Paediatric basic life support

Published on 23/06/2015 by admin

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2.2 Paediatric basic life support

Jane Cocks

Essentials

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

• Don’t panic
• Get help
• 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.

image

Fig. 2.2.1

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