As with the adult BLS recommendations, the AHA 2010 guidelines revised the initial CPR sequence of steps from ABC (airway, breathing, chest compressions) to CAB (chest compressions, airway, breathing). [50] This change was reaffirmed in the 2020 update, which states "It may be reasonable to initiate CPR with compressions-airway-breathing over airway breathing-compressions." [43] The AHA 2020 guidelines also recommend that (1) lay rescuers should begin CPR for any victim who is unresponsive, not breathing normally, and does not have signs of life; do not check for a pulse and (2) in infants and children with no signs of life, it is reasonable for healthcare providers to check for a pulse for up to 10 seconds and begin compressions unless a definite pulse is felt. [43] For lay rescuers Step 1. Make sure the scene is safe. Check to see if the person is awake and breathing normally. Step 2. If not, shout for help.
Step 3. Repeat cycles of CPR (30 compressions:2 breaths); use AED as soon as it arrives. For single healthcare providers on scene Step 1. Make sure the scene is safe. Check to see if the person is awake and breathing normally. Step 2. If not, shout for help. Activate 911. Step 3. Look for no breathing or only gasping and (simultaneously) check for a DEFINITE pulse WITHIN 10 SECONDS. 3b. If pulse and normal breathing, monitor until EMS arrives. 3c. If pulse but NO normal breathing:
3d. If no pulse or normal breathing AND a witnessed sudden collapse, call 911, then go get an AED, then use the AED and perform CPR (30 compressions:2 breaths). 3e. If no pulse and NOT witnessed sudden collapse:
Step 4. Use AED as soon as it is available. If shock is advised, give 1 shock. Resume CPR immediately for 2 minutes (until prompted by AED to allow rhythm check). Continue until ALS providers take over or the person starts to move. For two or more healthcare providers on scene Step 1. Make sure the scene is safe. Check to see if the person is awake and breathing normally. Step 2. If not, shout for help. Step 3. One person calls 911 and then gets an AED, while the other person looks for no breathing or only gasping and (simultaneously) checks for a DEFINITE pulse WITHIN 10 SECONDS. 3b. If pulse and normal breathing, monitor until EMS arrives. 3c. If pulse but NO normal breathing:
3d. If no pulse or normal breathing, start CPR. The first rescuer performs cycles of 30 compressions and 2 breaths. When the second rescuer returns, the two perform cycles of 15 compressions and 2 breaths. Use the AED as soon as it is available. Step 4. Use AED as soon as it is available. Use AED as soon as it is available. If shock is advised, give 1 shock. Resume CPR immediately for 2 minutes (until prompted by AED to allow rhythm check). Continue until ALS providers take over or the person starts to move. Step 1: Begin CPR. Begin bag-mask ventilation and give oxygen. Attach monitor/defibrillator. Step 2a: If VF/pVT, deliver shock. Step 2b: If PEA/asystole, give epinephrine as soon as possible and go to step 8 (below). Step 3. Continue CPR for 2 min (5 rounds). Establish IV (preferred) or IO access. Step 4a. If VF/pVT, deliver shock. Step 4b: If PEA/asystole, give epinephrine as soon as possible and go to step 8 (below). Step 5. Continue CPR for 2 min (5 rounds). Give epinephrine every 3-5 minutes. Consider advanced airway placement. Step 6a. If VF/pVT, deliver shock. Step 6b: If PEA/asystole, give epinephrine as soon as possible and go to step 8 (below). Step 7. Continue CPR for 2 min (5 rounds). Continue epinephrine every 3-5 minutes. Give amiodarone (or lidocaine). Treat reversible causes. Go to step 4 (above). Step 8. Continue CPR for 2 min (5 rounds). Establish IV (preferred) or IO access. Continue epinephrine every 3-5 min. Consider advanced airway and capnography. Step 9a. If VF/pVT, go to step 6a (above) (deliver shock). Step 9b: If PEA/asystole, continue CPR for 2 min (5 rounds). Treat reversible causes. Step 10a. If VF/pVT, go to step 6a (above) (deliver shock). Step 10b: If PEA/asystole, go to step 8 (above). If signs of ROSC are noted, go to Post–Cardiac Arrest Care The following are considered essential elements of high-quality CPR:
As with BLS, algorithms are a key component of pediatric advanced life support (PALS) and are designed to simplify and expedite recognition and treatment of life-threatening conditions. Unlike BLS, PALS typically involves a coordinated team of trained responders who are able to initiate several processes simultaneously. The following summarizes the AHA PALS algorithm for VF or pVT [49] :
Once the child is attached to the monitor or AED, the rhythm should be analyzed and determined to be shockable or nonshockable. Shockable rhythms include pulseless ventricular tachycardia or ventricular fibrillation. Nonshockable rhythms include pulseless electrical activity or asystole. If the rhythm indicates ventricular tachycardia or ventricular fibrillation, then it is a shockable rhythm and intervention proceeds as follows:
If the rechecked rhythm is determined to be shockable, intervention proceeds as follows:
If the rhythm is nonshockable, intervention proceeds as follows:
Once the patient is intubated, chest compressions and ventilations should work independently, with the compressions at a continuous rate of 100/min and the ventilations 10/min. In addition, identify and correct the following if necessary:
Emergency treatment of bradycardia is indicated when the rhythm results in hemodynamic compromise. The AHA algorithm for the recognition and management of bradyarrhythmias is summarized below. [49] When a pediatric patient is found to be bradycardiac, quickly check for a pulse. If no pulse is found, proceed to the pulseless arrest algorithm. If a pulse is found, assess for signs of cardiopulmonary compromise. These signs include the following:
If cardiopulmonary compromise is evident, the following immediate steps should be taken:
If the heart rate continues to be below 60 bpm and cardiopulmonary compromise is evident despite oxygenation and ventilation, then chest compressions should be initiated. While the algorithm is being applied, attempt to identify and treat any underlying causes. If bradycardia persists after 2 minutes of chest compressions, consider the following:
If the bradycardia resolves, continue to support the ABCs, monitor the child, and consider expert consultation. If the bradycardia evolves into pulseless arrest, proceed to the pulseless arrest algorithm. The most common types of tachycardia in the pediatric population are sinus tachycardia, supraventricular tachycardia, and ventricular tachycardia. As with other elements of PALS, an algorithmic approach is used for tachyarrhythmia, as outlined below. If a pediatric patient is found to be unresponsive and not breathing in the context of tachycardia on the monitor, then proceed to the pulseless arrest algorithm. If a pulse is found, assess for signs of cardiopulmonary compromise. These signs include the following:
If cardiopulmonary compromise is evident, the following immediate steps should be taken:
If the QRS is wide on the initial ECG, ventricular tachycardia should be assumed. Supraventricular tachycardia with aberrant conduction is a less common possibility. If the patient shows signs of cardiopulmonary compromise, synchronized cardioversion is delivered at 0.5-1 J/kg, with an increase to 2 J/kg if initially unsuccessful. If the patient shows no signs of cardiopulmonary compromise, adenosine may be empirically given for the possibility of supraventricular tachycardia with aberrancy. Amiodarone and procainamide should not be routinely administered together, but they may be given in conjunction with expert consultation, as follows:
If the QRS is narrow, determine whether sinus tachycardia or supraventricular tachycardia is more probable. Evidence supporting sinus tachycardia includes the following:
Evidence supporting supraventricular tachycardia includes the following:
Treat the underlying cause(s). Common causes of sinus tachycardia include hypovolemia, sepsis, fever, pain, hypoxia, and anemia. The history and physical examination can provide important information for narrowing the differential diagnosis. Supraventricular tachycardia While preparations are being made for chemical or electrical cardioversion, vagal maneuvers may be attempted to break the dysrhythmia. Vagal maneuvers include the following:
If vagal maneuvers are unsuccessful and the patient has IV or IO access, then chemical cardioversion with adenosine is indicated. The regimen is as follows:
If chemical cardioversion is unsuccessful or not available, electrical cardioversion is indicated. The regimen is as follows:
If chemical and electrical cardioversion continue to be unsuccessful, consider expert consultation for additional antiarrhythmics and rate-controlling recommendations. |
How many cycles of CPR 30 compressions and 2 breaths should be completed in 2 minutes or less when performing CPR?
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