Cardiopulmonary resuscitation in newborns and children

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

Despite cardiopulmonary resuscitation, mortality in cases of circulatory arrest in newborns and children remains at 80-97%. Mortality in cases of isolated respiratory arrest is 25%.

About 50-65% of children requiring CPR are under one year of age; most of them are under 6 months of age. About 6% of newborns require CPR after birth; especially if the newborn weighs less than 1500 g.

It is necessary to create a system for assessing the outcomes of cardiopulmonary resuscitation in children. An example is the assessment according to the modified Pittsburgh Outcome Categories Scale, based on the assessment of the general condition and function of the central nervous system.

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Carrying out cardiopulmonary resuscitation in children

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

1. Aire way open ("open the way for air") means the need to clear the airways of obstructions: retraction of the root of the tongue, accumulation of mucus, blood, vomit and other foreign bodies;
2. Breath for victim means artificial ventilation;
3. 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 hard surface on his back (face up), and if possible, in the Trendelenburg position;
• straighten the head in the cervical region, move the lower jaw forward and simultaneously open the victim’s mouth (R. Safar’s triple technique);
• clear the patient's mouth of various foreign bodies, mucus, vomit, blood clots using a finger wrapped in a handkerchief or suction.

Having ensured the patency of the airways, they immediately begin artificial ventilation. There are several basic methods:

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

The first ones are mainly of historical significance and are not considered at all in modern guidelines on cardiopulmonary resuscitation. At the same time, manual artificial 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, rhythmic compressions (simultaneously with both hands) of the lower ribs of the victim's chest, synchronized with his exhalation, can be used. This technique can be useful during transportation of a patient with severe asthmatic status (the patient lies or semi-sitting with his head thrown back, the doctor stands in front or to the side and rhythmically squeezes his chest from the sides during exhalation). The technique is not indicated for rib fractures or severe airway obstruction.

The advantage of direct lung inflation methods in the victim is that a lot of air (1-1.5 l) is introduced with one breath, with active lung stretching (Hering-Breuer reflex) and 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 resuscitation of young children.

The rescuer kneels at the side of the victim. Holding his head in an extended position and pinching his nose with two fingers, he tightly covers the victim's mouth with his lips and makes 2-4 vigorous, slow (within 1-1.5 seconds) exhalations in a row (the patient's chest excursion should be noticeable). An adult is usually provided with up to 16 breathing cycles per minute, a child - up to 40 (taking into account age).

Ventilators vary in the complexity of their design. At the pre-hospital stage, self-expanding breathing bags such as "Ambu", simple mechanical devices such as "Pneumat" or constant air flow interrupters, for example, according to the Eyre method (through a tee - with a finger) can be used. In hospitals, complex electromechanical devices are used that provide long-term ventilation (weeks, months, years). Short-term forced ventilation is provided through a nasal-oral mask, long-term - through an intubation or tracheotomy tube.

Usually, artificial ventilation is combined with external, indirect cardiac massage, achieved by 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 - an imaginary line passing one transverse finger above the nipples. The frequency of chest compressions in adults is 60-80, in infants - 100-120, in newborns - 120-140 per minute.

In infants, one breath is taken for every 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: rib and sternum fractures, damage to internal organs. Direct cardiac massage is performed in case of cardiac tamponade, multiple rib fractures.

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

The condition for successful cardiopulmonary resuscitation in children is the release of the airways, artificial 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 an intubation tube. V. A. Mikhelson et al. (2001) supplemented R. Safar's "ABC" rule with 3 more letters: D (Drag) - drugs, E (ECG) - electrocardiographic monitoring, F (Fibrillation) - defibrillation as a method of treating cardiac arrhythmia. Modern cardiopulmonary resuscitation in children is unthinkable without these components, but the algorithm for their use depends on the type of cardiac disorder.

In asystole, the following drugs are administered intravenously or intratracheally:

• adrenaline (0.1% solution); 1st dose - 0.01 ml/kg, the following - 0.1 ml/kg (every 3-5 minutes until the effect is achieved). With intratracheal administration, the dose is increased;
• atropine (not very effective in asystole) is usually administered after adrenaline and ensuring adequate ventilation (0.02 ml/kg of 0.1% solution); repeated no more than 2 times at 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 occurred against the background of decompensated metabolic acidosis. The usual dose is 1 ml of 8.4% solution. Repeated administration of the drug can only be done under the control of the acid-base balance;
• dopamine (dopamine, dopmin) is used after restoration of cardiac activity against the background of unstable hemodynamics in 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 by 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 by an ECG monitor. If the device has a different scale (voltmeter), the 1st discharge in infants should be within 500-700 V, repeated ones - 2 times more. In adults, respectively, 2 and 4 thousand 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, euphyllin);

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

• adrenaline intravenously, intratracheally (if catheterization is impossible after 3 attempts or within 90 seconds); 1st dose 0.01 mg/kg, subsequent doses - 0.1 mg/kg. The drug is administered every 3-5 minutes until the effect is achieved (restoration of hemodynamics, pulse), then - in the form of infusions at a dose of 0.1-1.0 mcg/(kgmin);
• fluid to replenish the VCP; it is better to use a 5% solution of albumin or stabizol, you can use rheopolyglucin at a dose of 5-7 ml/kg quickly, by drip;
• atropine at a dose of 0.02-0.03 mg/kg; repeated administration is possible after 5-10 minutes;
• sodium bicarbonate - usually 1 time 1 ml of 8.4% solution intravenously slowly; the effectiveness of its administration is questionable;
• If the above mentioned treatment methods are ineffective, perform electrical cardiac stimulation (external, transesophageal, endocardial) immediately.

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

Currently, there are no legal grounds for stopping the intensive care that has been started and is being actively carried out in children before the natural cessation of blood circulation. Resuscitation is not started or 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 be started with any sudden cardiac arrest and 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 and sometimes simultaneously respiratory functions (primary resuscitation) in at least half of the victims, but subsequently, survival in patients is observed much less frequently. The reason for this is post-resuscitation disease.

The outcome of resuscitation is largely determined by the conditions of the brain blood supply in the early post-resuscitation period. In the first 15 minutes, the blood flow may exceed the initial one by 2-3 times, after 3-4 hours it falls by 30-50% in combination with a 4-fold increase in vascular resistance. Repeated deterioration of cerebral circulation may occur 2-4 days or 2-3 weeks after CPR against the background of almost complete recovery of the central nervous system function - delayed post-hypoxic encephalopathy syndrome. By the end of the 1st - beginning of the 2nd day after CPR, a repeated decrease in blood oxygenation may be observed, associated with non-specific lung damage - respiratory distress syndrome (RDS) and the development of shunt-diffusion respiratory failure.

Complications of post-resuscitation disease:

• in the first 2-3 days after CPR - cerebral and pulmonary edema, increased tissue bleeding;
• 3-5 days after CPR - dysfunction of parenchymal organs, development of manifest multiple organ failure (MOF);
• at later stages - 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) artificial ventilation. Its main tasks in this period are stabilization of hemodynamics and protection of the brain from aggression.

Restoration of the OCP and rheological properties of the blood is carried out by hemodilutants (albumin, protein, dry and native plasma, rheopolyglucin, saline solutions, less often a polarizing mixture with the introduction of insulin at the rate of 1 U per 2-5 g of dry glucose). The concentration of protein in the plasma should be at least 65 g / l. Improvement of gas exchange is achieved by restoring the oxygen capacity of the blood (transfusion of red blood cells), artificial ventilation (with an 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 HBO, 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), maintenance cardiotrophic therapy (polarizing mixture, panangin). Normalization of microcirculation is ensured by effective pain relief in case of injuries, neurovegetative blockade, introduction of antiplatelet agents (curantil 2-3 mg/kg, heparin up to 300 U/kg per day) and vasodilators (cavinton up to 2 ml by drip or trental 2-5 mg/kg per day by drip, sermion, euphyllin, nicotinic acid, complamine, etc.).

Antihypoxic (relanium 0.2-0.5 mg/kg, barbiturates in a saturation dose of up to 15 mg/kg for the first day, then up to 5 mg/kg, GHB 70-150 mg/kg every 4-6 hours, enkephalins, opioids) and antioxidant (vitamin E - 50% oil solution in a dose of 20-30 mg/kg strictly intramuscularly daily, for a course of 15-20 injections) therapy is carried out. To stabilize membranes, normalize blood circulation, large doses of prednisolone, methylprednisolone (up to 10-30 mg/kg) are prescribed intravenously by bolus or fractionally during the first 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, KOS and energy metabolism is carried out. Detoxification therapy (infusion therapy, hemosorption, plasmapheresis as indicated) is carried out to prevent toxic encephalopathy and secondary toxic (autotoxic) organ damage. Decontamination of the intestine with aminoglycosides. Timely and effective anticonvulsant and antipyretic therapy in young children prevents the development of post-hypoxic encephalopathy.

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

In the event of a rapid recovery of the patient from a critical condition (in 1-2 hours), the therapy complex and its duration should be adjusted depending on the clinical manifestations and the presence of post-resuscitation disease.

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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 the restoration of brain function. Treatment is carried out jointly with neurologists.

• The introduction of drugs that reduce metabolic processes in the brain is reduced.
• Prescribed drugs that stimulate metabolism: cytochrome C 0.25% (10-50 ml/day 0.25% solution in 4-6 doses depending on age), actovegin, solcoseryl (0.4-2.0g intravenously by drip in 5% glucose solution for 6 hours), piracetam (10-50 ml/day), cerebrolysin (up to 5-15 ml/day) for older children intravenously during the day. Subsequently, encephabol, acefen, nootropil are prescribed orally for a long time.
• 2-3 weeks after CPR, a course of HBO therapy (primary or repeated) is indicated.
• The administration of antioxidants and antiplatelet agents continues.
• Vitamins B, C, multivitamins.
• Antifungal drugs (Diflucan, Ancotil, Candizol), biopreparations. Discontinuation of antibacterial therapy as indicated.
• Membrane stabilizers, physiotherapy, exercise therapy (ET) and massage as indicated.
• General strengthening therapy: vitamins, ATP, creatine phosphate, biostimulants, adaptogens in long courses.

The main differences between cardiopulmonary resuscitation in children and adults

Conditions preceding circulatory arrest

Bradycardia in a child with respiratory distress is a sign of circulatory arrest. In newborns, infants, and young children, bradycardia develops in response to hypoxia, while in older children, tachycardia occurs initially. In newborns and children with a heart rate of 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 properly sized cuff; invasive blood pressure measurement is only indicated in the case of extreme severity of the child's condition.

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

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Equipment and external conditions

The size of the equipment, the dosage of drugs and the parameters of 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, the dose for the age of 2 years is prescribed.

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

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Respiratory tract

Children have peculiarities in 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 deviates more 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. The straight blade of the laryngoscope allows for better visualization of the glottis, since the larynx is located more ventrally and the epiglottis is very mobile.

Rhythm disturbances

In case of asystole, atropine and artificial rhythm stimulation are not used.

VF and VT with unstable hemodynamics occur 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 needed to a maximum of 4 J/kg at the third discharge.

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