Safe approach
Shout for help
Approach with care (safety for yourself)
Free from danger (safety for your patient)
Evaluate ABC.
Check responsiveness – “Are you all right?”
Airway opening (neutral position for infant: sniffing for
child = neck extended, nasal orifices to vertical).
LOOK, LISTEN, FEEL – for respiration for 10 seconds.
Give 2–5 rescue breaths if breathing absent or ineffective.
Check pulse – brachial in infant, carotid in child and/or heart
rate with stethoscope for 10 seconds. Look for “signs of
life”, for example movement, breathing. Check time (start
clock).
First priority – establish airway and ventilation
Open airway – head tilt (neutral – infant towel under
shoulders; sniffing – child), chin lift and jaw thrust (beware
of cervical spine injury: if suspected use jaw thrust without
head tilt).
Only do suction if airway blocked or filled with blood or
vomit – thin secretions not important: use Yankauer suction
catheter. Provide 5 initial breaths with self-inflating bag with
reservoir and 100% oxygen.
In absence of severe upper airway obstruction, adequate
ventilation should be obtained.
After 2–5 rescue breaths, do pulse check and support
circulation if required (i.e. don’t stick to A and B for 5
minutes and forget pulse).
If unable to inflate chest – check airway position.
Still unable to inflate chest – try oro-pharyngeal airway.
Still unable to inflate chest – consider intubation:
ET tube size in full-term newborn infant: 3–3·5 mm
ET tube size in child ± 0·5 = (age/4) + 4 mm.
ET tube size in infant < 1 year: 4–4·5 mm.
Depth of insertion: 3 × internal diameter = length at lips in
centimetres, add 2 cm at nares.
Uncuffed tube under 25 kg.
Ensure tube is passed only 2–3 cm below vocal cords – the
black line on the ET tube should just pass through the
cords.
After intubation check that lung inflation is occurring and that
chest wall expansion is adequate and equal. Chest movement
is the most useful sign. Auscultate in axillae and over
epigastrium. Ensure no air bubbling up from mouth or heard
in neck with stethoscope. Ventilate approximately every 2
seconds. Don’t forget mouth to mouth/mouth and nose, or
mouth to mask if self-inflating bag unavailable.
CXR to check endotracheal tube position – if prolonged
ventilation needed. Failure to ventilate effectively may be due
to incorrectly placed tube (oesophagus or right main
bronchus) or consider pneumothorax.
Second priority – establish cardiac output
Cardiac massage (ratio of compression to ventilation: 3 : 1 in
neonates, 5 : 1 in infants and children): 5 : 2 in older children
where both hands are needed for compressions.
Firm surface (board, floor, examination couch).
Infants: two fingers, one finger breadth below the internipple
line or use thumbs with hands encircling the chest wall.
Small children (< 8 years): use one hand to depress the sternum,
one finger breadth above xiphisternum.
Larger children (> 8 years): heels of both hands are used to
depress the sternum two finger breadths above xiphisternum.
Compress by one-third of AP diameter of chest. Effective
massage produces femoral pulses. Rate 100/min
Usual reason for ineffective massage is insufficient
compression. Tamponade is a rare cause.
Third priority – attach to ECG monitor, if available
Fourth priority – establish intravenous access
Peripheral, intraosseous, femoral/internal jugular, cut down
long saphenous.
Consider correctable factors:
Severe dehydration/shock: start 0·9% saline 20 ml/kg boluses
syringe in quickly.
Haemorrhage: start O rhesus negative blood 20 ml/kg initially
IV/IO.
Drug therapy
Epinephrine (adrenaline)
Give 10 micrograms/kg (0·01 ml/kg of 1 in 1000 solution) IV
or intraosseous (IO) and flush with 3–5 ml 0·9% saline or give
100 micrograms/kg( 0·1 ml/kg of 1 in 1000 solution) via ET
tube. For subsequent doses multiply the IV/IO dose by 10
(i.e. 0·1 ml/kg of 1 in 1000) in cases where shock caused the
cardiac arrest.
Sodium bicarbonate
When pH < 7·0 or cardiac output compromised, use
1 mmol/kg (2 ml/kg of 4·2%). Do not use intratracheal
route. Bicarbonate must not be given in same IV line as
calcium. Sodium bicarbonate inactivates epinephrine and
dopamine, therefore flush line with 0·9% saline if these drugs
are subsequently given.
Continuous and effective life support
Ventilate 100% oxygen
IV or IO access
Intubate
Epinephrine: 10 micrograms/kg (0·01 ml/kg of 1 in 1000 or
0·1 ml/kg of 1 in 10 000) IV or IO or 100 micrograms/kg down
ET tube.
Give 3 minutes of cardiopulmonary resuscitation cycles
Consider IV fluid bolus (20 ml/kg of 0·9% saline) and sodium
bicarbonate 1 mmol/kg = 2 ml/kg of 4·2% IV or IM (never
intratracheally)
Repeat epinephrine 10–100 micrograms/kg (0·1 ml/kg of 1 in 10000 or 1000) IV or IO
Repeat 3 minutes of cardiopulmonary resuscitation cycles
Repeat cycle of last two lines in box
Protocol for pulseless electrical activity (PEA)
(ECG looks normal or bradycardia but no palpable pulse)
Continuous and effective life support
Ventilate 100% oxygen
IV or IO access
Intubate
Epinephrine: 10 micrograms/kg (0·01 ml/kg of 1 in 1000 or
0·1 ml/kg of 1 in 10 000) IV or IO or 100 micrograms/kg
down ET tube.
Fluids: IV bolus of 20 ml/kg.
Continuous and effective life support
Ventilate 100% oxygen
IV or IO access
Intubate
Epinephrine: 10 micrograms/kg (0·01 ml/kg of 1 in 1000 or
0·1 ml/kg of 1 in 10 000) IV or IO or 100 micrograms/kg down
ET tube.
Give 3 minutes of cardiopulmonary resuscitation cycles
Consider IV fluid bolus (20 ml/kg of 0·9% saline) and sodium
bicarbonate 1 mmol/kg = 2 ml/kg of 4·2% IV or IM (never
intratracheally)
Repeat epinephrine 10–100 micrograms/kg (0·1 ml/kg of 1 in 10000 or 1000) IV or IO
Repeat 3 minutes of cardiopulmonary resuscitation cycles
Repeat cycle of last two lines in box
Protocol for pulseless electrical activity (PEA)
(ECG looks normal or bradycardia but no palpable pulse)
Continuous and effective life support
Ventilate 100% oxygen
IV or IO access
Intubate
Epinephrine: 10 micrograms/kg (0·01 ml/kg of 1 in 1000 or
0·1 ml/kg of 1 in 10 000) IV or IO or 100 micrograms/kg
down ET tube.
Fluids: IV bolus of 20 ml/kg.
144 POCKET EMERGENCY PAEDIATRIC CARE
use a broad tourniquet rather than a narrow one
place as close to the amputation as possible
pneumatic tourniquets or a BP cuff are best – inflate to
above arterial pressure.
• Always record time of tourniquet inflation/application.
Check every 10–15 mins: if bleeding controllable with
pressure, release tourniquet. Never use tourniquet for
> 2 hours.
• Good rapid fluid resuscitation is necessary.
• Urgent orthopaedic or plastic surgical help is necessary.
• Adequate analgesia, usually an opiate.
• Reimplantation of amputated limb may be possible.
• Amputated limb viable for 8 hours at room temperature.
• Amputated limb viable for 18 hours if kept sterile and in ice
(avoid direct contact between ice and skin).
• Amputated limb and child must be transported in the
same vehicle.
Gunshot wounds
Initial measures
Similar to those for any severe injury:
• General assessment and resuscitation, addressing
potentially life-threatening conditions according to ABC
priorities (airway, breathing, stopping haemorrhage).
• Application of dressings to open wounds.
• Emergency splintage of fractures.
• Obtaining intravenous access.
• The degree to which fluid resuscitation should be carried
out is controversial. Advanced trauma life support (ATLS)
teaching recommends an initial bolus of 20 ml/kg, after
which the child should be carefully monitored with respect
to the adequacy of organ perfusion and the response to
this initial fluid challenge.
• Analgesia as required.
• Antibiotics – the ICRC recommend benzylpenicillin IV at
a dose appropriate to the size of the child. (50 mg/kg IV
6 hourly).
