Youth and beauty 

Children's resuscitation of newborns in the maternity hospital. Other causes of respiratory failure. number of solution in a syringe

Currently, the Apgar score as a criterion for indications for resuscitation is subject to revision, however, it is quite acceptable to assess the effectiveness of resuscitation and the dynamics according to this scale. The fact is that to obtain a quantitative assessment of the condition of the newborn, one has to wait a whole (!) Minute, while resuscitation should be started in the first 20 seconds, and by the end of the first minute, an assessment should be made on the Apgar scale. If it is less than 7 points, then further evaluation should be carried out every 5 minutes until the condition is assessed at 8 points (GM Dementyeva et al., 1999).

It should be noted that the algorithms for carrying out resuscitation measures remain basically the same as in adults. However, there are differences in the performance of individual techniques due to the anatomical and physiological characteristics of newborns. Resuscitation measures ( principles A, B, C by P. Safar) are as follows:

A - ensuring the patency of the respiratory tract;

B - restoration of breathing;

C - restoration and maintenance of hemodynamics.

When principle A is followed, the correct position of the newborn is ensured, the suction of mucus or amniotic fluid from the oropharynx and trachea, and tracheal intubation.

Fulfillment of principle B involves various methods of tactile stimulation with a jet of oxygen through a mask, and artificial ventilation of the lungs.

The implementation of the C principle involves an indirect cardiac massage and drug stimulation.

Ventilation it is necessary if the child does not respond to tactile stimulation, while maintaining bradycardia and pathological types of breathing. Positive pressure ventilation can be performed using special breathing bags (Ambu bag), masks, or an endotracheal tube. A feature of the bags is the presence of a relief valve, usually at pressures exceeding 35-40 cm of water. Art. Breathing is carried out at a frequency of 40-60 per minute. It is important to provide the first 2 to 3 breaths with a pressure of 40 cm of water. Art. This should ensure good expansion of the lungs, reabsorption of intraalveolar fluid by the lymphatic and circulatory systems. Further breaths can be carried out with a peak pressure of 15-20 cm H2O. Art.

With the restoration of effective cardiac activity (> 100 beats per minute) and spontaneous breathing, ventilation can be turned off, leaving only oxygenation.

If spontaneous breathing is not restored, then ventilation should be continued. If the heart rate tends to increase (up to 100-120 per minute), then mechanical ventilation should be continued. The presence of persistent bradycardia (less than 80 per minute) is an indication for mechanical ventilation.

Considering the possibility of overstretching the stomach with an oxygen-air mixture followed by aspiration, it is necessary to insert a gastric tube and keep it open.

Correct selection of the diameter of the endotracheal tube is very important when intubating the trachea. With a body weight of less than 1000 g - 2.5 mm; 1000-2000 g - 3.0 mm; 2000-3000 g - 3.5 mm; more than 3000 - 3.5-4 mm. The intubation itself should be as gentle as possible and be completed within 15-20 seconds. It should be remembered that manipulations in the area of ​​the vocal cords can be accompanied by unwanted vagal reflexes. In this case, we will not describe them, because they are covered in detail in special guides.

Indirect cardiac massage carried out 15-30 s after the start of mechanical ventilation or oxygen inhalation, if the heart rate is 80 per minute. and less and does not tend to normalize.

For heart massage, the child is best placed on a firm surface with a small roller under the shoulders to create a moderate extension position. The point of pressure on the sternum is at the intersection of the nipple line and the midline, but the fingers should be slightly lower, without covering the point found. The depth of immersion of the sternum is 1-2 cm. The frequency of pressing on the chest should be kept within 120 per minute. The number of breaths should be 30-40 per minute, the ratio of breaths to the number of chest pressures is 1: 3; 1: 4.

For the implementation of an indirect heart massage in newborns (and precisely in them), 2 methods have been proposed. In the first method, 2 fingers of the hand (usually the index and middle) are placed on the pressure point, and the palm of the other hand is placed under the child's back, thus creating counterpressure.

The second method is to place the thumbs of both hands side by side at the pressure point, and the rest of the fingers of both hands are on the back. This method is more preferable, as it causes less fatigue on the hands of the personnel.

Every 30 seconds, the heart rate should be monitored and if it is less than 80 beats per minute, massage should be continued with the simultaneous administration of medications. If there is an increase in the frequency of contractions, then drug stimulation can be abandoned. Drug stimulation is also indicated in the absence of palpitations after 30 seconds of positive pressure ventilation with 100% oxygen.

The umbilical vein is used to administer drugs through a catheter and an endotracheal tube. It must be remembered that catheterization of the umbilical vein is a threatening risk factor for the development of septic complications.

Epinephrine is prepared at a dilution of 1: 10000 (1 mg / 10 ml), 1 ml is drawn into a syringe and injected intravenously, or through an endotracheal tube at a dose of 0.1-0.3 ml / kg. Typically, the dose introduced into the endotracheal tube is increased by 3 times, while the volume is diluted with saline and rapidly injected into the lumen of the tube.

If the heart rate does not reach 100 beats per minute after 30 seconds, then the introduction should be repeated every 5 minutes. If a child is suspected of hypovolemia, then within 5-10 minutes, drugs are administered to replenish the vascular bed: isotonic sodium chloride solution, Ringer's solution, 5% albumin in a total dose of up to 10 ml / kg of body weight. The lack of effect from these measures is an indication for the introduction of sodium bicarbonate at the rate of 1-2 mmol / kg (2-4 ml / kg of a 4% solution) at a rate of 1 mmol / kg / min. If the effect is not detected, then immediately after the end of the infusion, the entire specified amount of assistance should be repeated.

If there are suspicions of narcotic depression of breathing (administration of morphine-like drugs during anesthesia, drug addict mother who took drugs before childbirth), then the antidote of naloxone at a dose of 0.1 mg / kg of body weight is required. The child should be monitored due to the fact that after the end of the antidote (1-4 hours), repeated respiratory depression is possible.

Resuscitation measures end if, within 20 minutes. failed to restore cardiac activity.

When carrying out resuscitation measures, special attention should be paid to maintaining thermal conditions since even under normal thermal conditions in the delivery room (20-25 ° C) immediately after birth, the body temperature decreases by 0.3 ° C, and in the rectum - by 0.1 ° C per minute. Even in term infants, refrigeration can cause metabolic acidosis, hypoglycemia, respiratory distress and delayed recovery.

Lysenkov S.P., Myasnikova V.V., Ponomarev V.V.

Emergencies and anesthesia in obstetrics. Clinical pathophysiology and pharmacotherapy

“Small lumps, some the size of a palm, vulnerable to infections and complications, but extraordinarily persistent, ready to fight for their lives from the first second of their birth. The other day we visited the intensive care unit for premature babies and we want to tell you how this unit works, ”writes Stanislava Dvoeglazova.

(20 photos total)

1. The heaviest children from all maternity hospitals in Moscow are admitted to the department. The transportation of these children is carried out by a mobile resuscitation neonatal team.

A call comes from the maternity hospital, and a team consisting of a doctor and a paramedic leaves the place and brings the child to the intensive care unit. Here the children lie until their condition stabilizes.

Children are on mechanical ventilation, as their lungs are not fully expanded, and also when there is a manifestation of severe respiratory failure. The restoration of the respiratory function takes place just in this department.

2. Recently, medicine has seriously advanced in the treatment of respiratory failure, a lot of new equipment has appeared and for children, especially premature babies, with extremely low body weight, doctors are trying to carry out non-invasive artificial ventilation of the lungs, that is, without intubation (without inserting a tube into the larynx) of the child ... Doctors use a technique called nasal sipap, which creates the same pressure in the lungs as tracheal intubation with full ventilation.

The specialization of this resuscitation is premature babies, since the entire children's corps is designed to nurture them, but full-term babies with birth injuries who have swallowed water during childbirth or those who have convulsive syndrome also come here.

There are several similar branches of the second stage in Moscow: the branch at the 7th (from where, in fact, we are reporting), the 13th, at Filatovskaya, at the 70th and 8th GKB.

3. On the basis of the 7th City Clinical Hospital there is a single dispatch center, where calls are received from all maternity hospitals in Moscow, and then the dispatcher sends the children to the intensive care unit of a particular hospital, depending on the distance from the hospital and the workload of beds.

4. A total of 3 reanimobiles are on duty in Moscow, two of them are attached to the 7th city hospital and one to the 8th.

5. Modern medicine allows you to take care of children weighing 500 grams, from the 22nd week of gestation. The size of such a child is about 32-33 centimeters from head to toe.

6. When parents ask what the chances of their child's survival are, doctors say it is 50/50, but in fact, thanks to good equipment and doctors' qualifications, the mortality rate this year was 0.3 percent. When it comes to life, words like "just something" are completely inappropriate. You need to understand that doctors here are fighting for every child, for every day of his life, for every gram of his weight.

7. On average, 1100-1200 children are admitted to this department per year, this is 2-3, maximum 4 children per day. They are in intensive care from 5 to 30 days, but if we are talking about very small children, then they can be in the department for up to 3 months. The cost of nursing such a child can be up to half a million rubles. But that doesn't mean that parents need to be millionaires to pay for treatment. Everything is provided within the framework of state guarantees under the compulsory medical insurance policy, which all citizens of the Russian Federation have.

8. As far as I know, the other day the Moscow City MHI Fund announced an increase in expenditures on the provision of a number of types of medical assistance, including in the direction of nursing children, in particular, for nursing newborns with congenital digestive anomalies, hospitals will receive 122 thousand instead of the 61 thousand that are now due. Previously, not all tariffs covered the cost of treatment, especially if children weighing 600-800 grams were nursed, and the child is discharged only when the mother is able to cope with it, that is, the child must be able to breathe independently, keep warm and suck on the nipple.

And here, excuse me, I will deviate a little from the topic and will remain a boring teacher, remembering my teaching time at the university. So, the compulsory medical insurance policy is not just a piece of paper, but a piece according to which every citizen of the Russian Federation is entitled to free medical care in the compulsory health insurance system. At the same time, it does not matter at all that you received the policy in Uryupinsk, for example, you are registered in Vladivostok in general, and you or your child needed medical assistance in Moscow. So, if suddenly they refused to provide you with this very medical care, arguing that you are not a resident of the capital, or even demanded money for treatment, then do this: 1. Write a statement addressed to the head physician of the medical institution, where you explain the situation, and 2. Exactly You send the same letter of happiness to the insurance company that issued you the policy, as well as to the compulsory medical insurance fund, and, believe me, you will be happy, and those who tried to refuse treatment or asked for money - atat on a soft spot.

9. Let's go back to the department.

All children in the department are in special incubators, in which a certain temperature and humidity are maintained.

10. All incubators are covered with bed covers. This is not done for aesthetics, but due to the fact that the eyes of premature babies react painfully to daylight, and in order not to irritate them and not aggravate the development of retinopathy, incubators all over the world are covered.

11. Monitors with sensors are connected to each child, and if the parameters are outside the normal range, an alarm signal is generated, which is also duplicated on the monitor, which is located at the nurse's post.

Alla Lazarevna, a neonatologist, head of the perinatal center of the GBUZ "GKB No. 7 DZM", proudly told us that the department that is in her department is better than those that she saw in foreign clinics, where she and her employees went to exchange experience. Yes, the incubators there are exactly the same, the same manufacturers and modifications, but they have more overcrowding of children in the box, which does not correspond to Russian SanPins. In our case, children are placed in one box from one maternity hospital, in another box - from another, so as not to mix the flora of the maternity hospitals. They do it all together.

12. Parents come to the intensive care unit every day, and they are given information about the child's condition, they can also go to the intensive care unit and sit next to the child. If the child is on spontaneous breathing, then mothers are allowed into the department, they express milk and begin to feed the children with this milk.

13. Two laboratories for express diagnostics work in the department around the clock. One of the main tests is to determine the acid-base state of children, blood gases are taken for analysis every four hours from all children on artificial lung ventilation to determine the correctness of the selected parameters.

14. A biochemical blood test is done in another laboratory, it is located on the third floor of the department.

15. If there is a need to make an X-ray, the child is not taken anywhere, the radiologist is called and he takes the X-ray machine to the incubator. Everything is close to the child. Reanimation children cannot be moved somewhere once again, all assistance is provided on the spot.

16. If you need to put a catheter or intubate, then the child from the incubator is transferred to a special heated table. Correctly it is called "Open resuscitation system".

19. Reminders of this hang in front of every door.

20. After discharge, children under three years of age are observed not only in the polyclinics at the place of residence, but also in the polyclinic at the department.

And finally, I would like to express my deep gratitude to Alla Lazarevna Erlich personally and her staff for doing such a big and bright business, as well as for the excursion.

For the photos, special thanks to my beloved husband 🙂

Sometimes there are situations when a newly born child is admitted to the intensive care unit. Let's figure out what kind of department it is and why there is a need for additional medical supervision of a newborn, because parents in such cases have thousands of questions and concerns.


Usually, an intensive care unit consists of 2 blocks:

1) intensive care unit

2) block of the second stage of nursing

Intensive care unit

Babies who require increased attention and resuscitation care are admitted to the intensive care unit. It helps children who have serious neurological problems, who cannot breathe on their own, or who were born with a very low weight. This block has everything for an intensive child and constant monitoring of his health: incubators, monitoring supervision and, of course, qualified personnel.

Second stage nursing unit

Recovery is carried out in this block. Premature babies or babies with newborn jaundice are transferred here.

Equipment

The intensive care unit is usually equipped with modern medical equipment that allows you to create comfortable conditions for babies: modern incubators protect newborns from noise and bright light, conditions are created for very premature babies that are as close to life as possible. Children who cannot feed on their own are injected with nutrient solutions through a special tube. You may also need drugs to regulate your heart rate, stimulate respiration, blood pressure, ultrasound and x-rays. In the premises of the department, the level of humidity and air temperature is constantly monitored. If necessary, the child is prescribed antibiotic treatment.

A little about the medical staff

The ICU medical staff is one of the most highly qualified. Parents are constantly provided with all the information on the state of health of the newborn, on the features of the disease and the tactics of its treatment. Also, doctors can answer all the exciting questions that relate to the further care of children after discharge. The daily care of the child is carried out by nurses, with whom the parents establish close communication during the period of the child's stay in the department. In addition to them, a whole team of specialists will monitor the newborn. These are, first of all, a pediatrician, neonatologist, cardiologist, neurologist, physiotherapist, pharmacist, nutritionist, laboratory assistants.

When can a child be referred to an intensive care unit?

Newborns with various perinatal pathologies are admitted to the intensive care unit. They usually require artificial ventilation, parenteral nutrition, fluid therapy, correction and restoration of important body functions. Deeply premature newborns with low body weight, who often have severe health problems, also come here.

If your newborn baby is transferred to an intensive care unit, do not panic and despair. Here you will inevitably have to get acquainted with new medical technologies, new medical language, new rules and procedures that are designed to help your child. The ward staff will teach you how to care for your baby during this time. Thanks to medical professionals, parents quickly learn, and begin to understand the needs of the baby, to find out what can be done for him. And this is very important, because the correct care of the child in these difficult first days of his life depends on how quickly he will be able to adapt to the new conditions of life outside the mother's body. Only after the baby's health has improved so much that it will not cause fears, when he is ready for a full life in normal conditions, can we talk about the child's discharge from the intensive care unit.

Resuscitation of newborns in the delivery room is based on a strictly defined sequence of actions, including predicting the occurrence of critical situations, assessing the condition of the child immediately after birth and conducting resuscitation measures aimed at restoring and maintaining respiratory and circulatory function.

Predicting the likelihood of having a baby with asphyxiation or drug depression is based on an analysis of the antenatal and intrapartum history.

Risk factors

Antenatal risk factors include maternal diseases such as diabetes mellitus, hypertensive syndromes, infections, and the mother's drug and alcohol use. From the pathology of pregnancy, it should be noted high or low water, prolonged gestation, intrauterine growth retardation and the presence of multiple pregnancies.

Intrapartum risk factors include: premature or delayed delivery, abnormal presentation or position of the fetus, placental abruption, prolapsed umbilical cord loops, the use of general anesthesia, abnormalities in labor, the presence of meconium in the amniotic fluid, etc.

Before the start of resuscitation measures, the child's condition is assessed by signs of live birth:

  • the presence of spontaneous breathing,
  • palpitations,
  • pulsation of the umbilical cord,
  • voluntary muscle movements.

In the absence of all 4 signs, the child is considered stillborn and cannot be resuscitated. The presence of at least one sign of live birth is an indication for the immediate start of resuscitation measures.

Resuscitation Algorithm

The resuscitation care algorithm is determined by three main features:

  • the presence of spontaneous breathing;
  • heart rate;
  • the color of the skin.

Assessment on the Apgar scale is made, as was customary, at the 1st and 5th minutes, to determine the severity of asphyxia, but its indicators do not have any effect on the volume and sequence of resuscitation measures.

Primary care for newborns in the maternity hospital

Initial activities (duration 20-40 s).

In the absence of risk factors and light amniotic fluid, the umbilical cord is crossed immediately after birth, the child is wiped dry with a warm diaper and placed under a source of radiant heat. If there is a large amount of mucus in the upper respiratory tract, then it is sucked out of the oral cavity and nasal passages using a balloon or catheter connected to an electric suction. In the absence of breathing, light tactile stimulation is carried out by 1-2 times patting on the feet.

In the presence of asphyxia factors and pathological impurities in the amniotic fluid (meconium, blood), aspiration of the contents of the oral cavity and nasal passages is performed immediately after the birth of the head (before the birth of the shoulders). After birth, pathological impurities are aspirated from the stomach and trachea.

I. First assessment of condition and action:

A. Breathing.

Absent (primary or secondary epnea) - start mechanical ventilation;

Independent, but inadequate (convulsive, superficial, irregular) - start mechanical ventilation;

Self-Regular - Assess your heart rate (HR).

B. Heart rate.

Heart rate less than 100 beats per minute. - carry out mask ventilation with 100% oxygen until the heart rate is normalized;

B. Skin color.

Completely pink or pink with cyanosis of hands and feet - observe;

Cyanotic - inhale 100% oxygen through a face mask until cyanosis disappears.

Artificial ventilation technique

Artificial lung ventilation is carried out with a self-expanding bag (Ambu, Penlon, Laerdal, etc.) through a face mask or an endotracheal tube. Before the start of mechanical ventilation, the bag is connected to an oxygen source, preferably through a gas mixture humidifier. A roller is placed under the child's shoulders and the head is slightly thrown back. The mask is applied to the face so that it lies on the bridge of the nose with the upper part of the obturator, and on the chin with the lower part. When pressing on the bag, an excursion of the chest should be clearly traced.

Indications for the use of an oral airway for mask ventilation are: bilateral choanal atresia, Pierre-Robin syndrome and the inability to ensure free airway with proper positioning of the child.

Intubation of the trachea and the transition to mechanical ventilation through an endotracheal tube is indicated for suspected diaphragmatic hernia, ineffectiveness of mask ventilation for 1 minute, as well as for apnea or inadequate breathing in a child with gestational age less than 28 weeks.

Artificial ventilation of the lungs is carried out with 90-100% oxygen-air mixture with a frequency of 40 breaths per 1 minute and an inhalation to exhalation ratio of 1: 1.

After ventilation of the lungs for 15-30 seconds, the heart rate is monitored again.

If the heart rate is above 80 per minute, continue ventilation until adequate spontaneous breathing is restored.

If the heart rate is less than 80 beats per minute - while continuing the ventilation, start chest compressions.

Technique of indirect heart massage

The child is laid down on a hard surface. Two fingers (middle and forefinger) of one hand or two thumbs of both hands produce pressure on the border of the lower and middle third of the sternum at a frequency of 120 per minute. The displacement of the sternum towards the spine should be 1.5-2 cm. Ventilation and heart massage do not synchronize, i.e. each manipulation is carried out in its own rhythm.

30 seconds after the start of the closed heart massage, the heart rate is again monitored.

If the heart rate is above 80 beats per minute, stop cardiac massage and continue ventilation until adequate spontaneous breathing is restored.

If the heart rate is below 80 per minute, continue chest compressions, mechanical ventilation and start drug therapy.

Drug therapy

With asystole or heart rate below 80 beats per minute, adrenaline is immediately administered at a concentration of 1: 10000. For this, 1 ml of an ampouled solution of adrenaline is diluted in 10 ml of saline. The solution prepared in this way is taken in an amount of 1 ml into a separate syringe and injected intravenously or endotracheally at a dose of 0.1-0.3 ml / kg of body weight.

The heart rate is monitored every 30 seconds.

If the heart rate recovers and exceeds 80 beats per minute, stop cardiac massage and other medications.

If asystole or heart rate is below 80 beats per minute, continue chest compressions, mechanical ventilation, and drug therapy.

Repeat the injection of epinephrine at the same dose (if necessary, this can be done every 5 minutes).

If the patient has signs of acute hypovolemia, which is manifested by pallor, weak threadlike pulse, low blood pressure, then the child is shown the introduction of a 5% albumin solution or saline solution at a dose of 10-15 ml / kg of body weight. The solutions are administered intravenously over 5-10 minutes. With persisting signs of hypovolemia, repeated administration of these solutions in the same dose is permissible.

The introduction of sodium bicarbonate is indicated in case of confirmed decompensated metabolic acidosis (pH 7.0; BE -12), as well as in the absence of the effect of mechanical ventilation, cardiac massage and drug therapy (presumably severe acidosis that prevents the restoration of cardiac activity). A solution of sodium bicarbonate (4%) is injected into the umbilical cord vein at the rate of 4 ml / kg of body weight (2 meq / kg). The rate of drug administration is 1 meq / kg / min.

If within 20 minutes after birth, despite the resuscitation measures carried out in full, the child's cardiac activity is not restored (no heartbeats), resuscitation in the delivery room is stopped.

With a positive effect from resuscitation measures, the child should be transferred to the intensive care unit (ward), where specialized treatment will continue.

Primary neonatal resuscitation

Death is the death of body cells due to the cessation of their supply of blood, which carries oxygen and nutrients. Cells die after sudden cardiac and respiratory arrest, albeit quickly, but not instantly. The cells of the brain suffer the most from the cessation of oxygen supply, especially to the cerebral cortex, that is, the department on the functioning of which consciousness, spiritual life, and human activity as a person depend.

If oxygen does not enter the cells of the cerebral cortex within 4 - 5 minutes, then they are irreversibly damaged and die. Cells of other organs, including the heart, are more viable. Therefore, if respiration and blood circulation are quickly restored, then the vital activity of these cells will resume. However, this will only be the biological existence of the organism, while consciousness, mental activity will either not be restored at all, or will be profoundly changed. Therefore, the revitalization of a person must begin as early as possible.

That is why everyone needs to know the methods of primary resuscitation of children, that is, to learn a set of measures to provide assistance at the scene of the accident, prevent death and revitalize the body. It is everyone's duty to be able to do this. Inactivity in anticipation of medical workers, no matter what motivates it - confusion, fear, inability - should be considered as a failure to fulfill a moral and civic duty in relation to a dying person. If this concerns your beloved crumbs, it is simply necessary to know the basics of intensive care!

Resuscitation of a newborn

How is primary resuscitation of children carried out?

Cardiopulmonary and cerebral resuscitation (CLCR) is a set of measures aimed at restoring the basic vital functions of the body (heart and respiration), disturbed in terminal states, in order to prevent brain death. Such resuscitation is aimed at reviving a person after stopping breathing.

The leading causes of terminal conditions that developed outside medical institutions in childhood are sudden death syndrome of newborns, car injury, drowning, and obstruction of the upper respiratory tract. The maximum number of deaths in children occurs between the age of 2 years.

Periods of cardiopulmonary and cerebral resuscitation:

  • The period of elementary life support. In our country, it is called the immediate stage;
  • The period of further life support. It is often referred to as a specialized stage;
  • The period of prolonged and long-term maintenance of life, or postresuscitation.

At the stage of elementary life support, techniques are performed to replace ("prosthetics") the vital functions of the body - the heart and respiration. At the same time, the events and their sequence are conventionally designated by a well-remembered abbreviation of three English letters ABS:

- from the English. airway, literally opening the airways, restoring the patency of the airways;

- breath for victim, literally - breath for the victim, mechanical ventilation;

- circulation his blood, literally - ensuring his blood flow, external heart massage.

Transportation of victims

Functionally justified for transporting children is:

  • in severe hypotension - horizontal position with the head end lowered by 15 °;
  • with damage to the chest, acute respiratory failure of various etiologies - semi-sedentary;
  • in case of spinal injury - horizontal on the shield;
  • with fractures of the pelvic bones, damage to the abdominal organs - the legs are bent at the knees and hip; joints and spread apart ("frog position");
  • for injuries of the skull and brain with a lack of consciousness - horizontal on the side or on the back with a raised head end by 15 °, fixation of the head and cervical spine.

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

  1. Aire way orep ("open the way for air") means the need to free the respiratory tract from obstacles: sinking of the root of the tongue, accumulation of mucus, blood, vomit and other foreign bodies;
  2. Breath for victim refers to mechanical ventilation;
  3. Circulation his blood refers to chest compressions or chest compressions.

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

  • the victim is laid 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 victim's mouth (R. Safar's triple reception);
  • free 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 airways, they immediately begin mechanical ventilation. There are several main methods:

  • indirect, manual methods;
  • methods of direct injection of air exhaled by the resuscitator into the victim's respiratory tract;
  • hardware methods.

The former are mainly of historical importance and are not considered at all in modern guidelines on cardiopulmonary resuscitation. At the same time, manual mechanical ventilation should not be neglected in difficult situations when it is not possible to provide assistance to the victim in other ways. In particular, rhythmic compression (with both hands) of the lower ribs of the victim's chest, synchronized with his exhalation, can be applied. This technique can 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 on the side and rhythmically squeezes his chest from the sides during exhalation). Reception is not indicated for fractured 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 liters) is injected 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) , the patient's respiratory center is stimulated. The methods are used "mouth to mouth", "mouth to nose", "mouth to nose and mouth"; the latter method is usually used in the resuscitation of young children.

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

Ventilators vary in design complexity. At the prehospital stage, it is possible to use self-expanding breathing bags of the "Ambu" type, simple mechanical devices of the "Pneumat" type, or a constant air flow interrupter, for example, according to the Air 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 compulsory ventilation is provided through a nasal mask, long-term - through an endotracheal or tracheotomy tube.

Usually mechanical ventilation is combined with external, indirect cardiac 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 third of the sternum, in young children - 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, one breath is necessary for 3-4 compression of the chest; in older children and adults, this ratio is 1: 5.

The effectiveness of chest compressions is evidenced by a decrease in cyanosis of the lips, auricles and skin, a narrowing 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 improper position of the hands of the resuscitator 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 for cardiac tamponade, multiple rib fractures.

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

The condition for the success of cardiopulmonary resuscitation in children is airway clearance, 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) added 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, but 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 before the effect is obtained). With intratracheal administration, the dose is increased;
  • atropine (ineffective in asystole) 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 has occurred against the background of decompensated metabolic acidosis. The usual dose is 1 ml of an 8.4% solution. Repeating the administration of the drug is possible only under the control of the KOS;
  • 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 urine output 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 bolus at a dose of 1.0-1.5 mg / kg, followed by infusion at a dose of 1-3 mg / kg-h), or 20-50 μg / (kg-min) ...

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

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

  • adrenaline intravenously, intratracheally (if catheterization is impossible from 3 attempts or within 90 s); 1st dose 0.01 mg / kg, subsequent dose 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 replenishing VCP; it is better to use a 5% solution of albumin or stabilizol, you can reopolyglucin 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 questionable;
  • if the listed therapy is ineffective - electrocardiostimulation (external, transesophageal, endocardial) immediately.

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

In cases where the damage to the brain is so deep and extensive that it becomes impossible to restore its functions, including 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 terminating the initiated and actively ongoing intensive care in children before the natural cessation of blood circulation. Resuscitation does not start 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, life preservation in patients is observed much less often. The reason for this is post-resuscitation illness.

The outcome of the revival is largely predetermined by the conditions for the 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 drops by 30-50% in combination with an increase in vascular resistance by 4 times. A repeated deterioration of cerebral circulation can occur 2-4 days or 2-3 weeks after CPR against the background of almost complete recovery of central nervous system function - delayed posthypoxic encephalopathy syndrome. By the end of the 1st or the beginning of the 2nd day after CPR, there may be a repeated decrease in blood oxygenation associated with nonspecific lung damage - respiratory distress syndrome (RDS) and the development of shunt-diffusion respiratory failure.

Complications of postresuscitation disease:

  • in the first 2-3 days after CPR - edema of the brain, lungs, increased tissue bleeding;
  • 3-5 days after CPR - dysfunction of parenchymal organs, development of manifest multiple organ failure (MOF);
  • at a later date - inflammatory and suppurative processes. In the early postresuscitation period (1-2 weeks), intensive therapy
  • is carried out against the background of impaired consciousness (somnolence, stupor, coma) mechanical ventilation. Its main tasks in this period are hemodynamic stabilization and protection of the brain from aggression.

The restoration of VCP and rheological properties of blood is carried out by hemodilutants (albumin, protein, dry and native plasma, rheopolyglucin, saline solutions, less often a polarizing mixture with the introduction of insulin at the rate of 1 U per 2-5 g of dry glucose). The plasma protein concentration should be at least 65 g / l. An improvement in gas exchange is achieved by restoring the oxygen capacity of the blood (transfusion of erythrocyte mass), mechanical ventilation (with an oxygen concentration in the air mixture, preferably less than 50%). With reliable restoration of spontaneous breathing and stabilization of hemodynamics, HBO is possible, 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 with low doses of dopamine (1-3 μg / kg per minute for a long time), carrying out supportive cardiotrophic therapy (polarizing mixture, Panangin). The normalization of microcirculation is ensured by effective anesthesia in trauma, neurovegetative blockade, the introduction of antiplatelet agents (Curantil 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 drip per day, sermion , aminophylline, nicotinic acid, compliance, etc.).

Antihypoxic treatment is performed (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 - 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, intravenous large doses of prednisolone, metipred (up to 10-30 mg / kg) are prescribed, bolus or fractionally for 1 day.

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

Correction of HEO, CBS and energy metabolism is carried out. Detoxification therapy (infusion therapy, hemosorption, plasmapheresis according to indications) is carried out to prevent toxic encephalopathy and secondary toxic (autotoxic) organ damage. Decontamination of the intestine with aminoglycosides. Timely and effective anticonvulsant and antipyretic therapy in young children prevents the development of post-hypoxic encephalopathy.

Prevention and treatment of pressure ulcers (treatment with camphor oil, curiosin of places with microcirculation disorders), hospital infections (asepsis) are necessary.

In the case of a quick exit of the patient from a critical state (within 1 - 2 hours), the complex of therapy and its duration should be corrected depending on the clinical manifestations and the presence of postresuscitation disease.

Treatment in the late postresuscitation period

Therapy in the late (subacute) postresuscitation 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, Og intravenously 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, acefen, and nootropil are prescribed internally for a long time.
  • 2-3 weeks after CPR, a (primary or repeated) course of HBO therapy is indicated.
  • The introduction of antioxidants and antiaggregants is continued.
  • Vitamins of group B, C, multivitamins.
  • Antifungal drugs (Diflucan, Ancotil, Candizol), biological products. Termination of antibiotic therapy according to indications.
  • Membrane stabilizers, physiotherapy, physiotherapy exercises (exercise therapy) and massage according to indications.
  • General strengthening therapy: vitamins, ATP, creatine phosphate, biostimulants, adaptogens for long courses.

The main differences between cardiopulmonary resuscitation in children and adults

Conditions preceding circulatory arrest

Bradycardia in a child with respiratory disorders is a sign of circulatory arrest. Newborns, infants and young children develop bradycardia in response to hypoxia, while older children develop tachycardia first. In newborns and children with a heart rate of less than 60 per minute and signs of low organ perfusion in the absence of improvement after the start of artificial respiration, a closed heart massage should be performed.

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

Blood pressure must be measured with a properly sized cuff; invasive blood pressure is indicated only when the child is extremely severe.

Since the BP 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 (an increase in heart rate and peripheral vascular resistance). However, following hypotension, cardiac and respiratory arrest occurs very quickly. Therefore, even before the onset of hypotension, all efforts should be directed to treating shock (the manifestations of which are an increase in heart rate, cold extremities, capillary filling for more than 2 s, weak peripheral pulse).

Equipment and environmental conditions

The size of the equipment, dosage of medications and parameters of cardiopulmonary resuscitation depend on age and body weight. When choosing doses, the child's age should be rounded down, for example, at the age of 2 years, a dose is prescribed for the age of 2 years.

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 within the range from 36.5 "C in newborns to 35" C in children. When basal body temperature is below 35 ° C, CPR becomes problematic (in contrast to the beneficial effects of hypothermia in the postresuscitation period).

Airways

Children have structural features of the upper respiratory tract. The size of the tongue in relation to the oral cavity is disproportionately large. The larynx is higher and more deflected forward. The epiglottis is long. The narrowest part of the trachea is located below the vocal cords at the level of the cricoid cartilage, which makes it possible to use the tube without a cuff. The straight blade of the laryngoscope allows better visualization of the glottis, since the larynx is located more ventrally and the epiglottis is very mobile.

Rhythm disturbances

With asystole, atropine and artificial rhythm 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 discharge rate should be 2-4 J / kg for a monophasic defibrillator. It is recommended to start at 2 J / kg and increase as necessary to a maximum of 4 J / kg on the third shock.

Statistics show that cardiopulmonary resuscitation in children allows at least 1% of patients or victims of accidents to return to full life.