What are the initial steps in resuscitating a child involved in a road traffic accident (RTA)?

Initial Resuscitation of a Child with Road Traffic Accident

Verify scene safety first to avoid becoming a second victim in the traffic accident setting, then immediately assess the child's responsiveness while simultaneously checking breathing and pulse within 10 seconds, maintaining cervical spine immobilization throughout. 1, 2

Scene Safety and Initial Assessment

• Ensure scene safety before approaching the child—this is critical in RTA settings where ongoing traffic hazards exist 1, 2
• Check responsiveness by shouting and tapping the child while shouting for nearby help to designate roles among rescuers 3
• Simultaneously assess breathing and pulse within 10 seconds—look for no breathing or only gasping while palpating for a pulse 3
• Maintain cervical spine immobilization when the mechanism of injury is compatible with spinal injury, which is inherent in RTAs 3

Critical Airway Management Considerations for Trauma

• Use jaw thrust without head tilt to open the airway while maintaining cervical spine protection 3
• If jaw thrust fails to open the airway, use head tilt-chin lift—a patent airway takes priority over potential spinal injury 3
• Anticipate airway obstruction from dental fragments, blood, or debris and have suction immediately available 3
• If two rescuers are present, one should manually restrict cervical spine motion while the other opens the airway 3

Immediate CPR Initiation Based on Assessment

If Pulse Present but No Normal Breathing:

• Provide rescue breathing at 1 breath every 2-3 seconds (approximately 20-30 breaths per minute) 3
• Reassess pulse every 2 minutes—if no pulse develops, immediately start CPR 3

If No Pulse or Heart Rate <60/min with Poor Perfusion:

• Start CPR immediately with high-quality chest compressions 1
• First rescuer remains with the child while second rescuer activates emergency services and retrieves AED 3
• If alone, perform CPR for 2 minutes first before leaving to activate emergency services 3

High-Quality CPR Technique

• Compression depth: at least one-third of anterior-posterior chest diameter (approximately 5 cm in children) 1, 3
• Compression rate: 100-120 per minute with complete chest recoil between compressions 1, 3
• Minimize interruptions in compressions—continuous compressions are essential for survival 1, 3
• Change compressor every 2 minutes or sooner if fatigued to maintain compression quality 1, 3

Compression-to-Ventilation Ratios:

• Single rescuer: 30 compressions to 2 breaths (30:2) 1, 3
• Two or more rescuers: 15 compressions to 2 breaths (15:2)—this is pediatric-specific 1, 3
• Once advanced airway placed: provide continuous compressions with 1 breath every 2-3 seconds 3

Trauma-Specific Resuscitation Priorities

• Stop all external bleeding with direct pressure immediately 3
• Secure the child to immobilization board at minimum the thighs, pelvis, and shoulders 3
• Account for disproportionately large head in young children—may require recessing the occiput or elevating the torso to avoid cervical flexion on the backboard 3
• Transport to a trauma center with pediatric expertise if possible 3

Early Defibrillation Protocol

• Use AED as soon as available—do not delay CPR to retrieve it, but apply immediately once present 1, 2
• Check rhythm to determine if shockable (ventricular fibrillation or pulseless ventricular tachycardia) 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 before rechecking rhythm 3

Advanced Life Support Interventions

Drug Therapy:

• Epinephrine IV/IO: 0.01 mg/kg (0.1 mL/kg of 0.1 mg/mL concentration), maximum 1 mg—repeat every 3-5 minutes 1, 3
• For refractory VF/pulseless VT: Amiodarone 5 mg/kg IV/IO bolus (may repeat up to 3 total doses) or Lidocaine 1 mg/kg loading dose 1, 3

Airway Management:

• Begin bag-mask ventilation with oxygen as soon as equipment available 3
• Consider endotracheal intubation or supraglottic airway for advanced airway management 3
• Use waveform capnography to confirm and monitor endotracheal tube placement 3

Critical Pitfalls to Avoid in Pediatric RTA Resuscitation

• Never perform blind finger sweeps of the pharynx—this can impact foreign bodies in the larynx 3
• Do not sacrifice airway patency for spinal precautions—if jaw thrust fails, use head tilt-chin lift 3
• Avoid inadequate compression depth—must be at least one-third of chest diameter, not superficial compressions 1
• Do not lean on chest between compressions—prevents adequate cardiac refilling 2
• Do not delay CPR for prolonged pulse checks—if uncertain after 10 seconds, start CPR 2