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Lalitha
Janakiraman
Dr. Lalitha Janakiraman, National Convener,
Indian Academy of Pediatrics, PALS Group and Consultant, Kanchi
Kamakoti Childs Trust Hospital, 12-A, Nageswara Road, Nungambakkam,
Chennai 600 034, India.
E-mail:[email protected]
Cardiopulmonary arrest in infants and children is
rarely a sudden event and does not often result from a primary cardiac
cause unlike in adults. Pediatric cardiac arrest frequently represents
the terminal event of progression of shock or respiratory failure.
Pediatric advanced life support (PALS) refers to
the assessment and support of the pulmonary and circulatory functions
in the period prior to arrest, during and after an arrest.
The goals of the PALS course are to provide the
participants with the information and strategies to:
1. Prevent injury and death in infants and
children
2. Recognize and initiate treatment for infants
and children with impending respiratory failure, shock and
cardiopulmonary arrest.
• Provide
basic life support (BLS)
• Provide
advanced support of oxygenation and ventilation
• Obtain
vascular access
• Initiate
appropriate resuscitation fluid and drug therapy.
3. Support families and providers in coping with
emergencies and death.
Methods
The International Liaison Committee On
Resuscitation (ILCOR) formed in 1992 has addressed many important
issues including an advisory statement on pediatric resuscitation and
recommendations in the areas of Pediatric BLS and Pediatric Advanced
Life Support (PALS) and BLS for the newly born(1).
To develop international guidelines 2000, the
subcommittee on pediatric resuscitation of the American Heart
Association and other members of ILCOR identified issues or new
developments and conducted evidence based evaluation of these areas.
This culminated in assignment of consensus defined "levels of
evidence" for specific guideline questions. After identification
and careful review of these evidences the pediatric working group of
ILCOR updated PALS guidelines. Based on the critical assessment of the
quality and number of studies, measured outcome and magnitude of
benefit, final recommendations were formulated and presented(2).
New Recommendations
The basic principles as well as sequence of events
remain unchanged. Only new incorporations or major guideline changes
are highlighted below.
1. Cardiac arrest and cardiovascular emer-gencies
related to special circumstances: Drug overdose, Toxins, Electrolyte
abnor-malities, asthma and anaphylaxis(3).
As we now know more about specific arrhythmias and
cardiovascular effects of drug toxicities and poisonings, specific
guidelines for managing these conditions are included.
2. Bag mask ventilation versus tracheal
intuba-tion by pediatric health care providers(4).
Though it is well known that tracheal intubation is
an effective and reliable method of assisted ventilation, it still
needs initial mastery and continuous practice to maintain the skills.
Hence, it has been recommended that a properly performed bag mask
ventilation is safer and more effective than tracheal intubation.
3. Recommendations for secondary confirma-tion of
proper tracheal tube placement(5).
The techniques for confirmation of correct tracheal
tube placement include qualitative ETCO2
(End Tidal Carbon Dioxide) detectors and quantitative and continuous
CO2 measure-ment in addition to radiological and clinical confirmation.
However, this is reliable only in a child with perfusing rhythm.
4. Laryngeal mask airway: An alternative advanced
airway device(6).
Laryngeal mask airway (LMA) is clinically
equivalent to ventilation with a tracheal tube and mastery of LMA
insertion is simpler than mastery of tracheal intubation and
complication rate is low.
5. Post resuscitation interventions that improve
neurological outcome(7).
The new guidelines stress on the following
interventions:
(a) Maintain normal ventilation
without-hyperventilation,
(b) Monitor temperature and treat hyperthermia;
and
(c) Maintain normal glucose levels.
6. lntraosseous route is acceptable in older
children(8).
Intraosseous route is acceptable and recommended to
include children older than 6 years unlike the earlier
recommendations, which did not include older children.
7. Vagal maneuvers added to the treatment
algorithm for supraventricular tachy-cardia(9)
In children with milder symptoms of supra
ventricular tachycardia or while waiting for cardioversion or drug
therapy, vagal maneuvers like icewater application and others could
still be used safely.
8. Amiodarone added to the pediatric treat-ment
algorithm for supraventricular and ventricular
fibrillation/ventricular tachy-cardia(10).
Amiodarone was added because studies have shown
that it is safe and effective in pediatric arrythmias especially for
refractory ventricular fibrillation that persists despite 3 shocks.
9. Use of high dose epinephrine
de-empha-sized(11).
The recommended initial dose of epinephrine for
pediatric cardiac arrest is 0.01 mg/kg (IV/IO) followed by the same
dose every 3-5 minutes as against the earlier recom-mendation of
higher maintenance doses because of the adverse effects that was
reported by large multi institutional adult studies and uncontrolled
retrospective pediatric data.
10. Automated external defibrillator(12).
Automated external defibrillators should be used in
older children, as ventricular fibrillation is more common in this
group.
Comment
These guidelines must be incorporated in all future
PALS courses with immediate effect. The new guidelines which are
evidence based must be adapted during resuscitation. Every one who has
been trained in PALS must collect data to see the impact on the
outcome of patients and report the same to the national PALS Convener.
This will enable us to contribute to the global knowledge.
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