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.

General Consideration

• Performing a high-quality CPR based on the above guidelines can save a child's life and improve neurological outcomes.
• Every community should be encouraged to get BLS- trained to ensure any person is able to deliver high-quality CPR until the EMS arrives.

Limitations

• C-A-B sequence change from A-B-C
  • In order to accurately predict prognostic outcomes ROSC, survival to hospital admission, or survival to 180 days with the good neurologic outcome with respect to the C-A-B protocol there is a need for more pediatric clinical (human) studies in children as opposed to pediatric manikin studies.
• Chest compression depth
  • Pediatric studies for the chest compression depth has a small sample size and the age of children is above 14 years in the adolescent phase which does not provide data for children less than 14 years and infants.
  • The hospital data for OHCA is not available for the depth of compression on different surfaces.

AED (Automated external defibrillator)

• AED is a device that is useful in as it delivers shock and does not require the bystander or lay rescuer to recognize different types of heart rhythm.
• If you want to be trained in AED access this website by REDCROSS https://www.redcross.org/take-a-class/aed
• If a manual defibrillator is not available an AED automated external defibrillator is used.
• A study published by Ecker R et al concluded that older bystanders previously trained in AED are successfully able to deliver shock for ventricular fibrillation with dispatcher assistance.
• 2 minutes compression and ventilation cycle should be done before using the AED.
• If there are 2 bystanders send one person to get the AED and one person should start CPR immediately.
• A study by Dianne L.Atkinsa et all found the AED used in children less than 8 years of age is able to find both shockable rhythm with high sensitivity and high specificity.

Steps to use AED

• Follow the AED Prompt.
• Stop CPR when the AED is analyzing the rhythm and giving a shock.
• Resume compressions immediately after giving shock and minimize interruptions during compressions.
• Place the right pad of the AED on right below the clavicle.
• Place the left pad of the AED on the left chest lateral to the left breast.
• Other positions - Left pad is placed at the apex 5th Intercoastal space and the right pad placed on the left upper back.
• Keep the one-inch distance between the pads and the implantable device.
• Don't put the pads on a transdermal patch as it can burn the skin where the patch is placed.

Foreign Body Airway Obstruction(FBAO)

• Foreign Body Airway Obstruction(FBAO) also known as choking is blocking the airway which comprises of the pharynx and trachea. Children less than 3 years are at risk of choking due to the still-developing phase for swallowing and chewing. Parents, teachers should keep an eye for objects like coins, toys, balloons, and other food.
• A study by C S Harris et al concluded that one death due to choking occurred every 5 days the data was analyzed for infants and children from 0-9 years for a period of 3 years.
• The choking was associated with high risk in children less than 5 years of age due to meat products.
• Hot dog was the most common food identified along with hard candy, nuts.
• Airway obstruction - Steps to follow
  • If the airway obstruction is mild, where the child is able to respond wait for the child to clear it and monitor for signs of severe obstruction.
  • If the airway obstruction is severe, where the child will be silent quickly start the Heimlich maneuver or subdiaphragmatic abdominal thrust for children.
  • For infants do 5 back blows followed by 5 compressions as abdominal thrust can damage the liver.
  • If the child/infant becomes unresponsive start CPR immediately.
    • After 1 cycle which will be 30 compressions check the airway if the foreign body is visible remove it but if it's not visible or accessible do not probe blindly as the foreign body can be displaced which will further damage the oropharynx.
    • Give 2 rescue breaths after compressions and continue with compressions and ventilation cycle until the foreign body is out.

Special situations

Resuscitation in special circumstances

Child with a tracheostomy tube or stoma

• The caregiver (Parents, nurse, or teacher) should be trained in how to use the tracheostomy tube.
• If there is a cardiac arrest in a child with a tracheostomy start immediately CPR with compressions followed by ventilation of 2 rescue breaths.
• Ventilation
  • Give rescue breaths from mouth to a tracheostomy tube, if the chest does not rise to suction the tube, if still there is no chest rise then can give mouth to stoma ventilation or bag - mask ventilation if available.

Child with spinal trauma

• Steps to follow in a pediatric trauma case with cardiac arrest.
• Look for airway obstruction.
• If there is bleeding try to tie a tourniquet and apply external pressure.
• If spinal trauma is suspected try to avoid cervical spine movement.
  • In spinal trauma ventilation should be done with caution apply jaw thrust and do not tilt head.
  • If the jaw thrust is not successful then one rescuer would minimize the motion of the cervical spine and the other rescuer should attempt to give rescue breadth by head still and chin lift method.
  • To achieve a neutral position for a child while in supine posture a study by Nypaver M et all mentions that the back needs to be elevated in children less than 7 years.
  • In children less than 7 years its found that they have a disproportionately large head compared to their full bodies and when in a supine position the neck gets flexed.
    • To prevent cervical motion changes should be made to the backboard.
    • Changes like Raise the chest by putting a double mattress pad or use a recess for the occiput to lower the head.

Child drowning

• The rescuer should try to get the drowning child as soon as possible out of the water and start CPR after checking pulse and ventilation.
• If the rescuer has training in In water resuscitation start ventilation in water

Below is the IWR (In Water Resuscitation) guidelines

• Check if the child is breathing or conscious in the water.
  • If the child is breathing quickly swim back and get the child out of the water.
  • If the child is not breathing then give rescue breaths if spinal trauma is suspected then try to immobilize the spine while opening the airway and try to reach the shore as soon as possible.
  • If the distance to reach the shore is more than 5 minutes, try to give one more rescue breath 12-16 breaths/minute.