CPR in children under 1 year of age

Sequencing:

1. Lightly shake or pat your baby if you suspect he is unconscious

2. Place the baby on his back;

3. Call someone for help;

4. Clear your airways

Remember! When straightening the baby's head, avoid bending it!

5. Check if there is breathing, if not, start mechanical ventilation: take a deep breath, cover the baby’s mouth and nose with your mouth and take two slow, shallow breaths;

6. Check for a pulse for 5 - 10 seconds. (in children under 1 year of age, the pulse is determined on the brachial artery);

Remember! If you are offered help at this time, ask to call an ambulance.

7. If there is no pulse, place the 2nd and 3rd fingers on the sternum, one finger below the nipple line and begin chest compressions

Frequency of at least 100 per minute;

Depth 2 - 3 cm;

The ratio of sternum thrusts and blows is 5:1 (10 cycles per minute);

Remember! If there is a pulse, but breathing is not detected; Ventilation is performed at a frequency of 20 breaths per minute. (1 blow every 3 seconds)!

8. After performing indirect cardiac massage, they proceed to mechanical ventilation; do 4 full cycles

In children under 1 year of age, breathing problems are most often caused by a foreign body in the respiratory tract.

As in an adult victim, the airway may be partially or completely blocked. If the airways are partially blocked, the baby is frightened, coughs, and inhales with difficulty and noisily. If the respiratory tract is completely blocked, the skin turns pale, the lips become bluish, and there is no cough.

The sequence of actions when resuscitating a baby with complete blockage of the airways:

1. Place the baby face down on your left forearm so that the baby's head hangs over the rescuer's arm;

2. Make 4 claps on the victim’s back with the heel of your palm;

3. Place your baby face up on your other forearm;

4. Make 4 compressions on the chest, as with chest compressions;

5. Follow steps 1 - 4 until the airway is restored or the baby loses consciousness;

Remember! An attempt to remove a foreign body blindly, as in adults, is not acceptable!

6. If the baby has lost consciousness, do a cycle of 4 claps on the back, 4 pushes on the sternum;

7. Examine the victim's mouth:

If a foreign body is visible, remove it and perform mechanical ventilation (2 injections);

If the foreign body is not removed, repeat back slaps, sternum thrusts, mouth inspection, and mechanical ventilation until baby's chest rises:
- after 2 successful insufflations, check the pulse in the brachial artery.

Features of mechanical ventilation in children

To restore breathing in children under 1 year of age, mechanical ventilation is carried out “mouth to mouth and nose”, in children over 1 year of age - by the “mouth to mouth” method. Both methods are carried out with the child in the supine position. For children under 1 year of age, a low cushion (for example, a folded blanket) is placed under the back, or the upper part of the body is slightly raised with an arm placed under the back, and the child’s head is slightly thrown back. The person providing assistance takes a shallow breath, tightly covers the mouth and nose of a child under 1 year old, or only the mouth in children older than one year, and blows air into the respiratory tract, the volume of which should be smaller the smaller the child. In newborns, the volume of inhaled air is 30-40 ml. When a sufficient volume of air is blown in and air enters the lungs (and not the stomach), movements appear chest. Having finished insufflation, you need to make sure that the chest descends.

Blowing in a volume of air that is too large for the child can lead to serious consequences - rupture of the alveoli and lung tissue and the release of air into the pleural cavity.

Remember!

The frequency of insufflations should correspond to the age-related frequency of respiratory movements, which decreases with age.

On average, the respiratory rate per minute is:

In newborns and children up to 4 months - 40

In children 4-6 months - 35-40

In children 7 months - 35-30

For children 2-4 years old - 30-25

For children 4-6 years old - about 25

For children 6-12 years old - 22-20

For children 12-15 years old - 20-18 years old.

Features of indirect cardiac massage in children

In children, the chest wall is elastic, so indirect cardiac massage is performed with less effort and with greater efficiency.

The technique of chest compressions in children depends on the age of the child. For children under 1 year old, it is enough to press on the sternum with 1-2 fingers. To do this, the person providing assistance places the child on his back with his head facing him, covers him so that the thumbs are located on the front surface of the chest, and their ends are on the lower third of the sternum, the remaining fingers are placed under the back.

For children over 1 to 7 years of age, heart massage is performed while standing on the side, with the base of one hand, and for older children - with both hands (like adults).

During the massage, the chest should bend by 1-1.5 cm in newborns, 2-2.5 cm in children 1-12 months old, 3-4 cm in children over one year old.

The number of compressions on the sternum for 1 minute should correspond to the average age pulse rate, which is:

In newborns - 140

In children 6 months - 130-135

In children 1 year old - 120-125

In children 2 years old - 110-115

In children 3 years old - 105-110

In children 4 years old - 100-105

For children 5 years old - 100

For children 6 years old - 90-95

For children 7 years old - 85-90

For children 8-9 years old - 80-85

For children 10-12 years old - 80

For children 13-15 years old - 75

Educational literature

UMP on Fundamentals of Nursing, edited by Ph.D. A.I. Shpirna, M., GOU VUNMC, 2003, pp. 683-684, 687-988.

S.A. Mukhina, I.I. Tarnovskaya, Atlas on manipulative techniques of nursing care, M., 1997, pp. 207-211.

He who saved one life saved the whole world

Mishnah Sanhedrin

Features of cardiopulmonary resuscitation in children of different ages, recommended by the European Council on Resuscitation, were published in November 2005 in three foreign journals: Resuscitation, Circulation and Pediatrics.

The sequence of resuscitation measures in children is generally similar to that in adults, but when carrying out life-sustaining measures in children (ABC) Special attention is given to points A and B. If the resuscitation of adults is based on the fact of the primacy of heart failure, then in a child, cardiac arrest 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-rest” phase, which determines the need early diagnosis of this phase.

Pediatric resuscitation consists of two stages, which are presented in the form of algorithmic diagrams (Fig. 1, 2).

Restoring airway patency (AP) in patients with loss of consciousness is aimed at reducing obstruction, a common cause of which is tongue retraction. If the muscle tone of the lower jaw is sufficient, then throwing back the head will cause the lower jaw to move forward and open the airway (Fig. 3).

In the absence of sufficient tone, throwing back the head must be combined with moving the lower jaw forward (Fig. 4).

However, in infants there are peculiarities of performing these manipulations:

• Do not tilt the child’s head back excessively;
• Do not squeeze the soft tissue of the chin, as this may cause airway obstruction.

After clearing the airways, it is necessary to check how effectively the patient is breathing: you need to look closely, listen, and observe the movements of his chest and abdomen. Often, restoring and maintaining the airway is sufficient for the patient to continue breathing effectively.

Features of artificial lung ventilation in children early age determined by the fact that the small diameter of the child’s airways provides great resistance to the flow of inhaled air. To minimize the increase in airway pressure and prevent gastric overdistension, inhalations should be slow, and the frequency of respiratory cycles should be determined by age (Table 1).

A sufficient volume of each breath is a volume that provides adequate chest movement.

Make sure that breathing is adequate, there is a cough, movements, and pulse. If there are signs of circulation, continue respiratory support; if there is no circulation, begin chest compressions.

In children under one year of age, the person providing assistance tightly and hermetically grasps the child’s nose and mouth 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 swelling. Very important differential diagnosis between airway obstruction caused by a foreign body and infection. In the setting of infection, the act of removing a foreign body is dangerous because it may lead to unnecessary delay in transport and treatment of the patient. In patients without cyanosis and with adequate ventilation, cough should be stimulated; artificial respiration should not be used.

The method of eliminating airway obstruction caused by a foreign body depends on the age of the child. Blind cleaning of the upper respiratory tract with a finger is not recommended in children, since at this moment the foreign body can be pushed deeper. If the foreign body is visible, it can be removed using a Kelly forceps or Medgil forceps. Pressing on the abdomen is not recommended for children under one year of age, since there is a risk of damage to the abdominal organs, especially the liver. A child at this age can be helped by holding him on his arm in the “rider” position with his head lowered below his body (Fig. 7).

The baby's head is supported with a hand around the lower jaw and chest. Four blows are given quickly to the back between the shoulder blades. proximal part palms. Then the child is placed on his back so that the victim’s head is lower than the body during the entire procedure and four pressures are applied to the chest. If the child is too large to be placed on the forearm, he is placed on the hip so that the head is lower than the body. After clearing the airways and restoring their free patency in the absence of spontaneous breathing, artificial ventilation is started. In older children or adults with airway obstruction by a foreign body, it is recommended to use the Heimlich maneuver - a series of subdiaphragmatic pressures (Fig. 8).

Emergency cricothyroidotomy is an option for maintaining airway patency in patients who cannot be intubated.

As soon as the airways are cleared and two test breathing movements are performed, it is necessary to determine whether the child had only respiratory arrest or whether there was cardiac arrest at the same time - the pulse in the large arteries is determined.

In children under one year of age, the pulse is assessed at the brachial artery (Fig. 9)

Because the baby’s short and wide neck makes it difficult to quickly find the carotid artery.

In older children, as in adults, the pulse is assessed at the carotid artery (Fig. 10).

Primary cardiopulmonary resuscitation in children

With the development of terminal conditions, timely and correct implementation of primary cardiopulmonary resuscitation allows, in some cases, to save the lives of children and return victims to normal life activities. Mastery of the elements of emergency diagnosis of terminal conditions, solid knowledge of the methods of primary cardiopulmonary resuscitation, extremely clear, “automatic” execution of all manipulations in the required rhythm and strict sequence are an indispensable condition for success.

Cardiopulmonary resuscitation methods 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 Committee on Emergency Care of the American Heart Association, published in JAMA (1992).

Clinical diagnosis

Main features clinical death:

lack of breathing, heartbeat and consciousness;

disappearance of the pulse in the carotid and other arteries;

pale or sallow skin color;

the pupils are wide, without reacting to light.

Emergency measures in case of clinical death:

reviving a child with signs of circulatory and respiratory arrest must begin immediately, from the first seconds of establishing this condition, extremely quickly and energetically, in strict sequence, without wasting time on finding out the reasons for its occurrence, auscultation and measuring blood pressure;

record the time of clinical death and the moment of the start of resuscitation measures;

sound the alarm, call assistants and the resuscitation team;

if possible, find out how many minutes have passed since the expected moment of clinical death.

If it is known for sure that this period is more than 10 minutes, or the victim shows early signs of biological death (symptoms “ cat eye" - after pressing on the eyeball, the pupil takes and retains a spindle-shaped horizontal shape and a “melting piece of 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 measures are carried out in the classical sequence. The main provisions of primary cardiopulmonary resuscitation are proposed by the American Heart Association in the form of the “ABC Rules” according to R. Safar:

The first step of A(Airways) is to restore patency of the airway.

The second step B (Breath) is to restore breathing.

The third step C (Circulation) is the restoration of blood circulation.

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 clean 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), place a soft cushion made of a towel or sheet under your neck.

A cervical vertebral fracture 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 stress due to diving, falling, or a motor vehicle accident.

4. Pull out lower jaw forward and upward (the chin should be in the highest position), which prevents the tongue from sticking to the back wall of the pharynx and facilitates air access.

IN ( Breath ) - restoration of breathing:

Start mechanical ventilation using expiratory methods “mouth to mouth” - in children over 1 year old, “mouth to nose” - in children under 1 year old (Fig. 1).

Ventilation technique. When breathing “from mouth to mouth and nose,” it is necessary with your left hand, placed under the patient’s neck, to pull up his head and then, after a preliminary deep breath, tightly wrap your lips around the child’s nose and mouth (without pinching it) and with some effort blow in air (the initial part of your tidal volume) (Fig. 1). For hygienic purposes, the patient’s face (mouth, nose) can first be covered with a gauze cloth or handkerchief. As soon as the chest rises, air inflation is stopped. After this, move your mouth away from the child’s face, giving him the opportunity to exhale passively. The ratio of the duration of inhalation and exhalation is 1:2. The procedure is repeated with a frequency equal to the age-related breathing rate of the person being resuscitated: in children of the first years of life - 20 per 1 min, in adolescents - 15 per 1 min

When breathing “mouth to mouth,” the resuscitator wraps his lips around the patient’s mouth and pinches his nose with his right hand. The rest of the technique is the same (Fig. 1). With both methods, there is a danger of partial penetration of the blown air into the stomach, its distension, regurgitation of gastric contents into the oropharynx and aspiration.

The introduction of an 8-shaped air duct or an adjacent oronasal mask significantly facilitates mechanical ventilation. Manual breathing apparatus (Ambu bag) is connected to them. When using manual breathing apparatus, the resuscitator presses the mask tightly with his left hand: the nose part with the thumb, and the chin part with the index finger, while simultaneously (with the remaining fingers) pulling the patient’s chin up and back, thereby achieving closure of the mouth under the mask. The bag is compressed with the right hand until chest excursion occurs. This serves as a signal that pressure must be released to allow exhalation.

WITH ( 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 continuing mechanical ventilation, must begin chest compressions.

Method of indirect cardiac massage (Fig. 2, Table 1). The patient lies on his back, on a hard surface. The resuscitator, having chosen a hand position appropriate for the child’s age, applies rhythmic pressure at an age-appropriate frequency to the chest, balancing the force of pressure with the elasticity of the chest. Heart massage is carried out until complete recovery heart rate, pulse in peripheral arteries.

Table 1.

Method of performing indirect cardiac massage in children

Complications of chest compressions: with excessive pressure on the sternum and ribs, there may be fractures and pneumothorax, and with strong pressure over the xiphoid process, liver rupture is possible; It is also necessary to remember about the danger of regurgitation of gastric contents.

In cases where mechanical ventilation is performed in combination with chest compressions, it is recommended to do one inflation every 4-5 chest compressions. The child's condition is re-evaluated 1 minute after the start of resuscitation and then every 2-3 minutes.

Criteria for the effectiveness of mechanical ventilation and chest compressions:

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 in the carotid arteries (checked in the intervals between chest compressions - at the moment of compression a massage wave is felt on the carotid artery, indicating that the massage is being carried out correctly);

Restoration of independent 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-sustaining measures:

1. If the heartbeat is not restored, without stopping mechanical ventilation and chest compressions, provide access to a peripheral vein and administer intravenously:

0,1% solution of adrenaline hydrogen tartrate 0.01 ml/kg (0.01 mg/kg);

0.1% atropine sulfate solution 0.01-0.02 ml/kg (0.01-0.02 mg/kg). Atropine during resuscitation in children is used in dilution: 1 ml of 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 isotonic solution sodium chloride (1 ml of solution will contain 0.1 mg of the drug). It is possible to use doses of adrenaline increased by 2 times.

If necessary, repeat intravenous administration of the above drugs after 5 minutes.

4% sodium bicarbonate solution 2 ml/kg (1 mmol/kg). Administration of sodium bicarbonate is indicated only in conditions of prolonged cardiopulmonary resuscitation (more than 15 minutes) or if it is known that circulatory arrest has occurred due to metabolic acidosis; administration of a 10% calcium gluconate solution at a dose of 0.2 ml/kg (20 mg/kg) is indicated only in the presence of hyperkalemia, hypocalcemia and an overdose of calcium antagonists.

2. Oxygen therapy with 100% oxygen through a face mask or nasal catheter.

3. For ventricular fibrillation, defibrillation (electrical and drug) 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.

No signs of recovery of cardiac activity against the background of ongoing activities for 30 - 40 minutes. is an indication to stop resuscitation.

INDEPENDENT WORK OF STUDENTS:

The student independently performs emergency medical care techniques using the ELTEK-baby simulator.

LIST OF REFERENCES FOR INDEPENDENT PREPARATION:

Main literature:

1. Outpatient pediatrics: textbook / ed. A.S. Kalmykova. - 2nd edition, revised. and additional – M.: GEOTAR-Media. 2011.- 706 p.

Polyclinic pediatrics: textbook for universities / ed. A.S. Kalmykova. - 2nd ed., - M.: GEOTAR-Media. 2009. - 720 pp. [Electronic resource] – Access from the Internet. ‑ //

2. Guide to outpatient pediatrics / ed. A.A. Baranova. – M.: GEOTAR-Media. 2006.- 592 p.

Guide to outpatient pediatrics / ed. A.A. Baranova. - 2nd ed., rev. and additional - M.: GEOTAR-Media. 2009. - 592 pp. [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 VUNMC Ministry of Health of the Russian Federation, 2004.

Galaktionova M.Yu. Urgent Care children. Prehospital stage: training manual. – Rostov on Don: Phoenix. 2007.- 143 p.

Tsybulkin E.K. Emergency pediatrics. Algorithms for diagnosis and treatment. M.: GEOTAR-Media. 2012.- 156 p.

Emergency pediatrics: textbook / Yu. S. Aleksandrovich, V. I. Gordeev, K. V. Pshenisnov. - St. Petersburg. : SpetsLit. 2010. - 568 pp. [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. etc.: textbook / Tver State. honey. academic; Practical skills for a student studying in the specialty "pediatrics", [Tver]:; 2005 1 electric wholesale (CD–ROM).

Software and Internet resources:

1.Electronic resource: access mode: // www. Consilium- medicum. com.

catalog of medical resources INTERNET

2. "Medline"

4.Corbis catalogue,

5.Professionally oriented website : http:// www. Medpsy.ru

6.Student advisor: www.studmedlib.ru(name – polpedtgma; password – polped2012; code – X042-4NMVQWYC)

The student’s knowledge of the main provisions of the lesson topic:

Examples of baseline tests:

1. At what severity of laryngeal stenosis is emergency tracheotomy indicated?

A. At 1st degree.

b. At 2nd degree.

V. At 3 degrees.

d. For grades 3 and 4.

* d. At 4 degrees.

2. What is the first action in urgent treatment of anaphylactic shock?

* A. Stopping access of the allergen.

b. Injection of the allergen injection site with adrenaline solution.

V. Administration of corticosteroids.

d. Applying a tourniquet above the allergen injection site.

d. Apply a tourniquet below the allergen injection site.

3. Which of the criteria will first indicate to you that the ongoing indirect cardiac massage is effective?

a.Warming of the extremities.

b.Return of consciousness.

c. The appearance of intermittent breathing.

d. Pupil dilation.

* d. Constriction of pupils._

4. What change on the ECG is threatening for the syndrome? sudden death in children?

* A. Prolongation of the Q-T interval.

b. Shortening of the Q-T interval.

V. Prolongation of the P - Q interval.

d. Shortening of the P-Q interval.

d. Deformation of the QRS complex.

Questions and typical tasks of the final level:

Exercise 1.

Calling an ambulance to the house of a 3-year-old boy.

Temperature 36.8°C, number of respirations – 40 per 1 minute, number of heartbeats – 60 per 1 minute, blood pressure – 70/20 mm Hg. Art.

Parents' complaints about the child's lethargy and inappropriate behavior.

Medical history: allegedly 60 minutes before the arrival of the ambulance, the boy ate an unknown number of tablets kept by his grandmother, who suffers from hypertension and takes nifedipine and reserpine for treatment.

Objective data: The condition is serious. Doubtfulness. Glasgow scale score 10 points. The skin, especially the chest and face, as well as the sclera, is hyperemic. The pupils are constricted. Convulsions with a predominance of the clonic component are periodically observed. Nasal breathing is difficult. Breathing is shallow. Pulse is weak and tense. On auscultation, against the background of puerile breathing, a small number of wheezing sounds are heard. Heart sounds are muffled. The stomach is soft. The liver protrudes 1 cm from under the edge of the costal arch along the midclavicular line. The spleen is not palpable. Haven't urinated for the last 2 hours.

a) Make a diagnosis.

b) Provide prehospital emergency care and determine transportation conditions.

c) Characterize the pharmacological action of nefedipine and reserpine.

d) Define the Glasgow scale. What is it used for?

e) Indicate how long it takes for acute renal failure to develop and describe the mechanism of its occurrence.

f) Determine the possibility of performing forced diuresis to remove 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 doctor at a summer health camp.

Over the past week there has been hot, dry weather, with daytime air temperatures of 29-30°C in the shade. In the afternoon, a 10-year-old child was brought to you who complained of lethargy, nausea, and decreased visual acuity. During the examination, you noticed redness of the face, an increase in body temperature to 37.8°C, increased breathing, and tachycardia. From the anamnesis it is known that the child played “beach volleyball” for more than 2 hours before lunch. Your actions?

Response standard

Perhaps these are early signs of sunstroke: lethargy, nausea, decreased visual acuity, redness of the face, increased body temperature, increased breathing, tachycardia. In the future, loss of consciousness, delirium, hallucinations, and a change from tachycardia to bradycardia may occur. In the absence of help, the child may die due to 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. In case of initial manifestations of heat stroke and preserved consciousness, give plenty of glucose-saline solution (1/2 teaspoon each of sodium chloride and sodium bicarbonate, 2 tablespoons of sugar per 1 liter of water) no less than the volume of age-appropriate daily requirement in water.

3. With a full-blown heatstroke clinic:

Carry out physical cooling with cold water with constant rubbing of the skin (stop when body temperature drops below 38.5°C);

Provide access to the vein and begin intravenous administration of Ringer's solution or Trisol at a dose of 20 ml/kg per hour;

For convulsive syndrome, administer 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 when overheating is combined 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 at the children's health camp was called by passers-by who saw a drowning child in the lake near the camp. Upon examination, a child, estimated to be 9-10 years old, is lying on the shore of the lake, unconscious, in wet clothes. The skin is pale, cold to the touch, the lips are cyanotic, and water flows from the mouth and nose. Hyporeflexia. In the lungs, breathing is weakened, the yielding areas of the chest and sternum sink during inspiration, respiratory rate is 30 per minute. Heart sounds are muffled, heart rate is 90 beats/min, the pulse is weak and tense, rhythmic. Blood pressure – 80/40 mm Hg. The abdomen is soft and painless.

1.What is your diagnosis?

2. Your actions at the inspection site (first medical aid).

3. Your actions at the medical center of the health camp (pre-hospital assistance).

4. Further tactics.

Standard answer.

1. Drowning.

2. On the spot: - clean the oral cavity, - bend the victim over the thigh, and remove water with palm strikes between the shoulder blades.

3. In the medical center: - undress the child, rub with alcohol, wrap in a blanket, - inhalation with 60% oxygen, - insert a probe into the stomach, - inject an age-specific dose of atropine into the muscles of the floor of the mouth, - polyglucin 10 ml/kg IV; prednisolone 2-4 mg/kg.

4.Subject to emergency hospitalization in the intensive care unit of the nearest hospital.

​

Reanimation is a set of therapeutic measures aimed at revitalization, i.e. restoration of vital functions in patients in a state of clinical death.

Critical condition(terminal state) - this is the extreme degree

any, including iatrogenic pathology, which requires artificial replacement or maintenance of vital functions. In other words, a terminal state is the final period of extinction of the body’s vital functions.

Clinical death- the state of the body after the cessation of spontaneous breathing and blood circulation, during which the cells of the cerebral cortex are still able to fully restore their function. The duration of clinical death in adults is 3-5 minutes, in newborns and young children - 5-7 minutes (under normothermia).

Following clinical death comes biological death, in which irreversible changes occur in organs and tissues, primarily in the central nervous system.

Social death is a condition in which there is no function of the cerebral cortex, and the person cannot function as part of society (society).

It should be noted that the final stages of a critical condition are preagony and agony.

Preagonia is characterized by lethargy, a drop in systolic arterial pressure to 50-60 mm Hg, an increase and decrease in pulse filling, shortness of breath, a change in skin color (pallor, cyanosis, marbled pattern). The duration of preagonia ranges from several minutes and hours to days. Throughout the entire period, sharp progressive disorders of hemodynamics and spontaneous breathing are observed, microcirculation disorders, hypoxia and acidosis develop in all organs and tissues, products of perverted metabolism accumulate, and a “biochemical “storm” (the release of a huge amount of various biologically active substances) rapidly increases. As a result, all this leads to the development of agony.

Agony- a condition in which consciousness and ocular reflexes are absent. Heart sounds are muffled. Blood pressure is not determined. The pulse in the peripheral vessels is not palpable, and in the carotid arteries there is weak filling. Breathing is rare, convulsive or deep, frequent. The duration of the agonal state ranges from several minutes to several hours. During agony, a complex of the body’s final compensatory reactions may be activated. Often there is a “surge” in the almost extinct activity of the cardiovascular and respiratory systems. Sometimes on a short time consciousness is restored. However, exhausted organs very quickly lose their ability to function, and breathing and circulation stop, i.e. clinical death occurs.

If in adults the main cause of the development of this condition is most often heart failure (in the vast majority of cases - ventricular fibrillation), then in children in 60-80% clinical death occurs as a result of respiratory disorders. Moreover, against this background, the heart stops due to progressive hypoxia and acidosis.

Reanimation

The diagnosis of clinical death is made based on certain signs:

Absence of pulse in the carotid arteries during palpation is the simplest and quick way diagnosis of circulatory arrest. For the same purpose, you can use another technique: auscultation of the heart (with a phonendoscope or directly with the ear) in the area of ​​​​the projection of its apex. The absence of heart sounds will indicate cardiac arrest.

Stopping breathing can be determined by the absence of vibrations of a thread or hair brought to the mouth or nose. It is difficult to establish based on observation of chest movements respiratory arrest, especially in young children.

Dilated pupils and lack of reaction to light are signs of brain hypoxia and appear 40-60 seconds after circulatory arrest.

When declaring (as quickly as possible) clinical death in a patient, even before resuscitation begins, two mandatory actions must be performed:

1. Note the time of cardiac arrest (or the start of resuscitation measures).

2. Call for help. It is a well-known fact that one person, no matter how trained he is, will not be able to sufficiently carry out effective resuscitation measures even to a minimum extent.

Considering extremely short term, during which one can hope for success in the treatment of children in a state of clinical death, all resuscitation measures should begin as quickly as possible and be carried out clearly and competently. To do this, the person resuscitating must know the strict algorithm of actions in this situation. The basis of such an algorithm was Peter Safar’s “ABC of Reanimation Measures,” in which the stages of the revival process are described in strict order and “linked” to the letters of the English alphabet.

The first stage of resuscitation is called primary cardiopulmonary resuscitation and consists of three points:

A. Free airway patency is ensured depending on the circumstances different ways. In cases where one suspects that there is not a large amount of content in the respiratory tract, the following measures are carried out: the child is placed on his side (or simply turned his head to the side), his mouth is opened and the oral cavity and pharynx are cleaned with a swab or a finger wrapped in cloth.

If there is a large amount of liquid in the respiratory tract (for example, during drowning) small child lift the head down by the legs, throw back the head slightly, tap on the back along the spine, and then carry out the digital sanitation already described above. In the same situation, older children can be placed with their stomachs on the resuscitator’s thigh so that their heads hang down freely (Fig. 23.1.).

When removing a solid body, it is best to perform the Heimlich maneuver: tightly clasp the patient’s torso with both hands (or fingers, if this is a small child) under the costal arch and apply sharp compression of the lower chest in combination with a push of the diaphragm in the cranial direction through the epigastric region. The technique is designed to instantly increase intrapulmonary pressure, with which a foreign body can be pushed out of the respiratory tract. Sharp pressure on the epigastric region leads to an increase in pressure in the tracheobronchial tree at least twice as much as tapping on the back.

If there is no effect and it is impossible to perform direct laryngoscopy, microconiostomy can be performed - perforation of the cricoid-thyroid membrane with a thick needle (Fig. 23.2.). The cricoid membrane is located between the lower edge of the thyroid and the upper edge of the cricoid cartilages of the larynx. There is a small layer between it and the skin muscle fibers, there are no large vessels and nerves. Finding the membrane is relatively easy. If you focus from the top notch thyroid cartilage, then going down the midline, we find a small depression between the anterior arch of the cricoid cartilage and the lower edge of the thyroid cartilage - this is the cricoid-thyroid membrane. The vocal cords are located just cranial to the membrane, so they are not damaged during manipulation. It takes a few seconds to perform a microconiostomy. The technique for carrying it out is as follows: the head is thrown back as much as possible (it is advisable to place a cushion under the shoulders); With the thumb and middle finger, the larynx is fixed to the lateral surfaces of the thyroid cartilage; The index finger identifies the membrane. The needle, pre-bent at an obtuse angle, is inserted into the membrane strictly along the midline until a “failure” sensation is felt, which indicates that the end of the needle is in the laryngeal cavity.

It should be noted that even in prehospital conditions, if the patient has complete obstruction in the larynx, it is possible to perform an emergency opening of the cricoid membrane, which is called coniotomy (Fig. 23.3.). To carry out this operation, the same positioning of the patient is required as for microconiostomy. The larynx is fixed in the same way and the membrane is determined. Then, a transverse skin incision about 1.5 cm long is made directly above the membrane. An index finger is inserted into the skin incision so that the tip of the nail phalanx rests against the membrane. But by touching the nail with the flat of the knife, the membrane is perforated and a hollow tube is inserted through the hole. The manipulation takes from 15 to 30 seconds (which distinguishes koniostomy from tracheostomy, which requires several minutes). It should be noted that special coniotomy kits are currently being produced, which consist of a razor-sting for cutting the skin, a trocar for inserting a special cannula into the larynx, and the cannula itself, put on the trocar.

In hospital settings, mechanical suction is used to remove the contents of the respiratory tract. After clearing the oral cavity and pharynx of contents, at the pre-medical stage it is necessary to place the child in a position that ensures maximum airway patency. This is done by straightening the head, moving the lower jaw forward and opening the mouth.

Head extension allows you to maintain airway patency in 80% of unconscious patients, since as a result of this manipulation, tissue tension occurs between the larynx and lower jaw. In this case, the root of the tongue moves away from back wall throats. In order to ensure that the head is tilted back, it is enough to place it under the upper shoulder girdle roller

When moving the lower jaw, it is necessary that the lower row of teeth is in front of the upper one. The mouth is opened with a small force, in the opposite direction thumbs. Head and jaw position must be maintained throughout resuscitation efforts until airway insertion or tracheal intubation.

In the prehospital setting, airways may be used to support the root of the tongue. The introduction of an air duct in the vast majority of cases (with normal anatomy of the pharynx) eliminates the need to constantly hold the lower jaw in an extended position, which significantly reduces the need for resuscitation measures. The insertion of the air duct, which is an arched tube of oval cross-section with a mouthpiece, is carried out as follows: first, the air duct is inserted into the patient’s mouth with a downward bend, advanced to the root of the tongue, and only then installed in the desired position by rotating it 180 degrees.

For exactly the same purpose, an S-shaped tube (Safara tube) is used, which resembles two air ducts connected together. The distal end of the tube is used to inflate air during artificial ventilation.

When performing cardiopulmonary resuscitation medical worker Tracheal intubation should be a smooth method of ensuring an open airway. Tracheal intubation can be either orotracheal (through the mouth) or nasotracheal (through the nose). The choice of one of these two methods is determined by how long the endotracheal tube is expected to remain in the trachea, as well as the presence of damage or diseases of the corresponding parts of the facial skull, mouth and nose.

The technique of orotracheal intubation is as follows: the endotracheal tube is always inserted (with rare exceptions) under direct laryngoscopic control. The patient is placed in horizontal position on your back, with your head thrown back as much as possible and your chin raised. To exclude the possibility of regurgitation of gastric contents at the time of tracheal intubation, it is recommended to use the Sellick maneuver: an assistant presses the larynx to the spine, and the pharyngeal end of the esophagus is compressed between them.

The laryngoscope blade is inserted into the mouth, moving the tongue upward to see the first landmark - the uvula of the soft palate. Moving the laryngoscope blade deeper, they look for the second landmark - the epiglottis. Lifting it upward, the glottis is exposed, into which, moving from the right corner of the mouth - so as not to block the field of vision - an endotracheal tube is inserted. Verification of correctly performed intubation is carried out by comparative auscultation of breath sounds over both lungs.

With nasotracheal intubation, the tube is inserted through the nostril (usually the right one - it is wider in most people) to the level of the nasopharynx and directed into the glottis using Megilla intubation forceps under laryngoscopic control (Fig. 23.7.).

In certain situations, tracheal intubation can be performed blindly using a finger or using a fishing line previously passed through the cricoid membrane and glottis.

Tracheal intubation completely eliminates the possibility of upper airway obstruction, with the exception of two easily detectable and removable complications: kinking of the tube and its obstruction with secretions from the respiratory tract.

Tracheal intubation not only ensures free patency of the airways, but also makes it possible to administer endotracheally some medications necessary for resuscitation.

B. Artificial ventilation.

The simplest are expiratory methods of mechanical ventilation (“mouth to mouth”, “mouth to nose”), which are used mainly in the prehospital stage. These methods do not require any equipment, which is their biggest advantage.

The most commonly used technique artificial respiration“mouth to mouth” (Fig. 23.8.). This fact is explained by the fact that, firstly, the oral cavity is much easier to clear of contents than the nasal passages, and, secondly, there is less resistance to the blown air. The technique for performing mouth-to-mouth ventilation is very simple: the resuscitator closes the patient’s nasal passages with two fingers or his own cheek, inhales and, pressing his lips tightly to the resuscitated person’s mouth, exhales into his lungs. After this, the resuscitator moves away slightly to allow air to escape from the patient’s lungs. The frequency of artificial respiratory cycles depends on the age of the patient. Ideally, it should be close to physiological age norm. For example, in newborns, mechanical ventilation should be performed at a frequency of about 40 per minute, and in children 5-7 years old - 24-25 per minute. The volume of air blown also depends on age and physical development child. The criterion for determining the proper volume is a sufficient amplitude of movement of the chest. If the chest does not rise, then it is necessary to improve the airway.

Artificial respiration “mouth to nose” is used in situations where there is damage in the mouth area that does not allow creating conditions of maximum tightness. The technique of this technique differs from the previous one only in that air is blown into the nose, while the mouth is tightly closed.

Recently, to facilitate all three of the above methods of artificial lung ventilation, Ambu International has produced a simple device called the “key of life.” It consists of a polyethylene sheet inserted into a keychain, in the center of which there is a flat unidirectional valve through which air is blown. The side edges of the sheet are hooked onto the patient’s ears using thin elastic bands. It is very difficult to misuse this “key of life”: everything is drawn on it - lips, teeth, ears. This device is disposable and prevents the need to touch the patient directly, which is sometimes unsafe.

In the case where an airway or S-shaped tube was used to ensure a clear airway. Then you can perform artificial respiration using them as conductors of injected air.

At the stage medical care When performing mechanical ventilation, a breathing bag or automatic respirators are used.

Modern modifications of the breathing bag have three mandatory components:

A plastic or rubber bag that expands (restores its volume) after compression due to its own elastic properties or due to the presence of an elastic frame;

an inlet valve that allows air from the atmosphere to enter the bag (when expanded) and to the patient (when compressed);

non-return valve with an adapter for a mask or endotracheal endotracheal tube, which allows passive exhalation into the atmosphere.

Currently, most manufactured self-expanding bags are equipped with a fitting to enrich the breathing mixture with oxygen.

The main advantage of mechanical ventilation using a breathing bag is that a gas mixture with an oxygen content of 21% is supplied to the patient’s lungs. In addition, artificial respiration, carried out even with such a simple manual respirator, significantly saves the doctor’s effort. Ventilation of the lungs with a breathing bag can be carried out through a face mask tightly pressed to the patient's mouth and nose, an endotracheal tube or a tracheostomy cannula.

The optimal method is mechanical ventilation using automatic respirators.

WITH. In addition to providing adequate alveolar ventilation, the main task of resuscitation is to maintain at least the minimum permissible blood circulation in organs and tissues, provided by cardiac massage (Fig. 23.9.).

From the very beginning of the use of closed cardiac massage, it was believed that when using it, the principle of the cardiac pump predominates, i.e. compression of the heart between the sternum and spine. This is the basis for certain rules for conducting closed cardiac massage, which are still in effect today.

1. When performing resuscitation measures, the patient must lie on a hard surface (table, bench, couch, floor). Moreover, to ensure greater blood flow to the heart during artificial diastole, as well as to prevent blood from entering the jugular veins during compression of the chest (venous valves do not work in a state of clinical death), it is desirable that the patient’s legs are raised 60 degrees above the horizontal level, and the head 20 degrees.
2. To perform closed cardiac massage, pressure must be applied to the sternum. The point of application of force during compression is infants located in the middle of the sternum, and in older children - between its middle and lower parts. In infants and newborns, massage is performed with the tips of the nail phalanges of the first or second and third fingers, in children from 1 to 8 years old - with the palm of one hand, over 8 years old - with two palms.
3. The vector of force applied during chest compression should be directed strictly vertically. Depth of sternum displacement and frequency of compressions in children of different ages presented in table.

Even in the recent past, when carrying out resuscitation measures, the ratio of artificial breaths and chest compressions was considered classic: 1:4 - 1:5. After the concept of a “chest pump” during closed cardiac massage was proposed and substantiated in the 70-80s of our century, the question naturally arose: is the pause for air injection every 4-5 sternum compressions really physiologically justified? After all, the flow of air into the lungs provides additional intrapulmonary pressure, which should increase the flow of blood from the lungs. Naturally, if resuscitation is carried out by one person, and the patient is not a newborn or an infant, then the resuscitator has no choice - the ratio of 1:4-5 will be observed. Provided that two or more people are caring for a patient in a state of clinical death, the following rules must be observed:

1. One reviver is engaged in artificial ventilation of the lungs, the second - cardiac massage. Moreover, there should be no pauses, no stops in either the first or the second event! The experiment showed that with simultaneous compression of the chest and ventilation of the lungs with high pressure, cerebral blood flow becomes 113-643% greater than with the standard technique.
2. Artificial systole should occupy at least 50% of the duration of the entire cardiac cycle.

The established understanding of the mechanism of the breast pump contributed to the emergence of some original techniques that make it possible to provide artificial blood flow during resuscitation measures.

The development of “vest” cardiopulmonary resuscitation is at the experimental stage, based on the fact that the thoracic mechanism of artificial blood flow can be caused by periodic inflation of a double-walled pneumatic vest worn on the chest.

In 1992, for the first time in humans, the “inserted abdominal compression” method - IAC - was used in humans, although the scientific development data that formed its basis were published back in 1976. When carrying out VAC, at least three people must take part in resuscitation measures: the first performs artificial ventilation of the lungs, the second compresses the chest, the third, immediately after the end of compression of the chest, compresses the abdomen in the navel area using the same method as the second resuscitator. The effectiveness of this method in clinical trials was 2-2.5 times higher than with conventional closed heart massage. There are probably two mechanisms for improving artificial blood flow with VAC:

1. Compression arterial vessels the abdominal cavity, including the aorta, creates a counterpulsation effect, increasing the volume of cerebral and myocardial blood flow;
2. Compression of the abdominal venous vessels increases the return of blood to the heart, which also increases the volume of blood flow.

Naturally, to prevent damage to parenchymal organs when performing resuscitation using “inserted abdominal compression”, preliminary training is required. By the way, despite the apparent increase in the risk of regurgitation and aspiration with VAC, in practice everything turned out to be completely different - the frequency of regurgitation decreased, because when the abdomen is compressed, the stomach is also compressed, and this prevents it from inflating during artificial respiration.

The next method of active compression - decompression is now quite widely used throughout the world.

The essence of the technique is that for CPR, the so-called Cardio Pump is used - a special round pen with a calibration scale (for dosing compression and decompression forces), which has a vacuum suction cup. The device is applied to the front surface of the chest, suctioned to it, and thus it becomes possible to carry out not only active compression, but also active stretching of the chest, i.e. actively provide not only artificial systole, but also artificial diastole.

The effectiveness of this technique is confirmed by the results of many studies. Coronary perfusion pressure (the difference between aortic and right atrial pressure) increases threefold compared to standard resuscitation, and it is one of the most important predictive criteria for the success of CPR.

It is necessary to note the fact that recently the possibility of artificial ventilation of the lungs (simultaneously with providing blood circulation) using the active compression-decompression technique by changing the volume of the chest, and, consequently, the airways, has been actively studied.

In the early 90s, information appeared about successful closed cardiac massage in patients in the prone position, when the chest was compressed from the back, and the fist of one of the resuscitators was placed under the sternum. Cuirass CPR, based on the principle of high-frequency mechanical ventilation of the lungs using a cuirass respirator, also occupies a certain place in modern research. The device is applied to the chest and, under the influence of a powerful compressor, alternating pressure differences are created - artificial inhalation and exhalation.

Open (or direct) cardiac massage is permitted only in hospital settings. The technique for performing it is as follows: the chest is opened in the fourth intercostal space on the left with an incision, from the edge of the sternum to the mid-axillary line. In this case, the skin is cut with a scalpel, subcutaneous tissue and fascia pectoral muscles. Next, the muscles and pleura are perforated using a forceps or clamp. The chest cavity is opened wide with a retractor and heart massage is immediately started. In newborns and infants, it is most convenient to press the heart with two fingers back surface sternum. In older children, the heart is squeezed with the right hand so that the first finger is located above the right ventricle, and the remaining fingers are above the left ventricle. Fingers should be placed flat on the myocardium to avoid perforating it. Opening the pericardium is necessary only when there is fluid in it or for visual diagnosis of myocardial fibrillation. The frequency of compressions is the same as with closed massage. If sudden cardiac arrest occurs during abdominal surgery, massage can be performed through the diaphragm.

It has been experimentally and clinically proven that direct cardiac massage provides higher arterial and lower venous pressure, resulting in better perfusion of the heart and brain during resuscitation, as well as a higher number of patient survivors. However, this manipulation is very traumatic and can lead to many complications.

Indications for open massage hearts are:

1. Cardiac arrest during thoracic or abdominal surgery;
2. Presence of pericardial cardiac tamponade;
3. Tension pneumothorax;
4. Massive thromboembolism pulmonary artery
5. Multiple fractures of the ribs, sternum and spine;
6. Deformation of the sternum and/or thoracic spine;
7. No signs of effectiveness of closed cardiac massage for 2.5-3 minutes.

It should be noted that in many foreign guidelines this method of ensuring blood flow during resuscitation in children is not supported, and the American Health Association believes that the indication for it in pediatric patients is only the presence of a penetrating wound to the chest, and even then, provided that the condition The patient deteriorated sharply in the hospital.

So, ensuring free patency of the airways, artificial ventilation of the lungs and maintaining artificial blood flow constitute the stage of primary cardiovascular resuscitation (or resuscitation in the amount of ABC). The criteria for the effectiveness of measures taken to revive a patient are:

1. The presence of a pulse wave in the carotid arteries in time with compression of the sternum;
2. Adequate chest excursion and improved skin color;
3. Constriction of the pupils and the appearance of a reaction to light.

The second section of the “ABC of Safar” is called “ Restoration of independent blood circulation” and also consists of three points:

D - Drug (medicines).

E - ECG (ECG).

F - Fibrillation

D- The first thing that a doctor performing resuscitation should take into account is that drug therapy does not replace mechanical ventilation and cardiac massage; it must be carried out against their background.

Routes of drug administration into the body of a patient in a state of clinical death require serious discussion.

Until access to the vascular bed is ensured, medications such as adrenaline, atropine, and lidocaine can be administered endotracheally. It is best to carry out such manipulation through a thin catheter inserted into the endotracheal tube. The drug can also be administered into the trachea through a conio- or tracheostomy. Absorption of drugs from the lungs in the presence of sufficient blood flow occurs almost as quickly as when they are intravenous administration.

When implementing this technique, the following rules must be observed:

for better absorption, the medication should be diluted in a sufficient volume of water or 0.9% NaCl solution;

the dose of the drug must be increased 2-3 times (however, some researchers believe that the dose of the drug administered into the trachea should be an order of magnitude higher);

after administering the drug, it is necessary to perform 5 artificial breaths for its better distribution throughout the lungs;

soda, calcium and glucose cause serious, sometimes irreversible damage to lung tissue.

By the way, all specialists involved in the study of this problem have noted the fact that when administered endotracheally, any drug acts longer than when administered intravenously.

Indications for intracardiac administration of medications using a long needle are currently significantly limited. Frequent refusal of this method is due to quite serious reasons. Firstly, the needle used to puncture the myocardium can damage it so much that with subsequent cardiac massage a hemipericardium with cardiac tamponade will develop. Secondly, the needle can damage the lung tissue (resulting in pneumothorax) and large coronary arteries. In all these cases, further resuscitation measures will not be successful.

Thus, intracardiac administration of drugs is necessary only when the child is not intubated and access to the venous bed is not provided within 90 seconds. Puncture of the left ventricle is performed with a long needle (6-8 cm) with a syringe containing a drug attached to it. The injection is made perpendicular to the surface of the sternum at its left edge in the fourth or fifth intercostal space along the upper edge of the underlying rib. As you move the needle deeper, you must constantly pull the syringe plunger towards you. When the walls of the heart are punctured, a slight resistance is felt, followed by a feeling of “failure.” The appearance of blood in the syringe indicates that the needle is in the ventricular cavity.

Intravenous The route of drug administration is the most preferred when performing CPR. It is advisable to use central beliefs whenever possible. This rule is especially relevant when performing resuscitation in children, since puncture of peripheral veins in this group of patients can be quite difficult. In addition, in patients in a state of clinical death, blood flow in the periphery, if not completely absent, is extremely small. This fact gives reason to doubt that the administered drug will quickly reach the point of application of its action (the desired receptor). We emphasize once again that, in the opinion of most experts, during resuscitation, you should not spend more than 90 seconds trying to puncture a peripheral vein in a child - after that you should move on to a different route of drug administration.

Intraosseous The route of drug administration during resuscitation is one of the alternative accesses to the vascular bed or critical conditions. This method is not widely used in our country, but it is known that with certain equipment and the resuscitator having the necessary practical skills, the intraosseous method significantly reduces the time required to deliver the medicine to the patient’s body. There is excellent outflow through the venous channels from the bone, and the drug injected into the bone quickly ends up in the systemic circulation. It should be noted that the veins located in the bone marrow do not collapse. For introduction medicinal substances the most commonly used bones are the calcaneus and the anterosuperior iliac spine.

All medications used during resuscitation are divided (depending on the urgency of their administration) into drugs of the 1st and 2nd groups.

Adrenaline is already on for long years holds the lead among all drugs used in resuscitation. Its universal adrenomimetic effect helps stimulate all myocardial functions, increase diastolic pressure in the aorta (on which coronary blood flow depends), and expand the cerebral microvasculature. According to experimental and clinical trials Not a single synthetic adrenergic agonist has any advantages over adrenaline. The dose of this drug is 10-20 mcg/kg (0.01-0.02 mg/kg). The drug is re-administered every 3 minutes. If there is no effect after double administration, the dose of adrenaline is increased 10 times (0.1 mg/kg). In the future, the same dosage is repeated after 3-5 minutes.

Atropine, being an m-anticholinergic, is able to eliminate the inhibitory effect of acetylcholine on the sinus and atrioventricular node. In addition, it may promote the release of catecholamines from the adrenal medulla. The drug is used against the background of ongoing resuscitation measures in the presence of single heartbeats at a dose of 0.02 mg/kg. It should be borne in mind that lower dosages may cause a paradoxical parasympathomimetic effect in the form of increased bradycardia. Repeated administration of atropine is acceptable after 3-5 minutes. However, its total dose should not exceed 1 mg in children under 3 years of age and 2 mg in older patients, as this is fraught with a negative effect on the ischemic myocardium.

Any stoppage of blood circulation and breathing is accompanied by metabolic and respiratory acidosis. A shift in pH to the acidic side disrupts the functioning of enzyme systems, excitability and contractility of the myocardium. That is why the use of such a strong anti-acidotic agent as sodium bicarbonate was considered mandatory when performing CPR. However, research by scientists has identified a number of dangers associated with the use of this drug:

increase in intracellular acidosis due to CO formation 2 and, as a consequence of this, a decrease in myocardial excitability and contractility, the development of hypernatremia and hyperosmolarity with a subsequent decrease in coronary perfusion pressure;

shift of the oxyhemoglobin dissociation curve to the left, which disrupts tissue oxygenation;

inactivation of catecholamines;

decreased effectiveness of defibrillation.

Currently, indications for the administration of sodium bicarbonate are:

1. Cardiac arrest due to severe metabolic acidosis and hyperkalemia;
2. Prolonged cardiopulmonary resuscitation (more than 15-20 minutes);
3. A condition after restoration of ventilation and blood flow, accompanied by documented acidosis.

The dose of the drug is 1 mmol/kg body weight (1 ml of 8.4% solution/kg or 2 ml of 4% solution/kg).

In the early 90s, it was determined that there was no evidence of a positive effect of calcium supplements on the effectiveness and outcome of cardiopulmonary resuscitation. Vice versa, increased level Calcium ions contribute to increased neurological disorders after cerebral ischemia, as it contributes to increased reperfusion damage. In addition, calcium disrupts energy production and stimulates the formation of eicosanoids. Therefore, indications for the use of calcium supplements during resuscitation are:

1. Hyperkalemia;
2. Hypocalcemia;
3. Cardiac arrest due to an overdose of calcium antagonists;

The dose of CaCl 2 is 20 mg/kg, calcium gluconate is 3 times more.

For cardiac fibrillation, lidocaine is included in the complex of drug therapy, which is considered one of the best means for relieving this condition. It can be administered either before or after electrical defibrillation. The dose of lidocaine in children is 1 mg/kg (in newborns - 0.5 mg/kg). In the future, it is possible to use a maintenance infusion at a rate of 20-50 mcg/kg/min.

Medications of the second group include dopamine (1-5 mcg/kg/min with reduced diuresis and 5-20 mcg/kg/min with reduced myocardial contractility), glucocorticoid hormones, cocarboxylase, ATP, vitamins C, E and group B, glutamic acid, glucose infusion with insulin.

To ensure patient survival, infusions of isotonic colloids or crystalloids that do not contain glucose should be used.

According to some researchers, the following drugs can have a good effect during resuscitation measures:

- ornid at a dose of 5 mg/kg, repeat dose after 3-5 minutes of 10 mg/kg (for persistent ventricular fibrillation or tachycardia);

- isadrin as an infusion at a rate of 0.1 mcg/kg/min (for sinus bradycardia or atrioventricular block);

- norepinephrine as an infusion with a starting rate of 0.1 mcg/kg/min (with electromechanical dissociation or weak myocardial contractility).

E- electrocardiography is considered classical method monitoring of cardiac activity during resuscitation measures. Under various circumstances, an isoline (complete asystole), single cardiac complexes (bradycardia), and a sinusoid with a smaller or larger amplitude of oscillations (small- and large-wave fibrillation) can be observed on the screen or tape of the electrocardiograph. IN in some cases The device can record almost normal electrical activity of the heart, in the absence of cardiac output. This situation can occur with cardiac tamponade, tense preumothorax, massive pulmonary embolism, cardiogenic shock and other variants of severe hypovolemia. This type called cardiac arrest electromechanical dissociation(EMD). It should be noted that, according to some specialists, EMD occurs during cardiopulmonary resuscitation in more than half of patients (however, these statistical studies were conducted among patients of all age groups).

F- (defibrillation). Naturally, this resuscitation technique is used only if cardiac fibrillation is suspected or if it is present (which can be established with 100% certainty only with the help of an ECG).

There are four types of cardiac defibrillation:

Chemical

Mechanical

Medication

Electric

Chemical defibrillation consists of rapid intravenous administration of a KCl solution. After this procedure, myocardial fibrillation stops and goes into asystole. However, it is not always possible to restore cardiac activity after this, so this method of defibrillation is not currently used.

Mechanical defibrillation is well known as precordial or “resuscitation” shock and is a fist blow (in newborns - a click) to the sternum. Although rare, it can be effective and, at the same time, not bring the patient (considering his condition) any tangible harm.

Medical defibrillation consists of administering antiarrhythmic drugs - lidocaine, ornid, verapamil in appropriate dosages.

Electrical cardiac defibrillation (EDC) is the most effective method and essential component cardiopulmonary resuscitation (Fig. 23.10.).

EDS should be carried out as early as possible. The speed of recovery of heart contractions and the likelihood of a favorable outcome of CPR depend on this. The fact is that during fibrillation, the energy resources of the myocardium are quickly depleted, and the longer fibrillation lasts, the less likely the subsequent restoration of electrical stability and normal functioning of the heart muscle becomes.

When carrying out EDS, certain rules must be strictly observed:

1. All discharges should be carried out during exhalation so that the size of the chest is minimal - this reduces transthoracic resistance by 15-20%.
2. It is necessary that the interval between discharges be minimal. Each previous discharge reduces the transthoracic resistance by 8% and with the subsequent discharge the myocardium receives more current energy.
3. During each shock, everyone involved in resuscitation, with the exception of the person performing the EDS, must move away from the patient (for a very short period of time - less than a second). Before and after the discharge, measures to maintain artificial ventilation, blood flow, and drug therapy are continued to the extent that they are necessary for the patient.
4. The metal plates of the defibrillator electrodes must be lubricated with electrode gel (cream) or use pads moistened with an electrolyte solution.
5. Depending on the design of the electrodes, there may be two options for their location on the chest: 1) - the first electrode is installed in the area of ​​the second intercostal space to the right of the sternum (+), the second - in the area of ​​the apex of the heart (-). 2) - the “positive” electrode is located under the right lower scapular region, and the negatively charged one is located along the left edge of the lower half of the sternum.
6. Electrical defibrillation should not be performed against the background of asystole. This will bring nothing but damage to the heart and other tissues.

Depending on the type of defibrillator, the shock value is measured in either volts (V) or joules (J). Thus, it is necessary to know two options for “dosing” discharges.

So in the first case it looks like this:

If the scale of discharge values ​​is graduated in joules, then the selection of the required “dose” electric current carried out in accordance with the values.

When performing electrical defibrillation on open heart the magnitude of the discharge decreases by 7 times.

It should be noted that most modern foreign guidelines for cardiopulmonary resuscitation in children recommend performing EDS in a series of three discharges (2 J/kg - 4 J/kg - 4 J/kg). Moreover, if the first series is unsuccessful, then against the background of ongoing cardiac massage, mechanical ventilation, drug therapy and metabolic correction, a second series of discharges should be started - again with 2 J / kg.

After successful resuscitation, patients should be transferred to a specialized department for further observation and treatment.

Problems associated with refusal to perform cardiopulmonary resuscitation and its termination are very important for doctors of all specialties.

CPR may not be started when, under normothermic conditions:

cardiac arrest occurred against the background full complex intensive care;

the patient is in a terminal stage incurable disease;

more than 25 minutes have passed since cardiac arrest;

if the patient has a documented refusal to perform cardiopulmonary resuscitation (if the patient is a child under 14 years of age, then the documented refusal to perform resuscitation measures must be signed by his parents).

CPR is stopped if:

during resuscitation it became clear that it was not indicated for the patient;

when using all available methods CPR showed no evidence of effectiveness within 30 minutes;

repeated cardiac arrests are observed that are not amenable to any medical intervention.

Sequence of three the most important techniques cardiopulmonary resuscitation is formulated by P. Safar (1984) in the form of the “ABC” rule:

1. Aire way orep (“open the way for air”) means the need to free the airways from obstacles: recessed root of the tongue, accumulation of mucus, blood, vomit and other foreign bodies;
2. Breath for victim (“breathing for the victim”) means mechanical ventilation;
3. Circulation his blood (“circulation of his blood”) means performing indirect or direct cardiac 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;
• bend their head in cervical spine, bring the lower jaw forward and at the same time open the victim’s mouth (triple move by R. Safar);
• free the patient's mouth from various foreign bodies, mucus, vomit, blood clots using a finger wrapped in a scarf and suction.

Having ensured airway patency, begin mechanical ventilation immediately. There are several main methods:

• indirect, manual methods;
• methods of directly blowing air exhaled by a resuscitator into the victim’s respiratory tract;
• hardware methods.

The first ones have mostly historical meaning 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, you can apply rhythmic compression (simultaneously with both hands) of the lower ribs of the victim's chest, synchronized with his exhalation. This technique may be useful during transportation of a patient with severe status asthmaticus (the patient lies or half-sits with his head thrown back, the doctor stands in front or to the side and rhythmically squeezes his chest from the sides during exhalation). Admission is not indicated for rib fractures or severe airway obstruction.

The advantage of direct inflation methods for the victim’s lungs is that a lot of air (1-1.5 liters) is introduced with one breath, with active stretching of the lungs (Hering-Breuer reflex) and the introduction of an air mixture containing an increased amount of carbon dioxide (carbogen) , stimulated respiratory center sick. The methods used are “mouth to mouth”, “mouth to nose”, “mouth to nose and mouth”; the latter method is usually used in the resuscitation of young children.

The rescuer kneels at the side of the victim. Holding his head in an extended position and holding his nose with two fingers, he tightly covers the victim’s mouth with his lips and makes 2-4 vigorous, not rapid (within 1-1.5 s) exhalations in a row (excursion of 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 design complexity. At the prehospital stage, you can use breathing self-expanding bags of the “Ambu” type, simple mechanical devices of the “Pneumat” type or constant air flow interrupters, for example, using the Eyre method (through a tee - with your 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.

Typically, mechanical ventilation is combined with external, indirect cardiac massage, achieved through 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 third of the sternum; in young children, it is a conventional line passing one transverse finger above the nipples. The frequency of chest compressions in adults is 60-80, in infants - 100-120, in newborns - 120-140 per minute.

In infants, one breath occurs per 3-4 chest compressions; in older children and adults, this ratio is 1:5.

The effectiveness of indirect cardiac massage is evidenced by a decrease in cyanosis of the lips, ears and skin, constriction of the pupils and the appearance of a photoreaction, an increase in blood pressure, and the appearance of individual respiratory movements in the patient.

Due to incorrect placement of the resuscitator's hands and excessive efforts, complications of cardiopulmonary resuscitation are possible: fractures of the ribs and sternum, damage to internal organs. Direct cardiac massage is done for cardiac tamponade and multiple rib fractures.

Specialized cardiopulmonary resuscitation includes more adequate mechanical ventilation techniques, as well as intravenous or intratracheal administration of medications. When administered intratracheally, the dose of drugs should be 2 times higher in adults, and 5 times higher in infants, than when administered intravenously. Intracardiac administration of drugs is not currently 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 supplied 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 type of cardiac dysfunction.

For asystole, intravenous or intratracheal administration of the following drugs is used:

• adrenaline (0.1% solution); 1st dose - 0.01 ml/kg, subsequent doses - 0.1 ml/kg (every 3-5 minutes until the effect is obtained). When administered intratracheally, the dose is increased;
• atropine (in asystole is ineffective) is usually administered after adrenaline and ensuring adequate ventilation (0.02 ml/kg of 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 has occurred against the background of decompensated metabolic acidosis. The usual dose is 1 ml of 8.4% solution. The drug can be administered again only under the supervision of CBS;
• dopamine (dopamine, dopmin) is used after restoration of cardiac activity against the background of unstable hemodynamics at a dose of 5-20 mcg/(kg min), to improve diuresis 1-2 mcg/(kg min) for a long time;
• lidocaine is administered after restoration of cardiac activity against the background of post-resuscitation ventricular tachyarrhythmia as a bolus at a dose of 1.0-1.5 mg/kg, followed by infusion at a dose of 1-3 mg/kg-h), or 20-50 mcg/(kg-min) .

Defibrillation is performed against the background of ventricular fibrillation or ventricular tachycardia in the absence of a pulse in the carotid or brachial artery. The power of the 1st discharge is 2 J/kg, subsequent ones - 4 J/kg; the first 3 discharges can be done in a row without monitoring with an ECG monitor. If the device has a different scale (voltmeter), the 1st digit in infants should be in the range of 500-700 V, repeated ones - 2 times more. In adults, 2 and 4 thousand, respectively. 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 magnesium sulfate, aminophylline);

For EMD in children with no pulse in the carotid and brachial arteries, following methods intensive care:

• adrenaline intravenously, intratracheally (if catheterization is impossible after 3 attempts or within 90 s); 1st dose 0.01 mg/kg, subsequent doses - 0.1 mg/kg. Administration 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);
• fluid to replenish the central nervous system; It is better to use a 5% solution of albumin or stabizol, you can use rheopolyglucin in a dose of 5-7 ml/kg quickly, drip-wise;
• atropine at a dose of 0.02-0.03 mg/kg; possible repeated administration after 5-10 minutes;
• sodium bicarbonate - usually 1 time 1 ml of 8.4% solution intravenously slowly; the effectiveness of its introduction is questionable;
• if the listed means of therapy are ineffective, electrical cardiac pacing (external, transesophageal, endocardial) is performed immediately.

If in adults ventricular tachycardia or ventricular fibrillation are the main forms of circulatory arrest, then in young children they are observed extremely rarely, so defibrillation is almost never used in them.

In cases where the damage to the brain is so deep and extensive that it becomes impossible to restore its functions, including brain 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 initiated and actively ongoing intensive care in children before natural circulatory arrest. Resuscitation is not started or carried out if there is chronic disease and pathology incompatible with life, which is determined in advance 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 in case of 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 function, sometimes simultaneously and respiratory function (primary revival) in at least half of the victims, but in the future, preservation of life in patients is much less common. The reason for this is post-resuscitation illness.

The outcome of recovery is largely determined by the conditions of the blood supply to the brain in the early post-resuscitation period. In the first 15 minutes, blood flow can exceed the initial one by 2-3 times, after 3-4 hours it drops by 30-50% in combination with an increase in vascular resistance by 4 times. Repeated deterioration of cerebral circulation may occur 2-4 days or 2-3 weeks after CPR against the background of almost complete restoration of central nervous system function - delayed posthypoxic encephalopathy syndrome. By the end of the 1st to the beginning of the 2nd day after CPR, a repeated decrease in blood oxygenation may be observed, associated with nonspecific lung damage - respiratory distress syndrome (RDS) and the development of shunt-diffusion respiratory failure.

Complications of post-resuscitation illness:

• in the first 2-3 days after CPR - swelling of the brain, lungs, increased tissue bleeding;
• 3-5 days after CPR - dysfunction of parenchymal organs, development of manifest multiple organ failure (MOF);
• in more late dates- inflammatory and suppurative processes. In the early post-resuscitation period (1-2 weeks) intensive therapy
• is carried out against the background of impaired consciousness (somnolence, stupor, coma) of mechanical ventilation. Its main tasks in this period are stabilization of hemodynamics and protection of the brain from aggression.

Restoration of the central nervous system and rheological properties of blood is carried out with hemodilutants (albumin, protein, dry and native plasma, rheopolyglucin, 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. Improved gas exchange is achieved by restoring the oxygen capacity of the blood (transfusion of red blood cells), mechanical ventilation (with the oxygen concentration in the air mixture preferably less than 50%). With reliable restoration of spontaneous breathing and stabilization of hemodynamics, it is possible to carry out HBOT, for a course of 5-10 procedures daily at 0.5 ATI (1.5 ATA) and a plateau of 30-40 minutes under the cover of antioxidant therapy (tocopherol, ascorbic acid and etc.). Maintaining blood circulation is ensured by small doses of dopamine (1-3 mcg/kg per minute for a long time) and maintenance cardiotrophic therapy (polarizing mixture, panangin). Normalization of microcirculation is ensured by effective pain relief for injuries, neurovegetative blockade, administration of antiplatelet agents (Curantyl 2-3 mg/kg, heparin up to 300 IU/kg per day) and vasodilators (Cavinton up to 2 ml drip or Trental 2-5 mg/kg per day drip, Sermion , aminophylline, nicotinic acid, complamin, etc.).

Antihypoxic therapy is carried out (Relanium 0.2-0.5 mg/kg, barbiturates in a saturation dose of up to 15 mg/kg on the 1st day, on subsequent days - up to 5 mg/kg, GHB 70-150 mg/kg after 4-6 hours , enkephalins, opioids) and antioxidant (vitamin E - 50% oil solution at a dose of 20-30 mg/kg strictly intramuscularly daily, for a course of 15-20 injections) therapy. To stabilize membranes and normalize blood circulation, large doses of prednisolone, metipred (up to 10-30 mg/kg) are prescribed intravenously as a bolus or in fractions over 1 day.

Prevention of post-hypoxic cerebral edema: cranial hypothermia, administration of diuretics, dexazone (0.5-1.5 mg/kg per day), 5-10% albumin solution.

Correction of VEO, CBS and energy metabolism is carried out. 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 (treatment with camphor oil, curiosin of places with impaired microcirculation), hospital infections (asepsis) are necessary.

If the patient quickly recovers from a critical condition (within 1-2 hours), the complex of therapy and its duration should be adjusted depending on the clinical manifestations and the presence of post-resuscitation illness.

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 focus is restoration of brain function. Treatment is carried out jointly with neurologists.

• The administration of drugs that reduce metabolic processes in the brain is reduced.
• Drugs that stimulate metabolism are prescribed: cytochrome C 0.25% (10-50 ml/day 0.25% solution in 4-6 doses depending on age), Actovegin, solcoseryl (0.4-2.00 intravenous drips 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, and nootropil are prescribed orally for a long time.
• 2-3 weeks after CPR, a (primary or repeated) course of HBO therapy is indicated.
• The introduction of antioxidants and disaggregants is continued.
• Vitamins B, C, multivitamins.
• Antifungal drugs (Diflucan, Ancotil, Candizol), biological products. Discontinuation of antibacterial therapy if indicated.
• Membrane stabilizers, physiotherapy, physical therapy (physical therapy) and massage according to indications.
• General restorative therapy: vitamins, ATP, creatine phosphate, biostimulants, adaptogens in long-term courses.

The main differences between cardiopulmonary resuscitation in children and adults

Conditions preceding circulatory arrest

Bradycardia in a child with respiratory disorders- a sign of circulatory arrest. Newborns, infants and young children develop bradycardia in response to hypoxia, while older children initially develop tachycardia. In newborns and children with a heart rate less than 60 beats per minute and signs of low organ perfusion, in the absence of improvement after the start of artificial respiration, it is necessary to carry out indoor massage hearts.

After adequate oxygenation and ventilation, epinephrine is the drug of choice.

Blood pressure must be measured with a correctly sized cuff; invasive blood pressure measurement is indicated only in cases of extreme severity of the child.

Since blood pressure depends on age, it is easy to remember lower limit norms are 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 quickly followed by cardiac and respiratory arrest. Therefore, even before the onset of hypotension, all efforts should be aimed at treating shock (manifestations of which are increased heart rate, cold extremities, capillary refill more than 2 s, weak peripheral pulses).

Equipment and external conditions

Equipment size, drug dosage, and CPR parameters depend on age and body weight. When choosing doses, the child’s age should be rounded down, for example, at the age of 2 years, a dose for the age of 2 years is prescribed.

In newborns and children, heat transfer is increased due to the larger body surface area relative to body weight and the small amount of subcutaneous fat. The ambient temperature during and after cardiopulmonary resuscitation should be constant, ranging from 36.5 °C in newborns to 35 °C in children. When basal body temperature is 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 vocal cords at the level of the cricoid cartilage, which makes it possible to use tubes without a cuff. 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 disorders

For asystole, atropine and artificial rhythm stimulation are not used.

VF and VT with unstable hemodynamics occurs in 15-20% 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 with 2 J/kg and increase as necessary to a maximum of 4 J/kg for the third shock.

Statistics show that cardiopulmonary resuscitation in children allows at least 1% of patients or accident victims to return to a full life.