Interactive Guide to Advanced Life Support in Pediatrics

Based on the guidelines of the Spanish Society of Pediatric Emergencies (SEUP) 2024

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Initial Patient Parameters

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Approach: Recognize Cardiac Arrest

  • Not conscious: Does not respond to stimuli.
  • No effective breathing: Absence of breathing or only gasping/gasping.
  • No signs of life: No palpable pulse within 10 seconds, extreme paleness, cyanosis.
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Start Basic CPR and Ask for Help

Initial CPR sequence:

  • Carry out 5 rescue vents initials.
  • Continue compressions and ventilations in a relationship 15:2.

AID!

  • If only one rescuer: Perform 1 minute of CPR before seeking help.
  • If more than one rescuer: One initiates CPR while the other calls for help and brings in the resuscitation/AED equipment.
  • If using telephone: Activate speaker to coordinate with emergencies.
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SVA Management During CPR

While continuing high-quality CPR, perform the following actions:

  • Oxygenate and Ventilate: Connect self-inflating bag with reservoir and 100% O₂.
  • Monitor: Apply defibrillator paddles/pads and monitor ECG, SpO₂, and ETCO₂ if intubated.
  • Vascular Access: Get IV or IO access as soon as possible.
  • Minimize Interruptions: Pauses in compressions should be < 10 seconds.
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Evaluate Heart Rate

After 2 minutes of CPR, briefly stop compressions to analyze the rhythm on the monitor.

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Defibrillatable Rhythm: Defibrillation

Identified rhythm: Ventricular Fibrillation (VF) o Pulseless Ventricular Tachycardia (SPVT).

  1. Manage 1st Download:
    • Dose: 4 Joules/kg.
    • Ensure that no one touches the patient.
  2. Resume CPR IMMEDIATELY during 2 minutes without checking the rhythm.
  3. After 2 min (3rd cycle), evaluate rhythm. If a defibrillatable rhythm persists, administer 2nd download.
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Pharmacological Management (Refractory Defibrillatable Rhythm)

If the shockable rhythm persists after the 3rd shock:

  1. Administer Adrenaline:
    • Dose: 10 µg/kg (0.1 ml/kg of the 1:10,000 dilution). Maximum 1 mg.
    • Repeat each 3-5 minutes (every 2 CPR cycles).
  2. Administer Amiodarone:
    • Dose: 5mg/kg in IV/IO bolus.
    • May be repeated up to 2 times for refractory VF/spVT.

Continue 2-minute cycles of CPR, assess rhythm, and defibrillate if indicated. Administer adrenaline every 3-5 min.

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NON-Shockable Rhythm: Management

Identified rhythm: Asystole o Pulseless Electrical Activity (PEA).

  1. Administer Adrenaline:
    • Manage AS SOON AS POSSIBLE.
    • Dose: 10 µg/kg (0.1 ml/kg of the 1:10,000 dilution). Maximum 1 mg.
    • Repeat each 3-5 minutes (every 2 CPR cycles).
  2. Resume CPR IMMEDIATELY during 2 minutes.
  3. DO NOT DEFIBRILLATE.

Continue 2-minute cycles of CPR and rhythm assessment, administering adrenaline when appropriate. Look for and treat reversible causes.

Considerations During CPR

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Ensure Quality CPR

  • Frequency: 100-120 compressions per minute.
  • Depth: 1/3 of the anteroposterior diameter of the thorax (approximately 4 cm in infants, 5 cm in children).
  • Complete chest recoil after each compression.
  • Minimize interruptions.
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Advanced Airway Control and Capnography

  • Consider endotracheal intubation or supraglottic device.
  • Once placed, perform continuous chest compressions (100-120/min).
  • Ventilate at a frequency of:
    • 25/min in < 1 year.
    • 20/min in 1-8 years.
    • 15/min in 8-12 years.
    • 10/min in > 12 years.
  • Wear capnography (ETCO₂) to confirm tube position and monitor CPR quality (target > 15 mmHg).
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Correct Reversible Causes (4H and 4T)

The 4 hours:

  • Hipoxia
  • Hipovolemia
  • Htype/Hhyperkalemia, hypoglycemia, etc.
  • Hipothermia

The 4 T's:

  • Pneumothorax a Tension
  • Tcardiac apnea
  • Toxic
  • Trhomboembolism (pulmonary or coronary)
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Immediate Treatment Post-Recovery of Spontaneous Circulation (SCR)

Once the patient has a sustained pulse:

  • Use ABCDE sequence for systematic reevaluation.
  • Controlled oxygenation and ventilation: Maintain SpO₂ between 94-98%. Avoid hyperventilation. Normalize PCO₂.
  • Additional investigations: 12-lead ECG, analysis, x-ray.
  • Treat precipitating cause from the stop.
  • Temperature control: Prevent fever and treat it aggressively.
  • Continuous hemodynamic monitoring.
  • Transfer to the Pediatric Intensive Care Unit (PICU).
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