Clinical Notes : Resuscitation

93. Basic Life Support (BLS)

Child 1 year to puberty

 

Some countries have a survival rate following out of hospital cardiac arrest of 5% while other countries have a survival rate

as high as 30%. 

Countries with the best outcome have raised national cardiac arrest awareness and have embedded Chain of Survival in their emergency response protocols, so that more bystanders and first responders are able to deliver effective CPR.

 

In out-of-hospital cardiac arrest, ALS care (Advanced Life Support) is associated with increased ROSC (Return of Spontaneous Circulation), but is not associated with greater functional outcome than BLS care alone .

 

BLS Child 1 year to puberty Cardiac Arrest Algorithm (2015 AHA)

Verify scene safety

Make sure you, the child and any bystanders are safe

 

00:30

 
 

Assess Responsiveness + Get Help

 

Stimulate and speak to the child asking " are you OK ?". Look at the chest and torso for movement and normal breathing.

 

If responsive :

  • Leave him in the position in which you find him, provided there is no further danger

  • Try to find out what is wrong with him and get help if needed

  • Reassess him regularly

If unresponsive :

  • Witnessed collapse

    • FIRST Activate emergency response system and retrieve AED

    • THEN Assess pulse and breathing, and proceed accordingly

 

  • Unwitnessed collapse

    • FIRST Assess pulse and breathing, and proceed accordingly

00:55

 
 

Assess for pulse and breathing

Check the child for a carotid or femoral pulse and breathing simultaneously for 5-10 seconds.

Do not check for more than 10 seconds

  • Airway

    • Ensure open airway (jaw thrust or head-tilt-chin-lift)

  • Pulse

    • the carotid pulse (or any other pulse) is an inaccurate method for confirming the presence or absence of circulation

    • assume that the child who is breathing normally has a pulse

  • Breathing

    • Agonal breathing (or gasping) may be present in up to 40% of children in the first minutes after cardiac arrest

    • can be interpreted incorrectly as evidence of a circulation and that CPR is not needed

 

00:40

Normal breathing and has a pulse :

  • Activate emergency response system and retrieve AED

  • Return to child and monitor until emergency service arrives

 

No breathing and has a pulse :​​

  • Breathing

    • Commence rescue breaths immediately.

      • if pulse <60/min, with signs of poor perfusion, then add compressions

    • After 2 min, activate emergency response system and retrieve AED

    • Return to child and resume rescue breaths 

    • After 2 min, check pulse

      • if pulse <60/min, with signs of poor perfusion, then add compressions

      • if no pulse, then start CPR

 

No breathing (or gasping only) and no pulse :

  • Witnessed collapse

    • FIRST Activate emergency response system and retrieve AED

    • THEN Start CPR

  • Unwitnessed collapse

    • Start CPR

 CPR  ( Cardio Pulmonary Resuscitation)

  • Place patient supine on a hard flat surface

  • One provider 

    • Give 2 minutes of CPR with cycles of 30 compressions to 2 breaths

    • Leave the child to activate the emergency response and get the AED (if not already done)

    • Return to the child and resume CPR

  • Two providers 

    • second provider calls the emergency response team and brings the AED

    • first provider begins cycles of 30 compressions to 2 breaths

    • when second provider returns switch to cycles of 15 compressions to 2 breaths

 

If the childt regains a pulse :

Return to the Airway and Breathing portion of the algorithm:

  • Provide 10-20 rescue breaths per minute (1 breath every 3-6 seconds).

  • Recheck pulse every 2 minutes.

If the childt does not regain a pulse :

Continue in the Circulation portion of the algorithm:

 

CIRCULATION (COMPRESSIONS)

Chest compressions:

  • Provide 100 to 120 compressions per minute. This is 30 compressions every 15 to 18 seconds.

  • Use one or two arms

    • Place both of your palms midline, one over the other, on the lower 1/3 of the patient’s sternum between the nipples.

    • Place the palm of one hand midline (optional for very small child) on the lower 1/3 of the child’s sternum between the nipples

    • Lock your arm/s.

  • Press to 1/3 the depth the child's chest or 5 cm (2 inches).

    • Press hard and fast.

  • Allow for full chest recoil with each compression.

  • Allow for only minimal interruptions to chest compressions.

 

1 cycle of child CPR is 30 chest compressions to 2 rescue breaths (one provider),

or 15 chest compressions to 2 rescue breaths (two providers).

If two providers are present: switch roles between compressor and rescue breather every 5 cycles.

Hand Placement

Arrange the heel of your hand directly over the heel of your other hand. Interlace your fingers.

Place the heels of your hands over the center of the child's chest on the lower half of the sternum.

Arm Alignment

Keep arm/s straight with your elbow/s fully extented.

Position your shoulders directly above your hand/s and the child's chest.

Compression Depth & Rate

Chest compressions should be at a depth of 1/3 the child's chest or 2 inches (5 cm ) and at a rate of 100 to 120 per minute.

2015 to 2020

Quality chest compressions

  • depth : 1/3 the child's chest or 5 cm (2 inches)

  • rate : between 100 and 120 compressions per minute

  • allow for complete chest recoil

 

Minimize chest compression interruption

  • Compression fraction is the time spent actually compressing the chest.

  • Compression fraction : 60% (Within 1 minute, 60% of that 1 minute, at least, should be spent actively doing chest compressions)

 

02:59

 

AIRWAY

In the event of an unwitnessed collapse, drowning, or trauma:

Use the Jaw Thrust maneuver. (This maneuver is used when a cervical spine injury cannot be ruled out.):

  • Place your fingers on the lower rami of the jaw.

  • Provide anterior pressure to advance the jaw forward.

Jaw-Thrust

(Use in place of head-tilt/chin-lift if neck injury is suspected)

Place your index fingers behind the angles of the child's jaw.

Provide upward pressure to lift the child's jaw while avoiding any neck movement.

In the event of a witnessed collapse with no reason to assume a C-spine injury :

Use the Head Tilt-Chin Lift maneuver:

  • place your palm on the child’s forehead and apply pressure to tilt the head backward.

  • place the fingers of your other hand under the mental protuberance of the chin and pull the chin forward and cephalic.

01:18

Head-tilt / Chin-lift

Using one hand, place downward pressure on the child's forehead.

Using your other hand, place two fingers below the edge of the child's chin and provide upward rotating pressure to tilt the head back.

 
 

BREATHING

If the child is breathing adequately:

Continue to assess and maintain a patent airway and place the child in the recovery position.

(Only use the recovery position if its unlikely to worsen patient injury.)

If the child is not breathing or is breathing inadequately:

  • If the child has a pulse:

    • Commence rescue breaths immediately.

  • If the child has no pulse:

    • Begin CPR. (move to the “Circulation” portion of the algorithm.)

Rescue Breaths

  • Use a barrier device if available.

  • Pinch the child’s nose closed.

  • Make a seal using your mouth over the mouth of the child or use a pocket mask or bag mask.

  • Each rescue breath should last approximately 1 second.

  • Watch for chest rise.

  • Allow time for the air to expel from the child.

Rescue Breaths

Pinch the nose using the hand that is resting on the child's forehead.

Make a complete seal over the patient's mouth.

Use a barrier if available.

Give a full deep breath to the child lasting approximately 1 second.

Watch for chest rise.

Rate of breathing :

  • During normal CPR without an advanced airway:

    • Provide approximately 10-20 rescue breaths per minute (1 breath every 3-6 seconds).

  • During normal CPR with an advanced airway:

    • Provide 10 rescue breaths per minute (don’t pause chest compressions for breaths).

  • If patient has a pulse and no CPR is required:

    • Provide 10 rescue breaths per minute (1 breath every 6 seconds).

    • Recheck pulse every 2 minutes.

2015 to 2020

Avoid gastric insufflation

  • Excessive breaths and excessive tidal volume can increase intrathoracic pressure and reduce blood return to the heart.

  • Excessive breaths and excessive tidal volume can also push air into the stomach leading to vomiting and aspiration.

01:25

 

Ensure 

  • use of proper child size mask 

    • should fit over the nose and the mouth of the child, not extend up into the eyes or past the chin, so you’re able to get a good seal

  • neutral position of child's head

    • may need to place a towel roll underneath the child’s shoulders to raise the shoulders up and allow for the child's large occiput

If there is a foreign body obstruction:

  • Perform abdominal thrusts

 

Recovery position (lateral recumbent or 3/4 prone position):

This position is used to maintain a patent airway in the unconscious child who is breathing adequately

  • Remove the child’s glasses, if worn

  • Kneel beside the child and make sure that both his legs are straight

  • Place the arm nearest to you out at right angles to his body, elbow bent with the hand palm-up

  • Bring the far arm across the chest, and hold the back of the hand against the child’s cheek nearest to you

  • With your other hand, grasp the far leg just above the knee and pull it up, keeping the foot on the ground

  • Keeping his hand pressed against his cheek, pull on the far leg to roll the child towards you on to his side

  • Adjust the upper leg so that both the hip and knee are bent at right angles

  • Tilt the head back to make sure that the airway remains open

  • If necessary, adjust the hand under the cheek to keep the head tilted and facing downwards to allow liquid material to drain from the mouth

  • Check breathing regularly

  • Assure the position is stable.

  • Avoid pressure of the chest that could impairs breathing.

  • Ensure there is no obstruction to turning the child back to supine position if necessry

  • Take precautions to stabilize the neck in case of cervical spine injury.

  • Continue to assess and maintain access of airway.

  • Be prepared to restart CPR immediately if the child deteriorates or stops breathing normally

Cricoid pressure during positive pressure ventilation

  • No longer recommended

2015 to 2020

 

DEFIBRILLATE

Arrival of the AED (Automated External Defibrillator)

 

Power:

  • Turn AED On IMMEDIATELY (early defibrillation is the single most important therapy for survival of cardiac arrest and should be done as soon as it arrives).

  • Follow verbal AED prompts.

 

Attachment:

  • Firmly place appropriate pads (adult/pediatric) to patient’s skin to the indicated locations (pad image).

 

Analyze:

A short pause in CPR is required to allow the AED to analyze the rhythm.

 

If the rhythm is not shockable:

  • Initiate 5 cycles of CPR.

  • Recheck the rhythm at the end of the 5 cycles of CPR.

 

If the shock is indicated:

  • Assure no one is touching the child or is in mutual contact of a good conductor of electricity by yelling “Clear, I’m Clear, you’re Clear!” prior to delivering a shock.

  • Press the shock button when the providers are clear of the child.

  • Resume 5 cycles of CPR.