Cardiac arrest (CA) in children carries a high morbidity and mortality. Research on cardiopulmonary resuscitation (CPR) is very complex,1–3 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.1–3

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.4,5 The European Resuscitation Council develops its guidelines for resuscitation based on the CoSTR5–8 and assumes that the recommended strategiesneed to be adapted in each country.6 The Spanish paediatric CPR recommendations developed by the Spanish Group on Paediatric and Neonatal CPR are an adaptation of the European recommendations.5

This article summarises the 2015 paediatric CPR recommendations,4,5 emphasising the main changes from the previous recommendations.9

• –

  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.

• –

  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.

• –

  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.10

• –

  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.11 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.12 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.5

• –

  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.5 The previous recommendation was an initial dose of 0.5J/kg.9

• –

  Diagnosis of CA: palpation of a pulse is not reliable as the sole determinant of the need for chest compressions.13 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.

• –

  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.

• –

  Basic life support (BSL) algorithm: Fig. 1 summarises the steps performed in basic paediatric life support. The manoeuvres are the same as those in the 2010 recommendations.5,9

  
  

  Figure 1.

  Steps in paediatric basic life support.

  (0.12MB).
• –

  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).4,14 Current European5 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.

• –

  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.

• –

  Compressions with rescue breathing versus compression-only: CPR with compressions and rescue breathing is superior to compression-only CPR.1 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.

• –

  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.15

• –

  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.

• –

  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.

• –

  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.

• –

  Foreign body airway obstruction (FBAO): there are no changes in the treatment recommendations (Fig. 2), 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.

  
  

  Figure 2.

  FBAO algorithm.

  (0.18MB).

• –

  The ABC sequence used in BLS should also be applied to advanced life support (ALS).

• –

  Coordinated care: Postresuscitation care must be a coordinated multidisciplinary activity and include all the treatments needed for complete neurologic recovery.

• –

  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.22

• –

  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.23Aiming for normocapnia is recommended, adapting to the needs of each patient.5 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.

• –

  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.24 On the other hand, fever after ROSC has been associated with a poorer prognosis.25 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.

• –

  Glucose: glucose levels must be monitored after resuscitation, avoiding hyperglycaemia and hypoglycaemia, as both are associated with impaired outcomes.

• –

  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.1,5 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.26

• –

  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.27

RETICS 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.

The authors have no conflict of interests to declare.