Pediatric BLS for the Single Rescuer
Pediatric BLS for the Single Rescuer
Short Description
This algorithm ensures that a pediatric patient receives the appropriate BLS care when only one rescuer is available.
Algorithm at a Glance
- Ensure scene safety
- Identify responsiveness
- Check for pulse and respirations
- Perform CPR as needed
- Use an AED when available
Goals for Management
The rescuer will be able to:
- Quickly recognize the need for BLS
- Intervene quickly using rescue breathing (if trained) and high-quality CPR
- Prevent deterioration
The Pediatric BLS for Single Rescuer Algorithm
This algorithm outlines the steps for assessing and managing children presenting with a need for basic life support when a single rescuer is present.
Single Rescuer BLS HCP Pediatric Cardiac Arrest Algorithm
Box 1: Ensure Scene Safety
The rescuer looks around the environment to ensure it is safe when tending to a child. If the scene is not secure, the provider moves the child to a safe area. If the area is safe, the rescuer should not attempt to move the child because movement can worsen the injury.
Box 2: Unresponsive Child
The rescuer taps the child’s shoulder, rubs her feet or belly, and shouts, “are you all right?” If the child does not respond, the rescuer calls for help and activates the emergency response system using a cell phone if available. The rescuer can put the dispatcher on speakerphone to facilitate their communication.
Related Video – Pediatric Assessment Triangle
Box 3: Visualize Chest Rise and Check Pulse
The rescuer spends no longer than 10 seconds looking for a pulse and checking for breathing. The rescuer should not mistake gasping for breathing.
Box 3a: Pulse Present and Normal Breathing
If the child is breathing and has a pulse, the responder stays with the child until EMS arrives.
Box 3b: Pulse Present and Abnormal Breathing
If the child is not breathing, but they have a pulse > 60 beats per minute, the rescuer begins rescue breathing, providing one breath every 2–3 seconds. The rescuer continues to check the child’s pulse every 2 minutes. If the child has no pulse and no breathing at any time, they proceed to box 4.
Related Video – Understanding Agonal Breathing
Related Video – Rescue Breathing for Children
Box 4: Witnessed Collapse?
If yes, the rescuer proceeds to Box 4a. If no, they proceed to Box 5.
Box 4a: Activate EMS and Retrieve an AED
If the collapse is witnessed, the rescuer calls emergency response and retrieves an AED.
Box 5: Initiate CPR
If the collapse is not witnessed and the child has a pulse of < 60 beats per minute, the rescuer begins high-quality CPR with 30 compressions followed by two breaths. High-quality CPR continues until the AED arrives. The compression rate should be 100–120 per minute. The depth of compressions should equal one-third of the chest circumference. Full chest recoil occurs between compressions to allow the heart chambers to fill.
A rescuer performs CPR on a child.
Related Video – Pediatric Assessment Triangle
Box 6: Activate EMS and Retrieve an AED
After 2 minutes of CPR, the rescuer activates EMS and retrieves an AED if not already done.
Box 7: Attach AED
When the AED is available, the rescuer opens the unit and follows the verbal instructions. The rescuer attaches the pads per the diagram on the AED. The rescuer pauses compressions and allows the AED to analyze the heart rhythm. If the AED determines the rhythm is shockable, the rescuer proceeds to Box 8. If the rhythm is not shockable, the AED will instruct the rescuer to resume CPR. The rescuer proceeds to Box 9.
Some pediatric AED pads are placed on the body’s anterior and posterior.
Related Video – How to Use an AED for Children
Related Video – Using an AED for an Infant
Box 8: Administer Shock
If the AED determines the child’s rhythm is shockable, the AED will tell the rescuer to deliver a shock. The rescuer ensures that no one is touching the child and pushes the shock button on the AED. The rescuer immediately resumes CPR following the shock.
Box 9: Resume CPR
If the AED determines the child’s rhythm is nonshockable, the rescuer immediately resumes high-quality CPR until advised by the AED to stop for a rhythm check. The rescuer continues to provide CPR and shocks until the child moves or EMS arrives.
Related Video – Understanding the Pediatric Cardiac Arrest Algorithm for the Single Rescuer
Understanding BLS for the Single-Rescuer
Verify Scene Safety and Determine Responsiveness
When a single rescuer arrives at the scene, it is crucial to first verify that the scene is safe. Next, the rescuer checks for the pediatric patient’s responsiveness and immediately calls for help by activating the emergency response system.
The rescuer shakes the child’s shoulder or taps the sole of an infant’s foot and shouts, “Are you okay?”
Nearby bystanders are summoned to call for help when possible. The rescuer should use their mobile phone if one is readily available. The speaker function on the cellphone may allow the rescuer to begin chest compressions while speaking with the 911 dispatcher.
Key Takeaway
Before beginning the CPR, verify that you and the patient are safe!
Breathing and Pulse
The rescuer simultaneously assesses the patient’s breathing status and checks for a pulse. The assessment of pulse and respirations should last no more than 10 seconds.
To determine if the patient is breathing, the rescuer observes the patient’s chest for chest rise. If breathing is absent, or if the patient exhibits agonal gasps (as seen on an actual patient in the Single Rescuer video), the rescuer assumes the child is in respiratory arrest.
When there is both respiratory arrest and no pulse, the patient is in cardiopulmonary arrest. When checking a pulse in an infant, the brachial artery should be palpated. The rescuer palpates either the carotid or the femoral artery when assessing a child (1 year of age to puberty)
*For resuscitation, puberty is the presence of underarm hair in males and any breast development in females.
Key Takeaway
In Pediatric population, rescue breathing is critical since respiratory failure often leads to cardiac arrest.
Studies have shown that rescuers have difficulty detecting the pulse of patients in emergencies, especially in infants and children.2 If the rescuer does not appreciate a pulse within 10 seconds, CPR should be started immediately, beginning with high-quality chest compressions.
Related Video – Understanding infant Landmarks
Interventions
If the patient is unresponsive but breathing spontaneously, the rescuer remains at the patient’s side and waits for additional help to arrive.
If respiration is absent or abnormal, but a pulse is present, the rescuer performs rescue breathing.
- One breath or ventilation should be given every 2–3 seconds (20–30 breaths/minute).
- Each breath should be administered over 1 second and result in visible chest rise.
- The pulse is checked every 2 minutes.
- If at any time a pulse cannot be felt, the rescuer should begin high-quality CPR, starting with chest compressions.
Infants and children require much higher heart rates than adults. Therefore, when there is bradycardia with a pulse rate of 60 beats per minute (bpm) or less with signs of poor perfusion, chest compressions are necessary.
Related Video – Understanding Agonal Breathing
The TAPS mnemonic is a tool for assessing perfusion:
- Temperature (cool extremities)
- Altered mental status
- Pulses (weak)
- Skin color changes (pallor, mottling, or cyanosis)
If the provider witnessed the collapse, and the patient is not breathing and has no pulse, then the rescuer leaves the patient to activate the emergency response system (EMS), e.g., dial 911. The rescuer should retrieve an AED and other emergency equipment for resuscitation. If someone else is present, the rescuer should ask them to activate EMS and get the AED and equipment while the rescuer tends to the patient.
If the rescuer is alone and does not witness the arrest, they should perform high-quality CPR for 2 minutes before calling for help.
Key Takeaway
If a pulse is not felt within 10 seconds, the rescuer should immediately conclude that the patient is in cardiac arrest and begin CPR.
High-quality CPR: Chest Compressions
High-quality CPR beginning with chest compressions should be initiated if the pediatric patient has no pulse and is not breathing or is only gasping. First, the child’s torso should be uncovered, allowing for the identification of landmarks to initiate chest compressions and for the placement of AED pads.
For both infants and children, it is essential to remember the principles of quality compressions. The rate for the single-rescuer is 100–120 compressions per minute. Full chest recoil should occur after every compression. The delivery of chest compressions resembles the up and down movement of a piston, with an equal amount of time allotted to both the compression and relaxation phases. Interruptions in chest compressions should be kept to < 10 seconds.
Single rescuer infant CPR: Chest compressions should be performed using the 2-finger technique if the patient is an infant. The tips of the index and middle finger are placed in the center of the chest just below the nipple line on the bottom half of the sternum, avoiding the xiphoid process. The chest is depressed 1.5 inches (4 cm), or one-third the depth of the chest.
Single rescuer child CPR: Chest compressions are performed with one or two hands if the patient is a child. The choice of one or two hands is determined by the rescuer’s ability to achieve the adequate depth of compression and the child’s size. One or two hands are placed on the chest just below the nipple line on the lower half of the sternum, avoiding the xiphoid process.
When using two hands, the heel of the second hand is placed on top of the heel of the first hand. The chest is then depressed at least 2 inches (5 cm), or approximately one-third the anterior-posterior diameter of the chest.
Single rescuer compression rate: The lone rescuer should deliver chest compressions at a rate of 100– 120 per minute with a compression to ventilation ratio of 30:2 for both infants and children. Chest compressions should be performed for 2 minutes. If the single rescuer is still alone at this point, they should stop to activate the emergency response system and get an AED. If an AED is already available, it should be used as soon as possible.
The compression rate changes to 15:2 when a second rescuer arrives.
AED: The rescuer should begin using the AED as soon as it is available and follow its prompts. After delivery of a shock, or if the AED does not advise a shock, CPR with chest compressions should be resumed immediately.
The AED will prompt the rescuer to resume chest compressions and count down 2 minutes. All subsequent prompts should be followed until advanced providers arrive or until the patient begins to move, breathe spontaneously, or show other signs of reactivity.
Key Takeaway
Full Chest Recoil
Full chest recoil allows for a significant amount of negative intrathoracic pressure, which causes blood to flow into the heart. Incomplete chest recoil restricts blood flow into the heart, leaving less blood to be pumped out with the next compression.
A lone rescuer should perform 2-finger compressions on an infant.
The rescuer can use either one or two hands for compressions, depending on the size of the child.
High-quality CPR: Rescue Breathing
Ventilation (giving breaths) is essential for children in cardiac arrest because respiratory failure and shock are the most common causes of cardiac arrest in pediatric patients. These medical conditions cause low oxygen content in the blood, making chest compression-only CPR less effective than it is in adults.
Opening the airway via the jaw-thrust or head tilt-chin lift maneuvers is vital to provide enough ventilation. The rescuer should use the jaw-thrust method for trauma patients with suspected cervical vertebrae fractures or head injury. When performing the head tilt-chin lift maneuver, it is important not to hyperextend the neck as this will further block the airway. The goal is to achieve a neutral position, in which the external ear canal is level with the superior border of the shoulder.
The rescuer should use a bag-mask or barrier device to deliver ventilations to an infant or child. It is essential to ensure that the team selects the right size mask. Masks should not cover the eyes or extend beyond the chin. Supplemental oxygen should be administered if it is available.
Related Video – Understanding Infant Rescue Breathing
Related Video -Can Infants Be Fitted With an Adult Ambu Mask?
Proper Size of Pediatric Bag Mask 3
The following flow chart summarizes the single-rescuer sequence:
Single-Rescuer BLS Sequence
2 Dick WF, Eberle B, Wisser G, Schneider T. The carotid pulse check revisited: what if there is no pulse? Crit Care Med. 2000;28(11 Suppl):N183–N185.
3 Hamilton P. Care of the newborn in the delivery room. BMJ. 1999;318:1403.