Resuscitation
You are in a supermarket when you hear shouts of "help" from the neighbouring aisle. You investigate and find a mother holding her unresponsive 2 year old. You lay the child on the floor whilst a member of staff phones 999. The patient does not appear to be breathing. What is the first management step in this situation?
Answer:
The preponderance of hypoxic causes of paediatric cardiorespiratory arrest means that oxygen delivery rather than defibrillation is the critical step in children.- Safety - check for danger and approach with caution
- Stimulate the child and ask if they are alright
- Shout for help
- Airway opening manoeuvres
- Look, listen and feel for breathing
- Five rescue breaths
- Check for signs of life, check pulse (no more than 10 secs)
- Start CPR - 15 chest compressions: 2 ventilations
Paediatric Cardiorespiratory Arrest: Basic Life Support
Resuscitation
Last Updated: 4th August 2021
Algorithm
- Safety - check for danger and approach with caution
- Stimulate the child and ask if they are alright
- Shout for help
- Airway opening manoeuvres
- Look, listen and feel for breathing
- Five rescue breaths
- Check for signs of life, check pulse (no more than 10 secs)
- Start CPR - 15 chest compressions: 2 ventilations
The preponderance of hypoxic causes of paediatric cardiorespiratory arrest means that oxygen delivery rather than defibrillation is the critical step in children.
N.B. children = > 1 years, infant = < 1 year
Airway
An obstructed airway may be the primary problem and correction of an obstructed airway can result in recovery without further intervention. If a child is not breathing, it may be because the airway has been blocked by the tongue falling back and obstructing the pharynx. An attempt to open the airway should be made using the head tilt/chin lift manoeuvre. The desirable degrees of tilt are 'neutral' in the infant and 'sniffing' in the child. If the head tilt/chin lift manoeuvre is not possible, or is contraindicated because of suspected neck injury, than the jaw thrust manoeuvre can be performed. The blind finger sweep technique for removal of a foreign body should not be used in children.
Breathing
If normal breathing starts after the airway is open, turn the child on their side in the recovery position maintaining the open airway. If the airway opening techniques do not result in the resumption of adequate breathing within 10 seconds, exhaled air resuscitation should commence. Five initial rescue breaths should be given.
While the airway is kept open, the rescuer breathes in and seals his/her mouth around the victims mouth (child) or mouth and nose (infant). Slow exhalation (1 sec) by the rescuer should make the victim's chest visibly rise as much as normal - too vigorous a breath will cause gastric inflation and increase the chance of regurgitation of stomach contents into the lungs. The rescuer should take a breath between rescue breaths to maximise oxygenation of the victim.
If the chest fails to rise then the airway is not clear. The airway opening techniques should be adjusted, but failure after correction of these should lead to suspicion that a foreign body is causing the obstruction, and appropriate action should be taken.
Circulation
The absence of signs of life (no normal breaths or cough in response to rescue breaths and no spontaneous movement) is the primary indication to start chest compressions. In addition if the pulse is absent for up to 10 secs or inadequate (less than 60 bpm with no signs of circulation and no reaction to ventilation) then chest compressions are required.
In children, the carotid artery or the femoral artery can be palpated. In infants, the neck is generally short and fat, therefore the brachial artery or the femoral artery are palpated. If a pulse is present - with an adequate rate, with good perfusion - but apnoea persists, exhaled air resuscitation should be continued until spontaneous breathing resumes.
Chest compression techniques:
- Infants: Infant is held with both the rescuer's hands encircling the chest, the thumbs are placed over the lower half of the sternum and compression carried out. This method is only possible when there is two rescuers as otherwise the airway cannot be maintained. The lone rescuer must use the two finger technique, placing two fingers on the lower half of the sternum and using the other hand to maintain airway position.
- Children: Place the heel of one hand over the lower half of the sternum and compress the sternum to at least one-third of the depth of the chest. For larger children, this may be achieved most easily by using two hands with the fingers interlocked.
Fifteen compressions should be given to two ventilations. Compressions can be recommenced at the end of inspiration and may augment expiration. Once the child has been intubated during ALS, asynchronous compressions may be carried out with a ventilation rate of 10 - 12 breaths per minute.
The compression rate at all ages is 100 - 120 per minute. If possible, change rescuers every 2 minutes to maintain optimal compressions. If no help has arrived, the emergency services must be contacted after 1 minute of CPR. Apart from this interruption, BLS must not be interrupted unless the child moves or takes a breath.
Summary
| BPLS Algorithm | Infant (< 1 year) | Child (1 year to puberty) |
|---|---|---|
| Head-tilt position | Neutral | Sniffing |
| Initial rescue breaths | 5 | 5 |
| Pulse check | Brachial or femoral | Carotid or femoral |
| Compression landmark | Lower half of sternum | Lower half of sternum |
| Compression technique | Two fingers or two thumbs | One or two hands |
| Compression ratio | 15:2 | 15:2 |
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
