Bag-mask ventilation and basic airway adjuncts: Case

This infant is apnoeic, cyanosed, bradycardic and limp after a seizure — the pre-terminal signature of hypoxia — so the immediate priority is to open the airway and ventilate. The slow heart rate is the heart's response to hypoxia, and effective ventilation with oxygen usually reverses it within seconds once the chest rises, which is why airway and breathing come before compressions. ^[2]

Clinical findings

The key findings are the apnoea, the central cyanosis, the bradycardia with a heart rate of 52, the hypoxaemia with a saturation of 70 percent, and the limp tone, which together are the pre-terminal picture of a hypoxic infant. The copious secretions and the stertorous breathing show that the airway is obstructed at the level of the tongue and oropharynx, which is the first problem to fix. ^[1]

The candidate should recognise that this is a respiratory problem masquerading as a cardiac one. The slow heart rate in a sick child is the heart's response to hypoxia, so the treatment is ventilation, not compressions; compressions are added only if the heart rate stays below 60 beats per minute despite at least 30 seconds of effective ventilation with oxygen. They should also note that there is no sign of trauma, so head tilt-chin lift is permissible here, though a jaw thrust is the more reliable manoeuvre for an obstructing tongue. ^[1]