PEDIATRICS EXIMIUS

AHA-PALS 2010 2021

DR. MACON DECEMBER 2019

2010 American Heart Guideline Update Pediatric Advance Life

Support

Pediatric Chain of Survival

Prevention Early Rapid access Rapid PALS Integrated

of Arrest CPR to EMS Support Post-cardiac
Arrest Care

• In contrast to adults, cardiac arrest in infants and children

SL.ppt/TR/FC 9 2
CHAIN OF SURVIVAL
Each link in the PEDIATRIC CHAIN OF SURVIVAL must be strong to
maximize survival and a neurologically intact outcome after life
threatening cardiovascular emergencies
1. The First Link: PREVENTION OF ARREST
In children, the leading cause of death is injury, and vehicular
accidents are the most common causes of fatal childhood injuries
and child passengers’ safety seats can reduce the risk of death.
2. The Second Link: EARLY AND EFFECTIVE BYSTANDER CPR
It is most effective when started immediately after the victim’s
collapse. The probability of survival approximately doubles when it is
initiated before the arrival of EMS. It is associated with successful
return of spontaneous circulation and
neurologically intact survival in children.
3. The Third Link: RAPID ACTIVATION OF THE EMS (OR OTHER
EMERGENCY RESPONSE) SYSTEM
It is the cornerstone therapy for patients who have just suddenly
collapsed probably due to ventricular fibrillation and pulse-less
ventricular tachycardia.
4. The Fourth Link: EARLY AND EFFECTIVE ADVANCED LIFE
SUPPORT (INCLUDING RAPID STABILIZATION AND TRANSPORT TO
DEFINITIVE CARE &REHABILITATION)
Initial steps in stabilization (provide warmth by placing baby under
a radiant heat source, position head in a “sniffing” position to open
the airway, clear airway w/ bulb syringe or suction catheter, dry
baby and stimulate breathing.
5. The Fifth Link: INTEGRATED POST-CARDIAC ARREST CARE
Post cardiac arrest care after return of spontaneous circulation
(ROSC) can improve the likelihood of patient survival with good
quality of life.
HUMAN BODY
ANATOMY AND PHYSIOLOGY
*Clinical death
0 - 1 min. - cardiac irritability
1 - 4 min. - brain damaged not likely
4 - 6 min. - brain damage possible
*Biological death
6 - 10 min. - brain damaged very likely
over 10 min. - irreversible brain damaged
does not usually result from a primary cardiac cause.
• More often it is the terminal result of progressive
respiratory failure or shock, also called an asphyxial arrest.
• Asphyxia begins with a variable period of systemic
hypoxemia, hypercapnea and acidosis, progresses to
bradycardia, and hypotension and culminates with cardiac
arrest.
BLS considerations during PALS
• PALS usually takes place in the setting of an organized
response in an advanced health care environment.
• In these circumstances, multiple responders are
mobilized and are capable of simultaneous coordinated
action.
• BLS is presented as a series of sequential events with the
assumption that there is only one responder
• Chest compressions should be immediately started by one
rescuer, while the second rescuer prepares to start
ventilations with a bag and mask.
• Effectiveness of PALS is dependent on high quality CPR
which requires:
o adequate compression rate (100/min)
o adequate compression depth
- 1/3 of AP diameter of chest
- 1 ½ in (4cms) in infants
- 2 in (5cms) in children
o complete recoil of chest after compression
- minimizing interruptions in compressions
- avoiding excessive ventilation reasons for
• inadequte CPR:
- rescuer inattention to detail
- rescuer fatigue
- long or frequent interruptions to secure the
airway
- check the heart rhythm and move the patient
- Optimum chest compressions are best delivered with the victim on a
firm surface
- While one rescuer performs chest compression and another
performs ventilation other rescuer should obtain monitor/
defibrillator, establish vascular access, calculate and prepare
anticipated medications

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DR. MACON DECEMBER 2019

E – events leading to presentation

A. Primary assessment
1. Airway C. Tertiary assessment
- Chest movement • Laboratory – ABG, Hb, O2sat, HCO3, lactate
- Breath sound • Radiography – CXR, ECG,
- Feel air passes through the nose and mouth - anytime you identify a life threatening condition, initiate
- Upper airway: clear/maintenable, not maintenable appropriate care immediately
2. Breathing
- RR Signs of life threatening condition
- Respiratory effort • Airway – complete or severe AO
- Tidal volume • Breathing – apnea, significant work of breathing
• Pulse oxymetry: • Circulation – absent pulse, poor perfusion, bradycardia
- 94% - adequate oxygenation • Disability – unresponsiveness, depress consciousness
- <94% - airway intervention • Exposure – significant hypothermia, bleeding, purpura,
- <90% - in 100% oxygen (non rebreathing mask – advanced abdominal distension due to bleeding
intervention: assisted ventilation)
3. Circulation Respiratory failure
Cardiovascular function • Inadequate ventilation and insufficient oxygenation
• Skin color: mottling • Anticipate respiratory failure if any of the following signs is
• HR present:
• BP 1. increase respiratory rate, with signs of
• Pulse(peripheral/central) distress(increased respiratory effort such as nasal
• Capillary refill flaring, retractions, seesaw breathing, grunting)
End organ 2. inadequate respiratory rate, effort or excursion
• Brain function (diminished breath sounds or gasping) especially if
• Skin perfusion mental status is depressed
• Renal perfusion(urine output) 3. cyanosis with abnormal breathing despite
supplementary oxygen
Definition of hypotension:
Term (0-28 day)------<60mmhg
• Infant (1-12 mo)------- <70mmhg
• Children 1 -10 yo (5th P) ---<70 + 2 (age yr)
• Children > 10 yo -------- < 90 mmhg

Capillary refill time

• Normal < 2 sec
• Prolonged CRT > 2 sec
• In case : shock, hypothermia, severe dehydration
• Warm shock : CRT < 2 sec due to peripheral vasodilation Shock
• Inadequate blood flow and oxygen delivery to meet tissue
Pulse check: metabolic demands.
• Use femoral/bracial pulse: < 1 year old • Hypovolemic shock – most common cause in children

4. Disability Compensated Shock:

• AVPU pediatric response scale ( alert, voice, painful, 1. tachycardia
unresponsiveness) 2. Cool and pale distal extremities
• Glasgow coma scale 3. Prolonged CRT ( despite ambient temperature)
• Pupillary response to light 4. Weak peripheral pulses compared with central pulses
5. Normal systolic blood pressure
5. Exposure
• Trauma Decompensated Shock
• Burn • As compensatory mechanism fail, signs of inadequate end-
• Child abuse organ perfusion develops
• Skin lesion 1. Depressed mental status
2. Decreased urine output
B. Secondary assessment 3. Metabolic acidosis
• SAMPLE 4. Tachypnea
S – signs and symptoms 5. Weak central pulses
A – allergies 6. Deterioration in color (mottling)
M – medication
P – past medical history
L – last meal
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DR. MACON DECEMBER 2019

Decompensated shock:
a. Inadequate delivery of oxygen to tissues
- pallor
- peripheral cyanosis
- tachypnea
- mottling
- decrease urine output
- metabollic acidosis
- depressed mental status
b. Weak or absent peripheral and central pulses
c. hypotension

Learn to integrate the signs of shock

1. CRT >2sec – useful indicator of moderate dehydration
when combined with decrease UO, absent
tears, dry mucous membranes, generally ill
appearance
2. Tachycardia is a common sign of shock but can also result from • Bag mask ventilation – effective and safer than
other causes (pain, anxiety, fever) endotracheal tube ventilation for short periods during out-
3. Pulses are weak in hypovolemic and cardiogenic shock. of-hospital resuscitation
bounding – anaphylactic, neurogenic, septic shock - correct mask size, maintaining an open airway,
4. BP may be normal in a child with compensated shock but may providing a tight seal between face and mask,
decline rapidly when the child decompensates providing ventilation and assessing effectiveness
of ventilation
Airway
• Oropharyngeal and nasopharyngeal airway – helps
maintain an open airway by displacing the tongue or soft
palate from the pharyngeal air passages
- used in unresposive victims who do not have a gag reflex
- too small – push the tongue farther into the airway
- too large - obstruct the airway
• Laryngeal mask airway – associated with higher incidence
of complication in young children
- used when bag-mask ventilation is unsuccessful
and ET intubation is not possible
• Oxygen – it is reasonable to ventilate with 100% oxygen
during CPR because there is insufficient information on the
optimal inspired oxygen concentration.
- avoid hyperoxia while ensuring adequate
oxygen delivery
• Pulse oxymetry – if the patient has perfusing rhythm,
monitor oxyhemoglobin saturation continuously Ventilation with endotracheal tube
– Unreliable in patients with poor peripheral • Verification of endotracheal tube placement
perfusion, carbon monoxide poisoning or 1. Look for bilateral chest movement and listen for equal breath
methemoglobinemia sounds over both lung fields
2. Listen for gastric insufflation sounds over the stomach ( they
should not be present when the tube is in the trachea)
3. If there is perfusing rhythm, check oxyhemoglobin concentration
with pulse oximeter
4. In hospital setting, perform a chest x-ray to verify tube placement

If an intubated patient deteriorates

• Mnemonic DOPE:
• D – displacement of the tube
• O – obstruction of the tube
• P – pneumothorax
• E – equipment failure

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DR. MACON DECEMBER 2019

Endotracheal tube size CPR: C- CIRCULATION

 Uncuffed ET tube • CIRCULATION represents a heart that is actively pumping
- 3.5mm ID tube – infants to 1yo blood, most often recognized by the presence of a pulse in
- 4.0 mm ID – 1-2 yo the neck
- >2yo ( cuffed ET tube mm ID = 4 + (age/4) ) • Assume there is no CIRCULATION if the following exist:
 Cuffed ET tube Unresponsive, Not breathing, Not moving and Poor skin
- 3.0 mm ID - < 1yo color
- 3.5 mm ID – 1-2yo “SIGNS OF CIRCULATION”
- >2yo ( cuffed ET tube mm ID = 3.5 + (age /4) )
Child CPR
Endotracheal drug administration Child CPR
• Vascular access( IV, IM) is the preferred method for drug  Lower half of the sternum, between the nipples.
delivery during CPR, but if not possible, lipid-soluble drugs  One hand only/ two hands
such as:  30:2 for single rescuer, 15:2 for 2-man rescuer
- lidocaine, epinephrine, atropine and naloxone (optional for HCP).
- However effects may not be uniform with tracheal as
compared with IV route Pediatric CPR
Infant CPR
Monitoring  Just below the nipple line, lower half of sternum
1. Electrocardiography – monitor cardiac rhythm  Middle and ring finger, flexing at the wrist (lone
2. Echocardiography – identify patients with potentially rescuer)
treatable causes of arrest (pericardial tamponade)  2-thumbs hand encircling technique (two HCP
3. End-tidal C02 (PETC02) – continuous capnography, to check rescuers)
the effectiveness of chest compressions  Puff only for artificial ventilation (observe for
4. Vascular asccess – administering medications and drawing visible chest rise)
blood samples
5. IO access INFANT 1- AND 2-Rescuer CPR
6. Venous access – peripheral or central venous access 1. Survey the scene.
7. Endotracheal drug administration 2. Introduce Self
3. Check for responsiveness
Intraosseous access 4. If “UNRESPONSIVE” activates medical assistance
• Rapid, safe, effective and acceptable route for vascular 5. C-CIRCULATION: Compression 30
access in critically ill patients and useful as the initial 6. A- AIRWAY
vascular access in cases of cardiac arrest 7. B-BREATHING: Rescue Breathing 2 breaths with visible
• All Iv meds can be administered intraosseously chest rise
• Epinephrine, adenosine, fluids and blood products, (2nd rescuer arrives takes over breathing with Bag-Valve Mask)
catecholamines 8. 1st rescuer pauses to allow 2nd rescuer to give 2 breaths
• Onset of action and drug levels for most drugs are 9. 1st rescuer continue compression and pauses to allow 2nd
comparable to venous administration rescuer to give 2 breaths
10. Rescuers switches places with little interruption. 1 st
rescuer takes over breathing using bag-valve mask)
11. Continue cycles of CPR
12. If patient becomes conscious, place patient in recovery
position
Table of Comparison on Cardiopulmonary Resuscitation
for Adult, Child and Infant

AHA 2010 Guidelines

• Early CPR improves the likelihood of survival.
• Chest Compressions are the foundations of CPR.
• Compressions create blood flow by increasing intra-
thoracic pressure and directly compress the heart;
generate blood flow and oxygen delivery to the
myocardium and brain.
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Adult Child Infant
Compression Lower half of sternum, between the nipples Just below the nipple
Landmark line (lower half of
sternum)
Compression Depth Approximately 1.5 to Approximately 1/3 to Approximately 1/3 to
2 inches (4 to 5 cm) ½ the depth of the ½ the depth of Infant
chest chest
Compression method Heel of one hand Heel of one hand Lone Rescuer: 2
(Push hard and fast, with hand of the with hand of the finger technique
Allow Complete other on top other on top 2 HCP rescuers: 2-
recoil) thumbs hand
encircling technique

Compression rate Approximately 100 Compressions per minute

Compression- Lone Rescuer (Lay rescuer and HCP): 30:2
Ventilation Ratio
Two Rescuers 30:2 Two-rescuer 15:2

Counting for 1,&2& 3&4&5&6&7&8&9&10&11,12,13,14,15, 16,17,18,19,20, 21,

Standardization 22, 23, 24, 25, 26, 27, 28, 29 &1… up to 5
Purpose

In a child, lay rescuers and healthcare providers should

compress the lower half of the sternum with the heel of 1
hand or with 2 hands (as used for adult victims) but should
not press on the xiphoid or the ribs. There is no outcome data
that shows a 1-hand or 2-hand method to be superior; higher
compression pressures can be obtained on a child manikin
with 2 hands.111 Because children and rescuers come in all BLS Sequence
sizes, rescuers may use either 1 or 2 hands to compress the • Recognize apnea or abnormal breathing
child’s chest. It is most important that the chest be compressed AED- if lone provider call for help after 2 minutes of CPR
about one third to one half the anterior-posterior • Check pulse (<10 seconds)
depth of the chest. • 30:2
• Use AED when it arrives
• Pulse check is deemphasized
– Often done for too long
– Ok to do CPR with a pulse
• Chest compression depth
– 1.5 inches infant
– 2 inches child
– At least 2 “ adolescents
–
High Quality CPR Cornerstone of Resuscitation
2005 Guidelines 2010 Guidelines
ABC CAB
• Airway • Chest Compressions
• Breathing • Airway
• Circulation • Breathing
• Compressions

Priorities
• Allow complete chest recoil
• Minimizing interruptions in chest compressions
• Avoiding excessive ventilations

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DR. MACON DECEMBER 2019

on either side of
patient
Guidelines out of hospital for
adults to stop CPR to avoid
ineffective dangerous CPR en
route

B. Airway
• Lay person
– Head tilt-chin lift
• Healthcare Provider
– Head tilt-chin lift
– Spinal cord injury suspected
Compressions – Jaw thrust
• Children and infants: 30:2 • Head tilt-chin lift if jaw thrust not
• 2 persons HCP: 15:2 adequate
• Rate of compressions at least 100/min • Spinal immobilization can interfere
with maintaining airway
Limit Interruptions – Manual hand placement
• Try to keep interruptions <10 seconds – Use immobilization devices
• Depth during transport
- Adults: at least 2 inches C. Breathing
- Children/infants: 1/3 the AP diameter • Untrained lay rescuer
– Hands only CPR
Compression only – Push hard and fast
• Compression only in untrained provider – Trained to stop when higher level of care arrives
• Number of respirations • Trained rescuer
- With advanced airway: 1 breath every 6-8 sec: 8-10 breaths per – 30:2
minute – No 2 man CPR
– Trained to stop when higher level of care arrives
Push Hard and Push Fast • Healthcare provider
• Out of hospital arrest 20-30% adults receive bystander CPR – “Reasonable to provide chest compressions and
• Imperative for survival to have CPR started immediately rescue breaths”
• Hands only technique simpler – Felt to be unreasonable for single HCP to do 1
man CPR with bag valve mask
• No look listen or feel for breathing anymore
• Breath over 1 second
– With mouth to mouth give regular breath to
CPR guidelines for Newborn with cardiac origin avoid rescuer hyperventilation
Compression:ventilation ratio Newly born and newborn – Less likely to use barrier device
-3:1 • Tidal volume to produce visible chest rise
How to provide ventilation in Infants two-rescuer – 15:2 • Stoma rescue breaths-use pediatric face mask
the presence of an advanced Newly born and newborn • 30:2
airways - pause after 3 • When advanced airway without pulse breath
compressions – q 6-8 seconds
Infants – no pauses for – q 10 breaths/minutes
ventilation • Breathing with advanced airway
– At least 100 compressions per minute
– 1 breath q 6-8 seconds
A. Compression • Cricoid pressure
2005 Guidelines 2010 Guidelines – can delay or prevent placement of advance
Approximately 100 per minute At least 100/ minute-stay tuned airway in adults
Mid-nipple line for what the upper limit maybe – Aspiration is not prevented as previously
½-1/3 the depth of the chest- Center of sternum thought
infant/child 1 ½-2 inches infant/child – Routine use not recommended in adults
Recoil of chest discussed Recoil of chest imperative – Can be used with an additional provider in
Keep interruptions < 10 Interruptions < 5-10 seconds children
seconds - Interruption 24-57% • Do not press too hard too prevent air
Change compressors q 2 of time movement into the trachea
minutes Change compressor at least q 2 – Can use to aid in tracheal intubation
minutes • Excessive breathing
- Position compressors – Gastric inflation
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– Increases intrathoracic pressure→ Exhaled CO2 detector or Recommended during the

• ↓venous return esophageal detector periarrest period
• ↓ cardiac output device to confirm Prehospital →ICU
• ↓ survival endotracheal tube (ET) Uses include
Breathing with a pulse placement Confirmation of
Adult 2005 Guidelines Adult 2010 Guidelines Monitoring can be useful ET placement
• Rescue breathing • Rescue breathing as a noninvasive Monitoring CPR
every 5 seconds every 5-6 seconds indicator of cardiac quality
• Children/infants • Children/infants output in CPR Monitoring of ET
every 3-5 seconds every 3-5 seconds placement
It is the most reliable way
to confirm and monitor ET
Capnography (Adult and Child) placement
2005 Guidelines 2010 Guidelines

both pupils with decrease response to light,

Fluid Resuscitation
• Use isotonic crystalloid solutions( lactated ringer’s
/normal saline – initial fluid for the treatment of shock
• No added benefit in using colloid (albumin) during the
early phase of resuscitation
• Bolus of 20ml/kg of isotonic crystalloid
Trauma
major cause of preventable pediatric deaths
1. Cevical spinal injury – restrict motion of cervical spine and
avoid traction or movement of head and neck
• Open airway with jaw thrust, do not tilt the
head
2. If airway cannot be opened with jaw thrust, use a head tilt-
chin lift because you must establish a patent airway
3. Do not routinely hyperventilate even in case of head injury
- Brief hyperventilation used as temporizing
rescue therapy if there are signs of impending
brain herniation ( inc ICP, dilatation of one or
TRANSCRIBERS EINA MARK DADO
bradycardia and hypertension)
4. 4. Suspect thoracic injury in all thoraco-abdominal trauma,
even in the absence of external injuries.
- tension pneumothorax, hemothorax,
pulmonary contusion may impair oxygenation
and ventilation
5. Maxillofacial trauma or basilar fracture – insert orogastric
rather than NGT
6. Consider intra-abdominal hemorrhage, tension
pneumothorax, pericardial tamponade and SCI in infants
and children, and IC hemorrhage in infants, as cause of
shock
AED (automated external defibrillator)
• Goal to defibrillate within 3 minutes
– Even in hospitals
• Staff that does not have rhythm
recognition
7
 PEDIATRICS EXIMIUS
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• Takes longer to get code cart to scene adults m

• Use pediatric pads < 8 years of age if possible Adenosine-narrow fast anywher
• Use in infants complex e
– Prefer manual if possible Chronotropic drugs Adenosine-now for narrow
– Use AED if necessary may be used while REGULAR wide complex
- AEDs are sophisticated, computerized devices that can awaiting pacer or Adult and children
analyze heart rhythms and generate high voltage electric pacing was ineffective Chronotropic drugs work as
shocks. well as pacing when Atropine
has been ineffective-in adults

Atropine
• Atropine is not recommended for routine use in the
management of pulseless electrical activity/asystole
• The adult guidelines now mirror this recommendation
Supraventricular Tachycardia (SVT)
2005 guidelines 2010 guidelines
Vagal maneuvers Vagal maneuvers
Adenosine Apply ice to the
Synchronized cardiovert face
Indications and Importance Ca rotid massage-
Early defibrillation is critical for victims of sudden cardiac arrest older child
because: Blow through a
• The most frequent rhythm in sudden cardiac arrest is VF narrow straw
• The most effective treatment for VF is defibrillation Adenosine
• Defibrillation is most likely to be successful if it occurs Synchronized cardiovert
within minutes of collapse (cardiac arrest) 0.5-1 J/kg
• Defibrillation may be ineffective if it is delayed 2 J/kg
• VF deteriorates to asystole if not treated Drugs-
Amiodorone
• Age 1-8: should use pediatric attenuated system if Procainamide
available. If not available use adult AED system.
• If < 1 year: manual defibrillator preferred. If none available Stable Ventricular Tachycardia (V Tach)
use AED with pediatric system. If neither available, Not enough evidence for a Expert consultation
standard AED may be used. recommendation Amiodorone
Procainamide
Defibrillation dose Synchronized cardioversion
• 2-4 J/Kg on first shock of either of monophasic or biphasic 0.5-1 J/kg
waveform is reasonable 2 J/kg
• At least 4 J/Kg for subsequent shocks
• Higher level may be considered PALS
• Not to exceed 10 J/kg
Calcium can be used in Calcium administration in
arrest situation cardiac arrest may have benefit
Pad Placement
Etomidate-minimal Known hypocalcemia
2005 Guidelines 2010 Guidelines hypotensive effect with Known calcium
Anterior-lateral Anterior-lateral position RSI channel blocker
position Only correct overdose
Implantable placement in PALS Hyper
defibrillator/pacemake Anterior-posterior magnesia/kalemia
r Anterior-left scapular Etomidate should not be used in
Place pad at Anterior-right infrascapular suspected shock
least 1” away Implantable
from device defibrillator/pacemaker
Do not delay Etomidate
defibrillation • Has been shown to facilitate endotracheal intubation in
Try to avoid placing infants and children with minimal hemodynamic effect
pads directly over BUT:
the device • Is not recommended for routine use in pediatric patients
DRUG THERAPY with evidence of septic shock.
Atropine-PEA/Asystole Atropine-PEA/Asystole Hypothermia
Q 3-5 Not in
minutes- algorith
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- Although there have been no published results of • Once unresponsive chest thrust with CPR generated
prospective randomized pediatric trials of therapeutic higher airway pressures than abdominal thrusts
hypothermia, based on adult evidence, therapeutic • No blind finger sweep
hypothermia (to 32-34C) may be beneficial for adolescents
who remain comatose after resuscitation from sudden Neonatal Resuscitation (NRP)
witnessed out of hospital VF cardiac arrest. The order is still
- Therapeutic hypothermia (32-34C) may also be considered • A
for infants and children • B
Ethical Issues • C
• DNAR-Do Not Attempt Resuscitation
– Does not preclude
• Parental fluid
• Nutrition
• Oxygen
• Nutrition
• Analgesia Neonate
• Sedation • Definition of neonate quite gray-at least through first
• Antiarrhythmics admission
• Vasopressors • 3:1
• Unless they are included in the order • Unless cardiogenic cause or maybe 3 day old in PICU
• Allow Natural Death (AND) 15:2
• Never ‘slow code’
NRP
Drowning 2005 Guidelines 2010 Guidelines
• Start mouth to mouth in the water 3:1 CPR 3:1-unless arrest felt to be
• Delay chest compression until out of water Therapeutic hypothermia is cardiac in nature then
• Lone rescuer once on land perform 5 cycles of CPR (2 an area where research is 15:2 two rescuer
minutes) before calling 911 needed 30:2 one rescuer
• Spinal cord injury is rare ≥ 36 weeks evidence of
– Remove from water ASAP moderate to severe anoxic
– Unless encephalopathy therapeutic
• signs of intoxication hypothermia is beneficial
• history of shallow water diving

Preterm and full turn infants

Clamp umbilical cord upon
delivery
that do not require
resuscitation
Delay cord clamping
for one minute
Infants that require
resuscitation there is
no guideline

• Once start positive pressure ventilation (PPV)

Foreign Body Obstruction – Use room air, not supplemental oxygen at first
• Infant – Assess the following to ensure improvement
– Back slaps and chest thrusts • Heart rate
• Child and Adult • Respiratory rate
– Abdominal thrusts until unresponsive • Evaluation state of oxygenation
– Then CPR with visual look in mouth before – Preferably by oxygen
respirations saturation not color
• 50% of episodes by the time EMS was summoned airway – Use pulse ox probe to right
obstruction was relieved upper extremity
– 0f the 50% that were not relieved EMS was able • Do not suction the airway unless has obvious obstruction
to remove 85% including meconium babies who are nonvigorous
– <4% died

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