Resuscitation: basic concepts

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

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

Dysregulation of vital functions. Damage occurs not only to central regulatory mechanisms (nervous and humoral), but also to local ones (the action of histamine, serotonin, kinins, prostaglandins, histamine, serotonin, cAMP system).

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

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

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

Intensive therapy - a set of methods for correction and temporary replacement of the functions of vital organs and systems of the patient’s body.

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

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

The most complex and intensive treatment methods are used in cases where the process of thanatogenesis reaches its apogee: cardiac arrest of the patient. It's not just about healing, it's also about revitalization.

Reanimation(revitalization of the body) - intensive therapy for stopping blood circulation and breathing.

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

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

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

Basic parameters of vital functions

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

Pre-hospital assessment (without special equipment);

Assessment at a specialized stage.

Pre-hospital assessment

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

CNS:

The presence of consciousness and the degree of its suppression;

Condition of the pupils (diameter, reaction to light);

Preservation of reflexes (the simplest is corneal).

The cardiovascular system:

Skin color;

Presence and character of pulse in peripheral arteries (a. radialis);

Presence and value of blood pressure;

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

Presence of heart sounds.

Respiratory system:

Presence of spontaneous breathing;

Frequency, rhythm and depth of breathing.

Assessment at a specialized stage

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

ECG;

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

Electroencephalography;

Continuous blood pressure measurement, central venous pressure monitoring;

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

Shock

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

We were introduced at the beginning of the 16th century by the French consultant physician to the army of Louis XV, Le Dran, who also proposed the simplest methods of treating shock: warming, rest, alcohol and opium. Shock must be distinguished from fainting and collapse.

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

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

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

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

Shock- an acutely severe condition of the body with progressive failure of all its systems, caused by a critical decrease in blood flow in the tissues.

Classification, pathogenesis

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

Rice. 8-1.Main types of shock

Hypovolemic shock

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

Cardiogenic shock

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

Rice. 8-2.Pathogenesis of hypovolemic shock

Rice. 8-3.Pathogenesis of cardiogenic shock

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

Septic shock

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

Rice. 8-4.Pathogenesis of septic shock

Rice. 8-5.Pathogenesis of anaphylactic shock

Anaphylactic shock

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

Microcirculation disturbance

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

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

Shock organs

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

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

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

Lung in shock.Characterized by impaired oxygen absorption and arterial hypoxia. If “shock lung” occurs, then after the shock is eliminated, severe respiratory failure quickly progresses. Patients complain of suffocation and rapid breathing. They experience a decrease in the partial pressure of oxygen in the arterial blood and a decrease in the elasticity of the lung. There is an increase in pa CO 2. In this progressive phase of shock, the “shock lung” syndrome, apparently, is no longer subject to reverse development: the patient dies from arterial hypoxia.

Kidneys in shock.Characterized by a sharp restriction of blood circulation with a decrease in the amount of glomerular filtrate, impaired concentration ability and a decrease in the amount of urine excreted. If these disorders, after eliminating the shock, do not undergo immediate reverse development, then diuresis progressively decreases, the amount of waste substances increases, and a “shock kidney” occurs, the main manifestation of which is the clinical picture of acute renal failure.

Liver -the central metabolic organ plays an important role in the course of shock. The development of “shock liver” can be suspected when the activity of liver enzymes increases even after the shock has stopped.

Clinical picture

Main symptoms

The clinical picture of shock is quite typical. The main symptoms are associated with inhibition of vital body functions. Patients in a state of shock are inhibited and reluctant to make contact. The skin is pale, covered with cold sweat, and acrocyanosis is often observed. Breathing is frequent and shallow. Tachycardia and decreased blood pressure are noted. The pulse is frequent, weak in filling, and in severe cases it is barely detectable (thread-like). Changes

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

Shock severity

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

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

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

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

IV degree shock.The preagonal state is one of the critical, terminal states.

General principles of treatment

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

The general principles of shock treatment can be presented in three stages.

Basic therapy for shock (first stage):

Replenishment of blood volume;

Oxygen therapy;

Correction of acidosis.

Pharmacotherapy of shock (second stage):

- dopamine;

Norepinephrine;

Cardiac glycosides.

Additional therapeutic measures (third stage):

Glucocorticoids;

Heparin sodium;

Diuretics;

Mechanical circulatory support;

Cardiac surgery.

When treating patients with shock, great attention is paid to the diagnostic program and monitoring. In Fig. 8-7 shows the minimum monitoring scheme. Among the presented indicators, the most important are heart rate, blood pressure, central venous pressure, blood gas composition and diuresis rate.

Rice. 8-7.Minimum monitoring regimen for shock

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

Moreover, diuresis in shock is measured not in a day, as usual, but in an hour or minutes, for which the bladder must be catheterized. With normal blood pressure, above the critical level of perfusion pressure (60 mm Hg), and with normal kidney function, the rate of urine excretion is more than 30 ml/h (0.5 ml/min). In Fig. 8-8 shows a diagram for measuring central venous pressure, knowledge of which is extremely important for conducting infusion therapy and replenishing blood volume. Normally, the central venous pressure is 5-15 cm of water column.

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

Terminal states

The main stages of the dying of the body are terminal states that successively replace each other: preagonal state, agony, clinical and biological death. The main parameters of these states are presented in table. 8-1.

Preagonal state

The preagonal state is the stage of the dying of the body, during which a sharp decrease in blood pressure occurs; first tachycardia and tachypnea, then bradycardia and bradypnea; progressive depression of consciousness, electrical activity of the brain and reflexes; build-up

Table 8-1.Characteristics of terminal states

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

Agony

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

Clinical death

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

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

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

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

Biological death

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

Reliable signs of biological death

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

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

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

Rigor mortis - thickening and shortening of skeletal muscles, creating an obstacle to passive movements in the joints. Occurs 2-4 hours after cardiac arrest, reaches a maximum after 24 hours, and resolves after 3-4 days.

Corpse decomposition - occurs late and is manifested by decomposition and rotting of tissues. The timing of decomposition largely depends on environmental conditions.

Ascertainment of biological death

The fact of the occurrence of biological death is determined by a doctor or paramedic by the presence of reliable signs, and before their appearance - by the combination of the following symptoms:

Absence of cardiac activity (no pulse in large arteries, heart sounds cannot be heard, no bioelectrical activity of the heart);

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

Lack of spontaneous breathing;

Maximum dilation of the pupils and their lack of reaction to light;

Absence of corneal reflex;

The presence of post-mortem hypostasis in sloping parts of the body.

Brain death

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

Complete and persistent lack of consciousness;

Persistent lack of spontaneous breathing;

Disappearance of reactions to external irritations and any types of reflexes;

Atony of all muscles;

Disappearance of thermoregulation;

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

The diagnosis of brain death has implications for organ transplantation. After it has been identified, organs can be removed for transplantation into recipients. In such cases, when making a diagnosis, it is additionally necessary to:

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

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

According to the legislation existing in most countries, “brain death” is equated to biological death.

Resuscitation measures

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

Early recognition of clinical death;

Immediate initiation of basic resuscitation;

The rapid arrival of professionals and the start of specialized resuscitation.

Diagnosis of clinical death

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

Loss of consciousness;

Absence of pulse in the central arteries;

Stopping breathing;

Absence of heart sounds;

Pupil dilation;

Change in skin color.

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

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

Basic cardiopulmonary resuscitation

Basic cardiopulmonary resuscitation is the first stage of care, the timeliness of which determines the likelihood of success. Conducted at the site of discovery of the patient by the first person possessing her skills. The main stages of basic cardiopulmonary resuscitation were formulated back in the 60s of the 20th century by P. Safar.

A - airway- ensuring free patency of the airways.

IN - breathing- Ventilator.

WITH - circulation- indirect cardiac massage.

Before starting these stages, it is necessary to place the patient on a hard surface and place him in a supine position with his legs elevated to increase blood flow to the heart (elevation angle 30-45? C).

Ensuring free airway patency

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

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

2. The main method of restoring airway patency (in case of tongue retraction, etc.) is the so-called triple technique of P. Safar (Fig. 8-9): straightening the head, moving the lower jaw forward, opening the mouth. In this case, you should avoid straightening your head if you suspect a cervical spine injury.

3. After completing the above measures, take a test breath of the “mouth to mouth” type.

Artificial ventilation

Mechanical ventilation begins immediately after the patency of the upper respiratory tract is restored, and is carried out according to the “mouth to mouth” and “mouth to nose” type (Fig. 8-10). The first method is preferable; the person resuscitating takes a deep breath, covers the victim’s mouth with his lips and

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

exhales. In this case, you should pinch the victim’s nose with your fingers. In children, breathing into the mouth and nose is used at the same time. The use of air ducts greatly simplifies the procedure.

General rules of mechanical ventilation

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

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

3. During mechanical ventilation, airway patency should be constantly monitored.

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

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

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

Ludka In this case, you should check the airway or change the position of the head.

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

Indirect (closed) cardiac massage

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

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

2. Chest pump: compression causes blood to be squeezed out of the lungs and sent to the heart, which greatly helps restore blood flow.

Choosing a point for chest compression

Pressure on the chest should be applied in the midline at the border of the lower and middle third of the sternum. Usually, moving the IV finger upward along the midline of the abdomen, the resuscitator feels the xiphoid process of the sternum, applies another II and III to the IV finger, thus finding the point of compression (Fig. 8-11).

Rice. 8-11.Selection of compression point and indirect massage technique: a - compression point; b - hand position; c - massage technique

Precordial beat

In case of sudden cardiac arrest, a precordial shock may be an effective method. Using a fist from a height of 20 cm, strike the chest twice at the point of compression. If there is no effect, proceed to closed cardiac massage.

Closed heart massage technique

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

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

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

Direct (open) heart massage

Direct cardiac massage is rarely used during resuscitation measures.

Indications

Cardiac arrest during intrathoracic or intraabdominal (transdiaphragmatic massage) operations.

Chest injury with suspected intrathoracic bleeding and lung damage.

Suspicion of cardiac tamponade, tension pneumothorax, pulmonary embolism.

Injury or deformation of the chest that prevents closed massage.

The ineffectiveness of a closed massage for several minutes (relative indication: used in young victims, with the so-called “unjustified death”, is a measure of despair).

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

Combination of mechanical ventilation and cardiac massage

The order of combining mechanical ventilation and cardiac massage depends on how many people are providing assistance to the victim.

Reanimating One

The resuscitator performs 2 breaths, followed by 15 chest compressions. This cycle is then repeated.

Two people resuscitating

One resuscitator performs mechanical ventilation, the other performs indirect cardiac massage. In this case, the ratio of breathing frequency and chest compressions should be 1:5. During inspiration, the second resuscitator should pause in compressions to prevent regurgitation from the stomach. However, when performing massage against the background of mechanical ventilation through an endotracheal tube, such pauses are not necessary. Moreover, compression during inspiration is useful, since more blood from the lungs enters the heart and artificial circulation becomes effective.

Effectiveness of resuscitation measures

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

Effectiveness of resuscitation;

The effectiveness of artificial respiration and blood circulation.

Effectiveness of resuscitation

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

Efficiency of artificial respiration and blood circulation

The effectiveness of artificial respiration and blood circulation is said when resuscitation measures have not yet led to the revival of the body (spontaneous blood circulation and breathing are absent), but the measures taken artificially support metabolic processes in tissues and thereby lengthen the duration of clinical death. The effectiveness of artificial respiration and blood circulation is assessed by the following indicators:

1. Constriction of the pupils.

2. The appearance of transmitting pulsation in the carotid (femoral) arteries (assessed by one resuscitator while another performs chest compressions).

3. Change in skin color (decreased cyanosis and pallor).

If artificial respiration and blood circulation are effective, resuscitation measures continue until a positive effect is achieved or until the indicated signs disappear permanently, after which resuscitation can be stopped after 30 minutes.

Drug therapy for basic resuscitation

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

Routes of administration

During resuscitation, three methods of drug administration are used:

Intravenous injection (it is advisable to administer drugs through a catheter in the subclavian vein);

Intracardiac;

Endotracheal (with tracheal intubation).

Intracardiac injection technique

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

Drugs used in basic resuscitation

For several decades, the administration of epinephrine, atropine, calcium chloride, and sodium bicarbonate was considered necessary during basic cardiopulmonary resuscitation. Currently, the only universal drug used in cardiopulmonary resuscitation is epinephrine at a dose of 1 mg (endotracheal - 2 mg), it is administered as early as possible, subsequently repeating the infusion every 3-5 minutes. The main effect of epinephrine during cardiopulmonary resuscitation is the redistribution of blood flow from peripheral organs and tissues to the myocardium and brain due to its α-adrenomimetic effect. Epinephrine also stimulates β-adrenoreactive structures of the myocardium and coronary vessels, increases coronary blood flow and contractility of the heart muscle. During asystole, it tones the myocardium and helps to “start” the heart. In case of ventricular fibrillation, it promotes the transition of small-wave fibrillation to large-wave fibrillation, which increases the effectiveness of defibrillation.

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

Basic resuscitation algorithm

Taking into account the complex nature of the necessary actions in case of clinical death and their desired speed, a number of specific actions have been developed.

Rice. 8-12.Algorithm for basic cardiopulmonary resuscitation

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

Basics of specialized cardiopulmonary resuscitation

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

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

Diagnostics

By clarifying the medical history, as well as special diagnostic methods, the causes of clinical death are identified: bleeding, electrical trauma, poisoning, heart disease (myocardial infarction), pulmonary embolism, hyperkalemia, etc.

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

Ventricular tachycardia or ventricular fibrillation;

Asystole;

Electromechanical dissociation.

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

Venous access

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

Defibrillation

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

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

Rice. 8-13.Layout of electrodes for defibrillation

Confirm with an electrocardioscope that fibrillation persists. Defibrillation can be repeated several times. At the same time, it is extremely important to observe safety precautions: no contact of medical personnel with the patient’s body.

Tracheal intubation

Intubation should be performed as early as possible, as this provides the following advantages:

Ensuring free airway patency;

Prevention of regurgitation from the stomach during chest compressions;

Ensuring adequate controlled ventilation;

The ability to simultaneously compress the chest while blowing air into the lungs;

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

Drug therapy

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

substances, calcium preparations, glucocorticoids, sodium bicarbonate, antihypoxants, means of replenishing blood volume. In case of bleeding, blood transfusion is of paramount importance.

Brain protection

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

Hypothermia;

Normalization of acid-base and water-electrolyte balance;

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

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

Antihypoxants and antioxidants;

Drugs that improve the rheological properties of blood.

Assisted circulation

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

Algorithm for specialized resuscitation

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

Forecast of resuscitation measures and post-resuscitation illness

The prognosis for the restoration of body functions after resuscitation is primarily associated with the prognosis for the restoration of brain functions. This prognosis is based on the duration of the absence of blood circulation, as well as the time at which signs of recovery of brain function appear.

The effectiveness of resuscitation, restoration of blood circulation and breathing do not always indicate complete restoration of body functions. Metabolic disorders during acute

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

Legal and moral aspects

Indications for resuscitation measures

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

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

The presence of obvious signs of biological death.

Contraindications to resuscitation measures

Cardiopulmonary resuscitation is not indicated in the following cases:

If death occurred during the use of the full complex of intensive therapy indicated for this patient, and was not sudden, but associated with a disease that is incurable for the current level of development of medicine;

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

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

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

Termination of resuscitation measures

Cardiopulmonary resuscitation may be discontinued in the following cases.

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

Professionals provide assistance:

If during the course of the procedure it turns out that resuscitation is not indicated for the patient;

If resuscitation measures are completely ineffective within 30 minutes;

If there are repeated cardiac arrests that are not amenable to medical intervention.

Problems of euthanasia

There are two types of euthanasia: active and passive.

Active euthanasia

This is intentional compassionate killing with or without the patient's request. It involves the active actions of the doctor and is otherwise called "filled syringe method". Such actions are prohibited by the laws of the vast majority of countries and are considered a criminal act - premeditated murder.

Passive euthanasia

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

All types of euthanasia are prohibited in Russia.

Report within the framework of the V All-Russian interdisciplinary scientific and practical conference "Critical conditions in obstetrics and gynecology." The lecture presents obstetric indications and contraindications for epidural analgesia. Cases where this anesthesia affects malposition are also considered.

Doctor's notes: When the result is there!

We assessed the necessary blood parameters - the results were within the reference values.There are no contraindications - drug treatment was started - COC (3 months). And about two months later, on the sixth day of the cycle, during a control ultrasound, the ovarian cyst significantly decreased. Everyone is happy, but...

A couple of months later, the girl complained of periodic pain in the lower abdomen: nagging pain. We performed an ultrasound of the pelvic organs: endometrioid cyst of the right ovary? Further, given the lack of effect from the treatment, laparoscopic diagnosis was performed.

As a result, the diagnosis: endometrioid cyst of the left ovary. A right cystectomy was performed.After the operation, Visanne was prescribed for six months. One of the side effects is mood swings, but who hasn’t experienced them?.. But just a couple of days ago, the patient herself called us and told us that the long-awaited pregnancy had begun.

Of course, there is no guarantee that endometriosis has left this patient forever. But what is difficult to cure must be compensated to the maximum!

SLIDE 1 CARDIOPULMONARY RESUSCITATION

BASIC CARDIOPULMONARY RESUSCITATION COMPLEX

Data on the effectiveness of resuscitation measures and survival of terminally ill patients vary greatly. For example, survival after sudden cardiac arrest varies widely depending on many factors (heart disease related or not, witnessed or not, in a medical facility or not, etc.). Outcomes of resuscitation from cardiac arrest are the result of a complex interaction of so-called “unmodified” (age, disease) and “programmed” factors (for example, time interval from the start of resuscitation measures). Initial resuscitation measures should be sufficient to prolong life while awaiting the arrival of trained professionals with appropriate equipment.

Based on the high mortality rate from injuries and in various emergency conditions, at the prehospital stage it is necessary to ensure that not only medical workers, but also as many of the active population as possible are trained in a single modern protocol for cardiopulmonary resuscitation.

SLIDE 2 Indications and contraindications for

cardiopulmonary resuscitation

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

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

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

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

SLIDE 3

SLIDE 4 Resuscitation measures are not carried out:

in the presence of signs of biological death;

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

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

SLIDE 5 Resuscitation measures are stopped:

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

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

if there are repeated cardiac arrests that are not amenable to any medical intervention;

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

SLIDE 6 Resuscitators - “non-medics” - carry out resuscitation measures:

before signs of life appear;

until qualified or specialized medical personnel arrive and continue resuscitation or pronounce death. Article 46 (“Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens.”);

exhaustion of the physical strength of the non-professional resuscitator.

SLIDE 7 Clinical picture of dying

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

Preagonal state characterized by disintegration of body functions, a critical decrease in blood pressure, disturbances of consciousness of varying severity, and breathing problems.

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

At the end of the terminal pause, it develops agony. One of the clinical signs of agony is agonal breathing with characteristic rare, short, deep convulsive respiratory movements, sometimes with the participation of skeletal muscles. Breathing movements can also be weak and of low amplitude. In both cases, the effectiveness of external respiration is reduced. The agony, ending with the last breath, turns into clinical death. In sudden cardiac arrest, agonal breaths may continue for several minutes in the absence of blood circulation.

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

The main signs of clinical death are:

• Lack of consciousness;

  Lack of spontaneous breathing;

  Absence of pulsation in the great vessels.

SLIDE 9 Additional signs of clinical death are:

• Wide pupils;

  Areflexia (no corneal reflex and pupillary reaction to light);

  Paleness, cyanosis of the skin.

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

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

Functional:

• lack of consciousness;

  lack of breathing, pulse, blood pressure;

  lack of reflex responses to all types of stimuli.

Instrumental:

• electroencephalographic;

  angiographic.

Biological:

• maximum pupil dilation;

  pallor and/or cyanosis, and/or marbling (spotting) of the skin;

  decrease in body temperature.

Cadaveric changes:

• early signs;

  late signs. SLIDE 11, 12,13

SLIDE 14 Ascertainment of a person’s death occurs when a person’s biological death (irreversible death of a person) or brain death.

Introduction.SLIDE 15

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

Initial examination

Restoration and maintenance of airway patency,

Artificial ventilation,

Indirect cardiac massage.

Slide 17 Goal the main complex of cardiopulmonary resuscitation is maintaining ventilation and blood circulation until the mechanism of respiratory arrest and/or blood circulation is determined to eliminate the causes.

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

Story.

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

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

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

The theory of closed cardiac massage.

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

It is necessary to realize that even with optimal closed cardiac massage, cerebral blood flow does not reach more than 30% of its normal level.

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

Pulse.

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

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

Make sure the safety of the resuscitator and the victim.

Examine the victim and assess his reaction. Gently shake your shoulder and ask loudly: “How are you feeling?”

1. SLIDE 20 If he reacts, then:

Leave the victim in the same position (making sure that there is no further danger), check his condition and, if necessary, seek help.

Check condition regularly.

If the victim does not respond: SLIDE 21

• Call for help.

  Turn onto your back and open your airways: SLIDE 22

  • Place your palm on your forehead and carefully tilt your head back so that your thumb and forefinger remain free so that if artificial respiration is necessary, you can cover your nose with them,

    SLIDE 23.24 Remove all visible foreign objects from the mouth, including extracted teeth, leaving fairly fixed teeth in place,

    With the fingers of the other hand placed under the chin, lift it to open the airway.

Try to avoid throwing your head back if you suspect a neck injury.

SLIDE25 While maintaining airway patency, determine the presence of spontaneous breathing:

• See chest movements.

  Hear noises coming from the victim's mouth.

  Feel the air flow with your cheek.

Spend no more than 10 seconds on this stage.

1. SLIDE 26 If spontaneous breathing is normal:

Rotate the victim to a safe position (further),

Send someone or go yourself for help,

Check for spontaneous breathing

SLIDE 27,28,29

If there is no breathing or there are only attempts to breathe:

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

Turn the victim onto his back if he is not already in this position.

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

• Make sure your head is tilted back and your chin is up,

  SLIDE 30 FREE YOUR BREATH PATH

  Pinch your nose with your index finger and thumb on the hand that is on the victim’s forehead,

  SLIDE 31 Open your mouth slightly, keeping your chin raised,

  Take a deep breath and press your lips tightly to the victim’s mouth,

  Exhale into the victim's mouth for approximately two seconds, observing the movement of the chest, so that the chest rises, as during normal breathing,

  Keeping your head tilted back and your chin raised, remove your mouth from the victim and make sure that the chest drops and air comes out.

If you cannot inhale effectively:

• Recheck the victim's mouth and remove anything that may be blocking the airway.

  Check that the head is tilted back and the chin is raised sufficiently,

  Make up to 5 attempts to produce 2 effective breaths,

  Even if they are unsuccessful, proceed to assess the circulation. SLIDE 32

SLIDE33,34,35,36

SLIDE 37.38

slide h9 Assessment of signs of blood circulation:

• Check for normal breathing, coughing, or movement;

  Determine the presence of a carotid pulse only if you have it;

  Spend no more than 10 seconds on this.

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

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

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

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

SLAD 41 If there are no signs of blood circulation or there is no confidence in their presence, start chest compressions:

• Using the hand that is located on the side of the victim’s legs, determine the lower half of the sternum:

  • SLIDE 42 Using your index and middle fingers, locate the edge of the lower rib on the resuscitator side. Without unclenching your fingers, move them upward to the point where the ribs and sternum meet. Place the clenched middle and index fingers so that the middle one is at the junction of the ribs and sternum, and the index finger is on the sternum;

    SLIDE 43 Move the wrist of the other hand down the sternum until it touches the index finger; this is the middle of the lower part of the sternum;

    Place the wrist of the other hand on the back of the palm of this hand;

    Straighten or spread the fingers of both hands and lift them, making sure that they do not put pressure on the ribs. Do not press on the upper abdomen or upper sternum under any circumstances;

    Position yourself over the victim’s chest and, with straightened arms, press on the sternum so as to displace it by 4–5 cm;

    Stop the pressure without losing contact between the hands and the sternum; repeat pressing with a frequency of approximately 100 per 1 minute. The pressure and pause should be equal in time;

Combination of artificial respiration and chest compressions:

• After every 15 compressions, tilt your head back, lift your chin and take two effective breaths;

  Place your hands again in the position described above and do 15 compressions, alternating compressions and breathing 15:2

  Interrupt resuscitation only to check for signs of circulation if the victim begins to move or take spontaneous breaths SLIDE 44- CARDIOPAMP.

  SLIDE45

Continue resuscitation until:

• Arrival of qualified assistance;

  The appearance of signs of life;

  Or until the resuscitator has exhausted all his strength.

When to go for help?

Getting help is vital.

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

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

However, if the likely cause is breathing problems, for example:

• Drowning,

  Aspiration,

  Drug or alcohol intoxication,

  Or the injured child or teenager,

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

Resuscitation by two rescuers.

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

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

Rescuers should be on opposite sides of the victim.

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

It is necessary to maintain a raised chin and tilt of the head at all times. The duration of the inhalation cycle should be 2 seconds. Chest compressions should be suspended at this point. Indirect cardiac massage must be resumed immediately after the cessation of inhalations.

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

Notes on the technique of performing the basic complex of cardiopulmonary resuscitation. SLIDE46

Artificial respiration.

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

If you inhale very quickly, the inspiratory resistance will be greater and excess volume will enter the lungs.

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

It is necessary to wait until the chest completely collapses before the next inhalation begins. This usually takes 2 – 4 seconds.

Slowing down the exhalation is not critical; You must wait until you exhale completely before starting the next inhalation.

Indirect cardiac massage. SLIDE47

In adults, the compression depth should be 4–5 cm and the applied force should not exceed that necessary to achieve this.

The direction of force must be strictly vertical.

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

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

In the past, dilated pupils were considered a sign of cardiac arrest, ineffective circulation during cardiopulmonary resuscitation, and irreversible brain damage. This sign is not reliable and should not influence decision making either before, during, or after cardiopulmonary resuscitation.

Airway obstruction.

If the airway is partially blocked, the victim is usually able to clear the airway on his own. But if the blockage is complete, then emergency intervention is required to prevent asphyxia.

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

Continued cough.

Complete obstruction or signs of decompensation or cyanosis:

Consciousness saved: SLIDE48

Perform back blows:

• Remove any visible foreign bodies or knocked-out teeth from the mouth,

  Stand to the side and slightly behind,

  Supporting the chest with one hand, tilt the victim forward,

  Apply 5 sharp blows between the shoulder blades with the wrist of the other hand.

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

• Stand behind the victim and clasp with both hands at the level of the upper abdomen,

  Make sure that the victim is leaning forward enough so that the removed foreign body does not get back into the respiratory tract,

  Make a fist and place it between the navel and the xiphoid process,

  Grab it with your other hand

  Press sharply inward and upward; the foreign object must be removed,

  If obstruction persists, check the oral cavity with a finger and continue alternating between 5 thrusts between the shoulder blades and 5 epigastric thrusts.

If consciousness disappears:

• Throw back your head and remove everything foreign from your mouth,

  Open the airway by lifting the chin,

  Check for breathing

  Try to give 2 effective artificial breaths,

  If effective breaths can be delivered in 5 attempts:

  • Check for signs of blood circulation,

    Start chest compressions and/or artificial respiration.

If effective breaths cannot be achieved after 5 attempts:

• Start chest compressions immediately. Do not check for signs of circulation,

  After 15 compressions, check the oral cavity, then try artificial respiration,

  Continue indirect cardiac massage - 15 compressions alternate with attempts at artificial respiration.

If artificial respiration becomes possible:

• Check for signs of circulation,

  Continue chest compressions and/or artificial respiration. SLIDE49

Safe position.

Once circulation and breathing have been restored, it is very important to maintain patency of the airway and prevent obstruction by the tongue. It is also very important to reduce the risk of aspiration of gastric contents.

To do this, the victim must be placed in a safe position in which tongue retraction is prevented and airway patency is maintained.

Kneel next to the victim,

Straighten your legs

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

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

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

Pull the victim by the leg and turn him onto his side, supporting him with his palm pressed to his cheek,

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

Tilt your head back, making sure the airway is open,

Assess your breathing regularly.

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

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

Variants of cardiopulmonary resuscitation techniques.

Artificial respiration from mouth to nose. SLIDE50

In some situations this technique may be preferable:

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

It is impossible to relieve obstruction in the oral cavity,

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

A child performs artificial respiration

For aesthetic reasons.

Krasnoyarsk Medical and Pharmaceutical College.

Bodrov Yu.I.

Lecture on resuscitation Dept. "Nursing"

Krasnoyarsk 1995

Bodrov Yu.I. Course of lectures on resuscitation, discipline: “Nursing in resuscitation”, - Krasnoyarsk: Krasnoyarsk Medical and Pharmaceutical College, 2005 – 65 p.

annotation

This course of lectures is intended for 4th year students of medical colleges and schools studying in the specialty “Nursing”. Compiled in accordance with the requirements of the State educational standard for the discipline “Nursing in Critical Care Medicine”.

The purpose of the lectures is to teach students the rules and techniques of working with patients who are in a terminal condition and require both resuscitation aids and intensive care.

Reviewer: Head of the Department of Pediatric Surgery, Doctor of Medical Sciences, Professor V.A. Yurchuk.

Introduction

Reanimatology is a discipline of fundamental importance in the training of students in medical schools and colleges. Students begin acquiring knowledge in resuscitation and mastering practical skills by studying a course of lectures on resuscitation.

The theoretical principles, and subsequently the practical skills acquired by students while studying this course, are necessary not only for future surgical nurses, but also for nurses of other professions. The purpose of these lectures is to facilitate students’ independent preparation for practical classes in resuscitation and help them master practical skills.

The main attention when writing a course of lectures is paid not only to the presentation of sections related to the practical work of nurses, but also to a clear understanding of the role of the regional component in the development and course of some “terminal conditions”. A modern nurse must not only carry out doctor’s orders, but be able to independently carry out and solve the problems of a patient in a “terminal state” within the limits of her competence.

The proposed educational material - a course of lectures on resuscitation, is necessary for students of medical schools and colleges for more successful development of the specialty.

Explanatory note.

The course of lectures on the discipline “Nursing in Reanimatology” is intended to implement the requirements for the minimum content and level of training of graduates in specialty 0406 “Nursing (basic level of secondary vocational education) and are written taking into account the requirements set out in the “Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens "from 22. O8 93, "Concepts for the development of healthcare and medical science in the Russian Federation" from 5.11.97, in the sectoral program for the development of nursing in the Russian Federation. These lectures are aimed at training a nurse who knows the principles of organizing resuscitation care for the population, individual clinical symptoms and syndromes of particular types of resuscitation pathology, who can provide resuscitation care in terminal conditions and carry out the nursing process. A modern nurse must not only competently carry out doctor’s orders, but also be able to independently carry out and solve patient problems within the limits of her competence.

In accordance with the State educational standard for the specialty “Nursing” in 2002, after reading a course of lectures on resuscitation, students must

Know:

Risk factors, clinical manifestations, complications and prevention of critical conditions (terminal conditions);

Responsibilities of a nurse when performing therapeutic and diagnostic measures when providing resuscitation care.

Must be able to:

carry out nursing process for patients in critical condition;

perform nursing procedures;

Ensure infection safety of the patient and staff of the intensive care unit;

Apply modern nursing technologies to prevent nosocomial infections;

Educate (consult) the patient and his family;

Provide first resuscitation aid.

The knowledge and skills acquired by students after completing a course of lectures on resuscitation will allow students to apply them in the future in everyday activities when working in any medical institution.

Anesthesiology and resuscitation: lecture notes Marina Aleksandrovna Kolesnikova

Lecture No. 1. The concept of resuscitation

Resuscitation is a branch of clinical medicine that studies the problems of revitalizing the body, developing principles for the prevention of terminal conditions, methods of resuscitation and intensive care. Practical methods of reviving the body are united by the concept of “resuscitation.”

Resuscitation (from the Latin “revival” or “animation”) is a system of measures aimed at restoring severely impaired or lost vital functions of the body and removing it from a terminal state and clinical death. Effective resuscitation measures include chest compressions and artificial ventilation. If they are ineffective within 30 minutes, biological death is declared.

Intensive care is a set of measures used to treat severe, life-threatening conditions and involves the use of a large range of therapeutic measures according to indications, including intravenous infusions, long-term artificial ventilation, cardiac pacing, dialysis methods, etc.

A critical condition is the impossibility of maintaining the integrity of the body’s functions as a result of an acute dysfunction of an organ or system, requiring medicinal or hardware-instrumental replacement.

A terminal state is a borderline state between life and death, a reversible extinction of body functions, including the stages of preagony, agony and clinical death.

Clinical death is a terminal condition in which there is no blood circulation and breathing, the activity of the cerebral cortex ceases, but metabolic processes are preserved. In case of clinical death, the possibility of effective resuscitation remains possible. The duration of clinical death is from 5 to 6 minutes.

Biological death is the irreversible cessation of physiological processes in organs and tissues, in which resuscitation is impossible. It is determined by a combination of a number of signs: the absence of spontaneous movements, contractions of the heart and pulse in large arteries, breathing, reaction to painful stimuli, corneal reflex, maximum dilation of the pupils and the absence of their reaction to light. Reliable signs of death are a decrease in body temperature to 20 ° C, the appearance of cadaver spots and muscle rigor.

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