Features of IVL for children. Features of resuscitation in children. What is cardiopulmonary resuscitation
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.
Most common cause obstruction respiratory tract in children without consciousness, it is language. 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.
The technique of mechanical ventilation is considered in this review as a combination of physiology, medicine and engineering principles. Their association contributed to the development of mechanical ventilation, revealed the most urgent needs for improving this technology and the most promising ideas for the future development of this direction.
What is resuscitation
Resuscitation is a complex of actions, which includes measures to restore suddenly lost vital body functions. Their main goal is the use of methods for carrying out artificial ventilation of the lungs in order to restore cardiac activity, respiration and vital activity of the body.
The terminal state of the body implies the presence of pathological changes. They affect areas of all organs and systems:
- brain and heart;
- and metabolic systems.
Methods of carrying out require taking into account the peculiarity of the organism that the life of organs and tissues continues a little even after the heart and breathing have completely stopped. Timely resuscitation allows you to achieve effective bringing the victim to his senses.
Artificial ventilation, also called artificial respiration, is any means of assisting or stimulating respiration, a metabolic process associated with general exchange gases in the body through ventilation of the lungs, external and internal respiration. It may take the form of manually delivering air to a person who is not breathing or is not making sufficient effort to breathe. Or it could be mechanical ventilation using a device to move air from the lungs when the person is unable to breathe on their own, such as during surgery to general anesthesia or when the person is in a coma.
The objective of resuscitation is to achieve the following results:
- the airways must be clear and free;
- it is necessary to carry out IVL in a timely manner;
- circulation needs to be restored.
Features of the IVL technique
Pulmonary ventilation is achieved by a manual device for blowing air into the lungs, either with the help of a rescuer who delivers it to the patient's organ by mouth-to-mouth resuscitation, or with a mechanical device designed for this procedure. Last method proved to be more effective than those involving manual manipulation of the patient's chest or arms, such as the Sylvester method.
Mouth-to-mouth resuscitation is also part of what makes it an important first aid skill. In some situations, this method is used as the most effective if there is no special equipment such as opiate overdoses. The performance of the method is currently limited in most protocols for healthcare professionals. junior medical workers it is recommended to perform mechanical ventilation in each case when the patient is not breathing properly.
Sequence of actions
The technique of artificial ventilation of the lungs is to carry out next steps:
- The victim is laid on his back, his clothes are unbuttoned.
- The head of the victim is thrown back. To do this, one hand is brought under the neck, the other gently raises the chin. It is important to throw back the head as much as possible and open the mouth of the victim.
- If there is such a situation when it is impossible to open the mouth, one should try to put pressure on the area of the chin and make the mouth automatically open.
- If the person is unconscious, move lower jaw forward by inserting a finger into the mouth.
- If you suspect that there is an injury in cervical region spine, it is important to gently tilt your head back and check if the airways are clogged.
Varieties of IVL techniques
To bring a person to his senses, the following methods of performing artificial ventilation have been developed:
- "mouth to mouth";
- "mouth to nose";
- "mouth-device-mouth" - with the introduction of an S-shaped tube.
The technique of artificial lung ventilation requires knowledge of some features.
When performing such operations, it is important to monitor whether the heart has stopped.
Signs of this condition may include:
- The appearance of a sharp cyanosis or pallor on the skin.
- Absence of pulse in the carotid arteries.
- Lack of consciousness.
If the heart stops
In case of cardiac arrest, closed heart massage should be performed:
- A person quickly fits on his back, it is important to choose a hard surface for this.
- The resuscitator kneels on the side.
- It is necessary to put the palm of the base on the area of \u200b\u200bthe sternum of the victim. At the same time, do not forget that you can not touch the xiphoid process. On top of one hand lies the other hand with the palm of your hand.
- Massage is performed with the help of vigorous jerky movements, the depth of which should be four to five centimeters.
- Each pressure should alternate with straightening.
Fulfillment implies following procedures during artificial ventilation of the lungs:
- Tilt the head as much as possible to straighten the airways.
- Pushing the lower jaw forward so that the tongue does not sink.
- Easy mouth opening.
Features of the mouth-to-nose method
The technique of carrying out artificial ventilation of the lungs using the "mouth-to-nose" method implies the need to close the victim's mouth and push the lower jaw forward. It is also necessary to cover the area of \u200b\u200bthe nose with the help of lips and blow air into it.
It is necessary to blow simultaneously into the oral and nasal cavities with care in order to protect the lung tissue from possible rupture. This applies, first of all, to the peculiarities of carrying out mechanical ventilation (artificial ventilation of the lungs) for children.
Rules for performing chest compressions
Cardiac starting procedures should be performed in conjunction with ventilation artificial way. It is important to ensure the position of the patient on a hard floor or boards.
It will be necessary to perform jerky movements using the weight of the rescuer's own body. The frequency of pushes should be 60 pressures in 60 seconds. After that, you need to perform ten to twelve pressures on the area. chest.
The technique of carrying out artificial ventilation of the lungs will show greater efficiency if it is carried out by two rescuers. Resuscitation should continue until breathing and heartbeat are restored. It will also be necessary to stop actions in the event that the biological death of the patient has occurred, which can be determined by characteristics.
Important Notes When Performing CPR
Rules for holding mechanically:
- ventilation can be done by using an apparatus called a ventilator;
- insert the device into the patient's mouth and manually activate it, observing the required interval when introducing air into the lungs;
- breathing can be assisted by a nurse, doctor, physician assistant, respiratory therapist, paramedic, or other suitable person squeezing a bag valve mask or a set of bellows.
Mechanical ventilation is called invasive if it involves any instrument that penetrates the mouth (eg, endotracheal tube) or skin (eg, tracheostomy tube).
There are two main modes of mechanical ventilation in two departments:
- forced-pressure ventilation, where air (or other gas mixture) enters the trachea;
- negative pressure ventilation, where air is essentially sucked into the lungs.
Tracheal intubation is often used for short-term mechanical ventilation. The tube is inserted through the nose (nasotracheal intubation) or mouth (orthotracheal intubation) and advanced into the trachea. In most cases, products with inflatable cuffs are used for leakage and aspiration protection. Cuff tube intubation is believed to provide better protection from aspiration. Tracheal tubes inevitably cause pain and coughing. Therefore, unless the patient is unconscious or otherwise anesthetized, sedatives usually prescribed to ensure tube tolerance. Other disadvantages are damage to the mucous membrane of the nasopharynx.
History of the method
General Method external mechanical manipulation, introduced in 1858, was the "Sylvester Method", invented by Dr. Henry Robert Sylvester. The patient lies on his back with his arms raised above his head to aid inhalation and then pressed against his chest.
The shortcomings of mechanical manipulation led doctors in the 1880s to develop improved methods of mechanical ventilation, including Dr. George Edward Fell's method and a second one consisting of a bellows and breathing valve to pass air through the tracheotomy. Collaboration with Dr. Joseph O "Dwyer led to the invention of the Fell-O" Dwyer apparatus: bellows and instruments for inserting and removing a tube that was advanced down the trachea of patients.
Summing up
Features of artificial lung ventilation in emergency is that it can be used not only by healthcare professionals (mouth-to-mouth method). Although for greater effectiveness, the tube must be inserted into the airway through the hole made surgically, which only paramedics or rescuers can do. This is similar to a tracheostomy, but the cricothyrotomy is reserved for emergency lung access. It is usually used only when the pharynx is completely blocked or if there is a massive maxillofacial injury that prevents the use of other aids.
Peculiarities of artificial ventilation of the lungs for children consist in the careful carrying out of procedures simultaneously in the oral and nasal cavities. Using a respirator and oxygen bag will help make the procedure easier.
When carrying out artificial ventilation of the lungs, it is necessary to control the work of the heart. Resuscitation procedures are stopped when the patient begins to breathe on his own, or he has signs of biological death.
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 a sine qua non 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 earthy gray color skin;
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 eye"- after pressing on the eyeball, the pupil takes and retains a spindle-shaped horizontal shape and "melting ice" - clouding of the pupil), then the need for cardiopulmonary resuscitation is doubtful.
Resuscitation will be effective only when it is properly organized and life-sustaining 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 occupy the most elevated position), which prevents the tongue from sticking to the back of the throat and facilitates air access.
V ( 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 closing the mouth under the mask. Right hand the bag is compressed until chest excursion occurs. This serves as a signal to stop the pressure to ensure expiration.
WITH ( Circulation ) - restoration of blood circulation:
After the first 3-4 air insufflations have been carried out, in the absence of a pulse in the carotid or femoral arteries, the resuscitator, along with 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);
Recovery 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.
v. 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.
v. 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 change on the ECG is threatening for the syndrome sudden death in children?
* a. Lengthening of the interval Q - T.
b. Shortening of the interval Q - T.
v. 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, no a large number of rales of a wired nature. 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 29-30С 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. When initial manifestations heat stroke and preserved consciousness, give a plentiful drink of glucose - saline 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 daily requirement in 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;
At convulsive syndrome inject 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 with a combination of overheating with diarrhea and salt-deficient dehydration, as well as with negative dynamics clinical manifestations when observing a child for 1 hour.
Task 3:
The doctor 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 with 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.
Manipulation - Technique of artificial lung ventilation in children.
Artificial respiration by the mouth-to-mouth method for a child under one year old.
Indication: lack of breathing in a child, a child under one year old.
Contraindications: no.
Required condition:
When you breathe for the baby, observe three conditions:
a) Blow air into your mouth and nose at the same time
b) do not forget that the "baby" neck is shorter, thicker and more fragile - be careful when throwing back his head
c) do not blow your full volume of air into the infant's airways, as the alveoli may rupture.
Manipulation:
2. Place a roller under your shoulders.
3. Gently tilt the child's head back, raise the chin.
4. Free the upper respiratory tract from mucus and homogeneous bodies.
5. Put a napkin on the baby's mouth and nose.
6. Inhale and position your mouth over the child's nose and mouth, forming a tight connection.
7. Inhale air into the baby's airways in an amount sufficient to gently lift the chest.
Note:
How less baby the less air needs to be inhaled into the lungs.
8. Pause, wait until the baby's chest drops.
9. Repeat steps 6-8 until spontaneous breathing appears or the ambulance arrives, or until cadaveric spots appear.
Carrying out artificial respiration for a child older than a year.
1. Lay the child on his back on a flat hard surface.
2. Place a roller under your shoulders.
3. Tilt the baby's head back, raising the chin.
4. Free the upper respiratory tract from mucus and foreign bodies.
5. Put a napkin on the baby's mouth.
6. Pinch the child's nose.
7. Inhale and position your mouth over the child's mouth, forming a tight connection.
8. Inhale air into the respiratory tract of the victim in an amount sufficient to make the chest
the cage was carefully lifted up.
9. pause, wait until the baby's chest drops.
10. Repeat steps 7-9 until spontaneous breathing appears or the ambulance arrives.
3. Carrying out artificial respiration with an Ambu bag.
Conducting I.V.L. facilitated when using manual respirators and carried out through the mouth-nose mask with an Ambu bag. It is an elastic self-filling bag that attaches to breathing mask. Inhalation is carried out by squeezing the bag, exhalation is passive.
During exhalation, the bag expands and a new portion of air enters it.
Artificial lung ventilation (ALV) devices are devices that provide a periodic flow of respiratory gases into the patient's lungs to ensure or maintain ventilation of the lungs. The principles of operation of respirators may be different, but in practical medicine, artificial lung ventilation devices operating on the principle of blowing are mainly used. Energy sources for them can be compressed gas, electricity or muscle power.
Apparatus for manual ventilation of the lungs
Ventilation of the lungs with an Ambu bag
For manual ventilation in intensive care, self-expanding counterlungs are commonly used. well-known manufacturers of these devices are the firms "Ambu" (Denmark), "Penlon" (Great Britain), "Laerdal" (Norway). The bag has a valve system that regulates the direction of the gas flow, a standard connector for accession to face mask or an endotracheal tube and a fitting for connecting to an oxygen source. When the bag is compressed by hand, the gas mixture enters the patient's respiratory tract, exhalation occurs into the atmosphere. The ventilation parameters depend on the frequency and intensity of bag compressions. To prevent the possibility of barotrauma, most self-expanding bags have a "safety valve" to vent excess pressure from excessive forceful compression to atmosphere.
Self-expanding counterlungs are commonly used for short-term mechanical ventilation during resuscitation and during patient transport.
During anesthesia, manual ventilation of the lungs is usually carried out using a breathing bag or the fur of an anesthesia machine.
Devices for automatic lung ventilation
Automatic respirators are mainly used for continuous ventilation in intensive care units and during anesthesia. Currently, a large number of different devices for artificial lung ventilation are produced in the world, which are divided into several groups according to their technical and functional characteristics. However, one can try to formulate General requirements for modern respirators.
The device provides the ability to ventilate the lungs in a controlled and one or more auxiliary modes, allow in a wide range to regulate the frequency of ventilation, tidal volume, the ratio of the phases of the respiratory cycle, the pressure and speed of the gas flow during inhalation and positive end-expiratory pressure, oxygen concentration, temperature and humidity of the respiratory mixture. In addition, the device must have a built-in monitoring unit that controls, at a minimum, the occurrence critical situations(depressurization of the breathing circuit, a drop in tidal volume, a decrease in oxygen concentration). Some modern ventilators have such an extensive monitoring system (including gas analyzers and respiratory mechanics recorders) that they allow for precise control of ventilation and gas exchange with little or no help from laboratory services.
Since many ventilation indicators are strictly interconnected, it is fundamentally impossible to create a respirator with absolutely independent adjustment of all settings. Therefore, in practice, it is traditionally customary to classify ventilators according to the principle of changing the phases of the respiratory cycle, or rather, according to which of the established parameters is guaranteed and cannot be changed under any conditions. In accordance with this, respirators can be controlled by volume (tidal volume is guaranteed), by pressure (the set inspiratory pressure is guaranteed) and by time (the invariance of the duration of the respiratory cycle phases is guaranteed).
In pediatric practice, for traditional (conventional) ventilation, devices such as time-cyclic respirators ("Sechrist", USA; "Bear", USA; "Babylog", Germany) and volumetric respirators ("Evita", Germany) are most often used. Puritan-Bennet, USA).
When ventilating the lungs in newborns and children younger age preference is given to time-cyclic respirators with constant circulation of gas in the breathing circuit. The advantages and disadvantages of devices of this type are presented in the table.
Child ventilator
The tables show the devices that carry out artificial ventilation of the lungs in young children:
Table. Respirators time-cyclic
In children weighing more than 10-15 kg, the tidal volume to a much lesser extent, compared with newborns, depends on changes in the aerodynamic resistance of the respiratory tract and lung compliance. Therefore, when ventilating children older than 2-3 years, preference is usually given to bulk respirators (table).
Table. Volumetric respirators
V Lately one of the methods of non-traditional artificial lung ventilation - high-frequency oscillatory ventilation - has gained some popularity. With such ventilation of the lungs, the device generates fluctuations from 6 to 15 Hz (360-900 breaths per 1 min.). With oscillatory ventilation, the tidal volume is less than the volume of the anatomical dead space and gas exchange in the lungs is carried out mainly due to diffusion.
Oscillatory ventilators are divided into "true" oscillators ("Sensormedics", USA) and flow interrupters ("SLE", UK). In addition, there are so-called hybrid oscillators that combine the features of flow breakers and oscillatory fans ("Infrasonic Infant Star", USA). The latter device also allows you to combine traditional convective ventilation with oscillatory ventilation. Some features noted during oscillatory ventilation are noted in the table.
Table. Oscillatory fans
Carrying out artificial ventilation of the lungs
For ventilation of the lungs, expiratory (i.e., exhaled revitalizing air) methods of artificial lung ventilation are used - from mouth to mouth or from mouth to nose.
In young children, artificial ventilation of the lungs is done as follows: the volume of air must be sufficient to ensure adequate chest excursion for the baby. In this case, the duration of inspiration is reduced to 1 - 1.4 s. For the purpose of mechanical ventilation in a child under the age of 1 year, the nose and mouth are simultaneously covered, and in older children, artificial ventilation of the lungs is performed using the mouth-to-mouth method.
Artificial ventilation mouth to mouth
Carrying out artificial ventilation of the lungs in children from mouth to nose is necessary if:
- convulsive compression of the jaws in a patient;
- the occurrence of difficulties in ensuring sealing during mechanical ventilation from mouth to mouth;
- injury to the lips, tongue, lower jaw.
First, the revivalist performs 1 - 2 test breaths. If there is no chest excursion, the airway restoration should be repeated. If after that there is no chest excursion during test breaths, therefore, there is an obstruction of the airways foreign body. In such cases, it is necessary to resort to methods of its removal.
If, with correctly performed test breaths, a chest excursion is observed in a child, then the airways are passable. In such cases, the next step should be to determine the safety of the activity of the heart. Such an assessment is performed by registering the pulse on large main vessels: carotid or brachial arteries.
Feeling the pulse in children
The brachial pulse is usually measured in children under 1 year of age, because their short, rounded neck makes it difficult to register the carotid pulse. The brachial artery is palpated along inner surface the upper part of the shoulder between the elbow and shoulder joints.
The pulse on the femoral artery can be determined in children of any age group. Most often, this is done by trained personnel. The femoral artery is palpated in the inguinal region below the inguinal ligament, approximately midway between the pubic articulation and the anterior spine. ilium.
The carotid pulse is usually examined in a child older than 1 year. To do this, the child's head is thrown back, the thyroid cartilage is determined by palpation, and then the fingers are lowered into the space between the trachea and the sternocleidomastoid muscle. The artery is palpated gently, trying not to pinch it completely.
If the activity of the heart is preserved, then assistance is limited to the implementation of measures A and B: the airway is maintained and artificial ventilation is performed. In this case, mechanical ventilation is performed with a frequency of pressure on the sternum 20 times per 1 min (the duration of the entire respiratory cycle is 3 s). Special attention is given to maintain airway patency during exhalation.
Artificial ventilation complications
These are complications arising from the rupture of the alveoli and the accumulation of air in the surrounding spaces and tissues. These complications can develop spontaneously in newborns (out of connection with therapeutic procedures), but more often occur with artificial or assisted ventilation of the lungs, as well as when using the PPD technique.
Air leak syndrome - a complication after mechanical ventilation
The pathogenesis of these complications of mechanical ventilation is well understood. The introduction or retention of excess air in the lungs leads to an increase in intra-alveolar pressure and rupture of the base of the alveoli. Air seeps through the cells of the capillary network and spreads through the perivascular spaces towards the root of the lung. Although perivascular spaces may to a large extent expand, the accumulating air inevitably compresses the surrounding vessels, creating prerequisites for lung hypoperfusion.
Further, air can penetrate into the mediastinum (pneumomediastinum), the pleural cavity (pneumothorax), and sometimes into the pericardial space (pneumopericardium). In rare cases, air from the mediastinum spreads down through the holes in the diaphragm and accumulates in the retroperitoneal space, and from there breaks into abdominal cavity(pneumoperitoneum).
Interstitial emphysema - a complication after mechanical ventilation
The accumulation of air in the interstitial space may not have any clinical manifestations. However, if severe interstitial emphysema develops in ventilated children, there is usually an increase in oxygen demand, as well as a trend towards an increase in PaCO2. Thus, ventilation disorders come to the fore, while critical disorders associated with vascular compression are usually not observed. The progression of interstitial emphysema in about 50% of cases leads to the development of pneumothorax.
Interstitial emphysema can only be diagnosed by x-ray. Typical features while there are cystic and linear enlightenment. Linear enlightenments vary considerably in width, look quite rough and do not branch out. They are well visible both in the center and along the periphery of the lung fields, so they are easy to distinguish from air bronchograms, which have a more even outline, branching structure and are not visible on the periphery of the lungs. Accumulations of small cystic lucencies give the lung a characteristic spongy appearance. The process, as a rule, captures both lungs, although in rare cases one lung, or even one lobe, may be affected.
Unfortunately, there is no definitive treatment for interstitial emphysema. Therapeutic measures should be aimed at minimizing peak inspiratory pressure, inspiratory time and positive end-expiratory pressure. In severe cases, a good effect can be obtained using high-frequency artificial lung ventilation.
Pneumothorax in children - a complication after mechanical ventilation
Spontaneous asymptomatic pneumothorax occurs in 1-2% of newborns. Most probable cause its development is considered to be high negative values of intrapleural pressure that occur during the first breaths of the child. Predisposing factors are early gestational age and respiratory distress syndrome. It is known that premature babies with RDS, pneumothorax is observed 3.5-4 times more often than with any other pathology.
Only in 10-20% of cases spontaneous pneumothorax has clinical manifestations in the form of tachypnea and cyanosis. At the same time, the vast majority of children require only an increase in the concentration of oxygen in the respiratory mixture and do not need puncture or drainage of the pleural cavity.
Severe pneumothorax is much more common in newborns receiving respiratory support. According to various researchers, in newborns with RDS who are on mechanical ventilation, pneumothorax is observed in 35-50% of cases. As a rule, this is a severe tension pneumothorax, requiring immediate diagnosis and emergency treatment.
Diagnosis of tension pneumothorax is usually not difficult. The child's condition suddenly deteriorates sharply, generalized cyanosis appears. Often one can note a clear protrusion of the affected half of the chest, bloating. Valuable diagnostic sign is the displacement of the apex beat in opposite side. During auscultation, there is a sharp weakening of respiratory sounds, deafness of heart sounds, tachycardia. An early diagnostic sign is a decrease in the voltage of the QRS complex on the heart monitor by about 2 times. A certain help in the diagnosis can be provided by transillumination of the chest with a fiber-optic light guide (transillumination method). There is a bright glow of the affected area. The diagnosis is confirmed by X-ray examination. The picture shows the accumulation of air in the pleural cavity, collapsed lung and mediastinal displacement in the healthy direction.
Practice shows that with tension pneumothorax, drainage of the pleural cavity is always required, therefore, puncture is permissible only in absolutely urgent situations.
The skin in the drainage area (4-5 intercostal space along the anterior or mid-axillary, or 3 intercostal space along the mid-clavicular line) is treated with a disinfectant solution and local anesthesia is performed with a 0.5-1.0% novocaine solution. By top edge ribs, a skin incision 1 cm long is made, then the intercostal muscles are bluntly separated. A drainage tube with a diameter of 2.5-3.5 mm is inserted into the pleural cavity with the help of a trocar in an upward and forward direction to a depth of 2-3 cm. After fixation, the drainage is connected to a constant suction system with a vacuum of 10 cm of water. Art. Then perform a control X-ray examination. If the drain is patent and the lung does not fully expand, another drain tube may be inserted.
Pneumopericardium in children - a complication after mechanical ventilation
Pneumopericardium is a much rarer complication than pneumothorax or interstitial emphysema. It is often associated with right interstitial emphysema, but may also occur with pneumomediastinum and/or pneumothorax. The severity of clinical manifestations of pneumopericardium varies widely. Often, it is diagnosed incidentally on follow-up radiography by the characteristic dark rim of air accumulated in the pericardial space and surrounding the heart. However, tense pneumopericardium leads to cardiac tamponade and therefore requires emergency treatment. The development of this complication can be suspected with a sudden sharp deterioration in the patient's condition, increased cyanosis. Heart tones during auscultation are sharply muffled or not heard at all.
To evacuate air, it is necessary to perform a puncture of the pericardium. The cannula on a G21 needle is connected through a 3-way stopcock to a 10 ml syringe. The puncture is performed under the costal arch to the left of the xiphoid process. The needle is directed upward at an angle of 45o to the horizontal plane and 45o to middle line. When the needle is inserted, the plunger of the syringe is pulled, creating a slight vacuum. At a depth of approximately 1 cm, the needle reaches the pericardial space and air begins to flow into the syringe. After puncture, in about 50% of cases there is a re-accumulation of air. In this case, the cannula is left in the pericardial space, connected to the water valve.
Spontaneous pneumomediastinum occurs in approximately 0.25% of all newborns. Its genesis is the same as that of spontaneous pneumothorax. This complication occurs somewhat more often after ventilation with an Ambu bag in delivery room, as well as in children with RDS and meconium aspiration syndrome. Clinically, pneumomediastinum after mechanical ventilation is usually manifested by tachypnea, deafness of heart tones, and sometimes cyanosis. The diagnosis is made by X-ray examination. The most informative side projection, which clearly shows the zone of enlightenment, located behind the sternum or in the upper part of the mediastinum, if the child is in a vertical position. On a direct roentgenogram, sometimes accumulated air in the mediastinum separates the shadow of the heart from the thymus gland. This radiological sign is called "butterfly wings" or "sails".
Air from the mediastinum usually resolves spontaneously and no additional therapeutic measures are required.