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Protocol for paediatric basic life support

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

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The UK Resuscitation Council has adopted the European Resuscitation Council Guidelines (1). Important changes with respect to these Paediatric Basic Life Support (BLS) guidelines are:

Summary of changes in paediatric basic life support since the 2010 Guidelines

  • duration of delivering a breath is about 1 second, to coincide with adult practice
  • for chest compressions, the lower sternum should be depressed by at least one third the anterior-posterior diameter of the chest, or by 4 cm for the infant and 5 cm for the child

Summary Protocol:

  • recognition of cardiac arrest
    • determining need for CPR depends on the presence of ‘signs of life’ (response to stimuli, normal breathing (rather than abnormal gasps) or spontaneous movement)
    • palpation of the pulse is not the sole determinant of CPR as palpation of pulse for 10s is not a reliable measurement of presence of absence of effective circulation, and if pulse is palpated, CPR should be only withheld if there is a ‘definite pulse’ in the absence of other signs of life.
    • decision to start CPR should be arrived at within 10s of starting evaluation
  • compression:ventilation ratios
    • 3:1 at birth (although the best ratio for use in neonates outside of the delivery room is
    • CPR delay is more dangerous for child than an adult, and bystanders should be encouraged to perform at least chest compression only CPR in asphyxial arrest
  • chest compression quality
    • data suggests that chest compression is frequently too shallow adults and older children
    • chest compressions should be ‘at least 1/3rd of the anterioposterior diameter of the chest wall’. This corresponds to 4cm and 5cm in infants and children respectively
    • post-mortem studies have shown that physical damage following CPR in children was very rare
  • automated electrical defibrillators in infants
    • evidence now favors the use of an AED (preferably with an attenuator) in infants with shockable rhythms
    • but the occurrence of shockable rhythm in children under the age of 1 is rare and emphasis is on good quality CPR.

Modifications from Adults CPR

  • give 5 initial rescue breaths before starting chest compression
  • if you are on your own, perform CPR for 1 min before going for help.
  • compress the chest by at least one-third of its depth. Use two fingers for an infant under 1 year; use one or two hands for a child over 1 year as needed to achieve an adequate depth of compression.

The following is the sequence that should be followed by healthcare professionals with a duty to respond to paediatric emergencies:

1) Ensure the safety of rescuer and child.

2) Check the child’s responsiveness:

  • Gently stimulate the child and ask loudly, ‘Are you all right?’
  • Do not shake infants, or children with suspected cervical spine injuries

3 A) If the child responds by answering or moving:

  • leave the child in the position in which you find him (provided he is not in further danger
  • check his condition and get help if needed
  • reassess him regularly

3 B) If the child does not respond:

  • shout for help
  • turn the child onto his back and open the child’s airway by tilting the head and lifting the chin:
    • Place your hand on his forehead and gently tilt his head back
    • At the same time, with your fingertip(s) under the point of the child’s chin, lift the chin. Do not push on the soft tissues under the chin as this may block the airway
    • If you still have difficulty in opening the airway, try the jaw thrust method: place the first two fingers of each hand behind each side of the child’s mandible (jaw bone) and push the jaw forward. Both methods may be easier if the child is turned carefully onto his back
  • If you suspect that there may have been an injury to the neck, try to open the airway using chin lift or jaw thrust alone. If this is unsuccessful, add head tilt a small amount at a time until the airway is open. Establishing an open airway takes priority over concerns about the cervical spine.

4) Keeping the airway open, look, listen, and feel for normal breathing by putting your face close to the child’s face and looking along the chest:

  • look for chest movements
  • listen at the child’s nose and mouth for breath sounds
  • feel for air movement on your cheek
    • look, listen, and feel for no more than 10 sec before deciding that breathing is absent
    • if you have any doubts whether breathing is normal, act as if it is not normal

5 A) If the child is breathing normally:

  • turn the child onto his side into the recovery position
  • send or go for help – call the relevant emergency number. Only leave the child if no other way of obtaining help is possible.
  • check for continued breathing

5 B) If the child is not breathing or is making agonal gasps (infrequent, irregular breaths):

  • carefully remove any obvious airway obstruction
  • give 5 initial rescue breaths
  • while performing the rescue breaths note any gag or cough response to your action. These responses, or their absence, will form part of your assessment of ‘signs of a circulation’
  • rescue breaths for a child over 1 year:
    • ensure head tilt and chin lift
    • pinch the soft part of his nose closed with the index finger and thumb of your hand on his forehead
    • open his mouth a little, but maintain the chin upwards
    • take a breath and place your lips around his mouth, making sure that you have a good seal
    • blow steadily into his mouth over about 1 sec watching for chest rise
    • maintaining head tilt and chin lift, take your mouth away from the victim and watch for his chest to fall as air comes out
    • Take another breath and repeat this sequence 5 times. Identify effectiveness by seeing that the child’s chest has risen and fallen in a similar fashion to the movement produced by a normal breath
  • rescue breaths for an infant:
    • ensure a neutral position of the head and (as an infant’s head is usually flexed when supine, this may require some extension)apply chin lift
    • take a breath and cover the mouth and nasal apertures of the infant with your mouth, making sure you have a good seal. If the nose and mouth cannot both be covered in the older infant, the rescuer may attempt to seal only the infant’s nose or mouth with his mouth (if the nose is used, close the lips to prevent air escape)
    • blow steadily into the infant’s mouth and nose over 1sec sufficient to make the chest visibly rise
    • maintain head tilt and chin lift, take your mouth away from the victim, and watch for his chest to fall as air comes out
    • take another breath and repeat this sequence 5 times
  • if you have difficulty achieving an effective breath, the airway may be obstructed:
    • open the child’s mouth and remove any visible obstruction. Do not perform a blind finger sweep
    • ensure that there is adequate head tilt and chin lift but also that the neck is not over extended.
    • if head tilt and chin lift has not opened the airway, try the jaw thrust method.
    • make up to 5 attempts to achieve effective breaths. If still unsuccessful, move on to chest compression

6) Check for signs of a circulation (signs of life): Take no more than 10 sec to:

  • look for signs of a circulation. These include any movement, coughing, or normal breathing (not agonal gasps - these are infrequent, irregular breaths)
  • check the pulse (if you are trained and experienced) but ensure you take no more than 10 sec to do this:
  • in a child over 1 year — feel for the carotid pulse in the neck
  • in an infant — feel for the brachial pulse on the inner aspect of the upper arm
  • for both infants and children the femoral pulse in the groin (mid way between the anterior superior iliac spine and the symphysis pubis) can also be used.

7 A) If you are confident that you can detect signs of a circulation within 10 sec:

  • continue rescue breathing, if necessary, until the child starts breathing effectively on his own
  • turn the child onto his side (into the recovery position) if he remains unconscious
  • re-assess the child frequently

7 B) If there are no signs of a circulation, or no pulse, or a slow pulse (less than 60 per minute with poor perfusion), or you are not sure:

  • start chest compression.
  • combine rescue breathing and chest compression.
  • for all children, compress the lower half of the sternum:
    • to avoid compressing the upper abdomen, locate the xiphisternum by finding the angle where the lowest ribs join in the middle. Compress the sternum one finger’s breadth above this
    • compression should be sufficient to depress the sternum by approximately one-third of the depth of the chest.
    • don’t be afraid to push too hard. Push “hard and fast”.
    • release the pressure, then repeat at a rate of about 100 - 120 per minute.
    • after 15 compressions, tilt the head, lift the chin, and give two effective breaths
    • continue compressions and breaths in a ratio of 15:2. Lone rescuers may use a ratio of 30:2, particularly if they are having difficulty with the transition between compression and ventilation
  • chest compression in infants:
    • the lone rescuer should compress the sternum with the tips of two fingers
    • if there are two or more rescuers, use the encircling technique:
      • place both thumbs flat, side by side, on the lower half of the sternum, with the tips pointing towards the infant’s head
      • spread the rest of both hands, with the fingers together, to encircle the lower part of the infant’s rib cage with the tips of the fingers supporting the infant’s back
      • press down on the lower sternum with your two thumbs to depress it at least one-third of the depth of the infant’s chest
  • chest compression in children over 1 year:
    • place the heel of one hand over the lower half of the sternum
    • lift the fingers to ensure that pressure is not applied over the child’s ribs
    • position yourself vertically above the victim’s chest and, with your arm straight, compress the sternum to depress it by at least one- third of the depth of the chest
    • in larger children, or for small rescuers, this may be achieved most easily by using both hands with the fingers interlocked

8 ) Continue resuscitation until:

  • the child shows signs of life (spontaneous respiration, pulse, movement)
  • further qualified help arrives
  • you become exhausted


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