Wirral University Teaching

Hospital NHS Foundation Trust

Paediatric Basic Life Support

(Healthcare professionals with a duty to
respond to paediatric emergencies)

Resuscitation Council (UK) Guidelines

2010

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Introduction

Paediatric resuscitation differs from that of adults due to the size,

anatomical and physiological differences that occur in children.

The 2010 Guidelines state:

An infant is a child under 1 year old

A child is between 1 year old and puberty.

It is not necessary to establish the onset of puberty formally. If the

rescuer believes the victim to be a child they should use the
paediatric guidelines.
If a misjudgement is made and the victim turns out to be an
adolescent then little harm will be have been made. It is necessary
to differentiate between infants and older children, as there are
important differences between these two groups.

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 SAFE APPROACH
Shout for Help, Approach with care, Free from danger, Evaluate

CHECK RESPONSE

“Are you alright”

Airway Opening Manoeuvres

Neutral, head tilt/chin lift/jaw thrust

NOT BREATHING
If Collapse is CHECK BREATHING
LOOK, LISTEN , FEEL BREATHING PRESENT
Witnessed &
(No more than 10 seconds) Put in recovery position
Sudden
If still alone get Carefully remove any
help ASAP airway obstruction

No Breathing

Give 5 Initial Rescue

Breaths

Check for signs of

Signs of Circulation circulation
(only if trained check central
Present = pulse)
Respiratory Arrest No more than 10 secs
Continue ventilating
& reassess regularly

No Circulation, Slow Pulse or

Unsure
Commence Chest
Compressions
15:2 Ratio
100-120 Comp per/min (rate)

Resuscitate for 1 minute

and if still alone
GO FOR HELP

Continue resuscitation:
Until child shows signs of life
Qualified help arrives & takes over 3
You become too exhausted
S.A.F.E Approach

S shout for help

A approach with care

F free from danger

E evaluate

Shout for help as soon as possible in any emergency and if

available use the emergency call system. If help arrives send them
to telephone for the paediatric emergency/cardiac arrest team and
to collect & return with the emergency equipment. Whilst this is on
route the rescuer must assess ABC and commence resuscitation if
it is required.

Ensure the safety of the resuser(s) and child. There is a saying

that no accident or emergency warrants another accident or
emergency.

In a hospital environment safety may not be a big cause for

concern. Things to think about in the hospital environment are:

♦ Contact with any type of body fluid- Take universal precautions

wear gloves, apron, and goggles ect..

♦ Manual Handling issues- if a collapse occurs in a toilet or

shower you will need think about how you are going to move
the child without injuring yourself.

♦ Jugs of water on bedside lockers- emergency team members

slipping or if defibrillation is required it will not be safe to
perform if the emergency team are standing in water.

If the accident/collapse occurs outside the hospital and it is a road

traffic accident, the rescuer may also be hit by a car. If a child has
been electrocuted the rescuer may also be electrocuted. The
rescuer must think about these issues and if possible remove the
child from danger before commencing resuscitation.
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Check Response

Child

Hold the child’s head & shaking the arm gently ask loudly

“Are you alright”

Infant (& any child with suspected C Spine Injury)

Do not shake infants (& suspected C spine injury) try and elicit a
response by tickling the foot or pulling the hair.

An infant can not respond or a child may be too frightened to

respond but they may open their eyes, cry or move- which is a sign
of life even if the child looks extremely ill.

If there is no response assess the ABC

A- Airway
B- Breathing
C- Circulation

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Airway Opening Manoeuvres

An airway obstruction may be the primary problem and correction

of the obstruction may result in complete recovery without further
intervention.

Management of the airway varies dependent on the age of the

child.

Infants

An infants airway is potentially the most difficult to manage as it is

soft and easily compressible. This combined with the large occiput,
which tends to cause the head to flex.

Put an infants head in to the neutral position (eyes looking straight

up to the ceiling). Apply a chin lift at the same time, ensuring the
soft tissue under the chin is not touched as this will compress and
occlude the airway.

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Children

As children get older their airway becomes more robust.

Put a child’s head in the “sniffing the morning air” position. Apply a
chin lift at the same time ensuring the soft tissue under the chin is
not touched as this will compress and occlude the airway.

Jaw Thrust

If trauma is suspected try to avoid moving the head and neck and
use the jaw thrust manoeuvre to open the airway.
Place hands either side of the child’s head and keep the head in
the neutral position. Put index fingers on the angle of the jaw and
push the jaw upwards.
If the jaw thrust manoeuvre is proving ineffective at opening the
airway the rescuer may have to apply a small amount of a head tilt
to open the airway but this should be avoided if possible.

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Clearing the Airway

Remove any obvious foreign body from the airway but DO NOT
attempt blind or repeated finger sweeps. This can impact the
object more deeply in the pharynx. Equally, the friable soft tissue in
a child’s mouth may be traumatised causing bleeding and swelling.
If an object can be easily seen then it may be pinched out of the
child’s mouth.

Check for Breathing

LOOK for chest movement

LISTEN at the child’s nose & mouth for breath sounds

FEEL for air movement on the cheek

For No More Than 10 Seconds

Not Breathing or Only Making Infrequent Irregular Gasps

The rescuer should breath for the child and give all 5 initial rescue
breaths. Whilst delivering these breaths the rescuer should note
any gag or cough reflex in response to them. The response or
absence of a response will form part of the assessment for ‘signs
of a circulation’.

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Rescue Breaths for an Infant- mouth to mouth & nose

♦ Ensure the head is in the neutral position

♦ The rescuer must take a breath and cover the mouth & nasal
openings of the infant with their mouth & ensure a good seal is
made.

♦ Blow steadily in to the mouth & nose for 1- second. Just enough
breath to make the chest visibly rise.

♦ Keeping the airway open the rescuer must take their mouth
away from the infant, turn their head to one side and watch the
chest fall before another breath is attempted.

♦ Repeat this sequence 5 times in total.

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Rescue Breaths for a child >1 year-mouth to mouth

♦ Ensure the child’s head is the “sniffing the morning air position”

♦ Pinch the soft part of the nose, open the child’s mouth slightly.

♦ The rescuer must take a breath and put their lips around the
child’s mouth and blow slowly and steadily for 1 second. Just
enough to see the chest visibly rise.

♦ Keeping the airway open the rescuer must take their mouth
away from the child, turn their head to one side and watch the
chest fall before another breath is attempted.

♦ Repeat this sequence 5 times in total.

Note: if breaths are delivered to forcefully the majority of the air will
enter the stomach, which increases the risk of regurgitation and
consequently aspiration. In an infant barotrauma (trauma to the
lungs) may be a possibility.

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Check for Signs of a Circulation

For No More Than 10 Seconds

♦ Look for signs of a circulation by observing for any movement,

coughing, regular breathing (not infrequent, irregular breaths).

and at the same time

♦ Only if trained and experienced check for a central pulse.

Even experienced rescuers find it difficult to feel for a central pulse

in an emergency situation. Consequently, the inexperienced
rescuer should take the absence of “signs of life” as a cardiac
arrest even if they are unsure. Inappropriate chest compressions
will rarely do harm but delaying CPR for longer than 10 seconds
whilst trying to detect a pulse will leave a victim’s brain and other
vital organs without oxygenation. DO NOT take more than 10
seconds to check- if in doubt start CPR.

If confident signs of a circulation are detected (Respiratory

Arrest):

♦ Continue to provide rescue breaths until the child starts to

breath effectively on their own.

♦ If the child starts to breath effectively on their own but remains

unconscious put them in to the recovery position. Be prepared
to turn the child over & recommence CPR if they stop breathing.

♦ If the child does not start to breath effectively on their own

reassess for signs of a circulation regularly. A respiratory arrest
may progress to a cardiac arrest and chest compressions will
need to be commenced.

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No Signs of a Circulation

Or no pulse

Or a slow pulse (<60bpm with signs of poor perfusion)

Or you are unsure

(in an unconscious, apnoeic child a pulse of 60bpm or below is

termed as terminal bradycardia, which indicates a failing
circulation. In the presence of this chest compressions should be
commenced without delay).

Start chest compressions and combine them with

rescue breaths

Chest Compression Techniques

For all children compress the lower third of the sternum.

♦ Locate the tip of the breastbone (xiphisternum) and compress

the sternum 1 finger breath above this.

♦ Compress the sternum by at least one third of the depth of the

chest and back.

♦ Release the pressure- repeat at a rate of 100-120

compressions per minute (although the rate of compressions is
100-120 per min the actual number will be less than 100-120
because of pauses for breaths).

♦ Give 15 chest compressions and follow this with 2 effective

breaths.

♦ Continue CPR for a ratio of 15:2 for children of all age groups.

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Chest Compressions in Infants

Lone rescuer 2 finger technique- Compress the sternum with the

tips of 2 fingers

Two or more rescuers encircle technique- Compress the sternum

with 2 thumbs

Research has shown that the encircling technique results in a

better coronary artery perfusion pressure. It is limited to 2 or more
rescuers as it would consume too much time for the lone rescuer
going from compressions to ventilation’s.

Chest Compressions in Children > 1year

Compress the sternum with the heel of 1 or 2 hands. In larger

children 2 hands may be needed or small rescuers may need 2
hands to compress a small child’s sternum. It is up to the rescuer
to assess how many hands to use depending on their clinical
decision that the chest compressions that they are performing are
effective regardless of if the child is below or above the age of 8
years.

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 ♦ Chest compression land marking in all age
groups is 1 fingers breadth above the tip of
the breast bone

♦ Ratio 15:2 in all age groups

♦ Compression Rate 100-120 per minute in all

age groups

♦ Compression Depth at least 1/3rd of the chest

& back diameter in all age groups

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Continue Resuscitation

Until:

♦ The child shows signs of life

♦ Qualified help arrives and takes over

♦ The rescuer becomes to exhausted to continue

Once the rescuer has decided that they are dealing with a cardiac
arrest they should not stop to check for signs of a circulation
regularly during CPR. The reason for this is that Basic Life Support
alone is unlikely to reverse the cause of a cardiac arrest so
checking the circulation regularly allows oxygenation/perfusion to
drop.

When to Call for Help

♦ It is vital for rescuers to get help as soon as possible when a

child collapses

♦ If more than one rescuer is available then one should start to

resuscitate whilst the other rescuer goes for help.

♦ If there is only one rescuer then the single rescuer should

resuscitate for approximately 1 minute before going for help. If
possible they should take the infant/child with them whilst
summoning help.

The exception to a lone rescuer performing CPR for 1 minute

before going for help is:

♦ In the case of a child who has a witnessed, sudden collapse or

has a known cardiac problem. The rescuer should leave the
child if they are alone and get help as soon as possible. The
reason for this is the collapse/cardiac arrest is likely to be due to
an arrhythmia and the child may need defibrillation. The quicker
help can be sought and a defibrillator is on route then the better
the chance of survival.

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 The Choking Child

Recognition of Foreign Body Airway Obstruction

ASSESS
SEVERITY

SIGNS OF SEVERE SIGNS OF MILD

AIRWAY AIRWAY
OBSTRUCTION OBSTRUCTION
Crying or verbal response to
questions
Unable to vocalise Loud cough
Quiet or silent cough
Unable to breathe
Able to breathe before
Cyanosis coughing
Reduced level of consciousness Fully responsive

TREATMENT TREATMENT
Encourage to cough- Do nothing
UNCONSCIOUS CONSCIOUS else

5 back blows Assess for ineffective

Open Airway 5 abdominal cough/deterioration
Give 5 breaths thrusts (for child
>1 year) or
Start CPR
5 chest thrust
(for child <1 year)

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Suspect Choking if:

♦ Witnessed event

♦ Sudden onset of coughing/choking

♦ There are no signs of illness for the cause of a collapse

♦ There are clues to the rescuer i.e. History of playing with small
items immediately prior to the onset of symptoms

Mild

The child is able to vocalise, cough.

If a child is coughing they should be encouraged to continue. No

physical intervention made by a rescuer is more effective than a
child’s own efforts to spontaneously cough and remove the object.
No intervention should be made unless the coughing becomes
quieter/ineffectual or the child loses consciousness.

A child with an obvious obstruction who is still breathing is still

breathing!!!

Any physical attempts to remove the object may cause a complete

airway obstruction.

Severe

Ineffective coughing, unable to vocalise, cyanosis and/or reduced

level of consciousness

Relief of a Foreign Body Airway Obstruction (FBAO)

The Conscious Infant

Always support the head in the neutral position to ensure the

airway is open. Put the infant in the head down position for all
manoeuvres as gravity can assist with the removal of a foreign
body.

Back Blows & Chest Thrusts

♦ Give up to 5 sharp back blows with the heel of the hand

between the shoulder blades. Check after each single blow as
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 the aim is to relieve the obstruction not to deliver all 5 blows if
they are not needed.

If 5 back blows are unsuccessful at removing the object and the

infant is still conscious then:

♦ Give up to 5 chest thrusts using the same land marking as for

chest compressions. The technique is sharper in nature than
chest compressions and delivered at a slower rate. Check after
each single thrust as the aim is to relieve the obstruction not to
deliver all 5 if they are not needed.

If the FBAO is not relieved and the infant is still conscious continue
to alternate between 5 back blows & 5 chest thrusts.

Do Not use the abdominal thrust (heimlich manoeuvre) in

infants as it may cause intra-abdominal injury.

The Conscious Child > 1 year

Try and position the child in the head down position over the
rescuers lap. If this is not possible support the child in a leaning
forward position.

♦ Give up to 5 sharp back blows with the heel of the hand

between the shoulder blades. Check after each single blow as
the aim is to relieve the obstruction not to deliver all 5 blows if
they are not needed.

If 5 back blows are not successful at removing the object and the
child is still conscious then:

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♦ Give up to 5 abdominal thrusts.

♦ Stand or kneel behind the child and place arms under the
child’s arms to encircle the torso. The rescuer should clench
their fists and place a fist between the umbilicus and
xiphisternum (tip of breastbone). The other hand should be put
over the fist and a sharp pull inwards and upwards should be
given. Ensure the pressure is not applied to the xiphoid process
or lower rib cage as this may cause abdominal trauma. Check
after each single manoeuvre as the aim is to relieve the
obstruction not to deliver all 5 thrusts if they are not needed.

If the FBAO is not relieved and the child is still conscious continue
to alternate between 5 back blows & 5 abdominal thrusts.

Note: If the object is expelled assess the child’s clinical condition. It

may be possible that part of the object is still in the respiratory
tract, if in doubt seek medical aid. Abdominal thrusts may cause
internal injuries and all victims should be examined by a medical
practitioner.

The Unconscious Infant & Child with FBAO

♦ Call for Help

♦ Open the airway and look for any obvious obstruction. If seen
make an attempt to remove it with a single finger sweep or
pinch it out. DO NOT attempt blind or repeated finger sweeps
as it may impact the object more deeply.

♦ Attempt to give 5 initial rescue breaths and then commence

CPR 15:2

♦ If the infant/child regains consciousness and is breathing

effectively put them in the recovery position.
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The Recovery Position

There is no set recovery position for children other than putting

them supported on their side and ensuring the airway is opened.

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Reference List

♦ Resuscitation Council (UK) (2010), Resuscitation Guidelines

2010, Paediatric Basic Life Support, London, Resuscitation
Council (UK).

Acknowledgements

♦ With grateful thanks from the Resuscitation Training

Department at Wirral Hospital NHS Trust to the Advanced Life
Support Group (ALSG) for use of images and photographs from
the Advanced Paediatric Life Support (APLS) Provider Course
teaching material (2005).

Note:

CPR Training is mandatory every 12 months for the majority

of staff with direct patient contact.

The Resuscitation Training Department would like to inform

staff that if they require extra training or advice outside of this
12 month period on airway equipment, defibrillators or pre
Advanced Life Support Course sessions etc… we will be more
than happy to arrange for you to come and see us.

You can do this by contacting a Resuscitation Officer on ext

2946/2671 or bleep

Lisa Delaney on 4480

or
Steve Bell on 4470
or
Gill Beasor on 2580

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