2010 guidelines for pediatric neonatal resuscitation: What you need to know

It's been 50 years since the publication of the first study demonstrating that chest compressions can be a life-saving measure for victims of cardiac arrest and 5 years since the American Heart Association (AHA) published their 2005 Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC). In mid-October, the new 2010 AHA guidelines for CPR and ECC were released, which include updated recommendations for adult and pediatric CPR, adult and pediatric advanced life support (PALS), and neonatal resuscitation. The new AHA guidelines are based on an extensive review of thousands of resuscitation studies by more than 350 experts from 29 countries who reached a consensus over a 3-year period. We can expect the new material to be integrated into PALS and Neonatal Resuscitation Program (NRP) courses sometime in 2011. There are substantial changes in the new guidelines that pediatricians should be prepared to implement.

Pediatric basic life support

The 2010 guidelines continue to emphasize chest compressions because studies have continued to show that effective chest compressions (ie, appropriate depth of compressions and rate) are associated with the best outcomes for victims of cardiac arrest of all ages. For infants through adults in cardiac arrest, the Airway, Breathing, and Chest compressions (A-B-C) sequence of basic life support (BLS) has been replaced by a new sequence: Chest compressions, Airway, and Breathing (C-A-B). In the new C-A-B sequence, "Look, listen, and feel" has been removed from the algorithm, and the guidelines advise that chest compressions should be initiated rapidly to all victims who are responsive and not breathing, without pausing longer than 10 seconds to check for a pulse. The reason is that studies have shown that both healthcare workers and lay rescuers have difficulty ascertaining if a pulse is present, and compressions administered to a patient with a pulse does no harm.

Additionally, the new pediatric basic life support guidelines approve the use of an automated external defibrillator (AED) or a manual defibrillator for infants. When a manual defibrillator is not available, an AED equipped with a pediatric dose attenuator should be used, and when a dose attenuator is not available, a standard AED may be used.

Pediatric advanced life support

The new 2010 PALS guidelines can be characterized as refining the preceding guidelines, with only a small number of new recommendations. PALS again continues to recommend exhaled carbon dioxide detection with either capnography or colorimeter to confirm tracheal tube placement and further advises that continuous capnography waveform tracings can be used to optimize the quality of chest compressions during CPR and can reduce the need to interrupt compressions for a pulse check.

PALS continues to recommend a single-shock strategy for defibrillation with the initial dose of 2 joules/kg and the second dose now of at least 4 joules/kg, with consideration of using higher doses not to exceed 10 joules/kg when necessary. Once circulation has been restored, pulse oximetry should be used to provide an inspired oxygen concentration that will keep the oxygen saturation between 94% and 99% to avoid tissue damage resulting from hyperoxia.

Other changes in PALS include a redefinition of wide-complex tachycardia and the recommendation that the anesthetic agent etomidate should not be used in the setting of septic shock. Additionally, therapeutic hypothermia may be considered for pediatric patients who remain comatose after resuscitation from cardiac arrest. PALS guidelines also suggest that children who die suddenly and unexpectedly undergo an autopsy performed by a pathologist with experience in cardiac pathology, because a correct tissue diagnosis of a genetic channel defect (channelopathy) can prove to be of enormous benefit to living relatives who may have inhertied this defect.