in Emergency Cardiovascular Care in Emergency Cardiovascular Care Volume 11 Number 3 Fall 2000 Volume 11 Number 3 Fall 2000 Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care International Consensus on Science Special Edition Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care International Consensus on Science Special Edition Currents Currents
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i n E m e r g e n c y C a r d i o v a s c u l a r C a r ei n E m e r g e n c y C a r d i o v a s c u l a r C a r e
Volume 11 Number 3Fall 2000
Volume 11 Number 3Fall 2000
Guidelines 2000for CardiopulmonaryResuscitationand EmergencyCardiovascular CareInternational Consensus on Science
Special Edition
Guidelines 2000for CardiopulmonaryResuscitationand EmergencyCardiovascular CareInternational Consensus on Science
Richard O. Cummins, MD, MPH, MScECC Senior Science EditorUniversity of Washington
Medical CenterSeattle, Washington
Mary Fran Hazinski, RN, MSNECC Senior Science EditorVanderbilt University Medical CenterNashville, Tennessee
Tom P. Aufderheide, MDECC BLS Science EditorMedical College of WisconsinMilwaukee, Wisconsin
Robert A. Berg, MDChair, AHA Pediatric
Resuscitation SubcommitteeUniversity of ArizonaTucson, Arizona
Ahamed H. Idris, MDChair, BLS SubcommitteeUniversity of FloridaGainesville, Florida
Richard E. Kerber, MDChair, AHA ECC CommitteeCardiology Division, University of
Iowa HospitalIowa City, Iowa
William H. Montgomery, MDPresident, Citizen CPR FoundationStraub Clinic and HospitalHonolulu, Hawaii
Vinay Nadkarni, MDECC Pediatric Resuscitation
Science EditorduPont Hospital for ChildrenWilmington, Delaware
Edward R. Stapleton, EMT-PECC BLS Science EditorState University of New YorkStony Brook, New York
F. G. Stoddard, PhDSenior Editor, ECC ProgramsAHA Office of Science and MedicineDallas, Texas
E D I T O R I A L A D V I S O RY B O A R DAHA ECC Website:cpr-ecc.americanheart.org
Currents in EmergencyCardiovascular Care is a quarterlypublication sponsored by theAmerican Heart Association andthe Citizen CPR Foundation andsupported by the American RedCross and the Heart and StrokeFoundation of Canada. Currentswas established to exchangeinformation about important ideas,developments, and trends inemergency cardiovascular care.Send editorial inquiries and lettersto Kathleen Jun at the AHA, ECCPrograms, 7272 Greenville Ave.,Dallas, TX 75231-4596. Phone1-800-242-1793, ext 9862; [email protected]. For bulkreprints, contact Julie Mallory at214-706-1658.
Subscriber ServicesCurrents in EmergencyCardiovascular Care is availableby free subscription in the UnitedStates and Canada with the helpof 11 underwriters, noted on theback cover of every issue. Individualsoutside these countries may registerto receive quarterly email noticesthat will link directly to each newissue of Currents when posted onthe ECC website. To register forthese subscriber services, call877-821-2010 toll-free from withinthe United States. Or sign up viathe internet at the AHA ECC websitewww.cpr-ecc.americanheart.org.You can also fax your registrationto 281-419-8238, ext 110. If youregister by fax, be sure to includeyour name, the courses you teach(PALS, BLS, etc), work and homeaddresses (specifying which touse for your subscription), phoneand fax numbers, and emailaddress as applicable. An entireroster of names may be sent atonce, but be certain to include allnecessary information. Missingissues? Call Mary Alcedo,214-706-1159; fax 214-987-9361;email [email protected] in the USA.
Richard O. Cummins, MD, and Mary Fran Hazinski,RN, MSN, Senior Science Editors, AHAEmergency Cardiovascular Care Programs
Chairs of the ECC Committee andSubcommittees and Science Editors of theAHA ECC Science Product Development Panel:(alphabetical) Tom P. Aufderheide, MD, Science Editor, Basic
Life Support; Robert A. Berg, MD, Chair, Pediatric Resuscitation
Subcommittee; John Field, MD, Science Editor, Advanced
Cardiovascular Life Support; Ahamed H. Idris, MD, Chair, Basic
Life Support Subcommittee; Richard E. Kerber, MD, immediate
past chair, ECC Committee; Karl B. Kern, MD, Chair, Advanced
Cardiovascular Life Support Subcommittee; Vinay M. Nadkarni,
MD, Science Editor, Pediatric Resuscitation and Chair-elect,
ECC Committee; Edward R. Stapleton, EMT-P, Science Editor,
Basic Life Support; Mark Swanson, MD, Chair, Program
Administration Subcommittee; Arno Zaritsky, MD, Science
Editor, Pediatric Resuscitation
International Editorial Board
Richard O. Cummins, MD, MPH, MSc (AHA); Mary Fran
Hazinski, RN, MSN (AHA); Peter J.F. Baskett, MD (European
Resuscitation Council [ERC]); Douglas Chamberlain, MD
(ERC); Leo L. Bossaert, MD (ERC); Vic Callanan, MD
(Australian Resuscitation Council [ARC]); Pierre Carli, MD
(ERC); Marc Gay, MD (Heart and Stroke Foundation of
Canada [HSFC]); Anthony J. Handley, MD (ERC); Ian Jacobs,
MD (ARC); Richard E. Kerber, MD (AHA); Walter G.J.
Kloeck, MD, BCh (Resuscitation Council of Southern Africa);
Pip Mason, RN (New Zealand Resuscitation Council); William
H. Montgomery, MD (AHA); Peter T. Morley, MD (ARC);
Martin H. Osmond, MDCM (HSFC); Colin Robertson, MD
(ERC); Michael Shuster, MD (HSFC); Petter A. Steen, MD
(ERC); James Tibballs, MD (ARC); Sergio Timerman, MD
(Latin American Council on Resuscitation); David A. Zideman,
MD (ERC)
Contents
Page 4 Overview and big-picture changes: international,
science-based guidelines; ACLS for Experienced Providers;
level of evidence defines class of recommendation; evidence-
based first aid: primary and secondary ABCD surveys
Page 6 Education, training, and examination: learning
objectives; open door to innovation; annotated examinations;
reconstruction of examinations; improving instructor quality
Page 8 Ethical concerns in resuscitation: family
presence during resuscitation; DNAR status; certification of
death in the field, not in the ED; survivor support
Page 9 BLS and PBLS: early defibrillation; special
a. Provide PBLS (open airway,rescue breathing, chestcompressions).
b. Provide advanced support ofoxygenation and ventilation.
c. Obtain vascular access.
d. Initiate appropriate resuscitativefluid and drug therapy.
3. Initiate the first 10 minutes ofresuscitation of the pediatric victimof cardiopulmonary arrest.
4. Provide support for familiesand providers in coping with achild's death
Adult and PediatricBasic Life Support
Core Training Objectives
Immediately after initial basic CPR trainingand for up to 2 years after, a rescuer shouldbe able to
1. Reduce the risk of the most commoncauses of injury and death.
2. Recognize unresponsiveness (or otheremergency situations where resuscitationis appropriate).
3. Phone 911 in a timely fashion (or otheremergency phone number, eg, in-hospital).
4. Provide an open airway (usinghead tilt–chin lift or jaw-thrust techniques).
5. Provide ventilations (breathing) that makethe chest rise, using mouth-to-mouth ormouth-to–barrier device ventilations(bag-mask ventilation by healthcareproviders).
6. Provide chest compressions (usingcompression force that moves sternumdown the appropriate depth for victim’sage [lay rescuer] or that generates apalpable pulse [healthcare provider]).
7. Perform all these skills in a manner thatis safe for the rescuer, the patient, andbystanders.
8. (If healthcare provider) Show proficiencyin bag-mask ventilation for victims ofall ages and use of AEDs for victims8 years of age or older.
Auditory and/or visual prompts (includes the valuablevoice prompts supplied with most AEDs).These prompts
guide the learner in multiple aspects of performance (ie, com-
pression location, depth, and rate; ventilation rate and volume).
Currently accepted are those prompts that require hands-on prac-
tice such as audible counting devices, sequence directive devices,
and compression-force prompts.
High-tech ACLS and BLS simulatorsguide and improve the
learner’s performance by providing constant device-operator
feedback as the learner attempts the procedure. Currently accept-
ed: Laerdal ALS units, a validated computer-aided learning pro-
gram to maintain healthcare provider skills with AEDs.
Increasing the Value of Examination Part I: Fully Annotated Written ExamsSupporting Pre-test and Post-test Learning
New All ACLS, PALS, and BLS written exams now have
a companion annotated exam. The annotations state why
each of the possible answers in the multiple choice list was
either correct or incorrect and refer the learner to the appropriate
text references and page numbers. After learners complete an
answer sheet, course directors can use student grading,
instructor grading, or colleague grading followed by distribution
of annotated versions. Learners review the annotated version
for discussions of questions that were unclear, misunderstood, or
answered incorrectly. This increases a learner’s independence,
aids self-learning, and frees course time formerly required for
review of written exams. (Circulation, page I-9)
Old From 1992 to 1997 the written exams had only an answer
sheet, with no information on why the right answer was correct
or why the other answers were incorrect. Annotations to the
questions in the written exams were not offered.
Why? Learners and instructors need to know why a particular
answer is either right or wrong. Instructors have complained that
they sometimes did not understand why certain answers were
correct and others were wrong. Exams with annotated answers
have been found to be a valuable self-teaching technique.
Advanced CardiacLife Support
Core Training Objectives
Upon leaving an ACLS course and for 2years after, the successful ACLS providershould be able to
1. Recognize and initiate treatment forprearrest conditions that may leadto a cardiac arrest, including acutecoronary syndromes, respiratoryfailure, and stroke.
2. Manage the first 10 minutes of anarrest due to ventricular fibrillation.
a. Provide BLS care, includingproper operation of an AED.
b. Provide proper operation of aconventional defibrillator.
c. Provide advanced airway supportof oxygenation and ventilationwith secondary confirmation oftracheal tube placement.
Part II: Complete Reconstruction of the ECCWritten Exams (for ACLS, PEDS, and BLS)
New New questions for the written exams have been created,
pilot tested, and validated. The questions evaluate mastery of the
major learning objectives. Educational consultants participated in
the writing, evaluation, and validation of these exams.
Old The former written questions did not eliminate ambiguity
and confusion. The subject matter of the questions seldom
aligned with the learning objectives of the course.
Why? This was a long-requested program improvement initia-
tive, undertaken to increase the learning value of written exams
for both the learners and the instructors.
New Focus on Measuring andImproving Instructor QualityNew Emphasis on Consistency inthe Quality of Teaching
New Training centers will create levels of faculty within
the center to facilitate instructor training, mentoring, and moni-
toring. Instructor and instructor-trainer monitoring forms provide
detailed outlines for evaluating instructor and instructor-trainer
performance. Training centers will be able to develop their
instructor corps internally without having to rely on outside
regional faculty. AHA-prepared videos and other standardized
teaching tools allow for core material to be presented consistently
and concisely in every course.
Old Instructor training and monitoring required regional
faculty assistance, which was not always available within
the training center. Instructor monitoring was subjective,
with little or no written guidelines for instructor
performance evaluation.
Why? This initiative enables training centers to meet the
demands for instructor development using internal resources.
Training centers will have the autonomy they need to operate
effectively and efficiently in developing their instructors.
Ethical Concerns inResuscitation
Family Presence DuringResuscitation Attempts Valuedby Families and Loved OnesNew Pediatric critical care nurses pioneered studies
demonstrating that family presence during resuscitation attempts
produces positive psychological effects. This practice is
recommended by the International Guidelines 2000 provided it
is done with planning, staff acceptance, and a designated staff
member who offers this opportunity to the family and remains
with them during their presence at the resuscitation attempt.
(Circulation, page I-19)
Searching for and Honoring“Do Not Attempt Resuscitation”(DNAR) Status In Field, EmergencyDepartment, and HospitalReviewed and Reaffirmed Many individuals, exe-
cuting their right of self-determination, have declared they want
no one to attempt resuscitation if they show indications of dis-
tress (unresponsive, not breathing, no pulse). They wish this even
if they or their family have called the EMS system. This DNAR
decision often takes the form of living wills, advance directives,
or other documents and even bracelets and anklets worn on the
body. Valid expressions of self-determination must be honored;
to do otherwise is unethical and prohibited by law.
(Circulation, pages I-14 to I-16, I-18)
Certification of Death in the Field—No TransportDeath Pronouncement in the Field
Reviewed and Reaffirmed There are very few indi-
cations for transporting a victim of nontraumatic cardiac arrest
who has failed a successfully executed prehospital ACLS resus-
citation effort to an Emergency Department to continue the resus-
citation attempt. The danger to personnel and bystanders is
greater than the probability of resuscitating the victim.
(Circulation, page I-17)
Criteria for Pronouncement of DeathReviewed and Reaffirmed EMS systems should
develop criteria for stopping resuscitation attempts in the out-of-
hospital setting. Advanced life support personnel, in collaboration
with the on-line medical control physician, can gather clinical
available, the skilled rescuer should attempt to provide smaller
tidal volumes during mouth-to-mask and bag-mask ventilation,
theoretically 400 to 600 mL over 1 to 2 seconds (Class IIb).
(Circulation,page I-38)
Old Provide tidal volume of 800 to 1200 mL during mouth-
to-mouth or mouth-to-mask or bag-mask ventilation.
Why? Smaller tidal volumes with oxygen supplementation
and/or bag-mask ventilation can support adequate oxygen satura-
tion but reduce the risk of gastric inflation (and its attendant
complications). If the smallest tidal volumes are used, the chest
should rise visibly and the oxygen saturation should be main-
tained. Note that smaller ventilation volumes can be associated
with hypercarbia and acidosis.
Mouth-to-Nose Breathing Is anAcceptable Alternative to Mouth-to-Nose-and-Mouth or Mouth-to-MouthRescue Breathing for an InfantNew Mouth-to-nose breathing is an acceptable alternative
to mouth-to-nose-and-mouth or mouth-to-mouth breathing if
the rescuer is unable to cover the infant’s nose and mouth
(Class IIb). (Circulation, pages I-265 to I-266)
Old Only mouth-to-nose-and-mouth and mouth-to-mouth res-
cue breathing were recommended. Mouth-to-nose breathing in
adults was offered as an alternative in the adult BLS 1992
Guidelines: “This technique is more effective in some patients
than the mouth-to-mouth technique. The mouth-to-nose tech-
nique is recommended when it is impossible to ventilate through
the victim’s mouth, the mouth cannot be opened (trismus), the
mouth is seriously injured, or a tight mouth-to-mouth seal is dif-
ficult to achieve. …” (JAMA, pages 2187-2188)
Why? Studies have shown that some rescuers may have
difficulty covering both the mouth and nose of an infant with
the rescuer’s mouth. In addition, these same studies have
shown that mouth-to-nose breathing may provide effective
ventilation of infants.
Consideration of AlternativeAirway Devices (LMA) forTrained Healthcare ProvidersNew Use of alternative advanced airways should be encour-
aged when rescuers are properly trained in their use (Class
Indeterminate). (Circulation, page I-297)
Old Tracheal intubation was thought to be the gold
standard for airway control.
Why? Several studies have documented the high complication
rate that can occur in some EMS systems when tracheal
intubation is performed by rescuers with limited experience in
performing pediatric intubation. Therefore, alternative techniques
to help isolate the airway and reduce gastric inflation are encour-
aged when rescuers are properly trained.
The “Pulse Check” Should Not BeTaught to Lay Rescuers New In the ABC sequence of CPR, lay rescuers will no longer
be taught to check for a carotid pulse. Instead they will be taught
to look and examine for “signs of circulation,” which include
normal breathing, coughing, or movement (Class IIa). If no signs
of circulation are detected, the rescuer should begin chest com-
pressions and attach an AED, if available. (Circulation, pages I-
39 to I-40 and I-269)
Old Lay rescuers were taught to palpate the carotid artery
located on the same side of the neck as the rescuer and, taking no
more than 10 seconds, decide whether they could feel a pulse. If
they felt no pulse, they would begin chest compressions and
attach the AED.
Why? Lay rescuers perform the pulse check primarily as the
signal to start chest compressions and, if trained as a Heartsaver
AED provider, to call for and attach an AED. Considerable evi-
dence demonstrates that rescuers have trouble locating the cor-
rect place for palpation. They require much more than the recom-
mended upper limit of 10 seconds. Finally, when palpating in the
correct location for as long as needed, the rescuer is unacceptably
inaccurate. A serious type II or false-negative error is committed
10% of the time. This leads to 1 of 10 cardiac arrest patients not
receiving either chest compressions or AED attachment.
Dropping the pulse check will not result in as much potential
harm as keeping the pulse check.
Simplification of Maneuvers for LayRescuer Relief of Foreign-BodyAirway Obstruction in theUnresponsive Victim of Any Age(Class IIb)New Previously recommended maneuvers for relief of
foreign-body airway obstruction (FBAO) in the unconscious
victim will no longer be taught to lay rescuers. Instead the lay
rescuer will begin standard CPR when an unrelieved responsive,
choking victim becomes unresponsive, or an unresponsive
person suspected of an FBAO is encountered, evaluated, and
treated. The only difference from regular CPR is that the rescuer
leads to marked reduction in blood flow and blood pressure.
With a 5:1 ratio the single ventilation, sandwiched between
short periods of rapid chest compressions, leads to faster,
more forceful ventilations from the rescuers. This in turn
leads to greater risks for gastric inflation, regurgitation, aspira-
tion, and severe lung damage.
Reaffirmed The 5:1 ratio should be used in pediatric arrest
by professional responders regardless of whether 1 or 2 rescuers
are involved.
Why? This topic has been reviewed several times since 1992.
There is no evidence to justify a change. Emphasis on oxygena-
tion and ventilation is justified in infants and children based on
the epidemiology of cardiac arrest.
“CPR” Performed Without Mouth-to-Mouth VentilationsReviewed and Reaffirmed CPR with compressions
and ventilations remains the ideal method of maintaining blood
flow until the arrival of a lay responder with an AED or EMS
personnel. However, if unwilling to perform mouth-to-mouth
rescue breathing for an adult victim, the rescuer should access
the EMS system, open the airway, and perform chest
compressions at the rate of approximately 100 compressions
per minute (Class IIa). (Circulation, page I-43)
CPR without ventilation may be taught by emergency
medical dispatchers (Class IIa).
The 2 Thumb–Encircling HandsChest Compression Technique IsRecommended Over the 2-FingerCompression Technique for 2-RescuerInfant CPR by Healthcare Providers
New The 2 thumb–encircling hands technique of chest com-
pression is preferred for chest compressions in infants performed
by healthcare providers when 2 rescuers are available (Class IIb).
(Circulation,page I-351)
Old The 2 thumb–encircling hands technique was an alterna-
tive technique for chest compression in the neonate.
Why? Data show that the 2 thumb–encircling hands tech-
nique can provide better blood flow than the 2-finger technique.
However, a single rescuer providing chest compressions using
this technique may have difficulty alternating between rescue
breathing and chest compressions. For simplicity and retention,
this technique is not taught to the lay rescuer and anyone per-
forming 1-rescuer CPR.
Use of Automated ExternalDefibrillators Is Encouraged forVictims of Cardiac Arrest OlderThan About 8 Years of Age orAbout 25 kg (55 lbs), AlthoughData Is Regarding the Use of AEDsin Pediatric Victims Are Limited
Reviewed An AED can be used in children 8 years of
age and older. The mean weight of an 8-year-old is 25 kg (55 lbs).
At that weight, an adult biphasic defibrillator will provide
nonescalating defibrillation energy doses of 150 J (6 J/kg) for
a 25-kg child. A monophasic defibrillator with escalating
dose will provide approximately 200 J (8 J/kg) for a 25-kg
child initially and then higher doses. Available evidence suggests
that these devices are accurate in differentiating between
shockable and nonshockable rhythms for adolescents. Note
that the guidelines still suggest the use of defibrillators with
adjustable energy dose for in-hospital use in areas that routinely
care for infants and children (Class IIb). (Circulation,page I-271)
Management ofthe Airway and
VentilationNew Airway AdjunctsNew The guideline sections on airway management and
ventilation contain the greatest number of new recommendations.
Most of these recommendations apply to healthcare providers
at both the BLS and ALS level. (Circulation,page I-95)
Why? New evidence. Since the 1992 Guidelines, many
scientists, researchers, corporate engineers, and entrepreneurs
have provided new information, new products, and new insights.
New evidence addresses ventilation volumes, ventilation
rates, maintenance of oxygenation, and prevention of hypercarbia,
acidosis, and aspiration. The international collaboration for
the International Guidelines 2000 increased awareness of
many devices and techniques that would otherwise have
remained unknown to the AHA training network.
The most important airway and ventilation developments come
from quality assessment efforts and outcome evaluation projects
conducted by a number of national and international centers.
These efforts have given us valuable information on the relative
merit of different devices and approaches. More important, this
work has stunned the resuscitation community by unequivocal
Early identification of critical illness (respiratory failure
and shock) and implementation of advanced life support to
prevent cardiac arrest continue to be emphasized in the new
guidelines. The default sequence of PALS interventions is
based on the most common cause of arrest for a given age
group. New information is provided to help the participant
to identify and treat special resuscitation circumstances that
may alter the ALS intervention approach.
Cardiac Arrest and CardiovascularEmergencies Related to SpecialResuscitation Circumstances: DrugOverdoses, Toxins, ElectrolyteAbnormalities, Asthma, andAnaphylaxis
New Slightly modified approaches to resuscitation and
advanced life support are provided for infants and children with
suspected drug toxicity or poisoning, such as cocaine
or ß-blocker overdose, or suspected electrolyte emergencies.
(Circulation, pages I-322 to I-325)
Old PALS rescuers should “seek and treat” reversible
causes, but no specific information regarding modification of
existing algorithms or treatment approaches was offered.
Why? We now know more about specific arrhythmias and
the cardiovascular effects of drug toxicities and poisonings.
In addition, the old PALS course was not designed to teach
advanced provider therapies and interventions. As more
providers have mastered the previous course content, it was
necessary for the course to evolve to meet the needs of these
trained providers. The advanced life support provider
can now apply PALS guidelines with specific recommendation
for managing common poisonings, toxicologic problems, and
electrolyte abnormalities.
Bag-Mask Ventilation VersusTracheal Intubation by PediatricHealthcare ProvidersReviewed and Reaffirmed All healthcare providers
who provide prehospital care for infants and children must be
trained to provide effective oxygenation and ventilation using
the bag-mask technique. This is an essential core skill for all
healthcare providers.
New For out-of-hospital PALS-level providers, ventilation via
a tracheal tube continues to be recommended under specific con-
ditions. A properly placed and secured tracheal tube is the most
effective and reliable method of assisted ventilation and has long
been considered the gold standard. However, this method
requires initial mastery and continued practice or frequent field
use to maintain safe and effective technical skills.
(Circulation, page I-296)
Tracheal intubation in unconscious patients should be
encouraged only for healthcare providers well trained
in performing this skill, verified by significant and
frequent field experience, and continually monitored
by an ongoing quality-improvement program.
Old In the out-of-hospital setting, for pediatric emergencies,
ventilation via a properly placed tracheal tube is the most
effective and safest ventilatory method. (While this statement
remains true and is still a part of the guidelines, proper
insertion and reliable maintenance of the tracheal tube are
difficult, particularly in EMS systems where paramedics
have infrequent opportunity to attempt intubation.)
Why? Recent research has confirmed new observations
about pediatric airway maintenance and ventilation in the
out-of-hospital setting: (1) properly performed bag-mask
ventilation is safer and more effective than previously realized,
particularly when transport time is short and (2) tracheal tube
intubation is more difficult to master and more dangerous
than previously realized. These observations together suggest
a restatement: bag-mask ventilation may be equivalent to
tracheal tube intubation for respiratory emergencies in some
out-of-hospital pediatric ALS settings.
Bag-mask ventilation, compared with tracheal tube intubation,
can provide equally effective ventilation and oxygenation in
prehospital settings where transport times are short. One urban
EMS system with short transport times and trained providers
with infrequent pediatric intubations in the field observed that
children who required ventilatory support had equivalent sur-
vival rates regardless of whether they received bag-mask venti-
lation or ventilation through a tracheal tube placed in the out-
of-hospital setting. Other studies confirm that in some EMS
systems the success rate for pediatric intubation is mediocre,
equivalent alternative airway devices can be placed with a
high success/low complication rate, their use is acceptable.
Intraosseous Route Acceptableand Recommended to IncludeVictims 6 Years of Age or Older(Circulation, page I-305)
New The age range within which intraosseous access is
acceptable and recommended is extended to all victims
including children over the age of 6 years. There is no upper
age limit.
New When healthcare personnel are unable to achieve
vascular access in pediatric emergencies within a reasonable
time, intraosseous access is acceptable and recommended.
“Reasonable” depends on the condition of the patient—PALS
uses the 90-second suggested limit for establishment of vascular
access in cardiac arrest but offers a little more flexibility if the
patient is stable (Class IIa).
Old In children 6 years of age or younger, intraosseous
vascular access should be established if reliable venous access
cannot be achieved within 3 attempts or 90 seconds, whichever
comes first.
Why? Access to the circulation is critical and lifesaving
for drug and fluid administration to the pediatric patient, although
it is often difficult to achieve. Successful use of intraosseous
access has been documented in patients well beyond 6 years of
age and can be achieved routinely within 30 to 60 seconds. The
success rate for intraosseous cannulation is lower for older chil-
dren than it is for younger children, but it still provides a reason-
able alternative when vascular access cannot be achieved in a
timely manner.
Vagal Maneuvers Added to theTreatment Algorithm forSupraventricular Tachycardia(Circulation, pages I-314 to I-315)
New Vagal maneuvers are recommended for the treatment of
supraventricular tachycardia, provided these maneuvers do not
delay cardioversion or use of adenosine for the child with poor
systemic perfusion. Ice water applied to the face is most effective
in infants and young children (Class IIb).
Old Vagal maneuvers were not mentioned.
Why? Evidence shows that vagal maneuvers can terminate
supraventricular tachycardia. In children with milder symptoms,
vagal maneuvers may be attempted during preparation for
cardioversion or drug therapy, provided the child is hemo-
dynamically stable. Success rates with these maneuvers are
variable and depend on underlying conditions, the patient’s
level of cooperation, and the patient’s age.
Amiodarone Added to thePediatric Treatment Algorithmsfor Supraventricular and VentricularTachycardia and VF/VT New Amiodarone can be used for both supraventricular and
ventricular arrhythmias; in particular, amiodarone may be
considered for refractory VF that persists despite 3 shocks.
(Circulation, page I-318)
Old Intravenous forms of amiodarone were not approved for
use until the late 1990s.
Why? Amiodarone has been used most commonly in children
in the postoperative period after cardiac surgery. Amiodarone
is effective on ectopic atrial tachycardia or junctional ectopic
tachycardia.
Amiodarone is also effective for VT in postoperative patients
or children with underlying cardiac disease. Successful expe-
rience with this drug in children continues to accumulate.
There are no prospective, randomized trials of amiodarone in
pediatric cardiac arrest.
Amiodarone has been added as a drug to consider in pediatric
pulseless arrest on the basis of evidence extrapolated from adult
prospective, clinical trials. In a large, prospective, randomized
trial in adults, amiodarone was associated with a significant
increase in the rate of admission to hospital but not survival rate
for adults with shock-refractory VF/pulseless VT. For ease of
learning, PALS and ACLS algorithms attempt to achieve
Why? Several reports document a high incidence of both
initial esophageal intubations (tube misplacement) as well
as subsequent tube dislodgments, when seriously ill or
injured children are intubated by providers inexperienced
in the technique. Proper bag-mask ventilation can provide
effective ventilation, particularly for short periods.
New Airway Adjunct—the Laryngeal Mask Airway (LMA)Now Available and Acceptable for Use but Only byAppropriately Trained Providers
New Masks that fit over the laryngeal inlet have been shown
to be effective for ventilating newly born full-term infants. The
LMA, when used by appropriately trained providers, shows
promise as an effective alternative for establishing an airway
in the newly born infant. This is especially true in the case of
ineffective bag-mask ventilation or failed endotracheal intubation
(Class Indeterminate). (Circulation,page I-350)
Old The LMA was not available for clinical use until the
late 1990s.
Why? See previous guideline. Note that the LMA is not
recommended routinely and it should not replace the endotracheal
tube for use in neonates with meconium-stained amniotic fluid.
Recommendations forSecondary Confirmation ofTracheal Tube Placement New An exhaled-CO2 monitor is one of several secondary
confirmation devices that should be used to verify tracheal
tube placement. These devices are associated with some
false-negative results (may lead to removal of a properly
placed tube), but few false-positive results (infrequently lead
to thinking an esophageal intubation is in the correct location).
Monitoring of exhaled CO2 can be useful in the secondary
confirmation of tracheal intubation in the newly born, particularly
when clinical assessment is equivocal (Class Indeterminate).
(Circulation, page I-351)
Old Confirmation of tracheal tube placement is accomplished
by clinical assessment, with no mention of use of exhaled
CO2 for secondary confirmation.
Why? Intubation of the small infant can be difficult,
particularly if the rescuer is inexperienced. Several reports
have documented a significant incidence of undetected tube
misplacement or tube dislodgment following intubation of
seriously ill or injured children in the prehospital setting.
Secondary confirmation reduces the risk of undetected tube
misplacement, and continued use of these confirmation
techniques provides early recognition of tube dislodgment.
Caution should be used when applying this technique in
the setting of pulseless arrest or on infants less than 2 kg.
(Circulation, page I-302)
Use of Crystalloid Solutions for InitialVolume Resuscitation Instead ofAlbumin-Containing SolutionsNew The fluid of choice for volume expansion is an isotonic
crystalloid solution such as normal saline or Ringer’s lactate
(Class IIb). Administration of O-negative red blood cells may be
indicated for replacement of large-volume blood loss. Albumin-
containing solutions are less frequently used for initial volume
expansion. (Circulation, page I-352)
Old Blood volume expansion may be accomplished by
using 10 mL/kg of (1) normal saline or Ringer’s lactate,
(2) 5% albumin-saline or other plasma substitute, or
(3) O-negative blood cross-matched with the mother’s blood.
Why? Albumin-containing solutions are less frequently used
because of limited availability, a potential for risk of infectious
disease, and an observed association with increased mortality.
Ethical IssuesNew There are circumstances in which noninitiation or dis-
continuation of resuscitation in the delivery room may be appro-
priate. Specific situations are suggested in the guidelines (eg,
infants with confirmed gestation <23 weeks or birthweight
<400 g, anencephaly, or confirmed trisomy 13 or 18).
(Circulation, pages I-354 to I-355)
Old No mention of noninitiation of resuscitation in the chapter
on neonatal resuscitation; brief discussion in ethics chapter.
Why? Considerable evidence now documents the long-term
outcomes of a large number of premature, small, or impaired
infants following delivery resuscitation. Such information pro-
vides data to support discussions with parents, family members,
and staff about not starting or early discontinuation of resuscita-
tion attempts.
Hypothermia and ResuscitationNew Recent animal and human studies have suggested that
selective (cerebral) hypothermia of the asphyxiated infant may
protect against brain injury. This approach cannot be recom-
mended routinely until appropriate controlled studies in
LidocaineNew Lidocaine remains acceptable for the treatment of
shock-refractory VF, but the levels of evidence supporting a
strong role for lidocaine are at best levels 6, 7, and 8. The
conference conclusions therefore were that lidocaine should
continue to be listed in the algorithm for VF/VT but with an
Indeterminate Class of Recommendation. Lidocaine has not
been recommended for routine prophylaxis of ventricular
arrhythmias in the setting of acute myocardial infarction for
more than 8 years. Conference experts reexamined this ques-
tion and reported that no significant data has accumulated
since 1992 to change the classification of lidocaine to a Class
III (evidence of harm) agent. (Circulation,page I-149)
Magnesium has demonstrated effectiveness for treatment of
VF/pulseless VT in 2 clinical situations: (1) torsades de
pointes, for which it still has a Class IIb recommendation and
(2) VF/VT and other arrhythmias associated with known
hypomagnesemia (Class IIb).
Figure 4: Pulseless Electrical Activity
New The PEA algorithm contains all of the new guide-
lines discussed above in the VF/VT algorithm including tra-
cheal tube insertion, verification of proper tube placement,
epinephrine, and atropine. Note that vasopressin does not
appear in any algorithm other than VF/VT (Class
Indeterminate). (Circulation,page I-150)
Figure 5: Asystole
New The asystole algorithm contains few new clinical rec-
ommendations in terms of the epinephrine, atropine, and pac-
ing that have been the only 3 interventions used for
asystole for more than a decade. Many experts, however,
consider this algorithm to contain the most significant and
important new guidelines changes. (Circulation,page I-152)
New Healthcare providers are advised to specifically
survey the resuscitation scene for a living will, advance
directive, or no-CPR bracelet or anklet and to be particularly
aware and sensitive that asystole often occurs in terminally
ill patients who are expecting to die. The 911 call does not
mean the family or patient has changed the decision to
forego or renounce a no-CPR decision. The call most often
means the patient or family is uncomfortable with death at
home; support, information, and conscientious efforts to
make the patient as comfortable as possible are needed.
(Circulation,page I-152)
New Relatively specific criteria are listed in the algorithm
and in the notes for withholding or stopping resuscitation
efforts. These criteria direct the resuscitation team to consider
the quality of the resuscitation, whether unusual clinical fea-
tures might be present, and whether cease-effort protocols
have been developed and are in place. (Circulation,page I-154)
New Protocols for leaving the body at the scene. The
algorithm notes and the ECC textbook discuss the steps
necessary to adopt these important new protocols for leaving
the body at the scene, including designating an EMS person
designated
to care for the family and survivors and establishing who to
call for completion of death certification documents.
(Circulation,page I-155)
Figure 6: Bradycardias
Reviewed and Reaffirmed Unlike the tachycardia
algorithms, in which massive changes, revisions, and new agents
now appear, clinical research has not identified the need for new
guidelines for bradycardias. The existing intervention sequence
of atropine, transcutaneous pacing, dopamine, and epinephrine
remains intact and unmodified. (Circulation,page I-155)
Figure 7: Tachycardia Overview Plus Wide-Complex TachycardiasTable 7B: Control of Rate and Rhythm inAtrial Fibrillation and FlutterFigure 8: Narrow-ComplexSupraventricular TachycardiasFigure 9: Ventricular Tachycardias Thatare Stable
The most critical new guidelines for the management of
tachycardias are several important management principles:
New Cardiologists who specialize in treatment of arrhythmias
helped develop the new algorithms for tachycardias
(Circulation,page I-158). Proper treatment of tachyarrhythmias
is complicated. ACLS providers can best serve their patients
by understanding and practicing 5 new perspectives on the
ACLS guidelines:
1. Antiarrhythmics are also proarrhythmics. All antiarrhyth-
mic agents are now recognized to possess some degree of
proarrhythmic activity.
2. The use of more than 1 antiarrhythmic to treat tachycardia is
undesirable because it increases the risk of complications.
Administration of more than 1 antiarrhythmic during treatment
of an episode of tachycardia is not routinely recommended.
3. If the patient has impaired myocardial function, most antiar-
rhythmics will make cardiac function worse. Selection of the
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