Made sure that I, child and bystanders were safe?

Tab the bottom of the child’s feet and asked loudly: ‘Are you alright?’

As unresponsive shouted for help?

Assessed airways by turning child onto their back, tilted head and lifted chin?

As this did not work or trauma suspected applied jaw thrust technique?

Assessed breathing by looking, listening and feeling for normal breathing for no more than 10 seconds?

As unresponsive and not breathing called 999 (as alone and no mobile phone commenced BLS for 1 min. and then when and summoned help)?

Sent for an AED?

Gave 5 rescue breaths with below technique?

<= 1 year:

- Ensured a neutral position of the head (as an infant’s head is usually flexed when supine, applied appropriate some gentle extension) and applied chin lift

- Took a breath and covered the mouth and nose of the infant with my mouth, making sure I had a good seal

- As the nose and mouth could both be covered in the older infant, attempted to seal only the infant’s nose or mouth with my mouth (as the nose was used, closed the lips to prevent air escape)

- Blowed steadily into the infant’s mouth and nose over 1 second sufficiently to make the chest rise visibly

- Maintained head position and chin lift, took my mouth away and watched for the child’s chest to fall as air came out

- Took another breath and repeated this sequence four more times

> 1 year:

- Ensured head tilt and chin lift; extended the head into 'sniffing’ position

- Pinched the soft part of the nose closed with the index finger and thumb of my hand on the child’s forehead

- Opened the mouth a little but maintained the chin lift

- Took a breath and placed my lips around the mouth, making sure that I had a good seal

- Blowed steadily into the child’s mouth over 1 second sufficient to make the chest rise visibly

- Maintained head tilt and chin lift, took my mouth away and watched for the chest to fall as air came out

- Took another breath and repeated this sequence four more times

- Identified effectiveness by seeing that the child’s chest had risen and fallen in a similar fashion to the movement produced by a normal breath

As untrained, unable or unwilling to provide rescue breaths, proceeded with compressions?

Applied chest compressions with below technique?

All infants and children:

- Compressed sternum one finger’s breadth above xiphisternum

- Rate 100-120 per minute

- Released all pressure on the chest between compressions

- After 15 compression tilted the head, lifted the chin and gave 2 rescue breaths

- Changed person given chest compressions every 2 minutes

- Minimised interruptions to compressions

<= 1 year:

- Preferably used a two-thumb encircling technique for chest compression in infants – was careful to ensure complete chest recoil after each chest compression

Placed both thumbs flat, side-by-side, on the lower half of the sternum (as above), with the tips pointing towards the infant’s head

Spread the rest of both hands, with the fingers together, to encircle the lower part of the infant’s rib cage with the tips of the fingers supporting the infant’s back

Pressed down on the lower sternum with my two thumbs to depress it at least one-third of the depth of the infant’s chest, approximately 4 cm

As small infants, needed to overlap my thumbs to provide effective compressions

- As single rescuers alternatively used a two-finger technique

Compressed the lower sternum with the tips of two of your fingers (index and middle fingers) by at least one-third of the depth of the infant’s chest, approximately 4 cm

> 1 year:

- Placed the heel of one hand over the lower half of the sternum

- Lifted the fingers to ensure that pressure was not applied over the child’s ribs

- Positioned myself vertically above the victim’s chest and, with my arm straight, compressed the sternum by at least one-third of the depth of the chest, approximately 5 cm

- As larger child or small rescuers, this was achieved more easily by using both hands with the fingers interlocked

As soon as AED arrived:

- Switched on and follow instructions, but minimised the interruptions to CPR?

- Attached electrodes onto the bare chest?

- As more than one rescuer, continued CPR whilst pads are attached?

- Followed instructions, ensuring no one is touching the patient, when the shock was delivered?

Continued CPR 15 chest compressions : 2 rescue breaths until help arrived, did not stop CPR?

Covid-19 infection?

As chest compressions were aerosol generating used (ideally) full (level 3) PPE (Resus UK 2021)`/

Did not put my face near the patients to listen/feel for breath?

As level 3 PPE was not available individual decisions were made on course of action depending on risks?

Chest compression were undertaken as a minimum with following technique?

- Level 2 PEE (eye protection, gloves, apron and fluid resistant face mask)

- Covered the child’s nose and mouth with cloth/mask

Ventilations (eg bag valve mask) only as level 3 PPE available?

Attach defibrillator ASAP?

Paediatric ALS

Oxygenated and ventilated by using bag-valve mask ventilation and high concentration oxygen as soon as available - 2 ventilations to every 15 chest compressions?

Intubate only if ventilation became problematic and could be done with minimal interruption to chest compressions?

Once intubated continued with chest compressions at a rate of 100-120/minute and ventilated at age appropriate rate as outlined below?

- Infants: 25 breaths per minute

- Children 1-8 years old: 20 breaths per minute

- Children 8-12 years old: 15 breaths per minute

- Children >12 years old: 10-12 breaths per minute

Attach defibrillator with following technique?

- Placed one defibrillator pad or paddle on the chest wall just below the right clavicle and one in the mid-axillary line

- As under 8 years old used a paediatric attenuated set of pads

- As this was not available, used adult pads

- Noted that pads for children should be 8–12 cm in size and for infants 4.5 cm in size

- As infant/small child, applied pads to the front and back of the chest as they could not be adequately separated in the standard positions

- Assess rhythm and checked for signs of life

- If non-shockable rhythm (pulseless electrical activity (PEA) or asystole) considered as the most common findings in children and corrected reversible causes as below:

4 Hs: Hypoxia, Hypovolaemia, Hyper/Hypokalaemia/metabolic changes, Hypothermia

4 Ts: Thrombosis (coronary or pulmonary), Tension pneumothorax, Tamponade (cardiac), Toxins

If shockable rhythm used 4J/Kg and did not exceed the normal max dose for adults (200J)

During CPR:

Use waveform capnography?

Established IO or IV access?

Gave adrenaline (10 mcg/kg = 0.1ml of 1:1000 per kg) immediately if non-shockable? Then every 3-5 minutes if shockable or non-shockable?

Considered Amiodarone (5 mg/kg) after 3 and 5 shocks, if in a shockable rhythm?

Paused briefly every 2 minutes to reassess rhythm?

Acknowledged the below?

In adults majority of events (75-85%) caused by a primary cardiac pathology, but in children only 5-10% caused by a primary cardiac pathology and SIDS, trauma, respiratory arrest and drowning are most common causes

Resource(s):

Resuscitation Council UK: Paediatric basic life support Guidelines

Resuscitation Council UK: Paediatric advanced life support Guidelines