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 ).66In 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