Dr David Zideman,
Hammersmith Hospital, London, UK

Introduction		Treatment Algorithms
Paediatric Life Support		Resuscitation of the Newborn
Age Definitions		Newborn Basic Life Support
Anatomy		Newborn Advanced Life Support
Basic Life Support		Conclusion
Advanced Life Support		Further Reading
Drugs

Introduction

Paediatric Resuscitation is an essential cornerstone in the practice of paediatric anaesthesia. It is fundamental that all who treat infants and children are well versed in simple basic life support and that those who are required to perform the more complex skills are taught and regularly practise the advanced life support procedures.

Resuscitation of infants and children is different from adult resuscitation. Although there may be many similarities in the methodologies used in the resuscitation protocols with those used in adults, paediatric life support is governed by the fact that it begins from a different starting point. Adult sequences are based on the observation that the majority will be primarily cardiac in origin; they are therefore rapid and immediate in onset giving little or no warning of their occurrence and usually requiring a rapid defibrillation to achieve any measure of success. In infants and children the cause is usually a primary respiratory event which leads to the final cardiac event if not recognised and dealt with promptly^1-5. Primary cardiac arrest in children is rare and ventricular fibrillation and ventricular tachycardia have been reported in less than 15% of the study population in the young^6-8. The aetiology and pathogenesis of sudden death in this age group is therefore important. Many children have had a relatively long 'pre-arrest' phase, cardiac arrest signalling the end of a progressive physiological decline. It could be argued in such events early recognition and aggressive therapy could prevent many deaths in this 'pre-arrest' phase but, unfortunately, some will remain irreversible despite all the best efforts of the carers.

Trauma is the one cause of cardiac arrest where children and adults overlap. Trauma is the most common cause of death in the first four decades of life. Again, it could be argued that trauma is preventable and, even more importantly, cardiac arrest secondary to trauma can in some cases be prevented by careful correct management of the airway, breathing and circulation of the trauma victims before managing the secondary injuries.

The outcome of paediatric life support is poor. Survival rates are quoted at between 3 and 17%^1,2,5,8-16 and can be considered even more dismal when the majority are reported as showing significant neurological impairment after arrest. Outcome is related to the aetiology of the initial event. Better outcomes have been reported when the primary event was respiratory ^{10, 16, 17} rather than cardiac in nature.^10,11,18

The audit and analysis of paediatric life support events is complex. Events are relatively uncommon and many studies have to collect data over many years and still have small sample numbers. In the BRESUS study in the United Kingdom only 2% of the victims were aged under 14 years¹⁹. In an American study surveying 15 years of prehospital events, only 7% of victims were below 30 years of age and only 3.7% were under 8 years old⁶. Furthermore the definitions used in evaluating events are inconsistent and often not comparable from study to study. In an effort to improve our knowledge of paediatric life support and its outcome a revised reporting template was formulated. This, the Paediatric Utstein Style Guidelines,²⁰ it is hoped, will help to standardise the reporting of outcomes of Paediatric Life Support and thereby provide an evidence based practice of comparable data sets to establish the true worth of these events.

One conclusion that is clear is that infants and children who progress to cardiac arrest have a very poor prognosis. Because of the aetiology of resuscitation in these age groups it is important that the pre-event symptoms are recognised early and treated effectively before there is respiratory collapse and the inevitable cardiac arrest. Therefore in paediatric life support prevention and recognition of the impending event is a major factor in the overall survival. 

Paediatric Life Support

Guidelines for paediatric life support have been published by a number of national organisations^21-24. In 1992 an International Liaison Group was established to examine the basic scientific data, analyse the national differences and to make recommendations formulated on science which would form the basis of international guidelines to be used in the future by individual national organisations. In 1997 the International Liaison Committee on Resuscitation (ILCOR), a multinational committee comprised of members representing most of the major national resuscitation organisations published a series of advisory statements including a paediatric statement²⁵.

In 1998 the European Resuscitation Council published its revised recommendations for resuscitation of infants and children, and for the resuscitation of babies at birth^26-28. 

Age definitions

Paediatric life support deals with the resuscitation of infants and children. Because of the wide variation in anatomy, physiology and epidemiology throughout the paediatric age band it is therefore important to define various age ranges in an effort to rationalise treatment. 

Anatomy

The size of a child is an obvious important consideration in determining the practical resuscitation protocol to be followed. Age will determine the finer details of the procedures to be performed especially in basic life support.

An infant is a child under the age of one year.

A child is aged between 1 and 8 years of age.

Children over the age of 8 years should still be treated as younger children but may require different techniques to attain adequate chest compressions.

The upper age limit of 8 years for children has been proposed as a watershed particularly in relation to the technique of chest compression. A small child under the age of eight will probably receive adequate chest compressions using a 'one-handed' technique. An older or larger child will probably require a 'two-handed' (adult) technique to achieve an adequate depth of compression. Nonetheless, because of the variability of size in children no definitive upper age limit can be stipulated and the rescuer must judge the effectiveness of the resuscitation and adapt his technique appropriately.

Adult resuscitation protocols have also been modified by the European Resuscitation Council to dovetail with the above definitions^29,30. They require the rescuer to determine the cause of the arrest and where this is not primarily cardiac in origin, for example trauma or drowning, to use a protocol that more closely aligns to the paediatric recommendations. 

(Continued ...)

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