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    Quality of chest compressions during pediatric resuscitation with 15:2 and 30:2 compressions

    The main objetive was to compare 30:2 and 15:2 compression-to-ventilation ratio in two simulated pediatric cardiopulmonary resuscitation (CPR) models with single rescuer. The secondary aim was to analyze the errors or omissions made during resuscitation. A prospective randomized parallel controlled study comparing 15:2 and 30:2 ratio in two manikins (child and infant) was developed. The CPR was performed by volunteers who completed an basic CPR course. Each subject did 4 CPR sessions of 3 minutes each one. Depth and rate of chest compressions (CC) during resuscitation were measured using a Zoll Z series defibrillator. Visual assessment of resuscitation was performed by an external researcher. A total of 26 volunteers performed 104 CPR sessions. Between 54–62% and 44–53% of CC were performed with an optimal rate and depth, respectively, with no significant differences. No differences were found in depth or rate of CC between 15:2 and 30:2 compression-to-ventilation ratio with both manikins. In the assessment of compliance with the ERC CPR algorithm, 69.2–80.8% of the subjects made some errors or omissions during resuscitation, the most frequent was not asking for help and not giving rescue breaths. The conclusions were that a high percentage of CC were not performed with optimal depth and rate. Errors or omissions were frequently made by rescuers during resuscitation.

    Discussion

    The main objective of our study was to compare CC quality between 30:2 and 15:2 compression-to-ventilation ratio in pediatric and infant manikins. In our study, there were no differences in the rate or depth of CC between the ratio 15:2 and 30:2. A high percentage of compressions were not performed with optimal rate and depth. Furthermore, depth and rate of CC were not modified throughout the CPR session. The results could not allow to conclude that a compression-ventilation ratio is better than the other. Our study highlights the relevance of periodic recertifications.

    No differences were found in depth or rate of CC in both manikins between 15:2 and 30:2 compression-to-ventilation ratio. In our knowledge, there are no studies in pediatric CPR comparing CC quality in 15:2 or 30:2 compressions-to-ventilations ratios developed by volunteers without PALS accreditation. There is only one study11 that compared, in manikin-simulated pediatric resuscitation, three compressions-to-ventilations ratios (5:1, 10:2 and 15:2). In this study there were no differences in depth and rate between the three ratios.

    Although depth and rate of chest compressions is the same with both compression-to-ventilation ratios, it is not clear whether survival increases with increasing number of ventilations or prioritizing chest compressions. In a study of adults with out-of-hospital cardiac arrest, continuous CC without ventilations did not result in significantly higher rates of survival or favorable neurologic function than 30 compressions to two ventilations16. In other similar study the percentage of one-month survival patients with good neurological outcome was lower with continuous CC, however, in the multivariate analysis the continuous CC group showed better neurological outcome than the CC plus ventilation group17. In a pediatric asphyxial arrest animal model18 CC plus ventilation produced better oxygenation, ventilation, and cerebral oxygenation than compression-only CPR. In observational studies of children resuscitation who had out-of-hospital CA19,20 CPR with CC plus ventilation produced better outcomes than compression-only CPR. The fact that the main cause of pediatric CA is respiratory failure could be the reason for better outcomes of CPR with CC plus ventilations than compression-only CPR.

    We found slightly higher chest compression release velocity with 15:2 ratio but these differences are not relevant. One study showed the association of chest compression release velocity with higher survival and favorable neurologic outcome after out-of-hospital cardiac arrest in adults patients21. In this study the adjusted odds of survival increased from slow (<300 mm/s) to fast release velocity (≥400 mm/s) and from moderate (300–399.9 mm/s) to fast (≥400 mm/s) release velocity. It should be noted that in our study the release velocity in all groups oscillated between 220 and 300 mm/s, corresponding in all cases with the slow velocity. However, the influence of CC release velocity and survival is still controversial because other studies have found no relationship between them22. More studies are needed to analyze the role of this parameter in the quality of resuscitation.

    There is good evidence supporting the use of CPR feedback/prompt devices during CPR training to evaluate and improve CPR quality23. In our study, we use one device to analyze CC quality. We also used video recordings to asses pediatric resuscitation management and to detect errors or omissions during resuscitation because previous studies showed that it is a useful tool for this purpose24.

    Some studies have investigated optimal depth of CC but there is a lack of evidence in infants and children CC25,26,27. Although deeper CC have shown higher arterial blood pressure28, excessive CC depth may cause serious mechanical complications25. In both manikins but, especially, in the infant model, high percentage of CC were shallower than recommended. This fact may be due to the difficulty of performing CC in an infant manikin encircling the chest and compressing only with the thumbs. Smereka and Ladny designed a new technique for chest compressions in infants using two thumbs directed at the angle of 90 degrees to the chest while closing the fingers of both hands in a fist. They described this new technique and compared it in two studies performed on manikins with those maneuvers used routinely29,30 showing that a higher simulated blood pressure was reached with this new technique29,30. As in our study, other studies that have analyzed the quality of CC in pediatric manikins, found a depth of CC lower than recommended7. Therefore, shallow CC could also be related to low fidelity of the manikin used.

    Vaillancourt et al.13 developed an adult simulated CPR manikin cross-over study with elderly volunteers that compare 15:2 to 30:2. This study showed that the 15:2 ratio resulted in proportionally more adequate compressions (defined as depth of 4–5 cm followed by full decompression during each minute). They used a metronome to encourage the administration of chest compressions at a rate of 100 per minute, so rate of CC should not be evaluated.

    In our study, in both compression-to-ventilation ratios, an important percentage of CC were performed with a higher or lower rate than optimal (>120 or <100 cpm). It should be noted that, although half of CC were performed with optimal rate, the number of CC performed in each minute is not high, which can be explained by the time used for ventilation. With the ratio 30:2 the number of CC performed was higher than the ratio 15:2. In a study by Haque et al.15 more compression cycles were achieved with 30:2 ratio without effect in compression depth and rate, similar to our results. However, they reported higher subjective fatigue in the 30:2 ratio.

    Depth and rate of chest compressions did not change significantly during the three minutes of CPR with any of the compressions-to-ventilation ratios in our study. This might have been because each CPR session lasted only 3 minutes. Nevertheless, other published studies with simulated CPR sessions and shorter periods found a decrease in depth over time26. Vaillancourt et al.13 measured objective fatigue by changes in heart rate, mean arterial pressure and venous lactate, and perceived level of exhaustion using the validated Borg Rating of Perceived Exertion scale. They have found that the 30:2 ratio resulted in similar objective measures of fatigue, but higher perceived fatigue than the 15:2 ratio. In our study, 60% of the rescuers felt that 30:2 ratio was more comfortable than 15:2 in the child model. This could be due to the smaller number of position changes for ventilation that needs to be done in 30:2 ratio. In contrast, 82% of the volunteers reported that the 15:2 ratio was more comfortable for infant CPR, attributing it to the fact that the 30:2 ratio caused greater weariness of the fingers.

    We have observed that, despite having done a pediatric CPR course in the last year, a high percentage of rescuers made some errors or omissions in CPR algorithm, the most frequent giving five initial recue breaths and forgetting to ask for help. Rescuers who performed without error or omissions one CPR session, usually did it without errors in another session. This may be because some volunteers internalize knowledge better than others. There is no agreement in which the best time interval for doing CPR recertification courses is and the best method to keep the skills acquired. Traditionally it has been recommended that recertification should be done every 1 or 2 years at most31. Our results highlight the importance of frequent refreshment of CPR training, possibly between 6 months and 1 year.

    The study is a pediatric simulation model with manikins that compare to compression-to-ventilation ratios. Experimental or clinical studies should be carried out, in which other factors that may affect survival, such as ventilation, oxygenation, blood pressure, etc., will be analyzed in addition to the quality of CC.

    The scope of the study is limited to single rescuer CPR. It could be different in situations in which two rescuers are providing CPR. The pauses of transitions between compressions and ventilations by a single rescuer should be longer than when CPR is performed by more than one rescuer. The study also has the inherent limitations of those performed with manikins. Experimental and clinical studies are needed to analyze the effect of the two compression-to-ventilation ratios and the interaction between quality of chest compressions and ventilation and oxygenation achieved during resuscitation. Other potential limitation was that the researchers could not be blinded to resuscitation method and the small sample size. The assessment of the resuscitations maneuvers as opening of the airway and ventilation was carried out subjectively, although evaluation criteria were defined previously. The qualitive assessment was performed by the same researcher to avoid interobserver variability. Finally, in our study participant expressed their preference between 15:2 or 30:2 ratio from and subjective point of view, but no other objective fatigue scale was used as in Vaillantcourt13 study.

    Quality of chest compressions during pediatric resuscitation with 15:2 and 30:2 compressions

    Source : www.nature.com

    Key Updates From the 2020 AHA Pediatric Basic Life Support Guidelines

    US Pharm. 2021;46(8):HS2-HS9.

    ABSTRACT: The American Heart Association (AHA) guidelines for pediatric basic and advanced life support and the International Liaison Committee on Resuscitation (ILCOR) treatment recommendations were updated in 2020. In terms of basic life support for pediatric patients, the AHA guidelines continue to emphasize high-quality cardiopulmonary resuscitation (CPR)—i.e., chest compressions of adequate rate and depth, full chest recoil with each compression, minimal interruptions, and avoidance of excessive ventilation. In infants and children receiving CPR who have an advanced airway in place or who have a pulse but are undergoing rescue breathing, a key update is the recommendation to increase the respiratory rate to 20 to 30 breaths per minute (one breath every 2-3 seconds). Pharmacists should be aware of these important changes from previous guidelines, as a growing body of pediatric-specific evidence supports these new recommendations.

    The American Heart Association (AHA) has published frequent updates on pediatric basic life support (BLS), and the International Liaison Committee on Resuscitation (ILCOR) has published annual treatment recommendations based on a body of data. In particular, the pediatric BLS guidelines differ according to patient age and other factors. These differences are specified for infants (age <1 year) and children (age 1 year to start of puberty [i.e., breast development in females and presence of axillary hair in males]). The approach to BLS in infants and children for a single rescuer differs slightly from when two or more rescuers are available (for algorithms, see www.ahajournals.org/doi/epub/10.1161/CIR.0000000000000901). The 2020 AHA cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) guidelines reaffirm that the compressions-airway-breathing (C-A-B) sequence is still preferred for pediatric CPR. The guidelines also emphasize that conventional CPR, which has better outcomes compared with compression-only CPR, is preferable.1-4

    This article will discuss important updates from the guidelines that pharmacists should be aware of. However, it must be noted that this is a brief update chiefly of pediatric BLS and does not go into detail regarding pediatric advanced life support (ALS). Therefore, pharmacists should always renew their pediatric CPR certification before expiration and not only review, but also learn to apply, those concepts not discussed in further detail here.

    BLS APPROACH

    The 2020 AHA guidelines address two indications for the use of BLS in critically ill or injured infants and children: cardiac arrest (no pulse) and bradycardia (heart rate [HR] <60 beats/minute) with poor perfusion.1,5,6

    As healthcare providers (HCPs), pharmacists should follow the sequence of key actions as described in the guidelines when there is an indication to do so1:
    • First, the rescuer must confirm the scene’s safety.
    • Next, the rescuer should determine the patient’s responsiveness, get aid, and activate the emergency medical response system. If the patient is unresponsive, the rescuer should call for help and activate emergency medical services (EMS) via a mobile device (single rescuer outside of the hospital) or hospital system (e.g., code button). Alternatively, if there are two or more HCPs, one rescuer should continue to care for the patient and a second rescuer should activate EMS and retrieve an automated external defibrillator (AED) and other emergency equipment. If the patient is responsive, the rescuer should determine additional medical needs and the necessity for EMS activation based on the patient’s condition.
    • The rescuer should assess the patient’s breathing and pulse and determine whether the patient is breathing, only gasping, or not breathing while simultaneously checking for a pulse.

    This assessment guides further action depending on the number of rescuers. If there is no breathing or only gasping and there is no definitive pulse within 10 seconds, guidance is as follows1:
    Single rescuer: The approach depends on whether or not the sudden collapse is witnessed. If the collapse is not witnessed, the rescuer should start CPR (C-A-B) with a ratio of 30 compressions to two breaths; after about 2 minutes, if still alone, the rescuer should activate EMS, retrieve an AED, and apply and activate it immediately. If the collapse is witnessed, the rescuer should activate EMS and retrieve an AED (or, for ALS, a manual defibrillator); the single rescuer should then use the AED (or manual defibrillator, for ALS) immediately. If an AED is not nearby or available, the rescuer should start CPR while awaiting the arrival of EMS.
    Two or more rescuers: If a single rescuer is acting, CPR (C-A-B) should be initiated with a ratio of 30 compressions to two breaths; if two or more rescuers are acting, the ratio should be 15 compressions to two breaths.

    In infants and children, the method and depth of compressions vary by age. Chest compressions should always be accompanied by ventilation in infants and children who remain pulseless after the initial sequence of compressions. The guidelines acknowledge that it is difficult to quickly determine whether or not a pulse is present; therefore, when a pulse is not definitively identified within 10 seconds, CPR should be initiated.1

    If there is no normal breathing but a pulse is present, single or multiple rescuers should follow this procedure1:

    • Start rescue breathing by providing one breath every 2-3 seconds (20-30 breaths/minute). Pharmacists should take note of this instruction, as this is a change from the 2015 guidelines’ suggested rate of every 3-5 seconds (12-20 breaths/minute).
    • Perform a pulse check for no longer than 10 seconds. Add chest compressions if the HR remains <60 beats/minute with poor perfusion, and activate EMS.
    • Continue rescue breathing. Perform a pulse check every 2 minutes. If no pulse is present, begin CPR (C-A-B) starting with a ratio of 30 compressions to two breaths for a single rescuer and 15 compressions to two breaths for two or more rescuers.

    If the patient exhibits normal breathing and a pulse is present, single or multiple rescuers should use the following procedure1:
    • Monitor the patient until EMS arrives.
    • Take the following actions, which constitute CPR: Perform chest compressions, open the airway, and provide ventilations (C-A-B).

    The sequence in which HCPs should perform the actions of CPR on infants and children is as follows1:
    • Initiate CPR in an infant or child who is unresponsive, has no normal breathing, and has no definitive pulse after 10 seconds.
    • Start chest compressions before performing airway or breathing maneuvers (C-A-B).
    • After 30 compressions (15 compressions, if two rescuers), open the airway and give two breaths.
    • If the HR is 60 beats/minute or greater after about 2 minutes of CPR, stop chest compressions and continue ventilation.
    • Use the AED (or manual defibrillator, for ALS).

    This sequence will differ slightly with the number of rescuers. For a single rescuer and for a witnessed collapse, the HCP should retrieve the AED (or manual defibrillator, for ALS) and use it as soon as possible. For an unwitnessed collapse, the single rescuer should perform about 2 minutes of CPR and then activate EMS and retrieve the AED (or manual defibrillator, for ALS). However, when there are two or more rescuers, one rescuer should initiate CPR while the other rescuer activates EMS and retrieves the AED (or manual defibrillator, for ALS). The AED (or manual defibrillator) is used as soon as it is available.1

    The HCP can proceed as follows based on AED analysis1:
    Shockable rhythm: It is recommended to provide one shock and resume CPR immediately for about 2 minutes (until prompted by the AED to allow a rhythm check). CPR should be continued with pulse check and AED rhythm check every 2 minutes until ALS HCPs take over or the patient starts to move.
    Nonshockable rhythm: CPR should be resumed immediately for about 2 minutes (until prompted by the AED to allow a rhythm check). CPR should be continued with pulse check and AED rhythm check every 2 minutes until ALS HCPs take over or the patient starts to move.

    For a single rescuer and for two or more rescuers, respectively, CPR should be performed for approximately 2 minutes (five cycles for single rescuer; 10 cycles for two or more rescuers) before AED use in a patient with an unwitnessed arrest. This approach is based on limited evidence in adults that—even for prolonged arrest from ventricular fibrillation—an initial period of CPR improves the likelihood of successful defibrillation.1

    HIGH-QUALITY CPR

    Chest Compressions

    The 2020 AHA CPR and ECC guidelines reaffirm the previous recommendations and continue to emphasize the importance of proper technique in the performance of chest compressions. Compressions should be performed over the lower half of the sternum, as compression of the xiphoid process can cause trauma to the liver, spleen, or stomach and must be avoided.1

    The guidelines address the effectiveness of chest compressions and how HCPs can maximize efficacy by learning and following these key points1:
    • The chest should be depressed at least one-third of its anterior-posterior diameter with each compression. The compression depth for infants is approximately 4 cm (1.5 inches), and the depth for children is 5 cm (2 inches). For a child who has reached puberty, it is reasonable to use the adult compression depth of at least 5 cm but no more than 6 cm.
    • The optimal rate of compressions is approximately 100-120 per minute, which is achieved by ensuring that the compression and decompression phases are of equal duration.
    • The sternum should return briefly to its normal position at the end of each compression, allowing the chest to recoil fully.
    • A smooth compression-decompression rhythm with minimal interruption should be developed.
    • Chest compressions should be performed on a firm surface.

    Audiovisual feedback, coaching, and frequent training improve HCP adherence to these recommendations, so an emphasis on recertification is critical for enabling pharmacists to apply what they learn from the new guidelines.1

    Infants: The 2020 AHA and ECC guidelines reaffirm that chest compressions may be performed using either the two-fingers technique or the two-thumb–encircling hands technique as described below. If the rescuer is unable to compress at least one-third of the anterior-posterior diameter of the chest via either of these techniques, it is reasonable to use the heel of one hand. The AHA suggests using the two-fingers technique when there is a single rescuer. The two-fingers technique during single-rescuer infant CPR permits both easier transition from compressions to ventilation and maintenance of the head-tilt maneuver during compressions, thereby avoiding head repositioning for ventilation. Chest compressions are performed with the index and middle fingers placed on the sternum just below the nipples. Because of the size of the back of the infant’s head, slight neck extension and placement of a hand or rolled towel beneath the upper thorax and shoulders may be necessary to ensure that the compressions target the heart. For infants undergoing two-rescuer CPR, compressions may be performed using the two-thumb–encircling hands technique. The thorax is encircled with both hands and chest compressions are performed with the thumbs. The thumbs compress the lower half of the sternum, avoiding the xiphoid process, while the hands are spread around the thorax.1,2

    Children: In these patients, chest compressions should be performed over the lower half of the sternum either with the heel of one hand or with two hands.1,2

    Compression-to-Ventilation Ratio

    No Advanced Airway: In infants and children who remain pulseless after the initial sequence of compressions, chest compressions should always be accompanied by ventilation. However, every effort should be made to avoid excessive ventilation and to limit interruptions of chest compressions to under 10 seconds. Experimental evidence in animals indicates that coronary artery perfusion pressure declines with interruptions in chest compressions. Observational reports suggest that long interruptions in CPR occur commonly. Therefore, compression-to-ventilation ratios of 30 to 2 and 15 to 2 are recommended to minimize interruptions and for ease of teaching and retention.1,2,7,8 For a single rescuer, two ventilations should be delivered during a short pause at the end of every 30th compression. For two rescuers, two ventilations should be delivered at the end of every 15th compression.

    Advanced Airway: Once the patient is under hospital care and the trachea is intubated, chest compressions and ventilations may be performed independently. In infants and children, chest compressions are delivered at a rate of 100 to 120 per minute without pauses, and ventilations are administered at a rate of 20 to 30 breaths per minute (i.e., one breath every 2-3 seconds). This new 2020 guideline change in compression-to-ventilation ratio in infants and children with an advanced airway is based on a multicenter observational study of 47 pediatric patients with in-hospital cardiac arrest, which determined that ventilation rates of at least 30 breaths per minute in infants and 25 breaths per minute in children were associated with increased rates of return of spontaneous circulation and survival.1,2,9

    Airway: The airway should be opened with a head tilt–chin lift maneuver unless a cervical spine injury is suspected. In the setting of trauma in which cervical spine injury is suspected, a jaw-thrust maneuver without head tilt should be employed; however, if this action is unsuccessful, the head tilt–chin lift maneuver should be used.1

    Breathing: Ventilations can be provided mouth-to-mouth, mouth-to-nose, or with a bag and mask. The bag-and-mask technique is often sufficient to achieve adequate ventilation during CPR, and it is a reasonable alternative to an advanced airway (e.g., endotracheal intubation) before arrival at the hospital for pediatric cardiac arrest.1,2

    Evidence in adults and animals suggests that hyperventilation is associated with increased intrathoracic pressure and decreased coronary and cerebral perfusion. These data are the basis for the following recommendations1,2,10,11:
    • Each rescue breath should be delivered over 1 second.
    • The volume of each breath should be sufficient to see the chest wall rise.
    • An infant or child with an HR of 60 or more beats/minute without normal breathing should receive one breath every 2-3 seconds (20-30 breaths/minute).
    • Infants and children who require chest compressions should receive two breaths per 30 compressions for a single rescuer, and two breaths per 15 compressions for two rescuers.
    • Intubated infants and children should be ventilated at a rate of 20-30 breaths/minute (one breath every 2-3 seconds), with a goal of 30 breaths/minute in infants and 20-25 breaths/minute in children without any interruption of chest compressions.

    This portable device identifies shockable rhythms that should be treated with defibrillation. The AED instructs the operator on how to use the device to deliver a standard shock to the patient. It also identifies nonshockable rhythms, accordingly advising no shock followed by a prompt to resume CPR.1,2

    The 2020 AHA CPR and ECC guidelines reaffirm the following for infants and children with cardiac arrest.1,2

    Witnessed Arrest: An AED should be used as soon as possible if a manual defibrillator is not available. CPR should be performed until the AED (or manual defibrillator, if available) is ready to deliver a shock. A single shock followed by immediate chest compressions is recommended for infants and children with a shockable rhythm.

    Unwitnessed Arrest: The algorithms for a single rescuer and two or more rescuers are designed so that CPR is performed for approximately 2 minutes (five cycles for a single rescuer, and 10 cycles for two or more rescuers) before an AED is used.

    Age <8 Years: An AED with a pediatric dose-attenuating system should be used whenever possible. However, if a manual defibrillator or an AED with a pediatric dose-attenuating system is not available, it is advised to use an AED without a dose attenuator.

    SUSPECTED OR CONFIRMED COVID-19

    The AHA has also published interim guidance, including updated algorithms, for BLS and ALS in children with suspected or confirmed COVID-19.12 (ALS is not discussed in detail here, but information may be found in the updated guidelines.) For pediatric cardiac arrest, the modifications to BLS include the following (see www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.047463 for algorithm)12:
    • Wear personal protective equipment (PPE) prior to entering the scene or the patient’s room.
    • Limit the number of personnel performing CPR.
    • Consider using a mechanical CPR device for adolescents who meet height and weight criteria.
    • Provide rescue breathing using a bag-and-mask device with a high-efficiency particulate air filter, and ensure a tight mask seal.

    Some HCPs may be concerned that PPE could cause hindrances, but pharmacists should note that preliminary evidence from a study suggests that quality of BLS and amount of rescuer fatigue are not significantly affected.13 This study aimed to determine whether PPE resulted in deterioration in chest-compression quality and greater fatigue for administering HCPs. Results showed that neither chest-compression quality (rate, depth, and release velocity) nor self-reported fatigue worsened significantly in HCPs who performed BLS on pediatric manikins while wearing PPE. This suggests that the current pediatric BLS recommendation for chest-compression providers to switch every 2 minutes need not be altered with PPE use.13

    CONCLUSION

    Survival after cardiac arrest requires an integrated system of HCPs, training, equipment, and organizations. BLS providers, among others working within EMS systems, contribute to successful resuscitation from out-of-hospital cardiac arrest. Within the U.S. healthcare system, the work of HCPs such as pharmacists supports resuscitation outcomes, and pharmacists should be cognizant of and certified in the latest updates from the 2020 AHA pediatric guidelines.

    REFERENCES

    1. Topjian AA, Raymond TT, Atkins D, et al. Part 4: pediatric basic and advanced life support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16 suppl 2):S469-S523.
    2. Nolan JP, Machonochie I, Soar J, et al. Executive summary: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020;142;16(suppl 1):S2-S27.
    3. Maconochie IK, Aickin R, Hazinski MF, et al. Pediatric life support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2020;156:A120-A155.
    4. Duff JP, Topjian AA, Berg MD, et al. 2019 American Heart Association focused update on pediatric advanced life support: an update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2019;140(24):e904-e914.
    5. Khera R, Tang Y, Girotra S, et al. Pulselessness after initiation of cardiopulmonary resuscitation for bradycardia in hospitalized children. Circulation. 2019;140(5):370-378.
    6. Donoghue A, Berg RA, Hazinski MF, et al. Cardiopulmonary resuscitation for bradycardia with poor perfusion versus pulseless cardiac arrest. Pediatrics. 2009;124(6):1541-1548.
    7. Berg RA, Sanders AB, Kern KB, et al. Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest. Circulation. 2001;104(20):2465-2470.
    8. Kern KB, Hilwig RW, Berg RA, et al. Importance of continuous chest compressions during cardiopulmonary resuscitation: improved outcome during a simulated single lay-rescuer scenario. Circulation. 2002;105(5):645-649.
    9. Sutton RM, Reeder RW, Landis WP, et al. Ventilation rates and pediatric in-hospital cardiac arrest survival outcomes. Crit Care Med. 2019;47(11):1627-1636.
    10. Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 suppl 3):S876-S908.
    11. Berg MD, Schexnayder SM, Chameides L, et al. Part 13: pediatric basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 suppl 3):S862-S875.
    12. Edelson DP, Sasson C, Chan PS, et al. Interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed COVID-19: from the Emergency Cardiovascular Care Committee and Get With the Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association. Circulation. 2020;141(25):e933-e943.
    13. Donoghue AJ, Kou M, Good GL, et al. Impact of personal equipment on pediatric cardiopulmonary resuscitation performance: a controlled trial. Pediatr Emerg Care. 2020;36(6):267-273.

    The content contained in this article is for informational purposes only. The content is not intended to be a substitute for professional advice. Reliance on any information provided in this article is solely at your own risk.

    To comment on this article, contact [email protected]

    Key Updates From the 2020 AHA Pediatric Basic Life Support Guidelines

    Source : www.uspharmacist.com

    Effect of one

    C:V ratio and manikin size have a significant influence on the number of effective compressions and ventilations delivered during ideal, metronome-paced, one-rescuer CPR. Low ratios of 3:1, 5:1, and 10:2 favor ventilation, and high ratios of 15:2 favor compression, especially in adult manikins. Resc …

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    Effect of one

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