BASIC LIFE SUPPORT

1
SILVIA TRIRATNA
Learning objective
 Mampu mengenal dan
pertolongan segera kegawatan
mengancam jiwa pada bayi dan
anak
 Mampu mengenal dan
pertolongan segera pada henti
jantung bayi dan anak
Definisi cardiac Arrest

▪Berhentinya aliran sirkulasi

darah
▪Akibat dari aktivitas mekanik
jantung yang tidak ada atau
tidak efektif
 Definition of cardiac Arrest
▪Cardiopulmonary arrest
occurs when a
PATIENT’S HEART AND LUNGS stop
functioning
 Unresponsiveness to pain
(coma)
CLINICALLY  Apnoea or gasping respiratory
pattern.
 Absent circulation.
 Pallor or deep cyanosis.
 Definition of cardiac Arrest

CLINICALLY
 UNRESPONSIVE and
 NOT BREATHING or only GASPING
• Cerebral Hypoxia causes  lose consciousness and stop
breathing, although agonal gasps may be observed during the
first minutes after sudden arrest

• When circulation stops, the resulting organ and tissue

ischemia can cause cell, organ, and patient death if not rapidly
reversed
patients with cardiac arrest

Survival rates and neurologic outcomes are poor,

early appropriate resuscitation(CPR),

early defibrillation,
appropriate post–cardiac arrest care,

leads to improved survival and

neurologic outcomes.

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 all cases
accompanied with
hypoxia
EXTRA CARDIAC

CARDIAC
Primary lesion of cardiac muscle leading to the
progressive decline of contractility, conductivity
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disorders, mechanical factors
Pathway to Pediatric Cardiac Arrest

Precipitating Problems
Sudden Cardiac
Respiratory Circulatory Arrest
(Arrhytmia)
Respiratory
Distress

Respiratory shock
Failure

Cardiopulmonary Failure

CARDIAC ARREST
Pathway to Pediatric Cardiac Arrest

Precipitating Problems
Sudden Cardiac
Respiratory Circulatory Arrest
(Arrhytmia)

Respirato Sudden cardiac

ry arrest in children is
Distress less common than
in adults
Hypoxic/
Respirator asphyxial Arrest
y shock
Failure

Cardiopulmonary Failure

CARDIAC ARREST
 Examples Of Underlying Causes
Pathways Leading To Cardiac Arrest
In Childhood

Advanced Paediatric Life Support: A Practical Approach to Emergencies, Sixth Edition. Edited by Martin Samuels and Sue Wieteska. ｩ
2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd)
Pediatric Chain of Survival

prevention Early CPR EMS Rapid PALS Intergrated

Post-cardiac
Arrest care

Berg, M. D. et al. Circulation 2010;122:S862-S875

CPR
 A technique combining artificial
ventilation and chest compressions
designed to perfuse vital organs or
restore circulation in cardiac
standstill.

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CPR Indications
 should be performed immediately on
any person who has become
unconscious and is found to be
pulseless

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For the purpose of resuscitation,
children are divided into 3 age
groups:

Infants: under one year of age

Small children: 1 to 8 years of age
Older children/adults: 9 years and over
For the purpose of resuscitation,
children are divided into 2 age
groups:

Infants : under one year of age

children: 1 to 8 years of age
Adults: 9 years and over
 BLS guidelines 2015
▪ Infant : younger than approximately 1 year of age.
▪ Child BLS : children approximately 1year of age
until puberty.
 For teaching purposes, puberty is defined as
 breast development in females and
 the presence of axillary hair in males.

▪ Adult ; at and beyond puberty

 C-A-B approach compared with an A-B-C
approach.
 demonstrated that time to first ventilation is delayed by
only approximately 6 – 9 seconds (9 seconds or less) for 2
rescuers
 to decrease the time to initiation of chest compressions
and reduce “no blood flow” time
1. Marsch S, Tschan F, Semmer NK, Zobrist R, Hunziker PR, Hunziker S. ABC versus CAB for cardiopulmonary resuscitation: a prospective, randomized simulator-based trial. Swiss
Med Wkly. 2013;143:w13856. doi: 10.4414/ smw.2013.13856
2. Lubrano R, Cecchetti C, Bellelli E, Gentile I, Loayza Levano H, Orsini F, Bertazzoni G, Messi G, Rugolotto S, Pirozzi N, Elli M. Comparison of times of intervention during pediatric
CPR maneuvers using ABC and CAB sequences: a randomized trial. Resuscitation. 2012;83:1473–1477. doi: 10.1016/j.resuscitation.2012.04.011
American Heart Association
(AHA) guidelines 2010

standard for CPR comprises 3 steps:

 chest compressions,
 airway, and
 breathing

 (CAB),
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2015
C A B

100 /min -
120 /min
The goal of optimize cerebral
effective and coronary
CPR perfusion

High Quality
CPR
Components of High-Quality CPR

The 5 components of high-quality

CPR are

▪ Ensuring chest compressions of adequate rate

▪ Ensuring chest compressions of adequate depth
▪ Allowing full chest recoil between compressions
▪ Minimizing interruptions in chest compressions
▪ Avoiding excessive ventilation
BLS Survey

First
Check simultaneously:
1) Responsiveness
2) Breathing

Then If victim unresponsive and not

breathing:
1) Activate emergency response system
2) Retrieve AED if available
3) If no pulse felt within 10 seconds, begin
CPR
performed by
healthcare
providers and
23
not by
rescuers
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


 25
PROCEDURE

1. Ensure the safety of rescuer and

child.
2. Check the child’s responsiveness.
3. Look for no breathing or only
gasping and check pulse
(simultaneously).
4. No pulse: Begin CPR
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1. CALL
Check the victim for unresponsiveness.
If the person is not responsive and not
breathing or not breathing normally.
 Call 911 and return to the victim.

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Preparation
Position a child on a hard surface.
Position a neonate or infant on a hard
surface or on the forearm of the
rescuer with the hand supporting the
head.

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Positioning for CPR is as follows

 CPR is most easily and effectively performed by laying

the patient supine on a relatively hard surface, which
allows effective compression of the sternum

 Delivery of CPR on a mattress or other soft material is

generally less effective

 The person giving compressions should be positioned

high enough above the patient to achieve sufficient
leverage, so that he or she can use body weight to
adequately compress the chest
2. Determine
Responsiveness

 Gently tap on shoulder and speak

loudly.
 If responsive, the child responds by
answering, crying or moving:
 Place in position of comfort
 Leave the child in the position in which you
find him (provided he is not in further
danger).
 Check his condition and call for help.
 Reassess him regularly 30
2. Determine
Responsiveness

 Gently tap on shoulder and speak

loudly.
 If the child does not respond
 If there is no response and not
breathing or
 not breathing normally,
position the infant on his or her back
and begin CPR
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3. Assess the child’s
circulation
 Check Pulse

 Take no more than 10 s

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 Brachial pulse check in infant

Circulation 2000;102:253I--290I-

Copyright ©2000 American Heart Association

 Carotid pulse check in child

Circulation 2000;102:253I--290I-

Copyright ©2000 American Heart Association

i. Give 30 Compressions
 Give 30 gentle chest compressions at
the rate of 100-120/minute.
 Use two or three fingers in the center
of the chest just below the nipples.
 Press down approximately one-third
the depth of the chest (about 1 and a
half inches).

35.
i. Give 30 Compressions
 Open The Airway Open the airway
using a head tilt lifting of chin.
 Do not tilt the head too far back

36.
ii. Give 2 Gentle Breaths
 If the baby is not breathing or not
breathing normally, cover the baby's
mouth and nose with your mouth and
give 2 gentle breaths.
 Each breath should be 1 second long.
 You should see the baby's chest rise
with each breath

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INFANT
CPR

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Infant CPR
 Place infant on firm
surface and maintain
airway.
 Place two fingers in the
middle of the sternum.
 Use two fingers to
compress the chest
about 1" at a rate of
least 100/min
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40
 CPR Infant
Compression depth: Finger/Thumb
1/3 of the depth of the chest position:
lower 1/2 of the sternum

Slide 42
45
46
 Allow sternum to
return briefly to its
normal position
between compressions.
 Coordinate rapid
compressions and
ventilations in a
15:2 or 30 :2 ratio.
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CHILD
CPR
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50
One-hand chest compression
technique in child

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One-hand chest compression
technique in child

Circulation 2000;102:253I--290I-
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56
High-Quality CPR
 Ensuring chest compressions of
adequate rate,
 Ensuring chest compressions of
adequate depth
 Allowing full chest recoil between
compressions
 Minimizing interruptions in chest
compressions
 Avoiding excessive ventilation
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 High quality CPR…
 Chest compressions of appropriate rate and
depth.
 "Push fast": push at a rate of at least 100
compressions per minute.
 "Push hard": push with sufficient force to
depress the chest (at least 1/3 of the AP diameter
of the chest or approximately 1½ in. = 4 cm in
infants and approximately 2 in. = 5 cm in
children)
 allowing complete recoil of the chest after each
compression
 minimizing interruptions in compressions
 avoiding excessive ventilation
Circulation, Circulation,
Circulation

Push hard
Push fast
62



 should be performed 5 times - 30
compressions and 2 breaths
 check the victim's artery for pulse
(for no longer than 10 seconds) and
other signs of consciousness.
 If you not feel a pulse within 10
seconds, you should begin cycles of
chest compressions and ventilations.

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Do not interrupt resuscitation
until
 The child shows signs of life (starts
to wake up, to move, opens eyes
and to breathe normally).
 More healthcare workers arrive and
can either assist or take over.
 You become exhausted

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 Minimize interruptions in compressions
 Avoid excessive ventilation
 Rotate compressor every 2 minutes
 If no advanced airway, 15:2
compressionventilation ratio.
 If advanced airway, 8 -10 breaths per
minute with continuous chest
compressions
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Breathing

 Objective: Maintain Gas Exchange

Rescue Breathing
 Mouth to mouth/nose-mouth

 Bag and Mask

Self-inflating Bag-Mask
without reservoir 30 -80 % O2
with reservoir 60-95 % O2
Do NOT use demand valve
69
Breathing-How much and how
fast?
 Adequate ventilation= adequate volume x
adequate rate

 Volume: enough to cause chest rise over

1-1.5 sec (esophageal resistance
may be overcome if faster)

 Rate: 20/min
synchronized w/ compressions at
a ratio of 1:5
Drug Therapy

Epinephrine IO/IV Dose:

 0.01 mg/kg (0.1 mL/kg of
1:10,000 concentration).
 Repeat every 2- 3 minutes.
 If no IO/IV access, may give
endotracheal dose: 0.1 mg/kg (0.1
mL/kg of 1:1,000 concentration).

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

72
 Optimal Recovery Position ( children )

▪ Place the child in as near true lateral position as

possible, with his mouth dependent, which should
enable the free drainage of fluid
▪ The position should be stable.
In an infant:
 may require a small pillow or a rolled-up
blanket to be placed along his back to maintain
the position,
 To preventing the infant from rolling into Either
the supine or prone position
 Optimal Recovery Position
PROSEDUR:
▪ Berlutut di samping korban dan pastikan kedua
kakinya lurus,
▪ Letakkan lengan yang terdekat dengan anda
pada sudut kanan tubuh, siku ditekuk dengan
telapak tangan menghadap keatas
▪ Geserkan tangan yang lebih jauh dari penolong,
bawa melewati dada kearah pemolong. Pegang
punggung tangan ke arah pipi korban yang
terdekat dengan penolong
ERC
 Optimal Recovery Position
PROSEDUR:
▪ Dengan tangan Anda yang lain, pegang kaki yang
jauh dari penolong tepat di atas lutut dan tarik ke
atas, jaga kaki di tanah
▪ Menjaga tangan menempel di pipi, tarik pada
kaki yang jauh jauh dari penolong agar bergulir
kearah penolong bertumpu pada sisi korban

ERC
 Optimal Recovery Position ( children )

▪ Avoid any pressure on the child’s chest that

may impair breathing
▪ It should be possible to turn the child onto
his side and back again to the recovery
position easily and safely, taking into
consideration the possibility of cervical spine
injury by in-line cervical stabilisation
techniques.
▪ Regularly change side to avoid pressure
points (i.e. every 30 min).
Advanced Airway
 Endotracheal intubation or
supraglottic advanced airway
 Waveform capnography or
capnometry to confirm and monitor
ET tube placement.
 Once advanced airway in place give 1
breath every 3- 6 seconds (10 -20
breaths per minute)

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AIRWAY

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80
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Airway Opening Manoeuvres
Chin lift/head tilt

Infants Smaller children

Neutral head position Sniffing position
with chin lift with chin lift
Slide 84
Airway Opening Manoeuvres
Chin lift/head tilt

Older children/adults
Backward head tilt
with pistol grip
Slide 85
86
Airway Opening Manoeuvres
Use when concerned re
Jaw thrust
cervical spine injury
May also facilitate
bag and mask
ventilation

Slide 88
Jaw thrust
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90
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92
93
94
95
Nasopharyngeal Airway

96
97
98
Bag to Mask Ventilation
105
Monitor the Effectiveness of
Ventilation
 Visible chest rise with each breath.
 Oxygen saturation.
 Heart rate.
 Blood pressure.
 Distal air entry.
 Patient response

107
Foreign-Body
Airway
Obstruction
(Choking)
Foreign Body
Obstruction
Foreign Body
Obstruction
 Foreign Body
Assess Severity

Severe airway Mild airway

obstruction obstruction
Ineffective Cough Effective Cough

Unconscious Conscious • Encourage

coughing
• Continue to check
Call for help victim until recovery
Call for help or deterioration
Commence Give up to 5 back
blows • Call for help
CPR
If not effective
Give up to 5 chest
Slide
thrusts 113
 Foreign Body Airway
Obstruction
Management
Minimize intervention if child conscious, maintaining own
airway
100% oxygen as tolerated
No blind sweeps of oral cavity
Wheezing  Object in small airway
Avoid trying to dislodge in field
For infants:

▪ Lay the infant on one arm or on the thigh in a

head-down position.
▪ Give five blows to the infant’s back with the heel
of the hand.
▪ If the obstruction persists, turn the infant over
and give five chest thrusts with two fingers, 1
finger’s breadth below the nipple level in the
midline.
▪ If the obstruction persists,
check the infant’s mouth
for any obstruction which
can be removed
▪ If necessary, repeat this
sequence with back slaps
again.
 Infant back blows to
relieve complete FBAO

Circulation 2000;102:253I--290I-
Back blows infant Back blows small child
Slide
120
▪ Hold the infant facedown.
▪ Deliver five back blows.
▪ Bring infant upright on the
thigh.
▪ Give five quick chest thrusts.
▪ Check airway.
▪ Repeat cycle as often as
necessary.
 Foreign Body
If 5 back blows unsuccessful:

Chest thrusts
• Identify same compression point
as for CPR
• Give up to 5 chest thrusts
• Similar to compressions but
sharper and delivered at a slower
rate
• Check to see if each thrust has
relieved the airway obstruction
Slide 123
 Hand
position
is lower
half of
the
sternum

Chest thrusts infant Chest thrusts small child

Slide
124
• Do not perform abdominal
thrusts in infants as there is
risk of injury to the abdominal
organs.
 Unconscious infant
• First open the mouth wide by grasping the tongue and
jaw, and look for the foreign body in the oral cavity.
• If an object is seen, remove it, but do not perform a
blind sweep.
• If there is no improvement, begin cardiopulmonary
resuscitation (CPR) providing five cycles (30:2) over 2
minutes.
• If breaths cannot be delivered, reposition the head and
try again, or proceed with advanced airway maneuvers
until respirations have been restored.
 In a conscious child:

– Kneel behind the

child.
– Give the child five
abdominal thrusts.
– Repeat the
technique until
object comes out. 4
• Position the heel of the hand in the midline of the
epigastrium with the other hand on top of the first,
• then give a rapid series of separate and distinct upward
thrusts.
• With each thrust use sufficient force to dislodge the
foreign body.
• For a small child, the heel of one hand is sufficient 
overly vigorous abdominal thrusts may cause damage
to internal organs.
• If the patient loses consciousness, reposition the head
• A foreign body may also be removed under
direct visualization with a laryngoscope and
Magill forceps.
• On rare occasions, if there is total obstruction
of the proximal upper airway, cricothyrotomy
may be needed.
• Consult an otolaryngologist to remove more
distal tracheal or laryngeal foreign bodies via
flexible bronchoscopy
 Hand
position is
lower half
of the
sternum

Chest thrusts small child

Slide 132
cpr
 Any question ?

Check for pulsE

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134
Intraosseous Cannulation

Indication

 Vascular access required

 Peripheral site cannot be obtained
 In three attempts, or
 After 90 seconds
Intraosseous Cannulation

 Devices
 16 gauge hypodermic needle
 Spinal needle with stylet
 Bone marrow needle (preferred)
Intraosseous Cannulation
Site
Children 6 to 12 years of age: Children 0 to 6 years of age:
A. Medially to tibial tuberosity A. Medially to tibial tuberosity
B. Above medial malleolus B. Above medial malleolus
C. Humeral head

2-3 cm

1-3 cm
Intraosseous Cannulation
Needle in place if:
 Lack of resistance felt
 Needle stands without support
 Bone marrow aspirated
 Infusion flows freely
Intraosseous Cannulation

 Contraindications
 Fractures
 Failed attempt on same bone
Intraosseous Cannulation
Complications

Incomplete penetration of the bony Fluid escaping around the needle

cortex. through the puncture site.

Fluid leaking through a nearby

Penetration of the posterior cortex. previous cortical puncture site.
What can be put through an
IO?

Anything that can be put through an

IV!