RCH@Home Manual: Basic Life Support
for Children with a Tracheostomy
Table of Contents
1
2
3
4
5
6
7
8
9
Basic life support .................................................................................... 2
1.1
What is basic life support? .....................................................................2
D.R.S.A.B.C.D .......................................................................................... 2
2.1
Dangers ..............................................................................................2
2.2
Response ............................................................................................2
2.3
Send for help .......................................................................................2
2.4
Airway ................................................................................................2
2.5
Breathing ............................................................................................2
2.6
Compressions ......................................................................................2
2.7
Defibrillate ..........................................................................................3
Opening the airway for children with a tracheostomy............................. 3
3.1
If unable to insert any tracheostomy following the above methods you will
need to administer breaths in the following way: ..............................................3
Rescue breathing using the one way valve ............................................. 3
Rescue breathing using the resuscitation bag......................................... 4
Cardiac compressions ............................................................................. 6
6.1
What are cardiac compressions? ............................................................6
6.2
How to do cardiac compressions: ...........................................................6
Management of a choking child ............................................................... 8
7.1
Partial airway obstruction ......................................................................8
7.2
Severe airway obstruction .....................................................................8
Calling an ambulance .............................................................................. 9
8.1
Making the call ....................................................................................9
8.2
To assist the ambulance officers ............................................................9
Special circumstances ............................................................................. 9
9.1
Children who have oxygen available for resuscitation purposes ..................9
9.2
Children with no upper airway ............................................................. 10
Version
2.0
Date revised
November 2012
Next revision date
November 2014
This section is written to follow the 2010 Australian Resuscitation Council guidelines
(www.resus.org.au)
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1.
Basic life support
1.1
What is basic life support?
Basic life support is where a person or people provide rescue efforts to keep another
person alive until medical officers can take over. The homecare nurses will teach it to you
(the support worker) using the D.R.S.A.B.C.D method.
2.
2.1
D.R.S.A.B.C.D
Dangers
Check the area and make sure there is no danger to you, the child or others. If it is safe
to do so remove yourselves from danger.
2.2
Response
Check the child’s response by touching and talking to the child.
2.3
Send for help
If the child is not responsive then call for help, ring 000.
2.4
Airway

Tilt the child’s head back and look in the tracheostomy
1. Suction the tracheostomy

If you detect a blockage follow procedure outlined in section 8.2 Managing
a severe airway obstruction, changing tracheostomy tube if
2. Check the mouth and nose are clear. If it is safe to do so, remove any foreign
body e.g. food, either by suction (if available) or by turning the child on their side
and letting anything drain out (if using fingers to remove foreign body, keep finger
tips in sight).
2.5
Breathing

After opening the airway check if the child is.
o
Responsive - they respond when you speak to or touch them (touch
and talk)
o
Breathing normally
To check if the child is breathing normally

Look for the rise and fall of the chest

Listen for breath sounds

Feel for air coming out of their nose and mouth
3. Give two breaths through the tracheostomy tube using one way valve and check
for rise and fall of the chest.
4. If the child is not breathing normally and is unresponsive then start compressions.
5. If the child is breathing normally place them in the recovery position and continue
to watch them closely. If they stop breathing normally begin compressions.
2.6
Compressions

30 compressions followed by 2 breaths (see section 4 for description on
compressions)

Keep on doing compressions and breaths until the child is responsive and
breathing normally or the ambulance arrives and the ambulance officers take
over
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2.7
Defibrillate
If an AED (automatic external defibrillator) is available for the child you care for follow the
instructions for use detailed in the defibrillation section.
3.
Opening the airway for children with a
tracheostomy
Image 1 Example of opening the airway for children with a tracheostomy
Start in neutral position (a) and move the head into a sniffing position (b) by putting one
hand on the forehead, two fingers under the chin (on the bone, not the soft tissue) and
lifting. This is known as a ‘head tilt, chin lift’ movement. It may be easier to put a rolled
towel under the child’s shoulders as this helps to put the head in the correct position.
3.1
4.
If unable to insert any tracheostomy following the above methods you will
need to administer breaths in the following way:

If the child has an upper airway tape over the stoma give rescue breaths
via mouth and nose

If the tracheostomy is the child’s only airway (the only way they can
breathe) give the child breaths by placing your mouth over their stoma
(use of a flat face shield wherever possible) and breathe through this.
Rescue breathing using the one way valve
Procedure
1. Open the airway (chin lift or rolled towel under shoulders for better access to
tracheostomy)
2. Attach the one-way valve to the tracheostomy (the valve only fits one way)
3. The end with the lip is the end you give breaths into
4. Place your mouth on the one way valve and exhale ensuring that the child’s chest
rises. Then remove your mouth from the valve so that the child’s chest can
deflate
5. When you blow in the one way valve, look at the child’s chest and make sure that
the chest rises

If it doesn’t rise:
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o
Cover the child’s mouth and nose with your hand to stop air
coming out
o
Check the tracheostomy, suction if necessary or change if
completely blocked
6. Remove the one way valve to suction when necessary

You don’t have to take the one way valve off for the child to breathe out

If the child vomits:
Procedure
1. Remove the one-way valve
2. Clear the child’s airway
3. Suction the tracheostomy
4. Shake the valve to remove vomit
5. Blow through the one-way valve or rinse with water to clear it
6. Continue mouth to one way valve rescue breathing
The one-way valve is single use only. Throw if out after you have used it for emergency
rescue breathing when a spare is available.
Image2 Example of rescue breathing using a one way valve
5.
Rescue breathing using the resuscitation bag

For infants up to 2 years use a 500ml (medium) bag. Children 2 years and older
use a 2 litre (large) bag

If oxygen is available attach it to the resuscitation bag and turn on the oxygen to
10-15 litres (depends on the size of the bag)

Open the child’s airway using head tilt and towel under shoulders if easily available

Attach bag to the tracheostomy

If air can escape through the child’s mouth and nose, cover them with one hand so
the air you push into the tracheostomy does not escape

Squeeze the bag and then release the bag

While squeezing the bag watch to see if the child’s chest rises

If it doesn’t rise:
o
Check that you are squeezing the bag hard enough
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o
Check to make sure you air isn’t escaping out the mouth or nose
o
Check the bag is connected properly to the tracheostomy and then try
squeezing the bag again
o
If the chest still doesn’t rise try suctioning the tracheostomy or perform an
emergency tracheostomy change (if you haven’t already done this)

If you have to do compressions and rescue breathing on your own, you must
remove the bag from the tracheostomy while doing compressions

If the child vomits:
Procedure
1. Remove the resuscitation bag
2. Suction the tracheostomy and mouth if needed
3. Shake the resuscitation bag to remove vomit
4. Restart bag to tracheostomy rescue breathing
Image 3 Example of rescue breathing using the resuscitation bag
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6.
Cardiac compressions
3.1.1
What are cardiac compressions?
Cardiac compressions (also known as heart massage) are when the rescuer (person
performing cardiac compressions) puts pressure on the child’s chest to help make the
heart beat (contract) which helps to move blood around the body. Before starting cardiac
compressions for the first time, check the child quickly for signs of life.
3.1.2
How to do cardiac compressions:

Place the child onto a hard surface, such as the floor

Place fingers or hands on the centre of the chest (see table 1 for the right
technique)

Push down on the chest about one third of the depth of the chest and then
release (up and down action)

Aim to give compressions at a rate of 100 compressions in one minute.
This is almost two up and down actions (compressions) every second

Give 30 compressions followed by two breaths

You must stop the compressions to give the two breaths

As soon as you have given the two breaths restart the compressions

Continue the compressions and breaths until the child becomes responsive
and is breathing normally or an ambulance officer tells you to

If the child becomes responsive and is breathing normally stop
compressions and rescue breathing (CPR) place them in the recovery
position and continue to watch them closely. If they stop breathing
normally and become unresponsive again then restart CPR
Table 1
Hands
Hand Position
Breaths/Compressions
Infant
(birth to 1 year)
Two fingers
or two
thumbs
Centre of chest
30 compressions - 2
breaths
Young Child
1-8 years (or under
25 kg)
Heel of one
hand
Centre of the chest Lower
half of sternum
(breastbone)
Older child/ adult
8-14 years( or over
25 kg)
two hands,
one on top
of the
other
Centre of the chest
Lower half of sternum
(breastbone)
30 compressions - 2
breaths
30 compressions - 2
breaths
Lower half of sternum (breastbone)
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Two finger compression for an infant (up to one year) (Image 4 below)
One hand compression for a young child (Image 5 below)
Two hand compression for an older child or adult (Image 6 below)
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7.
Management of a choking child
3.1.3
Partial airway obstruction
This means that the child’s airway is partly blocked. The child is still breathing, may be
coughing, crying and in distress.
Food, toys, vomit and secretions can block a
tracheostomy.
3.1.3.1 Managing a partial airway obstruction
3.1.4

If the child can cough well (effectively) it is a partial obstruction

Reassure the child and suction them

Continue to watch the child and suction tracheostomy as needed using saline
as required

If the child gets worse call an ambulance 000 and follow the steps for a
severe airway obstruction
Severe airway obstruction
This means that the child’s airway is so blocked that they can’t clear it on their own
(unable to cough). If the blockage isn’t removed the child will become unconscious and
will not be breathing.
3.1.4.1 Emergency care of a blocked single lumen tracheostomy
Procedure: Proceed to the next step ONLY if the problem is not yet alleviated.
1. Remain as calm as possible
2. Suction the tracheostomy
3. Instil saline and suction
4. Perform an emergency tracheostomy change (refer to Emergency tracheostomy
change 7.4 in the Tracheostomy Manual section)
5. If this does not relieve the obstruction call an Ambulance 000
NB. Perform basic life support if required at any stage (refer to Tracheostomy basic life
support manual)
3.1.4.2 Emergency care of a blocked double lumen tracheostomy
Procedure: Proceed to the next step ONLY if the problem is not yet alleviated.
1. Remain as calm as possible
2. Remove the inner lumen
3. Look, listen and feel if the child is breathing easily. If so reinsert a new inner
lumen
4. Instil saline and suction
5. Perform an emergency tracheostomy change (refer to Emergency tracheostomy
change 7.4 in the Tracheostomy Manual section)
6. If this does not relieve the obstruction call an Ambulance 000
NB. Perform basic life support if required at any stage (refer to Tracheostomy basic life
support manual)
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3.1.4.3 Child becomes unconscious and is not breathing
8.

Call an ambulance 000 if you have not already done so

Complete an emergency tracheostomy change if the tracheostomy is blocked
and you haven’t already done this

Start rescue breathing and cardiac compressions (CPR)

Continue CPR until an ambulance arrives or the child becomes responsive
and starts breathing normally.
Calling an ambulance
5.1
Making the call

Stay calm

Dial 000 ask for an ambulance

Or if you have a speech or hearing disability dial 106 – National Relay
Service

Be prepared to answer the following questions:
o
Where is the location of the emergency?
o
What is the telephone number you are calling from?
o
What is the problem? (What exactly happened?)
o
Who is hurt and how many?
o
How old is the patient?
o
Is the patient conscious?
o
Is the patient breathing?
Do not hang up. The phone operator will give you instructions; you may be asked further
questions.
5.2
To assist the ambulance officers
9.

Answer calmly and accurately

Tell the phone operator that the child has a tracheostomy

Identify the property clearly and give the nearest intersections or street
names

If possible, have someone wait outside the location to direct ambulance
officers to the emergency

Have any of the child’s medications available

Put any dogs away
Special circumstances
9.1
Children who have oxygen available for resuscitation purposes
While doing CPR, oxygen can be attached to the resuscitation bag to help with rescue
breathing. If oxygen is available, attach the oxygen tubing to the Resuscitation bag with a
reservoir and turn on the oxygen flow:

Medium bag: 10-15 litres of oxygen

Large bag: 15 litres of oxygen
Image 7 Example of medium bag
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9.2
Children with no upper airway
The tracheostomy is the child’s only airway (the only way they can breathe). You must
make all efforts possible to reinsert a tracheostomy as you will not be able to give rescue
breaths through the child’s mouth or nose.
If you are unable to reinsert a tracheostomy then give the child breaths by placing your
mouth over their stoma (use of a flat face shield wherever possible) and breathe through
this. If this is unsuccessful attempt to give breaths by using bag and mask to mouth and
nose. Remember to continue with cardiac compressions.
9.3
Children with Gastrostomy tubes
During rescue breathing air can be accidentally forced into the stomach when giving rescue
breaths. Air in the stomach can cause the child to vomit and make it hard to give breaths
to the child.
If you are doing rescue breathing to a child with a gastrostomy and you have extra people
to help you, the air can be removed (vented) by opening the gastrostomy tube. If the
child has a Mic-Key or Bard button then you must attach the correct venting tube to let the
air out. If the tube isn’t attached then the air can’t come out.
Remember that ABC (airway, breathing, circulation) are the most important things. Only
vent the tube if you have extra help.
10. If the child is taken to hospital

Once the ambulance arrives, the support worker is no longer responsible for the care
of the child as this passes to the ambulance officers

The support worker must not make any medical decisions in relation to the child or
give any directions as to the care of the child but may provide the ambulance officers
with information about the child’s care needs and current condition

If a child’s parents are not present, support workers are required to stay with the
child until the ambulance leaves to take the child to hospital

Support workers must not travel in the ambulance with the child or attend to their
care in the hospital setting. Should the child need to be transported to hospital by
ambulance the support worker is no longer required to remain with the child, but will
be paid for the duration of their scheduled shift
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