AED Use In Infants
March 22, 2023
As discussed, the attached call was received this month for an infant unconscious post fall. Whilst there is a lot to educate this calltaker on in general, I would like to obtain some clarity around the Academy’s stance on AEDs on infants (<1 yo).
As you will hear in the call, the police attached the defib prior to ambulance arrival and from reviewing the patient care record “AED pads placed by police, single shock advised and delivered at unknown joules or rhythm.” In speaking with our commercial manager, public access defibrillators that St John NT supply do have a paediatric (<8 years or 25 kg) setting and/or pads. These are available throughout our state and country as a whole.
Research suggests that whilst there are models that may not have paediatric setting, these are still considered safe to use in paediatrics. The Journal of Paediatric Emergency Care also notes that “in the absence of prompt defibrillation for ventricular fibrillation or pulseless ventricular tachycardia, survival is unlikely. Automated external defibrillators should be used in infants with suspected cardiac arrest if a manual defibrillator with a trained rescuer is not immediately available. Automated external defibrillators that attenuate the energy dose (e.g., via application of paediatric pads) are recommended for infants. If an AED with paediatric pads is not available, the AED with adult pads should be used.” (pubmed.ncbi.nlm.nih.gov/26148104).
Whilst I understand that the 2000 International Guidelines recommend the use of AEDs for rhythm identification in children ≥8 years of age and some defibrillators may not have a paediatric setting available (which would mean that they may deliver a higher dose (j/kg) or misinterpret arrhythmias as shockable) (ahajournals.org/doi/full/10.1161/01.cir.0000074201.73984.fd), there seems to be significant information contradicting this stance, stating that it is “safe” to use adult pads.
I feel it would be remiss of us to advise against the use of an AED, particularly where the device has paediatric settings, as is occurring more and more. I guess moving forward, am I to continue to educate our EMDs not to utilise these devices, despite them being available for paediatrics?
Quality Assurance & Improvement Officer
Emergency Communication Centre
St John Ambulance Australia (NT) Inc.
Good day Taleaha,
Thanks for reaching out on this.
The Academy is aware of the evolving standards regarding the use of AEDs on children. As monophasic defibrillators have largely been replaced by biphasic models, their recommended use in children has followed. Note the subsequent evolution of the MPDS® to recommend their use in children under 8 years of age but older than 1 year.
AED use in infants has multiple considerations in the dispatch environment, and the Medical Council of Standards has been hesitant to formally recommend their use in protocol. As mentioned in this correspondence (well done, Taleaha, by the way), adult pads have been one of these considerations. While pad placement has historically been of concern, we know now that any reasonable placement on the chest works, as long as the pads are not touching. Obviously, this may be more problematic in the small infant as compared to a child over the age of 1, especially when an untrained bystander is placing them. But this is just one consideration.
The primary concern involves weighing the benefit of an AED in the infant cardiac arrest setting versus the impact of any delay in the provision of other PAIs, namely ventilations and compressions, in that order. AEDs are very effective at reversing sudden ventricular arrhythmias, a very common cause of sudden cardiac arrest in adults.
However, these arrhythmias are not initially responsible for the vast majority of infant arrests. The most common etiologies in the out-of-hospital emergency environment are of respiratory origin, including trauma, where AEDs have far less value. Your associated case makes that point well; AEDs are not nearly as beneficial for traumatic arrest.
So while AED use may be “safe” for infants in these cases, they are not likely to be effective. And of great concern is any associated delay in ventilations and compressions, which we know adversely affects survival, and we are rapidly learning that these early interventions increase the chances of successful defibrillation upon responder arrival.
Rest assured that the Academy very closely monitors resuscitation science and the subsequent recommendations, but such recommendations must be considered in light of the unique dispatch environment. And the Council of Standards regularly consults with resuscitation scientists and researchers on these matters to be sure we are making clinically sound protocol decisions.
I hope I have addressed your concerns. Please let me know if I can help further.
Brett A. Patterson
Chair, Medical Council of Standards
International Academies of
Thank you, Brett, for the speedy response.
To clarify, am I to educate our EMDs to advise against any caller attempting to apply a defibrillator to a child (<1 yo)? For example, if the caller is heard to be applying a defibrillator should our EMDs advise “I need you to focus on CPR right now. We will leave the defibrillator for the paramedics”?
I did assume the case would be that most paediatric arrests are respiratory in nature, and CPR is more pertinent in these cases. However, as it turns out, this patient did have a shockable rhythm (according to information I received from the clinicians today).
Thank you, Taleaha.
We play a bit of a numbers game in dispatch as we use probabilities to structure protocol. So while respiratory arrest precedes cardiac arrest in infants most commonly, shockable arrhythmias do happen. We simply believe the emphasis should be on ventilations and compressions initially to avoid any delays.
With that said, our message IS NOT to advise against AED use in infants if it is being done at the scene. Like anything else, we provide the instructions contained in the protocol, and only advise against other attempts to help if it is clearly contraindicated. If an AED is being applied and instructions are not needed, let them go. If they ask for instructions, only provide those contained in the protocol. This is an unlikely scenario with an infant, but I suppose anything is possible.
Thanks for reaching out on this.
And any anonymized clinical information you can provide regarding this case will be well received. This is how protocol evolves.
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