Joule Settings for Peds

Thank you for your MedicASK regarding joule settings for pediatric patients in AED mode. As some services currently use Lifepack 15 and others the Zoll X series, below you will find the answer to your question for both monitors as this varies.

Lifepack 15 Monitor Manufacturer Guidelines:

"In AED mode, the LIFEPAK 15 monitor/defibrillator is not intended
for use on pediatric patients less than eight years old" (p. 119). From the LP15 Operations Manual and in correspondence with Stryker, the distributor of PhysioControl products we learned that this statement is countered by a 2012 letter from PhysioControl, manufacturers of the LP15.

As you may or may not recall, a medical advisory was sent out to all paramedics across Eastern Ontario back in 2022 (see below) regarding pediatric pads and when it is appropriate to use them. Please know, you always have access to these medical advisories on the RPPEO website. On the home page go to "Policies and Practices" > "In this Section" on the right hand side >"RPPEO Policies" > "Medical Advisories."

It is preferable to use an AED with pediatric pads and an attenuator however, if no attenuator and no manual defibrillation is available, then AED is still acceptable. Attenuation is the reduction of the electrical current delivered by the electrodes to adjust for smaller body size of children, infants and small adults.

To summarize, if you are in AED mode and NOT manual mode, you should be using the adult defib pads for pediatrics who are less than 8 years of age or <25kg. The reason for this is because the pediatric pads are meant to deliver lesser joules through smaller electrodes which ACP's in manual mode (or PCP's certified in manual defibrillation) can titrate using the patient's weight (2J/kg and 4J/kg). The risk is that delivery of recommended adult energies through the relatively smaller pediatric defib pad surface increases the possibility of skin burns. That said, pediatric pads are capable of handling 360J and there is no evidence that there is an increased risk of arcing. PALS also states up to 10J/kg is not harmful.

"The energy settings and other AED setup options are consistent with the 2010 and 2015 American Heart Association (AHA) and European Resuscitation Council (ERC) guidelines." (p. 120). When in AED mode, "Biphasic output energy shock levels ranging from 150–360 joules with same or greater energy level for each successive shock." (p. 238) This is service dependent, but the Lifepack 15 is typically set to deliver 200J, 300J, 360J. Currently, this aligns with public AED's which also defibrillate both adults and pediatrics at 250J (there is no escalation). Something to keep in mind is that this age group typically suffers more from respiratory issues rather than cardiac.

The 2020 AHA Guidelines published the following:

1. "Although there are no direct comparisons between pediatric attenuator and non-attenuator AED-delivered shocks, multiple case reports and case series document shock success with survival when a pediatric attenuator was used."
2. "There are no specific studies comparing manual defibrillators with AEDs in infants or children. Manual defibrillators are preferred for in-hospital (and out of hospital as per the Medical Directive) use because the energy dose can be titrated to the patient’s weight."
3. "AEDs without pediatric modifications deliver 120 to 360 Joules, exceeding the recommended dose for children weighing less than 25 kg. However, there are reports of safe and effective AED use in infants and young children when the dose exceeded 2 to 4 J/kg. Because defibrillation is the only effective therapy for VF, an AED without a dose attenuator may be lifesaving."

Zoll X Series Manufacturer Guidelines:

"WARNING! Use only pediatric electrodes to defibrillate patients under 8 years of age in AED mode, and make sure the patient mode is set to pediatric. Use of adult electrodes or adult mode with pediatric patients can result in the delivery of excessive energy doses." (p. 179)

The default energy selections for pediatric patients are:
Shock 1 - 50 joules
Shock 2 - 70 joules
Shock 3 - 85 joules

(p. 182)

That said, the monitor automatically measures chest impedance and will only deliver the necessary number of joules. For example, you may charge and shock at 50 joules however, you will see on the monitor/print out that only 40 joules was actually delivered to the patient.