Lecia 4 MASAJUL CARDIACEXTERN Programul de Reanimare Neonatal. Kit de Slide-uriAcademia American de Pediatrie nu este responsabil de nici una din modificrile aduse acestui program de Echipa de Training in Reanimarea Neonatal a Latter-day Saints Charities. Acest program, modificat astfel, nu poate fi distribuit n Statele Unite

Masajul Cardiac ExternConinutul leciei:Cnd s ncepei masajul cardiac n timpul unei reanimriCum s administrai masajul cardiac externCum s coordonai masajul cardiac extern cu ventilaia cu presiune pozitivCnd s oprii masajul cardiac extern

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Indicaiile pentru Masajul Cardiac ExternFrecvena cardiac mai mic de 60 bpm n pofida a 30 de secunde de ventilaie cu presiune pozitiv (VPP) eficient

p. 135

Masajul cardiac:Comprim imima pe coloana vertebralCrete presiunea intratoracicCircul sngele spre organele vitale, inclusiv creierulp. 136Facei click pe imagine pentru video

Masajul Cardiac: Este nevoie de 2 PersoaneO persoan continu ventilaia i st la capul copiluluiCea de-a doua persoan comprim toracele de pe o parte sau de la capul patuluip. 137

Comparaie a Tehnicilor de Masaj Cardiac Tehnica policelui (Preferat)Asigur o presiune mai consistentUn control mai bun al profunzimii compresiei

Tehnica celor dou degeteMai bun pentru cei cu mini miciAsigur acces la bontul ombilical pentru administrare de medicaie

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Masajul Cardiac: Poziionarea Policelor sau DegetelorPlimbai degetele pe marginea inferioar a coastelor, pn cnd este localizat apendicele xifoid

Plasai degetele pe stern deasupra procesului xifoid i sub linia intermamelonar

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Masajul Cardiac:Tehnica Policelui

nconjurai toracele cu ambele miniPolicele comprim sternulCelelalte degete susin spatele

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Masajul Cardiac: Tehnica celor 2 Degete

Vrfurile degetului mijlociu i index sau inelar de la o mn comprim sternulCealalt mn susine spatele

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Masajul cardiac:Presiune i Profunzime

p. 141Comprimai sternul cu o treime din diametrul antero-posterior al toraceluiinei policele sau degetele n contact cu toracele

Masajul Cardiac: ComplicaiiLaceraia ficatului

Coaste rupte

p. 142Coaste fracturate pot leza structurilesubiacenteHemoragie sau pneumotoraxInimaPlamniFicat

Masajul cardiac: Coordonare cu VentilaiaFacei click pe imagine pentru videop. 143

Masajul cardiac: Coordonare cu VentilaiaUn ciclu de 3 compresii i o respiraie dureaz 2 secundeFrecvena respiratorie este 30 de respiraii pe minut i frecvena compresiilor este de 90 de compresii pe minut. Aceasta nseamn un numr total de 120 evenimente pe minut

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Oprirea masajuluiDup 45-60 secunde de masaj cardiac i ventilaie, oprii i verificai din nou frecvena cardiacp. 145

Masaj Cardiac: Frecvena Cardiac Rmne mai mic de 60 bpmEste ventilaia adecvat?Se administreaz oxigen suplimentar?Este profunzimea masajului cardiac adecvat?Este masajul coordonat cu VPP?Luai n considerare intubaiaLuai n considerare administrarea de adrenalin p. 146

Sfritul Leciei 4

**In Lesson 4 you will learn When to begin chest compressions during a resuscitation How to administer chest compressions How to coordinate chest compressions with positive-pressure ventilation When to stop chest compressions*When chest compressions are indicated, the newborn probably has very low blood oxygen levels and significant acidosis. The myocardium is depressed and unable to contract strongly enough to pump blood to the lungs. Chest compressions will mechanically pump blood through the heart while ventilation continues.

Instructor Tip: Even experienced resuscitators are concerned at the point when a baby requires chest compressions. Talk to each other and calmly plan your next steps. Concentrate on the tasks at hand and anticipate the need for additional help to record events, insert an orogastric tube if not already done, prepare for intubation if not already done, prepare for administration of epinephrine, and prepare for establishment of an umbilical venous line.*Chest compressions, sometimes referred to as external cardiac massage, consist of rhythmic compressions of the sternum that

Compress the heart against the spine. Increase the intrathoracic pressure. Circulate blood to the vital organs.

The heart lies between the lower third of the sternum and the spine. Compressing the sternum compresses the heart and increases the pressure in the chest, causing blood to be pumped into the arteries.*Two people are required to administer chest compressionsone to compress the chest and one to continue ventilation. These 2 people need to coordinate their activities. The person administering chest compressions must have access to the chest and be able to position his or her hands correctly. The person assisting ventilation will need to be positioned at the newborns head to achieve an effective face-mask seal (or to stabilize the endotracheal tube), ventilate appropriately, and watch for effective chest movement.*With the thumb technique, the 2 thumbs are used to depress the sternum while the hands encircle the torso and the fingers support the spine.

With the 2-finger technique, the tips of the middle finger and either the index or ring finger of one hand are used to compress the sternum. The other hand is used to support the newborns back so that the heart is more effectively compressed between the sternum and spine. With the second hand supporting the back, you can feel the pressure and depth of compressions.

Instructor Tip: The requirement to put your hand under the newborns back also serves to keep you focused on the task at hand, and prevents someone from expecting you to reach for equipment or to do other tasks with your spare hand.

*Run your fingers along the lower edge of the rib cage until you locate the xyphoid. Place your thumbs or fingers on the sternum, immediately above the xyphoid. Pressure is applied to the lower third of the sternum. Care must be used to avoid applying pressure to the xyphoid, which is a small projection where the lower ribs meet at the midline.

*The thumb technique is accomplished by encircling the torso with both hands and placing the thumbs on the sternum and the fingers under the babys back, supporting the spine. The thumbs can be placed side by side or, on a small baby, one over the other.

*Position the 2 fingers perpendicular to the chest, as shown, and press vertically with your fingertips.

When compressing the chest, only the 2 fingertips should rest on the chest. This gives the best control of the pressure applied to the sternum.

If you rest other portions of your hand on the chest, you can restrict chest expansion during ventilation and apply pressure to the vulnerable area of the chest, risking a pneumothorax or fractured ribs.*Care must be taken to not squeeze the chest (ribs) with your whole hand during compression. If the chest is squeezed, fractured ribs or a pneumothorax may result.

The thumb technique cannot be used effectively if the newborn is large or your hands are small. However, you may find the thumb technique less tiring than the 2-finger technique if chest compressions are required for a prolonged period.

The thumb technique makes access to the umbilical cord more difficult when intravenous medications become necessary.

Instructor Tip: Its easy for a nervous resuscitator to inadvertently squeeze the newborns chest or to hold on tightly during and between compressions. All members of the team should watch each others technique and calmly make suggestions for modification if necessary. Remember that parents may be listening and trying to interpret your comments. Rather than saying, Jane, youre squeezing his chest and I cant ventilate. It would be better to say, Jane, loosen your hands a little. *As you perform chest compressions, you must apply enough pressure to compress the heart between the sternum and spine without damaging underlying organs. Potential complications can occur.

The ribs are fragile and can be easily broken.

Pressure over the lower tip of the sternum (xyphoid) can lead to laceration of the liver.*During resuscitation, chest compressions always must be accompanied by positive-pressure ventilation with 100% oxygen. Avoid giving compressions and ventilation simultaneously, because one will decrease the efficacy of the other. Therefore, the 2 activities must be coordinated, with 1 ventilation interposed between every third compression, for a total of 30 breaths and 90 compressions per minute.

The person doing the compressions should take over the counting from the person doing the ventilations. The compressor should count, One-and-Two-and-Three-and Breathe-and, while the person ventilating squeezes during Breathe-and and releases during One-and. Note that exhalation occurs during the downward stroke of the next compression. Counting the cadence will help develop a smooth and well-coordinated procedure.

Instructor Tip: The person ventilating the newborn must be ready to deliver the breath in the moment the compressor says, Breathe. Do not allow a long pause to wait for the breath. The pace is rapid and the ventilator must keep up.

*During chest compressions, the ventilation rate is actually 30 breaths per minute rather than the rate you previously learned for positive-pressure ventilation without compressions, which was 40 to 60 breaths per minute.

This lower ventilatory rate is necessitated by the need to provide an adequate number of compressions, yet avoid simultaneous compressions and ventilation. To ensure that the process can be coordinated, it is important that you practice with another person and practice both roles.

*After approximately 30 seconds of well-coordinated compressions and ventilation, stop for 6 seconds to determine the heart rate again. To determine heart beats per minute, count the beats in 6 seconds and multiply by 10. Announce the actual heart rate (say the heart rate is 70 not I count 7 beats).

If the heart rate is >60 bpm, discontinue chest compressions but continue positive-pressure ventilation at the rate of 40 to 60 breaths per minuteIf the heart rate is >100 bpm and the newborn begins to breathe spontaneously, slowly withdraw positive-pressure ventilation and move the newborn to the nursery for post resuscitation careIf the heart rate is