Внезапная остановка сердца: техника проведения дефибрилляции

Аmerican Нeart Аssociation с 2001 года рекомендует обязательно размещать автоматические внешние дефибрилляторы  9АВД) в публичных общественных местах, учреждениях, офисах, предприятиях. Европейское сообщество кардиологов и Европейский совет реаниматологов в 2002 году единогласно подтвердили главную роль автоматического внешнего дефибриллятора в решении проблемы внезапной кардиальной смерти.
В странах Европы разработаны и реализуются программы внедрения АВД, обучение дефибрилляции и приемам сердечно-легочной реанимации немедицинского персонала - людей, не медиков, которые могут оказаться около потенциальной жертвы внезапной остановки сердца. Правительствами стран Европы и Америки было объявлено решение проблемы внезапной кардиальной смерти стратегически важным заданием 2002-2005 годов. Подтверждением этого является разработка и законодательное утверждение правительствами стран Европы и США рекомендаций по оснащению автоматическими внешними дефибрилляторами разных учереждений и общественных мест. В мае 2004 года Федеральные агенства органов самоуправления (США) приказали установить на всех внутренних авиалиниях автоматические внешние дефибрилляторы. С декабря 2004 года каждый международный самолет любой страны без дефибриллятора на борту не имеет права приземлиться на територии США. В соответствии с рекомендациями АНА (American Heart Association), 40 % патрульных полицейских машин в США оснащено АВД. Каждый автомобиль скорой помощи, парамедиков, спасателей оснащены АВД. С 2002 года АВД обязательно устанавливается в каждой государственной школе штата Нью-Йорк. США более 50 % государственных учреждений оснащено АВД.
Правительство Великобритании выступило с инициативой реализации программы установки АВД в общественных местах и обучения персонала их эффективному использованию. Планируется установить оборудование в залах торговых центров, железнодорожных и автовокзалах, аэропортах, отелях, концертных залах, школах. По мнению британских экспертов, инициатива правительства позволит сберечь тысячи жизней в ближайшие 10 лет. В Венгрии  у всех частных врачей есть АВД. Был принят закон по оснащению АВД каждого здания всех лечебных учереждений. В Германии все крупные предприятия оснащены АВД.

Статистические данные выживания пациентов с внезапной кардиальной смертью за пределами медицинских учреждений:

- в учреждениях и публичных местах, без оснащения АВД - 5 %
- в учреждениях, оснащенных АВД:
  • места для отдыха (концертные залы, казино, рестораны и т.п.) - 74%
  • на борту самолетов и в аэропортах - 40..60 %
  • на рабочих местах (в офисах, министерствах, ведомствах и др.) - 52 %


Время до первого разряда (минут)Коэффициент выживания (%)
Традиционная скорая помощь10меньше 10
Пожарные службы640
Полиция550
Дефибрилляция... на месте3больше 70


В соответствии с таблицей, среднее время прибытия скорой помощи в такой экономически развитой стране, как США, 8 - 12 минут. Таким образом, только наличие АВД может спасти жизнь от внезапной кардиальной смерти.
Американские эксперты считают реальным спасение 15000 жизней в год на 20 млн. населения страны при достаточном оснащении автоматическими внешними дефибрилляторами публичных общественных мест и немедицинских учреждений, а также при широком оснащении и дооснащении медицинских учреждений.
Таким образом, в Украине ориентировочный прогноз спасения жизней при возникновении внезапной кардиальной смерти в общественных местах может составлять около 30 - 50 тысяч людей в год, при достаточном оснащении АВД общественных мест, учреждений

Увеличить выживаемость больных, перенесших остановку кровообращения на догоспитальном этапе, можно, если удаётся быстро: вызвать скорую помощь, начать сердечно-лёгочную реанимацию (СЛР), провести дефибрилляцию, а затем обеспечить квалифицированную терапию. Эти 4 звена были включены в концепцию «цепочки выживания» («chain of survival»), сформулированную в начале 90-х годов прошлого столетия экспертами Американской Кардиологической Ассоциации (AHA). Первые 3 звена «цепочки выживания» являются этапами современной «базовой» СЛР. Замедление проведения любого звена приводит к ухудшению результатов в целом.
Первым звеном «цепочки выживания» является необходимость быстрого прибытия к больному обученных людей, имеющих необходимое оборудование (прежде всего дефибриллятор). На этом этапе большое значение имеет уровень образованности населения и наличие эффективной системы служб экстренной медицинской помощи (наличие дефибриллятора). Принципиально важная роль второго звена: ранняя СЛР. Быстрое начало реанимации (пока отсутствует дефибриллятор) замедляет трансформацию ФЖ в асистолию, увеличивает шанс успешной дефибрилляции и выживаемости. Кроме того, быстрое начало массажа сердца и вентиляции лёгких уменьшает в постреанимационном периоде дисфункцию сердца и мозга. Установлено, что при раннем начале СЛР насосную функцию фибриллирующего сердца можно поддерживать на 10 минут дольше и, таким образом, продлить жизнь пострадавшего до прибытия обученных специалистов.
Самым важным (ключевым) звеном «цепочки выживания» является ранняя дефибрилляция. Концепция ранней дефибрилляции (идеально, в первые 2—4 мин ФЖ) была сформулирована экспертами AHA. Основные принципы, на которых базируется концепция ранней дефибрилляции:

1) Самой частой причиной засвидетельствованной остановки кровообращения является ФЖ;
2) Единственный эффективный метод ее устранения - электрическая дефибрилляция;
3) Через несколько минут ФЖ может трансформироваться в асистолию;
4) Уже в первые минуты остановки кровообращения вероятность вероятность успешной реанимации быстро снижается.

Первоначально во внебольничных условиях дефибрилляцию в Западной Европе и США проводили только медицинские работники или парамедики, которые использовали обычные дефибрилляторы-мониторы с ручным управлением. С 1979 г. в США стали применять автоматические наружные дефибрилляторы (AED), которые достаточно точно анализируют сердечный ритм и, если необходимо, дают совет или сами наносят электрический разряд. С внедрением автоматических внешних дефибрилляторов в практику догоспитальной реанимации стало возможным использовать данные аппараты не только медицинскими работниками, но и людьми, не имеющими специального медицинского образования и не прошедшими длительных курсов обучения СЛР. Широкое использование автоматических внешних дефибрилляторов вне больницы минимально обученными людьми без медицинского образования легло в основу концепции «общедоступной дефибрилляции» («public access defibrillation»). На основании данной концепции были разработаны программы использования автоматических внешних дефибрилляторов в США и Европе.
В Европе программа широкого использования автоматических внешних дефибрилляторов на догоспитальном этапе, внедрена в Великобритании, Нидерландах, Скандинавии, Германии и Бельгии. Многочисленные экспериментальные и клинические данные подтверждают, что ранняя дефибрилляция может и должна быть стандартной процедурой в медицинской практике. Обнадеживающие результаты были получены при обеспечении дефибрилляторами полицейских машин, гражданских самолётов и бригад спасателей - добровольцев, работающих в местах скопления людей (предприятия торговли, места отдыха и т. д.).
Концепция «домашнего доктора». Актуальность данной концепции связана с тем, что около 70% от всех случаев внезапной смерти наступает дома. Впервые использование автоматических внешних дефибрилляторов в домашних условиях было предпринято в 1984 г. в США. Наряду с этим широкое использование автоматических внешних дефибрилляторов в больницах, поликлиниках и других медицинских учреждениях позволит увеличивать выживаемость больных с внутригоспитальной внезапной смертью.
Современный автоматический внешний дефибриллятор — это компьютеризированный, надёжный и простой в управлении малогабаритный аппарат, помогающий спасателю (как с медицинским, так и без медицинского образования) оценивать ритм, проводить дефибрилляцию и СЛР. Одна из главных функций автоматического внешнего дефибриллятора — анализ ритма сердца. Анализ ритма осуществляется с помощью специальной программы (алгоритма) распознавания ФЖ и других аритмий. После электрокардиографической регистрации ритма алгоритм автоматического внешнего дефибриллятора выбирает одну из двух возможных ситуаций: наносить или не наносить электрический разряд. Если дефибриллятор полностью автоматический, он самостоятельно наносит или не наносит разряд; полуавтоматический — даёт только совет в виде голосового сообщения и/или выводит информацию на экран монитора. Автоматический внешний дефибриллятор может также известить о возможном артефакте, возникшем на электрокардиограмме. Полностью автоматический дефибриллятор применяется в специальных условиях (например, в отделениях неотложной кардиологии, когда аппарат находится у постели больного с высоким риском развития ФЖ при желудочковой тахикардии (ЖТ) без пульса. В некоторых моделях автоматических внешних дефибрилляторов имеется ручной режим управления аппаратом.

Техника дефибрилляции
Успешность реанимационных мероприятий в значительной степени зависит от ранней ЭКГ диагностики (электрокардиограф или монитор дефибриллятора) механизма остановки кровообращения, поскольку это определяет дальнейшую тактику реанимационных мероприятий.
В реаниматологической практике для оценки ЭКГ используют II стандартное отведение, позволяющее дифференцировать мелковолновую фибрилляцию желудочков от асистолия.
Нередко при регистрации ЭКГ с электродов дефибриллятора ФЖ может выглядеть как асистолия. Поэтому во избежание возможной ошибки необходимо изменить расположение электродов, перемещая их на 90° относительно первоначального расположения. Следует также отметить, что во время сердечно-лёгочной реанимации нередко на монитор появляются различного рода помехи (электрические; связанные с неконтролируемыми движениями больного во время транспортировки и т.д.), которые могут существенно искажать ЭКГ.
Выделяют 3 основных механизм остановки кровообращения: электрическую активность без пульса (ЭАБП), включающую в себя электромеханическую диссоциацию и тяжйлую брадиаритмию (клинически брадиаритмия проявляется при ЧСС <45 уд.,мин. у больного человека и при ЧСС <30 уд./мин. у здорового), фибрилляцию желудочков или желудочковую тахикардию без пульса (ФЖ/ЖТ без пульса) и асистолию.

Показания к проведения электрической дефибрилляции сердца:

1) Желудочковая тахикардия без пульса. ЖТ без пульса характеризуется деполяризацией кардиомиоцитов желудочков с высокой частотой. На ЭКГ отсутствуют зубцы Р и отмечаются широкие QRS-комплексы (рис. 1).
2) Фибрилляция желудочков. Фибрилляция желудочков характеризуется хаотическим, асинхронными сокращениями кардиомиоцитов с наличием на ЭКГ нерегулярных, с частотой 400-600 /мин., низко-, средне- или крупноамплитудных колебаний (рис. 2).
При ФЖ/ЖТ без пульса рекомендуется как можно раннее проведение дефибрилляции (Класс I), т.к. с ее задержкой, вероятность успешной дефибрилляции уменьшается на 10 % каждую минуту. Уровень выживаемости пациентов, которым была проведена дефибрилляция, в первые 3 минуты с момента остановки кровообращения, составляет 74 %. В современном алгоритме дефибрилляции Европейского Совета по реанимации 2005 г. (ERC2005) рекомендуется проведение 1 начального разряда, в замен стратегии трех последовательных разрядов ранних рекомендаций ERC2000. В случае не восстановления самостоятельного кровообращения проводят базовый комплекс СЛР в течение 2 минут. После чего проводят второй разряд, и в случае не эффективности цикл повторяют.
Энергия первого разряда, которая рекомендуется в настоящее время ERC2005, должна составлять для монополярных дефибрилляторов 360 Дж как и все последующие разряды по 360 Дж. Что способствует большей вероятности деполяризации критической массы миокарда. Начальный уровень энергии для биполярных дефибрилляторов должен составлять 150-200 Дж, с последующей эскалацией энергии до 360 Дж при повторных разрядах. С обязательной оценкой ритма после каждого разряда.

РАЗРЯД —► СЛР В ТЕЧЕНИЕ 2 МИН —► РАЗРЯД —► СЛР В ТЕЧЕНИЕ 2 МИН...

Смысл дефибрилляции заключается в деполяризации критической массы миокарда, приводящей к восстановлению синусового ритма естественным водителем ритма (т.к. клетки пейсмекера синусового узла является первыми клетками миокарда, способными деполяризоваться спонтанно). Уровень энергии первого разряда, является компромиссом между его эффективностью и повреждающим воздействием на миокард. Только 4% трансторакального тока проходит через сердце, а 96% - через остальные структуры грудной клетки. Было показано, что проведение дефибрилляции у пациентов с пролонгированной нелеченной ФЖ почти в 60 % конвертирует ритм в ЭАБП/асистолию. Вторичная постконверсионная ЭАБП/асистолия в сравнении с первичной, имеет более неблагоприятный прогноз и низкий уровень выживаемости (0 - 2%). Кроме того, дефибрилляция разрядами с высокой энергией вызывает повреждение миокарда и развитие постреанимационной миокардиальной дисфункции.
В случае, если до момента проведения электрической дефибрилляции при ФЖ/ЖТ без пульса прошло более 4-5 минут, в функциональном состоянии кардиомицитов происходят нарушения вследствие снижения содержания в миокарде АТР, гиперпродукции лактата и внеклеточной аккумуляции Na+, что ведет к снижению сократительной функции миокарда. Поэтому проведение дефибриляции в этом случае может неблагоприятно влиять на миокард и резко снижать эффективность проводимой дефибрилляции, поскольку дополнительное нанесение разряда дефибрилляции, пациенту находящемуся в состоянии гипоксии, может вызвать дополнительное электроповреждение структур миокарда.
В этой связи, согласно последних рекомендаций, в случае пролонгирования ФЖ/ЖТ без пульса > 4-5 мин., начальное проведение компрессии грудной клетки в течении 2 мин., с последующим проведение электрической дефибрилляции.
Эффективность и безопасность электрической дефибрилляции зависит от целого ряда кардиальных и экстракардиальных факторов.

Среди экстракардиальных факторов можно выделить следующие:

1) Ведущее место принадлежит форме электрического импульса - для проведения успешной дефибрилляции биполярным импульсом (по сравнению с монополярным), требуется примерно в 2 раза меньше энергии (максимально выделяемая на пациента энергия составляет, соответственно, 200 Дж для бифазного и 400 Дж монофазного разрядов). Согласно последним данным успех дефибрилляции импульсом биполярной синусоидальной формы <115 Дж составляет 92% (В.А. Востриков и соавт, 1998). Следовательно, только 8% больных требовалась энергия 150-200 Дж. В то же время суммарная эффективность импульса монополярной формы в зависимости от вида ФЖ составляет при энергии разряда 200 Дж 60-90% или в среднем около 70% (Gascho J.H соавт, 1997; Dalzell G. и соавт. 1991). В связи с этим многим больным приходится наносить высокоэнергетические разряды монополярной формы (300-360 Дж). Следует отметить, что это преимущественно пациенты с вторичной ФЖ, которая развивается на фоне сердечной недостаточности и нередко характеризуется рецидивирующим течением. Как показали исследования J. Gascho и соавт. (1979) и R. Kerber и соавт. (1998-1990), у больных с выраженной сердечной патологией выделяемая энергия повторных разрядов более 240 Дж (3,5 Дж/кг) приводит не к увеличению, а наоборот к снижению эффективности дефибрилляции. Преимущества биполярной формы дефибриллирующего импульса изложены в главе 6 настоящих рекомендаций.

2) Вторым важным фактором влияющим на эффективность дефибриляции является правильное расположение электродов на грудной клетке. Поскольку только 4% трансторакального тока проходит через сердце, а 96% - через
остальные структуры грудной клетки, поэтому очень важным является адекватное их расположение (рис. 16).
При передне-переднем расположении, один электрод устанавливается у правого края грудины под ключицей, второй латеральнее левого соска по срединно-подмышечной линии (рис. 17А). При передне-заднем расположении, один электрод устанавливается медиальнее левого соска, другой под левой лопаткой (рис. 17Б).
Если у пациента имеется имплантированный кардиостимулятор, электроды дефибриллятора должны находится от него на расстоянии около 6-10 см.

3) Третим фактором влияющим на эффективность дефибрилляции является сопротивление грудной клетки или трансторакальное сопротивление. Явление трансторакального импеданса (сопротивления) имеет важное клиническое значение, так как именно оно объясняет разницу энергий Tqjca между набираемой на шкале аппарата и выделяемой на пациента. Если при реанимации имеют место факторы, существенно повышающие трансторакальный импеданс, то вполне вероятно, что при установленной на шкале дефибриллятора энергии 360 Дж ее
реальное значение может составить на миокарде в лучшем случае 10% (т. е. 30-40) Дж.
Трансторакальное сопротивление зависит от массы тела и в среднем составляет 70-80 Ом у взрослого человека. Для уменьшения трансторакального сопротивления дефибрилляцию необходимо проводить в фазу выдоха, т.к. трансторакальное сопротивление в этих условиях снижается на 16 %, оптимальным считается усилие, прикладываемое на электроды равное 8 кг для взрослых и 5 кг для детей в возрасте 1-8 лет. Однако 84% снижения трансторакального сопротивления приходится на обеспечение хорошего контакта границы между кожей и электродами за счет применения токопроводящих растворов. Необходимо подчеркнуть, что использование «сухих» электродов существенно снижает эффективность дефибрилляции и вызывает ожоги. Для уменьшения электрического сопротивления грудной клетки применяют специальные самоклеющиеся прокладки для электродов, электропроводный гель или марлю, смоченную гипертоническим раствором. В крайней ситуации поверхность электрода можно просто смочить любым токопроводящим раствором (водой).
Нами было проведено изучение величины трансторакального сопротивления при наложении электродов дефибриллятора на сухую кожу и с использовании различных токопроводящих растворов (рис. 3). В результате было получено, что наиболее оптимальным является гипертонический раствор NaCL 10 % концентрации.
Густой волосяной покров на грудной клетке обуславливает плохой контакт электродов с кожей пациента, и повышает импеданс, снижая т.о. эффективность наносимого разряда, а также повышает риск возникновения ожогов. Поэтому желательно побрить область наложения электродов на грудную клетку. Однако в ургентнои ситуации при проведении дефибрилляции это не всегда возможно. В случае же проведения плановой кардиоверсии это условие должно быть выполнено обязательно.

4) Оптимальный диаметр электродов 11-12 см. В настоящее время во многих странах используются так называемые мягкие "наклеиваемые" электроды. Последние имеют целый ряд преимуществ, по сравнению с общепринятыми жесткими электродами: обеспечивают хороший контакт кожа-электрод, освобождают руки реаниматора, уменьшая тем самым так называемые "интервалы выключенных рук", и позволяют непрерывно мониторировать ЭКГ.
Таким образом, обязательное выполнение в клинической практике прежде всего трех основных условий: правильного расположения электродов, силы приложения электродов в пределах 8 кг и обязательного использования прокладок смоченных гипертоническим раствором, являются важными условиями обеспечивающими эффективность проводимой электрической дефибриляции.
Во время дефибрилляции никто из участников реанимации не должен касаться кожных покровов больного (и/или его кровати).

Наиболее частые ошибки во время проведения дефибрилляции:

а) неправильное расположение электродов (в частности у женщин на левой груди необходимо непосредственно под ней);
б) плохой контакт кожа-электрод;
в) использование электродов маленького диаметра (8 см).

Предупреждение повторного возникновения ФЖ является одной из первоочередных задач после восстановления эффективной сердечной деятельности. Профилактическая терапия рецидивирующей ФЖ должна быть по возможности дифференцированной. Количество разрядов для устранения рефрактерной (особенно быстро рецидивирующей) ФЖ не ограничено, если реанимационные мероприятия начаты своевременно и остается надежда на восстановление сердечной деятельности.
До последнего времени лидокаин считали препаратом первого выбора для профилактики и лечения ФЖ. Однако в настоящее время проспективные исследования не выявили однозначных данных о его достаточной эффективности именно для этих целей. Получены данные, свидетельствующие о том, что у больных с устойчивой ФЖ лидокаин, вводимый во время реанимации, увеличивал на догоспитальном этапе процент спонтанного восстановления кровообращения и госпитализации, но не приводил к увеличению процента выписки больных из госпиталя. Ряд других крупных исследований свидетельствует о часто встречающихся побочных эффектах и даже увеличении летальности при остром
ИМ от асистолии.
В настоящее время нет достаточных оснований считать лидокаин полезным дополнением к электрической дефибрилляции. Вместе с тем получены данные о том, что альтернативой лидокаину является амиодарон (кордарон), который рекомендуют вводить при ранней дефибрилляции (1-2 мин ФЖ), если не эффективены первые три разряда, в дозе 300 мг в/в струйно однократно после первой дозы адреналина (больший успех оживления по сравнению с лидокаином); кордарон рекомендуется вводить при рецидивирующей ФЖ с периодами гемодинамически эффективного ритма (введение амиодарона, если это необходимо, можно повторить в дозе 150 мг) у больных с тяжёлой дисфункцией миокарда левого желудочка амиодарон, по сравнению с другими антиаритмиками предпочтительней; он в этих случаях или более эффективен, или менее аритмогенен.
У больных с обширным инфарктом миокарда, осложненным кардиогенным шоком или отеком легких, а также у больных с тяжелой хронической сердечной недостаточностью устранение ФЖ часто сопровождается ее быстрым рецидивированием или развитием выраженной брадикардии и асистолии, а также электромеханической диссоциации. Наряду с этим отмечаются случаи рефрактерной (персистирующей) ФЖ, которая не устраняется повторными разрядами дефибриллятора (более 3-4 разрядов при условии правильной методики дефибрилляции).
К основным патогенетическим факторам, приводящим к развитию рефрактерной или быстро рецидивирующей ФЖ относят: метаболический ацидоз; респираторный алкалоз; необоснованное или избыточное введение бикарбоната натрия, сопровождающееся нередко парадоксальным увеличением внутриклеточного гиперкарбического ацидоза); гипокалиемия и гипомагниемия (часто встречается у больных с сердечной недостаточностью и/или мерцательной аритмией, а также у больных алкоголизмом); чрезмерная экзо- и эндогенная симпатическая или, наоборот, парасимпатическая стимуляция сердца, приводящая, соответственно, к развитию префибрилляторных тахи- или брадикардии. Наиболее часто встречаются состояния, связанные с чрезмерной симпатической стимуляцией (например передозировка симпатомиметиков или кокаина; последний, стимулируя симпатическую нервную систему, может приводить к некрозу субэндокардиальных участков миокарда и острому тромбозу коронарных артерий.
Следует отметить, что после разрядов (особенно максимальных значений) нередко на экране монитора в течение нескольких секунд регистрируется "изоэлектрическая" линия. Обычно это следствие быстро преходящего "оглушения" высоковольтным разрядом электрической активности сердца. В данной ситуации "изоэлектрическую" линию не следует расценивать как асистолию, т.к. вслед за ней появляется координированный ритм или продолжается ФЖ. В то же время, если на мониторе после дефибрилляции появилась "прямая" линия продолжительностью больше 5 с (визуально это больше ширины экрана монитора дефибриллятора), необходимо в течение 2 мин провести СЛР и затем оценить ритм и пульс. Если продолжает сохраняться асистолия или регистрируется какой-либо другой ритм без пульса (но не ФЖ/ЖТ), следует ввести новую дозу адреналина и еще в течение 2 мин провести СЛР, затем повторно оценить ритм и пульс. Дальнейшая тактика реанимации будет зависеть от вида электромеханической активности сердца: устойчивая (персистирующая) асистолия, ее трансформация в ФЖ7ЖТ, развитие ЭМД или гемодинамически эффективного ритма.
Основной критерий потенциально успешной реанимации и полноценного восстановления больных - ранняя дефибрилляция, т.е. в течение первых минут ФЖ, при условии, что массаж сердца и искусственное дыхания начаты не позднее 1-2 мин от момента остановки кровообращения. При отсутствии выраженной гипоксии миокарда и/или его тяжелых повреждений одна лишь дефибрилляция, проведенная в течение 1-2 мин от начала ФЖ, способна привести к восстановлению эффективной работы сердца. В связи с этим оправдана методика "слепой" дефибрилляции. Идеальный вариант дефибриллировать сердце не позднее к 90-120 с, т.к., даже, несмотря на хорошо проводимую СЛР, с этого периода начинает прогрессивно нарастать внутримиокардиальный ацидоз и снижаться успех оживления.
Современные дефибрилляторы с интегрированной функцией "компенсации" влияния импеданса позволяют нанести на область сердца разряд, близкий установленному пользователем. Приборы с данной технологией определяют межэлектродное сопротивление непосредственно, перед или в момент нанесения импульса и затем, в зависимости от значений импеданса, устанавливают необходимую величину напряжения, для того чтобы реальная энергия разряда оказалась близкой к установленной на шкале дефибриллятора.

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