Basic Life Support

The need for CPR in the pediatric age group is rare after the neonatal period. Pediatric cardiac arrests usually result from hypoxemia linked to respiratory failure or airway obstruction. Initial efforts should be directed toward the establishment of a secure airway and adequate ventilation. The pediatric guidelines apply to infants between the ages of about 1 month and 1 year and to children more than 1 year of age. For newborns, see section V below. The definition of “children” for health care providers is patients between the ages of 1 year and the start of puberty; for the lay public, a child is defined as aged 1 to 8 years. In contrast to the guideline of “phone first” for adult CPR, one should “phone fast” for infants and children. That is, the lone rescuer should perform five cycles (about 2 minutes) of CPR before phoning 911. The “phone fast” rule also applies to resuscitation from drowning, traumatic arrest, or drug overdose. Exceptions include witnessed and sudden arrests (e.g., an athlete who collapses on the playing field) or situations in which a child is known to be at high risk for a sudden arrhythmia. Modifications of the rate and magnitude of compressions and ventilations, as well as of the hand position for compressions, are necessary because of anatomic and physiologic differences (Table 38.2). Differences between pediatric and adult resuscitation techniques are detailed below.

1. Airway and breathing. Maneuvers to establish an airway are the same as in the adult, with a few caveats. For children less than 1 year of age, abdominal thrusts are not used, since the gastrointestinal tract can be damaged easily. Hyperextension of an infant's neck for the head tilt/chin lift may lead to airway obstruction because of the small diameter and ease of compression of the immature airway. Submental compression while performing the chin lift can also lead to airway obstruction by pushing the tongue into the pharynx. Ventilations should be given slowly with low airway pressures to avoid gastric distention and should be of sufficient volume to cause the chest to rise and fall.
2. Circulation. The brachial or femoral artery is used for pulse assessment in infants (patients <1 year old) because the carotid artery is difficult to palpate. Upon determination that a pulse is absent, chest compressions should be initiated. Chest compressions in infants are delivered using two fingertips applied to the sternum or by encircling the chest with both hands and using the thumbs to depress the sternum one fingerbreadth below the intermammary line. In older children, the correct hand position is determined as for adults, but with only one hand depressing the sternum. The chest should be compressed about one third to one half of its anterior–posterior depth. The compression/ventilation ratio is 30:2 for one-rescuer CPR of infants and children, and 15:2 when 2 rescuers are available. If an advanced airway is in place during two-person CPR, there is no need to synchronize breaths between compressions. Ventilations should be given at a rate of approximately 8 to 10 breaths/min, and chest compressions should be given at a rate of 100/min without pauses for ventilation.