Primary cardiopulmonary resuscitation in children
With the development of terminal conditions, timely and correct conduct of primary cardiopulmonary resuscitation allows, in some cases, to save the lives of children and return the victims to normal life. Mastering the elements of emergency diagnosis of terminal conditions, solid knowledge of the methodology of primary cardiopulmonary resuscitation, extremely clear, “automatic” execution of all manipulations in the right rhythm and strict sequence are an indispensable condition for success.
Cardiopulmonary resuscitation techniques are constantly being improved. This publication presents the rules of cardiopulmonary resuscitation in children, based on the latest recommendations of domestic scientists (Tsybulkin E.K., 2000; Malyshev V.D. et al., 2000) and the Emergency Committee of the American Association of Cardiology, published in JAMA (1992).
Clinical diagnostics
Main features clinical death:
lack of breathing, heartbeat and consciousness;
the disappearance of the pulse in the carotid and other arteries;
pale or gray-earthy skin color;
pupils are wide, without reaction to light.
Immediate measures for clinical death:
resuscitation of a child with signs of circulatory and respiratory arrest should begin immediately, from the first seconds of ascertaining this condition, extremely quickly and energetically, in strict sequence, without wasting time on finding out the causes of its onset, auscultation and measuring blood pressure;
fix the time of onset of clinical death and the start of resuscitation;
sound an alarm, call assistants and an intensive care team;
if possible, find out how many minutes have passed since the expected moment of development of clinical death.
If it is known for sure that this period is more than 10 minutes, or the victim has early signs of biological death (symptoms of "cat's eye" - after pressing on eyeball the pupil assumes and retains a spindle-shaped horizontal shape and "melting ice" - clouding of the pupil), then the need for cardiopulmonary resuscitation is doubtful.
Resuscitation will be effective only when it is properly organized and life-sustaining activities are performed in the classical sequence. The main provisions of primary cardiopulmonary resuscitation are proposed by the American Association of Cardiology in the form of the "ABC Rules" according to R. Safar:
The first step of A(Airways) is to restore airway patency.
The second step B (Breath) is the restoration of breathing.
The third step C (Circulation) is the restoration of blood circulation.
The sequence of resuscitation measures:
A ( Airways ) - restoration of airway patency:
1. Lay the patient on his back on a hard surface (table, floor, asphalt).
2. Mechanically clear the oral cavity and pharynx from mucus and vomit.
3. Slightly tilt your head back, straightening the airways (contraindicated if you suspect a cervical injury), put a soft roller made of a towel or sheet under your neck.
Fracture of the cervical vertebrae should be suspected in patients with head trauma or other injuries above the collarbones, accompanied by loss of consciousness, or in patients whose spine has been subjected to unexpected overload associated with diving, falling, or an automobile accident.
4. Push lower jaw forward and upward (the chin should be in the most elevated position), which prevents the tongue from sticking to the back of the throat and facilitates air access.
AT ( breath ) - restoration of breathing:
Start mechanical ventilation by mouth-to-mouth expiratory methods - in children over 1 year old, "mouth-to-nose" - in children under 1 year old (Fig. 1).
IVL technique. When breathing "from mouth to mouth and nose", it is necessary with the left hand, placed under the neck of the patient, to pull up his head and then, after a preliminary deep breath, tightly clasp the child's nose and mouth with his lips (without pinching it) and with some effort blow in the air (the initial part of his tidal volume) (Fig. 1). For hygienic purposes, the patient's face (mouth, nose) can first be covered with a gauze or handkerchief. As soon as the chest rises, the air is stopped. After that, take your mouth away from the child's face, giving him the opportunity to passively exhale. The ratio of the duration of inhalation and exhalation is 1:2. The procedure is repeated with a frequency equal to the age-related respiratory rate of the resuscitated person: in children of the first years of life - 20 per 1 min, in adolescents - 15 per 1 min
When breathing "from mouth to mouth", the resuscitator wraps his lips around the patient's mouth, and pinches his nose with his right hand. Otherwise, the execution technique is the same (Fig. 1). With both methods, there is a risk of partial entry of the blown air into the stomach, its swelling, regurgitation of gastric contents into the oropharynx and aspiration.
The introduction of an 8-shaped air duct or an adjacent mouth-to-nasal mask greatly facilitates mechanical ventilation. They are connected to manual breathing apparatus (Ambu bag). When using manual breathing apparatus, the resuscitator presses the mask tightly with his left hand: the nose with the thumb, and the chin with the index fingers, while (with the rest of the fingers) pulling the patient's chin up and back, which achieves the mouth closing under the mask. The bag is squeezed with the right hand until an excursion of the chest occurs. This serves as a signal to stop the pressure to ensure expiration.
FROM ( Circulation ) - restoration of blood circulation:
After the first 3-4 air insufflations have been carried out, in the absence of a pulse in the carotid or femoral arteries, the resuscitator, along with the continuation of mechanical ventilation, should proceed to an indirect heart massage.
Methodology indirect massage heart (Fig. 2, table 1). The patient lies on his back, on a hard surface. The resuscitator, having chosen the position of the hands corresponding to the age of the child, performs rhythmic pressure with age frequency on the chest, commensurate the force of pressure with the elasticity of the chest. Heart massage is carried out until the heart rhythm and pulse on the peripheral arteries are fully restored.
Table 1.
The method of conducting indirect heart massage in children
Complications of indirect heart massage: with excessive pressure on the sternum and ribs, there may be fractures and pneumothorax, and with strong pressure over the xiphoid process, liver rupture may occur; it is necessary to remember also about the danger of regurgitation of gastric contents.
In cases where mechanical ventilation is done in combination with chest compressions, it is recommended to do one breath every 4-5 chest compressions. The child's condition is reassessed 1 minute after the start of resuscitation and then every 2-3 minutes.
Criteria for the effectiveness of mechanical ventilation and indirect heart massage:
Constriction of the pupils and the appearance of their reaction to light (this indicates the flow of oxygenated blood into the patient's brain);
The appearance of a pulse on the carotid arteries (checked between chest compressions - at the time of compression, a massage wave is felt on the carotid artery, indicating that the massage is performed correctly);
Restoration of spontaneous breathing and heart contractions;
The appearance of a pulse on the radial artery and an increase in blood pressure to 60 - 70 mm Hg. Art.;
Reducing the degree of cyanosis of the skin and mucous membranes.
Further life support activities:
1. If the heartbeat is not restored, without stopping mechanical ventilation and chest compressions, provide access to the peripheral vein and inject intravenously:
0,1% rr adrenaline hydrotartrate 0.01 ml/kg (0.01 mg/kg);
0.1% solution of atropine sulfate 0.01-0.02 ml/kg (0.01-0.02 mg/kg). Atropine in resuscitation in children is used in dilution: 1 ml of a 0.1% solution per 9 ml of isotonic sodium chloride solution (obtained in 1 ml of a solution of 0.1 mg of the drug). Adrenaline is also used in a dilution of 1: 10,000 per 9 ml of isotonic sodium chloride solution (0.1 mg of the drug will be in 1 ml of the solution). Perhaps the use of doses of adrenaline increased by 2 times.
If necessary, repeated intravenous administration of the above drugs after 5 minutes.
4% sodium bicarbonate solution 2 ml/kg (1 mmol/kg). The introduction of sodium bicarbonate is indicated only in conditions of prolonged cardiopulmonary resuscitation (more than 15 minutes) or if it is known that circulatory arrest occurred against the background of metabolic acidosis; the introduction of a 10% solution of calcium gluconate at a dose of 0.2 ml / kg (20 mg / kg) is indicated only in the presence of hyperkalemia, hypocalcemia and overdose of calcium antagonists.
2. Oxygen therapy with 100% oxygen through a face mask or nasal catheter.
3. In case of ventricular fibrillation, defibrillation (electrical and medical) is indicated.
If there are signs of restoration of blood circulation, but there is no independent cardiac activity, chest compressions are performed until effective blood flow is restored or until signs of life permanently disappear with the development of symptoms of brain death.
Absence of signs of restoration of cardiac activity against the background of ongoing activities for 30-40 minutes. is an indication for termination of resuscitation.
INDEPENDENT WORK OF STUDENTS:
The student independently performs emergency medical care on the simulator "ELTEK-baby".
LIST OF LITERATURE FOR INDEPENDENT TRAINING:
Main literature:
1. Outpatient pediatrics: textbook / ed. A.S. Kalmykova. - 2nd edition, revised. and additional – M.: GEOTAR-Media. 2011.- 706 p.
Polyclinic pediatrics: a textbook for universities / ed. A.S. Kalmykova. - 2nd ed., - M.: GEOTAR-Media. 2009. - 720 p. [Electronic resource] - Access from the Internet. - //
2. Guide to outpatient pediatrics / ed. A.A. Baranov. – M.: GEOTAR-Media. 2006.- 592 p.
Guide to outpatient pediatrics / ed. A.A. Baranova. - 2nd ed., corrected. and additional - M.: GEOTAR-Media. 2009. - 592 p. [Electronic resource] - Access from the Internet. - // http://www.studmedlib.ru/disciplines/
Additional literature:
Vinogradov A.F., Akopov E.S., Alekseeva Yu.A., Borisova M.A. CHILDREN'S HOSPITAL. - M .: GOU VUNMTs of the Ministry of Health of the Russian Federation, 2004.
Galaktionova M.Yu. Emergency care for children. Prehospital stage: tutorial. - Rostov-on-Don: Phoenix. 2007.- 143 p.
Tsybulkin E.K. Emergency pediatrics. Algorithms for diagnosis and treatment. Moscow: GEOTAR-Media. 2012.- 156 p.
Emergency pediatrics: textbook / Yu. S. Aleksandrovich, V. I. Gordeev, K. V. Pshenisnov. - St. Petersburg. : Special Lit. 2010. - 568 p. [Electronic resource] - Access from the Internet. - // http://www.studmedlib.ru/book/
Baranov A.A., Shcheplyagina L.A. Physiology of growth and development of children and adolescents - Moscow, 2006.
[Electronic resource] Vinogradov A.F. and others: textbook / Tver state. honey. acad.; Practical skills for a student studying in the specialty "pediatrics", [Tver]:; 2005 1 electronic opt. (CD-ROM).
Software and Internet Resources:
1.Electronic resource: access mode: // www. Consilium- medicine. com.
INTERNET medical resource catalog
2. "Medline",
4.Catalog "Corbis",
5.Professional-oriented site : http:// www. Medpsy.ru
6. Student advisor: www.studmedlib.ru(name - polpedtgma; password - polped2012; code - X042-4NMVQWYC)
Knowledge by the student of the main provisions of the topic of the lesson:
Examples of baseline tests:
1. At what severity of laryngeal stenosis is emergency tracheotomy indicated?
a. At 1 degree.
b. At 2 degrees.
in. At 3 degrees.
g. At 3 and 4 degrees.
* e. At 4 degrees.
2. What is the first action in urgent therapy of anaphylactic shock?
* a. Termination of access to the allergen.
b. Injection of the injection site of the allergen with adrenaline solution.
in. Introduction of corticosteroids.
d. Applying a tourniquet above the injection site of the allergen.
e. Applying a tourniquet below the injection site of the allergen.
3. Which of the criteria will first indicate to you that the chest compressions being performed are effective?
a. Warming of the extremities.
b. The return of consciousness.
c. The appearance of intermittent breathing.
d. Pupil dilation.
* d. Constriction of the pupils._
4. What ECG change is threatening for sudden death syndrome in children?
* a. Lengthening of the interval Q - T.
b. Shortening of the interval Q - T.
in. Prolongation of the interval P - Q.
d. Shortening of the interval P - Q.
e. Deformation of the QRS complex.
Questions and typical tasks of the final level:
Exercise 1.
An ambulance call to the house of a 3-year-old boy.
The temperature is 36.8°C, the number of breaths is 40 per minute, the number of heartbeats is 60 per minute, blood pressure is 70/20 mm Hg. Art.
Complaints of parents about lethargy and inappropriate behavior of the child.
Medical history: allegedly 60 minutes before the arrival of the ambulance, the boy ate an unknown number of pills kept by his grandmother, who suffers from hypertension and takes nifedipine and reserpine for treatment.
Objective data: Serious condition. Doubtfulness. Glasgow score 10 points. The skin, especially the chest and face, as well as the sclera, are hyperemic. The pupils are constricted. Seizures with a predominance of the clonic component are periodically noted. Nasal breathing is difficult. Breathing is superficial. Pulse of weak filling and tension. On auscultation, against the background of puerile breathing, a small amount of rales of a wired nature is heard. Heart sounds are muffled. The abdomen is soft. The liver protrudes 1 cm from under the edge of the costal arch along the mid-clavicular line. The spleen is not palpable. Haven't peed in the last 2 hours.
a) Make a diagnosis.
b) Provide pre-hospital emergency care and determine the conditions of transportation.
c) Characterize the pharmacological action of nefedipine and reserpine.
d) Define the Glasgow scale. What is it used for?
e) Indicate the time after which the development of acute renal failure is possible, and describe the mechanism of its occurrence.
f) Determine the possibility of conducting forced diuresis to remove the absorbed poison at the prehospital stage.
g) List the possible consequences of poisoning for the life and health of the child. How many tablets of these drugs are potentially lethal at a given age?
a) Acute exogenous poisoning with reserpine and nefedipine tablets of moderate severity. Acute vascular insufficiency. Convulsive syndrome.
Task 2:
You are a summer camp doctor.
During the last week, the weather has been hot, dry, with daytime air temperatures of 29-30С in the shade. In the afternoon, a 10-year-old child was brought to you, who complained of lethargy, nausea, decreased visual acuity. On examination, you noticed reddening of the face, an increase in body temperature up to 37.8°C, increased respiration, and tachycardia. From the anamnesis it is known that the child played “beach volleyball” for more than 2 hours before lunch. Your actions?
Sample response
Perhaps these are early signs of sunstroke: lethargy, nausea, decreased visual acuity, reddening of the face, fever, increased respiration, tachycardia. In the future, there may be a loss of consciousness, delirium, hallucinations, a change from tachycardia to bradycardia. In the absence of help, the death of a child is possible with symptoms of cardiac and respiratory arrest.
Urgent care:
1. Move the child to a cool room; lay in a horizontal position, cover your head with a diaper moistened with cold water.
2. With the initial manifestations of heat stroke and preserved consciousness, give a plentiful drink of glucose-salt solution (1/2 teaspoon of sodium chloride and sodium bicarbonate, 2 tablespoons of sugar per 1 liter of water) not less than the volume of the age-related daily need for water.
3. With an expanded clinic of heat stroke:
Conduct physical cooling with cold water with constant rubbing of the skin (stop when the body temperature drops below 38.5 ° C);
Provide access to the vein and start the intravenous administration of Ringer's solution or "Trisol" at a dose of 20 ml / kg hour;
In case of convulsive syndrome, inject a 0.5% solution of seduxen 0.05-0.1 ml / kg (0.3-0.5 mg / kg) intramuscularly;
oxygen therapy;
With the progression of respiratory and circulatory disorders, tracheal intubation and transfer to mechanical ventilation are indicated.
Hospitalization of children with heat or sunstroke in the intensive care unit after first aid. For children with initial manifestations without loss of consciousness, hospitalization is indicated with a combination of overheating with diarrhea and salt-deficient dehydration, as well as with negative dynamics clinical manifestations when observing a child for 1 hour.
Task 3:
The doctor of the children's health camp was called by passers-by who saw a drowning child in the lake near the camp. On examination, a child lies on the shore of the lake, the estimated age is 9-10 years old, unconscious, in wet clothes. The skin is pale, cold to the touch, cyanotic lips are noted, water flows from the mouth and nose. Hyporeflexia. In the lungs, breathing is weakened, retraction of the compliant places of the chest and sternum on inspiration, NPV - 30 per 1 min. The heart sounds are muffled, the heart rate is 90 beats/min, the pulse is of weak filling and tension, rhythmic. BP - 80/40 mm Hg. The abdomen is soft and painless.
1. What is your diagnosis?
2. Your actions at the place of examination (first aid).
3. Your actions in the medical center of the health camp (assistance at the pre-hospital stage).
4. Further tactics.
Sample response.
1. Drowning.
2. On the spot: - clean the oral cavity, - bend the victim over the thigh, remove water with palm strokes between the shoulder blades.
3. In the medical center: -undress the child, rub with alcohol, wrap in a blanket, -inhalation of 60% oxygen, -insert the probe into the stomach, -inject the age-specific dose of atropine into the muscles of the floor of the mouth, -polyglukin 10ml/kg IV; prednisone 2-4 mg/kg.
4.Subject to emergency hospitalization in the intensive care unit of the nearest hospital.
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To do this, you need to be able to diagnose terminal conditions, know the method of resuscitation, perform all the necessary manipulations in a strict sequence, up to automatism.
In 2010, at the international association AHA (American Heart Association), after long discussions, new rules for conducting cardiopulmonary resuscitation were issued.
The changes primarily affected the sequence of resuscitation. Instead of the previously performed ABC (airway, breathing, compressions), CAB (cardiac massage, airway patency, artificial respiration).
Now consider urgent measures upon clinical death.
Clinical death can be diagnosed by the following signs:
there is no breathing, there is no blood circulation (the pulse on the carotid artery is not determined), dilation of the pupils is noted (there is no reaction to light), consciousness is not determined, reflexes are absent.
If clinical death is diagnosed:
- Record the time when clinical death occurred and the time when resuscitation began;
- Sound the alarm, call the resuscitation team for help (one person is not able to provide resuscitation with high quality);
- Resuscitation should begin immediately, without wasting time on auscultation, measuring blood pressure and finding out the causes of the terminal condition.
CPR sequence:
1. Resuscitation begins with an indirect heart massage, regardless of age. This is especially true if one person is resuscitating. Immediately recommend 30 compressions in a row before the start of artificial ventilation.
If resuscitation is carried out by people without special training, then only heart massage is done without artificial respiration attempts. If resuscitation is carried out by a team of resuscitators, then closed heart massage is done simultaneously with artificial respiration, avoiding pauses (without stops).
Chest compressions should be fast and hard, in children under one year old by 2 cm, 1-7 years old by 3 cm, over 10 years old by 4 cm, in adults by 5 cm. The frequency of compressions in adults and children is up to 100 times per minute.
In infants under one year old, heart massage is performed with two fingers (index and ring), from 1 to 8 years old with one palm, for older children with two palms. The place of compression is the lower third of the sternum.
2. Restoration of airway patency (airways).
It is necessary to clear the airways of mucus, push the lower jaw forward and upward, slightly tilt the head back (in case of an injury to the cervical region, this is contraindicated), a roller is placed under the neck.
3. Restoration of breathing (breathing).
At the pre-hospital stage, mechanical ventilation is carried out by the “mouth-to-mouth and nose” method - in children under 1 year old, “mouth-to-mouth” method - in children over 1 year old.
The ratio of respiratory rate to the frequency of shocks:
- If one rescuer conducts resuscitation, then the ratio is 2:30;
- If several rescuers carry out resuscitation, then a breath is taken every 6-8 seconds, without interrupting the heart massage.
The introduction of an air duct or a laryngeal mask greatly facilitates IVL.
At the stage of medical care for mechanical ventilation, a manual breathing apparatus (Ambu bag) or an anesthetic apparatus is used.
Tracheal intubation should be with a smooth transition, breathe with a mask, and then intubate. Intubation is performed through the mouth (orotracheal method), or through the nose (nasotracheal method). Which method to give preference depends on the disease and damage to the facial skull.
Medicines are administered against the background of ongoing closed heart massage and mechanical ventilation.
The route of administration is desirable - intravenous, if not possible - endotracheal or intraosseous.
With endotracheal administration, the dose of the drug is increased by 2-3 times, the drug is diluted in saline to 5 ml and injected into the endotracheal tube through a thin catheter.
Intraosseously, the needle is inserted into the tibia in its anterior surface. A mandrel spinal needle or a bone marrow needle may be used.
Intracardiac administration in children is not currently recommended due to possible complications (hemipericardium, pneumothorax).
In clinical death, the following drugs are used:
- Adrenaline hydrotartate 0.1% solution at a dose of 0.01 ml / kg (0.01 mg / kg). The drug can be administered every 3 minutes. In practice, dilute 1 ml of adrenaline with saline
9 ml (results in a total volume of 10 ml). From the resulting dilution, 0.1 ml/kg is administered. If there is no effect after double administration, the dose is increased ten times
(0.1 mg/kg).
The dose of the drug is 1 mmol/kg of body weight.
I would like to note that in adults, defibrillation is a priority and should begin simultaneously with closed heart massage.
In children, ventricular fibrillation occurs in about 15% of all cases of circulatory arrest and is therefore less commonly used. But if fibrillation is diagnosed, then it should be carried out as soon as possible.
There are mechanical, medical, electrical defibrillation.
- Mechanical defibrillation includes a precordial blow (a punch to the sternum). Now in pediatric practice is not used.
- Medical defibrillation consists in the use of antiarrhythmic drugs - verapamil 0.1-0.3 mg / kg (no more than 5 mg once), lidocaine (at a dose of 1 mg / kg).
- Electrical defibrillation is the most effective method and an essential component of cardiopulmonary resuscitation.
(2J/kg - 4J/kg - 4J/kg). If there is no effect, then against the background of ongoing resuscitation, a second series of discharges can be carried out again starting from 2 J / kg.
During defibrillation, you need to disconnect the child from the diagnostic equipment and the respirator. Electrodes are placed - one to the right of the sternum below the collarbone, the other to the left and below the left nipple. There must be a saline solution or cream between the skin and the electrodes.
Resuscitation is stopped only after the appearance of signs of biological death.
Cardiopulmonary resuscitation is not started if:
- More than 25 minutes have passed since cardiac arrest;
- The patient is in the terminal stage of an incurable disease;
- The patient received a full complex of intensive treatment, and against this background, cardiac arrest occurred;
- Biological death was declared.
In conclusion, I would like to note that cardiopulmonary resuscitation should be carried out under the control of electrocardiography. It is a classic diagnostic method for such conditions.
Single cardiac complexes, large or small wave fibrillation or isolines may be observed on the electrocardiograph tape or monitor.
It happens that normal electrical activity of the heart is recorded in the absence of cardiac output. This type of circulatory arrest is called electromechanical dissociation (it happens with cardiac tamponade, tension pneumothorax, cardiogenic shock, etc.).
In accordance with the data of electrocardiography, you can more accurately provide the necessary assistance.
Cardiopulmonary resuscitation in children
The words "children" and "resuscitation" should not occur in the same context. It is too painful and bitter to read in the news feed that, through the fault of parents or by a fatal accident, children die, end up in intensive care units with severe injuries and injuries.
Cardiopulmonary resuscitation in children
Statistics show that every year the number of children who die in early childhood childhood, is growing steadily. But if there was a person nearby at the right time who knows how to provide first aid and who knows the features of cardiopulmonary resuscitation in children ... In a situation where the life of children hangs in the balance, there should not be “if only”. We, adults, have no right to assumptions and doubts. Each of us is obliged to master the technique of cardiopulmonary resuscitation, to have a clear algorithm of actions in our head in case the case suddenly forces us to be in the same place, at the same time ... After all, the most important thing depends on the correct, coordinated actions before the arrival of an ambulance - The life of a little man.
1 What is cardiopulmonary resuscitation?
This is a set of measures that should be carried out by any person in any place before the arrival of an ambulance, if children have symptoms that indicate respiratory and / or circulatory arrest. Further, we will focus on basic resuscitation measures that do not require specialized equipment or medical training.
2 Causes leading to life-threatening conditions in children
Help with airway obstruction
Respiratory and circulatory arrest is most common among children in the neonatal period, as well as in children under the age of two years. Parents and others need to be extremely attentive to children of this age category. Often the causes of the development of a life-threatening condition can be a sudden blockage of the respiratory organs by a foreign body, and in newborns - by mucus, the contents of the stomach. Often there is a syndrome of sudden death, congenital malformations and anomalies, drowning, suffocation, injuries, infections and respiratory diseases.
There are differences in the mechanism of development of circulatory and respiratory arrest in children. They are as follows: if in an adult, circulatory disorders are more often associated directly with problems of the cardiac plan (heart attacks, myocarditis, angina pectoris), then in children such a relationship is almost not traced. In children, progressive respiratory failure comes to the fore without damage to the heart, and then circulatory failure develops.
3 How to understand that a violation of blood circulation has occurred?
Checking a child's pulse
If there is a suspicion that something is wrong with the baby, you need to call him, ask simple questions “what is your name?”, “Is everything all right?” if you have a child 3-5 years old and older. If the patient does not respond, or is completely unconscious, it is necessary to immediately check whether he is breathing, whether he has a pulse, a heartbeat. A violation of blood circulation will indicate:
- lack of consciousness
- violation / lack of breathing,
- pulse on large arteries is not determined,
- heartbeats are not audible,
- pupils are dilated,
- reflexes are absent.
Checking for breath
The time during which it is necessary to determine what happened to the child should not exceed 5-10 seconds, after which it is necessary to start cardiopulmonary resuscitation in children, call an ambulance. If you do not know how to determine the pulse, do not waste time on this. First of all, make sure that consciousness is preserved? Lean over him, call, ask a question, if he does not answer - pinch, squeeze his arm, leg.
If the child does not react to your actions, he is unconscious. You can make sure that there is no breathing by leaning your cheek and ear as close as possible to his face, if you do not feel the victim’s breathing on your cheek, and also see that his chest does not rise from respiratory movements, this indicates a lack of breathing. You can't delay! It is necessary to move on to resuscitation techniques in children!
4 ABC or CAB?
Ensuring airway patency
Until 2010, there was a single standard for the provision of resuscitation care, which had the following abbreviation: ABC. It got its name from the first letters English alphabet. Namely:
- A - air (air) - ensuring the patency of the respiratory tract;
- B - breathe for victim - ventilation of the lungs and access to oxygen;
- C - circulation of blood - compression of the chest and normalization of blood circulation.
After 2010, the European Resuscitation Council changed the recommendations, according to which chest compressions (point C), and not A, come first in resuscitation. The abbreviation changed from “ABC” to “CBA”. But these changes have had an effect in the adult population, in which the cause of critical situations is mostly heart disease. Among the child population, as mentioned above, respiratory disorders prevail over cardiac pathology, therefore, among children, the ABC algorithm is still guided, which primarily ensures airway patency and respiratory support.
5 Resuscitation
If the child is unconscious, there is no breathing or there are signs of its violation, it is necessary to make sure that the airways are passable and take 5 mouth-to-mouth or mouth-to-nose breaths. If a baby under 1 year old is in critical condition, you should not take too strong artificial breaths into his airways, given the small capacity of small lungs. After 5 breaths into the patient's airways, the vital signs should be checked again: respiration, pulse. If they are absent, it is necessary to start an indirect heart massage. To date, the ratio of the number of chest compressions and the number of breaths is 15 to 2 in children (in adults 30 to 2).
6 How to create airway patency?
The head must be in such a position that the airway is clear.
If a small patient is unconscious, then often the tongue sinks into his airways, or in the supine position, the back of the head contributes to the flexion of the cervical spine, and the airways will be closed. In both cases, artificial respiration will not bring any positive results - the air will rest against the barriers and will not be able to get into the lungs. What should be done to avoid this?
- It is necessary to straighten the head in the cervical region. Simply put, tilt your head back. Too much tilting should be avoided, as this may move the larynx forward. The extension should be smooth, the neck should be slightly extended. If there is a suspicion that the patient has an injury to the spine in the cervical region, do not tilt back!
- Open the victim's mouth, trying to bring the lower jaw forward and towards you. Inspect the oral cavity, remove excess saliva or vomit, foreign body, if any.
- The criterion of correctness, which ensures the patency of the airways, is the following such position of the child, in which his shoulder and the external auditory meatus are located on one straight line.
If, after the above actions, breathing is restored, you feel the movements of the chest, abdomen, the flow of air from the child's mouth, and a heartbeat, pulse is heard, then other methods of cardiopulmonary resuscitation in children should not be performed. It is necessary to turn the victim into a position on his side, in which his upper leg will be bent in knee joint and pushed forward, while the head, shoulders and body are located on the side.
This position is also called "safe", because. it prevents reverse obturation of the airways with mucus, vomit, stabilizes the spine, and provides good access to monitor the child's condition. After the little patient is placed in a safe position, his breathing is preserved and his pulse is felt, heart contractions are restored, it is necessary to monitor the child and wait for the ambulance to arrive. But not in all cases.
After fulfilling criterion "A", breathing is restored. If this does not happen, there is no breathing and cardiac activity, artificial ventilation and chest compressions should be carried out immediately. First, 5 breaths are performed in a row, the duration of each breath is approximately 1.0-.1.5 seconds. In children older than 1 year, mouth-to-mouth breaths are performed, in children under one year old - mouth-to-mouth, mouth-to-mouth and nose, mouth-to-nose. If after 5 artificial breaths there are still no signs of life, then proceed to an indirect heart massage in a ratio of 15: 2
7 Features of chest compressions in children
chest compressions for children
In cardiac arrest in children, indirect massage can be very effective and “start” the heart again. But only if it is carried out correctly, taking into account age features little patients. When conducting an indirect heart massage in children, the following features should be remembered:
- Recommended frequency of chest compressions in children per minute.
- The depth of pressure on the chest for children under 8 years old is about 4 cm, over 8 years old - about 5 cm. The pressure should be strong and fast enough. Do not be afraid to make deep pressure. Since too superficial compressions will not lead to a positive result.
- In children in the first year of life, pressure is performed with two fingers, in older children - with the base of the palm of one hand or both hands.
- Hands are located on the border of the middle and lower thirds of the sternum.
Primary cardiopulmonary resuscitation in children
With the development of terminal conditions, timely and correct conduct of primary cardiopulmonary resuscitation allows, in some cases, to save the lives of children and return the victims to normal life. Mastering the elements of emergency diagnosis of terminal conditions, solid knowledge of the methodology of primary cardiopulmonary resuscitation, extremely clear, “automatic” execution of all manipulations in the right rhythm and strict sequence are an indispensable condition for success.
Cardiopulmonary resuscitation techniques are constantly being improved. This publication presents the rules of cardiopulmonary resuscitation in children, based on the latest recommendations of domestic scientists (Tsybulkin E.K., 2000; Malyshev V.D. et al., 2000) and the Emergency Committee of the American Association of Cardiology, published in JAMA (1992).
The main signs of clinical death:
lack of breathing, heartbeat and consciousness;
the disappearance of the pulse in the carotid and other arteries;
pale or gray-earthy skin color;
pupils are wide, without reaction to light.
Immediate measures for clinical death:
resuscitation of a child with signs of circulatory and respiratory arrest should begin immediately, from the first seconds of ascertaining this condition, extremely quickly and energetically, in strict sequence, without wasting time on finding out the causes of its onset, auscultation and measuring blood pressure;
fix the time of onset of clinical death and the start of resuscitation;
sound an alarm, call assistants and an intensive care team;
if possible, find out how many minutes have passed since the expected moment of development of clinical death.
If it is known for sure that this period is more than 10 minutes, or the victim has early signs of biological death (symptoms of "cat's eye" - after pressing on the eyeball, the pupil takes and retains a spindle-shaped horizontal shape and "melting ice" - clouding of the pupil), then the need for cardiopulmonary resuscitation is questionable.
Resuscitation will be effective only when it is properly organized and life-sustaining activities are performed in the classical sequence. The main provisions of primary cardiopulmonary resuscitation are proposed by the American Association of Cardiology in the form of the "ABC Rules" according to R. Safar:
The first step of A(Airways) is to restore airway patency.
The second step B (Breath) is the restoration of breathing.
The third step C (Circulation) is the restoration of blood circulation.
The sequence of resuscitation measures:
1. Lay the patient on his back on a hard surface (table, floor, asphalt).
2. Mechanically clear the oral cavity and pharynx from mucus and vomit.
3. Slightly tilt your head back, straightening the airways (contraindicated if you suspect a cervical injury), put a soft roller made of a towel or sheet under your neck.
Fracture of the cervical vertebrae should be suspected in patients with head trauma or other injuries above the collarbones, accompanied by loss of consciousness, or in patients whose spine has been subjected to unexpected overload associated with diving, falling, or an automobile accident.
4. Push the lower jaw forward and upward (the chin should be in the most elevated position), which prevents the tongue from sticking to the back of the throat and facilitates air access.
Start mechanical ventilation by mouth-to-mouth expiratory methods - in children over 1 year old, "mouth-to-nose" - in children under 1 year old (Fig. 1).
IVL technique. When breathing "from mouth to mouth and nose", it is necessary with the left hand, placed under the neck of the patient, to pull up his head and then, after a preliminary deep breath, tightly clasp the child's nose and mouth with his lips (without pinching it) and with some effort blow in the air (the initial part of his tidal volume) (Fig. 1). For hygienic purposes, the patient's face (mouth, nose) can first be covered with a gauze or handkerchief. As soon as the chest rises, the air is stopped. After that, take your mouth away from the child's face, giving him the opportunity to passively exhale. The ratio of the duration of inhalation and exhalation is 1:2. The procedure is repeated with a frequency equal to the age-related respiratory rate of the resuscitated person: in children of the first years of life - 20 per 1 min, in adolescents - 15 per 1 min
When breathing "from mouth to mouth", the resuscitator wraps his lips around the patient's mouth, and pinches his nose with his right hand. Otherwise, the execution technique is the same (Fig. 1). With both methods, there is a risk of partial entry of the blown air into the stomach, its swelling, regurgitation of gastric contents into the oropharynx and aspiration.
The introduction of an 8-shaped air duct or an adjacent mouth-to-nasal mask greatly facilitates mechanical ventilation. They are connected to manual breathing apparatus (Ambu bag). When using manual breathing apparatus, the resuscitator presses the mask tightly with his left hand: the nose with the thumb, and the chin with the index fingers, while (with the rest of the fingers) pulling the patient's chin up and back, which achieves the mouth closing under the mask. The bag is squeezed with the right hand until an excursion of the chest occurs. This serves as a signal to stop the pressure to ensure expiration.
After the first air insufflations have been carried out, in the absence of a pulse on the carotid or femoral arteries, the resuscitator, along with the continuation of mechanical ventilation, should proceed to an indirect heart massage.
The technique of indirect heart massage (Fig. 2, table 1). The patient lies on his back, on a hard surface. The resuscitator, having chosen the position of the hands corresponding to the age of the child, performs rhythmic pressure with age frequency on the chest, commensurate the force of pressure with the elasticity of the chest. Heart massage is carried out until the heart rhythm and pulse on the peripheral arteries are fully restored.
The method of conducting indirect heart massage in children
Cardiopulmonary resuscitation in children: features and algorithm of actions
The algorithm for conducting cardiopulmonary resuscitation in children includes five stages. At the first, preparatory measures are performed, At the second, the patency of the airways is checked. At the third stage, artificial ventilation of the lungs is performed. The fourth stage is an indirect heart massage. Fifth - in the correct drug therapy.
Algorithm for conducting cardiopulmonary resuscitation in children: preparation and mechanical ventilation
In preparation for cardiopulmonary resuscitation in children, the presence of consciousness, spontaneous breathing, and a pulse on the carotid artery are checked. Also, the preparatory stage includes identifying the presence of neck and skull injuries.
The next step in the algorithm for cardiopulmonary resuscitation in children is to check the airway.
To do this, the child's mouth is opened, the upper respiratory tract is cleaned of foreign bodies, mucus, vomit, the head is thrown back, and the chin is raised.
If an injury to the cervical spine is suspected, the cervical region spine.
During cardiopulmonary resuscitation, children are given artificial lung ventilation (ALV).
In children up to a year. The mouth is wrapped around the mouth and nose of the child and the lips are pressed tightly against the skin of his face. Slowly, for 1-1.5 seconds, evenly inhale air until the visible expansion of the chest. A feature of cardiopulmonary resuscitation in children at this age is that the tidal volume should not exceed the volume of the cheeks.
In children older than one year. The child's nose is pinched, his lips are wrapped around his lips, while throwing back his head and raising his chin. Slowly exhale air into the patient's mouth.
In case of damage to the oral cavity, mechanical ventilation is carried out using the “mouth-to-nose” method.
Respiratory rate: up to a year: per minute, from 1 to 7 years per minute, over 8 years per minute (normal respiratory rate and blood pressure indicators depending on age are presented in the table).
Age norms of pulse rate, blood pressure, respiratory rate in children
Respiratory rate, per minute
Cardiopulmonary resuscitation in children: cardiac massage and drug administration
The child is placed on his back. Children under 1 year old are pressed on the sternum with 1-2 fingers. The thumbs are placed on the front surface of the baby's chest so that their ends converge at a point located 1 cm below the line mentally drawn through the left nipple. The remaining fingers should be under the back of the child.
For children over 1 year old, heart massage is performed with the base of one hand or both hands (at an older age), standing on the side.
Subcutaneous, intradermal and intramuscular injections for babies are done in the same way as for adults. But this way of administering medicines is not very effective - they begin to act in 10-20 minutes, and sometimes there is simply no such time. The fact is that any disease in children develops at lightning speed. The simplest and safest thing is to put a microclyster in a sick baby; the drug is diluted with warm (37-40 ° C) 0.9% sodium chloride solution (3.0-5.0 ml) with the addition of 70% ethyl alcohol (0.5-1.0 ml). 1.0-10.0 ml of the drug is injected through the rectum.
Features of cardiopulmonary resuscitation in children are the dosage of the drugs used.
Adrenaline (epinephrine): 0.1 ml/kg or 0.01 mg/kg. 1.0 ml of the drug is diluted in 10.0 ml of 0.9% sodium chloride solution; 1 ml of this solution contains 0.1 mg of the drug. If it is impossible to make a quick calculation according to the weight of the patient, adrenaline is used at 1 ml per year of life in breeding (0.1% - 0.1 ml / year of pure adrenaline).
Atropine: 0.01 mg/kg (0.1 ml/kg). 1.0 ml of 0.1% atropine is diluted in 10.0 ml of 0.9% sodium chloride solution, with this dilution, the drug can be administered in 1 ml per year of life. The introduction can be repeated every 3-5 minutes until a total dose of 0.04 mg/kg is reached.
Sodium bicarbonate: 4% solution - 2 ml / kg.
Cardiopulmonary resuscitation in newborns and children
Cardiopulmonary resuscitation(CPR) is a specific algorithm of actions to restore or temporarily replace the lost or significantly impaired function of the heart and respiration. By restoring the activity of the heart and lungs, the resuscitator ensures the maximum possible preservation of the brain of the victim in order to avoid social death (complete loss of vitality of the cerebral cortex). Therefore, a mortal term is possible - cardiopulmonary and cerebral resuscitation. Primary cardiopulmonary resuscitation in children is performed directly at the scene by anyone who knows the elements of CPR techniques.
Despite cardiopulmonary resuscitation, mortality in circulatory arrest in newborns and children remains at the level of%. With isolated respiratory arrest, the mortality rate is 25%.
About % of children requiring cardiopulmonary resuscitation are under one year of age; Most of them are under 6 months of age. About 6% of newborns require cardiopulmonary resuscitation after birth; especially if the weight of the newborn is less than 1500 g.
It is necessary to create a system for assessing the outcomes of cardiopulmonary resuscitation in children. An example is the modified Pittsburgh Outcome Categories Scale, which is based on general condition and CNS functions.
Carrying out cardiopulmonary resuscitation in children
The sequence of the three most important methods of cardiopulmonary resuscitation was formulated by P. Safar (1984) as the ABC rule:
- Aire way orep (“open the way for air”) means the need to free the airways from obstacles: sinking of the root of the tongue, accumulation of mucus, blood, vomit and other foreign bodies;
- Breath for victim ("breath for the victim") means mechanical ventilation;
- Circulation his blood ("circulation of his blood") means an indirect or direct heart massage.
Measures aimed at restoring airway patency are carried out in the following sequence:
- the victim is placed on a rigid base supine (face up), and if possible - in the Trendelenburg position;
- unbend the head in the cervical region, bring the lower jaw forward and at the same time open the mouth of the victim (R. Safar's triple technique);
- release the patient's mouth from various foreign bodies, mucus, vomit, blood clots with a finger wrapped in a handkerchief, suction.
Having ensured the patency of the respiratory tract, immediately proceed to mechanical ventilation. There are several main methods:
- indirect, manual methods;
- methods of direct blowing of air exhaled by the resuscitator into the airways of the victim;
- hardware methods.
The former are mainly of historical importance and are not considered at all in modern guidelines for cardiopulmonary resuscitation. At the same time, manual ventilation techniques should not be neglected in difficult situations when it is not possible to provide assistance to the victim in other ways. In particular, it is possible to apply rhythmic compressions (simultaneously with both hands) of the victim's lower chest ribs, synchronized with his exhalation. This technique may be useful during transportation of a patient with severe asthmatic status (the patient lies or half-sitting with his head thrown back, the doctor stands in front or to the side and rhythmically squeezes his chest from the sides during exhalation). Reception is not indicated for fractures of the ribs or severe airway obstruction.
The advantage of methods of direct inflation of the lungs in the victim is that with one breath a lot of air (1-1.5 l) is introduced, with active stretching of the lungs (Hering-Breuer reflex) and the introduction of an air mixture containing an increased amount of carbon dioxide(carbogen), the patient's respiratory center is stimulated. Mouth-to-mouth, mouth-to-nose, mouth-to-nose and mouth methods are used; the latter method is usually used in resuscitation of children early age.
The rescuer kneels on the side of the victim. Holding his head in an unbent position and holding his nose with two fingers, he tightly covers the mouth of the victim with his lips and makes 2-4 energetic, not fast (within 1-1.5 s) exhalations in a row (the patient's chest should be noticeable). An adult is usually provided with up to 16 respiratory cycles per minute, a child - up to 40 (taking into account age).
Ventilators vary in complexity of design. At the prehospital stage, you can use self-expanding breathing bags of the Ambu type, simple mechanical devices of the Pnevmat type, or interrupters of a constant air flow, for example, using the Eyre method (through a tee - with a finger). In hospitals, complex electromechanical devices are used that provide mechanical ventilation for a long period (weeks, months, years). Short-term forced ventilation is provided through a nasal mask, long-term - through an endotracheal or tracheotomy tube.
Usually, mechanical ventilation is combined with an external, indirect heart massage, achieved with the help of compression - compression of the chest in the transverse direction: from the sternum to the spine. In older children and adults, this is the border between the lower and middle thirds of the sternum; in young children, it is a conditional line passing one transverse finger above the nipples. The frequency of chest compressions in adults is 60-80, in infants, in newborns per minute.
In infants, there is one breath for every 3-4 chest compressions; in older children and adults, the ratio is 1:5.
The effectiveness of indirect heart massage is evidenced by a decrease in cyanosis of the lips, auricles and skin, constriction of the pupils and the appearance of a photoreaction, an increase in blood pressure, the appearance of individual respiratory movements in the patient.
Due to the incorrect position of the resuscitator's hands and with excessive efforts, complications of cardiopulmonary resuscitation are possible: fractures of the ribs and sternum, damage to internal organs. Direct cardiac massage is done with cardiac tamponade, multiple fractures of the ribs.
Specialized cardiopulmonary resuscitation includes more adequate mechanical ventilation, as well as intravenous or intratracheal medication. With intratracheal administration, the dose of drugs in adults should be 2 times, and in infants 5 times higher than with intravenous administration. Intracardiac administration of drugs is currently not practiced.
The condition for the success of cardiopulmonary resuscitation in children is the release of the airways, mechanical ventilation and oxygen supply. The most common cause of circulatory arrest in children is hypoxemia. Therefore, during CPR, 100% oxygen is delivered through a mask or endotracheal tube. V. A. Mikhelson et al. (2001) supplemented R. Safar's "ABC" rule with 3 more letters: D (Drag) - drugs, E (ECG) - electrocardiographic control, F (Fibrillation) - defibrillation as a method of treating cardiac arrhythmias. Modern cardiopulmonary resuscitation in children is unthinkable without these components, however, the algorithm for their use depends on the variant of cardiac dysfunction.
With asystole, intravenous or intratracheal administration of the following drugs is used:
- adrenaline (0.1% solution); 1st dose - 0.01 ml / kg, the next - 0.1 ml / kg (every 3-5 minutes until the effect is obtained). With intratracheal administration, the dose is increased;
- atropine (with asystole is ineffective) is usually administered after adrenaline and adequate ventilation (0.02 ml / kg 0.1% solution); repeat no more than 2 times in the same dose after 10 minutes;
- Sodium bicarbonate is administered only in conditions of prolonged cardiopulmonary resuscitation, and also if it is known that circulatory arrest occurred against the background of decompensated metabolic acidosis. The usual dose is 1 ml of an 8.4% solution. Repeat the introduction of the drug is possible only under the control of CBS;
- dopamine (dopamine, dopmin) is used after the restoration of cardiac activity against the background of unstable hemodynamics at a dose of 5-20 μg / (kg min), to improve diuresis 1-2 μg / (kg-min) for a long time;
- lidocaine is administered after the restoration of cardiac activity against the background of postresuscitation ventricular tachyarrhythmia as a bolus at a dose of 1.0-1.5 mg/kg, followed by an infusion at a dose of 1-3 mg/kg-h), or µg/(kg-min).
Defibrillation is carried out against the background of ventricular fibrillation or ventricular tachycardia in the absence of a pulse on the carotid or brachial artery. The power of the 1st discharge is 2 J/kg, subsequent - 4 J/kg; the first 3 discharges can be given in a row without being monitored by an ECG monitor. If the device has a different scale (voltmeter), the 1st category in infants should be within V, repeated - 2 times more. In adults, respectively, 2 and 4 thousand. V (maximum 7 thousand V). The effectiveness of defibrillation is increased by repeated administration of the entire complex of drug therapy (including a polarizing mixture, and sometimes magnesia sulphate, aminophylline);
For EMD in children with no pulse on the carotid and brachial arteries, the following methods are used intensive care:
- adrenaline intravenously, intratracheally (if catheterization is not possible after 3 attempts or within 90 seconds); 1st dose 0.01 mg/kg, subsequent - 0.1 mg/kg. The introduction of the drug is repeated every 3-5 minutes until the effect is obtained (restoration of hemodynamics, pulse), then in the form of infusions at a dose of 0.1-1.0 μg / (kgmin);
- liquid for replenishment of the central nervous system; it is better to use a 5% solution of albumin or stabizol, you can reopoliglyukin at a dose of 5-7 ml / kg quickly, drip;
- atropine at a dose of 0.02-0.03 mg/kg; re-introduction is possible after 5-10 minutes;
- sodium bicarbonate - usually 1 time 1 ml of 8.4% solution intravenously slowly; the effectiveness of its introduction is doubtful;
- with the ineffectiveness of the listed means of therapy - electrocardiostimulation (external, transesophageal, endocardial) without delay.
If in adults ventricular tachycardia or ventricular fibrillation are the main forms of circulatory cessation, then in young children they are extremely rare, so defibrillation is almost never used in them.
In cases where the brain damage is so deep and extensive that it becomes impossible to restore its functions, including stem functions, brain death is diagnosed. The latter is equated to the death of the organism as a whole.
Currently, there are no legal grounds for stopping the started and actively conducted intensive care in children before natural circulatory arrest. Resuscitation does not begin and is not carried out in the presence of a chronic disease and pathology incompatible with life, which is predetermined by a council of doctors, as well as in the presence of objective signs of biological death ( cadaveric spots, rigor mortis). In all other cases, cardiopulmonary resuscitation in children should begin with any sudden cardiac arrest and be carried out according to all the rules described above.
The duration of standard resuscitation in the absence of effect should be at least 30 minutes after circulatory arrest.
With successful cardiopulmonary resuscitation in children, it is possible to restore cardiac, sometimes simultaneously, respiratory functions (primary revival) in at least half of the victims, however, in the future, survival in patients is much less common. The reason for this is post-resuscitation illness.
The outcome of resuscitation is largely determined by the conditions of blood supply to the brain in the early postresuscitation period. In the first 15 minutes, the blood flow can exceed the initial one by 2-3 times, after 3-4 hours it falls by % in combination with an increase in vascular resistance by 4 times. Re-deterioration of cerebral circulation may occur 2-4 days or 2-3 weeks after CPR against the background of an almost complete restoration of CNS function - the syndrome of delayed posthypoxic encephalopathy. By the end of the 1st to the beginning of the 2nd day after CPR, there may be a repeated decrease in blood oxygenation associated with non-specific lung damage - respiratory distress syndrome (RDS) and the development of shunt-diffusion respiratory failure.
Complications of postresuscitation illness:
- in the first 2-3 days after CPR - swelling of the brain, lungs, increased bleeding of tissues;
- 3-5 days after CPR - violation of the functions of parenchymal organs, the development of overt multiple organ failure (MON);
- in later periods - inflammatory and suppurative processes. In the early postresuscitation period (1-2 weeks) intensive care
- carried out against the background of disturbed consciousness (somnolence, stupor, coma) IVL. Its main tasks in this period are the stabilization of hemodynamics and the protection of the brain from aggression.
Restoration of the BCP and the rheological properties of blood is carried out by hemodilutants (albumin, protein, dry and native plasma, reopoliglyukin, saline solutions, less often a polarizing mixture with the introduction of insulin at the rate of 1 unit per 2-5 g of dry glucose). Plasma protein concentration should be at least 65 g/L. Improving gas exchange is achieved by restoring the oxygen capacity of the blood (red blood cell transfusion), mechanical ventilation (with an oxygen concentration in the air mixture preferably less than 50%). With reliable restoration of spontaneous respiration and stabilization of hemodynamics, it is possible to carry out HBO, for a course of 5-10 procedures daily, 0.5 ATI (1.5 ATA) and platomin under the cover of antioxidant therapy (tocopherol, ascorbic acid, etc.). Maintaining blood circulation is provided by small doses of dopamine (1-3 mcg / kg per minute for a long time), carrying out maintenance cardiotrophic therapy (polarizing mixture, panangin). Normalization of microcirculation is provided effective pain relief with injuries, neurovegetative blockade, the introduction of antiplatelet agents (chimes 2-Zmg / kg, heparin up to 300 U / kg per day) and vasodilators (Cavinton up to 2 ml drip or trental 2-5 mg / kg per day drip, sermion, eufillin, nicotinic acid , complamin, etc.).
Antihypoxic therapy is carried out (Relanium 0.2-0.5 mg / kg, barbiturates at a saturation dose of up to 15 mg / kg for the 1st day, in the subsequent - up to 5 mg / kg, GHB mg / kg after 4-6 hours, enkephalins, opioids ) and antioxidant (vitamin E - 50% oil solution in dozemg / kg strictly intramuscularly daily, for a course of injections) therapy. To stabilize the membranes, normalize blood circulation, large doses of prednisolone, metipred (domg / kg) are prescribed intravenously as a bolus or fractional within 1 day.
Prevention of posthypoxic cerebral edema: cranial hypothermia, administration of diuretics, dexazone (0.5-1.5 mg/kg per day), 5-10% albumin solution.
The VEO, KOS and energy metabolism are being corrected. Detoxification therapy is carried out (infusion therapy, hemosorption, plasmapheresis according to indications) for the prevention of toxic encephalopathy and secondary toxic (autotoxic) organ damage. Intestinal decontamination with aminoglycosides. Timely and effective anticonvulsant and antipyretic therapy in young children prevents the development of post-hypoxic encephalopathy.
Prevention and treatment of bedsores is necessary (treatment camphor oil, curiosin in places with impaired microcirculation), nosocomial infection (asepsis).
In the case of a patient's rapid exit from a critical condition (in 1-2 hours), the complex of therapy and its duration should be adjusted depending on the clinical manifestations and the presence of post-resuscitation disease.
Treatment in the late post-resuscitation period
Therapy in the late (subacute) post-resuscitation period is carried out for a long time - months and years. Its main direction is the restoration of brain function. Treatment is carried out in conjunction with neuropathologists.
- The introduction of drugs that reduce metabolic processes in the brain is reduced.
- Prescribe drugs that stimulate metabolism: cytochrome C 0.25% (10-50 ml / day 0.25% solution in 4-6 doses, depending on age), actovegin, solcoseryl (0.4-2.0g intravenous drip for 5 % glucose solution for 6 hours), piracetam (10-50 ml / day), cerebrolysin (up to 5-15 ml / day) for older children intravenously during the day. Subsequently, encephabol, acephen, nootropil are prescribed orally for a long time.
- 2-3 weeks after CPR, a (primary or repeated) course of HBO therapy is indicated.
- Continue the introduction of antioxidants, antiplatelet agents.
- Vitamins of group B, C, multivitamins.
- Antifungal drugs (diflucan, ancotyl, candizol), biologics. Termination of antibiotic therapy as indicated.
- Membrane stabilizers, physiotherapy, exercise therapy (LFK) and massage according to indications.
- General strengthening therapy: vitamins, ATP, creatine phosphate, biostimulants, adaptogens for a long time.
The main differences between cardiopulmonary resuscitation in children and adults
Conditions preceding circulatory arrest
Bradycardia in a child respiratory disorders- a sign of circulatory arrest. Newborns, infants, and young children develop bradycardia in response to hypoxia, while older children develop tachycardia first. In newborns and children with a heart rate of less than 60 beats per minute and signs of low organ perfusion, if there is no improvement after the start of artificial respiration, closed heart massage should be performed.
After adequate oxygenation and ventilation, epinephrine is the drug of choice.
Blood pressure should be measured with a properly sized cuff, and invasive blood pressure measurement is indicated only when the child is extremely severe.
Since the blood pressure indicator depends on age, it is easy to remember the lower limit of the norm as follows: less than 1 month - 60 mm Hg. Art.; 1 month - 1 year - 70 mm Hg. Art.; more than 1 year - 70 + 2 x age in years. It is important to note that children are able to maintain pressure for a long time due to powerful compensatory mechanisms (increased heart rate and peripheral vascular resistance). However, hypotension is followed very quickly by cardiac and respiratory arrest. Therefore, even before the onset of hypotension, all efforts should be directed to the treatment of shock (manifestations of which are an increase in heart rate, cold extremities, capillary refill for more than 2 s, weak peripheral pulse).
Equipment and environment
Equipment size, drug dosage, and CPR parameters depend on age and body weight. When choosing doses, the age of the child should be rounded down, for example, at the age of 2 years, the dose for the age of 2 years is prescribed.
In newborns and children, heat transfer is increased due to the larger body surface relative to body weight and a small amount of subcutaneous fat. The ambient temperature during and after cardiopulmonary resuscitation should be constant, ranging from 36.5°C in neonates to 35°C in children. At a basal body temperature below 35 ° C, CPR becomes problematic (in contrast to the beneficial effect of hypothermia in the post-resuscitation period).
Airways
Children have structural features of the upper respiratory tract. The size of the tongue relative to the oral cavity is disproportionately large. The larynx is located higher and more inclined forward. The epiglottis is long. The narrowest part of the trachea is located below the vocal cords at the level of the cricoid cartilage, which makes it possible to use uncuffed tubes. The straight blade of the laryngoscope allows better visualization of the glottis, since the larynx is located more ventrally and the epiglottis is very mobile.
Rhythm disturbances
With asystole, atropine and artificial pacing are not used.
VF and VT with unstable hemodynamics occurs in % of cases of circulatory arrest. Vasopressin is not prescribed. When using cardioversion, the shock force should be 2-4 J/kg for a monophasic defibrillator. It is recommended to start at 2 J/kg and increase as needed to a maximum of 4 J/kg on the third shock.
Statistics show that cardiopulmonary resuscitation in children allows at least 1% of patients or victims of accidents to return to normal life.
Medical Expert Editor
Portnov Alexey Alexandrovich
Education: Kyiv National Medical University. A.A. Bogomolets, specialty - "Medicine"
Purpose of CPR in children
Primary resuscitation
Algorithm of actions during ventilation
Breathing and the normal functioning of the heart are functions that, when stopped, life leaves our body within a few minutes. First, a person falls into a state of clinical death, soon followed by biological death. The cessation of breathing and heartbeat strongly affects the tissues of the brain.
Metabolic processes in the brain tissues are so intense that the lack of oxygen is detrimental to them.
At the stage of clinical death of a person, it is quite possible to save if you correctly and promptly begin to provide the first emergency care. A set of methods aimed at restoring breathing and heart function is called cardiopulmonary resuscitation. There is a clear algorithm for conducting such rescue operations, which should be applied right at the scene. One of the latest and most comprehensive guidelines for dealing with respiratory and cardiac arrest is a guide issued by the American Heart Association in 2015.
Cardiopulmonary resuscitation in children is not much different from similar activities for adults, but there are nuances that you should be aware of. Cardiac and respiratory arrests are common in newborns.
A bit of physiology
After the breathing or heartbeat stops, oxygen stops flowing into the tissues of our body, which causes their death. The more complex the tissue is, the more intensively metabolic processes take place in it, the more detrimental it is to oxygen starvation.
The brain tissue suffers most of all, a few minutes after the oxygen supply is cut off, irreversible structural changes begin in them, which lead to biological death.
The cessation of breathing leads to a violation of the energy metabolism of neurons and ends with cerebral edema. Nerve cells begin to die about five minutes after this, it is during this period that assistance should be provided to the victim.
It should be noted that clinical death in children very rarely occurs due to problems with the work of the heart, much more often it occurs due to respiratory arrest. This important difference determines the characteristics of cardiopulmonary resuscitation in children. In children, cardiac arrest is usually the final stage of irreversible changes in the body and is caused by the extinction of its physiological functions.
First aid algorithm
The first aid algorithm for stopping the work of the heart and breathing in children is not much different from similar activities for adults. Resuscitation of children also consists of three stages, which were first clearly formulated by the Austrian physician Pierre Safari in 1984. After this moment, the rules for first aid have been repeatedly supplemented, there are basic recommendations issued in 2010, and there are later ones prepared in 2015 by the American Heart Association. The 2015 guide is considered the most complete and detailed.
Techniques for helping in such situations are often referred to as the "ABC rule". Here are the main steps to follow in accordance with this rule:
- Air way open. It is necessary to free the victim's airways from obstructions that can prevent air from entering the lungs (this paragraph translates as "open the way for air"). Vomit, foreign bodies, or a sunken root of the tongue can act as an obstacle.
- Breath for the victim. This item means that the victim needs to do artificial respiration (in translation: "breathing for the victim").
- Circulation his blood. The last item is a heart massage (“circulation of his blood”).
When resuscitating children, special attention should be paid to the first two points (A and B), since primary cardiac arrest is quite rare in them.
Signs of clinical death
You should be aware of the signs of clinical death, in which cardiopulmonary resuscitation is usually performed. In addition to stopping the heart and breathing, it is also dilated pupils, as well as loss of consciousness and areflexia.
The cessation of the heart can be detected very easily by checking the victim's pulse. It is best to do this on the carotid arteries. The presence or absence of breathing can be determined visually, or by placing a palm on the victim's chest.
After the cessation of blood circulation, loss of consciousness occurs within fifteen seconds. To verify this, turn to the victim, shake his shoulder.
Carrying out first aid
Resuscitation should begin with clearing the airways. For this, the child needs to be laid on its side. With a finger wrapped in a handkerchief or napkin, you need to clean the mouth and throat. The foreign body can be removed by tapping the victim on the back.
Another way is the Heimlich maneuver. It is necessary to clasp the body of the victim with your hands under the costal arch and sharply squeeze the lower part of the chest.
After clearing the airways, start artificial ventilation. To do this, it is necessary to push the lower jaw of the victim and open his mouth.
The most common method of artificial lung ventilation is the mouth-to-mouth method. It is possible to blow air into the victim's nose, but it is much more difficult to clean it than the oral cavity.
Then you need to close the victim's nose and inhale air into his mouth. The frequency of artificial breaths should correspond to physiological norms: for newborns it is about 40 breaths per minute, and for children aged five years - 24-25 breaths. You can put a napkin or handkerchief on the victim's mouth. Artificial ventilation of the lungs contributes to the inclusion of one's own respiratory center.
The last type of manipulation that is performed during cardiopulmonary resuscitation is an indirect heart massage. Heart failure is more often the cause of clinical death in adults, it is less common in children. But in any case, during the provision of assistance, you must ensure at least a minimum blood circulation.
Before starting this procedure, lay the victim on a hard surface. His legs should be slightly raised (about 60 degrees).
Then you should begin to strongly and vigorously squeeze the chest of the victim in the sternum. The point of effort in infants is right in the middle of the sternum, in older children it is slightly below the center. When massaging newborns, the point should be pressed with the tips of the fingers (two or three), in children from one to eight years old with the palm of one hand, in older ones - simultaneously with two palms.
It is clear that it is extremely difficult for one person to do both processes simultaneously. Before starting resuscitation, you need to call someone for help. In this case, everyone takes on one of the above tasks.
Try to time the time that the child has been unconscious. This information is then useful to doctors.
Previously, it was believed that 4-5 chest compressions should be done per breath. However, now experts believe that this is not enough. If you are resuscitating alone, then you are unlikely to be able to provide the necessary frequency of breaths and compressions.
In the event of the appearance of a pulse and independent respiratory movements of the victim, resuscitation should be stopped.
Features of cardiopulmonary resuscitation in children
Whoever saves one life saves the whole world
Mishnah Sanhedrin
Features of cardiopulmonary resuscitation in children of different ages, recommended by the European Council for Resuscitation, were published in November 2005 in three foreign journals: Resuscitation, Circulation and Pediatrics.
The sequence of resuscitation in children is broadly similar to that in adults, but when carrying out life support in children (ABC), points A and B are given special attention. this is the end of the process of gradual extinction of the physiological functions of the body, initiated, as a rule, by respiratory failure. Primary cardiac arrest is very rare, with ventricular fibrillation and tachycardia being the cause in less than 15% of cases. Many children have a relatively long "pre-stop" phase, which determines the need for early diagnosis of this phase.
Pediatric resuscitation consists of two stages, which are presented in the form of algorithmic schemes (Fig. 1, 2).
Restoration of airway patency (AP) in patients with loss of consciousness is aimed at reducing obstruction, common cause which is the retraction of the language. If the tone of the muscles of the lower jaw is sufficient, then tilting the head will cause the lower jaw to move forward and open the airways (Fig. 3).
In the absence of sufficient tone, the tilting of the head must be combined with the forward thrust of the lower jaw (Fig. 4).
However, in infants, there are features of performing these manipulations:
- do not tilt the head of the child excessively;
- do not squeeze the soft tissues of the chin, as this may cause airway obstruction.
After releasing the airways, it is necessary to check how effectively the patient is breathing: you need to look closely, listen, observe the movements of his chest and abdomen. Often, airway management and maintenance is sufficient for the patient to subsequently breathe efficiently.
The peculiarity of artificial lung ventilation in young children is determined by the fact that the small diameter of the child's respiratory tract provides a large resistance to the flow of inhaled air. To minimize airway pressure buildup and prevent gastric overdistension, breaths should be slow and the respiratory rate determined by age (Table 1).
Sufficient volume of each breath is the volume that provides adequate movement of the chest.
Make sure of the adequacy of breathing, the presence of cough, movements, pulse. If signs of circulation are present, continue breathing support; if there is no circulation, begin chest compressions.
In children under one year of age, the person providing assistance tightly and tightly captures the nose and mouth of the child with his mouth (Fig. 5)
in older children, the resuscitator first pinches the patient's nose with two fingers and covers his mouth with his mouth (Fig. 6).
In pediatric practice, cardiac arrest is usually secondary to airway obstruction, which is most often caused by a foreign body, infection, or allergic process leading to airway edema. Differential diagnosis between airway obstruction caused by a foreign body and infection is very important. Against the background of an infection, the steps to remove the foreign body are dangerous, as they can lead to an unnecessary delay in the transport and treatment of the patient. In patients without cyanosis, with adequate ventilation, coughing should be stimulated, it is not advisable to use artificial respiration.
The technique for eliminating airway obstruction caused by a foreign body depends on the age of the child. Blind finger cleaning of the upper airways in children is not recommended, as at this point the foreign body can be pushed deeper. If the foreign body is visible, it can be removed using a Kelly forceps or Mejil forceps. Pressure on the abdomen is not recommended for children under one year old, since there is a threat of organ damage. abdominal cavity especially the liver. A child at this age can be helped by holding him on the arm in the position of the "rider" with his head lowered below the body (Fig. 7).
The child's head is supported by a hand around the lower jaw and chest. On the back between the shoulder blades, four blows are quickly applied with the proximal part of the palm. Then the child is laid on his back so that the victim's head is lower than the body during the entire reception and four chest compressions are performed. If the child is too large to be placed on the forearm, it is placed on the thigh with the head lower than the torso. After cleaning the airways and restoring their free patency in the absence of spontaneous breathing, artificial ventilation of the lungs is started. In older children or adults with obstruction of the airways by a foreign body, it is recommended to use the Heimlich maneuver - a series of subdiaphragmatic pressures (Fig. 8).
Emergency cricothyrotomy is one of the options for maintaining airway patency in patients who fail to intubate the trachea.
As soon as the airways are freed and two test breathing movements are performed, it is necessary to establish whether the child had only respiratory arrest or cardiac arrest at the same time - determine the pulse on the large arteries.
In children under one year old, the pulse is measured on the brachial artery (Fig. 9)
Since the short and wide neck of the baby makes it difficult to quickly find the carotid artery.
In older children, as in adults, the pulse is measured on the carotid artery (Fig. 10).
When the child has a pulse, but there is no effective ventilation, only artificial respiration is performed. The absence of a pulse is an indication for cardiopulmonary bypass using a closed heart massage. Closed heart massage should never be performed without mechanical ventilation.
The recommended chest compression area for newborns and infants is a finger's width below the intersection of the nipple line and sternum. In children under one year old, two methods of performing closed heart massage are used:
- the location of two or three fingers on the chest (Fig. 11);
- covering the child's chest with the formation of a rigid surface of four fingers on the back and using thumbs to perform compressions.
The compression amplitude is approximately 1/3-1/2 of the anteroposterior size of the child's chest (Table 2).
If the child's thumb and three fingers do not create adequate compression, then to conduct a closed heart massage, you need to use the proximal part of the palmar surface of the hand of one or two hands (Fig. 12).
The speed of compressions and their ratio to breathing depends on the age of the child (see Table 2).
Mechanical chest compressions have been extensively used in adults but not in children due to the very high incidence of complications.
Precordial impact should never be used in pediatric practice. In older children and adults, it is considered an optional appointment when the patient has no pulse and the defibrillator cannot be used quickly.
Read more articles on helping children in different situations
Algorithm of actions for cardiopulmonary resuscitation in children, its purpose and varieties
Restoring the normal functioning of the circulatory system, maintaining air exchange in the lungs is the primary goal of cardiopulmonary resuscitation. Timely resuscitation measures allow avoiding the death of neurons in the brain and myocardium until blood circulation is restored and breathing becomes independent. Cardiac arrest in a child due to a cardiac cause is extremely rare.
For infants and newborns, the following causes of cardiac arrest are distinguished: suffocation, SIDS - sudden infant death syndrome, when an autopsy cannot establish the cause of termination of life, pneumonia, bronchospasm, drowning, sepsis, neurological diseases. In children after twelve months, death occurs most often due to various injuries, strangulation due to illness or a foreign body entering the respiratory tract, burns, gunshot wounds, drowning.
Purpose of CPR in children
Doctors divide little patients into three groups. The algorithm for resuscitation is different for them.
- Sudden circulatory arrest in a child. Clinical death during the entire period of resuscitation. Three main outcomes:
- CPR ended with a positive outcome. At the same time, it is impossible to predict what the patient's condition will be after the clinical death he has suffered, how much the functioning of the body will be restored. There is a development of the so-called postresuscitation disease.
- The patient does not have the possibility of spontaneous mental activity, the death of brain cells occurs.
- Resuscitation does not bring positive result, doctors ascertain the death of the patient.
- The prognosis is unfavorable during cardiopulmonary resuscitation in children with severe trauma, in a state of shock, and complications of a purulent-septic nature.
- Resuscitation of a patient with oncology, anomalies in the development of internal organs, severe injuries, if possible, is carefully planned. Immediately proceed to resuscitation in the absence of a pulse, breathing. Initially, it is necessary to understand whether the child is conscious. This can be done by shouting or lightly shaking, while avoiding sudden movements of the patient's head.
Indications for resuscitation - sudden circulatory arrest Primary resuscitation
CPR in a child includes three stages, which are also called ABC - Air, Breath, Circulation:
- Air way open. The airway needs to be cleared. Vomiting, retraction of the tongue, foreign body may be an obstruction in breathing.
- Breath for the victim. Carrying out measures for artificial respiration.
- Circulation his blood. Closed heart massage.
When performing cardiopulmonary resuscitation of a newborn baby, the first two points are most important. Primary cardiac arrest in young patients is uncommon.
Ensuring the child's airway
The first stage is considered the most important in the CPR process in children. The algorithm of actions is the following.
The patient is placed on his back, neck, head and chest are in the same plane. If there is no trauma to the skull, it is necessary to throw back the head. If the victim has an injured head or upper cervical region, it is necessary to push the lower jaw forward. In case of loss of blood, it is recommended to raise the legs. Violation of the free flow of air through the respiratory tract in an infant may be aggravated by excessive bending of the neck.
The reason for the ineffectiveness of measures for pulmonary ventilation may be the incorrect position of the child's head relative to the body.
If there are foreign objects in the oral cavity that make breathing difficult, they must be removed. If possible, tracheal intubation is performed, an airway is inserted. If it is impossible to intubate the patient, mouth-to-mouth and mouth-to-nose and mouth-to-mouth breathing is performed.
Algorithm of actions for ventilation of the lungs "mouth to mouth" Solving the problem of tilting the patient's head is one of the primary tasks of CPR.
Airway obstruction leads to cardiac arrest in the patient. This phenomenon causes allergies, inflammatory infectious diseases, foreign objects in the mouth, throat or trachea, vomit, blood clots, mucus, sunken tongue of the child.
Algorithm of actions during ventilation
Optimal for the implementation of artificial ventilation of the lungs will be the use of an air duct or a face mask. If it is not possible to use these methods, an alternative course of action is to actively blow air into the nose and mouth of the patient.
To prevent the stomach from stretching, it is necessary to ensure that there is no excursion of the peritoneum. Only the volume of the chest should decrease in the intervals between exhalation and inhalation when carrying out measures to restore breathing.
When carrying out the procedure of artificial ventilation of the lungs, the following actions are carried out. The patient is placed on a hard, flat surface. The head is slightly thrown back. Observe the child's breathing for five seconds. In the absence of breathing, take two breaths lasting one and a half to two seconds. After that, stand for a few seconds to release air.
When resuscitating a child, inhale air very carefully. Careless actions can provoke a rupture of lung tissue. Cardiopulmonary resuscitation of the newborn and infant is carried out using the cheeks for blowing air. After the second inhalation of air and its exit from the lungs, a heartbeat is probed.
Air is blown into the lungs of a child eight to twelve times per minute with an interval of five to six seconds, provided that the heart is functioning. If the heartbeat is not established, they proceed to indirect heart massage, other life-saving actions.
It is necessary to carefully check for the presence of foreign objects in the oral cavity and upper respiratory tract. This kind of obstruction will prevent air from entering the lungs.
The sequence of actions is as follows:
- the victim is placed on the arm bent at the elbow, the baby's torso is above the level of the head, which is held with both hands by the lower jaw.
- after the patient is laid in the correct position, five gentle strokes are made between the patient's shoulder blades. The blows must have a directed action from the shoulder blades to the head.
If the child cannot be placed in the correct position on the forearm, then the thigh and the leg bent at the knee of the person involved in resuscitation of the child are used as a support.
Closed heart massage and chest compressions
Closed massage of the heart muscle is used to normalize hemodynamics. It is not carried out without the use of IVL. Due to the increase in intrathoracic pressure, blood is ejected from the lungs into the circulatory system. The maximum air pressure in the lungs of a child falls on the lower third of the chest.
The first compression should be a trial, it is carried out to determine the elasticity and resistance of the chest. The chest is squeezed during a heart massage by 1/3 of its size. Chest compression is performed differently for different age groups of patients. It is carried out due to pressure on the base of the palms.
Features of cardiopulmonary resuscitation in children
Features of cardiopulmonary resuscitation in children are that it is necessary to use fingers or one palm for compression due to the small size of patients and fragile physique.
- Infants are pressed on the chest only with their thumbs.
- For children from 12 months to eight years old, massage is performed with one hand.
- For patients older than eight years, both palms are placed on the chest. like adults, but measure the force of pressure with the size of the body. The elbows of the hands during the massage of the heart remain in a straightened state.
There are some differences in CPR that is cardiac in nature in patients over 18 years of age and that resulting from strangulation in children. cardiopulmonary insufficiency, therefore resuscitators are advised to use a special pediatric algorithm.
Compression-ventilation ratio
If only one physician is involved in resuscitation, he should deliver two breaths of air into the patient's lungs for every thirty compressions. If two resuscitators are working at the same time - compression 15 times for every 2 air injections. When using a special tube for IVL, a non-stop heart massage is performed. The frequency of ventilation in this case is from eight to twelve beats per minute.
A blow to the heart or a precordial blow in children is not used - the chest can be seriously affected.
The frequency of compressions is from one hundred to one hundred and twenty beats per minute. If the massage is performed on a child under 1 month old, then you should start with sixty beats per minute.
Remember that the child's life is in your hands. CPR should not be stopped for more than five seconds. 60 seconds after the start of resuscitation, the doctor should check the patient's pulse. After that, the heartbeat is checked every two to three minutes at the moment the massage is stopped for 5 seconds. The state of the pupils of the reanimated indicates his condition. The appearance of a reaction to light indicates that the brain is recovering. Persistent dilation of the pupils is an unfavorable symptom. If it is necessary to intubate the patient, do not stop resuscitation for more than 30 seconds.
CPR in children
Guidelines for resuscitation published by the European Resuscitation Council
Section 6. Resuscitation in children
Introduction
Background
The European Resuscitation Council (ERC) has previously issued a Guide to Pediatric Resuscitation (PLS) in 1994, 1998 and 2000. The latest edition was created on the basis of the final recommendations of the International Scientific Consensus, published by the American Heart Association in collaboration with the International Conciliation Committee on Resuscitation (ILCOR); it included separate recommendations on cardiopulmonary resuscitation and emergency cardiac care, published in the "Guideline 2000" in August 2000. Following the same principle in 2004-2005. The final conclusions and practical recommendations of the Consensus Meeting were first published simultaneously in all leading European publications on this topic in November 2005. The Working Group of the Pediatrics Section (PLS) of the European Council for Resuscitation reviewed this document and relevant scientific publications and recommended that changes be made to the pediatric section of the Guidelines. These changes are presented in this edition.
Changes made to this manual
The changes were made in response to new evidence-based scientific evidence, as well as the need to simplify practices as much as possible, which facilitates learning and maintaining these techniques. As in previous editions, there is a lack of evidence from direct pediatric practice, and some conclusions are drawn from animal simulations and extrapolation of adult outcomes. The emphasis in this guide is on simplification, based on the fact that many children do not receive any resuscitation care for fear of harm. This fear is supported by the notion that resuscitation techniques in children are different from those used in adult practice. Based on this, many studies have clarified the possibility of using the same methods of resuscitation in adults and children. On-scene resuscitation by bystanders significantly increases survival, and it has been clearly shown in young animal simulations that chest compressions or ventilations alone can be much more beneficial than doing nothing at all. Thus, survival can be increased by teaching bystanders how to use resuscitation techniques, even if they are not familiar with resuscitation in children. Of course, there are differences in the treatment of predominantly cardiac in origin in adults, and asphyxial in children, acute pulmonary heart failure, therefore, a separate pediatric algorithm is recommended for use in professional practice.
Compression-ventilation ratio
ILCOR recommends different compression-ventilation ratios depending on the number of caregivers. For non-professionals trained in only one technique, a ratio of 30 compressions to 2 ventilatory exhalations, that is, the use of adult resuscitation algorithms, is suitable. Professional rescuers, two or more in a group, should use a different ratio - (15:2), as the most rational for children, obtained as a result of experiments with animals and dummies. Professional physicians should be familiar with the peculiarities of resuscitation techniques for children. A ratio of 15:2 has been found to be optimal in animal, mannequin and mathematical model studies using various ratios ranging from 5:1 to 15:2; the results did not deduce an optimal compression-ventilation ratio, but indicated that a 5:1 ratio was the least suitable for use. Because it has not been shown that different resuscitation techniques are needed for children over and under 8 years of age, the ratio of 15:2 was chosen as the most logical for professional rescue teams. For non-professional rescuers, regardless of the number of participants in the care, it is recommended to adhere to a ratio of 30:2, which is especially important if the rescuer is alone and it is difficult for him to switch from compression to ventilation.
Dependence on the age of the child
The use of various resuscitation techniques for children over and under 8 years of age, as recommended by previous guidelines, has been recognized as inappropriate, and restrictions on the use of automatic external defibrillators (AEDs) have also been removed. The reason for the different tactics of resuscitation in adults and children is etiological; adults are characterized by primary cardiac arrest, while in children it is usually secondary. A sign of the need to switch to resuscitation tactics used in adults is the onset of puberty, which is the most logical indicator of the end of the physiological period of childhood. This approach facilitates recognition, since the age at the start of resuscitation is often unknown. At the same time, it is obvious that there is no need to formally determine the signs of puberty, if the rescuer sees a child in front of him, he needs to use the pediatric resuscitation technique. If the tactics of child resuscitation are applied in early adolescence, this will not bring harm to health, since studies have proven the commonality of the etiology of pulmonary heart failure in childhood and early adolescence. Childhood should be considered the age from one year to the period of puberty; age up to 1 year should be considered infantile, and at this age the physiology is significantly different.
chest compression technique
Simplified recommendations for choosing the area on the chest for the application of compression force for different ages. It is recognized that it is advisable to use the same anatomical landmarks for infants (children under one year old) as for older children. The reason for this is that following previous guidelines sometimes resulted in compression in the upper abdomen. The technique for performing compression in infants remains the same - using two fingers if there is only one rescuer; and using the thumbs of both hands with a chest grip if there are two or more rescuers, but for older children there is no distinction between one-handed and two-handed techniques. In all cases it is necessary to achieve a sufficient depth of compression with minimal interruptions.
Automated external defibrillators
Publication data since the 2000 Guidelines have reported safe and successful use of AEDs in children under 8 years of age. Moreover, recent data show that AEDs accurately detect arrhythmias in children, and there is very little chance of mistimed or incorrect shock delivery. Therefore, AED is now recommended for all children older than 1 year of age. But any device that suggests the possibility of using it for arrhythmias in children must undergo appropriate testing. Many manufacturers today equip the devices with pediatric electrodes and programs that involve adjusting the discharge in the range of 50-75 J. Such devices are recommended for use in children from 1 to 8 years old. In the absence of a device equipped with such a system or the possibility of manual adjustment, an unmodified adult model can be used in children over one year old. For children under 1 year of age, the use of AEDs is questionable as there is not enough evidence either for or against such use.
Manual (non-automatic) defibrillators
The 2005 Consensus Conference recommended prompt defibrillation for children with ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). Adult life resuscitation (ALS) tactics involve delivering a single shock with immediate resumption of CPR without pulse detection and return to rhythm (see Section 3). When using a monophasic shock, it is recommended to use the first shock of a higher power than previously recommended - 360, and not 200J. (See Section 3). The ideal shock rate for children is not known, but animal models and a small amount of pediatric data show that more than 4 J/kg-1 delivers a good defibrillation effect with few side effects. Bipolar discharges are at least more effective and less disruptive to the myocardium. To simplify the technique of the procedure and in accordance with recommendations for adult patients, we recommend the use of a single defibrillating shock (mono- or biphasic) in children with a dose not exceeding 4 J/kg.
Algorithm of actions in case of airway obstruction by a foreign body
The algorithm of actions for airway obstruction by a foreign body in children (FBAO) was simplified as much as possible and as close as possible to the algorithm used in adult patients. The changes made are discussed in detail at the end of this section.
6a Basic life support in children.
Sequencing
Rescuers trained in basic adult resuscitation and unfamiliar with pediatric resuscitation techniques can use the adult resuscitation technique, with the difference that it is necessary to deliver at the beginning of 5 rescue breaths before starting CPR (see Figure 6.1) 
Rice. 6.1 Algorithm for basic resuscitation in pediatrics. All healthcare professionals should know this UNRESPONSIVE? - Check for consciousness (reacting or not?) Shout for help - Call for help Open airway - clear the airways NOT BREATHING NORMALLY? - Check breathing (adequate or not?) 5 rescue breaths - 5 rescue breaths STILL UNRESPONSIVE? (no signs of a circulation) 15 chest compressions 15 chest compressions 2 rescue breaths After 1 minute call resuscitation team then continue CPR resuscitation The sequence of actions recommended for professionals in pediatric resuscitation: 1 Ensure the safety of the child and others
Gently shake your child and ask out loud, "Are you all right?"
Don't rub your baby if you suspect a neck injury
3a If the child responds with speech or movement
Leave the child in the position in which you found him (so as not to aggravate the damage)
Re-evaluate his condition periodically
3b If the child does not respond, then
first, without changing the position of the child, put your hand on his forehead and tilt his head back;
at the same time put your finger in the chin fossa and lift the jaw. Do not press on the soft tissues below the chin, as this may block the airways;
if opening the airway fails, use the jaw extraction method. Taking the corners of the lower jaw with two fingers of both hands, lift it;
both techniques are facilitated if the child is carefully placed on his back.
loudly call for help;
open his airway by tilting his head back and raising his chin as follows:
If a neck injury is suspected, open the airway by retraction of the mandible alone. If this is not enough, very gradually, in dosed movements, tilt your head back until the airways open.
4 While securing the airway, listen and feel the baby's breathing by bringing your head close to him and following the movement of his chest.
See if your chest is moving.
Listen to see if the child is breathing.
Try to feel his breath on your cheek.
Evaluate visually, aurally and tactilely for 10 seconds to assess the state of breathing
5a If the child is breathing normally
Place the child in a stable side position (see below)
Keep checking for breath
5b If the child is not breathing, or his breathing is agonal (rare and irregular)
carefully remove anything that interferes with breathing;
give five initial rescue breaths;
during their conduct, watch for the possible appearance of coughing or gagging. This will determine your next steps, which are described below.
Resuscitation breathing for a child older than 1 year is performed as shown in Fig. 6.2.
Do a head tilt and chin up.
Pinch the soft tissues of the nose with the thumb and forefinger of the hand lying on the forehead of the child.
Open his mouth slightly, keeping his chin up.
Inhale and, clasping the child's mouth with your lips, make sure the contact is tight.
Exhale uniformly into the respiratory tract for 1-1.5 seconds, watching the response movement of the chest.
Leaving the baby's head in the tilted position, follow the lowering of his chest as you exhale.
Inhale again and repeat everything in the same sequence up to 5 times. Monitor the effectiveness with a sufficient amount of movement of the child's chest - as with normal breathing.
Rice. 6.2 Mouth-to-mouth ventilation in a child older than one year.
Resuscitation breathing in an infant is carried out, as shown in Fig. 6.3.
Make sure your head is in a neutral position and your chin is up.
Inhale and cover the baby's mouth and nasal passages with your lips, make sure the contact is tight. If the child is large enough and it is not possible to cover the mouth and nasal passages at the same time, only mouth-to-mouth or mouth-to-nose breathing can be used (while closing the child's lips).
Exhale evenly into the airways for 1-1.5 seconds, tracking the subsequent movement of his chest.
Leaving the child's head in the tilted position, evaluate the movement of his chest during exhalation.
Take another breath and repeat the ventilation in the same sequence up to 5 times.
Rice. 6.3 Ventilation mouth-to-mouth and nose in a child up to a year.
If the required breathing efficiency is not achieved, airway obstruction is possible.
Open the child's mouth and remove anything that might interfere with his breathing. Don't do blind cleansing.
Make sure that the head is thrown back and the chin is raised, while there is no overextension of the head.
If tilting the head back and raising the jaw does not open the airway, try moving the jaw around its corners.
Perform five ventilatory breath attempts. If they are ineffective, move on to chest compressions.
If you are a professional, determine the pulse, but do not spend more than 10 seconds on it.
If the child is older than 1 year, check for carotid pulsation. If it is an infant, take the pulse at the radial artery above the elbow.
7a If within 10 seconds you can unambiguously determine the signs of the presence of blood circulation
Continue rescue breathing for as long as necessary until the child has adequate spontaneous breathing.
Turn the child on its side (into the recovery position) if still unconscious
Constantly re-evaluate the child's condition
7b If there are no signs of circulation, or the pulse is not detected, or it is too sluggish and less often than 60 beats / min, -1 weak filling, or not determined confidently
start chest compressions
combine chest compressions with ventilatory breathing.
Chest compression is performed as follows: pressure is applied to the lower third of the sternum. To avoid compression of the upper abdomen, position xiphoid process at the point of convergence of the lower ribs. The pressure point is located on the tire of one finger above it; compression should be deep enough - about a third of the thickness of the chest. Start pressing at a rate of about 100/min-1. After 15 compressions, tilt the child's head back, raise the chin, and take 2 effective breaths. Continue compressions and breathing at a ratio of 15:2, and if you are alone at 30:2, especially if at a compression rate of 100/min, the actual number of shocks produced will be less due to breath breaks. The optimal compression technique for infants and children is slightly different. In infants, conduction is performed by pressure on the sternum with the tips of two fingers. (Fig. 6.4). If there are two or more rescuers, the girth technique is used. Place your thumbs on the lower third of the sternum (as above), pointing the fingertips towards the baby's head. Grasp the child's chest with the fingers of both hands so that the fingertips support his back. Press your thumbs on the sternum to about a third of the thickness of the chest.
Rice. 6.4 Chest compression in a child under one year old. To perform chest compressions on a child older than one year, place the base of the palm of your hand on the lower third of the child's sternum. (Fig. 6.5 and 6.6). Raise your fingers so that there is no pressure on the baby's ribs. Stand vertically above the child's chest and, with your arms extended, compress the lower third of the sternum to a depth of approximately one third of the thickness of the chest. In adult children or with a small mass of the rescuer, this is easier to do by interlacing the fingers. 
Rice. 6.5 Chest compression in a child under one year old. 
Rice. 6.6 Chest compression in a child under one year old.
8 Continue resuscitation until
The child retains signs of life (spontaneous breathing, pulse, movement)
Until qualified help arrives
Until complete exhaustion sets in
When to call for help
If the child is unconscious, call for help as soon as possible.
If two people are involved in resuscitation, then one starts resuscitation, while the second goes to call for help.
If there is only one rescuer, it is necessary to carry out resuscitation within one minute before going to call for help. To reduce interruptions in compression, you can take an infant or small child with you when calling for help.
Only in one case can you immediately leave for help without resuscitation for a minute - if someone saw that the child suddenly lost consciousness, and there was only one rescuer. In this case, acute heart failure is most likely arrhythmogenic, and the child needs urgent defibrillation. If you are alone, go for help immediately.
restorative position
An unconscious child with an airway that is still open and spontaneously breathing should be placed in the recovery position. There are several variants of such provisions, each has its supporters. It is important to follow the following principles:
Features of cardiopulmonary resuscitation in children
Under sudden cardiac arrest understand the clinical syndrome, which is characterized by the disappearance of signs of cardiac activity (the cessation of pulsation in the femoral and carotid arteries, the absence of heart sounds), as well as the arrest of spontaneous breathing, loss of consciousness and dilated pupils. and symptoms are the most important diagnostic criteria for cardiac arrest, which can be predicted or sudden. foreseen heart failure can be observed in the terminal state, which means the period of extinction of the vital activity of the organism. The terminal state may result from critical disorder homeostasis due to disease or inability of the body to adequately respond to external influences (trauma, hypothermia, overheating, poisoning, etc.). Cardiac arrest and circulatory failure may be associated with asystole, ventricular fibrillation, and collapse. Heart failure always accompanied by respiratory arrest; like sudden apnea associated with airway obstruction, CNS depression, or neuromuscular paralysis, it can result in cardiac arrest.
Without wasting time on finding out the cause of cardiac arrest or breathing, they immediately begin treatment, including the following set of measures: cardiac arrest resuscitation defibrillation
- 1. Lower the head end of the bed, raise the lower limbs, create access to the chest and head.
- 2. To ensure the patency of the airways, the head is slightly thrown back, the lower jaw is lifted up and 2 slow blows of air into the lungs of the child are made (1 - 1.5 s per 1 breath). Inspiratory volume should provide minimal chest excursion. Forced air insufflation causes gastric distension, which drastically impairs the effectiveness of resuscitation! Blowing is carried out by any method - "from mouth to mouth", "mouth - mask" or breathing devices "bag - mask", "fur - mask" are used. If the blowing of air does not have an effect, then it is necessary to improve the patency of the airways, giving them a more appropriate anatomical location by extending the head. If this manipulation also did not give an effect, then it is necessary to free the airways from foreign bodies and mucus, continue breathing at a frequency of 20-30 per 1 min.
- 3. Using 2 or 3 fingers of the right hand, press on the sternum in a place located 1.5 - 2 cm below the intersection of the sternum with the nipple line. In newborns and infants, pressure on the sternum can be done by placing the thumbs of both hands in the indicated place, clasping the chest with palms and fingers. The depth of deflection of the sternum inward is from 0.5 to 2.5 cm, the frequency of pressure is at least 100 times per 1 min, the ratio of pressure and artificial respiration is 5:1. Heart massage is carried out by placing the patient on a hard surface, or placing an infant under the back left hand. In newborns and infants, an asynchronous method of ventilation and massage is acceptable without observing pauses for breaths, which increases minute blood flow.
Performance criteria resuscitation- the appearance of a distinct pulsation in the femoral and carotid arteries, constriction of the pupils. It is advisable to perform emergency tracheal intubation and implant ECG monitoring of cardiac activity.
If against the backdrop of ongoing heart massage and mechanical ventilation, cardiac activity is not restored, then 0.01 mg / kg of adrenaline hydrochloride (epinephrine) is administered intravenously, then sodium bicarbonate - 1 - 2 mmol / kg. If intravenous administration is not possible, then at least resort to intracardiac, sublingual or endotracheal administration of drugs. The feasibility of using calcium preparations during resuscitation is currently questioned. To maintain cardiac activity after its resumption, dopamine or dobutamine (dobutrex) is administered - 2-20 mcg / kg per 1 minute. In case of ventricular fibrillation, lidocaine is prescribed - 1 mg / kg intravenously, if there is no effect, emergency electrical defibrillation is indicated (2 W / kg in 1 s). If necessary, it is done again - 3 - 5 W / kg in 1 s.
Maintenance therapy consists in the use of mechanical ventilation in the mode of constant or variable positive outlet pressure to maintain Pa0 2 at the level of 9.3 - 13.3 kPa (70 - 100 mm Hg) and PaCO 2 within 3.7-4 kPa (28-30 mm Hg). With bradycardia, isoproterenol is administered - at 0.05 - 1.5 μg / kg per 1 minute, if it is ineffective, an artificial pacemaker is used. If resuscitation lasts more than 15 minutes or the pre-resuscitation period lasts more than 2 minutes, then measures are taken to prevent cerebral edema. Enter mannitol - 1 g / kg, dexazon - 1 mg / kg with an interval of 6 hours. Hyperventilation is advisable to achieve PaCO 2 within 3.7 kPa (28 mm Hg). Nifedipine is administered at a dose of 1 mg/kg for six days under the control of blood pressure. Assign thiopental-sodium - 3 - 5 mg / kg intravenously under the control of respiratory rate (remember the negative inotropic effect of the drug). Mandatory monitoring of vital signs of heart rate, CVP, blood pressure, body temperature. Control of urination and state of consciousness is very important. EEG control and ECG monitoring is carried out until the stabilization of cardiac activity and respiration.
Contraindications for resuscitation:
- 1. Terminal conditions due to an incurable disease.
- 2. Severe irreversible diseases and brain damage, hospitalization is carried out in the intensive care unit.
Hospitalization is carried out in the intensive care unit.
Primary cardiac arrest in children is much less common than in adults. Less than 10% of all cases of clinical death in children are caused by ventricular fibrillation. Most often it is the result congenital pathology.
Trauma is the most common cause of CPR in children.
Cardiopulmonary resuscitation in children has certain features.
When breathing "from mouth to mouth" it is necessary to avoid excessively deep breaths (that is, exhalation of the resuscitator). An indicator can be the volume of chest wall excursion, which is labile in children and its movements are well controlled visually. Foreign bodies cause airway obstruction in children more often than in adults.
In the absence of spontaneous breathing in a child, after 2 artificial breaths, it is necessary to begin cardiac massage, since in apnea, cardiac output is usually inadequately low, and palpation of the carotid pulse in children is often difficult. It is recommended to palpate the pulse on the brachial artery.
It should be noted that the absence of a visible apex beat and the impossibility of its palpation do not yet indicate cardiac arrest.
If there is a pulse, but there is no spontaneous breathing, then the resuscitator should take approximately 20 breaths per 1 minute until spontaneous breathing is restored or more modern ventilation methods are used. If there is no pulsation of the central arteries, cardiac massage is necessary.
Compression of the chest in a small child is performed with one hand, and the other is placed under the child's back. In this case, the head should not be higher than the shoulders. The place of application of force in young children is the lower part of the sternum. Compression is carried out with 2 or 3 fingers. The amplitude of movement should be 1-2.5 cm, the frequency of compressions should be approximately 100 per 1 min. Just like in adults, you need to pause for ventilation. The ventilation to compression ratio is also 1:5. Approximately every 3 to 5 minutes check for the presence of spontaneous cardiac contractions. Hardware compression in children, as a rule, is not used. The use of an anti-shock suit in children is not recommended.
If open heart massage in adults is considered more effective than closed heart massage, then in children there is no such advantage of direct massage. Apparently, this is due to the good compliance of the chest wall in children. Although in some cases, if indirect massage is ineffective, direct massage should be resorted to. With the introduction of drugs into the central and peripheral veins, such a difference in the speed of onset of the effect in children is not observed, but if possible, then catheterization of the central vein should be performed. The onset of action of drugs administered intraosseously to children is comparable in time to intravenous administration. This route of administration can be used in cardiopulmonary resuscitation, although complications (osteomyelitis, etc.) may occur. There is a risk of microfat pulmonary embolism with intraosseous injection, but clinically this is not of particular importance. Endotracheal administration of fat-soluble drugs is also possible. It is difficult to recommend a dose due to the large variability in the rate of absorption of drugs from the tracheobronchial tree, although it seems likely that the intravenous dose of epinephrine should be increased 10 times. The dose of other drugs should also be increased. The drug is injected deep into the tracheobronchial tree through a catheter.
Intravenous fluid administration during cardiopulmonary resuscitation in children is more important than in adults, especially in severe hypovolemia (blood loss, dehydration). Children should not be administered glucose solutions (even 5%), because large volumes of glucose-containing solutions lead to hyperglycemia and an increase in neurological deficit faster than in adults. In the presence of hypoglycemia, it is corrected with a glucose solution.
The most effective drug in circulatory arrest is epinephrine at a dose of 0.01 mg/kg (endotracheally 10 times more). If there is no effect, it is administered again after 3-5 minutes, increasing the dose by 2 times. In the absence of effective cardiac activity, continue intravenous infusion adrenaline at a rate of 20 mcg / kg per minute, with the resumption of heart contractions, the dose is reduced. With hypoglycemia, drip infusions of 25% glucose solutions are necessary, bolus injections should be avoided, since even short-term hyperglycemia can adversely affect the neurological prognosis.
Defibrillation in children is used for the same indications (ventricular fibrillation, ventricular tachycardia with no pulse) as in adults. In young children, electrodes of a slightly smaller diameter are used. The initial discharge energy should be 2 J/kg. If this value of the discharge energy is insufficient, the attempt must be repeated with a discharge energy of 4 J/kg. The first 3 attempts should be made at short intervals. If there is no effect, hypoxemia, acidosis, hypothermia are corrected, adrenaline hydrochloride, lidocaine are administered.
Currently, the Apgar score as a criterion for indications for resuscitation is subject to revision, however, it is quite acceptable to evaluate the effectiveness of resuscitation and the dynamics on this scale. The point is that in order to quantification the state of the newborn should be waited for a whole (!) minute, while resuscitation should be started in the first 20 seconds, and by the end of the 1st minute, an Apgar score should be given. If it is less than 7 points, then in the future, an assessment should be made every 5 minutes until the condition is assessed at 8 points (G. M. Dementieva et al., 1999).
It should be noted that the algorithms for resuscitation remain basically the same as in adults. However, there are differences in the performance of individual techniques due to the anatomical and physiological characteristics of newborns. resuscitation measures ( principles A, B, C according to P. Safar) are as follows:
A - ensuring the patency of the respiratory tract;
B - restoration of breathing;
C - restoration and maintenance of hemodynamics.
When principle A is followed, the correct position of the newborn is ensured, suction of mucus or amniotic fluid from the oropharynx and trachea, and tracheal intubation.
The implementation of principle B involves various methods of tactile stimulation with a jet supply of oxygen through a mask, and artificial ventilation of the lungs.
The implementation of principle C involves indirect heart massage and drug stimulation.
Carrying out IVL necessary if the child does not respond to tactile stimulation, while maintaining bradycardia and pathological types of breathing. Positive pressure ventilation can be performed using special breathing bags (Ambu bag), masks or an endotracheal tube. A feature of the bags is the presence of a relief valve, usually at pressures exceeding 35-40 cm of water. Art. Breathing is carried out at a frequency of 40-60 per minute. It is important to provide the first 2-3 breaths with a pressure of 40 cm of water. Art. This should ensure good expansion of the lungs, reabsorption of the intraalveolar fluid by the lymphatic and circulatory systems. Further breaths can be taken with a peak pressure of 15-20 cm of water. Art.
When effective cardiac activity (>100 beats per minute) and spontaneous breathing are restored, ventilation can be turned off, leaving only oxygenation.
If spontaneous breathing is not restored, then ventilation should be continued. If the heart rate tends to increase (up to 100-120 per minute), then ventilation should be continued. The presence of persistent bradycardia (less than 80 per minute) is an indication for mechanical ventilation.
Considering the possibility of overdistension by the oxygen-air mixture of the stomach with subsequent aspiration, it is necessary to insert a gastric tube and keep it open.
The correct selection of the diameter of the endotracheal tube is very important for tracheal intubation. With body weight less than 1000 g - 2.5 mm; 1000-2000 g - 3.0 mm; 2000-3000 g - 3.5 mm; more than 3000 - 3.5-4 mm. The intubation itself should be as gentle as possible and be completed within 15-20 seconds. It should be remembered that manipulations in the vocal cords may be accompanied by unwanted vagal reflexes. In this case, we will not describe them, because. they are covered in detail in specific manuals.
Indirect cardiac massage carried out 15-30 seconds after the start of mechanical ventilation or oxygen inhalation, if the heart rate is 80 per minute. and less and has no tendency to normalize.
For heart massage, it is best to lay the child on a hard surface with a small roll under the shoulders to create a moderate extension position. The point of pressure on the sternum is located at the intersection of the inter-nipple line and the midline, but the fingers should be slightly lower, without covering the point found. The depth of immersion of the sternum is 1-2 cm. The frequency of chest compressions should be maintained within 120 per minute. The number of breaths should be 30-40 per minute, the ratio of breaths to the number of chest compressions is 1:3; 1:4.
For the implementation of indirect heart massage in newborns (and precisely in them), 2 methods have been proposed. In the first method, 2 fingers of the hand (usually index and middle) are placed on the pressure point, and the palm of the other hand is placed under the child's back, thus creating counter pressure.
The second way is that the thumbs of both hands are located side by side at the pressure point, and the remaining fingers of both hands are located on the back. This method is more preferable, as it causes less fatigue of the hands of the staff.
Every 30 seconds, the heart rate should be monitored and if it is less than 80 beats per minute, massage should be continued with simultaneous administration medications. If there is an increase in the frequency of contractions, then drug stimulation can be abandoned. Medical stimulation is also indicated in the absence of palpitations after 30 s of positive pressure ventilation with 100% oxygen.
For the introduction of drugs, the umbilical vein is used through a catheter and an endotracheal tube. It must be remembered that catheterization of the umbilical vein is a threatening risk factor for the development of septic complications.
Adrenaline is prepared at a dilution of 1:10,000 (1 mg / 10 ml), drawn into a 1 ml syringe and administered intravenously or through an endotracheal tube at a dose of 0.1-0.3 ml / kg. Typically, the dose injected into the endotracheal tube is increased by a factor of 3, while the volume is diluted with saline and quickly injected into the lumen of the tube.
If the heart rate after 30 seconds does not reach 100 beats per minute, then injections should be repeated every 5 minutes. If hypovolemia is suspected in a child, then within 5-10 minutes, drugs are administered that replenish the vascular bed: isotonic sodium chloride solution, Ringer's solution, 5% albumin in a total dose of up to 10 ml / kg of body weight. The lack of effect from these measures is an indication for the introduction of sodium bicarbonate at the rate of 1-2 mmol / kg (2-4 ml / kg of 4% solution) at a rate of 1 mmol / kg / min. If no effect is found, then immediately after the end of the infusion, the entire indicated volume of assistance should be repeated.
If there are suspicions of narcotic respiratory depression (administration of morphine-like drugs during anesthesia, drug addict mother who took drugs before childbirth), then the introduction of the antidote naloxone at a dose of 0.1 mg / kg of body weight is required. The child should be under monitor control due to the fact that after the end of the antidote (1-4 hours), repeated respiratory depression is possible.
Resuscitation measures end if within 20 minutes. failed to restore cardiac activity.
When carrying out resuscitation, special attention should be paid to maintaining the thermal regime, because even under normal thermal conditions in delivery room(20-25°C) immediately after birth, the body temperature decreases by 0.3°C, and in the rectum - by 0.1°C per minute. Cooling can cause metabolic acidosis, hypoglycemia, respiratory disturbances, and delayed recovery even in full-term newborns.
Lysenkov S.P., Myasnikova V.V., Ponomarev V.V.
Emergency conditions and anesthesia in obstetrics. Clinical pathophysiology and pharmacotherapy
In newborns, massage is performed in the lower third of the sternum, with one index finger at the level of the nipples. The frequency is 120 per minute. Inspirations are carried out general rules, but the volume of buccal space (25-30 ml of air).
In children under 1 year old - grasp the chest with both hands, with thumbs press in front of the sternum 1 cm below the nipples. The depth of compression should be equal to 1/3 of the height of the chest (1.5-2cm). The frequency is 120 per minute. Inhalations are carried out according to the general rules.
In children under 8 years of age, massage is performed on a hard surface with one hand in the lower half of the sternum to a depth of 1/3 of the height of the chest (2-3 cm) with a frequency of 120 per minute. Inhalations are carried out according to the general rules.
The CPR cycle in all cases is an alternation of 30 compressions with 2 breaths.
Features of CPR in various situations
Features of CPR in drowning.
Drowning is one of the types of mechanical asphyxia as a result of water entering the respiratory tract.
Necessary:
observing the measures of their own safety, remove the victim from under the water;
clean the oral cavity from foreign bodies (algae, mucus, vomit);
during evacuation to the shore, holding the victim's head above the water, perform artificial respiration according to the general rules of cardiopulmonary resuscitation using the mouth-to-mouth or mouth-to-nose method (depending on the experience of the rescuer);
on the shore, call the ambulance to prevent complications that occur after drowning as a result of water, sand, silt, vomit, etc. entering the lungs;
warm the victim and observe him until the ambulance arrives;
in case of clinical death - cardiopulmonary resuscitation.
Features of CPR in case of electric shock.
If you suspect the effects of electric current on a person, be sure to:
compliance with personal security measures;
termination of the impact of current on a person;
calling the ambulance and monitoring the victim;
in the absence of consciousness, lay in a stable lateral position;
in case of clinical death - to carry out cardiopulmonary resuscitation.
Foreign bodies of the respiratory tract
The ingress of foreign bodies into the upper respiratory tract causes a violation of their patency for the supply of oxygen to the lungs - acute respiratory failure. Depending on the size of the foreign body, the obstruction may be partial or complete.
Partial airway obstruction- the patient breathes with difficulty, the voice is hoarse, coughing.
call SMP;
execute first Heimlich maneuver(with ineffective cough): having folded the palm of the right hand with a “boat”, apply several intense blows between the shoulder blades.
Complete obstruction of the airway- the victim cannot speak, breathe, cough, the skin quickly becomes bluish. Without the help of assistance, he will lose consciousness and cardiac arrest occurs.
First aid:
if the victim is conscious, perform second Heimlich maneuver- standing behind to grab the victim, clasp hands in the lock in the epigastric region of the abdomen and perform 5 sharp squeezes (shocks) with the ends of the fists from the bottom up and from front to back under the diaphragm;
if the victim is unconscious or there is no effect from previous actions, perform Third Heimlich maneuver lay the victim on his back, apply 2-3 sharp pushes (not blows!) With the palmar surface of the hand in the epigastric region of the abdomen from bottom to top and from front to back under the diaphragm;
In pregnant and obese people, the second and third Heimlich maneuvers are performed in the lower 1/3 of the sternum (in the same place where chest compressions are performed).
According to statistics, every tenth newborn child receives medical care in the delivery room, and 1% of all births need medical care. full complex resuscitation actions. A high level of training of medical personnel can increase the chances of life and reduce the possible development of complications. Adequate and timely resuscitation of newborns is the first step to reduce the number of deaths and the development of diseases.
Basic concepts
What is neonatal resuscitation? This is a series of activities that are aimed at revitalizing the child's body and restoring the work of lost functions. It includes:
- intensive care methods;
- use of artificial lung ventilation;
- installation of a pacemaker, etc.
Full-term babies do not require resuscitation. They are born active, scream loudly, pulse and heart rate are within normal limits, the skin has a pink color, the child responds well to external stimuli. Such children are immediately placed on the mother's stomach and covered with a dry, warm diaper. Mucous contents are aspirated from the respiratory tract to restore their patency.
CPR is considered an emergency. It is performed in case of respiratory and cardiac arrest. After such an intervention, in case of a favorable result, the basics of intensive care are applied. Such treatment is aimed at eliminating possible complications of stopping the work of important organs.
If the patient cannot maintain homeostasis on his own, then resuscitation of the newborn includes either setting a pacemaker.
What is needed for resuscitation in the delivery room?
If the need for such events is small, then one person will be required to carry them out. In the case of a severe pregnancy and waiting for a full range of resuscitation, there are two specialists in the maternity ward.
Resuscitation of a newborn in the delivery room requires careful preparation. Before the birth process, you should check the availability of everything you need and make sure that the equipment is in working order.
- It is necessary to connect a heat source so that the resuscitation table and diapers are warmed up, roll up one diaper in the form of a roller.
- Check if the oxygen supply system is properly installed. There must be sufficient oxygen, properly adjusted pressure and flow rate.
- The readiness of the equipment required for suctioning the contents of the respiratory tract should be checked.
- Prepare instruments to eliminate gastric contents in case of aspiration (probe, syringe, scissors, fixing material), meconium aspirator.
- Prepare and check the integrity of the resuscitation bag and mask, as well as the intubation kit.
The intubation set consists of guidewires, a laryngoscope with different blades and spare batteries, scissors and gloves.
What is the success of events?
Neonatal resuscitation in the delivery room is based on the following success principles:
- availability of the resuscitation team - resuscitators must be present at all births;
- coordinated work - the team must work harmoniously, complementing each other as one big mechanism;
- qualified staff - every resuscitator should have high level knowledge and practical skills;
- work taking into account the reaction of the patient - resuscitation should begin immediately when they become necessary, further measures are carried out depending on the reaction of the patient's body;
- serviceability of equipment - equipment for resuscitation must be serviceable and available at any time.
Reasons for the need for events
The etiological factors of oppression of the work of the heart, lungs and other vital organs of the newborn include the development of asphyxia, birth trauma, the development of congenital pathology, toxicosis of infectious origin and other cases of unexplained etiology.
Children's resuscitation of newborns and its need can be predicted even during the period of bearing a child. In such cases, the resuscitation team should be ready to immediately help the baby.
The need for such events may arise in the following conditions:
- a lot or a lack of water;
- overwearing;
- maternal diabetes;
- hypertonic disease;
- infectious diseases;
- fetal hypotrophy.
There are also a number of factors that already arise during childbirth. If they appear, you can expect the need for resuscitation. Such factors include bradycardia in a child, caesarean section, premature and rapid delivery, placenta previa or abruption, uterine hypertonicity.
Asphyxia of newborns
The development of a violation of respiratory processes with hypoxia of the body causes the appearance of disorders from the circulatory system, metabolic processes and microcirculation. Then there is a disorder in the work of the kidneys, heart, adrenal glands, brain.
Asphyxia requires immediate intervention to reduce the possibility of complications. Causes of respiratory disorders:
- hypoxia;
- violation of the airway (aspiration of blood, mucus, meconium);
- organic lesions of the brain and the work of the central nervous system;
- malformations;
- insufficient amount of surfactant.
Diagnosis of the need for resuscitation is carried out after assessing the child's condition on the Apgar scale.
| What is assessed | 0 points | 1 point | 2 points |
| Breathing state | Missing | Pathological, non-rhythmic | Loud cry, rhythmic |
| heart rate | Missing | Less than 100 beats per minute | Over 100 beats per minute |
| skin color | Cyanosis | Pink skin, bluish limbs | Pink |
| State of muscle tone | Missing | The limbs are slightly bent, the tone is weak | Active movements, good tone |
| Reaction to stimuli | Missing | Weakly expressed | Well expressed |
A state score of up to 3 points indicates the development of severe asphyxia, from 4 to 6 - asphyxia of moderate severity. Resuscitation of a newborn with asphyxia is carried out immediately after assessing his general condition.
Condition assessment sequence
- The child is placed under a heat source, his skin is dried with a warm diaper. The contents are aspirated from the nasal cavity and mouth. There is tactile stimulation.
- Breathing is assessed. In the case of a normal rhythm and the presence of a loud cry, proceed to the next stage. With non-rhythmic breathing, mechanical ventilation is carried out with oxygen for 15-20 minutes.
- Heart rate is assessed. If the pulse is above 100 beats per minute, go to the next stage of the examination. In the case of less than 100 strokes, IVL is performed. Then the effectiveness of the measures is evaluated.
- Pulse below 60 - indirect heart massage + IVL.
- Pulse from 60 to 100 - IVL.
- Pulse above 100 - IVL in case of irregular breathing.
- After 30 seconds, with the ineffectiveness of indirect massage with mechanical ventilation, it is necessary to carry out drug therapy.
- The skin color is examined. Pink color indicates the normal condition of the child. With cyanosis or acrocyanosis, it is necessary to give oxygen and monitor the condition of the baby.
How is primary resuscitation performed?
Be sure to wash and treat hands with an antiseptic, put on sterile gloves. The time of birth of the child is recorded, after the necessary measures are taken, it is documented. The newborn is placed under a heat source, wrapped in a dry warm diaper.
To restore airway patency, you can lower the head end and put the child on his left side. This will stop the aspiration process and allow the contents of the mouth and nose to be removed. Carefully aspirate the contents without resorting to deep insertion of the aspirator.
If such measures do not help, resuscitation of the newborn continues by sanitizing the trachea using a laryngoscope. After the appearance of breathing, but the absence of its rhythm, the child is transferred to a ventilator.
The neonatal resuscitation and intensive care unit accepts the child after primary resuscitation to provide further assistance and maintain vital functions.
Ventilation
The stages of resuscitation of newborns include carrying out ventilation:
- lack of breathing or the appearance of convulsive respiratory movements;
- pulse less than 100 times per minute, regardless of the state of breathing;
- persistent cyanosis during normal functioning of the respiratory and cardiovascular systems.
This set of activities is carried out using a mask or bag. The head of the newborn is thrown back a little and a mask is applied to the face. It is held with index and thumb fingers. The rest is taken out the jaw of the child.
The mask should be on the chin, nose and mouth area. It is enough to ventilate the lungs with a frequency of 30 to 50 times in 1 minute. Bag ventilation can cause air to enter the stomach cavity. You can remove it from there using
To control the effectiveness of the conduction, it is necessary to pay attention to the rise of the chest and the change in heart rate. The child continues to be monitored until the respiratory rhythm and heart rate are fully restored.
Why and how is intubation performed?
Primary resuscitation of newborns also includes tracheal intubation, in case of ineffective mechanical ventilation for 1 minute. The correct choice of the tube for intubation is one of the important points. It is done depending on the body weight of the child and his gestational age.
Intubation is also performed in the following cases:
- the need to remove the aspiration of meconium from the trachea;
- continuous ventilation;
- facilitating the management of resuscitation;
- the introduction of adrenaline;
- deep prematurity.
On the laryngoscope, the lighting is turned on and taken in the left hand. The head of the newborn is held with the right hand. The blade is inserted into the mouth and held to the base of the tongue. Raising the blade towards the handle of the laryngoscope, the resuscitator sees the glottis. The intubation tube is inserted from the right side into the oral cavity and passed through the vocal cords at the moment of their opening. It happens on the inhale. The tube is held to the planned mark.
The laryngoscope is removed, then the conductor. The correct insertion of the tube is checked by squeezing the breathing bag. Air enters the lungs and causes chest expansion. Next, the oxygen supply system is connected.
Indirect cardiac massage
Resuscitation of a newborn in the delivery room includes which is indicated when the heart rate is less than 80 beats per minute.
There are two ways to conduct indirect massage. When using the first, pressure on the chest is carried out using the index and middle fingers of one hand. In another version, the massage is performed with the thumbs of both hands, and the remaining fingers are involved in supporting the back. The resuscitator-neonatologist applies pressure on the border of the middle and lower thirds of the sternum so that the chest caves in by 1.5 cm. The frequency of pressing is 90 per minute.
It is imperative to ensure that inhalation and pressing on the chest are not carried out at the same time. In a pause between pressures, you can not remove your hands from the surface of the sternum. Pressing on the bag is done after every three pressures. For every 2 seconds, you need to carry out 3 pressures and 1 ventilation.
What to do if water is contaminated with meconium
Features of neonatal resuscitation include assistance with staining amniotic fluid with meconium and assessing the child on the Apgar scale less than 6 points.
- In the process of childbirth, after the appearance of the head from the birth canal, immediately aspirate the contents of the nasal cavity and mouth.
- After birth and placing the baby under a heat source, before the first breath, it is desirable to intubate with the largest possible tube in order to extract the contents of the bronchi and trachea.
- If it is possible to extract the contents and it has an admixture of meconium, then it is necessary to reintubate the newborn with another tube.
- Ventilation is established only after all the contents have been removed.
Drug therapy
Pediatric resuscitation of newborns is based not only on manual or hardware interventions, but also on the use medications. In the case of mechanical ventilation and indirect massage, when the measures are ineffective for more than 30 seconds, drugs are used.
Resuscitation of newborns involves the use of adrenaline, funds to restore the volume of circulating blood, sodium bicarbonate, naloxone, dopamine.
Adrenaline is injected through an endotracheal tube into the trachea or into a vein by jet. The concentration of the drug is 1:10,000. The drug is used to increase the force of contraction of the heart and accelerate the heart rate. After endotracheal administration, mechanical ventilation is continued so that the drug can be evenly distributed. If necessary, the agent is administered after 5 minutes.
Calculation of the dose of the drug depending on the weight of the child:
- 1 kg - 0.1-0.3 ml;
- 2 kg - 0.2-0.6 ml;
- 3 kg - 0.3-0.9 ml;
- 4 kg - 0.4-1.2 ml.
If there is blood loss or the need to replace, albumin, saline sodium chloride solution, or Ringer's solution are used. The drugs are injected into the vein of the umbilical cord in a jet (10 ml per 1 kg of the child's body weight) slowly over 10 minutes. The introduction of BCC supplements can increase blood pressure, reduce the level of acidosis, normalize the pulse rate and improve tissue metabolism.
Resuscitation of newborns, accompanied by effective ventilation of the lungs, requires the introduction of sodium bicarbonate into the umbilical vein to reduce signs of acidosis. The drug should not be used until adequate ventilation of the child's lungs has been established.
Dopamine is used to increase cardiac index and glomerular filtration. The drug dilates the vessels of the kidneys and increases sodium clearance when using infusion therapy. It is administered intravenously under the constant monitoring of blood pressure and heart rate.
Naloxone is administered intravenously at the rate of 0.1 ml of the drug per 1 kg of the child's body weight. The remedy is used when the skin color and pulse are normal, but there are signs of respiratory depression. The newborn should not be given naloxone while the mother is using narcotic drugs or is being treated with narcotic analgesics.
When to stop resuscitation?
IVL continues until the child scores 6 Apgar points. This assessment is carried out every 5 minutes and lasts up to half an hour. If after this time the newborn has an indicator of less than 6, then he is transferred to the intensive care unit of the maternity hospital, where further resuscitation and intensive care of newborns are carried out.
If the effectiveness of resuscitation measures is completely absent and asystole and cyanosis are observed, then the measures last up to 20 minutes. When even the slightest signs of effectiveness appear, their duration increases for as long as the measures give a positive result.
Neonatal intensive care unit
After the successful restoration of the work of the lungs and heart, the newborn is transferred to the intensive care unit and intensive care. There, the work of doctors is aimed at preventing possible complications.
A newborn after resuscitation needs to prevent the occurrence of swelling of the brain or other disorders of the central nervous system, restore the functioning of the kidneys and the excretory function of the body, and normalize blood circulation.
The child may appear metabolic disorders in the form of acidosis, lactic acidosis, which is due to violations of peripheral microcirculation. On the part of the brain, seizures, hemorrhage, cerebral infarction, edema, development may also appear. acute insufficiency kidneys, atony Bladder, adrenal insufficiency and other endocrine organs.
Depending on the condition of the baby, he is placed in an incubator or an oxygen tent. Specialists monitor the work of all organs and systems. Allow the child to feed only after 12 hours, in most cases - after
Mistakes that are not allowed
It is strictly forbidden to carry out activities, the safety of which has not been proven:
- pour water on the baby
- squeeze his chest;
- strike on the buttocks;
- direct an oxygen jet in the face, and the like.
Albumin solution should not be used to increase initial volume, as this increases the risk lethal outcome newborn.
Carrying out resuscitation does not mean that the baby will have any deviations or complications. Many parents expect pathological manifestations after the newborn was in intensive care. Reviews of such cases show that in the future, children have the same development as their peers.
The neonatal department has been part of the Central Clinical Hospital since 1989. The department organizes the joint stay of mothers and newborns from the first minutes of life. We provide support breastfeeding, important from the first hours of a child's life, we teach mothers the skills of caring for a baby. Our caring and experienced staff will help you take care of your newborn. nurses, and qualified neonatologists will observe him daily.
If you are expecting a baby, know that not only you are waiting for him! They are waiting for him in the neonatal department, because people who love their profession work here.
The structure of the department includes a resuscitation and intensive care unit, a room for preparing baby food, as well as a room for storing vaccines and vaccinating.
A neonatologist is the first doctor in your child's life, he meets a newborn baby, takes him in his arms, puts him on his mother's breast, watches him in the first hours, days and weeks of his life. A neonatologist is always present during childbirth and is ready to help a weakened or premature baby. For this, the department of newborns has everything you need. After stabilization of the child's condition, you will have the opportunity to be in the same room with the child.
The department is equipped with modern diagnostic and medical equipment: incubators; breathing apparatus for artificial lung ventilation; monitors for monitoring blood pressure, blood oxygen saturation, temperature, respiratory rate and heart rate; resuscitation tables with heating; electric pumps; perfusors for long-term infusion therapy; phototherapy lamps, as well as a centralized oxygen system; oxygen dosimeters; sets for puncture of the spinal canal; sets of brownies for puncture of peripheral veins; catheters for catheterization of the umbilical vein; sets for replacement blood transfusion; intragastric probes.
On the basis of the hospital laboratory, laboratory tests are carried out for newborns: a clinical blood test, acid-base balance, electrolyte composition, determination of the blood group and Rh factor, Coombs reaction, bilirubin and its fractions, glucose levels, biochemical analysis blood, blood coagulation factors, urinalysis, analysis of cerebrospinal fluid, it is possible to conduct immunological and microbiological blood tests. The following examinations can also be performed: X-ray, ECG, ECHO-KG, ultrasound of internal organs and neurosonography. If necessary, otolaryngologists, ophthalmologists, surgeons, dermatologists from other departments of the Central Clinical Hospital, cardiologists of the Scientific Center of the SSH named after A.I. A.N. Bakuleva and consultant neurologist Professor A.S. Petrukhin. The department screens all newborns for phenylketonuria, hypothyroidism, adrenogenital syndrome, cystic fibrosis, galactosemia. According to the national vaccination schedule, vaccination against tuberculosis with the BCG-M vaccine and vaccination against hepatitis B with the Engerix B vaccine, audiological screening are carried out. Fulfillment of all requirements for the sanitary and epidemiological regime is the most important section of the department's work. As a result of the measures taken, there were no nosocomial infections during the operation of the department. The greatest attention in our department is given to breastfeeding and the joint stay of mother and child.
