Basic Life Support (BLS): Pediatric Resuscitation

Basic Life Support: Child Arrest 

Verify scene safety. ^{[1, 2, 3, 4, 5]}

Check responsiveness; if none, follow steps below:

• Shout for nearby help
• Activate emergency response system (eg, facility protocol, mobile phone).
• Witnessed collapse: If alone, leave to call emergency response and get AED before CPR.
• Unwitnessed collapse: Give 2 minutes of CPR and then leave the child/infant to call emergency response.
• Get automated external defibrillator (AED) and emergency equipment or send someone to do so.
• Assess for breathing and pulse.

Assess for no breathing (or only gasping) and check pulse for less than 10 seconds, simultaneously. 

If normal breathing  and a pulse is DEFINITELY present, monitor until additional help arrives

If no breathing  (or only gasping) and pulse present, follow the steps below:

• Provide rescue breathing immediately: 1 breath every 2-3 seconds (20-30 breaths/minute)
• If pulse is < 60 beats per minute (bpm) with signs of poor perfusion: Start chest compressions!

  • Signs of poor perfusion: cool extremities, decrease in responsiveness, weak pulses, paleness, mottling, and/or cyanosis
• If pulse > 60 bpm: continue rescue breaths and re-check pulses every 2 minutes; if no pulse, begin CPR
• Activate emergency response system (if not already done) after 2 minutes
• Abnormal or no beathing could be a sign of opioid overdose – consider naloxone and follow opioid overdose protocol

If no breathing  (or only gasping) and no pulse, follow the steps below:

• If alone, start high-quality cardiopulmonary resuscitation (CPR) at a compressions-to-breaths ratio of 30:2.
• If not alone, start high-quality CPR at a compressions-to-breaths ratio of 15:2.
• Every 2 minutes, check pulse, check rhythm, and switch compressors.
• Use AED as soon as available and follow the machine prompts

  • if shockable rhythm, defibrillate and then immediately re-start CPR.
  • If not shockable, resume CPR for about 2 minutes and reassess for pulse and shockable rhythm.

High-quality CPR

High-quality CPR improves a victim’s chance of survival

• Allow complete chest recoil after each compression
• Compression rate: 100-120 per minute
• Compressions-to-ventilations ratio: 30:2 if single rescuer, 15:2 if multiple rescuers
• Continuous compressions if advanced airway present and asynchronous ventilation
• Rotate compressor every 2 minutes or if fatigued.
• Minimize interruptions in compressions to less than 10 seconds.
• Avoid excessive ventilation.

Compressions: Children aged 1 year to puberty

Administration of chest compressions to children aged 1 year to puberty should proceed as follows:

• Check pulse at carotid or femoral artery.
• Compression landmarks: lower half of sternum between the nipples
• Compression method: heel of one hand, other hand on top if needed
• Depth: at least one-third anteroposterior (AP) chest diameter, about 2 inches (5 cm)

Compressions: Infants (< 1 year, excluding newborns)

Administration of chest compressions to infants(< 1 year, excluding newborns) should proceed as follows:

• Check pulse at brachial artery
• Compression landmarks: lower third of sternum between the nipples
• Compression method: two fingers if alone or thumb-encircling if multiple providers
• Depth: at least one-third AP chest diameter, about 1.5 inches (4 cm)

Airway

Establishing a patent airway should proceed as follows:

• Children: head tilted, chin lifted
• Infants: sniffing position
• If trauma suspected, minimize neck movement – jaw thrust without head tilt is recommended

Breathing

Administration of artificial respirations should proceed as follows:

• Rescue breathing (compressions to ventilation): 1-rescuer - 30:2, multiple rescuers - 15:2
• Ventilation with advanced airway (ie: endotracheal tube or supraglottic airway): Deliver 1 breath every 2-3 seconds (20-30 breaths/min)

  • Use waveform capnography or capnometry, if available
• Watch for visible chest rise

Defibrillation

Defibrillation should proceed as follows:

• Use AED as soon as available

  • In infants and children (< 8 years old), use a pediatric dose attenuator and/or pediatric pads, if available
  • If pediatric pads are not available, use adult pads
• For infants, manual defibrillator is preferred; if not available and patient in a shockable rhythm, using an adult AED may be lifesaving, but this is not clearly endorsed in the literature

  • Shockable rhythms (VT/VF) are uncommon in infants
• Resume CPR beginning with compressions immediately after each shock. 
• Minimize interruptions in chest compressions before and after shock.