Cardiopulmonary_cerebral resuscitation. Terminal stages
Life is an infinite process of energy and substance exchange and
transformation. Different pathological agents may break these
processes and thus cause violations of activity both separate organs
and body organ systems. This is the way disease appears. If organism
is not able to control violations through compensative mechanisms
or those mechanisms do not have enough time to react a terminal
state appears – situation of an absolute life_threat.
Fig. Importance of CPR
Intensive care and resuscitation in many cases may prevent and
eliminate energy and substrate deficiency, which appear during the
terminal state and consequently save the organism from death.
Intensive care is a complex of methods, which allows a temporary
replacement of vital functions. These methods are used to prevent
the adaptation mechanisms exhaustion and to avoid the terminal
Fig. Checking of patients condition
Fig Method of CPR
Reanimatology is a science about vitalization of the organism,
prevention and treatment of the terminal states (according to
Fig. Artificial lung ventilation
Human being for existence needs continues entry and
consumption of oxygen and elimination of carbonic acid. Those
processes are provided with the coordinated functioning of
respiration and circulation under the control of the central nervous
system. These 3 systems are so called “triple gates of death” (lungs,
heart and brain). Arrest of vital functions (death) might be sudden
(accidents) or quite predictable consequence of aging or an incurable
Fig. Cleaning of oral cavity
The whole process of dying might be divided into next stages:
Preagony. Physiologic mechanisms of vital activity are deeply
exhausted: central nervous system is depressed (coma is possible);
heart sounds are weak, pulse is thready, systolic blood pressure is
lower than the critical level of
weak and not effective, tidal volume and respiratory frequency are
inadequate; functions of parenchymal organs are violated. Preagony
can last for minutes, hours or even days. During this time condition
of patient becomes worse and finally everything ends with a terminal
pause. Patient faints, blood pressure and pulse become hard to
measure, respiratory arrest appears and reflexes are lost.
Fig. Artificial lung ventilation
Terminal pause ends within a minute and final stage – agony begins. According
to the complete exhaustion of superior control centers of the CNS
lower centers (bulbar respiratory and vasomotor centers, reticular
formation) are getting more active. Muscular tone, reflexes and
external respiration (chaotic, with auxiliary respiratory muscles
participation) are restored.
Fig. Position of hands
The pulse is palpated over the main arteries; systolic blood pressure may rise up to 50_70 mm Hg (due to
temporary renewed vascular tone). At the same time irreversible
cell metabolic changes take place: reserves of high_energy substances
are burnt out and in 20_40 seconds clinical death appear.
Fig. Artificial lung ventilation
In quite a long list of pathological cases (drowning, electrical or
lightning injuries, strangulated asphyxia, communication accidents,
myocardial infarction, etc.) clinical death appears suddenly, without
any previous sings of dying.
Fig. Position of precardial beat
Main sings of clinical death are:
1. Lack of pulse over the main arteries (carotid, femoral arteries)
2. Persistent pupil’s dilatation with a lack of photoreaction.
3. Lack of unassisted ventilation.
Fig. Laringeal mask like alternative method of intubation
Additional sings of clinical death:
1. Changes of the skin color (gray or cyanotic)
3. Lack of reflexes and muscular atony.
The effectiveness of resuscitation is greatly affected by the
temperature of the environment and the duration of dying.
Fig. Position of hands during CPR
Normally clinical death caused by a sudden cardiac arrest in case of normal
environment temperature lasts nearly 5 minutes. In case of
hypothermia – 10 minutes and more.
Fig. Heart massage
The longer process of dying
lasts, the shorter clinical death is and thus lower are the chances of
positive resuscitation outcome.
Fig. Heart massage
Biological death appears as a result of irreversible changes of
the whole organism, especially of the CNS changes.
Stages and phases of resuscitation.
Resuscitation is a complex of actions, which prevent irreversible
changes and restore vital functions of an organism in a state of clinical
death. A person, who conducts these actions is called a rescuer.
The final goal of resuscitation is to bring back life of full value to
a patient after clinical death. This task might be realized only with
immediate, professional and sequential measures.
Fig. steps of CPR
Nevertheless always care about your own safety, as your duty is to help, not to
increase the number of victims. Pay attention to the conditions in
which clinical death appeared, make sure you are not in danger, use
gloves and eyewear if they are available. Of course final decision about
priorities belongs to you, but every biological liquid contacting your
skin and mucosa is a potential infection source. If you feel unwilling
to perform rescue breathing mouth_to_mouth or physically it is
impossible to ventilate the patient for some reason at least do chest
Fig. New recommendation for performing CPR
According to the modern level of resuscitation
knowledge blood flow is the most important target of CPR.
The first stage of resuscitation is basic life support. It is
conducted by a rescuer who is not obligatory a health care professional, but a witness who acquired basic life support skills.
Fig. Precardial beat
After clinical death is stated (try not to evaluate respiration (B)
and heart action (C) more than 10 seconds) a rescuer should
immediately start basic life support (optimal position of
patient who is on the flat surface lying supinely).
Successful cardiopulmonary resuscitation is based on three
I. Airways (A). To make
ABC check upper airways free use triple
method of Peter Safar: 1. Open the mouth of the patient and empty
the oral cavity, if necessary, from foreign bodies and liquids such as
vomit, sputum, false jaws, blood cloths, etc (using your finger or
forceps with surgical drape).
Fig. Ventilation through mask
2. Title the head backwards (remember, that in case of each
trauma patient we always suspect neck injury, so titling and sharp
neck moves should be rather avoided). After this in most cases upper
airways become conductive (soft palate and tong are not blocking
air passage any more).
Fig. Artificial lung ventilation and heart massage
Fig. Artificial lung ventilation
3 . Thrust the jaw forward. In all cases this part of Safar method
provides final air passage.
You can also use simple airway adjuncts such as oropharyngeal
and nasopharyngeal airways.
II. Breathing (B). Respiratory support in conditions of BLS is
usually mouth_to_mouth ventilation. If only there is a chance use
devices for pre_hospital ventilation: pocket resuscitation masks of
different types or at least handkerchief. Place closely your mouth
over that of the patient and make a normal exhale (volume 600_800
ml). Remember to keep the airways conductive using the methods
Fig. Using of intraosseal injection during CPR
described above; use fingers of your free hand to close the nostrils of
the patient. In case of correct ventilation chest rises and falls silently.
Repeat this action one more time.
III. External heart massage (C– circulation). Standing aside
the patient (on your knees), place your hands in the center of the
chest: heel of the hand in the middle of the lower part of
sternum or between lower and middle thirds of sternum. Don’t
loose precious time looking for anatomic landmarks, as soon as
possible start heart massage. Pay attention to your fingers – they
should not lean on the chest, otherwise you will break the ribs
during compressions. The frequency of compressions
should be 100 per minute. It means that until you haven’t provided airways with endotracheal tube you make 30 compressions per every 2 breathes. Heart massage
is extremely important: do it correctly as its efficiency (and thus
cerebral blood circulation) depends on your technique. Use the most
developed muscles of your body – back muscles, keep your elbows
straight and compress the chest with the power of your trunk, not
upper limbs. Every compression should be 5_6 cm deep. After each
compression don’t forget to let the chest recoil completely.
Sings of effective resuscitation actions are pupils contraction,
normalization of the skin color, appearance of peripheral pulse
synchronized with the massage, sometimes even possibility of blood
pressure measurement. Sometimes heart action restores even during
Fig. Defibrilation Fig. Defibrilation
Second stage is advanced life support, which is provided by health_
care professionals in hospitals with the usage of medicines, diagnostic
and therapy equipment. The main ideas of ALS are: determination of
cardiac arrest type (shockable/nonshockable rhythm),
pharmaceutical and electric treatment, usage of advanced artificial
ventilation (if available also devices for heart massage) and therapy
of reversible clinical death reasons.
When resuscitation team works together functions of
rescuers must be divided in order to gain maximal efficiency. After
CPR started the main purpose is to decide whether the
defibrillation is necessary or not, other words: to monitor the type
of cardiac arrest. Shockable rhythms are ventricular
fibrillation (VF) and pulseless ventricular tachycardia (VT
without pulse); nonshockable rhythms are asystole (A) and
pulseless electrical activity (PEA) of the heart.
Fig. Performing CPR by team
Without energetic resources VF and pulseless VT quickly change into PEA and asystole,
so to shorten the time between arrest and defibrillation paddles
visualization (apex_sternum position) should be used even before the
electrodes will be placed on the chest. For the first defibrillation use
the dose of 360 Joules for monophasic defibrillators (old models) and
150_200 Joules for biphasic defibrillators (modern devices).
Subsequent shocks might be of the same (200 J) or escalated energy
(150_360 J) – the efficiency of energy increase is not proved, so it
depends on you and local standards.
Cardiac arrest types:
1. Asystole – flat line on ECG
2. Ventricular fibrillation – chaotic contractions of myocardial
fibers visualized on ECG as waves of different shape and amplitude
(high, medium and low).
3. PEA – different ECG rhythms, including normal, but
combined with the lack of effective systole (pulse).
Simultaneously a venous access attempt should be done, as after
third defibrillation administration of adrenaline (1 ml of 0,1%
solution =1 mg followed by 20 ml of 0,9% NaCl solution) and
amiodarone (6 ml of 5% solution = 300 mg with 5% Glucose solution,
total volume – 20 ml) are required. Adrenaline administration should
be repeated every 3_5 minutes in the same dose. In case of PEA and
asystole adrenaline should be given from the moment of intravascular
access achievement. Atropine is not any more included into the official
algorithms of ALS if the cardiac arrest is not caused by vagal effect.
However according to actual Ukrainian standards single
administration of Atropine is still recommended (3 ml of 0,1%
solution=3 mg, followed by 20 ml of 0,9% NaCl solution).
If, however, venous access attempts are unsuccessful within 2
minutes you should think about alternatives, such as intraosseous
access. As for the medicine delivery via the tracheal tube – it is no
longer recommended. Central venous line insertion is a prerogative
of the most skilled and competent members of the team. Previously
it was thought, that triple doses of resuscitation drugs given through
endotracheal tube or through the needle in the crico_thyroid
membrane will be effective, but according to the actual
recommendations such way of admission is unpredictable and thus
can not be an alternative. Intracardiac delivery of drugs nowadays
has rather historical value: in most developed countries it is not
practiced any more.
Mechanical ventilation is much more effective than the mouth_
to_mouth one. There are different types of devises for respiration
(carrying and stationary) and numerous devises which play the
role of connector between patient’s airways and apparatus for
artificial pulmonary ventilation (ventilation masks, laryngeal
masks and tubes, combitubes, endotracheal tubes, etc). In case of
CPR the endotracheal tube with cuff is an absolute golden
standard, as it allows asynchronous ventilation/massage and
protects patient from aspiration (cardiac arrests are mostly
sudden, so there is always a risk of regurgitation, aspiration and
thus aspiration syndrome development). Under control of direct
laryngoscopy it’s possible to clean upper airways with electric or
pneumatic suction device and what is even more important – to
intubate the trachea.
During the CPR think about reversible cardiac arrest reasons
and try to treat them: there are easy mnemonic schemes of 4 H and 4
T for this purpose. So, the reversible causes of the clinical death are:
hypoxia tension pneumothorax hypovolemia tamponade (cardiac)
hypothermia toxins hypo/hyper electrolytic and metabolic disorders thrombosis
Treat them with: oxygen and artificial ventilation in case
of hypoxia; crystalloids and colloids in case of hypovolemia; warming
(including warm infusions) in case of hypothermia and proper
electrolyte infusions in case of electrolytes and metabolic disorders
(for example use 5_10 ml of 10% calcium chloride solution if you
suspect hyperkalemia or hypocalcemia caused by dialysis, hemolysis,
massive tissue damage, etc.).
Fig. Scheme of CPR
Use needle thoracocentesis for tension pneumothorax, needle pericardiocentesis for cardiac tamponade, antidotes and detoxification methods for toxic agents and
thrombolytic therapy for thrombosis (if required).
The third stage of resuscitation is post_resuscitation care
provided also in intensive treatment unit.
Fig. Scheme of CPR
On the first stage of this care check again the patient’s condition:
monitor constantly condition of cardiovascular and respiratory
systems, measure blood pressure and central venous pressure,
evaluate CNS state (reflexes, neurological deficiency), perform
laboratory tests (take blood and urine samples, liquor if necessary),
etc. Well_planned, comprehensive examination allows us to identify
homoeostasis disorder and choose optimal treatment. After main
parameters are stabilized central nervous system becomes your main
concern: protect the brain from hypoxia by all available means,
because hypoxic damage of neurons is usually irreversible. To achieve
this purpose you should:
– provide adequate oxygenation (however excess of oxygen is
no longer recommended, so keep blood saturation at the level 94_
98%); hyperventilation might be used in case of brain oedema (first
12_24 hours of artificial ventilation);
Fig. The chain of survival
– decrease metabolic needs of the CNS by craniocerebral
hypothermia (give saline solution with the temperature
to lower body temperature to 32_34 °C for 12_24 hours) or by
continuous narcosis (sodium thiopental 3_5 mg/kg, diazepam 0,2 mg/
kg, neuroleptics, etc.);
– control blood glucose level (avoid hyperglycaemia over 10
mmol/l; hypoglycaemia can not be accepted at all);
– additionally prescribe antihypoxants like sodium oxybate (20_
40 mg/kg every 4 hours), cytochrome C (0,5 mg/kg i/v);
antioxidants like tocopheryl acetate (500 mg i/v), B_vitamins (2_3
ml), ascorbic acid (5 ml of 5% solution 3 times a day); calcium
antagonists like verapamil (2 ml 3 times a day), magnesium sulphate
(5_10 ml of 25% solution i/v every 4 hours with blood pressure
– improve cerebral perfusion with haemodilution (give
crystalloids to get hematocrit 0,3_0,35 l/l), relative hypertension (20_
30% over the normal level), solutions influencing rheological
properties of the blood and microcirculation (rheopolyglucin, 2 ml
of 0,5% curantil solution, heparin 5000 units every 4 hours, etc);
– treat cerebral oedema with mannitol (1g/kg), furosemide
solution 10 mg i/v 3 times a day), dexametazon solution (8 mg every
– use hyperbaric oxygenation from the 5_th day of post_
resuscitation care (totally 10 procedures);
– give nootropic drugs and neuroprotectors (piracetam,
cerebrolysin, aminalon, etc.)
Cardiac arrest in special circumstances
Regardless to the cardiac arrest reasons the main factors of
thanatogenesis [*Thanatos – god of death in Ancient Greece] are
hypoxia, hypercapnia, electrolytic disorders and pathological reflexes.
In 90% of cases heart stops in the moment of diastole, in 10% – systole.
Heart, lungs and brain are the death entrance gate.
In_hospital cardiac arrest.
The most common reasons of primary cardiac arrest:
a. acute cardiac failure (coronary disease, myocardial infarction,
rhythm disorders, sudden coronary death)
b. acute obstruction of main vessels (pulmonary
c. acute and severe deficiency of blood volume (significant blood
d. acute decline of peripheral vessels resistance (acute suprarenal
failure, anaphylactic shock, somatogenic collapse in case of acute
intoxication, orthostatic medication collapse)
The most common reasons of acute respiratory failure:
a. airways obstruction (tongue, vomit, foreign bodies)
b. inhibition of respiratory center (opiates, anesthetics)
c. disorders of breathing biomechanics (convulsions, myasthenia,
tension pneumothorax or hemothorax)
d. restrictive disorders (massive pneumonias, shock lung
syndrome, pneumothorax or hemothorax).
The most common reasons of primary brain death: acute vascular
disorders (subarachnoid hemorrhage, hemorrhagic and ischemic
strokes, brain dislocation).
Patients with a predictably high risk of sudden death should be
constantly under complex vital monitoring. In case of compensation
failures medical personnel of the department should intrude with a
treatment directed at correction of disorders and intensive care. That
is why an in_hospital sudden death should be an exception. Never the
less hospital staff should be prepared to provide immediate life
Here is the list of equipment for in_hospital resuscitation:
1. Portable manual respirator.
2. Oxygen supply (cylinder).
3. Electric suction device with suction catheters.
4. Electrocardiograph, defibrillator, tonometer.
5. Mouth_gag, tongue forceps, clips.
6. Set of face masks and airways.
7. Laryngoscope with a set of tubes.
8. Set for conicotomy and for pericardiocentesis.
9. Solutions of adrenaline, atropine, sodium bicarbonate, lidocaine,
steroids, colloids and crystalloids.
10. Infusion sets, i/v catheters, syringes of different sizes.
11. Bandages, medical napkins, antiseptic solutions.
Peculiarities of in_hospital resuscitation.
Patient is usually lying in bed.
1. To get a firm surface [efficiency of chest compressions depends
on this] lay under the patient spinal board or move him/her on the
2. Duration of the first stage should be minimal (5 to 7 minutes)
as the beginning of advanced life support in intensive care unit is
fibrillation during first 20_30 seconds precardiac thump might be
effective (so called “mechanical defibrillation”).
4. Sometimes tracheostomy or conicotomy might be necessary
in case of upper airways obstruction (laryngospasm, stenosis of
larynx, foreign body in the glottis).
The most favorable resuscitation prognosis is connected with
primary respiratory arrest and the most unfavorable – with the
primary cerebral death.
Drowning: types and resuscitation.
There are different types of drowning thanatogenesis.
True drowning. Most victims under the water according to a
reflex stop breathing. But after some time due to hypercapnic
stimulation of the respiratory center they unwillingly begin to make
respiratory movements. Liquid gets to the lungs: fresh water, which
is hypoosmolar to plasma, diffuses easily through blood_air barrier
into the blood, thus increasing it’s volume. Extra 1500_2000 ml of
water in addition to hypoxia lead to cardiac arrest. At the same time
osmotic hemolysis (caused by rapid lowering of plasma osmolarity)
and hyperpotassemia are also cardiac arrest factors.
In case of salt water true drowning fluid part of blood according
to the osmotic gradient moves from bloodstream into the bronchi
and trachea. This way surfactant is being destroyed and pulmonary
Dry drowning. 8_10% of victims in the moment of water aspiration
have reflexive vocal cords closure. This prevents further water entering
into the lower airways. The cardiac arrest is caused by hypoxia.
Syncopal drowning happens in 5 % of cases. Due to fear,
immersion in cold water, injury of reflexogenic zones caused by falling
primary cardiac arrest appears. It is called “syncope”. Those victims
have gray color of skin and there is no water in their airways.
Peculiarities of resuscitation.
important. Right after airways management (head titling, oral cavity
cleaning) rescue breathing should be provided. Don’t waste victim’s
precious time on shaking out the water by pressing the abdomen or
lowering the head: the amount of water inside is not that dangerous
and your efforts are hopeless and unnecessary. The only thing you
really can achieve by these actions is vomiting and aspiration of gastric
contents, which are much more dangerous, than aspiration of water.
2. During resuscitation of the patient, who drowned in sweet
water, 10 % solution of calcium chloride is used (5 or 10 ml).
3. All patients who were drowning should be transported to the
ICU and observed most carefully (few days).
4. To avoid secondary drowning (fulminant pulmonary edema
causing death) patients with true drowning should receive
respiratory support with positive end expiratory pressure.
5. On the third stage of resuscitation patients with true drowning
in sweet water should receive solution of sodium bicarbonate in order
to prevent renal failure (renal tubules are being blocked by
hemoglobin, which accumulates due to hemolysis) and diuretics.
6. On the third stage of resuscitation patients with true drowning
in salt water should receive hypotonic infusions (in order to correct
In case of dry drowning and syncopal drowning prognosis is
favorable even after prolonged clinical death, unlike drowning in
sweet water. In case of drowning in cold water (
is not stated until the body becomes warm, resuscitation lasts much
longer, than in conditions with normal temperature.
Resuscitation in case of mechanical injuries (fall from a height,
1. Clinical death might be caused by severe injuries incompatible
with life or reflex cardiac arrest. It is obvious, that resuscitation will
be successful in second case, but not first. If it is a witnessed cardiac
arrest precardiac thump might be effective.
patient: always suspect backbone injury until it is not excluded with
additional methods of diagnostics (computer tomography
diagnostics, X_ray diagnostics). Don’t title the head backwards: in
such cases it’s enough to thrust the jaw forward.
3. If the patient has fractures of facial skeleton or injuries of face
soft tissues mouth_to mouth respiration might be ineffective or even
impossible, however mouth_to_nose respiration might be useful.
Transportation, if it’s possible, should be in a save position with head
4. Constantly examine patient’s condition: injuries, which seem
to be unimportant at the beginning sometimes change into life
threatening; this is why examinations should be repeated and accurate.
Transportation of severe patients sometimes ends with
decompensation of main vital systems.
Electric trauma and lightning stroke.
1. After electric injury or lightning stroke clinical death might
happen due to primary respiratory arrest (spasms of respiratory
muscles, respiratory center damage), ventricular fibrillation or
cerebral affection (in last case vital sings are minimal, so there were
cases, when patients were buried “alive” and “raised”; this could be
the reason of a superstitious belief that for bringing back life after
lightning stroke victim should be buried).
2. As soon as possible break the contact between victim and
electricity source. Still, remember that your own safety is of not less
4. Even patients who seem to be fine according to their vital
parameters should be admitted to the ITU and observed most
carefully for few days. There is always a risk of sudden cardiac arrest
due to violation of myocardial excitability and conductivity during
first 24 hours after electric trauma or lightning stroke.
of airways (clear the oral cavity, throat, larynx with your finger or
any available equipment (clamp, forceps, aspirator) with
laryngoscopy or without it and then decide what type of respiratory
support patient needs.
2. If there is no chance to treat the obstruction of upper airways
using usual methods or tries were unsuccessful urgent conicotomy
(3.3) or tracheostomy (3.4, in hospital conditions) are the only ways
of rescuing patient’s life.
3. Never ever try to push “deeper” the foreign body you can’t
Medical operations and manipulations
Indications: respiratory arrest or ineffective patient’s breathing,
when there is no respiratory apparatus.
Necessary equipment: napkin or handkerchief; artificial airway,
gloves– if available.
Procedure: First of all free upper airways – open the mouth of
the patient and clear oral cavity as mentioned above: turn the head
aside, open the mouth and remove vomit, blood cloths, foreign bodies
with a finger. Then title head backwards and thrust the jaw forward.
To make mouth_to_mouth ventilation less unpleasant you can put a
napkin or a piece of bandage on the mouth of the victim. Close
patient’s nostrils with your fingers, press your mouth against the
mouth of the patient and make a forced expiration. Inhaling the air
observe the chest: if it moves according to your respiratory efforts
breathing is effective. However if chest is not rising check again
airways patency: thrust the jaw placing your fingers over its angle
and moving them forward (lower teeth should overlap upper teeth).
Your aim is to exhale nearly 600_800 ml of air with the frequency of
10 times per minute (2 breathes to 30 compressions) during CPR. If
it is respiratory arrest alone you can make 15_20 breathes per minute.
Chest compressions (External heart massage).
Indications: cardiac arrest (clinical death).
Necessary equipment: doesn’t need any; gloves if they are
Procedure: place the patient on the firm flat surface in supine
position; if you have an assistant one of you should provide airways
patency and breathing, another – chest compressions. Staying on
your knees aside the patient place one hand in the middle of the chest
and cover it with another. Your fingers should not touch the chest,
otherwise while compressions you will break the ribs. Frequency of
compressions should be 100 per minute*, depth – 5_6 cm. Keep your
elbows straight and use mainly mussels of your back (weight of the
body): thus you will exhaust slower. In case of effectively provided
CPR you might observe constriction of pupils, normalization of skin
color, pulse on peripheral vessels, sometimes it’s even possible to
measure blood pressure.
There are two types of heart punction: punction of heart cavity
(previously used for adrenaline injection or in case of air embolism)
and pericardial punction performed for extraction of blood in case of
Indications: air embolism, haemopericardium.
Necessary equipment: 7_10 cm needle, 10_20 ml syringe.
Procedure: find the forth intercostal space and puncture the skin
with a saline filled syringe 1_1,5 cm to the left from the sternum border.
Needle should be directed over the fifth rib sugittally and a bit to the
middle, all the time control the needle position pulling the plunger
back. At a depth of 4_5 cm you will feel a kind of resistance – wall of
the right ventricle, after that expect appearance of blood in the
syringe – sign of the needle located in the left ventricle. Control the
hub with your left hand and push the plunger with the right hand to
infuse the medicine from the syringe (or aspirate the air n case of air
Electric heart defibrillation
Indications: ventricular fibrillation, ventricular tachycardia
Necessary equipment: defibrillator, electrode paste (electricity
Procedure: evaluate the rhythm during CPR as soon as possible.
After stating “shockable rhythm” defibrillate immediately. According
to the actual CPR recommendations heart massage should be
interrupted only for a moment of defibrillation itself and continued
during paddles placement and charging. So while 2 rescuers are
continuing CPR the third should place the paddles in sternum_apex
position (previously putting on them layer of electrode gel), choose
the correct mode on the defibrillator and press charge button. Begin
with 150_200 J in case of biphasic defibrillator and 360 J in case of
monophasic. Make sure neither you nor your colleagues are
contacting the patient or equipment, otherwise you might get injured.
At the moment of defibrillation remove the source of the oxygen
from the patient and stop the infusion. After defibrillator is loaded
press “defibrillate” button on the paddle and at the moment
defibrillation is over restart the massage. Put paddles on their place
without crossing or contacting them in the air. In two minutes
check the rhythm and vital sings again and if necessary – repeat
the defibrillation with a greater voltage (300_360J).
Paddles placement: a) one electrode is placed in front of the
heart (anterior position) and another one on the back, behind
the heart, between the scapula (posterior position); b) apex_
sternum position: one electrode is placed over the heart and another
one on the right side of the sternum.
2.5. Control tests
1. Name the stages of dying:
A.Preagony, terminal pause, agony, clinical death;
B.Agony, clinical and biological death;
C.Coma, agony, clinical death;
D.Preagony, agony, clinical death, social death;
E.Hypotension (blood pressure lower than
2. What sign is not one of the main clinical death signs?
A.lack of blood pressure
B.lack of pulse on femoral arteries
C.lack of breathing
D.mydriasis and lack of photoreaction
E.lack of pulse on carotid arteries
3. What should be expiratory volume during “mouth_to_mouth”
C. 1200_1600 ml
D. 800_1100 ml
E. maximal exhalation
4. The duration of clinical death in conditions of normal temperature
A. 7_12 minutes
C. 4_5 minutes
D. 5_7 minutes
E. 10 minutes
5. Name the exact hand placement during heart massage:
A. on the chest, fingers to chin
B. lower third of the sternum, fingers along ribs
C. middle of the chest
D. 4_th intercostal space, left part of the chest
E. on the chest in the heart area
6. What are the signs of effective artificial ventilation?
A. narrowing of the pupils
B. noises during ventilation
C. silent chest movements
D. bulged out epigastrium
E dizziness of the rescuer
7. Choose an absolute sign of cardiac arrest:
A. flat line on ECG
C. cyanotic color of skin
D. lack of pulse over carotid arteries
E. lack of blood pressure
8. Choose the place of heart puncture:
A. 5_th intercostal space, in the place of apex projection
B. 3_d intercostal space, on the left from sternum
C. lower edge of the 4_th rib
D. 4_th intercostal space,
E. in the place where heart action is noticeable
9. What medicines are usually used during CPR?
A. adrenaline, atropine, cordaron
B. adrenalin, dopamine
C. atropine, dopamine
D. atropine, steroids, dopamine, magnesium
E. adrenaline, magnesium
10. What is the reason of Sodium bicarbonate usage during CPR?
A. correction of metabolic acidosis
B. prevention of respiratory acidosis
C. liquidation of hypoxia
D. treatment of metabolic alkalosis
E. protection of central nervous system
11. Choose the indication for defibrillation during CPR:
A. low blood pressure
E. lack of pulse over carotid arteries
Andrew, the student of medicine, is a witness of an accident: wireman,
who was working with a transformer, suddenly was kicked few meters
from it. During examination it turned out, that victim is unconscious, his
pupils are dilated and do not react on light, his skin is pale; there is no
pulse over carotid arteries; fingers of the right hand are burnt, in the middle
of the palm there is a lacerated wound.
What diagnosis should Andrew think about? What should be done?
What is the order of these actions?
Annie, the nurse, is a witness of such situation: a man of 40, lying at
the city bus station, is being ventilated by a passing pedestrian through
chest pressing and arms abducting. The victim is unconscious, his pupils
are dilated, skin is pale and there are no pulse, no breathing and no reflexes.
What diagnoses should Annie think about? What way should Annie
provide the CPR?
Walking near the
notices a 4_year old girl who felt to the water and disappeared under the
surface. What should Andrew do?
„The laymen”, local group of amateur rescuers, dragged from the water
a young girl. They turned her down at the same time pressing with the
knee her abdomen in order to force the water out from the airways. After
that they putted her on her back, attached with a pin her tongue to the
chin (in order to provide airways potency). Next they started CPR: forced
maximal breathes (14
per minute) together with chest compressions (
deep, 60 per minute). Name 5 mistakes of „The layman”.
„The Dream team”, group of professional rescuers, started CPR of a
patient in a state of clinical death. Then they cleared the upper airways
with an electric suction machine, connected respiratory machine. Next
they gave adrenaline (0,5 ml of 0,1% solution) sodium bicarbonate (4%
solution, 10 ml), calcium chloride (10%, 5 ml) and atropine (0,5 ml of 0,1%
solution) at the same time and connected patient to a monitor (flat line on
the ECG). After that rescuers did a defibrillation of 300 J, which resulted
in a flat line on the ECG. They repeated everything again, this time with
defibrillation of 400J. Unfortunately there was no effect. Patient died.
Name 5 mistakes of „The Dream team
The importance of the water to the organism.
Life on earth was born in the water environment. Water is a universal solvent for all the biochemical processes of the organism. Only in case of stable quantitative and qualitative composition of both intracellular and extra cellular fluids homoeostasis is remained.
The body of an adult human contains 60% of water. Intracellular water makes 40% of the body weight, the water of intercellular space makes 15% of body weight and 5% of body weight are made by the water in the vessels. It is considered that due to unlimited diffusion of water between vessels and extra vascular space the volume of extracellular fluid is 20% of body weight (15%+5%).
Physiologically insignificant amounts of water are distributed beyond the tissues in the body cavities: gastrointestinal tract, cerebral ventricles, joint capsules (nearly 1% of the body weight). However during different pathologic conditions this “third space” can cumulate large amounts of fluid: for example in case of ascitescaused by chronic cardiac insufficiency or cirrhosis abdominal cavity contains up to 10 liters of fluid. Peritonitis and intestinal obstructions remove the fluid part of blood from the vessels into the intestinal cavity.
is extremely dangerous for the patient. Water gets to the body with food and
drinks, being absorbed by the mucous membranes of gastro-intestinal tract in
total amount of 2-3 liters per day. Additionally in different
metabolic transformations of lipids, carbohydrates and proteins nearly 300 of
endogenous water are created. Water is evacuated from the body with urine (1,5-
Water balance is regulated through complicated, but reliable mechanisms. Control over water and electrolytes excretion is realized by osmotic receptors of posterior hypothalamus, volume receptors of the atrial walls, baroreceptors of carotid sinus, juxtaglomerular apparatus of the kidneys and adrenal cortical cells.
When there is a water deficiency or electrolytes excess (sodium, chlorine) thirst appears and this makes us drink water. At the same time posterior pituitary produces antidiuretic hormone, which decreases urine output. Adrenals reveal into the blood flow aldosterone, which stimulates reabsorption of sodium ions in the tubules and thus also decreases diuresis (due to osmosis laws water will move to the more concentrated solution). This way organism can keep precious water.
On the contrary, in case of water excess endocrine activity of glands is inhibited and water is actively removed from the body through the kidneys.
Importance of osmolarity for homoeostasis.
Water sections of the organism (intracellular and extracellular) are divided with semipermeable membrane – cell wall. Water easily penetrates through it according to the laws of osmosis. Osmosis is a movement of water through a partially permeable membrane from the solution with lower concentration to a solution with higher concentration.
Osmotic concentration (osmolarity) is the concentration of active parts in one liter of solution (water). It is defined as a number of miliosmoles per liter(mOsm/l). Normally osmotic concentration of plasma, intracellular and extracellular fluids is equal and varies between 285mOsm/l. This value is one of the most important constants of the organism, because if it changes in one sector the whole fluid of the body will be redistributed (water will move to the environment with higher concentration). Over hydration of one sector will bring dehydration of another. For example, when there is a tissue damage concentration of active osmotic parts increases and water diffuses to this compartment, causing oedema. On the contrary plasma osmolarity decreases, when there is a loss of electrolytes and osmotic concentration of the cellular fluid stays on the previous level. This brings cellular oedema, because water moves through the intracellular space to the cells due to their higher osmotic concentration.
Cerebral oedema appears when the plasma osmolarity is lower than 270 mOsm/l. Activity of central nervous system is violated and hypoosmolar coma occurs.Hyperosmolar coma appears when the plasma osmolarity is over 320 mOsm/l: water leaves the cells and fills the vascular bed and this leads to cellular dehydration. The sensitive to cellular dehydration are the cells of the brain.
Plasma osmolarity is measured with osmometer. The principle of measurement is based on difference in freezing temperature between distillated water and plasma. The higher is the osmolarity (quantity of molecules) the lower is freezing temperature.
Plasma osmotic concentration can be calculated according to the formula:
Osmotic concentration= 1,86*Na+glucose+urea+10,
Plasma osmolarity (osmotic concentration) – mOsm/l
Na- sodium concentration of plasma, mmol/l
Glucose- glucose concentration of the plasma, mmol/l
Urea- urea concentration of the plasma, mmol/l
According to this formula sodium concentration is the main factor influencing plasma osmolarity. Normally sodium concentration is 136-144 mmol/l. Water and electrolytes balance can be violated with external fluid and electrolytes loss, their excessive inflow or wrong distribution.
9.3 Fluid imbalance and principles of its intensive treatment.
Water imbalance is divided into dehydration and overhydration.
Dehydration is caused by:
- excessive perspiration in conditions of high temperature;
- rapid breathing (dyspnea, tachypnea) or artificial ventilation without humidification of the air;
- vomiting, diarrhoea, fistulas;
- blood loss, burns;
- diuretics overdose;
- excessive urine output;
- inadequate enteral and parenteral nutrition or infusion therapy (comatose patients, postoperative care);
- pathological water distribution (“third space” in case of inflammation or injury).
Dehydration signs: weight loss, decrease of skin turgor and eyeballs tone, dry skin and mucous membranes; low central venous pressure, cardiac output and blood pressure (collapse is possible); decreased urine output and peripheral veins tone; capillary refill over 2 seconds (microcirculation disorders) and low skin temperature; intracellular dehydration is characterized with thirst and consciousness disorders. Laboratory tests show blood concentration: hematocrit, hemoglobinconcentration, protein level and red blood cells concentration increase.
Overhydration appears in case of:
- excessive water consumption, inadequate infusion therapy;
- acute and chronic renal failure, hepatic and cardiac insufficiency;
- disorders of fluid balance regulation;
- low protein edema.
Clinical findings in case of overhydration are: weight gain, peripheral oedema, transudation of the plasma into the body cavities (pleural, abdominal), high blood pressure and central venous pressure. In case of intracellular overhydration appear additional symptoms: nausea, vomiting, signs of cerebral edema (spoor, coma). Laboratory tests prove hemodilution.
According to the osmotic concentration of plasma dehydration and overhydration are divided into hypotonic, isotonic and hypertonic.
Isotonic dehydration is caused by equal loss of electrolytes and fluid from the extracellular space (without cellular disorders).Blood tests showhemoconcentration; sodium level and osmotic concentration are normal.
To treat this type of water imbalance use normal saline solution, Ringer solution, glucose-saline solutions, etc.. The volumes of infusions can be calculated according to the formula:
VH2O= 0,2*BW* (Htp-0,4)/0,4 ,
VH2O – volume of infusion, l
Htp – patient’s hematocrit, l/l,
BW – body weight, 0,2*BW – volume of extracellular fluid,
0,4- normal hematocrit, l/l,
Hypertonic dehydration is caused by mostly water loss: first it appears in the vascular bed, than in the cells. Laboratory tests show hemoconcentration: elevated levels of proteins, red blood cells, hematocrit. Plasma sodium is over 155 mmol/l and osmotic concentration increases over 310 mOsm/l.
Intensive treatment: if there is no vomiting allow patients to drink. Intravenously give 0,45% saline solution and 2,5 % glucose solution, mixed with insulin. The volume of infusions is calculated according to the formula:
VH2O=0,6*BW (Nap -140)/140,
VH2O – water deficiency, l
Nap – plasma sodium, mmol/l
BW – body weight, 0,6*BW volume of general body fluid
140 – physiological plasma sodium concentration
Hypotonic dehydration is characterized with clinical features of extracellular dehydration. Laboratory tests show decrease of sodium and chlorine ions. Those changes cause intracellular movement of the water (intracellular overhydration). Hemoglobin, hematocrit and protein levels are increased. Sodium is lower than 136mmol/l, osmolarity is lower than 280 mOsm/l.
To treat this type of water imbalance use normal or hypertonic saline and sodium bicarbonate solution (depends on blood pH). Do not use glucose solutions!
The deficiency of electrolytes is calculated according to the formula:
Nad = (140-Nap)*0,2 BW,
Nad – sodium deficiency, mmol
Nap – plasma sodium, mmol/l
BW – body weight, 0,2 BW – volume of extracellular fluid
Isotonic overhydration is caused by excess of the water in the vascular bed and extracellular space; however intracellular homoeostasis is not violated.Hemoglobin is less than 120 g/l, protein level is less than 60 g/l, plasma sodium is 136-144 mmol/l, osmotic concentration is 285-310 mOsm/l.
Treat the reason of imbalance: cardiac failure, liver insufficiency, etc. Prescribe cardiac glycosides, limit salt and water consumption. Give osmotic diuretics (mannitol solution 1,5 g/kg), saluretics (furosemide solution 2 mg/kg), aldosterone antagonists (triamterene – 200 mg), steroids (prednisolone solution 1-2 mg/kg) albumin solution if necessary (0,2-0,3 g/kg).
Hypertonic overhydration is a state of extracellular electrolytes and water excess combined with intracellular dehydration. Blood tests show decrease ofhemoglobin, hematocrit, protein level, however sodium concentration is increased over 144 mmol/l, osmotic concentration is over 310 mOsm/l.
To treat this condition use solutions without electrolytes: glucose with insulin, albumin solutions and prescribe saluretics (furosemide solution), aldosteroneantagonists (spironolactone). If it is necessary perform dialysis and peritoneal dialysis. Do not use crystalloids!
Hypotonic overhydration is a state of extracellular and intracellular water excess. Blood tests show decrease of haemoglobin, hematocrit, proteins, sodium and osmotic concentration. Intensive therapy of this condition includes osmotic diuretics (200-400 ml of 20% mannitol solution), hypertonic solutions (50 ml of 10% saline intravenously), steroids. When it is required use ultrafiltration to remove water excess.
Electrolytes disorders and their treatment
Potassium is a main intracellular cation. Its normal plasma concentration is 3,8-5,1 mmol/l. Daily required amount of potassium is 1 mmol/kg of body weight.
Potassium level less than 3,8 mmol/l is known as kaliopenia. Potassium deficiency is calculated according to the formula:
Kd= (4,5-Kp)*0,6 BW
K- potassium deficiency, mmol;
Kp – potassium level of the patient mmol/l;
0,6*BW – total body water, l.
To treat this state use 7,5% solution of potassium chloride (1ml of this solution contains 1 mmol of potassium). Give it intravenously slowly with glucose and insulin (20-25 ml/hour). You can also prescribe magnesium preparations. Standard solution for kaliopenia treatment is:
10% glucose solution 400 ml
7,5% potassium chloride solution 20 ml
25% magnesium sulphate solution 3 ml
insulin 12 units
Give it intravenously slowly, during one hour. Forced bolus infusion of potassium solutions (10-15 ml) can bring cardiac arrest.
Potassium level over 5,2 mmol/l is a state called hyperkalemia. To treat this condition use calcium gluconate or calcium chloride solutions (10 ml of 10% solution intravenously), glucose and insulin solution, saluretics, steroids, sodium bicarbonate solution. Hyperkalemia over 7 mmol/l is an absolute indication for dialysis.
Sodium is the main extracellular cation. Its normal plasma concentration is 135-155 mmol/l. Daily required amount of potassium is 2 mmol/kg of body weight.
Sodium concentration which is lower than 135 mmol/l is known as hyponatraemia. This condition is caused by sodium deficiency or water excess. Sodium deficiency is calculated according to the formula:
Nad= (140-Nap)*0,2 BW,
Na- sodium deficiency, mmol;
Nap – sodium concentration of the patient mmol/l;
0,2*BW – extracellular fluid volume, l.
To treat it use normal saline (1000 ml contains 154 Na mmol) or 5,8% solution of sodium chloride – your choice will depend on osmotic concentration.
Sodium concentration over 155 mmol/l is a state called hypernatremia. This condition usually appears in case of hypertonic dehydration or hypertonicoverhydration. Treatment was described in the text above.
Chlorine is the main extracellular anion. Its normal plasma concentration is 98-107 mmol/l. Daily requirement of chlorine is 215 mmol.
Hypochloremia is a condition of decreased plasma chlorine concentration (less than 98 mmol/l).
Chlorine deficiency is calculated according to the formula:
Cld = (100-Clp)*0,2 BW,
Cld- chlorine deficiency, mmol
Clp – plasma chlorine concentration of the patient, mmol/l
0,2*BW – extracellular fluid volume, l.
To treat hypochloremia use normal saline (1000 ml contains 154 mmol of chlorine) or 5,8% sodium chlorine solution (1 ml contains 1 mmol of chlorine). The choice of solution depends on the osmotic concentration of the plasma.
Hyperchloremia is a condition of increased chlorine concentration (over 107 mmol/l). Intensive therapy of this state includes treatment of the disease, which caused it (decompensated heart failure, hyperchloremic diabetes insipidus, glomerulonephritis). You can also use glucose, albumin solutions and dialysis.
Magnesium is mostly an intracellular cation. Its plasma concentration is 0,8-1,5 mmol/l. Daily requirement of magnesium is 0,3 mmol/kg.
Hypomagnesemia is a state of decreased magnesium concentration: less than 0,8 mmol/l. Magnesium deficiency is calculated according to the formula:
Mgd =(1,0 - Mgp)*0,6BW,
Mgd - magnesium deficiency, mmol
Mgp – plasma magnesium concentration of the patient, mmol/l
0,6*BW – extracellular fluid volume, l.
Use 25% magnesium sulphate solution to treat this state (1 ml of it contains 0,5 mmol of magnesium).
Hypermagnesemia is a state of increased magnesium concentration (more than 1,5 mmol/l). This condition appears usually in case of hyperkalemia and you should treat it as you treat hyperkalemia.
Calcium is one of the extracellular cations. Its normal concentration is 2,35-2,75 mmol/l. Daily requirement of calcium is 0,5 mmol/kg.
Calcium concentration less than 2,35 mmol/l is called hypocalcemia. Calcium deficiency is calculated according to the formula:
Cad = (2,5-Cap)*0,2 BW,
Cad – calcium deficiency, mmol
Clp – plasma calcium concentration of the patient, mmol/l
0,2*BW – extracellular fluid volume, l.
To treat this state use 10% calcium chloride (1 ml of the solution contains 1,1 mmol of calcium), ergocalciferol; in case of convulsions prescribe sedative medicines.
Hypercalcemia is a condition with increased calcium concentration (over 2,75 mmol/l). Treat the disease, which caused it: primary hyperparathyroidism, malignant bone tumors, etc. Additionally use infusion therapy (solutions of glucose with insulin), steroids, dialysis and hemosorbtion.
Acid-base imbalance and its treatment.
There are 2 main types of acid-base imbalance: acidosis and alkalosis.
pH is a decimal logarithm of the reciprocal of the hydrogen ion activity. It shows acid-base state of the blood.
Normal pH of arterial blood is 7,36-7,44. Acid based imbalance is divided according to the pH level into:
pH 7,35-7,21 – subcompensated acidosis
pH < 7,2 – decompensated acidosis
pH 7,45-7,55 – subcompansated alkalosis
pH > 7,56 – decompensated alkalosis
Respiratory part of the acid-base imbalance is characterized with pCO2. Normally pCO2 of arterial blood is 36-44 mm Hg. Hypercapnia (pCO2 increased over45 mm Hg) is a sign of respiratory acidosis. Hypocapnia (pCO2 less than 35 mm Hg) is a symptom of respiratory alkalosis.
Basis excess index is also a characteristic of metabolic processes. Normally H+ ions produced during metabolic reactions are neutralized with buffer system. BE of arterial blood is 0±1,5. Positive value of BE (with +) is a sign of base excess or plasma acid deficiency (metabolic alkalosis). Negative value of BE (with -) is a symptom of bases deficiency, which is caused by acid neutralization in case of metabolic acidosis.
Respiratory acidosis (hypercapnia) is a condition caused by insufficient elimination of CO2 from the body during hypoventilation. Laboratory tests show:
pCO2a > 46 mm Hg
BE - normal values
However when the respiratory acidosis progresses renal compensation fails to maintain normal values and BE gradually increases. In order to improve this condition you should treat acute and chronic respiratory violations. When pCO2 is over 60 mm Hg begin artificial lung ventilation (through the mask or tube; when the necessity of ventilation lasts longer than 3 days – perform tracheostomy).
Respiratory alkalosis (hypocapnia) is usually an effect of hyperventilation, caused by excessive stimulation of respiratory centre (injuries, metabolic acidosis, hyperactive metabolism, etc.) or wrong parameters of mechanical ventilation. Gasometry shows:
pCO2a <33 mm Hg
BE < +1,5 mmol/l.
However prolong alkalosis brings decrease of BE due to compensatory retain of H+ ions. To improve this imbalance treat its reason: normalize ventilation parameters; if patients breathing has rate over 40 per minute – sedate the patient, perform the intubation and begin artificial ventilation with normal parameters.
Metabolic acidosis is characterized with absolute and relative increase of H+ ions concentration due to acid accumulation (metabolic disorders, block of acid elimination, excessive acid consumption in case of poisonings, etc.). Laboratory tests show:
pCO2a < 35 mm Hg
BE (-3) mmol/l.
Treat the main reason of acid-base disorder: diabetic ketoacidosis, renal insufficiency, poisoning, hyponatremia or hyperchloremia, etc. Normalize pH with 4% sodium bicarbonate solution. Its dose is calculated according to the formula:
V- volume of sodium bicarbonate solution, ml
BE – bases excess with “-”, mmol/l
BW – body weight, kg
Metabolic alkalosis is a condition of absolute and relative decrease of H+ ions concentration. Blood tests show:
pCO2a normal or insignificantly increased (compensatory reaction)
BE 3,0 mmol/l.
To treat this condition use “acid” solutions, which contain chlorides (saline, potassium chloride). In case of kaliopenia give potassium solutions.
Respiratory and metabolic imbalances can mix in case of severe decompensated diseases due to failure of compensatory mechanisms. Correct interpretation of these violations is possible only in case of regular and iterative gasometry blood tests.
Calculate the total body water volume and its extracellular and intracellular volumes of the Patience, the patient of 48 years and body weight 88 kg.
Patience, the patient of 23 with body weight 70 kg has sodium level 152 mmol/l and hematocrit 0,49 l/l. Name the type of water balance disorder.
Patience, the patient of 54 with body weight 76 kg has sodium level 128 mmol/l. Calculate the volume of saline and 7,5% sodium chloride solution necessary for the treatment of this condition.
Patience, the patient of 60 with body weight 60 kg has sodium level 140 mmol/l and hematocrit 0,55 l/l. Name the type of disorder and prescribe infusion therapy.
Patience, the patient of 42 with body weight 80 kg has potassium level 2,6 mmol/l. Calculate the volume of 4% potassium chloride solution necessary for treatment of this condition.
Patience, the patient of 33 with body weight 67 kg and diagnosis “gastric ulcer, complicated with pylorostenosis” has potassium concentration 3 mmol/l, chlorine concentration 88 mmol/l. pH 7,49, pCO2a 42 mm Hg, BE + 10 mmol/l. Name the type of disorder.
Patience, the patient of 50 with body weight 75 kg, was transported to the admission unit of the hospital with: unconsciousness, cyanotic skin, low blood pressure, shallow breathing. Blood tests show: pH 7,18, pCO2a 78 mm Hg, pO2A – 57 mm Hg, BE -4,2 mmol/l. Name the type of acid-base disorder and prescribe treatment.
Patience, the patient with body weight 62 kg and renal insufficiency has: potassium concentration 5,2 mmol/l, sodium concentration 130 mmol/l, calcium concentration 1,5 mmol/l, pH 7,22, pCO2a 34 mm Hg, BE -9,2 mmol/l. Name the type of disorder.