The C-A-B of saving a child

I did a PALS ( Paediatric Advanced Life Support ) course this weekend. In addition to getting an internationally certified 'License to use defibrillator on kids and stick them with big pointy needles' card, I also learned a couple of things :

1. That it isn't just old dogs who have trouble learning new things. ( Woof ! )

2. All jokes aside, the majority of the 'parent' population of this country of billions are neither equipped nor aware of even the very basic knowledge to save their children should anything bad happen. Keeping that in mind, I thought, I'd share a few tips that may help you avert any possible tragedy.

Why you need to know this :

• Accidents happen. You may be the best parent in the world, but your eyes cannot be glued to your child 24/7. There is always a swimming pool, a loose circuit, a simple peanut or just a bad chest cold lurking around the corner.
• Unlike in adults who have a cardiac arrest due to heart problems, in children the issue is most commonly due to breathing/respiratory distress leading to failure. The other option maybe shock due to various causes ( severe loss of fluids due to vomiting and diarrhea /anaphylaxis /infective )
• The survival rate for children in 'out-of-hospital' arrests worldwide is 10% (a meagre  4% if the child is below 1 year of age i.e. an infant ) The number for our country has to be lesser than that, given our lag period between a witnessed arrest and arrival at the hospital.
• With basic CPR, upto 70% of these children survive without any neurological damage which may occur due to loss of prolonged blood flow to the brain. 
• Statistics have proven consistently that the most important factor determining the survival of a child found unresponsive is when bystander high quality CPR is performed at the earliest. While each of those italicised words are important, I personally want to point out the term 'bystander' here. You don't need to be a doctor... if you can provide CPR till help arrives, you can save your child. 
• Many children die because their parents don't know what to do and sadly, we live in a country where pizza arrives thrice as fast as an ambulance. So if you can start measures at home while waiting for help to arrive, it could be critical.

When I wrote the first draft of this, I added a whole lot of the science behind each step. The end result seemed like a medical exam answer. I've since deleted the explanations and instead borrowed diagrams for easier understanding. 

So what are the very basic steps that you do if you see a child lying unresponsive ?

• Look for a response - call loudly, tap the child physically ( in infants, tap the sole of their feet. ) See if the child is breathing. If you are not getting a response, CALL FOR HELP.
• Check for a pulse ( neck vessels in children - do not waste more than 10 seconds for steps 1 & 2 together. ) If you cannot feel one, assume the need for CPR and start compressions.
• Remember C-A-B : 
• Circulation ( of blood via heart )/ Compressions 
• Airway 
• Breathing.

Circulation/ Compressions : 

 

In infants, use 2 finger compression over breastbone ( not on the left side of chest where you assume the heart should be ) if you are alone. If two people are there, encircle the infant using both your hands and use both thumbs to compress over the lower 1/3rd of breast bone. For children, use the base of your palm over the lower third of the breastbone. 

The recommended rate is 100 compressions per minute - with a depth of atleast 1/3rd the chest ( ~4cm in infants). The ratio is 30 compressions to 2 rescue breaths if you are alone. Once help arrives, you can switch to a 15:2 ratio.

Airway : 

Before the issue of giving mouth to mouth arises, you need to make sure the airway is patent and air can enter the lungs. This can be done by basic maneuvering of the childs head. The concept is called 'head tilt, chin lift' - with one hand, gently press on the child's forehead while your other hand lifts the chin up ( the child appears to be tilting the head up and 'sniffing' ) This basic positioning opens up the airway and allows the breath you give a better chance of reaching the lungs. 

If you suspect trauma to the bones of the neck, do not use this maneuver but instead stabilize the neck and give a mild jaw thrust as shown below.

  

Choking on a foreign body is a whole different issue which I'll cover separately if anyone really wants a blogpost on that topic. Definitely, if you can visualise a foreign body in the airway, remove it. 

Breathing : 

Give two rescue breaths making sure you can see the chest rise. Cover the nose and mouth with your mouth for effective ventilation.

Resume compressions with same 30:2 ratio (15:2 if two people are around ) till help arrives or child starts breathing spontaneously. Switch between rescuers if you get tired ( and you will get tired - take it for granted. )

One factor which everyone is hesitant about - giving mouth to mouth. I get it. Diseases. Infections. The world is a worse place today for it. You maybe a good samaritan and try to save a child and end up getting AIDS/Hepatitis for your efforts. If you don't want to do it, that's your choice. But atleast provide chest compressions. Compressions alone ( and keeping the airway open ) are better than doing nothing at all.

There are so many more factors required to saving a child - identifying the cause, the need for defibrillation or cardioversion, the right medication, reevaluations, getting help, congested traffic, the distance from an emergency room. But none of that is going to matter unless you give the child a fighting chance to survive till you reach a hospital or an ambulance arrives at your location.