2020 AHA PALS Instructor Update

The American Heart Association has made many new science and education recommendations that are relevant to the 2020 Pediatric Advanced Life Support (PALS) courses.

These updates are documented in the 2020 AHA Guidelines for CPR and ECC.

• Identify the PALS 2020 science and education updates
• Describe the rationale for these updates
• Apply the updates to your training

Systems of Care: Using Mobile Phone Devices to Summon Rescuers

2020 (New): The use of mobile phone technology by emergency dispatch systems to alert willing bystanders to nearby events that may require CPR or AED use is reasonable.

Why: Most communities experience low rates of bystander CPR and AED use. A recent systematic review from the International Liaison Committee on Resuscitation (ILCOR) systematic review found that notification of lay rescuers via a smartphone app or text message alert is associated with shorter bystander response times, higher bystander CPR rates, shorter time to defibrillation, and higher rates of survival to hospital discharge for individuals who experience out-of-hospital cardiac arrest.

Systems of Care: Data Registries to Improve System Performance

2020 (New): It is reasonable for organizations that treat cardiac arrest patients to collect processes-of-care data and outcomes.

Why: Many industries, including healthcare, collect and assess performance data to measure quality and identify opportunities for improvement. This can be done through participation in data registries that collect information on processes of care (CPR performance data, defibrillation times, adherence to guidelines) and outcomes of care (return of spontaneous circulation [ROSC], survival) associated with cardiac arrest. The AHA Get With the Guidelines®-Resuscitation registry (for in-hospital cardiac arrest) and the Resuscitation Outcomes Consortium Cardiac Epistry and AHA Cardiac Arrest Registry to Enhance Survival registry (for out-of-hospital cardiac arrest) are 3 such initiatives, and many regional databases also exist.

Pediatric Chains of Survival

A new pediatric Chain of Survival was created for in-hospital cardiac arrest in infants, children, and adolescents.

A sixth link, recovery, was added to the pediatric out-of-hospital Chain of Survival and is included in the new pediatric in-hospital Chain of Survival.

Pediatric Tachycardia With a Pulse Algorithm

A single algorithm now covers both narrow- and wide-complex tachycardias.

Opioid-Associated Emergency for Healthcare Providers Algorithm

The opioid-associated resuscitation emergency algorithm is used for both adult and pediatric patients.

Pediatric Post–Cardiac Arrest Care Checklist

A checklist is provided for pediatric post–cardiac arrest care. Healthcare providers should use this checklist as a training tool, and to ensure that the most high-impact interventions are being used.

Changes to the Pediatric Assisted Ventilation Rate

Rescue Breathing

2020 (Updated): For infants and children with a pulse but absent or inadequate respiratory effort, it is reasonable to give 1 breath every 2 to 3 seconds (20 to 30 breaths/min).

Ventilation Rate During CPR With an Advanced Airway

2020 (Updated): When performing CPR in infants and children with an advanced airway, it may be reasonable to target a respiratory rate range of 1 breath every 2 to 3 seconds (20 to 30 breaths/ min), accounting for age and clinical condition. Rates exceeding these recommendations may compromise hemodynamics.

Why: New data show that higher ventilation rates (at least 30 breaths/min in infants less than 1 year of age and at least 25 breaths/min in older children) are associated with improved rates of ROSC and survival in pediatric in-hospital cardiac arrest.

Although there are no data about the ideal ventilation rate during CPR without an advanced airway, or for children in respiratory arrest with or without an advanced airway, for simplicity of training, the respiratory arrest recommendation was standardized for all situations.

Cuffed Endotracheal Tubes

2020 (Updated): It is reasonable to choose cuffed endotracheal tubes (ETTs) over uncuffed ETTs for intubating infants and children. When a cuffed ETT is used, attention should be paid to ETT size, position, and cuff inflation pressure (usually less than 20-25 cm H2O).

Why: Several studies and systematic reviews support the safety of cuffed ETTs and demonstrate decreased need for tube changes and reintubation. Cuffed tubes may decrease the risk of aspiration. Subglottic stenosis is rare when cuffed ETTs are used in children and careful technique is followed.

Cricoid Pressure During Intubation

2020 (Updated): Routine use of cricoid pressure is not recommended during endotracheal intubation of pediatric patients.

Why: New studies have shown that routine use of cricoid pressure reduces intubation success rates and does not reduce the rate of regurgitation. Previous recommendations to discontinue cricoid pressure if it interferes with ventilation or the speed or ease of intubation have been reaffirmed.

Emphasis on Early Epinephrine Administration

2020 (Updated): For pediatric patients in any setting, it is reasonable to administer the initial dose of epinephrine within 5 minutes from the start of chest compressions.

Why: A study of children with in-hospital cardiac arrest who received epinephrine for an initial nonshockable rhythm (asystole and pulseless electrical activity) demonstrated that, for every minute delay in administration of epinephrine, there was a significant decrease in ROSC, survival at 24 hours, survival to discharge, and survival with favorable neurologic outcome. Patients who received epinephrine within 5 minutes of CPR initiation compared with those who received epinephrine more than 5 minutes after CPR initiation were more likely to survive to discharge. Studies of pediatric out-of-hospital cardiac arrest demonstrated that earlier epinephrine administration increased rates of ROSC, survival to intensive care unit admission, survival to discharge, and 30-day survival.

In the previous (2018) version of the Pediatric Cardiac Arrest Algorithm, patients with nonshockable rhythms received epinephrine every 3 to 5 minutes, but early administration of epinephrine was not emphasized. Although the sequence of resuscitation has not changed, the algorithm and recommendation language have been updated to emphasize the importance of giving epinephrine as early as possible, particularly when the rhythm is nonshockable.

Invasive Blood Pressure Monitoring to Assess CPR Quality

2020 (Updated): For patients with continuous invasive arterial blood pressure monitoring in place at the time of cardiac arrest, it is reasonable for providers to use diastolic blood pressure to assess CPR quality.

Why: Providing high-quality chest compressions is critical to successful resuscitation. A new study showed that, among pediatric patients receiving CPR with an arterial line in place, rates of survival with favorable neurologic outcome were improved if the diastolic blood pressure was at least 25 mmHg in infants and at least 30 mm Hg in children.

Detecting and Treating Seizures After ROSC

2020 (Updated): When resources are available, continuous electroencephalographic monitoring is recommended for the detection of seizures after cardiac arrest in patients with persistent encephalopathy.

2020 (Updated): It is recommended to treat clinical seizures after cardiac arrest.

2020 (Updated): It is reasonable to treat nonconvulsive status epilepticus after cardiac arrest in consultation with experts.

Why: For the first time, the 2020 Guidelines provide pediatric-specific recommendations for the management of seizures after cardiac arrest. Nonconvulsive seizures, including nonconvulsive status epilepticus, are common and cannot be detected without electroencephalography. Although outcome data from the post–cardiac arrest population are lacking, both convulsive and nonconvulsive status epilepticus are associated with poor outcome, and treatment of status epilepticus is beneficial in pediatric patients in general.

Evaluation and Support for Cardiac Arrest Survivors

2020 (New): It is recommended that pediatric cardiac arrest survivors be evaluated for rehabilitation services.

2020 (New): It is reasonable to refer pediatric cardiac arrest survivors for ongoing neurologic evaluation for at least the first year after cardiac arrest.

Why: There is a growing recognition that recovery from cardiac arrest extends for a long time after the initial hospitalization. Survivors may require ongoing integrated medical, rehabilitative, caregiver, and community support in the months to years after their cardiac arrest. A recent AHA Scientific Statement highlights the importance of supporting patients and families during this time to achieve the best possible long-term outcome.

Septic Shock: Fluid Boluses

2020 (Updated): In patients with septic shock, it is reasonable to administer fluid in 10-mL/kg or 20-mL/kg aliquots with frequent reassessment.

Why: Although fluids remain the mainstay of initial therapy for infants and children in shock, especially in hypovolemic and septic shock, fluid overload can lead to increased morbidity. In recent trials of patients with septic shock, those who received higher fluid volumes or faster fluid resuscitation were more likely to develop clinically significant fluid overload and require mechanical ventilation. Previous recommendations to reassess patients after each fluid bolus and to use either crystalloid or colloid fluids for septic shock resuscitation are reaffirmed.

Septic Shock: Choice of Vasopressor

2020 (New): In infants and children with fluid-refractory septic shock, it is reasonable to use either epinephrine or norepinephrine as an initial vasoactive infusion.

2020 (New): In infants and children with fluid-refractory septic shock, if epinephrine and norepinephrine are unavailable, dopamine may be considered.

Why: Previous versions of the Guidelines did not provide recommendations about choice of vasopressor or the use of corticosteroids in septic shock. Two RCTs suggest that epinephrine is superior to dopamine as the initial vasopressor in pediatric septic shock, and norepinephrine is also appropriate.

Septic Shock: Corticosteroid Administration

2020 (New): For infants and children with septic shock unresponsive to fluids and requiring vasoactive support, it may be reasonable to consider stress-dose corticosteroids.

Why: Recent clinical trials suggest a benefit from corticosteroid administration in some pediatric patients with refractory septic shock.

Hemorrhagic Shock

2020 (New): Among infants and children with hypotensive hemorrhagic shock after trauma, it is reasonable to administer blood products, when available, instead of crystalloid for ongoing volume resuscitation.

Why: Previous versions of the Guidelines did not differentiate the treatment of hemorrhagic shock from other causes of hypovolemic shock. A growing body of evidence (largely from adults, but with some pediatric data) suggests a benefit to early, balanced resuscitation with packed red blood cells, fresh frozen plasma, and platelets. Balanced resuscitation is supported by recommendations from several US and international trauma societies.

Opioid Overdose

2020 (Updated): For patients in respiratory arrest, rescue breathing or bag-mask ventilation should be maintained until spontaneous breathing returns, and standard pediatric basic life support or advanced life support measures should continue if return of spontaneous breathing does not occur.

2020 (Updated): For a patient with suspected opioid overdose who has a definite pulse but no normal breathing or only gasping (ie, a respiratory arrest), in addition to providing standard pediatric BLS or PALS care, it is reasonable for responders to administer intramuscular or intranasal naloxone.

2020 (Updated): For patients known or suspected to be in cardiac arrest, in the absence of a proven benefit from the use of naloxone, standard resuscitative measures should take priority over naloxone administration, with a focus on high-quality CPR (compressions plus ventilation).

Why: The opioid epidemic has not spared children. In the United States in 2018, opioid overdose caused 65 deaths in children younger than 15 years old and 3618 deaths in people 15 to 24 years old (Wilson 2020), and many more children required resuscitation. These Guidelines contain new recommendations for the management of children with respiratory arrest or cardiac arrest from opioid overdose. These recommendations are identical for adults and children, except that compression-ventilation CPR is recommended for all pediatric victims of suspected cardiac arrest. Naloxone can be administered by trained providers, lay responders with focused training, and the lay public. Separate treatment algorithms are provided for management of opioid-associated resuscitation emergencies by lay responders (who cannot reliably check for a pulse) and by trained rescuers. Opioid-associated out-of-hospital cardiac arrest is the subject of a 2020 AHA Scientific Statement (Dezfulian 2020 in press).

Myocarditis

2020 (New): Given the high risk of cardiac arrest in children with acute myocarditis who demonstrate arrhythmias, heart block, ST-segment changes, and/or low cardiac output, early consideration of transfer to an intensive care unit for monitoring and therapy is recommended.

2020 (New): For children with myocarditis or cardiomyopathy and refractory low cardiac output, prearrest use of extracorporeal life support (ECLS) or mechanical circulatory support can be beneficial to provide end-organ support and prevent cardiac arrest.

2020 (New): Given the challenges to successful resuscitation of children with myocarditis and cardiomyopathy, once cardiac arrest occurs, early consideration of extracorporeal CPR may be beneficial.

Why: Although myocarditis accounts for about 2% of sudden cardiovascular deaths in infants, 5% of sudden cardiovascular deaths in children, and 6% to 20% of sudden cardiac death in athletes, previous PALS guidelines did not contain specific recommendations for management. These recommendations are consistent with the 2018 AHA Scientific Statement on CPR in infants and children with cardiac disease (Marino 2018).

Single Ventricle: Preoperative and Postoperative Stage I Palliation (Norwood/Blalock-Tausig Shunt)

2020 (New): Direct and/or indirect oxygen saturation monitoring can be beneficial to trend and direct management in critically ill neonates after stage I Norwood palliation or shunt placement.

2020 (Updated): For neonates before stage I repair with pulmonary overcirculation and symptomatic low systemic cardiac output and delivery of oxygen, or DO2, it is reasonable to target a PaCO2 of 50 to 60 mm Hg. This can be achieved during mechanical ventilation by reducing minute ventilation or by administering analgesia/sedation with or without neuromuscular blockade.

2010 (Old): Neonates in a prearrest state due to elevated pulmonary-to-systemic flow ratio before stage I repair might benefit from a PaCO2 of 50 to 60 mm Hg, which can be achieved during mechanical ventilation by reducing minute ventilation, increasing the inspired fraction of CO2, or administering opioids with or without chemical paralysis.

2020 (New): In a patient with an appropriately restrictive shunt, manipulation of pulmonary vascular resistance may have little effect, whereas lowering systemic vascular resistance with the use of systemic vasodilators (α-adrenergic antagonists and/or phosphodiesterase type III inhibitors) with or without the use of oxygen can be useful to increase systemic DO2.

2020 (New): ECLS after stage I Norwood palliation can be useful to treat low systemic DO2.

2020 (New): In the situation of known or suspected shunt obstruction, it is reasonable to administer oxygen, vasoactive agents to increase shunt perfusion pressure, and heparin (50-100 units/kg bolus) while preparing for catheter-based or surgical intervention.

Single Ventricle: Postoperative Stage II (Bidirectional Glenn/Hemi-Fontan) and Stage III (Fontan) Palliation

2020 (New): For patients in a prearrest state with superior cavopulmonary anastomosis physiology and severe hypoxemia due to inadequate pulmonary blood flow (Qp), ventilatory strategies that target a mild respiratory acidosis and a minimum mean airway pressure without atelectasis can be useful to increase cerebral and systemic arterial oxygenation.

2020 (New): ECLS in patients with superior cavopulmonary anastomosis or Fontan circulation may be considered to treat low DO2 from reversible causes or as a bridge to a ventricular assist device or surgical revision.

Why: Approximately 1 in 600 infants and children are born with critical congenital heart disease. Staged surgery for children born with single-ventricle physiology, such as hypoplastic left heart syndrome, spans the first several years of life (Oster 2013). Resuscitation of these infants and children is complex and differs in important ways from standard PALS care. Previous PALS guidelines did not contain recommendations for the management of this specialized patient population. These recommendations are consistent with the 2018 AHA Scientific Statement on CPR in infants and children with cardiac disease (Marino 2018).

Pulmonary Hypertension

2020 (Updated): Inhaled nitric oxide or prostacyclin should be used as the initial therapy to treat pulmonary hypertensive crises or acute right-sided heart failure secondary to increased pulmonary vascular resistance.

2020 (New): Provide careful respiratory management and monitoring to avoid hypoxia and acidosis in the postoperative care of children with pulmonary hypertension.

2020 (New): For pediatric patients who are at high risk for pulmonary hypertensive crises, provide adequate analgesics, sedatives, and neuromuscular blocking agents.

2020 (New): For the initial treatment of pulmonary hypertensive crises, oxygen administration and induction of alkalosis through hyperventilation or alkali administration can be useful while pulmonary-specific vasodilators are administered.

2020 (New): For children who develop refractory pulmonary hypertension, including signs of low cardiac output or profound respiratory failure despite optimal medical therapy, ECLS may be considered.

Why: Pulmonary hypertension is a rare disease in infants and children that is associated with significant morbidity and mortality and requires specialized management. Previous PALS guidelines did not provide recommendations for the management of infants and children with pulmonary hypertension. These recommendations are consistent with guidelines on pediatric pulmonary hypertension published by the AHA and the American Thoracic Society in 2015 (Abman 2015) and with recommendations in a 2018 AHA Scientific Statement on CPR in infants and children with cardiac disease (Marino 2018).

Deliberate Practice and Mastery Learning

2020 (New): Incorporating a deliberate practice and mastery learning model into basic or advanced life support courses may be considered for improving skill acquisition and performance.

Why: Deliberate practice is a training approach where learners are given (1) a discrete goal to achieve, (2) immediate feedback on their performance, and (3) ample time for repetition to improve performance. Mastery learning is defined as the use of deliberate practice training along with testing that uses a set of criteria to define a specific passing standard that implies mastery of the tasks being learned. Evidence suggests that incorporating a deliberate practice and mastery learning model into basic or advanced life support courses improves multiple learning outcomes.

Booster Training and Spaced Learning

2020 (New): It is recommended to implement booster sessions when utilizing a massed learning approach for resuscitation training.

2020 (New): It is reasonable to use a spaced learning approach in place of a massed learning approach for resuscitation training.

Why: The addition of booster training sessions (ie, brief, frequent sessions focused on repetition of prior content) to resuscitation courses improves the retention of CPR skills. Studies show that spaced learning courses (ie, separation of training into multiple sessions) are of equal or greater effectiveness when compared with courses delivered as a single training event. Learner attendance across all sessions is required to ensure course completion because new content is presented at each session.

In Situ Education

2020 (New): It is reasonable to conduct in situ simulation-based resuscitation training in addition to traditional training.

Why: In situ simulation refers to training activities that are conducted in actual patient care areas.

New evidence shows that training in the in situ environment, either alone or in combination with traditional training, can have a positive impact on learning outcomes (eg, faster time to perform critical tasks and team performance) and patient outcomes.

When conducting in situ simulation, instructors should be wary of potential risks, such as mixing training supplies with real medical supplies.

EMS Practitioner Experience and Exposure to Out-of-Hospital Cardiac Arrest

2020 (New): It is reasonable for EMS systems to monitor clinical personnel’s exposure to resuscitation to ensure treating teams have members competent in the management of cardiac arrest cases. Competence of teams may be supported through staffing or training strategies.

Why: A recent systematic review found that EMS provider exposure to cardiac arrest cases is associated with improved patient outcomes, including rates of return of spontaneous circulation and survival.

Because exposure can be variable, the AHA recommends that EMS systems monitor provider exposure and develop strategies to address low exposure.

Course Formats

Instructor-led training is held in a classroom setting and includes both the instructional portion and skills practice.

The HeartCode blended-learning format uses online learning to deliver the instructional portion of the course. This online technology adapts to the learner’s knowledge and then presents content specifically to further the learner’s development. A hands-on session with an instructor or a HeartCode-compatible manikin completes the course requirements.

Resuscitation Quality Improvement, or RQI®, is an AHA program that uses low-dose, high-frequency training to deliver quarterly coursework and practice to support the mastery of high-quality CPR skills.

Online Exams

• Exam security
• Key performance data

While administering exams electronically is the preferred method, there may occasionally be a need to administer a paper exam.

See the AHA Instructor Network website for more information.

Online Course Videos

Course Video Formats

Available in digital format online and on DVD

Instructor Manual Part 1: General Concepts

• Science and educational principles of resuscitation training
• Basic logistics for conducting any AHA course for healthcare providers

Precourse Work

• Students review cognitive content before entering the classroom
• More classroom time is used for skills practice and testing

Skills Testing

Infant CPR and Child CPR and AED Skills Testing

• Includes enhanced Prebriefing and Debriefing
• Assesses students as a group
• Includes new CPR Coach role

Provider Manual Updates

The PALS Provider Manual includes new information on the use of a CPR Coach and high-performance teams.

eCards

Course completion cards are available in eCard format.

Cards may only be issued from a valid AHA Training Center and instructors aligned with that Training Center.

Conclusion

2020 Guidelines and Guidelines Highlights summary:
eccguidelines.heart.orgOpens in a new window

Resuscitation Education resources:
cpr.heart.orgOpens in a new window

Interim training materials:
AHA Instructor Network websiteOpens in a new window

Select Exit Exercise at the top right to return to the course home page, where you will

• Complete the course evaluation
• Obtain your certificate of completion
• Claim continuing education (CME/CE) credit if applicable

The American Heart Association thanks the following people for their contributions to the development of this course: Sallie Johnson, PharmD, BCPS; Kelly D. Kadlec, MD, MEd; Reylon Meeks, RN, BSN, MS, MSN, EMT, PhD; Jeanette Previdi, MPH, RN; Principled Technologies; and the AHA 2020 Instructor Update Project Team.