PALS Update – Pediatric Advanced Life Support in 2019

December 19, 2019

Written by Michael Wolf

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These are the updated recommendations for airway management, ECPR, and targeted temperature management (TTM) in pediatric cardiac arrest in (IHCA) and out (OHCA) of hospitals.

Why does this matter?
Most pediatric cardiac arrests are caused by airway compromise. ECMO as a rescue for conventional CPR (ECPR) has gained popularity. Recent trials of TTM in kids post-arrest have led to debate.

Choose your own adventure
These recommendations make note of differences between institutional practices, availability of equipment, and training of personnel. They also distinguish between IHCA and OHCA. Recognizing that cardiac arrest and its management are heterogeneous and high stress, the guidelines allow you to make your own educated choices.

Airway management:
Studies comparing bag-mask ventilation (BMV) to advanced airways (tracheal intubation,  various supraglottic devices) have led to divergent and confusing conclusions. Intubation does not necessarily definitively improve survival or neurologic outcome in all cases of cardiac arrest. In the pre-hospital setting, intubation requires specialized training and equipment that may or may not be present. Therefore, BMV is reasonable compared to advanced airway in OHCA. There is not enough evidence for a recommendation for IHCA.

ECPR:
ECPR has been associated with better survival to hospital discharge and higher favorable neurologic outcome at discharge in IHCA. ECPR may be considered for kids with cardiac diagnoses who have IHCA in a hospital with ECMO capability. There is not enough OHCA data for a recommendation.

TTM:
Therapeutic hypothermia after pediatric cardiac arrest in both IHCA and OHCA did not show a benefit to cooling (32-34⁰C) vs. normothermia (36-37.5⁰C). But cooling works for neonates, adults, and in animal models. Either way, fever is bad and should be prevented, with continuous core temperature measurement. For kids who are persistently comatose after OHCA or IHCA, it is reasonable to choose TTM to 32-34⁰C or 36-37.5⁰C.

Source
2019 American Heart Association Focused Update on Pediatric Advanced Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2019 Nov 14:CIR0000000000000731. doi: 10.1161/CIR.0000000000000731. [Epub ahead of print]

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