pediatric bls

Basic Life Support

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PBLS 2009

Prof Mona el-samahy Head of the fifth unit of Pediatric medicine Assistant Prof Mervat Jamal


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PBLS 2009

DAY 2-11-2009 5-11-2009 12-11-2009 14-11-2009 19-11-2009 20-11-2009 21-11-2009 23-11-2009 ACTION First meeting for discussion and choosing the subject. Choosing BLS. As a subject. Studying the American and UK guidelines. Practical learning BLS. Distribute responsibilities Discussing the questionnaire. Remolding of the questionnaire by dr. Mervat. Pre-teaching questionnaire distribution. Teaching our colleges. Post-teaching questionnaire distribution.

We are grateful to Prof. Prof Mona el-samahy the Head of the fifth unit of Pediatric medicine, dr. Mervat Jamal who gives us a lot of her time, effort and patience, to our colleges whose were positive participant in practical part of the search and to all the members of the team.

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Title: Pediatric Basic life support

• • • Save lives. Filling our gap of knowledge about basic life support. Teaching our colleges BLS Technique: Successful participants will be able to: Demonstrate the ability to identify patients who require BLS. Demonstrate recognition of major life threatening situations including full arrest, respiratory arrest and foreign body airway obstruction. Demonstrate understanding of new BLS for Healthcare guideline changes and perform the guidelines in an emergency situation. Follow most recent guide lines in BLS.

Basic life support (BLS) is a level of medical care which is used for patients with lifethreatening illness or injury until the patient can be given full medical care. It can be provided by trained medical personnel, including emergency medical technicians, and by laypersons who have received BLS training. BLS is generally used in the pre-hospital setting, and can be provided without medical equipment.

BLS generally does not include the use of drugs or invasive skills, and can be contrasted with the provision of Advanced Life Support (ALS). Most laypersons can master BLS skills after attending a short course. Firefighters and police officers are often required to be BLS certified. BLS is also immensely useful for many other professions, such as daycare providers, teachers and security personnel. CPR provided in the field buys time for higher medical responders to arrive and provide ALS care. For this reason it is essential that any person starting CPR also obtains ALS support by calling for help via radio using agency policies and procedures and/or using an appropriate emergency telephone number. An important advance in providing BLS is the availability of the automated external defibrillator or AED, which can be used to defibrillation or delivery. This improves survival outcomes in cardiac arrest cases.

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Basic life support consists of a number of life-saving techniques focused on the medicine "ABC"s of pre-hospital emergency care:

• •

Airway: the protection and maintenance of a clear passageway for gases (principally oxygen and carbon dioxide) to pass between the lungs and the outside of the body Breathing: inflation and deflation of the lungs (respiration) via the airway Circulation: providing an adequate blood supply to the body, especially critical organs, so as to deliver oxygen to all cells and remove carbon dioxide, via the perfusion of blood throughout the body,

Healthy people maintain the ABCs by themselves. In an emergency situation, due to illness (medical condition) or trauma, BLS helps the patient ensure his or her own ABCs, or assists in maintaining fir the patient who is unable to do so. For airways, this will include maintaining optimal angles or possible insertion of oral or nasal adjuncts, to keep the airway unblocked. For breathing, this may include artificial respiration, often assisted by emergency oxygen. For circulation, this may include bleeding control or Cardiopulmonary Resuscitation (CPR) techniques to manually stimulate the heart and assist its pumping action. In each case, the BLS provider is trained to detect ABC problems and attempt to correct them. BLS also typically includes considerations of patient transport such as various forms immobilization to prevent additional injury, including cervical collars, splinting limbs, and full body splints (backboards).

S AFETY OF RESCUER AND VICTIM Always make sure that the area is safe for you and the victim. Move a victim only to ensure the victim’s safety. Although exposure to a victim while providing CPR carries a theoretical risk of infectious disease transmission, the risk is very low. (1) Check for Response and activate the EMS system:
-Gently tap the victim and ask loudly, “Are you okay?” Call the child’s name if you know it. -Look for movement:


PBLS 2009

he or she will answer or move. Quickly check to see if the child has any injuries or needs medical assistance. If necessary, leave the child to phone EMS, but return quickly and recheck the child’s condition frequently. Children with respiratory distress often assume a position that maintains airway patency and optimizes ventilation. Allow the child with respiratory distress to remain in a position that is most comfortable.
THE UNRESPONSIVE CHILD AND IS IS NOT MOVING, shout for help and start CPR. If you are alone, continue CPR for 5 cycles (about 2 minutes). One cycle of CPR for the lone rescuer is 30 compressions and 2 breaths then activate the EMS. If you are alone and there is no evidence of trauma, you may carry a small child with you to the telephone. The EMS dispatcher can guide you through the steps of CPR. If a second rescuer is present, that rescuer should immediately activate the EMS system and get an AED (if the child is 1 year of age or older) while you continue CPR. If you suspect trauma, the second rescuer may assist by stabilizing the child’s cervical spine . If the child must be moved for safety reasons, support the head and body to minimize turning, bending, or twisting of the head and neck.

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Position the Victim: If the victim is unresponsive, make sure that the victim is in a supine (face-up) position on a flat, hard surface such as a sturdy table, the floor, or the ground. If you must turn the victim, minimize turning or twisting of the head and neck. Open the Airway:

LAY RESCUER: Open the airway using a head tilt-chin lift maneuver for both injured and non-injured victims. The jaw thrust is no longer recommended for lay rescuers because • • • IT is difficult to learned perform It is often not an effective way to open the airway may cause spinal movement

FOR HEALTH CARE P ROVIDER: A health care provider should use the head tilt-chin lift maneuver to open the airway of a victim without evidence of head or neck trauma. If there is cervical spine injury, open airway using jaw thrust without head tilt. (2, 3, 4) Check Breathing: While maintaining an open airway, take no more than 10 seconds to check whether the victim is breathing:
• • • Look for rhythmic chest and abdominal movement. Listen for exhaled breath sounds at the nose and mouth. Feel for exhaled air on your cheek. (5, 6)

If the child is breathing and there is no evidence of trauma: turn the child onto the side (recovery position) .This helps maintain a patent airway and Decreases risk of aspiration. GIVE RESCUE BREATHS: If the child is not breathing: maintain an open airway and give 2 breaths. Make sure that the breaths are effective (i.e. the chest rises) . In an infant, use a mouth-to-mouth-and-nose technique. In a child, use a mouth-to-mouth technique but pinch the nose closed to avoid passage of air outside from the nose. (7)

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BARRIER DEVICES: Some health care providers and lay rescuers may hesitate to give mouth-to-mouth Rescue breathing and prefer to use a barrier device (8-10). Barrier devices have not reduced the risk of transmission of infection, and some may increase resistance to air flow. If you use a barrier device, do not delay rescue breathing. BAG-MASK VENTILATION (HEALTH CARE PROVIDERS) Bag-mask ventilation can be as effective as end tracheal intubation and safer when providing ventilation for short period (11-14). But, bag-mask ventilation requires training and special skills. VENTILATION BAGS A self-inflating bag with a volume of at least 450 to 500 mL(15); smaller bags may not deliver an effective tidal volume(16).





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Two-finger chest compression technique in infant (1 rescuer). Two thumb-encircling hands chest compression in infant (2 rescuers). Pulse Check

Try to palpate pulse (brachial in infant or carotid and femoral in a child). No more than 10 seconds to start chest compression. Compression is recommended when pulse is <60bpm and there is poor perfusion (pallor-cyanosis)
Chest Compressions

Compress lower half of the sternum but not the xiphoid process. Allow chest recoil by lifting hand slightly off chest. Push hard and fast and minimize interruptions. In infant, use 2 fingers placed just below mammary line BUT, the 2 thumb encircling technique is preferred when 2 rescuers are present. In a child, use the heel of 1-hand or 2-hands.103,

Coordinate Chest Compressions and Breathing

IN 2000, compression\ventilation ratio was 5:1 with 100 compression rate per minute. Ventilations are less important during 1st minutes of CPR in arrhythmia induced cardiac arrest. FOR 1- RESCUER the ratio is 30:2 FOR 2-RESCUERS CPR, the ratio is 15:2 (one should make CPR while the other maintain ventilation) Don’t ventilate and compress at the same time. Once an advanced air way is placed,2 rescuers no longer deliver cycles of compressions interrupted with pauses for ventilation .1The rescuer delivers 100 compressions per minute without pauses for ventilation.29,130 They should change the role every 2 minutes to prevent fatigue and deterioration in quality(no more than 2 seconds).

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Compression only CPR

In asphyxia induced arrest, both ventilations and compressions are a mast. But in VF induced arrest, CPR is more necessary than ventilations. If person unable to do both, compression is better than no CPR.
Activate the EMS System and Get the AED

In the case of 1 system.


he must do 5 cycles of compression before activating EMS

In the case of 2 RESCUERS, one makes CPR while the other activates EMS system.

Children with sudden collapse during an athletic event are likely to have VF or pulselesss VT need rapid defibrillation. They are referred to as "shockable rhythms" because they respond to electric shocks. It was shown that it is safe and suitable for children1to8 years of age. However there is no sufficient data for infants less than 1year.36-138
Foreign-Body Airway Obstruction (Choking)

EPIDEMIOLOGY AND RECOGNITION More than 90% of deaths from foreign body airway obstruction occur in children <5years of age 65 % are infants. SIGNS OF FBAO Includes respiratory distress with coughing, gagging, stridor, or wheezing. The characters that distinguish it from other causes are sudden onset and absence of fever or respiratory symptoms. RELIEF OF FBAO In mild cases Don’t interfere and allow him to cough while you observe only. In severe cases, abdominal thrust (hemlich maneuver) is used in a child while 5 back slaps followed by chest thrust is used in infant. Abdominal thrust leads to liver damage in infants. If the victim unresponsive, make CPR but first try to remove foreign body.

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Special Resuscitation Situations

TRAUMA Remove any dental fragments or any blood debris, stop any external bleeding by pressure. Use jaw thrust method not head tilt and chain lift. DROWNING Don't waste time to remove water from the victim. Start CPR by opening airway, giving 2 effective breaths followed by chest compressions.

Differences between European and American guidelines
European guidelines and American guidelines are almost the same and the main difference is in the sequence: • • • • • The American guidelines activate EMS system before starting resuscitation while in European guidelines checks breathing first then call the ambulance. In American guidelines cycle of CPR continues for 2 minutes while in European guidelines it continues for 1 minute In American guidelines 2 effective rescue breaths are given while in European 2 effective breaths out of 5 European guidelines added: 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 European guidelines put a criteria for diagnosis of FBAO (foreign body airway obstruction):

General signs of FBAO Witnessed episode Coughing or choking Sudden onset Recent history of playing with or eating small objects

Ineffective coughing Unable to vocalize Quiet or silent cough Unable to breathe Cyanosis Decreasing level of Consciousness

Effective cough: Crying or verbal response to questions Loud cough Able to take a breath before Coughing Fully responsive

European guidelines 2005 differ from previous versions in a number of ways: They allow the rescuer to diagnose cardiac arrest if the victim is unresponsive and not breathing normally. Rescuers are taught to give chest compressions in the centre of the chest, rather than measuring from the lower border of the sternum.

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Rescue breaths should be given over 1 second rather than 2 seconds. Rescuers should use the ratio of 30:2 for compressions to breaths, rather than the previous 15:2 or 5:1 ratios. For an adult victim, the initial 2 rescue breaths should be omitted, so that 30 chest compressions are given immediately a cardiac arrest has been diagnosed. These changes were introduced to simplify the algorithm, to allow for faster decision maki making and to maximize the time spent giving chest compressions; this is because interruptions in chest compressions have been shown to reduce the chance of survival. It is also acknowledged that rescuers may either be unable, or unwilling, to give effective rescue breaths; in this situation, rescue continuing chest compressions alone is advised although this is only effective for about 5 advised, minutes COMPRESSION-VENTILATION RATIO Following Guidelines 2005, the compression ventilation ratio has increased from 15:2 to 30:2, compression: already emphasizing the importance of minimally interrupted high quality chest compressions. high-quality Furthermore, unlike the AHA guidelines the ERC guidelines indicate that 30 compressions are guidelines, given before attempting ventilation. CHEST COMPRESSION ONLY: The European Resuscitation Council continues to recommend the teaching and administration of high quality, minimally interrupted chest compressions at a rate of 100/minute alternated with minute two mouth-to-mouth ventilations in a ratio of 30:2. For those rescuers who are unwilling or mouth ho unable to give mouth-to-mouth ventilations, chest compression only is much more acceptable mouth compression-only than performing no CPR at all. (18 18) Survival with chest compression with and without assisted ventilation. Five minutes after ventricular fibrillation, swine were treated for 8 additional minutes with simulated mouth-to-mouth exhaled gas ventilation mouth (17% O2 and 4% CO2) plus chest compression (CC & vent), chest compression alone (CC alone), or no CPR. No differences could be detected between groups with or without ventilation if chest compression was provided. Both CPR groups tended toward improved survival compared with no CPR. Open bar indicates return of spontaneous circulation; solid bar 24-hour survival. bar, Data from Berg et al.(19)

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ACTIVE COMPRESSION DECOMPRESSION CPR (ACD CPR): Background Recent studies have demonstrated improved cardiopulmonary circulation during cardiac arrest with the use of a hand-held suction device (Ambu Cardio Pump) to perform active compression-decompression

ACD CPR significantly increased arterial blood pressure, coronary perfusion pressure, minute ventilation, and negative inspiratory pressure compared with standard CPR. (20)

Statistics BLS
Studies showed that incidence of cardiac arrest in pediatrics are about 9.8 / 100,000 inhabitants less than 16 years old. (1) CONCERNING OUT-OF HOSPITAL CARDIAC ARRESTS, the most common causes were sudden infant death syndrome (SIDS), trauma, and airway related cardiac arrest and finally near drowning. 78.9% of cardiac arrests were presented as Asystole. 13.5% as pulseless electrical activity and 3.8% as ventricular fibrillation (VF). (1) Survival to hospital discharge varied between studies. In one study, survival rate was 12.1% with 4% were neurologically free. Cardiac arrests due to submersion injury have 22.7% overall survival with 6% neurologically free. Trauma (21.9% overall survival and 6.8% neurologically free). Rigorous cardiac arrest (1.1% and 0.3%) (3) As we see the overall survival rates of CPR are generally very poor. May factors affect survival after a CPR. Factors associated with favorable outcome are collapse in a public place, the near-drowning etiology of arrest, bystander initiated CPR and short duration of resuscitation. (1) This very poor outcome of CPR isn't in fact due to the ineffectiveness of this procedure, but the real cause is that most cases of cardiac arrests are unwitnessed and so most cases receive delayed CPR. This delay is usually associated with poor outcomes.(3). Unfortunately only 34% of cardiac arrest patients are witnessed, and in 32% of cases CPR are started by a lay rescuer while 66% of cases are unwitnessed. (4) In fact studies showed that early access is the weakest link in the chain of survival and so should receive major attention in the near future.(5) BUT IN FACT THE PICTURE ISN'T THAT BLACK, many studies showed that CPR is beneficial in many situations. In a study to determine the effect of immediate resuscitation on children with submersion injury, it was found that Children with a good outcome were 4.75 times more likely to have a history of immediate resuscitation than children with

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poor outcome. (6) Another study showed that Survival to discharge in a cardiac arrest was more common among children and adolescents than infants or adults. (7) Another study stated that Precounter shock CPR can result in substantial physiologic benefits and superior response to initial defibrillation attempts compared with immediate defibrillation in the setting of prolonged ventricular fibrillation. i.e. it's better to begin with CPR then do Defibrillation that begging defibrillation from the start. (13) This means that although the overall outcomes of CPR are seemed to be poor, this is not the case in every situation. As we mentioned above this poor overall outcomes are due to either late resuscitation in unwitnessed arrest or due some causes of the arrest like arrests of cardiac origin. So studies always stress that immediate resuscitation is always advised in a cardio-pulmonary arrests.(6) BUT WHAT ARE THE NEGATIVE IMPACTS THE CPR MAY HAVE? In a study assessing injuries during CPR, it was found that injuries occurred in 42.5% of cases , but almost all of these injuries were of minor nature consisting principally of bruises and abrasions. The likelihood of injury increased with the length of resuscitation. In children resuscitated for less than 60 minutes the incidence of injury was 27% compared with 62% for children resuscitated for longer.(8) In another study it was found that 7% had at least one injury as a result of CPR; 3% had injuries that were considered medically significant. These included retroperitoneal hemorrhage, pneumothorax , pulmonary hemorrhage , epicardial hematoma , and gastric perforation , in spite of prolonged resuscitation performed with variable degrees of skill, only one patient was noted to have rib fractures.(9) In a systematic review to find out if CPR causes rib fracture, 3 cases only of 923 children had a rib fracture which was anterior.(10) This means that rescuer should begin CPR immediately without hesitating because of fear of causing injuries. BUT WHAT ABOUT GETTING INFECTION DURING CPR ESPECIALLY DURING MOUTH-TO-MOUTH BREATHING ? In a study about the risk of getting HIV infection through saliva during mouth to mouth (MTM) breathing, it was found that the risk of transmission of HIV and other infectious diseases by saliva during CPR training practice is extremely low because of low infectious virus titers and properties of saliva that inhibit HIV. (11) In another study it was found that although pathogens can be isolated from the saliva of infected persons, salivary transmission of blood-borne viruses is unusual and transmission of infection has been rare: Only 15 documented cases have been reported. Most of these cases involved a bacterial pathogen, such as Neisseria meningitides. Transmission of hepatitis B virus, hepatitis C virus, or cytomegalovirus during CPR has not been reported; all three reported cases of HIV infection acquired during resuscitation of an infected patient

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resulted from high-risk cutaneous exposures. There have been no reports of infection acquired during CPR training. (12) In fact, the benefit of initiating lifesaving resuscitation in a patient in cardiopulmonary arrest greatly outweighs the risk for secondary infection in the rescuer or the patient. All the above studies show that the benefits of doing CPR are much more the rare drawbacks. BUT WHY DOCTORS MAY STOP CPR? In a study comparing CPR in adults and children it was found that: 1) several laboratory and clinical factors significantly influence physician's decisions regarding termination of resuscitative efforts. 2) Regardless of setting, time of pulselessness does appear to be an influential factor in determining when to terminate resuscitation in children for most physicians; 3) Pediatric physicians are more likely to terminate resuscitative efforts than are General physicians if return of spontaneous circulation is not achieved by 25 minutes. (14) CPR IN THE EYES OF OTHERS: WILLING TO DO MOUTH- TO-MOTH BREATHING: In one study it was found that only 50% of health care providers were willing to perform mouth-to-mouth breathing for an unknown adult. The nice thing is that their percentage increased as the person is more familiar to the rescuer. Overall, the group was willing to do mouth-to-mouth resuscitation on victims known to them: their neighbors (84%), children at a pool (88%), spouses (94%), and parents (93%). In the hospital setting, knowing a patient's human immunodeficiency virus (HIV) status greatly influenced the willingness to do mouth-to-mouth rescue. If a patient's HIV status was unknown, only a third of providers would do mouth-to-mouth resuscitation; if the HIV status was known to be negative, two thirds would do mouth-to-mouth resuscitation. Children in the hospital whose HIV status was unknown would receive mouth-to-mouth resuscitation by 57% of the respondents. Children known to be HIV-negative would be resuscitated by 79% of the respondents. Co-workers were more willing to resuscitate a known physician or nurse than an unknown co-worker, with physicians more willing than nurses to do mouthto-mouth resuscitation on an unknown co-worker. Experienced providers of mouth-tomouth wanted to receive mouth-to-mouth resuscitation less frequently 75% than inexperienced providers 84%. (15) In another study which was done on homosexual males to detect their willingness to perform mouth-to-mouth (MTM) breathing, it was found that the willingness of male homosexuals to perform MMR is high, in contrast to the general reluctance of internists and medical nurses to perform MMR in the same outpatient scenarios. The different perceived risks of male homosexuals and physicians acquiring infectious diseases by performing MMR is probably responsible for the

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difference in willingness of these two groups to perform MMR. The HIV positive homosexual males were less willing to perform MTM breathing than HIV negative (85% & 93% respectively) (16) CPR IN THE EYES OF LAY PEOPLE: Despite numerous scientific advances in information about treatment modalities and outcomes available to physicians, the knowledge of the general public regarding resuscitation is greatly inadequate and inaccurate. Numerous studies have found inaccurate beliefs regarding CPR and the expected outcomes among the general public. Many laypersons believe that the success rate of cardiopulmonary resuscitation is between 40% and 60%. This is mainly due to the effect of media which usually exaggerate benefits of the CPR. In fact CPR is usually shown to be successful on television. (23) REALLY IT WORTH WORKING: As CPR is needed in many situation efforts should be done to improve CPR skill in different levels. For example, it was found that School-based established emergency response plan programs provide a high survival rate for both student athletes and older non-students who suffer sudden cardiac arrest on school grounds. High schools are strongly encouraged to implement onsite established emergency response plan programs as part of a comprehensive emergency response plan to sudden cardiac arrest. In one study in western countries it was found that 83% of schools have an established emergency response plan for sudden cardiac arrest. (18) Even in primary schools, Students as young as 9 years are able to successfully and effectively learn basic life support skills including AED deployment, correct recovery position and emergency calling. As in adults, physical strength may limit depth of chest compressions and ventilation volumes but skill retention is good. (28) Another study showed that CPR training can be disseminated in a population by distributing personal resuscitation manikins among children even in primary schools.(19) Really it deserves trying. In the state university of New York There was a 78 per cent rate of initial response to therapy and a 47 per cent survival rate. This is almost twice the survival rate of the best previously reported study and five times the average.(20) Wile in developing countries it was found that : Cardiopulmonary arrest after admission has a very poor prognosis in hospitals. Infectious diseases are the main underlying causes of arrest. If a child fails to respond to the basic tenements within 15 min then it is unlikely that further efforts to sustain life will be fruitful in hospitals where ventilation facilities are not present. (21)

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SOME ETHICAL CONSIDERATIONS: In all emergency cases if no advance decision has been made or is known, CPR should be attempted unless:
• • • The patient has refused CPR. The patient is clearly in the terminal phase of illness. The burdens of the treatment outweigh the benefits.

CPR AND MEDICAL FUTILITY: Medical futility is defined when medical treatment “offers no reasonable hope of recovery or improvement or when the person is permanently unable to experience any benefit”. (23) Many cases are in their end-stage disease and wouldn't really get benefits from CPR. In these circumstances – according to ethical statements – there is no obligation for a physician to render treatment that is of little or no benefits for the patient. So in this situation no CPR will be done. (24) But if the patient's family wanted a CPR- although of no benefit - to be done Can physicians withhold CPR against family wishes in an end-state case most probably wouldn't benefit from CPR? The answer is yes according to many ethical statements but many authors see this unethical and against the dignity principle of ethics. (23) Also we should be aware that medical futility is as defined above and isn't a reflection of the quality of life. The quality of life is determined only by the patient himself. So if the CPR could succeed but with low quality of life e.g. with a great neurological insult, the only one to determine whether to proceed with CPR or not is the patient himself. The physician doesn't have the right to stop CPR even with a poor quality of life according to his point of view. (22) CPR SHOULD BE DONE IN THE PRESENCE OF OTHER FAMILY MEMBERS OR NOT? Traditionally, family members have not been allowed to witness resuscitation attempts. However, several recent reports have shown positive results of allowing family to be present during resuscitative efforts. When asked if they favor the presence of relatives during the resuscitation process or not, most survivors indicated that they favor the presence of their relatives and most of them believed that their relatives benefit from such experience. (25) And concerning the patients' relatives, most of them also preferred to witness the resuscitation of their patient relatives. Most common causes were to take care of the patient and to witness the intervention. Males were more common to prefer this. But those who already witnessed this intervention before on one of their relatives showed unwillingness to witness it again. (26) When asking parents of resuscitated

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children about if they prefer to be present during the resuscitation or not, most of them preferred that they prefer to be present and believed that this would comfort their children and help them accept the fact of their death after that. (27) In fact despite concerns of physicians that family members may be traumatized by witnessing such procedures, or may interfere with medical care, data do not support such concerns. (22)

The questionnaire was made over students of the fifth year of medical school of Ain Shams. The questionnaire designed to assess the general knowledge about the basic life support and the technique of cardiopulmonary resuscitation. It was designed to distribute the questionnaire among the sample, then BLS tutorial will be taught to the sample, and finally the same questionnaire is distributed again to evaluate the BLS tutorial. The analysis of the first questionnaire revealed the following: 1. 37.5% of the sample answered the question no. 4 correctly. 2. 25% of the sample answered the question no. 5 correctly. 3. 68.75% of the sample answered question no. 6 correctly. 4. 87.5% of the sample answered question no. 7 correctly. 5. 75% of the sample answered question no. 8 correctly. 6. 81.5% of the sample answered question no. 9 correctly. 7. 93.75% of the sample answered question no. 10 correctly. 8. 68.75% of the sample answered question no. 11 correctly. 9. 37.5% of the sample answered question no. 12 correctly. 10. 50% of the sample answered question no. 13 correctly. 11. 12.5% of the sample answered question no. 14 correctly. 12. 62.5% of the sample answered > 50% of the questionnaire correctly. 13. The most answered questions were question no. 10. 14. The least answered questions were question no. 14. When the same questionnaire is distributed after the BLS tutorial among the same sample which received the pre - tutorial questionnaire. The analysis revealed the following: 1. All students had answered the questions no. 8, 9 and 10 correctly. 2. 50% of the student had answered the questions no. 4, 5 and 6 correctly. 3. Students who get score above 6/11 were 5 students. 4. Students who get score below 6/11 were 1 student.

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CPR Is an emergency medical procedure for a victim of cardiac arrest or, in some circumstances, respiratory arrest. CPR is performed in hospitals or in the community by laypersons or by emergency response professionals. CPR involves physical interventions to create artificial circulation through rhythmic pressing on the patient's chest to manually pump blood through the heart, called chest compressions, and usually also involves the rescuer exhaling into the patient (or using a device to simulate this) to inflate the lungs and pass oxygen in to the blood, called artificial respiration. Some protocols now downplay the importance of the artificial respirations, and focus on the chest compressions only. CPR is unlikely to restart the heart; its main purpose is to maintain a flow of oxygenated blood to the brain and the heart, thereby delaying tissue death and extending the brief window of opportunity for a successful resuscitation without permanent brain damage. Advanced life support and defibrillation, the administration of an electric shock to the heart, is usually needed for the heart to restart, and this only works for patients in certain heart rhythms, namely ventricular fibrillation or ventricular tachycardia, rather than the 'flat line’ asystolic patient although CPR can help bring a patient in to a shockable rhythm. CPR is generally continued, usually in the presence of advanced life support (such as from a medical team or paramedics), until the patient regains a heart beat (called "return of spontaneous circulation" or "ROSC") or is declared dead. The practical part of this research was to assess the knowledge of medical students and to teach our colleagues the basic life support steps.

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THE BLS SEQUENCE FOR INFANTS AND CHILDREN (1) Mejicano GC, Maki DG. Infections acquired during cardiopulmonary resuscitation: estimating the risk and defining strategies for prevention. Ann Intern Med. 1998;129:813–828 (2) Elam JO, Greene DG, Schneider MA, et al. Head-tilt method of oral resuscitation. JAMA. 1960;172:812–815 (3) Roth B, Magnusson J, Johansson I, Holmberg S, Westrin P. Jaw lift: a simple and effective method to open the airway in children. Resuscitation. 1998;39:171–174 (4) Bruppacher H, Reber A, Keller JP, Geiduschek J, Erb TO, FreiFJ. The effects of common airway maneuvers on airway pressure and flow in children undergoing adenoidectomies. Anesth Analg. 2003;97:29–34, table of contents (5) Clark JJ, Larsen MP, Culley LL, Graves JR, Eisenberg MS. Incidence of agonal respirations in sudden cardiac arrest. Ann Emerg Med. 1992;21:1464–1467 (6) Poets CF, Meny RG, Chobanian MR, Bonofiglo RE. Gasping and other cardiorespiratory patterns during sudden infant deaths. Pediatr Res. 1999;45:350–354 (7) Zideman DA. Paediatric and neonatal life support. Br J Anaesth.1997;79:178–187 (8) Ornato JP, Hallagan LF, McMahan SB, Peeples EH, RostafinskiAG. Attitudes of BCLS instructors about mouth-to-mouth resuscitation during the AIDS epidemic. Ann Emerg Med. 1990; 19:151–156 (9) Brenner BE, Van DC, Cheng D, Lazar EJ. Determinants of reluctance to perform CPR among residents and applicants: the impact of experience on helping behavior. Resuscitation. 1997;35:203–211 (10) Hew P, Brenner B, Kaufman J. Reluctance of paramedics and emergency medical technicians to perform mouth-to-mouth resuscitation. J Emerg Med. 1997;15:279–284 (11) Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-ofhospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA. 2000; 283:783–790 (12) Cooper A, DiScala C, Foltin G, Tunik M, Markenson D, Welborn C. Prehospital endotracheal intubation for severe head injury in children: a reappraisal. Semin Pediatr Surg. 2001;10: 3–6

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(13) Stockinger ZT, McSwain NE Jr. Prehospital endotracheal intubation for trauma does not improve survival over bagvalve- mask ventilation. J Trauma. 2004;56:531–536 (14) Pitetti R, Glustein JZ, Bhende MS. Prehospital care and outcome of pediatric outof-hospital cardiac arrest. Prehosp Emerg Care. 2002;6:283–290 (15) Terndrup TE, Kanter RK, Cherry RA. A comparison of infant ventilation methods performed by prehospital personnel. Ann Emerg Med. 1989;18:607–611 (16) Field D, Milner AD, Hopkin IE. Efficiency of manual resuscitators at birth. Arch Dis Child. 1986;61:300–302 (17) Finer NN, Bates R, Tomat P. Low flow oxygen delivery via nasal cannula to neonates. Pediatr Pulmonol. 1996;21:48–51 (18) Pediatrics 2006;117;e989-e1004 American Heart Association and Neonatal Patients: Pediatric Basic Life Support Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) of Pediatric 2005 American Heart Association (AHA) Guidelines for Cardiopulmonary REFERENCE DIFFERENCES BETWEEN EUROPEAN AND A MERICAN GUIDELINES (18) Advisory statement of the European Resuscitation Council on Basic Life Support 31 March 2008 (19) Berg RA, Wilcoxson D, Hilwig RW, Kern KB, Sanders AB, Otto CW, Eklund DK, Ewy GA. The need for ventilatory support during bystander CPR. Ann Emerg Med.. 1995;26:342-350 (20) Evaluation of standard and active compression-decompression CPR in an acute human model of ventricular fibrillation.JJ Shultz, P Coffeen, M Sweeney, B Detloff, C Kehler, E Pineda, P Yakshe, SW Adler, M Chang and KG Lurie University of Minnesota, Minneapolis STATISTICS REFERENCE 1- Kuisma M, Suominen P, Korpela R. Paediatric out-of-hospital cardiac arrests-epidemiology and outcome. Resuscitation. 1995 Oct;30(2):141-50. 2- Reis AG, Nadkarni V, Perondi MB, Grisi S, Berg RA. A prospective investigation into the epidemiology of in-hospital pediatric cardiopulmonary resuscitation using the international Utstein reporting style. Pediatrics. 2002 Feb;109(2):200-9. 3- Donoghue AJ, Nadkarni V, Berg RA, Osmond MH, Wells G, Nesbitt L, Stiell IG; CanAm Pediatric Cardiac Arrest Investigators. Out-of-hospital pediatric cardiac arrest:

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15- Horowitz BZ, Matheny L. Health care professionals' willingness to do mouth-tomouth resuscitation. West J Med. 1997 Dec;167(6):392-7. 16- Brenner B. Willingness of male homosexuals to perform mouth-to-mouth resuscitation. Resuscitation. 1994 Jan;27(1):23-30. 17- Van den Bulck J, Damiaans K. Cardiopulmonary resuscitation on Flemish television: challenges to the television effects hypothesis. Emerg Med J. 2004 Sep;21(5):565-7. 18- Drezner JA, Rao AL, Heistand J, Bloomingdale MK, Harmon KG. Effectiveness of emergency response planning for sudden cardiac arrest in United States high schools with automated external defibrillators. Circulation. 2009 Aug 11;120(6):518-25. Epub 2009 Jul 27. 19- Isbye DL, Rasmussen LS, Ringsted C, Lippert FK. Disseminating cardiopulmonary resuscitation training by distributing 35,000 personal manikins among school children. Circulation. 2007 Sep 18;116(12):1380-5. Epub 2007 Aug 27. 20- Ehrlich R, Emmett SM, Rodriguez-Torres R. Pediatric cardiac resuscitation team: a 6 year study. J Pediatr. 1974 Jan;84(1):152-5. 21- Olotu A, Ndiritu M, Ismael M, Mohammed S, Mithwani S, Maitland K, Newton CR. Characteristics and outcome of cardiopulmonary resuscitation in hospitalised African children. Resuscitation. 2009 Jan;80(1):69-72. Epub 2008 Nov 14. 22- Marco CA. Ethical issues of resuscitation: an American perspective. Postgrad Med J. 2005 Sep;81(959):608-12. 23- Weijer C. Cardiopulmonary resuscitation for patients in a persistent vegetative state: futile or acceptable?. CMAJ. 1998 Feb 24;158(4):491-3. 24- British Medical Association; Resuscitation Council (UK); Royal College of Nursing. Decisions Relating to Cardiopulmonary Resuscitation: a joint statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. J Med Ethics. 2001 Oct;27(5):310-6; discussion 317-23. 25- Albarran J, Moule P, Benger J, McMahon-Parkes K, Lockyer L., Family witnessed resuscitation: the views and preferences of recently resuscitated hospital inpatients, compared to matched controls without the experience of resuscitation survival. Resuscitation. 2009 Sep;80(9):1070-3. Epub 2009 Jul 26- Ersoy G, Yanturali S, Suner S, Karakus NE, Aksay E, Atilla R., Turkish patient relatives' attitudes towards family-witnessed resuscitation and affecting sociodemographic factors. Eur J Emerg Med. 2009 Aug;16(4):188-93. *

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27- Tinsley C, Hill JB, Shah J, Zimmerman G, Wilson M, Freier K, Abd-Allah S.Experience of families during cardiopulmonary resuscitation in a pediatric intensive care unit. Pediatrics. 2008 Oct;122(4):e799-804. 28- Fleischhackl R, Nuernberger A, Sterz F, Schoenberg C, Urso T, Habart T, Mittlboeck M, Chandra-Strobos N. School children sufficiently apply life supporting first aid: a prospective investigation. Crit Care. 2009;13(4):R127. Epub 2009 Jul 31.

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