Clinical examples on emergency care with resuscitation. Clinical death

Ensure your own safety when examining a patient.

Conduct inspection patient. Assess vital functions:

reflex responses to stimuli;
breath;
carotid pulse.

Exclude:

biological death (presence of cadaveric changes);
clinical death due to the progression of a reliably established incurable disease;
clinical death due to the incurable consequences of acute injury incompatible with life.

Find out from relatives/surroundings the possible cause and time of onset of the patient’s critical condition, if possible.

Carry out functional-instrumental testing examination:

ECG in at least two leads and/or monitoring from defibrillator plates.

Determine the type of circulatory arrest.

Through the PPV paramedic:

Call the SB EMS according to indications, taking into account the capabilities of the health care facility.
inform the relevant department of the health care facility about the emergency hospitalization of a patient who has suffered clinical death.

While performing CPR:

Monitor ECG or carotid pulse every 2 minutes (every 5 resuscitation cycles).

When restoring cardiac activity, take action - see "".

Design“EMS call card.”

Upon the onset of clinical death in the patient against the background

progression of a reliably established incurable disease;
incurable consequences of acute injury incompatible with life;

act according to

“On approval of the Instructions for determining the criteria and procedure for determining the moment of death of a person and cessation of resuscitation measures”;
« », « ».

Scope and tactics of treatment measures

Make sure you are safe when providing assistance.

In case of agony, treatment should be aimed at relieving the leading syndrome that determined the patient’s critical condition (see the relevant sections of tactical recommendations).

Place the patient on his back on a flat, hard surface.

Restore and maintain patency of the upper respiratory tract. Ensure guaranteed venous access and an adequate infusion therapy program.

In case of clinical death, act in accordance with the CPR procedure. Consider the type of circulatory arrest when performing CPR.

Indirect cardiac massage carry out with a frequency of 100 compressions per minute and a depth of at least 5 cm.

mechanical ventilation pass the breathing bag through a mask, endotracheal tube, alternative breathing devices, in the “mouth-to-mouth” manner with a frequency of 10 breaths per minute.

Start CPR with 30 massage thrusts.

Perform CPR in a 30:2 ratio until ECG monitoring and/or the defibrillator is ready for use.

Medication resuscitation

Adrenaline 0.1% - 1 ml (1 mg) in solution Sodium chloride 0.9% - 19 ml IV every 3-5 minutes for all types of circulatory arrest.

Defibrillation carry out the maximum discharge energy of the available defibrillator in case of ventricular fibrillation or pulseless ventricular tachycardia.

For persistent fibrillation ventricles Introduce medical resuscitation only after the third defibrillation:

Adrenaline 0.1% - 1 ml (1 mg) in solution Sodium chloride 0.9% - 19 ml i.v.
Amiodarone (Cordarone) 300 mg (6 ml - 2 ampoules) IV. In the absence of Cordarone - Lidocaine 100 mg (1 -1.5 mg/kg) IV.

When cardiac activity is restored, see “Early post-resuscitation period”.

L. E. Elchinskaya, A. Yu. Shchurov, N. I. Sesina, M. I. Yurshevich

This article presents a review of clinical cases of medical care for patients with complicated forms of myocardial infarction of the anterior wall of the left ventricle in men of the same age group (50-60 years) without a previous history of coronary heart disease, with a different course of complications in the conditions of a specialized resuscitation-cardiology team of the City Emergency Medical Station assistance from St. Petersburg.

The goal is to emphasize the importance and necessity of a differential approach to therapy and tactics of medical care for acute myocardial infarction, treatment of patients in the conditions of a specialized intensive care team (RCT) for complicated forms of myocardial infarction at the prehospital stage.

Let us consider several clinical cases of providing medical care to patients with a complicated course of acute myocardial infarction, in the conditions of a specialized resuscitation-cardiology team of the city ambulance station of St. Petersburg.

1st case

A call to a 57-year-old man, K., to help the emergency medical team. Reason for call: “Acute myocardial infarction, candidate for thrombolysis.” From the anamnesis it is known that, against the background of physical activity, substernal chest pain of a pressing nature suddenly arose. The patient called an ambulance 10 minutes after the pain began. The arriving medical team diagnosed acute myocardial infarction. Considering the time of onset of the pain syndrome and the expected time of delivery to the emergency hospital with a vascular center, the RCH was called in for possible CTLT. RCH arrived 45 minutes from the onset of pain.

At the time of arrival of the resuscitation cardiology team:

When actively questioned, he makes no complaints.

The patient was conscious, in a hemodynamically stable condition, with no signs of microcirculation disturbances, blood oxygenation was satisfactory, and there were no signs of heart failure.

Before the arrival of the SKB, the EMS doctor recorded an ECG, which showed the following changes - subepicardial damage to the anterior wall of the LV

(ST elevation in V1-V4 up to 5 mm.)

The pain syndrome, accompanied by general weakness, dizziness, and sweating, was relieved by the administration of fentanyl (100 mcg IV). Also, before SCB, aspirin 250 mg, heparin 5000 units were prescribed, and oxygen inhalation was performed.

The ECG registered by the RCH shows positive dynamics compared to the previous ECG: a decrease in ST to the isoline, the rise in V2-V3 remains up to 1 mm). When monitoring ECG - single supraventricular extrasystoles. These changes were regarded as spontaneous thrombolysis, taking into account the duration of the pain syndrome (1 hour). The idea that a patient with AMI has an anterior wall of the left ventricle has not changed.

Therapy was carried out according to WHO recommendations. The patient was prescribed clopidogrel 300 mg, anaprilin 20 mg (BP = 120/80 mmHg, heart rate = 85 per minute), heparin infusion 1000 U/h using an infusion pump. The patient was prepared for transportation to the hospital.

A few minutes later, without previous deterioration of the condition or life-threatening rhythm disturbances, ventricular fibrillation occurred, which was regarded as reperfusion syndrome.

Resuscitation measures were started according to the “ventricular fibrillation” protocol recommended by ERS (2010). Tracheal intubation was performed, the patient was transferred to mechanical ventilation, and local hypothermia of the head was performed as part of cerebroprotection. Refractory VF remained. Resuscitation measures continued for 15 minutes, VF was stopped after the 7th defibrillation, a total dose of cordarone 450 mg, CMS was carried out by the LUCAS 2 system for chest compressions, which is available on the equipment of the resuscitation and cardiology teams of the St. Petersburg State Budgetary Healthcare Institution State Emergency Medical Service. When using the LUCAS 2 device, the effectiveness of indirect cardiac massage increases due to stable and identical chest compressions, cardiac output is up to 50% of the initial value, according to various data. At the 16th minute, effective blood circulation was restored, there is a tendency to arterial hypotension due to post-resuscitation syndrome. Hemodynamics were quickly stabilized by inotropic support of dopamine at a dose of 7 mcg/kg/min. A central venous catheter was installed, and a moderate increase in central venous pressure was noted. For neuroprotective purposes, anesthesia was administered with fentanyl 100 mcg, Relanium 10 mg, propofol infusion at a dose of 4 mg/kg/h, against the background of stabilized hemodynamics, Cytoflavin was prescribed, and prolonged mechanical ventilation was performed using the Drager apparatus (against the background of FiO - 1 - 0.5). Bladder catheterization was performed and 200 ml of “pre-shock” urine was obtained. The rate of diuresis is reduced. Furosemide 20 mg IV was prescribed to prevent prerenal acute renal failure as part of the treatment of post-resuscitation syndrome. According to the i-STAT gas analyzer, which is equipped with resuscitation teams of the State Emergency Medical Service, (Na 137 mmo/L, K 2.9 mmo/L, CL 110 mmo/L, pH 7.109, PCO 44.0 mmHg, HCO3 9.2 mmo/ L, BEecf -20 mmo/L) metabolic acidosis, which inevitably develops in critical conditions, was confirmed; for the purpose of correction, sodium bicarbonate 5% - 100 ml was prescribed, mechanical ventilation parameters were selected in the mode of moderate hyperventilation.

An infusion of electrolytes (K, Mg) was carried out, since hypokalemia, which often develops in AMI, can serve as one of the reasons provoking life-threatening rhythm disturbances, which in this situation was proven laboratory (data from the i-STAT system).

After stabilizing the patient's condition, he was taken to the nearest hospital with a vascular center. The patient was transferred to prolonged mechanical ventilation, deep medical sedation, and minimal inotropic support. ECG without negative dynamics.

It is subsequently known that the patient underwent coronary angioplasty with stenting of the infarction-related artery (LAD) as soon as possible, within an hour, for emergency indications. According to CAG data, there is a parietal thrombus in the LAD area, angiographic criteria for completed thrombolysis. The patient was on mechanical ventilation and inotropic support in minimal doses for 24 hours. On the second day he was extubated, in clear consciousness, stable hemodynamics, minimal neurological deficit (post-hypoxic encephalopathy). He was hospitalized for 18 days, after which he was sent to sanatorium treatment.

Thanks to the fact that medical care was provided in a specialized resuscitation team, it was possible to cope with the complications of acute myocardial infarction. Perform CPR effectively. Begin targeted rather than symptomatic correction of metabolic acidosis, implement neuroprotection, select the correct ventilation mode, stabilize the patient’s condition and deliver him to a specialized vascular center.

2nd case

A call to a 60-year-old man, S., to help the emergency medical team with the cause of AMI, cardiogenic shock.

At the time of arrival of the SKB - 3.5 hours from the onset of a typical anginal pain syndrome. The patient is in depressed consciousness (E-3, M-6, V-4, 13b. on the GLASGOW scale - stunning). Blood pressure=60/40 mmHg, heart rate=120/min., sinus tachycardia. On auscultation, moist coarse bubbling rales over all pulmonary fields, RR = 24 per minute, SpO2 = 88%. The skin is cold to the touch, moist, pale gray in color. The ECG shows subepicardial damage, necrosis of the anterior-lateral wall of the LV (QS in V1-V4, ST elevation up to 8 mm in V1-V6).

Before SCB, the following was administered: fentanyl 100 mcg, heparin 5000 units, aspirin 500 mg, dopamine infusion was started. Moderate pain persists.

The SKB team started oxygen insufflation, dose adjustment of dopamine based on blood pressure levels, introduced fentanyl 100 mcg, and prescribed clopidogrel 300 mg. Shock persists, refractory to inotropic support. Treatment options for pulmonary edema due to arterial hypotension are limited. Despite the time from the onset of AMI of more than 3 hours, the presence of an area of myocardial necrosis, taking into account the preservation of a large area of myocardial damage that cannot be corrected for true cardiogenic shock, and the absence of contraindications, a decision was made to perform STL (Metalise). The 2nd peripheral vein was catheterized and 10,000 units were injected. Metalysis (calculation based on body weight), heparin infusion of 1000 units/hour was started. ECG monitoring was performed. Preparations for EIT have been carried out. Within 35 minutes after administration of the thrombolytic, the patient's unstable, serious condition remained. ECG without dynamics. At the 35th minute - the appearance of reperfusion arrhythmias in the form of an accelerated ideoventricular rhythm of 80 per minute

Against this background, a positive trend in hemodynamics was observed, stabilization of blood pressure at the level of 100/70 mmHg, and clearing of consciousness. The skin is dry, moderately pale. ECG - decrease in ST elevation, persists in V2-V4 up to 4 mm.

Subsequently, dopamine dosage was adjusted, and a positive reaction to inotropic support was observed (reperfusion in the zone of viable myocardium, which was in a state of stagnation and hibernation, due to which it is possible to improve myocardial contractility, stimulated by B-adrenergic agonists, and increase EF). Blood pressure is stabilized at 130/80 mmHg, dopamine - 7 mcg/kg/min. Treatment for pulmonary edema was started: fractional administration of morphine, furosemide, slow infusion of nitrates, along with dopamine infusion under blood pressure control. Auscultation in the lungs - a decrease in the caliber and prevalence of wheezing, respiratory rate - 18-20 per minute, SpO2 - 94%. Consciousness is clear.

The patient was transported to the nearest vascular center, where coronary angiography, coronary angioplasty with stenting of infarction-related LAD were performed in the shortest possible time (according to the coronary angiography data, angiographic criteria for effective thrombolysis). The patient received an IABP (intra-aortic balloon counterpulsation). For several days he was on IABP support, inotropic support, in a clear consciousness, breathing independently. The symptoms of OSSN have been stopped. The patient was discharged for outpatient treatment after 21 days.

Thanks to the correctly chosen tactics by the resuscitator, pre-hospital STLT, and intensive therapy, it was possible to stabilize the patient’s extremely serious condition and safely transport him to the hospital.

3rd case.

A call to a 54-year-old man, M., to help the paramedic ambulance team with the cause of AMI, cardiogenic shock.

According to the patient’s relatives, he did not notice any chest pain. I felt unwell about 19 hours ago, there was general weakness, sweating, according to relatives, they noted an unsteady gait, strange behavior during the day, and several times there were pre-fainting states. I was abroad, driving a vehicle in this state, then moved to the passenger seat, because... was no longer able to drive the vehicle. Upon returning to the city, the relatives called emergency services. From the anamnesis it is known that the patient has been suffering from diabetes, type 2, on insulin therapy for a long time.

At the time of arrival of the SKB, the patient is in clear consciousness, intellectual and mental disorders are observed, the patient is euphoric, underestimating the severity of his condition.

There are no focal neurological or meningeal symptoms. The skin is moderately pale, moist, and cold to the touch. BP=80/60 mmHg, heart rate=130/min., sinus tachycardia, SpO2=83%, RR=26/min. On auscultation, breathing is harsh, carried out in all parts of the lungs, no wheezing. The ECG shows subepicardial damage, necrosis of the anterior wall of the LV (QS, ST elevation in V1-V5 5-8mm).

The above-described symptoms are regarded as a manifestation of prolonged hypoxia of mixed origin (hypoxic, circulatory) against the background of the development of complicated AHF AMI. The estimated duration of AMI is 19 hours.

A qualitative test was performed for markers of myocardial necrosis, which is available on the equipment of the cardiac intensive care teams of St. Petersburg State Budgetary Institution of Health and Emergency Medicine (troponin, myoglobin, CPK-MB) - positive, which confirms the age of the MI. A decrease in saturation in the absence of moist rales in the lungs indicates interstitial pulmonary edema.

Before SCB, heparin 5000 units and aspirin 500 mg were administered. No narcotic analgesics were administered. Oxygen insufflation, dopamine infusion 7 mcg/kg/min, fractional administration of morphine, furosemide, Zilt 300 mg were started. BP=115/70 mmHg, heart rate=125/min., RR=26/min., SpO2=92%. Given the tendency to arterial hypotension, the administration of nitrates is impossible. Consciousness without dynamics. Against the background of long-term shock, compensated acidosis was determined by gas analyzer indicators, but in this case, taking into account spontaneous breathing, the administration of sodium bicarbonate is dangerous. Taking into account the correction of respiratory failure with medication, there are no indications for transfer to mechanical ventilation. With the development of ARF due to pulmonary edema against the background of cardiogenic shock, indications for mechanical ventilation should be determined very biasedly, because Respiratory therapy for pulmonary edema involves aggressive parameters to displace extravascular lung water, which significantly reduces cardiac output and aggravates hemodynamic disturbances). : according to echocardiography data (performed at the prehospital stage, available on the equipment of the cardio-resuscitation teams of St. Petersburg State Budgetary Healthcare Institution State Emergency Medical Service - akinesia of the proximal and distal segments of the anterior and lateral walls, the apex of the LV, a sharp decrease in EF.

Despite the age, the patient has an emergency indication for coronary angiography.

The patient was transported to the vascular center. At the time of transfer, the condition was the same.

In the first hour after admission, coronary angiography was performed, revascularization in the territory of the infarct-related artery, and an IABP was installed. The next day the patient was supported by IABP, combined inotropic support, and spontaneous breathing. In this case, the follow-up is unknown.

Having considered the above cases, we see the need for specialized cardio-resuscitation teams in the structure of the ambulance station. To effectively provide care to patients with complicated forms of myocardial infarction, in addition to medications, special training of a doctor (anesthesiology-reanimation, cardiology), additional diagnostic and therapeutic equipment is required. According to statistics from St. Petersburg State Budgetary Healthcare Institution State Ambulance Hospital, the number of cases with stabilization of vital functions of patients in extremely severe and terminal condition in the conditions of specialized teams is 15%-20% higher than in linear ambulance teams.

Having analyzed the provision of care to patients with complicated forms of myocardial infarction by specialized cardiac intensive care teams, we came to the following conclusions:

When providing medical care to patients with ACS at the prehospital stage, despite the justified need to transport the patient as soon as possible to the nearest vascular center to perform early PCI. In some cases, the risk of death during transportation is extremely high in the absence of specialized cardiac resuscitation care; in order to stabilize the patient and prepare for transportation, a doctor must have specialization in anesthesiology and resuscitation, and the team must have additional diagnostic and therapeutic equipment.
When providing specialized resuscitation care to seriously ill patients in full at the prehospital stage, the “door-to-balloon” time in the hospital is reduced and the patient’s prognosis is improved.
According to research, the widespread use of STL in the prehospital stage increases survival and improves the long-term prognosis of patients with ACS with pST. However, in some cases, a balanced and individual approach to determining the indications for STL is necessary.
The presence of a gas analyzer in the equipment of the SKB facilitates work with patients in severe and critical condition, providing objective data for the correction of EBV, CBS, determining indications for transfer to mechanical ventilation, selecting ventilation parameters, as well as assessing the contribution of the hemic component in mixed hypoxia. These features make it easier to stabilize the condition of these patients.
The presence of a qualitative and quantitative analyzer for determining myocardial damage allows for a timely and more accurate approach to the treatment of patients with ACS.

Conclusion:

Considering the trend towards reduction of medical teams in the structure of ambulance stations, to reduce the mortality rate from acute myocardial infarction it is necessary to increase the number of specialized resuscitation teams. The presence of expensive equipment in resuscitation teams: ventilators, gas analyzers, echocardiography, closed heart massage systems, pacemakers, etc. is justified by the high number of stabilized patients and the favorable prognosis for the further course of the disease.

Literature:

1. Diagnosis and treatment of patients with acute myocardial infarction with ST segment elevation of the ECG. Russian recommendations. - M; 2007

2. Diagnosis and treatment of myocardial infarction with ST segment elevation. Recommendations from the American Heart Association and the American College of Cardiology. - M; 2004

3. Guide to emergency medical care / ed. S.F. Bagnenko, A.L. Vertkina, A.G. Miroshnichenko, M.Sh. Khubutia. - M.: GEOTAR-Media, 2007. - 816 p.

4. Ruksin V.V. Emergency cardiology / V.V. Ruxin. - St. Petersburg: Nevsky dialect; M.: Publishing house "Laboratory of Basic Knowledge", 2003. - 512 p.

7. The ASSENT 3 Investigators. Efficacy and safety of tenecteplase in combination with enoxaparin, abciximab, or unfractionated heparin: the ASSENT 3 randomized trial. Lancet 2001;358:605-13.

16.19. Cardiopulmonary resuscitation

Cardiopulmonary resuscitation – This is a set of measures aimed at reviving the body in the event of circulatory and/or respiratory arrest, that is, when clinical death occurs.

Clinical death – this is a kind of transitional state between life and death, which is not yet death, but can no longer be called life. Pathological changes in all organs and systems are reversible.

Graph of the relationship between effective cardiopulmonary resuscitation measures and the time of clinical death.

As you can see in the graph, the chance of being successfully resuscitated decreases by 10% every minute if primary care is not provided. The duration of the period of clinical death is 4–7 minutes. With hypothermia, the period is extended to 1 hour.

There is an algorithm of actions aimed at maintaining the life of the victim:

Assessment of pulsation in the main arteries is not carried out due to frequent diagnostic errors; it is used only as a technique for assessing the effectiveness of cardiopulmonary resuscitation. First aid for patients with cardiopulmonary attacks includes providing breathing with the help of special medical equipment, defibrillation, and emergency drug injections.

Assessing the victim's reactions

Gently shake him by the shoulders and ask loudly, “Are you okay?”

If he reacts then:

Leave him in the same position, making sure that he is not in danger.

Try to find out what happened to him and call for help if necessary.

Re-evaluate his condition periodically.

If he doesn't respond, then follows:

Call someone to help you;

Turn the victim onto his back.

Opening the airways

With your head back and your palm on your forehead, gently tilt the patient's head back, leaving your thumb and index finger free to close the nose if artificial respiration is needed.

Using your fingers to hook the hollow under the chin, lift the victim's chin upward to open the airway.

Breathing assessment

Look closely to see if the chest moves.

Listen to whether the victim is breathing.

Try to feel his breath on your cheek.

During the first few minutes after cardiac arrest, the victim may experience weak breathing or occasional noisy breaths. Don't confuse this with normal breathing. Look, listen, and feel for at least 10 seconds to determine if the victim is breathing normally. If you have any doubt that breathing is normal, assume it is not.

If the victim is breathing normally:

Rotate it to a stable side position;

Ask someone or go for help/call a doctor yourself;

Continue checking for breathing.

Call a doctor

Have someone go for help, or, if you are alone, leave the victim and call the on-call physician or emergency physician, then return and begin chest compressions as follows.

30 chest compressions:

Kneel at the victim's side;

Place the heel of your palm in the middle of the victim’s chest;

Place the heel of the second palm on top of the first;

Interlock your fingers and make sure that the pressure is not placed on the victim's ribs. Do not apply pressure to the upper abdomen or the end of the sternum;

Stand vertically above the victim’s chest and press on the chest with straight arms (compression depth 4–5 cm);

After each compression, do not take your hands off the chest, the frequency of compressions is 100 per minute (slightly less than 2 per 1 second);

Compressions and the intervals between them should take approximately the same amount of time.

2 breaths

After 30 compressions, reopen the victim's airway by tilting his head back and lifting his chin.

Place your palm on your forehead and use your thumb and index finger to compress the soft tissues of your nose.

Open the patient's mouth while keeping their chin up.

Inhale normally and place your lips tightly around the patient's mouth, ensuring a tight seal.

Exhale evenly into his mouth for one second, as with normal breathing, watching the movement of his chest, this will be (sufficient) artificial respiration.

Leaving the patient's head in the same position and slightly straightened, observe the movement of the patient's chest as he exhales.

Take a second normal breath in and out into the patient's mouth (there should be 2 blows in total). Then immediately place your hands on the victim's sternum in the manner described above and perform another 30 chest compressions.

Continue chest compressions and mechanical ventilation at a 30:2 ratio.

Evaluating the effectiveness of actions

Perform 4 sets of “30 compressions – 2 breaths”, then place your fingertips over the carotid artery and evaluate its pulsation. If it is absent, continue to perform the sequence: 30 compressions - 2 breaths, and so on 4 complexes, after which again evaluate the effectiveness.

Continue resuscitation until:

The doctors will not arrive;

The victim will not begin to breathe normally;

You will not lose strength completely (you will not become completely tired).

Stopping to assess the patient's condition can be done only when he begins to breathe normally; Do not interrupt resuscitation until this point.

If you are not performing resuscitation alone, change positions every one to two minutes to avoid fatigue.

Stable lateral position – optimal patient position

There are several options for optimal patient positioning, each of which has its own advantages. There is no universal situation suitable for all victims. The position should be stable, close to this side position with the head down, without pressure on the chest, for free breathing. There is the following sequence of actions to place the victim in a stable lateral position:

Remove the victim's glasses.

Kneel next to the victim and make sure both legs are straight.

Place the patient's arm closest to you at a right angle to the body, with the elbow bent so that the palm faces up.

Stretch your far arm across your chest, pressing the back of his hand to the cheek of the victim on your side.

With your free hand, bend the victim's leg farthest from you, grasping it slightly above the knee and without lifting his foot off the ground.

Keeping his hand pressed to his cheek, pull your far leg to turn the victim onto your side.

Adjust your upper leg so that your hip and knee are bent at a right angle.

Tilt your head back to make sure your airway remains open.

If you need to keep your head tilted, place your cheek on the palm of his bent hand.

Check for breathing regularly.

If the victim must remain in this position for more than 30 minutes, he is turned to the other side to relieve pressure on the lower arm.

In most cases, emergency care in a hospital is associated with fainting and falling . In such cases, it is also necessary to first carry out an inspection according to the algorithm described above. If possible, help the patient return to bed. It is necessary to make a record in the patient's chart that the patient fell, under what conditions this happened and what assistance was provided. This information will help your doctor choose treatment that will prevent or reduce the risk of fainting and falls in the future.

Another common cause requiring immediate attention is respiratory disorders . Their cause may be bronchial asthma, allergic reactions, pulmonary embolism. When examining according to the specified algorithm, it is necessary to help the patient cope with anxiety and find the right words to calm him down. To make the patient's breathing easier, raise the head of the bed, use oxygen pillows and masks. If the patient finds it easier to breathe while sitting, be present to help prevent a possible fall. A patient with respiratory problems should be referred for an x-ray, his arterial gas levels should be measured, an ECG should be performed, and the respiratory rate should be calculated. The patient's medical history and reasons for hospitalization will help determine the causes of breathing problems.

Anaphylactic shock - a type of allergic reaction. This condition also requires emergency care. Uncontrolled anaphylaxis leads to bronchoconstriction, circulatory collapse, and death. If a patient is receiving a blood or plasma transfusion during an attack, it is necessary to immediately stop the supply and replace it with a saline solution. Next, you need to raise the head of the bed and carry out oxygenation. While one member of the medical staff monitors the patient's condition, another must prepare the adrenaline for injection. Corticosteroids and antihistamines can also be used to treat anaphylaxis. A patient suffering from such serious allergic reactions must always have with him an ampoule of adrenaline and a bracelet warning of possible anaphylaxis or a memo for emergency doctors.

Loss of consciousness

There are many reasons why a person may lose consciousness. The patient's medical history and reasons for hospitalization provide information about the nature of this disorder. Treatment for each individual is selected strictly individually, based on the causes of loss of consciousness. Some of these reasons are:

taking alcohol or drugs: Do you smell alcohol on the patient? Are there any obvious signs or symptoms? What is the reaction of the pupils to light? Is your breathing shallow? Does the patient respond to naloxone?

attack(apoplectic, cardiac, epileptic): have there been attacks before? Does the patient experience urinary or bowel incontinence?

metabolic disorders: Does the patient suffer from kidney or liver failure? Does he have diabetes? Check your blood glucose levels. If the patient is hypoglycemic, determine if the patient requires intravenous glucose;

traumatic brain injury: The patient has just suffered a traumatic brain injury. Remember that the elderly patient may develop a subdural hematoma several days after TBI;

stroke: if a stroke is suspected, a CT scan of the brain should be performed;

infection: whether the patient has signs or symptoms of meningitis or sepsis.

Remember that loss of consciousness is always very dangerous for the patient. In this case, it is necessary not only to provide first aid and further treatment, but also to provide emotional support.

Foreign body obstruction of the airway (choking) is a rare but potentially preventable cause of accidental death.

– Give five blows to the back as follows:

Stand to the side and slightly behind the victim.

Supporting the chest with one hand, tilt the victim so that the object that exits the respiratory tract falls out of the mouth rather than gets back into the respiratory tract.

Make about five sharp strokes between your shoulder blades with the heel of your other hand.

– After each beat, monitor to see if the obstruction has improved. Pay attention to efficiency, not the number of hits.

– If five back blows have no effect, perform five abdominal thrusts as follows:

Stand behind the victim and wrap your arms around his upper abdomen.

Tilt the victim forward.

Make a fist with one hand and place it on the area between the navel and the xiphoid process of the victim.

Grasping your fist with your free hand, make a sharp push in an upward and inward direction.

Repeat these steps up to five times.

Currently, the development of cardiopulmonary resuscitation technology is carried out through simulation training (simulation - from lat. . Simulatio“pretense”, a false image of a disease or its individual symptoms) - creating an educational process in which the student acts in a simulated environment and knows about it. The most important qualities of simulation training are the completeness and realism of the modeling of its object. As a rule, the biggest gaps are identified in the area of resuscitation and patient management in emergency situations, when the time for decision-making is reduced to a minimum and the refinement of actions comes to the fore.

This approach makes it possible to acquire the necessary practical and theoretical knowledge without harming human health.

Simulation training allows you to: teach how to work in accordance with modern emergency care algorithms, develop team interaction and coordination, increase the level of performing complex medical procedures, and evaluate the effectiveness of one’s own actions. At the same time, the training system is built on the method of acquiring knowledge “from simple to complex”: starting from basic manipulations and ending with practicing actions in simulated clinical situations.

The simulation training class should be equipped with devices used in emergency conditions (respiratory equipment, defibrillators, infusion pumps, resuscitation and trauma placements, etc.) and a simulation system (mannequins of various generations: for practicing primary skills, for simulating elementary clinical situations and for practicing actions of the prepared group).

In such a system, with the help of a computer, the physiological states of a person are simulated as completely as possible.

All the most difficult stages are repeated by each student at least 4 times:

At a lecture or seminar;

On a mannequin - the teacher shows;

Independent performance on the simulator;

The student sees from the side of his fellow students and notes mistakes.

The flexibility of the system allows it to be used for training and modeling a variety of situations. Thus, simulation education technology can be considered an ideal model for training in prehospital and inpatient care.

Ambulance. Guide for paramedics and nurses Arkady Lvovich Vertkin

16.19. Cardiopulmonary resuscitation

Cardiopulmonary resuscitation – This is a set of measures aimed at reviving the body in the event of circulatory and/or respiratory arrest, that is, when clinical death occurs.

Graph of the relationship between effective cardiopulmonary resuscitation measures and the time of clinical death.

There is an algorithm of actions aimed at maintaining the life of the victim:

Assess the victim's reaction;

Call for help;

Open the airways;

Assess breathing;

Call the doctor on duty or a resuscitator;

Do 30 compressions;

Take 2 breaths;

Evaluate the effectiveness of actions.

Assessing the victim's reactions

Gently shake him by the shoulders and ask loudly, “Are you okay?”

If he reacts then:

Leave him in the same position, making sure that he is not in danger.

Try to find out what happened to him and call for help if necessary.

Re-evaluate his condition periodically.

If he doesn't respond, then follows:

Call someone to help you;

Turn the victim onto his back.

Opening the airways

With your head back and your palm on your forehead, gently tilt the patient's head back, leaving your thumb and index finger free to close the nose if artificial respiration is needed.

Using your fingers to hook the hollow under the chin, lift the victim's chin upward to open the airway.

Breathing assessment

Look closely to see if the chest moves.

Listen to whether the victim is breathing.

Try to feel his breath on your cheek.

If the victim is breathing normally:

Rotate it to a stable side position;

Ask someone or go for help/call a doctor yourself;

Continue checking for breathing.

Call a doctor

Have someone go for help, or, if you are alone, leave the victim and call the on-call physician or emergency physician, then return and begin chest compressions as follows.

30 chest compressions:

Kneel at the victim's side;

Place the heel of your palm in the middle of the victim’s chest;

Place the heel of the second palm on top of the first;

Interlock your fingers and make sure that the pressure is not placed on the victim's ribs. Do not apply pressure to the upper abdomen or the end of the sternum;

Stand vertically above the victim’s chest and press on the chest with straight arms (compression depth 4–5 cm);

After each compression, do not take your hands off the chest, the frequency of compressions is 100 per minute (slightly less than 2 per 1 second);

Compressions and the intervals between them should take approximately the same amount of time.

2 breaths

After 30 compressions, reopen the victim's airway by tilting his head back and lifting his chin.

Place your palm on your forehead and use your thumb and index finger to compress the soft tissues of your nose.

Open the patient's mouth while keeping their chin up.

Inhale normally and place your lips tightly around the patient's mouth, ensuring a tight seal.

Exhale evenly into his mouth for one second, as with normal breathing, watching the movement of his chest, this will be (sufficient) artificial respiration.

Leaving the patient's head in the same position and slightly straightened, observe the movement of the patient's chest as he exhales.

Continue chest compressions and mechanical ventilation at a 30:2 ratio.

Evaluating the effectiveness of actions

Continue resuscitation until:

The doctors will not arrive;

The victim will not begin to breathe normally;

You will not lose strength completely (you will not become completely tired).

Stopping to assess the patient's condition can be done only when he begins to breathe normally; Do not interrupt resuscitation until this point.

If you are not performing resuscitation alone, change positions every one to two minutes to avoid fatigue.

Stable lateral position – optimal patient position

Remove the victim's glasses.

Kneel next to the victim and make sure both legs are straight.

Place the patient's arm closest to you at a right angle to the body, with the elbow bent so that the palm faces up.

Stretch your far arm across your chest, pressing the back of his hand to the cheek of the victim on your side.

With your free hand, bend the victim's leg farthest from you, grasping it slightly above the knee and without lifting his foot off the ground.

Keeping his hand pressed to his cheek, pull your far leg to turn the victim onto your side.

Adjust your upper leg so that your hip and knee are bent at a right angle.

Tilt your head back to make sure your airway remains open.

If you need to keep your head tilted, place your cheek on the palm of his bent hand.

Check for breathing regularly.

If the victim must remain in this position for more than 30 minutes, he is turned to the other side to relieve pressure on the lower arm.

Loss of consciousness

attack(apoplectic, cardiac, epileptic): have there been attacks before? Does the patient experience urinary or bowel incontinence?

traumatic brain injury: The patient has just suffered a traumatic brain injury. Remember that the elderly patient may develop a subdural hematoma several days after TBI;

stroke: if a stroke is suspected, a CT scan of the brain should be performed;

infection: whether the patient has signs or symptoms of meningitis or sepsis.

Remember that loss of consciousness is always very dangerous for the patient. In this case, it is necessary not only to provide first aid and further treatment, but also to provide emotional support.

Foreign body obstruction of the airway (choking) is a rare but potentially preventable cause of accidental death.

– Give five blows to the back as follows:

Stand to the side and slightly behind the victim.

Supporting the chest with one hand, tilt the victim so that the object that exits the respiratory tract falls out of the mouth rather than gets back into the respiratory tract.

Make about five sharp strokes between your shoulder blades with the heel of your other hand.

– After each beat, monitor to see if the obstruction has improved. Pay attention to efficiency, not the number of hits.

– If five back blows have no effect, perform five abdominal thrusts as follows:

Stand behind the victim and wrap your arms around his upper abdomen.

Tilt the victim forward.

Make a fist with one hand and place it on the area between the navel and the xiphoid process of the victim.

Grasping your fist with your free hand, make a sharp push in an upward and inward direction.

Repeat these steps up to five times.

This approach makes it possible to acquire the necessary practical and theoretical knowledge without harming human health.

In such a system, with the help of a computer, the physiological states of a person are simulated as completely as possible.

All the most difficult stages are repeated by each student at least 4 times:

At a lecture or seminar;

On a mannequin - the teacher shows;

Independent performance on the simulator;

The student sees from the side of his fellow students and notes mistakes.

This text is an introductory fragment. From the book Great Soviet Encyclopedia (RE) by the author TSB

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III. Clinical examples

Renal colic

This is a symptom complex that occurs when there is an acute disruption of the outflow of urine from the kidney, which leads to the development of pyelocaliceal hypertension, reflex spasm of the arterial renal vessels, venous stasis, edema of the renal parenchyma, its hypoxia and overstretching of the fibrous capsule of the kidney.

Renal colic is a syndrome that, without revealing the cause of the disease, only indicates the involvement of the kidney or ureter in the pathological process.

Most often, upper urinary tract obstruction is caused by a stone in the ureter. Occlusion of the ureter can also occur with strictures, kinks and torsions of the ureter, with obstruction of its lumen by a blood clot, mucus or pus, caseous masses (with kidney tuberculosis), or a rejected necrotic papilla.

Renal colic is characterized by the sudden appearance of intense pain in the lumbar region, often at night, during sleep, sometimes after physical activity, long walking, shaking, or taking large amounts of liquid or diuretics.

Renal colic is often accompanied by nausea, repeated vomiting, stool and gas retention, and bloating, which makes diagnosis difficult. Palpation reveals sharp pain in the kidney area and muscle resistance on the side of the disease. Sometimes it is possible to palpate an enlarged and painful kidney. Microhematuria may often occur. In some cases, fever, chills, and leukocytosis are observed in the absence of other signs of urinary infection.

Typically, pain begins in the costovertebral angle and radiates to the hypochondrium, along the ureter into the genitals, along the inner surface of the thigh. Less commonly, pain begins along the ureter, and then spreads to the lumbar region on the corresponding side and radiates to the testicle or labia majora.

Atypical irradiation of pain is possible (in the shoulder, scapula, in the navel area), which is explained by the wide nerve connections of the renal nerve plexus. Paradoxical pain in the area of a healthy kidney is often observed. Some patients experience a predominance of pain at the site of irradiation.

Characteristic is the restless behavior of patients who moan, rush about, take incredible poses and cannot find a position in which the intensity of pain would decrease. Pallor and cold sweat appear. Sometimes blood pressure rises. Dysuric phenomena quite often accompany an attack of renal colic. Dysuria is manifested by frequent, painful urination: the closer to the bladder the stone is localized, the more severe the dysuria.

Clinical example

At 12 noon, a call was received to a 46-year-old patient with complaints of lower back pain, frequent painful urination, nausea, and vomiting twice. From the anamnesis it became known that the patient had been suffering from KB and chronic pyelonephritis for two years. The pain arose after traveling in public transport.

Objectively: the general condition is of moderate severity. The patient groans, rushes about, cannot find any place for herself in pain. The skin is pale. Heart sounds are clear and rhythmic. Heart rate - 100 per minute. Blood pressure – 130/80. Vesicular breathing in the lungs. The tongue is dry, covered with a white coating. The abdomen is soft, sharply painful along the left ureter. The symptom of effleurage is sharply positive on the left. Urination is painful, frequent, mixed with blood (with normal stools. Temperature 37.1 degrees.

After examining the patient and collecting anamnesis, I made a diagnosis: ICD, left-sided renal colic. Conducted the following activities:

She administered 5.0 ml of baralgin solution intravenously. The pain was not completely relieved, and the condition improved slightly.
Transported the patient to the Central District Hospital (the patient was hospitalized).

Acute cerebrovascular accidents

A stroke is an acute circulatory disorder in the brain or spinal cord, accompanied by the development of persistent symptoms of damage to the nervous system. There are hemorrhagic and ischemic strokes.

Hemorrhagic stroke (bleeding) develops as a result of rupture of a vessel. The main causes of intracerebral hemorrhage are arterial hypertension, intracranial aneurysm, cerebral amyloid angiopathy, and the use of anticoagulants or thrombolytics. To diagnose hemorrhagic stroke, the following combination of signs is important:

History indicating high blood pressure and hypertensive cerebral crises.
Acute onset of the disease, often during the day, during vigorous activity. Rapid, progressive deterioration of the patient's condition.
Severe autonomic disorders: hyperemia or, in especially severe cases, pale face, sweating, increased body temperature.
Early onset of symptoms caused by displacement and compression of the brain stem. In this case, in addition to disturbances of consciousness, breathing and cardiac activity, oculomotor disorders, nystagmus, and muscle tone disorders are noted.

The main causes of ischemic stroke (cerebral infarction) are atherosclerosis of large arterial vessels or diseases accompanied by thrombotic embolization of cerebral arteries. Diagnostic signs characteristic of ischemic stroke:

Indication in the anamnesis of coronary artery disease, myocardial infarction, atrial fibrillation and transient ischemic attacks.
Development is less rapid than with a hemorrhagic stroke, often during sleep or in the morning immediately after sleep.
The predominance of focal symptoms over general cerebral ones, relative stability of vital functions, preservation of consciousness.

Clinical example

At 9:30 a call was received for a 55-year-old woman. According to relatives, the patient complained of a severe headache in the evening, and in the morning she could not get out of bed, her speech was impaired. From the anamnesis: a woman has been suffering from hypertension for 15 years and was regularly observed by a local physician.

Objectively: the condition is serious. Consciousness is preserved. Skin of normal color, facial hyperemia. Heart sounds are sonorous and rhythmic. Heart rate - 90 per minute, blood pressure - 250/130 mm Hg. Art. In the lungs, breathing is vesicular, there are no wheezes. The abdomen is soft and painless. When examining the face - smoothing of the nasolabial fold on the left, asymmetry of the “grin”. Muscle tone on the left in the upper and lower extremities is sharply reduced. On the right, the tone in the limbs is preserved. Speech is slurred, like “porridge in the mouth.” Stool and urine output are said to be normal.

After examining the patient and collecting anamnesis, I made a diagnosis: cerebral infarction with left-sided hemiparesis. Conducted the following activities:

I recorded a cardiogram (ECG is a normal variant).
She administered intravenously a 25% magnesium solution, 10 ml, diluted in 10 ml of isotonic sodium chloride solution.
I gave 4 glycine tablets under the tongue. 20 minutes after assistance, the patient’s condition was stable, blood pressure was 190/100 mm Hg. Art.
She transported the patient on a stretcher to the central district hospital (the patient was hospitalized in the intensive care unit).

IV. Conclusion

The health worker must earn the trust and respect of the patient. Only in this case can one expect that various advice and recommendations will be followed. Without contact with the patient, with the formal performance of official duties, without attention, sensitivity, and goodwill, it is impossible to achieve a good treatment effect.

An ambulance paramedic must be able to remain calm, be collected and ready to solve problems when providing emergency care to sick and injured people at the prehospital stage. Under any circumstances, a paramedic must be kind and friendly, simple and attentive, modest and sociable, tactful and neat.

An ambulance paramedic has a very short time to make a diagnosis and provide first aid. This requires complete dedication of spiritual and physical strength, great nervous and emotional stress. All the paramedic's attention should be focused on the sick person.

I see my task for the future in the constant improvement of my practical and theoretical skills, more attentive and high-quality patient care. In particular, I plan to increase my knowledge in the field of diagnostics and pre-hospital care for people with cardiovascular diseases, and improve my skills in interpreting ECGs in acute cardiac pathology.

Paramedic Lazareva Yu.V.

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Clinical examples on emergency care with resuscitation. Clinical death

Scope and tactics of treatment measures

1st case

2nd case

3rd case.

III. Clinical examples

Renal colic

Clinical example

Acute cerebrovascular accidents

Clinical example

IV. Conclusion

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