Emergency medicine - Paediatric basic life support update

The guidelines for resuscitation and choking in children have been updated. Dr Kathryn Deakin explains.

Paediatric modifiers to adult basic life support will provide necessary skills for an emergency situation (Photograph: Istock)
Paediatric modifiers to adult basic life support will provide necessary skills for an emergency situation (Photograph: Istock)

Many children do not receive any resuscitation in emergency situations because first responders fear causing harm due to a lack of training. This fear is unfounded. The Resuscitation Council UK states that in emergency situations it is far better to use the adult basic life support sequence than do nothing.

Cardiorespiratory arrest is much less common in children than in adults and most cases will initially be managed by life support providers who are not paediatric specialists.

The Resuscitation Council UK 2010 guidelines for paediatric basic life support have been published, with the aim of simplifying the approach to paediatric resuscitation.

This article looks at what has been simplified in the guidelines for resuscitation, choking and the use of automated external defibrillators (AEDs) in children.

Resuscitation
There is still a paucity of good-quality evidence on paediatric resuscitation. However, some studies have shown that bystander resuscitation in children significantly improves outcome.

Full paediatric life support courses should be taught to healthcare professionals who work within a team that would be expected to resuscitate an infant or child during the course of their work.

Those working in primary care, who tend to work alone and are rarely required to resuscitate children, can be taught the skills they need by learning some paediatric modifiers on adult basic life support courses.

The paediatric modifiers to the adult basic life support sequence are listed below:

  • Give five initial rescue breaths before starting chest compressions.
  • Chest compressions should be at least one third the depth of the chest.
  • If you are a lone rescuer, perform CPR for approximately one minute before going for help.
  • For CPR use two fingers for those less than one year of age. Use one or two hands for children over a year of age, as needed to achieve an adequate depth of compression.

With any emergency situation, it is vital for rescuers to get help as quickly as possible when a child collapses:

  • When there is more than one rescuer available, one should go for help while the other rescuer starts resuscitation.
  • If only one rescuer is present, undertake resuscitation for one minute before seeking assistance. To minimise interruptions in CPR it may be possible to carry an infant or small child whilst summoning help.
  • If a lone rescuer has witnessed the collapse of a child, they should seek help immediately. It is likely that this child has arrested due to arrhythmia, and will need defibrillation.

Choking
Foreign body airway obstruction is characterised by the rapid onset of respiratory distress with coughing, gagging or stridor. It should be suspected if:

  • The onset was sudden.
  • There are no other signs of illness.
  • There is a history of eating or playing with small items prior to the onset of symptoms.

When a foreign body enters the airway, the child reacts immediately by coughing in an attempt to expel it. A spontaneous cough is likely to be more effective and safer than any manoeuvre a rescuer might perform.

The child with a suspected foreign body who is conscious should be encouraged to cough. If the cough becomes ineffective, the rescuer should call for help and quickly commence interventions.

In the event of a conscious child with absent or ineffective cough, the aim is to create an artificial cough:

  • Give up to five back blows, which are more effective if the child is placed head down, for example positioned across a knee (see figure A).

Figure A - child choking: give up to five back blows in a child less than one year

  • If these are ineffective go on to give five chest thrusts to those less than one year of age, or five abdominal thrusts to older children (see figure B).

Figure B: If back blows are ineffective, give five chest thrusts (Photographs: SPL)

For children who are unconscious, chest compressions are used to relieve the airway obstruction, with occasional positive pressure breaths in case the obstruction has moved sufficiently for chest inflation to be possible.

Automated external defibrillator
It must be remembered that the overwhelming majority of paediatric cardiac arrests will be due to hypoxia, not primary cardiac arrhythmia. Therefore the most important interventions are early oxygenation and good-quality CPR, which must not be delayed in order to apply a defibrillator.

The benefits of these interventions outweigh the unlikely chance of finding a shockable rhythm, especially in those less than one year of age.

Below is the Resuscitation Council UK guidance on AED use:

  • AEDs are capable of identifying arrhythmias accurately in children.
  • A standard AED can be used in children over one year of age. However purpose-made paediatric pads (supplied by many manufacturers), or programmes which attenuate the energy output to 50-75 joules, are recommended for children between one and eight years.
  • In children less than one year old, an AED can be used if it is the only defibrillator available, ideally with paediatric pads and an attenuator.

For more information on the 2010 guidelines for paediatric basic life support, or information on the courses, go to the Resuscitation Council UK, www.resus.org.uk

  • Dr Deakin is a consultant paediatrician at Pinderfields General Hospital, Wakefield, West Yorkshire.

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