Those with a duty to respond to paediatric emergencies (usually healthcare professional teams) should use the following sequence:
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?’
3A. 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.
3B. If the child does not respond:
- Shout for help.
- Turn the child onto his back and open the airway using head tilt and chin lift:
- Place your hand on his forehead and gently tilt his head back.
- 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.
Have a low threshold for suspecting injury to the neck. If you suspect this, try to open the airway using jaw thrust alone. If this is unsuccessful, add head tilt gradually 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.
In the first few minutes after cardiac arrest a child may be taking infrequent, noisy gasps. Do not confuse this with normal breathing. Look, listen, and feel for no more than 10 seconds before deciding – if you have any doubts whether breathing is normal, act as if it is not normal.
5A. If the child IS breathing normally:
- Turn the child onto his side into the recovery position (see below).
- 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 normal breathing.
5B. If the breathing is NOT normal or absent:
- Carefully remove any obvious airway obstruction.
- Give 5 initial rescue breaths.
- Although rescue breaths are described here, it is common in healthcare environments to have access to bag-mask devices. Providers trained in their use should use them as soon as they are available.
- 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 life’, described below.
Rescue breaths for an infant:
- Ensure a neutral position of the head (as an infant’s head is usually flexed when supine, this may require some extension) and 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 1 second sufficient to make the chest rise visibly. This is the same time period as in adult practice.
- Maintain head position and chin lift, take your mouth away, and watch for his chest to fall as air comes out.
- Take another breath and repeat this sequence four more times.
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 lift.
- Take a breath and place your lips around his mouth, making sure that you have a good seal.
- Blow steadily into his mouth over 1 second sufficient to make the chest rise visibly.
- Maintaining head tilt and chin lift, take your mouth away and watch for his chest to fall as air comes out.
- Take another breath and repeat this sequence four more 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.
For both infants and children, 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. Assess the circulation (signs of life):
Take no more than 10 seconds to:
- Look for signs of life. These include any movement, coughing, or normal breathing (not abnormal gasps or infrequent, irregular breaths).
- If you check the pulse take no more than 10 seconds:
- In a child aged 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.
7A. If confident that you can detect signs of a circulation within 10 seconds:
- 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 starts breathing effectively but remains unconscious.
- Re-assess the child frequently.
7B. If there are no signs of life, unless you are CERTAIN that you can feel a definite pulse of greater than 60 min-1 within 10 seconds:
- Start chest compressions.
- Combine rescue breathing and chest compressions.
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 at least one-third of the depth of the chest, which is approximately 4 cm for an infant and 5 cm for a child.
- Release the pressure completely, then repeat at a rate of 100–120 min-1.
- Allow the chest to return to its resting position before starting the next compression.
- After 15 compressions, tilt the head, lift the chin, and give two effective breaths.
- Continue compressions and breaths in a ratio of 15:2.
The best method for compression varies slightly between infants and children.
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 (as above), 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, approximately 4 cm.
Chest compression in children aged over 1 year:
- Place the heel of one hand over the lower half of the sternum (as above).
- 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, approximately 5 cm.
- 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 (normal breathing, cough, movement or definite pulse of greater than 60 min-1).
- Further qualified help arrives.
- You become exhausted.
When to call for assistance
It is vital for rescuers to get help as quickly as possible when a child collapses:
- When more than one rescuer is available, one (or more) starts resuscitation while another goes for assistance.
- If only one rescuer is present, undertake resuscitation for about 1 min before going for assistance. To minimise interruptions in CPR, it may be possible to carry an infant or small child whilst summoning help.
- The only exception to performing 1 min of CPR before going for help is in the unlikely event of a child with a witnessed, sudden collapse when the rescuer is alone and primary cardiac arrest is suspected. In this situation, a shockable rhythm is likely and the child may need defibrillation. Seek help immediately if there is no one to go for you.
Reproduced with kind permission of Resuscitation Council UK from