Chu Review: Hoffman 2023’s review of PALS updates

Hoffman, et al. 2023. A review of the 2020 Update of the Pediatric Advanced Life Support Guidelines. Pediatric emergency medicine practice, 20, 6.
https://www.ebmedicine.net/topics/emergency-procedures/pediatric-emergency-medicine-PALS-2020

One Liner: Focus on preventing and treating reversible causes, especially as children have good physiologic reserve up until they don’t

Brief Summary:

• Every 5 yrs AHA publishes revisions to PALS, this issue looks at the 2020 guidelines and updates. PALS has been associated w better survival in IHCA but not in OHCA (survival out of hospital 6-10%).
• In children, respiratory failure, hypoxemia, acidosis lead to shock, depressed myocardium, bradycardia, and arrest. Intrinsic cardiac causes rarer in peds compared to adults.
• Many physiologic considerations for peds resusc, like importance of weight estimation (e.g. Broselow or otherwise), an airway that is most anterior, superior, and floppy, favoring use of Miller blade and use of cuffed tubes and pop-off valve on BVM to avoid barotrauma, consideration of IO if IV fails (and getting peripheral or central access after stabilization), temperature mgmt (quick loss of body heat from surface area, concern of if hypothermia can be cause of cardiac arrest or due to prolonged down time), difficulty palpating a pulse.
• Ddx is broad, primary cardiac issues less common in peds compared to adults.
• Prehospital, AEDs are essential to OHCA. If < 8 yo recommend dose attenuators or peds pads, but can use adult AEDs if these tools unavailable. EMS should give a concise history focusing on interventions performed and possible reversible causes (e.g. H’s and T’s of PEA).
• Typical labs and imaging pretty useless during a resuscitation. Focus more on finding reversible causes (like with physical exam, POCUS, maybe an iStat Chem8 for potassium). Arterial lines can be unrealistic to start in the ER on a peds patient during active chest compressions.
• 5’s and T’s: hypovolemia, hypothermia, hydrogen (acidosis), hyper/hypokalemia, hypoglycemia; tension, trauma, tamponade, thrombosis (MI), thromboembolism (DVT/PE). POCUS can evaluate for most of these.
• Rapid rise in EtCO2 appears to detect ROSC, in adults > 28 mmHg, in peds can be lower like around 17.
• Uninterrupted high quality CPR saves lives. Peds pts 100-120 compressions/min, 1/3 of the AP thoracic diameter. Mechanical devices like Leukas have failed to show survival benefit in adults and are contraindicated for children. AHA recommends instead a CPR coach for real time feedback.
• As respiratory failure is a leading cause of peds cardiac arrest, very important to optimize ventilation and oxygenation. Miller and VL tend to outperform Mac’s. Use cuffed tubes in all children. No cricoid pressure. Supraglottic airways can be considered, but if you reach a “can’t intubate can’t ventilate” situation, cric. Children < 5 yo, needle cric (oxygenation w/out good ventilation). Age 10+ can use adult sized equipment for cric.
• Increasing age and cardiac muscle mass increases chances for fibrillation. Defib, start 2 J/kg initial shock, then 4 J/kg second shock, then 4-10 J/kg subsequent shocks.
• Plethora of Rx: Epi (0.01 mg/kg q3-5′), lidocaine (1 mg/kg VF/VT), amiodarone (5 mg/kg for pulseless q3-5′); calcium and bicarb not routine unless suspect CCB or sodium channel blockade, tox, cocaine; magnesium (20-50 mg/kg over 10-20 min for VT w pulse), adenosine (0.1 mg/kg rapid IV max 6 mg, repeat double dose for SVT), atropine (0.02 mg/kg, max 0.5 mg, significant bradycardia), naloxone (0.1 mg/kg IV q2′ PRN opioid induced apnea, but not cardiac arrest), defib (2 J/kg follow 4 J/kg then 4-10 J/kg), cardioversion (1 J/kg, increase to 2 J/kg after).
• Bradycardia w a pulse, CPR ASAP, atropine, epinephrine; trancutaneous pacing (target HR 70-80 bpm except if < 1 yo, target 100 bpm; initial output 5-10 mA, increase in 5-10 mA intervals to get pacing, then another 5-10 mA to keep capture, often around 20-140 mA). Remember analgesia
• Tachycardia w a pulse, no updates to AHA; sinus tach most frequent, SVT next most frequent tachycardia. In stable pts, can try vagal maneuvers, adenosine noted to be safe in wide complex monomorphic QRS tachycardia and can terminate AV dependent wide complex tachycardia; if become sunstable or vagal and pharm interventions don’t work, synchronized cardioversion 0.5 to 2 J/kg.
• Use NRP for those as precipitous delivery in the ED or complications from home delivery that just occurred. Note that NRP focuses on prolonged ventilation, graded O2 sat based on minutes from birth, compression to breath 3:1, epi is 0.02 mg/kg compared to PALS 0.01 mg/kg.
• Use PALS up until puberty (breast development, axillary hair) and then switch to ACLS.
• Naloxone has no role in cardiac arrest; can help in bradypnea and apnea but once cardiac arrest occurs, no more.
• ECMO enhanced CPR (eCPR) might help outcomes, but studies showing benefits all from ICU or OR. Don’t transfer a pt actively getting chest compressions to an ECMO center.
• Low study evidence as to when to terminate resuscitation.
• After ROSC, go to PICU, try to tamp down post cardiac arrest syndrome, brain injury, cerebral blood flow, keep normotension, body temperature (fever worse outcomes), normoxemia and normocapnea, seizures.