In a pulseless pediatric patient with a chest impalement, what should you do first?

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The main idea is that in a child with a penetrating chest injury who has no pulse, restoring circulation with CPR is the immediate priority, and any object obstructing chest compressions needs to be removed so you can perform effective CPR. A knife stuck in the chest prevents full chest compression and recoil, which sharply reduces the effectiveness of CPR. Removing the impaling object allows you to deliver compressions properly and maximize intrathoracic pressure changes needed to generate blood flow, improving the chance of return of spontaneous circulation. After the object is removed, control bleeding around the wound and continue high-quality CPR with rapid transport to advanced care. Defibrillation, if indicated by rhythm, comes after initiating CPR and addressing the airway and breathing, rather than as the first step in this trauma scenario.