Basic life support in infants and children Author Pamela Bailey, MD Section Editor Susan B Torrey, MD Deputy Editor

James F Wiley, II, MD, MPH Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Nov 2013. | This topic last updated: ene 25, 2013. INTRODUCTION Early recognition and treatment of sudden cardiac arrest improve survival for children and adults [1-3]. Basic life support (BLS) involves a systematic approach to initialpatient assessment, activation of emergency medical services, and the initiation of cardiopulmonary resuscitation (CPR), including defibrillation. Key components of effective CPR include adequate ventilation and chest compressions. BLS can be performed by trained lay persons, as well as by healthcare providers. This topic will review BLS principles for healthcare providers. Basic airway management for children, neonatal resuscitation, and basic life support for adults is discussed separately. (See "Basic airway management in children" and "Neonatal resuscitation in the delivery room" and "Basic life support (BLS) in adults".) EPIDEMIOLOGY AND SURVIVAL Cardiopulmonary arrest among infants and children is typically caused by progressive tissue hypoxia and acidosis as the result of respiratory failureand/or shock [4]. Causes of respiratory failure and shock leading to cardiopulmonary arrest in these age groups include accidents, sudden infant death syndrome, respiratory distress, and sepsis [1,5-7]. This is in contrast to adults, for whom the most common cause of cardiac arrest is ischemic cardiovascular disease. (See "Basic life support (BLS) in adults", section on 'Epidemiology and survival'.) Overall survival rates vary between 4 and 40 percent for infants and children who have had out-ofhospital cardiopulmonary arrest [1,6-10]. Increased survival rates occur in pediatric patients who receive early CPR and those with an initial cardiac arrest rhythm of ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) [1,9,10]. For example, in one multicenter observation study of 78 children with out-of hospital cardiopulmonary arrest, 50 percent of children who received CPR within four minutes of arrest and 22 percent of children with an initial rhythm of VF or pVT survived compared with an overall survival rate of 14 percent [1]. In another observational study of 361 patients with cardiopulmonary arrests including 90 children younger than 14 years of age cared for by a regional emergency medical service agency, overall survival rate was 27 percent [9]. Survival was significantly improved in patients who had a witnessed arrest (OR 13.4), received bystander CPR (OR 3.2), and had an initial rhythm of VF or pVT (OR 9.4). Thus early recognition of cardiopulmonary arrest and prompt initiation of CPR are essential to successful resuscitation of children with cardiopulmonary arrest. Among children with in-hospital cardiopulmonary arrest, acute resuscitation survival approaches 78 percent and survival to discharge occurs in 39 to 48 percent of patients who receive cardiopulmonary resuscitation (CPR) [11,12]. In one multicenter observational study of 1031 children with in-hospital cardiopulmonary arrests occurring in academic pediatric hospitals over a 10 year period (2000 to 2009), adjusted survival to discharge increased from 14 to 43 percent while the rates of significant neurologic disability remained stable [12]. This improvement in survival occurred

despite a high prevalence of asystole and pulseless electrical activity (PEA) found as the initial arrest rhythm (up to 85 percent of patients) and was similar regardless of the initial cardiac arrest rhythm (ventricular fibrillation, pulseless ventricular tachycardia, asystole or PEA). The use of extracorporeal membrane oxygenation during resuscitation and postresuscitation care (ECPR) significantly increased from 8 to 14 percent of patients during the study but was not associated with overall survival to discharge. Thus, rates of survival from cardiopulmonary arrest are higher for in-hospital pediatric cardiopulmonary arrests than for out-of-hospital arrests and improved survival among children with in-hospital arrests cannot be attributed to differences in initial cardiac arrest rhythm or ability to perform ECPR. In contrast, if promptly treated, children with a respiratory arrest are much more likely to recover than those with a cardiopulmonary arrest [1,13]. As an example, in an observational study of 95 children with out-of-hospital arrest, 82 percent of children with respiratory arrest were alive at one year compared with 14 percent of patients with a cardiopulmonary arrest [1]. Thus, the best outcomes in critically ill children occur if cardiac arrest is avoided altogether. THE 2010 INTERNATIONAL RESUSCITATION GUIDELINES Based upon extensive review of clinical and laboratory evidence, the American Heart Association (AHA) and the International Liaison Committee on Resuscitation (ILCOR) published updated guidelines for pediatric basic life support (BLS) in 2010 [13-16]. For the purposes of these guidelines, a newborn is defined as from birth to hospital discharge, an infant is younger than one year of age, and a child is from one year to the start of puberty. The guidelines are designed to be simple, practical, and effective. Changes for infants and children from the previous basic life support guidelines of 2005 include new criteria for the initiation of CPR, compressions prior to airway and breathing for infants and children in cardiac arrest (CAB instead of ABC), and evidence-based reaffirmation of conventional cardiopulmonary resuscitation (CPR) as preferred to compression only CPR. The sequence for neonatal resuscitation is described separately (algorithm 1). (See "Neonatal resuscitation in the delivery room", section on 'Overview of resuscitative steps'.) BASIC LIFE SUPPORT SEQUENCE Before beginning basic life support (BLS), rescuers must ensure that the scene is safe for them and the victim (such as by removing the victim from a burning building). The next steps in BLS are activating emergency medical services (EMS), getting an automated external defibrillator (AED), and starting cardiopulmonary resuscitation (CPR). Activate EMS For activating EMS, the guidelines recommend the following in infants and children for healthcare providers [13-16]: For unwitnessed and witnessed cardiac arrests with two or more rescuers present, initiation of CPR, activation of the emergency response system, and getting an automated external defibrillator (AED) occur simultaneously. CPR should be performed for two minutes (five cycles) before using an AED in a patient with an unwitnessed arrest based on limited evidence in adults that even for prolonged arrest from ventricular fibrillation (VF), an initial period of CPR improves the likelihood of successful defibrillation. This approach is the same as for adults with cardiac arrest. (See "Basic life support (BLS) in adults", section on 'Phases of resuscitation'.) For the lone rescuer, the sequence varies:

If the cardiac arrest is witnessed, the lone rescuer should first activate the emergency response system, obtain an AED, and then start CPR. This approach is the same as for adults with cardiac arrest. (See "Basic life support (BLS) in adults", section on 'Phases of resuscitation'.) If the cardiac arrest is unwitnessed, the lone rescuer should first perform two minutes of CPR, activate the emergency response system, and then obtain an AED. CPR is recommended initially for infants and children with an unwitnessed cardiac arrest being cared for by a lone rescuer because most pediatric arrests are likely to be asphyxial. This approach differs from that recommended for adults. (See "Basic life support (BLS) in adults", section on 'Phases of resuscitation'.) Initiate CPR The actions that constitute cardiopulmonary resuscitation (CPR) are opening the airway, providing ventilations (rescue breaths), and performing chest compression. (See"Basic airway management in children", section on 'Noninvasive relief of obstruction' and 'Ventilation' below and 'Chest compressions' below.) The sequence in which the actions of CPR for infants and children should be performed by health care providers is as follows (algorithm 2): Initiate CPR in an infant or child who is unresponsive and not breathing (or only gasping) If there is no pulse or it is not definitively identified within 10 seconds, then start compressions BEFORE performing airway or breathing maneuvers After 30 compressions (15 compressions if two rescuers) open the airway and give two breaths (see 'Ventilation' below) If a definite pulse is found within 10 seconds, provide ventilation only If the pulse is 60 beats per minute (bpm), continue ventilation If the pulse is <60 bpm, add chest compressions to ventilation Substantial evidence indicates that healthcare providers are often unable to quickly determine whether or not a pulse is present [15]. Consequently, when a pulse is not definitely identified within 10 seconds, CPR should be initiated. High quality CPR focuses on the effective delivery of chest compressions and avoidance of excessive ventilation. (See 'Chest compressions' below.) VENTILATION Ventilations can be provided with mouth-to-mouth, mouth-to-nose, or with a bag and mask. (See "Basic airway management in children", section on 'Ventilation'.) Evidence in adults and animals suggest that hyperventilation is associated with increased intrathoracic pressure and decreased coronary and cerebral perfusion (see "Basic life support (BLS) in adults", section on 'Ventilations'). These data are the basis for the following recommendations [13,17]: Each rescue breath should be delivered over one second. The volume of each breath should be sufficient to see the chest wall rise. A child with a pulse 60 bpm who is not breathing should receive one breath every three to five seconds (12 to 20 breaths per minute). Infants and children who require chest compressions should receive two breaths per 30 chest compressions for a lone rescuer and two breaths per 15 chest compressions for two rescuers (see 'Compression to ventilation ratio' below).

Intubated infants and children should be ventilated at a rate of 8 to 10 breaths per minute without any interruption of chest compressions (see 'Compression to ventilation ratio' below). CHEST COMPRESSIONS The 2010 international resuscitation guidelines emphasize the importance of hard, fast chest compression, with full chest recoil and minimal interruptions [15]. Evidence in adults and animals suggest that these are the essential elements for effective chest compressions [18-20]. Chest compressions should be performed over the lower half of the sternum [13,15,21]. Compression of the xiphoid process can cause trauma to the liver, spleen, or stomach, and must be avoided. The effectiveness of compressions can be maximized by attention to the following: The chest should be depressed at least one-third of its anterior-posterior diameter with each compression (approximately 4 cm [1 inches] in most infants and 5 cm [2 inches] in most children). The optimum rate of compressions is approximately 100 per minute. Each compression and decompression phase should be of equal duration. The sternum should return briefly to its normal position at the end of each compression, allowing the chest to recoil fully. A smooth compression-decompression rhythm, with minimal interruption, should be developed. Infants Chest compressions for infants (younger than one year) may be performed with either two fingers or with the two thumb-encircling hands technique. No outcome studies have compared these two techniques in children with cardiac arrest [13,15,16]. Two fingers This technique is recommended by the American Heart Association when there is a single rescuer [13,16]. Compressions are performed with index and middle fingers, placed on the sternum just below the nipples (figure 1). Because of the infant's large occiput, slight neck extension and the placement of a hand or rolled towel beneath the upper thorax and shoulders may be necessary to ensure that the work of compression is focused on the heart [22]. Rescuer fatigue has been raised as a concern with this method and data are conflicting. In one randomized study of CPR on infant manikins by 16 experienced pediatric health care providers, rescuer fatigue did not significantly differ between the two finger and thumb encirclement techniques [23]. However, in a randomized crossover study of 20 healthcare providers that compared the two fingers versus the two thumb technique, the two thumb technique was associated with better compression depth, rate, and consistency than the two finger technique [24]. Providers also reported that the two thumb technique was less tiring and that performing compressions on a table rather than on the floor or in a radiant warmer was most comfortable. On the other hand, providers noted that the two finger technique permitted easier transition from compressions to ventilation and allowed the provider to maintain the head tilt during compressions which prevented the need for repositioning for ventilation when performing one-person infant CPR. Two thumb encircling hands The two thumb-encircling hands technique is suggested when there are two rescuers [13]. The thorax is encircled with both hands and cardiac compressions are performed with the thumbs (figure 2). The thumbs compress over the lower half of the sternum, avoiding the xiphoid process, while the fingers are spread around the thorax [13,16]. The following evidence supports the recommendation of the two thumb-encircling hands technique: In a pediatric animal model, arterial and coronary perfusion pressures were improved with circumferential compression [25].

In a similar study using an infant mannequin, the two-thumb method provided higher blood and perfusion pressures than the two-finger method [26]. A randomized trial compared the adequacy of compressions performed on an infant mannequin by healthcare providers using either the two-thumb or two-finger method [27]. Although 71 percent of participants failed to give a sufficient number of adequate compressions by either method, the depth of compression was significantly better using the two-thumb method. Children For children (from one year until the start of puberty), compressions should be performed over the lower half of the sternum with either the heel of one hand or with two hands, as for adult victims (picture 1 and picture 2). (See "Basic life support (BLS) in adults".) No outcome studies have compared these two techniques in children with cardiac arrest [15]. Evidence to support using two hands to perform chest compressions for children is limited. In a small randomized trial that compared the pressure generated by one and two handed compressions on a pediatric mannequin, significantly higher pressures were generated using two hands [28]. The two hand method for CPR has not been associated with increased rescuer fatigue versus the one hand method in randomized studies that used manikins [23,29]. However, the rate of compression slowed significantly more among emergency department staff who used the one hand method versus the two hand method (decrease of 7 versus 3 compressions per minute during one minute, respectively) [29]. COMPRESSION TO VENTILATION RATIO Chest compressions in infants and children should always be accompanied by ventilation for infants and children who remain pulseless after the initial sequence of compressions [13-16]. However, every effort should be made to avoid excessive ventilation and to limit interruptions of chest compressions to less than ten seconds. For lone rescuers, two ventilations should be delivered during a short pause at the end of every 30th compression. For two rescuers, two ventilations should be delivered at the end of every 15th compression. The compression to ventilation ratio for newborns is 3 to 1. (See "Neonatal resuscitation in the delivery room", section on 'Chest compressions'.) Once the trachea is intubated, ventilation and compression can be performed independently. For infants and children, ventilations are given at a rate of 8 to 10 per minute. Compressions are delivered at a rate of 100 per minute without pauses. Experimental evidence in animals indicates that coronary artery perfusion pressure declines with interruptions in chest compressions [19,20]. Observational reports suggest that long interruptions in CPR occur commonly [30,31]. Compression to ventilation ratios of 30 to 2 and 15 to 2 are recommended to minimize interruption and for ease of teaching and retention [14,15]. Coordination of compression and ventilation may be facilitated by counting compressions aloud or using an audio-prompted rate guide [32]. Conventional versus compression-only CPR We recommend that rescuers provide conventional CPR to infants and children with cardiac arrest, regardless of whether the arrest occurs within or outside of the hospital [14,15]. Although compression-only CPR (CO-CPR) for bystanders is suggested in limited situations in adults with cardiac arrest (see "Basic life support (BLS) in adults", section on 'Compression-only CPR (CO-CPR)'), conventional CPR is recommended in infants and children, because cardiac

arrest in this population is more commonly due to hypoxia when compared to adults [13-15]. (See 'Epidemiology and survival' above.) One nationwide, observational study of 5158 children 17 years of age, who had an out -of-hospital arrest, found that, among the children who suffered arrests from noncardiac causes, those who received conventional CPR were significantly more likely to have favorable neurologic outcomes at one month than those who received COO-CPR (7.2 versus 1.6 percent, OR 5.5; 95% CI 2.5-17.0) [8]. Neurologic outcomes were similar between conventional CPR and CO-CPR for children who suffered arrests from cardiac etiologies (10 versus 9 percent, OR 1.2; 95% CI 0.6-2.7). Favorable neurologic outcome was more common in patients who received bystander CPR compared to no CPR (5.1 versus 1.5 percent, OR 4.17, 95% CI: 2.4-7.3). Infants had poor outcomes regardless of the type of CPR received. Another observational study of 759 children sampled from the same national database also showed significantly improved survival and neurologically favorable survival at one month in children who received conventional CPR [33]. Since the cause of an arrest is not typically known in the out of hospital setting and the majority of pediatric arrests are due to noncardiac causes, the available evidence supports conventional CPR as the method that is associated with the best neurologic outcome in infants and children. AUTOMATED EXTERNAL DEFIBRILLATOR The 2010 international resuscitation guidelines recommend that, if a manual defibrillator is not available, an automated external defibrillator (AED) be used as soon as possible for infants and children who experience a witnessed cardiac arrest [13-16]. For patients with unwitnessed arrest, CPR should be performed for two minutes (five cycles) prior to using an AED (algorithm 2). For infants and children <8 years of age, an AED with a pediatric dose attenuating system should be used whenever possible. However, if a manual defibrillator or an AED with a pediatric dose attenuating system is not available, then use of an AED without a dose attenuator is advised [13,16]. AEDs are portable devices that have been used extensively to provide prompt defibrillation to adults in cardiac arrest. They are designed to be used by untrained bystanders and are increasingly available in public locations such as airports, athletic events, and the workplace. The device identifies rhythms that should be treated with defibrillation. It then instructs the operator how to use the device to deliver a standard shock to the patient. (See "Automated external defibrillators".) In observational series, 6 to 19 percent of infants and children in cardiac arrest had ventricular fibrillation (VF) as the initial rhythm, indicating that a substantial number of children in cardiac arrest might benefit from early defibrillation [1,6,7,34,35]. Limited evidence suggests that AEDs can be appropriately and safely used for infants and children [36-41]. The American Academy of Pediatrics recommends that lay rescuer AED programs (such as in schools) be implemented as part of comprehensive emergency response plans, rather than as programs focused on a single piece of equipment [42]. INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and Beyond the Basics. The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10 th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and the keyword(s) of interest.) Basics topic (see "Patient information: CPR for children (The Basics)") SUMMARY AND RECOMMENDATIONS Cardiopulmonary arrest among children is typically caused by progressive tissue hypoxia and acidosis as the result of respiratory failure and/or shock. Survival rates for children with cardiac arrest depend upon setting (outpatient versus inpatient arrest) and are improved by prompt initiation of cardiopulmonary resuscitation (CPR). (See 'Epidemiology and survival'above.) The American Heart Association (AHA) and the International Liaison Committee on Resuscitation (ILCOR) published updated guidelines for basic life support (BLS) and advanced cardiac life support (ACLS) in late 2010 (2010 guidelines). The most important elements of the BLS guidelines are included in the summary below. We suggest the practices described in the 2010 guidelines and summarized below be followed when providing BLS to patients (Grade 2C). Among the specific elements of the BLS guidelines, we recommend that infants and children with cardiac arrest receive conventional CPR rather than compressiononly CPR (Grade 1B). (See 'Conventional versus compression-only CPR' above.) The initial steps in the BLS sequence for infants and children are to initiate CPR and call for help (algorithm 2). Infants and children who have experienced an unwitnessed arrest should receive two minutes (five cycles) of CPR before an AED is used. (See 'Basic life support sequence' above.) A cardiac arrest is assumed in an infant or child who is unresponsive and not breathing (or with only gasping respirations) UNLESS a pulse is definitely identified within 10 seconds by a health care provider. (See 'Initiate CPR' above.) Chest compressions should be initiated BEFORE ventilation in infants and children with cardiac arrest. (See 'Initiate CPR' above.) Each chest compression should depress the chest by a minimum of one-third of its anteriorposterior diameter, at a rate of about 100 compressions per minute. The chest should fully recoil at the end of each compression. Interruptions in chest compressions should be minimal (less than 10 seconds). (See 'Chest compressions' above.) Ventilations should be delivered over one second with enough volume to see the chest wall rise. (See 'Ventilation' above.) The compression to ventilation ratio varies depending on the circumstance (see 'Compression to ventilation ratio' above): 30 compressions followed by two breaths for a lone rescuer 15 compressions followed by two breaths for two rescuers resuscitating an infant (<1 year of age) or child (1 year to start of puberty) Intubated infants and children should be ventilated at a rate of 8 to 10 breaths per minute without any interruption of chest compressions The compression to ventilation ratio for newborns is 3 to 1 (see "Neonatal resuscitation in the delivery room", section on 'Chest compressions') If a manual defibrillator is not available, an automated defibrillator (AED) should be used as soon as possible for all infants and children with a witnessed arrest. Those with unwitnessed arrest should receive CPR for two minutes (five cycles) before the AED is used. (See 'Automated external defibrillator' above.)

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