Paediatric basic life support

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2.2 Paediatric basic life support

1 Paediatric cardiopulmonary resuscitation is different to adult resuscitation in many aspects, but the basic principles remain the same:

• Don’t panic

• Ensure both the patient and you are safe

• Initiate basic life support at the earliest possible moment: Airway, Breathing, Circulation.

2 Stabilise the cervical spine if the collapse follows any significant trauma.

3 DRSABC is a mnemonic to aid the sequence of events that should be followed when met with any collapsed patient. Check for Danger, Responsiveness, Shout for help, Open the Airway, Check for Breathing and if patient is not breathing normally give 5 rescue breaths, if there are no signs of life commence Chest compressions.

4 Quality chest compressions involve compressing the chest to at least one third of the antero-posterior chest diameter at a rate of 100 compressions per minute with subsequent complete release to allow recoil of the chest wall.

5 Lone rescuers should use a 30:2 compression to ventilation ratio, while healthcare professionals performing two-rescuer CPR should use a 15:2 compression to ventilation ratio for all children, except in newly born where it is 3:1.

6 The rate of compressions is 100 per minute for all age groups, except in neonates where it is 120 per minute. The chest should be seen to fully recoil before the next compression is commenced.

Introduction

Basic life support (BLS) or basic cardiopulmonary resuscitation (CPR) is a process by which an individual’s basic cardiac and respiratory functions can be restored and maintained through a combination of expired air resuscitation (EAR) and external cardiac compressions (ECC). The provision of BLS sustains the vital functions of the collapsed individual without the need for specialised equipment, minimising the potential hypoxic damage that may occur while advanced life support is being activated.

Paediatric versus adult basic life support

The aim of basic life support in all age groups is the same and the techniques utilised follow the same general principles, but paediatric BLS differs significantly from adult BLS in some very fundamental ways.

Aetiology of arrests

In adults the most common cause of cardiopulmonary arrest is a sudden, massive cardiac event with little preceding deterioration. Most adults requiring BLS measures are already in a state of full cardiopulmonary arrest, defined as a state of pulseless apnoea.

In children, the most common causes of cardiopulmonary arrest are hypoxic and, as a consequence, children generally undergo a period of deterioration with worsening bradycardia preceding the final arrested state. It is therefore important that paediatric BLS is commenced as soon as this bradycardic deterioration is noted and is not withheld until the patient becomes pulseless.

The currently accepted international recommendation for the commencement of external cardiac compressions (ECC) in children of all age groups who are unresponsive with no spontaneous breathing is a heart rate below 60 beats per minute (bpm).

Anatomy and physiology

The anatomy and physiology of the human body changes markedly with age, progressing from the immature neonatal form to the more adult form of the older child, and these changes are relevant to the provision of BLS at any particular age. The following differences from the adult form are of direct importance in the provision of BLS in children:

• Airway: Large head (particularly the occiput) and short neck leading to neck flexion; large tongue which is predominantly intra-oral; easily compressible oropharyngeal soft tissues; larynx lies more anteriorly and higher (C2–3); cricoid ring is the narrowest part of the airway; soft and short trachea.

• Breathing: Increased respiratory rate; more compliant chest wall; dependence on diaphragmatic breathing; reduced end expiratory lung volume.

• Circulation: Increased heart rate; more dependence on heart rate for delivery of adequate circulation; small absolute volume of circulating blood.

• Metabolism: Increased metabolic rate; increased body surface area (BSA).

BLS techniques and age

BLS techniques are modified depending on the child’s age and size to ensure that they will be maximally effective. In view of this, children are arbitrarily divided into the following internationally accepted age groups:

• newborn/neonate: birth to 1 month old;

• infant: between 1 month and 1 year of age;

• small child: age between 1 and 8 years;

• large child: age older than 8 years.

Preparation and equipment

Basic CPR requires no extra equipment other than personnel trained in its administration. It is advantageous, however, to have available certain basic equipment to assist in the resuscitation process.

• Portable suction and suction catheters, for clearing secretions, improve the ability to achieve and maintain a patent airway.

• An oropharyngeal (Guedel) airway may assist in achieving a patent airway.

• A self-inflating bag and mask, suitable for the size of the patient, improves artificial ventilation and reduces the risk of cross infection.

• Oxygen for ventilation will further reduce the risk of hypoxic injury.

Basic life support sequence

A ‘SAFE’ approach

It is extremely important to ensure maximum rescuer and patient safety as a priority on first approaching the collapsed child. To this end, the Advanced Paediatric Life Support (APLS) course advocates a ‘SAFE’ approach to collapsed patients. This acronym stands for:

• S = Shout for help. Call for assistance from surrounding people and request that an ambulance is called, do not leave the patient as immediate resuscitation may be required.

• A = Approach with care. Ensure that you are not putting yourself at risk.

• F = Free from danger. Remove the patient from immediate danger, if present.

• E = Evaluate the ABCs (airway, breathing, circulation).

The activation of the Emergency Medical Services (EMS) should be performed as early as possible in the sequence of resuscitation, provided there are adequate numbers of bystanders to allow this to occur without delaying the commencement of BLS. Most paediatric arrests will have an underlying hypoxic cause and therefore any delay of BLS will significantly reduce its effectiveness. Commencement of BLS should therefore precede activation of EMS for a lone rescuer. In a witnessed sudden collapse of a child, the possibility of a sudden cardiac event is higher and activation of the EMS should occur immediately prior to commencement of BLS by a lone rescuer. These cases require rapid access to Advanced Cardiac Life Support measures, as is the case with most adult arrests.

Assess responsiveness

Assess the responsiveness of the patient by gently, but firmly, stimulating the patient and asking if they are OK. It is important to remember the possibility of cervical spinal injury and, if this is likely, stabilise the cervical spine by placing a hand on the patient’s forehead prior to gently shaking their arm.

Airway

Open and maintain the airway

Position yourself at the patient’s head, open the mouth and remove any obvious debris. Do not use a blind finger sweep in children as this may damage the delicate palatal tissues or move a foreign body further into the airway. Suction using a large-bore Yankeur catheter is useful for removing vomitus and secretions, preferably under direct vision.

Three manoeuvres will assist in opening and maintaining the airway (Figs 2.2.1, 2.2.2 and 2.2.3), which is most commonly obstructed by the child’s tongue.

Fig. 2.2.1 Chin lift and head position in infants.

Fig. 2.2.2 Head tilt and chin lift in children.

Fig. 2.2.3 Jaw thrust.

Head tilt

Place one hand on the patient’s forehead and gently tilt the head back. In children the ‘sniffing’ position is desired, as in adult resuscitation. In an infant or neonate, a neutral position is required as they have a relatively large occiput and are naturally positioned in a sniffing position. A small towel placed under the infant’s shoulders will eliminate the excessive neck flexion caused by the prominent occiput. If there is any possibility of cervical spine injury, the head tilt manoeuvre should be avoided.

Chin lift

Placing the fingers of the other hand on the jawbone, lift the chin, taking care not to compress the soft tissues of the floor of the mouth under the jaw.

Jaw thrust

Place two or three fingers under the angle of the mandible bilaterally, and lift the jaw upwards. This technique can be performed without head tilt and is indicated particularly if the possibility of cervical injury exists.

The patency of the airway can then be assessed by looking for chest movement, listening for breath sounds and feeling for exhaled breath. This assessment is best achieved from the patient’s side, by placing an ear over the patient’s mouth and nose, whilst watching the chest.

Oropharyngeal airway

Insertion of an oropharyngeal airway may assist in maintaining patency of the airway if the above manoeuvres are inadequate. An appropriately sized oropharyngeal airway should reach from the central incisors to the angle of the jaw. In infants and small children, the oropharyngeal airway should be inserted under direct vision ‘the right way up’; that is, it should be inserted concave down in the position in which it will sit in the oropharynx. Gentle depression of the child’s tongue with a spatula will help facilitate airway placement. In children older than 8 years, the usual adult oropharyngeal airway insertion technique may be used. This involves inserting the airway concave up and then rotating it through 180 degrees to sit snugly in the oropharynx. Oropharyngeal airways will not be tolerated in conscious or semi-conscious patients because of gagging. If this occurs, the airway should be removed. In this situation a nasopharyngeal airway may be a useful alternative in the patient who is not completely obtunded.

Cervical spine

Be aware of the risk of cervical spine injury if the collapse is following a motor vehicle accident (MVA) or other form of significant trauma. If this is likely, stabilise the cervical spine by placing one hand on either side of the head and maintaining the head in line with the body at all times. CPR in this case generally requires two operators to perform successfully. If a second operator is not available, attempt to immobilise the cervical spine between sandbags or in a hard cervical collar before proceeding.

Breathing

Once the airway is opened and patent, if the patient is not spontaneously breathing, deliver two to five slow rescue breaths via expired air resuscitation. Each breath is delivered slowly over 1 to 1.5 seconds’ duration (inspiratory phase) and up to five may be required to ensure that two effective breaths are delivered.

Expired air resuscitation (EAR) is most commonly performed as ‘mouth-to-mouth’ but may also be delivered using ‘mouth-to-mouth-and-nose’ in the smaller child. In the ‘mouth-to-mouth’ technique, the rescuer seals his or her mouth over the mouth of the patient, pinching off the nose with the free hand, whilst maintaining the patency of the airway with head tilt and chin lift. The ‘mouth-to-mouth-and-nose’ technique may be necessary for the infant or small child and in that case the rescuer’s mouth should seal around the infant’s mouth and nose. In the hospital setting the rescue breaths will be delivered utilising bag and mask ventilation (see Chapter 2.3 Paediatric advanced life support).

Ensure that the degree of chest excursion is frequently reassessed during the EAR. The chest must be seen to rise as if the child was taking a deep breath. Excessive tidal volumes or force may cause gastric dilatation and regurgitation. If there is no chest movement, the most likely cause is an obstructed airway due to poor positioning of the child’s head. Reposition the patient using the above manoeuvres and retry. If there is still no chest movement, there may be a foreign body obstructing the airway, which can be removed with suction or forceps under direct vision (see below).

Circulation

Following the initial five rescue breaths, assess the circulation. Although the pulse check has always been considered the gold standard of circulation assessment, the International Liaison Committee on Resuscitation (ILCOR) recommendations suggest that for non-healthcare professionals, the assessment of pulse has both poor sensitivity and specificity and often delays the decision to commence ECC. The current recommendations, therefore, suggest that lay rescuers assess for ‘signs of circulation’, specifically the presence of normal breathing, coughing or movement in response to rescue breaths.

Healthcare professionals may check for a pulse as well as assessing for signs of circulation. The pulses that are easiest to feel are the carotid, brachial or femoral pulses and they should be palpated for no longer than a period of 10 seconds. The carotid pulse is difficult to feel in small children who have relatively short necks. If there is no pulse or severe bradycardia (heart rate <60 bpm) with signs of poor perfusion, then ECC on the lower half of the sternum should be commenced.

Chest compressions

The technique of providing ECC varies with the patient’s age.

• Infants and neonates require compression with two fingers over the lower half of the sternum, avoiding the xiphisternum. An alternative technique involves the rescuer encircling the infant’s chest with both hands and providing compressions with the thumbs at the same landmark site. This technique is felt to be more effective, but requires two rescuers to provide effective EAR and ECC (Figs 2.2.4 and 2.2.5).

• All other children require compressions with the heel of one or two hands over the lower half of the sternum, avoiding the xiphisternum (Figs 2.2.6 and 2.2.7).

• The emphasis in cardiac compressions is to minimise interruptions. The depth of compression is relative and should be one third to one half of the AP diameter of the chest in all age groups. The chest should be seen to fully recoil before the next compression is commenced. ECC should be performed on a firm flat surface.

• The rate of compressions is 100 per minute for all age groups, except in neonates, where it is 120 per minute (Table 2.2.1). Note that this is the rate or speed of compressions, not the actual number delivered per minute. The actual number of compressions delivered per minute will be less than 100 as there will be pauses for the delivery of EAR.

Fig. 2.2.4 Infant with two-finger technique of ECC.

Fig. 2.2.5 Infant with two-thumb technique of ECC.

Fig. 2.2.6 Child with one-hand technique of ECC.

Fig. 2.2.7 Child with two-hand technique of ECC.

Compression to ventilation ratio

For a lone rescuer, external cardiac compressions should be combined with expired air resuscitation in a ratio of 30 compressions to 2 ventilations for all age groups (except neonates – see below). Healthcare providers performing two-rescuer BLS should use a ratio of 15 compressions to 2 ventilations for all infants and children (see Table 2.2.1). Note that the ratio of 30:2 is utilised in adults regardless of the number of rescuers.

Neonates require a combination of ECC:EAR at a ratio of 3 compressions to every 1 ventilation and a rate of 120 ‘events’ per minute. This rate aims to achieve approximately 90 compressions and 30 breaths per minute.

It is important to check that the chest rises normally when the ventilation is provided to ensure that an effective breath is being delivered. When two rescuers are delivering BLS, the rescuer providing ECC should pause every 15th compression for the delivery of the breath. Once the airway is secured with intubation, this pause in ECC is no longer required.

Any interruption to basic life support measures should last no longer than 10 seconds, after which BLS should be promptly recommenced to optimise outcome.

Mechanical devices to provide chest compressions during ECC have been designed and tested only in adults and are not recommended for use in children.

Duration of BLS in the field

Continue BLS for a period of five cycles and then reassess the patient. If there is no return of spontaneous breathing or circulation and the rescuer is alone, he/she should seek help by activating emergency medical services. If the patient is small enough, the rescuer should take the patient with them and attempt to continue BLS whilst seeking help. If the patient is too large to be moved, the rescuer should position the patient on their side and leave to seek help. Once EMS has been activated, BLS should continue until EMS arrives or signs of life return.

Precautions and complications

Severe iatrogenic injuries are extremely uncommon in children who have undergone CPR, with an incidence of about 3%. The risk of infection to the rescuer from CPR is minimal, with the greatest risk being meningococcus from airway secretions. Standard antibiotic prophylaxis is recommended for any rescuer involved in the resuscitation of the airway of a patient with known or suspected meningococcal infection. There have been no reported cases of transmission of hepatitis B or HIV from mouth-to-mouth ventilation to date. Airway secretions, tears, sweat and vomitus are low-risk fluids, but extra precautions should be taken when contact with blood or other bodily fluids is likely.

Relief of foreign body airway obstruction

Presentation

Foreign body airway obstruction (FBAO) in both adults and children is commonly caused by the aspiration of food, but in children it may also occur during play with small objects. In both of these situations, it is likely that a parent or guardian will be present and the event may have been witnessed. Clinical signs will include the sudden onset of respiratory distress, associated with coughing, gagging and inspiratory stridor. These signs may also be caused by upper airway infections; however, the onset is slower and usually associated with other signs of infection, such as fever, lethargy, or coryza.

FBAO management in the responsive infant or child

In a child or infant who is responsive with good respiratory effort and forceful coughing, do not interfere with the child’s spontaneous efforts. Any attempt to relieve the obstruction in this situation may dislodge the foreign body and worsen the situation by turning partial to complete airway obstruction. Call for help and get the child or infant urgently to an emergency facility.

Attempts to relieve FBAO should only be commenced when the cough becomes ineffective with increasing respiratory distress, or the child becomes unconscious or apnoeic.

FBAO management in the unresponsive patient

A combination of back blows and chest thrusts are utilised to relieve the obstruction. Abdominal thrusts are not recommended for any age group because of the risk of trauma to abdominal structures.

The sequence of response for an unresponsive, apnoeic patient with FBAO is as follows:

Open the airway using chin lift or jaw thrust. Look inside the mouth and remove any visible foreign body. Do not perform a blind finger sweep because of the risk of damaging palatal tissues or pushing a foreign body further into the airway.

Attempt up to five rescue breaths. If unsuccessful, reposition and try again.

If rescue breaths are still unsuccessful, perform a sequence of five back blows and five chest thrusts.

• Deliver up to five back blows using the heel of the one hand between the shoulder blades, deliver five blows with sufficient force to dislodge a foreign body. Check after each back blow to see in the FB has been dislodged. Infants can be placed in a prone, head down position lying along the rescuer’s forearm with the jaw supported by the rescuer’s hand to deliver back blows (Fig. 2.2.8).

• If the obstruction is not relieved perform up to five chest thrusts utilising the same position and technique as for ECC but at a rate of one per second with sufficient force to expel the foreign object. Check after each chest thrust to see if the FB has been dislodged. Infants should be positioned supine lying along the rescuer’s thigh, in a head down position (Fig. 2.2.9).

If the obstruction is not relieved, continue the above sequence until the obstruction is relieved or for approximately one minute. If the patient remains unresponsive at one minute, seek help. If the patient is small enough, the rescuer should take the patient with them and attempt to continue FBAO relief manoeuvres whilst seeking help. If the patient is too large to be moved, the rescuer should position the patient appropriately and leave to seek help.

For management in the emergency department setting see inhaled FB (Chapter 6.2).

Fig. 2.2.8 Back blows in an infant.

Fig. 2.2.9 Chest thrusts in an infant.

FBAO management in the unresponsive child

A combination of abdominal thrusts, back blows and chest thrusts are utilised to relieve the obstruction. The sequence of response for an unresponsive, apnoeic child with FBAO is as for the infant except the rescuer should alternate between chest thrusts and abdominal thrusts with each cycle.

Abdominal thrusts (Heimlich manoeuvre) may be performed with the victim in the upright or supine position.

• With the child in the upright position (standing, sitting or kneeling), the rescuer stands behind the victim and places the fist of one hand on the child’s abdomen above the umbilicus and below the xiphisternum. The rescuer’s other hand covers the fist and both hands are thrust sharply inwards and upwards into the abdomen (Fig. 2.2.10).

• With the child in the supine position, the rescuer kneels at the child’s feet or astride the child’s hips. The heel of one hand is placed on the child’s abdomen above the umbilicus and below the xiphisternum, the rescuer’s other hand covers the first and both hands are thrust sharply inwards and upwards into the abdomen in the midline (Fig. 2.2.11).

• Abdominal thrusts should be repeated five times unless the foreign body is expelled before then.

• It is important to take care not to touch the xiphisternum or ribs during this manoeuvre due to the risk of internal damage.

Fig. 2.2.10 Abdominal thrusts in a standing child.

Fig. 2.2.11 Abdominal thrusts in a supine child.

Further reading

Advanced Life Support Group. Advanced paediatric life support: The practical approach, 4th rev. ed. BMJ Publishing Group: London, 2004.

3 Australian Resuscitation Council Guidelines. sections 12 and 13 http://www.resus.org.au/; December 2010

Biarent D., Bingham R., Eich C., et al. European Resuscitation Council Guidelines for Resuscitation. Section 6: Paediatric life support. Resuscitation. 2010;81(10):1364-1368.

International Liaison Committee (ILCOR). Consensus on Science with Treatment Recommendations for Pediatric and Neonatal Patients: Pediatric Basic and Advanced Life Support. Pediatrics. 117(5), 2005.

Kleinman M.E., de Caen A.R., de Chameides L., et al. Part 10: Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2010;16(Suppl 2):S466-515.

Richmond S., Wyllie J. European Resuscitation Council Guidelines for Resuscitation. Section 7: Resuscitation of babies at birth. Resuscitation. 2010;8(10):1389-1399.

Textbook of Paediatric Emergency Medicine