A 4 year old child is in respiratory failure. her central pulse rate is 65 bpm

Welcome!

We’re excited that you’ve decided to take Child and Infant CPR, and that you’ve chosen us to direct your learning experience.

You never know when you may be called upon to perform CPR on a child or infant. All parents, grandparents, babysitters, older siblings, daycare workers, teachers and anyone else who lives or works with children should learn how to perform CPR when disaster strikes. CPR can save a child’s life by providing the brain, heart and other organs with life-giving oxygen in the event of respiratory and/or cardiac arrest. Drowning, poisoning, accidents, smoke inhalation and SIDS are only a few of the emergencies that could result in death if not treated quickly.

In this course, you will learn:

• The Pediatric Chain of Survival and your place within the chain
• How to provide high quality chest compressions for children and infants
• How to initiate early use of an AED (automated external defibrillator)
• How to provide rescue breathing for pediatric victims of respiratory arrest
• How to provide CPR to children and infants when there are 2 rescuers
• How to assist child and infant victims of choking

Let’s get started!

Two Rescuer CPR for Children (aged 1 year to puberty)

When two rescuers are present, performing CPR on a child is the same as performing CPR on an adult, except that the compression ventilation ratio when 2 rescuers are present drops to 15:2. One or two hands may be used to compress the chest to a depth of 1/3 the diameter of the chest. Remember that compressions should be done when there is no pulse present or when the child’s heart rate is less than 60 beats a minute and there are signs of poor perfusion.Rescuers should trade off performing compressions every two minutes to avoid fatigue.

CPR for Infants (up to 12 months of age)

CPR for infants is similar to CPR for adults and children. There are a few differences as follows:

• Checking for responsiveness: never shake an infant as this may cause brain damage. To check for responsiveness in an infant, tap the soles of the feet while calling to the infant in a loud voice.
• Pulse check location– for an infant, it is easiest to check for a pulse using the brachial artery. To locate the brachial artery, place 2 or 3 fingers on the inside of the upper arm between the shoulder and elbow. Press the fingers gently for 5 to 10 seconds to feel for a pulse. Pushing too firmly may occlude the infant’s pulse.
• Depth of compressions– compress the infant’s chest to one-third the depth of the chest, or approximately 1 ½ inches.
• Compression delivery technique– 2 finger technique: when one rescuer is present, the chest is compressed using two fingers on the lower half of the sternum, avoiding the xiphoid process (the very end of the sternum where it narrows and comes to a point). To landmark, place 2 fingers in the center of the infant’s chest, just below the nipple line. Push down on the infant’s chest one-third the depth of the chest, or approximately 1 ½ inches. Allow the chest to fully recoil (return to its neutral position) in between compressions. Compressions should be delivered at a rate of 100-120 compressions/minute.
• 2 thumb-encircling hand technique: When two rescuers are present, the compression: ventilation ratio drops to 15:2, the same as for children. To perform this technique, position yourself at the infant’s feet. Place your thumbs side by side on the center of the infant’s chest just below the nipple line. Encircle the infant’s chest so that the fingers of both hands support the infant’s back. Use your thumbs to deliver compressions at the appropriate depth and rate (100-120 compressions/minute; 1/3 of the depth of the chest or approximately 1 ½ inches). This position allows another rescuer to support airway and breathing without getting in the way of the rescuer performing chest compressions, and is therefore the preferred technique when two rescuers are present. This technique also allows for more consistent chest compressions and superior blood flow and blood pressure compared to the 2-finger technique.
  
  

• Compression: ventilation ratio– The compression: ventilation ratio for 1 rescuer CPR in infants is 30:2, the same as for two rescuer CPR children.
• When to call EMS– it is far more common for infants to experience a respiratory arrest prior to going into cardiac arrest, unless the infant has a congenital heart problem; in adults the opposite is true- cardiac arrests are more common due to cardiovascular disease. Therefore, the goal is to intervene before the infant goes into cardiac arrest. For this reason, when to call EMS is dependent upon whether you witnessed the infant’s arrest. If you did NOT witness the infant’s arrest (unwitnessed arrest) and you are alone, you should provide CPR for 2 minutes prior to calling EMS and finding an AED. If you witness the arrest (i.e., the infant suddenly becomes unresponsive), you should call EMS and get an AED before returning to the child to start CPR.

The Pediatric Chain of Survival

The pediatric chain of survival can be thought of as a sequence of events that must occur in order to restore health in a child or infant victim of sudden cardiac arrest. Because children are more prone to respiratory arrest and shock, it is essential to recognize and prevent airway and breathing problems before they occur to prevent cardiac arrest and to ensure survival and full recovery. For this reason, the most important link in the pediatric chain of survival is prevention. Unintentional injuries are the number one cause of death in children. Children’s lives can be saved by focusing on prevention of emergencies. Knowing CPR is important, but even more important is ensuring that CPR is never needed in the first place!

Therefore, the Pediatric Chain of Survival includes:

• Prevention of respiratory/cardiac arrest
• Early high-quality CPR
• Activation of the Emergency Response System
• Early advanced life support
• Comprehensive post- cardiac arrest care

One Rescuer Child CPR

If you are alone and come across a child who is down, follow the steps below. If someone else is immediately available to assist, use the ‘Two Rescuer’ sequence.

Stay Safe: If you come upon a child who may need CPR, look around and make sure you and the child are in a safe place. If the child is in water or on a road, try to move the child to a safer area.  If you are in a safe area, do not try to move the child as he/she may have other injuries that you cannot see.  Simply roll him/her over onto his back. Make sure the child is on a firm surface, in case compressions are needed.

Assess the Victim: To quickly assess the victim, shake his shoulder and yell at him.  Check for breathing.  If he/she is not breathing, or is not breathing normally (i.e., only gasping), shout for help.
Activate the Emergency Response System and Find an AED: Yell for help. If someone responds, tell him/her to call for help by dialing 9-1-1.  If you are in an area where an AED may be available, tell him/her to go find the AED.  Make sure you tell the person to return to assist you as soon as possible. If you are alone and witnessed the child collapse, call for help by dialing 9-1-1 and run to get the AED if you know where one is nearby.  If you do not know where an AED is, begin CPR immediately after dialing 9-1-1.
 

Begin CPR

1. Check for a pulse on the side of the neck. Feel for a pulse for at least 5 seconds but NO MORE THAN 10 seconds. To check for a carotid pulse, slide 2 or 3 fingers into the groove between the traches (windpipe) and the neck muscles at the side of the neck. Alternately, you can check for a pulse in the femoral artery located in the groin. To do this, place two fingers in the inner thigh, part way between the pubic bone and the hip bone, just below the crease where the leg joins the abdomen. Remember, do not feel for a pulse for more than 10 seconds.
2. If there is no pulse or the pulse is less than 60 /minute with signs of poor perfusion* (or if you are unsure if there is a pulse), begin CPR starting with chest compressions. Provide 30 chest compressions, followed by two breaths. NOTE: If you are not comfortable giving rescue breathing and/or you do not have a mask available, do ‘Compression Only’ CPR.
   1. Use the heel of one hand on the lower half of the breastbone in the middle of the chest.
   2. Place the other hand on top of the first hand.
   3. Straighten your arms and lock your elbows so that your body weight is over your hands.
   4. The most important part of CPR is to remember to push HARD and FAST. Each compression should be one-third the depth of the chest or approximately two inches deep and the rate should be 100-120 compressions per minute.
   5. Be sure to let up on the pressure on the sternum after each compression (chest recoil) so the chest can re-expand and blood can flow back into the heart. The purpose of CPR is to help the blood flow through the heart and into the rest of the vital organs; if you allow the chest to fully re-expand, more blood will flow into the heart and will be available to deliver to the rest of the body.
   6. Count out loud as you do compressions. When you have done 30 compressions, try to open the victim’s airway by doing a head tilt/chin lift. Note that if you are doing ‘Compressions Only’ CPR, you can skip this step.
      1. With your non-dominant hand, push on the victim’s forehead to tilt the head back.
      2. With your dominant hand, place your fingers under the bony part of the lower jaw and gently lift the jaw to bring the chin forward. Be sure you lift up on the bony part of the jaw and not the soft tissue under the jaw so you don’t block the victim’s airway. Do not use your thumb to lift the jaw. Allow the victim’s mouth to remain slightly open.
      3. If you think the person’s neck may be injured, avoid the head tilt/chin lift and use the jaw thrust maneuver if you have been trained to do so. Instructions for performing a jaw thrust are provided later in the unit.
   7. If you have a barrier device to use between your mouth and the child’s face, use it. Although the risk of infection from performing CPR is very, very low, it is recommended to use a barrier device when providing CPR. This includes the use of face masks. Give each breath slowly – each breath should last one second. Make sure the chest rises with each breath. Repeat, giving a second breath.
   8. Start another cycle of chest compressions. Remember, push HARD and FAST. Alternate chest compressions (30) and breaths (2) until help arrives.

*Signs of poor perfusion: this refers to a lack of blood flow that results in certain visible signs, including pale skin color or bluish discoloration of the skin. Fingers, earlobes, lips and nail beds may look bluish or light gray. Sometimes there may be mottling, which is a mixture of a purplish or blotchy red-blue coloring on the extremities (arms or legs).

One Rescuer CPR for Infants (up to 12 months of age)

If you are the lone rescuer of an infant:

1. Assess the child for responsiveness by tapping the soles of the infant’s feet while calling his/her name loudly. Check for breathing- if there is no breathing or the infant is breathing abnormally or only gasping, call for help.
2. If someone responds to your call for help, ask them to call 9-1-1 (activate EMS) and find an AED. If you are alone and witness the infant go into arrest, perform CPR for 2 minutes before calling for help; if you come across and infant who has been “down” for an unknown period of time, call 9-1-1 first before beginning CPR.
3. Check the infant’s brachial pulse for at least 5, but no more than 10, seconds. Place 2 or 3 fingers on the inside of the upper arm between the shoulder and elbow. Press the fingers down gently for 5 to 10 seconds to feel for a pulse. Remember: pushing too firmly may occlude the infant’s pulse.
   
   
4. If you are not sure you can feel the pulse, the pulse is absent or the infant’s heart rate is below 60 beats per minute with signs of poor perfusion (pale or bluish discoloration in the face, extremities or nail beds), start CPR, beginning with 30 compressions followed by two breaths.
   1. Place the infant on his back on the ground or on a firm surface.
   2. Place 2 fingers in the center of his chest just below the nipple line; do not press on the end of the breastbone.
   3. Provide 100-120 chest compressions per minute to a depth of 1/3 the depth of the chest or approximately 1 ½ inches.
   4. The principles of providing breaths for infants are the same as for children and adults. Use the correct sized face mask for the infant (the mask should cover the mouth and nose without extending past the chin or covering the eyes). Each breath should go in over 1 second and should cause visible chest rise. A breath should require only a small puff of air into the mouthpiece of the device to cause chest rise- avoid excessive ventilations. Lastly, perform a head tilt-chin lift maneuver to open the infant’s airway; the infant’s head should be placed in “sniffing position” with the infant’s head tilted just enough that the nose appears to be sniffing the air. In this position, the external ear canal should be level with the top of the infant’s shoulder. Avoid hyperextending the neck- you also want to avoid allowing the chin to fall down towards the neck. You can do this by placing one hand on the infant’s forehead while you perform chest compressions. In this way, the infant’s airway will remain open and will not close off. Placing a small towel under the infant’s shoulders can help to maintain proper positioning.
   

5. After about two minutes of compressions (five cycles of 30 compressions and 2 breaths), leave the child to call 911 and get an AED if you know where one is (and you or someone has not already done so). Then return to the infant to continue CPR.
6. Use an AED as soon as it is available.

Two Rescuer CPR for Infants (up to 12 months of age)

If there are 2 rescuers available:

1. Rescuer 1– Assess the child for responsiveness by tapping the soles of the feet and calling to him/her loudly. Check for breathing- if the infant is not breathing or is breathing abnormally or only gasping, send Rescuer 2 to activate EMS and bring the AED (if one is available).
2. Rescuer 1– Check the infant’s brachial pulse for at least 5, but not more than 10, seconds. Place 2 or 3 fingers on the inside of the upper arm between the shoulder and elbow. Press the fingers down gently for 5 to 10 seconds to feel for a pulse. Remember: pushing too firmly may occlude the infant’s pulse.
3. Rescuer 1– If you are not sure you can feel the pulse, the pulse is absent or the infant’s heart rate is below 60 beats per minute with signs of poor perfusion (pale or bluish discoloration in the face, extremities or nail beds), start CPR, beginning with 30 compressions followed by two breaths.
   1. Place the infant on his back on the ground or on a firm surface.
   2. b. Place 2 fingers in the center of the infant’s chest just below the nipple line; do not press on the end of the breastbone.
   3. Provide 100-120 chest compressions per minute to a depth of 1/3 the depth of the chest or approximately 1 ½ inches.
   4. The principles of providing breaths for infants are the same as for children and adults. Use the correct sized face mask for the infant (the mask should cover the mouth and nose without extending past the chin or covering the eyes). Each breath should go in over 1 second and should cause visible chest rise. A breath should require only a small puff of air into the mouthpiece of the device to cause chest rise- avoid excessive ventilations. When the second person returns, change the ratio of compressions to ventilations to 15:2.
4. Rescuer 2 should place the thumbs of both hands on the lower half of the infant’s breastbone, while being careful not to press on the end of the breastbone (xiphoid process). Put the fingers of both hands around the infant’s back to provide support. Use the thumbs to depress the sternum approximately 1/3 the depth of the chest, or approximately 1 ½ inches. Compress at a rate of 100-120 compressions per minute.
5. Rescuer 1 should provide breaths as described above.
6. Continue CPR at a ratio of 15 compressions to 2 breaths and switch roles every 2 minutes to avoid fatigue.
7. Use the AED when available.

Mouth-to-Mouth-and Nose Breathing

To provide breaths to an infant when there is no face mask available:

1. Use a head tilt-chin lift to maintain an open airway (sniffing position), being careful not to hyperextend the neck, which could block the airway.
2. Place your mouth over the victim’s mouth AND NOSE to create a tight seal.
3. Blow into the infant’s nose and mouth over 1 second, with just enough volume and force to cause the chest to rise with each breath. Be careful not to ventilate too forcefully, as doing so may cause lung damage.
4. If the chest does not rise, repeat the head tilt-chin lift and try to ventilate the victim again. You may need to try to provide breaths at a few different positions before you achieve airway patency (airway is in an open position).
5. If the infant is older and you cannot cover both the infant’s mouth and nose, pinch the nostrils closed and place your mouth over the victim’s to form a tight seal- just the same as you would do for a child.

You may wonder how mouth-to-mouth or mouth-to-mouth-and-nose breathing can sustain the victim. In actual fact, your expired air contains about 17% oxygen- this is just enough oxygen to meet the victim’s needs for a brief period of time.

When providing mouth-to-mouth or mouth-to-mouth-and-nose breathing, it is important not to provide breaths that are too forceful or too rapid. Doing so may cause air to enter the stomach rather than the lungs, which can cause gastric inflation. Gastric inflation may result in vomiting, and an unconscious victim may develop pneumonia if vomitus makes its way to the lungs. To avoid gastric inflation, give each breath slowly over 1 second and deliver just enough air to make the chest rise.

Rescue Breathing

Respiratory arrest is defined as the cessation of breathing. During respiratory arrest, as well as when there is inadequate breathing, the victim will still have some amount of cardiac output, which you will be able to detect as a palpable pulse.

It is important to be able to recognize respiratory arrest, or impending respiratory arrest, which may be seen as slow, irregular or gasping respirations. These abnormal respirations are inadequate to support life. Respiratory arrest inevitably leads to cardiac arrest if not treated, therefore rescuers should intervene quickly to prevent this deterioration by providing rescue breathing. For children and infants, give one breath every 3-5 seconds (12-20 breaths per minute). Check for a pulse every 2 minutes- if the victim loses their pulse, begin chest compressions combined with breaths.

Choking in the Conscious Child (older than 1 year of age)

1. STAND (OR KNEEL) BEHIND THE VICTIM AND WRAP YOUR ARMS AROUND THE VICTIM’S WAIST.
2. IF STANDING, PUT ONE FOOT IN BETWEEN THE VICTIM’S FEET AND ONE FOOT BEHIND YOU-THIS POSITION PROVIDES STABILITY SHOULD THE VICTIM BECOME UNCONSCIOUS AND YOU NEED TO EASE THE VICTIM TO THE GROUND.
3. PLACE YOUR FIST WITH THE THUMB SIDE IN JUST ABOVE THE VICTIM’S BELLYBUTTON AND BELOW THE STERNUM (BREASTBONE).
4. GRAB YOUR FIST WITH YOUR OTHER HAND.
5. ADMINISTER ABDOMINAL THRUSTS, PULLING INWARD AND UPWARD UNTIL THE FOREIGN OBJECT COMES OUT OR THE VICTIM BECOMES UNCONSCIOUS. EACH THRUST SHOULD BE FORCEFUL, DISTINCT AND SEPARATE.

Choking in the Conscious Infant (less than 12 months of age)

1. SIT OR KNEEL WITH THE INFANT IN YOUR LAP.
2. IF NOT DIFFICULT TO DO, REMOVE THE INFANT’S CLOTHING TO EXPOSE THE INFANT’S CHEST.
3. REST THE INFANT’S BODY ON YOUR FOREARM WITH THE INFANT’S HEAD LOWER THAN THE BODY. SUPPORT THE JAW AND HEAD WITH YOUR HAND. REST YOUR FOREARM ON YOUR THIGH OR LAP TO PROVIDE SUPPORT.
4. GIVE 5 BACK BLOWS FORCEFULLY WITH THE HEEL OF YOUR HAND BETWEEN THE INFANT’S SHOULDER BLADES.
5. SUPPORT THE BACK OF THE INFANT’S HEAD WITH THE PALM OF YOUR HAND AND THE INFANT’S JAW AND HEAD WITH THE OTHER PALM WHILE TURNING HIM OVER (FACE UP) ONTO YOUR OTHER FOREARM. KEEP THE INFANT’S HEAD LOWER THAN ITS BODY. REST YOUR FOREARM ON YOUR THIGH FOR SUPPORT.
6. GIVE 5 CHEST THRUSTS, JUST AS YOU WOULD WHEN PERFORMING CHEST COMPRESSIONS IN CPR. CHEST THRUSTS SHOULD BE DELIVERED AT A RATE OF 1 CHEST THRUST PER SECOND AND SHOULD BE GIVEN WITH ENOUGH FORCE TO DISLODGE A FOREIGN BODY.
7. REPEAT BACK BLOWS/CHEST THRUSTS UNTIL THE OBJECT COMES OUT OR THE VICTIM LOSES CONSCIOUSNESS.

Choking in the Unconscious Child

1. IF YOU ARE CARINIG FOR A CHILD WHO IS CHOKING AND THEY LOSE CONSCIOUSNESS, LOWER THE VICTIM GENTLY TO THE GROUND.
2. ACTIVATE EMS/CALL 9-1-1
3. BEGIN CPR, STARTING WITH CHEST COMPRESSIONS- DO NOT CHECK FOR A PULSE.
4. EACH TIME YOU OPEN THE AIRWAY TO PROVIDE VENTILATIONS, OPEN THE VICTIM’S MOUTH AND CHECK FOR THE OBJECT. IF YOU CAN SEE THE OBJECT, TURN THE VICTIM’s HEAD TO THE SIDE AND SWEEP IT OUT OF THE VICTIM’S MOUTH WITH YOUR INDEX FINGER. NEVER PERFORM A BLIND FINGER SWEEP- THIS MAY FORCE THE OBJECT FARTHER DOWN THE VICTIM’S AIRWAY.
5. IF YOU DO NOT SEE THE OBJECT, ATTEMPT TO PROVIDE BREATHS. IF BREATHS WILL NOT GO IN, RESUME CHEST COMPRESSIONS.
6. AFTER APPROXIMATELY 5 CYCLES OF COMPRESSIONS AND VENTILATIONS, ACTIVATE EMS/CALL 9-1-1 IF NOT ALREADY DONE.
7. IF THE OBSTRUCTION IS RELIEVED, CHECK RESPONSIVENESS, BREATHING AND PULSE. PROVIDE RESCUE BREATHING OR CPR AS REQUIRED. IF THE VICTIM IS RESPONSIVE, THEY SHOULD BE TAKEN TO HOSPITAL TO RULE OUT ANY INJURY CAUSED BY ABDOMINAL OR CHEST THRUSTS.

Choking in the Unconscious Infant

1. CALL FOR HELP. IF SOMEONE RESPONDS, SEND THEM TO ACTIVATE EMS/CALL 9-1-1
2. PLACE THE INFANT ON A FLAT, FIRM SURFACE.
3. BEGIN CPR, STARTING WITH COMPRESSIONS. EACH TIME YOU OPEN THE AIRWAY TO DELIVER BREATHS, LOOK TO SEE IF THE OBJECT IS VISBLE. IF THE OBJECT IS VISIBLE, TURN THE INFANT’S HEAD TO THE SIDE AND USE YOUR INDEX FINGER TO SWEEP THE OBJECT OUT OF THE INFANT’S MOUTH. NEVER PERFORM A BLIND FINGER SWEEP, AS THIS MAY FORCE THE OBJECT FARTHER DOWN INTO THE AIRWAY.
4. AFTER 5 CYCLES OF COMPRESSIONS AND VENTILATIONS (OR ATTEMPTED VENTILATIONS), ACTIVATE THE EMERGENCY RESPONSE SYSTEM IF NOT ALREADY DONE.
5. IF THE OBSTRUCTION IS RELIEVED, CHECK RESPONSIVENESS, BREATHING AND PULSE. PROVIDE RESCUE BREATHING OR CPR AS REQUIRED. IF THE VICTIM IS RESPONSIVE, THEY SHOULD BE TAKEN TO HOSPITAL TO RULE OUT ANY INJURY CAUSED BY ABDOMINAL OR CHEST THRUSTS.

CPR Certification Skills Review

When a child or infant has a pulse of 60 minute or less with poor perfusion you should begin rescue breaths versus compressions?

What is the CPR ratio for a 4 year old?

What is the correct rate of ventilation for a child in respiratory failure?

How many times per minute should you ventilate a 4 year old who is not breathing and has a pulse of 100 beats per minute?