Emergency cardiopulmonary resuscitation and defibrillation measures: review and implementation algorithms

Imprint

Elena N. Kamenskaya, Konstantin V. Kamyshev. Emergency cardiopulmonary resuscitation and defibrillation measures: review and implementation algorithms. Cardiometry; Issue No. 30; February 2024; p. 50-54; DOI: 10.18137/cardiometry.2024.30.5054; Available from:

Emergency cardiopulmonary resuscitation is needed for various sudden conditions, in particular, it is first aid in case of circulatory arrest. Cardiac arrest can be caused by many circumstances, including heart disease and accidents. The main signs of a heart attack are: chest pain, shortness of breath, loss of consciousness and cardiac arrhythmia. If you suspect a heart attack, you should call an ambulance and immediately provide first aid to the victim. Stopping blood circulation leads to disruption of the oxygen supply to all 50 | Cardiometry | Issue 30. February 2024

organ systems, which leads to the death of all cells in the body. Therefore, assistance must be provided in a timely, correct and fast manner. Every second counts. Therefore, if you witness a situation where a person’s heart and breathing stop, you should know how to behave and what to do, because the person’s life is in your hands.

Although almost all of us have some knowledge in the field of first aid, in most cases it is a bizarre mixture of stereotypes that are completely inapplicable in practice. For example, everyone has an idea of what chest compressions and artificial respiration are. However, not everyone knows in what situation cardiopulmonary resuscitation is necessary and how to carry it out correctly.

Cardiopulmonary resuscitation is a set of measures aimed at returning a person to life in the event of circulatory or respiratory arrest.

In general, all activities can be divided into two large groups: basic and specialized cardiopulmonary resuscitation (CPR).

Specialized, as the name suggests, is carried out in specialized wards and requires appropriate equipment and medications, as well as education. Here we will consider only the problems of basic resuscitation [1-4].

When is CPR necessary?

Indications for CPR: complete ignorance of the victim, that is, loss of consciousness, breathing, pulse in the carotid arteries, preagonal, agonal states, clinical death. These simple factors indicate that it is time to move on to active resuscitation efforts. Diagnosis of cardiac (circulatory) and respiratory arrest should take no more than 10 seconds!

If the heartbeat is audible, the pulse and breathing are maintained and even quite rhythmic, resuscitation measures are not required [5-7].

Basic cardiopulmonary resuscitation includes three stages (ABC):

– clearing the respiratory tract from foreign objects;

– performing artificial respiration;

– indirect cardiac massage.

Examination of the victim

First, it is necessary to assess the presence of injury, especially to the head or neck; If there is a suspicion of injury, the victim should only be moved if absolute- ly necessary. Ensure airway conductivity and assess spontaneous breathing. After this, you can lightly pat the patient on the shoulder or shake him while asking aloud a question, for example: “Is everything okay?”

The actions can be described point by point as follows:

First, the victim should be placed on his back on a hard, flat surface. In this case, you should turn “as a whole,” avoiding the movement of body parts relative to each other or their rotation.

Second: empty your mouth of liquid contents (with the index and middle fingers wrapped in a piece of cloth) and solid foreign bodies (with the bent index finger). Then, keep your upper airway open by tilting your head back and lifting your chin or pushing your lower jaw forward. If a head or neck injury is suspected, only the mandible is moved forward.

Third: put your ear to the victim’s mouth and nose and evaluate the movements of the chest during inhalation and exhalation, the presence of exhaled air noise and the sensation of air movement (the assessment should not take more than 10 seconds).

Fourth: if, after securing the airway, breathing is restored and signs of circulation appear, the victim should turn on his side and place his head so that fluid can flow freely from the mouth.

If there is no breathing, you should proceed to the next stage – performing artificial respiration.

In the absence of special equipment (for example, a bag for AMBU), mouth-to-mouth breathing is most effective, which is carried out immediately after ensuring the airway is open [8-10].

The main disadvantage of this method is the presence of a psychological barrier: it is difficult to force yourself to breathe into the mouth or nose of another person, sometimes a stranger and stranger, especially if he has previously vomited.

With your left hand, holding the victim’s head in an inclined position, at the same time cover the nasal passages with your fingers to ensure a tight seal. Then you need to take a deep breath, wrap your lips around the victim’s mouth, and blow. The mouth is first closed for hygienic purposes with any clean substance.

This procedure should be repeated at a frequency of 10-12 breaths per minute (once every 5-6 seconds). Volume: 500-600 ml of air (6-7 ml/kg). Passive exhalation should be complete (time does not matter), another breath of air can be taken when the chest drops.

The main criterion for the effectiveness of artificial respiration is the movement of the chest during inhalation and exhalation, the sound of exhaled air and the sensation of its movement. If this is not observed, it is necessary to re-clear the airway and also ensure that there is no blockage (for example, a foreign body) at the level of the larynx.

When the victim shows signs of spontaneous breathing, artificial ventilation does not stop immediately, it continues until the number of spontaneous breaths reaches 12-15 per minute. At the same time, if possible, synchronize the rhythm of inhalations with the restored breathing of the victim [11-12].

Assessment of blood circulation is carried out in parallel with artificial respiration; it is necessary to determine the pulsation in the carotid or femoral arteries: lightly press with two to three fingers on the hole between the lateral surface of the larynx and the muscle roll on the lateral surface of the neck.

In addition, non-professional rescuers are recommended to additionally be guided by indirect signs: breathing, coughing, movements of the victim in response to artificial respiration (the assessment should not take more than 10-15 seconds).

After making sure that the patient has no cardiac activity, it is necessary to begin performing indirect (closed) cardiac massage.

The rescuer’s hands are placed on the victim’s sternum 2-3 cm above the xiphoid process – the part of the sternum located below the attachment point of the rib cartilage. Hands are placed one on top of the other (“locked”) in the lower third of the sternum.

Before starting chest compression, it is necessary to take 2-3 intense breaths of air into the victim’s lungs and strike with a fist in the area of the projection of the heart (precordial blow). Sometimes this is enough to get the heart “working” again, while a “full blow” to the sternum is unnecessary and dangerous, it can break a person’s ribs. After this, chest compressions begin in the anteroposterior direction by 2.5-5 cm with a frequency of 80-100 times per minute.

The efforts are performed strictly vertically in the lower third of the sternum using crossed wrists and arms extended at the elbows, without touching the chest with the fingers. The compression and release of the compression should take the same amount of time; when the compression stops, the hands do not leave the chest.

At the same time, artificial respiration and closed cardiac massage are performed.

Then, if resuscitation is performed by a person, 15 chest compressions should be alternated with two breaths, or two to 5 chest compressions should be alternated with one breath, stopping chest compressions for 1-2 seconds while blowing air into the lungs.

Mouth-to-mouth breathing poses a hazard to the rescuer and can cause infection. It is believed that indirect cardiac massage can be performed without artificial ventilation, if there are no special devices for artificial respiration: an AMBU bag, a ventilator, etc. However, this method is less effective and artificial respiration should be performed if possible.

Monitoring the victim’s condition during resuscitation

After every 4 cycles of artificial respiration and chest compressions, it is necessary to check the pulse in the carotid artery (within 3-5 seconds). When a pulse appears, indirect cardiac massage should be stopped and spontaneous breathing assessed.

If it is not there, artificial respiration should be continued, determining the pulsation in the carotid artery after every 10 breaths of air into the lungs.

When spontaneous breathing is restored and there is no consciousness, it is necessary to maintain the patency of the upper respiratory tract and carefully monitor the presence of breathing and pulsation in the carotid artery until the arrival of the resuscitation team.

Irreversible changes in the brain occur within 3-4 minutes from the moment blood circulation stops, so timely assistance and the start of resuscitation measures are of great importance. Refusal to use resuscitation measures or their cessation is permissible only if biological death is established or if these measures are absolutely useless.

In parallel with resuscitation efforts (without interrupting them), it is necessary to call an ambulance and diagnose the victim’s condition.

Masks for artificial respiration and their types

There are also masks available to provide safe and effective artificial respiration to maintain oxygen saturation in the blood and save a person’s life in the event of cardiac or respiratory arrest. There are several types of such masks:

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Clear masks: Clear masks allow you to see the patient and perform necessary medical procedures such as artificial respiration.

Faceless Masks: Faceless masks eliminate the possibility of cross-contamination and ensure the safety of the rescuer and patient.

Adjustable Elastic Strap: An adjustable elastic strap allows you to secure the mask behind the victim’s head, ensuring a snug, secure fit to the face.

Oxygen Tubing: The bottom of the mask has a port for connecting an oxygen tube, which allows you to supply additional oxygen and speed up the resuscitation of the patient.

Individual Cases: Masks often come with individual cases for storage and carrying.

Preservation and Shelf Life: CPR masks usually come complete with instructions and recommendations for preservation and shelf life.

It is important to note that CPR masks are universal and suitable for use by both medical professionals and citizens to provide first aid in the event of a heart attack. CPR masks are manufactured by many companies in various countries such as the USA, China, Germany, Japan and others. The use of CPR masks replaces the traditional mouth-to-mouth technique and reduces the risk of cross-infection.

In the future, we can expect further developments in CPR masks, including improvements to existing technologies, the introduction of new approaches to patient care, and increased public awareness of the importance of using CPR masks.

Cardiopulmonary resuscitation is carried out in accordance with algorithms developed by the National Council for Resuscitation of Russia and the European Council for Resuscitation. The main methods of CPR are artificial heart massage and artificial respiration. In cases where vital functions are preserved, devices for cardiopulmonary resuscitation reduce pain to a minimum.

Electrical defibrillation of the heart

The main indication for electrical cardiac defibrillation (EDC) is ventricular fibrillation. This is a variant of arrhythmia in which the ventricles contract at a chaotic and rapid pace (250 or more contractions per minute). This leads to a sharp decrease in the volume of blood removed from the heart and a huge expenditure of energy on the heart cells [13,14].

Fibrillation always occurs suddenly. Lack of effective blood circulation leads to loss of consciousness, and then to clinical (reversible) and biological (irreversible) death.

In absolutely all cases of ventricular fibrillation, defibrillation is used. It is able to restore normal heart rhythm. Under the influence of a powerful short-acting electrical discharge, depolarization (activation) of heart cells occurs. Then comes a period of refractoriness – immunity to excitability, after which the pulse of the SA node can restore normal heartbeat.

EDS is also carried out in the following cases:

– ventricular tachycardia with signs of circulatory arrest (lack of pulse in large arteries and loss of consciousness);

– paroxysmal supraventricular tachycardia;

– atrial fibrillation and flutter.

In the last two cases, defibrillation is carried out in a synchronized mode and is called synchronized electrical cardioversion. This is a type of treatment for arrhythmias. In this case, impulses are used that act on the myocardium in a strictly defined phase of heart contractions.

Based on the shape of the generated pulse, two-phase and single-phase defibrillators are distinguished. Currently, two-phase charging is used in almost all device models. The current passes through the heart, then changes polarity and passes through the myocardium again. As a result, less energy is required to restore heart rhythm, and the risk of tissue damage is lower. Recommended defibrillation settings for adults are 360 J single-phase and 200 J biphasic.

From a practical point of view, devices come in several types. The device package usually consists of: – monitor unit with electrocardiogram;

– defibrillation unit with electrodes;

– replaceable battery;

– charger.

Defibrillator monitors are used in medical clinics and can operate not only from a 220 V mains voltage, but also autonomously in case of electrical problems.

Portable models are a separate option. They are typically smaller and lighter, allowing defibrillators to be used in emergency ambulances and can also be used by cardiac (and other) emergency care teams. As for their configuration and technical capabilities, they may not be inferior to conventional ones.

Depending on the operating mode, there are manual and automatic defibrillators. Automatic devices perform the functions of heart rate analysis, marking and load shedding by the operator. The process is ac- companied by voice or text prompts, which simplifies resuscitation efforts. In a manual defibrillator, all these functions rest on the shoulders of the operator.

Features of defibrillators may include various operating modes, ECG monitoring capabilities, automatic heart rate detection, the ability to adapt to patient characteristics, built-in defibrillation electrodes, etc.

Complications after defibrillation procedure

With defibrillation, burns are the main complications; arterial thromboembolism is less common. Burns are explained by powerful discharges and are treated with corticosteroid ointments. Thromboembolism is much more difficult to treat; thrombolytics and blood thinners are used, and sometimes emergency surgery is required.

But these complications justify the goal: emergency saving of the patient’s life. When choosing elective cardioversion, it is necessary to carefully evaluate possible negative consequences.

The same consequences are possible here:

– Ventricular fibrillation. This happens rarely, usually in case of non-compliance with technical rules.

– A sharp decrease in blood pressure is treated by increasing it with the introduction of vasopressors.

– Atrial and ventricular extrasystoles.

– Pulmonary edema. It does not appear immediately, but after a few hours. It is treated with diuretics, antispasmodics and oxygen inhalations.

Well-known defibrillator manufacturers include Zoll Medical Corporation, Philips Healthcare, Medtronic, Cardiac Science, Defibtech and Heartsine Technologies.

The main manufacturer of defibrillators is the American company Medtronic. It specializes in the production of medical devices and occupies a leading position in the global market.

Some defibrillators may include a compact design for easy portability, an intuitive user interface for quick and efficient use, self-diagnosis capability for readiness for use, and the ability to record heart rate and defibrillation procedure data for further analysis.

The development of defibrillators can be divided into several stages:

First stage: The beginning of the development of electrical defibrillation is associated with the accumulation of empirical knowledge, which began to form at the end of the 18th – beginning of the 20th centuries

Second stage: during this period, the first electrical defibrillators were developed, which were used to restore heart rhythm in case of cardiac arrest

Third stage: As a result of improvements in technology and the introduction of new technologies, such as the development of microprocessors, defibrillators were reduced in size and increased in efficiency

Currently, companies such as Medtronic continue to work on improving and developing next-generation defibrillators, including cordless and hybrid designs.

Statistics on the use of defibrillators show that they play an important role in saving lives during heart attacks. Using a defibrillator within the first minutes of cardiac arrest can significantly increase a patient’s chances of survival. Thus, their availability and use in public places such as airports, shopping malls, sports facilities, etc. is becoming an increasingly common practice.

In the future, we can expect further developments in medical defibrillators, including improvements to existing technologies and the introduction of new approaches to treating patients in cardiac arrest. However, it is worth noting that despite technological advances, defibrillators remain medical equipment that requires strict regulation and monitoring.

CONCLUSIONS

Thus, it can be concluded that first aid in the event of cardiac or respiratory arrest, as well as acute heart failure, plays a decisive role in saving lives. Using cardiopulmonary resuscitation and defibrillation measures in the first minutes after the problem appears can significantly increase the patient’s chances of survival. Statistics on the use of defibrillators show that their availability and accessibility in public places is becoming an increasingly common practice, helping to improve the system of first aid for heart attacks and respiratory arrest. However, to improve the effectiveness of medical care, it is necessary to continue to educate the population and ensure the availability of equipment in different countries and regions.