Paediatric Basic Life Support Theory (2015 guidelines)

Objectives: By the end of this session you will: Be able to describe how to confirm cardiac arrest in children of different ages Know how to summon help Understand how to perform CPR for these groups Be able to prepare to defibrillate a child Be able to recognise and treat a child who is choking Be able to place a child into the recovery position

Basic Life Support (BLS) BLS provides recognition and treatment of the person in cardiac arrest and buys time until the victim can receive more advanced treatment by means of achieving oxygenation of vital organs. For the purposes of BLS: An infant is a baby less than 1 year of age A child is aged between 1 year and puberty (NB it is not necessary or appropriate to establish the onset of puberty), if it looks like a child treat it as a child

Do not delay CPR if unsure of which guidelines to follow – any CPR is better than no CPR If uncertain or untrained, perform adult basic life support with the following paediatric modifiers: Give 5 initial rescue breaths before starting chest compressions If you are on your own perform CPR for 1 minute before going for help Compress chest by at least 1/3 of its depth, 4cm for an infant and 5cm for an older child Use 2 fingers for an infant <1 yr and 1 or 2 hands for a child >1 yr

BLS It is important that guidelines for BLS are followed closely, as if one manoeuvre is missed or incorrectly performed this will impact upon effectiveness of subsequent interventions Cardiac arrest in children is usually hypoxic in origin so the priority is prompt is oxygenation The most common cardiac arrhythmia in children is profound bradycardia deteriorating into asystole, hence BLS is more important than access to defibrillator Shockable cardiac arrests are rare in children, however in sudden witnessed collapse (particularly if history of a cardiac condition) calling for help and accessing a defibrillator is preferable

Initial approach to the collapsed child Safety: Assess the situation to ensure safety of rescuers then victim. Check for clues that may have caused the emergency, including risk of head/cervical spine injury Stimulate: Never shake a child Stabilise the child’s head by placing one hand on their forehead while tugging their hair gently, calling their name or telling them to wake up If there is no response then follow BLS guidelines as follows:

BLS algorithm

Shout for help Open airway Not breathing normally If only 1 rescuer do not leave the child, shout help and start assessment. The 2nd rescuer should dial 2222 stating “paediatric medical emergency” followed by precise location before returning to the areas with emergency equipment and more help if available Open airway Briefly check mouth for obstruction and clear if necessary In an unconscious child the tongue is likely to occlude the airway. Use head tilt, chin lift to open the airway Infant – head to neutral position Child – head in “sniffing” position In suspicion of head/neck trauma use jaw thrust Not breathing normally Put head next to child’s nose and mouth looking at the chest with airway open.. Look, listen and feel for normal breathing for no longer than 10 seconds, ignoring agonal or occasional gasps

Positions used to open airway: Neutral position Infant Sniffing position Child Jaw thrust C spine injury

If the child is breathing normally: Maintain patency of airway while awaiting further help Unless c-spine injury is suspected place child on their side If the child is not breathing normally: Or if they are making occasional or agonal breaths, immediately attempt 5 rescue breaths. Agonal breaths are indicative of the early stages of cardiac arrest and must not be confused with normal breathing

Rescue breaths: As you deliver breaths, ensure an adequate seal. Until equipment arrives you may consider: - covering child’s nose and mouth with your mouth (infant) - breathing into child’s nose while closing mouth (infant) - mouth to mouth (child) The 5 rescue breaths should be delivered slowly over appr. 1 second (slow breaths minimise the chance of gastric distension) You may consider moving the child’s head slightly as you deliver breaths until you see chest movement If no chest movement check airway is clear Add supplemental oxygen via resuscitation masks as soon as available

Circulation Compressions Now check if the child has adequate circulation or if they now need chest compressions. Take no longer than 10 seconds to look for obvious signs of life, if confident also checking for a central pulse (femoral or brachial in infants, femoral or carotid in a child). Circulation Compressions If no signs of life and rescuer is not certain they can feel a pulse >60 bpm immediately commence chest compressions If there is signs of life and a pulse >60bpm, reassess breathing. If normal place child on side. If breathing is absent/inadequate/agonal deliver 12-20 breaths per minute

Chest compressions: Chest compressions must be of a high quality to achieve best outcomes Victim should be lying on a firm flat surface Position of hands should be lower half of the sternum, one finger’s breadth above the xiphisternum 2 fingers should be used to depress chest in an infant Encircling technique can be used if 2 rescuers 1-2 hands one of top of the other should be used in a child Should be performed at a rate of 100-120 per minute Should be performed at a depth of 4cm in infants and 5cm in a child Full recoil of the chest should be allowed between each compression

Chest compressions: 2 fingers Infant Encircling technique Infant, 2 rescuers 1-2 hands Child

When to stop: If a single rescuer stop and make phone call for help after approximately 1 minute of CPR. Use a mobile or carry the child to a phone if necessary so you can continue CPR In hospital call 2222 stating “paediatric medical emergency (+/- anaesthetic team)” followed by your location Out of hospital call 999/112 Otherwise only stop if: The child exhibits adequate signs of life Help arrives and takes over You are a single rescuer and too exhausted to continue When paediatric resuscitation equipment is available advanced life support techniques can commence

Paediatric advanced life support algorithm

Paediatric defibrillation Paediatric pads should be placed in the anterior-posterior position in an infant or in a child place one pad just below the right clavicle to the right of the sternum and the other in the mid axillary line to the let of the chest, or the anterior-posterior position if unable to do so Pads must not touch each other Manual defibrillation should be attempted at 4j/kg to a maximum dose not exceeding the recommended energy level for an adult as per the defib manufacturers guidance AED should only be used if the child >25 kg or 8 years requires defibrillation and there is no manual defib available, in which case turn on the AED and follow voice prompts

Pad placement positions for infants/children

Choking If a child is coughing effectively, no external manoeuvres are necessary. Encourage the child to cough and observe. Effective cough: Crying or talking Able to take breath before cough Fully responsive If the cough becomes ineffective/absent then we should quickly ascertain level of consciousness after calling for help Ineffective cough: Unable to vocalise/cry/breathe Quiet or silent cough Cyanosis Decreasing level of consciousness

Choking algorithym

Choking infant Choking child

Choking manoeuvres unsuccessful? Reassess following each intervention If the choking child collapses lie them on a firm flat surface and commence CPR Each time the airway is opened to deliver rescue breaths check the mouth for foreign body, if obstruction visible attempt removal with a single finger sweep. Do not perform blind finger sweeps as this can worsen obstruction Do approximately 1 minute of CPR before leaving to call for help

Recovery position There is no universally accepted recovery position for children, but the following principles should be considered when placing an infant/child in a safe side lying position: - ensure airway is patent, secretions can drain freely from mouth - patient is stable and cannot roll (consider placing towel/blanket in small of back, in as true a lateral position as possible - no pressure on chest that can impact on breathing - can be easily observed and moved for treatment if necessary - Turn side to side every hour to relieve pressure on lower arm

Policies: DATIX or electronic incident report should be completed for every incident involving a child within the trust which has necessitated support from the MET or anaesthetic team Unless there is clear evidence of a “Do not attempt cardiopulmonary resuscitation” order or DNACPR then CPR should be commenced immediately with no unnecessary interruptions The Royal and Broadgreen use the National early warning score system (NEWS) for adults, recognising adult parameters. If it is necessary to record observations for children, paediatric charts and paramaters should be used