MODULE 1: BASIC LIFE SUPPORT

Learning objectives:
By the end of the lesson, the participants will be able to:
● Perform Adult CPR
● Perform Infant and Child CPR
● Able to relieve Choking
● Able to use Automated External Defibrillator
1.1 OVERVIEW OF BASIC LIFE SUPPORT (BLS)

Cardiac arrest is common in Nepal, with the rise of non-communicable diseases such as
hypertension, diabetes and cardiac failure. The keys to survival from sudden cardiac
arrest are early recognition and immediate initiation of high quality cardiopulmonary
resuscitation and early defibrillation. All health care providers (HCP), regardless of their
specialty or their years of experience require regular updates in the basic skills of
cardiopulmonary resuscitation (CPR). This session is designed to equip you with the skills
you need to perform high quality basic life support for victims of all ages, which is the
essential foundation for more advanced life support techniques. You will learn to perform
CPR in a team setting both in and outside of hospital. You will also learn how to relieve
choking in adults, children and infants. The course is based on the American Heart
Association (AHA) 2020 BLS guidelines.
Critical concepts for high quality CPR:
● Start compressions within 10 seconds of recognition of cardiac arrest
● Push hard, push fast – at least 100/min but no more than120/min
● Allow complete chest recoil after each compression
● Minimize interruptions in compressions (<10secs)
● Give effective breaths that make the chest rise
● Avoid excessive ventilation
1.1.1 ADULT CHAIN OF SURVIVAL

The Chain of Survival is the term coined to remind HCPs of the core elements of
emergency cardiovascular care in adults. The Adult out-of-hospital cardiac arrest (OHCA)
and in-hospital cardiac arrest (IHCA) Chains of Survival have been updated to better
highlight the evolution of systems of care and the critical role of recovery and survivorship
with the addition of a new link. (Figure 1.1) This Recovery link highlights the enormous
recovery and survivorship journey, from the end of acute treatment for critical illness
through multimodal rehabilitation (both short- and long-term), for both survivors and
families after cardiac arrest. This new link acknowledges the need for the system of care
to support recovery, discuss expectations, and provide plans that address treatment,
surveillance, and rehabilitation for cardiac arrest survivors and their caregivers as they
transition care from the hospital to home and return to role and social function. The care
for all post–cardiac arrest patients, regardless of where their arrests occur, converges in
the hospital where post–cardiac arrest care is provided. The elements of structure and
process have been recommended that identify the different pathways of care for patients
who experience cardiac arrest in the hospital as distinct from out-of hospital settings.

The components of chains of survival are as follows:

● Call for help - Immediate recognition of cardiac arrest
● Early cardiopulmonary resuscitation (CPR) with an emphasis on chest
compressions
● Rapid defibrillation (where available)
● Effective advanced life support
● Integrated post-cardiac care
● Activation of emergency response
● High-quality CPR
● Defibrillation
● Post-cardiac arrest care
● Recovery
Figure 1.1. Adult chain of survival
1.1.2 PEDIATRIC CHAIN OF SURVIVAL

A separate OHCA Chain of Survival has been created to distinguish the differences
between OHCA and IHCA. (Figure 1.2) In both the OHCA and IHCA chains, a sixth link
has been added to stress the importance of recovery, which focuses on short- and long-
term treatment evaluation, and support for survivors and their families. For both chains of
survival, activating the emergency response is followed immediately by the initiation of
high-quality CPR. If help is nearby or a cell phone is available, activating the emergency
response and starting CPR can be nearly simultaneous. However, in the out-of-hospital
setting, a single rescuer who does not have access to a cell phone should begin CPR
(compressions-airway-breathing) for infants and children before calling for help because
respiratory arrest is the most common cause of cardiac arrest and help may not be
nearby. In the event of sudden witnessed collapse, rescuers should use an available
automatic external defibrillator (AED), because early defibrillation can be lifesaving.
The components of chains of survival are as follows:
○ Prevention of arrest
○ Early high-quality CPR
○ Rapid activation of emergency response system
○ Effective advanced life support
○ Integrated post-cardiac arrest care
○ Activation of emergency response
○ High-quality CPR
○ Advanced resuscitation
○ Post-cardiac arrest care
○ Recovery
Figure 1.2: The pediatric Chain of Survival

1.1.3 KEY CHANGES TO BLS

Coronavirus Disease 2019 guidance:

Interim guidance has been provided for basic and advanced life support in adults and
children with suspected or confirmed coronavirus disease 2019 (COVID-19). (See figures
1.11, 1.15 and 1.16)

Adult Basic Life Support: 2020 Updates, and Reaffirmed Recommendations

● CPR reaffirmed
● Double sequential defibrillation
● Early adrenaline administration reaffirmed
● Chain of survival
CPR reaffirmed:

Updated evidence reaffirms the importance of chest compression quality as well as the
following:

● During manual CPR, rescuers should perform chest compressions to a depth of at

least 2 inches, or 5 cm, for an average adult while avoiding excessive chest
compression depths
● It is reasonable for rescuers to perform chest compressions at a rate of 100 to
120/min
● Lay rescuers are recommended to initiate CPR for presumed cardiac arrest
because the risk of harm to patients is low if they are not in cardiac arrest.

Double sequential defibrillation:

Along with CPR, early defibrillation is critical to survival when sudden cardiac arrest is
caused by ventricular fibrillation or pulseless ventricular tachycardia. However, rescuers
may encounter victims who are refractory to defibrillation attempts. Double sequential
defibrillation—shock delivery by 2 defibrillators nearly simultaneously—has emerged
as a new technological approach to manage these patients.

Early adrenaline administration reaffirmed:

Administration of adrenaline increased ROSC and survival, leading to a recommendation

that adrenaline be administered for patients in cardiac arrest. New concepts are as
follows:

● With respect to timing, for cardiac arrest with a nonshockable rhythm, it is

reasonable to administer adrenaline as soon as feasible.
● With respect to timing, for cardiac arrest with a shockable rhythm, it may be
reasonable to administer adrenaline after initial defibrillation attempts have failed.
Pediatric Basic Life Support: 2020 Updates, and Reaffirmed Recommendations

● Respiratory rate
● Early adrenaline
● Chain of survival

Respiratory rate:

New data support a higher respiratory rate for children with an advanced airway than was
previously recommended. When performing CPR in infants and children with an
advanced airway, it may be reasonable to target a respiratory rate range of 1 breath every
2 to 3 seconds (20–30 breaths/min), accounting for age and clinical condition. For infants
and children with a pulse but absent or inadequate respiratory effort, it is reasonable to
give 1 breath every 2 to 3 seconds (20–30 breaths/min)

Early adrenaline:

The goal of adrenaline administration during CPR is to optimize coronary perfusion

pressure and maintain cerebral perfusion pressure. Earlier administration of adrenaline
during CPR may increase survival-to-discharge rates. For pediatric patients in any setting,
it is reasonable to administer the initial dose of adrenaline within 5 minutes from the start
of chest compressions.
Table 1.2: Summary of steps of CPR for Adults, Children and Infants
Component Adults and Children (Age 1 Infants
Adolescents year to puberty) (Age less than one year,
Excluding Newborn)
Scene safety • Make sure the environment is safe for rescuers and victim
Recognition of • Check for responsiveness
cardiac arrest • No breathing or only gasping (i.e. no normal breathing)
• No definite pulse felt within 10 seconds
(Breathing and pulse check can be performed simultaneously in less than 10 sec

Activation of • If you are alone with • Witnessed collapsed

emergency no mobile phone, leave the Follow steps for adults and adolescents on the left
response victim to activate the • Unwitnessed collapse
system emergency response system Give 2 minutes of CPR
and get the AED before Leave the victim to activate the emergency response
beginning system and get the AED
CPR Return to the child of infant and resume CPR
• Otherwise send someone Use the AED as soon as it is available
and begin CPR immediately;
use the AED as soon as it is
available
Compression – 1 rescuer
Ventilation 1 or 2 rescuers 30:2 30:2
ratio 2 or more rescuer 15:2
without
advanced
airway
Compression – • Continuous Continuous compressions at a rate of 100-120/min
ventilation compressions at a rate of Give one breath every 2-3 seconds (20-30 breaths/min)
ratio with 100-120/min
advanced Give one breath every 5- 6
airway seconds (10-12 breaths/min)
Compression 100-120/min
rate
Compression • At least 2 inches (5 cm)* • At least one At least one third AP diameter of
depth third AP diameter of chest About 1.5 inches (4 cm)
chest
• About 2 inches
(5cm)
 Hand • 2 hands on the lower half • 2 hands or 1 hand • 1 rescuer
Placement of the breastbone (optional for very 2 fingers in the center of chest,
(sternum) small child) on the just below the nipple line
lower half of the • 2 or more rescuers 2 thumb-
breastbone encircling hands in the center of
(sternum) the chest, just below the nipple
line

Chest recoil • Allow full recoil of chest after each compression; do not lean on the chest after each
compression
Minimizing • Limit interruptions between compressions to less than 10 seconds
interruptions

*Compression depth should be no more than 2.4 inches (6 cm)

Abbreviations: AED, automated external defibrillator; AP anteroposterior; CPR, Cardiopulmonary

resuscitation
1.2 ADULT BLS

1.2.1 OVERVIEW OF INITIAL BLS STEPS

Fundamental aspects of adult BLS include immediate recognition of sudden cardiac

arrest and activation of the emergency response system, early high-quality CPR,
and rapid defibrillation with an automated external defibrillator (AED).

1.2.2 RECOGNITION OF ARREST

Conditions:
a) Pulse Present, Normal Breathing
• Closely monitor the patient, and activate the emergency response system
as indicated by location and patient condition
b) Pulse Present, No Normal Breathing • For a patient with known or suspected
opioid overdose who has a definite pulse but no normal breathing or only
gasping (i.e., a respiratory arrest), in addition to providing standard BLS care,
it is reasonable for appropriately trained BLS healthcare providers to
administer intramuscular or intranasal naloxone
• For patients in cardiac arrest, naloxone administration may be considered
after initiation of CPR if there is high suspicion for opiate overdose
c) Pulse Absent, No Breathing or Only Gasping
Initiate CPR and use an AED as soon as possible. There are four main parts to
BLS:
• Chest compressions
• Airway
• Breathing
• Defibrillation
 You will learn about each of these in a step wise fashion through the course, so that
you can master each individual skill, and so that you can perform single rescuer
CPR if necessary. However, most of you will be working in a hospital or clinic, and
will be able to provide CPR as a part of a team. In this situation, several actions
should be performed simultaneously. For example: one rescuer provides high
quality chest compressions, while another goes to call for help and a third either
provides mouth to mouth or goes to retrieve a bag-mask device. A fourth rescuer
might go to get a defibrillator if one was available.

1.2.3 FOLLOW THESE INITIAL BLS STEPS FOR ADULTS:

Step Action

1 Assess the victim for responsiveness.

2 Call for nearby help upon finding the victim unresponsive. If you are alone, call
for help either by shouting or phoning, and get a defibrillator if possible.
Return to the victim.

3 Continue to assess the breathing and pulse simultaneously. (take at least 5

seconds but no more than 10 secs). Activate the emergency response system
or call for backup

4 If you do not definitely feel a pulse within 10 seconds, start chest

compressions (C-AB sequence) and perform 5 cycles of compressions and
breaths (30:2)

Step 1: Assessment and scene safety

- The first rescuer should quickly be sure that the scene is safe – this is
particularly important in out of hospital situations. Be aware of the road traffic
and possible electrical injuries, you do not want to be a second victim. - Tap the
victim’s shoulder and shout “Are you alright?” - If the victim is unresponsive you
must call for help.\
Step 2: Call for help
- If you are alone and find an unresponsive victim, shout for help.
- If no-one responds, phone for help yourself and then return to the victim
to check pulse and breathing and start CPR (C-A-B sequence)
- If someone responds, they should phone for further assistance, or collect
equipment such as bag and mask and a defibrillator if available.

Step 3: Breathing and Pulse check

- Check for breathing and central pulse simultaneously. Agonal gasps are
not normal breathing. In adults, the carotid pulse should be checked. In
infants it is easier to look for a brachial pulse, in a child, look for carotid or
femoral pulses.

To locate the carotid pulse, first locate the tracheal cartilage using two or three
fingers. Then slide these fingers into the groove between the trachea and the
muscles at the side of the neck (sterno-cleido mastoid muscle), where you should
be able to feel the carotid pulse.

Figure 1.4: Feeling for the Carotid Pulse

 Feel for a pulse for at least 5 seconds, but no longer than 10 seconds. If the victim
is not breathing or having agonal gasps and you do not definitely feel a pulse, begin
CPR, starting with chest compressions.

Step 4: Begin cycles of 30 chest compressions and 2 breaths (CPR)

- The single rescuer should use the compression-ventilation ratio of 30

compressions to 2 breaths when giving CPR to victims of any age. For
adults the ratio is 30:2 regardless of number of rescuers.
- Begin with chest compressions - Push hard and fast
• Perform chest compressions at a rate of 100/min to 120/min
• Perform chest compressions to a depth of at least 2 inches or 5 cm for
an average adult, while avoiding excessive chest compression depths
(greater than 2.4 inches or 6 cm or 1/3 of A-P chest diameter in children
or infants)
- Avoid leaning on the chest between compressions to allow full chest wall
recoil for adults in cardiac arrest
- Allow complete chest recoil after each compression.
- Minimize interruptions in compressions.
- Total pre-shock and post-shock pauses in chest compressions should be
as short as possible
- In CPR without an advanced airway, it is reasonable to pause
compressions for less than 10 seconds to deliver 2 breaths

[With an unprotected airway, it may be reasonable to perform CPR with the goal of
a chest compression fraction as high as possible, with a target of at least 60% ]
Feel for a pulse for at least 5 seconds, but no longer than 10 seconds. If the victim
is not breathing or having agonal gasps and you do not definitely feel a pulse, begin
CPR, starting with chest compressions.
1.2.4 CHEST COMPRESSION TECHNIQUE

Good chest compression technique is the foundation of high-quality CPR. Follow

these steps to perform compressions in an adult:

Step Action

1 Position yourself at the victim’s side. It doesn’t matter which side.

2 Make sure the victim is lying faceup on a firm, flat surface. If the victim is lying
face down, carefully roll him faceup. If you suspect the victim has a head or
neck injury – use a log roll technique with someone supporting the head and
neck. This requires at least three helpers.

3 Put the heel of one hand on the center of the victim’s chest on the lower half
of the sternum (Figure 1.5)

4 Put the heel of your other hand on top of the first hand. Alternatively, if you
have difficulty pushing deeply using this technique you can grasp the wrist of
the first hand with your other hand to help it push the chest.

5 Straighten your arms and position your shoulders directly over your hands.
This is where the relative height of rescuer and victim is important. If the
victim is on a hospital trolley or bed, a short rescuer may need to step on a
chair, or kneel on the side of the bed.

6 Push hard, push fast

• Press down at least 5cm with each compression but not more than 6cm

• For each compression make sure you push straight down on the
victim’s sternum (see figure)

• Deliver compressions in a smooth fashion at a rate of at 100/min to

120/min

7 At the end of each compression make sure you allow the chest to recoil (re-
expand) completely. This allows blood to flow into the heart and is necessary
for chest compressions to create blood flow. Incomplete chest recoil is
 harmful. Chest compression and chest recoil times should be approximately
equal.

8 Minimize interruptions (less than 10 seconds between sets of 30 compressions

if possible).

Figure 1.5: Chest Compression Technique in the Adult

Do not move the victim while CPR is in progress, unless the victim (or rescuers) are in
a dangerous environment (such as a burning building), or if you cannot perform CPR
effectively in the victim’s present position (e.g., they are lying on a very soft bed).
 * A firm surface is essential for good quality CPR.
Compressions
pump the blood in the heart to the rest of the body. If a firm
surface is
under the victim, the force you use will be more likely to
compress the
chest and create blood flow rather than simply push the
victim into the
mattress or other soft surface.

1.2.5 OPENING THE AIRWAY

Technique for Performing Head Tilt-Chin Lift Maneuver:

The best method for opening the airway is the head tilt-chin lift maneuver (Figure
1.6). This lifts the tongue, relieving any airway obstruction in an unconscious victim.
The steps to perform this are:
• Place one hand on the victim's forehead and push with you palm to tilt the
head back
• Place the fingers of the other hand under the bony part of the lower jaw
near the chin
• Lift the jaw to bring the chin forward
Figure 1.6: Head Tilt – Chin Lift Maneuver to Open the Airway

Cautions with head tilt-chin lift:

• Do not press deeply into the soft tissue under the chin because
this
might block the airway
• Do not use the thumb to lift the chin
• Do not close the victim’s mouth completely
• If you suspect a head or neck injury do not perform a head tilt
chin
lift – use jaw thrust instead
Technique for Performing Jaw Thrust:
• Place one hand on each side of the victim’s head, resting your elbows on
the surface on which the victim is lying
• Place your fingers under the angles of the victim’s lower jaw and lift with
both hands, displacing the jaw forwards
• If the lips close, push the lower lip with your thumb to open the lips

Figure 1.7: Jaw Thrust Technique

1.2.6 MOUTH TO MOUTH BREATHING

As the first rescuer to the scene you may not have access immediately to special
equipment such as a bag and mask, even in a hospital setting. Rescue breathing
should be started using the mouth to mouth technique. In the context of Nepal, you
are unlikely to have access to proper barrier devices such as a mouth- to- face mask
device. The risk of infection from CPR is extremely low, so the lack of a barrier
device should not stop you initiating mouth to mouth breathing. Some doctors,
 however, like to use a “makeshift” face shield, such as a thin piece of gauze placed
over the face.

The steps for mouth to mouth breathing are:

Step Action

1 Position yourself at the victim’s side

2 Open the airway using head tilt, chin lift

3 Close the victim's nostrils by pinching the fleshy part with the upper most hand
(using your thumb and index finger)

4 Take a regular (not a deep breath) and seal your lips over the victim's mouth

5 Breath into the victim's mouth over 1 second (Figure 1.8)

6 Observe at the same time as breathing to make sure the chest rises*

7 Give two breaths and then restart 30 chest compressions

* If the chest does not rise, repeat the head tilt-chin lift and give a second breath.
Watch for the chest to rise. If you are unable to ventilate the victim after two attempts
promptly return to chest compressions.
 Figure 1.8: Mouth to Mouth Ventilation

If you give breaths too quickly or with too much force this will cause air to enter the
stomach rather than the lungs. This can cause gastric inflation. Gastric inflation may
lead to vomiting, aspiration or pneumonia.

• Take one second to deliver each breath

• Deliver air until you make the victim’s chest rise

Gastric inflation can however occur even when rescuers give breaths correctly.

1.2.7 USING A BAG-MASK DEVICE DURING 2-RESCUER CPR

The bag-mask device is the most commonly used method for delivering positive
pressure ventilation during CPR. This should not be used in 1-rescuer CPR, as it is
clumsy and difficult to use for one person who also has to perform chest
compressions. It is very useful in 2-rescuer CPR.

The steps for using a bag-mask device during 2-rescuer CPR are:
Step Action

1 Position yourself directly above the victim’s head

2 Open the air way using head tilt – chin lift

3 Place the mask on the victim’s face using the bridge of the nose as a guide for
the correct position. The narrow portion of the mask should be at the bridge
of the nose.

4 Use the E-C clamp technique to hold the mask in place while you lift the jaw to
keep the airway open (Figure 1.9).

• Use the thumb and index finger of one hand to make a “C” on the side
of the mask, pressing the edges of the mask to the face

• Use the remaining fingers to lift the angles of the jaw (3 fingers form an
“E”), open the airway and press the face to the mask.

5 Squeeze the bag to give breaths (1 second each) while watching for chest rise.
If your hands are too small to effectively compress the bag, press the bag with
your free hand against your thigh

6 Deliver two breaths over 1 second each and then the second rescuer re-
commences 30 chest compressions.
Figure 1.9: E-C Clamp Technique

Some bag and mask devices allow you to administer supplemental oxygen through
the mask. The length of each breath should remain 1 second, in order to minimize
interruptions in chest compression and avoid excessive ventilation.

1.2.8 TWO- RESCUER ADULT BLS TEAM SEQUENCE

Wherever possible BLS should be a team effort. Where there is more than one
rescuer, each member of the team will take on a specific role.
If there are two rescuers at the scene – the first rescuer assesses the patient and
then sends the second rescuer for help and to bring more equipment. The second
rescuer should bring a defibrillator if that is available, as well as a bag and mask
 and medications for advanced life support. While he/she is doing this the first
rescuer should begin 1-rescuer CPR immediately.

When the second rescuer returns, the roles (of administering chest compressions
or of giving breaths) should be switched after every 5 cycles (~2 minutes) to avoid
fatigue.

Duties for each Rescuer (Figure 1.10)

Rescuer Location Duties

• Perform chest compressions

- Depth of at least 5cm chest compression not more

than 6cm

- Rate at 100/min to 120/min

- Allow complete chest recoil after each compression

Rescuer 1 At victim’s
side - Minimize any interruptions in compressions to < 10
seconds

- Use compression: breath ratio of 30:2

- Count compressions aloud

• Switch duties with the second rescuer every 5 cycles or at

about 2 minutes, taking < 5 seconds to switch.

••
Maintain an open airway using head tilt-chin lift
•
Give two breaths, watching for chest rise and avoiding
Rescuer 2
excessive ventilation
 At victim’s Encourage 1st rescuer to perform compressions that are
head deep enough and fast enough, allowing complete chest
recoil

• Switch duties with the 1st rescuer every 5 cycles or about

2 minutes taking < 5 seconds to switch

Figure 1.10: Two-Rescuer CPR

If there are three rescuers, then the third rescuer can be used to assist with bag-
mask ventilation. One person opens the airway using head tilt-chin lift and holds
the mask to the face. A second person squeezes the bag. This is a more effective
ventilation method than just one person performing both actions.
The aim of teamwork is to minimize interruptions to compressions by:
1. Compressor counts aloud so rescuer providing breaths is ready to
deliver them, and is ready for the switch after 5 cycles
2. Compression is hard work and switching roles avoids rescuer
fatigue.
3. If you have an AED, the time taken for the rhythm analysis can be
used to switch roles
4. Each switch should take < 5 seconds
Figure 1.11: Adult BLS Algorithm
1.3 PEDIATRIC/CHILD BLS (CHILDREN FROM ONE YEAR AGE TO PUBERTY)

1.3.1 KEY DIFFERENCES BETWEEN ADULT AND CHILD BLS

There are many similarities between CPR in adults and children but there are few
key differences:
1. Compression-ventilation ratio for 2-rescuer CPR: in children is 15:2 (for 1-
rescuer it is still 30:2)
2. Compression depth: For children compress at least 1/3 of the anterior-
posterior diameter of the chest (approx. 5cm)
3. Compression technique: May use 1 or 2-handed chest compressions for very
small children to achieve the above-mentioned depth.
4. Timing of activation of the emergency response system:
a. If you did not witness the arrest and are alone, provide 2 minutes of CPR
before leaving the child to call for help

If the arrest is sudden and witnessed, leave the child to call for help and get a defibrillator,
then return to the child.

The reason for this is that children are more

likely to
develop respiratory arrest before a cardiac
arrest. If a
child with respiratory arrest or bradycardia
receives
prompt CPR before a cardiac arrest has
occurred, they
have a high survival rate.
1.3.2 CHEST COMPRESSIONS IN CHILDREN (From one year to puberty)

The key principles of chest compression in children remain the same as for an adult:
• Start compressions within 10 seconds of recognition of cardiac arrest
• Push hard –1/3 AP diameter of the chest about 2inches (5 cm)
• Rate of compression100-120 beats /minute
• Allow complete chest recoil between compressions
• Minimize interruptions between compressions (<10 seconds)

In larger children, the same chest compression technique can be used as in adults.
In smaller children it may be sufficient to use a one hand technique, as described in
the box below and shown in the Figure 1.12. In very small children both hands can
be used to encircle the chest as described in the next section for infant resuscitation.

Step Action

1 Position yourself at the victim’s side. It doesn’t matter which side.

2 Make sure the victim is lying faceup on a firm, flat surface.

3 Put the heel of one hand on the center of the victim’s chest on the lower half
of the sternum (Figure 1.12). This may be sufficient to achieve adequate chest
compression in a child

4 Straighten your arm and position your shoulders directly over your hand.

5 Push hard, push fast • Press down at least 1/3 the AP diameter of the chest
with each compression about 2 inches or 5 cm

• For each compression make sure you push straight down on the
victim’s sternum (Figure 1.13)

• Deliver compressions in a smooth fashion at a rate of at 100-120/min

6 At the end of each compression make sure you allow the chest to recoil (re-
expand) completely.
7 Minimize interruptions (less than 10 seconds between sets of 30
compressions if possible).

Figure 1.12: One Handed Chest Compression on Child

Figure 1.13: Two Handed Chest Compression on Child
1.3.3 GIVING BREATHS IN CHILDREN

In adults it is sometimes alright to perform just chest compressions, if the rescuer is not
confident or willing to provide rescue breathing. This is because in sudden cardiac arrest
the oxygen content of the blood is usually normal so compressions alone can provide
adequate oxygen delivery to the brain and heart for the first few minutes after an arrest.

Figure 1.14: Mouth to Mouth Ventilation- Child

In children, usually there has been preceding respiratory failure or shock that
reduces the oxygen content in the blood even before the onset of arrest. This
means that chest compressions alone cannot deliver adequate oxygen to the brain.
A combination of compressions and breaths is essential in CPR for children.

During giving of breaths there should be visible chest rise. Rescuers should avoid
excessive ventilation by giving breaths over 1 second (Figure 1.14).

When using a bag-mask device, the size of the mask should be appropriate for the
child – covering the victim’s mouth and nose completely without covering the eyes
 or overlapping the chin. After selecting the correct size mask, open the airway using
head tilt-chin lift, then press the mask to the child’s face making a seal as you lift the
jaw. Supplementary oxygen can be connected to the bag-mask when available.

Critical Concepts:
Give effective breaths that make the chest rise
Avoid excessive ventilation

1.3.4 ONE-RESCUER CHILD BLS SEQUENCE

If you are the first rescuer to the scene, follow these steps to perform BLS sequence
for a child:

Step Action

1 Verify scene safety.

See if the child is responsive or not by gentle shaking and calling to them. If
there is no response shout for nearby help or activate emergency response
system via mobile device if available

2 Simultaneously check for breathing and pulse. You can try to feel the carotid or
the femoral pulse. To locate the femoral artery pulse place 2 fingers in the
inner thigh, midway between the hipbone and the pubic bone and just below
the crease where the leg meets the abdomen.

3 If no breathing or only gasping breathing and no definite pulse felt within 10

seconds:

• If no-one responds and you witnessed the child’s sudden collapse –

leave the child to call for help and get an AED if available.

• If no-one responds and you didn’t witness the child’s collapse – give 5
cycles of CPR (as described below) before leaving the child to get help.
4 If no normal breathing but pulse is felt:

• Provide rescue breathing – 1 breath every 2-3 seconds

• Add compressions if pulse remains ≤ 60/min with signs of poor perfusion.

• Activate emergency response system if not done already.

• Continue rescue breathing and check pulse about every 2 minutes. If you
don’t definitely feel a pulse within 10 seconds, or if the heart rate is <60bpm
with signs of poor perfusion despite adequate oxygenation and ventilation,
start cycles of compressions and breaths, starting with chest compressions (C-
A-B) at a ratio of 30:2. (Use 15:2 if second rescuer arrives)

5 Use the AED as soon as it becomes available.

1.3.5 TWO-RESCUER CHILD BLS SEQUENCE

The rescue sequence when there are two rescuers is as follows:

Step Action

1 Verify scene safety.

Check the child for responsiveness. If there is no response the first rescuer
remains with the victim and the second rescuer should go for help, activate the
emergency response system and retrieve AED if available and more equipment.

2 First rescuer checks the child’s breathing and carotid or femoral pulse (within 5-
10 seconds) simultaneously.

3 If no breathing or only gasping and no pulse is found within 10 seconds or the

heart rate is < 60bpm with signs of poor perfusion, start cycles of compression
and breaths at a ratio of 30:2.

4 When the second rescuer arrives, change to a compression and breaths ratio of
15:2. Use AED as soon as possible.
1.3.6 RECOVERY POSITION

After the initial assessment of any unconscious child whose airway is clear, and who
is breathing normally, should be kept in recovery position.

The main aim is to prevent airway obstruction and reduce the likelihood of fluids
such as saliva, secretions and vomitus from entering into the upper airway. Place
the child in the lateral position with mouth on dependent position to let the free
drainage of the fluid. Make the position stable by putting a small pillow or a rolled-
up blanket along the back.
Figure 1.15: Pediatric BLS Algorithm for the Single Rescuer
Figure 1.16: Pediatric BLS Algorithm for Two or More Rescuer
1.4 INFANT BLS (children under the age of 1 year (12 months)

1.4.1 KEY DIFFERENCES BETWEEN INFANT BLS AND CHILD OR ADULT CPR

In this context, infant is defined as children under the age of 1 year (12 months), but
excludes newly born infants in the delivery room. There are a few key differences
between infant CPR and CPR in children over 1 year:
1. Location of pulse check: brachial artery in infants
2. Technique of delivering compressions: 2 fingers in the center of the chest,
just below the nipple line for single rescuer and 2 thumb-encircling hands in
the center of the chest, just below the nipple line for 2 rescuers
3. Compression depth: at least 1/3 the chest depth, approximately 1½ inches
(4cm)
4. Compression-ventilation rate and ratio for 2 rescuers: same as for child
– At the rate of 100 to 120 /min 15:2 ratio for 2 rescuers and 30:2 for 1 rescuer.
5. When to activate the emergency response system (same as for child):
a. If you did not witness the arrest and are alone, provide 2 minutes of CPR
before leaving the infant to get further help and get a defibrillator
b. If the arrest is sudden and witnessed, leave the infant briefly to call for
further help, then return to the infant.

1.4.2 BRACHIAL PULSE CHECK

To find the brachial pulse in an infant, place 2 or 3 fingers on the inside of the upper
arm, between the infant’s elbow and shoulder. Press gently for at least 5 seconds,
but no more than 10 seconds while trying to feel for a pulse (Figure 1.17).
Figure 1.17: Checking an Infant’s Brachial Pulse

It can be difficult to perform the pulse check in an infant, so if you are not sure
whether you have felt a pulse after 10 seconds, and the child is unresponsive and
not breathing or gasping – you should immediately start chest compressions.

1.4.2 CHEST COMPRESSION IN INFANT- ONE RESCUER

When there is just one rescuer in infant BLS you should use the 2-finger chest
compression technique described below:

Step Action

1 Place the infant on a firm flat surface

2 *Place 2 fingers in the center of the infant’s chest just below the nipple line.
Do not press on the bottom of the breastbone (Figure 1.18).

3 Push hard and fast. Press the infant’s breast bone down at least 1/3 the depth
of the chest (approximately 4cm). Deliver compressions in a smooth fashion at
a rate of at least 100 to 120/min
4 At the end of each compression make sure you allow the chest to recoil
completely. This allows blood to flow into the heart and is necessary to create
blood flow during chest compressions. Incomplete chest recoil will reduce the
blood flow created by chest compressions. Chest compression and chest recoil
times should be approximately equal.

5 Minimize interruptions in chest compressions

* Studies suggest that the 2-thumb–encircling hands technique may improve CPR
quality when compared with 2-finger compressions, particularly for depth.

Figure 1.18: Two Finger Chest Compressions in Infant

1.4.2 CHEST COMPRESSION IN INFANT- TWO RESCUER

When there are two rescuers in infant CPR you should give chest compressions
using the 2 thumb-encircling hands technique. This leads to better blood flow and
more consistently results in appropriate depth or force of compression than the 2-
finger technique.
 The steps for 2 thumb-encircling hands technique are as follows:

Step Action

1 Place both thumbs side by side in the center of the infant’s chest on the lower
half of the breast bone. The thumbs may overlap in very small infants (Figure
1.19).

2 Encircle the infant’s chest with 2 fingers in the center of the chest, just below
the nipple line and support the infant’s back with the fingers of both hands

3 With your hands encircling the chest, use both thumbs to depress the
breastbone at least 1/3 the depth of the infant’s chest (approx. 4cm)

4 Deliver compressions in a smooth fashion at a rate of at least 100 to 120/min

5 After each compression completely release the pressure on the breastbone to

allow complete chest recoil

6 After every 15 compressions, pause to allow the second rescuer to open the
airway with head tilt-chin left and give 2 breaths. The chest should rise with
each breath

7 Continue compressions and breaths in a ratio of 15:2 (for 2 rescuers),

switching roles every 2 minutes (10 cycles of 15:2) to avoid rescuer fatigue.
 Figure 1.19: Two Thumb Encircling Technique

1.4.2 INFANT MOUTH TO MOUTH AND NOSE BREATHING

Mouth to mouth breathing may be necessary in the pre-hospital context where there
is no bag and mask available. The rescuer’s exhaled air contains approximately
17% oxygen and 4% carbon dioxide. This is enough oxygen to meet the victim’s
needs.
In the infant it is preferred to give mouth to mouth-and-nose breaths. The steps to
take are as follows:
1. Open the airway with head tilt-chin lift. Take care not to over extend
the infants head beyond the neutral position as this may block the
airway. The external ear canal should be level with the top of the
infant’s shoulder.
2. Place your mouth over the infant’s mouth and nose to create an airtight
seal (Figure 1.20).
3. Blow into the infant’s nose and mouth (pausing to inhale between
breaths) to make the chest rise with each breath
4. If the chest does not rise, repeat the head tilt-chin lift to reopen the
airway and try to give a breath that makes the chest rise. It may be
necessary to move the infant’s head through a range of positions to
provide optimal airway patency and effective rescue breaths.
5. When the airway is open, give 2 breaths that make the chest rise. You
may need to try a couple of times.

In the infant, if you cannot cover both the nose and mouth with your own mouth, it
is possible to give just mouth-to-mouth breaths. In this case the infant’s nose should
be pinched tightly closed with thumb and forefinger.
Figure 1.20: Mouth to Mouth and Nose Breaths for an Infant
1.4.6 INFANT VENTILATION WITH BAG AND MASK

The principles of using a Bag and mask device is the same in infants as for adults.
It is important to select a mask of the appropriate size – it should cover the infant’s
mouth and nose completely without covering the eyes or overlapping the chin.

Perform a head tilt – chin lift to open the victim’s airway, then press the mask onto
the infant's face, making a seal. Connect supplementary oxygen to the mask when
available. It is also important not to over extend an infant’s head beyond the neutral
(sniffing) position. This may lead to blocking of the airway. The external ear canal
should be level with the top of the infant’s shoulder.

`1.4.7 ONE-RESCUER INFANT BLS SEQUENCE

For a single rescuer, the compression to ventilation ratio should be 30:2 for giving
CPR. The sequence to follow is shown in the table:

Step Action

1 Verify scene safety.

See if the infant is responsive or not by gentle shaking and calling to them. If
there is no response shout for nearby help or activate emergency response
system via mobile device if available

2 Simultaneously check for breathing and brachial pulse (at least 5 seconds but
no more than 10 seconds)

3 If no breathing or only gasping breathing and no definite pulse felt within 10

seconds:

• If no-one responds and you witnessed the child’s sudden collapse –

leave the child to call for help and get an AED if available.

• If no-one responds and you didn’t witness the child’s collapse – give 5
cycles of CPR (as described below) before leaving the child to get help.
4 If no breathing or only gasping and no pulse is found within 10 seconds or the
heart rate is < 60bpm with signs of poor perfusion, start cycles of compression
and breaths at a ratio of 30:2 starting with compressions with two fingers
technique.

5 After 5 cycles, if you are alone and no-one else has gone for help, then you
must go for help yourself and get a defibrillator if available

1.4.8 TWO-RESCUER INFANT BLS SEQUENCE

Step Action

1 Verify scene safety.

Check the infant for responsiveness. If there is no response the first rescuer
remains with the victim and the second rescuer should go for help activates
emergency response system and retrieves AED if available and more
equipment.

2 First rescuer checks the infant’s breathing and brachial pulse (within 5-10
seconds) simultaneously

3 If no breathing or only gasping and no pulse is found within 10 seconds or the

heart rate is < 60bpm with signs of poor perfusion, rescuer 1 should start
cycles of compression and breaths at a ratio of 30:2, starting with
compressions.

4 When the second rescuer arrives, change to a compression and breaths ratio
of 15:2. The two-thumb encircling technique should now be used for chest
compressions

5 Use infant AED as soon as possible if available.

1.4.9 RESCUE BREATHING
When a victim has a pulse but is not breathing effectively, rescuers should give
breaths without chest compressions. This is rescue breathing.

Rescue breathing for adults Rescue breathing for children and infants

Give 1 breath every 5-6 seconds Give 1 breath every 2-3 seconds

(about 10 to 12 breaths per minute) (about 2-30 breaths per minute)

Give each breath in 1 second

Each breath should result in visible chest rise

Check the pulse about every 2 minutes

In infants and children, if the heart rate remains below 60bpm, with signs of
inadequate perfusion despite adequate ventilation and oxygenation, then full CPR
should be started.
1.5 USE OF AUTOMATED EXTERNAL DEFIBRILLATOR (AED)

Automated external defibrillator (AED) is not available everywhere in the context of

Nepal but it is one of the most important components of BLS and early defibrillation
is proven to save lives. We will describe the key principles, so that you will be able
to use it in future.

The time from collapse to defibrillation is one of the most important determinants of
survival from sudden cardiac arrest with ventricular fibrillation or pulse less
ventricular tachycardia AED can identify cardiac arrhythmias requiring a shock and
then deliver it. They are simple to use and in many countries are safely used by
non-medical personnel.

When a second rescuer arrives with an AED, they should place it at the victim’s side
and prepare it for use. The first rescuer should continue chest compressions
uninterrupted until the AED is ready.

There are several different models of AED, so the instructions should be read before
use, but there are four key principles.
1. Power on the AED – which will then guide you through the next steps to
take

2. Attach AED pads to the victim’s bare chest

a. Choose right size pads (adult or child)
b. Peel backing away from the AED pads
c. Attach the pads – one on the upper-right chest, directly below the collar
bone – the other to the side of the left nipple with the top edge of the pad
a few inches below the armpit (see Figure 1.21 and 1.22)
d. Attach the AED connecting cables to the AED box (some are pre-
connected)
Figure 1.21: AED Attached

Figure 1.22: AED Attached for Infant and Child

3. “Clear” the victim and ANALYZE the rhythm

 a. The AED will prompt you to “clear” the victim during rhythm analysis. This
means everyone should stop touching the patient (both chest
compressions and breathing)
b. The AED will tell you if a shock is required

4. If the AED advises a shock it will tell you to “clear” the victim
a. Be sure no-one is touching the victim
b. Usually the AED will automatically deliver the shock or it may tell you to
press the
SHOCK button
c. The shock will produce a sudden contraction of the victim’s muscles

If no shock is needed, or immediately after a shock is delivered– chest

compressions should be restarted immediately. Do not stop for a pulse check or
to recheck the rhythm after the delivery of a shock. After a further 5 cycles of CPR,
the AED will prompt you to repeat steps 3 and 4. Do not turn off the AED during
CPR.
1.6 CHOKING - RELIEF OF CHOKING IN ADULTS AND CHILDREN OLDER
THAN 1 YEAR

The management of choking varies with the severity of airway obstruction and
whether the victim is responsive or non-responsive.

1.6.1 MILD AIRWAY OBSTRUCTION

In mild airway obstruction due to choking the victim is still able to cough forcefully
and there is good air exchange. They may be wheezy between coughs. In this
situation the rescuer should just encourage the victim to continue their own coughing
and breathing efforts. The rescuer SHOULD NOT INTERFERE with the victims
attempts to expel the foreign body, but should stay with the victim and monitor their
condition.

If the victim continues to choke and mild airway obstruction persists, they should be
brought to hospital for further management.

1.6.2 SEVERE AIRWAY OBSTRUCTION

In severe airway obstruction the victim is coughing very weakly or not at all and
there is poor or no air exchange. There may be a high-pitched noise on inspiration
(stridor) or no noise at all. The patient may become cyanosed, will be unable to
speak and is clutching the neck as shown in the diagram below (Figure 1.23).
 Figure 1.23: Universal Choking Sign
In this situation the rescuer should ask the victim “Are you choking?” If the victim nods
their head for yes, but cannot talk, they have severe airway obstruction and need further
urgent management with abdominal thrusts (the Heimlich Maneuver).

Heimlich Maneuver – For the Responsive Victim (Figure 1.24).

This is performed in the responsive adult or child more than 1 year old who has
severe airway obstruction due to choking. It should not be done in infants. In very
obese patients or in pregnant women it may be necessary to do chest thrusts
instead of abdominal thrusts.

Step Action

1 Stand or kneel behind the victim and wrap your arms around the victim’s
waist

2 Make a fist with one hand

3 Place the thumb side of your fist against the victim’s abdomen in the
midline, slightly above the umbilicus and well below the breastbone
(sternum)

4 Grasp your fist with the other hand and press your fist into the victim’s
abdomen with a quick forceful upward thrust

5 Repeat thrusts until the object is expelled from the airway or the victim
becomes unresponsive

6 Give each new thrust with a separate, distinct movement to relieve the
obstruction
Figure1.24: Heimlich’s Maneuver

Relieving Choking in the Unresponsive Victim Aged 1 Year or Older

If a choking victim becomes unresponsive during your attempt to help them, call for
an ambulance, lie the victim gently on the ground and begin CPR (30:2). It is not
necessary to check for a pulse.

Every time you open the airway to give breaths, look carefully in the mouth to see if
you can identify the foreign body. If you can see it, you can try to remove it with
your finger. Do not perform blind finger sweeps as this may just push a foreign body
further down the throat.

If you cannot see the foreign body, give two breaths and then re-commence chest
compressions.
1.6.3 AFTER RELIEF OF CHOKING

If you see and remove a foreign body from the victim's mouth, and/ or air movement
occurs with chest rise when you are giving breaths, then you know you have
removed the airway obstruction. The patient should now be managed as for any
other unresponsive victim (check response, breathing and pulse) and provide CPR
or rescue breathing as needed. If the victim responds, they should be encouraged
to seek medical attention in case the foreign body has lodged further down the
airway and to check if there has been any complication from the abdominal thrusts.

1.6.4 RELIEF OF CHOKING IN INFANTS

The recognition and initial management of mild or severe airway obstruction is the
same in infants as it is in adults and children over the age of one. However, the
technique for removing the obstruction in severe airway obstruction in an infant is
very different from that in older children.

Relieving Choking in Responsive Infant (Figure 1.25)

This requires a combination of back slaps and chest thrusts. Abdominal thrusts
should not be used in infants as you are likely to cause harm to the liver or spleen.

Step Action

1 Kneel or sit with the infant on your knee

2 Remove the clothing from the infant’s chest if it is simple to do so

3 Hold the infant facedown with the head slightly lower than the chest, resting
on your forearm. Support the infant’s head and jaw with your hand. Be careful
not to smother the child’s nose and mouth, or to press on the soft tissues of
the neck.

Rest your forearm on your own thigh, to support the infant.

4 Deliver up to 5 back slaps forcefully between the infant’s shoulder blades, using
the heel of your hand. Deliver each slap with sufficient force to attempt to
dislodge the foreign body

5 After delivering up to 5 back slaps, place your free hand on the infant’s back,
supporting the back of the infant’s head with the palm of your hand. The infant
will be “sandwiched” between your two forearms, with the palm of one hand
supporting the face and jaw, while the palm of the other hand supports the
back of the infant’s head.

6 Turn the infant as a unit while carefully supporting the head and neck. Hold the
infant faceup, with your forearm resting on your thigh. Keep the infant’s head
lower than the trunk.

7 Give up to 5 quick downward chest thrusts in the middle of the chest over the
lower half of the breastbone (as for chest compressions during CPR). Deliver
chest thrusts at a rate of about 1 per second, each with the intention of
creating enough force to dislodge the foreign body.

8 Repeat the sequence of up to 5 back slaps and up to 5 chest thrusts until the
object is removed or the infant becomes unresponsive.
Figure 1.25: Relieving choking in a responsive infant

Relieving Choking in Unresponsive Infant

If the infant becomes unresponsive, stop giving back slaps and begin CPR.

Step Action

1 Call for help. Place the infant on a firm, flat surface

2 Begin CPR starting with compressions (30:2)

3 Each time you open the airway to give breaths, check to see if you can see the
foreign body. If you see an object and can easily remove it, do so. Do not
perform blind finger sweeps

4 Continue CPR until help arrives