Pediatric Defibrillation

Question#: 589

Question:

I was having a discussion with our coworkers regarding the use of pediatric pads for PCPs. The general impression was that the LP15 attenuated the energy dose for pediatric patients in SAED mode. However, I found evidence to support otherwise. The document stated that the LP does not attenuate doses in SAED mode with ped pads (reference attached picture and link). Additionally, our directives indicate that we only use these pads if they are attenuated (reference attached picture). Thus, I wanted to inquire if PCPs who do not manually analyze rhythms only defibrillate pediatric patients who are => 8 y? If so, I think that PCPs in our service should be notified - I do not believe they all know this.

Answer:

For patients less than 8 years/25 kg manual defibrillation at prescribed doses or attenuated AED is preferred.
Where only non-attenuated SAED is available for patients less than 8 years/25 kg:
1. Place adult defibrillation pads in the anterior-posterior position.
2. Ensure that the pads do not contact each other and are completely stuck to the skin.
3. If the patient is so small that the adult pads either make contact with each other or cannot be completely stuck to the skin of the chest and back, then pediatric defibrillation pads should be used.

Reason for this position

AHA's 2020 position on pad size and defibrillation energy in pediatric patients less than 25 kg or under 8-years
* Regardless of defibrillation type, manual at specified joules or SAED, the largest pad that can be used should be used, as larger pads reduce transthoracic impedance.
* It is acceptable to place pads anterior-posterior to accommodate the pads.
* It is preferable to use an AED with pediatric pads and an attenuator.
* If no attenuator and no manual defibrillation is available then AED is still acceptable.
* Defibrillation is the only effective treatment for VF and is, therefore, potentially lifesaving even at higher doses

LP15 Operations Manual and correspondence with Stryker:
* Delivery of recommended adult energies through this relatively smaller pediatric defib pad surface increases the possibility of skin burns.
* The statement in the Operations Manual that AED should not be used below 8 years is countered by a 2012 letter from PhysioControl.
* Pediatric pads are capable of handling 360 J and there is no evidence that there is an increased risk of arcing

References
AHA, 2020. Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000901
PhysioControl 2010. LIFEPAK 15 Monitor/Defibrillator Operating Instructions. https://www.physio-control.com/uploadedFiles/Physio85/Contents/Emergency_Medical_Care/Products/Operating_Instructions/LIFEPAK15_OperatingInstructions_3306222-002.pdf
Lank, P., July 2012. Letter on AED use in pediatrics less than 8 years. PhysioControl.
Dust, D., 16 March 2022. Email: LP15 Pedi pads question. Stryker via Frontenac Paramedic Services.