The latest in paediatric resuscitation recommendations

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Hospital General Universitario Gregorio Marañón, Madrid, Instituto de investigación sanitaria, Hospital Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Grupo Español de Reanimación Cardiopulmonar Pediátrica y Neonatal, Red de Salud Maternoinfantil y del Desarrollo (RedSAMID), RETICS, ISCIII, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Área de Pediatría, Servicio de Críticos, Intermedios y Urgencias Pediátricas, Hospital Clínico Universitario de Santiago de Compostela, Grupo de Investigación CLINURSID, Departamento de Enfermería, Universidade de Santiago de Compostela, Instituto de Investigación de Santiago (IDIS), Red de Salud Maternoinfantil (SAMID II), RETICS, ISCIII, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "SAMUR-Protección Civil, Madrid, Grupo Español de Reanimación Cardiopulmonar Pediátrica y Neonatal, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Emérito SAS, Asociado a UGC Críticos y Urgencias Pediátricas, Hospital Regional Universitario de Málaga, Grupo Español de Reanimación Cardiopulmonar Pediátrica y Neonatal, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Centro de Salud de Barranco Grande, Tenerife, Grupo Español de Reanimación Cardiopulmonar Pediátrica y Neonatal, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Centro de Salud Integrado Burriana II, Castellón, Grupo Español de Reanimación Cardiopulmonar Pediátrica y Neonatal, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Servicio de Pediatría, Hospital Dr. Peset, Valencia, Grupo Español de Reanimación Cardiopulmonar Pediátrica y Neonatal, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Servicio de Críticos y Urgencias Pediátricas, Instituto Valenciano de Pediatría, Grupo Español de Reanimación Cardiopulmonar Pediátrica y Neonatal, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Novedades en las recomendaciones de reanimación cardiopulmonar pediátrica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1604 "Ancho" => 1724 "Tamanyo" => 163005 ] ] "descripcion" => array:1 [ "en" => "Advanced life support algorithm for nonshockable rhythms." ] ] ] "textoCompleto" => "IntroductionCardiac arrest (CA) in children carries a high morbidity and mortality. Research on cardiopulmonary resuscitation (CPR) is very complex,<a class="elsevierStyleCrossRefs" href="#bib0140">1–3</a> and advances come at a slow pace. Nevertheless, the outcomes of paediatric CPR have improved considerably with the diffusion of international CPR guidelines and the education of health care professionals and the general population.<a class="elsevierStyleCrossRefs" href="#bib0140">1–3</a>The International Liaison Committee on Resuscitation (ILCOR) reviews advances in CPR and develops the international Consensus on Science with Treatment Recommendations (CoSTR) every five years.<a class="elsevierStyleCrossRefs" href="#bib0155">4,5</a> The European Resuscitation Council develops its guidelines for resuscitation based on the CoSTR<a class="elsevierStyleCrossRefs" href="#bib0160">5–8</a> and assumes that the recommended strategiesneed to be adapted in each country.<a class="elsevierStyleCrossRef" href="#bib0165">6</a> The Spanish paediatric CPR recommendations developed by the Spanish Group on Paediatric and Neonatal CPR are an adaptation of the European recommendations.<a class="elsevierStyleCrossRef" href="#bib0160">5</a>This article summarises the 2015 paediatric CPR recommendations,<a class="elsevierStyleCrossRefs" href="#bib0155">4,5</a> emphasising the main changes from the previous recommendations.<a class="elsevierStyleCrossRef" href="#bib0180">9</a>Cardiac arrest prevention<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsit0245">–Identification of children at risk of CA: a significant percentage of children that experience CA do so following a period of clinical decompensation. Thus, early recognition of patient deterioration is crucial in reducing morbidity and mortality in seriously ill children.</li><li class="elsevierStyleListItem" id="lsti0005">–Action: in children at risk of CA, it is very important to follow a structured assessment and intervention scheme adhering to the following sequence: A (airway), B (breathing), C (circulation), D (disability/neurologic) and E (exposure). The child should be reevaluated frequently following this sequence.</li><li class="elsevierStyleListItem" id="lsti0010">–Organisation of CA care: each hospital must decide how to organise CA care based on its particular characteristics, taking into account that rapid response teams can reduce adverse events and improve outcomes associated with CA in hospitalised children.<a class="elsevierStyleCrossRef" href="#bib0185">10</a></li><li class="elsevierStyleListItem" id="lsti0015">–Volume expansion: expansion is needed in cases of absolute or relative hypovolaemia (septic or anaphylactic shock). Although the solution used most frequently for initial expansion continues to be physiological saline solution, balanced crystalloids are less likely to lead tohyperchloraemic acidosis.<a class="elsevierStyleCrossRef" href="#bib0190">11</a> The findings of a large-scale study in African children with febrile illness found that mortality was higher in patients that received a fluid bolus compared to patients that did not.<a class="elsevierStyleCrossRef" href="#bib0195">12</a> Due to the potential risks in volume expansion, administration of a fluid bolus in children with febrile illness when circulatory failure is absent is currently not recommended.<a class="elsevierStyleCrossRef" href="#bib0160">5</a></li><li class="elsevierStyleListItem" id="lsti0020">–Treatment of arrhythmias: in children with supraventricular tachycardia that do not respond to vagal manoeuvres and/or drugs and require electrical treatment (synchronised cardioversion), an initial dose of 1J/kg is recommended.<a class="elsevierStyleCrossRef" href="#bib0160">5</a> The previous recommendation was an initial dose of 0.5J/kg.<a class="elsevierStyleCrossRef" href="#bib0180">9</a></li></ul>Diagnosis of cardiac arrest<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025">–Diagnosis of CA: palpation of a pulse is not reliable as the sole determinant of the need for chest compressions.<a class="elsevierStyleCrossRef" href="#bib0200">13</a> Thus, in the absence of signs of life in the child, chest compressions should be initiated unless rescuers are certain that they can feel a central pulse within 10s.</li><li class="elsevierStyleListItem" id="lsti0030">–Echocardiography: echocardiography may help to detect cardiac activity and some potentially treatable causes of CA, but its use should not interfere with performance of CPR manoeuvres.</li></ul>Basic life support<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035">–Basic life support (BSL) algorithm: <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> summarises the steps performed in basic paediatric life support. The manoeuvres are the same as those in the 2010 recommendations.<a class="elsevierStyleCrossRefs" href="#bib0160">5,9</a><elsevierMultimedia ident="fig0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0040">–Sequence of actions: there is no evidence supporting the superiority of the CAB sequence (compressions, airway and breathing) over the ABC sequence (airway, breathing and compressions).<a class="elsevierStyleCrossRefs" href="#bib0155">4,14</a> Current European<a class="elsevierStyleCrossRef" href="#bib0160">5</a> and Spanish recommendations maintain the ABC sequence, which is the one that has been taught thus far. Furthermore, the cause of CA in children is often respiratory, and thus ventilation is essential to recover from CA. Therefore, in children, after assessing and opening the airway, five initial rescue breaths followed by 1min of CPR should be performed before going for assistance.</li><li class="elsevierStyleListItem" id="lsti0045">–Duration of breaths: the recommended duration of delivering a breath in BSL is approximately 1s so that recommendations for children and adults in the general population coincide, facilitating learning.</li><li class="elsevierStyleListItem" id="lsti0050">–Compressions with rescue breathing versus compression-only: CPR with compressions and rescue breathing is superior to compression-only CPR.<a class="elsevierStyleCrossRef" href="#bib0140">1</a> The recommendation for children with CA is to perform rescue breathing and chest compressions. Rescuers that do not know how to give rescue breaths may use compressions only, as this is preferable to doing nothing.</li><li class="elsevierStyleListItem" id="lsti0055">–Depth of compressions: in chest compressions, the sternum should be depressed by at least a third of the anterior-posterior diameter of the chest (approximately 4cm in infants and 5cm in children). However, assessing the depth of compression during CPR is very complicated. Some devices allow its measurement, but there is no evidence of their usefulness in guiding CPR in children.<a class="elsevierStyleCrossRef" href="#bib0210">15</a></li><li class="elsevierStyleListItem" id="lsti0060">–Chest compression technique in infants: if there is only one rescuer, compression with two fingers perpendicular to the sternum facilitates the coordination of chest compressions and breaths. However, if at least two rescuers are present, the chest should be compressed with two hands using the encircling method, as it is more effective.</li><li class="elsevierStyleListItem" id="lsti0065">–Activation of emergency system: if a child becomes unconscious, it is vital to get help quickly. If only one rescuer is present, CPR should be performed for 1min before going for help. If there are at least two rescuers, one should initiate CPR while the other seeks assistance. A lone rescuer should only seek assistance first and then initiate resuscitation in the rare instance that the child suddenly collapses and the rescuer suspects primary cardiac arrest, as the child will likely need defibrillation.</li><li class="elsevierStyleListItem" id="lsti0070">–Automated external defibrillator (AED): CPR should never be discontinued to go seek an AED unless ventricular arrhythmia is suspected as the cause of CA and the AED is nearby and accessible. In children aged more than 8 years or weighing more than 25kg, the AED should be used with adult-size paddles. Paediatric paddles should be used in children aged 1–8 years (attenuated paddles delivering 50–75J). Adult pads should be used whenever paediatric paddles are not available.</li><li class="elsevierStyleListItem" id="lsti0075">–Foreign body airway obstruction (FBAO): there are no changes in the treatment recommendations (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), as there has been no further research on this subject. Back blows, chest thrusts and chest compressions are used to try to increase intrathoracic pressure to push out the foreign body. If one of these measures is not effective, the others can be attempted on rotation until the object is cleared or the obstruction is relieved. However, rotating the three manoeuvres is difficult to learn, remember and implement in a life-threatening situation. For this reason, the Spanish Group on Paediatric and Neonatal CPR recommends rotating back blows and chest thrusts in infants, and back blows and abdominal thrusts in children in groups of five as long as the child remains conscious.<elsevierMultimedia ident="fig0010"></elsevierMultimedia></li></ul>Paediatric advanced life support<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0080">–The ABC sequence used in BLS should also be applied to advanced life support (ALS).</li></ul>Airway<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0085">–Bag ventilation and supraglottic devices: bag-mask ventilation is the initial method used in airway management and ventilation during CPR in children. However, supraglottic devices (laryngeal mask and others) may be helpful in airway management when used by well-trained rescuers.</li><li class="elsevierStyleListItem" id="lsti0090">–Endotracheal intubation: cuffed tracheal tubes are as safe as uncuffed ones and reduce air leaks. However, an excessive cuff pressure can cause damage to the larynx and secondary stenosis. Thus, after the return of spontaneous circulation (ROSC), cuff inflation pressure should be monitored and maintained at less than 25cm H2O.</li><li class="elsevierStyleListItem" id="lsti0095">–Newly developed laryngoscopes: new laryngoscopes may facilitate complicated intubations if the rescuer is trained in their use, although there is still little evidence on their use in children.<a class="elsevierStyleCrossRef" href="#bib0215">16</a></li><li class="elsevierStyleListItem" id="lsti0100">–Confirmation of tube placement: physical examination (chest wall movement and auscultation), vital signs and capnography can be used to confirm tube placement, but none of these methods is completely reliable. The presence of a capnographic waveform for more than four breaths is a good indicator of correct placement, but the absence of exhaled CO2 during CPR does not guarantee tube misplacement, as it may be due to reduced pulmonary blood flow. However, if the child is in CA and exhaled CO2is not detected despite adequate chest compressions, or there is any doubt as to the tube position, the placement of the tube should be confirmed by laryngoscopy.<a class="elsevierStyleCrossRef" href="#bib0165">6</a></li></ul>Ventilation and oxygenation<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0105">–Oxygen: when performing CPR in children, except in newborns, oxygen should be given at the highest possible concentration (100%), as hypoxia is more frequent and harmful than hyperoxiain this situation. Once there is ROSC, the fraction of inspired oxygen (FiO2) should be titrated to maintain SpO2 in the range of 94–98%.</li><li class="elsevierStyleListItem" id="lsti0110">–Respiratory rate: there are no reliable data to determine the most appropriate respiratory rate during CPR and after ROSC in children.</li><li class="elsevierStyleListItem" id="lsti0115">–Non-intubated patients: the European guidelines recommend using a ratio of 15 chest compressions to 2 breaths and a compression rate of 100–120 compressions per minute during BLS and ALS if the child is not intubated.</li><li class="elsevierStyleListItem" id="lsti0120">–Intubated patients: once the child is intubated, ventilation should be maintained at a rate of 10 breaths per minute without interrupting the chest compressions. Care should be taken to ensure that lung inflation is adequate during chest compressions.</li><li class="elsevierStyleListItem" id="lsti0125">–After ROSC: once ROSC has been achieved, normal ventilation (in rate and volume) should be provided based on the child's age and illness, and end-tidal CO2 and blood gases should be monitored to achieve normal PaCO2 and PaO2 values.</li><li class="elsevierStyleListItem" id="lsti0130">–Capnography: an end-tidal CO2 higher than 15mmHg may be an indicator of adequate resuscitation. However, the current evidence does not suffice to support the use of a specific threshold end-tidal CO2 value as an indicator for the quality of CPR, as a sign of return of spontaneous circulation or for the discontinuation of resuscitation.</li></ul>Circulation<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0135">–Vascular access: peripheral venous access is the access of choice, but it may be difficult to establish in children during CPR. Thus, if venous access cannot be attained within 1min, an intraosseous needle should be inserted and maintained only until definitive intravenous access is established. The tracheal route is not recommended for the administration of drugs unless no other route is available.</li><li class="elsevierStyleListItem" id="lsti0140">–Sodium bicarbonate: there is no evidence that supports the routine administration of sodium bicarbonate during CPR. Its administration can be considered in children with prolonged CA (for instance, lasting more than 10min) and/or severe metabolic acidosis.</li><li class="elsevierStyleListItem" id="lsti0145">–Atropine: atropine is only recommended for bradycardia caused by increased vagal tone or cholinergic drug toxicity. The most commonly used dose is 20μg/kg. In cases of bradycardia with poor peripheral perfusion unresponsive to ventilation and oxygenation, adrenaline is the first-line drug.</li></ul>Diagnosis and treatment of arrhythmias<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0150">–ECG monitoring: cardiac monitoring should be initiated as soon as possible. However, since most cardiac rhythms in children with CA are nonshockable, initial efforts should prioritise ventilation, chest compressions, establishing vascular access and administering adrenaline rather than wasting time searching for a monitor.</li><li class="elsevierStyleListItem" id="lsti0155">–The most common ECG patterns in children with CA are bradycardia, asystole and pulseless electrical activity.<a class="elsevierStyleCrossRefs" href="#bib0150">3,17</a> If a child with bradycardia (heart rate <60bpm in the absence of signs of life) does not respond quickly to ventilation with oxygen, chest compressions should be started immediately and adrenaline administered.</li><li class="elsevierStyleListItem" id="lsti0160">–Ventricular fibrillation and pulseless ventricular tachycardia are present in fewer than 20% of cases of CA in children. The incidence of shockable rhythms increases with age, and they are more likely to occur in children that collapse suddenly or with underlying heart disease.</li><li class="elsevierStyleListItem" id="lsti0165">–The algorithm for ALS is presented in <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>, and the algorithms for nonshockable and shockable rhythms in <a class="elsevierStyleCrossRefs" href="#fig0020">Figs. 4 and 5</a>.<elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0170">–Defibrillators: manual defibrillators must be available in all health care facilities. If a manual defibrillator is not available, an AED may be used, as these devices can recognise shockable paediatric rhythms.<a class="elsevierStyleCrossRef" href="#bib0225">18</a></li><li class="elsevierStyleListItem" id="lsti0175">–Defibrillation pads and paddles: self-adhesive pads facilitate CPR by reducing the time that chest compressions are discontinued to deliver the shock.</li><li class="elsevierStyleListItem" id="lsti0180">–Energy dose for electric shocks: in Europe, a dose of 4J/kg is still recommended for every shock.</li><li class="elsevierStyleListItem" id="lsti0185">–Antiarrhythmic drugs: administration of one 5mg/kg dose of amiodarone as a rapid bolus after the third shock is recommended, and can be repeated after the fifth shock. A recent study has reinforced that lidocaine may be useful in shockable rhythms in children.<a class="elsevierStyleCrossRef" href="#bib0230">19</a> However, the European guidelines continue to recommend amiodarone as the drug of choice for shockable rhythms that do not respond to defibrillation. It must be kept in mind that during CA, amiodarone must be administered as a rapid bolus. Conversely, when amiodarone is administered to treat other cardiac rhythm disturbances in children that are not in CA, it must be injected slowly over 10–20min with systemic BP and ECG monitoring.<a class="elsevierStyleCrossRef" href="#bib0235">20</a></li><li class="elsevierStyleListItem" id="lsti0190">–<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> provides a summary of the dosage of different drugs during paediatric CPR.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia></li></ul>Life support in special circumstances<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0195">–Extracorporeal membrane oxygenation (ECMO): the use of ECMO can be considered in children with CA due to a potentially reversible cause and refractory to conventional CPR if the child is in a facility with the necessary resources, trained staff and organisation allowing for quick initiation of ECMO.</li><li class="elsevierStyleListItem" id="lsti0200">–Life support in trauma patients: cardiac arrest from major trauma is associated with a high mortality. Resuscitation in these patients does not differ from the routine management of CA from other causes, although the use of resuscitative thoracotomy can be considered in children with penetrating injuries.</li><li class="elsevierStyleListItem" id="lsti0205">–Pulmonary hypertension: children with pulmonary hypertension are at increased risk of CA. These patients should be managed with a high FiO2, alkalosis and hyperventilation, which may be as effective as inhaled nitric oxide in reducing pulmonary vascular resistance.<a class="elsevierStyleCrossRef" href="#bib0240">21</a></li></ul>Postresuscitation care<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0210">–Coordinated care: Postresuscitation care must be a coordinated multidisciplinary activity and include all the treatments needed for complete neurologic recovery.</li><li class="elsevierStyleListItem" id="lsti0215">–Haemodynamic treatment: treatment must be adjusted to maintain a systolic blood pressure above the 5th percentile for age. After resuscitation, it is important to avoid hypotension, as this factor is associated with significantly worse outcomes.<a class="elsevierStyleCrossRef" href="#bib0245">22</a></li><li class="elsevierStyleListItem" id="lsti0220">–Oxygenation and ventilation: once the child is stabilised, management must aim for a normal PaO2 range. There is insufficient evidence to suggest a specific PaCO2 target after ROSC in children, and both hypocapnia and hypercapnia are associated with a poor prognosis.<a class="elsevierStyleCrossRef" href="#bib0250">23</a>Aiming for normocapnia is recommended, adapting to the needs of each patient.<a class="elsevierStyleCrossRef" href="#bib0160">5</a> Therefore, it would be appropriate to initiate ventilation with a normal rate and volume, adjusting them to the child's age and illness, while monitoring end-tidal CO2and blood gas levels.</li><li class="elsevierStyleListItem" id="lsti0225">–Temperature: the THAPCA study did not find significant differences in neurologic status at one year from CA between children treated with hypothermia and children treated with normothermia.<a class="elsevierStyleCrossRef" href="#bib0255">24</a> On the other hand, fever after ROSC has been associated with a poorer prognosis.<a class="elsevierStyleCrossRef" href="#bib0260">25</a> Therefore, the current recommendation is to keep a strict control of temperature after ROSC, preventing both hyperthermia (>37.5°C) and severe hypothermia (<32°C), maintaining the patient in normothermia or mild hypothermia.</li><li class="elsevierStyleListItem" id="lsti0230">–Glucose: glucose levels must be monitored after resuscitation, avoiding hyperglycaemia and hypoglycaemia, as both are associated with impaired outcomes.</li><li class="elsevierStyleListItem" id="lsti0235">–Prognosis of CA: the duration of CPR, the cause of arrest, pre-existing medical conditions, age, site of arrest, whether the arrest was witnessed, the duration of untreated CA, the presence of a shockable rhythm and special circumstances such as icy water drowning or exposure to toxic drugs are significant prognostic factors in children with CA.<a class="elsevierStyleCrossRefs" href="#bib0140">1,5</a> However, there is no single reliable predictor of outcome after CPR. In adults, a multidisciplinary approach combining physical examination, electroencephalography, electrophysiology, imaging tests and biomarkers can guide prognostication starting at 72h after ROSC.<a class="elsevierStyleCrossRef" href="#bib0265">26</a></li><li class="elsevierStyleListItem" id="lsti0240">–Parental presence: in some countries, parents often want to be present while CPR is performed on their children, which facilitates the grieving process. However, evidence on this subject cannot be generalised to all of Europe, where there may be different sociocultural characteristics. Therefore, parental presence will depend on the characteristics of both the parents and the resuscitation team.<a class="elsevierStyleCrossRef" href="#bib0270">27</a></li></ul>FundingRETICS funded by Spain's PN I+D+I 2013-2016 (National Plan for Scientific Research, Development and Innovation), Instituto de Salud Carlos III – Sub-Directorate General for Research Assessment and Promotion and the European Regional Development Fund (ERDF), ref. RD16/0022.Conflict of interestsThe authors have no conflict of interests to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres820056" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec817005" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres820055" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec817006" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Cardiac arrest prevention" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Diagnosis of cardiac arrest" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Basic life support" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Paediatric advanced life support" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Airway" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Ventilation and oxygenation" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Circulation" ] 3 => array:2 [ "identificador" => "sec0045" "titulo" => "Diagnosis and treatment of arrhythmias" ] 4 => array:2 [ "identificador" => "sec0050" "titulo" => "Life support in special circumstances" ] ] ] 9 => array:2 [ "identificador" => "sec0055" "titulo" => "Postresuscitation care" ] 10 => array:2 [ "identificador" => "sec0060" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflict of interests" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-10-14" "fechaAceptado" => "2016-11-11" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec817005" "palabras" => array:7 [ 0 => "Cardiac arrest" 1 => "Cardiopulmonary resuscitation" 2 => "Basic life support" 3 => "Advanced life support" 4 => "Resuscitation recommendations" 5 => "Post-resuscitation care" 6 => "Children" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec817006" "palabras" => array:7 [ 0 => "Parada cardiaca" 1 => "Reanimación cardiopulmonar" 2 => "Reanimación cardiopulmonar básica" 3 => "Reanimación cardiopulmonar avanzada" 4 => "Recomendaciones de reanimación cardiopulmonar" 5 => "Cuidados posresucitación" 6 => "Niños" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Cardiac arrest has a high mortality in children. To improve the performance of cardiopulmonary resuscitation, it is essential to disseminate the international recommendations and the training of health professionals and the general population in resuscitation.This article summarises the 2015 European Paediatric Cardiopulmonary Resuscitation recommendations, which are based on a review of the advances in cardiopulmonary resuscitation and consensus in the science and treatment by the International Council on Resuscitation. The Spanish Paediatric Cardiopulmonary Resuscitation recommendations, developed by the Spanish Group of Paediatric and Neonatal Resuscitation, are an adaptation of the European recommendations, and will be used for training health professionals and the general population in resuscitation.This article highlights the main changes from the previous 2010 recommendations on prevention of cardiac arrest, the diagnosis of cardiac arrest, basic life support, advanced life support and post-resuscitation care, as well as reviewing the algorithms of treatment of basic life support, obstruction of the airway and advanced life support." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La parada cardiaca en niños tiene una elevada mortalidad. Para mejorar los resultados de la reanimación cardiopulmonar (RCP) es esencial la difusión de las recomendaciones internacionales de RCP y el entrenamiento de los profesionales sanitarios y la población general. Este artículo resume las recomendaciones europeas de RCP pediátrica de 2015, que están basadas en la revisión de los avances en RCP y el consenso en la ciencia y de tratamiento realizados por el Consejo Internacional de Resucitación. Las recomendaciones españolas de RCP pediátrica elaboradas por el Grupo Español de Reanimación Cardiopulmonar Pediátrica y Neonatal son una adaptación de las recomendaciones europeas y serán las utilizadas para la formación en reanimación a los profesionales sanitarios y la población general.En el artículo se destacan los principales cambios con respecto a las anteriores del 2010 en prevención de la parada cardiaca, diagnóstico de la parada cardiaca, RCP básica, RCP avanzada y cuidados posresucitación, y se presentan los algoritmos de tratamiento de RCP básica, desobstrucción de la vía aérea y RCP avanzada." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: López-Herce J, Rodríguez A, Carrillo A, de Lucas N, Calvo C, Civantos E, et al. Novedades en las recomendaciones de reanimación cardiopulmonar pediátrica. An Pediatr (Barc). 2017;86:229." ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2290 "Ancho" => 1140 "Tamanyo" => 130272 ] ] "descripcion" => array:1 [ "en" => "Steps in paediatric basic life support." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1778 "Ancho" => 2875 "Tamanyo" => 192156 ] ] "descripcion" => array:1 [ "en" => "FBAO algorithm." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 3343 "Ancho" => 2687 "Tamanyo" => 506785 ] ] "descripcion" => array:1 [ "en" => "Paediatric advanced life support algorithm." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1604 "Ancho" => 1724 "Tamanyo" => 163005 ] ] "descripcion" => array:1 [ "en" => "Advanced life support algorithm for nonshockable rhythms." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1918 "Ancho" => 2151 "Tamanyo" => 229766 ] ] "descripcion" => array:1 [ "en" => "Advanced life support algorithm for shockable rhythms." ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "CA, cardiac arrest; ET, endotracheal; IO, intraosseous; IV, intravenous; Max, dose maximum; PEA, pulseless electrical activity; PS, physiologic saline; PVT, pulseless ventricular tachycardia; SVT, supraventricular tachycardia; VF, ventricular fibrillation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Drug \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Dose \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Preparation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Route \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Indication \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Adrenaline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.01mg/kg Max: 1mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diluted in PS. (1+9)=0.1mL/kg ET: undiluted \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IV, IO, ET As bolus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Adenosine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1. 0.2mg/kg Max: 6mg 2. 0.4mg/kg Max: 12mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Quickly flush after administration with 5mL of PS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IV, IO as bolus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SVT \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Amiodarone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5mg/kg Max: 300mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IV, IO As bolus in CA Slow infusion otherwise \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Refractory VF or PVT SVT o TV \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Atropine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.02mg/kg Max: 1mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diluted in saline (1+9)=0.2mL/kg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IV, IO As bolus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Vagal bradycardia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bicarbonate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1mEquiv./kg Max: 50mEquiv. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diluted 1:1 with PS=2mL/kg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IV, IO As bolus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Refractory CA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Calcium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.2mEquiv./kg = Max: 10mEquiv. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Calcium gluconate 10% 0.4mL/kg Calcium chloride 10% 0.2mL/kg 1:1 dilution \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IV, IO lento \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hypocalcaemia, hyperkalaemia, hypermagnesaemia Calcium channel blocker toxicity \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Glucose \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.2–0.4g/kg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Glucose 10% =2–4mL/kg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IV, IO As bolus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Documented hypoglycaemia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lidocaine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1mg/kg Max: 100mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Undiluted \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IV, IO As bolus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Refractory VF or PVT \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fluids \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20mL/kg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IV, IO Rapid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PEA Hypovolaemia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Magnesium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50mg/kg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Undiluted \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IV, IO As bolus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Polymorphic VT With torsades de pointes \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1378360.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Drugs used in paediatric life support." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:27 [ 0 => array:3 [ "identificador" => "bib0140" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Implementation working group for All-Japan Utstein Registry of the Fire and Disaster Management Agency. 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Spanish Association of Paediatrics

The latest in paediatric resuscitation recommendations

Novedades en las recomendaciones de reanimación cardiopulmonar pediátrica

Jesús López-Hercea,

Corresponding author

pielvi@hotmail.com

Corresponding author.

, Antonio Rodríguezb, Angel Carrilloa, Nieves de Lucasc, Custodio Calvod, Eva Civantose, Eva Suárezf, Sara Ponsg, Ignacio Manriqueh

a Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, Instituto de investigación sanitaria, Hospital Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Grupo Español de Reanimación Cardiopulmonar Pediátrica y Neonatal, Red de Salud Maternoinfantil y del Desarrollo (RedSAMID), RETICS, ISCIII, Spain

b Área de Pediatría, Servicio de Críticos, Intermedios y Urgencias Pediátricas, Hospital Clínico Universitario de Santiago de Compostela, Grupo de Investigación CLINURSID, Departamento de Enfermería, Universidade de Santiago de Compostela, Instituto de Investigación de Santiago (IDIS), Red de Salud Maternoinfantil (SAMID II), RETICS, ISCIII, Spain

c SAMUR-Protección Civil, Madrid, Grupo Español de Reanimación Cardiopulmonar Pediátrica y Neonatal, Spain

d Emérito SAS, Asociado a UGC Críticos y Urgencias Pediátricas, Hospital Regional Universitario de Málaga, Grupo Español de Reanimación Cardiopulmonar Pediátrica y Neonatal, Spain

e Centro de Salud de Barranco Grande, Tenerife, Grupo Español de Reanimación Cardiopulmonar Pediátrica y Neonatal, Spain

f Centro de Salud Integrado Burriana II, Castellón, Grupo Español de Reanimación Cardiopulmonar Pediátrica y Neonatal, Spain

g Servicio de Pediatría, Hospital Dr. Peset, Valencia, Grupo Español de Reanimación Cardiopulmonar Pediátrica y Neonatal, Spain

h Servicio de Críticos y Urgencias Pediátricas, Instituto Valenciano de Pediatría, Grupo Español de Reanimación Cardiopulmonar Pediátrica y Neonatal, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cardiac arrest &#40;CA&#41; in children carries a high morbidity and mortality&#46; Research on cardiopulmonary resuscitation &#40;CPR&#41; is very complex&#44;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">1&#8211;3</span></a> and advances come at a slow pace&#46; Nevertheless&#44; the outcomes of paediatric CPR have improved considerably with the diffusion of international CPR guidelines and the education of health care professionals and the general population&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The International Liaison Committee on Resuscitation &#40;ILCOR&#41; reviews advances in CPR and develops the international Consensus on Science with Treatment Recommendations &#40;CoSTR&#41; every five years&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">4&#44;5</span></a> The European Resuscitation Council develops its guidelines for resuscitation based on the CoSTR<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">5&#8211;8</span></a> and assumes that the recommended strategiesneed to be adapted in each country&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">6</span></a> The Spanish paediatric CPR recommendations developed by the Spanish Group on Paediatric and Neonatal CPR are an adaptation of the European recommendations&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">This article summarises the 2015 paediatric CPR recommendations&#44;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">4&#44;5</span></a> emphasising the main changes from the previous recommendations&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Cardiac arrest prevention</span><p id="par0020" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsit0245"><span class="elsevierStyleLabel">&#8211;</span><p id="par0320" class="elsevierStylePara elsevierViewall">Identification of children at risk of CA&#58; a significant percentage of children that experience CA do so following a period of clinical decompensation&#46; Thus&#44; early recognition of patient deterioration is crucial in reducing morbidity and mortality in seriously ill children&#46;</p></li><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8211;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Action&#58; in children at risk of CA&#44; it is very important to follow a structured assessment and intervention scheme adhering to the following sequence&#58; A &#40;airway&#41;&#44; B &#40;breathing&#41;&#44; C &#40;circulation&#41;&#44; D &#40;disability&#47;neurologic&#41; and E &#40;exposure&#41;&#46; The child should be reevaluated frequently following this sequence&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8211;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Organisation of CA care&#58; each hospital must decide how to organise CA care based on its particular characteristics&#44; taking into account that rapid response teams can reduce adverse events and improve outcomes associated with CA in hospitalised children&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">10</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8211;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Volume expansion&#58; expansion is needed in cases of absolute or relative hypovolaemia &#40;septic or anaphylactic shock&#41;&#46; Although the solution used most frequently for initial expansion continues to be physiological saline solution&#44; balanced crystalloids are less likely to lead tohyperchloraemic acidosis&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">11</span></a> The findings of a large-scale study in African children with febrile illness found that mortality was higher in patients that received a fluid bolus compared to patients that did not&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">12</span></a> Due to the potential risks in volume expansion&#44; administration of a fluid bolus in children with febrile illness when circulatory failure is absent is currently not recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">5</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8211;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Treatment of arrhythmias&#58; in children with supraventricular tachycardia that do not respond to vagal manoeuvres and&#47;or drugs and require electrical treatment &#40;synchronised cardioversion&#41;&#44; an initial dose of 1<span class="elsevierStyleHsp" style=""></span>J&#47;kg is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">5</span></a> The previous recommendation was an initial dose of 0&#46;5<span class="elsevierStyleHsp" style=""></span>J&#47;kg&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">9</span></a></p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Diagnosis of cardiac arrest</span><p id="par0045" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8211;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Diagnosis of CA&#58; palpation of a pulse is not reliable as the sole determinant of the need for chest compressions&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">13</span></a> Thus&#44; in the absence of signs of life in the child&#44; chest compressions should be initiated unless rescuers are certain that they can feel a central pulse within 10<span class="elsevierStyleHsp" style=""></span>s&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8211;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Echocardiography&#58; echocardiography may help to detect cardiac activity and some potentially treatable causes of CA&#44; but its use should not interfere with performance of CPR manoeuvres&#46;</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Basic life support</span><p id="par0060" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8211;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Basic life support &#40;BSL&#41; algorithm&#58; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> summarises the steps performed in basic paediatric life support&#46; The manoeuvres are the same as those in the 2010 recommendations&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">5&#44;9</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8211;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Sequence of actions&#58; there is no evidence supporting the superiority of the CAB sequence &#40;compressions&#44; airway and breathing&#41; over the ABC sequence &#40;airway&#44; breathing and compressions&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">4&#44;14</span></a> Current European<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">5</span></a> and Spanish recommendations maintain the ABC sequence&#44; which is the one that has been taught thus far&#46; Furthermore&#44; the cause of CA in children is often respiratory&#44; and thus ventilation is essential to recover from CA&#46; Therefore&#44; in children&#44; after assessing and opening the airway&#44; five initial rescue breaths followed by 1<span class="elsevierStyleHsp" style=""></span>min of CPR should be performed before going for assistance&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8211;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Duration of breaths&#58; the recommended duration of delivering a breath in BSL is approximately 1<span class="elsevierStyleHsp" style=""></span>s so that recommendations for children and adults in the general population coincide&#44; facilitating learning&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8211;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Compressions with rescue breathing versus compression-only&#58; CPR with compressions and rescue breathing is superior to compression-only CPR&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> The recommendation for children with CA is to perform rescue breathing and chest compressions&#46; Rescuers that do not know how to give rescue breaths may use compressions only&#44; as this is preferable to doing nothing&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8211;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Depth of compressions&#58; in chest compressions&#44; the sternum should be depressed by at least a third of the anterior-posterior diameter of the chest &#40;approximately 4<span class="elsevierStyleHsp" style=""></span>cm in infants and 5<span class="elsevierStyleHsp" style=""></span>cm in children&#41;&#46; However&#44; assessing the depth of compression during CPR is very complicated&#46; Some devices allow its measurement&#44; but there is no evidence of their usefulness in guiding CPR in children&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">15</span></a></p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8211;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Chest compression technique in infants&#58; if there is only one rescuer&#44; compression with two fingers perpendicular to the sternum facilitates the coordination of chest compressions and breaths&#46; However&#44; if at least two rescuers are present&#44; the chest should be compressed with two hands using the encircling method&#44; as it is more effective&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8211;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Activation of emergency system&#58; if a child becomes unconscious&#44; it is vital to get help quickly&#46; If only one rescuer is present&#44; CPR should be performed for 1<span class="elsevierStyleHsp" style=""></span>min before going for help&#46; If there are at least two rescuers&#44; one should initiate CPR while the other seeks assistance&#46; A lone rescuer should only seek assistance first and then initiate resuscitation in the rare instance that the child suddenly collapses and the rescuer suspects primary cardiac arrest&#44; as the child will likely need defibrillation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8211;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Automated external defibrillator &#40;AED&#41;&#58; CPR should never be discontinued to go seek an AED unless ventricular arrhythmia is suspected as the cause of CA and the AED is nearby and accessible&#46; In children aged more than 8 years or weighing more than 25<span class="elsevierStyleHsp" style=""></span>kg&#44; the AED should be used with adult-size paddles&#46; Paediatric paddles should be used in children aged 1&#8211;8 years &#40;attenuated paddles delivering 50&#8211;75<span class="elsevierStyleHsp" style=""></span>J&#41;&#46; Adult pads should be used whenever paediatric paddles are not available&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8211;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Foreign body airway obstruction &#40;FBAO&#41;&#58; there are no changes in the treatment recommendations &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; as there has been no further research on this subject&#46; Back blows&#44; chest thrusts and chest compressions are used to try to increase intrathoracic pressure to push out the foreign body&#46; If one of these measures is not effective&#44; the others can be attempted on rotation until the object is cleared or the obstruction is relieved&#46; However&#44; rotating the three manoeuvres is difficult to learn&#44; remember and implement in a life-threatening situation&#46; For this reason&#44; the Spanish Group on Paediatric and Neonatal CPR recommends rotating back blows and chest thrusts in infants&#44; and back blows and abdominal thrusts in children in groups of five as long as the child remains conscious&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Paediatric advanced life support</span><p id="par0110" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8211;</span><p id="par0115" class="elsevierStylePara elsevierViewall">The ABC sequence used in BLS should also be applied to advanced life support &#40;ALS&#41;&#46;</p></li></ul></p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Airway</span><p id="par0120" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8211;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Bag ventilation and supraglottic devices&#58; bag-mask ventilation is the initial method used in airway management and ventilation during CPR in children&#46; However&#44; supraglottic devices &#40;laryngeal mask and others&#41; may be helpful in airway management when used by well-trained rescuers&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">&#8211;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Endotracheal intubation&#58; cuffed tracheal tubes are as safe as uncuffed ones and reduce air leaks&#46; However&#44; an excessive cuff pressure can cause damage to the larynx and secondary stenosis&#46; Thus&#44; after the return of spontaneous circulation &#40;ROSC&#41;&#44; cuff inflation pressure should be monitored and maintained at less than 25<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">&#8211;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Newly developed laryngoscopes&#58; new laryngoscopes may facilitate complicated intubations if the rescuer is trained in their use&#44; although there is still little evidence on their use in children&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">16</span></a></p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">&#8211;</span><p id="par0140" class="elsevierStylePara elsevierViewall">Confirmation of tube placement&#58; physical examination &#40;chest wall movement and auscultation&#41;&#44; vital signs and capnography can be used to confirm tube placement&#44; but none of these methods is completely reliable&#46; The presence of a capnographic waveform for more than four breaths is a good indicator of correct placement&#44; but the absence of exhaled CO<span class="elsevierStyleInf">2</span> during CPR does not guarantee tube misplacement&#44; as it may be due to reduced pulmonary blood flow&#46; However&#44; if the child is in CA and exhaled CO<span class="elsevierStyleInf">2</span>is not detected despite adequate chest compressions&#44; or there is any doubt as to the tube position&#44; the placement of the tube should be confirmed by laryngoscopy&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">6</span></a></p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Ventilation and oxygenation</span><p id="par0145" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">&#8211;</span><p id="par0150" class="elsevierStylePara elsevierViewall">Oxygen&#58; when performing CPR in children&#44; except in newborns&#44; oxygen should be given at the highest possible concentration &#40;100&#37;&#41;&#44; as hypoxia is more frequent and harmful than hyperoxiain this situation&#46; Once there is ROSC&#44; the fraction of inspired oxygen &#40;FiO<span class="elsevierStyleInf">2</span>&#41; should be titrated to maintain SpO2 in the range of 94&#8211;98&#37;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">&#8211;</span><p id="par0155" class="elsevierStylePara elsevierViewall">Respiratory rate&#58; there are no reliable data to determine the most appropriate respiratory rate during CPR and after ROSC in children&#46;</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">&#8211;</span><p id="par0160" class="elsevierStylePara elsevierViewall">Non-intubated patients&#58; the European guidelines recommend using a ratio of 15 chest compressions to 2 breaths and a compression rate of 100&#8211;120 compressions per minute during BLS and ALS if the child is not intubated&#46;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">&#8211;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Intubated patients&#58; once the child is intubated&#44; ventilation should be maintained at a rate of 10 breaths per minute without interrupting the chest compressions&#46; Care should be taken to ensure that lung inflation is adequate during chest compressions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">&#8211;</span><p id="par0170" class="elsevierStylePara elsevierViewall">After ROSC&#58; once ROSC has been achieved&#44; normal ventilation &#40;in rate and volume&#41; should be provided based on the child&#39;s age and illness&#44; and end-tidal CO<span class="elsevierStyleInf">2</span> and blood gases should be monitored to achieve normal PaCO<span class="elsevierStyleInf">2</span> and PaO<span class="elsevierStyleInf">2</span> values&#46;</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">&#8211;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Capnography&#58; an end-tidal CO<span class="elsevierStyleInf">2</span> higher than 15<span class="elsevierStyleHsp" style=""></span>mmHg may be an indicator of adequate resuscitation&#46; However&#44; the current evidence does not suffice to support the use of a specific threshold end-tidal CO<span class="elsevierStyleInf">2</span> value as an indicator for the quality of CPR&#44; as a sign of return of spontaneous circulation or for the discontinuation of resuscitation&#46;</p></li></ul></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Circulation</span><p id="par0180" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">&#8211;</span><p id="par0185" class="elsevierStylePara elsevierViewall">Vascular access&#58; peripheral venous access is the access of choice&#44; but it may be difficult to establish in children during CPR&#46; Thus&#44; if venous access cannot be attained within 1<span class="elsevierStyleHsp" style=""></span>min&#44; an intraosseous needle should be inserted and maintained only until definitive intravenous access is established&#46; The tracheal route is not recommended for the administration of drugs unless no other route is available&#46;</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">&#8211;</span><p id="par0190" class="elsevierStylePara elsevierViewall">Sodium bicarbonate&#58; there is no evidence that supports the routine administration of sodium bicarbonate during CPR&#46; Its administration can be considered in children with prolonged CA &#40;for instance&#44; lasting more than 10<span class="elsevierStyleHsp" style=""></span>min&#41; and&#47;or severe metabolic acidosis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">&#8211;</span><p id="par0195" class="elsevierStylePara elsevierViewall">Atropine&#58; atropine is only recommended for bradycardia caused by increased vagal tone or cholinergic drug toxicity&#46; The most commonly used dose is 20<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#46; In cases of bradycardia with poor peripheral perfusion unresponsive to ventilation and oxygenation&#44; adrenaline is the first-line drug&#46;</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Diagnosis and treatment of arrhythmias</span><p id="par0200" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">&#8211;</span><p id="par0205" class="elsevierStylePara elsevierViewall">ECG monitoring&#58; cardiac monitoring should be initiated as soon as possible&#46; However&#44; since most cardiac rhythms in children with CA are nonshockable&#44; initial efforts should prioritise ventilation&#44; chest compressions&#44; establishing vascular access and administering adrenaline rather than wasting time searching for a monitor&#46;</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">&#8211;</span><p id="par0210" class="elsevierStylePara elsevierViewall">The most common ECG patterns in children with CA are bradycardia&#44; asystole and pulseless electrical activity&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">3&#44;17</span></a> If a child with bradycardia &#40;heart rate &#60;60<span class="elsevierStyleHsp" style=""></span>bpm in the absence of signs of life&#41; does not respond quickly to ventilation with oxygen&#44; chest compressions should be started immediately and adrenaline administered&#46;</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">&#8211;</span><p id="par0215" class="elsevierStylePara elsevierViewall">Ventricular fibrillation and pulseless ventricular tachycardia are present in fewer than 20&#37; of cases of CA in children&#46; The incidence of shockable rhythms increases with age&#44; and they are more likely to occur in children that collapse suddenly or with underlying heart disease&#46;</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">&#8211;</span><p id="par0220" class="elsevierStylePara elsevierViewall">The algorithm for ALS is presented in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#44; and the algorithms for nonshockable and shockable rhythms in <a class="elsevierStyleCrossRefs" href="#fig0020">Figs&#46; 4 and 5</a>&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">&#8211;</span><p id="par0225" class="elsevierStylePara elsevierViewall">Defibrillators&#58; manual defibrillators must be available in all health care facilities&#46; If a manual defibrillator is not available&#44; an AED may be used&#44; as these devices can recognise shockable paediatric rhythms&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">&#8211;</span><p id="par0230" class="elsevierStylePara elsevierViewall">Defibrillation pads and paddles&#58; self-adhesive pads facilitate CPR by reducing the time that chest compressions are discontinued to deliver the shock&#46;</p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">&#8211;</span><p id="par0235" class="elsevierStylePara elsevierViewall">Energy dose for electric shocks&#58; in Europe&#44; a dose of 4<span class="elsevierStyleHsp" style=""></span>J&#47;kg is still recommended for every shock&#46;</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">&#8211;</span><p id="par0240" class="elsevierStylePara elsevierViewall">Antiarrhythmic drugs&#58; administration of one 5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg dose of amiodarone as a rapid bolus after the third shock is recommended&#44; and can be repeated after the fifth shock&#46; A recent study has reinforced that lidocaine may be useful in shockable rhythms in children&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">19</span></a> However&#44; the European guidelines continue to recommend amiodarone as the drug of choice for shockable rhythms that do not respond to defibrillation&#46; It must be kept in mind that during CA&#44; amiodarone must be administered as a rapid bolus&#46; Conversely&#44; when amiodarone is administered to treat other cardiac rhythm disturbances in children that are not in CA&#44; it must be injected slowly over 10&#8211;20<span class="elsevierStyleHsp" style=""></span>min with systemic BP and ECG monitoring&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">20</span></a></p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">&#8211;</span><p id="par0245" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> provides a summary of the dosage of different drugs during paediatric CPR&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Life support in special circumstances</span><p id="par0250" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">&#8211;</span><p id="par0255" class="elsevierStylePara elsevierViewall">Extracorporeal membrane oxygenation &#40;ECMO&#41;&#58; the use of ECMO can be considered in children with CA due to a potentially reversible cause and refractory to conventional CPR if the child is in a facility with the necessary resources&#44; trained staff and organisation allowing for quick initiation of ECMO&#46;</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">&#8211;</span><p id="par0260" class="elsevierStylePara elsevierViewall">Life support in trauma patients&#58; cardiac arrest from major trauma is associated with a high mortality&#46; Resuscitation in these patients does not differ from the routine management of CA from other causes&#44; although the use of resuscitative thoracotomy can be considered in children with penetrating injuries&#46;</p></li><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">&#8211;</span><p id="par0265" class="elsevierStylePara elsevierViewall">Pulmonary hypertension&#58; children with pulmonary hypertension are at increased risk of CA&#46; These patients should be managed with a high FiO<span class="elsevierStyleInf">2</span>&#44; alkalosis and hyperventilation&#44; which may be as effective as inhaled nitric oxide in reducing pulmonary vascular resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">21</span></a></p></li></ul></p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Postresuscitation care</span><p id="par0270" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">&#8211;</span><p id="par0275" class="elsevierStylePara elsevierViewall">Coordinated care&#58; Postresuscitation care must be a coordinated multidisciplinary activity and include all the treatments needed for complete neurologic recovery&#46;</p></li><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">&#8211;</span><p id="par0280" class="elsevierStylePara elsevierViewall">Haemodynamic treatment&#58; treatment must be adjusted to maintain a systolic blood pressure above the 5th percentile for age&#46; After resuscitation&#44; it is important to avoid hypotension&#44; as this factor is associated with significantly worse outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">22</span></a></p></li><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">&#8211;</span><p id="par0285" class="elsevierStylePara elsevierViewall">Oxygenation and ventilation&#58; once the child is stabilised&#44; management must aim for a normal PaO<span class="elsevierStyleInf">2</span> range&#46; There is insufficient evidence to suggest a specific PaCO<span class="elsevierStyleInf">2</span> target after ROSC in children&#44; and both hypocapnia and hypercapnia are associated with a poor prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">23</span></a>Aiming for normocapnia is recommended&#44; adapting to the needs of each patient&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">5</span></a> Therefore&#44; it would be appropriate to initiate ventilation with a normal rate and volume&#44; adjusting them to the child&#39;s age and illness&#44; while monitoring end-tidal CO<span class="elsevierStyleInf">2</span>and blood gas levels&#46;</p></li><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">&#8211;</span><p id="par0290" class="elsevierStylePara elsevierViewall">Temperature&#58; the THAPCA study did not find significant differences in neurologic status at one year from CA between children treated with hypothermia and children treated with normothermia&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">24</span></a> On the other hand&#44; fever after ROSC has been associated with a poorer prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">25</span></a> Therefore&#44; the current recommendation is to keep a strict control of temperature after ROSC&#44; preventing both hyperthermia &#40;&#62;37&#46;5<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; and severe hypothermia &#40;&#60;32<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; maintaining the patient in normothermia or mild hypothermia&#46;</p></li><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">&#8211;</span><p id="par0295" class="elsevierStylePara elsevierViewall">Glucose&#58; glucose levels must be monitored after resuscitation&#44; avoiding hyperglycaemia and hypoglycaemia&#44; as both are associated with impaired outcomes&#46;</p></li><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">&#8211;</span><p id="par0300" class="elsevierStylePara elsevierViewall">Prognosis of CA&#58; the duration of CPR&#44; the cause of arrest&#44; pre-existing medical conditions&#44; age&#44; site of arrest&#44; whether the arrest was witnessed&#44; the duration of untreated CA&#44; the presence of a shockable rhythm and special circumstances such as icy water drowning or exposure to toxic drugs are significant prognostic factors in children with CA&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">1&#44;5</span></a> However&#44; there is no single reliable predictor of outcome after CPR&#46; In adults&#44; a multidisciplinary approach combining physical examination&#44; electroencephalography&#44; electrophysiology&#44; imaging tests and biomarkers can guide prognostication starting at 72<span class="elsevierStyleHsp" style=""></span>h after ROSC&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">26</span></a></p></li><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">&#8211;</span><p id="par0305" class="elsevierStylePara elsevierViewall">Parental presence&#58; in some countries&#44; parents often want to be present while CPR is performed on their children&#44; which facilitates the grieving process&#46; However&#44; evidence on this subject cannot be generalised to all of Europe&#44; where there may be different sociocultural characteristics&#46; Therefore&#44; parental presence will depend on the characteristics of both the parents and the resuscitation team&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">27</span></a></p></li></ul></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Funding</span><p id="par0310" class="elsevierStylePara elsevierViewall">RETICS funded by Spain&#39;s PN I&#43;D&#43;I 2013-2016 &#40;National Plan for Scientific Research&#44; Development and Innovation&#41;&#44; Instituto de Salud Carlos III &#8211; Sub-Directorate General for Research Assessment and Promotion and the European Regional Development Fund &#40;ERDF&#41;&#44; ref&#46; RD16&#47;0022&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interests</span><p id="par0315" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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            0 => "Parada cardiaca"
            1 => "Reanimaci&#243;n cardiopulmonar"
            2 => "Reanimaci&#243;n cardiopulmonar b&#225;sica"
            3 => "Reanimaci&#243;n cardiopulmonar avanzada"
            4 => "Recomendaciones de reanimaci&#243;n cardiopulmonar"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cardiac arrest has a high mortality in children&#46; To improve the performance of cardiopulmonary resuscitation&#44; it is essential to disseminate the international recommendations and the training of health professionals and the general population in resuscitation&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This article summarises the 2015 European Paediatric Cardiopulmonary Resuscitation recommendations&#44; which are based on a review of the advances in cardiopulmonary resuscitation and consensus in the science and treatment by the International Council on Resuscitation&#46; The Spanish Paediatric Cardiopulmonary Resuscitation recommendations&#44; developed by the Spanish Group of Paediatric and Neonatal Resuscitation&#44; are an adaptation of the European recommendations&#44; and will be used for training health professionals and the general population in resuscitation&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">This article highlights the main changes from the previous 2010 recommendations on prevention of cardiac arrest&#44; the diagnosis of cardiac arrest&#44; basic life support&#44; advanced life support and post-resuscitation care&#44; as well as reviewing the algorithms of treatment of basic life support&#44; obstruction of the airway and advanced life support&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La parada cardiaca en ni&#241;os tiene una elevada mortalidad&#46; Para mejorar los resultados de la reanimaci&#243;n cardiopulmonar &#40;RCP&#41; es esencial la difusi&#243;n de las recomendaciones internacionales de RCP y el entrenamiento de los profesionales sanitarios y la poblaci&#243;n general&#46; Este art&#237;culo resume las recomendaciones europeas de RCP pedi&#225;trica de 2015&#44; que est&#225;n basadas en la revisi&#243;n de los avances en RCP y el consenso en la ciencia y de tratamiento realizados por el Consejo Internacional de Resucitaci&#243;n&#46; Las recomendaciones espa&#241;olas de RCP pedi&#225;trica elaboradas por el Grupo Espa&#241;ol de Reanimaci&#243;n Cardiopulmonar Pedi&#225;trica y Neonatal son una adaptaci&#243;n de las recomendaciones europeas y ser&#225;n las utilizadas para la formaci&#243;n en reanimaci&#243;n a los profesionales sanitarios y la poblaci&#243;n general&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">En el art&#237;culo se destacan los principales cambios con respecto a las anteriores del 2010 en prevenci&#243;n de la parada cardiaca&#44; diagn&#243;stico de la parada cardiaca&#44; RCP b&#225;sica&#44; RCP avanzada y cuidados posresucitaci&#243;n&#44; y se presentan los algoritmos de tratamiento de RCP b&#225;sica&#44; desobstrucci&#243;n de la v&#237;a a&#233;rea y RCP avanzada&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; L&#243;pez-Herce J&#44; Rodr&#237;guez A&#44; Carrillo A&#44; de Lucas N&#44; Calvo C&#44; Civantos E&#44; et al&#46; Novedades en las recomendaciones de reanimaci&#243;n cardiopulmonar pedi&#225;trica&#46; An Pediatr &#40;Barc&#41;&#46; 2017&#59;86&#58;229&#46;</p>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">CA&#44; cardiac arrest&#59; ET&#44; endotracheal&#59; IO&#44; intraosseous&#59; IV&#44; intravenous&#59; Max&#44; dose maximum&#59; PEA&#44; pulseless electrical activity&#59; PS&#44; physiologic saline&#59; PVT&#44; pulseless ventricular tachycardia&#59; SVT&#44; supraventricular tachycardia&#59; VF&#44; ventricular fibrillation&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Drug&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Dose&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Preparation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Route&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Indication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Adrenaline&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;01<span class="elsevierStyleHsp" style=""></span>mg&#47;kg<br>Max&#58; 1<span class="elsevierStyleHsp" style=""></span>mg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Diluted in PS&#46; &#40;1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>9&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;1<span class="elsevierStyleHsp" style=""></span>mL&#47;kg<br>ET&#58; undiluted&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&#44; IO&#44; ET<br>As bolus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Adenosine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46; 0&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;kg<br>Max&#58; 6<span class="elsevierStyleHsp" style=""></span>mg<br>2&#46; 0&#46;4<span class="elsevierStyleHsp" style=""></span>mg&#47;kg<br>Max&#58; 12<span class="elsevierStyleHsp" style=""></span>mg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Quickly flush after administration with 5<span class="elsevierStyleHsp" style=""></span>mL of PS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&#44; IO as bolus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SVT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Amiodarone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg<br>Max&#58; 300<span class="elsevierStyleHsp" style=""></span>mg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&#44; IO<br>As bolus in CA<br>Slow infusion otherwise&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Refractory VF or PVT<br>SVT o TV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Atropine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;02<span class="elsevierStyleHsp" style=""></span>mg&#47;kg<br>Max&#58; 1<span class="elsevierStyleHsp" style=""></span>mg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Diluted in saline &#40;1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>9&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;2<span class="elsevierStyleHsp" style=""></span>mL&#47;kg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&#44; IO<br>As bolus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vagal bradycardia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bicarbonate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>mEquiv&#46;&#47;kg<br>Max&#58; 50<span class="elsevierStyleHsp" style=""></span>mEquiv&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Diluted 1&#58;1 with PS<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>mL&#47;kg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&#44; IO<br>As bolus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Refractory CA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Calcium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;2<span class="elsevierStyleHsp" style=""></span>mEquiv&#46;&#47;kg &#61;<br>Max&#58; 10<span class="elsevierStyleHsp" style=""></span>mEquiv&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Calcium gluconate 10&#37; 0&#46;4<span class="elsevierStyleHsp" style=""></span>mL&#47;kg<br>Calcium chloride 10&#37; 0&#46;2<span class="elsevierStyleHsp" style=""></span>mL&#47;kg 1&#58;1 dilution&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&#44; IO lento&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypocalcaemia&#44; hyperkalaemia&#44; hypermagnesaemia<br>Calcium channel blocker toxicity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Glucose&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;2&#8211;0&#46;4<span class="elsevierStyleHsp" style=""></span>g&#47;kg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Glucose 10&#37;<br>&#61;2&#8211;4<span class="elsevierStyleHsp" style=""></span>mL&#47;kg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&#44; IO<br>As bolus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Documented hypoglycaemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lidocaine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg<br>Max&#58; 100<span class="elsevierStyleHsp" style=""></span>mg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Undiluted&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&#44; IO<br>As bolus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Refractory VF or PVT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fluids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20<span class="elsevierStyleHsp" style=""></span>mL&#47;kg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&#44; IO<br>Rapid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PEA<br>Hypovolaemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Magnesium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Undiluted&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&#44; IO<br>As bolus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Polymorphic VT<br>With torsades de pointes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Drugs used in paediatric life support&#46;</p>"
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:27 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
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                            4 => "H&#46; Tanaka"
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                  ]
                  "host" => array:1 [
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                      "Revista" => array:6 [
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46;A&#46; Berg"
                            1 => "V&#46;M&#46; Nadkarni"
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                  "contribucion" => array:1 [
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                      "titulo" => "Factors associated with mortality in pediatric in-hospital cardiac arrest&#58; a prospective multicenter multinational observational study"
                      "autores" => array:1 [
                        0 => array:3 [
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; L&#243;pez-Herce"
                            1 => "J&#46; del Castillo"
                            2 => "M&#46; Matamoros"
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                    0 => array:2 [
                      "doi" => "10.1007/s00134-012-2709-7"
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            3 => array:3 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pediatric basic life support and pediatric advanced life support&#58; 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "I&#46;K&#46; Maconochie"
                            1 => "A&#46;R&#46; de Caen"
                            2 => "R&#46; Aickin"
                            3 => "D&#46;L&#46; Atkins"
                            4 => "D&#46; Biarent"
                            5 => "A&#46;M&#46; Guerguerian"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.resuscitation.2015.07.044"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26477423"
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                        ]
                      ]
                    ]
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                ]
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                  "contribucion" => array:1 [
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                      "titulo" => "Paediatric life support section collaborators&#46; European resuscitation council guidelines for resuscitation 2015&#58; section 6&#46; Paediatric life support"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "I&#46;K&#46; Maconochie"
                            1 => "R&#46; Bingham"
                            2 => "C&#46; Eich"
                            3 => "J&#46; L&#243;pez-Herce"
                            4 => "A&#46; Rodr&#237;guez-N&#250;&#241;ez"
                            5 => "T&#46; Rajka"
                          ]
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                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.resuscitation.2015.07.028"
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                        "tituloSerie" => "Resuscitation"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26477414"
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                        ]
                      ]
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              ]
            ]
            5 => array:3 [
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "European Resuscitation Council Guidelines for Resuscitation 2015&#58; Section 10&#46; Education and implementation of resuscitation&#46; Section 10&#46; Education and implementation of resuscitation"
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                        0 => array:3 [
                          "colaboracion" => "Education and implementation of resuscitation section Collaborators&#59; Collaborators"
                          "etal" => false
                          "autores" => array:6 [
                            0 => "R&#46; Greif"
                            1 => "A&#46;S&#46; Lockey"
                            2 => "P&#46; Conaghan"
                            3 => "A&#46; Lippert"
                            4 => "W&#46; de Vries"
                            5 => "K&#46;G&#46; Monsieurs"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.resuscitation.2015.07.032"
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                        "tituloSerie" => "Resuscitation"
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                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0170"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "European Resuscitation Council Guidelines for Resuscitation 2015&#58; Section 1&#46; Executive summary"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "K&#46;G&#46; Monsieurs"
                            1 => "J&#46;P&#46; Nolan"
                            2 => "L&#46;L&#46; Bossaert"
                            3 => "R&#46; Greif"
                            4 => "I&#46;K&#46; Maconochie"
                            5 => "N&#46;I&#46; Nikolaou"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.resuscitation.2015.07.038"
                      "Revista" => array:6 [
                        "tituloSerie" => "Resuscitation"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26477410"
                            "web" => "Medline"
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                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0175"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "European Resuscitation Council Guidelines for Resuscitation 2015&#58; Section 7&#46; Resuscitation and support of transition of babies at birth"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46; Wyllie"
                            1 => "J&#46; Bruinenberg"
                            2 => "C&#46;C&#46; Roehr"
                            3 => "M&#46; R&#252;diger"
                            4 => "D&#46; Trevisanuto"
                            5 => "B&#46; Urlesberger"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.resuscitation.2015.07.029"
                      "Revista" => array:6 [
                        "tituloSerie" => "Resuscitation"
                        "fecha" => "2015"
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                        "paginaFinal" => "263"
                        "link" => array:1 [
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                        ]
                      ]
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                ]
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            ]
            8 => array:3 [
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "European Resuscitation Council Guidelines for Resuscitation 2010&#58; Section 6&#46; Paediatric life support"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46; Biarent"
                            1 => "R&#46; Bingham"
                            2 => "C&#46; Eich"
                            3 => "J&#46; L&#243;pez-Herce"
                            4 => "I&#46; Maconochie"
                            5 => "A&#46; Rodr&#237;guez-N&#250;&#241;ez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.resuscitation.2010.08.012"
                      "Revista" => array:6 [
                        "tituloSerie" => "Resuscitation"
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                        "link" => array:1 [
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            ]
            9 => array:3 [
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46;P&#46; Bonafide"
                            1 => "A&#46;R&#46; Localio"
                            2 => "L&#46; Song"
                            3 => "K&#46;E&#46; Roberts"
                            4 => "V&#46;M&#46; Nadkarni"
                            5 => "M&#46; Priestley"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1542/peds.2014-0140"
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    "identificador" => "33443"
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      "titulo" => "Spanish Association of Paediatrics"
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]

Article information

ISSN: 23412879
Original language: English

DOI:10.1016/j.anpede.2016.11.003

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Year/Month	Html	Pdf	Total

2024 November	6	6	12
2024 October	81	64	145
2024 September	80	50	130
2024 August	74	83	157
2024 July	68	46	114
2024 June	66	39	105
2024 May	62	37	99
2024 April	80	43	123
2024 March	72	48	120
2024 February	60	36	96
2024 January	58	39	97
2023 December	56	28	84
2023 November	62	34	96
2023 October	74	58	132
2023 September	72	28	100
2023 August	63	20	83
2023 July	70	34	104
2023 June	73	32	105
2023 May	140	28	168
2023 April	69	21	90
2023 March	114	23	137
2023 February	88	17	105
2023 January	68	23	91
2022 December	116	22	138
2022 November	96	44	140
2022 October	115	63	178
2022 September	74	42	116
2022 August	98	52	150
2022 July	70	51	121
2022 June	92	46	138
2022 May	64	46	110
2022 April	55	36	91
2022 March	99	80	179
2022 February	113	46	159
2022 January	129	47	176
2021 December	110	49	159
2021 November	118	52	170
2021 October	180	81	261
2021 September	77	59	136
2021 August	88	57	145
2021 July	76	52	128
2021 June	120	60	180
2021 May	169	78	247
2021 April	458	170	628
2021 March	204	55	259
2021 February	152	35	187
2021 January	148	42	190
2020 December	131	31	162
2020 November	126	34	160
2020 October	117	42	159
2020 September	110	44	154
2020 August	110	35	145
2020 July	127	35	162
2020 June	144	23	167
2020 May	187	36	223
2020 April	122	33	155
2020 March	137	30	167
2020 February	120	25	145
2020 January	126	25	151
2019 December	153	32	185
2019 November	106	28	134
2019 October	116	31	147
2019 September	110	33	143
2019 August	129	26	155
2019 July	90	38	128
2019 June	117	29	146
2019 May	151	14	165
2019 April	163	48	211
2019 March	95	28	123
2019 February	77	19	96
2019 January	61	19	80
2018 December	73	34	107
2018 November	213	35	248
2018 October	304	19	323
2018 September	144	17	161
2018 August	4	0	4
2018 July	5	0	5
2018 June	6	0	6
2018 May	13	0	13
2018 April	42	0	42
2018 March	44	0	44
2018 February	32	0	32
2018 January	23	0	23
2017 December	27	0	27
2017 November	36	0	36
2017 October	25	0	25
2017 September	24	0	24
2017 August	25	0	25
2017 July	23	1	24
2017 June	36	15	51
2017 May	41	10	51
2017 April	156	143	299
2017 March	7	20	27

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