Basic life support in infants and children
- Pamela Bailey, MD
Pamela Bailey, MD
- Assistant Professor
- Baylor College of Medicine
Early recognition and treatment of sudden cardiac arrest improve survival for children and adults [1-3]. Basic life support (BLS) involves a systematic approach to initial patient assessment, activation of emergency medical services, and the initiation of cardiopulmonary resuscitation (CPR), including defibrillation. Key components of effective CPR include adequate ventilation and chest compressions.
BLS can be performed by trained lay persons, as well as by healthcare providers. This topic will review BLS principles for healthcare providers. Basic airway management for children, neonatal resuscitation, and basic life support for adults is discussed separately. (See "Basic airway management in children" and "Neonatal resuscitation in the delivery room" and "Basic life support (BLS) in adults".)
EPIDEMIOLOGY AND SURVIVAL
Cardiopulmonary arrest among infants and children is typically caused by progressive tissue hypoxia and acidosis as the result of respiratory failure and/or shock . Causes of respiratory failure and shock leading to cardiopulmonary arrest in these age groups include accidents, sudden infant death syndrome, respiratory distress, and sepsis [1,5-7]. This is in contrast to adults, for whom the most common cause of cardiac arrest is ischemic cardiovascular disease. (See "Basic life support (BLS) in adults", section on 'Epidemiology and survival'.)
Overall survival rates vary between 4 and 40 percent for infants and children who have had out-of-hospital cardiopulmonary arrest [1,6-10]. Increased survival rates occur in pediatric patients who receive early CPR and those with an initial cardiac arrest rhythm of ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) [1,9,10]. For example, in one multicenter observation study of 78 children with out-of hospital cardiopulmonary arrest, 50 percent of children who received CPR within four minutes of arrest and 22 percent of children with an initial rhythm of VF or pVT survived compared with an overall survival rate of 14 percent . In another observational study of 361 patients with cardiopulmonary arrests including 90 children younger than 14 years of age cared for by a regional emergency medical service agency, overall survival rate was 27 percent . Survival was significantly improved in patients who had a witnessed arrest (OR 13.4), received bystander CPR (OR 3.2), and had an initial rhythm of VF or pVT (OR 9.4). Thus early recognition of cardiopulmonary arrest and prompt initiation of CPR are essential to successful resuscitation of children with cardiopulmonary arrest.
Among children with in-hospital cardiopulmonary arrest, acute resuscitation survival approaches 78 percent and survival to discharge occurs in 39 to 65 percent of patients who receive cardiopulmonary resuscitation (CPR) [11-13]. In one multicenter observational study of 1031 children with in-hospital cardiopulmonary arrests occurring in academic pediatric hospitals over a 10 year period (2000 to 2009), adjusted survival to discharge increased from 14 to 43 percent while the rates of significant neurologic disability remained stable . This improvement in survival occurred despite a high prevalence of asystole and pulseless electrical activity (PEA) found as the initial arrest rhythm (up to 85 percent of patients) and was similar regardless of the initial cardiac arrest rhythm (ventricular fibrillation, pulseless ventricular tachycardia, asystole or PEA). The use of extracorporeal membrane oxygenation during resuscitation and postresuscitation care (ECPR) significantly increased from 8 to 14 percent of patients during the study but was not associated with overall survival to discharge.
- López-Herce J, García C, Domínguez P, et al. Outcome of out-of-hospital cardiorespiratory arrest in children. Pediatr Emerg Care 2005; 21:807.
- Samson RA, Nadkarni VM, Meaney PA, et al. Outcomes of in-hospital ventricular fibrillation in children. N Engl J Med 2006; 354:2328.
- Vaillancourt C, Stiell IG, Canadian Cardiovascular Outcomes Research Team. Cardiac arrest care and emergency medical services in Canada. Can J Cardiol 2004; 20:1081.
- Young KD, Seidel JS. Pediatric cardiopulmonary resuscitation: a collective review. Ann Emerg Med 1999; 33:195.
- Schindler MB, Bohn D, Cox PN, et al. Outcome of out-of-hospital cardiac or respiratory arrest in children. N Engl J Med 1996; 335:1473.
- Young KD, Gausche-Hill M, McClung CD, Lewis RJ. A prospective, population-based study of the epidemiology and outcome of out-of-hospital pediatric cardiopulmonary arrest. Pediatrics 2004; 114:157.
- Herlitz J, Engdahl J, Svensson L, et al. Characteristics and outcome among children suffering from out of hospital cardiac arrest in Sweden. Resuscitation 2005; 64:37.
- Kitamura T, Iwami T, Kawamura T, et al. Conventional and chest-compression-only cardiopulmonary resuscitation by bystanders for children who have out-of-hospital cardiac arrests: a prospective, nationwide, population-based cohort study. Lancet 2010; 375:1347.
- Meyer L, Stubbs B, Fahrenbruch C, et al. Incidence, causes, and survival trends from cardiovascular-related sudden cardiac arrest in children and young adults 0 to 35 years of age: a 30-year review. Circulation 2012; 126:1363.
- Mitani Y, Ohta K, Yodoya N, et al. Public access defibrillation improved the outcome after out-of-hospital cardiac arrest in school-age children: a nationwide, population-based, Utstein registry study in Japan. Europace 2013; 15:1259.
- Knudson JD, Neish SR, Cabrera AG, et al. Prevalence and outcomes of pediatric in-hospital cardiopulmonary resuscitation in the United States: an analysis of the Kids' Inpatient Database*. Crit Care Med 2012; 40:2940.
- Girotra S, Spertus JA, Li Y, et al. Survival trends in pediatric in-hospital cardiac arrests: an analysis from Get With the Guidelines-Resuscitation. Circ Cardiovasc Qual Outcomes 2013; 6:42.
- Gupta P, Tang X, Gall CM, et al. Epidemiology and outcomes of in-hospital cardiac arrest in critically ill children across hospitals of varied center volume: A multi-center analysis. Resuscitation 2014; 85:1473.
- Berg MD, Schexnayder SM, Chameides L, et al. Part 13: pediatric basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S862.
- Kleinman ME, de Caen AR, Chameides L, et al. Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Pediatrics 2010; 126:e1261.
- Kleinman ME, de Caen AR, Chameides L, et al. Part 10: Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122:S466.
- Berg MD, Schexnayder SM, Chameides L, et al. Pediatric basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics 2010; 126:e1345.
- Maconochie IK, Bingham R. Paediatric resuscitation. BMJ 2014; 348:g1732.
- Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S876.
- Part 2: Adult Basic Life Support. Circulation 2005; II2:III5.
- Berg RA, Sanders AB, Kern KB, et al. Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest. Circulation 2001; 104:2465.
- Kern KB, Hilwig RW, Berg RA, et al. Importance of continuous chest compressions during cardiopulmonary resuscitation: improved outcome during a simulated single lay-rescuer scenario. Circulation 2002; 105:645.
- Finholt DA, Kettrick RG, Wagner HR, Swedlow DB. The heart is under the lower third of the sternum. Implications for external cardiac massage. Am J Dis Child 1986; 140:646.
- Ludwig, SL, Lavelle, JM. Resuscitation-Pediatric basic and advanced life support. In: Textbook of Pediatric Emergency Medicine, 5th, Fleisher, GR, Ludwig, S, Henretig, FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.3.
- Udassi JP, Udassi S, Theriaque DW, et al. Effect of alternative chest compression techniques in infant and child on rescuer performance. Pediatr Crit Care Med 2009; 10:328.
- Huynh TK, Hemway RJ, Perlman JM. The two-thumb technique using an elevated surface is preferable for teaching infant cardiopulmonary resuscitation. J Pediatr 2012; 161:658.
- Menegazzi JJ, Auble TE, Nicklas KA, et al. Two-thumb versus two-finger chest compression during CRP in a swine infant model of cardiac arrest. Ann Emerg Med 1993; 22:240.
- Dorfsman ML, Menegazzi JJ, Wadas RJ, Auble TE. Two-thumb vs. two-finger chest compression in an infant model of prolonged cardiopulmonary resuscitation. Acad Emerg Med 2000; 7:1077.
- Whitelaw CC, Slywka B, Goldsmith LJ. Comparison of a two-finger versus two-thumb method for chest compressions by healthcare providers in an infant mechanical model. Resuscitation 2000; 43:213.
- Stevenson AG, McGowan J, Evans AL, Graham CA. CPR for children: one hand or two? Resuscitation 2005; 64:205.
- Peska E, Kelly AM, Kerr D, Green D. One-handed versus two-handed chest compressions in paediatric cardio-pulmonary resuscitation. Resuscitation 2006; 71:65.
- Abella BS, Alvarado JP, Myklebust H, et al. Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest. JAMA 2005; 293:305.
- Wik L, Kramer-Johansen J, Myklebust H, et al. Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest. JAMA 2005; 293:299.
- Berg RA, Sanders AB, Milander M, et al. Efficacy of audio-prompted rate guidance in improving resuscitator performance of cardiopulmonary resuscitation on children. Acad Emerg Med 1994; 1:35.
- Ogawa T, Akahane M, Koike S, et al. Outcomes of chest compression only CPR versus conventional CPR conducted by lay people in patients with out of hospital cardiopulmonary arrest witnessed by bystanders: nationwide population based observational study. BMJ 2011; 342:c7106.
- Mogayzel C, Quan L, Graves JR, et al. Out-of-hospital ventricular fibrillation in children and adolescents: causes and outcomes. Ann Emerg Med 1995; 25:484.
- Smith BT, Rea TD, Eisenberg MS. Ventricular fibrillation in pediatric cardiac arrest. Acad Emerg Med 2006; 13:525.
- Cecchin F, Jorgenson DB, Berul CI, et al. Is arrhythmia detection by automatic external defibrillator accurate for children?: sensitivity and specificity of an automatic external defibrillator algorithm in 696 pediatric arrhythmias. Circulation 2001; 103:2483.
- Atkinson E, Mikysa B, Conway JA, et al. Specificity and sensitivity of automated external defibrillator rhythm analysis in infants and children. Ann Emerg Med 2003; 42:185.
- Atkins DL, Jorgenson DB. Attenuated pediatric electrode pads for automated external defibrillator use in children. Resuscitation 2005; 66:31.
- Jones P, Lodé N. Ventricular fibrillation and defibrillation. Arch Dis Child 2007; 92:916.
- Divekar A, Soni R. Successful parental use of an automated external defibrillator for an infant with long-QT syndrome. Pediatrics 2006; 118:e526.
- Bar-Cohen Y, Walsh EP, Love BA, Cecchin F. First appropriate use of automated external defibrillator in an infant. Resuscitation 2005; 67:135.
- Markenson D, Pyles L, Neish S, et al. Ventricular fibrillation and the use of automated external defibrillators on children. Pediatrics 2007; 120:e1368.
- EPIDEMIOLOGY AND SURVIVAL
- THE 2010 INTERNATIONAL RESUSCITATION GUIDELINES
- BASIC LIFE SUPPORT SEQUENCE
- Activate EMS
- Initiate CPR
- CHEST COMPRESSIONS
- - Two fingers
- - Two thumb encircling hands
- COMPRESSION TO VENTILATION RATIO
- Conventional versus compression-only CPR
- AUTOMATED EXTERNAL DEFIBRILLATOR
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS