First Priority in Assessment of Unresponsive Child During Pediatric Resuscitation
The first priority is to verify scene safety, immediately followed by checking for responsiveness and simultaneously assessing breathing and pulse within 10 seconds. 1
Initial Assessment Sequence
The most recent 2020 American Heart Association guidelines establish a clear algorithmic approach for the unresponsive child 1:
Step 1: Scene Safety and Responsiveness
- Verify the scene is safe before approaching the child 1, 2
- Check for responsiveness by gently tapping and calling out loudly 1
- Shout for nearby help immediately 1
Step 2: Simultaneous Assessment (Within 10 Seconds)
- Look for no breathing or only gasping AND check pulse simultaneously 1
- This dual assessment must be completed within 10 seconds 1
- Gasping should be treated as absent breathing and requires CPR 1
Critical Decision Points Based on Assessment
If Pulse Present but No Normal Breathing:
- Provide rescue breathing at 1 breath every 2-3 seconds (20-30 breaths/minute) 1
- Reassess pulse every 2 minutes 1
If Heart Rate <60/min with Signs of Poor Perfusion:
- Start CPR immediately 1, 2, 3
- This represents a critical threshold where bradycardia compromises cardiac output 2, 3
If No Breathing (or Only Gasping) and No Pulse:
- Begin chest compressions immediately 1
- Activate emergency response system 1
- Retrieve AED/defibrillator 1
Special Considerations for Hyperkalemia Context
While the expanded question mentions acute kidney injury and severe hyperkalemia, the initial assessment priorities remain unchanged 1. However, be aware that:
- Calcium administration is indicated during resuscitation for documented hyperkalemia 1
- Calcium stabilizes cardiac membranes against hyperkalemia's toxic effects 4
- This intervention occurs AFTER the initial assessment and CPR initiation, not before 1
Common Pitfalls to Avoid
- Never delay assessment to gather equipment 1
- Do not perform blind finger sweeps 1
- Do not spend more than 10 seconds checking for pulse 1
- Do not delay chest compressions when HR <60/min with poor perfusion 2, 3
- Assessment and treatment should proceed simultaneously to avoid losing vital time 1
Rationale for This Approach
The 2020 guidelines prioritize this sequence because most pediatric cardiac arrests result from respiratory failure 1, making rapid airway and breathing assessment critical. The simultaneous pulse check ensures immediate recognition of cardiac arrest or severe bradycardia requiring CPR 1. This approach maximizes the chance of survival by minimizing time to effective resuscitation 1.