PALS: CLINICAL PEARLS

Can I use the “two-thumb, encircling hands technique” for all infant CPR, including a 1-rescuer situation?

The “two-thumb, encircling hands technique” should only be used with multiple rescuers. While the “two-thumb, encircling hands technique” may provide more effective chest compressions, in a single rescuer situation the time needed to move from giving chest compressions to giving breaths would be excessive, causing  unwanted interruptions in CPR. For this reason, single rescuers should still use a two-finger chest compression technique until more help arrives.

For an infant in cardiac arrest with a shockable rhythm, should I use an automated external defibrillator or a manual defibrillator?

If both devices are present and you are trained in their use, the manual defibrillator is preferred. A manual defibrillator may be better for recognizing an infant’s very fast heart rates, and the energy size may be adjusted more precisely for the infant’s weight.

However, if a manual defibrillator is not readily available or you are not trained in its use, the AED should be applied as soon as it is available – do not delay defibrillation to wait for a manual defibrillator to arrive!

The new Guidelines call for immediate CPR after defibrillation, without stopping to check for a pulse. Won’t this be harmful if the infant or child has a return of pulses?

No, this is not harmful and is likely helpful, even if a pulse is present. When defibrillation is successful and an organized rhythm is present, pulses are unlikely to be palpable in the moments after defibrillation. Beginning CPR without checking for a pulse provides immediate CPR if defibrillation was unsuccessful, and provides support of circulation if defibrillation was successful.

When an organized heart rhythm returns after defibrillation, it takes time for the heart to generate enough circulation to sustain a palpable pulse. Providing chest compressions during this time will not cause arrhythmia, and does not harm circulation if the heart is pumping. In fact, studies suggest that chest compressions will boost circulation during this critical time, making ROSC more likely to occur.

Should all ROSC patients receive an antiarrhythmic to prevent further arrhythmia?

The PALS guidelines focus on initial resuscitative efforts, and there is no recommendation to administer an antiarrhythmic to all patients with ROSC. Immediately after ROSC, use the post-arrest care guidelines to optimize ventilation and oxygenation, and support circulation. Administration of an antiarrhythmic may be helpful for some patients with recurrent arrhythmia; however the ABCs of post-arrest care should be your first priorities. This is a good example of a situation where you should consider seeking “expert consultation” to guide further care.

When treating an infant or child for tachycardia with poor perfusion, should sedation be given prior to synchronized cardioversion?

With PALS, synchronized cardioversion is used for the infant or child with poor perfusion, as evidenced by altered mental status, hypotension, or serious signs and symptoms of shock. For infants and children with poor perfusion, the administration of sedation before cardioversion is controversial. The patient’s instability and the need to act quickly are two concerns with administration of sedation prior to cardioversion. On the other hand, cardioversion is expected to be successful and quickly stabilize the patient’s condition. The PALS guidelines do not take a firm stance on this issue; you may consider giving sedation/analgesia prior to cardioversion if it can be administered safely without delaying care.

I heard that patients in un-witnessed cardiac arrest should receive CPR prior to defibrillation, what do the guidelines recommend?

The guidelines recommend applying the AED or defibrillator as soon as it arrives.

There are several recent studies investigating whether a set period of high-quality CPR would improve defibrillation success when no bystander CPR was provided. While these studies have promising results, there is insufficient evidence to warrant a Guidelines change at this time. A period of CPR prior to defibrillation may be considered if you are working in a system with a specific protocol in place, otherwise, you should attempt defibrillation as soon as possible for all patients in VF/VT arrest.

What should I do if I am treating a pediatric patient in cardiac arrest, but I only have an AED with adult pads?

If no pediatric pads are available, use the adult AED pads. The most important actions during cardiac arrest are to provide immediate CPR and prompt defibrillation (if indicated). While the adult AED pads do provide more energy than is recommended, using the AED with adult pads is more likely to improve the patient’s condition than no defibrillation at all. For pediatrics, if the adult pads must be used they should be applied using an anterior-posterior placement to allow for sufficient space between the pads.

Should cricoid pressure be applied during CPR to prevent gastric distention?

The routine use of cricoid pressure is not recommended. Routine use of cricoid pressure may delay or interfere with effective ventilation and airway management. Cricoid pressure may be considered to assist with visualization of the vocal cords during intubation.

Acidosis is common during cardiac arrest, should Sodium Bicarbonate be given to all cardiac arrest patients to treat for acidosis?

No, routine or prophylactic administration of sodium bicarbonate during cardiac arrest is not recommended. While acidosis is common during cardiac arrest, this is typically a respiratory acidosis. Respiratory acidosis is best treated by restoring adequate ventilation. Sodium bicarbonate therapy should be reserved for suspected metabolic acidosis, generally when metabolic acidosis is considered a possible reversible cause of arrest.

I was told to try defibrillating asystole in case the patient was in fine VF… It can’t do any harm, right?

Defibrillation is used to interrupt disorganized electrical activity – asystole is the absence of electrical activity, therefore defibrillation will not help correct asystole. It is true that you should verify asystole by checking ECG connections, looking at more than one ECG lead, and checking the gain (size) of the ECG waveform. However, if the patient is clearly in asystole, defibrillating will not help, and may be harmful. Defibrillating asystole may decrease the likelihood of a spontaneous rhythm returning.

The new PALS guidelines call for titrating oxygen delivery to pulse oximetry of 94-99%. Does this mean high-flow oxygen should not be used during resuscitation?

No, the guidelines still recommend considering the use of high-flow oxygen during initial resuscitation for infants and children. (High-flow oxygen is not always used for the resuscitation of neonates, however neonatal resuscitation is outside the scope of the PALS course).  Once return of spontaneous circulation (ROSC) occurs, then oxygenation should be optimized by titrating oxygen delivery to maintain pulse oximetry between 94 – 99%.

Why do the guidelines call for titrating oxygen to a pulse oximetry of 94-99%? Why not 100%?

Pulse oximetry is the easiest way for us to assess patients’ oxygenation, however it is not without limitations. Pulse oximetry attempts to measure the percentage of red blood cells that are oxygenated – it does not directly measure the amount of oxygen in the circulatory system. Therefore, a patient with normal oxygenation may have a pulse oximetry value of 100%, and a patient that is receiving too much oxygen (hyperoxia) will also have a pulse oximetry value of 100%. We can avoid hyperoxia by titrating oxygen to a pulse oximetry range of 94-99%.

Why do patients with polymorphic ventricular tachycardia (or torsades de pointe) receive unsynchronized cardioversion?

Synchronized cardioversion depends upon the monitor/defibrillator recognizing the QRS complexes of the tachyarrhythmia. If the monitor/defibrillator cannot recognize (“Sync” with) the QRS complexes, attempts at synchronized cardioversion may result in delayed energy delivery or failure to delivery energy at all. Polymorphic VT by definition has QRS complexes of varying size and shape, which are difficult for the monitor/defibrillator to recognize. Polymorphic VT (or torsades de pointe) is the only rhythm treated with unsynchronized cardioversion.

Why shouldn’t I check for a pulse after defibrillating?

The goal of defibrillation is to interrupt ventricular fibrillation or tachycardia, to allow for an organized rhythm to return. When an organized rhythm returns after defibrillating, it is unlikely the infant or child will have a palpable pulse immediately. When the heart starts beating again, it takes time for the heart to get blood circulating normally again. Providing CPR immediately after shock delivery helps maintain circulation, and helps prevent the patient with an organized rhythm from going back into an arrhythmia.

After delivering synchronized cardioversion, you see ventricular fibrillation on the monitor. What should be done first – CPR or defibrillation?

If cardioversion results in pulseless VF/VT, follow the Cardiac Arrest algorithm. For any patient in pulseless VF/VT, immediate defibrillation is needed. Begin chest compressions, if possible, while preparing for defibrillation. Do not wait for 2 minutes of CPR to be completed; defibrillate as soon as possible.

What happened to “stacked shocks” for defibrillation?

Evidence shows that defibrillation is most effective when the time between stopping chest compressions and delivering the shock is minimized – the goal is less than 10 seconds. Providing “stacked shocks,” without CPR in between attempts, is less likely to be successful and reduces the amount CPR provided.

For how long should an infant or child be resuscitated before resuscitative efforts are terminated?

Deciding to terminate resuscitative efforts is a difficult decision, especially when caring for a pediatric patient. Unfortunately there is no blanket answer to this question, as each case will be different. While brain death will begin within a few minutes of cardiac arrest if no resuscitation is provided, in many cases high-quality CPR can allow for neurologically-intact survival even after prolonged resuscitation.

Factors to consider when deciding if resuscitative efforts should be terminated include:

• Assess for obvious signs of death, such as rigor mortis and dependent lividity.
• Determine if the patient has a do-not-resuscitate (DNR) order or other advanced directive.
• Assure that high-quality CPR is being performed.
• Review the PALS care provided, and search for and treat possible reversible causes of arrest.
• Seek input from the resuscitation team to determine if anything has been missed, or if there are other suggestions prior to terminating efforts.

Can medications be given through the endotracheal tube if vascular access is not available?

Endotracheal administration of medications is a last resort option for some medications, including: Epinephrine, Atropine, Lidocaine, Naloxone, and Diazepam. If the endotracheal route is used, consider doubling the normal IV dose. If Epinephrine is administered, ten times the IV dose should be used (0.1mL/kg of 1:1,000 solution). However, there are no studies demonstrating that endotracheal administration is beneficial. Additionally, with the increased availability of IO devices, the use of the endotracheal route should be a rare occurrence!

Is intraosseous access (IO) as effective as a peripheral IV during resuscitation?

Drug delivery via an intraosseous (IO) device is similar to drug delivery through a peripheral IV. Medications given through an IO should be given at the same dose as through a peripheral IV. Medications with an extremely short half-life, such as Adenosine, may be less effective through an IO depending on where the IO device is placed.

Do all pediatrics with a very low heart rate (i.e. less than 60 beats per minute) require CPR?

No, CPR is indicated for bradycardia with poor perfusion after taking actions to improve oxygenation and ventilation. Signs and symptoms of poor perfusion include: hypotension, altered mental status, and signs of shock.

Why is CPR recommended a child or infant with severe bradycardia if he/she still has a palpable pulse?

Bradycardia with poor perfusion is a life threatening condition. If left uncorrected, cardiac arrest is likely to follow. When initial measures to improve oxygenation and ventilation (i.e. supplemental oxygen, assisted ventilations) are not helpful, CPR is needed to improve perfusion and prevent cardiac arrest.

If an infant of child has a partial airway obstruction, can I use the Heimlich maneuver to help remove the object?

No, using the Heimlich maneuver for a partial airway obstruction is not recommended (provided the infant or child has adequate perfusion). The reason for not attempting to expel the partial airway obstruction is that doing so could also make the obstruction worse. Think of the example of a child that has swallowed a coin – if the coin rests in the airway at an angle, air is able to pass around the coin. If attempts to expel the obstruction cause the coin to move, it may completely block the airway.

For the infant or child with a partial airway obstruction, keep the patient calm and in a position of comfort.

Can Albuterol be administered for upper airway obstruction?

Albuterol could be administered; however it is not the best choice for the treatment of upper airway obstruction and is unlikely to be helpful. Albuterol acts via Beta-2 receptors in the lungs, resulting in bronchodilation. However, upper airway obstruction is typically not accompanied by bronchospasm. Albuterol will not reduce the swelling or inflammation of the soft tissues in the upper airway.

Racemic epinephrine is the medication of choice for upper airway obstruction; it works by stimulating alpha receptors to cause vasoconstriction in the soft tissues of the upper airway, reducing airway swelling.

What is meant by the terms “warm shock” and “cold shock” for sepsis?

“Warm shock” and “cold shock” are simplified ways of describing the types of signs and symptoms that may accompany septic shock. These terms are important because the guidelines use warm and cold shock to guide treatment choices for sepsis, in particular the choice of vasoactive agents.

Patients with “warm shock” have considerable vasodilation and third-spacing of fluid; they may also be in a ‘hyperdynamic’ state, with increased cardiac output. As a result these patients may have warm or hot skin temperature and normal or flushed skin color – these findings are different from most types of shock.

Patients with “cold shock” have vasoconstriction and low cardiac output. These patients have the more typical signs and symptoms of shock: cool skin, pale or mottled skin color.

Warm and cold shock are often described as representing the early and late stages of septic shock – however, do not be fooled by this generalization – all patients with signs and symptoms of septic shock require aggressive treatment!