1. Prepared by: Dr. Salma Elgazzar

4. ABC or CAB 2010 AHA for CPR recommend a CAB sequence:  C hest compression  A irway  B reathing\ventilation

9. CABS Sequence Assess need for CPR If health care provider take 10 seconds to check for pulse :  Brachial in infant  Carotid or femoral in a child “ARE YOU OKAY?”

10. BREATHING CHILD If child is breathing, put in recovery position, call emergency response system, return quickly and re-assess child’s condition. Turn child on-side (recovery position).

11. INADEQUATE BREATHING WITH PULSE if pulse > 60 per minutes but there is inadequate breathing give rescue breathing at a rate of about 12 to 20 breathes per minute. Reassess pulse about every 2 minutes  Carotid or femoral for child  Brachial for infant

12. UNRESPONSIVE AND NOT BREATHING If the child is unresponsive and not breathing (or only gasping) begin CPR. Start with high-quality chest compression. (30 chest compressions) After 2 minutes check for pulses Call for help when able

13. Bradycardia with Poor Perfusion If pulse is less than 60 per minutes and there are signs of poor perfusion  Pallor  Mottling  cyanosis despite support of oxygenation and ventilation – start CHEST COMPRESSION

16. CHEST COMPRESSION:  Rate of 100 compression per minute  Push hard: sufficient force to depress at least one third the anterior-posterior diameter of the chest.  1 ½ inches in infants  2 inches in children  Allow chest recoil after each compression to allow the heart to refill with blood.

17. HAND PLACEMENT: INFANT: compress the sternum with 2 fingers placed just below the inter-mammary line CHILD: compress the lower half of the sternum at least one third of the AP diameter of the chest (2 inches) with one or two hands Note: do not compress over the xiphoid or ribs

19. VENTILATION \ COMPRESSION: One rescuer: 30 compression to 2 ventilation Two rescuers: 15 compression to 2 ventilation After initial 30 compression(or 15), open airway using a head tilt-chin lift and give 2 breaths using mouth-to- mouth-and nose. Note: if you use mouth to mouth, pinch off the nose. Continue for approximately 2 minutes (about 5 cycles) before calling for ERS and AED.

20. AED IN CHILDREN Age > 8 years use adult AED Age 1-8 years use paediatric pads / settings if available (otherwise use adult mode) Age < 1 year use only if manufacturer instructions indicate it is safe

21. DEFIBRILLATION DOSING  The recommended first energy dose for defibrillation is 2 J/kg.  If second dose is required, it should be doubled to 4 J/kg.  AED with pediatric attenuator is preferred for children < 8 years of age.

22. DEFIBRILLATION SEQUENCE Turn AED on Follow the AED prompts End CPR cycle (for analysis and shock) Resume chest compressions immediately after the shock. Minimize interruptions in chest compressions. State CLEAR when giving the shock and have visual / verbal communication with any other rescue personal

23. AED DEFIBRILLATION

24. ATTACH PADS TO CASUALTY’S BARE CHEST

25. ANALYSING RHYTHM - DO NOT TOUCH VICTIM

26. Stand clear Deliver shock SHOCK INDICATED

27. SHOCK DELIVERED FOLLOW AED INSTRUCTIONS

28. PEDIATRIC ADVANCED LIFE SUPPORT Timely intervention in seriously ill or injured children is the key to preventing progression toward cardiac arrest and to saving lives.

29. PEDIATRIC CARDIAC ARREST  Pediatric cardiopulmonary arrest results when respiratory failure or shock is not identified and treated in the early stages.  Early recognition and intervention prevents deterioration to cardiopulmonary arrest and probable death.

30. CARDIAC ARREST Pediatric cardiac arrest is:  Uncommon  Rarely sudden cardiac arrest caused by primary cardiac arrhythmias.  Most often asphyxial, resulting from the progression of respiratory failure or shock or both.

31. RESPIRATORY FAILURE A respiratory rate of less than 10 or greater than 60 is an ominous sign of impending respiratory failure in children. Breathing is assessed to determine the child’s ability to oxygenate. Assessment:  Respiratory rate  Respiratory effort  Breath sounds  Skin color

32. CIRCULATION  Circulation reflects perfusion.  Shock is a physiologic state where delivery of oxygen and substrates are inadequate to meet tissue metabolic needs. Circulation Assessment:  Heart rate ( most accurate assessment )  Blood pressure  End organ perfusion Urine output (1-2 mL / kg / hour) Muscle tone Level of consciousness

33. CIRCULATION ASSESSMENT: HEART RATE : is the most sensitive parameter for determining perfusion and oxygenation in children.  Heart rate needs to be at least 60 beats per minute to provide adequate perfusion.  Heart rate greater than 140 beats per minute at rest needs to be evaluated. BLOOD PRESSURE: Minimal changes in blood pressure in children may indicate shock. Hypotension is defined as systolic blood pressure  Neonates: < 60 mm Hg  Infants: <70 mm Hg  Child (1 to 10): < 70 mm Hg  Child (>10): < 90 mm Hg

39. AIRWAY MUST BE CLEAR AND PATENT FOR SUCCESSFUL VENTILATION.  Position  Suction  Administration of oxygen  Bag-mask ventilation Note: suctioning is helpful if secretions, blood or debris is present. Use with caution if upper airway swelling is edema (eg. croup, epiglottitis)

43. Bag-valve-mask

45. LMA –Laryngeal Mask Airway

47. Uncuffed ET tubes

48. Cuffed ET Tube

49. Endotracheal Tube Intubation New guidelines:  Secondary confirmation of tracheal tube placement.  Use of end-tidal carbon dioxide monitor or colorimetric device (capnography)

50. Capnography : is the monitoring of the concentration or partial pressure of carbon dioxide (CO 2) in the respiratory gases. Its main development has been as a monitoring tool for use during anesthesia and intensive care.partial pressurecarbon dioxideanesthesiaintensive care It is usually presented as a graph of expiratory CO2 (measured in millimeters of mercury, "mmHg") plotted against time, or, less commonly, but more usefully, expired volume. The plot may also show the inspired CO2, which is of interest when rebreathing systems are being used.rebreathing

51. Vascular Access – New Guidelines New guidelines: in children who are six years or younger after 90 seconds or 3 attempts at peripheral intravenous access – Intraosseous vascular access in the proximal tibia or distal femur should be initiated.

52. Post-resuscitation Care  Re-assessment of status is ongoing.  Laboratory and radiologic information is obtained.  Etiology of respiratory failure or shock is determined.  Transfer to facility where child can get maximum care.

53.  Abdominal thrusts  Stand behind the individual.  Make a fist with one hand and place it thumb side up just above the umbilicus of the victim.  Wrap the other hand on top and thrust forcefully inward and upward.  Repeat this until the object is free from blocking the air way or until the person becomes unconscious. If they become unconscious follow the steps of CPR.

55. INFANT CPR/CHOKING  An infant should be held with one hand with the body resting across the forearm and thumb and index finger around the jar/head for support.  5 Back Blows should be administered with the heel of the hand followed by 5 chest compressions with 2-3 fingers.

56.  Continue with 5 back blows and 5 chest thrusts until the baby begins coughing, the object is forced out, or the baby becomes unconscious.  If the baby becomes unconscious the steps for infant CPR should be followed.