SUDDEN DEATH
Diagnostics. Lack of consciousness and pulse on the carotid arteries, a little later - the cessation of breathing.
In the process of carrying out CPR - according to the ECP, ventricular fibrillation (in 80% of cases), asystole or electromechanical dissociation (in 10-20% of cases). If emergency ECG recording 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 closed massage heart - 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 on 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 accessible way(ratio massage movements and breath 5:1. and with the work of one doctor - 15: 2), ensure the patency of the respiratory tract (throw back the head, push the lower jaw, insert the air duct, according to indications - sanitize the respiratory tract);
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 possible cause 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 no evidence of effective CPR within 30 min.
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:
For intracardiac injection: administration medicines to the myocardium, damage 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 given rapidly intravenously.
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, an 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 pouch tachycardias ; atrial fibrillation in the syndrome of IgP\V; ventricular tachycardia).
Urgent Care
emergency recovery sinus rhythm or correction of heart rate are indicated for tachyarrhythmias complicated by acute circulatory disorders, with a threat of cessation of blood circulation, or with repeated paroxysms of tachyarrhythmias with known way 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:
Perform 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 in case of repeated paroxysms of arrhythmia with a known method of suppression, 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. With a paroxysm of tachycardia of unknown origin with wide complexes 9K5 on the ECG (if there are no indications for EIT), inject intravenous lidocaine (p. 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. Constantly monitor heartbeat and conductivity.
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.
In the presence of 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.
Render emergency care with repeated, habitual paroxysms, tachyarrhythmias should be taken 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 (heart rate less than 50 beats per minute) causes MAC syndrome or its equivalents, shock, pulmonary edema, arterial hypotension, anginal pain, or there is 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 infarction myocardium, cardialgia. extracardiac pain.
Urgent Care
1. Shown:
Nitroglycerin (tablets or aerosol 0.4-0.5 mg under the tongue repeatedly);
oxygen therapy;
Correction 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 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.
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! 3-10 hours after the onset of the disease - 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 as soon as possible over 30 minutes:
In case of subendocardial myocardial infarction with depression of the 8T segment on the ECG (or the impossibility of thrombolytic therapy), 5000 IU of heparin should be 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 conducting thrombolytic therapy, ensure control over the heart rate and basic hemodynamic parameters, readiness to correct possible complications (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. tissue hyperhydration, 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 (cardiomonitor, 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 auxiliary means and may be indicated for bronchospasm or severe bradycardia.
Glucocorticoid hormones are used only for respiratory distress syndrome (aspiration, infection, pancreatitis, inhalation irritants and so on.).
Cardiac glycosides (strophanthin, digoxin) can be prescribed only for moderate congestive heart failure in patients with tachysystolic atrial fibrillation (flutter).
At aortic stenosis, hypertrophic cardiomyopathy, cardiac tamponade, nitroglycerin and other peripheral vaedilators 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 (disappearance time white spot after pressing on the nail bed or palm - more than 2 s), decreased diuresis (less than 20 ml / h), impaired consciousness (from mild inhibited ™ 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, right ventricular damage), 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. Increased 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, adynamia, 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, arching 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, β-blockers, etc.) should be distinguished, hypertensive crises should be differentiated from cerebrovascular accidents, 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 (may 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 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 only be used 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 jugular 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, elderly age, prolonged immobilization, recent surgery, heart disease, heart failure, atrial fibrillation, oncological diseases, TGV.
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 orally acetylsalicylic acid.
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 lesions cranial nerves- facial, sublingual, 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 excitation, 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 important 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% solution of sodium hydroxybutyrate 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. Maybe early application antihypoxants and activators of cellular metabolism (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 table. under the tongue riboyusin 10 ml intravenously bolus, solcoseryl 4 ml intravenous bolus, in severe cases 250 ml of a 10% solution of Solcoseryl intravenously drip can significantly reduce the number of irreversibly damaged cells in the ischemia zone, reduce the zone 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 agents (mannitol, rheogluman, glycerol) should not be administered in the prehospital setting. 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 the 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 rales 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 improvement clinical condition patient.
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:
Number respiratory movements 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 - biting of the tongue, 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 seizures, inhibition may be observed motor activity; 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, most 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 the first convulsive seizure in their lives should be hospitalized to find out 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.).
Most frequent clinical form is a vasodepressor syncope, in which there is a reflex decrease in peripheral vascular tone in response to external or psychogenic factors (fear, excitement, type of blood, medical instruments, vein puncture. heat environment, 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.
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 pathology of cardio-vascular system usually occur 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 tests to the use of a special inclined table), to increase 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: ECG Holter monitoring, echocardiography, electrophysiological examination, positional tests: if necessary, cardiac catheterization.
In the absence of heart disease: positional tests, consultation with a neuropathologist, psychiatrist, ECG Holter 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 was 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 - tachyarrhythmia, 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 material 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 medical care, including mediator syndromes, which are the result of increased or suppressed sympathetic and parasympathetic systems(see Attachment).
GENERAL ALGORITHM FOR PROVIDING EMERGENCY AID
1. Ensure normalization of respiration 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 the insensitivity of the terminal vascular bed to vasopressors, extrapyramidal syndrome(cramps of the muscles 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:
Preparations short action, 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 solution glucose is injected into a vein at a rate of 100 drops / min (or 5 ml of 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 deep coma, hypotension, hypoglycemia, hypothermia, cardiac arrhythmias, 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 consumption and determine its characteristics (date last appointment, 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, power level.
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 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 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, 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“impose” an artificial rhythm to the heart in the event of severe disorders of systemic or regional circulation due to bradycardia. When it is performed, the electrode under ECG control through the subclavian, internal jugular, ulnar or femoral vein injected into the right atrium or right ventricle.
Temporary atrial transesophageal pacing and transesophageal ventricular pacing (TEPS) have also become widespread. CHPES is used as replacement therapy with bradycardia, bradyarrhythmia, asystole and sometimes with 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 increased risk the development of 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 there is no need (and no opportunity) 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 presence of fear in the patient, apply general anesthesia or intravenous analgesia and sedation (eg, fentanyl 1 mcg/kg followed by midazolam 1–2 mg or diazepam 5–10 mg; in elderly or debilitated patients, promedol 10 mg). 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 the electrodes on the front surface chest:
One electrode is placed above the zone of cardiac dullness (in women - outward from the apex 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 area 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 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 is required only 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 the antiarrhythmic drug indicated for this type arrhythmias.
· Immediately after electropulse therapy, the rhythm should be assessed and, if it is restored, an ECG should be recorded in 12 leads.
If ventricular fibrillation continues, antiarrhythmic drugs are used to lower the defibrillation threshold.
Lidocaine - 1.5 mg / kg intravenously, by stream, repeat 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, 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, the dose can be repeated 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 introduction of the drug for 30-60 seconds, general resuscitation is carried out, 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 - shock 360 J - adrenaline - shock 360 J - antiarrhythmic drug - shock 360 J - 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 occasionally occurs 1-3 hours after the 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 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 treatment and diagnostic 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
URGENT MEASURES
SELF-HELP AND MUTUAL ASSISTANCE IN THE DEVELOPMENT OF ACUTE
LIFE-THREATING DISEASES (CONDITIONS)
Reminder for the patient
In our country, up to 80% of deaths occur outside medical organizations - at home, at work, in the country, in public and other places. Most of them occur suddenly or by the mechanism of sudden death. However, with the possession of simple methods of providing first aid by people surrounding a person who finds himself in such a critical condition, as well as everyone's knowledge of first self-help measures, in most cases can save the patient's life. In addition, statistics show that many patients themselves (or their relatives) call an ambulance doctor late, which delays and reduces the likelihood of rescue.
This memo is addressed to almost all people, but especially to patients with cardiovascular diseases, with high and very high risk their development and complications and their relatives and friends, as it is known that often a life-threatening complication, dangerous with a fatal outcome, can be the first symptom of these diseases.
The memo is aimed at preventing and reducing the likelihood of fatal outcomes in life-threatening conditions, it describes the clinical symptoms for which you should be especially vigilant, and provides rational methods of first aid while waiting for the arrival of an ambulance doctor.
I. FIRST AID FOR HEART ATTACK
characteristic signs (symptoms) of a heart attack (myocardial infarction)
Sudden (paroxysmal) arising pressing, squeezing, burning, bursting pains in the chest (behind the sternum) lasting more than 5 minutes;
Similar pains are often observed in the region of the left shoulder (forearm), left shoulder blade, left half of the neck and lower jaw, both shoulders, both arms, lower sternum along with top abdomen
Shortness of breath, shortness of breath, severe weakness, cold sweats, nausea often occur together sometimes follow or precede chest discomfort/pain;
Not infrequently, these manifestations of the disease develop against the background of physical or psycho-emotional stress, but more often with some interval after them.
uncharacteristic signs that are often confused with a heart attack:
Stitching, cutting, throbbing, boring, constant aching for many hours and pains that do not change their intensity in the region of the heart or in a specific well-defined region of the chest
Algorithm of urgent actions:
If you or someone else suddenly develops the above characteristic signs of a heart attack, even if they are mild or moderate in intensity, which last more than 5 minutes. - do not hesitate, immediately call the ambulance team. Do not wait more than 10 minutes - in such a situation it is life-threatening.
If you have symptoms of a heart attack and there is no way to call an ambulance, then ask someone to take you to the hospital - this is the only right decision. Never drive yourself, except total absence another choice.
In the most the best option in the event of a heart attack, it is necessary to follow the instructions received from the attending physician, if there is no such instruction, then it is necessary to act according to the following algorithm:
Call for an ambulance.
Sit down (preferably in a chair with armrests) or lie in bed with a raised headboard, take 0.25 g of acetylsalicylic acid (aspirin) (chew the tablet, swallow it) and 0.5 mg of nitroglycerin (put the tablet / capsule under the tongue, bite the capsule first, do not swallow); release the neck and ensure the supply of fresh air (open the vents or window).
If after 5-7 minutes. after taking acetylsalicylic acid (aspirin) and nitroglycerin, the pain persists, it is necessary to take nitroglycerin a second time.
If after 10 min. after taking the second dose of nitroglycerin, the pain persists, it is necessary to take nitroglycerin a third time.
If after the first or subsequent doses of nitroglycerin there is a sharp weakness, sweating, shortness of breath, you need to lie down, raise your legs (on a roller, etc.), drink 1 glass of water and then, as with a severe headache, do not take nitroglycerin.
If the patient has previously taken cholesterol-lowering drugs from the statin group (simvastatin, lovastatin, fluvastatin, pravastatin, atorvastatin, rosuvoastatin), give the patient their usual daily dose and take the drug with you to the hospital.
Attention! A patient with a heart attack is strictly forbidden to get up, walk, smoke and eat food until the special permission of the doctor;
you can not take aspirin (acetylsalicylic acid) with intolerance to it (allergic reactions), as well as with an obvious and exacerbation of gastric ulcer and duodenal ulcer;
you can not take nitroglycerin with severe weakness, sweating, as well as severe headache, dizziness, acute visual impairment, speech or coordination of movements.
II. FIRST AID FOR ACUTE CEREBRAL CIRCULATION (CVA)
The main signs (symptoms) of acute cerebrovascular accident:
Numbness, weakness "disobedience" or paralysis (immobilization) of the arm, leg, half of the body, distortion of the face and / or salivation on one side;
Speech disorders (difficulties in finding the right words, understanding speech and reading, slurred and fuzzy speech, up to complete loss of speech);
Violations or loss of vision, double vision, difficulty focusing vision;
Disturbance of balance and coordination of movements (feelings of "swaying, falling, rotation of the body, dizziness", unsteady gait up to a fall);
unusual severe headache (often after stress or physical exertion);
Confusion or loss of consciousness, uncontrolled urination or defecation.
If any of these signs suddenly appear, call an ambulance immediately, even if these manifestations of the disease have been observed for only a few minutes.
Algorithm of urgent actions
1. Urgently call an ambulance team, even if these manifestations of the disease were observed for only a few minutes
2. Before the arrival of the ambulance team:
If the patient is unconscious, lay him on his side, remove removable dentures from the oral cavity (food debris, vomit), make sure that the patient is breathing.
If the victim is conscious, help him to take a comfortable sitting or half-sitting position in a chair or on a bed, placing pillows under his back. Provide fresh air. Unbutton the shirt collar, belt, belt, remove tight clothing.
Measure blood pressure if its upper level exceeds 220 mm Hg. Art., give the patient a drug that lowers blood pressure, which he took before.
Measure body temperature. If t 38 ° or more, give the patient 1 g of paracetamol (2 tablets of 0.5 g chew, swallow) (if paracetamol is not available, do not give other antipyretic drugs!).
Put ice on your forehead and head, you can take food from the freezer, packed in waterproof bags and wrapped in a towel.
If the patient has previously taken statin cholesterol-lowering drugs (simvastatin, lovastatin, fluvastatin, pravastatin, atorvastatin, rosuvastatin), give the patient the usual daily dose.
If the casualty has difficulty swallowing and is dripping saliva from his mouth, tilt his head to a more weak side body, blot dripping saliva with clean tissues.
If the casualty is unable to speak or is slurred, reassure and reassure them that the condition is temporary. Hold his hand on the non-paralyzed side, stop trying to talk, and don't ask questions that require an answer. Remember that although the victim cannot speak, he is aware of what is happening and hears everything that is said around him.
Remember!
What is only called in the first 10 minutes. from the onset of a heart attack or stroke ambulance health care allows full use of modern highly effective methods inpatient treatment and greatly reduce mortality from these diseases.
That acetylsalicylic acid (aspirin) and nitroglycerin, taken in the first minutes, can prevent the development of myocardial infarction and significantly reduce the risk of death from it.
That the state of alcoholic intoxication is not a reasonable basis for delaying the call of an ambulance team in the development of a heart attack and acute cerebrovascular accident - about 30% of people who suddenly died at home were in a state of alcoholic intoxication.
That a closed heart massage performed in the first 60-120 seconds after a sudden cardiac arrest allows up to 50% of patients to be brought back to life.
III. FIRST AID FOR HYPERTENSION CRISIS
Hypertensive crisis (Hc) is a condition manifested by high blood pressure (systolic "upper" blood pressure, usually more than 180 mm Hg; diastolic "lower" blood pressure - more than 120 mm Hg) and the following symptoms:
Headache, more often in the occipital region, or heaviness and noise in the head;
Flashing "flies", a veil or a grid before the eyes;
Nausea, feeling of weakness, overwork, internal tension;
Shortness of breath, weakness, constant monotonous aching pain / discomfort in the heart area;
The appearance or increase of pastosity / swelling of the skin of the face, arms, legs.
First aid measures
When symptoms of a hypertensive crisis appear, it is necessary:
Remove bright light, provide peace, access to fresh air (unbutton the shirt collar, ventilate the room, etc.);
Measure blood pressure (see the end of this section for the method of measuring blood pressure) and, if its "upper" level is higher than or equal to 160 mm Hg. Art., it is necessary to take an antihypertensive drug previously recommended by the doctor. In the absence of an antihypertensive drug recommended by a doctor or when blood pressure levels are above 200 mm Hg. Art. urgent need to call an ambulance.
Before the arrival of an ambulance, it is necessary, if possible, to sit in a chair with armrests and take a hot foot bath (dip your feet in a container of hot water).
Attention! A patient with a hypertensive crisis is prohibited from any sudden movements (get up abruptly, sit down, lie down, bend over, push) and any physical activity.
After 40-60 min. after taking the medication recommended by the doctor, it is necessary to re-measure blood pressure and if its level has not decreased by 20-30 mm Hg. Art. from the original and / or the condition has not improved - urgently call an ambulance.
When you feel better and your blood pressure drops, you need to rest (go to bed with a raised headboard) and then contact your local (family) doctor.
When talking with a doctor, you need to clarify which drugs you need to take in the development of a hypertensive crisis, clearly write down their names, dosage and time sequence (algorithm) of taking them, and also check with the doctor for which manifestations of the disease you need to urgently call an ambulance.
All patients with hypertension it is necessary to form an individual mini-first aid kit for hypertensive crisis and always carry it with you, since a hypertensive crisis can develop at any time and in any place.
Blood pressure measurement
To diagnose a hypertensive crisis, it is necessary to measure blood pressure, which is performed manually, using a stethoscope (stethophonendoscope) and a special inflatable cuff equipped with a bulb pump and a sphygmamanometer (Fig. 1), as well as an automatic (semi-automatic) method using various models of tonometers, specially designed for this purpose (Fig. 2)
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Rice. 1. Stethophonendoscope (left) 2. Tonometer
And an inflatable cuff equipped for automatic measurement
Bulb pump and blood pressure sphygmomanometer
(not given)
The accuracy of blood pressure measurement and, accordingly, the guarantee of correct diagnosis and the severity of the hypertensive crisis depend on compliance with the rules for its measurement.
The measurement should be carried out while sitting (leaning on the back of a chair, with relaxed and uncrossed legs, the hand rests on the table, at heart level), in a calm atmosphere, after a 5-minute rest. During the measurement, do not actively move and talk. Measurement of blood pressure in special occasions can be done lying or standing.
The cuff is superimposed on the shoulder, its lower edge is 2 cm above the elbow. The size of the cuff should correspond to the size of the arm: the rubber inflated part of the cuff should cover at least 80% of the circumference of the upper arm; for adults, a cuff 12-13 cm wide and 30-35 cm long is used ( the average size); it is necessary to have a large and small cuff for full and thin arms, respectively.
The mercury column or the arrow of the sphygmomanometer before the start of the measurement should be at zero and in front of the eyes of the researcher. (Fig. 3)
Rice. 3. Illustration of the rules for measuring blood pressure
Technique for measuring blood pressure:
Install the head of the phonendoscope in the cubital fossa above the brachial artery passing through it (Fig. 3);
Quickly inflate the cuff to a pressure of 20-30 mm Hg. Art. exceeding the level of "upper" systolic blood pressure that is normal for a given person (if the measurement is made for the first time, then the pressure level in the cuff is usually raised to 160 mm Hg. Art.). If, at this pressure level, the pulsation of the vessel in the cubital fossa persists, then the pressure in the cuff continues to increase to a level of 20 mm Hg. Art. exceeding the level of pressure at which the pulsation of the artery in the cubital fossa disappeared);
Open the cuff bleed valve located next to the bulb pump and reduce the pressure in the cuff at a rate of approximately 2-3 mm Hg. Art. per second;
In the process of deflating the cuff, two parameters are simultaneously controlled:
1) the pressure level on the pressure gauge scale and
2) the appearance of pulsation sounds (called Korotkoff tones) of the artery in the cubital fossa. The pressure level at the time of the appearance of pulsation tones corresponds to the level
"upper" systolic blood pressure, and the pressure level at the time of the complete disappearance of the tones of the pulsation of the artery corresponds to
"lower" diastolic blood pressure (in children, adolescents and young people immediately after exercise, in pregnant women and under some pathological conditions in adults, the tones of the artery pulsation do not disappear, then the "lower" diastolic blood pressure should be determined by the moment of significant weakening of the tones).
If the tones of the pulsation of the artery in the cubital fossa are very weak, then you should raise your hand and perform several squeezing movements with the brush, then repeat the measurement, while not strongly squeezing the artery with the membrane of the phonendoscope;
When measuring blood pressure to oneself, the head of the phonendoscope is fixed over the cubital fossa using a cuff.
For a reliable assessment of the value of blood pressure, it is necessary to perform at least two measurements of blood pressure on each arm with an interval of at least a minute (during the pauses between measurements, it is necessary to completely loosen the cuff); when detecting a pressure level difference of more than 5 mm Hg. Art. make one additional measurement; the final (recorded) value is the average of the last two measurements.
IV. FIRST AID FOR ACUTE HEART FAILURE
Acute heart failure (AHF) is a serious pathological condition that develops in patients with various diseases heart and hypertension. This is one of the most common causes calling an ambulance and hospitalization of patients, as well as the mortality of the population of our country and the whole world.
The main manifestations (symptoms) of acute heart failure are:
Severe, frequent (more than 24 per minute) noisy breathing - shortness of breath, sometimes reaching the degree of suffocation, with predominant difficulty in inhaling and a clear increase in shortness of breath and cough in a horizontal position. A sitting position or a lying position with a high headboard facilitates the patient's condition;
Often, during breathing, wet squelching rales/sounds interrupted by coughing become audible; in the terminal stage, breathing takes on the character of bubbling with the appearance of foam at the patient's mouth;
Characteristic sitting posture of the patient, resting with straight arms on his knees.
Acute heart failure can develop very quickly and lead to the death of the patient within 30-60 minutes. In most cases, from the first clinical signs to severe manifestations AHF takes 6-12 hours or more, but without medical care, the vast majority of patients with AHF die.
First aid measures
When patients with hypertension, or heart disease (but not lungs or bronchi), the above symptoms of AHF appear, it is necessary:
Call an ambulance
Give the patient a sitting position, preferably in a chair with armrests on which he can lean and include the intercostal muscles in the act of breathing
Provide physical and psycho-emotional peace and fresh air by ventilating the room
Lower your legs into a large container (basin, tank, bucket, etc.) with hot water
In extremely severe cases, tourniquets are applied to the legs in the groin area, squeezing superficial veins, but not deep arteries, which reduces blood flow to the heart and thereby facilitates its work.
If the patient or the person providing first aid has experience in the use of nitroglycerin, it is prescribed at a dose of 0.4 (0.5) mg (inhalation into the oral cavity is performed under the root of the tongue, the tablet / capsule is placed under the tongue, the capsule must first be cracked, do not swallow). When the patient's well-being improves after the use of nitroglycerin, it is used repeatedly, every 5-10 minutes. before the arrival of the ambulance. In the absence of improvement in the patient's well-being after the use of nitroglycerin, it is no longer used.
Attention! A patient with AHF is strictly forbidden to get up, walk, smoke, drink water and take liquid food until the special permission of the doctor; do not take nitroglycerin with blood pressure less than 100 mm Hg. Art. with severe headache, dizziness, acute impairment of vision, speech or coordination of movements.
All patients with hypertension or heart disease with shortness of breath and swelling in the legs should discuss with the attending physician which drugs should be taken in the development of AHF, clearly write down their names, dosage and time sequence (algorithm) of their administration, and also check with the doctor if what manifestations of the disease should urgently call an ambulance. Each such patient needs to form an individual first aid kit for AHF and always have it with him.
V. SUDDEN DEATH
Most often, sudden death occurs due to the sudden cessation of cardiac activity.
The main signs (symptoms) of sudden death:
Sudden loss of consciousness, often accompanied by agonal movements (standing or sitting person falls, often there are convulsive muscle tension, involuntary urination and defecation; a lying person sometimes makes a convulsive attempt to sit up or turn on his side)
Sudden complete cessation of breathing, often after a short period (5-10 seconds) of agonal pseudo-respiration: the patient makes wheezing and / or gurgling sounds, sometimes similar to a convulsive attempt to say something.
Immediate Action Sequence.
If a person suddenly lost consciousness, immediately call an ambulance team (if there are other people nearby, they call an ambulance). Next, shake the patient by the shoulder and ask loudly "What's wrong with you?". If there is no response, an active pat on the patient's cheeks is carried out, in the absence of any reaction, immediately proceed to a closed heart massage.
The patient is placed on a hard flat surface (floor, ground, flat hard ground and the like, but not on a sofa, bed, mattress and other soft surfaces), the front of the chest is freed from clothing. Determine the location of the hands on the chest of the patient, as indicated in the figure. One palm is placed in the place indicated in the figure, and the palm of the second hand is placed on top of the first in exact accordance with the image of the hands in the figure.
With straight arms (not bent at the elbows), vigorous rhythmic compression of the victim's chest is performed to a depth of 5 cm with a frequency of 100 chest compressions per minute (the technique of closed heart massage is schematically shown in Figure 5).
If signs of life appear (any reactions, facial expressions, movements or sounds made by the patient), heart massage must be stopped. With the disappearance of these signs of life, cardiac massage must be resumed. Cardiac massage stops should be minimal - no more than 5-10 seconds. When the signs of life resume, the heart massage stops, the patient is provided with warmth and peace. In the absence of signs of life, cardiac massage continues until the arrival of the ambulance team.
If the first aid provider has special training and experience in cardiopulmonary resuscitation, he can, in parallel with a closed heart massage, carry out and artificial ventilation lungs. In the absence of special training, the patient should not be artificially ventilated and the pulse on the carotid artery should not be determined, since special scientific studies have shown that such procedures in inexperienced hands lead to an unacceptable loss of time and sharply reduce the frequency of resuscitation of patients with sudden cardiac arrest.
Rice. 5. Illustration of the method of conducting a closed heart massage
Quality first aid is extremely important. Each condition and disease requires a special approach from the medical staff. Algorithms for helping patients with different symptoms are available for download
Quality first aid for emergencies (ES) is vital. Each condition and disease requires a special approach from the medical staff.
Algorithms for helping patients with different symptoms are available for download.
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The main thing in the material
First aid for emergencies includes the provision of primary medical measures to patients whose condition threatens their health. These are exacerbations of various diseases, seizures, injuries and poisoning.
When providing first aid, conditions are distinguished that differ in the speed of their development in the patient's body.
For example, some conditions may develop over several days (ketoacidotic coma in diabetes mellitus), while others develop rapidly (anaphylactic shock).
In all such emergency situations, the task of physicians is to prevent the deterioration of the patient's condition. This will improve the patient's condition.
When providing first aid, it is important to pay attention to the appearance of the patient. He can say more than a man's complaints spoken aloud. Many signs can be recognized by a person without a medical education.
For example, this is loss of consciousness, unusual skin color, voice change, high temperature, atypical pulse, etc.
The patient can call an ambulance at the first symptoms of conditions that physicians should not ignore. This can be high fever, bleeding, vomiting, headaches, dizziness, etc.
From the recommendation of the Chief Physician System, you will learn how to apply the procedures for the provision and standards of medical care Download Ambulance Standards
According to these and other signs, it can be understood that a person needs emergency assistance in case of emergency.
What is important to consider:
Help with NS has several important tasks:
- eliminate a real threat to life, for which priority medical measures are taken;
- ensure the smooth operation of the main systems of the human body;
- minimize the risk of complications.
And finally, the physician must act effectively and accurately, so as not to harm the health of the patient.
In an emergency form, medical assistance is provided in case of a threat to human life during sudden acute diseases conditions, exacerbation of chronic diseases.
From the recommendation in the Chief Physician System, you will learn when help is needed
Help with various conditions and diseases
First aid includes a number of typical actions specified in the first aid algorithms for different states and diseases.
Let's look at a few examples.
- With dehydration (dehydration), the first actions of physicians include:
- intravenous administration of a special solution in an amount equal to 10% of the patient's weight (trisol, quartasol, sodium chlorine solution, etc.);
- the rate of injection of the solution is observed. The first 2 liters - at a rate of up to 120 ml per minute, then - at a rate of 30-60 ml per minute;
- preferably the introduction of a solution of quartasol.
- In case of infectious-toxic shock, the first medical aid for emergency conditions includes:
- carrying out oxygen inhalation;
- staging prednisolone 60 mg with a solution of sodium chloride;
- trental is administered intravenously or drip;
- if these drugs are not available, 400 ml of gemodez, saline and glucose, etc. are injected intravenously.
- further with it doctors of a hospital are engaged.
- In acute neurological syndrome, emergency care includes:
- placing it in the most functionally advantageous position;
- psychomotor agitation is removed, for which the patient is given diazepam, sodium oxybutyrate, prednisolone, oxygen inhalation, etc.;
- in the presence of hyperthermia - amidopyrine, reopyrin, etc.;
- further care includes general and local physical hypothermia.
How to provide first aid for anaphylactic shock
In emergencies that develop rapidly, first aid is vital. For example, when anaphylactic shock Medics have a few minutes at their disposal.
9 steps emergency medical care:
- The entry of the alleged allergen into the human body must be stopped immediately. If this is a drug, its administration should be stopped immediately, and ice should be applied to the injection site.
- The physician evaluates the general condition, the type of skin, breathing and blood circulation of the patient, the patency of the respiratory tract.
An ambulance is immediately called, and if the patient is in the hospital, the resuscitation team.
- Epinephrine (adrenaline) is injected intramuscularly into the middle of the anterolateral surface of the thigh in a dosage corresponding to the age and weight of the person. Most patients respond to the first dose of adrenaline, if this does not happen, after 5-15 minutes the procedure is repeated.
- Having laid the patient on his back, he should raise his legs and turn his head to the side so as to prevent the tongue from falling and asphyxia. If the patient has dentures, they must be removed.
At this stage, it is important to ensure that the patient breathes freely. The rest of the actions are performed by ambulance doctors or resuscitation team.
- If there is difficulty in breathing, a triple intake according to P. Safar is performed, an endotracheal tube is inserted.
If there is swelling of the larynx or pharynx, it is necessary to intubate the trachea. In severe cases, a conicotomy is performed.
- After normalization of breathing, an influx of fresh air into the room is organized. If this is not possible, pure oxygen is used.
- Intravenous access should be established. According to the doctor's prescription, a solution of sodium chloride is introduced. Doctors must be prepared to conduct emergency resuscitation.
Help with NS also includes chest compressions according to indications.
- Readings such as respiratory rate, pressure, pulse and oxygenation are continuously monitored. So, if there is no special monitor, the pulse and pressure must be manually monitored every 3-5 minutes.
- The patient is transported to the intensive care unit.
Help with OOI
especially dangerous infection requires a special approach to first aid.
If disinfectants enter the body
- if chloractive preparations, for example, disinfectants, have entered the patient's stomach, immediate gastric lavage with a 2% hyposulfite solution is necessary;
- in case of formaldehyde poisoning, a 3% solution of acetate or sodium carbonate is added to the washing water;
- if the disinfectant gets into the eyes, it is necessary to rinse them with a 2% solution of baking soda or running water for 3-7 minutes;
- in the presence of irritation, a solution of sodium sulfacyl 30% is instilled into the eyes;
- if disinfectants come into contact with the skin, the affected area of \u200b\u200bthe skin is washed with water. Then it is lubricated with a softening ointment;
- if disinfectants have passed through the respiratory tract, the victim is taken to fresh air or to a well-conditioned room. The nasopharynx and mouth are washed with water;
- if these actions did not have a positive effect and the victim became worse, he is placed in a hospital for further diagnosis.
As we can see, first aid and medical actions differ depending on what kind of condition is suspected in the patient.
The following are algorithms to help with various diseases and states in the form of a memo for download.
The first aid provided must be correct and timely. Our memos reflect the key points that are worth paying attention to.
For example, what mistakes should not be made when drowning, how to help with various injuries and to carry out the fastest localization.
- Wounds: emergency care depending on the type and location
First aid tasks
Closed pneumothorax, arterial hypertension, cholelithiasis, etc. - all these are conditions in which competent first aid is important.
In the memos, briefly - the tasks of health workers, their primary actions, the necessary medicines and techniques.
Topic: Acute emergencies in therapy.
Yekaterinburg 2007
A specialist with a secondary medical education should be able to differentiate an emergency and provide the necessary emergency first aid.
The lecture is intended for paramedical personnel.
Introduction
Every day, acute diseases tear hundreds of people away from their duties at work, at home, and at schools. Only with timely and the right help There is hope for a positive result of further treatment for the victims. In these conditions great importance acquires first aid at the prehospital stage. The paramedic and nurse. As a rule, they are the first to come into contact with the injured and patients who are in critical condition, when the time counts down to minutes and everything depends on the average health worker: the effectiveness of further treatment, and often life or death. At the same time, one should take into account the conditions in which one has to provide emergency and emergency care - on the street, at work, transport, at home. This situation dictates special requirements for nursing staff. In matters of diagnosis and emergency care in critical conditions, the average medical worker should be a highly qualified specialist. He must be able to quickly assess the patient's condition in the shortest possible time to make a preliminary diagnosis, act consistently and energetically, in any situation, remain calm and composure. First aid at the prehospital stage is often not at the proper level. The need for first aid is often underestimated, there are no uniform measures, outdated methods are often used, so classes on the provision of emergency first aid are conducted by several teachers, and a unified approach to the topics studied has been developed.
Emergency conditions in therapy
syncope
syncope- fainting, a sudden short-term disturbance of consciousness caused by brain hypoxia, accompanied by a weakening of cardiac activity and respiration and their rapid recovery.
2000 traffic accidents are due to syncope, of which 38% are due to epilepsy.
Etiology. Depending on the causes, the following groups of syncope are distinguished.
1. Violation of the regulation of the cardiovascular system:
orthostatic hypotension (distinguish between hyperadrenergic orthostatic hypotension due to a decrease in venous return to the heart - varicose veins veins of the lower extremities; hypovolemia; weakening of postural reflexes and hypoadrenergic orthostatic hypotension (diabetes mellitus, cancer)
situational syncope (the same situation - type of blood)
reflex syncope (influence of parasympathetic nervous system- sinus bradycardia, with diseases of the pharynx and larynx, carotid sinus hypersensitivity syndrome, when turning the head, overextending the neck, while eating)
hyperventilation syndrome (increased frequency and depth of breathing - a feeling of lack of air, connective tissue dysplasia)
2. Mechanical obstruction of blood flow at the level of the heart and large vessels (bronchial asthma, COPD, mitral stenosis, aortic stenosis, pulmonary artery stenosis).
3. Violation of the heart rhythm and conduction (complete a-v blockade, arrhythmic tachy - paroxysmal tachycardia.
4. Vascular lesions of the brain (more often atherosclerosis of cerebral vessels, with a decrease in blood pressure)
5. Diseases of the brain (benign and malignant brain tumors).
6. Loss of consciousness in other diseases (epilepsy, diabetes mellitus).
Correctly collected anamnesis helps to recognize the cause of syncope.
Methods of examination with syncope:
ECG in 12 leads;
ECHO graphics;
FLG of the cervical spine;
Holter monitoring.
Questions clarifying the picture of the unconscious state: fall, skin color - pallor, cyanosis, redness, duration of loss of consciousness, bite of the tongue.
clinical picture.
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 therapeutic measures. 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 in connection with inappropriate behavior sick
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, putting 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 contraction chewing 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.
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Rice. IVL "mouth to mouth". |
Stand on the right side, with your left hand holding the victim's head in a tilted position, at the same time cover the nasal passages with your fingers. Right hand the lower jaw should be pushed forward and upward. In this case, the following manipulation is very important: a) hold the jaw by the zygomatic arches with the thumb and middle fingers; b) open the mouth with the index finger; c) with the tips of the ring finger and little finger (fingers 4 and 5) control the pulse on the carotid artery. |
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Do deep breath, clasping the mouth of the victim with his lips and blowing. For hygienic purposes, cover the mouth with any clean cloth. At the moment of inspiration, control the rise of the chest When signs of spontaneous breathing appear in the victim, mechanical ventilation is not immediately stopped, continuing until the number of spontaneous breaths corresponds to 12-15 per minute. At the same time, if possible, the rhythm of breaths is synchronized with the recovering breathing of the victim. ALV "from mouth to nose" is indicated when assisting a drowning person, if resuscitation is carried out directly in the water, with fractures of the cervical spine (tilting the head back is contraindicated). IVL using the Ambu bag is indicated if the provision of assistance is mouth-to-mouth or mouth-to-nose
Rice. IVL with the help of simple devices. a - through S - shaped air duct; b- using a mask and an Ambu bag; c- through an endotracheal tube; d- percutaneous transglottal IVL. (fig. by Moroz F.K.) |
Rice. IVL "from mouth to nose" | |||
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 rescuer's shoulders should be directly above the palms, the arms should not be bent at the elbows. With rhythmic pushes of the proximal part of the hand, they press on the sternum in order to shift it towards the spine by approximately 4-5 cm. The pressure should be such that one of the team members can clearly determine the 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. Position of the patient and caregiver indirect massage hearts.
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% sodium chloride solution 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, cordaron 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.
Magnesia sulfate - 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 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, aminophylline, 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 antihistamines new generation: 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 (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 resulting from acute circulatory failure, which develops due to a deterioration in myocardial contractility, pumping function of the heart, or a disturbance in 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 arrhythmia, 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 tinge, skin covering marble color
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
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