Indirect cardiac massage should be performed. Cardiac massage and artificial respiration: closed and open massage techniques

From this article you will learn: what is indirect cardiac massage, why, to whom and who can do it. Is it possible to harm a person by performing this procedure, and how to make it really help.

Article publication date: 02/08/2017

Article updated date: 05/29/2019

Indirect cardiac massage is an emergency resuscitation measure aimed at replacing and restoring stopped cardiac activity.

This procedure is the most important for saving the life of a person whose heart has stopped and is in a state of clinical death. Therefore, every person must be able to do cardiac massage. Even if you are not a specialist, but you at least know approximately how this procedure should take place, do not be afraid to do it.

You will not harm the patient if you do something not quite right, but if you do nothing, it will lead to his death. The main thing is to make sure that there are really no heartbeats. Otherwise, even a perfectly performed massage will cause harm.

The essence and meaning of cardiac massage

The purpose of cardiac massage is to artificially recreate and replace cardiac activity if it stops. This can be achieved by squeezing the cavities of the heart from the outside, which imitates the first phase of cardiac activity - contraction (systole) with further weakening of pressure on the myocardium, which imitates the second phase - relaxation (diastole).

This massage can be done in two ways: direct and indirect. The first is possible only with surgery, when there is direct access to the heart. The surgeon takes it in his hand and performs a rhythmic alternation of compression and relaxation.

Indirect cardiac massage is called indirect because there is no direct contact with the organ. Compression is applied through the chest wall, as the heart is located between the spine and the sternum. Effective pressure on this area can release about 60% of the blood volume into the vessels compared to self-contracting myocardium. Thus, blood will be able to circulate through the largest arteries and vital organs (brain, heart, lungs).

Indications: who really needs this procedure

The most important thing in cardiac massage is to determine whether a person needs it or not. There is only one indication - complete. This means that even if an unconscious patient has severe rhythm disturbances, but at least some cardiac activity is preserved, it is better to refrain from the procedure. Compressing the contracting heart can cause it to stop.

The exception is cases of severe ventricular fibrillation, in which they seem to tremble (about 200 times per minute), but do not perform a single full contraction, as well as weakness of the sinus node and, in which the heartbeat is less than 25 beats per minute. If such patients are not helped, the condition will inevitably worsen and cardiac arrest will occur. Therefore, they can also be given indirect massage if there is no other way to help.

The rationale for the feasibility of this procedure is described in the table:

Clinical death is the stage of dying after the cessation of cardiac activity lasting 3–4 minutes. After this time, irreversible processes occur in the organs (primarily in the brain) - biological death occurs. Therefore, the only time when you need to do cardiac massage is the period of clinical death. Even if you don't know when your heart stopped and you're not sure if there's a heartbeat, look for other signs of cardiac arrest.

The sequence of actions that make up the technique of indirect cardiac massage includes:

1. Determine whether the patient has a pulse and heartbeat:

• Feel the anterolateral surfaces of the neck with your fingers in the projection of the location of the carotid arteries. The absence of pulsation indicates cardiac arrest.
• Listen with your ear or phonendoscope to the left half of the chest.

2. If you doubt the absence of heartbeats, before performing chest compressions, determine other signs of clinical death:

3. If these signs occur, feel free to begin chest compressions, following the technique:

• Place the patient on his back, but only on a hard surface.
• Open the patient's mouth, if there is mucus, vomit, blood or any foreign bodies in it, clean the oral cavity with your fingers.
• Tilt the victim's head back well. This will prevent the tongue from retracting. It is advisable to fix it in this position by placing any cushion under the neck.
• Stand to the patient's right at chest level.
• Place the hands of both hands on the sternum at a point that is located two fingers above the lower end of the sternum (the border between the middle and lower third).
• The hands should lie in this way: the fulcrum of one hand is the soft part of the palm in the area of ​​​​the eminence of the thumb and little finger just below the wrist. Place the second hand on the one located on the chest and interlace their fingers into a lock. Fingers should not rest on the ribs, as they can cause fractures during the massage.
• Bend over the victim so that with your correctly positioned hands you seem to be resting on the sternum. Arms should be straight (elbows bent).

The technique for performing chest compressions should be as follows:

1. At least 100 times per minute.
2. So that it is pressed in 3–5 cm.
3. Apply compression not by bending and straightening your elbows, but by applying pressure throughout your body. Your hands should be a kind of transmission lever. This way you won’t get tired and will be able to massage as much as you need. This procedure requires a lot of strength and energy.

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Indirect cardiac massage can last about 20 minutes. After every minute, assess whether a pulse appears in the carotid arteries. If after this time the heartbeat has recovered, further massage is not advisable.

It is not necessary to perform artificial respiration simultaneously with cardiac massage, but it is possible. The correct technique in this case: after 30 pressures, take 2 breaths.

Forecast

The effectiveness of chest compressions is unpredictable - from 5 to 65% result in restoration of cardiac activity and saving a person’s life. The prognosis is better when it is performed in young people without concomitant diseases and injuries. But cardiac arrest without indirect massage 100% ends in death.

Lay the patient on a hard, flat surface, unfasten or remove any clothing, belt, or belt that is constricting the body. Determine the place of compression - the middle of the distance between the lower and upper ends of the sternum determined by palpation (with both hands).

While on the patient's side, place the proximal part of the palm of one hand on the pressure point. Place the proximal part of the palm of the other hand on top of the first. The arms are straight and positioned vertically.

Push the sternum down towards the spine by about 4-5 cm (for adults). Help the massage with your body weight.

Fix the sternum in this position for half a cycle to push blood out of the heart (artificial systole). Then quickly release it and wait half the cycle to allow the heart to fill with blood (artificial diastole).

Repeat pressures at a frequency of 80-100 per minute (slightly slower than 2 per 1 second).

One resuscitator alternates 2 inflations with 15 chest compressions. If there are two resuscitators, the ratio of the frequency of compressions to the rate of artificial ventilation is 4:1.

17.Methodology of artificial ventilation of the lungs

Restore airway patency (put the patient on his back, tilt his head back, put one hand under the neck, the other on the forehead - in this position, the root of the tongue extends from the back wall of the pharynx and provides free access of air to the larynx and trachea).

Use protective devices that reduce the risk of disease transmission during mouth-to-mouth artificial ventilation (mask, protective film for the face), Ambu bag.

Pinch the patient's nose with your fingers, take a deep breath and, tightly covering the patient's mouth with your lips, blow air into it for 1.5 - 2 seconds. Exhalation occurs passively. The frequency of injections depends on the rate of passive exhalation - for an adult, 10-12 per minute (one injection every 5 seconds). The volume of blown air is 0.5-1.0 liter.

The person performing artificial ventilation checks for pulsation of the carotid artery and monitors the patency of the airways. If it is not possible to inflate the lungs, it is necessary to check whether the head is tilted back correctly, pull the patient's chin towards you and try to inflate the lungs again.

Artificial ventilation of the lungs can be carried out using a manual portable device such as RPA, artificial ventilation devices for the ambulance service, and artificial ventilation devices for intensive care units.

18. Emergency care for acute gastrointestinal bleeding

Causes of acute gastrointestinal bleeding: gastric and duodenal ulcers, tumors of the gastrointestinal tract, gastric erosions, varicose veins of the esophagus, ulcerative colitis, hemorrhoids, hemorrhagic diathesis.

Clinical symptoms of bleeding include general symptoms of acute anemia and signs of gastrointestinal bleeding.

General signs of blood loss depend on its volume and can be minimal (with bleeding up to 400-500 ml) or correspond to hemorrhagic shock (with bleeding more than 700 ml). The approximate amount of blood loss is determined by the Algover “shock” index: the quotient of dividing the pulse rate by the value of systolic blood pressure. With a loss of 20-30% of circulating blood volume (CBV), the Algover index corresponds to 1.0; with a loss of 30 - 50% - 1.5; with a loss of more than 50% - 2.0.

Signs of acute posthemorrhagic anemia: thirst, dizziness, tinnitus, weakness, yawning, chills. Objectively, pallor of the mucous membranes and skin, tachycardia, a transient decrease in blood pressure, preservation of the loudness of heart sounds, and functional systolic murmur at the apex are detected. In the general blood test, hemoglobin was reduced to 100 g/l, hematocrit to 0.35.

Hemorrhagic shock:

Mental status disorders from agitation to coma,

Tachycardia from 90 or more,

Drop in blood pressure

Oliguria,

Pale mucous membranes and skin, there may be cyanosis,

The pulse is weakly filled and tense to threadlike,

Deafness of heart sounds.

In a general blood test, a decrease in hemoglobin is below 100 g/l, hematocrit is below 0.35.

Signs of gastrointestinal bleeding:

Bloody vomiting (hematemesis) of unchanged blood or “coffee grounds” with bleeding from the upper sections,

Black tarry stools (melena) with prolonged blood in the upper intestines,

Dark cherry coloring of the stool with rapid passage through the intestines or bleeding from its lower parts,

Unchanged scarlet blood in the stool (hematochezia) from the distal intestine,

Fecal masses of the “raspberry jelly” type in nonspecific ulcerative colitis.

Treatment:

1) Strict bed (stretcher) rest. Transportation in the Trendelenburg position to the surgical hospital.

2) Ice pack on the epigastric region.

4) Plasma-substituting solutions: dextran/sodium chloride, 10% hydrosethyl starch solution, 7.5% sodium chloride solution 5-7 ml per 1 kg of body weight - first intravenously, then (at blood pressure more than 80 mm Hg) - drip. The volume of infusion should exceed the volume of blood loss by 3-4 times.

5) Mezaton (phenylephrine) 1% -1 ml in 800 ml of 5% glucose solution (with blood pressure less than 80 - 90 mm Hg).

6) Dicynone (sodium etamsylate) 2-4 ml of 12.5% ​​solution intravenously every 6 hours.

7) If the effect of infusion therapy is insufficient (blood pressure below 80 - 90 mm Hg), norepinephrine 1-2 ml of 0.2% solution or dopamine 5 ml of 0.5% solution per 400 ml of plasma replacement solution intravenously, prednisolone up to 30 mg/kg intravenously slowly.

8) Oxygen therapy - inhalation of humidified oxygen through a mask or nasal catheters.

9) Blackmore probe for bleeding from the esophagus.

Heart massage(artificial rhythmic compression of the victim’s heart, simulating its independent contractions) is carried out to artificially maintain blood circulation in the victim’s body and restore normal natural contractions of the heart (Fig. 1). Since oxygen is delivered to all organs and tissues during blood circulation, during massage it is necessary to enrich the blood with oxygen, which is achieved by artificial respiration. Thus, artificial respiration should be performed simultaneously with cardiac massage.

When providing assistance to a person struck by an electric current, a so-called indirect or external heart massage is performed by rhythmically pressing on the chest, i.e. on the front wall of the victim's chest.

As a result of this, the heart is compressed between the sternum and the spine and pushes blood out of its cavities. After the pressure stops, the chest and heart straighten, and the heart fills with blood coming from the veins. In a person in a state of clinical death, the chest, due to loss of muscle tension, easily shifts (compresses) when pressure is applied to it, providing the necessary compression of the heart.

When performing a massage, you should press with a quick push so as to move the lower part of the sternum down by 3-4 cm, and in obese people - by 5-6 cm.

The pressure when pressing is concentrated on the lower part of the sternum, which is more mobile. You should avoid pressing on the upper part of the sternum, as well as on the ends of the lower ribs, as this can lead to their fracture; press below the edge of the chest, as you can damage the organs located here, primarily the liver.

The dotted line shows the displacement of the chest and heart when pressing on the sternum. Pressing (push) on the sternum should be repeated approximately every 1 second to create sufficient blood flow. After a quick push, the arms should remain in the achieved position for approximately 0.5 s. After this, the person providing assistance straightens slightly and relaxes his hands without removing them from the sternum. To enrich the victim’s blood with oxygen, simultaneously with cardiac massage, it is necessary to perform artificial respiration using the “Mouth to mouth” (“mouth to mouth”) or “Mouth to nose” (“mouth to nose”) method. If there are two people providing assistance, then one of them performs artificial respiration, the other - cardiac massage (Fig. 2).

It is advisable to alternately perform artificial respiration and cardiac massage, replacing each other every 5-10 minutes. In this case, the order of assistance should be as follows: after two deep insufflations, thirty compressions are performed on the chest, i.e. the new optimal ratio of chest compressions and mechanical ventilation breaths is 30:2, regardless of the number of participants in the care).

If the victim does not have a pulse, the following cardiac dysfunctions are possible:

• A sharp weakening or even complete cessation of heart contractions, which occurs as a result of the victim being under the influence of current for a long time, as well as the lack of timely assistance in the event of primary respiratory damage;
• The formation under the influence of electric current of isolated and multi-time (fibrillar) contractions of individual groups of cardiac muscle fibers, which cannot ensure the functioning of the heart as a pump forcing blood into the vessels, which occurs under the influence of high-power alternating current even when the victim is under voltage for a short time; in this case, breathing may still continue for some time after the victim is released from the action of the current, but the work of the heart is not effective and is not capable of supporting life.

Therefore, if the victim does not have a pulse, in order to maintain the vital functions of the body (to restore blood circulation), it is necessary, regardless of the reason that caused the cessation of heart function, to carry out external cardiac massage simultaneously with artificial respiration (air injection). It should be borne in mind that without correct and timely preliminary assistance to the victim before the doctor arrives, medical assistance may be delayed and ineffective.

External (indirect) massage is performed by rhythmically compressing the heart through the anterior wall of the chest while pressing on the relatively mobile lower part of the sternum, behind which the heart is located. In this case, the heart is pressed against the spine and blood is squeezed out of its cavities into the blood vessels. By repeating pressure at a frequency of 66 - 70 times per minute, you can ensure sufficient blood circulation in the body in the absence of heart function.

The possibility of such an imitation of the work of the heart arises as a result of a profound loss of muscle tone (tension) in a dying person, as a result of which his chest becomes more mobile and pliable than that of a healthy person.

To perform external cardiac massage, the victim should be laid with his back on a hard surface (low table, bench or floor), his chest should be exposed, and his belt, suspenders and other items of clothing that would restrict breathing should be removed. The person providing assistance should stand on the right or left side of the victim and take a position in which a more or less significant bend over the victim is possible. If the victim is laid on a table, the person providing assistance should stand on a low chair, and if the victim is on the floor, the person providing assistance should kneel next to the victim.

Having determined the position of the lower third of the sternum (Figure 6, a), the person providing assistance should place the upper edge of the palm of an extended arm on it, and then put the other hand on top of the hand (Figure 6, b) and press on the victim’s chest, while slightly helping tilting your body. Pressing should be done with a quick push so as to move the lower part of the sternum down towards the spine by 3 - 4 cm, and in obese people - by 5 - 6 cm. The force when pressing should be concentrated on the lower part of the sternum, which, due to its attachment to the cartilage, The cheek ends of the lower ribs are movable. The upper part of the sternum is fixedly attached to the bony ribs and can break if pressure is applied to it. You should also avoid pressing on the end of the lower ribs, as this can lead to their fracture. In no case should you press below the edge of the chest (on soft tissues), as you can damage the organs located here, primarily the liver.

Pressing on the sternum should be repeated approximately once per second.

After a quick push, the arms remain in the achieved position for approximately one-third of a second. After this, the hands should be removed, freeing the chest from pressure, in order to allow it to straighten. This facilitates the suction of blood from the large veins into the heart and its filling with blood.

If there is an assistant, one of those providing assistance, less experienced in this matter, should perform artificial respiration by insufflating air as a less complex procedure, and the second, more experienced one should perform indirect cardiac massage. To provide the body with a sufficient amount of oxygen in the absence of heart function, artificial respiration should be performed simultaneously with cardiac massage by blowing air into the victim’s lungs.

Since pressing on the chest makes it difficult to expand during inhalation, inflation should be done in the intervals between compressions or during a special pause provided every 4 to 6 compressions on the chest.

If the person providing assistance does not have an assistant and is forced to carry out artificial respiration and external cardiac massage alone, the above operations should be alternated in the following order: after 2–3 deep blows into the victim’s mouth or nose, make 15–20 pressures on the chest, then again makes 2 - 3 deep blows and again makes 15 - 20 pressures for the purpose of cardiac massage, etc. In this case, the air blowing should be timed to coincide with the end of the pressure on the chest or interrupting the heart massage for the duration of the blowing (about 1 second).

If the persons providing assistance are equally qualified, it is advisable for each of them to perform artificial respiration and external cardiac massage, alternately replacing each other every 5-10 minutes. Such alternation will be less tiring than continuously performing the same procedure, especially cardiac massage.

The effectiveness of external cardiac massage is manifested primarily in the fact that each pressure on the sternum leads to the appearance of a pulsating oscillation of the artery walls in the victim (checked by another person).

When artificial respiration and cardiac massage are performed correctly, the victim will show the following signs of recovery:

1. Improvement in complexion, acquiring a pinkish tint instead of the gray-sallow color with a bluish tint that the victim had before receiving assistance;
2. The appearance of independent respiratory movements, which become more and more uniform as assistance (resuscitation) measures continue;
3. Constriction of the pupils.

The degree of pupil constriction can serve as the most reliable indicator of the effectiveness of the assistance provided. The narrow pupils of the person being revived indicate a sufficient supply of oxygen to the brain, and conversely, the beginning dilation of the pupils indicates a deterioration in the blood supply to the brain and the need to take more effective measures to revive the victim. This can be helped by raising the victim's legs approximately 0.5 m from the floor and leaving them in an elevated position during the entire time of external cardiac massage. This position of the victim’s legs promotes better blood flow to the heart from the veins of the lower body. To support your legs in an elevated position, you should put something under them.

Artificial respiration and external cardiac massage should be carried out until spontaneous breathing and heart function appear, however, the appearance of weak breaths (in the presence of a pulse) does not provide grounds for stopping artificial respiration.

In this case, as already mentioned above, the injection of air should be timed to coincide with the moment the victim begins to inhale. The recovery of the victim’s heart activity is judged by the appearance of his own regular pulse, which is not supported by massage. To check the pulse, interrupt the massage for 2–3 seconds, and if the pulse persists, this indicates that the heart is working independently. If there is no pulse during the break, the massage must be resumed immediately.

A prolonged absence of pulse and heart rhythm with spontaneous breathing and narrow pupils indicates cardiac fibrillation. In these cases, it is necessary to continue measures to revive the victim until the doctor arrives or until the victim is delivered to a medical facility, with continuous continuation of revival measures in the car.

It should be remembered that even a short-term cessation of revitalizing activities (1 minute or less) can lead to irreparable consequences.

After the first signs of revival appear, external cardiac massage and artificial respiration should be continued for 5 to 10 minutes, timing the insufflation to coincide with the moment of one’s own inhalation.

Cardiac massage is a mechanical effect on the heart after it has stopped in order to restore its activity and maintain continuous blood flow until the heart resumes functioning.

Signs of sudden cardiac arrest are:

Sharp pallor

Loss of consciousness

Disappearance of the pulse in the carotid arteries, cessation of breathing or the appearance of rare convulsive breaths (agonal breathing),

Pupil dilation.

The heart is located between the posterior surface of the sternum and the anterior surface of the spine, i.e. between two hard surfaces. By reducing the space between them, you can compress the heart area and cause artificial systole. In this case, blood from the heart is ejected into the large arteries of the systemic and pulmonary circulation. If the pressure is stopped, the compression of the heart stops and blood is sucked into it. This is artificial diastole. The rhythmic alternation of chest compressions and cessation of pressure replaces cardiac activity, which ensures the necessary blood circulation in the body. This is the so-called indirect cardiac massage - the most common method of resuscitation, carried out simultaneously with mechanical ventilation.

Indications for cardiac massage are all cases of cardiac arrest.

ACTION ALGORITHM:

1. Lay the victim on his back on a hard base.

2. Stand to the left of the victim and place your palms on the lower third of the sternum, 2 transverse fingers above the xiphoid process.

Place the palm of one hand perpendicular to the axis of the sternum, the palm of the other hand on the back surface perpendicular to the first.

3. Bring both hands to the position of maximum extension; fingers should not touch the chest. fingers,

located below should be directed upward (toward the head).

4. Using the whole body with the help of your hands (your hands should remain straight during the massage), push and rhythmically press on

the sternum so that it bends by 4-5 cm. In the position of maximum deflection, it must be held for a little less than 1 second. Then

Stop pressing, but do not lift your palms from the sternum.

REMEMBER! The number of compressions on the sternum should be an average of 70 per minute.

Criterion for the effectiveness of indirect cardiac massage

1. Change in skin color (they become less pale, gray, cyanotic)

2. Constriction of the pupils with the appearance of a reaction to light

3. Appearance of pulse in large arteries (carotid, femoral)

4. Appearance of blood pressure at the level of 60-8 mm Hg.

5. Subsequent restoration of spontaneous breathing.

Complications of chest compressions

Fracture of the ribs and sternum with injury to the heart, lung and pleura, development of pneumo- and hemothorax.

REMEMBER! CPR must be started immediately in any setting where respiratory and cardiac arrest occurs. The main condition for successful revival is the correct combination of free airway, mechanical ventilation and cardiac massage. Only the combined use of 3 stages ensures a sufficient supply of oxygen to the blood and its delivery to the organs, primarily to the brain.