home Audience 5 Cardiopulmonary resuscitation for a 1 month old child. Procedure for performing cardiopulmonary resuscitation in adults and children

Cardiopulmonary resuscitation for a 1 month old child. Procedure for performing cardiopulmonary resuscitation in adults and children

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 consider urgent measures during the offensive clinical death.

Clinical death can be diagnosed based on the following signs:

there is no breathing, no blood circulation (pulse cannot be detected on carotid artery), the pupils are dilated (there is no reaction to light), consciousness is not determined, reflexes are absent.

If clinical death is diagnosed, you need to:

Record the time when clinical death occurred and the time when resuscitation began;
Sound the alarm, call the resuscitation team for help (one person is not able to provide high-quality resuscitation);
Revival should begin immediately, without wasting time on auscultation, measuring blood pressure and determining the causes of the terminal condition.

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 a cervical injury, this is contraindicated), and place a cushion 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:

If one rescuer performs resuscitation, then the ratio is 2:30;
If several rescuers are performing resuscitation, then a breath is taken every 6-8 seconds, without interrupting the heart massage.

The introduction of an air duct or laryngeal mask greatly facilitates mechanical ventilation.

At the stage medical care For mechanical ventilation, a manual breathing apparatus (Ambu bag) or an anesthesia machine is used.

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 backdrop of ongoing closed massage hearts and 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 in saline to 5 ml and injected into the endotracheal tube through a thin catheter.

An intraosseous needle is inserted into the 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:

Adrenaline hydrotartate 0.1% solution at a dose of 0.01 ml/kg (0.01 mg/kg). The drug can be administered every 3 minutes. In practice, 1 ml of adrenaline is diluted with saline solution

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).

Previously they introduced 0.1% atropine solution sulfate 0.01 ml/kg (0.01 mg/kg). Now it is not recommended for asystole and electromech. dissociation due to lack of therapeutic effect.

The administration of sodium bicarbonate used to be mandatory, now only when indicated (for hyperkalemia or severe metabolic acidosis).

The dose of the drug is 1 mmol/kg body weight.

Calcium supplements are not recommended. Prescribed only when cardiac arrest is caused by an overdose of calcium antagonists, with hypocalcemia or hyperkalemia. Dose of CaCl 2 - 20 mg/kg

I would like to note that in adults, defibrillation is a priority measure and should begin simultaneously with closed heart massage.

In children, ventricular fibrillation occurs in about 15% of all cases of circulatory arrest and is therefore 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.

Mechanical defibrillation includes precordial shock (a blow to the sternum with a fist). Currently not used in pediatric practice.
Medical defibrillation consists of the use of antiarrhythmic drugs - verapamil 0.1-0.3 mg/kg (no more than 5 mg once), lidocaine (at a dose of 1 mg/kg).
Electrical defibrillation is the most effective method and an essential component of cardiopulmonary resuscitation.

(2J/kg – 4J/kg – 4J/kg). If there is no effect, then against the background of ongoing resuscitation 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:

More than 25 minutes have passed since cardiac arrest;
The patient is in the terminal stage of an incurable disease;
The patient received full complex intensive treatment, and against this background cardiac arrest occurred;
Biological death was declared.

In conclusion, I would like to note that cardiopulmonary resuscitation should be carried out under the control of electrocardiography. It is a classic diagnostic method for such conditions.

Single cardiac complexes, 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.

Cardiopulmonary resuscitation in children

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 say that every year the number of children who die in early childhood is steadily growing. But if next to right moment turned out to be a person who knows how to provide first aid and knows 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.

1 What is cardiopulmonary resuscitation?

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.

2 Causes leading to life-threatening conditions in children

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. The syndrome is often encountered sudden death, 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 respiratory failure without damage to the heart comes to the fore in children, and then circulatory failure develops.

3 How to understand that a circulatory disorder has occurred?

Checking a child's pulse

If you suspect that something is wrong with the baby, you need to call him, ask simple questions “what is 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:

lack of consciousness
difficulty/absence of breathing,
the pulse in the large arteries is not detected,
heartbeats are not heard,
pupils are dilated,
no reflexes.

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!

4 ABC or CAB?

Maintaining airway patency

Until 2010, there was a single standard for the provision of resuscitation care, which had the following abbreviation: ABC. It got its name from the first letters of the English alphabet. Namely:

A - air (air) - ensuring airway patency;
B - breathe for victim - ventilation of the lungs and access of oxygen;
C - circulation of blood - compression of the chest and normalization of blood circulation.

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.

5 Carrying out resuscitation

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).

6 How to create airway patency?

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 into a position on his side, in which his upper leg is bent at the knee joint and extended forward, while the head, shoulders and body are 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

7 Features of chest compressions in children

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:

Recommended frequency of chest compressions in children per minute.
The depth of pressure on the chest for children under 8 years old is about 4 cm, over 8 years old - about 5 cm. The pressure should be quite strong and fast. Don't be afraid to apply deep pressure. Because too superficial compressions will not lead to a positive result.
In children in the first year of life, pressure is performed with two fingers, in older children - with the base of the palm of one hand or both hands.
The hands are located on the border of the middle and lower third of the sternum.

Primary cardiopulmonary resuscitation in children

With the development of terminal conditions, timely and correct conduct of primary cardiopulmonary resuscitation allows, in some cases, to save the lives of children and return victims to normal life. 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 eyeball If the pupil takes on 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:

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. 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

Cardiopulmonary resuscitation in children: features and algorithm of actions

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. The fifth is proper drug therapy.

Algorithm for performing cardiopulmonary resuscitation in children: preparation and mechanical ventilation

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.

Respiratory rate: up to a year: per minute, from 1 to 7 years per minute, over 8 years per minute (normal respiratory rate and blood pressure indicators depending on age are presented in the table).

Age norms of heart rate, blood pressure, respiratory rate in children

Respiratory rate, per minute

Cardiopulmonary resuscitation in children: cardiac massage and medication administration

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 a 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 in newborns and children

Cordially- pulmonary resuscitation(CPR) is a specific algorithm of 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 general condition and functions of the central nervous system.

Carrying out cardiopulmonary resuscitation in children

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

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;
Breath for victim (“breathing for the victim”) means mechanical ventilation;
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;
straighten the head in the cervical region, bring the lower jaw forward and at the same time open the victim’s mouth (triple maneuver 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 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 methods for the victim’s lungs 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), stimulates the patient's respiratory center. 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 chest compressions is evidenced by a decrease in cyanosis of the lips, ears and skin, constriction of the pupils and the appearance of a photoreaction, increased 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 reason circulatory arrest in children - 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 occurred against the background of decompensated metabolic acidosis. Usual dose 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-hour), or µg/(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 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 methods are used 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.

Does not currently exist legal grounds to stop initiated and actively ongoing intensive therapy in children until natural circulatory arrest occurs. 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 % in combination with an increase in vascular resistance by 4 times. Repeated deterioration 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);
at a later date - 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 central processing unit and rheological properties blood is carried out with hemodilutants (albumin, protein, dry and native plasma, rheopolyglucin, saline solutions, less often a polarizing mixture with the administration 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 dosemg/kg strictly intramuscularly daily, for a course of injections) therapy. To stabilize membranes and normalize blood circulation, large doses of prednisolone and metipred (domg/kg) are prescribed intravenously 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, WWTP and energy metabolism. Detoxification therapy is carried out (infusion therapy, hemosorption, plasmapheresis according to indications) for prevention 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.

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, 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 when extreme the severity of the child.

Since blood pressure depends on age, it is easy to remember the lower limit of normal 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. At basal temperature body below 35 “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 most narrow part 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% 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.

Medical Expert Editor

Portnov Alexey Alexandrovich

Education: Kyiv National Medical University them. A.A. Bogomolets, specialty - “General Medicine”

Algorithm of actions for cardiopulmonary resuscitation in children, its purpose and types

Restoring the normal functioning of the circulatory system and 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 occurs most often due to various injuries, suffocation due to illness or foreign body entering the respiratory tract, burns, gunshot wounds, drowning.

Purpose of CPR in children

Doctors divide young patients into three groups. The algorithm for resuscitation is different for them.

Sudden stoppage of blood circulation in a child. Clinical death throughout the entire period of resuscitation. Three main outcomes:

CPR ended with a positive result. At the same time, it is impossible to predict what the patient’s condition will be after his clinical death, and how much the functioning of the body will be restored. The so-called post-resuscitation illness develops.
The patient lacks the possibility of spontaneous mental activity, and brain cells die.
Resuscitation does not bring a positive result; doctors declare the patient’s death.

The prognosis for cardiopulmonary resuscitation in children with severe trauma is poor, in in a state of shock, complications of a purulent-septic nature.
Resuscitation of a patient with oncology, abnormal development of internal organs, or severe injuries is carefully planned whenever possible. Immediately proceed to resuscitation efforts in the absence of pulse and breathing. Initially, it is necessary to understand whether the child is conscious. This can be done by shouting or lightly shaking, while avoiding sudden movements of the patient’s head.

Primary resuscitation

CPR in a child includes three stages, which are also called ABC - Air, Breath, Circulation:

Air way open. The airway must be cleared. Vomiting, tongue retraction, foreign body may be an obstacle to breathing.
Breath for victim. Carrying out activities on artificial respiration.
Circulation his blood. Closed heart massage.

When performing cardiopulmonary resuscitation on a newborn baby, the first two points are most important. Primary cardiac arrest is uncommon in young patients.

Maintaining a child's airway

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 in an infant may increase with excessive bending of the neck.

The reason for the ineffectiveness of pulmonary ventilation measures may be the lack of correct position 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.

Solving the problem of the patient's head tilting is one of the primary tasks of 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 the child.

Algorithm of actions for mechanical ventilation

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 actions. 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 respiratory tract. This kind of obstruction will prevent air from entering the lungs.

The sequence of actions is as follows:

The victim is placed on the arm bent at the elbow, the baby’s torso is above the level of the head, which is held by the lower jaw with both hands.
After the patient is placed in the correct position, five gentle blows are applied between the patient's shoulder blades. The blows should have a directed effect from the shoulder blades to the head.

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 heart massage and chest compression

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 the 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

The peculiarities of cardiopulmonary resuscitation in children are that it is necessary to use fingers or one palm to perform compression due to the small size of the patients and fragile physique.

For infants, pressure is applied to the chest using only the thumbs.
For children from 12 months to eight years old, massage is performed with one hand.
For patients over eight years of age, both palms are placed on the chest. as for adults, but the force of pressure is proportional to the size of the body. The elbows of the hands remain straight during cardiac massage.

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.

Compression-ventilation ratio

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.

Breathing and normal heart function are functions that, when stopped, life leaves our body within a few minutes. First, a person falls into a state of clinical death, soon followed by biological death. Stopping breathing and heartbeat has a strong impact on the brain tissue.

Metabolic processes in brain tissue are so intense that the lack of oxygen is detrimental to them.

At the stage of clinical death, it is quite possible to save a person if you begin to provide first emergency aid correctly and promptly. A set of methods aimed at restoring breathing and heart function is called cardiopulmonary resuscitation. There is a clear algorithm for carrying out such rescue operations, which should be applied directly at the scene of the incident. One of the latest and most comprehensive recommendations regarding what to do during respiratory and cardiac arrest is a guide released by the American Heart Association in 2015.

Cardiopulmonary resuscitation in children is not much different from similar activities for adults, but there are nuances that you should know. Cardiac and respiratory arrest often occurs in newborns.

A little physiology

Once breathing or heartbeat stops, oxygen stops flowing to the tissues of our body, which causes their death. The more complex the tissue is, the more intense the metabolic processes take place in it, the more destructive the effect of oxygen starvation is on it.

The brain tissues suffer the most; a few minutes after the oxygen supply is cut off, irreversible damage begins in them. structural changes which lead to biological death.

Cessation of breathing leads to disruption of the energy metabolism of neurons and ends in cerebral edema. Nerve cells begin to die approximately five minutes after this, it is during this period that assistance must be provided to the victim.

It should be noted that clinical death in children very rarely occurs due to problems with the heart; much more often this occurs due to respiratory arrest. This important difference determines the characteristics of cardiopulmonary resuscitation in children. In children, cardiac arrest is usually the final stage of irreversible changes in the body and is caused by the extinction of its physiological functions.

First aid algorithm

The algorithm for carrying out first aid in case of cardiac and respiratory arrest in children is not much different from similar measures for adults. Resuscitation of children also consists of three stages, which were first clearly formulated by the Austrian physician Pierre Safari in 1984. After this point, the first aid rules were repeatedly supplemented; there are basic recommendations issued in 2010, and there are later ones prepared in 2015 by the American Heart Association. The 2015 guide is considered the most complete and detailed.

Techniques for providing assistance in such situations are often called the “ABC rule.” Here are the main stages of action in accordance with this rule:

Air way oren. It is necessary to free the victim's airways from obstacles that could prevent air from entering the lungs (this point is translated as “open the way for air”). Vomit may act as an obstacle, foreign bodies or sunken root of the tongue.
Breath for victim. This point means that the victim needs to be given artificial respiration (translated: “breathing for the victim”).
Circulation his blood. The last point is heart massage (“circulation of its blood”).

When resuscitating children, special attention should be paid to the first two points (A and B), since primary cardiac arrest is quite rare in them.

Signs of clinical death

You should know the signs of clinical death, which is usually when cardiopulmonary resuscitation is performed. In addition to cardiac and respiratory arrest, it also causes dilation of the pupils, as well as loss of consciousness and areflexia.

Stopping the heart can be detected very easily by checking the victim's pulse. This is best done on the carotid arteries. The presence or absence of breathing can be determined visually, or by placing your palm on the victim’s chest.

After cessation of blood circulation, loss of consciousness occurs within fifteen seconds. To make sure of this, turn to the victim and shake his shoulder.

Carrying out first aid

Resuscitation measures should begin with clearing the airways. To do this, the child needs to be placed on his side. Use a finger wrapped in a handkerchief or napkin to clean the mouth and throat. The foreign body can be removed by tapping the victim on the back.

Another way is the Heimlich maneuver. It is necessary to clasp the victim’s torso with your hands under the costal arch and sharply squeeze bottom part chest.

After clearing the airways, artificial ventilation should begin. To do this, it is necessary to extend the victim’s lower jaw and open his mouth.

The most common method of artificial ventilation is the mouth-to-mouth method. You can blow air into the victim’s nose, but it is much more difficult to clean it than the oral cavity.

Then you need to close the victim’s nose and breathe air into his mouth. The frequency of artificial breaths must correspond to physiological standards: for newborns this is approximately 40 breaths per minute, and for children aged five years – 24-25 breaths. You can place a napkin or handkerchief over the victim's mouth. Artificial ventilation helps to activate your own respiratory center.

The last type of manipulation that is performed during cardiopulmonary resuscitation is chest compressions. Heart failure is more often the cause of clinical death in adults; it is less common in children. But in any case, during the provision of assistance, you must ensure at least minimal blood circulation.

Before starting this procedure, place the victim on a hard surface. His legs should be slightly elevated (about 60 degrees).

Then you should begin to strongly and energetically compress the victim’s chest in the sternum area. The point for applying force in infants is right in the middle of the sternum, in older children it is just below the center. When massaging newborns, the point should be pressed with the tips of your fingers (two or three), for children from one to eight years old with the palm of one hand, for older ones - with both palms at the same time.

It is clear that it is extremely difficult for one person to do both processes simultaneously. Before you begin resuscitation, you need to call someone for help. In this case, everyone takes on one of the above tasks.

Try to time the time the child spent unconscious. This information will then be useful to doctors.

Previously, it was believed that 4-5 chest compressions were needed per breath. However, now experts believe that this is not enough. If you perform resuscitation alone, you are unlikely to be able to provide the required frequency of breaths and compressions.

If a pulse appears and spontaneous breathing movements of the victim appear, resuscitation measures should be stopped.

vseopomoschi.ru

Features of cardiopulmonary resuscitation in children

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 paid to points A and B. If resuscitation of adults is based on the fact of primary heart failure, then a child in cardiac arrest - this is the finale of the process of gradual extinction of the physiological functions of the body, initiated, as a rule, 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-arrest” phase, which determines the need for early diagnosis of this phase.

Pediatric resuscitation consists of two stages, which are presented in the form of algorithmic 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.

The peculiarity of artificial pulmonary ventilation in young children is determined by the fact that the small diameter of the child’s respiratory tract 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, start 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 quickly applied to the back between the shoulder blades with the proximal part of the palm. 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).

When a child has a pulse but there is no effective ventilation, only artificial respiration is performed. The absence of a pulse is an indication for performing artificial circulation using closed heart massage. Closed heart massage should never be performed without artificial ventilation.

The recommended area of chest compression in newborns and infants is a finger's width below the intersection of the nipple line and the sternum. In children under one year old, two methods of performing closed cardiac massage are used:

– location of two or three fingers on the chest (Fig. 11);

– covering the child’s chest with the formation of a rigid surface of four fingers on the back and using thumbs to perform compressions.

The amplitude of compression is approximately 1/3-1/2 of the anteroposterior size of the child’s chest (Table 2).

If the child’s thumb and three fingers do not create adequate compression, then to perform closed cardiac massage, you need to use the proximal part of the palmar surface of one or both hands (Fig. 12).

The speed of compressions and their ratio to breathing depends on the age of the child (see Table 2).

Mechanical chest compression devices have been used extensively in adults, but not in children due to the very high incidence of complications.

Precordial shock should never be used in pediatric practice. In older children and adults, it is considered an optional procedure when the patient does not have a pulse and a defibrillator cannot be used quickly.

Read other articles on helping children in different situations

medspecial.ru

Algorithm of actions for cardiopulmonary resuscitation in children, its purpose and types

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.

Purpose of CPR in children

Doctors divide young patients into three groups. The algorithm for resuscitation is different for them.

Sudden stoppage of blood circulation in a child. Clinical death throughout the entire period of resuscitation. Three main outcomes:

CPR ended with a positive result. At the same time, it is impossible to predict what the patient’s condition will be after his clinical death, and how much the functioning of the body will be restored. The so-called post-resuscitation illness develops.
The patient lacks the possibility of spontaneous mental activity, and brain cells die.
Resuscitation does not bring a positive result; doctors declare the patient’s death.

The prognosis is unfavorable when performing cardiopulmonary resuscitation in children with severe trauma, in a state of shock, and purulent-septic complications.
Resuscitation of a patient with oncology, abnormal development of internal organs, or severe injuries is carefully planned whenever possible. Immediately proceed to resuscitation efforts in the absence of pulse and breathing. Initially, it is necessary to understand whether the child is conscious. This can be done by shouting or lightly shaking, while avoiding sudden movements of the patient’s head.

Indications for resuscitation - sudden cessation of blood circulation

Primary resuscitation

CPR in a child includes three stages, which are also called ABC - Air, Breath, Circulation:

Air way open. The airway must be cleared. Vomiting, tongue retraction, foreign body may be an obstacle to breathing.
Breath for victim. Carrying out artificial respiration measures.
Circulation his blood. Closed heart massage.

When performing cardiopulmonary resuscitation on a newborn baby, the first two points are most important. Primary cardiac arrest is uncommon in young patients.

Maintaining a child's airway

The first stage is considered the most important in the process of CPR in children. The algorithm of actions is as follows.

The reason for the ineffectiveness of pulmonary ventilation measures may be the incorrect position of the child’s head relative to the body.

Algorithm of actions for mouth-to-mouth ventilation

Solving the problem of the patient's head tilting is one of the primary tasks of CPR.

Airway obstruction causes the patient's heart to stop. This phenomenon is caused by allergies, inflammatory infectious diseases, foreign objects in the mouth, throat or trachea, vomit, blood clots, mucus, and a child’s sunken tongue.

Algorithm of actions for mechanical ventilation

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.

It is necessary to carefully check for the presence of foreign objects in the oral cavity and upper respiratory tract. This kind of obstruction will prevent air from entering the lungs.

The sequence of actions is as follows:

The victim is placed on the arm bent at the elbow, the baby’s torso is above the level of the head, which is held by the lower jaw with both hands.
After the patient is placed in the correct position, five gentle blows are applied between the patient's shoulder blades. The blows should have a directed effect from the shoulder blades to the head.

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 heart massage and chest compression

Features of cardiopulmonary resuscitation in children

The peculiarities of cardiopulmonary resuscitation in children are that it is necessary to use fingers or one palm to perform compression due to the small size of the patients and fragile physique.

For infants, pressure is applied to the chest using only the thumbs.
For children from 12 months to eight years old, massage is performed with one hand.
For patients over eight years of age, both palms are placed on the chest. as for adults, but the force of pressure is proportional to the size of the body. The elbows of the hands remain straight during cardiac massage.

Compression-ventilation ratio

A heart blow or precordial blow is not used in children - the chest may be seriously damaged.

Remember that the child's life is in your hands

lechiserdce.ru

CPR in children

Resuscitation guidelines published by the European Resuscitation Council

Section 6. Resuscitation measures in children

Introduction

Background

The European Resuscitation Council (ERC) has previously issued Guidelines for Pediatric Life Support (PLS) in 1994, 1998 and 2000. The latest edition was based on the final recommendations of the International Scientific Consensus issued by the American Heart Association in collaboration with the International Consensus Committee on Resuscitation (ILCOR); it included separate recommendations for cardiopulmonary resuscitation and emergency cardiac care, published in “Guide 2000” in August 2000. According to the same principle in 2004-2005. final conclusions and practical recommendations The consensus meeting was initially published simultaneously in all leading European publications on the topic in November 2005. The Pediatric Section (PLS) Working Group of the European Council of Critical Care Medicine reviewed this document and relevant scientific publications and recommended changes to the pediatric section of the Guidelines. These changes are presented in this edition.

Changes made to this manual

The changes were made in response to new scientific evidence and the need to simplify practices as much as possible to facilitate learning and maintenance of the practices. As in previous editions, there is a paucity of evidence from direct pediatric practice and some conclusions are drawn from animal modeling and extrapolation from adult patients. This guide focuses on simplifying techniques, recognizing that many children do not receive any resuscitation care for fear of harm. This fear is supported by the idea that resuscitation techniques in children are different from those used in adult practice. Based on this, many studies have clarified the issue of the possibility of using the same resuscitation methods in adults and children. Resuscitation assistance When provided at the scene by witnesses to the incident, it significantly increases survival and in modeling situations in young animals it is clearly shown that performing chest compressions or ventilatory breathing alone can be much more beneficial than doing nothing at all. Thus, survival can be increased by training bystanders to use resuscitation techniques, even if they are not familiar with pediatric resuscitation. Of course, there are differences in the treatment of predominantly cardiac in origin in adults and asphyxial in children acute pulmonary heart failure, therefore a separate pediatric algorithm is recommended for use in professional practice.

Compression-ventilation ratio

ILCOR recommends different compression-ventilation ratios depending on the number of participants in care. For non-professionals trained in only one technique, a ratio of 30 compressions to 2 ventilating exhalations is suitable, that is, the use of resuscitation algorithms for adult patients. Professional rescuers, two or more in a group, should use a different ratio - (15:2), as the most rational for children, obtained as a result of experiments with animals and mannequins. Medical professionals should be familiar with the peculiarities of pediatric resuscitation techniques. A ratio of 15:2 has been found to be optimal in animal, mannequin and mathematical model studies, with various ratios ranging from 5:1 to 15:2; the results did not deduce an optimal compression-ventilation ratio, but indicated that a 5:1 ratio was the least usable. Because the need for different resuscitation techniques for children over and under 8 years of age has not been demonstrated, the ratio of 15:2 was chosen as the most logical ratio for professional rescue teams. For non-professional rescuers, regardless of the number of participants in providing assistance, it is recommended to adhere to the ratio of 30:2, which is especially important if there is only one rescuer and it is difficult for him to move from compression to ventilation.

Dependence on the child's age

The use of different resuscitation techniques for children over and under 8 years of age, as recommended by previous guidelines, has been deemed inappropriate, and restrictions on the use of automated external defibrillators (AEDs) have also been lifted. The reason for different resuscitation tactics in adults and children is etiological; For adults, primary cardiac arrest is typical, while in children it is usually secondary. A sign of the need to switch to resuscitation tactics used in adults is the onset of puberty, which is the most logical indicator of the end of the physiological period of childhood. This approach facilitates recognition, since age at the start of resuscitation is often unknown. At the same time, it is obvious that there is no need to formally determine the signs of puberty; if a rescuer sees a child in front of him, he needs to use pediatric resuscitation techniques. If pediatric resuscitation tactics are used in early adolescence, this will not cause harm to health, since studies have proven the common etiology of pulmonary heart failure in childhood and early adolescence. Children's age should be considered from one year to puberty; Ages up to 1 year should be considered infantile, and at this age the physiology is significantly different.

Chest compression technique

Recommendations for choosing an area on the chest to apply compression force for different ages have been simplified. It is considered advisable to use the same anatomical landmarks in infants (children under one year old) as for older children. The reason for this is that following previous guidelines sometimes resulted in compression in the upper abdominal area. The technique for performing compression in infants remains the same - using two fingers if there is only one rescuer; and the use of the thumbs of both hands with a chest girth if there are two or more rescuers, but for older children there is no division into one- and two-handed techniques. In all cases, it is necessary to achieve a sufficient depth of compression with minimal interruptions.

Automatic external defibrillators

Publication data since the 2000 Guidelines have reported safe and successful use of AEDs in children under 8 years of age. Moreover, recent evidence shows that AEDs accurately detect arrhythmias in children and the likelihood of mistimed or incorrect shock delivery is very low. Therefore, the use of AEDs in all children over 1 year of age is now recommended. But any device that suggests the possibility of use for arrhythmias in children must undergo appropriate testing. Many manufacturers today equip devices with pediatric electrodes and programs that involve adjusting the discharge in the range of 50-75 J. Such devices are recommended for use in children from 1 to 8 years. In the absence of a device equipped with a similar system or the ability to manually configure it, for children over one year old it is possible to use an unmodified model for adults. For children under 1 year of age, the use of AEDs remains questionable because there is insufficient data either for or against such use.

Manual (non-automatic) defibrillators

The 2005 Consensus Conference recommended prompt defibrillation in children with ventricular fibrillation (VF) or pulseless ventricular tachycardia (PT). Adult life support (ALS) involves delivering a single shock and immediately resuming CPR without detecting a pulse or returning the heart rate (see Section 3). When using a monophasic discharge, it is recommended to use a first discharge of higher power than previously recommended - 360 rather than 200 J. (See Section 3). The ideal shock power for children is unknown, but animal modeling and a small number of pediatric data suggest that power greater than 4 J kg-1 produces good defibrillation with few side effects. Bipolar discharges are at least more effective and less disruptive to myocardial function. To simplify the procedure technique and in accordance with recommendations for adult patients, we recommend the use of one defibrillating discharge (mono- or biphasic) with a dose not exceeding 4 J/kg in children.

Algorithm of actions for airway obstruction by a foreign body

The algorithm of actions for foreign body airway obstruction in children (FBAO) has been simplified as much as possible and is as close as possible to the algorithm used in adult patients. The changes made are discussed in detail at the end of this section.

6a Basic resuscitation in children.

Sequencing

Rescuers trained in basic adult resuscitation and unfamiliar with pediatric resuscitation techniques can use adult resuscitation techniques with the difference that they must first give 5 rescue breaths before starting CPR (see Figure 6.1).
Rice. 6.1 Algorithm of basic resuscitation measures in pediatrics. All healthcare workers should know this UNRESPONSIVE? - Check for consciousness (responsive or not?) Shout for help - Call for help Open airway - clear the airways NOT BREATHING NORMALLY? - Check your breathing (is it adequate or not?) 5 rescue breaths - 5 artificial breaths STILL UNRESPONSIVE? (no signs of a circulation) - Still no consciousness (no signs of circulation) 15 chest compressions - 15 chest compressions 2 rescue breaths - 2 artificial breaths After 1 minute call resuscitation team then continue CPR - Call the resuscitation team in a minute, then continue resuscitation Sequence of actions recommended for pediatric resuscitation professionals: 1 Ensure the safety of the child and others

Gently stir the child and ask loudly: “Are you okay?”

Do not handle your child if you suspect a neck injury.

3a If the child reacts with speech or movement

Leave the child in the position in which you found him (to avoid aggravating the damage)

Re-evaluate his condition periodically

3b If the child does not respond, then

call loudly for help;

open his airway by tilting his head back and lifting his chin as follows:

If a neck injury is suspected, open the airway only by withdrawing the mandible. If this is not enough, very gradually, with measured movements, tilt your head back until the airways open.

4 While ensuring the airway is clear, listen and try to feel the baby's breathing by bringing your head close to him and watching the movement of his chest.

Look closely to see if the chest moves.

Listen to see if the child is breathing.

Try to feel his breath on your cheek.

Assess visually, auditorily and tactilely for 10 seconds to assess breathing status

5a If the child is breathing normally

Place baby in a stable side position (see below)

Continue checking for breathing

5b If the child is not breathing, or his breathing is agonal (slow and irregular)

carefully remove anything that interferes with breathing;

give five initial rescue breaths;

during their implementation, keep an eye on possible appearance coughing or gagging. This will determine your further actions, their description is given below.

Resuscitation breathing for a child over 1 year of age is performed as shown in Fig. 6.2.

Tilt your head back and lift your chin up.

Pinch the soft tissues of the nose with the thumb and forefinger of the hand lying on the child's forehead.

Open his mouth slightly, leaving his chin raised.

Inhale and, wrapping your lips around the child’s mouth, make sure the contact is tight.

Exhale evenly into the airways for 1-1.5 seconds, observing the response movement of the chest.

Leaving the baby's head in a tilted position, watch the lowering of his chest as he exhales.

Inhale again and repeat in the same sequence up to 5 times. Monitor the effectiveness of sufficient movement of the child's chest - as during normal breathing.

Rice. 6.2 Mouth-to-mouth ventilation in a child older than one year.

Resuscitation breathing in an infant is carried out as shown in Fig. 6.3.

Make sure your head is in a neutral position and your chin is lifted.

Inhale and cover the baby's mouth and nasal passages with your lips, making sure there is a tight seal. If the child is large enough and it is impossible to cover the mouth and nasal passages at the same time, you can use mouth-to-mouth or mouth-to-nose breathing only (while keeping the child's lips closed).

Exhale evenly into the airway for 1-1.5 seconds, noticing the subsequent movement of his chest.

Leaving the baby's head in a tilted position, evaluate the movement of his chest as he exhales.

Take another breath and repeat ventilation in the same sequence up to 5 times.

Rice. 6.3 Mouth-to-mouth and nose ventilation in a child up to one year old.

If the required breathing efficiency is not achieved, airway obstruction may occur.

Open your baby's mouth and remove anything that may be obstructing his breathing. Don't do blind cleansing.

Make sure that the head is tilted back and the chin is raised, without hyperextension of the head.

If tilting your head back and lifting your jaw does not open your airway, try moving your jaw beyond its corners.

Make five attempts at ventilating breathing. If they are ineffective, move on to chest compressions.

If you are a professional, determine your pulse, but do not spend more than 10 seconds on it.

If the child is older than 1 year, determine the carotid pulsations. If the child is an infant, check the radial pulse above the elbow.

7a If within 10 seconds you were able to clearly identify signs of blood circulation

Continue CPR as long as necessary until the child is breathing adequately on his own.

Turn the child onto his side (in the recovery position) if he is still unconscious

Constantly re-evaluate the child's condition

7b If there are no signs of blood circulation, or the pulse is not detected, or it is too sluggish and less than 60 beats/min, -1 weak filling, or is not determined reliably

start chest compressions

combine chest compressions with ventilatory breathing.

Chest compression is carried out as follows: pressure is applied to the lower third of the sternum. To avoid compression of the upper abdomen, determine the position of the xiphoid process at the point of convergence of the lower ribs. The pressure point is located one finger splint above it; the compression should be deep enough - approximately a third of the thickness of the chest. Start pressing at a rate of about 100/min-1. After 15 compressions, tilt the child's head back, lift the chin and take 2 fairly effective exhalations. Continue compression and breathing at a ratio of 15:2, or if you are alone, 30:2, especially if the compression rate is 100/min, the actual number of shocks produced will be less due to the breaks in breathing. The optimal compression technique for infants and children is slightly different. In infants, the procedure is performed by pressing on the sternum with the tips of two fingers. (Fig. 6.4). If there are two or more rescuers, the girth technique is used. Place your thumbs on the lower third of the sternum (as above), with your fingertips pointing toward your baby's head. Wrap the fingers of both hands around the baby's chest so that the fingertips support his back. Press your thumbs into your sternum to about a third of the thickness of your ribcage.

Rice. 6.4 Chest compression in a child under one year old. To perform chest compressions on a child older than one year, place the heel of your hand on the lower third of his sternum. (Fig. 6.5 and 6.6). Raise your fingers so there is no pressure on the baby's ribs. Stand vertically over the baby's chest and, with your arms straight, apply compression to the lower third of the sternum to a depth of approximately one-third of the thickness of the chest. In adult children or when the rescuer has a small mass, this is easier to do by intertwining the fingers.

Rice. 6.5 Chest compression in a child under one year old.

Rice. 6.6 Chest compression in a child under one year old.

8 Continue resuscitation until

The child still has signs of life (spontaneous breathing, pulse, movement)

Until qualified help arrives

Until complete exhaustion sets in

When to Call for Help

If the child is unconscious, it is necessary to call for help as soon as possible.

If two people are involved in resuscitation, then one begins resuscitation, while the second goes to call for help.

If there is only one rescuer, it is necessary to perform resuscitation measures for one minute before going to call for help. To reduce interruptions in compression, you can take the infant or small child with you when calling for help.

There is only one case where you can immediately go for help without performing resuscitation for a minute - if someone saw that the child suddenly lost consciousness, and there was only one rescuer. In this case, acute heart failure is most likely arrhythmogenic, and the child needs urgent defibrillation. If you are alone, seek help immediately.

Recovery position

Unconscious child with patency preserved airways, and maintaining spontaneous breathing, should be placed in the recovery position. There are several options for such provisions, each with its own supporters. It is important to follow the following principles:

The baby's position should be as close to the lateral position as possible to allow fluid to drain from the mouth.

The situation must be stable. The baby needs to place a small pillow or folded blanket under his back.

Avoid any pressure on the chest to prevent shortness of breath.

It must be possible to safely turn onto your back and back onto your side, as there is always a possibility of spinal injury.

Access to the airway must be maintained.

The position used in adults can be used.

Low heart pressure in older people: what to do

Heart rate is normal in children

In children under 1 year of age, the heart is located relatively lower in the chest than in older children, so the correct position for chest compressions is one finger width below the internipple line. The resuscitator should apply pressure with 2-3 fingers and shift the sternum to a depth of 1.25-2.5 cm at least 100 times/min. Ventilation is carried out at a frequency of 20 breaths/min. When performing cardiopulmonary resuscitation in children over 1 year of age, the base of the resuscitator’s palm is located on the sternum two fingers’ width above the sternal notch. The optimal compression depth is 2.5-3.75 cm and at least 80 times/min. Ventilation rate - 16 breaths/min.

What is the Thaler dose during cardiopulmonary resuscitation in children under 1 year of age?

Otherwise, the Thaler technique is called the encirclement technique. The resuscitator connects the fingers of both hands on the spine, surrounding the chest; in this case, compression is carried out with the thumbs. It is important to remember that compression of the chest during ventilation should be minimal.

Can performing cardiopulmonary resuscitation on children under 1 year of age cause rib fractures?

Very unlikely. According to one study, in 91 cases, autopsies and post-mortem x-rays of dead children, despite performing cardiopulmonary resuscitation, did not reveal any rib fractures. When identifying rib fractures, you must first suspect child abuse.

Is a "precordial beat" used during the procedure?

Precordial shock is no more effective in restoring normal rhythm in confirmed and documented ventricular fibrillation than chest compressions. In addition, a precordial stroke increases the risk of internal organ damage.

When does a child develop pupillary changes with sudden onset asystole if cardiopulmonary resuscitation is not started?

Pupil dilation begins 15 s after cardiac arrest and ends 1 min 45 s.

Why are children's airways more susceptible to obstruction than adults?

1. In children, the safety threshold is lowered due to the small diameter of the respiratory tract. Minor changes in the diameter of the trachea lead to a significant decrease in air flow, which is explained by Poiseuille's law (the amount of flow is inversely proportional to the fourth power of the radius of the tube).

2. The cartilage of the trachea in a child under 1 year of age is soft, which makes it possible for the lumen to collapse due to overextension, especially if cardiopulmonary resuscitation is performed with excessive extension of the neck. In this case, the lumen of the trachea and bronchi may be blocked.

3. The lumen of the oropharynx in children under 1 year of age is relatively smaller due to large sizes tongue and small lower jaw.

4. The narrowest part of the airway in children is at the level of the cricoid cartilage, below the vocal cords.

5. The lower respiratory tract in children is smaller and less developed. The diameter of the lumen of the main bronchus in children under 1 year of age is comparable to that of an average-sized groundnut.

Are there contraindications to intracardiac administration of adrenaline?

Intracardiac administration of adrenaline is used extremely rarely, since it leads to the suspension of cardiopulmonary resuscitation and can cause tamponade and injury. coronary arteries and pneumothorax. If the drug is accidentally administered into the myocardium rather than into the ventricular cavity, intractable ventricular fibrillation or cardiac arrest in systole may develop. Other routes of administration (peripheral or central intravenous, intraosseous, endotracheal) are readily available.

What is the role of high-dose epinephrine during cardiopulmonary resuscitation in children?

Animal studies, anecdotal and limited reports clinical trials in children they show that adrenaline in high doses (100-200 times higher than usual) facilitates the restoration of spontaneous circulation. Large studies in adults have not confirmed this. A retrospective analysis of cases of out-of-hospital clinical death also does not contain evidence of the effectiveness of the use of high doses of epinephrine. Currently, the American Heart Association recommends intraosseous or intravenous administration of higher doses of epinephrine (0.1-0.2 mg/kg solution 1:1000) only after the administration of standard doses (0.01 mg/kg solution 1:10,000). In cases of confirmed cardiac arrest, the use of high doses of epinephrine should be considered.

How effective is intratracheal administration of epinephrine?

Adrenaline is poorly absorbed in the lungs, so intraosseous or intravenous administration is preferable. If it is necessary to administer the drug endotracheally (in the acute condition of the patient), it is mixed with 1-3 ml of isotonic saline solution and is inserted through a catheter or feeding tube below the end of the endotracheal tube to facilitate distribution. The ideal dose for endotracheal administration is unknown, but given poor absorption, more should be used initially. high doses(0.1-0.2 mg/kg solution 1:1000).

When is atropine indicated for cardiopulmonary resuscitation?

Atropine may be used in children with symptomatic bradycardia after initiation of other resuscitation procedures (eg mechanical ventilation and oxygenation). Atropine helps with bradycardia caused by stimulation of the vagus nerve (during laryngoscopy), and to some extent with atrioventricular block. Adverse effects of bradycardia are more likely in children older than younger age, because cardiac output in them depends more on the dynamics of heart rate than on changes in volume or contractility. The use of atropine in the treatment of asystole is not recommended.

What are the risks associated with prescribing too low a dose of atropine?

If the dose of atropine is too low, a paradoxical increase in bradycardia may occur. This is due to the central stimulating effect of small doses of atropine on the nuclei of the vagus nerve, as a result of which atrioventricular conduction deteriorates and the heart rate decreases. The standard dose of atropine for the treatment of bradycardia is 0.02 mg/kg intravenously. However, the minimum dose should not be less than 0.1 mg even in the youngest children.

When are calcium supplements indicated during cardiopulmonary resuscitation?

These are not indicated during standard cardiopulmonary resuscitation. The ability of calcium to enhance post-ischemic injury during the intracranial reperfusion phase after cardiopulmonary resuscitation has been reported. Calcium supplements are used only in three cases: 1) overdose of calcium channel blockers; 2) hyperkalemia leading to arrhythmias; 3) reduced serum calcium levels in children.

What should be done in case of electromechanical dissociation?

Electromechanical dissociation is a condition when organized electrical activity on the ECG is not accompanied by effective myocardial contractions (absence of blood pressure and pulse). Impulses can be frequent or rare, complexes can be narrow or wide. Electromechanical dissociation is caused by both myocardial disease (myocardial hypoxia/ischemia due to respiratory arrest, which is most common in children) and causes external to the heart. Electromechanical dissociation occurs due to prolonged myocardial ischemia, the prognosis is unfavorable. Rapid diagnosis of a noncardiac cause and its elimination can save the patient's life. Noncardiac causes of electromechanical dissociation include hypovolemia, tension pneumothorax, cardiac tamponade, hypoxemia, acidosis, and pulmonary embolism. Treatment of electromechanical dissociation consists of chest compressions and ventilation with 100% oxygen, followed by epinephrine and sodium bicarbonate. Noncardiac causes can be treated with fluid resuscitation, pericardiocentesis, or thoracentesis (depending on indications). Empirical prescription of calcium supplements is currently considered incorrect.

Why is one bone usually used for intraosseous infusion?

Intraosseous administration of drugs has become the method of choice in therapy emergency conditions in children, since intravenous access is sometimes difficult for them. The doctor gains faster access to the vascular bed through the medullary cavity, which drains into the central venous system. The rate and distribution of drugs and infusion media are comparable to those of intravenous administration. The technique is simple and involves inserting a stylet needle, bone marrow needle, or bone needle into the proximal tibia (approximately 1-3 cm below the tibial tuberosity), or less commonly into the distal tibia and proximal femur.

Is a clinical sign such as capillary refilling used in diagnosis?

Capillary refilling is determined by recovery normal color nail or finger pulp after pressing, which in healthy children occurs in approximately 2 s. Theoretically, normal capillary refill time reflects adequate peripheral perfusion (ie, normal cardiac output and peripheral resistance). Previously, this indicator was used to assess the state of perfusion in trauma and possible dehydration, but, as studies have shown, it should be used in conjunction with other clinical data, because in isolation it is not sensitive and specific enough. It was found that with dehydration of 5-10%, an increase in the capillary filling time was observed only in 50% of children; Moreover, it increases at low ambient temperatures. Capillary refill time is measured on the upper limbs.

Is the MAST device effective for resuscitation in children?

Pneumatic anti-shock clothing, or MAST (Military Anti-Shock Trousers), is an air-inflated bag that covers the legs, pelvis and abdomen. This device can be used to increase blood pressure in patients who are hypotensive or hypovolemic, especially those with pelvic fractures and lower limbs. To potential negative effects include: exacerbation of bleeding in the supradiaphragmatic region, worsening pulmonary edema and the development of lacunar syndrome. The effectiveness of MAST in children remains to be studied.

Are steroid medications indicated for the treatment of shock in children?

No. Initially, the need to use steroids in the treatment of septic shock was questioned. Animal studies have found that administering steroids before or concomitantly with endotoxin may improve survival. However, numerous clinical observations have not confirmed a reduction in mortality during early steroid therapy in adults. Steroids may even contribute to increased mortality in patients with sepsis compared with those in the control group due to an increased incidence of secondary infections. There are no data available for children. Still, steroids should probably be avoided in children.

What is better to use in the treatment of hypotension - colloid or crystalloid solutions?

In the treatment of hypovolemic hypotension, colloid (blood, fresh frozen plasma, 5 or 25% salt-free albumin) and crystalloid (isotonic saline, lactated Ringer's solution) solutions are equally effective. For hypovolemic shock, use the solution that is most readily available at the moment. In various specific conditions, it is necessary to select a means of restoring the volume of circulating blood. Hypotension that develops as a result of massive blood loss is treated with the administration of whole blood or red blood cells in combination with plasma (to correct anemia). For hypotension with hyperkalemia, lactated Ringer's solution is rarely used because it contains 4 mEq/L potassium. It is always necessary to take into account the risk of complications from prescribing blood products, as well as the cost of albumin, which is 50-100 times more expensive than isotonic saline solution.

What is the normal tidal volume for a child?

Approximately 7 ml/kg.

What should you do if a large volume of air is accidentally injected into a vein in a 6-year-old child?

The main complication may be blockage of the outlet of the right ventricle or the main pulmonary artery, which is similar to the “gas lock” that occurs in a car carburetor when air entering it obstructs the flow of fuel, causing the engine to stop. The patient should be placed on his left side - to prevent air from escaping from the cavity of the right ventricle - on a bed with the head end low. Therapy includes:

1) oxygenation with 100% oxygen;

2) intensive surveillance, ECG monitoring;

3) identifying signs of arrhythmia, hypotension and cardiac arrest;

4) puncture of the right ventricle, if auscultation reveals
air;

5) standard cardiopulmonary resuscitation in case of cardiac arrest, since with the help of manual chest compression it is possible to expel the air embolus.

How is the defibrillation procedure different for children?
1. Lower dose: 2 J/kg and, if necessary, further doubling.

2. Smaller electrode area: standard pediatric electrodes have a diameter of 4.5 cm, while those for adults have a diameter of 8.0 cm.

3. Less common use: ventricular fibrillation occurs infrequently in children.

What is the difference between livor mortis and rigor mortis?

Livor mortis(cadaveric stains) - gravitational accumulation of blood, leading to a linear mauve-purple staining of the underlying half of the body of a recently deceased person. Often this phenomenon can be detected 30 minutes after death, but it is very pronounced after 6 hours.

Rigor mortis(rigor mortis) is a thickening and contraction of muscles that occurs as a result of continued post-mortem cell activity with the consumption of ATP, the accumulation of lactic acid, phosphate and the crystallization of salts. On the neck and face, rigor begins after 6 hours, on the shoulders and upper limbs - after 9 hours, on the torso and legs - after 12 hours. Cadaveric spots and rigor - absolute readings to refuse resuscitation, therefore, during the initial examination it is necessary to carefully examine the patient for their detection.

When do you stop unsuccessful resuscitation?

There is no exact answer. According to some studies, the likelihood of death or survival with irreversible damage to the nervous system increases significantly after two attempts to use medications (for example, epinephrine and bicarbonate), which did not lead to improvement in neurological and cardiovascular picture, and/or after more than 15 minutes have passed after the start. cardiopulmonary resuscitation. In cases of unwitnessed cardiac arrest outside the hospital, the prognosis is almost always poor. If asystole develops due to hypothermia, before stopping cardiopulmonary resuscitation, the patient’s body temperature should be brought to 36 “C.

How successful is resuscitation in the pediatric emergency department?

In the event of clinical death of a child without witnesses and adequate assistance, the prognosis is very poor, much worse than in adults. More than 90% of patients cannot be resuscitated. Survivors in almost 100% of cases subsequently develop autonomic disorders and severe neurological complications.

Why is resuscitation less successful in children than in adults?

In adults, the causes of collapse and cardiac arrest are often primary cardiac pathology and associated arrhythmias - ventricular tachycardia and fibrillation. These changes are easier to stop, and the prognosis for them is better. In children, cardiac arrest usually occurs secondary to airway obstruction, apnea, often associated with infection, hypoxia, acidosis, or hypovolemia. At the time of cardiac arrest, the child almost always has heavy defeat nervous system.

Ten most common mistakes during resuscitation:

1. The person responsible for its implementation is not clearly defined.

2. The nasogastric tube is not installed.

3. The medications needed in this situation have not been prescribed.

4. Periodic assessment of respiratory sounds, pupil size, and pulse is not carried out.

5. Delay in installing an intraosseous or other infusion system.

6. The team leader is overly involved in the procedure he is conducting individually.

7. Roles in the team are distributed incorrectly.

8. Errors in the initial assessment of the patient’s condition (incorrect diagnosis).

9. Lack of control over the correctness of cardiac massage.

10. Cardiopulmonary resuscitation carried out for too long in case of out-of-hospital cardiac arrest.

Three groups of patients can be distinguished, which differ in their approach to cardiopulmonary resuscitation.

Cardiopulmonary resuscitation in children with sudden cessation of blood circulation - in this case, the dying process lasts as long as resuscitation measures continue. The main outcomes of resuscitation measures: successful resuscitation and subsequent post-resuscitation illness (with varying outcomes), development of a persistent vegetative state, unsuccessful resuscitation, after cessation of which death is declared.
Carrying out CPR against the background of a severe potentially treatable pathology - most often this is a group of children with severe combined trauma, shock, severe purulent-septic complications - in this case the prognosis of CPR is often unfavorable.
Carrying out CPR against the background of an incurable pathology: congenital malformations, non-life-threatening injury, cancer patients - requires a careful, if possible, pre-planned approach to CPR.

The main task of cardiopulmonary resuscitation in children is to maintain blood circulation and mechanical ventilation, preventing irreversible changes in the brain and myocardium until blood circulation and breathing are restored.

First of all, the presence of consciousness should be determined by shouting and shaking (no need to subject the head to sudden movements until injury is ruled out). Check for exhalation and pulse; if they are not detected, CPR should be started immediately. Revitalization consists of a number of activities:

Primary resuscitation is measures to maintain life activity, which are formulated in the form of the “ABC” rule. When starting cardiopulmonary resuscitation in children, you should call colleagues or other people nearby for help.

Restoration of vital functions - restoration of independent blood circulation, activity of the pulmonary system; introduction pharmacological drugs, infusion of solutions, electrography and, if necessary, electrical defibrillation.

Primary resuscitation

Stage 1 of cardiopulmonary resuscitation in children includes 3 stages:

A (air) - airway patency.
B (breath) - ventilation of the lungs.
C (circulation) - artificial maintenance of blood circulation (heart).

Airway patency

Stage 1 is the most important. It is necessary to give the patient the appropriate position: put him on his back; the head, neck and chest should be on the same plane. If you are hypovolemic, you should elevate your legs slightly. Throw back your head - if there is no neck injury, if there is - remove the lower jaw. Excessive hyperextension of the head in infants can aggravate airway obstruction. Incorrect head position is a common cause of ineffective ventilation.

If necessary, clear your mouth of foreign bodies. Insert an airway or, if possible, perform tracheal intubation; if not, take two breaths “mouth to mouth” or “mouth to mouth and nose”.

Head tilting is an important and primary task of resuscitation.

Circulatory arrest in children is often secondary to airway obstruction, which can be caused by:

infectious or disease;
presence of a foreign body;
tongue retraction, mucus, vomit, blood.

Artificial ventilation

Ventilation is carried out by actively blowing air into the lungs using the “mouth to mouth” or “mouth to mouth and nose” methods; but it’s better through an air duct, a face mask with an Ambu bag.

To prevent overdistension of the stomach, mechanical ventilation must be performed so that only excursion of the chest, but not the abdominal wall, is observed. The method of emptying the stomach of gas by pressing on the epigastrium while turning on its side is acceptable only at the prehospital stage (due to the danger of regurgitation and aspiration of stomach contents). In such situations, you need to place a tube in the stomach.

Sequencing:

Place the patient on a hard surface, tilt his head slightly back.

Observe breathing for 5 s; if there is no breathing, take 2 breaths, then pause to exhale. Air is blown into the child very carefully to avoid rupture of the lung (for a newborn or infant - using the cheeks); be sure to watch the chest - when inflated it rises; inhalation time is 1.5-2 s.

If the chest rises, the inflation is stopped and passive exhalation is allowed to pass.

After the end of exhalation, a second inflation is performed; After this, the presence of a pulse is determined.

With preserved heart activity, regardless of the patient’s age, artificial respiratory cycles of the lungs are repeated 8-12 times/minute (every 5-6 s); If there is no pulse, cardiac massage and other measures are started.

If the blowing does not work, check the position of the head and repeat the blowing; if again ineffective, a foreign body in the respiratory tract should be suspected. In this case, open the mouth and clear the throat; the fluid is drained out by turning the head to the side (not possible in case of spinal injury).

Removing foreign bodies from infants has its own specifics. In them, the technique described by Heimlich (a sharp push in the epigastric region in the direction of the diaphragm) is unacceptable due to the real threat of trauma to the abdominal organs, primarily the liver. Infants are placed on the forearm so that the head is lower than the body, but does not hang passively down, but is supported by the index finger and thumb by the lower jaw. After this, 5 gentle blows are performed between the shoulder blades.

If the child’s size does not allow him to fully perform this technique, holding him with one hand, then the doctor’s thigh and knee are used as support. Back blows are essentially an artificial cough that allows you to “push out” a foreign body.

Closed heart massage

Stage 3 aims to restore blood circulation. The essence of the method is compression of the heart. Blood circulation is ensured not so much by compression as by an increase in intrathoracic pressure, which promotes the ejection of blood from the lungs. Maximum compression occurs in the lower third of the sternum: in children - the width of a transverse finger below the nipple line in the center of the sternum; in adolescents and adults - 2 fingers above the xiphoid process. Pressure depth - about 30% anterior-posterior size chest. Cardiac massage techniques vary depending on age:

children under one year old - compressions are performed with the thumbs,
children from one to 8 years old - compressions are performed with one hand,
children from 8 years old, adults - apply pressure on the chest with both hands, with straight elbows.

When working with one doctor, the ventilation: massage ratio is 2:30 at any age (for every 30 sternum compressions, 2 breaths are taken). When two doctors are working, they use the 2:15 technique (2 breaths, 15 compressions). When performing mechanical ventilation through an endotracheal tube, the massage is done without pauses, it is not synchronized in relation to artificial respiratory cycles, the ventilation rate is 8-12 per minute.

Precordial shock is not recommended even in adults, especially in out-of-hospital settings. In ICU conditions (in adults), it is carried out only with ECG monitoring. A stroke against the background of ventricular tachycardia can lead to asystole or the development of ventricular fibrillation.

The frequency of compressions does not depend on age; it is at least 100, but not more than 120 compressions per minute. In newborns, resuscitation (including cardiac massage) begins at a rate of 60 per minute.

Performance monitoring Cardiopulmonary resuscitation in children is performed by a ventilator; he checks the pulse a minute after the start of resuscitation, then every 2-3 minutes during the cessation of the massage (for 5 seconds). Periodically, the same doctor monitors the condition of the pupils. The appearance of their reaction indicates the restoration of the brain; their persistent expansion is an unfavorable indicator. Resuscitation should not be interrupted for more than 5 seconds, except during the period when tracheal intubation or defibrillation is performed. The pause for intubation should not exceed 30 s.

The article was prepared and edited by: surgeon

In children, the causes of sudden cessation of breathing and circulation are very diverse, including sudden infant death syndrome, asphyxia, drowning, trauma, foreign bodies in the respiratory tract, electric shock, sepsis, etc. Therefore, unlike adults, it is difficult to determine the cause factor (“gold standard”) on which survival would depend upon the development of a terminal condition.

Resuscitation measures for infants and children differ from those for adults. Although there are many similarities in the methodology for performing CPR in children and adults, life support in children, as a rule, begins from a different starting point. As noted above, in adults the sequence of actions is based on symptoms, most of which are cardiac in nature. As a result, a clinical situation is created that usually requires emergency defibrillation to achieve effect. In children, the primary cause is usually respiratory in nature, which, if not recognized promptly, quickly leads to fatal cardiac arrest. Primary cardiac arrest in children is rare.

Due to the anatomical and physiological characteristics of pediatric patients, several age limits are identified to optimize the technique of resuscitation care. These are newborns, infants under 1 year of age, children from 1 to 8 years of age, children and adolescents over 8 years of age.

The most common cause of airway obstruction in unconscious children is the tongue. Simple techniques of extending the head and lifting the chin or moving the lower jaw open the baby's airway. If the cause of the child's serious condition is injury, it is recommended to maintain airway patency only by removing the lower jaw.

The peculiarity of performing artificial respiration in young children (under the age of 1 year) is that, taking into account the anatomical features - the small space between the child’s nose and mouth - the rescuer breathes “from mouth to mouth and nose” of the child at the same time. However, recent research suggests that mouth-to-nose breathing is the preferred method for basic CPR in infants. For children aged 1 to 8 years, the mouth-to-mouth breathing method is recommended.

Severe bradycardia or asystole is the most frequent sight rhythm associated with cardiac arrest in children and infants. Assessing blood circulation in children traditionally begins with checking the pulse. In infants, the pulse is assessed on the brachial artery, in children - on the carotid artery. The pulse is checked for no longer than 10 s, and if it is not palpable or its frequency is in infants less than 60 beats per minute, it is necessary to immediately begin external cardiac massage.

Features of indirect heart massage in children: for newborns, the massage is performed with the nail phalanges of the thumbs, after first covering the back with both hands, for infants - with one or two fingers, for children from 1 to 8 years old - with one hand. In children under 1 year of age, when performing CPR, it is recommended to maintain a frequency of compressions of more than 100 per minute (2 compressions per 1 s), for children aged 1 to 8 years - at least 100 per minute, with a ratio of 5:1 to respiratory cycles. For children over 8 years of age, adult recommendations should be followed.

The upper conventional age limit of 8 years for children was proposed due to the peculiarities of the method of performing indirect cardiac massage. However, children can have different body weights, so it is impossible to speak categorically about a certain upper age limit. The rescuer must independently determine the effectiveness of resuscitation measures and apply the most appropriate technique.

The recommended initial dose of epinephrine is 0.01 mg/kg or 0.1 ml/kg in saline, administered intravenously or intraosseously. Recent studies prove the advantage of using high doses of adrenaline in children for areactive asystole. If there is no response to the initial dose, it is recommended after 3-5 minutes to either repeat the same dose or administer adrenaline in a high dose - 0.1 mg/kg 0.1 ml/kg in saline solution.

Atropine is a parasympathetic blockade drug that has an antivagal effect. For the treatment of bradycardia, it is used at a dose of 0.02 mg/kg. Atropine is a mandatory drug used during cardiac arrest, especially if it occurs through vagal bradycardia.