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Category: Cardiology

Topic: Basic Life Support

Level: EMR

Next Unit: CPR in the Infant

19 minute read

CPR is used to maintain blood flow through the body in the event of cardiac arrest. This has a dual function, it provides oxygen to vital tissues such as the brain, which rapidly dies without oxygen and increases the preload reaching the right side of the heart which stimulates it to resume beating. 

children have different needs than adults, like infants they have a dramatically higher healthy respiratory rate and heart rate. Balancing these needs is the reason why the recommendations for CPR in children differs from that of adults.

Remember, Scene safety is paramount in all situations, even a cardiac arrest. Ensure that you and your team is safe prior to attempt any rescue!


The C.A.B Protocol for CPR in Children

For the consideration of CPR a pediatric patient is one that is between 1 and ~13 years of age (the age of puberty). Like infants, these patients require a higher compression and breath rate and a changing ratio of compressions to breaths depending on the number of rescuers. 


The quality of chest compressions is the greatest determinant of patient outcomes with all patients. For infants, you should be depressing the chest approximately 1/3 of its anteroposterior diameter. The goal rate of compressions is between 100 and 120 compressions per minute. 

There is a large variation in anatomy between children, leaving the decision on which compression method to use up to the rescuer. For extremely small children it may be appropriate to use the infant 2-thumb and 2 finger techniques. Moderate-sized children may only need the palm of one hand, while older children will be best served with the traditional 2 handed technique. 

AEDs will also have specialized pediatric pads that are specifically for the smaller size chest of pediatric patients. If the pediatric pads are unavailable, you can use adult pads, one placed on the center of the chest and one applied between the shoulder blades on the back. In an emergency, adult pads can be used at any age. However, it is best to use the pediatric pads whenever possible until at least the age of 8.


For pediatric patients, use the "sniffing position" with the head tilted back and the chin forward to open the airway. Ensure that chest rise is occurring with each breath. Elevating the shoulders of the child with a towel roll can help to keep the airway in the ideal position. 

In younger children, copious oral secretions and vomit should be expected, have suction on hand for these situations.


Again, just as in adults you will deliver breaths with a barrier device or bag-valve-mask. Ensure that you are using a pediatric-sized bag! Using an adult bag in a pediatric patient can cause significant lung trauma. Using an infant bag in a pediatric patient may not provide a large enough ventilation. 

With smaller/younger children or when you are performing "mouth to mouth" with a one-way mask, ensure that you stop squeezing the bag when the chest stops rising to minimize the potential for damage to the lungs. 

Remember that with children and infants the compression to breath ratio changes when more than one rescuer is involved. Provide 30 compressions per 2 breaths (30:2) if you are alone, but if you are with a partner deliver 15 compressions followed by 2 breaths (15:2). This is an essential testing point that is often encountered on exams.


Single Rescuer CPR

Responsive or Unresponsive

First, determine if the patient is responsive or not via rubbing the sternum or providing firm palm slaps to the infants back. If they respond, evaluate for any other potential life threats. If there is no response, check for a pulse at the carotid. Activate the emergency response system by radioing for ACLS support and if available, obtain an AED.

Pulse Check

If unresponsive, simultaneously check for a carotid pulse and visible breathing via chest rise for no more than 10 seconds. Note that Gasping or grunting is not breathing.

  • Definite pulse + inadequate breathing: 1 rescue breath 2-3  seconds.
  • Definite pulse + breathing effectively: monitor until ALS unit arrives.
  • Pulseless or pulse below 60bpm + apneic: remove clothes from the chest and begin CPR.
  • BEGIN compressions if pulse is less than 60 beats per minute in infants.

Get an AED

The AED will guide you through each step once powered on. Be sure to listen carefully to each command and follow accordingly. Each AED has defibrillator pads. Follow the instructions and utilize the pictures on the pads if you forget placement. Though not ideal, adult pads can be used by placing one on the front of the infant and another between the shoulder blades. Typically, around adolescence or if the child's size warrants, you can utilize adult AED pads with proper positioning as their body size will accommodate it and benefit during defibrillation. 

AEDs are becoming increasingly available to EMS services and the public. Nearly all BLS teams will carry an AED, if one is not available in your ambulance there will often be AEDs available in many public places such as malls, airports, gyms, college campuses, and retirement homes. 

If it is not immediately obvious where to obtain an AED, you should activate the emergency response, initiate CPR, and specifically instruct one or more bystanders to search for an AED. 

For witnessed cardiac arrest, attach the AED pads to the patient’s bare chest. Do not touch the patient during this time as the AED is determining if a shock is advised. If a shock is not advised, quickly begin high-quality chest compressions for 2 minutes and recheck a rhythm every 2 minutes until an ALS crew arrives or the patient begins to move. The AED should prompt you to do this.

Shock Advised

If a shock is indicated, resume compressions while the AED is charging. 

AED's will not deliver a shock until the button is pressed, as a matter of safety, the individual giving chest compressions at that moment should be the one to press the shock button. Once the AED has charged, STAND CLEAR then press the button to deliver the shock. Immediately resume chest compressions for 2 minutes. The AED prompts you when to stop to re-analyze the rhythm.


Dual Rescuer CPR vs. Single Rescuer CPR

Unlike newer adult guidelines where a 30:2 compression ratio is always recommended, in pediatric patients the use of a 15:2 ratio is called for when a second rescuer is present. This is due to the increased needs of oxygen for younger patients and the lower circulating blood volume. 

  • Additionally, the 2nd rescuer may:
    • activate the emergency response system;
    • be an extra set of eyes for scene safety;
    • obtain the AED and first aid kit;
    • attach AED pads while breaths are being administered between compressions;
    • alternate every 2 minutes in performing high-quality chest compressions;
    • perform pulse checks when indicated by the AED;
    • encourage you to do better chest compressions, ensuring high-quality CPR;
    • assist in other tasks as needed to optimize patient survival.

Be sure to assign responsibilities and stick with them. Communication is key here. No one wins a prize for being a "better rescuer." Someone's life depends on you working together as a TEAM.