HIGH-QUALITY CPR FOR INFANTS AND CHILDREN (PALS GUIDELINES)
High-quality cardiopulmonary resuscitation (CPR) is the single most effective intervention for pediatric cardiac arrest. Unlike adults, where cardiac causes dominate, pediatric arrests are usually respiratory in origin, making early, effective CPR critical for survival.
Key Goals of High-Quality CPR:
Maximize perfusion to vital organs (brain, heart). Optimize chest compressions and ventilation. Minimize interruptions for continuous circulation. Ensure rapid defibrillation for shockable rhythms (VF/pVT).
BASIC PRINCIPLES OF HIGH-QUALITY CPR
Start CPR immediately when a child is unresponsive, not breathing, and has no pulse (or HR <60 bpm with poor perfusion). Push hard, push fast, allow full recoil. Minimize interruptions—compressions should be continuous whenever possible. Avoid over-ventilation—hyperventilation can worsen outcomes.
COMPRESSION TECHNIQUE & DEPTH
| Age Group | Compression Depth | Compression Technique | Hand Placement |
|---|---|---|---|
| Infants (<1 year) | At least 1.5 inches (4 cm) | 2-finger (single rescuer) or 2-thumb encircling (2 rescuers, preferred) | Just below the nipple line |
| Children (1 year to puberty) | At least 2 inches (5 cm) | 1-hand (small child) or 2-hand (larger child) | Lower half of the sternum |
| Adolescents (puberty and older) | At least 2 inches (5 cm) | Same as adult (2-hand technique) | Lower half of the sternum |
Key Differences in Infant vs. Child CPR:
Infants: 2-thumb technique (preferred for better depth & consistency). Children: Use 1 or 2 hands depending on size and rescuer strength.
COMPRESSION-TO-VENTILATION RATIOS
| Scenario | Compression-to-Ventilation Ratio |
|---|---|
| Single Rescuer (All Ages) | 30:2 |
| Two Rescuers (Infants & Children) | 15:2 |
| With Advanced Airway (ETT/LMA in place) | Continuous compressions + 1 breath every 2-3 sec (20-30 breaths/min) |
Higher ventilation rates (20-30 breaths/min) are critical in pediatrics due to high oxygen demand!
OPTIMIZING COMPRESSION QUALITY
Compression Rate: 100-120 per minute Full Chest Recoil: Allow the chest to fully expand after each compression to maximize cardiac output. Minimize Interruptions:
- Limit interruptions to <10 seconds (e.g., for defibrillation, intubation).
- Pre-charge defibrillator before pausing compressions.
- Rotate rescuers every 2 minutes to prevent fatigue.
Chest compressions should be continuous—any pause reduces survival!
EFFECTIVE VENTILATION TECHNIQUE
If NO Advanced Airway (Bag-Mask Ventilation):
- Deliver 2 breaths every 30 compressions (single rescuer) or every 15 compressions (2 rescuers).
- Each breath over 1 second—enough to cause visible chest rise.
- Avoid excessive volume (can cause gastric inflation and aspiration).
If Advanced Airway is Placed (ETT or LMA):
- Provide 1 breath every 2-3 seconds (20-30 breaths per minute).
- Continuous compressions (no need to pause for breaths).
Avoid hyperventilation—excessive ventilation increases intrathoracic pressure, decreasing venous return and cardiac output!
MINIMIZING INTERRUPTIONS: THE “C-A-B” APPROACH
C = Circulation: Start chest compressions immediately. A = Airway: Open the airway after 30 compressions (or 15 if two rescuers). B = Breathing: Give 2 breaths after every 30 or 15 compressions.
CPR Prioritization: “Push hard, push fast—compressions first, then airway & breathing.”
DEFIBRILLATION FOR SHOCKABLE RHYTHMS (VF/PULSELESS VT)
Attach AED/Defibrillator as soon as possible. Shockable rhythms: Ventricular fibrillation (VF) & pulseless ventricular tachycardia (pVT).
Defibrillation Energy Doses (Biphasic or Monophasic):
- First shock: 2 J/kg
- Second shock: 4 J/kg
- Subsequent shocks: 4 J/kg (max 10 J/kg or adult dose).
- Resume CPR immediately after shock—do not delay!
Defibrillation is most effective when performed within 3 minutes of arrest!
SIGNS OF HIGH-QUALITY CPR & EFFECTIVE RESUSCITATION
Capnography (ETCO₂):
- >15 mmHg → Good CPR quality.
- <10 mmHg → Improve compressions.
Arterial Diastolic Blood Pressure (If Art Line Present):
- >25 mmHg in infants/children = Good CPR.
- <20 mmHg = Inadequate chest compressions.
Return of Spontaneous Circulation (ROSC) Indicators:
- Sudden rise in ETCO₂ (>40 mmHg).
- Spontaneous pulses return.
- Improved perfusion (warm skin, strong pulses).
Use ETCO₂ to gauge CPR effectiveness—low values suggest poor perfusion.
WHEN TO STOP CPR? (TERMINATION OF RESUSCITATION)
Consider stopping CPR if: No ROSC after 20-30 minutes of high-quality CPR. Persistent asystole despite epinephrine and defibrillation (if shockable rhythm initially). No reversible causes (H’s & T’s) identified. Family or provider decision in accordance with ethical guidelines.
Children have higher survival rates post-cardiac arrest—continue CPR aggressively unless futility is clear!
FINAL TAKEAWAYS: WHY HIGH-QUALITY CPR MATTERS
Start CPR immediately when pulseless or HR <60 bpm with poor perfusion. Compression Rate: 100-120/min; Depth: 1.5” (infants), 2” (children). Full chest recoil and minimal interruptions = Better survival. Ventilation Rate: 20-30 breaths/min in pediatrics (avoid hyperventilation). Use ETCO₂ and diastolic BP to assess CPR effectiveness. Defibrillate VF/pVT ASAP (First dose: 2 J/kg).
Takeaway: High-quality CPR improves survival—”Push hard, push fast, and don’t stop unless absolutely necessary!”