《心肺复苏指南》参考资料（英文版）Part 11 Pediatric Basic Life Support

Circulation Atmegiso tmO Learn and live JOURNAL OF THE AMERICAN HEART ASSOCIATION Part 11: Pediatric Basic Life Support Circulation 2005: 1 12, 156-166, originally published online Nov 28, 2005 DOI: 10.1161/CIRCULATIONAHA. 105.166572 Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, Tx 72514 Copyright o 2005 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online ISSN:15244539 The online version of this article, along with updated information and services, is located on the world wide web at http://circ.ahajournals.org/cgi/content/full/112/24suppl/iv-156 Subscriptions: Information about subscribing to Circulation is online at http://circ.ahajournals.org/subsriptions/ Permissions: Permissions Rights Desk, Lippincott Williams Wilkins, 351 West Cam Street. Baltimore MD 21202-2436 Phone 410-5280-4050. Fax: 410-528-8550 En journalpermissions@lww.com Reprints: Information about reprints can be found online at http://www.Iww.com/static/html/reprints.html Downloaded from circ. ahajournals. org by on February 21, 2006

ISSN: 1524-4539 Copyright © 2005 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online 72514 Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX DOI: 10.1161/CIRCULATIONAHA.105.166572 Circulation 2005;112;156-166; originally published online Nov 28, 2005; Part 11: Pediatric Basic Life Support http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-156 located on the World Wide Web at: The online version of this article, along with updated information and services, is http://www.lww.com/static/html/reprints.html Reprints: Information about reprints can be found online at journalpermissions@lww.com Street, Baltimore, MD 21202-2436. Phone 410-5280-4050. Fax: 410-528-8550. Email: Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, 351 West Camden http://circ.ahajournals.org/subsriptions/ Subscriptions: Information about subscribing to Circulation is online at Downloaded from circ.ahajournals.org by on February 21, 2006

Part 11: Pediatric Basic Life Support F or best survival and quality of life, pediatric basic life support(BLS) should be part of a community effort that includes prevention, basic CPR, prompt access to the emer- gency medical services(EMS) system, and prompt pediatric advanced life support (PALS). These 4 links form the American Heart Association(AHA) pediatric Chain of Sur- ival(Figure 1). The first 3 links constitute pediatric BLS Rapid and effective bystander CPR is associated with Figure 1. Pediatric Chain of Survival successful return of spontaneous circulation and neurologi- cally intact survival in children. ,2 The greatest impact occurs nhtsa. gov. Look for the Comprehensive Child Passenger in respiratory arrest, in which neurologically intact survival Safety Information rates of >70% are possible, 4-6 and in ventricular fibrillation Adolescent drivers are responsible for a disproportionate CVF), in which survival rates of 30% have been documented. 7 number of motor vehicle-related injuries; the risk is highest in the first 2 years of driving. Driving with teen passengers But only 2% to 10% of all children who develop out-of- and driving at night dramatically increase the risk. Additional hospital cardiac arrest survive, and most are neurologically devastated. 7-13 Part of the disparity is that bystander CPR is risks include not wearing a seat belt, drinking and drivin provided for less than half of the victims of out-of-hospital speeding, and aggressive driving arrest & 11, 14 Some studies show that survival and neurolo Pedestrian Injuries outcome can be improved with prompt CPR.6, 15-17 Pedestrian injuries account for a third of motor vehicle related injuries. Adequate supervision of children in the street Prevention of Cardiopulmonary Arrest is important because injuries typically occur when a child major causes of death in infants and children are darts out mid-block, dashes across intersections, or gets off espiratory failure, sudden infant death syndrome(SIDS), bus. 22 sepsis, neurologic diseases, and injuries. 8 Bicycle Injuries Injuries Bicycle crashes are responsible for approximately 200 000 Injuries, the leading cause of death in children and young Injuries and nearly 150 deaths per year in children and adults. cause more childhood deaths than all other cause adolescents. 2 Head injuries are a major cause of bicycle combined. s Many injuries are preventable. The most com- related morbidity and mortality. It is estimated that bicycle mon fatal childhood injuries amenable to prevention are helmets can reduce the severity of head injuries by >80%0.24 motor vehicle passenger injuries, pedestrian injuries, bicycle burns injuries, drowning, burns, and firearm injuries. 9 Approximately 80% of fire-related and burn-related deaths Motor Vehicle Injuries result from house fires and smoke inhalation 25.26 Smoke Motor vehicle-related injuries account for nearly half of all detectors are the most effective way to prevent deaths and pediatric deaths in the United States. 8 Contributing factors injuries; 70% of deaths occur in homes without functioning include failure to use proper passenger restraints, inexpert- smoke alarms. 27 nced adolescent drivers and alcohol Firearm Injuries Appropriate restraints include properly installed, rear- The United States has the highest firearm-related injury rate facing infant seats for infants <20 pounds(<9 kg)and <I of any industrialized nation-more than twice that of any year of age, child restraints for children I to 4 years of age, other country. 28 The highest number of deaths is in adoles and booster seats with seat belts for children 4 to 7 years of cents and young adults, but firearm injuries are more likely to age 0 The lifesaving benefit of air bags for older children and be fatal in young children. 29 The presence of a gun in the adults far outweighs their risk. Most pediatric air bag-related home is associated with an increased likelihood of adoles- fatalities occur when children <12 years of age are in the cent30, 31 and adult suicides or homicides. 32 Although overall vehicle's front seat or are improperly restrained for their age firearm-related deaths declined from 1995 to 2002. firearm For additional information consult the website of the National homicide remains the leading cause of death among African- HighwayTrafficsaFetyAdministration(nhtsa):http://amEricanadolescentsandyoungadultsI8 Sudden Infant Death Syndrome (Circulation. 2005: 112: IV-156-1V-166) SIDS is"the sudden death of an infant under I year of age, o 2005 American Heart Association which remains unexplained after a thorough case investiga This special supplement to Circulation is freely available at http://www.circulationaha.org tion, including performance of a complete autopsy, tion of the death scene, and review of the clinical history. "3 DOI: 10.1161/CIRCULATIONAHA. 105.166572 The peak incidence of SIDs occurs in infants 2 to 4 months of

Part 11: Pediatric Basic Life Support For best survival and quality of life, pediatric basic life support (BLS) should be part of a community effort that includes prevention, basic CPR, prompt access to the emer￾gency medical services (EMS) system, and prompt pediatric advanced life support (PALS). These 4 links form the American Heart Association (AHA) pediatric Chain of Sur￾vival (Figure 1). The first 3 links constitute pediatric BLS. Rapid and effective bystander CPR is associated with successful return of spontaneous circulation and neurologi￾cally intact survival in children.1,2 The greatest impact occurs in respiratory arrest,3 in which neurologically intact survival rates of
70% are possible,4–6 and in ventricular fibrillation (VF), in which survival rates of 30% have been documented.7 But only 2% to 10% of all children who develop out-of￾hospital cardiac arrest survive, and most are neurologically devastated.7–13 Part of the disparity is that bystander CPR is provided for less than half of the victims of out-of-hospital arrest.8,11,14 Some studies show that survival and neurologic outcome can be improved with prompt CPR.6,15–17 Prevention of Cardiopulmonary Arrest The major causes of death in infants and children are respiratory failure, sudden infant death syndrome (SIDS), sepsis, neurologic diseases, and injuries.18 Injuries Injuries, the leading cause of death in children and young adults, cause more childhood deaths than all other causes combined.18 Many injuries are preventable. The most com￾mon fatal childhood injuries amenable to prevention are motor vehicle passenger injuries, pedestrian injuries, bicycle injuries, drowning, burns, and firearm injuries.19 Motor Vehicle Injuries Motor vehicle–related injuries account for nearly half of all pediatric deaths in the United States.18 Contributing factors include failure to use proper passenger restraints, inexperi￾enced adolescent drivers, and alcohol. Appropriate restraints include properly installed, rear￾facing infant seats for infants 20 pounds (9 kg) and 1 year of age, child restraints for children 1 to 4 years of age, and booster seats with seat belts for children 4 to 7 years of age.20 The lifesaving benefit of air bags for older children and adults far outweighs their risk. Most pediatric air bag–related fatalities occur when children 12 years of age are in the vehicle’s front seat or are improperly restrained for their age. For additional information consult the website of the National Highway Traffic Safety Administration (NHTSA): http:// nhtsa.gov. Look for the Comprehensive Child Passenger Safety Information. Adolescent drivers are responsible for a disproportionate number of motor vehicle–related injuries; the risk is highest in the first 2 years of driving. Driving with teen passengers and driving at night dramatically increase the risk. Additional risks include not wearing a seat belt, drinking and driving, speeding, and aggressive driving.21 Pedestrian Injuries Pedestrian injuries account for a third of motor vehicle￾related injuries. Adequate supervision of children in the street is important because injuries typically occur when a child darts out mid-block, dashes across intersections, or gets off a bus.22 Bicycle Injuries Bicycle crashes are responsible for approximately 200 000 injuries and nearly 150 deaths per year in children and adolescents.23 Head injuries are a major cause of bicycle￾related morbidity and mortality. It is estimated that bicycle helmets can reduce the severity of head injuries by
80%.24 Burns Approximately 80% of fire-related and burn-related deaths result from house fires and smoke inhalation.25,26 Smoke detectors are the most effective way to prevent deaths and injuries; 70% of deaths occur in homes without functioning smoke alarms.27 Firearm Injuries The United States has the highest firearm-related injury rate of any industrialized nation—more than twice that of any other country.28 The highest number of deaths is in adoles￾cents and young adults, but firearm injuries are more likely to be fatal in young children.29 The presence of a gun in the home is associated with an increased likelihood of adoles￾cent30,31 and adult suicides or homicides.32 Although overall firearm-related deaths declined from 1995 to 2002, firearm homicide remains the leading cause of death among African￾American adolescents and young adults.18 Sudden Infant Death Syndrome SIDS is “the sudden death of an infant under 1 year of age, which remains unexplained after a thorough case investiga￾tion, including performance of a complete autopsy, examina￾tion of the death scene, and review of the clinical history.”33 The peak incidence of SIDs occurs in infants 2 to 4 months of (Circulation. 2005;112:IV-156-IV-166.) © 2005 American Heart Association. This special supplement to Circulation is freely available at http://www.circulationaha.org DOI: 10.1161/CIRCULATIONAHA.105.166572 Figure 1. Pediatric Chain of Survival. IV-156

Part 11: Pediatric Basic Life Support IV-157 age. 4 The etiology of SIDS remains unknown, but risk respiratory distress to remain in a position that is most factors include prone sleeping position, sleeping on a soft comfortable surface, 5-37 and second-hand smoke. 38,39 The incidence of If the child is unresponsive and is not moving, shout for SIDS has declined 40%040 since the"Back to Sleep" public help and start CPR. If you are alone, continue CPR for 5 education campaign was introduced in the United States in cycles(about 2 minutes). One cycle of CPR for the lone 1992. This campaign aims to educate parents about placing an rescuer is 30 compressions and 2 breaths(see below ). Then infant on the back rather than the abdomen or side to sleep activate the EMS system and get an automated external defibrillator(AED)(see below ). If you are alone and there Drowning is no evidence of trauma, you may carry a small child with Drowning is the second major cause of death from uninten- you to the telephone. The EMs dispatcher can guide you tional injury in children <5 years of age and the third major through the steps of CPR. If a second rescuer is present cause of death in adolescents. Most young children drown at rescuer should immediately activate the EMs system after falling into swimming pools while unsupervised; ado- and get an aEd (if the child is I year of age or older) while descents more commonly drown in lakes and rivers while you continue CPR. If you suspect trauma, the second swimming or boating. Drowning can be prevented by install- rescuer may assist by stabilizing the child's cervical spine ing isolation fencing around swimming pools(gates should (see below ). If the child must be moved for safety reasons, be self-closing and self-latching )I and wearing personal support the head and body to minimize turning, bending, flotation devices (life jackets) while in, around, or on water twisting of the head and neck The BLS Sequence for Infants and Children Activate the EMs System and Get the aED (Box 2) For the purposes of these guidelines, an"infant"is less than If the arrest is witnessed and sudden 27. 43(eg, an athlete who approximately I year of age. This section does not deal with newborn infants(see Part 13: "Neonatal Resuscitation Guide- collapses on the playing field), a lone healthcare provider should activate the EMS system(by telephoning 91l in most lines"). For lay rescuers the"child "BLS guidelines should be locales)and get an AED (if the child is I year of age or older) applied when performing CPR for a child from about I year before starting CPR. It would be ideal for the lone lay rescuer of age to about 8 years of age. For a healthcare provider, the who witnesses the sudden collapse of a child to also activate the EMs system and get an AED and return to the child to about the start of puberty. For an explanation of the differ begin CPR and use the AED. But for simplicity of lay rescuer ences in etiology of arrest and elaboration of the differences education it is in the recommended sequence for lay rescuer and healthcare about 5 cycles(about 2 minutes) of CPR for any infant or rovider cpr for infants. children. and adults. see Part 3 child victim before leaving to phone 911 and get an AED (if “ Overview of cPr appropriate). This sequence may be tailored for some learners These guidelines delineate a series of skills as a sequence (eg, the mother of a child at high risk for a sudden arrhyth mia). If two rescuers are present, one rescuer should begi (eg, starting CPR and activating the EMS system), especially CPR while the other rescuer activates the EMS system and hen more than one rescuer is presen gets the AED. depicted in the Pediatric Healthcare Provider BLs Algorithm Figure 2). The numbers listed with the headings below refer Position the victim to the corresponding box in that algorithm If the victim is unresponsive, make sure that the victim is in Safety of Rescuer and victim sturdy t(face up) position on a flat, hard surface, such as a sturdy table, the floor, or the ground. If you must turn the Always make sure that the area is safe for you and the victim. victim, minimize turning or twisting of the head and neck Move a victim only to ensure the victim's safety. Although exposure to a victim while providing CPR carries a theoret Open the Airway and Check Breathing(Box 3) ical risk of infectious disease transmission, the risk is very In an unresponsive infant or child, the tongue may obstruct low. 42 the airway, so the rescuer should open the airway. 4-4 Check for Response(Box 1) Open the Airway: Lay Rescuer If you are a lay rescuer, open the airway using a head tilt-chin lift maneuver for both injured and noninjured Gently tap the victim and ask loudly, "Are you okay? "Call victims( Class Ila). The jaw thrust is no longer recommended the child,s name if you know it. Look for movement. If the child is responsive, he or she for lay rescuers because it is difficult to learn and perform, is ill answer or move. Quickly check to see if the child has often not an effective way to open the airway, d may cause es or needs medical assistance If necessary, leave spinal movement(Class Ilb the child to phone EMS, but return quickly and recheck th Open the Airway: Healthcare Provider child,s condition frequently. Children with respiratory A healthcare provider should use the head tilt-chin lift distress often assume a position that maintains airway maneuver to open the of a victim without evidence of patency and optimizes ventilation. Allow the child with head or neck trauma

age.34 The etiology of SIDS remains unknown, but risk factors include prone sleeping position, sleeping on a soft surface,35–37 and second-hand smoke.38,39 The incidence of SIDS has declined 40%40 since the “Back to Sleep” public education campaign was introduced in the United States in 1992. This campaign aims to educate parents about placing an infant on the back rather than the abdomen or side to sleep. Drowning Drowning is the second major cause of death from uninten￾tional injury in children 5 years of age and the third major cause of death in adolescents. Most young children drown after falling into swimming pools while unsupervised; ado￾lescents more commonly drown in lakes and rivers while swimming or boating. Drowning can be prevented by install￾ing isolation fencing around swimming pools (gates should be self-closing and self-latching)41 and wearing personal flotation devices (life jackets) while in, around, or on water. The BLS Sequence for Infants and Children For the purposes of these guidelines, an “infant” is less than approximately 1 year of age. This section does not deal with newborn infants (see Part 13: “Neonatal Resuscitation Guide￾lines”). For lay rescuers the “child” BLS guidelines should be applied when performing CPR for a child from about 1 year of age to about 8 years of age. For a healthcare provider, the pediatric (“child”) guidelines apply from about 1 year to about the start of puberty. For an explanation of the differ￾ences in etiology of arrest and elaboration of the differences in the recommended sequence for lay rescuer and healthcare provider CPR for infants, children, and adults, see Part 3: “Overview of CPR.” These guidelines delineate a series of skills as a sequence of distinct steps, but they are often performed simultaneously (eg, starting CPR and activating the EMS system), especially when more than one rescuer is present. This sequence is depicted in the Pediatric Healthcare Provider BLS Algorithm (Figure 2). The numbers listed with the headings below refer to the corresponding box in that algorithm. Safety of Rescuer and Victim Always make sure that the area is safe for you and the victim. Move a victim only to ensure the victim’s safety. Although exposure to a victim while providing CPR carries a theoret￾ical risk of infectious disease transmission, the risk is very low.42 Check for Response (Box 1) ● Gently tap the victim and ask loudly, “Are you okay?” Call the child’s name if you know it. ● Look for movement. If the child is responsive, he or she will answer or move. Quickly check to see if the child has any injuries or needs medical assistance. If necessary, leave the child to phone EMS, but return quickly and recheck the child’s condition frequently. Children with respiratory distress often assume a position that maintains airway patency and optimizes ventilation. Allow the child with respiratory distress to remain in a position that is most comfortable. ● If the child is unresponsive and is not moving, shout for help and start CPR. If you are alone, continue CPR for 5 cycles (about 2 minutes). One cycle of CPR for the lone rescuer is 30 compressions and 2 breaths (see below). Then activate the EMS system and get an automated external defibrillator (AED) (see below). If you are alone and there is no evidence of trauma, you may carry a small child with you to the telephone. The EMS dispatcher can guide you through the steps of CPR. If a second rescuer is present, that rescuer should immediately activate the EMS system and get an AED (if the child is 1 year of age or older) while you continue CPR. If you suspect trauma, the second rescuer may assist by stabilizing the child’s cervical spine (see below). If the child must be moved for safety reasons, support the head and body to minimize turning, bending, or twisting of the head and neck. Activate the EMS System and Get the AED (Box 2) If the arrest is witnessed and sudden2,7,43 (eg, an athlete who collapses on the playing field), a lone healthcare provider should activate the EMS system (by telephoning 911 in most locales) and get an AED (if the child is 1 year of age or older) before starting CPR. It would be ideal for the lone lay rescuer who witnesses the sudden collapse of a child to also activate the EMS system and get an AED and return to the child to begin CPR and use the AED. But for simplicity of lay rescuer education it is acceptable for the lone lay rescuer to provide about 5 cycles (about 2 minutes) of CPR for any infant or child victim before leaving to phone 911 and get an AED (if appropriate). This sequence may be tailored for some learners (eg, the mother of a child at high risk for a sudden arrhyth￾mia). If two rescuers are present, one rescuer should begin CPR while the other rescuer activates the EMS system and gets the AED. Position the Victim If the victim is unresponsive, make sure that the victim is in a supine (face up) position on a flat, hard surface, such as a sturdy table, the floor, or the ground. If you must turn the victim, minimize turning or twisting of the head and neck. Open the Airway and Check Breathing (Box 3) In an unresponsive infant or child, the tongue may obstruct the airway, so the rescuer should open the airway.44 – 47 Open the Airway: Lay Rescuer If you are a lay rescuer, open the airway using a head tilt– chin lift maneuver for both injured and noninjured victims (Class IIa). The jaw thrust is no longer recommended for lay rescuers because it is difficult to learn and perform, is often not an effective way to open the airway, and may cause spinal movement (Class IIb). Open the Airway: Healthcare Provider A healthcare provider should use the head tilt– chin lift maneuver to open the airway of a victim without evidence of head or neck trauma. Part 11: Pediatric Basic Life Support IV-157

IV-158 Circulation December 13. 2005 No or response Send someone to phone 911, get AED For SUDDEN COLLAP ONE 911, Get AED Open AIRWAY, check BREATHING If not breathing. give 2 BREATHS that make chest rise within 10 seconds? Recheck pulse every Ne plan Figure 2. Pediatric Healthcare Provider BLS Algorithm. Note that the boxes bor- dered by dotted lines are performed by Push hard and fast (100/n healthcare providers and not by lay rescuers. Two Rescuers: Give cycles of 15 COMPRESSIONS and 2 BREATHS If not already done, PHONE 911, for child get AED/defibrillator Infant (<1 year Continue CPR until ALS responders take over or Child (l year): Continue CPR; use AEDMdefbrillator after 5 cycles of CPR Use AED as soon as it is available for sudden, witnessed collapse) Check rhyl Shockable rhythm? Resume CPR immediately for 5 cycles victim starts to move Approximately 2% of all victims with blunt trauma requir- If the child is breathing and there is no evidence of trauma ing spinal imaging in an emergency department have a spinal turn the child onto the side(recovery position, Figure 3). injury. This risk is tripled if the victim has craniofacial This helps ma n a patent airway and decreases risk of injury, 48 a Glasgow Coma Scale score of <8, 9 or both. 48.50 If you are a healthcare provider and suspect that the victim may have a cervical spine injury, open the airway using a jaw thrust without head tilt(Class lIb).46.51. 2 Because maintaining Give Rescue Breaths(Box 4) a patent airway and providing adequate ventilation is a pri- If the child is not breathing or has only occasional gasp ority in CPR(Class I), use a head tilt-chin lift maneuver if the jaw thrust does not open the airway For the lay rescuer: maintain an open airway and give 2 breaths For the healthcare provider: maintain an open airway Check Breathing(Box 3) and give 2 breaths. Make sure that the breaths are While maintaining an open airway, take no more than 10 seconds to ffective(ie, the chest rises ). If the chest does not rise check whether the victim is breathing: Look for rhythmic chest and eposition the head, make a better seal, and try again. 55 abdominal movement, listen for exhaled breath sounds at the nose It may be necessary to move the childs head through a and mouth, and feel for exhaled air on your cheek. Periodic gasping range of positions to obtain optimal airway patency and also called agonal gasps, is not breathing.5354 effective rescue breathing

Approximately 2% of all victims with blunt trauma requir￾ing spinal imaging in an emergency department have a spinal injury. This risk is tripled if the victim has craniofacial injury,48 a Glasgow Coma Scale score of 8,49 or both.48,50 If you are a healthcare provider and suspect that the victim may have a cervical spine injury, open the airway using a jaw thrust without head tilt (Class IIb).46,51,52 Because maintaining a patent airway and providing adequate ventilation is a pri￾ority in CPR (Class I), use a head tilt– chin lift maneuver if the jaw thrust does not open the airway. Check Breathing (Box 3) While maintaining an open airway, take no more than 10 seconds to check whether the victim is breathing: Look for rhythmic chest and abdominal movement, listen for exhaled breath sounds at the nose and mouth, and feel for exhaled air on your cheek. Periodic gasping, also called agonal gasps, is not breathing.53,54 ● If the child is breathing and there is no evidence of trauma: turn the child onto the side (recovery position, Figure 3). This helps maintain a patent airway and decreases risk of aspiration. Give Rescue Breaths (Box 4) If the child is not breathing or has only occasional gasps: ● For the lay rescuer: maintain an open airway and give 2 breaths. ● For the healthcare provider: maintain an open airway and give 2 breaths. Make sure that the breaths are effective (ie, the chest rises). If the chest does not rise, reposition the head, make a better seal, and try again.55 It may be necessary to move the child’s head through a range of positions to obtain optimal airway patency and effective rescue breathing. Figure 2. Pediatric Healthcare Provider BLS Algorithm. Note that the boxes bor￾dered by dotted lines are performed by healthcare providers and not by lay rescuers. IV-158 Circulation December 13, 2005

Part 11: Pediatric Basic Life Support Iv-159 15 L/min into a reservoir attached to a pediatric bag2 and a flow of at least 15 L/min into an adult bag Precautions Avoid hyperventilation; use only the force and tidal volume necessary to make the chest rise. Give each breath over I second In a victim of cardiac arrest with no advanced airway in place, pause after 30 compressions(I rescuer) or 15 compressions(2 rescuers)to give 2 ventilations when usin either mouth-to-mouth or bag-mask technique. During CPR for a victim with an advanced airway(eg, Figure 3. Recovery position. endotracheal tube, esophageal-tracheal combitube [Combi- tube], or laryngeal mask airway [LMAD in place, rescuers In an infant, use a mouth-to-mouth-and-nose technique should no longer deliver"cycles"of CPR. The compress- LOE 7: Class Ilb); in a child, use a mouth-to-mouth ing rescuer should compress the chest at a rate of 100 times per minute without pauses for ventilations, and the rescuer providing the ventilation should deliver 8 to 10 breaths per Comments on Technique minute. Two or more rescuers should change the compres In an infant, if you have difficulty making an effective seal sor role approximately every 2 minutes to prevent com- over the mouth and nose, try either mouth-to-mouth or pressor fatigue and deterioration in quality and rate of ches mouth-to-nose ventilation(LOE 5; Class IIb).56-58 If you use the mouth-to-mouth technique, pinch the nose closed. If you If the victim has a perfusing rhythm(ie, pulses are present) use the mouth-to-nose technique, close the mouth. In either but no breathing, give 12 to 20 breaths per minute(I breath case make sure the chest rises when you give a breath every 3 to 5 seconds) Barrier devices Healthcare providers often deliver excessive ventilation Despite its safety, 42 some healthcare providers 59-6l and lay during CPR, 73-75 particularly when an advanced airway is in rescuers 2.63 may hesitate to give mouth-to-mouth rescue place Excessive ventilation is detrimental because it barrier device. barrier devices have not reduced the risk of transmission of infection. 42 and .Impedes venous return and therefore decreases cardiac some may increase resistance to air flow. 64,65 If you use a output, cerebral blood flow, and barrier device, do not delay rescue breathing increasing intrathoracic pressure7 Coronary perfusion by Causes air trapping and barotrauma in patients with small Bag-Mask Ventilation(Healthcare Providers) airway obstruction Bag-mask ventilation can be as effective as endotracheal Increases the risk of regurgitation and aspiration intubation and safer when providing ventilation for short periods. 66-69 But bag-mask ventilation requires training and Rescuers should provide the recommende periodic retraining in the follow escue breaths per minute correct mask size, opening the airway, making a tight seal You may need high pressures to ventilate patients with between the mask and face, delivering effective ventilation. airway obstruction or poor lung compliance. A pressure-relief and assessing the effectiveness of that ventilation. In the valve can prevent delivery of sufficient tidal volume. 72 Make out-of-hospital setting, preferentially ventilate and oxygenate sure that the manual bag allows you to use high pressures if infants and children with a bag and mask rather than attempt necessary to achieve visible chest expansion. 6 intubation if transport time is short( Class Ia; LOE 166: 367; Two-Person Bag-Mask Ventilation A 2-person technique may be necessary to provide effective Ventilation Bags bag-mask ventilation when there is significant airway ob Use a self-inflating bag with a volume of at least 450 to 500 struction, poor lung compliance, 6 or difficulty in creating a mL70, smaller bags may not deliver an effective tidal volume tight seal between the mask and the face. One rescuer uses or the longer inspiratory times required by full-term neonates both hands to open the airway and maintain a tight mask-to- and infants. 71 face seal while the other compresses the ventilation bag. Both A self-inflating bag delivers only room air unless supple- rescuers should observe the chest to ensure chest rise. mentary oxygen is attached, but even with an oxygen inflow of 10 L/min, the concentration of delivered oxygen varie Gastric Inflation and Cricoid Pressure Gastric inflation may interfere with effective ventilation77 and from 30% to 80% and depends on the tidal volume and peak cause regurgitation. To minimize gastric inflation inspiratory flow rate. 72 To deliver a high oxygen concentra- tion (60% to 95%0), attach an oxygen reservoir to the Avoid excessive peak inspiratory pressures(eg, ventilate self-inflating bag. You must maintain an oxygen flow of 10 to slowly ).66

In an infant, use a mouth-to–mouth-and-nose technique (LOE 7; Class IIb); in a child, use a mouth-to-mouth technique.55 Comments on Technique In an infant, if you have difficulty making an effective seal over the mouth and nose, try either mouth-to-mouth or mouth-to-nose ventilation (LOE 5; Class IIb).56 –58 If you use the mouth-to-mouth technique, pinch the nose closed. If you use the mouth-to-nose technique, close the mouth. In either case make sure the chest rises when you give a breath. Barrier Devices Despite its safety,42 some healthcare providers59 – 61 and lay rescuers8,62,63 may hesitate to give mouth-to-mouth rescue breathing and prefer to use a barrier device. Barrier devices have not reduced the risk of transmission of infection,42 and some may increase resistance to air flow.64,65 If you use a barrier device, do not delay rescue breathing. Bag-Mask Ventilation (Healthcare Providers) Bag-mask ventilation can be as effective as endotracheal intubation and safer when providing ventilation for short periods.66 – 69 But bag-mask ventilation requires training and periodic retraining in the following skills: selecting the correct mask size, opening the airway, making a tight seal between the mask and face, delivering effective ventilation, and assessing the effectiveness of that ventilation. In the out-of-hospital setting, preferentially ventilate and oxygenate infants and children with a bag and mask rather than attempt intubation if transport time is short (Class IIa; LOE 166; 367; 468,69). Ventilation Bags Use a self-inflating bag with a volume of at least 450 to 500 mL70; smaller bags may not deliver an effective tidal volume or the longer inspiratory times required by full-term neonates and infants.71 A self-inflating bag delivers only room air unless supple￾mentary oxygen is attached, but even with an oxygen inflow of 10 L/min, the concentration of delivered oxygen varies from 30% to 80% and depends on the tidal volume and peak inspiratory flow rate.72 To deliver a high oxygen concentra￾tion (60% to 95%), attach an oxygen reservoir to the self-inflating bag. You must maintain an oxygen flow of 10 to 15 L/min into a reservoir attached to a pediatric bag72 and a flow of at least 15 L/min into an adult bag. Precautions Avoid hyperventilation; use only the force and tidal volume necessary to make the chest rise. Give each breath over 1 second. ● In a victim of cardiac arrest with no advanced airway in place, pause after 30 compressions (1 rescuer) or 15 compressions (2 rescuers) to give 2 ventilations when using either mouth-to-mouth or bag-mask technique. ● During CPR for a victim with an advanced airway (eg, endotracheal tube, esophageal-tracheal combitube [Combi￾tube], or laryngeal mask airway [LMA]) in place, rescuers should no longer deliver “cycles” of CPR. The compress￾ing rescuer should compress the chest at a rate of 100 times per minute without pauses for ventilations, and the rescuer providing the ventilation should deliver 8 to 10 breaths per minute. Two or more rescuers should change the compres￾sor role approximately every 2 minutes to prevent com￾pressor fatigue and deterioration in quality and rate of chest compressions. ● If the victim has a perfusing rhythm (ie, pulses are present) but no breathing, give 12 to 20 breaths per minute (1 breath every 3 to 5 seconds). Healthcare providers often deliver excessive ventilation during CPR,73–75 particularly when an advanced airway is in place. Excessive ventilation is detrimental because it ● Impedes venous return and therefore decreases cardiac output, cerebral blood flow, and coronary perfusion by increasing intrathoracic pressure74 ● Causes air trapping and barotrauma in patients with small￾airway obstruction ● Increases the risk of regurgitation and aspiration Rescuers should provide the recommended number of rescue breaths per minute. You may need high pressures to ventilate patients with airway obstruction or poor lung compliance. A pressure-relief valve can prevent delivery of sufficient tidal volume.72 Make sure that the manual bag allows you to use high pressures if necessary to achieve visible chest expansion.76 Two-Person Bag-Mask Ventilation A 2-person technique may be necessary to provide effective bag-mask ventilation when there is significant airway ob￾struction, poor lung compliance,76 or difficulty in creating a tight seal between the mask and the face. One rescuer uses both hands to open the airway and maintain a tight mask-to￾face seal while the other compresses the ventilation bag. Both rescuers should observe the chest to ensure chest rise. Gastric Inflation and Cricoid Pressure Gastric inflation may interfere with effective ventilation77 and cause regurgitation. To minimize gastric inflation: ● Avoid excessive peak inspiratory pressures (eg, ventilate slowly).66 Figure 3. Recovery position. Part 11: Pediatric Basic Life Support IV-159

lV-160 Circulation December 13. 2005 Apply cricoid pressure. Do this only in an unresponsi victim and if there is a second rescuer 78-80 Avoid exces- sive pressure so as not to obstruct the trachea. sI O Despite animal and theoretic data suggesting possible adverse effects of 100% oxygen, 82-85 there are no studies comparing various concentrations of oxygen during resuscitation beyond the newborn period. Until additional information becomes available, healthcare providers should use 100% oxygen during resuscitation( Class Indeterminate). Once the patient is stable, wean supplementary oxygen but ensure adequate oxygen delivery by appropriate monitoring. Whenever pos- sible, humidify oxygen to prevent mucosal drying and thick Masks Masks provide an oxygen concentration of 30% to 50% to a (1 rescuer) igure 4. Two-finger chest compression technique in infant victim with spontaneous breathing. For a higher concentra tion of oxygen, use a tight-fitting nonrebreathing mask wi an oxygen inflow rate of approximately 15 L/min that Rescue breathing Without Chest Compressions maintains inflation of the reservoir bag. (for Healthcare Providers Only)(Box 5A) If the pulse is 260 bpm but there is no spontaneous breathing or inadequate breathing, give rescue breaths at a rate of about Infant and pediatric size nasal cannulas are suitable for 12 to 20 breaths per minute(I breath every 3 to 5 seconds) children with spontaneous breathing. The concentration of until spontaneous breathing resumes(Box 5A). Give each delivered oxygen depends on the childs size, respiratory rate, breath over I second. Each breath should cause visible chest and respiratory effort. 86 For example, a flow rate of only 2 rise L/min can provide young infants with an inspired oxygen During delivery of rescue breaths, reassess the pulse about ery 2 minutes(Class Ia), but spend no more than 10 seconds doing Pulse Check(for Healthcare Providers)(Box 5) If you are a healthcare provider, you should try to palpate a Chest Compressions(Box 6) pulse(brachial in an infant and carotid or femoral in a child) To give chest compressions, compress the lower half of the Take no more than 10 seconds. Studies show that healthcare sternum but do not compress over the xiphoid. After each providers87-93 as well as lay rescuers94-96 are unable compression allow the chest to recoil fully(Class IIb) reliably detect a pulse and at times will think a pulse is because complete chest reexpansion improves blood fle present when there is no pulse. For this reason, if you do not into the heart. 7 A manikin study%7 showed that one way to definitely feel a pulse(eg, there is no pulse or you are not sure ensure complete recoil is to lift your hand slightly off the you feel a pulse) within 10 seconds, proceed with chest chest at the end of each compression, but this has not been impressions. studied in humans(Class Indeterminate). The following ar If despite oxygenation and ventilation the pulse is <60 beats per minute(bpm) and there are signs of poor perfusion characteristics of good compressions (ie, pallor, cyanosis), begin chest compressions. Profound ."Push hard" push with sufficient force to depress the chest bradycardia in the presence of poor perfusion is an indication approximately one third to one half the anterior-posterior for chest compressions because an inadequate heart rate with diameter of the chest. ndicates that cardiac arrest is imminent.."Push fast": push at a rate of approximately 100 cor Cardiac output in infancy and childhood largely depends on sions per minute heart rate. No scientific data has identified an absolute heart Release completely to allow the chest to fully recoil rate at which chest compressions should be initiated: the Minimize interruptions in chest compressions. recommendation to provide cardiac compression for a heart rate<60 bpm with signs of poor perfusion is based on ease In an infant victim, lay rescuers and lone rescuers should of teaching and skills retention. For additional information compress the sternum with 2 fingers(Figure 4) placed just see"Bradycardia"in Part 12: "Pediatric Advanced Life below the intermammary line(Class IIb: LOE 5, 6).98-102 Support.” The 2 thumb-encircling hands technique(Figure 5)is If the pulse is 60 bpm but the infant or child is not recommended for healthcare providers when 2 rescuers are breathing, provide rescue breathing without chest compres- present. Encircle the infant,s chest with both hands; spread sions(see below) your fingers around the thorax, and place your thumbs Lay rescuers are not taught to check for a pulse. The lay together over the lower half of the sternum. 95-102 Forcefully rescuer should immediately begin chest compressions after compress the sternum with your thumbs as you squeeze the delivering 2 rescue breaths thorax with your fingers for counterpressure(Class Ila; LOE

● Apply cricoid pressure. Do this only in an unresponsive victim and if there is a second rescuer.78 – 80 Avoid exces￾sive pressure so as not to obstruct the trachea.81 Oxygen Despite animal and theoretic data suggesting possible adverse effects of 100% oxygen,82– 85 there are no studies comparing various concentrations of oxygen during resuscitation beyond the newborn period. Until additional information becomes available, healthcare providers should use 100% oxygen during resuscitation (Class Indeterminate). Once the patient is stable, wean supplementary oxygen but ensure adequate oxygen delivery by appropriate monitoring. Whenever pos￾sible, humidify oxygen to prevent mucosal drying and thick￾ening of pulmonary secretions. Masks Masks provide an oxygen concentration of 30% to 50% to a victim with spontaneous breathing. For a higher concentra￾tion of oxygen, use a tight-fitting nonrebreathing mask with an oxygen inflow rate of approximately 15 L/min that maintains inflation of the reservoir bag. Nasal Cannulas Infant and pediatric size nasal cannulas are suitable for children with spontaneous breathing. The concentration of delivered oxygen depends on the child’s size, respiratory rate, and respiratory effort.86 For example, a flow rate of only 2 L/min can provide young infants with an inspired oxygen concentration
50%. Pulse Check (for Healthcare Providers) (Box 5) If you are a healthcare provider, you should try to palpate a pulse (brachial in an infant and carotid or femoral in a child). Take no more than 10 seconds. Studies show that healthcare providers87–93 as well as lay rescuers94 –96 are unable to reliably detect a pulse and at times will think a pulse is present when there is no pulse. For this reason, if you do not definitely feel a pulse (eg, there is no pulse or you are not sure you feel a pulse) within 10 seconds, proceed with chest compressions. If despite oxygenation and ventilation the pulse is 60 beats per minute (bpm) and there are signs of poor perfusion (ie, pallor, cyanosis), begin chest compressions. Profound bradycardia in the presence of poor perfusion is an indication for chest compressions because an inadequate heart rate with poor perfusion indicates that cardiac arrest is imminent. Cardiac output in infancy and childhood largely depends on heart rate. No scientific data has identified an absolute heart rate at which chest compressions should be initiated; the recommendation to provide cardiac compression for a heart rate 60 bpm with signs of poor perfusion is based on ease of teaching and skills retention. For additional information see “Bradycardia” in Part 12: “Pediatric Advanced Life Support.” If the pulse is
60 bpm but the infant or child is not breathing, provide rescue breathing without chest compres￾sions (see below). Lay rescuers are not taught to check for a pulse. The lay rescuer should immediately begin chest compressions after delivering 2 rescue breaths. Rescue Breathing Without Chest Compressions (for Healthcare Providers Only) (Box 5A) If the pulse is
60 bpm but there is no spontaneous breathing or inadequate breathing, give rescue breaths at a rate of about 12 to 20 breaths per minute (1 breath every 3 to 5 seconds) until spontaneous breathing resumes (Box 5A). Give each breath over 1 second. Each breath should cause visible chest rise. During delivery of rescue breaths, reassess the pulse about every 2 minutes (Class IIa), but spend no more than 10 seconds doing so. Chest Compressions (Box 6) To give chest compressions, compress the lower half of the sternum but do not compress over the xiphoid. After each compression allow the chest to recoil fully (Class IIb) because complete chest reexpansion improves blood flow into the heart.97 A manikin study97 showed that one way to ensure complete recoil is to lift your hand slightly off the chest at the end of each compression, but this has not been studied in humans (Class Indeterminate). The following are characteristics of good compressions: ● “Push hard”: push with sufficient force to depress the chest approximately one third to one half the anterior-posterior diameter of the chest. ● “Push fast”: push at a rate of approximately 100 compres￾sions per minute. ● Release completely to allow the chest to fully recoil. ● Minimize interruptions in chest compressions. In an infant victim, lay rescuers and lone rescuers should compress the sternum with 2 fingers (Figure 4) placed just below the intermammary line (Class IIb; LOE 5, 6).98 –102 The 2 thumb– encircling hands technique (Figure 5) is recommended for healthcare providers when 2 rescuers are present. Encircle the infant’s chest with both hands; spread your fingers around the thorax, and place your thumbs together over the lower half of the sternum.98 –102 Forcefully compress the sternum with your thumbs as you squeeze the thorax with your fingers for counterpressure (Class IIa; LOE Figure 4. Two-finger chest compression technique in infant (1 rescuer). IV-160 Circulation December 13, 2005

Part 11: Pediatric Basic Life Support IV-16 tachycardia [VTD) than they are after asphyxia-induced II 124=127 but even in asphyxial arrest, a minute ventilation that is lower than normal is likely to maintain an adequate ventilation-perfusion ratio because cardiac output and, therefore, pulmonary blood flow produced by che compressions is quite low For lay rescuers, a single compression-ventilation ratio (30: 2)for all age groups may increase the number of bystanders who perform CPR because it is easier to If you are the only rescuer, perform cycles of 30 chest compressions(Class Indeterminate) followed by 2 effecti ventilations with as short a pause in chest compressions as possible(Class IIb). Make sure to open the airway before Figure 5. Two thumb-encircling hands chest compression in giving ventilations. infant(2 rescuers For 2-rescuer CPR(eg, by healthcare providers or others, such as lifeguards, who are trained 5103, 104:6105, 106). If you are alone or you cannot physically provider should perform chest compressions while the other encircle the victims chest, compress the chest with 2 fingers maintains the airway and performs ventilations at a ratio as above). The 2 thumb-encircling hands technique is 15: 2 with as short a pause in compressions as possible. Do not preferred because it produces higher coronary artery perfu- ventilate and compress the chest simultaneously with either sion pressure, more consistently results in appropriate depth mouth-to-mouth or bag-mask ventilation. The 15: 2 ratio for 2 or force of compression, 105-108 and may generate higher rescuers is applicable in children up to the start of puberty systolic and diastolic pressures. 103, 104.10 Rescuer fatigue can lead to inadequate compression rate In a child, lay rescuers and healthcare providers should and depth and may cause the rescuer to fail to allow complete ompress the lower half of the sternum with the heel of 1 chest wall recoil between compressions. 28 The quality of hand or with 2 hands (as used for adult victims)but should chest compressions deteriorates within minutes even when not press on the xiphoid or the ribs. There is no outcome data the rescuer denies feeling fatigued. 29, 30 Once an advanced that shows a 1-hand or 2-hand method to be superior; higher airway is in place for infant, child, or adult victims, 2 rescuers compression pressures can be obtained on a child manikin no longer deliver cycles of compressions interrupted with with 2 hands. 111 Because children and rescuers come in all pauses for ventilation. Instead, the compressing rescuer sizes, rescuers may use either I or 2 hands to compress the should deliver 100 compressions per minute continuously childs chest. It is most important that the chest be com- without pauses for ventilation. The rescuer delivering the pressed about one third to one half the anterior-posterior ventilations should give 8 to 10 breaths per minute and should depth of the chest. be careful to avoid delivering an excessive number of ventilations. Two or more rescuers should rotate the com- ordinate Chest Compressions and Breathing(Box 6) ideal compression-ventilation ratio is unknown, bu pressor role approximately every 2 minutes to prevent com- ies have emphasized the followin pressor fatigue and deterioration in quality and rate of chest compressions. The switch should be accomplished as quickly In 2000112 a compression-ventilation ratio of 5: 1 and a as possible (ideally in less than 5 seconds) to minimize compression rate of 100 per minute were recommended. interruptions in chest compressions. on-Only CPR compressions per minute were performed in an adult Ventilation may not be essential in the first minutes of VF manikin, and fewer than 60 compressions per minute were cardiac arrest, 16, 124, 127. 31 during which periodic gasps and performed in a pediatric manikin even under ideal passive chest recoil may provide some ventilation if the circumstances airway is open. 24 This, however, is not true for most cardiac It takes a number of chest compressions to raise coronary arrests in infants and children, which are more likely to be rfusion pressure, which drops with each pause(eg, to asphyxial cardiac arrest. These victims require both prompt provide rescue breathing, check for a pulse, attach an ventilations and chest compressions for optimal resuscitation AED).116.1 If a rescuer is unwilling or unable to provide ventilations, terruptions in chest compressions hay chest compressions alone are better than no resuscitation at been documented during CPR by lay rescuers 18. 119 and by all(LOE 5 through 7: Class IIb).125,126 healthcare providers75, 120 in the out-of-hospital and in-hospital settings. Interruptions in chest compressions are associated Activate the EMS System and Get the AED (Box 7) with decreased rate of returm of spontaneous circulation 121-123 In the majority of infants and children with cardiac arrest, the Ventilations are relatively less important during the first arrest is asphyxial. 8. 11. 7.132.133 Lone rescuers(with the excep minutes of CPR for victims of a sudden arrhythmia- tion of healthcare providers who witness sudden collapse) induced cardiac arrest (VF or pulseless ventricular should perform CPR for 5 cycles(about 2 minutes) before

5103,104; 6105,106). If you are alone or you cannot physically encircle the victim’s chest, compress the chest with 2 fingers (as above). The 2 thumb– encircling hands technique is preferred because it produces higher coronary artery perfu￾sion pressure, more consistently results in appropriate depth or force of compression,105–108 and may generate higher systolic and diastolic pressures.103,104,109,110 In a child, lay rescuers and healthcare providers should compress the lower half of the sternum with the heel of 1 hand or with 2 hands (as used for adult victims) but should not press on the xiphoid or the ribs. There is no outcome data that shows a 1-hand or 2-hand method to be superior; higher compression pressures can be obtained on a child manikin with 2 hands.111 Because children and rescuers come in all sizes, rescuers may use either 1 or 2 hands to compress the child’s chest. It is most important that the chest be com￾pressed about one third to one half the anterior-posterior depth of the chest. Coordinate Chest Compressions and Breathing (Box 6) The ideal compression-ventilation ratio is unknown, but studies have emphasized the following: ● In 2000112 a compression-ventilation ratio of 5:1 and a compression rate of 100 per minute were recommended. But at that ratio and compression rate, fewer than 50 compressions per minute were performed in an adult manikin, and fewer than 60 compressions per minute were performed in a pediatric manikin even under ideal circumstances.113–115 ● It takes a number of chest compressions to raise coronary perfusion pressure, which drops with each pause (eg, to provide rescue breathing, check for a pulse, attach an AED).116,117 ● Long and frequent interruptions in chest compressions have been documented during CPR by lay rescuers118,119 and by healthcare providers75,120 in the out-of-hospital and in-hospital settings. Interruptions in chest compressions are associated with decreased rate of return of spontaneous circulation.121–123 ● Ventilations are relatively less important during the first minutes of CPR for victims of a sudden arrhythmia￾induced cardiac arrest (VF or pulseless ventricular tachycardia [VT]) than they are after asphyxia-induced arrest,116,117,124 –127 but even in asphyxial arrest, a minute ventilation that is lower than normal is likely to maintain an adequate ventilation-perfusion ratio because cardiac output and, therefore, pulmonary blood flow produced by chest compressions is quite low. ● For lay rescuers, a single compression-ventilation ratio (30:2) for all age groups may increase the number of bystanders who perform CPR because it is easier to remember. If you are the only rescuer, perform cycles of 30 chest compressions (Class Indeterminate) followed by 2 effective ventilations with as short a pause in chest compressions as possible (Class IIb). Make sure to open the airway before giving ventilations. For 2-rescuer CPR (eg, by healthcare providers or others, such as lifeguards, who are trained in this technique), one provider should perform chest compressions while the other maintains the airway and performs ventilations at a ratio of 15:2 with as short a pause in compressions as possible. Do not ventilate and compress the chest simultaneously with either mouth-to-mouth or bag-mask ventilation. The 15:2 ratio for 2 rescuers is applicable in children up to the start of puberty. Rescuer fatigue can lead to inadequate compression rate and depth and may cause the rescuer to fail to allow complete chest wall recoil between compressions.128 The quality of chest compressions deteriorates within minutes even when the rescuer denies feeling fatigued.129,130 Once an advanced airway is in place for infant, child, or adult victims, 2 rescuers no longer deliver cycles of compressions interrupted with pauses for ventilation. Instead, the compressing rescuer should deliver 100 compressions per minute continuously without pauses for ventilation. The rescuer delivering the ventilations should give 8 to 10 breaths per minute and should be careful to avoid delivering an excessive number of ventilations. Two or more rescuers should rotate the com￾pressor role approximately every 2 minutes to prevent com￾pressor fatigue and deterioration in quality and rate of chest compressions. The switch should be accomplished as quickly as possible (ideally in less than 5 seconds) to minimize interruptions in chest compressions. Compression-Only CPR Ventilation may not be essential in the first minutes of VF cardiac arrest,116,124,127,131 during which periodic gasps and passive chest recoil may provide some ventilation if the airway is open.124 This, however, is not true for most cardiac arrests in infants and children, which are more likely to be asphyxial cardiac arrest. These victims require both prompt ventilations and chest compressions for optimal resuscitation. If a rescuer is unwilling or unable to provide ventilations, chest compressions alone are better than no resuscitation at all (LOE 5 through 7; Class IIb).125,126 Activate the EMS System and Get the AED (Box 7) In the majority of infants and children with cardiac arrest, the arrest is asphyxial.8,11,17,132,133 Lone rescuers (with the excep￾tion of healthcare providers who witness sudden collapse) should perform CPR for 5 cycles (about 2 minutes) before Figure 5. Two thumb– encircling hands chest compression in infant (2 rescuers). Part 11: Pediatric Basic Life Support IV-161

lV-162 Circulation December 13. 2005 ating EMS, then start CPR again with as few interrup- Relief of FBAO of chest compressions as possible. If there are more FBAO may cause mild or severe airway obstruction. When rescuers present, one rescuer should begin the steps of CPR as the airway obstruction is mild, the child can cough and make soon as the infant or child is found to be unresponsive and some sounds. When the airway obstruction is severe, the second rescuer should activate the EMs system and get an victim cannot cough or make any sound. AED. Minimize interruption of chest compressions If fao is mild do not interfere. allow the victim to clear Defibrillation(Box 8) the airway by coughing while you observe for signs of severe FbAo be the of sudden collapse, or it op If the Fbao is severe(ie, the victim is unable to make a during resuscitation attempts. 7. 134 Children with sudden wit- nessed collapse(eg, a child collapsing during an athletic event)are likely to have VF or pulseless VT and need For a child, perform subdiaphragmatic abdominal thrusts(Heimlich maneuver) 43, 44 until the object is immediate CPR and rapid defibrillation VF and pulseless VT expelled or the victim becomes unresponsive. For an are referred to as""shockable rhythms" because they respond infant, deliver 5 back blows(slaps)followed by 5 chest to electric shocks(defibrillation). thrustsl45-149 repeatedly until the object is expelled or Many AEDs have high specificity in recognizing pediatric the victim becomes unresponsive. Abdominal thrusts shockable rhythms, and some are equipped to decrease the are not recommended for infants because they may delivered energy to make it suitable for children I to 8 years damage the relatively large and unprotected liver of age. 134, 135 Since the publication of the ECC Guidelines If the victim becomes unresponsive, lay rescuers and 2000, 12 data has shown that AEDs can be safely and healthcare providers should perform CPR but should effectively used in children I to 8 years of age 36 look into the mouth before giving breaths. If you see a However. there is insufficient data to make a recommenda- foreign body, remove it. Healthcare providers should tion for or against using an AED in infants <I year of age not perform blind finger sweeps because they may push Class Indeterminate). 36-138 bstructing objects further into the pharynx and may In systems and institutions that care for children and have damage the oropharynx 53.54 Healthcare providers an AED program, it is recommended that the AED have both should attempt to remove an object only if they can see a high specificity in recognizing pediatric shockable rhythms it in the pharynx. Then rescuers should attempt venti- and a pediatric dose-attenuating system to reduce the dose lation and follow with chest compressions delivered by the device. In an emergency if an AED with a pediatric attenuating system is not available, use a standard Special Resuscitation Situations AED. Turn the AED on, follow the AED prompts, and Children With Special Healthcare Needs resume chest compressions immediately after the shock. Children with special healthcare needs 55-57 may require emer Minimize interruptions in chest compressions gency care for complications of chronic conditions(eg, obstruction of a tracheostomy), failure of support technology(eg, ventilator CPR Techniques and Adjuncts failure), progression of underlying disease, or events unrelated to There is insufficient data in infants and children to recom- those special needs. 58 Care is often complicated by a lack of of mechanical device medical information, plan of medical care, list of current medica- tions, and Do Not Attempt Resuscitation(DNAR)orders. Parents compress the sternum, active compression-decompression and child-care providers are encouraged to keep copies of medical CPR, interposed abdominal compression CPR (IAC-CPR), or information at home, with the child, and at the childs school or the impedance threshold device( Class Indeterminate). See child-care facility. School nurses should have copies and should Part 6: CPR Techniques and Devices "for adjuncts in adults maintain a readily available list of children with DNAR or- ders. 58, 159 An Emergency Information Form(ElF) was developed Foreign-Body Airway Obstruction( Choking) by the American Academy of Pediatrics and the American College Ep logy and recognitio mergency Physicians 57and is available on the Worldwide Web More than 90% of deaths from foreign-body aspiration occur athttp://www.pediatrics.org/cgicontent/fuln104/4e53 If a decision to limit or withhold resuscitative efforts is in children <5 years of age: 65% of the victims are infants. Liquids are the most common cause of choking in infants, 139 made, the physician must write an order clearly detailing the limits of any attempted resuscitation. A separate order must whereas balloons, small objects, and foods(eg, hot dogs, be written for the out-of-hospital setting. Regulations regard- round candies, nuts, and grapes)are the most common causes ing out-of-hospital"do not attempt resuscitation"(DNAR or of foreign-body airway obstruction(FBAO)in children. 40- so-called"no-CPr") directives vary from state to state. For 142 Signs of FBAO include a sudden onset of respiratory further information about ethical issues of resuscitation. see distress with coughing, gagging, stridor(a high-pitched, noisy Part 2:"Ethical Issues or wheezing. The characteristics that distinguish When a child with a chronic or potentially life-threatenin from other causes(eg, croup) are sudden onset in a condition is discharged from the hospital, parents, school setting and the absence of antecedent fever or respi- nurses, and home healthcare providers should be informed ratory symptoms about the reason for hospitalization, hospital course, and how

activating EMS, then start CPR again with as few interrup￾tions of chest compressions as possible. If there are more rescuers present, one rescuer should begin the steps of CPR as soon as the infant or child is found to be unresponsive and a second rescuer should activate the EMS system and get an AED. Minimize interruption of chest compressions. Defibrillation (Box 8) VF can be the cause of sudden collapse, or it may develop during resuscitation attempts.7,134 Children with sudden wit￾nessed collapse (eg, a child collapsing during an athletic event) are likely to have VF or pulseless VT and need immediate CPR and rapid defibrillation. VF and pulseless VT are referred to as “shockable rhythms” because they respond to electric shocks (defibrillation). Many AEDs have high specificity in recognizing pediatric shockable rhythms, and some are equipped to decrease the delivered energy to make it suitable for children 1 to 8 years of age.134,135 Since the publication of the ECC Guidelines 2000,112 data has shown that AEDs can be safely and effectively used in children 1 to 8 years of age.136 –138 However, there is insufficient data to make a recommenda￾tion for or against using an AED in infants 1 year of age (Class Indeterminate).136 –138 In systems and institutions that care for children and have an AED program, it is recommended that the AED have both a high specificity in recognizing pediatric shockable rhythms and a pediatric dose-attenuating system to reduce the dose delivered by the device. In an emergency if an AED with a pediatric attenuating system is not available, use a standard AED. Turn the AED on, follow the AED prompts, and resume chest compressions immediately after the shock. Minimize interruptions in chest compressions. CPR Techniques and Adjuncts There is insufficient data in infants and children to recom￾mend for or against the use of mechanical devices to compress the sternum, active compression-decompression CPR, interposed abdominal compression CPR (IAC-CPR), or the impedance threshold device (Class Indeterminate). See Part 6: “CPR Techniques and Devices” for adjuncts in adults. Foreign-Body Airway Obstruction (Choking) Epidemiology and Recognition More than 90% of deaths from foreign-body aspiration occur in children 5 years of age; 65% of the victims are infants. Liquids are the most common cause of choking in infants,139 whereas balloons, small objects, and foods (eg, hot dogs, round candies, nuts, and grapes) are the most common causes of foreign-body airway obstruction (FBAO) in children.140 – 142 Signs of FBAO include a sudden onset of respiratory distress with coughing, gagging, stridor (a high-pitched, noisy sound), or wheezing. The characteristics that distinguish FBAO from other causes (eg, croup) are sudden onset in a proper setting and the absence of antecedent fever or respi￾ratory symptoms. Relief of FBAO FBAO may cause mild or severe airway obstruction. When the airway obstruction is mild, the child can cough and make some sounds. When the airway obstruction is severe, the victim cannot cough or make any sound. ● If FBAO is mild, do not interfere. Allow the victim to clear the airway by coughing while you observe for signs of severe FBAO. ● If the FBAO is severe (ie, the victim is unable to make a sound): — For a child, perform subdiaphragmatic abdominal thrusts (Heimlich maneuver)143,144 until the object is expelled or the victim becomes unresponsive. For an infant, deliver 5 back blows (slaps) followed by 5 chest thrusts145–149 repeatedly until the object is expelled or the victim becomes unresponsive. Abdominal thrusts are not recommended for infants because they may damage the relatively large and unprotected liver.150 –152 — If the victim becomes unresponsive, lay rescuers and healthcare providers should perform CPR but should look into the mouth before giving breaths. If you see a foreign body, remove it. Healthcare providers should not perform blind finger sweeps because they may push obstructing objects further into the pharynx and may damage the oropharynx.153,154 Healthcare providers should attempt to remove an object only if they can see it in the pharynx. Then rescuers should attempt venti￾lation and follow with chest compressions. Special Resuscitation Situations Children With Special Healthcare Needs Children with special healthcare needs155–157 may require emer￾gency care for complications of chronic conditions (eg, obstruction of a tracheostomy), failure of support technology (eg, ventilator failure), progression of underlying disease, or events unrelated to those special needs.158 Care is often complicated by a lack of medical information, plan of medical care, list of current medica￾tions, and Do Not Attempt Resuscitation (DNAR) orders. Parents and child-care providers are encouraged to keep copies of medical information at home, with the child, and at the child’s school or child-care facility. School nurses should have copies and should maintain a readily available list of children with DNAR or￾ders.158,159 An Emergency Information Form (EIF) was developed by the American Academy of Pediatrics and the American College of Emergency Physicians157and is available on the Worldwide Web at http://www.pediatrics.org/cgi/content/full/104/4/e53. If a decision to limit or withhold resuscitative efforts is made, the physician must write an order clearly detailing the limits of any attempted resuscitation. A separate order must be written for the out-of-hospital setting. Regulations regard￾ing out-of-hospital “do not attempt resuscitation” (DNAR or so-called “no-CPR”) directives vary from state to state. For further information about ethical issues of resuscitation, see Part 2: “Ethical Issues.” When a child with a chronic or potentially life-threatening condition is discharged from the hospital, parents, school nurses, and home healthcare providers should be informed about the reason for hospitalization, hospital course, and how IV-162 Circulation December 13, 2005

Part 11: Pediatric Basic Life Support IV-163 to recognize signs of deterioration. They should receive sions and ventilations before activating EMS and (for chil- specific instructions about CPR and whom to contact159 dren I year of age and older) getting an AED. If 2 rescuers are With Tracheostomy or sthima wit present, send the second rescuer to activate the EMS system th a tracheos immediately and get an AED(if appropriate), while you lthcare providers) continue CPR. y of the airway, clear the Summary: The Quality of BLS Immediate CPR can improve survival from cardiorespiratory tion and verity arrest in children, but not enough children receive high- quality CPR. We must increase the number of laypersons who ow eftective learn, remember, and perform CPR and must improve the quality of CPR provided by lay rescuers and healthcare Systems that deliver professional CPR should implement s quality improvement that include monitoring the quality of CPR delivered at the scene of cardiac arrest, other process-of-care measures(eg,initial der CPR, and response intervals), and patient utcome up t pital discharge (see Part 3: "Overview of e failure to CPR"). This evidence should be us R a et sed to optimize the quality of CPR delivered (Class Indeterminate). References u DN, Arcinue EL, Peek C, Kraus JF. Effect of immediate tal fragments, blood, 2. Hickey. Cohen DM. Strausbaugh. Di M. Pediatric patients Med.199525 o ardiac origin: 1128. f the cervical spine and avoid I of pediatric Ann Emerg ptratory C. Herndon P. MJ, Ward MA, demographics, ss in the the victim. Start CPR by opening the airway and giving S, Ranta S, Olkkola KT. elfective breaths followed by chest compressionsi you ar perature on outcome in alon 5 cycle

to recognize signs of deterioration. They should receive specific instructions about CPR and whom to contact.159 Ventilation With a Tracheostomy or Stoma Everyone involved with the care of a child with a tracheos￾tomy (parents, school nurses, and home healthcare providers) should know how to assess patency of the airway, clear the airway, and perform CPR using the artificial airway. Use the tracheostomy tube for ventilation and verify adequacy of airway and ventilation by watching for chest expansion. If the tracheostomy tube does not allow effective ventilation even after suctioning, replace it. Alternative ven￾tilation methods include mouth-to-stoma ventilation and bag￾mask ventilation through the nose and mouth while you or someone else occludes the tracheal stoma. Trauma The principles of BLS resuscitation for the injured child are the same as those for the ill child, but some aspects require emphasis; improper resuscitation is a major cause of prevent￾able pediatric trauma death.160 Errors include failure to properly open and maintain the airway and failure to recog￾nize and treat internal bleeding. The following are important aspects of resuscitation of pediatric victims of trauma: ● Anticipate airway obstruction by dental fragments, blood, or other debris. Use a suction device if necessary. ● Stop all external bleeding with pressure. ● When the mechanism of injury is compatible with spinal injury, minimize motion of the cervical spine and avoid traction or movement of the head and neck. Open and maintain the airway with a jaw thrust and try not to tilt the head. If a jaw thrust does not open the airway, use a head tilt– chin lift. If there are 2 rescuers, the first opens the airway while the second restricts cervical spine motion. To limit spine motion, secure at least the thighs, pelvis, and shoulders to the immobilization board. Because of the disproportionately large size of the head in infants and young children, optimal positioning may require recessing the occiput161 or elevating the torso to avoid undesirable backboard-induced cervical flexion.161,162 ● If possible, transport children with multisystem trauma to a trauma center with pediatric expertise. Drowning Outcome after drowning depends on the duration of submer￾sion, the water temperature, and how promptly CPR is started.1,16,163 An excellent outcome can occur after prolonged submersion in icy waters.164,165 Start resuscitation by safely removing the victim from the water as rapidly as possible. If you have special training, start rescue breathing while the victim is still in the water166 if doing so will not delay removing the victim from the water. Do not attempt chest compressions in the water, however. There is no evidence that water acts as an obstructive foreign body; don’t waste time trying to remove water from the victim. Start CPR by opening the airway and giving 2 effective breaths followed by chest compressions; if you are alone, continue with 5 cycles (about 2 minutes) of compres￾sions and ventilations before activating EMS and (for chil￾dren 1 year of age and older) getting an AED. If 2 rescuers are present, send the second rescuer to activate the EMS system immediately and get an AED (if appropriate), while you continue CPR. Summary: The Quality of BLS Immediate CPR can improve survival from cardiorespiratory arrest in children, but not enough children receive high￾quality CPR. We must increase the number of laypersons who learn, remember, and perform CPR and must improve the quality of CPR provided by lay rescuers and healthcare providers alike. Systems that deliver professional CPR should implement processes of continuous quality improvement that include monitoring the quality of CPR delivered at the scene of cardiac arrest, other process-of-care measures (eg, initial rhythm, bystander CPR, and response intervals), and patient outcome up to hospital discharge (see Part 3: “Overview of CPR”). This evidence should be used to optimize the quality of CPR delivered (Class Indeterminate). References 1. Kyriacou DN, Arcinue EL, Peek C, Kraus JF. Effect of immediate resuscitation on children with submersion injury. Pediatrics. 1994;94(pt 1):137–142. 2. Hickey RW, Cohen DM, Strausbaugh S, Dietrich AM. Pediatric patients requiring CPR in the prehospital setting. Ann Emerg Med. 1995;25: 495–501. 3. Kuisma M, Alaspaa A. Out-of-hospital cardiac arrests of non-cardiac origin: epidemiology and outcome. Eur Heart J. 1997;18:1122–1128. 4. Friesen RM, Duncan P, Tweed WA, Bristow G. Appraisal of pediatric cardiopulmonary resuscitation. Can Med Assoc J. 1982;126:1055–1058. 5. Zaritsky A, Nadkarni V, Getson P, Kuehl K. CPR in children. Ann Emerg Med. 1987;16:1107–1111. 6. Lopez-Herce J, Garcia C, Rodriguez-Nunez A, Dominguez P, Carrillo A, Calvo C, Delgado MA. Long-term outcome of paediatric cardiorespiratory arrest in Spain. Resuscitation. 2005;64:79 – 85. 7. Mogayzel C, Quan L, Graves JR, Tiedeman D, Fahrenbruch C, Herndon P. Out-of-hospital ventricular fibrillation in children and adolescents: causes and outcomes. Ann Emerg Med. 1995;25:484 – 491. 8. Sirbaugh PE, Pepe PE, Shook JE, Kimball KT, Goldman MJ, Ward MA, Mann DM. A prospective, population-based study of the demographics, epidemiology, management, and outcome of out-of-hospital pediatric car￾diopulmonary arrest [published correction appears in Ann Emerg Med. 1999;33:358]. Ann Emerg Med. 1999;33:174 –184. 9. Schindler MB, Bohn D, Cox PN, McCrindle BW, Jarvis A, Edmonds J, Barker G. Outcome of out-of-hospital cardiac or respiratory arrest in children. N Engl J Med. 1996;335:1473–1479. 10. O’Rourke PP. Outcome of children who are apneic and pulseless in the emergency room. Crit Care Med. 1986;14:466 – 468. 11. Young KD, Seidel JS. Pediatric cardiopulmonary resuscitation: a collective review. Ann Emerg Med. 1999;33:195–205. 12. Dieckmann R, Vardis R. High-dose epinephrine in pediatric out-of-hospital cardiopulmonary arrest. Pediatrics. 1995;95:901–913. 13. Herlitz J, Engdahl J, Svensson L, Young M, Angquist KA, Holmberg S. Characteristics and outcome among children suffering from out of hospital cardiac arrest in Sweden. Resuscitation. 2005;64:37– 40. 14. Pell JP, Sirel JM, Marsden AK, Ford I, Walker NL, Cobbe SM. Presenta￾tion, management, and outcome of out of hospital cardiopulmonary arrest: comparison by underlying aetiology. Heart (British Cardiac Society). 2003; 89:839 – 842. 15. Lopez-Herce J, Garcia C, Dominguez P, Carrillo A, Rodriguez-Nunez A, Calvo C, Delgado MA. Characteristics and outcome of cardiorespiratory arrest in children. Resuscitation. 2004;63:311–320. 16. Suominen P, Baillie C, Korpela R, Rautanen S, Ranta S, Olkkola KT. Impact of age, submersion time and water temperature on outcome in near-drowning. Resuscitation. 2002;52:247–254. Part 11: Pediatric Basic Life Support IV-163

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Brent DA, Perper JA, Allman CJ, Moritz GM, Wartella ME, Zelenak JP. The presence and accessibility of firearms in the homes of adolescent suicides: a case-control study. JAMA. 1991;266:2989 –2995. 31. Svenson JE, Spurlock C, Nypaver M. Pediatric firearm-related fatalities: not just an urban problem. Arch Pediatr Adolesc Med. 1996;150:583–587. 32. Dahlberg LL, Ikeda RM, Kresnow MJ. Guns in the home and risk of a violent death in the home: findings from a national study. Am J Epidemiol. 2004;160:929 –936. 33. Willinger M, James LS, Catz C. Defining the sudden infant death syndrome (SIDS): deliberations of an expert panel convened by the National Institute of Child Health and Human Development. Pediatr Pathol. 1991;11: 677– 684. 34. Changing concepts of sudden infant death syndrome: implications for infant sleeping environment and sleep position. American Academy of Pediatrics. Task Force on Infant Sleep Position and Sudden Infant Death Syndrome. Pediatrics. 2000;105:650 – 656. 35. 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