Changes to APLS Guidelines

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Changes to APLS Guidelines

• SpR Training Day
• 24th February 2006

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Changes?

• Published by UK Resuscitation Council in December
  2005
• Implemented by QMC February 2005
• Not yet incorporated into ALSG courses

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DONT PANIC!

• The updated treatment recommendations in
  Guidelines 2005 do not define the only way that
  resuscitation should be achieved, they merely
  represent a widely accepted view of how
  resuscitation can be undertaken both safely and
  effectively.
• The publication of new treatment recommendations
  does not imply that current clinical care is
  either unsafe or ineffective.

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Changing Behaviour
Long term change
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Objectives

• Why change?
• Paediatric BLS
• Paediatric ALS
• Questions

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Why Change?

• New scientific evidence
• Simplification
• Consistency

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Paediatric BLS

• Compressionventilation ratios
• Age definitions
• Foreign body airway obstruction sequence

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Bystander Resus
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Duty to Respond Paediatric BLS
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FBAO
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Paediatric ALS

• IV or IO (rather than into trachea)
• Either cuffed or uncuffed tubes
• One shock not three - 4J/KG
• Adrenaline dose 10mcg/kg

• AEDs
• Other Drugs
• Temperature Control
• Parental Presence

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Paediatric ALS

• Shock energy level 4J/Kg
• Biphasic as effective as monophasic and less
  post-shock myocardial dysfunction
• No difference between 2-4J/Kg
• Adrenaline 10mcg/kg
• Vasoconstricts, improves CPP, improved
  contractility, stimulates spont. contraction,
  more intense VF
• No evidence of improved outcome with high dose
  and maybe worse outcome

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AEDs

• Standard AED can be used in children over 8yrs
• Purpose made pads/programs for children 1-8 yrs
• IF NOT AVAILABLE
• Unmodified adult AED gt 1yr old
• Insufficient evidence for lt 1yr old

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Paediatric ALS

• Several studies show no greater risk from cuffed
  tubes
• Correct size, position and inflation pressure
• May be preferable in some circumstances
• Shock sequence
• High success rate from 1st shock
• Less interruption of CPR

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Paediatric ALS

• Amiodarone
• Membrane stabilising drug
• Increases duration of action potential and
  refractory period
• Slows AV conduction
• Mild negative inotrope
• Peripheral vasodilatation
• 5mg/kg diluted in D5
• Large/central vein

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Paediatric ALS

• Atropine
• For bradycardia unresponsive to ventilation and
  circulatory support
• 20mcg/kg (max 600mcg min 100mcg)
• Magnesium
• Arrythmia due to hypomagnesaemia or polymorphic
  VT torsade de pointes
• MgSO4 ivi 25-50mcg/kg (max 2g) over several
  minutes

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Paediatric ALS

• Calcium
• may have detrimental effects on ischameic
  myocardium and impair cerebral recovery
• thus only if indicated
• Hypocalcaemia
• Hyperkalaemia
• Ca channel blocker OD
• Dose 0.2mls/kg of 10 Calcium chloride
• Slow IV if spontaneous circulation
• Fast IV push if arrest

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Paediatric ALS

• Sodium Bicarbonate
• Arrest leads to mixed acidosis
• Giving bicarb generates CO2
• Exacerbates intracellular acidosis
• Produces a negative inotropic effect on ischaemic
  myocardium
• Large osmotically active sodium load to already
  compromised circulation and brain
• Left shift in oxygen dissociation curve
  inhibiting release of oxygen to tissues
• Prolonged arrest, hyperkalaemia and TCA overdose
• 1-2ml/kg of 8.4 solution

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Paediatric ALS

• Temperature
• Mild hypothermia suppresses many of chemical
  reactions associated with reperfusion injury
• Some evidence of benefit from adults
• If core temp lt37.5C DO NOT rewarm
• If lt33C rewarm to 34C
• If temp gt37.5 then cool
• Prevent shivering by sedation/nm blockade

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Paediatric ALS

• Studies show benefits for families who are
  present at resus
• Dedicated staff member
• If impeding then alternative arrangements
• Team leader decides when to stop
• Team debrief

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Summary

• Changes are in response to new evidence and drive
  for simplification
• Dont delay start of compressions and emphasis on
  continuous CPR
• Changes to timing/doses of adrenaline and shocks

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BUT

• Some CPR is always better than NO CPR
• If you cant remember the new way do it the old
  way

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Questions?