+ IMPROVING CARE THROUGH EVIDENCE
GUIDELINES UPDATE
| PRINT | SUBSCRIBE | WEBSITE
Guideline:
22
| |Clinical
2010Practice
American
PAGE
PAGE
Benign
HeartParoxysmal
Association
Positional
VertigoFor
Guidelines
Cardiopulmonary
Parameter:And
PAGE 3 | Practice
Resuscitation
Therapies
For Benign
Emergency
Paroxysmal
Positional
Cardiovascular
Vertigo
Evidence-Based
Care(An
Science
Review): Report Of The
Circulation.
Quality
Standards Subcommittee Of The American
of Neurology
Editorial
Comment
PAGE 8|Academy
5 | Clinical Practice Guideline:
References
PAGE 9|Acute
Otitis Externa
PAGE
Editor’s Note: To read more about this publication
and the background and methodologies for practice
guideline development, go to:
http://www.ebmedicine.net/introduction
CurrentParoxysmal
Guidelines Positional
For
Benign
Pediatric Advanced Life Support:
Vertigo
AndAHA
Acute
Otitis Externa
The 2010
Guidelines
this issue
of EM
Practice Guidelines
Update, we reIn nThe
ED:
Current
Guidelines
I
I
view the 2010 American Heart Association Guidelines for
Resuscitation
and Emergency
InCardiopulmonary
this issue of EM Practice
Guidelines Update,
we review 2Cardiovascular
Care,
with
the
focus
on
recommendations
guidelines that address the diagnosis and management of for
pediatric
resuscitation,
interpreted
as they
apply
to emerbenign paroxysmal
positional
vertigo (BPPV)
and
1 guideline
on
gency
the
topic medicine.
of acute otitis externa (AOE). BPPV is the most common
cause of vertigo, with a lifetime prevalence of 2.4%, and while
Guideline
itPractice
is not dangerous
per se,Impact
it is an important cause of patient
discomfort
and
missed
work
as well
falls, particularly
in the over
• In pediatric cardiac arrest,
chestascompressions
are stressed
elderly.
The most common
emergency
department
for
ventilations,
demonstrated
with the
mnemonic therapies
of CAB (compresBPPVsions,
(antihistamines,
anticholinergics,
and
sedatives)
are
not
airway, breathing) with at least 100 high-quality chest
recommended
by specialists.
compressions
provided per minute. However, evidence does
show that
optimal
cardiopulmonary
resuscitation
(CPR) in infants
The second
topic
for review,
AOE, is a prevalent
and painful
and
children
includes
both
compressions
and
ventilations.
condition seen by emergency clinicians whose management can be
complicated
by several
common
pitfalls.
• A laryngeal
mask airway
(LMA)
is an acceptable alternative
when bag-mask ventilation is not adequate and endotracheal
Practice
Guideline
Impact: Care should be taken with LMA use in
intubation
is impossible.
• Vestibular
suppressant
medications
of the benzodiazepine,
younger children, as the
rate of complication
is higher than in
anticholinergic,
and
antihistamine
classes
have a limited role
older children and adults.
in the management of BPPV.
• Intraosseous (IO) access should be used as a rapid, safe, and
• Aeffective
particle repositioning
maneuver
theadministration
therapy of choice
route for vascular
accessisand
of allin
the
management
of BPPV andduring
shouldpediatric
be performed
the ED
intravenous
(IV) medications
cardiacinarrest.
or
arranged
from
the
ED.
• Administration of calcium and sodium bicarbonate are to be
•
considered
only in specific
(documented
hypocalcemia,
Systemic
antibiotics
shouldsituations
be avoided
in most cases
of
calcium-channel
blocker
overdose,
hyperkalemia
or
hypermagdiffuse AOE.
nesemia for calcium administration, and hyperkalemic cardiac arrest or certain toxidromes for sodium bicarbonate administration).
April 2011
November
2009
Volume
3, Number
Number 24
Volume 1,
Author
Editor-In-Chief
Louis
A. Spina, MD
Assistant Professor of Emergency Medicine, Mount Sinai School of Medicine,
Reuben
J. Strayer, MD
New
York, NY
Assistant Professor of Emergency Medicine,
Editor-In-Chief
Mount Sinai School of Medicine, New York, NY
Reuben J. Strayer, MD
Assistant Professor of Emergency Medicine, Mount Sinai School of Medicine,
Editorial
Board
New
York, NY
Andy Jagoda,
Editorial
Board MD, FACEP
Professor and Chair, Department of Emergency Medicine
Nicole C. Bouchard, MD, FRCPC
Mount Sinai School of Medicine, New York, NY
Assistant Clinical Professor, Assistant Site Director; Director of Medical Toxicology,
New
Hospital,
ErikYork-Presbyterian
Kulstad, MD,
MS Columbia University Medical Center, New York, NY
Research
Director,
Andy
Jagoda,
MD,Advocate
FACEP Christ Medical Center
Department
of Emergency
OakMedicine,
Lawn, IL
Professor
and Chair,
DepartmentMedicine,
of Emergency
Mount Sinai School of
Medicine,
York, NY
Eddy S.New
Lang,
MDCM,
CCFP (EM), CSPQ
Associate
Professor,
McGill University, SMBD Jewish General
Erik
Kulstad,
MD, MS
Hospital,Director,
Montreal,
Canadaof Emergency Medicine, Advocate Christ
Research
Department
Lewis S. Nelson, MD
Medical Center, Oak Lawn, IL
Eddy
S. Lang,
MDCM,
CCFP (EM),
CSPQNew York City Poison
Director,
Fellowship
in Medical
Toxicology,
Senior
Researcher,
Alberta Health
Services;
Associate Professor,
University of
Control
Center, Associate
Professor,
Department
of Emergency
Calgary;
Adjunct
University,
Montreal,
Medicine,
NYUProfessor,
Medical McGill
Center,
New York,
NY Quebec, Canada
Lewis
S. Nelson,
MD MD, RDMS
Gregory
M. Press,
Associate Professor of Emergency Medicine, New York University School of
Assistant Professor, Director of Emergency Ultrasound, Emergency
Medicine; Director, Fellowship in Medical Toxicology, New York City Poison Control
Ultrasound Fellowship Director, Department of Emergency Medicine,
Center, New York, NY
University of Texas at Houston Medical School, Houston, TX
Gregory M. Press, MD, RDMS
Scott M.
Silvers,
MDof Emergency Ultrasound, Emergency Ultrasound
Assistant
Professor,
Director
Chair, Department
of Emergency
Medicine
Fellowship
Director, Department
of Emergency
Medicine, University of Texas at
Mayo Clinic,
Jacksonville,
FL TX
Houston
Medical
School, Houston,
ScottS.Weingart,
MD FACEP
Maia
Rutman, MD
Assistant
Professor,
Department
Emergency
Medicine, Elmhurst
Medical
Director,
Pediatric
Emergency of
Services,
Dartmouth-Hitchcock
Medical
Hospital
Center,Professor
Mount Sinai
School
of Medicine,
NewDartmouth
York, NY
Center;
Assistant
of Pediatric
Emergency
Medicine,
Medical School, Lebanon, NH
Prior toM.
beginning
Scott
Silvers,this
MDactivity, see “Physician CME Information” on
page 7.
Chair,
Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL
Scott Weingart, MD, FACEP
Editor’s Note: Introduction to a New Series
Assistant Professor, Director of the Division of Emergency Critical Care,
Department
of Emergency
Medicine,
MountisSinai
School
of Medicine, from
EM Practice
Guidelines
Update
a new
publication
New York, NY
EB Medicine that will help emergency department clinicians stay current with practice guidelines. To read more
Priorpublication
to beginning this
activity,
“CME Information”
about this
and
the see
background
and methodon page 10.
ologies for practice guideline development, http://www.
ebmedicine.net/introduction
| print | SUBSCRIBE | WEBSITE
Current Guidelines For Pediatric Advanced Life Support: 2010 AHA Guidelines
2010 American Heart Association Guidelines For Cardiopulmonary Resuscitation And Emergency Cardiovascular Care Science1
Circulation. 2010;122(18)S639-S933.
Link: http://circ.ahajournals.org/content/vol122/18_suppl_3/
T
his document was developed by clinicians from various subspecialties organized by the American Heart Associated (AHA)
based on the 2010 International Liaison Committee on Resuscitation (ILCOR) International Consensus on CPR and Emergency
Cardiovascular Care (ECC) Science. The AHA transforms international scientific consensus statements into periodic revisions of the
AHA Guidelines for CPR and ECC. The 2010 document serves as an
update to the last major revision published in 2005. The full guidelines
document consists of 17 chapters that were published in the AHA journal Circulation.
erally labeled Class IIb when the evidence documented only short-term
benefits from the therapy or weakly positive or mixed results. Class IIb
recommendations are identified by terms such as “can be considered”
or “may be useful” or “usefulness/effectiveness is unknown or unclear
or not well established.” Class III recommendations were reserved for
interventions for which the available evidence suggests more harm
than good, and experts agreed that the intervention should be avoided.
The Levels of Evidence (LOE) used by the ACCF/AHA Task Force
on Practice Guidelines employs an alphabetic system (A, B, or C) to
describe the body of evidence supporting a given recommendation.
Generally, Level A body of evidence indicates 2 or more ILCOR LOE
1 studies support of the recommendation (multiple populations have
been evaluated, or data are derived from multiple randomized clinical trials or meta-analyses). Level B designation indicates that most
studies supporting the recommendation are ILCOR LOE 2 or 3 studies
(limited populations have been evaluated, or data are derived from a
single randomized trial or nonrandomized trial). A Level C body of evidence indicates that very limited populations have been evaluated or
that only the consensus opinions of experts, case studies, or standards
of care support the recommendation.
The chairs and writing group members for each chapter of the 2010
AHA Guidelines for CPR and ECC were nominated and required to
complete an AHA conflict of interest disclosure. Writing group chairs
and most of the writing group members were required to be free of
relevant conflicts of interest. In developing these guidelines, the writing groups used a recommendation system consistent with that used
by the American College of Cardiology Foundation/American Heart
Association (ACCF/AHA) collaboration on evidence-based guidelines.
Recommendation grades represent the integration of the weight and
quality of scientific evidence with contextual factors such as expert
assessment of the magnitude of benefit, usefulness, or efficacy; cost;
educational and training challenges; and difficulties in implementation.
The AHA CPR/ECC recommendations encompass a variety of topics
in adult and pediatric medicine. The following is an abstraction of the
questions and recommendations on the topic of pediatric resuscitation interpreted as they apply to emergency medicine. According to
copyright requirements of the American Heart Association, excerpted
recommendations from these guidelines are presented here on pages
3-7 with no publication logos, trademarks, headers or commingled
commentary in order to not imply endorsement or affiliation of this publication with the American Heart Association. Editorial comment on the
excerpted sections begins on page 8.
For Class I recommendations, high-level prospective studies support the action or therapy, and the benefit substantially outweighs the
potential for harm. An exception is possible for actions or therapies
with extraordinarily large treatment effects for which expert consensus
alone may suffice. For Class IIa recommendations, the weight of available evidence supports the action or therapy, and the therapy is considered reasonable and generally useful. Recommendations were genEM Practice Guidelines Update © 2011
2
ebmedicine.net • April 2011
Current Guidelines For Management Of Spontaneous Intracerebral Hemorrhage In The ED
Defibrillation
A manual defibrillator is preferred when a shockable rhythm is identified by a trained healthcare provider. The recommended first energy
dose for defibrillation is 2 J/kg. If a second dose is required, it should
be doubled to 4 J/kg. If neither [a manual defibrillator or an AED
equipped with a pediatric attenuator] is available, an AED without a
dose attenuator may be used (Class IIb, LOE C).
Excerpts From Part 13: Pediatric Basic Life Support2
Immediate Recognition And Activation Of The Emergency Response
• It is reasonable for healthcare providers to tailor the sequence of
rescue actions to the most likely cause of arrest. (Class IIa, LOE C).
• ...in the heat of an emergency, ...studies show that healthcare
providers, as well as lay rescuers, are unable to reliably detect a
pulse. If, within 10 seconds, you don't feel a pulse or are not sure if
you feel a pulse, begin chest compressions (Class IIa, LOE C).
• If there is a palpable pulse ≥ 60 per minute but there is inadequate
breathing, give rescue breaths at a rate of about 12 to 20 breaths
per minute (1 breath every 3 to 5 seconds) until spontaneous
breathing resumes. Reassess the pulse about every 2 minutes
(Class IIa, LOE B) but spend no more than 10 seconds doing so.
Excerpts From Part 14: Pediatric Advanced Life Support3
Pediatric Advanced Life Support usually takes place in an environment
where multiple providers are nearby and rapidly mobilized; actions
may therefore be performed simultaneously, unlike in Basic Life Support, where only one responder is assumed to be present.
Chest Compressions And Ventilations
• After 30 compressions (15 compressions if 2 rescuers), open the
airway with a head tilt–chin lift and give 2 breaths. If there is evidence of trauma that suggests spinal injury, use a jaw thrust without head tilt to open the airway (Class IIb LOE C).
• A lone rescuer uses a compression-to-ventilation ratio of 30:2. For
2-rescuer infant and child CPR, one provider should perform chest
compressions while the other keeps the airway open and performs
ventilations at a ratio of 15:2. Deliver ventilations with minimal interruptions in chest compressions (Class IIa, LOE C).
• Optimal CPR in infants and children includes both compressions
and ventilations, but compressions alone are preferable to no CPR
(Class 1 LOE B).
• Healthcare providers often deliver excessive ventilations during
CPR...[This] increases intrathoracic pressure and impedes venous
return and therefore decreases cardiac output, causes... barotrauma...[and] increases the risk of regurgitation and aspiration. Avoid
excessive ventilation (Class III, LOE C).
• Until additional information becomes available, it is reasonable for
healthcare providers to use 100% oxygen during resuscitation.
Once circulation is restored, monitor systemic oxygen saturation.
It may be reasonable, when appropriate equipment is available, to
titrate oxygen administration to maintain the oxyhemoglobin saturation ≥ 94% (Class IIb, LOE C).
Chest Compressions
• Chest compressions should be immediately started by one rescuer,
while a second rescuer prepares to start ventilations with a bag
and mask (Class I, LOE C).
• High-quality CPR requires 100 compressions/min, an adequate
compression depth (at least one-third of the AP diameter of the
chest or approximately 1.5 inches [4 cm] in infants and approximately 2 inches [5 cm] in children), allowing complete recoil of the
chest after each compression.
Airway Considerations
When bag-mask ventilation is unsuccessful and when endotracheal
intubation is not possible, the LMA is acceptable when used by experienced providers to provide a patent airway and support ventilation
(Class IIa, LOE C). LMA insertion is associated with a higher incidence of
complications in young children compared with older children and adults.
Bag-Mask Ventilation
• Bag-mask ventilation can be as effective, and may be safer, than
endotracheal tube ventilation for short periods during out-of-hospital resuscitation. In the prehospital setting, it is reasonable to ventilate and oxygenate infants and children with a bag-mask device,
especially if transport time is short (Class IIa, LOE B).
3
Current Guidelines For Management Of Spontaneous Intracerebral Hemorrhage In The ED
•
•
•
Apply... cricoid pressure in an unresponsive victim to reduce air
entry into the stomach (Class IIa, LOE B). This may require a third
rescuer if cricoid pressure cannot be applied by the rescuer who is
securing the bag to the face.
Avoid excessive cricoid pressure so as not to obstruct the trachea
(Class III, LOE B).
In the victim with a perfusing rhythm but absent or inadequate
respiratory effort, give 1 breath every 3 to 5 seconds (12 to 20
breaths per minute), using the higher rate for the younger child
(Class I, LOE C).
•
Uncuffed endotracheal tube ID (mm) = 4 + (age/4)
Cuffed Tube
• If a cuffed tube is used for emergency intubation of an infant less
than 1 year of age, it is reasonable to select a 3.0 mm ID tube.
• For children between 1 and 2 years of age, it is reasonable to use
a cuffed endotracheal tube with an internal diameter of 3.5 mm
(Class IIa, LOE B).
• After age 2 it is reasonable to estimate tube size with the following
formula (Class IIa, LOE B):
Cuffed endotracheal tube ID (mm) = 3.5 + (age/4)
Ventilation Rates
• If the infant or child is intubated [during cardiac arrest], ventilate
at a rate of about 1 breath every 6 to 8 seconds (8 to 10 times per
minute) without interrupting chest compressions (Class I, LOE C).
• It may be reasonable to [ventilate at a rate of 1 breath every 6-8
seconds without interrupting chest compressions in a pulseless
patient] if an LMA is place (Class IIB, LOE C).
Verification Of Endotracheal Tube Placement
• Since no single confirmation technique, including clinical signs or
the presence of water vapor in the tube, is completely reliable, use
both clinical assessment and confirmatory devices to verify proper
tube placement immediately after intubation, again after securing
the endotracheal tube, during transport, and each time the patient
is moved (eg, from gurney to bed) (Class I, LOE B). In hospital
settings, perform a chest x-ray to verify that the tube is not in a
bronchus and to identify proper position in the midtrachea.
• When available, exhaled CO2 detection (capnography or colorimetry) is recommended as confirmation of tracheal tube position for
neonates, infants, and children with a perfusing cardiac rhythm in
all settings (Class I, LOE C).
• Exhaled CO2 detection is also recommended during intrahospital or
interhospital transfer (Class IIb, LOE C).
• During cardiac arrest, if exhaled CO2 is not detected, confirm tube
position with direct laryngoscopy (Class IIa, LOE C), because the
absence of CO2 may reflect very low pulmonary blood flow rather
than tube misplacement.
• If capnography is not available, an esophageal detector device
(EDD) may be considered to confirm endotracheal tube placement
in children weighing > 20 kg with a perfusing rhythm (Class IIb,
LOE B), but the data are insufficient to make a recommendation for
or against its use in children during cardiac arrest.
Cricoid Pressure During Intubation
There is insufficient evidence to recommend routine cricoid pressure
application to prevent aspiration during endotracheal intubation in children. Do not continue cricoid pressure if it interferes with ventilation or
the speed or ease of intubation (Class III, LOE C).
Choosing The Correct Endotracheal Tube
• Both cuffed and uncuffed endotracheal tubes are acceptable for
intubating infants and children (Class IIa, LOE C).
• Cuffed endotracheal tubes may decrease the risk of aspiration. If
cuffed endotracheal tubes are used, cuff inflating pressure should
be monitored...(usually less than 20 to 25 cm H2O). In certain circumstances (eg, poor lung compliance, high airway resistance, or
a large glottic air leak), a cuffed endotracheal tube may be preferable...(Class IIa, LOE B).
Uncuffed Tube
• If an uncuffed endotracheal tube is used for emergency intubation, it is
reasonable to select a 3.5-mm ID tube for infants up to 1 year of age
and a 4.0-mm ID tube for patients between 1 and 2 years of age.
After age 2, uncuffed endotracheal tube size can be estimated by
the following formula:
4
Current Guidelines For Management Of Spontaneous Intracerebral Hemorrhage In The ED
Transtracheal Catheter Oxygenation And Ventilation
Transtracheal catheter oxygenation and ventilation may be considered for patients with severe airway obstruction above the level of the
cricoid cartilage if standard methods to manage the airway are unsuccessful. This technique is intended for temporary use while a more
effective airway is obtained. Attempt this procedure only after proper
training and with appropriate equipment (Class IIb, LOE C).
Medications: Calcium
Calcium administration is not recommended for pediatric cardiopulmonary arrest in the absence of documented hypocalcemia, calcium channel
blocker overdose, hypermagnesemia, or hyperkalemia (Class III, LOE B).
Medications: Glucose
Check blood glucose concentration during the resuscitation and treat
hypoglycemia promptly (Class I, LOE C).
Extracorporeal Life Support
Extracorporeal life support (ECLS) should be considered only for
children in cardiac arrest refractory to standard resuscitation attempts,
with a potentially reversible cause of arrest (Class IIa, LOE C).
Medications: Sodium Bicarbonate
Routine administration of sodium bicarbonate is not recommended
in cardiac arrest (Class III, LOE B). Sodium bicarbonate may be
administered for some toxidromes or... hyperkalemic cardiac arrest.
Excessive sodium bicarbonate may impair tissue oxygen delivery;
cause hypokalemia, hypocalcemia, hypernatremia, and hyperosmolality; decrease the VF threshold; and impair cardiac function.
Bedside Echocardiography
There is insufficient evidence for or against the routine use of echocardiography in pediatric cardiac arrest. When appropriately trained personnel are available, echocardiography may be considered to identify patients
with potentially treatable causes of the arrest (Class IIb, LOE C).
Pulseless Arrest: Non-Shockable Rhythm; Asystole/PEA
• Continue CPR with as few interruptions in chest compressions as
possible. A second rescuer obtains vascular access and delivers
epinephrine, 0.01 mg/kg (0.1 mL/kg of 1:10 000 solution) maximum
of 1 mg (10 mL), while CPR is continued. The same epinephrine
dose is repeated every 3 to 5 minutes (Class I, LOE B).
• There is no survival benefit from high-dose epinephrine, and it may
be harmful, particularly in asphyxia (Class III, LOE B).
• High-dose epinephrine may be considered in exceptional circumstances, such as beta-blocker overdose (Class IIb, LOE C).
End-Tidal CO2
Continuous capnography or capnometry monitoring, if available, may
be beneficial during CPR to help guide therapy, especially the effectiveness of chest compressions (Class IIa, LOE C).
Intraosseus Access
Intraosseus access (IO) is a rapid, safe, effective, and acceptable
route for vascular access in children, and it is useful as the initial vascular access in cases of cardiac arrest (Class I, LOE C). All intravenous medications can be administered intraosseously.
Pulseless Arrest: Shockable Rhythm; VF/Pulseless VT
• Defibrillation is the definitive treatment for VF (Class I, LOE B) with
an overall survival rate of 17% to 20%... if early, high-quality CPR
is provided with minimal interruptions.
• It is acceptable to use an initial dose of 2 to 4 J/kg (Class IIa, LOE
C), but for ease of teaching an initial dose of 2 J/kg may be considered (Class IIb, LOE C). For refractory VF, it is reasonable to
increase the dose to 4 J/kg (Class IIa, LOE C). Subsequent energy levels should be at least 4 J/kg, and higher energy levels may
be considered, not to exceed 10 J/kg or the adult maximum dose
(Class IIb, LOE C).
Estimating Weights
• If the child’s weight is unknown, it is reasonable to use a body
length tape with precalculated doses (Class IIa, LOE C).
• There are no data regarding the safety or efficacy of adjusting the
doses of resuscitation medications in obese patients. Therefore,
regardless of the patient’s habitus, use the actual body weight for
calculating initial resuscitation drug doses or use a body length
tape with precalculated doses (Class IIb, LOE C).
5
Current Guidelines For Management Of Spontaneous Intracerebral Hemorrhage In The ED
•
•
•
•
•
Provide CPR until the defibrillator is ready to deliver a shock; after
shock delivery, resume CPR, beginning with chest compressions.
Ideally, chest compressions should be interrupted only for ventilations (until an advanced airway is in place), rhythm check, and
shock delivery.
Give 1 shock (2 J/kg) as quickly as possible and immediately
resume CPR, beginning with chest compressions. It is important to
minimize the time between chest compressions and shock delivery
and between shock delivery and resumption of postshock compressions.
If a “shockable” rhythm persists, give another shock (4 J/kg). Immediately resume chest compressions. Continue CPR for approximately 2 minutes.
During CPR, give epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10 000 concentration), maximum of 1 mg (Class I, LOE B) every 3 to 5 minutes.
While continuing CPR, give amiodarone (Class IIb, LOE C) or
lidocaine if amiodarone is not available.
Temperature Control
• [For] very low-birth-weight (1500 g) preterm babies...additional
warming techniques are recommended (eg, ...covering the baby in
plastic wrapping...(Class I, LOE A)... and placing the baby under
radiant heat (Class IIb, LOE C).
• Other techniques for maintaining temperature during stabilization of
the baby in the delivery room have been used (eg, prewarming the
linen, drying and swaddling, placing the baby skin-to-skin with the
mother, and covering both with a blanket) and are recommended,
but they have not been studied specifically (Class IIb, LOE C).
• Hyperthermia should be avoided (Class IIb, LOE C). Infants born
to febrile mothers have been reported to have a higher incidence
of perinatal respiratory depression, neonatal seizures, and cerebral
palsy and an increased risk of mortality.
Clearing The Airway
• When the amniotic fluid is clear, it is recommended that suctioning
immediately following birth (including suctioning with a bulb syringe) should be reserved for babies who have obvious obstruction
to spontaneous breathing or who require positive-pressure ventilation (PPV) (Class IIb, LOE C).
• There is insufficient evidence to recommend a change in the current practice of performing endotracheal suctioning of nonvigorous
babies with meconium-stained amniotic fluid (Class IIb, LOE C).
Family Presence During Resuscitation
• Whenever possible, provide family members with the option of being
present during resuscitation of an infant or child (Class I, LOE B).
• If the presence of family members creates undue staff stress or is
considered detrimental to the resuscitation, then family members
should be respectfully asked to leave (Class IIa, LOE C).
Excerpts From Part 15: Neonatal Resuscitation4
Supplementary Oxygen
• If blended oxygen is not available, resuscitation should be initiated
with air (Class IIb, LOE B).
• If the baby is bradycardic after 90 seconds of resuscitation with a
lower concentration of oxygen, oxygen concentration should be
increased to 100% until recovery of a normal heart rate (Class IIb,
LOE B).
Those newly born infants who do not require resuscitation can generally be identified by a rapid assessment of the following 3 characteristics:
• Term gestation?
• Crying or breathing?
• Good muscle tone?
If the answer to any of these assessment questions is “no,” the infant
should receive one or more of the following 4 categories of action in
sequence:
A. Initial steps in stabilization (provide warmth, clear airway if necessary, dry, stimulate)
B. Ventilation
C. Chest compressions
D. Administration of epinephrine and/or volume expansion
Positive Pressure Ventilation
• If the infant remains apneic or gasping, or if the heart rate remains
< 100 [beats] per minute after administering the initial steps, start
positive pressure ventilation (PPV).
• An initial inflation pressure of 20 cm H2O may be effective, but 30 to
40 cm H2O may be required in some term babies without spontaneous
ventilation (Class IIb, LOE C).
6
Current Guidelines For Management Of Spontaneous Intracerebral Hemorrhage In The ED
•
Volume Expansion
• Volume expansion should be considered when blood loss is known
or suspected...and the baby’s heart rate has not responded adequately to other resuscitative measures (Class IIb, LOE C).
• An isotonic crystalloid solution or blood is recommended for volume expansion in the delivery room (Class IIb, LOE C).
• The recommended dose is 10 mL/kg, which may need to be repeated. Care should be taken to avoid giving volume expanders
rapidly, because rapid infusions of large volumes have been associated with intraventricular hemorrhage (Class IIb, LOE C).
Assisted ventilation should be delivered at a rate of 40 to 60
breaths per minute to promptly achieve or maintain a heart rate
> 100 [beats] per minute (Class IIb, LOE C).
Laryngeal Mask Airway
• Laryngeal mask airways [LMAs]... have been shown to be effective
for ventilating newborns weighing more than 2000 g or delivered
≥ 34 weeks gestation (Class IIb, LOE B).
• There are limited data on the use of these devices in small preterm
infants, ie, < 2000 g or < 34 weeks [gestation] (Class IIb, LOE C).
• A LMA should be considered during resuscitation if facemask ventilation is unsuccessful and tracheal intubation is unsuccessful or not
feasible (Class IIa, LOE B).
Withholding Resuscitation
• When gestation, birth weight, or congenital anomalies are associated with almost certain early death and when unacceptably high
morbidity is likely among the rare survivors, resuscitation is not
indicated. Examples include extreme prematurity (gestational age
< 23 weeks or birth weight < 400 g), anencephaly, and some major
chromosomal abnormalities, such as trisomy 13 (Class IIb, LOE C).
• In conditions associated with a high rate of survival and acceptable
morbidity, resuscitation is nearly always indicated. This will generally include babies with gestational age ≥ 25 weeks and those with
most congenital malformations (Class IIb, LOE C).
• In conditions associated with uncertain prognosis in which survival
is borderline, the morbidity rate is relatively high, and the anticipated burden to the child is high, parental desires concerning initiation
of resuscitation should be supported (Class IIb, LOE C).
Endotracheal Intubations
Exhaled CO2 detection is effective for confirmation of endotracheal
tube placement in infants, including very low-birth-weight infants
(Class IIa, LOE B).
Chest Compressions
• Compressions should be delivered on the lower third of the sternum to a depth of approximately one-third of the anteriorposterior
diameter of the chest (Class IIb, LOE C).
• The 2 thumb–encircling hands technique is recommended for performing chest compressions in newly born infants (Class IIb, LOE C).
• There should be a 3:1 ratio of compressions to ventilations with 90
compressions and 30 breaths to achieve approximately 120 events
per minute (Class IIb, LOE C).
• Rescuers should consider using higher ratios (eg, 15:2) if the arrest
is believed to be of cardiac origin (Class IIb, LOE C).
Discontinuing Resuscitative Efforts
In a newly born baby with no detectable heart rate, it is appropriate to
consider stopping resuscitation if the heart rate remains undetectable
for 10 minutes (Class IIb, LOE C).
■
Epinephrine
• Epinephrine is recommended to be administered intravenously
(Class IIb, LOE C). Given the lack of supportive data for endotracheal epinephrine, the IV route should be used as soon as venous
access is established (Class IIb, LOE C).
• The recommended IV dose is 0.01 to 0.03 mg/kg per dose.
• Administration of a higher dose (0.05 to 0.1 mg/kg) through the endotracheal tube may be considered, but the safety and efficacy of this
practice have not been evaluated (Class IIb, LOE C). The concentration of epinephrine for either route should be 1:10,000 (0.1 mg/mL).
Reprinted with permission. Circulation. 2010;122[suppl 3]. ©2010,
American Heart Association, Inc.
7
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Current Guidelines For Pediatric Advanced Life Support: 2010 AHA Guidelines
Editorial Comment
The focus on uninterrupted, high-quality chest compressions initiated
in the 2005 guidelines is most obvious in the change from the ABC
(airway, breathing, compressions) mnemonic to CAB (compressions,
then airway and breathing), even in pediatric resuscitation. The decision to apply the CAB sequence to pediatric arrest is based on the
desire to teach a singular message with a focus on high-quality chest
compressions for all patients—adult as well as pediatric. Though pediatric arrest is commonly respiratory in origin rather than cardiac, the
CAB sequence is thought to result in a delay of only 18 seconds before
the first breath is delivered. A recent review of patients under 17
years of age demonstrated that conventional CPR produced improved
neurological outcomes when compared to chest compressions alone,
however.5 The guidelines do allow the rescuer to tailor the sequence
of interventions to the individual situation; therefore, if cardiac arrest is
thought to result from respiratory arrest, a focus on airway and breathing is appropriate.
Intra-arrest pharmacotherapy is de-emphasized in pediatric advanced
life support. The only medication recommended empirically for undifferentiated cardiac arrest is epinephrine. Amiodarone is suggested for
ventricular tachycardia or ventricular fibrillation not responding to defibrillation. The use of glucose is emphasized in the very young, given
their increased glucose demand and more limited ability to maintain
euglycemia during stress, compared to older children. Medications
such as calcium and sodium bicarbonate are no longer recommended
during pediatric cardiac arrest except during specific circumstances. For calcium administration, these include documented hypocalcemia,
hyperkalemia, or calcium channel blocker overdose; bicarbonate is
indicated when cardiac arrest is thought to be the result of certain
toxins or hyperkalemia. Although less strongly worded than in the adult
cardiac arrest recommendations, medications administered through
the endotracheal tube are very poorly absorbed, and this route should
only be used if IV or IO access is unavailable.
Regarding airway management in pediatric life support, bag-mask ventilation is emphasized only in the prehospital setting, with more focus
placed on endotracheal intubation and the use of laryngeal mask airway devices. The option to use a cuffed endotracheal tube in all infants
and children, which was first recommended in the 2005 guidelines, is
re-emphasized. Routine cricoid pressure is no longer recommended
during intubation; cricoid pressure does not offer the protection against
aspiration commonly attributed to it, and it makes laryngeal exposure
more difficult. Cricoid pressure is an option during bag-valve-mask
ventilation, however. Capnography is emphasized as the technique of
choice to confirm endotracheal tube placement; if there is concern for
a false negative (ie, the device or waveform does not suggest tracheal
placement, but the tube is in fact in the trachea), the next maneuver
should either be an esophageal detector device or repeat visualization
of the glottis using direct laryngoscopy or an alternate device.
The 2010 guidelines discuss parental presence during resuscitation,
recommending their presence whenever possible; however, the guidelines also provide recommendations to direct the escorting of patients
away from the resuscitation theater when appropriate.
EM Practice Guidelines Update © 2011
Newborn delivery is a stressful procedure infrequently undertaken
in most EDs. Recommendations regarding which newborns require
resuscitative maneuvers have shifted in recent years; in general,
newborns who cry vigorously on delivery should not require suctioning
or interventions beyond drying and warming. For emergency clinicians
unlucky enough to deliver a baby with severe prematurity or evident
genetic defects, the guidelines briefly but meaningfully address which
infants should or should not be resuscitated and the role of parental
wishes in these challenging circumstances.
■
8
ebmedicine.net • April 2011
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Current Guidelines For Pediatric Advanced Life Support: 2010 AHA Guidelines
References
1. Field JM, Hazinski, MF, Sayre MR et al. 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care science. Circulation. 2010;122:S639-S933. (Review)
2. Berg MD, Schexnayder SM, Chameides L, et al. Part 13: pediatric basic life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care science. Circulation. 2010;122(18 Suppl 3):S862-S875. (Review)
3. Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: pediatric advanced life support: 2010 American Heart Association guidelines
for cardiopulmonary resuscitation and emergency cardiovascular care science. Circulation. 2010;122(18 Suppl 3):S876-S908. (Review)
4. Kattwinkel J, Perlman JM, Aziz K, et al. Part 15: neonatal resuscitation: 2010 American Heart Association guidelines for cardiopulmonary
resuscitation and emergency cardiovascular care science. Circulation. 2010; 122(18 Suppl 3):S911-S919. (Review)
5. Kitamura T, Iwami T, Kawamura T, et al. Implementation Working Group for All-Japan Utstein Registry of the Fire and Disaster Management
Agency. Conventional and chest-compression-only cardiopulmonary resuscitation by bystanders for children who have out-of-hospital cardiac arrests: a prospective, nationwide, population-based cohort study. Lancet. 2010;375:1347-1354. (Prospective cohort; review)
EM Practice Guidelines Update © 2011
9
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Current Guidelines For Pediatric Advanced Life Support: 2010 AHA Guidelines
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Current Guidelines
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A chief-complaint focus: Every issue starts with a patient complaint — just like your daily practice. You’re guided step-by-step
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An evidence-based medicine approach: The degree of acceptance and scientific validity of each recommendation is assessed
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