Reanimación neonatal: Lección 4 MASAJE CARDIACO

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Curso de Reanimación neonatal, lección 4 de 9.
Lección 4: MASAJE CARDIACO
American Heart Association. American Academy of Pediatrics.

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  • 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 a newborn becomes hypoxic, the heart rate slows and myocardial contractility decreases. As a result, there is a diminished flow of blood and oxygen to the vital organs.
    The decreased supply of oxygen to these tissues can lead to irreparable damage to the brain, heart, kidneys, and bowel.
    Chest compressions are used to temporarily increase circulation and oxygen delivery.
    Chest compressions should always be accompanied by ventilation with 100% oxygen.
    Ventilation must be performed to ensure that the blood being circulated during chest compressions is oxygenated.
  • 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 compressions—one 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 newborn’s 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 newborn’s 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 newborn’s 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 baby’s back, supporting the spine. The thumbs can be placed side by side or, on a small baby, one over the other.
  • 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: It’s easy for a nervous resuscitator to inadvertently squeeze the newborn’s chest or to hold on tightly during and between compressions. All members of the team should watch each other’s 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, you’re squeezing his chest and I can’t ventilate.” It would be better to say, “Jane, loosen your hands a little.”
  • This is a demonstration of the proper method of the thumb technique for chest compressions.
  • 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.
  • This is a demonstration of the correct method of the 2-finger technique of chest compressions.
    Instructor Tip: Notice that the 2 people engaged in providing chest compressions and ventilations cannot perform other tasks. Do not expect them to reach for equipment, engage in lengthy conversation with others, document resuscitation events, or draw up medications.
  • Controlling the pressure used in compressing the sternum is an important part of the procedure. With your fingers and hands correctly positioned, you should use enough pressure to depress the sternum to a depth of approximately one third of the anterior-posterior diameter of the chest, then completely release the pressure to allow the heart to refill. One compression consists of the downward stroke plus the release. The actual distance compressed will depend on the size of the newborn.
    The duration of the downward stroke of the compression should be somewhat shorter than the duration of the release for generation of maximum cardiac output.
  • Your thumbs or the tips of your fingers should remain in contact with the chest at all times during compression and release. If you take your thumbs or fingers off the sternum after compression, you
    Waste time relocating the compression area.
    Lose control over the depth of compression.
    May compress the wrong area, producing trauma to the chest or underlying organs.
  • 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 minute
    If 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 care
    If the heart rate is <60 bpm, intubate the infant (if not already done), insert an umbilical venous catheter and give epinephrine
    Instructor Tip: Learn to assess the heart rate quickly. You should be able to recognize, within a few beats, if the heart rate is less than 60 bpm, 100 bpm, and more than 100 bpm.
  • When you are administering chest compressions and coordinating ventilation, continue to ask yourself the following questions:
    Is chest movement adequate?
    Is supplemental oxygen being given?
    Is the depth of chest compression approximately one third of the anterior-posterior diameter of the chest?
    Are the chest compressions and ventilation being well-coordinated?
    If the heart rate remains less than 60 beats per minute, you should give epinephrine, as described in Lesson 6.
    By this point in resuscitation, you most likely will have intubated the trachea, giving a more reliable means of ventilating, and called for additional personnel to record events. Because epinephrine administration seems likely, establishment of an umbilical venous line should be in progress.
    Instructor Tip: A newborn who requires chest compressions is seriously ill and needs a skilled and coordinated team to administer interventions. This is why we practice these skills frequently, so that all team members feel confident and competent during a more extensive resuscitation.
  • The inflation of a flow-inflating bag depends on a sealed system. If the bag does not inflate, check for potential problems, such as those mentioned here.
  • Reanimación neonatal: Lección 4 MASAJE CARDIACO

    1. 1. Lección 4: MASAJE CARDÍACO
    2. 2. Masaje Cardíaco Contenido: • Indicaciones para el masaje cardíaco • Como dar el masaje cardíaco • Como coordinar el masaje cardíaco con la ventilación con presión positiva • Cuando suspender el masaje cardíaco 4-2
    3. 3. Masaje Cardíaco Masaje Cardíaco • Aumenta temporalmente la circulación • Debe ser acompañado de ventilación • Debe usarse oxígeno al 100% 4-3
    4. 4. Masaje Cardíaco : Indicaciones FC menor de 60 a pesar de ventilación positiva efectiva durante 30 segundos  4-4
    5. 5. Masaje Cardíaco : • Comprime el corazón contra la columna • Aumenta la presión intratorácica • Permite circular la sangre hacia órganos vitales incluyendo el cerebro  Click on the image to play video 4-5
    6. 6. Masaje Cardíaco : Se Requieren 2 Personas • Una persona comprime el tórax • La otra persona continúa la ventilación 4-6
    7. 7. Comparación De Las Técnicas De Masaje Cardíaco • Técnica de los Pulgares (Preferida) – Menos cansada – Mejor control de la profundidad de las compresiones • Técnica de los 2 Dedos – Es mejor para manos pequeñas – Permite el acceso al cordón umbilical para la administración de medicamentos  4-7
    8. 8. Masaje Cardíaco : Colocación de los Pulgares o Dedos • Ubique los dedos en la parte baja de la caja torácica hasta que localice la apófisis xifoides • Coloque sus dedos o pulgares sobre el esternón, arriba del xifoides sobre la línea que conecta los pezones  4-8
    9. 9. Masaje Cardíaco : Masaje Cardíaco • Los pulgares comprimen el esternón • Los dedos dan apoyo a la espalda 4-9
    10. 10. Masaje Cardíaco : Técnica de los Pulgares • Aplique presión solo sobre el esternón, al retirar la presión, se permite que el tórax se expanda y pueda darse ventilación 4-10
    11. 11. Técnica de los Pulgares Click on the image to play video 4-11
    12. 12. Masaje Cardíaco : Técnica de los 2 Dedos • Con las puntas de los dedos medio e índice o anular, se comprime el esternón • La otra mano de la soporte a la espalda 4-12
    13. 13. Masaje Cardíaco : Técnica de los 2 Dedos Click on the image to play video 4-13
    14. 14. Masaje Cardíaco : Compresión Presión y Profundidad • Comprima el esternón 1/3 del diámetro anteroposterior del tórax. 4-14
    15. 15. Masaje Cardíaco : Técnica • La duración de la compresión debe ser mas corta que la relajación 4-15
    16. 16. Masaje Cardíaco : Complicaciones • Laceración del hígado • Fractura de costillas 4-16
    17. 17. Masaje Cardíaco : Coordinación Con la Ventilación  Click on the image to play video 4-17
    18. 18. Masaje Cardíaco : Coordinación con la Ventilación • Un ciclo de 3 compresiones y una ventilación toma 2 segundos • La frecuencia respiratoria es de 30 ventilaciones por minuto y el masaje cardíaco de 90 compresiones por minuto. Esto es igual a 120 “eventos” por segundo  4-18
    19. 19. Masaje Cardíaco : Suspendiendo el Masaje Después de 30 segundos de masaje cardíaco y ventilación debe detenerse y medir la frecuencia cardíaca  4-19
    20. 20. Masaje Cardíaco : Si la FC Permanece por debajo de 60 lpm • Compruebe que haya una ventilación adecuada • Considere intubación endotraqueal si no se ha hecho ya • Inserte un catéter umbilical para administrar adrenalina  4-20
    21. 21. Fin de la Lección 4 4-21

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