The Critically Ill Child

Pediatric Advanced Life Support

Every few years, the American Heart Association (AHA) publishes updated Pediatric Advanced Life Support (PALS) guidelines, incorporating the latest findings in pediatric resuscitation science. At the time of this writing, the most recent version was published in 2020. Since the 2010 guidelines, the focus of resuscitation is to use the “CAB” (Circulation, Airway, Breathing) approach, with an emphasis on achieving and maintaining optimum cerebral and coronary perfusion via quality cardiopulmonary resuscitation (Q-CPR). Chest compressions should begin immediately upon recognition of cardiac arrest while trying to establish airway and breathing (simultaneous but secondary actions). It is easier and faster to establish vital organ blood flow through effective chest compressions during a no-flow state of cardiac arrest before gathering equipment and securing an airway.

The PALS update in 2020 focuses on CPR quality and postresuscitation care . CPR quality is assessed by the fraction, depth, and rate of chest compressions ( Table 38.1 ). These can be measured using technologically advanced defibrillators and defibrillator pads that provide real-time feedback on CPR quality. The use of end tidal CO ₂ (EtCO ₂ ) and arterial blood pressure monitoring are also useful guides of CPR quality. Postresuscitation care focuses on maintaining normal core temperature, adequate blood pressure for coronary and cerebral perfusion, and normal oxygenation.

Circulation

When encountering the pulseless child, chest compressions should be initiated immediately. In infants, the best way to perform chest compressions is to encircle the chest with your hands, with the thumbs placed one finger-width below the intermammary line over the midsternum. For older children, the chest is compressed by placing the heel of your hand two-finger breadths above the lower end of the sternum and with a depth of at least 1/3 the anterior-posterior diameter of the chest (approximately 2 inches [or 5 cm]). Avoid compressions over the lower third of the sternum, which may cause trauma to internal abdominal organs. Compressions are delivered at a rate of 100 to 120 times per minute. The most important aspect of pediatric CPR is to maintain the frequency and depth of the compressions while minimizing interruptions and allowing for full chest recoil. Rotate compressors every 2 minutes to minimize fatigue and ensure effective compressions.

During CPR, peripheral venous access should be obtained, and if unsuccessful after 3 attempts or 90 seconds, whichever comes first, intraosseous (IO) vascular access is indicated. Isotonic fluids, such as lactated Ringer solution or normal saline, should be rapidly administered in 10 to 20 mL/kg doses, and continued until blood pressure is normalized. If unable to establish normal-for-age hemodynamics after ~60 mL/kg isotonic fluid administration, vasoactive medications should be considered with choice of agent dependent on hemodynamic profile. Children with hemorrhagic shock should receive uncrossmatched type O, Rh-negative packed red blood cells or whole blood. (Type-specific blood can be administered if the patient’s blood type is already known) Medications that can be administered through the endotracheal tube and absorbed from the bronchial tree include lidocaine, atropine, naloxone, and epinephrine (mnemonic = LANE).

Pulseless electrical activity (PEA) may be seen during cardiac arrest in children and is often caused by a reversible process. Thus the differential diagnosis should be kept in mind by remembering the Hs and the Ts ( Table 38.2 ).

Airway and Breathing

Assuming the child in cardiac arrest did not have previous airway management, it is addressed once chest compressions have begun. Proper airway positioning is important to maximize oxygenation and ventilation. Usual airway maneuvers (e.g., head tilt, chin lift, and/or jaw thrust) are performed to maintain airway patency with bag-mask ventilation; securing the airway with tracheal tube placement is preferred but a supraglottic airway may be acceptable when tracheal intubation is unobtainable or when attempts at tracheal intubation would compromise the provision of high-quality CPR. Hyperventilation is a known risk during CPR with an advanced airway and may increase intrathoracic pressure, impeding venous return and decreasing cardiac output. When an advanced airway is in place, breaths do not need to be coordinated with compressions and should be given at a rate of 20 to 30 breaths per minute (approximately one breath every 2–3 seconds). Before an advanced airway, compression and bag-mask breaths should be coordinated. In single-rescuer CPR, it should be a ratio of 30 compressions to 2 breaths; and for two-rescuer CPR in children, it should be 15 compressions to 2 breaths.

Disability and Drugs

Exposure and Environment

Once ventilation and circulation are stabilized, all the child’s clothing should be removed to search for additional traumatic or toxic injuries. Hypothermia and hyperthermia should be aggressively treated to prevent clotting disorders and to prevent further focal neurologic injury. Profound hypothermia resulting in arrest may warrant extracorporeal rewarming; consultation with intensive care specialists should be pursued.

Post arrest Care

The foundation of postarrest care is focused on minimizing secondary injury and this may be required in the operative environment if the postarrest patient requires operative care or if they require anesthesia expertise to facilitate imaging or other diagnostic/therapeutic maneuvers.

After return of spontaneous circulation (ROSC) or after cannulation onto extracorporeal support during emergency CPR (E-CPR), efforts should be focused on ensuring age-appropriate physiology that minimizes metabolic demand and end organ injury. Hypertension and hypotension can both be injurious but the postarrest patient is most at risk for hypotension and blood pressure should be targeted to age-standardized norms that prevent end-organ hypoperfusion. Metabolic demand should be minimized by avoiding fevers, shivering, and seizures. This may require around-the-clock administration of antipyretic medications and temperature-regulating devices such as a thermoregulation blanket. (Pediatric studies of targeted temperature management [TTM] of the postarrest patient have not demonstrated benefit of empiric cooling) . The postarrest patient may require neuromuscular blockade to limit shivering, and for arrests where neurologic status is altered from baseline after arrest, continuous electroencephalography (EEG) monitoring should be considered to monitor subclinical status epilepticus to treat quickly and minimize metabolic demand. Hypo- and hyperglycemia should be avoided and routine glucose monitoring should be instituted to minimize effects from these metabolic derangements.

Treatment Algorithms

Because it is difficult to memorize the specific treatment algorithms for the various possible dysrhythmias, anesthesiologists should have immediate access to the most current AHA guidelines. We recommend that each anesthesia practitioner have a copy (or have access to a copy in each anesthetizing location) of a PALS Pocket Reference Card (AHA 20-1118) that can be easily obtained from many Internet retailers.

Common Pediatric Critical Illnesses