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) before5103,104; 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