Release date: 2018-03-12

For more than half a century, cardiopulmonary resuscitation (CPR), which is dominated by chest compressions, has continued to this day and has become the protagonist of cardiac arrest (CA) patients. Due to the implementation of the traditional standard CPR (STD-CPR), there is a contraindication for chest compression, and during the implementation process, about 30% to 80% of rib or sternal fractures and osteochondral junctions lead to lung, pleural and cardiac damage. In order to limit the implementation of high-quality STD-CPR in CA patients, affecting the CPR success rate of CA patients, such a variety of abdominal pressure cardiopulmonary resuscitation (AACD-CPR) came into being.

With the in-depth clinical research and practice in recent years, Professor Wang Lixiang of the Emergency Medical Center of the Armed Police General Hospital has deeply analyzed and combed the reasons, mechanisms, methods and applications of AACD-CPR and STD-CPR in order to be more accurate. Dialectical and comprehensive grasp of the "essence" of the two, complement each other and move in the opposite direction, and improve the clinical CPR survival rate.

Reasons: Another way to "walk the road without a chest"

The modern CPR theory system was established in 1958. Guy Knickerbocker of the Johns Hopkins University in the United States and partner William Kouwenhoven found that the arterial pressure increased when the electrodes were close to the canine chest. Kouwenhoven et al. published a paper on the principle of blood circulation necessary for external compression of the chest to maintain life.

At this point, chest compressions have become an important part of STD-CPR, and together with mouth-to-mouth breathing and external shock defibrillation have opened a new era of modern CPR theory system.

However, the success rate of STD-CPR recovery is still low and the survival rate is lower. The overall survival rate of patients with global out-of-hospital cardiac arrest was not high. The neurological function rate in the United States was 10.8%, and that in China (Beijing) was only 1.0%. The reason is mainly because the patient has trauma, a variety of complex diseases and other contraindications, resulting in the inability to perform chest compressions. At the same time, when the compression is applied, sufficient strength (45~55 kg) and amplitude (5~6 cm) are required. The rescued person is prone to rib fracture, and continued compression after fracture can easily lead to fracture of the lung and pleura. At the same time, the thoracic reconstruction is limited, and it is difficult to ensure the standard pressing force and amplitude, thereby affecting the CPR effect.

Faced with so many contraindications and high fracture rates, the clinical application of STD-CPR has been greatly narrowed.

Based on this, Professor Wang’s team started from the clinical practical problems and carefully studied the classics of the Golden Jubilee. From “If it is already stiff, but gradually strengthens it, and according to its abdomen, such a sigh of relief, gas from the mouth, breathing Eyes open, but still arbitrarily set, do not work hard" to get the revelation, combined with the human physiological and anatomical basis, creatively proposed AACD-CPR.

A new approach to AACD-CPR in the "breastless path" has emerged to compensate for the lack of chest compressions in STD-CPR, and more CA patients with contraindications to chest compression have been resuscitated.

Mechanism: abdominal pump chest pump heart pump linkage to achieve stereo CPR treatment

In the case of STD-CPR, the "thoracic pump" mechanism is mainly used. The pressure in the closed thoracic cavity consisting of the diaphragm and the thorax is elevated, and the pressure is balanced to the large blood vessels in the chest, and the blood flows forward. For CA patients with clinical chest trauma, thoracic rib fracture, blood pneumothorax, thoracic deformity, aortic aneurysm and other chest compressions, the normal closed thoracic environment is broken, and the chest cavity can not be formed enough by pressing the sternum. The pump mechanism is not working properly, and STD-CPR cannot perform an effective recovery.

AACD-CPR's "abdominal pump" mechanism, that is, the chest and abdomen of the human body are separated by the diaphragm between the chest and abdomen. When the abdominal pressure is changed by pulling and pressing the abdomen, the diaphragm between the chest and abdomen is driven up and down. Movement, which in turn changes the internal volume of the chest, creates a pressure gradient inside and outside the chest, which in turn produces an artificial circulation.

Abdominal internal organs accommodated a quarter of the total systemic circulation of blood, during the process of pressing the abdomen, the amount of blood flow to the inferior vena cava increased; when lifting, coronary perfusion pressure (CPP) increased. The up and down movement of the diaphragm can directly squeeze the heart, increase the heart discharge volume and “heart pump”; it can also change the pressure of the chest cavity, and play the role of “thoracic pump” while exerting artificial respiration.

The abdominal pressure is raised through the diaphragm to produce chest and abdomen linkage, that is, the "abdominal pump" drives the "thoracic pump", and by changing the blood volume and the diaphragm to lift the heart, that is, the "abdominal pump" drives the "heart pump", through a series of joint actions, Make full use of the structural function of the body to maintain the effective circulation of the body, and play the role of CPR in the cardiopulmonary brain to achieve the same effect as STD-CPR.

Method: STD-CPR and AACD-CPR complement each other

The chest compression and ventilation ratio, the frequency of chest compressions and the depth of compression are adjusted several times to increase the pressure difference between the chest and the outside to provide effective circulating blood volume for important organs.

In the 2015 Cardiopulmonary Resuscitation Guide and Cardiovascular First Aid Guide Update, the high-quality CPR chest compression method is: the lower third of the sternum, with the left palm and the patient's chest, the two hands overlap, the left hand five fingers tilted, double The arm is straight and pressed continuously 30 times with the strength of the upper body (the compression frequency is 100~120 times/min, the compression depth is 5~6 cm of the sternal subsidence, the sternum is completely rebounded after pressing, and the interruption is minimized when the chest is pressed) .

According to the "Agreement on Abdominal Pressure Cardiopulmonary Resuscitation Experts", the AACD-CPR method is: the rescuer adopts the abdominal pressure-carrying cardiopulmonary resuscitation device, and the pressure-lifting handle of the cardiopulmonary resuscitation device is grasped by both hands, and the lifting plate is placed in the rescue. In the middle and upper abdomen, the triangular apex angle above the lifting plate is placed under the rib and the xiphoid. The opening of the vacuum device is in close contact with the skin of the rescued person, and the negative pressure device is quickly activated to tightly combine the patient's abdomen and the pressure plate. . The rescuer continuously presses down and pulls up at a frequency of 100 times/min on the side of the patient, and the time ratio of pressing and pulling is 1:1, and the vertical force is pressed when pressing down, do not swing left and right. When lifting, the vertical upward balance is applied, the pressing force is controlled at about 50 kg, and the pulling force is controlled at about 30 kg.

AACD-CPR can perform CPR with abdominal cardiopulmonary resuscitation instrument, which can overcome the limitations of STD-CPR contraindications and rib fractures, assist respiratory muscle movement to maintain a good ventilation/blood flow ratio (V/Q), and make up for STD- Defects in CPR.

Application: Synergistic use to improve CPR quality

STD-CPR emphasizes high-quality CPR including rapid, powerful compression; minimizes compression interruptions; full thoracic rebound; avoids hyperventilation.

AACD-CPR has ingeniously strengthened every aspect and laid the foundation for achieving high quality CPR.

Open airway (airway, A)

STD-CPR only removes foreign bodies in the respiratory tract, ignoring obstruction of foreign bodies such as sputum and blood clots in the lower respiratory tract.

When AACD-CPR opens the airway for the patient, pressing the abdomen increases the pressure in the abdominal cavity, moves the diaphragm up, increases the pressure in the thoracic cavity, and instantly increases the airway pressure, rapidly generating a higher exhalation flow rate to discharge the airway and lungs. The foreign matter stored in the body produces the Heimlich effect, helping the patient to open the lower respiratory tract, and clearing the foreign body in the mouth to clear the upper and lower respiratory tract.

Breathing (B)

When a single person performs a CPR operation, the STD-CPR is operated in accordance with an updated chest compression and ventilation ratio of 30:2. When the air is blown, stopping the compression causes a sudden decrease in blood flow, and the blood cannot be sufficiently oxygenated.

When AACD-CPR is used for artificial respiration, the lifting and pressing of the abdomen will cause the diaphragm to move up and down. By changing the pressure in the abdomen and thoracic cavity, the lungs can complete the inhalation and exhalation movements to achieve the effect of abdominal breathing in vitro, so as to help the patient. Establish artificial respiration support to provide oxygenation. At the same time, AACD-CPR circumvents hyperventilation (as determined by V/Q in CA patients) and provides extracorporeal abdominal respiratory support for patients with secondary CA (breathing muscle paralysis).

Artificial circulation (circulation, C)

STD-CPR's high-quality chest compression emphasizes the depth of compression, which may lead to fracture of the thoracic rib. It does not guarantee sufficient rebound of the thorax during chest compression and rapid and powerful compression. It can not produce the best CPP and greatly reduce the high quality CPR. In addition, STD-CPR can not perform subclavian arteriovenous puncture, tracheal intubation and other related operations when directly pressing the chest, affecting the quality of CPR.

AACD-CPR is a resuscitation of the chest and abdomen when the patient is in manual circulation. Lifting and pressing the abdomen can drive the increase of arteriovenous blood return, especially increase the abdominal aortic pressure, increase CPP (about 60%), increase the heart. The amount of blood discharged, establish a more effective manual circulation, combined with the artificial circulation support in the traditional CPR, the abdominal operation has less impact on the upper body puncture, tracheal intubation and other related operations, fully providing blood volume and improving the synergistic efficiency.

External defibrillation (defibrillation, D)

STD-CPR needs to stop pressing to perform external defibrillation preparation and operation. When the patient performs AACD-CPR, it does not affect the preparation of external defibrillation, minimizes the interruption of circulation, and wins valuable time for recovery.

summary

When CA patients have no contraindications for chest compression, AACD-CPR and STD-CPR techniques can be used in combination; when CA patients have contraindications for chest compressions, AACD-CPR can be used to open airways, assist in breathing, establish circulation, Putting the electrode patch to defibrillation without stopping the press can play an important role in fighting against "Death" and racing against time.

Source: New ideas for cardiopulmonary resuscitation: Abdominal pressure cardiopulmonary resuscitation, Armed Police General Hospital Emergency Medical Center, [539]. Physician, 2018-3-8 (14-15)

Source: Physician

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