Lecture number 4. Cardiopulmonary resuscitation

Cardiopulmonary resuscitation (CPR) is a complex of surgical and therapeutic measures performed in the absence of life-threatening injuries and aimed at restoring and supporting the function of the cardiorespiratory system. Indications for cardiopulmonary resuscitation: carried out in patients with no effective pulse on the carotid arteries or a thready, weak pulse, who are unconscious and (or) in the absence of effective respiratory movements. The most common cases of primary cardiac arrest, as well as primary respiratory failure.

Contraindications: trauma incompatible with life, terminal stages of incurable diseases and biological death.

Basic principles

Primary efforts in CPR are aimed at:

1) chest compression;

2) blowing air into the lungs and ventilation;

3) preparation and administration of drugs;

4) installation and maintenance of intravenous access;

5) specialized activities (defibrillation, pacemaker installation, tracheal intubation).

Thus, to complete the full scope of activities, 4 people and a team leader are needed. One person should be in charge of CPR. This person should integrate all available information and prioritize impact. He must monitor the ECG monitor, the use of drugs and ensure that the actions of other team members are corrected. He should be removed from the performance of procedures that detract from the leadership role. For more than 40 years, the Safar resuscitation alphabet has been used for CPR. In this complex, the sequence of actions of the resuscitator is sustained; according to their English name, they are indicated by the corresponding letters.

A - Airway - ensuring airway patency.

B - Breathing - artificial ventilation of the lungs (ALV) in an accessible way, for example, when breathing "mouth to mouth".

C - Circulation - ensuring hemocirculation - indirect heart massage.

D - Drugs - the introduction of drugs.

E - Electrocardiography - ECG registration.

F - Fibrilation - conducting, if necessary, electrical defibrillation (cardioversion).

G - Gauging - evaluation of primary results.

H - Hypothermy - head cooling.

I - Intensive care - intensive care for post-resuscitation syndromes.

A - Airway - airway management

The patient is placed horizontally on his back.

The head is thrown back as much as possible, for this the doctor puts one hand under the neck, the other is placed on the patient's forehead; a test breath is taken from mouth to mouth.

If a patient with reduced muscle tone lies on his back, his tongue may sink, as if packing the throat. At the same time, the epiglottis descends, further blocking the airways. Appear: sonorous breathing, then violations of the respiratory rhythm up to its complete stop. Such phenomena develop especially rapidly in patients who are unconscious.

To prevent and eliminate the retraction of the tongue, the lower jaw should be brought forward and at the same time hyperextension in the occipito-cervical joint should be performed. To do this, with the pressure of the thumbs on the chin, the lower jaw of the patient is shifted down, and then with the fingers placed at the corners of the jaw, they push it forward, supplementing this technique with overextension of the head posteriorly (triple Safar technique). With the correct and timely conduct of these manipulations, the patency of the airways at the level of the pharynx is quickly restored. Foreign bodies (blood clots, mucus, dentures, etc.) can be the cause of airway obstruction. They are quickly removed with any improvised materials (napkin, handkerchief). The patient's head should be turned to the side due to the danger of aspiration. The restoration of patency of the upper respiratory tract is facilitated by the use of various air ducts. The most appropriate is the use of an S-shaped duct. For its introduction, the patient's mouth is opened with crossed fingers II and I, and the tube is advanced to the root of the tongue so that its opening "slides" along the palate. Care must be taken to ensure that the air duct does not move during transport. If all the described procedures are not effective, then we can assume the presence of obturation of the airways in the underlying sections. In these cases, direct laryngoscopy and active aspiration of pathological secretion is required, followed by tracheal intubation for 10-15 seconds. It is advisable to perform conicotomy and tracheostomy.

B - Breathing - artificial lung ventilation (ALV) in an accessible way

The simplest and most effective method of artificial respiration during resuscitation is the "mouth-to-mouth" method, when the resuscitator's exhaled air is blown into the victim's lungs under pressure. Having thrown back the head of the victim, with one hand they pinch his nostrils, put the other hand under his neck, take a deep breath, tightly pressing his lips to the lips of the victim (in children, to the lips and to the nose at the same time) and blow air into the lungs of the victim, observing the rise of the chest during inhalation time. As soon as the chest rises, the air injection is stopped, they move their face to the side, they take a deep breath again, and the patient at this time has a passive exhalation.

After 2-3 inflations of the lungs, the presence of a pulse on the carotid artery is determined, if it is not detected, then they proceed to artificial restoration of blood circulation. Manual ventilation is used using a self-expanding Ambu-type bag. When using a ventilator, the respiratory rate is 12-15 per minute, the inspiratory volume is 0,5-1,0 liters. In a hospital, tracheal intubation is performed and the patient is transferred to a ventilator.

C-Circulation - ensuring hemocirculation - indirect heart massage

Closed heart massage is the simplest and most efficient way of emergency artificial circulatory support. Closed heart massage should be started immediately, as soon as the diagnosis of acute circulatory arrest is made, without clarifying its causes and mechanisms. In cases of ineffective heart contractions, one should not wait for a complete cardiac arrest or an independent restoration of adequate cardiac activity.

Basic rules for closed heart massage.

1. The patient should be in a horizontal position on a solid base (floor or low couch) to prevent the possibility of displacement of his body under the strengthening of the massaging hands.

2. The zone of application of the force of the hands of the resuscitator is located on the lower third of the sternum, strictly along the midline; the resuscitator can be on either side of the patient.

3. For massage, one palm is placed on top of the other and pressure is applied to the sternum in the area located 3-4 transverse fingers above the place of attachment to the sternum of the xiphoid process; the hands of the massager, straightened at the elbow joints, are positioned so that only the wrist produces pressure.

4. Compression of the victim's chest is performed due to the gravity of the doctor's torso. The displacement of the sternum towards the spine (i.e., the depth of the deflection of the chest) should be 4-6 cm.

5. The duration of one chest compression is 0,5 s, the interval between individual compressions is 0,5-1 s. Rate of massage - 60 massage movements per minute. In intervals, the hands are not removed from the sternum, the fingers remain raised, the arms are fully extended at the elbow joints.

When resuscitation is carried out by one person, after two quick injections of air into the lungs of the patient, 15 chest compressions are performed, i.e. the ratio "ventilation: massage" is 2: 15. If 2 persons are involved in resuscitation, then this ratio is 1: 5, i.e., there are 5 chest compressions per breath.

A prerequisite for cardiac massage is the constant monitoring of its effectiveness. The criteria for the effectiveness of massage should be considered as follows.

1. Change in skin color: it becomes less pale, gray, cyanotic.

2. Constriction of the pupils, if they were dilated, with the appearance of a reaction to light.

3. The appearance of a pulse impulse on the carotid and femoral arteries, and sometimes on the radial artery.

4. Determination of blood pressure at the level of 60-70 mm Hg. Art. when measured at the shoulder.

5. Sometimes the appearance of independent respiratory movements.

If there are signs of restoration of blood circulation, but in the absence of a tendency to preserve independent cardiac activity, heart massage is performed either until the desired effect is achieved (restoration of effective blood flow), or until the signs of life disappear permanently with the development of symptoms of brain death. In the absence of signs of restoration of even reduced blood flow, despite heart massage for 25-30 minutes, the patient should be recognized as dying and resuscitation measures can be stopped.

D - Drugs - drug administration

In case of acute cessation of blood circulation, the introduction of agents that stimulate cardiac activity should begin as soon as possible, if necessary, be repeated during resuscitation. After the start of cardiac massage, 0,5-1 ml of adrenaline should be administered as soon as possible (intravenously or intratracheally). Its repeated introductions are possible after 2-5 minutes (up to 5-6 ml in total). With asystole, adrenaline tones the myocardium and helps "start" the heart, with ventricular fibrillation it contributes to the transition of small-wave fibrillation to large-wave, which greatly facilitates defibrillation. Adrenaline facilitates coronary blood flow and increases the contractility of the heart muscle.

Instead of epinephrine, isodrin can be used, which is 3 times more effective than adrenaline in terms of the effectiveness of the effect on the myocardium. The initial dose is 1-2 ml intravenously, and the next 1-2 ml in 250 ml of a 5% glucose solution. In conditions of impaired blood circulation, metabolic acidosis progressively increases, therefore, immediately after the infusion of adrenaline, a 4-5% solution of sodium bicarbonate is administered intravenously at the rate of 3 ml / kg of the patient's body weight. In the process of dying, the tone of the parasympathetic nervous system increases significantly, the brain is depleted, therefore, M-cholinolytics are used. With asystole and bradycardia, atropine is administered intravenously in a 0,1% solution - 0,5-1 ml, up to a maximum dose of 3-4 ml. To increase myocardial tone and reduce the effect of hyperkalemia, intravenous administration of 5 ml of a 10% solution of calcium chloride is recommended. Adrenaline, atropine and calcium chloride can be administered together in the same syringe.

With severe tachycardia and especially with the development of fibrillation, the use of lidocaine at a dose of 60-80 mg is indicated, but since it is short-acting, it is infused at a rate of 2 mg / min. It is also indicated to use glucocorticoids, which, by increasing the sensitivity of adrenoreactive myocardial structures to catecholamines and normalizing the permeability of cell membranes, contribute to the restoration of adequate cardiac activity.

E - Electrocardiography - ECG recording

With the help of an ECG study, the nature of the violation of cardiac activity is determined. Most often it can be asystole - complete cessation of heart contractions, fibrillation - chaotic uncoordinated contraction of myocardial fibers with a frequency of 400-500 beats / min, in which cardiac output practically stops. Initially, large-wave fibrillation is noted, which, within 1-2 minutes, passes into small-wave fibrillation, followed by asystole. The presence of any rhythm on the ECG is better than the complete absence of electrical activity of the myocardium. Therefore, the key task of CPR is to stimulate the electrical activity of the myocardium and subsequently modify it into an effective (presence of a pulse) rhythm.

The presence of asystole serves as a marker of severe myocardial perfusion disorder and serves as a poor prognostic sign for restoring cardiac rhythm. However, it is important to differentiate between low-amplitude microwave ventricular fibrillation and asystole, which is best done in standard ECG leads 2-3. Adrenaline (1 mg intravenously) and atropine (1 mg increased to 2-4 mg) are most effective in restoring electrical activity. In refractory cases, correction of potassium and calcium levels is effective.

Ventricular fibrillation (VF)

In pulseless patients, immediate blind electropulse therapy should be performed (before the cause of circulatory arrest is recognized by ECG), since VF is the most common cause of sudden death, and the success of defibrillation is largely determined by the time it is performed. It should be noted that "blind" defibrillation will not harm patients with asystole and bradycardia and is usually effective in patients with tachycardia and VF. It is important to remember that the rule of "blind" cardioversion is not acceptable in children, since they are much more likely than VF to have respiratory arrest as a cause of terminal illness. The success of defibrillation depends on VF amplitude, which in turn is inversely correlated with the duration of the VF episode. If two initial attempts at cardioversion are ineffective, in this case it is necessary to administer adrenaline to increase the amplitude of fibrillation waves and increase vascular tone (in cases of restoration of the heart rhythm, it allows increasing perfusion of the heart and brain). On the other hand, it is necessary to use optimal doses of adrenaline so as not to increase the oxygen demand of the myocardium.

F - Fibrilation - performing electrical defibrillation if necessary (cardioversion)

Cardiac fibrillation can be eliminated by the use of electrical defibrillation. It is necessary to apply electrodes tightly to the chest (in the anterolateral position, one electrode is located in the region of the apex of the heart, the second in the subclavian region to the right of the sternum), which increases the force of the discharge and, accordingly, the effectiveness of defibrillation. In a number of patients, the anteroposterior (apex of the heart - interscapular space) position of the electrodes is more effective. Do not apply electrodes over the overlays of the ECG monitor.

It should be noted that electrical defibrillation is effective only when large-wave oscillations with an amplitude of 0,5 to 1 mV or more are recorded on the ECG. This kind of myocardial fibrillation indicates the safety of its energy resources and the possibility of restoring adequate cardiac activity. If the oscillations are low, arrhythmic and polymorphic, which is observed in severe myocardial hypoxia, then the possibility of restoring cardiac activity after defibrillation is minimal. In this case, with the help of heart massage, mechanical ventilation, intravenous administration of adrenaline, atropine, calcium chloride, it is necessary to achieve the transfer of fibrillation to large-wave, and only after that defibrillation should be performed. The first attempt at defibrillation is carried out with a discharge of 200 J, with subsequent attempts the charge increases to 360 J. The electrodes must be moistened and firmly pressed to the surface of the chest. The most common errors during defibrillation, which cause the ineffectiveness of the latter, include the following.

1. Long interruptions in heart massage or complete absence of resuscitation during the preparation of the defibrillator for discharge.

2. Loose pressing or insufficient moistening of the electrodes.

3. Application of a discharge against the background of low-wave fibrillation without taking measures that increase the energy resources of the myocardium.

4. Applying a discharge of low or excessively high voltage.

It should be noted that electrical defibrillation of the heart is an effective method for correcting such cardiac arrhythmias as paroxysmal ventricular tachycardia, atrial flutter, nodal and supraventricular tachycardia, atrial fibrillation. The indication for electrical defibrillation, at the prehospital stage, is most often paroxysmal ventricular tachycardia. A feature of defibrillation in these conditions is the presence of consciousness in the patient and the need to eliminate the reaction to pain when applying an electric discharge.

G - Gauging - evaluation of primary results

The primary evaluation of the results is carried out not only to ascertain the state of the circulatory and respiratory system, but also in order to outline the tactics of further therapeutic measures. Upon completion of the resuscitation process, in which the restoration of cardiac activity appeared, the resuscitator must perform a number of final actions:

1) assess the condition of the respiratory tract (symmetry of breathing, with the continuation of forced breathing, the adequacy of ventilation);

2) check the pulsation in the central and peripheral arteries;

3) evaluate the color of the skin;

4) determine the level of blood pressure;

5) measure the volume of circulating blood (measure CVP, assess the condition of the jugular veins);

6) check the correct position of the catheters in the central veins;

7) in case of elimination of cardiac fibrillation, which was the cause of sudden death, make sure that the infusion of any antifibrillary agent is continued;

8) carry out correction of therapy if it was carried out to the patient before the episode of sudden death.

H - Hypothermy - head cooling

With hypothermia, the critical time of circulatory arrest can increase significantly. To prevent the development of posthypoxic encephalopathy, measures should be taken to reduce the intensity of metabolic processes in the brain, as well as antihypoxic and antioxidant drugs.

Key events

1. Craniocerebral hypothermia - wrapping the head and neck with ice packs, snow, cold water.

2. Parenteral administration of antihypoxants (sodium oxybutyrate, mafusol, small doses of sedatives), as well as improving the rheological properties of blood (rheopolyglucin, hemodez, heparin, trental).

3. The introduction of calcium antagonists (nimoton, lidoflazin, etc.).

4. Introduction of antioxidants (mafusol, unitiol, vitamin C, catalase, etc.).

I - intensive care - conducting intensive care of postresuscitation syndromes

Although a rapid positive response to CPR improves the chances of a favorable prognosis in patients, subsequent development of sepsis, acute pulmonary insufficiency and pneumonia is possible, which naturally worsens the prognosis. Long-term survival of patients with previous diseases of vital organs after CPR is not typical, since during this period their lesions deepen, and the nerve centers that provide autonomous control and maintenance of protective reflexes are damaged. Also, when intensive chest compression is used, ruptures of the liver, aorta, pneumothorax, fractures of the ribs and sternum are noted. Frequent complications are aspiration pneumonitis, convulsions (due to cerebral ischemia) and lidocaine intoxication. A number of patients develop bleeding from stress ulcers of the stomach and duodenum. After CPR, there is a significant increase in the level of liver (and/or skeletal muscle) enzymes, although the development of liver necrosis and insufficiency of its function are rare. In high-energy defibrillation regimens, there is a significant increase in the level of creatine phosphokinase, but an increase in the MB fraction is present only with repeated high-energy discharges.

1. Correction of CBS and water-electrolyte balance. Often after CPR, metabolic alkalosis, hypokalemia, hypochloremia, and other electrolyte disorders develop. There is a shift in pH to an acidic or alkaline environment. The key to pH correction is adequate ventilation. The use of bicarbonate should be carried out under the control of the gas composition of the blood. As a rule, there is no need to introduce NSO₃ with the rapid restoration of blood circulation and respiration. With a functioning heart, a pH level of ~ 7,15 is adequate for the functioning of the cardiovascular system. The commonly recommended dose of bicarbonate (1 mg/kg) may cause side effects including:

1) arrhythmogenic alkalosis;

2) increased CO production₂;

3) hyperosmolarity;

4) hypokalemia;

5) paradoxical intracellular acidosis of the central nervous system;

6) shift to the left of the hemoglobin dissociation curve, limiting the tissue supply of O₂.

Therefore, the appointment of this drug should be strictly according to indications. To eliminate hypokalemia, an intravenous infusion of potassium chloride is performed at a dose of 2 mmol/kg per day.

2. Normalization of the antioxidant defense system. Intensive therapy includes a complex of antioxidant drugs with multidirectional action - mafusol, unitiol, vitamin C, multibiont, tocopherol, probucol, etc.

3. The use of antioxidants helps to reduce the intensity of metabolic processes and, consequently, reduce the need for oxygen and energy, as well as the maximum use of the reduced amount of oxygen that is available during hypoxia. This is achieved through the use of neurovegetative protection drugs and antihypoxants (seduxen, droperidol, ganglion blockers, mexamine, sodium hydroxybutyrate, cytochrome, gutimin, etc.).

4. An increase in energy resources is provided by intravenous administration of concentrated glucose solutions with insulin and the main coenzymes involved in energy utilization (vitamin B₆, cocarboxylase, ATP, riboxin, etc.).

5. Stimulation of the synthesis of protein and nucleic acids - substrates that are absolutely necessary for the normal functioning of cells, the synthesis of enzymes, immunoglobulins and others, is carried out by the use of anabolic hormones (retabolil, nerabolil, insulin, retinol), folic acid, as well as the introduction of amino acid solutions.

6. Activation of aerobic metabolism is achieved by introducing a sufficient amount of oxidation substrates (glucose), as well as using hyperbolic oxygenation (HBO) - this method ensures the supply of the required amount of oxygen even in conditions of sharp violations of its delivery.

7. Improvement of redox processes (succinic acid, riboxin, tocopherol, etc.).

8. Active detoxification therapy contributes to the normalization of metabolic processes. For this, various methods of infusion therapy (gelatinol, albumin, plasma), forced diuresis, etc. are used. In severe cases, extracorporeal detoxification methods are used (hemosorption, hemodialysis, plasmapheresis).

9. Elimination of violations of microcirculation processes. For this, heparin therapy is performed.

There is no single guideline for all clinical situations. During ongoing CPR, neurological signs cannot serve as markers of outcome and, accordingly, cannot be guided by them when CPR is stopped. Resuscitation is rarely effective if more than 20 minutes is needed to restore a coordinated heart rhythm. A number of studies have shown that the lack of response within 30 minutes to full CPR, with rare exceptions, leads to death. The best results occur in cases of immediate effective cardioversion. Prolonged resuscitation with a good neurological outcome is possible with hypothermia and deep pharmacological depression of the central nervous system (for example, barbiturates).

Methods for determining the non-viability of the brain:

1) angiography of cerebral vessels (lack of blood flow);

2) EEG (straight line for at least 24 hours);

3) computed tomography.

CPR Termination Criteria:

1) if within 30 minutes all correctly performed resuscitation measures do not bring any effect - spontaneous breathing does not appear, blood circulation is not restored, the pupils remain dilated and do not react to light;

2) if within 30 minutes there are repeated cardiac arrests that are not amenable to therapy, and at the same time there are no other signs of successful resuscitation;

3) if in the process of resuscitation it was found that this patient was not shown at all;

4) if within 45-60 minutes, despite the partial restoration of breathing, the victim has no pulse and there are no signs of restoration of brain function.

Author: Kolesnikova M.A.

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