Anesthesiology and resuscitation. Fundamentals of resuscitation Anesthesiology and resuscitation for nurses lectures orders

Anesthesiology and resuscitation: lecture notes Marina Aleksandrovna Kolesnikova

Lecture number 4. Cardiopulmonary resuscitation

Cardiopulmonary resuscitation (CPR) is a complex of surgical and therapeutic measures performed in the absence of life-threatening injuries and aimed at restoring and supporting the function of the cardiorespiratory system. Indications for cardiopulmonary resuscitation: carried out in patients with no effective pulse on the carotid arteries or a thready, weak pulse, who are unconscious and (or) in the absence of effective respiratory movements. The most common cases of primary cardiac arrest, as well as primary respiratory failure.

Contraindications: trauma incompatible with life, terminal stages of incurable diseases and biological death.

Basic principles

Primary efforts in CPR are aimed at:

1) chest compression;

2) blowing air into the lungs and ventilation;

3) preparation and administration of drugs;

4) installation and maintenance of intravenous access;

5) specialized activities (defibrillation, pacemaker installation, tracheal intubation).

Thus, to complete the full scope of activities, 4 people and a team leader are needed. One person should be in charge of CPR. This person should integrate all available information and prioritize impact. He must monitor the ECG monitor, the use of drugs and ensure that the actions of other team members are corrected. He should be removed from the performance of procedures that detract from the leadership role. For more than 40 years, the Safar resuscitation alphabet has been used for CPR. In this complex, the sequence of actions of the resuscitator is sustained; according to their English name, they are indicated by the corresponding letters.

A- Airway - ensuring the patency of the respiratory tract.

B- Breathing - artificial ventilation of the lungs (ALV) in an accessible way, for example, when breathing "mouth to mouth".

C- Circulation - ensuring hemocirculation - indirect heart massage.

D- Drugs - the introduction of drugs.

E– Electrocardiography – ECG registration.

F– Fibrilation – conducting, if necessary, electrical defibrillation (cardioversion).

G– Gauging – evaluation of primary results.

H– Hypothermy – head cooling.

I– Intensive care – intensive care of post-resuscitation syndromes.

A - Airway - airway management

The patient is placed horizontally on his back.

The head is thrown back as much as possible, for this the doctor puts one hand under the neck, the other is placed on the patient's forehead; a test breath is taken from mouth to mouth.

If a patient with reduced muscle tone lies on his back, his tongue may sink, as if packing the throat. At the same time, the epiglottis descends, further blocking the airways. Appear: sonorous breathing, then violations of the respiratory rhythm up to its complete stop. Such phenomena develop especially rapidly in patients who are unconscious.

To prevent and eliminate the retraction of the tongue, the lower jaw should be brought forward and at the same time hyperextension in the occipito-cervical joint should be performed. To do this, with the pressure of the thumbs on the chin, the lower jaw of the patient is shifted down, and then with the fingers placed at the corners of the jaw, they push it forward, supplementing this technique with overextension of the head posteriorly (triple Safar technique). With the correct and timely conduct of these manipulations, the patency of the airways at the level of the pharynx is quickly restored. Foreign bodies (blood clots, mucus, dentures, etc.) can be the cause of airway obstruction. They are quickly removed with any improvised materials (napkin, handkerchief). The patient's head should be turned to the side due to the danger of aspiration. The restoration of patency of the upper respiratory tract is facilitated by the use of various air ducts. The most appropriate is the use of an S-shaped duct. For its introduction, the patient's mouth is opened with crossed fingers II and I, and the tube is advanced to the root of the tongue so that its opening "slides" along the palate. Care must be taken to ensure that the air duct does not move during transport. If all the described procedures are not effective, then we can assume the presence of obturation of the airways in the underlying sections. In these cases, direct laryngoscopy and active aspiration of pathological secretions are required, followed by tracheal intubation for 10–15 s. It is advisable to perform conicotomy and tracheostomy.

B - Breathing - artificial lung ventilation (ALV) in an accessible way

The simplest and most effective method of artificial respiration during resuscitation is considered to be the “mouth to mouth” method, when the exhaled air of the resuscitator is blown into the lungs of the victim under pressure. Having thrown back the head of the victim, with one hand they pinch his nostrils, put the other hand under the neck, take a deep breath, tightly pressing his lips to the lips of the victim (in children, to the lips and to the nose at the same time) and blow air into the lungs of the victim, observing the rise of the chest during inhalation time. As soon as the chest rises, the air injection is stopped, they move their face to the side, they take a deep breath again, and the patient at this time has a passive exhalation.

After 2–3 inflations of the lungs, the presence of a pulse on the carotid artery is determined, if it is not detected, then they proceed to artificial restoration of blood circulation. Manual ventilation is used using a self-expanding Ambu-type bag. When using mechanical ventilation apparatus, the respiratory rate is 12–15 per minute, the inspiratory volume is 0.5–1.0 l. In a hospital, tracheal intubation is performed and the patient is transferred to a ventilator.

C-Circulation - ensuring hemocirculation– indirect heart massage

Closed heart massage is the simplest and most efficient way of emergency artificial circulatory support. Closed heart massage should be started immediately, as soon as the diagnosis of acute circulatory arrest is made, without clarifying its causes and mechanisms. In cases of ineffective heart contractions, one should not wait for a complete cardiac arrest or an independent restoration of adequate cardiac activity.

Basic rules for closed heart massage.

1. The patient should be in a horizontal position on a solid base (floor or low couch) to prevent the possibility of displacement of his body under the strengthening of the massaging hands.

2. The zone of application of the strength of the hands of the resuscitator is located on the lower third of the sternum, strictly along the midline; the resuscitator can be on either side of the patient.

3. For massage, one palm is placed on the other and pressure is applied to the sternum in the area located 3-4 transverse fingers above the place of attachment to the sternum of the xiphoid process; the hands of the massager, straightened at the elbow joints, are positioned so that only the wrist produces pressure.

4. Compression of the victim's chest is performed due to the gravity of the doctor's torso. The displacement of the sternum towards the spine (i.e., the depth of the deflection of the chest) should be 4-6 cm.

5. The duration of one chest compression is 0.5 s, the interval between individual compressions is 0.5–1 s. The pace of massage is 60 massage movements per minute. In intervals, the hands are not removed from the sternum, the fingers remain raised, the arms are fully extended at the elbow joints.

When carrying out resuscitation by one person, after two quick injections of air into the lungs of the patient, 15 chest compressions are performed, i.e. the ratio "ventilation: massage" is 2: 15. If 2 persons are involved in resuscitation, then this ratio is 1: 5, i.e., there are 5 chest compressions per breath.

A prerequisite for cardiac massage is the constant monitoring of its effectiveness. The criteria for the effectiveness of massage should be considered as follows.

1. Change in skin color: it becomes less pale, gray, cyanotic.

2. Constriction of the pupils, if they were dilated, with the appearance of a reaction to light.

3. The appearance of a pulse impulse on the carotid and femoral arteries, and sometimes on the radial artery.

4. Determination of blood pressure at the level of 60–70 mm Hg. Art. when measured at the shoulder.

5. Sometimes the appearance of independent respiratory movements.

If there are signs of restoration of blood circulation, but in the absence of a tendency to preserve independent cardiac activity, heart massage is performed either until the desired effect is achieved (restoration of effective blood flow), or until the signs of life disappear permanently with the development of symptoms of brain death. In the absence of signs of restoration of even reduced blood flow, despite heart massage for 25–30 minutes, the patient should be recognized as dying and resuscitation measures can be stopped.

D– drugs– drug administration

In case of acute cessation of blood circulation, the introduction of agents that stimulate cardiac activity should begin as soon as possible, if necessary, be repeated during resuscitation. After the start of cardiac massage, 0.5-1 ml of adrenaline should be injected as soon as possible (intravenously or intratracheally). Its repeated injections are possible after 2-5 minutes (total up to 5-6 ml). With asystole, adrenaline tones the myocardium and helps to "start" the heart, with ventricular fibrillation it contributes to the transition of small-wave fibrillation to large-wave, which greatly facilitates defibrillation. Adrenaline facilitates coronary blood flow and increases the contractility of the heart muscle.

Instead of epinephrine, isodrin can be used, which is 3 times more effective than adrenaline in terms of the effectiveness of the effect on the myocardium. The initial dose is 1–2 ml intravenously, and the next 1–2 ml in 250 ml of a 5% glucose solution. In conditions of impaired blood circulation, metabolic acidosis progressively increases, therefore, immediately after the infusion of adrenaline, a 4–5% solution of sodium bicarbonate is administered intravenously at the rate of 3 ml/kg of the patient's body weight. In the process of dying, the tone of the parasympathetic nervous system increases significantly, the brain is depleted, therefore, M-cholinolytics are used. With asystole and bradycardia, atropine is administered intravenously in a 0.1% solution - 0.5-1 ml, up to a maximum dose of 3-4 ml. To increase myocardial tone and reduce the effect of hyperkalemia, intravenous administration of 5 ml of a 10% solution of calcium chloride is recommended. Adrenaline, atropine and calcium chloride can be administered together in the same syringe.

With severe tachycardia and especially with the development of fibrillation, the use of lidocaine at a dose of 60-80 mg is indicated, but since it is a short-acting drug, it is infused at a rate of 2 mg / min. It is also indicated to use glucocorticoids, which, by increasing the sensitivity of adrenoreactive myocardial structures to catecholamines and normalizing the permeability of cell membranes, contribute to the restoration of adequate cardiac activity.

E - Electrocardiography - ECG registration

With the help of an ECG study, the nature of the violation of cardiac activity is determined. Most often it can be asystole - complete cessation of heart contractions, fibrillation - chaotic uncoordinated contraction of myocardial fibers with a frequency of 400-500 beats / min, in which cardiac output practically stops. Initially, large-wave fibrillation is noted, which, within 1-2 minutes, passes into small-wave fibrillation, followed by asystole. The presence of any rhythm on the ECG is better than the complete absence of electrical activity of the myocardium. Therefore, the key task of CPR is to stimulate the electrical activity of the myocardium and subsequently modify it into an effective (presence of a pulse) rhythm.

The presence of asystole serves as a marker of severe myocardial perfusion disorder and serves as a poor prognostic sign for restoring cardiac rhythm. However, it is important to differentiate between low-amplitude microwave ventricular fibrillation and asystole, which is best done in standard ECG leads 2–3. Adrenaline (1 mg IV) and atropine (1 mg increased to 2–4 mg) are most effective in restoring electrical activity. In refractory cases, correction of potassium and calcium levels is effective.

Ventricular fibrillation (VF)

In pulseless patients, immediate blind electropulse therapy should be performed (before the cause of circulatory arrest is recognized by ECG), since VF is the most common cause of sudden death, and the success of defibrillation is largely determined by the time it is performed. It should be noted that "blind" defibrillation will not harm patients with asystole and bradycardia and is usually effective in patients with tachycardia and VF. It is important to remember that the rule of "blind" cardioversion is not acceptable in children, since they are much more likely than VF to have respiratory arrest as a cause of terminal illness. The success of defibrillation depends on VF amplitude, which in turn is inversely correlated with the duration of the VF episode. If two initial attempts at cardioversion are ineffective, in this case it is necessary to administer adrenaline to increase the amplitude of fibrillation waves and increase vascular tone (in cases of restoration of the heart rhythm, it allows increasing perfusion of the heart and brain). On the other hand, it is necessary to use optimal doses of adrenaline so as not to increase the oxygen demand of the myocardium.

F– Fibrilation– performing electrical defibrillation if necessary (cardioversion)

Cardiac fibrillation can be eliminated by the use of electrical defibrillation. It is necessary to apply electrodes tightly to the chest (in the anterolateral position, one electrode is located in the region of the apex of the heart, the second in the subclavian region to the right of the sternum), which increases the force of the discharge and, accordingly, the effectiveness of defibrillation. In a number of patients, the anteroposterior (apex of the heart - interscapular space) position of the electrodes is more effective. Do not apply electrodes over the overlays of the ECG monitor.

It should be noted that electrical defibrillation is effective only when large-wave oscillations with an amplitude of 0.5 to 1 mV or more are recorded on the ECG. This kind of myocardial fibrillation indicates the safety of its energy resources and the possibility of restoring adequate cardiac activity. If the oscillations are low, arrhythmic and polymorphic, which is observed in severe myocardial hypoxia, then the possibility of restoring cardiac activity after defibrillation is minimal. In this case, with the help of heart massage, mechanical ventilation, intravenous administration of adrenaline, atropine, calcium chloride, it is necessary to achieve the transfer of fibrillation to large-wave, and only after that defibrillation should be performed. The first attempt at defibrillation is carried out with a discharge of 200 J, with subsequent attempts the charge increases to 360 J. The electrodes must be moistened and firmly pressed to the surface of the chest. The most common errors during defibrillation, which cause the ineffectiveness of the latter, include the following.

1. Long interruptions in heart massage or complete absence of resuscitation during the preparation of the defibrillator for discharge.

2. Loose pressing or insufficient moistening of the electrodes.

3. Application of a discharge against the background of low-wave fibrillation without taking measures that increase the energy resources of the myocardium.

4. Applying a discharge of low or excessively high voltage.

It should be noted that electrical defibrillation of the heart is an effective method for correcting such cardiac arrhythmias as paroxysmal ventricular tachycardia, atrial flutter, nodal and supraventricular tachycardia, atrial fibrillation. The indication for electrical defibrillation, at the prehospital stage, is most often paroxysmal ventricular tachycardia. A feature of defibrillation in these conditions is the presence of consciousness in the patient and the need to eliminate the reaction to pain when applying an electric discharge.

G– Gauging– evaluation of primary results

The primary evaluation of the results is carried out not only to ascertain the state of the circulatory and respiratory system, but also in order to outline the tactics of further therapeutic measures. Upon completion of the resuscitation process, in which the restoration of cardiac activity appeared, the resuscitator must perform a number of final actions:

1) assess the condition of the respiratory tract (symmetry of breathing, with the continuation of forced breathing, the adequacy of ventilation);

2) check the pulsation in the central and peripheral arteries;

3) evaluate the color of the skin;

4) determine the level of blood pressure;

5) measure the volume of circulating blood (measure CVP, assess the condition of the jugular veins);

6) check the correct position of the catheters in the central veins;

7) in case of elimination of cardiac fibrillation, which was the cause of sudden death, make sure that the infusion of any antifibrillary agent is continued;

8) carry out correction of therapy if it was carried out to the patient before the episode of sudden death.

H– Hypothermy– head cooling

With hypothermia, the critical time of circulatory arrest can increase significantly. To prevent the development of posthypoxic encephalopathy, measures should be taken to reduce the intensity of metabolic processes in the brain, as well as antihypoxic and antioxidant drugs.

Main activities

1. Craniocerebral hypothermia - wrapping the head and neck with ice packs, snow, cold water.

2. Parenteral administration of antihypoxants (sodium oxybutyrate, mafusol, small doses of sedatives), as well as improving the rheological properties of blood (rheopolyglucin, hemodez, heparin, trental).

3. The introduction of calcium antagonists (nimoton, lidoflazin, etc.).

4. Introduction of antioxidants (mafusol, unitiol, vitamin C, catalase, etc.).

I– intensive care– conducting intensive care of postresuscitation syndromes

Although a rapid positive response to CPR improves the chances of a favorable prognosis in patients, subsequent development of sepsis, acute pulmonary insufficiency and pneumonia is possible, which naturally worsens the prognosis. Long-term survival of patients with previous diseases of vital organs after CPR is not typical, since during this period their lesions deepen, and the nerve centers that provide autonomous control and maintenance of protective reflexes are damaged. Also, when using intensive chest compression, ruptures of the liver, aorta, pneumothorax, fractures of the ribs and sternum are noted. Aspiration pneumonitis, convulsions (due to cerebral ischemia) and lidocaine intoxication are common complications. A number of patients develop bleeding from stress ulcers of the stomach and duodenum. After CPR, there is a significant increase in the level of liver (and/or skeletal muscle) enzymes, although the development of liver necrosis and insufficiency of its function are rare. In high-energy defibrillation regimens, there is a significant increase in the level of creatine phosphokinase, but an increase in the MB fraction is present only with repeated high-energy discharges.

1. Correction of CBS and water-electrolyte balance. Often after CPR, metabolic alkalosis, hypokalemia, hypochloremia, and other electrolyte disorders develop. There is a shift in pH to an acidic or alkaline environment. The key to pH correction is adequate ventilation. The use of bicarbonate should be carried out under the control of the gas composition of the blood. As a rule, there is no need for the introduction of HCO 3 with a rapid restoration of blood circulation and respiration. With a functioning heart, a pH level of ~ 7.15 is adequate for the functioning of the cardiovascular system. The commonly recommended dose of bicarbonate (1 mg/kg) may cause side effects including:

1) arrhythmogenic alkalosis;

2) increased production of CO 2 ;

3) hyperosmolarity;

4) hypokalemia;

5) paradoxical intracellular acidosis of the central nervous system;

6) shift to the left of the hemoglobin dissociation curve, which limits the tissue supply of O 2 .

Therefore, the appointment of this drug should be strictly according to indications. To eliminate hypokalemia, an intravenous infusion of potassium chloride is performed at a dose of 2 mmol/kg per day.

2. Normalization of the antioxidant defense system. Intensive therapy includes a complex of antioxidant drugs with multidirectional action - mafusol, unitiol, vitamin C, multibiont, tocopherol, probucol, etc.

3. The use of antioxidants helps to reduce the intensity of metabolic processes and, consequently, reduce the need for oxygen and energy, as well as the maximum use of the reduced amount of oxygen that is available during hypoxia. This is achieved through the use of neurovegetative protection drugs and antihypoxants (seduxen, droperidol, ganglion blockers, mexamine, sodium hydroxybutyrate, cytochrome, gutimin, etc.).

4. An increase in energy resources is provided by intravenous administration of concentrated glucose solutions with insulin and the main coenzymes involved in energy utilization (vitamin B 6 , cocarboxylase, ATP, riboxin, etc.).

5. Stimulation of the synthesis of protein and nucleic acids - substrates that are absolutely necessary for the normal functioning of cells, the synthesis of enzymes, immunoglobulins and others, is carried out by the use of anabolic hormones (retabolil, nerabolil, insulin, retinol), folic acid, as well as the introduction of amino acid solutions.

6. Activation of aerobic metabolism is achieved by introducing a sufficient amount of oxidation substrates (glucose), as well as by using hyperbolic oxygenation (HBO) - this method ensures the supply of the required amount of oxygen even in conditions of sharp violations of its delivery.

7. Improvement of redox processes (succinic acid, riboxin, tocopherol, etc.).

8. Active detoxification therapy contributes to the normalization of metabolic processes. For this, various methods of infusion therapy (gelatinol, albumin, plasma), forced diuresis, etc. are used. In severe cases, extracorporeal detoxification methods are used (hemosorption, hemodialysis, plasmapheresis).

9. Elimination of violations of microcirculation processes. For this, heparin therapy is performed.

There is no single guideline for all clinical situations. During ongoing CPR, neurological signs cannot serve as markers of outcome and, accordingly, cannot be guided by them when CPR is stopped. Resuscitation is rarely effective if more than 20 minutes is needed to restore a coordinated heart rhythm. A number of studies have shown that the lack of response within 30 minutes to full CPR, with rare exceptions, leads to death. The best results occur in cases of immediate effective cardioversion. Prolonged resuscitation with a good neurological outcome is possible with the provision of hypothermia and deep pharmacological depression of the central nervous system (for example, barbiturates).

Methods for determining the non-viability of the brain:

1) angiography of cerebral vessels (lack of blood flow);

2) EEG (straight line for at least 24 hours);

3) computed tomography.

CPR Termination Criteria:

1) if within 30 minutes all correctly performed resuscitation measures do not bring any effect - spontaneous breathing does not appear, blood circulation is not restored, the pupils remain dilated and do not react to light;

2) if within 30 minutes there are repeated cardiac arrests that are not amenable to therapy, and at the same time there are no other signs of successful resuscitation;

3) if in the process of resuscitation it was found that this patient was not shown at all;

4) if within 45-60 minutes, despite the partial restoration of breathing, the victim has no pulse and there are no signs of restoration of brain function.

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Chapter 1 Cardiopulmonary resuscitation Cardiopulmonary resuscitation is performed in case of respiratory arrest, severe oxygen deficiency, cardiac arrest, life-threatening cardiac arrhythmias. The concept of cardiopulmonary resuscitation includes the following:

SLIDE 1 CARDIOpulmonary resuscitation

BASIC COMPLEX OF CARDIO-PULMONARY REANIMATION

Data on the effectiveness of resuscitation and survival of patients in the terminal state vary greatly. For example, survival after sudden cardiac arrest varies widely depending on many factors (heart related or not, witnessed or not, in a medical facility or not, etc.). Cardiac arrest resuscitation outcomes are the result of a complex interaction between so-called "unmodified" (age, disease) and "programmed" factors (eg, time interval from the start of resuscitation). Primary resuscitation should be sufficient to prolong life in anticipation of the arrival of trained professionals with appropriate equipment.

Based on the high mortality rate from injuries and in various emergency conditions, at the prehospital stage, it is necessary to provide training not only for medical workers, but also for the largest possible number of the active population in a single modern protocol for cardiopulmonary resuscitation.

SLIDE 2 Indications and contraindications for

cardiopulmonary resuscitation

When determining indications and contraindications for cardiopulmonary resuscitation, one should be guided by the following regulatory documents:

"Instructions for determining the criteria and procedure for determining the moment of death of a person, the termination of resuscitation" of the Ministry of Health of the Russian Federation (No. 73 of 03/04/2003)

"Instructions for ascertaining the death of a person on the basis of brain death" (Order of the Ministry of Health of the Russian Federation No. 460 of December 20, 2001 was registered by the Ministry of Justice of the Russian Federation on January 17, 2002 No. 3170).

"Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens" (dated July 22, 1993 No. 5487-1).

SLIDE 3

SLIDE 4 Resuscitation measures are not carried out:

in the presence of signs of biological death;

upon the onset of a state of clinical death against the background of the progression of reliably established incurable diseases or incurable consequences of an acute injury incompatible with life. The hopelessness and hopelessness of cardiopulmonary resuscitation in such patients should be determined in advance by a council of doctors and recorded in the medical history. Such patients include the last stages of malignant neoplasms, atonic coma in cerebrovascular accidents in elderly patients, injuries incompatible with life, etc.;

if there is a documented refusal of the patient to carry out cardiopulmonary resuscitation (Article 33 "Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens").

SLIDE 5 Resuscitation measures are terminated:

when ascertaining the death of a person on the basis of brain death, including against the background of ineffective use of a full range of measures aimed at maintaining life;

if resuscitation measures aimed at restoring vital functions within 30 minutes are ineffective (during resuscitation measures after the appearance of at least one pulse on the carotid artery during external heart massage, a 30-minute time interval is counted again);

if there are multiple cardiac arrests that are not amenable to any medical effects;

if during the course of cardiopulmonary resuscitation it turned out that it was not indicated for the patient (that is, if clinical death occurred in an unknown person, cardiopulmonary resuscitation is started immediately, and then during resuscitation it is found out whether it was shown, and if resuscitation is not was shown, it is stopped).

SLIDE 6 Resuscitators - "not doctors" carry out resuscitation measures:

before the appearance of signs of life;

before the arrival of qualified or specialized medical personnel who continue resuscitation or ascertain death. Article 46 (“Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens.”);

depletion of the physical strength of a non-professional resuscitator.

SLIDE 7 Clinical picture of dying

In the process of dying, several stages are usually distinguished - preagony, agony, clinical death, biological death.

Preagonal state characterized by disintegration of body functions, a critical decrease in blood pressure, impaired consciousness of varying severity, respiratory disorders.

Following the preagonal state develops terminal pause- a state lasting 1-4 minutes: breathing stops, bradycardia develops, sometimes asystole, pupil reactions to light disappear, corneal and other stem reflexes disappear, pupils dilate.

At the end of the terminal pause develops agony. One of the clinical signs of agony is agonal breathing with characteristic rare, short, deep convulsive respiratory movements, sometimes involving skeletal muscles. Respiratory movements can be weak, low amplitude. In both cases, the efficiency of external respiration is reduced. The agony, ending with the last breath, turns into clinical death. With a sudden cardiac arrest, agonal breaths can last several minutes against the background of an absent blood circulation.

clinical death. In this state, with external signs of death of the body (lack of heart contractions, spontaneous breathing, and any neuro-reflex reactions to external influences), the potential possibility of restoring its vital functions with the help of resuscitation methods remains. SLIDE 8

The main signs of clinical death are:

Lack of consciousness;
Lack of spontaneous breathing;
Absence of pulsation on the main vessels.

SLIDE 9 Additional signs of clinical death are:

Wide pupils;
Areflexia (no corneal reflex and pupillary reaction to light);
Paleness, cyanosis of the skin.

SLIDE 10 Biological death. It is expressed by post-mortem changes in all organs and systems that are permanent, irreversible, cadaveric in nature.

Post-mortem changes have functional, instrumental, biological and cadaveric features:

Functional:

lack of consciousness;
lack of breathing, pulse, blood pressure;
lack of reflex responses to all types of stimuli.

Instrumental:

electroencephalographic;
angiographic.

Biological:

maximum pupil dilation;
pallor and / or cyanosis, and / or marbling (spotting) of the skin;
decrease in body temperature.

Corpse changes:

early signs;
late signs. SLIDE 11, 12,13

SLIDE 14 Ascertaining the death of a person occurs with the biological death of a person (irreversible death of a person) or with brain death.

Introduction.SLIDE 15

The basic complex of cardiopulmonary resuscitation includes the following: elements:SLIDE 16

initial inspection,

Restoration and maintenance of airway patency,

artificial lung ventilation,

Indirect cardiac massage.

SLIDE 17 Purpose the main complex of cardiopulmonary resuscitation - maintaining ventilation and blood circulation until the mechanism of respiratory arrest and / or blood circulation is clarified to eliminate the causes.

Stopping blood circulation for three to four minutes leads to permanent brain damage. Any delay inevitably reduces the chances of a successful outcome.

Story.

The first report of successful mouth-to-mouth artificial respiration was made by Tossach in 1774. However, after that, attention was paid to the manual methods described by Silvester, Schafer, Nielsen. This continued until the 1950s, when mouth-to-mouth resuscitation became universally accepted as the method of choice.

Closed heart massage was first described in 1878 by Boehm and was used with success in several cases of cardiac arrest over the next 10 years. However, open heart massage then became the standard method for cardiac arrest until 1960, when the classic study by Kouwenhoven, Jude, and Knickerbocker was published.

The combination of mouth-to-mouth resuscitation and closed heart massage in 1960 can be considered the year of the birth of modern cardiopulmonary resuscitation.

The theory of closed heart massage.

The original term "cardiac massage" reflects the original theory describing how chest compressions induce cardiopulmonary bypass - by compressing the heart. This "heart pump" theory was criticized in the mid-1970s based on the following facts. First, echocardiography has shown that during CPR, heart valves do not play a role. Second: coughing can maintain sufficient circulation. The alternative "thoracic pump" theory states that when chest compressions occur, blood is expelled from the chest as a result of increased intrathoracic pressure; the direction of flow is determined by the fact that the veins at the outlet of the chest collapse, playing the role of valves, while the arteries retain their lumen.

It must be recognized that even with optimal chest compressions, cerebral blood flow does not reach more than 30% of its normal level.

By the first letters of the three elements of the main Airway / Breathing / Circulation cardiopulmonary resuscitation complex, it is called “ABC”.

Pulse.

The main sign of cardiac arrest is the absence of a pulse in the carotid artery (or other large arteries). However, it has been found that carotid pulse evaluation is time-consuming and gives incorrect conclusions (presence or absence) in 50% of cases. Therefore, for non-physicians, training to determine the carotid pulse as a sign of cardiac arrest is not recommended. SLIDE 18

SLIDE 19The sequence of the main complex of cardiopulmonary resuscitation.

Make sure the rescuer and victim are safe.

Examine the victim and evaluate his reaction. Gently shake your shoulder and ask out loud, “How are you feeling?”

Leave the victim in the same position (making sure that he is not exposed to further danger), check his condition and, if necessary, seek help.

Check condition regularly.

If the victim does not respond: SLIDE 21

Call for help.
Roll onto back and open airway: SLIDE 22
- Place the palm on the forehead and gently tilt the head so that the thumb and forefinger remain free so that, if artificial respiration is necessary, they can close the nose,
  SLIDE 23,24 Remove all visible foreign objects from the oral cavity, including extracted teeth, leaving sufficiently fixed teeth in place,
  With the fingers of the other hand placed under the chin, lift it up to open the airway.

Try to avoid tilting the head if a neck injury is suspected.

SLIDE25 Maintaining airway patency, determine the presence of spontaneous breathing:

See chest movements.
Hear noises from the victim's mouth.
Feel the flow of air on your cheek.

Spend no more than 10 seconds on this step.

Turn the victim to a safe position (next),

Send someone or go yourself for help,

Check for spontaneous breathing

SLIDE 27,28,29

If there is no breathing or only attempts to breathe:

Send someone for help or, if you are alone, leave the victim and call for help; on return, begin artificial respiration,

Turn the victim onto their back if they are not already in that position.

Make 2 slow effective artificial breaths, with each of which, the chest should rise and fall:

Make sure that the head is thrown back and the chin is raised,
SLIDE 30 FREE THE BREATH OF THE WAY
Pinch the nose with the index and thumb fingers of the hand that is on the victim's forehead,
SLIDE 31 Open your mouth while keeping your chin up
Take a deep breath and press your lips tightly to the victim's mouth,
Exhale into the victim's mouth for about two seconds, observing the movement of the chest, so that the chest rises, as in normal breathing,
Keeping your head back and your chin up, move your mouth away from the casualty and make sure your chest is dropping and air is escaping.

If you cannot inhale effectively:

Re-check the victim's mouth and remove anything that may be blocking the airway,
Check if the head is tilted back enough and the chin is raised,
Make up to 5 attempts to deliver 2 effective breaths,
Even if they are not successful, move on to assessing the circulation. SLIDE 32

SLIDE33,34,35,36

SLIDE 37.38

slide h9 Evaluation of signs of blood circulation:

Check for normal breathing, coughing or movement;
Determine the presence of a carotid pulse, only if you own it;
Spend no more than 10 seconds on this.

SLIDE40 If you are sure that there are signs of circulation:

Continue artificial respiration until the victim begins to breathe on his own;

Approximately every 10 breaths (or approximately every minute), check for signs of circulation, spending no more than 10 seconds;

If the victim begins to breathe normally on his own, but remains unconscious, move him to a safe position. Be ready to roll him onto his back and resume artificial respiration.

SLAD 41 If there are no signs of circulation or there is no certainty about their presence, start chest compressions:

With the hand that is located on the side of the victim's legs, determine the lower half of the sternum:
- SLIDE 42 Using the index and middle fingers, find the edge of the lower rib on the side of the resuscitator. Without unclenching your fingers, hold them up to the junction of the ribs and sternum. Place the clenched middle and index fingers so that the middle one is at the junction of the ribs and the sternum, and the index finger is on the sternum;
  SLIDE 43 Move the wrist of the other hand down the sternum until it touches the index finger; this is the middle of the lower part of the sternum;
  Place the wrist of the other hand on the back of the palm of this hand;
  Straighten or spread the fingers of both hands and lift them, making sure that they do not put pressure on the ribs. In no case do not put pressure on the upper abdomen or upper sternum;
  Position yourself above the chest of the victim and with straightened arms press on the sternum so as to displace it by 4-5 cm;
  Stop the pressure without losing contact between the arms and the sternum; repeat pressing with a frequency of approximately 100 in 1 minute. Pressure and pause should be equal in time;

Combination of artificial respiration and chest compressions:

After every 15 compressions, tilt your head back, raise your chin and take two effective breaths;
Place your hands back in the position described above and do 15 compressions, alternating compressions and breaths 15:2
Interrupt resuscitation only to check for signs of circulation if the victim begins to move or breathe on his own SLIDE 44 - CARDIOPAMP.
SLIDE45

Continue resuscitation until:

Arrival of qualified assistance;
The appearance of signs of life;
Or until the resuscitator has exhausted all his strength.

When to go for help?

Getting help is vital.

When two people start resuscitation, one of them immediately goes for help.

One rescuer must decide whether to initiate resuscitation or seek help first. If the victim is an adult, then you need to make sure that most likely the cardiac and respiratory arrest is caused by cardiac causes, and go for help immediately. The decision must be made based on the availability of emergency medical care.

However, if breathing problems are the likely cause, such as:

Drowning,
Aspiration,
Drug or alcohol intoxication,
Or an injured child or teenager,

it is necessary to carry out a resuscitation complex within 1 minute before going for help.

Resuscitation by two rescuers.

Resuscitation by two rescuers is less tiring than by one. However, it is very important that both rescuers are prepared for this method. Therefore, this method is recommended only by medical personnel or trained rescuers. The following points should be noted:

First, you need to call for help. One rescuer begins CPR, the other goes to call for help.

Rescuers should be on opposite sides of the victim.

A ratio of 15 compressions and 2 breaths should be used. It is advisable that the rescuer performing chest compressions count aloud.

It is necessary that the chin up and the head tilted back be maintained at all times. The duration of the inhalation cycle should be 2 seconds. Chest compressions should be suspended at this point. Indirect cardiac massage must be resumed immediately after the cessation of breaths.

If the rescuers want to change places, then this must be done as quickly as possible.

Notes on the technique of conducting the main complex of cardiopulmonary resuscitation. SLIDE46

Artificial respiration.

When performing artificial respiration, only slight resistance should be felt. Each breath should last about 2 seconds.

If the breath is taken very quickly, then the resistance to inhalation will be greater, and excess volume will flow into the lungs.

The tidal volume should be 700 - 1000 ml, this is the amount of air that causes a noticeable expansion of the chest.

It is necessary to wait for the complete collapse of the chest before the start of the next breath. This usually takes 2 to 4 seconds.

Expiratory deceleration is not critical; wait for a full exhalation before starting the next breath.

Indirect cardiac massage. SLIDE47

In adults, the depth of compression should be 4 to 5 cm and the force applied should not exceed what is needed to achieve this.

The direction of force must be strictly vertical.

The duration of the compression and relaxation phases should be approximately equal.

Since the chances of restoring effective spontaneous circulation with a basic cardiopulmonary resuscitation suite without the use of other methods or full CPR (including defibrillation) are slim, there is no need to spend time further checking for signs of circulation. However, if movements or independent breaths appear, then it is necessary to check for signs of blood circulation. In other cases, resuscitation should not be interrupted.

In the past, dilated pupils were seen as a sign of cardiac arrest, circulatory failure during CPR, irreversible brain damage. This sign is not reliable and should not influence the decision either before, during or after cardiopulmonary resuscitation.

Blockage of the airways.

If the airway obstruction is partial, the victim is usually able to clear the airway on their own. But if the blockage is complete, then emergency intervention is required to prevent asphyxia.

Consciousness and breathing are preserved, despite the presence of signs of obstruction:

Continued cough.

Complete obstruction or signs of decompensation or cyanosis:

Consciousness preserved: SLIDE48

Perform back blows:

Remove all visible foreign bodies or knocked out teeth from the mouth,
Stand sideways and slightly behind
Supporting the chest with one hand, tilt the victim forward,
Inflict 5 sharp blows between the shoulder blades with the wrist of the other hand.

Epigastric thrusts, if blows to the back have no effect:

Stand behind the victim and grab both hands at the level of the upper abdomen,
Make sure that the victim is tilted forward enough so that the removed foreign body does not get back into the airways,
Make a fist and place it between the navel and the xiphoid process,
Grab it with your other hand
Press sharply inward and upward; the foreign object must be removed,
If the obstruction persists, check the mouth with a finger and continue alternating between 5 scapular beats and 5 epigastric thrusts.

If consciousness disappears:

Tilt your head back and remove all foreign matter from your mouth,
Open the airways by lifting the chin
Check for breathing
Attempt to deliver 2 effective artificial breaths,
If effective breaths can be delivered in 5 attempts:
- Check for signs of circulation
  Start chest compressions and/or artificial respiration.

If effective breaths cannot be delivered after 5 attempts:

Start chest compressions immediately. Do not check for signs of circulation,
After 15 compressions, check the oral cavity, then try to perform artificial respiration,
Continue indirect heart massage - alternate 15 compressions with artificial respiration attempts.

If artificial respiration is possible:

Check for signs of circulation
Continue chest compressions and/or artificial respiration. SLIDE49

Safe position.

After restoration of circulation and breathing, it is very important to maintain the patency of the airways and prevent their obstruction with the tongue. It is also very important to reduce the risk of aspiration of gastric contents.

To do this, the victim must be given a safe position in which the retraction of the tongue is excluded and the airway is maintained.

Kneel beside the victim

Straighten your legs

Place the arm closest to the rescuer at a right angle to the body, bent at the elbow, palm up,

Take the hand farthest from the rescuer and place it so that the back of the hand is located on the cheek closest to the rescuer,

With the other hand, grab under the knee of the far leg and pull towards you so that the foot remains on the ground,

Pull the victim by the leg and turn him over on his side, keeping the palm pressed to the cheek,

Bend the upper leg at the knee at a right angle,

Tilt your head back to make sure your airway is open

Regularly evaluate breathing.

It is necessary to observe the circulation in the lower arm. After 30 minutes, it is necessary to turn the victim on the other side.

Putting an unconscious but spontaneously breathing victim into the position described above can be vital.

Variants of the technique of cardiopulmonary resuscitation.

Artificial respiration from mouth to nose. SLIDE50

In some situations, this technique may be preferable:

Artificial mouth-to-mouth respiration is difficult, for example, due to the unusual arrangement of teeth or their absence,

Impossible to eliminate obstruction in the oral cavity,

When rescuing a casualty in the water, when one hand of the rescuer is required to support the victim's body and cannot be used to cover the nose,

Artificial respiration is carried out by a child,

For aesthetic reasons.

Resuscitation: basic concepts

Life and death are the two most important philosophical concepts that determine the existence of an organism and its interaction with the external environment. In the process of life of the human body, there are three states: health, illness and critical (terminal) state.

Terminal state - the critical condition of the patient, in which there is a complex of dysregulation of the vital functions of the body with characteristic general syndromes and organ disorders, poses a direct threat to life and is the initial stage of thanatogenesis.

Violation of the regulation of vital functions. There is damage not only to the central regulatory mechanisms (nervous and humoral), but also to local ones (the action of histamine, serotonin, kinins, prostaglandins, histamine, serotonin, the cAMP system).

General syndromes. Syndromes characteristic of any terminal state are observed: violation of the rheological properties of blood, metabolism, hypovolemia, coagulopathy.

Organ disorders. There is an acute functional insufficiency of the adrenal glands, lungs, brain, blood circulation, liver, kidneys, gastrointestinal tract. Each of these disorders is expressed to varying degrees, but if some specific pathology has led to the development of a terminal condition, the elements of these disorders always exist, so any terminal condition should be considered as multiple organ failure.

In a terminal state, only a "lifeline" in the form of intensive therapy and resuscitation can stop the process of thanatogenesis (physiological mechanisms of dying).

Intensive therapy - a set of methods for correcting and temporarily replacing the functions of vital organs and systems of the patient's body.

In the terminal state, the intensity of treatment is extremely high. It is necessary to constantly monitor the parameters of the main

vital systems (heart rate, blood pressure, respiratory rate, consciousness, reflexes, ECG, blood gases) and the use of complex methods of treatment that quickly replace each other or are performed simultaneously (central venous catheterization, continuous infusion therapy, intubation, mechanical ventilation, sanitation tracheobronchial tree, transfusion of components and blood products).

The most complex and intensive methods of treatment are used in cases where the process of thanatogenesis reaches its climax: the patient's heart stops. It is not only about healing, but also about revitalization.

resuscitation(revitalization of the body) - intensive therapy in case of circulatory and respiratory arrest.

The science of resuscitation deals with the study of the dying of an organism and the development of methods for its revival.

resuscitation(re- again, animare- revive) - the science of the laws of the extinction of life, the principles of revitalization of the body, the prevention and treatment of terminal conditions.

From the time of Hippocrates and until the 20th century, the opinion was true that it was necessary to fight for the life of the patient until his last breath, the last heartbeat. After the cessation of cardiac activity - in a state of clinical death - it is necessary to fight for the patient's life.

Key parameters of vital functions

In resuscitation, the time factor is extremely important, so it makes sense to simplify the examination of the patient as much as possible. In addition, to solve resuscitation problems, it is necessary to find out the fundamental changes in the vital systems of the patient's body: the central nervous system, cardiovascular and respiratory systems. The study of their condition can be divided into two groups:

Assessment at the prehospital stage (without special equipment);

Evaluation at a specialized stage.

Assessment at the prehospital stage

In resuscitation, it is necessary to determine the following parameters of the main vital systems of the body:

CNS:

The presence of consciousness and the degree of its oppression;

The state of the pupils (diameter, reaction to light);

Preservation of reflexes (the most simple - corneal).

The cardiovascular system:

Skin color;

The presence and nature of the pulse in the peripheral arteries (a. radialis);

The presence and magnitude of blood pressure;

The presence of a pulse in the central arteries (a. carotis, a. femoralis- similar to the points of their pressing during a temporary stop of bleeding);

The presence of heart sounds.

Respiratory system:

The presence of spontaneous breathing;

Frequency, rhythm and depth of breathing.

Assessment at a specialized stage

The assessment at the specialized stage includes all the parameters of the prehospital stage, but at the same time they are supplemented with data from instrumental diagnostic methods. The most commonly used monitoring method includes:

ECG;

Study of blood gases (O 2, CO 2);

Electroencephalography;

Constant measurement of blood pressure, control of CVP;

Special diagnostic methods (finding out the cause of the development of a terminal state).

Shock

This is a serious condition of the patient, closest to the terminal, in translation shock- hit. In everyday life, we often use this term, meaning, first of all, a nervous, emotional shock. In medicine, shock is really a "blow on the patient's body", leading not only to some specific disorders in the functions of individual organs, but accompanied by general disorders, regardless of the point of application of the damaging factor. Perhaps there is not a single syndrome in medicine that mankind has been familiar with for so long. The clinical picture of shock was described by Ambroise Pare. The term "shock" when describing the symptoms of severe trauma

we introduced at the beginning of the 16th century the French doctor-consultant of the army of Louis XV Le Dran, he also proposed the simplest methods of treating shock: warming, rest, alcohol and opium. Shock must be distinguished from fainting and collapse.

Fainting- sudden short-term loss of consciousness associated with insufficient blood supply to the brain.

A decrease in cerebral blood flow during fainting is associated with a short-term spasm of cerebral vessels in response to a psycho-emotional stimulus (fear, pain, sight of blood), stuffiness, etc. Women with arterial hypotension, anemia, and an unbalanced nervous system are prone to fainting. The duration of fainting is usually from a few seconds to several minutes without any consequences in the form of disorders of the cardiovascular, respiratory and other systems.

Collapse- a rapid drop in blood pressure due to sudden cardiac weakness or a decrease in the tone of the vascular wall.

Unlike shock, in collapse, the primary reaction to various factors (bleeding, intoxication, etc.) is from the cardiovascular system, changes in which are similar to those in shock, but without pronounced changes in other organs. The elimination of the cause of the collapse leads to the rapid restoration of all body functions. In shock, unlike fainting and collapse, there is a progressive decline in all vital functions of the body. There are many definitions of shock, both general and simple, and very complex, reflecting the pathogenetic mechanisms of the process. The authors consider the following to be optimal.

Shock- an acute serious condition of the body with a progressive failure of all its systems, due to a critical decrease in blood flow in the tissues.

Classification, pathogenesis

Due to the occurrence of shock, it can be traumatic (mechanical trauma, burns, cooling, electric shock, radiation injury), hemorrhagic, surgical, cardiogenic, septic, anaphylactic. It is most expedient to divide shock into types, taking into account the pathogenesis of changes occurring in the body (Fig. 8-1). From this point of view, hypovolemic, cardiogenic, septic and anaphylactic shock are distinguished. With each of these types of shock, specific changes occur.

Rice. 8-1.The main types of shock

hypovolemic shock

The circulatory system of the body consists of three main parts: the heart, blood vessels, and blood. Changes in the parameters of the activity of the heart, vascular tone and bcc determine the development of symptoms characteristic of shock. Hypovolemic shock occurs as a result of an acute loss of blood, plasma, and other body fluids. Hypovolemia (decrease in BCC) leads to a decrease in venous return and a decrease in the filling pressure of the heart, which is shown in Fig. 8-2. This, in turn, leads to a decrease in the stroke volume of the heart and a drop in blood pressure. As a result of stimulation of the sympathetic-adrenal system, the heart rate increases, vasoconstriction (increase in total peripheral resistance) and centralization of blood circulation occur. At the same time, α-adrenergic receptors of vessels innervated by n. splanchnicus, as well as the vessels of the kidneys, muscles and skin. Such a reaction of the body is quite justified, but if hypovolemia is not corrected, then due to insufficient tissue perfusion, a picture of shock occurs. Thus, hypovolemic shock is characterized by a decrease in BCC, cardiac filling pressure and cardiac output, blood pressure, and an increase in peripheral resistance.

Cardiogenic shock

The most common cause of cardiogenic shock is myocardial infarction, less often myocarditis and toxic myocardial damage. In case of violation of the pumping function of the heart, arrhythmias and other acute causes of a decrease in the efficiency of heart contractions, a decrease in the stroke volume of the heart occurs, as a result of which blood pressure decreases, and the filling pressure of the heart increases (Fig. 8-3). As a result of

Rice. 8-2.The pathogenesis of hypovolemic shock

Rice. 8-3.The pathogenesis of cardiogenic shock

stimulation of the sympathetic-adrenal system occurs, heart rate and total peripheral resistance increase. Changes are similar to those in hypovolemic shock. These are hypodynamic forms of shock. Their pathogenetic difference is only in the value of the filling pressure of the heart: in hypovolemic shock it is reduced, and in cardiogenic shock it is increased.

Septic shock

In septic shock, peripheral circulatory disorders first occur. Under the influence of bacterial toxins, short arteriovenous shunts open, through which blood rushes, bypassing the capillary network, from the arterial bed to the venous one (Fig. 8-4). With a decrease in blood flow to the capillary bed, the blood flow in the periphery is high and the total peripheral resistance is reduced. Accordingly, there is a decrease in blood pressure, a compensatory increase in the stroke volume of the heart and heart rate. This is the so-called hyperdynamic circulation response in septic shock. A decrease in blood pressure and total peripheral resistance occurs with a normal or increased stroke volume of the heart. With further development, the hyperdynamic form passes into the hypodynamic one.

Rice. 8-4.The pathogenesis of septic shock

Rice. 8-5.The pathogenesis of anaphylactic shock

Anaphylactic shock

An anaphylactic reaction is an expression of a special hypersensitivity of the body to foreign substances. The development of anaphylactic shock is based on a sharp decrease in vascular tone under the influence of histamine and other mediator substances (Fig. 8-5). Due to the expansion of the capacitive part of the vascular bed (vein), a relative decrease in BCC occurs: there is a discrepancy between the volume of the vascular bed and BCC. Hypovolemia leads to a decrease in blood flow to the heart and a decrease in the filling pressure of the heart. This leads to a drop in stroke volume and blood pressure. A direct violation of myocardial contractility also contributes to a decrease in the productivity of the heart. Anaphylactic shock is characterized by the absence of a pronounced reaction of the sympathetic-adrenal system, which leads to the progressive clinical development of anaphylactic shock.

Violation of microcirculation

Despite the difference in the pathogenesis of the presented forms of shock, the end of their development is a decrease in capillary blood flow. Following-

As a result, the delivery of oxygen and energy substrates, as well as the excretion of end products of metabolism, become insufficient. Hypoxia occurs, a change in the nature of metabolism from aerobic to anaerobic. Less pyruvate is included in the Krebs cycle and turns into lactate, which, along with hypoxia, leads to the development of tissue metabolic acidosis. Under the influence of acidosis, two phenomena occur, leading to a further deterioration of microcirculation during shock: shock specific dysregulation of vascular tone and violation of the rheological properties of blood. The precapillaries expand, while the postcapillaries are still narrowed (Fig. 8-6c). Blood enters the capillaries, and the outflow is impaired. There is an increase in intracapillary pressure, the plasma passes into the interstitium, which leads to a further decrease in BCC, a violation of the rheological properties of blood, and cell aggregation in the capillaries. Red blood cells stick together in "coin columns", clumps of platelets are formed. As a result of an increase in blood viscosity, an insurmountable resistance to blood flow occurs, capillary microthrombi are formed, and DIC develops. This is how the center of gravity of changes occurs during progressive shock from macrocirculation to microcirculation. Violation of the latter is characteristic of all forms of shock, regardless of the cause that caused it. It is the microcirculation disorder that is the immediate cause that threatens the life of the patient.

shock organs

Violation of cell functions, their death due to microcirculation disorders during shock can affect all cells of the body, but there are organs that are especially sensitive to shock - shock organs.

Rice. 8-6.The mechanism of microcirculation disorders in shock: a - normal; b - the initial phase of shock - vasoconstriction; c - specific dysregulation of vascular tone

us. These include, first of all, the lungs and kidneys, and secondly, the liver. At the same time, it is necessary to distinguish between changes in these organs during shock (lung during shock, kidneys and liver during shock), which disappear when the patient recovers from shock, and organ disorders associated with the destruction of tissue structures, when, after recovery from shock, insufficiency or complete loss of functions persists. organ (shock lung, shock kidneys and liver).

Mild in shock.Disturbance of absorption of oxygen and an arterial hypoxia are characteristic. If a “shock lung” occurs, then after the shock is eliminated, severe respiratory failure rapidly progresses. Patients complain of suffocation, rapid breathing. They have a decrease in the partial pressure of oxygen in the arterial blood, a decrease in the elasticity of the lung. There is an increase in p a CO 2 . In this progressive phase of shock, the “shock lung” syndrome, apparently, no longer undergoes regression: the patient dies from arterial hypoxia.

Kidneys in shock.Characterized by a sharp restriction of blood circulation with a decrease in the amount of glomerular filtrate, a violation of the concentration ability and a decrease in the amount of urine excreted. If these disorders, after the elimination of the shock, did not undergo an immediate regression, then diuresis progressively decreases, the amount of slag substances increases, a "shock kidney" occurs, the main manifestation of which is the clinical picture of acute renal failure.

Liver -central organ of metabolism, plays an important role in the course of shock. The development of a "shock liver" can be suspected when the activity of liver enzymes increases after shock relief.

Clinical picture

Main symptoms

The clinical picture of shock is quite characteristic. The main symptoms are associated with the inhibition of the vital functions of the body. Patients in a state of shock are inhibited, reluctant to make contact. The skin is pale, covered with cold sweat, acrocyanosis is often observed. Breathing is frequent, shallow. Tachycardia, decrease in blood pressure are noted. The pulse is frequent, weakly filled, and in severe cases it is barely defined (filamentous). Changes

hemodynamics - basic in shock. Against this background, there is a decrease in diuresis. The pulse and blood pressure change most dynamically during shock. In this regard, Allgover suggested using the shock index: the ratio of heart rate to the level of systolic blood pressure. Normally, it is approximately equal to 0.5, in the transition to shock it approaches 1.0, with developed shock it reaches 1.5.

Shock severity

Depending on the severity, four degrees of shock are distinguished.

Shock I degree.Consciousness is preserved, the patient is in contact, slightly inhibited. Systolic blood pressure is slightly reduced, but exceeds 90 mm Hg, the pulse is slightly quickened. The skin is pale, sometimes muscle tremors are noted.

Shock II degree.Consciousness is preserved, the patient is inhibited. The skin is pale, cold, sticky sweat, slight acrocyanosis. Systolic blood pressure 70-90 mm Hg. The pulse is speeded up to 110-120 per minute, weak filling. CVP is reduced, shallow breathing.

Shock III degree.The patient's condition is extremely serious: he is adynamic, lethargic, answers questions in monosyllables, does not respond to pain. The skin is pale, cold, with a bluish tint. Breathing is shallow, frequent, sometimes rare. The pulse is frequent - 130-140 per minute. Systolic blood pressure 50-70 mm Hg. CVP is zero or negative, there is no diuresis.

Shock IV degree.The predagonal state is one of the critical, terminal states.

General principles of treatment

Treatment of shock largely depends on the etiological factors and pathogenesis. Often it is the elimination of the leading syndrome (stopping bleeding, elimination of the source of infection, the allergic agent) that is an indispensable and main factor in the fight against shock. At the same time, there are general patterns of treatment. Shock therapy can be roughly divided into three stages. But even the very first, “zero step” is considered leaving. Patients should be surrounded by attention, despite the large amount of diagnostic and therapeutic measures. The berths must be functional, accessible for the transportation of equipment. Patients must be completely undressed. The air temperature should be 23-25? C.

The general principles of shock treatment can be summarized in three steps.

Basic shock therapy (first step):

Replenishment of the BCC;

oxygen therapy;

acidosis correction.

Pharmacotherapy of shock (second step):

- dopamine;

norepinephrine;

cardiac glycosides.

Additional therapeutic measures (third stage):

Glucocorticoids;

Heparin sodium;

Diuretics;

Mechanical circulatory support;

Cardiac surgery.

In the treatment of patients with shock, a large place is given to the diagnostic program and monitoring. On fig. Figure 8-7 shows a minimal monitoring scheme. Among the presented indicators, the most important are heart rate, blood pressure, CVP, blood gas composition and diuresis rate.

Rice. 8-7.Minimum monitoring regimen for shock

Rice. 8-8.Scheme for measuring central venous pressure

Moreover, diuresis in shock is measured not per day, as usual, but per hour or minutes, for which the bladder is catheterized without fail. With normal blood pressure, above the critical level of perfusion pressure (60 mm Hg), and with normal kidney function, the rate of urine output is more than 30 ml / h (0.5 ml / min). On fig. 8-8 shows a scheme for measuring CVP, knowledge of which is extremely important for infusion therapy and replenishment of BCC. Normally, the CVP is 5-15 cm of water.

It should be noted that in the treatment of shock, a clear program of action is needed, as well as a good knowledge of the pathogenesis of changes occurring in the body.

Terminal States

The main stages of the organism's dying are consecutive terminal states: pre-agonal state, agony, clinical and biological death. The main parameters of these states are presented in Table. 8-1.

Predagonal state

Predagonal state - the stage of the dying of the body, in which there is a sharp decrease in blood pressure; first tachycardia and tachypnea, then bradycardia and bradypnea; progressive depression of consciousness, electrical activity of the brain and reflexes; growth

Table 8-1.Characteristics of terminal states

depth of oxygen starvation of all organs and tissues. The IV stage of shock can be identified with the preagonal state.

Agony

Agony is the stage of dying preceding death, the last flash of vital activity. During the period of agony, the functions of the higher parts of the brain are turned off, the regulation of physiological processes is carried out by the bulbar centers and are of a primitive, disordered nature. Activation of stem formations leads to some increase in blood pressure and increased respiration, which usually has a pathological character (Kussmaul, Biot, Cheyne-Stokes respiration). The transition from the pre-agonal state to the agonal state, therefore, is primarily due to the progressive depression of the central nervous system. The agonal flash of vital activity is very short-lived and ends with the complete suppression of all vital functions - clinical death.

clinical death

Clinical death is a reversible stage of dying, “a kind of transitional state that is not yet death, but is no longer

can be called life” (V.A. Negovsky, 1986). The main difference between clinical death and the states preceding it is the absence of blood circulation and respiration, which makes redox processes in cells impossible and leads to their death and death of the organism as a whole. But death does not occur directly at the moment of cardiac arrest. Exchange processes fade away gradually. The cells of the cerebral cortex are most sensitive to hypoxia, so the duration of clinical death depends on the time that the cerebral cortex experiences in the absence of respiration and blood circulation. With its duration of 5-6 minutes, damage to most of the cells of the cerebral cortex is still reversible, which makes it possible to fully revive the body. This is due to the high plasticity of CNS cells; the functions of dead cells are taken over by others that have retained their vital activity. The duration of clinical death is affected by:

The nature of the previous dying (the more sudden and faster clinical death occurs, the longer it can be);

Ambient temperature (with hypothermia, the intensity of all types of metabolism is reduced and the duration of clinical death increases).

biological death

Biological death follows clinical death and is an irreversible state when the revival of the organism as a whole is no longer possible. This is a necrotic process in all tissues, starting with the neurons of the cerebral cortex, the necrosis of which occurs within 1 hour after the cessation of blood circulation, and then within 2 hours the cells of all internal organs die (skin necrosis occurs only after a few hours, and sometimes days ).

Reliable signs of biological death

Reliable signs of biological death are cadaveric spots, rigor mortis and cadaveric decomposition.

cadaveric spots- a kind of blue-violet or purple-violet coloration of the skin due to draining and accumulation of blood in the lower parts of the body. Their formation occurs 2-4 hours after the cessation of cardiac activity. The duration of the initial stage (hypostasis) is up to 12-14 hours: the spots disappear with pressure

vanishing, then reappear within a few seconds. Formed cadaveric spots do not disappear when pressed.

Rigor mortis - compaction and shortening of skeletal muscles, creating an obstacle to passive movements in the joints. Occurs after 2-4 hours from the moment of cardiac arrest, reaches a maximum in a day, is resolved after 3-4 days.

cadaveric decomposition - occurs at a later date, manifested by decomposition and decay of tissues. Decomposition time largely depends on environmental conditions.

Statement of biological death

The fact of the onset of biological death is established by a doctor or paramedic by the presence of reliable signs, and before they appear, by the combination of the following symptoms:

Lack of cardiac activity (no pulse on large arteries, heart sounds are not heard, there is no bioelectrical activity of the heart);

The time of the absence of cardiac activity is significantly more than 25 minutes (at normal ambient temperature);

Lack of spontaneous breathing;

The maximum expansion of the pupils and the absence of their reaction to light;

Lack of corneal reflex;

The presence of postmortem hypostasis in sloping parts of the body.

brain death

With some intracerebral pathology, as well as after resuscitation, a situation sometimes arises when the functions of the central nervous system, primarily the cerebral cortex, are completely and irreversibly lost, while cardiac activity is preserved, blood pressure is maintained or maintained by vasopressors, and breathing is provided by mechanical ventilation. This condition is called brain death (“brain death”). The diagnosis of brain death is very difficult to make. There are the following criteria:

Complete and permanent absence of consciousness;

Sustained lack of spontaneous breathing;

Disappearance of reactions to external stimuli and any kind of reflexes;

Atony of all muscles;

The disappearance of thermoregulation;

Complete and persistent absence of spontaneous and induced electrical activity of the brain (according to electroencephalogram data).

The diagnosis of brain death has implications for organ transplantation. After its ascertainment, it is possible to remove organs for transplantation to recipients. In such cases, when making a diagnosis, it is additionally necessary:

Angiography of cerebral vessels, which indicates the absence of blood flow or its level is below critical;

The conclusions of specialists (neurologist, resuscitator, forensic medical expert, as well as an official representative of the hospital), confirming brain death.

According to the legislation existing in most countries, "brain death" is equated with biological.

Resuscitation measures

Resuscitation measures are the actions of a doctor in case of clinical death, aimed at maintaining the functions of blood circulation, respiration and revitalizing the body. There are two levels of resuscitation: basic and specialized resuscitation. The success of resuscitation depends on three factors:

Early recognition of clinical death;

Start basic resuscitation immediately;

Prompt arrival of professionals and start of specialized resuscitation.

Diagnosis of clinical death

Clinical death (sudden cardiac arrest) is characterized by the following symptoms:

Loss of consciousness;

Absence of a pulse in the central arteries;

Stop breathing;

Absence of heart sounds;

Pupil dilation;

Change in skin color.

However, it should be noted that the first three signs are sufficient to ascertain clinical death and start resuscitation measures: lack of consciousness, pulse on the central arteries and

breathing. After the diagnosis is made, basic cardiopulmonary resuscitation should be started as soon as possible and, if possible, a team of professional resuscitators should be called.

Basic cardiopulmonary resuscitation

Basic cardiopulmonary resuscitation is the first stage of care, the likelihood of success depends on the timeliness of which begins. Carried out at the place of detection of the patient by the first person who owns her skills. The main stages of basic cardiopulmonary resuscitation were formulated back in the 60s of the XX century by P. Safar.

BUT - airways- Ensuring free airway patency.

AT - breathing- IVL.

FROM - circulation- indirect heart massage.

Before starting the implementation of these stages, it is necessary to lay the patient on a hard surface and give him a position on his back with raised legs to increase blood flow to the heart (lift angle 30-45? C).

Ensuring free airway patency

To ensure free patency of the respiratory tract, the following measures are taken:

1. If there are blood clots, saliva, foreign bodies, vomit in the oral cavity, it should be mechanically cleaned (the head is turned on its side to prevent aspiration).

2. The main way to restore airway patency (when the tongue is retracted, etc.) is the so-called triple technique of P. Safar (Fig. 8-9): extension of the head, protrusion of the lower jaw, opening of the mouth. In this case, head extension should be avoided if a cervical spine injury is suspected.

3. After performing the above measures, a test breath is performed according to the "mouth to mouth" type.

Artificial lung ventilation

IVL begins immediately after the restoration of the patency of the upper respiratory tract, carried out according to the type of "mouth-to-mouth" and "mouth-to-nose" (Fig. 8-10). The first method is preferable, the resuscitator takes a deep breath, covers the mouth of the victim with his lips and

Rice. 8-9.Triple reception of P. Safar: a - retraction of the tongue; b - extension of the head; c - protrusion of the lower jaw; d - mouth opening

produces exhalation. In this case, fingers should pinch the nose of the victim. In children, breathing into the mouth and nose is used at the same time. The use of air ducts greatly facilitates the procedure.

General rules of ventilation

1. The volume of injection should be about 1 liter, the frequency is about 12 times per minute. The blown air contains 15-17% oxygen and 2-4% CO 2 , which is quite enough, taking into account the dead space air, which is close in composition to atmospheric.

2. Exhalation should last at least 1.5-2 s. Increasing the duration of expiration increases its efficiency. In addition, the possibility of gastric expansion is reduced, which can lead to regurgitation and aspiration.

3. During mechanical ventilation, the patency of the airways should be constantly monitored.

4. To prevent infectious complications in the resuscitator, you can use a napkin, handkerchief, etc.

5. The main criterion for the effectiveness of mechanical ventilation: expansion of the chest when air is blown in and its collapse during passive exhalation. Swelling of the epigastric region indicates swelling of the

Rice. 8-10.Types of artificial respiration: a - mouth to mouth; b - mouth to nose; in - in the mouth and nose at the same time; g - with the help of an air duct; d - the position of the duct and its types

puddle. In this case, check the patency of the airways or change the position of the head.

6. Such mechanical ventilation is extremely tiring for the resuscitator, therefore it is advisable to switch to mechanical ventilation as soon as possible using the simplest devices of the Ambu type, which also increases the efficiency of mechanical ventilation.

Indirect (closed) heart massage

Indirect cardiac massage is also referred to as basic cardiopulmonary resuscitation and is performed in parallel with mechanical ventilation. Chest compression leads to the restoration of blood circulation due to the following mechanisms.

1. Heart pump: squeezing the heart between the sternum and the spine due to the presence of valves leads to a mechanical extrusion of blood in the right direction.

2. Chest pump: Compression causes blood to be squeezed out of the lungs and into the heart, which greatly contributes to the restoration of blood flow.

Choice of point for chest compression

Pressure on the chest should be made along the midline at the border of the lower and middle thirds of the sternum. Usually, moving the IV finger along the midline of the abdomen upwards, the resuscitator gropes for the xiphoid process of the sternum, applies another II and III to the IV finger, thus finding a compression point (Fig. 8-11).

Rice. 8-11.Choice of compression point and method of indirect massage: a - compression point; b - the position of the hands; c - massage technique

precordial beat

In sudden cardiac arrest, a precordial stroke can be an effective method. A fist from a height of 20 cm is struck twice on the chest at the point of compression. In the absence of effect, proceed to a closed heart massage.

Closed heart massage technique

The victim lies on a rigid base (to prevent the possibility of displacement of the whole body under the action of the hands of the resuscitator) with raised lower limbs (increased venous return). The resuscitator is located on the side (right or left), puts one palm on top of the other and presses on the chest with arms straightened at the elbows, touching the victim at the compression point only with the proximal part of the palm located below. This enhances the pressure effect and prevents damage to the ribs (see Figure 8-11).

Intensity and frequency of compressions. Under the action of the hands of the resuscitator, the sternum should shift by 4-5 cm, the frequency of compressions should be 80-100 per minute, the duration of pressure and pauses are approximately equal to each other.

Active "compression-decompression". Active "compression-decompression" of the chest for resuscitation has been used since 1993, but it has not yet found wide application. It is carried out using the Cardiopamp apparatus, equipped with a special suction cup and providing active artificial systole and active diastole of the heart, contributing to mechanical ventilation.

Direct (open) heart massage

Direct cardiac massage during resuscitation is rarely resorted to.

Indications

Cardiac arrest during intrathoracic or intra-abdominal (transdiaphragmatic massage) operations.

Chest trauma with suspected intrathoracic bleeding and lung injury.

Suspicion of cardiac tamponade, tension pneumothorax, pulmonary embolism.

Injury or deformity of the chest, interfering with the implementation of a closed massage.

Ineffectiveness of closed massage within a few minutes (relative indication: used in young victims, with the so-called "unjustified death", is a measure of desperation).

Technique.Produce thoracotomy in the fourth intercostal space on the left. The hand is inserted into the chest cavity, four fingers are brought under the lower surface of the heart, and the first finger is placed on its front surface and rhythmic compression of the heart is performed. During operations inside the chest cavity, when the latter is wide open, the massage is carried out with both hands.

Combination of ventilation and cardiac massage

The order of combination of mechanical ventilation and heart massage depends on how many people are helping the victim.

Reanimating one

The resuscitator produces 2 breaths, after which - 15 chest compressions. This cycle is then repeated.

Reanimating two

One resuscitator performs mechanical ventilation, the other - an indirect heart massage. In this case, the ratio of respiratory rate and chest compressions should be 1:5. During inspiration, the second rescuer should pause the compressions to prevent gastric regurgitation. However, during massage on the background of mechanical ventilation through an endotracheal tube, such pauses are not necessary. Moreover, compression during inhalation is useful, as more blood from the lungs enters the heart and artificial circulation becomes effective.

The effectiveness of resuscitation

A prerequisite for carrying out resuscitation measures is constant monitoring of their effectiveness. Two concepts should be distinguished:

Efficiency of resuscitation;

Efficiency of artificial respiration and blood circulation.

Resuscitation efficiency

The effectiveness of resuscitation is understood as a positive result of resuscitation of the patient. Resuscitation measures are considered effective in the event of the appearance of sinus rhythm of heart contractions, restoration of blood circulation with registration of systolic blood pressure of at least 70 mm Hg, constriction of the pupils and the appearance of a reaction to light, restoration of the color of the skin and the resumption of spontaneous breathing (the latter is not necessary) .

Efficiency of artificial respiration and circulation

The effectiveness of artificial respiration and blood circulation is said when resuscitation measures have not yet led to the revival of the body (there is no independent blood circulation and respiration), but the measures taken artificially support metabolic processes in tissues and thereby lengthen the duration of clinical death. The effectiveness of artificial respiration and blood circulation is evaluated by the following indicators:

1. Constriction of the pupils.

2. The appearance of a transmission pulsation on the carotid (femoral) arteries (assessed by one resuscitator when another chest compressions are performed).

3. Change in the color of the skin (reduction of cyanosis and pallor).

With the effectiveness of artificial respiration and blood circulation, resuscitation continues until a positive effect is achieved or until the indicated signs disappear permanently, after which resuscitation can be stopped after 30 minutes.

Drug therapy in basic resuscitation

In some cases, during basic resuscitation, it is possible to use pharmacological preparations.

Routes of administration

During resuscitation, three methods of administering drugs are used:

Intravenous jet (in this case, it is desirable to administer drugs through a catheter in the subclavian vein);

Intracardiac;

Endotracheal (with tracheal intubation).

Intracardiac technique

The ventricular cavity is punctured at a point located 1-2 cm to the left of the sternum in the fourth intercostal space. This requires a needle 10-12 cm long. The needle is inserted perpendicular to the skin; a reliable sign of the needle being in the cavity of the heart is the appearance of blood in the syringe when the piston is pulled towards itself. Intracardiac administration of drugs is not currently used due to the threat of a number of complications (lung injury, etc.). This method is considered only in the historical aspect. The only exception is the intracardiac injection of epinephrine into the ventricular cavity during open heart massage using a conventional injection needle. In other cases, drugs are injected into the subclavian vein or endotracheally.

Drugs used in basic resuscitation

For several decades, epinephrine, atropine, calcium chloride, and sodium bicarbonate have been considered essential in basic cardiopulmonary resuscitation. Currently, the only universal drug used in cardiopulmonary resuscitation is epinephrine at a dose of 1 mg (endotracheally - 2 mg), it is administered as early as possible, subsequently repeating infusions every 3-5 minutes. The main effect of epinephrine during cardiopulmonary resuscitation is the redistribution of blood flow from peripheral organs and tissues to the myocardium and brain due to its α-adrenomimetic effect. Epinephrine also excites β-adrenergic structures of the myocardium and coronary vessels, increases coronary blood flow and contractility of the heart muscle. With asystole, it tones the myocardium and helps to "start" the heart. In ventricular fibrillation, it promotes the transition of small-wave fibrillation to large-wave fibrillation, which increases the efficiency of defibrillation.

The use of atropine (1 ml of a 0.1% solution), sodium bicarbonate (4% solution at a rate of 3 ml/kg of body weight), lidocaine, calcium chloride and other drugs is carried out according to indications, depending on the type of circulatory arrest and the cause that caused it. In particular, lidocaine at a dose of 1.5 mg/kg of body weight is the drug of choice for fibrillation and ventricular tachycardia.

Basic resuscitation algorithm

Taking into account the complex nature of the necessary actions in case of clinical death and their desirable speed, a number of specific

Rice. 8-12.Algorithm for basic cardiopulmonary resuscitation

nyh algorithms of actions of the resuscitator. One of them (Yu.M. Mikhailov, 1996) is shown in the diagram (Fig. 8-12).

Basics of specialized cardiopulmonary resuscitation

Specialized cardiopulmonary resuscitation is carried out by professional resuscitators using special diagnostic and treatment tools. It should be noted that specialized activities are carried out only against the background of basic cardiopulmonary resuscitation, supplement or improve it. Free airway patency, mechanical ventilation and indirect heart massage are essential and main components of all resuscitation

events. Among the ongoing additional activities in order of their implementation and significance, the following can be distinguished.

Diagnostics

By clarifying the anamnesis, as well as special diagnostic methods, the causes that caused clinical death are revealed: bleeding, electrical injury, poisoning, heart disease (myocardial infarction), pulmonary embolism, hyperkalemia, etc.

For treatment tactics, it is important to determine the type of circulatory arrest. Three mechanisms are possible:

Ventricular tachycardia or ventricular fibrillation;

asystole;

Electromechanical dissociation.

The choice of priority therapeutic measures, the result and prognosis of cardiopulmonary resuscitation depend on the correctness of recognition of the mechanism of circulatory arrest.

Venous access

Ensuring reliable venous access is a prerequisite for resuscitation. The most optimal - catheterization of the subclavian vein. However, catheterization itself should not delay or interfere with resuscitation. Additionally, it is possible to administer drugs into the femoral or peripheral veins.

Defibrillation

Defibrillation is one of the most important specialized resuscitation measures necessary for ventricular fibrillation and ventricular tachycardia. The powerful electric field created during defibrillation suppresses multiple sources of myocardial excitation and restores sinus rhythm. The earlier the procedure is performed, the higher the likelihood of its effectiveness. For defibrillation, a special apparatus is used - a defibrillator, the electrodes of which are placed on the patient, as shown in the diagram (Fig. 8-13).

The power of the first discharge is set to 200 J, if this discharge is ineffective, the second is 300 J, and then the third is 360 J. The interval between discharges is minimal - only in order to

Rice. 8-13.The layout of the electrodes during defibrillation

make sure on the electrocardioscope that fibrillation persists. Defibrillation can be repeated several times. At the same time, it is extremely important to observe safety precautions: the absence of contact between medical personnel and the patient's body.

Tracheal intubation

Intubation should be done as early as possible, as it provides the following benefits:

Ensuring free airway patency;

Prevention of regurgitation from the stomach with indirect heart massage;

Ensuring adequate controlled ventilation;

The possibility of simultaneous compression of the chest when blowing air into the lungs;

Ensuring the possibility of intratracheal administration of medicinal substances (drugs are diluted in 10 ml of saline and injected through a catheter distal to the end of the endotracheal tube, after which 1-2 breaths are taken; the dose of drugs is increased by 2-2.5 times compared to intravenous administration).

Medical therapy

Drug therapy is extremely diverse and largely depends on the cause of clinical death (the underlying disease). The most commonly used are atropine, antiarrhythmic

agents, calcium preparations, glucocorticoids, sodium bicarbonate, antihypoxants, means of replenishing BCC. When bleeding paramount importance is given to blood transfusion.

Brain protection

During resuscitation, cerebral ischemia always occurs. To reduce it, use the following means:

Hypothermia;

Normalization of acid-base and water-electrolyte balance;

Neurovegetative blockade (chlorpromazine, levomepromazine, diphenhydramine, etc.);

Decreased permeability of the blood-brain barrier (glucocorticoids, ascorbic acid, atropine);

Antihypoxants and antioxidants;

Drugs that improve the rheological properties of blood.

Assisted circulation

In the event of clinical death during cardiac surgery, it is possible to use a heart-lung machine. In addition, the so-called auxiliary circulation (aortic counterpulsation, etc.) is used.

Algorithm for specialized resuscitation

Specialized cardiopulmonary resuscitation is a branch of medicine, a detailed presentation of which is in special manuals.

Prognosis of resuscitation and post-resuscitation illness

The prognosis of the restoration of body functions after resuscitation is primarily associated with the prognosis of the restoration of brain functions. This prognosis is based on the duration of the absence of blood circulation, as well as on the time of appearance of signs of restoration of brain functions.

The effectiveness of resuscitation, the restoration of blood circulation and respiration do not always indicate a complete restoration of body functions. Metabolic disorders during OS-

Circulation and respiration, as well as during urgent resuscitation, lead to insufficiency of the functions of various organs (brain, heart, lungs, liver, kidneys), which develops after stabilization of the parameters of the main vital systems. The complex of changes that occur in the body after resuscitation is called “post-resuscitation disease”.

Legal and moral aspects

Indications for resuscitation

Issues on the conduct and termination of resuscitation are regulated by legislative acts. Carrying out cardiopulmonary resuscitation is indicated in all cases of sudden death, and only in the course of its implementation, the circumstances of death and contraindications to resuscitation are clarified. The exception is:

Injury incompatible with life (detachment of the head, crushing of the chest);

The presence of clear signs of biological death.

Contraindications for resuscitation

Cardiopulmonary resuscitation is not indicated in the following cases:

If death occurred against the background of the use of the full complex of intensive care indicated for this patient, and was not sudden, but associated with a disease incurable for the present level of development of medicine;

In patients with chronic diseases in the terminal stage, while the hopelessness and futility of resuscitation should be recorded in advance in the medical history; such diseases often include stage IV malignant neoplasms, severe forms of stroke, incompatible with life injuries;

If it is clearly established that more than 25 minutes have passed since the moment of cardiac arrest (at normal ambient temperature);

If patients have previously recorded their justified refusal to conduct resuscitation in the manner prescribed by law.

Termination of resuscitation

Cardiopulmonary resuscitation may be terminated in the following cases.

Assistance is provided by non-professionals - in the absence of signs of the effectiveness of artificial respiration and blood circulation within 30 minutes of resuscitation or at the direction of resuscitation specialists.

Help from professionals:

If during the course of the procedure it turned out that resuscitation was not indicated for the patient;

If resuscitation measures are not fully effective within 30 minutes;

If there are multiple cardiac arrests that are not amenable to medical influences.

Problems of euthanasia

There are two types of euthanasia: active and passive.

Active euthanasia

This is intentional compassionate mortification at the request of the patient or without it. It implies the active actions of a doctor and is otherwise called "filled syringe method". Such actions are prohibited by the laws of the vast majority of countries, they are considered as a criminal act - deliberate murder.

Passive euthanasia

Passive euthanasia is the limitation or exclusion of particularly complex medical methods, which, although they would lengthen the life of the patient at the cost of further suffering, would not save her. Otherwise, passive euthanasia is called "Delayed syringe method". Particularly relevant is the problem of passive euthanasia in the treatment of extremely severe, incurable diseases, decortication, and severe congenital malformations. The morality, humanity and expediency of such actions of doctors are still perceived by society ambiguously, in the vast majority of countries such actions are not recommended.

All types of euthanasia are prohibited in Russia.

Lectures for obstetricians and paramedics (for medical schools and medical colleges).
Lecture 1

The concept of resuscitation

Terminal States

Signs of clinical death

Stages of SLCR

Signs of brain death
Lecture 2

Cardiovascular insufficiency

Pulmonary edema

Acute right ventricular failure, pulmonary embolism

Heart arrhythmias

myocardial infarction

Cardiogenic shock

angina pectoris

Hypertensive crisis
Lecture 3
Resuscitation and intensive care in acute respiratory failure.
Acute respiratory failure

Hypoxia, hypercapnia

Stenosing laryngotracheobronchitis

Hanging

Drowning

asthmatic condition

Aspiration syndrome
Lecture 4
Resuscitation and intensive care for shock.
Classification of shocks

Hemorrhagic shock

burn shock

Anaphylactic shock

Toxic-infectious shock

polytrauma
Lecture 5
Resuscitation and intensive therapy for comas.
Coma, causes, signs

diabetic coma

Hypoglycemic coma

hepatic coma

Acute renal failure

Acute cerebrovascular accident, stroke

Traumatic brain injury

convulsive syndrome

Thyrotoxic crisis
Lecture 6
Resuscitation and intensive therapy in acute exogenous poisonings.
poisonous substances

Major Syndromes

Providing emergency care

Common acute poisonings
Lecture 7 (for paramedics)
Resuscitation and intensive therapy under adverse effects of environmental factors.
Hyperthermia

Hypothermia

electrical injury

Prolonged crushing of soft tissues
Lecture 8 (for paramedics)
Resuscitation and intensive care in obstetric pathology.
Asphyxia of the newborn

Newborn resuscitation

Indications for IVL

Eclampsia

Amniotic fluid embolism
Lecture 9
The concept of anesthesiology and resuscitation. Types of general anesthesia. Local anesthesia.
Pain, anesthesiology

Local anesthesia

Anesthesia equipment

Complications of anesthesia
Bibliography
terminal states. Cardiopulmonary and cerebral resuscitation.

Lecture 1
Resuscitation is a clinical specialty and an independent science about the regularities of the extinction of the main functions of the body, their immediate restoration and long-term active maintenance using specific techniques, methods and means.
Resuscitation is a set of measures aimed at restoring lost or severely impaired vital body functions in patients in a state of clinical death.
Intensive care is a complex medical care for patients in a serious or terminal condition, due to a violation of the vital functions of the body.
Intensive care consists of two interrelated parts: the actual intensive care (treatment measures) and intensive monitoring.
A critical level of life dysfunction with a catastrophic drop in blood pressure, a profound disruption of gas exchange and metabolism is called a terminal state. Classification of the terminal state according to Negovsky: pre-agony, agony, clinical death.
Predagonal state: consciousness is confused, blood pressure is not determined, there is no pulse on the peripheral arteries, but it is palpated on the carotid and femoral arteries; respiratory disorders are manifested by severe shortness of breath, external breathing is weakened, ineffective, cyanosis or pallor of the skin and mucous membranes.
Following the preagonal state, a terminal pause develops - a state lasting 1-4 minutes: breathing stops, bradycardia develops, sometimes asystole, pupil reactions to light disappear, corneal and other stem reflexes disappear, pupils dilate. At the end of the terminal pause, agony develops - the stage of dying, which is characterized by the activity of the bulbar parts of the brain. One of the clinical signs of agony is terminal (agonal) breathing with characteristic rare, short, deep convulsive respiratory movements, sometimes with the participation of skeletal muscles. Vascular tone can be restored - systolic blood pressure rises to 50-70 mm Hg. A pulse is palpated over the main arteries. However, in this case, metabolic disorders in the cells of the body become irreversible. The remnants of energy accumulated in macroergic bonds quickly burn out, and after 20-40 seconds clinical death occurs.
Clinical death is ascertained at the moment of complete cessation of blood circulation, respiration and switching off the functional activity of the central nervous system.
There are 3 types of conditions that develop after the cessation of the activity of the heart:
1- (reversible) - clinical death, during which there are no irreversible changes in vital organs and systems, in particular in the central nervous system

2- (partially reversible) - social death, in which, with the non-viability of the cerebral cortex, changes in other tissues are still reversible
3- (irreversible) - biological death, when all tissues are not viable and irreversible changes develop in them.
In the terminal stage of any incurable disease, resuscitation is futile and should not be used. An absolute contraindication to revival is pronounced hypostatic spots in sloping parts of the body as a reliable sign of biological death.
The diagnosis of clinical death is made on the basis of signs of death, basic and additional.
Main:
1) Absence of a pulse in the carotid or femoral artery
2) Stop breathing
3) Lack of consciousness
Additional:
4) Discoloration of the skin (very pale or cyanotic)
5) Pupil dilation
When determining the signs of clinical death, the nurse should act in the following sequence:
- To establish the fact of cessation of blood circulation by the absence of a pulse on the main vessels (to determine the location of the carotid artery, 4 fingers are placed across the lateral surface of the neck, in the groove between the trachea and the sternocleidomastoid muscle).
- Make sure that there is no breathing (lack of respiratory excursions of the chest and air flow near the mouth and nose on exhalation)
- Establish the fact of lack of consciousness - loss of consciousness is noted almost immediately (after 15-30 seconds), after the cessation of blood circulation. Preservation of consciousness excludes the cessation of blood circulation!
- Raise the upper eyelid and determine the width of the pupils. When blood circulation and breathing stop, the pupils dilate after 25-60 seconds and become unnaturally wide.
- Assess visually the shade of the skin (progressive cyanosis or deathly pallor).

You can not waste time measuring blood pressure, recording an ECG, listening to heart sounds.
No more than 8-10 seconds should be spent on establishing a diagnosis.
The presence of any three of the four main signs (loss of consciousness, dilated pupils, absence of pulse, respiratory arrest) in any combination gives the right to make a diagnosis of "clinical death" and start LACR.
According to the algorithm of actions, when performing CPR, first of all, you need to call for help. But the nurse is obliged to start CPR, having established clinical death, without waiting for the arrival of a doctor.
There are 3 stages of LTCR according to P. Safar:
Stage 1 - elementary life support, the main purpose of which is general oxygenation. It consists of 3 stages:
a) restore airway patency
b) IVL
c) external cardiac massage
Stage II - further maintenance of life. The main task of this stage is the restoration of independent blood circulation. These activities are carried out by a specialized medical care team or hospital doctors. There are such stages of this stage:

a) medication
b) ECG control to determine the type of circulatory arrest
c) performing defibrillation in case of ventricular fibrillation.
Stage III - long-term maintenance of life. Its goal is cerebral resuscitation, further therapy of homeostasis disorders, complications. It is also carried out in 3 stages:
a) assessment of the patient's condition in terms of the possibility of its full recovery
b) measures aimed at restoring normal thinking
c) intensive care of complications of the post-resuscitation period
The significance of the three most important techniques of cardiopulmonary resuscitation in their logical sequence was formulated by P. Safar in the form of the "ABC rule": 1) aire way open -

ensure the patency of the airways; 2) breath for victim - start artificial respiration; 3) circulation his blood - restore blood circulation.
Restoration of airway patency is carried out by a triple technique according to Safar - throwing the head back, the maximum forward displacement of the lower jaw and opening the patient's mouth.
IVL at the stage of first aid is carried out "mouth to mouth" with exhaled air. In this case, the effectiveness of inhalation is judged by the rise of the chest.
In the absence of blood circulation, immediately proceed to an indirect heart massage. The patient lies on his back on a hard surface. The caregiver stands on the side of the victim and puts the hand of one hand on the lower middle third of the sternum, and the second hand on top, across the first to increase pressure. The rescuer's shoulders should be directly above the palms, the arms should not be bent at the elbows. With rhythmic pushes of the proximal part of the hand, they press on the sternum in order to shift it towards the spine by approximately 4-5 cm. The pressure force should be such that one of the team members can clearly identify an artificial pulse wave on the carotid or femoral artery. The number of chest compressions should be 100 in 1 minute. The ratio of chest compressions to rescue breathing in adults is 30:2 regardless of whether one or two people are doing CPR. In children, 15:2 if CPR is performed by 2 people, 30:2 if it is performed by 1 person.
If, despite the correct resuscitation within 30 minutes, signs of clinical death persist, and it is impossible to call a specialized ambulance team, LACR can be stopped.
At stage II, against the background of mechanical ventilation and heart massage, medications are administered.
As soon as possible, ideally at the same time as the massage begins, epinephrine and atropine are injected into the vein. If intravenous administration is not possible, the drugs are used endotracheally in doses 2-2.5 times higher than intravenous in adults and 10 times higher in children. Preparations are preliminarily diluted with 10 ml of distilled water.
Every 3-5 minutes, 1 mg of adrenaline is injected intravenously or 2-3 ml endotracheally.
Atropine - 3 mg is administered intravenously once.
At stage II, electrocardiography is performed to determine the type of circulatory arrest.
There are 3 types of circulatory arrest:
- asystole (isoline on the ECG)
- ventricular fibrillation - (uncoordinated contractions of individual muscle fibers), on the ECG - in the form of random teeth of different amplitudes

- "inefficient heart" - the electrical activity of the heart is preserved, but cardiac contractions are sharply weakened or absent. On the ECG, the complexes are preserved, but more often they are deformed, with a low amplitude.
In ventricular fibrillation, an effective means of restoring cardiac activity is electrical defibrillation. Shocks of 200, 200 and 360 J (4500 and 7000 V) are recommended. All subsequent discharges - 360 J.
In case of ventricular fibrillation after the 3rd discharge, cordarone is administered at an initial dose of 300 mg (in 20 ml of saline or 5% glucose solution), repeatedly - 150 mg each (up to a maximum of 2 g). In the absence of cordarone, lidocaine is administered - 1-1.5 mg / kg every 3-5 minutes to a total dose of 3 mg / kg.
Soda is administered (4% - 100 ml) only in case of severe acidosis, after 20-25 minutes of SLCR.
Magnesia sulfate - 1-2 g IV for 1-2 minutes, repeat after 5-10 minutes.
The second stage of SLCR continues until the restoration of cardiac activity. If, despite the implementation of all of the above measures, a straight line (asystole) is determined on the ECG for 30 minutes, the SLCR is stopped.
Stage III of the LTCR begins after the patient is delivered to the ICU. Its effectiveness depends on the severity of the initial state (before circulatory arrest), the duration of circulatory arrest, the severity of the violation of basic vital functions and the nature of the complications that arose after resuscitation.
It should be noted that if the nurse can and should carry out stages I–II of the LACR on her own, then only the doctor prescribes therapeutic measures, and the nurse fulfills his appointments. The success of the treatment of the patient largely depends on the care of the nurse. A round-the-clock nursing post is established near the post-resuscitation patient. Of great importance is the correct maintenance of medical records (the nurse constantly monitors and records clinical and laboratory data, the results of monitoring observation).
Various complications of resuscitation are associated with deviations from the above methodology. Prolonged tracheal intubation - longer than 15 s - leads to asphyxia and irreversible cardiac arrest. Another complication - rupture of the lung parenchyma, tension pneumothorax - occurs during forced air injection under pressure and is more often observed in young children. Unqualified external heart massage entails a fracture of the ribs; relatively more often this complication is observed in the elderly. If, with a closed heart massage, the point of maximum pressure on the sternum is excessively shifted to the left, then along with a fracture of the ribs, lung tissue is damaged; if it is shifted down, then a liver rupture may occur; if up - a fracture of the sternum. These complications are now considered gross errors in the resuscitation technique.
One of the complications of resuscitation (especially in cases where tracheal intubation was not performed) is the regurgitation of gastric contents into the respiratory tract. It occurs due to the ingress of air into the stomach during its forced inflation. Usually,

this happens in case of insufficient tilting of the head, when the root of the tongue partially blocks the entrance to the trachea, and the main part of the air enters not into the lungs, but into the stomach and overstretches it. In unconscious patients, the cardiac sphincter is relaxed, so the contents of the stomach flow out of it and into the lungs.
Signs of brain death:
- lack of consciousness, spontaneous breathing, areflexia
- unstable hemodynamics (BP is supported only by stimulation therapy)
- progressive decrease in body temperature
- lack of electrical activity on the electroencephalogram (straight line, recorded for 30 minutes, twice a day)
- no EEG changes after intravenous administration of bemegride solution
- negative cold test (absence of nystagmus when 5 ml of chilled saline is injected into the external auditory canal
- the absence of a difference in the oxygen content in the inflowing (arterial) and outflowing from the brain (venous) blood.
No matter how perfect the ambulance is in the present and future, it will be late when it comes to acute circulatory and respiratory arrest; 3-5 minutes separate a reversible state - clinical death from irreversible damage to the central nervous system and a number of organs characteristic of biological death. Real help can only be expected from people in the immediate vicinity of the scene. The practice of revival fully proved the possibility of a successful return to life on the street and on the shore of a reservoir, in an apartment and at work. An excellent proof of this are tens of thousands of dead and brought back to life, thanks to the successful application of a clear method of resuscitation that has developed today.
So, a person who suddenly died before your eyes is not hopeless. Remember that only you can help him. Hurry, because with every minute his chances of life are falling!
Chepky L.P. "Resuscitation and intensive care", pp. 96-111.

Resuscitation and IT in acute cardiovascular failure.

Lecture 2
Acute cardiovascular failure is a pathological condition caused by the inadequacy of cardiac output to the metabolic needs of the body. In this condition, the heart does not provide organs and tissues with a sufficient amount of blood, and hence oxygen and energy substances. In medical practice, there is a term "small ejection syndrome", which can be due to three reasons: a) a sudden decrease in myocardial contractility; b) a sudden decrease in blood volume; c) a sudden drop in vascular tone or a combination of these causes.
Conventionally, cardiovascular insufficiency is divided into cardiac and vascular. The occurrence of hemodynamic disturbances in heart failure is due to the pathology of the heart, and in vascular insufficiency - a decrease in vascular tone.
The causes of heart failure are: hypertension, acquired and congenital heart defects, pulmonary embolism, myocardial infarction, myocarditis, cardiosclerosis, myocardiopathy, myocardial dystrophy.
One of the most common forms of heart failure is acute left ventricular failure. Clinically, acute left ventricular failure is manifested by pulmonary edema.
Pulmonary edema develops under the condition of massive fluid leakage into the interstitial tissues and alveoli. This leads to increased hydrodynamic pressure in the pulmonary capillaries or reduced oncotic pressure, increased permeability of alveolocapillary membranes.
The patient's condition is serious. Forced position in bed (sitting). Expressed inspiratory dyspnea, cyanosis. There may be a choking cough with bloody frothy sputum. First, hard breathing, dry rales are heard in the lungs. With the further development of the pathological process, multiple wet rales, bubbling breathing, audible at a distance, are heard.
According to the rate of development of O.L. can be instant (develops over 5-10 minutes), acute (increases over 1 hour) and protracted (lasts from 1 to 2 days). It may be accompanied by arterial hypertension or a decrease in blood pressure (small ejection syndrome).
Treatment. The patient is given an elevated position of the body, better sitting with his legs down, which contributes to the deposition of blood in the lower sections and a decrease in pressure in the vessels of the pulmonary circulation. In the case of high blood pressure, distracting measures are used (mustard plasters on the calf muscles, venous tourniquets on the lower limbs). The use of distractions in patients with low blood pressure is contraindicated.
If there is a large amount of foam, it is immediately sucked off with suction. To combat hypoxia, inhalation of oxygen with defoamers is carried out. As defoamers

use solutions of ethyl alcohol, antifomsilane. Oxygen is passed through a Bobrov jar or, better, an anesthesia machine vaporizer at a rate of 8-12 l/min. With the ineffectiveness of these measures and the progression of respiratory failure, the trachea is intubated and the patient is transferred to mechanical ventilation with a positive D on exhalation (5-15 cm of water column).
With increased or normal blood pressure, to reduce hydrostatic pressure in a small circle, nitrates are used, primarily nitroglycerin, first sublingually (0.8 mg each), then intravenously (10-40 mcg / min) under constant control of blood pressure. Nitrates reduce hydrostatic D in the pulmonary artery, and also improve coronary circulation.
To reduce psychomotor agitation and shortness of breath, narcotic analgesics are used. Morphine - 5-10 mg / m. It has a sedative effect, reduces the excitability of the respiratory center, reduces shortness of breath, dilates the veins, but can cause respiratory depression.
A good "unloading" effect is provided by diuretics. Furosemide IV 20-40 mg.
Glucocorticoids are used to combat arterial hypotension. (Hydrocortisone 5-15 mg/kg or prednisolone 5-10 mg/kg), polarizing (glucose-potassium-insulin) mixture with vitamins. Glucocorticoids are also used to reduce the permeability of the alveolocapillary membrane.
If O.L. develops against the background of arterial hypotension, it is necessary to use cardiotonic drugs (dopamine, dobutamine). Dopamine should be used in combination with nitrate infusion. Infusion therapy should be carried out under the control of the CVP. You can not increase it above the norm.
Acute right ventricular failure develops as a result of an obstacle that occurs in the pulmonary circulation (pulmonary embolism, fat and air embolism, uncontrolled asthma attack).
TELA. The following factors play a decisive role in the pathogenesis of development: damage to the inner surface of the vascular wall, slowing of blood flow and deterioration of the rheological properties of blood, and disorders of the blood coagulation system. The clinic of pulmonary embolism depends on the site of thrombus formation, the size of the embolus, and the severity of cardiovascular insufficiency. The initial signs of thromboembolism may not be pronounced, increase gradually. When the embolus is large and blocks the lumen of the pulmonary artery, death can occur instantly.
With PE, certain syndromes are noted that the nurse must be able to recognize:

ARF - a feeling of lack of air, shortness of breath, hemoptysis, pleural rub. In patients with massive thromboembolism, pronounced cyanosis of the face and upper body is noted.

Acute cardiovascular insufficiency, which occurs in the first minutes of the disease. It is characterized by severe tachycardia, arrhythmia, swelling of the cervical veins, an increase in

liver, arterial hypotension, signs of acute coronary insufficiency. Increased CVP.

Pain syndrome. More often it occurs suddenly, like a dagger strike in the upper part of the chest. It is caused by acute coronary insufficiency, expansion of the pulmonary artery, right ventricle

Cerebral syndrome - characterized by stupor, in some cases, loss of consciousness, convulsions caused by hypoxia, cerebral edema.
If PE is suspected, the nurse should immediately start inhaling oxygen through a mask or nasal catheter, and in the event of a sharp deterioration in the general condition (increasing cardiovascular and respiratory failure), prepare everything necessary for tracheal intubation, transferring the patient to a ventilator and performing LTSR.
To stop the pain syndrome, 1-2 ml of a 0.005% solution of fentanyl, analgin or promedol are administered intravenously in generally accepted doses. When excited, 1-2 ml of sibazon is injected.
All patients with suspected thromboembolic complications are immediately given fibrinolytic therapy (streptase, streptokinase, urokinase), anticoagulant therapy. 10,000 units of heparin are administered intravenously at once, and then 1000 units every hour. Enter drugs that improve microcirculation (reopoliglyukin, trental).
CVP control is required. To reduce pressure in the pulmonary circulation, intravenous injections of a 2% solution of papaverine or no-shpa, 2 ml every four hours, are recommended under the control of blood pressure. In addition, a 2% solution of aminophylline 10 ml in 200 ml of isotonic sodium chloride solution is injected intravenously.
In the event of progressive heart failure, cardiac glycosides, diuretics (furosemide), glucocorticoids, sympathomimetics (dopamine) are prescribed. It is mandatory to carry out oxygen therapy with humidified oxygen through nasal catheters at a rate of 5-7 l/min.
When cardiac activity stops, resuscitation is carried out.
Arrhythmias of the heart.
The main types of cardiac arrhythmias are asystole, fibrillation, frequent ventricular extrasystoles, paroxysmal tachycardia, atrioventricular blockade, atrial fibrillation. The causes of arrhythmias can be myocardial infarction, rheumatic heart disease, cardioatherosclerosis, myocarditis, hypertension, intoxication, hypoxia.
Asystole is a type of heart rhythm disorder characterized by the absence of myocardial contractions, which is determined by a straight line on the ECG and clinical signs of circulatory arrest.
Ventricular fibrillation is a chaotic contraction of individual myocardial fibers, as a result of which blood does not enter the circulatory system.
Ventricular extrasystole - the ectopic focus of excitation is located directly in the myocardium of the ventricles or in the interventricular septum. On the ECG, the QRS complex is widened and deformed. The R wave is absent. Violations of central hemodynamics and heart failure are determined.
Paroxysmal tachycardia - an ectopic focus of excitation is located in the atria of the atrioventricular node, ventricles. This pathology leads to frequent rhythmic heart contractions. On the ECG, ventricular extrasystoles are observed with a frequency of 140 to 220 per 1 minute, which follow one after another. Shock Clinic. Stopped by intravenous drip injection of a polarizing mixture, intravenous administration of verapamil 2-4 ml in 20 ml of saline solution
Atrial fibrillation - it is caused by scattered local disturbances in the conduction of the heart. On the ECG, instead of the P wave, flicker waves are observed, the intervals between individual complexes are different. Pulse 90-200 in 1 minute. Thromboembolism may develop. Hemodynamic disturbances are not always severe, and if appropriate therapy is prescribed, the development of heart failure can be prevented. It is stopped by the introduction of cordarone (300 mg in 200 ml of 5% glucose), novocainamide (10 ml + 10 ml of physical solution + 0.3 ml of mezaton).
Atrioventricular (atrioventricular) blockade - occurs due to impaired conduction of impulses from the atria to the ventricles (IHD, I.M., heart defects, vegetovascular dystonia, as well as intoxication with digitalis preparations, quinidine, novocainamide). There are 4 degrees of PZHB:
Grade 1 - on the ECG, only the prolongation of the PQ interval is determined - the time of passage of the impulse from the atria to the ventricles. Does not appear clinically.
11 art. - There is a gradual, from cycle to cycle, lengthening of the PQ interval, and then after one of the teeth, the QRS complex does not occur. The next P wave occurs in a timely manner and again there is a gradual lengthening of the PQ interval
111 Art. - Only every second, third I.d. reaches the ventricles. impulses. Patients have bradycardia, increased manifestations of cardiovascular insufficiency
1U Art.- Mark a complete atrioventricular (transverse) blockade. Not a single impulse from the atria reaches the ventricles. The atria and ventricles work independently of each other, each in its own rhythm. The frequency of atrial contractions is normal, and the frequency of ventricular contractions is of course less than 50 per minute, sometimes even decreasing to 20-30 per minute.
To the typical clinical signs of blockade 1U Art. include rare heart contractions, loss of consciousness, which is accompanied by convulsions. The so-called Morgagni-Adams-Stokes attacks. Atropine, isadrin, furosemide. Pacemaker.
^ MYOCARDIAL INFARCTION.

A disease caused by the occurrence of ischemic necrosis of a section of the heart muscle due to insufficiency of the coronary circulation. Atherosclerosis of the coronary arteries is the most common cause of a heart attack. The deposition of atherosclerotic plaques leads to a narrowing of the lumen of the vessels, and then to its blockage, as a result of which the blood supply to the myocardial area worsens and then stops. Less often, the development of I.M. cause prolonged spasm of the coronary vessels, arterial hypotension.
One of the main symptoms of I.M. - an attack of intense pain. There is a rapidly growing pain in the region of the heart, the left half of the chest, behind the sternum, which lasts more than 30 minutes. It can have a different character: pressing, squeezing, stabbing, burning, chest pain, etc. Sometimes pronounced vegetative reactions are observed (sweating, pallor of the skin, a sense of fear of death, arousal).
BP can be elevated, normal, or low. There may be cardiac arrhythmias (group extrasystoles, paroxysmal tachycardia, ventricular fibrillation).
In patients with I.M. life-threatening complications may occur: heart failure, cardiogenic shock, cardiac arrhythmias, reflex collapse, thromboembolism.
Urgent care. Patients with I.M. assisted by specialized cardiological emergency medical teams. help, and then they are treated in the ICU. The role of the nurse in the treatment of patients with I.M. very large.
The nurse directly takes part in resuscitation (performs closed heart massage, mechanical ventilation, drug treatment), monitors the work of monitors, respirators, electrocardiographs and other medical and diagnostic equipment.
To relieve pain, the patient is first given 1-2 tablets of nitroglycerin. If there is no relief, analgesics are used (analgin-papaverine-diphenhydramine, + sibazon). If there is no effect, droperidol is added (if there is no arterial hypotension), and if necessary, narcotic analgesics (fentanyl, morphine).
Be sure to use a constant, as early as possible inhalation of oxygen!
The patient is given an aspirin tablet to chew. 10 thousand units of heparin are administered intravenously, then in doses that depend on the indicators of blood clotting time, coagulogram data. The clotting time is monitored every 4-6 hours from the moment of development of I.M. and initiation of anticoagulant therapy.
Nitroglycerin is introduced intravenously (drip, slowly, under the control of blood pressure), calcium channel antagonists (verapamil, nifedipine), beta-blockers (0.1% solution of obzidan - 2 ml intravenously slowly, no faster than 5 minutes; 2-3 times in the first hour and then 0.05 mg / kg every 8 hours, followed by a transition (2-3 days) to taking anaprilin inside, 20 mg 4-6 times a day.

CARDIOGENIC SHOCK. A serious condition of the body due to acute circulatory failure, which develops due to a deterioration in myocardial contractility, pumping function of the heart, or a violation of the rhythm of its activity. The most common cause of shock is myocardial infarction. Shock can also develop as a result of cardiac injury, acute myocarditis, and other cardiovascular diseases.
The ICU nurse should be familiar with the symptoms and techniques of IT for this type of shock.
The clinical picture of shock is determined by its form and severity. There are 3 forms of KSh:
reflex (pain), arrhythmogenic, true cardiogenic.
Reflex cardiogenic shock is sometimes called pain shock, because the pain factor plays an important role in the pathogenesis of its development. Most often, pain shock occurs during myocardial infarction of the lower-posterior localization in middle-aged men. This complication occurs at the height of the pain attack. Hemodynamics normalizes after relief of pain.
Arrhythmogenic cardiogenic shock develops as a result of cardiac arrhythmias. More often it develops during ventricular tachysystole (more than 150 in 1 minute) due to atrial fibrillation or supraventricular paroxysmal tachycardia.

True cardiogenic shock is primarily due to impaired myocardial contractility. This is the most severe form of shock. The cause of its development is most often extensive necrosis of the left ventricle, which occurs suddenly and leads to a sharp decrease in cardiac output.
Shock Clinic. The patient is adynamic, lethargic. Sometimes there is short-term psychomotor agitation. The face is pale, with a grayish-ash tint. The lips are cyanotic, the extremities are cold, the veins are collapsed. The skin becomes marbled. Cold clammy sweat comes out. Leading symptoms: a catastrophic drop in blood pressure, tachycardia, shortness of breath, congestion in the lungs up to edema, oliguria.
When providing medical care to patients with cardiogenic shock, the role of a nurse is enormous. It checks the operation of the electrocardiograph, monitor, respirator and other medical and diagnostic equipment. The nurse independently performs indirect heart massage and mechanical ventilation during resuscitation. If during the ECG registration the heart stops or fibrillation occurs, the nurse is obliged, without waiting for the doctor's instructions, to hit the edge of her palm in the region of the lower-middle third of the sternum (precordial impact).

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