Paediatric cardiopulmonary resuscitation

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Chapter 106 Paediatric cardiopulmonary resuscitation

This chapter concerns basic and advanced cardiopulmonary resuscitation (CPR) for infants and children (Figure 106.1). The essentials of resuscitation of the ‘newly-born’ (at birth) infant are also provided (Figure 106.2). The recommendations are based on guidelines published by several authoritative resuscitation organisations¹^–³ which are in turn derived from an extensive evaluation of the science of resuscitation conducted by the International Liaison Committee on Resuscitation.⁴

Figure 106.1 Paediatric resuscitation. PEA, pulseless electrical activity; VF, ventricular fibrillation; VT, ventricular tachycardia.

(Reproduced with permission from the Australian Resuscitation Council, Melbourne.)

Figure 106.2 Newly-born infant resuscitation.

(Reproduced with permission from the Australian Resuscitation Council, Melbourne.)

This chapter is intended primarily for use by medical and nursing personnel in hospital (health carers). To add ability to knowledge, it is advisable to undertake a specialised paediatric cardiopulmonary resuscitation course, such as the Advanced Paediatric Life Support (APLS) or Paediatric Advanced Life Support (PALS) courses. This chapter should be regarded as an addendum to Chapters 17 (Adult cardiopulmonary resuscitation), 96 (The critically ill child) and 104 (Equipment for paediatric intensive care).

Distinctions within the term paediatric are based on combinations of physiology, physical size and age. Some aspects of CPR are different for the ‘newly-born’, infant, small (younger) child and large (older) child. ‘Newly-born’ refers to the infant at birth or within several hours of birth. ‘Infant’ refers to an infant outside the ‘newly-born’ period up to the age of 12 months. Other terms, such as newborn or neonate, do not enable that distinction. ‘Small/young child’ refers to a child of preschool and early primary school from the age of 1–8 years. ‘Large/older child’ refers to a child of late primary school from the age of 9 up to 14 years. Children older than 14 years may be treated as adults but they do not have the same propensity for ventricular fibrillation as do adults.

EPIDEMIOLOGY

The causes of cardiopulmonary arrest (CPA) in infants and children are many but include any cause of hypoxaemia or hypotension or both. Common causes are trauma (motor vehicle accidents, near-drowning, falls, burns, gunshot), drug overdose and poisoning, respiratory illness (asthma, upper-airway obstruction, parenchymal diseases), postoperative (especially cardiac), septicaemia and sudden infant death syndrome. As many as 10% of newly-born infants require some form of resuscitation for varied conditions of which birth asphyxia is the most common.

BASIC LIFE SUPPORT

ASSESSMENT OF AIRWAY AND BREATHING

On determining that the patient is not responsive to tactile and auditory stimulation, not breathing normally and not moving, airway opening manoeuvres and assessment of breathing should be performed. Assessment of the patient’s airway and breathing can be performed effectively in either the supine or lateral position.

Obvious causes of airway obstruction in the pharynx should be removed. Fluids such as vomitus or blood should be aspirated with a Yankauer sucker. Solid or semi-solid objects, such as food particles or foreign objects, should be removed with an instrument, e.g. Magill’s forceps. Since the most common cause of airway obstruction in an obtunded state is the tongue, first-aid manoeuvres to elevate it should be performed. The manoeuvres are backward head tilt, chin lift and jaw thrust. Head tilt and chin lift are often combined. If neck injury is present or suspected, neither the head tilt nor the chin lift manoeuvre should be used. Following establishment of an airway, the presence or absence of adequate breathing is assessed by inspection of movement of the chest and abdomen, and by listening and feeling for escape of exhaled air from the mouth and nose (look, listen and feel). If adequate breathing is occurring the patient should be placed on the side in a coma position.

RESCUE BREATHING (EXPIRED AIR RESUSCITATION)

If inadequate breathing is present, rescue breathing (expired air resuscitation) or bag-valve-mask ventilation should be commenced immediately. There is no evidence to dictate the number of initial breaths. However, at least two breaths are recommended by all resuscitation organisations, with some stating up to five. While maintaining the airway, slow breaths over 1–1.5 seconds should be given with enough air to achieve adequate chest inflation. In children of all sizes, a mouth-to-mouth technique is possible by pinching the nostrils closed. In newly-born and infants, a mouth-to-mouth-and-nose technique is recommended, but if the rescuer has a small mouth, a mouth-to-nose technique is an alternative. Lack of chest rise may signify obstruction of the airway requiring repositioning of the head and neck.

ASSESSMENT OF SIGNS OF LIFE OR CIRCULATION

If ‘signs of life’ or ‘signs of circulation’ are absent (unresponsiveness, inadequate breathing, lack of movement) or a pulse cannot be detected within 10 seconds or is inadequate (<60 beats/min) external cardiac compression (ECC) should be commenced. Although the pulse check has been discarded in guidelines for lay-person CPR, because of their inability to reliably check the pulse, it has been retained in guidelines for health care personnel. Palpation of any major pulse (carotid, brachial, femoral) is appropriate.

EXTERNAL CARDIAC COMPRESSION (ECC)

Different techniques are used for infants and children of different sizes but in all patients the depth of compression is one-third the depth of their chest. For newly-born infants and infants, two techniques are in common use. In the ‘two-finger technique’, the middle and forefinger are used. This technique is taught to lay-persons and is also the preferred technique by a single health care rescuer. With the ‘two-thumb technique’, the hands encircle the thorax, approaching the chest from either above or below, and the thumbs are placed either opposite, alongside or atop one another. With this technique, the rescuer must take care to avoid restriction of the patient’s chest during inflation. With premature newly-borns and small infants, the rescuer’s encircling fingers may reach and stabilise the vertebral column, without limiting chest inflation. With both techniques, the sternum is compressed above the xiphoid or about one finger breadth below the internipple line.

Either a single hand or both hands may be used for infants and children as determined by the relationship between the size of the patient’s chest and the hands of the rescuer. For young children, ECC can be performed with the heel of one hand. For older children, a bimanual technique as per adults may be used. In all ages, the ‘centre of the chest’ – which corresponds to the lower sternum – is compressed. Approximately 50% of each cycle should be compression.

RATES OF COMPRESSION AND RATIO OF COMPRESSION TO VENTILATION

In hospitals where there are usually two (or more) rescuers, the ratio of compressions to ventilation for infants and children should be 15:2. After every 15 compressions, a pause should allow delivery of two ventilations whenever expired air resuscitation or any type of mask ventilation is given. ECC can be given during the second exhalation. The aim should be to achieve about five cycles per minute, i.e. about 75 compressions and 10 breaths. If circulation returns, but respiration remains inadequate, the number of ventilations should be higher but care should be taken to avoid hypocarbia which results in cerebral ischaemia. A health care rescuer, when alone, may use the lay-person ratio of 30:2, aiming to achieve about five cycles in 2 minutes, i.e. about 75 compressions and 5 breaths per minute.

For infants and children, compressions should be delivered at a rate of 100/min, i.e. one compression every 0.6 seconds or approximately two per second. This does not mean that 100 actual compressions are given each minute. When ventilation is interposed between compressions, the actual compressions delivered will be less than 100 each minute.

If the airway has been secured, e.g. by intubation, strict coordination of compression and ventilation is not crucial: ventilation can be given against resistance imposed by chest compression. In this case about 100 compressions/minute will be achieved but ventilation should be limited to about 10–12 per minute and wherever possible guided by arterial blood gas analysis.

For newly-born infants the total number of recommended ‘events’ per minute is 120, with the aim of achieving 90 compressions and 30 inflations each minute, i.e. in a ratio of 3:1.

ADVANCED LIFE SUPPORT

As soon as practicable, mechanical ventilation with added oxygen should be commenced with either a bag-valve-mask or via endotracheal intubation. Although intubation is preferred (see below), valuable time should not be wasted in numerous unsuccessful attempts. Initial effective bag-valve-mask ventilation is a necessary prerequisite for successful paediatric CPR. Bags of appropriate sizes should be available for infants, small children and large children. A bag of ∼500 ml volume should be available for newly-born infants. Insertion of an oropharyngeal (Guedel) airway may be necessary to facilitate bag-valve-mask ventilation. Access to the circulation and display of the electrocardiograph should also be achieved as soon as possible. Thereafter treatment should be guided by the cardiac rhythm. Underlying causes of CPA should be sought and treated.

AIRWAY MANAGEMENT

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