Features of resuscitation in children. How to understand that a circulatory disorder has occurred? Direct cardiac massage

Primary cardiopulmonary resuscitation in children

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

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

Clinical diagnosis

Main features clinical death:

lack of breathing, heartbeat and consciousness;

disappearance of the pulse in the carotid and other arteries;

pale or sallow skin color;

the pupils are wide, without reacting to light.

Emergency measures in case of clinical death:

reviving a child with signs of circulatory and respiratory arrest must begin immediately, from the first seconds of establishing this condition, extremely quickly and energetically, in strict sequence, without wasting time on finding out the reasons for its occurrence, auscultation and measuring blood pressure;

record the time of clinical death and the moment of the start of resuscitation measures;

sound the alarm, call assistants and the resuscitation team;

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

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

Resuscitation will be effective only when it is properly organized and life-sustaining measures are carried out in the classical sequence. The main provisions of primary cardiopulmonary resuscitation are proposed by the American Heart Association in the form of the “ABC Rules” according to R. Safar:

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

The second step B (Breath) is to restore breathing.

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

Sequence of resuscitation measures:

A ( Airways ) - restoration of airway patency:

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

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

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

A cervical vertebral fracture should be suspected in patients with head trauma or other injuries above the collarbones accompanied by loss of consciousness, or in patients whose spine has been subjected to unexpected stress due to diving, falling, or a motor vehicle accident.

4. Move the lower jaw forward and upward (the chin should occupy the highest position), which prevents the tongue from sticking to the back wall of the pharynx and facilitates air access.

IN ( Breath ) - restoration of breathing:

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

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

When breathing “mouth to mouth,” the resuscitator wraps his lips around the patient’s mouth and pinches his nose with his right hand. The rest of the technique is the same (Fig. 1). With both methods, there is a danger of partial penetration of the blown air into the stomach, its distension, regurgitation of gastric contents into the oropharynx and aspiration.

The introduction of an 8-shaped air duct or an adjacent oronasal mask greatly facilitates performing mechanical ventilation. Manual breathing apparatus (Ambu bag) is connected to them. When using manual breathing apparatus, the resuscitator presses the mask tightly with his left hand: bow with the thumb, and the chin with the index finger, while simultaneously (with the remaining fingers) pulling the patient’s chin upward and backward, thereby achieving closure of the mouth under the mask. The bag is compressed with the right hand until chest excursion occurs. This serves as a signal that pressure must be released to allow exhalation.

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 continuing mechanical ventilation, must begin chest compressions.

Methodology indirect massage hearts (Fig. 2, table 1). The patient lies on his back, on a hard surface. The resuscitator, having chosen a hand position appropriate for the child’s age, applies rhythmic pressure with age frequency on the chest, balancing the force of pressure with the elasticity chest. Heart massage is carried out until complete recovery heart rate, pulse in peripheral arteries.

Table 1.

Method of performing indirect cardiac massage in children

Complications of chest compressions: with excessive pressure on the sternum and ribs, there may be fractures and pneumothorax, and with strong pressure over the xiphoid process, liver rupture is possible; It is also necessary to remember about the danger of regurgitation of gastric contents.

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

Criteria for the effectiveness of mechanical ventilation and chest compressions:

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 in the carotid arteries (checked in the intervals between chest compressions - at the time of compression on carotid artery a wave of massage is felt, indicating that the massage is being carried out 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-sustaining measures:

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

0,1% solution of adrenaline hydrogen tartrate 0.01 ml/kg (0.01 mg/kg);

0,1% atropine solution sulfate 0.01-0.02 ml/kg (0.01-0.02 mg/kg). Atropine during resuscitation in children is used in dilution: 1 ml of 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 (1 ml of solution will contain 0.1 mg of the drug). It is possible to use doses of adrenaline increased by 2 times.

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

4% sodium bicarbonate solution 2 ml/kg (1 mmol/kg). Administration 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; administration of a 10% calcium gluconate solution at a dose of 0.2 ml/kg (20 mg/kg) is indicated only in the presence of hyperkalemia, hypocalcemia and an overdose of calcium antagonists.

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

3. For ventricular fibrillation, defibrillation (electrical and drug) 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.

No signs of recovery of cardiac activity against the background of ongoing activities for 30 - 40 minutes. is an indication to stop resuscitation.

INDEPENDENT WORK OF STUDENTS:

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

LIST OF REFERENCES FOR INDEPENDENT PREPARATION:

Main literature:

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

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

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

Guide to outpatient pediatrics / ed. A.A. Baranova. - 2nd ed., rev. and additional - M.: GEOTAR-Media. 2009. - 592 pp. [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 VUNMC Ministry of Health of the Russian Federation, 2004.

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

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

Emergency pediatrics: textbook / Yu. S. Aleksandrovich, V. I. Gordeev, K. V. Pshenisnov. - St. Petersburg. : SpetsLit. 2010. - 568 pp. [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. etc.: textbook / Tver State. honey. academic; Practical skills for a student studying in the specialty "pediatrics", [Tver]:; 2005 1 electric wholesale (CD–ROM).

Software and Internet resources:

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

catalog of medical resources INTERNET

2. "Medline"

4.Corbis catalogue,

5.Professionally oriented website : http:// www. Medpsy.ru

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

The student’s knowledge of the main provisions of the lesson topic:

Examples of baseline tests:

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

A. At 1st degree.

b. At 2 degrees.

V. At 3 degrees.

d. For grades 3 and 4.

* d. At 4 degrees.

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

* A. Stopping access of the allergen.

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

V. Administration of corticosteroids.

d. Applying a tourniquet above the allergen injection site.

d. Applying a tourniquet below the allergen injection site.

3. Which of the criteria will first indicate to you that the ongoing indirect cardiac massage is effective?

a.Warming of the extremities.

b.Return of consciousness.

c. The appearance of intermittent breathing.

d. Pupil dilation.

* d. Constriction of pupils._

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

* A. Prolongation of the Q-T interval.

b. Shortening of the Q-T interval.

V. Prolongation of the P - Q interval.

d. Shortening of the P-Q interval.

d. Deformation of the QRS complex.

Questions and typical tasks of the final level:

Exercise 1.

Calling an ambulance to the house of a 3-year-old boy.

Temperature 36.8°C, number of respirations – 40 per 1 minute, number of heartbeats – 60 per 1 minute, blood pressure – 70/20 mm Hg. Art.

Parents' complaints about the child's lethargy and inappropriate behavior.

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

Objective data: The condition is serious. Doubtfulness. Glasgow scale score 10 points. The skin, especially the chest and face, as well as the sclera, is hyperemic. The pupils are constricted. Convulsions with a predominance of the clonic component are periodically observed. Nasal breathing is difficult. Breathing is shallow. Pulse is weak and tense. On auscultation, against the background of puerile breathing, a small number of wheezing sounds are heard. Heart sounds are muffled. The stomach is soft. The liver protrudes 1 cm from under the edge of the costal arch along the midclavicular line. The spleen is not palpable. Haven't urinated for the last 2 hours.

a) Make a diagnosis.

b) Provide prehospital emergency care and determine transportation conditions.

c) Characterize the pharmacological action of nefedipine and reserpine.

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

e) Indicate how long it takes for acute renal failure to develop and describe the mechanism of its occurrence.

f) Determine the possibility of performing forced diuresis to remove 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 doctor at a summer health camp.

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

Response standard

Perhaps these are early signs of sunstroke: lethargy, nausea, decreased visual acuity, redness of the face, increased body temperature, increased breathing, tachycardia. In the future, loss of consciousness, delirium, hallucinations, and a change from tachycardia to bradycardia may occur. In the absence of help, the child may die due to 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 plenty of glucose-saline solution (1/2 teaspoon each of sodium chloride and sodium bicarbonate, 2 tablespoons of sugar per 1 liter of water) not less than the age-specific daily water requirement.

3. With a full-blown heatstroke clinic:

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

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

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

Oxygen therapy;

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

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

Task 3:

The doctor at the children's health camp was called by passers-by who saw a drowning child in the lake near the camp. Upon examination, a child, estimated to be 9-10 years old, is lying on the shore of the lake, unconscious, in wet clothes. The skin is pale, cold to the touch, the lips are cyanotic, and water flows from the mouth and nose. Hyporeflexia. In the lungs, breathing is weakened, the yielding areas of the chest and sternum sink during inspiration, respiratory rate is 30 per minute. Heart sounds are muffled, heart rate is 90 beats/min, the pulse is weak and tense, rhythmic. Blood pressure – 80/40 mm Hg. The abdomen is soft and painless.

1.What is your diagnosis?

2. Your actions at the examination site (first medical aid).

3. Your actions at the medical center of the health camp (help with prehospital stage).

4. Further tactics.

Standard answer.

1. Drowning.

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

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

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

Development cardiopulmonary resuscitation in children essential for everyone medical worker, since the life of a child sometimes depends on the correct assistance provided.

To do this, you need to be able to diagnose terminal conditions, know the technique of resuscitation, and perform all the necessary manipulations in a strict sequence, even to the point of automation.

Methods of providing assistance in terminal conditions are constantly being improved.

In 2010 at international association The AHA (American Heart Association), after much discussion, has issued new guidelines for cardiopulmonary resuscitation.

The changes primarily affected the sequence of resuscitation. Instead of the previously performed ABC (airway, breathing, compressions), CAB (cardiac massage, patency) is now recommended respiratory tract, artificial respiration).
The new recommendations were issued mainly for adults and therefore require some correction for the child’s body.

Now let's look at emergency measures when clinical death occurs.

Clinical death can be diagnosed based on the following signs:
there is no breathing, no blood circulation (the pulse in the carotid artery is not detected), dilation of the pupils is noted (there is no reaction to light), consciousness is not determined, and there are no reflexes.

If clinical death is diagnosed, you need to:

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

CPR sequence:

1. Resuscitation begins with chest compressions regardless of age. This is especially true if one person is performing resuscitation. They immediately recommend 30 compressions in a row before starting artificial ventilation.

If resuscitation is carried out by people without special training, then only cardiac massage is performed without attempts at artificial respiration. If resuscitation is carried out by a team of resuscitators, then closed cardiac massage is performed simultaneously with artificial respiration, avoiding pauses (without stopping).

Chest compressions should be fast and hard, in children under one year old by 2 cm, 1-7 years by 3 cm, over 10 years by 4 cm, in adults by 5 cm. The frequency of compressions in adults and children is up to 100 times per minute.

In infants up to one year old, heart massage is performed with two fingers (index and ring), from 1 to 8 years old with one palm, for older children with two palms. The place of compression is the lower third of the sternum.

2. Restoration of airway patency (airways).

It is necessary to clear the airways of mucus, move the lower jaw forward and upward, slightly tilt the head back (in case of a cervical injury, this is contraindicated), and place a cushion under the neck.

3. Restoration of breathing (breathing).

At the prehospital stage, mechanical ventilation is performed using the “mouth to mouth and nose” method in children under 1 year of age, and “mouth to mouth” in children over 1 year of age.

Ratio of breathing frequency to impulse frequency:

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

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

At the stage medical care for mechanical ventilation use manual Breathe-helping machine(Ambu bag) or anesthesia machine.

Tracheal intubation should be a smooth transition, we breathe with a mask, and then intubate. Intubation is performed through the mouth (orotracheal method) or through the nose (nasotracheal method). Which method is preferred depends on the disease and damage to the facial skull.

4. Administration of medications.

Medicines are administered against the backdrop of ongoing closed massage hearts and ventilation.

The route of administration is preferably intravenous; if not possible, endotracheal or intraosseous.

With endotracheal administration, the dose of the drug is increased 2-3 times, the drug is diluted by saline solution up to 5 ml and is inserted into the endotracheal tube through a thin catheter.

An intraosseous needle is inserted into the tibia into its anterior surface. A spinal puncture needle with a mandrel or a bone marrow needle can be used.

Intracardiac administration in children is currently not recommended due to possible complications (hemipericardium, pneumothorax).

In case of clinical death, the following drugs are used:

• Adrenaline hydrotartate 0.1% solution at a dose of 0.01 ml/kg (0.01 mg/kg). The drug can be administered every 3 minutes. In practice, 1 ml of adrenaline is diluted with saline solution
  9 ml (total volume is 10 ml). From the resulting dilution, 0.1 ml/kg is administered. If there is no effect after double administration, the dose is increased tenfold.
  (0.1 mg/kg).
• Previously, a 0.1% solution of atropine sulfate 0.01 ml/kg (0.01 mg/kg) was administered. Now it is not recommended for asystole and electromech. dissociation due to lack of therapeutic effect.
• The administration of sodium bicarbonate used to be mandatory, now only when indicated (for hyperkalemia or severe metabolic acidosis).
  The dose of the drug is 1 mmol/kg body weight.
• Calcium supplements are not recommended. Prescribed only when cardiac arrest is caused by an overdose of calcium antagonists, with hypocalcemia or hyperkalemia. Dose of CaCl 2 - 20 mg/kg

5. Defibrillation.

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

In children, ventricular fibrillation occurs in about 15% of all cases of circulatory arrest and is therefore used less frequently. But if fibrillation is diagnosed, then it should be carried out as quickly as possible.

There are mechanical, medicinal, and electrical defibrillation.

• Mechanical defibrillation includes precordial shock (a blow to the sternum with a fist). Currently not used in pediatric practice.
• Medical defibrillation consists of the use of antiarrhythmic drugs - verapamil 0.1-0.3 mg/kg (no more than 5 mg once), lidocaine (at a dose of 1 mg/kg).
• Electrical defibrillation is the most effective method and an essential component of cardiopulmonary resuscitation.
  It is recommended to perform electrical defibrillation of the heart with three shocks.
  (2J/kg – 4J/kg – 4J/kg). If there is no effect, then against the background of ongoing resuscitation measures, a second series of shocks can be performed again starting from 2 J/kg.
  During defibrillation, the child must be disconnected from the diagnostic equipment and the respirator. Electrodes are placed - one to the right of the sternum below the collarbone, the other to the left and below the left nipple. There must be a saline solution or cream between the skin and the electrodes.

Resuscitation is stopped only after signs of biological death appear.

Cardiopulmonary resuscitation is not started if:

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

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

Single cardiac complexes, coarse or small wave fibrillation or isoline may be observed on the electrocardiograph tape or monitor.

It happens that normal electrical activity of the heart is recorded in the absence of cardiac output. This type of circulatory arrest is called electromechanical dissociation (occurs with cardiac tamponade, tension pneumothorax, cardiogenic, etc.).

In accordance with electrocardiography data, the necessary assistance can be provided more accurately.

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

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

Is a "precordial beat" used during the procedure?

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

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

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

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

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

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

Are there contraindications to intracardiac administration of adrenaline?

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

How effective is intratracheal administration of epinephrine?

When is atropine indicated for cardiopulmonary resuscitation?

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

When are calcium supplements indicated during cardiopulmonary resuscitation?

What should be done in case of electromechanical dissociation?

Why is one bone usually used for intraosseous infusion?

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

Is the MAST device effective for resuscitation in children?

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

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

What is the normal tidal volume for a child?

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

1) oxygenation with 100% oxygen;

2) intensive observation, ECG monitoring;

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

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

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

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

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

3. More rare use: Ventricular fibrillation occurs infrequently in children.

What is the difference between livor mortis and rigor mortis?

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

When do you stop unsuccessful resuscitation?

How successful is resuscitation in the pediatric emergency department?

Why is resuscitation less successful in children than in adults?

Ten most common mistakes during resuscitation:

2. The nasogastric tube is not installed.

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

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

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

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

7. Roles in the team are distributed incorrectly.

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

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

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

It can save a person who has fallen into a state of clinical (reversible) death medical intervention. The patient will have only a few minutes before death, so those nearby are obliged to provide him with emergency first aid. Cardiopulmonary resuscitation (CPR) is ideal in this situation. It is a set of measures to restore respiratory function and circulatory systems. Not only rescuers, but also ordinary people nearby can provide assistance. The reasons for carrying out resuscitation measures are manifestations characteristic of clinical death.

Cardiopulmonary resuscitation is a set of primary methods of saving a patient. Its founder is the famous doctor Peter Safar. He was the first to create correct algorithm actions of emergency aid to the victim, which is used by most modern resuscitators.

Performance base complex to save a person is necessary when identifying a clinical picture characteristic of reversible death. Its symptoms are primary and secondary. The first group refers to the main criteria. This:

• disappearance of the pulse in large vessels (asystole);
• loss of consciousness (coma);
• complete lack of breathing (apnea);
• dilated pupils (mydriasis).

The voiced indicators can be identified by examining the patient:

Secondary symptoms vary in severity. They help ensure the need for pulmonary-cardiac resuscitation. Acquainted with additional symptoms clinical death can be found below:

• pale skin;
• loss of muscle tone;
• lack of reflexes.

Contraindications

Basic form of cardiopulmonary resuscitation is performed by nearby people in order to save the patient’s life. An extended version of assistance is provided by resuscitators. If the victim has fallen into a state of reversible death due to a long course of pathologies that have depleted the body and cannot be treated, then the effectiveness and expediency of rescue methods will be in question. This usually results in the terminal stage of development oncological diseases, severe failure of internal organs and other ailments.

There is no point in resuscitating a person if there are visible injuries that are incomparable to life against the background of a clinical picture of characteristic biological death. You can see its signs below:

• post-mortem cooling of the body;
• the appearance of spots on the skin;
• clouding and drying of the cornea;
• the emergence of the “cat’s eye” phenomenon;
• hardening of muscle tissue.

Drying and noticeable clouding of the cornea after death is called the “floating ice” symptom due to appearance. This sign is clearly visible. The "cat's eye" phenomenon is determined by light pressure on the lateral parts of the eyeball. The pupil contracts sharply and takes the shape of a slit.

The rate at which the body cools depends on the ambient temperature. Indoors, the decrease occurs slowly (no more than 1° per hour), but in a cool environment everything happens much faster.

Cadaveric spots are a consequence of the redistribution of blood after biological death. Initially, they appear on the neck from the side on which the deceased was lying (front on the stomach, back on the back).

Rigor mortis is the hardening of muscles after death. The process begins with the jaw and gradually covers the entire body.

Thus, it makes sense to perform cardiopulmonary resuscitation only in the case of clinical death, which was not provoked by serious degenerative changes. Her biological form irreversible and has characteristic symptoms, so people nearby will only have to call an ambulance for the team to pick up the body.

Correct procedure

The American Heart Association regularly provides advice on how to help better effective assistance sick people. Cardiopulmonary resuscitation according to new standards consists of the following stages:

• identifying symptoms and calling an ambulance;
• performing CPR according to generally accepted standards with an emphasis on chest compressions of the heart muscle;
• timely implementation of defibrillation;
• use of methods intensive care;
• carrying out complex treatment of asystole.

The procedure for performing cardiopulmonary resuscitation is compiled according to the recommendations of the American Heart Association. For convenience, it was divided into certain phases, entitled in English letters “ABCDE”. You can see them in the table below:

The voiced stages of cardiopulmonary resuscitation are compiled for doctors. For ordinary people who are close to the patient, it is enough to carry out the first three procedures while waiting for an ambulance. WITH correct technique implementation can be found in this article. Additionally, pictures and videos found on the Internet or consultations with doctors will help.

For the safety of the victim and the resuscitator, experts have compiled a list of rules and advice regarding the duration of resuscitation measures, their location and other nuances. You can find them below:

Time to make a decision is limited. Brain cells are rapidly dying, so pulmonary-cardiac resuscitation must be carried out immediately. There is only no more than 1 minute to make a diagnosis of “clinical death”. Next, you need to use the standard sequence of actions.

Resuscitation procedures

An ordinary person without medical education has only 3 techniques available to save the life of a patient. This:

• precordial stroke;
• indirect form of cardiac muscle massage;
• artificial ventilation.

Specialists will have access to defibrillation and direct cardiac massage. The first remedy can be used by a visiting team of doctors if they have the appropriate equipment, and the second only by doctors in the intensive care unit. The sound methods are combined with the administration of medications.

Precordial shock is used as a replacement for a defibrillator. Usually it is used if the incident happened literally before our eyes and no more than 20-30 seconds passed. The algorithm of actions for this method is as follows:

• If possible, pull the patient onto a stable and durable surface and check for pulse wave. If it is absent, you must immediately proceed to the procedure.
• Place two fingers in the center of the chest in the area xiphoid process. The blow must be applied slightly above their location with the edge of the other hand, gathered into a fist.

If the pulse cannot be felt, then it is necessary to move on to massage the heart muscle. The method is contraindicated for children whose age does not exceed 8 years, since the child may suffer even more from such a radical method.

Indirect cardiac massage

The indirect form of cardiac muscle massage is compression (squeezing) of the chest. This can be done using the following algorithm:

• Place the patient on a hard surface so that the body does not move during the massage.
• The side where the person performing resuscitation measures will stand is not important. You need to pay attention to the placement of your hands. They should be in the middle of the chest in its lower third.
• Hands should be placed one on top of the other, 3-4 cm above the xiphoid process. Press only with the palm of your hand (fingers do not touch the chest).
• Compression is carried out mainly due to the rescuer’s body weight. It is different for each person, so you need to make sure that the chest sag no deeper than 5 cm. Otherwise, fractures are possible.

• pressure duration 0.5 seconds;
• the interval between presses does not exceed 1 second;
• the number of movements per minute is about 60.

When performing cardiac massage in children, it is necessary to take into account the following nuances:

• in newborns, compression is performed with 1 finger;
• in infants, 2 fingers;
• in older children, 1 palm.

If the procedure turns out to be effective, the patient will develop a pulse, the skin will turn pink and the pupillary effect will return. It must be turned on its side to avoid tongue sticking or suffocation by vomit.

Before carrying out the main part of the procedure, you must try the Safar method. It is performed as follows:

• First, you should lay the victim on his back. Then tilt his head back. The maximum result can be achieved by placing one hand under the victim’s neck and the other on the forehead.
• Next, open the patient’s mouth and take a test breath of air. If there is no effect, push his lower jaw forward and down. If in oral cavity If there are objects that cause blockage of the respiratory tract, they should be removed using improvised means (handkerchief, napkin).

If there is no result, you must immediately proceed to artificial ventilation. Without the use of special devices, it is performed according to the instructions below:

To avoid infection of the rescuer or patient, it is advisable to carry out the procedure through a mask or using special devices. Its effectiveness can be increased by combining it with indirect cardiac massage:

• When performing resuscitation measures alone, you should apply 15 pressures on the sternum, and then 2 breaths of air to the patient.
• If two people are involved in the process, then air is injected once every 5 presses.

Direct cardiac massage

The heart muscle is massaged directly only in hospital conditions. Often resort to this method at sudden stop hearts during surgical intervention. The technique for performing the procedure is given below:

• The doctor opens the chest in the area of ​​the heart and begins to rhythmically compress it.
• Blood will begin to flow into the vessels, due to which the functioning of the organ can be restored.

The essence of defibrillation is the use of a special device (defibrillator), with which doctors apply current to the heart muscle. Shown this radical method at severe forms arrhythmias (supreventricular and ventricular tachycardias, ventricular fibrillation). They provoke life-threatening disruptions in hemodynamics, which often lead to death. If the heart stops, using a defibrillator will not bring any benefit. In this case, other resuscitation methods are used.

Drug therapy

Enter special drugs performed by doctors intravenously or directly into the trachea. Intramuscular injections are ineffective, so they are not carried out. The following medications are most commonly used:

• Adrenaline is the main drug for asystole. It helps start the heart by stimulating the myocardium.
• "Atropine" represents a group of M-cholinergic receptor blockers. The drug helps to release catecholamines from the adrenal glands, which is especially useful in cardiac arrest and severe bradysystole.
• "Sodium bicarbonate" is used if asystole is a consequence of hyperkalemia ( high level potassium) and metabolic acidosis (impaired acid-base balance). Especially during a prolonged resuscitation process (over 15 minutes).

Other medications, including antiarrhythmic drugs, are used as appropriate. After the patient’s condition improves, they will be kept under observation in the intensive care unit for a certain period of time.

Consequently, cardiopulmonary resuscitation is a set of measures to recover from the state of clinical death. Among the main methods of providing assistance are artificial respiration and indirect cardiac massage. They can be performed by anyone with minimal training.

Doctors of any specialty have to teach others and themselves perform procedures related to emergency care and saving the patient’s life. This is the very first thing a medical student hears at university. Therefore, special attention is paid to the study of such disciplines as anesthesiology and resuscitation. To ordinary people For those not related to medicine, it also wouldn’t hurt to know the protocol for action in a life-threatening situation. Who knows when this might come in handy.

Cardiopulmonary resuscitation is an emergency procedure aimed at restoring and maintaining the body’s vital functions after clinical death. It includes several mandatory steps. The SRL algorithm was proposed by Peter Safar, and one of the techniques for saving a patient is named after him.

Ethical issue

It is no secret that doctors are constantly faced with the problem of choice: what is best for their patient. And often it is this that becomes a stumbling block for further therapeutic measures. The same applies to performing CPR. The algorithm is modified depending on the conditions of care, the training of the resuscitation team, the age of the patient and his current condition.

There has been much discussion about whether it is worthwhile to explain to children and adolescents the complexity of their condition, given the fact that they do not have the right to make decisions about own treatment. The question was raised about organ donation from victims who underwent CPR. The algorithm of actions in these circumstances should be slightly modified.

When is CPR not performed?

In medical practice, there are cases when resuscitation is not carried out, since it is already pointless, and the patient’s injuries are incompatible with life.

1. When there are signs of biological death: rigor mortis, cooling, cadaveric spots.
2. Signs of brain death.
3. The final stages of incurable diseases.
4. The fourth stage of cancer with metastasis.
5. If doctors know for sure that more than twenty-five minutes have passed since breathing and circulation stopped.

Signs of clinical death

There are main and secondary signs. The main ones include:
- no pulse on large arteries(carotid, femoral, brachial, temporal);
- lack of breathing;
- persistent expansion pupils.

Secondary signs include loss of consciousness, pallor with a bluish tint, lack of reflexes, voluntary movements and muscle tone, strange, unnatural position of the body in space.

Stages

Conventionally, the CPR algorithm is divided into three large stages. And each of them, in turn, branches into stages.

The first stage is carried out immediately and consists of maintaining life at a level of constant oxygenation and airway patency. It eliminates the use of specialized equipment, and life is supported solely by the efforts of the resuscitation team.

The second stage is specialized, its goal is to preserve what non-professional rescuers have done and provide constant blood circulation and oxygen access. It includes diagnosing heart function, using a defibrillator, and using medications.

The third stage is carried out in the ICU (resuscitation and intensive care unit). It is aimed at preserving brain functions, restoring them and returning a person to normal life.

Procedure

In 2010, a universal CPR algorithm was developed for the first stage, which consists of several stages.

• A - Airway - or air permeability. The rescuer examines the external respiratory tract, removes everything that interferes with the normal passage of air: sand, vomit, algae, water. To do this, you need to tilt your head back, move your lower jaw and open your mouth.
• B - Breathing - breathing. Previously, it was recommended to carry out artificial respiration techniques “mouth to mouth” or “mouth to nose”, but now, due to the increased threat of infection, air enters the victim exclusively through
• C - Circulation - blood circulation or indirect cardiac massage. Ideally, the rhythm of chest compressions should be 120 beats per minute, then the brain will receive a minimum dose of oxygen. It is not recommended to interrupt, since during the injection of air a temporary stop of blood circulation occurs.
• D - Drugs - medicines, which are used at the stage specialized assistance to improve blood circulation, maintain heart rhythm or rheological properties blood.
• E - electrocardiogram. It is carried out to monitor the functioning of the heart and check the effectiveness of measures.

Drowning

There are some features of CPR for drowning. The algorithm changes slightly, adapting to environmental conditions. First of all, the rescuer must take care to eliminate the threat to his own life, and if possible, do not enter the reservoir, but try to deliver the victim to the shore.

If, nevertheless, help is provided in the water, then the rescuer must remember that the drowning person does not control his movements, so you need to swim from behind. The main thing is to hold the person’s head above the water: by the hair, by catching it under the armpits, or by throwing it over one’s back.

The best thing a rescuer can do for a drowning person is to start blowing air right in the water, without waiting for transportation to shore. But technically this is only available to a physically strong and prepared person.

As soon as you remove the victim from the water, you need to check that he has a pulse and is breathing spontaneously. If there are no signs of life, you need to start immediately. They need to be carried out according to general rules, since attempts to remove water from the lungs usually lead to the opposite effect and aggravate neurological damage due to oxygen starvation brain

Another feature is the time period. You should not rely on the usual 25 minutes, since in cold water the processes slow down and brain damage occurs much more slowly. Especially if the victim is a child.

Resuscitation can be stopped only after restoration of spontaneous breathing and blood circulation, or after the arrival of an ambulance team that can provide professional life support.

Advanced CPR, the algorithm of which is carried out using medications, includes inhalation of 100% oxygen, intubation of the lungs and mechanical ventilation. Additionally, antioxidants and fluid infusions are used to prevent falls system pressure and repeated diuretics to eliminate pulmonary edema, and active warming of the victim so that the blood is evenly distributed throughout the body.

Stopping breathing

The CPR algorithm for respiratory arrest in adults includes all stages of chest compressions. This makes the work of rescuers easier, since the body itself will distribute the incoming oxygen.

There are two methods without improvised means:

Mouth to mouth;
- mouth to nose.

For better air access, it is recommended to tilt the victim’s head back, extend the lower jaw and clear the airways of mucus, vomit and sand. The rescuer should also worry about his health and safety, so it is advisable to carry out this manipulation through a clean scarf or gauze, in order to avoid contact with the patient’s blood or saliva.

The rescuer pinches his nose, tightly wraps his lips around the victim’s lips and exhales air. In this case, you need to look to see if it is inflated. epigastric region. If the answer is yes, this means that air is entering the stomach and not the lungs, and there is no point in such resuscitation. Between exhalations you need to take breaks of a few seconds.

During high-quality mechanical ventilation, an excursion of the chest is observed.

Circulatory arrest

It is logical that the CPR algorithm for asystole will include everything except: If the victim is breathing on his own, you should not transfer him to artificial mode. This complicates the work of doctors in the future.

The cornerstone of proper cardiac massage is the laying on of hands technique and the coordinated work of the rescuer’s body. Compression is done with the base of the palm, not the wrist, not the fingers. The resuscitator's arms should be straightened, and compression is carried out by tilting the body. The arms are positioned perpendicular to the sternum, they can be held in a lock or the palms lie in a cross (in the shape of a butterfly). The fingers do not touch the surface of the chest. The algorithm for performing CPR is as follows: for thirty presses - two breaths, provided that resuscitation is carried out by two people. If there is only one rescuer, then fifteen compressions and one breath are performed, since big break without blood circulation can damage the brain.

Resuscitation of pregnant women

CPR for pregnant women also has its own characteristics. The algorithm includes saving not only the mother, but also the child in her womb. A doctor or bystander providing first aid to an expectant mother should remember that there are many factors that worsen the survival prognosis:

Increased oxygen consumption and rapid utilization;
- reduced lung volume due to compression by the pregnant uterus;
- high probability of aspiration of gastric contents;
- reduction of the area for mechanical ventilation, since the mammary glands are enlarged and the diaphragm is raised due to the enlargement of the abdomen.

Unless you are a doctor, the only thing you can do for a pregnant woman to save her life is to place her on her left side with her back at about a thirty-degree angle. And move her belly to the left. This will reduce pressure on the lungs and increase air flow. Be sure to start and don’t stop until the ambulance arrives or some other help arrives.

Rescue Children

CPR in children has its own characteristics. The algorithm resembles an adult one, but due to physiological characteristics it is difficult to carry out, especially for newborns. You can divide the resuscitation of children by age: up to one year and up to eight years. Everyone who is older receives the same amount of assistance as adults.

1. Call ambulance needed after five unsuccessful cycles of resuscitation. If the rescuer has assistants, then you should entrust them with this immediately. This rule works only if there is one person resuscitating.
2. Throw your head back even if you suspect a neck injury, as breathing is a priority.
3. Start mechanical ventilation with two blows of 1 second each.
4. Up to twenty blows should be made per minute.
5. When the airways are blocked foreign body The child is slapped on the back or hit on the chest.
6. The presence of a pulse can be checked not only in the carotid artery, but also in the brachial and femoral arteries, because the child’s skin is thinner.
7. When performing chest compressions, pressure should be placed immediately below the nipple line, since the heart is located slightly higher than in adults.
8. Press on the sternum with the heel of one palm (if the victim is a teenager) or two fingers (if the victim is an infant).
9. The pressure force is one third of the thickness of the chest (but not more than half).

General rules

Absolutely all adults should know how to carry out basic CPR. Its algorithms are quite simple to remember and understand. This could save someone's life.

There are several rules that can make rescue operations easier for an untrained person.

1. After five cycles of CPR, you can leave the victim to call the rescue service, but only if there is only one person providing assistance.
2. Determining signs of clinical death should not take more than 10 seconds.
3. The first artificial breath should be shallow.
4. If after the first breath there was no movement of the chest, it is worth throwing back the victim’s head again.

The remaining recommendations for the CPR algorithm have already been presented above. The success of resuscitation and the further quality of life of the victim depend on how quickly eyewitnesses get their bearings and how competently they can provide assistance. Therefore, you should not shy away from lessons that describe how to perform CPR. The algorithm is quite simple, especially if you remember it using a letter cheat sheet (ABC), as many doctors do.

Many textbooks say that CPR should be stopped after forty minutes of unsuccessful resuscitation, but in fact, only signs of biological death can be a reliable criterion for the absence of life. Remember: while you are pumping the heart, blood continues to feed the brain, which means the person is still alive. The main thing is to wait for the ambulance or rescuers to arrive. Believe me, they will thank you for this hard work.