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PALS Update
PALS Update
This 2019 focused update to the American Heart Association pediatric abstract
advanced life support guidelines follows the 2018 and 2019 systematic
reviews performed by the Pediatric Life Support Task Force of the
International Liaison Committee on Resuscitation. It aligns with the
continuous evidence review process of the International Liaison Committee
on Resuscitation, with updates published when the International Liaison
Committee on Resuscitation completes a literature review based on new
published evidence. This update provides the evidence review and treatment
recommendations for advanced airway management in pediatric cardiac
arrest, extracorporeal cardiopulmonary resuscitation in pediatric cardiac
arrest, and pediatric targeted temperature management during post–cardiac
arrest care. The writing group analyzed the systematic reviews and the
original research published for each of these topics. For airway management,
the writing group concluded that it is reasonable to continue bag-mask Key Words: advanced cardiac life support n airway
ventilation (versus attempting an advanced airway such as endotracheal management n cardiopulmonary resuscitation n
intubation) in patients with out-of-hospital cardiac arrest. When extracorporeal membrane oxygenation n heart
arrest n hypothermia, induced n pediatrics
extracorporeal membrane oxygenation protocols and teams are readily
available, extracorporeal cardiopulmonary resuscitation should be considered The American Heart Association and the American
for patients with cardiac diagnoses and in-hospital cardiac arrest. Finally, it Academy of Pediatrics make every effort to avoid any
actual or potential conflicts of interest that may
is reasonable to use targeted temperature management of 32°C to 34°C
arise as a result of an outside relationship or
followed by 36°C to 37.5°C, or to use targeted temperature management of a personal, professional, or business interest of
36°C to 37.5°C, for pediatric patients who remain comatose after resuscitation a member of the writing panel. Specifically, all
from out-of-hospital cardiac arrest or in-hospital cardiac arrest. members of the writing group are required to
complete and submit a Disclosure Questionnaire
showing all such relationships that might be
perceived as real or potential conflicts of interest.
return of spontaneous circulation. causes.33 ECPR use rates have the use of ECPR in pediatric cardiac
ECPR is a resource-intense, complex increased, with single-center reports arrest. The first study was
multidisciplinary therapy that in both adults and children a retrospective review (2000–2008)
traditionally has been limited to large suggesting that application of this of the Get With The
academic medical centers with therapy across broader patient Guidelines–Resuscitation registry of
providers who have expertise in the populations may improve survival pediatric patients with IHCA after
management of children with cardiac after both OHCA and IHCA.34–36 cardiac surgery.37 On adjusted
disease. Judicious use of ECPR for multivariate analysis, the use of ECPR
specialized patient populations and Evidence Summary—Updated 2019 was associated with higher rates of
within dedicated and highly practiced The ILCOR Pediatric Life Support survival to hospital discharge than
environments has proved successful, Task Force and the AHA pediatric conventional CPR. A second review of
especially for IHCA with reversible writing group reviewed 3 studies on the same database used a propensity
5
analysis to examine the association of
This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit. A
relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-mo period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns
Other
None
None
None
None
None
None
ECPR with favorable neurologic
outcome in patients with IHCA of any
origin.38 During an 11-year period
Consultant/
Advisory
Board
None
None
None
None
None
591 receiving ECPR. Compared with
conventional CPR, the use of ECPR
Expert Ownership
Witness Interest
None
None
None
None
None
neurologic outcome at hospital
discharge (odds ratio, 1.78 [95% CI,
1.31–2.41]).
None
None
None
None
None
None
None
None
None
None
None
$10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
None
None
None
None
None
AHRQ (PI on a K08 from AHRQ studying prediction and diagnosis of pediatric septic shock. I do None
Recommendation—Updated 2019
1. ECPR may be considered for
pediatric patients with cardiac
diagnoses who have IHCA in
settings with existing ECMO
protocols, expertise, and
equipment (Class 2b; Level of
Evidence C-LD).
There is insufficient evidence to
recommend for or against the use of
None
None
None
None
None
Johns Hopkins
Tennessee
University of
University of
University
Colorado
conventional CPR.
Mexico
Center
Reviewer Disclosures
Discussion
The 2015 AHA PALS guidelines
Mark Meredith
McBride
Greene
Jeffers
* Significant.
Justin M.
Reviewer
Mary E.
This document was approved by the American Heart Association Science Advisory and Coordinating Committee on July 19, 2019, and the American Heart
Association Executive Committee on August 9, 2019.
The American Heart Association requests that this document be cited as follows: Duff JP, Topjian AA, Berg MD, Chan M, Haskell SE, Joyner BL Jr, Lasa JJ, Ley SJ,
Raymond TT, Sutton RM, Hazinski MF, Atkins DL. 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 [published online ahead of print November 14, 2019].
Circulation. doi: 10.1161/CIR.0000000000000731
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