This year, the American Heart Association (AMA) released new guidelines for pediatric resuscitation. Marianne Gausche-Hill, MD, FACEP, FAAP, director of emergency medical services and director of the EMS and pediatric emergency medicine fellowships at Harbor-UCLA Medical Center in Torrance, California, shared some of the most important changes and strategies for improving outcomes among the youngest of patients.
To start, there is a new algorithm for neonatal resuscitation. If the neonate remains in cardiac arrest, the new guidelines recommend continuous positive airway pressure before intubating. To avoid hypoxemia, resuscitation should begin with room air, advancing to 100 percent oxygen once CPR has been initiated. Titrate the oxygen if there is a return of spontaneous circulation.
The AMA has reversed its position on routine intubation for tracheal suction. Due to insufficient evidence, the AHA is not recommending this practice continue for all newborns. “This is a considerable change,” Dr. Gausche-Hill said. Because of the unique physiology of a child, cricoid pressure is not recommended. “Even a little pressure blocks the airway,” she said.
Also new for 2015, the AHA guidelines no longer recommend routine use of atropine as a premedication for emergency tracheal intubation in non-neonates. Dr. Gausche-Hill does recommend high-flow nasal cannulas at 5L per minute. “There’s not great evidence, but I can tell you anecdotally that I love it,” she said.
While medical providers are still required to do ventilations with chest compressions during CPR, she noted that there have been changes for lay people, including the use of compression-only for children in cardiac arrest. The recommended technique for all rescuers is the thumb-and-finger method, instead of the two-finger approach.
Dr. Gausche-Hill strongly recommended attending to ventilation rates when performing CPR on a pediatric patient. “If you want to save lives, slow down,” she said. “Don’t bag at your own personal pulse rate. Squeeze just until you see chest rise.” The recommended rate is 8–10 ventilations per minute.
The AHA has approved using adult AED pads for children as long as the pads do not touch. She suggests placing the pads on the front and back of the child to avoid that situation. When defibrillating, the new guidelines recommend 2–4 J/kg to start.
If a newborn has an APGAR score that remains at zero for 10 minutes and no heartbeat has been detected, the AHA suggests that resuscitation efforts can cease. Dr. Gausche-Hill said that the physician still has the option of continuing resuscitation efforts, depending on the situation.
Dr. Gausche-Hill admitted that pediatric resuscitation is an emotionally charged situation for everyone involved. She recommended allowing the family to be present. Studies have shown that it can make a difference in the outcome for those who experience such a difficult situation.
Teresa McCallion is a freelance medical writer based in Washington State.