Cardiopulmonary Resuscitation

Shamiel SaliePaediatric Intensive Care UnitRed Cross Children’s Hospital,University of Cape Town

BasicLifeSupport

SAFE approach

Are you alright?

Airway opening manoeuvres

Look, listen, feel

5 rescue breaths

Check pulseCheck for signs of circulation

CPR15 chest compressions

2 ventilations

Call emergency services

1 minute

Age Definitions:

• Newborn

• Infant - under 1 year

• Child - from 1 year to puberty

2005 BLS Changes:• Lay rescuers should start compressions for an

unresponsive child who is not breathing/moving

• Universal compression-ventilation ratio of 30:2 for the lone rescuer of infants, children and adults

• Increased evidence on the importance of uninterrupted chest compressions

Compression Compression TechniquesTechniques

Position: for all ages: compress the lower third of the sternum

number of hands:• In infants: two thumbs or two fingers

• in children: use one or two hands: depressing the sternum by approximately one third of the depth of the chest

Chest Compressions

• Push hard

• Push Fast

• Complete chest recoil

• Minimize interruptions

Calling for help!!Calling for help!!• Perform 5 cycles or about 2 minutes of CPR

before calling for help

• Indications for activating EMS before BLS by a lone rescuer are:– witnessed sudden collapse with no apparent

preceding morbidity– witnessed sudden collapse in a child with a known

cardiac abnormality

Choking

Assess

Ineffectivecough

Effectivecough

Conscious Unconscious

5 back blows Open airway

5 chest/abdothrusts

Assess andrepeat

5 rescue breaths

CPR 15:2Check for FB

Encouragecoughing

Support andassess

continuously

Universal Algorithm

Stimulate andassess response

Open airway

Check breathing

5 rescue breaths

Check pulseCheck for signs of circulation

CPR15 chest compressions

2 ventilations

Assessrhythm

Asystole andPEA

VF/VT

Asystole and PEA

Ventilate with highconcentration O2

Adrenaline10 mcg/kg IV or IO

Continue CPRIntubateIV/IO access

4 min CPR

Consider 4 Hs & 4 TsConsider alkalising agents

Check monitorevery 2 minutes

VF/VT

Neonatal Resuscitation

Drugs in Cardiac Arrest

• 10mcg/kg of adrenalin as the first and subsequent iv doses.

• high dose iv adrenalin is not recommended and may be harmful

• Insufficient evidence to recommend for or against the routine use of vasopressin in children

Route of drug delivery in ALSRoute of drug delivery in ALS

• where possible give drugs intra-vascularly rather than via the tracheal route

– lower adrenaline concentrations may produce transient beta adrenergic effects resulting in hypotension.

• Intra-osseous access is safe for fluid resuscitation and drug delivery.

Airway ManagementAirway Management

• guedel airways

• laryngeal airways

• Cuffed or uncuffed endotracheal tubes

Do children have Ventricular fibrillation?

Number of Defibrillating ShocksNumber of Defibrillating Shocks

• one shock rather than three “stacked” shocks

• Modern biphasic defibrillators have a high first shock efficacy

• Most patients have a non perfusing rhythm after successful defibrillation

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AED IN CHILDREN

• Age > 8 years• use adult AED

• Age 1-8 years• use paediatric pads /

settings if available (otherwise use adult mode)

• Age < 1 year• use only if

manufacturer instructions indicate it is safe

Fluid Resuscitation

• Boluses of fluid may be required to maintain systemic perfusion

• Crystalloids - ringers or normal saline

• Septic children may require in excess of 100ml/kg fluid resuscitation

Family Presence during Resuscitation

• Evidence suggests that the majority of parents would like to be present during resuscitation, that they gain a realistic understanding of the efforts made to save the child, and they subsequently show less anxiety and depression.

When do you start?

When do you stop?

• In the absence of reversible causes eg drowning with severe hypothermia, poisoning, prolonged CPR in children is unlikely to result in intact neurological survival.

• One should consider stopping resuscitation after 20 minutes.

Post Resuscitation Care

• Ventilate to normo-capnoea• Hypothermia for 12-24 hours post arrest may

be helpful, whilst hyperthermia should be treated aggressively

• Vaso-active drugs should be considered to improve haemodynamic status.

• Maintain normoglycaemia

Conclusions: • The 2005 guidelines minimizes the differences in the steps

and techniques of CPR used for infants, children and adults.

• Push hard, push fast, minimizing interruptions

• Respiratory failure and hypoxia is the commonest reason for paediatric arrests.

• There are usually warning signs of impending doom, and early and effective therapy will prevent cardiac arrest

Questions