A young mother presents to the ED with a 6-

month-old boy who has had constant vomiting for

24 hours.

The infant is lying still and has poor muscle tone.
He is irritable if touched, and his cry is weak. There
are no abnormal airway sounds, retractions, or
flaring. He is pale and mottled. The respiratory rate
is 30 breaths/min, heart rate is 180 beats/min, and
blood pressure is 50 mm Hg/palp. Air movement is
normal and breath sounds are clear to
auscultation. The skin feels cool and capillary refill
time is 4 seconds. The brachial pulse is weak. His
abdomen is distended.
What
Have I To
do ?
Basic Life Support
Slide 4
S A F E
Shout for help
Aprroach with care
Free from danger
Evaluate ABC
Basic Life Support
Check for DANGER, stop and look
Check RESPONSE, verbal and
tactile but do not shake and shout
If conscious, assess carefully,
patient may still need urgent medical
review
Continue to assess and manage
Airway
Breathing
Circulation

Slide 7
D
R
A
B
C
Slide 8
Basic Life Support Flowchart
Check for DANGER
Check for RESPONSE
CONSCIOUS
Make comfortable
Observe ABC
UNCONSCIOUS
Alert assistance
Clear airway
Apply head tilt and jaw support
Check for breathing
NOT BREATHING
2 rescue breaths
Check for pulse
Look for signs of life
BREATHING
Lateral position
Observe ABC
INADEQUATE PULSE
No signs of life
Commence CPR
Slide 9
Basic Life Support Flowchart
Check for DANGER
Check for RESPONSE
CONSCIOUS
Make comfortable
Observe ABC
BREATHING
lateral position
Observe ABC
Slide 10
Basic Life Support Flowchart
Check for DANGER
Check for RESPONSE
INADEQUATE PULSE
No signs of life
Commence CPR
UNCONSCIOUS
Alert assistance
Clear airway, Apply head tilt and jaw support, Check for breathing
NOT BREATHING
2 rescue breaths
Check for pulse
Look for signs of life
Slide 11
Basic Life Support
Airway

Breathing

Circulation
Is The patient
able to
speak or cry ?

Airway Assessment
Slide 14
Observe for secretions and clear (suction)
Do not attempt a blind finger sweep
Open the airway
chin lift / jaw thrust
neutral position in infants
sniffing position in children


Small amounts of
secretions
will affect the airway
Always suction
under direct vision
using a Yankauer sucker

Slide 18
Airway Opening
Manoeuvres
Chin lift/head tilt
Infants
Neutral head position
with chin lift
Smaller children
Sniffing position
with chin lift
Slide 19
Airway Opening
Manoeuvres
Chin lift/head tilt

Older children/adults
Backward head tilt
with pistol grip
Slide 22
Airway Opening
Manoeuvres
Jaw thrust
Jaw thrust
Use when concerned re
cervical spine injury
May also facilitate
bag and mask ventilation
Slide 24
Foreign Body
Mild airway
obstruction
Effective Cough
Assess Severity
Severe airway
obstruction
Ineffective Cough
Unconscious
Call for
help
Commence
CPR
Conscious
Call for help
Give up to 5 back
blows
If not effective
Give up to 5 chest
thrusts
Encourage
coughing
Continue to check
victim until recovery
or deterioration
Call for help
Slide 25
Foreign Body
Assess Severity
Effective Cough
Mild airway
obstruction
Encourage coughing
Continue to check
victim until recovery or
deterioration
Call for help
Slide 26
Foreign Body
If there is an effective cough (mild
obstruction):
Encourage coughing
Continue to check victim until recovery or
deterioration
Call for help
Do not attempt any manoeuvres to remove
unless this is very easily done


Slide 27
Foreign Body
Assess Severity
Severe airway
obstruction
Ineffective Cough
Unconscious Conscious
Call for help
Commence CPR
Call for help
Give up to 5 back blows
If not effective
Give up to 5 chest
thrusts
Slide 28
Foreign Body
If there is an ineffective cough (severe
obstruction):
Unconscious
call for help, commence CPR
Conscious
call for help
give up to 5 back blows firm blows
between the shoulder blades using the heel
of the hand
Slide 29
Back blows infant

Back blows small child
Slide 30
Foreign Body
If 5 back blows unsuccessful:
Chest thrusts
identify same compression point as for CPR
give up to 5 chest thrusts
similar to compressions but sharper and delivered at a
slower rate
check to see if each thrust has relieved the airway
obstruction
Infant
place in a head down supine position across rescuers
thigh
Child/ older child / adult
may be placed in sitting or standing position
Note: this is not the same as a Heimlich
manouvere this manouvere is on the chest
Airway Adjuncts
Slide 32
Oropharyngeal Airways

Use: to keep the airway open in an unconscious patient
and to facilitate bag and mask ventilation
Use with caution
If airway is able to be
maintained with head
positioning and jaw support
dont use an oropharyngeal
airway
Use of oropharyngeal airways:
size is imperative measure
from centre of teeth/mouth
to angle of the jaw layed
across the face
In the infant and small child
insert the concave side over
the tongue under direct
vision. This avoids damage
to the palate

Slide 33
Oropharyngeal Airways

Potential problems:
Trauma
Obstruction
Illicit a gag reflex
causing
aspiration
Laryngospasm
Vagal response
Nasopharyngeal Airway
Slide 37
Basic Life Support
Airway

Breathing

Circulation
Evaluation of
Respiratory
Performance
Slide 39
Look, Listen & Feel
10 seconds
Breathing assessment
Respiratory Rate and Regularity
Level of Consciousness
Color of the Skin and Mucous
Membranes
Respiratory Mechanics

Within few minutes of non-breathing,
the patient will suffer irreversible
damage.
The etiology of CPA in pediatric is
asphyxial rather than cardiogenic.
Oxygen therapy is the most
important and initial treatments of
the sick child.

is the administration of
oxygen at concentrations
greater than that in ambient
air (21%).
Oxygen
therapy
The exchange of air between
the lungs and the
atmosphere so that oxygen
can be exchanged for
carbon dioxide in the alveoli
(the tiny air sacs in the
lungs).
Ventilation:

Initial assesment of the sick
child
Breathing
No
efective
breathing
Airway
Maintain
able
Un
maintain
able
Bag
mask
ventil
ation
NIPP
V
Intub
ation
s
oxyg
en
Airway
adjunct

Simple mask
partial rebreathing mask
low flow
oxygen mixes with entrained room air during
inspiration because the oxygen flow is less
than the patients inspiratory.
It deliver variable concentration of oxygen23%
to 80%.
nasal
cannula.
simple
oxygen mask.
high flow:

flow rate and reservoir capacity provide
adequate gas flow to meet the total inspired
flow requirements of the patient.
High-flow systems can reliably deliver either
low or high inspired oxygen concentrations.
nonrebreathing masks.
Venturi masks.
oxygen hoods
oxygen tents.
aspirationfsh.swf

Slide 53
Breathing
If breathing is absent or inadequate:
Give 2 rescue breaths allowing about 1
second per inspiration
Sufficient breath to achieve gentle rise
and fall of chest, this means
puffs for an infant
breaths for a child
full breaths for an older child/adult
Slide 54
Bag and Mask
Correct mask size: cover mouth and nose only
Holding the mask: C-grip
C
Slide 55
Bag and Mask
a few technicalities...
Mask size
Bridge of nose to cleft of chin and sufficiently wide to cover
mouth
If too big you may get an air leak and also potential damage
especially with pressure applied to the eyes
Self inflating bag
Connect to oxygen 10L/Min
Once reservoir bag full, delivering 95-100% oxygen
Pressure release valve prevents too high pressure
Self-inflating, so can be used to deliver room air
Slide 56
Self Inflating Bag Sizes

Child (500ml) 2.5 25kg

Preterm
Infant
(240ml)
<2.5kg
Adult
(1600ml)
>25kg
Slide 57
Checking Self Inflating Bags
Check that the self inflating bag compresses and
reinflates quickly and air is felt from patient outlet
Check the one way valve opens when self inflating
bag is compressed
Occlude patient outlet with hand and compress
bag, listen for the pressure release value to release
Take off oxygen reservoir bag and place over the
patient outlet. Inflate the reservoir bag checking for
holes
Bag mask ventilation

Bag to Mask Ventilation
Slide 61
Cricoid pressure:
Place two fingers on the level of the cricoid cartilage and
apply pressure (gently!)
Closes the oesophagus and straightens trachea
Dont release pressure until instructed or if
the patient actively vomits

Monitor the Effectiveness of
Ventilation
Monitor the Effectiveness of
Ventilation
Visible chest rise with each breath.
Oxygen saturation.
Heart rate.
Blood pressure.
Distal air entry.
Patient response.
Copyright 2000 American Heart Association
Circulation 2000;102:253I--290I-
Bag-mask ventilation for child victim
Contraindicated if
gag-reflex is intact

Higher success rate

Does NOT protect
from aspiration

Difficult to maintain
during transport

Slide 70
Basic Life Support
Airway

Breathing

Circulation
Color of skin and capillary refill
Strength of peripheral and
central pulses
Skin temperature
Obtain vascular access (set IV
lines)
Initiate volume replacement
Perform chest
compressions
Defibrillate or provide
synchronized cardioversion
Initiate drug therapy

PULSE Check
Take no more than 10
seconds
Cardiac output in infancy and childhood
largely depends on heart rate.
No scientific data has identified an absolute
heart rate at which chest compressions
should be initiated;
the recommendation to provide cardiac
compression for a heart rate <60 bpm
with signs of poor perfusion
Slide 74
Pulse Check
the smallprint
Do not check the pulse for longer than 10 seconds
Research has shown that pulse check is an unreliable indicator and
is now de-emphasised. Recommendation: health care personnel
may use pulse palpation in their assessment but valuable time
should not be wasted. If the patient shows no sign of life and a
pulse cannot be palpated in 10 seconds presume it to be absent!
Brachial is recommended in the infant as carotid pulse is
difficult to find and extension of the neck may compromise the
airway
Carotid pulse locate thyroid cartilage and feel to side, dont
feel too high due to the risk of inadvertently massaging the
carotid sinus, inducing bradycardia and hypotension

Locating and palpating carotid artery
pulse ( > 1 year)
Locating and palpating brachial pulse ( <
1 year)
75
Slide 76
Look for signs of life
No signs of life =
unconscious
unresponsive
not moving
not breathing normally
No signs of life commence external cardiac
compressions



Slide 77
Circulation
Assess for pulse
and signs of life

If no pulse,
inadequate pulse or
no signs of life

commence ECC
Slide 78

ECC is compression of the heart and
major vessels between the sternum and
vertebral column. This increases
intrathoracic pressure causing a pressure
gradient, resulting in blood flow

Patient should be on a hard surface
eg. cardiac board
Rhythmic action, equal time for
compression and relaxation
Aim for a rate of 100 compressions
per minute
Slide 79
CPR Ratio
CIRCULATION
Hand Position
Depth of
Compression
INFANT
1/3 depth of chest
OLDER
CHILD


30 compressions: 2 breaths
5 cycles / 2 min


SMALL
CHILD
Lower half of sternum
Ratio and Rate
1 rescuer
The ratio describes the number of compressions
in relation to breaths, the rate is the number
of compressions/breaths given per minute.
Ratio and Rate
2 rescuers
15: 2
5 cycles/min
30: 2
5 cycles/2 min
Slide 80
CPR Infant
Infant
Locate the lower half of the sternum
Two fingers one operator CPR
Two thumbs / two fingers if two operators
Ratio
Lone health care provider/ lay rescuer
30 compressions : 2 breaths (5 cycles per 2 minute)
Two health care providers
15 compressions : 2 breaths (5 cycles per 1
minute)
Aim for a rate of 100 compressions per
minute
Slide 81
CPR Infant
Finger/Thumb
position:
lower 1/2 of the sternum

Compression depth:
1/3 of the depth of the chest
Slide 82
CPR Ratio
CIRCULATION
Hand Position
Depth of
Compression
INFANT
1/3 depth of chest
OLDER
CHILD


30 compressions: 2 breaths
5 cycles / 2 min


SMALL
CHILD
Lower half of sternum
Ratio and Rate
1 rescuer
Ratio and Rate
2 rescuers
15: 2
5 cycles/min
30: 2
5 cycles/2 min
Slide 83
CPR Small Child
Child: Up to 8 years
Use the heel of one hand
Locate lower half of sternum
Ratio
Lone health care provider/ lay rescuer
30 compressions : 2 breaths (5 cycles per 2 minute)
Two health care providers
15 compressions : 2 breaths (5 cycles per 1 minute)
Aim for a rate of 100 compressions per minute




Slide 84
CPR Ratio
CIRCULATION
Hand Position
Depth of
Compression
INFANT
1/3 depth of chest
OLDER
CHILD


30 compressions: 2 breaths
5 cycles / 2 min


SMALL
CHILD
Lower half of sternum
Ratio and Rate
1 rescuer
Ratio and Rate
2 rescuers
15: 2
5 cycles/min
30: 2
5 cycles/2 min
Slide 85
CPR Older Child/Adult
Older child/adult i.e.>9years
Use two hands
Locate lower half of sternum
Ratio:
Lone health care provider/ lay rescuer or two
health care providers
30 compressions : 2 breaths (5 cycles per 2
minute)
Aim for a rate of 100 compressions per minute
Pressure is exerted through the heel of the hand,
with arm/s straight, using body weight as the
compression force
Slide 86
CPR
(Small and older child)
Compression depth: 1/3 of chest
CPR older child/ adult
1/3
CPR small child
Slide 87
CPR
ARC recommend minimum interruptions of
ECC and CPR should not be interrupted to
check for signs of life
Ineffective CPR:
too gentle
too slow
incorrect hand position
too many interruptions
Slide 88
Basic Life Support Flowchart
A last overview before we move to something else
Check for DANGER
Check for RESPONSE
CONSCIOUS
Make comfortable
Observe ABC
UNCONSCIOUS
Alert assistance
Clear airway
Apply head tilt and jaw support
Check for breathing
NOT BREATHING
2 rescue breaths
Check for pulse
Look for signs of life
BREATHING
Lateral position
Observe ABC
INADEQUATE PULSE
No signs of life
Commence CPR
CPR of the pediatric patient

89
90
PIJAT JANTUNG LUAR
Locating finger position for chest
compressions in infant (< 1 year)
Imagine a line drawn between the nipples
Place 2 fingers on sternum 1 fingers width below
line.
Depress - 1 in.
At least 100 per min
1 breath to every 5 compressions
92
Locating hand position for chest
compressions in child (> 1 year)
Use 2-3 fingers to locate lower margin of rib cage.
Follow rib margin to base of sternum (xiphoid
process)
Over 8 yr
Place other hand on top of hand on sternum
Depress 1 - 2 in
80-100 per min
2 breaths to every 15 compressions
93
1 ~ 8 yr
Use heel of one hand
Depress 1 1 in
100 per min
One-rescuer
1 breath to every 5 compressions
Two-rescuer
2 breaths to every 15 compressions
94
Airway obstruction
Back blow in infant
Heimlich maneuver with child standing (>
1 y)
Heimlich maneuver with child lying
Recovery position
95
Copyright 2000 American Heart Association
Circulation 2000;102:253I--290I-
Brachial pulse check in infant
Copyright 2000 American Heart Association
Circulation 2000;102:253I--290I-
Carotid pulse check in child
Pulse
Check
Compression
Location
Me
thod
Depth Rate
Vent
ratio
New
born

umbilical
1 Fg
below
mama
line
2 Fg or
2 th

chest
120/m
in
3:1
< 1
year
Brachial
1 Fg
below
mama line
2 Fg
1/3
chest
100/m
in
15:1
30:2

1-8
year
Carotid
lower
Sternum
Heel of
1 hd
1/3
100/m
in
15:1
30:2

>8
year
Carotid
lower
Sternum
2 hd 1/3
100/m
in
15:1
30:2
Circulation 2000;102:253I--290I-
One-hand chest compression
technique in child
After each compression
allow the chest to recoil
fully
because complete chest
reexpansion improves
blood flow into the heart
Foreign-Body Airway
Obstruction
(Choking)
Circulation 2000;102:253I--290I-
Infant back blows to relieve
complete FBAO
subdiaphragmatic abdominal
thrusts (Heimlich maneuver
Trauma Foreign body
Newborn

Head tilt,
Chin lift,
Jaw thrust
Suction
< 1 year
Head tilt,
Chin lift,
Jaw thrust
Back Blows,
Chest Thrust,
1-8 year
Head tilt,
Chin lift,
Jaw thrust
abdominal thrust
>8 year
Head tilt, chin
lift, Jaw thrust
abdominal thrust