Clinical Notes : Resuscitation

95. Basic Life Support (BLS)

Infant - Birth to 1 year 

 

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 sequence, Infant : birth to 1 year 

Verify scene safety

Make sure you, the child and any bystanders are safe

 

00:30

 
 

Assess Responsiveness + Get Help

 

Lightly shake or tap the infant’s foot and say their name Look at the chest and torso for movement and normal breathing.

 

If responsive :

  • Assess and proceed accordingly

If unresponsive :

  • Witnessed collapse - One provider

    • FIRST Activate emergency response system and retrieve AED

    • THEN Assess pulse and breathing, and proceed accordingly

  • Witnessed collapse - Two providers

    • FIRST PROVIDER 

      • Place infant supine on a hard flat surface

      • Start CPR

    • SECOND PROVIDER

      • Call the emergency response team and bring the AED

 

  • Unwitnessed collapse

    • FIRST Assess pulse and breathing, and proceed accordingly

00:44

 
 

Assess for pulse and breathing

Check the infant for a brachial 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 infant 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

 

00:44

Normal breathing and has a pulse :

  • Activate emergency response system and retrieve AED

  • Return to infant 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:

  • One provider

    • Place two fingers on the sternum of the lower chest. One between the nipple line and the other 1cm below
  • ​Two providers

    • Encircle the infant’s torso with both hands with both thumbs pointing cephalic positioned 1cm below the nipples over the sternum

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

  • Press to 1/3 the depth the infant's chest 

  • 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.

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)

 

01:32

 

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 infant's jaw.

Provide upward pressure to lift the infant'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 infant’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 infant'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 infant is breathing adequately:

Continue to assess and maintain a patent airway and place the infant 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 infant has a pulse:

    • Commence rescue breaths immediately.

  • If the infant has no pulse:

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

Rescue Breaths

  • Use a barrier device if available.

  • Make a seal using your mouth over the mouth and nose of the infant

  • Each rescue breath should last approximately 1 second.

  • Watch for chest rise.

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

Rate of breathing :

  • During normal CPR without an advanced airway - one provider:

    • Provide at least 6 to 8 rescue breaths per minute.

  • During normal CPR without an advanced airway - two providers:

    • Provide at least 12 rescue breaths per minute.

  • During normal CPR with an advanced airway:

    • Provide 12-20 rescue breaths per minute (don’t pause chest compressions for breaths).

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

    • Provide 12-20 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 infant, 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 infant’s shoulders to raise the shoulders up and allow for the child's large occiput

 

01:07

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

  • Cradle the infant with the infant’s head tilted downward and slightly to the side to avoid choking or aspiration

  • Check breathing regularly

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

 

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 infant 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 infant.

  • Resume 5 cycles of CPR.

 

Guidelines for CPR & Emergency Cardiovascular Care

American Heart Association

Updated November 2017

view/access

Highlights of the 2015 American Heart Association Guidelines Updates for CPR and ECC

AHA

view/access

Resuscitation Council; UK

Adult basic life support and automated external defibrillation

view/access

ERC Guidelines 2015

European Resuscitation Council

view/access

Advanced vs. Basic Life Support in the Treatment of Out-of-Hospital Cardiopulmonary Arrest in the Resuscitation Outcomes Consortium.

Kurz et al

Resuscitation. 2018 Jul;128:132-137

view/access

 

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