AMERICAN HEART ASSOCIATION COURSES
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PALS Pretest and Study Guide

To access pretest and study guides go to www.heart.org/eccstudent and enter this code: palsprovider

STUDY GUIDE:

If you are new to PALS don’t memorize or be overwhelmed by the enclosed material. Review and relax. Be familiar with the material and I’ll show you how to put it together and the memorization will be easier.

 

What’s New PALS 2010 Guidelines

The following are the major PALS changes in the 2010 guidelines:

• There is further caution about the use of endotracheal tubes. LMA's are acceptable when used by experienced providers (Class IIb).

• Cuffed endotracheal tubes may be used in infants (except newborns) and children in in-hospital settings provided that cuff inflation pressure is kept <20 cm H2 O.

• Confirmation of tube placement requires clinical assessment and assessment of exhaled carbon dioxide (CO2); esophageal detector devices may be considered for use in children weighing >20 kg who have a perfusing rhythm. Waveform capnography will confirm tube placement, quality of CPR and R.O.S.C. (return of spontaneous circulation). Correct placement must be verified when the tube is inserted, during transport, and whenever the patient is moved.

• During CPR with an advanced airway in place, rescuers will no longer perform “cycles” of CPR. Instead the rescuer performing chest compressions will perform them continuously at a rate of 100/minute without pauses for ventilation. The rescuer providing ventilation will deliver 8 to 10 breaths per minute (1 breath approximately every 6 to 8 seconds). For further information, see the Basic Life Support for Healthcare Providers section.

• More evidence has accumulated to reinforce that vascular access (IV/IO) is preferred to endotracheal drug administration.

• Timing of 1 shock, CPR, and drug administration during pulseless arrest has changed and now is identical to that for ACLS. See ACLS section for details.

• Routine use of high-dose epinephrine is not recommended (Class III).

• Lidocaine is de-emphasized, but it can be used for treatment of VF/pulseless VT if amiodarone is not available.

• Induced hypothermia (32ºC to 34ºC for 12 to 24 hours) may be considered if the child remains comatose after resuscitation (Class IIb).

• Indications for the use of inodilators are mentioned in the postresuscitation section.

• Termination of resuscitative efforts is discussed. It is noted that intact survival has been reported following prolonged resuscitation and absence of spontaneous circulation despite 2 doses of epinephrine.

  • C-A-B instead of A-B-C for CPR

Things that have NOT changed in PALS:

• Shock doses for VF/VT (note that the second dose was 2 to 4 J/kg and is now 4 J/kg)

• Shock doses for cardioversion

• Major steps in bradycardia and unstable tachycardia algorithm

• Most drug doses

• Appreciation that most cardiac arrests in infants and children result from a progression of shock or respiratory failure

• Most recommendations for treatments of poisonings and drug overdose

The New PALS OVERVIEW: Major 2010 Changes

Adoption of International Terminology

• Tracheal tube instead of endotracheal tube

• Manual resuscitator instead of bag-valve mask

• Exhaled CO2 detection instead of end-tidal CO2 detection

• Defibrillation clarified. “Shocks are administered to victims in an attempt to achieve defibrillation.”

Ventilation

• Discussion of endotracheal intubation vs. laryngeal mask airway vs. manual resuscitator, with an emphasis on intubation and the contention that sufficient skill and experience need to be present to warrant using this technique with children. Skill with the manual resuscitator is mandatory for anyone providing ALS for children and infants.

Fluid Therapy

• Suggests the use of intraosseous infusions for children (and adults).

Medications

• New information on determining and treating the cause of arrest, with considerable material on toxic drug overdose and metabolic derangements.

• While high dose epinephrine and vasopressin are discussed, data is insufficient to allow firm recommendation for their use with children (Class Indeterminate)

Treatment of Arrhythmias

• Vagal maneuvers are introduced in the SVT discussion. “Ice to face” is the preferred method for infants.

• Amiodarone is offered as a new treatment for pediatric VT and shock-refractory VF

Postarrest Stabilization

• Emphasis on normal ventilation rather than hyperventilation

• Control of temperature, management of postischemic myocardial dysfunction and glucose control

Introduction

"Bystander CPR is provided for only 30% of out-of-hospital pediatric arrests."

Adjuncts for Airway and Ventilation

• Bag-valve-mask ventilation (ventilation bag) is the primary method of ventilatory support for prehospital BLS care, particularly if the transport time is short.

• Intubation of pediatric patients in the out-of-hospital setting requires adequate initial training, ongoing experience, and outcome monitoring.

• While the LMA (laryngeal mask airway) is a proven, effective adjunct for pediatric ventilation, there are two concerns noted in the Guidelines: "An LMA may be more difficult to maintain during patient transport than a tracheal tube." "Furthermore, the LMA is relatively expensive, and a number of sizes are needed…The cost of equipping out-of hospital providers must be considered."

• Neonatal (250 ml) ventilation bags should not be used in ventilation of full-term neonates and infants. Using only the force necessary to cause the chest to visibly rise, ventilation bags with a minimum volume of 450-500 ml are preferred.

"E-C clamp" technique for opening the airway and sealing the mask to the face introduced for ventilation bag performance: "The third, fourth and fifth fingers (forming an E) are positioned to lift it forward; then the thumb and index finger (forming a C) hold the mask on the child’s face."

• Uncuffed tracheal tubes recommended for children younger than 8 years old. Rationale: obstruction to passage of the tube may occur at a point just below the glottic opening.

• A formula for determining tracheal tube size: Size (mm) = (age in yrs / 4) + 4, if cuffed , add 3 instead of 4. For tracheal tubes, length-based resuscitation tapes are accurate for children to approximately 35 kg

• Preparing for endotracheal intubation, assemble three tracheal tubes: the tube of estimated size, one 0.5 mm larger and one 0.5 mm smaller

• Interrupt intubation attempts “if bradycardia develops, the child’s color or perfusion deteriorates, or the oxygen saturation by pulse oximetry falls to an unacceptable level”

• When intubating, use a small pillow to achieve “sniffing” position (slight flexion) for children older than 2 years of age. For younger children (<2) and infants, a pillow is not used. Rather, a small roll is often used to elevate the shoulders.

• Two formulas to estimate appropriate depth of insertion for the tracheal tube:

1) Depth of insertion (cm) = internal diameter (mm) x 3. Alternative (for children older than 2)

 2) Depth of insertion (cm) = (age in yrs/2) + 12

• Regarding exhaled or end-tidal CO2 monitoring: “Six ventilations are recommended to wash out CO2 that may be present in the stomach and esophagus after bag-valve-mask ventilation. After 6 ventilations, detected CO2 can be presumed to be from the trachea rather than from a misplaced tube in the esophagus.”

• Also regarding exhaled or end-tidal CO2 monitoring: Detection of exhaled CO2 in patients with a perfusing rhythm is both specific and sensitive for tube placement in the trachea (Class IIa), exhaled CO2 detection is not as useful for patients in cardiac arrest (Class Indeterminate).

• Emphasis on multi-factor confirmation of tracheal tube placement and continuous efforts to ensure preservation of that correct placement.

Establishing and Maintaining Venous Access

• While the preferred site for intraosseous access in children is the proximal anterior tibia, the Guidelines mention the alternative sites of the distal femur, medial malleolus and anterior superior iliac spine. It also takes note that “In older children and adults intraosseous cannulas were successfully inserted into the radius and ulna in addition to the proximal tibia.”

• The Guidelines refine instructions for endotracheal instillation of medications: dilution of the drug with up to 5 ml of normal saline followed by 5 ventilations is equivalent to, and preferred over, delivery of the drug through a catheter or feeding tube threaded though the endotracheal tube.

Drugs Used for Cardiac Arrest Resuscitation

Vasopressin is a Class Indeterminate action. While data supports its use in adult shock-refractory VF, there is inadequate data supporting its use in infants and children.

• “Ionized hypocalcemia is relatively common in critically ill children, particularly those with sepsis.” Accordingly, calcium chloride 10% is discussed. It is preferred over calcium gluconate because of the greater “bioavailability of calcium.”

• Evaluation for hypoglycemia is again addressed, with treatment using 25% glucose and / or 10% glucose boluses. The Guidelines state, however, that hypoglycemia should be treated with continuous infusions when possible, as bolus therapy can cause osmotic diuresis.

• The discussion of sodium bicarbonate is interesting for the notation that while the “dilute solution (4.2%, 0.5 mEq/ml) may be used in neonates to limit the osmotic load, but there is no evidence that the dilute solution is beneficial for older infants and children.”

Rhythm Disturbances

• The Guidelines note that, while the rhythm most commonly recorded in pediatric cardiac arrest is asystole or a bradyarrhythmia, approximately 10% of these patients had VF or pulseless VT. This number might be as large as 20% when SIDS patients are excluded. It appears that children older than 9 years of age had significantly more VF than those under 4.

• There are four algorithms in the PALS Guidelines:

�� Pulseless Arrest (which combines VF, pulseless VT, PEA and asystole),

�� Bradycardia,

�� “Tachycardia for infants and children with rapid rhythm and adequate perfusion”, and

�� “Tachycardia for infants and children with rapid rhythm and evidence of poor perfusion”

• While epinephrine remains the first choice of medication for the treatment of symptomatic pediatric bradycardia, atropine (0.02 mg/kg) is offered as the preferred medication for bradycardia caused by increased vagal tone.

• Symptomatic bradycardia, as detailed in the algorithm: “poor perfusion, hypotension, respiratory difficulty, altered consciousness”

• While transthoracic pacing has not been proven effective for pediatric asystole or bradycardia secondary to postarrest hypoxia / ischemia or respiratory failure, the Guidelines note that pacing “may be lifesaving” for “selected cases of bradycardia caused by complete heart block or abnormal function of the sinus node.”

• The bradycardia algorithm includes the performance of chest compressions for bradycardia causing severe cardiorespiratory compromise (see “symptomatic bradycardia”, above) if, despite oxygenation and ventilation, the infant or child’s heart rate is less than 60 and the infant or child shows evidence of poor systemic perfusion.

• Each of the four algorithms emphasizes “Identify and Treat Possible Causes”. Pulseless Arrest and both Tachycardia algorithms use “The 6 H’s and 5 T’s”:

  • Hypovolemia
  • Hypoglycemia
  • Hypoxemia
  • Hypothermia
  • Hyperkalemia (and other metabolic disturbances)
  • Hydrogen ion excess (acidosis)
  •  Tension Pneumothorax
  • Pericardial Tamponade
  • Toxins
  • Thromboembolus
  • Trauma

• “Supraventricular tachycardia (SVT) is the most common nonarrest arrhythmia during childhood and is the most common arrythmia that produces cardiovascular instability.”

• The Guidelines note that while P waves are difficult to identify in childhood tachycardia, P waves in sinus tachycardia will be upright in leads I and aVF, while P waves in SVT will be negative in leads II, III, and aVF.

Vagal maneuvers are introduced as a Class IIa action for the treatment of SVT. Ice water applied to the face for infants and young children is described, as is having the child blow through a straw for a Valsalva maneuver. External ocular pressure is specifically excluded.

• “When medications are indicated, adenosine is the drug of choice for SVT in children.” The “two-syringe technique” is described and recommended, with one syringe containing adenosine and the other containing 5-ml of normal saline.

Verapamil for SVT is Class III for infants (refractory hypotension and cardiac arrest), and its use is discouraged in children (hypotension and myocardial depression.)

• The use of Amiodarone in children is introduced. The drug is a Class IIb action for VT with a pulse and a Class Indeterminate for VF and pulseless VT. Use of the drug in shock-refractory VF and pulseless VT follows one shock, epinephrine and another shock. The recommended dose is 5 mg/kg, rapid IV bolus. For SVT, this same dose (5 mg/kg) is recommended as a loading dose given IV, “over several minutes to 1 hour”. Repeated doses of 5 mg/kg, to a maximum of 15 mg/kg/day can be given.

Lidocaine’s use in VT/VF is now Class Indeterminate. “Although lidocaine has long been recommended for treatment of ventricular arrhythmias in infants and children, data suggests it is not very effective unless the arrhythmia is associated with myocardial ischemia.”

Procainamide is no longer recommended for use in childhood VF and pulseless VT, by virtue of the requirement for administration by slow infusion. Its use in perfusing rhythms, including VT with a pulse, can be considered as a Class IIb action: 15 mg/kg over 30 to 60 minutes, with continuous monitoring of ECG and BP.

• The use of vasopressin and high dose epinephrine is addressed briefly as a “vasoconstrictor regimen.” “ …high dose (0.1-0.2 mg/kg) may be considered in shock-resistant VF/pulseless VT (Class IIb)..” Promising adult data places vasopressin as a Class Indeterminate agent for the same rhythms.

Defibrillation, Cardioversion, and External Pacing

• Biphasic AED's are acceptable (Class Indeterminate) for use for children over 8 years of age, though there is a need for additional data to support this use. Additional AED recommendations include:

Regarding adult defibrillation settings in the out-of-hospital setting: "may be reasonable" for children older than 8 years of age, "certainly reasonable" for children who weigh at least 50 kg

AED's may be considered for rhythm identification in children older than 8 years of age

PALS for the Pediatric Trauma Victim

Regarding intubation in the traumatized victim: "We particularly encourage confirmation of proper tracheal tube placement by use of capnography or exhaled CO2 detection both after intubation and throughout transport (Class IIa)..."

Hyperventilation of pediatric head trauma patients is no longer routinely recommended (Class III)

The E aspect of ABCDE Primary Survey "involves maintenance of a neutral thermal environment - keeping the child warm". It also means "completely examine the child for hidden injuries."

Special Resuscitation Situations

The Guidelines include an extensive and detailed section on Toxicological Emergencies, including:

o Cocaine

o Tricyclic Antidepressants and Other Sodium Channel Blockers

o Calcium Channel Blocker Toxicity

o Beta-Adrenergic Blocker Toxicity

o Opioid Toxicity

Post Resuscitation Stabilization

The Neurological Preservation section includes the following information about hyperthermia and active cooling:

While "recent data suggests that postarrest or postischemia hypothermia (core temperatures 33 to 36 degrees Centigrade) may have beneficial effects on neurological function." "There is insufficient data, however, to recommend the routine application of hypothermia (Class Indeterminate)

However - Postarrest patients with core temperatures greater than 33 degrees Centigrade and less than 37.5 degrees Centigrade should not be actively rewarmed.

Postarrest patients with core temperatures lower than 33 degrees Centigrade should only be rewarmed to 34 degrees

"In the brain-injured patient or in the postarrest patient with compromised cardiac output, correct hyperthermia to achieve a normal core temperature (Class IIa)

Family Presence During Resuscitation

The Guidelines offer multiple studies that promote and explain the validity of family presence during resuscitative efforts.

Termination of Resuscitative Efforts

"If a child fails to respond to at least 2 doses of epinephrine with a return of spontaneous circulation, the child is unlikely to survive. In the absence of recurring or refractory VF or VT, history of a toxic drug exposure, or a primary hypothermic insult, resuscitative efforts may be discontinued if there is no return of spontaneous circulation despite ALS interventions. In general, this requires no more than 30 minutes."

Neonatal Resuscitation - Major Changes

• Discussion of room air vs. 100% oxygen during positive pressure ventilation

• Introduction of the laryngeal mask airway (LMA)

• End tidal CO2 detection

• Two thumb technique for chest compressions

"Although 100% oxygen has been used traditionally for rapid reversal of hypoxia, there is biochemical evidence and preliminary clinical evidence to argue for resuscitation with lower oxygen concentrations. Current clinical data, however, is insufficient to justify adopting this practice."

Regarding laryngeal mask airways (LMA's): ..." may be an effective alternative for establishing an airway in resuscitation of the newly born infant, especially in the case of ineffective bag-mask ventilation or failed endotracheal intubation (Class Indeterminate. However, we cannot recommend routine use of the laryngeal mask airway at this time, and the device cannot replace endotracheal intubation for meconium suctioning."

Regarding chest compressions:

• "Although it is common practice to give compressions if the heart is 60 to 80 bpm and not rising, ventilation should be the priority in resuscitation of the newly born. Provision of chest compressions is likely to compete with provision of effective ventilation." Resolved: Chest compressions if the newly born infant's heart rate falls below 60

• Use the "2 thumb-encircling hands technique"

• Compression depth should be one third the depth of the chest, "but the compression depth must be adequate to produce a pulse."

• Coordinate compressions and ventilations to avoid simultaneous delivery. 3:1 ratio, 120 events/minute.

Epinephrine: High dose is now Class Indeterminate. "The tracheal route of administration may result in a more variable response to epinephrine than the intravenous route; however, neonatal data is insufficient to recommend a higher dose of epinephrine for tracheal administration."

Discontinuation of resuscitative efforts may be appropriate if resuscitation of an infant with cardiorespiratory arrest does not result in spontaneous circulation in 15 minutes. Resuscitation of newly born infants after 10 minutes of asystole is unlikely to result in survival or survival without disability (Class IIb)"

PEDIATRIC ADVANCED LIFE SUPPORT

Recommended Guidelines 2000 (still using)

Besides incorporating a new approach to teaching advanced life support, the revised PALS course places increased emphasis on special resuscitation circumstances that require immediate intervention (such as hypothermia, anaphylaxis, and electrical injuries) and includes optional teaching modules on such topics as pediatric sedation, children with special healthcare needs (those on home respirators and those with tracheostomy tubes, for example), coping with death, and toxicology for special circumstances (such as overdoses involving cocaine, tricyclic antidepressants, narcotics, calcium- channel blockers and ß-adrenergic blockers).

It also provides instruction in the use of innovative advanced life support technologies, including exhaled and end-tidal carbon dioxide detectors, the laryngeal mask airway (LMA), and the AED.

In adults, cardiopulmonary arrest is typically sudden and primarily cardiac in origin. In contrast, arrest in children usually follows progressive shock and respiratory failure. Arrest in a young child is most often associated with sudden infant death syndrome, sepsis, or trauma.

Trauma is the most common cause of arrest in children older than 6 months. The success of any advanced life support intervention depends on early recognition of respiratory and circulatory compromise combined with aggressive management of the airway, treatment of rhythm disturbances, and expeditious fluid resuscitation.

OXYGENATION, VENTILATION AND FLUIDS!

Pediatric BLS:

Trained Pre-Hospital pediatric rescuers should provide approximately 2 minute of BLS before activating the EMS system. In hospital rescuers call the code for unresponsive pediatrics.

Automated external defibrillators. Medical evidence indicates that, in nontraumatic arrest, the incidence of ventricular fibrillation is only 3% in children under 8 years, but rises significantly—to 17%—in those older than 9 years. Based on this information, new PALS guidelines approve the use of AED's for assessing heart rhythms and defibrillating children 8 years and older who collapse suddenly outside the hospital. AED's, which have proved to be extremely useful in adults, are conveniently located in many public places (such as airports). They deliver an initial dose of 150 to 200 J, or fewer than 10 J/kg for most children older than 8 years— a dose that is believed to be safe as previously noted, instruction in the use of an AED is encouraged in BLS training.

There is continued emphasis on the need to provide rescue breaths slowly (1-1.5 second duration) to ensure adequate ventilation and to reduce the likelihood of gastric distention. If breathing is absent, but a pulse is present, rescue breathing should be provided at a rate of 20 breaths/minute (approximately 1 breath every 3 seconds) for the infant or child victim.

In order to simplify the BLS guidelines, the compression rates for infants and children are now virtually identical- 100/minute for children and at least 100/minute for infants. With pauses for ventilation.  Instead of the familiar "a-b-c" for airway, breathing and circulation, the new order of initiating CPR is "C-A-B" with emphasis on commencing compression sooner. The recommended compression depth of .5-1 inch for the infant and 1-1.5 inches for the child remains unchanged, but is approximate. Rule of Thumb: The sternum of the infant or child is compressed approximately 1/3 the depth of the chest.

Chest compressions should be initiated when the heart rate is less than 80 per minute in an infant or less than 60 per minute in a child.

Respiratory Assessment and Airway Management: Compensation for Perfusion

Airway support may be provided by means of various airways, a manual resuscitator, endotracheal intubation, or an LMA, depending on the training and skill of the rescuers and the nature and circumstances of the arrest.

There are two types of manual resuscitators (ventilation bags): The self-inflating resuscitator (ambubag) uses a valve system to fill the bag with oxygen or air following a compression, whereas the flow-inflating bag (anesthesia bag) refills only with oxygen inflow, which must be regulated. A self-inflating bag is easier to use for most medical personnel, but cannot be used to provide supplemental oxygen during spontaneous respiration and provides only room air unless it is connected to an oxygen source. An attached oxygen reservoir enables self-inflating bags to provide as much as a 95% inspired oxygen concentration.

The latest PALS guidelines recommend that the self-inflating bag be used for pediatric resuscitation (the flow-inflating bag can be used as an alternative by properly trained personnel to resuscitate newly born). Rescuers should use a self-inflating bag with a minimum volume of 450 mL for full-term newly born, infants, and children.

Neonatal-sized (250 mL) manual resuscitators are no longer recommended because they may not support effective tidal volume and longer inspiratory times in full-term neonates and infants.

In regard to intubated pediatric patients, the new guidelines recommend confirming tracheal tube placement by using exhaled waveform capnography or end-tidal carbon dioxide detectors. Waveform capnography can continuously determine tube placement, quality of compressions and R.O.S.C. Exhaled carbon dioxide detectors are colorimetric systems that change color if CO2 is produced during exhalation. End-tidal carbon dioxide monitors measure and display the quantity of CO2 at the end of exhalation.

The use of pulse oximetry is encouraged in critically ill infants and children because it enables continuous evaluation of the arterial oxygen saturation.

Pulse oximetry has been successfully used in the pre-hospital as well as the hospital setting. It may provide early indication of respiratory deterioration and development of hypoxemia and should be used during stabilization and transport.

If peripheral perfusion is inadequate (i.e., shock is present, vasopressors used), pulse oximetry is unreliable because accurate readings require the presence of pulsatile blood flow. Care must also be taken to assure proper placement for accurate results.

An end-tidal carbon dioxide detector can enable verification of endotracheal tube placement and displacement in infants larger than 2 kg during stabilization and transport in the pre-hospital and hospital setting.

End-tidal carbon dioxide is negligible in esophageal ET tube placement during resuscitation of the child with no spontaneous circulation.

However, the information provided by end-tidal carbon dioxide monitoring may be misleading because extremely low end-tidal carbon dioxide may indicate either poor cardiac output or esophageal tube placement

The new guidelines also address the use of the laryngeal mask airway in young children.

The LMA is a tube, with a mask-like projection at the end. It is introduced into the hypopharynx, and a balloon cuff is inflated, securing the distal opening of the tube above the glottic opening. Many believe that an LMA can be inserted more readily than a tracheal tube. ET is still the best airway control.

LMA's do not protect the airway from aspiration, and medications cannot be administered through them. They should not be used in a child with an intact gag reflex.

Intravenous Flush:

Central venous drug administration has been shown to produce more rapid onset of action and higher peak drug levels than peripheral venous administration in adult resuscitation models.

However, these differences have not been demonstrated in pediatric resuscitation models and may not be important during pediatric CPR.

Peripheral venous access or intraosseous access provides adequate delivery of fluids and drugs provided that the drugs are flushed into the central circulation (2-5 cc of saline).

Endotracheal Drug Administration:

Endotracheal administration of lipid-soluble resuscitation drugs, including epinephrine, should be provided if vascular access has not been achieved within 3 to 5 minutes. ( LEAN) NARCAN, ATROPINE, EPI, Lido.

The recommended dose of epinephrine to be administered via endotracheal tube during pediatric resuscitation has been increased to 10 times the intravenous or intraosseous route (0.1 mg/kg, 1:1000 solution).

Doses of other resuscitation drugs should probably also be increased from the intravenous dose when administered endotracheally, however, the optimal dosage has yet been determined.

When drugs are administered by the endotracheal route, they should be instilled as deeply as possible into the tracheobronchial tree, using a catheter or feeding tube inserted beyond the distal tip of the endotracheal tube. Dilution of the drug into 1 or 2 mL of normal/half-normal saline or LR may aid drug delivery into the peripheral airways.

Optimal doses for epinephrine given by the endotracheal tube in newborns are not known.

At present, the same doses of epinephrine for intravenous and endotracheal administration (0.01 to 0.03mg/kg) are recommended.

Consideration should be given to using higher doses of 0.1 to 0.2mg/kg of epinephrine by the endotracheal route if intravenous access is not available and the neonate does not respond to standard doses.

Intraosseous Access:

In children six years of age or younger, intraosseous access should be established if reliable venous access cannot be achieved within three attempts or 90 seconds. Any fluid or drug that can be administered intravenously, may be administered intraosseous.

Intravenous Fluids:

Expansion of circulating blood volume is a critical component of pediatric ALS in children who have sustained trauma with acute blood loss, and it may also be lifesaving in the treatment of non-traumatic shock, such as severe dehydration or septic shock. Early assessment of circulating blood volume is important to prevent progression to refractory shock or cardiac arrest. If the patient in cardiac arrest fails to respond to epinephrine and initial resuscitative efforts, a volume bolus may be considered to rule out hypovolemia.

Glucose Therapy:

Infants have high glucose needs and low glycogen stores.

As a result, during periods of stress and high energy requirements, the infant may become hypoglycemic. For this reason blood glucose concentrations should be closely monitored during coma, shock, or respiratory failure. Documented hypoglycemia should be treated with an infusion of a glucose-containing solution in a dose of 0.5 to 1.0 g/kg. This can be accomplished with 2-4 mL/kg of 25% glucose solution or 10-20 mL/kg of a 5% glucose solution (D5LR or D5NS).

If possible, hypoglycemia should be treated with a continuous infusion of a glucose-containing solution. Bolus therapy with hypertonic glucose should be avoided because it may result in hyperglycemia, secondary osmotic diuresis, and a potentially worse neurological outcome.

If a bedside glucose determination is not available and clinically the infant is at risk for hypoglycemia, empiric treatment with glucose 0.5 to 1.0 g/kg can be ‘considered’.

Epinephrine Dosage:

In cardiac arrest, alpha-adrenergic-mediated vasoconstriction is the most important pharmacologic action of epinephrine because restoration of aortic diastolic pressure is a critical determinant of success or failure of resuscitation.

To manage unresponsive asystolic and pulseless arrest, epinephrine is initially administered intravascularly or intraosseously in a dose of 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution). The latest PALS guidelines recommend the same amount of epinephrine for second and subsequent doses instead of "high-dose" epinephrine. Although high-dose epinephrine is no longer recommended, it still may be considered in refractory arrest situations.

The epinephrine dose for treatment of bradycardia is 0.01 mg/kg (0.1 cc/kg of 1:10,000 solution) by IV or I0 route or 0.1 mg/kg (0.1 cc/kg of 1:1,000 solution) by ET route. The epinephrine dose is not increased as long as the pulse remains palpable.

The recommended initial resuscitation dose of epinephrine for asystolic or pulseless arrest is 0.01 mg/kg (0.1 cc/kg of 1:10,000 solution) given by the IV or I0 route.

Second and subsequent epinephrine doses for unresponsive asystolic and pulseless arrest should be 0.1 mg/kg (0.1 cc/kg of 1:1000 solution).

The higher dose of epinephrine should be administered within 3 to 5 minutes following the initial dose and should be repeated every 3 to 5 minutes during resuscitation. Second and subsequent doses as high as 0.2 mg/kg may be effective.

In newborn resuscitation the recommendation of epinephrine is 0.01 to 0.03 mg/kg and may be repeated every 3 to 5 minutes if required. There are inadequate data to evaluate the efficacy and safety of higher doses of epinephrine in newborns.

**Because this new dosing requires use of two different dilutions of epinephrine, care must be taken to avoid errors in concentration selection and dosing.

In summary, 0.1 cc/kg of the 1:10,000 dilution is used to administer 0.01 mg/kg of epinephrine and 0.1 cc/kg of the 1:1000 dilution is used to administer 0.1 mg/kg of epinephrine. The cc/kg dose remains the same; only the dilution changes.

New Treatment Protocols:

New detailed treatment protocols are provided for bradycardias, asystole, pulseless electrical activity, and ventricular fibrillation/pulseless ventricular tachycardia.

Amiodarone, in a dose of 5 mg/kg, is now considered the drug of choice for ventricular fibrillation or pulseless ventricular tachycardia unresponsive to three initial defibrillation attempts.

It can also be used to manage hemodynamically stable ventricular tachycardia refractory to cardioversion.

Treatment of_SVT/PSVT:

Vagal maneuvers have been added to the treatment algorithm for supraventricular tachycardia in children with milder symptoms who are hemodynamically stable. They may also be tried during preparation for cardioversion or drug therapy. Such maneuvers include applying ice water to the face (most effective in infants and young children), carotid sinus massage, and the Valsalva maneuver. External ocular pressure is not recommended. A 12-lead ECG should be obtained before and after performing a vagal maneuver, and the ECG should be monitored continuously during the maneuver.

SVT/PSVT that causes circulatory instability (unstable SVT) is most expeditiously treated with synchronized electrical cardioversion at a starting dose of 0.5 J/kg.

If intravenous access is already available, Adenosine may be administered before cardioversion, but cardioversion should not be delayed while intravenous access is achieved. With continuous ECG monitoring, adenosine 0.1 mg/kg should be given as a rapid intravenous bolus. If there is no effect, the dose may be doubled and repeated. The maximum single dose of adenosine should not exceed 12 mg. Verapamil should not be used in infants and its use is discouraged in children.

Meconium-Stained Amniotic Fluid:

Thorough suctioning of the nose, mouth, and posterior pharynx before delivery of the shoulders and thorax should be performed in all neonates having difficulty, with meconium staining, regardless of whether the meconium is thin or thick.

Use of a large-bore (12F or 14F) suction catheter is recommended, although a bulb syringe may be adequate. If the infant is depressed ~ the meconium is thick or particulate, further suctioning is required immediately after delivery and before performing the usual initial resuscitative steps.

The posterior pharynx should be suctioned. Direct endotracheal suctioning, using the endotracheal tube as a suction catheter, should be performed if the neonate is depressed or the meconium is thick or particulate.

Endotracheal suctioning may not be necessary if the meconium is thin and the newborn is vigorous.

After meconium has been removed by several passes of the tube, if positive pressure ventilation is required, it may be appropriate to leave the endotracheal tube in place.

Subsequent suctioning may then be performed by passing a suction catheter through the endotracheal tube. If the baby is severely depressed, the use of positive-pressure ventilation with 100% oxygen should be considered even if some meconium remains in the airway. This addition is based on the need to balance the urgency of establishing a clear airway with the need for oxygenation-ventilation. Personnel should not suction the stomach until after the infant has been fully resuscitated and vital signs are stable.

Resuscitation bags used for ventilation of full-term neonates, infants and children should have a minimum volume of 450 mL.

Intraosseous access. The new PALS guidelines have dropped the recommendation to attempt IV access before inserting an intraosseous (IO) line in a pediatric arrest victim. The guidelines now support using an IO line in children older than 6 years in an emergency situation.

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