Part 11: Pediatric Basic Life Support
2005; Lippincott Williams & Wilkins; Volume: 112; Issue: 24_supplement Linguagem: Inglês
10.1161/circulationaha.105.166572
ISSN1524-4539
Tópico(s)Emergency and Acute Care Studies
ResumoHomeCirculationVol. 112, No. 24_supplementPart 11: Pediatric Basic Life Support Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBPart 11: Pediatric Basic Life Support Originally published28 Nov 2005https://doi.org/10.1161/CIRCULATIONAHA.105.166572Circulation. 2005;112:IV-156–IV-166Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: November 28, 2005: Previous Version 1 For best survival and quality of life, pediatric basic life support (BLS) should be part of a community effort that includes prevention, basic CPR, prompt access to the emergency medical services (EMS) system, and prompt pediatric advanced life support (PALS). These 4 links form the American Heart Association (AHA) pediatric Chain of Survival (Figure 1). The first 3 links constitute pediatric BLS. Download figureDownload PowerPointFigure 1. Pediatric Chain of Survival.Rapid and effective bystander CPR is associated with successful return of spontaneous circulation and neurologically intact survival in children.1,2 The greatest impact occurs in respiratory arrest,3 in which neurologically intact survival rates of >70% are possible,4–6 and in ventricular fibrillation (VF), in which survival rates of 30% have been documented.7 But only 2% to 10% of all children who develop out-of-hospital cardiac arrest survive, and most are neurologically devastated.7–13 Part of the disparity is that bystander CPR is provided for less than half of the victims of out-of-hospital arrest.8,11,14 Some studies show that survival and neurologic outcome can be improved with prompt CPR.6,15–17Prevention of Cardiopulmonary ArrestThe major causes of death in infants and children are respiratory failure, sudden infant death syndrome (SIDS), sepsis, neurologic diseases, and injuries.18InjuriesInjuries, the leading cause of death in children and young adults, cause more childhood deaths than all other causes combined.18 Many injuries are preventable. The most common fatal childhood injuries amenable to prevention are motor vehicle passenger injuries, pedestrian injuries, bicycle injuries, drowning, burns, and firearm injuries.19Motor Vehicle InjuriesMotor vehicle–related injuries account for nearly half of all pediatric deaths in the United States.18 Contributing factors include failure to use proper passenger restraints, inexperienced adolescent drivers, and alcohol.Appropriate restraints include properly installed, rear-facing infant seats for infants <20 pounds (<9 kg) and <1 year of age, child restraints for children 1 to 4 years of age, and booster seats with seat belts for children 4 to 7 years of age.20 The lifesaving benefit of air bags for older children and adults far outweighs their risk. Most pediatric air bag–related fatalities occur when children 80%.24BurnsApproximately 80% of fire-related and burn-related deaths result from house fires and smoke inhalation.25,26 Smoke detectors are the most effective way to prevent deaths and injuries; 70% of deaths occur in homes without functioning smoke alarms.27Firearm InjuriesThe United States has the highest firearm-related injury rate of any industrialized nation—more than twice that of any other country.28 The highest number of deaths is in adolescents and young adults, but firearm injuries are more likely to be fatal in young children.29 The presence of a gun in the home is associated with an increased likelihood of adolescent30,31 and adult suicides or homicides.32 Although overall firearm-related deaths declined from 1995 to 2002, firearm homicide remains the leading cause of death among African-American adolescents and young adults.18Sudden Infant Death SyndromeSIDS is "the sudden death of an infant under 1 year of age, which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history."33 The peak incidence of SIDs occurs in infants 2 to 4 months of age.34 The etiology of SIDS remains unknown, but risk factors include prone sleeping position, sleeping on a soft surface,35–37 and second-hand smoke.38,39 The incidence of SIDS has declined 40%40 since the "Back to Sleep" public education campaign was introduced in the United States in 1992. This campaign aims to educate parents about placing an infant on the back rather than the abdomen or side to sleep.DrowningDrowning is the second major cause of death from unintentional injury in children <5 years of age and the third major cause of death in adolescents. Most young children drown after falling into swimming pools while unsupervised; adolescents more commonly drown in lakes and rivers while swimming or boating. Drowning can be prevented by installing isolation fencing around swimming pools (gates should be self-closing and self-latching)41 and wearing personal flotation devices (life jackets) while in, around, or on water.The BLS Sequence for Infants and ChildrenFor the purposes of these guidelines, an "infant" is less than approximately 1 year of age. This section does not deal with newborn infants (see Part 13: "Neonatal Resuscitation Guidelines"). For lay rescuers the "child" BLS guidelines should be applied when performing CPR for a child from about 1 year of age to about 8 years of age. For a healthcare provider, the pediatric ("child") guidelines apply from about 1 year to about the start of puberty. For an explanation of the differences in etiology of arrest and elaboration of the differences in the recommended sequence for lay rescuer and healthcare provider CPR for infants, children, and adults, see Part 3: "Overview of CPR."These guidelines delineate a series of skills as a sequence of distinct steps, but they are often performed simultaneously (eg, starting CPR and activating the EMS system), especially when more than one rescuer is present. This sequence is depicted in the Pediatric Healthcare Provider BLS Algorithm (Figure 2). The numbers listed with the headings below refer to the corresponding box in that algorithm. Download figureDownload PowerPointFigure 2. Pediatric Healthcare Provider BLS Algorithm. Note that the boxes bordered by dotted lines are performed by healthcare providers and not by lay rescuers.Safety of Rescuer and VictimAlways make sure that the area is safe for you and the victim. Move a victim only to ensure the victim's safety. Although exposure to a victim while providing CPR carries a theoretical risk of infectious disease transmission, the risk is very low.42Check for Response (Box 1)Gently tap the victim and ask loudly, "Are you okay?" Call the child's name if you know it.Look for movement. If the child is responsive, he or she will answer or move. Quickly check to see if the child has any injuries or needs medical assistance. If necessary, leave the child to phone EMS, but return quickly and recheck the child's condition frequently. Children with respiratory distress often assume a position that maintains airway patency and optimizes ventilation. Allow the child with respiratory distress to remain in a position that is most comfortable.If the child is unresponsive and is not moving, shout for help and start CPR. If you are alone, continue CPR for 5 cycles (about 2 minutes). One cycle of CPR for the lone rescuer is 30 compressions and 2 breaths (see below). Then activate the EMS system and get an automated external defibrillator (AED) (see below). If you are alone and there is no evidence of trauma, you may carry a small child with you to the telephone. The EMS dispatcher can guide you through the steps of CPR. If a second rescuer is present, that rescuer should immediately activate the EMS system and get an AED (if the child is 1 year of age or older) while you continue CPR. If you suspect trauma, the second rescuer may assist by stabilizing the child's cervical spine (see below). If the child must be moved for safety reasons, support the head and body to minimize turning, bending, or twisting of the head and neck.Activate the EMS System and Get the AED (Box 2)If the arrest is witnessed and sudden2,7,43 (eg, an athlete who collapses on the playing field), a lone healthcare provider should activate the EMS system (by telephoning 911 in most locales) and get an AED (if the child is 1 year of age or older) before starting CPR. It would be ideal for the lone lay rescuer who witnesses the sudden collapse of a child to also activate the EMS system and get an AED and return to the child to begin CPR and use the AED. But for simplicity of lay rescuer education it is acceptable for the lone lay rescuer to provide about 5 cycles (about 2 minutes) of CPR for any infant or child victim before leaving to phone 911 and get an AED (if appropriate). This sequence may be tailored for some learners (eg, the mother of a child at high risk for a sudden arrhythmia). If two rescuers are present, one rescuer should begin CPR while the other rescuer activates the EMS system and gets the AED.Position the VictimIf the victim is unresponsive, make sure that the victim is in a supine (face up) position on a flat, hard surface, such as a sturdy table, the floor, or the ground. If you must turn the victim, minimize turning or twisting of the head and neck.Open the Airway and Check Breathing (Box 3)In an unresponsive infant or child, the tongue may obstruct the airway, so the rescuer should open the airway.44–47Open the Airway: Lay RescuerIf you are a lay rescuer, open the airway using a head tilt–chin lift maneuver for both injured and noninjured victims (Class IIa). The jaw thrust is no longer recommended for lay rescuers because it is difficult to learn and perform, is often not an effective way to open the airway, and may cause spinal movement (Class IIb).Open the Airway: Healthcare ProviderA healthcare provider should use the head tilt–chin lift maneuver to open the airway of a victim without evidence of head or neck trauma.Approximately 2% of all victims with blunt trauma requiring spinal imaging in an emergency department have a spinal injury. This risk is tripled if the victim has craniofacial injury,48 a Glasgow Coma Scale score of 50%.Pulse Check (for Healthcare Providers) (Box 5)If you are a healthcare provider, you should try to palpate a pulse (brachial in an infant and carotid or femoral in a child). Take no more than 10 seconds. Studies show that healthcare providers87–93 as well as lay rescuers94–96 are unable to reliably detect a pulse and at times will think a pulse is present when there is no pulse. For this reason, if you do not definitely feel a pulse (eg, there is no pulse or you are not sure you feel a pulse) within 10 seconds, proceed with chest compressions.If despite oxygenation and ventilation the pulse is <60 beats per minute (bpm) and there are signs of poor perfusion (ie, pallor, cyanosis), begin chest compressions. Profound bradycardia in the presence of poor perfusion is an indication for chest compressions because an inadequate heart rate with poor perfusion indicates that cardiac arrest is imminent. Cardiac output in infancy and childhood largely depends on heart rate. No scientific data has identified an absolute heart rate at which chest compressions should be initiated; the recommendation to provide cardiac compression for a heart rate <60 bpm with signs of poor perfusion is based on ease of teaching and skills retention. For additional information see "Bradycardia" in Part 12: "Pediatric Advanced Life Support."If the pulse is ≥60 bpm but the infant or child is not breathing, provide rescue breathing without chest compressions (see below).Lay rescuers are not taught to check for a pulse. The lay rescuer should immediately begin chest compressions after delivering 2 rescue breaths.Rescue Breathing Without Chest Compressions (for Healthcare Providers Only) (Box 5A)If the pulse is ≥60 bpm but there is no spontaneous breathing or inadequate breathing, give rescue breaths at a rate of about 12 to 20 breaths per minute (1 breath every 3 to 5 seconds) until spontaneous breathing resumes (Box 5A). Give each breath over 1 second. Each breath should cause visible chest rise.During delivery of rescue breaths, reassess the pulse about every 2 minutes (Class IIa), but spend no more than 10 seconds doing so.Chest Compressions (Box 6)To give chest compressions, compress the lower half of the sternum but do not compress over the xiphoid. After each compression allow the chest to recoil fully (Class IIb) because complete chest reexpansion improves blood flow into the heart.97 A manikin study97 showed that one way to ensure complete recoil is to lift your hand slightly off the chest at the end of each compression, but this has not been studied in humans (Class Indeterminate). The following are characteristics of good compressions: "Push hard": push with sufficient force to depress the chest approximately one third to one half the anterior-posterior diameter of the chest."Push fast": push at a rate of approximately 100 compressions per minute.Release completely to allow the chest to fully recoil.Minimize interruptions in chest compressions.In an infant victim, lay rescuers and lone rescuers should compress the sternum with 2 fingers (Figure 4) placed just below the intermammary line (Class IIb; LOE 5, 6).98–102Download figureDownload PowerPointFigure 4. Two-finger chest compression technique in infant (1 rescuer).The 2 thumb–encircling hands technique (Figure 5) is recommended for healthcare providers when 2 rescuers are present. Encircle the infant's chest with both hands; spread your fingers around the thorax, and place your thumbs together over the lower half of the sternum.98–102 Forcefully compress the sternum with your thumbs as you squeeze the thorax with your fingers for counterpressure (Class IIa; LOE 5103,104; 6105,106). If you are alone or you cannot physically encircle the victim's chest, compress the chest with 2 fingers (as above). The 2 thumb–encircling hands technique is preferred because it produces higher coronary artery perfusion pressure, more consistently results in appropriate depth or force of compression,105–108 and may generate higher systolic and diastolic pressures.103,104,109,110Download figureDownload PowerPointFigure 5. Two thumb–encircling hands chest compression in infant (2 rescuers).In a child, lay rescuers and healthcare providers should compress the lower half of the sternum with the heel of 1 hand or with 2 hands (as used for adult victims) but should not press on the xiphoid or the ribs. There is no outcome data that shows a 1-hand or 2-hand method to be superior; higher compression pressures can be obtained on a child manikin with 2 hands.111 Because children and rescuers come in all sizes, rescuers may use either 1 or 2 hands to compress the child's chest. It is most important that the chest be compressed about one third to one half the anterior-posterior depth of the chest.Coordinate Chest Compressions and Breathing (Box 6)The ideal compression-ventilation ratio is unknown, but studies have emphasized the following: In 2000112 a compression-ventilation ratio of 5:1 and a compression rate of 100 per minute were recommended. But at that ratio and compression rate, fewer than 50 compressions per minute were performed in an adult manikin, and fewer than 60 compressions per minute were performed in a pediatric manikin even under ideal circumstances.113–115It takes a number of chest compressions to raise coronary perfusion pressure, which drops with each pause (eg, to provide rescue breathing, check for a pulse, attach an AED).116,117Long and frequent interruptions in chest compressions have been documented during CPR by lay rescuers118,119 and by healthcare providers75,120 in the out-of-hospital and in-hospital settings. Interruptions in chest compressions are associated with decreased rate of return of spontaneous circulation.121–123Ventilations are relatively less important during the first minutes of CPR for victims of a sudden arrhythmia-induced cardiac arrest (VF or pulseless ventricular tachycardia [VT]) than they are after asphyxia-induced arrest,116,117,124–127 but even in asphyxial arrest, a minute ventilation that is lower than normal is likely to maintain an adequate ventilation-perfusion ratio because cardiac output and, therefore, pulmonary blood flow produced by chest compressions is quite low.For lay rescuers, a single compression-ventilation ratio (30:2) for all age groups may increase the number of bystanders who perform CPR because it is easier to remember.If you are the only rescuer, perform cycles of 30 chest compressions (Class Indeterminate) followed by 2 effective ventilations with as short a pause in chest compressions as possible (Class IIb). Make sure to open the airway before giving ventilations.For 2-rescuer CPR (eg, by healthcare providers or others, such as lifeguards, who are trained in this technique), one provider should perform chest compressions while the other maintains the airway and performs ventilations at a ratio of 15:2 with as short a pause in compressions as possible. Do not ventilate and compress the chest simultaneously with either mouth-to-mouth or bag-mask ventilation. The 15:2 ratio for 2 rescuers is applicable in children up to the start of puberty.Rescuer fatigue can lead to inadequate compression rate and depth and may cause the rescuer to fail to allow complete chest wall recoil between compressions.128 The quality of chest compressions deteriorates within minutes even when the rescuer denies feeling fatigued.129,130 Once an advanced airway is in place for infant, child, or adult victims, 2 rescuers no longer deliver cycles of compressions interrupted with pauses for ventilation. Instead, the compressing rescuer should deliver 100 compressions per minute continuously without pauses for ventilation. The rescuer delivering the ventilations should give 8 to 10 breaths per minute and should be careful to avoid delivering an excessive number of ventilations. Two or more rescuers should rotate the compressor role approximately every 2 minutes to prevent compressor fatigue and deterioration in quality and rate of chest compressions. The switch should be accomplished as quickly as possible (ideally in less than 5 seconds) to minimize interruptions in chest compressions.Compression-Only CPRVentilation may not be essential in the first minutes of VF cardiac arrest,116,124,127,131 during which periodic gasps and passive chest recoil may provide some ventilation if the airway is open.124 This, however, is not true for most cardiac arrests in infants and children, which are more likely to be asphyxial cardiac arrest. These victims require both prompt ventilations and chest compressions for optimal resuscitation. If a rescuer is unwilling or unable to provide ventilations, chest compressions alone are better than no resuscitation at all (LOE 5 through 7; Class IIb).125,126Activate the EMS System and Get the AED (Box 7)In the majority of infants and children with cardiac arrest, the arrest is asphyxial.8,11,17,132,133 Lone rescuers (with the exception of healthcare providers who witness sudden collapse) should perform CPR for 5 cycles (about 2 minutes) before activating EMS, then start CPR again with as few interruptions of chest compressions as possible. If there are more rescuers present, one rescuer should begin the steps of CPR as soon as the infant or child is found to be unresponsive and a second rescuer should activate the EMS system and get an AED. Minimize interruption of chest compressions.Defibrillation (Box 8)VF can be the cause of sudden collapse, or it may develop during resuscitation attempts.7,134 Children with sudden witnessed collapse (eg, a child collapsing during an athletic event) are likely to have VF or pulseless VT and need immediate CPR and rapid defibrillation. VF and pulseless VT are referred to as "shockable rhythms" because they respond to electric shocks (defibrillation).Many AEDs have high specificity in recognizing pediatric shockable rhythms, and some are equipped to decrease the delivered energy to make it suitable for children 1 to 8 years of age.134,135 Since the publication of the ECC Guidelines 2000,112 data has shown that AEDs can be safely and effectively used in children 1 to 8 years of age.136–138 However, there is insufficient data to make a recommendation for or against using an AED in infants <1 year of age (Class Indeterminate).136–138In systems and institutions that care for children and have an AED program, it is recommended that the AED have both a high specificity in recognizing pediatric shockable rhythms and a pediatric dose-attenuating system to reduce the dose delivered by the device. In an emergency if an AED with a pediatric attenuating system is not available, use a standard AED. Turn the AED on, follow the AED prompts, and resume chest compressions immediately after the shock. Minimize interruptions in chest compressions.CPR Techniques and AdjunctsThere is insuf
Referência(s)