Pediatric BLS

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Neepa Shah, M.D.

Synonyms and keywords:

Overview

Pediatric Basic Life Support is a life-saving skill comprising of high quality CPR (Cardiopulmonary Resuscitation) and Rescue Breadths with Artificial External Defibrillator (AED).

• Bystander CPR - Bystander resuscitation plays a key role in out of hospital CPR. A study by Maryam Y Naim et all found out communities, where bystander CPR is practiced, have better survival outcomes in children less than 18 years from out of hospital cardiac arrest(CA)

• Two studies (Total children 781) concluded that about half of the Cardio-Respiratory arrests in children under 12 months occur outside the hospital.
• Good Prognostic Factor upon arrival at the emergency department-
  • The short interval between arrest and arrival at the hospital.
  • Less than 20 minutes of resuscitation in the emergency department.
  • Less than 2 doses of epinephrine.

Classification

• Pediatric Basic Life Support is classified according to age
  • Age - Less than 1 year - Infant Basic Life Support
  • Age - 1 year to Puberty - Child Basic Life Support
  • Age - After Puberty - Adult Basic Life Support

• BLS can be classified as
  • BLS in Out of hospital cardiac arrest (OHCA)
  • BLS inpatient cardiac arrest (IHCA)

Causes of Cardiac arrest(CA) in children

• Ventricular Fibrillation
• Pulseless Ventricular tachycardia
• Children with preexisting cardiac disorders
  • Hypertrophic cardiomyopathy
  • Anomalous coronary artery (from the pulmonary artery)
  • Long QT syndrome
  • Myocarditis
• Drug intoxication (eg, tricyclic antidepressants, digoxin, cocaine)
• Commotio cordis

Goals of Resuscitation

The goal of resuscitation is to perform high- quality CPR and have a better neurological outcome post-discharge.

High - quality CPR

Cardiopulmonary resuscitation comprises of effective chest compression and ventilation by rescue breath.

• According to the AHA guidelines 2015,2017,2010, the following are the steps for high-quality CPR.
  • Rate - Rate of CPR is the frequency of the chest compressions in a minute the AHA guidelines recommend 100 compressions per minute.
  • Depth- For high-quality CPR, the depth of the compressions should be 4 cm for infants and 5 cm for children more than 1 year of age.
  • Chest recoil- Allow the chest to recoil during chest compression which allows blood to flow back to the heart and hence the to the other vital organs.
  • CPR with rescue breaths- The above guidelines suggest better neurological complications in children more than 1 year of age who were given CPR with the rescue breaths as compared to children who received Compression- only CPR for cardiac arrest

Variables with the good prognostic outcome

• Age >1 year
• Shockable rhythm like ventricular fibrillation
• Less duration of CPR
• Reactive pupil at 24 hours after ROSC
• Lower serum lactate levels at 0 to 12 hours after ROSC is associated with improved outcomes.

The following tables provide the details of the different studies done to determine which factors during pediatric cardiac arrest resuscitation have a superior prognosis. OHCA - Out of hospital cardiac arrest. ROSC- Return of spontaneous circulation.

Summary of studies for OHCA to determine age as a prognostic factor

	Age <1 year compared to >1 year	Author	Study details
30- Day survival with good neurological outcome
	Good prognosis associated in children >1 year	Tetsuhisa Kitamura, MD	Study group - 5158 Children (RR -2.4; 95% CI,1.7-3.4)
30-Day survival in age >1 year	Good prognosis associated in children >1 year	Tetsuhisa Kitamura, MD	Study group- 5158 Children (RR- 1.5; 95% CI,1.3-1.8)
Survival to hospital discharge	Good prognosis associated in children >1 year	Dianne L. Atkins	Study group- 621 Children (RR- 2.7; 95% CI,1.3-5.7)
	Good prognosis associated in children >1 year	Kelly D. Young	Study group- 599 Children (RR- 1.3; 95% CI,0.8-2.1)
	Good prognosis associated in children >1 year	Moler, Frank W. MD	Study group- 138 Children (RR- 1.4; 95% CI,0.8-2.4)

Summary of studies for OHCA to determine shockable rhythm vs non-shockable rhythm as a prognostic factor

	Shockable rhythm vs non-Shockable rhythm	Author	Study details
30- Day survival with good neurological outcome	Good prognosis with shockable rhythm like VF	Tetsuhisa Kitamura, MD	Study group- 5170 Children (RR- 4.4; 95% CI,3.6-5.3)
30-Day survival	Good prognosis with shockable rhythm like VF	Tetsuhisa Kitamura, MD	Study group- 5170 Children (RR- 9.0; 95% CI,6.7-12.3)
Survival to hospital discharge	Good prognosis with shockable rhythm like VF	Dianne L. Atkins	Study group- 366 Children (RR- 4.0; 95% CI,1.8-8.9)
	Good prognosis with shockable rhythm like VF	Moler, Frank W. MD	Study group- 138 Children (RR- 2.7; 95% CI,1.3-5.6)

Approach to Suspected Patient of Cardiac or Respiratory Arrest

Algorithm

According to the AHA guidelines

• Look out for the safety of yourself as a bystander and the child/infant.
• Call for help if alone and if 2 rescuers are present send one person to call the EMS (Emergency medical service) and get the AED(Automated external defibrillator).
• Check for response ask "What is your name?" Can you hear me"
• Check if the child is breathing,
  • If the child is breathing normally, don't do CPR.
  • If the child is not breathing or is gasping for air start CPR
• Check for a pulse in an infant it is the Brachial pulse. For children above 1 year of age check the Femoral artery pulse or the Brachial pulse, not more than 10 seconds.
• The new AHA guidelines in 2010,2015 have changed the order from "ABC" Airway, Breathing/ventilation, and Chest compressions (or Circulation) to "CAB" Compression (Circulation) Airway and Breathing/Ventilation.
• High-quality chest compressions:
  • For infants - Place 2 fingers below the intermammary line not compressing any rib or xiphoid process and start compressions 100/minute and up to 4 cm or 1.5-inch depth in infants and 5 cm or 2-inch depth in children above 1 year.
  • Use two hands wrapped around the thorax for better grip depending on the size of the child to avoid exhaustion especially if its a lone rescuer.
  • If 2 people are there give 15 chest compressions followed by 2 rescue breaths. Interchange the position every 2 minutes if 2 people are present to avoid exhaustion and ensure high-quality CPR.
  • If there is a single person for CPR give 30 chest compressions followed by 2 rescue breaths.
  • CPR with rescue breaths has more survival benefit in children vs CPR- Only Compressions.
  • In children the majority of the cause for cardiac arrest is Asphyxia .
  • If the lone rescuer is not trained in ventilation then Compression only CPR can be done.
• Ventilation
  • If you are a lone rescuer, follow 30 x 2 cycle which is 30 compressions with 2 breaths. Observe for a chest rise as you are giving ventilation.
  • Use the head tilt and chin lift method to open the airway for injured and non-injured children.
  • If there is no chest rise after mouth to mouth ventilation adjust the neck.
  • Infants- Follow mouth to mouth ventilation, pinch the nose to prevent air movement out of the nose.
    • Mouth to nose ventilation can also be administered, close the mouth to prevent air being lost in the mouth.
  • Children- Follow Mouth to Mouth ventilation with pinching the nose.
  • In each of the rescue breaths make sure the chest rises and quickly resume immediately compressions in 30 x 2 cycle if you are a lone rescuer for improving the survival

Basic Life Support Guidelines (Revised American Heart Association 2010 Guidelines)

Changes made in the new AHA guidelines 2010,2015,2017,2019

According to the 2010,2015,2017,2019 Pediatric BLS Guidelines, the following changes were made and are followed:

Pediatric BLS algorithm for single and 2 or more rescuers

• For single rescuers start with 30 compressions followed by 2 rescue breaths.
• For 2 or more rescuers start with 15 compressions followed by 2 rescue breaths and then both rescuers should change the positions alternating between compressions and breathing every 2 minutes.

Change of order of A-B-C TO C-A-B

• A-B-C is airway, breathing, and compressions in that order. C-A-B is compression, airway, and breathing.
• This change was advised by the 2010 guidelines but in 2015 there is more evidence supporting this sequence of CPR.
• Evidence
  • Manikin studies in both adults and children show a decrease in time to achieve the first chest compressions by following C-A-B compared to A-B-C.
  • The delay in getting to ventilation was of 6 seconds compared with the new C-A-B compared to A-B-C

Chest compression rate and the depth

• Adult model for compression rate and depth is to be followed for pediatrics cases due to lack of evidence.
• More studies need to be found for the pediatric rate of compressions.
• A study by Sutton RM et al reported among 87 pediatric CPR of more than 8 years of age, found that compression depth greater than 51 mm for more than 60% of the compressions during 30-second epochs within the first 5 minutes was associated with improved 24-hour survival.

Compression-only (Hands-Only) CPR

• Adult BLS protocols advise for CPR-Only resuscitation to achieve more compressions.
• Pediatric cardiac arrest are majority due to asphyxia. Hence for children, it is advised to continue with CPR with rescue breaths.
• If the rescuer is not trained or is not able to give rescue breaths then CPR-Only resuscitation is advised.