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Infants' and Children's Resuscitation: A Summary

The Resuscitation of Children begins with the pre-resuscitation phase. Can we stop the children progressing to needing resuscitation? The Paediatric Assessment triangle has been used as a means of working out if a child is SICK or NOT SICK

Primary Assessment of the child proceeds along the normal parameters:

AIRWAY: Is it patent and protected? Are there extra sounds such as stridor?

BREATHING: Is there adequate oxygenation and ventilation? Signs of breathing difficulty may include head bobbing, nasal flaring and subcostal retractions

CIRCULATION: What is the pulse, heart rate and blood pressure? Is there adequate urine output. What is the skin colour and capillary refill time?

DISABILITY: A Glasgow Coma Score can be calculated. We can use the well known AVPU

  • A-Alert
  • V-Responds to Verbal Stimuli
  • P-Responds to Pain
  • U-Unresponsive

EXPOSURE:Expose the child for a total examination

Infants and Children Resuscitation is very similar to that of adults. It has been purposefully set out that way, to maximise effectiveness and minimise uncertainty in terms of what to do in this patient group.

Infant = 0-1yo
Child 1-8 yo
Children > 9 yo can use adult protocols.
Most of this is very similar to adult resuscitation.
These guidelines should be used for any child greater than a few hours old. The main concern becomes when to swap from the 3:1 compressions to 15:2- Give 15:2 in all except the newborn.

Guideline Recommendations

The Australian and New Zealand Resuscitation Committee on Resuscitation (ANZCOR) make the following recommendations:
1. Cardiac arrest should be suspected in a child or infant if they are unresponsive and not breathing normally. Pulse check may be used but should not delay CPR for more than 10 seconds. If the rescuer is uncertain about the presence of a pulse then CPR should be started.
2. For a single rescuer and an unwitnessed collapse, commence CPR before seeking help.
3. For a witnessed collapse and/or multiple rescuers call for help immediately and then start CPR.
4. Rescuers should provide both ventilation and chest compressions for infant and child cardiac arrest.
5. For infants and children, CPR should commence with 2 ventilations.
6. Infant and child CPR should be delivered with a ratio of 2 breaths to 15 compressions.
7. Compressions should be delivered at a rate of 100-120/min
8. Compression depth should be approximately 1/3 the AP diameter of the chest (4cm in infants, 5cm in children).
9. A two thumb technique is preferred for delivering compressions to an infant.
10. Either one or two handed technique may be used for delivering compressions to children.
11. Vascular access should be attempted by peripheral intravenous cannula or by an intraosseous route if an IV cannot be placed within 60 seconds.
12. An ECG should be displayed (leads/pads/paddles) as soon as this can be achieved during management of the arrest.
13. Ventilation may be provided by mouth to mouth, bag/valve/mask, or more advanced airway techniques.
14. Endotracheal intubation should not be attempted or persisted with if it results in prolongation of hypoxia.
15. Following endotracheal intubation compressions should be given continously at 100-120/min with ventilations delivered at 10 breaths/minute.
16. Drugs should be given via the IV or IO route, with the ETT used only when vascular access cannot be achieved.
17. Infants and children who have a sudden cardiac arrest should be investigated for underlying causes such as membrane channelopathies.

THE DETAILS

Airway

Good bag valve mask technique is important. A laryngeal mask can be used, but definitive airway control is with an endotracheal tube.
For children > 1yo the formula age/4 + 4
The depth of the tube at lip >1 yo  is age/2 + 12

CPR

Minimal interruption is the key. Immediate CPR to a depth of 4-5cm, after defibrillation and ventilation for 2 minutes.

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