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 howactivating 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