Pediatric Advanced Life Support (PALS) – 2020 Update
- Pediatric cardiac arrest is a rare event, regardless of the size of centre you work at.
- While there are an estimated 38,000+ adult out-of-hospital cardiac arrests (OHCA) in Canada per year, the incidence of OHCA for pediatric patients is estimated to be less than 1,000.
- Pediatric cardiac arrest is a classic “HALO” event, or “high opportunity, low occurrence” presentation. As such it is something we should review regularly and incorporate into our local simulation practice.
- PALS guidelines in Canada are updated every 5 years by the Heart and Stroke Foundation in conjunction with the American Heart Association (AHA) and International Liaison Committee On Resuscitation (ILCOR).
- Important to appreciate that pediatric cardiac arrest and resuscitation are incredibly challenging areas to study so the data we have is limited in scope and quality.
- The 2020 PALS update does feature some notable changes in the management of both pediatric cardiac arrest and pediatric sepsis.
- Fortunately, the PALS algorithm for the management of pediatric cardiac arrest is very similar to the adult algorithm with 2x arms: one for shockable rhythms, and one for non-shockable.
- Pediatric specific numbers to remember:
- CPR rate: 100 – 120 BPM, depth (1/3rd AP diameter of the chest)
- Ventilation rate: 20 – 30 breaths / minute
- Defibrillation energy doses: 2 – 4J / kg (max of 10J / kg)
- Epinephrine dose: 0.01mg / kg
2020 Airway Updates
1. “It is reasonable to choose cuffed endotracheal tubes over uncured tubes when intubating infants and children”.
- Evidence has demonstrated safety, better respiratory mechanics, more reliable capnography, and lower rates of re-intubation. Also lowers the cognitive burden for providers: no longer have to consider uncuffed ETT’s.
2. “Routine use of cricoid pressure is not recommended during endotracheal intubation of pediatric patients”.
- Historically a practice thought to reduce the rates of gastric insufflation, new data since 2015 have shown no improvement in rates of regurgitation, and a decrease in first-pass success when cricoid pressure is applied.
2020 Breathing Update
3. “When performing CPR in infants and children with an advanced airway, it may be reasonable to target a respiratory rate of 1 breath every 2-3 seconds (20 – 30 breaths / minute)”.
- Some new evidence showing a potential mortality benefit with good neurologic outcomes from higher ventilation rates in pediatric cardiac arrest.
2020 Circulation Update
4. “For pediatric patients in any setting, it is reasonable to administer the initial dose of epinephrine within 5 minutes from the start of chest compressions.”
- New emphasis on earlier / immediate epinephrine administration in PEA arrest.
5. “In patients with septic shock, it is reasonable to administer fluid in 10 or 20 mL per kg aliquots with frequent re-assessment.”
- New recommendation for more judicious fluid administration in pediatric septic shock.
6. “In infants and children with fluid refractory septic shock, it is reasonable to use either epinephrine or norepinephrine as an initial vasoactive infusion.”
- Improved 28-day mortality and better rates of resolution of shock with these agents as compared to dopamine.
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Given the challenges inherent to cardiac arrest research, the 2020 PALS guidelines are informed by the best available evidence as well as expert consensus.
OTHER RELEVANT INFORMATION
Kojima, Taiki, et al. “Cricoid pressure during induction for tracheal intubation in critically Ill children: a report from national emergency airway registry for children.” Pediatric Critical Care Medicine| Society of Critical Care Medicine 19.6 (2018): 528-537.
Ramaswamy, Karthik Narayanan, et al. “Double-blind randomized clinical trial comparing dopamine and epinephrine in pediatric fluid-refractory hypotensive septic shock.” Pediatric Critical Care Medicine 17.11 (2016): e502-e512.
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Mar 05, 2021
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