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Heart attack, stop, complete cardiac arrest.
Patients with cardiac arrest.
The most important therapy for cardiac arrest is timely defibrillation with minimal interruptions between chest compressions
1. Start chest compression if none of the passers-by has started the procedure or replace the passerby with a person who has already started chest compression, at this time the second rescuer brings, adjusts the external automatic defibrillator or manual defibrillator
a) if CPR is performed correctly by an outsider or if cardiac arrest occurs in front of EMF workers, immediately start analyzing heart rhythms and defibrillate (if necessary);
b) it is justified to modify the provision of assistance depending on the most likely cause of cardiac arrest;
c) there is insufficient evidence for or against defibrillation delay for short-term CPR in ventricular fibrillation/ventricular tachycardia without pulse at the pre-hospital stage;
d) in adults and children with cardiac arrest and no monitoring or in whom an automatic external defibrillator is not immediately available, it is advisable to initiate CPR in preparation for defibrillator use if indicated.
2. The maximum value on the defibrillator should be used for initial and subsequent defibrillation attempts. The defibrillation dosage should be in accordance with the manufacturer’s recommendations in the case of two-phase defibrillators. If the manufacturer’s recommendation is unknown, use the maximum possible setting. In the case of monophasic devices, the installation should be 360 J (or 4 J/kg for children).
3. Chest compression should continue immediately after defibrillation without stopping to check the pulse for the next 2 minutes, regardless of the indication on the heart monitor.
4. All measures must be taken to avoid interruptions in chest compressions, such as pre-charging the defibrillator and pressure on the chest, and not to withdraw during defibrillation.
5. If possible, you need to get in/in or in/out access. Introduce epinephrine during the first or second compression cycle.
6. Continue the cycle of chest compressions for 2 minutes, then rhythm analysis and unstable heart rhythm defibrillation; during this time period, the proper airway management strategy is not defined and there are many airway control options. Regardless of your airway control and ventilation strategy, consider the following principles:
6.1. Airway patency control strategy should not interrupt chest compressions.
6.2. Successful resuscitation in the event of cardiac arrest mainly depends on effective continuous chest pressures and proper defibrillation; airway patency control is secondary at this stage and should not interfere with compressions and defibrillation.
Options for controlling airway patency:
a) passive ventilation:
b) ventilation with an AMBU bag with a frequency of 10 breaths/min (one breath every 10 presses) is performed during the return of the chest walls to normal (and not at the time of pressing the chest), without interrupting the pressing;
c) ventilation with an AMBU bag with a frequency of 30:2 (number of presses: number of breaths) – every 30 presses are accompanied by 2 breaths with a bag, after which pressing on the chest immediately continues:
d) installation of intubation tubes:
6.3. When working with children: the ventilation volume should help raise the walls of the chest.
7. Apply one of the antiarrhythmic drugs for persistent ventricular fibrillation/pulseless ventricular tachycardia:
a) the main purpose of using antiarrhythmic drugs for ventricular fibrillation and ventricular tachycardia without pulse, is to restore and maintain a spontaneous perfusion rhythm consistent with the shock cessation of ventricular fibrillation/ventricular tachycardia, some antiarrhythmic drugs are associated with a high rate of restoration of spontaneous circulation and hospitalization however, none provided long-term survival or survival without further neurological problems:
b) there is insufficient evidence to support routine use by EMF specialists of lidocaine and beta-blockers after cardiac arrest. There is insufficient evidence to recommend for or against routine initiation or continuation of other antiarrhythmic drugs after restoration of spontaneous circulation from cardiac arrest;
c) with pirouette tachycardia, inject magnesium sulfate 2 g IV (or 25-50 mg/kg for children). There is insufficient evidence to recommend for or against routine use during cardiac arrest.
8. Remember the reverse reasons for stopping blood circulation, including:
a) hypothermia – in addition to treatment, active warming is performed (see instruction “Hypothermia/Influence of cold environment”);
b) patients on dialysis or with a history of hyperkalemia – should receive in addition to treatment:
c) overdose of tricyclic antidepressants – in addition to treatment, sodium bicarbonate 1 mEq/kg (50 mmol) IV is added;
d) hypovolemia – in addition to treatment, 2 liters of saline IV (or 20 ml/kg, with the possibility of repeating up to 3 times in children) are added;
f) if the patient with cardiac arrest is intubated, check for the presence of strained pneumothorax and the correct location of the endotracheal tube;
e) if stressed pneumothorax is suspected, perform needle decompression. Assess the location of the endotracheal tube, in case of incorrect position, replace the tube.у.
9. If spontaneous circulation is restored during resuscitation, proceed according to the instruction “Assistance to adult patients after restoration of spontaneous circulation.”
10. If resuscitation is ineffective, you can stop it (see. instruction “Termination of resuscitation measures”).
1. Effective pressure and defibrillation are the most important components of resuscitation during cardiac arrest. A sign of effective pressing is:
a) pressing frequency is not less than 100 and not more than 120/min;
b) the depth of pressure on the chest is not less than 5 cm and not more than 6 cm in adults and children or 4 cm in babies; the depth of pressure in adolescents of puberty is the same as in adults;
c) allow the chest to fully return to its original position after each pressing on the chest – spreading of the chest (do not rely on the chest);
d) minimize interruptions between presses;
d) avoid EMF fatigue by changing every 2 minutes. Some EMF crews use the tactic of placing one rescuer on each side of the chest, replacing each other every minute or every 100 clicks.
2. Avoid excessive ventilation and be aware of the possibility of delaying airway control. If you do not need special ducts, consider the following:
a) passive ventilation using a non-reversible mask for 3-4 cycles of pressure on the chest (if a certain etiology of cardiac arrest is suspected). Apply AMBU ventilation bag or epiglottic duct after 3-4 cycles;
b) ventilate with an AMBU bag every 10-15 continuous presses on the chest. Ventilation occurs during the rise of the walls of the chest. For adults, the ratio of compressions to breaths is 30:2, for children 15:2 in the presence of two EMF workers;
c) after installation of the endotracheal tube, the ventilation frequency should not exceed 10 breaths/minute (1 inhalation every 6 seconds or 1 inhalation every 10 presses) in adults. In children, in case of installation of an intubation tube, the recommended frequency of ventilation is 1 breath every 3-5 seconds (12-20 breaths/minute).
3. The caprograph should be used to monitor the effectiveness of compressions:
a) if the exhalation SO2 is less than 10 mm Hg during the primary phase of resuscitation, try to improve the quality of pressing;
b) be aware of the possibility of using monitors with biometric data, as they can help in strict compliance with all the provisions of the instructions of the “Resuscitation” section.
4. Chest compressions are the very first therapy used in cardiac arrest and should begin as soon as the lack of breathing and pulse is detected. If electrodes are connected to the patient and heart rhythms are visible on the monitor at the time of cardiac arrest, then defibrillation has the highest priority among all therapies. Despite this, if there is a moment of defibrillation delay (for example, the installation of electrodes on the patient’s body), then it is necessary to press on the chest while the electrodes are installed. There is no clear instruction on the duration of the initial clicks; however, it is quite correct to perform them for 30 seconds – 2 minutes if passers-by at the scene did not perform chest compressions, or to defibrillate at the first opportunity after pressing the chest after detecting cardiac arrest.
5. There is insufficient evidence to recommend the routine use of in vitro CPR (ESLR) in cardiac arrest patients. In circumstances where it can be rapidly implemented, ESLR can be considered in some patients with cardiac arrest in whom the suspected etiology of cardiac arrest is reversible for a limited period of mechanical cardiorespiratory support.
6. Chest compressions should be re-started immediately after defibrillation with the appearance of a pulse, since the pulse, if any, is often difficult to detect, and checking the rhythm and pulse interrupts the compression.
7. Continue chest compressions between completion of ADA analysis and ADA charging.
8. The effectiveness of pressing decreases in the presence of any extraneous movements
a) resuscitation measures should take place as close as possible to the scene of the incident, only in case of possible threats or lack of space for the implementation of resuscitation measures it is necessary to move the patient;
b) chest presses are also less effective during transportation;
c) also performing chest compressions in a moving car is dangerous for specialists of the EMF system, the patient, passers-by and other road users;
d) for these reasons, and because usually the care provided by EMF workers is equivalent to that provided in the emergency department, resuscitation measures should be carried out at the scene.
9. The maximum value on the defibrillator should be used for initial and subsequent defibrillation attempts. The defibrillation dosage should be in accordance with the manufacturer’s recommendations in the case of two-phase defibrillators. If the manufacturer’s recommendation is unknown, use the maximum possible value. In the case of monophasic devices, the value should be 360 J (or 4 J/kg for children).
10. The installation of IV or IV access should not interfere with chest compressions.
11. Administer epinephrine (0.1 mg/kg, adult dose 1 mg) during the first or second cycle (30:2) of chest presses.
12. Currently, there is no single most effective mechanism for controlling airway patency, since some systems use an aggressive approach, while others are limited to basic manipulations, but each of the systems receives impeccable results. Regardless of the tactics of maintaining airway patency, you must adhere to the following principles:
d) caution when working with children: special attention is paid to maintaining the patency of the respiratory tract/breathing in children. Since breathing is often the cause of cardiac arrest, it is necessary to take care of airway patency and ventilation already in the early stages of assistance.
However, the following order: circulation – airway – breathing is still recommended by the American Heart Association for resuscitation of children in order to ensure timely initiation of chest compressions to maintain perfusion regardless of the underlying cause of the stop.
In addition, conventional CPR is preferred in children as it is associated with better outcomes compared to compression-only CPR.
13. Special circumstances during cardiac arrest:
13.1. Trauma, assist according to the General Trauma guideline.
13.2. Pregnancy:
a) the key to fetal survival is the survival of the mother;
b) place the patient in a lying position, meanwhile the second rescuer manually shifts the uterus to the left to avoid pressure on the arteries and improve
blood outflow to the lower vena cava;
c) if it was not possible to manually displace the uterus, the patient should be placed in a lying position with an inclination of 30 degrees to the left.
This position is less acceptable compared to the manual displacement of the uterus due to the complexity of pressing on the chest;
d) pressure on the chest should be performed slightly higher on the sternum than in non-pregnant patients, taking into account the increased position of the diaphragm and abdominal organs in pregnant women;
d) defibrillation is carried out according to the same rules as in non-pregnant patients;
13.3. Circulatory arrest due to respiratory etiology (drowning, etc.). In addition to the above, provide early control of airway patency. Passive ventilation through a non-revertive mask is not shown in these patients.
14. Application of “team” interaction during resuscitation.
14.1. Ideally, EMF service providers should use a command interaction protocol approach to ensure maximum effectiveness in cardiac arrest care. The exercises should include a simulation of the teamwork of rescuers of all levels (first on the scene, basic life support, extended life support) who usually work together. EMF specialists must hone the skills of using a command model with predetermined roles and a scheme for distributing the roles of a rescue crew. The following is an example of EMF “command” interaction:
a) the rescuer 1 and 2 are located on both sides of the patient’s chest, press the chest, replacing each other every 100 presses to avoid fatigue;
b) rescuers use a metronome or a special device for CPR, which provides information on the number of presses on the chest (frequency 100-120 presses/minute);
c) pressure on the chest is interrupted only at the time of analysis of heart rhythms with a defibrillator and defibrillation – pressure continues during charging of the defibrillator;
d) another team member provides IV or IV access and administers Epinephrine. To provide I/C access:
14.2. To maximize the effectiveness of the team approach, EMF medical management should establish a clear list of options that rescuers can use in the systems. These options include:
a) airway/ventilation control schemes, if any, that can be applied;
b) primary method of obtaining vascular access.
15. The EMF service should perform a review of quality of care indicators and results under the supervision of the medical director for each patient receiving CPR.
15.1. Quality indicators (AIs) should be coordinated with local hospital admissions departments, including hospitalization, discharge, and patient status information. These EMD quality indicators can be calculated by participating in a cardiac arrest registry.
15.2. AIs should be coordinated with local single duty dispatch/dispatch centers to ensure optimal recognition of possible cardiac arrest events and CPR through dispatching (including manual CPR when necessary).
There should be a binding to local registries, however, it should contain a certain minimum, which consists of the following elements:
a) associated with heart disease;
b) injury;
c) drowning;
d) strangulation;
e) other causes unrelated to heart disease;
e) unknown.
a) duration of compressions;
b) average and longest stop times in pressing after defibrillation;
c) frequency and depth of compressions.