Pediatric Cardiac Arrest

Algorithm
2020 American Heart Association Guidelines for
Pediatric Basic and Advanced Life Support
Donald S. Escaño PH RN, HAAD RN
BSN University Instructor/ National Board Reviewer for Philippine Nursing Licensure Exam/
International Speaker.

PHILIPPINES
2020 UPDATED GUIDELINES

• The American Heart Association released the updated 2020 guidelines

for cardiopulmonary resuscitation and emergency cardiovascular care;
the first major update to the internationally recognized guideline in five
years.

• These Highlights summarize the key issues and changes in the 2020
American Heart Association (AHA) Guidelines for Cardiopulmonary
Resuscitation (CPR) and Emergency Cardiovascular Care (ECC).
• More than 20 000 infants and children have a cardiac arrest each year
in the United States. Despite increases in survival and comparatively
good rates of good neurologic outcome after pediatric IHCA, survival
rates from pediatric OHCA remain poor, particularly in infants.
Pediatric advanced life support guidelines
• For the purposes of the pediatric advanced life support guidelines, pediatric patients are
infants, children, and adolescents up to 18 years of age, excluding newborns. For
pediatric basic life support (BLS), guidelines apply as follows:

• Infant guidelines apply to infants younger than approximately 1 year of age.

• Child guidelines apply to children approximately 1 year of age until puberty. For teaching
purposes, puberty is defined as breast development in females and the presence of
axillary hair in males.

• For those with signs of puberty and beyond, adult basic life support guidelines should be
followed.
 Pediatric Basic and Advanced Life Support
(PALS)
• The American Heart Association (AHA) has updated its Pediatric Basic
and Advanced Life Support (PALS) guidelines since their last update in
2010.

• These new recommendations focus on:

- airway management, emphasizing that pediatric patients with an
advanced airway should have a target respiratory rate of 1 breath every
2-3 seconds (20-30 breaths per minute).
- This is changed from the past recommendation of 1 breath every 6
seconds.
Two indications for the use of BLS
• The 2020 AHA guidelines address two indications for the use of BLS in
critically ill or injured infants and children:
-cardiac arrest (no pulse) and
-bradycardia (heart rate [HR] <60 beats/minute) with poor perfusion.
 Key issues, major changes, and enhancements in the
2020 Guidelines
include the following:
• Based on newly available data from pediatric resuscitations, the
recommended assisted ventilation rate has been increased to 1 breath
every 2 to 3 seconds (20-30 breaths per minute) for all pediatric
resuscitation scenarios.

Cuffed ETTs are suggested to reduce air leak and the need
for tube exchanges for patients of any age who require
intubation.
 Key issues, major changes, and enhancements in the 2020
Guidelines
include the following:
• The routine use of cricoid pressure during intubation is no longer
recommended.

• To maximize the chance of good resuscitation outcomes, epinephrine

should be administered as early as possible, ideally within 5 minutes
of the start of cardiac arrest from a nonshockable rhythm (asystole
and pulseless electrical activity).
 Key issues, major changes, and enhancements in the 2020
Guidelines
include the following:
- For patients with arterial lines in place, using feedback from
continuous measurement of arterial blood pressure may improve CPR
quality.

-After ROSC, patients should be evaluated for seizures; status

epilepticus and any convulsive seizures should be treated.
(Return of spontaneous circulation (ROSC) is the resumption
of a sustained heart rhythm that perfuses the body after cardiac
arrest. It is commonly associated with significant respiratory
effort)
 Key issues, major changes, and enhancements in the 2020
Guidelines
include the following:
-Because recovery from cardiac arrest continues long after the initial
hospitalization, patients should have formal assessment and support
for their physical, cognitive, and psychosocial needs.

-A titrated approach to fluid management, with epinephrine

or norepinephrine infusions if vasopressors are needed,
is appropriate in resuscitation from septic shock.
 Key issues, major changes, and enhancements in the 2020
Guidelines
include the following:
-Opioid overdose management includes CPR and the timely
administration of naloxone by either lay rescu.ers or trained rescuers.

-Children with acute myocarditis who have arrhythmias, heart block, ST-
segment changes, or low cardiac output are at high risk of cardiac
arrest. Early transfer to an intensive care unit is important, and some
patients may require mechanical circulatory support or extracorporeal
life support (ECLS).
 Key issues, major changes, and enhancements in the 2020
Guidelines
include the following:
-Infants and children with congenital heart disease and single ventricle
physiology who are in the process of staged reconstruction require
special considerations in PALS management.

-Management of pulmonary hypertension may include the use of

inhaled nitric oxide, prostacyclin, analgesia, sedation, neuromuscular
blockade, the induction of alkalosis, or rescue therapy with ECLS
Algorithms and Visual Aids
Major New and Updated Recommendations

• Changes to the Assisted Ventilation Rate: Rescue Breathing

-2020 (Updated): (PBLS) For infants and children with a pulse but absent
or inadequate respiratory effort, it is reasonable to give 1 breath every 2
to 3 seconds (20-30 breaths/min).

-2010 (Old): (PBLS) If there is a palpable pulse 60/min or greater but

there is inadequate breathing, give rescue breaths at a rate of about 12
to 20/min (1 breath every 3-5 seconds) until spontaneous breathing
resumes.
• Changes to the Assisted Ventilation Rate: Ventilation Rate During CPR With an
Advanced Airway

2020 (Updated): (PALS) When performing CPR in infants and children with an
advanced airway, it may be reasonable to target a respiratory rate range of 1
breath every 2 to 3 seconds (20-30/min), accounting for age and clinical
condition. Rates exceeding these recommendations may compromise
hemodynamics.

2010 (Old): (PALS) If the infant or child is intubated, ventilate at a rate of about 1
breath every 6 seconds (10/min) without interrupting chest compressions.

Why: New data show that higher ventilation rates (at least 30/min in infants [younger than 1 year] and at least 25/min
in children) are associated with improved rates of ROSC and survival in pediatric IHCA. Although there are no data
about the ideal ventilation rate during CPR without an advanced airway, or for children in respiratory arrest with or
without an advanced airway, for simplicity of training, the respiratory arrest recommendation was standardized for
both situations.
Cricoid Pressure During Intubation

• 2020 (Updated): Routine use of cricoid pressure is not recommended

during endotracheal intubation of pediatric patients.

• 2010 (Old): There is insufficient evidence to recommend routine

application of cricoid pressure to prevent aspiration during
endotracheal intubation in children.

Why: New studies have shown that routine use of cricoid pressure reduces intubation success rates and does not reduce the
rate of regurgitation. The writing group has reaffirmed previous recommendations to discontinue cricoid pressure if it
interferes with ventilation or the speed or ease of intubation
Emphasis on Early Epinephrine Administration

2020 (Updated): 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. 2015

(Old): It is reasonable to administer epinephrine in pediatric cardiac arrest.

Why: A study of children with IHCA who received epinephrine for an initial nonshockable rhythm (asystole and pulseless
electrical activity) demonstrated that, for every minute of delay in administration of epinephrine, there was a significant
decrease in ROSC, survival at 24 hours, survival to discharge, and survival with favorable neurological outcome
• Patients who received epinephrine within 5 minutes of CPR initiation
compared with those who received epinephrine more than 5 minutes
after CPR initiation were more likely to survive to discharge. Studies of
pediatric OHCA demonstrated that earlier epinephrine administration
increases rates of ROSC, survival to intensive care unit admission,
survival to discharge, and 30-day survival.
Invasive Blood Pressure Monitoring to Assess CPR Quality 2020

(Updated): For patients with continuous invasive arterial blood pressure

monitoring in place at the time of cardiac arrest, it is reasonable for providers
to use diastolic blood pressure to assess CPR quality. eccguidelines.heart.org
21 2015

(Old): For patients with invasive hemodynamic monitoring in place at the

time of cardiac arrest, it may be reasonable for rescuers to use blood
pressure to guide CPR quality

Why: Providing high-quality chest compressions is critical to successful resuscitation. A new study shows that, among
pediatric patients receiving CPR with an arterial line in place, rates of survival with favorable neurologic outcome were
improved if the diastolic blood pressure was at least 25 mm Hg in infants and at least 30 mm Hg in children.
• Hemorrhagic Shock 2020

(New): Among infants and children with hypotensive hemorrhagic shock

following trauma, it is reasonable to administer blood products, when
available, instead of crystalloid for ongoing volume resuscitation.

Why: Previous versions of the Guidelines did not differentiate the treatment of hemorrhagic shock from other causes
of hypovolemic shock. A growing body of evidence (largely from adults but with some pediatric data) suggests a
benefit to early, balanced resuscitation using packed red blood cells, fresh frozen plasma, and platelets. Balanced
resuscitation is supported by recommendations from the several US and international trauma societies.
Effective education is a key variable in improving survival outcomes from
cardiac arrest. Without effective education, lay rescuers and healthcare
providers would struggle to consistently apply the science supporting the
evidence-based treatment of cardiac arrest. Evidence based instructional
design is critical to improving provider performance and patient-related
outcomes from cardiac arrest. Instructional design features are the active
ingredients, the key elements of resuscitation training programs that
determine how and when content is delivered to students.