Child Cardiac Arrest

The procedure is the same as that of the infant CPR, with some significant changes in assessing for responsiveness, cardiac arrest, and delivering chest compressions. The instructions for rescuers are as follows:

Step 1: Verify Scene Safety

The lay rescuer must ensure their own safety for a good number of reasons. One reason is to avoid adding another patient to the scene if a rescuer is in a dangerous situation. A second reason is that there may be no one to rescue the child if the lay rescuer is incapacitated.

If the child needs to be moved away from danger, this becomes the lay rescuer’s priority as long as it can be done safely.

The child should be moved so that their back is on a hard and flat surface if possible because this is the best position to facilitate high-quality CPR.

Step 2: Determine Unresponsiveness, Then Call for Help

When a lay rescuer comes upon an unresponsive child, they tap firmly on the child’s shoulders while shouting, “Hey! Hey! Are you okay?” to elicit a response such as sound or movement.

When this action fails to elicit a response, the rescuer then calls for:

• Assistance in calling 9-1-1.
• Assistance in performing CPR.
• Someone to get the AED.

In the unfortunate event that the rescuer is alone, they should proceed straight to step 3: assess for breathing. If CPR is necessary, after step 3, the rescuer immediately performs step 4: CPR for five cycles first before leaving the infant to call 9-1-1, asking for help, or getting an AED (if the location is known).

Step 3: Assess for Breathing and Signs of Life

After calling for help, the lay rescuer assesses if the child is in cardiac arrest. The lay rescuer has only 10 seconds to determine if the child is in cardiac arrest.

At this point, the lay rescuer is only concerned for the presence of breathing, no breathing, or only gasping. If the child is not breathing or only gasping, and there are no signs of life, then the rescuer immediately proceeds to step 4: chest compressions.

If the infant is breathing, the rescuer monitors them every 2 minutes while awaiting the arrival of paramedics.

Step 4: Initiate CPR

When it is determined the child is in cardiac arrest, high-quality CPR should be initiated immediately. If the technique is incorrect, the chances of survival diminish. Giving high-quality CPR is simplified by pushing hard and pushing fast on the center of the chest.

Single Rescuer Approach

Use the one-handed or two-handed approach. The approach to use will depend on the child’s size. Most small children will only require the one-handed approach when providing chest compressions. If the child is older and the chest is larger, the rescuer can perform the two-handed approach. 

Instructions for the one-handed technique are as follows:

1. Locate the body of the sternum, the long and broad bone at the center of the chest. 
2. With the palm of one hand and the elbow locked, apply pressure to the middle third of the body of the sternum, and depress the center of the chest by about 2 inches (or 1/3 the circumference of the child’s chest) on the downstroke and allow full chest recoil in the upstroke.

Full chest recoil means there is enough space between the fingers and the chest that a piece of paper can be easily pulled out at the end of the upstroke.

3. To avoid fatigue, the body weight from the waist up should be used and not the arms to depress the chest to the appropriate depth.

For the two-handed technique:

1. Locate the body of the sternum, the long and broad bone at the center of the chest. 
2. Place one hand on top of the other, and with the elbows locked, apply pressure to the middle third of the sternum body. Depress the center of the chest by about 2 inches (or 1/3 the circumference of the child’s chest) on the downstroke and allow for full chest recoil on the upstroke.

Full chest recoil means that there is enough space between the fingers and the chest that a piece of paper can be easily pulled out at the end of the upstroke.

3. To avoid fatigue, the body weight from the waist up should be used and not the arms to depress the chest to the appropriate depth.
4. Give 100 to 120 chest compressions per minute. This can be timed in the tune of “Stayin’ Alive,” or the more recent popular kids’ song “Baby Shark.”
5. After 30 chest compressions, open the airway and give two rescue breaths, also known as mouth-to-mouth resuscitation. Instructions for performing mouth-to-mouth resuscitation are as follows:

• • Perform the head tilt-chin lift maneuver.
  • Form a seal over the child’s mouth.
  • Blow into the child’s mouth or the infant’s mouth and nose for 1 second, enough to elicit a visible chest rise.

6. Immediately resume CPR and repeat the cycle. Only stop the process if the following has occurred:

• The AED gives a prompt to stop to analyze the child’s rhythm or recommends the administration of a shock.
• You are giving mouth-to-mouth breaths.
• There is a response from the child.
• The paramedics have arrived to take over.

7. Apply the AED once it is made available. Use the pads made specifically for children. If they are not available, adult pads may be used. If the pads are too big, one pad can be applied on the front and the other on the child’s back. 
8. Defibrillate as soon as advised, even if it means that CPR must be paused. Immediately perform CPR after a shock is administered.
9. Stop CPR when the child exhibits signs of consciousness or paramedics arrive to take over.

Related Video: Single Rescuer CPR for children

Two-Rescuer Approach

The main differences between the two-rescuer approach and the single rescuer approach in child CPR are the following:

• The compression to ventilation ratio is 15 chest compressions to 2 rescue breaths.
• The rescuers switch roles after five cycles or roughly 2 minutes of high-quality CPR.

Related Video: 2-Rescuer CPR for children

How to Operate an AED for Children

Early utilization of an AED has shown better outcomes in infants and children with witnessed cardiac arrest.

Related Video:  How to Use an AED for Children

Each AED model is different. They are designed to provide the user with easy-to-follow instructions to operate. The following are basic instructions on how lay rescuers should use an AED:

1. Switch ON the device. Some AEDs automatically turn on once removed from the casing.
2. Use the self-adhesive pads specially made for children in which the electrodes are connected to a pediatric dose attenuator. The pediatric dose attenuator provides the appropriate amount of energy (35 J to 50 J) recommended for children. If pediatric pads are not available, use the adult pads. It will provide the adult dose to the child.
3. Apply the pads in the ANTERIOR-ANTERIOR (APEX) positions. If the child is too small, apply the pads in the ANTERIOR-POSTERIOR positions.
4. Plug the electrodes into the AED.
5. Do not touch the patient while the AED analyzes their rhythm.
6. The AED will indicate if a shock is necessary.
7. Perform chest compressions while the AED is charging.
8. Once charged, stop compressions and clear the patient.
9. When prompted to do so, push the SHOCK button.
10. Resume CPR immediately after the shock is delivered.
11. Check the pulse after 2 minutes or five cycles of CPR.

A Word About the Adult Dose

The energy to induce significant damage to the heart is significantly higher than the AED’s energy. This is the reason why giving the adult dose of 150 J to 360 J is better than no defibrillation at all when attempting to defibrillate an infant or child in cardiac arrest.

Inadvertently Shocking a Child

If the patient already has an organized perfusing rhythm, and a shock was inadvertently delivered, that shock may cause a cardiac arrest rhythm (likely ventricular fibrillation).

When a shock is delivered across 100% oxygen (from a bag-mask device or oxygen insufflation therapy), it will ignite the oxygen gas. Thus, oxygen sources must be moved at least 1 meter from the patient before giving a shock. 

Other rare and unwanted effects from an AED include precipitation of cardiac arrhythmias, myocardial injury, or skin burns.