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ОБЗОРЫ ЛИТЕРАТУРЫ
© КОЛЛЕКТИВ АВТОРОВ, 2015 УДК 616.012.08-08
G. S. Zhumabekova, G. N. Azhimetova, B. S. Orazbayeva, Y. L. Ganzhula, A. A. Eshetova, M. A. Kim, N. M. Kazhikenov
FROM THE HISTORY OF CARDIO-PULMANATORY RESUSCITATION
Department of Emergency aid №2 of Karaganda State Medical University the Chair of Department
The article analyzes the literature data on the evolution of algorithms of cardiopulmonary resuscitation. All over the world the problem of human revival at sudden death remains topical, therefore an approach to basic cardiopulmonary resuscitation is globally reconsidered: sequence of basic measures for life support are modified A-B-C (clearing the airway, artificial respiration, chest compressions) to C-A-B (chest compressions, clearing the airway, artificial respiration).
Keywords: (cardiopulmonary resuscitation, indirect heart massage, artfficial pulmonary ventilation, sudden death
Cardiopulmonary resuscitation has always been and remains relevant among the main activities on life support at sudden coronary death, performed by all regardless of whether they are qualified medical workers or non-professionals [34].
History of resuscitation numbers centuries. Even in 1543 Vesalius described intermittent positive pressure pulmonary ventilation, However, the set of measures that can be called cardiopulmonary resuscitation (CPR) was formed in the middle of the XX centuries to the present day has not undergone fundamental changes [16].
According to the definition of CPR is a complex of measures aimed at revival in the event of circulatory or respiratory arrest [22, 28, 33].
In the analysis of statistical data it was identified that the prevalence of sudden coronary death is 0,36 to 1,28 cases per 1000 population per year. In the USA there are 250 000 - 500 000 cases of death each year, in Russia there are 200,000 cases. Most common cause of sudden death is myocardial infarction. CHD is diagnosed at 80% of deaths from sudden death, almost 50% of all dead from MI die in the first hour of the disease [12, 31].
By definition of European Society of Cardiology, sudden cardiac death (primary respiratory arrest) is the death in presence of witnesses that has come instantly or within 6 (even one) hours, most commonly caused by ventricular fibrillation and which doesn't have signs that allow to make a diagnosis other than CHD, less often in cases of other diseases or cardiac abnormalities (aortic stenosis, cardiomyopathy, long QT syndrome and others) [25].
The death of organism does not occur at the moment of cardiorespiratory arrest. Between life and death there is «a kind of transition state, which is not yet a death, but cannot be called a life» (V. A. Negovsky). This condition is called
clinical death and may be reversible. During this period, irreversible cell damage, especially of CNS, as yet not available [22].
Basic principles of cardiopulmonary resuscitation (CPR) were published in the papers of V.A. Negovsky, P. Safar as early as 1954 - 1960. They have proved the effectiveness of chest compressions, the necessity of doing it in combination with ALV and the importance of restoring airway patency. More than forty years of experience in the application of complex of measures of CPR around the world proved the possibility of reviving a dead. However, the results of CPR, particularly in the pre-hospital stage, still leave much to be desired [22, 28].
Principles of cardiopulmonary resuscitation described in domestic modern diagnostic and treatment protocols, correspond to modern world idea. According to the principles a brain experiences a lack of blood flow only for 2-3 minutes -precisely for this period of time reserves of glucose in the brain is enough to ensure energy metabolism in anaerobic glycolysis, therefore resuscitation should begin with cardiac performance prosthetics, the main task - to provide blood perfusion for brain [3, 7].
Modern research has shown that despite the fact that the maximum promptness in CPR delivery in cardiac arrest remains a matter of life and death, its surplus can then have a negative impact on the health of resuscitated [26].
According to Russian scientists effectiveness of CPR outside the hospital in many ways is not only medical but also social problem. In the fate of the patient many things, but not all, depend on knowledge, skills, good equipment and rapid arrival of primary care physicians. It is important that each person who witnessed the occurrence of sudden death could properly and as soon as possible to begin the basic CPR. In the first place, initiators in educating the public to
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CPR should be experienced doctors of prehospital stage [19].
Studies of a number of leading both domestic and foreign authors have made changes to the methodology of providing resuscitation. CPR is no longer limited to chest compressions and ALV, but already includes advanced resuscitation techniques and intensive therapy at the pre -hospital stage, which methods of conducting is selected depending on the mechanism of circulatory arrest [1, 2, 4, 5, 6, 9, 10, 13, 14, 15, 17, 18, 21, 23, 27, 32, 35].
The modern concept of resuscitation from cardiac arrest is reflected in materials and recommendations of the National Conference of the United States, dedicated to resuscitation and emergency cardiac care, which was published in the Journal of the American Medical Association (JAMA) in 1992 [8].
Despite the fact that in initial submission P. Safar recommended sharply restrict the use of "precordial thump" (precardiac blow), conducted in Russian studies have shown that timely applied precordial thump is able to restore cardiac activity during ventricular fibrillation, ventricular tachycardia, and a systole.
In 1999, Russian scientists has first published algorithm of CPR, including precordial thump (sharp pressing in the center of the sternum) and composed by first letters of resuscitation steps abbreviation UNIVERSAL:
• thump (precardiac);
• indirect heart massage (IHM);
• artificial lung ventilation (by perforce);
• venipuncture (catheter needle in external jugular vein);
• E (ECG);
• discharge (countershock, defibrillation);
• stimulation (pacing) / Soda, intake;
• adrenaline and/or Atropine and/or Amiodaron and/or Lidocaine (depends on the type of circulatory arrest identified by ECG).
Information of the American Heart Association (AHA), researches published before and after 2005, have shown: quality of chest compressions requires improvement, despite the fact that implementation of AHA recommendations for CPR and emergency care for cardiovascular diseases from 2005 has led to improved quality of CPR and survival rates; survival rates from cardiac arrest outside the medical institutions vary depending on the service providing ambulance emergency care; majority of affected by sudden death outside the medical institution does not receive care (CPR) from bystanders [10, 30].
Numerous researches and their results have significantly changed approaches to the
CPR, thus AHA recommendations for CPR and emergency care for cardiovascular diseases from 2010 stress the importance of high-quality CPR: frequency of compressions must be not less than 100 compressions per minute (instead of «about 100 compressions per minute»); depth of impression must be not less than 5 cm for adults and not less than 4 cm for children; (depth of impressions were increased for adults: instead of 4-5, at least 5 cm, for children: increase in the depth is significant); thorax must recover after each compression; intervals between compressions must be minimal; the need to avoid excessive ventilation. Recommended ratio of «compression-breath» 30:2 in helping adults and children (except infants) by one person has not changed. In 20l0 AHA recommendations for CPR and emergency care for cardiovascular diseases have suggested to replace the sequence of basic measures for life support A-B-C (clearing the airway, artificial respiration, chest compressions) to C-A-B (chest compressions, clearing the airway, artificial respiration) [5, 9].
Results of the study of tens of thousands of peer-reviewed researches in the field of intensive care in 29 countries over 36 months allowed a conclusion that cardiac arrest more often occurs among adult patients. The highest level of survival after cardiac arrest was observed among the victims, whose cardiac arrest took place in the presence of witnesses and was accompanied by ventricular fibrillation. The most important initial measures to maintain vital functions of such patients are compressions and timely defibrillation that are performed with delay by using the sequence A-B-C, when there is a time delay in liberation of the airways, preparation of the ventilator. When using C-A-B compressions will start earlier, artificial respiration will be performed with minimum delay necessary to carry out the first cycle of 30 compressions that will take time - about 18 seconds. The new sequence of CPR, beginning with chest compressions (C-A-B) used if the adult victim is unconscious, not breathing or breathing not properly. Thus, breathing is checked simultaneously with the check for presence of cardiac arrest. After the first series of compressions re-suscitator releases the airways and makes 2 breaths [11, 20].
Modern «European» point of view: when ventricular fibrillation with circulatory arrest occurred in front of witnesses, and the defibrillator is not immediately available, it is possible to apply precordial thump. In the presence of a defibrilla-tor, you must immediately apply one unsynchro-nized electric discharge of monophasic shape 360 J or biphasic shape 150-360 J (required energy
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depends on the model of device; in the absence of information, maximum energy discharge should be used). If, after the development of VF several minutes have passed or time of its origin is unknown, it is necessary to begin cardiopulmo-nary resuscitation (closed cardiac massage with artificial respiration in combination 30:2) and to continue it at least for 2 min till attempts of defibrillation [10, 11, 20].
It is proved that the survival rate in VF depends on two factors: the time of defibrillation and maintaining perfusion coronary circulation. Continuous chest compression is the only way to maintain coronary perfusion pressure. Therefore, CPR should be started not with lung ventilation, but with chest compressions or applying an electrical charge as soon as possible [11, 19, 20].
Modern «American» point of view: in ventricular fibrillation it is not recommended to start defibrillation with high discharge. Researches in health care settings and outside showed that bi-phasic discharge pulses which energy corresponds to 200 J of monophasic pulses and lower are equal or even more effective for the termination of ventricular fibrillation. Due to the differences in shape of the pulses, the energy value in a range from 120 to 200 J recommended by the manufacturer for the corresponding pulse shape should be used. Based on the available data, if ventricular fibrillation cannot be stopped with the first biphasic pulse, the energy of following pulses must be not less than the energy of the first pulse or higher if possible (200 - 300 - 360 J) [11, 20].
Thus, all over the world the problem of human revival at sudden death remains topical, in 2010 approach to basic cardiopulmonary resuscitation was globally reconsidered: sequence of basic measures for life support are modified A-B-C (clearing the airway, artificial respiration, chest compressions) to C-A-B (chest compressions, artificial respiration, clearing the airway); a frequency of compressions must be not less than 100 compressions per minute; depth of impression must be not less than 5 cm for adults and not less than 4 cm for children; intervals between compressions must be minimal; recommended ratio of «compression-breath» 30:2 in helping adults and children (except infants).
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Received 16.03.2015
Г. С. Жумабекова, Г. Н. Ажиметова, Б. С. Оразбаева, Ю. Л. Ганжула, А. А. Ешетова, М. А. Ким, Н. М. Кажикенов ИЗ ИСТОРИИ СЕРДЕЧНО-ЛЕГОЧНОЙ РЕАНИМАЦИИ
Проведен анализ литературных данных об эволюции алгоритмов сердечно-легочной реанимации. Во всем мире остается актуальным вопрос оживления человека при внезапной смерти, однако результаты сердечно-лёгочной реанимации, особенно на догоспитальном этапе, оставляют желать лучшего. В настоящее время на мировом уровне пересмотрен подход к базовой сердечно-легочной реанимации: изменена последовательность основных мероприятий по поддержанию жизнедеятельности А-В-С (освобождение дыхательных путей, искусственное дыхание, компрессионные сжатия) на С-А-В (компрессионные сжатия, освобождение дыхательных путей, искусственное дыхание).
Ключевые слова: сердечно-легочная реанимация, непрямой массаж сердца, искусственная вентиляция легких, внезапная смерть
Г. С Жумабекова, Г. Н. джметова, Б. С. Оразбаева, Ю. Л. Ганжула, А. д. Ешетова, М. А. Ким, Н. М. Кажыкенов ЖYРЕК-eКПЕ РЕАНИМАЦИЯСЫНЫН ТАРИХЫНАН
Макалада жYрек-тамыр реанимациясы бойынша мэселелерге эдебиетлк талдау жасалFан. ДYниежYЗi бойынша адамнын кенеттен елу^ен кешн кайта тiрiлуi непзп мэселе болып отыр. Бiрак, жYрек-тамыр реанимациясынын нэтижелер^ эаресе госпитaльFa дей^п кезенде, тек жаксылыкты ттеуге мэжбYрлейдi. К,аз1рп кезде элемдк денгейде жYрек-тaмыр реанимациясынын базасына кол жетюзу карастырылуда: емiрге кажетт кызметтердi колдаудын бaFыттaмaсы А-В-С-дан (тыныс жолдарын босату, жасанды дем алдыру, жYрек компрессиясы) С-А-В-ра (жYрек компрессиясы, тыныс жолдарын босату, жасанды дем алдыру) езгертшдк
Клт сездер: жYрек-екпе реанимациясы, жYректiн ткелей емес массажы, екпенщ жасанды вентиляциясы, кенеттен елiм.
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