basic%20life%20support%20-%20pediatric
BASIC LIFE SUPPORT - PEDIATRIC
Basic life support (BLS) is the fundamental approach to saving lives following cardiac arrest.  Primary aspects of BLS include immediate recognition of sudden cardiac arrest and activation of the emergency response system, early cardiopulmonary resuscitation, and rapid defibrillation with an automated external defibrillator.

Recovery Position

  • Recovery position aims to decrease the chance of saliva, vomitus or secretions from entering the upper airway & prevent airway obstruction
  • If alone, get help or if available, send someone for help
  • Observe for continued breathing

If spinal injury is not suspected, turn child to recovery position:

  • Unconscious child should be placed on his side with care for the possibility of spinal injury
  • Place child as close as possible to a true lateral position
  • Mouth should be in position to allow free drainage of fluid
  • Infants may need a small pillow or rolled-up blanket along his back to stabilize his position
  • Child should be on a firm surface if chest compressions are necessary
    • If child is found on the floor, manage where found; if on a mattress, deflate mattress or move the child & place on the floor if possible
    • Your forearm may be used for small infants

Chest Compressions & Ventilations

  • If not alone, send one rescuer for help
  • If alone, administer 5 cycles or about 2 minutes of cardiopulmonary resuscitation (CPR) before going for help
    • If child has known heart disease & collapses suddenly, it is best to seek help immediately 
  • May be possible to carry child while getting help
  • Carefully remove any obvious airway obstruction from the child’s mouth
  • Recommended sequence of resuscitation for children without normal breaths & pulses is (1) chest compressions, (2) airways, & (3) breathing
    • Decreases the “no blood flow” time
    • Interval between pulselessness & initiation of chest compression is reduced 
  • For an infant or child in cardiac arrest, compression-only CPR may be considered if unable or unwilling to deliver rescue breaths

Chest Compressions

  • Start chest compressions if:
    • No signs of circulation
    • Unsure that pulse is present
    • Pulse <60 bpm with poor perfusion (eg cyanosis, pallor)
      • There is actually no known absolute heart rate at which chest compressions are started; this recommendation is based on ease of retention of skills 
  • Place patient on a firm surface in a horizontal supine position (which may be your forearm if it is a small infant)

Infants (<1 year old)

For Lone Rescuer

Locate the lower sternum

  • Two-finger technique: 2 fingers placed just below the intermammary line

Perform compressions

  • With the 2 fingers, apply pressure down at least 1/3 the depth of the anterior-posterior diameter of the infant’s chest (approximately 4 cm or 1.5 inches)
  • Release completely after each compression to allow chest to recoil fully
    • Allows the heart to refill with blood 
  • Repeat at a rate of about 100-120 compressions/minute
  • Compressing and releasing should take equal amounts of time
  • Actual number of compressions will be <100 because of time taken to give rescue breaths

Combine Compressions & Rescue Breathing

  • After 30 compressions, administer 2 effective breaths

More Than One Rescuer (Two-Thumb Method)

Locate the lower sternum

  • Put both thumbs side by side flat side down on the lower sternum 1 finger breadth below an imaginary line connecting nipples
  • Thumb tips should point towards the infant’s head
  • With the rest of the fingers together, spread both hands around the lower part of the infant’s rib cage

Perform compressions

  • Press down on sternum with thumbs & apply pressure down at least 1/3 the depth of the infant’s chest (approximately 4 cm or 1.5 inches)
  • Release pressure without removing your hands from infant
  • Repeat at a rate of about 100 times/minute
  • Compressing and releasing should take equal amounts of time
  • Actual number of compressions will be <100 because of time taken to give rescue breaths

Combine Compressions & Ventilations

  • Ratio of compressions to breaths should be 15:2, with the shortest possible pause in compressions

Children (>1 year old until puberty)

Locate Sternum & Position Yourself

  • Place heel of 1 hand or of 2 hands on the lower half of sternum (do not push on the xiphoid or the ribs)
  • Extend fingers away from body to ensure pressure is not applied to ribs
  • Position yourself vertically above the child’s chest
  • Keep your arms straight with elbows locked

Perform Compressions

  • Using the heel of one or both hands, press down on sternum & apply pressure down approximately 1/3 of the AP dimension of the child’s chest or about 5 cm (2 inches)
  • Release pressure to allow chest to recoil fully
  • Repeat at a rate of about 100 times/minute
    • Slightly <2 compressions/second
  • Counting out loud may be helpful
  • Compressing & releasing should take equal amounts of time

Combine Compressions & Rescue Breathing

  • For 2-rescuer resuscitation, rotate roles between rescuers every 2 minutes
  • After 15 compressions administer 2 effective breaths
  • Ratio of compressions to breaths should be 15:2 or 8-10 breaths/minute
    • For lone rescuers, 30:2 is recommended 
  • Stop & check for signs of breathing or circulation after 20 cycles of compressions & every few minutes after that

Open the Airway

  • Put hand on forehead & gently tilt head back
  • Using fingertips under chin point, lift chin to open airway
  • Check for airway patency while doing the head tilt-chin lift maneuver

If neck injury is suspected:

  • Avoid head tilt
  • Open the child’s mouth if it is not yet open
  • Use jaw thrust maneuver: Put first 2 fingers of both hands on each side of child’s jaw bones & push jaw forward
    • This maneuver is not recommended for lay rescuers since it may cause spinal movement, often ineffective in opening the airway & is difficult to learn & perform 
  • If jaw thrust does not open the airway, healthcare professionals may do the head tilt-chin lift maneuver with caution

Inadequate breathing with circulation (presence of a definite pulse)

  • Do rescue breathing at a rate of 12-20 breaths/minute until child breathes on his own (1 breath every 3-5 seconds)
    • Technique will depend on child’s age 
  • If patient starts to breathe, but remains unconscious, place in recovery position
  • Child should be reassessed regularly

Inadequate breathing in the presence of bradycardia or poor perfusion

  • Give 2 slow, effective breaths
  • Clear airway of any obvious obstruction
  • Technique will depend on child’s age

Infants: Mouth to Mouth & Nose Rescue Breathing Technique

  • Confirm head tilt & chin lift
  • Take a breath and place lips around infant’s mouth and nares ensuring a good seal
  • If both nose & mouth can’t be covered, attempt to seal around only mouth or nose
    • Ensure mouth is closed if breathing in nose
    • Pinch the nose closed if breathing in mouth 
  • Blow steadily into the infant’s mouth/nose for about 1-1.5 seconds
  • Watch chest to rise with breath (if chest does not rise, reposition the head, ensure a better seal & try again)
  • Keeping head tilt & chin lift, remove your mouth & watch for chest to fall
  • Repeat to give 2 effective rescue breaths

Children: Mouth to Mouth Rescue Breathing Technique

  • Do head tilt & chin lift
  • Using your thumb & index finger of hand placed on forehead, pinch close the soft part of nose
  • Open child’s mouth slightly while maintaining chin lift
  • Take a breath & place lips around patient’s mouth ensuring good seal
  • Blow steadily into the child’s mouth for about 1-1.5 seconds
  • Watch chest to rise with breath (if chest does not rise, reposition the head, ensure a better seal & try again)
  • Keeping head tilt & chin lift, remove mouth & watch for chest to fall
  • Repeat to give 2 effective rescue breaths

Mobilize Automated External Defibrillator (AED)

  • For witnessed sudden collapse wherein ventricular fibrillation or pulseless ventricular tachycardia is considered (also called “shockable rhythms”)
  • May be treated by monophasic or biphasic shocks with initial dose of 2 J/kg & subsequent dose of 4 J/kg
  • For infants & children <8 years of age, a manual defibrillator or an AED with pediatric attenuator is preferred
    • Evidence to support use of AED in children <1 year is limited to case studies
  • Administer 1 shock then resume chest compressions immediately for about 2 minutes to minimize the no-flow time
  • Check or reassess rhythm every 2 minutes

Continue Resuscitation

Continue resuscitation until:

  • Qualified help arrives & takes over
  • Child shows signs of life or recovery (eg child starts to move, wake up, opens eyes, normally breathes, or with definite pulse)
  • You become exhausted

Foreign Body Airway Obstruction (FBAO) Sequence

If unable to give effective breaths after rechecking the airway:

  • May need to perform foreign body airway obstruction (FBAO) sequence
  • Active interventions to relieve foreign body airway obstruction (FBAO) are recommended only when coughing becomes ineffective and there is complete obstruction of airway
  • Signs of foreign body airway obstruction (FBAO) include sudden onset of resp distress with gagging, coughing, wheezing or stridor

Foreign Body Airway Obstruction Sequence in Infants

Partial Airway Obstruction

  • If infant is breathing on his own, allow him to attempt to clear obstruction by coughing on his own

Complete Airway Obstruction: Infant stops breathing or coughing

  • Rescuer must act to relieve obstruction
  • Do not use blind finger sweep in mouth or upper airway to remove foreign body as this may push objects further down the airways

Conscious Infant

Healthcare worker rescuing conscious infant with known foreign body airway obstruction: use back blows followed by chest thrusts if back blows are not effective

  • 5 back blows
    • Rest infant in a prone position on your forearm making sure head is lower than chest
    • Support infant’s head by supporting the jaw firmly (do not press on the infant’s throat)
    • To support infant, rest your forearm on your thigh
    • Administer 5 slaps using the heel of your hand to the mid back between the shoulder blades
    • If 5 blows fail to remove foreign object, try chest thrusts 
  • 5 chest thrusts
    • Turn infant as a whole unit by placing other forearm on infant’s back & the palm of your hand supporting the infant’s head
    • Place infant in supine position & if possible, head lower than chest
    • Administer 5 chest thrusts to sternum (position is similar to chest compressions) 
  • Check mouth after a sequence of 5 back blows & 5 chest thrusts
    • Using care, remove any foreign objects in mouth

Unconscious Infant

Healthcare worker rescuing unconscious infant with known foreign body airway obstruction: use chest thrusts

  • Use 5 back blows followed by 5 chest thrusts
  • Check mouth for foreign object by using tongue jaw lift
    • Grasp both the tongue & lower jaw between your thumb & fingers & lift the mandible
    • If foreign object is visible, carefully remove it (do not use blind sweep)
  • Open airway
    • Put hand on forehead & gently tilt head back
    • Using fingertips under chin point, lift chin to open airway or use jaw thrust
    • Attempt up to 5 rescue breaths
    • If airway still obstructed repeat 5 back blows & 5 chest thrusts

Foreign Body Airway Obstruction Sequence in Children

Partial Airway Obstruction

  • If child is breathing on his own, encourage him to clear obstruction by coughing on his own

Complete Airway Obstruction: Child stops breathing or coughing

  • Do not use blind finger sweep in mouth or upper airway to remove foreign body as this may push objects further down the airways

Conscious Child

Several techniques are used, check with local protocol

  • Abdominal thrusts used alone
  • 5 back blows followed by 5 abdominal thrusts
  • 5 back blows followed by 5 chest thrusts (see Chest Thrust Technique)

Abdominal Thrusts

  • Stand or kneel behind patient
  • Make fist with 1 hand
  • Place fist with thumb side in against the patient’s midline abdomen slightly above the navel making sure to be well below the bottom tip of the sternum
  • Place other hand over fist & press fist into the abdomen with a quick inward & upward thrust
  • Continue until foreign object is removed or patient loses consciousness
  • Avoid applying pressure to the xiphoid process or lower rib cage to prevent causing abdominal trauma
  • Child should seek medical attention after abdominal thrusts are performed to rule out any internal injury

Back blows

  • Position the child’s head down for more effective back blows
  • As with the infants, place the child across rescuer’s lap
  • If above position is not possible, place the child in a forward leaning position & perform the back blows from behind

Unconscious Child

Healthcare worker rescuing unconscious child with known foreign body airway obstruction: use abdominal thrusts

  • Place patient in supine position
  • Facing towards the patient’s head, straddle his thighs
  • Place the heel of 1 hand in the middle of upper abdomen
  • While supporting with the other hand, give sharp push up & back towards center of chest for 5 thrusts
  • Check mouth for foreign object by using tongue jaw lift
    • Grasp both the tongue & lower jaw between your thumb & fingers & lift the mandible 
  • If foreign object is visible carefully remove it (do not use blind sweep)
  • Open airway & if still unable to administer effective breaths, repeat sequence

Resuscitation in Special Cases

Drowning

  • Carefully remove patient from water as quickly as possible
  • Rescue breathing while in water may be attempted by trained rescuers; however, this should not delay removing the victim from the water
  • Chest compressions should never be done while in the water
  • Start resuscitation as soon as victim is removed from water
    • Lone rescuer may administer 5 cycles of chest compressions and rescue breathing for 2 minutes
    • If more than 1 rescuer are present, one may start mobilizing AED while the other is doing CPR

 Trauma

  • Basic life support resuscitation for children w/ trauma or injury are governed by the same principles as the non-injured child, taking into account the following:
    • Jaw thrust is the preferred technique in opening & maintaining the airway; if this does not open the airway, use the head tilt-chin lift
    • Airway obstruction should be anticipated; a suction device may be necessary
    • As much as possible, avoid movement of the head & neck in cases of spinal injury; secure the shoulders, pelvis & thighs to the immobilization board
    • Apply direct pressure for presence of any external bleeding
  • It is recommended to transport the patients with potential for serious trauma to a trauma center
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