4.3 Child Assessment, Rescue Breathing & Bradycardia

4.3 Child Assessment, Rescue Breathing & Bradycardia

Pediatric BLS includes one circulation decision not used in the adult algorithm: a child with a pulse may still need chest compressions when severe bradycardia produces poor perfusion despite effective oxygenation and ventilation.

Perform the initial assessment

After scene safety and a responsiveness check, call for help and activate emergency response. Check breathing and either a carotid or femoral pulse at the same time for at least 5 but no more than 10 seconds.

Classify the findings:

Agonal gasps are not normal breathing. Do not wait for complete apnea when breathing is clearly ineffective.

Rescue breathing when circulation is adequate

If the child has a definite pulse of at least 60/min but is not breathing normally:

1. Open the airway.
2. Give 1 breath every 2-3 seconds—20-30 breaths/min.
3. Deliver each breath over about 1 second with visible chest rise.
4. Reassess pulse and breathing about every 2 minutes.
5. If the pulse is lost or falls below 60/min with poor perfusion despite effective breaths, begin CPR.

Avoid excessive breaths. A rate faster than the target or a breath that is too forceful can impair circulation and inflate the stomach.

Severe bradycardia with poor perfusion

Hypoxia can slow a child's heart rate before the pulse disappears. Provide effective oxygenation and ventilation promptly. If the heart rate remains below 60/min and there are signs of poor perfusion, begin chest compressions.

Signs of poor perfusion can include weak central pulses, pallor or cyanosis, altered responsiveness, or other evidence that circulation is inadequate. The rule is not “compress every child whose heart rate is 59.” The full condition is:

Heart rate below 60/min + signs of poor perfusion + persistence despite effective oxygenation and ventilation.

There is no required instruction to ventilate for exactly 1 minute before acting. If effective oxygenation and ventilation are being provided and the child remains severely bradycardic with poor perfusion, begin compressions without an arbitrary delay.

CPR pattern

Use a rate of 100-120 compressions/min and a depth of at least one-third the chest diameter, about 2 inches (5 cm). Use:

• 30:2 with one rescuer.
• 15:2 with 2 or more healthcare rescuers.

Allow complete recoil and keep pauses under 10 seconds. Apply the AED as soon as available, use pediatric attenuation when available for a child younger than 8 years, and resume CPR immediately after analysis or shock.

Reassessment

During rescue breathing, reassess about every 2 minutes because the child may improve or deteriorate. During CPR, follow the AED or organized team cycle. If signs of life appear, pause briefly to assess breathing and a pulse. Do not interrupt compressions repeatedly merely to see whether a slow pulse has changed.

Team priorities

When a second rescuer arrives, one continues airway support while the other prepares for compressions and AED use. State the clinical finding clearly: “Pulse below 60 with poor perfusion despite effective ventilation—start compressions.” This closed-loop statement helps prevent confusion between rescue breathing and CPR.

Common errors

• Counting for longer than 10 seconds to find a pediatric pulse.
• Giving adult respiratory-arrest breaths at 1 every 6 seconds instead of 1 every 2-3 seconds.
• Starting compressions for a heart rate below 60/min without considering perfusion and effective ventilation.
• Delaying indicated compressions for a fixed 1-minute trial.
• Continuing breaths alone despite worsening severe bradycardia and poor perfusion.

Exam questions often provide all three elements of the bradycardia rule. Read the wording completely before selecting rescue breaths alone or CPR.

Scenario practice

Say the complete finding before choosing an action: “Pulse 70, inadequate breathing,” “pulse 50 with poor perfusion despite effective ventilation,” or “no definite pulse.” The first calls for rescue breaths, while the latter two call for CPR. This verbal discipline prevents a common error—responding to a heart-rate number without reading the perfusion and ventilation facts. During practice, switch findings every 2 minutes so the ventilation rescuer must recognize when the pathway changes.