Basic Life Support (BLS)

Question 1

Define infant and child.

Answer 1

Infant = < 1 year

Child = 1 yo - puberty

Question 2

What is the main cause of cardiorespiratory arrest in children and what is the critical step for management of cardiac arrest in children as a result?

Answer 2

Main cause of cardioresp arrest in children (even in adolescents) =

HYPOXIA

Critical step = OXYGEN delivery, rather than defibrillation

GIVE RESCUE BREATHS

Question 3

Describe the BLS Algorithm.

Answer 3

BLS

START WITH SSS –> ABC

1. SAFETY (to approach, free from danger)
2. STIMULATE
   
   • Are you alright?
   • hold head in place + shake arm
   • NEVER shake an infant
   • NB pre-verbal/ scared children will not reply meaninfully (may make sound or open eyes)
3. SHOUT for HELP!
4. A
   
   • airway opening manoeuvres - tongue may fall back and obstruct pharynx
     
     • HEAD TILT CHIN LIFT (may need to part lips gently, do not press chin too hard)
       
       • infant: NEUTRAL
       • child: sniffing the morning air)
     • JAW THRUST (C-spine injury suspected)
       
       • NB rest elbows on same surface as child’s head
       • can add head tilt if no C-spine issue
       • even in trauma A takes priority - MILS by an assistant + increasing head tilt applied by 1st rescuer
   • SUCTION if trache
   • NB let child adopt any position they like if conscious - best at maintaining own airway
   • assess success of airway opening manoeuvres w/ look/ listen/ feel
5. B
   
   • LOOK - movement of chest and abdo
     
     • LISTEN - for breath
       
       • FEEL - for breath
   • 5 RESCUE BREATHS
     
     • whilst maintaining head tilt chin lift
     • pinch nose shut in children
     • slow exhalation 1 second
     • not too vigorous - gastric inflation –> regurgitation –> aspiration
     • check that the chest rises
     • failure? –> readjust head tilt chin lift –> try jaw thrust –> consider foreign body
     • note any GAG/ COUGH response (signs of life)
6. C – not > 10 secs
   
   • Check for SIGNS of LIFE
     
     • NORMAL BREATHING (following on from B) - ineffective, gasping, obstructed, agonal breathing, do NOT count!
     • COUGHING/ GAGGING (in response to rescue breaths)
     • MOVEMENT (spontaneous)
   • Check PULSE
     
     • Child: neck (carotid), groin (femoral)
     • Infant: antecubital fossa (brachial), groin (femoral)
7. YES signs of life –> RECOVERY position
8. NO - CPR 15 chest compressions: 2 ventilations – IF:
   
   • NO signs of life
   • NO/ ? pulse (central)
   • PULSE < 60 bpm (+ no signs of life)
     
     • NB ‘unnecessary’ chest compressions are almost NEVER damaging
     • If in doubt, start compressions
     • pulse present but apnoeic –> continue exhaled air resuscitation but no compressions
9. Continue for 1 min (if alone - NB take child with you to a phone! OR ask another bystander to call LAS whilst you start CPR)
10. Call emergency services

Question 4

When should EMS (emergency medical services) be activated FIRST in the case of a lone rescuer BEFORE 1 min of CPR has been given? Why?

Answer 4

BLS

LONE RESCUER

WHEN TO CALL EMS FIRST

Witnessed sudden collapse with:

1. NO apparent preceding morbidity
2. KNOWN CARDIAC condition (in the absence of another known/ supsected cause of arrest)

WHY:

• these cardiac arrests may be caused by arrhythmias
• early defibrillation (by EMS/ in hospital) can be life saving
• NB AED’s (automatic external defibrillators) in public also helpful in these cases

VS.

• majority of cardioresp arrest in children due to hypoxia
• where oxygenation and initial rescue breaths are more likely to be life saving

Question 5

Should the blind finger sweep technique be used in children for removal of foreign body? Why/ why not?

Answer 5

NO.

Do NOT use blind finger sweep technique for removal of foreign body in children.

WHY:

• soft palate easily damaged causing bleeding into the mouth
• can force foreign bodies further down the airway e.g. below vocal cords, making them harder to remove

Question 6

What are agonal gasps?

Answer 6

Irregular, infrequent breaths.

Does not constitute effective breathing.

Question 7

Describe how to give effective chest compressions.

Answer 7

CHEST COMPRESSIONS

• Lie flat on back on hard surface (backboard on hospital bed)
• Hands on the lower half of the sternum
• Take care not to press the xiphisternum into the abdomen (hands too low)
• Technique:
  
  • Infants (<1 yo):
    
    • 2 rescuers: 2 thumbs = hand encircling technique with both thumbs over lower half of sternum (other rescuer airway Mx)
    • 1 rescuer: 2 fingers method
  • Child:
    
    • one hand: heel of hand, vertically above child’s chest, arm straught
    • two hands (larger child, small rescuer): both hands w/ fingers interlocked
• Depress 1/3 of the depth of the chest
  
  • infant: 4 cm
  • child: 5cm
• Allow full recoil of chest wall (allows coronary arteries to fill)
• only interrupt chest compression for ventilation - unless child moves or takes a breath (pauses in compression reduce coronary perfusion pressure to 0 –> several compressions needed before adequate coronary perfusion recurs)
• 100-120 bpm (staying alive/ baby shark)
• HARD & FAST
• 15:2 (compressions: ventilations)
• once intubated, asynchronous compressions w/ 10-12 breaths per min ventilation rate
• change rescuers every 2 mins
• biometric devices can be used to give feedback on adequacy of compressions in older children (do not use if application delays compressions)

Question 8

Describe the recovery position and how to put the child in such a position.

Answer 8

RECOVER POSITION

• Stable lateral position
• Ensures
  
  • Open airway maintained
  • Free drainage of fluid from mouth
  • C-spine secured
  • Pressure points attended to
  • Allows access for monitoring + Mx
• Technique:
  
  • kneel next to victim
  • straighten legs
  • arm nearest to you - bent at right angle, palm up
  • bring far arm across the chest whilst keeping back of their hand against the cheek nearest to you
  • with your other hand grab their leg just above the knee and bend it, keeping their foot on the ground
  • holding them like this pull them towards you
  • adjust the leg to make sure hip and knee are at right angles
  • tilt the head back to keep the airway open
  • make sure the head is tilted and facing downwards (adjust the hand under the cheek as necessary)
  • check breathing regularly
  • turn to the opposite side in 30 mins if still needs to be in recovery position (to relieve pressure on the lower arm)

Question 9

What changes to the BLS algorithm are made for lay rescuers and why?

Answer 9

Compression: ventilation ratio

30:2

As in adults

Ideally give 5 rescue breaths but not if averse

Simplified to encourage bystander CPR as this is associated with better neurological outcome.

Question 10

Is there a risk of infection when performing BLS? What kind of risks are there and how can this be mitigated?

Answer 10

BLS & INFECTION RISK

• Few reports of transmission of infectious Dz from casualty to rescuer during mouth to mouth resus
• Main risks
  
  • meningococcus –> take rifampicin/ cipro
  • TB –> take prophylaxis
  • HIV –> negligible risk in non trauma situation
• Greater risk in
  
  • trauma
  • contact with
    
    • blood / visible blood in body secretions
    • semen/ vaginal secretions / amniotic fluid
    • CSF
    • pleural fluid
    • peritoneal fluid
• Low risk fluids
  
  • sputum
  • saliva
  • sweat
  • tears
  • urine
  • vomit
• Mitigate risk - wear a resus mask
• No benefit from porous materials e.g. gauze over the mouth

Question 11

In what age group do the majority of deaths from FBAO (foreign body airway obstruction) occur? What is the most common agent?

Answer 11

Pre-school children.

Foodstuffs.

Question 12

When should the diagnosis of FBAO (foreign body airway obstruction) be suspected?

Answer 12

FBAO

Foreign Body Airway Obstruction

Suspect when:

• SUDDEN resp compromise

+

• COUGHING
• GAGGING
• STRIDOR

Question 13

When should children with suspect airway obstruction be taken to hospital urgently?

Answer 13

Suspected airway obstruction

Take to hospital urgently when:

• ? Infectious cause e.g. croup, epiglottitis
• Cause unclear (but still breathing)

Question 14

What are the only situations in which the algorithm for FBAO (foreign body airway obstruction) should be followed?

Answer 14

FBAO ALGORITHM

ONLY FOLLOW WHEN:

1. Clear cut diagnosis
   
   • witnessed or strongly suspected
   • • ineffective coughing
   • • increasing SOB / apnoea/ LOC
2. Apnoeic child + head tilt/ chin lift and jaw thrust have failed (consider foreign body at this stage)

Question 15

What manoeuvre should NOT be done in cases where FBAO (foreign body airway obstruction) is suspected?

Answer 15

FBAO

Do NOT perform blind fingers sweeps as this may:

• push the foreign body further into the airway
• damage soft tissues causing bleeding

i.e. only remove an easily visible and accessible foreign body

Question 16

Describe the management of the choking child.

Answer 16

CHOKING CHILD

1. Foreign body easily accessible and visible –> remove
2. Assess cough
   
   • EFFECTIVE - able to:
     
     • Speak/ Cry
     • Breathe (b/w coughs)
   • INEFFECTIVE - ONLY in these situations should intervention be made
     
     • UNABLE to
       
       • speak/ cry
       • breathe (b/w coughs)
     • OR change to
       
       • Cough becoming quieter/ silent
       • Cyanosis
       • Apnoea
       • LOC
3. Encourage EFFECTIVE cough if present
   
   • most effective way to relieve an obstruction
4. INEFFECTIVE COUGH
   
   • UNCONSCIOUS –> BLS
     
     1. call for help
     2. flat surface
     3. open mouth and remove FB if visible
     4. airway opening manouvres
     5. 5 RESCUE BREATHS - reposition the airway w/ each breath if no chest rise
     6. CPR 15:2 (even if rescue breaths ineffective)
     7. continue for 1 min
     8. call EMS
   • CONSCIOUS –> 5 + 5
     
     1. 5 BACK BLOWS
     2. 5 CHEST/ ABDO THRUSTS
        
        • Infants
          
          • NOT abdo thrust - injury
          • head down
          • along the L arm, resting on the L thigh (or in the lap if larger)
          • hold the jaw open (neutral position) with the L hand
          • heel of hand
          • 5 back blows b/w shoulder blades
          • turn over
          • sharp chest thrusts
          • 2 fingers
          • same spot as compression, 1 / second
        • Children
          
          • sit leaning forward
          • hold the chin and open mouth with L hand
          • back blows (smaller child same as infants)
          • Abdo thrust = Heimlich
          • standing or lying
          • standing = kneel behind child
          • form a fist
          • below xiphisternum, above umbilicus
          • other hand over
          • thrust upwards into abdo x5
          • lying = kneel beside or astride
          • heel of hand in same place
          • link hands
          • thrust upward into abdo in midline
          • avoid pressure + trauma to xiphisternum/ lower rib cage
          • assess for abdo injury
     3. examine mouth for FB every time breath is attempted
     4. remove if FB visible
     5. REPEAT
     6. FB removed
     7. is BLS needed?
        
        • Ventilate if
          
          • moving/ gagging
          • NOT breathing
        • Ventilate + Compressions if
          
          • no signs of life
     8. If BLS not needed –> Recovery position
     9. Monitor regularly