Pediatric Advanced Life Support (PALS)

Part 12, IV-167 to IV-187

Highlights:

Superiority and greater safety of biphasic over monophasic shocks for defibrillation are emphasized.

With manual biphasic or monophasic defibrillation, the initial dose remains 2 J/kg. Subsequent shock doses are 4 J/kg.

Confirmation of endotracheal tube placement after insertion, during transport, and whenever the patient is moved, by clinical exam and assessment of exhaled CO₂ (i.e., capnography, colorimetric detector).

Pediatric Manual Defibrillation (IV-174)

"The lowest energy dose for effective defibrillation and the upper limit for safe defibrillation in infants and children are not known."(p. IV-174)

"Based on data from adult studies and pediatric animal models, biphasic shocks appear to be at least as effective as monophasic shocks and less harmful." (p. IV-174)

Medtronic's adult OOH study (van Alem, et al) and pediatric animal study (Berg, et al) were included in the data that led to this statement.

Initial dose of 2 J/kg is unchanged from 2000. Subsequent dose has been changed to 4 J/kg; older guidelines recommended 2-4 J/kg for second and subsequent shocks. (p. IV-174)

"Energy doses > 4 J/kg (up to 9 J/kg) have effectively defibrillated children and pediatric animal models with negligible adverse effects." (p. IV-174)

Manual defibrillation dose(mono or biphasic):

First attempt: 2 J/kg (Class IIa)

Subsequent attempts: 4 J/kg (Class Indeterminate)

Shock doses for cardioversion have not changed. (p. IV-177)

Give one shock ASAP and immediately resume CPR, beginning with chest compressions (unstacked shocks).

Unstacked shocks are recommended for all victims.

Pediatric Capnography/SpO2

If patient has a perfusing rhythm, monitor oxygen saturation continuously with pulse oximeter because clinical recognition of hypoxia is not reliable. (p. IV-168)

"In infants and children with a perfusing rhythm, use a colorimetric detector or capnography to detect exhaled CO₂ to confirm endotracheal tube position in the prehospital and in-hospital setting (Class IIa) and during intrahospital and interhospital transport." Class IIb. (p. IV-169)

Intubated patients post resuscitation: "Ideally correlate blood gases with capnographic end-tidal CO₂ concentration to enable noninvasive monitoring of ventilations." (p. IV-179). Oridion Microstream technology used in the LIFEPAK 12 device is ideal for use on infants and children because it requires such a small sample size. It can provide continuous breath to breath analysis of CO₂, unlike the colorimetric device that gives a one-time reading and needs to be replaced and reattached to the endotracheal tube for each additional assessment.

Pediatric Miscellaneous

"Routine use of high-dose epinephrine is not recommended." Class III. (p. IV-174)

"Induced hypothermia (32° to 34° for 12-24 hours) may be considered if the child remains comatose after resuscitation." Class IIb.