What are the initial resuscitation steps for a 9-year-old child involved in a road traffic accident (RTA)?

Initial Resuscitation of a 9-Year-Old Child After Road Traffic Accident

Immediately verify scene safety, then simultaneously assess breathing and pulse within 10 seconds while maintaining cervical spine immobilization—if the child has no pulse or a heart rate <60/min with poor perfusion, start CPR immediately with 30:2 compression-to-ventilation ratio (or 15:2 if two rescuers present) while a second rescuer activates emergency services and retrieves an AED. 1, 2

Scene Safety and Initial Assessment

• Verify scene safety first to avoid becoming a second victim in the traffic accident setting 1, 3
• Check for responsiveness by shouting and tapping the child 1
• Shout for nearby help and designate roles: first rescuer stays with child, second rescuer activates emergency response system and retrieves AED and emergency equipment 1
• Maintain cervical spine stabilization throughout assessment using bimanual immobilization technique, as trauma mechanism suggests potential spinal injury 4

Simultaneous Breathing and Pulse Check

• Look for no breathing or only gasping while checking pulse simultaneously—complete this within 10 seconds 1, 3
• If uncertain about pulse presence after 10 seconds, immediately start CPR rather than continuing assessment 3

Decision Pathways Based on Assessment

If Normal Breathing and Pulse Present:

• Monitor continuously until emergency responders arrive while maintaining cervical spine precautions 1
• Proceed with secondary survey for injuries 4

If No Normal Breathing But Pulse Present:

• Provide rescue breathing at 1 breath every 2-3 seconds (20-30 breaths/minute) 1
• Reassess pulse every 2 minutes—if pulse disappears, immediately start CPR 1
• If heart rate <60/min with signs of poor perfusion, start CPR immediately as this represents inadequate cardiac output 1, 2

If No Breathing/Only Gasping AND No Pulse (or HR <60/min with poor perfusion):

Start CPR immediately 1, 2

High-Quality CPR Technique for 9-Year-Old

• Compression depth: at least one-third of anterior-posterior chest diameter (approximately 5 cm in this age group) 1, 2
• Compression rate: 100-120 per minute 1, 2
• Allow complete chest recoil between compressions—do not lean on chest as this prevents cardiac refilling 1, 3
• Minimize interruptions in compressions 1, 3

Compression-to-Ventilation Ratios:

• Single rescuer: 30 compressions to 2 breaths (30:2) 1, 2
• Two or more rescuers: 15 compressions to 2 breaths (15:2) 1, 2
• Change compressor every 2 minutes or sooner if fatigued 1

Early Defibrillation

• Use AED as soon as available—do not delay CPR to retrieve it, but apply immediately once present 1, 3
• Check rhythm to determine if shockable (VF/pulseless VT) 1, 3
• If shockable: deliver 1 shock, then immediately resume CPR for 2 minutes before rechecking rhythm 1, 3
• If non-shockable: resume CPR immediately for 2 minutes 1

Advanced Airway and Ventilation

• Begin bag-mask ventilation with oxygen as soon as equipment available 1
• If advanced airway placed: provide continuous compressions with 1 breath every 2-3 seconds (no pauses for ventilation) 1
• Use waveform capnography to confirm and monitor endotracheal tube placement 1

Drug Therapy

• Epinephrine IV/IO: 0.01 mg/kg (0.1 mL/kg of 0.1 mg/mL concentration), maximum 1 mg 1
• Repeat epinephrine every 3-5 minutes 1, 3
• If no IV/IO access: endotracheal dose 0.1 mg/kg (0.1 mL/kg of 1 mg/mL concentration) 1
• For refractory VF/pulseless VT: Amiodarone 5 mg/kg IV/IO bolus (may repeat up to 3 doses) or Lidocaine 1 mg/kg loading dose 1, 3

Critical Pitfalls to Avoid

• Do not delay CPR for detailed history or prolonged assessment—immediate compressions are the priority 3, 2
• Do not perform pulse checks >10 seconds—if uncertain, start CPR 3
• Do not provide inadequate compression depth or rate—compressions must be hard and fast to generate adequate perfusion 1, 3
• Do not forget cervical spine precautions throughout resuscitation in trauma patients 4
• Do not interrupt compressions for rhythm checks more frequently than every 2 minutes 1, 3

Trauma-Specific Considerations

While traditional ABC (Airway-Breathing-Circulation) has been standard, in exsanguinating trauma hemorrhage control may take priority 5, 6. However, for a 9-year-old post-RTA in cardiac arrest or near-arrest, the immediate priority remains high-quality CPR per pediatric guidelines 1, 2, as cardiorespiratory arrest in the first minutes after trauma typically results from airway obstruction, inadequate ventilation, or massive blood loss—all requiring immediate CPR and oxygenation 4.