Paediatric CPR overview

I now want to take a look at child CPR and an overview of what we are trying to achieve. I think one of the big problems we have with first aid and resuscitation is, we teach it very well but we actually miss the point of teaching the students or teaching people actually what we are trying to achieve, on what our compression is actually trying to do and the difference between adult and child. The first thing we need to remember is, it is going to be extremely stressful. It does not matter whether it is an adult, a child or a baby that we are resuscitating, it is extremely stressful. But when you start dropping down into your child resuscitation, even for a paramedic, a nurse, intensive care nurse, or an anaesthetist, or a doctor, it is an extremely stressful, frightening, worrying time, and it is also where you have got to be at the top of your game because you need to draw on your underpinning knowledge and understanding. And if you understand what you are trying to achieve, everything seems to be much easier, tends to flow better, and tends to be far, far more effective. Practice makes perfect, understanding your subject makes practice efficient and effective.

A child is just a smaller adult; the heart, slightly different place, slightly different size, but remember a child's heart rate will be much faster than an adult. The way I always try to get people to understand the differences is, imagine a child as a Formula 1 engine, it needs perfect oxygenation, it needs perfect electrocution, it needs everything to be at it's absolute optimum and it runs very fast but it also breaks very fast. If you have Louis Hamilton's car that has a tiny weeny electrical fault, it will not work at all, it just goes into idle mode, sits beside of the road and he cannot do anything. Whereas an adult, if you look at those as an old trucker, an old bus, the wrong fuel, it gets low on fuel, low on energy, chaffs away smokes like a train, it will still keep going, it does not run as fast, but it will still get from A to B, and that is what we have got to look at. A child in cardiac arrest will drop like a stone, whereas an adult will go downhill gradually.

A child runs out of oxygen very, very quickly where an adult has six to eight minutes' worth still in their bloodstream. The heart will be much larger on an adult, smaller on a child, roughly the same place. But unless we understand what the compression does, we do not understand what we are doing, consequently, we start to overthink and we start to make things too complex.

So if you look at a very, very simple model on the table, if we look at this as an adult heart and this is a child's heart, the process is exactly the same. When we put our hands on to the top of the ribs, centre of the nipple line, centre of the chest, and compress 5 to 6 centimetres, what we are actually trying to do is on a hard surface, squash the top of the chest against the bottom of this chest and consequently squashing blood from the heart to push blood up to the brain. And the target organ we need to remember is the brain, if we keep the brain oxygenated, the brain will function, and we have basically a viable body. We can get all the other organs going no problem at all, but if you lose the brain which takes between four and eight minutes, we lose everything.

But it is also crucial to understand that we must do it at the right speed to be efficient. Remember, we are only 30% efficient, whether it is an adult or a child, we are still only 30% efficient. And the other big, big crucial point about this CPR is that we fully recoil a hand off the chest, because if we do not fully recoil, every time we do a compression we are only half emptying the heart, which means instead of 30% efficiency, we are probably only 10% to 15% efficient. So the speed we go at, the depth, we press 5 to 6 centimetres, and a full recoil of the hand of the chest are critically important, whether it is an adult heart, a child's heart or a baby's heart, if we are not doing it properly because we do not understand what we are trying to achieve, the resus becomes much less efficient, and the outcome has become far, far less effective.

If we actually look at a child in itself, the first problem we have, the airway is smaller, easily occluded. So we use sniffing the morning air, we put two fingers on the jaw bone because if you push on the soft palate underneath the mouth on an adult it will not really create many problems, but on a child, it will push the tongue to the back of the throat. So we have got to make sure that the airway is clear and patent. And then we look, listen, and feel no more than 10 seconds to see whether there is breathing. But we will also remember that cyanosis will come on very quickly, these are the blue tinges to the face, the blue fingers and this sort of stuff will happen very quickly. But we still do the 10-second check, look, listen and feel, fingers on the chest, listen for the breathing, and do we have breathing? If we do, great; if we do not, now we have got a problem, now we have got a cardiac arrest child. So whether you are in a house, in hospital, or on the street, we have now got to follow the process.

With a child, we do one minute's worth of CPR, good quality CPR, the centre of the chest, third of the chest depth, for an adult 5 to 6 centimetres in depth. But we are talking about children, so a third of the chest depth, because children are different sizes and different shapes. A third of the chest depth should give us a good compression of the heart, pushing blood to the brain, oxygenating the brain and keeping everything functioning until services can arrive.

After one minute's worth of CPR, if nobody has come to help us, we then stop, make the trouble line call. Remember, it is always advised to do it now on your mobile phone. On your mobile phone you can push speakerphone, put it down by the side of you, and you can talk to the emergency services whilst carrying on. So we have got communication with emergency services, but if this is an ambulance situation, you are waiting for an ambulance to arrive to back you up. If it is a hospital situation, we still start CPR but we hit the crash button. The crash team in a hospital environment will be your resuscitation officers, your crash trolley with the defibs, the drugs, the anaesthetists and everybody else will come to your aid.

In the community, it will be an ambulance with a similar set of people on board, paramedics and technicians, but they will have all the defibs and all the equipment that you require, but the sooner they come on the scene, the sooner the advanced resuscitation takes place. But remember, you cannot get to the advanced resuscitation unless we get the basic resuscitation on the scene, at home, in the street or in a hospital or nursing environment. If we do not get it going quickly that eight-minute span, that eight-minute time that we have got to keep the brain alive has expired and the patient is now non-viable, we will not ever get an amp put out of this patient.

The five breaths are to replace the oxygen that the patient or the child has used in their circulatory system. Remember what I said, they need plenty of oxygen and it needs to be pumped around the body effectively and efficiently, and they run much quicker than you do. So the five breaths is to pre-load. We then do the 30 compressions. That pumps that pre-loaded oxygen into their system when we are now beginning to get oxygen back into the bloodstream. We are now converting to your 30, 2; so your next set of breaths are two breaths, 30 compressions; two breaths, 30 compressions, and we keep on with the basic life support. Even in a hospital environment, they will only keep on with basic life support until further assistance arrives. So that is what we are going to talk about. We are going to say that basically, you have to start that early process to keep the brain alive and all we are trying to do is to keep the brain alive until such time, as a crash team, an ambulance or somebody who has got more skills, or a defib, or anybody can give you a hand.

As soon as you have got a second, third, fourth person, they will start to help you. The process starts to become more efficient, more effective and expands what we can actually use. We can still use postural drainage if fluid comes to the airway, we have not got suction on scene yet, but as soon as suction arrives, we can suction the airway. We are doing chest compressions and breaths until a defib arrives on scene. When the defib arrives, we can shock the heart back in to hopefully, a normal rhythm again and everything should start to return to normal. But I will reiterate again, the basic life support is the most critical skill that you will ever learn. That is the bit without doubt and evidence proves that that is the bit that saves people lives. Evidence also proves that good CPR in the community done by bystanders is more effective than CPR done by paramedics, doctors, and nurses because it is quicker, it is at the point of arrest. And that is the key. You have no time to stop, talk, and think. You have to work and think and act all in one, all at the same time, and that is what makes it difficult.

But if you understand it, you understand why we are compressing the chest 5 to 6 centimetres, why we are putting breaths in, why we are only going to sniffing the morning air position with the child, why we do not put our fingers under the tongue then the whole process becomes so much easier, so much easy to remember and so much more efficient.