Part 10: Paediatric basic and advanced life support

Special Report—Pediatric Basic and AdvancedLife Support: 2010 International Consensus onCardiopulmonary Resuscitation and EmergencyCardiovascular Care Science WithTreatment Recommendations

Note From theWriting Group: Throughout this article, the reader willnotice combinations of superscripted letters and numbers (eg, “FamilyPresence During ResuscitationPeds-003”). These callouts are hyper-linked to evidence-based worksheets, which were used in the develop-ment of this article. An appendix of worksheets, applicable to thisarticle, is located at the end of the text. The worksheets are available inPDF format and are open access.

The 2010 ILCOR Pediatric Task Force experts developed 55 questionsrelated to pediatric resuscitation. Topics were selected based on the2005 Consensus on Science and Treatment Recommendations (CoSTR)document,1,2 emerging science, and newly identified issues. Not everytopic reviewed for the 2005 International Consensus on Science wasreviewed in the 2010 evidence evaluation process. In general, evidence-based worksheets were assigned to at least 2 authors for each topic.The literature search strategy was first reviewed by a “worksheet ex-pert” for completeness. The expert also approved the final worksheetto ensure that the levels of evidencewere correctly assigned accordingto the established criteria. Worksheet authors were requested to draftCoSTR statements (see Part 3: Evidence Evaluation Process). Eachworksheet author or pair of authors presented their topic to the TaskForce in person or via a webinar conference, and Task Force membersdiscussed the available science and revised the CoSTR draft accord-ingly. These draft CoSTR summaries were recirculated to the Interna-tional Liaison Committee on Resuscitation (ILCOR) Pediatric Task Forcefor further refinement until consensus was reached. Selected contro-versial and critical topics were presented at the 2010 ILCOR Interna-tional Evidence Evaluation conference in Dallas, Texas, for further dis-cussion to obtain additional input and feedback. This documentpresents the 2010 international consensus on the science, treatment,and knowledge gaps for each pediatric question.

The most important changes or points of emphasis in the recommen-dations for pediatric resuscitation since the publication of the 2005ILCOR International Consensus on CPR and ECC Science With TreatmentRecommendations1,2 are summarized in the following list. The scientificevidence supporting these changes is detailed in this document.

Monica E. Kleinman, Co-Chair*, Allan R. de Caen,Co-Chair*, Leon Chameides, Dianne L. Atkins, Robert A.Berg, Marc D. Berg, Farhan Bhanji, Dominique Biarent,Robert Bingham, Ashraf H. Coovadia, Mary Fran Hazinski,Robert W. Hickey, Vinay M. Nadkarni, Amelia G. Reis,Antonio Rodriguez-Nunez, James Tibballs, Arno L.Zaritsky, David Zideman, on behalf of the PEDIATRIC BASICAND ADVANCED LIFE SUPPORT CHAPTER COLLABORATORS

KEY WORDSarrhythmia, cardiopulmonary resuscitation, pediatrics,resuscitation

The American Heart Association requests that this document becited as follows: Kleinman ME, de Caen AR, Chameides L, AtkinsDL, Berg RA, Berg MD, Bhanji F, Biarent D, Bingham R, CoovadiaAH, Hazinski MF, Hickey RW, Nadkarni VM, Reis AG, Rodriguez-Nunez A, Tibballs J, Zaritsky AL, Zideman D; on behalf of thePediatric Basic and Advanced Life Support ChapterCollaborators. Special report—pediatric basic and advanced lifesupport: 2010 International Consensus on CardiopulmonaryResuscitation and Emergency Cardiovascular Care Science WithTreatment Recommendations. Circulation. 2010;122(suppl 2):S466–S515.

*Co-chairs and equal first co-authors.

(Circulation. 2010;122[suppl 2]:S466–S515.)

© 2010 American Heart Association, Inc., European ResuscitationCouncil, and International Liaison Committee on Resuscitation.

Circulation is available at http://circ.ahajournals.org

doi:10.1542/peds.2010-2972A

FROM THE AMERICAN ACADEMY OF PEDIATRICS

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● Additional evidence shows thathealthcare providers do not reliablydetermine the presence or absenceof a pulse in infants or children.

● New evidence documents the impor-tant role of ventilations in CPR forinfants and children. However, res-cuers who are unable or unwillingto provide ventilations should be en-couraged to perform compression-only CPR.

● To achieve effective chest compres-sions, rescuers should compress atleast one third the anterior-posteriordimension of the chest. This corre-sponds to approximately 11⁄2 inches(4 cm) in most infants and 2 inches(5 cm) in most children.

● When shocks are indicated for ven-tricular fibrillation (VF) or pulselessventricular tachycardia (VT) in in-fants and children, an initial energydose of 2 to 4 J/kg is reasonable;doses higher than 4 J/kg, especiallyif delivered with a biphasic defibril-lator, may be safe and effective.

● More data support the safety andeffectiveness of cuffed trachealtubes in infants and young children,and the formula for selecting the ap-propriately sized cuffed tube wasupdated.

● The safety and value of using cricoidpressure during emergency intuba-tion are not clear. Therefore, the ap-plication of cricoid pressure shouldbe modified or discontinued if it im-pedes ventilation or the speed orease of intubation.

● Monitoring capnography/capnom-etry is recommended to confirmproper endotracheal tube position.

● Monitoring capnography/capnom-etry may be helpful during CPR tohelp assess and optimize quality ofchest compressions.

● On the basis of increasing evidenceof potential harm from exposure tohigh-concentration oxygen after

cardiac arrest, once spontaneouscirculation is restored, inspired ox-ygen concentration should be ti-trated to limit the risk ofhyperoxemia.

● Use of a rapid response system in apediatric inpatient setting may bebeneficial to reduce rates of cardiacand respiratory arrest and in-hospital mortality.

● Use of a bundled approach to man-agement of pediatric septic shock isrecommended.

● The young victim of a sudden, unex-pected cardiac arrest should havean unrestricted, complete autopsy,if possible, with special attention tothe possibility of an underlying con-dition that predisposes to a fatal ar-rhythmia. Appropriate preservationand genetic analysis of tissueshould be considered; detailed test-ing may reveal an inherited “chan-nelopathy” that may also be presentin surviving family members.

SYSTEMSMedical emergency teams (METs) orrapid response teams (RRTs) havebeen shown to be effective in prevent-ing respiratory and cardiac arrests inselected pediatric inpatient settings.

Family presence during resuscitationshas been shown to be beneficial for thegrieving process and in general wasnot found to be disruptive. Thus, familypresence is supported if it does not in-terfere with the resuscitative effort.

Medical Emergency or RapidResponse TeamPeds-025A, Peds-025B

Consensus on ScienceThe introduction of METs or RRTs wasassociated with a decrease in pediat-ric hospital mortality in 1 LOE 3 meta-analysis3 and 3 pediatric LOE 3 studieswith historic controls.4–6 The introduc-tion of a MET or RRT was associatedwith

● a decrease in respiratory but notcardiac arrest in 1 LOE 37 study withhistoric controls

● a decrease in preventable totalnumber of arrests in 1 LOE 3 studycompared with a retrospectivechart review8

● a decrease in total number of ar-rests in 2 LOE 34,8 studies

● a decrease in preventable cardiacarrests in 1 LOE 36 study

● a decrease in cardiac arrest andnon–pediatric intensive care unit(PICU) mortality in 1 LOE 39 pedi-atric cohort study using historicalcontrols

Treatment RecommendationsPediatric RRT or MET systems may bebeneficial to reduce the risk of respira-tory and/or cardiac arrest in hospital-ized pediatric patients outside an in-tensively monitored environment.

Knowledge GapsIs it the team or the staff educationassociated with MET or RRT implemen-tation that leads to improved patientoutcomes? Is the team effectivenessdue to validated team activation crite-ria or specific team composition? Dothe benefits attributed to these teamsextend to children in a community hos-pital setting?

Family Presence DuringResuscitationPeds-003

Consensus on ScienceTen studies (LOE 210; LOE 311; LOE 412–19)documented that parents wish to begiven the option of being present dur-ing the resuscitation of their children.One LOE 2,10 1 LOE 3,11 2 LOE 4,13,19 and 1LOE 520 studies confirmed that mostparents would recommend parentpresence during resuscitation.

One LOE 2,10 1 LOE 3,11 6 LOE 4,12,14,19,21–23

and 2 LOE 520,24 studies of relativespresent during the resuscitation of afamily member reported that they be-

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lieved their presence was beneficial tothe patient.

One LOE 2,10 1 LOE 3,11 6 LOE 4,12,13,16–19

and 1 LOE 524 studies reported thatmost relatives present during the re-suscitation of a family member bene-fited from the experience. One LOE 3,11

4 LOE 4,12,13,20,21 and 2 LOE 524,25 studiesreported that being present during theresuscitation helped their adjustmentto the family member’s death.

One LOE 210 and 2 LOE 412,13 studies ob-served that allowing family membersto be present during a resuscitation ina hospital setting did them no harm,whereas 1 LOE 426 study suggested thatsome relatives present for the resusci-tation of a family member experiencedshort-term emotional difficulty.

One LOE 2,10 1 LOE 3,27 3 LOE 4,12,23,28 and3 LOE 520,24,29 studies showed that fam-ily presence during resuscitation wasnot perceived as being stressful tostaff or to have negatively affectedstaff performance. However, 1 survey(LOE 430) found that 39% to 66% ofemergency medical services (EMS)providers reported feeling threatenedby family members during an out-of-hospital resuscitation and that familypresence interfered with their abilityto perform resuscitations.

Treatment RecommendationsIn general, family members should beoffered the opportunity to be presentduring the resuscitation of an infantor child. When deciding whether toallow family members to be presentduring an out-of-hospital resuscita-tion, the potential negative impact onEMS provider performance must beconsidered.

Knowledge GapsHow does the presence of a dedicatedsupport person help family membersand, potentially, healthcare providersduring the resuscitation of an infant orchild? What training is appropriate forstaff who may serve as support per-

sons for family members during re-suscitation of an infant or child? Why isfamily presence during resuscitationperceived more negatively by out-of-hospital care providers than by in-hospital staff?

ASSESSMENTMany healthcare providers find it diffi-cult to rapidly and accurately deter-mine the presence or absence of apulse. On the basis of available evi-dence, the Task Force decided to deem-phasize but not eliminate the pulsecheck as part of the healthcare pro-vider assessment. The Task Forcemembers recognized that healthcareproviders who work in specialized set-tings may have enhanced skills in ac-curate and rapid pulse checks, al-though this has not been studied.

There are considerable data regardinguse of end-tidal carbon dioxide (PETCO2)measurement, capnography and cap-nometry, during cardiopulmonary re-suscitation (CPR) as an indicator ofCPR quality and as a predictive mea-sure of outcome. Although capnogra-phy/capnometry may reflect the qual-ity of CPR, there is insufficient evidenceof its reliability in predicting resuscita-tion success in infants and children.

Pulse Check Versus Check forSigns of LifePeds-002A

Consensus on ScienceThirteen LOE 5 studies31–43 observedthat neither laypersons nor healthcareproviders are able to perform an accu-rate pulse check in healthy adults orinfants within 10 seconds. In 2 LOE 5studies in adults44,45 and 2 LOE 3 stud-ies in children with nonpulsatile circu-lation,46,47 blinded healthcare provid-ers commonly assessed pulse statusinaccurately and their assessmentoften took�10 seconds. In the pediat-ric studies, healthcare professionalswere able to accurately detect a pulseby palpation only 80% of the time. Theymistakenly perceived a pulse when it

was nonexistent 14% to 24% of thetime and failed to detect a pulse whenpresent in 21% to 36% of the assess-ments. The average time to detect anactual pulse was approximately 15seconds, whereas the average time toconfirm the absence of a pulse was 30seconds. Because the pulseless pa-tients were receiving extracorporealmembrane oxygenation (ECMO) sup-port, one must be cautious in extrapo-lating these data to the arrest situa-tion; all pulseless patients did haveperfusion and therefore had signs ofcirculation as evidenced by warm skintemperature with brisk capillary refill.All patients evaluated were in an inten-sive care unit (ICU) setting without on-going CPR.

Treatment RecommendationsPalpation of a pulse (or its absence) isnot reliable as the sole determinant ofcardiac arrest and need for chest com-pressions. If the victim is unrespon-sive, not breathing normally, and thereare no signs of life, lay rescuers shouldbegin CPR. In infants and children withno signs of life, healthcare providersshould begin CPR unless they can defi-nitely palpate a pulse within 10seconds.

Knowledge GapsIs there an association between thetime required to successfully detect asuspected cardiac arrest victim’spulse and resuscitation outcome? Isthere a difference in outcome whenthe decision to start chest compres-sions is based on the absence of signsof life as opposed to absence of apulse?

Focused Echocardiogram to DetectReversible Causes of CardiacArrestPeds-006B

Consensus on ScienceIn 1 small LOE 4 pediatric case series48

cardiac activity was rapidly visualizedby echocardiography without pro-






longed interruption of chest compres-sions, and this cardiac activity corre-lated with the presence or absence ofa central pulse. In 1 pediatric LOE 4case report,49 echocardiography wasuseful for diagnosing pericardial tam-ponade as the cause of cardiac arrestand was useful in guiding treatment.

In 8 LOE 5 adult case series,50–57 echo-cardiographic findings correlated wellwith the presence or absence of car-diac activity in cardiac arrest. Thesereports also suggested that echocardi-ography may be useful in identifyingpatients with potentially reversiblecauses for the arrest.

Treatment RecommendationsThere is insufficient evidence to rec-ommend for or against the routine useof echocardiography during pediatriccardiac arrest. Echocardiography maybe considered to identify potentiallytreatable causes of an arrest when ap-propriately skilled personnel are avail-able, but the benefits must be carefullyweighed against the known deleteri-ous consequences of interruptingchest compressions.

Knowledge GapsCan echocardiography be performedduring cardiac arrest in infants andchildren without significant interrup-tions in chest compressions? How of-ten does echocardiography duringcardiac arrest provide informationthat can affect treatment andoutcome?

End-tidal CO2 (PETCO2) and Quality ofCPRPeds-005A, Peds-005B

Consensus on ScienceThree LOE 5 animal studies,58–60 4 LOE 5adult,61–64 and 1 LOE 5 pediatric series65

showed a strong correlation betweenPETCO2 and interventions that increasecardiac output during resuscitationfrom shock or cardiac arrest. Similarly3 LOE 5 animalmodels66–68 showed that

measures that markedly reduce car-diac output result in a fall in PETCO2.

Two LOE 5 adult out-of-hospital stud-ies69,70 supported continuous PETCO2monitoring during CPR as a way of de-termining return of spontaneous cir-culation (ROSC), particularly if thereadings during CPR are �15 mm Hg(2.0 kPa). In 1 LOE 471 and 2 LOE 5 adultcase series,72,73 an abrupt and sus-tained rise in PETCO2 often precededidentification of ROSC.

Two LOE 4 pediatric cases series,65,74 8LOE 5 adult,70,75–81 and 1 LOE 5 animalstudy59 showed that a low PETCO2(�10 mm Hg [1.33 kPa] to�15 mm Hg[2.0 kPa]) despite 15 to 20 minutes ofadvanced life support (ALS) is stronglyassociated with failure to achieveROSC. On the basis of 2 LOE 5 animalstudies71,82 and 2 adult LOE 5 case se-ries,70,78 PETCO2 after at least 1 minute ofCPR may be more predictive of out-come than the initial value because theinitial PETCO2 is often increased in pa-tients with asphyxial cardiac arrest.

The wide variation for initial PETCO2 dur-ing resuscitation limits its reliability inpredicting outcome of resuscitationand its value as a guide to limiting re-suscitation efforts. Two LOE 5 animalstudies71,82 and 2 large LOE 5 adult tri-als70,78 suggested that the initial PETCO2is higher if the etiology of the cardiacarrest is asphyxial rather than if it is aprimary cardiac arrest.

Interpretation of the end-tidal CO2during resuscitation is affected by thequality of the measurement, theminute ventilation delivered during re-suscitation, the presence of lung dis-ease that increases anatomic deadspace, and the presence of right-to-leftshunting.83–85

In 1 LOE 5 adult study,86 sodium bi-carbonate transiently increased end-tidal CO2, and in 3 LOE 5 adult87–89 and2 LOE 5 animal90,91 studies, epinephrine

(and other systemic vasoconstrictiveagents) transiently decreased PETCO2.

Treatment RecommendationsContinuous capnography or capnom-etry monitoring, if available, may bebeneficial by providing feedback on theeffectiveness of chest compressions.Whereas a specific target number can-not be identified, if the PETCO2 is consis-tently �15 mm Hg, it is reasonable tofocus efforts on improving the qualityof chest compressions and avoidingexcessive ventilation.

Although a threshold PETCO2 may pre-dict a poor outcome from resuscita-tion and might be useful as a guide totermination of CPR, there are insuffi-cient data to establish the thresholdand the appropriate duration of ALSneeded before such evaluation in chil-dren. The PETCO2 must be interpretedwith caution for 1 to 2 minutes afteradministration of epinephrine or othervasoconstrictive medications becausethese medications may decrease thePETCO2.

Knowledge GapsDoes PETCO2 monitoring during CPR im-prove quality of chest compressionsand/or outcome of pediatric resuscita-tion? During CPR, can PETCO2 be reliablymeasured via a laryngeal mask airway(LMA)? Is there a threshold PETCO2 thatpredicts ROSC or low likelihood ofROSC during resuscitation from pedi-atric cardiac arrest? Can the initialPETCO2 distinguish asphyxial from car-diac etiology of pediatric cardiac ar-rest? Is detection of ROSC using PETCO2monitoring more accurate than palpa-tion of a pulse? Are PETCO2 targets dur-ing CPR different for subgroups of in-fants and children with alterations inpulmonary blood flow or high airwayresistance?

AIRWAY AND VENTILATIONOpening and maintaining a patent air-way and providing ventilations are fun-




damental elements of pediatric CPR,especially because cardiac arrest of-ten results from, or is complicated by,asphyxia. There are no new data tochange the 2005 ILCOR recommenda-tion to use manual airway maneuvers(with or without an oropharyngeal air-way) and bag-mask ventilation (BMV)for children requiring airway controlor positive-pressure ventilation forshort periods in the out-of-hospital set-ting. When airway control or BMV is noteffective, supraglottic airways may behelpful when used by properly trainedpersonnel.

When performing tracheal intubation,data suggest that the routine use ofcricoid pressure may not protectagainst aspiration and may make intu-bation more difficult.

Routine confirmation of tracheal tubeposition with capnography/capnom-etry is recommended with the caveatthat the PETCO2 in infants and childrenin cardiac arrest may be below detec-tion limits for colorimetric devices.

Following ROSC, toxic oxygen byprod-ucts (reactive oxygen species, freeradicals) are produced that maydamage cell membranes, proteins,and DNA (reperfusion injury). Althoughthere are no clinical studies in chil-dren (outside the newborn period)comparing different concentrationsof inspired oxygen during and immedi-ately after resuscitation, animal dataand data from newborn resuscitationstudies suggest that it is prudent totitrate inspired oxygen after return ofa perfusing rhythm to preventhyperoxemia.

Supplementary OxygenPeds-015

Consensus on ScienceThere are no studies comparing venti-lation of infants and children in cardiacarrest with different inspired oxygen con-centrations. Two LOE 5 meta-analysesof several randomized controlled trialscomparing neonatal resuscitation initi-

ated with room air versus 100% oxy-gen92,93 showed increased survival whenresuscitation was initiated with roomair.

Seven LOE 5 animal studies94–100 sug-gested that ventilation with room airor an FIO2 of �1.0 during cardiac ar-rest may be associated with less neu-rologic deficit than ventilation with anFIO2 of 1.0, whereas 1 LOE 5 animalstudy101 showed no difference in out-come. In 5 LOE 5 animal studies95,97–99,102

ventilation with 100% oxygen duringand following resuscitation contrib-uted to free radical–mediated reperfu-sion injury to the brain.

Treatment RecommendationsThere is insufficient evidence to rec-ommend any specific inspired oxygenconcentration for ventilation duringresuscitation from cardiac arrest ininfants and children. Once circulationis restored, it is reasonable to titrateinspired oxygen to limit hyperoxemia.

Knowledge GapsDoes the use of any specific concen-tration of supplementary oxygen dur-ing resuscitation from cardiac arrestin infants and children improve orworsen outcome? What is the appro-priate target oxygen saturation for thepediatric patient after achieving ROSC?

Cuffed Versus Uncuffed TrachealTubePeds-007

Consensus on ScienceThere are no studies that compare thesafety and efficacy of cuffed versus un-cuffed tubes in infants and childrenwho require emergency intubation.

Two LOE 5 randomized controlled stud-ies103,104 and 1 LOE 5 cohort-controlledstudy105 in a pediatric anesthesia set-ting showed that the use of cuffed tra-cheal tubes was associated with ahigher likelihood of selecting the cor-rect tracheal tube size (and hence alower reintubation rate) with no in-creased risk of perioperative or air-

way complications. Cuff pressures inthese 3 studies were maintained at�25 cm H2O. Two perioperative LOE 5cohort-controlled pediatric studies105,106

similarly showed that cuffed tubes werenot associated with an increased risk ofperioperative airway complications.

One LOE 5 pediatric case series107 ob-served that the use of cuffed trachealtubes was not a risk factor for devel-oping subglottic stenosis in patientshaving corrective surgery for congeni-tal cardiac defects. In the intensivecare setting, 2 LOE 5 prospectivecohort-controlled studies108,109 and 1LOE 5 retrospective cohort-controlledstudy110 documented no greater risk ofcomplications for children. �8 yearsof age who were intubated with cuffedcompared with uncuffed trachealtubes.

One small LOE 5 case-controlledstudy111 showed that cuffed trachealtubes decreased the incidence of aspi-ration in the PICU, and 1 LOE 5 caseseries105 of children with burns under-going general anesthesia showed asignificantly higher rate of excessiveair leak requiring immediate reintuba-tion in patients initially intubated withan uncuffed tracheal tube.

Treatment RecommendationsBoth cuffed and uncuffed trachealtubes are acceptable for infants andchildren undergoing emergency intu-bation. If cuffed tracheal tubes areused, avoid excessive cuff pressures.

Knowledge GapsWhat is the best technique to deter-mine cuff pressure and/or the pres-ence of an air leak when using cuffedtracheal tubes in infants and children?What is the optimal cuff or leak pres-sure for children of different ages?Does optimal cuff pressure vary basedon the type of cuffed tube (eg, Micro-cuff�) used?

Are the data generated in elective op-erating room studies applicable to






emergency resuscitation scenarios?Are there select populations of pediat-ric patients whose outcomes are im-proved by the use of cuffed trachealtubes during resuscitation?

Tracheal Tube SizePeds-057A, Peds-057B

Consensus on ScienceEvidence from 1 LOE 2 prospective ran-domized trial of elective intubation ina pediatric operating room103 wasused to support the existing formulafor estimation of appropriate cuffedtracheal tube internal diameter (ID):ID (mm)�(age in years/4)� 3, alsoknown as the Khine formula. Detailedanalysis of this paper, however, re-veals that the aggressive rounding upof age employed by the authors in theircalculations commonly resulted in se-lection of a tube with an ID 0.5 mmlarger than the size derived from theformula.

Evidence from 1 LOE 2 prospective ran-domized multicenter study,104 1 LOE2,112 and 3 LOE 4 prospective observa-tional studies of elective intubation inthe pediatric operating room113–115

supported use of 3-mm ID cuffed tra-cheal tubes for newborns and infants(3.5 kg to 1 year of age) and 3.5-mm IDcuffed tracheal tubes for patients 1 to2 years of age.

One LOE 2 prospective randomizedmulti-center study104 and 3 LOE 4 prospec-tive observational studies of elective in-tubation in the pediatric operatingroom113–115 using Microcuff� trachealtubes support the use of the followingformula for cuffed endotracheal tubesin children: ID (mm)�(age/4) � 3.5.One LOE 2 prospective observationalstudy of elective intubation in the pedi-atric operating room112 found that for-mula acceptable but associated with amarginally greater reintubation ratethanwith the Khine formula (ID [mm]�[age in years/4]� 3).

Treatment RecommendationsIf a cuffed tracheal tube is used in in-fants�3.5 kg and�1 year of age, it isreasonable to use a tube with an ID of3.0 mm. If a cuffed tracheal tube isused in children between 1 and 2 yearsof age, it is reasonable to use a tubewith an ID of 3.5 mm.

After the age of 2, it is reasonable toestimate the cuffed tracheal tube sizewith the formula ID (mm)�(age inyears/4) � 3.5. If the tracheal tubemeets resistance during insertion, atube with an ID 0.5 mm smaller shouldbe used. If there is no leak around thetube with the cuff deflated, reintuba-tion with a tube ID 0.5 mm smaller maybe beneficial when the patient isstable.

Knowledge GapsAre the formulas for estimation of tra-cheal tube size that are used for elec-tive intubation in the operating roomsetting applicable during resuscita-tion? Is there an upper age limit for thevalidity of the formula to estimate tubesize? Are length-based formulas moreaccurate compared with age- or weight-based formulas for estimating trachealtube size in infants and children?

Bag-Mask Ventilation VersusIntubationPeds-008

Consensus on ScienceOne LOE 1 study116 compared para-medic out-of-hospital BMV with intu-bation for children with cardiac ar-rest, respiratory arrest, or respiratoryfailure in an EMS system with shorttransport intervals and found equiva-lent rates of survival to hospital dis-charge and neurologic outcome. OneLOE 1 systematic review that includedthis study117 also reached the sameconclusion.

One LOE 2 study of pediatric traumapatients118 observed that out-of-hospitalintubation is associated with a higherrisk of mortality and postdischarge

neurologic impairment compared within-hospital intubation. These findingspersisted even after stratification for se-verity of trauma and head trauma.

In 1 LOE 2 (nonrandomized) prehospi-tal pediatric study,119 if paramedicsprovided BMV while awaiting the ar-rival of a physician to intubate thepatient, the risk of cardiac arrest andoverall mortality was lower than ifthe patient was intubated by the para-medics. These findings persisted evenafter adjusting for Glasgow Coma Scalescore.

Four LOE 4 studies120–123 showed a sig-nificantly greater rate of failed intuba-tions and complications in childrencompared with adults in the out-of-hospital and emergency departmentsettings. Conversely 1 LOE 3 out-of-hospital study124 and 1 LOE 4 out-of-hospital study125 failed to demonstrateany difference in intubation failurerates between adults and children.

Treatment RecommendationsBMV is recommended over tracheal in-tubation in infants and children whorequire ventilatory support in the out-of-hospital setting when transporttime is short.

Knowledge GapsFor the experienced airway specialist,does tracheal intubation improve out-comes in comparison with BMV for pe-diatric resuscitation? Does the use ofneuromuscular blocking drugs im-prove the outcome of children under-going intubation during resuscitation?What is the minimal initial training andongoing experience needed to improvesuccess rate and reduce complica-tions of emergent intubation of infantsand children?

Bag-Mask Ventilation VersusSupraglottic AirwayPeds-009

Consensus on ScienceNo studies have directly comparedBMV to the use of supraglottic airway






devices during pediatric resuscita-tion other than for the newly born inthe delivery room. Nine LOE 5 case re-ports126–134 demonstrated the effective-ness of supraglottic airway devices, pri-marily the LMA, for airway rescue of chil-dren with airway abnormalities.

One LOE 5 out-of-hospital adult study135

supports the use of LMAs by first re-sponders during CPR, but another LOE5 out-of-hospital adult cardiac arreststudy136 of EMS personnel providing as-sisted ventilation by either bag-mask de-vice or LMA failed to show any signifi-cant difference in ventilation (PaCO2).Six LOE 5 studies during anesthesia137–142

demonstrated that complication rateswith LMAs increase with decreasingpatient age and size.

In 2 LOE 5 manikin studies143,144 trainednonexpert providers successfully de-livered positive-pressure ventilationusing the LMA. Tracheal intubations re-sulted in a significant incidence of tubemisplacement (esophageal or rightmainstem bronchus), a problem notpresent with the LMA, but time to effec-tive ventilation was shorter and tidalvolumes were greater with BMV.

In 2 LOE 5 studies of anesthetized chil-dren145,146 suitably trained ICU andward nurses placed LMAs with a highsuccess rate, although time to firstbreath was shorter in the BMV group.In a small number of cases ventilationwas achieved with an LMA when itproved impossible with BMV.

Treatment RecommendationsBMV remains the preferred techniquefor emergency ventilation during theinitial steps of pediatric resuscitation.In infants and children for whom BMVis unsuccessful, use of the LMA by ap-propriately trained providers may beconsidered for either airway rescue orsupport of ventilation.

Knowledge GapsAre the data regarding use of supra-glottic airways for elective airway

management in the operating roomapplicable to emergency resuscitationscenarios? With an LMA in place, is itnecessary to pause chest compres-sions to provide effective ventilations?Is the combination of an oropharyn-geal airway with BMV more or less ef-fective than supraglottic airways?

Minute VentilationPeds-013A

Consensus on ScienceThere are no data to identify the opti-mal minute ventilation (tidal volume orrespiratory rate) for infants or chil-dren with an advanced airway duringCPR, regardless of arrest etiology.

Three LOE 5 animal studies147–149

showed that ventilation during CPR af-ter VF or asphyxial arrest resulted inimproved ROSC, survival, and/or neu-rologic outcome compared with nopositive-pressure breaths.

Evidence from 4 LOE 5 adult studies150–153

showed that excessive ventilation iscommon during resuscitation from car-diac arrest. In 1 LOE 5 animal study150

excessive ventilation during resusci-tation from cardiac arrest decreasedcerebral perfusion pressure, ROSC,and survival compared with lower ven-tilation rates. One good LOE 5 animalstudy149 found that increasing respira-tory rate during conditions of reducedcardiac output improved alveolar ven-tilation but not oxygenation, and it re-duced coronary perfusion pressure.

In 1 LOE 5 prospective, randomizedadult study154 constant-flow insuffla-tion with oxygen compared with con-ventional mechanical ventilation dur-ing CPR did not change outcome (ROSC,survival to admission, and survival toICU discharge). In another LOE 5 adultstudy,155 adults with witnessed VF ar-rest had improved neurologically in-tact survival with passive oxygen insuf-flation compared with BMV, whereasthere was no difference in survival ifthe VF arrest was unwitnessed.

Two LOE 5 animal studies showed thatventilation or continuous positive air-way pressure (CPAP) with oxygencompared with no ventilation im-proved arterial blood gases156 but didnot change neurologically intact sur-vival.157 One good-quality LOE 5 animalstudy158 showed that reducing tidal vol-ume by 50% during CPR resulted inless excessive ventilation without af-fecting ROSC.

Treatment RecommendationsFollowing placement of a secure air-way, avoid excess ventilation of infantsand children during resuscitationfrom cardiac arrest, whether asphyx-ial or due to VF. A reduction in minuteventilation to less than baseline forage is reasonable to provide suffi-cient ventilation to maintain adequateventilation-to-perfusion ratio duringCPR while avoiding the harmful effectsof excessive ventilation. There are in-sufficient data to identify the optimaltidal volume or respiratory rate.

Knowledge GapsWhat is the optimal minute ventilationto achieve ventilation-perfusion match-ing during pediatric CPR? Is it prefera-ble to reduce tidal volume or respira-tory rate to achieve optimal minuteventilation during pediatric CPR? Doeshypoventilation (ie, hypercarbia) dur-ing resuscitation affect outcome frompediatric cardiac arrest? Does passiveoxygen insufflation or CPAP during car-diac arrest in infants and children pro-vide adequate gas exchange or im-prove outcome from resuscitation?

Devices to Verify Advanced AirwayPlacementPeds-004

Consensus on ScienceNo single assessment method accu-rately and consistently confirms tra-cheal tube position. Three LOE 4 stud-ies71,159,160 showed that when aperfusing cardiac rhythm is present ininfants (�2 kg) and children, detec-






tion of exhaled CO2 using a colorimet-ric detector or capnometer has a highsensitivity and specificity for confirm-ing endotracheal tube placement. Oneof these studies71 included infantsand children in cardiac arrest. In thecardiac arrest population the sensi-tivity of exhaled CO2 detection wasonly 85% (ie, false-negatives occurred),whereas the specificity remained at100%.

One neonatal LOE 5 study161 of deliveryroom intubation demonstrated thatdetection of exhaled CO2 by capnogra-phy was 100% sensitive and specificfor detecting esophageal intubationand took less time than clinical assess-ment to identify esophageal intuba-tion. Two additional neonatal LOE 5studies162,163 showed that confirma-tion of tracheal tube position is fasterwith capnography than with clinicalassessment.

Two pediatric LOE 4 studies164,165

showed that in the presence of a per-fusing rhythm, exhaled CO2 detectionor measurement can confirm trachealtube position accurately during trans-port, while 2 LOE 5 animal studies166,167

showed that tracheal tube displace-ment can be detected more rapidly byCO2 detection than by pulse oximetry.

One LOE 2 operating room study168

showed that the esophageal detectordevice (EDD) is highly sensitive andspecific for correct tracheal tubeplacement in children �20 kg with aperfusing cardiac rhythm; there havebeen no studies of EDD use in childrenduring cardiac arrest. An LOE 4 oper-ating room (ie, non-arrest) study169

showed that the EDD performed wellbut was less accurate in children�20 kg.

Treatment RecommendationsConfirmation of tracheal tube positionusing exhaled CO2 detection (colori-metric detector or capnography) should

be used for intubated infants and chil-dren with a perfusing cardiac rhythmin all settings (eg, out-of-hospital,emergency department, ICU, inpatient,operating room).

In infants and children with a perfus-ing rhythm, it may be beneficial tomonitor continuous capnography orfrequent intermittent detection of ex-haled CO2 during out-of-hospital andintra-/interhospital transport.

The EDD may be considered for confir-mation of tracheal tube placement inchildren weighing�20 kg when a per-fusing rhythm is present.

Knowledge GapsWhich technique for CO2 detection (col-orimetric versus capnography) ismore accurate during pediatric resus-citation? For infants and children incardiac arrest, what is the most reli-able way to achieve confirmation oftracheal tube position?

Cricoid PressurePeds-039A, Peds-039B

Consensus on ScienceThere are no data to show that cricoidpressure prevents aspiration duringrapid sequence or emergency trachealintubation in infants or children. TwoLOE 5 studies170,171 showed that cricoidpressure may reduce gastric inflationin children. One LOE 5 study in chil-dren172 and 1 LOE 5 study in adult ca-davers173 demonstrated that esopha-geal reflux is reduced with cricoidpressure.

In 1 LOE 5 adult systematic review174

laryngeal manipulation enhanced BMVor intubation in some patients whileimpeding it in others. One LOE 5 studyin anesthetized children175 showedthat cricoid pressure can distort theairway with a force of as low as 5newtons.

Treatment RecommendationsIf cricoid pressure is used duringemergency intubations in infants and

children it should be discontinued if itimpedes ventilation or interferes withthe speed or ease of intubation.

Knowledge GapsCan cricoid pressure reduce the inci-dence of aspiration during emergentintubation of infants or children? Howmuch cricoid pressure should be ap-plied, and what is the best technique toreduce gastric inflation during BMV?

CHEST COMPRESSIONSThe concept of chest compression-onlyCPR is appealing because it is easier toteach than conventional CPR, and im-mediate chest compressions may bebeneficial for resuscitation from sud-den cardiac arrest caused by VF orpulseless VT. Animal studies showedthat conventional CPR, including venti-lations and chest compressions, isbest for resuscitation from asphyxialcardiac arrest. In a large study of out-of-hospital pediatric cardiac arrest,176

few children with asphyxial arrest re-ceived compression-only CPR and theirsurvival was no better than in childrenwho received no CPR.

To be effective, chest compressionsmust be deep, but it is difficult to deter-mine the optimal depth in infants andchildren; should recommended depthbe expressed as a fraction of the depthof the chest or an absolute measure-ment? How can this be made practicaland teachable?

Compression-Only CPRPeds-012A

Consensus on ScienceEvidence from 1 LOE 2 large out-of-hospital pediatric prospective obser-vational investigation176 showed thatchildrenwith cardiac arrest of noncar-diac etiology (asphyxial arrest) had ahigher 30-day survival with more fa-vorable neurologic outcome if they re-ceived standard bystander CPR (chestcompressions with rescue breathing)compared with chest compression-only CPR. Standard CPR and chest





compression-only CPR were similarlyeffective and better than no bystanderCPR for pediatric cardiac arrest fromcardiac causes. Of note, the samestudy showed that more than 50% ofchildren with out-of-hospital cardiacarrest did not receive any bystanderCPR. Compression-only CPR was as in-effective as no CPR in the small num-ber of infants and children with as-phyxial arrest who did not receiveventilations.

Two LOE 5 animal studies148,177 demon-strated improved survival rates and fa-vorable neurologic outcome with stan-dard CPR compared with no CPR. OneLOE 5 animal study178 showed that bloodgases deteriorated with compression-only CPR compared with standard CPRin asphyxial arrests.

Data from 1 LOE 5 animal study177 indi-cated that compression-only CPR isbetter than no CPR for asphyxial arrestbut not as effective as standard CPR,and 7 LOE 5 clinical observationalstudies in adults179–184 showed thatcompression-only CPR can result insuccessful resuscitation from an as-phyxial arrest. Moreover, in 10 LOE 5animal studies185–194 and 7 LOE 5 adultclinical observational studies179–184,195

compression-only bystander CPR wasgenerally as effective as standard1-rescuer bystander CPR for arrestsfrom presumed cardiac causes.

Treatment RecommendationsRescuers should provide conventionalCPR (rescue breathing and chest com-pressions) for in-hospital and out-of-hospital pediatric cardiac arrests. Layrescuers who cannot provide rescuebreathing should at least performchest compressions for infants andchildren in cardiac arrest.

Knowledge GapsDoes teaching compression-only CPRto lay rescuers increase the likelihoodthat CPR will be performed during out-of-hospital pediatric cardiac arrest?

One- Versus 2-Hand ChestCompression in ChildrenPeds-033

Consensus on ScienceThere are no outcome studies compar-ing 1- versus 2-hand chest compres-sions for children in cardiac arrest.Evidence from1 LOE 5 randomized cross-over child manikin study196 showedthat higher chest-compression pres-suresaregeneratedbyhealthcareprofes-sionals using the 2-hand technique. TwoLOE 5 studies197,198 report no increase inrescuer fatigue comparing 1-hand with2-hand chest compressions delivered byhealthcare providers to a child-sizedmanikin.

Treatment RecommendationsEither a 1- or 2-hand technique can beused for performing chest compres-sions in children.

Knowledge GapsDoes the use of 1-hand compared with2-hand chest compressions during pe-diatric cardiac arrest affect quality ofCPR or outcome?

Circumferential Chest Squeeze inInfantsPeds-034

Consensus on ScienceThere are no studies that compare the2-thumb chest compression techniquewith and without a “circumferentialsqueeze” in infants.

Treatment RecommendationsThere are insufficient data for oragainst the need for a circumferentialsqueeze of the chest when performingthe 2-thumb technique of externalchest compression for infants.

Knowledge GapsDoes the addition of a circumferentialsqueeze to 2-thumb compression in in-fants provide more effective chestcompressions or improve resuscita-tion outcome?

Chest CompressionDepthPeds-040A, Peds-040B

Consensus on ScienceEvidence from anthropometric mea-surements in 3 good-quality LOE 5 caseseries199–201 showed that in childrenthe chest can be compressed to onethird of the anterior-posterior chest di-ameter without causing damage to in-trathoracic organs. One LOE 5 mathe-matical model based on neonatal chestcomputed tomography scans202 sug-gests that one third anterior-posteriorchest compression depth is more ef-fective than one fourth compressiondepth and safer than one half anterior-posterior compression depth.

A good-quality LOE 5152 adult studyfound that chest compressions areoften inadequate, and a good-qualityLOE 4 pediatric study200 showed thatduring resuscitation of patients �8years of age, compressions are oftentoo shallow, especially following res-cuer changeover. Evidence from 1 pe-diatric LOE 4 systematic review ofthe literature203 showed that rib frac-tures are rarely associated with chestcompressions.

Treatment RecommendationsIn infants, rescuers should be taughtto compress the chest by at least onethird the anterior-posterior dimensionor approximately 11⁄2 inches (4 cm). Inchildren, rescuers should be taught tocompress the chest by at least onethird the anterior-posterior dimensionor approximately 2 inches (5 cm).

Knowledge GapsCan lay rescuers or healthcare provid-ers reliably perform compressions tothe recommended depth during pedi-atric cardiac arrest? Is there harmfrom compressions that are “toodeep” in infants?

COMPRESSION-VENTILATION RATIOThe ILCOR Neonatal Task Force contin-ues to recommend a compression-








ventilation ratio of 3:1 for resuscita-tion of the newly born in the deliveryroom, with a pause for ventilationwhether or not the infant has an ad-vanced airway. The Pediatric TaskForce reaffirmed its recommendationfor a 15:2 compression-ventilation ra-tio for 2-rescuer infant CPR, with apause for ventilation in infants withoutan advanced airway, and continuouscompressions without a pause for ven-tilation for infants with an advancedairway.

No previous recommendations weremade for hospitalized newborns caredfor in areas other than the deliveryarea or with primary cardiac ratherthan asphyxial arrest etiology. For ex-ample, consider the case of a 3-week-old infant who has a cardiac arrestfollowing cardiac surgery. In the neo-natal intensive care unit such an infantwould be resuscitated according tothe protocol for the newly born, but ifthe same infant is in the PICU, resusci-tation would be performed accordingto the infant guidelines. A resolution tothis dilemma is suggested on the ba-sis of the arrest etiology and ease oftraining.

Optimal Compression-VentilationRatio for Infants andChildrenPeds-011B

Consensus on ScienceThere are insufficient data to identifyan optimal compression-ventilationratio for CPR in infants and children.In 4 LOE 5 manikin studies204–207 exam-ining the feasibility of compression-ventilation ratios of 15:2 and 5:1, lonerescuers could not deliver the de-sired number of chest compressionsper minute at a ratio of 5:1. In 5 LOE 5studies208–212 using a variety of mani-kin sizes comparing compression-ventilation ratios of 15:2 with 30:2, aratio of 30:2 yielded more chest com-pressions with no, or minimal, in-crease in rescuer fatigue. One LOE 5

study213 of volunteers recruited in anairport to perform 1-rescuer layper-son CPR on an adult-sized manikinobserved less “no flow time” with theuse of a 30:2 ratio compared with a15:2 ratio.

One LOE 5 observational humanstudy214 comparing resuscitations byfirefighters before and after thechange from a recommended 15:2 to30:2 compression-ventilation ratio re-ported more chest compressions perminute with the 30:2 ratio, but the rateof ROSC was unchanged. Three LOE 5animal studies192,215,216 showed thatcoronary perfusion pressure, a majordeterminant of success in resuscita-tion, rapidly declines when chest com-pressions are interrupted; once com-pressions are resumed, several chestcompressions are needed to restorecoronary perfusion pressure to prein-terruption levels. Thus, frequent inter-ruptions of chest compressions pro-long the duration of low coronaryperfusion pressure and flow and re-duce the mean coronary perfusionpressure. Three LOE 5 manikin stud-ies213,217,218 and 3 LOE 5151,152,219 in- andout-of-hospital adult human studiesdocumented long interruptions inchest compressions during simulatedor actual resuscitations. Three LOE 5adult studies220–222 demonstrated thatthese interruptions reduced ROSC.

In 5 LOE 5 animal studies191,192,194,215–216

chest compressions without ventila-tions were sufficient to resuscitateanimals with VF-induced cardiac ar-rest. Conversely in 2 LOE 5 animal stud-ies223,224 decreasing the frequency ofventilation was detrimental in the first5 to 10 minutes of resuscitation ofVF-induced cardiac arrest.

One LOE 5 mathematical model225 sug-gested that the compression-ventilationratio in children should be lower (moreventilations to compressions) than inadults and should decrease with de-creasing weight. Two LOE 5 studies of

asphyxial arrest inpigs148,177 showed thatventilations added to chest compres-sions improved outcome comparedwithcompressions alone. Thus, ventilationsare more important during resuscita-tion from asphyxia-induced arrest thanduring resuscitation from VF. But evenin asphyxial arrest, fewer ventilationsare needed to maintain an adequateventilation-perfusion ratio in the pres-ence of the low cardiac output (and con-sequently low pulmonary blood flow)produced by chest compressions.

Treatment RecommendationsFor ease of teaching and retention, acompression-ventilation ratio of 30:2is recommended for the lone rescuerperforming CPR in infants and children,as is used for adults. For healthcareproviders performing 2-rescuer CPR ininfants and children, a compression-ventilation ratio of 15:2 is recom-mended. When a tracheal tube is inplace, compressions should not be in-terrupted for ventilations.

Knowledge GapsWhat is the optimal compression-ventilation ratio to improve outcomefor neonates, infants, and children incardiac arrest?

Newborns (Out of the DeliveryArea) Without an EndotrachealAirwayPeds-027A

Consensus on ScienceThere are insufficient data to identifyan optimal compression-ventilationratio for all infants in the first month oflife. One LOE 5 animal study192 showedthat coronary perfusion pressure de-clined with interruptions in chestcompressions; after each interruption,several chest compressions were re-quired to restore coronary perfusionpressure to preinterruption levels.One LOE 5 adult human study221 and 2LOE 5 animal studies215,222 showed thatinterruptions in chest compression




reduced the likelihood of ROSC in VFcardiac arrest.

One LOE 5 1-rescuer manikin study207

showed that more effective ventilationwas achieved with a 3:1 ratio thanwith a 5:1, 10:2, or 15:2 ratio. One LOE 5mathematical study of cardiovascularphysiology226 suggested that bloodflow rates in neonates are best at com-pression rates of�120/min.

Treatment RecommendationsThere are insufficient data to rec-ommend an optimal compression-ventilation ratio during CPR for all in-fants in the first month of life (beyondthe delivery room). The limited dataavailable suggest that if the etiology ofthe arrest is cardiac, a 15:2 ratio (2rescuers) may be more effective thana 3:1 ratio.

Knowledge GapsDo healthcare providers perform bet-ter CPR if they learn 1 rather than 2compression-ventilation ratios basedon etiology of the arrest (cardiac orasphyxial)?

Newborns (Out of Delivery Area)With a Tracheal TubePeds-026A

Consensus on ScienceThere is insufficient evidence to de-termine if an intubated neonate has abetter outcome from cardiac arrestusing a 3:1 compression-ventilationratio and interposed ventilationscompared with continuous chest com-pressions without pause for ventila-tions (asynchronous compressionsand ventilations).

Two LOE 5 adult220,222 and 2 LOE 5 ani-mal191,192 studies demonstrated that in-terruptions in chest compressions re-duced coronary perfusion pressure,a key determinant of successful resus-citation in adults, and decreased ROSC.There are no equivalent studies evalu-ating the impact of interrupted chestcompressions in asphyxiated neonatesor neonatal animal models.

In 1 LOE 5 piglet study227 of VF arrest,myocardial blood flow increased usingsimultaneous chest compressions andhigh–airway pressure ventilations in a1:1 ratio as compared with conven-tional CPR at a 5:1 ratio. Another LOE 5VF piglet study228 demonstrated equiv-alent cardiac output but worsened gasexchange using a 1:1 compression-ventilation ratio (ie, simultaneouscompressions and ventilations) withhigh airway pressures compared withconventional CPR at a 5:1 ratio.

One LOE 5148 study in nonintubated as-phyxiated piglets resuscitated with a5:1 compression-ventilation ratio showedthat ventilations are important for suc-cessful resuscitation. One LOE 5 studyin intubated asphyxiated piglets178

showed that the addition of ventila-tions resulted in lower arterial CO2 ten-sion (PaCO2) without compromisinghemodynamics when compared withcompressions alone. One LOE 5 mani-kin study229 found that healthcare pro-viders were unable to achieve the rec-ommended rate of ventilations duringinfant CPR at a 3:1 compression-ventilation ratio, with 20% delivering anet rate of 40 breaths per minute after5 minutes of resuscitation. There areno studies that evaluate the impact ofcontinuous compressions on minuteventilation, gas exchange, or the out-come of resuscitation during CPR forintubated neonates.

Treatment RecommendationsFor ease of training, providers shoulduse the compression-ventilation ratioand resuscitation approach that ismost commonly used in their practiceenvironment for intubated term ornear-term newborns within the firstmonth of life. Intubated newborns (ie,those with an advanced airway) whorequire CPR in non-neonatal settings(eg, prehospital, emergency depart-ment, PICU, etc) or thosewith a cardiacetiology of cardiac arrest, regardlessof location, should receive CPR accord-

ing to infant guidelines (continuouschest compressions without pause forventilations).

Knowledge GapsIn intubated infants in cardiac arrest,can effective ventilations be per-formed during continuous chest com-pressions with asynchronous venti-lations? Do pauses for ventilationsduring CPR affect the outcome fromcardiac arrest in intubated infants?

VASCULAR ACCESSAND DRUG DELIVERYThere is no new evidence to changethe 2005 ILCOR recommendations onvascular access, including the earlyuse of intraosseous (IO) access and de-emphasis of the tracheal route of drugdelivery. Epidemiological data, largelyfrom the National Registry of CPR(NRCPR), reported an association be-tween vasopressin, calcium, or so-dium bicarbonate administration andan increased likelihood of death. Thesedata, however, cannot be interpretedas a cause-and-effect relationship. Theassociation may be due to more fre-quent use of these drugs in childrenwho fail to respond to standard basicand advanced life support interven-tions. These and other data in adultsquestion the benefit of intravenous (IV)medications during resuscitation andreemphasize the importance of high-quality CPR.

Intraosseous AccessPeds-035

Consensus on ScienceThere are no studies comparing IOwith IV access in children with cardiacarrest. In 1 LOE 5 study of childrenin shock230 IO access was frequentlymore successful and achieved morerapidly than IV access. Eight LOE 4 caseseries231–238 showed that providerswith many levels of training could rap-idly establish IO access with minimalcomplications for children with car-diac arrest.






Treatment RecommendationsIO cannulation is an acceptable routeof vascular access in infants and chil-dren with cardiac arrest. It should beconsidered early in the care of criti-cally ill children whenever venous ac-cess is not readily attainable.

Knowledge GapsDoes the use of IO compared with IVvascular access improve outcome ofpediatric cardiac arrest? Does the useof newer IO devices (eg, bone injectionguns and drills) compared with con-ventional IO needles affect outcome inpediatric cardiac arrest?

Tracheal Drug DeliveryPeds-036

Consensus on ScienceOne LOE 3 study of children with in-hospital cardiac arrest239 demon-strated similar ROSC and survivalrates, whereas 2 LOE 5 studies ofadults in cardiac arrest240,241 demon-strated reduced ROSC and survival tohospital discharge rates when tra-cheal instead of IV epinephrine wasgiven. One LOE 5 case series of neo-natal asphyxial bradycardia242 demon-strated similar rates of ROSC whetherIV or tracheal epinephrine was ad-ministered, whereas another LOE 5study243 demonstrated a lower rate ofROSC in neonates given tracheal as op-posed to IV epinephrine. Many of thehuman studies used tracheal epineph-rine doses of�0.1 mg/kg.

In some animal studies244–249 lowerdoses of tracheal epinephrine (0.01 to0.05 mg/kg) produced transient dele-terious �-adrenergic vascular effectsresulting in lower coronary artery per-fusion. One LOE 5 study250 of animals inVF cardiac arrest demonstrated ahigher rate of ROSC in those treatedwith tracheal vasopressin comparedwith IV placebo.

Four LOE 5 studies of animals in car-diac arrest251–254 demonstrated similarROSC and survival rates when either

tracheal or IV routes were used to de-liver epinephrine. These studies alsodemonstrated that to reach an equiva-lent biological effect, the tracheal dosemust be up to 10 times the IV dose.

Treatment RecommendationsThe preferred routes of drug deliveryfor infants and children in cardiac ar-rest are IV and IO. If epinephrine is ad-ministered via a tracheal tube to in-fants and children (not including thenewly born) in cardiac arrest, the rec-ommended dose is 0.1 mg/kg.

Knowledge GapsWhat is the optimal dose of trachealepinephrine during pediatric cardiacarrest?

DEFIBRILLATIONThe Pediatric Task Force evaluatedseveral issues related to defibrillation,including safe and effective energydosing, stacked versus single shocks,use of automated external defibrilla-tors (AEDs) in infants �1 year of ageand paddle/pad type, size, and posi-tion. There were a few new human andanimal studies on these topics, and thelevel of evidence (LOE) was generally 3to 5. No new data are available to sup-port a change in drug treatment of re-current or refractory VF/pulseless VT.There were several human and animalpublications on defibrillation energydose, but the data are contradictoryand the optimal safe and effective en-ergy dose remains unknown.

The new recommendation of an initialdose of 2 to 4 J/kg is based on cohortstudies showing low success in termi-nation of VF in children with 2 J/kg.However, these studies do not providedata on success or safety of higher en-ergy doses. The reaffirmation of therecommendation for a single initialshock rather than stacked shocks(first made in 2005) is extrapolatedfrom the ever-increasing adult datashowing that long pauses in chest

compressions required for stackedshocks are associated with worse re-suscitation outcomes and that the ini-tial shock success rate is relativelyhigh with biphasic defibrillation.

No changes are recommended in pad/paddle size or position. Although thesafety of AEDs in infants�1 year is un-known, case reports have documentedsuccessful defibrillation using AEDs ininfants. A manual defibrillator or anAED with pediatric attenuation capabil-ities is preferred for use in infants andsmall children.

Paddle Size and OrientationPeds-029

Consensus on ScienceOne LOE 5 study in adults255 demon-strated that shock success increasedfrom 31% to 82% when pad size wasincreased from 8�8 cm to 12�12 cm.Three pediatric LOE 4,256–258 3 adult LOE5,255,259,260 and 3 LOE 5 animal261–263 stud-ies demonstrated that transthoracicimpedance decreases with increasingpad size. Decreased transthoracic im-pedance increases transthoracic cur-rent and, thus, presumably, transmyo-cardial current.

Pad Position

Consensus on ScienceOne pediatric LOE 4 study264 observedno difference in the rate of ROSC be-tween antero-lateral and anterior-posterior electrode positions forshock delivery. One pediatric LOE 2study,256 2 adult LOE 5 studies,265,266 and1 LOE 5 animal study263 demonstratedthat transthoracic impedance is notdependent on pad position. Transtho-racic impedance was increased in 1adult LOE 5267 study by placing the padstoo close together and in 1 LOE 5260

study when the pads were placed overthe female breast. Additionally, 1 adultLOE 5268 study showed that placing theapical pad in a horizontal position low-ers transthoracic impedance.




Treatment RecommendationThere is insufficient evidence to alterthe current recommendations to usethe largest size paddles/pads that fiton the infant or child’s chest withouttouching each other or to recommendone paddle/pad position or type overanother.

Self-Adhesive Pads VersusPaddlesPeds-043A, Peds-043B

Consensus on ScienceThere are limited studies comparingself-adhesive defibrillation pads (SADPs)with paddles in pediatric cardiac ar-rest. One pediatric LOE 4264 study dem-onstrated equivalent ROSC rates whenpaddles or SADPs were used. One LOE5269 adult out-of-hospital cardiac ar-rest study suggested improved sur-vival to hospital admission whenSADPs rather than paddles were used.

One adult LOE 5270 study showed alower rate of rhythm conversion, and1 small adult LOE 5271 study showed atleast equivalent success with the useof SADPs in comparison with paddlesin patients undergoing cardioversionfor atrial fibrillation. Twoadult LOE 5272,273

studies showed equivalent transthorac-ic impedancewithSADPsorpaddles.Oneadult LOE 5266 and 2 LOE 5 animal274,275

studies showed that SADPs had a highertransthoracic impedance than paddles.

One LOE 4276 study described difficultywith fitting self-adhesive pads onto thethorax of a premature infant withoutthe pads touching. One LOE 5277 studydemonstrated the improved accuracyof cardiac rhythm monitoring follow-ing defibrillation using SADPs com-pared with the combination of paddlesand gel pads.

Using standard resuscitation proto-cols in simulated clinical environ-ments, 1 LOE 5278 study found no signif-icant difference in the time required todeliver shocks using either SADPs orpaddles, and 1 LOE 5279 study found nosignificant difference in time without

compressions when SADPs or paddleswere used.

Treatment RecommendationsEither self-adhesive defibrillation padsor paddles may be used in infants andchildren in cardiac arrest.

Knowledge GapsIs the use of hands-on defibrillationsafe for rescuers and does it improveoutcome for infants and children in car-diac arrest (eg, by presumably reducinginterruptions in chest compressions)?

Number of ShocksPeds-022A

Consensus on ScienceThere are no randomized controlledstudies examining a single versus se-quential (stacked) shock strategy inchildren with VF/pulseless VT. Evidencefrom 7 LOE 5 studies in adults withVF221,280–285 supported a single-shockstrategy over stacked or sequentialshocks because the relative efficacy ofa single biphasic shock is high andthe delivery of a single shock reducesduration of interruptions in chestcompressions.

Treatment RecommendationsA single-shock strategy followed by im-mediate CPR (beginning with chestcompressions) is recommended forchildren with out-of-hospital or in-hospital VF/pulseless VT.

Knowledge GapsAre there circumstances during whichthe use of stacked or multiple shockscan improve outcome from pediatriccardiac arrest?

Energy DosePeds-023A, Peds-023B

Consensus on ScienceTwo LOE 4264,286 studies reported no re-lationship between defibrillation doseand survival to hospital discharge orneurologic outcome from VF/pulselessVT. Evidence from 3 LOE 4 studies inchildren in out-of-hospital and in-hospital settings264,287,288 observed that

an initial dose of 2 J/kg was effective interminating VF 18% to 50% of the time.Two LOE 4 studies286,289 reported thatchildren often received more than 2J/kg during out-of hospital cardiac ar-rest, with many (69%) requiring �3shocks of escalating energy doses.One in-hospital cardiac arrest LOE 4study264 reported that the need formultiple shocks with biphasic energydoses of 2.5 to 3.2 J/kg was associatedwith lack of ROSC.

Evidence from 2 LOE 5 animal stud-ies290,291 observed that 0% to 8% of ep-isodes of long-duration VF were termi-nated by a 2 J/kg monophasic shockand up to 32% were terminated by bi-phasic shocks. Animals in these stud-ies received both fixed and escalateddoses, and most required 2 or moreshocks to terminate VF. In 1 LOE 5 ani-mal study263 the defibrillation thresh-old for short-duration VF was 2.4 J/kg,whereas in another291 it was 3.3 J/kg.

In 4 LOE 5 animal studies290,292–294 of AEDshocks delivered using a pediatric at-tenuator, 50 J and 50376386 J (2.5 to4 J/ kg) escalating doses were effec-tive at terminating long-duration VFbut requiredmultiple shocks. In 1 LOE 5animal study295 10 J/kg shocks weremore effective at terminating long-duration VF (6 minutes) with 1 shockthan 4 J/kg shocks.

In 2 LOE 4 pediatric studies264,286 and 4LOE 5 animal studies,290,292–294 energydoses of 2 to 10 J/kg for short- or long-duration VF resulted in equivalentrates of survival. Myocardial damage,as assessed by hemodynamic or bio-chemical measurements, was lesswhen a pediatric attenuator was usedwith an adult energy dose comparedwith a full adult AED dose, but the de-gree of myocardial damage was notassociated with any difference in 4- or72-hour survival. An LOE 5 animalstudy295 found no difference in hemo-dynamic parameters or biochemicalmeasurements of myocardial damage









comparing biphasic 150 J (4 J/kg) withmonophasic 360 J/kg (10 J/kg) shocks.

In 2 LOE 5 animal studies290,291 biphasicwaveforms were more effective thanmonophasic waveforms for treatmentof VF/pulseless VT. There are no humandata that directly compare monopha-sic to biphasic waveforms for pediat-ric defibrillation.

Treatment RecommendationsAn initial dose of 2 to 4 J/kg is reason-able for pediatric defibrillation. Highersubsequent energy doses may be safeand effective.

Knowledge GapsWhat is the minimum effective andmaximum safe defibrillation energydose for pediatric VF/pulseless VT?What is the optimal parameter (eg,weight or length) on which to base de-fibrillation energy doses for infantsand children? Should the energy dosefor defibrillation be escalated forshock-refractory VF?

Does the use of biphasic waveformswhen compared to monophasic wave-forms improve outcome from pediat-ric cardiac arrest?

Amiodarone Versus Lidocaine forRefractory VF/Pulseless VTPeds-019

Consensus on ScienceIn 2 LOE 5 prospective out-of-hospitaladult trials IV amiodarone improvedROSC and survival to hospital admis-sion but not hospital discharge whencompared with placebo296 or lido-caine297 for treatment of shock-refractory VF/pulseless VT. Evidencefrom 2 LOE 5 case series in chil-dren298,299 supported the effectivenessof amiodarone for the treatment andacute conversion of life-threatening(nonarrest) ventricular arrhythmias.There are no pediatric data investigat-ing the efficacy of lidocaine for shockrefractory VF/ pulseless VT.

Treatment RecommendationsAmiodarone may be used for the treat-ment of shock-refractory or recur-rent VF/pulseless VT in infants andchildren; if amiodarone is not avail-able, lidocaine may be considered.

Knowledge GapsDoes the use of amiodarone comparedwith lidocaine improve outcome fromshock-refractory or recurrent VF/pulseless VT in infants and children? Islidocaine effective for the treatment ofVF/pulseless VT in children?

AED Use in InfantsPeds-001A, Peds-001B

Consensus on ScienceOne LOE 4300 and 2 LOE 5288,301 studiesshowed that infants in cardiac arrest(in- and out-of-hospital) may haveshockable rhythms. Evidence from 3LOE 5302–304 studies showed that manyAED devices can safely and accuratelydistinguish between a shockable andnonshockable rhythm in infants andchildren.

The optimal energy dose for defibrilla-tion in infants has not been estab-lished, but indirect data from 5 LOE 5animal studies287,294,305–307 showed thatthe young myocardium may be able totolerate high-energy doses. In 3 LOE 5animal studies a pediatric attenuatorused with an adult-dose biphasic AEDshock was as effective and less harm-ful than monophasic weight-baseddoses290 or biphasic adult doses.292,293

Two LOE 4 case reports308,309 describedsurvival of infants with out-of-hospitalcardiac arrest when AED use was cou-pled with bystander CPR and defibrilla-tion using an AED. Two pediatric LOE 5case reports310,311 noted successful de-fibrillation with minimal myocardialdamage and good neurologic outcomeusing an AED with adult energy doses.

Treatment RecommendationsFor treatment of out-of-hospital VF/pulseless VT in infants, the recom-mended method of shock delivery by

device is listed in order of preferencebelow. If there is any delay in the avail-ability of the preferred device, the de-vice that is available should be used.The AED algorithm should have demon-strated high specificity and sensitivityfor detecting shockable rhythms in in-fants. The order of preference is asfollows:

1. Manual defibrillator

2. AED with dose attenuator

3. AED without dose attenuator

Knowledge GapsIs there a lower limit of infant size orweight below which an AED should notbe used?

ARRHYTHMIA THERAPYPeds-030

The evidence on emergency treatmentof arrhythmias was reviewed and theonly change was the addition of pro-cainamide as possible therapy for re-fractory supraventricular tachycardia(SVT).

Unstable VT

Consensus on ScienceThere is insufficient evidence to sup-port or refute the efficacy of electrictherapy over drug therapy or the supe-riority of any drug for the emergencytreatment of unstable VT in the pediat-ric age group. In 2 LOE 5 adult caseseries,312,313 early electric cardiover-sion was effective for treatment of un-stable VT.

In 4 small LOE 4 pediatric case se-ries298,299,314,315 amiodarone was effec-tive in the management of VT. Oneprospective randomized multicentersafety and efficacy LOE 2 trial evaluat-ing amiodarone for the treatment ofpediatric tachyarrhythmias316 foundthat 71% of children treated with ami-odarone experienced cardiovascularside effects. Both efficacy and adverseevents were dose-related.






Treatment RecommendationsIt is reasonable to use synchronizedelectric cardioversion as the pre-ferred first therapy for pediatric VTwith hypotension or evidence of poorperfusion. If drug therapy is used totreat unstable VT, amiodarone may bea reasonable choice, with careful he-modynamic monitoring performedduring its slow delivery.

Knowledge GapsWhat is the optimal dose of energyfor synchronized cardioversion duringtreatment of unstable VT in pediatricpatients?

Drugs for SupraventricularTachycardiaPeds-031

Consensus on ScienceTwenty-two LOE 4 studies in infants andchildren317–338 demonstrated the effec-tiveness of adenosine for the treat-ment of hemodynamically stable orunstable SVT. One LOE 4 study339 and4 larger LOE 5 studies involving teen-agers and adults340–343 also demon-strated the efficacy of adenosine, al-though frequent but transient sideeffects were reported.

One LOE 2 study344 showed highly suc-cessful (approximately 90%) treatmentof SVT in infants and children usingadenosine or verapamil and superior-ity of these drugs to digitalis (61% to71%). One LOE 5 randomized prospec-tive adult study345 and 1 LOE 5 meta-analysis, primarily involving adultsbut including some children,346 demon-strated the effectiveness of verapamiland adenosine in treating SVT andhighlighted the cost-effectiveness ofverapamil over adenosine.

One LOE 4 randomized, prospectivestudy316 and 15 LOE 4 small case seriesand observational studies in infants andchildren298,299,314,315,347–357 showed thatamiodarone was effective in the treat-ment of supraventricular tachyarrhyth-mias. Generalization to pediatric SVT

treatment with amiodarone may be lim-ited, however, since most of these stud-ies in children involved postoperativejunctional tachycardia.

Rare but significant side effects havebeen reported in association with rapidadministration of amiodarone. Brady-cardia and hypotension were reportedin 1 prospective LOE 4 study,316 cardio-vascular collapse was reported in 2 LOE5 case reports,358,359 and polymorphic VTwas reported in 1 small LOE 4 case se-ries.360 Other LOE5case reportsdescribelate side effects of pulmonary toxicity359

and hypothyroidism.362

In 1 LOE 2 pediatric comparison controlstudy363 procainamidehadasignificantlyhigher success rate and an equal inci-dence of adverse effects when com-pared with amiodarone for treating re-fractory SVT. In 5 LOE 4 observationalstudies364–368and5LOE5casereports369–373

procainamide effectively suppressed orslowed the rate in children with SVT. Awide variety of arrhythmias were stud-ied, including ectopic atrial tachycardia,atrial flutter, and orthodromic recipro-cating tachycardia.

In LOE 5 studies in children,374

adults,375,376 and animals,377 hypotensionfrom procainamide infusion resultedfrom vasodilation and not decreasedmyocardial contractility. Initial observa-tional LOE 4 reports378–380 and 1 LOE 4case series381 described successfultreatment of pediatric SVT with verap-amil. However, multiple small LOE 4 caseseries344,382 and LOE 5 case reports383,384

documented severe hypotension, brady-cardia, and heart block causing hemo-dynamic collapse and death followingIV administration of verapamil for SVTin infants. Two small LOE 4 pediatriccase series385,386 described esmolol anddexmedetomidine in the treatment ofSVT.

Treatment RecommendationsFor infants and children with SVT witha palpable pulse, adenosine should be

considered the preferred medication.Verapamil may be considered as alter-native therapy in older children butshould not be routinely used in infants.Procainamide or amiodarone given bya slow IV infusion with careful hemody-namic monitoring may be consideredfor refractory SVT.

Knowledge GapsDoes the use of alternate medications(eg, esmolol, dexmedetomidine) in thetreatment of SVT in infants and chil-dren improve outcome? What is therole of vagal maneuvers in the treat-ment of SVT?

SHOCKThe Task Force reviewed evidence re-lated to several key questions aboutthe management of shock in children.There is ongoing uncertainty about theindications for using colloid versuscrystalloid in shock resuscitation. Onelarge adult trial suggested that normalsaline (isotonic crystalloid) is equiva-lent to albumin, although subgroupanalysis suggested harm associatedwith the use of colloid in patients withtraumatic brain injury. There were in-sufficient data to change the 2005recommendations.

The optimal timing for intubation ofchildren in shock remains unclear, al-though reports of children and adultswith septic shock suggested potentialbeneficial effects of early intubation(before signs of respiratory failuredevelop) combined with a protocol-driven management approach. Whenchildren in septic shock were treatedwith a protocol that included therapydirected to normalizing central venousoxygen saturation, patient outcomeappeared to improve.

Performing rapid sequence inductionand tracheal intubation of a child withshock can cause acute cardiovascularcollapse. Etomidate typically causesless hemodynamic compromise thanother induction drugs and is therefore





often used in this setting. However,data suggest that the use of this drugin children and adults with septicshock is associated with increasedmortality that may be secondary toetomidate’s inhibitory effects on corti-costeroid synthesis. Administeringstress-dose corticosteroids in septicshock remains controversial, with re-cent adult trials failing to show a ben-eficial effect.

Graded Volume Resuscitation forHemorrhagic ShockPeds-032

Consensus on ScienceThere are no pediatric studies of thetiming or extent of volume resuscita-tion in hemorrhagic shock with hypo-tension. Nine LOE 5 adult387–395 studiesreported conflicting results with re-gard to the effect of timing and extentof volume resuscitation on outcome ofhemorrhagic shock with hypotension.

Treatment RecommendationsThere is insufficient evidence as to thebest timing or quantity for volume re-suscitation in infants and childrenwithhemorrhagic shock following trauma.

Knowledge GapsWhat is the appropriate clinical indica-tor for volume resuscitation duringtreatment of hemorrhagic shock in in-fants and children?

Early Ventilation in ShockPeds-038B

Consensus on ScienceThere are no studies investigating therole of intubation and assisted ventila-tion before the onset of respiratoryfailure in infants and children withshock. Two LOE 5 animal studies in sep-tic shock396,397 and 1 LOE 5 animal studyin pericardial tamponade398 showedimproved hemodynamics and selectorgan perfusion with intubation be-fore the onset of respiratory failure.One report of 2 adult patients399 (LOE 5)described cardiac arrest followingintubation of 1 adult patient with

tamponade due to penetrating traumaand improvement in hemodynamicsduring spontaneous breathing in 1me-chanically ventilated adult patient withpost–cardiac surgery tamponade.

One LOE 5 study of septic shock inadults400 suggested a reduced mortal-ity with early ventilation comparedwith historic controls who only re-ceived ventilation for respiratory fail-ure. One LOE 5 study of animals in sep-tic shock401 showed that early assistedventilation does not reduce oxygen ex-traction or prevent the development oflactic acidosis.

Treatment RecommendationsThere is insufficient evidence to sup-port or refute the use of endotrachealintubation of infants and children inshock before the onset of respiratoryfailure.

Knowledge GapsDoes the timing of respiratory supportin infants and children with shock af-fect outcome?

Colloid Versus Crystalloid FluidAdministrationPeds-044A, Peds-044B

Consensus on ScienceEvidence from 3 randomized blindedLOE 1 controlled trials in children withdengue shock syndrome402–404 and 1LOE 1 open randomized trial in childrenwith septic shock405 suggested no clin-ically important differences in survivalfrom therapy with colloid versus ther-apy with isotonic crystalloid solutionsfor shock.

In 1 large LOE 5 randomized controlledtrial of fluid therapy in adult ICU pa-tients406 and in 6good-quality LOE 5meta-analyses, predominantly of adults,407–412

no mortality differences were notedwhen colloid was compared with hy-pertonic and isotonic crystalloid solu-tions, and no differences were notedbetween types of colloid solutions.

Three LOE 5 studies comparing the useof crystalloids and colloids for adults

in shock suggested that crystalloidmay have an associated survival bene-fit over colloid in subgroups of patientswith shock, including general trau-ma,409 traumatic brain injury,413 andburns.414 One randomized controlledLOE 5 study of children with severe ma-laria suggested better survival withcolloid than with crystalloid infusion.415

Treatment RecommendationsIsotonic crystalloids are recommendedas the initial resuscitation fluid for in-fants and children with any type ofshock. There is insufficient evidence toidentify the superiority of any specificisotonic crystalloid over others.

Knowledge GapsDoes the use of any specific crystalloidsolution (Ringer’s lactate, normal sa-line, hypertonic saline) improve out-come for pediatric shock? Are theresubgroups of children in shock whoseoutcome is improved with the use ofcolloid compared with crystalloid?

Vasoactive Agents in DistributiveShockPeds-045A, Peds-045B

Consensus on ScienceOne LOE 4 observational study416 sug-gested that the course of pediatricseptic shock physiology is dynamicand that serial assessments are re-quired to titrate the type and dose ofinotropes or vasopressor therapy toachieve optimal hemodynamic results.Evidence from 4 LOE 1 pediatric ran-domized controlled studies,417–420 3 LOE5 adult randomized controlled stud-ies,421–423 and 1 LOE 5 adult systematicreview424 showed that no inotrope orvasopressor is superior in reducingmortality from pediatric or adult dis-tributive shock.

Two LOE 1 pediatric randomized con-trolled studies417,418 showed that chil-dren with “cold” (ie, low cardiac index)septic shock improved hemodynami-cally with brief (4-hour) administrationof milrinone (bolus and infusion). One








LOE 1 pediatric randomized controlledstudy420 of vasodilatory shock comparedthe addition of vasopressin versus pla-cebo to standard vasoactive agents andshowed no change in duration of vaso-pressor infusion but observed a trendtoward increased mortality.

Eleven small LOE 4 pediatric case se-ries425–435 showed improved hemody-namics but not survival when vasopres-sin or terlipressin was administered tochildren with refractory, vasodilatory,septic shock.

Treatment RecommendationsThere is insufficient evidence to rec-ommend a specific inotrope or vaso-pressor to improvemortality in pediat-ric distributive shock. Selection of aninotrope or vasopressor to improvehemodynamics should be tailored toeach patient’s physiology and adjustedas clinical status changes.

Knowledge GapsDoes the use of any specific vasoactiveagent improve outcome for infants andchildren with distributive shock?

Vasoactive Agents in CardiogenicShockPeds-046A

Consensus on ScienceOne LOE 4 pediatric case series436

showed that critically ill children re-quiring inotropic support have widevariability in hemodynamic responsesto different infusion rates of dobuta-mine. One LOE 2 blinded crossoverstudy437 found dopamine and dobuta-mine had equal hemodynamic effectsin infants and children requiring post–cardiac surgical inotropic support butthat dopamine at an infusion rate of�7 mcg/kg per minute increased pul-monary vascular resistance.

Six LOE 3 studies438–443 showed thatboth dopamine and dobutamine infu-sions improve hemodynamics in chil-dren with cardiogenic shock.

Evidence from 1 LOE 1 pediatric placebo-controlled trial444 showed that milrinone

is effective in preventing low cardiacoutput syndrome in infants and childrenfollowing biventricular cardiac repair.One LOE 4 study445 showed thatmilrinoneimproved cardiac index in neonateswithlow cardiac output following cardiacsurgery.

One small LOE 1 study446 showed thatchildren had better hemodynamic pa-rameters and shorter ICU stays if theyreceived milrinone compared withlow-dose epinephrine plus nitroglycer-in for inotropic support following re-pair of tetralogy of Fallot.

In 2 LOE 4 small case series,447,448 whenchildren with heart failure secondaryto myocardial dysfunction were givenlevosimendan, they demonstrated im-proved ejection fraction, required ashorter duration of catecholamine in-fusions,447 and showed a trend towardimproved hemodynamics and reducedarterial lactate levels.448

In subgroup analysis from 1 LOE 5 ran-domized controlled trial in adults,449 pa-tients with cardiogenic shock treatedwith norepinephrine versus dopaminehad an improved survival at 28 days.When all causes of shock were included,patients treated with norepinephrinealso had fewer arrhythmias than thosetreated with dopamine (12% versus24%).

Treatment RecommendationsThe catecholamine dose for inotropicsupport in cardiogenic shock must beindividually titrated because there isa wide variability in clinical response.It is reasonable to use epinephrine,levosimendan, dopamine, or dobuta-mine for inotropic support in infantsand children with cardiogenic shock.Milrinone may be beneficial for theprevention and treatment of low car-diac output following cardiac surgery.

There are insufficient data to supportor refute the use of norepinephrine inpediatric cardiogenic shock.

Knowledge GapsDoes the use of any specific vasoactiveagent improve outcome for infants andchildren with cardiogenic shock whohave not undergone cardiac surgery?

Etomidate for Intubation inHypotensive SepticShockPeds-047A, Peds-047B

Consensus on ScienceOne LOE 4 study of children with septicshock450 showed that adrenal suppres-sion occurred after the administrationof a single dose of etomidate and per-sisted for at least 24 hours. Evidencefrom 2 LOE 4451,452 studies and 1 LOE 5453

study showed that etomidate can beused to facilitate tracheal intubation ininfants and children with minimal he-modynamic effect, but very few ofthese reports included patients withhypotensive septic shock. One LOE 4study450 suggested an association withmortality when etomidate is used tofacilitate the intubation of childrenwith septic shock.

One adult LOE 5 study454 observed anincreased mortality associated withthe use of etomidate for intubation ofpatients in septic shock, even with ste-roid supplementation. Conversely, 1underpowered adult LOE 5 study455 inseptic patients did not show an in-crease in mortality.

One multicenter adult LOE 5 compara-tive trial of etomidate versus keta-mine for intubation456 found no differ-ence in organ failure over the first 72hours and no mortality difference, butthis study included only a small num-ber of patients with shock. Adrenal in-sufficiency was more common inetomidate-treated patients.

Treatment RecommendationsEtomidate should not be routinely usedwhen intubating an infant or child withseptic shock. If etomidate is used ininfants and children with septic shock,







the increased risk of adrenal insuffi-ciency should be recognized.

Knowledge GapsIf etomidate is used, does steroid ad-ministration improve outcome for in-fants and children with septic shock?

Corticosteroids in HypotensiveShockPeds-049A, Peds-049B

Consensus on ScienceIn 6 LOE 5 randomized controlledtrials in adults with septic shock454,457–461

the addition of low-dose hydrocortisonedecreased the time to shock reversal.Three LOE 5 randomized controlled trialsin adults with vasopressor-dependentseptic shock457,462,463 showed that sur-vival was improved when low-dosehydrocortisone was administered,while 1 small adult LOE 5 randomizedcontrolled trial464 showed a trend to-ward increased survival.

One fair-quality, small LOE 1 study inchildren with septic shock465 foundthat low-dose hydrocortisone admin-istration resulted in no survival bene-fit. One fair-quality LOE 1 study ofadministration of low-dose hydrocorti-sone to children with septic shock466

demonstrated earlier shock reversal.Data from 1 LOE 4 hospital dischargedatabase467 noted the association be-tween the use of steroids in childrenwith severe sepsis and decreasedsurvival.

In 1 LOE 5 study in adults with septicshock457 survival improved signifi-cantly with the use of low-dose hydro-cortisone and fludrocortisone com-pared with placebo. Conversely 4 LOE 5adult trials in septic shock454,459–461

showed no survival benefit with low-dose corticosteroid therapy. In 1 largeLOE 5 randomized controlled trial ofadults in septic shock,454 corticoste-roid administration was associatedwith an increased risk of secondaryinfection.

Treatment RecommendationsThere is insufficient evidence to sup-port or refute the routine use ofstress-dose or low-dose hydrocorti-sone and/or other corticosteroids ininfants and children with septic shock.Stress-dose corticosteroids may beconsidered in children with septicshock unresponsive to fluids and re-quiring vasoactive support.

Knowledge GapsWhat is the appropriate “stress dose”of hydrocortisone for hypotensive sep-tic shock? Should the dose of hydro-cortisone be titrated to the degree ofshock? Should an adrenocorticotro-phin (ACTH) stimulation test be per-formed to determine if an infant orchild in septic shock has adrenalinsufficiency?

Diagnostic Tests asGuide to Management ofShockPeds-050A, Peds-050B

Consensus on ScienceIn 1 LOE 1 randomized controlled trialin children with severe sepsis or fluid-refractory septic shock,468 protocol-driven therapy that included targetinga superior vena caval oxygen satura-tion�70%, coupled with treating clin-ical signs of shock (prolonged capil-lary refill, reduced urine output, andreduced blood pressure), improvedpatient survival to hospital dischargein comparison to treatment guided byassessment of clinical signs alone.

Two LOE 5 studies of adults with septicshock, one a randomized controlledtrial469 and the other a cohort study,470

documented improved survival to hos-pital discharge following implementa-tion of protocol-driven early goal-directed therapy, including titration toa central venous oxygen saturation(SvcO2) �70%. In 1 large multicenterLOE 5 adult study471 evaluating the“Surviving Sepsis” bundle, early goal-directed therapy to achieve an SvcO2�70% was not associated with an im-

provement in survival, but venous oxy-gen saturations were measured in�25% of participants.

There are insufficient data on the util-ity of other diagnostic tests (eg, pH,lactate) to help guide the managementof infants and children with shock.

Treatment RecommendationsA protocol-driven therapy, which in-cludes titration to a superior venacaval oxygen saturation �70%, maybe beneficial for infants and children(without cyanotic congenital heartdisease) with fluid-refractory septicshock. No treatment recommendationscan bemade to target SvcO2 saturationin the management of fluid-refractoryseptic shock in pediatric patients withcyanotic congenital heart disease orfor other forms of pediatric shock.

Knowledge GapsWhat is the optimal diagnostic test (ie,lactate, SvcO2) to guidemanagement ofpediatric shock? Does continuous ver-sus intermittent SvcO2 monitoring af-fect outcome?

MEDICATIONS IN CARDIAC ARRESTAND BRADYCARDIAThe Task Force reviewed and updatedevidence to support medications usedduring cardiac arrest and bradycar-dia, but no new recommendationswere made. It was again emphasizedthat calcium and sodium bicarbonateshould not be routinely used in pediat-ric cardiac arrest (ie, should not beused without specific indications).

Calculating Drug DosePeds-017B

Consensus on ScienceEight LOE 5 studies472–479 concludedthat length-based methods are moreaccurate than age-based or observer(parent or provider) estimate-basedmethods in the prediction of bodyweight. Four LOE 5 studies472,474,480,481

suggested that the addition of a cate-







gory of body habitus to length may im-prove prediction of body weight.

Six LOE 5 studies482–487 attempted tofind a formula based on drug pharma-cokinetics and physiology that wouldallow the calculation of a pediatricdose from the adult dose.

Treatment RecommendationsIn nonobese pediatric patients, initialresuscitation drug doses should bebased on actual body weight (whichclosely approximates ideal bodyweight).If necessary, body weight can be esti-mated from body length.

In obese patients the initial doses ofresuscitation drugs should be basedon ideal body weight that can be esti-mated from length. Administration ofdrug doses based on actual bodyweight in obese patients may result indrug toxicity.

Subsequent doses of resuscitationdrugs in both nonobese and obese pa-tients should take into account ob-served clinical effects and toxicities. Itis reasonable to titrate the dose to thedesired therapeutic effect, but itshould not exceed the adult dose.

Knowledge GapsWhat is the most accurate method forcalculating resuscitation drug dosesfor children? Does the accuracy ofthe estimated weight used to calculatedrug dose affect patient outcome? Dospecific resuscitation drugs requiredifferent adjustments for estimatedweight, maturity and/or bodycomposition?

Are formulas for scaling drug doseswith formulas from adult doses supe-rior to existingweight-basedmethods?

Epinephrine DosePeds-018

Consensus on ScienceNo studies have compared epineph-rine versus placebo administrationfor pulseless cardiac arrest in infantsand children. One LOE 5 randomized

controlled adult study488 of standarddrug therapy compared with no drugtherapy during out-of-hospital cardiacarrest showed improved survival tohospital admissionwith any drug deliv-ery but no difference in survival to hos-pital discharge.

Evidence from 1 LOE 1 prospective,randomized, controlled trial,489 2 LOE 2prospective trials,490,491 and 2 LOE 2case series with concurrent con-trols492,493 showed no increase in sur-vival to hospital discharge or improvedneurologic outcome when epinephrinedoses of �10 mcg/kg IV were used inout-of-hospital or in-hospital pediatriccardiac arrest. In 1 LOE 1 prospectivetrial489 of pediatric in-hospital cardiacarrest comparing high-dose (100 mcg/kg) with standard-dose epinephrineadministered if cardiac arrest per-sisted after 1 standard dose of epi-nephrine, 24-hour survival was re-duced in the high-dose epinephrinegroup.

Evidence extrapolated from adult pre-hospital or in-hospital studies, includ-ing 9 LOE 1 randomized trials,494–502 3LOE 2 trials,503–505 and 3 LOE 3 stud-ies,506–508 showed no improvement insurvival to hospital discharge or neu-rologic outcome when doses�1 mg ofepinephrine were given.

Treatment RecommendationsIn infants and children with out-of-hospital or in-hospital cardiac arrest,the appropriate dose of IV epinephrineis 10 mcg/kg per dose (0.01 mg/kg) forthe first and for subsequent doses. Themaximum single dose is 1 mg.

Knowledge GapsDoes epinephrine administration im-prove outcome from cardiac arrestin infants and children? Are there spe-cific patients or arrest types (eg, pro-longed arrest, asphyxial arrest, VF ar-rest) for which epinephrine is moreeffective?

Sodium Bicarbonate DuringCardiac ArrestPeds-028

Consensus on ScienceThere are no randomized controlledstudies in infants and children exam-ining the use of sodium bicarbonate aspart of themanagement of pediatric car-diac arrest. One LOE 2 multicenter retro-spective in-hospital pediatric study509

found that sodium bicarbonate admin-istered during cardiac arrest was as-sociated with decreased survival, evenafter controlling for age, gender, andfirst documented cardiac rhythm.

Two LOE 5 randomized controlled stud-ies have examined the value of sodiumbicarbonate in the management of ar-rest in other populations: 1 adult out-of-hospital cardiac arrest study510 and1 study in neonates with respiratoryarrest in the delivery room.511 Bothfailed to show an improvement in over-all survival.

Treatment RecommendationsRoutine administration of sodium bi-carbonate is not recommended in themanagement of pediatric cardiacarrest.

Knowledge GapsAre there circumstances under whichsodium bicarbonate administrationimproves outcome from pediatric car-diac arrest?

VasopressinPeds-020A, Peds-020B

Consensus on ScienceIn 1 pediatric LOE 3 study512 vasopres-sin was associated with lower ROSCand a trend toward lower 24-hourand discharge survival. In 3 pediatricLOE 4513–515 and 2 adult LOE 5516,517 caseseries/reports (9 patients) vasopres-sin513 or its long-acting analogue, terli-pressin,514,515 administration was as-sociated with ROSC in patients withrefractory cardiac arrest (ie, standardtherapy failed).








Extrapolated evidence from 6 LOE 5adult studies518–523 and 1 LOE 1 adultmeta-analysis524 showed that vaso-pressin used either by itself or in com-bination with epinephrine during car-diac arrest does not improve ROSC,hospital discharge, or neurologic out-come. Evidence from 1 LOE 5 animalstudy525 of an infant asphyxial arrestmodel showed no difference in ROSCwhen terlipressin was administeredalone or in combination with epineph-rine as compared with epinephrinealone.

Treatment RecommendationsThere is insufficient evidence for oragainst the administration of vaso-pressin or its long-acting analogue,terlipressin, in pediatric cardiac arrest.

Knowledge GapsAre there patient subgroups whomight benefit from vasopressin (withor without other vasopressors) for pe-diatric cardiac arrest? Does the use of“early” versus “late” (ie, rescue) vaso-pressin affect outcome in pediatriccardiac arrest? Is vasopressin effec-tive when administered via a trachealtube?

Calcium in CardiacArrestPeds-021A, Peds-021B

Consensus on ScienceEvidence from 3 LOE 2509,526,527 studies inchildren and 5 LOE 5 adult studies528–532

failed to document an improvement insurvival to hospital admission, hospi-tal discharge, or favorable neurologicoutcome when calcium was adminis-tered during cardiopulmonary arrestin the absence of documented hypocal-cemia, calcium channel blocker over-dose, hypermagnesemia, or hyperka-lemia. Four LOE 5 animal studies533–536

showed no improvement in ROSC whencalcium, compared with epinephrineor placebo, was administered duringcardiopulmonary arrest.

Two studies investigating calcium forin-hospital pediatric cardiac arrestsuggested a potential for harm. OneLOE 2 study examining data from theNRCPR526 observed an adjusted oddsratio of survival to hospital dischargeof 0.6 in children who received cal-cium, and 1 LOE 3 multicenter study509

showed an odds ratio for increasedhospital mortality of 2.24 associatedwith the use of calcium. One LOE 2study of cardiac arrest in the PICUsetting527 suggested a potential forharm with the administration of cal-cium during cardiac arrest; the ad-ministration of 1 or more boluses wasan independent predictor of hospitalmortality.

Treatment RecommendationsRoutine use of calcium for infants andchildren with cardiopulmonary arrestis not recommended in the absenceof hypocalcemia, calcium channelblocker overdose, hypermagnesemia,or hyperkalemia.

Knowledge GapsAre there indications for calcium ad-ministration that may be associatedwith improved outcome from pediatriccardiac arrest? Does the increasedmortality risk associated with calciumadministration reflect harm from cal-cium or does it simply identify patientswho failed to respond to other ALS in-terventions and therefore were at ahigher risk of death?

Atropine Versus Epinephrinefor BradycardiaPeds-052A

Consensus on ScienceEvidence from 1 LOE 3 study of in-hospital pediatric cardiac arrest537 ob-served an improved odds of survival todischarge for those patients who re-ceived atropine based on multivariateanalysis, whereas the use of epineph-rine was associated with decreasedodds of survival. Another large LOE 3study538 demonstrated no association

between atropine administration andsurvival.

In 1 LOE 5 adult case series,539 6 of 8 pa-tients in cardiac arrest who did not re-spond to epinephrine did respond toatropine with a change to a perfus-ing rhythm; 3 survived to hospital dis-charge. An LOE 5 retrospective adultreview540 observed that a small num-ber of asystolic patients who failed torespond to epinephrine did respond toatropine, but none survived to hospitaldischarge.

Four LOE 5 adult studies541–544 showeda benefit of atropine in vagally medi-ated bradycardia. One small LOE 4 pe-diatric case series545 showed thatatropine is more effective than epi-nephrine in increasing heart rate andblood pressure in children with post–cardiac surgical hypotension and brady-cardia (Bezold-Jarisch reflex mediatedbradycardia).

Four LOE 5 adult542,546–548 and 4 LOE 5animal549–552 studies showed no benefitfrom atropine used to treat bradycar-dia or cardiac arrest. One LOE 5 animalstudy553 did show a benefit of atropinewhen used with epinephrine in cardiacarrest.

Treatment RecommendationsEpinephrine may be used for infantsand children with bradycardia andpoor perfusion that is unresponsive toventilation and oxygenation. It is rea-sonable to administer atropine forbradycardia caused by increased va-gal tone or cholinergic drug toxicity.There is insufficient evidence to sup-port or refute the routine use of atro-pine for pediatric cardiac arrest.

Knowledge GapsWhat is the optimal dose of epineph-rine for pediatric bradycardia? Isthere a role for titrated doses? Doesthe use of epinephrine versus atropineimprove outcome from pediatric bra-dycardia? Are there circumstancesunder which atropine administration





improves outcome from pediatric car-diac arrest?

EXTRACORPOREAL CARDIACLIFE SUPPORTPeds-014, Peds-014B

There is increasing evidence that extra-corporeal cardiac life support (ECLS)can act as a bridge tomaintain oxygen-ation and circulation in selected in-fants and children with cardiac arrestif they are transplant candidates orhave a self-limited or treatable illness.When ECLS is initiated for the treat-ment of cardiac arrest, it is referred toas ECPR (extracorporeal CPR). ECPRcan only be employed if the cardiacarrest occurs in a monitored environ-ment with protocols and personnel forrapid initiation.

Consensus on ScienceOne LOE 2554 and 26 LOE 4 studies555–580

reported favorable early outcome af-ter ECPR in children with primary car-diac disease who were located in anICU or other highly supervised environ-ment using ECPR protocols at the timeof the arrest.

One LOE 2554 and 2 LOE 4555,564 studiesindicated poor outcome from ECPR inchildren with noncardiac diseases.

In 1 LOE 4 study556 survival followingECPR in children was associated withshorter time interval between arrestand ECPR team activation and shorterCPR duration. Two LOE 4 studies560,581

found insignificant improvements inoutcome after ECPR in children follow-ing protocol changes leading toshorter durations of CPR. One LOE 2554

and 3 LOE 4555,559,565 studies found norelationship between CPR durationand outcome after ECPR in children.

Three small LOE 4 studies,582–584 includ-ing a total of 21 children, showed favor-able outcome with ECPR following out-of-hospital cardiac arrest associatedwith environmentally induced severehypothermia (temperature�30°C).

Treatment RecommendationsECPR may be beneficial for infants andchildren with cardiac arrest if theyhave heart disease amenable to recov-ery or transplantation and the arrestoccurs in a highly supervised environ-ment such as an ICU with existing clin-ical protocols and available expertiseand equipment to rapidly initiate ECPR.There is insufficient evidence for anyspecific threshold for CPR durationbeyond which survival with ECPR isunlikely. ECPR may be considered incases of environmentally induced se-vere hypothermia (temperature�30°C)for pediatric patients with out-of-hospital cardiac arrest if the appropri-ate expertise, equipment, and clinicalprotocols are in place.

Knowledge GapsWhat are the long-term neurologic out-comes of pediatric patients treatedwith ECPR? Is there an upper limit forthe duration of standard CPR beyondwhich using ECPR will be of no benefit?

POST-RESUSCITATION CAREThe Task Force reviewed evidence re-garding hypothermia for pediatric pa-tients who remain comatose followingresuscitation from cardiac arrest.There is clear benefit for adult patientswho remain comatose after VF arrest,but there is little evidence regardingeffectiveness for infants (ie, beyondthe neonatal period) and young chil-dren who most commonly have as-phyxial arrest.

Some patients with sudden death with-out an obvious cause have a geneticabnormality of myocardial ion chan-nels (ie, a channelopathy), which pre-sumably leads to a fatal arrhythmia.Because this is an inherited abnormal-ity, family members might be affected,but special tests are required for thedetection of this inherited geneticdefect.

HypothermiaPeds-010A, Peds-010B

Consensus on ScienceThere are no randomized pediatricstudies on induced therapeutic hypo-thermia following cardiac arrest.

Two prospective randomized LOE 5studies of adults with VF arrest585,586

and 2 prospective randomized LOE 5studies of newborns with birth asphyx-ia587,588 showed that therapeutic hypo-thermia (32° to 34°C) up to 72 hoursafter resuscitation has an acceptablesafety profile and may be associatedwith better long-termneurologic outcome.

One LOE 2 observational study589 nei-ther supports nor refutes the use oftherapeutic hypothermia after resus-citation from pediatric cardiac arrest.However, patients in this study werenot randomized, and the cooled pa-tients were much sicker and youngerthan those not cooled.

Treatment RecommendationsTherapeutic hypothermia (to 32°C to34°C) may be beneficial for adoles-cents who remain comatose followingresuscitation from sudden witnessedout-of-hospital VF cardiac arrest. Ther-apeutic hypothermia (to 32°C to 34°C)may be considered for infants and chil-dren who remain comatose followingresuscitation from cardiac arrest.

Knowledge GapsDoes therapeutic hypothermia improveoutcome following pediatric cardiacarrest? Is there a difference in effec-tiveness for VF arrest versus asphyxialarrest? What is the optimal protocolfor cooling after pediatric cardiac ar-rest (timing, duration, goal tempera-ture, rate of rewarming)?

Vasoactive DrugsPeds-024A, Peds-024B

Consensus on ScienceThere are no studies evaluating therole of vasoactive medications afterROSC in children. Evidence from 2 LOE 3studies in children,590,591 2 LOE 5 studies










in adults,592,593 and 2 LOE 5 animal stud-ies594,595 documented that myocardialdysfunction and vascular instabilityare common following resuscitationfrom cardiac arrest.

Evidence from 6 LOE 5 animal stud-ies594–599 documented hemodynamicimprovement when vasoactive medi-cations (dobutamine, milrinone, levo-simendan) were given in the post–car-diac arrest period. Evidence from 1large LOE 5 pediatric444 and 4 LOE 5adult600–603 studies of patients with lowcardiac output or at risk for low car-diac output following cardiac surgerydocumented consistent improvementin hemodynamics when vasoactivemedications were administered.

Treatment RecommendationsIt is reasonable to administer vasoac-tive medications to infants and chil-dren with documented or suspectedcardiovascular dysfunction after car-diac arrest. These vasoactive medica-tions should be selected and titrated toimprove myocardial function and/ororgan perfusion while trying to limitadverse effects.

Knowledge GapsWhat is the optimal vasoactive drugregimen for postarrest myocardialdysfunction in infants and children?

GlucosePeds-016

Consensus on ScienceThere is insufficient evidence to sup-port or refute any specific glucosemanagement strategy in infants andchildren following cardiac arrest. Al-though there is an association of hy-perglycemia and hypoglycemia withpoor outcome following ROSC aftercardiac arrest, there are no studiesthat show causation and no studiesthat show that the treatment of eitherhyperglycemia or hypoglycemia fol-lowing ROSC improves outcome.

Two studies of adult survivors of car-diac arrest, including 1 LOE 5 prospec-

tive observational study604 and 1 LOE 5randomized controlled trial compar-ing tight with moderate glucose con-trol605 observed no survival benefitwith tight glucose control. Two studiesof tight glucose control in adult surgi-cal ICU patients, including 1 LOE 1 pro-spective randomized controlled trial606

and 1 LOE 1 meta-analysis607 observedreduced mortality with tight glucosecontrol. Two LOE 5 meta-analyses com-paring tight with moderate glucosecontrol in adult ICU patients608,609 and 1LOE 5 randomized controlled trial com-paring tight with moderate glucosecontrol in adult medical ICU patients610

observed no differences in survival.Three LOE 5 studies of tight glucosecontrol in adult ICU patients, including1 randomized controlled trial in car-diac surgical patients,611 1 multicenterrandomized controlled trial in medicaland surgical ICU patients,612 and 1cohort-controlled study of medical andsurgical ICU patients613 demonstratedincreased mortality with tight glucosecontrol.

One LOE 5 randomized controlled trialof critically ill children614 observed animprovement in inflammatory bio-chemical markers and reduced ICUlength of stay with tight glucose con-trol. One study of tight glucose controlof critically ill neonates615 was termi-nated early for reasons of futility. Sig-nificant rates of hypoglycemia arewidely reported with the use of tightglucose control without explicit meth-odology or continuous glucose moni-toring in critically ill neonates,615 chil-dren,614 and adults.607,608,612

Evidence from LOE 5 animal studies ofneonatal cerebral ischemia616 and crit-ically ill adults617,618 suggest that hypo-glycemia combined with hypoxia andischemia is harmful and associatedwith higher mortality. Evidence from 3LOE 5 animal studies619–621 showed thatprolonged hyperglycemia after resus-citation is harmful to the brain. One

LOE 5 animal study622 showed that glu-cose infusion with associated hyper-glycemia after resuscitation worsenedoutcome, whereas another LOE 5 ani-mal study623 showed that moderate hy-perglycemia managed with insulin im-proved neurologic outcome.

Treatment RecommendationsIt is appropriate to monitor blood glu-cose levels and avoid hypoglycemia aswell as sustained hyperglycemia fol-lowing cardiac arrest. There is insuffi-cient evidence to recommend specificstrategies tomanage hyperglycemia ininfants and children with ROSC follow-ing cardiac arrest. If hyperglycemia istreated following ROSC in children,blood glucose concentrations shouldbe carefully monitored to reduce epi-sodes of hypoglycemia.

Knowledge GapsDoes the use of “tight” glucose controlimprove outcome following pediatriccardiac arrest?

ChannelopathyPeds-048A, Peds-048B

Consensus on ScienceIn 4 LOE 4 studies624–627 14% to 35% ofyoung patients with sudden, unex-pected death had no abnormalitiesfound at autopsy.

In 7 LOE 3 studies628–634 mutationscausing channelopathies occurred in2% to 10% of infants with sudden in-fant death syndrome noted as thecause of death. In 1 LOE 3635 and 2 LOE4636,637 studies 14% to 20% of youngadults with sudden, unexpected deathhad no abnormalities on autopsy buthad genetic mutations causing chan-nelopathies. In 4 LOE 4 studies,638–641 us-ing clinical and laboratory (electrocar-diographic, molecular-genetic screening)investigations, 22% to 53% of first- andsecond-degree relatives of patients withsudden, unexplained death had inher-ited, arrhythmogenic disease.





Treatment RecommendationsWhen sudden unexplained cardiac ar-rest occurs in childrenand youngadults,a complete past medical and family his-tory (including a history of syncopal epi-sodes, seizures, unexplained accidents/drownings, or sudden death) shouldbe obtained and any available previousECGs shouldbe reviewed. All infants, chil-dren, and young adults with sudden,unexpected death should, if possible,have an unrestricted, complete autopsy,preferably performed by pathologistswith training and expertise in cardiovas-cular pathology. Consideration shouldbe given to preservation and geneticanalysis of tissue to determine the pres-ence of a channelopathy. It is recom-mended that families of patients whosecauseofdeath isnot foundonautopsybereferred to a healthcare provider or cen-ter with expertise in cardiac rhythmdisturbances.

Knowledge GapsWhat is the population-based inci-dence of inherited arrhythmic deathsin patients with sudden, unexpecteddeath and a negative autopsy? Whatare the most effective strategies (eg,for emergencymedicine physician, pri-mary care provider, coroner, or oth-ers) to identify families at risk?

SPECIAL SITUATIONSNew topics introduced in this docu-ment include resuscitation of infantsand children with certain congenitalcardiac abnormalities, namely singleventricle following stage I procedureand following the Fontan or bidirec-tional Glenn procedures (BDGs) aswellas resuscitation of infants and chil-dren with cardiac arrest and pulmo-nary hypertension.

Life Support forTraumaPeds-041A, Peds-041B

Consensus on ScienceCardiac arrest (out-of-hospital andin-hospital) due to major (blunt or

penetrating) injury (out-of-hospitaland in-hospital) in children has a veryhigh mortality rate.642–645 In 1 LOE 4645

and 1 LOE 5117 study there was no sur-vival advantage to intubating child vic-tims of traumatic cardiac arrest in theout-of-hospital setting. One LOE 2646 and4 LOE 4647–650 studies suggested thatthere is minimal survival advantageassociated with resuscitative thora-cotomy with or without internal car-diac massage for blunt trauma–in-duced cardiac arrest in children. TwoLOE 4 studies648,649 suggested that sur-vival in children with cardiac arrestfrom penetrating trauma is improvedby thoracotomy if time from event tohospital is short and signs of life arerestored in the field.

Treatment RecommendationsThere is insufficient evidence to makea recommendation for modification ofstandard resuscitation for infants andchildren suffering cardiac arrest dueto major trauma, although consider-ation should be given to selectivelyperforming a resuscitative thoracot-omy in children with penetrating inju-ries who arrive at the hospital with aperfusing rhythm.

Knowledge GapsWhat is the role of open-chest CPR fornontraumatic etiologies of pediatriccardiac arrest?

Single-Ventricle Post Stage IRepairPeds-059

Consensus on ScienceIn 1 LOE 4 case series651 cardiac arrestoccurred frequently (in 20% of 112patients) in infants following stage Irepair for single-ventricle anatomy.Two LOE 5 case series of mechanicallyventilated, chemically paralyzed pa-tients with a single ventricle in the pre-operative period652,653 showed that ex-cessive pulmonary blood flow may beattenuated in the short term by in-creasing the inspired fraction of CO2 to

achieve a PaCO2 of 50 to 60 mm Hg. Inthe same population, decreasing thefraction of inspired oxygen below 0.21did not appear to improve systemic ox-ygen delivery. Three LOE 4 studies654–656

showed that clinical identification ofthe prearrest state in patients with asingle ventricle is difficult and may beaided by monitoring systemic oxygenextraction using superior vena cavaloxygen saturation or near infraredspectroscopy of cerebral and splanch-nic circulations.

One LOE 3 prospective, crossover de-sign study657 of infants following stageI repair showed that inspired carbondioxide increased systemic oxygen de-livery. Evidence from 3 LOE 4 studies ofinfants following stage I repair658–660

showed that reducing systemic vascu-lar resistance with agents such asphenoxybenzamine improved systemicoxygen delivery,659 reduced the risk forcardiovascular collapse,658 and im-proved survival.660

There is no evidence for or against anyspecific modification of standard re-suscitation practice for cardiac arrestin infants with single-ventricle anato-my following stage I repair.

Five LOE 4 pediatric studies555,558,578,661,662

showed that survival to hospital dis-charge for patients with single-ventricle anatomy following ECPR (seeECPR above) is comparable to that ofother neonates undergoing cardiacsurgery. In 1 LOE 4 study578 survivalfollowing ECPR initiated as a conse-quence of systemic-to-pulmonary ar-tery shunt block after stage I repairwas consistently higher than for otheretiologies of cardiac arrest.

Treatment RecommendationsStandard resuscitation (prearrest andarrest) procedures should be followedfor infants and children with single-ventricle anatomy following stage I re-pair. Neonates with a single ventriclebefore stage I repair who demonstrate







shock caused by elevated pulmonaryto systemic flow ratio (Qp-to-Qs ratio)might benefit from inducing mild hy-percarbia (PaCO2 to 50 to 60 mm Hg);this can be achieved during mechani-cal ventilation by reducing minute ven-tilation, adding CO2 to inspired air, oradministering opioids with or withoutchemical paralysis.

Neonates in a prearrest state follow-ing stage I repair may benefit from�-adrenergic antagonists to treat orameliorate excessive systemic vaso-constriction in order to improve sys-temic blood flow and oxygen deliveryand reduce the likelihood of cardiacarrest. Assessment of systemic oxygenextraction by monitoring SvcO2 or nearinfrared spectroscopy monitoring ofcerebral and splanchnic circulationmay help identify evolving hemody-namic changes in infants followingstage I procedures; such hemodynam-ic changes may herald impending car-diac arrest.

Knowledge GapsIs there benefit in using heparin orthrombolytics during cardiac arrest toopen a potentially occluded systemic-to-pulmonary artery (PA) or right ven-tricle to pulmonary artery (RV-PA)shunt following stage I repair? What isthe role of monitoring near infraredspectroscopy/SvcO2 to guide resuscita-tion following stage I repair? Is there apotential benefit from the administra-tion of milrinone during the prearreststate in infants with a single ventricle?Is it better to use a pure �-adrenergicagonist (isoproterenol) or an �- and�-agonist (epinephrine) to achieveROSC after cardiac arrest followingstage I repair? Does PETCO2 reflect pul-monary blood flow in single-ventriclephysiology and can it be used to guideresuscitative procedures? Should theinspired oxygen concentration (100%versus room air) be different in infantswith single-ventricle physiology duringresuscitation from cardiac arrest?

How does the Sano modification ofStage I repair (RV-PA conduit instead ofa systemic-pulmonary artery shunt)affect response to therapies for car-diac arrest?

Single-Ventricle Post-Fontanand Bidirectional GlennProceduresPeds-055B

Consensus on ScienceIn 1 LOE 4 case series663 ECLS was use-ful in resuscitating patients with Fon-tan circulation but was not successfulin hemi-Fontan/BDG patients. One LOE 4case report664 described manual ex-ternal abdominal compressions withclosed chest cardiac compressions asan alternative for standard CPR follow-ing a modified Fontan procedure.

Evidence from 4 LOE 5 studies665–668 ofpatients with BDG circulation whowere not in cardiac arrest or shocksupports increasing CO2 tension andhypoventilation to improve cerebral,superior vena caval, and pulmonaryblood flow in order to increase sys-temic oxygen delivery. In 2 LOE 5 stud-ies669,670 of patients with BDG circula-tion who were not in cardiac arrestor a prearrest state, excessive ventila-tion reduced cerebral oxygenation. In2 LOE 5 studies671,672 of patients follow-ing a Fontan procedure who were notin cardiac arrest or a prearrest state,negative-pressure ventilation improvedstroke volume and cardiac outputcompared with intermittent positive-pressure ventilation.

One LOE 5 case series673 of patients fol-lowing a Fontan procedure who werenot in cardiac arrest or a prearreststate showed that high-frequency jetventilation improved pulmonary vas-cular resistance and cardiac index.However, another LOE 5 case series674

found that high-frequency oscillationventilation did not increase cardiac in-dex or decrease pulmonary vascularresistance.

Changes in pulmonary blood flow typi-cally reflect changes in cardiac output,but in infants and children with right-to-left shunts, an increase in right-to-left shunting that bypasses the lungs,as occurs in some infants and childrenwith congenital heart disease or pul-monary hypertension, decreases theproportion of blood flowing throughthe pulmonary circulation, and as a re-sult, the PETCO2 falls.675 Conversely, in-creasing pulmonary blood flow, ashappens following shunt insertion ininfants with cyanotic heart disease, in-creases the PETCO2 and reduces the dif-ference between the PaCO2 and end-tidal CO2.84,85 Likewise, if there areintrapulmonary shunts that bypassthe alveoli, there will be a greater dif-ference between the PaCO2 and PETCO2.83

Treatment RecommendationsIn patients with Fontan or hemi-Fontan/BDG physiology who are in aprearrest state, hypercarbia achievedby hypoventilation may be beneficial toincrease oxygenation and cardiac out-put, while negative-pressure ventila-tion, if available, may be beneficial byincreasing cardiac output. During car-diopulmonary arrest it is reasonableto consider ECPR for patients withFontan physiology. There is insufficientevidence to support or refute the useof ECPR in patients with hemi-Fontan/BDG physiology.

Knowledge GapsWhat is the optimal method for cannu-lation for ECPR in patients with hemi-Fontan/BDG or Fontan physiology? Whatis the optimal CPR strategy (eg, withor without manual external abdominalcompression; with or without activechest decompression; with or with-out an impedance threshold device)for patients with hemi-Fontan/BDG orFontan physiology? Is there an idealcompression-ventilation ratio duringCPR for infants following hemi-Fontan/BDG or Fontan procedures? Are com-



pression “boots” or a MAST (militaryantishock trouser) suit beneficial forpatients in prearrest states or cardiacarrest following hemi-Fontan/BDG orFontan procedures?

Pulmonary HypertensionPeds-056A

Consensus on ScienceTwo LOE 5 observational pediatricstudies676,677 showed that children withpulmonary hypertension are at in-creased risk for cardiac arrest. Thereare no studies that demonstrate thesuperiority of any specific therapy forresuscitation from cardiac arrest ininfants and children with a pulmonaryhypertensive crisis.

In 1 LOE 5 retrospective study in adults678

standard CPR techniques were oftenunsuccessful in victims with pulmonaryhypertension and cardiac arrest. Thosewho were successfully resuscitated hada reversible cause and received a bolusof IV iloprost or inhaled nitric oxide (NO)during the resuscitation.

One LOE 5 study of adults after cardiactransplant679 and 2 LOE 5 studies inchildren with congenital heart dis-ease680,681 observed that inhaled NOand aerosolized prostacyclin or ana-logues appear to be equally effective inreducing pulmonary vascular resis-tance. In 1 LOE 5 study in children withpulmonary hypertension after cardiacsurgery682 inhaled NO and alkalosis ap-peared to be equally effective in reduc-ing pulmonary vascular resistance.There is no evidence of benefit or harmof excessive ventilation for infants andchildren in cardiac arrest with pulmo-nary hypertension.

Four LOE 5 studies in pulmonary hyper-tensive adults and children with crisesor cardiac arrest683–686 showed thatmechanical right ventricular supportimproved survival.

Treatment RecommendationsRescuers should provide conventionalpediatric advanced life support, includ-

ing oxygenation and ventilation for car-diac arrest associated with pulmonaryhypertension. It may be beneficial toattempt to correct hypercarbia. If theadministration of medications (IV orinhaled) to decrease pulmonary arterypressure has been interrupted, it maybe advisable to reinstitute it.

Inhaled NO or aerosolized prostacyclinor analogue to reduce pulmonary vas-cular resistance should be consid-ered. If unavailable, an IV bolus of pros-tacyclin may be considered.

Knowledge GapsIs epinephrine harmful for resusci-tation of pediatric patients with pulmo-nary hypertension who are in pre-arrest states or cardiac arrest? Isexcessive ventilation of infants andchildren in prearrest states or car-diac arrest in the setting of pulmo-nary hypertension helpful or harmful?Does vasopressin improve outcomefor cardiac arrest in the setting of pul-monary hypertensive crisis? Is a pure�-agonist, such as isoproterenol, ef-fective or harmful during prearreststates or cardiac arrest associatedwith pulmonary hypertension? If usedearly in resuscitation, does the use ofECLS improve the outcome of the infantor child with pulmonary hypertension?

PROGNOSIS AND DECISION TOTERMINATE CPRPeds-060

Consensus on ScienceIn 1 LOE 3687 and 1 LOE 4688 study, sur-vival from in-hospital pediatric cardiacarrest in the 1980s was approximately9%. One LOE 1538 and 1 LOE 3 pediatricstudy689 showed that survival from in-hospital cardiac arrest in the early2000s was 16% to 18%. Three prognos-tic LOE 1 prospective observational pe-diatric studies from 2006537,690,691 re-ported that survival from in-hospitalcardiac arrest in 2006 was 26% to 27%.

One LOE 1 prospective study300 showedthat survival from all pediatric out-of-

hospital cardiac arrest was 6% com-pared with 5% for adults. Survival ininfants was 3%, and in children andadolescents survival was 9%. Thisstudy demonstrated that earlier poorsurvival rates were heavily influencedby poor infant survival (many of whomprobably had sudden infant death syn-drome and had probably been dead forsome time).

Thirteen (LOE 1300,301,537,538,690,692,693; LOE3577,687,694; LOE 4688,695,696) studies showedan association between several fac-tors and survival from cardiac arrest.These factors include duration of CPR,number of doses of epinephrine, age,witnessed versus unwitnessed car-diac arrest, obesity,697 and the first andsubsequent cardiac rhythm. Thirteenstudies (LOE 1300,645; LOE 2698; LOE3643,650,694,699–703; LOE 4704,705) showed anassociation between mortality andcauses of arrest such as submersionand trauma for out-of-hospital cardiacarrest. None of the associations re-ported in these studies allow predic-tion of outcome.

Treatment RecommendationsThere is insufficient evidence to allowa reliable prediction of success or fail-ure to achieve ROSC or survival fromcardiac arrest in infants and children.

Knowledge GapsAre there reliable prognostic factorsto guide decision making to terminateCPR in infants and children? Are therereliable clinical factors to predict neu-rologic outcome following resuscita-tion from cardiac arrest in infants andchildren?

ACKNOWLEDGMENTSWe thank the following individuals(the Pediatric Basic and Advanced LifeSupport Chapter Collaborators) fortheir collaborations on theworksheetscontained in this section: Ian Adatia;Richard P. Aickin; John Berger; JeffreyM. Berman; Desmond Bohn; Kate L.






Brown; Mark G. Coulthard; Douglas S.Diekema; Aaron Donoghue; JonathanDuff; Jonathan R. Egan; Christoph B.Eich; Diana G. Fendya; Ericka L. Fink;Loh Tsee Foong; Eugene B. Freid; SusanFuchs; Anne-Marie Guerguerian; Brad-ford D. Harris; George M. Hoffman;

James S. Hutchison; Sharon B. Kinney;Sasa Kurosawa; Jesus Lopez-Herce;Sharon E. Mace; Ian Maconochie; Dun-canMacrae; Mioara D. Manole; BradleyS. Marino; Felipe Martinez; Reylon A.Meeks; Alfredo Misraji; Marilyn Morris;AkiraNishisaki;MasahikoNitta; Gabrielle

Nuthall; Sergio Pesutic Perez; Lester T.Proctor; Faiqa A. Qureshi; Sergio Ren-dich; Ricardo A. Samson; Kennith Sar-torelli; Stephen M. Schexnayder; WilliamScott; Vijay Srinivasan; Robert M. Sutton;Mark Terry; Shane Tibby; Alexis Topjian;Elise W. van der Jagt; and David Wessel.

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661. Raymond TT, Cunnyngham CB, ThompsonMT, Thomas JA, Dalton HJ, Nadkarni VM.Outcomes among neonates, infants, andchildren after extracorporeal cardiopul-monary resuscitation for refractory inhos-pital pediatric cardiac arrest: a reportfrom the National Registry of Cardiopul-monary Resuscitation. Pediatr Crit CareMed. 2010;11:362–371

662. Tajik M, Cardarelli MG. Extracorporealmembrane oxygenation after cardiac ar-rest in children: what do we know? EurJ Cardiothorac Surg. 2008;33:409–417

663. Booth KL, Roth SJ, Thiagarajan RR, Almodo-var MC, del Nido PJ, Laussen PC. Extracor-poreal membrane oxygenation support ofthe Fontan and bidirectional Glenn circula-tions. Ann Thorac Surg. 2004;77:1341–1348

664. Tewari P, Babu SG. Resuscitation aftermodified Fontan procedure. Ann ThoracSurg. 1994;58:880–882

665. Hoskote A, Li J, Hickey C, Erickson S, VanArsdell G, Stephens D, Holtby H, Bohn D,Adatia I. The effects of carbon dioxide onoxygenation and systemic, cerebral, andpulmonary vascular hemodynamics afterthe bidirectional superior cavopulmonaryanastomosis. J Am Coll Cardiol. 2004;44:1501–1509

666. Li J, Hoskote A, Hickey C, Stephens D, BohnD, Holtby H, Van Arsdell G, Redington AN,Adatia I. Effect of carbon dioxide on sys-temic oxygenation, oxygen consumption,and blood lactate levels after bidirectionalsuperior cavopulmonary anastomosis.Crit Care Med. 2005;33:984–989

667. Fogel MA, Durning S, Wernovsky G, PollockAN, Gaynor JW, Nicolson S. Brain versuslung: hierarchy of feedback loops in single-ventricle patients with superior cavopul-monary connection. Circulation. 2004;110:II147–152

668. Bradley SM, Simsic JM, Mulvihill DM. Hy-poventilation improves oxygenation after

bidirectional superior cavopulmonaryconnection. J Thorac Cardiovasc Surg.2003;126:1033–1039

669. Bradley SM, Simsic JM, Mulvihill DM. Hy-perventilation impairs oxygenation afterbidirectional superior cavopulmonaryconnection. Circulation. 1998;98:II372–376;discussion II376–377

670. Mott AR, Alomrani A, Tortoriello TA, PerlesZ, East DL, Stayer SA. Changes in cerebralsaturation profile in response to mechan-ical ventilation alterations in infants withbidirectional superior cavopulmonaryconnection. Pediatr Crit Care Med. 2006;7:346–350

671. Shekerdemian LS, Shore DF, Lincoln C,Bush A, Redington AN. Negative-pressureventilation improves cardiac output afterright heart surgery. Circulation. 1996;94:II49–55

672. Shekerdemian LS, Bush A, Shore DF, Lin-coln C, Redington AN. Cardiopulmonaryinteractions after Fontan operations: aug-mentation of cardiac output using nega-tive pressure ventilation. Circulation.1997;96:3934–3942

673. Meliones JN, Bove EL, Dekeon MK, CusterJR, Moler FW, Callow LR, Wilton NC, RosenDB. High-frequency jet ventilation im-proves cardiac function after the Fontanprocedure. Circulation. 1991;84:III364–368

674. Kornecki A, Shekerdemian LS, Adatia I,Bohn D. High-frequency oscillation in chil-dren after Fontan operation. Pediatr CritCare Med. 2002;3:144–147

675. Burrows FA. Physiologic dead space, ve-nous admixture, and the arterial to end-tidal carbon dioxide difference in infantsand children undergoing cardiac surgery.Anesthesiology. 1989;70:219–225

676. Polderman FN, Cohen J, Blom NA, DelhaasT, Helbing WA, Lam J, Sobotka-Plojhar MA,Temmerman AM, SreeramN. Sudden unex-pected death in children with a previouslydiagnosed cardiovascular disorder. IntJ Cardiol. 2004;95:171–176

677. Sanatani S, Wilson G, Smith CR, HamiltonRM, Williams WG, Adatia I. Sudden unex-pected death in children with heart dis-ease. Congenit Heart Dis. 2006;1:89–97

678. Hoeper MM, Galie N, Murali S, OlschewskiH, Rubenfire M, Robbins IM, Farber HW,McLaughlin V, Shapiro S, Pepke-Zaba J,Winkler J, Ewert R, Opitz C, Westerkamp V,Vachiery JL, Torbicki A, Behr J, Barst RJ.Outcome after cardiopulmonary resusci-tation in patients with pulmonary arterialhypertension. Am J Respir Crit Care Med.2002;165:341–344

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Laks H, Esmailian F, Marelli D, Beygui R,Shemin R, Watson L, Vartapetian I, ArdehaliA. A prospective, randomized, crossoverpilot study of inhaled nitric oxide versusinhaled prostacyclin in heart transplantand lung transplant recipients. J ThoracCardiovasc Surg. 2009;138:1417–1424

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681. Limsuwan A, Wanitkul S, Khosithset A, At-tanavanich S, Samankatiwat P. Aerosol-ized iloprost for postoperative pulmonaryhypertensive crisis in children with con-genital heart disease. Int J Cardiol. 2008;129:333–338

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686. Arpesella G, Loforte A, Mikus E, Mikus PM.Extracorporeal membrane oxygenation

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691. Tibballs J, Kinney S. A prospective study ofoutcome of in-patient paediatric cardio-pulmonary arrest. Resuscitation. 2006;71:310–318

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DISCLOSURES

CoSTR Part 10: Writing Group Disclosures

Writing Group

Member

Employment Research Grant Other

Research

Support

Speakers’ Bureau/

Honoraria

Ownership

Interest

Consultant/Advisory

Board

Other

Monica E.

Kleinman

Children’s Hospital Anesthesia

Foundation: Non-profit

organization—Senior Associate in

Critical Care Medicine

None None None None None None

Allan R. de

Caen

Self-employed, Clinical Associate

Professor Pediatric Critical Care

Medicine, Stollery Children’s

Hospital/University of Alberta

None None None None None *Medical Expert for the Canadian

Medical Protective Association

Leon

Chameides

Emeritus Director, Pediatric

Cardiology, Connecticut Children’s

Medical Center; Clinical Professor,

University of Connecticut


Dianne L.

Atkins

University of Iowa: Medical

School—Professor †Serving as a

Worksheet editor for 2010

Guidelines Process. Compensation

is paid partially to my institution

(66%) and partially to me (34%).

The salary from my institution is

not altered by this

None None None None None *Serving as a defense expert witness

in a case of ventricular fibrillation in a

2 year old child. Compensation is paid

directly to me

Robert A.

Berg

U of Pennsylvania—Professor None None None None None None

Marc D. Berg University of Arizona—Assoc. Prof.

Clinical Pediatrics; Attending

Physician’s Healthcare (UPH): Also

serve on the UPH Board of

Directors—Intensivist, Pediatric

Critical Care Medicine


Farhan Bhanji Montreal Children’s Hospital,

McGill University—Assistant

Professor of Pediatrics


Dominique

Biarent

Hôpital Universitaire des Enfants

reine Fabiola: PICU Director

None None None None None *Medical expert consultant in one trial

for an insurance co. (Fortis) Medical

expert for legal proceedings

†grant of 25000 euro from �Fondation

Roi Baudoin� to the non profit

organization �sauvez mon enfant� for

a psychological research in the PICU (I

am administrator of the non profit

organization and promotor of

research). The grant is not given to

me but to the NPO Grant of 67500 euro

from the Belgian �Loterie Nationale� to

build a teaching lab to teach

paediatric resuscitation to health care

provider Grant given to the non profit

organization �sauvez mon enfant� for

psychological research in the PICU (I

am administrator of the non profit

organization and promotor of the

research) the grant is not given to me

but to the NPO Grant from Baxter

Foundation to pay a psychologist in my

PICU (44.540 $) the grant is paid to the

NPO

Robert

Bingham

National Health Service of

England—Consultant paediatric

anaesthetist

None None None None None *Occasional expert witness reports on

pediatric resuscitation related topics

(Continued)




CoSTR Part 10: Writing Group Disclosures, ContinuedWriting Group

Member

Employment Research Grant Other

Research

Support

Speakers’ Bureau/

Honoraria

Ownership

Interest

Consultant/Advisory

Board

Other

Ashraf

Coovadia

Rahima Moosa Mother and Child

Hospital: Paediatric Consultant

(Attending) in Department of

Paediatrics and Child Health—

Adjunct Professor in Paediatrics


Mary Fran

Hazinski

Vanderbilt University School of

Nursing—Prof; AHA ECC Product

Dev.—Senior Science Editor. I

receive significant compensation†

from the AHA as consultant/ SSE to

provide protected time to serve as

the co-editor of the 2010 ILCOR

CoSTR and the 2010 AHA Guidelines

for CPR and ECC


Robert W.

Hickey

University of

Pittsburgh—Associate Professor

†Salary support from

NIH for examining

cyclopentenone prosta-

glandin effects in ische-

mic brain injury

None None None None *1–2 X/year medical malpractice

expert

Vinay M.

Nadkarni

University of Pennsylvania School

of Medicine, Children’s Hospital of

Philadelphia: Non-profit, Academic,

University Hospital—Attending

Physician, Anesthesia, Critical Care

and Pediatrics

†NIH RO1: Therapeutic

Hypothermia after

Cardiac Arrest, Co-

Investigator. †Center of

Excellence Grant, Laerdal

Foundation for Acute

Care Medicine, PI:

Understanding the

mechanics and quality of

CPR

*NHTSA: Mechanics of

Chest Compression in

children, Co-Investigator

None None None None None

Amelia Reis Hospital das Clinico Universidade

de Sao Paulo, Pediatric Emergency

Physician


Antonio

Rodriguez-

Nunez

Hospital Clinico Universitario de

Santiago de

Compostela—Pediatric Emergency

and Critical Care Division;

University of Santiago de

Compostela—Associate Professor

of Pediatrics


James

Tibballs

Royal Children’s Hospital,

Melbourne Healthcare, Physician

ICU


Arno L.

Zaritsky

Children’s Hospital of The King’s

Daughters—Sr. VP for Clinical

Services

None None None None *Data Safety Monitoring

Board for NIH-

sponsored trial of

therapeutic

hypothermia after

pediatric cardiac arrest

None

David

Zideman

Imperial College NHS Trust: United

Kingdom Healthcare provider—

Consultant Anaesthetist; London

Organizing Committee of the

Olympic Games—Lead Clinician

for EMS

None None None None None *Expert testimony on Cardiac Arrest

under General Anaesthesis to Her

Majesty’s Coroner for Surrey (Expert

witness fee for case review and court

appearance) less than 1500 US dollars

This table represents the relationships of writing groupmembers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire,which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-monthperiod, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of theentity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.*Modest.†Significant.


CoSTR Part 10: Worksheet Collaborator DisclosuresWorksheet

Collaborator

Employment Research Grant Other Research Support Speakers’ Bureau/Honoraria Ownership

Interest

Consultant/Advisory Board Other

Ian Adatia University of Alberta and Alberta Health

Services; Professor Pediatrics, Director

Pediatric Cardiac Critical Care Program

and Pulmonary Hypertension Clinic


Richard P.

Aickin

Auckland District Health Board Government

Funded Healthcare Provider (primary care

through to tertiary hospital services) for

Auckland population and for national

tertiary services. Director of Child Health

None None None None *New Zealand Health and

Disability Commission:

occasional expert reports

provided with respect to

alleged breaches of

healthcare standards. 1–2

reports per year. Small

personal payment received

*Expert Witness:

Occasional expert

testimony for Coroner’s

Court and criminal (Child

protection) cases.

Approx 1� year. No

personal payment—

small payment to

Auckland District Health

Board for my time

John Berger Children’s National Medical Center Non-

profit children’s hospital Medical Director,

Cardiac Intensive Care and Pulmonary

Hypertension

†5 U 10 HD 049981—DL Wessel (PI) 12/1/

09/–11/30/14 Sponsor: NIH/NICHD/NCMRR

Pediatric Critical Care Research Network

The major aims of the network are to

reduce morbidity and mortality in pediatric

critical illness and injury, and to provide a

framework for the development of the

scientific basis of pediatric critical care

practice. I am responsible for conduct of

network approved studies at CNMC. As a

member of the network steering committee,

I am responsible for contributing to design

of studies, analyzing results and

disseminating research findings. Grant

money comes to institution.

Role: Co-Investigator

*Therapeutic Hypothermia after Pediatric

Cardiac Arrest (THAPCA) Trials. PI:JT Berger

2009

Sponsor: of Michigan

I am the site PI for the conduct of a

randomized trial of therapeutic

hypothermia in children who have had a

cardiac arrest funded by NHLBI. Money

comes to the institution.

Role: Consortium Site PI

*Tracking Outcomes and Practice in

Pediatric Pulmonary Hypertension. PI: JT

Berger. 2008

Sponsor: Association in Pediatric Pulmo-

nary Hypertension

I am the site PI responsible for contributing

subject data to a registry of pediatric pul-

monary hypertension patients and their

therapy

Role: Site PI


Jeffrey M.

Berman

University of North Carolina:Faculty

member UNC School of

Medicine—Professor of Anesthesiology


Desmond

Bohn

The Hospital for Sick Children, Toronto—

Chief, Department of Critical Care Medicine


Kate L.

Brown

Great Ormond Street Hospital for Children

NHS Trust Hospital consultant in paediatric

intensive care Consultant paediatric

cardiac intensive care


Mark G.

Coulthard

Queensland Health: State Health Employer

Organisation—Paediatric Intensive Care

Specialist


Douglas S.

Diekema

Children’s University Medical Group:

Delivery of medical care in Children’s

Hospital of Seattle and the University of

Washington—Professor of Pediatrics,

Attending Physician, Emergency

Department


(Continued)




CoSTR Part 10: Worksheet Collaborator Disclosures, ContinuedWorksheet

Collaborator


Interest


Aaron

Donoghue

University of Pennsylvania—Assistant

Professor


Jonathan

Duff

Alberta Health Services: Pediatric

Intensivist


Jonathan R.

Egan

The Children’s hospital at Westmead,

Sydney—Pediatric Intensivist


Christoph B.

Eich

University Medical Centre of Göttingen,

Germany: Attending Anesthesiologist,

Intensivist and Emergency Physician


Diana G.

Fendya

Children’s National Medical Center, EMSC

National Resource Center; Trauma/Acute

Care Nursing Specialist


Ericka L. Fink Children’s Hospital of Pittsburgh of

UPMC—Assistant Professor

†P.I., K23 from NINDS Duration of

Hypothermia for Neuroprotection after

Pediatric Cardiac Arrest Institution P.I.,

Laerdal Foundation grant $21,365 Same

topic Institution

*Children’s Hospital of Pittsburgh of UPMC

Clinical and Translational Science Institute

$6500 Same topic Institution


Loh Tsee

Foong

KK Women’s and Children’s Hospital None None None None None None

Eugene B.

Freid

Nemours Children’s Clinics Health Care

Organization Staff Anesthesiologist and

Intensivist

University of Florida Jacksonville Health

Care Organization Pediatric Intensivist

None None *University of North

Carolina—Speaker at

Anesthesiology Refresher

Course. 1000–1500/year

honorarium sent to

institution

None None None

Susan Fuchs Children’s Memorial Hospital-Assoc

Director, Div Pediatric Emergency Medicine

None None None None None *Currently on the

American Academy of

Pediatrics Advanced

Pediatric Life Support

Steering Committee and

Currently Co-chairperson

of the AAP Pediatric

Education for

Prehospital Professional

(PEPP) steering

committee

Anne-Marie

Guerguerian

The Hospital for Sick Children; Staff

Physician


Bradford D.

Harris

UNC at Chapel Hill; Assist Prof †5 P01 AT002620–02 (Peden) 09/30/04–06/

30/09 5% NIH/NCCAM $1,660,813 Annual

Direct Translational Research Center for

CAM Therapy of Asthma The objective of this

research is to identify antioxidant

complementary and alternative medicine

therapies for application in asthma. 5 RO1

ES012706–02 (Peden) 09/01/04–07/31/09

5% NIH/NIEHS $ 209,314 O3 and LPS-Induced

Airway Inflammation in Humans in vivo The

objective is to test three hypotheses to

define the ways that O3 and LPS interact to

exacerbate airway disease. 5 R01

HL080337–02 (Peden) 05/06/05–04/30/09

5% NIH NHLBI/NIAID $350,000 Airway Biology

of Acute Asthma: Translational Studies The

major goal is to determine if asthma

exacerbation and allergen challenge models

allow for examination of innate/acquired

immune interactions. R82952201

Cooperative Agreement (Bromberg) 11/01/

01–10/31/06 5% U.S. Environmental

Protection Agency $1,583,867 Health Effects

of Exposure to Air Pollutants in Humans The

major goal of this cooperative agreement is

to examine the health effects of inhalation

of environmental ambient air pollutants on

human subjects

None *Assoc Clinical Research

Professor on peds pharm

None None None

(Continued)



Collaborator


Interest


George M.

Hoffman

Medical College of Wisconsin medical

school Professor, Anesthesiology and

Pediatrics

�View Children’s Hospital of Wisconsin

hospital Medical Director, Pediatric

Anesthesiology

None None *Somanetics, Inc biomedical

device manufacturer 1653

East Maple Road Troy, MI

48083-4208 i have informally

served in

consultant/advisory capacity

and have received honoraria

for speaking

None *Edwards Life Sciences, Inc

biomedical device

manufacturer One

Edwards Way Irvine, CA

92614 i have served

informally in consultant/

advisory capacity

*Masimo, Inc biomedical

device manufacturer 2852

Kelvin Ave. Irvine, CA, 92614

i have served informally in

consultant/advisory

capacity

None

James S.

Hutchison

SickKIds Hospital Director Neurocritical

Care


Sharon B.

Kinney

University of Melbourne and Royal

Children’s Hospital Melbourne—Lecturer

and MET Coordinator


Sasa

Kurosawa

Shizuoka Children’s Hospital Depertoment

of Pediatric Emergency & General

Pediatrics Doctor

National Center for Child Health &

Development Department of Health Policy,

Research Institution researcher


Jesús López-

Herce

Hospital General Universitario Gregorio

Marañón—Pediatric Assistant


Sharon E.

Mace

Clerveland Clinic—Physician employed

fulltime by the hospital; Attending staff

physician

None None *Baxter Healthcare

Pharmaceutical Speaker

Bureau

None *Baxter Healthcare

Pharmaceutical Consul-

tant, Advisory Board

None

Ian

Maconochie

Imperial Academic Health Sciences Centre,

London: I run the pediatric emergency

medicine department at St Mary’s Hospital

in Paddington, London—Lead Consultant in

Pediatric Emergency medicine

None *Postal for survey of UK

departments about use

of pain relief from

Therakind, a company

looking to obtain license

for use of commonly

used drugs from the

medical regulatory

authority in UK.

Estimated payment was

about 150 pounds

sterling

None None *I am a deputy editor for

The Emergency Medicine

Journal, a commissioning

editor for the Archives of

Diseases of Childhood and

sit on the editorial

advisory panel for the

British Medical Journal. I

am editorial board

member for Current

Pediatric Reviews and

Pediatric Emergency

Medical Journal. The latter

2 I do not receive payment.

I act as a consultant

advisory to TSG associates

in relation to major

disaster management

systems. I have advised

Therakind on the licensing

of drugs in the pediatric

population., ie

approaching the medical

regulatory authority to

obtain a license on the use

of a commonly used drug

in the treatment of fitting

children in UK

*I have acted as an

expert witness in cases

relating to the

management of children

who may have had non

accidental injury.

Duncan

Macrae

The Royal Brompton and Harefield NHS

Foundation Trust—Director of Children’s

Services


Mioara D.

Manole

Univ of Pittsburgh: Ped Emerg. Medicine

attending physician; assist Prof Ped

NIH

K08HD58798-funds go to Univ Children’s

Hosp of Pitts RAC grant-funds to Univer.


Bradley S.

Marino

Cincinnati Children’s Hospital Medical

Center Associate Professor of Pediatrics


(Continued)





Collaborator


Interest


Felipe

Martinez

Universidad de Valparaíso—Professor None None None None None None

Reylon A.

Meeks

Blank Children’s Hospital, Pleasant Hill Fire

Dept., N Clinical Specialist


Alfredo

Misraji

Unidad Coronaria Movil None None None None None None

Marilyn

Morris

Columbia Univ; assist Prof Ped None None None None None *Expert witness $900 for

3 hour case for defense

of child that received

ECPR

Akira

Nishisaki

Children’s Hosp of Philadelphia, non profit

tertiary children’s hospital; attending MD

CCMedicine


Masahiko

Nitta

Osaka Medical College—Assistant

Professor


Gabrielle

Nuthall

Auckland District Health Board: Pediatric

Intensive Care Specialist


Sergio

Pesutic

Pérez

Centro de Formación en Apoyo Vital

Director


Lester T.

Proctor

University of Wisconsin-Madison College of

Medicine and Public Health—Professor


Faiqa A.

Qureshi

Children’s Specialty Group—Physician None None None None None None

Sergio

Rendich

Hospital Naval Almirante Nef—Pediatrician;

Hospital Gustavo Fricke; Pediatrician—

Intensive Care Unit; Universidad de

Valparaíso Professor, Pediatrics

Clínica Las Condes Critical Patient Unit

Centro de Formación en Apoyo Vital;

Instructor, NRP


Ricardo A.

Samson

The University of Arizona: Faculty member

within the Department of Pediatrics Chief of

the Cardiology Section Provide clinical

care, teaching and research related to the

field of Pediatric Cardiology—Professor of

Pediatrics


Kennith

Sartorelli

University of Vermont Associate Professor

of Surgery


Stephen M.

Schexnayder

University of Arkansas for Medical

Sciences–College of Medicine: Physician -

Clinician Educator–Professor and Division

Chief: AHA Consultant

*Pharmacokinetics of pantoperazole in

pediatrics patients (Pediatric Pharmacology

Research Unit) Pharmacokinetics of

esomeprazole in pediatric patients (Astra

Zeneca)

None *Contemporary Forums

(Nursing conference)

Pediatric Clinics of North

America (guest editor)

None None *Expert witness in

various medicolegal

cases involving pediatric

critical care and

emergency medicine

William Scott UT Southwestern Medical

Center—Professor


Vijay

Srinivasan

Children’s Hospital of

Philadelphia—Attending Physician,

Pediatric Intensive Care Unit

*A Reproducible Method for Blood Glucose

Control in Critically Ill Children (RC1 sub

contract with Inter Mountain Medical

Center, PI: Alan Morris), site PI: Vijay

Srinivasan—submitted for NIH Challenge

Grants July 2009, approval pending

*PI: A Novel Application

of Impedance Threshold

Device technologies to

optimize Fluid Removal

during Hemodialysis in

Children (unfunded

research at CHOP—IRB

Research Protocol No:

2007–12-5712)—have

received impedance

threshold devices for

this study from

Advanced Circulatory

Systems, Inc,

EdenPrairieMN

None None None None

Robert M.

Sutton

The Children’s Hospital of Philadelphia

Critical Care Attending

*Unrestricted research grant support from

the Laerdal Foundation for Acute Care

Medicine


Mark Terry Johnson County Med-Act: County

government ambulance service—Deputy

Chief Operations


(Continued)



Collaborator


Interest


Shane Tibby Guy’s and St Thomas’ NHS Foundation Trust,

London National Health Service Hospital

trust in United Kingdom Consultant in

Pediatric Intensive Care


Alexis

Topjian

The Children’s Hospital of Philadelphia—

attending physician

*site PI for the Therapeutic hypothermia

after cardiac arrest study. NIH funded

study. Money goes to the institution


Elise W. van

der Jagt

University of Rochester: Academic

Institution including Medical

School/Center—Professor of Pediatrics

and Critical Care

†Project Title: Therapeutic Hypothermia

After Pediatric Cardiac Arrest (THAPCA)

Trials PI: Frank W. Moler, M.D. (University of

Michigan) Proposed project period: 7/1/

2009–6/30/2014 We are part of this multi-

institutional grant but after the grant was

funded, the initial institutions that would be

involved were the higher volume/larger

children’s hospitals. At this time we are not

receiving any funding from this grant.*PI

andCo-Investigator/Site


David Wessel Children’s National Medical Center Senior

Vice President

None None None None †IKARIA Holdings Inc.

Pharmaceutical Consultant

None

This table represents the relationships of worksheet collaborators thatmay be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire,which all worksheet collaborators are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-monthperiod, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of theentity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.*Modest.†Significant.

APPENDIXCoSTR Part 10: Worksheet AppendixTask Force WS ID PICO Title Short Title Authors URL

Peds Peds-001A In infants (�1 year, not including newly born) in cardiac arrest

(prehospital [OHCA], in-hospital [IHCA]) (P), does the use of AEDs (I)

compared with standard management (which does not include use of

AEDs) (C), improve outcomes (eg. termination of rhythm, ROSC, survival)

(O)?

AEDs in children less

than 1 yr

Reylon A. Meeks http://circ.ahajournals.org/site/C2010/Peds-001A.pdf

Peds Peds-001B In infants (�1 year, not including newly born) in cardiac arrest

(prehospital [OHCA], in-hospital [IHCA]) (P), does the use of AEDs (I)

compared with standard management (which does not include use of

AEDs) (C), improve outcomes (eg. termination of rhythm, ROSC, survival)

(O)?

AEDs in children less

than 1 yr

Antonio Rodriguez-

Nunez


Peds Peds-002A For infants and children in cardiac arrest, does the use of a pulse check (I)

vs. assessment for signs of life (C) improve the accuracy of diagnosis of

pediatric CPA (O)?

Pulse check accuracy Aaron Donoghue,

James Tibballs


Peds Peds-003 During cardiac arrest in infants or children (P), does the presence of

family members during the resuscitation (I) compared to their absence (C)

improve patient or family outcome measures (O)?

Family presence Douglas S. Diekema http://circ.ahajournals.org/site/C2010/Peds-003.pdf

Peds Peds-004 In infants and children with respiratory failure who undergo endotracheal

intubation (prehospital [OHCA], in-hospital [IHCA]) (P), does the use of

devices (eg. CO2 detection device, CO2 analyzer or esophageal detector

device) (I) compared with usual management (C), improve the accuracy of

diagnosis of airway placement (O)?

Verification of airway

placement

Diana G. Fendya,

Monica Kleinman


Peds Peds-005A In pediatric patients with cardiac arrest (prehospital [OHCA] or in-hospital

[IHCA]) (P), does the use of end-tidal CO2 (I), compared with clinical

assessment (C), improve accuracy of diagnosis of a perfusing rhythm (O)?

End-tidal CO2 to

diagnose perfusing

rhythm

Arno Zaritsky http://circ.ahajournals.org/site/C2010/Peds-005A.pdf

Peds Peds-005B In pediatric patients with cardiac arrest (prehospital [OHCA] or in-hospital

[IHCA]) (P), does the use of end-tidal CO2 (I), compared with clinical

assessment (C), improve accuracy of diagnosis of a perfusing rhythm (O)?

End-tidal CO2 to

diagnose perfusing

rhythm

Anne-Marie

Guerguerian


Peds Peds-006B In pediatric patients in clinical cardiac arrest (prehospital [OHCA] or in

hospital [IHCA]) (P), does the use of a focused echocardiogram (I)

compared with standard assessment, assist in the diagnosis of reversible

causes of cardiac arrest?

Methods to diagnose

perfusing rhythm

Christoph B. Eich,

Faiqa A. Qureshi


Peds Peds-007 In children requiring emergent intubation (prehospital, in-hospital) (P),

does the use of cuffed ETTs (I) compared with uncuffed ETTs (C) improve

therapeutic endpoints (eg, oxygenation and ventilation) or reduce

morbidity or risk of complications (eg, need for tube change, airway injury,

aspiration) (O)?

Cuffed vs uncuffed

ETTs

Ashraf Coovadia http://circ.ahajournals.org/site/C2010/Peds-007.pdf

(Continued)




CoSTR Part 10: Worksheet Appendix, ContinuedTask Force WS ID PICO Title Short Title Authors URL

Peds Peds-008 In children requiring assisted ventilation (prehospital, in-hospital) (P), doesthe use of bag-valve-mask (I) compared with endotracheal intubation (C)improve therapeutic endpoints (oxygenation and ventilation), reduce

morbidity or risk of complications (eg, aspiration), or improve survival (O)?

BVM vs intubation Dominique Biarent http://circ.ahajournals.org/site/C2010/Peds-008.pdf

Peds Peds-009 In pediatric patients in cardiac arrest (prehospital [OHCA] or in-hospital[IHCA]) (P), does the use of supraglottic airway devices (I) compared withbag-valve-mask alone (C), improve therapeutic endpoints (eg, ventilationand oxygenation), improve quality of resuscitation (eg, reduce hands-offtime, allow for continuous compressions), reduce morbidity or risk of

complications (eg, aspiration) or improve survival (O)?

Supraglottic airwaydevices

Robert Bingham http://circ.ahajournals.org/site/C2010/Peds-009.pdf

Peds Peds-010A For infants and children who have ROSC after cardiac arrest (P), does theuse of induced hypothermia (I) compared with normothermia (C) improveoutcome (survival to discharge, survival with good neurologic outcome)

(O)?

Induced hypothermiaafter ROSC

Robert Hickey http://circ.ahajournals.org/site/C2010/Peds-010A.pdf

Peds Peds-010B For infants and children who have ROSC after cardiac arrest (P), does theuse of induced hypothermia (I) compared with normothermia (C) improveoutcome (survival to discharge, survival with good neurologic outcome)

(O)?

Induced hypothermiaafter ROSC

James S. Hutchison http://circ.ahajournals.org/site/C2010/Peds-010B.pdf

Peds Peds-011B In infants and children with cardiac arrest from a non-asphyxial orasphyxial cause (excluding newborns) (prehospital [OHCA] or in-hospital[IHCA]) (P), does the use of another specific C:V ratio by laypersons andHCPs (I) compared with standard care (15:2) (C), improve outcome (eg,

ROSC, survival) (O)?

Compressionventilation ratio

Robert Bingham,Robert Hickey


Peds Peds-012A In infants and children (not including newborns) with cardiac arrest (out-of-hospital and in-hospital) (P), does the use of compression-only CPR (I) asopposed to standard CPR (ventilations and compressions) (C), improve

outcome (O) (eg, ROSC, survival)?

Compression onlyCPR

Robert A. Berg,Dominique Biarent


Peds Peds-013A In pediatric patients with cardiac arrest (prehospital [OHCA] or in-hospital[IHCA]) and a secure airway (P), does the use of a specific minute

ventilation (combination of respiratory rate and tidal volume) depending onthe etiology of the arrest (I) as opposed to standard care (8–10

asynchronous breaths per minute) (C), improve outcome (O) (eg. ROSC,survival)?

Etiology specificminute ventilation

Monica Kleinman http://circ.ahajournals.org/site/C2010/Peds-013A.pdf

Peds Peds-013B In pediatric patients with cardiac arrest (prehospital [OHCA] or in-hospital[IHCA]) and a secure airway (P), does the use of a specific minute

ventilation (combination of respiratory rate and tidal volume) depending onthe etiology of the arrest (I) as opposed to standard care (8–10

asynchronous breaths per minute) (C), improve outcome (O) (eg. ROSC,survival)?

Etiology specificminute ventilation

Naoki Shimizu http://circ.ahajournals.org/site/C2010/Peds-013A.pdf

Peds Peds-014 In pediatric patients in cardiac arrest (prehospital [OHCA] or in-hospital[IHCA]) (P) does the use of rapid deployment ECMO or emergency cardiopul-monary bypass (I), compared with standard treatment (C), improveoutcome (ROSC, survival to hospital discharge, survival with favorable

neurologic outcomes) (O)?”

ECMO Marilyn Morris http://circ.ahajournals.org/site/C2010/Peds-014.pdf

Peds Peds-014B In pediatric patients in cardiac arrest (prehospital [OHCA] or in-hospital[IHCA]) (P) does the use of rapid deployment ECMO or emergency cardiopul-monary bypass (I), compared with standard treatment (C), improveoutcome (ROSC, survival to hospital discharge, survival with favorable

neurologic outcomes) (O)?

ECMO Kate L. Brown http://circ.ahajournals.org/site/C2010/Peds-014B.pdf

Peds Peds-015 In pediatric patients in cardiac arrest, associated with or without asphyxia(prehospital [OHCA] or in-hospital [IHCA]) (P) does ventilation with aspecific oxygen concentration (room air or a titrated concentrationbetween 0.21 and 1.0) (I), compared with standard treatment (100%oxygen) (C), improve outcome (ROSC, survival to hospital discharge,

survival with favorable neurologic outcome) (O)?

Titrated oxygen vs100% oxygen

Robert Hickey http://circ.ahajournals.org/site/C2010/Peds-015.pdf

Peds Peds-016 In infants and children with ROSC after cardiac arrest (prehospital or in-hospital) (P), does the use of a specific strategy to manage blood glucose(eg. target range) (I) as opposed to standard care (C), improve outcome (O)

(eg. survival)?

Glucose controlfollowingresuscitation

Duncan Macrae,Vijay Srinivasan


Peds Peds-017B In pediatric patients with cardiac arrest (pre-hospital [OHCA] or in-hospital[IHCA]) (P), does the use of any specific alternative method for calculatingdrug dosages (I) compared with standard weight-based dosing (C), improveoutcome (eg, achieving expected drug effect, ROSC, survival, avoidance of

toxicity) (O)?

Methods forcalculating drugdosages

Ian Maconochie,Vijay Srinivasan


Peds Peds-018 In adult and pediatric patients with cardiac arrest (pre-hospital [OHCA] orin-hospital [IHCA) (P), does the use of any specific alternative dosing

regimen for epinephrine (I) compared with standard recommendations (C),improve outcome (eg. ROSC, survival to hospital discharge, survival with

favorable neurologic outcome) (O)?

Epinephrine dose Amelia Reis http://circ.ahajournals.org/site/C2010/Peds-018.pdf

Peds Peds-019 In pediatric patients with cardiac arrest (pre-hospital [OHCA] or in-hospital[IHCA]) due to VF/pulseless VT (P), does the use of amiodarone (I)compared with lidocaine (C), improve outcome (eg, ROSC, survival tohospital discharge, survival with favorable neurologic outcome) (O)?

Amiodarone vslidocaine for VF/VT

Dianne L. Atkins http://circ.ahajournals.org/site/C2010/Peds-019.pdf

Peds Peds-020A In adult and pediatric patients with cardiac arrest (pre-hospital [OHCA] orin-hospital [IHCA]) (P), does the use of vasopressin or vasopressin� epi-nephrine (I) compared with standard treatment recommendations (C),improve outcome (eg, ROSC, survival to hospital discharge, or survival with


Vasopressin Elise W. van der Jagt http://circ.ahajournals.org/site/C2010/Peds-020A.pdf

(Continued)



Peds Peds-020B In adult and pediatric patients with cardiac arrest (pre-hospital [OHCA] orin-hospital [IHCA]) (P), does the use of vasopressin or vasopressin� epi-nephrine (I) compared with standard treatment recommendations (C),improve outcome (eg, ROSC, survival to hospital discharge, or survival with


Vasopressin Dominique Biarent http://circ.ahajournals.org/site/C2010/Peds-020B.pdf

Peds Peds-021A In pediatric patients with cardiac arrest (pre-hospital [OHCA] or in-hospital[IHCA]) (P), does the use of calcium (I) compared with no calcium (C),improve outcome (O) (eg. ROSC, survival to hospital discharge, survival

with favorable neurologic outcome)?

Calcium Allan de Caen http://circ.ahajournals.org/site/C2010/Peds-021A.pdf

Peds Peds-021B In pediatric patients with cardiac arrest (pre-hospital [OHCA] or in-hospital[IHCA]) (P), does the use of calcium (I) compared with no calcium (C),improve outcome (O) (eg. ROSC, survival to hospital discharge, survival

with favorable neurologic outcome)?

Calcium Felipe Martinez,Sergio Pesutic,Sergio Rendich


Peds Peds-022A In pediatric patients with cardiac arrest due to primary or secondary VF orpulseless VT (pre-hospital [OHCA] or in-hospital [IHCA]) (P), does the use ofmore than one shock for the initial or subsequent defibrillation attempt(s)(I), compared with standard management (C), improve outcome (eg.termination of rhythm, ROSC, survival to hospital discharge, survival with


Single or stackedshocks

Marc Berg http://circ.ahajournals.org/site/C2010/Peds-022A.pdf

Peds Peds-023A In pediatric patients with cardiac arrest due to primary or secondary VF orpulseless VT (pre-hospital [OHCA] or in-hospital [IHCA]) (P), does the use ofa specific energy dose or regimen of energy doses for the initial orsubsequent defibrillation attempt(s) (I), compared with standardmanagement (C), improve outcome (eg. termination of rhythm, ROSC,

survival to hospital discharge, survival with favorable neurologic outcome)(O)?

Energy doses Jonathan R. Egan http://circ.ahajournals.org/site/C2010/Peds-023A.pdf

Peds Peds-023B In pediatric patients with cardiac arrest due to primary or secondary VF orpulseless VT (pre-hospital [OHCA] or in-hospital [IHCA]) (P), does the use ofa specific energy dose or regimen of energy doses for the initial orsubsequent defibrillation attempt(s) (I), compared with standardmanagement (C), improve outcome (eg. termination of rhythm, ROSC,

survival to hospital discharge, survival with favorable neurologic outcome)(O)?

Energy doses Dianne L. Atkins http://circ.ahajournals.org/site/C2010/Peds-023B.pdf

Peds Peds-024A In pediatric patients with ROSC after cardiac arrest (pre-hospital [OHCA] orin-hospital [IHCA]) who have signs of cardiovascular dysfunction (P), doesthe use of any specific cardioactive drugs (I) as opposed to standard care(or different cardioactive drugs) (C), improve physiologic endpoints(oxygen delivery, hemodynamics) or patient outcome (eg, survival todischarge or survival with favorable neurologic outcome) (O)?

Cardioactive drugspost resuscitation

Allan de Caen http://circ.ahajournals.org/site/C2010/Peds-024A.pdf

Peds Peds-024B In pediatric patients with ROSC after cardiac arrest (pre-hospital [OHCA] orin-hospital [IHCA]) who have signs of cardiovascular dysfunction (P), doesthe use of any specific cardioactive drugs (I) as opposed to standard care(or different cardioactive drugs) (C), improve physiologic endpoints(oxygen delivery, hemodynamics) or patient outcome (eg, survival todischarge or survival with favorable neurologic outcome) (O)?

Cardioactive drugspost resuscitation

Mark G. Coulthard http://circ.ahajournals.org/site/C2010/Peds-024B.pdf

Peds Peds-025A In pediatric patients with in-hospital cardiac or respiratory arrest (P), doesuse of EWSS/response teams/MET systems (I) compared with no suchresponses (C), improve outcome (eg, reduce rate of cardiac and

respiratory arrests and in-hospital mortality) (O)?

METs Elise W. van der Jagt http://circ.ahajournals.org/site/C2010/Peds-025A.pdf

Peds Peds-025B In pediatric patients with in-hospital cardiac or respiratory arrest (P), doesuse of EWSS/response teams/MET systems (I) compared with no suchresponses (C), improve outcome (eg, reduce rate of cardiac and

respiratory arrests and in-hospital mortality) (O)?

METs James Tibballs http://circ.ahajournals.org/site/C2010/Peds-025B.pdf

Peds Peds-026A For intubated newborns within the first month of life (beyond the deliveryroom) who are receiving chest compressions (P), does the use of

continuous chest compressions (without pause for ventilation) (I) vs. chestcompressions with interruptions for ventilation (C) improve outcome (timeto sustained heart rate�100, survival to ICU admission, survival todischarge, survival with favorable neurologic status) (O)?

Continuous chestcompressions forintubated newbornsoutside of DR

Monica Kleinman http://circ.ahajournals.org/site/C2010/Peds-026A.pdf

Peds Peds-027A For newborns within the first month of life (beyond the delivery room) whoare not intubated and who are receiving CPR (P), does the use of a 3:1compression to ventilation ratio (I), compared with a 15:2 compression toventilation ratio (C) improve outcome (time to sustained heart rate�100,survival to ICU admission, survival to discharge, discharge with favorable

neurologic status) (O)?

3:1 vs 15:2 ratio forneonates outside of

DR

Leon Chameides http://circ.ahajournals.org/site/C2010/Peds-027A.pdf

Peds Peds-028 In pediatric patients with cardiac arrest (out-of-hospital and in-hospital)(including prolonged arrest states) (P), does the use of NaHCO3 (I)

compared with no NaHCO3 (C), improve outcome (O) (eg. ROSC, survival)?

Sodium bicarbonate Stephen M.Schexnayder


Peds Peds-029 In infants and children in cardiac arrest (prehospital [OHCA], in-hospital[IHCA]) (P), does the use of any specific paddle/pad size/orientation andposition (I) compared with standard resuscitation or other specific paddle/pad size/orientation and position) (C), improve outcomes (eg. successful

defibrillation, ROSC, survival) (O)?

Paddle size andplacement fordefibrillation

Dianne L. Atkins http://circ.ahajournals.org/site/C2010/Peds-029.pdf

(Continued)





Peds Peds-030 In infants and children with unstable ventricular tachycardia (pre-hospitaland in-hospital) (P), does the use of any drug/ combination of drugs/intervention (eg. cardioversion) (I) compared with no drugs/intervention(C) improve outcome (eg, termination of rhythm, survival) (O)?

Unstable VT Jeffrey M. Berman,Bradford D. Harris


Peds Peds-031 In infants and children with supraventricular tachycardia with a pulse (P),does the use of any drug or combination of drugs (I), compared with aden-osine (C), result in improved outcomes (termination of rhythm, survival)?

Drugs for SVT Ricardo A. Samson http://circ.ahajournals.org/site/C2010/Peds-031.pdf

Peds Peds-032 In infants and children with hemorrhagic shock following trauma (P), doesthe use of graded volume resuscitation (I) as opposed to standard care (C),

improve outcome (hemodynamics, survival) (O)?

Graded volumeresuscitation fortraumatic shock

Jesus Lopez-Herce http://circ.ahajournals.org/site/C2010/Peds-032.pdf

Peds Peds-033 In pediatric patients in cardiac arrest (prehospital [OHCA], in-hospital[IHCA]) (P), does the use of one hand chest compressions (I) comparedwith two hand chest compressions (C) improve outcomes (eg. ROSC,

rescuer performance) (O)?

One hand vs twohand compressions

Sharon B. Kinney http://circ.ahajournals.org/site/C2010/Peds-033.pdf

Peds Peds-034 In infants with cardiac arrest (prehospital [OHCA], in-hospital [IHCA]) (P),does the use of two-thumb chest compression without circumferentialsqueeze (I) compared to two-thumb chest compression withcircumferential squeeze (C) improve outcome (eg. ROSC, rescuer

performance (O)?

Circumferentialsqueeze for infant

CPR

James Tibballs http://circ.ahajournals.org/site/C2010/Peds-034.pdf

Peds Peds-035 In infants and children with cardiac arrest (P), does establishingintraosseous access (I) compared to establishing conventional (non-intraosseous) venous access (C) improve patient outcome (eg. ROSC,

survival to hospital discharge (O)?

IO vs IV Jonathan Duff http://circ.ahajournals.org/site/C2010/Peds-035.pdf

Peds Peds-036 In infants and children with cardiac arrest (P), does the use of trachealdrug delivery (I) compared to intravenous drug delivery (C) worsen patient

outcome (eg. ROSC, survival to hospital discharge (O)?

ET vs IV drugs Mioara D. Manole http://circ.ahajournals.org/site/C2010/Peds-036.pdf

Peds Peds-038B In infants and children in shock, does early intubation and assistedventilation compared to the use of these interventions only for associatedrespiratory failure lead to improved patient outcome (hemodynamics,

survival?)

Intubation for shock(timing)

Amelia Reis http://circ.ahajournals.org/site/C2010/Peds-038B.pdf

Peds Peds-039A In infants and children with respiratory failure who require emergentendotracheal intubation (P), does the use of cricoid pressure or laryngealmanipulation (I), when compared with standard practice (C), improve orworsen outcome (eg. success of intubation, aspiration risk, side effects,

etc) (O )?

Cricoid pressure andlaryngealmanipulation

Lester T. Proctor http://circ.ahajournals.org/site/C2010/Peds-039A.pdf

Peds Peds-039B In infants and children with respiratory failure who require emergentendotracheal intubation (P), does the use of cricoid pressure or laryngealmanipulation (I), when compared with standard practice (C), improve orworsen outcome (eg. success of intubation, aspiration risk, side effects,

etc) (O )?

Cricoid pressure andlaryngealmanipulation

Ian Maconochie http://circ.ahajournals.org/site/C2010/Peds-039B.pdf

Peds Peds-040A In infants and children in cardiac arrest (out-of-hospital and in-hospital)(P), does any specific compression depth (I) as opposed to standard care(ie. depth specified in treatment algorithm) (C), improve outcome (O) (eg.

Blood pressure, ROSC, survival)?

Compression depth Robert M. Sutton http://circ.ahajournals.org/site/C2010/Peds-040A.pdf

Peds Peds-040B In infants and children in cardiac arrest (out-of-hospital and in-hospital)(P), does any specific compression depth (I) as opposed to standard care(ie. depth specified in treatment algorithm) (C), improve outcome (O) (eg.

Blood pressure, ROSC, survival)?

Compression depth David Zideman http://circ.ahajournals.org/site/C2010/Peds-040B.pdf

Peds Peds-041A In children and infants with cardiac arrest due to major (blunt orpenetrating) injury (out-of-hospital and in-hospital) (P), does the use of anyspecific modifications to standard resuscitation (I) compared with

standard resuscitation (C), improve outcome (O) (eg. ROSC, survival)? eg.open vs closed chest CPR, other examples.

Traumatic arrest Kennith Sartorelli http://circ.ahajournals.org/site/C2010/Peds-041A.pdf

Peds Peds-041B In children and infants with cardiac arrest due to major (blunt orpenetrating) injury (out-of-hospital and in-hospital) (P), does the use of anyspecific modifications to standard resuscitation (I) compared with

standard resuscitation (C), improve outcome (O) (eg. ROSC, survival)? eg.open vs closed chest CPR, other examples.

Traumatic arrest Jesus Lopez-Herce http://circ.ahajournals.org/site/C2010/Peds-041B.pdf

Peds Peds-043A In infants and children in cardiac arrest (prehospital [OHCA], in-hospital[IHCA]) (P), does the use of self-adhesive defibrillation pads (I) comparedwith paddles (C), improve outcomes (eg. successful defibrillation, ROSC,

survival) (O)?

Hands offdefibrillation vspaddles

Mark Terry http://circ.ahajournals.org/site/C2010/Peds-043A.pdf

Peds Peds-043B In infants and children in cardiac arrest (prehospital [OHCA], in-hospital[IHCA]) (P), does the use of self-adhesive defibrillation pads (I) comparedwith paddles (C), improve outcomes (eg. successful defibrillation, ROSC,

survival) (O)?

Hands offdefibrillation vspaddles

Farhan Bhanji http://circ.ahajournals.org/site/C2010/Peds-043B.pdf

Peds Peds-044A In infants and children with any type of shock (P), does the use of anyspecific resuscitation fluid or combination of fluids [eg: isotonic crystalloid,colloid, hypertonic saline, blood products] (I) when compared with

standard care (C) improve patient outcome (hemodynamics, survival) (O)?

Resuscitation fluids Sharon E. Mace http://circ.ahajournals.org/site/C2010/Peds-044A.pdf

Peds Peds-044B In infants and children with any type of shock (P), does the use of anyspecific resuscitation fluid or combination of fluids [eg: isotonic crystalloid,colloid, hypertonic saline, blood products] (I) when compared with

standard care (C) improve patient outcome (hemodynamics, survival) (O)?

Resuscitation fluids Richard P. Aickin http://circ.ahajournals.org/site/C2010/Peds-044B.pdf

(Continued)



Peds Peds-045A In infants and children with distributive shock with and without myocardialdysfunction (P), does the use of any specific inotropic agent (I) when

compared to standard care (C), improve patient outcome (hemodynamics,survival) (O)?

Distributive shockand inotropes

Ericka L. Fink, AlfredoMisraji


Peds Peds-045B In infants and children with distributive shock with and without myocardialdysfunction (P), does the use of any specific inotropic agent (I) when

compared to standard care (C), improve patient outcome (hemodynamics,survival) (O)?

Distributive shockand inotropes

Loh Tsee Foong http://circ.ahajournals.org/site/C2010/Peds-045B.pdf

Peds Peds-046A In infants and children with cardiogenic shock (P), does the use of anyspecific inotropic agent (I) when compared with standard care (C),

improve patient outcome (hemodynamics, survival) (O)?

Cardiogenic shockand inotropes

Akira Nishisaki http://circ.ahajournals.org/site/C2010/Peds-046A.pdf

Peds Peds-047A In infants and children with hypotensive septic shock (P), does the use ofetomidate as an induction agent to facilitate intubation (I) compared with astandard technique without etomidate (C) improve patient outcome (hemo-

dynamics, survival) (O)?

Etomidate and septicshock

Stephen M.Schexnayder


Peds Peds-047B In infants and children with hypotensive septic shock (P), does the use ofetomidate as an induction agent to facilitate intubation (I) compared with astandard technique without etomidate (C) improve patient outcome (hemo-

dynamics, survival) (O)?

Etomidate and septicshock

Jonathan Duff http://circ.ahajournals.org/site/C2010/Peds-047B.pdf

Peds Peds-048A In infants and children who are undergoing resuscitation from cardiacarrest (P), does consideration of a channelopathy as the etiology of thearrest (I), as compared with standard management (C), improve outcome(ROSC, survival to discharge, survival with favorable neurologic outcome)

(O)?

Channelopathies Robert Hickey http://circ.ahajournals.org/site/C2010/Peds-048A.pdf

Peds Peds-048B In infants and children who are undergoing resuscitation from cardiacarrest (P), does consideration of a channelopathy as the etiology of thearrest (I), as compared with standard management (C), improve outcome(ROSC, survival to discharge, survival with favorable neurologic outcome)

(O)?

Channelopathies William Scott http://circ.ahajournals.org/site/C2010/Peds-048B.pdf

Peds Peds-049A In infants and children with hypotensive septic shock (P), does the use ofcorticosteroids in addition to standard care (I) when compare withstandard care without the use of corticosteroids (C), improve patient

outcome (eg. Hemodynamics or survival) (O)?

Corticosteroids andseptic shock

Arno Zaritsky http://circ.ahajournals.org/site/C2010/Peds-049A.pdf

Peds Peds-049B In infants and children with hypotensive septic shock (P), does the use ofcorticosteroids in addition to standard care (I) when compare withstandard care without the use of corticosteroids (C), improve patient

outcome (eg. Hemodynamics or survival) (O)?

Corticosteroids andseptic shock

Mark G. Coulthard http://circ.ahajournals.org/site/C2010/Peds-049B.pdf

Peds Peds-050A In infants and children with acute illness or injury (P), do specific diagnos-tic tests (laboratory data [mixed venous oxygen saturation, pH, lactate], (I)as opposed to clinical data (vital signs, capillary refill, mental status, end-organ function [urine output]) (C), increase the accuracy of diagnosis of

shock (O)?

Diagnostic tests forshock

Alexis Topjian http://circ.ahajournals.org/site/C2010/Peds-050A.pdf

Peds Peds-050B In infants and children with acute illness or injury (P), do specific diagnos-tic tests (laboratory data [mixed venous oxygen saturation, pH, lactate], (I)as opposed to clinical data (vital signs, capillary refill, mental status, end-organ function [urine output]) (C), increase the accuracy of diagnosis of

shock (O)?

Diagnostic tests forshock

Sharon B. Kinney http://circ.ahajournals.org/site/C2010/Peds-050B.pdf

Peds Peds-052A In infants and children with cardiac arrest or symptomatic bradycardiathat is unresponsive to oxygenation and/or ventilation (P), does the use ofatropine (I), as compared with epinephrine or no atropine (C), improvepatient outcome (return to age-appropriate heart rate, subsequent

pulseless arrest, ROSC, survival) (O)?

Atropine vs epineph-rine for bradycardia

Susan Fuchs, SasaKurosawa, Masahiko

Nitta


Peds Peds-055B For infants and children with Fontan or hemi-Fontan circulation whorequire resuscitation from cardiac arrest or pre-arrest states (prehospital[OHCA] or in-hospital [IHCA]) (P), does any specific modification to standardpractice (I) compared with standard resuscitation practice (C) improveoutcome (eg. ROSC, survival to discharge, survival with good neurologic

outcome (O)?

Resuscitation forhemi-Fontan/Fontancirculation

Desmond Bohn,Bradley S. Marino


Peds Peds-056A For infants and children in cardiac arrest with pulmonary hypertension(prehospital [OHCA] or in-hospital [IHCA]) (P), do any specific modificationsto resuscitation techniques (I) compared with standard resuscitationtechniques (C), improve outcome (ROSC, survival to discharge, favorable

neurologic survival) (O)?

Resuscitation of thepatient with pulmo-nary hypertension

Ian Adatia, JohnBerger, David Wessel


Peds Peds-057A For infants and children who require endotracheal intubation (prehospitalor in hospital) (P) does the use of a specific formula to guide cuffed

endotracheal tube size (I), as opposed to the use of the existing formula of3� age/4 (C), achieve better outcomes (eg. successful tube placement)

(O)?

Formula for cuffed ETtube size

Robert Bingham http://circ.ahajournals.org/site/C2010/Peds-057A.pdf

Peds Peds-057B For infants and children who require endotracheal intubation (prehospitalor in hospital) (P) does the use of a specific formula to guide cuffed

endotracheal tube size (I), as opposed to the use of the existing formula of3� age/4 (C), achieve better outcomes (eg. successful tube placement)

(O)?

Formulas forpredicting ET tube

size

Eugene B. Freid http://circ.ahajournals.org/site/C2010/Peds-057B.pdf

(Continued)





Peds Peds-059 For infants and children with single ventricle, s/p stage I repair whorequire resuscitation from cardiac arrest or pre-arrest states (prehospital[OHCA] or in-hospital [IHCA]) (P), does any specific modification to standardpractice (I) compared with standard resuscitation practice (C) improveoutcome (eg. ROSC, survival to discharge, survival with good neurologic

outcome) (O)?

Resuscitation of thepatient with singleventricle

George M. Hoffman,Shane Tibby


Peds Peds-060 For pediatric patients (in any setting (P), is there a clinical decision rule (I)that enables reliable prediction of ROSC (or futile resuscitation efforts)?

(PROGNOSIS)

Clinical decisionrules to predict ROSC

Gabrielle Nuthall http://circ.ahajournals.org/site/C2010/Peds-060.pdf


DOI: 10.1542/peds.2010-2972A; originally published online October 18, 2010; 2010;126;e1261Pediatrics

CHAPTER COLLABORATORSand on behalf of the PEDIATRIC BASIC AND ADVANCED LIFE SUPPORT

Reis, Antonio Rodriguez-Nunez, James Tibballs, Arno L. Zaritsky, David Zideman H. Coovadia, Mary Fran Hazinski, Robert W. Hickey, Vinay M. Nadkarni, Amelia G.A. Berg, Marc D. Berg, Farhan Bhanji, Dominique Biarent, Robert Bingham, Ashraf Monica E. Kleinman, Allan R. de Caen, Leon Chameides, Dianne L. Atkins, Robert

With Treatment RecommendationsCardiopulmonary Resuscitation and Emergency Cardiovascular Care Science Pediatric Basic and Advanced Life Support: 2010 International Consensus on

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DOI: 10.1542/peds.2010-2972A; originally published online October 18, 2010; 2010;126;e1261Pediatrics

CHAPTER COLLABORATORSand on behalf of the PEDIATRIC BASIC AND ADVANCED LIFE SUPPORT

Reis, Antonio Rodriguez-Nunez, James Tibballs, Arno L. Zaritsky, David Zideman H. Coovadia, Mary Fran Hazinski, Robert W. Hickey, Vinay M. Nadkarni, Amelia G.A. Berg, Marc D. Berg, Farhan Bhanji, Dominique Biarent, Robert Bingham, Ashraf Monica E. Kleinman, Allan R. de Caen, Leon Chameides, Dianne L. Atkins, Robert

With Treatment RecommendationsCardiopulmonary Resuscitation and Emergency Cardiovascular Care Science Pediatric Basic and Advanced Life Support: 2010 International Consensus on

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