updates of 2015 pals guidlines

Updates of 2015 PALS Updates of 2015 PALS guidelinesguidelines

Marwa Elhadylecturer of pediatrics

Faculty of medicine for girlsAl-Azhar University

2016

تعالى الناس: ) قال أحيا فكأنما أحياها ومن جميعا (

IntroductionObjectives What is CPR??

overview on CPR 2015

Explanations & New studies

overview on CPR 2010

2015 AHA Guidelinesupdate for CPR & BLS for

pediatric in comparison with 2010

Summary of High-Quality CPR Components for BLS

Providers in pediatrics

Introduction:

Start CPR Start CPR ImmediatelyImmediately

Brain damage starts in 4-6 minutesBrain damage is certain after 10

minutes

Better chance of survival

Without CPR

SO

Checking Vital Checking Vital SignsSigns

A – Airway Open the airway Head tilt chin lift

B – Check For Breathing Look, listen and feel for breathing No longer than 10 seconds If the victim is not breathing, give

two breaths (1 second or longer)

Mouth to Mouth Barrier Mouth to Mouth Barrier DevicesDevices

Shields Masks

After giving breaths…Locate proper hand position for

chest compressions

C – Chest compression

Checking for CPR Checking for CPR EffectivenessEffectiveness

Does chest rise and fall with rescue breaths?

Have a second rescuer check pulse while you give compressions

1- Ensure chest compression of adequate rate2- Chest compression of adequate depth3-Allow full chest recoil in between compressions4-Minimizing interruptions of chest compressions5- Avoid excessive ventilation

Components of high quality CPR

Old

BLS 2010

BLS 2015 (1 rescue)

BLS 2015 (2 rescue)

Basic Life Support BLS

ITEM 2015 ( UPDATE( 2010 ( Old ) Explanation

New algorithms

Two algorithms for 1-Rescuer and Multiple-Rescuers

Handheld cellular telephones with speakers allowsingle rescuerto activate an

emergency response while beginning CPR

One algorithm for one or Multiple-Rescuers

CPR have been separated to better guide

rescuers

ITEM 2015 ( UPDATE( as 2010 ( Old)

Explanation

C-A-B Sequence

Chest compression first

CPR should begin with 30 compressions (if 1 rescuer) or 15

compressions (if 2 rescuer) rather 2 breaths

Beginning CPR by compressions

rather than breaths

(C-A-B rather than A-B-C).

leads to a shorter delay to 1st

compression providing vital blood flow to

heart & brain.

ITEM 2015 (UPDATE(

2010 ( Old ) Explanation

Chest Compression

Depth

depress the chest at least 1/3 the

anteroposterior diameter in pediatric

approximately 1.5 inches (4 cm)

in infants to 2 inches (5 cm) in

children

Max limit is 2.4 inches (6 cm) as

adult

compress at least 1/3 of the

anteroposterior diameter of the

chest

No maximum limit

Studies showed that

compressions deeper than 2.4 inches (6 cm) is

harmful.

ITEM 2015 (UPDATE(


Chest Compression

Rate

Use the recommended

adult chest compression rate of 100

to 120/min for infants and

children

Push at a rate of at least 100compressions per minute.

To maximize educational

consistency and retention,

pediatric experts adoptedthe same

recommendation for compression rate as is madefor adult BLS.

ITEM 2015 (UPDATE(


Compression-Only CPR

rescue breaths and chest

compressions should be provided

But if rescuers are unwilling or unable to deliver

breaths compression-

only CPRcan be effective in patients with cardiac arrest.

Optimal CPR includes both compressions

and ventilations

When cardiac etiology was

present, outcomes were similar whether conventional orcompression-only CPR was

provided.

compressions alone are

preferable to no CPR.

Reaffirming the C-A-B sequence as the preferred sequence for pediatric CPR

New algorithms for 1-rescuer and multiple-rescuer pediatric HCP with use of cell phone

Establishing an upper limit of 6 cm for chest compression depth in an adolescent

Mirroring the adult BLS recommended chest compression rate of 100 to 120/min

Strongly reaffirming that compressions and ventilation are needed for pediatric BLS.

Summary of Key Issues and Major Changes

Pediatric Advanced life support PALS

• Fluid resuscitation in febrile illness

• Atropine use before tracheal intubation

• Use of amiodarone and lidocaine in shock- refractory

VF/pVT

• TTM after resuscitation from cardiac arrest in infants

and children

• Post–cardiac arrest management of blood pressure.

updates are provided about:

ITEM 2015 (UPDATE( Explanation

Fluid Resuscitation

Early, rapid IV administration of isotonic fluids for septic

shock.(20 mL/kg)

If febrile illness with limited

access to critical care resources (ie, MV and inotropics)

administration of bolus IV fluids with extreme caution, as it may

be harmful.

In resource- limited settings, excessive fluid

boluses to febrile children may

lead to complications

where the appropriate

equipment and expertise might

not be present to effectively

address them.

ITEM 2015 (UPDATE(


Atropine for ETT

no evidence support routine use of atropine

as a premedication to in ER pediatric

intubations.

Considered in situations with

increased risk of bradycardia.

atropine 0.1 mg IV was

recommended to prevent

bradycardia

Recent evidence is conflicting

Recent studies did use atropine doses less than 0.1 mg without an increase in

the likelihood of arrhythmias.

ITEM 2015 (UPDATE(


Invasive hemodynamic

monitoring during CPR

If invasive hemodynamic monitoring is in place at the

time of a cardiac arrest

in a child, use it to guide CPR quality.

Chest compressing to

a specific systolic blood

pressure target has not been

studied in humans but

may improve outcomes in

animals.

Recent evidence of improved

outcome when CPR technique was adjusted on

the basis of invasive

hemodynamic monitoring.

ITEM 2015 (UPDATE(


antiarrhythmic medications

for shock refractory VF

or pulseless VT

Amiodarone or lidocaine is

equallyacceptable for the treatment

of shock-refractory VF

or pulseless VT in

children

Amiodarone was

recommended for shock

refractory VF or pulselessVT.

Lidocaine can be given if

amiodarone isnot available.

Recent evidence that lidocaine was associated

with higher rates of survival

compared with amiodarone,.

ITEM 2015 (UPDATE(


Vasopressors for

Resuscitation

It is reasonable to

give epinephrine

during cardiac arrest

Epinephrine should be given

for pulseless cardiac arrest.

Recent evidence that epinephrine was associated with improved

ROSC and survival in

cardiac arrest

ITEM 2015 (UPDATE(


ECPR Compared

With Standard

Resuscitation

ECPR may be considered for children with

underlying cardiac

conditions who have an

IHCA, provided

appropriate protocols,

expertise, and equipment are

available.

Extracorporeal life support should be

considered only for children in cardiac arrest refractory to

standard resuscitation

attempts, with a potentially

reversible cause of arrest.

One retrospective

registry review showed better outcome with

ECPR for patients with

cardiac disease than for those

with non cardiac disease.

ITEM 2015 (UPDATE(


Targeted Temperature Management

For comatose children maintain

either 5 days normothermia (36°C -37.5°C)

or Initial 2 days hypothermia (32°C - 34°C) followed by 3

days normothermia

Therapeutic hypothermia

(32°C to 34°C) may be

considered for children who

remain comatose after resuscitation

from cardiac arrest.

Recent evidence show no

difference in functional

outcome at 1 year between use

therapeutic hypothermia

(32°C to 34°C) or

normothermia (36°C to 37.5°C)

ITEM 2015 (UPDATE(


Intra-arrest and Post-

arrest Prognostic

Factors

Multiple factors should be considered

to predict outcomes of

cardiac arrest. And

for decision to continue or terminate

resuscitation.

Practitioners should consider

multiple variables

to prognosticate

outcomes and

use judgment to titrate efforts appropriately.

No single intra-arrest or post–cardiac arrest variable has

been found that reliably predicts

favorable or poor outcomes

ITEM 2015 (UPDATE( Explanation

Post–Cardiac Arrest Fluids and Inotropes

fluids and inotropes/vasopressors

should be used to maintain a systolic blood pressure above

the fifth percentile for age.

Intra-arterial pressure monitoring

should be used to continuously monitor blood pressure and

identify and treat hypotension.

children who had hypotension

had worse survival and

worse neurologic outcome

ITEM 2015 (UPDATE(


Post–Cardiac Arrest Pao2 and Paco2

avoidHypoxemia.

titrate oxygen administration

to achieve(sat. > 94%).

target PaCO2appropriate for each patient.

Avoid hypercapnia or

hypocapnia.

maintain an oxyhemoglobin

saturation of 94% or greater.

No recommendations

weremade about

PaCO2.

normoxemia associated with

improved outcome

compared with hyperoxemia

Worse patient outcomes

associated with hypocapnia.

Restrictive fluid volumes in febrile illness. Routine use of atropine as a premedication for emergency

ETT in non-neonates is controversial. If invasive arterial blood pressure monitoring is already

in place, use it to adjust CPR. Epinephrine continues to be recommended as a

vasopressor in pediatric cardiac arrest fluids and inotropes used to maintain a systolic blood

pressure above the fifth percentile for age. Maintain O2 sat >94%, Avoid hype or hypocapnia. Therapeutic hypothermia have no advantage than

normothermia ECPR is considered in children with cardiac disease

Summary of Key Issues and Major Changes

updates of 2015 pals guidlines

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