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Cardio-Pulmonary Resuscitation. Methods . GUIDELINES FOR STUDENTS The studies of V.A. Nehovskiy and P. Safara PS in the second half of the twentieth century gave the birth to Health critical states, has made considerable progress. Today, a cardio- pulmonary resuscitation (CPR) restores blood circulation in the 17.4 - 58%  and even 61.2% [1,6] patients with sudden cardiac standstill. Thus 18.5% of patients who experienced CPR, live 7 years or more . Weather CPR depends on the start time and the accuracy of the complex resuscitation measures . Every year the world record over 200 thousand resuscitation in the hospital, resulting in the return of life to about 70 thousand patients (approximately 35% of the reanimated) . According V.J. Mayo, in non-medical conditions can revive only 5% of patients . Currently, the development and systematization of standards dealing with CPR American Heart Association (AHA) and the European Resuscitation Council (ERC). For the generalization of research results from CPR, which hold around the world, was created the International Liason Comittee on Resuscitation (ILCOR), who conducted regular reviews by international consensus decisions. Last viewed recommendations were made in the ERC in 2005, Complex measures CPR conditionally divided into 3 stages (immediate, specialized and of post). The first phase (immediate, basic life support phase) should begin immediately on the spot events by anyone who is familiar with the elements of the CPR (see Fig. 1): 1) to pack the victim on his back on solid ground; 2) clinical diagnosis based on the availability of the death of at least 2 major signs (no longer than 10 s): - Pulseless on large arteries (the carotid artery - at the upper edge of thyroid cartilage «the adams apple» , displacing the cushions of index and middle fingers to the internal edge of the sterno-claeido-mastoideus muscle, femoral - on the verge of middle and medial thirds of the inguinal ligament) - Lack of self-breathing (by sight, feeling his breath on the cheek - the tactics of "see, hear, sense of"); - Dilation of the pupils (eyelid lift). 3) to proceed to stage I CPR: Indications and contraindications for the CPR - see Annex 1. Step 1 Call 103 Step 2 Step 4 Straighten his Run 3 head, to bring forward the breaths lower jaw, check breathing Step 3 Step 5 Set hands at center To run 30 chest of the sternum compressions at depths of 4-5 cm Continue CPR 2 breaths: 30 compressions before the arrival of specialized teams Fig. 1. Algorithm of CPR on prehospital stage Stage I - Stage elementary basic life support (immediate period) Objective: Emergency oxygenation, restoring the passability of the respiratory tract 1. Restoring the passability of the respiratory tract with triple method of P. Safara, which consists of straightening of head in the atloido-occipital articulation, put out the lower jaw and open the mouth. To do this, place the palm of one hand so that its edge will be located on the border of the scalp. Other hand, hold the chin (alternate method - to place under neck). Simultaneously by the motion of two hands drive away head in neck- occipital articulation (Figure 2). Fig. 2. Triple method P. Safara 2. For conducting the ventilation of lungs in the victim without the bstruction of the respiratory tract: • to to overlap the nose openings of the victim with a large and index fingers, which lies on the forehead; • Open the victim mouth, hold his chin up top. • Take a normal breath, then spend a quiet breath of the victim's mouth, watching the movement of the chest. The total length of expiration should be about 1 s, corresponds to the amount of respiratory volume of the resuscitator (400-600 ml.). • Keep airways open, check availability passive exhalation. • Repeat shift again, and then immediately start conducting compresses the chest and breaths in a ratio of 30:2. 3. For the artificial pulmonary ventilation in a victim in violation of bstruction of the respiratory tract: • to conduct the revision of oral cavity by forefinger, remove the foreign body, fragments of teeth, vomit, etc. • ensure the passability of the respiratory tract and begin the ventilation of lungs with the most appropriate method: oxygen mask, Ambu bag, air duct, I- gel-mask. The intubation of the trachea is the most reliable method of guaranteeing the passability of the respiratory tract- to introduce air duct after opening the mouth by bend from the tongue, then turn 180 ° and push inward to lock the end of the tube in soft tissue. • Inspiratory time is 1 sec., breathing volume should be 400-600 ml. • In case of intubation of the trachea ventilation with a frequency of 10-12 held for 1 minute, chest compression with a frequency of at least 100 for 1 minute. 4. Deliver precardial impact (if resuscitator it directly observes the cessation of the blood circulation and defibrillator is currently unavailable ). Effective in ventricular fibrillation (VF) in the first 10 seconds since the onset of the cessation of the blood circulation ). In this situation prekardial impact initiate immediate by ulnar surface of fist tightly compressed in the lower half of sternum from a distance of 20 cm, give the nature of the sharp pulse to impact. 5. Start artificial circulatory support. Start chest compression (indirect massage of heart): • Set the side of the victim. • Place the palm of one hand basis so that your fingers are parallel to the outside edge of the lower and middle thirds of the sternum. • arrange the palm of the second hand perpendicular above the first . • Sit upright position above the chest of the victim. • Straighten hand at the elbow and bend them during compression. • Do the compressions with frequency not less than 100 for 1 min and depth 4.5cm • Monitor the return of the chest to the starting position, do not lose contact with the chest. • After 30 compresses do 2 expiration of the victim. Stage II - Stage continue to support life (special period) Purpose: To restore self-circulation. Includes support for the medicament, diagnostic type of arhythmia and heart defibrillation against the background the methods I stages. It should be conducted by specialized team. 1. Pharmacological support. ESR (2005) recommends 2 ways of the njection of drugs: - Intravenous (i/ v) - central (subclavia or jugular) or peripheral veins. In this case, the drug dissolve in 10-20 ml of physiological solution; - Endotracheal - through the catheter to the endotracheal tube. In this case, the dose of drugs will increase by 2 times and dissolve in 5 - 10 ml water for injection. Adrenaline. Once implemented intravenous access, enter 1 mg of adrenaline. Regardless of other action, adrenaline continue to inject in a dose of 1 mg every 3-5 minutes. CPR continue with checking heart rate every 2 minutes and the introduction of 1 mg of adrenaline every 3-5 minutes of resuscitation to restore effective cardiac rhythm or conversion of ventricular fibrillation / ventricular tachycardia (FSH / unit). Atropine. Is the drug of choice in documented asystole in a dose of 3 mg, injected once, bolus; when asystole and bradycardia resistant to atropine enter eufilin 2.4% 250-500 mg (5 mg / kg) v / v. 2. Defibrillation. Ensure that VF/VT takes place in the patientt, place the electrodes in a classical sterno-apical position. Sternal electrode set right from the sternum under collarbone, apical electrode - in mid clavicular line approximately at the ECG electrode V6 (Figure 3). After the first initial level CPR continue to test your heart rate every 2 minutes. Fig. 3. Classical defibrillator electrode placement Possible schemes placing electrodes : • The two electrodes on the surface of the lateral chest - one to the right, second left ; • One electrode in a standard riding position, the second - on the dorsal surface of the chest to the right or left; • One front electrode on the left precardial surface, the second - behind and under the left scapula. Power of pressure on the electrodes should be about 8 kg in case of adult patient . To improve the conductivity of current apply to the contact surface electrode conductor - a special gel, water, saline, etc. Methods of defibrillation: • The doctor who conducts defibrillation, loud sounds, click "discharge", during which he and all members of the brigade did not affect patient and bed. After the discharge, without changes in heart rate determination CPR still continue for 2 minutes. • Quickly check the heart rhythm, and the presence of persistent VF/VT spend a second defibrillator discharge. Energy first and subsequent discharges on unipole defibrillator is 360 J for bipolar - 150 200J with further increases to 360J. • Immediately continue CPR another 2 minutes, then check heart rate. While maintaining VF/VT inject adrenaline and spend directly after it the third the discharge of the defibrillator. Continue CPR another 2 minutes. • Check the heart rate. While maintaining VT/VF immediately inject 300 mg of Amiodarone and spend the fourth defibrillation, continue CPR . The next dose of Amiodarone (150 mg) in refractory type of VT/VF or VT/VF, which has occurred. Over the next 24 hours dose Amiodarone can make up to 900-1200 mg. Lidocaine at a rate of 1 mg / kg can apply as an alternative to Amiodarone in the absence of the latter, but after Amiodarone lidocaine can not enter. • Whether other action, adrenaline 1 mg dose enters every 3-5 minutes. • resuscitation conducted in this mode to restore effective cardiac rhythm, or the conversion of VT/VF (see also annex 2). • The suspected presence a decrease in the level of magnesium in the blood inject of magnesium sulfate (4 ml 50% solution), while lowering blood pH less than 7.1 or increase of potassium inject sodium hydrogen carbonate (50ml 8.4% solution). Stage III - Stage maintenance of long life (the period of post) Purpose: To restore the functions of the brain, postresuscitation intensive care. In the postoperative period are: -Support of normal BP. - Support partial pressure of oxygen and carbon dioxide (PaO2 and PaCo2). - Support normal temperature. Patients without consciousness after the successful SLR recommended body hypothermia (32-340S) for 12-24 hours. - Support normal level of glucose (4,4-6,1 mmol/l). When glucose levels more than 9.1mol/L should assign insulin. Annex 1. Contraindications for the CPR. CPR shows all patients who are in a state of clinical death and have Contraindications. CPR is carried out at [2.3]: 1)signs of biological death; 2)brain death; 3)the terminal stages of chronic illnesses; 4) inoperable malignant formations of metastasis; 5) if you are aware that since the stop of blood circulation has been more than 25 minutes in a normal temperature. Appendix 2. Criteria for termination of resuscitation [2,3] CPR can be terminated when: • reconstruction and the emergence of an independent blood pulse in large arteries and / or restoring self-breathing; • failure of resuscitation measures within 30 minutes; • the development of stable, at least within 30 minutes ofdeath of the heart - electrical asystole (direct line on an electrocardiogram), despite the CPR and pharmacological support; • signs of biological death. Appendix 3. Diagnosis of brain death. According to the order № 226 from 25.09.2000 "On approval of legal documents for transplantation" Health of Ukraine, brain death is defined as the complete and irreversible cessation of all its functions, registering at the heart of running and artificial pulmonary ventilation. Brain death equate to the death of a person. Complex clinical criteria, the existence of which is required for the diagnosis of brain death (order MZ of Ukraine № 226): •Full rack and lack of consciousness (coma). •atonia of muscles. •Lack of response to strong pain irritation. •Absence of pupil response to direct bright light. •Eye apples still. •No corneal reflexes. •No oculocefalic reflexes. •No oculo-vestibular reflexes. •No pharyngeal and tracheal reflexes. •Lack of independent breathing. Tests confirming the complex clinical criteria in the diagnosis of brain death as follows: • Definition of absence of cerebral blood flow (according transcraneal dopler- sonography three times at intervals of not less than 30 minutes). • Definition of lack of oxygen brain learning cloth (no arteriovenous difference of partial pressure of oxygen). It should be noted that the use as supporting tests and electroencephalography pananhiohraphy not provided by the Order № 226 from 25.09.2000h. "On approval of legal documents for transplantation", Ministry of Health of Ukraine. Diagnosis of brain death establishes a council of doctors. After the death of brain resuscitation measures, including artificial pulmonary ventilation may be terminated. References: 1. Глумчер Ф.С., Москаленко В.Ф. Неотложная медицинская помощь. Киев.: «Медицина», 2008. - с.52-53. 2. Дубров С.А., Глумчер Ф.С. Серцево-легенева реанімація// Внутрішня медицина, 2008. – с. 46-51. 3. Усенко Л.В, Царев А.В. Сердечно-легочная и церебральная реанимация. Практическое руководство, Днепропетровск, 2008. – с. 35-36. 4. Rosenberg M., Wang C. et al. Results of cardiopulmonary resuscitation: failure to predict survival in town community hospital // Arch. Intern. Med. – 1993. – Vol. 153(11). – р.1370 – 1375. 5. Abella B.S., Sandbo N. et al. Chest compression rates during cardiopulmonary resuscitation are suboptimal // Circulation. – 2005. – Vol. 111(2). – P 428 – 434. 6. Zoch T.W., Desbiens N.A. et al. Short- and long-term survival after cardiopulmonary resuscitation // Arch. Int. Med. – 2000. – Vol. 160(7). – P. 1969 – 1973. 7. Mayo V.J. The quest to improve cardiac arrest survival: overcoming the hemodynamic effect ov ventilation // Crit Care Med. – 2005. – Vol. 33. – P. 898 – 899. 8. Anthony J. Handley, Rudolph Koster, Koen Monsieurs, Gavin D. Perkins, Sian Davies, Leo Bossaert. European Resuscitation Council Guidelines for Resuscitation 2005 Section 2. Adult basic life support and use of automated external defibrillators. - P. 4 – 10. 9. Safar P. Reanimatology – the science of resuscitation // Critical Care Medicine/ - 1982. – V. 10, №2. – P.134-136. 10. Caldwell G., Millar G., Quinn E. Simple mechanical methods for cardioversion: defence of the precordial thump and cough version // Qr. Med. J. - 1985. – V. 291 – Р. 627-630. 11.Kohl P., King A.M., Boulin C. Antiarrhythmic effects of acute mechanical stiumulation. In: Kohl P., Sachs F., Franz M.R., editors. Cardiac mechano-electric feedback and arrhythmias: form pipette to patient. Philadelphia: Elsevier Saunders, 2005. - p. 304-314. 12.Charles D. Deakin, Jerry P. Nolan. European Resuscitation Council Guidelines for Resuscitation 2005 Section 3. Electrical therapies: Automated external defibrillators, defibrillation, cardioversion and pacing. - P. 27. 13.Deakin C., Sado D., Petley G., Clewlow F. Determining the optimal paddle force for external defibrillation/Am. J. Cardiol. – 2002. - V. 90. – P. 812- 813. 14.Jerry P. Nolan, Charles D. Deakin, Jasmeet Soar, Bernd W. Bottiger, Gary Smith. European Resuscitation Council Guidelines for Resuscitation, 2005. Section 4. Adult advanced life support. - P.44 – 52.
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