Paediatric basic and advanced life support — formative SAQs

SAQ 1 — Basic life support sequence and high-quality CPR (10 marks)

A 2-year-old is found unresponsive and not breathing after a short seizure. You are the registrar first on scene with a skilled nurse. The child has no signs of life. [1] [4]

Questions

1. Outline the basic life support sequence from arrival at the scene to ongoing compressions, including the compression-to-ventilation ratio. (5 marks) [1]
2. State the five quality parameters of high-quality paediatric CPR and explain why each matters. (5 marks) [4]

Model answer

BLS sequence (5). First ensure the scene is safe, then check responsiveness by tapping and shouting. If unresponsive, shout for help and send a specific person to fetch the defibrillator and call the arrest team. Open the airway with a head tilt and chin lift, and look, listen and feel for normal breathing for no more than ten seconds. If the child is not breathing normally, give five rescue breaths, each about one second, with enough volume to produce gentle chest rise. Then begin chest compressions at a ratio of fifteen compressions to two ventilations, because two rescuers are present. Cycle every two minutes, swapping compressors, and attach the defibrillator as soon as it arrives. [1]

High-quality CPR parameters (5). First, push hard — compress one third of the anteroposterior chest depth, about 4 cm in an infant and 5 cm in a child, because adequate depth generates coronary and cerebral perfusion. Second, push fast — 100 to 120 per minute, because this rate optimises flow. Third, allow full chest recoil between compressions, because recoil allows the heart to refill. Fourth, minimise interruptions to keep the chest compression fraction above 0.8, because every pause longer than ten seconds drains the aortic pressure the cycle just built. Fifth, avoid excessive ventilation — two breaths of one second each — because over-ventilation raises intrathoracic pressure and lowers cardiac output. [4]

SAQ 2 — Advanced life support loop and post-arrest care (10 marks)

The child from SAQ 1 is now in cardiac arrest. The defibrillator shows ventricular fibrillation, weighing approximately 12 kilograms. Intraosseous access has just been obtained. [5] [8]

Questions

1. Describe the advanced life support loop from this point, stating the defibrillation dose, the adrenaline dose, and the antiarrhythmic strategy. (6 marks) [1] [5]
2. Outline the post-arrest temperature, oxygen and carbon dioxide strategy after return of spontaneous circulation, citing the trial evidence. (4 marks) [9] [10]

Model answer

ALS loop (6). Ventricular fibrillation is a shockable rhythm. The first shock is delivered at 4 joules per kilogram — about 48 joules for this 12 kg child — using paediatric pads in an anterolateral position, and chest compressions resume immediately afterwards for two minutes before reassessing the rhythm. If fibrillation persists, a second shock at 4 J per kg is given and CPR resumed. Adrenaline is given at 10 micrograms per kilogram intravenously or intraosseously — that is 0.1 mL per kilogram of the 1 in 10,000 solution, repeated every three to five minutes — starting after the third shock and continuing each cycle. For refractory fibrillation after the third shock, amiodarone 5 mg per kilogram is given (lidocaine 1 mg per kg is an alternative). High-dose adrenaline is not used. Throughout, the four Hs and four Ts are searched and corrected, capnography is monitored, and the compressor is swapped every two minutes. [1] [5]

Post-arrest strategy (4). After return of spontaneous circulation, the THAPCA trials showed that routine therapeutic hypothermia was not superior to normothermia for survival with good neurological outcome in comatose children after cardiac arrest. The current strategy is to maintain normothermia and actively avoid fever, because hyperthermia in the first 24 hours worsens neurological injury. Oxygen is titrated to normoxia, targeting a saturation of 94 to 99 per cent to avoid hyperoxia, and ventilation is adjusted to normocapnia using capnography to avoid both hypocapnia and hypercapnia. Blood glucose is monitored, seizures are surveilled with electroencephalography, and the child is admitted to the paediatric intensive care unit. [9] [10]