Ministry of Health of the Republic of Uzbekistan Republican Center for Emergency Medical Aid avaks c. E., Churilova o. B. Cardiopulmonary resuscitation. Features of CPR in children

Primary cardiac arrest in children is much less common than in adults. Less than 10% of all cases of clinical death in children are caused by ventricular fibrillation. Most often, it is a consequence of congenital pathology.

Trauma is the most common cause of CPR in children.

Cardiopulmonary resuscitation in children has certain features.

When breathing "from mouth to mouth" it is necessary to avoid excessively deep breaths (that is, exhalation of the resuscitator). An indicator can be the volume of chest wall excursion, which is labile in children and its movements are well controlled visually. Foreign bodies cause airway obstruction in children more often than in adults.

In the absence of spontaneous breathing in a child after 2 artificial breaths, it is necessary to begin cardiac massage, since in apnea, cardiac output is usually inadequately low, and palpation of the carotid pulse in children is often difficult. It is recommended to palpate the pulse on the brachial artery.

It should be noted that the absence of a visible apex beat and the impossibility of its palpation do not yet indicate cardiac arrest.

If there is a pulse, but there is no spontaneous breathing, then the resuscitator should do about 20 breaths per 1 min until spontaneous breathing is restored or more modern ventilation methods are used. If there is no pulsation of the central arteries, cardiac massage is necessary.

Compression of the chest in a small child is performed with one hand, and the other is placed under the child's back. In this case, the head should not be higher than the shoulders. The place of application of force in young children is the lower part of the sternum. Compression is carried out with 2 or 3 fingers. The amplitude of movement should be 1-2.5 cm, the frequency of compressions should be approximately 100 per 1 min. Just like in adults, you need to pause for ventilation. The ventilation to compression ratio is also 1:5. Approximately every 3 to 5 minutes check for the presence of spontaneous cardiac contractions. Hardware compression in children, as a rule, is not used. The use of an anti-shock suit in children is not recommended.

If open heart massage in adults is considered more effective than closed heart massage, then in children there is no such advantage of direct massage. Apparently, this is due to the good compliance of the chest wall in children. Although in some cases, if indirect massage is ineffective, direct massage should be resorted to. With the introduction of drugs into the central and peripheral veins, such a difference in the speed of onset of the effect in children is not observed, but if possible, then catheterization of the central vein should be performed. The onset of action of drugs administered intraosseously to children is comparable in time to intravenous administration. This route of administration can be used in cardiopulmonary resuscitation, although complications (osteomyelitis, etc.) may occur. There is a risk of microfat pulmonary embolism with intraosseous injection, but clinically this is not of particular importance. Endotracheal administration of fat-soluble drugs is also possible. It is difficult to recommend a dose due to the large variability in the rate of absorption of drugs from the tracheobronchial tree, although it seems likely that the intravenous dose of epinephrine should be increased 10 times. The dose of other drugs should also be increased. The drug is injected deep into the tracheobronchial tree through a catheter.

Intravenous fluid administration during cardiopulmonary resuscitation in children is more important than in adults, especially in severe hypovolemia (blood loss, dehydration). Children should not be administered glucose solutions (even 5%), because large volumes of glucose-containing solutions lead to hyperglycemia and an increase in neurological deficit faster than in adults. In the presence of hypoglycemia, it is corrected with a glucose solution.

The most effective drug in circulatory arrest is epinephrine at a dose of 0.01 mg/kg (endotracheally 10 times more). If there is no effect, it is administered again after 3-5 minutes, increasing the dose by 2 times. In the absence of effective cardiac activity, intravenous infusion of adrenaline is continued at a rate of 20 μg / kg per 1 minute, with the resumption of heart contractions, the dose is reduced. With hypoglycemia, drip infusions of 25% glucose solutions are necessary, bolus injections should be avoided, since even short-term hyperglycemia can adversely affect the neurological prognosis.

Defibrillation in children is used for the same indications (ventricular fibrillation, ventricular tachycardia with no pulse) as in adults. In young children, electrodes of a slightly smaller diameter are used. The initial discharge energy should be 2 J/kg. If this value of the discharge energy is insufficient, the attempt must be repeated with a discharge energy of 4 J/kg. The first 3 attempts should be made at short intervals. If there is no effect, hypoxemia, acidosis, hypothermia are corrected, adrenaline hydrochloride, lidocaine are administered.

For children under 1 year old, it is enough to press on the sternum with one or two fingers. To do this, lay the child on his back and grasp the child so that the thumbs are located on the front surface of the chest and their ends converge at a point located 1 cm below the nipple line, place the rest of the fingers under the back. For children over the age of 1 year and up to 7 years, heart massage is performed while standing on the side (often on the right), with the base of one hand, and for older children - with both hands (as adults).

Ensure airway patency.

Carry out tracheal intubation, but only after the first breaths of mechanical ventilation, you can not waste time trying to intubate (at this time the patient does not breathe for more than 20 seconds).

During inhalation, the chest and abdomen should rise. To determine the depth of inhalation, one should focus on the maximum excursion of the patient's chest and abdomen and the appearance of inhalation resistance.

Pause between breaths 2 s.

Inhalation is normal, not forced. Features of IVL depending on the age of the child.

The victim is a child under one year old:

it is necessary to wrap your mouth around the mouth and nose of the child;

the respiratory volume should be equal to the volume of the cheeks;

with mechanical ventilation using an Ambu bag, a special Ambu bag is used for children under one year old;

when using the Ambu bag for adults, the volume of one breath is equal to the volume of the doctor's hand.

The victim is a child older than a year:

Pinch the nose of the victim and breathe mouth to mouth;

It is necessary to take two test breaths;

Assess the patient's condition.

Attention: If there is damage to the mouth, you can use mouth-to-nose breathing: the mouth is closed, the rescuer's lips are compressing the victim's nose. However, the effectiveness of this method is much lower than mouth-to-mouth breathing.

Caution: When performing mouth-to-mouth ventilation (mouth to mouth and nose, mouth to nose), do not breathe deeply and quickly, otherwise you will not be able to ventilate.

Breathe as fast as possible for you, as close as possible to the recommended, depending on the age of the patient.

Up to 1 year 40-36 per minute

1-7 years old 36-24 per min

Over 8 years old, adult 24-20 min

DEFIBRILLATION

Defibrillation is performed during ventricular fibrillation in the mode of 2 J/kg first discharge, 3 J/kg - second discharge, 3.5 J/kg - third and all subsequent discharges.

The algorithm for drug administration and defibrillation is the same as for adult patients.

COMMON ERRORS

Performing precordial strikes.

Carrying out an indirect heart massage in the presence of a pulse on the carotid artery.

Putting under the shoulders of any objects.

Palm overlay with pressure on the sternum in a position so that the thumb is pointed at the resuscitator.

METHOD OF APPLICATION AND DOSES OF MEDICINES

In cardiopulmonary resuscitation, two paths are optimal:

intravenous;

intratracheal (through the endotracheal tube or by puncture of the cricoid-thyroid membrane).

Attention: With intratracheal administration of drugs, the dose is doubled and the drugs, if they have not been diluted earlier, are diluted in 1-2 ml of sodium chloride solution. The total amount of administered drugs can reach 20-30 ml.

CLINICAL PHARMACOLOGY OF DRUGS

Atropine in resuscitation in children is used in case of asystole and bradycardia at a dose of 0.01 mg / kg (0.1 ml / kg) at a dilution of 1 ml of 0.1% solution in 10 ml of sodium chloride solution (in 1 ml solution 0.1 mg of the drug). In the absence of information about body weight, it is possible to use a dose of 0.1 ml of 0.1% solution per year of life or at the indicated dilution of 1 ml / year. You can repeat the injection every 3-5 minutes until a total dose of 0.04 mg / kg is reached.

Epinephrine is used in the case of asystole, ventricular fibrillation, electromechanical dissociation. The dose is 0.01 mg / kg or 0.1 ml / kg at a dilution of 1 ml of 0.1% epinephrine solution in 10 ml of sodium chloride solution (0.1 mg of the drug in 1 ml of solution). In the absence of information about body weight, it is possible to use a dose of 0.1 ml of 0.1% solution per year of life or at the indicated dilution of 1 ml / year. You can repeat the introduction every 1-3 minutes. If cardiopulmonary resuscitation fails

within 10-15 minutes, it is possible to use doubled doses of epinephrine.

Lidocaine is used in case of ventricular fibrillation at a dose of 1 mg/kg 10% solution.

Sodium bicarbonate 4% is used when cardiopulmonary resuscitation is started later than 10-15 minutes after cardiac arrest, or in case of prolonged ineffective cardiopulmonary resuscitation (more than 20 minutes without effect with adequate ventilation of the lungs). Dose 2 ml/kg body weight.

Post-resuscitation drug therapy should be aimed at maintaining stable hemodynamics and protecting the central nervous system from hypoxic damage (antihypoxants)

Article publication date: 07/01/2017

Article last updated: 12/21/2018

From this article you will learn: when it is necessary to carry out cardiopulmonary resuscitation, what activities include helping a person who is in a state of clinical death. The algorithm of actions during and breathing is described.

Cardiopulmonary resuscitation (abbreviated as CPR) is a complex of urgent measures in case of cardiac and respiratory arrest, with the help of which they try to artificially support the vital activity of the brain until spontaneous circulation and respiration are restored. The composition of these activities directly depends on the skills of the person providing assistance, the conditions for their implementation and the availability of certain equipment.

Ideally, resuscitation carried out by a person who does not have a medical education consists of a closed heart massage, artificial respiration, and the use of an automatic external defibrillator. In reality, such a complex is almost never performed, since people do not know how to properly carry out resuscitation, and there are simply no external external defibrillators.

Determination of vital signs

In 2012, the results of a huge Japanese study were published that included more than 400,000 people with cardiac arrest that occurred outside of a hospital setting. Approximately 18% of those victims who underwent resuscitation were able to restore spontaneous circulation. But only 5% of patients remained alive after a month, and with preserved functioning of the central nervous system - about 2%.

It should be taken into account that without CPR, these 2% of patients with a good neurological prognosis would have no chance of life. 2% of 400,000 victims is 8,000 lives saved. But even in countries with frequent resuscitation courses, care for cardiac arrest outside the hospital is less than half of the cases.

It is believed that resuscitation, correctly carried out by a person who is close to the victim, increases his chances of resuscitation by 2-3 times.

Resuscitation must be able to carry out physicians of any specialty, including nurses and doctors. It is desirable that people without a medical education could do it. Anesthesiologists-resuscitators are considered the greatest professionals in the restoration of spontaneous circulation.

Indications

Resuscitation should be started immediately after the discovery of the injured person, who is in a state of clinical death.

Clinical death is a period of time lasting from cardiac arrest and breathing to the occurrence of irreversible disorders in the body. The main signs of this condition include the absence of a pulse, breathing, and consciousness.

It must be recognized that not all people without a medical education (and with it, too) can quickly and correctly determine the presence of these signs. This can lead to an unjustified delay in the start of resuscitation, which greatly worsens the prognosis. Therefore, current European and American recommendations for CPR take into account only the absence of consciousness and breathing.

Resuscitation techniques

Check the following before starting resuscitation:

• Is the environment safe for you and the victim?
• Is the victim conscious or unconscious?
• If it seems to you that the patient is unconscious, touch him and ask loudly: "Are you all right?"
• If the victim did not answer, and there is someone else besides you, one of you should call an ambulance, and the second should start resuscitation. If you are alone and have a mobile phone, call an ambulance before starting resuscitation.

To remember the order and technique of conducting cardiopulmonary resuscitation, you need to learn the abbreviation "CAB", in which:

1. C (compressions) - closed heart massage (ZMS).
2. A (airway) - opening of the airways (ODP).
3. B (breathing) - artificial respiration (ID).

1. Closed heart massage

Carrying out VMS allows you to ensure the blood supply to the brain and heart at a minimum - but critically important - level that maintains the vital activity of their cells until spontaneous circulation is restored. With compressions, the volume of the chest changes, due to which there is a minimum gas exchange in the lungs, even in the absence of artificial respiration.

The brain is the organ most sensitive to reduced blood supply. Irreversible damage in its tissues develop within 5 minutes after the cessation of blood flow. The second most sensitive organ is the myocardium. Therefore, successful resuscitation with a good neurological prognosis and restoration of spontaneous circulation directly depends on the quality of the VMS.

The victim with cardiac arrest should be placed in the supine position on a hard surface, the person providing assistance should be placed to the side of him.

Place the palm of your dominant hand (depending on whether you are right-handed or left-handed) in the center of your chest, between your nipples. The base of the palm should be placed exactly on the sternum, its position should correspond to the longitudinal axis of the body. This focuses the compression force on the sternum and reduces the risk of rib fractures.

Place the second palm on top of the first and interlace their fingers. Make sure that no part of the palms touches the ribs to minimize pressure on them.

For the most efficient transfer of mechanical force, keep your arms straight at the elbows. Your body position should be such that your shoulders are vertically above the victim's chest.

The blood flow created by a closed heart massage depends on the frequency of compressions and the effectiveness of each of them. Scientific evidence has demonstrated the existence of a relationship between the frequency of compressions, the duration of pauses in the performance of VMS and the restoration of spontaneous circulation. Therefore, any breaks in compressions should be minimized. It is possible to stop VMS only at the time of artificial respiration (if it is carried out), assessment of the recovery of cardiac activity and for defibrillation. The required frequency of compressions is 100-120 times per minute. To get a rough idea of ​​the pace at which the VMS is being carried out, you can listen to the rhythm in the song of the British pop group BeeGees "Stayin' Alive". It is noteworthy that the very name of the song corresponds to the goal of emergency resuscitation - "Staying Alive".

The depth of chest deflection during VMS should be 5–6 cm in adults. After each pressing, the chest should be allowed to fully straighten, since incomplete restoration of its shape worsens blood flow. However, you should not remove your hands from the sternum, as this can lead to a decrease in the frequency and depth of compressions.

The quality of the VMS performed decreases sharply over time, which is associated with the fatigue of the person providing assistance. If resuscitation is carried out by two people, they should change every 2 minutes. More frequent shifts can lead to unnecessary breaks in HMS.

2. Opening the airways

In a state of clinical death, all the muscles of a person are in a relaxed state, due to which, in the supine position, the victim’s airways can be blocked by a tongue that has shifted to the larynx.

To open the airways:

• Place the palm of your hand on the victim's forehead.
• Tilt his head back, straightening it in the cervical spine (this technique should not be done if there is a suspicion of damage to the spine).
• Place the fingers of the other hand under the chin and push the lower jaw up.

3. CPR

Current CPR guidelines allow people who have not received special training not to perform ID, as they do not know how to do it and only waste precious time, which is better to devote entirely to chest compressions.

People who have undergone special training and are confident in their ability to perform ID with high quality are recommended to carry out resuscitation measures in the ratio of “30 compressions - 2 breaths”.

ID rules:

• Open the victim's airway.
• Pinch the patient's nostrils with the fingers of your hand on his forehead.
• Press your mouth firmly against the victim's mouth and exhale normally. Take 2 such artificial breaths, following the rise of the chest.
• After 2 breaths, start VMS immediately.
• Repeat cycles of "30 compressions - 2 breaths" until the end of resuscitation.

Algorithm for basic resuscitation in adults

Basic resuscitation (BRM) is a set of actions that a person providing assistance can carry out without the use of medicines and special medical equipment.

The cardiopulmonary resuscitation algorithm depends on the skills and knowledge of the person providing assistance. It consists of the following sequence of actions:

1. Make sure there is no danger at the point of care.
2. Determine if the victim is conscious. To do this, touch him and loudly ask if everything is all right with him.
3. If the patient somehow reacts to the appeal, call an ambulance.
4. If the patient is unconscious, turn him onto his back, open his airway, and assess for normal breathing.
5. In the absence of normal breathing (not to be confused with infrequent agonal sighs), start VMS at a rate of 100-120 compressions per minute.
6. If you know how to do an ID, perform resuscitation with a combination of "30 compressions - 2 breaths."

Features of resuscitation in children

The sequence of this resuscitation in children has slight differences, which are explained by the peculiarities of the causes of cardiac arrest in this age group.

Unlike adults, in whom sudden cardiac arrest is most often associated with cardiac pathology, in children, respiratory problems are the most common causes of clinical death.

The main differences between pediatric resuscitation and adult:

• After identifying a child with signs of clinical death (unconscious, not breathing, no pulse on the carotid arteries), resuscitation should begin with 5 artificial breaths.
• The ratio of compressions to artificial breaths during resuscitation in children is 15 to 2.
• If assistance is provided by 1 person, an ambulance should be called after resuscitation within 1 minute.

Using an automated external defibrillator

An automated external defibrillator (AED) is a small, portable device that can deliver an electrical shock (defibrillation) to the heart through the chest.

This shock has the potential to restore normal cardiac activity and resume spontaneous circulation. Since not all cardiac arrests require defibrillation, the AED has the ability to evaluate the victim's heart rate and determine if a shock is needed.

Most modern devices are capable of reproducing voice commands that give instructions to people providing assistance.

AEDs are very easy to use and have been specifically designed to be used by non-medical people. In many countries, AEDs are placed in high-traffic areas such as stadiums, train stations, airports, universities, and schools.

The sequence of actions for using the AED:

• Turn on the power of the device, which then starts to give voice instructions.
• Expose your chest. If the skin on it is wet, dry the skin. The AED has sticky electrodes that must be attached to the chest as shown on the device. Attach one electrode above the nipple, to the right of the sternum, the second - below and to the left of the second nipple.
• Make sure the electrodes are firmly attached to the skin. Connect the wires from them to the device.
• Make sure no one is touching the victim and click the "Analyze" button.
• After the AED analyzes the heart rate, it will give you instructions on how to proceed. If the machine decides that defibrillation is needed, it will warn you about it. At the time of application of the discharge, no one should touch the victim. Some devices perform defibrillation on their own, some require the Shock button to be pressed.
• Resume CPR immediately after shock is applied.

Termination of resuscitation

CPR should be stopped in the following situations:

1. An ambulance arrived, and its staff continued to provide assistance.
2. The victim showed signs of the resumption of spontaneous circulation (he began to breathe, cough, move, or regained consciousness).
3. You are completely exhausted physically.

Statistics show that every year the number of children who die in early childhood is steadily increasing. But if there was a person nearby at the right time who knows how to provide first aid and who knows the features of cardiopulmonary resuscitation in children ... In a situation where the life of children hangs in the balance, there should not be “if only”. We, adults, have no right to assumptions and doubts. Each of us is obliged to master the technique of conducting cardiopulmonary resuscitation, to have a clear algorithm of actions in our head in case the case suddenly forces us to be in the same place, at the same time ... After all, the most important thing depends on the correct, well-coordinated actions before the arrival of an ambulance the life of a little man.

1 What is cardiopulmonary resuscitation?

This is a set of measures that should be carried out by any person in any place before the arrival of an ambulance, if children have symptoms that indicate respiratory and / or circulatory arrest. Further, we will focus on basic resuscitation measures that do not require specialized equipment or medical training.

2 Causes leading to life-threatening conditions in children

Respiratory and circulatory arrest is most common among children in the neonatal period, as well as in children under the age of two years. Parents and others need to be extremely attentive to children of this age category. Often the causes of the development of a life-threatening condition can be a sudden blockage of the respiratory organs by a foreign body, and in newborns - by mucus, the contents of the stomach. Often there is a syndrome of sudden death, congenital malformations and anomalies, drowning, suffocation, injuries, infections and respiratory diseases.

There are differences in the mechanism of development of circulatory and respiratory arrest in children. They are as follows: if in an adult, circulatory disorders are more often associated directly with problems of the cardiac plan (heart attacks, myocarditis, angina pectoris), then in children this relationship is almost not traced. In children, progressive respiratory failure comes to the fore without damage to the heart, and then circulatory failure develops.

3 How to understand that a violation of blood circulation has occurred?

If there is a suspicion that something is wrong with the baby, you need to call him, ask simple questions “what is your name?”, “Is everything all right?” if you have a child 3-5 years old and older. If the patient does not respond, or is completely unconscious, it is necessary to immediately check whether he is breathing, whether he has a pulse, a heartbeat. A violation of blood circulation will indicate:

• lack of consciousness
• violation / lack of breathing,
• pulse on large arteries is not determined,
• heartbeats are not audible,
• pupils are dilated,
• reflexes are absent.

The time during which it is necessary to determine what happened to the child should not exceed 5-10 seconds, after which it is necessary to start cardiopulmonary resuscitation in children, call an ambulance. If you do not know how to determine the pulse, do not waste time on this. First of all, make sure that consciousness is preserved? Lean over him, call, ask a question, if he does not answer - pinch, squeeze his arm, leg.

If the child does not react to your actions, he is unconscious. You can make sure that there is no breathing by leaning your cheek and ear as close as possible to his face, if you do not feel the victim’s breathing on your cheek, and also see that his chest does not rise from respiratory movements, this indicates a lack of breathing. You can't delay! It is necessary to move on to resuscitation techniques in children!

4 ABC or CAB?

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 the patency of the respiratory tract;
• B - breathe for victim - ventilation of the lungs and access to oxygen;
• C - circulation of blood - compression of the chest and normalization of blood circulation.

After 2010, the European Resuscitation Council changed the recommendations, according to which chest compressions (point C), and not A, come first in resuscitation. The abbreviation changed from “ABC” to “CBA”. But these changes have had an effect in the adult population, in which the cause of critical situations is mostly heart disease. Among the child population, as mentioned above, respiratory disorders prevail over cardiac pathology, therefore, among children, the ABC algorithm is still guided, which primarily ensures airway patency and respiratory support.

5 Resuscitation

If the child is unconscious, there is no breathing or there are signs of its violation, it is necessary to make sure that the airways are passable and take 5 mouth-to-mouth or mouth-to-nose breaths. If a baby under 1 year old is in critical condition, you should not take too strong artificial breaths into his airways, given the small capacity of small lungs. After 5 breaths into the patient's airways, the vital signs should be checked again: respiration, pulse. If they are absent, it is necessary to start an indirect heart massage. To date, the ratio of the number of chest compressions and the number of breaths is 15 to 2 in children (in adults 30 to 2).

6 How to create airway patency?

If a small patient is unconscious, then often the tongue sinks into his airways, or in the supine position, the back of the head contributes to the flexion of the cervical spine, and the airways will be closed. In both cases, artificial respiration will not bring any positive results - the air will rest against the barriers and will not be able to get into the lungs. What should be done to avoid this?

1. It is necessary to straighten the head in the cervical region. Simply put, tilt your head back. Too much tilting should be avoided, as this may move the larynx forward. The extension should be smooth, the neck should be slightly extended. If there is a suspicion that the patient has an injury to the spine in the cervical region, do not tilt back!
2. Open the victim's mouth, trying to bring the lower jaw forward and towards you. Inspect the oral cavity, remove excess saliva or vomit, foreign body, if any.
3. The criterion of correctness, which ensures the patency of the airways, is the following such position of the child, in which his shoulder and the external auditory meatus are located on one straight line.

If, after the above actions, breathing is restored, you feel the movements of the chest, abdomen, the flow of air from the child's mouth, and a heartbeat, pulse is heard, then other methods of cardiopulmonary resuscitation in children should not be performed. It is necessary to turn the victim into a position on his side, in which his upper leg will be bent 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 obturation of the airways with mucus, vomit, stabilizes the spine, and provides good access to monitor the child's condition. After the little patient is placed in a safe position, his breathing is preserved and his pulse is felt, heart contractions are restored, it is necessary to monitor the child and wait for the ambulance to arrive. But not in all cases.

After fulfilling criterion "A", breathing is restored. If this does not happen, there is no breathing and cardiac activity, artificial ventilation and chest compressions should be carried out immediately. First, 5 breaths are performed in a row, the duration of each breath is approximately 1.0-.1.5 seconds. In children older than 1 year, mouth-to-mouth breaths are performed, in children under one year old - mouth-to-mouth, mouth-to-mouth and nose, mouth-to-nose. If after 5 artificial breaths there are still no signs of life, then proceed to an indirect heart massage in a ratio of 15: 2

7 Features of chest compressions in children

In cardiac arrest in children, indirect massage can be very effective and “start” the heart again. But only if it is carried out correctly, taking into account the age characteristics of small patients. When conducting an indirect heart massage in children, the following features should be remembered:

1. The recommended frequency of chest compressions in children is 100-120 per minute.
2. The depth of pressure on the chest for children under 8 years old is about 4 cm, over 8 years old is about 5 cm. The pressure should be strong and fast enough. Do not be afraid to make deep pressure. Since too superficial compressions will not lead to a positive result.
3. 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.
4. Hands are located on the border of the middle and lower thirds of the sternum.

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

Resuscitation measures for infants and children differ from those for adults. Although there are many similarities in CPR methodology for children and adults, life support in children usually starts from a different starting point. As noted above, in adults the sequence of actions is based on symptoms, most of which are of a cardiac nature. As a result, a clinical situation is created, usually requiring emergency defibrillation to achieve the 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 is rare in children.

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

The most common cause of airway obstruction in unconscious children is the tongue. Simple head extension and chin lift or mandibular thrust techniques help to secure the child's airway. If the cause of the serious condition of the child is trauma, then it is recommended to maintain the patency of the airway 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 - a small space between the nose and mouth of the child - the rescuer conducts breathing "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 common rhythm associated with cardiac arrest in children and infants. Circulation assessment in children traditionally begins with a pulse check. In infants, the pulse is measured on the brachial artery, in children - on the carotid. The pulse is checked for no longer than 10 s, and if it is not palpable or its frequency in infants less than 60 strokes per minute, you must immediately start an external heart massage.

Features of indirect heart massage in children: for newborns, massage is performed with the nail phalanges of the thumbs, after covering the back with the hands of 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, during CPR, it is recommended to adhere to a frequency of compressions of more than 100 per minute (2 compressions per 1 s), at the age of 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 conditional age limit of 8 years for children was proposed in connection with the peculiarities of the method of conducting chest compressions. Nevertheless, 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 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 show the benefit of using high doses of adrenaline in children with areactive asystole. If there is no response to the initial dose, it is recommended after 3-5 minutes either to repeat the same dose or to inject epinephrine at a high dose - 0.1 mg / kg 0.1 ml / kg in saline.

Atropine is a parasympathetic blockade drug with antivagal action. 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 occurred through vagal bradycardia.