The Egyptian Pediatic Advanced Life Support

·        We suggest hospitals caring for pediatric inpatients to  establish and train a pediatric Rapid Response Team (RRT) with pediatric expertise (e.g., pediatrician/ICU physician, critical care nurse, respiratory therapist where available), adapted to local staffing and resources.(Conditional)

·        Pediatric RRT (or on duty paediatrician)  activation criteria should be simple, standardized, age-appropriate, and available 24/7, based on abnormal vital signs, mental status change, increased oxygen requirement, staff concern, or elevated PEWS. (Strong)

·        Pediatricians  should be supported by regular simulation-based multidisciplinary training, including escalation, communication, airway, and shock response. (Strong)

·        We advise institutions to monitor RRT (paediatricians) performance through quality indicators including response time, unplanned PICU transfer, ward cardiac arrest, and escalation delays,unneeded PICU admission. (Good Practice Statement)

·        All acutely ill children should undergo rapid initial assessment using a structured paediatric triage or quick-look approach. The Paediatric Assessment Triangle (PAT) may be used for rapid recognition of a potentially critically ill child, followed by an ABCDE assessment when indicated. (Strong)

·        Reassess the child after every intervention and whenever there is concern about deterioration, repeating the ABCDE assessment as appropriate. (Strong)

·        Airway patency should be assessed immediately in all critically ill children, with positioning, suction, and airway adjuncts used as needed. (Strong)

·        Oxygen should be administered to children with hypoxemia, severe respiratory distress, shock, seizures, or altered mental status. (Strong)

·        Oxygen therapy is asdvised to be titrated according to clinical response and pulse oximetry where available, avoiding unnecessary hyperoxia. (Conditional)

·        High-flow nasal oxygen (HFNC) or non-invasive ventilation (NIV) is considered early in moderate respiratory distress where available. (Conditional)

·        Early intubation is considered in apnea, exhaustion, failure of oxygenation/ventilation, refractory shock, or reduced consciousness with loss of airway protection. (Conditional)

·        Shock management should be etiology-directed (septic, hypovolemic, hemorrhagic, cardiogenic, obstructive, anaphylactic). (Strong)

·        Sepsis should be recognized early in any child with suspected infection and organ dysfunction or abnormal perfusion. (Strong)

·        Broad-spectrum antibiotics should be administered as early as possible after recognition of septic shock. (Strong)

·        Fluid resuscitation in septic shock should be cautious and guided by repeated reassessment. (Strong)

·        Vasoactive support advised that not to be delayed in fluid-refractory septic shock. (Conditional)

·        Actively seizing childen advise to receive immediate first-line benzodiazepine therapy. (Conditional)

·        If IV access is unavailable, buccal or rectal or  intranasal benzodiazepines is suggested. (Conditional)

·        Blood glucose should be checked early in all children with altered consciousness or seizures. (Strong)

·        Consider second-line antiseizure therapy  administered early in persistent seizures/status epilepticus. (Conditonal)

H.    Trauma

·        Critically injured children should be managed using pediatric trauma ABCDE principles with simultaneous hemorrhage control. (Good practice statement)

·        Cervical spine protection should be maintained when trauma mechanism suggests risk. . (Good practice statement)

·        Early transfer planning should begin immediately in children requiring trauma surgery, neurosurgery, or PICU support beyond local capability. . (Good practice statement)

·        Bag-mask ventilation is recommended as initial airway management during pediatric cardiac arrest. (Strong)

·        High-quality CPR (rate 100–120/min, depth 1/3 chest diameter, full recoil, minimal interruptions) is essential for all pediatric cardiac arrest patients. (Strong)

·        Chest compression fraction should be maximized, minimizing interruptions to <10 seconds during rhythm checks or interventions. (Strong)

·        Rhythm analysis should be performed every 2 minutes with immediate resumption of CPR after shock or rhythm check. (Strong)

·        Early defibrillation is advised for pediatric VF/pulseless VT as soon as a defibrillator is available. (Conditional)

·        Use of manual defibrillator is preferred; AED with pediatric attenuator is acceptable if manual defibrillator is unavailable. (Conditional)

·        Epinephrine should be administered for non-shockable rhythms (PEA/asystole) as early as possible and repeated every 3–5 minutes. (Strong)

·        In shockable rhythms, epinephrine should be given after the third shock. (Strong)

·        Amiodarone (or lidocaine) is recommended for refractory VF/pVT after defibrillation attempts. (Conditional)

·        Advanced airway (ETT or supraglottic airway) may be considered by experienced providers if it does not interrupt chest compressions. (Conditional)

·        Consider Continuous waveform capnography to confirm tube placement and monitor CPR quality when advanced airway is in place. (Conditional)

·        Reversible causes of cardiac arrest (4 Hs & 4 Ts) should be actively identified and treated during resuscitation. (Strong)

·        Extracorporeal CPR (ECPR) may be considered in selected pediatric in-hospital cardiac arrest cases in specialized centers. (Conditional)

·        Oxygen therapy should be titrated after ROSC to avoid both hypoxemia and hyperoxia, targeting normal oxygen saturation appropriate for age. (Strong)

·        Ventilation should be adjusted to maintain normocapnia; both hypo- and hypercapnia should be avoided after ROSC. (Strong)

·        Invasive blood pressure monitoring is advised in critically ill post–cardiac arrest children to guide hemodynamic management when available. (Conditional)

·        Hypotension after ROSC should be identified and treated urgently using isotonic fluids to maintain age-appropriate perfusion. (Strong)

·        We suggest early initiation of vasoactive infusions (e.g., epinephrine, norepinephrine) is recommended in persistent post-arrest shock. (Conditional)

·        Targeted temperature management should be used in comatose children after ROSC, with strict avoidance of fever. (Strong)

·        Continuous temperature monitoring is recommended for all post–cardiac arrest pediatric patients. (Strong)

·        Sedation and analgesia should be provided to prevent pain, agitation, and increased metabolic demand after ROSC. (Strong)

·        Blood glucose should be monitored and both hypo- and hyperglycemia should be avoided in post-arrest care. (Strong)

·        Continuous EEG monitoring may be considered in comatose children to detect subclinical seizures or status epilepticus. (Conditional)

·        Clinical and electrographic seizures is advised to be actively treated after ROSC. (Conditional)

·        Early neuroprognostication should be avoided immediately after ROSC; neurological outcome assessment should be delayed until after stabilization. (Strong)

·        Multimodal neurological assessment (clinical exam, EEG, imaging, biomarkers) is suggested for prognosis rather than a single modality. (Conditional)

·        Consider early evaluation for underlying cause of arrest (cardiac, respiratory, metabolic, toxic, infectious)  and treat. (Conditional)

·        Hemoglobin and oxygen-carrying capacity considered to  be optimized; transfusion may be considered in post-arrest anemia with poor perfusion. (Conditional)

·        Early consultation with pediatric intensive care, cardiology, neurology, and relevant specialties is advised. (Conditional)

·        Family communication and structured post-resuscitation counseling should be provided early after stabilization. (Strong)