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《心肺复苏指南》参考资料（英文版）Part 11 Pediatric Basic Life Support

For best survival and quality of life, pediatric basic life support(BLS) should be part of a community effort that includes prevention, basic CPR, prompt access to the emer- gency medical services(EMS) system, and prompt pediatric advanced life support (PALS). These 4 links form the American Heart Association(AHA)

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Part 11: Pediatric Basic Life Support F or best survival and quality of life, pediatric basic life support(BLS) should be part of a community effort that includes prevention, basic CPR, prompt access to the emer- gency medical services(EMS) system, and prompt pediatric advanced life support (PALS). These 4 links form the American Heart Association(AHA) pediatric Chain of Sur- ival(Figure 1). The first 3 links constitute pediatric BLS Rapid and effective bystander CPR is associated with Figure 1. Pediatric Chain of Survival successful return of spontaneous circulation and neurologi- cally intact survival in children. ,2 The greatest impact occurs nhtsa. gov. Look for the Comprehensive Child Passenger in respiratory arrest, in which neurologically intact survival Safety Information rates of >70% are possible, 4-6 and in ventricular fibrillation Adolescent drivers are responsible for a disproportionate CVF), in which survival rates of 30% have been documented. 7 number of motor vehicle-related injuries; the risk is highest in the first 2 years of driving. Driving with teen passengers But only 2% to 10% of all children who develop out-of- and driving at night dramatically increase the risk. Additional hospital cardiac arrest survive, and most are neurologically devastated. 7-13 Part of the disparity is that bystander CPR is risks include not wearing a seat belt, drinking and drivin provided for less than half of the victims of out-of-hospital speeding, and aggressive driving arrest & 11, 14 Some studies show that survival and neurolo Pedestrian Injuries outcome can be improved with prompt CPR.6, 15-17 Pedestrian injuries account for a third of motor vehicle related injuries. Adequate supervision of children in the street Prevention of Cardiopulmonary Arrest is important because injuries typically occur when a child major causes of death in infants and children are darts out mid-block, dashes across intersections, or gets off espiratory failure, sudden infant death syndrome(SIDS), bus. 22 sepsis, neurologic diseases, and injuries. 8 Bicycle Injuries Injuries Bicycle crashes are responsible for approximately 200 000 Injuries, the leading cause of death in children and young Injuries and nearly 150 deaths per year in children and adults. cause more childhood deaths than all other cause adolescents. 2 Head injuries are a major cause of bicycle combined. s Many injuries are preventable. The most com- related morbidity and mortality. It is estimated that bicycle mon fatal childhood injuries amenable to prevention are helmets can reduce the severity of head injuries by >80%0.24 motor vehicle passenger injuries, pedestrian injuries, bicycle burns injuries, drowning, burns, and firearm injuries. 9 Approximately 80% of fire-related and burn-related deaths Motor Vehicle Injuries result from house fires and smoke inhalation 25.26 Smoke Motor vehicle-related injuries account for nearly half of all detectors are the most effective way to prevent deaths and pediatric deaths in the United States. 8 Contributing factors injuries; 70% of deaths occur in homes without functioning include failure to use proper passenger restraints, inexpert- smoke alarms. 27 nced adolescent drivers and alcohol Firearm Injuries Appropriate restraints include properly installed, rear- The United States has the highest firearm-related injury rate facing infant seats for infants <20 pounds(<9 kg)and <I of any industrialized nation-more than twice that of any year of age, child restraints for children I to 4 years of age, other country. 28 The highest number of deaths is in adoles and booster seats with seat belts for children 4 to 7 years of cents and young adults, but firearm injuries are more likely to age 0 The lifesaving benefit of air bags for older children and be fatal in young children. 29 The presence of a gun in the adults far outweighs their risk. Most pediatric air bag-related home is associated with an increased likelihood of adoles- fatalities occur when children <12 years of age are in the cent30, 31 and adult suicides or homicides. 32 Although overall vehicle's front seat or are improperly restrained for their age firearm-related deaths declined from 1995 to 2002. firearm For additional information consult the website of the National homicide remains the leading cause of death among African- HighwayTrafficsaFetyAdministration(nhtsa):http://amEricanadolescentsandyoungadultsI8 Sudden Infant Death Syndrome (Circulation. 2005: 112: IV-156-1V-166) SIDS is"the sudden death of an infant under I year of age, o 2005 American Heart Association which remains unexplained after a thorough case investiga This special supplement to Circulation is freely available at http://www.circulationaha.org tion, including performance of a complete autopsy, tion of the death scene, and review of the clinical history. "3 DOI: 10.1161/CIRCULATIONAHA. 105.166572 The peak incidence of SIDs occurs in infants 2 to 4 months of

Part 11: Pediatric Basic Life Support For best survival and quality of life, pediatric basic life support (BLS) should be part of a community effort that includes prevention, basic CPR, prompt access to the emergency medical services (EMS) system, and prompt pediatric advanced life support (PALS). These 4 links form the American Heart Association (AHA) pediatric Chain of Survival (Figure 1). The first 3 links constitute pediatric BLS. Rapid and effective bystander CPR is associated with successful return of spontaneous circulation and neurologically intact survival in children.1,2 The greatest impact occurs in respiratory arrest,3 in which neurologically intact survival rates of 70% are possible,4–6 and in ventricular fibrillation (VF), in which survival rates of 30% have been documented.7 But only 2% to 10% of all children who develop out-ofhospital cardiac arrest survive, and most are neurologically devastated.7–13 Part of the disparity is that bystander CPR is provided for less than half of the victims of out-of-hospital arrest.8,11,14 Some studies show that survival and neurologic outcome can be improved with prompt CPR.6,15–17 Prevention of Cardiopulmonary Arrest The major causes of death in infants and children are respiratory failure, sudden infant death syndrome (SIDS), sepsis, neurologic diseases, and injuries.18 Injuries Injuries, the leading cause of death in children and young adults, cause more childhood deaths than all other causes combined.18 Many injuries are preventable. The most common fatal childhood injuries amenable to prevention are motor vehicle passenger injuries, pedestrian injuries, bicycle injuries, drowning, burns, and firearm injuries.19 Motor Vehicle Injuries Motor vehicle–related injuries account for nearly half of all pediatric deaths in the United States.18 Contributing factors include failure to use proper passenger restraints, inexperienced adolescent drivers, and alcohol. Appropriate restraints include properly installed, rearfacing infant seats for infants 20 pounds (9 kg) and 1 year of age, child restraints for children 1 to 4 years of age, and booster seats with seat belts for children 4 to 7 years of age.20 The lifesaving benefit of air bags for older children and adults far outweighs their risk. Most pediatric air bag–related fatalities occur when children 12 years of age are in the vehicle’s front seat or are improperly restrained for their age. For additional information consult the website of the National Highway Traffic Safety Administration (NHTSA): http:// nhtsa.gov. Look for the Comprehensive Child Passenger Safety Information. Adolescent drivers are responsible for a disproportionate number of motor vehicle–related injuries; the risk is highest in the first 2 years of driving. Driving with teen passengers and driving at night dramatically increase the risk. Additional risks include not wearing a seat belt, drinking and driving, speeding, and aggressive driving.21 Pedestrian Injuries Pedestrian injuries account for a third of motor vehiclerelated injuries. Adequate supervision of children in the street is important because injuries typically occur when a child darts out mid-block, dashes across intersections, or gets off a bus.22 Bicycle Injuries Bicycle crashes are responsible for approximately 200 000 injuries and nearly 150 deaths per year in children and adolescents.23 Head injuries are a major cause of bicyclerelated morbidity and mortality. It is estimated that bicycle helmets can reduce the severity of head injuries by 80%.24 Burns Approximately 80% of fire-related and burn-related deaths result from house fires and smoke inhalation.25,26 Smoke detectors are the most effective way to prevent deaths and injuries; 70% of deaths occur in homes without functioning smoke alarms.27 Firearm Injuries The United States has the highest firearm-related injury rate of any industrialized nation—more than twice that of any other country.28 The highest number of deaths is in adolescents and young adults, but firearm injuries are more likely to be fatal in young children.29 The presence of a gun in the home is associated with an increased likelihood of adolescent30,31 and adult suicides or homicides.32 Although overall firearm-related deaths declined from 1995 to 2002, firearm homicide remains the leading cause of death among AfricanAmerican adolescents and young adults.18 Sudden Infant Death Syndrome SIDS is “the sudden death of an infant under 1 year of age, which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history.”33 The peak incidence of SIDs occurs in infants 2 to 4 months of (Circulation. 2005;112:IV-156-IV-166.) © 2005 American Heart Association. This special supplement to Circulation is freely available at http://www.circulationaha.org DOI: 10.1161/CIRCULATIONAHA.105.166572 Figure 1. Pediatric Chain of Survival. IV-156

Part 11: Pediatric Basic Life Support IV-157 age. 4 The etiology of SIDS remains unknown, but risk respiratory distress to remain in a position that is most factors include prone sleeping position, sleeping on a soft comfortable surface, 5-37 and second-hand smoke. 38,39 The incidence of If the child is unresponsive and is not moving, shout for SIDS has declined 40%040 since the"Back to Sleep" public help and start CPR. If you are alone, continue CPR for 5 education campaign was introduced in the United States in cycles(about 2 minutes). One cycle of CPR for the lone 1992. This campaign aims to educate parents about placing an rescuer is 30 compressions and 2 breaths(see below ). Then infant on the back rather than the abdomen or side to sleep activate the EMS system and get an automated external defibrillator(AED)(see below ). If you are alone and there Drowning is no evidence of trauma, you may carry a small child with Drowning is the second major cause of death from uninten- you to the telephone. The EMs dispatcher can guide you tional injury in children <5 years of age and the third major through the steps of CPR. If a second rescuer is present cause of death in adolescents. Most young children drown at rescuer should immediately activate the EMs system after falling into swimming pools while unsupervised; ado- and get an aEd (if the child is I year of age or older) while descents more commonly drown in lakes and rivers while you continue CPR. If you suspect trauma, the second swimming or boating. Drowning can be prevented by install- rescuer may assist by stabilizing the child's cervical spine ing isolation fencing around swimming pools(gates should (see below ). If the child must be moved for safety reasons, be self-closing and self-latching )I and wearing personal support the head and body to minimize turning, bending, flotation devices (life jackets) while in, around, or on water twisting of the head and neck The BLS Sequence for Infants and Children Activate the EMs System and Get the aED (Box 2) For the purposes of these guidelines, an"infant"is less than If the arrest is witnessed and sudden 27. 43(eg, an athlete who approximately I year of age. This section does not deal with newborn infants(see Part 13: "Neonatal Resuscitation Guide- collapses on the playing field), a lone healthcare provider should activate the EMS system(by telephoning 91l in most lines"). For lay rescuers the"child "BLS guidelines should be locales)and get an AED (if the child is I year of age or older) applied when performing CPR for a child from about I year before starting CPR. It would be ideal for the lone lay rescuer of age to about 8 years of age. For a healthcare provider, the who witnesses the sudden collapse of a child to also activate the EMs system and get an AED and return to the child to about the start of puberty. For an explanation of the differ begin CPR and use the AED. But for simplicity of lay rescuer ences in etiology of arrest and elaboration of the differences education it is in the recommended sequence for lay rescuer and healthcare about 5 cycles(about 2 minutes) of CPR for any infant or rovider cpr for infants. children. and adults. see Part 3 child victim before leaving to phone 911 and get an AED (if “ Overview of cPr appropriate). This sequence may be tailored for some learners These guidelines delineate a series of skills as a sequence (eg, the mother of a child at high risk for a sudden arrhyth mia). If two rescuers are present, one rescuer should begi (eg, starting CPR and activating the EMS system), especially CPR while the other rescuer activates the EMS system and hen more than one rescuer is presen gets the AED. depicted in the Pediatric Healthcare Provider BLs Algorithm Figure 2). The numbers listed with the headings below refer Position the victim to the corresponding box in that algorithm If the victim is unresponsive, make sure that the victim is in Safety of Rescuer and victim sturdy t(face up) position on a flat, hard surface, such as a sturdy table, the floor, or the ground. If you must turn the Always make sure that the area is safe for you and the victim. victim, minimize turning or twisting of the head and neck Move a victim only to ensure the victim's safety. Although exposure to a victim while providing CPR carries a theoret Open the Airway and Check Breathing(Box 3) ical risk of infectious disease transmission, the risk is very In an unresponsive infant or child, the tongue may obstruct low. 42 the airway, so the rescuer should open the airway. 4-4 Check for Response(Box 1) Open the Airway: Lay Rescuer If you are a lay rescuer, open the airway using a head tilt-chin lift maneuver for both injured and noninjured Gently tap the victim and ask loudly, "Are you okay? "Call victims( Class Ila). The jaw thrust is no longer recommended the child,s name if you know it. Look for movement. If the child is responsive, he or she for lay rescuers because it is difficult to learn and perform, is ill answer or move. Quickly check to see if the child has often not an effective way to open the airway, d may cause es or needs medical assistance If necessary, leave spinal movement(Class Ilb the child to phone EMS, but return quickly and recheck th Open the Airway: Healthcare Provider child,s condition frequently. Children with respiratory A healthcare provider should use the head tilt-chin lift distress often assume a position that maintains airway maneuver to open the of a victim without evidence of patency and optimizes ventilation. Allow the child with head or neck trauma

age.34 The etiology of SIDS remains unknown, but risk factors include prone sleeping position, sleeping on a soft surface,35–37 and second-hand smoke.38,39 The incidence of SIDS has declined 40%40 since the “Back to Sleep” public education campaign was introduced in the United States in 1992. This campaign aims to educate parents about placing an infant on the back rather than the abdomen or side to sleep. Drowning Drowning is the second major cause of death from unintentional injury in children 5 years of age and the third major cause of death in adolescents. Most young children drown after falling into swimming pools while unsupervised; adolescents more commonly drown in lakes and rivers while swimming or boating. Drowning can be prevented by installing isolation fencing around swimming pools (gates should be self-closing and self-latching)41 and wearing personal flotation devices (life jackets) while in, around, or on water. The BLS Sequence for Infants and Children For the purposes of these guidelines, an “infant” is less than approximately 1 year of age. This section does not deal with newborn infants (see Part 13: “Neonatal Resuscitation Guidelines”). For lay rescuers the “child” BLS guidelines should be applied when performing CPR for a child from about 1 year of age to about 8 years of age. For a healthcare provider, the pediatric (“child”) guidelines apply from about 1 year to about the start of puberty. For an explanation of the differences in etiology of arrest and elaboration of the differences in the recommended sequence for lay rescuer and healthcare provider CPR for infants, children, and adults, see Part 3: “Overview of CPR.” These guidelines delineate a series of skills as a sequence of distinct steps, but they are often performed simultaneously (eg, starting CPR and activating the EMS system), especially when more than one rescuer is present. This sequence is depicted in the Pediatric Healthcare Provider BLS Algorithm (Figure 2). The numbers listed with the headings below refer to the corresponding box in that algorithm. Safety of Rescuer and Victim Always make sure that the area is safe for you and the victim. Move a victim only to ensure the victim’s safety. Although exposure to a victim while providing CPR carries a theoretical risk of infectious disease transmission, the risk is very low.42 Check for Response (Box 1) ● Gently tap the victim and ask loudly, “Are you okay?” Call the child’s name if you know it. ● Look for movement. If the child is responsive, he or she will answer or move. Quickly check to see if the child has any injuries or needs medical assistance. If necessary, leave the child to phone EMS, but return quickly and recheck the child’s condition frequently. Children with respiratory distress often assume a position that maintains airway patency and optimizes ventilation. Allow the child with respiratory distress to remain in a position that is most comfortable. ● If the child is unresponsive and is not moving, shout for help and start CPR. If you are alone, continue CPR for 5 cycles (about 2 minutes). One cycle of CPR for the lone rescuer is 30 compressions and 2 breaths (see below). Then activate the EMS system and get an automated external defibrillator (AED) (see below). If you are alone and there is no evidence of trauma, you may carry a small child with you to the telephone. The EMS dispatcher can guide you through the steps of CPR. If a second rescuer is present, that rescuer should immediately activate the EMS system and get an AED (if the child is 1 year of age or older) while you continue CPR. If you suspect trauma, the second rescuer may assist by stabilizing the child’s cervical spine (see below). If the child must be moved for safety reasons, support the head and body to minimize turning, bending, or twisting of the head and neck. Activate the EMS System and Get the AED (Box 2) If the arrest is witnessed and sudden2,7,43 (eg, an athlete who collapses on the playing field), a lone healthcare provider should activate the EMS system (by telephoning 911 in most locales) and get an AED (if the child is 1 year of age or older) before starting CPR. It would be ideal for the lone lay rescuer who witnesses the sudden collapse of a child to also activate the EMS system and get an AED and return to the child to begin CPR and use the AED. But for simplicity of lay rescuer education it is acceptable for the lone lay rescuer to provide about 5 cycles (about 2 minutes) of CPR for any infant or child victim before leaving to phone 911 and get an AED (if appropriate). This sequence may be tailored for some learners (eg, the mother of a child at high risk for a sudden arrhythmia). If two rescuers are present, one rescuer should begin CPR while the other rescuer activates the EMS system and gets the AED. Position the Victim If the victim is unresponsive, make sure that the victim is in a supine (face up) position on a flat, hard surface, such as a sturdy table, the floor, or the ground. If you must turn the victim, minimize turning or twisting of the head and neck. Open the Airway and Check Breathing (Box 3) In an unresponsive infant or child, the tongue may obstruct the airway, so the rescuer should open the airway.44 – 47 Open the Airway: Lay Rescuer If you are a lay rescuer, open the airway using a head tilt– chin lift maneuver for both injured and noninjured victims (Class IIa). The jaw thrust is no longer recommended for lay rescuers because it is difficult to learn and perform, is often not an effective way to open the airway, and may cause spinal movement (Class IIb). Open the Airway: Healthcare Provider A healthcare provider should use the head tilt– chin lift maneuver to open the airway of a victim without evidence of head or neck trauma. Part 11: Pediatric Basic Life Support IV-157

IV-158 Circulation December 13. 2005 No or response Send someone to phone 911, get AED For SUDDEN COLLAP ONE 911, Get AED Open AIRWAY, check BREATHING If not breathing. give 2 BREATHS that make chest rise within 10 seconds? Recheck pulse every Ne plan Figure 2. Pediatric Healthcare Provider BLS Algorithm. Note that the boxes bor- dered by dotted lines are performed by Push hard and fast (100/n healthcare providers and not by lay rescuers. Two Rescuers: Give cycles of 15 COMPRESSIONS and 2 BREATHS If not already done, PHONE 911, for child get AED/defibrillator Infant (<1 year Continue CPR until ALS responders take over or Child (l year): Continue CPR; use AEDMdefbrillator after 5 cycles of CPR Use AED as soon as it is available for sudden, witnessed collapse) Check rhyl Shockable rhythm? Resume CPR immediately for 5 cycles victim starts to move Approximately 2% of all victims with blunt trauma requir- If the child is breathing and there is no evidence of trauma ing spinal imaging in an emergency department have a spinal turn the child onto the side(recovery position, Figure 3). injury. This risk is tripled if the victim has craniofacial This helps ma n a patent airway and decreases risk of injury, 48 a Glasgow Coma Scale score of <8, 9 or both. 48.50 If you are a healthcare provider and suspect that the victim may have a cervical spine injury, open the airway using a jaw thrust without head tilt(Class lIb).46.51. 2 Because maintaining Give Rescue Breaths(Box 4) a patent airway and providing adequate ventilation is a pri- If the child is not breathing or has only occasional gasp ority in CPR(Class I), use a head tilt-chin lift maneuver if the jaw thrust does not open the airway For the lay rescuer: maintain an open airway and give 2 breaths For the healthcare provider: maintain an open airway Check Breathing(Box 3) and give 2 breaths. Make sure that the breaths are While maintaining an open airway, take no more than 10 seconds to ffective(ie, the chest rises ). If the chest does not rise check whether the victim is breathing: Look for rhythmic chest and eposition the head, make a better seal, and try again. 55 abdominal movement, listen for exhaled breath sounds at the nose It may be necessary to move the childs head through a and mouth, and feel for exhaled air on your cheek. Periodic gasping range of positions to obtain optimal airway patency and also called agonal gasps, is not breathing.5354 effective rescue breathing

Part 11: Pediatric Basic Life Support Iv-159 15 L/min into a reservoir attached to a pediatric bag2 and a flow of at least 15 L/min into an adult bag Precautions Avoid hyperventilation; use only the force and tidal volume necessary to make the chest rise. Give each breath over I second In a victim of cardiac arrest with no advanced airway in place, pause after 30 compressions(I rescuer) or 15 compressions(2 rescuers)to give 2 ventilations when usin either mouth-to-mouth or bag-mask technique. During CPR for a victim with an advanced airway(eg, Figure 3. Recovery position. endotracheal tube, esophageal-tracheal combitube [Combi- tube], or laryngeal mask airway [LMAD in place, rescuers In an infant, use a mouth-to-mouth-and-nose technique should no longer deliver"cycles"of CPR. The compress- LOE 7: Class Ilb); in a child, use a mouth-to-mouth ing rescuer should compress the chest at a rate of 100 times per minute without pauses for ventilations, and the rescuer providing the ventilation should deliver 8 to 10 breaths per Comments on Technique minute. Two or more rescuers should change the compres In an infant, if you have difficulty making an effective seal sor role approximately every 2 minutes to prevent com- over the mouth and nose, try either mouth-to-mouth or pressor fatigue and deterioration in quality and rate of ches mouth-to-nose ventilation(LOE 5; Class IIb).56-58 If you use the mouth-to-mouth technique, pinch the nose closed. If you If the victim has a perfusing rhythm(ie, pulses are present) use the mouth-to-nose technique, close the mouth. In either but no breathing, give 12 to 20 breaths per minute(I breath case make sure the chest rises when you give a breath every 3 to 5 seconds) Barrier devices Healthcare providers often deliver excessive ventilation Despite its safety, 42 some healthcare providers 59-6l and lay during CPR, 73-75 particularly when an advanced airway is in rescuers 2.63 may hesitate to give mouth-to-mouth rescue place Excessive ventilation is detrimental because it barrier device. barrier devices have not reduced the risk of transmission of infection. 42 and .Impedes venous return and therefore decreases cardiac some may increase resistance to air flow. 64,65 If you use a output, cerebral blood flow, and barrier device, do not delay rescue breathing increasing intrathoracic pressure7 Coronary perfusion by Causes air trapping and barotrauma in patients with small Bag-Mask Ventilation(Healthcare Providers) airway obstruction Bag-mask ventilation can be as effective as endotracheal Increases the risk of regurgitation and aspiration intubation and safer when providing ventilation for short periods. 66-69 But bag-mask ventilation requires training and Rescuers should provide the recommende periodic retraining in the follow escue breaths per minute correct mask size, opening the airway, making a tight seal You may need high pressures to ventilate patients with between the mask and face, delivering effective ventilation. airway obstruction or poor lung compliance. A pressure-relief and assessing the effectiveness of that ventilation. In the valve can prevent delivery of sufficient tidal volume. 72 Make out-of-hospital setting, preferentially ventilate and oxygenate sure that the manual bag allows you to use high pressures if infants and children with a bag and mask rather than attempt necessary to achieve visible chest expansion. 6 intubation if transport time is short( Class Ia; LOE 166: 367; Two-Person Bag-Mask Ventilation A 2-person technique may be necessary to provide effective Ventilation Bags bag-mask ventilation when there is significant airway ob Use a self-inflating bag with a volume of at least 450 to 500 struction, poor lung compliance, 6 or difficulty in creating a mL70, smaller bags may not deliver an effective tidal volume tight seal between the mask and the face. One rescuer uses or the longer inspiratory times required by full-term neonates both hands to open the airway and maintain a tight mask-to- and infants. 71 face seal while the other compresses the ventilation bag. Both A self-inflating bag delivers only room air unless supple- rescuers should observe the chest to ensure chest rise. mentary oxygen is attached, but even with an oxygen inflow of 10 L/min, the concentration of delivered oxygen varie Gastric Inflation and Cricoid Pressure Gastric inflation may interfere with effective ventilation77 and from 30% to 80% and depends on the tidal volume and peak cause regurgitation. To minimize gastric inflation inspiratory flow rate. 72 To deliver a high oxygen concentra- tion (60% to 95%0), attach an oxygen reservoir to the Avoid excessive peak inspiratory pressures(eg, ventilate self-inflating bag. You must maintain an oxygen flow of 10 to slowly ).66

In an infant, use a mouth-to–mouth-and-nose technique (LOE 7; Class IIb); in a child, use a mouth-to-mouth technique.55 Comments on Technique In an infant, if you have difficulty making an effective seal over the mouth and nose, try either mouth-to-mouth or mouth-to-nose ventilation (LOE 5; Class IIb).56 –58 If you use the mouth-to-mouth technique, pinch the nose closed. If you use the mouth-to-nose technique, close the mouth. In either case make sure the chest rises when you give a breath. Barrier Devices Despite its safety,42 some healthcare providers59 – 61 and lay rescuers8,62,63 may hesitate to give mouth-to-mouth rescue breathing and prefer to use a barrier device. Barrier devices have not reduced the risk of transmission of infection,42 and some may increase resistance to air flow.64,65 If you use a barrier device, do not delay rescue breathing. Bag-Mask Ventilation (Healthcare Providers) Bag-mask ventilation can be as effective as endotracheal intubation and safer when providing ventilation for short periods.66 – 69 But bag-mask ventilation requires training and periodic retraining in the following skills: selecting the correct mask size, opening the airway, making a tight seal between the mask and face, delivering effective ventilation, and assessing the effectiveness of that ventilation. In the out-of-hospital setting, preferentially ventilate and oxygenate infants and children with a bag and mask rather than attempt intubation if transport time is short (Class IIa; LOE 166; 367; 468,69). Ventilation Bags Use a self-inflating bag with a volume of at least 450 to 500 mL70; smaller bags may not deliver an effective tidal volume or the longer inspiratory times required by full-term neonates and infants.71 A self-inflating bag delivers only room air unless supplementary oxygen is attached, but even with an oxygen inflow of 10 L/min, the concentration of delivered oxygen varies from 30% to 80% and depends on the tidal volume and peak inspiratory flow rate.72 To deliver a high oxygen concentration (60% to 95%), attach an oxygen reservoir to the self-inflating bag. You must maintain an oxygen flow of 10 to 15 L/min into a reservoir attached to a pediatric bag72 and a flow of at least 15 L/min into an adult bag. Precautions Avoid hyperventilation; use only the force and tidal volume necessary to make the chest rise. Give each breath over 1 second. ● In a victim of cardiac arrest with no advanced airway in place, pause after 30 compressions (1 rescuer) or 15 compressions (2 rescuers) to give 2 ventilations when using either mouth-to-mouth or bag-mask technique. ● During CPR for a victim with an advanced airway (eg, endotracheal tube, esophageal-tracheal combitube [Combitube], or laryngeal mask airway [LMA]) in place, rescuers should no longer deliver “cycles” of CPR. The compressing rescuer should compress the chest at a rate of 100 times per minute without pauses for ventilations, and the rescuer providing the ventilation should deliver 8 to 10 breaths per minute. Two or more rescuers should change the compressor role approximately every 2 minutes to prevent compressor fatigue and deterioration in quality and rate of chest compressions. ● If the victim has a perfusing rhythm (ie, pulses are present) but no breathing, give 12 to 20 breaths per minute (1 breath every 3 to 5 seconds). Healthcare providers often deliver excessive ventilation during CPR,73–75 particularly when an advanced airway is in place. Excessive ventilation is detrimental because it ● Impedes venous return and therefore decreases cardiac output, cerebral blood flow, and coronary perfusion by increasing intrathoracic pressure74 ● Causes air trapping and barotrauma in patients with smallairway obstruction ● Increases the risk of regurgitation and aspiration Rescuers should provide the recommended number of rescue breaths per minute. You may need high pressures to ventilate patients with airway obstruction or poor lung compliance. A pressure-relief valve can prevent delivery of sufficient tidal volume.72 Make sure that the manual bag allows you to use high pressures if necessary to achieve visible chest expansion.76 Two-Person Bag-Mask Ventilation A 2-person technique may be necessary to provide effective bag-mask ventilation when there is significant airway obstruction, poor lung compliance,76 or difficulty in creating a tight seal between the mask and the face. One rescuer uses both hands to open the airway and maintain a tight mask-toface seal while the other compresses the ventilation bag. Both rescuers should observe the chest to ensure chest rise. Gastric Inflation and Cricoid Pressure Gastric inflation may interfere with effective ventilation77 and cause regurgitation. To minimize gastric inflation: ● Avoid excessive peak inspiratory pressures (eg, ventilate slowly).66 Figure 3. Recovery position. Part 11: Pediatric Basic Life Support IV-159

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