Part 11: Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality

    Key Words:
  • automatic external defibrillator
  • cardiopulmonary resuscitation
  • pediatrics
PDF Accessible Version

1
Introduction

For the purposes of these guidelines:

  • Infant BLS guidelines apply to infants younger than approximately 1 year of age.
  • Child BLS guidelines apply to children approximately 1 year of age until puberty. For teaching purposes, puberty is defined as breast development in females and the presence of axillary hair in males.
  • Adult BLS guidelines apply at and beyond puberty (see “Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality” in this Web-based Integrated Guidelines regarding the use of the AED and methods to achieve high-quality CPR).

2
Prevention of Cardiopulmonary Arrest

In infants, the leading causes of death are congenital malformations, complications of prematurity, and SIDS.

In children over 1 year of age, injury is the leading cause of death.

Survival from cardiac arrest associated with blunt trauma is poor, emphasizing the importance of injury prevention in reducing deaths.

Motor vehicle crashes are the most common cause of fatal childhood injuries.

3
BLS Sequences for Use in Infants and Children in Cardiac Arrest

The guidelines delineate a series of skills as a sequence of distinct steps depicted in the Pediatric Basic Life Support (BLS) Algorithm, However, many of the steps may be performed simultaneously by a trained rescuer (eg, using a cellular telephone with speaker to activate the emergency response system while beginning CPR) and will be performed simultaneously when more than one rescuer is present.

In 2010, the international resuscitation councils, including the American Heart Association agreed to change the recommended sequence of CPR from “A-B-C” (airway, breaths and compressions) to “C-A-B” (compressions, airway, breaths), in order to minimize delay to the start of compressions. Because most cardiac arrests in infants and children are asphyxial in origin, delivery of both compressions and breaths is important. However, beginning CPR with 30 compressions (or, in the case of 2 rescuers, with 15 compressions) will not substantially delay delivery of rescue breaths. As a result, the CAB sequence is recommended for infants, children and adults to simplify training with the hopes that more victims of cardiac arrest will receive bystander CPR.

It may be reasonable to maintain the sequence from the 2010 Guidelines by initiating CPR with C-A-B over A-B-C sequence. (Class IIb, LOE C-EO) (2015 Part 11)

Knowledge gaps exist and specific research is required to examine the best approach to initiating CPR in children.

4
BLS Sequence for Lay Rescuers

4.1
Safety of Rescuer and Victim

Always make sure that the area is safe for you and the victim.

4.2
Assess Need for CPR

Assume that cardiac arrest is present if the victim is unresponsive and not breathing or only gasping.

4.2.1
Check for Response

  • Gently tap the victim and ask loudly, “Are you okay?”
  • If the child is unresponsive, shout for help.

4.2.2
Check for Breathing

  • No Breathing:
    • If the victim is unresponsive and not breathing (or only gasping), begin CPR.
    • Treat the victim with gasps as though there is no breathing and begin CPR
  • Breathing present:
    • If you see regular breathing, the victim does not need CPR.
    • Quickly check to see if the child has any injuries or needs medical assistance. If there is no evidence of trauma, turn the child onto the side (recovery position).
    • If you are alone and the child is not responsive but is breathing, leave the child (in recovery position if uninjured) to phone the emergency response system, but return quickly and recheck the child’s breathing.
    • Allow a child in respiratory distress to remain in a position that is most comfortable.

Formal training as well as “just in time” training, such as that provided by an emergency response system dispatcher, should emphasize how to recognize the difference between gasping and normal breathing; rescuers should be instructed to provide CPR even when the unresponsive victim has occasional gasps. (Class IIa, LOE C) (2010 Part 13)

4.3
Chest Compressions

During cardiac arrest, high-quality chest compressions generate blood flow to vital organs and increase the likelihood of ROSC.

The following are characteristics of high-quality CPR:

  • Chest compressions of adequate rate (100-120 compressions/min),
  • Chest compressions of adequate depth (at least one third of the anterior-posterior diameter of the chest or approximately 1 ½ inches (4 cm) in infants and approximately 2 inches (5 cm) in children)
  • Complete recoil of the chest after each compression, Minimal interruptions in compressions,
  • Avoiding excessive ventilation.

Inadequate compression depth is common even during CPR by health care providers. For best results, deliver chest compressions on a firm surface.

For simplicity in CPR training, in the absence of sufficient pediatric evidence, it is reasonable to use the adult BLS-recommended chest compression rate of 100/minute to 120/minute for infants and children. (Class IIa, LOE C-EO) (2015 Part 11)

The use of feedback devices likely helps the rescuer optimize adequate chest compression rate and depth, and we suggest their use, when available. (Class IIb, LOE C-EO) (2015 Part 11) Note: The evidence of the effectiveness of CPR feedback devices was not reviewed by this writing group, but this recommendation was made with group consensus.

It is reasonable that for pediatric patients (birth to the onset of puberty) rescuers provide chest compressions that depress the chest at least one third the anterior-posterior diameter of the chest. This equates to approximately 1.5 inches (4 cm) in infants to 2 inches (5 cm) in children. (Class IIa, LOE C-LD) (2015 Part 11)

For an infant, lone rescuers (whether lay rescuers or healthcare providers) should compress the sternum with 2 fingers placed just below the intermammary line. (Class IIb, LOE C) (2010 Part 13) Do not compress over the xiphoid or ribs. (Figure 1)

For a child, lay rescuers and healthcare providers should compress the lower half of the sternum at least one third the anterior-posterior dimension of the chest or approximately 5 cm (2 inches) with the heel of 1 or 2 hands. Do not press on the xiphoid or the ribs. There are no data to determine if the 1- or 2-hand method produces better compressions and better outcome. (Class IIb, LOE C) (2010 Part 13)

Once children have reached puberty, the recommended adult compression depth of at least 5 cm but no more than 6 cm is used for the adolescent of average adult size. (Class I, LOE C-LD) (2015 Part 11)

After each compression, allow the chest to recoil completely. (Class IIb, LOE B) (2010 Part 13) Complete chest re-expansion improves the flow of blood returning to the heart after each compression and contributes to blood flow generated by compressions during CPR.

Figure 1: Two-finger chest compression technique in infant (1 rescuer)
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4.4
Open the Airway and Give Breaths

For the lone rescuer a compression-to-ventilation ratio of 30:2 is recommended.

After the initial set of 30 compressions, open the airway and give 2 breaths.

In an unresponsive infant or child, the tongue may obstruct the airway and interfere with ventilation, so rescuers must open the airway before giving breaths.

To give breaths to an infant, use a mouth-to-mouth-and-nose technique.

To give breaths to a child, use a mouth-to-mouth technique.

Each breath should take about 1 second.

Make sure the breaths are effective (ie, the chest rises).

If the chest does not rise, reposition the head, make a better seal, and try again.

It may be necessary to move the child’s head through a range of positions to provide optimal airway patency and effective rescue breaths.

Open the airway using a head tilt–chin lift maneuver for both injured and noninjured victims. (Class I, LOE B) (2010 Part 13)

In an infant, if you have difficulty making an effective seal over the mouth and nose, try either mouth-to- mouth or mouth-to-nose ventilation. (Class IIb, LOE C) (2010 Part 13) If you use the mouth-to-mouth technique, pinch the nose closed. If you use the mouth-to-nose technique, close the mouth.

Make sure the chest rises when you give a breath. If you are the only rescuer, provide 2 effective breaths using as short a pause in chest compressions as possible after each set of 30 compressions. (Class IIa, LOE C) (2010 Part 13)

4.5
Coordinate Chest Compressions and Breaths

After giving 2 breaths, immediately give 30 compressions.

The lone rescuer should continue giving 30 compressions followed by 2 breaths for approximately 2 minutes (about 5 cycles) before leaving the victim to activate the emergency response system and obtain an automated external defibrillator (AED) if one is nearby. When 2 or more rescuers are present, one rescuer provides CPR while the second rescuer activates the emergency response system and retrieves the AED and uses it.

4.6
Conventional vs Compression-only CPR

Conventional CPR is optimal for children, because most cardiac arrests are asphyxial in origin. However, chest compressions are better than no CPR at all.

CPR using chest compressions with rescue breaths should be provided for infants and children in cardiac arrest. (Class I, LOE B-NR) (2017 Pediatric BLS)

If bystanders are unwilling or unable to deliver rescue breaths, we recommend that rescuers provide chest compressions for infants and children. (Class I, LOE B-NR) (2017 Pediatric BLS)

4.7
Activate Emergency Response System

If there are 2 rescuers, one should start CPR immediately and the other should activate the emergency response system (in most locales by phoning 911) and obtain an AED, if one is available.

If there is only 1 rescuer, give about 2 minutes of CPR before activating the emergency response system and getting an AED if one is nearby. Return to the victim as soon as possible and use the AED (if available) and resume CPR.

Continue with cycles of 30 compressions to 2 breaths until emergency response rescuers arrive or the victim starts breathing spontaneously.

5
Dispatcher-Assisted CPR

Effective bystander CPR is a key component of the chain of survival for out-of-hospital cardiac arrest and can improve survival. Unfortunately, rates of bystander CPR remain low. The provision of CPR instructions by emergency dispatchers has been associated with increased rates of bystander CPR.

It may be reasonable to maintain the sequence from the 2010 Guidelines by initiating CPR with C-A-B over A-B-C sequence. (Class I, LOE, C-EO) (2015 Part 11)

We recommend that emergency dispatchers provide CPR instructions for pediatric cardiac arrest when no bystander CPR is in progress. (Class I, LOE C-LD) (2019 PBLS)

There is insufficient evidence to make a recommendation for or against dispatch-assisted CPR instructions for pediatric cardiac arrest when bystander CPR is in progress. (2019 PBLS)

Additional evidence is needed regarding the specific instructions that will most efficiently and effectively assist lay rescuers in performing conventional CPR (ie, compressions plus breaths).

Continuous quality improvement is required to evaluate the speed with which dispatchers can identify possible cardiac arrest and the time required for the bystander to begin CPR.

6
BLS Sequence for Healthcare Providers and Others Trained in 2-Rescuer CPR

The algorithms for 1- and 2-person pediatric healthcare provider CPR have been separated to better guide rescuers through the initial stages of resuscitation (Figure 2 and Figure 3).

Activities described as a series of individual sequences can often be performed simultaneously (eg, chest compressions and preparing a bag and mask and opening the airway to prepare to deliver rescue breaths) when more than one rescuer is present, so there is less significance regarding which is performed first than if there is only 1 rescuer.

It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrest. For example, if the arrest is witnessed and sudden (eg, sudden collapse in an adolescent or a child identified at high risk for arrhythmia or during an athletic event), the healthcare provider may assume that the victim has suffered a sudden VF–cardiac arrest and as soon as the rescuer verifies that the child is unresponsive and not breathing (or only gasping) the rescuer should immediately phone the emergency response system, get the AED and then begin CPR and use the AED. (Class IIa LOE C) (2010 Part 13)

Figure 2: BLS Healthcare Provider Pediatric Cardiac Arrest Algorithm for the Single Rescuer
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Figure 3: BLS Healthcare Provider Pediatric Cardiac Arrest Algorithm for 2 or More Rescuers
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6.1
Scene Safety

Be sure the scene is safe.

6.2
Assess the Need for CPR

Check for response and breathing. If the victim is unresponsive and is not breathing (or only gasping), send someone to activate the emergency response system.

6.2.1
Pulse Check

If the infant or child is unresponsive and not breathing (gasps do not count as breathing), healthcare providers may take up to 10 seconds to attempt to feel for a pulse (brachial in an infant and carotid or femoral in a child). Ideally, if the infant or child is unresponsive, the rescuer checks for breathing and a pulse simultaneously.

If, within 10 seconds, you don’t feel a pulse or are not sure if you feel a pulse, begin chest compressions. (Class IIa, LOE C) (2010 Part 13)

6.3
Inadequate Breathing With Pulse

If there is a palpable pulse ≥60 per minute but there is inadequate breathing, give rescue breaths at a rate of about 12 to 20 breaths per minute (1 breath every 3 to 5 seconds) until spontaneous breathing resumes. Reassess the pulse about every 2 minutes but spend no more than 10 seconds doing so. (Class IIa, LOE B) (2010 Part 13)

6.4
Bradycardia With Poor Perfusion

If the pulse is <60 per minute and there are signs of poor perfusion (ie, pallor, mottling, cyanosis) despite support of oxygenation and ventilation, begin chest compressions. See Bradycardia in Part 12: Pediatric Advanced Life Support.

6.5
Chest Compressions

If the infant or child is unresponsive, not breathing, and has no pulse (or you are unsure whether there is a pulse), start chest compressions.

The lone healthcare provider should use the 2-finger chest compression technique for infants (see Figure 1, above).

The 2- thumb–encircling hands technique (Figure 4) is recommended when CPR is provided by 2 rescuers.

In an infant victim, lay rescuers and lone rescuers should compress the sternum with 2 fingers placed just below the intermammary line. (Class IIb LOE C) (2010 Part 13)

The 2-thumb—encircling hands technique is recommended for healthcare providers when 2 rescuers are present. Encircle the infant’s chest with both hands; spread your fingers around the thorax, and place your thumbs together over the lower half of the sternum. Forcefully compress the sternum with your thumbs as you squeeze the thorax with your fingers for counter pressure. (Class IIa LOE C) (2010 Part 13)

If you are alone or you cannot physically encircle the victim’s chest, compress the chest with 2 fingers.

It is reasonable that for pediatric patients (birth to the onset of puberty) rescuers provide chest compressions that depress the chest at least one third the anterior-posterior diameter of the chest. This equates to approximately 1.5 inches (4 cm) in infants to 2 inches (5 cm) in children. (Class IIa, LOE C-LD) (2015 Part 11)

For a child, lay rescuers and healthcare providers should compress the lower half of the sternum at least one third the anterior-posterior dimension of the chest or approximately 5 cm (2 inches) with the heel of 1 or 2 hands. Do not press on the xiphoid or the ribs. There are no data to determine if the 1- or 2-hand method produces better compressions and better outcome. (Class IIb LOE C) (2010 Part 13)

Once children have reached puberty, the recommended adult compression depth of at least 5 cm but no more than 6 cm is used for the adolescent of average adult size. (Class I, LOE C-LD) (2015 Part 11)

After each compression, allow the chest to recoil completely. (Class IIb, LOE B) (2010 Part 13) Complete chest re-expansion improves the flow of blood returning to the heart after each compression and contributes to blood flow generated by compressions during CPR.

Figure 4: Two thumb-encircling hands chest compression in infant (2 rescuers)
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6.6
Ventilations

After 30 compressions (after 15 compressions if 2 rescuers), open the airway with a head tilt–chin lift and give 2 breaths.

If there is evidence of trauma that suggests spinal injury, use a jaw thrust without head tilt to open the airway. (Class IIb LOE C) (2010 Part 13) Because maintaining a patent airway and providing adequate ventilation is important in pediatric CPR, use a head tilt–chin lift maneuver if the jaw thrust does not open the airway.

6.7
Coordinate Chest Compressions and Ventilation


A lone rescuer uses a compression-to-ventilation ratio of 30:2.

For 2-rescuer infant and child CPR, one rescuer performs chest compressions while the other keeps the airway open and provides ventilation at a ratio of 15 compressions to 2 breaths (15:2). Change compressors every 2 minutes (see Compression Quality and Rescuer Fatigue immediately below).

Coronary perfusion pressure, a major determinant of successful resuscitation, begins to fall as soon as chest compressions are interrupted. It is critical to minimize the number and duration of interruptions in chest compressions when providing ventilation or using an AED.

Deliver ventilation with minimal interruptions in chest compressions. (Class IIa, LOE C) (2010 Part 13)

6.8
Compression Quality and Rescuer Fatigue

Rescuer fatigue – even when the rescuer denies feeling fatigued – can lead to inadequate compression rate, depth, and recoil.

Change compressors approximately every 2 minutes to prevent compressor fatigue and deterioration in quality and rate of chest compressions.

Switch the compressor role as quickly as possible (ideally in less than 5 seconds) to minimize interruptions in chest compressions.

6.9
CPR with an Advanced Airway in Place

If an advanced airway is in place, chest compressions are no longer paused for delivery of breaths, instead compressions are delivered continuously at a rate of 100-120/minute and breaths are delivered asynchronously at a rate of 10 breaths per minute.

Deliver ventilation with minimal interruptions in chest compressions. (Class IIa, LOE C) (2010 Part 13)

If the infant or child is intubated, ventilate at a rate of about 1 breath every 6 seconds (10 times per minute) without interrupting chest compressions. (Class I, LOE C) (2010 Part 14)

Note: For simplicity of teaching and consistency with 2015 ACLS recommendations, frequency of breaths during CPR in an intubated infant or child was changed to 1 breath every 6 seconds (10 breaths/minute) in the 2016 PALS training materials.

Avoid excessive ventilation. (Class III, LOE C) (2010 Part 13)

6.10
Defibrillation

For infants, a manual defibrillator is preferred when a shockable rhythm is identified by a trained healthcare provider. (Class IIb, LOE C) (2010 Part 13)

It is reasonable to use an initial dose of 2 to 4 J/kg of monophasic or biphasic energy for defibrillation. (Class IIa, LOE C-LD), but for ease of teaching, an initial dose of 2 J/kg may be considered. (Class IIb, LOE C-EO) (2015 Part 12)

For refractory ventricular fibrillation, it is reasonable to increase the dose to 4 J/kg. (Class IIa, LOE C-LD) (2015 Part 12) For subsequent energy levels, a dose of 4 J/kg may be reasonable and higher energy levels may be considered, though not to exceed 10 J/kg or the adult maximum dose. (Class IIb, LOE C-LD) (2015 Part 12)

If a manual defibrillator is not available, an AED equipped with a pediatric attenuator is preferred for infants. An AED with a pediatric attenuator is also preferred for children <8 years of age. If neither is available, an AED without a dose attenuator may be used. (Class IIb, LOE C) (2010 Part 13)

For additional information about manual defibrillation, see Part 12, Pediatric Advanced Life Support.

6.10.1
Defibrillation Sequence Using an AED

Turn the AED on.

Follow the AED prompts.

Minimize interruptions in chest compressions.

6.10.2
Integrating CPR with Defibrillation

In adults, shorter “peri-shock pauses” (ie, total time compressions are interrupted for shock delivery) were associated with greater likelihood of shock success, greater likelihood of return of spontaneous circulation, and greater survival to hospital discharge.

Shock delivery should occur as soon as possible after compressions are interrupted.

Compressions are needed immediately after shock delivery to provide blood flow and coronary perfusion. Even if a shock eliminates VF, it takes time for the heart to resume a perfusing rhythm.

The AED will prompt the rescuer to re-analyze the rhythm about every 2 minutes. If a manual defibrillator is used, perform a rhythm check after 2 minutes of CPR.

7
Barrier Devices

If you use a barrier device, do not delay rescue breathing.

If there is any delay in obtaining a barrier device or ventilation equipment, give mouth-to-mouth ventilation (if willing and able) or continue chest compressions alone.

8
Bag-Mask Ventilation (Healthcare Providers)

8.1
Bag and Mask Devices

Use a self-inflating bag with a volume of at least 450 to 500 mL for infants and young children.

In older children or adolescents, an adult self-inflating bag (1000 mL) may be needed to reliably achieve chest rise.

A self-inflating bag delivers only room air unless supplementary oxygen is attached, but even with an oxygen inflow of 10L/min, the concentration of oxygen delivered varies from 30% to 80% and is affected by the tidal volume and peak inspiratory flow rate. To deliver a high oxygen concentration (60% to 95%), attach an oxygen reservoir to the self-inflating bag.

Maintain an oxygen flow of 10 to 15 L/min into a reservoir attached to a pediatric bag and a flow of at least 15 L/min into an adult bag.

8.2
Bag-Mask Ventilation Technique

Effective bag-mask ventilation requires a tight seal between the mask and the victim’s face:

  • Open the airway by lifting the jaw toward the mask making a tight seal and squeeze the bag until the chest rises (Figure 5).
  • Three fingers of one hand lift the jaw (they form the “E”) while the thumb and index finger hold the mask to the face (making a “C”).

Give each breath slowly, over approximately 1 second, and watch for chest rise.

If the chest does not rise, reopen the airway, verify that there is a tight seal between the mask and the face (or between the bag and the advanced airway), and reattempt ventilation.

During CPR the lone rescuer should use mouth-to-barrier device techniques for ventilation. Bag-mask ventilation can be provided effectively during 2-person CPR.

8.3
Two-Person Bag-Mask Ventilation

If skilled rescuers are available, a 2-person technique may provide more effective bag-mask-ventilation than a single-person technique, particularly if there is significant airway obstruction, poor lung compliance or difficulty creating a tight seal between the mask and the face. To provide 2-rescuer ventilation with bag and mask:

  • one rescuer uses both hands to open the airway and maintain a tight mask-to-face seal while the other compresses the ventilation bag.
  • Both rescuers observe the chest to ensure chest rise.
  • Avoid delivering too high a tidal volume or excessive ventilation rate or pressure.

Figure 5: The EC clamp technique of bag-mask ventilations.
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8.4
Precautions

Avoid excessive ventilation; use only the force and tidal volume necessary to just make the chest rise. (Class III, LOE C) (2010 Part 13)

Deliver each breath over approximately 1 second.

Excessive ventilation volume or pressure can produce gastric inflation and increase risk of regurgitation and aspiration.

In addition, positive pressure ventilation can decrease venous return to the heart and cardiac output generated by chest compressions.

Bag-mask ventilation is not recommended for ventilation by a lone rescuer during CPR, because it will likely require longer interruptions in chest compressions (the rescuer would have to change positions, open the airway, create a seal and deliver two breaths and then return to the chest).

Patients with airway obstruction or poor lung compliance may require high inspiratory pressures to produce chest rise and adequate ventilation: a pressure-relief valve may prevent the delivery of enough tidal volume in these patients. Make sure that the bag-mask device allows you to bypass the pressure-relief valve and use high pressures, if necessary, to achieve visible chest expansion.

8.5
Cricoid Pressure

Cricoid pressure may be considered, but only in an unresponsive victim if there is an additional healthcare provider to apply the pressure.

Avoid excessive cricoid pressure so as not to obstruct the trachea.

9
Oxygen

It is reasonable for healthcare providers to use 100% oxygen during resuscitation.

Once circulation is restored, it may be reasonable, when appropriate equipment is available, to titrate oxygen administration to maintain the oxyhemoglobin saturation ≥94%.

Since an oxygen saturation of 100% may correspond to a PaO2 anywhere between ~80 and 500 mm Hg, in general it is appropriate to wean the FIO2 for a saturation of 100%, provided the oxyhemoglobin saturation can be maintained ≥94%. (Class IIb, LOE C) (2010 Part 13 and 2015 Part 12) Note: See Part 13 for additional information regarding targeting of normoxemia post-cardiac arrest.

Whenever possible, humidify oxygen to prevent mucosal drying and thickening of pulmonary secretions.

9.1
Oxygen Masks

To provide an oxygen concentration of 30% to 50% to a victim who is breathing spontaneously, a simple oxygen mask is usually adequate.

To deliver an oxygen concentration of higher than 30% to 50%, use a tight-fitting nonrebreathing mask with an oxygen inflow rate of approximately 15 L/min to maintain inflation of the reservoir bag.

9.2
Nasal Cannulas

Infant- and pediatric-size nasal cannulas are suitable for children with spontaneous breathing but the concentration of inspired oxygen is limited unless a high-flow device is used.

10
Other CPR Techniques and Adjuncts

The following techniques and adjuncts have not been reviewed for use in infants and children so the writing group cannot make recommendations for or against their use:

  • mechanical devices to compress the chest,
  • active compression-decompression CPR,
  • interposed abdominal compression CPR (IAC-CPR),
  • the impedance threshold device, and
  • pressure sensor accelerometer (feedback) devices.

11
Foreign-Body Airway Obstruction (Choking) (FBAO)

Note: This topic has not been reviewed since 2010.

11.1
Epidemiology and Recognition

Signs of FBAO include a sudden onset of respiratory distress with coughing, gagging, stridor, or wheezing.

Sudden onset of respiratory distress in the absence of fever or other respiratory symptoms (eg, antecedent cough, congestion) suggests FBAO rather than an infectious cause of respiratory distress, such as croup.

11.2
Relief of FBAO

If FBAO is mild (ie, the child can cough and make some sounds), do not interfere. Allow the victim to clear the airway by coughing while you observe for signs of severe FBAO.

If the FBAO is severe (ie, the victim cannot cough or make a sound), you must act to relieve the obstruction.

  • For a child perform subdiaphragmatic abdominal thrusts (Heimlich maneuver) until the object is expelled or the victim becomes unresponsive.
  • For an infant, deliver repeated cycles of 5 back blows (slaps) followed by 5 chest compressions until the object is expelled or the victim becomes unresponsive.

If the victim becomes unresponsive, start CPR with chest compressions (do not perform a pulse check).

After 30 chest compressions, open the airway.

If you see a foreign body, remove it but do not perform blind finger sweeps because they may push obstructing objects farther into the pharynx and may damage the oropharynx.

Attempt to give 2 breaths and continue with cycles of chest compressions, checking the airway and attempted breaths until the object is expelled.

After 2 minutes, if no one has already done so, activate the emergency response system.

12
Special Resuscitation Situations

12.1
Children With Special Healthcare Needs

Children with special healthcare needs may require emergency care for complications of chronic conditions (eg, obstruction of a tracheostomy), failure of support technology (eg, ventilator malfunction), progression of underlying disease, or events unrelated to those special needs.

Encourage parents and child-care providers of children with special healthcare needs to keep copies of medical information at home, with the child, and at the child’s school or child-care facility.

School nurses should have copies of medical information and should maintain a readily available list of children with Do Not Attempt Resuscitation (DNAR)/Allow Natural Death (AND) orders.

An Emergency Information Form developed by the American Academy of Pediatrics and the American College of Emergency Physicians is available online (https://www.acep.org/by-medical-focus/pediatrics/medical-forms/emergency-information-form-for-children-with-special-health-care-needs/).

12.2
Advanced Directives

If a decision to limit or withhold resuscitative efforts is made, the physician must write an order clearly detailing the limits of any attempted resuscitation. A separate order must be written for the out-of-hospital setting. These orders must be consistent with regulations.

When a child with a chronic or potentially life-threatening condition is discharged from the hospital, it’s important to provide parents, school nurses, and home healthcare providers with summary of the hospital course, and signs of deterioration. They should receive specific instructions about CPR and whom to contact for emergencies.

12.3
Ventilation With a Tracheostomy or Stoma

Everyone involved with the care of a child with a tracheostomy (parents, school nurses, and home healthcare providers) should know how to assess patency of the airway, clear the airway, change the tracheostomy tube.

Use the tracheostomy tube for ventilation and verify adequacy of airway and ventilation by watching for chest expansion.

If the tracheostomy tube does not allow effective ventilation, suction it immediately. If ventilation through the tracheostomy tube is still unsuccessful even after suctioning, replace it.

If, after replacing the tracheostomy tube you are still unable to achieve chest rise, remove the tracheostomy tube and attempt alternative ventilation methods, such as mouth-to-stoma ventilation or bag-mask ventilation through the nose and mouth (while you or a second rescuer occludes the tracheal stoma).

12.4
Trauma

The principles of BLS resuscitation for the injured child are the same as those for the ill child.

The following are important aspects of resuscitation of pediatric victims of trauma:

  • Anticipate airway obstruction by dental fragments, blood, or other debris — suction if necessary.
  • Stop all external bleeding with direct pressure.
  • When the mechanism of injury is compatible with spinal injury, minimize motion of the cervical spine and movement of the head and neck.

Professional rescuers should open and maintain the airway with a jaw thrust and try not to tilt the head.

If there is evidence of trauma that suggests spinal injury, use a jaw thrust without head tilt to open the airway. (Class IIb LOE C) (2010 Part 13) Because maintaining a patent airway and providing adequate ventilation is important in pediatric CPR, use a head tilt–chin lift maneuver if the jaw thrust does not open the airway.

If there are 2 rescuers, 1 can manually restrict cervical spine motion while the other rescuer opens the airway.

To limit spine motion, secure at least the thighs, pelvis, and shoulders to the immobilization board.

Optimal positioning may require recessing the occiput or elevating the torso to avoid undesirable backboard-induced cervical flexion.

If possible, transport children with potential for serious trauma to a trauma center with pediatric expertise.

12.5
Drowning

Start resuscitation by safely removing the victim from the water as rapidly as possible.

If you have special training, start rescue breathing while the victim is still in the water if doing so will not delay removing the victim from the water.

Do not attempt chest compressions in the water.

After removing the victim from the water start CPR if the victim is unresponsive and is not breathing.

  • If you are alone, continue with 5 cycles (about 2 minutes) of compressions and breaths before activating the emergency response system and getting an AED.
  • If 2 rescuers are present, one rescuer begins CPR and the second rescuer activates the emergency response system and gets the AED (if one is available).

13
CPR Quality

Immediate CPR can improve survival from cardiac arrest in children, but not enough children receive high-quality CPR.

We must increase the number of laypersons who learn, remember, and perform CPR, and must improve the quality of CPR provided by lay rescuers and healthcare providers alike.

The 5 components of high-quality CPR are:

  • chest compressions of adequate rate (100-120 compressions/min),
  • chest compressions of adequate depth (at least one third of the anterior-posterior diameter of the chest or approximately 1 ½ inches [4 cm] in infants and approximately 2 inches [5 cm] in children),
  • complete recoil of the chest after each compression,
  • minimal interruptions in compressions, and
  • avoiding excessive ventilation.

Healthcare systems that deliver CPR should implement processes of performance improvement including monitoring:

  • time required for recognition and activation of the emergency response system,
  • quality of CPR delivered at the scene of cardiac arrest,
  • other process-of-care measures (eg, initial rhythm, bystander CPR, and response intervals), and
  • patient outcome.

Performance data should be used to optimize the quality of CPR delivered.

14
Authorship and Disclosures

14.1
2017 Writing Team

Dianne L. Atkins, MD, FAHA, Chair; Allan R. de Caen, MD; Stuart Berger, MD FAHA; Ricardo A. Samson, MD; Stephen M. Schexnayder, MD; Benny L. Joyner, Jr, MD, MPH; Blair L. Bigham, MD, MSc; Dana E. Niles, MS; Jonathan P. Duff, MD, MEd; Elizabeth A. Hunt, MD, MPH, PhD; Peter A. Meaney, MD, MPH

Table 1: Part 11: PBLS and CPR Quality: 2017 Guidelines Update Writing Group Disclosures

14.2
2017 Reviewers

Marc Auerbach; Aarti Bavare; Silvia M. Hartmann; Georg Schmölzer

Table 2: Part 11: PBLS and CPR Quality: 2017 Guidelines Update Reviewer Disclosures

14.3
2015 Writing Team

Dianne L. Atkins, Chair; Stuart Berger; Jonathan P. Duff; John C. Gonzales; Elizabeth A. Hunt; Benny L. Joyner; Peter A. Meaney; Dana E. Niles; Ricardo A. Samson; Stephen M. Schexnayder

Table 3: Part 11: Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 Guidelines Update Writing Group Disclosures

14.4
2010 Writing Team

Marc D. Berg, Chair; Stephen M. Schexnayder; Leon Chameides; Mark Terry; Aaron Donoghue; Robert W. Hickey; Robert A. Berg; Robert M. Sutton; Mary Fran Hazinski

Table 4: 2010 - Guidelines Part 13: Pediatric BLS Writing Group Disclosures

15
Footnotes

The American Heart Association requests that this document be cited as follows:

American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care – Part 11: Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality. ECCguidelines.heart.org.

© Copyright 2015, 2017 American Heart Association, Inc.

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References

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