- Include the choking algorithm
Widespread standard basic life support (BLS)-related workshops including about the choking algorithm should be implemented for emergency first responder parents, irrespective of their educational level.
These recommendations were made in an original article on ‘Knowledge and awareness of paediatric BLS among parents in the Lady Ridgeway Hospital for Children [LRH]’ which was authored by H.M.D.M. Arachchige (Acting Consultant Emergency Physician at the National Hospital, Colombo) and published in the Sri Lanka Journal of Child Health's 53rd Volume's Second Issue, this month.
What is Paediatric BLS?
Out of hospital cardiac arrest in children is, as noted in P. Chia and W. Lian's ‘Parental knowledge, attitudes and perceptions regarding infant BLS’, rare but significant, with poor survival rates and high morbidity. Asystole (when the heart's electrical system fails entirely, which causes the heart to stop pumping) is the most common dysrhythmia (abnormality in the heart's rhythm). Paediatric BLS is, as explained in M. Samuels and S. Wieteska's ‘BLS in advanced paediatric LS: A practical approach to emergencies’, the initial resuscitation in a child with cardiac arrest or choking which should be initiated immediately, even outside the hospital, until advanced life support is initiated. Some of the techniques are different depending on the size of the child, particularly between infants and older children. As far as the causes of cardiac arrest are concerned, as pointed out in ‘Electrocardiogram (ECG) (a quick test to check the heartbeat which records the electrical signals in the heart) guidelines part nine: Paediatric BLS’, respiratory failure is overall the commonest cause in newborns, whereas sudden infant death syndrome, respiratory diseases, airway obstruction (including foreign body aspiration), submersion, sepsis (the body responds improperly to an infection where the infection fighting processes turn on the body, causing the organs to work poorly), and neurological disease are the leading causes in infants. Beyond one-year of age, injuries are the leading cause of death. Thus, effective breathing should be delivered by correct technique to achieve successful resuscitation.
The sequence of BLS in cardiac arrest is: out of danger (D), check response (R), shout for help (S), check and open the airway (A), give two rescue breaths (B), chest compression (C), and defibrillation (D) (DRSABCD). In an out of hospital environment, the rescuer should not become a second victim, and therefore, the child should be removed from continuing danger as quickly as possible. Following that, the rescuer should check the response with stimulation by tapping. If the child does not respond, the airway should be assessed using the look, listen, and feel technique. As soon as it is identified that the child is not responding, the rescuer should call for help either by shouting or dialling 1990 for an emergency ambulance available (1990 Suwa Seriya Foundation).
Then, two rescue breaths should be given immediately using the mouth to mouth breathing method, unless a specific mask is available. Once effective breathing is present, which is evident by chest expansion, chest compression should be started with a compression to breathing ratio of 15:22. Ideally, a child’s head should be positioned in neutral and sniffing positions for infants and older children, respectively. This sequence should be followed in the case of an unresponsive child.
Choking, as elaborated in U. Mayorathan, S. Manikkavasakar and S. Pranavan's ‘Accidental choking in children: An area to be focused on’, is the mechanical obstruction of the internal airways (pharynx [throat], hypopharynx [the throat's bottom part], trachea [the windpipe which is a long, u shaped tube that connects the voice box to the lungs]) by a foreign body, causing respiratory failure, and it is a type of asphyxia. According to G. Lorenzoni, D. Azzolina, S. Baldas, G. Messi, C. Lanera, M.A. French, L.D. Dalt and D. Gregori's ‘Increasing awareness of food choking and nutrition in children through the education of caregivers: The CHOking Prevention project community intervention trial study protocol’, it is a major cause of death in children, and 60-80% deaths following choking are due to food. Anatomical and physiological characteristics specific to young children are thought to be the reason for increased choking among them while eating. Choking can cause death within minutes, and prompt intervention, using the BLS choking protocol, is required to save the victim's life.
Steps in BLS
The first crucial step in the BLS choking protocol is to identify whether the victim has an effective cough or is in cardiac arrest. A conscious older child should be encouraged to cough if there is an effective cough. If acute stridor (noisy breathing that occurs due to obstructed airflow through a narrowed airway) develops or the child does not have an effective cough, the foreign body should be dislodged immediately using back blows and chest thrusts. Combining manoeuvres gives better results than doing them individually. However, if the child becomes unresponsive with features of cardiac arrest, cardiopulmonary resuscitation (CPR) should be started immediately.
Out of hospital cardiac arrest in infants or toddlers mainly occurs, as documented in R. Uehara, R. Shinohara, Y. Akiyama, K. Ichikawa, T. Ojima, K. Matsuura, Y. Yamazaki and Z. Yamagata's ‘Awareness of CPR among parents of three-year-old children’, at home. A family member is usually, as emphasised in an Indian study, the first responder available at the time of the incident. Asystole indicates the need for effective CPR. In children, early and effective bystander CPR has been associated with the successful return of spontaneous circulation and neurologically intact survival (J. Marchant, N.G. Cheng, L.T. Lam, F.E. Fahy, S.V. Soundappan, D.T. Cass and G.J. Browne's ‘Bystander BLS: An important link in the chain of survival for children suffering a drowning or near drowning episode’, L. Pyles and J. Knapp's ‘Role of paediatricians in advocating LS’, and C.T. Souverbielle, F. González-Martínez, M.I. González-Sánchez, M. Carrón, L.G. Miguez, L. Butragueño, H. Gonzalo, T. Villalba, J.P. Moreno, B. Toledo and R. Rodríguez-Fernández's ‘Strengthening the chain of survival: CPR workshop for caregivers of children at risk’). BLS courses should be offered to target populations such as expectant parents, childcare providers, teachers, sports supervisors, and others who regularly care for children.
Therefore, Arachchige conducted this study with a sample of parents of children who were brought to the Preliminary Care Unit (PCU) and Wards Two and Four in the LRH. This descriptive, cross sectional study was conducted between October, 2022, and January of last year (2023). All parents or guardians that brought their children to the PCU and the two said Wards for any form of assessment, investigation, or treatment were enrolled. A convenient sampling technique was used.
Results
Questionnaires were distributed among 410 parents but only 350 responded. Of the participants, 322/92% were females. Only 17/5% had participated in any form of BLS training (previously attended a BLS course). A total of 11 participants mentioned that they underwent training between 2005 and 2014. Most participants were educated only up to the General Certificate of Education Ordinary Level.
Questions on basic health included: 1) the pumping of blood to the body is done by the heart; 2) the loss of consciousness takes place due to the poor supply of blood to the brain; and 3) how long can the brain survive in a functioning state without breathing or oxygen. More than 80% responded correctly to the first two questions. Only 33% knew that the brain cannot survive for more than five minutes without the blood supply.
Methods of seeing BLS or the choking algorithm were: on television [TV]; in the hospital; in films; on the roadside; at home; and via YouTube videos. While 216/61.7% had seen initial treatment for cardiac arrest, 225/64.3% had seen initial treatment for choking. Most of them have seen that on TV, whereas about 5% have seen it on the roadside. However, nearly 25% had observed initial treatment for choking at home.
Responses to questions on BLS included: steps in the correct order that should be followed if one encounters an unresponsive child – correct order is BCFDEA, BCDEAF or BCDFEA; how to identify cardiac arrest (‘heart not working’ state) in a child at the earliest stage? – absent pulse, absent movements, absent breathing or not talking; how to wake up an unconscious child? – by tapping and gently shaking the shoulders, or by talking aloud repeatedly; on the chest, where is the place you should compress – lower half of the sternum (the breastbone); how deep should the chest compression be done? – one third of the height of the chest; what should be the rate of chest compression (beats per minute)? – 100; how to confirm that the child is not breathing? – by looking at the moving up and down of the chest, by feeling the fat of the cheek for air flow out of the nose and mouth, or by listening to the child's breathing related sounds; and the chest compression to mouth to mouth breathing ratio should be – 15:two. Only 2.8% had an idea about the correct order of steps to follow in the case of cardiac arrest, 16-57% knew how to identify cardiac arrest early, 16-36% knew the correct way to wake up an unconscious child, while 80% identified the application of water, which is a substandard and common practice, as another way to do it. Only 50% knew the correct site of chest compression, while 40% knew the correct depth. However, most individuals did not know the correct rate of chest compression; the majority believed it to be 50 beats per minute, while only 10% knew the correct rate. The majority knew how to confirm that the child was not breathing. Only 11% knew the correct ratio of chest compression to breathing, while 44% believed that it was three:one. Most of that sample (78.2%) incorrectly responded to the question ‘chest compression to mouth to mouth breathing ratio should be’ three:one.
The correct responses to questions on the initial management of choking included: what will you do immediately, if you see that a child is choking after putting something into his/her mouth? – give back blows and chest thrusts, or give abdominal thrusts for older children; to where should the back blows be given in choking? – the lower half of the sternum; and to where should chest thrusts be given in choking – the lower half of the sternum. On the correct responses to the questions on the choking algorithm; 16-59% knew the correct immediate treatment for choking, while 49% identified turning the child upside down and shaking as the correct method, which is not recommended. A total of 88% knew the correct site of back blows, and nearly 48% knew the correct site of chest thrusts.
Correct responses regarding the parents' attitude towards BLS included: the most preferred mode of learning BLS -TV programmes, training workshops at a convenient place, YouTube videos, or leaflets; will you attend a workshop if you get a chance to learn BLS?; if not, what is the reason? – I already know, have no time, I have no capability to practise it, or financial difficulties; and do you think that BLS is important to save lives?. A total of 45% preferred workshops to learn BLS; 84% are willing to participate in such a workshop, while the majority of those who are not willing to do so mentioned time constraints as a barrier. Approximately 93% believed that BLS was important to save lives.
The total scores of basic health had to vary between zero and three among the participants. A mean score of 1.95 was obtained in the group of those who had seen BLS performed. However, none of the other variables showed a statistically significant correlation. The total scores on BLS had to be between zero and 14 among those who had observed BLS earlier (216). However, there was no statistically significant correlation between the BLS-related total scores and the BLS related training status or the highest educational level. The total scores on the choking algorithm had to be between zero and four among those who had observed the initial treatment of choking (225). There was also no statistically significant correlation between the total scores on choking and the BLS training status or the highest educational level.
Discussion
Overall, the research results revealed that the parents had an inadequate level of knowledge of BLS, choking, or basic health, irrespective of their educational level. However, they had optimistic attitudes toward the need for BLS-related training.
Most parents could answer some correct facts on basic health (physiology), even though they could not differentiate correct responses which are numerical (i.e., duration in minutes), from incorrect responses. This answering pattern was observed in the assessment of knowledge on BLS and the choking algorithm. The awareness of important facts, such as on brain survival without oxygen being very short lasting, was lacking among parents. Common but substandard practices were also included in the responses and parents responded to them as correct ones, such as applying water to wake up an unconscious child or putting the child upside down when choking. Nearly 10% had precise knowledge such as the chest compression rate, the compression to ventilation ratio, and giving abdominal thrusts in choking, which could not be guessed without a proper background knowledge. Only knowledge of basic health would have been greater if they had seen BLS previously. Otherwise, previous training, the observation of BLS or the choking algorithm, and their highest educational level did not correlate with their knowledge of the said three aspects. If proper training had been followed, their knowledge of those aspects should have been improved by their training. Thus, it is rational to argue about the quality of those training programmes. Most participants had seen them on TV, and therefore, it can be concluded that this source of education had not been effective for the people.
N.K. Edirisinghe, S.A.C. Dalpatadu and T.S. Dissanayake's ‘A study of the knowledge of choking, burns, acute poisoning and their first aid practices among mothers of children below 14-years attending the (paediatric wards) District General Hospital, Kalutara’ found that only 11% had adequate knowledge of first aid for choking. A. Balasuriya and U. Gangodawila's ‘Prevalence of home accidents among children aged one-four and its association of knowledge, attitudes and first aid practices of mothers (in the Bulathsinghala Medical Officer [MO] of Health area)’ showed that 64% had adequate knowledge of first aid for choking. P. Alahakoon, K. Bandaranayaka, P. Perera and C. Wijesundara's ‘Knowledge and attitudes on first aid among Advanced Level students in the Gampaha Educational Zone’ found that educational qualifications related to biology have improved the knowledge of first aid but that the previous training status had not affected the knowledge of first aid.
D. Ralapanawa, K. Jayawickreme and E. Ekanayake's ‘A study on the knowledge and attitudes on advanced LS among (final-year) medical students and MOs in a tertiary care hospital’ demonstrated that the overall knowledge and attitudes in nearly 10% in the Peradeniya Teaching Hospital were inadequate. V. Thoradeniya, S. Munasinghe, G. Thilakarathna, A. Jayasena and N. Wijesooriya's ‘Knowledge and attitudes on BLS and associated factors, among selected nursing schools and faculties’ found that only 50% of nursing students had good knowledge and attitudes towards BLS. D.W.G.S.C. Alukumbura, R.E.M.W.S.K.V.B. Ekanayaka, S.K.I. Kalpani, D.M.D. Sandeepanie, R.M.M.T. Thilakarathna, U.R.W.M.K. Wijerathne, W.G.C. Kumara and R.A.N.K. Wijesinghe's ‘Knowledge, attitudes and practices on BLS among Traffic Police officers, Police Division – Nugegoda’ showed that knowledge and attitudes were inadequate.
Chia et al. (Singapore) revealed that those who had participated in the BLS course had better knowledge and that those who had higher educational qualifications demonstrated better knowledge. Uehara et. al. (Japan) found that the age of the mother at the time of delivery, the awareness of medical facilities for emergency services at night or during the weekend, the current occupational status of the mother and the current economic status, were independently associated with CPR awareness. The aforementioned Indian study revealed that only 1% of the injured used ambulance services, while motorbikes were the most preferred mode of transport, and the same study revealed potentially harmful practices used as first aid. M. Pai, S. Mahalingam and C.V.S. Reddy's ‘Knowledge retention of BLS in rural school adolescents: A comparison of two educational methods’ revealed that knowledge of BLS improved more by ‘hands on training’ compared to educational videos.