ODESSA NATIONAL MEDICAL UNIVERSITY

Department of Anesthesiology, Intensive Care and Emergency Medicine

Methodological instructions

for students of practice

Discipline "Anesthesiology and intensive care"

Lesson №__1__ « CARDIO-PULMONARY RESUSCITATION»

Course_____V_____ Medical Faculty

Speciality7.12010001. "Medicine"

7.12010002. "Pediatrics"

7.12010003. "Medical-preventive work"

It is confirmed at the methodical meeting

of the Department № 1 from. 29.08.2019
Head of the department
Professor ___________O.A.Tarabrin

Odessa 2019
1. Lesson №__1__ « CARDIO-PULMONARY RESUSCITATION»-3 hours.

2. Relevance of the topic:the blood circulation stop is terminal complication of any

critical status which can be a consequence of heavy disease or sudden defeat by
external factors. For this reason mastering by skills of rendering of the urgent help at
a blood circulation stop is obligatory for each graduate of a medical educational
institution.
3. Objectives of the activity:
3.1.Training objectives:
-to familiarise with history of development of resuscitation in the world, in Ukraine;
to know about modern achievements and perspective directions of researches in the
field of is cardio-pulmonary resuscitation.
-students should realise a moral and legal duty of each medical worker irrespective of
a speciality, to be able to find out in due time in the patient or the victim a status of
clinical death and to render the urgent help, necessity of periodic updating of skills
and knowledge concerning methods of cardio-pulmonary resuscitations.

3.2. Educational objectives:

-To be able to define signs of clinical and biological death;
-To apply methods of renewal and maintenance of passableness of respiratory ways;
-To spend indirect massage of heart;
3.3. Specific objectives:
- To know:
The reasons of a stop of blood circulation;
Features of pathogenesis stops of blood circulation and renewal prospect at primary
defeat of different systems (CNS, respiratory and cardiovascular);
Factors which predetermine duration of clinical death;
The general rules of carrying out of cardio-pulmonary resuscitation;
Theoretical substantiation of application of different methods and medical actions at
resuscitation carrying out;

4. Interdisciplinary integration

№ Disciplines The nobility To be able

п/п
The providing:
1 Human anatomy Human anatomy
Structure of orolaryngeal and a
skeleton of the face. A structure
of mediastinum
 2 Human physiology Conditions of blood supply of a
brain. Spirografic indicators
Influence of breath on a status
of cardiovascular system and
brain blood supply
The provided:

1 Neurology Postanoxygen encephalopathy. to define a kind of

An Apallitics syndrome. infringement of
Akynetic syndrom. consciousness and
coma degree
to spend
neurologic inspection
Intrasubject integration

1 Syndrome Factors SMOI in post

insufficiency of all resuscitation the period
organs

5. Contents of exercises.
Throughout the history of human society in the minds of people
never thought extinguished - the dream of finding ways to conserve life and prevention of
death. There in recent decades, the science of resuscitation from the standpoint of modern
ideas about life and death, to a certain extent solve this painful and eternal question of how
the struggle for life, establish reasonable limits of this struggle, indications and
contraindications to it. Although nowadays no one builds illusions of eternal life, the
struggle for the life of a dying patient, when this is the real reason, do not lose the
greatness and nobility."
"Resuscitation is a positive force in the evolution of mankind, as based on the concept of
the value of every human life as a unique phenomenon in the universe."
Peter Safar (1924 - 2003).

Historical Review
Methods revival of man after death have a long history. In his early forms of resuscitation,
perhaps as old as humanity. In Egyptian mythology, Isis, goddess of fertility, water and
wind, breathable depicted in her mouth to her husband god Osiris, thus reviving it. The
Bible tells how the prophet Elisha revived the dead child:
32 And when Elisha was come into the house, behold, the child was dead on his bed.
33. And he went and locked the door behind him, and prayed to the Lord.
34. I went and lay on the child, and put his mouth to his mouth, and his eyes to his eyes,
and his hands to his hands, and stretched it, and it became warm baby's body.
35. ... and the child sneezed seven times, and the child opened his eyes.
(Old Testament Book of Kings 4, Chapter 4).
In the Middle century the development issues associated with recovery of A. Vesalius
(1514-1564), who in his classic work "De HumaniCorporisFabrica" (1513h). Shown in
animal experiments that the holding of mechanical ventilation (mechanical ventilation) air
under positive pressure through the tracheostomy hole restores the activity of the heart,
and T. Paracelsus (1493-1541), who first used the blacksmith furs (1530) as a makeshift
manual respirator for mechanical ventilation in the intensive care people.
An important milestone was the creation in 1767 of the Dutch Society rescue drowning,
becoming the world's organization resuscitation people, which gave start to form similar
partnerships in other countries. Complex intensive care aids, used at the time to save
drowned consisted of: warming the victim, remove water that gets in swallowing or
breathing, breath holding "mouth to mouth" and blowing smoke into the rectum.
The beginning of the era of general anesthesia, was a significant impetus for further
development, development of methods of resuscitation. Thus, in 1874 the Norwegian
anesthesiologist Heiberg to preventing retraction tongue in laryngo-pharyngeal area
during anesthesia by chloroform, invited to nominate up the lower jaw, and in 1878.
Esmarch as a supplement to this method, proposed to hold the maximum extension head in
the cervical region. In Germany R. Boehm (1878) conducted intensive care animals from
cardiac arrest caused by an overdose of chloroform by external (indirect) cardiac massage
and Maass (1892) applied this method in humans. In Norway, K. Igelsrud (1901) was first
held direct cardiac massage surgical patient. Subsequently, until 1960, direct cardiac
massage was the main method of resuscitation. Open in 1890. Adrenaline was first used
GV Crile and D.H. Dolley (1906) in experimental animals for resuscitation, but only later
was studied in detail the mechanism of its action in the work of CJ Wiggers (1936 r.), J.S.
Redding and J.W. Pearson (1963), which allowed to introduce into clinical practice
epinephrine during cardiopulmonary resuscitation (CPR) as first-line drug.
Electrical defibrillation was first described by French physiologist J. L. Provost and F
Bateiii (1900), which showed in experiments on dogs that ventricular fibrillation can be
eliminated by a high-voltage shock. Pioneer external defibrillation NL Gurvich in 1938 -
1947 he was justified .. first of its use in experiments on animals, and then the clinical
practice. He proved that defibrillation is not necessary to use alternating and direct current
in a pulse capacitor discharge. This principle was implemented them in one of the first
clinical use of defibrillators for ID-1 VEI, in 1967 NL Gurvich was invented defibrillator
that uses a bipolar pulse (pulse Gurvich) - a principle laid at the foundation of all modern
defibrillator. The first direct defibrillation (electrodes with a open heart) in man-century
operating fulfilled OS Beck (1947) and the first external defibrillation PM Zoll (1956).
The first automatic respirator for mechanical ventilation was developed by R. Drager and
began industrially produced in Germany in 1911 - it was the legendary "Pulmotor." He
was a post-wives balloon with oxygen and used for respiratory resuscitation miners and
firefighters. The feature was respirator ventilation cycle regulation suppression. A peculiar
impulse stimulating development of devices for mechanical ventilation, was the polio
epidemic that broke out in 1952 as of Denmark, and in 1953 in Sweden, which has
necessitated the replacement of lung function in a large number of patients. In this
connection, the Danish researcher CG Engstrom was created and began to industrially
produced eponymous device for mechanical ventilation, the basis of which was based on a
new principle of control - volume ventilation. "Enhstrem - Respirator" became the
prototype of all modern respirators and the first mechanical device for mechanical
ventilation, which began to be widely used in clinics around the world.
World's first scientific justification opportunities struggle for life, while in the border state
with death gave a brilliant scientist, a long time ahead of his time - Vladimir Nehovskyy -
creator resuscitation (term coined it in 1961). On his own initiative, in 1936 he achieved
the establishment in Moscow at the Institute of Neurosurgery world's first research center
with resuscitation - laboratory spe-lnoho destination on the "Restoring life processes with
symptoms similar to the death," which was turned into a Later in modern resuscitation
Institute of General Medical Sciences. He and his scientific school of pathophysiology is
the creator of all terminal states, allowed then to prove the reality of clinical practice and
the need for resuscitation people through events, called him resuscitation complex. In the
Great Patriotic War, he and his team succeeded in successfully providing intensive care to
soldiers who were in a state of clinical death.
This allowed VA Nehovskym summarize all the experience gained both experimental and
clinical observations in world first monograph on CPR, which was translated into English
and published in the US - "Restoration of vital body functions in a state of agony or period
of clinical death," published in 1943 m. On his initiative in 1956 opened the first in the
Soviet Union ICU, which is located in Moscow at the hospital. JV. Botkin, and in 1959 the
first resuscitation ambulance crew. VA Nehovskim et al. in 1972 was introduced and
proved the concept post-resuscitation disease.
The modern complex CPR was created works of another patriarch resuscitation - Peter
Safar (1961), who showed in patient which was introduced curare volunteers more
efficient respiration "mouth to mouth" versus external methods of breathing (1956)
developed a "triple reception" on the airways and S-shaped duct (1958), organized in
1958, the first in the US ICU (intensive care unit - ICU), first justified the need for the
development of the cerebral resuscitation and modification CPR in CPCR (1966 ). By the
first international guidance of CPCR, which lasted three editions (1968, 1981, 1987 ),
which has become the "gold standard" for more than 30 years for physicians worldwide.
Founded (1979) International Centre for resuscitation research that bears his name is at the
University of Pittsburgh.
Currently, standards CPR developed: in the US - the American Heart Association
(American Heart Association - AHA), which gives guidance on CPR and emergency
cardiac care (1966, 1974, 1980, 1985, 1992, 2000, 2005) in Europe - created in 1989
European Resuscitation Council (European Resuscitation Council - ERC), which
published its recommendations in 1992,1998,2000 years .. At the end of 2005 were
published new recommendations of the European Resuscitation Council, which was
introduced several significant changes algorithm in cardiopulmonary resuscitation.
Since 1972 issued an international journal of CPR - "Resuscitation" (Resuscitation),
which is now printed Xia body ERC.

INTRODUCTION TO THE PROBLEM

About 1/4 of all deaths in people not associated with disease or senile unremediable or
destructive changes in the brain. In the United States each year about 400 000 cases of
sudden death. In the late 1950s, during postmortem studies, noted the lack of
morphological studies lethal in large part dead. In figurative expression S.B. Veek - "Heart
of these patients were too healthy to die, and it was necessary to enable them to recover
their work." This principle, later rehashed P. Safar in the "heart and brains too good to
die," was the basis for the modern concept of cardiopulmonary and cerebral resuscitation
(CPCR). Philosophy resuscitation paid to the individual people whose lives were suddenly
interrupted by any reasons when there is a completely unjustified death of a viable and
healthy body, with no fatal incurable disease or severe senile dementia. This criterion
determining the success of CPCR is the restoration of full brain function. In the case of
sustainable vegetative state, which should be regarded as a defect CPCR, such people
should be allowed to die with dignity as meaningless extension dying process is unethical.
These guidelines are modern changes in the program CPR in adults, based on the
published recommendations of the European Resuscitation Council 2005 (ERS2005) and
cerebral resuscitation recommendations based on published data of recent years.

BASIC CONCEPTS AND DEFINITIONS

Intensive - the science of extinction mechanisms, management techniques, artificial

replacement and restoration of vital (vital) functions, in terms of aggression such an extent
that exceeds the capacity of autoregulation.
The subject of resuscitation is critical and terminal condition.
Critical conditions - extreme degree of any pathology in which there are physiological
function disorder and violation of the individual systems that can not corrected by self-
regulation and require partial or complete correction artificial substitution (Ryabov, 1979).
Terminal states - the last stage of life (the stage between life and death): preagony, agony,
clinical death (V.A. Nehovskyy, 1966). Resuscitation (lat. reanimation - recovery) - a set
of therapeutic measures aimed at restoring the vital functions of the body when you stop
breathing and circulation. Dying - process of extinction of vital body functions. There is
not only a qualitative transition from life to death, but is consistent and regular dysfunction
and systems, ending their exclusion. Availability consistency and continuity of functions
allows time off and leads to the possibility of invasion to restore life (V.A. Nehovskyy,
1966).
The main stages of the extinction of vital functions
Preagony - the initial stage of the process of dying, which is characterized by severe
violation of the central nervous system, respiratory and circulatory reversible. At this
stage, the gradual suppression of consciousness and reduced reflexes, abuse pattern of
breathing (rapid shallow or slow) developed hypotension and expressed microcirculatory
disorders that manifest hypostatic appearance of spots on the extremities, increases
cyanosis or pale skin. At that stage preagony may be absent at fast dying (electric shock)
or take a few hours (blood loss).
Terminal pause - the transition between agony and preagony characterized fading reflex
activity, temporary sleep, critical hypotension, severe bradycardia, further deepening the
inhibition of the cerebral cortex and its off to the regulation of vital body functions. This
period of "anarchy" when higher parts of the brain are disconnected from the process
control vital body functions and evolutionarily ancient structures stem not yet assumed
regulatory functions. It was at this moment there is a temporary enhance vagal effect,
which causes the development of apnea and bradycardia sharp.
Agony - the last "flash" of life, characterized by transient activation of brain structures to
combat fading vitality of the body. After a period of apnea at first appear rare and more
frequent breathing movements involving the supporting muscles. There may be abnormal
breathing type "haspinh" - the maximum short breath with a fast full exhalation. There is
increased heart rate and blood pressure rise. In some cases, this activation vital functions
leads to the restoration of reflex action and sometimes (very rarely) and consciousness.
But at a certain point, further maintaining life is impossible, is a progressive suppression
of reflex activity, respiration and hemodynamics, with subsequent development of clinical
death.
Clinical death - a reversible condition that begins with the cessation of vital functions
(blood circulation, respiration) before irreversible changes in the cerebral cortex. In other
words, it is time to preserve their viability neurons of the cerebral cortex in conditions of
anoxia (as O2 content in brain tissue is reduced to zero for 1 min. Since cardiac arrest).
The duration of clinical death, first of all, depends on the temperature of the body of the
victim, when the temperature during clinical death is reduced to 1 - 2 minutes. By
increasing oxygen consumption tissues due to the prevalence of oxyhemoglobin
dissociation processes of its products. Conversely, when the temperature decreases (under
hypothermia) during clinical death is extended to an average of 12 minutes. by reducing
the consumption of oxygen by tissues (in exceptional cases, such as drowning in icy water,
it can be 30-60 minutes or more). In terms normotermia period of clinical death is 3-5
min.неврологічними So when CPR was started within 5 min. after circulatory arrest and
ended with the restoration of spontaneous circulation and breathing, there is every chance
of a full recovery with no neurological deficit thinking. If CPR is started within 10
minutes. after cardiac arrest, the recovery of consciousness neurologicalviolations will be
accompanied by varying degrees of severity; and if after 15 minutes. - The possible
recovery of only vegetative functions, while the recovery of consciousness is impossible
(that is, in most cases there will be a so-called social death synonym - vegetative state).
CPR, launched in 20 more minutes of cardiac arrest associated with the total destruction of
the brain, including stem structure (decerebration) when recovery becomes impossible
even vegetative functions.
Socialdeath -
partiallyreversibleconditioncharacterizedbytheirreversiblelossoffunctionofthecerebralcorte
x (decortication) whilemaintainingvegetativefunctions.
Biologicaldeath -
irreversiblestateofcellsofvitalorganswhenanimatingbodyasanintegratedsystempossible.
Braindeath - thecompleteandirreversiblecessationofallbrainfunction, recordedwith a
beatingheart, onthebackgroundofmechanicalventilation, infusionanddrugtherapy.
Inthemodernsense, braindeathisconsideredasthelegalequivalentofdeath.

Signsofclinicaldeath

A) Basic:
Carotidpulsedeterminedbypalpation, padsindexandmiddlefingers,
slowlyshiftingtheangleofthethyroidcartilage ("Adam'sapple")
totheinneredgeofthesternoclavicular-mastoidmuscle.

Thepresenceofrespiratorysymptomsevaluatedbylisteningtothemovementofairaroundthevict
im'sairwayandobservationtourofthechest.
B) Other:
1. Lackofawareness.
2. Pale (earthy-gray), cyanosisormarblingskin.
3. Atony, arefleksiya.
Diagnosis of clinical death to be carried out quickly (within 10-15 seconds) to start
immediate resuscitation because if critical period of 3-5 minutes of clinical death will be
overlooked, comes irreversible brain death.

Indications for cardiopulmonary resuscitation

All cases of clinical death, regardless of its causes have caused
.
Contraindications to cardiopulmonary resuscitation
All cases where it is known that the person in the resuscitation is absolutely useless.
1. Death in patients with incurable diseases (cancer patients in the terminal stage, injuries
incompatible with life, terminal stage of stroke - strokes).
2. If there are signs of biological death:
- Drying of the cornea - "dull luster herring";
 - Corpse spots - there 1 hour after cardiac arrest primarily on the back of the neck and
fully manifested in 6-12 hours;
- Rigor mortis - in the lower jaw occurs after 1 hour (maximum 3 hours after the onset
of death, so it spreads throughout the body;
- Cadaverous smell - there depending on the ambient temperature, humidity, after about
2 days after death.
Stopping resuscitation
Recorded as the time of death.
American Heart Association (AHA) was proposed algorithm of first aid, called the "chain
of survival". Early activation of emergency medical care.
1. Early start basic life support (modified step C-A-B).
2. Early defibrillation using automated external defibrillators (Automated external
defibrillators-AED).
3. Early initiation stage further life support, including intubation and use of drugs.
MODIFIED UNDER CARDIOPULMONARY AND CEREBRAL RESUSCITATION
(P. Safari)
The whole complex CPCR P. Safar divided into 3 stages, each of which has its own
purpose and successive stages, under the new ERC guidelines 2010 CPR algorithm (A-B-
C) was modified in the C-A-B, so the first step is immediate this event compress the chest
and then restore airway and CPR:

Phase I: Elementary support life

Purpose - emergency oxygen.
Steps:
A. Artificially maintaining circulation.
B. Control and restoring airway.
C. Maintaining artificial respiration.

Phase II: Further maintenance respiration.

The goal - restoration spontaneous circulation.
Steps:
D. Drug therapy.
E. Electrocardiography or electrocardioscopy.
F. Defibrillation.

III. Stage: Prolonged life support

Purpose - cerebral resuscitation and intensive therapy post resuscitation IT
G. Assessment (the cause of cardiac arrest and his removal) and the possibility of saving
the patient valuable considering the degree of damage to the CNS.
H. Restoration of normal thinking.
I. intensive therapy aimed at correcting the disturbed functions of other organs and
systems.

STAGE ELEMENTARY SUSTAINING LIFE

A. Artificially maintaining circulatory first thing to do next victim - it verify the absence
of consciousness (loudly ask: What happened? Open your eyes!), Pat in the face,
shoulders shake guards. In the absence of consciousness to assess the vital functions - if
the main signs of clinical death, immediately start CPR complex.
B. Precordial hit carried out when resuscitation immediately start watching the monitor
ventricular fibrillation or ventricular tachycardia without pulse (VF / VT without
pulse), and the defibrillator is not currently available. It makes sense only in the first 10
seconds of cardiac arrest. According to K. and D. Hroer, Cavallari, precordial hit
sometimes stops VF / VT without pulse (mainly PCS), but is often ineffective and vice
versa can transform the rhythm in less favorable mechanism of cardiac arrest - asystoly.
If a doctor is available ready to use defibrillator from precordial hit better to abstain.
Compression of the chest. To explain the mechanisms that provide blood flow during
chest compressions, it was proposed two theories. The earliest was the theory of the
heart pump, whereby the blood circulation caused by compression of the heart between
the sternum and the spine, resulting in increased intrathoracic pressure pushes blood
from the ventricles in systemic and pulmonary bed. This is a prerequisite for the normal
functioning of atrioventricular heart valves that prevent retrograde flow of blood into
the atrium. In artificial diastole phase there is a negative intrathoracic and intracardiac
pressure that provides venous return and ventricular filling. However in 1980. J.T
Niemann, C.F. Babbs et al. discovered that coughing, increasing intrathoracic pressure,
long retains adequate cerebral blood flow. This phenomenon is called cough
autoresuscitation. Deep rhythmic increased cough frequency of 30-60 per minute, is
able to maintain consciousness in trained patients (at cardiac catheterization) in the
course of the first 30-60 seconds of the onset of cardiac arrest, enough to connect and
use a defibrillator. Subsequently, many studies have shown that positive intrathoracic
pressure involved in the generation of systemic blood pressure. The authors measured
the direct method (in the radial artery) blood pressure of the patient in a state of clinical
death with refractory asystoly during mechanical ventilation bag "Ambu" without chest
compressions. It was found that pressure peaks on the curves are caused by rhythmic
blow lungs. In periods of mechanical ventilation discontinuation phase pressure
disappeared, indicating the ability of positive intrathoracic pressure to participate in the
generation of systemic blood pressure.

Technique of chest compressions

1. Proper patient laying on a flat, hard surface. Determination of compression -
palpation of the xiphoid process and retreat two transverse thumbs up, then placed the
hand on the border of the palmar surface of the middle and lower third of the sternum,
fingers parallel to the edges, and it another.
2. Option palms location "lock".
3. Proper conduct compression: locked arms at the elbows using the weight of his body.
Compression of the chest. The fundamental problem artificially maintain blood
circulation is very low (less than 30% of normal), cardiac output (CO), which occurs
when chest compressions. Properly performed compression maintains systolic BP at
60-80 mm Hg, while the diastolic blood pressure rarely exceeds 40 mm Hg and as a
result, causes brain low (30-60% of normal) and coronary (5-20% of normal) blood
flow. In carrying out chest compressions coronary perfusion pressure rises only
gradually and so with each another pause, required for respiration mouth to mouth, it
quickly goes down. However, carrying out several additional leads to compress restore
the original level of brain and coronary perfusion. In connection with this, significant
changes have occurred on the algorithm carrying out chest compressions. It was shown
that the ratio ofcompression to the respiratory rate of 30: 2 is more effective than the
15: 2, providing the most optimal balance between blood flow and oxygen delivery.
The ratio of compressions and the number of artificial breaths for one and for two
reanimator should be 30: 2.
Chest compressions should be performed with a frequency of at least 100
compresses / min to a depth of at least 5 cm in adults (as it should be noted that most
reanimator not click on the chest deep enough that reduces the effectiveness of induced
compression of blood flow, and therefore degrades the result of CPR), pausing for
artificial respiration (unacceptable conduct in patients not intubating blowing air at the
time of chest compressions - the danger of getting air into the stomach).
Signs of accuracy and efficacy of chest compressions is. The presence of pulse wave on
main and peripheral arteries. Direct cardiac massage is a later option. Despite the fact
that direct cardiac massage provides a higher level of coronary and cerebral perfusion
pressure (respectively 50% and 63-94% of normal) than compression of the chest, but
there are no data about its ability to improve outcome CPCR addition, it use is
associated with more frequent complications. However, there are some direct
indications of the meeting:
1) Presence of open chest in the operating conditions;
2) Suspected intrathoracic bleeding;
3) Suspected violations abdominal circulation, due to clamping of the descending
thoracic aorta department;
4) Massive pulmonary embolism;
5) Stop circulation against the background of hypothermia (allowing the direct
warming of the heart);
6) Failure chest compressions generate a pulse at the carotid and femoral arteries
because of bone deformities of the chest or spine;
7) Suspected unnoticed for a long period of clinical death;
8) Failure to correctly performed chest compressions in combination with other on-
stage moves further maintenance restore life spontaneous normotension

B. Control and restoring airway

The main problem that occurs in individuals without consciousness, airway
obstruction is the tongue and epiglottis hypopharynx in the area due to muscular atony.
These phenomena occur at any position of the patient (even in the abdomen), and the
tilt of the head (chin to chest), airway obstruction occurs in virtually 100% of cases. So
after established that the victim is unconscious, it is necessary to provide airway.
"Gold standard" to ensure the airway is "triple reception" by P. Safar and
endotracheal intubation.
P. Safar developed "triple reception" on the airways include: drawing back of the head,
opening his mouth and nomination of the lower jaw forward. Alternative methods of
restoring airway shown.
In carrying out manipulations on the airways should be mindful of the possible
injury to the spine in the cervical region. The greatest likelihood of whiplash injuries
can occur in two groups of victims:
1) When highway injuries (person or vehicle was knocked down during clashes in the
car);
2) If you fall from a height (including the "divers").
So victims can not tilt (neck bent forward) and turn his head to the side. In these cases
it is necessary to moderate pulling over the head, followed by holding the head, neck
and chest in one plane, eliminating the "triple reception" hyperextension neck,
ensuring minimal throwing the head and the simultaneous opening of the mouth and
the nomination of the lower jaw forward.
When providing first aid application shown fixing the neck "collar".
Only one casting head does not guarantee restoration of the airway. Thus, in 1/3
patients unconscious by muscular atony nasal passages during exhalation closed soft
palate, like moving valve.
In addition, it may be necessary to allocate a homogeneous substance (blood clots,
vomit, fragments of teeth and so forth.) Contained in the oral cavity Therefore,
especially in people with injuries, it is necessary to conduct an audit of the mouth and if
necessary, clean it from third-party content. To open the mouth using one of the
following methods.
1. Admission by means of crossed fingers at moderately relaxed lower jaw.
Reanimator stands at the head end or side at the head of the patient. The index finger
introduced into the victim's mouth corner and click on the upper teeth, then the index
finger is placed opposite the thumb on the lower teeth and forced open his mouth.
Thus, we can achieve significant sliding force, opens his mouth and examine the
mouth. If foreign bodies should remove them immediately. To do this, turn your head
to the right without moving the fingers of his left hand. Right index finger retard the
 right corner of his mouth down, which facilitates independent drainage of oral liquid
contents. One or two fingers, wrapped a scarf or other cloth, clean the mouth and
throat. Solid foreign bodies removed by the index and middle finger like tweezers or
curved as a hook index finger.
2. Admission "finger teeth" is used in the case of densely compressed jaws.
Enter the index finger of his left hand behind the molars and open mouth while relying
on the victim's head with his right hand, placed on the forehead.
3. In the event completely relaxed mandible injected left thumb to the mouth of the
victim and his tongue root tip lift. The other fingers grasp the lower jaw and chin in
nominated it forward.

Restoration of the airway may also be provided via air Hvedela and Safar (S-
shaped duct).

1. Choosethedesiredsizeducts - distancefromtheductstoshieldtheearlobe;
2. Followingtheforcedopeninghismouthductintroducedbulgedown, slippingon TVE-
rdomuskytothelevelofthepanel;
3. Afterthat, itrotated 180
degreessothatitscurvaturecoincideswiththecurvatureofthebackofthetongue.
Safarductsusedformechanicalventilationby "mouth-to-airducts."
Theseductscanbeanadequatesubstituteforthetwocomponents "triplereception" -
mouthopeningandmandibularnomination,
butevenwiththeuseofairnecessarytoperformthethirdcomponent - gettinghead.
Themostreliablemethodthatprovidessealingairway, endotrachealintubationis.
It should be noted that of tracheal intubation in patients with cardiac arrest associated with
chest compressions delay lasting an average of 110 seconds (from 113 to 146) and 25% of
endotracheal intubation lasted more than 3 minutes.
Therefore, an attempt intubation should be no more than 30 seconds, if that time you
can not intubated patient should immediately stop trying intubation and mechanical
ventilation start Ambu bag (or respirator) through a face mask with reservoir bag and the
binding oxygen to bag at a speed of 10-15 l/min.
After 2 minutes necessary to make a second attempt intubation or use alternative
methods of providing airway.
As an alternative to endotracheal intubation is recommended to use double barreled
ducts or laryngeal mask as technically simpler compared to intubation, but also reliable
methods of protection airway, unlike the use of face masks and air.
When using laryngeal mask must be remembered that in comparison with tracheal
intubation increased risk of aspiration. In this connection it is necessary to pause in chest
compressions during mechanical ventilation (ALV) through laryngeal mask.
a. After selecting laryngeal mask according to patient body weight, grease seals, by one
hand performed extension of the head and neck flexion the patient. Laryngeal mask take
a pen for writing (aperture up), set the tip of the mask at the center of the front incisors to
the inner surface of the mouth, pressing it to the hard palate. Middle finger dipped lower
jaw and examine the mouth. While pressing the tip of the cuff, pushing down laryngeal
mask (if laryngeal mask starts to turn out, it should be removed and reinstalled)
b. Continue to hold down laryngeal mask while pressing forefinger in connection
snorkeling, constantly keeping the pressure on the structure of the pharynx. The index
finger remains in this position for as long as the mask is not held together with tongue and
throat to not fall;
c. Forefinger, drawing in place of the tube and laryngeal mask promote further down
while performing light brush pronation. This allows you to quickly set the end of it. The
resistance that occurs means that the tip laryngeal mask located opposite the upper
esophageal sphincter.
d. Holding the tube laryngeal mask one hand, the index finger is removed from the throat.
With your other hand, gently pressing laryngeal mask, check its installation.
where. Inflate the cuff and record laryngeal mask.
In addition to standard laryngeal mask permitted use laryngeal mask I-gel, the shape of
the larynx, "cuff" thermoplastic elastomeric gel that does not swell, which are necessary
when setting themselves elementary skills.
If the victim is unconscious, but he has a pulse and remains adequate independent
breathing, you must provide a stable position on the side, to the prophylaxis policy-
aspiration of gastric contents due to vomiting or regurgitation and hold a reception in the
airways.
It is necessary to bend the leg of the victim on the side on which the person that help put
your hand under the victim's buttock on the same side. Then carefully turn the victim on
the same side at the same time throw the victim's head and held face down. Put his hand at
the top, under his cheek to keep the head position and avoid turning face down. This arm
of the victim, who is behind him, not let him take the supine position.

Algorithm assist with airway obstruction foreign body

With partial airway obstruction (maintaining normal color of the skin, the patient's
ability to speak and efficiency cough) an immediate intervention is indicated. In the event
of a complete airway obstruction (at the inability of the patient to say, ineffective cough,
presence of increasing difficulty in breathing, cyanosis) recommended the following
amount of aid, depending on whether or not the patient's consciousness:
a) With consciousness
- 5 slaps his hand in the blade area or abdominal compress 5 - Heymliha reception. In the
latter case reanimator is behind the victim, squeezes his hand in a fist and puts (to the side
where the thumb) his belly to the median line between the navel and the xiphoid process.
Firmly clutching fist brush the other hand, presses his fist in the stomach by briefly
pressing the direction upwards. Reception Heymliha not carried out in pregnant and
smooth people, replacing it with chest compressions, which technique is similar to how
during the reception Heymliha.
b) Without consciousness:
1. Open your mouth and fingers to try to remove the foreign body.
2. Diagnose the absence of spontaneous breathing (look, listen, feel).
3. Hold 2 artificial breath by "mouth to mouth". If succeeded in restoring the airway in 5
attempts, following the paragraphs 1 -3 - move on to paragraph 6.1.
4. In the event that attempts to draw an artificial lung ventilation (ALV) unsuccessful even
after changing head position, immediately begin chest compression to eliminate airway
obstruction.
5. After 15 compressions, open your mouth and try to remove the foreign body, to produce
2 artificial inspiration.
6. Evaluate effectiveness:
6.1. If there is an effect - identify signs of spontaneous circulation and if necessary
continue chest compressions and / or CPR.
6.2. If there is no effect - repeat cycle - points 5-6.

B. Artificial maintain breathing after cardiac arrest and CPR for a reduction of
compliance lungs.
This in turn leads to increased pressure required for injection optimum tidal volume to
the lungs of the patient, on a background of pressure that causes gastroesophageal
sphincter opening, facilitates the ingress of air into the stomach, thus increasing the risk
of regurgitation and aspiration of gastric contents. So during mechanical ventilation by
"mouth to mouth" each piece breath should not beforced and held for 1 second for
optimal respiratory volume. If seen getting air into the stomach (bulging in the epigastric
region) should clear the air. For this to prevent aspiration of gastric contents, the patient's
head and shoulders turn away and pressed his hand between the stomach and chest dome.
Then, if necessary, cleanse the mouth and throat, and then carry "triple reception" on the
airways and keep breathing "from mouth to mouth."
After the "triple reception" for airway, one hand placed on the forehead of the victim,
providing a cast of the head and nose while pinching your fingers victim, then pressed his
lips tightly around the mouth of the victim, blown air, watching excursion chest. If you
see the victim's chest rose, released his mouth, giving for victim the opportunity make
full passive exhalation.
It is essential to minimize breaks of chest compressions - is the best of two breaths
"mouth-to-mouth or face mask" for no more than 5 seconds, followed by immediate
continuation of chest compressions.
Respiratory volume should be 400-600 ml. (6.7 ml/kg), respiratory rate - 10 per min.,
In order to prevent hyperventilation. It was demonstrated that hyperventilation during
CPR, increasing intrathoracic pressure decreases venous return to the heart and reduces
cardiac output, associating with a bad levelsurvival such patients.
a) the ratio of respiratory rate to compress without airway protection or patronage of
laryngeal mask or Combitube duct for both one and two reanimators should be 30: 2 and
carried out with a pause on mechanical ventilation (risk of aspiration!);
b) with the patronage airway (endotracheal intubation) - compression of the chest should
be carried out at a frequency of at least 100 / min, ventilation frequency of 10 / min (in the
case of bag Ambu - 1 breath every 5 seconds), without pause during mechanical
ventilation ( because chest compression with simultaneous blow lungs increases coronary
perfusion pressure).

II STAGE FURTHER SUSTAINING LIFE

C. Medical Therapy

Route of administration of drugs.

According to the recommendations of the ERC '2010, endotracheal route of administration
of drugs is no longer recommended. Studies have shown that a dose of adrenaline during
CPR introduced endotracheal which is equivalent dose intravenous route of administration
should be 3 to 10 times higher. A number of experimental studies suggest that low
concentrations of epinephrine during endotracheal route of administration may cause
transient beta-adrenergic effects that lead to the development of hypotension and reduced
coronary perfusion pressure, which in turn impairs the effectiveness of CPR. In addition, a
large volume of fluid injected endotracheal capable worsen gas exchange. In this
connection, the new guidelines are two main access for drug administration:
a) intravenously, in the central and peripheral vein. The best way is the introduction of
central veins - subclavian and internal jugular, as provided by the drug delivery to the
central circulation. To achieve the same effect when injected into the peripheral vein,
preparations to be diluted with 10-20 ml saline or water for injection.
b) intraosseous way - intraosseous injection of drugs in the shoulder bone or tibial
provides adequate plasma concentration versus time for the introduction of drugs into the
central vein. The use of mechanical devices for intraosseous administration of drugs
provides the simplicity and accessibility of the route of administration.
Pharmacological provide resuscitation.
1) Adrenaline:
a) the electrical activity without pulse / asystoly - 1 mg intravenously every 3-5 minutes;
b) if VF / VT without pulse adrenaline introduced only after the third level of inefficient
electrical defibrillation dose of 1 mg. Later this dose administered intravenously every 3-5
minutes (ie before each second defibrillation) as long as kept VF / VT without pulse.
2) Amiodarone (Cordaron) - antiarrhythmic drug first line with ventricular fibrillation /
ventricular tachycardia without pulse (VF/VT) refractory to electric pulse therapy after
three ineffective discharge in an initial dose of 300 mg (diluted in 20 ml saline or 5%
glucose) by retyping 150 mg. After the restoration of an independent circulation at a dose
of 900 mg in the first 24 hours postresuscitation period to prevent refibrillation.
3) Lidocaine - in the absence of amiodarone (this should not be used as a supplement to
amiodarone) - initial dose of 100 mg (1-1.5 mg / kg) / in, if necessary, an additional bolus
of 50 mg (in the total dose should not exceed 3 mg / kg over 1 hour).
4) sodium bicarbonate - routine use during CPR or after restoration of an independent
circulation is not recommended.
Cardiac arrest is a combination of respiratory and metabolic acidosis. The best method of
correcting acidemia when stopping circulation is of chest compressions, additional benefit
provided by carrying out ventilation.
Routine administration of sodium bicarbonate during CPR by generating CO2 diffuses
into the cells, causing a number of adverse effects:
- Increased intracellular acidosis;
- Negative inotropic effect on ischemic myocardium;
- Poor circulation in the brain due to the presence of high osmolarity sodium;
- Shift of oxyhemoglobin dissociation curve to the left, which can reduce oxygen delivery
to the tissues.
The indication for administration of sodium bicarbonate are cases of cardiac arrest
associated with hyperkalemia, or tricyclic antidepressant overdose in doses of 50 mg (50
ml - 8.4% solution) IV.
5) Calcium chloride - a dose of 10 ml of 10% solution IV (6.8 mmol𝐶𝑎+2 ) with
hyperkalemia, hypocalcemia, an overdose of calcium channel blockers.
The use of atropine during CPR is no longer recommended.

D. Electrocardiographic diagnosis mechanism circulatory arrest

Successful resuscitation largely depends on early diagnosis electrocardiogram (ECG
monitor or defibrillator) mechanism of cardiac arrest because it defines further tactics of
resuscitation.
In reanimatology practice used for assessment of ECG II standard abduction, allowing
shallow wave differentiate from ventricular fibrillation asystole.
Often, ECG electrodes defibrillator VF may look like asystole. Therefore, to avoid
possible errors need to change the location of the electrodes, moving them to 90 ° relative
to the first location. It should also be noted that during cardiopulmonary resuscitation
frequently appear on your monitor various kinds of obstacles (electric, uncontrollable
movements associated with the patient during transport, etc.) that can significantly distort
the ECG.
There are 3 basic mechanisms of cardiac arrest, the electrical activity without pulse
(EAWP), ventricular fibrillation or ventricular tachycardia without pulse (VF/VT without
pulse) and asystole.
1) Electrical activity without pulse (EABP) includes electromechanical dissociation and
severe bradyarrhythmia (bradyarrhythmia clinically manifested in heart rate < 45 beats /
min. In a sick person and with heart rate <30 beats / min. With sound). Electromechanical
dissociation (old name - inefficient heart), characterized by the absence of mechanical
activity of the heart with preserved electrical activity. The ECG is recorded normal or
modified QRS-complexes with regular or irregular intervals.
2) Ventricular tachycardia without a pulse. VT without pulse depolarization characterized
by ventricular cardiomyocytes with high frequency. The ECG missing teeth and marked P
wide QRS-complexes.
3) Ventricular fibrillation. Ventricular fibrillation is characterized by chaotic,
asynchronously cuts cardiomyocytes with the presence of ECG irregular, with a frequency
of 400-600 per min., low-, medium- or large wave fluctuations.
4) Asystole - no mechanical as well as electrical activity of the heart, the ECG contours.

D. Defibrillation.

Principle defibrillation is a critical mass of myocardial depolarization, leading to the

restoration of sinus rhythm natural pacemaker (as pacemaker cells of the sinus node are
the first cells of the myocardium, capable of spontaneous depolarized). The level of the
first power level, a compromise between efficiency and its damaging effects on the
myocardium.
If you notice on cardiomonitor/defibrillator VF/VT without pulse must immediately put
one category of electrical defibrillation. Immediately after applying the discharge
defibrillation should continue chest compressions and other components of CPR for 2
minutes, and then to assess the rhythm on the ECG in the case of restoration of sinus
rhythm assess its hemodynamic efficiency by the presence of pulse in the carotid and
radial artery (by simultaneous palpation of these vessels). Because even if defibrillation is
effective and will resume according to ECG sinus rhythm, rarely immediately after
defibrillation he is hemodynamically effective (ie, able to generate a pulse, and thus blood
flow). Of course you need more than 1 minute of chest compressions to restore self-
circulation (pulse). Restoring hemodynamically effective rate, additional compression of
the chest will not re-development of VF. Conversely, when recovery only organized
bioelectrical activity of the heart, but not hemodynamically effective, cessation of chest
compressions inevitably refibrillation ventricles. The above facts are justification for the
immediate start of chest compressions after applying defibrillation discharge for 2
minutes, and only then the next assessment by the ECG rhythm, and in the case of
restoration of sinus rhythm assessment pulsations in the carotid and radial arteries.
The gap between the conduct discharge defibrillation and start chest compressions should
be less than 10 seconds.
Estimation of rate / pulse rate should also not exceed 10 seconds - if saving ECG
VF/VT without pulse, you must re-apply defibrillation discharge followed by chest
compressions and CPR ingredients for 2 minutes. If the recovery sinus rate according to
ECG monitoring, but no pulse - need to immediately continue chest compressions for 2
minutes, followed by assessment of rhythm and pulse.

DISCHARGE → CPR FOR 2 min → ASSESSMENT RATE / PULSE →

DISCHARGE → CPR FOR 2 min ...

The energy of the first level, which is currently recommended ERS'2010 should be for
monophasic defibrillators as J 360 and all subsequent bits to 360 J. The results showed that
biphasic defibrillation using lessenergy, more effective and cause less damage and
postresuscitation dysfunction compared with equivalent energy monophasic pulse.
The initial level of energy for biphasic defibrillators should be 150 J (or lower level,
depending on the model defibrillator), followed by increasing energy to 360 J. Repeated
discharges.
When VF/VT without pulse - adrenaline 1 mg and 300 mg amiodarone IV enter only
after the third level of inefficient electrical defibrillation. In the future, if persistent VF,
adrenalin injected every 3-5 minutes, IV during the period of CPR, amiodarone 150 mg
before the next defibrillation discharges.
Efficacy and safety of electrical defibrillation depends on a number of cardiac and
extracardial factors.
1) The leading role belongs to the form of the electric impulse - for successful defy-
brillyatsii bipolar pulse (versus monopolar) should be approximately 2 times less power
(maximum allocated to patient power is respectively 200 J for biphasic and 400 J
monophasic bits). According to recent successful defibrillation pulses of bipolar sinusoidal
< 115 J is 92%. Consequently, only 8% of patients required a 150 - 200 J energy.
However, the total efficiency monopolar pulse shapes depending on the type VF is at an
energy level of 200 J 60-90% or environments, it is about 70%.
2) The second important factor affecting the effectiveness of defibrillation is the correct
location of the electrodes on the chest. Since only 4% transthoracic current passes through
the heart, and 96% - in other structures of the chest, so it is important an adequate location.
With front-front location, one electrode installed in the right edge of the sternum below the
clavicle, the second lateral left nipple in the mid-axillary line. With front-back
arrangement, each electrode set medial left nipple, the other under the left shoulder blade.
If the patient is implanted pacemaker, defibrillator electrodes have located him at a
distance of 6-10 cm.
3) A third factor that affects the efficiency of defibrillation, is the resistance of the chest or
transthoracic impedance. The phenomenon transthoracic impedance (resistance) has
important clinical implications, since it explains the difference between the current
energytyped on the scale of the device and released on the patient. If resuscitation there are
factors that significantly increase the transthoracic impedance, it is likely that the
established on the scale of energy defibrillator 360 J its real value may amount to the
myocardium at best 10% (30 - 40) J.
Transthoracic resistance depends on body weight and an average of 70-80 ohms adult. To
reduce transthoracic defibrillation is necessary to support a phase of exhalation, because
transthoracic impedance in these circumstances is reduced by 16%, the best is the effort
which is applied to the electrodes at 8 kg for adults and 5 kg for children aged 1-8 years.
However, 84% decrease transthoracic impedance necessary to ensure good contact
boundary between the skin and the electrodes through the use of conductive fluids. It must
be emphasized that the use of "dry" the electrodes significantly reduces the efficiency of
defibrillation and causes burns. To reduce the electrical resistance of the chest using
special adhesive pad electrodes, conductive gel or gauze soaked in hypertonic solution. In
extreme situations electrode surface can simply moisten any conductive solution (water).
Thick hair on the chest electrodes causes poor contact with the skin of the patient and
increases the impedance, thus reducing the effectiveness inflicted discharge, and increases
the risk of burns. Therefore, it is advisable to shave region imposing electrodes on the
chest. However, in emergency situations during defibrillation is not always possible.
While none of the participants defibrillation resuscitation should not touch the skin of the
patient (and / or bed).

Features and conditions of termination of CPR

The probability of a successful outcome CPR at EABP/asystole (as in refractory VF/VT)

can increase only if there is a potentially reversible causes of cardiac arrest treatable:
hypoxia, hypovolemia, hyper/hypokalemia (metabolic disorders), hypothermia and tension
(tense pneumothorax), cardiac tamponade, thrombosis (coronary, pulmonary) toxic
overdose.

Stopping resuscitation

CPR should be performed as long as stored ECG ventricular fibrillation, as this remains
minimal metabolism in the myocardium, which provides the potential to restore self-
circulation.
In the case of cardiac arrest on the mechanism EABP / asystole in the absence of
potentially reversible causes - CPR is carried out for 30 minutes and stop at its
inefficiency.
CPR more than 30 minutes in case of hypothermia, drowning in icy water and
overdose of drugs.

III phase long-term life support

F-evaluation of the patient

 The first task after restoring blood flow is an independent assessment of the patient. It
can roughly be divided into two sub-tasks:
1) determining the causes of clinical death (to prevent recurrent cardiac arrest, all of which
worsens the prognosis of full recovery of the patient);
2) determination of sanctions homeostasis in general and in particular brain functions (to
determine the extent and nature of intensive care).

3 - Restoring normal mentality

And - Intensive therapy aimed at correcting the disturbed functions of other organs and
systems
According to the National Register in cardiopulmonary resuscitation USA (National
Registry of Cardiopulmonary Resuscitation - NRCPR), among 19,819 adults and 524
children after restoration of spontaneous circulation nosocomial mortality rate was 67 and
55% respectively. According to epidemiological studies of 24,132 patients in Britain
revived level of mortality in post resuscitation period was 71%. It should be noted that
among the survivors have only 15-20% rapid recovery of adequate awareness, the
remaining 80% of patients going through post resuscitation disease. Causes of death in
post resuscitation period: 1/3 - cardiac (the highest risk in the first 24 hours post
resuscitation period), 1/3 - dysfunction of various organs and extracerebral 1/3 -
neurological (causes of death in the late period post resuscitation disease - PRD).
According O.N. Nehovsky, "for post resuscitation disease (PRD) characterized by its own
specific etiology - indivisible combination of global ischemia and reperfusion
reoxygenation. As reoxygenation and reperfusion after undergoing cardiac arrest not only
cope with the consequences of the primary pathological effects, but also cause a cascade
of new lesions. It is important that the reason for these changes is not in itself a global
ischemia, and its combination with reoxygenation and reperfusion". PRD is a combination
of pathophysiological processes, including four key components:
1) post resuscitation brain damage;
2) post resuscitation myocardial dysfunction;
3) systemic ischemic-reperfusion reaction.
Post resuscitation prevalence of brain damage due to the severity of the morphological
structure of the brain, performed his functions and low tolerance to ischemia and hypoxia.
No cell organism does not depend on the level of oxygen and glucose as a neuron. The
maximum duration of clinical death (anoxia) under normotermya, where possible survival
of neurons, is no more than 5 minutes.
Neuronal damage in the PRD is multifactor in nature and developed at the time of cardiac
arrest, during CPR, as well as the restoration of an independent circulation period:
- The period of ischemia - anoxia at the time of absence of circulation during clinical death
(no-flow);
- The period of hypoperfusion - hypoxia artificial circulatory support during CPR (low-
flow), as the highest possible level of cardiac output (CO) reaches only 25% of the
original;
- Reperfusion period consisting of consecutive phases: no-reflow, then the next phase
hyperemia and subsequent global and multifocal hypoperfusion.
In post resuscitation period are the following stages of brain perfusion after the restoration
of an independent circulation:
1. The initial development of multifocal no reperfusion (the phenomenon of no-reflow).
2. Stage transient global redness - develops in 5 - 40 minutes after restoration of
spontaneous circulation. The mechanism of development associated with cerebral
vasodilation by increasing intracellular concentrations of Na and adenosine, and reduced
levels of intracellular pH and 𝐶𝑎+2 . The duration of cerebral ischemia later stage
determines the duration of flushing, which, in turn, is heterogeneous in nature in different
regions of the brain, leading to a decrease in perfusion and swelling of astrocytes.
3. Stage prolonged global and multifocal hypoperfusion - develops from 2 to 12 hours post
resuscitation period. The rate of cerebral glucose metabolism is reduced to 50% from
baseline, however, global consumption of oxygen by the brain returns to normal (or
higher) level from baseline to the moment of cardiac arrest. Cerebral venous pO2 may be
at critically low levels (less than 20 mm Hg), reflecting violation delivery and oxygen
consumption. The reason for this is to develop vasospasm, swelling, sludge red blood cells
and excessive production of endothelin.
4. This stage can develop in several directions:
4.1. The normalization of cerebral blood flow and oxygen consumption of brain tissue
with subsequent restoration of consciousness.
4.2. Storing persistent coma when a total cerebral blood flow and oxygen consumption
remains low.
4.3. Re-development of congestion of the brain, associated with a decrease in oxygen
consumption and the development of neuronal death.
Post resuscitation dysfunction has various clinical manifestations. Thus, in experiments
on pigs has been shown to decrease in the first 30 minutes Post resuscitation period
ejection fraction of 55 to 20%, and increasing end-diastolic pressure (EDP) of the left
ventricle from 8-10 to 20-22 mmHg According to other studies, patients in 49% of cases
post resuscitation dysfunction manifested by tachycardia, increased left ventricular CRT,
in the first 6 hours hypotension (SBP < 75 mmHg) and low cardiac output (CI < 2.2
l/min/m2).
According to a recent international consensus, are five phases post resuscitation period,
each of which determines the tactics of intensive care.
Prognostic assessment in post resuscitation period
Coma for 48 hours or more acts predictor of poor neurological outcome. If 72 hours
after cardiac arrest neurological deficit reaches £ 5 points for the Glasgow Coma Scale in
the absence of motor reactions in response to painful stimulation or pupillary reflex, it is a
predictor of persistent vegetative state in all patients.

Principles of intensive therapy post resuscitation period

1. Extratcerebral homeostasis.
1.1. The early hemodynamic optimization, as is the failure of autoregulation of cerebral
blood flow, the level of cerebral perfusion pressure (CPP) is dependent on the level of
mean arterial pressure (MAP):
CPP = MAP - ICP.
It is therefore important to maintain normotension - 70-90 mmHg MAP Moreover, severe
hypotension and hypertension need to be adjusted. CVP is supported within 8-12 cm H2O;
1.2. Oxygenation: arterial hyperoxia should be excluded, the level should provide FiO2
SaO2 94-96%, as shown that mechanical ventilation with FiO2 1.0 in the first hour post
resuscitation period associated with poor neurological outcome by creating additional
oxidative stress in neurons post ischemical.
13. Maintaining normal levels of PaO2 (normoxemia) and PaSO2 (normocapniya) -
vazoconstriction caused by hyperventilation, hypoventilation as well as causing increased
intracranial pressure, leading to cerebral ischemia deepening;
1.4. Keeping normotermia of the body. The risk of poor neurological outcome increases by
ka-degree > 37 ° C. According to A. Takasu et al. (2001), fever > 39 ° C in first 72 hours
significantly increases the risk of brain death.
1.5. Keeping normoglycemia - persistent hyperglycemia is associated with poor neurologic
outcome. The threshold level at which the correction should begin insulin - 10.0 mmol/l.
Hypoglycemia should also be excluded.
Target values necessary to achieve in post resuscitation period:
- CAP 70-90 mm Hg ;
- CVP 8-12 cm H2O;
- Hemoglobin > 100 g/l;
- Lactate < 2.0 mmol/l;
- The temperature of 32-34 ° C within the first 12-24 hours, then maintaining
normotermia;
- SaO2 94-96%;
- SvO2 65-75%;
- DO2 400-500 ml/min/ m2;
- VO2> 90 ml/min /m2;
- Exclude dependent oxygen consumption of its delivery.
2. Intracerebral homeostasis.
2.1. Pharmacological methods. Currently there are no effective and safe in terms of
evidence-based medicine techniques pharmacological effects on the brain in post
resuscitation period. Conducted at our department study revealed the feasibility of
perftoran in post resuscitation period. Perftoran reduces brain swelling, post resuscitation
severity of encephalopathy and increases the activity of the cerebral cortex and subcortical
structures, facilitating rapid exit from coma. Perftoran administered intravenously is
recommended in the first 6 hours after resuscitation period at a dose of 5.7 ml/kg.
2.2. Physical methods. Currently, hypothermia is the most promising method and protect
the brain.
According to current guidelines, all patients unconscious, suffered cardiac arrest, it is
necessary to ensure that the therapeutic hypothermia (TH) of the body to 32-34 ° C for 12-
24 hours.
The side effects of TH are: increased blood viscosity, cold diuresis, but not in violation of
renal function, increased risk of pneumonia. The development of serious arrhythmias
rarely occurs in T - 33 ° C, even in patients with myocardial ischemia. Contrindication for
the TH is pregnancy, cardiogenic shock (systolic blood pressure less than 90 mmHg at
sympathomimetic infusion), an overdose of drugs and narcotics.
Currently, it is recommended that the following requirements for TH:
- Monitoring the temperature of the nucleus (inner esophageal, tympanic, rectal) and
surface temperature control parameters of hemostasis, blood gases and electrolytes,
glucose and lactate levels, hemodynamic;
- Duration - 12-24 hours;
- Target core temperature 32-34 ° C;
- Method - external cooling using hypothermia or intravenous infusion psychologists-
agency solution or Ringer's lactate solution (4 ° C) at a dose of 30 ml/kg at a speed of
introduction of 100 ml/min;
- Carrying out artificial respiration;
- To relieve cold shiver - analhosedation, muscle relaxants, use vasodilatator (nitrates);
- Slow warming - not faster 0,2-0,5 ° C/h.
We use the combined technology of inducing hypothermia intravenous infusion 0,9%
NaCl or Ringer's lactate solution (4 ° C) at a dose of 30 ml/kg, followed by maintaining
external cooling hypothermia hypothermiaBlanketrol II CSZ to target core temperature -
32-34 ° C analhosedation conditions and mechanical ventilation with providing
normoventilater.
In conclusion, it seems extremely important introduction of modern Strait la CPCR in
clinical practice and teaching hospitals on the basis of medical personnel, especially after
the creation in Ukraine of the National Council of resuscitation.

ADDITION

I. The observation of a person's death based on brain death

The observation of a person's death based on brain death
1. General information
Decisive for ascertaining brain death is a combination of the fact of termination of the
functions of the entire brain with evidence of the irreversibility of the suspension.
 Right diagnosis of brain death makes the availability of accurate information on the
causes and mechanisms of this condition. Brain death can develop as a result of primary or
secondary damage.
Brain death as a result of the initial damage develops due to a sharp rise in intracranial
pressure and caused him cessation of cerebral circulation (severe closed head injury,
spontaneous and other intracranial hemorrhage, cerebral infarction, brain tumors, closed
acute hydrocephalus, etc.), and also due to open cranio-cerebral trauma, intracranial
surgery on the brain, and others.
Secondary damage of the brain resulting from hypoxia of various origins, including at
cardiac arrest and stopping or severe deterioration of the circulatory system, resulting in
prolong shock and others.
2. Conditions for the diagnosis of brain death
The diagnosis of brain death is not considered as long as these are not excluded effect:
intoxication, including medical, primary hypothermia, hypovolemic shock, metabolic
endocrine places and use opioids and muscle relaxants.
3. Complex clinical criteria, whose presence is necessary for the diagnosis of brain death
3.1 Full and persistent lack of consciousness (coma).
3.2 Atony of muscles.
3.3 No response to strong pain stimulation in trigeminy points and any other reflexes
closed above the cervical spinal cord.
3.4 The lack of reaction of pupils to direct glare. This should be aware that any drugs that
extend the pupils are not used. Eye balls still.
3.5 The lack corneal reflexes.
3.6 The lack oculusefalic reflexes.
To induce reflex oculusefalic the doctor holds the position of the bed so that the head of
the patient was maintained between doctor wrists and thumbs raised eyelids. Head rotates
180 degrees in one direction and held in this position 3 - 4 seconds, then - in the opposite
direction at the same time. If the head turning eye movements is not stable and they
remain central position, it indicates a lack oculusefalic reflexes. Oculusefalic reflexes are
not investigated in the presence or suspected traumatic injury of the cervical spine.
3.7 The lack oculuvestybulyarn reflexes.
To investigate oculuvestybulyarn held bilateral caloric reflex test. By its conduct must
ensure no perforations eardrums. Head patient lift 30 degrees above the horizontal level. In
the external auditory canal catheter introduced a small, slow conducted irrigation of the ear
canal with cold water (t 20 ° C, 100 ml) for 10 sec. When intact brainstem function 20 - 25
sec. appears nystagmus or deviation of the eyes toward the slow component of nystagmus.
Absence of nystagmus and deviation in the major apple caloric test done on both sides,
indicates a lack oculuvestybulyar reflexes.
3.8 The lack of pharyngeal and tracheal reflexes which are determined by the movement
of endotracheal tube in the trachea and upper airways, as well as promoting the catheter
for the aspiration of bronchial secretions.
3.9 The absence of spontaneous breathing.
Absence of breathing not to be a simple disconnection of the ventilator unit, as this
develops, hypoxia have harmful effects on the body and especially the brain and heart.
Disconnect the patient from the ventilator unit must be carried out using a specially
designed disconnecting test. Disconnecting test conducted after the results p.3.1 - 3.8. The
test consists of three elements:
a) to monitor the gas composition of blood (Pa02 and PaS02);
b) before disconnecting the respirator should spend 10-15 minutes in ventilation mode that
ensures elimination of hypoxemia and hypercapnia P02 1.0 (100% oxygen), the optimal
PEEP (positive end expiratory pressure);
c) after the claims. "A" and "B" unit disconnect the ventilator and endotracheal tube or
tracheostomy served humidified 100% oxygen at a speed of 8-10 liters per minute. At this
time, the accumulation of endogenous carbon dioxide, controlled by sampling arterial
blood. Stages monitoring blood gases are: before the test in terms of ventilation; 10-15
minutes after the 100% oxygen ventilation immediately after disconnecting from the
ventilator; then every 10 minutes until PaS02 reaches 60 mm Hg. Art. If these and (or)
higher values PaS02 spontaneous respiratory movements are not restored, disconnect test
confirms the absence of function of the respiratory center of the brain stem. When the
minimum ventilation breaths immediately resumed.
4. Additional (confirm) tests to complex clinical criteria for the diagnosis of brain death.
4.1. Setting absence of brain electrical activity is carried out in accordance with
international provisions electroencephalographic studies in terms of brain death. Used
needle electrodes, at least 8 located under the "10 - 20%," and 2 ear electrode.
Interelectrode resistance should be at least 100 ohms and 10 ohms maximum,
interelectrode distance - at least 10 cm. It is necessary to preserve the definition of
switching and no intentional or unintentional creation of electrode artifacts. Recording is
carried on channels with a time constant of at least 0.3 with the amplification of at least 2
mV / mm (upper limit bandwidth frequency not below 30 Hz). Used machines with at least
8 channels. EEG recorded at bi- and monopolar leads. Electrical silence cortex in these
conditions should be kept at least 30 minutes of continuous recording. If you doubt the
silence of electric cord required re-registration of EEG. Assessment of EEG reactivity to
light, loud sound and pain: the total time of stimulation by light flashes, sound stimuli and
painful irritation least 10 minutes. Source of outbreaks submitted at a frequency of 1 Hz to
30 shall be at a distance of 20 cm from the eye. The intensity sound stimuli (clicks) - 100
dB. The speaker is the ear of the patient. Incentives maximum intensity generated by
standard photo - and fonostimulator. For strong pain stimuli are applied punctures the skin
with a needle.
EEG recorded on the phone can be used to determine brain electrical silence.
4.2. Setting absence of cerebral circulation.
Make angiography twice four heads of major vessels (common carotid and vertebral
arteries) at intervals of not less than 30 minutes. Average blood pressure during
angiography must be at least 80 mm Hg If angiography revealed that none of intracerebral
arteriyne filled with contrast medium, this indicates cessation of cerebral circulation.
5. The duration of observation
In the primary lesion of the brain to establish the clinical picture of brain death long-ness
of observation should not be less than 12 hours since the first installation of the signs
described in pp.3.1 - 3.9; the secondary lesions - monitoring should last at least 24 hours.
Suspicion of intoxication duration of observation is increased to 72 hours.
During these periods every 2 hours are recorded the results of neurological examinations
that detect loss of brain function in accordance with paragraphs. 3.1 - 3.8. It should be
borne in mind that spinal reflexes and automatism may occur in conditions of continued
mechanical ventilation. In the absence of features cortex and brain stem and cerebral
circulation suspension according angiography (p. 4.2). Brain death is stated without further
observation.
6. Establishing the diagnosis of brain death and documentation
6.1 The diagnosis of brain death is established commission of doctors consisting of:
resuscitator with experience in the department of intensive care for at least 5 years and a
neurologist with the same professional experience. For special studies of the Commission
include experts with additional research methods with professional experience of at least 5
years, including a required with other agencies on a consultative basis. Appointment of
commission and approval of "the Protocol establishing brain death" is made the head of
the intensive care unit where the patient, and in the absence of another doctor responsible
institution.
The commission can not include experts who participate in the fence and organ
transplantation.
The main document is the "Protocol establishing brain death," which is important for all
conditions, including the removal of organs. In the "Protocol" should be referred to the
data of research, surname, name and patronymic doctors - members of the commission and
their signatures, date and time of registration of brain death and therefore death. After
establishing brain death and execution of "Protocol" resuscitation, including mechanical
ventilation may be suspended.
Responsibility for the diagnosis of a person's death rests with the doctor that
established the diagnosis of brain death, the same hospital where the patient died.
These recommendations are not valid for establishing brain death in children, for which
appropriate diagnosis has not yet been developed.
Cardiac arrest during CA
In connection with the widespread SA, particularly in obstetrics, should be considered
separately cardiac arrest at SA. It can occur at any stage of anesthesia, and usually against
the background of complete well-being. Sometimes short stop prior progressive
hypotension and/or bradycardia.
The cause of this complication is unknown. Clear communication of the applicable
anesthetics is not installed, if not detected and depending on the level of protein, described
cases of asystole even in the so-called blockade truck (sacral and lower lumbar segments).
It is noticed that cardiac arrest occurs when a sudden change in body position - turn the
patient on the side, lifting and lowering the legs, shifting from the table on the gurney.
When showing asystole and immediately begin resuscitation immediately (mechanical
ventilation with oxygen, heart massage, adrenaline intravenously), heart rate recovered
rapidly, indicating the nature of reflex complications. Keep in mind the basic features of
the CPR in pregnant women, along with the actions resuscitator (required to ensure the
prevention of the syndrome of the inferior vena cava) midwives should immediately
perform a cesarean section. This is necessary not only and not so much in the interests of
the fetus, how to improve cardiac massage.

Throughout the history of human society in the minds of people

never thought extinguished - the dream of finding ways to conserve life and prevention of
death. There in recent decades, the science of resuscitation from the standpoint of modern
ideas about life and death, to a certain extent solve this painful and eternal question of how
the struggle for life, establish reasonable limits of this struggle, indications and
contraindications to it. Although nowadays no one builds illusions of eternal life, the
struggle for the life of a dying patient, when this is the real reason, do not lose the
greatness and nobility."
"Resuscitation is a positive force in the evolution of mankind, as based on the concept of
the value of every human life as a unique phenomenon in the universe."
Peter Safar (1924 - 2003).

Historical Review
Methods revival of man after death have a long history. In his early forms of resuscitation,
perhaps as old as humanity. In Egyptian mythology, Isis, goddess of fertility, water and
wind, breathable depicted in her mouth to her husband god Osiris, thus reviving it. The
Bible tells how the prophet Elisha revived the dead child:
32 And when Elisha was come into the house, behold, the child was dead on his bed.
33. And he went and locked the door behind him, and prayed to the Lord.
34. I went and lay on the child, and put his mouth to his mouth, and his eyes to his eyes,
and his hands to his hands, and stretched it, and it became warm baby's body.
35. ... and the child sneezed seven times, and the child opened his eyes.
(Old Testament Book of Kings 4, Chapter 4).
In the Middle century the development issues associated with recovery of A. Vesalius
(1514-1564), who in his classic work "De HumaniCorporisFabrica" (1513h). Shown in
animal experiments that the holding of mechanical ventilation (mechanical ventilation) air
under positive pressure through the tracheostomy hole restores the activity of the heart,
and T. Paracelsus (1493-1541), who first used the blacksmith furs (1530) as a makeshift
manual respirator for mechanical ventilation in the intensive care people.
An important milestone was the creation in 1767 of the Dutch Society rescue drowning,
becoming the world's organization resuscitation people, which gave start to form similar
partnerships in other countries. Complex intensive care aids, used at the time to save
drowned consisted of: warming the victim, remove water that gets in swallowing or
breathing, breath holding "mouth to mouth" and blowing smoke into the rectum.
The beginning of the era of general anesthesia, was a significant impetus for further
development, development of methods of resuscitation. Thus, in 1874 the Norwegian
anesthesiologist Heiberg to preventing retraction tongue in laryngo-pharyngeal area
during anesthesia by chloroform, invited to nominate up the lower jaw, and in 1878.
Esmarch as a supplement to this method, proposed to hold the maximum extension head in
the cervical region. In Germany R. Boehm (1878) conducted intensive care animals from
cardiac arrest caused by an overdose of chloroform by external (indirect) cardiac massage
and Maass (1892) applied this method in humans. In Norway, K. Igelsrud (1901) was first
held direct cardiac massage surgical patient. Subsequently, until 1960, direct cardiac
massage was the main method of resuscitation. Open in 1890. Adrenaline was first used
GV Crile and D.H. Dolley (1906) in experimental animals for resuscitation, but only later
was studied in detail the mechanism of its action in the work of CJ Wiggers (1936 r.), J.S.
Redding and J.W. Pearson (1963), which allowed to introduce into clinical practice
epinephrine during cardiopulmonary resuscitation (CPR) as first-line drug.
Electrical defibrillation was first described by French physiologist J. L. Provost and F
Bateiii (1900), which showed in experiments on dogs that ventricular fibrillation can be
eliminated by a high-voltage shock. Pioneer external defibrillation NL Gurvich in 1938 -
1947 he was justified .. first of its use in experiments on animals, and then the clinical
practice. He proved that defibrillation is not necessary to use alternating and direct current
in a pulse capacitor discharge. This principle was implemented them in one of the first
clinical use of defibrillators for ID-1 VEI, in 1967 NL Gurvich was invented defibrillator
that uses a bipolar pulse (pulse Gurvich) - a principle laid at the foundation of all modern
defibrillator. The first direct defibrillation (electrodes with a open heart) in man-century
operating fulfilled OS Beck (1947) and the first external defibrillation PM Zoll (1956).
The first automatic respirator for mechanical ventilation was developed by R. Drager and
began industrially produced in Germany in 1911 - it was the legendary "Pulmotor." He
was a post-wives balloon with oxygen and used for respiratory resuscitation miners and
firefighters. The feature was respirator ventilation cycle regulation suppression. A peculiar
impulse stimulating development of devices for mechanical ventilation, was the polio
epidemic that broke out in 1952 as of Denmark, and in 1953 in Sweden, which has
necessitated the replacement of lung function in a large number of patients. In this
connection, the Danish researcher CG Engstrom was created and began to industrially
produced eponymous device for mechanical ventilation, the basis of which was based on a
new principle of control - volume ventilation. "Enhstrem - Respirator" became the
prototype of all modern respirators and the first mechanical device for mechanical
ventilation, which began to be widely used in clinics around the world.
World's first scientific justification opportunities struggle for life, while in the border state
with death gave a brilliant scientist, a long time ahead of his time - Vladimir Nehovskyy -
creator resuscitation (term coined it in 1961). On his own initiative, in 1936 he achieved
the establishment in Moscow at the Institute of Neurosurgery world's first research center
with resuscitation - laboratory spe-lnoho destination on the "Restoring life processes with
symptoms similar to the death," which was turned into a Later in modern resuscitation
Institute of General Medical Sciences. He and his scientific school of pathophysiology is
the creator of all terminal states, allowed then to prove the reality of clinical practice and
the need for resuscitation people through events, called him resuscitation complex. In the
Great Patriotic War, he and his team succeeded in successfully providing intensive care to
soldiers who were in a state of clinical death.
This allowed VA Nehovskym summarize all the experience gained both experimental and
clinical observations in world first monograph on CPR, which was translated into English
and published in the US - "Restoration of vital body functions in a state of agony or period
of clinical death," published in 1943 m. On his initiative in 1956 opened the first in the
Soviet Union ICU, which is located in Moscow at the hospital. JV. Botkin, and in 1959 the
first resuscitation ambulance crew. VA Nehovskim et al. in 1972 was introduced and
proved the concept post-resuscitation disease.
The modern complex CPR was created works of another patriarch resuscitation - Peter
Safar (1961), who showed in patient which was introduced curare volunteers more
efficient respiration "mouth to mouth" versus external methods of breathing (1956)
developed a "triple reception" on the airways and S-shaped duct (1958), organized in
1958, the first in the US ICU (intensive care unit - ICU), first justified the need for the
development of the cerebral resuscitation and modification CPR in CPCR (1966 ). By the
first international guidance of CPCR, which lasted three editions (1968, 1981, 1987 ),
which has become the "gold standard" for more than 30 years for physicians worldwide.
Founded (1979) International Centre for resuscitation research that bears his name is at the
University of Pittsburgh.
Currently, standards CPR developed: in the US - the American Heart Association
(American Heart Association - AHA), which gives guidance on CPR and emergency
cardiac care (1966, 1974, 1980, 1985, 1992, 2000, 2005) in Europe - created in 1989
European Resuscitation Council (European Resuscitation Council - ERC), which
published its recommendations in 1992,1998,2000 years .. At the end of 2005 were
published new recommendations of the European Resuscitation Council, which was
introduced several significant changes algorithm in cardiopulmonary resuscitation.
Since 1972 issued an international journal of CPR - "Resuscitation" (Resuscitation),
which is now printed Xia body ERC.

INTRODUCTION TO THE PROBLEM

About 1/4 of all deaths in people not associated with disease or senile unremediable or
destructive changes in the brain. In the United States each year about 400 000 cases of
sudden death. In the late 1950s, during postmortem studies, noted the lack of
morphological studies lethal in large part dead. In figurative expression S.B. Veek - "Heart
of these patients were too healthy to die, and it was necessary to enable them to recover
their work." This principle, later rehashed P. Safar in the "heart and brains too good to
die," was the basis for the modern concept of cardiopulmonary and cerebral resuscitation
(CPCR). Philosophy resuscitation paid to the individual people whose lives were suddenly
interrupted by any reasons when there is a completely unjustified death of a viable and
healthy body, with no fatal incurable disease or severe senile dementia. This criterion
determining the success of CPCR is the restoration of full brain function. In the case of
sustainable vegetative state, which should be regarded as a defect CPCR, such people
should be allowed to die with dignity as meaningless extension dying process is unethical.
These guidelines are modern changes in the program CPR in adults, based on the
published recommendations of the European Resuscitation Council 2005 (ERS2005) and
cerebral resuscitation recommendations based on published data of recent years.

BASIC CONCEPTS AND DEFINITIONS

Intensive - the science of extinction mechanisms, management techniques, artificial

replacement and restoration of vital (vital) functions, in terms of aggression such an extent
that exceeds the capacity of autoregulation.
The subject of resuscitation is critical and terminal condition.
Critical conditions - extreme degree of any pathology in which there are physiological
function disorder and violation of the individual systems that can not corrected by self-
regulation and require partial or complete correction artificial substitution (Ryabov, 1979).
Terminal states - the last stage of life (the stage between life and death): preagony, agony,
clinical death (V.A. Nehovskyy, 1966). Resuscitation (lat. reanimation - recovery) - a set
of therapeutic measures aimed at restoring the vital functions of the body when you stop
breathing and circulation. Dying - process of extinction of vital body functions. There is
not only a qualitative transition from life to death, but is consistent and regular dysfunction
and systems, ending their exclusion. Availability consistency and continuity of functions
allows time off and leads to the possibility of invasion to restore life (V.A. Nehovskyy,
1966).
The main stages of the extinction of vital functions
Preagony - the initial stage of the process of dying, which is characterized by severe
violation of the central nervous system, respiratory and circulatory reversible. At this
stage, the gradual suppression of consciousness and reduced reflexes, abuse pattern of
breathing (rapid shallow or slow) developed hypotension and expressed microcirculatory
disorders that manifest hypostatic appearance of spots on the extremities, increases
cyanosis or pale skin. At that stage preagony may be absent at fast dying (electric shock)
or take a few hours (blood loss).
Terminal pause - the transition between agony and preagony characterized fading reflex
activity, temporary sleep, critical hypotension, severe bradycardia, further deepening the
inhibition of the cerebral cortex and its off to the regulation of vital body functions. This
period of "anarchy" when higher parts of the brain are disconnected from the process
control vital body functions and evolutionarily ancient structures stem not yet assumed
regulatory functions. It was at this moment there is a temporary enhance vagal effect,
which causes the development of apnea and bradycardia sharp.
Agony - the last "flash" of life, characterized by transient activation of brain structures to
combat fading vitality of the body. After a period of apnea at first appear rare and more
frequent breathing movements involving the supporting muscles. There may be abnormal
breathing type "haspinh" - the maximum short breath with a fast full exhalation. There is
increased heart rate and blood pressure rise. In some cases, this activation vital functions
leads to the restoration of reflex action and sometimes (very rarely) and consciousness.
But at a certain point, further maintaining life is impossible, is a progressive suppression
of reflex activity, respiration and hemodynamics, with subsequent development of clinical
death.
Clinical death - a reversible condition that begins with the cessation of vital functions
(blood circulation, respiration) before irreversible changes in the cerebral cortex. In other
words, it is time to preserve their viability neurons of the cerebral cortex in conditions of
anoxia (as O2 content in brain tissue is reduced to zero for 1 min. Since cardiac arrest).
The duration of clinical death, first of all, depends on the temperature of the body of the
victim, when the temperature during clinical death is reduced to 1 - 2 minutes. By
increasing oxygen consumption tissues due to the prevalence of oxyhemoglobin
dissociation processes of its products. Conversely, when the temperature decreases (under
hypothermia) during clinical death is extended to an average of 12 minutes. by reducing
the consumption of oxygen by tissues (in exceptional cases, such as drowning in icy water,
it can be 30-60 minutes or more). In terms normotermia period of clinical death is 3-5
min.неврологічними So when CPR was started within 5 min. after circulatory arrest and
ended with the restoration of spontaneous circulation and breathing, there is every chance
of a full recovery with no neurological deficit thinking. If CPR is started within 10
minutes. after cardiac arrest, the recovery of consciousness neurologicalviolations will be
accompanied by varying degrees of severity; and if after 15 minutes. - The possible
recovery of only vegetative functions, while the recovery of consciousness is impossible
(that is, in most cases there will be a so-called social death synonym - vegetative state).
CPR, launched in 20 more minutes of cardiac arrest associated with the total destruction of
the brain, including stem structure (decerebration) when recovery becomes impossible
even vegetative functions.
Socialdeath -
partiallyreversibleconditioncharacterizedbytheirreversiblelossoffunctionofthecerebralcorte
x (decortication) whilemaintainingvegetativefunctions.
Biologicaldeath -
irreversiblestateofcellsofvitalorganswhenanimatingbodyasanintegratedsystempossible.
Braindeath - thecompleteandirreversiblecessationofallbrainfunction, recordedwith a
beatingheart, onthebackgroundofmechanicalventilation, infusionanddrugtherapy.
Inthemodernsense, braindeathisconsideredasthelegalequivalentofdeath.

Signsofclinicaldeath

A) Basic:
Carotidpulsedeterminedbypalpation, padsindexandmiddlefingers,
slowlyshiftingtheangleofthethyroidcartilage ("Adam'sapple")
totheinneredgeofthesternoclavicular-mastoidmuscle.

Thepresenceofrespiratorysymptomsevaluatedbylisteningtothemovementofairaroundthevict
im'sairwayandobservationtourofthechest.
B) Other:
1. Lackofawareness.
2. Pale (earthy-gray), cyanosisormarblingskin.
3. Atony, arefleksiya.
Diagnosis of clinical death to be carried out quickly (within 10-15 seconds) to start
immediate resuscitation because if critical period of 3-5 minutes of clinical death will be
overlooked, comes irreversible brain death.

Indications for cardiopulmonary resuscitation

All cases of clinical death, regardless of its causes have caused
.
Contraindications to cardiopulmonary resuscitation
All cases where it is known that the person in the resuscitation is absolutely useless.
3. Death in patients with incurable diseases (cancer patients in the terminal stage, injuries
incompatible with life, terminal stage of stroke - strokes).
4. If there are signs of biological death:
- Drying of the cornea - "dull luster herring";
- Corpse spots - there 1 hour after cardiac arrest primarily on the back of the neck and
fully manifested in 6-12 hours;
- Rigor mortis - in the lower jaw occurs after 1 hour (maximum 3 hours after the onset
of death, so it spreads throughout the body;
- Cadaverous smell - there depending on the ambient temperature, humidity, after about
2 days after death.
Stopping resuscitation
Recorded as the time of death.
American Heart Association (AHA) was proposed algorithm of first aid, called the "chain
of survival". Early activation of emergency medical care.
1. Early start basic life support (modified step C-A-B).
2. Early defibrillation using automated external defibrillators (Automated external
defibrillators-AED).
3. Early initiation stage further life support, including intubation and use of drugs.
MODIFIED UNDER CARDIOPULMONARY AND CEREBRAL RESUSCITATION
(P. Safari)
The whole complex CPCR P. Safar divided into 3 stages, each of which has its own
purpose and successive stages, under the new ERC guidelines 2010 CPR algorithm (A-B-
C) was modified in the C-A-B, so the first step is immediate this event compress the chest
and then restore airway and CPR:

Phase I: Elementary support life

Purpose - emergency oxygen.
Steps:
A. Artificially maintaining circulation.
B. Control and restoring airway.
C. Maintaining artificial respiration.

Phase II: Further maintenance respiration.

The goal - restoration spontaneous circulation.
Steps:
D. Drug therapy.
E. Electrocardiography or electrocardioscopy.
F. Defibrillation.

III. Stage: Prolonged life support

Purpose - cerebral resuscitation and intensive therapy post resuscitation IT
G. Assessment (the cause of cardiac arrest and his removal) and the possibility of saving
the patient valuable considering the degree of damage to the CNS.
H. Restoration of normal thinking.
I. intensive therapy aimed at correcting the disturbed functions of other organs and
systems.

STAGE ELEMENTARY SUSTAINING LIFE

C. Artificially maintaining circulatory first thing to do next victim - it verify the absence
of consciousness (loudly ask: What happened? Open your eyes!), Pat in the face,
 shoulders shake guards. In the absence of consciousness to assess the vital functions - if
the main signs of clinical death, immediately start CPR complex.
D. Precordial hit carried out when resuscitation immediately start watching the monitor
ventricular fibrillation or ventricular tachycardia without pulse (VF / VT without
pulse), and the defibrillator is not currently available. It makes sense only in the first 10
seconds of cardiac arrest. According to K. and D. Hroer, Cavallari, precordial hit
sometimes stops VF / VT without pulse (mainly PCS), but is often ineffective and vice
versa can transform the rhythm in less favorable mechanism of cardiac arrest - asystoly.
If a doctor is available ready to use defibrillator from precordial hit better to abstain.
Compression of the chest. To explain the mechanisms that provide blood flow during
chest compressions, it was proposed two theories. The earliest was the theory of the
heart pump, whereby the blood circulation caused by compression of the heart between
the sternum and the spine, resulting in increased intrathoracic pressure pushes blood
from the ventricles in systemic and pulmonary bed. This is a prerequisite for the normal
functioning of atrioventricular heart valves that prevent retrograde flow of blood into
the atrium. In artificial diastole phase there is a negative intrathoracic and intracardiac
pressure that provides venous return and ventricular filling. However in 1980. J.T
Niemann, C.F. Babbs et al. discovered that coughing, increasing intrathoracic pressure,
long retains adequate cerebral blood flow. This phenomenon is called cough
autoresuscitation. Deep rhythmic increased cough frequency of 30-60 per minute, is
able to maintain consciousness in trained patients (at cardiac catheterization) in the
course of the first 30-60 seconds of the onset of cardiac arrest, enough to connect and
use a defibrillator. Subsequently, many studies have shown that positive intrathoracic
pressure involved in the generation of systemic blood pressure. The authors measured
the direct method (in the radial artery) blood pressure of the patient in a state of clinical
death with refractory asystoly during mechanical ventilation bag "Ambu" without chest
compressions. It was found that pressure peaks on the curves are caused by rhythmic
blow lungs. In periods of mechanical ventilation discontinuation phase pressure
disappeared, indicating the ability of positive intrathoracic pressure to participate in the
generation of systemic blood pressure.

Technique of chest compressions

1. Proper patient laying on a flat, hard surface. Determination of compression -
palpation of the xiphoid process and retreat two transverse thumbs up, then placed the
hand on the border of the palmar surface of the middle and lower third of the sternum,
fingers parallel to the edges, and it another.
2. Option palms location "lock".
3. Proper conduct compression: locked arms at the elbows using the weight of his body.
Compression of the chest. The fundamental problem artificially maintain blood
circulation is very low (less than 30% of normal), cardiac output (CO), which occurs
when chest compressions. Properly performed compression maintains systolic BP at
60-80 mm Hg, while the diastolic blood pressure rarely exceeds 40 mm Hg and as a
result, causes brain low (30-60% of normal) and coronary (5-20% of normal) blood
flow. In carrying out chest compressions coronary perfusion pressure rises only
gradually and so with each another pause, required for respiration mouth to mouth, it
quickly goes down. However, carrying out several additional leads to compress restore
the original level of brain and coronary perfusion. In connection with this, significant
changes have occurred on the algorithm carrying out chest compressions. It was shown
that the ratio ofcompression to the respiratory rate of 30: 2 is more effective than the
15: 2, providing the most optimal balance between blood flow and oxygen delivery.
The ratio of compressions and the number of artificial breaths for one and for two
reanimator should be 30: 2.
Chest compressions should be performed with a frequency of at least 100
compresses / min to a depth of at least 5 cm in adults (as it should be noted that most
reanimator not click on the chest deep enough that reduces the effectiveness of induced
compression of blood flow, and therefore degrades the result of CPR), pausing for
artificial respiration (unacceptable conduct in patients not intubating blowing air at the
time of chest compressions - the danger of getting air into the stomach).
Signs of accuracy and efficacy of chest compressions is. The presence of pulse wave on
main and peripheral arteries. Direct cardiac massage is a later option. Despite the fact
that direct cardiac massage provides a higher level of coronary and cerebral perfusion
pressure (respectively 50% and 63-94% of normal) than compression of the chest, but
there are no data about its ability to improve outcome CPCR addition, it use is
associated with more frequent complications. However, there are some direct
indications of the meeting:
1) Presence of open chest in the operating conditions;
2) Suspected intrathoracic bleeding;
3) Suspected violations abdominal circulation, due to clamping of the descending
thoracic aorta department;
4) Massive pulmonary embolism;
5) Stop circulation against the background of hypothermia (allowing the direct
warming of the heart);
6) Failure chest compressions generate a pulse at the carotid and femoral arteries
because of bone deformities of the chest or spine;
7) Suspected unnoticed for a long period of clinical death;
8) Failure to correctly performed chest compressions in combination with other on-
stage moves further maintenance restore life spontaneous normotension

B. Control and restoring airway

The main problem that occurs in individuals without consciousness, airway
obstruction is the tongue and epiglottis hypopharynx in the area due to muscular atony.
These phenomena occur at any position of the patient (even in the abdomen), and the
tilt of the head (chin to chest), airway obstruction occurs in virtually 100% of cases. So
after established that the victim is unconscious, it is necessary to provide airway.
"Gold standard" to ensure the airway is "triple reception" by P. Safar and
endotracheal intubation.
P. Safar developed "triple reception" on the airways include: drawing back of the head,
opening his mouth and nomination of the lower jaw forward. Alternative methods of
restoring airway shown.
In carrying out manipulations on the airways should be mindful of the possible
injury to the spine in the cervical region. The greatest likelihood of whiplash injuries
can occur in two groups of victims:
1) When highway injuries (person or vehicle was knocked down during clashes in the
car);
2) If you fall from a height (including the "divers").
So victims can not tilt (neck bent forward) and turn his head to the side. In these cases
it is necessary to moderate pulling over the head, followed by holding the head, neck
and chest in one plane, eliminating the "triple reception" hyperextension neck,
ensuring minimal throwing the head and the simultaneous opening of the mouth and
the nomination of the lower jaw forward.
When providing first aid application shown fixing the neck "collar".
Only one casting head does not guarantee restoration of the airway. Thus, in 1/3
patients unconscious by muscular atony nasal passages during exhalation closed soft
palate, like moving valve.
In addition, it may be necessary to allocate a homogeneous substance (blood clots,
vomit, fragments of teeth and so forth.) Contained in the oral cavity Therefore,
especially in people with injuries, it is necessary to conduct an audit of the mouth and if
necessary, clean it from third-party content. To open the mouth using one of the
following methods.
2. Admission by means of crossed fingers at moderately relaxed lower jaw.
Reanimator stands at the head end or side at the head of the patient. The index finger
introduced into the victim's mouth corner and click on the upper teeth, then the index
finger is placed opposite the thumb on the lower teeth and forced open his mouth.
Thus, we can achieve significant sliding force, opens his mouth and examine the
mouth. If foreign bodies should remove them immediately. To do this, turn your head
to the right without moving the fingers of his left hand. Right index finger retard the
right corner of his mouth down, which facilitates independent drainage of oral liquid
contents. One or two fingers, wrapped a scarf or other cloth, clean the mouth and
throat. Solid foreign bodies removed by the index and middle finger like tweezers or
curved as a hook index finger.
2. Admission "finger teeth" is used in the case of densely compressed jaws.
Enter the index finger of his left hand behind the molars and open mouth while relying
on the victim's head with his right hand, placed on the forehead.
 3. In the event completely relaxed mandible injected left thumb to the mouth of the
victim and his tongue root tip lift. The other fingers grasp the lower jaw and chin in
nominated it forward.

Restoration of the airway may also be provided via air Hvedela and Safar (S-
shaped duct).

1. Choosethedesiredsizeducts - distancefromtheductstoshieldtheearlobe;
2. Followingtheforcedopeninghismouthductintroducedbulgedown, slippingon TVE-
rdomuskytothelevelofthepanel;
3. Afterthat, itrotated 180
degreessothatitscurvaturecoincideswiththecurvatureofthebackofthetongue.
Safarductsusedformechanicalventilationby "mouth-to-airducts."
Theseductscanbeanadequatesubstituteforthetwocomponents "triplereception" -
mouthopeningandmandibularnomination,
butevenwiththeuseofairnecessarytoperformthethirdcomponent - gettinghead.
Themostreliablemethodthatprovidessealingairway, endotrachealintubationis.
It should be noted that of tracheal intubation in patients with cardiac arrest associated with
chest compressions delay lasting an average of 110 seconds (from 113 to 146) and 25% of
endotracheal intubation lasted more than 3 minutes.
Therefore, an attempt intubation should be no more than 30 seconds, if that time you
can not intubated patient should immediately stop trying intubation and mechanical
ventilation start Ambu bag (or respirator) through a face mask with reservoir bag and the
binding oxygen to bag at a speed of 10-15 l/min.
After 2 minutes necessary to make a second attempt intubation or use alternative
methods of providing airway.
As an alternative to endotracheal intubation is recommended to use double barreled
ducts or laryngeal mask as technically simpler compared to intubation, but also reliable
methods of protection airway, unlike the use of face masks and air.
When using laryngeal mask must be remembered that in comparison with tracheal
intubation increased risk of aspiration. In this connection it is necessary to pause in chest
compressions during mechanical ventilation (ALV) through laryngeal mask.
a. After selecting laryngeal mask according to patient body weight, grease seals, by one
hand performed extension of the head and neck flexion the patient. Laryngeal mask take
a pen for writing (aperture up), set the tip of the mask at the center of the front incisors to
the inner surface of the mouth, pressing it to the hard palate. Middle finger dipped lower
jaw and examine the mouth. While pressing the tip of the cuff, pushing down laryngeal
mask (if laryngeal mask starts to turn out, it should be removed and reinstalled)
b. Continue to hold down laryngeal mask while pressing forefinger in connection
snorkeling, constantly keeping the pressure on the structure of the pharynx. The index
finger remains in this position for as long as the mask is not held together with tongue and
throat to not fall;
c. Forefinger, drawing in place of the tube and laryngeal mask promote further down
while performing light brush pronation. This allows you to quickly set the end of it. The
resistance that occurs means that the tip laryngeal mask located opposite the upper
esophageal sphincter.
d. Holding the tube laryngeal mask one hand, the index finger is removed from the throat.
With your other hand, gently pressing laryngeal mask, check its installation.
where. Inflate the cuff and record laryngeal mask.
In addition to standard laryngeal mask permitted use laryngeal mask I-gel, the shape of
the larynx, "cuff" thermoplastic elastomeric gel that does not swell, which are necessary
when setting themselves elementary skills.
If the victim is unconscious, but he has a pulse and remains adequate independent
breathing, you must provide a stable position on the side, to the prophylaxis policy-
aspiration of gastric contents due to vomiting or regurgitation and hold a reception in the
airways.
It is necessary to bend the leg of the victim on the side on which the person that help put
your hand under the victim's buttock on the same side. Then carefully turn the victim on
the same side at the same time throw the victim's head and held face down. Put his hand at
the top, under his cheek to keep the head position and avoid turning face down. This arm
of the victim, who is behind him, not let him take the supine position.

Algorithm assist with airway obstruction foreign body

With partial airway obstruction (maintaining normal color of the skin, the patient's
ability to speak and efficiency cough) an immediate intervention is indicated. In the event
of a complete airway obstruction (at the inability of the patient to say, ineffective cough,
presence of increasing difficulty in breathing, cyanosis) recommended the following
amount of aid, depending on whether or not the patient's consciousness:
a) With consciousness
- 5 slaps his hand in the blade area or abdominal compress 5 - Heymliha reception. In the
latter case reanimator is behind the victim, squeezes his hand in a fist and puts (to the side
where the thumb) his belly to the median line between the navel and the xiphoid process.
Firmly clutching fist brush the other hand, presses his fist in the stomach by briefly
pressing the direction upwards. Reception Heymliha not carried out in pregnant and
smooth people, replacing it with chest compressions, which technique is similar to how
during the reception Heymliha.
b) Without consciousness:
1. Open your mouth and fingers to try to remove the foreign body.
2. Diagnose the absence of spontaneous breathing (look, listen, feel).
3. Hold 2 artificial breath by "mouth to mouth". If succeeded in restoring the airway in 5
attempts, following the paragraphs 1 -3 - move on to paragraph 6.1.
4. In the event that attempts to draw an artificial lung ventilation (ALV) unsuccessful even
after changing head position, immediately begin chest compression to eliminate airway
obstruction.
5. After 15 compressions, open your mouth and try to remove the foreign body, to produce
2 artificial inspiration.
6. Evaluate effectiveness:
6.1. If there is an effect - identify signs of spontaneous circulation and if necessary
continue chest compressions and / or CPR.
6.2. If there is no effect - repeat cycle - points 5-6.

E. Artificial maintain breathing after cardiac arrest and CPR for a reduction of
compliance lungs.
This in turn leads to increased pressure required for injection optimum tidal volume to
the lungs of the patient, on a background of pressure that causes gastroesophageal
sphincter opening, facilitates the ingress of air into the stomach, thus increasing the risk
of regurgitation and aspiration of gastric contents. So during mechanical ventilation by
"mouth to mouth" each piece breath should not beforced and held for 1 second for
optimal respiratory volume. If seen getting air into the stomach (bulging in the epigastric
region) should clear the air. For this to prevent aspiration of gastric contents, the patient's
head and shoulders turn away and pressed his hand between the stomach and chest dome.
Then, if necessary, cleanse the mouth and throat, and then carry "triple reception" on the
airways and keep breathing "from mouth to mouth."
After the "triple reception" for airway, one hand placed on the forehead of the victim,
providing a cast of the head and nose while pinching your fingers victim, then pressed his
lips tightly around the mouth of the victim, blown air, watching excursion chest. If you
see the victim's chest rose, released his mouth, giving for victim the opportunity make
full passive exhalation.
It is essential to minimize breaks of chest compressions - is the best of two breaths
"mouth-to-mouth or face mask" for no more than 5 seconds, followed by immediate
continuation of chest compressions.
Respiratory volume should be 400-600 ml. (6.7 ml/kg), respiratory rate - 10 per min.,
In order to prevent hyperventilation. It was demonstrated that hyperventilation during
CPR, increasing intrathoracic pressure decreases venous return to the heart and reduces
cardiac output, associating with a bad levelsurvival such patients.
a) the ratio of respiratory rate to compress without airway protection or patronage of
laryngeal mask or Combitube duct for both one and two reanimators should be 30: 2 and
carried out with a pause on mechanical ventilation (risk of aspiration!);
b) with the patronage airway (endotracheal intubation) - compression of the chest should
be carried out at a frequency of at least 100 / min, ventilation frequency of 10 / min (in the
case of bag Ambu - 1 breath every 5 seconds), without pause during mechanical
ventilation ( because chest compression with simultaneous blow lungs increases coronary
perfusion pressure).

II STAGE FURTHER SUSTAINING LIFE

F. Medical Therapy

Route of administration of drugs.

According to the recommendations of the ERC '2010, endotracheal route of administration
of drugs is no longer recommended. Studies have shown that a dose of adrenaline during
CPR introduced endotracheal which is equivalent dose intravenous route of administration
should be 3 to 10 times higher. A number of experimental studies suggest that low
concentrations of epinephrine during endotracheal route of administration may cause
transient beta-adrenergic effects that lead to the development of hypotension and reduced
coronary perfusion pressure, which in turn impairs the effectiveness of CPR. In addition, a
large volume of fluid injected endotracheal capable worsen gas exchange. In this
connection, the new guidelines are two main access for drug administration:
a) intravenously, in the central and peripheral vein. The best way is the introduction of
central veins - subclavian and internal jugular, as provided by the drug delivery to the
central circulation. To achieve the same effect when injected into the peripheral vein,
preparations to be diluted with 10-20 ml saline or water for injection.
b) intraosseous way - intraosseous injection of drugs in the shoulder bone or tibial
provides adequate plasma concentration versus time for the introduction of drugs into the
central vein. The use of mechanical devices for intraosseous administration of drugs
provides the simplicity and accessibility of the route of administration.
Pharmacological provide resuscitation.
1) Adrenaline:
a) the electrical activity without pulse / asystoly - 1 mg intravenously every 3-5 minutes;
b) if VF / VT without pulse adrenaline introduced only after the third level of inefficient
electrical defibrillation dose of 1 mg. Later this dose administered intravenously every 3-5
minutes (ie before each second defibrillation) as long as kept VF / VT without pulse.
2) Amiodarone (Cordaron) - antiarrhythmic drug first line with ventricular fibrillation /
ventricular tachycardia without pulse (VF/VT) refractory to electric pulse therapy after
three ineffective discharge in an initial dose of 300 mg (diluted in 20 ml saline or 5%
glucose) by retyping 150 mg. After the restoration of an independent circulation at a dose
of 900 mg in the first 24 hours postresuscitation period to prevent refibrillation.
3) Lidocaine - in the absence of amiodarone (this should not be used as a supplement to
amiodarone) - initial dose of 100 mg (1-1.5 mg / kg) / in, if necessary, an additional bolus
of 50 mg (in the total dose should not exceed 3 mg / kg over 1 hour).
4) sodium bicarbonate - routine use during CPR or after restoration of an independent
circulation is not recommended.
Cardiac arrest is a combination of respiratory and metabolic acidosis. The best method of
correcting acidemia when stopping circulation is of chest compressions, additional benefit
provided by carrying out ventilation.
Routine administration of sodium bicarbonate during CPR by generating CO2 diffuses
into the cells, causing a number of adverse effects:
- Increased intracellular acidosis;
- Negative inotropic effect on ischemic myocardium;
- Poor circulation in the brain due to the presence of high osmolarity sodium;
- Shift of oxyhemoglobin dissociation curve to the left, which can reduce oxygen delivery
to the tissues.
The indication for administration of sodium bicarbonate are cases of cardiac arrest
associated with hyperkalemia, or tricyclic antidepressant overdose in doses of 50 mg (50
ml - 8.4% solution) IV.
5) Calcium chloride - a dose of 10 ml of 10% solution IV (6.8 mmol𝐶𝑎+2 ) with
hyperkalemia, hypocalcemia, an overdose of calcium channel blockers.
The use of atropine during CPR is no longer recommended.

D. Electrocardiographic diagnosis mechanism circulatory arrest

Successful resuscitation largely depends on early diagnosis electrocardiogram (ECG
monitor or defibrillator) mechanism of cardiac arrest because it defines further tactics of
resuscitation.
In reanimatology practice used for assessment of ECG II standard abduction, allowing
shallow wave differentiate from ventricular fibrillation asystole.
Often, ECG electrodes defibrillator VF may look like asystole. Therefore, to avoid
possible errors need to change the location of the electrodes, moving them to 90 ° relative
to the first location. It should also be noted that during cardiopulmonary resuscitation
frequently appear on your monitor various kinds of obstacles (electric, uncontrollable
movements associated with the patient during transport, etc.) that can significantly distort
the ECG.
There are 3 basic mechanisms of cardiac arrest, the electrical activity without pulse
(EAWP), ventricular fibrillation or ventricular tachycardia without pulse (VF/VT without
pulse) and asystole.
1) Electrical activity without pulse (EABP) includes electromechanical dissociation and
severe bradyarrhythmia (bradyarrhythmia clinically manifested in heart rate < 45 beats /
min. In a sick person and with heart rate <30 beats / min. With sound). Electromechanical
dissociation (old name - inefficient heart), characterized by the absence of mechanical
activity of the heart with preserved electrical activity. The ECG is recorded normal or
modified QRS-complexes with regular or irregular intervals.
2) Ventricular tachycardia without a pulse. VT without pulse depolarization characterized
by ventricular cardiomyocytes with high frequency. The ECG missing teeth and marked P
wide QRS-complexes.
3) Ventricular fibrillation. Ventricular fibrillation is characterized by chaotic,
asynchronously cuts cardiomyocytes with the presence of ECG irregular, with a frequency
of 400-600 per min., low-, medium- or large wave fluctuations.
4) Asystole - no mechanical as well as electrical activity of the heart, the ECG contours.

G. Defibrillation.

Principle defibrillation is a critical mass of myocardial depolarization, leading to the

restoration of sinus rhythm natural pacemaker (as pacemaker cells of the sinus node are
the first cells of the myocardium, capable of spontaneous depolarized). The level of the
first power level, a compromise between efficiency and its damaging effects on the
myocardium.
If you notice on cardiomonitor/defibrillator VF/VT without pulse must immediately put
one category of electrical defibrillation. Immediately after applying the discharge
defibrillation should continue chest compressions and other components of CPR for 2
minutes, and then to assess the rhythm on the ECG in the case of restoration of sinus
rhythm assess its hemodynamic efficiency by the presence of pulse in the carotid and
radial artery (by simultaneous palpation of these vessels). Because even if defibrillation is
effective and will resume according to ECG sinus rhythm, rarely immediately after
defibrillation he is hemodynamically effective (ie, able to generate a pulse, and thus blood
flow). Of course you need more than 1 minute of chest compressions to restore self-
circulation (pulse). Restoring hemodynamically effective rate, additional compression of
the chest will not re-development of VF. Conversely, when recovery only organized
bioelectrical activity of the heart, but not hemodynamically effective, cessation of chest
compressions inevitably refibrillation ventricles. The above facts are justification for the
immediate start of chest compressions after applying defibrillation discharge for 2
minutes, and only then the next assessment by the ECG rhythm, and in the case of
restoration of sinus rhythm assessment pulsations in the carotid and radial arteries.
The gap between the conduct discharge defibrillation and start chest compressions should
be less than 10 seconds.
Estimation of rate / pulse rate should also not exceed 10 seconds - if saving ECG
VF/VT without pulse, you must re-apply defibrillation discharge followed by chest
compressions and CPR ingredients for 2 minutes. If the recovery sinus rate according to
ECG monitoring, but no pulse - need to immediately continue chest compressions for 2
minutes, followed by assessment of rhythm and pulse.

DISCHARGE → CPR FOR 2 min → ASSESSMENT RATE / PULSE →

DISCHARGE → CPR FOR 2 min ...
The energy of the first level, which is currently recommended ERS'2010 should be for
monophasic defibrillators as J 360 and all subsequent bits to 360 J. The results showed that
biphasic defibrillation using lessenergy, more effective and cause less damage and
postresuscitation dysfunction compared with equivalent energy monophasic pulse.
The initial level of energy for biphasic defibrillators should be 150 J (or lower level,
depending on the model defibrillator), followed by increasing energy to 360 J. Repeated
discharges.
When VF/VT without pulse - adrenaline 1 mg and 300 mg amiodarone IV enter only
after the third level of inefficient electrical defibrillation. In the future, if persistent VF,
adrenalin injected every 3-5 minutes, IV during the period of CPR, amiodarone 150 mg
before the next defibrillation discharges.
Efficacy and safety of electrical defibrillation depends on a number of cardiac and
extracardial factors.
1) The leading role belongs to the form of the electric impulse - for successful defy-
brillyatsii bipolar pulse (versus monopolar) should be approximately 2 times less power
(maximum allocated to patient power is respectively 200 J for biphasic and 400 J
monophasic bits). According to recent successful defibrillation pulses of bipolar sinusoidal
< 115 J is 92%. Consequently, only 8% of patients required a 150 - 200 J energy.
However, the total efficiency monopolar pulse shapes depending on the type VF is at an
energy level of 200 J 60-90% or environments, it is about 70%.
2) The second important factor affecting the effectiveness of defibrillation is the correct
location of the electrodes on the chest. Since only 4% transthoracic current passes through
the heart, and 96% - in other structures of the chest, so it is important an adequate location.
With front-front location, one electrode installed in the right edge of the sternum below the
clavicle, the second lateral left nipple in the mid-axillary line. With front-back
arrangement, each electrode set medial left nipple, the other under the left shoulder blade.
If the patient is implanted pacemaker, defibrillator electrodes have located him at a
distance of 6-10 cm.
3) A third factor that affects the efficiency of defibrillation, is the resistance of the chest or
transthoracic impedance. The phenomenon transthoracic impedance (resistance) has
important clinical implications, since it explains the difference between the current
energytyped on the scale of the device and released on the patient. If resuscitation there are
factors that significantly increase the transthoracic impedance, it is likely that the
established on the scale of energy defibrillator 360 J its real value may amount to the
myocardium at best 10% (30 - 40) J.
Transthoracic resistance depends on body weight and an average of 70-80 ohms adult. To
reduce transthoracic defibrillation is necessary to support a phase of exhalation, because
transthoracic impedance in these circumstances is reduced by 16%, the best is the effort
which is applied to the electrodes at 8 kg for adults and 5 kg for children aged 1-8 years.
However, 84% decrease transthoracic impedance necessary to ensure good contact
boundary between the skin and the electrodes through the use of conductive fluids. It must
be emphasized that the use of "dry" the electrodes significantly reduces the efficiency of
defibrillation and causes burns. To reduce the electrical resistance of the chest using
special adhesive pad electrodes, conductive gel or gauze soaked in hypertonic solution. In
extreme situations electrode surface can simply moisten any conductive solution (water).
Thick hair on the chest electrodes causes poor contact with the skin of the patient and
increases the impedance, thus reducing the effectiveness inflicted discharge, and increases
the risk of burns. Therefore, it is advisable to shave region imposing electrodes on the
chest. However, in emergency situations during defibrillation is not always possible.
While none of the participants defibrillation resuscitation should not touch the skin of the
patient (and / or bed).

Features and conditions of termination of CPR

The probability of a successful outcome CPR at EABP/asystole (as in refractory VF/VT)

can increase only if there is a potentially reversible causes of cardiac arrest treatable:
hypoxia, hypovolemia, hyper/hypokalemia (metabolic disorders), hypothermia and tension
(tense pneumothorax), cardiac tamponade, thrombosis (coronary, pulmonary) toxic
overdose.

Stopping resuscitation

CPR should be performed as long as stored ECG ventricular fibrillation, as this remains
minimal metabolism in the myocardium, which provides the potential to restore self-
circulation.
In the case of cardiac arrest on the mechanism EABP / asystole in the absence of
potentially reversible causes - CPR is carried out for 30 minutes and stop at its
inefficiency.
CPR more than 30 minutes in case of hypothermia, drowning in icy water and
overdose of drugs.

III phase long-term life support

F-evaluation of the patient

The first task after restoring blood flow is an independent assessment of the patient. It
can roughly be divided into two sub-tasks:
1) determining the causes of clinical death (to prevent recurrent cardiac arrest, all of which
worsens the prognosis of full recovery of the patient);
2) determination of sanctions homeostasis in general and in particular brain functions (to
determine the extent and nature of intensive care).
3 - Restoring normal mentality

And - Intensive therapy aimed at correcting the disturbed functions of other organs and
systems
According to the National Register in cardiopulmonary resuscitation USA (National
Registry of Cardiopulmonary Resuscitation - NRCPR), among 19,819 adults and 524
children after restoration of spontaneous circulation nosocomial mortality rate was 67 and
55% respectively. According to epidemiological studies of 24,132 patients in Britain
revived level of mortality in post resuscitation period was 71%. It should be noted that
among the survivors have only 15-20% rapid recovery of adequate awareness, the
remaining 80% of patients going through post resuscitation disease. Causes of death in
post resuscitation period: 1/3 - cardiac (the highest risk in the first 24 hours post
resuscitation period), 1/3 - dysfunction of various organs and extracerebral 1/3 -
neurological (causes of death in the late period post resuscitation disease - PRD).
According O.N. Nehovsky, "for post resuscitation disease (PRD) characterized by its own
specific etiology - indivisible combination of global ischemia and reperfusion
reoxygenation. As reoxygenation and reperfusion after undergoing cardiac arrest not only
cope with the consequences of the primary pathological effects, but also cause a cascade
of new lesions. It is important that the reason for these changes is not in itself a global
ischemia, and its combination with reoxygenation and reperfusion". PRD is a combination
of pathophysiological processes, including four key components:
1) post resuscitation brain damage;
2) post resuscitation myocardial dysfunction;
3) systemic ischemic-reperfusion reaction.
Post resuscitation prevalence of brain damage due to the severity of the morphological
structure of the brain, performed his functions and low tolerance to ischemia and hypoxia.
No cell organism does not depend on the level of oxygen and glucose as a neuron. The
maximum duration of clinical death (anoxia) under normotermya, where possible survival
of neurons, is no more than 5 minutes.
Neuronal damage in the PRD is multifactor in nature and developed at the time of cardiac
arrest, during CPR, as well as the restoration of an independent circulation period:
- The period of ischemia - anoxia at the time of absence of circulation during clinical death
(no-flow);
- The period of hypoperfusion - hypoxia artificial circulatory support during CPR (low-
flow), as the highest possible level of cardiac output (CO) reaches only 25% of the
original;
- Reperfusion period consisting of consecutive phases: no-reflow, then the next phase
hyperemia and subsequent global and multifocal hypoperfusion.
In post resuscitation period are the following stages of brain perfusion after the restoration
of an independent circulation:
1. The initial development of multifocal no reperfusion (the phenomenon of no-reflow).
2. Stage transient global redness - develops in 5 - 40 minutes after restoration of
spontaneous circulation. The mechanism of development associated with cerebral
vasodilation by increasing intracellular concentrations of Na and adenosine, and reduced
levels of intracellular pH and 𝐶𝑎+2 . The duration of cerebral ischemia later stage
determines the duration of flushing, which, in turn, is heterogeneous in nature in different
regions of the brain, leading to a decrease in perfusion and swelling of astrocytes.
3. Stage prolonged global and multifocal hypoperfusion - develops from 2 to 12 hours post
resuscitation period. The rate of cerebral glucose metabolism is reduced to 50% from
baseline, however, global consumption of oxygen by the brain returns to normal (or
higher) level from baseline to the moment of cardiac arrest. Cerebral venous pO2 may be
at critically low levels (less than 20 mm Hg), reflecting violation delivery and oxygen
consumption. The reason for this is to develop vasospasm, swelling, sludge red blood cells
and excessive production of endothelin.
4. This stage can develop in several directions:
4.1. The normalization of cerebral blood flow and oxygen consumption of brain tissue
with subsequent restoration of consciousness.
4.2. Storing persistent coma when a total cerebral blood flow and oxygen consumption
remains low.
4.3. Re-development of congestion of the brain, associated with a decrease in oxygen
consumption and the development of neuronal death.
Post resuscitation dysfunction has various clinical manifestations. Thus, in experiments
on pigs has been shown to decrease in the first 30 minutes Post resuscitation period
ejection fraction of 55 to 20%, and increasing end-diastolic pressure (EDP) of the left
ventricle from 8-10 to 20-22 mmHg According to other studies, patients in 49% of cases
post resuscitation dysfunction manifested by tachycardia, increased left ventricular CRT,
in the first 6 hours hypotension (SBP < 75 mmHg) and low cardiac output (CI < 2.2
l/min/m2).
According to a recent international consensus, are five phases post resuscitation period,
each of which determines the tactics of intensive care.
Prognostic assessment in post resuscitation period
Coma for 48 hours or more acts predictor of poor neurological outcome. If 72 hours
after cardiac arrest neurological deficit reaches £ 5 points for the Glasgow Coma Scale in
the absence of motor reactions in response to painful stimulation or pupillary reflex, it is a
predictor of persistent vegetative state in all patients.

Principles of intensive therapy post resuscitation period

1. Extratcerebral homeostasis.
1.1. The early hemodynamic optimization, as is the failure of autoregulation of cerebral
blood flow, the level of cerebral perfusion pressure (CPP) is dependent on the level of
mean arterial pressure (MAP):
CPP = MAP - ICP.
It is therefore important to maintain normotension - 70-90 mmHg MAP Moreover, severe
hypotension and hypertension need to be adjusted. CVP is supported within 8-12 cm H2O;
1.2. Oxygenation: arterial hyperoxia should be excluded, the level should provide FiO2
SaO2 94-96%, as shown that mechanical ventilation with FiO2 1.0 in the first hour post
resuscitation period associated with poor neurological outcome by creating additional
oxidative stress in neurons post ischemical.
13. Maintaining normal levels of PaO2 (normoxemia) and PaSO2 (normocapniya) -
vazoconstriction caused by hyperventilation, hypoventilation as well as causing increased
intracranial pressure, leading to cerebral ischemia deepening;
1.4. Keeping normotermia of the body. The risk of poor neurological outcome increases by
ka-degree > 37 ° C. According to A. Takasu et al. (2001), fever > 39 ° C in first 72 hours
significantly increases the risk of brain death.
1.5. Keeping normoglycemia - persistent hyperglycemia is associated with poor neurologic
outcome. The threshold level at which the correction should begin insulin - 10.0 mmol/l.
Hypoglycemia should also be excluded.
Target values necessary to achieve in post resuscitation period:
- CAP 70-90 mm Hg ;
- CVP 8-12 cm H2O;
- Hemoglobin > 100 g/l;
- Lactate < 2.0 mmol/l;
- The temperature of 32-34 ° C within the first 12-24 hours, then maintaining
normotermia;
- SaO2 94-96%;
- SvO2 65-75%;
- DO2 400-500 ml/min/ m2;
- VO2> 90 ml/min /m2;
- Exclude dependent oxygen consumption of its delivery.
2. Intracerebral homeostasis.
2.1. Pharmacological methods. Currently there are no effective and safe in terms of
evidence-based medicine techniques pharmacological effects on the brain in post
resuscitation period. Conducted at our department study revealed the feasibility of
perftoran in post resuscitation period. Perftoran reduces brain swelling, post resuscitation
severity of encephalopathy and increases the activity of the cerebral cortex and subcortical
structures, facilitating rapid exit from coma. Perftoran administered intravenously is
recommended in the first 6 hours after resuscitation period at a dose of 5.7 ml/kg.
2.2. Physical methods. Currently, hypothermia is the most promising method and protect
the brain.
According to current guidelines, all patients unconscious, suffered cardiac arrest, it is
necessary to ensure that the therapeutic hypothermia (TH) of the body to 32-34 ° C for 12-
24 hours.
The side effects of TH are: increased blood viscosity, cold diuresis, but not in violation of
renal function, increased risk of pneumonia. The development of serious arrhythmias
rarely occurs in T - 33 ° C, even in patients with myocardial ischemia. Contrindication for
the TH is pregnancy, cardiogenic shock (systolic blood pressure less than 90 mmHg at
sympathomimetic infusion), an overdose of drugs and narcotics.
Currently, it is recommended that the following requirements for TH:
- Monitoring the temperature of the nucleus (inner esophageal, tympanic, rectal) and
surface temperature control parameters of hemostasis, blood gases and electrolytes,
glucose and lactate levels, hemodynamic;
- Duration - 12-24 hours;
- Target core temperature 32-34 ° C;
- Method - external cooling using hypothermia or intravenous infusion psychologists-
agency solution or Ringer's lactate solution (4 ° C) at a dose of 30 ml/kg at a speed of
introduction of 100 ml/min;
- Carrying out artificial respiration;
- To relieve cold shiver - analhosedation, muscle relaxants, use vasodilatator (nitrates);
- Slow warming - not faster 0,2-0,5 ° C/h.
We use the combined technology of inducing hypothermia intravenous infusion 0,9%
NaCl or Ringer's lactate solution (4 ° C) at a dose of 30 ml/kg, followed by maintaining
external cooling hypothermia hypothermiaBlanketrol II CSZ to target core temperature -
32-34 ° C analhosedation conditions and mechanical ventilation with providing
normoventilater.
In conclusion, it seems extremely important introduction of modern Strait la CPCR in
clinical practice and teaching hospitals on the basis of medical personnel, especially after
the creation in Ukraine of the National Council of resuscitation.

ADDITION

I. The observation of a person's death based on brain death

The observation of a person's death based on brain death
1. General information
Decisive for ascertaining brain death is a combination of the fact of termination of the
functions of the entire brain with evidence of the irreversibility of the suspension.
Right diagnosis of brain death makes the availability of accurate information on the
causes and mechanisms of this condition. Brain death can develop as a result of primary or
secondary damage.
Brain death as a result of the initial damage develops due to a sharp rise in intracranial
pressure and caused him cessation of cerebral circulation (severe closed head injury,
spontaneous and other intracranial hemorrhage, cerebral infarction, brain tumors, closed
acute hydrocephalus, etc.), and also due to open cranio-cerebral trauma, intracranial
surgery on the brain, and others.
Secondary damage of the brain resulting from hypoxia of various origins, including at
cardiac arrest and stopping or severe deterioration of the circulatory system, resulting in
prolong shock and others.
2. Conditions for the diagnosis of brain death
The diagnosis of brain death is not considered as long as these are not excluded effect:
intoxication, including medical, primary hypothermia, hypovolemic shock, metabolic
endocrine places and use opioids and muscle relaxants.
3. Complex clinical criteria, whose presence is necessary for the diagnosis of brain death
3.1 Full and persistent lack of consciousness (coma).
3.2 Atony of muscles.
3.3 No response to strong pain stimulation in trigeminy points and any other reflexes
closed above the cervical spinal cord.
3.4 The lack of reaction of pupils to direct glare. This should be aware that any drugs that
extend the pupils are not used. Eye balls still.
3.5 The lack corneal reflexes.
3.6 The lack oculusefalic reflexes.
To induce reflex oculusefalic the doctor holds the position of the bed so that the head of
the patient was maintained between doctor wrists and thumbs raised eyelids. Head rotates
180 degrees in one direction and held in this position 3 - 4 seconds, then - in the opposite
direction at the same time. If the head turning eye movements is not stable and they
remain central position, it indicates a lack oculusefalic reflexes. Oculusefalic reflexes are
not investigated in the presence or suspected traumatic injury of the cervical spine.
3.7 The lack oculuvestybulyarn reflexes.
To investigate oculuvestybulyarn held bilateral caloric reflex test. By its conduct must
ensure no perforations eardrums. Head patient lift 30 degrees above the horizontal level. In
the external auditory canal catheter introduced a small, slow conducted irrigation of the ear
canal with cold water (t 20 ° C, 100 ml) for 10 sec. When intact brainstem function 20 - 25
sec. appears nystagmus or deviation of the eyes toward the slow component of nystagmus.
Absence of nystagmus and deviation in the major apple caloric test done on both sides,
indicates a lack oculuvestybulyar reflexes.
3.8 The lack of pharyngeal and tracheal reflexes which are determined by the movement
of endotracheal tube in the trachea and upper airways, as well as promoting the catheter
for the aspiration of bronchial secretions.
3.9 The absence of spontaneous breathing.
Absence of breathing not to be a simple disconnection of the ventilator unit, as this
develops, hypoxia have harmful effects on the body and especially the brain and heart.
Disconnect the patient from the ventilator unit must be carried out using a specially
designed disconnecting test. Disconnecting test conducted after the results p.3.1 - 3.8. The
test consists of three elements:
a) to monitor the gas composition of blood (Pa02 and PaS02);
b) before disconnecting the respirator should spend 10-15 minutes in ventilation mode that
ensures elimination of hypoxemia and hypercapnia P02 1.0 (100% oxygen), the optimal
PEEP (positive end expiratory pressure);
c) after the claims. "A" and "B" unit disconnect the ventilator and endotracheal tube or
tracheostomy served humidified 100% oxygen at a speed of 8-10 liters per minute. At this
time, the accumulation of endogenous carbon dioxide, controlled by sampling arterial
blood. Stages monitoring blood gases are: before the test in terms of ventilation; 10-15
minutes after the 100% oxygen ventilation immediately after disconnecting from the
ventilator; then every 10 minutes until PaS02 reaches 60 mm Hg. Art. If these and (or)
higher values PaS02 spontaneous respiratory movements are not restored, disconnect test
confirms the absence of function of the respiratory center of the brain stem. When the
minimum ventilation breaths immediately resumed.
4. Additional (confirm) tests to complex clinical criteria for the diagnosis of brain death.
4.1. Setting absence of brain electrical activity is carried out in accordance with
international provisions electroencephalographic studies in terms of brain death. Used
needle electrodes, at least 8 located under the "10 - 20%," and 2 ear electrode.
Interelectrode resistance should be at least 100 ohms and 10 ohms maximum,
interelectrode distance - at least 10 cm. It is necessary to preserve the definition of
switching and no intentional or unintentional creation of electrode artifacts. Recording is
carried on channels with a time constant of at least 0.3 with the amplification of at least 2
mV / mm (upper limit bandwidth frequency not below 30 Hz). Used machines with at least
8 channels. EEG recorded at bi- and monopolar leads. Electrical silence cortex in these
conditions should be kept at least 30 minutes of continuous recording. If you doubt the
silence of electric cord required re-registration of EEG. Assessment of EEG reactivity to
light, loud sound and pain: the total time of stimulation by light flashes, sound stimuli and
painful irritation least 10 minutes. Source of outbreaks submitted at a frequency of 1 Hz to
30 shall be at a distance of 20 cm from the eye. The intensity sound stimuli (clicks) - 100
dB. The speaker is the ear of the patient. Incentives maximum intensity generated by
standard photo - and fonostimulator. For strong pain stimuli are applied punctures the skin
with a needle.
EEG recorded on the phone can be used to determine brain electrical silence.
4.2. Setting absence of cerebral circulation.
Make angiography twice four heads of major vessels (common carotid and vertebral
arteries) at intervals of not less than 30 minutes. Average blood pressure during
angiography must be at least 80 mm Hg If angiography revealed that none of intracerebral
arteriyne filled with contrast medium, this indicates cessation of cerebral circulation.
5. The duration of observation
In the primary lesion of the brain to establish the clinical picture of brain death long-ness
of observation should not be less than 12 hours since the first installation of the signs
described in pp.3.1 - 3.9; the secondary lesions - monitoring should last at least 24 hours.
Suspicion of intoxication duration of observation is increased to 72 hours.
During these periods every 2 hours are recorded the results of neurological examinations
that detect loss of brain function in accordance with paragraphs. 3.1 - 3.8. It should be
borne in mind that spinal reflexes and automatism may occur in conditions of continued
mechanical ventilation. In the absence of features cortex and brain stem and cerebral
circulation suspension according angiography (p. 4.2). Brain death is stated without further
observation.
6. Establishing the diagnosis of brain death and documentation
6.1 The diagnosis of brain death is established commission of doctors consisting of:
resuscitator with experience in the department of intensive care for at least 5 years and a
neurologist with the same professional experience. For special studies of the Commission
include experts with additional research methods with professional experience of at least 5
years, including a required with other agencies on a consultative basis. Appointment of
commission and approval of "the Protocol establishing brain death" is made the head of
the intensive care unit where the patient, and in the absence of another doctor responsible
institution.
The commission can not include experts who participate in the fence and organ
transplantation.
The main document is the "Protocol establishing brain death," which is important for all
conditions, including the removal of organs. In the "Protocol" should be referred to the
data of research, surname, name and patronymic doctors - members of the commission and
their signatures, date and time of registration of brain death and therefore death. After
establishing brain death and execution of "Protocol" resuscitation, including mechanical
ventilation may be suspended.
Responsibility for the diagnosis of a person's death rests with the doctor that
established the diagnosis of brain death, the same hospital where the patient died.
These recommendations are not valid for establishing brain death in children, for which
appropriate diagnosis has not yet been developed.
Cardiac arrest during CA
In connection with the widespread SA, particularly in obstetrics, should be considered
separately cardiac arrest at SA. It can occur at any stage of anesthesia, and usually against
the background of complete well-being. Sometimes short stop prior progressive
hypotension and/or bradycardia.
The cause of this complication is unknown. Clear communication of the applicable
anesthetics is not installed, if not detected and depending on the level of protein, described
cases of asystole even in the so-called blockade truck (sacral and lower lumbar segments).
It is noticed that cardiac arrest occurs when a sudden change in body position - turn the
patient on the side, lifting and lowering the legs, shifting from the table on the gurney.
When showing asystole and immediately begin resuscitation immediately (mechanical
ventilation with oxygen, heart massage, adrenaline intravenously), heart rate recovered
rapidly, indicating the nature of reflex complications. Keep in mind the basic features of
the CPR in pregnant women, along with the actions resuscitator (required to ensure the
prevention of the syndrome of the inferior vena cava) midwives should immediately
perform a cesarean section. This is necessary not only and not so much in the interests of
the fetus, how to improve cardiac massage.

6. Materialsofmethodicalmaintenanceofemployment.
6.1. Materialscontrolthepreparatoryphaseoftraining.
1. A man, about 40-45, lies on earth, skin covers are pale, vital sparks absent.
Your first actions must be:
А) to make attempt call him, and to shake;
B) to begin the indirect massage of heart immediately;
C)to begin artificial ventilation of lungs immediately;
D)immediately to conductdefibrillation;
E)to go by him.

2. A old years man lies without consciousness on the streetcar stop. On a call
irresponsive, atony, a skin is pale, breathing is not determined. What must be
checked up?
А) tendon reflexes;
B)presence of documents;
C)pulse on carotids and width of pupils;
D)there is an alcoholemia;
E)it is needed to check up time.
6.2. INFORMATION, necessary for the formation of knowledge, skills can be found
in textbooks:
- primary

Literature (Basic)

1. The Law of Ukraine dated July 5, 2012 № 5081-VI "On emergency medical
assistance".
2. Harwood-Nuss’ Сlinical practice of emergency medicine. Sixth ed. Allan B.
Wolfson Ed. 2015 Wolters Kluwer. - 4901 pp.

3. Buchenmaier C, Nahoney PF (eds.). COMBAT ANESTHESIA: THE

FIRST 24 HOURS. Textbooks of Military Medicine. Fort Sam Houston,
Texas. 2015, - 977 pp.

4. Hadzic admir, ed. New york school of regional anesthesia. «Тextbook of

regional anesthesia and acute pain management» New York: mcgraw-hill
education, 2016.
 5. Marcucci CE, Schoettker P (eds). Perioperative Hemostasis. Coagulation
for Anesthesiologists. Springer-Verlag Berlin Heidelberg, 2015, - 456 pp.

6. Miller RD (ed.) Miller’s anesthesia. Eighth ed. 2 v. 2015, - 3377 рр.

7. van de Velde M, Clark V, Fernando R. Oxford Textbook of Obstetric

Anaesthesia. Oxford University Press. 2016 - 1072 pp.

Literature (Additional)

1. Anesthesiology, Second Edition by David Longnecker, David L. Brown, Mark

F. Newman and Warren Zapol (May 2, 2012) – 312p.

2. Clinical Anesthesia, 7ed: by Paul Barash, Bruce F. Cullen, Robert K. Stoelting

and Michael Cahalan (Apr 15, 2013) – 183p

3. Scher CS (ed). Anesthesia for Trauma. New Evidence and New Challenges.
Springer, New York 2014, - 461 pp.

4. Danilo Jankovic, Philip Peng. «Regional Nerve Blocks in Anesthesia and Pain
Therapy» Traditional and Ultrasound-Guided Techniques. Fourth Edition.
Springer Cham Heidelberg New York Dordrecht London. Springer
International Publishing Switzerland. 2015 - 1002 pp.

5. Anaesthesia, Trauma and Critical Care. Course Manual. The ATACC Group
Eighth Edition, 2014, - 460 pp.

6. Clinical Anesthesia, 7ed: by Paul Barash, Bruce F. Cullen, Robert K. Stoelting

and Michael Cahalan (Apr 15, 2013) – 433p

7. Materials for self-control of quality of training.

A. Questions for self-control
1. Clinical signs of a preagony, a terminal pause and an agony.
2. Signs of clinical and biological death.
3. Factors of development of clinical death and reliability of renewal of independent
blood circulation at different mechanisms of its stop.
4. Stages of is cardio-pulmonary and brain resuscitation for P.Safar.
5. A modern technique of base support of a life.
6. Methods of renewal and maintenance of passableness of respiratory ways at
carrying out resuscitations actions.
7. Kinds of a stop of blood circulation and feature of actions for renewal of
independent blood circulation.

It was made by________________________Danilova G.O.