What are the protocols for cardiopulmonary resuscitation (CPR) in infants?

Infant CPR Protocols

For infants requiring cardiopulmonary resuscitation (CPR), healthcare providers should use the 2-thumb–encircling hands technique when two rescuers are available, and the 2-finger technique for single rescuers, with chest compressions that depress the chest at least one-third the anterior-posterior diameter (approximately 1.5 inches or 4 cm) at a rate of 100-120 compressions per minute. 1, 2

Initial Assessment

• Verify scene safety before approaching the infant 2
• Check for responsiveness by gently tapping the infant 2
• Look for no breathing or only gasping and check pulse simultaneously (at the brachial artery) 1
• Determine if pulse is definitely felt within 10 seconds 1, 2

Response Algorithm Based on Assessment

• If normal breathing and pulse are present: Monitor until emergency responders arrive 1
• If no normal breathing but pulse is present: Provide rescue breathing at 1 breath every 2-3 seconds (20-30 breaths/minute) 1, 2
• If no breathing (or only gasping) and no pulse: Start CPR immediately 1
• If heart rate is <60/min with signs of poor perfusion: Start CPR 2

Single-Rescuer CPR Technique for Infants

• Compress the sternum with 2 fingers placed just below the intermammary line 1, 2
• Compress at least one-third the anterior-posterior diameter of the chest (approximately 1.5 inches or 4 cm) 1, 2
• Maintain a rate of 100-120 compressions per minute 1, 2
• Allow complete chest recoil after each compression 1
• Perform cycles of 30 compressions followed by 2 breaths 1
• Minimize interruptions in compressions 1, 2

Two-Rescuer CPR Technique for Infants

• Use the 2-thumb–encircling hands technique, with thumbs placed just below the intermammary line 1, 2
• This technique provides superior compression depth compared to the 2-finger technique 3, 4
• Perform cycles of 15 compressions followed by 2 breaths 1
• Change compressors every 2 minutes or sooner if fatigued to maintain quality 1, 2
• If advanced airway is in place, provide continuous compressions (100-120/min) with ventilations at 20-30 breaths/minute 1

Ventilation Technique

• Open airway using a head tilt-chin lift maneuver 2
• Use mouth-to-mouth-and-nose technique for infants 2
• It is reasonable to ventilate with 100% oxygen during CPR when available 1
• For healthcare providers, bag-mask ventilation with oxygen is recommended 1, 2

Support Surface Considerations

• Perform chest compressions on a firm surface 1
• During in-hospital cardiac arrest (IHCA), activate the bed's "CPR mode" when available to increase mattress stiffness 1
• During IHCA, use a backboard to improve chest compression depth 1

Advanced Life Support Considerations (for Healthcare Providers)

• Perform a rhythm check lasting no more than 10 seconds approximately every 2 minutes 1
• Consider cardiac monitoring to identify shockable rhythms 1, 2
• Establish IV/IO access for medication administration 1, 2
• Administer epinephrine IV/IO at a dose of 0.01 mg/kg (0.1 mL/kg of 0.1 mg/mL concentration) if heart rate remains <60 bpm after adequate ventilation and chest compressions 1, 2

Common Pitfalls to Avoid

• Inadequate compression depth - ensure proper depth of at least one-third of chest diameter 2, 4
• Incomplete chest recoil - allow full chest recoil between compressions 1
• Excessive ventilation rates - avoid rates exceeding recommendations as they may compromise hemodynamics 1
• Prolonged interruptions in compressions - minimize pauses to maintain perfusion 1, 2
• Incorrect hand/finger position - ensure proper placement just below the intermammary line 1, 2

Special Considerations

• If the rescuer is unable to achieve the recommended compression depth with the 2-finger technique, it may be reasonable to use the heel of 1 hand 1
• While two-thumb technique provides better compression depth, it may result in slightly fewer delivered compressions per minute compared to the two-finger technique (87 vs. 92) 3
• Studies show that compliance with all international recommendations during infant CPR is challenging, with overall compliance <1% even among APLS instructors 4