General procedures of child emergency care include a set of actions intended to restore effective breathing and blood circulation of children suffering from apneusis or interruption of blood circulation.

BREATHING EVALUATION:

Rescuer shall monitor raising of chest and belly and check if the exhaled air can be heard or felt at the mouth of the injured child. If the breathing of child is obvious, it is necessary to keep the breathing passages free and clean.

BREATHING PASSAGES, EVALUATION AND RELEASE OF BREATHING PASSAGES:

Flabby muscles due to unconsciousness may lead to child's tongue lock-on and consecutive limitation of breathing. It is necessary to immediately release the breathing passages and eventually remove any food residues from the mouth using suction flask! For this purpose we recommend you to purchase a suction flask in your drugstore. Carefully bend the head backward and pull up the bottom jaw as shown on the pictures 1 and 2.

Picture 1 – Release of breathing passages by bending the head backward and putting the jaw up. Rescuer uses one hand to bend the head of the injured person and stretch the neck. Using the forefinger of the second hand he puts up the bottom jaw (up and forward). Head shall not be bent backward in case of suspicion on spine injury.	Picture 2 – Release of breathing passages by advancing the bottom jaw. Breathing passages are released due to increased angle of the bottom jaw. To advance the bottom jaw, two or three fingers of the rescuer should be used. The remaining fingers pull the jaw upwards and forward.	Picture 3 – Artificial breathing (nurse child). The rescuer surrounds by his mouth the nose and mouth of the child. Using one hand he bents the head of the child backward while the second hand keeps the jaw upwards. Head bend shall be prevented in case of suspicion on head or neck injury.

ARTIFICIAL BREATHING:

Artificial breathing is to be carried out at released breathing passages (see above – head bent backward, jaw put up and forward). You must breath in, then surround by mouth the nose and mouth of injured person (if nurse child) or mouth only (if older child) and press the nose firmly – see pictures 3 and 4. Perform two slow inspirations (1 inspiration should take about 1 – 1,5 s). As the injured children may be of various age and height, it is not easy to recommend a pressure or breathing capacity to put forth. Therefore we consider as adequate a pressure and breathing capacity at which the chest of the injured child rises up. If the chest is not moving, the breathing is not effective. Sometimes a bit stronger pressure is necessary as the breathing passages of children are narrow and may resist. If the free air circulation cannot be achieved despite the above described action, we must thoroughly check the mouth, whether there is some obstruction (foreign item – e.g. toy, food residues, etc.) or check the backward bend of the head and position of the bottom jaw. Try to find such a position where the clearness of the breathing passages is optimal.

If even then the breathing passages cannot be released, there is a high probability of foreign item in the breathing passages (see bellow for the procedure how to remove the item). If the breathing passages are free and we can feel the pulse, perform the artificial breathing at frequency of 20 inspirations per minute.

Picture 4 – Artificial breathing (child). Rescuer carefully surround the mouth of child by his own mouth and uses one hand to keep the head bent backwards and block the nose of the child by thumb and forefinger.

Picture 5 – Pulse examination on carotid artery

Picture 6 – Pulse examination on brachial artery

EXAMINATION OF BLOOD CIRCULATION:

As soon as the breathing passages are free and we did the first two inspirations, we should check the blood circulation, i.e. pulse. If you cannot feel the pulse, it may refer to insufficient of missing heart systole. Then we may try to feel the pulse on large arteries (e.g. carotid on neck or arm, eventually femoral artery) – see pictures 5 and 6. In general we can say that if the child is not breathing, the heart activity is insufficient and indirect heart stimulation is recommended. It is also true that checking the pulse on main arteries of children is quite difficult and therefore we should not waste too much time with it. Heart activity may be verified by simple hearing apply your ear on the middle of the chest, eventually slightly to the left from the sternum, at level of teats. If you feel no pulse nor hear the heart activity, the external heart massage should be initiated.

FACILITATION OF EXTERNAL HEART STIMULATION ON INFANT BABY:

External heart massage is a rhythmical pressing of chest leading to circulation of blood to the important body apparatuses. It shall always be accompanied with artificial breathing! To achieve the required chest pressure, it is necessary to lay the child on its back on the flat and hard bed. External heart stimulation is facilitated by pressing the sternum of injured child in its bottom third – see picture 8. The pressure shall be applied approx. 1 finger under the imaginary connection line between nipples. The pressing is made by middle finger and ring finger to the depth of one third of distance between sternum and spine. At the end of each press release the pressure without putting the fingers from the chest. The movement should be smooth and even maintaining the same time for pressing as well as releasing. Pressing frequency for infant babies should be about 80 presses per minute.

Picture 7 – Searching for the correct area for heart stimulation of nurse child. The second hand of rescuer shall keep the head bent backwards to facilitate the ventilation.

Picture 8 – Position of hands at external heart stimulation of child. The second hand of the rescuer keeps the head bent backwards to facilitate the ventilation.

Picture 9 – Hits between spatulas (up) and pressing the chest (down) to remove the foreign item from breathing passages of infant baby.

When facilitating the external heart stimulation of older children, the press is made by bottom part of our palm – see picture 9. The pressing is made down to one third up to one half of the distance between sternum and spine. Frequency remains the same, i.e. 80 presses per minute.

COORDINATION OF EXTERNAL HEART STIMULATION AND ARTIFICIAL BREATHING:

After each fifth press of the chest there should be a delay up to 1,5 seconds during which we shall perform the inspiration. This means a frequency 5 : 1 (disregarding the number of rescuers).

BLOCKAGE OF BREATHING PASSAGES BY FOREIGN ITEMS:

If the breathing passages cannot be released, it is very probable that the passages are blocked with some foreign item. In these cases children are mostly coughing, vomiting, livid or hardly breath before falling to unconsciousness. More than 90% of deaths due to inspiration of foreign item is experienced by children up to 5 years of age, 65% of whose are nurse children.

These foreign items are mainly various toys, but also food, nuts, grapes, candies, stones, etc. We should not forget suffocation due to certain disease (e.g. epiglottiditis).

In this case we should look for the temperature, increased salivation, food refusing, rough voice and mucous swelling as well. If the breathing passages are not limited by inflammation, then we should try to release the passages.

For release of breathing passages of nurse child see picture 10. Child should be held on forearm, laying on belly with head lower than body. By bottom edge of your palm make five strong hits between spatulas. Carefully supporting the head of the child, lay the child on your thighs with head lower than body. In the same area as we perform the indirect external heart stimulation do some intense presses of chest. They should be rather impacts than presses, focused on displacement of the foreign item by sudden air flow. If we can see it, take it out. If no positive reaction can be seen, repeat the process until the foreign item is completely out and breathing is effective again.

For older children perform a series of belly presses. In total we do five belly presses with fisted hands in the area between navel and chest. This is referred to Heimlich maneuver. It is facilitated on standing or sitting child. If the child is unconscious, we perform a set of belly presses with the child lying on the bed. We repeat this procedure until the foreign item is out and try whether the artificial breathing may be provided, i.e. whether the breathing passages are free again.

VOCATIONAL HELP:

If there are two rescuers and one of them easily handles all the required actions, the second should immediately call emergency service, usually number 155. If there is only one rescuer, he should call for help and contact the emergency service only after the child breathes again, having the heart activity restored. Before leaving the child, put it into stabilized position on side.

Picture 10 – Belly pressing on standing or sitting child (consciousness)

Information from JAMA vocational magazine was used. General pediatric emergency care.