7.2 Pediatric and Infant T-CPR: Technique Variations & Rescue Breathing

7.2 Pediatric and Infant T-CPR: Technique Variations & Rescue Breathing

Quick Answer: While adult cardiac arrest is primarily a cardiac dysrhythmic event treated with continuous compressions, pediatric and infant cardiac arrests are overwhelmingly hypoxic events secondary to progressive respiratory failure, drowning, foreign body obstruction, or SIDS. Consequently, rescue breathing is physiologically vital in children and infants. In children (age 1 to puberty), CPR is coached at 30 compressions to 2 breaths (or continuous compressions if the caller refuses/cannot breathe) using 1 or 2 hands to a depth of at least one-third the chest diameter (~2 inches / 5 cm). For infants (<1 year), compressions are delivered with two fingers just below the nipple line to a depth of 1.5 inches (4 cm), accompanied by gentle cheek-puff breaths covering both the mouth and nose, while maintaining the head in a strictly neutral 'sniffing' position to prevent soft airway collapse.

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Pathophysiological Divergence: Hypoxic Arrest vs. Primary Dysrhythmic Collapse

The fundamental clinical reason why pediatric Telephone CPR protocols differ from adult guidelines lies in the underlying etiology of cardiopulmonary arrest:

+=============================================================================+
|                   ADULT VS PEDIATRIC ARREST PATHOPHYSIOLOGY                 |
|                                                                             |
|   ADULT (Primary Dysrhythmic Arrest):                                       |
|   Normal Breathing -> Ventricular Fibrillation -> Circulatory Arrest        |
|   [Blood is FULLY OXYGENATED at minute 0] --> Priority: Circulate existing  |
|                                               oxygen via Compressions-Only  |
|                                                                             |
|   PEDIATRIC (Secondary Hypoxic Arrest):                                     |
|   Respiratory Distress -> Hypoxia & Hypercarbia -> Bradycardia -> Asystole  |
|   [Blood is SEVERELY DEOXYGENATED at minute 0] --> Priority: Provide Oxygen |
|                                                    via 30:2 CPR             |
+=============================================================================+

1. The Hypoxic Cascade in Children

In infants and children, primary cardiac electrical failure (such as idiopathic ventricular fibrillation) is rare, accounting for less than 10% of pediatric arrests. Instead, the overwhelming majority of pediatric arrests stem from respiratory deterioration:

• Progressive airway obstruction (croup, foreign body, asthma, bronchiolitis)
• Alveolar failure or submersion (drowning, smoke inhalation, pneumonia)
• Sudden Infant Death Syndrome (SIDS) or accidental suffocation
• Severe septic or hypovolemic shock leading to respiratory fatigue

As the child struggles to breathe, profound hypoxemia (lack of oxygen) and hypercapnia (carbon dioxide retention) develop over minutes or hours. The pediatric myocardium is exquisitely sensitive to hypoxia; as oxygen tension falls, the heart slows down (bradycardia), cardiac output plunges, and the patient deteriorates into pulseless electrical activity (PEA) or asystole.

2. Why Compressions Alone Are Inadequate in Children

At the moment of adult sudden VF arrest, the circulating blood contains a 4-to-6 minute reservoir of oxygen. But in a child whose heart has stopped from asphyxia, the blood is already completely depleted of oxygen. Circulating severely deoxygenated, acidotic blood through chest compressions alone cannot restore cellular metabolism in the ischemic brain or myocardium.

Therefore, international consensus guidelines establish that ventilations are critical in pediatric resuscitation. The combination of compressions and rescue breaths (30:2) produces significantly higher survival rates with favorable neurological outcomes in pediatric arrests compared to compression-only CPR.

[!NOTE] The EMD Operational Compromise: While 30 compressions to 2 breaths is the gold standard for pediatric resuscitation, the EMD must immediately adapt if the caller refuses, panics, or is physically incapable of delivering breaths. IAED protocols dictate: "If the caller cannot or will not give breaths, immediately instruct continuous chest compressions." Delivering compressions alone is infinitely superior to delaying resuscitation or abandoning the patient entirely.

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Child T-CPR Protocol (Age 1 Year to Puberty)

In the Medical Priority Dispatch System, a child for resuscitation purposes is defined as a patient between 1 year of age and the onset of puberty (manifested by breast development in females or underarm/facial hair in males).

+-----------------------------------------------------------------------------+
|                      CHILD T-CPR PROTOCOL SPECIFICATIONS                    |
|                                                                             |
|   Patient Age:        1 year old to puberty                                 |
|   Compression Ratio:  30 compressions to 2 breaths (or continuous)          |
|   Compression Rate:   100 to 120 beats per minute                           |
|   Compression Depth:  At least 1/3 AP chest diameter (approx. 2 inches/5 cm)|
|   Hand Placement:     Heel of 1 hand (or 2 hands for larger child)          |
|                       Center of chest, lower half of breastbone             |
|   Airway Maneuver:    Head-tilt / chin-lift (moderate extension)            |
+-----------------------------------------------------------------------------+

1. Hand Technique and Sternal Placement

Depending on the child's size, compressions can be performed with one hand or two hands:

• Small child (ages 1–4): The heel of a single hand placed on the lower half of the breastbone (between the nipples) is typically sufficient to achieve the required 2-inch depth without causing excessive trauma.
• Older/larger child (ages 5 to puberty): The rescuer uses two hands with interlocked fingers, identical to adult technique, to generate sufficient force.

2. Compression Depth & Rate

• Depth must be at least one-third the anterior-posterior (AP) diameter of the chest, which equates to approximately 2 inches (5 cm).
• Rate remains standardized at 100 to 120 compressions per minute.
• Full recoil must be ensured between every stroke.

3. Delivering Child Rescue Breaths

The EMD instructs the caller:

"Tilt his head back gently and lift his chin. Pinch his nose closed with your fingers. Cover his mouth with your mouth to make a tight seal. Blow 2 gentle breaths into his mouth, just enough to see his chest rise. Each breath should take about 1 second."

If the chest does not rise, the caller is instructed to readjust the head tilt and attempt once more, then immediately return to chest compressions without wasting time.

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Infant T-CPR Protocol (Under 1 Year of Age)

Resuscitation of an infant (under 12 months, excluding newborns in the delivery setting) requires precise anatomical adaptations due to the infant's unique developmental anatomy.

+=============================================================================+
|                    INFANT ANATOMICAL AND AIRWAY HAZARDS                     |
|                                                                             |
|   1. Prominent Occiput:  Causes head to flex forward when supine on a flat  |
|                          surface, collapsing the pharyngeal space.          |
|   2. Funnel Trachea:     Infant tracheal cartilage is soft and pliable;     |
|                          hyperextending the neck kinks the airway like a    |
|                          crimped garden hose, blocking airflow completely.  |
|   3. Visceral Exposure:  The liver and spleen extend well below the ribs;   |
|                          compressing low on the sternum lacerates organs.   |
+=============================================================================+

1. Airway Alignment: The Neutral "Sniffing" Position

Unlike adults, who require significant head-tilt and neck extension to open the airway, an infant's airway is occluded by hyperextension. The infant's trachea is composed of soft, membranous cartilage. Tilting an infant's head far back pinches the anterior tracheal wall against the posterior pharynx, completely shutting off airflow.

The EMD must explicitly coach the neutral "sniffing" position:

• The infant's head must be positioned so the external ear canal aligns horizontally with the top of the shoulder.
• The face should look directly upward toward the ceiling.
• If the infant's large back of the head (prominent occiput) forces the chin down onto the chest, the caller can place a small folded washcloth under the infant's shoulders to maintain a neutral plane.

2. Hand Technique: Two Fingers vs. Two Encircling Thumbs

• Single Rescuer (Standard Dispatch Instruction): The EMD directs the caller to use two fingers (index and middle fingers) placed in the center of the chest, just below the imaginary nipple line.
• Two Rescuers (Alternative Technique): If two rescuers are present, the two thumb-encircling hands technique is superior: both thumbs press on the lower sternum while the fingers encircle the infant's ribcage to provide structural support.

3. Compression Depth & Rate

• Depth is at least one-third the AP diameter of the chest, which in an infant is approximately 1.5 inches (4 cm).
• Rate is 100 to 120 compressions per minute.

4. Ventilations: The Gentle Cheek-Puff

An infant's total lung capacity is minute (approximately 20 to 50 mL). Forcing a full adult breath into an infant causes catastrophic gastric distension, diaphragmatic splinting, and pulmonary barotrauma (tension pneumothorax).

The EMD coaches:

"Cover both his mouth AND his nose with your mouth to make an airtight seal. Blow gentle puffs of air—just from your cheeks, like blowing out a candle—until you see his chest barely rise. Give 2 gentle puffs, then go straight back to pumping."

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Age-Specific Resuscitation Parameters Matrix

Note: If caller is unable or unwilling to deliver breaths, continuous compressions are coached across all age categories.

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Realistic Dispatch Transcript: Infant T-CPR Coaching

EMD:        "9-1-1 Emergency, what is the address of the emergency?"
CALLER:     "22 Maple Ridge! My baby isn't breathing! Please God, help me!"
EMD:        "What is your phone number?"
CALLER:     "555-0193."
EMD:        "Tell me exactly what happened."
CALLER:     "I went to get him from his crib. He is completely limp and blue!"
EMD:        "How old is the baby?"
CALLER:     "He is only 4 months old!"
EMD:        "Is he awake?"
CALLER:     "No! He won't open his eyes!"
EMD:        "Is he breathing normally?"
CALLER:     "No, nothing! He isn't breathing!"
            [SYSTEM TRIGGERS 9-E-1 ECHO DISPATCH INSTANTLY]
EMD:        "I am sending the paramedics to help you right now. Stay on the line. 
            I am going to tell you exactly how to help him."
CALLER:     "Hurry, please!"
EMD:        "Place the baby flat on his back on a firm table or on the floor. 
            Do not put any pillows under his head."
CALLER:     "He's on the table."
EMD:        "Keep his head in a neutral position, looking straight up at the ceiling. 
            Do not tilt his head back too far, or it will close his throat."
CALLER:     "Okay, he's looking straight up."
EMD:        "Place two fingers on the center of his chest, just below his nipple line."
CALLER:     "I have my fingers there."
EMD:        "Press down firmly, about an inch and a half deep. Pump hard and fast: 
            1, 2, 3, 4... do 30 pumps! Count with me! 1, 2, 3, 4, 5, 6, 7, 8, 9, 10..."
CALLER:     "(crying) ...25, 26, 27, 28, 29, 30!"
EMD:        "Now cover his mouth AND nose with your mouth. Blow 2 gentle puffs of air 
            from your cheeks, just enough to see his chest rise."
CALLER:     "(puff... puff) Okay, his chest moved!"
EMD:        "Now put your two fingers right back on his chest and pump 30 more times! 
            1, 2, 3, 4! Do not stop!"