Cardiopulmonary Resuscitation for Healthcare Providers

CLINICAL GUIDELINES

All healthcare providers who are properly trained may perform cardiopulmonary resuscitation (CPR), including bag-mask ventilation and use of automated external defibrillators (AEDs).
CPR, or basic life support, is indicated in any situation in which breathing, heartbeat, or both are absent [Table 25-1).
CPR must be initiated in all children who do not have a “do not resuscitate” (DNR) order.
Newborn resuscitation program guidelines are appropriate for newborns in the first hour after birth or at any time during the initial hospital admission (this time period could extend for a few days to months after the birth).
Infant CPR guidelines are appropriate for victims younger than approximately 1 year of age.
Child CPR guidelines are appropriate for victims from about 1 year of age to the onset of adolescence or puberty (about 12 to 14 years of age); the size of the child should be taken into consideration when deciding whether to use adult or child CPR techniques. Institution policy may designate the use of Pediatric Advanced Life Support (PALS) guidelines to pediatric patients of all ages (generally up to about 16 to 18 years of age).
For the purposes of this procedure, the term “child” is used to represent all newborn/infant/child CPR guidelines that are applicable to all three age groups. If guidelines are specific to a specific age group, this is so indicated by use of the term newborns, infants, or children (>1 year old).
Age-appropriate resuscitation equipment should remain easily accessible in all areas of the healthcare facility where pediatric patients may be seen or treated.

CHILD AND FAMILY ASSESSMENT AND PREPARATION

The PALS guidelines support the option of family presence during resuscitation. A person on the rescue team has a discussion with family members to determine how they would like to be involved and whether they want to be in the area in which the resuscitation efforts are being conducted.
Assess the family’s emotional needs and ensure support from an assigned volunteer, social worker, nurse, or chaplain. The patient’s family should be that support person’s sole focus (Chart 25-1).
Maintain frequent communication with the family during this stressful time and allow the family to be with the child, regardless of the outcome of the resuscitation efforts.
Children identified by the healthcare providers as at-risk for respiratory or cardiac should be placed on a unit where access to resuscitation equipment and trained resuscitation personnel is immediately available.

TABLE 25-1 Basic Life Support Maneuvers by Healthcare Providers for Children, Infants, and Newborns

		Child (Lay Rescuers: 1-8 Years; HCP: 1 Year to Adolescence)	Infant (<1 Year of Age)	Newborn (First Hour of Life or at Any Time During the Initial Hospital Admission)
Activate		Activate after performing five cycles of CPR. For sudden witnessed collapse, activate after verifying the victim is unresponsive	Same as child	Same as child
CPR sequence		CAB	CAB	ABC
Circulation
	Pulse check (<10 seconds) Compression landmarks Compression method Push hard and fast Allow complete recoil Compression depth Compression rate Compression-ventilation ratio	Carotid or femoral Center of chest, between nipples Two hands: heel of one hand, with second hand on top One hand: heel of one hand only Approximately one third the anterior-posterior dimension of the chest (about 2 in or 5 cm) Approximately 100/minute One rescuer: 30:2 Layperson: compression only Two HCP rescuers: 15:2	Brachial or femoral Just below nipple line (lower half of sternum) One rescuer: two or three fingers Two rescuers: two-thumb-encircling hands The anterior-posterior dimension of the chest (about 1.5 in or 4 cm) Same as child Same as child	Same as infant Lower half of sternum between the nipples Two-thumb-encircling hands To one third of the depth of the chest Approximately 90/minute 3:1 (90 compressions and 30 breaths to achieve 120 events/minute)
Airway		Head-tilt/chin-lift. Suspected trauma, use jaw-thrust	Same as child	Head-tilt/chin-lift; checking airway remains first step in CPR sequence
Breathing
	Initial Rescue breathing without chest compressions Ventilations during CPR with advanced airway Foreign-body airway obstruction	Two effective breaths at 1 second/breath 12-20 breaths/minute (approximately 1 breath every 3-5 seconds) 8-10 breaths/minute (approximately 1 breath every 6-8 seconds) Abdominal thrusts	Same as child Same as child Same as child Back slaps and chest thrusts	Same as child 40-60 breaths/minute 30 breaths/minute If meconium present, perform endotracheal suctioning immediately after birth only on infants who are not vigorous (strong respiratory efforts, good muscle tone, and heart rate)
Defibrillation
	AED	Use pediatric system for child 1-8 years old if available. Use adult system for child >8 years of age Provide one shock immediately followed by CPR Attach and use AED as soon as available Minimize interruptions in chest compression before and after shock	No recommendation for infants <1 year of age	No recommendation for newborns
ABC, airway breathing circulation; AED, automatic external defibrillator; CAB, circulation, airway breathing; CPR, cardiopulmonary resuscitation; HCP, healthcare provider. From Travers, A., Rea, T., Bobrow, B., et al. (2010). Part 4: CPR overview: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 122(suppl 3), S677. (Level I)

CHART 25-1 Responsibilities of Support Staff Assigned to the Family During Resuscitation

Discuss with family how they would like to be involved and whether they want to be present in the resuscitation room.
Make final determination about family member’s ability to be present without interference to healthcare interventions or danger to themselves (e.g., fainting).
Establish boundaries or limits related to family member presence.
Ensure that all communication with the family from the healthcare team goes through the support staff person.
If family members choose not to be present, support person provides ongoing updates of child’s status to the family.
Provide anticipatory guidance to the family in regard to general atmosphere, medical equipment, procedures, etc.
Assist in debriefing the family after the resuscitation efforts are completed, whether successful or not.

PROCEDURE
Assessing the Child

Steps	Rationale/Points of Emphasis
1 Assess child’s ability to respond. Gently tap the child on the shoulder to arouse him or her and loudly call for help.	Determine whether the child is sleeping or unconscious and in need of assistance. These actions may startle a conscious child.
2 If the child is unresponsive and you are alone, start CPR immediately, continue for 2 minutes, and then call for help.	In adults, starting compressions immediately has been demonstrated to have more positive outcomes. The CAB sequence is recommended for children by the AHA in order to simplify training.
If there are two rescuers, one should start CPR immediately and the other should activate the emergency medical system and obtain an AED if available.
3a If child is in respiratory distress, allow the child to remain in a position that is of most comfort.	Children in respiratory distress often position themselves in a manner that opens the airway and allows the best ventilation for the child.
3b For the child that will require chest compressions, place the child on a firm, flat surface, in a horizontal supine position, turning the body as a whole unit.	The child must be on his or her back for the rescuer to perform CPR. It is important to prevent movement of the head and neck when positioning the infant/child to prevent aggravation of possible neck injuries. A firm, flat surface is optimal for facilitating proper compression of the chest.
3c If it is necessary to transport the newborn or infant in which trauma is not suspected, support the head and back with your hand and forearm. Keep your arm positioned so that the newborn’s/infant’s head is not above the feet.	The supine position facilitates blood flow to the brain.
4a For child or infant CPR sequence initiate CAB: Circulation, Airway, Breathing (go to Procedure: Managing Circulation).	Asphyxial cardiac arrest is more common than ventricular fibrillation (VF) arrest in children. However it is not known if the sequencing of ABC or CAB makes any difference in the outcomes for children. The AHA has selected to employ CAB sequencing with infants and children to maintain consistency in training. Neonates continue to use ABC sequencing because VF cardiac arrest is rarely the cause of cardiopulmonary deterioration.
4b For newborn/neonate CPR sequence initiate ABC: Airway, Breathing, Circulation (go to Procedure: Managing the Airway).

PROCEDURE
Assessing the Child

Steps		Rationale/Points of Emphasis
1 Check the pulse for no longer than 10 seconds.
1a The brachial pulse (located on the inside of the upper arm between the elbow and shoulder) or femoral artery is used to check pulse in newborns and infants (Figure 25-1).		Newborns/infants have short necks, making it difficult to palpate the carotid artery; thus, the brachial artery is used.
1b The carotid artery (located on the side of the neck between the trachea and the sternocleidomastoid muscles) is used to check pulse in children (>1 year old) (Figure 25-2).		The carotid pulse is the most accessible pulse to find in children (>1 year old). Many healthcare providers palpate the femoral pulse in both infants and children in the hospital setting.
Figure 25-1 Palpating brachial pulse in an infant.		Figure 25-2 Palpating carotid pulse in a child.
2 If the pulse is present and the respirations are absent, give a breath at a rate of approximately 40-60 breaths/minute for newborns and at a rate of 12-20 breaths/minute for the infant and child (>1 year of age) as long as necessary.		Without breathing, the child will not be oxygenated, and his or her heart will soon stop. It is very important to maintain oxygenation to prevent cardiac arrest and decrease oxygen perfusion to the brain and other vital organs. This breathing rate is adequate for short-term oxygenation.
3 If there is no pulse, you are uncertain a pulse is present, or the pulse is less than 60 beats/minute with signs of poor perfusion, begin chest compressions.		If you are uncertain if a pulse is present and the child is not breathing, it is better to start chest compressions than omit them. Compressions provide blood to the vital organs, including the lungs and brain.
3a Neonatal resuscitation should begin if the heart rate is 60 beats/minute or less for more than 30 seconds despite adequate ventilation with supplementary oxygen for 30 seconds and stopped when the heart rate is >60 beats/minute.		Prompt treatment of asphyxia can prevent tissue hypoxia, acidosis, poor cardiac function, and cardiac arrest.
3b Place the child on a firm, flat surface.		Facilitates the effectiveness of compressions.
3c Children (>1 year old) with no signs of circulation should be placed on an AED or cardiac monitor/defibrillator/pacer if available.		Children (>1 year old) are at greater risk of cardiac arrhythmia as the primary cause of cardiopulmonary arrest.
4 FOR NEWBORN: Perform chest compressions (Figure 25-3A) after Airway and Breathing sequence of CPR is complete.
Figure 25-3 Locating proper finger position for cardiac compressions on newborn (A) and infant (B).
4a The two-thumb-encircling hands technique should be implemented to perform compressions. Place both thumbs side by side on the lower third of sternum and encircle the chest with your hands. Press straight down to a depth of one third the depth (anterior-posterior diameter) of the chest.		Proper placement facilitates adequate cardiac output and minimizes chances for injuries to the sternum and ribs. The chest of a newborn is smaller and more flexible than that of adults and does not require as much pressure to compress.
		caREminder
		Data show that the two-thumb-encircling hands technique is recommended because this technique can provide better blood flow than two-finger compressions. Compression with two fingers just below the nipple line with a second hand supporting the back may be used.
4b Release the pressure and allow the chest to expand fully.		Allows the heart time to refill.
4c Keep fingers in contact with the chest.		Maintains proper positioning and minimizes injury to the sternum and ribs.
4d Give rescue breaths at a 3:1 compression-ventilation ratio (30 breaths/minute) (see Procedure: Managing the Airway and Procedure: Implementing Rescue Breathing). Each breath should take 2 seconds for inspiration in newborns, with exhalation occurring during the first compression after each ventilation.		Provides oxygen to the newborn.
4e Watch for normal chest rise while delivering a breath.		Ensures adequate ventilation of the newborn.
4f Compression rate is 90/minute for newborns.		Provides perfusion to vital organs.
4g After 1 minute of CPR or 120 events (90 compressions and 30 breaths), stop for 5 seconds to recheck the pulse.		Determines whether there is a pulse present or if you need to continue CPR.
4h Call for help if alone.		The sooner the child can receive further treatment, the better are his or her chances of recovery.
4i If you must leave the child to get help, position the child on his or her side if there is no evidence of neck or back injury.		Prevents aspiration and helps keep the airway open.
4j Once calling for help has been initiated, if there is still not a pulse present, resume 3:1 cycles in newborn of compressions and ventilations.		Allows for oxygenation and ventilation at the proper ratios to maintain optimal recovery.
4k Repeat pulse check every few minutes and then continue CPR as indicated.		Determines resumption of spontaneous breathing and circulation and whether you need to continue CPR.
5 FOR INFANT: Perform infant chest compressions as the first step of the CPR sequencing, and before Airway and Breathing sequencing (CAB).
5a For one rescuer, compress with two fingers just below the intermammary line (lower half of the sternum). Press straight down to at least one third of the chest (about 1.5 in or 4 cm) (Figure 25-3B).		Proper placement facilitates adequate cardiac output and minimizes chances for injuries to the sternum and ribs. The chest of an infant is smaller and more flexible than that of adults and does not require as much pressure to compress.
5b For two rescuers, the two-thumb-encircling hands technique should be implemented to perform compressions. Place both thumbs side by side on the lower half of sternum between the nipples and encircle the chest with your hands.		Most effective method of providing cardiac output.
5c Release the pressure and allow the chest to expand fully.		Allows the heart time to refill.
5d Keep fingers in contact with the chest.		Maintains proper positioning and minimizes injury to the sternum and ribs.
5e Deliver 30 compressions. Compression rate is 100/minute for infant.		Provides perfusion to vital organs.
5f Open the airway and give two rescue breaths (see Procedure: Managing the Airway and Procedure: Implementing Rescue Breathing). Each breath should take 1 second for inspiration (8-10 breaths/minute) in infants.		Provides oxygen to the newborn.
5g Watch for normal chest rise while delivering a breath.		Ensures adequate ventilation of the infant.
5h After 2 minutes of CPR, stop to recheck the pulse and rotate the compressor role. This switch and pulse check should be accomplished quickly (ideally less than 5 seconds).		Rotating the compressor role is recommended to minimize rescuer fatigue that may lead to inadequate compressions rate, depth, and recoil.
5i After 2 minutes of compressions the lone rescuer may leave the child to activate the emergency medical system.		The sooner the child can receive further treatment, the better are his or her chances of recovery.
5j If you must leave the child to get help, position the child on his or her side if there is no evidence of neck or back injury.		Prevents aspiration and helps keep the airway open.
5k Once calling for help has been initiated, if there is still not a pulse present, resume 30:2 (single rescuer) or 15:2 (two rescuers) cycle of compressions and ventilations and continue this cycle until other rescuers arrive or the child starts to breathe spontaneously.		Allows for oxygenation and ventilation at the proper ratios to maintain optimal recovery.
6 FOR CHILD: Perform child (>1 year old) chest compressions as the first step of the CPR sequencing, and before Airway and Breathing sequencing (CAB) (Figure 25-4). Figure 25-4 Locating proper hand placement for cardiac compression on a child.
6a Place the heel of one hand over the lower half of the sternum between the nipples. Avoid compressing the xiphoid process.		Proper placement facilitates adequate cardiac output and minimizes chances for injuries to the sternum and ribs.
6b Press straight down to a depth of at least one third of the anterior-posterior dimension of the chest (about 2 in or 5 cm).		The chest of a child is smaller and more flexible than that of an adult and does not require as much pressure to compress.
6c Complete steps 5c through 5i. These steps are the same for the infant and the child.		Allow chest to recoil after each compression to allow the heart to refill with blood.
7 Automated external defibrillation may be used in the treatment of cardiac arrest in children 1-8 years old. For children 8 years of age and older, immediately provide defibrillation with an adult-dosage AED or manual defibrillation if VF is indicated.
The universal steps to operate an AED are as follows:
7a Turn on the power to the AED.		Pediatric VF may be more common than previously suspected. Early defibrillation of VF and pulseless ventricular tachycardia (VT) are important and highly successful treatment measures. For a lone rescuer responding to a child without signs of circulation, provision of 1 minute of CPR is still recommended before any other action such as activating EMS or attaching the AED.
7b Select the appropriate age-specific electrode pads. Children 1-8 years of age use pediatric pads, children >8 years of age use adult pads and dosage.		Use an AED specifically designed for defibrillation of young children and infants or an attenuated adult-dosage AED tested for efficacy and safety in children depending on which device is available first.
7c Attach the AED to the child’s chest using the age-appropriate electrode pads. For most children <8 years of age, place one pad on the child’s chest between the nipples and the other pad on the child’s back between the shoulder blades. For children >8 years place one pad on the right upper chest toward the middle and one pad in the left side of the chest, just below and to the side of the left breast.		Pediatric attenuator systems (e.g., pad-cable systems or a key), will reduce the delivered energy to a dose suitable for children.
7d Analyze the rhythm.
7e Shock if indicated.
	i. Recommended manual defibrillation (mono-phasic or biphasic) doses are 2 J/kg for the first attempt and 4 J/kg for subsequent attempts.	Biphasic shocks with an automated external defibrillator (AED) are acceptable for children 1 year of age. Attenuated shocks using child cables or activation of a key or switch are recommended in children <8 years old.
7f If “no shock indicated” or “no shock advised” check for circulation.
	i. If circulation present, check for breathing. If breathing is inadequate, assist breathing. If breathing is present, place the child in the recovery position, but leave AED attached to the child. ii. If no circulation, resume CPR for 2 minutes and then recheck for signs of circulation. If no circulation present, analyze the rhythm and shock if indicated.
8 Maintain ongoing resuscitation efforts as directed by the healthcare prescriber (see Procedure: Stabilization of the Child).		Ongoing assessments and interventions will likely be necessary to ensure optimal health outcomes for the child.