THE UNSUSPECTED INHALED OBJECT
C: C HECK FOR S IGNS OF C IRCULATION
1. As soon as you’ve determined with two successful breaths that the airway is clear, check for signs of circulation. Checking for a pulse is no longer considered necessary (since a pulse may be difficult for a nonprofessional to locate in a small child), so look instead for signs of life—such as movement and responsiveness. If you feel comfortable looking for a pulse, you can do so—but don’t spend more than 10 seconds trying to locate it. With an infant under a year, try to find the brachial pulse in the arm closest to you: keeping one hand on baby’s head to maintain an open airway, use the other to pull baby’s arm away from the body and turn it palm up. Use your index and middle fingers to try to locate the pulse between the two muscles on the inside of the middle arm, between the shoulder and elbow; see illustration. (With a baby over age one, take the carotid pulse in the neck—feel for the artery in the neck under the ear and just below the jawbone.)
Checking brachial pulse in infants.
2. If you find no signs of life, begin chest compressions (see facing page) immediately. If you find signs of life, but breathing has not resumed, begin rescue breathing immediately (see below).
Important: Activate Emergency Medical System. If the EMS has not yet been called and there is someone available to make the call, have them do so now. If a call was made before baby’s condition was assessed, have the caller contact the dispatcher again to give further information on baby’s condition: whether or not baby is
conscious, is breathing, and shows signs of life. Do not take time to call yourself if baby requires rescue breathing or CPR. Proceed without delay, periodically calling loudly to attract help from a neighbor or passersby.
RESCUE BREATHING (MOUTH-TO-MOUTH RESUSCITATION)
If, after following Steps 1-2-3 (A-B-C) on page 593, you find a pulse but baby’s breathing has not resumed spontaneously, begin the following protocol:
1. Blow into baby’s mouth or mouth and nose as described on page 595 at a rate of roughly one slow breath every 3 seconds (20 breaths per minute) for a baby under a year old (breathe, one and two and three and breathe), and once every 4 seconds (15 breaths per minute) for a baby older than a year. Watch to be sure baby’s chest rises and falls with each breath.
2. Check for signs of life after a minute of rescue breathing to be sure the heart has not stopped.
If it has, go to chest compressions (CPR). If it hasn’t, look, listen, and feel for spontaneous breathing (see page 594) for 3 to 5 seconds. If baby has begun breathing independently, continue to maintain an open airway and check breathing and pulse frequently while waiting for help to arrive; keep baby warm and as quiet as possible. If there is no spontaneous breathing, continue rescue breathing, checking for signs of life. and breathing once every minute.
Important: The airway must be kept open for rescue breathing to be effective. Be sure to maintain baby’s head in the neutral position during rescue breathing.
3. If you’re alone and emergency medical help has not yet been summoned, call as soon as independent breathing has been established. If within a few minutes baby hasn’t starting breathing independently, carry the child in the football hold to a phone, continuing rescue breathing as you go.
On the phone, simply report, “My baby isn’t breathing,” and quickly but clearly give all pertinent information (see facing page). Don’t hang up until the dispatcher does; if possible, continue rescue breathing while the dispatcher is speaking.
Important: Do not discontinue rescue breathing until the baby is breathing independently or until medical professionals arrive to take over.
CHEST COMPRESSIONS (CPR): BABIES UNDER ONE YEAR2
If, after following Steps 1-2-3 (A-B-C) on page 593, baby is not breathing and has no signs of life (movement, responsiveness), begin the following CPR protocol:
Important: In CPR, rescue breaths, which force oxygen into the lungs where it is picked up by the bloodstream, must be alternated with chest compressions, which artificially pump the oxygen-laden blood to the vital organs and the rest of the body.
Compressions on infants can be done with two or three fingers.
1. With baby still lying on a firm, flat surface, faceup, head level with the heart, continue to maintain baby’s head in a neutral position with one hand on forehead. Place a small rolled towel, diaper, or other support under baby’s shoulders and lift them just a bit, which will also help maintain an open airway. Do not cause the head to dip back more than slightly (see illustration, page 591).
2. Position the three middle fingers of your free hand on baby’s chest. Imagine a horizontal line from nipple to nipple. Place the pad of the index finger just under the intersection of this line with the breastbone, or sternum (the flat bone running midline down baby’s chest between the ribs). The area to compress is one finger’s width below this point of intersection (see illustration, above).
3. Using two or three fingers, compress the sternum straight down to a depth of ẵ to 1 inch (your elbow should be bent). At the end of each compression, release the pressure without removing your fingers from the sternum and allow it to return to its normal position. Develop a smooth compression- relaxation rhythm that allots equal time to each phase and avoids jerky movements.
4. After every fifth compression, pause with your fingers still in position on the sternum and deliver one slow rescue breath of 1 to 1ẵ seconds. Watch for the chest to rise. (If it doesn’t, remove your fingers from the breastbone and lift the chin and blow again.) Aim for a rate of 100
compressions per minute, with a rescue breath after every five compressions. Count at a more rapid rate than you would if counting seconds: one, two, three, four, five—breathe.
5. After about a minute, take 5 seconds to check for signs of life. If you see no signs of life, give one slow rescue breath, then continue the compression/ventilation cycles of CPR, checking every few minutes for signs of life. If you see movement or responsiveness, discontinue chest compressions.
Look, listen, and feel for 3 to 5 seconds for spontaneous respiration. If breathing is present, keep airway open and baby warm and quiet, and continue to monitor baby’s breathing. If baby is still not breathing, continue with rescue breathing alone as described above.
6. After one minute of CPR, if you are alone and have not been able to attract anyone who could call for emergency medical assistance up until now, go quickly to a phone (carrying baby with you, if possible, or bringing the phone to where baby is) and summon help; then immediately return to rescue procedures as needed.
Important: Do not discontinue CPR until breathing is reestablished or until medical relief arrives.
CHEST COMPRESSIONS (CPR): BABIES OVER ONE YEAR
If, after following Steps 1-2-3 (A-B-C) on page 593, your child over a year is not breathing and has no signs of life (movement, responsiveness), begin the following CPR protocol:
1. Continue with the child face up on a firm, flat surface. There should be no pillow under the child’s head; the head should be level with the heart. The child’s head should be in the neutral-plus position (see page 595) to keep the airway clear.
2. Position your hands. Place the heel of one hand over the lower third of the breast bone (the flat bone running down the child’s chest between the ribs).
Important: Do not apply pressure to the tip of the sternum. Doing so could cause severe internal damage.
3. Compress the chest with the heel of your hand to a depth of 1 to 1ẵ inches. The only contact should be between the heel of your hand and the flat lower half of the sternum—do not press on the ribs during compressions. Allow the chest to return to its resting position after each compression without lifting your hand from the chest. Develop a compression-relaxation rhythm that allots equal time to each phase and avoids jerky movements.
4. At the end of every fifth compression, pause, and with baby’s nostrils pinched closed, deliver a slow breath of 1 to 1ẵ seconds. Chest compressions must always be accompanied by rescue
breathing to ensure a steady supply of oxygen to the brain (a child without a heartbeat is not breathing and is not getting oxygen).
Hand position for CPR compression for children over a year old.
Aim for a rate of 80 to 100 compressions a minute, with a breath after every five compressions.
Count at a more rapid rate than you would if counting seconds: one, two, three, four, five—breathe.
5. After about a minute, take 5 seconds to check for signs of life. If you see no signs of life, give one slow breath with the nostrils pinched closed, then continue the compression/ventilation cycles of CPR, checking periodically for signs of life. If you see movement or responsiveness, discontinue chest compressions.
6. If you have not been able to attract help by calling, and emergency medical assistance has not been summoned, take a moment to go to a phone and call now; then immediately return to rescue
procedures as needed. If possible, carry the child with you to the phone and continue rescue breathing as you go.
Important: Do not discontinue CPR until breathing is reestablished or until mediccal relief arrives.
1 If you suspect a head, neck, or back injury, go first to Step B to look, listen, and feel for breathing before moving baby. If breathing is present, don’t move baby unless there is immediate danger (as from fire or explosion) at the present site. If breathing is absent, and rescue breathing cannot be accomplished in the position baby is in, roll baby to a faceup position as a unit so that head, neck, and body move as one without twisting.
2. One year is the arbitrary cutoff chosen by the American Heart Association, the American Red Cross, and the American Academy of Pediatrics for switching from infant to child resuscitation procedures. The child’s size may be a factor in some cases, but experts say that a slight error either way is not critical.
CHAPTER 20