Basic Life Support (BLS): Pediatric Resuscitation

Change from 2015 Guidelines

The respiratory rate has changed  for infants and children who are (a) receiving CPR with an advanced airway in place or (b) receiving rescue breathing and have a pulse. The rate now sjould be one breath every 2-3 seconds (20-30 breaths/minute), increased from the 2015 guidelines’ suggested rate of every 3-5 seconds (12-20 breaths/minute).

Basic Life Support: Child Arrest

1. Verify scene safety. ^{[1, 2, 3, 4, 5]}

2. Check responsiveness; if none, follow steps below:

• Shout for nearby help
• Activate emergency response system (eg, facility protocol, mobile phone).
• Witnessed collapse: If alone, leave to call emergency response and get AED before CPR.
• Unwitnessed collapse: Give 2 minutes of CPR and then leave the child/infant to call emergency response.
• Get automated external defibrillator (AED) and emergency equipment or send someone to do so.
• Assess for breathing or only gasping.

3. Assess for no breathing or only gasping and check pulse for less than 10 seconds, simultaneously. If normal breathing and pulse definitely present, monitor until additional help arrives.

4. If no normal breathing but pulse present, follow the steps below:

• Provide rescue breathing: 1 breath every 2-3 seconds (20-30 breaths/minute). Note: This is a change from the 2015 guidelines.
• Start compressions if pulse is 60 or fewer beats per minute (bpm) with signs of poor perfusion (signs of poor perfusion include cool extremities, decrease in responsiveness, weak pulses, paleness, mottling [patchy skin appearance], and cyanosis [turning blue]).
• Activate emergency response system (if not already done) after 2 minutes.
• Continue rescue breathing with pulse check every 2 minutes; if no pulse, begin CPR.
• If possible opioid overdose, administer naloxone, if available, per protocol.

5. If no breathing (or only gasping) and no pulse, follow the steps below:

• If alone, start high-quality cardiopulmonary resuscitation (CPR) at a compressions-to-breaths ratio of 30:2.
• If not alone, start high-quality CPR at a compressions-to-breaths ratio of 15:2.
• In infants, start CPR if heart rate is less than 60 bpm and poor perfusion despite adequate oxygen and ventilation.
• Every 2 minutes, check pulse, check rhythm, and switch compressors.
• Use AED as soon as available (for child, not infant); if shockable rhythm, defibrillate and then immediately start CPR.
• High-quality CPR and changing rescuers every 2 minutes improves a victim’s chance of survival.

6. With the AED attached (for child, not infant), assess for shockable rhythm, as follows:

• If shockable, defibrillate and then immediately start CPR for about 2 minutes.
• If nonshockable, resume CPR for about 2 minutes and reassess for pulse and shockable rhythm.

Compressions: Children aged 1 year to puberty

Administration of chest compressions to children aged 1 year to puberty should proceed as follows:

• Check pulse at carotid artery.
• Compression landmarks: lower half of sternum between the nipples
• Compression method: heel of one hand, other hand on top if needed
• Depth: at least one-third anteroposterior (AP) chest diameter
• Depth: about 2 inches (5 cm)
• Allow complete chest recoil after each compression
• Compression rate: 100-120 per minute
• Compressions-to-ventilations ratio: 30:2 if single rescuer, 15:2 if multiple rescuers
• Continuous compressions if advanced airway present and asynchronous ventilation
• Rotate compressor every 2 minutes or if fatigued.
• Minimize interruptions in compressions to less than 10 seconds.
• Avoid excessive ventilation.

Compressions: Infants (< 1 year, excluding newborns)

Administration of chest compressions to infants(< 1 year, excluding newborns) should proceed as follows:

• Check pulse at brachial artery
• Compression landmarks: lower third of sternum between the nipples
• Compression method: two fingers if alone or thumb-encircling if multiple providers
• Depth: at least one-third AP chest diameter
• Depth: about 1.5 inches (4 cm)
• Allow complete chest recoil after each compression.
• Compression rate: 100-120 per minute
• Compressions-to-ventilations ratio: 30:2 if single rescuer, 15:2 if multiple rescuers
• Continuous compressions if advanced airway present and timed ventilation
• Rotate compressor every 2 minutes or if fatigued.
• Minimize interruptions in compressions to less than 10 seconds.
• Avoid excessive ventilation.

Airway

Establishing a patent airway should proceed as follows:

• Children: head tilted, chin lifted
• Infants: sniffing position
• Jaw thrust if trauma suspected (children and infants)

Breathing

Administration of artificial respirations should proceed as follows:

• Ventilation with advanced airway every 2-3 seconds, asynchronous with compressions (children) or timed (infants)  Note:  This is a change from the 2015 guidelines.
• Rescue breathing every 2-3 seconds  Note:  This is a change from the 2015 guidelines.
• Deliver at about 1 second/breath.
• Watch for visible chest rise.

Defibrillation

Defibrillation should proceed as follows:

• In children, attach and use AED as soon as available.
• In infants, there are currently no defibrillation recommendations from the American Heart Association, although some sources ^[6] suggest using defibrillation in the same dose as with children.
• Minimize interruptions in chest compressions before and after shock.
• Resume CPR beginning with compressions immediately after each shock.
• In children, use dose attenuator, if available; otherwise, adult pads may be used.