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