Cardiopulmonary resuscitation

Cardiopulmonary resuscitation (CPR), also called basic life support, is an emergency medical procedure performed to restore breathing and blood flow (circulation). "Cardio-" refers to heart function and "pulmonary" refers to lung function. CPR is a combination of rescue breathing (i.e., mouth-to-mouth resuscitation or ventilation) and chest compressions.

Serious injuries and medical conditions, such as sudden infant death syndrome (SIDS), severe respiratory infections, and neurological and heart disorders, can cause a child to stop breathing (called respiratory arrest) and his or her heart to stop beating (called cardiac arrest). When the brain is without oxygen, permanent brain damage and death can occur in a matter of minutes

The initial simple assessment of responsiveness consists of asking the child “Are you alright?” and gently applying painful stimulus to the child. Infants and very small children who cannot talk yet, and older children who are very scared, are unlikely to reply meaningfully, but may make some sound or open their eyes to the rescuer’s voice or touch.
In cases associated with trauma, the neck and spine should be immobilized during this assessment. This can be achieved by a lone rescuer by placing one hand firmly on the head.

Airway (A)

An obstructed airway may be the primary problem, and correction of the obstruction can result in recovery without further intervention. If a child is having difficulty breathing, but is conscious, then transport to hospital should be arranged as quickly as possible. A child will often find the best position to maintain his or her own airway, and should not be forced to adopt a position that may be less comfortable. Attempts to improve a partially maintained airway in an environment where immediate advanced support is not available can be dangerous, because total obstruction may occur.

If the child is not breathing it may be because the airway has been blocked by the tongue’s falling back and obstructing the pharynx. An attempt to open the airway should be made using the head tilt/chin lift manoeuvre. The rescuer places the hand nearest to the child’s head on the forehead and applies pressure to tilt the head back gently. The desirable degrees of tilt are neutral, in the infant, and sniffing, in the child.

The fingers of the other hand should then be placed under the chin and the chin should be lifted upwards. Care should be taken not to injure the soft tissue by gripping too hard.

As this action can close the child’s mouth, it may be necessary to use the thumb of the same hand to part the lips slightly.

The patency of the airway should then be assessed. This is done by: LOOKing for chest and/or abdominal movement,
LISTENing for breath sounds and FEELing for breath, and is best achieved by the rescuer placing his or her face above the child’s, with the ear over the nose, the cheek over the mouth and the eyes looking along the line of the chest for up to 10 seconds.

If the head tilt/chin lift manoeuvre is not possible or is contraindicated because of suspected neck injury, then the jaw thrust manoeuvre can be performed. This is achieved by placing two or three fingers under the angle of the mandible bilaterally and lifting the jaw upwards. This technique may be easier if the rescuer’s elbows are resting on the same surface as the child is lying on. A small degree of head tilt may also be applied if there is no concern about neck injury.
As before, the success or failure of the intervention is assessed using the technique described above.

LOOK
LISTEN
FEEL

It should be noted that, if there is a history of trauma, then the head tilt/chin lift
manoeuvre may exacerbate cervical spine injury. The safest airway intervention in these circumstances is jaw thrust without head tilt. Proper cervical spine control can only be achieved in such cases by a second rescuer maintaining in-line cervical stabilization throughout.

The finger sweep technique often recommended in adults should not be used in children.

The child’s soft palate is easily damaged, and bleeding from within the mouth can worsen the situation. Furthermore, foreign bodies may be forced further down the airway; they can become lodged below the vocal cords (vocal folds) and be even more difficult to remove.

If a foreign body is not obvious but is highly suspected and sufficient ventilation is occurring, inspection should be done under direct vision with a laryngoscope in hospital and, if appropriate, removal should be attempted using Magill’s forceps. For intervention in the absence of effective ventilation see section 4.5.
In the child with a tracheostomy, additional procedures may be necessary. (see Chapter
20, section on management of a blocked tracheostomy

Breathing (B)

If the airway-opening techniques described above do not result in the resumption of adequate breathing within 10 seconds, exhaled air resuscitation should be commenced. The rescuer should distinguish between adequate and ineffective, and gasping or obstructed breathing. If in doubt, attempt rescue breathing. Up to five initial rescue breaths should be given to achieve two effective breaths.

While the airway is kept open as described above, the rescuer breathes in and seals his or her mouth around the victim’s mouth, or mouth and nose as If the mouth alone is used then the nose should be pinched closed using the thumb and index fingers of the hand that is maintaining head tilt. Slow exhalation (1–1.5 seconds) by the rescuer should make the victim’s chest rise. The rescuer should take a breath between rescue breaths to maximize oxygenation of the victim.

If the rescuer is unable to cover the mouth and nose in an infant he or she may attempt to seal only the infant’s nose or mouth with his or her mouth and should close the infant’s lips or pinch the nose to prevent air escape. As children vary in size only general guidance can be given regarding the volume and pressure of inflation (see the box).

General guidance for exhaled air resuscitation
• The chest should be seen to rise
• Inflation pressure may be higher because the airway is small
• Slow breaths at the lowest pressure reduce gastric distension
• Firm, gentle pressure on the cricoid cartilage may reduce gastric insufflation

If the chest does not rise then the airway is not clear. The usual cause is failure to apply correctly the airway-opening techniques discussed above. Thus, the first thing to do is to readjust the head tilt/chin lift position, and try again. If this does not work jaw thrust should be tried. It is quite possible for a single rescuer to open the airway using this technique and perform exhaled air resuscitation; however, if two rescuers are present one should maintain the airway whilst the other breathes for the child. Up to five rescue breaths may be attempted so that for the inexperienced rescuer at least two are effective.

Failure of both head tilt/chin lift and jaw thrust should lead to the suspicion that a foreign body is causing the obstruction, and appropriate action should be taken.

Circulation (C)
Once the rescue breaths have been given as above, attention should be turned to the circulation.

Assessment
Inadequacy of the circulation is recognised by the absence of a central pulse for up to 10 seconds, by the presence of a pulse at an insufficient rate and by the absence of other signs of circulation, i.e. no breaths or cough in response to rescue breaths and no spontaneous movement. In children, as in adults, the carotid artery in the neck can be palpated.
In infants the neck is generally short and fat and the carotid artery may be difficult to identify. Therefore the brachial artery in the medial aspect of the antecubital fossa or the femoral artery in the groin, should be felt.

Start chest compressions if
• no pulse
• slow pulse
• no signs of circulation
“Unnecessary” chest compressions are almost never damaging.
If the pulse is absent for up to 10 seconds or is inadequate (less than 60 beats per minute, with signs of poor perfusion) and/or there are no other signs of circulation, then cardiac compression is required. If the pulse is present – and has an adequate rate, with good perfusion – but apnoea persists, exhaled air resuscitation must be continued until spontaneous breathing resumes. Signs of poor perfusion include pallor, lack of responsiveness and poor muscle tone.

Cardiac compression
For the best output the child must be placed lying flat on his or her back, on a hard surface. In infants it is said that the palm of the rescuer’s hand can be used for this purpose, but this may prove difficult in practice.
Children vary in size, and the exact nature of the compressions given should reflect this.
In general, infants (less than 1 year) require a technique different from small children. In children over 8 years of age, the method used in adults can be applied with appropriate modifications for their size. Compressions should be approximately one third to one half of the depth of the child’s or infant’s chest.

Infants As the infant heart is lower with relation to external landmarks when compared to older children and adults, the area of compression is found by imagining a line between the nipples and compressing over the sternum one finger-breadth below this line. Two fingers are used to compress the chest. There is some evidence that infant cardiac compression can be more effectively achieved using the hand-encircling technique: the infant is held with both the rescuer’s hands encircling or partially encircling the chest. The thumbs are placed over the correct part of the sternum and compression carried out, as shown in Figure 4.9. This method is only possible when there are two rescuers, as the time needed to reposition the airway precludes its use by a single rescuer if the recommended rates of compression and ventilation are to be achieved. The single rescuer should use the two-finger method, employing the other hand to maintain the airway position as shown in Figure 4.8.
Small children The area of compression is one finger-breadth above the xiphisternum.

The heel of one hand is used to depress the sternum
Larger children (in general those of 8 years and older) The area of compression is two finger-breadths above the xiphisternum. The heels of both hands are used to depress the sternum

Chest compression in older children
Once the correct technique has been chosen and the area for compression identified, five compressions should be given, in older children (8 years and above) the number of
compressions is 15.

Continuing cardiopulmonary resuscitation
The compression rate at all ages is 100 per minute. A ratio of five compressions to one ventilation is maintained whatever the number of rescuers, except in older children (8 years and above) who should receive a ratio of 15 compressions to 2 ventilations with any number of rescuers. If no help has arrived the emergency services must be contacted after 1 minute of cardiopulmonary resuscitation. With pauses for ventilation there will be less than 100 compressions per minute although the rate is 100 per minute. Compressions can be recommenced at the end of inspiration and may augment exhalation. Apart from this interruption to summon help, basic life support must not be interrupted unless the child moves or takes a breath.
Any time spent readjusting the airway or re-establishing the correct position for compressions will seriously decrease the number of cycles given per minute. This can be a very real problem for the solo rescuer, and there is no easy solution. In the infant and small child, the free hand can maintain the head position. The correct position for compressions does not need to be remeasured after each ventilation.