Basic life support in childhood and early defibrillation
2005 guidelines
• ILCOR recommendations (International Liaison Committee on Resuscitation) • Consensus Conference, Dallas 2005 ➢ Study Groups ➢ Analysis Reports ➢ Tasks Force
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Guidelines
• Modifications based on scientific evidence to improve the effectiveness of resuscitation maneuvers • Simplification to facilitate learning and skill retention • Reduction of differences with adult guidelines to improve the timeliness and effectiveness of child rescue
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Objective To acquire • Theoretical knowledge • Practical skills • Patterns of behavior
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Structure • Theoretical lessons • Practical training with mannequins • Theoretical/practical final evaluation
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Objective of the PBLSD
Prevent anoxic brain damage In the subject in which one or more vital functions are compromised: • consciousness • respiratory activity • circulatory activity
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PBLSD
Includes • Accident prevention • Early recognition of respiratory and cardiac arrest • The timely and effective alarm • Breath and circulation support (RCP) • Early defibrillation • Recognition and treatment of foreign body airway obstruction
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The pediatric chain of survival Early warning
Accident prevention
Early RCP
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Early PALS
Early defibrillation
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Etiopathogenesis of cardiac arrest RESPIRATORY PATHOLOGY
CNS PATHOLOGY INTOXICATIONS
HEART DISEASE ARRHYTHMIA
SHOCK
CIRCULATORY INSUFFICIENCY
RESPIRATORY INSUFFICIENCY
BRADYCARDIA - ARRHYTHMIA
CARDIAC ARREST
PRIMARY cardiac arrest: RARE in pediatric age PBLSD course
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Pediatric patients
Infant under one year
Child from 1 year to puberty
The techniques differ according to the age of the child PBLSD course
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PBLSD Sequence of intervention
Airway
vie aeree
Breathing
respiro
Circulation
circolo
Defibrillation
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defibrillazione
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Environmental risk ASSESSMENT Environment
ACTION If danger move the victim
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A
Airway
ASSESSMENT State of consciousness
• Verbal and painful stimulus • Avoid trauma PBLSD course
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A
Airway ABSENT STATE OF CONSCIOUSNESS
ACTION
• CALL FAST: call for help without abandoning the victim and ask for the AED if older than 1 year • CALL FIRST: activate 118 immediately and ask for the AED if the child has heart disease and/or sudden collapse • Position the child • Establish a patent airway
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A
Airway patency
INFANT neutral position
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CHILD extension
Jaw thrust
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Oropharyngeal cannula: placement
A
Insertion without rotation in direct view
Tongue depressor or laryngoscope blade
Why • •
Reduce risk of damage to the palate Avoid airway obstruction by posterior tongue movement
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B
Breathing
ASSESSMENT Watch Listen Feel
• 10 seconds
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B
Breathing
ACTION BREATH PRESENT
BREATH ABSENT
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maintain a patent airway
•
possible safety position
5 rescue breaths
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Artificial ventilation WITHOUT additional means
INFANT mouth – mouth/nose
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B
CHILD mouth – mouth
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Artificial ventilation WITH additional means
mask
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B
mask – bag
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Percentages of oxygen in bag-mask ventilation • Bag • Bag + O2 (10-12 l/m) • Bag + O2 (10-12 l/m) + reservoir
B 40-60%
21% 80-90%
ADULT
CHILD
INFANT
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Breathing
B
Assessment of face mask size
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B
Breathing Hand placement to ensure ventilation C and E position
The C is formed by the thumb and forefinger The E is made up of the pinkie, the ring finger and the middle finger The E supports the jaw The C pushes the mask onto the face
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Breathing
B
Hand placement to ensure ventilation
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Ineffective ventilation and complications
•
Insufficient opening of the airways
•
Incomplete adherence
•
Insufflation too rapid or abrupt
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B
HYPOVENTILATION
GASTRIC DISTENSION PNEUMOTHORAX
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C
Circulation
ASSESSMENT Central pulse and vital signs (movements, respiratory activity, cough) CHILD carotid pulse
INFANT brachial pulse
• 10 seconds
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C
Circulation
ACTION PRESENT PULSE
ABSENT PULSE OR FC<60/MIN WITHOUT CIRCULATION SIGNS
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Artificial ventilation
•
20 breaths per minute
EXTERNAL CHEST COMPRESSIONS
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External chest compressions Landmark
C
UNIQUE TECHNIQUE FOR INFANTS AND CHILDREN
Lower half of the sternum Identify the meeting angle of the costal arch with the sternum and compress about 1-2 cm above this point
Why •
Reduce the risk of misplaced compressions
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C
External chest compressions
INFANT 2-finger technique 2-hand technique
CHILD 1-2 hand technique
COMPRESSION/VENTILATION RATIO 15:2 FREQUENCY 100 COMPRESSIONS PER MINUTE
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Ineffective chest compressions and complications
•
Compressions too intense or abrupt
•
Incorrect site
•
Compressions too superficial
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C
STERNAL, RIB FRACTURES, INJURY OF INTERNAL ORGANS
INSUFFICIENT CIRCULATION
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Early semi-automatic defibrillation Pediatric Basic Life Support - Early Defibrillation
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Semi-automatic external defibrillator (AED) Rational: • Primary cardiac arrest in children is less common than in adults • Ventricular fibrillation is rare, but under diagnosed in children compared to adults (7-15% of cases of cardiopulmonary arrest) • Among the most frequent causes of shockable rhythms: congenital heart disease, long QT syndrome, drug intoxication, hypothermia, trauma • Early defibrillation improves the outcome of these children
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Semi-automatic external defibrillator (AED) Rational: • In pediatric studies, shockable cardiac arrest treated with early defibrillation demonstrates good survival • The AEDs tested in adult and pediatric arrhythmia studies have shown high accuracy in rhythm analysis (near 100% specificity)
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Semi-automatic external defibrillator INDICATIONS • Child aged 1-8 years ✓ AED with energy deliverable at 50-75 J ✓ Adult AED if adapted AED is not available • Child aged > 8 years ✓ Adult AED • Infant
✗ AED not recommended
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AED and PBLS
The AED becomes an integral component of basic rescue performed by both healthcare and lay personnel Semi-automatic AED
Automatic AED
4-key AED: on, analyze, charge, shock
1-key AED: on
3-key AED: on, analyze, shock 2-key AED: on, shock
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Semi-automatic external defibrillator (AED) DELIVERABLE ENERGY • Child aged 1-8 years ✓ Mono-phasic or bio-phasic AED 50-75 Joule • Child aged > 8 years ✓ AED in children > di 8 years as in adults AED FOR ADULTS mono-phasic 360 J bio-phasic 150-200 J
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Manual defibrillators
• Plate position right subclavicular and left anterior axillary or left anterior parasternal and left subscapularis • Energy dose 4 J /Kg
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Semi-automatic external defibrillator OPERATING SEQUENCE • Turn on the device • Connect it to the patient • Activate rhythm analysis • Say the safety rhyme • Deliver shock if indicated • Alternate: 1 shock – 2 minutes of CPR – rhythm analysis
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PBLSD Intervention sequence Environmental risk assessment
A AIRWAY State of consciousness assessment If the child is unconscious
ACTIONS • call for help (call fast – call first) • ask for AED • place the child • establish a patent airway PBLSD course
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PBLSD Intervention sequence
B BREATHING Respiratory activity assessment WLF for 10 seconds The child is breathing
The child is NOT breathing
ACTION
ACTION
• security position • breath control
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• 5 rescue breaths
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X
PBLSD Intervention sequence
C CIRCULATION Central pulse and vital signs assessment for 10 seconds The child has a pulse
ACTION • 20 breaths per minute
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The child does NOT have a pulse or has FC <60/min without vital signs
ACTION • 15:2 ratio CPR
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PBLSD Intervention sequence Environmental risk assessment
A AIRWAY State of consciousness assessment If the infant is unconscious
ACTIONS • call for help (call fast – call first) • place the infant • establish a patent airway PBLSD course
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PBLSD Intervention sequence
B BREATHING Respiratory activity assessment WLF for 10 seconds The infant is breathing
The infant is NOT breathing
ACTION
ACTION
• security position • breath control
• 5 rescue breaths
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X
PBLSD Intervention sequence
C CIRCULATION Central pulse and vital signs assessment for 10 seconds The infant has a pulse
The infant does NOT have a pulse or has FC <60/min without vital signs
ACTION
ACTION
• 20 breaths per minute
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• 15:2 ratio CPR
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Revaluation • After the first minute of CPR 5 cycles ratio 15:2 Call 118 if you haven’t already • If AED is available rhythm control every 2 minutes • If AED is not available reappearance of vital signs arrival of advanced rescue physical exhaustion • If isolated respiratory arrest is present pulse check every minute
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Duration of resuscitation maneuvers Consider suspending CPR after 15-20 minutes of resuscitation with no clinical response Assess: • • • •
Reasons for arrest Pre-existing clinical conditions Untreated duration arrest (“no flow time”) Rescue intervention times (basic/advanced) and CPR effectiveness (“low flow time”) • Availability of specific treatment for particular causes (eg. toxics) Decision manager: team leader Important: operator debriefing immediately after the event PBLSD course
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Parental presence during CPR Parents want to be present during CPR For the parents: • Allows them to see that everything possible has been done In case of decease: • Improves grieving process • Reduces anxiety and depression For the health personnel: • Stimulates appropriate professional behavior • Helps to see the child as a whole
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Foreign body airway obstruction Pediatric Basic Life Support - Early Defibrillation
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Foreign body airway obstruction
Maximum incidence Object Degree of obstruction
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6 months – 2 years toys – food incomplete – complete
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Partial airway obstruction The child can cry, cough, talk
NO DESTRUCTION MANEUVER
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Encourage the child to cough and maintain the position it prefers
•
Give oxygen if possible
•
If dyspnoea persists, call 118 or take the child to the Emergency Room
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Complete airway obstruction The child is NOT able to cry, cough, speak Rapid cyanosis
DESTRUCTION MANEUVER
•
Sharp increase in intrathoracic pressure (ARTIFICIAL COUGH)
Immediately alert
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Complete airway obstruction CONSCIOUS INFANT
+ 5 BACK PATS
5 CHEST COMPRESSIONS
Continue until cleared or infant becomes unconscious
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Complete airway obstruction CONSCIOUS CHILD
+ 5 BACK PATS
5 SUBDIAPHRAMATIC COMPRESSIONS
Continue until cleared or until child becomes unconscious
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The infant/child becomes unconscious SEQUENCE • Place the patient on a hard surface • Alert 118 without abandoning the patient • Lift the tongue-jaw and perform digital emptying of the oral cavity (if a foreign body emerges) • Extend your head • Perform 5 ventilation attempts repositioning the head after each insufflation if ineffective • Start CPR without doing any other assessments • Perform 1 minute of CPR • Alert 118 if you haven’t already • Continue CPR pending advanced rescue
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Trauma AVOID SHARP MOVEMENTS IN ALL PHASE OF PBLS
Place the collar if available
Use the jaw thrust maneuver, not head tilt
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Do not use the recovery position
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2010 guidelines PEDIATRIC BLS • Prevention of arrest in childhood • ABC or CAB? • CPR quality
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Prevention of arrest FIRST LINK TO THE SURVIVAL CHAIN: unchanged since 2005 Main causes of death in childhood: •
In infants: congenital malformations, complications of prematurity, SIDS
•
In children > 1 years: traumas
Prevention: • • •
prevention of trauma and violence against children information campaigns on SIDS recognition and early treatment of the child’s hemodynamic instability
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ABC or CAB? The CAB sequence is also recommended for infants and children (except newborns) to streamline CPR training with the hope that more cardiac arrest victims will receive cardiopulmonary resuscitation
Motivations: •
Positioning the head and having to initiate ventilations delays the onset of compressions
•
It is not known whether starting ventilations or compressions makes a difference in survival
•
Starting with compressions (CAB) instead of ventilations (ABC) leads to a delay in ventilations of only about 18 seconds (if 1 rescuer only) or even less (if 2 rescuers)
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CPR quality
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Further deemphasis on wrist relief
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High quality chest compressions
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Depth of compressions
•
Frequency
•
Complete chest relaxation after each compression
•
Minimize interruptions in compressions
•
Avoid hyperventilation
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Chest compressions
• • • • •
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Compress the chest “hard and fast” at the rate of at least 100/m’ Lower the chest at least 1/3 of the anteroposterior diameter (4 cm in infants and 5 cm in children) Allow the chest to rise completely Minimize interruptions in compressions Avoid hyperventilation!
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Ventilations during CPR
• • •
Avoid hyperventialtion Deliver 1 breath over 1 second, controlling chest rise The routine use of cricoid pressure is no longer recommended
• • • •
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1 rescuer: 30:2 2 rescuers: 15:2 Respiratory arrest: 12-20 ventilations/m’ Intubated child: 8-10 ventilations/m’ (1 ogni 6-8”)
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Defibrillation with AED even in infants
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Prefer a manual defibrillator if possible
•
If not available, use pediatric or attenuator AEDs
•
If neither pediatric AEDs nor attenuator paddles are available, use adult AEDs and adult paddles
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Cardiac arrest algorithm
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The novelties of the cardiac arrest algorithm
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Defibrillation energies
•
ROSC: • Pulse • Pressure wave on intra-arterial monitoring • Elevation of PETCO2 on capnography/capnometry
•
Different algorithm for neonatal resuscitation
•
Advanced airway: intubation or supraglottic garrison
•
Nothing new compared to 2005 regarding the sequence
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Defibrillation
• • • • •
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Dimensions of the plates Interface Position Energy Automatic defibrillators
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Dimensions of the plates
• Adults (8-10 cm for b > 10 kg) • Infant size (< 10 kg) • Located below the adult ones in the manual defs • There are also “hands free” stickers • Same effectiveness • If possible, leave 3 cm between the plates or electrodes Unchanged since 2005
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Defibrillation energy
• The minimum effective dose and the upper safe limit for infants and children are not known • Biphasic shock as effective as mono-phasic and less harmful • It is acceptable to use an initial dose between 2 and 4 J/Kg (Class IIa. LOE C). For educational purposes it can be simplified to an initial dose of 2 J/Kg (Class IIb, LOE C). In refractory VF, a dose of 4 J/Kg (Class IIa, LOE C) which in subsequent shocks can be further increased without however exceeding 10J/Kg or the maximum adult dose (Class IIb, LOE C)
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Airway management: bag-mask ventilation •
Ventilation as effective and safe as intubation for short periods during pre-hospital resuscitation (class IIa, LOE B)
•
Use sufficient volume to give visible chest lift (class I, LOE C), avoid hyperventilation during arrest (class III, LOE C)
•
Cricoid pressure if a third rescuer is present, avoid excessive pressure on the trachea (class III,LOE B)
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Airway management •
Pediatric oropharyngeal and nasopharyngeal cannula: assicurarsi di avere scelto la misura corretta
•
AML: “when bag-mask ventilation is not effective and when tracheal intubation is not possible, AML is acceptable when used by experienced providers, to ensure a patent airway and ventilate” (class IIa, LOE C)
•
However, AML is associated with a higher incidence of complications in young children than in older children or adults
•
There are insufficient clinical studies to recommend other supraglottic devices in children other than AML
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