Resuscitation of newborns: indications, types, stages, medications. Algorithm of actions for cardiopulmonary resuscitation in children, its purpose and varieties Intensive care unit for children

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resuscitation- this is a complex of therapeutic measures aimed at revitalizing, i.e. restoration of vital functions in patients who are in a state of clinical death.

Critical situation(terminal state) is an extreme degree

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

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

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

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

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

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

Agony- a state in which consciousness and eye reflexes are absent. Heart sounds are muffled. Arterial pressure is not determined. The pulse on the peripheral vessels is not palpable, on the carotid arteries - weak filling. Breathing is rare, convulsive or deep, frequent. The duration of the agonal state is from several minutes to several hours. With agony, the complex of the last compensatory reactions of the body may be turned on. Often there is a "splash" of almost extinct activity of the cardiovascular and respiratory systems. Sometimes consciousness is restored for a short time. However, exhausted organs very quickly lose their ability to function, and respiratory and circulatory arrest occurs, i.e. clinical death occurs.

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

resuscitation

The diagnosis of clinical death is made on the basis of certain signs:

The absence of a pulse on the carotid arteries during palpation is the easiest and fastest way to diagnose circulatory arrest. For the same purpose, another technique can be used: auscultation of the heart (with a phonendoscope or directly with the ear) in the area of ​​​​the projection of its apex. The absence of heart sounds will indicate cardiac arrest.

Respiratory arrest can be determined by the absence of vibrations of a thread or hair brought to the area of ​​​​the mouth or nose. It is difficult to determine from observation of chest movements respiratory arrest, especially in young children.

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

When ascertaining (as quickly as possible) clinical death in a patient, even before the start of resuscitation, it is necessary to perform two mandatory actions:

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

2. Call for help. It is a well-known fact that one person, no matter how trained, will not be able to adequately carry out effective resuscitation measures, even in a minimal amount.

Considering the extremely short period during which one can hope for success in the treatment of children who are in a state of clinical death, all resuscitation measures should begin as quickly as possible and be carried out clearly and competently. To do this, the resuscitator must know a strict algorithm of actions in this situation. The basis of such an algorithm was the "ABC of resuscitation" by Peter Safar, in which the stages of the revival process are described in strict order and "tied" to the letters of the English alphabet.

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

BUT. Free airway patency is provided depending on the circumstances in various ways. In cases where it can be suspected that there is not a large amount of content in the airways, the following measures are taken: the child is laid on its side (or simply turned its head on its side), its mouth is opened and the oral cavity and pharynx are cleaned with a tupfer or a finger wrapped in cloth.

If there is a large amount of liquid content in the respiratory tract (for example, when drowning), a small child is lifted by the legs down the torso, slightly tilted back, tapped on the back along the spine, and then the digital sanitation already described above is carried out. In the same situation, older children can be placed with their stomachs on the resuscitator's thigh so that their head hangs down freely (Fig. 23.1.).

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

If there is no effect and it is impossible to perform direct laryngoscopy, it is possible to perform microconiostomy - perforation of the cricoid-thyroid membrane with a thick needle (Fig. 23.2.). The cricoid-thyroid membrane is located between the lower edge of the thyroid and the upper edge of the cricoid cartilage of the larynx. Between it and the skin there is an insignificant layer of muscle fibers, there are no large vessels and nerves. Finding the membrane is relatively easy. If we orient ourselves from the upper notch of the thyroid cartilage, then going down the midline, we find a small depression between the anterior arch of the cricoid cartilage and the lower edge of the thyroid cartilage - this is the cricoid-thyroid membrane. The vocal cords are located slightly cranial to the membrane, so they are not damaged during manipulation. It takes a few seconds to perform a microconiostomy. The technique of its implementation is as follows: the head is thrown back as much as possible (it is advisable to put a roller under the shoulders); the larynx is fixed with the thumb and middle finger on the lateral surfaces of the thyroid cartilage; the index finger is determined by the membrane. The needle, previously bent at an obtuse angle, is inserted into the membrane strictly along the midline until a “dip” is felt, which indicates that the end of the needle is in the laryngeal cavity.

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

In hospital conditions, mechanical suction is used to remove the contents of the respiratory tract. After cleaning the oral cavity and pharynx from the contents at the pre-medical stage, it is necessary to give the child a position that ensures maximum airway patency. To do this, the head is extended, the lower jaw is brought forward and the mouth is opened.

Extension of the head makes it possible to maintain airway patency in 80% of patients who are unconscious, since as a result of this manipulation, tissue tension occurs between the larynx and the lower jaw. In this case, the root of the tongue moves away from the back wall of the pharynx. In order to ensure the tilting of the head, it is enough to place a roller under the upper shoulder girdle.

When removing the lower jaw, it is necessary that the lower row of teeth is in front of the upper one. The mouth is opened with a small, oppositely directed movement of the thumbs. The position of the head and jaw must be maintained during all resuscitation until the introduction of an airway or tracheal intubation.

In the prehospital setting, air ducts can be used to support the root of the tongue. The introduction of the air duct in the vast majority of cases (with normal pharyngeal anatomy) eliminates the need to constantly keep the lower jaw in the withdrawn position, which significantly circumvents resuscitation. The introduction of the air duct, which is an arcuate tube of oval cross section with a mouthpiece, is carried out as follows: first, the air duct is inserted into the patient's mouth with a downward bend, advanced to the root of the tongue, and only then set to the desired position by turning it 180 degrees.

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

When performing cardiopulmonary resuscitation by a healthcare worker, tracheal intubation should be a gentle method of establishing a clear airway. Tracheal intubation can be either orotracheal (through the mouth) or nasotracheal (through the nose). The choice of one of these two methods is determined by how long the endotracheal tube is supposed to stay in the trachea, as well as the presence of damage or diseases of the corresponding parts of the facial skull, mouth and nose.

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

The blade of the laryngoscope is inserted into the mouth, moving the tongue up to see the first landmark - the uvula of the soft palate. By moving the laryngoscope blade deeper, they are looking for a second landmark - the epiglottis. Lifting it up, the glottis is exposed, into which, with a movement from the right corner of the mouth - so as not to close the field of view - an endotracheal tube is inserted. Verification of correctly performed intubation is performed by comparative auscultation of respiratory sounds over both lungs.

During nasotracheal intubation, the tube is inserted through the nostril (more often the right one - it is wider in most people) to the level of the nasopharynx and directed into the glottis using Megill intubation forceps under laryngoscope control (Fig. 23.7.).

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

Tracheal intubation completely eliminates the possibility of upper airway obstruction, with the exception of two easily detected and eliminated complications: kinking of the tube and its obstruction with a secret from the respiratory tract.

Tracheal intubation not only provides free airway patency, but also makes it possible to administer some medications necessary for resuscitation endotracheally.

B. Artificial ventilation of the lungs.

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

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

Mouth-to-nose artificial respiration is used in situations where there are injuries in the mouth area that do not allow creating conditions for maximum tightness. The technique of this technique differs from the previous one only in that air is blown into the nose, while the mouth is tightly closed.

Recently, to facilitate the implementation of all three of the above methods of artificial lung ventilation, Ambu Intenational has produced a simple device called the “key of life”. It is a polyethylene sheet enclosed in a keychain, in the center of which there is a flat unidirectional valve through which air is blown. The lateral edges of the sheet are hooked on the patient's auricles with the help of thin rubber bands. It is very difficult to apply this “key of life” incorrectly: everything is drawn on it - lips, teeth, ears. This device is disposable and prevents the need to touch the patient directly, which is sometimes unsafe.

In the case when an airway or S-tube was used to ensure a free airway. Then it is possible to carry out artificial respiration, using them as conductors of the blown air.

At the stage of medical assistance during mechanical ventilation, a breathing bag or automatic respirators are used.

Modern modifications of the breathing bag have three mandatory components:

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

an inlet valve that ensures the flow of air from the atmosphere into the bag (when expanded) and to the patient (when compressed);

a non-return valve with an adapter for a mask or endotracheal tube that allows passive exhalation to the atmosphere.

Currently, most self-expanding bags produced are equipped with a fitting for enriching the respiratory mixture with oxygen.

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

Optimal is mechanical ventilation with automatic respirators.

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

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

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

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

1. One reviver is engaged in artificial ventilation of the lungs, the second - a heart massage. Moreover, there should be no pauses, no stops in the first or second event! In the experiment, it was shown that with simultaneous compression of the chest and ventilation of the lungs with high pressure, cerebral blood flow becomes 113-643% more than with the standard method.
2. Artificial systole should take at least 50% of the duration of the entire cardiac cycle.

The established concept of the mechanism of the chest pump contributed to the emergence of some original techniques that allow providing artificial blood flow during resuscitation.

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

In 1992, for the first time in humans, the method of “inserted abdominal compression” - VAC was applied, although the data of scientific developments that are easy to base on it were published as early as 1976. When conducting VAK, at least three people should take part in resuscitation measures: the first performs artificial ventilation of the lungs, the second compresses the chest, the third - immediately after the end of chest compression, squeezes the abdomen in the navel according to the same method as the second resuscitator. The effectiveness of this method in clinical trials was 2-2.5 times higher than with conventional closed heart massage. There are probably two mechanisms for improving artificial blood flow in VAC:

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

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

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

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

The effectiveness of this technique is confirmed by the results of many studies. Coronary perfusion pressure (the difference between aortic and right atrial pressures) is three times higher than standard resuscitation, and it is one of the most important predictors of CPR success.

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

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

Conducting an open (or direct) heart massage is allowed only in a hospital setting. The technique of its implementation is as follows: the chest is opened in the fourth intercostal space on the left with an incision, from the edge of the sternum to the midaxillary line. In this case, the skin, subcutaneous tissue and fascia of the pectoral muscles are cut with a scalpel. Next, the muscles and pleura are perforated with a forceps or clamp. With a retractor, the chest cavity is widely opened and immediately begin to massage the heart. In newborns and infants, it is most convenient to press the heart with two fingers against the back of the sternum. In older children, the heart is squeezed with the right hand so that the first finger is located above the right ventricle, and the remaining fingers are above the left ventricle. Fingers should be laid flat on the myocardium so as not to perforate it. Opening the pericardium is required only when there is fluid in it or for visual diagnosis of myocardial fibrillation. The frequency of compressions is the same as with a closed massage. If sudden cardiac arrest occurs during abdominal surgery, massage can be done through the diaphragm.

Direct cardiac massage has been experimentally and clinically proven to provide higher arterial and lower venous pressure, resulting in better cardiac and brain perfusion during resuscitation, as well as more patient survival. However, this manipulation is very traumatic and can lead to many complications.

Indications for open heart massage are:

1. Cardiac arrest during operations on the chest or abdomen;
2. The presence of pericardial tamponade of the heart;
3. Tension pneumothorax;
4. Massive pulmonary embolism
5. Multiple fractures of the ribs, sternum and spine;
6. Deformation of the sternum and / or thoracic spine;
7. No signs of effectiveness of closed heart massage for 2.5-3 minutes.

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

So, ensuring free airway patency, artificial ventilation of the lungs and maintaining artificial blood flow constitute the stage of primary cardiovascular resuscitation (or resuscitation in the volume ABC). The criteria for the effectiveness of measures taken during the revival of the patient are:

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

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

D - Drug (medicines).

E - ECG (ECG).

F - Fibrillation (defibrillation)

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

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

As long as there is no access to the vascular bed, drugs such as adrenaline, atropine, lidocaine can be administered endotracheally. It is best to carry out such manipulation through a thin catheter inserted into the endotracheal tube. The medicinal substance can also be introduced into the trachea through a conio- or tracheostomy. Absorption of drugs from the lungs in the presence of sufficient blood flow occurs almost as quickly as when they are administered intravenously.

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

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

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

after the introduction of the drug, it is necessary to make 5 artificial breaths for its better distribution through the lungs;

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

By the way, all specialists involved in the study of this problem noted the fact that with endotracheal administration, any drug acts longer than with intravenous administration.

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

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

Intravenous the route of administration of drugs is the most preferred when performing CPR. If possible, it is desirable to use central beliefs. This rule is especially important during resuscitation in children, since the puncture of peripheral veins in this group of patients can be quite difficult. In addition, in patients in a state of clinical death, the blood flow in the periphery, if not completely absent, is extremely small. This fact gives reason to doubt that the injected drug will quickly reach the point of application of its action (the desired receptor). We emphasize once again that, according to most experts, during resuscitation, an attempt to puncture a peripheral vein in a child should not be spent more than 90 seconds - after that, you should switch to a different route of drug administration.

Intraosseous the route of administration of drugs during resuscitation is one of the alternative accesses to the vascular bed or critical conditions. This method is not widely used in our country, however, it is known that with certain equipment and the presence of the necessary practical skills in the resuscitator, the intraosseous method significantly reduces the time required to deliver the medication to the patient's body. There is an excellent outflow from the bone through the venous channels, and the drug injected into the bone quickly enters the systemic circulation. It should be noted that the veins located in the bone marrow do not collapse. For the introduction of drugs, the calcaneus and the anterior superior iliac spine are most often used.

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

Adrenaline has for many years held the lead among all drugs used in resuscitation. Its universal adrenomimetic effect stimulates all myocardial functions, increases diastolic pressure in the aorta (on which coronary blood flow depends), and expands the cerebral microvasculature. According to experimental and clinical studies, no synthetic adrenergic agonist has advantages over adrenaline. The dose of this drug is 10-20 mcg / kg (0.01-0.02 mg / kg). The drug is re-introduced every 3 minutes. If there is no effect after a double injection, the dose of adrenaline is increased 10 times (0.1 mg / kg). In the future, the same dosage is repeated after 3-5 minutes.

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

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

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

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

inactivation of catecholamines;

decrease in the effectiveness of defibrillation.

Currently, the indications for the introduction of sodium bicarbonate are:

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

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

In the early 1990s, it was found that there was no evidence of a positive effect of calcium supplements on the effectiveness and outcomes of cardiopulmonary resuscitation. On the contrary, an increased level of calcium ions contributes to an increase in neurological disorders after cerebral ischemia, as it contributes to an increase in its reperfusion damage. In addition, calcium causes disruption of energy production and stimulates the formation of eicosanoids. Therefore, indications for the use of calcium preparations during resuscitation are:

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

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

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

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

Infusion of isotonic colloids or glucose-free crystalloids should be used to ensure patient survival.

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

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

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

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

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

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

There are four types of cardiac defibrillation:

Chemical

Mechanical

Medical

Electrical

Chemical defibrillation consists in the rapid intravenous administration of a KCl solution. Myocardial fibrillation after this procedure stops and passes into asystole. However, it is far from always possible to restore cardiac activity after this, therefore this method of defibrillation is not currently used.

Mechanical defibrillation is well known as a precordial or “resuscitation” punch and is a punch (in newborns, a click) on the sternum. Albeit rarely, but it can be effective and, at the same time, not bringing the patient (given his condition) any tangible harm.

Medical defibrillation consists in the introduction of antiarrhythmic drugs - lidocaine, ornida, verapamil in appropriate dosages.

Electrical defibrillation of the heart (EMF) is the most effective method and the most important component of cardiopulmonary resuscitation (Fig. 23.10.).

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

When conducting EDS, certain rules must be strictly observed:

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

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

So in the first case it looks like this:

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

When conducting electrical defibrillation on an open heart, the magnitude of the discharge is reduced by 7 times.

It should be noted that in most modern foreign guidelines on cardiopulmonary resuscitation in children, it is recommended to carry out EMF in series of three discharges (2 J / kg - 4 J / kg - 4 J / kg). Moreover, if the first series is unsuccessful, then against the background of ongoing heart massage, mechanical ventilation, drug therapy and metabolic correction, the second series of discharges should be started - again with 2 J / kg.

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

Very important for doctors of all specialties are the problems associated with the refusal to conduct cardiopulmonary resuscitation and its termination.

CPR may not be initiated when, under normothermic conditions:

cardiac arrest occurred against the background of a full complex of intensive care;

the patient is in the terminal stage of an incurable disease;

more than 25 minutes have passed since the cardiac arrest;

in case of documented refusal of the patient from cardiopulmonary resuscitation (if the patient is a child under the age of 14, then the documented refusal to carry out resuscitation should be signed by his parents).

CPR is stopped if:

in the course of resuscitation, it turned out that it was not shown to the patient;

when using all available methods of CPR, there were no signs of effectiveness within 30 minutes;

there are multiple cardiac arrests that are not amenable to any medical effects.

The sequence of the three most important methods of cardiopulmonary resuscitation was formulated by P. Safar (1984) as the ABC rule:

1. Aire way orep (“open the way for air”) means the need to free the airways from obstacles: sinking of the root of the tongue, accumulation of mucus, blood, vomit and other foreign bodies;
2. Breath for victim ("breath for the victim") means mechanical ventilation;
3. Circulation his blood ("circulation of his blood") means an indirect or direct heart massage.

Measures aimed at restoring airway patency are carried out in the following sequence:

• the victim is placed on a rigid base supine (face up), and if possible - in the Trendelenburg position;
• unbend the head in the cervical region, bring the lower jaw forward and at the same time open the mouth of the victim (R. Safar's triple technique);
• release the patient's mouth from various foreign bodies, mucus, vomit, blood clots with a finger wrapped in a handkerchief, suction.

Having ensured the patency of the respiratory tract, immediately proceed to mechanical ventilation. There are several main methods:

• indirect, manual methods;
• methods of direct blowing of air exhaled by the resuscitator into the airways of the victim;
• hardware methods.

The former are mainly of historical importance and are not considered at all in modern guidelines for cardiopulmonary resuscitation. At the same time, manual ventilation techniques should not be neglected in difficult situations when it is not possible to provide assistance to the victim in other ways. In particular, it is possible to apply rhythmic compressions (simultaneously with both hands) of the victim's lower chest ribs, synchronized with his exhalation. This technique may be useful during transportation of a patient with severe asthmatic status (the patient lies or half-sitting with his head thrown back, the doctor stands in front or to the side and rhythmically squeezes his chest from the sides during exhalation). Reception is not indicated for fractures of the ribs or severe airway obstruction.

The advantage of methods of direct inflation of the lungs in the victim is that 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 an increased amount of carbon dioxide (carbogen) stimulates the patient's respiratory center. Mouth-to-mouth, mouth-to-nose, mouth-to-nose and mouth methods are used; the latter method is usually used in the resuscitation of young children.

The rescuer kneels on the side of the victim. Holding his head in an unbent position and holding his nose with two fingers, he tightly covers the mouth of the victim with his lips and makes 2-4 energetic, not fast (within 1-1.5 s) exhalations in a row (the patient's chest should be noticeable). An adult is usually provided with up to 16 respiratory cycles per minute, a child - up to 40 (taking into account age).

Ventilators vary in complexity of design. At the prehospital stage, you can use self-expanding breathing bags of the Ambu type, simple mechanical devices of the Pnevmat type, or interrupters of a constant air flow, for example, using the Eyre method (through a tee - with a finger). In hospitals, complex electromechanical devices are used that provide mechanical ventilation for a long period (weeks, months, years). Short-term forced ventilation is provided through a nasal mask, long-term - through an endotracheal or tracheotomy tube.

Usually, mechanical ventilation is combined with an external, indirect heart massage, achieved with the help of compression - compression of the chest in the transverse direction: from the sternum to the spine. In older children and adults, this is the border between the lower and middle thirds of the sternum; in young children, it is a conditional line passing one transverse finger above the nipples. The frequency of chest compressions in adults is 60-80, in infants - 100-120, in newborns - 120-140 per minute.

In infants, there is one breath for every 3-4 chest compressions; in older children and adults, the ratio is 1:5.

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

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

Specialized cardiopulmonary resuscitation includes more adequate mechanical ventilation, as well as intravenous or intratracheal medication. With intratracheal administration, the dose of drugs in adults should be 2 times, and in infants 5 times higher than with intravenous administration. Intracardiac administration of drugs is currently not practiced.

The condition for the success of cardiopulmonary resuscitation in children is the release of the airways, mechanical ventilation and oxygen supply. The most common cause of circulatory arrest in children is hypoxemia. Therefore, during CPR, 100% oxygen is delivered through a mask or endotracheal tube. V. A. Mikhelson et al. (2001) supplemented R. Safar's "ABC" rule with 3 more letters: D (Drag) - drugs, E (ECG) - electrocardiographic control, F (Fibrillation) - defibrillation as a method of treating cardiac arrhythmias. Modern cardiopulmonary resuscitation in children is unthinkable without these components, however, the algorithm for their use depends on the variant of cardiac dysfunction.

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

• adrenaline (0.1% solution); 1st dose - 0.01 ml / kg, the next - 0.1 ml / kg (every 3-5 minutes until the effect is obtained). With intratracheal administration, the dose is increased;
• atropine (with asystole is ineffective) is usually administered after adrenaline and adequate ventilation (0.02 ml / kg 0.1% solution); repeat no more than 2 times in the same dose after 10 minutes;
• Sodium bicarbonate is administered only in conditions of prolonged cardiopulmonary resuscitation, and also if it is known that circulatory arrest occurred against the background of decompensated metabolic acidosis. The usual dose is 1 ml of an 8.4% solution. Repeat the introduction of the drug is possible only under the control of CBS;
• dopamine (dopamine, dopmin) is used after the restoration of cardiac activity against the background of unstable hemodynamics at a dose of 5-20 μg / (kg min), to improve diuresis 1-2 μg / (kg-min) for a long time;
• lidocaine is administered after the restoration of cardiac activity against the background of postresuscitation ventricular tachyarrhythmia as a bolus at a dose of 1.0-1.5 mg/kg followed by an infusion at a dose of 1-3 mg/kg-h), or 20-50 mcg/(kg-min) .

Defibrillation is carried out against the background of ventricular fibrillation or ventricular tachycardia in the absence of a pulse on the carotid or brachial artery. The power of the 1st discharge is 2 J/kg, subsequent - 4 J/kg; the first 3 discharges can be given in a row without being monitored by an ECG monitor. If the device has a different scale (voltmeter), the 1st category in infants should be in the range of 500-700 V, repeated - 2 times more. In adults, respectively, 2 and 4 thousand. V (maximum 7 thousand V). The effectiveness of defibrillation is increased by repeated administration of the entire complex of drug therapy (including a polarizing mixture, and sometimes magnesium sulfate, aminophylline);

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

• adrenaline intravenously, intratracheally (if catheterization is not possible after 3 attempts or within 90 seconds); 1st dose 0.01 mg/kg, subsequent - 0.1 mg/kg. The introduction of the drug is repeated every 3-5 minutes until the effect is obtained (restoration of hemodynamics, pulse), then in the form of infusions at a dose of 0.1-1.0 μg / (kgmin);
• liquid for replenishment of the central nervous system; it is better to use a 5% solution of albumin or stabizol, you can reopoliglyukin at a dose of 5-7 ml / kg quickly, drip;
• atropine at a dose of 0.02-0.03 mg/kg; re-introduction is possible after 5-10 minutes;
• sodium bicarbonate - usually 1 time 1 ml of 8.4% solution intravenously slowly; the effectiveness of its introduction is doubtful;
• with the ineffectiveness of the listed means of therapy - electrocardiostimulation (external, transesophageal, endocardial) without delay.

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

In cases where the brain damage is so deep and extensive that it becomes impossible to restore its functions, including stem functions, brain death is diagnosed. The latter is equated to the death of the organism as a whole.

Currently, there are no legal grounds for stopping the started and actively conducted intensive care in children before natural circulatory arrest. Resuscitation does not begin and is not carried out in the presence of a chronic disease and pathology incompatible with life, which is predetermined by a council of doctors, as well as in the presence of objective signs of biological death (cadaveric spots, rigor mortis). In all other cases, cardiopulmonary resuscitation in children should begin with any sudden cardiac arrest and be carried out according to all the rules described above.

The duration of standard resuscitation in the absence of effect should be at least 30 minutes after circulatory arrest.

With successful cardiopulmonary resuscitation in children, it is possible to restore cardiac, sometimes simultaneously, respiratory functions (primary revival) in at least half of the victims, however, in the future, survival in patients is much less common. The reason for this is post-resuscitation illness.

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

Complications of postresuscitation illness:

• in the first 2-3 days after CPR - swelling of the brain, lungs, increased bleeding of tissues;
• 3-5 days after CPR - violation of the functions of parenchymal organs, the development of overt multiple organ failure (MON);
• in later periods - inflammatory and suppurative processes. In the early postresuscitation period (1-2 weeks) intensive care
• carried out against the background of disturbed consciousness (somnolence, stupor, coma) IVL. Its main tasks in this period are the stabilization of hemodynamics and the protection of the brain from aggression.

Restoration of the BCP and the rheological properties of blood is carried out by hemodilutants (albumin, protein, dry and native plasma, reopoliglyukin, saline solutions, less often a polarizing mixture with the introduction of insulin at the rate of 1 unit per 2-5 g of dry glucose). Plasma protein concentration should be at least 65 g/l. Improving gas exchange is achieved by restoring the oxygen capacity of the blood (red blood cell transfusion), mechanical ventilation (with an oxygen concentration in the air mixture preferably less than 50%). With reliable restoration of spontaneous respiration and stabilization of hemodynamics, it is possible to carry out HBO, for a course of 5-10 procedures daily, 0.5 ATI (1.5 ATA) and a plateau of 30-40 minutes under the cover of antioxidant therapy (tocopherol, ascorbic acid, etc.). Maintaining blood circulation is provided by small doses of dopamine (1-3 mcg / kg per minute for a long time), carrying out maintenance cardiotrophic therapy (polarizing mixture, panangin). Normalization of microcirculation is ensured by effective pain relief in case of injuries, neurovegetative blockade, administration of antiplatelet agents (curantyl 2-Zmg/kg, heparin up to 300 U/kg per day) and vasodilators (cavinton up to 2 ml drip or trental 2-5 mg/kg per day drip, sermion , eufillin, nicotinic acid, complamin, etc.).

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

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

The VEO, KOS and energy metabolism are being corrected. Detoxification therapy is carried out (infusion therapy, hemosorption, plasmapheresis according to indications) for the prevention of toxic encephalopathy and secondary toxic (autotoxic) organ damage. Intestinal decontamination with aminoglycosides. Timely and effective anticonvulsant and antipyretic therapy in young children prevents the development of post-hypoxic encephalopathy.

Prevention and treatment of bedsores (treatment with camphor oil, curiosin of places with impaired microcirculation), nosocomial infections (asepsis) are necessary.

In the case of a patient's rapid exit from a critical condition (in 1-2 hours), the complex of therapy and its duration should be adjusted depending on the clinical manifestations and the presence of post-resuscitation disease.

Treatment in the late post-resuscitation period

Therapy in the late (subacute) post-resuscitation period is carried out for a long time - months and years. Its main direction is the restoration of brain function. Treatment is carried out in conjunction with neuropathologists.

• The introduction of drugs that reduce metabolic processes in the brain is reduced.
• Prescribe drugs that stimulate metabolism: cytochrome C 0.25% (10-50 ml / day 0.25% solution in 4-6 doses, depending on age), actovegin, solcoseryl (0.4-2.0g intravenous drip for 5 % glucose solution for 6 hours), piracetam (10-50 ml / day), cerebrolysin (up to 5-15 ml / day) for older children intravenously during the day. Subsequently, encephabol, acephen, nootropil are prescribed orally for a long time.
• 2-3 weeks after CPR, a (primary or repeated) course of HBO therapy is indicated.
• Continue the introduction of antioxidants, antiplatelet agents.
• Vitamins of group B, C, multivitamins.
• Antifungal drugs (diflucan, ancotyl, candizol), biologics. Termination of antibiotic therapy as indicated.
• Membrane stabilizers, physiotherapy, exercise therapy (LFK) and massage according to indications.
• General strengthening therapy: vitamins, ATP, creatine phosphate, biostimulants, adaptogens for a long time.

The main differences between cardiopulmonary resuscitation in children and adults

Conditions preceding circulatory arrest

Bradycardia in a child with respiratory problems is a sign of circulatory arrest. Newborns, infants, and young children develop bradycardia in response to hypoxia, while older children develop tachycardia first. In newborns and children with a heart rate of less than 60 beats per minute and signs of low organ perfusion, if there is no improvement after the start of artificial respiration, closed heart massage should be performed.

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

Blood pressure should be measured with a properly sized cuff, and invasive blood pressure measurement is indicated only when the child is extremely severe.

Since the blood pressure indicator depends on age, it is easy to remember the lower limit of the norm as follows: less than 1 month - 60 mm Hg. Art.; 1 month - 1 year - 70 mm Hg. Art.; more than 1 year - 70 + 2 x age in years. It is important to note that children are able to maintain pressure for a long time due to powerful compensatory mechanisms (increased heart rate and peripheral vascular resistance). However, hypotension is followed very quickly by cardiac and respiratory arrest. Therefore, even before the onset of hypotension, all efforts should be directed to the treatment of shock (manifestations of which are an increase in heart rate, cold extremities, capillary filling for more than 2 s, a weak peripheral pulse).],

Equipment and environment

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

In newborns and children, heat transfer is increased due to the larger body surface relative to body weight and a small amount of subcutaneous fat. The ambient temperature during and after cardiopulmonary resuscitation should be constant, ranging from 36.5°C in neonates to 35°C in children. At a basal body temperature below 35 ° C, CPR becomes problematic (in contrast to the beneficial effect of hypothermia in the post-resuscitation period).

Rhythm disturbances

With asystole, atropine and artificial pacing are not used.

VF and VT with unstable hemodynamics occurs in 15-20% of cases of circulatory arrest. Vasopressin is not prescribed. When using cardioversion, the shock force should be 2-4 J/kg for a monophasic defibrillator. It is recommended to start at 2 J/kg and increase as needed to a maximum of 4 J/kg on the third shock.

As statistics show, cardiopulmonary resuscitation in children allows to return to a full life at least 1% of patients or victims of accidents.

Infrequently, but there are such cases: a person was walking down the street, evenly, confidently, and suddenly he fell, stopped breathing, turned blue. In such cases, people around usually call an ambulance and wait a long time. Five minutes later, the arrival of specialists is no longer necessary - the person has died. And extremely rarely there is a person nearby who knows the algorithm for conducting cardiopulmonary resuscitation and is able to apply his actions in practice.

Causes of cardiac arrest

In principle, any disease can cause cardiac arrest. Therefore, listing all those hundreds of diseases that are known to specialists is pointless and there is no need. However, the most common causes of cardiac arrest are:

• heart diseases;
• trauma;
• drowning;
• electric shocks;
• intoxication;
• infections;
• respiratory arrest in case of aspiration (inhalation) of a foreign body - this cause most often occurs in children.

However, regardless of the cause, the algorithm of actions for cardiopulmonary resuscitation always remains the same.

Movies very often show the attempts of heroes to resuscitate a dying person. Usually it looks like this - a positive character runs up to a motionless victim, falls on his knees next to him and begins to intensely press on his chest. With all his artistry, he shows the drama of the moment: he jumps over a person, trembles, cries or screams. If the case occurs in the hospital, the doctors always report that "he is leaving, we are losing him." If, according to the scriptwriter's plan, the victim should live, he will survive. However, such a person has no chance of salvation in real life, since the "resuscitator" did everything wrong.

In 1984, the Austrian anesthesiologist Peter Safar proposed the ABC system. This complex formed the basis of modern recommendations for cardiopulmonary resuscitation, and for more than 30 years, this rule has been used by all doctors without exception. In 2015, the American Heart Association released an updated guide for practitioners, which covers in detail all the nuances of the algorithm.

ABC algorithm- this is a sequence of actions that give the victim the maximum chance for survival. Its essence lies in its very name:

• airway- respiratory tract: detection of their blockage and its elimination in order to ensure the patency of the larynx, trachea, bronchi;
• breathing- breathing: carrying out artificial respiration according to a special technique with a certain frequency;
• Circulation- ensuring blood circulation during cardiac arrest by its external (indirect massage).

Cardiopulmonary resuscitation according to the ABC algorithm can be performed by any person, even without a medical education. This is the basic knowledge that everyone should have.

How is cardiopulmonary resuscitation performed in adults and adolescents

First of all, you should ensure the safety of the victim, not forgetting about yourself. If you remove a person from a car that has been in an accident, immediately pull him away from it. If a fire is raging nearby, do the same. Move the victim to any nearest safe place and proceed to the next step.

Now we need to make sure that the person really needs CPR. To do this, ask him "What is your name?" It is this question that will best attract the attention of the victim if he is conscious, even clouded.

If he does not answer, shake him up: lightly pinch his cheek, pat him on the shoulder. Do not move the victim unnecessarily, as you cannot be sure of the absence of injuries if you find him already unconscious.

In the absence of consciousness, check for the presence or absence of breathing. To do this, put your ear to the mouth of the victim. Here the rule “See. Hear. Touch":

• you see chest movements;
• you hear the sound of exhaled air;
• you feel the movement of air with your cheek.

In movies, this is often done by putting the ear to the chest. This method is relatively effective only if the patient's chest is completely exposed. Even one layer of clothing will distort the sound and you will not understand anything.

Simultaneously with the breath check, you can check for the presence of a pulse. Don't look for it on your wrist: the best way to detect a pulse is by palpation of the carotid artery. To do this, place your index and ring fingers on the top of the "Adam's apple" and move them towards the back of the neck until the fingers rest against the muscle that runs from top to bottom. If there is no pulsation, then cardiac activity has stopped and it is necessary to start saving lives.

Attention! You have 10 seconds to check for pulse and breathing!

The next step is to make sure that there are no foreign bodies in the victim's mouth. In no case look for them by touch: a person may have convulsions and your fingers will simply be bitten off, or you may accidentally rip off an artificial tooth crown or bridge, which will get into the airways and cause asphyxia. You can remove only those foreign bodies that are visible from the outside and are close to the lips.

Now attract the attention of others, ask them to call an ambulance, and if you are alone, do it yourself (calling the emergency services is free), and then start cardiopulmonary resuscitation.

Lay the person on their back on a hard surface - earth, asphalt, table, floor. Tilt back his head, push the lower jaw forward and slightly open the victim's mouth - this will prevent the tongue from falling back and allow effective artificial respiration ( triple Safar maneuver).

If a neck injury is suspected, or if the person has been found already unconscious, limit yourself to lower jaw protrusion and mouth opening ( double Safar maneuver). Sometimes this is enough for a person to start breathing.

Attention! The presence of breathing is almost one hundred percent evidence that the human heart is working. If the victim is breathing, he should be turned on his side and left in this position until the arrival of doctors. Observe the casualty, checking for pulse and respiration every minute.

In the absence of a pulse, start an external cardiac massage. To do this, if you are right-handed, then place the base of your right palm on the lower third of the sternum (2-3 cm below the conditional line passing through the nipples). Put the base of your left palm on it and interlace your fingers, as shown in the figure.

Hands must be straight! Press with your whole body on the chest of the victim with a frequency of 100-120 clicks per minute. The depth of pressing is 5-6 cm. Do not take long breaks - you can rest for no more than 10 seconds. Let the chest expand completely after pressing, but do not take your hands off it.

The most effective method of artificial respiration is mouth-to-mouth. To carry it out, after the triple or double Safar maneuver, cover the victim's mouth with your mouth, pinch his nose with the fingers of one hand and exhale vigorously for 1 second. Let the patient breathe.

The effectiveness of artificial respiration is determined by the movements of the chest, which must rise and fall during inhalation and exhalation. If this is not the case, then the person's airways are clogged. Check the mouth again - you may see a foreign body that can be removed. In any case, do not interrupt cardiopulmonary resuscitation.

ATTENTION! The American Heart Association recommends that you do not need to administer artificial respiration, as chest compressions provide the body with the minimum amount of air it needs. However, artificial respiration increases the likelihood of a positive effect from CPR by several percent. Therefore, if possible, it should still be carried out, remembering that a person may be sick with an infectious disease such as hepatitis or HIV infection.

One person is not able to simultaneously press on the chest and carry out artificial respiration, so the actions should be alternated: after every 30 presses, 2 respiratory movements should be performed.

Stop every two minutes and check for a pulse. If it appears, pressing on the chest should be stopped.

A detailed algorithm for conducting cardiopulmonary resuscitation for adults and adolescents is presented in the video review:

When to Stop CPR

Termination of cardiopulmonary resuscitation:

• with the appearance of spontaneous breathing and pulse;
• when signs of biological death appear;
• 30 minutes after the start of resuscitation;
• if the rescuer is completely exhausted and unable to continue CPR.

Numerous studies show that carrying out CPR for more than 30 minutes can lead to the appearance of a heart rhythm. However, during this time the cerebral cortex dies and the person is not able to recover. That is why a half-hour interval has been set, during which the victim has a chance of recovery.

In childhood, asphyxia is a more common cause of clinical death. Therefore, it is especially important for this category of patients to carry out the full range of resuscitation measures - both external heart massage and artificial respiration.

Note: if an adult is allowed to be left for a very short time in order to call for help, then the child must first carry out CPR for two minutes, and only then can he be absent for a few seconds.

To carry out chest compressions in a child should be with the same frequency and amplitude as in adults. Depending on his age, you can press with two or one hand. In infants, an effective method is when the baby’s chest is clasped with both palms, placing the thumbs in the middle of the sternum, and the rest are pressed tightly against the sides and back. Pressing is done with the thumbs.

The ratio of compressions and respiratory movements in children can be either 30:2, or if there are two resuscitators - 15:2. In newborns, the ratio is 3 clicks per breath.

Bozbey Gennady Andreevich, emergency doctor

Primary cardiopulmonary resuscitation in children

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

Cardiopulmonary resuscitation techniques are constantly being improved. This publication presents the rules of cardiopulmonary resuscitation in children, based on the latest recommendations of domestic scientists (Tsybulkin E.K., 2000; Malyshev V.D. et al., 2000) and the Emergency Committee of the American Association of Cardiology, published in JAMA (1992).

Clinical diagnostics

The main signs of clinical death:

lack of breathing, heartbeat and consciousness;

the disappearance of the pulse in the carotid and other arteries;

pale or gray-earthy skin color;

pupils are wide, without reaction to light.

Immediate measures for clinical death:

resuscitation of a child with signs of circulatory and respiratory arrest should begin immediately, from the first seconds of ascertaining this condition, extremely quickly and energetically, in strict sequence, without wasting time on finding out the causes of its onset, auscultation and measuring blood pressure;

fix the time of onset of clinical death and the start of resuscitation;

sound an alarm, call assistants and an intensive care team;

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

If it is known for sure that this period is more than 10 minutes, or the victim has early signs of biological death (symptoms of "cat's eye" - after pressing on the eyeball, the pupil takes and retains a spindle-shaped horizontal shape and "melting ice" - clouding of the pupil), then the need for cardiopulmonary resuscitation is questionable.

Resuscitation will be effective only when it is properly organized and life-sustaining activities are performed in the classical sequence. The main provisions of primary cardiopulmonary resuscitation are proposed by the American Association of Cardiology in the form of the "ABC Rules" according to R. Safar:

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

The second step B (Breath) is the restoration of breathing.

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

The sequence of resuscitation measures:

A ( Airways ) - restoration of airway patency:

1. Lay the patient on his back on a hard surface (table, floor, asphalt).

2. Mechanically clear the oral cavity and pharynx from mucus and vomit.

3. Slightly tilt your head back, straightening the airways (contraindicated if you suspect a cervical injury), put a soft roller made of a towel or sheet under your neck.

Fracture of the cervical vertebrae should be suspected in patients with head trauma or other injuries above the collarbones, accompanied by loss of consciousness, or in patients whose spine has been subjected to unexpected overload associated with diving, falling, or an automobile accident.

4. Push the lower jaw forward and upward (the chin should be in the most elevated position), which prevents the tongue from sticking to the back of the throat and facilitates air access.

AT ( breath ) - restoration of breathing:

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

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

When breathing "from mouth to mouth", the resuscitator wraps his lips around the patient's mouth, and pinches his nose with his right hand. Otherwise, the execution technique is the same (Fig. 1). With both methods, there is a risk of partial entry of the blown air into the stomach, its swelling, regurgitation of gastric contents into the oropharynx and aspiration.

The introduction of an 8-shaped air duct or an adjacent mouth-to-nasal mask greatly facilitates mechanical ventilation. They are connected to manual breathing apparatus (Ambu bag). When using manual breathing apparatus, the resuscitator presses the mask tightly with his left hand: the nose with the thumb, and the chin with the index fingers, while (with the rest of the fingers) pulling the patient's chin up and back, which achieves the mouth closing under the mask. The bag is squeezed with the right hand until an excursion of the chest occurs. This serves as a signal to stop the pressure to ensure expiration.

FROM ( Circulation ) - restoration of blood circulation:

After the first 3-4 air insufflations have been carried out, in the absence of a pulse in the carotid or femoral arteries, the resuscitator, along with the continuation of mechanical ventilation, should proceed to an indirect heart massage.

The technique of indirect heart massage (Fig. 2, table 1). The patient lies on his back, on a hard surface. The resuscitator, having chosen the position of the hands corresponding to the age of the child, conducts rhythmic pressure with age frequency on the chest, commensurate the force of pressure with the elasticity of the chest. Heart massage is carried out until the heart rhythm and pulse on the peripheral arteries are fully restored.

Table 1.

The method of conducting indirect heart massage in children

Complications of indirect heart massage: with excessive pressure on the sternum and ribs, there may be fractures and pneumothorax, and with strong pressure over the xiphoid process, liver rupture may occur; it is necessary to remember also about the danger of regurgitation of gastric contents.

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

Criteria for the effectiveness of mechanical ventilation and indirect heart massage:

Constriction of the pupils and the appearance of their reaction to light (this indicates the flow of oxygenated blood into the patient's brain);

The appearance of a pulse on the carotid arteries (checked between chest compressions - at the time of compression, a massage wave is felt on the carotid artery, indicating that the massage is performed correctly);

Restoration of spontaneous breathing and heart contractions;

The appearance of a pulse on the radial artery and an increase in blood pressure to 60 - 70 mm Hg. Art.;

Reducing the degree of cyanosis of the skin and mucous membranes.

Further life support activities:

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

0.1% solution of adrenaline hydrotartrate 0.01 ml/kg (0.01 mg/kg);

0.1% solution of atropine sulfate 0.01-0.02 ml/kg (0.01-0.02 mg/kg). Atropine in resuscitation in children is used in dilution: 1 ml of a 0.1% solution per 9 ml of isotonic sodium chloride solution (obtained in 1 ml of a solution of 0.1 mg of the drug). Adrenaline is also used in a dilution of 1: 10,000 per 9 ml of isotonic sodium chloride solution (0.1 mg of the drug will be in 1 ml of the solution). Perhaps the use of doses of adrenaline increased by 2 times.

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

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

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

3. In case of ventricular fibrillation, defibrillation (electrical and medical) is indicated.

If there are signs of restoration of blood circulation, but there is no independent cardiac activity, chest compressions are performed until effective blood flow is restored or until signs of life permanently disappear with the development of symptoms of brain death.

Absence of signs of restoration of cardiac activity against the background of ongoing activities for 30-40 minutes. is an indication for termination of resuscitation.

INDEPENDENT WORK OF STUDENTS:

The student independently performs emergency medical care on the simulator "ELTEK-baby".

LIST OF LITERATURE FOR INDEPENDENT TRAINING:

Main literature:

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

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

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

Guide to outpatient pediatrics / ed. A.A. Baranova. - 2nd ed., corrected. and additional - M.: GEOTAR-Media. 2009. - 592 p. [Electronic resource] - Access from the Internet. - // http://www.studmedlib.ru/disciplines/

Additional literature:

Vinogradov A.F., Akopov E.S., Alekseeva Yu.A., Borisova M.A. CHILDREN'S HOSPITAL. - M .: GOU VUNMTs of the Ministry of Health of the Russian Federation, 2004.

Galaktionova M.Yu. Emergency care for children. Pre-hospital stage: textbook. - Rostov-on-Don: Phoenix. 2007.- 143 p.

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

Emergency pediatrics: textbook / Yu. S. Aleksandrovich, V. I. Gordeev, K. V. Pshenisnov. - St. Petersburg. : Special Lit. 2010. - 568 p. [Electronic resource] - Access from the Internet. - // http://www.studmedlib.ru/book/

Baranov A.A., Shcheplyagina L.A. Physiology of growth and development of children and adolescents - Moscow, 2006.

[Electronic resource] Vinogradov A.F. and others: textbook / Tver state. honey. acad.; Practical skills for a student studying in the specialty "pediatrics", [Tver]:; 2005 1 electronic opt. (CD-ROM).

Software and Internet Resources:

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

INTERNET medical resource catalog

2. "Medline",

4.Catalog "Corbis",

5.Professional-oriented site : http:// www. Medpsy.ru

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

Knowledge by the student of the main provisions of the topic of the lesson:

Examples of baseline tests:

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

a. At 1 degree.

b. At 2 degrees.

in. At 3 degrees.

g. At 3 and 4 degrees.

* e. At 4 degrees.

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

* a. Termination of access to the allergen.

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

in. Introduction of corticosteroids.

d. Applying a tourniquet above the injection site of the allergen.

e. Applying a tourniquet below the injection site of the allergen.

3. Which of the criteria will first indicate to you that the chest compressions being performed are effective?

a. Warming of the extremities.

b. The return of consciousness.

c. The appearance of intermittent breathing.

d. Pupil dilation.

* d. Constriction of the pupils._

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

* a. Lengthening of the interval Q - T.

b. Shortening of the interval Q - T.

in. Prolongation of the interval P - Q.

d. Shortening of the interval P - Q.

e. Deformation of the QRS complex.

Questions and typical tasks of the final level:

Exercise 1.

An ambulance call to the house of a 3-year-old boy.

The temperature is 36.8°C, the number of breaths is 40 per minute, the number of heartbeats is 60 per minute, blood pressure is 70/20 mm Hg. Art.

Complaints of parents about lethargy and inappropriate behavior of the child.

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

Objective data: Serious condition. Doubtfulness. Glasgow score 10 points. The skin, especially the chest and face, as well as the sclera, are hyperemic. The pupils are constricted. Seizures with a predominance of the clonic component are periodically noted. Nasal breathing is difficult. Breathing is superficial. Pulse of weak filling and tension. On auscultation, against the background of puerile breathing, a small amount of rales of a wired nature is heard. Heart sounds are muffled. The abdomen is soft. The liver protrudes 1 cm from under the edge of the costal arch along the mid-clavicular line. The spleen is not palpable. Haven't peed in the last 2 hours.

a) Make a diagnosis.

b) Provide pre-hospital emergency care and determine the conditions of transportation.

c) Characterize the pharmacological action of nefedipine and reserpine.

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

e) Indicate the time after which the development of acute renal failure is possible, and describe the mechanism of its occurrence.

f) Determine the possibility of conducting forced diuresis to remove the absorbed poison at the prehospital stage.

g) List the possible consequences of poisoning for the life and health of the child. How many tablets of these drugs are potentially lethal at a given age?

a) Acute exogenous poisoning with reserpine and nefedipine tablets of moderate severity. Acute vascular insufficiency. Convulsive syndrome.

Task 2:

You are a summer camp doctor.

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

Sample response

Perhaps these are early signs of sunstroke: lethargy, nausea, decreased visual acuity, reddening of the face, fever, increased respiration, tachycardia. In the future, there may be a loss of consciousness, delirium, hallucinations, a change from tachycardia to bradycardia. In the absence of help, the death of a child is possible with symptoms of cardiac and respiratory arrest.

Urgent care:

1. Move the child to a cool room; lay in a horizontal position, cover your head with a diaper moistened with cold water.

2. With the initial manifestations of heat stroke and preserved consciousness, give a plentiful drink of glucose-salt solution (1/2 teaspoon of sodium chloride and sodium bicarbonate, 2 tablespoons of sugar per 1 liter of water) not less than the volume of the age-related daily need for water.

3. With an expanded clinic of heat stroke:

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

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

In case of convulsive syndrome, inject a 0.5% solution of seduxen 0.05-0.1 ml / kg (0.3-0.5 mg / kg) intramuscularly;

oxygen therapy;

With the progression of respiratory and circulatory disorders, tracheal intubation and transfer to mechanical ventilation are indicated.

Hospitalization of children with heat or sunstroke in the intensive care unit after first aid. For children with initial manifestations without loss of consciousness, hospitalization is indicated when there is a combination of overheating with diarrhea and salt deficiency dehydration, as well as with a negative dynamics of clinical manifestations when observing the child for 1 hour.

Task 3:

The doctor of the children's health camp was called by passers-by who saw a drowning child in the lake near the camp. On examination, a child lies on the shore of the lake, the estimated age is 9-10 years old, unconscious, in wet clothes. The skin is pale, cold to the touch, cyanotic lips are noted, water flows from the mouth and nose. Hyporeflexia. In the lungs, breathing is weakened, retraction of the compliant places of the chest and sternum on inspiration, NPV - 30 per 1 min. The heart sounds are muffled, the heart rate is 90 beats/min, the pulse is of weak filling and tension, rhythmic. BP - 80/40 mm Hg. The abdomen is soft and painless.

1. What is your diagnosis?

2. Your actions at the place of examination (first aid).

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

4. Further tactics.

Sample response.

1. Drowning.

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

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

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