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

Initial Resuscitation of a 9-Year-Old Child with 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 heart rate <60/min with poor perfusion, start CPR immediately with 15:2 compression-to-ventilation ratio (if two rescuers present) while activating emergency services. 1, 2

Primary Survey: ABCDE Sequence

A: Airway with Cervical Spine Protection

• Maintain cervical spine immobilization throughout all resuscitation efforts using bimanual stabilization or cervical collar placement 3, 4
• Check for responsiveness by shouting and tapping the child 1, 2
• Assess for airway obstruction and remove any visible foreign body during airway opening—never perform blind finger sweeps 5
• If the child is unresponsive, shout for nearby help and designate roles immediately 1, 2

B: Breathing Assessment

• Simultaneously assess breathing and pulse within 10 seconds to avoid delays 1, 2
• Look for no breathing or only gasping while checking pulse 1
• If no normal breathing but pulse is present, provide rescue breathing at 1 breath every 2-3 seconds (20-30 breaths/minute) 1
• Reassess pulse every 2 minutes during rescue breathing 1, 5

C: Circulation and Critical Decision Point

• If heart rate is <60/min with signs of poor perfusion, immediately start CPR regardless of whether a pulse is palpable 2, 5, 6
• This bradycardia threshold represents compromised cardiac output and tissue perfusion requiring immediate chest compressions 5, 6
• Activate emergency response system and retrieve AED/defibrillator 1
• Control any visible hemorrhage during the primary survey 3, 4

High-Quality CPR Technique

Compression Parameters

• Compression depth: at least one-third of anterior-posterior chest diameter (approximately 5 cm for a 9-year-old) 2
• Compression rate: 100-120 per minute 2, 5
• Allow complete chest recoil between compressions 2, 5
• Minimize interruptions in compressions—never delay CPR for any reason when HR <60/min with poor perfusion 5, 6

Compression-to-Ventilation Ratios

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

Advanced Airway Considerations

• Once an advanced airway is placed, switch to continuous compressions at 100-120/minute with 1 breath every 6 seconds (10 breaths/minute) without pausing compressions 5
• Confirm endotracheal tube placement using clinical assessment and exhaled CO2 detection 7
• Verify correct placement when tube is inserted, during transport, and whenever the patient is moved 7

Early Defibrillation Protocol

• Use AED as soon as available 1, 2
• Check rhythm to determine if shockable (VF/pulseless VT) 1, 2
• If shockable: deliver 1 shock, then immediately resume CPR for 2 minutes before rechecking rhythm 1, 2
• If nonshockable: resume CPR immediately for 2 minutes 1
• Do not attempt defibrillation unless a shockable rhythm is confirmed 5

Medication Administration

Epinephrine

• Administer epinephrine 0.01 mg/kg IV/IO (0.1 mL/kg of 0.1 mg/mL concentration), maximum 1 mg, as soon as vascular access is obtained 2, 5
• Repeat every 3-5 minutes during ongoing CPR 2, 5
• Do not use high-dose epinephrine routinely 7

Antiarrhythmics for Refractory VF/Pulseless VT

• Amiodarone 5 mg/kg IV/IO bolus 2
• Lidocaine 1 mg/kg loading dose if amiodarone unavailable 2, 7

Medications to Avoid

• Do not use atropine in pediatric cardiac arrest—it delays appropriate epinephrine administration 5

D: Disability and Neurological Assessment

• Assess for signs of increased intracranial pressure and impending cerebral herniation 4
• Evaluate neurological status once circulation is stabilized 3, 4

E: Exposure While Preventing Hypothermia

• Expose the child to assess for injuries but prevent hypothermia 4
• Consider induced hypothermia (32-34°C for 12-24 hours) if the child remains comatose after resuscitation 7

Critical Pitfalls to Avoid

• Never delay chest compressions to establish IV access—start compressions first 5
• Do not waste time with prolonged pulse checks—limit to 10 seconds maximum 1, 2
• Avoid blind finger sweeps for foreign body removal 5
• Do not interrupt compressions for rhythm checks until 2 minutes have elapsed 1, 2

Ongoing Resuscitation and Reassessment

• Reassess pulse and rhythm every 2 minutes 1, 5
• Continue CPR until heart rate improves to >60/min with adequate perfusion, advanced life support providers take over, or the child shows signs of recovery 5, 6
• Intact survival has been reported following prolonged resuscitation, so continue efforts beyond initial response 7