The 2005 Guidelines for CPR and EmergencyCardiovascular Care: Implications for EmergencyMedical Services for ChildrenKathleen Brown, MD,*y Cynthiana Lightfootz

1522-8401/$ - see fro

doi:10.1016/j.cpem.2

*Division of Emergen

Washington, DC.

yGeorge Washington

zCenter for Prehosp

Children’s Nation

Reprint requests and

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Michigan Avenue

(E-mail: kbrown@

In 2005, the American Heart Association published revised guidelines for cardiopulmonaryresuscitation (CPR) and emergency cardiovascular care. In most emergency medicalservices systems in this country, these guidelines are used to guide the training ofprehospital care providers and also to revise the protocols that these caregivers follow.Therefore, they will have an important impact on emergency medical care of children. Thelargest impact will be in the way that cardiopulmonary CPR is performed in victims of allages. The guidelines emphasize the importance of effective uninterrupted chest compres-sions during CPR. Pediatric-specific changes in the guidelines include the following: when apatient should be identified as a pediatric patient; methods for delivering CPR; and the use ofthe automated external defibrillator. The guidelines also ask dispatchers and healthcareproviders to distinguish between sudden cardiac arrest and asphyxial arrest, and then tobase their initial care on the most likely cause of arrest. The goal of the revisions is to guidecaregivers to provide the most effective initial care for patients in need of resuscitation.Clin Ped Emerg Med 7:105-113 ª 2006 Elsevier Inc. All rights reserved.

KEYWORDS emergency medical services, cardiopulmonary resuscitation

In December 2005, the American Heart Association

(AHA) published revised Guidelines for Cardiopulmo-

nary Resuscitation and Emergency Cardiovascular Care(ECC) [1]. These guidelines contain recommendations for

resuscitation of victims of all ages. As in 2000, these guide-

lines are the result of examination of the available scientific

evidence and expert consensus. The process was organized

by the International Liaison Committee on Resuscitation.

The guidelines contain recommendations that are

divided into classes based on the level of evidence

nt matter ª 2006 Elsevier Inc. All rights reserved.

006.04.002

cy Medicine, Children’s National Medical Center,

University School of Medicine, Washington, DC.

ital Pediatrics, Division of Emergency Medicine,

al Medical Center, Washington, DC.

correspondence: Kathleen Brown, MD, Division of

cine, Children’s National Medical Center, 111

, NW, Washington, DC 20010.

cnmc.org.)

available to support the recommendation. The evidence

classification system has not changed from the process

described in 2000. Table 1 illustrates the 5 classes ofevidence that can be applied to recommendations and the

level of evidence supporting each class.

In most emergency medical services (EMS) systems in

this country, these guidelines are incorporated into the

protocols that EMS personnel use for providing care to

patients requiring resuscitation. They are also used to

augment initial emergency medical technician (EMT)

training and continuing education curricula for all

prehospital care providers. Thus, changes in these

recommendations often have a large impact on the way

EMS cares for acutely ill children. The guidelines also

contain information on the delivery of cardiopulmonary

resuscitation (CPR) by nonhealthcare providers. This

may further impact EMS personnel if they train lay

rescuers or provide emergency medical direction at a

dispatch center. However, most EMS providers follow the

guidelines for healthcare providers when they are

105

Table 1 Applying classification of recommendations and level of evidence.a

Class I Class IIa Class IIb Class III

Benefit NNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNN Risk Benefit NNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNN Risk Benefit zzzz__ Risk Risk zzzz__ BenefitProcedure, treatment or

diagnostic test/assessment should beperformed/administered

It is reasonable toperform procedure,administer treatment orperform diagnostic test/assessment

Procedure, treatment ordiagnostic test/assessment may beconsidered

Procedure, treatment ordiagnostic test/assessment should notbe performed/administered. It is nothelpful and may beharmful

Class Indeterminate! Research just getting started! Continuing area of research! No recommendations until further research (eg, cannot recommend for or against)

a From: American Heart Association. 2005 American Heart Association guidelines for cardiopulmonary resuscitation andemergency cardiovascular care. International Consensus on Science. Circulation 2005;112:IV-1-IV-211 [1].

Table 2 Recommendations for lay rescuer CPR of infants andchildren: differences from health care provider (HCP) CPR.

Definition of child For lay rescuer, younger than 8years (HCP = no signs of puberty).

Activate EMS Lay rescuers are not taught todistinguish between ventricularfibrillation sudden cardiac arrestand asphyxial arrest in children.Two minutes of CPR should beprovided before activating EMS forall pediatric victims.

Airway Head tilt chin lift(Jaw thrust is not taught).

Breathing Check for presence or absence ofbreathing (bnormal breathingQ in adult)2 breaths at 1 second.Each breath over 1 second, shouldsee chest rise (Same as HCP).If not, retry head tilt after firstbreath once (Do not try ba couple oftimesQ as recommended for HCP).

Circulation No pulse check: begin chest

K. Brown, C. Lightfoot106

delivering care; therefore, the focus of discussion will be

on the recommendations for healthcare providers. The

differences in the recommendations for CPR by lay

rescuers compared to the recommendations for health-care providers are summarized in Table 2.

In this article we will review the changes from the

previous set of ECC recommendations that will likely

affect the practice of EMS care providers. Most changes

have occurred in basic life support (BLS), specifically in

the way CPR is performed. These changes apply to

victims of all ages with the emphasis on provision of chest

compressions at an optimal rate and depth. Pediatricspecific changes in BLS care, including when a patient

should be identified as a pediatric patient, methods for

administering CPR in children, and the use of the

automated external defibrillator (AED) on pediatric

patients will be discussed. Areas of emphasis in the

recommendations for pediatric advanced life support

(PALS) are reviewed, and guidelines for family member

presence during resuscitation and the termination ofpediatric resuscitation are also discussed. Finally, the

needs of children require integration into the general

EMS system and consideration of these recommendations

in the context of EMS system development is discussed.

compressions after two breaths.Rescue breathing without chestcompressions is not taught.30:2 compression/ventilation ratiofor all victims (Does not changewith age or number of rescuers).Compressions for child: one or twohands at the nipple line.Compressions for infant: two fingersjust below nipple line (Two thumbswith hand encircling chest techniqueis not taught).

AED Use One shock followed by CPR,rhythm check every 2 minutes(Same as HCP).

What is a Pediatric Patient?The AHA recommendations for bpediatricQ patients apply

to patients from hospital discharge after birth to puberty.

Newborn CPR applies to infants in the first few hours of

life until hospital discharge. In some instances, the

guidelines distinguish between infant (younger than

1 year) and child (older than 1 year). The pediatric

2005 ECC guidelines recognize that there is no singleanatomical or physiological characteristic or scientific

evidence that denotes when an individual patient would

benefit from pediatric or adult resuscitation techniques.

However, for practical and educational reasons, a

definable bcutoffQ is needed. In the new guidelines, the

Table 3 AHA definitions for bpediatricQ victims.

Term Definition

Newborn Birth to initial hospital discharge

Infant Hospital discharge to 1 year

Child: for healthcare provider

1 year to signs of puberty

Child: for lay rescuer 1 to 8 years

Pediatric = Infant and child (not newborn)Hospital discharge to signs ofpuberty

Adult Signs of puberty to death

The 2005 guidelines for CPR and emergency cardiovascular care 107

AHA defines the upper limit of the bchildQ category as

bpubertyQ (about 12 to 14 years). Recognizing that a

rescuer may not always know the age of an acutely ill orinjured child, they recommend that rescuers treat a

patient who displays signs of secondary sex character-

istics (breast development, armpit hair) according to the

adult guidelines. Using these definitions, most adoles-

cents will be treated according to the adult guidelines.

Therefore, wherever the adult guidelines are referenced,

it should be noted that these will also apply to some

bpediatricQ patients in many systems. An exception tousing signs of puberty as the cutoff for child CPR

guidelines occurs when instructing a lay rescuer. For

lay rescuers, it is recommended that 8 years be used as

the upper limit for child CPR. Another instance in which

the age of 8 years is used to distinguish child and adult is

the use of an adult AED. In the case where an AED is

indicated and the child is older than 8 years, adult pads

should be used. Hospitals, especially children’s hospitalsor those that provide pediatric intensive care, may choose

to apply the bchildQ guidelines to older patients. Table 3

provides a summary of the definitions relating to

pediatric patients used by the AHA guidelines.

What Are The Changes in CPRGuidelines That Apply toPatients of All Ages?There are 5 major changes in the 2005 guidelines, and

they apply to how initial CPR is performed in victims of

all ages. These recommendations were designed to both

reflect what we have learned about effective CPR and to

simplify the guidelines by eliminating differencesbetween age groups that were not based on scientific

evidence. This will make teaching and maintaining CPR

skills simpler. Rather than focusing on the memorization

of different compression/ventilation ratios, the healthcare

provider can focus on the delivery of effective compres-

sions and ventilations.

The 5 major changes are as follows:

1. Emphasis on the delivery of effective chest

compressions.

2. A single compression/ventilation ratio (30:2) for

all lone rescuers.

3. All breaths should be delivered over 1 second and

produce visible chest rise.4. When attempting defibrillation, 1 shock should be

given followed by 2 minutes of CPR.

5. Lone rescuers should decide whether to call for

help first or call fast (initiate CPR first) based on

the likely cause of arrest.

Emphasis on Effective Chest CompressionsEvidence shows that effective chest compressions lead to

better perfusion of vital organs during CPR. This is a Class

I recommendation. Because every time chest compressions

are interrupted blood flow ceases, interruptions to chest

compressions during CPR should be minimized. The

effectiveness of chest compressions is additive; ie, eachtime compressions are stopped and restarted, the first

few compressions are not as effective as later compressions

[2]. In real-life situations, rescuers interrupt compressions

more frequently than they should to promote adequate

perfusion [3,4]. In addition, both the depth and rate of

compressions need to be adequate to produce effective

circulation. The mantra of bpush hard and push fastQsummarizes what is needed. Chest compressions should begiven at a rate of about 100 compressions/minute for all

victims, except newborns. Studies have shown that res-

cuers frequently give chest compressions that are too slow

and shallow [5]. The current guidelines state that for

pediatric patients, the depth should be one third to one half

the depth of the chest. For adults and adolescents, a depth

of 1O to 2 inches is recommended. The chest should be

allowed to return to its normal position after each com-pression. This should result in approximately equal lengths

of time devoted to compression of the chest and relaxation

or recoil of the chest wall. Mechanically, this permits better

refilling of the heart, and therefore better perfusion with

the subsequent compression [6]. Table 4 provides a sum-

mary of the guidelines for delivery of chest compressions.

Single Compression/Ventilation Ratio (30:2)for All Lone RescuersThe new guidelines recommend that both healthcare

providers and lay rescuers use a compression/ventilation

ratio of 30:2. This is a dramatic change for BLS care in

infants and in children, in whom ratios of 3:1 and 5:1,

respectively, were previously recommended. This change

not only simplifies the teaching and provision of CPR, but

will, it is to be hoped, result in more effective CPR. As

noted previously, interruptions to chest compressions togive rescue breaths result in diminished perfusion of vital

Table 4 Recommendations for chest compressions.

Infant Child Adult

Location Just below nipple line Center of chest between nipples

Method 1 rescuer: 2 fingers 2 hands: heel of one hand 2 hands: heel of onebHard and FastQ

complete chestrecoil

HCP or two rescuers:two thumb encirclinghands technique

with second handon top1 hand: heel of 1 hand only

hand with secondhand on top

Depth 1/3 to 1/2 depth of chest 1/3 to 1/2 depth of chest 1O-2 in.

Rate 100/minute 100/minute 100/minute

Compression/ventilation 30:2 (1 rescuer) 30:2 (1 rescuer) 30:215:2 (2 rescuers) 15:2 (2 rescuers)

! All: minimize interruptions to compressions as much as possible

K. Brown, C. Lightfoot108

organs [7]. Provision of a longer series of uninterrupted

effective chest compressions will improve circulation. If 2

healthcare providers are available to perform CPR in an in-

fant or child, then a ratio of 15:2 should be used (Table 4).

Breaths Should be Given Over 1 Second andProduce Visible Chest RiseThe new guidelines recommend that each breath should be

given over 1 second. This is a Class IIa recommendation.

Each breath should result in chest rise. Rescuers should

avoid hyperventilating the patient and the delivery of

breaths that are too forceful and large. During CPR, blood

flow to the lungs is much lower than normal so the victimrequires commensurately less ventilation. The previous

guidelines taught that breaths should be delivered over a

1- to 2-second period, and various tidal volumes were re-

commended. The new guidelines state that less ventilation

is needed during CPR and note that: bHyperventilation

during CPR is not necessary and can be harmful for several

reasons. The positive pressure in the chest that is created

by rescue breaths will decrease venous return to the heart.This limits the refilling of the heart, so it will reduce cardiac

output created by subsequent chest compressionQ [1].

When Attempting Defibrillation, One ShockShould be Given Followed by 2 Minutesof CPRPrevious recommendations called for delivery of up to 3shocks before CPR is performed. This is now thought to be

suboptimal for a number of reasons. The AED takes an

interval between shocks to analyze the rhythm and

determine if another shock is warranted. This results in a

period of 30 to 60 seconds after each shock where no CPR

is being performed. In most cases in which ventricular

fibrillation (VF) is detected by an AED and a shock is

delivered, the VF is terminated by the initial shock. Incases where the first shock does not work, it is thought that

the value of CPR is greater than another immediate shock.

When VF is terminated, it can take several minutes for

normal heart function and blood flow to return. During

this time, CPR will help ensure that the heart itself is

perfused and thus better able to recover. The new

recommendations will require AED manufacturers to

reprogram current AEDs to allow rescuers to perform arhythm check after 5 cycles, ie, 2 minutes, of CPR.

Lone Rescuers Should Decide Whether toCall First or Provide CPR First Based on theLikely Cause of ArrestThis is not an actual change from the 2000 guidelines,

which also asked rescuers to attempt to make this

distinction. However, the importance of providing the

best initial care based on this distinction is emphasized in

the 2005 guidelines. The 2005 guidelines ask the lone

provider to differentiate the likely cause of arrest to

choose the most likely effective initial course of action.

The 2 major etiologies to be distinguished are VF suddencardiac arrest (SCA) vs hypoxic or asphyxial arrest.

Children are more likely to suffer hypoxic arrest than VF

SCA [8]. However, a child who is witnessed to have an

out-of-hospital sudden collapse should be thought to

have VF SCA. Likewise, adults who are known to be

victims of drowning, hypoventilation due to drug over-

dose or injury should be treated as victims of hypoxic

arrest. The differentiation needs to be made becausevictims of VF SCA are likely to benefit from a strategy that

provides defibrillation as soon as possible, ie, bphone first.QIn such cases, rescuers should dial 911, and get an AED, if

available, and then return to the victim to start CPR and

use the AED. Victims of hypoxic arrest are likely to

benefit from early CPR with ventilation, ie, bCPR firstQ or

bphone fast.Q The recommendation for this group is to

immediately perform 5 cycles (2 minutes) of CPR beforecalling 911 or using an AED (Figure 1).

Figure 1 Sequence of events for out-of-hospital resuscitation of an

infant or child by a health care provider.

The 2005 guidelines for CPR and emergency cardiovascular care 109

What Changes in BLS AreSpecific to Infants and Children?

Airway and BreathingWhen assessing breathing, BLS providers should check foradequate breathing in adults and the presence or absenceof breathing in infants and children. Advanced life supportproviders will look for adequate breathing in victims of allages. Healthcare providers should attempt ba couple oftimesQ to give effective breaths to the pediatric victim,looking for the chest to rise with each breath. This mayrequire the rescuer to reposition or try alternative maneu-vers to open the airway. This is thought to be essential inpediatric victims because the most likely cause of anunwitnessed arrest is asphyxial. Therefore, it is crucial thatrescuers provide effective rescue breaths as indicated bychest rise.

Infants or children who are not breathing, or are not

breathing adequately, but have a perfusing rhythm (not

receiving compressions) should be given 12 to 20

breaths/min, or 1 breath every 3 to 5 seconds. Adultsreceiving rescue breathing without chest compressions

should be given 10 to 12 breaths/min. It is important that

rescuers deliver breaths at the recommended rate.

Rescuers often deliver excessive ventilation during CPR

[6,9]. Excessive ventilation can be harmful because it

may compromise venous return and therefore decrease

cardiac output. It may also increase the risk of aspiration.

Foreign Body Airway Obstruction (Choking)Simplified terms now separate choking victims into 2categories, based on the degree of airway obstruction, ie,mild or severe. Children with mild airway obstruction areable to cough or make vocal sounds. These children shouldbe allowed to attempt to clear their own airway while theprovider watches for signs of severe obstruction. Action isonly taken when rescuers observe signs of severe airwayobstruction: poor air exchange, breathing difficulties, asilent cough, and cyanosis. The course of action forobstruction remains unchanged. For severe obstructionin a child, abdominal thrusts are performed until the objectis expelled or the child becomes unresponsive. In aninfant, 5 back blows are administered followed by 5 chestthrusts until the object is expelled or the infant becomesunresponsive. If the infant or child becomes unresponsive,the provider should open the airway with a head tilt-chinlift maneuver and look into the mouth. If the object isvisualized, it should be removed and CPR initiated.

Pulse CheckHealthcare providers should perform pulse checks

when assessing an unresponsive victim and duringCPR (Figure 1). However, it is emphasized that no more

than 10 seconds be spent on each pulse check. If a definite

pulse is not felt, it should be assumed to be absent. Lay

rescuers are not taught to perform a pulse check.

K. Brown, C. Lightfoot110

Chest CompressionsThe guidelines recommend that the lone healthcareprovider perform chest compressions for infants just

below the nipple line. When 2 healthcare providers

are performing CPR, the healthcare provider who is

compressing the chest should use the 2-thumb–encircling

hands technique. When the victim is a child (older than

1 year), rescuers should compress over the lower half of

the sternum at the nipple line (as for adults). The depth of

compressions for infants and children should be one thirdto one half the depth of the chest; a depth recommenda-

tion in inches is no longer given. When 2 rescuers are

available to perform CPR in a pediatric victim, the

rescuers should use a 15:2 compression/ventilation ratio.

This differs from the adult recommendation that provides

a ratio of 30:2 even with 2 rescuers. It is also a significant

change from past recommendations that provided differ-

ent ratios depending on the age of the victim (Table 4).The new guidelines also recommend that if, despite

adequate ventilation and oxygenation to an unresponsive

pediatric patient, the heart rate remains less than

60 beats/min with signs of poor perfusion, the rescuer

should begin chest compressions. This is not a change

from the 2000 guidelines, but was not previously

incorporated into BLS teaching. Because bradycardia is

a common terminal rhythm in pediatric victims of cardiacarrest, and the outcome from pulseless arrest is so poor in

infants and children, initiating chest compressions for

bradycardia may improve outcomes. Moving forward,

this recommendation should be formally incorporated

into BLS training.

Use of AEDs in Pediatric VictimsCardiac arrest is less common in the pediatric populationthan in adults, but the etiologies are more diverse.Ventricular fibrillation is not a common dysrhythmia inchildren. It has been observed in 5% to 15% of pediatricand adolescent cardiac arrests. However, rapid defibrilla-tion of these patients may improve outcome [10,11]. The2000 guidelines did not endorse the use of AEDs inchildren younger than 8 years. This was attributable toconcerns regarding harm from excessive voltage from atypical monophasic AED and the ability of an AED todifferentiate shockable from nonshockable dysrhythmiasin young children. Since that time, manufacturers havedeveloped bpediatric padsQ for AEDs that reduce thevoltage to a safe range for children ages 1 to 8 years. Therehave also been studies published describing the sensitivityand specificity of particular AED systems in differentiatingshockable rhythms in infants and young children [12,13].In 2003, the AHA, through the International LiaisonCommittee on Resuscitation, recommended the use ofthese devices in children aged 1 to 8 years [14]. In the2005 guidelines, they reaffirmed that recommendation.Rescuers should use a pediatric dose-attenuation systemfor children aged 1 to 8 years. They should also use a

system that has been shown to be able to differentiate VFfrom other rhythms in pediatric patients. The currentrecommendations also support the use of a bregular AEDQwith adult pads in children younger than 8 years ifpediatric pads are not available. Child pads should not beused for victims older than 8 years or those heavier than25 kg.

The new guidelines also reaffirm the 2003 recommen-dation that when treating a child in an unwitnessed

cardiac arrest in an out-of-hospital setting, rescuers

should perform 2 minutes of CPR before attaching an

AED (see previous section on call first vs call fast). The

reason is that because most cardiac arrests in children are

not caused by ventricular dysrhythms, immediate attach-

ment and operation of an AED, with hands-off time

required for rhythm analysis, will delay or interruptprovision of rescue breathing and chest compressions.

However, if treating a witnessed sudden collapse, the

rescuer should seek and use an AED as soon as possible

as they would in an adult patient with SCA.

The current recommendations do not support the use

of AEDs in children younger than 1 year. The consensus

opinion was that there was insufficient evidence (Class

indeterminate) to make such a recommendation. Duringinfancy, most cardiac arrests are thought to arise from

respiratory failure and the rate of VF is thought to be even

lower than that in childhood or adolescence. Therefore,

interruption of CPR for the detection and treatment of

this rhythm may be more harmful than beneficial.

What are the Important PALSGuidelines Changes?The recommended changes in PALS are less dramatic

than those for adult and child BLS. Many of the changes

discussed later represent confirmations or emphasis of

recommendations made in the 2000 guidelines. The PALS

provider should keep in mind that without effectivepediatric BLS, advanced life support efforts are not likely

to be effective. CPR must be performed effectively, with

proper rate and depth of compressions (hard and fast)

and adequate chest recoil. Priority should be placed on

avoiding interruptions in CPR for ALS maneuvers. The

following elements are the most important changes in the

2005 PALS guidelines.

Airway, Breathing, and CirculationThe 2000 recommendation that endotracheal tubes (ETs)

should only be placed by experienced providers who have

had the opportunity to maintain their skill in pediatric ETintubation is reemphasized in the 2005 guidelines. Bag-

mask ventilation can be equally effective as ventilation via

endotracheal intubation and safer when providing ven-

tilation for a short period [15-17]. An emphasis is placed

on appropriate and periodic retraining in skill areas such

The 2005 guidelines for CPR and emergency cardiovascular care 111

opening the airway, effective ventilation, and equipment

sizing. In the out-of-hospital setting, preference should be

given to ventilation and oxygenation of infants and

children with a bag and mask rather than attempting

intubation if transport time is short (Class IIa).

Laryngeal mask airways (LMAs) are an acceptable

alternative to endotracheal intubation when used byproviders who are experienced in their use. There is

insufficient evidence to recommend for or against the

routine use of LMAs during cardiac arrest (Class

Indeterminate). However, when endotracheal intubation

is not possible, the LMA is an acceptable adjunct for

experienced providers (Class IIb). LMAs are associated

with a higher incidence of complications in young

children [18]. Cuffed ETs may be used in infants andchildren (except newborns) in inpatient settings, eg,

pediatric intensive care units [19,20]. They are still not

recommended for infants and children in the prehos-

pital setting.

As noted previously, studies have demonstrated that

providers often overventilate victims during CPR. This is

especially true if an advanced airway is in place. With an

advanced airway in place, rescuers should ventilate at arate of 8 to 10 times/min without pausing chest compres-

sions. One way to achieve this rate is to use the mnemonic

bsqueeze-release-releaseQ at a normal speaking rate [21].

The importance of secondary confirmation of ET place-

ment is emphasized as it was in 2000. Correct placement

should be confirmed when the tube is initially placed,

when the child is transported and whenever the patient is

moved. ET tube assessment should include primaryconfirmation (auscultation and chest rise) and secondary

confirmation (exhaled carbon dioxide detection). Either

colorimetric carbon dioxide detectors or capnography can

be used, depending on availability. Esophageal detector

devices can be considered for children weighing more than

20 kg who have a perfusing rhythm (Class IIb) [22,23].

When an advanced airway is in place, CPR should not be

performed in cycles. Chest compressions should beprovided at 100 compressions/min. At the same time,

ventilation should be provided at 8 to 10 breaths/min.

Ventilations should not interrupt chest compressions.

Medications and Other PALSRecommendationsDrug delivery should not interrupt CPR. In VF pulselessarrest, one shock should be given followed by 2 minutes

of CPR as previously noted. Drugs, if indicated, should be

given while the defibrillator is charging or during CPR, as

soon as possible after the rhythm has been checked. This

means that the rescuers must prepare the next drug dose

before it is time for the next rhythm check. The

guidelines for the timing of shock, CPR, and drug

administration is now the same for adult and pediatricVF arrest.

Evidence suggests that intraosseous delivery of resus-

citation medications is preferable to endotracheal admin-

istration [24]. However, the endotracheal route can still

be used if other access is not available. The new

guidelines recommend that endotracheal medications

be diluted to at least 5 mL and followed by 5 breaths.

Routine use of high dose epinephrine for pulseless arrestis not recommended. Studies have not shown it to be

beneficial in improving survival, and suggest it may be

harmful in asphyxial arrest [25,26]. This is now a Class

III recommendation (not recommended—may cause

harm). High-dose epinephrine may be considered in

exceptional circumstances such as h-blocker overdose

(Class IIb). As in the adult algorithms, lidocaine is

deemphasized but can be used for treatment of VF arrestor pulseless VT if amiodarone is not available. This is

based on a study in adults [27]. Vasopressin is still not

recommended for use in pediatric patients (Class

Indeterminate). Induced hypothermia (328C-348C) may

be considered if the child remains comatose after

resuscitation (Class IIb). Studies in adults suggest that

hypothermia may improve outcomes [28,29].

What Other Important Issuesare Discussed in the 2005Guidelines?

Family Presence During ResuscitationThe 2005 guidelines, like the 2000 guidelines, discuss

the issue of family member presence during resuscitation

[30,31]. Studies have shown that most family members

would like to be offered the option to be present while

their loved one is resuscitated. There is also evidence that

this may be helpful in their grieving process and that it

rarely interferes with the provision of appropriate care

[31-33]. Healthcare providers should offer the oppor-tunity whether resuscitation is taking place in or out of

the hospital. Whenever possible, a member of the

resuscitation team should be assigned to comfort, answer

questions, and discuss the needs of the family.

Termination of ResuscitationThe authors of the 2005 guidelines did not feel there was

sufficient evidence to recommend when to terminate

resuscitative efforts. The 2000 guidelines suggested thatchildren who underwent prolonged resuscitation and

absence of return of spontaneous circulation after 2 doses

of epinephrine were unlikely to survive. However, the

2005 guidelines note that intact survival after unusually

prolonged in-hospital resuscitation has been documented

[34-37]. The new guidelines suggest that bprolonged

efforts should be made for infants and children with

recurring or refractory VF or ventricular tachycardia, drugtoxicity, or a primary hypothermic insult.Q

K. Brown, C. Lightfoot112

What Changes Were Made in theGuidelines for NewbornResuscitation?For newborn resuscitation, the emphasis remains on

establishing effective airway and breathing. Few changes

were recommended in the 2005 AHA guidelines. New

evidence was available to reaffirm or change some previousguidelines. Those that are relevant for EMS providers

include the following: recommendations for intrapartum

and tracheal suctioning of the newborn after delivery; use

of exhaled carbon dioxide detection to confirm tube

placement; dosing of epinephrine; and use of naloxone.

Current recommendations no longer advise routine

intrapartum suctioning of the oropharyngeal and naso-

pharyngeal airway of the newborn when there ismeconium-stained fluid. A 2004 multicenter trial study

did not show that this practice decreased the risk of

aspiration syndrome (Class I) [38]. In the past, endo-

tracheal intubation and deep suctioning was recommen-

ded for infants with meconium-stained fluid. The 2000

guidelines recommended that only infants who were not

vigorous immediately after birth receive this treatment. In

2005, this recommendation was reaffirmed and issupported by additional evidence [37-40].

An increase in heart rate should be used as the primary

sign of improved ventilation during resuscitation of

newborns. The new guideline reaffirms the utility of

exhaled carbon dioxide measurement to confirm correct

ET placement if the heart rate does not increase promptly

(Class IIa). There is insufficient evidence to recommend

the use of esophageal detector devices in newborns orinfants lighter than 20 kg.

As in PALS, the recommendation for high dose

epinephrine was changed from Class Indeterminate (not

enough evidence) to Class III (evidence of harm). The

dose of epinephrine recommended for newborn resusci-

tation is 0.01 to 0.03 mg/kg per dose. Routine naloxone

administration is not recommended during initial resus-

citation of a newborn with respiratory depression. If it isused, heart rate and color must first be restored by

supporting ventilation. There is a lack of evidence for

the appropriate dosing of endotracheal epinephrine or

naloxone (Class Indeterminate). Therefore, it is advised

that the intravenous or intraosseus route be used when-

ever possible.

What are the Recommended EMSSystem Changes that May AffectPediatric Patients?The new guidelines recommend that EMS systems evaluate

protocols for cardiac arrest patients and look to reduce

response times when feasible (Class I). Each EMS systemshould also measure the rate of survival to hospital dis-

charge for victims of cardiac arrest and use this informa-

tion to document procedural changes. This change will

help EMS systems develop ongoing quality improvement.

The 2005 guidelines also suggest that EMS medical

directors consider implementation of a protocol that

would allow prehospital responders to provide 2 minutes

of CPR before defibrillation in VF SCA when the call-to-response interval is longer than 4 to 5 minutes. This is a

change from the previous guideline recommendation of

immediate defibrillation. In 2 studies it was shown that

when EMS response exceeded 4 to 5 minutes, a period of

CPR (1O to 3 minutes) before defibrillation improved

patient outcomes [41,42].

The 2005 guidelines describe the training and abilities

that EMS dispatchers should have in order to maximize thenumber of victims receiving high-quality CPR. They

recommend that EMS dispatchers should receive appro-

priate CPR training to be able to give instruction to callers

by telephone (Class IIa). Dispatchers should be able to

help callers recognize the signs of cardiac arrest to increase

the chance of victims receiving bystander CPR. Specifi-

cally, they recommend that if a caller describes an unres-

ponsive victim who is gasping that the victim be treated asthough (s)he is in cardiac arrest (Class IIb). In addition,

the 2005 guidelines suggest that dispatchers should be able

to recognize when a caller is describing a victim of likely

VF sudden cardiac arrest vs a victim of likely hypoxic

(asphyxial) arrest (eg, children and adult drowning

victims). This will, in turn, dictate the initial telephone

advice given by the dispatcher. In victims of VF SCA,

compression-only CPR should be advised. In victims ofhypoxic arrest, CPR with rescue breaths and chest com-

pressions should be advised (Class IIb). The 2000 guide-

lines recommended that compression-only CPR directions

be given to lay rescuers of all cardiac arrest victims.

ConclusionThe new ECC guidelines emphasize improving the quality

of CPR for victims of all ages. A major impact of these

guidelines will be to simplify and improve the way BLS care

is provided for children in the EMS system. Although the

guidelines emphasize effective CPR, and specifically effec-

tive chest compressions, they also attempt to ensure that

victims of hypoxic arrest receive effective ventilation. This

will be accomplished by asking dispatchers and healthcareproviders to distinguish between the 2 general causes of

cardiac arrest. As children represent a minority of cardiac

arrest victims, but are more likely to suffer hypoxic arrest

than adult victims, this distinction followed by appropriate

actions will be a vital step to improving the outcomes of

pediatric cardiac arrest victims in the EMS system.

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