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more likely to have received rates between 85 and 100 and the average depth of
compression 2.4 mm deeper than nonsurvivors.
Though a rescuer may not feel fatigued, chest compression quality deteriorates
within the first 2 minutes of chest compressions, leading to the current
recommendation of switching providers every 2 minutes. However, frequent
changes in providers cause an interruption in compressions and new compressors
may be more likely to lean during the first compressions. Some providers may
maintain high-quality compressions beyond the recommended 2-minute limit.
Using a real-time CPR feedback system may provide objective information
regarding when to change compressors. In Bobrow’s study of adults with an
OHCA, chest compression rate, depth, ventilation rate, and preshock pause were
all improved when audiovisual feedback was used in combination with rescuer
retraining. Most importantly, feedback and training improved survival by 30%.

INTRAVENOUS ACCESS
The site used for vascular access depends on the patient’s condition and the
provider’s experience. The most common sites used in the ill pediatric patient
include peripheral venous access, IO access, and central venous access via the
femoral vein.
In the arrested patient, IO access is indicated and can be accomplished quickly
(30 to 60 seconds) and provides a route for all drugs and fluids needed during
resuscitation. The onset of action of drugs administered via this route is
comparable to that of drugs administered into the central circulation. Adenosine,
which is rapidly metabolized once administered, may not work when given via
the IO. Manual pressure, a push–pull fluid delivery system, or use of a pressure
bag is necessary when giving fluids to restore the vascular volume in order to
overcome the resistance of the marrow venous plexus. The preferred site in
children is the medial surface of the tibia 1 to 3 cm below the tibial tuberosity.
Alternative sites include the anterior surface of the distal femur, proximal medial
malleolus, and the anterior iliac spine ( Fig. 9.12 ). There are several types of
rigid, styletted needles commercially available for this procedure in infants and

children. There are also semiautomated IO devices available for use in children.
The bone injection gun (BIG) is a spring-loaded device that can be used in
adolescents/adults and can effectively penetrate the thicker bony cortex. The EZIO (Vidacare, San Antonio, TX), a battery-powered handheld drill, is available
for use in both children and adults. Further research is needed to evaluate efficacy
of the semiautomated IO placement devices as compared to manual IO needles.
Contraindications to IO placement include recently fractured bone, osteogenesis