US Pharm. 2021;46(8):HS2-HS9.

ABSTRACT: The American Heart Association (AHA) guidelines for pediatric basic and advanced life support and the International Liaison Committee on Resuscitation (ILCOR) treatment recommendations were updated in 2020. In terms of basic life support for pediatric patients, the AHA guidelines continue to emphasize high-quality cardiopulmonary resuscitation (CPR)—i.e., chest compressions of adequate rate and depth, full chest recoil with each compression, minimal interruptions, and avoidance of excessive ventilation. In infants and children receiving CPR who have an advanced airway in place or who have a pulse but are undergoing rescue breathing, a key update is the recommendation to increase the respiratory rate to 20 to 30 breaths per minute (one breath every 2-3 seconds). Pharmacists should be aware of these important changes from previous guidelines, as a growing body of pediatric-specific evidence supports these new recommendations.

The American Heart Association (AHA) has published frequent updates on pediatric basic life support (BLS), and the International Liaison Committee on Resuscitation (ILCOR) has published annual treatment recommendations based on a body of data. In particular, the pediatric BLS guidelines differ according to patient age and other factors. These differences are specified for infants (age <1 year) and children (age 1 year to start of puberty [i.e., breast development in females and presence of axillary hair in males]). The approach to BLS in infants and children for a single rescuer differs slightly from when two or more rescuers are available (for algorithms, see www.ahajournals.org/doi/epub/10.1161/CIR.0000000000000901). The 2020 AHA cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) guidelines reaffirm that the compressions-airway-breathing (C-A-B) sequence is still preferred for pediatric CPR. The guidelines also emphasize that conventional CPR, which has better outcomes compared with compression-only CPR, is preferable.^1-4

This article will discuss important updates from the guidelines that pharmacists should be aware of. However, it must be noted that this is a brief update chiefly of pediatric BLS and does not go into detail regarding pediatric advanced life support (ALS). Therefore, pharmacists should always renew their pediatric CPR certification before expiration and not only review, but also learn to apply, those concepts not discussed in further detail here.

BLS APPROACH

The 2020 AHA guidelines address two indications for the use of BLS in critically ill or injured infants and children: cardiac arrest (no pulse) and bradycardia (heart rate [HR] <60 beats/minute) with poor perfusion.^1,5,6

As healthcare providers (HCPs), pharmacists should follow the sequence of key actions as described in the guidelines when there is an indication to do so¹:
• First, the rescuer must confirm the scene’s safety.
• Next, the rescuer should determine the patient’s responsiveness, get aid, and activate the emergency medical response system. If the patient is unresponsive, the rescuer should call for help and activate emergency medical services (EMS) via a mobile device (single rescuer outside of the hospital) or hospital system (e.g., code button). Alternatively, if there are two or more HCPs, one rescuer should continue to care for the patient and a second rescuer should activate EMS and retrieve an automated external defibrillator (AED) and other emergency equipment. If the patient is responsive, the rescuer should determine additional medical needs and the necessity for EMS activation based on the patient’s condition.
• The rescuer should assess the patient’s breathing and pulse and determine whether the patient is breathing, only gasping, or not breathing while simultaneously checking for a pulse.

This assessment guides further action depending on the number of rescuers. If there is no breathing or only gasping and there is no definitive pulse within 10 seconds, guidance is as follows¹:
• Single rescuer: The approach depends on whether or not the sudden collapse is witnessed. If the collapse is not witnessed, the rescuer should start CPR (C-A-B) with a ratio of 30 compressions to two breaths; after about 2 minutes, if still alone, the rescuer should activate EMS, retrieve an AED, and apply and activate it immediately. If the collapse is witnessed, the rescuer should activate EMS and retrieve an AED (or, for ALS, a manual defibrillator); the single rescuer should then use the AED (or manual defibrillator, for ALS) immediately. If an AED is not nearby or available, the rescuer should start CPR while awaiting the arrival of EMS.
• Two or more rescuers: If a single rescuer is acting, CPR (C-A-B) should be initiated with a ratio of 30 compressions to two breaths; if two or more rescuers are acting, the ratio should be 15 compressions to two breaths.

In infants and children, the method and depth of compressions vary by age. Chest compressions should always be accompanied by ventilation in infants and children who remain pulseless after the initial sequence of compressions. The guidelines acknowledge that it is difficult to quickly determine whether or not a pulse is present; therefore, when a pulse is not definitively identified within 10 seconds, CPR should be initiated.¹

If there is no normal breathing but a pulse is present, single or multiple rescuers should follow this procedure¹:

• Start rescue breathing by providing one breath every 2-3 seconds (20-30 breaths/minute). Pharmacists should take note of this instruction, as this is a change from the 2015 guidelines’ suggested rate of every 3-5 seconds (12-20 breaths/minute).
• Perform a pulse check for no longer than 10 seconds. Add chest compressions if the HR remains <60 beats/minute with poor perfusion, and activate EMS.
• Continue rescue breathing. Perform a pulse check every 2 minutes. If no pulse is present, begin CPR (C-A-B) starting with a ratio of 30 compressions to two breaths for a single rescuer and 15 compressions to two breaths for two or more rescuers.

If the patient exhibits normal breathing and a pulse is present, single or multiple rescuers should use the following procedure¹:
• Monitor the patient until EMS arrives.
• Take the following actions, which constitute CPR: Perform chest compressions, open the airway, and provide ventilations (C-A-B).

The sequence in which HCPs should perform the actions of CPR on infants and children is as follows¹:
• Initiate CPR in an infant or child who is unresponsive, has no normal breathing, and has no definitive pulse after 10 seconds.
• Start chest compressions before performing airway or breathing maneuvers (C-A-B).
• After 30 compressions (15 compressions, if two rescuers), open the airway and give two breaths.
• If the HR is 60 beats/minute or greater after about 2 minutes of CPR, stop chest compressions and continue ventilation.
• Use the AED (or manual defibrillator, for ALS).

This sequence will differ slightly with the number of rescuers. For a single rescuer and for a witnessed collapse, the HCP should retrieve the AED (or manual defibrillator, for ALS) and use it as soon as possible. For an unwitnessed collapse, the single rescuer should perform about 2 minutes of CPR and then activate EMS and retrieve the AED (or manual defibrillator, for ALS). However, when there are two or more rescuers, one rescuer should initiate CPR while the other rescuer activates EMS and retrieves the AED (or manual defibrillator, for ALS). The AED (or manual defibrillator) is used as soon as it is available.¹

The HCP can proceed as follows based on AED analysis¹:
• Shockable rhythm: It is recommended to provide one shock and resume CPR immediately for about 2 minutes (until prompted by the AED to allow a rhythm check). CPR should be continued with pulse check and AED rhythm check every 2 minutes until ALS HCPs take over or the patient starts to move.
• Nonshockable rhythm: CPR should be resumed immediately for about 2 minutes (until prompted by the AED to allow a rhythm check). CPR should be continued with pulse check and AED rhythm check every 2 minutes until ALS HCPs take over or the patient starts to move.

For a single rescuer and for two or more rescuers, respectively, CPR should be performed for approximately 2 minutes (five cycles for single rescuer; 10 cycles for two or more rescuers) before AED use in a patient with an unwitnessed arrest. This approach is based on limited evidence in adults that—even for prolonged arrest from ventricular fibrillation—an initial period of CPR improves the likelihood of successful defibrillation.¹

HIGH-QUALITY CPR

Chest Compressions

The 2020 AHA CPR and ECC guidelines reaffirm the previous recommendations and continue to emphasize the importance of proper technique in the performance of chest compressions. Compressions should be performed over the lower half of the sternum, as compression of the xiphoid process can cause trauma to the liver, spleen, or stomach and must be avoided.¹

The guidelines address the effectiveness of chest compressions and how HCPs can maximize efficacy by learning and following these key points¹:
• The chest should be depressed at least one-third of its anterior-posterior diameter with each compression. The compression depth for infants is approximately 4 cm (1.5 inches), and the depth for children is 5 cm (2 inches). For a child who has reached puberty, it is reasonable to use the adult compression depth of at least 5 cm but no more than 6 cm.
• The optimal rate of compressions is approximately 100-120 per minute, which is achieved by ensuring that the compression and decompression phases are of equal duration.
• The sternum should return briefly to its normal position at the end of each compression, allowing the chest to recoil fully.
• A smooth compression-decompression rhythm with minimal interruption should be developed.
• Chest compressions should be performed on a firm surface.

Audiovisual feedback, coaching, and frequent training improve HCP adherence to these recommendations, so an emphasis on recertification is critical for enabling pharmacists to apply what they learn from the new guidelines.¹

Infants: The 2020 AHA and ECC guidelines reaffirm that chest compressions may be performed using either the two-fingers technique or the two-thumb–encircling hands technique as described below. If the rescuer is unable to compress at least one-third of the anterior-posterior diameter of the chest via either of these techniques, it is reasonable to use the heel of one hand. The AHA suggests using the two-fingers technique when there is a single rescuer. The two-fingers technique during single-rescuer infant CPR permits both easier transition from compressions to ventilation and maintenance of the head-tilt maneuver during compressions, thereby avoiding head repositioning for ventilation. Chest compressions are performed with the index and middle fingers placed on the sternum just below the nipples. Because of the size of the back of the infant’s head, slight neck extension and placement of a hand or rolled towel beneath the upper thorax and shoulders may be necessary to ensure that the compressions target the heart. For infants undergoing two-rescuer CPR, compressions may be performed using the two-thumb–encircling hands technique. The thorax is encircled with both hands and chest compressions are performed with the thumbs. The thumbs compress the lower half of the sternum, avoiding the xiphoid process, while the hands are spread around the thorax.^1,2

Children: In these patients, chest compressions should be performed over the lower half of the sternum either with the heel of one hand or with two hands.^1,2

Compression-to-Ventilation Ratio

No Advanced Airway: In infants and children who remain pulseless after the initial sequence of compressions, chest compressions should always be accompanied by ventilation. However, every effort should be made to avoid excessive ventilation and to limit interruptions of chest compressions to under 10 seconds. Experimental evidence in animals indicates that coronary artery perfusion pressure declines with interruptions in chest compressions. Observational reports suggest that long interruptions in CPR occur commonly. Therefore, compression-to-ventilation ratios of 30 to 2 and 15 to 2 are recommended to minimize interruptions and for ease of teaching and retention.^1,2,7,8 For a single rescuer, two ventilations should be delivered during a short pause at the end of every 30th compression. For two rescuers, two ventilations should be delivered at the end of every 15th compression.

Advanced Airway: Once the patient is under hospital care and the trachea is intubated, chest compressions and ventilations may be performed independently. In infants and children, chest compressions are delivered at a rate of 100 to 120 per minute without pauses, and ventilations are administered at a rate of 20 to 30 breaths per minute (i.e., one breath every 2-3 seconds). This new 2020 guideline change in compression-to-ventilation ratio in infants and children with an advanced airway is based on a multicenter observational study of 47 pediatric patients with in-hospital cardiac arrest, which determined that ventilation rates of at least 30 breaths per minute in infants and 25 breaths per minute in children were associated with increased rates of return of spontaneous circulation and survival.^1,2,9

Airway: The airway should be opened with a head tilt–chin lift maneuver unless a cervical spine injury is suspected. In the setting of trauma in which cervical spine injury is suspected, a jaw-thrust maneuver without head tilt should be employed; however, if this action is unsuccessful, the head tilt–chin lift maneuver should be used.¹

Breathing: Ventilations can be provided mouth-to-mouth, mouth-to-nose, or with a bag and mask. The bag-and-mask technique is often sufficient to achieve adequate ventilation during CPR, and it is a reasonable alternative to an advanced airway (e.g., endotracheal intubation) before arrival at the hospital for pediatric cardiac arrest.^1,2

Evidence in adults and animals suggests that hyperventilation is associated with increased intrathoracic pressure and decreased coronary and cerebral perfusion. These data are the basis for the following recommendations^1,2,10,11:
• Each rescue breath should be delivered over 1 second.
• The volume of each breath should be sufficient to see the chest wall rise.
• An infant or child with an HR of 60 or more beats/minute without normal breathing should receive one breath every 2-3 seconds (20-30 breaths/minute).
• Infants and children who require chest compressions should receive two breaths per 30 compressions for a single rescuer, and two breaths per 15 compressions for two rescuers.
• Intubated infants and children should be ventilated at a rate of 20-30 breaths/minute (one breath every 2-3 seconds), with a goal of 30 breaths/minute in infants and 20-25 breaths/minute in children without any interruption of chest compressions.

AED

This portable device identifies shockable rhythms that should be treated with defibrillation. The AED instructs the operator on how to use the device to deliver a standard shock to the patient. It also identifies nonshockable rhythms, accordingly advising no shock followed by a prompt to resume CPR.^1,2

The 2020 AHA CPR and ECC guidelines reaffirm the following for infants and children with cardiac arrest.^1,2

Witnessed Arrest: An AED should be used as soon as possible if a manual defibrillator is not available. CPR should be performed until the AED (or manual defibrillator, if available) is ready to deliver a shock. A single shock followed by immediate chest compressions is recommended for infants and children with a shockable rhythm.

Unwitnessed Arrest: The algorithms for a single rescuer and two or more rescuers are designed so that CPR is performed for approximately 2 minutes (five cycles for a single rescuer, and 10 cycles for two or more rescuers) before an AED is used.

Age <8 Years: An AED with a pediatric dose-attenuating system should be used whenever possible. However, if a manual defibrillator or an AED with a pediatric dose-attenuating system is not available, it is advised to use an AED without a dose attenuator.

SUSPECTED OR CONFIRMED COVID-19

The AHA has also published interim guidance, including updated algorithms, for BLS and ALS in children with suspected or confirmed COVID-19.¹² (ALS is not discussed in detail here, but information may be found in the updated guidelines.) For pediatric cardiac arrest, the modifications to BLS include the following (see www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.047463 for algorithm)¹²:
• Wear personal protective equipment (PPE) prior to entering the scene or the patient’s room.
• Limit the number of personnel performing CPR.
• Consider using a mechanical CPR device for adolescents who meet height and weight criteria.
• Provide rescue breathing using a bag-and-mask device with a high-efficiency particulate air filter, and ensure a tight mask seal.

Some HCPs may be concerned that PPE could cause hindrances, but pharmacists should note that preliminary evidence from a study suggests that quality of BLS and amount of rescuer fatigue are not significantly affected.¹³ This study aimed to determine whether PPE resulted in deterioration in chest-compression quality and greater fatigue for administering HCPs. Results showed that neither chest-compression quality (rate, depth, and release velocity) nor self-reported fatigue worsened significantly in HCPs who performed BLS on pediatric manikins while wearing PPE. This suggests that the current pediatric BLS recommendation for chest-compression providers to switch every 2 minutes need not be altered with PPE use.¹³

CONCLUSION

Survival after cardiac arrest requires an integrated system of HCPs, training, equipment, and organizations. BLS providers, among others working within EMS systems, contribute to successful resuscitation from out-of-hospital cardiac arrest. Within the U.S. healthcare system, the work of HCPs such as pharmacists supports resuscitation outcomes, and pharmacists should be cognizant of and certified in the latest updates from the 2020 AHA pediatric guidelines.

REFERENCES

1. Topjian AA, Raymond TT, Atkins D, et al. Part 4: pediatric basic and advanced life support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16 suppl 2):S469-S523.
2. Nolan JP, Machonochie I, Soar J, et al. Executive summary: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020;142;16(suppl 1):S2-S27.
3. Maconochie IK, Aickin R, Hazinski MF, et al. Pediatric life support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2020;156:A120-A155.
4. Duff JP, Topjian AA, Berg MD, et al. 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;140(24):e904-e914.
5. Khera R, Tang Y, Girotra S, et al. Pulselessness after initiation of cardiopulmonary resuscitation for bradycardia in hospitalized children. Circulation. 2019;140(5):370-378.
6. Donoghue A, Berg RA, Hazinski MF, et al. Cardiopulmonary resuscitation for bradycardia with poor perfusion versus pulseless cardiac arrest. Pediatrics. 2009;124(6):1541-1548.
7. Berg RA, Sanders AB, Kern KB, et al. Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest. Circulation. 2001;104(20):2465-2470.
8. Kern KB, Hilwig RW, Berg RA, et al. Importance of continuous chest compressions during cardiopulmonary resuscitation: improved outcome during a simulated single lay-rescuer scenario. Circulation. 2002;105(5):645-649.
9. Sutton RM, Reeder RW, Landis WP, et al. Ventilation rates and pediatric in-hospital cardiac arrest survival outcomes. Crit Care Med. 2019;47(11):1627-1636.
10. Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 suppl 3):S876-S908.
11. Berg MD, Schexnayder SM, Chameides L, et al. Part 13: pediatric basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 suppl 3):S862-S875.
12. Edelson DP, Sasson C, Chan PS, et al. Interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed COVID-19: from the Emergency Cardiovascular Care Committee and Get With the Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association. Circulation. 2020;141(25):e933-e943.
13. Donoghue AJ, Kou M, Good GL, et al. Impact of personal equipment on pediatric cardiopulmonary resuscitation performance: a controlled trial. Pediatr Emerg Care. 2020;36(6):267-273.

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