Section

Updated Guidance

Previous Guidance

5.0

In infants and children who are unresponsive and breathing is absent (or agonal), healthcare providers should begin cardiopulmonary resuscitation (CPR).

In infants and children who are unresponsive and not breathing normally, healthcare providers should begin CPR unless they can definitely feel a pulse within 10 seconds.

9.1

ANZCOR suggest that external cardiac compression should be started while rescuers wait for a bag-mask ventilation (BMV) device to arrive. If a BMV device is immediately available, 2 initial ventilations should be provided before commencement of external cardiac compression.

ANZCOR suggest that two initial ventilations should be provided before commencement of external cardiac compressions because asphyxial causes are more common than cardiac causes in paediatric cardiorespiratory arrest. In circumstances where the usual equipment used to provide ventilations (e.g. BVM) is not immediately available, CPR should be commenced immediately with chest compressions.

9.2

ANZCOR suggest the use of BMV rather than endotracheal tube (ETT) or supraglottic airway (SGA) insertion in the management of children during cardiac arrest in the out-of-hospital setting. ANZCOR suggest that clinicians consider transitioning to an advanced airway intervention (SGA or ETT) when the team has sufficient expertise, resources, and equipment to allow SGA/ETT placement to occur with minimal interruptions to chest compressions or when BMV is not providing adequate oxygenation/ventilation.

ANZCOR suggest the use of BVM ventilation rather than ETT or SGA insertion in the management of children during cardiac arrest in the out-of-hospital setting.

9.5

ANZCOR suggest that cuffed tracheal tubes are used for emergency intubation of infants (>28 days and >3kg) and children. If cuffed tracheal tubes are used, avoid excessive cuff pressures.

ANZCOR suggest that both cuffed and uncuffed tracheal tubes are acceptable for use in infants and children undergoing emergency intubation.

9.7

ANZCOR suggest that, after placement of a secure airway, ventilation rates close to age-appropriate respiratory rates should be used, with avoidance of hypoventilation and hyperventilation. ANZCOR suggest a ventilation rate approximating 30 breaths/minute for infants and 25 breaths/minute for older children (>1 year).

ANZCOR suggest that, after placement of a secure airway, avoid hyperventilation of infants and children during resuscitation from cardiac arrest, whether asphyxial or arrhythmic in origin. A reduction in minute ventilation to less than baseline for age is reasonable to provide sufficient ventilation to maintain adequate ventilation-to-perfusion ratio during CPR while avoiding the harmful effects of hyperventilation.

10.2

ANZCOR suggest that chest compression for an infant be performed with the two-thumb encircling technique as it results in consistently greater chest compression depth and less fatigue. Chest compression for an infant using the heel of one hand may be considered if the rescuer is unable to achieve optimal compression depth using the two-thumb encircling technique.

Chest compression for an infant can be performed with the two-thumb technique or two-finger technique. The two-thumb technique is the strongly preferred technique for healthcare rescuers.

12.2

If hypovolaemia is suspected as the cause of cardiorespiratory arrest, intravenous (IV) or intraosseous (IO) crystalloid (e.g. 0.9% Sodium Chloride) may be used initially for resuscitation as a bolus of 10mL/kg.

If hypovolaemia is suspected as the cause of cardiorespiratory arrest, IV or IO crystalloid may be used initially for resuscitation as a bolus of 10 to 20mL/kg.

13.1

CPR providers using manual defibrillation in infants and children, place pads in an anterior-posterior position.

Pads allow chest compression to continue while charging, probably permit faster resumption of chest compression after delivery of a shock, may be safer and may allow easier use of an antero-posterior position which may be more efficacious than the standard antero-lateral positions of pads.

13.3

ANZCOR suggest a single-shock strategy followed by immediate CPR (beginning with chest compressions) for children with out-of-hospital cardiac arrest (OHCA) or in-hospital cardiac arrest (IHCA) with ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT).

Three stacked shocks may be considered when the onset of a shockable rhythm is witnessed (with monitoring) in special circumstances such as: 

·       In the cardiac catheter laboratory

·       In the ICU or cardiac ward post cardiac surgery

·       In other circumstances when a defibrillator is already attached.

16.3

ANZCOR suggest that end tidal carbon dioxide (ETCO₂) be considered as a part of cardiac arrest monitoring in infants and children to provide feedback on the quality of CPR and to help early identification of return of spontaneous circulation (ROSC).

A recommendation is still too speculative.

16.5

ANZCOR suggest targeting an intra-arrest diastolic blood pressure of ≥25 mmHg for infants <1 year and ≥30 mmHg for children 1 to 18 years when invasive blood pressure monitoring is in place at the time of cardiac arrest.

For children with IHCA and an arterial line already in place, hemodynamic-directed CPR may be considered but at present the confidence in effect estimates is so low that a recommendation is too speculative.

18.0

ANZCOR suggest that family members be provided with the option to be present during resuscitation from cardiac arrest

Policies or protocols about family presence during resuscitation should be developed to guide and support health care professional decision-making.

When implementing family presence procedures, healthcare providers should receive education about family presence during cardiac arrest resuscitation, including how to manage these stressful situations, family distress and their own responses to these situations.

ANZCOR suggest that family members of patients undergoing resuscitation should be given the option to be present, ideally with an assigned support person. Each healthcare institution should have a family presence policy and staff education strategy in place.

Section

Updated Guidance

Previous Guidance

1.0

ANZCOR suggests that infants and children with ROSC who have been resuscitated after cardiorespiratory arrest should be admitted to a facility with the necessary resources for post cardiac arrest care.

ANZCOR suggests that infants and children with ROSC who have been resuscitated after cardiorespiratory arrest should be admitted to a facility with the necessary resources for proper post-ROSC neuroprotective care, organ- and/or life supporting treatments, comprehensive neurological assessment and psychosocial support.

2.0

ANZCOR recommends that for infants and children after ROSC, a systolic or mean arterial blood pressure >10th percentile for age should be targeted.

ANZCOR recommends that for infants and children after ROSC, parenteral fluids and/or inotropes or vasopressors should be used to maintain a systolic blood pressure of at least greater than the fifth percentile for age.

3.0

ANZCOR suggests that rescuers measure partial pressure of arterial carbon dioxide (PaCO₂) after ROSC and target normocapnia. Consider adjustments to the target PaCO₂ for specific patient populations where normocapnia may not be desirable (e.g. chronic lung disease, congenital heart disease, increased intracranial pressure).

ANZCOR suggests that rescuers measure partial pressure of arterial oxygen (PaO₂) after ROSC and target a value appropriate to the specific patient condition and suggest rescuers target normoxemia after ROSC.

ANZCOR suggests that, to achieve normoxia, targeting an oxygen saturation of 94 to 99% may be a reasonable alternative to measuring PaO₂.

ANZCOR suggests that rescuers measure PaCO₂ after ROSC and target normocapnia. Consider adjustments to the target PaCO₂ for specific patient populations where normocapnia may not be desirable (e.g. chronic lung disease with chronic hypercapnia, congenital heart disease with single-ventricle physiology, increased intracranial pressure with impending herniation).

ANZCOR suggests that rescuers measure PaO₂ after ROSC and target a value appropriate to the specific patient condition. In the absence of specific patient data, we suggest rescuers target normoxemia after ROSC. Given the availability of continuous pulse oximetry, targeting an oxygen saturation of 94% to 99% may be a reasonable alternative to measuring PaO₂ and titrating oxygen when feasible to achieve normoxia.

6.0

ANZCOR suggests continuous electroencephalogram (EEG) monitoring should be considered post-arrest within the first 24 hours and the treatment of seizures is suggested for children post–cardiac arrest. Routine use of prophylactic anti-seizure medication is not advised.

Nil

7.0

ANZCOR recommends that no single test be used in isolation to predict good neurological outcome in children after cardiac arrest. Clinicians should use multiple tests in combination for good neurological outcome prediction.

ANZCOR recommends that no single test be used in isolation to predict poor neurological outcome in children after cardiac arrest. Clinicians should use multiple tests in combination for poor neurological outcome.

ANZCOR suggests that practitioners use multimodal tools to predict neurologic outcomes for infants and children after cardiac arrest.

9.0

ANZCOR suggests performing post-event debriefing after paediatric cardiac arrest in all settings.

ANZCOR suggests data-driven, performance-focused debriefing of rescuers after IHCA or OHCA in children.

Updated Guidance

Previous Guidance

2.0

Added a new section on children with cardiac arrest due to hypovolaemia.

Nil

4.0

Added a new section on children with cardiac arrest due to electrolyte or metabolic disorders.

Some advice previously covered in 12.2

7.0

Added a new section on children with cardiac arrest due to pulmonary embolism.

Nil

9.0

Added new guidance on management of children with LVADs.

Nil

9.0

Added new ILCOR Good Practice Statement: In children who develop signs of pulmonary hypertensive crisis, low cardiac output, or right ventricular failure despite optimal medical therapy, extracorporeal membrane oxygenation (ECMO) may be considered before cardiac arrest or for refractory cardiac arrest as a bridge to recovery or as a bridge to the evaluation for organ replacement and transplantation in very select cases.

Nil

Section

Updated Guidance

Previous Guidance

2.0

(Previous Sections 2.0-2.2 combined)

ANZCOR suggests that, for patients with bradycardia and hemodynamic compromise not responsive to oxygenation and ventilation commence CPR, follow the standard paediatric advanced life support algorithm and treat underlying causes.

2.1 ANZCOR suggests that, for the treatment of children with bradycardia:

IV/IO Adrenaline (epinephrine) 10 micrograms/kg (maximum 1mg per dose) may be administered to infants and children with bradycardia and poor perfusion that is unresponsive to treating the underlying cause, for example hypoxia.

IV/IO Atropine 20 micrograms/kg (maximum 600 micrograms) may be administered for bradycardia caused by increased vagal tone.

2.2 ANZCOR suggests that, for the treatment of children with bradycardia:

Transthoracic pacing may be lifesaving in selected cases of life-threatening bradycardia caused by complete heart block or abnormal function of the sinus node. Specialist advice should be sought.

Pacing is not helpful in children with bradycardia secondary to a post-arrest hypoxic/ischemic myocardial insult or respiratory failure.