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    Pediatric Advanced Life Support (PALS) – 2020 Update

    Pediatrics

    Last Updated Mar 05, 2021
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    Context

    • 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.

    Recommended Treatment

    • 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.

     

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    Quality Of Evidence?

    Justification

    Given the challenges inherent to cardiac arrest research, the 2020 PALS guidelines are informed by the best available evidence as well as expert consensus.

    Moderate

    Related Information

    OTHER RELEVANT INFORMATION

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    RELEVANT RESEARCH IN BC

    Sepsis and Soft Tissue Infections

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