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