The pediatric chain of survival is different from the adult for some very good reasons. Lets take a look at the first link; prevention. Unintentional injuries are the number one cause of death in children and young people in the United States. Most of these injuries can be prevented with proper education and information. If we can prevent an emergency from happening in the first place, we are that much more effective in saving the lives of our children.

In an adult, child, and infant CPR First Aid class, it is the responsibility of the BLS instructor to not only teach students how to effectively respond to pediatric emergencies, but also how to prevent them from happening in the first place. It is not enough to just teach CPR. Since most of the students in our class will never actually have to do CPR on an infant or child (some will), it is important that prevention issues that have daily significance are addressed. In this manner instructors and training programs make the most of the time and also are able to effectively deal with emergencies before they even happen.

For example: As I write this article I am at the park with my one and half year old son. A gentleman has just arrived to use the park to run his rather large Pit Bull Rottweiler mix....with no leash, around a park full of kids. Hmm… I have nothing against family pets, but animals by nature can be unpredictable, and in my own personal experience when someone says "he doesn’t bite" he usually does just that. This is why there are city ordinances made to "prevent" issues. That’s like riding in your car with all 5 of your kids, rushing through traffic because you’re late and no one is wearing a seat belt. I have seen my share of animal attacks and certainly am not interested in visiting the ER this morning. So I will take my son far out of any potential harms way. This would be prevention. Prevention in this situation might mean bringing the family pet at a time when there isn't so many kids. But today, for me and my son it means find a place to play with less of a risk. I like 0 risk factors.

Prevention is a proactive way of dealing with emergencies, whereas CPR, bleeding control, etc., would be reactive. The reactive measures have there place, but the proactive measures give us the much more effective silent victories over emergencies and that is why prevention is the first link in the pediatric chain of survival.

Early CPR

The second link in the pediatric chain of survival is early CPR although a critical skill, its application is not necessary for every pediatric patient in an emergency situation. Those who are providing care should assess the victim to determine the most appropriate course of action. The pediatric chain of survival in not the pediatric "cardiac" chain of survival. Children are less likely to suffer from cardiac arrest due to heart disease and most often are found to require emergency medical assistance due to another type of circumstance that has caused them to stop breathing.

In any case what is important to understand is that children cannot survive very long at all without oxygen. For this reason it is important that a lone rescuer who finds a child unresponsive assess the need for rescue breathing or CPR even before spending any time calling 911. Of course when multiple bystanders are present, calling 911 and the assessment of the child’s airway breathing and circulation can be performed simultaneously.

Effective CPR is best when started immediately after the victim’s collapse. Studies consistently show that bystander CPR is most effective at producing the desired result when it is started immediately and has a significantly positive effect on patient survival. The keywords here are "immediately" and "effective". Poor CPR is almost as good as no CPR. Chest compressions need to be fast and hard in order to do the job right.

CPR includes chest compression and breaths. Currently as of this article, the ratio of compressions to breaths for CPR for the pediatric victim is 30 to 2 (30 compressions for every 2 breaths). CPR keeps oxygen rich blood flowing to the heart which keeps vital organs alive, buying the victim some time before advanced personnel arrive and take over. This can make the difference between a victim going home brain dead (if at all) or going home in a neurologically sound condition.

We like success in dealing with emergencies when is comes to our children. We want to respond correctly and effectively when the time comes. This is done by correct training and education. Training is in the prevention link of the pediatric chain of survival. In the event that CPR is needed for a child, training can keep us from doing the wrong thing and quite possibly give someone’s child the best chance of survival.

EARLY ACTIVATION OF EMS

Early activation of Emergency Medical Service is one of the most critical elements of the pediatric chain of survival. If there is more then one bystander or rescuer the call should be made immediately upon recognition of a potential life threatening problem. It is preferable that the call be made from a grounded line as opposed to cellular phone, if the option is available. Many cities have an enhanced 911 system that enables the dispatch center to trace the location of the call almost immediately when a connection is made. Cellular service quality varies by service provider and location and should be used if there is no other alternative to activating the EMS system.

When asking someone to make the emergency call for you, you will need to verify that the call is made and ensure that help is on the way. Have the person come back and tell you that EMS has been called. If you are the caller, speak slowly, and clearly so that the dispatcher can understand what exactly the emergency is. In some cases when there is a high call volume or disaster has taken place, there may be a busy signal or a caller can be put on hold. If it is a busy signal you will need to hang up and call back. If placed on hold, it is best to wait until a dispatcher is ready to take your call. Most of the time a dispatcher is available to take the call without any problems. However, it is important to understand that these problems can and do occur.

Dispatchers are trained to ask questions in a way that helps them to determine what the priority is and decide what resources are needed. Depending on the region where the call is made, the fire department may respond to medical emergencies. This would account for a fire truck showing up instead of an ambulance. Most metropolitan cities where the fire department responds to medical calls, engines and trucks are staffed with paramedics and the appropriate equipment to provide immediate care as need. Remember in medical emergencies the closest available unit is what is needed. This could be a fire truck with a hundred foot ladder on it. However, the experience of the providers and the equipment and medications is what is needed and being made available.

Dispatchers generally ask a lot of questions. The call will run smoother if the caller expresses what kind of emergency they have, and then let the dispatcher ask the questions from that point on. Taking a basic level CPR or First Aid class can help the community with understanding and recognizing emergencies and accessing emergency services.

EARLY ADVANCED LIFE SUPPORT

ALS is the EMS acronym for advanced life support, which is a service provided by EMS. ALS services are also provided by emergency department and intensive care units. ALS providers have special training providing advanced emergency interventions that are often needed for patients that are critically injured or ill. ALS is highly dependant on BLS, which is basic life support. The skills taught in a CPR class are basic life support skills. If BLS is not provided, or is done poorly prior to the arrival of ALS care, the chances of the survival of the critically injured or ill decreases rapidly. Therapies like endotracheal intubation, administration of drugs and other advanced interventions will often be found to be useless if the victim has been without oxygen for some time.

This is why the basic life support (CPR) class is so important. Providers of ALS have to maintain advanced level certifications like, advanced cardiac life support (ACLS), and pediatric advanced life support (PALS), every twos years in order to understand the current guidelines and to have their competency evaluated. Some EMS systems and agencies require ALS providers to have and maintain multiple certifications in order to qualify for employment. This is not only in the best interest of the public, but the ALS provider as well. Science is constantly progressing, and newer and more effective methods of providing the best patient care are constantly being developed. So it is important that providers are brought up to speed with the most current changes in emergency medicine.

Those who work in emergency services must also maintain a minimum amount of continuing education hours in order to maintain licensure and certification. The amount of hours varies by region but is generally between 48 and 60 hours every two years, in addition to being actively employed in patient care.

Today, emergency care really excels. Paramedics, emergency department staff, and surgery teams, working together save many lives on account of there dedication and commitment to excellence. Emergency teams are constantly being pushed to higher standards, and those who have been in EMS for along time will agree, we have come along way in just a short time. Although ALS care is the last link in the pediatric chain of survival it is a vital one. A chain is only as strong as its weakest link, and when all of the links in this chain are intact, this will give the pediatric victim of injury or illness the best chance of survival.

Michael Morales EMT-Paramedic