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Resuscitation (2005) 67S1, S97S133

European Resuscitation Council Guidelines forResuscitation 2005Section 6. Paediatric life support

Dominique Biarent, Robert Bingham, Sam Richmond, Ian Maconochie,Jonathan Wyllie, Sheila Simpson, Antonio Rodriguez Nunez,David Zideman

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he European Resuscitation Council (ERC) issueduidelines for paediatric life support (PLS) in 1994,998 and 2000.14 The last edition was based onhe International Consensus on Science publishedy the American Heart Association in collaborationith the International Liaison Committee on Resus-itation (ILCOR), undertaking a series of evidence-ased evaluations of the science of resuscitationhich culminated in the publication of the Guide-ines 2000 for Cardiopulmonary Resuscitation andmergency Cardiovascular Care in August 2000.5,6

his process was repeated in 2004/2005, and theesulting Consensus on Science and Treatment Rec-mmendations were published simultaneously inesuscitation, Circulation and Pediatrics in Novem-er 2005.7,8 The PLS Working Party of the ERC hasonsidered this document and the supporting sci-ntific literature, and has recommended changes

Guidelines changes

The approach to changes has been to alter theguidelines in response to convincing new scientificevidence and, where possible, to simplify them inorder to assist teaching and retention. As before,there remains a paucity of good-quality evidence onpaediatric resuscitation specifically and some con-clusions have had to be drawn from animal workand extrapolated adult data.

The current guidelines have a strong focus onsimplification based on the knowledge that manychildren receive no resuscitation at all because res-cuers fear doing harm. This fear is fuelled by theknowledge that resuscitation guidelines for chil-dren are different. Consequently, a major area ofstudy was the feasibility of applying the same guid-ance for all adults and children. Bystander resusci-tation improves outcome significantly,9,10 and thereis good evidence from paediatric animal modelsthat even doing chest compressions or expired airventilation alone may be better than doing noth-o the ERC PLS Guidelines. These are presented inhis paper.

ing at all.11 It follows that outcomes could beimproved if bystanders, who would otherwise donothing, were encouraged to begin resuscitation,es

Coun0300-9572/$ see front matter 2005 European Resuscitationoi:10.1016/j.resuscitation.2005.10.010ven if they do not follow an algorithm targetedpecifically at children. There are, however, dis-

cil. All Rights Reserved. Published by Elsevier Ireland Ltd.

S98 D. Biarent et al.

tinct differences between the predominantly adultarrest of cardiac origin and asphyxial arrest, whichis most common in children,12 so a separate paedi-atric algorithm is justified for those with a duty torespond to paediatric emergencies (usually health-care professionals), who are also in a position toreceive enhanced training.

Compression:ventilation ratios

The ILCOR treatment recommendation was thatthe compression:ventilation ratio should be basedon whether one or more than one rescuers werepresent. ILCOR recommends that lay rescuers,who usually learn only single rescuer techniques,should be taught to use a ratio of 30 compres-sions to 2 ventilations, which is the same as theadult guidelines and enables anyone trained inBLS techniques to resuscitate children with mini-mal additional information. Two or more rescuerswith a duty to respond should learn a differentratio (15:2), as this has been validated by animaland manikin studies.1317 This latter group, whowould normally be healthcare professionals, shouldreceive enhanced training targeted specifically at

ondary cardiac arrest. The onset of puberty, whichis the physiological end of childhood, is the mostlogical landmark for the upper age limit for useof paediatric guidance. This has the advantage ofbeing simple to determine, in contrast to an agelimit in years, as age may be unknown at the start ofresuscitation. Clearly, it is inappropriate and unnec-essary to establish the onset of puberty formally; ifrescuers believe the victim to be a child they shoulduse the paediatric guidelines. If a misjudgement ismade and the victim turns out to be a young adult,little harm will accrue, as studies of aetiology haveshown that the paediatric pattern of arrest contin-ues into early adulthood.19 An infant is a child under1 year of age; a child is between 1 year and puberty.It is necessary to differentiate between infants andolder children, as there are some important differ-ences between these two groups.

Chest compression technique

The modification to age definitions enables a sim-plification of the advice on chest compression.Advice for determining the landmarks for infantcompression is now the same as for older chil-dourgfttqtp

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the resuscitation of children. Although there areno data to support the superiority of any partic-ular ratio in children, ratios of between 5:1 and15:2 have been studied in manikins, and animaland mathematical models, and there is increasingevidence that the 5:1 ratio delivers an inadequatenumber of compressions.14,18 There is certainly nojustification for having two separate ratios for chil-dren aged greater or less than 8 years, so a singleratio of 15:2 for multiple rescuers with a duty torespond is a logical simplification.

It would certainly negate any benefit of simplic-ity if lay rescuers were taught a different ratio foruse if there were two of them, but those with a dutyto respond can use the 30:2 ratio if they are alone,particularly if they are not achieving an adequatenumber of compressions because of difficulty in thetransition between ventilation and compression.

Age definitions

The adoption of single compression:ventilationratios for children of all ages, together with thechange in advice on the lower age limit for theuse of automated external defibrillators (AEDs),renders the previous guideline division betweenchildren above and below 8 years of age unneces-sary. The differences between adult and paediatricresuscitation are based largely on differing aeti-ology, as primary cardiac arrest is more commonin adults whereas children usually suffer from sec-ren, as there is evidence that the previous rec-mmendation could result in compression over thepper abdomen.20 Infant compression techniqueemains the same: two-finger compression for sin-le rescuers and two-thumb, encircling techniqueor two ormore rescuers,2125 but for older childrenhere is no division between the one- or two-handechnique.26 The emphasis is on achieving an ade-uate depth of compression with minimal interrup-ions, using one or two hands according to rescuerreference.

utomated external defibrillators

ase reports published since International Guide-ines 2000 have reported safe and successful use ofEDs in children less than 8 years of age.27,28 Fur-hermore, recent studies have shown that AEDs areapable of identifying arrhythmias in children accu-ately and that, in particular, they are extremelynlikely to advise a shock inappropriately.29,30 Con-equently, advice on the use of AEDs has beenevised to include all children aged greater than 1ear.31 Nevertheless, if there is any possibility thatn AED may need to be used in children, the pur-haser should check that the performance of thearticular model has been tested against paediatricrrhythmias.Many manufacturers now supply purpose-made

aediatric pads or programmes, which typicallyttenuate the output of the machine to 5075 J.32

European Resuscitation Council Guidelines for Resuscitation 2005 S99

These devices are recommended for children aged18 years.33,34 If no such system or manuallyadjustable machine is available, an unmodifiedadult AED may be used in children older than 1year.35 There is currently insufficient evidence tosupport a recommendation for or against the use ofAEDs in children aged less than 1 year.

Manual defibrillators

The 2005 Consensus Conference treatment rec-ommendation for paediatric ventricular fibrillation(VF) or paediatric pulseless ventricular tachycar-dia (VT) is to defibrillate promptly. In adult ALS,the recommendation is to give a single shock andthen resume CPR immediately without checking fora pulse or reassessing the rhythm (see Section 3). Asa consequence of this single-shock strategy, whenusing a monophasic defibrillator in adults a higherinitial energy dose than used previously is recom-mended (360 J versus 200 J) (see Section 3). Theideal energy dose for safe and effective defibril-lation in children is unknown, but animal modelsand small paediatric series show that doses largerthan 4 J kg1 defibrillate effectively with negligiblesadsBuo

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Figure 6.1 Paediatric basic life support algorithm.

The following sequence is to be observed bythose with a duty to respond to paediatric emer-gencies (usually health professionals).

1. Ensure the safety of rescuer and child.2. Check the childs responsiveness.

Gently stimulate the child and ask loudly:Are you all right?

Do not shake infants or children with sus-pected cervical spinal injuries.

3a If the child responds by answering or moving leave the child in the position in which you

find him (provided he is not in further danger) check his condition and get help if needed reassess him regularly

3b If the child does not respond shout for help; open the childs airway by tilting the head and

lifting the chin, as follows:o initially with the child in the position in

which you find him, place your hand on hisforehead and gently tilt his head back;

o at the same time, with your fingertip(s)under the point of the childs chin, lift theide effects.27,34,36,37 Biphasic shocks are at leasts effective and produce less post-shock myocardialysfunction than monophasic shocks.33,34,3740 Forimplicity of sequence and consistency with adultLS and ALS, we recommend a single-shock strategysing a non-escalating dose of 4 J kg1 (monophasicr biphasic) for defibrillation in children.

oreign-body airway obstruction sequence

he guidance for managing foreign-body airwaybstruction (FBAO) in children has been simpli-ed and brought into closer alignment to the adultequence. These changes are discussed in detail athe end of this section.In the following text the masculine includes the

eminine and child refers to both infants and chil-ren unless noted otherwise.

a Paediatric basic life support

equence of action

escuers who have been taught adult BLS and haveo specific knowledge of paediatric resuscitationay use the adult sequence, with the exceptionhat they should perform 5 initial breaths followedy approximately 1min of CPR before they go forelp (Figure 6.1; also see adult BLS guideline).chin. Do not push on the soft tissues underthe chin as this may block the airway;

o if you still have difficulty in opening the air-way, try the jaw thrust method. Place thefirst two fingers of each hand behind eachside of the childs mandible and push thejaw forward;

o both methods may be easier if the child isturned carefully onto his back.


If you suspect that there may have been an injuryto the neck, try to open the airway using chin lift orjaw thrust alone. If this is unsuccessful, add headtilt a small amount at a time until the airway isopen.

4. Keeping the airway open, look, listen and feelfor normal breathing by putting your face closeto the childs face and looking along the chest.

Look for chest movements. Listen at the childs nose and mouth for breath

sounds. Feel for air movement on your cheek.Look, listen and feel for no more than 10 s beforedeciding.

5a If the child is breathing normally turn the child on his side into the recovery

position (see below) check for continued breathing

5b If the child is not breathing or is making agonalgasps (infrequent, irregular breaths) carefully remove any obvious airway obstruc-

Pinch the soft part of the nose closed with theindex finger and thumb of your hand on his fore-head.

Open his mouth a little, but maintain the chinupwards.

Take a breath and place your lips around themouth, making sure that you have a good seal.

Blow steadily into the mouth over about 11.5 s,watching for chest rise.

Maintain head tilt and chin lift, take your mouthaway from the victim and watch for his chest tofall as air is expelled.

Take another breath and repeat this sequencefive times. Identify effectiveness by seeing thatthe childs chest has risen and fallen in a similarfashion to the movement produced by a normalbreath.

Rescue breaths for an infant are performed asfollows (Figure 6.3).

Ensure a neutral position of the head and a chinlift.

Take a breath and cover the mouth and nasalapertures of the infant with your mouth, makingtion; give five initial rescue breaths; while performing the rescue breaths, note

any gag or cough response to your action.These responses or their absence will formpart of your assessment of signs of a circu-lation, which will be described later.

Rescue breaths for a child over 1 year are per-formed as follows (Figure 6.2).

Ensure head tilt and chin lift.

Figure 6.2 Mouth-to-mouth ventilation child. 2005ERC.sure you have a good seal. If the nose and mouthcannot be covered in the older infant, the res-cuer may attempt to seal only the infants noseor mouth with his mouth (if the nose is used, closethe lips to prevent air escape).

Blow steadily into the infants mouth and noseover 11.5 s, sufficient to make the chest visiblyrise.

Maintain head tilt and chin lift, take your mouthaway from the victim and watch for his chest tofall as air is expelled.

Take another breath and repeat this sequencefive times.

Figure 6.3 Mouth-to-mouth and nose ventilationinfant. 2005 ERC.


If you have difficulty achieving an effective breath,the airway may be obstructed.

Open the childs mouth and remove any visibleobstruction. Do not perform a blind finger sweep.

Ensure that there is adequate head tilt and chinlift but also that the neck is not over-extended.

If head tilt and chin lift have not opened the air-way, try the jaw thrust method.

Make up to five attempts to achieve effectivebreaths; if still unsuccessful, move on to chestcompressions.

6. Assess the childs circulation. Take no more than10 s to look for signs of a circulation. This includes

any movement, coughing or normal breathing(not agonal gasps, which are infrequent, irreg-ular breaths);

check the pulse (if you are a health careprovider) but ensure you take no more than10 s.

If the child is aged over 1 year, feel for thecarotid pulse in the neck.

In an infant, feel for the brachial pulse on thei

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Figure 6.4 Chest compression infant. 2005 ERC.

rate of compressions will be 100min1, the actualnumber delivered per minute will be less than 100because of pauses to give breaths. The best methodfor compression varies slightly between infants andchildren.

To perform chest compression in infants, the lonerescuer compresses the sternum with the tips oftwo fingers (Figure 6.4). If there are two or morerescuers, use the encircling technique. Place boththumbs flat side by side on the lower third of thesternum (as above) with the tips pointing towardsthe infants head. Spread the rest of both handswith the fingers together to encircle the lower partof the infants rib cage with the tips of the fin-gers supporting the infants back. Press down on thelower sternum with the two thumbs to depress itapproximately one third of the depth of the infantschest.

To perform chest compression in children over1 year of age, place the heel of one handover the lower third of the sternum (as above)(Figures 6.5 and 6.6). Lift the fingers to ensure thatpressure is not applied over the childs ribs. Positionyourself vertically above the victims chest and,with your arm straight, compress the sternum todott

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nner aspect of the upper arm.

7a If you are confident that you can detect signs ofa circulation within 10 s continue rescue breathing, if necessary, until

the child starts breathing effectively on hisown

turn the child onto his side (into the recoveryposition) if he remains unconscious

re-assess the child frequentlyb If there are no signs of a circulation, or no pulse

or a slow pulse (less than 60min1 with poorperfusion), or you are not sure start chest compressions combine rescue breathing and chest compres-

sions

Chest compressions are performed as follows.or all children, compress the lower third of theternum. To avoid compressing the upper abdomen,ocate the xiphisternum by finding the angle wherehe lowest ribs join in the middle. Compress theternum one fingers breadth above this; the com-ression should be sufficient to depress the ster-um by approximately one third of the depth ofhe chest. Release the pressure and repeat at aate of about 100min1. After 15 compressions,ilt the head, lift the chin, and give two effectivereaths. Continue compressions and breaths in aatio of 15:2. Lone rescuers may use a ratio of 30:2,articularly if having difficulty with the transitionetween compression and ventilation. Although theepress it by approximately one third of the depthf the chest. In larger children or for small rescuers,his is achieved most easily by using both hands withhe fingers interlocked.

. Continue resuscitation until the child shows signs of life (spontaneous res-

piration, pulse, movement) qualified help arrives you become exhausted

hen to call for assistance

t is vital for rescuers to get help as quickly as pos-ible when a child collapses.


When more than one rescuer is available, onestarts resuscitation while another rescuer goesfor assistance.

If only one rescuer is present, undertake resus-citation for about 1min before going for assis-tance. To minimise interruption in CPR, it maybe possible to carry an infant or small child whilesummoning help.

The only exception to performing 1min of CPRbefore going for help is in the case of a child witha witnessed, sudden collapse when the rescuer isalone. In this case cardiac arrest is likely to bearrhythmogenic in origin and the child will needdefibrillation. Seek help immediately if there isno one to go for you.

Recovery position

An unconscious child whose airway is clear, and whois breathing spontaneously, should be turned on hisside into the recovery position. There are several

recovery positions; each has its advocates. Thereare important principles to be followed.

Place the child in as near true lateral positionas possible, with his mouth dependent to enablefree drainage of fluid.

The position should be stable. In an infant thismay require the support of a small pillow ora rolled-up blanket placed behind the back tomaintain the position.

Avoid any pressure on the chest that impairsbreathing.

It should be possible to turn the child onto his sideand to return him back easily and safely, takinginto consideration the possibility of cervical spineinjury.

Ensure the airway can be observed and accessedeasily.

The adult recovery position is suitable for use inchildren.

Foreign-body airway obstruction (FBAO)

No new evidence on this subject was presented dur-Figure 6.5 Chest compression with one hand child. 2005 ERC.Figure 6.6 Chest compression with two hands child. 2005 ERC.ing the 2005 Consensus Conference. Back blows,chest thrusts and abdominal thrusts all increaseintrathoracic pressure and can expel foreign bod-ies from the airway. In half of the episodes,more than one technique is needed to relieve theobstruction.41 There are no data to indicate whichmeasure should be used first or in which order theyshould be applied. If one is unsuccessful, try theothers in rotation until the object is cleared.

The International Guidelines 2000 algorithm isdifficult to teach and knowledge retention poor.The FBAO algorithm for children has been simpli-fied and aligned with the adult version (Figure 6.7).This should improve skill retention and encouragepeople, who might otherwise have been reluctant,to perform FBAO manoeuvres on children.

Figure 6.7 Paediatric foreign body airway obstructionalgorithm.


The most significant difference from the adultalgorithm is that abdominal thrusts should not beused to treat choking infants. Although abdominalthrusts have caused injuries in all age groups, therisk is particularly high in infants and very youngchildren. This is because of the horizontal positionof the ribs, which leaves the upper abdominal vis-ceramuchmore exposed to trauma. For this reason,the guidelines for the treatment of FBAO are differ-ent between infants and children.

Recognition of FBAO

When a foreign body enters the airway, the childreacts immediately by coughing in an attempt toexpel it. A spontaneous cough is likely to be moreeffective and safer than any manoeuvre a rescuermight perform. However, if coughing is absent orineffective and the object completely obstructs theairway, the child will rapidly become asphyxiated.Active interventions to relieve FBAO are thereforerequired only when coughing becomes ineffective,but they then need to be commenced rapidly andconfidently.

The majority of choking events in infants andchildren occur during play or eating episodes when

treatment of the choking child.

If the child is coughing effectively, no externalmanoeuvre is necessary. Encourage the child tocough, and monitor continually.

If the childs coughing is (or is becoming) ineffec-tive, shout for help immediately and determinethe childs conscious level.

2. Conscious child with FBAO

If the child is still conscious but has absent orineffective coughing, give back blows.

If back blows do not relieve the FBAO, givechest thrusts to infants or abdominal thrusts tochildren. These manoeuvres create an artificialcough to increase intrathoracic pressure and dis-lodge the foreign body.

Back blows. Back blows in the infant are per-formed as follows.

Support the infant in a head downwards, proneposition, to enable gravity to assist removal ofthe foreign body.a carer is usually present; thus, the events are fre-quently witnessed and interventions are usually ini-tiated when the child is conscious.

Foreign-body airway obstruction is characterizedby the sudden onset of respiratory distress associ-ated with coughing, gagging or stridor. Similar signsand symptoms may be associated with other causesof airway obstruction, such as laryngitis or epiglot-titis, which require different management. SuspectFBAO if the onset was very sudden and there are noother signs of illness and if there are clues to alertthe rescuer, e.g. a history of eating or playing withsmall items immediately before the onset of symp-toms.

Relief of FBAO

1. Safety and summoning assistance

Safety is paramount: rescuers must not place them-selves in danger and should consider the safest A seated or kneeling rescuer should be able tosupport the infant safely across their lap.

Support the infants head by placing the thumb ofone hand at the angle of the lower jaw, and oneor two fingers from the same hand at the samepoint on the other side of the jaw.

Do not compress the soft tissues under theinfants jaw, as this will exacerbate the airwayobstruction.

Deliver up to five sharp back blows with the heelof one hand in the middle of the back betweenthe shoulder blades.

The aim is to relieve the obstruction with eachblow rather than to give all five blows.

Back blows in the child over 1 year of age areperformed as follows.

Back blows are more effective if the child is posi-tioned head down.

A small child may be placed across the rescuerslap, as with the infant.

If this is not possible, support the child in aforward-leaning position and deliver the backblows from behind.

If back blows fail to dislodge the object, andthe child is still conscious, use chest thrusts forinfants or abdominal thrusts for children. Do notuse abdominal thrusts (Heimlich manoeuvre) ininfants.


Chest thrusts for infants.

Turn the infant into a head-downwards supineposition. This is achieved safely by placing thefree arm along the infants back and encirclingthe occiput with the hand.

Support the infant down your arm, which isplaced down (or across) your thigh.

Identify the landmark for chest compressions(lower sternum approximately a fingers breadthabove the xiphisternum).

Give five chest thrusts; these are similar to chestcompressions but sharper and delivered at aslower rate.

Abdominal thrusts for children over 1 year.

Stand or kneel behind the child; place your armsunder the childs arms and encircle his torso.

Clench your fist and place it between the umbili-cus and xiphisternum.

Grasp this hand with the other hand and pullsharply inwards and upwards.

Repeat up to five times. Ensure that pressure is not applied to the xiphoid

object more deeply into the pharynx and causeinjury.

Open the airway using a head tilt and/or chinlift and attempt five rescue breaths. Assess theeffectiveness of each breath; if a breath does notmake the chest rise, reposition the head beforemaking the next attempt.

Attempt five rescue breaths and, if there isno response (moving, coughing, spontaneousbreaths), proceed to chest compressions withoutfurther assessment of the circulation.

Follow the sequence for single-rescuer CPR (step7b above) for approximately 1min before sum-moning the EMS (if this has not already been doneby someone else).

When the airway is opened for attempted deliv-ery of rescue breaths, look to see if the foreignbody can be seen in the mouth.

If an object is seen, attempt to remove it with asingle finger sweep.

If it appears the obstruction has been relieved,open and check the airway as above; deliver res-cue breaths if the child is not breathing.

If the child regains consciousness and exhibitsspontaneous effective breathing, place him in aprocess or the lower rib cage; this might causeabdominal trauma.

Following the chest or abdominal thrusts,reassess the child. If the object has not beenexpelled and the victim is still conscious, continuethe sequence of back blows and chest (for infant) orabdominal (for children) thrusts. Call out, or send,for help if it is still not available. Do not leave thechild at this stage.

If the object is expelled successfully, assessthe childs clinical condition. It is possible thatpart of the object may remain in the respira-tory tract and cause complications. If there isany doubt, seek medical assistance. Abdominalthrusts may cause internal injuries, and all vic-tims so treated should be examined by a medicalpractitioner.42

3. Unconscious child with FBAO

If the child with FBAO is, or becomes, uncon-scious, place him on a firm, flat surface. Callout, or send, for help if it is still not available.Do not leave the child at this stage; proceed asfollows.

Open the mouth and look for any obvious object.If an object is seen, make an attempt to remove itwith a single finger sweep. Do not attempt blindor repeated finger sweeps; these can impact thesafe position lying on his side and monitor breath-ing and conscious level while awaiting the arrivalof the EMS.

6b Paediatric advanced life support

Prevention of cardiopulmonary arrest

In children, secondary cardiopulmonary arrests,caused by either circulatory or respiratory fail-ure, are more frequent than primary arrestscaused by arrhythmias.9,12,4346 So-called asphyx-ial arrests or respiratory arrests are also morecommon in young adulthood (e.g., trauma, drown-ing, poisoning).47,48 The outcome from cardiopul-monary arrests in children is poor; identification ofthe antecedent stages of cardiac or respiratory fail-ure is a priority, as effective early intervention maybe life saving.

The order of assessment and intervention for anyseriously ill or injured child follows the ABC princi-ples.

A indicates airway (Ac for airway and cervicalspine stabilisation for the injured child).

B indicates breathing. C indicates circulation.

Interventions are made at each step of theassessment as abnormalities are identified; the next


step of the assessment is not started until thepreceding abnormality has been managed and cor-rected if possible.

Diagnosing respiratory failure: assessmentof A and B

The first steps in the assessment of the seriously illor injured child are the management of the airwayand breathing. Abnormalities in airway patency andbreathing lead to respiratory failure. Signs of res-piratory failure are

respiratory rate outside the normal range for thechilds ageeither too fast or too slow

initially increasing work of breathing whichmay progress to inadequate/decreased workof breathing, additional noises such as stridor,wheeze or grunting, or the loss of breath sounds

cyanosis (without/with supplemental oxygen)There may be associated signs in other organ sys-

tems affected by inadequate ventilation and oxy-genation; these are detectable in the C steps ofassessment, such as

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level of consciousness may decrease because ofpoor cerebral perfusion

Diagnosing cardiopulmonary arrest

Signs of cardiopulmonary arrest include

unresponsiveness apnoea or gasping respiratory pattern absent circulation pallor or deep cyanosis

In the absence of signs of life, search for acentral pulse or cardiac sounds (by direct chest aus-cultation) for a maximum of 10 s, before startingCPR. If there is any doubt, start CPR.5053

Management of respiratory andcirculatory failure

A and B

Open the airway and ensure adequate ventilationand oxygenation.increasing tachycardia progressing to bradycar-dia (this latter sign being an ominous indicator ofthe loss of compensatory mechanisms)alteration in the level of consciousness

iagnosing circulatory failure: assessmentf C

hock is characterised by a mismatch betweenetabolic tissue demand and delivery of oxy-en and nutrients by the circulation.49 Physiolog-cal compensatory mechanisms lead to changesn the heart rate, in the systemic vascular resis-ance (which commonly increases as an adaptiveesponse) and in tissue and organ perfusion. Signsf circulatory failure are

increased heart rate (bradycardia is an ominoussign, heralding physiological decompensation)decreased systemic blood pressuredecreased peripheral perfusion (prolonged capil-lary refill time, decreased skin temperature, paleor mottled skin)weak or absent peripheral pulsesdecreased or increased preloaddecreased urine output and metabolic acidosis

Other systems may be affected, for example

respiratory rate may be increased initially, be-coming bradypnoeic with decompensated shock Deliver high-flow oxygen. Achieving adequate ventilation and oxygenation

may include the use of airway adjuncts, bag-maskventilation (BMV), use of a laryngeal mask airway(LMA), securing a definitive airway by trachealintubation and positive pressure ventilation.

In rare, extreme circumstances, a surgical airwaymay be required.

C

Establish cardiac monitoring.

Secure vascular access to the circulation. Thismay be via peripheral or central intravenous (IV)or by intraosseous (IO) cannulation.

Give a fluid bolus and/or inotropes as required.Assess and re-assess the child continuously, each

time commencing at Airway before Breathing,thereafter moving onto the Circulation

Airway

Open the airway using basic life support tech-niques. Oropharyngeal and nasopharyngeal airwaysadjuncts can help maintain the airway. Use theoropharyngeal airway only in the unconscious child,in whom there is no gag reflex. Use the appro-priate size, to avoid pushing the tongue back-ward and obstructing the epiglottis, or directlycompressing the glottic area. The soft palate in


the child can be damaged by insertion of theoropharygneal airway; avoid this by inserting theoropharygneal airway under direct vision and pass-ing it over a tongue depressor or laryngoscope.The nasopharyngeal airway is tolerated better inthe conscious child (who has an effective gagreflex), but should not be used if there is a basalskull fracture or a coagulopathy. These simpleairway adjuncts do not protect the airway fromaspiration of secretions, blood or stomach con-tents.

Laryngeal mask airway

The LMA is an acceptable initial airway device forproviders experienced in its use. It may be particu-larly helpful in airway obstruction caused by upperairway abnormalities. The LMA does not, however,protect the airway from aspiration of secretions,blood or stomach contents, and therefore closeobservation is required. LMA use is associated witha higher incidence of complications in small chil-dren compared with adults.54

Tracheal intubation

tor must be experienced and familiar with rapid-sequence induction drugs.

Tracheal tube sizes. The tracheal tube internaldiameters (ID) for different ages are

for neonates, 2.53.5mm according to the for-mula (gestational age in weeks 10)

for infants, 4 or 4.5mm for children older than 1 year, according to the

formula [(age in years/4) + 4]

Tracheal tube size estimation according thelength of the childs body as measured by resusci-tation tapes is more accurate than using the aboveformulae.67

Cuffed versus uncuffed tracheal tubes. In the pre-hospital setting, an uncuffed tracheal tube may bepreferable when using sizes of up to 5.5mm ID (i.e.,for children up to 8 years). In hospital, a cuffed tra-cheal tube may be useful in certain circumstances,e.g. in cases of poor lung compliance, high air-way resistance or large glottic air leak.6870 Thecorrectly sized cuffed tracheal tube is as safe asan uncuffed tube for infants and children (not forneonates), provided attention is paid to its place-mcttc

CDfcgomb

Tracheal intubation is the most secure and effectiveway to establish and maintain the airway, preventgastric distension, protect the lungs against pul-monary aspiration, enable optimal control of theairway pressure and provide positive end expiratorypressure (PEEP). The oral route is preferable duringresuscitation. Oral intubation is usually quicker andis associated with fewer complications than nasalplacement. The judicious use of anaesthetics, seda-tives and neuromuscular blocking drugs is indicatedin the conscious child to avoid multiple intubationattempts or intubation failure.5565 The anatomyof a childs airway differs significantly from that ofan adult; hence, intubation of a child requires spe-cial training and experience. Check that trachealtube placement is correct by clinical examinationand end-tidal capnography. The tracheal tube mustbe secured, and monitoring of the vital signs isessential.66

It is also essential to plan an alternative airwaymanagement technique in case the trachea cannotbe intubated.

Rapid sequence induction and intubation. Thechild who is in cardiopulmonary arrest and deepcoma does not require sedation or analgesia to beintubated; otherwise, intubation must be precededby oxygenation, rapid sedation, analgesia and theuse of neuromuscular blocking drugs to minimiseintubation complications and failure.63 The intuba-ent, size and cuff inflation pressure; excessiveuff pressure can lead to ischaemic necrosis ofhe surrounding laryngeal tissue and stenosis. Main-ain the cuff inflation pressure below 20 cmH2O andheck it regularly.71

onfirmation of correct tracheal tube placement.isplaced, misplaced or obstructed tubes occurrequently in the intubated child and are asso-iated with increased risk of death.72,73 No sin-le technique is 100% reliable for distinguishingesophageal from tracheal intubation.7476 Assess-ent of the correct tracheal tube position is madey

observation of the tube passing beyond the vocalcordsobservation of symmetrical chest wall movementduring positive pressure ventilationobservation of mist in the tube during the expi-ratory phase of ventilationabsence of gastric distensionequal air entry heard on bilateral auscultation ofboth axillae and apices of the chestabsence of air entry into the stomach on auscul-tationdetection of end-tidal CO2 if the child has a per-fusing rhythm (this may be seen with effectiveCPR)improvement or stabilisation of SpO2 to theexpected range


improvement of heart rate towards the age-expected value (or remaining within the normalrange)

If the child is in cardiopulmonary arrest andexhaled CO2 is not detected, or if there is anydoubt, confirm tracheal tube position by directlaryngoscopy. After correct placement and confir-mation, secure the tracheal tube and reassess itsposition. Maintain the childs head in neutral posi-tion; flexion of the head drives the tube further intothe trachea whereas extensionmay pull it out of theairway.77 Confirm the position of the tracheal tubeat mid trachea by plain chest radiograph; the tra-cheal tube tip should be at the level of the 2nd or3rd thoracic vertebra.

DOPES is a useful acronym for the causes of sud-den deterioration in an intubated child

D: displacement of the tracheal tube O: obstruction of the tracheal tube P: pneumothorax E: equipment failure (source of gas, BMV, venti-

lator, etc.) S: stomach (gastric distension may alter dia-

phragm mechanics)

B

O

Udgg

udIa

V

HvpHsaTwvr

b1c

tion is adequate during chest compressions. Whencirculation is restored, or if the child still has a per-fusing rhythm, ventilate at 1220 breaths min1 toachieve a normal pCO2. Hyperventilation is harm-ful.

Bag-mask ventilation. BMV is effective and safefor a child requiring assisted ventilation for a shortperiod, i.e. in the prehospital setting or in an emer-gency department.73,9092 Assess the effectivenessof BMV by observing adequate chest rise, monitor-ing heart rate, auscultating for breath sounds andmeasuring peripheral oxygen saturation (SpO2). Anyhealthcare provider dealing with children must beable to deliver BMV effectively.

Prolonged ventilation. If prolonged ventilation isrequired, the benefits of a secured airway prob-ably outweigh the potential risks associated withtracheal intubation.

Monitoring of breathing and ventilation

End tidal CO2. Monitoring end-tidal CO2 with acolorimetric detector or capnometer confirms tra-cheal tube placement in the child weighing moretsccioaoebam

Obdmatm

Plpoccficm

reathing

xygenation

se oxygen at the highest concentration (i.e., 100%)uring resuscitation. Once circulation is restored,ive sufficient oxygen to maintain peripheral oxy-en saturation at or above 95%.78,79

Studies in neonates suggest some advantages tosing room air during resuscitation, but the evi-ence as yet is inconclusive (see Section 6c).8083

n the older child, there is no evidence for any suchdvantages, so use 100% oxygen for resuscitation.

entilation

ealthcare providers commonly provide excessiveentilation to victims of cardiopulmonary or res-iratory arrest, and this may be detrimental.yperventilation causes increased thoracic pres-ure, decreased cerebral and coronary perfusion,nd poorer survival rates in animals and adults.8489

he ideal tidal volume should achieve modest chestall rise. Use a ratio of 15 chest compressions to 2entilations (a lone rescuer may use 30:2); the cor-ect compression rate is 100min1.Once the airway is protected by tracheal intu-

ation, continue positive pressure ventilation at220 breaths min1 without interrupting chestompressions. Take care to ensure that lung infla-han 2 kg, and may be used in pre- and in-hospitalettings, as well as during any transportation of thehild.9397 A colour change or the presence of aapnographic waveform indicates that the tube isn the tracheobronchial tree, both in the presencef a perfusing rhythm and during cardiopulmonaryrrest. Capnography does not rule out intubationf the right mainstem bronchus. The absence ofxhaled CO2 during cardiopulmonary arrest may note caused by tube misplacement, since a low orbsent end-tidal CO2 may reflect low or absent pul-onary blood flow.98101

esophageal detector devices. The self-inflatingulb or aspirating syringe (oesophageal detectorevice, ODD) may be used for the secondary confir-ation of tracheal tube placement in children withperfusing rhythm.102,103 There are no studies onhe use of ODD in children who are in cardiopul-onary arrest.

ulse oximetry. Clinical evaluation of the oxygenevel is unreliable; therefore monitor the childseripheral oxygen saturation continuously by pulseximetry. Pulse oximetry can be unreliable underertain conditions, e.g. if the child is in shock, inardiopulmonary arrest or has poor peripheral per-usion. Although pulse oximetry is relatively simple,t is a poor guide to tracheal tube displacement;apnography detects tracheal tube dislodgementore rapidly than pulse oximetry.104


Circulation

Vascular access

Vascular access is essential to give drugs and fluidsand obtain blood samples. Venous access can be dif-ficult to establish during resuscitation of an infantor child.105 Limit the maximum number of attemptsto obtain IV access to three; thereafter, insert an IOneedle.106

Intraosseous access. IO access is a rapid, safe,and effective route to give drugs, fluids and bloodproducts.107113 The onset of action and timeto achieve adequate plasma drug concentrationsare similar to those provided by central venousaccess.114,115 Bone marrow samples can be used tocross-match for blood type or group,116 for chem-ical analysis,117,118 and for blood gas measure-ment (the values are comparable to central venousblood gases).117,119,120 Flush each drug with a bolusof normal saline to ensure dispersal beyond themarrow cavity and to achieve faster distributionto the central circulation. Inject large boluses offluid usingmanual pressure. Intraosseous access canbe maintained until definitive IV access has been

Fluids and drugs

Volume expansion is indicated when a child showssigns of shock in the absence of volume overload.135

If systemic perfusion is inadequate, give a bolusof 20ml kg1 of an isotonic crystalloid, even if thesystemic blood pressure is normal. Following everybolus, re-assess the childs clinical state using ABC,to decide whether a further bolus or other treat-ment is required.

There are insufficient data to make recommen-dations about the use of hypertonic saline for shockassociated with head injuries or hypovolaemia.136

There are also insufficient data to recommenddelayed fluid resuscitation in the hypotensive childwith blunt trauma.137 Avoid dextrose-containingsolutions unless there is hypoglycaemia.138141

However, hypoglycaemia must actively be soughtand avoided, particularly in the small child orinfant.

Adenosine

Adenosine is an endogenous nucleotide whichcauses a brief atrioventricular (AV) block andiAmsiman

A

ApIamaicmcqcoatthnsm

established.

Intravenous access. Peripheral IV access pro-vides plasma concentrations of drugs and clinicalresponses equivalent to central or IO access.121125

Central lines provide more secure long-termaccess121,122,124,125 but offer no advantages duringresuscitation, compared with IO or peripheral IVaccess.

Tracheal tube access

IV and IO access are better than the tracheal routefor giving drugs.126 Lipid-soluble drugs, such aslidocaine, atropine, adrenaline and naloxone areabsorbed via the lower airway.127131 Optimal tra-cheal tube drug doses are unknown because of thegreat variability of alveolar drug absorption, butthe following dosages have been recommended asguidance

adrenaline, 100mcg kg1 lidocaine, 23mg kg1 atropine, 30mcg kg1

The optimal dose of naloxone is not known.Dilute the drug in 5ml of normal saline and fol-

low administration with five ventilations.132134 Donot give non-lipid soluble medications (e.g., glu-cose, bicarbonate, calcium) via the tracheal tubebecause they will damage the airway mucosa.mpairs accessory bundle re-entry at the level of theV node. Adenosine is recommended for the treat-ent of supraventricular tachycardia (SVT).142 It isafe to use, as it has a short half-life (10 s); givet intravenously via upper limb or central veins, toinimise the time taken to reach the heart. Givedenosine rapidly, followed by a flush of 35ml oformal saline.143

drenaline (epinephrine)

drenaline is an endogenous catecholamine withotent alpha, beta-1 and beta-1 adrenergic actions.t is the essential medication in cardiopulmonaryrrest, and is placed prominently in the treat-ent algorithms for non-shockable and shock-ble rhythms. Adrenaline induces vasoconstriction,ncreases diastolic pressure and thereby improvesoronary artery perfusion pressure, enhancesyocardial contractility, stimulates spontaneousontractions and increases the amplitude and fre-uency of VF, so increasing the likelihood of suc-essful defibrillation. The recommended IV/IO dosef adrenaline in children is 10mcg kg1. The dose ofdrenaline given via the tracheal tube is ten timeshis (100mcg kg1).127,144146 If needed, give fur-her doses of adrenaline every 35min. The use ofigher doses of adrenaline via the IV or IO route isot recommended routinely, as it does not improveurvival or neurological outcome after cardiopul-onary arrest.147150


Once spontaneous circulation is restored, a con-tinuous infusion of adrenaline may be required. Itshaemodynamic effects are dose related; there isalso considerable variability between children inresponse, therefore, titrate the infusion dose tothe desired effect. High infusion rates may causeexcessive vasoconstriction, compromising extrem-ity, mesenteric, and renal blood flow. High-doseadrenaline may cause severe hypertension andtachyarrhythmias.151

To avoid tissue damage it is essential to giveadrenaline through a secure intravascular line (IV orIO). Adrenaline and other catecholamines are inac-tivated by alkaline solutions and should never bemixed with sodium bicarbonate.152

Amiodarone

Amiodarone is a non-competitive inhibitor of adren-ergic receptors; it depresses conduction in myocar-dial tissue and therefore slows AV conduction andprolongs the QT interval and the refractory period.Except when given for the treatment of refrac-tory VF/pulseless VT, amiodarone must be injectedslowly (over 1020min) with systemic blood pres-srwip

A

Abam

C

Ctna

G

Nhaaogonh

and hypoglycaemia following return of spontaneouscirculation (ROSC).

Magnesium

There is no evidence for giving magnesium rou-tinely during cardiopulmonary arrest.165 Magne-sium treatment is indicated in the child with doc-umented hypomagnesaemia or with torsades depointes VF, regardless of the cause.166

Sodium bicarbonate

Giving sodium bicarbonate routinely during car-diopulmonary arrest and CPR or after ROSC isnot recommended.167,168 After effective ventila-tion and chest compressions have been achievedand adrenaline given, sodium bicarbonate may beconsidered for the child who has had a prolongedcardiopulmonary arrest and severe metabolic aci-dosis. Sodium bicarbonate may also be consid-ered in the case of haemodynamic instabilityand co-existing hyperkalaemia, or in the man-agement of tricyclic overdose. Excessive quan-tities of sodium bicarbonate may impair tissueonc

L

Ldtd

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PlSipbvs

V

VaswTaT

ure and ECG monitoring to avoid fast-infusion-elated hypotension. This side effect is less commonith the aqueous solution.153 Other rare but signif-cant adverse effects are bradycardia and polymor-hic VT.154

tropine

tropine accelerates sinus and atrial pacemakersy blocking the parasympathetic response. It maylso increase AV conduction. Small doses (


or refute the use of vasopressin as an alternative to,or in combination with, adrenaline in any cardiacarrest rhythm in adults. Thus, there is currentlyinsufficient evidence to recommend the routine useof vasopressin in the child with cardiopulmonaryarrest.178180

Defibrillators

Defibrillators are either automatically (such as theAED) or manually operated, and may be capableof delivering either monophasic or biphasic shocks.Manual defibrillators capable of delivering the fullenergy requirements from neonates upwards mustbe available within hospitals and in other health-care facilities caring for children at risk of car-diopulmonary arrest. Automated external defibril-lators are preset for all variables, including theenergy dose.

Pad/paddle size for defibrillation. The largestpossible available paddles should be chosen to pro-vide good contact with the chest wall. The idealsize is unknown, but there should be good separa-tion between the pads.181,182 Recommended sizes

Figure 6.8 Paddle positions for defibrillation child. 2005 ERC.

Biphasic shocks are at least as effective and pro-duce less post-shock myocardial dysfunction thanmonophasic shocks.33,34,3740 Animal models showbetter results with paediatric doses of 34 J kg1than with lower doses,34,37 or adult doses.35 Doseslarger than 4 J kg1 (as much as 9 J kg1) have defib-rillated children effectively with negligible sideeffects.27,36 When using a manual defibrillator, use4 J kg1 (biphasic or monophasic waveform) for thefirst and subsequent shocks.

If no manual defibrillator is available, usean AED that can recognise paediatric shockablerhythms.29,30,185 This AED should be equipped witha dose attenuator which decreases the deliveredenergy to a lower dose more suitable for childrenaged 18 years (5075 J).31 If such an AED in notavailable, in an emergency use a standard AED andthe preset adult energy levels. For children weigh-ing more than 25 kg (above 8 years), use a standardAED with standard paddles. There is currently insuf-ficient evidence to support a recommendation foror against the use of AEDs in children less than 1year.

M

A

C(

A

O

are

4.5 cm diameter for infants and children weighing10 kg (older than1 year)

To decrease skin and thoracic impedance,an electrically conducting interface is requiredbetween the skin and the paddles. Preformed gelpads or self-adhesive defibrillation electrodes areeffective. Do not use ultrasound gel, saline-soakedgauze, alcohol-soaked gauze/pads or ultrasoundgel.

Position of the paddles. Apply the paddles firmlyto the bare chest in the anterolateral position, onepaddle placed below the right clavicle and the otherin the left axilla (Figure 6.8). If the paddles are toolarge, and there is a danger of charge arcing acrossthe paddles, one should be placed on the upperback, below the left scapula, and the other on thefront, to the left of the sternum. This is known asthe anteroposterior position.

Optimal paddle force. To decrease transthoracicimpedance during defibrillation, apply a force of3 kg for children weighing


Figure 6.9 Paediatric advanced life support algorithm.

tion in the ratio of 15:2 (lone rescuer may use30:2).

Avoid rescuer fatigue by changing the rescuerperforming chest compressions frequently.

Establish cardiac monitoring.

C

Assess cardiac rhythm and signs of circulation(check for a central pulse for no more than 10 s).

Asystole, pulseless electrical activity(PEA)non-shockable

Give adrenaline, 10mcg kg1 IV or IO, and repeatevery 35min.

If no vascular access is available and a trachealtube is in situ, give adrenaline, 100mcg kg1, viathis route until IV/IO access is obtained.

Identify and treat any reversible causes (4Hs &4Ts).

VF/pulseless VTshockable

Attempt defibrillation immediately (4 J kg1 forall shocks).

Resume CPR as soon as possible. After 2min, check the cardiac rhythm on the

monitor. Give second shock if still in VF/pulseless

VT.


Immediately resume CPR for 2min and checkmonitor; if no change, give adrenaline followedimmediately by a 3rd shock.

CPR for 2min. Give amiodarone if still in VF/pulseless VT fol-

lowed immediately by a 4th shock. Give adrenaline every 35min during CPR. If the child remains in VF/pulseless VT, continue

to alternate shocks with 2min of CPR. If signs of life become evident, check the monitor

for an organised rhythm; if this is present, checkfor a central pulse.

Identify and treat any reversible causes (4Hs &4Ts).

If defibrillation was successful but VF/pulselessVT recurs, resume CPR, give amiodarone anddefibrillate again at the dose that was effectivepreviously. Start a continuous infusion of amio-darone.

Reversible causes of cardiac arrest (4 Hsand 4 Ts)

Hypoxia Hypovolaemia

tion between a shockable and a non-shockable car-diac rhythm. Invasive monitoring of systemic bloodpressure may help to improve effectiveness of chestcompression,186 but must not delay the provision ofbasic or advanced resuscitation.

Shockable rhythms comprise pulseless VT andVF. These rhythms are more likely in the childwho presents with sudden collapse. Non-shockablerhythms comprise PEA, bradycardia (50% survival. However,he success of defibrillation decreases dramaticallys the time to defibrillation increases; for everyinute delay in defibrillation (without any CPR),urvival decreases by 710%. Survival after morehan 12min of VF in adult victims is


VF/pulseless VT. Experimental and clinical experi-ence with amiodarone in children is scarce; evi-dence from adult studies169,196,197 demonstratesincreased survival to hospital admission, but notto hospital discharge. One paediatric case seriesdemonstrates the effectiveness of amiodarone forlife-threatening ventricular arrhythmias.198 There-fore, IV amiodarone has a role in the treatment ofdefibrillation refractory or recurrent VF/pulselessVT in children.

Arrhythmias

Unstable arrhythmias

Check the central pulse of any child with anarrhythmia; if the pulse is absent, proceed totreating the child as being in cardiopulmonaryarrest. If the child has a central pulse, evaluatehis haemodynamic status. Whenever the haemody-namic status is compromised, the first steps are asfollows.

Open the airway.

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Aooii

Tachycardia

Narrow complex tachycardia. If supraventricu-lar tachycardia (SVT) is the likely rhythm, vagalmanoeuvres (Valsalva or diving reflex) may be usedin haemodynamically stable children. The manoeu-vres can be used in unstable children if they donot delay chemical or electrical cardioversion.200 Ifthe child is haemodynamically unstable, omit vagalmanoeuvres and attempt electrical cardioversionimmediately. Adenosine is usually effective in con-verting SVT into sinus rhythm. Adenosine is givenby rapid IV injection as closely as practical to theheart (see above), followed immediately by a bolusof normal saline.

Electrical cardioversion (synchronised with Rwave) is indicated in the haemodynamically com-promised child, in whom vascular access is notavailable, or in whom adenosine has failed to con-vert the rhythm. The first energy dose for electricalcardioversion of SVT is 0.51 J kg1 and the seconddose is 2 J kg1. If unsuccessful, give amiodaroneor procainamide under guidance from a paediatriccardiologist or intensivist before the third attempt.

Amiodarone has been shown to be effectiveistcdicta

WQsHudwlcdcmssdt

S

Cm

Assist ventilation and give oxygen.Attach ECGmonitor or defibrillator and assess thecardiac rhythm.Evaluate if the rhythm is slow or fast for thechilds age.Evaluate if the rhythm is regular or irregular.Measure QRS complex (narrow complexes, 0.08 s).The treatment options are dependent on thechilds haemodynamic stability.

radycardia

radycardia is caused commonly by hypoxia, acido-is and severe hypotension; it may progress to car-iopulmonary arrest. Give 100% oxygen, and posi-ive pressure ventilation if required, to any childresenting with bradyarrhythmia and circulatoryailure.If a poorly perfused child has a heart rate


childs clinical history, presentation and ECG diag-nosis, a child with stable, wide-QRS-complex tachy-cardia may be treated for SVT and be given vagalmanoeuvres or adenosine. Otherwise, consideramiodarone as a treatment option; similarly, con-sider amiodarone if the diagnosis of VT is confirmedby ECG. Procainamide may also be considered instable SVT refractory to vagal manoeuvres andadenosine210212 as well as in stable VT.172,213,214

Do not give procainamide with amiodarone.

Post-arrest management

Myocardial dysfunction is common after cardiopul-monary resuscitation.215,216 Vasoactive drugs mayimprove the childs post-arrest haemodynamic val-ues, but the drugs must be titrated according to theclinical condition. They must be given continuouslythrough an IV line.

Temperature control and management

Hypothermia is common in the child following car-217

Fever is common following cardiopulmonaryresuscitation; it is associated with a poor neuro-logical outcome,230232 the risk of which increaseswith each degree of body temperature greaterthan 37 C.230 There are limited experimentaldata suggesting that the treatment of fever withantipyretics and/or physical cooling reduces neu-ronal damage.233,234 Antipyretics and accepteddrugs to treat fever are safe; therefore, use themto treat fever aggressively.

Prognosis of cardiopulmonary arrest

There are no simple guidelines to determine whenresuscitative efforts become futile. After 20minof resuscitation, the team leader of the resus-citation team should consider whether or notto stop.187,235239 The relevant considerations inthe decision to continue the resuscitation includethe cause of arrest,45,240 pre-existing conditions,whether the arrest was witnessed, the durationof untreated cardiopulmonary arrest (no flow),the effectiveness and duration of CPR (lowflow), the promptness of extracorporeal life sup-pad

P

TdrtptttrttsiPhsc

F

Asp

diopulmonary resuscitation. Central hypother-mia (3234 C) may be beneficial, whereas fevermay be detrimental to the injured brain of sur-vivors. Although there are no paediatric studies,mild hypothermia has an acceptable safety pro-file in adults218,219 and neonates;220224 it couldincrease the number of neurologically intact sur-vivors.

A child who regains a spontaneous circulationbut remains comatose after cardiopulmonary arrestmay benefit from being cooled to a core tem-perature of 3234 C for 1224 h. The success-fully resuscitated child with hypothermia and ROSCshould not be actively rewarmed unless the coretemperature is below 32 C. Following a periodof mild hypothermia, rewarm the child slowly at0.250.5 Ch1.

There are several methods to induce, moni-tor and maintain body temperature in children.External and/or internal cooling techniques canbe used to initiate cooling.225227 Shivering canbe prevented by deep sedation and neuromuscularblockade. Complications can occur and include anincreased risk of infection, cardiovascular instabil-ity, coagulopathy, hyperglycaemia and electrolyteabnormalities.228,229

The optimum target temperature, rate of cool-ing, duration of hypothermia and rate of re-warming after deliberate cooling have yet to bedetermined; currently, no specific protocol for chil-dren can be recommended.ort for a reversible disease process241243 andssociated special circumstances (e.g, icy waterrowning,9,244 exposure to toxic drugs).

arental presence

he majority of parents would like to be presenturing resuscitation and when any procedure is car-ied out on their child.245255. Parents witnessingheir childs resuscitation can see that everythingossible has been attempted.256260 Furthermore,hey may have the opportunity to say goodbye toheir child; allowing parents to be at the side ofheir child has been shown to help them gain aealistic view of the attempted resuscitation andhe childs death.261 Families who were present atheir childs death showed less anxiety and depres-ion, better adjustment and had an improved griev-ng process when assessed several months later.260

arental presence in the resuscitation room mayelp healthcare providers maintain their profes-ional behaviour while also helping them to see thehild as a human being and a family member.261

amily presence guidelines

dedicated member of the resuscitation teamhould be present with the parents to explain therocess in an empathetic manner, ensuring that


the parents do not interfere with or distract theresuscitation. If the presence of the parents isimpeding the progress of the resuscitation, theyshould be sensitively asked to leave. When appro-priate, physical contact with the child should beallowed and, wherever possible, the parents shouldbe allowed to be with their dying child at the finalmoment.256,261264

The leader of the resuscitation team, not theparents, will decide when to stop the resuscita-tion; this should be expressed with sensitivity andunderstanding. After the event the team should bedebriefed, to enable any concerns to be expressedand for the team to reflect on their clinical practicein a supportive environment.

6c Resuscitation of babies at birth

Introduction

The following guidelines for resuscitation at birthhave been developed during the process that cul-minated in the 2005 International Consensus Con-ference on Emergency Cardiovascular Care (ECC)awetto

wths

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(0.2%) appeared to need resuscitation at delivery.Of these, 90% responded to mask inflation alone,whereas the remaining 10% appeared not to respondto mask inflation and therefore were intubated atbirth.

Resuscitation or specialist help at birth is morelikely to be needed by babies with intrapartum evi-dence of significant fetal compromise, babies deliv-ering before 35 weeks gestation, babies deliveringvaginally by the breech and multiple pregnancies.Although it is often possible to predict the needfor resuscitation before a baby is born, this is notalways the case. Therefore, personnel trained innewborn life support should be easily available atevery delivery and, should there be any need forresuscitation, the care of the baby should be theirsole responsibility. One person experienced in tra-cheal intubation of the newborn should also beeasily available for normal low-risk deliveries and,ideally, in attendance for deliveries associated witha high risk for neonatal resuscitation. Local guide-lines indicating who should attend deliveries shouldbe developed based on current practice and clinicalaudit.

An organised programme educating in the stan-dni

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nd Cardiopulmonary Resuscitation (CPR) Scienceith Treatment Recommendations.265 They are anxtension of the guidelines already published byhe ERC,2 and take into account recommenda-ions made by other national266 and internationalrganisations.267

The guidelines that follow do not define the onlyay that resuscitation at birth should be achieved;hey merely represent a widely accepted view ofow resuscitation at birth can be carried out bothafely and effectively.

reparation

elatively few babies need any resuscitation atirth. Of those that do need help, the overwhelm-ng majority will require only assisted lung aera-ion. A small minority may need a brief period ofhest compressions in addition to lung aeration.f 100,000 babies born in Sweden in 1 year, only0 per 1000 (1%) babies weighing 2.5 kg or moreppeared to need resuscitation at delivery.268 Ofhose babies receiving resuscitation, 8 per 1000esponded to mask inflation and only 2 per 1000ppeared to need intubation.268 The same studyried to assess the unexpected need for resuscita-ion at birth, and found that for low-risk babies, i.e.hose born after 32 weeks gestation and follow-ng an apparently normal labour, about 2 per 1000ards and skills required for resuscitation of theewborn is therefore essential for any institutionn which deliveries occur.

lanned home deliveries

he recommendations for those who should attendplanned home delivery vary from country to coun-ry, but the decision to undergo a planned homeelivery, once agreed by the medical and midwiferytaff, should not compromise the standard of ini-ial resuscitation at birth. There will inevitablye some limitations to resuscitation of a newbornaby in the home because of the distance fromurther assistance, and this must be made clearo the mother at the time plans for home deliveryre made. Ideally, two trained professionals shoulde present at all home deliveries;269 one of theseust be fully trained and experienced in providingask ventilation and chest compressions in theewborn.

quipment and environment

esuscitation at birth is often a predictable event.t is therefore simpler to prepare the environmentnd the equipment before delivery of the babyhan is the case in adult resuscitation. Resuscita-ion should ideally take place in a warm, well-lit,raught-free area with a flat resuscitation surfacelaced below a radiant heater and other resusci-


tation equipment immediately available. All equip-ment must be checked daily.

When a birth takes place in a non-designateddelivery area, the recommended minimum set ofequipment includes a device for safe, assisted lungaeration of an appropriate size for the newborn,warm dry towels and blankets, a clean (sterile)instrument for cutting the umbilical cord and cleangloves for the attendant. It may also be helpful tohave a suction device with a suitably sized suctioncatheter and a tongue depressor (or laryngoscope),to enable the oropharynx to be examined.

Temperature control

Naked, wet, newborn babies cannot maintain theirbody temperature in a room that feels comfortablywarm for adults. Compromised babies are partic-ularly vulnerable.270 Exposure of the newborn tocold stress will lower arterial oxygen tension271 andincrease metabolic acidosis.272 Prevent heat loss by

protecting the baby from draughts keeping the delivery room warm

Respiratory activity

Check whether the baby is breathing. If so, eval-uate the rate, depth and symmetry of respiration,together with any abnormal breathing pattern suchas gasping or grunting.

Heart rate

This is best evaluated by listening to the apex beatwith a stethoscope. Feeling the pulse in the baseof the umbilical cord is often effective but can bemisleading; cord pulsation is only reliable if foundto be more than 100 beats min1.276

Colour

A healthy baby is born blue but becomes pink within30 s of the onset of effective breathing. Observewhether the baby is centrally pink, cyanosed orpale. Peripheral cyanosis is common and does not,by itself, indicate hypoxaemia. drying the term baby immediately after delivery.Cover the head and body of the baby, apart fromthe face, with a warm towel to prevent furtherheat loss. Alternatively, place the baby skin toskin with the mother and cover both with a towel

placing the baby on a warm surface under a pre-heated radiant warmer if resuscitation is needed

In very preterm babies (especially below 28weeks gestation), drying and wrapping may not besufficiently effective. A more effective method ofkeeping these babies warm is to cover the head andbody of the baby (apart from the face) with plas-tic wrapping, without drying the baby beforehand,and then to place the baby so covered under radiantheat.

Initial assessment

The Apgar scoring system was not designed to iden-tify prospectively babies needing resuscitation.273

Several studies have also suggested that it ishighly subjective.274 However, components of thescore, namely respiratory rate, heart rate andcolour, if assessed rapidly, can identify babies need-ing resuscitation.275 Furthermore, repeated assess-ment of these components can indicate whether thebaby is responding or whether further efforts areneeded.Tone

A very floppy baby is likely to be unconscious and islikely to need respiratory support.

Tactile stimulation

Drying the baby usually produces enough stimula-tion to induce effective respiration. Avoid morevigorous methods of stimulation. If the baby failsto establish spontaneous and effective respirationsfollowing a brief period of stimulation, further sup-port will be required.

Classification according to initial assessment

On the basis of the initial assessment, the babiescan usually be divided into four groups.

Group 1: vigorous breathing or cryinggood tonerapidly becoming pinkheart rate higher than 100 beats min1

This baby requires no intervention other thandrying, wrapping in a warm towel and, whereappropriate, handing to the mother. The baby willremain warm through skin-to-skin contact withmother under a cover, and may be put to the breastat this stage.


Group 2: breathing inadequately or apnoeicremaining centrally bluenormal or reduced toneheart rate less than 100 beats min1

This baby may respond to tactile stimulationand/or facial oxygen, but may need mask inflation.

Group 3: breathing inadequately or apnoeicblue or palefloppyheart rate less than 100 beats min1

This baby may improve with mask inflation butmay also require chest compressions.

Group 4: breathing inadequately or apnoeicpalefloppyno detectable heart rate

This baby will require immediate airway control,lung inflation and ventilation. Once this has beensuccessfully accomplished, the baby may also needchest compressions and perhaps drugs.

There remains a very rare group of babies who,though breathing adequately and with a good heartrate, remain blue. This group includes a range of

bradycardia.277 The presence of thick meconium ina non-vigorous baby is the only indication for con-sidering immediate suction. If suction is required,it is best done under direct vision. Connect a 1214FG suction catheter, or a Yankauer sucker, to a suc-tion source not exceeding 100mmHg.

Breathing

There is currently insufficient evidence to specifythe concentration of oxygen to be used when start-ing resuscitation. After initial steps at birth, if res-piratory efforts are absent or inadequate, lung aer-ation is the priority (Figure 6.12). The primary mea-sure of adequate initial lung inflation is a promptimprovement in heart rate; assess chest wall move-ment if the heart rate does not improve.

For the first few breaths maintain the initialinflation pressure for 23 s. This will help lungexpansion. Most babies needing resuscitation atbirth will respond with a rapid increase in heartrate within 30 s of lung inflation. If the heart rateincreases but the baby is not breathing adequately,continue ventilation at a rate of about 30 breathsmin1, allowing approximately 1 s for each infla-ti

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possible diagnoses such as diaphragmatic hernia,surfactant deficiency, congenital pneumonia, pneu-mothorax or cyanotic congenital heart disease.

Newborn life support

Commence newborn life support (Figure 6.10) ifassessment demonstrates that the baby has failedto establish adequate regular normal breathing, orhas a heart rate of less than 100 beats min1. Open-ing the airway and aerating the lungs is usuallyall that is necessary. Furthermore, more complexinterventions will be futile unless these two firststeps have been successfully completed.

Airway

The baby should be on his or her back with thehead in a neutral position (Figure 6.11). A 2-cmthickness of the blanket or towel placed underthe babys shoulder may be helpful in maintainingproper head position. In floppy babies, applicationof jaw thrust or the use of an appropriately sizedoropharyngeal airway may be helpful in opening theairway.

Suction is needed only if there is particulate mat-ter or blood obstructing the airway. Aggressive pha-ryngeal suction can delay the onset of spontaneousbreathing and cause laryngeal spasm and vagalion, until there is adequate spontaneous breath-ng.Adequate passive ventilation is usually indicated

y either a rapidly increasing heart rate or a heartate that is maintained faster than 100 beats min1.f the baby does not respond in this way, theost likely reason is inadequate airway control orentilation. Look for passive chest movement inime with inflation efforts; if these are present,hen lung aeration has been achieved. If thesere absent, then airway control and lung aerationave not been confirmed. Without adequate lungeration chest compressions will be ineffective;herefore, confirm lung aeration before progress-ng to circulatory support. Some practitioners willnsure lung aeration by tracheal intubation, buthis requires training and experience to be achievedffectively. If this skill is not available and the heartate is decreasing, re-evaluate airway position andeliver aeration breaths while summoning a col-eague with intubation skills.Continue ventilatory support until the baby has

stablished normal regular breathing.

irculatory support

irculatory support with chest compressions isffective only if the lungs have first been success-ully inflated. Give chest compressions if the heartate is less than 60 beats min1 despite adequateentilation. The optimal technique is to place the


Figure 6.10 Newborn life support algorithm.

two thumbs side by side over the lower third ofthe sternum, with the fingers encircling the torsoand supporting the back (Figure 6.13).21,22,25,278,279

The lower third of the sternum is compressed to a

Figure 6.11 Newborn head in neutral position. 2005Resuscitation Council (UK).

depth of approximately one third of the anterior-posterior diameter of the chest. A compression torelaxation ratio with a slightly shorter compres-sion than relaxation phase offers theoretical advan-tages for blood flow in the very young infant.280

Do not lift the thumbs off the sternum duringthe relaxation phase, but allow the chest wall toreturn to its relaxed position between compres-sions. Use a 3:1 ratio of compressions to ventila-tions, aiming to achieve approximately 120 eventsmin1, i.e. approximately 90 compressions and 30breaths. However, the quality of the compressionsand breaths are more important than the rate.281

Check the heart rate after about 30 s and peri-odically thereafter. Discontinue chest compressionswhen the spontaneous heart rate is faster then 60beats min1.


Figure 6.12 Airway and ventilation newborn. 2005Resuscitation Council (UK).

Drugs

Drugs are rarely indicated in resuscitation of thenewborn infant. Bradycardia in the newborn infantis usually caused by inadequate lung inflation orprofound hypoxia, and establishing adequate ven-tilation is the most important step to correct it.However, if the heart rate remains less than 60beats min1 despite adequate ventilation and chestcompressions, drugs may be needed. These drugsare presumed to exert their effect by their actionon the heart and are being given because cardiacfunction is inadequate. It is therefore necessary togive them as close to the heart as possible, ide-ally via a rapidly inserted umbilical venous catheter(Figure 6.14).

Adrenaline

Despite the lack of human data, it is reasonable tocontinue to use adrenaline when adequate ventila-tion and chest compressions have failed to increasethe heart rate above 60 beats min1. Use the IVroute as soon as venous access is established. Therecommended IV dose is 1030mcg kg1. The tra-c

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Figure 6.14 Newborn umbilical cord showing the arter-ies and veins. 2005 Resuscitation Council (UK).

it is used, it is highly likely that doses of 30mcg kg1or less are ineffective. Try a higher dose (up to100mcg kg1). The safety of these higher trachealdoses has not been studied. Do not give high IVdoses.

Bicarbonate

If effective spontaneous cardiac output is notrestored despite adequate ventilation and ade-quate chest compressions, reversing intracar-diac acidosis may improve myocardial functionand achieve a spontaneous circulation. Give12mmol kg1 IV.

Fluids

Consider volume expansion when there has beensuspected blood loss or the infant appears to bein shock (pale, poor perfusion, weak pulse) andhas not responded adequately to other resuscita-tive measures. In the absence of suitable blood(i.e., irradiated and leucocyte-depleted group ORaib

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heal route is not recommended (see below) but, if

igure 6.13 Ventilation and chest compression new-orn. 2005 Resuscitation Council (UK).h-negative blood) isotonic crystalloid rather thanlbumin is the solution of choice for restoringntravascular volume in the delivery room. Give aolus of 1020ml kg1.

topping resuscitation

ocal and national committees will determine thendications for stopping resuscitation. However,ata from infants without signs of life from birthasting at least 10min or longer show either highortality or severe neurodevelopmental disability.fter 10min of continuous and adequate resusci-ation efforts, discontinuation of resuscitation maye justified if there are no signs of life.


Communication with the parents

It is vitally important that the team caring forthe newborn baby informs the parents of thebabys progress. At delivery adhere to the routinelocal plan and, if possible, hand the baby to themother at the earliest opportunity. If resuscitationis required, inform the parents of the proceduresbeing undertaken and why they are required.

Decisions to discontinue resuscitation ideallyshould involve senior paediatric staff. Wheneverpossible, the decision to attempt resuscitation ofan extremely preterm baby should be taken in closeconsultation with the parents and senior paediatricand obstetric staff. Where a difficulty has beenforeseen, for example in the case of severe con-genital malformation, the options and prognosisshould be discussed with the parents, midwives,obstetricians and birth attendants before deliv-ery.

All discussions and decisions should be carefullyrecorded in the mothers notes before delivery andalso in the babys records after birth.

Meconium

Five years ago, a large randomised controlled studyshowed that attempting to intubate and aspirateinhaled meconium from the tracheas of vigorousinfants at birth was not beneficial.290 A more recentlarge multicentre randomised controlled study hasnow shown that suctioning meconium from thebabys nose and mouth before delivery of the babyschest (intrapartum suctioning) does not reducethe incidence or severity of meconium aspirationsyndrome.291 Intrapartum suctioning is thereforeno longer recommended. Intubation and suction ofmeconium from the trachea of non-vigorous infantsborn through meconium-stained liquor is still rec-ommended.

Air or 100% oxygen

Several studies in recent years have raised concernsabout the potential adverse effects of 100% oxygenon respiratory physiology and cerebral circulation,and the potential tissue damage from oxygen freeradicals. There are also concerns about tissue dam-age from oxygen deprivation during and followingabowi(gpSisoir1cic

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Specific questions addressed at the2005 Consensus Conference

Maintaining normal temperature in preterminfants

Significantly, preterm babies are likely to becomehypothermic despite careful application of the tra-ditional techniques for keeping them warm (dry-ing, wrapping and placing under radiant heat).282

Several randomised controlled trials and observa-tional studies have shown that placing pretermbabies under radiant heat and then covering thebabies with food-grade plastic wrapping, withoutdrying them, significantly improves temperature onadmission to intensive care compared with tra-ditional techniques.283285 The babys tempera-ture must be monitored closely because of thesmall but described risk of hyperthermia with thistechnique.286 All resuscitation procedures, includ-ing intubation, chest compression and insertion oflines, can be achieved with the plastic cover inplace.

Infants born to febrile mothers have beenreported to have a higher incidence of perina-tal respiratory depression, neonatal seizures, earlymortality and cerebral palsy.286288 Animal stud-ies indicate that hyperthermia during or followingischaemia is associated with a progression of cere-bral injury.233,289 Hyperthermia should be avoided.sphyxia. Studies examining blood pressure, cere-ral perfusion, and various biochemical measuresf cell damage in asphyxiated animals resuscitatedith 100% versus 21% oxygen, have shown conflict-ng results.292296 One study of preterm infantsbelow 33 weeks gestation) exposed to 80% oxy-en found lower cerebral blood flow when com-ared with those stabilised with 21% oxygen.297

ome animal data indicate the opposite effect,.e. reduced blood pressure and cerebral perfu-ion with air versus 100% oxygen.292 Meta-analysisf four human studies demonstrated a reductionn mortality and no evidence of harm in infantsesuscitated with air versus those resuscitated with00% oxygen. However, there are several signifi-ant concerns about the methodology of these stud-es, and these results should be interpreted withaution.80,298

At present, the standard approach to resuscita-ion is to use 100% oxygen. Some clinicians maylect to start resuscitation with an oxygen con-entration less than 100%, including some whoay start with air. Evidence suggests that thispproach may be reasonable. However, where pos-ible, ensure supplemental oxygen is availableor use if there is no rapid improvement follow-ng successful lung aeration. If supplemental oxy-en is not readily available, ventilate the lungsith air. Supplemental oxygen is recommendedor babies who are breathing but have centralyanosis.


Monitoring the oxygen saturation of babiesundergoing resuscitation may be useful, but stud-ies have shown that term healthy newborns maytake more than 10min to achieve a preductal oxy-gen saturation above 95% and nearly an hour toachieve this post-ductally.299301 Giving a variableconcentration of oxygen guided by pulse oximetrymay improve the ability to achieve normal oxy-gen saturation values while more quickly avoidinghyperoxia, but the definition of these two termsin the baby at birth are undetermined. Oxygen is adrug, and oxidant injury is theoretically more likelyin preterm infants.

Initial breaths and assisted ventilation

In term infants, spontaneous or assisted initialinflations create a functional residual capacity(FRC).302309 The optimum pressure, inflation timeand flow required to establish an effective FRC havenot been determined. Average initial peak inflat-ing pressures of 3040 cmH2O (inflation time unde-fined) usually ventilate unresponsive term infantssuccessfully.305307,309 Assisted ventilation rates of3060 breaths min1 are used commonly, but thert

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of 2025 cmH2O, though some infants appear torequire a higher pressure.313,314

When ventilating preterm infants, very obviouspassive chest wall movement may indicate exces-sive tidal volumes and should be avoided. Monitor-ing of pressure may help to provide consistent infla-tions and avoid high pressures. If positive-pressureventilation is required, an initial inflation pres-sure of 2025 cmH2O is adequate for most preterminfants. If a prompt increase in heart rate or chestmovement is not obtained, higher pressures maybe needed. If continued positive-pressure ventila-tion is required, PEEPmay be beneficial. Continuouspositive airway pressure (CPAP) in spontaneouslybreathing preterm infants following resuscitationmay also be beneficial.314

Devices

Effective ventilation can be achieved with eithera flow-inflating or self-inflating bag or with aT-piece mechanical device designed to regu-late pressure.315317 The blow-off valves of self-inflating bags are flow dependent, and pressuresgenerated may exceed the value specified by them 318

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elative efficacy of various rates has not been inves-igated.The primary measure of adequate initial ven-

ilation is prompt increase in heart rate; assessassive chest wall movement if the heart rateoes not increase. The initial peak inflating pres-ures needed are variable and unpredictable, andhould be individualised to achieve an increase ineart rate or movement of the chest with eachreath. Where pressure is being monitored, an ini-ial inflation pressure of 20 cmH2O may be effec-ive, but 3040 cmH2O or higher may be requiredn some term babies. If pressure is not being moni-ored but merely limited by a non-adjustable blow-ff valve, use the minimum inflation required tochieve an increase in heart rate. There is insuffi-ient evidence to recommend an optimum inflationime. In summary, provide artificial ventilation at060 breaths min1 to achieve or maintain a heartate higher than 100 beats min1 promptly.

ssisted ventilation of preterm infants

nimal studies show that preterm lungs are eas-ly damaged by large volume inflations immediatelyfter birth,310 and that maintaining a positive end-xpiratory pressure (PEEP) immediately after birthrotects against lung damage. PEEP also improvesung compliance and gas exchange.311,312 Humanase series show that most apnoeic preterm infantsan be ventilated with an initial inflation pressureanufacturer. Target inflation pressures and longnspiratory times are achieved more consistently inechanical models when using T-piece devices thanhen using bags,319 although the clinical implica-ions are not clear. More training is required torovide an appropriate pressure using flow-inflatingags compared with self-inflating bags.320 A self-nflating bag, a flow-inflating bag or a T-pieceechanical device, all designed to regulate pres-ure or limit pressure applied to the airway, can besed to ventilate a newborn.Laryngeal mask airways (LMAs) are effective

or ventilating newborn near-term and full-termnfants.321,322 There are few data on the use ofhese devices in small preterm infants.323,324 Threease series show that the LMA can provide effectiveentilation in a time frame consistent with currentesuscitation guidelines, although the babies beingtudied were not being resuscitated.322,325,326 Aandomised controlled trial found no clinicallyignificant difference between the LMA and tra-heal intubation when bag-mask ventilation wasnsuccessful.321 It is unclear whether the conclu-ions of this study can be generalized, since theMA was inserted by experienced providers. Caseeports suggest that when bag-mask ventilation haseen unsuccessful and tracheal intubation is unfea-ible or unsuccessful, the LMA may provide effec-ive ventilation.327329 There is insufficient evi-ence to support the routine use of the LMA as therimary airway device for resuscitation at birth.


Table 6.1 Calculation of tracheal tube size and depth of insertiona

Childs weight (kg) Gestation (weeks) Tube size (mm ID) Depth of insertion (cm)a

38 3.5/4.0 >9

a Depth of insertion from the upper

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