Cardiopulmonary Resuscitation
Shamiel Salie
Paediatric Intensive Care Unit
Red Cross Children’s Hospital,
University of Cape Town
Basic
Life
Support
SAFE approach
Are you alright?
Airway opening manoeuvres
Look, listen, feel
5 rescue breaths
Check pulse
Check for signs of circulation
CPR
15 chest compressions
2 ventilations
1 minute
Call emergency services
Age Definitions:
• Newborn
• Infant - under 1 year
• Child - from 1 year to puberty
2005 BLS Changes:
• Lay rescuers should start compressions for
an unresponsive child who is not
breathing/moving
• Universal compression-ventilation ratio of
30:2 for the lone rescuer of infants, children
and adults
• Increased evidence on the importance of
uninterrupted chest compressions
Compression Techniques
Position:
for all ages: compress the lower third of the sternum
number of hands:
• In infants: two thumbs or two fingers
• in children: use one or two hands: depressing the sternum by
approximately one third of the depth of the chest
Chest Compressions
• Push hard
• Push Fast
• Complete chest recoil
• Minimize interruptions
Calling for help!!
• Perform 5 cycles or about 2 minutes of CPR
before calling for help
• Indications for activating EMS before BLS by a
lone rescuer are:
– witnessed sudden collapse with no apparent
preceding morbidity
– witnessed sudden collapse in a child with a known
cardiac abnormality
Choking
Assess
Ineffective
cough
Effective
cough
Conscious
Unconscious
5 back blows
Open airway
5 chest/abdo
thrusts
5 rescue breaths
Assess and
repeat
CPR 15:2
Check for FB
Encourage
coughing
Support and
assess
continuously
Universal
Algorithm
Stimulate and
assess response
Open airway
Check breathing
5 rescue breaths
Check pulse
Check for signs of circulation
CPR
15 chest compressions
2 ventilations
VF/VT
Assess
rhythm
Asystole and
PEA
Asystole and PEA
Ventilate with high
concentration O2
Continue CPR
Intubate
IV/IO access
Adrenaline
10 mcg/kg IV or IO
4 min CPR
Check monitor
every 2 minutes
Consider 4 Hs & 4 Ts
Consider alkalising agents
DC Shock 4J/kg
VF/VT
2 min CPR,
check monitor
Intubate, High flow O2
IV/IO access
DC Shock 4J/kg
2 min CPR,
check monitor
Intubate
IV/IO access
Adrenaline then
DC Shock 4J/kg
2 min CPR,
check monitor
Amiodarone then
DC Shock 4J/kg
2 min CPR,
check monitor
Adrenaline then
DC Shock 4J/kg
2 min CPR,
check monitor
DC Shock 4J/kg
2 min CPR,
check monitor
Adrenaline dose 10 mcg/kg
Consider
4 Hs
4 Ts
Consider
alkalising
agents
Neonatal
Resuscitation
Drugs in Cardiac Arrest
• 10mcg/kg of adrenalin as the first and subsequent iv
doses.
• high dose iv adrenalin is not recommended and may
be harmful
• Insufficient evidence to recommend for or against the
routine use of vasopressin in children
Route of drug delivery in ALS
• where possible give drugs intra-vascularly rather
than via the tracheal route
– lower adrenaline concentrations may produce
transient beta adrenergic effects resulting in
hypotension.
• Intra-osseous access is safe for fluid resuscitation
and drug delivery.
Airway Management
• guedel airways
• laryngeal airways
• Cuffed or uncuffed endotracheal tubes
Do children have Ventricular
fibrillation?
Number of Defibrillating Shocks
• one shock rather than three “stacked” shocks
• Modern biphasic defibrillators have a high
first shock efficacy
• Most patients have a non perfusing rhythm
after successful defibrillation
European Resuscitation Council
AED IN CHILDREN
• Age > 8 years
• use adult AED
• Age 1-8 years
• use paediatric pads /
settings if available
(otherwise use adult
mode)
• Age < 1 year
• use only if
manufacturer
instructions indicate it
is safe
Fluid Resuscitation
• Boluses of fluid may be required to
maintain systemic perfusion
• Crystalloids - ringers or normal saline
• Septic children may require in excess of
100ml/kg fluid resuscitation
Family Presence during Resuscitation
• Evidence suggests that the majority of parents
would like to be present during resuscitation,
that they gain a realistic understanding of the
efforts made to save the child, and they
subsequently show less anxiety and
depression.
When do you start?
When do you stop?
• In the absence of reversible causes eg
drowning with severe hypothermia, poisoning,
prolonged CPR in children is unlikely to result
in intact neurological survival.
• One should consider stopping resuscitation
after 20 minutes.
Post Resuscitation Care
• Ventilate to normo-capnoea
• Hypothermia for 12-24 hours post arrest may
be helpful, whilst hyperthermia should be
treated aggressively
• Vaso-active drugs should be considered to
improve haemodynamic status.
• Maintain normoglycaemia
Conclusions:
• The 2005 guidelines minimizes the differences in the steps
and techniques of CPR used for infants, children and adults.
• Push hard, push fast, minimizing interruptions
• Respiratory failure and hypoxia is the commonest reason for
paediatric arrests.
• There are usually warning signs of impending doom, and
early and effective therapy will prevent cardiac arrest
Questions