A. Is patient unresponsive? Establish unresponsiveness using vocal or physical stimulation.
B. Is airway patent? Open airway using the head tilt-chin lift maneuver.
C. Is there a history or suspicion of injury to head or neck? If injury is present or suspected, immobilize cervical spine and perform the jaw-thrust maneuver to open the airway. If airway remains obstructed, patient should be repositioned and maneuvers for relieving airway obstruction attempted.
D. Is patient breathing? If patient does not have spontaneous respirations, assist ventilation using a bag-valve-mask device, while delivering 100% oxygen (rate of 1 breath every 5 seconds in infants).
E. Does patient have a pulse? Recommended sites to assess presence of a pulse in infants are brachial and femoral. If patient is pulseless, start chest compressions (rate of 100 per minute or ratio of 5 compressions to 1 ventilation in infants). Establish IV access rapidly. If attempt at peripheral IV access is unsuccessful, place an intraosseous (IO) line immediately. Administer epinephrine by endotracheal (ET), IV, or IO route every 3-5 minutes. Reassess pulse between dosages of epinephrine.
F. Is patient in shock? If patient is in shock, secure the airway, provide 100% oxygen, and obtain IV access. Provide fluid boluses of 20 mL/kg of isotonic (NS or Ringer lactate) solution at least twice. Reassess patient after each fluid bolus. Consider an inotropic agent drip if there is no or minimal improvement in BP or perfusion after second fluid bolus. Some patients will require additional fluid boluses.
G. Are there treatable causes of cardiopulmonary arrest? Consider the 5 H's and 4 T's: Hypoxemia; Hypovolemia; Hypothermia; Hyperkalemia or hypokalemia and metabolic disorders; intracranial Hypertension; cardiac Tamponade; Tension pneumothorax; Toxins, poisons, and drugs; and Thromboembolism.
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