Cardiopulmonary resuscitation

Cardiopulmonary resuscitation is an organized sequential procedure for stopping blood circulation, including the diagnosis of absence of blood circulation and breathing, maintenance of basic life support (BLS) with closed heart massage and artificial respiration, specialized cardiac care support - ACLS) and postresuscitation treatment.

The rapid, effective and correct performance of cardiopulmonary resuscitation determines a favorable neurological outcome. Rare exceptions are cases of deep hypothermia, when resuscitation was successful after a long period of circulatory arrest.

After confirming the lack of consciousness and breathing, a set of measures to maintain vital functions begins - maintenance of airway, breathing, circulation (ABC). In the presence of ventricular fibrillation (VF) or ventricular tachycardia (VT), defibrillation (D) is performed to restore the normal rhythm of the heart.

[1], [2], [3], [4], [5],

Ensuring airway patency and breathing

Providing airway patency is a priority.

Immediately start mouth-to-mouth breathing (in adults and children) or mouth-in-mouth-and-nose (in infants). It is necessary to prevent regurgitation of gastric contents by pressing on the cricoid cartilage until the intubation of the trachea is performed. In children, the pressure should be moderate, so as not to cause compression of the trachea. The introduction of the nasogastric tube is postponed until suction appears, as this procedure can cause regurgitation and aspiration of the gastric contents. If ventilation causes a significant stretching of the stomach, which can not be eliminated by the above methods, the patient is laid on his side, pressed onto the epigastric region and the airway patency is controlled.

Defibrillation should not be postponed until intubation of the trachea. Closed cardiac massage should continue during the preparation and intubation of the trachea.

[6], [7], [8], [9], [10]

Circulation

[11], [12], [13], [14], [15], [16], [17]

Closed heart massage

In case of sudden loss of consciousness and collapse, it is necessary to immediately start a closed heart massage and artificial respiration. If, during a circulatory stop, defibrillation is possible within the first 3 minutes, it must precede a closed massage to the heart.

Technique of cardiopulmonary resuscitation

	One lifeguard	Two rescuers	Volume of inhalation
Adults	2 inhalations (1 second each) after 30 shocks at a frequency of 100 / min	2 inhalations (1 second each) after 30 shocks at a frequency of 100 / min	Each inhalation of about 500 ml (avoid hyperventilation)
Children (1-8 years old)	2 breaths (1 second each) after every 30 shocks at a frequency of 100 / min	2 breaths (1 second each) after every 15 shocks with a frequency of 100 / min	Less than in adults (enough to lift the chest)
Infants (up to a year)	2 breaths (1 second each) after every 30 shocks at a frequency of 100 / min	2 breaths (1 second each) after every 15 shocks with a frequency of 100 / min	Small breaths equal to the volume of the operator's oral cavity

With reliable airway patency, 8-10 breaths per minute are produced without a break for closed heart massage.

Ideally, when carrying out a closed heart massage with each compression, the pulse should be palpated, despite the fact that the cardiac output is only 30-40% normal. However, palpation of the pulse during the massage is difficult to carry out. Monitoring of CO2 concentration in exhaled air (etCO2) provides a more objective assessment of cardiac output; patients with inadequate perfusion have a small venous return to the lungs and a correspondingly low etC0 ₂. Pupils of normal size with preserved photoreaction indicate adequate blood circulation and oxygenation of the brain. The saved photoreaction with dilated pupils indicates inadequate brain oxygenation, but irreversible brain damage could not yet occur. Constantly widened pupils without reaction to light also do not indicate damage or death of the brain, since high doses of cardiotonics and other drugs, the presence of cataracts can change the size and response of the pupils. Restoration of spontaneous breathing or opening of the eyes indicates the restoration of blood circulation.

One-sided compression of the chest can be effective, but it is contraindicated in patients with penetrating chest injury, cardiac tamponade, as well as thoracotomy and cardiac arrest (in the operating room).

[18], [19], [20], [21]

Medicines for specialized cardiac care

Despite widespread and well-established use, no medicine has improved the hospital survival of patients with circulatory arrest. Some drugs help to restore blood circulation and therefore it is advisable to apply them.

In patients with peripheral venous access, the administration of the drugs is carried out against the backdrop of bolus administration of fluids (in adults, a dropper is opened, 3-5 ml in children), this is necessary for the drug to enter the central bloodstream. In patients without intravenous and intraosseous access, atropine and epinephrine can be introduced into the endotracheal tube at a dose of 2-2.5 times higher than intravenous.

First-line drugs. Norepinephrine is the main drug used for stopping blood circulation, but there is increasing evidence of inefficiency in its use. Usually, it is repeated every 3-5 minutes. Norepinephrine is a- and b-adrenomimetic. A-adrenergic effect increases coronary diastolic pressure and subendocardial perfusion during cardiac massage, increases the probability of effective defibrillation. B-Adrenergic effect is unfavorable, as it increases the need for myocardium in oxygen and causes vasodilation. Intracardiac norepinephrine is not recommended because of the risk of complications such as pneumothorax, coronary artery disease and cardiac tamponade.

Single administration of vasopressin in a dose of 40 units may be an alternative to norepinephrine (adults only); However, before administration of norepinephrine, its use is considered not justified.

Atropine has a vagolytic effect, increases the heart rate and conductivity in the atrioventricular node. It is used in asystole (except children), bradyarrhythmia and high degree of atrioventricular blockade, but its effect on the survival of patients is not proven.

Amiodarone is prescribed once, if defibrillation was ineffective after the administration of noradrenaline or vasopressin. Amiodarone can be effective if VF or VT is resumed after cardioversion; while a repeated reduced dose is given after 10 minutes, and then the drug is used as a continuous infusion.

Medicines used in cardiopulmonary resuscitation

Medicinal products	Doses for adults	Doses for children	A comment
Adenosine	6 mg, then 12 mg (2 times)	0.1 mg / kg, then 0.2 mg / kg (2 times) The maximum dose of 12 mg	Intravenous bolus against infusion of solutions, maximum dose of 12 mg
Amiodarone for VF / VT (with unstable hemodynamics	300 mg	5 mg / kg	Intravenous spray infusion for 2 min
With VT (with stable hemodynamics	Immediately 150 mg, then drip infusion: 1 mg / min for 6 hours, then 0.5 g / min for 24 h	5 mg / kg for 20-60 minutes You can repeat, but do not exceed the dose of 15 mg / kg / day	The first dose is administered intravenously for 10 min
Amprinon	Immediately 0.75 mg / kg for 2-3 minutes, then a drop infusion of 5-10 μg / kg / min	Immediately 0.75-1 mg / kg for 5 minutes, can be repeated up to 3 mg / kg, then infusion: 5-10 μg / kg / min	500 mg in 250 ml of 0.9% NaCl solution, infusion rate 2 mg / ml
Atropine	0.5-1 mg 1-2 mg Endotracheal	0.02 mg / kg	Repeat 3-5 minutes before the effect or total dose of 0.04 mg / kg; the minimum dose of 0.1 mg
Chloride Ca	1g	20 mg / kg	10% solution contains 100 mg / ml
Glycerate	0.66 g	Not Applicable	22% solution, 220 mg / ml
Gluconate	0.6 g	60-100 mg / kg	10% solution contains 100 mg / ml
Dobutamine	2-20 μg / kg / min; start with 2-5 μg / kg / min	Also	500 mg in 250 ml 5% glucose contains 2000 μg / ml
Dopamine	2-20 μg / kg / min; start with 2-5 μg / kg / min	Also	400 mg in 250 ml of 5% glucose contains 1600 μg / ml
Norepinephrine Bolus	1 mg	0.01 mg / kg	Repeat in 3-5 minutes At Need
Endotracheal	2-2.5 mg	0.01 mg / kg	8 mg in 250 ml of 5% glucose - 32 μg / ml
Infusion	2-10 μg / min	0.1-1.0 μg / kg / min
Glucose	25 g in 50% solution	0.5-1 g / kg	Avoid high concentrations: 5% solution - 10-20 ml / kg; 10% solution - 5-10 ml / kg 25% solution - 2-4 ml / kg (to older children, to large veins)

Other drugs. Calcium chloride solution is recommended for patients with hyperkalemia, hypermagnesia, hypocalcemia and overdose of calcium channel blockers. In other cases, when the concentration of intracellular calcium already exceeds the norm, additional calcium intake is contraindicated. Heart failure in patients on hemodialysis occurs as a result of or against a background of hyperkalemia, so they are shown the administration of calcium, if it is not possible to immediately determine the level of potassium. With the introduction of calcium, it must be remembered that it increases the toxicity of digitalis preparations, which can be the cause of cardiac arrest.

Magnesium sulfate does not improve the outcome of resuscitation, which has been proven in randomized studies. But it can be useful in patients with hypomagnesemia (with alcoholism, prolonged diarrhea).

Procainamide is a second-line drug in the treatment of refractory VF or VT. It is not recommended for use in children with unstable hemodynamics.

Phenytoin is rarely used in the treatment of VF or VT only if these rhythm disturbances are caused by intoxication with digitalis preparations or are not amenable to treatment with other medications.

NaHC0 _{3 is} no longer recommended unless circulatory arrest caused by hyperkalemia, hypermagnesia, or an overdose of tricyclic antidepressants with complicated ventricular arrhythmias. In pediatric practice, it is prescribed if cardiopulmonary resuscitation lasts more than 10 minutes, provided there is good ventilation. When using NaHC0 _3, it is necessary to measure the pH of the arterial blood before the infusion and after every 50 meq (1-2 meq / kg).

Lidocaine and brethulium are no longer used in CPR.

Treatment of rhythm disturbances

FF / VT with unstable hemodynamics. Defibrillation is performed once. The recommended discharge strength for a two-phase defibrillator is 120-200 J, for a monophasic defibrillator 360 J. In case of unsuccessful cardioversion, 1 mg of noradrenaline is administered intravenously and the procedure is repeated after 4-5 minutes. Once you can enter 40 units of vasopressin intravenously instead of epinephrine (in children it is impossible). Cardioversion is repeated the same strength 1 minute after drug administration (there is no established validity of the increase in discharge strength for a two-phase defibrillator). With ongoing VF, 300 mg of amiodarone is given intravenously. If VF / VT resumes, a 6-hour infusion of amiodarone at a dose of 1 mg / min, then 0.5 mg / min, begins.

Asystole. To eliminate the error, it is necessary to check the contacts of the ECG electrodes of the monitor. When confirming asystole, a percutaneous pacemaker is prescribed and 1 mg of noradrenaline is given intravenously with 3-5 min and 1 mg of atropine intravenously and repeated 3-5 minutes to a total dose of 0.04 mg / kg. The electric imposition of rhythm is rarely successful. Note: atropine and imposition of rhythm are contraindicated in pediatric practice with asystole. Defibrillation with proven asystole is unacceptable, since an electrical discharge damages the unperfused myocardium.

Electrical dissociation is a condition in which circulation of blood in the body stops when there are satisfactory cardiac complexes on the ECG. With electrical dissociation, intravenously, 500-1000 ml (20 ml / kg) of 0.9% NaCI solution and 0.5-1.0 mg noradrenaline should be administered intravenously as a rapid infusion, which can be re-introduced after 3-5 min. With a heart rate of less than 60 per minute, 0.5-1.0 mg of atropine is given intravenously. Cardiac tamponade causes electrical dissociation in exudative pericarditis or severe chest trauma. In this case, a pericardiocentesis should be performed immediately.

Discontinuation of resuscitation

Cardiopulmonary resuscitation is carried out until the spontaneous circulation is restored, death is ascertained or one person physically can not continue to continue cardiopulmonary resuscitation. In patients undergoing hypothermia, cardiopulmonary resuscitation should continue until the body temperature rises to 34 ° C.

Biological death is usually noted after an unsuccessful attempt to restore self-circulation during 30-45 minutes of cardiopulmonary resuscitation and the provision of specialized cardiac care. Nevertheless, this assessment is subjective despite the fact that it takes into account the length of the period of absence of blood circulation before the start of treatment, the age, the previous state and other factors,

[22], [23], [24], [25],

Assisting after a successful resuscitation

Restoration of spontaneous circulation (VSC) is only an intermediate goal of resuscitation. Only 3-8% of patients with VSK survive to discharge from the hospital. To maximize the outcome, it is necessary to optimize the physiological parameters and take measures to treat co-morbidities. In adults, it is especially important to recognize myocardial infarction and start reperfusion therapy as soon as possible (thrombolysis, percutaneous transluminal coronary angioplasty). It should be remembered that thrombolysis after aggressive CPR can lead to cardiac tamponade.

Laboratory studies after cardiopulmonary resuscitation include the determination of arterial blood gases, a general blood count (OAK), and a biochemical blood test, including an assessment of electrolyte, glucose, blood urea nitrogen, creatinine, and myocardial damage markers (CPK will usually be increased because of injuries of skeletal muscles during cardiopulmonary resuscitation). Arterial PaO2 should be maintained within the normal range (80-100 mm Hg), Hct - slightly above 30%, the level of glucose - 80-120 mg / dl, electrolytes, especially potassium, within normal limits.

Stabilization of blood pressure. The mean arterial blood pressure (SAD) should be 80 mm Hg. Art. In elderly patients or more than 60 mm Hg. Art. In young and previously healthy people. In patients with hypertension, the target systolic blood pressure should be 30 mm Hg. Art. Below the pressure that could be before the circulation stopped.

In patients with low CAP or signs of left ventricular failure, pulmonary artery catheterization may be required to monitor cardiac output, pulmonary artery wedge pressure (PZL), and O2 saturation of mixed venous blood (peripheral perfusion assessment), which will optimize drug therapy. Saturation O2 mixed venous blood should be above 60%.

Patients with low RAD, low CVP or DZLA should correct hypovolemia by discrete administration of 250 ml of a 0.9% solution of NaCl. In elderly patients with a moderately reduced CAP (70-80 mm Hg) and normal or elevated CVP / DZLA, it is advisable to initiate inotropic support with dobutamine, starting at a dose of 2-5 μg / kg / min. You can use milrinone or amrinone. In the absence of effect - a drug with a dose-dependent inotropic and vasoconstrictive action - dopamine. An alternative are adrenaline and peripheral vasoconstrictors norepinephrine and phenylephrine. Vasoactive drugs should be used in minimum doses, which allow maintaining the SAD at the lowest acceptable level, because they can increase vascular resistance and reduce organ perfusion, especially in the intestine. These drugs increase the burden on the heart with its reduced reserves. If the RAD remains below 70 mm Hg. Art. In patients with myocardial infarction, intra-aortic balloon counterpulsation is necessary. Patients with normal SAD and high CVP / DZLA are prescribed either inotropic drugs or reduce postload with nitroprusside or nitroglycerin.

Intra-aortic balloon counterpulsation is used at low cardiac output due to reduced left ventricular pump function, refractory to drug treatment. The balloon catheter is guided through the femoral artery retrograde into the thoracic aorta distal to the left subclavian artery. The balloon inflates during each diastole, improving coronary perfusion, and deflates during systole, reducing afterload. The value of this technique lies in the fact that it allows you to gain time in those cases when the cause of heart failure can be eliminated by surgical methods.

Treatment of rhythm disturbance. Although VF or VT can resume after cardiopulmonary resuscitation, anti-arrhythmic agents are not prescribed for prophylactic purposes, since they do not improve outcome. In principle, such rhythm disturbances can be treated with procainamide or amiodarone according to the procedure described above.

Nadzheludochkovaya tachycardia in the postresuscitation period against the background of a high level of endogenous and exogenous catecholamines requires treatment if it is prolonged and is associated with hypotension or signs of coronary ischemia. To do this, the injection of esmolol is administered intravenously, starting at a dose of 50 μg / kg / min.

Patients with cardiac arrest as a result of VF or VT without myocardial infarction are candidates for the use of an implantable cardioverter-defibrillator (ICD). This device recognizes arrhythmia and conducts either defibrillation, or imposes a given rhythm.

Neurological support. In 8-20% of adults who underwent circulatory arrest, there are violations of the central nervous system. Damage to the brain is the result of direct ischemic action on neurons and edema.

The lesion can develop 48 to 72 hours after CPR.

Maintaining adequate oxygenation and cerebral perfusion can reduce the likelihood of cerebral complications. You can not tolerate hyperglycemia, since it can enhance post-ischemic damage to the brain. It is necessary to avoid the appointment of glucose, except for cases of hypoglycemia.

There is no convincing evidence of the benefits of moderate hypothermia. The use of numerous pharmacological agents (antioxidants, glutamate inhibitors, calcium channel blockers) is of high theoretical interest. Their effectiveness is shown in animal models, but has not been confirmed in studies in humans.

Pediatric scale categories of cerebral manifestations

Points	Category	Description
1	Norm	Mental development corresponds to age
2	Easy disorders	Minimal neurological disorders that are controlled and do not affect daily life. Preschool children have a minimal developmental delay, but more than 75% of control markers of daily activity are higher than the 10th percentile. Children attend a regular school, but the class does not match their age, or children complete the appropriate class, but are unsatisfactory due to cognitive disorders.
3	Average disorders	Severe neurological disorders that are not controlled and affect daily life. Most control marks of daily activity are below the 10th percentile. Children attend a special school in connection with cognitive disorders.
4	Severe disorders	In pre-school children, the indicators of daily activity are lower than the 10th percentile, children depend significantly on others in everyday life. Children of school age are not able to attend school, in everyday life depend on others. Abnormal motor activity of preschool and school-age children may include non-targeted, decorticative or decerebral responses to pain.
5	Coma or vegetative status	Unconsciousness
6th	Death

"For the category, the worst manifestation of any criterion is taken into account. Only neurological disorders are considered. Conclusions are made only on the basis of medical records or from the words of the guardian.

[26], [27], [28], [29], [30], [31], [32]

Complications of closed cardiac massage

Damage to the liver - the most severe (sometimes lethal) complication, usually occurs when pressure on the chest is made below the sternum. Gastric rupture is rare, usually when it is stretched by air. Spleen rupture is rare. More often, regurgitation and aspiration of gastric contents occur, followed by the development of aspiration pneumonia, which can be lethal.

Fractures of the ribs can sometimes be avoided, since the tremors must be quite deep enough to provide sufficient blood flow. Children rarely have fractures due to the elasticity of the thoracic cage. Damage to the lung tissue is rare, but pneumothorax can occur with fracture of the ribs. Trauma to the heart in the absence of an aneurysm of the heart is rarely observed. The danger of these reassurance is not a reason for refusing to carry out cardiopulmonary resuscitation.

Monitoring and intravenous access. ECG monitoring is being adjusted. Provides intravenous access; the presence of two vascular access reduces the likelihood of its loss during cardiopulmonary resuscitation. Preferably, peripheral venous access is provided using a large diameter catheter on the forearm. If peripheral access is impossible in adults, access to the central veins (subclavian or internal jugular vein) should be ensured. Intraosseous and femoral approaches are preferable in children. The installation of a long femoral venous catheter, which is performed in the central vein, is very practical, since it does not require the interruption of cardiopulmonary resuscitation, but this procedure is complicated by the fact that it is impossible to palpate the pulsation of the femoral artery. The type of the infusion solution and its volume depend on the clinical situation. Usually a slow infusion of physiological solution is used to maintain open vascular access. When hypovolemia is recommended the introduction of large amounts of crystalloids, colloids and blood products.

Defibrillation

The most frequent rhythm disturbance in stopping blood circulation is VF; it is necessary to carry out cardioversion as soon as possible. VT with ineffective hemodynamics is treated in the same way as VF.

In the absence of the possibility of defibrillation, a precordial stroke is used. A strong precordial stroke is rarely effective, and it is not recommended for children. One or two strokes are made at the border of the middle and lower third of the sternum with a compressed fist from a height of 20-25 cm above the breastbone.

Defibrillation is more effective than antiarrhythmic drugs; although its effectiveness is reduced by 10% with every minute. The contact electrodes of the defibrillator are located between the clavicle and the second intercostal space on the right (from the operator) from the sternum and on the apex of the heart in the 5th or 6th intercostal space. When applying electrodes, an electrically conductive paste or gel is used, in some defibrillators, the conductive material is already embedded in the electrodes. Cardioversion is performed once (previously recommended - 3 times). The discharge energy for two-phase defibrillators is 120-200 J (2J / kg for children); for monophasic - 360 J. Immediately after cardioversion, the heart rate is not evaluated, this is done after 2 minutes of cardiopulmonary resuscitation; at constant monitoring it can be done earlier. Each consecutive discharge produces energy of the same or greater power (maximum 360 J, 2-4 J / kg in children). With persisting VF or VT, drug therapy is performed.

Special circumstances

In the event of an electric shock, make sure that the patient does not come into contact with the source of electricity. To do this, any non-metallic object must move the victim to a safe place to begin cardiopulmonary resuscitation.

When drowning, artificial respiration can begin in shallow water, while for effective heart massage it is necessary to put a person on a hard surface.

If the circulatory arrest occurs after an injury, you must first restore breathing. Movement in the cervical spine should be minimal, without jerking the head forward jaw. In most cases, with severe trauma, closed heart massage will not be effective because of significant blood loss or brain damage incompatible with life. With a cardiac tamponade or a strained pneumothorax, it is necessary to immediately decompress the needle, otherwise all resuscitation will be ineffective.

[33], [34], [35], [36], [37], [38]