Paediatric Basic Life Support

Overview

Definitions

This is a summary of the Resuscitation Council UK guidelines and like all material on this website, must only be used for exams and revision and must not be used for patient care. Always check the Resuscitation Council UK guidelines, NICE, and any other relevant guidelines for updates or changes.

The Resuscitation Council UK have the following definitions:

• Newborn – an infant just after birth
• Infant – <1 year old
• Child – between 1-18 years old

Unlike adults, most paediatric arrests are due to respiratory arrest or hypoxia rather than a primary cardiac problem.

If the responder believes the person is a child, then they should use the paediatric guidelines. It is important to differentiate between infants and children as their management differs.

Danger and Response

Danger

Always check the safety of both the rescuer and the child. Two injured people is always worse than one.

Response

Gently stimulate the child and ask loudly, ‘Are you alright?’

• Avoid shaking infants or children with suspected cervical spine injuries.

Child is Responding

Overview

If the child responds (e.g. by answering or moving):

• Leave the child in the position you found them (provided they are not in danger)
• Check condition and arrange urgent medical help if needed with a full ABCDE assessment
• Reassess the child regularly

No Response From Child

Get help and inspect the airway

Shout for help and call 999:

• Or 2222 if in an NHS hospital

Open the child’s airway:

• Turn child onto back and open the airway via head tilt chin lift:
  • Place hand on forehead and gently tilt head back
  • Place fingertips under chin and lift
• If head tilt chin lift is difficult: perform jaw thrust:
  • Place the first two fingers of each hand behind each side of the mandible
  • Push the jaw forward
• If cervical spine injury suspected (e.g. significant trauma):
  • Use jaw thrust alone and gradually add head tilt until the airway is open
  • An open airway takes priority over cervical spine injuries

Check for obstruction:

• Only remove obvious and accessible obstructions.
• Do not perform a blind finger sweep

Assess breathing and signs of life

Keeping the airway open, assess breathing by placing your face near the child’s face, and looking down at the chest for no more than 10 seconds:

• This involves:
  • Looking for chest movements (rising and falling with inspiration/expiration)
  • Listening to the child’s nose and mouth for breath sounds
  • Feeling for air movement on your cheek
  • Also looking for signs of life (e.g. movement, coughing)
• Infrequent, noisy gasps do not count as normal breathing
• If in doubt, act as if breathing is not normal

In regards to checking the pulse:

• Studies have shown that checking the pulse to determine circulation in children is unreliable, even for trained paediatric healthcare professionals. Looking for breathing and signs of life is more important.
• If a pulse check is to be done, this should be done simultaneously with a breathing assessment:
  • For an infant, the femoral pulse is checked
  • For a child, the carotid pulse is checked
  • A pulse <60 bpm is treated the same as no pulse

Child is breathing normally

Place the child into the recovery position, maintain an open airway, and call for help.

• Only leave the child if there is no other possible way of getting help
• Continue to reassess

Child’s breathing is abnormal or absent

• Give 5 rescue breaths and initiate basic life support discussed below under ‘No Signs of Life’

No Signs of Life

Call for help and give 5 rescue breaths

If there are no signs of life, no or abnormal breathing, or there is uncertainty, give 5 rescue breaths and start basic life support and call 999 or 2222 if in an NHS hospital (if not already done).

• If in hospital, state your location (e.g. ward) and if the arrest is in an infant or child 

Rescue breaths

If the child’s breathing is abnormal/absent or there are no signs of life, give 5 rescue breaths:

• This may be done with a bag valve mask in hospital or pocket masks in larger children
• If there is no immediate access to medical equipment, give manual rescue breaths
• Note any gagging/coughing, or movement – these suggest signs of life

For an infant:

• Ensure the infant’s head is neutral and apply chin lift (avoid overextension):
  • This is because many infants have head flexion when lying down
• Take a deep breath, cover the infant’s mouth and nose with your mouth, and ensure you have a good seal
  • If the infant is too big, the rescuer may seal only the nose or mouth (close the lips if the nose is used to prevent air escape)
• Blow steadily over 1 second and look for the chest rising to ensure a good seal
• Take your mouth away after breathing and watch the chest fall as air comes out
• Take another breath and repeat 4 more times (making 5 in total)

For a child:

• Head tilt and chin lift and place the child’s head in the ‘sniffing position’
• Take a deep breath, pinch the child’s nose and cover the child’s mouth with your nose and ensure you have a good seal
• Blow steadily over 1 second and look for the chest rising to ensure a good seal
• Take your mouth away after breathing and watch the chest fall as air comes out
• Take another breath and repeat 4 more times (making 5 in total)

Difficulties with rescue breaths

If there are difficulties with effective breathing:

• There may be obstruction:
  • Only remove obvious and accessible obstruction.
  • Do not perform a blind finger sweep
• Ensure there is adequate head tilt and chin lift but no overextension
  • If head tilt and chin lift are unsuccessful, try jaw thrust
• Attempt rescue breaths up to 5 times, if unsuccessful, move on to chest compressions

After giving rescue breaths

If signs of life can confidently be detected: (e.g. movement, coughing, normal breathing, but not infrequent, irregular gasps – also known as ‘agonal gasps’):

• Continue rescue breathing until the child breathes effectively on their own
• Place the child in the recovery position, maintain the airway, seek urgent medical help, and reassess frequently

If signs of life are not present or there is uncertainty start chest compressions.

Chest compressions

If after rescue breaths there are no signs of life or you are unsure, start chest compressions and start cardiopulmonary resuscitation (CPR):

• Give 15 chest compressions followed by 2 ventilations and repeat
• Compress the lower half of the sternum

For infants, the encircling technique is preferred:

• If one rescuer, use the two-finger technique:
  • Compress the lower half of the sternum using the tips of the index and middle fingers
• If two rescuers, use the encircling technique:
  • Place both thumbs side-by-side on the lower half of the sternum with the tips pointing to the infant’s head and spread and encircle the rest of the hands around the infant’s ribcage with the rest of the fingertips supporting their back
  • For small infants, the thumbs may overlap

For a child over 1 year, the technique involves:

• Small child: place the heel of one hand over the lower half of the sternum and lift fingers to avoid pushing on the rips
• Larger child: two hands with interlocked fingers as per adult basic life support may be used

Do not interrupt CPR unless there are clear signs of life:

• If more than one person is available, alternate the person performing chest compressions to avoid fatigue

High-quality chest compressions require:

• A rate of 100-120 bpm (such as the tempo of Stayin’ Alive by The BeeGees)
• A depth of 1/3 of the distance of the chest from front to back:
  • Usually 4 cm in an infant, 5 cm for a child
  • Never deeper than 6 cm (around the length of an adult thumb)
• Allowing full recoil after each compression by:
  • Releasing all pressure on the chest between compressions
  • Giving enough time for the chest to recoil
• Minimising interruptions and pauses between CPR 
• Performing compressions on a flat, hard surface

Automated external defibrillators (AEDs)

A lone rescuer should start CPR immediately and if possible, look for an automated external defibrillator (AED) while calling for emergency help:

• If a second person is available, they should call for help and collect the AED if possible

Immediately attach the 2 self-adhesive pads to the patient’s bare chest. The AED has instructions on where to place the pads. In small children, this may be different to the location in adults:

• Adhesive pad 1: on the front on the upper chest between the nipples
• Adhesive pad 2: on the upper back between the shoulder blades

Turn on the AED and follow its instructions, which may vary from device to device.

• The time between CPR should be minimised as much as possible and perform CPR up to the point of analysis and immediately after the shock delivery or no shock decision.

Stopping CPR

Continue CPR until:

• Clear signs of life appear
• Further qualified help arrives
  • Once the resuscitation team arrives, advanced life support is initiated
• You become exhausted