Writing Group R.A. Samson, MD*; R.A. Berg, MD*; R. Bingham, MBBS, FRCA , Members of the PALS Task Force ; D. Biarent, MD ; A. Coovadia, MD ; M.F. Hazinski, RN, MSN*; R.W. Hickey, MD*; V. Nadkarni, MD*; G. Nichol, MD, MPH ; J. Tibballs, MBBS||; A.G. Reis, MD; S. Tse, MD ; D. Zideman, MBBS , Additional Contributors ; Jerry Potts, PhD*; K. Uzark, PhD, CPNP*; D. Atkins, MD*
From the *American Heart Association, European Resuscitation Council, Resuscitation Council of Southern Africa, Heart and Stroke Foundation of Canada, ||Australia and New Zealand Resuscitation Councils, and InterAmerican Heart Foundation.
On the basis of the published evidence to date, the Pediatric Advanced Life Support (PALS) Task Force of the International Liaison Committee on Resuscitation (ILCOR) has made the following recommendation (October 2002):
Automated external defibrillators (AEDs) may be used for children 1 to 8 years of age who have no signs of circulation. Ideally the device should deliver a pediatric dose. The arrhythmia detection algorithm used in the device should demonstrate high specificity for pediatric shockable rhythms, ie, it will not recommend delivery of a shock for nonshockable rhythms (Class IIb).
Currently there is insufficient evidence to support a recommendation for or against the use of AEDs in children <1 year of age.
For a lone rescuer responding to a child without signs of circulation, the task force continues to recommend provision of 1 minute of CPR before any other action, such as activating the emergency medical services (EMS) system or attaching the AED.
Defibrillation is recommended for documented ventricular fibrillation (VF)/pulse-less ventricular tachycardia (VT) (Class I).
This statement expands and clarifies the 2000 ILCOR recommendations about the potential use of AEDs in children. The need for this update has become critical. A growing number of AEDs for adults are being placed in public access settings, and the use of AEDs by nontraditional responders is increasing. The likelihood for use of AEDs in smaller (<25 kg), younger (<8 years of age) patients is now a reality. This statement provides the rationale for development of AEDs, outlines questions about the efficacy and safety of AEDs used in smaller, younger children, and summarizes recent efforts to justify the use of existing or modified AEDs in smaller, younger children.
Rationale for AED Use
The primary determinant of survival from VF cardiac arrest is the time interval from collapse until defibrillation. Out-of-hospital defibrillation within the first 3 minutes of witnessed adult VF arrest results in survival rates >50%. But the success of resuscitative efforts decreases dramatically with the passage of time. For every 1-minute delay in defibrillation, the survival rate may decrease by 7% to 10%, although this number is influenced by the presence and quality of bystander CPR. After >12 minutes of VF, the survival rate of adults is <5%.1
Therefore, ILCOR encourages the placement of simple AEDs for use by first responders in public settings. In some settings AED use has substantially improved the rate of survival from VF in adults.2,3 The AED is the only defibrillator available for use by first-responding EMS personnel, and it is now considered the standard of care by first responders. ILCOR has become a strong advocate for greater use of public access defibrillation, calling for and supporting widespread availability of AEDs. Trained responders have effectively used AEDs in many public settings, including casinos, airport terminals, and airplanes.4-6
The Conundrum of Pediatric VF and AEDs for Use in Adults
All commercially available AEDs use algorithmic rhythm analysis programs derived from in vitro rhythm libraries of adult shockable and nonshockable rhythms. AED developers use an empirical, iterative process to create and adjust filters, measurements, and decision rules. This process enables the AED to "decide" to recommend a shock for the highest possible percentage of shockable rhythms (maximum sensitivity) and to avoid shocking the highest possible percentage of nonshockable rhythms (maximum specificity).
All currently available AEDs are programmed to deliver adult-dose shocks with energies ranging from 150 to 360 J when adult pads/cables are used. These adult doses of energy were selected to be safe and effective for adult victims only. At the time of publication of the ILCOR Guidelines 2000, no devices were designed for use in children <8 years of age, and none was approved or cleared by the United States Food and Drug Administration (FDA) for use in children. Moreover, there were no data regarding the safety and efficacy of either (1) an AED diagnostic rhythm analysis program to differentiate shockable from nonshockable rhythms in children or (2) an appropriate defibrillation dose or dosing sequence for children <8 years of age. Therefore, the Class of Recommendation for use of AEDs in children <8 years of age was necessarily Indeterminate.7
As a result, children with VF in the prehospital setting have been "orphans" with respect to this effective technology. This issue was highlighted as one of the most pressing problems for pediatric cardiac arrest victims at ILCOR'S 1999 Emergency Cardiovascular Care Evidence Evaluation Conference and the 1998 AHA conference "Ventricular Fibrillation: A Pediatric Problem."8