Newborn department (with a resuscitation and intensive care unit for premature babies). Cardiopulmonary resuscitation in newborns and children Carrying out CPR for children of different ages

Sudden cardiac arrest is a clinical syndrome characterized by the disappearance of signs of cardiac activity (cessation of pulsation in the femoral and carotid arteries, absence of heart sounds), as well as cessation of spontaneous breathing, loss of consciousness and dilated pupils. These symptoms are the most important diagnostic criteria for cardiac arrest, which can be planned or sudden. Cardiac arrest, which is assumed, can be observed in a terminal state, which refers to the period of extinction of the body’s vital activity. A terminal condition can arise as a result of a critical disorder of homeostasis due to disease or the body’s inability to adequately respond to external action (trauma, hypothermia, overheating, poisoning, and so on). Cardiac arrest and cessation of circulation may be associated with asystole, ventricular fibrillation and collapse. Cardiac arrest is always accompanied by respiratory arrest; like sudden respiratory arrest, is associated with airway obstruction, central nervous system depression or neuromuscular paralysis, it can result in cardiac arrest.

The sequence of resuscitation measures in children is generally similar to that in adults, but there are some peculiarities. If resuscitation of adults is based on the fact of the primacy of heart failure, then in a child, cardiac arrest is the end of the process of gradual extinction of the physiological functions of the body, initiated, as a rule, by respiratory failure. Primary cardiac arrest in children is very rare, with ventricular fibrillation and tachycardia being the cause in less than 15% of cases. Many children have a relatively long “pre-arrest” phase, which determines the need for early diagnosis of this phase.

Without wasting time to find out the cause of cardiac or respiratory arrest, they immediately begin treatment, which includes the following set of measures. The head end of the bed is lowered, the lower limbs are raised, and access to the chest and head is created. To ensure airway patency, slightly throw the head back, lift the lower jaw up and make 2 slow blows of air into the child’s lung (1-1.5 seconds per 1 breath). The inspiratory volume should ensure minimal chest excursion. Forced injection of air causes gastric distension, which dramatically impairs the effectiveness of resuscitation! Insufflations are carried out using any method - “mouth to mouth”, “mouth - mask”, or using breathing devices “bag - mask”, “fur - mask”. However, in infants there are peculiarities in performing these manipulations:

Do not throw the baby's head overly;

Do not apply pressure to the soft tissue of the chin as this may cause airway obstruction.

If air blowing does not have an effect, then it is necessary to improve the patency of the airways, giving them an appropriate anatomical position by straightening the head. If this manipulation also does not produce an effect, then it is necessary to clear the airways of foreign bodies and mucus and continue breathing at a frequency of 20-30 per minute.

The method of eliminating airway obstruction caused by a foreign body depends on the age of the child. Blind cleansing of the upper respiratory tract with a finger is not recommended in children, since at this point the foreign body can be pushed deeper. If the foreign body is visible, it can be removed using a Kelly forceps or Medgil forceps. Pressing on the abdomen is not recommended for use in children under one year of age, since there is a risk of damage to the abdominal organs, especially the liver. A child at this age can be helped by holding him on his arm in a “rider” position with his head lowered below his body. The baby's head is supported with a hand around the lower jaw and chest. Four blows are quickly applied to the back between the shoulder blades with the proximal part of the palm. Then the child is placed on his back so that the head is lower than the body throughout the entire procedure, and four chest compressions are performed. If the child is very large, in order to place him on the forearm, he is placed on the thigh so that the head is lower than the body. After clearing the airways and restoring their free patency in the absence of spontaneous breathing, artificial ventilation of the lungs begins. In older children or adults with airway obstruction by a foreign body, it is recommended to use the Heimlich maneuver - a series of subdiaphragmatic pressures.

Emergency cricothyroidotomy is an option for airway management in patients who cannot be intubated.

Method of indirect cardiac massage. Using 2 or 3 fingers of the right hand, press on the sternum in a place located 1.5-2 cm below the intersection of the sternum with the nipple line. In newborns and infants, pressing on the sternum can be done by placing the thumbs of both hands in the indicated place, clasping the chest with your palms and fingers. The depth of deflection of the sternum is from 0.5 to 2.5 cm, the frequency of pressing is not less than 100 times per 1 minute, the ratio of pressing and artificial respiration is 5:1. Cardiac massage is performed by placing the patient on a hard surface, or by placing the left hand under the back of an infant. In newborns and infants, an acceptable asynchronous method of ventilation and massage without pauses for breaths, which increases minute blood flow.

Criteria for the effectiveness of resuscitation are the appearance of expressive pulsation in the femoral and carotid arteries, constriction of the pupils. It is advisable to develop emergency tracheal intubation and provide ECG monitoring of cardiac activity.

If, against the background of cardiac massage and mechanical ventilation, cardiac activity is not restored, then 0.01 mg/kg of adrenaline hydrochloride (epinephrine) is administered intravenously, then sodium bicarbonate - 1-2 mmol/kg. If intravenous administration is not possible, then, as a last resort, they turn to intracardiac, sublingual or endotracheal administration of drugs. The advisability of using calcium supplements during resuscitation is currently questioned. To support cardiac activity after its recovery, Dopamine or Dobutamine (Dobutrex) is administered - 2-20 mcg/kg per 1 minute. For ventricular fibrillation, lidocaine is prescribed - 1 mg/kg intravenously; if there is no effect, emergency electrodefibrillation is indicated (2 W/kg per 1 sec). If necessary, it is repeated - 3-5 W/kg per 1 second.

It is important to quickly provide access to the venous system during cardiopulmonary resuscitation. Central venous access is better than peripheral venous access because there is a significant delay in the circulation of the drug administered through the peripheral vein, although the doses of the drugs are the same.

Intravenous access is performed in this way.

Children under 5 years old:

· first attempt - peripheral line, if there is no success within 90 seconds - intraosseous line;

· later - the central line (femoral, internal and external jugular veins, subclavian), venesection of the saphenous vein of the leg.

Children over 5 years old:

· first attempt - peripheral line;

· second attempt - central line or venesection of the saphenous vein of the leg.

All medications used during cardiopulmonary resuscitation and all fluids, including whole blood, can be administered intraosseously. A standard 16-18G needle, a spinal puncture needle with a stylet, or a medullary needle is inserted into the anterior surface of the tibia 1-3 cm below its hump. The needle is directed at an angle of 90 degrees to the medial surface of the tibia, so as not to damage the epiphysis.

According to statistics, every tenth newborn child receives medical care in the delivery room, and 1% of all births require a full range of resuscitation actions. A high level of training of medical personnel allows you to increase your chances of life and reduce the possible development of complications. Adequate and timely resuscitation of newborns is the first step towards reducing mortality and disease development.

Basic Concepts

What is neonatal intensive care? This is a series of activities that are aimed at revitalizing the child’s body and restoring lost functions. It includes:

• intensive care methods;
• use of artificial lung ventilation;
• installation of a pacemaker, etc.

Full-term babies do not require resuscitation measures. They are born active, scream loudly, pulse and heart rate are within normal limits, the skin is pink, and the child responds well to external stimuli. Such children are immediately placed on the mother's stomach and covered with a dry, warm diaper. Mucous contents are aspirated from the respiratory tract to restore their patency.

Carrying out cardiopulmonary resuscitation is considered an emergency response. It is performed in case of respiratory and cardiac arrest. After such an intervention, in case of a favorable result, the basics of intensive care are applied. Such treatment is aimed at eliminating possible complications of stopping the functioning of important organs.

If the patient cannot independently maintain homeostasis, then resuscitation of the newborn includes either inserting a pacemaker.

What is needed to perform resuscitation in the delivery room?

If the need for such activities is small, then one person will be required to carry them out. In case of a difficult pregnancy and waiting for a full range of resuscitation actions, there are two specialists in the maternity room.

Resuscitation of a newborn in the delivery room requires careful preparation. Before the birth process, you should check that everything you need is available and make sure that the equipment is in working condition.

1. You need to connect a heat source so that the resuscitation table and diapers are warmed up, roll one diaper into a roll.
2. Check that the oxygen supply system is installed correctly. There must be a sufficient amount of oxygen, correctly adjusted pressure and flow rate.
3. The readiness of the equipment required for suctioning the contents of the respiratory tract should be checked.
4. Prepare instruments to remove gastric contents in case of aspiration (probe, syringe, scissors, fixing material), meconium aspirator.
5. Prepare and check the integrity of the resuscitation bag and mask, as well as the intubation kit.

The intubation kit consists of guides, a laryngoscope with different blades and spare batteries, scissors and gloves.

What makes events successful?

Neonatal resuscitation in the delivery room is based on the following principles of success:

• availability of resuscitation team - resuscitators must be present at all births;
• coordinated work - the team must work harmoniously, complementing each other as one big mechanism;
• qualified staff - every resuscitator must have a high level of knowledge and practical skills;
• work taking into account the patient’s reaction - resuscitation actions should begin immediately when the need arises, further measures are carried out depending on the reaction of the patient’s body;
• serviceability of equipment - equipment for resuscitation must be in working order and accessible at all times.

Reasons for the need for events

Etiological factors that inhibit the functioning of the heart, lungs and other vital organs of a newborn include the development of asphyxia, birth injuries, the development of congenital pathology, toxicosis of infectious origin and other cases of unknown etiology.

Pediatric neonatal resuscitation and its need can be predicted even during the period of pregnancy. In such cases, a team of resuscitators must be ready to immediately provide assistance to the baby.

The need for such measures may arise in the following conditions:

• high or low water levels;
• post-maturity;
• maternal diabetes;
• hypertonic disease;
• infectious diseases;
• fetal malnutrition.

There are also a number of factors that already arise during childbirth. If they occur, you can expect the need for resuscitation measures. Such factors include bradycardia in the child, cesarean section, premature and rapid labor, placenta previa or abruption, and uterine hypertonicity.

Asphyxia of newborns

The development of impaired breathing processes with hypoxia of the body causes the appearance of disorders in the circulatory system, metabolic processes and microcirculation. Next, a disorder in the functioning of the kidneys, heart, adrenal glands, and brain appears.

Asphyxia requires immediate intervention to reduce the possibility of complications. Causes of breathing disorders:

• hypoxia;
• airway obstruction (aspiration of blood, mucus, meconium);
• organic damage to the brain and central nervous system;
• developmental defects;
• insufficient amount of surfactant.

The need for resuscitation is diagnosed after assessing the child’s condition using the Apgar scale.

What is being assessed	0 points	1 point	2 points
Breathing status	Absent	Pathological, irregular	Loud scream, rhythmic
Heart rate	Absent	Less than 100 beats per minute	More than 100 beats per minute
Skin color	Cyanosis	Pink skin, bluish limbs	Pink
State of muscle tone	Absent	Limbs are slightly bent, tone is weak	Active movements, good tone
Reaction to irritant factors	Absent	Weakly expressed	Well expressed

A condition score of up to 3 points indicates the development of severe asphyxia, from 4 to 6 - asphyxia of moderate severity. Resuscitation of a newborn with asphyxia is carried out immediately after assessing his general condition.

Sequence of condition assessment

1. The child is placed under a heat source, his skin is dried with a warm diaper. The contents are aspirated from the nasal cavity and mouth. Tactile stimulation is provided.
2. A breathing assessment is performed. If the rhythm is normal and there is a loud cry, move on to the next stage. In case of irregular breathing, mechanical ventilation is performed with oxygen for 15-20 minutes.
3. Heart rate is assessed. If the pulse is above 100 beats per minute, proceed to the next stage of examination. In case of less than 100 beats, mechanical ventilation is performed. Then the effectiveness of the measures is assessed.
   • Pulse below 60 - indirect cardiac massage + mechanical ventilation.
   • Pulse from 60 to 100 - mechanical ventilation.
   • Pulse above 100 - mechanical ventilation in case of irregular breathing.
   • After 30 seconds, if indirect massage with mechanical ventilation is ineffective, it is necessary to carry out drug therapy.
4. Skin color is examined. Pink color indicates the normal condition of the child. In case of cyanosis or acrocyanosis, it is necessary to give oxygen and monitor the baby’s condition.

How is primary resuscitation performed?

Be sure to wash and treat your hands with antiseptic and wear sterile gloves. The time of birth of the child is recorded, and after the necessary measures are taken, it is documented. The newborn is placed under a heat source and wrapped in a dry, warm diaper.

To restore airway patency, you can lower the head end and place the child on his left side. This will stop the aspiration process and allow the contents of the mouth and nose to be removed. Carefully suck out the contents without resorting to deep insertion of the aspirator.

If such measures do not help, resuscitation of the newborn continues by sanitation of the trachea using a laryngoscope. After breathing appears, but there is no rhythm, the child is transferred to mechanical ventilation.

The neonatal intensive care unit admits the child after initial resuscitation measures to provide further assistance and maintain vital functions.

Ventilation

The stages of neonatal resuscitation include ventilation:

• lack of breathing or the appearance of convulsive respiratory movements;
• pulse less than 100 times per minute, regardless of breathing status;
• persistent cyanosis during normal functioning of the respiratory and cardiovascular systems.

This set of measures is carried out using a mask or bag. The newborn's head is tilted back slightly and a mask is placed on the face. It is held with the index fingers and thumbs. The rest is used to remove the child's jaw.

The mask should be on the chin, nose and mouth. It is enough to ventilate the lungs at a frequency of 30 to 50 times per minute. Ventilating with a bag may cause air to enter the stomach cavity. You can remove it from there using

To monitor the effectiveness of the exercise, you need to pay attention to the rise of the chest and changes in heart rate. The child continues to be monitored until the breathing rhythm and heartbeat are completely restored.

Why and how is intubation performed?

Primary resuscitation of newborns also includes tracheal intubation, if mechanical ventilation is ineffective for 1 minute. The correct choice of tube for intubation is one of the important points. It is done depending on the baby’s body weight and gestational age.

Intubation is also performed in the following cases:

• the need to remove meconium aspiration from the trachea;
• carrying out prolonged ventilation;
• facilitating the management of resuscitation measures;
• injection of adrenaline;
• deep prematurity.

The laryngoscope is illuminated and held in the left hand. The right hand holds the newborn's head. The blade is inserted into the mouth and passed to the base of the tongue. Raising the blade towards the handle of the laryngoscope, the resuscitator sees the glottis. The intubation tube is inserted from the right side into the oral cavity and passed through the vocal cords at the moment they open. This happens while inhaling. The tube is carried out to the planned mark.

The laryngoscope is removed, then the guidewire. The correct insertion of the tube is checked by squeezing the breathing bag. Air enters the lungs and causes chest excursion. Next, the oxygen supply system is connected.

Indirect cardiac massage

Resuscitation of a newborn in the delivery room includes that indicated when the heart rate is less than 80 beats per minute.

There are two ways to perform indirect massage. When using the first, pressure on the chest is carried out using the index and middle finger of one hand. In another version, the massage is carried out with the thumbs of both hands, and the remaining fingers are involved in supporting the back. The resuscitator-neonatologist applies pressure at the border of the middle and lower third of the sternum so that the chest sag by 1.5 cm. The frequency of pressure is 90 per minute.

It is imperative to ensure that inhalation and pressing on the chest are not carried out simultaneously. During the pause between pressures, you cannot remove your hands from the surface of the sternum. Pressing the bag is done after every three pressures. For every 2 seconds you need to perform 3 pressures and 1 ventilation.

Actions in case of water contamination with meconium

Features of neonatal resuscitation include assistance with meconium staining of amniotic fluid and an Apgar score of less than 6 points for the child.

1. During childbirth, after the head appears from the birth canal, immediately aspirate the contents of the nasal and oral cavity.
2. After birth and placing the baby under a heat source, before the first breath, it is advisable to perform intubation with a tube of the largest possible size in order to extract the contents of the bronchi and trachea.
3. If it is possible to extract the contents and it contains an admixture of meconium, then it is necessary to reintubate the newborn with another tube.
4. Ventilation is established only after all contents have been removed.

Drug therapy

Pediatric neonatal resuscitation is based not only on manual or hardware interventions, but also on the use of medications. In the case of mechanical ventilation and indirect massage, when the measures are ineffective for more than 30 seconds, medications are used.

Resuscitation of newborns involves the use of adrenaline, means to restore circulating blood volume, sodium bicarbonate, naloxone, and dopamine.

Adrenaline is injected through an endotracheal tube into the trachea or into a vein. The concentration of the drug is 1:10,000. The drug is used to increase the force of heart contraction and accelerate the heart rate. After endotracheal administration, mechanical ventilation is continued so that the drug can be evenly distributed. If necessary, the product is administered after 5 minutes.

Calculation of the drug dose depending on the child’s weight:

• 1 kg - 0.1-0.3 ml;
• 2 kg - 0.2-0.6 ml;
• 3 kg - 0.3-0.9 ml;
• 4 kg - 0.4-1.2 ml.

If blood loss or need to be replaced, albumin, saline sodium chloride solution or Ringer's solution are used. The drugs are injected into the umbilical cord vein in a stream (10 ml per 1 kg of the child’s body weight) slowly over 10 minutes. The introduction of BCC replenishers allows you to increase blood pressure, reduce the level of acidosis, normalize the pulse rate and improve tissue metabolism.

Resuscitation of newborns with effective ventilation requires administration of sodium bicarbonate into the umbilical vein to reduce signs of acidosis. The drug should not be used until adequate ventilation of the child’s lungs has been established.

Dopamine is used to increase cardiac index and glomerular filtration rate. The drug dilates renal vessels and increases sodium clearance when using infusion therapy. It is administered intravenously via a micro-jet under constant monitoring of blood pressure and heart rate.

Naloxone is administered intravenously at the rate of 0.1 ml of the drug per 1 kg of the child’s body weight. The drug is used when skin color and pulse are normal, but there are signs of respiratory depression. A newborn should not be given naloxone when the mother is using narcotic drugs or undergoing treatment with narcotic analgesics.

When to stop resuscitation?

Ventilation continues until the child scores 6 Apgar points. This assessment is carried out every 5 minutes and lasts up to half an hour. If after this time the newborn has an indicator of less than 6, then he is transferred to the ICU of the maternity hospital, where further resuscitation and intensive care of newborns are carried out.

If the effectiveness of resuscitation measures is completely absent and asystole and cyanosis are observed, then the measures continue for up to 20 minutes. When even the slightest signs of effectiveness appear, their duration is increased for as long as the measures provide a positive result.

Neonatal intensive care unit

After successful restoration of lung and heart function, the newborn is transferred to the intensive care unit. There, the work of doctors is aimed at preventing possible complications.

A newborn after resuscitation needs to prevent the occurrence of brain swelling or other central nervous system disorders, restore kidney function and excretory function of the body, and normalize blood circulation.

The child may develop metabolic disorders in the form of acidosis, lactic acidosis, which is caused by disturbances in peripheral microcirculation. From the side of the brain, the appearance of convulsive attacks, hemorrhage, cerebral infarction, edema, development may also occur. Violations of the function of the ventricles of the heart, acute kidney failure, atony of the bladder, insufficiency of the adrenal glands and other endocrine organs may also appear.

Depending on the baby’s condition, he is placed in an incubator or an oxygen tent. Specialists monitor the functioning of all organs and systems. The child is allowed to feed only after 12 hours, in most cases - after

Mistakes that are prohibited

It is strictly prohibited to carry out activities whose safety has not been proven:

• pour water over the baby;
• squeeze his chest;
• strike the buttocks;
• direct a stream of oxygen into the face and the like.

Albumin solution should not be used to increase the initial volume of blood volume, as this increases the risk of death in the newborn.

Carrying out resuscitation measures does not mean that the baby will have any abnormalities or complications. Many parents expect pathological manifestations after the newborn has been in intensive care. Reviews of such cases show that in the future children have the same development as their peers.

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 airways from obstacles: recessed root of the tongue, accumulation of mucus, blood, vomit and other foreign bodies;
2. Breath for victim (“breathing for the victim”) means mechanical ventilation;
3. Circulation his blood (“circulation of his blood”) means performing indirect or direct cardiac massage.

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

• the victim is placed on a rigid base supine (face up), and if possible, in the Trendelenburg position;
• straighten the head in the cervical region, bring the lower jaw forward and at the same time open the victim’s mouth (triple maneuver by R. Safar);
• free the patient's mouth from various foreign bodies, mucus, vomit, blood clots using a finger wrapped in a scarf and suction.

Having ensured airway patency, begin mechanical ventilation immediately. There are several main methods:

• indirect, manual methods;
• methods of directly blowing air exhaled by a resuscitator into the victim’s respiratory tract;
• hardware methods.

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

The advantage of direct inflation methods for the victim’s lungs is that a lot of air (1-1.5 liters) is introduced with one breath, with active stretching of the lungs (Hering-Breuer reflex) and the introduction of an air mixture containing an increased amount of carbon dioxide (carbogen) , the patient's respiratory center is stimulated. The methods used are “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 at the side of the victim. Holding his head in an extended position and holding his nose with two fingers, he tightly covers the victim’s mouth with his lips and makes 2-4 vigorous, not rapid (within 1-1.5 s) exhalations in a row (excursion of the patient’s chest should be noticeable). An adult is usually provided with up to 16 respiratory cycles per minute, a child - up to 40 (taking into account age).

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

Typically, mechanical ventilation is combined with external, indirect cardiac massage, achieved through 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, it is a conventional 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 occurs per 3-4 chest compressions; in older children and adults, this ratio is 1:5.

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

Due to incorrect positioning of the resuscitator's hands and 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 and multiple rib fractures.

Specialized cardiopulmonary resuscitation includes more adequate mechanical ventilation techniques, as well as intravenous or intratracheal administration of medications. When administered intratracheally, the dose of drugs should be 2 times higher in adults, and 5 times higher in infants, than when administered intravenously. Intracardiac administration of drugs is not currently practiced.

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

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

• adrenaline (0.1% solution); 1st dose - 0.01 ml/kg, subsequent doses - 0.1 ml/kg (every 3-5 minutes until the effect is achieved). When administered intratracheally, the dose is increased;
• atropine (in asystole is ineffective) is usually administered after adrenaline and ensuring adequate ventilation (0.02 ml/kg of 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 8.4% solution. The drug can be administered again only under the supervision of CBS;
• dopamine (dopamine, dopmin) is used after restoration of cardiac activity against the background of unstable hemodynamics at a dose of 5-20 mcg/(kg min), to improve diuresis 1-2 mcg/(kg min) for a long time;
• lidocaine is administered after restoration of cardiac activity against the background of post-resuscitation ventricular tachyarrhythmia as a 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 mcg/(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 discharge is 2 J/kg, subsequent ones - 4 J/kg; the first 3 discharges can be done in a row without monitoring with an ECG monitor. If the device has a different scale (voltmeter), the 1st digit in infants should be in the range of 500-700 V, repeated ones - 2 times more. In adults, 2 and 4 thousand, respectively. V (maximum 7 thousand V). The effectiveness of defibrillation is increased by repeated administration of the entire complex of drug therapy (including a polarizing mixture, and sometimes magnesium sulfate, aminophylline);

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

• adrenaline intravenously, intratracheally (if catheterization is impossible after 3 attempts or within 90 s); 1st dose 0.01 mg/kg, subsequent doses - 0.1 mg/kg. Administration 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);
• fluid to replenish the central nervous system; It is better to use a 5% solution of albumin or stabizol, you can use rheopolyglucin in a dose of 5-7 ml/kg quickly, drip-wise;
• atropine at a dose of 0.02-0.03 mg/kg; possible repeated administration 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 means of therapy are ineffective, electrical cardiac pacing (external, transesophageal, endocardial) is performed immediately.

If in adults ventricular tachycardia or ventricular fibrillation are the main forms of circulatory arrest, then in young children they are observed extremely rarely, so 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 brain stem functions, brain death is diagnosed. The latter is equated to the death of the organism as a whole.

Currently, there are no legal grounds for stopping initiated and actively ongoing intensive care in children before natural circulatory arrest. Resuscitation does not begin and is not carried out in the presence of a chronic disease and pathology incompatible with life, which is determined in advance 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 in case of 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 function, sometimes simultaneously and respiratory function (primary revival) in at least half of the victims, but in the future, preservation of life in patients is much less common. The reason for this is post-resuscitation illness.

The outcome of recovery is largely determined by the conditions of the blood supply to the brain in the early post-resuscitation period. In the first 15 minutes, 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. Repeated deterioration of cerebral circulation may occur 2-4 days or 2-3 weeks after CPR against the background of almost complete restoration of central nervous system function - delayed posthypoxic encephalopathy syndrome. By the end of the 1st to the beginning of the 2nd day after CPR, a repeated decrease in blood oxygenation may be observed, associated with nonspecific lung damage - respiratory distress syndrome (RDS) and the development of shunt-diffusion respiratory failure.

Complications of post-resuscitation illness:

• in the first 2-3 days after CPR - swelling 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 post-resuscitation period (1-2 weeks) intensive therapy
• is carried out against the background of impaired consciousness (somnolence, stupor, coma) of mechanical ventilation. Its main tasks in this period are stabilization of hemodynamics and protection of the brain from aggression.

Restoration of the central nervous system and rheological properties of blood is carried out with hemodilutants (albumin, protein, dry and native plasma, rheopolyglucin, saline solutions, less often a polarizing mixture with the administration of insulin at the rate of 1 unit per 2-5 g of dry glucose). Plasma protein concentration should be at least 65 g/l. Improved gas exchange is achieved by restoring the oxygen capacity of the blood (transfusion of red blood cells), mechanical ventilation (with the oxygen concentration in the air mixture preferably less than 50%). With reliable restoration of spontaneous breathing and stabilization of hemodynamics, it is possible to carry out HBOT, for a course of 5-10 procedures daily at 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 ensured by small doses of dopamine (1-3 mcg/kg per minute for a long time) and maintenance cardiotrophic therapy (polarizing mixture, panangin). Normalization of microcirculation is ensured by effective pain relief for injuries, neurovegetative blockade, administration of antiplatelet agents (Curantyl 2-3 mg/kg, heparin up to 300 IU/kg per day) and vasodilators (Cavinton up to 2 ml drip or Trental 2-5 mg/kg per day drip, Sermion , aminophylline, nicotinic acid, complamin, etc.).

Antihypoxic therapy is carried out (Relanium 0.2-0.5 mg/kg, barbiturates in a saturation dose of up to 15 mg/kg on the 1st day, on subsequent days - up to 5 mg/kg, GHB 70-150 mg/kg after 4-6 hours , enkephalins, opioids) and antioxidant (vitamin E - 50% oil solution at a dose of 20-30 mg/kg strictly intramuscularly daily, for a course of 15-20 injections) therapy. To stabilize membranes and normalize blood circulation, large doses of prednisolone, metipred (up to 10-30 mg/kg) are prescribed intravenously as a bolus or in fractions over 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 VEO, CBS and energy metabolism is carried out. Detoxification therapy is carried out (infusion therapy, hemosorption, plasmapheresis according to indications) to prevent toxic encephalopathy and secondary toxic (autotoxic) organ damage. Intestinal decontamination with aminoglycosides. Timely and effective anticonvulsant and antipyretic therapy in young children prevents the development of post-hypoxic encephalopathy.

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

If the patient quickly recovers from a critical condition (within 1-2 hours), the complex of therapy and its duration should be adjusted depending on the clinical manifestations and the presence of post-resuscitation illness.

Treatment in the late post-resuscitation period

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

• The administration of drugs that reduce metabolic processes in the brain is reduced.
• Drugs that stimulate metabolism are prescribed: cytochrome C 0.25% (10-50 ml/day 0.25% solution in 4-6 doses depending on age), Actovegin, solcoseryl (0.4-2.00 intravenous drips for 5 % glucose solution for 6 hours), piracetam (10-50 ml/day), Cerebrolysin (up to 5-15 ml/day) for older children intravenously during the day. Subsequently, encephabol, acephen, and nootropil are prescribed orally for a long time.
• 2-3 weeks after CPR, a (primary or repeated) course of HBO therapy is indicated.
• The introduction of antioxidants and disaggregants is continued.
• Vitamins B, C, multivitamins.
• Antifungal drugs (Diflucan, Ancotil, Candizol), biological products. Discontinuation of antibacterial therapy if indicated.
• Membrane stabilizers, physiotherapy, physical therapy (physical therapy) and massage according to indications.
• General restorative therapy: vitamins, ATP, creatine phosphate, biostimulants, adaptogens in long-term 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 initially develop tachycardia. In newborns and children with a heart rate less than 60 beats per minute and signs of low organ perfusion in the absence of improvement after the start of artificial respiration, closed cardiac massage should be performed.

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

Blood pressure must be measured with a correctly sized cuff; invasive blood pressure measurement is indicated only in cases of extreme severity of the child.

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

Equipment and external conditions

Equipment size, drug dosage, and CPR parameters 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 for the age of 2 years is prescribed.

In newborns and children, heat transfer is increased due to the larger body surface area relative to body weight and the small amount of subcutaneous fat. The ambient temperature during and after cardiopulmonary resuscitation should be constant, ranging 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 effect of hypothermia in the post-resuscitation period).

Rhythm disturbances

For asystole, atropine and artificial rhythm stimulation are not used.

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

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