Критические состояния: 4 шага "цепочки выживания" (chain of survival)

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.

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