1. PEDIATRICS

4. Pediatric Basic Life Support
Toktam Faghihi, Pharm.D
TUMS

5. EPIDEMIOLOGY
Cause of Cardiopulmonary arrest: Adults: most common cause of cardiac arrest: ischemic cardiovascular disease: a primary cardiac event Infants and children is a terminal result of respiratory failure and/or shock: progressive tissue hypoxia and acidosis

6. EPIDEMIOLOGY…
Adult cardiac arrest: focused on diagnosis and treatment of ventricular fibrillation (VF).
Studies showed that VF was the most common initial dysrrhythmia in adults with sudden death, in some reports the prevalence of VF was 60% to 85%.
Cardiac arrest due to VF as the initial cardiac rhythm occurs in only 5% to 15% of pediatrics.

7. EPIDEMIOLOGY…
Children: arrest is the terminal result of progressive respiratory failure or shock.
It is essential to recognize and treat pediatric patients with respiratory distress, pneumonia and shock to prevent the development of systemic hypoxemia, hypercapnia, acidosis that may then progress to bradycardia, hypotension and eventually cardiorespiratory arrest.

8. EPIDEMIOLOGY…
Causes of respiratory failure and shock: accidents, sudden infant death syndrome (SIDS), respiratory distress, and sepsis.
Respiratory distress:

9. Respiratory Distress Respiratory rate and effort Work of breathing
Quality and magnitude of breath sounds
Patients mental status

10. Respiratory Rate
Tachypnea is one of the most important findings in children with respiratory disease.

11. Age
RR (breaths/min)
Tachypnea (breaths/min)
Newborn- 2 months
30-60
>60
2 months-12 months
25-40
>50
1-3 years
20-30
>40
3-6 years
16-22
7-12 years
14-20
> 12 years
12-20

12. Intercostal, subcostal and supracostal retractions increase with increasing respiratory distress.

13. Nasal flaring: an effort to increase airway diameter, and is often seen with hypoxemia

14. Sudden infant death syndrome (SIDS)
The sudden death of an infant less than one year of age, which remains unexplained after a thorough case investigation.
The mechanism of sudden death is unknown.
The most compelling hypothesis involves a brainstem abnormality or maturational delay related to neuroregulation or cardiorespiratory control, combined with a trigger event such as airflow obstruction.

15. SIDS… Number of risk factors for SIDS have been identified:
Exposure to cigarette smoke
Low birth weight,
prematurity,
Prone sleep position fold increased risk,
soft bedding,
soft sleep surfaces,
bed-sharing,
Overheating (excessive clothing).
 Breast feeding

17. Apparent Life-Threatening Event (ALTE)
Not a specific diagnosis but a description of an acute, unexpected change in an infant's breathing behavior that is frightening to the caretaker and that includes some combination of the following features:
Apnea — usually no respiratory effort (central) or sometimes effort with difficulty (obstructive)
Color change — usually cyanotic or pallid but occasionally erythematous or plethoric
Marked change in muscle tone (usually limpness or rarely rigidity)
Choking or gagging

18. ETIOLOGY
specific cause for the ALTE can be identified in over one-half of patients after a careful history, physical examination, and appropriate laboratory evaluation:
Gastroesophageal reflux
Neurologic problems (such as seizures or breath-holding spells)
Infection

19. ALTE Acute conditions Chronic conditions Infections Gastrointestinal
Respiratory infections (eg, pertussis, respiratory syncytial virus, bronchiolitis)
Gastroesophageal reflux
Sepsis, meningitis, encephalitis
Swallowing incoordination
Neurologic
Intussusception, Volvulus
Seizure
Drug effect
Vasovagal syncope
Cold medications
CNS hemorrhage

20. October 2010, the American Heart Association (AHA)
and Heart and Stroke Foundation of Canada (HSFC)
updated Guidelines on Pediatric Basic Life Support (PBLS)
and Pediatric Advanced Life Support (PALS).

22. Pediatric Basic Life Support (PBLS)
Introduction
Basic Life Support Sequence
Ventilation
Chest Compressions

23. Introduction
Basic life support (BLS) involves a systematic approach to initial patient assessment, activation of emergency medical services, and the initiation of cardiopulmonary resuscitation (CPR), including defibrillation.
Key components of effective CPR include:
adequate ventilation
and
chest compressions

24. Introduction… For the purposes of these guidelines:
a newborn is defined as from birth to hospital discharge
an infant is younger than one year of age,
a child is from one year to the start of puberty.

25. Normal Vital Signs According To Age
HR (beats/min)
BP (mmHg)
RR (breaths/min)
Premature
55-75/35-45
40-70
0-3 mo
65-85/45-55
35-55
3-6 mo
90-120
70-90/50-65
30-45
6-12 mo
80-120
80-100/55-65
25-40
1-3 yr
70-110
90-105/55-70
20-30
3-6 yr
65-110
95-110/60-75
20-25
6-12 yr
60-95
/60-75
14-22
12+ yr
55-85
/65-85
12-18

26. Pediatric Basic Life Support (PBLS)
Introduction
Basic Life Support Sequence
Ventilation
Chest Compressions

27. BASIC LIFE SUPPORT SEQUENCE
Activate EMS 
Initiate CPR — The actions that constitute cardiopulmonary resuscitation (CPR) are opening the airway, providing ventilations (rescue breaths), and performing chest compression.

28. BASIC LIFE SUPPORT SEQUENCE…
The sequence in which the actions of CPR for infants and children should be performed by health care providers is as follows:
Initiate CPR in an infant or child who is unresponsive and not breathing (or only gasping).
If there is no pulse or it is not definitively identified within 10 seconds, then start compressions BEFORE performing airway or breathing maneuvers.

29. BASIC LIFE SUPPORT SEQUENCE…
After 30 compressions (15 compressions if two rescuers) open the airway and give two breaths.
If a definite pulse is found within 10 seconds, provide ventilation only
If the pulse is ≥60 beats per minute (bpm), continue ventilation
If the pulse is <60 bpm, add chest compressions to ventilation

30. ABC vs CAB? The Change of Sequence from ABC to CAB
“A-B-C” i.e. Airway, Breathing, and Chest Compression to “C-A-B” i.e. Chest Compressions first

31. Rationale 1
Reluctance to initiate CPR may, in part, relate to the technical difficulty in opening the airway and delivering rescue breaths.
Therefore, starting with chest compressions (the ‘simpler’ component of CPR) may encourage more witnesses to act when faced with victims of cardiac arrest.

32. Rationale 2
The majority of cardiac arrest victims are adults where Ventricular Fibrillation (VF) or pulseless Ventricular Tachycardia (VT) is common.
Those victims have better survival when the arrest is witnessed and when chest compression and defibrillation are initiated rapidly.

33. Rationale 3
In contrast to adults, cardiac arrests in infants and children are usually asphyxial in nature i.e. secondary to hypoxia or shock (which, if left untreated, leads to progressive bradycardia and ultimately asystole, not primary VF as in adults).
Thus ventilation is critically important in pediatric resuscitation.

34. Rationale 3…
However, performing 30 chest compressions before ventilation will theoretically only delay ventilation by approximately 18 seconds (for the lone rescuer) and even less for two healthcare providers.
This minimal delay is unlikely to affect the outcome of resuscitation, but will probably generate blood flow to vital organs sooner.
There is no evidence to suggest that starting with ventilation (as in ABC) is superior to starting with chest compressions (as in CAB).

35. High quality CPR focuses on:
Effective delivery of chest compressions
And avoidance of excessive ventilation

36. Pediatric Basic Life Support (PBLS)
Introduction
Basic Life Support Sequence
Ventilation
Chest Compressions

37. Ventilation
hyperventilation is associated with increased intrathoracic pressure and decreased coronary and cerebral perfusion.

38. Ventilation… Recommendations:
Each rescue breath should be delivered over one second.
The volume of each breath should be sufficient to see the chest wall rise.
A child with a pulse ≥60 bpm who is not breathing should receive one breath every three to five seconds (12 to 20 breaths per minute).
Infants and children who require chest compressions should receive two breaths per 30 chest compressions for a lone rescuer and two breaths per 15 chest compressions for two rescuers.
Intubated infants and children should be ventilated at a rate of 8 to 10 breaths per minute without any interruption of chest compressions.

39. Pediatric Basic Life Support (PBLS)
Introduction
Basic Life Support Sequence
Ventilation
Chest Compressions

40. Chest Compressions
The 2010 international resuscitation guidelines emphasize the importance of hard, fast chest compression, with full chest recoil and minimal interruptions.

41. Chest Compressions…
Chest compressions should be performed over the lower half of the sternum.
Compression of the xiphoid process can cause trauma to the liver, spleen, or stomach, and must be avoided.
The chest should be depressed at least one-third of its anterior-posterior diameter with each compression (approximately 4 cm [1 ½ inches] in most infants and 5 cm [2 inches] in most children).
The optimum rate of compressions is approximately 100 per minute.
Each compression and decompression phase should be of equal duration.
The sternum should return briefly to its normal position at the end of each compression, allowing the chest to recoil fully.

45. COMPRESSION TO VENTILATION RATIO
every effort should be made to avoid excessive ventilation and to limit interruptions of chest compressions to less than ten seconds.
For lone rescuers, two ventilations should be delivered during a short pause at the end of every 30th compression.
For two rescuers, two ventilations should be delivered at the end of every 15th compression.

46. Once the trachea is intubated, ventilation and compression can be performed independently.
Ventilations are given at a rate of 8 to 10 per minute.
Compressions are delivered at a rate of 100 per minute without pauses.

47. Conventional vs compression-only CPR???
Although compression-only CPR (CO-CPR) is suggested in limited situations in adults with cardiac arrest.
Conventional CPR is recommended in infants and children, because cardiac arrest in this population is more commonly due to hypoxia when compared to adults.

48. In Summary Key elements of high quality CPR:
• Push fast (at least 100/min)
• Push hard (4 cm in infant, 5 cm or 1/3 of chest depth in
children)
• Allow full chest recoil between compressions
• Avoid excessive ventilation
Minimize interruptions
• Resume CPR immediately after a shock
• Rotate compressor role every 2 min (to avoid fatigue).

49. Thank You
Questions?