The purpose of this article is to outline the fundamentals of Paediatric Basic Life Support (BLS). The issues covered are the common causes of cardiorespiratory arrest in infants and children; paediatric BLS sequences, automated electrical defibrillation and choking treatment algorithms. The guidelines presented here are consistent with the Resuscitation Council (UK) recommendations in 2010.
In contrast to adults, children rarely suffer cardiorespiratory arrest due to a cardiac cause. Their arrests are most commonly followed by progressive respiratory deterioration from severe asthma, epiglottitis and anaphylaxis etc. The occurence of which is considered to be 60%. Cardiac structural abnormalities and electrical disorders of the heart are also responsible for some cases in children. In contrary to adults, children very often present with prolonged pre-arrest deterioration.
The common causes of cardiorespiratory arrest in infants and children are listed as follows:
1. Respiratory obstruction:
- asthma, croup, epiglottitis
- bronchiolitis, pneumonia
- foreign body
2. Respiratory depression:
- prolonged convulsions
- raised intracranial pressure (ICP)
- poisoning/ drug overdose
- neuromuscular diseases
- smoke inhalation
3. Circulatory failure due to fluid loss:
- blood loss
- trauma, e.g. Commodial cordis
- fulminant diarrhoea and vomiting
4. Circulatory failure - others:
5. Congenital heart disease and electrical abnormalities
Rescuers who have been trained in adult BLS who do not feel confident using paediatric sequences should perform resuscitation based on the adult BLS principles.
The paediatric sequence differs from the adult in several ways that make it more suitable for children. When performing cardiopulmonary resuscitation (CPR) on children the following rules should apply:
1. 5 initial rescue breaths should be performed before starting chest compressions
2. If the rescuer is on their own, they should perform CPR for 1 minute before leaving to seek help
3. Chest should be compressed by at least one third of its depth
4. Use two fingers for chest compression in an infant younger than 12 months, use one or two hands on a child over 1 year old to achieve adequate depth of compression
Below is the sequence that should be used by those with a duty to respond to paediatric emergencies, such as the healthcare professionals.
1. Ensure your own safety
2. Check the child's response; stimulate them gently and ask loudly: 'Are you all right?'
- Do not shake infants or children with suspected neck or spinal injury
3A. If the child responds:
- Leave them in the position you found them, as long as they are not in danger
- Get help if necessary. Remember to reassess regularly as children may deteriorate any moment
3B. If the child does not respond:
- Shout for help
- Turn the child onto their back and open the airway using head tilt and chin lift
- Make sure that you don't press on the soft tissue under the chin - this may compromise airway
- If those maneuvers are inadequate, you may perform jaw thrust
- If you suspect cervical spine injury, try obtaining adequate airway via chin lift and jaw thrust only. Remember that maintaining airway takes precedence over concerns about cervical spine injury.
4. Assess breathing while keeping the airway open
- Look - for movements of the chest
- Feel - for air movement on your cheek
- Listen - for breath sounds coming from the nose and mouth of the child
Assess breathing for 10 seconds only - if you are not sure if the breathing is normal, act as if it was not
5A. If the child is breathing normally:
- Place the child in the recovery position
- Send or go for help - call the relevant emergency number
- Reassess breathing regularly
5B. If the child is not breathing normally, or the breathing is absent
- Carefully remove any airway obstruction. Do not perform blind finger sweep
- Give 5 rescue breaths
- If the child is <1 year old: ensure neutral position of the head and perform chin lift. Take a breath and make a seal around the infants face and nose to ensure no leakage. Breathe into the baby's airway for 1-1.5s to ensure adequate chest wall movement. Take the mouth away and watch the chest to lower. Repeat 4 more times.
- If the child is >1 year old: ensure head tilt and chin lift. Take a breath and make a seal around mouth only. Breathe into the child's mouth for 1-1.5s to ensure chest wall rises and observe chest wall falls once you take your mouth away. Repeat 4 more times.
6. Assess the child's circulation and signs of life
- No more than 10 seconds
- Check for signs of life: coughing, moving, normal breathing
- You may assess pulse if you feel you are capable: in an infant - brachial pulse, in a child - carotid pulse. Again, do so for no longer than 10 seconds
7A. If you are confident that the signs of circulation are adequate, i.e. regular pulse over 60 beats per minute (bpm)
- Continue rescue breathing if necessary until the child starts breathing for themselves
- Turn the child into recovery position once they start breathing but are unconscious
- Reassess the child regularly
7B. If there are no signs of life - start chest compressions:
- General rules: compress the sternum 2 cm above the xiphisternum; compress by at least one third of the depth of the chest; push 'hard and fast'; maintain rate of 100-120 compressions per minute. After 15 compressions, perform head tilt and chin lift and administer 2 rescue breaths. Continue compressions and rescue breaths at a ratio of 15:2.
- In an infant <1 year old - compress the sternum with the tips of two fingers. If there are 2 rescuers, you may use the encircling technique (encircle the baby's chest with two hands with thumbs on the sternum and 'squeeze').
- In a child >1 year old - put your hand on the sternum and lift the fingers up to reduce pressure on the ribs. Position yourself vertically over the child's chest and press down with your arm straight at the elbow.
8. Continue the compressions and rescue breaths at a ratio of 15:2 until:
- The child shows signs of life
- Further qualified help arrives
- You become exhausted
Following the introduction of public access Automated External Defibrillators questions have been raised as to the use of these devices in children. Currently, according to the Resuscitation Council (UK), these devices are deemed to be safe for use in children older than 8 years old. In children aged 1-8 years, smaller paediatric pads should be used, but if they are unavailable adult pads can be used as well.
The use of AED is not recommended in children aged <1 year old, unless it is the only defibrillator available. It is important to remember that non-shockable rhythms are much more common than shockable rhythms, with only 10% of cases of cardiac arrest in children being due to ventricular fibrillation. This is in contrast to adult patients, where shockable rhythms are much more common and therefore AED is more likely to be useful.
Choking is a sudden onset of acute respiratory distress characterized by coughing, gagging and/or stridor. In majority of cases choking occurs whilst playing or eating, witnessed by a carer, so treating maneuvres are usually quickly initiated. It is important to remember that effective coughing is a much more effective and safer than any maneuvres initiated by the rescuer, therefore active interventions to relieve choking should only be started once coughing becomes ineffective.
- crying or verbally able to respond to questions
- loud cough
- able to inspire before the next bout of cough
- fully responsive
- unable to respond verbally
- cough faint or silent
- unable to breathe
- decreasing level of consciousness
(Source: Resuscitation Council Guidelines 2010)
1. The rescuers safety is paramount. Do not initiate any maneuvres if cough is effective. Once it becomes ineffective, shout for help immediately.
2. If the child is conscious, but coughing ineffectively, administer back blows:
- in an infant - support the infant in a downwards prone position across your lap and support the head with your fingers under the angle of the jaw. Deliver 5 back blows with the heel of your hand between the shoulder blades.
- in a child >1 year old - back blows are more effective if delivered with child's head in a downward position. If a child is small, place it on your lap like in an infant. Otherwise support the child in a forward leaning position and deliver 5 sharp back blows with the heel of your hand between the shoulder blades.
3. If the back blows were ineffective and child is still coughing, but is conscious:
- in an infant - DO NOT PERFORM ABDOMINAL THRUSTS. Use chest thrusts instead. Turn the baby into supine, downwards position. Identify the compression point - 1 finger breadth above the xiphisternum. Push downwards into the chest, similarly to chest compressions but more sharply and at a slower rate, 5 times.
- in a child >1year old - perform abdominal thrusts. Kneel or stand behind the child. Encircle the child's torso with your arms and place a fist of one of your hands at the midpoint between umbilicus and xiphisternum. Grasp the fist with your other hand and pull sharply inwards and upwards. Repeat up to 4 more times.
4. Reassess the child. If the child is still choking but the child is conscious, repeat the sequence. If the child has become unconscious, place them on a firm flat surface and open the airway. Attempt 5 rescue breaths and follow with CPR algorithm as outlined above.
Below is the sequence for performing recovery position. Look at the diagram above and Paediatric BLS sequence to find out about situations which require use of recovery position. The adult recovery position is suitable for use in children.
1.Kneel on the floor on one side of the child.
2. Remove all foreign objects from the mouth and check the pockets for items that might cause pressure damage to the skin.
3. Place the child’s arm that is nearest you at a right angle to their body, so it is bent at the elbow with the hand pointing upwards.
4. Pick up their other hand with your palm against theirs. Place the back of their hand onto their contralateral cheek. Keep your hand there to guide and support their head when you roll them later.
5. Use your other arm and pull up the knee that is furtherst away from you, so that the child's leg is bent and their foot is flat on the floor. Gently pull their knee towards you so they roll over onto their side.
6. Ensure that the knee and foot of the bent leg is touching the floor. Place the knee at 90 degrees to the body.
7. Gently tilt the head and lift the chin to ensure open airway.
8. Reassess breathing and the status of the child frequently.
Remember that the position should be stable and as near true lateral position as possible. In an infant, this may require use of a blanket or a pillow behind their back to ensure stability. Make sure that there is not too much pressure exerted on the chest which may impair breathing.
Paediatric Basic Life Support - Resuscitation Council Guidelines 2010 - http://www.resus.org.uk/pages/pbls.pdf
Paediatric Advanced Life Support - Resuscitation Council Guidelines 2010- http://www.resus.org.uk/pages/pals.pdf
Recovery Position (with pictures) - Epilepsy Society - http://www.epilepsysociety.org.uk/aboutepilepsy/firstaid/step-by-steprecoveryposition
Cardiac Arrest in Children - FRCA
Fastbleep © 2019.