PALS Certification Course 2023 with complete solution

Which topics are included in the PALS course ? PALS includes the following: (1) Overview of assessment (2) Recognition and management of respiratory distress and failure (3) Recognition and management of shock (4) Recognition and management of cardiac arrhythmias (5) Recognition and management of cardiac arrest (6) Postresuscitation management of patients with pulmonary and cardiac arrest (7) Review of pharmacology What should be the primary focus of the clinician on prevention of cardiopulmonary failure The clinician should primarily focus on prevention of cardiopulmonary failure through early recognition and management of respiratory distress, respiratory failure, and shock that can lead to cardiac arrest from hypoxia, acidosis, and ischemia. What is the main cause of cardiac arrests in children? In infants and children, most cardiac arrests result from progressive respiratory failure and/or shock, thus one of the aims of PALS rapid assessment model is to prevent progression to cardiac arrest. What is the pediatric assessment triangle? Brief visual and auditory observation of child's overall (1) appearance, (2) work of breathing, (3) circulation What are the components of the primary assessment? What signs should the clinician look for? The clinician should in rapid sequence assess: (1) Airway (patent, patent with maneuvers/adjuncts, partially or completely obstructed) (2) Breathing (respiratory rate, effort, tidal volume, lung sounds, pulse oximetry) (3) Circulation (skin color and temperature, heart rate and rhythm, blood pressure, peripheral and central pulses, capillary refill time) (4) Disability: (a)AVPU pediatric response scale: Alert, Voice, Pain, Unresponsive; (b) Pupillary response to light (c) Presence of hypoglycemia (rapid bedside glucose or response to empiric administration of dextrose) (d) Glasgow Coma Scale What are the components of the secondary assessment? For what should the clinician look for during the secondary assessment? This portion of the evaluation includes a thorough head to toe physical examination, as well as a focused medical history that consists of the "SAMPLE" history: (S) Signs and Symptoms (A) Allergies (M) Medications (P) Past medical history (L) Last meal (E) Events leading to current illness What are the components of the tertiary assessment? Injury and infection are common causes of life-threatening illness in children. Thus, for this stage, ancillary studies are frequently directed towards identifying the extent of trauma or an infectious focus. There are many causes of acute respiratory compromise in children. The clinician should strive to categorize respiratory distress or failure into one or more of the following: (1) Upper airway obstruction (eg, croup, epiglottitis) (2) Lower airway obstruction (eg, bronchiolitis, status asthmaticus) (3) Lung tissue (parenchymal) disease (eg, bronchopneumonia) (4) Disordered control of breathing (eg, seizure, coma, muscle weakness) What is the focus of initial management The main focus of initial management is to support airway, breathing, and circulation How can the clinician support the airway? (1) Provide 100 percent inspired oxygen (2) Allow child to assume position of comfort or manually open airway (3) Clear airway (suction) (4) Insert an airway adjunct if consciousness is impaired (eg, nasopharyngeal airway or, if gag reflex absent, oropharyngeal airway) How can the clinician support breathing? For supporting breathing, the clinician should: (1) Assist ventilation manually in patients not responding to basic airway maneuvers or with inadequate or ineffective respiratory effort (2) Monitor oxygenation by pulse oximetry (3) Monitor ventilation by end-tidal carbon dioxide (EtCO2) if available (4) Administer medications as needed (eg, albuterol, epinephrine) T of F: in preparation for intubation, the patient should receive 100 percent oxygen? True! In preparation for intubation, the patient should receive 100 percent oxygen via a high-concentration mask, or if indicated, positive pressure ventilation with a bag-valve-mask to preoxygenate and improve ventilation. What should be done if the patient cannot maintain their airway, oxygenation, or ventilatory requirements? In such cases, the patient should undergo placement of an artificial airway, usually via endotracheal intubation and less commonly with a laryngeal mask airway or alternative device. T or F some patients with upper airway obstruction and/or respiratory failure may respond to noninvasive ventilation if airway reflexes are preserved. True! Certain populations of patients with upper airway obstruction and/or respiratory failure may respond to noninvasive ventilation (CPAP or BiPAP) if airway reflexes are preserved. When a patient appears to be in shock, what should be the goal of the next action taken? The goal should be to recognize and categorize the type of shock in order to prioritize treatment options Why is the early management of shock so critical for patient survival? Early treatment of shock may prevent the progression to cardiopulmonary failure In children, does shock present with low or high cardiac output? Shock in children usually presents with low cardiac output, but some patients may have high cardiac output, such as with sepsis or severe anemia. How can shock be classified? Shock severity is usually classified based on its effect on systolic blood pressure at presentation (i.e. compensated vs. decompensated) or based on its pathophysiology (i.e hypovolemic; distributive; cardiogenic; obstructive shock) What is the meaning of "compensated" shock, when does it occur? Compensated shock occurs when compensatory mechanisms (including tachycardia, increased systemic vascular resistance, increased inotropy, and increased venous tone) maintain a systolic blood pressure within a normal range What is the meaning of hypovolemic "decompensated" shock? When does it occur? Hypotensive shock occurs when compensatory mechanisms fail to maintain systolic blood pressure. Define hypotension in term infants? In term infants 0 to 1 month of age, systolic pressure 60 mmHg Define hypotension in infants 1 to 12 months of age? For infants 1 to 12 months of age, hypotension is defined by systolic pressure 70 mmHg Define hypotension in infants 1 to 10 years of age? In children 1 to 10 years of age, hypotension is defined as: Systolic pressure (5th percentile) (70 mmHg + [child's age in years x 2]) Define hypotension in children over 10 years of age? In children over 10 years of age, systolic blood pressure 90 mmHg What is key to know about hypotensive "decompensated" shock in contrast to compensated shock? Hypotensive shock may rapidly progress to cardiopulmonary failure. How can shock be classified according to its pathophysiology? Shock can be classified as being hypotensive, distributive; cardiogenic or obstructive What is hypovolemic shock? Shock that is characterized by inadequate circulating blood volume (from fluid loss). Common causes include diarrhea, hemorrhage (internal and external), vomiting, inadequate fluid intake, osmotic diuresis (eg, diabetic ketoacidosis), third-space losses, and burns. What is distributive shock? A form of shock arising from inappropriately distributed blood volume typically associated with decreased systemic vascular resistance. Common causes include septic shock, anaphylactic shock, and neurogenic shock (eg, head injury, spinal injury). What is cardiogenic shock? A form of shock arising from impaired heart contractility. Common causes include congenital heart disease, myocarditis, cardiomyopathy, arrhythmias, sepsis, poisoning or drug toxicity, and myocardial injury (trauma). What is obstructive shock? A form of shock that arises from obstructed blood flow to the heart or great vessels. Common causes include cardiac tamponade, tension pneumothorax, ductal-dependent congenital heart lesions, and massive pulmonary embolism. Can patients suffer from more than one type of shock? Yes, any given patient may suffer from more than one type of shock. For example, a child in septic shock may develop hypovolemia during the prodrome phase, distributive shock during the early phase of sepsis, and cardiogenic shock later in the course. What is the definition of cardiopulmonary failure? Respiratory failure + hypotensive shock Which are the "airway" physical findings preceding cardiopulmonary failure that a clinician should look for? Stridor, stertor, drooling, and/or severe retractions Which are the "breathing" physical findings preceding cardiopulmonary failure that a clinician should look for? Bradypnea, irregular, ineffective respiration, gasping, and/or cyanosis • What are the "circulation" physical findings preceding cardiopulmonary failure that a clinician should look for? Bradycardia, capillary refill 5 seconds, weak central pulses, no peripheral pulses, hypotension, cool extremities, and/or mottled/cyanotic skin What are the "disability" physical findings preceding cardiopulmonary failure that a calinician should look for? Signs suggesting the presence of diminished level of consciousness What interventions should be performed in all patients with cardiopulmonary failure? Positive pressure ventilations with 100 percent inspired oxygen, chest compressions for heart rate 60 beats per minute in patients with poor perfusion, and administration of intravenous fluids and medications tailored to treat the underlying cause are indicated How is the heart rate status classified in children? In children, the heart rate is classified as bradycardia, tachycardia, and pulseless arrest. Why is being able to detect the presence of a bradyarrythmia in children so important? What is usually the primary cause? Bradyarrhythmias are common pre-arrest rhythms in children and are often due to hypoxia. In general terms, in children, what is the definition of bradycardia? A heart rate that is slow compared with normal heart rates for the patient's age (can be classified into primary or secondary based on etiology) What is a bradyarrthymia? Slow abnormal rhythm originating in the atria or the ventricles. What is primary bradycardia? Primary bradycardia is the result of congenital and acquired heart conditions that directly slow the spontaneous depolarization rate of the heart's pacemaker or slow conduction through the heart's conduction system. What is secondary bradycardia? Secondary bradycardia is the result of conditions that alter the normal function of the heart, including hypoxia, acidosis, hypotension, hypothermia, and drug effects. What are the ECG findings of bradycardia (1) Slow heart rate relative to normal rates (table 4) (2) P waves that may or may not be visible (3) QRS complex that is narrow (electrical conduction arising from the atrium or high nodal area) or wide (electrical conduction from low nodal or ventricular region) (4) P wave and QRS complex may be unrelated (ie, atrioventricular dissociation) or have an abnormally long period between them (atrioventricular block) What are the subtypes of bradycardia? (1) Sinus bradycardia (2) AV block (first, second, third degree) In general terms what is the definition of tachycardia in children? A heart rate that is too fast for the child's age, level of activity, and clinical condition What are the usual causes of sinus tachycardia? Hypovolemia, fever, physiologic response to stress or fear, or drug effect (such as with beta agonists). What are tachyarrhythmias? Fast abnormal rhythms originating in the atria or the ventricles. How can tachyarrhythmias present in children? In children tachyarrythmia symptoms may include palpitations, lightheadedness, dizziness, fatigue and syncope How can prolonged tachycardia present in infants? In infants, prolonged tachycardia may cause poor feeding, tachypnea, and irritability with signs of heart failure. What factors determine the management of tachycardia? Treatment priorities in managing tachycardias rely on whether hemodynamic instability is present and differentiating between tachycardia with narrow QRS complex and wide QRS complex tachycardias What are the most common causes of sinus tachycardia? Hypoxia, hypovolemia, fever, metabolic stress, injury, pain, anxiety, toxins/poisons/drugs, and anemia. What are other less common causes of sinus tachycardia in children? Cardiac tamponade, tension pneumothorax, and thromboembolism. Frequent ECG findings of tachycardia in children include (1) Heart rate usually 220/min in infants, 180/min in children and exhibit beat to beat variability in rate. (2) P waves are present with normal appearance. (3) Constant PR intervals and exhibit a normal duration for age. (4) Variable R-R intervals. (5) Narrow QRS complexes. What is pulseless arrest? Pulseless arrest refers to the cessation of blood circulation caused by absent or ineffective cardiac mechanical activity What is the most common cause of pediatric cardiac arrest? Most pediatric cardiac arrests are hypoxic/asphyxial arrests that result from a progression of respiratory distress, respiratory failure, or shock rather than from primary cardiac arrhythmias ("sudden cardiac arrest"). What is the most frequent presentation of children with pulseless arrest? Children with pulseless arrest usually appear apneic or display a few agonal gasps. They have no palpable pulses and are unresponsive. How can we classify pulseless arrest rhythms? (1) Shockable rhythms and (2) Asystole and Pulseless electrical activity Which are the "shockable" rhythms? (1) Shockable rhythms: (a) V. Fib (b)Pulseless V. Tach; and (c) TDP What is asystole? What is the most common cause in children? Patients with asystole have cardiac standstill with no discernible electrical activity. The most common cause in children is respiratory failure progressing to critical hypoxemia, bradycardia, and then cardiac standstill. Underlying conditions include airway obstruction, pneumonia, submersion, hypothermia, sepsis, and poisoning (eg, carbon monoxide poisoning, sedative-hypnotics) leading to hypoxia and acidosis. What is Pulseless electrical activity (PEA)? PEA consists of any organized electrical activity observed on ECG in a patient with no central palpable pulse. PEA 6 H's Hypovolemia; hypoxia, hydrogen ions, hypo/hyperkalemia, hypoglycemia and, hypothermia eat Bananas when Dry, Acidic, Hungry or Cold PEA 5 T's Toxins, Tamponade, Tension pneumothorax, Thrombosis (coronary or pulmonary), Trauma She uses Toxic Tampons while playing the Trombone under Traumatic Tension BRADYCARDIA ALGORITHM: What is the focus of bradycardia management in children? (1) Reestablishing or optimizing oxygenation and ventilation (2) Supporting circulation with chest compressions for patients with poor perfusion and a heart rate 60 beats per minute (3) Using medications (ie, epinephrine or atropine) to increase heart rate and cardiac output What if the above three measures fail? If these measures fail, transcutaneous pacing can be attempted; however, the same factors that are producing refractory bradycardia (eg, hypoxia, hypothermia, electrolyte disturbance, or drug overdose) may prevent effective electrical capture. TACHYCARDIA ALGORITHM: What is the focus of tachycardia management in children? The management of sinus tachycardia focuses on treatment of the underlying physiologic derangement and is largely supportive. What is the focus of the management of tachycardia that is not sinus in origin? The management of tachyarrhythmias that are not sinus in origin is guided by the appearance of the QRS complex, and by the patient's status, whether unstable or stable What is the management protocol for unstable patients? Patients with a pulse and either narrow or wide complex tachycardia who have significantly impaired consciousness and hypotensive shock should be treated with synchronized cardioversion (initial dose: 0.5 to 1 J/kg) What is the management protocol for stable patients? For patients who are mentating and not hypotensive, treatment is determined by the QRS complex: In stable patients with narrow QRS (≤0.09 seconds)? For narrow complex tachycardia suggestive of supraventricular tachycardia (SVT), vagal maneuvers may be attempted while preparing for medication administration. Appropriate vagal maneuvers include application of ice to the face or, in a cooperative child, a Valsalva maneuver by bearing down or blowing into an occluded straw. What is the first recommended medication for SVT? Adenosine, 0.1 mg/kg (maximum dose 6 mg) administered rapidly IV/IO and followed by a rapid saline flush What should be done is if the wide-complex rhythm is monomorphic and regular? If the wide-complex rhythm is monomorphic and regular, it is acceptable to administer a dose of adenosine to determine if the rhythm is actually supraventricular tachycardia with aberrant conduction. PULSELESS ARREST ALGORITHM ... What is needed to achieve highly effective chest compressions? For highly effective chest compressions, the individual performing the compressions needs to push at an adequate rate and depth, avoid leaning on the chest (allow full recoil), and minimize interruptions in chest compressions. The person performing chest compressions should be rotated approximately every two minutes, regardless of whether he/she feels capable of continuing. Which should be the only times for interrupting compressions? Compressions should only be interrupted for rhythm check at the appropriately defined intervals, shock delivery, and for insertion of breaths for patients without a secure airway at a ratio of 30 compressions to 2 ventilations (one rescuer or age or puberty and older) or 15 compressions to two ventilations (two rescuers and infants and children). How should compressions be administered once the patient's airway is secured by endotracheal intubation? Once the patient's airway is secured by endotracheal intubation, perform continuous chest compressions and ventilate at a rate of 8 to 10 breaths/minute (approximately one breath every six seconds T or F: Infants and children should receive both chest compressions and ventilations rather than compression-only CPR Infants and children should receive both chest compressions and ventilations rather than compression-only CPR based upon large population studies demonstrating improved survival and neurologic outcome What is the most appropriate management of patients "shockable" rhythm at presentation? Patients with ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) should receive immediate CPR and defibrillation at 2 J/kg as soon as a device is available. Then perform approximately two minutes of CPR (10 cycles for two person CPR or 5 cycles for one person CPR) before checking the rhythm What if the rhythm has not converted with defibrillation? If the rhythm has not converted with defibrillation, the patient should receive a repeated defibrillation at a higher dose (4 J/kg) followed by additional cycles of CPR as described above. Subsequent defibrillations should be provided at a minimum of 4 J/kg, up to 10 J/kg or the adult energy dose (typically 120 to 200 J for a biphasic defibrillator and 360 J for a monophasic defibrillator). T or F: automated external defibrillators without pediatric attenuating devices should not be used even if they are the only option available. False! Although manual defibrillators operated by advanced life support providers or automated external defibrillators with pediatric attenuating devices are preferred for use in infants and children, automated external defibrillators without pediatric attenuating devices may be used if they are the only option available. Are vascular or intraosseous access for drug administration a reason to interrupt chest compressions? No, attempts at vascular or intraosseous access should not interrupt chest compressions. During CPR, intraosseous access may be pursued initially, or simultaneously with peripheral vascular access. IV/IO Epinephrine dose The IV/IO dose of epinephrine is 0.01 mg/kg (0.1 mL/kg of the 0.1 mg/mL concentration [ratio 1:10,000]) given every three to five minutes; maximum single dose: 1 mg (10 mL). Endotracheal Epinephrine dose When epinephrine is administered via endotracheal tube, use a 10-fold higher dose or 0.1 mg/kg (0.1 mL/kg of the 1 mg/mL concentration [ratio 1:1000]) every three to five minutes Amiodarone dosages The initial IV/IO dose of amiodarone is 5 mg/kg (maximum single dose 300 mg). The 5 mg/kg (maximum 300 mg) dose can be repeated twice. What is the initial IV/IO bolus dose of lidocaine? The initial IV/IO bolus dose of lidocaine is 1 mg/kg. This may be followed by an infusion of 20 to 50 mcg/kg/min. The bolus dose should be repeated if the lidocaine infusion is started more than 15 minutes after the initial bolus. What should be the dosage of lidocaine when administered endotrachealy? Although lidocaine can be given through the endotracheal tube, the optimal dose is unknown. However, an increase of two- to threefold from the IV/IO dosage is suggested. What is the appropriate dose of MgSO4? The IV/IO dose is 25 to 50 mg/kg (maximum dose 2 g) given as an infusion diluted in a 5 percent dextrose solution (D5W) to a concentration of 20 percent or less and, in an arrested patient, infused over one to two minutes. What is the purpose of flushing the drug with saline? Resuscitation medications given through an IO or peripheral IV should be followed with a 5 to 10 mL flush of normal saline to move the drug from the peripheral to the central circulation. How are patients with asystole or pulseless electrical activity be managed initially? Patients with asystole or pulseless electrical activity should receive cardiopulmonary resuscitation and epinephrine as soon as possible after arrest. During the course of the resuscitation, the clinician should evaluate for and treat underlying causes (H's and T's) for the pulseless arrest. Timely administration of epinephrine is associated with improved survival. CPR Quality Monitoring In adults, end-tidal carbon dioxide (EtCO2) measurements from continuous waveform capnography accurately reflect cardiac output and cerebral perfusion pressure, and therefore the quality of CPR. Hence, a decline in EtCO2 during resuscitation may indicate inadequate effectiveness of compressions, dislodgement of an endotracheal tube, or disruption of pulmonary blood flow (eg, massive pulmonary embolus). However, whether EtCO2 has similar ability to identify the quality of CPR during pediatric resuscitations and specific values to guide therapy have not been established. Traditionally rate monitoring and clinical effectiveness of ventilation are used. What is the meaning of sudden increases in EtCO2 during CPR? Sudden, sustained increases in EtCO2 during CPR are associated with a return of spontaneous circulation (ROSC). What is the role of Extracorporeal membrane oxygenation during CPR? Extracorporeal membrane oxygenation with CPR (ECPR) for infants and children with inpatient hospital cardiac arrests is used in approximately 1 percent of arrests but has not been associated with overall benefit when compared with conventional CPR in most studies. Other observational studies indicate improved outcomes only for patients with underlying cardiac diseases (eg, cardiomyopathy, myocarditis, or congenital cardiac anomalies. Our approach is to prepare for possible ECPR after approximately 10 minutes of failed conventional resuscitation in patients with conditions that may be reversible after a period of ECPR (eg, myocarditis, pulmonary or air embolus, sudden arrest after cardiac surgery, poisoning, or primary hypothermic arrest) or who are candidates for the use of ECPR as a bridge to therapies such as cardiac transplantation. Which factors determine whether resuscitation should cease or continue? Although certain factors are associated with better or worse outcomes after cardiac arrest in infants and children, no single factor is reliable enough to accurately guide whether termination efforts should cease or continue. Thus the decision to terminate resuscitation should be individualized based on multiple factors including the following: (1) Duration of cardiac arrest (2) Presenting rhythm (e.g shockable versus asystole or PEA) Underlying disease or cause, if known cardiac disease, trauma, respiratory failure, or sepsis) (3) Setting and available resources (4) Do not resuscitate status What actions does the early postresuscitation period involve? The early postresuscitation period involves the time soon after return of spontaneous circulation or recovery from circulatory or respiratory failure. During this time, the clinician must continue to treat the underlying cause of the life-threatening event and monitor for common respiratory or circulatory problems that may cause secondary morbidity or death What actions does the early postresuscitation period involve? Part II (1) maintaining the airway; (2) avoiding low and high arterial O2; (3) monitor ventilation; (4) avoid recurrent shock; (5) maintain normal blood glucose; (5) EEG monitoring; (6) Targeted temperature management; (7) Transfer to pediatric center Avoiding low and high arterial O2 Once return of spontaneous circulation has been achieved, the clinician should titrate inspired oxygen to maintain pulse oximetry between 94 and 99 percent to avoid hypo- or hyperoxemia. Monitor ventilation The 2015 international resuscitation guidelines provide a recommendation that PaCO2 after return of spontaneous circulation may be targeted based upon the patient's specific condition and that exposure to severe hypocapnia (PaCO2 30 mmHg) or hypercapnia (PaCO2 50 mmHg) should be limited. Hypocapnia should also be avoided since indirect evidence suggests that hyperventilation may cause cerebral ischemia in pediatric patients with severe brain injury. Avoid recurrent shock The 2015 international guidelines recommend that parenteral fluids and vasoactive medications be used to maintain the systolic blood pressure 5th percentile for age. If hypovolemia is suspected in a patient with cardiogenic shock, the clinician should carefully infuse 5 to 10 mL/kg of isotonic fluids (eg, normal saline or Ringer's lactate) over 10 to 20 minutes followed by reevaluation of endpoint Maintaining normal blood glucose Sustained hyperglycemia (blood glucose 180 mg/dL [10 mmol/L]) is associated with higher mortality in critically ill children and should be avoided. Evidence indicates that blood glucose should be maintained below this threshold, but the role of "tight control" that uses insulin to achieve a specified blood glucose range is of uncertain value in children after cardiac arrest. If performed, tight glucose control requires close monitoring of blood glucose and avoidance of hypoglycemia. EEG monitoring Infants and children who remain comatose after cardiac arrest should have electroencephalogram (EEG) evaluation for the presence of seizures, with prompt management to reduce the risk of worsening neurologic injury. Targeted temperature management Use a target core body temperature of 36 to 37.5°C with the goal of avoiding fever (temperature 38°C) in children following cardiac arrest. Based upon the available evidence and international resuscitation guidelines, it is reasonable to either provide five days of normothermia (temperature 36 to 37.5°C), or to provide two days of therapeutic hypothermia followed by three days of continuous normothermia for comatose infants and children after an out-of-hospital cardiac arrest Transfer to pediatric center If the child is not being treated in a center with pediatric emergency and critical care expertise, the child should be stabilized and rapidly transferred for definitive care at a regional pediatric center. Critically ill or injured children typically benefit from transport by a team with pediatric expertise and advanced pediatric treatment capability, although in some isolated cases (eg, expanding epidural hematoma) more rapid transport by an immediately available non-pediatric team may be advantageous. Causes of sudden decompensation in a child who has been successfully intubated with an artificial airway The Causes of sudden decompensation in a child who has been successfully intubated with an artificial airway is described by the mnemonic "DOPE": (D) Dislodged or displaced endotracheal tube (right mainstem or esophageal location) (O) Obstructed endotracheal tube (eg, mucous plug, kinked endotracheal tube) (P) Pneumothorax (E) Equipment failure (eg, ventilator malfunction, oxygen disconnected or off) Family presence during resuscitation Observational studies indicate that caretakers should be given the option of being present during the in-hospital resuscitation of their child. When family members are present during a pediatric resuscitation, a staff member with clinical knowledge, empathy, and strong interpersonal skills should be present with them to provide support and answer questions. However, in the rare instance that family presence is disruptive to team resuscitation efforts, the family members should be respectfully asked to leave. Peds BLS: In whom should CPR be started? CPR should be started in patients with no or abnormal breathing and no definite pulse after 10 seconds Should chest compression begin before ventilation or the other way around? Chest compressions should be initiated BEFORE ventilation in infants and children with cardiac arrest Define what are adequate chest compressions Each chest compression should depress the chest by a minimum of one-third of its anterior-posterior diameter, at a rate of about 100 compressions per minute. The chest should fully recoil at the end of each compression. Interruptions in chest compressions should be minimal (less than 10 seconds). The use of a metronome may help to optimize the rate of compressions. Define what are adequate chest compressions. Part 2 The chest should be depressed at least one-third of its anterior-posterior diameter with each compression (approximately 4 cm [1.5 inches] in most infants and 5 cm [2 inches] in most children). Compressions in adolescents should attain the recommended adult depth of 5 to 6 cm, but should not exceed 6 cm (2.4 inches). The optimum rate of compressions is approximately 100 to 120 per minute Define what are adequate ventilations Ventilations should be delivered over 1 second with enough volume to see the chest wall rise. Excessive ventilation should be avoided What is an adequate compression to ventilation ratio? (1) 30 compressions followed by 2 breaths for a lone rescuer or (2) 15 compressions followed by 2 breaths for two rescuers resuscitating an infant (1 year of age) or child (≥1 year to start of puberty) or (3) Intubated infants and children should be ventilated at a rate of 8 to 10 breaths per minute without any interruption of chest compressions What is different between the management of a patient in which arrest was withnessed versus in one that was not witnessed? an automated defibrillator (AED) should be used as soon as possible for all infants and children with a witnessed arrest. On the other hand, CPR is performed for approximately 2 minutes (five cycles) before using an AED in a patient with an unwitnessed arrest. When the two-thumb compression technique is employed why is it important to avoid compressing the area over the xiphoid process? The area over the xiphoid process should be avoided to prevent injury to the liver, spleen, or stomach. What happens during compression interruption? Experimental evidence in animals indicates that coronary artery perfusion pressure declines with interruptions in chest compressions Why is avoiding hyperventilation critical to CPR success? Evidence in adults and animals suggest that hyperventilation is associated with increased intrathoracic pressure and decreased coronary and cerebral perfusion. Resucitation of infant with no breathing or only gasping and no definite pulse after 10 seconds: Single rescuer - If this is not a witnessed sudden collapse then the provider should start cardiopulmonary resuscitation (compressions-airway-breathing, C-A-B) with a ratio of 30 compressions to 2 breaths. Two or more rescuers - The providers should start CPR (compressions-airway-breathing, C-A-B), starting with a ratio of 30 compressions to 2 breaths for a single rescuer and 15 compressions to 2 breaths for two or more rescuers.