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Joseph Dunn is a nurse in the pediatric intensive care unit at Shriners Hospital for Children Northern California in Sacramento, and a member of the Pediatric/Neonatal Transport Team at the University of California San Francisco Medical Center. He has been a PALS instructor for 5 years.

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A Karen Zahn, RN, CCRN, and Joseph Dunn, RN, CCRN, reply:

The American Heart Association’s Subcommittee on Pediatric Resuscitation has made major changes to the PALS course. These changes are the result of an exhaustive effort of more than 500 experts who reviewed more than 25000 articles. This review of the literature provided the scientific basis for the changes to PALS, and the 2002 PALS Provider Manual includes these recommendations.¹ We will briefly cover some major changes to the curriculum but encourage readers to attend a PALS course or review the 2002 PALS Provider Manual for an in-depth understanding of the changes in the curriculum and the rationale for these changes.

The new guidelines reaffirm that adequate oxygenation and ventilation can be successfully obtained in infants and children using the bag and mask. Tracheal intubation is difficult in infants and children and should be performed by those trained in this procedure. The new guidelines also recommend the use of secondary confirmation of tracheal tube placement after intubation. This secondary confirmation includes evaluation of exhaled carbon dioxide and oxygenation. The use of the laryngeal mask airway is an addition to the 2002 PALS guidelines as an alternative for airway management in unresponsive patients.

The use of intraosseous access was previously recommended for children younger than 6 years of age when vascular access could not be rapidly achieved. The new guidelines recommend the use of intraosseous access in patients of any age when vascular access cannot be rapidly achieved. The rationale for this change is the successful use of the intraosseous needle in older children. The PALS guidelines no longer recommend the 90 seconds or 3 attempts at intravenous access before use of the intraosseous needle. The intraosseous route may be preferable in some patients when vascular assess is difficult, for example, in patients who are experiencing cardiac arrest.

Changes in the medications for PALS include the addition of amiodarone to the pediatric treatment algorithms, the elimination of bretylium from the algorithms, and the de-emphasis of high-dose epinephrine. Amiodarone, an antiar-rhythmic agent, is included in the pediatric pulseless arrest algorithm and may be considered in ventricular fibrillation or ventricular tachycardia that is refractory to defibrillation and epinephrine. Amiodarone is also included in the pediatric tachycardia algorithm and may be considered for the treatment of infants and children with stable wide-complex tachycardia. The use of amiodarone is considered an alternative medication in the pediatric tachycardia with poor perfusion algorithm. Cardioversion remains the initial treatment of choice for patients with wide-complex tachycardia with poor perfusion.

The use of bretylium for ventricular tachycardia or fibrillation is no longer recommended because there is a lack of evidence of its efficacy in children. The new guidelines de-emphasize the use of high-dose epinephrine in the treatment of pulseless arrest in children. The rationale for this change is the lack of data showing improved outcomes with the use of high-dose epinephrine and some evidence that it may cause adverse effects in the postresuscitation period.

Previous PALS guidelines did not recommend the use of automated external defibrillators (AEDs) in children. However, increasing evidence show that ventricular fibrillation may be more common in the pediatric population than previously realized. Early defibrillation may increase the likelihood for survival. Although experience with AEDs in children is limited, the current recommendation in the PALS guidelines is that use of AEDs in the prehospital environment in children older than 8 years and weighing more than 25 kg is acceptable. Healthcare professionals in the hospital environment should continue to use defibrillators that can deliver appropriate pediatric energy doses.

The 2002 PALS guidelines also recommend the use of vagal maneuvers for the treatment of supraventricular tachycardia in children. These maneuvers should not delay cardioversion or use of adenosine in unstable children. The most effective vagal maneuver for infants and small children is ice applied to the face. Other maneuvers may be tried in older children.

There are several changes in basic life support aimed at children older than 8 years. Because the incidence of sudden cardiac death from ventricular fibrillation, in this age group, is higher than previously believed, a change was prompted from "call fast"—perform 1 minute of cardiopulmonary resuscitation (CPR)—to "call first," very similar to the adult basic life support algorithm. Consequently, CPR has changed; the ventilation-breaths ratio is now 15:2 , just as in adult basic life support.

Changes in neonatal resuscitation programs have actually simplified most algorithms. When meconium is observed in the amniotic fluid, direct tracheal suctioning is only indicated if the infant has poor muscle tone, a heart rate less than 100 beats/min, or depressed respirations.

The need for infant CPR was previously based on a range of heart rates. The new guidelines state that CPR should be initiated if the infant’s heart rate is less than 60 beats/min. Ventilation is emphasized with compressions added for infants with a low heart rate of 60 beats/min. Depth of compression is not measured in inches, but simply referred to as pressure to generate a palpable pulse. The neonatal ratio remains 3 compressions to 1 breath at 120 beats/min.

Albumin 5% was recommended for volume expansion in the previous guidelines. Because of limited availability and the possible exposure to infectious disease, this drug is no longer recommended. Neonatal resuscitation program providers are cautioned about hyperthermia, which has been associated with respiratory depression. In the 2002 PALS guidelines, cerebral hypothermia is mentioned as a promising new treatment for asphyxiated infants.

Ethical issues in neonatal resuscitation programs are the most controversial. The 2002 PALS guidelines list circumstances in the delivery room in which nonresuscitation may be appropriate: confirmed gestation of 23 weeks or less, birthweight less than 400 g, anencephaly, or confirmed trisomy 13 or 18 syndrome. The previous guidelines did not mention specific conditions that might be considered nonresuscitive. The circumstances mentioned require discussions with parents, family members, and staff.

Reference

1. Hickey RW, ed. PALS Provider Manual. Dallas, Tex: American Heart Association; 2002.

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