Emergency conditions and emergency medical care. Algorithm of actions in case of emergency

The most important thing before the doctors arrive is to stop the influence of factors that worsen the well-being of the injured person. This step involves the elimination of life-threatening processes, for example: stopping bleeding, overcoming asphyxia.

Determine the actual status of the patient and the nature of the disease. The following aspects will help with this:

• what are the blood pressure values.
• whether visually bleeding wounds are visible;
• the patient has a pupillary reaction to light;
• whether the heart rate has changed;
• whether or not respiratory functions are preserved;
• how adequately a person perceives what is happening;
• the victim is conscious or not;
• if necessary, ensuring respiratory functions by accessing fresh air and gaining confidence that there are no foreign objects in the airways;
• carrying out non-invasive ventilation of the lungs (artificial respiration according to the "mouth to mouth" method);
• performing indirect (closed) in the absence of a pulse.

Quite often, the preservation of health and human life depends on the timely provision of high-quality first aid. In case of emergency, all victims, regardless of the type of disease, need competent emergency actions before the arrival of the medical team.

First aid for emergencies may not always be offered by qualified doctors or paramedics. Every contemporary must have the skills of pre-medical measures and know the symptoms of common diseases: the result depends on the quality and timeliness of measures, the level of knowledge, and the skills of witnesses of critical situations.

ABC algorithm

Emergency pre-medical actions involve the implementation of a set of simple therapeutic and preventive measures directly at the scene of the tragedy or near it. First aid for emergency conditions, regardless of the nature of the disease or received, has a similar algorithm. The essence of the measures depends on the nature of the symptoms manifested by the affected person (for example: loss of consciousness) and on the alleged causes of the emergency (for example: hypertensive crisis with arterial hypertension). Rehabilitation measures in the framework of first aid in emergency conditions are carried out according to uniform principles - the ABC algorithm: these are the first English letters denoting:

• Air (air);
• Breathing (breathing);
• Circulation (blood circulation).

Life sometimes brings surprises, and they are not always pleasant. We get into difficult situations or become their witnesses. And often we are talking about the life and health of loved ones or even random people. How to act in this situation? After all, quick action, the correct provision of emergency assistance can save a person's life. What are emergencies and emergency medical care, we will consider further. And also find out what should be the help in case of emergency, such as respiratory arrest, heart attack and others.

Types of medical care

The medical care provided can be divided into the following types:

• Emergency. It appears in the event that there is a threat to the life of the patient. This can be with an exacerbation of any chronic diseases or with sudden acute conditions.
• Urgent. It is necessary during the period of exacerbated chronic pathology or in case of an accident, but there is no threat to the life of the patient.

• Planned. This is the implementation of preventive and planned activities. At the same time, there is no threat to the patient's life even if the provision of this type of assistance is delayed.

Emergency and emergency care

Emergency and emergency medical care are very closely related to each other. Let's take a closer look at these two concepts.

In emergencies, medical attention is required. Depending on where the process occurs, in case of emergency, assistance is provided:

• External processes that arise under the influence of external factors and directly affect human life.
• internal processes. The result of pathological processes in the body.

Emergency care is one of the types of primary health care, provided during exacerbation of chronic diseases, in acute conditions that do not threaten the patient's life. It can be provided both on a day hospital and on an outpatient basis.

Emergency assistance should be provided in case of injuries, poisoning, acute conditions and diseases, as well as in case of accidents and in situations where assistance is vital.

Emergency care must be provided in any medical institution.

Pre-hospital care is very important in emergency situations.

Major emergencies

Emergency conditions can be divided into several groups:

1. Injuries. These include:

• Burns and frostbite.
• Fractures.
• Damage to vital organs.
• Damage to blood vessels with subsequent bleeding.
• Electric shock.

2. Poisoning. Damage occurs within the body, unlike injuries, it is the result of external influences. Violation of the internal organs with untimely emergency care can lead to death.

Poison can enter the body:

• Through the respiratory organs and mouth.
• Through the skin.
• Through the veins
• Through mucous membranes and through damaged skin.

Medical emergencies include:

1. Acute conditions of internal organs:

• Stroke.
• Myocardial infarction.
• Pulmonary edema.
• Acute liver and kidney failure.
• Peritonitis.

2. Anaphylactic shock.

3. Hypertensive crises.

4. Attacks of suffocation.

5. Hyperglycemia in diabetes mellitus.

Emergency conditions in pediatrics

Every pediatrician should be able to provide emergency care to the child. It may be required in case of a serious illness, in case of an accident. In childhood, a life-threatening situation can progress very quickly, since the child's body is still developing and all processes are imperfect.

Pediatric emergencies requiring medical attention:

• Convulsive syndrome.
• Fainting in a child.
• Coma in a child.
• collapse in a child.
• Pulmonary edema.
• The child is in shock.
• infectious fever.
• Asthmatic attacks.
• Croup syndrome.
• Incessant vomiting.
• Dehydration of the body.
• Emergency conditions in diabetes mellitus.

In these cases, the emergency medical service is called.

Features of emergency care for a child

The doctor's actions must be consistent. It must be remembered that in a child, the disruption of the functioning of individual organs or the whole organism occurs much faster than in an adult. Therefore, emergencies and emergency medical care in pediatrics require a quick response and coordinated action.

Adults should ensure the calm condition of the child and provide full cooperation in collecting information about the patient's condition.

The doctor should ask the following questions:

• Why did you seek emergency help?
• How was the injury received? If it's an injury.
• When did the child get sick?
• How did the disease develop? How did it go?
• What preparations and agents were used before the arrival of the doctor?

The child must be undressed for examination. The room should be at normal room temperature. In this case, the rules of asepsis must be observed when examining a child. If it is a newborn, a clean gown should be worn.

It should be borne in mind that in 50% of cases where the patient is a child, the diagnosis is made by the doctor based on the information collected, and only in 30% - as a result of the examination.

At the first stage, the doctor should:

• Assess the degree of disruption of the respiratory system and the work of the cardiovascular system. Determine the degree of need for emergency therapeutic measures according to vital signs.
• It is necessary to check the level of consciousness, breathing, the presence of convulsions and cerebral symptoms and the need for urgent measures.

You need to pay attention to the following points:

• How does the child behave?
• Sluggish or hyperactive.
• What an appetite.
• Condition of the skin.
• The nature of the pain, if any.

Medical emergencies and care

The health worker must be able to quickly assess emergencies, and emergency medical care must be provided in a timely manner. A correct and quick diagnosis is the key to a quick recovery.

Treatment emergencies include:

1. Fainting. Symptoms: pallor of the skin, skin moisture, muscle tone is reduced, tendon and skin reflexes are preserved. Blood pressure is low. There may be tachycardia or bradycardia. Fainting can be caused by the following reasons:

• Failure of the organs of the cardiovascular system.
• Asthma, various types of stenosis.
• Diseases of the brain.
• Epilepsy. Diabetes mellitus and other diseases.

Assistance is as follows:

• The victim is placed on a flat surface.
• Unbutton clothes, provide good access to air.
• You can spray water on the face and chest.
• Give a sniff of ammonia.
• Caffeine benzoate 10% 1 ml is administered subcutaneously.

2. Myocardial infarction. Symptoms: pain burning, squeezing, similar to an attack of angina pectoris. Pain attacks are undulating, decrease, but do not stop completely. The pain gets worse with every wave. At the same time, it can give to the shoulder, forearm, left shoulder blade or hand. There is also a feeling of fear, a breakdown.

Assistance is as follows:

• The first stage is pain relief. Nitroglycerin is used or Morphine or Droperidol is administered intravenously with Fentanyl.
• It is recommended to chew 250-325 mg of Acetylsalicylic acid.
• You need to measure your blood pressure.
• Then it is necessary to restore the coronary blood flow.
• Beta-adrenergic blockers are prescribed. During the first 4 hours.
• Thrombolytic therapy is carried out in the first 6 hours.

The doctor's task is to limit the size of necrosis and prevent the occurrence of early complications.

The patient must be urgently admitted to an emergency medicine center.

3. Hypertensive crisis. Symptoms: headache, nausea, vomiting, goosebumps, numbness of the tongue, lips, hands. Double vision, weakness, lethargy, high blood pressure.

Emergency assistance is as follows:

• It is necessary to provide the patient with rest and good access to air.
• With crisis type 1 "Nifedipine" or "Clonidine" under the tongue.
• At high pressure intravenously "Clonidine" or "Pentamine" up to 50 mg.
• If tachycardia persists, - "Propranolol" 20-40 mg.
• In a type 2 crisis, Furosemide is administered intravenously.
• With convulsions, Diazepam is administered intravenously or Magnesium sulfate.

The doctor's task is to reduce the pressure by 25% of the initial one during the first 2 hours. With a complicated crisis, urgent hospitalization is necessary.

4. Coma. It may be of different types.

Hyperglycemic. Develops slowly, begins with weakness, drowsiness, headache. Then there is nausea, vomiting, increased thirst, itchy skin. Then loss of consciousness.

Urgent care:

• Eliminate dehydration, hypovolemia. Sodium chloride solution is injected intravenously.
• Intravenously administered "Insulin".
• With severe hypotension, a solution of 10% "Caffeine" subcutaneously.
• Carry out oxygen therapy.

Hypoglycemic. It starts off sharp. The moisture of the skin is increased, the pupils are dilated, blood pressure is reduced, the pulse is quickened or normal.

Emergency care means:

• Ensuring complete rest.
• Intravenous administration of glucose.
• Correction of arterial pressure.
• Urgent hospitalization.

5. Acute allergic diseases. Serious diseases include: bronchial asthma and angioedema. Anaphylactic shock. Symptoms: the appearance of skin itching, excitability, increased blood pressure, a feeling of heat. Then loss of consciousness and respiratory arrest, failure of the heart rhythm are possible.

Emergency care is as follows:

• Position the patient so that the head is below the level of the legs.
• Provide air access.
• Open the airways, turn the head to the side, protrude the lower jaw.
• Introduce "Adrenaline", re-introduction is allowed after 15 minutes.
• "Prednisolone" in / in.
• Antihistamines.
• With bronchospasm, a solution of "Euphyllin" is administered.
• Urgent hospitalization.

6. Pulmonary edema. Symptoms: well expressed shortness of breath. Cough with white or yellow sputum. The pulse is fast. Seizures are possible. Breath is wheezing. Wet rales are heard, and in a serious condition "dumb lungs"

We provide emergency assistance.

• The patient should be in a sitting or semi-sitting position, legs lowered.
• Carry out oxygen therapy with defoamers.
• Enter / in "Lasix" in saline.
• Steroid hormones such as Prednisolone or Dexamethasone in saline.
• "Nitroglycerin" 1% intravenously.

Let's pay attention to emergency conditions in gynecology:

1. Ectopic pregnancy disturbed.
2. Torsion of the pedicle of an ovarian tumor.
3. Apoplexy of the ovary.

Consider the provision of emergency care for ovarian apoplexy:

• The patient should be in a supine position, with a raised head.
• Glucose and "Sodium chloride" are administered intravenously.

It is necessary to control indicators:

• Blood pressure.
• Heart rate.
• body temperature.
• Respiratory frequency.
• Pulse.

Cold is applied to the lower abdomen and urgent hospitalization is indicated.

How are emergencies diagnosed?

It is worth noting that the diagnosis of emergency conditions should be carried out very quickly and take literally seconds or a couple of minutes. The doctor must at the same time use all his knowledge and make a diagnosis in this short period of time.

The Glasgow scale is used when it is necessary to determine the impairment of consciousness. It evaluates:

• Eye opening.
• Speech.
• Motor responses to pain stimuli.

When determining the depth of the coma, the movement of the eyeballs is very important.

In acute respiratory failure, it is important to pay attention to:

• Color of the skin.
• Color of mucous membranes.
• Breathing frequency.
• Movement during breathing of the muscles of the neck and upper shoulder girdle.
• Retraction of the intercostal spaces.

Shock can be cardiogenic, anaphylactic, or post-traumatic. One of the criteria may be a sharp decrease in blood pressure. In traumatic shock, first of all, determine:

• Damage to vital organs.
• The amount of blood loss.
• Cold extremities.
• Symptom of "white spot".
• Decreased urine output.
• Decreased blood pressure.
• Violation of the acid-base balance.

The organization of emergency medical care consists, first of all, in maintaining breathing and restoring blood circulation, as well as in delivering the patient to a medical institution without causing additional harm.

Emergency Algorithm

For each patient, the methods of treatment are individual, but the algorithm of actions for emergency conditions must be performed for each patient.

The principle of action is as follows:

• Restoration of normal breathing and circulation.
• Help with bleeding.
• It is necessary to stop convulsions of psychomotor agitation.
• Anesthesia.
• Elimination of disorders that contribute to the failure of the heart rhythm and its conduction.
• Conducting infusion therapy to eliminate dehydration of the body.
• Decrease in body temperature or its increase.
• Conducting antidote therapy in acute poisoning.
• Strengthening natural detoxification.
• If necessary, enterosorption is carried out.
• Fixation of the damaged part of the body.
• Correct transportation.
• Constant medical supervision.

What to do before the doctor arrives

First aid in emergency conditions consists of performing actions that are aimed at saving human life. They will also help prevent the development of possible complications. First aid for emergencies should be provided before the doctor arrives and the patient is taken to a medical facility.

Action algorithm:

1. Eliminate the factor that threatens the health and life of the patient. Conduct an assessment of his condition.
2. Take urgent measures to restore vital functions: restoring breathing, artificial respiration, heart massage, stopping bleeding, applying a bandage, and so on.
3. Maintain vital functions until the ambulance arrives.
4. Transportation to the nearest medical facility.

1. Acute respiratory failure. It is necessary to carry out artificial respiration "mouth to mouth" or "mouth to nose". We tilt our head back, the lower jaw needs to be shifted. Close your nose with your fingers and take a deep breath into the victim's mouth. It is necessary to take 10-12 breaths.

2. Heart massage. The victim is in a supine position on his back. We stand on the side and put palm on palm on top of the chest at a distance of 2-3 fingers above the lower edge of the chest. Then we perform pressure so that the chest is displaced by 4-5 cm. Within a minute, 60-80 pressures must be done.

Consider the necessary emergency care for poisoning and injuries. Our actions in gas poisoning:

• First of all, it is necessary to take the person out of the polluted area.
• Loosen tight clothing.
• Assess the patient's condition. Check pulse, breathing. If the victim is unconscious, wipe the temples and give a sniff of ammonia. If vomiting has begun, then it is necessary to turn the head of the victim to one side.
• After the victim was brought to his senses, it is necessary to carry out inhalation with pure oxygen so that there are no complications.
• Then you can give hot tea, milk or slightly alkaline water to drink.

Help with bleeding:

• Capillary bleeding is stopped by applying a tight bandage, while it should not compress the limb.
• We stop arterial bleeding by applying a tourniquet or clamping the artery with a finger.

It is necessary to treat the wound with an antiseptic and contact the nearest medical facility.

Providing first aid for fractures and dislocations.

• With an open fracture, it is necessary to stop the bleeding and apply a splint.
• It is strictly forbidden to correct the position of the bones or remove fragments from the wound.
• Having fixed the place of injury, the victim must be taken to the hospital.
• A dislocation is also not allowed to be corrected on its own; a warm compress cannot be applied.
• It is necessary to apply cold or a wet towel.
• Rest the injured part of the body.

First aid for fractures should occur after bleeding has stopped and breathing has returned to normal.

What should be in a first aid kit

In order for emergency assistance to be provided effectively, it is necessary to use a first aid kit. It should contain components that may be needed at any moment.

The first aid kit must meet the following requirements:

• All medicines, medical instruments, as well as dressings should be in one special case or box that is easy to carry and transport.
• First aid kit should have many departments.
• Store in an easily accessible place for adults and out of the reach of children. All family members should know about her whereabouts.
• Regularly check the expiration dates of the drugs and replenish the used medicines and products.

What should be in the first aid kit:

1. Preparations for the treatment of wounds, antiseptics:

• Brilliant green solution.
• Boric acid in liquid or powder form.
• Hydrogen peroxide.
• Ethanol.
• Alcoholic iodine solution.
• Bandage, tourniquet, adhesive plaster, dressing bag.

2. Sterile or plain gauze mask.

3. Sterile and non-sterile rubber gloves.

4. Analgesics and antipyretics: "Analgin", "Aspirin", "Paracetamol".

5. Antimicrobials: Levomycetin, Ampicillin.

6. Antispasmodics: Drotaverine, Spazmalgon.

7. Cardiac drugs: "Corvalol", "Validol", "Nitroglycerin".

8. Adsorbents: "Atoxil", "Enterosgel".

9. Antihistamines: Suprastin, Dimedrol.

10. Ammonia.

11. Medical instruments:

• Clamp.
• Scissors.
• Cooling package.
• Disposable sterile syringe.
• Tweezers.

12. Antishock drugs: Adrenaline, Eufillin.

13. Antidotes.

Emergencies and emergency medical care are always highly individual and depend on the person and specific conditions. Every adult should have an understanding of emergency care in order to be able to help their loved one in a critical situation.

Angina.

angina pectoris

Symptoms:

Nurse tactics:

1. Syringes and needles for i/m, s/c injections.

2. Preparations: analgin, baralgin or tramal, sibazon (seduxen, relanium).

3. Ambu bag, ECG machine.

Evaluation of what has been achieved: 1. Complete cessation of pain

2. If pain persists, if this is the first attack (or attacks within a month), if the primary stereotype of an attack is violated, hospitalization in the cardiology department, resuscitation is indicated

Note: if a severe headache occurs while taking nitroglycerin, give a validol tablet sublingually, hot sweet tea, nitromint or molsidomine inside.

Acute myocardial infarction

myocardial infarction is an ischemic necrosis of the heart muscle, which develops as a result of a violation of the coronary blood flow.

Characterized by retrosternal pain of unusual intensity, pressing, burning, tearing, radiating to the left (sometimes right) shoulder, forearm, shoulder blade, neck, lower jaw, epigastric region, pain lasts more than 20 minutes (up to several hours, days), may be undulating (it intensifies, then subsides), or growing; accompanied by a feeling of fear of death, lack of air. There may be violations of the heart rhythm and conduction, instability of blood pressure, taking nitroglycerin does not relieve pain. Objectively: skin is pale, or cyanosis; extremities are cold, cold clammy sweat, general weakness, agitation (the patient underestimates the severity of the condition), restlessness, thready pulse, may be arrhythmic, frequent or rare, deafness of heart sounds, pericardial rub, fever.

atypical forms (options):

Ø asthmatic- asthma attack (cardiac asthma, pulmonary edema);

Ø arrhythmic Rhythm disturbances are the only clinical manifestation

or prevail in the clinic;

Ø cerebrovascular- (manifested by fainting, loss of consciousness, sudden death, acute neurological symptoms like a stroke;

Ø abdominal- pain in the epigastric region, may radiate to the back; nausea,

vomiting, hiccups, belching, severe bloating, tension in the anterior abdominal wall

and pain on palpation in the epigastric region, Shchetkin's symptom -

Blumberg negative;

Ø asymptomatic (painless) - vague sensations in the chest, unmotivated weakness, increasing shortness of breath, causeless fever;

Ø with atypical irradiation of pain in - neck, lower jaw, teeth, left arm, shoulder, little finger ( superior - vertebral, laryngeal - pharyngeal)

When assessing the patient's condition, it is necessary to take into account the presence of risk factors for coronary artery disease, the appearance of pain attacks for the first time or a change in habitual

Nurse tactics:

Prepare tools and preparations:

1. System for intravenous administration, tourniquet, electrocardiograph, defibrillator, heart monitor, Ambu bag.

2. As prescribed by a doctor: analgin 50%, 0.005% fentanyl solution, 0.25% droperidol solution, promedol solution 2% 1-2 ml, morphine 1% IV, tramal - for adequate pain relief, Relanium, heparin - for the purpose of prevention repeated blood clots and improvement of microcirculation, lidocaine - lidocaine for the prevention and treatment of arrhythmias;

Hypertensive crisis

Hypertensive crisis - a sudden increase in individual blood pressure, accompanied by cerebral and cardiovascular symptoms (disorder of cerebral, coronary, renal circulation, autonomic nervous system)

- hyperkinetic (type 1, adrenaline): is characterized by a sudden onset, with the onset of intense headache, sometimes pulsating, with predominant localization in the occipital region, dizziness. Excitation, palpitations, trembling throughout the body, hand tremor, dry mouth, tachycardia, increased systolic and pulse pressure. The crisis lasts from several minutes to several hours (3-4). The skin is hyperemic, moist, diuresis is increased at the end of the crisis.

- hypokinetic (type 2, norepinephrine): develops slowly, from 3-4 hours to 4-5 days, headache, "heaviness" in the head, "veil" before the eyes, drowsiness, lethargy, the patient is inhibited, disorientation, "ringing" in the ears, transient visual impairment , paresthesia, nausea, vomiting, pressing pains in the region of the heart, such as angina pectoris (pressing), swelling of the face and pastosity of the legs, bradycardia, diastolic pressure mainly increases, pulse decreases. The skin is pale, dry, diuresis is reduced.

Nurse tactics:

Prepare preparations:

Nifedipine (Corinfar) tab. under the tongue, ¼ tab. capoten (captopril) under the tongue, clonidine (clophelin) tab., amp; anaprilin tab., amp; droperidol (ampoules), furosemide (lasix tab., ampoules), diazepam (relanium, seduxen), dibazol (amp), magnesia sulfate (amp), eufillin amp.

Prepare tools:

Apparatus for measuring blood pressure. Syringes, intravenous infusion system, tourniquet.

Evaluation of what has been achieved: Reduction of complaints, gradual (in 1-2 hours) decrease in blood pressure to the normal value for the patient

Fainting

Fainting this is a short-term loss of consciousness that develops due to a sharp decrease in blood flow to the brain (several seconds or minutes)

The reasons: fright, pain, blood type, blood loss, lack of air, hunger, pregnancy, intoxication.

Pre-fainting period: feeling of lightheadedness, weakness, dizziness, darkening in the eyes, nausea, sweating, ringing in the ears, yawning (up to 1-2 minutes)

Fainting: consciousness is absent, pallor of the skin, decreased muscle tone, cold extremities, breathing is rare, shallow, the pulse is weak, bradycardia, blood pressure is normal or reduced, the pupils are constricted (1-3-5 min, prolonged - up to 20 min)

Post-mortem period: consciousness returns, pulse, blood pressure normalize , weakness and headache are possible (1-2 min - several hours). Patients do not remember what happened.

Nurse tactics:

Prepare tools and preparations:

Syringes, needles, cordiamine 25% - 2 ml / m, caffeine solution 10% - 1 ml s / c.

Prepare preparations: eufillin 2.4% 10ml IV or atropine 0.1% 1ml s.c. if syncope is due to transverse heart block

Evaluation of what has been achieved:

1. The patient regained consciousness, his condition improved - a doctor's consultation.

3. The patient's condition is alarming - call for emergency assistance.

Collapse

Collapse- this is a persistent and prolonged decrease in blood pressure, due to acute vascular insufficiency.

The reasons: pain, trauma, massive blood loss, myocardial infarction, infection, intoxication, a sharp decrease in temperature, a change in body position (getting up), getting up after taking antihypertensive drugs, etc.

Ø cardiogenic form - with heart attack, myocarditis, pulmonary embolism

Ø vascular form- with infectious diseases, intoxications, a critical drop in temperature, pneumonia (symptoms develop simultaneously with symptoms of intoxication)

Ø hemorrhagic form - with massive blood loss (symptoms develop several hours after blood loss)

Clinic: general condition is severe or extremely severe. First there is weakness, dizziness, noise in the head. Disturbed by thirst, chilliness. Consciousness is preserved, but patients are inhibited, indifferent to the environment. The skin is pale, moist, the lips are cyanotic, acrocyanosis, the extremities are cold. BP less than 80 mm Hg. Art., pulse is frequent, thready", breathing is frequent, shallow, heart sounds are muffled, oliguria, body temperature is reduced.

Nurse tactics:

Prepare tools and preparations:

Syringes, needles, tourniquet, disposable systems

cordiamine 25% 2 ml i/m, caffeine solution 10% 1 ml s/c, 1% mezaton solution 1 ml,

0.1% 1 ml of adrenaline solution, 0.2% norepinephrine solution, 60-90 mg of prednisolone polyglucin, reopoliglyukin, saline.
Evaluation of what has been achieved:

1. Condition improved

2. Condition has not improved - be prepared for CPR

shock - a condition in which there is a sharp, progressive decline in all vital body functions.

Cardiogenic shock develops as a complication of acute myocardial infarction.
Clinic: a patient with acute myocardial infarction develops severe weakness, skin
pale wet, "marble" cold to the touch, collapsed veins, cold hands and feet, pain. BP is low, systolic about 90 mm Hg. Art. and below. The pulse is weak, frequent, "filamentous". Breathing shallow, frequent, oliguria

Ø reflex form (pain collapse)

Ø true cardiogenic shock

Ø arrhythmic shock

Nurse tactics:

Prepare tools and preparations:

Syringes, needles, tourniquet, disposable systems, heart monitor, ECG machine, defibrillator, Ambu bag

0.2% norepinephrine solution, mezaton 1% 0.5 ml, saline solution, prednisolone 60 mg, reopo-

liglyukin, dopamine, heparin 10,000 IU IV, lidocaine 100 mg, narcotic analgesics (promedol 2% 2 ml)
Evaluation of what has been achieved:

Condition has not worsened

Bronchial asthma

Bronchial asthma - chronic inflammatory process in the bronchi, predominantly of an allergic nature, the main clinical symptom is an asthma attack (bronchospasm).

During an attack: a spasm of the smooth muscles of the bronchi develops; - swelling of the bronchial mucosa; formation in the bronchi of viscous, thick, mucous sputum.

Clinic: the appearance of seizures or their increase is preceded by exacerbation of inflammatory processes in the bronchopulmonary system, contact with an allergen, stress, meteorological factors. The attack develops at any time of the day, often at night in the morning. The patient has a feeling of "lack of air", he takes a forced position relying on his hands, expiratory dyspnea, unproductive cough, auxiliary muscles are involved in the act of breathing; there is retraction of the intercostal spaces, retraction of the subclavian fossae, diffuse cyanosis, puffy face, viscous sputum, difficult to separate, breathing is noisy, wheezing, dry wheezing, heard at a distance (remote), boxed percussion sound, pulse frequent, weak. In the lungs - weakened breathing, dry rales.

Nurse tactics:

Features of the use of freon-free inhalers (N) - the first dose is released into the atmosphere (these are vapors of alcohol that have evaporated in the inhaler).

Prepare tools and preparations:

Syringes, needles, tourniquet, intravenous infusion system

Medications: 2.4% 10 ml solution of eufillin, prednisolone 30-60 mg IM, IV, saline solution, adrenaline 0.1% - 0.5 ml s / c, suprastin 2% -2 ml, ephedrine 5% - 1 ml.

Evaluation of what has been achieved:

1. Suffocation has decreased or stopped, sputum comes out freely.

2. The condition has not improved - continue the ongoing activities until the arrival of the ambulance.

3. Contraindicated: morphine, promedol, pipolfen - depress breathing

Pulmonary bleeding

The reasons: chronic lung diseases (BEB, abscess, tuberculosis, lung cancer, emphysema)

Clinic: cough with the release of scarlet sputum with air bubbles, shortness of breath, possible pain when breathing, lowering blood pressure, skin is pale, moist, tachycardia.

Nurse tactics:

Prepare tools and preparations:

Everything you need to determine the blood type.

2. Calcium chloride 10% 10ml IV, vikasol 1%, dicynone (sodium etamsylate), 12.5% ​​-2 ml IM, IV, aminocaproic acid 5% IV drops, polyglucin, reopoliglyukin

Evaluation of what has been achieved:

Decrease in cough, decrease in the amount of blood in the sputum, stabilization of the pulse, blood pressure.

hepatic colic

Clinic: intense pain in the right hypochondrium, epigastric region (stabbing, cutting, tearing) radiating to the right subscapular region, scapula, right shoulder, collarbone, neck, jaw. Patients rush about, moan, scream. The attack is accompanied by nausea, vomiting (often with an admixture of bile), a feeling of bitterness and dryness in the mouth, and bloating. Pain worsens with inspiration, palpation of the gallbladder, positive Ortner's symptom, subicteric sclera, dark urine, fever

Nurse tactics:

Prepare tools and preparations:

1. Syringes, needles, tourniquet, intravenous infusion system

2. Antispasmodics: papaverine 2% 2 - 4 ml, but - shpa 2% 2 - 4 ml i / m, platifillin 0.2% 1 ml s / c, i / m. Non-narcotic analgesics: analgin 50% 2-4 ml, baralgin 5 ml IV. Narcotic analgesics: Promedol 1% 1 ml or Omnopon 2% 1 ml IV.

Do not inject morphine - causes spasm of the sphincter of Oddi

Renal colic

Occurs suddenly: after physical exertion, walking, bumpy driving, heavy fluid intake.

Clinic: sharp, cutting, unbearable pain in the lumbar region radiating along the ureter to the iliac region, groin, inner thigh, external genitalia lasting from several minutes to several days. Patients toss and turn in bed, moan, scream. Dysuria, pollakiuria, hematuria, sometimes anuria. Nausea, vomiting, fever. Reflex intestinal paresis, constipation, reflex pain in the heart.

On examination: asymmetry of the lumbar region, pain on palpation along the ureter, a positive symptom of Pasternatsky, tension in the muscles of the anterior abdominal wall.

Nurse tactics:

Prepare tools and preparations:

1. Syringes, needles, tourniquet, intravenous infusion system

2. Antispasmodics: papaverine 2% 2 - 4 ml, but - shpa 2% 2 - 4 ml i / m, platifillin 0.2% 1 ml s / c, i / m.

Non-narcotic analgesics: analgin 50% 2-4 ml, baralgin 5 ml IV. Narcotic analgesics: Promedol 1% 1 ml or Omnopon 2% 1 ml IV.

Anaphylactic shock.

Anaphylactic shock- this is the most formidable clinical variant of an allergic reaction that occurs with the introduction of various substances. Anaphylactic shock can develop when ingested:

a) foreign proteins (immune sera, vaccines, extracts from organs, poisons on-

insects...);

b) medicines (antibiotics, sulfonamides, B vitamins…);

c) other allergens (plant pollen, microbes, food products: eggs, milk,

fish, soybeans, mushrooms, tangerines, bananas...

d) with insect bites, especially bees;

e) in contact with latex (gloves, catheters, etc.).

Ø lightning form develops 1-2 minutes after the administration of the drug;

is characterized by the rapid development of the clinical picture of an acute ineffective heart, without resuscitation, it ends tragically in the next 10 minutes. Symptoms are poor: severe pallor or cyanosis; dilated pupils, lack of pulse and pressure; agonal breathing; clinical death.

Ø mild shock, develops 5-7 minutes after the administration of the drug

Ø severe form develops in 10-15 minutes, maybe 30 minutes after the administration of the drug.

Most often, shock develops within the first five minutes after the injection. Food shock develops within 2 hours.

Clinical variants of anaphylactic shock:

1. Typical shape: a feeling of heat "doused with nettles", fear of death, severe weakness, tingling, itching of the skin, face, head, hands; sensation of a rush of blood to the head, tongue, heaviness behind the sternum or chest compression; pain in the heart, headache, shortness of breath, dizziness, nausea, vomiting. With a lightning-fast form, patients do not have time to complain before losing consciousness.
2. Cardiac variant manifested by signs of acute vascular insufficiency: severe weakness, pallor of the skin, cold sweat, "threadlike" pulse, blood pressure drops sharply, in severe cases, consciousness and breathing are depressed.
3. Asthmoid or asphyxial variant manifested by signs of acute respiratory failure, which is based on bronchospasm or swelling of the pharynx and larynx; there is a feeling of tightness in the chest, coughing, shortness of breath, cyanosis.
4. cerebral variant manifested by signs of severe cerebral hypoxia, convulsions, foaming at the mouth, involuntary urination and defecation.

5. Abdominal variant manifested by nausea, vomiting, paroxysmal pain in
stomach, diarrhea.

Urticaria appears on the skin, in some places the rash merges and turns into a dense pale edema - Quincke's edema.

Nurse tactics:

Prepare tools and preparations:

tourniquet, ventilator, tracheal intubation kit, Ambu bag.

2. Standard set of drugs "Anaphylactic shock" (0.1% adrenaline solution, 0.2% norepinephrine, 1% mezaton solution, prednisone, 2% suprastin solution, 0.05% strophanthin solution, 2.4% aminophylline solution, saline .solution, albumin solution)

Medical care for anaphylactic shock without a doctor:

1. Intravenous administration of adrenaline 0.1% - 0.5 ml per physical. r-re.

After 10 minutes, the introduction of adrenaline can be repeated.

In the absence of venous access, adrenaline
0.1% -0.5 ml can be injected into the root of the tongue or intramuscularly.

Actions:

Ø adrenaline increases heart rate, increases heart rate, constricts blood vessels and thus increases blood pressure;

Ø adrenaline relieves spasm of the smooth muscles of the bronchi;

Ø adrenaline slows down the release of histamine from mast cells, i.e. fights an allergic reaction.

2. Establish intravenous access and start fluid administration (physiological

solution for adults> 1 liter, for children - at the rate of 20 ml per kg) - replenish the volume

fluid in the vessels and increase blood pressure.

3. The introduction of prednisolone 90-120 mg IV.

By doctor's prescription:

4. After stabilization of blood pressure (BP above 90 mm Hg) - antihistamines:

5. With a bronchospastic form, eufillin 2.4% - 10 iv. On saline. When on-
cyanosis, dry rales, oxygen therapy. Possible inhalations

alupenta

6. With convulsions and strong arousal - in / in sedeuxen

7. With pulmonary edema - diuretics (lasix, furosemide), cardiac glycosides (strophanthin,

corglicon)

After removing from shock, the patient is hospitalized for 10-12 days..

Evaluation of what has been achieved:

1. Stabilization of blood pressure, heart rate.

2. Restoration of consciousness.

Urticaria, angioedema

Hives: allergic disease , characterized by a rash on the skin of itchy blisters (edema of the papillary layer of the skin) and erythema.

The reasons: medicines, serums, foodstuffs…

The disease begins with intolerable skin itching in various parts of the body, sometimes on the entire surface of the body (on the trunk, extremities, sometimes the palms and soles of the feet). Blisters protrude above the surface of the body, from point sizes to very large, they merge, forming elements of various shapes with uneven, clear edges. Rashes can remain in one place for several hours, then disappear and reappear in another place.

There may be fever (38 - 39 0), headache, weakness. If the disease lasts more than 5-6 weeks, it becomes chronic and is characterized by an undulating course.

Treatment: hospitalization, withdrawal of drugs (stop contact with the allergen), fasting, repeated cleansing enemas, saline laxatives, activated charcoal, polypefan orally.

Antihistamines: diphenhydramine, suprastin, tavigil, fencarol, ketotefen, diazolin, telfast ... orally or parenterally

To reduce itching - in / in the solution of sodium thiosulfate 30% -10 ml.

Hypoallergenic diet. Make a note on the title page of the outpatient card.

Conversation with the patient about the dangers of self-treatment; when applying for honey. with the help of the patient should warn the medical staff about intolerance to the drugs.

Quincke's edema- characterized by edema of the deep subcutaneous layers in places with loose subcutaneous tissue and on the mucous membranes (when pressed, the fossa does not remain): on the eyelids, lips, cheeks, genitals, back of the hands or feet, mucous membranes of the tongue, soft palate, tonsils, nasopharynx, gastrointestinal tract (clinic of acute abdomen). When the larynx is involved in the process, asphyxia may develop (anxiety, puffiness of the face and neck, increasing hoarseness, "barking" cough, difficulty stridor breathing, lack of air, cyanosis of the face), with swelling in the head region, the meninges are involved in the process (meningeal symptoms) .

Nurse tactics:

Prepare tools and preparations:

1. System for intravenous infusion, syringes and needles for i/m and s/c injections,
tourniquet, ventilator, tracheal intubation kit, Dufo needle, laryngoscope, Ambu bag.

2. Adrenaline 0.1% 0.5 ml, prednisolone 30-60 mg; antihistamines 2% - 2 ml of suprastin solution, pipolfen 2.5% - 1 ml, diphenhydramine 1% - 1 ml; fast-acting diuretics: lasix 40-60mg IV bolus, mannitol 30-60mg IV drip

Inhalers salbutamol, alupent

3. Hospitalization in the ENT department

First aid for emergency conditions and acute diseases

Angina.

angina pectoris- this is one of the forms of coronary artery disease, the causes of which may be: spasm, atherosclerosis, transient thrombosis of the coronary vessels.

Symptoms: paroxysmal, squeezing or pressing pain behind the sternum, loads lasting up to 10 minutes (sometimes up to 20 minutes), passing when the load is stopped or after taking nitroglycerin. The pain radiates to the left (sometimes right) shoulder, forearm, hand, shoulder blade, neck, lower jaw, epigastric region. It can be manifested by atypical sensations in the form of lack of air, inexplicable sensations, stabbing pains.

Nurse tactics:

Definition. Emergency conditions are pathological changes in the body that lead to a sharp deterioration in health, threaten the life of the patient and require emergency treatment. There are the following emergency conditions:

Immediate life threatening

Not life-threatening, but without assistance, the threat will be real

Conditions in which failure to provide emergency assistance will lead to permanent changes in the body

Situations in which it is necessary to quickly alleviate the patient's condition

Situations requiring medical intervention in the interests of others due to inappropriate behavior of the patient

restoration of respiratory function

relief of collapse, shock of any etiology

relief of convulsive syndrome

prevention and treatment of cerebral edema

CARDIOLUMMARY REANIMATION.

Definition. Cardiopulmonary resuscitation (CPR) is a set of measures aimed at restoring lost or severely impaired vital body functions in patients in a state of clinical death.

The main 3 receptions of CPR according to P. Safar, "rule ABC":

A ire way open - ensure airway patency;

B reath for victim - start artificial respiration;

C irculation his blood - restore blood circulation.

A- carried out triple trick according to Safar - tilting the head, the maximum forward displacement of the lower jaw and opening the patient's mouth.

Give the patient an appropriate position: lay on a hard surface, put a roller of clothes on his back under the shoulder blades. Tilt your head as far back as possible

Open your mouth and examine the oral cavity. With convulsive compression of the masticatory muscles, use a spatula to open it. Clear the oral cavity of mucus and vomit with a handkerchief wound around the index finger. If the tongue is sunk, turn it out with the same finger

Rice. Preparation for artificial respiration: push the lower jaw forward (a), then move the fingers to the chin and, pulling it down, open the mouth; with the second hand placed on the forehead, tilt the head back (b).

Rice. Restoration of airway patency.

a- opening the mouth: 1-crossed fingers, 2-capturing the lower jaw, 3-using a spacer, 4-triple reception. b- cleaning of the oral cavity: 1 - with the help of a finger, 2 - with the help of suction. (fig. by Moroz F.K.)

B - artificial lung ventilation (ALV). IVL is the blowing of air or an oxygen-enriched mixture into the lungs of a patient without / using special devices. Each breath should take 1-2 seconds, and the respiratory rate should be 12-16 per minute. IVL at the stage of pre-hospital care is carried out "mouth to mouth" or "mouth to nose" exhaled air. At the same time, the effectiveness of inhalation is judged by the rise of the chest and passive exhalation of air. Either an airway, face mask and Ambu bag, or tracheal intubation and Ambu bag are usually used by the ambulance team.

C - 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 doctor should stand high enough (on a chair, stool, stand, if the patient is lying on a high bed or on the operating table), as if hanging with his body over the victim and putting pressure on the sternum not only with the effort of his hands, but also with the weight of his body.

The shoulders of the resuscitator should be directly above the palms, the arms at the elbows should not be bent. 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 artificial respiration in adults is 30: 2 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.

simultaneously with the onset of mechanical ventilation and massage intravenous bolus: every 3-5 minutes 1 mg of adrenaline or 2-3 ml endotracheally; atropine - 3 mg intravenously bolus once.

Rice. The position of the patient and assisting with chest compressions.

ECG- asystole ( isoline on the ECG)

intravenously 1 ml of 0.1% solution of epinephrine (adrenaline), repeated intravenously after 3-4 minutes;

intravenous atropine 0.1% solution - 1 ml (1 mg) + 10 ml of 0.9% solution of sodium chloride after 3-5 minutes (until the effect or a total dose of 0.04 mg / kg is obtained);

Sodium bicarbonate 4% - 100 ml is administered only after 20-25 minutes of CPR.

if asystole persists, immediate percutaneous, transesophageal, or endocardial temporary pacing.

ECG- ventricular fibrillation (ECG - teeth of different amplitudes randomly located)

electrical defibrillation (EIT). Shocks of 200, 200 and 360 J (4500 and 7000 V) are recommended. All subsequent discharges - 360 J.

In ventricular fibrillation, after the 3rd shock, cordarone in the initial dose of 300 mg + 20 ml of 0.9% sodium chloride solution or 5% glucose solution, again - 150 mg each (up to a maximum of 2 g). In the absence of cordarone, enter lidocaine- 1-1.5 mg/kg every 3-5 minutes for a total dose of 3 mg/kg.

Magnesium sulphate - 1-2 g IV for 1-2 minutes, repeat after 5-10 minutes.

EMERGENCY AID FOR ANAPHILACTIC SHOCK.

Definition. Anaphylactic shock is an immediate type of systemic allergic reaction to the repeated administration of an allergen as a result of a rapid massive immunoglobulin-E-mediated release of mediators from tissue basophils (mast cells) and basophilic granulocytes of peripheral blood (R.I. Shvets, E.A. Fogel, 2010 .).

Provoking factors:

taking medications: penicillin, sulfonamides, streptomycin, tetracycline, nitrofuran derivatives, amidopyrine, aminophylline, eufillin, diafillin, barbiturates, anthelmintic drugs, thiamine hydrochloride, glucocorticosteroids, novocaine, sodium thiopental, diazepam, radiopaque and iodine-containing substances.

Administration of blood products.

Food products: chicken eggs, coffee, cocoa, chocolate, strawberries, strawberries, crayfish, fish, milk, alcoholic beverages.

Administration of vaccines and sera.

Insect stings (wasps, bees, mosquitoes)

Pollen allergens.

Chemicals (cosmetics, detergents).

Local manifestations: edema, hyperemia, hypersalivation, necrosis

Systemic manifestations: shock, bronchospasm, DIC, intestinal disorders

Urgent care:

Stop contact with allergens: stop parenteral administration of the drug; remove the insect sting from the wound with an injection needle (removal with tweezers or fingers is undesirable, since it is possible to squeeze out the remaining poison from the reservoir of the poisonous gland of the insect remaining on the sting) Apply ice or a heating pad with cold water to the injection site for 15 minutes.

Lay the patient down (head above the legs), turn the head to the side, push the lower jaw forward, if there are removable dentures, remove them.

If necessary, perform CPR, tracheal intubation; with laryngeal edema - tracheostomy.

Indications for mechanical ventilation in anaphylactic shock:

Swelling of the larynx and trachea with impaired patency  - respiratory tract;

Intractable arterial hypotension;

Violation of consciousness;

Persistent bronchospasm;

Pulmonary edema;

Development - coagulopathy bleeding.

Immediate tracheal intubation and mechanical ventilation is performed with loss of consciousness, a decrease in systolic blood pressure below 70 mm Hg. Art., in the event of stridor.

The appearance of stridor indicates obstruction of the lumen of the upper respiratory tract by more than 70-80%, and therefore the patient's trachea should be intubated with a tube of the largest possible diameter.

Medical therapy:

Provide intravenous access into two veins and start transfusion of 0.9% - 1.000 ml of sodium chloride solution, stabisol - 500 ml, polyglucin - 400 ml

Epinephrine (adrenaline) 0.1% - 0.1 -0.5 ml intramuscularly, if necessary, repeat after 5-20 minutes.

In moderate anaphylactic shock, a fractional (bolus) injection of 1-2 ml of a mixture (1 ml of -0.1% adrenaline + 10 ml of 0.9% sodium chloride solution) is shown every 5-10 minutes until hemodynamic stabilization.

Intratracheal epinephrine is administered in the presence of an endotracheal tube in the trachea - as an alternative to intravenous or intracardiac routes of administration (2-3 ml at a time in a dilution of 6-10 ml in isotonic sodium chloride solution).

prednisolone intravenously 75-100 mg - 600 mg (1 ml = 30 mg prednisolone), dexamethasone - 4-20 mg (1 ml = 4 mg), hydrocortisone - 150-300 mg (if intravenous administration is not possible - intramuscularly).

with generalized urticaria or with a combination of urticaria with Quincke's edema - diprospan (betamethasone) - 1-2 ml intramuscularly.

with Quincke's edema, a combination of prednisolone and new generation antihistamines is indicated: semprex, telfast, clarifer, allertec.

membrane stabilizers intravenously: ascorbic acid 500 mg/day (8–10 10 ml of 5% solution or 4–5 ml of 10% solution), troxevasin 0.5 g/day (5 ml of 10% solution), sodium etamsylate 750 mg/day (1 ml = 125 mg), the initial dose is 500 mg, then every 8 hours, 250 mg.

intravenously eufillin 2.4% 10–20  ml, no-shpa 2 ml, alupent (brikanil) 0.05% 1–2 ml (drip); isadrin 0.5% 2 ml subcutaneously.

with persistent hypotension: dopmin 400 mg + 500 ml of 5% glucose solution intravenously drip (the dose is titrated until the systolic pressure reaches 90 mm Hg) and is prescribed only after replenishment of the circulating blood volume.

with persistent bronchospasm 2 ml (2.5 mg) salbutamol or berodual (fenoterol 50 mg, iproaropium bromide 20 mg) preferably through a nebulizer

with bradycardia, atropine 0.5 ml -0.1% of the solution subcutaneously or 0.5 -1 ml intravenously.

It is advisable to administer antihistamines to the patient only after stabilization of blood pressure, since their action can aggravate hypotension: diphenhydramine 1% 5 ml or   suprastin 2% 2-4 ml, or tavegil 6 ml intramuscularly, cimetidine 200-400 mg (10% 2-4 ml) intravenously, famotidine 20 mg every 12 hours (0.02 g of dry powder diluted in 5 ml of solvent) intravenously, pipolfen 2.5% 2-4 ml subcutaneously.

Hospitalization in the intensive care unit / allergology with generalized urticaria, Quincke's edema.

EMERGENCY CARE FOR ACUTE CARDIOVASCULAR FAILURE: CARDIOGENIC SHOCK, FANE COLLAPSE

Definition. Acute cardiovascular failure is a pathological condition caused by the inadequacy of cardiac output to the metabolic needs of the body. It can be due to 3 reasons or a combination of them:

Sudden decrease in myocardial contractility

Sudden decrease in blood volume

Sudden drop in vascular tone.

Causes of occurrence: arterial hypertension, acquired and congenital heart defects, pulmonary embolism, myocardial infarction, myocarditis, cardiosclerosis, myocardiopathies. Conventionally, cardiovascular insufficiency is divided into cardiac and vascular.

Acute vascular insufficiency is characteristic of conditions such as fainting, collapse, shock.

Cardiogenic shock: emergency care.

Definition. Cardiogenic shock is an emergency condition arising from 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. Causes: myocardial infarction, acute myocarditis, heart injury, heart disease.

The clinical picture of shock is determined by its form and severity. There are 3 main forms: reflex (pain), arrhythmogenic, true.

reflex cardiogenic shock complication of myocardial infarction that occurs at the height of the pain attack. It often occurs with lower-posterior localization of a heart attack in middle-aged men. Hemodynamics normalizes after the relief of the pain attack.

Arrhythmogenic cardiogenic shock a consequence of cardiac arrhythmias, more often against the background of ventricular tachycardia> 150 per 1 minute, atrial fibrillation, ventricular fibrillation.

True cardiogenic shock a consequence of a violation of myocardial contractility. The most severe form of shock against the background of extensive necrosis of the left ventricle.

Weakness, lethargy or short-term psychomotor agitation

The face is pale with a grayish-ash tint, the skin is marbled

Cold clammy sweat

Acrocyanosis, cold extremities, collapsed veins

The main symptom is a sharp drop in SBP< 70 мм. рт. ст.

Tachycardia, shortness of breath, signs of pulmonary edema

oliguria

0.25 mg acetylsalicylic acid to chew in the mouth

Lay down the patient with raised lower limbs;

oxygen therapy with 100% oxygen.

With an anginal attack: 1 ml of a 1% solution of morphine or 1-2 ml of a 0.005% solution of fentanyl.

Heparin 10,000 -15,000 IU + 20 ml of 0.9% sodium chloride intravenously drip.

400 ml of 0.9% sodium chloride solution or 5% glucose solution intravenously over 10 minutes;

intravenous jet solutions of polyglucin, refortran, stabisol, reopoliglyukin until blood pressure stabilizes (SBP 110 mm Hg)

With heart rate> 150 per minute. – absolute indication for EIT, heart rate<50 в мин абсолютное показание к ЭКС.

No stabilization of blood pressure: dopmin 200 mg intravenously + 400 ml of 5% glucose solution, the rate of administration is from 10 drops per minute until the SBP is at least 100 mm Hg. Art.

If there is no effect: norepinephrine hydrotartrate 4 mg in 200 ml of 5% glucose solution intravenously, gradually increasing the infusion rate from 0.5 μg / min to SBP 90 mm Hg. Art.

if the SBP is more than 90 mm Hg: 250 mg of dobutamine solution + in 200 ml of 0.9% sodium chloride intravenously by drip.

Hospitalization in the intensive care unit / intensive care unit

First aid for fainting.

Definition. Fainting is an acute vascular insufficiency with a sudden short-term loss of consciousness due to an acute insufficiency of blood flow to the brain. Causes: negative emotions (stress), pain, a sudden change in body position (orthostatic) with a disorder of the nervous regulation of vascular tone.

Tinnitus, general weakness, dizziness, pallor of the face

Loss of consciousness, the patient falls

Pale skin, cold sweat

Pulse is thready, blood pressure drops, extremities are cold

The duration of fainting from a few minutes to 10-30 minutes

Lay the patient down with head down and legs up, free from tight clothing

Give a sniff of 10% aqueous ammonia (ammonia)

Midodrine (gutron) orally 5 mg (tablets or 14 drops of 1% solution), maximum dose - 30 mg / day or intramuscularly, or intravenously 5 mg

Mezaton (phenylephrine) intravenously slowly 0.1-0.5 ml 1% solution + 40 ml 0.9% sodium chloride solution

With bradycardia and cardiac arrest atropine sulfate 0.5 - 1 mg intravenously by bolus

When breathing and circulation stops - CPR

Collapse emergency.

Definition. Collapse is an acute vascular insufficiency that occurs as a result of inhibition of the sympathetic nervous system and an increase in the tone of the vagus nerve, which is accompanied by the expansion of arterioles and a violation of the ratio between the capacity of the vascular bed and the bcc. As a result, venous return, cardiac output and cerebral blood flow are reduced.

Reasons: pain or its expectation, a sharp change in body position (orthostatic), an overdose of antiarrhythmic drugs, ganglioblockers, local anesthetics (novocaine). Antiarrhythmic drugs.

General weakness, dizziness, tinnitus, yawning, nausea, vomiting

Paleness of the skin, cold clammy sweat

Decreased blood pressure (systolic blood pressure less than 70 mm Hg), bradycardia

Possible loss of consciousness

Horizontal position with legs elevated

1 ml 25% cordiamine solution, 1-2 ml 10% caffeine solution

0.2 ml 1% mezaton solution or 0.5 - 1 ml 0.1% epinephrine solution

For prolonged collapse: 3–5 mg/kg hydrocortisone or 0.5–1 mg/kg prednisone

With severe bradycardia: 1 ml -0.15 solution of atropine sulfate

200 -400 ml of polyglucin / rheopolyglucin

SUDDEN DEATH

Diagnostics. Lack of consciousness and pulse on the carotid arteries, a little later - the cessation of breathing.

In the process of CPR - according to the ECP, ventricular fibrillation (in 80% of cases), asystole or electromechanical dissociation (in 10-20% of cases). If emergency ECG registration is not possible, they are guided by the manifestations of the onset of clinical death and the response to CPR.

Ventricular fibrillation develops suddenly, the symptoms appear sequentially: the disappearance of the pulse in the carotid arteries and loss of consciousness; a single tonic contraction of the skeletal muscles; violations and respiratory arrest. The response to timely CPR is positive, to the termination of CPR - fast negative.

With advanced SA- or AV-blockade, the symptoms develop relatively gradually: clouding of consciousness => motor excitation => moaning => tonic-clonic convulsions => respiratory disorders (MAS syndrome). When conducting a closed heart massage - a quick positive effect that persists for some time after the cessation of CPR.

Electromechanical dissociation in massive PE occurs suddenly (often at the time of physical exertion) and is manifested by the cessation of breathing, the absence of consciousness and pulse in the carotid arteries, and a sharp cyanosis of the skin of the upper half of the body. swelling of the neck veins. With the timely start of CPR, signs of its effectiveness are determined.

Electromechanical dissociation in myocardial rupture, cardiac tamponade develops suddenly (often after severe anginal syndrome), without convulsive syndrome, there are no signs of CPR effectiveness. Hypostatic spots quickly appear on the back.

Electromechanical dissociation due to other causes (hypovolemia, hypoxia, tension pneumothorax, drug overdose, progressive cardiac tamponade) does not occur suddenly, but develops against the background of the progression of the corresponding symptoms.

Urgent care :

1. With ventricular fibrillation and the impossibility of immediate defibrillation:

Apply a precordial strike: Cover the xiphoid process with two fingers to protect it from damage. It is located at the bottom of the sternum, where the lower ribs converge, and can break off with a sharp blow and injure the liver. Inflict a pericardial blow with the edge of a palm clenched into a fist slightly above the xiphoid process covered with fingers. It looks like this: with two fingers of one hand you cover the xiphoid process, and with the fist of the other hand strike (while the elbow of the hand is directed along the body of the victim).

After that, check the pulse on the carotid artery. If the pulse does not appear, then your actions are not effective.

No effect - start CPR immediately, ensure that defibrillation is possible as soon as possible.

2. Closed heart massage should be performed at a frequency of 90 per 1 min with a compression-decompression ratio of 1:1: the method of active compression-decompression (using a cardiopamp) is more effective.

3. GOING in an accessible way (the ratio of massage movements and breathing is 5:1, and with the work of one doctor - 15:2), ensure the patency of the airways (tilt back the head, push the lower jaw, insert the air duct, according to indications - sanitize the airways);

Use 100% oxygen:

Intubate the trachea (no more than 30 s);

Do not interrupt cardiac massage and ventilation for more than 30 s.

4. Catheterize a central or peripheral vein.

5. Adrenaline 1 mg every 3 minutes of CPR (how to administer here and below - see note).

6. As soon as possible - defibrillation 200 J;

No effect - defibrillation 300 J:

No effect - defibrillation 360 J:

No effect - see point 7.

7. Act according to the scheme: the drug - heart massage and mechanical ventilation, after 30-60 s - defibrillation 360 J:

Lidocaine 1.5 mg/kg - defibrillation 360 J:

No effect - after 3 minutes, repeat the injection of lidocaine at the same dose and defibrillation of 360 J:

No effect - Ornid 5 mg/kg - defibrillation 360 J;

No effect - after 5 minutes, repeat the injection of Ornid at a dose of 10 mg / kg - defibrillation 360 J;

No effect - novocainamide 1 g (up to 17 mg / kg) - defibrillation 360 J;

No effect - magnesium sulfate 2 g - defibrillation 360 J;

In pauses between discharges, conduct a closed heart massage and mechanical ventilation.

8. With asystole:

If it is impossible to accurately assess the electrical activity of the heart (do not exclude the atonic stage of ventricular fibrillation) - act. as in ventricular fibrillation (items 1-7);

If asystole is confirmed in two ECG leads, perform steps. 2-5;

No effect - atropine after 3-5 minutes, 1 mg until an effect is obtained or a total dose of 0.04 mg / kg is reached;

EKS as soon as possible;

Correct the possible cause of asystole (hypoxia, hypo- or hyperkalemia, acidosis, drug overdose, etc.);

The introduction of 240-480 mg of aminophylline can be effective.

9. With electromechanical dissociation:

Execute pp. 2-5;

Identify and correct its possible cause (massive PE - see relevant recommendations: cardiac tamponade - pericardiocentesis).

10. Monitor vital functions (heart monitor, pulse oximeter).

11. Hospitalize after possible stabilization of the condition.

12. CPR may be terminated if:

In the course of the procedure, it turned out that CPR is not indicated:

There is a persistent asystole that is not amenable to drug exposure, or multiple episodes of asystole:

When using all available methods, there is no evidence of effective CPR within 30 minutes.

13. CPR may not be started:

In the terminal stage of an incurable disease (if the futility of CPR is documented in advance);

If more than 30 minutes have passed since the cessation of blood circulation;

With a previously documented refusal of the patient from CPR.

After defibrillation: asystole, ongoing or recurrent ventricular fibrillation, skin burn;

With mechanical ventilation: overflow of the stomach with air, regurgitation, aspiration of gastric contents;

With tracheal intubation: laryngo- and bronchospasm, regurgitation, damage to the mucous membranes, teeth, esophagus;

With closed heart massage: fracture of the sternum, ribs, lung damage, tension pneumothorax;

When puncturing the subclavian vein: bleeding, puncture of the subclavian artery, lymphatic duct, air embolism, tension pneumothorax:

With intracardiac injection: the introduction of drugs into the myocardium, damage to the coronary arteries, hemotamponade, lung injury, pneumothorax;

Respiratory and metabolic acidosis;

Hypoxic coma.

Note. In case of ventricular fibrillation and the possibility of immediate (within 30 s) defibrillation - defibrillation of 200 J, then proceed according to paragraphs. 6 and 7.

All drugs during CPR should be administered intravenously rapidly.

When using a peripheral vein, mix the preparations with 20 ml of isotonic sodium chloride solution.

In the absence of venous access, adrenaline, atropine, lidocaine (increasing the recommended dose by 2 times) should be injected into the trachea in 10 ml of isotonic sodium chloride solution.

Intracardiac injections (with a thin needle, with strict observance of the technique of administration and control) are permissible in exceptional cases, with the absolute impossibility of using other routes of drug administration.

Sodium bicarbonate at 1 mmol / kg (4% solution - 2 ml / kg), then at 0.5 mmol / kg every 5-10 minutes, apply with very long CPR or with hyperkalemia, acidosis, overdose of tricyclic antidepressants, hypoxic lactic acidosis that preceded the cessation of blood circulation ( exclusively under conditions of adequate ventilation1).

Calcium preparations are indicated only for severe initial hyperkalemia or an overdose of calcium antagonists.

In treatment-resistant ventricular fibrillation, reserve drugs are amiodarone and propranolol.

In case of asystole or electromechanical dissociation after tracheal intubation and administration of drugs, if the cause cannot be eliminated, decide on the termination of resuscitation measures, taking into account the time elapsed from the onset of circulatory arrest.

CARDIAC EMERGENCIES tachyarrhythmias

Diagnostics. Severe tachycardia, tachyarrhythmia.

Differential Diagnosis- ECG. It is necessary to distinguish between non-paroxysmal and paroxysmal tachycardias: tachycardias with a normal duration of the OK8 complex (supraventricular tachycardias, atrial fibrillation and flutter) and tachycardias with a wide 9K8 complex on the ECG (supraventricular tachycardias, atrial fibrillation, atrial flutter with transient or permanent blockade of the bundle pedicle P1ca: antidromic supraventricular tachycardia ; atrial fibrillation in the syndrome of IgP\V; ventricular tachycardia).

Urgent care

Emergency restoration of sinus rhythm or correction of heart rate is indicated for tachyarrhythmias complicated by acute circulatory disorders, with a threat of cessation of blood circulation, or with repeated paroxysms of tachyarrhythmias with a known method of suppression. In other cases, it is necessary to provide intensive monitoring and planned treatment (emergency hospitalization).

1. In case of cessation of blood circulation - CPR according to the recommendations of “Sudden Death”.

2. Shock or pulmonary edema (caused by tachyarrhythmia) are absolute vital indications for EIT:

Carry out oxygen therapy;

If the patient's condition allows, then premedicate (fentanyl 0.05 mg or promedol 10 mg intravenously);

Enter into drug sleep (diazepam 5 mg intravenously and 2 mg every 1-2 minutes before falling asleep);

Control your heart rate:

Conduct EIT (with atrial flutter, supraventricular tachycardia, start with 50 J; with atrial fibrillation, monomorphic ventricular tachycardia - from 100 J; with polymorphic ventricular tachycardia - from 200 J):

If the patient's condition allows, synchronize the electrical impulse during EIT with the K wave on the ECL

Use well-moistened pads or gel;

At the moment of applying the discharge, press the electrodes against the chest wall with force:

Apply a discharge at the moment of exhalation of the patient;

Comply with safety regulations;

No effect - repeat EIT, doubling the discharge energy:

No effect - repeat EIT with a maximum energy discharge;

No effect - inject an antiarrhythmic drug indicated for this arrhythmia (see below) and repeat EIT with a maximum energy discharge.

3. In case of clinically significant circulatory disorders (arterial hypotension, anginal pain, increasing heart failure or neurological symptoms) or with repeated paroxysms of arrhythmia with a known suppression method, urgent drug therapy should be carried out. In the absence of effect, deterioration of the condition (and in the cases indicated below - and as an alternative to drug treatment) - EIT (p. 2).

3.1. With paroxysm of reciprocal supraventricular tachycardia:

Massage of the carotid sinus (or other vagal techniques);

No effect - inject ATP 10 mg intravenously with a push:

No effect - after 2 minutes ATP 20 mg intravenously with a push:

No effect - after 2 minutes verapamil 2.5-5 mg intravenously:

No effect - after 15 minutes verapamil 5-10 mg intravenously;

A combination of ATP or verapamil administration with vagal techniques may be effective:

No effect - after 20 minutes novocainamide 1000 mg (up to 17 mg / kg) intravenously at a rate of 50-100 mg / min (with a tendency to arterial hypotension - in one syringe with 0.25-0.5 ml of 1% mezaton solution or 0.1-0.2 ml of 0.2% norepinephrine solution).

3.2. With paroxysmal atrial fibrillation to restore sinus rhythm:

Novocainamide (clause 3.1);

With a high initial heart rate: first intravenously 0.25-0.5 mg of digoxin (strophanthin) and after 30 minutes - 1000 mg of novocainamide. To reduce heart rate:

Digoxin (strophanthin) 0.25-0.5 mg, or verapamil 10 mg intravenously slowly or 80 mg orally, or digoxin (strophanthin) intravenously and verapamil orally, or anaprilin 20-40 mg under the tongue or inside.

3.3. With paroxysmal atrial flutter:

If EIT is not possible, decrease in heart rate with the help of digoxin (strophanthin) and (or) verapamil (section 3.2);

To restore sinus rhythm, novo-cainamide after a preliminary injection of 0.5 mg of digoxin (strophanthin) may be effective.

3.4. With paroxysm of atrial fibrillation against the background of IPU syndrome:

Intravenous slow novocainamide 1000 mg (up to 17 mg/kg), or amiodarone 300 mg (up to 5 mg/kg). or rhythmylen 150 mg. or aimalin 50 mg: either EIT;

cardiac glycosides. blockers of p-adrenergic receptors, calcium antagonists (verapamil, diltazem) are contraindicated!

3.5. With paroxysm of antidromic reciprocal AV tachycardia:

Intravenously slowly novocainamide, or amiodarone, or aymalin, or rhythmylen (section 3.4).

3.6. In case of tactic arrhythmias against the background of SSSU to reduce heart rate:

Intravenously slowly 0.25 mg of digoxin (strophan tin).

3.7. With paroxysmal ventricular tachycardia:

Lidocaine 80-120 mg (1-1.5 mg/kg) and every 5 minutes at 40-60 mg (0.5-0.75 mg/kg) slowly intravenously until the effect or a total dose of 3 mg/kg is reached:

No effect - EIT (p. 2). or novocainamide. or amiodarone (section 3.4);

No effect - EIT or magnesium sulfate 2 g intravenously very slowly:

No effect - EIT or Ornid 5 mg/kg intravenously (for 5 minutes);

No effect - EIT or after 10 minutes Ornid 10 mg/kg intravenously (for 10 minutes).

3.8. With bidirectional spindle tachycardia.

EIT or intravenously slowly introduce 2 g of magnesium sulfate (if necessary, magnesium sulfate is administered again after 10 minutes).

3.9. In case of paroxysm of tachycardia of unknown origin with wide complexes 9K5 on the ECG (if there are no indications for EIT), administer intravenous lidocaine (section 3.7). no effect - ATP (p. 3.1) or EIT, no effect - novocainamide (p. 3.4) or EIT (p. 2).

4. In all cases of acute cardiac arrhythmia (except for repeated paroxysms with restored sinus rhythm), emergency hospitalization is indicated.

5. Continuously monitor heart rate and conduction.

Cessation of blood circulation (ventricular fibrillation, asystole);

MAC syndrome;

Acute heart failure (pulmonary edema, arrhythmic shock);

arterial hypotension;

Respiratory failure with the introduction of narcotic analgesics or diazepam;

Skin burns during EIT:

Thromboembolism after EIT.

Note. Emergency treatment of arrhythmias should be carried out only according to the indications given above.

If possible, the cause of the arrhythmia and its supporting factors should be addressed.

Emergency EIT with heart rate less than 150 in 1 min is usually not indicated.

With severe tachycardia and no indications for urgent restoration of sinus rhythm, it is advisable to reduce the heart rate.

If there are additional indications, before the introduction of antiarrhythmic drugs, potassium and magnesium preparations should be used.

With paroxysmal atrial fibrillation, the appointment of 200 mg of phencarol inside can be effective.

An accelerated (60-100 beats per minute) idioventricular or AV junctional rhythm is usually replacement, and antiarrhythmic drugs are not indicated in these cases.

To provide emergency care for repeated, habitual paroxysms of tachyarrhythmia should take into account the effectiveness of the treatment of previous paroxysms and factors that can change the patient's response to the introduction of antiarrhythmic drugs that helped him before.

BRADIARRHYTHMIAS

Diagnostics. Severe (heart rate less than 50 per minute) bradycardia.

Differential Diagnosis- ECG. Sinus bradycardia, SA node arrest, SA and AV block should be differentiated: AV block should be distinguished by degree and level (distal, proximal); in the presence of an implanted pacemaker, it is necessary to evaluate the effectiveness of stimulation at rest, with a change in body position and load.

Urgent care . Intensive therapy is necessary if bradycardia (HR less than 50 beats per minute) causes MAC syndrome or its equivalents, shock, pulmonary edema, arterial hypotension, anginal pain, or a progressive decrease in heart rate or an increase in ectopic ventricular activity.

2. With MAS syndrome or bradycardia that caused acute heart failure, arterial hypotension, neurological symptoms, anginal pain, or with a progressive decrease in heart rate or an increase in ectopic ventricular activity:

Lay the patient with the lower limbs raised at an angle of 20 ° (if there is no pronounced stagnation in the lungs):

Carry out oxygen therapy;

If necessary (depending on the patient's condition) - closed heart massage or rhythmic tapping on the sternum ("fist rhythm");

Administer atropine 1 mg intravenously every 3-5 minutes until an effect is obtained or a total dose of 0.04 mg/kg is reached;

No effect - immediate endocardial percutaneous or transesophageal pacemaker:

There is no effect (or there is no possibility of conducting an EX-) - intravenous slow jet injection of 240-480 mg of aminophylline;

No effect - dopamine 100 mg or adrenaline 1 mg in 200 ml of 5% glucose solution intravenously; gradually increase the infusion rate until the minimum sufficient heart rate is reached.

3. Continuously monitor heart rate and conduction.

4. Hospitalize after possible stabilization of the condition.

The main dangers in complications:

asystole;

Ectopic ventricular activity (up to fibrillation), including after the use of adrenaline, dopamine. atropine;

Acute heart failure (pulmonary edema, shock);

Arterial hypotension:

Anginal pain;

Impossibility or inefficiency of EX-

Complications of endocardial pacemaker (ventricular fibrillation, perforation of the right ventricle);

Pain during transesophageal or percutaneous pacemaker.

UNSTABLE ANGINA

Diagnostics. The appearance of frequent or severe anginal attacks (or their equivalents) for the first time, a change in the course of pre-existing angina pectoris, the resumption or appearance of angina pectoris in the first 14 days of myocardial infarction, or the appearance of anginal pain for the first time at rest.

There are risk factors for the development or clinical manifestations of coronary artery disease. Changes on the ECG, even at the height of the attack, may be vague or absent!

Differential diagnosis. In most cases - with prolonged exertional angina, acute myocardial infarction, cardialgia. extracardiac pain.

Urgent care

1. Shown:

Nitroglycerin (tablets or aerosol 0.4-0.5 mg under the tongue repeatedly);

oxygen therapy;

Correction of blood pressure and heart rate:

Propranolol (anaprilin, inderal) 20-40 mg orally.

2. With anginal pain (depending on its severity, age and condition of the patient);

Morphine up to 10 mg or neuroleptanalgesia: fentanyl 0.05-0.1 mg or promedol 10-20 mg with 2.5-5 mg droperidol intravenously fractionally:

With insufficient analgesia - intravenously 2.5 g of analgin, and with high blood pressure - 0.1 mg of clonidine.

5000 IU of heparin intravenously. and then drip 1000 IU / h.

5. Hospitalize after possible stabilization of the condition. Main dangers and complications:

Acute myocardial infarction;

Acute violations of the heart rhythm or conduction (up to sudden death);

Incomplete elimination or recurrence of anginal pain;

Arterial hypotension (including drug);

Acute heart failure:

Respiratory disorders with the introduction of narcotic analgesics.

Note. Emergency hospitalization is indicated, regardless of the presence of ECG changes, in intensive care units (wards), departments for the treatment of patients with acute myocardial infarction.

It is necessary to ensure constant monitoring of heart rate and blood pressure.

For emergency care (in the first hours of the disease or in case of complications), catheterization of a peripheral vein is indicated.

In case of recurrent anginal pain or moist rales in the lungs, nitroglycerin should be administered intravenously by drip.

For the treatment of unstable angina, the rate of intravenous heparin administration must be selected individually, achieving a stable increase in activated partial thromboplastin time by 2 times compared to its normal value. It is much more convenient to use low molecular weight heparin enoxaparin (Clexane). 30 mg of Clexane is administered intravenously by stream, after which the drug is administered subcutaneously at 1 mg/kg 2 times a day for 3-6 days.

If traditional narcotic analgesics are not available, then you can prescribe 1-2 mg of butorphanol or 50-100 mg of tramadol with 5 mg of droperidol and (or) 2.5 g of analgin with 5 mg of diaepam intravenously slowly or fractionally.

MYOCARDIAL INFARCTION

Diagnostics. Characterized by chest pain (or its equivalents) with irradiation to the left (sometimes to the right) shoulder, forearm, shoulder blade, neck. lower jaw, epigastric region; heart rhythm and conduction disturbances, blood pressure instability: the reaction to nitroglycerin is incomplete or absent. Other variants of the onset of the disease are less commonly observed: asthmatic (cardiac asthma, pulmonary edema). arrhythmic (fainting, sudden death, MAC syndrome). cerebrovascular (acute neurological symptoms), abdominal (pain in the epigastric region, nausea, vomiting), asymptomatic (weakness, vague sensations in the chest). In the anamnesis - risk factors or signs of coronary artery disease, the appearance for the first time or a change in habitual anginal pain. ECG changes (especially in the first hours) may be vague or absent! After 3-10 hours from the onset of the disease - a positive test with troponin-T or I.

Differential diagnosis. In most cases - with prolonged angina, unstable angina, cardialgia. extracardiac pain. PE, acute diseases of the abdominal organs (pancreatitis, cholecystitis, etc.), dissecting aortic aneurysm.

Urgent care

1. Shown:

Physical and emotional peace:

Nitroglycerin (tablets or aerosol 0.4-0.5 mg under the tongue repeatedly);

oxygen therapy;

Correction of blood pressure and heart rate;

Acetylsalicylic acid 0.25 g (chew);

Propranolol 20-40 mg orally.

2. For pain relief (depending on the severity of pain, the age of the patient, his condition):

Morphine up to 10 mg or neuroleptanalgesia: fentanyl 0.05-0.1 mg or promedol 10-20 mg with 2.5-5 mg droperidol intravenously fractionally;

With insufficient analgesia - intravenously 2.5 g of analgin, and against the background of high blood pressure - 0.1 mg of clonidine.

3. To restore coronary blood flow:

In case of transmural myocardial infarction with a rise in the 8T segment on the ECG (in the first 6, and with recurrent pain - up to 12 hours from the onset of the disease), inject streptokinase 1,500,000 IU intravenously in 30 minutes as early as possible:

In case of subendocardial myocardial infarction with depression of the 8T segment on the ECG (or the impossibility of thrombolytic therapy), 5000 units of heparin are administered intravenously as soon as possible, and then drip.

4. Continuously monitor heart rate and conduction.

5. Hospitalize after possible stabilization of the condition.

Main dangers and complications:

Acute cardiac arrhythmias and conduction disorders up to sudden death (ventricular fibrillation), especially in the first hours of myocardial infarction;

Recurrence of anginal pain;

Arterial hypotension (including medication);

Acute heart failure (cardiac asthma, pulmonary edema, shock);

arterial hypotension; allergic, arrhythmic, hemorrhagic complications with the introduction of streptokinase;

Respiratory disorders with the introduction of narcotic analgesics;

Myocardial rupture, cardiac tamponade.

Note. For emergency care (in the first hours of the disease or with the development of complications), catheterization of a peripheral vein is indicated.

With recurrent anginal pain or moist rales in the lungs, nitroglycerin should be administered intravenously by drip.

With an increased risk of developing allergic complications, 30 mg of prednisolone should be administered intravenously before the appointment of streptokinase. When carrying out thrombolytic therapy, ensure control over the heart rate and basic hemodynamic parameters, readiness to correct possible complications (the presence of a defibrillator, a ventilator).

For the treatment of subendocardial (with 8T segment depression and without pathological O wave) myocardial infarction, the rate of intravenous administration of gegyurin must be selected individually, achieving a stable increase in activated partial thromboplastin time by 2 times compared to its normal value. It is much more convenient to use low molecular weight heparin enoxaparin (Clexane). 30 mg of Clexane is administered intravenously by stream, after which the drug is administered subcutaneously at 1 mg/kg 2 times a day for 3-6 days.

If traditional narcotic analgesics are not available, then 1-2 mg of butorphanol or 50-100 mg of tramadol with 5 mg of droperidol and (or) 2.5 g of analgin with 5 mg of diaepam can be prescribed intravenously slowly or fractionally.

CARDIOGENIC PULMONARY EDEMA

Diagnostics. Characteristic: suffocation, shortness of breath, aggravated in the prone position, which forces patients to sit down: tachycardia, acrocyanosis. hyperhydration of tissues, inspiratory dyspnea, dry wheezing, then moist rales in the lungs, abundant foamy sputum, ECG changes (hypertrophy or overload of the left atrium and ventricle, blockade of the left leg of the Pua bundle, etc.).

History of myocardial infarction, malformation or other heart disease. hypertension, chronic heart failure.

Differential diagnosis. In most cases, cardiogenic pulmonary edema is differentiated from non-cardiogenic (with pneumonia, pancreatitis, cerebrovascular accident, chemical damage to the lungs, etc.), pulmonary embolism, bronchial asthma.

Urgent care

1. General activities:

oxygen therapy;

Heparin 5000 IU intravenous bolus:

Correction of heart rate (with a heart rate of more than 150 in 1 min - EIT. with a heart rate of less than 50 in 1 min - EX);

With abundant foam formation - defoaming (inhalation of a 33% solution of ethyl alcohol or intravenously 5 ml of a 96% solution of ethyl alcohol and 15 ml of a 40% glucose solution), in extremely severe (1) cases, 2 ml of a 96% solution of ethyl alcohol is injected into the trachea.

2. With normal blood pressure:

Run step 1;

To seat the patient with lowered lower limbs;

Nitroglycerin tablets (preferably aerosol) 0.4-0.5 mg sublingually again after 3 minutes or up to 10 mg intravenously slowly fractionally or intravenously drip in 100 ml of isotonic sodium chloride solution, increasing the rate of administration from 25 μg / min until effect by controlling blood pressure:

Diazepam up to 10 mg or morphine 3 mg intravenously in divided doses until the effect or a total dose of 10 mg is reached.

3. With arterial hypertension:

Run step 1;

Seating a patient with lowered lower limbs:

Nitroglycerin, tablets (aerosol is better) 0.4-0.5 mg under the tongue once;

Furosemide (Lasix) 40-80 mg IV;

Nitroglycerin intravenously (item 2) or sodium nitroprusside 30 mg in 300 ml of 5% glucose solution intravenously drip, gradually increasing the infusion rate of the drug from 0.3 μg / (kg x min) until the effect is obtained, controlling blood pressure, or pentamine to 50 mg intravenously fractionally or drip:

Intravenously up to 10 mg of diazepam or up to 10 mg of morphine (item 2).

4. With severe arterial hypotension:

Run step 1:

Lay down the patient, raising the head;

Dopamine 200 mg in 400 ml of 5% glucose solution intravenously, increasing the infusion rate from 5 μg / (kg x min) until blood pressure stabilizes at the minimum sufficient level;

If it is impossible to stabilize blood pressure, additionally prescribe norepinephrine hydrotartrate 4 mg in 200 ml of 5-10% glucose solution, increasing the infusion rate from 0.5 μg / min until blood pressure stabilizes at the minimum sufficient level;

With an increase in blood pressure, accompanied by increasing pulmonary edema, additionally nitroglycerin intravenously drip (p. 2);

Furosemide (Lasix) 40 mg IV after stabilization of blood pressure.

5. Monitor vital functions (heart monitor, pulse oximeter).

6. Hospitalize after possible stabilization of the condition. Main dangers and complications:

Lightning form of pulmonary edema;

Airway obstruction with foam;

respiratory depression;

tachyarrhythmia;

asystole;

Anginal pain:

The increase in pulmonary edema with an increase in blood pressure.

Note. Under the minimum sufficient blood pressure should be understood as a systolic pressure of about 90 mm Hg. Art. provided that the increase in blood pressure is accompanied by clinical signs of improved perfusion of organs and tissues.

Eufillin in cardiogenic pulmonary edema is an adjuvant and can be indicated for bronchospasm or severe bradycardia.

Glucocorticoid hormones are used only for respiratory distress syndrome (aspiration, infection, pancreatitis, inhalation of irritants, etc.).

Cardiac glycosides (strophanthin, digoxin) can only be prescribed for moderate congestive heart failure in patients with tachysystolic atrial fibrillation (flutter).

In aortic stenosis, hypertrophic cardiomycopathy, cardiac tamponade, nitroglycerin and other peripheral vasodilators are relatively contraindicated.

It is effective to create positive end-expiratory pressure.

ACE inhibitors (captopril) are useful in preventing recurrence of pulmonary edema in patients with chronic heart failure. At the first appointment of captopril, treatment should begin with a trial dose of 6.25 mg.

CARDIOGENIC SHOCK

Diagnostics. A pronounced decrease in blood pressure in combination with signs of impaired blood supply to organs and tissues. Systolic blood pressure is usually below 90 mm Hg. Art., pulse - below 20 mm Hg. Art. There are symptoms of deterioration of the peripheral circulation (pale cyanotic moist skin, collapsed peripheral veins, a decrease in the temperature of the skin of the hands and feet); decrease in blood flow velocity (time of disappearance of a white spot after pressing on the nail bed or palm - more than 2 s), decrease in diuresis (less than 20 ml / h), impaired consciousness (from mild retardation ™ to the appearance of focal neurological symptoms and the development of coma).

Differential diagnosis. In most cases, it is necessary to differentiate true cardiogenic shock from its other varieties (reflex, arrhythmic, drug-induced, with slow myocardial rupture, rupture of the septum or papillary muscles, damage to the right ventricle), as well as from pulmonary embolism, hypovolemia, internal bleeding and arterial hypotension without shock.

Urgent care

Emergency care must be carried out in stages, quickly moving on to the next stage if the previous one is ineffective.

1. In the absence of pronounced stagnation in the lungs:

Lay the patient down with the lower limbs raised at an angle of 20° (with severe congestion in the lungs - see “Pulmonary edema”):

Carry out oxygen therapy;

With anginal pain, conduct a full anesthesia:

Carry out heart rate correction (paroxysmal tachyarrhythmia with a heart rate of more than 150 beats per 1 min - an absolute indication for EIT, acute bradycardia with a heart rate of less than 50 beats per 1 min - for a pacemaker);

Administer heparin 5000 IU intravenously by bolus.

2. In the absence of pronounced stagnation in the lungs and signs of a sharp increase in CVP:

Introduce 200 ml of 0.9% sodium chloride solution intravenously over 10 minutes under the control of blood pressure and respiratory rate. Heart rate, auscultatory picture of the lungs and heart (if possible, control CVP or wedge pressure in the pulmonary artery);

If arterial hypotension persists and there are no signs of transfusion hypervolemia, repeat the introduction of fluid according to the same criteria;

In the absence of signs of transfusion hypervolemia (CVD below 15 cm of water column), continue infusion therapy at a rate of up to 500 ml / h, monitoring these indicators every 15 minutes.

If blood pressure cannot be quickly stabilized, then proceed to the next step.

3. Inject dopamine 200 mg in 400 ml of 5% glucose solution intravenously, increasing the infusion rate starting from 5 µg/(kg x min) until the minimum sufficient arterial pressure is reached;

No effect - additionally prescribe norepinephrine hydrotartrate 4 mg in 200 ml of 5% glucose solution intravenously, increasing the infusion rate from 0.5 μg / min until the minimum sufficient arterial pressure is reached.

4. Monitor vital functions: heart monitor, pulse oximeter.

5. Hospitalize after possible stabilization of the condition.

Main dangers and complications:

Late diagnosis and initiation of treatment:

Failure to stabilize blood pressure:

Pulmonary edema with increased blood pressure or intravenous fluids;

Tachycardia, tachyarrhythmia, ventricular fibrillation;

Asystole:

Recurrence of anginal pain:

Acute renal failure.

Note. Under the minimum sufficient blood pressure should be understood as a systolic pressure of about 90 mm Hg. Art. when signs of improvement in perfusion of organs and tissues appear.

Glucocorpoid hormones are not indicated in true cardiogenic shock.

emergency angina heart attack poisoning

HYPERTENSIVE CRISES

Diagnostics. An increase in blood pressure (usually acute and significant) with neurological symptoms: headache, “flies” or a veil before the eyes, paresthesia, a feeling of “crawling”, nausea, vomiting, weakness in the limbs, transient hemiparesis, aphasia, diplopia.

With a neurovegetative crisis (type I crisis, adrenal): sudden onset. excitation, hyperemia and moisture of the skin. tachycardia, frequent and copious urination, a predominant increase in systolic pressure with an increase in pulse.

With a water-salt form of a crisis (crisis type II, noradrenal): gradual onset, drowsiness, weakness, disorientation, pallor and puffiness of the face, swelling, a predominant increase in diastolic pressure with a decrease in pulse pressure.

With a convulsive form of a crisis: a throbbing, bursting headache, psychomotor agitation, repeated vomiting without relief, visual disturbances, loss of consciousness, tonic-clonic convulsions.

Differential diagnosis. First of all, the severity, form and complications of the crisis should be taken into account, crises associated with the sudden withdrawal of antihypertensive drugs (clonidine, p-blockers, etc.) should be distinguished, hypertensive crises should be differentiated from cerebrovascular accident, diencephalic crises and crises with pheochromocytoma.

Urgent care

1. Neurovegetative form of crisis.

1.1. For mild flow:

Nifedipine 10 mg sublingually or in drops orally every 30 minutes, or clonidine 0.15 mg sublingually. then 0.075 mg every 30 minutes until the effect, or a combination of these drugs.

1.2. With severe flow.

Clonidine 0.1 mg intravenously slowly (can be combined with 10 mg of nifedipine under the tongue), or sodium nitroprusside 30 mg in 300 ml of 5% glucose solution intravenously, gradually increasing the rate of administration until the required blood pressure is reached, or pentamine up to 50 mg intravenously drip or jet fractionally;

With insufficient effect - furosemide 40 mg intravenously.

1.3. With continued emotional tension, additional diazepam 5-10 mg orally, intramuscularly or intravenously, or droperidol 2.5-5 mg intravenously slowly.

1.4. With persistent tachycardia, propranolol 20-40 mg orally.

2. Water-salt form of crisis.

2.1. For mild flow:

Furosemide 40–80 mg orally once and nifedipine 10 mg sublingually or in drops orally every 30 minutes until effect, or furosemide 20 mg orally once and captopril 25 mg sublingually or orally every 30–60 minutes until effect.

2.2. With severe flow.

Furosemide 20-40 mg intravenously;

Sodium nitroprusside or pentamine intravenously (section 1.2).

2.3. With persistent neurological symptoms, intravenous administration of 240 mg of aminophylline can be effective.

3. Convulsive form of crisis:

Diazepam 10-20 mg intravenously slowly until seizures are eliminated, magnesium sulfate 2.5 g intravenously very slowly can be administered additionally:

Sodium nitroprusside (section 1.2) or pentamine (section 1.2);

Furosemide 40-80 mg intravenously slowly.

4. Crises associated with the sudden withdrawal of antihypertensive drugs:

Appropriate antihypertensive drug intravenously. under the tongue or inside, with pronounced arterial hypertension - sodium nitroprusside (section 1.2).

5. Hypertensive crisis complicated by pulmonary edema:

Nitroglycerin (preferably an aerosol) 0.4-0.5 mg under the tongue and immediately 10 mg in 100 ml of isotonic sodium chloride solution intravenously. by increasing the rate of infusion from 25 µg/min until effect is obtained, either sodium nitroprusside (section 1.2) or pentamine (section 1.2);

Furosemide 40-80 mg intravenously slowly;

Oxygen therapy.

6. Hypertensive crisis complicated by hemorrhagic stroke or subarachnoid hemorrhage:

With pronounced arterial hypertension - sodium nitroprusside (section 1.2). reduce blood pressure to values ​​​​exceeding the usual values ​​​​for this patient, with an increase in neurological symptoms, reduce the rate of administration.

7. Hypertensive crisis complicated by anginal pain:

Nitroglycerin (preferably an aerosol) 0.4-0.5 mg under the tongue and immediately 10 mg intravenously drip (item 5);

Required anesthesia - see "Angina":

With insufficient effect - propranolol 20-40 mg orally.

8. With a complicated course- monitor vital functions (heart monitor, pulse oximeter).

9. Hospitalize after possible stabilization of the condition .

Main dangers and complications:

arterial hypotension;

Violation of cerebral circulation (hemorrhagic or ischemic stroke);

Pulmonary edema;

Anginal pain, myocardial infarction;

Tachycardia.

Note. In case of acute arterial hypertension, immediately shortening life, reduce blood pressure within 20-30 minutes to the usual, “working” or slightly higher values, use intravenous. the route of administration of drugs, the hypotensive effect of which can be controlled (sodium nitroprusside, nitroglycerin.).

In a hypertensive crisis without an immediate threat to life, lower blood pressure gradually (for 1-2 hours).

When the course of hypertension worsens, not reaching a crisis, blood pressure must be reduced within a few hours, the main antihypertensive drugs should be administered orally.

In all cases, blood pressure should be reduced to the usual, "working" values.

To provide emergency care for repeated hypertensive crises of SLS diets, taking into account the existing experience in the treatment of previous ones.

When using captopril for the first time, treatment should begin with a trial dose of 6.25 mg.

The hypotensive effect of pentamine is difficult to control, so the drug can be used only in cases where an emergency lowering of blood pressure is indicated and there are no other options for this. Pentamine is administered in doses of 12.5 mg intravenously in fractions or drops up to 50 mg.

In a crisis in patients with pheochromocytoma, raise the head of the bed to. 45°; prescribe (rentolation (5 mg intravenously 5 minutes before the effect.); you can use prazosin 1 mg sublingually repeatedly or sodium nitroprusside. As an auxiliary drug, droperidol 2.5-5 mg intravenously slowly. Blockers of P-adrenoreceptors should be changed only (!) after the introduction of a-adrenergic blockers.

PULMONARY EMBOLISM

Diagnostics Massive pulmonary embolism is manifested by sudden circulatory arrest (electromechanical dissociation), or shock with severe shortness of breath, tachycardia, pallor or sharp cyanosis of the skin of the upper half of the body, swelling of the neck veins, antinose-like pain, electrocardiographic manifestations of acute cor pulmonale.

Non-gossive PE is manifested by shortness of breath, tachycardia, arterial hypotension. signs of pulmonary infarction (pulmonary-pleural pain, cough, in some patients - with sputum stained with blood, fever, crepitant wheezing in the lungs).

For the diagnosis of PE, it is important to take into account the presence of risk factors for the development of thromboembolism, such as a history of thromboembolic complications, advanced age, prolonged immobilization, recent surgery, heart disease, heart failure, atrial fibrillation, oncological diseases, DVT.

Differential diagnosis. In most cases - with myocardial infarction, acute heart failure (cardiac asthma, pulmonary edema, cardiogenic shock), bronchial asthma, pneumonia, spontaneous pneumothorax.

Urgent care

1. With the cessation of blood circulation - CPR.

2. With massive PE with arterial hypotension:

Oxygen therapy:

Catheterization of the central or peripheral vein:

Heparin 10,000 IU intravenously by stream, then drip at an initial rate of 1000 IU / h:

Infusion therapy (reopoliglyukin, 5% glucose solution, hemodez, etc.).

3. In case of severe arterial hypotension, not corrected by infusion therapy:

Dopamine, or adrenaline intravenously drip. increasing the rate of administration until blood pressure stabilizes;

Streptokinase (250,000 IU intravenously drip for 30 minutes, then intravenously drip at a rate of 100,000 IU/h to a total dose of 1,500,000 IU).

4. With stable blood pressure:

oxygen therapy;

Catheterization of a peripheral vein;

Heparin 10,000 IU intravenously by stream, then drip at a rate of 1000 IU / h or subcutaneously at 5000 IU after 8 hours:

Eufillin 240 mg intravenously.

5. In case of recurrent PE, additionally prescribe 0.25 g of acetylsalicylic acid orally.

6. Monitor vital functions (heart monitor, pulse oximeter).

7. Hospitalize after possible stabilization of the condition.

Main dangers and complications:

Electromechanical dissociation:

Inability to stabilize blood pressure;

Increasing respiratory failure:

PE recurrence.

Note. With a aggravated allergic history, 30 mg of predniolone is administered intravenously by stream before the appointment of strepyayukinoz.

For the treatment of PE, the rate of intravenous heparin administration must be selected individually, achieving a stable increase in activated partial thromboplastin time by 2 times compared to its normal value.

STROKE (ACUTE CEREBRAL CIRCULATION DISTURBANCE)

Stroke (stroke) is a rapidly developing focal or global impairment of brain function, lasting more than 24 hours or leading to death if another genesis of the disease is excluded. It develops against the background of atherosclerosis of cerebral vessels, hypertension, their combination or as a result of rupture of cerebral aneurysms.

Diagnostics The clinical picture depends on the nature of the process (ischemia or hemorrhage), localization (hemispheres, trunk, cerebellum), the rate of development of the process (sudden, gradual). A stroke of any genesis is characterized by the presence of focal symptoms of brain damage (hemiparesis or hemiplegia, less often monoparesis and damage to the cranial nerves - facial, hypoglossal, oculomotor) and cerebral symptoms of varying severity (headache, dizziness, nausea, vomiting, impaired consciousness).

CVA is clinically manifested by subarachnoid or intracerebral hemorrhage (hemorrhagic stroke), or ischemic stroke.

Transient cerebrovascular accident (TIMC) is a condition in which focal symptoms undergo complete regression over a period of less than 24 hours. The diagnosis is made retrospectively.

Suborocnoid hemorrhages develop as a result of rupture of aneurysms and less often against the background of hypertension. Characterized by the sudden onset of a sharp headache, followed by nausea, vomiting, motor agitation, tachycardia, sweating. With massive subarachnoid hemorrhage, as a rule, depression of consciousness is observed. Focal symptoms are often absent.

Hemorrhagic stroke - bleeding into the substance of the brain; characterized by a sharp headache, vomiting, rapid (or sudden) depression of consciousness, accompanied by the appearance of pronounced symptoms of dysfunction of the limbs or bulbar disorders (peripheral paralysis of the muscles of the tongue, lips, soft palate, pharynx, vocal folds and epiglottis due to damage to the IX, X and XII pairs of cranial nerves or their nuclei located in the medulla oblongata). It usually develops during the day, during wakefulness.

Ischemic stroke is a disease that leads to a decrease or cessation of blood supply to a certain part of the brain. It is characterized by a gradual (over hours or minutes) increase in focal symptoms corresponding to the affected vascular pool. Cerebral symptoms are usually less pronounced. Develops more often with normal or low blood pressure, often during sleep

At the prehospital stage, it is not required to differentiate the nature of the stroke (ischemic or hemorrhagic, subarachnoid hemorrhage and its localization.

Differential diagnosis should be carried out with a traumatic brain injury (history, the presence of traces of trauma on the head) and much less often with meningoencephalitis (history, signs of a general infectious process, rash).

Urgent care

Basic (undifferentiated) therapy includes emergency correction of vital functions - restoration of patency of the upper respiratory tract, if necessary - tracheal intubation, artificial ventilation of the lungs, as well as normalization of hemodynamics and cardiac activity:

With arterial pressure significantly higher than usual values ​​- its decrease to indicators slightly higher than the “working” one, which is familiar to this patient, if there is no information, then to the level of 180/90 mm Hg. Art.; for this use - 0.5-1 ml of a 0.01% solution of clonidine (clophelin) in 10 ml of a 0.9% solution of sodium chloride intravenously or intramuscularly or 1-2 tablets sublingually (if necessary, the administration of the drug can be repeated), or pentamine - no more than 0, 5 ml of a 5% solution intravenously at the same dilution or 0.5-1 ml intramuscularly:

As an additional remedy, you can use dibazol 5-8 ml of a 1% solution intravenously or nifedipine (Corinfar, fenigidin) - 1 tablet (10 mg) sublingually;

For the relief of convulsive seizures, psychomotor agitation - diazepam (Relanium, Seduxen, Sibazon) 2-4 ml intravenously with 10 ml of 0.9% sodium chloride solution slowly or intramuscularly or Rohypnol 1-2 ml intramuscularly;

With inefficiency - 20% sodium oxybutyrate solution at the rate of 70 mg / kg of body weight in 5-10% glucose solution intravenously slowly;

In case of repeated vomiting - cerucal (raglan) 2 ml intravenously in a 0.9% solution intravenously or intramuscularly:

Vitamin Wb 2 ml of 5% solution intravenously;

Droperidol 1-3 ml of 0.025% solution, taking into account the patient's body weight;

With a headache - 2 ml of a 50% solution of analgin or 5 ml of baralgin intravenously or intramuscularly;

Tramal - 2 ml.

Tactics

For patients of working age in the first hours of the disease, it is mandatory to call a specialized neurological (neuroresuscitation) team. Shown hospitalization on a stretcher in the neurological (neurovascular) department.

In case of refusal of hospitalization - a call to the neurologist of the polyclinic and, if necessary, an active visit to the emergency doctor after 3-4 hours.

Non-transportable patients in deep atonic coma (5-4 points on the Glasgow scale) with intractable severe respiratory disorders: unstable hemodynamics, with a rapid, steady deterioration.

Dangers and Complications

Obstruction of the upper respiratory tract by vomit;

Aspiration of vomit;

Inability to normalize blood pressure:

swelling of the brain;

Breakthrough of blood into the ventricles of the brain.

Note

1. Early use of antihypoxants and activators of cell metabolism is possible (nootropil 60 ml (12 g) intravenously bolus 2 times a day after 12 hours on the first day; cerebrolysin 15-50 ml intravenously by drip per 100-300 ml of isotonic solution in 2 doses; glycine 1 tablet under the tongue Riboyusin 10 ml intravenously bolus, Solcoseryl 4 ml intravenous bolus, in severe cases 250 ml of 10% Solcoseryl solution intravenously drip can significantly reduce the number of irreversibly damaged cells in the ischemic zone, reduce the area of ​​perifocal edema.

2. Aminazine and propazine should be excluded from the funds prescribed for any form of stroke. These drugs sharply inhibit the functions of the brain stem structures and clearly worsen the condition of patients, especially the elderly and senile.

3. Magnesium sulfate is not used for convulsions and to lower blood pressure.

4. Eufillin is shown only in the first hours of an easy stroke.

5. Furosemide (Lasix) and other dehydrating drugs (mannitol, reogluman, glycerol) should not be administered in the prehospital stage. The need to prescribe dehydrating agents can only be determined in a hospital based on the results of determining plasma osmolality and sodium content in blood serum.

6. In the absence of a specialized neurological team, hospitalization in the neurological department is indicated.

7. For patients of any age with a first or repeated stroke with minor defects after previous episodes, a specialized neurological (neuroresuscitation) team can also be called on the first day of the disease.

BRONCHOASTMATIC STATUS

Bronchoasthmatic status is one of the most severe variants of the course of bronchial asthma, manifested by acute obstruction of the bronchial tree as a result of bronchiolospasm, hyperergic inflammation and mucosal edema, hypersecretion of the glandular apparatus. The formation of the status is based on a deep blockade of p-adrenergic receptors of the smooth muscles of the bronchi.

Diagnostics

An attack of suffocation with difficulty exhaling, increasing dyspnea at rest, acrocyanosis, increased sweating, hard breathing with dry scattered wheezing and the subsequent formation of areas of a “silent” lung, tachycardia, high blood pressure, participation in breathing of auxiliary muscles, hypoxic and hypercapnic coma. When conducting drug therapy, resistance to sympathomimetics and other bronchodilators is revealed.

Urgent care

Asthmatic status is a contraindication to the use of β-agonists (agonists) due to loss of sensitivity (lung receptors to these drugs. However, this loss of sensitivity can be overcome with the help of nebulizer technique.

Drug therapy is based on the use of selective p2-agonists fenoterol (berotec) at a dose of 0.5-1.5 mg or salbutamol at a dose of 2.5-5.0 mg or a complex preparation of berodual containing fenoterol and the anticholinergic drug ypra using nebulizer technology. -tropium bromide (atrovent). The dosage of berodual is 1-4 ml per inhalation.

In the absence of a nebulizer, these drugs are not used.

Eufillin is used in the absence of a nebulizer or in especially severe cases with the ineffectiveness of nebulizer therapy.

The initial dose is 5.6 mg / kg of body weight (10-15 ml of a 2.4% solution intravenously slowly, over 5-7 minutes);

Maintenance dose - 2-3.5 ml of a 2.4% solution fractionally or drip until the patient's clinical condition improves.

Glucocorticoid hormones - in terms of methylprednisolone 120-180 mg intravenously by stream.

Oxygen therapy. Continuous insufflation (mask, nasal catheters) of an oxygen-air mixture with an oxygen content of 40-50%.

Heparin - 5,000-10,000 IU intravenously with one of the plasma-substituting solutions; it is possible to use low molecular weight heparins (fraxiparin, clexane, etc.)

Contraindicated

Sedatives and antihistamines (inhibit the cough reflex, increase bronchopulmonary obstruction);

Mucolytic mucus thinners:

antibiotics, sulfonamides, novocaine (have a high sensitizing activity);

Calcium preparations (deepen initial hypokalemia);

Diuretics (increase initial dehydration and hemoconcentration).

In a coma

Urgent tracheal intubation for spontaneous breathing:

Artificial ventilation of the lungs;

If necessary - cardiopulmonary resuscitation;

Medical therapy (see above)

Indications for tracheal intubation and mechanical ventilation:

hypoxic and hyperkalemic coma:

Cardiovascular collapse:

The number of respiratory movements is more than 50 in 1 min. Transportation to the hospital against the background of ongoing therapy.

SEVERAL SYNDROME

Diagnostics

A generalized generalized convulsive seizure is characterized by the presence of tonic-clonic convulsions in the limbs, accompanied by loss of consciousness, foam at the mouth, often - tongue bite, involuntary urination, and sometimes defecation. At the end of the seizure, there is a pronounced respiratory arrhythmia. Long periods of apnea are possible. At the end of the seizure, the patient is in a deep coma, the pupils are maximally dilated, without reaction to light, the skin is cyanotic, often moist.

Simple partial seizures without loss of consciousness are manifested by clonic or tonic convulsions in certain muscle groups.

Complex partial seizures (temporal lobe epilepsy or psychomotor seizures) are episodic behavioral changes when the patient loses contact with the outside world. The beginning of such seizures may be the aura (olfactory, gustatory, visual, sensation of “already seen”, micro or macropsia). During complex attacks, inhibition of motor activity may be observed; or smacking tubas, swallowing, walking aimlessly, picking off one's own clothes (automatisms). At the end of the attack, amnesia is noted for the events that took place during the attack.

The equivalents of convulsive seizures are manifested in the form of gross disorientation, somnambulism and a prolonged twilight state, during which unconscious severe antisocial acts can be performed.

Status epilepticus - a fixed epileptic state due to a prolonged epileptic seizure or a series of seizures that recur at short intervals. Status epilepticus and recurrent seizures are life-threatening conditions.

Seizures can be a manifestation of genuine ("congenital") and symptomatic epilepsy - a consequence of past diseases (brain injury, cerebrovascular accident, neuro-infection, tumor, tuberculosis, syphilis, toxoplasmosis, cysticercosis, Morgagni-Adams-Stokes syndrome, ventricular fibrillation , eclampsia) and intoxication.

Differential Diagnosis

At the prehospital stage, determining the cause of a seizure is often extremely difficult. The anamnesis and clinical data are of great importance. Special care must be taken with respect to first of all, traumatic brain injury, acute cerebrovascular accidents, cardiac arrhythmias, eclampsia, tetanus and exogenous intoxications.

Urgent care

1. After a single convulsive seizure - diazepam (Relanium, Seduxen, Sibazon) - 2 ml intramuscularly (as a prevention of recurrent seizures).

2. With a series of convulsive seizures:

Head and torso injury prevention:

Relief of convulsive syndrome: diazepam (Relanium, Seduxen, Sibazon) - 2-4 ml per 10 ml of 0.9% sodium chloride solution intravenously or intramuscularly, Rohypnol 1-2 ml intramuscularly;

In the absence of effect - sodium hydroxybutyrate 20% solution at the rate of 70 mg / kg of body weight intravenously in 5-10% glucose solution;

Decongestant therapy: furosemide (lasix) 40 mg per 10-20 ml of 40% glucose or 0.9% sodium chloride solution (in patients with diabetes mellitus)

intravenously;

Headache relief: analgin 2 ml 50% solution: baralgin 5 ml; tramal 2 ml intravenously or intramuscularly.

3. Status epilepticus

Prevention of trauma to the head and torso;

Restoration of airway patency;

Relief of convulsive syndrome: diazepam (Relanium, Seduxen, Syabazone) _ 2-4 ml per 10 ml of 0.9% sodium chloride solution intravenously or intramuscularly, Rohypnol 1-2 ml intramuscularly;

In the absence of effect - sodium hydroxybutyrate 20% solution at the rate of 70 mg / kg of body weight intravenously in 5-10% glucose solution;

In the absence of effect - inhalation anesthesia with nitrous oxide mixed with oxygen (2:1).

Decongestant therapy: furosemide (lasix) 40 mg per 10-20 ml of 40% glucose or 0.9% sodium chloride solution (in diabetic patients) intravenously:

Relief of headache:

Analgin - 2 ml of 50% solution;

- baralgin - 5 ml;

Tramal - 2 ml intravenously or intramuscularly.

According to indications:

With an increase in blood pressure significantly higher than the patient's usual indicators - antihypertensive drugs (clofelin intravenously, intramuscularly or sublingual tablets, dibazol intravenously or intramuscularly);

With tachycardia over 100 beats / min - see "Tachyarrhythmias":

With bradycardia less than 60 beats / min - atropine;

With hyperthermia over 38 ° C - analgin.

Tactics

Patients with a first-ever seizure should be hospitalized to determine its cause. In case of refusal of hospitalization with a rapid recovery of consciousness and the absence of cerebral and focal neurological symptoms, an urgent appeal to a neurologist at a polyclinic at the place of residence is recommended. If consciousness is restored slowly, there are cerebral and (or) focal symptoms, then a call for a specialized neurological (neuro-resuscitation) team is indicated, and in its absence, an active visit after 2-5 hours.

Intractable status epilepticus or a series of convulsive seizures is an indication for calling a specialized neurological (neuroresuscitation) team. In the absence of such - hospitalization.

In case of violation of the activity of the heart, which led to a convulsive syndrome, appropriate therapy or a call to a specialized cardiological team. With eclampsia, exogenous intoxication - action according to the relevant recommendations.

Main dangers and complications

Asphyxia during a seizure:

Development of acute heart failure.

Note

1. Aminazine is not an anticonvulsant.

2. Magnesium sulfate and chloral hydrate are not currently available.

3. The use of hexenal or sodium thiopental for the relief of status epilepticus is possible only in the conditions of a specialized team, if there are conditions and the ability to transfer the patient to mechanical ventilation if necessary. (laryngoscope, set of endotracheal tubes, ventilator).

4. With glucalcemic convulsions, calcium gluconate is administered (10-20 ml of a 10% solution intravenously or intramuscularly), calcium chloride (10-20 ml of a 10% solution strictly intravenously).

5. With hypokalemic convulsions, Panangin is administered (10 ml intravenously).

FAINTING (SHORT-TERM LOSS OF CONSCIOUSNESS, SYNCOPE)

Diagnostics

Fainting. - short-term (usually within 10-30 s) loss of consciousness. in most cases accompanied by a decrease in postural vascular tone. Syncope is based on transient hypoxia of the brain, which occurs due to various reasons - a decrease in cardiac output. heart rhythm disturbances, reflex decrease in vascular tone, etc.

Fainting (syncope) conditions can be conditionally divided into two most common forms - vasodepressor (synonyms - vasovagal, neurogenic) syncope, which are based on a reflex decrease in postural vascular tone, and syncope associated with diseases of the heart and great vessels.

Syncopal states have different prognostic significance depending on their genesis. Fainting associated with the pathology of the cardiovascular system can be harbingers of sudden death and require mandatory identification of their causes and adequate treatment. It must be remembered that fainting may be the debut of a severe pathology (myocardial infarction, pulmonary embolism, etc.).

The most common clinical form is vasodepressor syncope, in which there is a reflex decrease in peripheral vascular tone in response to external or psychogenic factors (fear, excitement, blood type, medical instruments, vein puncture, high ambient temperature, being in a stuffy room, etc. .). The development of syncope is preceded by a short prodromal period, during which weakness, nausea, ringing in the ears, yawning, darkening of the eyes, pallor, cold sweat are noted.

If the loss of consciousness is short-term, convulsions are not noted. If fainting lasts more than 15-20 s. clonic and tonic convulsions are noted. During syncope, there is a decrease in blood pressure with bradycardia; or without it. This group also includes fainting that occurs with increased sensitivity of the carotid sinus, as well as the so-called "situational" fainting - with prolonged coughing, defecation, urination. Syncope associated with the pathology of the cardiovascular system usually occurs suddenly, without a prodromal period. They are divided into two main groups - associated with cardiac arrhythmias and conduction disorders and caused by a decrease in cardiac output (aortic stenosis, hypertrophic cardiomyopathy, myxoma and spherical blood clots in the atria, myocardial infarction, pulmonary embolism, dissecting aortic aneurysm).

Differential Diagnosis syncope should be carried out with epilepsy, hypoglycemia, narcolepsy, coma of various origins, diseases of the vestibular apparatus, organic pathology of the brain, hysteria.

In most cases, the diagnosis can be made based on a detailed history, physical examination, and ECG recording. To confirm the vasodepressor nature of syncope, positional tests are performed (from simple orthostatic to the use of a special inclined table), to increase the sensitivity, the tests are performed against the background of drug therapy. If these actions do not clarify the cause of fainting, then a subsequent examination in the hospital is carried out depending on the identified pathology.

In the presence of heart disease: Holter ECG monitoring, echocardiography, electrophysiological examination, positional tests: if necessary, cardiac catheterization.

In the absence of heart disease: positional tests, consultation with a neurologist, psychiatrist, Holter ECG monitoring, electroencephalogram, if necessary - computed tomography of the brain, angiography.

Urgent care

When fainting is usually not required.

The patient must be laid in a horizontal position on his back:

to give the lower limbs an elevated position, to free the neck and chest from restrictive clothing:

Patients should not be seated immediately, as this may lead to a relapse of fainting;

If the patient does not regain consciousness, it is necessary to exclude a traumatic brain injury (if there has been a fall) or other causes of prolonged loss of consciousness indicated above.

If syncope is caused by cardiac disease, emergency care may be needed to address the immediate cause of syncope - tachyarrhythmias, bradycardia, hypotension, etc. (see relevant sections).

ACUTE POISONING

Poisoning - pathological conditions caused by the action of toxic substances of exogenous origin in any way they enter the body.

The severity of the condition in case of poisoning is determined by the dose of the poison, the route of its intake, the time of exposure, the patient's premorbid background, complications (hypoxia, bleeding, convulsive syndrome, acute cardiovascular failure, etc.).

The prehospital doctor needs:

Observe “toxicological alertness” (environmental conditions in which the poisoning occurred, the presence of foreign odors may pose a danger to the ambulance team):

Find out the circumstances that accompanied the poisoning (when, with what, how, how much, for what purpose) in the patient himself, if he is conscious or in those around him;

Collect physical evidence (drug packages, powders, syringes), biological media (vomit, urine, blood, wash water) for chemical-toxicological or forensic chemical research;

Register the main symptoms (syndromes) that the patient had before the provision of medical care, including mediator syndromes, which are the result of strengthening or inhibition of the sympathetic and parasympathetic systems (see Appendix).

GENERAL ALGORITHM FOR PROVIDING EMERGENCY AID

1. Ensure normalization of breathing and hemodynamics (perform basic cardiopulmonary resuscitation).

2. Carry out antidote therapy.

3. Stop further intake of poison into the body. 3.1. In case of inhalation poisoning - remove the victim from the contaminated atmosphere.

3.2. In case of oral poisoning - rinse the stomach, introduce enterosorbents, put a cleansing enema. When washing the stomach or washing off poisons from the skin, use water with a temperature not exceeding 18 ° C; do not carry out the poison neutralization reaction in the stomach! The presence of blood during gastric lavage is not a contraindication for gastric lavage.

3.3. For skin application - wash the affected area of ​​the skin with an antidote solution or water.

4. Start infusion and symptomatic therapy.

5. Transport the patient to the hospital. This algorithm for providing assistance at the prehospital stage is applicable to all types of acute poisoning.

Diagnostics

With mild and moderate severity, an anticholinergic syndrome occurs (intoxication psychosis, tachycardia, normohypotension, mydriasis). In severe coma, hypotension, tachycardia, mydriasis.

Antipsychotics cause the development of orthostatic collapse, prolonged persistent hypotension due to insensitivity of the terminal vascular bed to vasopressors, extrapyramidal syndrome (muscle cramps of the chest, neck, upper shoulder girdle, protrusion of the tongue, bulging eyes), neuroleptic syndrome (hyperthermia, muscle rigidity).

Hospitalization of the patient in a horizontal position. Cholinolytics cause the development of retrograde amnesia.

Opiate poisoning

Diagnostics

Characteristic: oppression of consciousness, to a deep coma. development of apnea, tendencies to bradycardia, injection marks on the elbows.

emergency therapy

Pharmacological antidotes: naloxone (narcanti) 2-4 ml of a 0.5% solution intravenously until spontaneous respiration is restored: if necessary, repeat the administration until mydriasis appears.

Start infusion therapy:

400.0 ml of 5-10% glucose solution intravenously;

Reopoliglyukin 400.0 ml intravenous drip.

Sodium bicarbonate 300.0 ml 4% intravenously;

oxygen inhalation;

In the absence of the effect of the introduction of naloxone, carry out mechanical ventilation in the hyperventilation mode.

Tranquilizer poisoning (benzodiazepine group)

Diagnostics

Characteristic: drowsiness, ataxia, depression of consciousness to coma 1, miosis (in case of poisoning with noxiron - mydriasis) and moderate hypotension.

Tranquilizers of the benzodiazepine series cause deep depression of consciousness only in “mixed” poisonings, i.e. in combination with barbiturates. neuroleptics and other sedative-hypnotic drugs.

emergency therapy

Follow steps 1-4 of the general algorithm.

For hypotension: reopoliglyukin 400.0 ml intravenously, drip:

Barbiturate poisoning

Diagnostics

Miosis, hypersalivation, "greasiness" of the skin, hypotension, deep depression of consciousness up to the development of coma are determined. Barbiturates cause a rapid breakdown of tissue trophism, the formation of bedsores, the development of positional compression syndrome, and pneumonia.

Urgent care

Pharmacological antidotes (see note).

Run point 3 of the general algorithm;

Start infusion therapy:

Sodium bicarbonate 4% 300.0, intravenous drip:

Glucose 5-10% 400.0 ml intravenously;

Sulfocamphocaine 2.0 ml intravenously.

oxygen inhalation.

POISONING WITH DRUGS OF STIMULANT ACTION

These include antidepressants, psychostimulants, general tonic (tinctures, including alcohol ginseng, eleutherococcus).

Delirium, hypertension, tachycardia, mydriasis, convulsions, cardiac arrhythmias, ischemia and myocardial infarction are determined. They have an oppression of consciousness, hemodynamics and respiration after the phase of excitation and hypertension.

Poisoning occurs with adrenergic (see Appendix) syndrome.

Poisoning with antidepressants

Diagnostics

With a short duration of action (up to 4-6 hours), hypertension is determined. delirium. dryness of the skin and mucous membranes, expansion of the 9K8 complex on the ECG (quinidine-like effect of tricyclic antidepressants), convulsive syndrome.

With prolonged action (more than 24 hours) - hypotension. urinary retention, coma. Always mydriasis. dryness of the skin, expansion of the OK8 complex on the ECG: Antidepressants. serotonin blockers: fluoxentine (Prozac), fluvoxamine (paroxetine), alone or in combination with analgesics, can cause “malignant” hyperthermia.

Urgent care

Follow point 1 of the general algorithm. For hypertension and agitation:

Short-acting drugs with a rapidly onset effect: galantamine hydrobromide (or nivalin) 0.5% - 4.0-8.0 ml, intravenously;

Long-acting drugs: aminostigmine 0.1% - 1.0-2.0 ml intramuscularly;

In the absence of antagonists, anticonvulsants: Relanium (Seduxen), 20 mg per 20.0 ml of 40% glucose solution intravenously; or sodium oxybutyrate 2.0 g per - 20.0 ml of 40.0% glucose solution intravenously, slowly);

Follow point 3 of the general algorithm. Start infusion therapy:

In the absence of sodium bicarbonate - trisol (disol. Chlosol) 500.0 ml intravenously, drip.

With severe arterial hypotension:

Reopoliglyukin 400.0 ml intravenously, drip;

Norepinephrine 0.2% 1.0 ml (2.0) in 400 ml of 5-10% glucose solution intravenously, drip, increase the rate of administration until blood pressure stabilizes.

POISONING WITH ANTI-TUBERCULOSIS DRUGS (ISONIAZIDE, FTIVAZIDE, TUBAZIDE)

Diagnostics

Characteristic: generalized convulsive syndrome, development of stunning. up to coma, metabolic acidosis. Any convulsive syndrome resistant to benzodiazepine treatment should alert for isoniazid poisoning.

Urgent care

Run point 1 of the general algorithm;

With convulsive syndrome: pyridoxine up to 10 ampoules (5 g). intravenous drip for 400 ml of 0.9% sodium chloride solution; Relanium 2.0 ml, intravenously. before relief of the convulsive syndrome.

If there is no result, muscle relaxants of antidepolarizing action (arduan 4 mg), tracheal intubation, mechanical ventilation.

Follow point 3 of the general algorithm.

Start infusion therapy:

Sodium bicarbonate 4% 300.0 ml intravenously, drip;

Glucose 5-10% 400.0 ml intravenously, drip. With arterial hypotension: reopoliglyukin 400.0 ml intravenously. drip.

Early detoxification hemosorption is effective.

POISONING WITH TOXIC ALCOHOL (METHANOL, ETHYLENE GLYCOL, CELLOSOLVES)

Diagnostics

Characteristic: the effect of intoxication, decreased visual acuity (methanol), abdominal pain (propyl alcohol; ethylene glycol, cellosolva with prolonged exposure), depression of consciousness to deep coma, decompensated metabolic acidosis.

Urgent care

Run point 1 of the general algorithm:

Run point 3 of the general algorithm:

Ethanol is the pharmacological antidote for methanol, ethylene glycol, and cellosolves.

Initial therapy with ethanol (saturation dose per 80 kg of the patient's body weight, at the rate of 1 ml of a 96% alcohol solution per 1 kg of body weight). To do this, dilute 80 ml of 96% alcohol with water in half, give a drink (or enter through a probe). If it is impossible to prescribe alcohol, 20 ml of a 96% alcohol solution is dissolved in 400 ml of a 5% glucose solution and the resulting alcohol glucose solution is injected into a vein at a rate of 100 drops / min (or 5 ml of a solution per minute).

Start infusion therapy:

Sodium bicarbonate 4% 300 (400) intravenously, drip;

Acesol 400 ml intravenously, drip:

Hemodez 400 ml intravenously, drip.

When transferring a patient to a hospital, indicate the dose, time and route of administration of the ethanol solution at the prehospital stage to provide a maintenance dose of ethanol (100 mg/kg/hour).

ETHANOL POISONING

Diagnostics

Determined: depression of consciousness to a deep coma, hypotension, hypoglycemia, hypothermia, cardiac arrhythmia, respiratory depression. Hypoglycemia, hypothermia lead to the development of cardiac arrhythmias. In alcoholic coma, the lack of response to naloxone may be due to concomitant traumatic brain injury (subdural hematoma).

Urgent care

Follow steps 1-3 of the general algorithm:

With depression of consciousness: naloxone 2 ml + glucose 40% 20-40 ml + thiamine 2.0 ml intravenously slowly. Start infusion therapy:

Sodium bicarbonate 4% 300-400 ml intravenously;

Hemodez 400 ml intravenous drip;

Sodium thiosulfate 20% 10-20 ml intravenously slowly;

Unithiol 5% 10 ml intravenously slowly;

Ascorbic acid 5 ml intravenously;

Glucose 40% 20.0 ml intravenously.

When excited: Relanium 2.0 ml intravenously slowly in 20 ml of 40% glucose solution.

Withdrawal state caused by alcohol consumption

When examining a patient at the prehospital stage, it is advisable to adhere to certain sequences and principles of emergency care for acute alcohol poisoning.

Establish the fact of recent alcohol intake and determine its characteristics (date of last intake, binge or single intake, quantity and quality of alcohol consumed, total duration of regular alcohol intake). Adjustment for the social status of the patient is possible.

· Establish the fact of chronic alcohol intoxication, the level of nutrition.

Determine the risk of developing a withdrawal syndrome.

· As part of toxic visceropathy, to determine: the state of consciousness and mental functions, to identify gross neurological disorders; the stage of alcoholic liver disease, the degree of liver failure; identify damage to other target organs and the degree of their functional usefulness.

Determine the prognosis of the condition and develop a plan for monitoring and pharmacotherapy.

It is obvious that the clarification of the patient's "alcohol" history is aimed at determining the severity of the current acute alcohol poisoning, as well as the risk of developing alcohol withdrawal syndrome (3-5 days after the last alcohol intake).

In the treatment of acute alcohol intoxication, a set of measures is needed aimed, on the one hand, at stopping the further absorption of alcohol and its accelerated removal from the body, and on the other hand, at protecting and maintaining systems or functions that suffer from the effects of alcohol.

The intensity of therapy is determined both by the severity of acute alcohol intoxication and the general condition of the intoxicated person. In this case, gastric lavage is carried out in order to remove alcohol that has not yet been absorbed, and drug therapy with detoxification agents and alcohol antagonists.

In the treatment of alcohol withdrawal the doctor takes into account the severity of the main components of the withdrawal syndrome (somato-vegetative, neurological and mental disorders). Mandatory components are vitamin and detoxification therapy.

Vitamin therapy includes parenteral administration of solutions of thiamine (Vit B1) or pyridoxine hydrochloride (Vit B6) - 5-10 ml. With severe tremor, a solution of cyanocobalamin (Vit B12) is prescribed - 2-4 ml. The simultaneous administration of various B vitamins is not recommended due to the possibility of enhancing allergic reactions and their incompatibility in one syringe. Ascorbic acid (Vit C) - up to 5 ml is administered intravenously along with plasma-substituting solutions.

Detoxification therapy includes the introduction of thiol preparations - a 5% solution of unitiol (1 ml per 10 kg of body weight intramuscularly) or a 30% solution of sodium thiosulfate (up to 20 ml); hypertonic - 40% glucose - up to 20 ml, 25% magnesium sulfate (up to 20 ml), 10% calcium chloride (up to 10 ml), isotonic - 5% glucose (400-800 ml), 0.9% sodium chloride solution ( 400-800 ml) and plasma-substituting - Hemodez (200-400 ml) solutions. It is also advisable, intravenous administration of a 20% solution of piracetam (up to 40 ml).

These measures, according to indications, are supplemented by the relief of somato-vegetative, neurological and mental disorders.

With an increase in blood pressure, 2-4 ml of a solution of papaverine hydrochloride or dibazol is injected intramuscularly;

In case of heart rhythm disturbance, analeptics are prescribed - a solution of cordiamine (2-4 ml), camphor (up to 2 ml), potassium preparations panangin (up to 10 ml);

With shortness of breath, difficulty breathing - up to 10 ml of a 2.5% solution of aminophylline is injected intravenously.

A decrease in dyspeptic phenomena is achieved by introducing a solution of raglan (cerucal - up to 4 ml), as well as spasmalgesics - baralgin (up to 10 ml), NO-SHPy (up to 5 ml). A solution of baralgin, along with a 50% solution of analgin, is also indicated to reduce the severity of headaches.

With chills, sweating, a solution of nicotinic acid (Vit PP - up to 2 ml) or a 10% solution of calcium chloride - up to 10 ml is injected.

Psychotropic drugs are used to stop affective, psychopathic and neurosis-like disorders. Relanium (dizepam, seduxen, sibazon) is administered intramuscularly, or at the end of intravenous infusion of solutions intravenously at a dose of up to 4 ml for withdrawal symptoms with anxiety, irritability, sleep disorders, autonomic disorders. Nitrazepam (eunoctin, radedorm - up to 20 mg), phenazepam (up to 2 mg), grandaxin (up to 600 mg) are given orally, while it should be borne in mind that nitrazepam and phenazepam are best used to normalize sleep, and grandaxin for stopping autonomic disorders.

With severe affective disorders (irritability, a tendency to dysphoria, outbursts of anger), antipsychotics with a hypnotic-sedative effect are used (droperidol 0.25% - 2-4 ml).

With rudimentary visual or auditory hallucinations, paranoid mood in the structure of abstinence, 2-3 ml of a 0.5% solution of haloperidol is intramuscularly injected in combination with Relanium to reduce neurological side effects.

With severe motor anxiety, droperidol is used in 2-4 ml of a 0.25% solution intramuscularly or sodium oxybutyrate in 5-10 ml of a 20% solution intravenously. Antipsychotics from the group of phenothiazines (chlorpromazine, tizercin) and tricyclic antidepressants (amitriptyline) are contraindicated.

Therapeutic measures are carried out until there are signs of a clear improvement in the patient's condition (reduction of somato-vegetative, neurological, mental disorders, normalization of sleep) under constant monitoring of the function of the cardiovascular or respiratory system.

pacing

Cardiac pacing (ECS) is a method by which external electrical impulses produced by an artificial pacemaker (pacemaker) are applied to any part of the heart muscle, as a result of which the heart contracts.

Indications for pacing

· Asystole.

Severe bradycardia regardless of the underlying cause.

· Atrioventricular or Sinoatrial blockade with attacks of Adams-Stokes-Morgagni.

There are 2 types of pacing: permanent pacing and temporary pacing.

1. Permanent pacing

Permanent pacing is the implantation of an artificial pacemaker or cardioverter-defibrillator. Temporary pacing

2. Temporary pacing is necessary for severe bradyarrhythmias due to sinus node dysfunction or AV block.

Temporary pacing can be carried out by various methods. Currently relevant are transvenous endocardial and transesophageal pacing, and in some cases, external transcutaneous pacing.

Transvenous (endocardial) pacing has received especially intensive development, since it is the only effective way to "impose" an artificial rhythm on the heart in the event of severe disorders of the systemic or regional circulation due to bradycardia. When it is performed, the electrode under ECG control is inserted through the subclavian, internal jugular, cubital or femoral veins into the right atrium or right ventricle.

Temporary atrial transesophageal pacing and transesophageal ventricular pacing (TEPS) have also become widespread. TSES is used as a replacement therapy for bradycardia, bradyarrhythmias, asystole, and sometimes for reciprocal supraventricular arrhythmias. It is often used for diagnostic purposes. Temporary transthoracic pacing is sometimes used by emergency physicians to buy time. One electrode is inserted through a percutaneous puncture into the heart muscle, and the second is a needle placed subcutaneously.

Indications for temporary pacing

· Temporary pacing is carried out in all cases of indications for permanent pacing as a "bridge" to it.

Temporary pacing is performed when it is not possible to urgently implant a pacemaker.

Temporary pacing is carried out with hemodynamic instability, primarily in connection with Morgagni-Edems-Stokes attacks.

Temporary pacing is performed when there is reason to believe that bradycardia is transient (with myocardial infarction, the use of drugs that can inhibit the formation or conduction of impulses, after cardiac surgery).

Temporary pacing is recommended for the prevention of patients with acute myocardial infarction of the anterior septal region of the left ventricle with blockade of the right and anterior superior branch of the left branch of the bundle of His, due to the increased risk of developing a complete atrioventricular block with asystole due to the unreliability of the ventricular pacemaker in this case.

Complications of temporary pacing

Displacement of the electrode and the impossibility (cessation) of electrical stimulation of the heart.

Thrombophlebitis.

· Sepsis.

Air embolism.

Pneumothorax.

Perforation of the wall of the heart.

Cardioversion-defibrillation

Cardioversion-defibrillation (electropulse therapy - EIT) - is a transsternal effect of direct current of sufficient strength to cause depolarization of the entire myocardium, after which the sinoatrial node (first-order pacemaker) resumes control of the heart rhythm.

Distinguish between cardioversion and defibrillation:

1. Cardioversion - exposure to direct current, synchronized with the QRS complex. With various tachyarrhythmias (except for ventricular fibrillation), the effect of direct current should be synchronized with the QRS complex, because. in the case of current exposure before the peak of the T wave, ventricular fibrillation may occur.

2. Defibrillation. The impact of direct current without synchronization with the QRS complex is called defibrillation. Defibrillation is performed in ventricular fibrillation, when it is not necessary (and not possible) to synchronize the exposure to direct current.

Indications for cardioversion-defibrillation

Flutter and ventricular fibrillation. Electropulse therapy is the method of choice. Read more: Cardiopulmonary resuscitation at a specialized stage in the treatment of ventricular fibrillation.

Persistent ventricular tachycardia. In the presence of impaired hemodynamics (Morgagni-Adams-Stokes attack, arterial hypotension and / or acute heart failure), defibrillation is carried out immediately, and if it is stable, after an attempt to stop it with medications if it is ineffective.

Supraventricular tachycardia. Electropulse therapy is performed according to vital indications with progressive deterioration of hemodynamics or in a planned manner with the ineffectiveness of drug therapy.

· Atrial fibrillation and flutter. Electropulse therapy is performed according to vital indications with progressive deterioration of hemodynamics or in a planned manner with the ineffectiveness of drug therapy.

· Electropulse therapy is more effective in reentry tachyarrhythmias, less effective in tachyarrhythmias due to increased automatism.

· Electropulse therapy is absolutely indicated for shock or pulmonary edema caused by tachyarrhythmia.

Emergency electropulse therapy is usually performed in cases of severe (more than 150 per minute) tachycardia, especially in patients with acute myocardial infarction, with unstable hemodynamics, persistent anginal pain, or contraindications to the use of antiarrhythmic drugs.

All ambulance teams and all units of medical institutions should be equipped with a defibrillator, and all medical workers should be proficient in this method of resuscitation.

Cardioversion-defibrillation technique

In the case of a planned cardioversion, the patient should not eat for 6-8 hours to avoid possible aspiration.

Due to the pain of the procedure and the patient's fear, general anesthesia or intravenous analgesia and sedation are used (for example, fentanyl at a dose of 1 mcg / kg, then midazolam 1-2 mg or diazepam 5-10 mg; elderly or debilitated patients - 10 mg promedol). With initial respiratory depression, non-narcotic analgesics are used.

When performing cardioversion-defibrillation, you must have the following kit on hand:

· Tools for maintaining airway patency.

· Electrocardiograph.

· Artificial lung ventilation apparatus.

Medications and solutions required for the procedure.

· Oxygen.

The sequence of actions during electrical defibrillation:

The patient should be in a position that allows, if necessary, to carry out tracheal intubation and closed heart massage.

Reliable access to the patient's vein is required.

· Turn on the power, turn off the defibrillator timing switch.

· Set the required charge on the scale (approximately 3 J/kg for adults, 2 J/kg for children); charge the electrodes; lubricate the plates with gel.

· It is more convenient to work with two manual electrodes. Install electrodes on the anterior surface of the chest:

One electrode is placed above the zone of cardiac dullness (in women - outward from the top of the heart, outside the mammary gland), the second - under the right clavicle, and if the electrode is dorsal, then under the left shoulder blade.

The electrodes can be placed in the anteroposterior position (along the left edge of the sternum in the region of the 3rd and 4th intercostal spaces and in the left subscapular region).

The electrodes can be placed in the anterolateral position (between the clavicle and the 2nd intercostal space along the right edge of the sternum and above the 5th and 6th intercostal spaces, in the region of the apex of the heart).

· For maximum reduction of electrical resistance during electropulse therapy, the skin under the electrodes is degreased with alcohol or ether. In this case, gauze pads are used, well moistened with isotonic sodium chloride solution or special pastes.

The electrodes are pressed against the chest wall tightly and with force.

Perform cardioversion-defibrillation.

The discharge is applied at the moment of complete exhalation of the patient.

If the type of arrhythmia and the type of defibrillator allow, then the shock is delivered after synchronization with the QRS complex on the monitor.

Immediately before applying the discharge, you should make sure that the tachyarrhythmia persists, for which electrical impulse therapy is performed!

With supraventricular tachycardia and atrial flutter, a discharge of 50 J is sufficient for the first exposure. With atrial fibrillation or ventricular tachycardia, a discharge of 100 J is required for the first exposure.

In the case of polymorphic ventricular tachycardia or ventricular fibrillation, a discharge of 200 J is used for the first exposure.

While maintaining arrhythmia, with each subsequent discharge, the energy is doubled up to a maximum of 360 J.

The time interval between attempts should be minimal and only required to assess the effect of defibrillation and set, if necessary, the next discharge.

If 3 discharges with increasing energy did not restore the heart rhythm, then the fourth - maximum energy - is applied after the intravenous administration of an antiarrhythmic drug indicated for this type of arrhythmia.

Immediately after electropulse therapy, the rhythm should be assessed and, if it is restored, a 12-lead ECG should be recorded.

If ventricular fibrillation continues, antiarrhythmic drugs are used to lower the defibrillation threshold.

Lidocaine - 1.5 mg / kg intravenously, by stream, repeated after 3-5 minutes. In case of restoration of blood circulation, a continuous infusion of lidocaine is carried out at a rate of 2-4 mg / min.

Amiodarone - 300 mg intravenously over 2-3 minutes. If there is no effect, you can repeat the intravenous administration of another 150 mg. In case of restoration of blood circulation, a continuous infusion is carried out in the first 6 hours 1 mg / min (360 mg), in the next 18 hours 0.5 mg / min (540 mg).

Procainamide - 100 mg intravenously. If necessary, you can repeat the dose after 5 minutes (up to a total dose of 17 mg / kg).

Magnesium sulfate (Kormagnesin) - 1-2 g intravenously over 5 minutes. If necessary, the introduction can be repeated after 5-10 minutes. (with tachycardia of the "pirouette" type).

After the administration of the drug, general resuscitation is carried out for 30-60 seconds, and then the electrical impulse therapy is repeated.

In case of intractable arrhythmias or sudden cardiac death, it is recommended to alternate the administration of drugs with electropulse therapy according to the scheme:

Antiarrhythmic drug - 360 J shock - adrenaline - 360 J shock - antiarrhythmic drug - 360 J shock - adrenaline, etc.

· You can apply not 1, but 3 discharges of maximum power.

· The number of digits is not limited.

In case of ineffectiveness, general resuscitation measures are resumed:

Perform tracheal intubation.

Provide venous access.

Inject adrenaline 1 mg every 3-5 minutes.

You can enter increasing doses of adrenaline 1-5 mg every 3-5 minutes or intermediate doses of 2-5 mg every 3-5 minutes.

Instead of adrenaline, you can enter intravenously vasopressin 40 mg once.

Defibrillator Safety Rules

Eliminate the possibility of grounding the personnel (do not touch the pipes!).

Exclude the possibility of touching others to the patient during the application of the discharge.

Make sure that the insulating part of the electrodes and hands are dry.

Complications of cardioversion-defibrillation

· Post-conversion arrhythmias, and above all - ventricular fibrillation.

Ventricular fibrillation usually develops when a shock is applied during a vulnerable phase of the cardiac cycle. The probability of this is low (about 0.4%), however, if the patient's condition, the type of arrhythmia and technical capabilities allow, synchronization of the discharge with the R wave on the ECG should be used.

If ventricular fibrillation occurs, a second discharge with an energy of 200 J is immediately applied.

Other post-conversion arrhythmias (eg, atrial and ventricular extrasystoles) are usually transient and do not require special treatment.

Thromboembolism of the pulmonary artery and systemic circulation.

Thromboembolism often develops in patients with thromboendocarditis and with long-term atrial fibrillation in the absence of adequate preparation with anticoagulants.

Respiratory disorders.

Respiratory disorders are the result of inadequate premedication and analgesia.

To prevent the development of respiratory disorders, full oxygen therapy should be carried out. Often, developing respiratory depression can be dealt with with the help of verbal commands. Do not try to stimulate breathing with respiratory analeptics. In severe respiratory failure, intubation is indicated.

skin burns.

Skin burns occur due to poor contact of the electrodes with the skin, the use of repeated discharges with high energy.

Arterial hypotension.

Arterial hypotension after cardioversion-defibrillation rarely develops. Hypotension is usually mild and does not last long.

· Pulmonary edema.

Pulmonary edema rarely occurs 1-3 hours after restoration of sinus rhythm, especially in patients with long-term atrial fibrillation.

Changes in repolarization on the ECG.

Changes in repolarization on the ECG after cardioversion-defibrillation are multidirectional, non-specific, and can persist for several hours.

Changes in the biochemical analysis of blood.

Increases in the activity of enzymes (AST, LDH, CPK) are mainly associated with the effect of cardioversion-defibrillation on skeletal muscles. The CPK MV activity increases only with multiple high-energy discharges.

Contraindications for EIT:

1. Frequent, short-term paroxysms of AF, which stop on their own or with medication.

2. Permanent form of atrial fibrillation:

More than three years old

The age is not known.

cardiomegaly,

Frederick Syndrome,

glycosidic toxicity,

TELA up to three months,

LIST OF USED LITERATURE

1. A.G. Miroshnichenko, V.V. Ruksin St. Petersburg Medical Academy of Postgraduate Education, St. Petersburg, Russia "Protocols of the diagnostic and treatment process at the prehospital stage"

2. http://smed.ru/guides/67158/#Pokazaniya_k_provedeniju_kardioversiidefibrillyacii

3. http://smed.ru/guides/67466/#_Pokazaniya_k_provedeniju_jelektrokardiostimulyacii

4. http://cardiolog.org/cardiohirurgia/50-invasive/208-vremennaja-ecs.html

5. http://www.popumed.net/study-117-13.html