Cardiopulmonary resuscitation in Pediatrics

Cardiopulmonary resuscitation (CPR) in pediatrics is a life-saving intervention tailored to the unique anatomy and physiology of infants and children. It differs from adult CPR in both technique and priorities—most pediatric arrests are due to respiratory failure or shock, not primary cardiac causes.

Manual application of chest compressions and ventilations to patients in cardiac arrest, done in an effort to maintain viability until advance help arrives. This procedure is an essential component of basic life support (BLS), basic cardiac life support (BCLS), and advanced life support (ALS).

Indications

The indications for cardiopulmonary resuscitation (CPR) are majorly divided into two parts:

1. Respiratory failure and arrest
2. Cardiopulmonary failure and arrest

The conditions that lead to either of the above are:

• Drowning
• Suffocation
• Choking
• Injuries-head trauma
• Electric shock
• Excessive bleeding
• Lung disease
• Poisoning
• Suffocation

Procedure

• Give 2 gentle breaths: If the baby is not breathing, give 2 small gentle breaths. Cover the baby’s mouth and nose with your mouth. Each breath should be 1 second long. You should see the baby’s chest rise with each breath.
• Give 30 compressions: Give 30 gentle compressions at the rate of 100/min. Use two fingers in the center of the chest below the nipples. Press down approximately one-third depth of the chest.
• Repeat with 2 breathes and 30 compressions until ALS service arrives.

Steps

1. Determining responsiveness: The child’s state of consciousness and ability to breath and the extent of any injuries should be quickly determined.
2. Shout and tap: Shout and gently tap the child on shoulder. If there is no response, position the infant on his or her back.
3. Gently shaking the child (assuming there is no risk of cervical spine injury) and speaking in a loud voice are helpful in assessing the level of responsiveness.
4. Respiratory effort and effectiveness as well as attempts to speak should be noted. If a head or neck injury is suspected, the cervical spine should be immobilized.
5. Look for any deformities, bleeding or environmental clues that indicate trauma.
6. A verbal call for help is made.
7. If there is a lone rescuer and CPR is necessary, it should be performed for five cycles (30 compressions and 2 breaths constitute a cycle for the lone rescuer).

• Patent airway: Airway should be assessed for patency using look, listen, and feel approach.
• Observe for airway compromise, listen over the patient’s nose and mouth for breathing, and/or place a hand or cheek close to the patient’s face to feel any air movement.
• If obstruction is suspected, establish a patent airway.
• For medical arrest: Head tilt-chin lift maneuver is preferred.
  Note: Any child who suffers a traumatic arrest should have full immobilization of the head and neck, and airway patency is established using the jaw thrust maneuver.
• Head tilt-chin lift: Place the child in supine position on a firm flat surface. Place one hand on the patient’s forehead and one or two fingers of the other hand just lateral to the chin. The neck is then extended slightly by gently pushing the forehead while pulling upward on the mandible.
• Jaw thrust: Three fingers are placed under the angles of jaw, which is lifted upward. The mouth is opened by depressing the chin with thumbs.
• Rescue breathing:

If the child is not breathing:

• Cover the child’s mouth tightly with your mouth.
• Pinch the nose closed.
• Keep the chin lifted and head tilted.
• Give 2 rescue breaths. Each breath should take about a second and make the chest rise.
• Perform chest compressions
• Place the heel of one hand on the breastbone just below the nipples. Make sure your heel is not at the very end of the breastbone.
• Keep your other hand on the child’s forehead, keeping the head tilted back.
• Press down on the child’s chest so that it compresses about one-third to one-half depth of the chest.
• Give 30 compressions. Each time, let the chest rise completely. These compressions should be fast and hard with no pausing. Count the compressions quickly.
• Give the child 2 more breaths. The chest should rise.
• Continue CPR (30 chest compressions, followed by 2 breaths then repeat) for about 2 minutes.
• After 2 minutes of CPR if the child still does not have normal breathing, coughing, or any movement, leave the child if you are alone and call for help.
• Repeat rescue breathing and chest compressions until the child recovers or help arrives.
• If the child starts breathing again, place him or her in the recovery position. Periodically recheck for breathing until the help arrives.
• In infants: Lower half of the sternum—1 fingerbreadth below the internipple line.
• Two fingers are used to compress the sternum about one-third of the depth.
• Another technique: Thumbs are placed on the sternum and the fingers of both hands are placed behind the infant’s back (encircling).
• Small children: Two fingerbreadth above xiphoid process. The heel of one hand is used to compress the sternum, one-third of the depth of chest.
• Older children: Two hands method (as in adult).

General instructions

       Airway

•  Cardiopulmonary arrest in children is often caused by respiratory insufficiency. The anatomical and physiological differences in the airway between the child and adult often contribute to this.
• The airway of the child is much narrower than that of the adult. Obstruction from edema or mucus can significantly reduce the airway diameter and increase resistance to airflow consequently increasing the work of breathing (WOB).
• Infants under 6 months are obligatory nose breathers, which makes clearing of blocked nostrils essential in this age group. The tongue of the infant is larger in proportion to the oral cavity. Posterior shifting of the tongue can cause severe airway obstruction.
• The epiglottis of young children is short and narrow, angling away from the axis of the trachea. This may cause some difficulties during endotracheal intubation.
• In children under 10 years of age, the narrowest part of the airway is below the vocal cord at the level of the cricoid cartilage.
• In teenagers, the narrowest area is at the glottis inlet.
• Opening the airway is important in unresponsive children since they may have airway obstruction because of displacement of the tongue.
• Establishing and maintaining airway patent is essential and can be achieved using one of two maneuvers as follows: head tilt and chin lift and jaw thrust.
• Feeling for the expired air movement on the chest.

Breathing

• Children have high oxygen demand because of their high metabolic rate. Therefore, the inadequate ventilation rapidly leads to hypoxia in children. Hypoxia results from respiratory failure due to (1) decreased lungs compliance and (2) increased airway resistance.
• Apnea is relatively common, and the respiratory rate should be carefully observed.
• If no spontaneous breathing is detected after opening maneuvers, rescue breaths should be administered while maintaining airway patency.

   Circulation

• The rescuer should feel for the pulse in a large artery for up to 10 seconds. This should assess rate and volume: palpation of the carotid pulse in older children and brachial pulse in infants. In all age-groups femoral pulse is an alternative.
• Chest compressions are serial, rhythmic compressions of the chest used to circulate the blood to the vital organs until ALS can be provided. To achieve the optimal compressions, the child must be supine on a hard surface.
• In infants, the area of compression is the lower half of the sternum, which can be located 1 fingerbreadth below the internipple line.

Special Considerations

• Most pediatric arrests are asphyxial—early ventilation is critical.
• Use pediatric-sized equipment (e.g., BVM, airway adjuncts).
• Monitor for return of spontaneous circulation (ROSC) and transition to post-arrest care.

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
4. Marcia London, Ruth Bindler, Principles of Paediatric Nursing: Caring for Children, 8th Edition, 2023, Pearson Publications, ISBN-13: 9780136859840
5. Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/

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