Pediatric Basic Life Support AHA 2015 Guidelines OS 213

Trans B02 Exam 3

Andrea Orel S. Valle, MD 10/18/2018

OUTLINE • Infant: above 30 days, less than 1 year of age, excluding the
I. Introduction neonate
A. Epidemiology • Child: those above 1 year of age until the onset of puberty
B. Pediatric Arrest o Males – presence of chest/underarm hair
C. Chain of Survival o Females – presence of breast buds
D. Definitions
II. Algorithm for Basic Life Support Injury Prevention
III. The Basic Life Support Sequence • Helmet in bicycles, use of lights and reflectors
A. High-quality Chest Compressions • Seatbelt, not just in the front seat, but also at the back
B. Airway • Teaching children how to cross the road, use the pedestrian lane
C. Breathing and follow the signs
D. Emergency Response System
E. Circulation
Initiate Chest Compressions
F. Defibrillation
IV. Foreign Body Obstruction • START IMMEDIATELY
V. Summary o Even if you know it is respiratory in origin/patient is in shock
• Why start with compressions?
o Blood needs to reach the coronary arteries and the brain
I. INTRODUCTION
o Venous blood still carries oxygen (normal saturation of O2 –
• Cardiopulmonary resuscitation (CPR) is important in preserving
95-100, 70-75 for venous)
the neurologic function of a person
o Compressions are easier to start
o Even if you succeed in reviving the patient but neurologic
o Delay not more than 18 seconds compared to regular beating
function is impaired, his quality of life is diminished.

A. EPIDEMIOLOGY II. ALGORITHM FOR BASIC LIFE SUPPORT

*See Appendix for the 2015 Updated Pediatric Cardiac Arrest
• Bystander resuscitation is associated with survival of >70% with
good neurologic outcome
BLS Algorithm.
• Start resuscitation early in age A. PREVENTION OF INJURY
o Goal is to have a neurologically intact individual after • Injury is the leading cause of death in children and young adults
resuscitation • Strategies:
o In the hospital, survival is highest for infants compared to other o Passive – airbags and seatbelts
age groups (infants > children > adult) § Among the two, seatbelt is more important
o The goal isn’t about getting the heart to start, it’s about keeping § Because there was a study conducted regarding the use of
the brain alive airbags in decreasing mortality. It was stated that the use
of airbags may increase mortality due to asphyxiation.
B. PEDIATRIC ARREST o Education
• Sudden primary cardiac arrest is very uncommon in children • Prevent injury so that you will no longer need to perform BLS
• Instead, the most common cause of arrest (for the pediatric age) is
still RESPIRATORY FAILURE and SHOCK B. SAFETY
o Cessation of breathing à bradycardia à cardiac arrest • Ensure first safety of the rescuer and patient.
o Patients who have pneumonia à tachypnea à heart muscles • Quickly look around to make sure there is no environmental
get tired à arrhythmia hazard (road traffic, electrical current, chemical spills, etc.)
o Adult: Cardiac in origin o Look around, look for clues as to what happened to the child –
• Why start the compressions? fallen? Choked?
o Blood needs to reach the coronary arteries and the brain o Injury to head, neck or spine?
o Venous blood still carries oxygen • Identify that you are a rescuer: “Make way, stand back, rescuer
o Compressions easier to start coming through! The scene is safe”, “Padaanin niyo po ako,
o Delay not more than 18 seconds sasaklolohan kop o ang bata.”
• Assess need for CPR:
C. CHAIN OF SURVIVAL o Unresponsive, not breathing, gasping

C. CHECK FOR RESPONSE

• Tap the victim’s shoulders or the heel of the infant’s foot and
shout to ask if the person is okay.
• Call the child’s name if you know it
Figure 1. Pediatric chain of survival. o “Hey, hey are you okay? Hey, hey are you alright?”
o Approach both ears of the patient (may be deaf), as loud as
1. Injury Prevention you can
2. Chest Compression • Do not pinch the nipple, nor put pressure on supraorbital notch of
3. Call for Help the patient
4. Emergency Medical Services • If the child moans or answers, phone the emergency response
5. Advanced Life Support/Integrated Post Support Care/Post system.
Arrest Care o PGH: 554-8400 (Save this number in your phones!!)
o Check for injuries or need for medical assistance.
Definitions o Allow the child to assume a position of comfort

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• If no response, still call for help and activate the emergency but not more than
response system by mobile device 1/2
o Again! PGH: 554-8400 One (1) Rescuer Two (2) Rescuers
o Put your phone on speaker 30:2 (compressions
o “There’s no response. Somebody help me. You, call PGH.” per breath ratio)
“Push fast”: ≥ 100- *At 30, you have
15:2
120/min given the patient
D. CHECK FOR BREATHING AND PULSE
effective
• Check pulse while checking for breathing at the same time. compressions
Together, should take at least 5 seconds but no more than 10 You may follow the tempo of “Staying Alive”
seconds only. in your head
o Do not use your thumb when checking the pulse
• Scan the victim’s chest for rise and fall.
o No rise and fall – no breathing
• Run hand above the chest.
• If with regular breathing, CPR not needed à place in recovery
position
o Maintains patency of airway
o Decreases risk of aspiration

Figure 3. Pediatric (infant) chest compressions techniques.

Figure 2. Recovery Position

• Position:
o Infant: brachial pulse à between the shoulder and the
antecubital fossa, 2-3 fingers away, inner arm
o Child: carotid or femoral pulse
• Begin CPR immediately if:
o Not breathing, or just gasping
o No pulse appreciated, or pulse > 60 beats/min
o Exemptions:
¨ Lone rescuer and witnessed sudden arrest
à Leave victim to activate emergency response first Figure 4. Pediatric (Child) chest compressions techniques.
à Get the AED
¨ Lone rescuer and arrest not sudden nor witnessed • Reminders:
à Do CPR for 2 minutes (one cycle) o Keep elbow straight (not bent), with strength coming from
à Call for help after (about 5 cycles of chest compression hips (not shoulders), the upper body should be one unit.
and breaths) o “it’s not your shoulders, it has to come from the core.
• Remember: o Put a hard surface underneath to make compressions more
o C – Compression or Circulation effective
o A – Airway o Allow chest to recoil after each compression
o B – Breathing o Do not lean on the chest on the recoil phase
• Note: o When you press, you are pumping out the blood
o Don’t start with rescue breaths! o Minimize interruptions to less than 10 seconds.
o Compressions should be high quality! Remember, true o Avoid excessive ventilation which can inflate your lungs too
compressions are quite painful but it doesn’t batter since the much making compressions less effective
patient is unconscious anyway. It is better to have a patient o Switch every two minutes for ≤ 5 secs, to minimize fatigue. It’s
with broken ribs but alive than a dead one because of not easy to do high quality chest compressions Quality of
improperly done compressions! (of course, don’t push too hard compressions is inversely related to responder fatigue.
either. Remember, depth should be 2”.) o Why do 2 hand technique only when you have two rescuers? To
avoid interruptions on compressions and avoid delayed breaths.
III. THE BASIC LIFE SUPPORT SEQUENCE
A. COMPRESSION
B. AIRWAY
Infant Child • Goal: to establish and maintain a patent airway, and deliver
Two (2) fingers just effective ventilation
below the Heel of hand/s at
Position
intermammary lower half of sternum
1. Head Tilt – Chin Lift
(nipple) line
Both should not be directly above the xiphoid 1. Place one hand on child’s forehead and tilt head gently back into
process (So as to avoid puncturing the heart) a neutral position
“Push hard”: 1/3 AP o External ear canal should be level with the top of the infant’s
4 cm 5-6 cm shoulder
diameter of the chest

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2. Place fingers of other hand under bony part of chin and lift
mandible upward and outward
3. Careful not to close the mouth or push on soft tissues of the neck

• Reminders:
o Be careful not to close the mouth or push on soft tissues of the
neck.
o If there is visible foreign body or vomitus, remove it only if you
see it clearly!
o Do NOT do blind finger sweeps!

2. Jaw Thrust
• Done if neck injury is suspected
• Place two or three fingers under each side of the lower jaw at its
angle and lift the jaw upward.
• Not an easy maneuver, may be quite painful Figure 6. 2 Left photos – Barrier Devices, 2 Right photos – Bag-Mask
Ventilation

• BAG-MASK VENTILATION
o Remember EC technique, thumb and index to control the
mask and the 3rd to 5th digits under the chin to close/control the
mouth
o Only for 2-person CPR
o Bag volume of at least 500mL
o Open airway by lifting the jaw towards the mask
o Ensure tight seal between mask and patient’s face
o Attach to O2 if available
o Make sure that the patient is not over-ventilated
Figure 5. Jaw Thrust vs Chin Lift § Lungs may be inflated and patient might die of
pneumothorax
C. BREATHING
Infant Child 2. Inadequate Breathing with Pulse
Position Mouth-to-mouth-and- Mouth-to-mouth (pinch • Pulse ≥ 60 per minute
nose OR Mouth-to-nose victim’s nose with thumb • Give rescue breaths: 12 – 20 per minute (1 breath every 3-5
(with closed mouth) and forefinger of the seconds)
hand; maintain head tilt)
• Reassess pulse every 2 minutes
• Process • Only start chest compressions if pulse disappears
o Take a regular breath
o Give 2 breaths about 1 second each 3. Bradycardia with Poor Perfusion
o Inhale between breaths • Bradychardia: HR < 60
• Reminder: Make sure there is chest rise! If not, may indicate • Signs of poor perfusion
ineffective breaths, improper angle or obstruction. o Mottling
o If there is only one rescuer: 32 compressions, 2 breaths o Pallor
o If there are two rescuers: 15 compressions, 2 breaths o Cyanosis
o Important because the most common cause of arrest in children o Cool extremities
is respiratory therefore a need to deliver more frequent breaths o Decreased consciousness
o Disappearing pulse
1. Devices Used in Rescue Breathing • Begin chest compressions immediately
• Do not use if rescuer is alone!
• BARRIER DEVICE 4. If with Advanced Airway
o Make a seal around the patient’s mouth and nose. Make sure • Advanced airway: endotracheal tube, tracheostomy, laryngeal
it is tight-sealed. Breathe manually through the valve. mask airway
o Disadvantage: size may not be suitable for the size of the • Compression rate: 100- 120/min
patient’s head • Breath rate: 1 breath every 6 seconds
o 2 fingers (thumb and pointing finger) are used to hold the mask • No pauses for breaths
down.
o The other 3 are used to adjust the position and stabilize the head.
• Remember:
o C – Compression or Circulation
o A – Airway
o B – Breathing
o D – Defribillation

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D. DEFIBRILLATION • Do jaw thrust – chin lift maneuver; if foreign body visible, remove
Shock it. If it’s too far back: don’t touch it.
• Do NOT make them drink water if the patient is choking as it will
enter the trachea as well
• If aspiration strongly considered, encourage child to continue
spontaneous coughing and breathing efforts as long a cough is
forceful
(mostly lifted from 2021):
A. Relief of FBAO: Child
• Do the Heimlich maneuver.
• Stand behind the victim with arms directly under the victims axilla,
encircling the torso
Figure 7. Pedia Defibrillator • Place the thumb side of one fist against the victim’s abdomen in the
• Should have AED 2 minutes into compressions. Attach AED once midline slightly above the navel and below the xiphoid
available. Pads should not touch each other o Do NOT extend the thumb out of the fist as it may break
• Use pediatric pads as much as possible because the dosage of the especially when the patient’s abdomen is hard or muscular
shock is different from those in adults • Grasp the fist with the other hand and exert a series of quick
• Adult pads can also be used as long as they are at least 3 upward thrusts (J-shaped). Do this until the foreign body
centimeters apart dislodges or until the patient loses conscousnes.
• First dose: 2J/kg o Unconscious: chest compressions
• Second dose: 4J/kg • Do not lift the child off his/her feet!
• Do not exceed adult dose: 300J • If pregnant – do chest compressions only
• Resume chest compressions after shock.
• Follow automatic external defibrillator (AED) prompts
• After attaching pads, AED will say “Analyzing rhythm.” While this
is happening, do not do chest compressions.
• If the AED says that it’s a non-shockable rhythm, resume chest
compressions. Otherwise, it will be charging. Resume chest
compressions while it’s charging until it’s ready (“delivering shock
now.”)
• “I’m clear, you’re clear. Everybody clear.”
o Stop making compressions before the shock.
o MAKE SURE YOU ARE ACTUALLY CLEAR.
o Recall: Anonymous fellow who forgot the patient was touching
his/her hand when the shock was released. Ouch!
• End CPR cycle with compression
• Resume compression immediately after analysis and/ or shock

IV. FOREIGN BODY AIRWAY OBSTRUCTION Figure 8. Heimlich Maneuver

• Ask first if the patient is choking! B. Relief of FBAO: Infant
• More than 90% of deaths from foreign body obstruction occur
• Done to infants who cannot hold their heads up yet
in <5 yo.
• Hold face down, hold jaw to support head
• Suspected sudden onset of respiratory distress with coughing,
• Give 5 slaps between shoulder blades using heel of hand
gagging, stridor, or wheeze
o Universal sign of choking • Sandwich between arms and turn over, with support on the
o ASK: “Are you choking?” / “Nasasamid ka ba?” infant’s head since infants still lack head control
o Universal sign of choking: • Give 5 chest compressions.
o Increases intrathoracic pressure
• Continue until the object is expelled or infant becomes
unresponsive.
• Do not do pulse check.
• In unresponsive, do 30 chest compressions immediately, then
check airway for foreign body
• If still not expelled, give 2 rescue breaths then proceed with CPR
• Call for help after 2 minutes if not done yet.

Figure 6. Universal sign of choking

o Mild obstruction
§ Able to cough and make sounds
§ Do not interfere, just let them cough it out
o Severe obstruction
§ No sound, no cough
§ Respiratory distress, cyanosis
• Do not do blind finger sweeps – could push the foreign body
further back

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REFERENCES
Dr. Valle-approved music that will guide you in giving 100-120 bpm
compressions (do not sing them out loud!):
https://tinyurl.com/studybls1
https://tinyurl.com/studybls2
https://tinyurl.com/helphelphoorayyy

Figure 9. Infant relief of FBAO.

C. Heimlich Maneuver: Unconscious

Rest in peace, Rescusci Anne

END OF TRANS

Figure 10. Heimlich Maneuver on Unconscious

From 2018:
• Place victim in supine position.
• Perform chin lift – jaw thrust maneuver and remove foreign body if
visible.
• If not, attempt 2 rescue breaths.
• If unsuccessful, straddle patient’s hips or kneel in the side.
• Place heel of one hand on the abdomen on the midline slightly
above the navel and avoid xiphoid process. Put the other hand on
top of the other
• Press both hands in the abdomen with a distinct upward thrust,
keeping to the midline. Perform 5 times.
• Look at the mouth again. Repeat as needed.

V. SUMMARY
• C-A-B-D
• Give high quality chest compressions
o Compress 100 to 120/min
o Compress at depth of 1/3 AP diameter of chest
o Allow complete chest recoil
o Minimize interruptions
o Avoid excessive ventilation
• Sequence
o 1 rescuer – 30:2
o 2 rescuers – 15:2
• Call for help!

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APPENDIX

Appendix 1. Summary of Differences Between Adult and Pedia BLS

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