Paediatric basic life support

Published on 23/06/2015 by admin

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2.2 Paediatric basic life support

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.

Basic life support sequence

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.

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.

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.

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Relief of foreign body airway obstruction

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:

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