2015 PALS Guidelines and Changes

BLS:

Agonal gasps are considered a sign of cardiac arrest.

Check breathing and pulse simultaneously.

Chest compressions at 100-120 per minute. (Compressions depth decreases as rate increases.)

Chest compression depth 1/3-1/2 the AP diameter of the chest (~2 inches for children, ~1 ½ inches for infant).

Hand placement for children is 1 or 2 hands lower half of sternum; for infants with one rescuer, two fingers below the nipple line, for infants with two rescuers, two thumbs encircling hands technique

Allow full chest recoil. (Chest recoil creates a relative negative intrathoracic pressure and promotes venous return.)

Minimize pauses in compressions.

Defib as soon as possible. Do CPR until defib ready for use. Use pedi AED pads if available. If not available, use adult AED pads.

1 breath every 6 seconds for children in school with advanced airway. 1 breath every 3-5 for children preschool and younger with advanced airway.

Fluid Resuscitation:

20 mL/kg still recommended for shock but should be limited to one bolus in children with fever and then re-evaluate before subsequent boluses. Individualized treatment and frequent clinical reassessment are emphasized.

Atropine for ET Intubation:

Evidence does not support routine administration of atropine as a premedication to prevent bradycardia in emergency intubations.

Invasive Hemodynamic Monitoring During CPR:

If in place at the time of arrest, use it guide GPR quality. Studied in animals only.

Antiarrythmic Medications for Shock Refractory VF or Pulseless VT:

Amiodarone and lidocaine are equally acceptable in children. Studies showed higher rates of ROSC and 24-hour survival with lidocaine but neither were associated with improved survival to discharge.

Vasopressors for Resuscitation:

Reasonable to give epinephrine during cardiac arrest but not required. Studies showed higher rates of ROSC and 24-hour survival but it was not associated with improved survival to discharge.

Extracorporeal CPR Compared with Standard Resuscitation:

Consider ECPR in children with underlying cardiac conditions assuming in-hospital arrest with appropriate protocols, expertise, and equipment available.

Targeted Temperature Management:

For children who are comatose in the first several days after cardiac arrest (in-hospital or out-of-hospital), temperature should be monitored continuously and fever should be treated aggressively. For comatose children with ROSC out-of-hospital, it is reasonable for personnel to maintain either 5 days of normothermia (36C-37.5C) or 2 days of initial continuous hypothermia (32C-34C) followed by 3 days of normothermia. In-hospital ROSC comatose children, there is insufficient data to recommend hypothermia over normothermia. Studies continue.

Intra-arrest and Post-arrest Prognostic Factors:

Multiple factors should be considered when trying to predict outcomes of cardiac arrest. No single intra-arrest or post-arrest variable has been found that reliably predicts favorable or poor outcomes.

Post-Cardiac Arrest PaO2 and PaCO2:

After ROSC in children, it may be reasonable for rescuers to titrate oxygen administration to achieve normoxemia (94%-99%). When the requisite equipment is available, oxygen should be weaned to target an oxyhemoglobin saturation within the range of 94%-99%. The goal should be to strictly avoid hypoxemia while maintaining normoxemia. Likewise, post-ROSC ventilation strategies in children should target a PaCO2 that is appropriate for each patient while avoiding extremes of hypercapnia or hypocapnia.

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Figure 4. Pediatric Cardiac Arrest Algorithm.