PHRONESIS MEDICARE INTERNATIONAL
BLS overview for infant
Basic life support (BLS) is a basic level of medical care used to help sustain a person who is experiencing cardiac arrest or respiratory failure, until they can be given full medical care by an advanced responder. BLS can be used in any scenario where breathing or heartbeat has been compromised, such as drowning, heart attack, or severe shock (eg, severe loss of blood).
BLS is more comprehensive than CPR alone, since it covers additional steps that are not expected from a layperson, as well as techniques for working with other rescuers.
The techniques used for BLS vary slightly depending on whether the victim is an adult, child, or infant. This module explains the techniques and procedure for performing BLS on an infant. The adult and child procedures are covered in separate modules.
Note:
The term 'infant' in this context refers to neonates outside the delivery room setting, up to 12 months old. Children 12 months or older should be treated using child CPR guidelines.
Basic life support in infants comprises the following principal interventions:
compressions
airway
breathing
defibrillation
evaluation
This sequence can be easily remembered with the acronym C-A-B-D-E.
Critical Concepts
The critical concepts that ensure good quality CPR and improve the chances of survival include:
avoiding hyperventilation of the patient
delivering 100-120 compressions per minute
achieving the required depth for each compression
allowing the chest to recoil fully after each compression
minimizing interruptions to compressions
Cardiac arrest in infants is usually due to respiratory or other non-cardiac causes. Sudden cardiac arrest due to ventricular fibrillation or ventricular tachycardia is uncommon in children and generally only seen in those with pre-existing heart disease or undiagnosed congenital heart defects.
Techniques used in Basic Life Support
The following techniques are used for performing infant BLS, and are referred to throughout this module:
Neutral Position
It may feel natural to hold an infant in your arms, but is not possible to give effective chest compressions or manage their airway while they are in that position. It is therefore recommended to use the neutral position for infant CPR.
To achieve the neutral position:
Lay the infant on their back, on a firm surface.
Place the head so the nose and chin are pointing directly upward (also referred to as a neutral head position).
Ensure the anterior neck space is open.
Support the head in that position with something like a folded towel or blanket (whatever is at hand) under the shoulders and back.
Position victim
Correct and incorrect head/neck
positioning
Head-tilt/chin-lift maneuver
This maneuver is used when delivering rescue breaths to an infant (unless they have a neck injury). Just as it sounds, the head is tilted and the chin is lifted, to give access to the infant's airway.
The correct technique for the head-tilt/chin-lift maneuver involves the following steps:
Place your hand on the infant's forehead.
Press the head back gently.
At the same time, place your middle and index fingers on the bony mandible of the jaw, under the chin.
Lift upward with your fingers to make the jaw tilt forward, opening the mouth.
Head-tilt/chin-lift maneuver
Avoid pushing the soft tissues under the chin as this may obstruct the airway,
If the infant's position is supine, place a rolled towel under the infant's shoulders and upper back to facilitate the neutral position. This will straighten the flexed position that may exacerbate an airway obstruction.
If there is a possibility that the infant has a neck injury, do not perform a head-tilt/chin-lift; instead, perform a jaw-thrust instead.
Jaw-thrust maneuver
When it is suspected that the infant has a neck injury, manage their airway using a jaw-thrust, instead of the head-tilt/chin-lift maneuver. The correct technique for performing a jaw-thrust is as follows:
Place one hand on each side of the infant's face.
Hook your fingers behind the angles of the infant's jaw, and lift with both hands. This will displace the jaw forward and lift the tongue away from the back of the airway.
Jaw-thrust maneuver
Rescue breathing
Rescue breathing provides oxygen to the lungs when the patient is not breathing. It should be performed immediately if the infant has a pulse but requires ongoing assistance with their breathing (for instance, in the case of respiratory failure).
The methods for administering breaths to an infant victim include:
mouth-to-mouth-and-nose breathing (the preferred method)
mouth-to-mouth or mouth-to-nose breathing (where the rescuer cannot cover both the mouth and the nose at the same time, or where either the mouth or nose are injured)
bag-mask breathing (when more than one rescuer is in attendance)
Rescue breathing
To perform rescue breaths using the preferred mouth-to-mouth-and-nose technique:
Place the infant in a neutral position, taking trauma or cervical injury into consideration.
Ensure the infant's head is in the neutral position.
Cover both the mouth and nose of the infant with your mouth, ensuring you have a good seal.
Blow a puff of air steadily and gently into the infant's mouth and nose for about 1 second:
Blow just enough air to make the infant's chest visibly rise, but take care to use less breath than you would with an adult or older child, to allow for the infant's small lung capacity.
While maintaining the infant's head position and chin lift, remove your mouth and watch for the chest to fall as air comes out.
Perform another rescue breath within 3-5 seconds.
For general rescue breathing, repeat this sequence 5 times in total, providing 1 breath every 3-5 seconds (about 12-20 breaths per minute).
If the infant is in cardiac arrest and receiving CPR at the rate of 15 compressions for every 2 breaths, then it should be two breaths delivered over 1 second each, with 1 second in between.
Mouth-to-mouth
Take position directly above the infant's head.
Hold the infant's airway open by performing a head-tilt/chin-lift maneuver and maintaining the neutral position.
With the hand on the infant's forehead, pinch the nose closed with your thumb and forefinger.
Take a breath and seal your lips around the infant's mouth using a face shield, if available.
Blow into the infant's mouth, just enough to make the chest rise and no more.
Remove your mouth while holding the position of the infant's head and watch the chest fall as air comes out.
Pause and give another breath while watching for the rise of the chest.
Note:
If the chest does not rise, adjust the head position. You may need to try a few times before getting 2 optimal breaths delivered.
Mouth-to-nose
Mouth-to-nose ventilation is an alternate method, if the infant's mouth cannot be used or is injured. To perform this technique:
Take position directly above the infant's head.
Maintain a head-tilt/chin-lift with one hand on the forehead.
With your other hand, lift the infant's lower jaw and close the mouth. Hold the lips together with the thumb.
Take a breath and seal your lips around the infant's nose.
Blow into the infant's nose, just enough to make the chest rise and no more.
Remove your mouth; open the infant's mouth and allow the infant to exhale passively.
Pause and give another breath while watching for the rise of the chest.
Note:
If the chest does not rise, adjust the head position. You may need to try a few times before getting 2 optimal breaths delivered.
Mouth-to-barrier device
If a barrier device is available, such as a disposable mask or full face-mask, perform the breathing technique as follows:
Take position directly above the infant's head.
Hold the infant's airway open by performing a head-tilt/chin-lift maneuver and maintaining the neutral position.
Place the barrier device over the face:
For a disposable mask, place the one-way valve into the infant's mouth, with the plastic sheeting over the nose.
For a full face-mask, fit the mask over the infant's nose and mouth, ensuring a tight seal.
Place your mouth over the one-way valve and blow, just enough to make the chest rise.
Remove your mouth after each breath, to allow the infant to manually exhale, and watch for chest fall.
Note:
1. Do not delay rescue breathing in order to wait for a barrier device. If a barrier device is not available, give mouth-to-mouth-and-nose (or mouth-to-nose only) ventilation if willing and able, or continue with chest compressions only.
2. When using a barrier device, if the chest does not rise, adjust the head position. The device can increase resistance to airflow, so you may need to try a few times before getting 2 optimal breaths delivered.
Mouth-to-barrier device breathing
Mouth-to-stoma
Some infants may have had surgery to remove part of the trachea and will breathe through an opening in the front of their neck called a stoma.
A stoma will be more obvious when the infant is on their back and the head is adjusted. The rescue breaths must be delivered directly into the stoma, as follows:
Cover the patient's mouth with your hand.
Seal your mouth over the stoma and deliver each rescue breath as you would for mouth-to-mouth-and-nose or mouth-to-mouth ventilation. Note that some patients may breathe through the stoma as well as their nose and/or mouth.
If the you do not see the patient's chest rise, cover the mouth and nose, and try again, ventilating through the stoma.
Note:
If the infant's chest does not rise, adjust the head position. You may need to try a few times before getting 2 optimal breaths delivered.
Bag-mask ventilation
A bag-mask device should only be used by a trained rescuer who is competent in its use. It may be used for administering breaths when more than one rescuer is in attendance; it is not recommended for use by a single rescuer. This method is covered here for completeness.
The device consists of a manual inflation bag attached to a face-mask. It may be used with or without oxygen. The mask connector port of the inflation bag is an internationally standardized size allowing it to be connected to a face-mask, laryngeal mask, or endotracheal tube.
The mask should cover the infant's mouth and nose completely, but should not cover the eyes or overlap the chin.
Unless you are trained and competent in using this device, you should not use one yourself. Perform rescue breaths instead.
The correct technique for bag-mask ventilation involves the following:
Take position directly above the infant's head.
Place the mask on the infant's face; use the bridge of the infant's nose as a guide for positioning the mask correctly.
Place one hand on the mask, and form a 'C' between the thumb and the index finger.
Place the 'C' over the edges of the mask and press the mask firmly onto the face.
Place the remaining three fingers on the bony part of the jaw to perform a simultaneous chin lift. These three fingers form an 'E', so this is often called the 'E-C' technique.
For a very small infant, you may choose to form a 'V' over the mask with your index and middle fingers. While holding the mask down, place your ring finger and little finger on the rim of the jaw. Your thumb may assist in holding the forehead in place for optimal head position.
With your free hand, gently squeeze the bag to give breaths of one second each.
Ensure that the chest rises and falls.
As soon as it is available, attach and turn on the oxygen, set the flow rate, and attach a reservoir bag, if not already in place.
Bag-mask ventilation using
E-C technique
Bag-mask ventilation
using V grip
Note:
Ventilation with an advanced airway:
Advanced rescuers, in addition to the above methods, are also required to perform ventilation with an advanced airway. Methods such as oropharyngeal airway or endotracheal intubation are outside the scope of Basic Life Support. However, ideally you should learn about the process and the airway equipment used, in case you are required to assist a more experienced rescuer.
Chest compressions
Chest compressions are believed to be the highest priority for someone with cardiac arrest, since this avoids any delay in providing care. Therefore, if heart failure is suspected, it is recommended to follow the C-A-B sequence, and defibrillate as soon as possible.
Compressions should be delivered at a rate of 100-120 per minute, regardless of whether the patient is an infant, child, or adult. To maintain this rate, it has been suggested to count out loud or to sing or hum a song that has a suitable tempo, although the speed of compressions is not enough on its own. It is also critical that the compressions are high quality:
For an infant, ensure that you press down roughly 1/3 to 1/2 the depth of the chest with each compression.
Push straight down on the breastbone.
Allow full chest recoil at the end of each compression, to allow maximal refill of the heart (incomplete recoil will reduce refill of the heart and thus decrease the blood flow provided by your chest compressions).
Keep checking that you are achieving the necessary depth of compression, as well as the recommended rate.
Note:
In infants, respiratory failure (eg, due to asthma attack, drowning, etc.) is more common than cardiac arrest. If respiratory failure is suspected, then rescue breathing is recommended as the first step, with compressions added later, if necessary.
Compressions: one-handed technique, two or three fingers (one rescuer)
A single rescuer should use a one-handed technique, where compressions are performed with two or three fingers. The one-handed approach allows a single rescuer to more quickly and easily swap between delivering compressions and ventilation during CPR. The one-handed technique is performed as follows:
Ensure the infant is on his or her back, on a firm surface, in a neutral position,
Position yourself at the infant's side and bare their chest, if the temperature allows.
Place two or three fingers of one hand on the breastbone, just below an imaginary line between the infant's nipples (avoid compressing the xiphisternum).
Start pushing down hard and fast, ensuring that you press down roughly 1/3 to 1/2 the depth of the chest with each compression.
Push straight down on the breastbone.
Deliver chest compressions at a rate of 100 to 120 per minute.
Allow full chest recoil at the end of each compression.
Perform 30 compressions followed by 2 breaths.
Keep checking that you are achieving the necessary depth of compression, as well as the recommended rate.
Continue compressions and breaths for as long as you can, or until help arrives. It is okay to stop if you become exhausted; however, start compressions again as soon as you are able.
Compressions using one-handed
technique
Compressions: two-thumb-encircling hands, or two-handed technique (two rescuers)
This technique is used when there are two rescuers. In this situation one rescuer performs the chest compressions and a second rescuer performs the rescue breathing.
In the two-handed technique, compressions are performed by placing two thumbs on the infant's breastbone and circling the fingers around each side of the chest. The two thumbs are used to compress the chest.
Perform the technique as follows:
Ensure the infant is on his or her back, on a firm surface.
Position yourself at the infant's side and bare their chest, if the temperature allows.
Spread your fingers around the sides of the chest and place your thumbs on the breastbone, just below the nipple line.
Compress the sternum with both of your thumbs.
Push down hard and fast, pressing down roughly 1/3 to 1/2 the depth of the chest with each compression.
Be sure to push straight down on the breastbone.
Deliver chest compressions at a rate of 100 to 120 per minute.
Allow full chest recoil at the end of each compression.
Perform 15 chest compressions (rescuer 1), followed by 2 breaths (rescuer 2).
Keep checking that you are achieving the necessary depth of compression.
The compression-to-ventilation ratio is different with two rescuers (15:2), since it is much easier to alternate between compressions and ventilation than when there is only one rescuer.
Note:
If the second rescuer is not willing or able to deliver rescue breaths, it is recommended to perform hands-only CPR (ie, compressions only) for infants and children in cardiac arrest.
Compressions using
two-thumb-encircling
hands technique
Compressions on an infant should depress the chest to around 1/3 the anterior-posterior diameter of the chest. This is approximately 1.5 inches or 4 cm.
Make sure the chest fully recoils back with each compression, to allow air to be released from the lungs.
Chest compression and recoil
To reduce fatigue when there is more than one rescuer, rotate positions every 2 minutes, swapping between compressions or ventilation. Move in the same direction (eg, clockwise), to facilitate the speed of changing over.
Do not interrupt compressions for more than 10 seconds, including when rotating positions. If possible, assign a timekeeper to keep track.
1. Preliminary actions
When you find an unconscious infant and you are first on the scene, it is critical to act quickly. The immediate preliminary steps are:
Verify scene safety.
Assess the infant's responsiveness.
Call for help.
Activate emergency response system (if possible) and provide immediate care.
These steps are explained below.
1.1 Verify scene safety
Before treatment is performed, verify the safety of the scene and ensure the safety of the infant and any rescuers.
The rescuer should move the infant to a safe location if the infant is:
in or near water
near a burning building
near smoke or a source of gas
in proximity to a dangerous electrical source
If trauma is suspected, do not move the infant, unless it is necessary to keep them safe.
Rescuers should wear gloves, a surgical mask, and a gown, if available, to avoid exposure to droplets of blood, saliva, or other bodily fluids.
Sterile gloves
Surgical mask
Gown
1.2 Assess responsiveness
Stimulate the infant by tapping or rubbing the foot. Look for a response, such as the infant moving or crying.
Note:
Do not move the infant if trauma is suspected, and never shake an infant under any circumstances.
Assess responsiveness
If the infant responds but is injured, leave them in position (assuming they are not in further danger) and go call for help. Return as quickly as possible.
Keep the infant warm and comfortable. Continue to monitor the infant and reassess their condition until advanced help arrives.
If the infant does not respond, continue with the following steps.
1.3 Call for help
If the infant is unresponsive and you are alone, shout out for help then continue quickly to the next step.
Call for help
1.4 Activate emergency response system
If there is a second rescuer
If your call for help brings another rescuer, send that person to activate the emergency response system and find an AED, while you perform the steps outlined below. If two other rescuers respond, send one to activate the emergency response system and ask the other to locate and bring an AED.
If you are not in a healthcare facility, one rescuer should call the emergency services on a cellphone.
If you are alone
Note:
If you witnessed the infant collapsing and suspect a primary cardiac arrest, the infant is likely to need urgent defibrillation. In this case, go and activate the emergency response system before commencing CPR.
If the infant is small and uninjured, carry them with you while you go to make the call, if possible. You can continue with CPR in the new location once the emergency response system is activated.
However, if you suspect or can see traumatic injury, do not move the infant or carry them with you.
If no emergency response system is available, use your cellphone to call for emergency assistance by dialing the emergency number for your location.
If you did not witness the infant collapsing, continue to the next step.
2. Assess vital signs
Quickly assess the infant's condition. This should take you only a few seconds in total.
2.1 Assess circulation
Quickly establish whether the infant has a pulse. Use the brachial site in the upper arm, which is recommended for pulse rate measurement in children under 2 years.
Place the child's hand with palm upwards, the arm slightly bent at the elbow, and well supported.
Place two or three fingers on the inside of the child's upper arm, roughly halfway between the elbow and the armpit, on the brachial artery. Do not use your thumb, as this digit has a discernible pulse of its own, which will interfere with the reading.
Press down gently on the arm, and feel for the pulse (taking care not to occlude the blood flow). Palpate for at least 5, but no more than 10, seconds.
Assess circulation
Note:
If no pulse can be detected within 10 seconds, immediately begin CPR (Step 3).
2.2 Assess breathing
At the same time as you are checking the infant's pulse, determine if their breathing is:
normal, or
abnormal, ie: gasping, or not breathing at all
2.3 Assess next course of action
Determine which of these situations applies:
abnormal/absent breathing, no pulse
abnormal/absent breathing, pulse present
normal breathing, pulse present
Then, immediately proceed as described below.
Abnormal/absent breathing, no pulse:
If you witnessed the infant collapsing, this is covered in step 1.4 above.
If you did not witness the infant collapsing, but you cannot find a pulse, and their breathing is abnormal or absent:
Check for and carefully remove any obvious obstruction from the infant's mouth with a rapid finger sweep.
Finger sweep
Commence CPR, as described in Step 3.
After about 2 minutes of CPR, if you are still alone, activate the emergency system, if that has not been done yet; if another rescuer has arrived, send them do that and ask them to bring an AED.
Note:
Where an infant has no pulse, use an AED as soon as one is available.
Abnormal/absent breathing, pulse present:
If you can feel a pulse but the infant is breathing abnormally or not at all:
Start rescue breathing, with one breath every 3-5 seconds (approximately 12-20 breaths per minute).
After about 2 minutes, activate the emergency response system, if you weren't able to do that earlier.
Continue rescue breathing and checking pulse every 2 minutes or so, until help arrives.
If the pulse remains lower than 60 beats per minute, with signs of poor perfusion, perform CPR by adding compressions (Step 3).
Normal breathing, pulse present:
Place the infant in the neutral position, taking trauma or cervical injury into consideration.
If you haven't already done so, send someone to activate the emergency system, or if you are alone, do that yourself and then hurry back to continue monitoring the infant.
Continue monitoring breathing and other signs.
Do not stop monitoring the infant until emergency responders arrive. Keep the infant warm and comfortable.
Monitor infant
3. Perform cardiopulmonary resuscitation (CPR)
If no pulse is felt within 10 seconds, immediately begin CPR with chest compressions. CPR keeps oxygenated blood circulating in the victim's body until advanced medical help arrives, or until an AED is available.
The following are the basic requirements of high-quality CPR:
a rate of 100-120 compressions per minute
a compression depth of at least 1/3 of the anterior-posterior diameter of the chest (approximately 1.5 inches or 4 cm)
complete chest recoil after each compression
minimized interruptions in chest compressions
the appropriate combination of compressions and rescue breaths, according to whether the rescuer is working alone or with another person
avoidance of excessive ventilation
3.1 Chest compressions
Single rescuer
For an infant, use the one-handed technique, and perform compressions with two or three fingers. This technique is covered in the Introduction to this module.
Key points to remember:
Push down hard and fast.
Press down roughly 1/3 to 1/2 the depth of the chest, with each compression.
Deliver chest compressions at a rate of 100-120 per minute.
Allow full chest recoil at the end of each compression.
Perform 30 compressions followed by 2 breaths.
Compressions using one-handed
technique
Two rescuers
Use the two-thumb-encircling hands, or two-handed technique, when there is more than one rescuer. This technique is covered in the Introduction to this module.
Note:
If the second rescuer is not willing or able to deliver breaths, it is recommended to perform hands-only CPR (ie, compressions only) for infants and children in cardiac arrest.
Key points to remember:
Place two thumbs on the infant's breastbone and circle the fingers around each side of the chest.
Use the two thumbs to compress the chest, just below the nipple line.
Compression rate should be 100-120 per minute.
Push down hard and fast, roughly 1/3 to 1/2 the depth of the chest with each compression (1.5 inches or 4 cm).
Be sure to push straight down on the breastbone.
Allow full chest recoil at the end of each compression.
15 chest compressions (rescuer 1), followed by 2 breaths (rescuer 2)
Rotate positions every 2 minutes to avoid fatigue.
Always move in the same direction when changing positions.
Do not interrupt compressions for more than 10 seconds, including when rotating positions.
If possible, assign a timekeeper to keep track.
Compressions using
two-thumb-encircling
hands technique
Compression depth and recoil
3.2 Ventilation
Compression-to-ventilation ratio
Compression-to-ventilation ratio refers to the ratio of chest compressions to breaths in CPR.
In infant CPR the compression-to-ventilation ratio is:
one rescuer: 30 compressions to 2 breaths (30:2)
two rescuers: 15 compressions to 2 breaths (15:2)
Managing the airway
When an infant is unresponsive and not breathing, the first priority is to facilitate a patent airway for unobstructed airflow to the lungs. The main potential causes of upper airway obstruction include:
foreign material in the mouth (such as food or vomitus)
a tongue that has fallen back, obstructing the airway (when an unconscious infant lies face-up, the tongue often falls back)
To ensure a patent airway:
Inspect the mouth for foreign material and perform a finger sweep to remove it from the mouth, if required.
Perform a head-tilt/chin-lift maneuver, or if the infant has a cervical injury, use a jaw-thrust instead.
Rescue breathing
Key points to remember:
Ensure a neutral head position.
Take a breath and cover both the mouth and nose with your mouth.
If that is not possible, cover the nose or the mouth.
Give a breath for one second.
Watch that each breath makes the chest rise.
Remove your mouth after each breath and check for chest recoil.
Perform two breaths each cycle.
Recheck the pulse approximately every 2 minutes.
Rescue breathing
Take no longer than 10 seconds to assess breathing.
3.3 Fetch defibrillator
As soon as an AED is available, proceed to Step 4: Defibrillation.
It is important to consider the following before defibrillating:
If the infant is small and uninjured, you should consider carrying them with you when you go to find an AED.
However, if you suspect or can see traumatic injury, do not carry the infant with you.
Switch a manual defibrillator on as soon as possible (even while being transported) so it can be charged immediately, if needed.
4. Defibrillation
Automated external defibrillators (AEDs)
AEDs allow prompt, on-the-spot treatment of sudden cardiac events, such as a lethal arrhythmia, by delivering electrical shocks to terminate fibrillation or extreme tachycardia and to restore organised and rhythmic cardiac function or heartbeat. AEDs are widely available in public areas such as shopping malls, airports, medical clinics, and education institutions.
AEDs are automated, and so can be used by laypeople as well as personnel trained in basic life support. An AED will guide users through the application of the electrodes (therapy pads), then analyze the patient's heart rhythm automatically and, depending on the model of AED, will tell the rescuer to deliver a shock.
Types of AED
Defibrillators can deliver energy in monophasic (one direction) or biphasic (two directions) waveforms. The earliest type of AED technology used monophasic defibrillation, which delivers a charge in only one direction. These older machines are bulkier and use larger paddles.
Modern defibrillators deliver energy in biphasic waveforms. They use the same type of technology used in the small automatic defibrillators that are surgically implanted in a patient's chest to regulate the heart. Therefore a modern biphasic AED is smaller and more compact, and can be effective with a less powerful shock than an older, monophasic AED.
A biphasic AED delivers a bi-directional charge between the two electrode pads: in one direction for half of the shock, and in the electrically opposite direction for the second half as well. This type of modern AED also delivers a more consistent magnitude of current and uses smaller electrode pads instead of the larger paddles required by the older AED technology.
Note:
It is recommended to become familiar with the model of AED that is provided in your place of work or study, so that the first time it is used is not in an emergency situation, when you need to work calmly and efficiently. This is recommended because while the basic principles of operation are the same across all AEDs, each model may operate slightly differently depending on the unit's design and the displays, controls, and options provided. Always follow the automated voice prompts of the AED.
Biphasic defibrillation
Manual versus automated defibrillation
Defibrillators can be manual or automated. An automated external defibrillator (AED) is pre-programmed with the energy dose and all variables, and can be used by anyone who can follow the instructions that are automatically provided by the device. In contrast, a manual external defibrillator is a device for advanced life support on which the settings can be changed manually. This type of device is designed for use only by trained professionals, such as an EMT or ER nurse.
Manual defibrillators, if available, are preferred for use with infants. However, if a trained responder is not available to operate a manual defibrillator, an AED must be used instead.
Note:
If the infant is in cardiac arrest, it is important to defibrillate as soon as possible. If no infant-specific AED options are available, you may use an adult AED, and child or adult pads, positioning them carefully as specified below.
4.1 Position the defibrillator
Set the defibrillator close to the infant, so that the electrode cables can reach from the machine to the infant.
4.2 Start the defibrillator
Note:
The steps outlined below may vary slightly, depending on the model of AED. Always listen to and follow the AED's voice prompts.
To operate an AED:
Turn the device on:
This usually happens automatically when you open the AED's lid, but may vary from model to model.
Each model is slightly different, so always follow the AED's voice and visual prompts.
4.3 Place the electrode pads
Bare the infant's chest, taking care if they have suffered any trauma.
Use the pre-formed gel pads or self-adhesive defibrillation electrodes provided with the AED; these are designed to decrease impedance.
For infants weighing < 10kgs, use 4.5cm (1.8 inches) diameter pads/paddles, if available.
If the infant is > 10kgs, use 8-12cm (3.2–4.7 inches) diameter pads/paddles, if available.
Some AED models only have two sizes of pads for either pediatric or adult use; always use the smaller pediatric ones, if provided.
Adult pads can be used if no smaller ones are available.
Place the pads directly onto the infant's body. If their skin is wet, quickly wipe the chest and back dry before placing the pads.
Due to the small size of an infant, it is not possible to place both pads on the chest as you would for an adult or adolescent, because they would touch or overlap.
For an infant, use the anteroposterior position:
Place one pad on the infant's upper back, below the left scapula.
Place the second pad on the chest, to the left of the sternum.
Anteroposterior position
4.4 Begin defibrillation
Attach the connecting cables to the AED device, if not pre-connected.
Call out "CLEAR!" and ensure that nobody is touching the infant while the analysis takes place.
Analyze the rhythm:
The AED will either start analyzing the rhythm automatically, or will prompt you to press a button to start it.
Once the rhythm is analyzed, the AED will advise you if a shock is needed, or if CPR is to be continued for a further 2 minutes before it re-analyses the rhythm.
If the AED advises a shock, it will tell you to "clear" the infant. Call out "CLEAR!", ensure that nobody is touching the infant, and then press the shock button. The shock will cause the infant's muscles to contract suddenly.
After the first shock has been delivered, or if no shock is advised by the AED, resume CPR immediately by proceeding with chest compressions. Do not delay CPR to check the infant's pulse.
After 2 minutes of CPR, the AED will prompt you to stop CPR to allow re-analysis of the rhythm.
Continue the cycles of CPR and rhythm analysis until the infant starts to move, or until advanced care providers arrive.
Note:
Most AEDs follow a "single-shock protocol" (single shock followed by 2 minutes of CPR) although some deliver a "triple-shock protocol" (3 shocks delivered sequentially). To avoid confusion, follow the AED's voice prompts at all times.
An advanced rescuer should also be able to use a manual defibrillator, gain IV access for drug administration, and administer drugs. Be ready to assist them if requested.
5. Evaluation and monitoring
Note:
Continue resuscitation until the infant begins to regain cardiac output and to breathe, or advanced trained medical personnel arrive to take over.
If the infant regains output and breathing, keep them warm and continue to evaluate pulse and breathing until advanced trained medical personnel arrive.
An unconscious infant whose airway is clear and who is breathing normally should not be placed in the recovery position.
Instead, place the infant in the neutral position, using a small pillow or rolled up towel or blanket if needed.
To avoid impairing the infant's breathing, do not place any pressure on the chest.
Monitoring
Monitor the infant's breathing and pulse continuously until assistance arrives.
Be ready to begin CPR again immediately if the infant stops breathing, or if the pulse stops.
Evaluate and monitor infant
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