Emergency conditions and emergency medical care. Pre-hospital medical care in emergency conditions
Having witnessed an accident, many of us may become confused, give up, and then shed bitter tears that they could not do anything. Editorial "So simple!" I am convinced that every conscious person must know how to behave if a disaster occurs.
quality first aid in emergencies, and most importantly - the ability to competently and without trembling in the fingers to provide it, is able to save the life of both a loved one and a random passerby. All in your hands!
First aid can be provided by any person who, at a critical moment, is next to the victim. This is an important skill - an elementary but indispensable skill for every person. In one of the following situations, it can become a real lifeline for the victim.
Help in emergencies
Fainting
Fainting is an unpleasant condition familiar to many. A short-term and sudden loss of consciousness occurs due to impaired cerebral circulation. The reasons for this are completely different: fear, nervous shock, physical exhaustion or insufficient fresh air in the room. How to recognize trouble and provide the victim with the necessary first aid?
Symptoms
- Fainting may be preceded by such indicative symptoms: dizziness, nausea, severe weakness, a veil before the eyes, tinnitus, numbness in the limbs.
- When loss of consciousness occurs, the victim falls. This, by the way, is not without reason: in a horizontal position, the blood supply to the brain improves and after a while the patient safely regains consciousness without outside help.
- The victim's airway is usually free, but breathing is shallow and rare.
- A weak and rare pulse is felt.
- The skin is pale, cold sweat may appear.
First aid
- The victim must be laid on his back in the so-called trendelenburg position, when the legs are raised at an angle of 45 °, and the head and shoulders are below the level of the pelvis. If it is not possible to lay the patient on the couch, it is enough to raise the legs above ground level.
- It is necessary to immediately unfasten the squeezing parts of clothing: collar, belt, tie.
- If an unpleasant situation has occurred indoors, it is necessary to open the windows and let in fresh air.
- You can put a wet and cold towel on the victim's forehead or moisten the face with cold water, pat on the cheeks or rub the ears.
- If vomiting occurs, lay the victim's head to one side. This will help prevent vomit from entering the respiratory tract.
- An effective and most famous way to deal with fainting is ammonia. Inhalation of ammonia vapor usually helps to return the victim to consciousness.
- In no case do not lift the patient after returning to consciousness! Urgently call an ambulance, because fainting may be the result of a serious illness, and the victim in any case needs a professional examination.
heart attack
Myocardial infarction is one of the forms of coronary heart disease, which occurs as a result of necrosis of a section of the heart muscle due to a violation of its blood supply. A heart attack develops at the time of blockage of the coronary artery of the heart by a thrombus.
The causes of the disease are different: atherosclerosis, hypertension, spasm of the coronary arteries, diabetes mellitus, obesity, alcoholism. If a heart attack occurs, quality first aid in the first minutes of a heart attack can save the victim's life!
Symptoms
- The first and main symptom of a heart attack is a strong squeezing pain behind the sternum, which extends to the left shoulder, shoulder blade, arm. The pain syndrome can last more than 15 minutes, sometimes it lasts for hours and even days.
- The victim is restless, there is a fear of death.
- Nausea, vomiting are possible, the face and lips may become bluish, sticky sweat occurs.
- Shortness of breath, cough, shortness of breath, feeling of lack of air may be noted. The airways are usually free. Breathing is frequent and shallow.
- The pulse is weak, fast, sometimes intermittent. Possible cardiac arrest.
First aid
- The first thing to do is call an ambulance.
- If a person is conscious, it is necessary to seat him in a chair with a back or give him a semi-lying position, bending his knees, and let him calm down.
- It is necessary to unfasten tight clothes, loosen the pressure of a collar or tie.
- It is likely that if the victim does not have problems with the cardiovascular system for the first time, he may have medicines with him: nitroglycerin, aspirin, validol, etc. Nitroglycerin is a drug that helps relieve pain during an angina attack.
If within 3 minutes after taking nitroglycerin the pain does not subside, it means that the victim has a real heart attack that cannot be relieved with medication. This indicative symptom will help distinguish a serious problem from a simple angina attack.
- If aspirin is at hand, and the patient is not allergic to it, it is necessary to let him chew 300 mg of the drug. Exactly chew! So the medicine will work much faster.
- It is necessary to carefully monitor the breathing and work of the heart of the victim. In the event of cardiac arrest, resuscitation should be initiated immediately. Their implementation before the arrival of an ambulance increases the patient's chances of survival many times over!
In the first seconds of ventricular fibrillation can be effective precordial beat. Two sharp, intense punches are applied from a height of 30–40 cm to the sternum at the border of its middle and lower thirds. In the absence of a pulse on the carotid artery after two strokes, you should immediately proceed to chest compressions and artificial respiration.
This video explains everything stages of cardiopulmonary resuscitation affected not only by a heart attack, but also in other emergency conditions!
Stroke
A stroke is damage to brain tissue and a violation of its functions, caused by a violation of cerebral circulation. The causes of a vascular accident can be different: insufficient blood supply to one of the brain regions, cerebral hemorrhage, thrombosis or embolism associated with diseases of the blood, heart, and blood vessels.
How to identify first signs of a stroke, everyone needs to know in order to provide assistance in time, because every minute counts!
Symptoms
- Sudden unexplained headache.
- The appearance of weakness in the muscles, numbness of half or individual parts of the body (arm, leg, face).
- Visual impairment may occur, possibly double vision.
- There may be a sudden loss of balance and coordination, nausea and loss of consciousness.
- Often there is a violation or slowing of speech, the victim may sag the corner of the mouth or the pupil will be dilated on the affected side.
- If you notice the above symptoms - act immediately!
First aid
- It is necessary to call an ambulance without delay - a stroke victim needs immediate help from professionals.
- If the patient is unconscious, it is necessary to check whether he can breathe. If you find a violation of breathing - free the patient's airways by laying him on his side and cleaning the oral cavity.
- Move the patient to a comfortable position. Many people say that it is absolutely impossible to touch and move a victim of a stroke, but this is a myth!
- If possible, blood pressure should be measured and recorded.
- If the patient is conscious, it is necessary to find out how long ago the stroke occurred. In the first 3 hours from the onset of a stroke, the patient can be emergency therapy - thrombolysis.
This procedure involves giving a drug intravenously to dissolve a blood clot that has blocked a cerebral artery. In this way, brain disorders can be eliminated or significantly reduced.
- Do not give the patient water and food.
- Never give medication to a patient! Reducing the pressure is also not recommended. Hypertension in the first hours of a vascular accident is the norm associated with the adaptation of the brain.
epileptic seizure
An epileptic seizure may look quite frightening, but in reality it does not require immediate medical attention. Nevertheless, everyone should know the symptoms of an epileptic attack and the simple rules for dealing with a patient!
Symptoms
- Most often, an attack begins with an aura. Preepileptic the aura can be olfactory, visual or auditory, when the patient feels unusual smells, sounds or sees complex images. Sometimes, during an aura, a patient with epilepsy can warn others about an impending attack, thus protecting himself.
- Often from the side it seems that the attack began for no reason at all - the patient lets out a cry and falls unconscious.
- Breathing becomes difficult, lips turn blue.
- There are convulsions. Limbs tense and then relax, twitching randomly.
- Sometimes patients may bite their tongue or cheeks.
- Pupils do not react to light stimuli.
- Spontaneous bowel movements, vomiting, profuse salivation are possible. Foam may come out of the mouth.
First aid
- The first thing to do is to calm down yourself. If the patient has given notice of a possible seizure, make sure that nothing threatens him when he falls (sharp corners, hard objects, etc.)
- If the patient is not in danger during an attack, do not touch or move him. Be there for the duration of the attack.
- Do not try to restrain the victim in an attempt to stop the convulsions. This will not help him in any way, but it can cause unwanted injuries.
- Be sure to note the time of the onset of the seizure. If the attack lasts longer than 5 minutes, you need to call an ambulance. A prolonged attack can lead to irreversible damage to brain cells.
- Important! Do not put foreign objects in the patient's mouth. Many people think that during an epileptic seizure, a person's tongue can fall. Alas, this is a serious misconception. All muscles, including the tongue, are in hypertonicity during an attack.
In no case do not try to open the jaws of a person and place a solid object between them. There is a risk that during the next tension, the patient will either bite you, or get injured in the teeth, or may choke on the fragments of the object.
- When the attack stops, put the patient in a comfortable position. Make sure your breathing is back to normal: check if your airways are clear (they may be blocked by food debris or dentures).
- If during an attack the patient was injured, it is necessary to treat all wounds.
- Until a person fully returns to normal, you can not leave him unattended. If a seizure is followed by another or an attack of epilepsy happened for the first time, the patient needs to be hospitalized.
Only timely and competently provided first, and then qualified medical care. And if, God forbid, a friend, colleague or a bystander is overtaken by trouble, each of us must know what to do.
41. Principles of first aid in an emergency.
First aid- this is a set of urgent measures aimed at restoring or preserving the life and health of the victim in case of injury or sudden illness, performed directly at the scene as soon as possible after the injury (damage). It turns out, as a rule, to be non-medical workers, but people who are nearby at the time of the incident. There are four basic rules for providing first aid in emergency situations: inspection of the scene, initial examination of the victim, call for an ambulance, secondary examination of the victim.
1) Inspection of the scene. When examining the scene of an accident, pay attention to things that could threaten the life of the victim, your safety and the safety of others: exposed electrical wires, falling debris, heavy traffic, fire, smoke, noxious fumes, adverse weather conditions, the depth of a body of water or fast current, and much more. other. If you are in any danger, do not approach the victim. Call an ambulance or rescue service immediately. Try to determine the nature of the incident. Pay attention to the details that could tell you the type of injury. They are especially important if the victim is unconscious. Look for other victims at the scene. Approaching the victim, try to calm him down.
2) Initial examination of the victim. During the initial examination, it is necessary to check for signs of life of the victim. The signs of life include: the presence of a pulse, respiration, the reaction of the pupil to light and the level of consciousness. In case of breathing problems, it is necessary to carry out artificial ventilation of the lungs; in the absence of cardiac activity - cardiopulmonary resuscitation.
Carrying out artificial lung ventilation (ALV). Artificial respiration is carried out in in cases where the victim does not breathe or breathes very badly (rarely, convulsively, as if with a sob), and also if his breathing is constantly deteriorating. The most effective method of artificial respiration is the "mouth-to-mouth" or "mouth-to-nose" method, since this ensures that a sufficient volume of air enters the lungs (up to 1000-1500 ml in one breath); the air exhaled by a person is physiologically suitable for the victim to breathe. Air is blown through gauze, a handkerchief, other loose fabric or a special "air duct". This method of artificial respiration makes it easy to control the flow of air into the lungs of the victim by expanding the chest after inhalation and lowering it as a result of passive exhalation. To carry out artificial respiration, the victim should be laid on his back, unfasten clothing that restricts breathing. A complex of resuscitation measures should begin with a check, and, if necessary, with the restoration of airway patency. When the victim is unconscious, the airways may be closed with a sunken tongue, there may be vomit in the mouth, displaced prostheses, etc., which must be quickly removed with a finger, wrapped in a scarf or edge of clothing. First you need to make sure that there are no contraindications to tilting the head - a severe neck injury, fractures of the cervical vertebrae. In the absence of contraindications, airway patency testing, as well as mechanical ventilation, are carried out using the head tilt method. The assisting person is located on the side of the victim’s head, slips one hand under his neck, and with the palm of the other hand presses on his forehead, throwing his head back as much as possible. In this case, the root of the tongue rises and frees the entrance to the larynx, and the victim's mouth opens. The resuscitator leans towards the victim's face, fully covers the victim's open mouth with his lips and makes an energetic exhalation, blowing air into his mouth with some effort; at the same time, he covers the nose of the victim with his cheek or fingers of the hand located on the forehead. In this case, it is necessary to observe the chest of the victim, which rises. After lifting the chest, the injection (inflation) of air is suspended, a passive exhalation occurs in the victim, the duration of which should be approximately twice as long as the inhalation. If the victim has a well-determined pulse and only artificial respiration is necessary, then the interval between artificial breaths should be 5 seconds (12 respiratory cycles per minute). With effective artificial respiration, in addition to expanding the chest, there may be pinking of the skin and mucous membranes, as well as the exit of the victim from an unconscious state and the appearance of independent breathing. If the jaws of the victim are tightly clenched and it is not possible to open the mouth, artificial respiration "from mouth to nose" should be carried out. When the first weak breaths appear, artificial inspiration should be timed to the moment the victim begins to breathe independently. Artificial respiration is stopped after the victim recovers sufficiently deep and rhythmic independent breathing.
Carrying out cardiopulmonary resuscitation (CPR). External heart massage is an essential part of resuscitation; it provides artificial contractions of the heart muscle, restoration of blood circulation. When conducting an external heart massage, the resuscitator chooses a position to the left or right of the victim and determines the point of application of pressure. To do this, he gropes for the lower end of the sternum and, retreating two transverse fingers higher, sets the palmar surface of the hand perpendicular to the sternum. The second hand is located on top, at a right angle . It is very important that the fingers do not touch the chest. This contributes to the effectiveness of cardiac massage and significantly reduces the risk of rib fractures. Indirect massage should begin with jerky squeezing of the sternum and shifting it towards the spine by 4 ... 5 cm, lasting 0.5 s and quickly relaxing the hands, without tearing them away from the sternum. When conducting external heart massage, a common cause of failure is long pauses between pressures. External heart massage is combined with artificial respiration. This may be done by one or two rescuers.
During resuscitation by one resuscitator after every two quick injections of air into the lungs, 15 compressions of the sternum (ratio 2:15) should be done with an interval between inspiration and heart massage of 1 second.
With the participation in resuscitation of two people the breath-massage ratio is 1:5, i.e. after one deep breath, five chest compressions should be performed. During the period of artificial inspiration, do not press on the sternum to massage the heart, i.e. it is necessary to strictly alternate resuscitation operations. With the right actions for resuscitation, the skin turns pink, the pupils constrict, spontaneous breathing is restored. The pulse on the carotid arteries during the massage should be well palpable if it is determined by another person. After the restoration of cardiac activity with a well-defined own (without massage) pulse, heart massage is immediately stopped, continuing artificial respiration with weak spontaneous breathing of the victim and trying to match natural and artificial breaths. When full spontaneous breathing is restored, artificial respiration is also stopped. If your efforts have been successful and the unconscious victim has breathing and pulse, do not leave him lying on his back, except for a neck or back injury. Turn the victim on their side so that their airway is open.
3) Call an ambulance."Ambulance" should be called in any situation. Especially in cases: unconscious or with a changing level of consciousness; breathing problems (difficulty breathing or lack of it); persistent pain or pressure in the chest; lack of pulse; heavy bleeding; severe pain in the abdomen; vomiting with blood or spotting (with urine, sputum, etc.); poisoning; convulsions; severe headache or slurred speech; head, neck or back injuries; the likelihood of bone fracture; sudden movement disturbances.
4) Secondary examination of the victim. After calling an ambulance and being sure that the victim does not have conditions that threaten his life, they proceed to a secondary examination. Interview the victim and those present again about what happened, conduct a general examination. The importance of a secondary examination is to detect problems that do not pose a threat to the life of the victim directly, but can have serious consequences (the presence of bleeding, fractures, etc.) if left unattended and first aid is provided. Upon completion of the secondary examination of the victim and the provision of first aid, continue to observe signs of life until the arrival of the ambulance.
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The most important thing before the doctors arrive is to stop the influence of factors that worsen the well-being of the injured person. This step involves the elimination of life-threatening processes, for example: stopping bleeding, overcoming asphyxia.
Determine the actual status of the patient and the nature of the disease. The following aspects will help with this:
- what are the blood pressure values.
- whether visually bleeding wounds are visible;
- the patient has a pupillary reaction to light;
- whether the heart rate has changed;
- whether or not respiratory functions are preserved;
- how adequately a person perceives what is happening;
- the victim is conscious or not;
- if necessary, ensuring respiratory functions by accessing fresh air and gaining confidence that there are no foreign objects in the airways;
- carrying out non-invasive ventilation of the lungs (artificial respiration according to the "mouth to mouth" method);
- performing indirect (closed) in the absence of a pulse.
Quite often, the preservation of health and human life depends on the timely provision of high-quality first aid. In case of emergency, all victims, regardless of the type of disease, need competent emergency actions before the arrival of the medical team.
First aid for emergencies may not always be offered by qualified doctors or paramedics. Every contemporary must have the skills of pre-medical measures and know the symptoms of common diseases: the result depends on the quality and timeliness of measures, the level of knowledge, and the skills of witnesses of critical situations.
ABC algorithm
Emergency pre-medical actions involve the implementation of a set of simple therapeutic and preventive measures directly at the scene of the tragedy or near it. First aid for emergency conditions, regardless of the nature of the disease or received, has a similar algorithm. The essence of the measures depends on the nature of the symptoms manifested by the affected person (for example: loss of consciousness) and on the alleged causes of the emergency (for example: hypertensive crisis with arterial hypertension). Rehabilitation measures in the framework of first aid in emergency conditions are carried out according to uniform principles - the ABC algorithm: these are the first English letters denoting:
- Air (air);
- Breathing (breathing);
- Circulation (blood circulation).
Conditions that require emergency care are called emergencies. First aid in these cases consists in a timely and accurate assessment of the condition of the victim, giving him an optimal position and performing the necessary priority actions to ensure the patency of the respiratory tract, breathing and blood circulation.
FAINTING
Fainting is a sudden, short-term loss of consciousness due to impaired blood circulation in the brain.
Fainting can last from a few seconds to several minutes. Usually a person comes to his senses after a while. Fainting in itself is not a disease, but rather a symptom of a disease.
Fainting can be due to various reasons:
1. Sudden sharp pain, fear, nervous shocks.
They can cause an instant decrease in blood pressure, resulting in a decrease in blood flow, a violation of the blood supply to the brain, which leads to fainting.
2. General weakness of the body, sometimes aggravated by nervous exhaustion.
General weakness of the body, due to a variety of reasons, ranging from hunger, poor nutrition, and ending with constant excitement, can also lead to low blood pressure and fainting.
3. Staying in a room with insufficient oxygen.
Oxygen levels can be reduced due to the presence of a large number of people in the room, poor ventilation and air pollution from tobacco smoke. As a result, the brain receives less oxygen than it needs, and the victim faints.
4. Long stay in a standing position without movement.
This leads to stagnation of blood in the legs, a decrease in its flow to the brain and, as a result, to fainting.
Symptoms and signs of fainting:
The reaction is a short-term loss of consciousness, the victim falls. In a horizontal position, the blood supply to the brain improves and after a while the victim regains consciousness.
Breathing is rare, superficial. Blood circulation - the pulse is weak and rare.
Other signs are dizziness, tinnitus, severe weakness, veil before the eyes, cold sweat, nausea, numbness of the extremities.
First aid for fainting
1. If the airways are free, the victim is breathing and his pulse is felt (weak and rare), he must be laid on his back and his legs raised.
2. Loosen tight clothing, such as collars and waistbands.
3. Put a wet towel on the victim's forehead, or wet his face with cold water. This will lead to vasoconstriction and improve the blood supply to the brain.
4. When vomiting, the victim must be transferred to a safe position, or at least turn his head to the side so that he does not choke on vomit.
5 It must be remembered that fainting can be a manifestation of a severe, including an acute illness that requires emergency care. Therefore, the victim always needs to be examined by his doctor.
6. Do not rush to lift the victim after consciousness has returned to him. If conditions allow, the victim can be given hot tea to drink, and then help to rise and sit down. If the victim again feels faint, he must be laid on his back and raise his legs.
7. If the victim is unconscious for several minutes, most likely it is not fainting and qualified medical assistance is needed.
SHOCK
Shock is a condition that threatens the life of the victim and is characterized by insufficient blood supply to tissues and internal organs.
The blood supply to tissues and internal organs can be disrupted for two reasons:
Heart problems;
Decrease in the volume of fluid circulating in the body (heavy bleeding, vomiting, diarrhea, etc.).
Symptoms and signs of shock:
Reaction - the victim is usually conscious. However, the condition can worsen very quickly, up to loss of consciousness. This is due to a decrease in blood supply to the brain.
The airways are usually free. If there is internal bleeding, there may be a problem.
Breathing - frequent, superficial. Such breathing is explained by the fact that the body is trying to get as much oxygen as possible with a limited amount of blood.
Blood circulation - the pulse is weak and frequent. The heart tries to compensate for the decrease in circulating blood volume by speeding up the circulation. A decrease in blood volume leads to a drop in blood pressure.
Other signs are that the skin is pale, especially around the lips and earlobes, cool and clammy. This is because the blood vessels in the skin close to direct blood to vital organs such as the brain, kidneys, etc. The sweat glands also increase activity. The victim may feel thirsty, due to the fact that the brain feels a lack of fluid. Muscle weakness occurs due to the fact that blood from the muscles goes to the internal organs. There may be nausea, vomiting, chills. Chill means lack of oxygen.
First aid for shock
1. If the shock is caused by impaired blood circulation, then first of all you need to take care of the brain - to ensure the supply of oxygen to it. To do this, if damage allows, the victim must be laid on his back, his legs raised and the bleeding stopped as soon as possible.
If the victim has a head injury, then the legs cannot be raised.
The victim must be laid on his back, putting something under his head.
2. If the shock is caused by burns, then first of all it is necessary to ensure the termination of the effect of the damaging factor.
Then cool the affected area of the body, if necessary, lay the victim with raised legs and cover with something to keep warm.
3. If the shock is caused by a violation of cardiac activity, the victim must be given a semi-sitting position, placing pillows or folded clothes under his head and shoulders, as well as under his knees.
Laying the victim on his back is impractical, since in this case it will be more difficult for him to breathe. Have the victim chew an aspirin tablet.
In all these cases, it is necessary to call an ambulance and, before its arrival, monitor the condition of the victim, being ready to start cardiopulmonary resuscitation.
When assisting a victim in shock, it is unacceptable:
Move the victim, except when necessary;
Give the victim food, drink, smoke;
Leave the victim alone, except in cases where it is necessary to leave to call an ambulance;
Warm the victim with a heating pad or some other source of heat.
ANAPHYLACTIC SHOCK
Anaphylactic shock is an extensive allergic reaction of an immediate type that occurs when an allergen enters the body (insect bites, drug or food allergens).
Anaphylactic shock usually develops within seconds and is an emergency that requires immediate attention.
If anaphylactic shock is accompanied by loss of consciousness, immediate hospitalization is necessary, since the victim in this case may die within 5-30 minutes with asphyxia or after 24-48 hours or more due to severe irreversible changes in vital organs.
Sometimes a fatal outcome can occur later due to changes in the kidneys, gastrointestinal tract, heart, brain and other organs.
Symptoms and signs of anaphylactic shock:
Reaction - the victim feels anxiety, a feeling of fear, as shock develops, loss of consciousness is possible.
Airways - Swelling of the airways occurs.
Respiration - similar to asthmatic. Shortness of breath, chest tightness, cough, intermittent, difficult, may stop altogether.
Blood circulation - the pulse is weak, rapid, may not be palpable on the radial artery.
Other signs - the chest is tense, swelling of the face and neck, swelling around the eyes, redness of the skin, rash, red spots on the face.
First aid first aid for anaphylactic shock
1. If the victim is conscious, give him a semi-sitting position to facilitate breathing. It is better to put him on the floor, unbutton the collar and loosen other pressing parts of the clothing.
2. Call an ambulance.
3. If the victim is unconscious, move him to a safe position, control breathing and blood circulation and be ready to proceed with cardiopulmonary resuscitation.
ATTACK OF BRONCHIAL ASTHMA
Bronchial asthma is an allergic disease, the main manifestation of which is an asthma attack caused by impaired bronchial patency.
An attack of bronchial asthma is caused by various allergens (pollen and other substances of plant and animal origin, industrial products, etc.)
Bronchial asthma is expressed in attacks of suffocation, experienced as a painful lack of air, although in reality it is based on difficulty exhaling. The reason for this is the inflammatory narrowing of the airways caused by allergens.
Symptoms and signs of bronchial asthma:
Reaction - the victim may be alarmed, in severe attacks he cannot utter a few words in a row, he may lose consciousness.
Airways - may be narrowed.
Breathing - characterized by obstructed elongated exhalation with many wheezing wheezes, often heard at a distance. Shortness of breath, cough, initially dry, and in the end - with the separation of viscous sputum.
Blood circulation - at first the pulse is normal, then it becomes rapid. At the end of a prolonged attack, the pulse may become thready until the heart stops.
Other signs are anxiety, extreme fatigue, sweating, tension in the chest, talking in a whisper, blue skin, nasolabial triangle.
First aid for an attack of bronchial asthma
1. Remove the victim to fresh air, unfasten the collar and loosen the belt. Sit with an inclination forward and with an emphasis on the chest. In this position, the airways open.
2. If the victim has any medications, help them use them.
3. Call an ambulance immediately if:
This is the first attack;
The attack did not stop after taking the medicine;
The victim has too difficult breathing and it is difficult for him to speak;
The victim is showing signs of extreme exhaustion.
HYPERVENTILATION
Hyperventilation is an excess of lung ventilation in relation to the level of metabolism, due to deep and (or) frequent breathing and leading to a decrease in carbon dioxide and an increase in oxygen in the blood.
The cause of hyperventilation is most often panic or serious excitement caused by fear or any other reasons.
Feeling a strong excitement or panic, a person begins to breathe more often, which leads to a sharp decrease in the carbon dioxide content in the blood. Hyperventilation sets in. The victim begins in connection with this to feel even more anxiety, which leads to increased hyperventilation.
Symptoms and signs of hyperventilation:
Reaction - the victim is usually alarmed, feels confused. Airways - open, free.
Breathing is naturally deep and frequent. As hyperventilation develops, the victim breathes more and more often, but subjectively feels suffocation.
Blood circulation - does not help to recognize the cause.
Other signs - the victim feels dizzy, sore throat, tingling in the arms, legs or mouth, the heartbeat may increase. Looking for attention, help, can become hysterical, faint.
First aid for hyperventilation.
1. Bring a paper bag to the nose and mouth of the victim and ask him to breathe the air that he exhales into this bag. In this case, the victim exhales air saturated with carbon dioxide into the bag, and inhales it again.
Usually after 3-5 minutes, the level of saturation of the blood with carbon dioxide returns to normal. The respiratory center in the brain receives relevant information about this and gives a signal: to breathe more slowly and deeply. Soon the muscles of the respiratory organs relax, and the entire respiratory process returns to normal.
2. If the cause of hyperventilation was emotional arousal, it is necessary to calm the victim, restore his sense of confidence, persuade the victim to sit down and relax calmly.
ANGINA
Angina pectoris (angina pectoris) - an attack of acute pain behind the sternum, due to transient insufficiency of the coronary circulation, acute myocardial ischemia.
The cause of an attack of angina pectoris is insufficient blood supply to the heart muscle, caused by coronary insufficiency due to narrowing of the lumen of the coronary (coronary) artery of the heart with atherosclerosis, vascular spasm, or a combination of these factors.
Angina pectoris can occur due to psycho-emotional stress, which can lead to spasm of pathologically unchanged coronary arteries of the heart.
However, most often, angina pectoris still occurs when the coronary arteries narrow, which can be 50-70% of the lumen of the vessel.
Symptoms and signs of angina pectoris:
Reaction - the victim is conscious.
The airways are free.
Breathing - superficial, the victim does not have enough air.
Blood circulation - the pulse is weak and frequent.
Other signs - the main symptom of pain syndrome - its paroxysmal. Pain has a fairly clear beginning and end. By nature, the pain is compressive, pressing, sometimes in the form of a burning sensation. As a rule, it is localized behind the sternum. Characterized by irradiation of pain in the left half of the chest, in the left hand to the fingers, left shoulder blade and shoulder, neck, lower jaw.
The duration of pain in angina pectoris, as a rule, does not exceed 10-15 minutes. Usually they occur at the time of physical exertion, most often when walking, and also during stress.
First aid for angina pectoris.
1. If the attack has developed during physical exertion, it is necessary to stop the load, for example, stop.
2. Give the victim a semi-sitting position, placing pillows or folded clothing under his head and shoulders, as well as under his knees.
3. If the victim has previously had angina attacks, for the relief of which he used nitroglycerin, he can take it. For faster absorption, a nitroglycerin tablet must be placed under the tongue.
The victim should be warned that after taking nitroglycerin, there may be a feeling of fullness in the head and headache, sometimes dizziness, and, if you stand, fainting. Therefore, the victim should remain in a semi-sitting position for some time even after the pain has passed.
In the case of the effectiveness of nitroglycerin, an angina attack disappears after 2-3 minutes.
If after a few minutes after taking the drug the pain has not disappeared, you can take it again.
If, after taking the third tablet, the victim's pain does not go away and drags on for more than 10-20 minutes, it is urgent to call an ambulance, since there is a possibility of developing a heart attack.
HEART ATTACK (MYOCARDIAL INFARCTION)
Heart attack (myocardial infarction) - necrosis (necrosis) of a section of the heart muscle due to a violation of its blood supply, manifested in a violation of cardiac activity.
A heart attack occurs due to blockage of a coronary artery by a thrombus - a blood clot that forms at the site of a narrowing of the vessel during atherosclerosis. As a result, a more or less extensive area of the heart is "turned off", depending on which part of the myocardium was supplied with blood by the clogged vessel. A thrombus cuts off the supply of oxygen to the heart muscle, resulting in necrosis.
Causes of a heart attack can be:
Atherosclerosis;
Hypertonic disease;
Physical activity in combination with emotional stress - vasospasm during stress;
Diabetes mellitus and other metabolic diseases;
genetic predisposition;
Environmental influence, etc.
Symptoms and signs of a heart attack (heart attack):
Reaction - in the initial period of a painful attack, restless behavior, often accompanied by a fear of death, in the future, loss of consciousness is possible.
The airways are usually free.
Breathing - frequent, shallow, may stop. In some cases, asthma attacks are observed.
Blood circulation - the pulse is weak, fast, may be intermittent. Possible cardiac arrest.
Other signs are severe pain in the region of the heart, usually occurring suddenly, more often behind the sternum or to the left of it. The nature of the pain is compressive, pressing, burning. Usually it radiates to the left shoulder, arm, shoulder blade. Often, with a heart attack, unlike angina pectoris, pain spreads to the right of the sternum, sometimes captures the epigastric region and "gives" to both shoulder blades. The pain is growing. The duration of a painful attack during a heart attack is calculated in tens of minutes, hours, and sometimes days. There may be nausea and vomiting, the face and lips may turn blue, severe sweating. The victim may lose the ability to speak.
First aid for a heart attack.
1. If the victim is conscious, give him a semi-sitting position, placing pillows or folded clothes under his head and shoulders, as well as under his knees.
2. Give the victim an aspirin tablet and ask him to chew it.
3. Loosen the squeezing parts of the clothing, especially at the neck.
4. Immediately call an ambulance.
5. If the victim is unconscious but breathing, put him in a safe position.
6. Control breathing and blood circulation, in case of cardiac arrest, immediately begin cardiopulmonary resuscitation.
STROKE
A stroke is an acute circulatory disorder in the brain or spinal cord caused by a pathological process with the development of persistent symptoms of damage to the central nervous system.
The cause of a stroke can be a hemorrhage in the brain, cessation or weakening of the blood supply to any part of the brain, blockage of the vessel by a thrombus or embolus (a thrombus is a dense blood clot in the lumen of a blood vessel or heart cavity, formed in vivo; an embolus is a substrate circulating in the blood, not normally occurring and capable of causing blockage of blood vessels).
Strokes are more common in the elderly, although they can occur at any age. More commonly seen in men than in women. About 50% of those affected by a stroke die. Of those who survive, about 50% become crippled and have another stroke weeks, months, or years later. However, many stroke survivors regain their health through rehabilitation measures.
Symptoms and signs of a stroke:
The reaction is confused consciousness, there may be a loss of consciousness.
The airways are free.
Breathing - slow, deep, noisy, wheezing.
Blood circulation - the pulse is rare, strong, with good filling.
Other signs are a severe headache, the face may turn red, become dry, hot, speech disturbances or slowdowns may be observed, the corner of the lips may sag even if the victim is conscious. The pupil on the affected side may be dilated.
With a slight lesion, weakness, with a significant one, complete paralysis.
First aid for stroke
1. Call for qualified medical assistance immediately.
2. If the victim is unconscious, check if the airways are open, restore airway patency if it is broken. If the victim is unconscious, but breathing, move him to a safe position on the side of the injury (to the side where the pupil is dilated). In this case, the weakened or paralyzed part of the body will remain at the top.
3. Be prepared for rapid deterioration and CPR.
4. If the victim is conscious, lay him on his back with something under his head.
5. The victim may have a micro-stroke, in which there is a slight speech disorder, slight clouding of consciousness, slight dizziness, muscle weakness.
In this case, when providing first aid, you should try to protect the victim from falling, calm and support him and immediately call an ambulance. To control DP - D - K and be ready to provide emergency assistance.
epileptic seizure
Epilepsy is a chronic disease caused by damage to the brain, manifested by repeated convulsive or other seizures and is accompanied by a variety of personality changes.
An epileptic seizure is caused by excessively intense excitation of the brain, which is due to an imbalance in the human bioelectrical system. Typically, a group of cells in one part of the brain loses electrical stability. This creates a strong electrical discharge that rapidly spreads to the surrounding cells, disrupting their normal functioning.
Electrical phenomena can affect the entire brain or only part of it. Accordingly, there are major and minor epileptic seizures.
A minor epileptic seizure is a short-term disturbance of brain activity, leading to a temporary loss of consciousness.
Symptoms and signs of a small epileptic seizure:
The reaction is a temporary loss of consciousness (from a few seconds to a minute). The airways are open.
Breathing is normal.
Blood circulation - pulse normal.
Other signs are an unseeing gaze, repetitive or twitching movements of individual muscles (head, lips, arms, etc.).
A person comes out of such a seizure as suddenly as he enters it, and he continues the interrupted actions, not realizing that a seizure has occurred to him.
First aid for a small epileptic seizure
1. Eliminate the danger, seat the victim and calm him down.
2. When the victim wakes up, tell him about the seizure, as this may be his first seizure and the victim does not know about the disease.
3. If this is your first seizure, see your doctor.
A grand mal seizure is a sudden loss of consciousness accompanied by severe convulsions (convulsions) of the body and limbs.
Symptoms and signs of a grand mal seizure:
Reaction - begins with sensations close to euphoric (unusual taste, smell, sound), then loss of consciousness.
The airways are free.
Breathing - may stop, but recovers quickly. Blood circulation - pulse normal.
Other signs - usually the victim falls to the floor without consciousness, he begins to have sharp convulsive movements of the head, arms and legs. There may be a loss of control over physiological functions. The tongue is bitten, the face turns pale, then becomes bluish. The pupils do not react to light. Foam may come out of the mouth. The total duration of the seizure ranges from 20 seconds to 2 minutes.
First aid for a major epileptic seizure
1. Noticing that someone is on the verge of a seizure, you must try to make sure that the victim does not harm himself when falling.
2. Make room around the victim and put something soft under his head.
3. Loosen clothing around the victim's neck and chest.
4. Do not try to restrain the victim. If his teeth are clenched, do not try to open his jaws. Do not try to put something in the victim's mouth, as this can lead to trauma to the teeth and block the airways with their fragments.
5. After the cessation of convulsions, transfer the victim to a safe position.
6. Treat all injuries sustained by the victim during the seizure.
7. After the seizure has stopped, the victim must be hospitalized if:
The attack happened for the first time;
There was a series of seizures;
There are damages;
The victim was unconscious for more than 10 minutes.
HYPOGLYCEMIA
Hypoglycemia - low blood glucose Hypoglycemia can occur in a diabetic patient.
Diabetes is a disease in which the body does not produce enough of the hormone insulin, which regulates the amount of sugar in the blood.
If the brain does not receive enough sugar, then, just as with a lack of oxygen, brain functions are impaired.
Hypoglycemia can occur in a diabetic patient for three reasons:
1) the victim injected insulin, but did not eat on time;
2) with excessive or prolonged physical activity;
3) with an overdose of insulin.
Symptoms and signs of hypoglycemia:
The reaction is confused consciousness, loss of consciousness is possible.
Respiratory tract - clean, free. Breathing - rapid, superficial. Blood circulation - a rare pulse.
Other signs are weakness, drowsiness, dizziness. Feeling of hunger, fear, pallor of the skin, profuse sweat. Visual and auditory hallucinations, muscle tension, trembling, convulsions.
First aid for hypoglycemia
1. If the victim is conscious, give him a relaxed position (lying or sitting).
2. Give the victim a sugar drink (two tablespoons of sugar in a glass of water), a sugar cube, chocolate or sweets, you can caramel or cookies. The sweetener doesn't help.
3. Provide rest until the condition is completely normal.
4. If the victim has lost consciousness, transfer him to a safe position, call an ambulance and monitor the condition, be ready to proceed with cardiopulmonary resuscitation.
POISONING
Poisoning - intoxication of the body caused by the action of substances entering it from the outside.
Poisonous substances can enter the body in various ways. There are different classifications of poisoning. So, for example, poisoning can be classified according to the conditions for the entry of toxic substances into the body:
During a meal;
Through the respiratory tract;
through the skin;
When bitten by an animal, insect, snake, etc.;
through mucous membranes.
Poisoning can be classified according to the type of poisoning:
food poisoning;
medicinal poisoning;
Alcohol poisoning;
Chemical poisoning;
gas poisoning;
Poisoning caused by bites of insects, snakes, animals.
The task of first aid is to prevent further exposure to the poison, to accelerate its removal from the body, to neutralize the remains of the poison and to support the activity of the affected organs and body systems.
To solve this problem, you need:
1. Take care of yourself so as not to get poisoned, otherwise you will need help yourself, and the victim will have no one to help.
2. Check the reaction, respiratory tract, breathing and blood circulation of the victim, if necessary, take appropriate measures.
5. Call an ambulance.
4. If possible, set the type of poison. If the victim is conscious, ask him about what happened. If unconscious - try to find witnesses of the incident, or packaging from toxic substances or some other signs.
SUDDEN DEATH
Diagnostics. Lack of consciousness and pulse on the carotid arteries, a little later - the cessation of breathing.
In the process of carrying out CPR - according to the ECP, ventricular fibrillation (in 80% of cases), asystole or electromechanical dissociation (in 10-20% of cases). If emergency ECG registration is not possible, they are guided by the manifestations of the onset of clinical death and the response to CPR.
Ventricular fibrillation develops suddenly, the symptoms appear sequentially: the disappearance of the pulse in the carotid arteries and loss of consciousness; a single tonic contraction of the skeletal muscles; violations and respiratory arrest. The response to timely CPR is positive, to the termination of CPR - fast negative.
With advanced SA- or AV-blockade, the symptoms develop relatively gradually: clouding of consciousness => motor excitation => moaning => tonic-clonic convulsions => respiratory disorders (MAS syndrome). When conducting a closed heart massage - a quick positive effect that persists for some time after the cessation of CPR.
Electromechanical dissociation in massive PE occurs suddenly (often at the time of physical exertion) and is manifested by the cessation of breathing, the absence of consciousness and pulse on the carotid arteries, and a sharp cyanosis of the skin of the upper half of the body. swelling of the neck veins. With the timely start of CPR, signs of its effectiveness are determined.
Electromechanical dissociation in myocardial rupture, cardiac tamponade develops suddenly (often after severe anginal syndrome), without convulsive syndrome, there are no signs of CPR effectiveness. Hypostatic spots quickly appear on the back.
Electromechanical dissociation due to other causes (hypovolemia, hypoxia, tension pneumothorax, drug overdose, progressive cardiac tamponade) does not occur suddenly, but develops against the background of the progression of the corresponding symptoms.
Urgent care :
1. With ventricular fibrillation and the impossibility of immediate defibrillation:
Apply a precordial strike: Cover the xiphoid process with two fingers to protect it from damage. It is located at the bottom of the sternum, where the lower ribs converge, and can break off with a sharp blow and injure the liver. Inflict a pericardial blow with the edge of a palm clenched into a fist slightly above the xiphoid process covered with fingers. It looks like this: with two fingers of one hand you cover the xiphoid process, and with the fist of the other hand strike (while the elbow of the hand is directed along the body of the victim).
After that, check the pulse on the carotid artery. If the pulse does not appear, then your actions are not effective.
No effect - start CPR immediately, ensure that defibrillation is possible as soon as possible.
2. Closed heart massage should be performed at a frequency of 90 per 1 min with a compression-decompression ratio of 1:1: the method of active compression-decompression (using a cardiopamp) is more effective.
3. GOING in an accessible way (the ratio of massage movements and breathing is 5:1, and with the work of one doctor - 15:2), ensure the patency of the airways (tilt back the head, push the lower jaw, insert the air duct, sanitize the airways according to indications);
Use 100% oxygen:
Intubate the trachea (no more than 30 s);
Do not interrupt cardiac massage and ventilation for more than 30 s.
4. Catheterize a central or peripheral vein.
5. Adrenaline 1 mg every 3 minutes of CPR (how to administer here and below - see note).
6. As soon as possible - defibrillation 200 J;
No effect - defibrillation 300 J:
No effect - defibrillation 360 J:
No effect - see point 7.
7. Act according to the scheme: the drug - heart massage and mechanical ventilation, after 30-60 s - defibrillation 360 J:
Lidocaine 1.5 mg/kg - defibrillation 360 J:
No effect - after 3 minutes, repeat the injection of lidocaine at the same dose and defibrillation of 360 J:
No effect - Ornid 5 mg/kg - defibrillation 360 J;
No effect - after 5 minutes, repeat the injection of Ornid at a dose of 10 mg / kg - defibrillation 360 J;
No effect - novocainamide 1 g (up to 17 mg / kg) - defibrillation 360 J;
No effect - magnesium sulfate 2 g - defibrillation 360 J;
In pauses between discharges, conduct a closed heart massage and mechanical ventilation.
8. With asystole:
If it is impossible to accurately assess the electrical activity of the heart (do not exclude the atonic stage of ventricular fibrillation) - act. as in ventricular fibrillation (items 1-7);
If asystole is confirmed in two ECG leads, perform steps. 2-5;
No effect - atropine after 3-5 minutes, 1 mg until an effect is obtained or a total dose of 0.04 mg / kg is reached;
EKS as soon as possible;
Correct the possible cause of asystole (hypoxia, hypo- or hyperkalemia, acidosis, drug overdose, etc.);
The introduction of 240-480 mg of aminophylline can be effective.
9. With electromechanical dissociation:
Execute pp. 2-5;
Identify and correct its possible cause (massive PE - see relevant recommendations: cardiac tamponade - pericardiocentesis).
10. Monitor vital functions (heart monitor, pulse oximeter).
11. Hospitalize after possible stabilization of the condition.
12. CPR may be terminated if:
In the course of the procedure, it turned out that CPR is not indicated:
There is a persistent asystole that is not amenable to drug exposure, or multiple episodes of asystole:
When using all available methods, there is no evidence of effective CPR within 30 minutes.
13. CPR may not be started:
In the terminal stage of an incurable disease (if the futility of CPR is documented in advance);
If more than 30 minutes have passed since the cessation of blood circulation;
With a previously documented refusal of the patient from CPR.
After defibrillation: asystole, ongoing or recurrent ventricular fibrillation, skin burn;
With mechanical ventilation: overflow of the stomach with air, regurgitation, aspiration of gastric contents;
With tracheal intubation: laryngo- and bronchospasm, regurgitation, damage to the mucous membranes, teeth, esophagus;
With closed heart massage: fracture of the sternum, ribs, lung damage, tension pneumothorax;
When puncturing the subclavian vein: bleeding, puncture of the subclavian artery, lymphatic duct, air embolism, tension pneumothorax:
With intracardiac injection: the introduction of drugs into the myocardium, damage to the coronary arteries, hemotamponade, lung injury, pneumothorax;
Respiratory and metabolic acidosis;
Hypoxic coma.
Note. In case of ventricular fibrillation and the possibility of immediate (within 30 s) defibrillation - defibrillation of 200 J, then proceed according to paragraphs. 6 and 7.
All drugs during CPR should be given rapidly intravenously.
When using a peripheral vein, mix the preparations with 20 ml of isotonic sodium chloride solution.
In the absence of venous access, adrenaline, atropine, lidocaine (increasing the recommended dose by 2 times) should be injected into the trachea in 10 ml of isotonic sodium chloride solution.
Intracardiac injections (with a thin needle, with strict observance of the technique of administration and control) are permissible in exceptional cases, with the absolute impossibility of using other routes of drug administration.
Sodium bicarbonate at 1 mmol / kg (4% solution - 2 ml / kg), then at 0.5 mmol / kg every 5-10 minutes, apply with very long CPR or with hyperkalemia, acidosis, an overdose of tricyclic antidepressants, hypoxic lactic acidosis that preceded the cessation of blood circulation ( exclusively under conditions of adequate ventilation1).
Calcium preparations are indicated only for severe initial hyperkalemia or an overdose of calcium antagonists.
In treatment-resistant ventricular fibrillation, reserve drugs are amiodarone and propranolol.
In case of asystole or electromechanical dissociation after tracheal intubation and administration of drugs, if the cause cannot be eliminated, decide on the termination of resuscitation measures, taking into account the time elapsed from the onset of circulatory arrest.
CARDIAC EMERGENCIES tachyarrhythmias
Diagnostics. Severe tachycardia, tachyarrhythmia.
Differential Diagnosis- ECG. It is necessary to distinguish between non-paroxysmal and paroxysmal tachycardias: tachycardia with a normal duration of the OK8 complex (supraventricular tachycardia, atrial fibrillation and flutter) and tachycardia with a wide complex of 9K8 on the ECG (supraventricular tachycardia, atrial fibrillation, atrial flutter with transient or permanent blockade of the bundle leg P1ca: antidromic supraventricular tachycardia ; atrial fibrillation in the syndrome of IgP\V; ventricular tachycardia).
Urgent care
Emergency restoration of sinus rhythm or correction of heart rate is indicated for tachyarrhythmias complicated by acute circulatory disorders, with a threat of cessation of blood circulation, or with repeated paroxysms of tachyarrhythmias with a known method of suppression. In other cases, it is necessary to provide intensive monitoring and planned treatment (emergency hospitalization).
1. In case of cessation of blood circulation - CPR according to the recommendations of “Sudden Death”.
2. Shock or pulmonary edema (caused by tachyarrhythmia) are absolute vital indications for EIT:
Carry out oxygen therapy;
If the patient's condition allows, then premedicate (fentanyl 0.05 mg or promedol 10 mg intravenously);
Enter into drug sleep (diazepam 5 mg intravenously and 2 mg every 1-2 minutes before falling asleep);
Control your heart rate:
Perform EIT (with atrial flutter, supraventricular tachycardia, start with 50 J; with atrial fibrillation, monomorphic ventricular tachycardia - from 100 J; with polymorphic ventricular tachycardia - from 200 J):
If the patient's condition allows, synchronize the electrical impulse during EIT with the K wave on the ECL
Use well-moistened pads or gel;
At the moment of applying the discharge, press the electrodes against the chest wall with force:
Apply a discharge at the moment of exhalation of the patient;
Comply with safety regulations;
No effect - repeat EIT, doubling the discharge energy:
No effect - repeat EIT with a maximum energy discharge;
No effect - inject an antiarrhythmic drug indicated for this arrhythmia (see below) and repeat EIT with a maximum energy discharge.
3. In case of clinically significant circulatory disorders (arterial hypotension, anginal pain, increasing heart failure or neurological symptoms) or in case of repeated paroxysms of arrhythmia with a known method of suppression, urgent drug therapy should be carried out. In the absence of effect, deterioration of the condition (and in the cases indicated below - and as an alternative to drug treatment) - EIT (p. 2).
3.1. With paroxysm of reciprocal supraventricular tachycardia:
Massage of the carotid sinus (or other vagal techniques);
No effect - inject ATP 10 mg intravenously with a push:
No effect - after 2 minutes ATP 20 mg intravenously with a push:
No effect - after 2 minutes verapamil 2.5-5 mg intravenously:
No effect - after 15 minutes verapamil 5-10 mg intravenously;
A combination of ATP or verapamil administration with vagal techniques may be effective:
No effect - after 20 minutes novocainamide 1000 mg (up to 17 mg / kg) intravenously at a rate of 50-100 mg / min (with a tendency to arterial hypotension - in one syringe with 0.25-0.5 ml of 1% mezaton solution or 0.1-0.2 ml of 0.2% norepinephrine solution).
3.2. With paroxysmal atrial fibrillation to restore sinus rhythm:
Novocainamide (clause 3.1);
With a high initial heart rate: first intravenously 0.25-0.5 mg of digoxin (strophanthin) and after 30 minutes - 1000 mg of novocainamide. To reduce heart rate:
Digoxin (strophanthin) 0.25-0.5 mg, or verapamil 10 mg intravenously slowly or 80 mg orally, or digoxin (strophanthin) intravenously and verapamil orally, or anaprilin 20-40 mg under the tongue or inside.
3.3. With paroxysmal atrial flutter:
If EIT is not possible, decrease in heart rate with the help of digoxin (strophanthin) and (or) verapamil (section 3.2);
To restore sinus rhythm, novo-cainamide after a preliminary injection of 0.5 mg of digoxin (strophanthin) may be effective.
3.4. With paroxysm of atrial fibrillation against the background of IPU syndrome:
Intravenous slow novocainamide 1000 mg (up to 17 mg/kg), or amiodarone 300 mg (up to 5 mg/kg). or rhythmylen 150 mg. or aimalin 50 mg: either EIT;
cardiac glycosides. blockers of p-adrenergic receptors, calcium antagonists (verapamil, diltazem) are contraindicated!
3.5. With paroxysm of antidromic reciprocal AV tachycardia:
Intravenously slowly novocainamide, or amiodarone, or aymalin, or rhythmylen (section 3.4).
3.6. In case of tactic arrhythmias against the background of SSSU to reduce heart rate:
Intravenously slowly 0.25 mg of digoxin (strophan tin).
3.7. With paroxysmal ventricular tachycardia:
Lidocaine 80-120 mg (1-1.5 mg/kg) and every 5 minutes at 40-60 mg (0.5-0.75 mg/kg) slowly intravenously until the effect or a total dose of 3 mg/kg is reached:
No effect - EIT (p. 2). or novocainamide. or amiodarone (section 3.4);
No effect - EIT or magnesium sulfate 2 g intravenously very slowly:
No effect - EIT or Ornid 5 mg/kg intravenously (for 5 minutes);
No effect - EIT or after 10 minutes Ornid 10 mg/kg intravenously (for 10 minutes).
3.8. With bidirectional spindle tachycardia.
EIT or intravenously slowly introduce 2 g of magnesium sulfate (if necessary, magnesium sulfate is administered again after 10 minutes).
3.9. In case of paroxysm of tachycardia of unknown origin with wide complexes 9K5 on the ECG (if there are no indications for EIT), administer intravenous lidocaine (section 3.7). no effect - ATP (p. 3.1) or EIT, no effect - novocainamide (p. 3.4) or EIT (p. 2).
4. In all cases of acute cardiac arrhythmia (except for repeated paroxysms with restored sinus rhythm), emergency hospitalization is indicated.
5. Continuously monitor heart rate and conduction.
Cessation of blood circulation (ventricular fibrillation, asystole);
MAC syndrome;
Acute heart failure (pulmonary edema, arrhythmic shock);
arterial hypotension;
Respiratory failure with the introduction of narcotic analgesics or diazepam;
Skin burns during EIT:
Thromboembolism after EIT.
Note. Emergency treatment of arrhythmias should be carried out only according to the indications given above.
If possible, the cause of the arrhythmia and its supporting factors should be addressed.
Emergency EIT with heart rate less than 150 in 1 min is usually not indicated.
With severe tachycardia and no indications for urgent restoration of sinus rhythm, it is advisable to reduce the heart rate.
If there are additional indications, before the introduction of antiarrhythmic drugs, potassium and magnesium preparations should be used.
With paroxysmal atrial fibrillation, the appointment of 200 mg of phencarol inside can be effective.
An accelerated (60-100 beats per minute) idioventricular or AV junctional rhythm is usually replacement, and antiarrhythmic drugs are not indicated in these cases.
To provide emergency care for repeated, habitual paroxysms of tachyarrhythmia should take into account the effectiveness of the treatment of previous paroxysms and factors that can change the patient's response to the introduction of antiarrhythmic drugs that helped him before.
BRADIARRHYTHMIAS
Diagnostics. Severe (heart rate less than 50 per minute) bradycardia.
Differential Diagnosis- ECG. Sinus bradycardia, SA node arrest, SA and AV block should be differentiated: AV block should be distinguished by degree and level (distal, proximal); in the presence of an implanted pacemaker, it is necessary to evaluate the effectiveness of stimulation at rest, with a change in body position and load.
Urgent care . Intensive therapy is necessary if bradycardia (heart rate less than 50 beats per minute) causes MAC syndrome or its equivalents, shock, pulmonary edema, arterial hypotension, anginal pain, or there is a progressive decrease in heart rate or an increase in ectopic ventricular activity.
2. With MAS syndrome or bradycardia that caused acute heart failure, arterial hypotension, neurological symptoms, anginal pain, or with a progressive decrease in heart rate or an increase in ectopic ventricular activity:
Lay the patient with the lower limbs raised at an angle of 20 ° (if there is no pronounced stagnation in the lungs):
Carry out oxygen therapy;
If necessary (depending on the patient's condition) - closed heart massage or rhythmic tapping on the sternum ("fist rhythm");
Administer atropine 1 mg intravenously every 3-5 minutes until an effect is obtained or a total dose of 0.04 mg/kg is reached;
No effect - immediate endocardial percutaneous or transesophageal pacemaker:
There is no effect (or there is no possibility of conducting an EX-) - intravenous slow jet injection of 240-480 mg of aminophylline;
No effect - dopamine 100 mg or adrenaline 1 mg in 200 ml of 5% glucose solution intravenously; gradually increase the infusion rate until the minimum sufficient heart rate is reached.
3. Continuously monitor heart rate and conduction.
4. Hospitalize after possible stabilization of the condition.
The main dangers in complications:
asystole;
Ectopic ventricular activity (up to fibrillation), including after the use of adrenaline, dopamine. atropine;
Acute heart failure (pulmonary edema, shock);
Arterial hypotension:
Anginal pain;
Impossibility or inefficiency of EX-
Complications of endocardial pacemaker (ventricular fibrillation, perforation of the right ventricle);
Pain during transesophageal or percutaneous pacemaker.
UNSTABLE ANGINA
Diagnostics. The appearance of frequent or severe anginal attacks (or their equivalents) for the first time, a change in the course of pre-existing angina pectoris, the resumption or appearance of angina pectoris in the first 14 days of myocardial infarction, or the appearance of anginal pain for the first time at rest.
There are risk factors for the development or clinical manifestations of coronary artery disease. Changes on the ECG, even at the height of the attack, may be vague or absent!
Differential diagnosis. In most cases - with prolonged exertional angina, acute myocardial infarction, cardialgia. extracardiac pain.
Urgent care
1. Shown:
Nitroglycerin (tablets or aerosol 0.4-0.5 mg under the tongue repeatedly);
oxygen therapy;
Correction of blood pressure and heart rate:
Propranolol (anaprilin, inderal) 20-40 mg orally.
2. With anginal pain (depending on its severity, age and condition of the patient);
Morphine up to 10 mg or neuroleptanalgesia: fentanyl 0.05-0.1 mg or promedol 10-20 mg with 2.5-5 mg droperidol intravenously fractionally:
With insufficient analgesia - intravenously 2.5 g of analgin, and with high blood pressure - 0.1 mg of clonidine.
5000 IU of heparin intravenously. and then drip 1000 IU / h.
5. Hospitalize after possible stabilization of the condition. Main dangers and complications:
Acute myocardial infarction;
Acute violations of the heart rhythm or conduction (up to sudden death);
Incomplete elimination or recurrence of anginal pain;
Arterial hypotension (including drug);
Acute heart failure:
Respiratory disorders with the introduction of narcotic analgesics.
Note. Emergency hospitalization is indicated, regardless of the presence of ECG changes, in intensive care units (wards), departments for the treatment of patients with acute myocardial infarction.
It is necessary to ensure constant monitoring of heart rate and blood pressure.
For emergency care (in the first hours of the disease or in case of complications), catheterization of a peripheral vein is indicated.
In case of recurrent anginal pain or moist rales in the lungs, nitroglycerin should be administered intravenously by drip.
For the treatment of unstable angina, the rate of intravenous heparin administration must be selected individually, achieving a stable increase in activated partial thromboplastin time by 2 times compared to its normal value. It is much more convenient to use low molecular weight heparin enoxaparin (Clexane). 30 mg of Clexane is administered intravenously by stream, after which the drug is administered subcutaneously at 1 mg/kg 2 times a day for 3-6 days.
If traditional narcotic analgesics are not available, then 1-2 mg of butorphanol or 50-100 mg of tramadol with 5 mg of droperidol and (or) 2.5 g of analgin with 5 mg of diaepam can be prescribed intravenously slowly or fractionally.
MYOCARDIAL INFARCTION
Diagnostics. Characterized by chest pain (or its equivalents) with irradiation to the left (sometimes to the right) shoulder, forearm, shoulder blade, neck. lower jaw, epigastric region; heart rhythm and conduction disturbances, blood pressure instability: the reaction to nitroglycerin is incomplete or absent. Other variants of the onset of the disease are less commonly observed: asthmatic (cardiac asthma, pulmonary edema). arrhythmic (fainting, sudden death, MAC syndrome). cerebrovascular (acute neurological symptoms), abdominal (pain in the epigastric region, nausea, vomiting), asymptomatic (weakness, vague sensations in the chest). In the anamnesis - risk factors or signs of coronary artery disease, the appearance for the first time or a change in habitual anginal pain. ECG changes (especially in the first hours) may be vague or absent! After 3-10 hours from the onset of the disease - a positive test with troponin-T or I.
Differential diagnosis. In most cases - with prolonged angina, unstable angina, cardialgia. extracardiac pain. PE, acute diseases of the abdominal organs (pancreatitis, cholecystitis, etc.), dissecting aortic aneurysm.
Urgent care
1. Shown:
Physical and emotional peace:
Nitroglycerin (tablets or aerosol 0.4-0.5 mg under the tongue repeatedly);
oxygen therapy;
Correction of blood pressure and heart rate;
Acetylsalicylic acid 0.25 g (chew);
Propranolol 20-40 mg orally.
2. For pain relief (depending on the severity of pain, the age of the patient, his condition):
Morphine up to 10 mg or neuroleptanalgesia: fentanyl 0.05-0.1 mg or promedol 10-20 mg with 2.5-5 mg droperidol intravenously fractionally;
With insufficient analgesia - intravenously 2.5 g of analgin, and against the background of high blood pressure - 0.1 mg of clonidine.
3. To restore coronary blood flow:
In case of transmural myocardial infarction with a rise in the 8T segment on the ECG (in the first 6, and with recurrent pain - up to 12 hours from the onset of the disease), inject streptokinase 1,500,000 IU intravenously as soon as possible over 30 minutes:
In case of subendocardial myocardial infarction with depression of the 8T segment on the ECG (or the impossibility of thrombolytic therapy), 5000 IU of heparin should be administered intravenously as soon as possible, and then drip.
4. Continuously monitor heart rate and conduction.
5. Hospitalize after possible stabilization of the condition.
Main dangers and complications:
Acute cardiac arrhythmias and conduction disorders up to sudden death (ventricular fibrillation), especially in the first hours of myocardial infarction;
Recurrence of anginal pain;
Arterial hypotension (including medication);
Acute heart failure (cardiac asthma, pulmonary edema, shock);
arterial hypotension; allergic, arrhythmic, hemorrhagic complications with the introduction of streptokinase;
Respiratory disorders with the introduction of narcotic analgesics;
Myocardial rupture, cardiac tamponade.
Note. For emergency care (in the first hours of the disease or with the development of complications), catheterization of a peripheral vein is indicated.
With recurrent anginal pain or moist rales in the lungs, nitroglycerin should be administered intravenously by drip.
With an increased risk of developing allergic complications, 30 mg of prednisolone should be administered intravenously before the appointment of streptokinase. When conducting thrombolytic therapy, ensure control over the heart rate and basic hemodynamic parameters, readiness to correct possible complications (presence of a defibrillator, a ventilator).
For the treatment of subendocardial (with 8T segment depression and without pathological O wave) myocardial infarction, the rate of intravenous administration of gegyurin must be selected individually, achieving a stable increase in activated partial thromboplastin time by 2 times compared to its normal value. It is much more convenient to use low molecular weight heparin enoxaparin (Clexane). 30 mg of Clexane is administered intravenously by stream, after which the drug is administered subcutaneously at 1 mg/kg 2 times a day for 3-6 days.
If traditional narcotic analgesics are not available, then 1-2 mg of butorphanol or 50-100 mg of tramadol with 5 mg of droperidol and (or) 2.5 g of analgin with 5 mg of diaepam can be prescribed intravenously slowly or fractionally.
CARDIOGENIC PULMONARY EDEMA
Diagnostics. Characteristic: suffocation, shortness of breath, aggravated in the prone position, which forces patients to sit down: tachycardia, acrocyanosis. tissue hyperhydration, inspiratory dyspnea, dry wheezing, then moist rales in the lungs, abundant foamy sputum, ECG changes (hypertrophy or overload of the left atrium and ventricle, blockade of the left leg of the Pua bundle, etc.).
History of myocardial infarction, malformation or other heart disease. hypertension, chronic heart failure.
Differential diagnosis. In most cases, cardiogenic pulmonary edema is differentiated from non-cardiogenic (with pneumonia, pancreatitis, cerebrovascular accident, chemical damage to the lungs, etc.), pulmonary embolism, bronchial asthma.
Urgent care
1. General activities:
oxygen therapy;
Heparin 5000 IU intravenous bolus:
Correction of heart rate (with a heart rate of more than 150 in 1 min - EIT. with a heart rate of less than 50 in 1 min - EX);
With abundant foam formation - defoaming (inhalation of a 33% solution of ethyl alcohol or intravenously 5 ml of a 96% solution of ethyl alcohol and 15 ml of a 40% glucose solution), in extremely severe (1) cases, 2 ml of a 96% solution of ethyl alcohol is injected into the trachea.
2. With normal blood pressure:
Run step 1;
To seat the patient with lowered lower limbs;
Nitroglycerin tablets (preferably aerosol) 0.4-0.5 mg sublingually again after 3 minutes or up to 10 mg intravenously slowly fractionally or intravenously drip in 100 ml of isotonic sodium chloride solution, increasing the rate of administration from 25 μg / min until effect by controlling blood pressure:
Diazepam up to 10 mg or morphine 3 mg intravenously in divided doses until the effect or a total dose of 10 mg is reached.
3. With arterial hypertension:
Run step 1;
Seating a patient with lowered lower limbs:
Nitroglycerin, tablets (aerosol is better) 0.4-0.5 mg under the tongue once;
Furosemide (Lasix) 40-80 mg IV;
Nitroglycerin intravenously (item 2) or sodium nitroprusside 30 mg in 300 ml of 5% glucose solution intravenously drip, gradually increasing the infusion rate of the drug from 0.3 μg / (kg x min) until the effect is obtained, controlling blood pressure, or pentamine to 50 mg intravenously fractionally or drip:
Intravenously up to 10 mg of diazepam or up to 10 mg of morphine (item 2).
4. With severe arterial hypotension:
Run step 1:
Lay down the patient, raising the head;
Dopamine 200 mg in 400 ml of 5% glucose solution intravenously, increasing the infusion rate from 5 μg / (kg x min) until blood pressure stabilizes at the minimum sufficient level;
If it is impossible to stabilize blood pressure, additionally prescribe norepinephrine hydrotartrate 4 mg in 200 ml of 5-10% glucose solution, increasing the infusion rate from 0.5 μg / min until blood pressure stabilizes at the minimum sufficient level;
With an increase in blood pressure, accompanied by increasing pulmonary edema, additionally nitroglycerin intravenously drip (p. 2);
Furosemide (Lasix) 40 mg IV after stabilization of blood pressure.
5. Monitor vital functions (heart monitor, pulse oximeter).
6. Hospitalize after possible stabilization of the condition. Main dangers and complications:
Lightning form of pulmonary edema;
Airway obstruction with foam;
respiratory depression;
tachyarrhythmia;
asystole;
Anginal pain:
The increase in pulmonary edema with an increase in blood pressure.
Note. Under the minimum sufficient blood pressure should be understood as a systolic pressure of about 90 mm Hg. Art. provided that the increase in blood pressure is accompanied by clinical signs of improved perfusion of organs and tissues.
Eufillin in cardiogenic pulmonary edema is an adjuvant and can be indicated for bronchospasm or severe bradycardia.
Glucocorticoid hormones are used only for respiratory distress syndrome (aspiration, infection, pancreatitis, inhalation of irritants, etc.).
Cardiac glycosides (strophanthin, digoxin) can be prescribed only for moderate congestive heart failure in patients with tachysystolic atrial fibrillation (flutter).
In aortic stenosis, hypertrophic cardiomyopathy, cardiac tamponade, nitroglycerin and other peripheral vasodilators are relatively contraindicated.
It is effective to create positive end-expiratory pressure.
ACE inhibitors (captopril) are useful in preventing recurrence of pulmonary edema in patients with chronic heart failure. At the first appointment of captopril, treatment should begin with a trial dose of 6.25 mg.
CARDIOGENIC SHOCK
Diagnostics. A pronounced decrease in blood pressure in combination with signs of impaired blood supply to organs and tissues. Systolic blood pressure is usually below 90 mm Hg. Art., pulse - below 20 mm Hg. Art. There are symptoms of deterioration of the peripheral circulation (pale cyanotic moist skin, collapsed peripheral veins, a decrease in the temperature of the skin of the hands and feet); decrease in blood flow velocity (the time for the disappearance of a white spot after pressing on the nail bed or palm is more than 2 s), a decrease in diuresis (less than 20 ml / h), impaired consciousness (from mild inhibition to the appearance of focal neurological symptoms and the development of coma).
Differential diagnosis. In most cases, it is necessary to differentiate true cardiogenic shock from its other varieties (reflex, arrhythmic, drug-induced, with slow myocardial rupture, rupture of the septum or papillary muscles, right ventricular damage), as well as from pulmonary embolism, hypovolemia, internal bleeding and arterial hypotension without shock.
Urgent care
Emergency care must be carried out in stages, quickly moving on to the next stage if the previous one is ineffective.
1. In the absence of pronounced stagnation in the lungs:
Lay the patient down with the lower limbs raised at an angle of 20° (with severe congestion in the lungs - see “Pulmonary edema”):
Carry out oxygen therapy;
With anginal pain, conduct a full anesthesia:
Carry out heart rate correction (paroxysmal tachyarrhythmia with a heart rate of more than 150 beats per 1 min - an absolute indication for EIT, acute bradycardia with a heart rate of less than 50 beats per 1 min - for a pacemaker);
Administer heparin 5000 IU intravenously by bolus.
2. In the absence of pronounced stagnation in the lungs and signs of a sharp increase in CVP:
Introduce 200 ml of 0.9% sodium chloride solution intravenously over 10 minutes under the control of blood pressure and respiratory rate. Heart rate, auscultatory picture of the lungs and heart (if possible, control CVP or wedge pressure in the pulmonary artery);
If arterial hypotension persists and there are no signs of transfusion hypervolemia, repeat the introduction of fluid according to the same criteria;
In the absence of signs of transfusion hypervolemia (CVD below 15 cm of water column), continue infusion therapy at a rate of up to 500 ml / h, monitoring these indicators every 15 minutes.
If blood pressure cannot be quickly stabilized, then proceed to the next step.
3. Inject dopamine 200 mg in 400 ml of 5% glucose solution intravenously, increasing the infusion rate starting from 5 µg/(kg x min) until the minimum sufficient arterial pressure is reached;
No effect - additionally prescribe norepinephrine hydrotartrate 4 mg in 200 ml of 5% glucose solution intravenously, increasing the infusion rate from 0.5 μg / min until the minimum sufficient arterial pressure is reached.
4. Monitor vital functions: heart monitor, pulse oximeter.
5. Hospitalize after possible stabilization of the condition.
Main dangers and complications:
Late diagnosis and initiation of treatment:
Failure to stabilize blood pressure:
Pulmonary edema with increased blood pressure or intravenous fluids;
Tachycardia, tachyarrhythmia, ventricular fibrillation;
Asystole:
Recurrence of anginal pain:
Acute renal failure.
Note. Under the minimum sufficient blood pressure should be understood as a systolic pressure of about 90 mm Hg. Art. when signs of improvement in perfusion of organs and tissues appear.
Glucocorpoid hormones are not indicated in true cardiogenic shock.
emergency angina heart attack poisoning
HYPERTENSIVE CRISES
Diagnostics. An increase in blood pressure (usually acute and significant) with neurological symptoms: headache, “flies” or a veil before the eyes, paresthesia, a feeling of “crawling”, nausea, vomiting, weakness in the limbs, transient hemiparesis, aphasia, diplopia.
With a neurovegetative crisis (type I crisis, adrenal): sudden onset. excitation, hyperemia and moisture of the skin. tachycardia, frequent and copious urination, a predominant increase in systolic pressure with an increase in pulse.
With a water-salt form of a crisis (crisis type II, noradrenal): gradual onset, drowsiness, adynamia, disorientation, pallor and puffiness of the face, swelling, a predominant increase in diastolic pressure with a decrease in pulse pressure.
With a convulsive form of a crisis: a throbbing, arching headache, psychomotor agitation, repeated vomiting without relief, visual disturbances, loss of consciousness, tonic-clonic convulsions.
Differential diagnosis. First of all, the severity, form and complications of the crisis should be taken into account, crises associated with the sudden withdrawal of antihypertensive drugs (clonidine, β-blockers, etc.) should be distinguished, hypertensive crises should be differentiated from cerebrovascular accidents, diencephalic crises and crises with pheochromocytoma.
Urgent care
1. Neurovegetative form of crisis.
1.1. For mild flow:
Nifedipine 10 mg sublingually or in drops orally every 30 minutes, or clonidine 0.15 mg sublingually. then 0.075 mg every 30 minutes until the effect, or a combination of these drugs.
1.2. With severe flow.
Clonidine 0.1 mg intravenously slowly (may be combined with 10 mg of nifedipine under the tongue), or sodium nitroprusside 30 mg in 300 ml of 5% glucose solution intravenously, gradually increasing the rate of administration until the required blood pressure is reached, or pentamine up to 50 mg intravenously drip or jet fractionally;
With insufficient effect - furosemide 40 mg intravenously.
1.3. With continued emotional tension, additional diazepam 5-10 mg orally, intramuscularly or intravenously, or droperidol 2.5-5 mg intravenously slowly.
1.4. With persistent tachycardia, propranolol 20-40 mg orally.
2. Water-salt form of crisis.
2.1. For mild flow:
Furosemide 40–80 mg orally once and nifedipine 10 mg sublingually or in drops orally every 30 minutes until effect, or furosemide 20 mg orally once and captopril 25 mg sublingually or orally every 30–60 minutes until effect.
2.2. With severe flow.
Furosemide 20-40 mg intravenously;
Sodium nitroprusside or pentamine intravenously (section 1.2).
2.3. With persistent neurological symptoms, intravenous administration of 240 mg of aminophylline can be effective.
3. Convulsive form of crisis:
Diazepam 10-20 mg intravenously slowly until seizures are eliminated, magnesium sulfate 2.5 g intravenously very slowly can be administered additionally:
Sodium nitroprusside (section 1.2) or pentamine (section 1.2);
Furosemide 40-80 mg intravenously slowly.
4. Crises associated with the sudden withdrawal of antihypertensive drugs:
Appropriate antihypertensive drug intravenously. under the tongue or inside, with pronounced arterial hypertension - sodium nitroprusside (section 1.2).
5. Hypertensive crisis complicated by pulmonary edema:
Nitroglycerin (preferably an aerosol) 0.4-0.5 mg under the tongue and immediately 10 mg in 100 ml of isotonic sodium chloride solution intravenously. by increasing the rate of infusion from 25 µg/min until effect is obtained, either sodium nitroprusside (section 1.2) or pentamine (section 1.2);
Furosemide 40-80 mg intravenously slowly;
Oxygen therapy.
6. Hypertensive crisis complicated by hemorrhagic stroke or subarachnoid hemorrhage:
With pronounced arterial hypertension - sodium nitroprusside (section 1.2). reduce blood pressure to values exceeding the usual values for this patient, with an increase in neurological symptoms, reduce the rate of administration.
7. Hypertensive crisis complicated by anginal pain:
Nitroglycerin (preferably an aerosol) 0.4-0.5 mg under the tongue and immediately 10 mg intravenously drip (item 5);
Required anesthesia - see "Angina":
With insufficient effect - propranolol 20-40 mg orally.
8. With a complicated course- monitor vital functions (heart monitor, pulse oximeter).
9. Hospitalize after possible stabilization of the condition .
Main dangers and complications:
arterial hypotension;
Violation of cerebral circulation (hemorrhagic or ischemic stroke);
Pulmonary edema;
Anginal pain, myocardial infarction;
Tachycardia.
Note. In acute arterial hypertension, immediately shortening life, reduce blood pressure within 20-30 minutes to the usual, “working” or slightly higher values, use intravenous. the route of administration of drugs, the hypotensive effect of which can be controlled (sodium nitroprusside, nitroglycerin.).
In a hypertensive crisis without an immediate threat to life, lower blood pressure gradually (for 1-2 hours).
When the course of hypertension worsens, not reaching a crisis, blood pressure must be reduced within a few hours, the main antihypertensive drugs should be administered orally.
In all cases, blood pressure should be reduced to the usual, "working" values.
To provide emergency care for repeated hypertensive crises of SLS diets, taking into account the existing experience in the treatment of previous ones.
When using captopril for the first time, treatment should begin with a trial dose of 6.25 mg.
The hypotensive effect of pentamine is difficult to control, so the drug can only be used in cases where an emergency lowering of blood pressure is indicated and there are no other options for this. Pentamine is administered in doses of 12.5 mg intravenously in fractions or drops up to 50 mg.
In a crisis in patients with pheochromocytoma, raise the head of the bed to. 45°; prescribe (rentolation (5 mg intravenously 5 minutes before the effect.); you can use prazosin 1 mg sublingually repeatedly or sodium nitroprusside. As an auxiliary drug, droperidol 2.5-5 mg intravenously slowly. Blockers of P-adrenoreceptors should be changed only (!) after the introduction of a-adrenergic blockers.
PULMONARY EMBOLISM
Diagnostics Massive pulmonary embolism is manifested by sudden circulatory arrest (electromechanical dissociation), or shock with severe shortness of breath, tachycardia, pallor or sharp cyanosis of the skin of the upper half of the body, swelling of the jugular veins, antinose-like pain, electrocardiographic manifestations of acute cor pulmonale.
Non-gossive PE is manifested by shortness of breath, tachycardia, arterial hypotension. signs of pulmonary infarction (pulmonary-pleural pain, cough, in some patients - with sputum stained with blood, fever, crepitant wheezing in the lungs).
For the diagnosis of PE, it is important to take into account the presence of risk factors for the development of thromboembolism, such as a history of thromboembolic complications, advanced age, prolonged immobilization, recent surgery, heart disease, heart failure, atrial fibrillation, oncological diseases, DVT.
Differential diagnosis. In most cases - with myocardial infarction, acute heart failure (cardiac asthma, pulmonary edema, cardiogenic shock), bronchial asthma, pneumonia, spontaneous pneumothorax.
Urgent care
1. With the cessation of blood circulation - CPR.
2. With massive PE with arterial hypotension:
Oxygen therapy:
Catheterization of the central or peripheral vein:
Heparin 10,000 IU intravenously by stream, then drip at an initial rate of 1000 IU / h:
Infusion therapy (reopoliglyukin, 5% glucose solution, hemodez, etc.).
3. In case of severe arterial hypotension, not corrected by infusion therapy:
Dopamine, or adrenaline intravenously drip. increasing the rate of administration until blood pressure stabilizes;
Streptokinase (250,000 IU intravenously drip for 30 minutes, then intravenously drip at a rate of 100,000 IU/h to a total dose of 1,500,000 IU).
4. With stable blood pressure:
oxygen therapy;
Catheterization of a peripheral vein;
Heparin 10,000 IU intravenously by stream, then drip at a rate of 1000 IU / h or subcutaneously at 5000 IU after 8 hours:
Eufillin 240 mg intravenously.
5. In case of recurrent PE, additionally prescribe 0.25 g of acetylsalicylic acid orally.
6. Monitor vital functions (heart monitor, pulse oximeter).
7. Hospitalize after possible stabilization of the condition.
Main dangers and complications:
Electromechanical dissociation:
Inability to stabilize blood pressure;
Increasing respiratory failure:
PE recurrence.
Note. With a aggravated allergic history, 30 mg of predniolone is administered intravenously by stream before the appointment of strepyayukinoz.
For the treatment of PE, the rate of intravenous heparin administration must be selected individually, achieving a stable increase in activated partial thromboplastin time by 2 times compared to its normal value.
STROKE (ACUTE CEREBRAL CIRCULATION DISTURBANCE)
Stroke (stroke) is a rapidly developing focal or global impairment of brain function, lasting more than 24 hours or leading to death if another genesis of the disease is excluded. It develops against the background of atherosclerosis of cerebral vessels, hypertension, their combination or as a result of rupture of cerebral aneurysms.
Diagnostics The clinical picture depends on the nature of the process (ischemia or hemorrhage), localization (hemispheres, trunk, cerebellum), the rate of development of the process (sudden, gradual). A stroke of any genesis is characterized by the presence of focal symptoms of brain damage (hemiparesis or hemiplegia, less often monoparesis and lesions of the cranial nerves - facial, hypoglossal, oculomotor) and cerebral symptoms of varying severity (headache, dizziness, nausea, vomiting, impaired consciousness).
CVA is clinically manifested by subarachnoid or intracerebral hemorrhage (hemorrhagic stroke), or ischemic stroke.
Transient cerebrovascular accident (TIMC) is a condition in which focal symptoms undergo complete regression over a period of less than 24 hours. The diagnosis is made retrospectively.
Suborocnoid hemorrhages develop as a result of rupture of aneurysms and less often against the background of hypertension. Characterized by the sudden onset of a sharp headache, followed by nausea, vomiting, motor agitation, tachycardia, sweating. With massive subarachnoid hemorrhage, as a rule, depression of consciousness is observed. Focal symptoms are often absent.
Hemorrhagic stroke - bleeding into the substance of the brain; characterized by a sharp headache, vomiting, rapid (or sudden) depression of consciousness, accompanied by the appearance of pronounced symptoms of dysfunction of the limbs or bulbar disorders (peripheral paralysis of the muscles of the tongue, lips, soft palate, pharynx, vocal folds and epiglottis due to damage to the IX, X and XII pairs of cranial nerves or their nuclei located in the medulla oblongata). It usually develops during the day, during wakefulness.
Ischemic stroke is a disease that leads to a decrease or cessation of blood supply to a certain part of the brain. It is characterized by a gradual (over hours or minutes) increase in focal symptoms corresponding to the affected vascular pool. Cerebral symptoms are usually less pronounced. Develops more often with normal or low blood pressure, often during sleep
At the prehospital stage, it is not required to differentiate the nature of the stroke (ischemic or hemorrhagic, subarachnoid hemorrhage and its localization.
Differential diagnosis should be carried out with a traumatic brain injury (history, the presence of traces of trauma on the head) and much less often with meningoencephalitis (history, signs of a general infectious process, rash).
Urgent care
Basic (undifferentiated) therapy includes emergency correction of vital functions - restoration of patency of the upper respiratory tract, if necessary - tracheal intubation, artificial ventilation of the lungs, as well as normalization of hemodynamics and cardiac activity:
With arterial pressure significantly higher than usual values - its decrease to indicators slightly higher than the “working” one, which is familiar to this patient, if there is no information, then to the level of 180/90 mm Hg. Art.; for this use - 0.5-1 ml of a 0.01% solution of clonidine (clophelin) in 10 ml of a 0.9% solution of sodium chloride intravenously or intramuscularly or 1-2 tablets sublingually (if necessary, the administration of the drug can be repeated), or pentamine - no more than 0, 5 ml of a 5% solution intravenously at the same dilution or 0.5-1 ml intramuscularly:
As an additional remedy, you can use Dibazol 5-8 ml of a 1% solution intravenously or nifedipine (Corinfar, fenigidin) - 1 tablet (10 mg) sublingually;
For the relief of convulsive seizures, psychomotor agitation - diazepam (Relanium, Seduxen, Sibazon) 2-4 ml intravenously with 10 ml of 0.9% sodium chloride solution slowly or intramuscularly or Rohypnol 1-2 ml intramuscularly;
With inefficiency - 20% solution of sodium hydroxybutyrate at the rate of 70 mg / kg of body weight in 5-10% glucose solution intravenously slowly;
In case of repeated vomiting - cerucal (raglan) 2 ml intravenously in a 0.9% solution intravenously or intramuscularly:
Vitamin Wb 2 ml of 5% solution intravenously;
Droperidol 1-3 ml of 0.025% solution, taking into account the patient's body weight;
With a headache - 2 ml of a 50% solution of analgin or 5 ml of baralgin intravenously or intramuscularly;
Tramal - 2 ml.
Tactics
For patients of working age in the first hours of the disease, it is mandatory to call a specialized neurological (neuroresuscitation) team. Shown hospitalization on a stretcher in the neurological (neurovascular) department.
In case of refusal of hospitalization - a call to the neurologist of the polyclinic and, if necessary, an active visit to the emergency doctor after 3-4 hours.
Non-transportable patients in deep atonic coma (5-4 points on the Glasgow scale) with intractable severe respiratory disorders: unstable hemodynamics, with a rapid, steady deterioration.
Dangers and Complications
Obstruction of the upper respiratory tract by vomit;
Aspiration of vomit;
Inability to normalize blood pressure:
swelling of the brain;
Breakthrough of blood into the ventricles of the brain.
Note
1. Early use of antihypoxants and activators of cellular metabolism is possible (nootropil 60 ml (12 g) intravenously bolus 2 times a day after 12 hours on the first day; cerebrolysin 15-50 ml intravenously by drip per 100-300 ml of isotonic solution in 2 doses; glycine 1 tablet under the tongue riboyusin 10 ml intravenously bolus, solcoseryl 4 ml intravenous bolus, in severe cases 250 ml 10% solution of solcoseryl intravenously drip can significantly reduce the number of irreversibly damaged cells in the ischemic zone, reduce the area of perifocal edema.
2. Aminazine and propazine should be excluded from the funds prescribed for any form of stroke. These drugs sharply inhibit the functions of the brain stem structures and clearly worsen the condition of patients, especially the elderly and senile.
3. Magnesium sulfate is not used for convulsions and to lower blood pressure.
4. Eufillin is shown only in the first hours of an easy stroke.
5. Furosemide (Lasix) and other dehydrating agents (mannitol, rheogluman, glycerol) should not be administered in the prehospital setting. The need to prescribe dehydrating agents can only be determined in a hospital based on the results of determining plasma osmolality and sodium content in blood serum.
6. In the absence of a specialized neurological team, hospitalization in the neurological department is indicated.
7. For patients of any age with the first or repeated stroke with minor defects after previous episodes, a specialized neurological (neuroresuscitation) team can also be called on the first day of the disease.
BRONCHOASTMATIC STATUS
Bronchoasthmatic status is one of the most severe variants of the course of bronchial asthma, manifested by acute obstruction of the bronchial tree as a result of bronchiolospasm, hyperergic inflammation and mucosal edema, hypersecretion of the glandular apparatus. The formation of the status is based on a deep blockade of p-adrenergic receptors of the smooth muscles of the bronchi.
Diagnostics
An attack of suffocation with difficulty exhaling, increasing dyspnea at rest, acrocyanosis, increased sweating, hard breathing with dry scattered wheezing and the subsequent formation of areas of a “silent” lung, tachycardia, high blood pressure, participation in breathing of auxiliary muscles, hypoxic and hypercapnic coma. When conducting drug therapy, resistance to sympathomimetics and other bronchodilators is revealed.
Urgent care
Asthmatic status is a contraindication to the use of β-agonists (agonists) due to loss of sensitivity (lung receptors to these drugs. However, this loss of sensitivity can be overcome with the help of nebulizer technique.
Drug therapy is based on the use of selective p2-agonists fenoterol (berotec) at a dose of 0.5-1.5 mg or salbutamol at a dose of 2.5-5.0 mg or a complex preparation of berodual containing fenoterol and the anticholinergic drug ypra using nebulizer technology. -tropium bromide (atrovent). The dosage of berodual is 1-4 ml per inhalation.
In the absence of a nebulizer, these drugs are not used.
Eufillin is used in the absence of a nebulizer or in especially severe cases with the ineffectiveness of nebulizer therapy.
The initial dose is 5.6 mg / kg of body weight (10-15 ml of a 2.4% solution intravenously slowly, over 5-7 minutes);
Maintenance dose - 2-3.5 ml of a 2.4% solution fractionally or drip until the patient's clinical condition improves.
Glucocorticoid hormones - in terms of methylprednisolone 120-180 mg intravenously by stream.
Oxygen therapy. Continuous insufflation (mask, nasal catheters) of an oxygen-air mixture with an oxygen content of 40-50%.
Heparin - 5,000-10,000 IU intravenously with one of the plasma-substituting solutions; it is possible to use low molecular weight heparins (fraxiparin, clexane, etc.)
Contraindicated
Sedatives and antihistamines (inhibit the cough reflex, increase bronchopulmonary obstruction);
Mucolytic mucus thinners:
antibiotics, sulfonamides, novocaine (have a high sensitizing activity);
Calcium preparations (deepen initial hypokalemia);
Diuretics (increase initial dehydration and hemoconcentration).
In a coma
Urgent tracheal intubation for spontaneous breathing:
Artificial ventilation of the lungs;
If necessary - cardiopulmonary resuscitation;
Medical therapy (see above)
Indications for tracheal intubation and mechanical ventilation:
hypoxic and hyperkalemic coma:
Cardiovascular collapse:
The number of respiratory movements is more than 50 in 1 min. Transportation to the hospital against the background of ongoing therapy.
SEVERAL SYNDROME
Diagnostics
A generalized generalized convulsive seizure is characterized by the presence of tonic-clonic convulsions in the limbs, accompanied by loss of consciousness, foam at the mouth, often - biting of the tongue, involuntary urination, and sometimes defecation. At the end of the seizure, there is a pronounced respiratory arrhythmia. Long periods of apnea are possible. At the end of the seizure, the patient is in a deep coma, the pupils are maximally dilated, without reaction to light, the skin is cyanotic, often moist.
Simple partial seizures without loss of consciousness are manifested by clonic or tonic convulsions in certain muscle groups.
Complex partial seizures (temporal lobe epilepsy or psychomotor seizures) are episodic behavioral changes when the patient loses contact with the outside world. The beginning of such seizures may be the aura (olfactory, gustatory, visual, sensation of “already seen”, micro or macropsia). During complex attacks, inhibition of motor activity may be observed; or smacking tubas, swallowing, walking aimlessly, picking off one's own clothes (automatisms). At the end of the attack, amnesia is noted for the events that took place during the attack.
The equivalents of convulsive seizures are manifested in the form of gross disorientation, somnambulism and a prolonged twilight state, during which unconscious, severe asocial acts can be performed.
Status epilepticus - a fixed epileptic state due to a prolonged epileptic seizure or a series of seizures that recur at short intervals. Status epilepticus and recurrent seizures are life-threatening conditions.
Seizures can be a manifestation of genuine ("congenital") and symptomatic epilepsy - a consequence of past diseases (brain injury, cerebrovascular accident, neuro-infection, tumor, tuberculosis, syphilis, toxoplasmosis, cysticercosis, Morgagni-Adams-Stokes syndrome, ventricular fibrillation , eclampsia) and intoxication.
Differential Diagnosis
At the prehospital stage, determining the cause of a seizure is often extremely difficult. The anamnesis and clinical data are of great importance. Special care must be taken with respect to first of all, traumatic brain injury, acute cerebrovascular accidents, cardiac arrhythmias, eclampsia, tetanus and exogenous intoxications.
Urgent care
1. After a single convulsive seizure - diazepam (Relanium, Seduxen, Sibazon) - 2 ml intramuscularly (as a prevention of recurrent seizures).
2. With a series of convulsive seizures:
Head and torso injury prevention:
Relief of convulsive syndrome: diazepam (Relanium, Seduxen, Sibazon) - 2-4 ml per 10 ml of 0.9% sodium chloride solution intravenously or intramuscularly, Rohypnol 1-2 ml intramuscularly;
In the absence of effect - sodium hydroxybutyrate 20% solution at the rate of 70 mg / kg of body weight intravenously in 5-10% glucose solution;
Decongestant therapy: furosemide (lasix) 40 mg per 10-20 ml of 40% glucose or 0.9% sodium chloride solution (in patients with diabetes mellitus)
intravenously;
Headache relief: analgin 2 ml 50% solution: baralgin 5 ml; tramal 2 ml intravenously or intramuscularly.
3. Status epilepticus
Prevention of trauma to the head and torso;
Restoration of airway patency;
Relief of convulsive syndrome: diazepam (Relanium, Seduxen, Syabazone) _ 2-4 ml per 10 ml of 0.9% sodium chloride solution intravenously or intramuscularly, Rohypnol 1-2 ml intramuscularly;
In the absence of effect - sodium hydroxybutyrate 20% solution at the rate of 70 mg / kg of body weight intravenously in 5-10% glucose solution;
In the absence of effect - inhalation anesthesia with nitrous oxide mixed with oxygen (2:1).
Decongestant therapy: furosemide (lasix) 40 mg per 10-20 ml of 40% glucose or 0.9% sodium chloride solution (in diabetic patients) intravenously:
Relief of headache:
Analgin - 2 ml of 50% solution;
- baralgin - 5 ml;
Tramal - 2 ml intravenously or intramuscularly.
According to indications:
With an increase in blood pressure significantly higher than the patient's usual indicators - antihypertensive drugs (clofelin intravenously, intramuscularly or sublingual tablets, dibazol intravenously or intramuscularly);
With tachycardia over 100 beats / min - see "Tachyarrhythmias":
With bradycardia less than 60 beats / min - atropine;
With hyperthermia over 38 ° C - analgin.
Tactics
Patients with a first-ever seizure should be hospitalized to determine its cause. In case of refusal of hospitalization with a rapid recovery of consciousness and the absence of cerebral and focal neurological symptoms, an urgent appeal to a neurologist at a polyclinic at the place of residence is recommended. If consciousness is restored slowly, there are cerebral and (or) focal symptoms, then a call for a specialized neurological (neuro-resuscitation) team is indicated, and in its absence, an active visit after 2-5 hours.
Intractable status epilepticus or a series of convulsive seizures is an indication for calling a specialized neurological (neuroresuscitation) team. In the absence of such - hospitalization.
In case of violation of the activity of the heart, which led to a convulsive syndrome, appropriate therapy or a call to a specialized cardiological team. With eclampsia, exogenous intoxication - action according to the relevant recommendations.
Main dangers and complications
Asphyxia during a seizure:
Development of acute heart failure.
Note
1. Aminazine is not an anticonvulsant.
2. Magnesium sulfate and chloral hydrate are not currently available.
3. The use of hexenal or sodium thiopental for the relief of status epilepticus is possible only in the conditions of a specialized team, if there are conditions and the ability to transfer the patient to mechanical ventilation if necessary. (laryngoscope, set of endotracheal tubes, ventilator).
4. With glucalcemic convulsions, calcium gluconate is administered (10-20 ml of a 10% solution intravenously or intramuscularly), calcium chloride (10-20 ml of a 10% solution strictly intravenously).
5. With hypokalemic convulsions, Panangin is administered (10 ml intravenously).
FAINTING (SHORT-TERM LOSS OF CONSCIOUSNESS, SYNCOPE)
Diagnostics
Fainting. - short-term (usually within 10-30 s) loss of consciousness. in most cases accompanied by a decrease in postural vascular tone. Syncope is based on transient hypoxia of the brain, which occurs due to various reasons - a decrease in cardiac output. heart rhythm disturbances, reflex decrease in vascular tone, etc.
Fainting (syncope) conditions can be conditionally divided into two most common forms - vasodepressor (synonyms - vasovagal, neurogenic) syncope, which are based on a reflex decrease in postural vascular tone, and syncope associated with diseases of the heart and great vessels.
Syncopal states have different prognostic significance depending on their genesis. Fainting associated with the pathology of the cardiovascular system can be harbingers of sudden death and require mandatory identification of their causes and adequate treatment. It must be remembered that fainting may be the debut of a severe pathology (myocardial infarction, pulmonary embolism, etc.).
The most common clinical form is vasodepressor syncope, in which there is a reflex decrease in peripheral vascular tone in response to external or psychogenic factors (fear, excitement, blood type, medical instruments, vein puncture, high ambient temperature, being in a stuffy room, etc. .). The development of fainting is preceded by a short prodromal period, during which weakness, nausea, ringing in the ears, yawning, darkening of the eyes, pallor, cold sweat are noted.
If the loss of consciousness is short-term, convulsions are not noted. If fainting lasts more than 15-20 s. clonic and tonic convulsions are noted. During syncope, there is a decrease in blood pressure with bradycardia; or without it. This group also includes fainting that occurs with increased sensitivity of the carotid sinus, as well as the so-called "situational" fainting - with prolonged coughing, defecation, urination. Syncope associated with the pathology of the cardiovascular system usually occurs suddenly, without a prodromal period. They are divided into two main groups - associated with cardiac arrhythmias and conduction disorders and caused by a decrease in cardiac output (aortic stenosis, hypertrophic cardiomyopathy, myxoma and spherical blood clots in the atria, myocardial infarction, pulmonary embolism, dissecting aortic aneurysm).
Differential Diagnosis syncope should be carried out with epilepsy, hypoglycemia, narcolepsy, coma of various origins, diseases of the vestibular apparatus, organic pathology of the brain, hysteria.
In most cases, the diagnosis can be made based on a detailed history, physical examination, and ECG recording. To confirm the vasodepressor nature of fainting, positional tests are performed (from simple orthostatic tests to the use of a special inclined table), to increase sensitivity, the tests are performed against the background of drug therapy. If these actions do not clarify the cause of fainting, then a subsequent examination in the hospital is carried out depending on the identified pathology.
In the presence of heart disease: ECG Holter monitoring, echocardiography, electrophysiological examination, positional tests: if necessary, cardiac catheterization.
In the absence of heart disease: positional tests, consultation with a neuropathologist, psychiatrist, ECG Holter monitoring, electroencephalogram, if necessary - computed tomography of the brain, angiography.
Urgent care
When fainting is usually not required.
The patient must be laid in a horizontal position on his back:
to give the lower limbs an elevated position, to free the neck and chest from restrictive clothing:
Patients should not be seated immediately, as this may lead to a relapse of fainting;
If the patient does not regain consciousness, it is necessary to exclude a traumatic brain injury (if there was a fall) or other causes of prolonged loss of consciousness indicated above.
If syncope is caused by cardiac disease, emergency care may be needed to address the immediate cause of syncope - tachyarrhythmia, bradycardia, hypotension, etc. (see relevant sections).
ACUTE POISONING
Poisoning - pathological conditions caused by the action of toxic substances of exogenous origin in any way they enter the body.
The severity of the condition in case of poisoning is determined by the dose of the poison, the route of its intake, the time of exposure, the patient's premorbid background, complications (hypoxia, bleeding, convulsive syndrome, acute cardiovascular failure, etc.).
The prehospital doctor needs:
Observe “toxicological alertness” (environmental conditions in which the poisoning occurred, the presence of foreign odors may pose a danger to the ambulance team):
Find out the circumstances that accompanied the poisoning (when, with what, how, how much, for what purpose) in the patient himself, if he is conscious or in those around him;
Collect material evidence (drug packages, powders, syringes), biological media (vomit, urine, blood, wash water) for chemical-toxicological or forensic chemical research;
Register the main symptoms (syndromes) that the patient had before the provision of medical care, including mediator syndromes, which are the result of strengthening or inhibition of the sympathetic and parasympathetic systems (see Appendix).
GENERAL ALGORITHM FOR PROVIDING EMERGENCY AID
1. Ensure normalization of respiration and hemodynamics (perform basic cardiopulmonary resuscitation).
2. Carry out antidote therapy.
3. Stop further intake of poison into the body. 3.1. In case of inhalation poisoning - remove the victim from the contaminated atmosphere.
3.2. In case of oral poisoning - rinse the stomach, introduce enterosorbents, put a cleansing enema. When washing the stomach or washing off poisons from the skin, use water with a temperature not exceeding 18 ° C; do not carry out the poison neutralization reaction in the stomach! The presence of blood during gastric lavage is not a contraindication for gastric lavage.
3.3. For skin application - wash the affected area of the skin with an antidote solution or water.
4. Start infusion and symptomatic therapy.
5. Transport the patient to the hospital. This algorithm for providing assistance at the prehospital stage is applicable to all types of acute poisoning.
Diagnostics
With mild and moderate severity, an anticholinergic syndrome occurs (intoxication psychosis, tachycardia, normohypotension, mydriasis). In severe coma, hypotension, tachycardia, mydriasis.
Antipsychotics cause the development of orthostatic collapse, prolonged persistent hypotension due to insensitivity of the terminal vascular bed to vasopressors, extrapyramidal syndrome (muscle cramps of the chest, neck, upper shoulder girdle, protrusion of the tongue, bulging eyes), neuroleptic syndrome (hyperthermia, muscle rigidity).
Hospitalization of the patient in a horizontal position. Cholinolytics cause the development of retrograde amnesia.
Opiate poisoning
Diagnostics
Characteristic: oppression of consciousness, to a deep coma. development of apnea, tendencies to bradycardia, injection marks on the elbows.
emergency therapy
Pharmacological antidotes: naloxone (narcanti) 2-4 ml of a 0.5% solution intravenously until spontaneous respiration is restored: if necessary, repeat the administration until mydriasis appears.
Start infusion therapy:
400.0 ml of 5-10% glucose solution intravenously;
Reopoliglyukin 400.0 ml intravenous drip.
Sodium bicarbonate 300.0 ml 4% intravenously;
oxygen inhalation;
In the absence of the effect of the introduction of naloxone, carry out mechanical ventilation in the hyperventilation mode.
Tranquilizer poisoning (benzodiazepine group)
Diagnostics
Characteristic: drowsiness, ataxia, depression of consciousness to coma 1, miosis (in case of poisoning with noxiron - mydriasis) and moderate hypotension.
Tranquilizers of the benzodiazepine series cause deep depression of consciousness only in “mixed” poisonings, i.e. in combination with barbiturates. neuroleptics and other sedative-hypnotic drugs.
emergency therapy
Follow steps 1-4 of the general algorithm.
For hypotension: reopoliglyukin 400.0 ml intravenously, drip:
Barbiturate poisoning
Diagnostics
Miosis, hypersalivation, "greasiness" of the skin, hypotension, deep depression of consciousness up to the development of coma are determined. Barbiturates cause a rapid breakdown of tissue trophism, the formation of bedsores, the development of positional compression syndrome, and pneumonia.
Urgent care
Pharmacological antidotes (see note).
Run point 3 of the general algorithm;
Start infusion therapy:
Sodium bicarbonate 4% 300.0, intravenous drip:
Glucose 5-10% 400.0 ml intravenously;
Sulfocamphocaine 2.0 ml intravenously.
oxygen inhalation.
POISONING WITH DRUGS OF STIMULANT ACTION
These include antidepressants, psychostimulants, general tonic (tinctures, including alcohol ginseng, eleutherococcus).
Delirium, hypertension, tachycardia, mydriasis, convulsions, cardiac arrhythmias, ischemia and myocardial infarction are determined. They have an oppression of consciousness, hemodynamics and respiration after the phase of excitation and hypertension.
Poisoning occurs with adrenergic (see Appendix) syndrome.
Poisoning with antidepressants
Diagnostics
With a short duration of action (up to 4-6 hours), hypertension is determined. delirium. dryness of the skin and mucous membranes, expansion of the 9K8 complex on the ECG (quinidine-like effect of tricyclic antidepressants), convulsive syndrome.
With prolonged action (more than 24 hours) - hypotension. urinary retention, coma. Always mydriasis. dryness of the skin, expansion of the OK8 complex on the ECG: Antidepressants. serotonin blockers: fluoxentine (Prozac), fluvoxamine (paroxetine), alone or in combination with analgesics, can cause “malignant” hyperthermia.
Urgent care
Follow point 1 of the general algorithm. For hypertension and agitation:
Short-acting drugs with a rapidly onset effect: galantamine hydrobromide (or nivalin) 0.5% - 4.0-8.0 ml, intravenously;
Long-acting drugs: aminostigmine 0.1% - 1.0-2.0 ml intramuscularly;
In the absence of antagonists, anticonvulsants: Relanium (Seduxen), 20 mg per 20.0 ml of 40% glucose solution intravenously; or sodium oxybutyrate 2.0 g per - 20.0 ml of 40.0% glucose solution intravenously, slowly);
Follow point 3 of the general algorithm. Start infusion therapy:
In the absence of sodium bicarbonate - trisol (disol. Chlosol) 500.0 ml intravenously, drip.
With severe arterial hypotension:
Reopoliglyukin 400.0 ml intravenously, drip;
Norepinephrine 0.2% 1.0 ml (2.0) in 400 ml of 5-10% glucose solution intravenously, drip, increase the rate of administration until blood pressure stabilizes.
POISONING WITH ANTI-TUBERCULOSIS DRUGS (ISONIAZIDE, FTIVAZIDE, TUBAZIDE)
Diagnostics
Characteristic: generalized convulsive syndrome, development of stunning. up to coma, metabolic acidosis. Any convulsive syndrome resistant to benzodiazepine treatment should alert for isoniazid poisoning.
Urgent care
Run point 1 of the general algorithm;
With convulsive syndrome: pyridoxine up to 10 ampoules (5 g). intravenous drip for 400 ml of 0.9% sodium chloride solution; Relanium 2.0 ml, intravenously. before relief of the convulsive syndrome.
If there is no result, muscle relaxants of antidepolarizing action (arduan 4 mg), tracheal intubation, mechanical ventilation.
Follow point 3 of the general algorithm.
Start infusion therapy:
Sodium bicarbonate 4% 300.0 ml intravenously, drip;
Glucose 5-10% 400.0 ml intravenously, drip. With arterial hypotension: reopoliglyukin 400.0 ml intravenously. drip.
Early detoxification hemosorption is effective.
POISONING WITH TOXIC ALCOHOL (METHANOL, ETHYLENE GLYCOL, CELLOSOLVES)
Diagnostics
Characteristic: the effect of intoxication, decreased visual acuity (methanol), abdominal pain (propyl alcohol; ethylene glycol, cellosolva with prolonged exposure), depression of consciousness to deep coma, decompensated metabolic acidosis.
Urgent care
Run point 1 of the general algorithm:
Run point 3 of the general algorithm:
Ethanol is the pharmacological antidote for methanol, ethylene glycol, and cellosolves.
Initial therapy with ethanol (saturation dose per 80 kg of the patient's body weight, at the rate of 1 ml of a 96% alcohol solution per 1 kg of body weight). To do this, dilute 80 ml of 96% alcohol with water in half, give a drink (or enter through a probe). If it is impossible to prescribe alcohol, 20 ml of a 96% alcohol solution is dissolved in 400 ml of a 5% glucose solution and the resulting alcohol solution of glucose is injected into a vein at a rate of 100 drops / min (or 5 ml of solution per minute).
Start infusion therapy:
Sodium bicarbonate 4% 300 (400) intravenously, drip;
Acesol 400 ml intravenously, drip:
Hemodez 400 ml intravenously, drip.
When transferring a patient to a hospital, indicate the dose, time and route of administration of the ethanol solution at the prehospital stage to provide a maintenance dose of ethanol (100 mg/kg/hour).
ETHANOL POISONING
Diagnostics
Determined: depression of consciousness to a deep coma, hypotension, hypoglycemia, hypothermia, cardiac arrhythmias, respiratory depression. Hypoglycemia, hypothermia lead to the development of cardiac arrhythmias. In alcoholic coma, the lack of response to naloxone may be due to concomitant traumatic brain injury (subdural hematoma).
Urgent care
Follow steps 1-3 of the general algorithm:
With depression of consciousness: naloxone 2 ml + glucose 40% 20-40 ml + thiamine 2.0 ml intravenously slowly. Start infusion therapy:
Sodium bicarbonate 4% 300-400 ml intravenously;
Hemodez 400 ml intravenous drip;
Sodium thiosulfate 20% 10-20 ml intravenously slowly;
Unithiol 5% 10 ml intravenously slowly;
Ascorbic acid 5 ml intravenously;
Glucose 40% 20.0 ml intravenously.
When excited: Relanium 2.0 ml intravenously slowly in 20 ml of 40% glucose solution.
Withdrawal state caused by alcohol consumption
When examining a patient at the prehospital stage, it is advisable to adhere to certain sequences and principles of emergency care for acute alcohol poisoning.
Establish the fact of recent alcohol intake and determine its characteristics (date of last intake, binge or single intake, quantity and quality of alcohol consumed, total duration of regular alcohol intake). Adjustment for the social status of the patient is possible.
· Establish the fact of chronic alcohol intoxication, the level of nutrition.
Determine the risk of developing a withdrawal syndrome.
· As part of toxic visceropathy, to determine: the state of consciousness and mental functions, to identify gross neurological disorders; the stage of alcoholic liver disease, the degree of liver failure; identify damage to other target organs and the degree of their functional usefulness.
Determine the prognosis of the condition and develop a plan for monitoring and pharmacotherapy.
It is obvious that the clarification of the patient's "alcohol" history is aimed at determining the severity of the current acute alcohol poisoning, as well as the risk of developing alcohol withdrawal syndrome (3-5 days after the last alcohol intake).
In the treatment of acute alcohol intoxication, a set of measures is needed aimed, on the one hand, at stopping the further absorption of alcohol and its accelerated removal from the body, and on the other hand, at protecting and maintaining systems or functions that suffer from the effects of alcohol.
The intensity of therapy is determined both by the severity of acute alcohol intoxication and the general condition of the intoxicated person. In this case, gastric lavage is carried out in order to remove alcohol that has not yet been absorbed, and drug therapy with detoxification agents and alcohol antagonists.
In the treatment of alcohol withdrawal the doctor takes into account the severity of the main components of the withdrawal syndrome (somato-vegetative, neurological and mental disorders). Mandatory components are vitamin and detoxification therapy.
Vitamin therapy includes parenteral administration of solutions of thiamine (Vit B1) or pyridoxine hydrochloride (Vit B6) - 5-10 ml. With severe tremor, a solution of cyanocobalamin (Vit B12) is prescribed - 2-4 ml. The simultaneous administration of various B vitamins is not recommended due to the possibility of enhancing allergic reactions and their incompatibility in one syringe. Ascorbic acid (Vit C) - up to 5 ml is administered intravenously along with plasma-substituting solutions.
Detoxification therapy includes the introduction of thiol preparations - a 5% solution of unithiol (1 ml per 10 kg of body weight intramuscularly) or a 30% solution of sodium thiosulfate (up to 20 ml); hypertonic - 40% glucose - up to 20 ml, 25% magnesium sulfate (up to 20 ml), 10% calcium chloride (up to 10 ml), isotonic - 5% glucose (400-800 ml), 0.9% sodium chloride solution ( 400-800 ml) and plasma-substituting - Hemodez (200-400 ml) solutions. It is also advisable, intravenous administration of a 20% solution of piracetam (up to 40 ml).
These measures, according to indications, are supplemented by the relief of somato-vegetative, neurological and mental disorders.
With an increase in blood pressure, 2-4 ml of a solution of papaverine hydrochloride or dibazol is injected intramuscularly;
In case of heart rhythm disturbance, analeptics are prescribed - a solution of cordiamine (2-4 ml), camphor (up to 2 ml), potassium preparations panangin (up to 10 ml);
With shortness of breath, difficulty breathing - up to 10 ml of a 2.5% solution of aminophylline is injected intravenously.
A decrease in dyspeptic phenomena is achieved by introducing a solution of raglan (cerucal - up to 4 ml), as well as spasmalgesics - baralgin (up to 10 ml), NO-ShPy (up to 5 ml). A solution of baralgin, along with a 50% solution of analgin, is also indicated to reduce the severity of headaches.
With chills, sweating, a solution of nicotinic acid (Vit PP - up to 2 ml) or a 10% solution of calcium chloride - up to 10 ml is injected.
Psychotropic drugs are used to stop affective, psychopathic and neurosis-like disorders. Relanium (dizepam, seduxen, sibazon) is administered intramuscularly, or at the end of intravenous infusion of solutions intravenously at a dose of up to 4 ml for withdrawal symptoms with anxiety, irritability, sleep disorders, autonomic disorders. Nitrazepam (eunoctin, radedorm - up to 20 mg), phenazepam (up to 2 mg), grandaxin (up to 600 mg) are given orally, it should be borne in mind that nitrazepam and phenazepam are best used to normalize sleep, and grandaxin for stopping autonomic disorders.
With severe affective disorders (irritability, a tendency to dysphoria, outbursts of anger), antipsychotics with a hypnotic-sedative effect are used (droperidol 0.25% - 2-4 ml).
With rudimentary visual or auditory hallucinations, paranoid mood in the structure of abstinence, 2-3 ml of a 0.5% solution of haloperidol is intramuscularly injected in combination with Relanium to reduce neurological side effects.
With severe motor anxiety, droperidol is used in 2-4 ml of a 0.25% solution intramuscularly or sodium oxybutyrate in 5-10 ml of a 20% solution intravenously. Antipsychotics from the group of phenothiazines (chlorpromazine, tizercin) and tricyclic antidepressants (amitriptyline) are contraindicated.
Therapeutic measures are carried out until there are signs of a clear improvement in the patient's condition (reduction of somato-vegetative, neurological, mental disorders, normalization of sleep) under constant monitoring of the function of the cardiovascular or respiratory system.
pacing
Cardiac pacing (ECS) is a method by which external electrical impulses produced by an artificial pacemaker (pacemaker) are applied to any part of the heart muscle, as a result of which the heart contracts.
Indications for pacing
· Asystole.
Severe bradycardia regardless of the underlying cause.
· Atrioventricular or Sinoatrial blockade with attacks of Adams-Stokes-Morgagni.
There are 2 types of pacing: permanent pacing and temporary pacing.
1. Permanent pacing
Permanent pacing is the implantation of an artificial pacemaker or cardioverter-defibrillator. Temporary pacing
2. Temporary pacing is necessary for severe bradyarrhythmias due to sinus node dysfunction or AV block.
Temporary pacing can be carried out by various methods. Currently relevant are transvenous endocardial and transesophageal pacing, and in some cases, external transcutaneous pacing.
Transvenous (endocardial) pacing has received especially intensive development, since it is the only effective way to “impose” an artificial rhythm on the heart in the event of severe disorders of the systemic or regional circulation due to bradycardia. When it is performed, the electrode under ECG control is inserted through the subclavian, internal jugular, ulnar or femoral veins into the right atrium or right ventricle.
Temporary atrial transesophageal pacing and transesophageal ventricular pacing (TEPS) have also become widespread. TSES is used as a replacement therapy for bradycardia, bradyarrhythmias, asystole, and sometimes for reciprocal supraventricular arrhythmias. It is often used for diagnostic purposes. Temporary transthoracic pacing is sometimes used by emergency physicians to buy time. One electrode is inserted through a percutaneous puncture into the heart muscle, and the second is a needle placed subcutaneously.
Indications for temporary pacing
· Temporary pacing is carried out in all cases of indications for permanent pacing as a "bridge" to it.
Temporary pacing is performed when it is not possible to urgently implant a pacemaker.
Temporary pacing is carried out with hemodynamic instability, primarily in connection with Morgagni-Edems-Stokes attacks.
Temporary pacing is performed when there is reason to believe that bradycardia is transient (with myocardial infarction, the use of drugs that can inhibit the formation or conduction of impulses, after cardiac surgery).
Temporary pacing is recommended for the prevention of patients with acute myocardial infarction of the anterior septal region of the left ventricle with blockade of the right and anterior superior branch of the left branch of the bundle of His, due to the increased risk of developing a complete atrioventricular block with asystole due to the unreliability of the ventricular pacemaker in this case.
Complications of temporary pacing
Displacement of the electrode and the impossibility (cessation) of electrical stimulation of the heart.
Thrombophlebitis.
· Sepsis.
Air embolism.
Pneumothorax.
Perforation of the wall of the heart.
Cardioversion-defibrillation
Cardioversion-defibrillation (electropulse therapy - EIT) - is a transsternal effect of direct current of sufficient strength to cause depolarization of the entire myocardium, after which the sinoatrial node (first-order pacemaker) resumes control of the heart rhythm.
Distinguish between cardioversion and defibrillation:
1. Cardioversion - exposure to direct current, synchronized with the QRS complex. With various tachyarrhythmias (except for ventricular fibrillation), the effect of direct current should be synchronized with the QRS complex, because. in the case of current exposure before the peak of the T wave, ventricular fibrillation may occur.
2. Defibrillation. The impact of direct current without synchronization with the QRS complex is called defibrillation. Defibrillation is performed in ventricular fibrillation, when there is no need (and no opportunity) to synchronize the exposure to direct current.
Indications for cardioversion-defibrillation
Flutter and ventricular fibrillation. Electropulse therapy is the method of choice. Read more: Cardiopulmonary resuscitation at a specialized stage in the treatment of ventricular fibrillation.
Persistent ventricular tachycardia. In the presence of impaired hemodynamics (Morgagni-Adams-Stokes attack, arterial hypotension and / or acute heart failure), defibrillation is carried out immediately, and if it is stable, after an attempt to stop it with medications if it is ineffective.
Supraventricular tachycardia. Electropulse therapy is performed according to vital indications with progressive deterioration of hemodynamics or in a planned manner with the ineffectiveness of drug therapy.
· Atrial fibrillation and flutter. Electropulse therapy is performed according to vital indications with progressive deterioration of hemodynamics or in a planned manner with the ineffectiveness of drug therapy.
· Electropulse therapy is more effective in reentry tachyarrhythmias, less effective in tachyarrhythmias due to increased automatism.
· Electropulse therapy is absolutely indicated for shock or pulmonary edema caused by tachyarrhythmia.
Emergency electropulse therapy is usually performed in cases of severe (more than 150 per minute) tachycardia, especially in patients with acute myocardial infarction, with unstable hemodynamics, persistent anginal pain, or contraindications to the use of antiarrhythmic drugs.
All ambulance teams and all units of medical institutions should be equipped with a defibrillator, and all medical workers should be proficient in this method of resuscitation.
Cardioversion-defibrillation technique
In the case of a planned cardioversion, the patient should not eat for 6-8 hours to avoid possible aspiration.
Due to the pain of the procedure and the fear of the patient, general anesthesia or intravenous analgesia and sedation are used (for example, fentanyl at a dose of 1 mcg / kg, then midazolam 1-2 mg or diazepam 5-10 mg; elderly or debilitated patients - 10 mg promedol). With initial respiratory depression, non-narcotic analgesics are used.
When performing cardioversion-defibrillation, you must have the following kit on hand:
· Tools for maintaining airway patency.
· Electrocardiograph.
· Artificial lung ventilation apparatus.
Medications and solutions required for the procedure.
· Oxygen.
The sequence of actions during electrical defibrillation:
The patient should be in a position that allows, if necessary, to carry out tracheal intubation and closed heart massage.
Reliable access to the patient's vein is required.
· Turn on the power, turn off the defibrillator timing switch.
· Set the required charge on the scale (approximately 3 J/kg for adults, 2 J/kg for children); charge the electrodes; lubricate the plates with gel.
· It is more convenient to work with two manual electrodes. Install electrodes on the anterior surface of the chest:
One electrode is placed above the zone of cardiac dullness (in women - outward from the apex of the heart, outside the mammary gland), the second - under the right clavicle, and if the electrode is dorsal, then under the left shoulder blade.
The electrodes can be placed in the anteroposterior position (along the left edge of the sternum in the area of the 3rd and 4th intercostal spaces and in the left subscapular region).
The electrodes can be placed in the anterolateral position (between the clavicle and the 2nd intercostal space along the right edge of the sternum and above the 5th and 6th intercostal spaces, in the region of the apex of the heart).
· For maximum reduction of electrical resistance during electropulse therapy, the skin under the electrodes is degreased with alcohol or ether. In this case, gauze pads are used, well moistened with isotonic sodium chloride solution or special pastes.
The electrodes are pressed against the chest wall tightly and with force.
Perform cardioversion-defibrillation.
The discharge is applied at the moment of complete exhalation of the patient.
If the type of arrhythmia and the type of defibrillator allow, then the shock is delivered after synchronization with the QRS complex on the monitor.
Immediately before applying the discharge, you should make sure that the tachyarrhythmia persists, for which electrical impulse therapy is performed!
With supraventricular tachycardia and atrial flutter, a discharge of 50 J is sufficient for the first exposure. With atrial fibrillation or ventricular tachycardia, a discharge of 100 J is required for the first exposure.
In the case of polymorphic ventricular tachycardia or ventricular fibrillation, a discharge of 200 J is used for the first exposure.
While maintaining arrhythmia, with each subsequent discharge, the energy is doubled up to a maximum of 360 J.
The time interval between attempts should be minimal and is required only to assess the effect of defibrillation and set, if necessary, the next discharge.
If 3 discharges with increasing energy did not restore the heart rhythm, then the fourth - maximum energy - is applied after the intravenous administration of an antiarrhythmic drug indicated for this type of arrhythmia.
· Immediately after electropulse therapy, the rhythm should be assessed and, if it is restored, an ECG should be recorded in 12 leads.
If ventricular fibrillation continues, antiarrhythmic drugs are used to lower the defibrillation threshold.
Lidocaine - 1.5 mg / kg intravenously, by stream, repeat after 3-5 minutes. In case of restoration of blood circulation, a continuous infusion of lidocaine is carried out at a rate of 2-4 mg / min.
Amiodarone - 300 mg intravenously over 2-3 minutes. If there is no effect, you can repeat the intravenous administration of another 150 mg. In case of restoration of blood circulation, continuous infusion is carried out in the first 6 hours 1 mg / min (360 mg), in the next 18 hours 0.5 mg / min (540 mg).
Procainamide - 100 mg intravenously. If necessary, the dose can be repeated after 5 minutes (up to a total dose of 17 mg/kg).
Magnesium sulfate (Kormagnesin) - 1-2 g intravenously over 5 minutes. If necessary, the introduction can be repeated after 5-10 minutes. (with tachycardia of the "pirouette" type).
After the introduction of the drug for 30-60 seconds, general resuscitation is carried out, and then the electrical impulse therapy is repeated.
In case of intractable arrhythmias or sudden cardiac death, it is recommended to alternate the administration of drugs with electropulse therapy according to the scheme:
Antiarrhythmic drug - shock 360 J - adrenaline - shock 360 J - antiarrhythmic drug - shock 360 J - adrenaline, etc.
· You can apply not 1, but 3 discharges of maximum power.
· The number of digits is not limited.
In case of ineffectiveness, general resuscitation measures are resumed:
Perform tracheal intubation.
Provide venous access.
Inject adrenaline 1 mg every 3-5 minutes.
You can enter increasing doses of adrenaline 1-5 mg every 3-5 minutes or intermediate doses of 2-5 mg every 3-5 minutes.
Instead of adrenaline, you can enter intravenously vasopressin 40 mg once.
Defibrillator Safety Rules
Eliminate the possibility of grounding the personnel (do not touch the pipes!).
Exclude the possibility of touching others to the patient during the application of the discharge.
Make sure that the insulating part of the electrodes and hands are dry.
Complications of cardioversion-defibrillation
· Post-conversion arrhythmias, and above all - ventricular fibrillation.
Ventricular fibrillation usually develops when a shock is applied during a vulnerable phase of the cardiac cycle. The probability of this is low (about 0.4%), however, if the patient's condition, the type of arrhythmia and technical capabilities allow, synchronization of the discharge with the R wave on the ECG should be used.
If ventricular fibrillation occurs, a second discharge with an energy of 200 J is immediately applied.
Other post-conversion arrhythmias (eg, atrial and ventricular extrasystoles) are usually transient and do not require special treatment.
Thromboembolism of the pulmonary artery and systemic circulation.
Thromboembolism often develops in patients with thromboendocarditis and with long-term atrial fibrillation in the absence of adequate preparation with anticoagulants.
Respiratory disorders.
Respiratory disorders are the result of inadequate premedication and analgesia.
To prevent the development of respiratory disorders, full oxygen therapy should be carried out. Often, developing respiratory depression can be dealt with with the help of verbal commands. Do not try to stimulate breathing with respiratory analeptics. In severe respiratory failure, intubation is indicated.
skin burns.
Skin burns occur due to poor contact of the electrodes with the skin, the use of repeated discharges with high energy.
Arterial hypotension.
Arterial hypotension after cardioversion-defibrillation rarely develops. Hypotension is usually mild and does not last long.
· Pulmonary edema.
Pulmonary edema occasionally occurs 1-3 hours after the restoration of sinus rhythm, especially in patients with long-term atrial fibrillation.
Changes in repolarization on the ECG.
Changes in repolarization on the ECG after cardioversion-defibrillation are multidirectional, non-specific, and can persist for several hours.
Changes in the biochemical analysis of blood.
Increases in the activity of enzymes (AST, LDH, CPK) are mainly associated with the effect of cardioversion-defibrillation on skeletal muscles. The CPK MV activity increases only with multiple high-energy discharges.
Contraindications for EIT:
1. Frequent, short-term paroxysms of AF, which stop on their own or with medication.
2. Permanent form of atrial fibrillation:
More than three years old
The age is not known.
cardiomegaly,
Frederick Syndrome,
glycosidic toxicity,
TELA up to three months,
LIST OF USED LITERATURE
1. A.G. Miroshnichenko, V.V. Ruksin St. Petersburg Medical Academy of Postgraduate Education, St. Petersburg, Russia "Protocols of the treatment and diagnostic process at the prehospital stage"
2. http://smed.ru/guides/67158/#Pokazaniya_k_provedeniju_kardioversiidefibrillyacii
3. http://smed.ru/guides/67466/#_Pokazaniya_k_provedeniju_jelektrokardiostimulyacii
4. http://cardiolog.org/cardiohirurgia/50-invasive/208-vremennaja-ecs.html
5. http://www.popumed.net/study-117-13.html
