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Resuscitation Council (UK)
69
RESUSCITATION GUIDELINES 2005
Paediatric Basic Life Support

Introduction
The paediatric basic life support guidelines have been changed, partly in
response to convincing new scientific evidence, and partly to simplify them in
order to assist teaching and retention. As in the past, there remains a paucity of
good quality evidence specifically on paediatric resuscitation, and some
conclusions have had to be drawn from experimental work or extrapolated from
adult data.
These guidelines have a strong focus on simplification, based on the knowledge
that many children receive no resuscitation at all because rescuers fear doing
harm as they have not been taught specific paediatric resuscitation.
Consequently, a major area of discussion during the development of Guidelines
2005 has been the feasibility of applying the same guidelines to children as to
adults.
Bystander resuscitation improves outcome significantly. There is good evidence
from experimental models that doing either chest compression or expired air
ventilation alone may result in a better outcome than doing nothing.
1
It follows
that outcomes could be improved if bystanders who would otherwise do nothing,
were encouraged to begin resuscitation, even if they do not follow an algorithm
targeted specifically at children. There are, however, distinct differences between
the predominantly adult arrest of cardiac origin and the asphyxial arrest which
occurs commonly in children. Therefore, a separate paediatric algorithm is
justified for healthcare professionals with a duty to respond to paediatric
emergencies, who are in a position to receive enhanced training.
Guideline changes
Compression:ventilation ratios
•
Lay rescuers should use a ratio of 30 compressions to 2 ventilations.
•
Two or more rescuers with a duty to respond should use a ratio of 15
compressions to 2 ventilations.
Age definitions
•
An infant is a child under 1 year.
•
A child is between 1 year and puberty.
Page 2
70 RESUSCITATION GUIDELINES 2005
Paediatric Basic Life Support
(Healthcare professionals
with a duty to respond)
UNRESPONSIVE ?
Shout for help
NOT BREATHING NORMALLY ?
15 chest compressions
2 rescue breaths
Open airway
5 rescue breaths
After 1 minute call resuscitation team then continue CPR
STILL UNRESPONSIVE ?
(no signs of a circulation)
Page 3
71
Automated external defibrillators
•
A standard AED can be used in children over 8 years.
•
Purpose-made paediatric pads, or programs which attenuate the
energy output of an AED, are recommended for children
between 1 and 8 years.
•
If no such system or manually adjustable machine is available,
an unmodified adult AED may be used for children older than
1 year.
•
There is insufficient evidence to support a recommendation for
or against the use of AEDs in children less than 1 year.
Foreign body airway obstruction sequence
•
A simplified sequence of actions should be used for the
management of foreign body airway obstruction (FBAO) in infants and
children.
Infant and child BLS sequence
Rescuers who have been taught adult BLS, and have no specific knowledge of
paediatric resuscitation, should use the adult sequence. The following
modifications to the adult sequence will, however, make it more suitable for use
in children:
•
Give five initial rescue breaths before starting chest compression
(adult sequence step 5B).
•
If you are on your own, perform CPR for 1 min before going for help.
•
Compress the chest by approximately one-third of its depth. Use two
fingers for an infant under 1 year; use one or two hands for a child
over 1 year as needed to achieve an adequate depth of compression.
(See adult BLS section)
The following is the sequence that should be followed by healthcare
professionals with a duty to respond to paediatric emergencies:
1
Ensure the safety of rescuer and child.
2
Check the child’s responsiveness:
•
Gently stimulate the child and ask loudly, ‘Are you all right?’
•
Do not shake infants, or children with suspected cervical spine
injuries.
Page 4
3 A If the child responds by answering or moving:
•
Leave the child in the position in which you find him (provided he is
not in further danger).
•
Check his condition and get help if needed.
•
Reassess him regularly.
3 B If the child does not respond:
•
Shout for help.
•
Open the child’s airway by tilting the head and lifting the chin:
o With the child initially in the position in which you find him,
place your hand on his forehead and gently tilt his head back.
o At the same time, with your fingertip(s) under the point of the
child’s chin, lift the chin. Do not push on the soft tissues under
the chin as this may block the airway.
o If you still have difficulty in opening the airway, try the jaw
thrust method: place the first two fingers of each hand behind
each side of the child’s mandible (jaw bone) and push the jaw
forward. Both methods may be easier if the child is turned
carefully onto his back.
If you suspect that there may have been an injury to the neck, try to open the
airway using chin lift or jaw thrust alone. If this is unsuccessful, add head tilt a
small amount at a time until the airway is open.
4
Keeping the airway open, look, listen, and feel for normal breathing by
putting your face close to the child’s face and looking along the
chest:
•
Look for chest movements.
•
Listen at the child’s nose and mouth for breath sounds.
•
Feel for air movement on your cheek.
Look, listen, and feel for no more than 10 sec before deciding that breathing is
absent.
5 A If the child is breathing normally:
•
Turn the child onto his side into the recovery position (see below).
•
Check for continued breathing.
5 B If the child is not breathing or is making agonal gasps (infrequent,
irregular breaths):
•
Carefully remove any obvious airway obstruction.
•
Give 5 initial rescue breaths.
•
While performing the rescue breaths note any gag or cough response
to your action. These responses, or their absence, will form part of
your assessment of ‘signs of a circulation’, described below.
Page 5
73
Rescue breaths for a child over 1 year:
•
Ensure head tilt and chin lift.
•
Pinch the soft part of his nose closed with the index finger and thumb
of your hand on his forehead.
•
Open his mouth a little, but maintain the chin upwards.
•
Take a breath and place your lips around his mouth, making sure that
you have a good seal.
•
Blow steadily into his mouth over about 1-1.5 sec watching for chest
rise.
•
Maintaining head tilt and chin lift, take your mouth away from the
victim and watch for his chest to fall as air comes out.
•
Take another breath and repeat this sequence 5 times. Identify
effectiveness by seeing that the child’s chest has risen and fallen in a
similar fashion to the movement produced by a normal breath.
Rescue breaths for an infant:
•
Ensure a neutral position of the head and apply chin lift.
•
Take a breath and cover the mouth and nasal apertures of the infant
with your mouth, making sure you have a good seal. If the nose and
mouth cannot both be covered in the older infant, the rescuer may
attempt to seal only the infant’s nose or mouth with his mouth (if the
nose is used, close the lips to prevent air escape).
•
Blow steadily into the infant’s mouth and nose over 1-1.5 sec sufficient
to make the chest visibly rise.
•
Maintain head tilt and chin lift, take your mouth away from the victim,
and watch for his chest to fall as air comes out.
•
Take another breath and repeat this sequence 5 times.
If you have difficulty achieving an effective breath, the airway may be obstructed:
•
Open the child’s mouth and remove any visible obstruction. Do not
perform a blind finger sweep.
•
Ensure that there is adequate head tilt and chin lift but also that the
neck is not over extended.
•
If head tilt and chin lift has not opened the airway, try the jaw thrust
method.
•
Make up to 5 attempts to achieve effective breaths. If still
unsuccessful, move on to chest compression
.
6
Check for signs of a circulation (signs of life):
Take no more than 10 sec to:
•
Look for signs of a circulation. These include any movement,
coughing, or normal breathing (not agonal gasps - these are
infrequent, irregular breaths).
Page 6
•
Check the pulse (if you are trained and experienced) but ensure you
take no more than 10 sec to do this:
o In a child over 1 year — feel for the carotid pulse in the neck.
o
In an infant — feel for the brachial pulse on the inner aspect
of the upper arm.
7 A If you are confident that you can detect signs of a circulation within
10 sec:
•
Continue rescue breathing, if necessary, until the child starts
breathing effectively on his own.
•
Turn the child onto his side (into the recovery position) if he remains
unconscious.
•
Re-assess the child frequently.
7 B If there are no signs of a circulation,
or no pulse,
or a slow pulse (less than 60 min
-1
with poor perfusion),

or you are not sure:
•
Start chest compression.
•
Combine rescue breathing and chest compression.
For all children, compress the lower third of the sternum:
•
To avoid compressing the upper abdomen, locate the xiphisternum by
finding the angle where the lowest ribs join in the middle. Compress
the sternum one finger’s breadth above this.
•
Compression should be sufficient to depress the sternum by
approximately one-third of the depth of the chest.
•
Release the pressure, then repeat at a rate of about 100 min
-1
.
•
After 15 compressions, tilt the head, lift the chin, and give two
effective breaths.
•
Continue compressions and breaths in a ratio of 15:2.
Lone rescuers may use a ratio of 30:2, particularly if they are having difficulty with
the transition between compression and ventilation.
Although the rate of compressions will be 100 min
-1
, the actual number delivered
will be less than 100 because of pauses to give breaths. The best method for
compression varies slightly between infants and children.
Chest compression in infants:
•
The lone rescuer should compress the sternum with the tips of two
fingers.
•
If there are two or more rescuers, use the encircling technique:
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75
o Place both thumbs flat, side by side, on the lower third of the
sternum (as above), with the tips pointing towards the infant’s
head.
o Spread the rest of both hands, with the fingers together, to
encircle the lower part of the infant’s rib cage with the tips of
the fingers supporting the infant’s back.
o Press down on the lower sternum with your two thumbs to
depress it approximately one-third of the depth of the infant’s
chest.
Chest compression in children over 1 year:
•
Place the heel of one hand over the lower third of the sternum (as
above).
•
Lift the fingers to ensure that pressure is not applied over the child’s
ribs.
•
Position yourself vertically above the victim’s chest and, with your arm
straight, compress the sternum to depress it by approximately one-
third of the depth of the chest.
•
In larger children, or for small rescuers, this may be achieved most
easily by using both hands with the fingers interlocked.
8
Continue resuscitation until:
•
the child shows signs of life (spontaneous respiration, pulse,
movement);
•
further qualified help arrives;
•
you become exhausted.
When to call for assistance
It is vital for rescuers to get help as quickly as possible when a child
collapses:
•
When more than one rescuer is available, one starts resuscitation
while another goes for assistance.
•
If only one rescuer is present, undertake resuscitation for about 1 min
before going for assistance. To minimise interruptions in CPR, it may
be possible to carry an infant or small child whilst summoning help.
•
The only exception to performing 1 min of CPR before going for help
is in the case of a child with a witnessed, sudden collapse when the
rescuer is alone. In this case cardiac arrest is likely to be an
arrhythmia and the child may need defibrillation. Seek help
immediately if there is no one to go for you.
Page 8
Explanatory notes
Definitions
An infant is a child under 1 year.
A child is between 1 year and puberty. It is neither appropriate nor necessary to
establish onset of puberty formally. If the rescuer believes the victim to be a child
he should use the paediatric guidelines.
Compression:ventilation ratios
The publication, 2005 International Consensus on Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care Science with Treatment
Recommendations (CoSTR), recommends that the compression:ventilation ratio
should be based on whether one or more rescuers are present. CoSTR also
recommends that lay rescuers, who usually learn only single-rescuer techniques,
should be taught to use a ratio of 30 compressions to 2 ventilations. This is the
same ratio as recommended for adults and enables anyone trained in BLS
techniques to resuscitate children with minimal additional information. Two or
more rescuers with a duty to respond should learn a ratio with more rescue
breaths (15:2), as this has been validated by experimental and mathematical
studies.
2,3
This latter group, who would normally be healthcare professionals,
should receive enhanced training targeted specifically at the resuscitation of
children.
Although there are no data to support the superiority of any particular ratio in
children, ratios of between 5:1 and 15:2 have been studied and there is
increasing evidence that the 5:1 ratio delivers an inadequate number of
compressions.
4,5
There is certainly no justification for having two separate ratios
for children greater or less than 8 years, so a single ratio of 15:2 for multiple
rescuers with a duty to respond is a logical simplification.
Although the CoSTR recommendation is based on the number of rescuers
present, it would certainly negate the main benefit of simplicity if lay rescuers
were taught a different ratio for use if there were two of them. Similarly, those
with a duty to respond, who would normally be taught to use a ratio of 15:2,
should not be compelled to use the 30:2 ratio if they are alone, unless they are
not achieving an adequate number of compressions because of difficulty in the
transition between ventilation and compression.
Age definitions
The adoption of a single compression:ventilation ratio for children of all ages,
together with the change in advice on the lower age limit for the use of automated
external defibrillators (AEDs), renders the Guidelines 2000 division between
children above and below 8 years unnecessary. The differences between adult
and paediatric resuscitation are largely based on differing aetiology, with primary
cardiac arrest being more common in adults whereas children usually suffer from
secondary cardiac arrest. The onset of puberty, which is the physiological end of
childhood, is the most logical landmark for the upper age limit for use of
Page 9
77
paediatric guidelines. This has the advantage of being simple to determine in
contrast to an age limit, as age may be unknown at the start of resuscitation.
Clearly, it is inappropriate and unnecessary to establish the onset of puberty
formally; if the rescuer believes the victim to be a child then he should use the
paediatric guidelines. If a misjudgment is made, and the victim turns out to be a
young adult, little harm will accrue as studies of aetiology have shown that the
paediatric pattern of arrest continues into early adulthood.
It is necessary to differentiate between infants and older children, as there are
some important differences between these two groups.
Chest compression technique
The modification of age definitions enables a simplification of the advice on chest
compression. The method for determining the landmarks for infant compression
is now the same as that for older children, as there is evidence that the previous
recommendation could result in compression over the upper abdomen.
6
Infant
compression techniques remain the same: two-finger compression for single
rescuers and two-thumb encircling technique for two or more rescuers. For older
children there is no division between the one- or two-hand techniques;
7
the
emphasis is on achieving an adequate depth of compression with minimal
interruptions, using one or two hands according to rescuer preference.
Automated external defibrillators
Since Guidelines 2000 there have been case reports of safe and successful use
of AEDs in children less than 8 years. Furthermore, recent studies have shown
that AEDs are capable of identifying arrhythmias accurately in children and are
extremely unlikely to advise a shock inappropriately. Consequently, advice on
the use of AEDs has been revised to include all children greater than 1 year.
8
Nevertheless, if there is any possibility that an AED may need to be used in
children, the purchaser should check that the performance of the particular model
has been tested against paediatric arrhythmias.
Many manufacturers now supply purpose-made paediatric pads or programs
which typically attenuate the output of the machine to 50-75 J.
9
These devices
are recommended for children between 1 and 8 years. If no such system or
manually adjustable machine is available, an unmodified adult AED may be used
in children older than 1 year. There is currently insufficient evidence to support a
recommendation for or against the use of AEDs in children less than 1 year.
Recovery position
An unconscious child whose airway is clear and who is breathing spontaneously
should be turned onto his side into the recovery position. There are several
recovery positions; each has its advocates. The important principles to be
followed are:
Page 10
•
The child should be placed in as near a true lateral position as
possible with his mouth dependant to enable free drainage of fluid.
•
The position should be stable. In an infant, this may require the
support of a small pillow or a rolled-up blanket placed behind his back
to maintain the position.
•
There should be no pressure on the chest that impairs breathing.
•
It should be possible to turn the child onto his side and to return him
back easily and safely, taking into consideration the possibility of
cervical spine injury.
•
The airway should be accessible and easily observed.
•
The adult recovery position is suitable for use in children.
Foreign body airway obstruction (FBAO)
Recognition of FBAO
When a foreign body enters the airway the child reacts immediately by coughing
in an attempt to expel it. A spontaneous cough is likely to be more effective and
safer than any manoeuvre a rescuer might perform. However, if coughing is
absent or ineffective, and the object completely obstructs the airway, the child will
rapidly become asphyxiated. Active interventions to relieve FBAO are therefore
required only when coughing becomes ineffective, but they then need to be
commenced rapidly and confidently.
The majority of choking events in children occur during play or whilst eating,
when a carer is usually present. Events are therefore frequently witnessed, and
interventions are usually initiated when the child is conscious.
FBAO is characterised by the sudden onset of respiratory distress associated
with coughing, gagging, or stridor. Similar signs and symptoms may also be
associated with other causes of airway obstruction, such as laryngitis or
epiglottitis, which require different management. Suspect FBAO if:
•
the onset was very sudden;
•
there are no other signs of illness;
•
there are clues to alert the rescuer, for example a history of eating or
playing with small items immediately prior to the onset of symptoms.
Page 11
79
General signs of FBAO
•
Witnessed episode
•
Coughing or choking
•
Sudden onset
•
Recent history of playing with or eating small objects
Ineffective coughing
Effective cough
•
Unable to vocalise
•
Quiet or silent cough
•
Unable to breathe
•
Cyanosis
•
Decreasing level of
consciousness
•
Crying or verbal response to
questions
•
Loud cough
•
Able to take a breath before
coughing
•
Fully responsive
Relief of FBAO
Safety and summoning assistance
Safety is paramount. Rescuers should avoid placing themselves in danger and
consider the safest action to manage the choking child:
•
If the child is coughing effectively, then no external manoeuvre is
necessary. Encourage the child to cough, and monitor continuously.
•
If the child’s coughing is, or is becoming, ineffective, shout for help
immediately and determine the child’s conscious level.
Conscious child with FBAO
•
If the child is still conscious but has absent or ineffective coughing,
give back blows.
•
If back blows do not relieve the FBAO, give chest thrusts to infants or
abdominal thrusts to children. These manoeuvres create an ‘artificial
cough’ to increase intrathoracic pressure and dislodge the foreign
body.
Back blows
In an infant:
•
Support the infant in a head-downwards, prone position, to enable
gravity to assist removal of the foreign body.
•
A seated or kneeling rescuer should be able to support the infant
safely across his lap.
Page 12
Paediatric FBAO Treatment
Unconscious
Open airway
5 breaths
Start CPR
Conscious
5 back blows
5 thrusts
(chest for infant)
(abdominal
for child > 1)
Encourage cough
Continue to check
for deterioration
to ineffective
cough
or relief of
obstruction
Assess severity
Ineffective cough
Effective cough
Page 13
81
•
Support the infant’s head by placing the thumb of one hand at the
angle of the lower jaw, and one or two fingers from the same hand at
the same point on the other side of the jaw.
•
Do not compress the soft tissues under the infant’s jaw, as this will
exacerbate the airway obstruction.
•
Deliver up to 5 sharp back blows with the heel of one hand in the
middle of the back between the shoulder blades.
•
The aim is to relieve the obstruction with each blow rather than to give
all 5.
In a child over 1 year:
•
Back blows are more effective if the child is positioned head down.
•
A small child may be placed across the rescuer’s lap as with an infant.
•
If this is not possible, support the child in a forward-leaning position
and deliver the back blows from behind.
If back blows fail to dislodge the object, and the child is still conscious, use chest
thrusts for infants or abdominal thrusts for children. Do not use abdominal
thrusts (Heimlich manoeuvre) for infants.
Chest thrusts for infants:
•
Turn the infant into a head-downwards supine position. This is
achieved safely by placing your free arm along the infant’s back and
encircling the occiput with your hand.
•
Support the infant down your arm, which is placed down (or across)
your thigh.
•
Identify the landmark for chest compression (lower sternum
approximately a finger’s breadth above the xiphisternum).
•
Deliver 5 chest thrusts. These are similar to chest compressions,
but sharper in nature and delivered at a slower rate.
Abdominal thrusts for children over 1 year:
•
Stand or kneel behind the child. Place your arms under the child’s
arms and encircle his torso.
•
Clench your fist and place it between the umbilicus and xiphisternum.
•
Grasp this hand with your other hand and pull sharply inwards and
upwards.
•
Repeat up to 5 times.
•
Ensure that pressure is not applied to the xiphoid process or the lower
rib cage as this may cause abdominal trauma.
Page 14
Following chest or abdominal thrusts, reassess the child:
•
If the object has not been expelled and the victim is still conscious,
continue the sequence of back blows and chest (for infant) or
abdominal (for children) thrusts.
•
Call out, or send, for help if it is still not available.
•
Do not leave the child at this stage.
If the object is expelled successfully, assess the child’s clinical condition. It is
possible that part of the object may remain in the respiratory tract and cause
complications. If there is any doubt, seek medical assistance. Abdominal thrusts
may cause internal injuries and all victims so treated should be examined by a
medical practitioner.
Unconscious child with FBAO
•
If the child with FBAO is, or becomes, unconscious place him on a
firm, flat surface.
•
Call out, or send, for help if it is still not available.
•
Do not leave the child at this stage.
Airway opening:
•
Open the mouth and look for any obvious object.
•
If one is seen, make an attempt to remove it with a single finger
sweep.
Do not attempt blind or repeated finger sweeps - these can impact the object
more deeply into the pharynx and cause injury.
Rescue breaths:
•
Open the airway and attempt 5 rescue breaths.
•
Assess the effectiveness of each breath: if a breath does not make
the chest rise, reposition the head before making the next attempt.
Chest compression and CPR:
•
Attempt 5 rescue breaths and if there is no response, proceed
immediately to chest compression regardless of whether the breaths
are successful.
•
Follow the sequence for single rescuer CPR (step 7B above) for
approximately 1 min before summoning EMS (if this has not already
been done by someone else).
•
When the airway is opened for attempted delivery of rescue breaths,
look to see if the foreign body can be seen in the mouth.
•
If an object is seen, attempt to remove it with a single finger sweep.
Page 15
83
•
If it appears that the obstruction has been relieved, open and check
the airway as above. Deliver rescue breaths if the child is not
breathing.
•
If the child regains consciousness and is breathing effectively, place
him in a safe side-lying (recovery) position and monitor breathing and
conscious level whilst awaiting the arrival of EMS.
References
1.
Berg RA, Hilwig RW, Kern KB, Babar I, Ewy GA. “Bystander” chest
compressions and assisted ventilation independently improve outcome
from piglet ashpyxial pulseless “cardiac arrest”. Circulation 2000;
101:1743 – 1748.
2.
Babbs CF, Nadkarni, V. Optimizing Chest Compression to Rescue
Ventilation Ratios during One-rescuer CPR by Professionals and Lay
Persons: Children are not just little adults. Resuscitation 2004; 61:173-81
.
3.
Berg RA, Hilwig RW, Kern KB, Babar I, Ewy GA. Simulated mouth-to-
mouth ventilation and chest compressions (bystander cardiopulmonary
resuscitation) improves outcome in a swine model of pre-hospital
paedicatric asphyxial cardiac arrest. Crit Care Med 1999; 27:1893 –1899.
4.
Dorph E, Wik L, Steen PA. Effectiveness of ventilation-compression
ratios 1:5 and 2:15 in simulated single rescuer paediatric resuscitation.
Resuscitation 2002; 54:259-64.
5.
Whyte S, Wyllie JP. Paediatric basic life support a practical assessment.
Resuscitation 1999; 41:153-157.
6.
Clements F, McGowan J. Finger position for chest compressions in
cardiac arrest in infants. Resuscitation 2000; 44:43-46.
7.
Stevenson AG, McGowan J, Evans AL, Graham CA. CPR for children:
one hand or two? Resuscitation 2005; 64: 205-8.
8.
Samson R, Berg R, Bingham R and Pediatric Advanced Life Support Task
Force, ILCOR. Use of automated external defibrillators for children: an
update. An advisory statement from the Pediatric Advanced Life Support
Task Force, International Liaison Committee on Resuscitation.
Resuscitation 2003; 57: 237- 43.
9.
Tang W, Weil MH, Jorgenson D, Klouche K, Morgan C, Yu T, Sun S,
Snyder D. Fixed-energy biphasic waveform defibrillation in a pediatric
model of cardiac arrest and resuscitation. Crit Care Med 2002; 30:2736-
41.
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New Guidelines Simplify Pediatric Resuscitation - Brief Article
Family Pratice News, Dec 1, 2000 by Miriam E. Tucker
E-mail
Print
Link
CHIGAGO -- New international guidelines on resuscitation will simplify pediatric

lifesaving strategies for health care professionals and lay people, Dr. Vinay Nadkarni
said at the annual meeting of the American Academy of Pediatrics.
The American Heart Association guidelines contain sections on pediatric advanced

life support (PALS) and neonatal resuscitation. The expert committee that prepared
the guidelines reviewed studies published from 1994 to 2000, focusing on new data
pertaining to controversial issues. Input was sought from more than 500
international experts, and more than 25,000 manuscripts were reviewed.
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Two principles were factored in: "Do no harm" and the "KISS [Keep it simple, stupid]
principle," said Dr. Nadkarni, a member of the committee who was a science editor
of the pediatric resuscitation guidelines and medical director of the pediatric ICU at
the Alfred I. duPont Hospital for Children, in Wilmington, Del.
Some of the recommendations from the previous 1992 guidelines did not change.
For example, a lone lay rescuer should give 1 minute of cardiopulmonary
resuscitation (if needed) to an unresponsive patient under the age of 8 prior to
calling 911. For an unresponsive child older than 8, the rescuer should call 911
before administering CPR.
The committee also kept the 1992 age-specific compression/ventilation ratios: 3:1
for newborns, 5:1 for children less than 8 years of age, and 15:2 after age 8.
The new pediatric resuscitation guidelines include these recommendations:
* Bag-mask ventilation. All health care providers who provide prehospital care for
infants and children must be trained to provide effective oxygenation and
ventilation using the bag-mask technique.
Recent studies have suggested that tracheal intubation is more difficult to master
and more dangerous than previously realized. Tracheal intubation should always be
confirmed by a primary (auscultation) and secondary (exhaled [CO.sub.2]) method.
* Laryngeal mask airway. This device can be used to secure an airway in an

unconscious patient. Ventilation via a laryngeal mask airway, which was not
available when the 1992 guidelines were published, appears to be clinically
equivalent to ventilation with a tracheal tube in some circumstances. With proper
training and supervision, this airway can be secured safely and reliably in infants
and children, but its value in cardiac arrest has not been determined.
* Vagal maneuvers. These are recommended for treating supraventricular

tachycardia, provided they don't delay cardioversion or the use of adenosine for the
child with poor systemic perfusion. Ice water to the face is effective in infants and
children. Vagal maneuvers, which were not in the old guidelines, have been shown
to stop supraventricular tachycardia in children. Success depends on the patient's
age, level of cooperation, and underlying condition.
* Epinephrine. The use of high-dose epinephrine for pulseless arrests is de-

emphasized in children. The recommended initial resuscitation dose of epinephrine
remains 0.01 mg/kg, given intravenously or intraosseously, or 0.1 mg/kg given by
the tracheal route. Repeated doses are advised every 3-5 minutes for ongoing
arrest.
New data called into question the benefit of the higher doses of epinephrine advised
in the old guidelines. High-dose epinephrine can have adverse effects, including
increased myocardial oxygen demand, hyperadrenergic state, tachycardia, and
myocardial necrosis. Also, patients vary greatly in dose response.
* Automated external defibrillators. These devices may be used in children over 8

years of age with out-of-hospital arrests. The old guidelines didn't mention use of
automated external defibrillators in children, although two subsequent textbooks
did recommend their use in children aged 8 and over. Mounting evidence suggests
that pediatric ventricular fibrillation is more common than previously suspected.
Limited data suggest that automated external defibrillators are sensitive and
specific in interpreting rhythms in older children and adolescents.
The new neonatal resuscitation guidelines include these recommendations:
* Meconium-stained fluid. When meconium is seen in the amniotic fluid, deliver the
head and suction meconium from the nasopharynx. Direct tracheal suction is
advised when meconium is observed and the infant is not vigorous, with absent or
depressed respirations, heart rate less than 100 beats per minute, or poor muscle
tone. The old guidelines advised direct tracheal suctioning if "the neonate is
depressed or the meconium is thick or particulate."
A recent randomized clinical trial suggested that when an infant has meconium-
stained amniotic fluid and spontaneous respirations, tracheal suctioning does not
improve outcome and could cause complications if the infant is active and vigorous.
* Chest compressions. Indications for chest compressions have been simplified to

when heart rate is absent or if heart rate remains less than 60 beats per minute
after 30 seconds of adequate ventilation. The "two thumbs and encircling fingers"
technique is now preferred over the two-finger compression technique when there
are two trained rescuers. New data suggest that the two-thumb technique
generates higher peak systolic and coronary perfusion pressures and that providers
prefer it.
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http://www.templejc.edu/dept/ems/documents/Presentations/3rdSemesterParamedic/Special
%20Populations/Pediatrics/Pediatric%20Resuscitation.ppt.
Google automatically generates html versions of documents as we crawl the web.
Pediatric Resuscitation
Pediatric Cardiac Arrest
Usually secondary to
respiratory failure or arrest
Most Important Intervention
Adequate
oxygenation, ventilation
Basic Life Support
• Airway
○ Head-tilt/chin-lift method
○ Big tongue; Forward jaw
displacement critical
○ Avoid extreme hyperextension
○ With possible neck injury, jaw
thrust
Basic Life Support

• Breathing
○ Look-Listen-Feel
○ Limit to volume causing chest rise
○ Children usually underventilated!
○ Use BVM only if proficient
○ Pedi BVM’s should not have pop-
off valves
Basic Life Support
• Breathing
○ Do NOT use demand valve on
children
○ Ventilate infants, children every 3
seconds
Basic Life Support

• Circulation
○ Infants: brachial
○ Children: carotid
Basic Life Support

• Circulation
○ Infant chest compressions
 2 fingers
 1 finger width below nipple line
 1/2 - 1 inches
 At least 100/minute
Basic Life Support
• Circulation
○ Child chest compressions
 One hand
 Lower half of sternum

 1 - 1.5 inches
 100/minute
Basic Life Support

• Circulation
○ Child CPR
 Maintain continuous head tilt
with hand on forehead

 Perform chin lift with other
hand while ventilating
Best Sign of Effective

Ventilation
Chest Rise
Best Sign of Effective
Circulation
Pulse with Each
Compression
Oxygen Therapy
• Initiate ASAP
• Do not delay BLS to obtain oxygen
Oxygen Therapy
• Use highest possible FiO2
○ No risk in short term100% O2
• Humidify if possible
○ Avoids plugging airways, adjuncts
Endotracheal Intubation
Need to intubate is not same as need to
ventilate!
• Proper tube size
○ Same size as child’s little finger
○ Child > 1 year: [(Age + 16 ) / 4]
• Children < 8 years old
○ Small tracheal diameter
○ Narrow cricoid ring
○ Uncuffed tubes
• Infants, small children

○ Narrow, soft epiglottis
○ Straight blade
• Attempts not >30 seconds
• Bradycardia: oxygenate, ventilate
• Avoid hyperextension
• Use “sniffing position”
• Lift up; do not pry back
•Confirm placement by:
○ Seeing tube go through cords
○ Chest rise
○ Equal breath sounds
○ No sounds over epigastrium
○ CO2 in exhaled air
• Mark tube at corner of mouth
• Avoid excessive head movement
• Frequently reassess breath sounds
• Ventilate to cause gentle chest rise
Endotracheal Drugs
Epinephrine, atropine,
lidocaine
• Drug administration
○ Do not delay while attempting IV
access
○ Dilute with normal saline
○ Stop compressions
○ Inject through catheter passed
beyond ETT
○ Follow 10 rapid ventilations
Cricothyrotomy
• Surgical contraindicated in children
<12
• Narrowing of trachea at cricoid ring
makes procedure hazardous
• Use needle technique only
Vascular Access
•Same reasons as adults
○ Drugs
○ Fluids
Scalp Veins
• No value in cardiac arrest
• Useful in infants < 1 year old for
maintenance fluids, drug route
Scalp Veins
• Rubber band for tourniquet
• 21, 23 gauge butterfly
• Attach syringe, flush needle before
inserting
Scalp Veins
• Point needle in direction of blood
flow
• Leave syringe attached, inject 1cc
saline after entering vein to check
infiltration
Hand, Arm, Foot Veins

• 22 gauge catheter for smaller
children
• Restrain extremity before attempting
• Incise overlying skin with 19 gauge
needle
• Flush needle as with scalp vein
technique
External Jugular
• Life-threatening situations only
• 22 gauge catheter
• Restrain by wrapping in sheet
• Extend head over end of table, rotate
900
• If vein perforates, do not go to other
side
○ Risk of paratracheal hematoma,
airway obstruction
Prevention of Fluid Overload

• Avoid using bags over 250cc
• Use mini-drip sets, Volutrols
• Fluid resuscitation: 20cc/kg boluses
Intraosseous Cannulation
•Placement of cannula
into long bone
intramedullary canal
(marrow space)
•Indication
○ Vascular access required
○ Peripheral site cannot be obtained
 In two attempts, or
 After 90 seconds
•Devices
○ 16 gauge hypodermic needle
○ Spinal needle with stylet
○ Bone marrow needle (preferred)
•Site
○ Anterior tibia
○ 1 - 3 cm below knee
○ Medial to tibial tuberosity
•Contraindications
○ Fractures
○ Osteogenesis imperfecta
○ Osteoporosis
○ Failed attempt on same bone
•Needle in place if:
○ Lack of resistance felt
○ Needle stands without support
○ Bone marrow aspirated
○ Infusion flows freely
What can be put thru an IO?

Anything that can be put through an IV!
Remember…….
• You don’t need a line to give drugs
during a code.
• Epinephrine, atropine, lidocaine can
go down tube
Defibrillation
• 90% of pediatric cardiac arrest is
○ Asystole, or
○ Bradycardic PEA
• Defibrillation seldom needed
Defibrillation
•Pediatric VF suggests
○ Electrolyte imbalances
○ Drug toxicity
○ Electrical injury
Defibrillation
• Paddle diameter:
○ Infants: 4.5 cm
○ Children: 8.0 cm
• Largest paddles that contact entire

chest wall without touching
• If pediatric paddles unavailable, use
adult paddles with A-P placement
Defibrillation
• Energy Settings
○ Initial: 2 J/kg
○ Repeat: 4 J/kg
Cardioversion
• Cardiovert only if signs of decreased
perfusion
• Energy settings:
○ Initial: 0.5 - 1.0 J/kg
○ Repeat: 2.0 J/kg
Cardioversion
• Narrow-complex tachycardia, rate <
200
○ Usually sinus tachycardia
○ Look for treatable underlying
cause
○ Do not cardiovert
Cardioversion
• Narrow-complex tachycardia, rate >
230
○ Usually supraventricular
tachycardia
○ Frequently associated with
congenital conduction
abnormalities
Cardioversion
230
○ If hemodynamically stable,
transport
○ Adenosine may be considered
Cardioversion
230
○ If hemodynamically unstable,
cardiovert
○ If no conversion after two shocks,
consider possibility rhythm is
sinus tachycardia
Drug Therapy
• Epinephrine
○ Asystole, bradycardia PEA
○ Stimulates electrical/mechanical
activity
Drug Therapy
• Epinephrine Dosage
○ IV or IO: 0.01 mg/kg 1:10,000
○ ET: 0.1 mg/kg 1:1000
Drug Therapy
• Atropine
○ 0.02 mg/kg IV or IO
 Double ET dose
○ Minimum dose: 0.1 mg to avoid
paradoxical bradycardia
○ Maximum single dose:
 Child: 0.5 mg
 Adolescent: 1mg
Drug Therapy
• Most bradycardias respond to
○ Oxygen
○ Ventilation
• For bradycardia 2o to
hypoxia/ischemia, preferred first drug
is epinephrine
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on
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Circulation. 1997;95:2185-2195 Ext
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(Circulation. 1997;95:2185-2195.) n is
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© 1997 American Heart Association, Inc. pos
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Pediatric Resuscitation ar
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An Advisory Statement From the Pediatric s
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Vinay Nadkarni, MD, Chair1; Mary Fran Hazinski, l
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MSN, RN1; David Zideman, MD2; John Kattwinkel, icl
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MD3; Linda Quan, MD1; Robert Bingham, MD2; es
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Arno Zaritsky, MD1; Jon Bland, MD2; Efraim via
Kramer, MD4; James Tiballs, MD5 Hig
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Key Words: pediatrics • AHA Medical/Scientific Sc
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Top
This summary document reflects the deliberation of the Purpose
Pediatric Working Group of the International Liaison
Committee on Resuscitation (ILCOR). The ILCOR goal is Background
to improve consistency of guidelines issued by Age Definitions: What Defines...
international resuscitation councils and associations. The
Pediatric BLS
purpose of this summary is to highlight areas of conflict or
controversy in current pediatric basic and advanced life Pediatric ALS
1 2 3 4 5
support guidelines, outline solutions considered, and Guidelines for the Newly...
provide recommendations reached by consensus of the
working group. Unresolved issues are listed and a few Research
areas of active guideline research interest and Areas of Controversy, Unresolved...
investigation are highlighted. This document does not
include a complete list of guidelines for which there is no Appendix 1
perceived controversy. The algorithm/decision tree figures References
presented attempt to illustrate a common flow of
assessments and interventions. Whenever possible, this
was coordinated to complement the basic life support (BLS) and advanced life support (ALS)
algorithms used for adult victims. Since arrest of the newly born infant presents unique
resuscitation challenges in terms of etiology, physiology, and required resources, the working
group developed a separate section addressing initial resuscitation of the newly born. Other areas
of departure from the adult algorithms are noted and the rationale explained in text.
In the absence of specific pediatric data (outcome validity), recommendations may be made or
supported on the basis of common sense (face validity) or ease of teaching or skill retention
(construct validity). Practicality of recommendations in the context of local resources (technology
and personnel) and customs must always be considered. In
compiling this document, it was surprising to the working
group participants how few differences exist among Top
current pediatric guidelines advocated by the American Purpose
Heart Association, the Heart and Stroke Foundation of
Canada, the European Resuscitation Council, the Background
Australian Resuscitation Council, and the Resuscitation Age Definitions: What Defines...
Councils of Southern Africa.
Pediatric BLS
Pediatric ALS
Guidelines for the Newly...
Background
Research
Areas of Controversy, Unresolved...
The epidemiology and outcome of pediatric Appendix 1
cardiopulmonary arrest and the priorities, techniques, and
References
sequence of pediatric resuscitation assessments and
interventions differ from those of adults. As a result, it is
imperative that any guidelines developed for pediatric
resuscitation address the unique needs of the newly born, infant, child, and young adult.
Unfortunately, specific data supporting these differences have been deficient in both quantity and
quality for several reasons: (1) pediatric cardiac arrest is uncommon, (2) in most circumstances
survival from documented asystolic pediatric cardiac arrest is dismal, and (3) most pediatric
studies have failed to utilize consistent patient inclusion criteria and resuscitation outcome
definitions and measures. Additional specific pediatric data including data for the newly born are
required to confirm or further refine pediatric resuscitation techniques.
In general, prehospital primary cardiac arrest is a less common etiology of arrest in children and
young adults than in older adults,6 7 8 and primary respiratory arrest appears to be a more
common etiology than primary cardiac arrest in children.9 10 11 12 13 However, most reports of
pediatric arrest contain insufficient patient numbers or utilize exclusion criteria that prohibit
broad generalization of study results to general or international pediatric populations. In a 15-
year retrospective study of prehospital cardiac arrest from the United States, only 7% of 10 992
victims of prehospital cardiac arrest were younger than 30 years, and only 3.7% were younger
than 8 years.6 Only 2% of victims of in-hospital cardiopulmonary resuscitation (CPR) in Great
Britain were 0 to 14 years of age.14
Cardiac arrest in children is rarely sudden; it is typically the end result of deterioration in
respiratory function or shock, and the terminal rhythm is typically bradycardia with progression
to pulseless electrical activity or asystole.15 16 Ventricular tachycardia and fibrillation have been
reported in 15% or less of a subset of pediatric and adolescent victims of prehospital cardiac
arrest,6 7 even when rhythm is assessed by first responders.17 18
Survival following prehospital cardiopulmonary arrest averages only approximately 3% to 17%
in most studies, and survivors are often neurologically devastated.7 9 10 11 15 17 18 19 20 21 22 23 In
addition, most pediatric resuscitation reports are retrospective in design and plagued with
inconsistent resuscitation definitions and patient inclusion criteria. As a result, conclusions based
upon statistical analysis of the efficacy of specific
resuscitative efforts are unreliable. Some of these
problems should be improved by application of uniform Top
guidelines for reporting outcomes of ALS interventions Purpose
outlined in the pediatric Utstein-style guidelines.24 Large,
randomized multicenter and multinational clinical trials Background
are clearly needed. Age Definitions: What Defines...
Pediatric BLS
Pediatric ALS
Age Definitions: What Defines an Infant,
Guidelines forChild, and
the Newly...
Adult? Research
The age of the victim is currently the primary Appendix 1
characteristic that guides decisions for application of
References
resuscitation sequences and techniques. Discrimination on
the basis of age alone is inadequate. Further, any single
age delineation of the "child" versus the "adult" is
arbitrary because there is no single parameter that separates the infant from the child from the
adult. The following factors should be considered.
Anatomy
There is consensus that the age cut-off for infants should be at approximately 1 year. In general,
cardiac compression can be accomplished using one hand for victims up to the age of
approximately 8 years. However, variability in the size of the victim or the size and strength of
the rescuer can require use of the two-handed "adult" compression technique for cardiac
compression. For instance, the chronically ill infant may be sufficiently small to enable
compression using circular hand technique, and a 6- or 7-year-old may be too large for the one-
hand compression technique. A small rescuer may need to use two hands to effectively compress
the chest of a child victim.
Physiology
The newly born provide an example of how physiological considerations may affect resuscitative
interventions. Perinatal circulatory changes during transition from fetus to newborn may result in
profound extrapulmonary shunting of blood. Fluid-filled alveoli may require higher initial
ventilation pressures than subsequent rescue breathing. Lung inspiratory and expiratory time
constants for filling and emptying and inflation volumes may need to be adjusted according to
both anatomic and physiological development.
Epidemiology
Ideally the sequence of resuscitation should be determined by the most likely cause of the arrest.
In the newly born infant this will be most likely related to respiratory failure. In the older infant
and child it may be related to progression of respiratory failure, shock, or neurological
dysfunction. In general, pediatric prehospital arrest has been characterized as hypoxic,
hypercarbic arrest with respiratory arrest preceding asystolic cardiac arrest.10 25 26 Therefore, a
focus on early ventilation and early CPR (rather than early emergency medical services [EMS]
activation and/or defibrillation) appears to be warranted. Early effective oxygenation and
ventilation must be established as quickly as possible. Primary dysrhythmic cardiac arrest may
occur and should particularly be considered in patients with underlying cardiac disease or history
consistent with myocarditis.
Resuscitation Sequence/EMS Activation
Local response intervals, dispatcher training, and EMS protocols may dictate the sequence of
early life support interventions. In addition, the sequence of resuscitation actions must consider
the most likely causes of arrest in the victim. Respiratory failure and/or trauma may be the
primary etiologies of cardiopulmonary arrest in victims
aged 40 years or younger,6 8 with a relatively low
incidence of primary ventricular fibrillation (VF). One Top
critical issue in determining the sequence of interventions Purpose
is whether the primary cause of arrest is due to a cardiac
or respiratory etiology. The probability of successful Background
resuscitation based on that etiology is another important Age Definitions: What Defines...
unresolved resuscitation question.
Pediatric BLS
Pediatric ALS
Pediatric BLS
Research
Determination of Responsiveness Appendix 1
Unresponsiveness mandates assessment and support of
References
airway and breathing. Infants and patients with suspected cervical spinal injury should not be
shaken to assess responsiveness.
Airway
Consensus continues to support use of the head tilt–chin lift or the jaw thrust (the jaw thrust
especially when cervical spine instability or neck trauma is suspected) to open the airway. Other
maneuvers, such as the tongue–jaw lift, may be considered if initial ventilation is unsuccessful
despite repositioning of the head. The most common cause of airway obstruction in the
unconscious pediatric victim is the tongue.27 Although the use of a tongue–jaw lift and visual
mouth inspection prior to ventilation of any unconscious infant may be considered if foreign
body airway obstruction is strongly suspected, there are no data to support the delay of attempted
ventilation in all victims. Blind removal or attempted visualization of unsuspected foreign bodies
is not likely to be effective for the following reasons: foreign bodies causing complete airway
obstruction are unlikely to be visible with cursory inspection, the object may not be retrievable,
and attempted intervention may result in displacement of the object further into the trachea. More
data are needed regarding the optimal method of keeping the airway open to ensure effective
ventilation during CPR.
Breathing
There is general consensus regarding the technique for rescue breathing for infants and children.
The current recommendations for initial number of attempted breaths, however, vary from 2 to
5.1 2 3 4 5 There are no data to support any specific number of initial breaths. There was agreement
that a minimum of 2 breaths be attempted. The rationale for attempting to deliver more than 2
initial ventilations includes the need to provide effective ventilation for pediatric victims based
upon the likely hypoxic and hypercarbic etiology of arrest, suspected inability of the lay rescuer
to establish effective ventilation with only 2 attempts, and clinical impressions that more than 2
breaths may be required to improve oxygenation and restore effective heart rate in the apneic,
bradycardic infant.
Initial breaths should be delivered slowly, over 1.0 to 1.5 seconds, with a force sufficient to make
the chest clearly rise. Care and attention to abdominal distention caused by insufflation of gas
into the stomach should be recognized and avoided.28 29 30
Consideration of the optimal method for delivering breaths to infants supports the current
recommendation of mouth to mouth-and-nose ventilation for infants up to 1 year old. However,
mouth-to-nose ventilation may be adequate in this population.31 32
Consensus continues to support the emphasis on the provision of more ventilation (breaths per
minute) for infants and children and more compressions per minute for adult victims. Current
recommended ventilation rates are based on normal ventilatory rates for age, the need for
coordination with chest compression, and the perceived practical ability of the rescuer to provide
them (See Fig 1 ). Ideal ventilation frequency during CPR is unknown.
Figure 1. Comparison of resuscitative interventions for newborns, infants,

View larger children, and adults. CPR indicates cardiopulmonary resuscitation; EMS,
version emergency medical services; BLS, basic life support; and ALS, advanced life
(0K): support. *Interventions recommended for suitably trained healthcare
[in this providers only.
window]
[in a new
window]
Circulation
There is a lack of specific pediatric data on the accuracy and time course for determining
pulselessness of victims who are apneic and unresponsive. Several reports have documented the
inability of lay rescuers and healthcare providers to reliably locate or count the pulse of the
victim.33 34 The utility of the pulse check during pediatric CPR has been questioned.35
Furthermore, the pulse check is difficult to teach to laypersons. It seems reasonable for healthcare
providers to search for a pulse because it may be palpated by trained personnel, does not require
sophisticated equipment, and there is no better alternative. However, resuscitative interventions
should not be delayed beyond 10 seconds if a pulse is not confidently detected.
Chest Compression
When to Start
There is consensus that all pulseless patients and patients with heart rates too low to adequately
perfuse vital organs warrant chest compressions. Because cardiac output in infancy and childhood
is largely heart-rate dependent, profound bradycardia is usually considered an indication for
cardiac compressions.
Location of Compression
There is consensus for compression over the lower half of the sternum, taking care to avoid
compression of the xiphoid.
Depth
Consensus supports recommendation of relative rather than absolute depth of compression (eg,
compress approximately one third of the depth of the chest rather than compress 4 to 5 cm).
Effectiveness of compression should be assessed by the healthcare provider. Methods of
assessment include palpation of pulses, evaluation of end-tidal carbon dioxide, and analysis of
arterial pressure waveform (if intra-arterial monitoring is in place). Although it is recognized that
pulses palpated during chest compression may reflect venous rather than arterial blood flow
during CPR,36 pulse detection during CPR for healthcare providers remains the most universally
practical "quick assessment" of chest compression efficacy.
Rate
Consensus supports a rate of approximately 100 compressions per minute. With interposed
ventilations, this will result in the actual delivery of <100 compressions to the patient in a 1-
minute period.
Compression-to-Ventilation Ratio
Ideal compression-ventilation ratios for infants and children are unknown. A single, universal
compression-ventilation ratio for all ages and both BLS and ALS interventions would be
desirable from an educational standpoint. There currently is consensus among resuscitation
councils for a compression-ventilation ratio of 3:1 for newborns and 5:1 for infants and children.
The justification for this difference from adult guidelines includes (1) the fact that respiratory
problems are the most common etiology of pediatric arrest and therefore ventilation should be
emphasized, and (2) physiological respiratory rates of infants and children are faster than those of
adults. Although the actual number of delivered interventions is dependent on the amount of time
the rescuer spends opening the airway and the effect of frequent airway repositioning on rescuer
fatigue, there is insufficient evidence to justify changing the current recommendations for
educational convenience at this time.
External chest compression must always be accompanied by rescue breathing in children. At the
end of every compression cycle a rescue breath should be given. Interposition of compressions
and ventilations is recommended to avoid simultaneous compression/ventilation.
Activation of the EMS System
Ideally the sequence of resuscitation is determined by the etiology of the arrest. In pediatric
arrest, dysrhythmias requiring defibrillation are relatively uncommon, and some data suggest that
early bystander CPR is associated with improved survival.9 36 37 However, it is impractical to
teach the lay public different resuscitation sequences based on arrest etiology. The consensus
recommendation is "phone fast" rather than "phone first" for young victims of cardiac arrest, but
the appropriate age cut-off for this recommendation remains to be determined. Local EMS
response intervals and the availability of dispatcher-guided CPR may override these
considerations.
Recovery Position
Although many recovery positions are used in the management of pediatric patients, particularly
in those emerging from anesthesia, no specific optimal recovery position can be universally
endorsed on the basis of scientific study in children. There is consensus that an ideal recovery
position considers the following: etiology of the arrest and stability of the C-spine, risk for
aspiration, attention to pressure points, ability to monitor adequacy of ventilation and perfusion,
maintenance of a patent airway, and access to the patient for interventions.
Relief of Foreign-Body Airway Obstruction
Consensus supports prompt recognition and treatment of complete airway obstruction. There are
three suggested maneuvers to remove impacted foreign bodies: back blows, chest thrusts, and
abdominal thrusts. The sequences differ slightly among resuscitation councils, but published data
do not convincingly support one technique sequence over another. There is consensus that the
lack of protection of the upper abdominal organs by the rib cage renders infants and newborns at
risk for iatrogenic trauma from abdominal thrusts; therefore, abdominal thrusts are not
recommended in infants and newborns. An additional practical consideration is that back blows
should be delivered with the victim positioned head down, which may be physically difficult in
older children. Suctioning is recommended for newborns rather than back blows or abdominal
thrusts, which are potentially harmful to this age group.
Barrier Equipment
Healthcare professionals should utilize appropriate barrier devices and universal precautions
whenever possible. However, issues related to efficacy of the devices in preventing bacterial or
viral transmission, anatomical fit of masks, use of devices in pediatric patients with increased
airway resistance and dead space ventilation, and the actual risk for pediatric disease
transmissibility during pediatric resuscitative interventions are not resolved.
Pediatric ALS
Automated External Defibrillators in Pediatrics Top
The true prevalence of VF among pediatric victims of Purpose
cardiopulmonary arrest is unknown. Early rhythm
Background
assessment for pediatric prehospital arrest is not
frequently reported or reliable. In most studies, pulseless Age Definitions: What Defines...
ventricular tachycardia (VT) or VF has been documented
Pediatric BLS
in less than 10% of all pediatric arrest victims,6 15 16 17 38
even when the victim was evaluated by first responders Pediatric ALS
7 18
within 6.2 minutes of EMS call. In some studies, VF Guidelines for the Newly...
treated with early defibrillation, both at the scene and in
the hospital, may result in better survival rates than Research
20
asystole or electromechanical dissociation. However, Areas of Controversy, Unresolved...
other studies contradict these data.17 18 The development of
Appendix 1
automated external defibrillators (AEDs) has not yet
addressed the energy levels required to treat VT or VF in References
children or the reliability of these devices in the detection
of VT and VF in children. The age-appropriate application
of AEDs is assumed to be similar to current guidelines for initial defibrillator placement and
energy delivery. Therefore, the conditions under which early detection and treatment of VF
should be emphasized requires further research.
Vascular Access
Vascular access for the arrested victim is needed for the delivery of resuscitative fluids and
medications. However, establishment of adequate ventilation with BLS support of circulation is
the first priority. The intravenous or intraosseous route for the delivery of medications is the
preferred route,39 40 41 42 43 but the endotracheal route can be used in circumstances when vascular
access is delayed. It is likely that drug delivery following endotracheal epinephrine
administration may be lower than that delivered by the intravascular approach. Drug doses may
need to be increased accordingly, with attention to drug concentration, volume of vehicle, and
delivery technique.44 45 46 47 There is consensus that the tibial intraosseous route is useful for
vascular access, particularly for victims up to the age of 6 years.48 49 In the newly born, the
umbilical vein is easy to find and frequently used for urgent vascular access.
Dose of Epinephrine
Consensus supports the initial dose of epinephrine (adrenaline) at 0.01 mg/kg (0.1 mL/kg of the
1:10 000 solution) by an intravascular route or 0.1 mg/kg (0.1 mL/kg of the 1:1000 solution) by
the endotracheal route. Because the outcome of asystolic and pulseless arrest in children is very
poor and a beneficial effect of higher doses of epinephrine has been suggested by some animal
studies and a single retrospective pediatric study,50 51 52 53 54 second and subsequent intravenous
doses and all endotracheal doses for unresponsive asystolic and pulseless arrest in infants and
children should be 0.1 mg/kg (0.1 mL/kg of the 1:1000 solution) as a Class IIa recommendation.
If no return of spontaneous circulation occurs beyond the second dose of epinephrine despite
adequate CPR, the outcome is likely to be dismal.11 17 21 High-dose epinephrine is of special
concern for patients with high risk for intracranial hemorrhage, such as the preterm newborn.
Disappointing efficacy of high-dose epinephrine when used in adult study populations55 56 and the
potential detrimental effects of high-dose epinephrine therapy, including the potential for
systemic and intracranial hypertension (particularly in the newborn), myocardial hemorrhage, or
necrosis57 58 suggest caution in advocating high-dose epinephrine therapy unless further study is
encouraging.
Sequence of Defibrillatory Shocks and Medications for Ventricular Fibrillation
VF and pulseless VT are relatively uncommon in infants and children. Although there are minor
differences between the names of the drugs, dose of second defibrillation, and number of
defibrillations between medication doses (see Fig 2 ) based on local availability and custom,
there is general consensus on medication/defibrillation dosage and sequence for VF/pulseless
VT. The initial treatment is defibrillation with 2 J/kg increasing to a maximum of 4 J/kg in a
series of three shocks. Subsequent series of up to three shocks following medication
administration is based on local custom and training (ie, first defibrillation up to three times [2
J/kg, 2 to 4 J/kg, 4 J/kg], then medication with adrenaline/epinephrine and circulation, then
defibrillation up to three times [4 J/kg], then repeat adrenaline/epinephrine at higher dose, then
defibrillation up to three times [4 J/kg] and consideration for other medications
[lignocaine/lidocaine] and the treatment of reversible causes) (see universal pediatric template,
Figs 3 and 4 ).
Figure 2. Examples of minor differences in

recommendations for treatment of ventricular fibrillation
and pulseless ventricular tachycardia between the
International Liaison Committee on Resuscitation
(ILCOR), the American Heart Association (AHA), the
Heart and Stroke Foundation of Canada (HSFC), the
View larger version (53K): European Resuscitation Council (ERC), the Resuscitation
[in this window] Councils of Southern Africa (RCSA), and the Australian
[in a new window] Resuscitation Council (ARC).
Figure 3. Universal pediatric basic life support (BLS)

template for lay rescuers. **Continue rescue breathing and
cardiopulmonary resuscitation as indicated. Activate
emergency medical services as soon as possible, based on
local and regional availability.
View larger version (40K):

[in this window]
[in a new window]
Figure 4. Universal pediatric template for pediatric healthcare
providers. VF indicates ventricular fibrillation; VT, ventricular
tachycardia; defib, defibrillation; CPR, cardiopulmonary
resuscitation; and ECG, electrocardiogram.

[in this window]
[in a new window]
Complications From CPR

Reported complications from appropriately applied resuscitative techniques are rare in infants
and children. The prevalence of significant adverse effects (rib fractures, pneumothorax,
pneumoperitoneum, hemorrhage, retinal hemorrhages, etc) from properly performed CPR
appears to be much lower in children than in adults.59 60 61
62 63 64 65 66
In the most recent study,59 despite prolonged
CPR by rescuers with variable resuscitation training skill Top
levels, medically significant complications were Purpose
documented in only 3% of patients. Therefore, there is
consensus that chest compressions should be provided for Background
children if the pulse is absent or critically slow or if the Age Definitions: What Defines...
rescuer is uncertain if a pulse is present.
Pediatric BLS
Pediatric ALS
Guidelines for the Newly Born
Research
There is a need for international guidelines on BLS for Appendix 1
newborns. A review of information from the US national
References
database, the World Health Organization, and Seattle/King
67
County EMS systems demonstrates the importance of
developing an early intervention sequence for the newly
born. In the United States, approximately 1% of births occur in out-of-hospital facilities, but
neonatal mortality is more than double for these children born out of hospital. Worldwide, more
than 5 million newborn deaths occur, with approximately 56% of all births out of facility.
Neonatal mortality is high, with birth asphyxia accounting for 19% of these deaths. These data
are only for mortality; the morbidity from asphyxia and inadequate newborn resuscitation must
be assumed to be much higher. The worldwide potential for lives saved from newborn asphyxia
with simple airway interventions is estimated at more than 900 000 infants per year. Therefore,
the consensus supports guidelines from ILCOR for the newly born as a worthy goal.
Although the following are intended as preliminary BLS advisory guidelines, the difference
between BLS and ALS interventions for the newly born may be subtle. The development of
specific ILCOR advisory guidelines for newborn ALS is beyond the scope of this document. It is
hoped that ILCOR member organizations will address newborn ALS in the near future. In the
newborn, because birth can usually be anticipated, it is often possible to have more personnel and
equipment on hand than may be available for unexpected BLS interventions in older children or
adults. Ideally, the mother should give birth in a location with optimum equipment available and
personnel trained in newborn resuscitation. If this is not possible, then certain rudimentary
equipment should be available at the birthsite or should be brought to the birth attendant. Such
equipment might include the following:
Bag-valve–mask ventilation device of appropriate size for the newborn
Suction device
Warm, dry towels and blanket
Clean (sterile, if possible) instrument for cutting the umbilical cord
Clean rubber gloves for the attendant
Most newly born infants will breathe spontaneously (usually manifested by a cry) within seconds
after birth. During this time, an attendant should dry the newborn with a warm towel and remove
wet linen to reduce heat loss. If the baby is limp and not crying, immediate resuscitation is
required.
BLS for the Newly Born
(See Fig 5 , universal newborn template)
Figure 5. Universal newborn (newly born) template.

*Advanced life support interventions recommended for
suitably trained healthcare providers only: pulse check,
chest compressions, endotracheal suction and intubation,
vascular access, and epinephrine administration.

[in this window]
[in a new window]
1. Stimulate and check responsiveness.

a. Stimulation is best provided by drying the newborn with a towel and flicking the soles of the
feet. Slapping, shaking, spanking, or holding the newborn upside down is contraindicated and
potentially dangerous.
b. Assess for a cry: A cry is the most common confirmation of adequate initial ventilation. If
present, further resuscitative efforts are probably not indicated.
c. Assess for regular respirations: Although the respiratory pattern may be irregular, respirations
should be sufficient to result in adequate oxygenation (ie, absence of persistent central cyanosis).
Occasional "gasping," without normal breaths interspersed, is generally indicative of severe
compromise and should be treated as inadequate respiration. If poor response, call or send for
additional assistance.
2. Open airway.
a. Clear the airway of material, particularly if blood or meconium is present. This has special
importance in the newborn because of the narrow airway, which creates high resistance to gas
flow. Clearing the airway will also provide additional respiratory stimulation. Clearing of
secretions should be accomplished with a suction device (bulb syringe, suction catheter);
otherwise, removal of secretions may be accomplished with a cloth wrapped around the rescuer's
finger.
b. Position the head to the "sniffing" position and particularly avoid excessive neck flexion or
hyperextension, which may result in airway obstruction.
c. If a suitably trained provider and equipment are available: if the newly born is stained with
thick meconium, the trachea should be suctioned as the initial resuscitative step. This is
accomplished by intubating the trachea, applying suction directly to the tube using any of a
variety of devices available for this purpose, and withdrawing the tube as suction is continued. If
meconium is recovered, it may be necessary to repeat this procedure several times until the
residual is sufficiently thin to permit suctioning through the tube using a standard suction
catheter.
3. Check breathing.
a. Assess for presence of a cry. If a strong cry is present, further resuscitation efforts are not
indicated. If the cry is weak or absent: look, listen, and feel for air entry and chest movement and
feel for evidence of spontaneous respiration.
b. If respirations are absent or inadequate (gasping), assisted ventilation is necessary. Further
attempts to stimulate the newborn in this case will waste valuable time.
4. Breathe.
a. Although it is recognized that a bag-valve mask is the most effective piece of equipment for
assisting ventilation, various other devices are available or are being developed. Use will be
dictated by local availability, cost, and custom.
b. If a resuscitation device is not available, consider using mouth to mouth-and-nose to assist
ventilation. Although some controversy exists about whether a mother's mouth can effectively
seal her older infant's mouth and nose,31 32 consensus supports initial attempts at newborn
ventilation via both the infant's mouth and nose. Because of the presence of maternal blood and
other body fluids on the face of the newborn, there is a perceived risk of infection to the rescuer.
Quickly wipe away as much of this material as possible before attempting mouth to mouth-and-
nose ventilation.
c. Blow sufficient air into the newborn airway to cause the chest to rise visibly.
d. Watch for chest rise as an indication of ventilation efficacy. If inadequate, adjust head
position, clear airway, achieve a seal over the mouth and nose on the face, and consider an
increase in inflation pressure.
e. Ventilate at a rate of approximately 30 to 60 times per minute.
f. Note that initial breaths may require a higher inflating pressure to overcome the resistance in
small and fluid-filled airways.
5. Assess response.
a. After assisting ventilation for 30 seconds to 1 minute, check again for response. If still no
response, deliver breaths, watching closely for adequate chest rise with each delivered breath.
b. In addition to the presence of a cry and spontaneous respirations, the response may also be
assessed by feeling for a pulse, although this may be difficult in the newborn and should not
distract the rescuer from providing adequate ventilations. A pulse may be detectable by feeling
the base of the umbilical cord and should be >100 beats per minute (bpm).
c. Continue to ventilate and assess (return to step 2) until there is either an adequate response
(crying, breathing, and heart rate >100 bpm), or additional medical assistance has arrived. If
effective spontaneous respirations resume, consider positioning the newborn on its side in a
recovery position.
6. Compress chest.
a. Laypersons: Chest compressions in the newborn are not recommended for administration by
persons untrained in neonatal resuscitation, particularly when rescue is being provided by a
single individual. Ventilation is nearly always the primary need of the newly born, and
administration of chest compressions may decrease the efficacy of assisted ventilation.68
b. Trained healthcare providers: If suitably trained healthcare providers are available and
adequate ventilations have not resulted in improvement, the following steps should be taken:
1. Feel for a pulse. In the newborn, a pulse is most easily palpated by lightly grasping the base of
the umbilical cord between the thumb and index finger. If a stethoscope is available, a heartbeat
may be detected by auscultating the chest.
2. Assess the heart rate for up to 10 seconds. If the heart rate is <60 bpm and not clearly rising,
begin chest compressions. If the heart rate is >60 and rising, consider continuing effective
ventilations alone and reassess the heart rate in 60 seconds.
3. Chest compressions for the newborn are delivered in series of three, followed by a pause for
delivery of a ventilation (ratio: 3 compressions and 1 ventilation per cycle). The rate should be
approximately 120 "events" (ie, -c-c-c-v-c-c-c-v-) per minute.
4. Reassess the heart rate approximately every 60 seconds, until the heart rate improves to >60 to
80 bpm or ALS resources are available for oxygen supplementation, endotracheal intubation, and
administration of epinephrine.
7. Other newborn issues
a. Temperature control: In addition to drying the newborn to decrease evaporative heat loss,
drape the baby in dry towels or a blanket during the resuscitation process. Remove the newborn
from wet surfaces or pools of fluid. As soon as resuscitation has been successful, place the baby
skin-to-skin on the mother's chest/breast and cover both with a blanket.
b. Infection control: Wash hands and wear gloves, using universal precautions for secretion
contact, if available. Use clean towels, blankets, and instruments and avoid rescuer exposure to
blood and other fluids.
c. Umbilical cord: It is not necessary to cut the umbilical cord before resuscitation of the
newborn. The umbilical cord can be cut after the baby is spontaneously breathing and the cord
has stopped pulsating. The cutting instrument and cord ties should be sterilized, if possible.
These may be sterilized by boiling in water for 20 minutes. A new packaged razor blade does not
require sterilization. If sterile equipment is not available, clean equipment should be used. Tie the
cord in two places with a string. Cut the cord between the ties with a razor blade, scissors, or
knife.
d. Do not forget the mother. Watch for and attend to Top
potential complications of childbirth. Excessive vaginal Purpose
bleeding, seizures, and infection are the most common
maternal complications of childbirth. Arrange for Background
healthcare provider support to attend to mother and child, Age Definitions: What Defines...
if possible.
Pediatric BLS
Pediatric ALS
Research
Research
The paucity of pediatric and newborn clinical Appendix 1
resuscitation outcome data makes scientific justification of
References
recommendations difficult. Therefore, the development of
prospective, pediatric-specific clinical studies and the
development of laboratory and animal resuscitation
models that specifically address pediatric and neonatal issues is of paramount importance.
Collection of data should follow the pediatric Utstein-style
guidelines.24 69 Specific data on the etiology of arrest,
success of interventions, frequency and severity of Top
complications, significant short- and long-term Purpose
neurological and overall performance outcomes,
educational value, and costs associated with resuscitation Background
techniques are urgently needed. Age Definitions: What Defines...
Pediatric BLS
Pediatric ALS
Areas of Controversy, Unresolved Guidelines
Issues,forand Need for
the Newly...
Additional Research Research
The ILCOR pediatric working group recognizes the Appendix 1
difficulty in creating advisory statements for universal
References
application. After careful review of the rationale for
current guidelines that exist in North America, Europe,
Australia, and Southern Africa, the working group identified the areas of controversy where it
was thought the greatest need for research exists before evolution to universal guidelines can
occur.
Some of these areas are listed below.
1. Should initial resuscitation interventions and sequences be based on etiology of arrest or the
likelihood of successfully resuscitating a presenting cardiac rhythm (eg, etiology:
hypoxia/asystole most likely for children but VF treated with defibrillation most likely to have
successful resuscitation)?
2. What is the prevalence of VF during or following resuscitation?
3. What number of breaths should be initially attempted after opening the airway? (AHA/Heart
and Stroke Foundation of Canada: 2 breaths; European Resuscitation Council: 5 breaths;
Australian Resuscitation Council: 4 breaths; Resuscitation Councils of Southern Africa: 2
breaths; ILCOR: 2 to 5 breaths.)
4. Is adult mouth to infant nose ventilation a better method than adult mouth to infant mouth-and-
nose ventilation for newborns and/or infants?
5. What sequence of interventions for the conscious choking child is most appropriate: back
blows versus abdominal thrusts versus chest thrusts, and should visual inspection of the mouth
for foreign body precede attempts at ventilation in infants?
6. What is an optimal recovery position for infants and children?
7. At what heart rate should chest compressions be initiated in ALS: when the pulse is absent or
"too slow"? (Currently: AHA/Heart and Stroke Foundation of Canada: <60 bpm; European
Resuscitation Council: <60 bpm; Australian Resuscitation Council: 40 to 60 bpm; Resuscitation
Councils of Southern Africa: <60 bpm; ILCOR: <60 bpm.)
8. What is the optimal depth for chest compressions? (One third to one half depth of chest or a
specified number of inches or centimeters. ILCOR: Approximately one third the depth of the
chest.)
9. What is an optimal compression-ventilation ratio for different age groups, and can a universal
compression-ventilation ratio be adopted that accommodates all victims from newborn to adult?
10. What is the appropriate dose of epinephrine? (ILCOR: First dose of adrenaline/epinephrine,
0.01 mg/kg, subsequent doses, 0.1 mg/kg.)
11. What defibrillation dose and how many defibrillation shocks should be delivered after
medication for VF in children? (ILCOR: 2 J/kg, 2 to 4 J/kg, 4 J/kg; 1 to 3 shocks at 4 J/kg after
medications.)
12. Should alternative medications (eg, lidocaine/lignocaine) be used for persistent VF if
defibrillation and initial epinephrine dose are not successful?
13. Can AEDs accurately and reliably be used for pediatric patients?
14. What is the role of alkalyzing agents in the arrested patient who is suspected of having severe
acidosis?
15. What is the role of transcutaneous (external) pacing in the resuscitation of pediatric patients
without an organized cardiac rhythm?
16. What sequence of interventions should be employed by advanced healthcare providers for the
newborn?
17. What is the effect of implementing ILCOR guidelines on arrest prevention, resuscitation
rates, and neurological outcomes from cardiopulmonary arrest in newborns, infants, and
children?
The epidemiology and outcome of pediatric cardiopulmonary arrest and the priorities,
techniques, and sequence of pediatric resuscitation assessments and interventions differ from
those of adults. The pediatric working group was surprised by the degree of conformity already
existing in current guidelines advocated by the American Heart Association, the Heart and Stroke
Foundation of Canada, the European Resuscitation Council, the Australian Resuscitation Council,
and the Resuscitation Councils of Southern Africa. Differences are currently based upon local
and regional preferences, training networks, and customs rather than scientific controversy. The
pediatric algorithm/decision tree figures presented attempt to follow a common flow of
assessments and interventions in coordination with their counterparts for adults.
Survival following pediatric prehospital cardiopulmonary arrest averages only approximately 3%
to 17%, and survivors are often neurologically devastated. Most pediatric resuscitation reports
have been retrospective in design and plagued with inconsistent resuscitation definitions and
patient inclusion criteria. Careful and thoughtful application of uniform guidelines for reporting
outcomes of ALS interventions using large, randomized multicenter and multinational clinical
trials are clearly needed. Pediatric advisory statements from ILCOR will, by necessity, be a
vibrant and evolving guideline fostered by national and international organizations intent on
improving the outcome of resuscitation for infants and children worldwide.
Correspondence should be sent to Vinay Nadkarni, MD, Department of Anesthesia and Critical
Care, DuPont Hospital for Children, 1600 Rockland Rd, P.O. Box 269, Wilmington, DE 19899
USA. Telephone 302-651-5159. Fax 302-651-6410. E-mail: vnadkar@aidi.nemours.org
Footnotes
1
American Heart Association
2
European Resuscitation Council
3
American Heart Association and American Academy of Pediatrics
4
Resuscitation Councils of Southern Africa
5
Australian Resuscitation Council.
`Pediatric Resuscitation' was approved by the American Heart Association Science Advisory and
Coordinating Committee in February 1997.
A single reprint is available by calling 800-242-8721 (US only) or writing the American Heart
Association, Public Information, 7272 Greenville Avenue, Dallas, TX 75231-4596. Ask for
reprint No. 71-0110. To purchase additional reprints: up to 999 copies, call 800-611-6083 (US
only) or fax 413-665-2671; 1000 or more copies, call 214-706-1466, fax 214-691-6342, or . To
make photocopies for personal or educational use, call the Copyright Clearance Center, 508-750-
8400.
Top
Purpose
Appendix 1
Background
Age Definitions: What Defines...
Pediatric ILCOR Participants Pediatric BLS
Robert Bingham, MD (European Resuscitation Council
[ERC]); Jon Bland, MD (ERC); David Burchfield, MD Pediatric ALS
(AHA/American Academy of Pediatrics [AAP]); Leon Guidelines for the Newly...
Chameides, MD (AHA); Mary Fran Hazinski, MSN, RN
Research
(AHA); John Kattwinkel, MD (AHA/AAP); Efraim
Kramer, MD (Resuscitation Councils of Southern Africa); Areas of Controversy, Unresolved...
Vinay Nadkarni, MD (AHA); Linda Quan, MD (AHA); Appendix 1
F.G. Stoddard, PhD (AHA); James Tiballs, MD
References
Top
Purpose (Australian Resuscitation Council);
Background Patrick Van Rempst, MD (ERC);
Arno Zaritsky, MD (AHA); David
Age Definitions: What Defines... Zideman, MD (ERC); and Jelka
Pediatric BLS Zupan, MD (World Health
Organization).
Pediatric ALS
Research
ReferencesAreas of Controversy, Unresolved...
Appendix 1
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O'Malley P, Chameides L, Cummins RO, and the Pediatric Utstein Consensus Panel.
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Pinching, electrocution, ravens' beaks, and positive pressure
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Arch. Dis. Child. Fetal Neonatal Ed., September 1, 2006; 91(5): F369 -
F373.
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Myocardial hamartoma as a cause of VF cardiac arrest in an
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Emerg. Med. J., August 1, 2005; 22(8): 590 - 591.
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V. D. Mayr, V. Wenzel, W. G. Voelckel, A. C. Krismer, T. Mueller, K. G.
Lurie, and K. H. Lindner
Developing a Vasopressor Combination in a Pig Model of Adult
Asphyxial Cardiac Arrest
Circulation, October 2, 2001; 104(14): 1651 - 1656.
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Rhodes, R. B. Griepp, and A. F. Rossi
Cardiac Arrest in Infants After Congenital Heart Surgery
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Zideman, P. Van Reempts, and M. Osmond
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An Advisory Statement From the Pediatric Working Group of the
International Liaison Committee on Resuscitation
Pediatrics, April 1, 1999; 103(4): 56e - 56.
[Abstract] [Full Text]
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Paediatric Basic Life Support

with poor perfusion),

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New Guidelines Simplify Pediatric Resuscitation - Brief Article

Family Pratice News, Dec 1, 2000 by Miriam E. Tucker

CHIGAGO -- New international guidelines on resuscitation will simplify pediatric

The American Heart Association guidelines contain sections on pediatric advanced

Resuscitation system.(Pediatric Care)

Pediatric Resuscitation - Brief Article - Statistical Data Included

Trust, E-innovation and Leadership in Change

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The new pediatric resuscitation guidelines include these recommendations:

* Laryngeal mask airway. This device can be used to secure an airway in an

* Vagal maneuvers. These are recommended for treating supraventricular

* Epinephrine. The use of high-dose epinephrine for pulseless arrests is de-

* Automated external defibrillators. These devices may be used in children over 8

The new neonatal resuscitation guidelines include these recommendations:

* Chest compressions. Indications for chest compressions have been simplified to

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○ Big tongue; Forward jaw

○ With possible neck injury, jaw

Basic Life Support

○ Limit to volume causing chest rise

○ Children usually underventilated!

○ Use BVM only if proficient

○ Pedi BVM’s should not have pop-

Basic Life Support

Basic Life Support