Doctors of any specialty have to teach others and themselves perform procedures related to emergency care and saving the patient’s life. This is the very first thing a medical student hears at university. Therefore, special attention is paid to the study of such disciplines as anesthesiology and resuscitation. To ordinary people For those not related to medicine, it also wouldn’t hurt to know the protocol for action in a life-threatening situation. Who knows when this might come in handy.
Cardiopulmonary resuscitation is a procedure for providing emergency care, aimed at restoring and maintaining the vital functions of the body after the onset of clinical death. It includes several mandatory steps. The SRL algorithm was proposed by Peter Safar, and one of the techniques for saving a patient is named after him.
It is no secret that doctors are constantly faced with the problem of choice: what is best for their patient. And often it is he who becomes a stumbling block for further therapeutic measures. The same goes for performing CPR. The algorithm is modified depending on the conditions of care, the training of the resuscitation team, the age of the patient and his current condition.
There has been much discussion about whether it is worthwhile to explain to children and adolescents the complexity of their condition, given the fact that they do not have the right to make decisions about own treatment. The question was raised about organ donation from victims who underwent CPR. The algorithm of actions in these circumstances should be slightly modified.
In medical practice, there are cases when resuscitation is not carried out, since it is already pointless, and the patient’s injuries are incompatible with life.
There are main and secondary signs. The main ones include:
- absence of pulse in large arteries (carotid, femoral, brachial, temporal);
- lack of breathing;
- persistent dilation of the pupils.
Secondary signs include loss of consciousness, pallor with a bluish tint, lack of reflexes, voluntary movements and muscle tone, strange, unnatural position of the body in space.
Conventionally, the CPR algorithm is divided into three large stages. And each of them, in turn, branches into stages.
The first stage is carried out immediately and consists of maintaining life at a level of constant oxygenation and airway patency. It eliminates the use of specialized equipment, and life is supported solely by the efforts of the resuscitation team.
The second stage is specialized, its goal is to preserve what non-professional rescuers have done and ensure constant blood circulation and oxygen access. It includes diagnosing heart function, using a defibrillator, and using medications.
The third stage is carried out already in the ICU (intensive care unit and intensive care). It is aimed at preserving brain functions, restoring them and returning a person to normal life.
In 2010, a universal CPR algorithm was developed for the first stage, which consists of several stages.
There are some features of CPR for drowning. The algorithm changes slightly, adapting to environmental conditions. First of all, the rescuer must take care to eliminate the threat to his own life, and if possible, do not enter the reservoir, but try to deliver the victim to the shore.
If, nevertheless, help is provided in the water, then the rescuer must remember that the drowning person does not control his movements, so you need to swim from behind. The main thing is to hold the person’s head above the water: by the hair, by catching it under the armpits, or by throwing it over one’s back.
The best thing a rescuer can do for a drowning person is to start blowing air right in the water, without waiting for transportation to shore. But technically this is only available to a physically strong and prepared person.
As soon as you remove the victim from the water, you need to check that he has a pulse and is breathing spontaneously. If there are no signs of life, you need to start immediately. They need to be carried out according to the general rules, since attempts to remove water from the lungs usually lead to the opposite effect and aggravate neurological damage due to oxygen starvation of the brain.
Another feature is the time period. You should not rely on the usual 25 minutes, as cold water processes slow down and brain damage occurs much more slowly. Especially if the victim is a child.
Resuscitation can be stopped only after restoration of spontaneous breathing and blood circulation, or after the arrival of an ambulance team that can provide professional life support.
Advanced CPR, the algorithm of which is carried out using medications, includes inhalation of 100% oxygen, intubation of the lungs and mechanical ventilation. In addition, antioxidants, fluid infusions to prevent a drop in systemic pressure and repeated diuretics are used to eliminate pulmonary edema, and active warming of the victim so that blood is evenly distributed throughout the body.
The CPR algorithm for respiratory arrest in adults includes all stages of chest compressions. This makes the work of rescuers easier, since the body itself will distribute the incoming oxygen.
There are two methods without improvised means:
Mouth to mouth;
- mouth to nose.
For better air access, it is recommended to tilt the victim’s head back, extend the lower jaw and clear the airways of mucus, vomit and sand. The rescuer should also worry about his health and safety, so it is advisable to carry out this manipulation through a clean scarf or gauze, in order to avoid contact with the patient’s blood or saliva.
The rescuer pinches his nose, tightly wraps his lips around the victim’s lips and exhales air. In this case, you need to look to see if the epigastric region is inflated. If the answer is yes, this means that air is entering the stomach and not the lungs, and there is no point in such resuscitation. Between exhalations you need to take breaks of a few seconds.
During high-quality mechanical ventilation, an excursion is observed chest.
It is logical that the CPR algorithm for asystole will include everything except: If the victim is breathing on his own, you should not transfer him to artificial mode. This complicates the work of doctors in the future.
cornerstone proper massage heart is the technique of laying on of hands and the coordinated work of the rescuer’s body. Compression is done with the base of the palm, not the wrist, not the fingers. The resuscitator's arms should be straightened, and compression is carried out by tilting the body. The arms are positioned perpendicular to the sternum, they can be held in a lock or the palms lie in a cross (in the shape of a butterfly). The fingers do not touch the surface of the chest. The algorithm for performing CPR is as follows: for thirty presses - two breaths, provided that resuscitation is carried out by two people. If there is only one rescuer, then fifteen compressions and one breath are performed, since a long break without blood circulation can damage the brain.
CPR for pregnant women also has its own characteristics. The algorithm includes saving not only the mother, but also the child in her womb. A doctor or bystander providing first aid to an expectant mother should remember that there are many factors that worsen the survival prognosis:
Increased oxygen consumption and rapid utilization;
- reduced lung volume due to compression by the pregnant uterus;
- high probability of aspiration of gastric contents;
- reduction of the area for mechanical ventilation, since the mammary glands are enlarged and the diaphragm is raised due to the enlargement of the abdomen.
Unless you are a doctor, the only thing you can do for a pregnant woman to save her life is to place her on her left side with her back at about a thirty-degree angle. And move her belly to the left. This will reduce pressure on the lungs and increase air flow. Be sure to start and don’t stop until the ambulance arrives or some other help arrives.
CPR in children has its own characteristics. The algorithm resembles an adult one, but due to physiological characteristics it is difficult to carry out, especially for newborns. You can divide the resuscitation of children by age: up to one year and up to eight years. Everyone who is older receives the same amount of assistance as adults.
Absolutely all adults should know how to perform basic CPR. Its algorithms are quite simple to remember and understand. This could save someone's life.
There are several rules that can make rescue operations easier for an untrained person.
The remaining recommendations for the CPR algorithm have already been presented above. The success of resuscitation and the further quality of life of the victim depend on how quickly eyewitnesses get their bearings and how competently they can provide assistance. Therefore, do not shy away from lessons that describe how to perform CPR. The algorithm is quite simple, especially if you remember it using a letter cheat sheet (ABC), as many doctors do.
Many textbooks say that CPR should be stopped after forty minutes of unsuccessful resuscitation, but in fact, only signs of biological death can be a reliable criterion for the absence of life. Remember: while you are pumping the heart, blood continues to feed the brain, which means the person is still alive. The main thing is to wait for the ambulance or rescuers to arrive. Believe me, they will thank you for this hard work.
In children, circulatory arrest due to cardiac causes occurs very rarely. In newborns and infants, the causes of circulatory arrest can be: asphyxia, sudden neonatal death syndrome, pneumonia and bronchiolospasm, drowning, sepsis, and neurological diseases. In children of the first years of life, the main cause of death is injuries (road, pedestrian, bicycle), asphyxia (as a result of diseases or aspiration of foreign bodies), drowning,
Burns and gunshot wounds. The manipulation technique is approximately the same as for adults, but there are some peculiarities.
Determining the pulse in the carotid arteries in newborns is quite difficult due to the short and round neck. Therefore, it is recommended to check the pulse in children under one year of age on the brachial artery, and in children over one year of age - on carotid artery.
Patency of the airways is achieved by simply lifting the chin or moving the lower jaw forward. If a child does not have spontaneous breathing in the first years of life, then the most important resuscitation measure is mechanical ventilation. When performing mechanical ventilation in children, they are guided by the following rules. In children under 6 months of age, mechanical ventilation is performed by blowing air into the mouth and nose at the same time. In children over 6 months of age, breathing is carried out from mouth to mouth, while pinching the child’s nose with fingers I and II. Care must be taken with the volume of air inhaled and the amount of airway pressure this creates. Air is blown in slowly for 1-1.5 s. The volume of each insufflation should cause a calm rise of the chest. The frequency of mechanical ventilation for children in the first years of life is 20 respiratory movements per minute. If the chest does not rise during mechanical ventilation, this indicates airway obstruction. The most common cause of obstruction is incomplete opening of the airways due to insufficiently correct positioning of the head of the resuscitated child. You should carefully change the position of the head and then start ventilation again.
Tidal volume is determined by the formula: DO (ml) = body weight (kg)x10. In practice, the effectiveness of mechanical ventilation is assessed by chest excursion and air flow during exhalation. The rate of mechanical ventilation in newborns is approximately 40 per minute, in children over 1 year old - 20 per minute, in adolescents - 15 per minute.
External cardiac massage in infants is performed with two fingers, and the compression point is located 1 finger below the internipple line. The caregiver supports the child's head in a position that ensures airway patency.
The depth of sternum compression is from 1.5 to 2.5 cm, the frequency of compressions is 100 per minute (5 compressions in 3 s or faster). Compression: ventilation ratio = 5:1. If the child is not intubated, 1-1.5 seconds are allotted for the respiratory cycle (in the pause between compressions). After 10 cycles (5 compressions: 1 breath), you should try to determine the pulse in the brachial artery for 5 seconds.
In children aged 1-8 years, press on the lower third of the sternum (the thickness of a finger above the xiphoid process) with the heel of the palm. The depth of sternum compression is from 2.5 to 4 cm, the massage frequency is at least 100 per minute. Every 5th compression is accompanied by a pause for inspiration. The ratio of the frequency of compressions to the rate of mechanical ventilation for children in the first years of life should be 5:1, regardless of how many people are involved in resuscitation. The child’s condition (carotid artery pulse) is re-evaluated 1 minute after the start of resuscitation, and then every 2-3 minutes.
For children over 8 years of age, the CPR technique is the same as for adults.
Dosage of drugs in children during CPR: adrenaline - 0.01 mg/kg; lido-caine - 1 mg/kg = 0.05 ml of 2% solution; sodium bicarbonate - 1 mmol/kg = 1 ml of 8.4% solution.
When administering an 8.4% sodium bicarbonate solution to children, it should be diluted in half isotonic solution sodium chloride.
Defibrillation in children under 6 years of age is performed with a discharge of 2 J/kg body weight. If repeated defibrillation is required, the shock can be increased to 4 J/kg body weight.
To do this, you need to be able to diagnose terminal conditions, know the technique of resuscitation, and perform all the necessary manipulations in a strict sequence, even to the point of automation.
In 2010, at the international association AHA (American Heart Association), after much discussion, new rules for 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) is now recommended.
Now let's look at emergency measures when clinical death occurs.
Clinical death can be diagnosed based on the following signs:
there is no breathing, no blood circulation (the pulse in the carotid artery is not detected), dilation of the pupils is noted (there is no reaction to light), consciousness is not determined, and there are no reflexes.
If clinical death is diagnosed, you need to:
CPR sequence:
1. Resuscitation begins with chest compressions, regardless of age. This is especially true if one person is performing resuscitation. 30 compressions in a row are immediately recommended before starting artificial ventilation.
If resuscitation is carried out by people without special training, then only cardiac massage is performed without attempts at artificial respiration. If resuscitation is carried out by a team of resuscitators, then closed cardiac massage is performed simultaneously with artificial respiration, avoiding pauses (without stopping).
Chest compressions should be fast and hard, in children under one year old by 2 cm, 1-7 years by 3 cm, over 10 years 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 up to 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, move the lower jaw forward and upward, slightly tilt the head back (in case of injury cervical region this is contraindicated), a cushion is placed under the neck.
3. Restoration of breathing (breathing).
At the prehospital stage, mechanical ventilation is performed using the “mouth to mouth and nose” method in children under 1 year of age, and “mouth to mouth” in children over 1 year of age.
Ratio of breathing frequency to impulse frequency:
The introduction of an air duct or laryngeal mask greatly facilitates mechanical ventilation.
At the stage of medical care, a manual breathing apparatus (Ambu bag) or an anesthesia machine is used for mechanical ventilation.
Tracheal intubation should be a smooth transition, we breathe with a mask, and then intubate. Intubation is performed through the mouth (orotracheal method) or through the nose (nasotracheal method). Which method is preferred depends on the disease and damage to the facial skull.
Medicines are administered against the background of ongoing closed cardiac massage and mechanical ventilation.
The route of administration is preferably intravenous; if not possible, endotracheal or intraosseous.
With endotracheal administration, the dose of the drug is increased 2-3 times, the drug is diluted by saline solution up to 5 ml and is inserted into the endotracheal tube through a thin catheter.
An intraosseous needle is inserted into tibia into its anterior surface. A spinal puncture needle with a mandrel or a bone marrow needle can be used.
Intracardiac administration in children is currently not recommended due to possible complications (hemipericardium, pneumothorax).
In case of clinical death, the following drugs are used:
9 ml (total volume is 10 ml). From the resulting dilution, 0.1 ml/kg is administered. If there is no effect after double administration, the dose is increased tenfold.
(0.1 mg/kg).
The dose of the drug is 1 mmol/kg body weight.
I would like to note that in adults defibrillation refers to priority measures and should begin simultaneously with closed cardiac massage.
In children, ventricular fibrillation occurs in about 15% of all cases of circulatory arrest and is therefore used less frequently. But if fibrillation is diagnosed, then it should be carried out as quickly as possible.
There are mechanical, medicinal, and electrical defibrillation.
(2J/kg – 4J/kg – 4J/kg). If there is no effect, then against the background of ongoing resuscitation measures, a second series of shocks can be performed again starting from 2 J/kg.
During defibrillation, the child must be disconnected 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 signs of biological death appear.
Cardiopulmonary resuscitation is not started if:
In conclusion, I would like to note that cardiopulmonary resuscitation should be carried out under the control of electrocardiography. She happens to be classical method diagnostics for such conditions.
Single cardiac complexes, coarse or small wave fibrillation or isoline 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 (occurs with cardiac tamponade, tension pneumothorax, cardiogenic shock, etc.).
In accordance with electrocardiography data, the necessary assistance can be provided more accurately.
The words “children” and “resuscitation” should not appear in the same context. It is too painful and bitter to read in the news feed that, due to the fault of parents or a fatal accident, children die and end up in intensive care units with serious injuries and mutilations.
Cardiopulmonary resuscitation in children
Statistics show that every year the number of children who die in early childhood childhood, is growing steadily. But if at the right moment there was a person nearby who knew how to provide first aid and knew the peculiarities of cardiopulmonary resuscitation in children... In a situation where the lives of children hang in the balance, there should be no “ifs.” We adults do not have the right to make assumptions and doubts. Each of us is obliged to master the technique of performing cardiopulmonary resuscitation, to have a clear algorithm of actions in our heads in case suddenly an incident forces us to be in that very place, at that very time... After all, the most important thing depends on the correct, coordinated actions before the arrival of an ambulance - the life of a little person.
This is a set of measures that should be carried out by any person anywhere before the arrival of an ambulance, if children have symptoms indicating respiratory and/or circulatory arrest. Next, we will talk about basic resuscitation measures that do not require specialized equipment or medical training.
Help with airway obstruction
Respiratory and circulatory arrest most often occurs among children during the newborn period, as well as in children under two years of age. Parents and others need to be extremely attentive to children of this age category. Often the reasons for the development of a life-threatening condition can be a sudden blockage of the respiratory system by a foreign body, and in newborn children - by mucus and stomach contents. Sudden death syndrome is common, birth defects and abnormalities, drowning, strangulation, trauma, 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 cardiac problems (heart attacks, myocarditis, angina), then in children such a relationship is almost not traced. Progressive development comes to the fore in children respiratory failure without damage to the heart, and then circulatory failure develops.
Checking a child's pulse
If you suspect that something is wrong with the baby, you need to call him and ask simple questions“What’s your name?”, “Is everything okay?” if the child in front of you is 3-5 years old or 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, or a heartbeat. Poor circulation will be indicated by:
Checking for breathing
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 begin cardiopulmonary resuscitation in children and call an ambulance. If you do not know how to determine your pulse, you should not waste time on this. First of all, make sure that consciousness is preserved? Bend over him, call him, ask a question, if he doesn’t answer, pinch, squeeze his arm or leg.
If there is no reaction to your actions on the part of the child, he is unconscious. You can verify the absence of breathing by leaning your cheek and ear as close to his face as possible; if you do not feel the victim’s breath on your cheek, and also see that his chest does not rise from breathing movements, this indicates a lack of breathing. You can't hesitate! It is necessary to move on to resuscitation techniques for children!
Maintaining airway patency
Until 2010, there was a single standard of provision resuscitation care, which had the following abbreviation: ABC. It got its name from the first letters of the English alphabet. Namely:
After 2010, the European Resuscitation Council changed its recommendations, according to which the first place in resuscitation measures is to perform chest compressions (point C), rather than A. The abbreviation changed from “ABC” to “CVA”. But these changes had an effect among the adult population, in whom the cause of critical situations is mostly cardiac pathology. Among the children's population, as mentioned above, respiratory disorders prevail over cardiac pathology, therefore among children they are still guided by the “ABC” algorithm, which primarily ensures airway patency and respiratory support.
If the child is unconscious, there is no breathing or there are signs of breathing disorder, you need to make sure that the airway is passable and take 5 mouth-to-mouth or mouth-to-nose breaths. If a baby under 1 year of age is in critical condition, you should not give too strong artificial breaths into his respiratory tract, given the small capacity of small lungs. After taking 5 breaths into the patient’s airway, vital signs should be checked again: breathing, pulse. If they are absent, it is necessary to start chest compressions. Today, the ratio of the number of chest compressions and the number of breaths is 15 to 2 in children (in adults, 30 to 2).
The head should be in such a position that the airway is clear
If a small patient is unconscious, then the tongue often falls into his airway, or in the supine position the back of the head contributes to flexion of the cervical spine, and the airway will be closed. In both cases, artificial respiration will not bring any positive results - the air will rest against barriers and will not be able to enter the lungs. What should you do to avoid this?
- It is necessary to straighten your head in the cervical region. Simply put, throw your head back. You should avoid tilting back too much, as this may cause the larynx to move forward. Extension should be smooth, the neck should be slightly straightened. If there is a suspicion that the patient has an injured spine in the cervical region, tilting should not be done!
- Open the victim's mouth, trying to move the lower jaw forward and towards you. Examine the oral cavity, remove excess saliva or vomit, and foreign body, if any.
- The criterion for correctness, ensuring airway patency, is the following position of the child, in which his shoulder and outer ear canal are located on one straight line.
If after the above actions breathing has been restored, you feel movements of the chest, abdomen, a flow of air from the child’s mouth, and you can also hear a heartbeat and pulse, then other methods of cardiopulmonary resuscitation should not be performed in children. It is necessary to turn the victim to a position on his side, in which his upper leg is bent in knee joint and pushed forward, with the head, shoulders and body located on the side.
This position is also called “safe”, because it prevents reverse obstruction of the respiratory tract with mucus and vomit, stabilizes the spine, and provides good access to monitor the child’s condition. After the small patient is placed in a safe position, he is breathing and his pulse is palpable, his heartbeat is restored, it is necessary to monitor the child and wait for the ambulance to arrive. But not in all cases.
After criterion “A” is met, breathing is restored. If this does not happen, there is no breathing and cardiac activity, artificial ventilation and chest compressions should be immediately performed. First, take 5 breaths in a row, the duration of each breath is approximately 1.0-1.5 seconds. For children over 1 year old, inhalations are performed “mouth to mouth”, for 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 begin chest compressions in a ratio of 15:2
Chest compressions for children
In case of 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 characteristics young patients. When performing chest compressions in children, the following features should be remembered:
With the development of terminal conditions, timely and correct execution Primary cardiopulmonary resuscitation allows, in some cases, to save the lives of children and return victims to normal 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).
The main signs of 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 has early signs 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 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:
1. Lay the patient on his back on a hard surface (table, floor, asphalt).
2. Clean mechanically oral cavity and throat 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. Move the lower jaw forward and upward (the chin should occupy the highest position), which prevents the tongue from sticking to the back wall of the pharynx and facilitates air access.
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 to lift his head with your left hand, placed under the patient’s neck, and then, after preliminary take a 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.
After the first 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. Cardiac massage is carried out until the heart rhythm and pulse in the peripheral arteries are completely restored.
Method of performing indirect cardiac massage in children
The algorithm for performing cardiopulmonary resuscitation in children includes five stages. At the first stage, preparatory measures are carried out, at the second stage, the patency of the airways is checked. At the third stage, artificial ventilation is performed. The fourth stage consists of indirect cardiac massage. Fifth - in the correct drug therapy.
When preparing for cardiopulmonary resuscitation, children are checked for consciousness, spontaneous breathing, and a pulse in the carotid artery. The preparatory stage also includes identifying the presence of neck and skull injuries.
The next stage of the cardiopulmonary resuscitation algorithm in children is checking the patency of the airway.
To do this, the child’s mouth is opened, the upper respiratory tract is cleared of foreign bodies, mucus, vomit, the head is tilted back, and the chin is raised.
If a cervical spine injury is suspected, the cervical spine is immobilized before treatment begins.
When performing cardiopulmonary resuscitation, children are given artificial ventilation (ALV).
In children under one year old. Cover the child's mouth and nose with your mouth and press your lips tightly to the skin of his face. Slowly, for 1-1.5 seconds, inhale air evenly until the chest expands visible. The peculiarity of cardiopulmonary resuscitation in children at this age is that the tidal volume should not be greater than the volume of the cheeks.
In children older than one year. They pinch the child's nose, wrap their lips around his lips, while simultaneously throwing his head back and lifting his chin. Slowly exhale air into the patient's mouth.
If the oral cavity is damaged, mechanical ventilation is performed using the “mouth to nose” method.
Respiration rate: up to a year: per minute, from 1 to 7 years per minute, over 8 years per minute ( normal frequency respiration and blood pressure indicators depending on age are presented in the table).
Respiratory rate, per minute
The child is placed on his back. For children under 1 year of age, press 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 child's back.
For children over 1 year of age, cardiac massage is performed using the base of one hand or both hands (at an older age), standing on the side.
Subcutaneous, intradermal and intramuscular injections are given to children in the same way as to adults. But this route of administering medications 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 give the sick baby a microenema; the medicine 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 administered through the rectum.
Features of cardiopulmonary resuscitation in children lie in the dosage of medications 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 based on the patient’s weight, adrenaline is used at a dose of 1 ml per year of life in dilution (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 at a rate of 1 ml per year of life. Administration can be repeated every 3-5 minutes until a total dose of 0.04 mg/kg is achieved.
Sodium bicarbonate: 4% solution - 2 ml/kg.
Cardiopulmonary resuscitation (CPR) is specific algorithm actions to restore or temporarily replace lost or significantly impaired cardiac and respiratory function. By restoring the activity of the heart and lungs, the resuscitator ensures the maximum possible preservation of the victim’s brain in order to avoid social death (complete loss of vitality of the cerebral cortex). Therefore, a temporary term is possible - cardiopulmonary and cerebral resuscitation. Primary cardiopulmonary resuscitation in children is performed directly at the scene of the incident by any person who knows the elements of CPR techniques.
Despite cardiopulmonary resuscitation, mortality during 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 old. About 6% of newborns require cardiopulmonary resuscitation after birth; especially if the newborn’s weight 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 an assessment of the general condition and function of the central nervous system.
The sequence of the three most important techniques of cardiopulmonary resuscitation is formulated by P. Safar (1984) in the form of the “ABC” rule:
Measures aimed at restoring airway patency are carried out in the following sequence:
Having ensured airway patency, begin mechanical ventilation immediately. There are several main methods:
The former are mainly of historical significance 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 of the lungs in a victim is that a lot of air (1-1.5 l) is introduced with one breath, with active stretching of the lungs (Hering-Breuer reflex) and the introduction of an air mixture containing increased amount 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, in newborns 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:
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 within B, repeated digits should be 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, the following intensive therapy methods are used:
If in adults ventricular tachycardia or ventricular fibrillation are the main forms of cessation of blood circulation, 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 the heart, sometimes simultaneously respiratory function(primary revival) in at least half of the victims, but in the future survival in patients is observed much less frequently. 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 % 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:
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, 0.5 ATI (1.5 ATA) and platomin under the cover of antioxidant therapy (tocopherol, ascorbic acid, 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, a 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 on the 1st day, on subsequent days - up to 5 mg/kg, GHB mg/kg after 4-6 hours, enkephalins, opioids ) and antioxidant (vitamin E - 50% oil solution in up to 1 mg/kg strictly intramuscularly daily, for a course of injections) therapy. To stabilize membranes and normalize blood circulation, it is prescribed intravenously large doses prednisolone, metipred (domg/kg) in bolus or fractional doses 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 is necessary (treatment camphor oil, curiosin in places with impaired microcirculation), hospital infection (asepsis).
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.
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.
Bradycardia in a child with respiratory disorders is 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, closed cardiac massage should be performed.
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 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).
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, making 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.
For asystole, atropine and artificial rhythm stimulation 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 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 you to return to full life at least 1% are sick or injured in accidents.
Portnov Alexey Alexandrovich
Education: Kyiv National Medical University named after. A.A. Bogomolets, specialty - “General Medicine”
Recovery normal functioning circulatory system, maintaining air exchange in the lungs is the primary goal of cardiopulmonary resuscitation. Timely resuscitation measures help avoid the death of neurons in the brain and myocardium until blood circulation is restored and breathing becomes independent. Circulatory arrest in a child due to a cardiac cause occurs extremely rarely.
For infants and newborns, the following causes of cardiac arrest are distinguished: suffocation, SIDS - sudden infant death syndrome, when an autopsy cannot determine the cause of cessation of vital activity, pneumonia, bronchospasm, drowning, sepsis, neurological diseases. In children after twelve months, death most often occurs due to various injuries, suffocation due to illness or foreign body entering the respiratory tract, burns, gunshot wounds, and drowning.
Doctors divide young patients into three groups. The algorithm for resuscitation is different for them.
CPR in a child includes three stages, which are also called ABC - Air, Breath, Circulation:
When performing cardiopulmonary resuscitation on a newborn baby, the first two points are most important. Primary cardiac arrest is uncommon in young patients.
The first stage is considered the most important in the process of CPR in children. The algorithm of actions is as follows.
The patient is placed on his back, with the neck, head and chest in the same plane. If there is no skull injury, you need to tilt your head back. If the victim has an injury to the head or upper cervical region, it is necessary to move the lower jaw forward. If you are losing blood, it is recommended to elevate your legs. Violation of the free flow of air through the respiratory tract infant may worsen with excessive bending of the neck.
The reason for the ineffectiveness of pulmonary ventilation measures 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 and an airway is inserted. If it is impossible to intubate the patient, breathing “mouth to mouth” and “mouth to nose and mouth” is performed.
The solution to the problem of the patient's head tilting refers to priority tasks CPR.
Airway obstruction causes the patient's heart to stop. This phenomenon causes allergies, inflammatory infectious diseases, foreign objects in the mouth, throat or trachea, vomit, blood clots, mucus, sunken tongue of a child.
When performing artificial ventilation, it is optimal to use 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 patient’s nose and mouth.
To prevent the stomach from distending, 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 steps 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. If there is no breathing, take two breaths lasting one and a half to two seconds. After this, wait a few seconds for the air to escape.
When resuscitating a child, you should inhale air very carefully. Careless actions can cause rupture of lung tissue. Cardiopulmonary resuscitation of a newborn and infant is carried out using the cheeks to blow air. After the second inhalation of air and its exit from the lungs, the heartbeat is felt.
Air is blown into the child's lungs eight to twelve times per minute at intervals of five to six seconds, provided that the heart is functioning. If a heartbeat is not detected, proceed to chest compressions and other life-saving actions.
It is necessary to carefully check for the presence of foreign objects in the oral cavity and upper section respiratory tract. This kind of obstruction will prevent air from entering the lungs.
The sequence of actions is as follows:
If the child cannot be placed in the correct position on the forearm, then the thigh and bent leg of the person resuscitating the child are used as support.
Closed cardiac muscle massage is used to normalize hemodynamics. Not carried out without the use of mechanical ventilation. Due to an increase in intrathoracic pressure, blood is released from the lungs into circulatory system. The maximum air pressure in a child's lungs occurs in the lower third of the chest.
The first compression should be a test, it is carried out to determine the elasticity and resistance of the chest. The chest is squeezed during cardiac massage by 1/3 of its size. Chest compression is performed differently for different age groups of patients. It is carried out by applying pressure to the base of the palms.
Features of cardiopulmonary resuscitation in children are that it is necessary to use fingers or one palm to perform compression due to small size patients and frail physique.
There are some differences in CPR of a cardiac nature in patients over 18 years of age and cardiopulmonary failure resulting from suffocation in children, therefore resuscitators are recommended to use a special pediatric algorithm.
If only one physician is involved in resuscitation, he should perform two air injections into the patient's lungs for every thirty compressions. If two resuscitators are working simultaneously, compression is performed 15 times for every 2 air injections. When using a special tube for ventilation, non-stop cardiac massage is performed. The ventilation rate ranges from eight to twelve beats per minute.
A heart blow or precordial blow is not used in children - the chest may be seriously damaged.
The compression frequency ranges 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.
Resuscitation efforts should not be interrupted for more than five seconds. 60 seconds after resuscitation begins, the physician should check the patient's pulse. After this, the heartbeat is checked every two to three minutes when the massage stops for 5 seconds. The state of the pupils of the person being resuscitated 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, resuscitation measures should not be interrupted for more than 30 seconds.
Relevance of the topic. Cardiopulmonary syncope (CPS) is a sudden and unexpected cessation of effective breathing or circulation, or both.
Respiratory and circulatory arrest most often occurs in children of the first two years of life, and among them in children of the first five months of life. In children, SIJ is of a polyetiological nature. The most common causes of SIDS are sudden infant death syndrome, road traffic injury, drowning, upper airway obstruction, respiratory diseases, congenital malformations, sepsis, and dehydration.
Common goal. Improve knowledge and skills in diagnosing and providing emergency care for cardiopulmonary syncope.
Specific goal. Based on complaints, medical history, objective examination data, determine the main signs of an emergency condition, carry out differential diagnosis, and provide the necessary assistance.
1. Etiology and pathophysiology of cardiopulmonary syncope.
2. Clinical signs of cardiopulmonary syncope.
3. Tactics of cardiopulmonary resuscitation.
4. Follow-up life support activities.
During preparation for the lesson, it is necessary to familiarize yourself with the main theoretical issues through the graph-logical structure of the topic, treatment algorithms (Fig. 1, 2), and literature sources.
The main clinical signs of cardiopulmonary syncope:
- lack of breathing, heartbeat and consciousness;
- disappearance of the pulse in the carotid and other arteries;
- pale or gray-sallow complexion;
- dilated pupils, lack of reaction to light;
- total hypotension, areflexia.
1. Immediately begin resuscitation measures.
2. Record the time of appearance of signs of clinical death and the beginning of resuscitation measures.
3. Sound the alarm, call assistants and the resuscitation team.
A (Airways)- restoration of airway patency
1. Place the patient’s 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, straighten your airways (contraindicated in case of injury to the cervical spine), and place a soft cushion under your neck.
4. Move the lower jaw forward and upward to prevent the tongue from sinking and facilitate air access.
B (Breath)- restoration of breathing
1. Start artificial ventilation of the lungs using expiratory methods from mouth to mouth in children over 1 year of age or from mouth to mouth and nose in children under 1 year of age.
2. Cover the patient’s face with a handkerchief or gauze pad.
When breathing from mouth to mouth and nose, the resuscitator with his left hand pulls up the patient’s head, and then, after a preliminary deep breath, tightly covers the child’s nose and mouth with his lips and blows in air. As soon as the chest rises, the air injection is stopped and the patient is allowed to exhale passively.
The procedure is repeated with a frequency equal to the age-related respiratory rate of the patient: in children of the first years of life - 20 per 1 minute, in adolescents - 15 per 1 minute. When breathing from mouth to mouth, the resuscitator covers the patient's mouth with his lips and pinches his nose with his right hand.
With both methods of artificial respiration there is a danger of air entering the stomach, its distension, regurgitation of gastric contents into the oropharynx and aspiration. Using a gastric tube can prevent this.
C (Circulation)- restoration of blood circulation
After 3-4 air insufflations in the absence of a pulse in the carotid artery, it is necessary to begin chest compressions.
The resuscitator selects a hand position appropriate for the child’s age and performs rhythmic chest compressions at the patient’s age-appropriate pulse rate (Table 1). The pressure force should correspond to the elasticity of the chest. Cardiac massage is carried out until the pulse in the peripheral arteries is restored.
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Complications of chest compressions: rib and sternum fractures, pneumothorax, liver rupture, regurgitation of gastric contents and aspiration.
For every two air insufflations, do 15 chest compressions. When both procedures are performed by one resuscitator, you can do 2 inflations in a row, and then 30 chest compressions.
The child’s condition must be 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:
— assessment of chest movements: depth of breathing, uniform participation of the chest in breathing;
— checking the transmission of massaging movements of the chest by the pulse in the carotid and radial arteries;
- increase in blood pressure to 50-70 mm Hg;
- reducing the degree of cyanosis of the skin and mucous membranes;
- narrowing of previously dilated pupils and the appearance of a reaction to light;
- resumption of spontaneous breaths and heart contractions.
1. If the heartbeat does not recover without stopping performing mechanical ventilation and chest compressions, provide access to a peripheral vein and administer intravenously:
— 0.1% solution of adrenaline 0.01 ml/kg (0.01 mg/kg)1;
- 0.1% solution of atropine sulfate 0.01-0.02 ml/kg (0.01-0.02 mg/kg).
If necessary, re-introduce these drugs intravenously after 5 minutes.
2. Oxygen therapy with 100% oxygen through a face mask or nasal catheter.
3. For ventricular fibrillation—defibrillation.
4. In the presence of metabolic acidosis, administer 4% sodium bicarbonate solution 2 ml/kg (1 mmol/kg) intravenously.
5. In the presence of hyperkalemia, hypocalcemia or an overdose of calcium blockers, administration of a 10% calcium gluconate solution 0.2 ml/kg (20 mg/kg) is indicated.
Intracardiac administration of drugs is not currently practiced.
Main
1. Berezhnoy V.V., Marushko T.V. The risk of sudden death in children and adolescents // Tauride Medical-Biological Bulletin. - 2009. - T. 12, No. 2(46). - P. 93-99.
2. Order of the Ministry of Health of Ukraine No. 437 dated 08/31/04. About the confirmation of clinical protocols for the provision of medical assistance for difficult conditions in children at the hospital and pre-hospital stages.
3. Gordeev V.I., Aleksandrovich Yu.S., Lapis G.A., Ironosov V.E. Emergency pediatrics of the prehospital stage. - St. Petersburg: Publication of the State Medical Academy, 2003. - P. 172-221.
4. Nagornaya N.V., Pshenichnaya E.V., Chetverik N.A. Sudden cardiac death in children. Risk stratification from the perspective of evidence-based medicine // Tauride Medical and Biological Bulletin. - 2009. - T. 12, No. 2(46).— P. 28-35.
5. Volosovets O.P., Marushko Yu.V., Tyazhka O.V. ta in. Uncomplicated topics in pediatrics: Beg. pos_b. / For ed. O.P. Volosovtsia and Yu.V. Marushko.— Kh.: Prapor, 2008.— 200 p.
6. Snisar V.I., Syrovatko Y.A. Features of cardiopulmonary resuscitation in children // Health of Ukraine. - 2005. - No. 13-14. - P. 27.
7. Uchaikin V.F., Molochny V.P. Emergency conditions in pediatrics: A practical guide. - M.: GEOTAR-Media, 2005. - 256 p.
Additional
1. Volosovets O.P., Savvo M.V., Krivopustov S.P. ta in. Selected nutrition for pediatric cardio-rheumatology / Ed. O.P.Volosovtsia, M.V. Savvo, S.P. Krivopustova.—Kiev; Kharkiv.— 2006.— 246 p.
2. Selbst S.M., Kronan K. Secrets of emergency pediatrics: Trans. from English / Under the general editorship. prof. N.P. Shabalova.— M.: MEDpress-inform, 2006.—480 p.
3. Standards and Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC) // JAMA. - 1992. - 268(16). - pp. 2171-3203.
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 (cessation of pulsation in the femoral and carotid arteries, absence of heart sounds), as well as cessation of spontaneous breathing, loss of consciousness and dilation of the pupils. and symptoms are the most important diagnostic criteria for cardiac arrest, which can be predictable or sudden. Foreseen heart failure can be observed in a terminal state, which means a period of extinction of the body’s vital functions. A terminal state may arise as a result of a critical disorder of homeostasis due to disease or the body’s inability to adequately respond to external influences (trauma, hypothermia, overheating, poisoning, etc.). Cardiac arrest and circulatory arrest may be associated with asystole, ventricular fibrillation and collapse. Heart failure always accompanied by cessation of breathing; Like sudden respiratory arrest associated with airway obstruction, central nervous system depression, or neuromuscular paralysis, it can result in cardiac arrest.
Without wasting time to find out the cause of cardiac or respiratory arrest, they immediately begin treatment, which includes the following set of measures: cardiac arrest, resuscitation, defibrillation
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 perform ECG monitoring of cardiac activity.
If against the backdrop of ongoing heart massage and cardiac ventilation does not restore cardiac activity, 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 advisability of using calcium supplements during resuscitation is currently questioned. To maintain cardiac activity after its resumption, dopamine or dobutamine (Dobutrex) is administered - 2 - 20 mcg/kg per minute. For ventricular fibrillation, lidocaine is prescribed - 1 mg/kg intravenously; if there is no effect, emergency electrodefibrillation is indicated (2 W/kg in 1 s). If necessary, it is repeated - 3 - 5 W/kg per 1 s.
Maintenance therapy consists of using 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 mmHg). For bradycardia, isoproterenol is administered at 0.05 - 1.5 mcg/kg per 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. Mannitol is administered - 1 g/kg, dexazone - 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 the first day under blood pressure control. Thiopental sodium is prescribed - 3 - 5 mg/kg intravenously under control of respiratory rate (one should remember the negative inotropic effect of the drug). Vital monitoring is required important indicators pulse, central venous pressure, blood pressure, body temperature. Control of urination and state of consciousness is very important. EEG control and ECG monitoring are carried out until cardiac activity and respiration are stabilized.
Contraindications to resuscitation:
Hospitalization is carried out in the intensive care unit.
Primary cardiac arrest occurs much less frequently in children than in adults. Ventricular fibrillation accounts for less than 10% of all clinical deaths in children. Most often it is a consequence of congenital pathology.
Most common cause performing cardiopulmonary resuscitation in children is trauma.
Cardiopulmonary resuscitation in children has certain features.
When carrying out mouth-to-mouth breathing, it is necessary to avoid excessively deep insufflations (that is, exhalation of the resuscitator). An indicator can be the volume of excursion of the chest wall, which in children is labile and its movements are well controlled visually. Foreign bodies cause airway obstruction more often in children than in adults.
If there is no spontaneous breathing in the child, after 2 artificial breaths it is necessary to begin cardiac massage, since apnea cardiac output, as a rule, is inadequately low, and palpation of the pulse in the carotid artery in children is often difficult. It is recommended to palpate the pulse in the brachial artery.
It should be noted that the absence of a visible apical impulse and the impossibility of 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 minute until spontaneous breathing is restored or more modern methods of ventilation are used. If there is no pulsation of the central arteries, cardiac massage is necessary.
Chest compression in small child performed with one hand, and the other 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 Bottom part sternum. Compression is performed with 2 or 3 fingers. The amplitude of movement should be 1-2.5 cm, the frequency of compressions should be approximately 100 per minute. Just like with adults, you need to pause for ventilation. The ventilation-compression ratio is also 1:5. Approximately every 3 to 5 minutes, check for spontaneous heartbeats. Hardware compression is usually not used in children. It is not recommended to use an anti-shock suit in children.
If outdoor massage While heart massage in adults is considered more effective than closed massage, in children no such advantage of direct massage has been identified. Apparently, this is explained by the good compliance of the chest wall in children. Although in some cases, if indirect massage is ineffective, you should resort to direct massage. When drugs are administered into the central and peripheral veins, such a difference in the rate of onset of effect in children is not observed, but if possible, 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 during cardiopulmonary resuscitation, although complications may occur (osteomyelitis, etc.). There is a risk of microfat pulmonary embolism with intraosseous injection, but this is not particularly important clinically. 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, apparently, the intravenous dose of adrenaline should be increased 10 times. The dose of other drugs should also be increased. The drug is injected deeply into the tracheobronchial tree through a catheter.
Intravenous fluid administration during cardiopulmonary resuscitation in children is more important than in adults, especially with severe hypovolemia (blood loss, dehydration). Children should not be given glucose solutions (even 5%) because large volumes of glucose-containing solutions lead to hyperglycemia and increased neurological deficits more quickly than in adults. If hypoglycemia is present, it is corrected with glucose solution.
The most effective drug for circulatory arrest is adrenaline at a dose of 0.01 mg/kg (10 times more endotracheally). If there is no effect, re-administer after 3-5 minutes, increasing the dose by 2 times. In the absence of effective cardiac activity, intravenous infusion of adrenaline is continued at a rate of 20 mcg/kg per minute; when heart contractions resume, the dose is reduced. For hypoglycemia, drip infusions of 25% glucose solutions are necessary; bolus injections should be avoided, since even short-term hyperglycemia can negatively affect the neurological prognosis.
Defibrillation in children is used for the same indications (ventricular fibrillation, ventricular tachycardia with absence of pulse) as in adults. In children younger age Electrodes of slightly smaller diameter are used. The initial discharge energy should be 2 J/kg. If this value of 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 and lidocaine are administered.
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