Mechanism of action and criteria for effectiveness
The main physiological purpose of this manipulation is to mechanically substitute the pumping function of the myocardium. Artificially creating cardiac output ensures oxygen delivery to tissues and prevents cell death.
During resuscitation, it is crucial to continuously evaluate its effectiveness. There are three main criteria for effectiveness indicating that blood flow has been restored to at least the minimum acceptable level:
- Ocular response: the patient exhibits distinct pupillary constriction.
- Pulsation of major vessels: a pulse begins to be palpable in the carotid and femoral arteries, which must occur strictly synchronously with chest compressions.
- Improvement in microcirculation: there is a noticeable decrease in cyanosis (bluish tint) and pronounced skin pallor.
Closed-chest (indirect) cardiac massage
This type of resuscitation is basic and primarily used at the pre-hospital stage.
The mechanism of action is based on anatomical features: physical compression of the heart occurs between the mobile sternum anteriorly and the rigid spine posteriorly. For this mechanism to work, strict conditions must be met: the victim must be on a completely hard surface. If the patient is lying on a soft bed, a rigid board must be placed under their chest.
Technique for performing closed-chest massage:
- Point of force application: the lower third of the sternum (strictly 2 centimeters above the xiphoid process).
- Resuscitator's hand placement: palms are placed one on top of the other at a right angle.
- Compression mechanics: compressions are performed exclusively with arms straightened at the elbow joints. The rescuer must use the weight of their entire body, not just arm muscle strength.
- Force and depth: it is necessary to apply a force equivalent to 8–9 kg, which ensures sternal displacement (compression depth) of 4–5 cm.
- Rate: the rhythm of compressions must be exactly 60 per minute.
Peculiarities of performing in children
Pediatric age requires significant modification of the technique due to smaller body size, high chest elasticity, and a physiologically higher baseline heart rate.
Depending on age, the following technical features are distinguished:
- Children under 10 years old: massage is performed with only one hand to prevent excessive compression and injury. The compression rate increases to 80 strokes per minute.
- Neonates: compressions are performed using only two fingers (usually the 2nd and 3rd fingers of the hand). The fingers must be positioned strictly parallel to the sagittal plane of the infant's sternum. The compression rate at this age reaches its maximum — 120 compressions per minute.
Open-chest (direct) cardiac massage
This complex invasive technique is used in a hospital setting when the closed method is physically impossible or has proven ineffective.
Main indications for switching to direct massage:
- Performing surgical interventions directly on thoracic organs.
- Presence of multiple rib fractures in the patient, compromising the rigidity of the chest cage.
- Pronounced anatomical chest deformations that prevent normal compression.
- Confirmed ineffectiveness of properly performed closed-chest massage.
Technique and surgical approach: The manipulation requires opening the chest. The standard approach is through the left IV intercostal space.
Following thoracotomy, the surgeon's hand is introduced directly into the thoracic cavity. Four fingers are carefully placed under the lower surface of the heart, and the thumb is placed on its anterior surface. The organ undergoes rhythmic manual compression. If a wide surgical approach is available, the physician can use both hands for compression.
Critically important note: if the patient has cardiac tamponade (accumulation of fluid preventing relaxation), the pericardium must be opened prior to beginning manual compressions.
Briefly: answers to topical questions
What is the sequence of resuscitation measures according to the BLS protocol during cardiac massage?
The sequence of steps in cardiopulmonary resuscitation includes primary assessment, airway management, and the cyclic performance of compressions with artificial ventilation.
- Initial actions — establishing the diagnosis of cardiac arrest, clearing the oral cavity, and initial ventilation (4 breaths into the lungs).
- Cycle for a single rescuer — alternating 15 chest compressions with 2 breaths into the lungs.
- Cycle for two rescuers — a 1:5 ratio (one breath for every 5 compressions).
- Compression rate — chest compressions are performed at a rate strictly between 100 and 120 per minute.
- Effectiveness monitoring — assessment of vital functions (appearance of pulse and breathing) is performed strictly after every 5 complete cycles.
Rule of increasing rate by age: Adults — 60, Children — 80, Neonates — 120. The smaller the heart volume, the faster the artificial rhythm must be!
Class and exam questions
Where exactly is the hand placement point during closed-chest massage?
Hands must be positioned in the lower third of the sternum, approximately 2 centimeters above the xiphoid process.
How to quickly determine if resuscitation is effective?
The victim's pupils should constrict, skin pallor or cyanosis should decrease, and a pulse synchronous with your compressions should appear in the carotid and femoral arteries.
In which cases do you switch to open-chest cardiac massage?
In multiple rib fractures, chest deformations, during intrathoracic surgeries, or if closed-chest massage yields no effect.
How to properly perform cardiac massage on a newborn?
Using only two fingers (index and middle), positioned parallel to the sagittal plane of the sternum, at a rate of 120 compressions per minute.
What else to study on this topic
- Topographic anatomy and projection of the heart onto the anterior chest wall
- Pathophysiology and mechanisms of cardiac tamponade development
- Criteria for biological and clinical death
- Technique of left-sided thoracotomy
- Complications from incorrect execution of closed-chest cardiac massage
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