Based upon extensive review of clinical and laboratory evidence, the American Heart Association (AHA) and the International Liaison Committee on Resuscitation (ILCOR) published updated guidelines for basic life support (BLS) and advanced life support (ALS) interventions in children and adults in 2010.
A. Pediatric Guidelines
A. 1. Basic Life Support (BLS)
The 2010 international resuscitation guidelines emphasize the importance of hard, fast chest compression, with full chest recoil and minimal interruptions. The major changes for basic cardiopulmonary resuscitation (CPR) from previous guidelines published in 2005 include: - Initiate CPR in infants or children who are unresponsive and not breathing (or only gasping).
- If no pulse is definitely identified within 10 seconds, give compressions before performing airway or breathing maneuvers.
- The use of conventional CPR (compressions with ventilation) rather than compression-only CPR in infants and children with cardiac arrest is reaffirmed, regardless of whether the arrest occurs within or outside of the hospital. Compression-only CPR is only appropriate in adults.
- For infants and children <8 years of age, a manual defibrillator or an AED with a pediatric dose attenuating system should be used whenever possible. However, if a manual defibrillator or an AED with a pediatric dose attenuating system is not available, then use of an AED without a dose attenuator is now acceptable.
The 2010 international resuscitation guidelines reaffirm the ALS approach to arrhythmias and cardiac arrest in children. The major changes for pediatric advanced life support from previous guidelines published in 2005 include:
- Beyond the newborn period, cuffed endotracheal (ET) tubes are equally as safe as uncuffed tubes, and are favored in some clinical circumstances. Monitoring should ensure that cuff pressures do not exceed 20 cm H2O.
- Evidence is insufficient to routinely recommend cricoid pressure (Sellick maneuver) in infants and children undergoing endotracheal intubation. If it is used, cricoid pressure should be removed if airway obstruction occurs when ventilation is required or if there is difficulty viewing the larynx.
- Etomidate should not be used routinely for rapid sequence intubation or sedation in children with septic shock. Ketamine, if available and not contraindicated, is preferable.
B. Adult Guidelines
The 2010 international resuscitation guidelines for basic and advanced cardiac life support continue to emphasize the critical importance of performing excellent cardiopulmonary resuscitation (CPR) without interruption and providing early defibrillation for amenable arrhythmias.
B.1. Basic Life Support (BLS)
The major changes for adult CPR from previous guidelines published in 2005 include the following:
- Begin chest compressions immediately for any unresponsive adult who is not breathing, is breathing abnormally (eg, gasping), or in whom a pulse cannot be readily palpated within 10 seconds. The new fundamental sequence for BLS is chest compressions, airway opening, and then rescue breathing (“C-A-B”).
- Encourage compression-only CPR for lay rescuers.
- Ensure that excellent chest compressions are performed: rate ≥100 per minute; compression of at least 5 cm (2 inches) with each down-stroke; full recoil between compressions; minimize interruptions.
The major changes for ACLS from previous guidelines published in 2005 include the following:
- Successful ACLS depends upon excellent CPR. Real-time monitoring and optimization of CPR is strongly encouraged.
- Intravenous infusion of a chronotropic agent (dopamine or epinephrine) is recommended for unstable bradycardia as an equally effective treatment compared to external pacing.
- Adenosine may be used for the diagnosis and treatment of stable patients with undifferentiated, regular, wide-complex tachycardia with a monomorphic QRS waveform.
- The management of pulseless electrical activity and asystole have been combined into a single algorithm.
- Atropine is no longer a recommended treatment for pulseless electrical activity or asystole.
- Quantitative waveform capnography is recommended for confirmation and monitoring of proper endotracheal tube placement.
- Systematic care provided by a multidisciplinary team is important to the survival of patients with a return of spontaneous circulation following cardiac arrest.