Lectures on resuscitation for students of medical colleges. Basics of resuscitation
Intensive therapy- this is the treatment of a patient who is in a terminal condition, i.e. artificial maintenance of vital body functions.
Reanimation is intensive therapy when breathing and circulation stop. There are 2 types (stages) of resuscitation: basic (it is carried out by any person trained in this) and specialized (it is carried out by professional resuscitators using special means).
Terminal states
These are 4 states that successively replace each other, ultimately ending in the death of the patient: preagonal state, agony, clinical death and biological death.
1). Preagonal state
It is characterized by a sharp decrease in blood pressure, progressive depression of consciousness, tachycardia and tachypnea, which are then replaced by bradycardia and bradypnea.
2). Agony
It is characterized by the “last outbreak of vital activity”, in which the regulation of the vital functions of the body passes from the higher nerve centers to the bulbar ones. There is a slight increase in blood pressure and increased respiration, which becomes pathological in nature (Cheyne-Stokes, Kussmaul, Biot breathing).
3). Clinical death
It occurs a few minutes after the agony and is characterized by cessation of breathing and circulation. However, metabolic processes in the body fade away within a few hours. The first to start dying nerve cells bark cerebral hemispheres(CBD) of the brain (after 5-6 minutes). During this time, changes in the KBP are still reversible.
Signs clinical death:
- Lack of consciousness.
- Absence of pulse in the central arteries (usually the pulse in the carotid arteries is determined).
- Lack of breathing.
- Pupil dilation, reaction to light is weak.
- Paleness and then cyanosis of the skin.
After a diagnosis of clinical death has been established, it is necessary to urgently begin basic cardiopulmonary resuscitation (CPR) and call specialist resuscitators.
The duration of clinical death is influenced by:
- Temperature environment- the lower it is, the longer clinical death lasts.
- The nature of dying - the more sudden clinical death occurs, the longer it can last.
- Accompanying illnesses.
4). Biological death
It occurs a few minutes after the clinical one and is an irreversible condition when full revival of the body is impossible.
Reliable signs of biological death:
- Cadaveric spots are purple spots in the underlying areas of the body. It is formed 2-3 hours after cardiac arrest and is caused by the release of blood from the vessels. In the first 12 hours, the spots temporarily disappear when pressed, later they stop disappearing.
- Rigor mortis - develops 2-4 hours after cardiac arrest, reaches a maximum after 24 hours and disappears after 3-4 days.
- Corpse decomposition.
- Drying and clouding of the cornea.
- “Slit-like” pupil.
Relative signs of biological death:
- Significant absence of breathing and blood circulation for more than 25 minutes (if resuscitation was not performed).
- Persistent dilation of the pupils, lack of their reaction to light.
- Absence of corneal reflex.
Statement of biological death carried out by a doctor or paramedic, taking into account the presence of at least one of the reliable signs, and before their appearance - according to a set of relative signs.
Concept of brain death
In most countries, including Russia, brain death is legally equivalent to biological death.
This condition is possible with some diseases of the brain and after delayed resuscitation (when a person who is in a state of biological death is revived). In these cases, the functions of the higher parts of the brain are irreversibly lost, and cardiac activity and breathing are supported by special equipment or medication.
Criteria for brain death:
- Lack of consciousness.
- Lack of spontaneous breathing (it is supported only with mechanical ventilation).
- Disappearance of all reflexes.
- Complete atony of skeletal muscles.
- Lack of thermoregulation.
- According to electroencephalography, there is a complete absence of bioelectrical activity of the brain.
- According to angiography, there is a lack of blood flow in the brain or a decrease in its level below critical.
For ascertaining brain death a consultation conclusion is required with the participation of a neurologist, resuscitator, forensic expert and an official representative of the hospital.
After brain death is declared, organs can be removed for transplantation.
Basic cardiopulmonary resuscitation
carried out at the place where the patient is found by any medical worker, and in their absence - by any trained person.
Basic principles of CPR proposed by Safar (ABCDE - Safar principles):
A - Airways open - ensuring patency of the upper respiratory tract (URT).
B - Breathing - artificial ventilation.
C - Cardiac massage - indirect massage or direct heart massage.
D - Drug therapy - drug therapy.
E - Electrotherapy - cardiac defibrillation.
The last 2 principles are applied at the stage of specialized resuscitation.
1). Ensuring the patency of the upper respiratory tract:
- The patient is placed on a horizontal hard surface.
- If necessary, empty the patient’s oral cavity: turn the head to the side and, with fingers wrapped in a scarf, clear the mouth of vomit, mucus or foreign bodies.
- Then do Safar triple move: straighten your head, move your lower jaw forward and open your mouth. This prevents the tongue from retracting, which occurs due to muscle relaxation.
2). Artificial ventilation
carried out using the “mouth-to-mouth”, “mouth-to-nose” methods, and in children - “mouth-to-mouth and nose”:
- A handkerchief is placed over the patient's mouth. If possible, an air duct (S-shaped tube) is inserted - first with the concave side up, and when it reaches the pharynx, it is turned down and the tube is inserted into the pharynx. When using a spatula, the air duct is inserted immediately with the concave side down, without turning it around.
- They begin to make injections lasting 2 seconds, with a frequency of approximately 12-16 per minute. The volume of blown air should be 800-1200 ml. It is better to use a special Ambu breathing bag with a mask or RPA-1 or -2 devices.
Criterion for the effectiveness of mechanical ventilation is the expansion of the chest. Swelling of the epigastrium indicates that the airways are obstructed and air goes into the stomach. In this case, the obstacle must be removed.
3). Closed (indirect) cardiac massage:
appears to be effective by “squeezing” blood out of the heart and lungs. A. Nikitin in 1846 first proposed striking the sternum in case of cardiac arrest. Modern method indirect massage was proposed by Koenig and Maas in 1883-1892. In 1947, Beck first used direct cardiac massage.
- The patient should lie on a hard surface with the leg end raised and the head end lowered.
- Usually the massage starts with precordial stroke fist from a height of 20-30 cm into the area of the lower third of the patient’s sternum. The blow can be repeated 1-2 times.
- If there is no effect, they begin to compress the chest at this point with straight arms at a frequency of 80-100 times per minute, and the sternum should move 4-5 cm towards the spine. The compression phase must be equal in duration to the decompression phase.
IN last years in the West the device is used "Cardiopump" having the appearance of a suction cup and performing active compression and decompression of the chest.
Open heart massage is performed by surgeons only in the operating room.
4). Intracardiac injections
Currently, they are practically not used due to possible complications (lung damage, etc.). Administration of drugs endobronchially or into the subclavian vein completely replaces intracardiac injection. It can be done only in the most extreme case: the needle is inserted 1 cm to the left of the sternum in the 4th intercostal space (i.e. in the zone of absolute cardiac dullness).
Basic CPR technique:
If there is only one resuscitator:
He performs 4 blows, followed by 15 chest compressions, 2 blows, 15 compressions, etc.
If there are two resuscitators:
One does 1 blow, and the second after that does 5 compressions, etc.
It is necessary to distinguish between 2 concepts:
Effectiveness of resuscitation- is expressed in the full revitalization of the body: the appearance of independent heartbeat and breathing, an increase in blood pressure of more than 70 mm Hg. Art., constriction of the pupils, etc.
Efficiency of artificial respiration and blood circulation- is expressed in maintaining metabolism in the body, although revival has not yet occurred. Signs of effectiveness are constriction of the pupils, transmission pulsation in the central arteries, and normalization of skin color.
If there are signs of the effectiveness of artificial respiration and blood circulation, CPR should be continued indefinitely until resuscitators appear.
Specialized SRL
carried out by specialists - resuscitators and surgeons.
1). Open (direct) cardiac massage carried out in the following cases:
- Cardiac arrest during abdominal surgery.
- Cardiac tamponade, pulmonary embolism, tension pneumothorax.
- Chest injury making chest compressions impossible.
- Relative indication: sometimes open cardiac massage is used as a measure of despair when closed massage is ineffective, but only in an operating room.
Technique:
A thoracotomy is performed in the 4th intercostal space to the left of the sternum. A hand is inserted between the ribs: thumb placed on the heart, and the remaining 4 fingers under it, and begin rhythmic compression of the heart 80-100 times per minute. Another way is to insert your fingers under the heart and press it to inner surface sternum. During operations on the chest cavity, open massage can be performed with both hands. Systole should take 1/3 of the time, diastole - 2/3. When performing open cardiac massage, it is recommended to press the abdominal aorta to the spine.
2). Catheterization of the subclavian or (abroad) jugular vein- for infusion therapy.
Technique:
- The head end is lowered to prevent air embolism. The patient's head is turned in the direction opposite to the puncture site. A pillow is placed under the chest.
- The angle is entered at one of the special points:
Obanyak's point - 1 cm below the collarbone along the border of its inner and middle third;
Wilson's point - 1 cm below the sternum in its middle;
Giles's point is 1 cm below the collarbone and 2 cm outward from the sternum.
Joff's point is in the corner between the outer edge of the sternocleidomastoid muscle and the upper edge of the clavicle.
Kilihan's point is in the jugular notch above the sternal end of the clavicle.
- A conductor is inserted through the needle channel and the needle is removed.
- A subclavian catheter is inserted into the vein along a guidewire and glued (or sutured) to the skin.
The method of inserting a catheter through a needle is also used.
In the West, catheterization of the internal jugular vein is now more common, because it causes fewer complications.
3). Defibrillation of the heart performed in case of cardiac arrest or ventricular fibrillation. A special device is used - a defibrillator, one electrode of which is placed in the 5th intercostal space to the left of the sternum, and the second - in the 1st-2nd intercostal space to the right of it. The electrodes must be lubricated with a special gel before application. The voltage of the discharges is 5000 volts; if the discharge fails, the discharge is increased by 500 volts each time.
4). Tracheal intubation to the maximum early dates .
Tracheal intubation was first proposed in 1858 by the Frenchman Bouchoux. In Russia it was first carried out by K.A. Rauchfuss (1890). Currently, orotracheal and nasotracheal intubation is performed.
Purpose of intubation:
- Ensuring free passage of the airborne traffic area.
- Prevention of aspiration of vomit, laryngospasm, tongue retraction.
- Possibility of simultaneous closed cardiac massage and mechanical ventilation.
- The possibility of intratracheal administration of drugs (for example, adrenaline), after which 1-2 insufflations are made. In this case, the concentration of the drug in the blood is 2 times higher than with intravenous administration.
Intubation technique:
The prerequisites for starting intubation are: lack of consciousness, sufficient muscle relaxation.
- Maximum extension of the patient's head is performed and it is raised 10 cm from the table, the lower jaw is brought forward (improved Jackson position).
- A laryngoscope (with a straight or curved blade and a light bulb at the end) is inserted into the patient's mouth, on the side of the tongue, with the help of which the epiglottis is lifted. Carry out an inspection: if vocal cords move, then intubation cannot be performed, because you can hurt them.
- Under the control of a laryngoscope, a plastic endotracheal tube of the required diameter (for adults, usually No. 7-12) is inserted into the larynx and then into the trachea (during inhalation) and fixed there by dosed inflation of a special cuff included in the tube. Too much inflation of the cuff can lead to bedsores of the tracheal wall, and too little inflation will break the seal. If intubation is difficult, a special guide (mandrel) is inserted into the tube, which prevents the tube from twisting. You can also use special anesthetic forceps (Mazhil forceps).
- After inserting the tube, it is necessary to listen to breathing over both lungs using a phonendoscope to ensure that the tube is in the trachea and functioning.
- The tube is then connected using a special adapter to the ventilator.
Ventilators are of the following types: RO-6 (works by volume), DP-8 (works by frequency), GS-5 (works by pressure, which is considered the most progressive).
If intubation of the trachea through the mouth is impossible, intubation is performed through the nose, and if this is not possible, a tracheostomy is applied (see below)
5). Drug therapy:
- Brain protection:
Hypothermia.
Neurovegetative blockade: aminazine + droperidol.
Antihypoxants (sodium hydroxybutyrate).
Drugs that reduce the permeability of the blood-brain barrier: prednisolone, vitamin C, atropine.
- Correction of water-salt balance: saline solution, disol, trisol, etc.
- Correction of acidosis: 4% sodium bicarbonate solution.
- According to indications - antiarrhythmic drugs, calcium supplements, replenishment of blood volume.
- Adrenaline IV (1 mg every 5 minutes) - maintains blood pressure.
- Calcium chloride - increases myocardial tone.
Prediction of resuscitation effectiveness is based on the duration of the absence of breathing and blood circulation: the longer this period, the greater the likelihood of irreversible damage to the cerebral cortex.
A complex of disorders in the body (damage to the heart, kidneys, liver, lungs, brain) that develop after resuscitation is called post-resuscitation illness .
Tracheal intubation through a tracheostomy
Indications:
- Facial trauma preventing laryngoscopy.
- Severe traumatic brain injury.
- Bulbar form of polio.
- Laryngeal cancer.
Technique:
1). Treatment of the surgical field according to all the rules (Grossikh-Filonchikov method).
2). A depression corresponding to the cricoid-thyroid membrane is palpated on the neck and a transverse incision is made in the skin, pancreas and superficial fascia.
3). The median vein of the neck is retracted to the side or crossed after applying ligatures.
4). The sternothyroid muscles are pulled apart with hooks and the pretracheal tissue space is opened.
5). The isthmus of the thyroid gland is exposed and pushed back. If it is wide, you can cross it and bandage the stumps. The tracheal rings become visible.
6). The trachea is fixed with single-pronged hooks and 2-3 rings of the trachea are cut with a longitudinal incision. The wound is widened with a Trousseau tracheal dilator and a tracheostomy cannula is inserted, and through it an endotracheal tube is connected to the ventilator and ventilation with pure oxygen begins.
Resuscitation is not performed in the following cases:
1). Injuries incompatible with life (head torn off, chest crushed).
2). Reliable signs of biological death.
3). Death occurs 25 minutes before the doctor arrives.
4). If death occurs gradually from the progression of an incurable disease, against the background of intensive care.
5). If death occurred from a chronic disease in the terminal stage. At the same time, the futility of resuscitation should be recorded in the medical history.
6). If the patient has written a written refusal of resuscitation measures in advance.
Resuscitation measures are stopped in the following cases:
1). When assistance is provided by non-professionals- in the absence of signs of effectiveness of artificial respiration and blood circulation within 30 minutes during CPR.
2). If assistance is provided by resuscitators:
- If it turns out that resuscitation is not indicated for the patient (see above).
- If CPR is ineffective within 30 minutes.
- If multiple cardiac arrests occur that are not amenable to drug therapy.
The concept of euthanasia
1). Active euthanasia is the intentional killing of a terminally ill patient out of compassion.
2). Passive euthanasia- this is a refusal to use complex therapeutic methods, which, although they would prolong the patient’s life at the cost of further suffering, would not save it.
All types of euthanasia in Russia and most civilized countries are prohibited (except for Holland), regardless of the patient’s wishes, and are prosecuted by criminal law: active euthanasia - as intentional murder, passive - as criminal inaction leading to death.
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: a 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!
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 that is of fundamental importance in preparing students in medical schools oh 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 develop practical skills.
The main attention when writing a course of lectures is paid not only to the presentation of sections related to practical work nurses, but also 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.
Proposed educational material– a course of lectures on resuscitation, 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 average vocational education) and 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” dated 22.08.93, “Concepts for the development of healthcare and medical science in the Russian Federation” dated 5.11.97, in the sectoral program for the development of nursing in RF. 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 in 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.
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.
Andrianova N.V., Samushiya Yu.A. Emergency care for allergic diseases M., 1968, 108.
Akimov G.A. Nervous system in acute circulatory disorders L., 1971, 262 p.
Andreev S.V. Restoration of the activity of the human heart after his death - M., 1955, 224 p.
Arshavsky I.A., Essays on age physiology M., 1967, 474 p.
Akhunbaev I.K., Frenkel G, L. Essays on shock and collapse. Frunze, 1967, 479 p.
Bogolepov N.K. Comatose states M., 1962, 490 p.
Bunatyan A.A., Ryabov G.A., Manevich A.Z. Anesthesiology and resuscitation-M:. Medicine, 1984, 512 p.
Belskaya T.P., Kassil V.L. Organization of resuscitation service In the book: Problems of resuscitation M, 1969, p3-28.
Vishnevsky A.A., Tsukerman B.M. Electrical pulse therapy for cardiac arrhythmias - “Experimental surgery and anesthesiology”, 1966, p. 39-53.
Vorobiev V.M. The use of assisted artificial ventilation in the early period after thoracic surgery. M., 1972.
Gaevskaya M.S. Biochemistry of the brain during the dying and revival of the body - M., 1963 205 p.
Glushchenko E.V. Theory and practice of parenteral nutrition M., 1974, 53 p.
Dagaev V.I., Luzhnikov V.A. Features of the treatment of terminal conditions in acute poisoning - In the book: Fundamentals of resuscitation M., 1966, 329 pp.
Darbinyan T.M. Work of the intensive care unit at the laboratory of anesthesiology M., 1974, 55-72 p.
Dyachenko P.K. Surgical shock. L., 1968, 332 p.
Zhilis B.G. Anesthesiology in the ambulance service M., 1963, p. 183.
Ivanov V.L. The role of mechanical external cardiac massage in the treatment of clinical death from blood loss Alma-Ata, 1971.
Kolpakov M.G. Adrenal glands and resuscitation M., 1964 142 p.
Lebedeva R.N. Prevention and therapy of acute respiratory failure after thoracic operations M., 1966 363 p.
Negovsky V.A. Pathophysiology and therapy of agony and clinical death M., 1954, 230 p.
Negovsky V.A. Actual problems resuscitation M., 1971, 214 p.
Negovsky. V.A. Fundamentals of resuscitation T., “Medicine”, 1977, 590 p.
Petrovsky B.V. Transfusion therapy in surgery M., 1971, 274 p.
Seleznev V.I. Liver in the dynamics of traumatic shock L, 1971, 117 p.
Bodrov Yu. I. Lecture.
^ LECTURE No. 5.
Topic: Intensive care and resuscitation measures for damage to the central nervous system(CNS), comatose states.
“The constancy of the internal environment is an indispensable condition for the independent existence of the organism …»
K. Bernard.
In the pathology of terminal conditions, hypoxic and posthypoxic changes in the central nervous system occupy a special position, which is determined by the following circumstances:
the central nervous system in general and the higher parts of the brain in particular are the formations in the body that are most easily damaged by oxygen starvation: despite the fact that the brain at rest takes approximately 15% of the cardiac output and 15–20% of the total oxygen consumed by the body;
main functional elements of the nervous system – neurons – unlike parenchyma cells of other organs, they do not have the ability to regenerate, therefore, the death of neurons due to hypoxia is irreversible and the resulting functional disorders can be eliminated, only within certain limits due to the restructuring of the interconnections of surviving neurons;
the brain is an organ consciousness, thinking, adaptation organism to the environment, therefore brain death (further than some its departments) leads to the destruction of personality, complete psychoneurological disability, and the impossibility of independent existence;
The central nervous system coordinates the activities of all internal organs and systems and organizes all homeostasis reactions, therefore, its destruction entails gross disturbances of homeostasis and the collapse of life support systems.
To the factors of selective vulnerability of various parts of the brain, one should add the factor of the relative complexity of the function (and, accordingly, its phylogenetic “age”, V.A. Negovsky, 1954). Phylogenetically younger functions that are also more complex (for example, thinking, higher nervous activity), served a large number neural systems located at a higher anatomical level and, naturally, turn out to be more vulnerable during oxygen starvation.
To study the general patterns of decline and restoration of central nervous system functions, to compare the severity different types dying, cessation of blood circulation in the brain and throughout the body, as well as to evaluate various methods of revival, the main parameter used is ( time)
Time of function preservation, time of latent recovery, time of complete recovery, time of brain death.
Sequence of neurological disorders during dying.
The sequence of extinction of central nervous system functions during death, as well as the restoration of functions during revival, passes through a number of stages, the duration and severity of which depends mainly on the suddenness of brain hypoxia, the depth of exposure, and the level of wakefulness of the body.
All the main stages are most clearly visible as oxygen starvation of the brain increases, following a short latent period, strong motor excitation occurs, this is largely associated with excitation of the brain stem, clinically this manifests itself in the form (short-term increase in blood pressure, increased breathing, heart rate, increased muscle tone and tone of tendon reflexes) . In the next stage, motor excitation disappears, a disturbance of consciousness occurs, and then the dying person plunges into an increasingly deeper coma, gradually the pupils dilate, breathing deepens and slows down, blood pressure decreases, and the excitability of tendon reflexes decreases.
In the next stage, simultaneously with gradual depression of breathing and increasing dilation of the pupils, there is a further slowdown and decrease in the amplitude of the electrical activity of the cortex and subcortical parts of the brain (D.A. Ginzburg 1973).
Much attention paid to brain damage in terminal conditions is dictated by the fact that it is the central nervous system that often limits the timing of clinical death, after which a complete and lasting restoration of vital functions is impossible. There is evidence in the literature that the death large number neurons in the cortex occurs through 3–5 min after temporary or complete cessation of blood circulation in the brain (V.P. Kurkovsky, 1946; Ya.L. Rapoport et al., 1967, etc.).
In conditions modern life with high intensity and great neurophysical stress, cerebral circulation disorders of an ischemic or hemorrhagic nature very often occur under the general clinical name - stroke.
Hemorrhagic : A) intracerebral (hemorrhage into the brain substance - apoplexy, stroke); b) suarochnaidal – hemorrhage under the arachnoid membrane.
Ischemic: a) thrombosis ; b) embolism ; V) moving (dynamic) cerebrovascular accident.
The disease is more common in the elderly, and in recent years, in young people - it is often subarachnoid (under the membranes) hemorrhage, which can occur with rheumatism, due to the rupture of an aneurysm.
Causes hypertension, renal hypertension, cerebral atherosclerosis, blood diseases, etc. For hemorrhage – there is a violation of the vascular wall, with thrombosis – blockage of a vessel by a thrombus , embolism – blockage of a vessel by an embolus (air, oil) , in case of dynamic disturbance cerebral circulation – spasm of cerebral vessels.
Risk factors :
weather conditions;
mental trauma;
physical stress;
overheating.
physical inactivity;
hereditary predisposition.
Cerebral hemorrhage usually occurs during the day, against the background of emotional or physical stress.
Clinic:
The onset is sudden, often accompanied by loss of consciousness and the development of coma. The face is purple, the breathing is noisy, one cheek "sails" the nasolabial fold is smoothed, there is no reaction of the pupils to light. Involuntary urination and defecation. Coma can last from several hours to several days. Hemiplegia, aphasia, and sensory disturbances appear. The condition is severe, often in the first days of the disease - death. With a successful course - after 1-2 months of movement in paralyzed limbs are being restored but often hemiparesis remains for life.
Ischemic stroke. The disease develops due to a partial or complete cessation of blood flow to the brain through some vessel.
This type of stroke is typical for older people and often develops during sleep. Ischemic stroke is characterized by the presence harbingers: dizziness, headache, transient paresthesia or paresis, consciousness may be preserved but obscured.
The prognosis for ischemic stroke is more favorable than for hemorrhagic stroke.
Subarachnoid hemorrhage.
The disease develops acutely, suddenly. The patient feels a blow to the back of the head, a sharp headache, nausea, vomiting, psychomotor agitation, and sometimes convulsions. Meningeal symptoms develop and increase rapidly, temperature rises to 38-39º. The study of cerebrospinal fluid is crucial in diagnosis. (blood, increased blood pressure). After treatment (up to 2-3 months), the patient recovers and returns to work.
Dynamic (transient) cerebrovascular accident.
There is a sudden deterioration in the general condition - headache, nausea, vomiting, dizziness, stupor, and less often, loss of consciousness. These general cerebral symptoms are accompanied by focal ones - paresthesia, paresis, speech disorders. All these symptoms last from a few minutes to 24 hours. Treatment 7-14 days. Under the influence of treatment, the symptoms disappear. The disease can recur and is a harbinger of ischemic stroke.
Treatment: should begin immediately, when the nature of the stroke has not yet been established:
complete peace;
position in bed: with hemorrhagic - raise the head, with ischemic - horizontally, with vomiting - turn to the side;
regardless of the stroke, intravenously 10 ml of a 2.4% solution of aminophylline in saline (this relieves vascular spasm, reduces cerebral edema, enhances collateral circulation);
intravenous slow cardiac glycosides (CG) according to indications (strophanthin, corglycon);
for edema of the brain and lungs - intramuscularly, intravenously Lasix 2% - 1.0;
antihypertensive drugs (as indicated).
Heavy (critical) traumatic brain injury is characterized by a deep and prolonged coma, accompanied by a violation of the vital functions of the body (III-IV degrees). Terminal conditions can develop with extensive crushing of the brain substance, the formation of intracranial and intracerebral hematomas, dislocation (shift) and compression of the brain stem. The location of the damage is of great importance. Traumatic brain injury is especially severe when combined with damage to skeletal bones and internal organs. The death of patients can be caused by both direct traumatic damage to vital brain formations and subsequent complications, which primarily include respiratory disorders, cerebral edema and intracranial hypertension. Breathing disorders develop in all patients with severe brain injury. They usually occur , in the early stages after injury and may be caused by a disorder central regulation of breathing , increasing tracheobronchial obstruction and pneumonia, often of aspiration nature. Cerebral edema and increased cerebrospinal fluid pressure are rarely detected in the first hours; they usually develop , starting from 18 – 24 hours after injuries. Although in case of traumatic brain injury the prognosis is determined not so much by the severity of intracranial hypertension as by the localization and volume of injury, the level of cerebrospinal fluid pressure, and especially its dynamics, have great importance to determine resuscitation tactics. It should also not be forgotten that if intracranial pressure becomes higher than mean arterial pressure, cerebral circulation is practically blocked and the brain dies. In the clinical picture of severe traumatic brain injury along with deep coma (often accompanied by convulsions) Symptoms of local damage to the central nervous system are often detected. Breathing may be arrhythmic or sharply rapid and deep. Less commonly, bradypnea or primary respiratory arrest occurs. Blood pressure is increased in the absence of concomitant blood loss. The pulse may be slow in the first hours (especially in the presence of intracranial hematoma), then persistent tachycardia develops. Prolonged coma is accompanied by persistent hyperthermia, both of central origin and caused by purulent-septic complications. Gastrointestinal dysfunction is also common (intestinal paresis). Disturbances in water and electrolyte balance are characteristic, primarily hypokalemia. Many patients experience hypercoagulability (increased intravascular coagulation).
The primary goal of resuscitation for critical traumatic brain injury is to eliminate hypoxia And correction of acid-base balance. The method of choice is artificial pulmonary ventilation (ALV) in the mode of moderate hyperventilation, which has a pronounced therapeutic effect, reducing liquor pressure by 30% (V.A. Negovsky, 1971).
Against the background of mechanical ventilation, it is necessary to correct impaired metabolic processes. To prevent cerebral edema, maintaining the oncotic pressure of the plasma is of great importance, for which concentrated protein solutions are administered to patients. Introduction of osmotic agents (urea, manitol).
Administration of saluretics is indicated only for high intracranial pressure.
Traumatic brain injuries are divided into closed – (concussion, bruise, compression by hematoma, fragments of skull bones) , open – (gunshot, stabbed, chopped, penetrating, non-penetrating) and Fracture of the base of the skull.
A). Brain concussion (commotion): swelling, pinpoint hemorrhages, hyperemia of the meninges, and venous congestion occur.
Symptoms of injury: characterized by loss of consciousness for several minutes (sometimes without loss of consciousness). The victim complains of headaches, nausea, vomiting, and dizziness. A characteristic symptom is retrograde amnesia, i.e. loss of memory for previous events.
Treatment – inpatient 2-3 weeks. The prognosis is favorable.
b). Brain contusion (contusion) .
Distinguish – 3 degrees of injury:
- mild degree – resembles a concussion, but there are mild focal symptoms;
average degree – loss of consciousness up to several hours + focal symptoms + meningeal symptoms;
severe – loss of consciousness up to several weeks, pronounced focal symptoms and impaired vital functions. The condition of the patients is severe, rapid breathing, repeated vomiting, deep coma.
Treatment: This category of patients is carried out in the intensive care unit of the neurosurgical department from 3 weeks to 1.5-2 months.
V). Brain compression (compression):
compression occurs as a depressed fracture of the skull bones or hematoma, often combined with a brain contusion. Loss of consciousness due to compression can last up to 2 hours or without loss of consciousness.
The general condition of the patient can be characterized as satisfactory or moderate severity. The victim suffers from headaches, nausea, vomiting, and strabismus. The victim is conscious and in contact. This period is called light interval. Then, after a few hours or days (as a result of the accumulation of blood - hematoma), the condition worsens: stupor turns into coma, bradycardia increases and focal symptoms appear: paralysis, anisokaria (different pupil sizes).
Treatment: urgent hospitalization in the neurosurgical department, surgical intervention (removal of bone fragments, hematomas).
G). Fracture of the base of the skull:
With this injury, rupture of the membranes of the brain, bruise, compression, rupture of cranial nerves, and focal necrosis occurs. The victim experiences the following symptoms: loss of consciousness, nausea, vomiting, headache, bleeding and liquorrhea from the ears, nose, as well as the symptom of “glasses”.
The patient's condition is serious. Careful transportation is necessary. Urgent hospitalization in a neurosurgical or trauma department.
Treatment: surgical or conservative within 5-6 weeks.
Transportation for TBI .
Carefully remove the victim .
Convenient to lay down, free from restrictive clothing.
Transport in a horizontal position, gentle.
When vomiting, turn your head to the side.
For an open wound, treat with an antiseptic and use an aseptic bandage.
In case of bleeding from the nose and ears - toilet the nose, ears, tamponade with a sterile napkin.
Raise lower jaw to avoid tongue retraction.
It is characterized by repeated paroxysmal convulsions and is a polyetiological, chronic disease.
Provoking factors are: psychological trauma, alcohol intake, infections, flashing bright light. There are several forms of epistatus, the most dangerous being generalized status. It starts suddenly. Clonic or tonic-clonic convulsions occur, which do not stop for a long time and are accompanied by severe breathing disorders (sometimes apnea, respiratory arrest) or of the Cheyne-Stokes type. Pulmonary edema is common, aspiration of saliva and mucus into the respiratory tract is possible, blood pressure rises sharply, all this leads to severe brain damage and the longer the status lasts, the more severe and extensive the damage is (electrolyte disorders, aspiration pneumonia, acute arrhythmias are possible).
Intensive therapy.
Ensure free passage of the airways (use a mouth dilator, tongue depressor.)
Remove dentures, mucus, insert an air duct into the respiratory tract.
Put clothes under your head to prevent injury.
Anticonvulsant therapy (seduxen, sodium hydroxybutyrate, relanium sodium thiopental).
Oxygen therapy.
Fighting cerebral edema.
Preparation for spinal puncture, for artificial ventilation.
“Resuscitation is the forefront in the fight for human life.
A city deprived of intensive care units is dangerous for its inhabitants...”
Academician B.V. Petrovsky.
Coma – "hibernation", "deep sleep" - a condition characterized by a lack of consciousness, disturbances in reflex activity and the functions of vital organs and systems. Regardless of etiology coma is a consequence of damage to the central nervous system.
Consciousness – this is a function of the brain, which consists in the ability to assess the external environment, one’s own personality, orientation in time, space, situation, etc.
Types of disorders of consciousness .
A) . Stun ( stunned ) – initial variant of depression of consciousness (lethargy, drowsiness, initial disorientation, decreased mental activity). Dysarthria, ataxia. Observed: after injuries, acute poisoning, neuroinfections, as well as upon recovery from coma or stupor.
b) . Doubtfulness (doubtlessness ) – the patient is sleeping, but when exposed to external influences, he awakens, mutters something to himself, can complete the task of the health worker, even answer questions, and immediately falls asleep.
Such a disorder of consciousness can be meet: for acute poisoning with neuroleptics and sleeping pills, traumatic brain injuries.
V) . Delirious syndrome – manifested by disorders of consciousness, visual and auditory hallucinations, motor and speech agitation, and delirium. Patients rush about, scream, catch something with their hands, etc. Observed: with liver failure, various severe infections (meningitis, pneumonia), alcohol intoxication, etc.
G ). Sopor – consciousness is sharply depressed, there is no verbal contact while maintaining coordinated defensive reactions to painful stimuli, strong sound and light. There is a facial reaction to a strong painful stimulus. When calling loudly, you can get a monosyllabic answer. Involuntary urination is noted, pupillary, corneal, swallowing, cough reflexes are usually preserved. This state is close to coma.
d) . Apallic syndrome - an intermediate state between deep stupor and coma. It develops when a significant part of the cortex is destroyed, but the brain stem is preserved.
Symptoms : inability to make contact with others, lack of movement, speech, emotions, memory. Breathing, functions of cardio-vascular system practically undamaged.
Alternation of sleep and wakefulness, regardless of the time of day. The patient lies with his eyes open, a symptom of “doll eyes” (when turning the head to the right or left, the eyeballs are turned in the opposite direction). There is no coordination of eye movements, it is impossible to fix attention. The muscle tone is increased, the swallowing reflex is absent, and he reacts to pain with chaotic movements.
Any disease and damage can, if it occurs - damage to the central nervous system - lead to coma, however, it is most likely to develop with primary brain damage due to severe hypoxia, poisoning, traumatic brain injury, cerebrovascular accidents, infection, and severe metabolic disorders. There are many classifications coma - according to etiology, pathogenesis depth, characterizing the characteristics and severity of damage to the central nervous system. In the pathogenesis of coma, oxygen starvation of the entire brain or its activating structures is of great importance. It is important to subdivide the coma according to its depth. In our country, the most common classification is N.K. Bogolepova, who divided coma into four degrees : mild, pronounced, deep and terminal.
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 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
Most common reason cardiogenic shock - myocardial infarction, less often 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. At further development the hyperdynamic form turns into a hypodynamic form.
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.
General principles for the treatment of shock can be presented in the form of three steps.
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 postmortem 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 establish clinical death and begin resuscitation measures, it is sufficient first three signs: 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 according to 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 effective method may be a precordial stroke. 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 - required condition carrying out 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 limitation 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.