adarcGieie coe 06Page1of5 October 2006 Paediatric Guidelines ● ● ● ● ● ● ● Ifthechildresponds (byansweringormoving): a. suspected cervicalspinalinjuries. right?” Gently stimulatethechildandaskloudly Checkresponsiveness: 2. Ensure thatyou,thechildandanybystandersare safe Safety 1. MANAGEMENT Appendix 1 a dutytorespond topaediatricemergencies ( The followingsequenceisthatfollowedbythosewith INTRODUCTION .Ifthechilddoesnotrespond: b. potential backorneckinjury. abouta airway takespriorityover concerns until theairwayisopen; establishing apatent or chinlift,addheadtiltasmall amountatatime persists despiteeffective applicationofjawthrust (if available).Iflifethreatening airwayobstruction stabilisation oftheheadandneckbyanassistant alone incombinationwithmanualin-line a clearupperairwaybyusingjawthrustorchinlift when there isariskofbackorneckinjury, establish lifting thechin: open thechild’s airwaybytiltingtheheadand child isnotinfurtherdanger) leave thechildinpositionfound(provided the summon helpifnecessary re-assess thechildregularly. summon helpifnecessary check thechild’s condition ifyoustillhavedifficulty in openingtheairway, – atthesametime,withyourfingertip(s)under – withthechildinpositionfound,placeyour – is turned carefully ontohisback is turned forward. Bothmethodsmaybeeasierifthe child child’s mandible(jawbone)andpushthejaw fingers ofeachhandbehindsidethe try thejawthrustmethod:placefirsttwo block theairway on thesofttissuesunderchinasthismay point ofthechild’s chin,liftthechin.Donotpush back hand ontheforehead andgentlytiltthehead - DONOT ). shake infants,orchildren with “Are youall see ● ● ● ● ● ● ● the chest: your faceclosetothechild’s faceandlookingalong Look, listenandfeelfornormalbreathing byputting Keepingtheairwayopen 3. ● ● ● ● ● ● ● ● .IfthechildisNOTbreathing orismaking agonal b. IfthechildISbreathing normally a. before decidingthatbreathing isabsent. Look, listenandfeelfornomore than10seconds Rescue breaths foraninfant: Rescue breaths forachildover1yearofage: gasps tothebackorneck appropriate precautions ifthere isanychanceof thechildcarefully ontohisbacktaking turn carefully remove anyobviousairwayobstruction if there isanychanceofinjurytotheneckorspine position (seebelow)takingappropriate precautions thechildontohissideintorecovery turn listen atthechild’s noseandmouthforbreath sounds sufficient tomake thechestvisiblyrise inflate thecheststeadilyover about1–1.5seconds mask appropriate tothesizeofchild)and use abagvalvemaskdevice ifavailable(witha chin lift ensure aneutralpositionoftheheadand apply a normalbreath. in asimilarfashiontothemovementproduced by by seeingthatthechild’s chesthasrisenandfallen repeat thissequence5times. Identifyeffectiveness fall asaircomesout maintaining headtiltandchinlift,watchthechest watching forchestrise inflate thecheststeadilyoverabout1–1.5seconds mask appropriate tothesizeofchild)and use abagvalvemaskdevice,ifavailable,(with ensure headtiltandchinlift described later. assessment of‘signsacirculation’, whichwillbe responses, ortheirabsence,willformpartofyour or coughresponse toyouraction.These while performingtherescue breaths noteanygag check forcontinuedbreathing. feel forairmovementonyourcheek. look forchestmovements give 5initialrescue breaths Child BasicLifeSupport(BLS) (infrequent, irregular breaths):

Paediatric Guidelines Child (BLS)

● maintain head tilt and chin lift, watch the chest fall ● make up to 5 attempts to achieve effective as air comes out breaths. If still unsuccessful, move on to chest compressions. ● repeat this sequence 5 times. Rescue breaths for a child over 1 year of age if no Paediatric Guidelines is available: 4. Assess the child’s circulation:

● ensure head tilt and chin lift Take no more than 10 seconds to look for signs of a circulation. This includes any movement, coughing, or ● pinch the soft part of the nose closed with the index normal breathing (not agonal gasps – these are finger and thumb, with the hand on the forehead infrequent, irregular breaths) check the pulse but ● open the mouth a little, but maintain the chin ensure you take no more than 10 seconds to do this: upwards ● in a child over 1 year— feel for the carotid pulse in ● take a breath and place your lips around the the neck mouth, making sure that you have a good seal ● in an infant — feel for the brachial pulse on the ● blow steadily into the mouth over about 1–1.5 inner aspect of the upper arm. seconds watching for chest rise a. If you are confident that you can detect signs of ● maintain head tilt and chin lift, take your mouth a circulation within 10 seconds: away from the child and watch for his chest to fall ● continue rescue breathing, if necessary, until as air comes out the child starts breathing effectively on his own ● take another breath and repeat this sequence five ● turn the child on to his side (into the recovery times. Identify effectiveness by seeing that the position) if he remains unconscious taking child’s chest has risen and fallen in a similar fashion appropriate precautions if there is any chance to the movement produced by a normal breath. of injury to the neck or spine Rescue breaths for an infant if no bag valve mask ● re-assess the child frequently. is available b. If there are no signs of a circulation OR no pulse ● ensure a neutral position of the head and a chin lift OR a slow pulse (less than 60/min with poor ● take a breath and cover the mouth and nasal perfusion) OR you are not sure: apertures of the infant with your mouth, making ● start chest compressions sure you have a good seal. If the nose and mouth cannot be covered in the older infant seal only the ● combine rescue breathing and chest infant’s nose or mouth with your mouth (if the nose compressions. is used, close the lips to prevent air escape) For all children, compress the lower third of the ● blow steadily into the child’s mouth and nose over sternum: 1–1.5 seconds, sufficient to make the chest visibly ● to avoid compressing the upper abdomen, locate rise the xiphisternum by finding the angle where the ● maintain head tilt and chin lift, take your mouth lowest ribs join in the middle away from the child and watch for the chest to fall ● compresss the sternum one finger’s breadth above as air comes out this ● take another breath and repeat this sequence five ● compressions should be sufficient to depress the times. sternum by approximately one-third of the depth of If you have difficulty achieving an effective breath, the chest the airway may be obstructed: ● release the pressure, then repeat at a rate of ● open the child’s mouth and remove any visible approximately 100 a minute obstruction. DO NOT perform a blind finger sweep ● after 15 compressions, tilt the head, lift the chin ● ensure that there is adequate head tilt and chin lift and give two effective breaths but also that the neck is not over extended ● continue compressions and breaths in a ratio of 15:2. ● if head tilt and chin lift has not opened the airway, try the jaw thrust method

Page 2 of 5 October 2006 Paediatric Guidelines adarcGieie coe 06Page3of5 October 2006 Paediatric Guidelines ● side intotherecovery position: ontohis is breathing spontaneouslyshouldbeturned An unconsciouschildwhoseairwayisclearandwho RECOVERY POSITION ● ● Continue resuscitation until: 5. fingers interlocked. achieved mosteasilybyusingbothhandswiththe In larger children orforsmallrescuers, thismaybe it byapproximately one-third ofthedepth the chest. todepresswith yourarmstraight,compress thesternum Position yourselfverticallyabovethechild’s chestand, over thechild’s ribs. Lift thefingerstoensure thatpressure isnotapplied (asabove). sternum Place theheelofonehandoverlowerthird ofthe Chest compression inchildren over1yearofage the infant’s chest. to depress itapproximately one-third ofthedepth withthetwothumbs Press downonthelowersternum the tipsoffingerssupportinginfant’s back. to encircle thelowerpartofinfant’s ribcagewith Spread therest ofbothhandswiththefingerstogether towards theinfant’s head. (asabove)withthetipspointing of thesternum Place boththumbsflatsidebyonthelowerthird technique. If there are 2ormore rescuers, usetheencircling the tipsof2fingers. The lonerescuer with shouldcompress thesternum Chest compressions ininfants infants andchildren. best methodforcompression variesslightlybetween less than100becauseofpausestogivebreaths. The minute, theactualnumberdelivered perminutewillbe Although therateofcompressions willbe100timesa compression andventilation. they are havingdifficulty withthetransitionbetween Lone rescuers mayusearatioof30:2,particularlyif allow free drainage offluid position aspossiblewithhis mouthdependentto the childshouldbeplaced in asnearatruelateral respiration, pulse,movement) the childshowssignsoflife(spontaneous you becomeexhausted. ● ● ● ● ● ● Key Points–PaediatricBasicLifeSupport ● ● children. the adultrecovery positionissuitableforusein observed the airwayshouldbeaccessibleandeasily consideration thepossibilityofcervicalspineinjury himbackeasilyandsafely,and toreturn takinginto thechildontohisside it shouldbepossibletoturn that impairsbreathing it isimportanttoavoidanypressure onthechest position blanket placedbehindhisbacktomaintainthe require thesupportofasmallpilloworrolled-up the positionshouldbestable.Inaninfant,thismay Child BasicLifeSupport(BLS) 1–1.5 secondswatchingforchestrise. breaths. Blowsteadilyintothemouthoverabout a blindfingersweep.Give5initialrescue obvious airwayobstructionbut If thechildisnotbreathing, carefully remove any of 15:2. Continue compressions andbreaths inaratio compressions ofapproximately 100aminute. or youare notsure startataratechest or aslowpulse(<60/bpmwithpoorperfusion) If there are nosignsofcirculation, pulse,orno DO NOT perform

Paediatric Guidelines Child Basic Life Support (BLS)

BIBLIOGRAPHY METHODOLOGY 1 Berg RA, Hilwig RW, Kern KB, Ewy GA. “Bystander” The methodology describing the development process Chest Compressions and Assisted Ventilation of the international cardio-pulmonary resuscitation Independently Improve Outcome From Piglet treatments recommendations on which this guideline Paediatric Guidelines Asphyxial Pulseless “Cardiac Arrest”. Circulation is based is fully described in the publications listed 2000;101(14):1743-1748. below. 2 Babbs CF, Nadkarni V. Optimizing chest Morley PT, Zaritsky A. The evidence evaluation process compression to rescue ventilation ratios during one- for the 2005 International Consensus Conference on rescuer CPR by professionals and lay persons: cardio-pulmonary resuscitation and emergency children are not just little adults. Resuscitation cardiovascular care science with treatment 2004;61(2):173. recommendations. Resuscitation 2005;67(2-3):167-170. 3 Dorph E, Wikc L, Steend PA. Effectiveness of Zaritsky A, Morley PT. The Evidence Evaluation ventilation–compression ratios 1:5 and 2:15 in Process for the 2005 International Consensus simulated single rescuer paediatric resuscitation. Conference on Cardiopulmonary Resuscitation and Resuscitation 2002;54(3):259-264. Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 4 Whyte SD, Wyllie JP. Paediatric basic life support: a 2005;112(22_suppl):III-128-130. practical assessment. Resuscitation 1999;41(2):153. 5 Clements F, McGowan J. Finger position for chest compressions in cardiac arrest in infants. Resuscitation 2000;44(1):43. 6 Stevenson AGM, McGowan J, Evans AL, Graham CA. CPR for children: one hand or two? Resuscitation 2005;64(2):205. 7 Samson R, Berg R, Bingham R, PALS Task Force. 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(3):237-243. 8 Berg RA, Hilwig RW, Kern KB, Babar I, Ewy GA. Simulated mouth-to-mouth ventilation and chest compressions (bystander cardio-pulmonary resuscitation) improves outcome in a swine model of pre-hospital pediatric asphyxial cardiac arrest. Critical Care Medicine 1999; 27(9):1893-1899. 9 Tang W, Weil MH, Jorgenson D, Klouche K, Morgan C, Yu T, et al. Fixed-energy biphasic waveform defibrillation in a pediatric model of cardiac arrest and resuscitation. Critical Care Medicine 2002.;30(12):2736-2741.

Page 4 of 5 October 2006 Paediatric Guidelines adarcGieie coe 06Page5of October 2006 Paediatric Guidelines APPENDIX 1–PaediatricBasicLifeSupportAlgorithm NOT BREATHING NORMALLY? Summon helpifappropriate (no signsofacirculation) STILL UNRESPONSIVE? 15 chestcompressions UNRESPONSIVE? 5 rescue breaths 2 rescue breaths Open airway Child BasicLifeSupport(BLS)

Paediatric Guidelines