Cardiopulmonary resuscitation in newborns and children

Cardiopulmonary resuscitation (CPR) is a specific algorithm for restoring or temporarily replacing lost or significantly impaired heart and respiratory function. Restoring the activity of the heart and lungs, the reanimator ensures the maximum possible safety of the brain of the victim in order to avoid social death (complete loss of viability of the cerebral cortex). Therefore, a perishable term is possible - cardiopulmonary and cerebral resuscitation. Primary cardiopulmonary resuscitation in children is performed directly at the scene by any person who knows the elements of CPR technique.

Despite carrying out cardiopulmonary resuscitation, mortality in stopping blood circulation in newborns and children remains at the level of 80-97%. With an isolated respiratory arrest, the mortality rate is 25%.

About 50-65% of children requiring cardiopulmonary resuscitation are age group under the age of one year; of them the majority is less than 6 months old. About 6% of newborns after birth need cardiopulmonary resuscitation; especially if the weight of the newborn is less than 1500 g.

It is necessary to create a system for assessing outcomes of cardiopulmonary resuscitation in children. An example is the Pittsburgh Outcome Categories Scale (Pittsburgh Outcome Categories Scale) score based on the evaluation of the general condition and function of the central nervous system.

[1], [2]

Carrying out cardiopulmonary resuscitation in children

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

1. Aire way "open the way to air" means the need to clear the airways of obstacles: the rooting of the tongue, the accumulation of mucus, blood, vomit, and other foreign bodies;
2. Breath for victim ("breathing for the injured") means ventilator;
3. Circulation his blood ("circulation of his blood") means conducting an indirect or direct massage of the heart.

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

• the victim is placed on a hard base on his back (upward face), and if possible - in Trendelenburg position;
• unbend the head in the cervical region, lower the jaw forward and simultaneously open the mouth of the victim (triple reception of R. Safar);
• free the patient's mouth from various foreign bodies, mucus, vomit, blood clots with a finger wrapped in a handkerchief, sucking.

By ensuring the patency of the airways, immediately proceed to the ventilation. There are several basic methods:

• indirect, manual methods;
• methods of direct injection of air, exhaled by the reanimator, in the respiratory tract of the victim;
• hardware methods.

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

The advantage of methods of direct inflation of the lungs in the victim is that with a single inhalation, a lot of air (1-1.5 l) is injected, with active stretching of the lungs (Goring-Breyer reflex) and the introduction of an air mixture containing an increased amount of carbon dioxide (carbogen) , the respiratory center of the patient is stimulated. Methods are used "from mouth to mouth", "from mouth to nose", "from mouth to nose and mouth"; The latter method is usually used for resuscitation of young children.

The rescuer is kneeling on the side of the victim. Holding his head in the unbent position and holding his nose with his two fingers, he tightly covers the lips of the victim and makes a contract of 2-4 energetic, not fast (for 1-1.5 s) exhalation (there should be a noticeable excursion of the chest of the patient). The adult is usually provided with up to 16 respiratory cycles per minute, the child up to 40 (including age).

Devices of artificial ventilation differ in the complexity of the design. At the pre-hospital stage, self-dispensing bags of the Ambu type can be used, simple mechanical devices such as Pnevmat or constant air flow interrupters, for example using the Eyre method (via a tee with a finger). In hospitals, sophisticated electromechanical devices are used to provide mechanical ventilation for a long period (weeks, months, years). Short-term forced ventilation is provided through a nasopharyngeal mask, prolonged - through the intubation or tracheotomy tube.

Usually, ventilation is combined with external, indirect heart massage, achieved by compression - chest compression in the transverse direction: from the sternum to the spine. In older children and adults, this is the boundary between the lower and middle third of the sternum, in young children - a conditional line that runs one transverse finger above the nipples. The incidence of chest compressions in adults is 60-80, in infants - 100-120, in newborns - 120-140 per minute.

Infants have one inhalation for 3-4 chest compressions, in older children and adults this ratio is 1: 5.

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

Due to improper placement of the hands of the reanimator and with excessive efforts, cardiopulmonary resuscitation complications are possible: fractures of the ribs and sternum, damage to the internal organs. Direct cardiac massage is done with cardiac tamponade, multiple fractures of the ribs.

Specialized cardiopulmonary resuscitation includes more adequate methods of IVL, as well as intravenous or intratracheal administration of medications. With intracerepal administration, the dose of drugs should be 2 times in adults, and in infants 5 times higher than with intravenous administration. Intradermal administration of drugs is not currently practiced.

The condition for the success of cardiopulmonary resuscitation in children is the release of the airways, 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 intubation tube. VA Mikhelson et al. (2001) supplemented the rule of "ABC" R. Safar with 3 letters: D (Drag) - drugs, E (ECG) - electrocardiographic control, F (Fibrillation) - defibrillation as a method of treatment of cardiac arrhythmias. Modern cardiopulmonary resuscitation in children is unthinkable without these components, but the algorithm for their use depends on the variant of cardiac dysfunction.

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

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

Defibrillation is performed against the background of ventricular fibrillation or ventricular tachycardia in the absence of a pulse on the carotid or brachial artery. The power of the 1st category is 2 J / kg, the subsequent - 4 J / kg; The first 3 digits can be done in a row without controlling the ECG monitor. If another scale (voltmeter) is used on the device, the first digit in infants should be within 500-700 V, repeated - in 2 times more. In adults, respectively 2 and 4 thousand. B (maximum 7 thousand V). The effectiveness of defibrillation is enhanced by the repeated introduction of the entire set of medications (including polarizing mixture, and sometimes sulfate magnesia, euphyllin);

With EMD in children with a lack of pulse on the carotid and brachial arteries, the following methods of intensive therapy are used:

• epinephrine intravenously, intratracheally (if it is impossible to catheterize with 3 attempts or within 90 s); The first dose is 0.01 mg / kg, the subsequent dose is 0.1 mg / kg. Introduction of the drug is repeated every 3-5 minutes until the effect is obtained (restoration of hemodynamics, pulse), then - in the form of enfusions in a dose of 0.1-1.0 mkg / (kgmin);
• liquid for replenishment of the VCP; it is better to apply a 5% solution of albumin or stabilazole, you can rheopolyglucin in a dose of 5-7 ml / kg quickly, drip;
• atropine in a dose of 0.02-0.03 mg / kg; possible repeated administration in 5-10 minutes;
• sodium bicarbonate - usually 1 time 1 ml 8.4% solution intravenously slowly; the effectiveness of its introduction is questionable;
• with ineffectiveness of the listed therapy - electrocardiostimulation (external, transesophageal, endocardial) without delay.

If in adults ventricular tachycardia or ventricular fibrillation are the main forms of cessation of circulation, in infants, they are extremely rare, so they are almost not used for defibrillation.

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

Currently, there is no legal basis for stopping initiated and actively conducted intensive therapy in children before the natural stop of blood circulation. 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 the doctors' consultation, and also in the presence of objective signs of biological death (corpse stains, rigor mortis). In all other cases, cardiopulmonary resuscitation in children should begin with any sudden cardiac arrest and follow all the rules described above.

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

With successful cardiopulmonary resuscitation in children, it is possible to restore cardiac, and sometimes simultaneous, respiratory function (primary recovery) to at least half of the victims, but further survival of patients is much less frequent. The reason for this is postresuscitative disease.

The outcome of the revival largely determines the conditions of the blood supply to the brain in the early postresuscitation period. In the first 15 minutes, the blood flow can exceed the initial blood flow by 2-3 times, after 3-4 hours, it falls by 30-50% in combination with an increase in vascular resistance by 4 times. Repeated worsening of cerebral circulation may occur after 2-4 days or 2-3 weeks after CPR on the background of almost complete recovery of the CNS function - a syndrome of delayed posthypoxic encephalopathy. By the end of the first and second days after CPR, a repeated decrease in blood oxygenation can be observed associated with non-specific lung involvement - respiratory distress syndrome (RDS) and the development of shunt diffusion respiratory failure.

Complications of postresuscitative disease:

• in the first 2-3 days after CPR - edema of the brain, lungs, increased bleeding tissues;
• 3-5 days after CPR - impaired functions of the parenchymal organs, development of a manifest multi-organ failure (PON);
• in later terms - inflammatory and suppuration processes. In the early postresuscitation period (1-2 weeks) intensive therapy
• is performed against the background of impaired consciousness (somnolentia, sopor, coma) IVL. Its main tasks in this period are the stabilization of hemodynamics and protection of the brain from aggression.

The restoration of the cerebral circulation and the rheological properties of the blood is carried out by hemodilutants (albumin, protein, dry and native plasma, reopolyglucin, saline solutions, less often a polarizing mixture with insulin administration at the rate of 1 ED per 2-5 g of dry glucose). The concentration of protein in the plasma should not be less than 65 g / l. Better gas exchange is achieved by restoring the oxygen capacity of the blood (transfusion of erythrocyte mass), ventilation (with an oxygen concentration in the air mixture, preferably less than 50%). With a reliable recovery of spontaneous breathing and stabilization of hemodynamics, it is possible to perform HBO on 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.). Maintenance of blood circulation is provided by small doses of dopamine (1-3 μg / kg per minute for a long time), maintenance cardiotrophic therapy (polarizing mixture, panangin). Normalization of microcirculation is provided by effective analgesia in traumas, neurovegetative blockade, administration of antiaggregants (curantil 2-Zmg / kg, heparin up to 300 U / kg per day) and vasodilators (cavinton up to 2 ml drip or trental 2-5 mg / kg per day drip, sermion , euphyllin, nicotinic acid, complamine, etc.).

An antihypoxic (Relanium 0.2-0.5 mg / kg, barbiturates in a saturation dose of up to 15 mg / kg for 1 day, in the subsequent - up to 5 mg / kg, GHB 70-150 mg / kg after 4-6 hours , enkephalins, opioids) and antioxidant (vitamin E - 50% oily solution in a dose of 20-30 mg / kg strictly intramuscularly daily, for a course of 15-20 injections) therapy. For the stabilization of membranes, normalization of blood circulation, intravenously prescribed large doses of prednisolone, metipreda (up to 10-30 mg / kg) bolus or fractional for 1 day.

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

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

It is necessary to prevent and treat decubitus (treatment with camphor oil, kuriozinom places with impaired microcirculation), hospital infection (aseptic).

In case of fast exit of the patient from a critical condition (for 1 to 2 hours), the therapy complex and its duration should be corrected depending on the clinical manifestations and the presence of postresuscitative disease.

[3]

Treatment in the late postresuscitation period

Therapy in the late (subacute) postresuscitation period is long - months and years. Its main direction is the restoration of brain function. Treatment is carried out together with neuropathologists.

• Reduced the introduction of drugs that reduce metabolic processes in the brain.
• Assign drugs that stimulate metabolism: cytochrome C 0.25% (10-50 ml / day 0.25% solution in 4-6 receptions, depending on age), actovegin, solcoseryl (0.4-2, Og intravenously drip 5 % solution of glucose for 6 hours), piracetam (10-50 ml / day), cerebrolysin (up to 5-15 ml / day) for older children intravenously by day. In the subsequent appoint encephabol, acefen, nootropil inside long.
• After 2-3 weeks after CPR, a primary (or repeated) course of HBO therapy is indicated.
• Continue the introduction of antioxidants, disaggregants.
• Vitamins of group B, C, multivitamins.
• Antifungal drugs (diflucan, ankotil, kandizol), biological products. Termination of antibiotic therapy according to indications.
• Membrane stabilizers, physiotherapy, exercise therapy (LFK) and massage according to indications.
• General strengthening therapy: vitamins, ATP, creatine phosphate, biostimulants, adaptogens for a long time courses.

The main differences between cardiopulmonary resuscitation in children and adults

Conditions preceding the arrest of the circulation

Bradycardia in a child with respiratory disorders is a sign of stopping blood circulation. In newborns, infants and young children, a bradycardia develops in response to hypoxia, while in older children, tachycardia first develops. In newborns and children with a heart rate of less than 60 per minute and signs of low organ perfusion, if there is no improvement after the onset of artificial respiration, closed heart massage should be performed.

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

BP must be measured correctly sized cuff, the measurement of invasive blood pressure is indicated only at the extreme severity of the child.

Since the index of blood pressure depends on age, it is easy to remember the lower limit of the norm as follows: less than 1 month - 60 mm Hg. P. 1 month - 1 year - 70 mm Hg. P. 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 thanks to powerful compensatory mechanisms (increased heart rate and peripheral vascular resistance). However, immediately after hypotension, cardiac arrest and respiration occur very quickly. Therefore, before the onset of hypotension, all efforts should be directed to the treatment of shock (manifestations of which are an increase in heart rate, cold extremities, capillary filling more than 2 seconds, weak peripheral pulse).

[4], [5], [6], [7], [8], [9]

Equipment and external conditions

The size of the equipment, the dosage of the drugs and the parameters of the cardiopulmonary resuscitation depend on the 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 age 2 years is prescribed.

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

[10], [11]

Airways

Children have peculiarities of the structure of the upper respiratory tract. The size of the tongue relative to the oral cavity is disproportionately large. The larynx is located higher and more inclined forward. The epiglottis is long. The narrowest part of the trachea is located below the vocal cords at the level of the cricoid cartilage, which makes it possible to use tubes without a cuff. A straight blade of the laryngoscope makes it possible to better visualize the vocal slit, since the larynx is located more ventrally and the epiglottis is very mobile.

Rhythm disturbances

With asystole, atropine and artificial imposition of rhythm are not used.

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

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