a 5 min Apgar score of < or = 5 and delayed onset of spontaneous respiration beyond 5 min had poor outcomes. CONCLUSION: Contrary to the majority of published evidence, delivery room CPR in our extremely small infants was not associated with a high risk of severe neurodevelopmental disability.     

What to do if A + B doesn't work

The majority of newborn resuscitations require very little beyond simple airway management and assisted ventilation. If cardiovascular collapse is serious enough to warrant additional support, resuscitation algorithms recommend moving to chest compressions and then on to medications and possibly volume replacement if vital signs remain marginal or absent. The evidence base upon which this part of the neonatal resuscitation algorithm is structured is sparse. Chest compressions and medications are rare interventions that do not lend themselves easily to clinical trials. Slowly but surely, however, the genesis of an empirical evidence base for this part of the algorithm is beginning to appear.     

Perinatal Physiology and Principles of Neonatal Resuscitation

Occasionally, deliveries occur in extramural settings or in the ED. These newborn infants are often brought to the emergency physician for initial stabilization. Rapid decision making based on periodic evaluation of heart rate, respiration, and color will determine need for and appropriate steps of resuscitation. Ventilation of the lungs is the key and improvement in heart rate is the best sign of successful neonatal resuscitation. Emergency physicians should be familiar with the principles and basics of neonatal resuscitation and maintain these skills with frequent mock codes.     

Blood flow during cardiopulmonary resuscitation with simultaneous compression and ventilation in infant pigs

We determined whether the simultaneous chest compression and ventilation (SCV) technique of cardiopulmonary resuscitation (CPR) enhances cerebral (CBF) and myocardial (MBF) blood flows and cerebral O2 uptake in an infant swine model of CPR as it does in most adult animal CPR models. We also tested whether SCV-CPR sustains CBF and MBF for prolonged periods of CPR when these flows ordinarily deteriorate. CPR was performed in two groups (n = 8) of pentobarbital anesthetized piglets (3.5-5.5 kg) with continuous epinephrine infusion (10 micrograms/kg/min). Conventional CPR was performed at 100 compressions/min, 60% duty cycle, 1:5 breath to compression ratio and 25-30 mm Hg peak airway pressure. SCV-CPR was performed at 60 compressions/min, 60% duty cycle and 60 mm Hg peak airway pressure applied during each chest compression. Peak right atrial and aortic pressures in excess of 80 mm Hg were generated during CPR in both groups. At 5 min of conventional and SCV-CPR, MBF was 38 +/- 7 and 46 +/- 7 mL.min-1.100 g-1 (+/- SE), respectively, and CBF was 15 +/- 3 and 13 +/- 2 mL.min1. 100 g-1, respectively. However, as CPR was prolonged to 50 min, the sternum progressively lost its recoil and the chest became more deformed. Lung inflation at high airway pressure with SCV-CPR did not prevent this chest deformation. Aortic pressure gradually declined, whereas right atrial and intracranial pressure remained constant in both groups. Consequently, MBF and CBF fell less than 10 mL.min-1.100 g-1 and cerebral O2 uptake was markedly impaired during prolonged conventional and SCV-CPR.(ABSTRACT TRUNCATED AT 250 WORDS)     

Resuscitation of the term and premature baby

Although most newly born babies establish normal respiration and circulation without help, up to 1−2% may require some resuscitation or stabilization. Babies who do not establish adequate regular normal breathing or who have a heart rate of less than 100 beats/min or other problems such as prematurity may require assistance. The differences in approach to the resuscitation of such babies originate in the physiology and pathophysiology of acute asphyxia at birth. However, management of airway and breathing remain the key features of resuscitation and where cardiac depression has occurred, this is nearly always due to hypoxia secondary to respiratory compromise. Therefore, most babies will respond within 2−3 min of effective aeration of the lungs and the need for intubation, chest compressions or drugs is rare. The International Liaison Committee on Resuscitation (ILCOR) evaluated evidence in 2000 and 2005 in order to provide guidelines for resuscitation: they will do so again for 2010. This evidence is limited in terms of both quantity and quality and controversies still exist. More research is needed to ensure that our future actions are based upon evidence rather than history. This article will review the recommended approach to resuscitation as well as some newer evidence.     

Chest compressions in an infant with osteogenesis imperfecta type II: No new rib fractures

The case report of a newborn female with osteogenesis imperfecta type II who underwent cardiopulmonary resuscitation (CPR) with manual chest compressions for several minutes is presented. Chest radiographs taken before and after the chest compressions were administered were reviewed by several radiologists from 3 different hospitals and demonstrated no new radiographically visible rib fractures. Collagen analysis, the patient's clinical appearance, and clinical course, as well as a consultant's opinion aided in confirmation of the diagnosis of osteogenesis imperfecta type II. A review of 4 previous studies concerning rib fractures and CPR is included. This unique case supports previous articles that have concluded that rib fractures rarely, if ever, result from CPR in pediatrics, even in children with a lethal underlying bone disease, such as osteogenesis imperfecta type II. cardiopulmonary resuscitation, chest compressions, osteogenesis imperfecta, rib fractures, bone disease.     

Neonatal resuscitation 3: manometer use in a model of face mask ventilation

BACKGROUND: Adequate ventilation is the key to successful neonatal resuscitation. Positive pressure ventilation (PPV) is initiated with manual ventilation devices via face masks. These devices may be used with a manometer to measure airway pressures delivered. The expiratory tidal volume measured at the mask (V(TE(mask))) is a good estimate of the tidal volume delivered during simulated neonatal resuscitation. AIM: To assess the effect of viewing a manometer on the peak inspiratory pressures used, the volume delivered, and leakage from the face mask during PPV with two manual ventilation devices in a model of neonatal resuscitation. METHODS: Participants gave PPV to a modified resuscitation mannequin using a Laerdal infant resuscitator and a Neopuff infant resuscitator at specified pressures ensuring adequate chest wall excursion. Each participant gave PPV to the mannequin with each device twice, viewing the manometer on one occasion and unable to see the manometer on the other. Data from participants were averaged for each device used with the manometer and without the manometer separately. RESULTS: A total of 7767 inflations delivered by the 18 participants were recorded and analysed. Peak inspiratory pressures delivered were lower with the Laerdal device. There were no differences in leakage from the face mask or volumes delivered. Whether or not the manometer was visible made no difference to any measured variable. CONCLUSIONS: Viewing a manometer during PPV in this model of neonatal resuscitation does not affect the airway pressure or tidal volumes delivered or the degree of leakage from the face mask.     

Resuscitation of the term and preterm infant

The vast majority of newborn infants make the transition from intrauterine to extrauterine life uneventfully, however there are a significant number who do require some assistance to make this transition. The unique physiology at this time needs to be taken into account when commencing resuscitation efforts. When a newborn infant requires assistance to make the transition to extrauterine life this usually takes the form of basic airway and breathing management, with more advanced airway management and chest compressions needed in fewer cases and pharmacological support only needed in rare cases.     

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??Asphyxia is a major cause of neonatal death and serious sequelae of nervous system. Timely evaluation and proper strategies are crucial to successful neonatal resuscitation. In October 2015??the neonatal resuscitation group of the American Academy of Pediatrics published updated guidelines for neonatal resuscitation. The guideline updated information on fast evaluation items??delayed ligation of the umbilical cord??intratracheal suction for neonates with meconium-contaminated amniotic fluid??oxygen for resuscitation of preterm infants and positive pressures ventilation. Meanwhile the guideline suggested that resuscitation training should be more frequent than the current interval of two years.     

Neonatal Resuscitation in the Delivery Room from a Tertiary Level Hospital: Risk Factors and Outcome

Objective

Timely identification and prompt resuscitation of newborns in the delivery room may cause a decline in neonatal morbidity and mortality. We try to identify risk factors in mother and fetus that result in birth of newborns needing resuscitation at birth.

Methods

Case notes of all deliveries and neonates born from April 2010 to March 2011 in Mahdieh Medical Center (Tehran, Iran), a Level III Neonatal Intensive Care Unit, were reviewed; relevant maternal, fetal and perinatal data was extracted and analyzed.

Findings

During the study period, 4692 neonates were delivered; 4522 (97.7%) did not require respiratory assistance. One-hundred seven (2.3%) newborns needed resuscitation with bag and mask ventilation in the delivery unit, of whom 77 (1.6%) babies responded to bag and mask ventilation while 30 (0.65%) neonates needed endotracheal intubation and 15 (0.3%) were given chest compressions. Epinephrine/volume expander was administered to 10 (0.2%) newborns. In 17 patients resuscitation was continued for >10 mins. There was a positive correlation between the need for resuscitation and following risk factors: low birth weight, preterm labor, chorioamnionitis, pre-eclampsia, prolonged rupture of membranes, abruptio placentae, prolonged labor, meconium staining of amniotic fluid, multiple pregnancy and fetal distress. On multiple regression; low birth weight, meconium stained liquor and chorioamnionitis revealed as independent risk factors that made endotracheal intubation necessary.

Conclusion

Accurate identification of risk factors and anticipation at the birth of a high-risk neonate would result in adequate preparation and prompt resuscitation of neonates who need some level of intervention and thus, reducing neonatal morbidity and mortality.     

2005 AHA心肺复苏与心血管急诊指南在儿科应用的思考

2005美国心脏病协会(AHA)心肺复苏与心血管急诊指南是尽力在循证基础上制定的,其中基础生命支持内容改变较多,如创伤时如何开放气道;胸外心脏按压的部位和方法;减少呼吸频率及通气量,避免过度通气与保证心脏按压;按压、通气的配合;1岁及1岁以上小儿可用成人AED除颤等。但本指南是一个国际性的应用指南,其制定更注重可行性与实际效果及利于推广。有些内容仅为专家们达成的共识,尚缺乏科学资料支持。因此,临床更应密切观察治疗反应,在使用中总结经验;更需注意本土化,使之适合国情。强化急救意识,确立急诊思维方法,加强技能培训是当务之急。