You are working in Paeds ED. The alert phone rings for a 2-year-old boy coming in a cardiac arrest. You hear some colleagues talking about Plasmalyte, capnography, and reduced respiration rates. Don’t panic! You had heard somebody mention that there were new resuscitation guidelines out though you’ve not read them yet. How much could have really changed?
Let’s take a step back. Where do these resus guidelines come from?
The Resuscitation Council UK recently issued their 2021 guidelines. They are tailored to UK clinical practice and derived from the European Resuscitation Council (ERC) 2021 Guidelines. The International Liaison Committee on Resuscitation (ILCOR) is responsible for the International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations (CoSTR). This consensus document is then used by international member organisations to develop guidelines. They are updated roughly every five years. CoSTR 2020 formed the ERC 2021 guidance.
The guideline development process utilised systematic reviews, scoping reviews, evidence updates and engagement from worldwide stakeholders (including members of the public and cardiac arrest survivors).
The 2021 Resuscitation Council UK Guidance covers both adult and paediatric basic and advanced life support. We have reviewed the corpus of generic guidance, some key additions and the main changes to both paediatric and neonatal life support algorithms.
The new guidelines do not specifically include the management of arrest secondary to COVID-19. You can be find them at https://www.resus.org.uk/covid-19-resources.
Epidemiology of Paediatric Cardiac Arrest
Changes in paediatric resuscitation
Paediatric Basic Life Support
There are a few minor changes in 2021 to the paediatric BLS guidelines. They all apply to children up to 18 years of age (except for newborns).
Assess for signs of life simultaneously with the delivery of rescue breaths. If there are no signs of life, start chest compressions immediately after initial rescue breaths (you do not need to pause here).
Deliver five rescue breaths followed by ventilation breaths with compressions at a ratio of 15:2.
Emphasis on achieving high quality CPR
We should use mobile phones on loudspeaker for dispatcher guidance on how to deliver CPR or to summon emergency medical services (EMS) without leaving the victim.
Whilst the majority of paediatric cardiac arrests are respiratory in nature, effective chest compressions still play their part. Do these on a firm surface( so not a bed) and to a depth of at least one third the anterior-posterior diameter of the chest (or by 4cm in an infant and 5cm in a child). The rate remains at a rate of 100-120/min. The chest needs to fully recoil after each compression and around 80% of the CPR cycle should be composed of compressions.
The Resus Council recommend cuffed endotracheal tubes in children, if intubation is needed, and uncuffed tubes in neonates (Ed. note-we’ll look at this another day). Monitor this cuff pressures and try to keep it below 20mmHg.
Target oxygen saturations (SpO2) of 94-98% with as little supplemental oxygen as possible. Avoid giving pre-emptive oxygen therapy without signs of hypoxemia or shock and try to avoid readings of up to 100% – unless in situations such as carbon monoxide poisoning. Hyperoxia appears to be almost as harmful as hypoxia.
High-flow nasal cannula oxygen (HFNC) or continuous positive airway pressure (CPAP)/non-invasive ventilation (NIV) support should be considered in children that have adeqaute respiratory drive but are not responding to low-flow oxygen. Bag-mask ventilation (BMV) is recommended in children with inadequate respiratory drive. If oxygenation/ventilation doesn’t improve, or ventilation may be ongoing, it is time for more advanced airway techniques – supraglottic airway devices (SGA) or endotracheal intubation.
End-Tidal CO2 monitoring is the gold standard, whether using an SGA or bag-valve-mask ventilation. Waveform capnography can reliably confirm tracheal tube placement when it has a perfusing rhythm, as long as they are over two kilos in weight. There is a reasonable correlation between ETCO2 and PaCO2, but the guidelines do not suggest a threshold ETCO2 or PaCO2 for stopping the resuscitation attempt.
What can the ETCO2 waveform tell us in resuscitation?
No single finding can reliably identify the severity of circulatory failure. We still need to reassess frequently and after every intervention. This can be done by monitoring mean arterial blood pressure, trends in lactate, urine output and, if competent, ultrasound findings.
Peripheral intravenous (IV) lines are the first choice for vascular access but it’s just two attempts and you are out. Then it is time to move on.
Intraosseous (IO) access is the primary rescue alternative. Remember it can be painful so give proper intraosseous analgesia before giving the first fluid bolus in every (awake) child.
A balanced approach to fluids
In children with shock, use a 10 mL/kg fluid bolus repeated up to 40-60 mls/kg.
How much should we give? There is an emphasis on smaller volumes with careful reassessment after each bolus to enable early identification of signs and symptoms of fluid overload. These include hepatomegaly, bilateral basal lung crackles, and jugular venous distention. Current evidence shows that a restrictive approach to fluid therapy is at least as effective as larger volumes.
In children with shock secondary to haemorrhage, we need to keep crystalloid boluses to a minimum (max 20mls/kg). Early use of blood products is the way to go in children who present with severe trauma.
Having decided to give fluid, what should we give? Balanced isotonic crystalloids (e.g. Plasmalyte) are the first choice with 0.9% sodium chloride being an acceptable alternative. Saline can induce hyperchloremic acidosis and may be associated with a worse outcome. The evidence for Hartmanns/Ringer’s lactate is still limited and shows ‘no more than a trend’ (?) towards a better outcome – so this is still left a bit unclear… Don’t use dextrose-based solutions for volume replacement – these will be redistributed rapidly away from the intravascular space and will cause hyponatremia and hyperglycaemia which may worsen neurological outcome.
Consider using permissive hypotension (mean arterial blood pressure (MAP) at 5th percentile for age) in traumatic injury. Be mindful that It is contraindicated in children with traumatic brain injury. You need to maintain a reasonable cerebral perfusion pressure. The Resus Council UK guidelines recommend giving tranexamic acid (TXA) to all children requiring transfusion after severe trauma and/or significant haemorrhage, as long as it is within three hours of injury
Vasoactive drugs need to be started early In children with persistent decompensated circulatory failure. Noradrenaline or adrenaline are recommended as first-line agents. Vasoactive drug choice may be directed by individual patient circumstances once more detailed information about the pathophysiology is available..
Dopamine is no longer recommended but can be used if adrenaline and noradrenaline are not available.
Cardiac Arrest in Special Circumstances
Specific approach to CPR needed during specific conditions such as cardiac surgery, neurosurgery, trauma, drowning, sepsis, and pulmonary hypertension. However, there are no major changes to any of these guidelines.
When managing traumatic cardiac arrest we need to fix the reversible causes.
We need to start simultaneous chest compressions whilst treating these causes. This trumps adrenaline use. Though exceedingly rare we should think about thoracotomy in paediatric TCA patients with penetrating trauma with or without signs of life on ED arrival.
Extracorporeal Life Support (ECLS)
Extracorporeal cardiopulmonary resuscitation (E-CPR) is the implementation of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in a patient with refractory cardiac arrest. E-CPR should only be considered if it is readily available and there is a (presumed) reversible cause.
For specific subgroups of children with decompensated cardiorespiratory failure (e.g. severe refractory septic shock or cardiomyopathy or myocarditis and refractory low cardiac output), the pre-arrest use of ECLS can be lifesaving and provide end-organ support, preventing cardiac arrest.
Post-cardiac arrest care
Avoid hypoxia, hypotension and fever in children and infants who have a return of spontaneous circulation (ROSC) following cardiac arrest. Targeted temperature management of children post-ROSC should comprise active treatment with either normothermia or mild hypothermia and continuous invasive temperature monitoring.
Changes in adult resuscitation guidance
Are you curious about the big people?
For the adults, there are no major changes in ADULT BLS/ ALS 2021 guidelines. The guide states that a child is any person up to 18 years – in terms of when we switch from paediatric to adult algorithm. If the child looks like a child, we use the paediatric algorithm. If it turns out that your patient looks more youthful than they actually are then little harm will ensue. They also recommend a stepwise approach to airway management. The expert consensus is that: providers with a high first-pass success rate should perform tracheal intubation.
The use of adrenaline is controversial. We don’t have great evidence for either the dosing or the timing of doses. A large trial in the UK (PARAMEDIC 3, expected Autumn 2021) will look in more detail at the timing of adrenaline and the potential benefits of an IO first approach.
There is a greater emphasis on POCUS and ECMO. This reflects the increasing evidence as a rescue therapy in certain adult patients in cardiac arrest. There is an increasing role of point-of-care ultrasound (POCUS) in peri-arrest care for diagnosis, but it requires a skilled operator, and the need to minimise interruptions during chest compression.
As with the paediatric population: there is a greater recognition that patients with both in- and out-of-hospital cardiac arrest have premonitory signs, and that many of these arrests may be preventable.
What else is in the guidance?
Health inequality (HI) and it’s impact on cardiac arrest outcome
There is vast inequality in the incidence of cardiac arrest, use of bystander CPR and the distribution of public access defibrillators. Deprived areas, and areas with a greater proportion of residents from minority ethnic backgrounds, have a higher incidence of cardiac arrest, lower incidence of bystander CPR and lower access to public access defibrillators. This needs further discussion and research. Teaching CPR to children in all schools would be a way of improving some of these inequalities.
Improving education and systems can save (more) lives
50% of out-of-hospital cardiac arrests (OHCAs) are witnessed. Bystanders performed CPR in 70% of these. Public education is crucial in saving lives. In 2018, 59% of members of the public in the UK reported having received training in CPR and 19% in how to use an automated external defibrillator (AED).
In 2019, over 291,000 people in the UK were trained in CPR as part of World Restart a Heart Day. Teaching the essential core skills in resuscitation will improve patient survival.
Technology-enhanced education, as well as simulation, can be used to improve teaching and engage learners. Social media and smartphone apps can be used to engage the community. A new section has been added to the guidance named ’Systems Saving Lives’ with the intended audience being governments, managers in health and education systems, health care professionals, teachers, students and members of the public. By emphasising the importance of the connections along the Chain of Survival, we can improve the performance of resuscitation systems.
4 Key areas that have been highlighted are:
Another key area in the new guidelines is around integrating decisions about CPR in advanced treatment plans (e.g. Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) process). The guideline highlights the need for communication strategies and interventions to support discussions with patients and their family around resuscitation.
What might we see in the next revision…
- Could IO become the first choice route of adrenaline?
- Will we still be using adrenaline in all arrest situations?
- Will (ab)normal saline be removed entirely?
- Will we have more concrete evidence on using Hartmann’s/ Ringer’s Lactate in resuscitation fluids?
- Will we have more information on the barriers and motivators to bystander CPR and AED use in respect of ethnic, socio-economic, cultural and educational background?
Selected references for the updated Resuscitation Council UK guidelines
Resuscitation Council UK Guidelines 2021 https://www.resus.org.uk/library/2021-resuscitation-guidelines
Madar Jet al European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth (2021). https://doi.org/10.1016/j.resuscitation.2021.02.014 ERC Guidelines 2021: https://cprguidelines.eu/
Wyckoff MH, ET AL. Neonatal Life Support Collaborators. Neonatal Life Support 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2020 Nov;156:A156-A187. https://doi.org/10.1016/j.resuscitation.2020.09.015 Epub 2020 Oct 21. PMID: 3309891