Clinical manifestations of the main syndromes of violation of the body's vital functions. KSMU Department of General Surgery Critical Vital Disorders in Surgical Patients. VII. Questions for self-control

Types of depression of consciousness Fainting - generalized muscle weakness, inability to stand upright, loss of consciousness. Coma - a complete shutdown of consciousness with a total loss of perception of the environment and oneself. Collapse - a drop in vascular tone with a relative decrease in the volume of circulating blood.

Degrees of impaired consciousness Sopor - unconsciousness, preservation of protective movements in response to pain and sound stimuli. Moderate coma - unawakening, lack of protective movements. Deep coma - inhibition of tendon reflexes, a drop in muscle tone. Terminal coma is an agonal state.

Assessment of the depth of impaired consciousness (Glasgow scale) Clear consciousness 15 Stunning Sopor 9-12 Coma 4-8 Brain death 3

Emergency care for loss of consciousness Eliminate etiological factors. Give the patient a horizontal position with a raised foot end. Ensure free breathing: unbutton the collar, belt. Give inhaled stimulants (ammonia, vinegar). Rub the body, cover with warm heating pads. Inject 1% mezaton 1 ml IM or s/c 10% caffeine 1 ml. With severe hypotension and bradycardia 0.1% atropine 0.5-1 ml.

Physiology of respiration The process of respiration The process of respiration is conditionally divided into 3 stages: The first stage includes the delivery of oxygen from the external environment to the alveoli. The second stage involves the diffusion of oxygen through the alveolar membrane of the acinus and its delivery to the tissues. The third stage includes the utilization of oxygen during the biological oxidation of substrates and the formation of energy in cells. If pathological changes occur at any of these stages, ARF may occur. With ARF of any etiology, there is a violation of the transport of oxygen to the tissues and the removal of carbon dioxide from the body.

Indicators of blood gases in a healthy person Indicator Arterial blood Mixed blood p O 2 mm Hg. st SaO 2, % pCO 2, mm Hg st

Etiological classification ONE PRIMARY (stage 1 pathology - oxygen delivery to the alveoli) Causes: mechanical asphyxia, spasm, tumor, vomit, pneumonia, pneumothorax. SECONDARY (stage 2 pathology - impaired oxygen transport from the alveoli to the tissues) Causes: microcirculation disorders, hypovolemia, LA thromboembolism, cardiogenic pulmonary edema.

The main syndromes of ARF 1. Hypoxia is a condition that develops with a decrease in tissue oxygenation. Exogenous hypoxia - due to a decrease in the partial pressure of oxygen in the inhaled air (accidents on submarines, high mountains). Hypoxia due to pathological processes that disrupt the supply of oxygen to tissues at its partial pressure.

Hypoxia due to pathological processes is divided into: a) respiratory (alveolar hypoventilation - impaired airway patency, a decrease in the respiratory surface of the lungs, respiratory depression of central origin); b) circulatory (against the background of acute and chronic circulatory failure); c) tissue (potassium cyanide poisoning - the process of oxygen uptake by tissues is disrupted); d) hemic (decrease in erythrocyte mass or hemoglobin in erythrocytes).

3. Hypoxemic syndrome - a violation of the oxygenation of arterial blood in the lungs. An integral indicator is a reduced level of oxygen partial tension in arterial blood, which occurs in a number of parenchymal lung diseases. The main syndromes of ARF

Clinical stages of ARF Stage I: Consciousness: preserved, anxiety, euphoria. Respiratory function: lack of air, respiratory rate per minute, mild acrocyanosis. Circulation: heart rate in min. BP is normal or slightly elevated. The skin is pale and moist. Partial pressure of O 2 and CO 2 of the blood: p O 2 up to 70 mm Hg. p CO 2 up to 35 mmHg

Stage II: Consciousness: impaired, agitation, delirium. Respiratory function: the strongest suffocation, NPV in min. Cyanosis, sweating of the skin. Circulation: heart rate in min. HELL Partial pressure O 2 and CO 2 of the blood: p O 2 up to 60 mm Hg. p CO 2 up to 50 mmHg Clinical stages of ARF

Stage III: Consciousness: absent, clonic-tonic convulsions, pupils dilated, do not react to light. Respiratory function: tachypnea 40 or more per minute turns into bradypnea 8-10 per minute, spotty cyanosis. Circulation: heart rate more than 140 per minute. BP, atrial fibrillation. Partial pressure of O 2 and CO 2: p O 2 up to 50 mm Hg. p CO 2 to mmHg Clinical stages of ARF

Emergency care for ARF 1. Restoration of airway patency. 2. Elimination of alveolar ventilation disorders (local and general). 3. Elimination of violations of the central hemodynamics. 4. Correction of the etiological factor of ARF. 5. Oxygen therapy 3-5 l/min. at the I stage of ODN. 6. In stage II-III of ARF, tracheal intubation and artificial lung ventilation are performed.

Treatment of AHF 1. Subcutaneous injection of 1-2 ml of morphine, preferably combined with the introduction of 0.5 ml of a 0.1% solution of atropine sulfate; 2. Nitroglycerin under the tongue - 1 tablet or 1-2 drops of 1% solution on a piece of sugar; 3. Analgesics: baralgin 5.0 iv, IM, no-shpa 2.0 IM, analgin 2.0 IM. 4. For cardiac arrhythmias: lidocaine mg IV, novocainamide 10% 10.0 IV, obzidan 5 mg IV. 5. With pulmonary edema: dopmin 40 mg IV on glucose, Lasix 40 mg IV, Eufillin 2.4% 10.0 IV.

ETIOLOGY OF OPN 1. Traumatic, hemorrhagic, blood transfusion, bacterial, anaphylactic, cardiogenic, burn, operational shock; electrical trauma, postpartum sepsis, etc. 2. Acute infarcted kidney. 3. Vascular abstraction. 4. Urological abstraction.

DIAGNOSIS 1. Decrease in diuresis (less than 25 ml/h) with the appearance of protein, erythrocytes, leukocytes, cylinders, decrease in urine density to 1.005-1, Increase in azotemia (16.7-20.0 mmol/l). 3. Hyperkalemia. 4. Decreased blood pressure. 5. Decrease in hemoglobin and erythrocytes.

Prevention and treatment of acute renal failure 1. Sufficient pain relief for injuries. 2. Elimination of hypovolemia. 3. Elimination of water and electrolyte disorders. 4. Correction of cardio dynamics and rheology. 5. Correction of respiratory function. 6. Correction of metabolic disorders. 7. Improvement of blood supply to the kidneys and elimination of foci of infection in them. 8. Antibacterial therapy. 9. Improvement of rheology and microcirculation in the kidneys. 10. Extracorporeal detoxification (hemodialysis). 11. Osmodiuretics (manitol 20% 200.0 IV), saluretics (Lasix mg IV).

Classification of OPEN 1. Endogenous - based on massive necrosis of the liver, resulting from direct damage to its parenchyma; 2. Exogenous (portocaval) - the form develops in patients with cirrhosis of the liver. This disrupts the metabolism of ammonia by the liver; 3. Mixed form.

CLINICAL MANIFESTATIONS OF OPEN 1. Depression of consciousness up to coma 2. Specific "liver smell" from the mouth 3. Icteric sclera and skin 4. Signs of hemorrhagic syndrome 5. The appearance of erythema in the form of stellate angiomas 6. Jaundice 7. Ascites 8. Splenomegaly

LABORATORY DIAGNOSIS Examination of the functions of the liver (increased bilirubin, transaminases, decreased protein), kidneys (azotemia), acid-base balance (metabolic acidosis), water-electrolyte metabolism (hypokalemia, hyponatremia), blood coagulation (hypocoagulation).

Principles of treatment of OPEN 1. Eliminate bleeding and hypovolemia. 2. Eliminate hypoxia. 3. Detoxification. 4. Normalization of energy metabolism. 5. The use of hepatotropic vitamins (B 1 and B 6), hepatoprotectors (Essentiale). 6. Normalization of protein metabolism. 7. Normalization of water-electrolyte metabolism, acid-base balance. 8. Normalization of the blood coagulation system.

SESSION PLAN #40

date according to the calendar-thematic plan

Groups: Medicine

Discipline: Surgery with the basics of traumatology

Number of hours: 2

Topic of the lesson:

Lesson type: lesson learning new educational material

Type of training session: lecture

The goals of training, development and education: formation of knowledge about the main stages of dying, the procedure for resuscitation; concept of post-resuscitation illness;

formation of knowledge about the etiology, pathogenesis, clinic of traumatic shock, the rules for providing PHC, the principles of treatment and patient care.

Education: on the specified topic.

Development: independent thinking, imagination, memory, attention,students' speech (enrichment of vocabulary words and professional terms)

Upbringing: responsibility for the life and health of a sick person in the process of professional activity.

As a result of mastering the educational material, students should: know the main stages of dying, their clinical symptoms, the procedure for resuscitation; have an idea about postresuscitation illness.

Logistics support of the training session: presentation, situational tasks, tests

STUDY PROCESS

Organizational and educational moment: checking attendance at classes, appearance, availability of protective equipment, clothing, familiarization with the lesson plan;

Student survey

Familiarization with the topic, setting learning goals and objectives

Presentation of new material,V polls(sequence and methods of presentation):

Fixing the material : solution of situational problems, test control

Reflection: self-assessment of the work of students in the classroom;

Homework: pp. 196-200 pp. 385-399

Literature:

1. Kolb L.I., Leonovich S.I., Yaromich I.V. General surgery. - Minsk: Vysh.shk., 2008.

2. Gritsuk I.R. Surgery. - Minsk: New Knowledge LLC, 2004

3. Dmitrieva Z.V., Koshelev A.A., Teplova A.I. Surgery with the basics of resuscitation. - St. Petersburg: Parity, 2002

4. L.I.Kolb, S.I.Leonovich, E.L.Kolb Nursing in Surgery, Minsk, Higher School, 2007

5. Order of the Ministry of Health of the Republic of Belarus No. 109 "Hygienic requirements for the arrangement, equipment and maintenance of healthcare organizations and for the implementation of sanitary-hygienic and anti-epidemic measures to prevent infectious diseases in healthcare organizations.

6. Order of the Ministry of Health of the Republic of Belarus No. 165 "On disinfection, sterilization by healthcare institutions

Teacher: L.G. Lagodich

LECTURE SUMMARY

Lecture topic: General disorders of the body's vital functions in surgery.

Questions:

1. Definition of terminal states. The main stages of dying. Preagonal states, agony. Clinical death, signs.

2. Resuscitation measures in terminal conditions. The order of carrying out resuscitation measures, criteria for effectiveness. Conditions for termination of resuscitation.

3. Post-resuscitation disease. Organization of observation and care of patients. biological death. Declaration of death.

4. Rules for handling a corpse.

1. Definition of terminal states. The main stages of dying. Preagonal states, agony. Clinical death, signs.

Terminal States - pathological conditions based on increasing hypoxia of all tissues (primarily the brain), acidosis and intoxication with metabolic products.

During terminal states, the functions of the cardiovascular system, respiration, central nervous system, kidneys, liver, hormonal system, and metabolism decay. The most significant is the extinction of the functions of the central nervous system. Increasing hypoxia and subsequent anoxia in the cells of the brain (primarily the cerebral cortex) lead to destructive changes in its cells. In principle, these changes are reversible and, when normal tissue oxygen supply is restored, do not lead to life-threatening conditions. But with continued anoxia, they turn into irreversible degenerative changes, which are accompanied by protein hydrolysis and, in the end, their autolysis develops. The tissues of the brain and spinal cord are the least resistant to this; only 4–6 minutes of anoxia are necessary for irreversible changes to occur in the cerebral cortex. The subcortical region and the spinal cord can function somewhat longer. The severity of terminal states and their duration depend on the severity and speed of development of hypoxia and anoxia.

Terminal states include:

Severe shock (grade IV shock)

transcendental coma

Collapse

Preagonal state

Terminal pause

Agony

clinical death

Terminal states in their development have3 stages:

1. Preagonal state;

– Terminal pause (since it does not always happen, it is not included in the classification, but it should still be taken into account);

2. An agonal state;

3. Clinical death.

The main stages of dying. Preagonal states, agony. Clinical death, signs.

Ordinary dying, so to speak, consists of several stages, successively replacing each otherStages of dying:

1. Predagonal state . It is characterized by profound disturbances in the activity of the central nervous system, manifested by the lethargy of the victim, low blood pressure, cyanosis, pallor or "marbling" of the skin. This condition can last quite a long time, especially in the context of medical care. Pulse and pressure are low or not detected at all. At this stage it often happens terminal pause. It is manifested by a sudden short-term sharp improvement in consciousness: the patient regains consciousness, may ask for a drink, pressure and pulse are restored. But all this is the remnants of the body's compensatory capabilities gathered together. The pause is short, lasting minutes, after which the next stage begins.

2. The next stage -agony . The last stage of dying, in which the main functions of the organism as a whole are still manifested - respiration, blood circulation and the leading activity of the central nervous system. Agony is characterized by a general disorder of body functions, so the provision of tissues with nutrients, but mainly oxygen, is sharply reduced. Increasing hypoxia leads to a cessation of respiratory and circulatory functions, after which the body passes into the next stage of dying. With powerful destructive effects on the body, the agonal period may be absent (as well as the pre-agonal one) or last for a short time; with some types and mechanisms of death, it can stretch for several hours or even more.

3. The next step in the process of dying isclinical death . At this stage, the functions of the body as a whole have already ceased, it is from this moment that it is customary to consider a person dead. However, minimal metabolic processes are preserved in the tissues that support their viability. The stage of clinical death is characterized by the fact that an already dead person can still be brought back to life by restarting the mechanisms of respiration and blood circulation. Under normal room conditions, the duration of this period is 6-8 minutes, which is determined by the time during which it is possible to fully restore the functions of the cerebral cortex.

4. biological death - this is the final stage of the dying of the organism as a whole, replacing clinical death. It is characterized by irreversible changes in the central nervous system, gradually spreading to other tissues.

Since the onset of clinical death, post-morbid (post-mortem) changes in the human body begin to develop, which are caused by the cessation of body functions as a biological system. They exist in parallel with ongoing life processes in individual tissues.

2. Resuscitation measures in terminal conditions. The order of carrying out resuscitation measures, criteria for effectiveness. Conditions for termination of resuscitation.

The distinction between clinical death (reversible stage of dying) and biological death (irreversible stage of dying) was decisive for the development of resuscitation - a science that studies the mechanisms of dying and reviving a dying organism. The term "resuscitation" itself was first introduced in 1961 by V. A. Negovsky at the International Congress of Traumatologists in Budapest. Anima - soul, re - reverse action, thus - resuscitation is the forced return of the soul to the body.

The formation of resuscitation in the 1960s and 1970s is considered by many to be a sign of revolutionary changes in medicine. This is due to overcoming the traditional criteria of human death - the cessation of breathing and heartbeat - and reaching the level of acceptance of a new criterion - "brain death".

Methods and technique of IVL. Direct and indirect heart massage. Criteria for the effectiveness of resuscitation.

Artificial respiration (artificial lung ventilation - IVL). Need for artificial respiration occurs when breathing is absent or disturbed to such an extent that it threatens the life of the patient. Artificial respiration is an urgent first aid measure for drowning, suffocation (asphyxia during hanging), electric shock, heat and sunstroke, and some poisoning. In case of clinical death, i.e., in the absence of spontaneous breathing and heartbeat, artificial respiration is carried out simultaneously with a heart massage. The duration of artificial respiration depends on the severity of respiratory disorders, and it should continue until fully spontaneous breathing is restored. If there are obvious signs of death, such as cadaveric spots, artificial respiration should be stopped.

The best method of artificial respiration, of course, is to connect special devices to the patient's airways, which can blow the patient up to 1000-1500 ml of fresh air for each breath. But non-specialists, of course, do not have such devices at hand. The old methods of artificial respiration (Sylvester, Schaeffer, etc.), which are based on various methods of chest compression, turned out to be insufficiently effective, since, firstly, they do not provide the release of the airways from the sunken tongue, and secondly, with with their help, no more than 200-250 ml of air enters the lungs in 1 breath.

Currently, mouth-to-mouth and mouth-to-nose breaths are recognized as the most effective methods of artificial respiration (see figure on the left).

The rescuer forcefully exhales air from his lungs into the lungs of the patient, temporarily becoming a breathing apparatus. Of course, this is not the fresh air with 21% oxygen that we breathe. However, as studies by resuscitators have shown, the air exhaled by a healthy person still contains 16-17% oxygen, which is enough to carry out full-fledged artificial respiration, especially in extreme conditions.

So, if the patient does not have his own respiratory movements, you must immediately begin artificial respiration! If there is any doubt whether the victim is breathing or not, one should, without hesitation, begin to “breathe for him” and not waste precious minutes looking for a mirror, applying it to his mouth, etc.

In order to blow "the air of his exhalation" into the patient's lungs, the rescuer is forced to touch the victim's face with his lips. For hygienic and ethical reasons, the following method can be considered the most rational:

1) take a handkerchief or any other piece of cloth (preferably gauze);

2) bite through (break) a hole in the middle;

3) expand it with your fingers up to 2-3 cm;

4) put a tissue with a hole on the nose or mouth of the patient (depending on the chosen method of I. d.); 5) press your lips tightly against the face of the victim through the tissue, and blow through the hole in this tissue.

Artificial respiration "mouth to mouth:

1. The rescuer stands on the side of the victim's head (preferably on the left). If the patient lies on the floor, you have to kneel.

2. Quickly clears the victim's oropharynx from vomit. If the victim's jaws are tightly compressed, the rescuer pushes them apart, if necessary, using a mouth expander tool.

3. Then, putting one hand on the forehead of the victim, and the other on the back of the head, he overbends (that is, throws back) the patient's head, while the mouth, as a rule, opens. To stabilize this position of the body, it is advisable to place a roller from the victim's clothing under the shoulder blades.

4. The rescuer takes a deep breath, slightly delays his exhalation and, bending down to the victim, completely seals the area of \u200b\u200bhis mouth with his lips, creating, as it were, an air-tight dome over the patient's mouth opening. In this case, the patient's nostrils must be clamped with the thumb and forefinger of the hand lying on his forehead, or covered with his cheek, which is much more difficult to do. Lack of tightness is a common mistake in artificial respiration. In this case, air leakage through the nose or corners of the mouth of the victim nullifies all the efforts of the rescuer.

After sealing, the rescuer makes a quick, strong exhalation, blowing air into the respiratory tract and lungs of the patient. Exhalation should last about 1 s and reach 1-1.5 liters in volume in order to cause sufficient stimulation of the respiratory center. In this case, it is necessary to continuously monitor whether the chest of the victim rises well during artificial inspiration. If the amplitude of such respiratory movements is insufficient, then the volume of air blown is small or the tongue sinks.

After the end of the exhalation, the rescuer unbends and releases the victim's mouth, in no case stopping the overextension of his head, because. otherwise, the tongue will sink and there will be no full-fledged independent exhalation. The exhalation of the patient should last about 2 seconds, in any case, it is better that it be twice as long as the inhalation. In a pause before the next breath, the rescuer needs to take 1-2 small ordinary breaths - exhalation “for himself”. The cycle is repeated first with a frequency of 10-12 per minute.

If a large amount of air enters not into the lungs, but into the stomach, the swelling of the latter will make it difficult to save the patient. Therefore, it is advisable to periodically release his stomach from the air, pressing on the epigastric (pituitary) region.

Artificial respiration "mouth to nose" carried out if the patient's teeth are clenched or there is an injury to the lips or jaws. The rescuer, placing one hand on the forehead of the victim, and the other on his chin, hyperextends his head and at the same time presses his lower jaw to the upper. With the fingers of the hand supporting the chin, he should press the lower lip, thereby sealing the mouth of the victim. After a deep breath, the rescuer covers the victim's nose with his lips, creating the same air-tight dome above him. Then the rescuer makes a strong blowing of air through the nostrils (1-1.5 l), while watching the movement of the chest.

After the end of artificial inhalation, it is necessary to release not only the nose, but also the patient's mouth, the soft palate can prevent air from escaping through the nose, and then there will be no exhalation at all when the mouth is closed! It is necessary with such an exhalation to keep the head overbent (i.e., thrown back), otherwise the sunken tongue will interfere with exhalation. The duration of the exhalation is about 2 s. In a pause, the rescuer takes 1-2 small breaths - exhalations “for himself”.

Artificial respiration should be carried out without interruption for more than 3-4 seconds, until full spontaneous breathing is restored or until a doctor appears and gives other instructions. It is necessary to continuously check the effectiveness of artificial respiration (good inflation of the patient's chest, absence of bloating, gradual pinking of the skin of the face). Constantly make sure that vomit does not appear in the mouth and nasopharynx, and if this happens, before the next breath, a finger wrapped in a cloth should be cleared through the mouth of the victim's airways. As artificial respiration is carried out, the rescuer may feel dizzy due to a lack of carbon dioxide in his body. Therefore, it is better that two rescuers carry out air injection, changing after 2-3 minutes. If this is not possible, then every 2-3 minutes the breaths should be reduced to 4-5 per minute, so that during this period the level of carbon dioxide in the blood and brain rises in the person who performs artificial respiration.

When carrying out artificial respiration in a victim with respiratory arrest, it is necessary to check every minute whether he also had a cardiac arrest. To do this, periodically feel the pulse with two fingers on the neck in the triangle between the windpipe (laryngeal cartilage, which is sometimes called the Adam's apple) and the sternocleidomastoid (sternocleidomastoid) muscle. The rescuer places two fingers on the lateral surface of the laryngeal cartilage, after which he “slips” them into the hollow between the cartilage and the sternocleidomastoid muscle. It is in the depths of this triangle that the carotid artery should pulsate.

If there is no pulsation on the carotid artery, an indirect heart massage should be started immediately, combining it with artificial respiration. If you skip the moment of cardiac arrest and perform only artificial respiration without heart massage for 1-2 minutes, then, as a rule, it will not be possible to save the victim.

IVL with the help of equipment - a special conversation in practical classes.

Features of artificial respiration in children. To restore breathing in children under 1 year of age, artificial ventilation of the lungs is carried out according to the method from mouth to mouth and nose, in children older than 1 year - according to the method from mouth to mouth. Both methods are carried out in the position of the child on the back, for children under 1 year old, a low roller (folded blanket) is placed under the back or the upper part of the body is slightly raised with the hand brought under the back, the child's head is thrown back. The caregiver takes a breath (shallow!), hermetically covers the mouth and nose of the child or (in children over 1 year old) only the mouth, and blows air into the child’s respiratory tract, the volume of which should be the smaller, the younger the child (for example, in a newborn it is equal to 30-40 ml). With a sufficient volume of air blown in and air entering the lungs (and not the stomach), chest movements appear. After completing the blow, you need to make sure that the chest is lowering. Blowing an excessively large volume of air for a child can lead to serious consequences - rupture of the alveoli of the lung tissue and air escaping into the pleural cavity. The frequency of inspirations should correspond to the age-related frequency of respiratory movements, which decreases with age. On average, the respiratory rate in 1 minute is in newborns and children up to 4 months. Life - 40, at 4-6 months. - 40-35, at 7 months. - 2 years old - 35-30, at 2-4 years old - 30-25, at 4-6 years old - about 25, at 6-12 years old - 22-20, at 12-15 years old - 20-18.

Heart massage - a method of resuming and artificially maintaining blood circulation in the body by rhythmic contractions of the heart, contributing to the movement of blood from its cavities into the main vessels. Applied in cases of sudden cessation of cardiac activity.

Indications for cardiac massage are determined primarily by general indications for resuscitation, i.e. in the case when there is at least the slightest chance to restore not only independent cardiac activity, but also all other vital body functions. Carrying out heart massage is not indicated in the absence of blood circulation in the body for a long time (biological death) and with the development of irreversible changes in organs that cannot be replaced later by transplantation. It is not advisable to massage the heart if the patient has injuries of organs that are clearly incompatible with life (primarily the brain); with precisely and in advance established terminal stages of oncological and some other incurable diseases. Cardiac massage is not required and when suddenly stopped blood circulation can be restored using electrical defibrillation in the first seconds of ventricular fibrillation of the heart, established during monitoring of the patient's heart activity, or by applying a jerky blow to the patient's chest in the area of the projection of the heart in case of sudden and documented on screen of the cardioscope of his asystole.

There are direct (open, transthoracic) heart massage, performed with one or two hands through a chest incision, and indirect (closed, external) heart massage, carried out by rhythmic compression of the chest and compression of the heart between the sternum and the spine that are displaced in the anteroposterior direction.

Mechanism of actiondirect cardiac massage lies in the fact that when the heart is compressed, the blood in its cavities enters from the right ventricle into the pulmonary trunk and, while artificial ventilation of the lungs is carried out, is saturated with oxygen in the lungs and returns to the left atrium and left ventricle; From the left ventricle, oxygenated blood enters the systemic circulation, and consequently, to the brain and heart. As a result, the restoration of myocardial energy resources makes it possible to resume the contractility of the heart and its independent activity during circulatory arrest as a result of asystole of the ventricles of the heart, as well as ventricular fibrillation, which is successfully eliminated.

Indirect cardiac massage can be performed both by human hands and with the help of special apparatus-massagers.

Direct heart massage is more often more effective than indirect, because. allows you to directly monitor the state of the heart, feel the tone of the myocardium and timely eliminate its atony by injecting intracardiac solutions of adrenaline or calcium chloride, without damaging the branches of the coronary arteries, since it is possible to visually select the avascular region of the heart. However, with the exception of a few situations (eg, multiple rib fractures, massive blood loss, and the inability to quickly resolve hypovolemia - an "empty" heart), indirect massage should be preferred, because. To perform a thoracotomy, even in an operating room, certain conditions and time are required, and the time factor in resuscitation is decisive. Chest compressions can be started almost immediately after circulatory arrest is detected and can be performed by any previously trained person.

Controlling circulatory efficiency , created by heart massage, is determined by three signs: - the occurrence of pulsation of the carotid arteries in time with the massage,

constriction of the pupils,

And the emergence of independent breaths.

The effectiveness of indirect heart massage is ensured by the correct choice of the place of application of force to the chest of the victim (the lower half of the sternum immediately above the xiphoid process).

The massager's hands should be correctly positioned (the proximal part of the palm of one hand is placed on the lower half of the sternum, and the palm of the other is placed on the back of the first, perpendicular to its axis; the fingers of the first hand should be slightly raised and not exert pressure on the victim's chest) (see. diagrams on the left). They should be straightened at the elbow joints. The person performing the massage should stand high enough (sometimes on a chair, stool, stand, if the patient is lying on a high bed or on the operating table), as if hanging with his body over the victim and putting pressure on the sternum not only by the force of his hands, but also by the weight of his body. The force of pressing should be sufficient to shift the sternum towards the spine by 4-6 cm. The pace of the massage should be such as to provide at least 60 heart compressions in 1 minute. When resuscitation is carried out by two persons, the massager squeezes the chest 5 times with a frequency of approximately 1 time in 1 s, after which the second assister makes one vigorous and quick exhalation from the mouth to the mouth or nose of the victim. In 1 min, 12 such cycles are carried out. If resuscitation is carried out by one person, then the specified mode of resuscitation becomes impossible; the resuscitator is forced to carry out an indirect heart massage in a more frequent rhythm - approximately 15 heart compressions in 12 seconds, then 2 vigorous blows of air into the lungs are carried out in 3 seconds; 4 such cycles are performed in 1 minute, and as a result, 60 heart contractions and 8 breaths. An indirect heart massage can only be effective when combined with artificial lung ventilation.

Monitoring the effectiveness of chest compressions carried out continuously in the course of its implementation. To do this, lift the upper eyelid of the patient with a finger and monitor the width of the pupil. If within 60-90 seconds of the heart massage, the pulsation in the carotid arteries is not felt, the pupil does not narrow and respiratory movements (even minimal ones) do not appear, it is necessary to analyze whether the rules for conducting a heart massage are strictly observed, resort to medical elimination of myocardial atony or go (subject to conditions) to direct cardiac massage.

If there are signs of the effectiveness of indirect heart massage, but there is no tendency to restore independent cardiac activity, the presence of ventricular fibrillation of the heart should be assumed, which is clarified using electrocardiography. According to the picture of fibrillation oscillations, the stage of ventricular fibrillation of the heart is determined and indications for defibrillation are established, which should be as early as possible, but not premature.

Non-compliance with the rules for conducting an indirect heart massage can lead to complications such as fracture of the ribs, development of pneumo- and hemothorax, liver rupture, etc.

There are somedifferences in chest compressions in adults, children, and neonates . For children aged 2-10 years, it can be carried out with one hand, for newborns - with two fingers, but at a more frequent rhythm (90 per 1 min in combination with 20 breaths of air into the lungs per 1 min).

3. Post-resuscitation disease. Organization of observation and care of patients. biological death. Declaration of death.

In the case of the effectiveness of the resuscitation measures carried out and the patient, spontaneous breathing and heart contractions are restored. He enters a periodpost-resuscitation illness.

Post-resuscitation period.

In the post-resuscitation period, several stages are distinguished:

1. The stage of temporary stabilization of functions occurs 10-12 hours after the start of resuscitation and is characterized by the appearance of consciousness, stabilization of respiration, blood circulation, and metabolism. Regardless of the further prognosis, the patient's condition improves.

2. The stage of repeated deterioration of the state begins at the end of the first, beginning of the second day. The general condition of the patient worsens, hypoxia increases due to respiratory failure, hypercoagulation develops, hypovolemia due to plasma loss with increased vascular permeability. Microthrombosis and fat embolism impair microperfusion of internal organs. At this stage, a number of severe syndromes develop, from which a "post-resuscitation illness" is formed and delayed death can occur.

3. Stage of normalization of functions.

biological death. Declaration of death.

biological death (or true death) is an irreversible cessation of physiological processes in cells and tissues. Irreversible termination is usually understood as “irreversible within the framework of modern medical technologies” termination of processes. Over time, the possibilities of medicine for the resuscitation of deceased patients change, as a result of which the border of death is pushed into the future. From the point of view of scientists - supporters of cryonics and nanomedicine, most people dying now can be revived in the future if their brain structure is preserved now.

TO early signs of biological death cadaveric spotswith localization in sloping places of the body, then there isrigor mortis , then cadaveric relaxation, cadaveric decomposition . Rigor mortis and cadaveric decomposition usually begin with the muscles of the face and upper limbs. The time of appearance and duration of these signs depend on the initial background, temperature and humidity of the environment, the reasons for the development of irreversible changes in the body.

The biological death of the subject does not mean the simultaneous biological death of the tissues and organs that make up his body. The time to death of the tissues that make up the human body is mainly determined by their ability to survive in conditions of hypoxia and anoxia. In different tissues and organs, this ability is different. The shortest lifetime under anoxic conditions is observed in the brain tissue, more precisely, in the cerebral cortex and subcortical structures. The stem sections and the spinal cord have a greater resistance, or rather resistance to anoxia. Other tissues of the human body have this property to a more pronounced degree. Thus, the heart retains its viability for 1.5-2 hours after the onset of biological death. Kidneys, liver and some other organs remain viable for up to 3-4 hours. Muscle tissue, skin and some other tissues may well be viable up to 5-6 hours after the onset of biological death. Bone tissue, being the most inert tissue of the human body, retains its vitality for up to several days. The phenomenon of survival of organs and tissues of the human body is associated with the possibility of their transplantation, and the earlier after the onset of biological death organs are removed for transplantation, the more viable they are, the greater the likelihood of their successful further functioning in another organism.

2. Clothes are removed from the corpse, laid on a specially designed gurney on the back with knees bent, the eyelids are closed, the lower jaw is tied up, covered with a sheet and taken to the sanitary room of the department for 2 hours (until cadaveric stains appear).

3. Only after that, the nurse writes down on the thigh of the deceased his last name, initials, case history number and the corpse is taken to the morgue.

4. Things and valuables are handed over to the relatives or relatives of the deceased on receipt, according to the inventory drawn up at the time of the patient's death and certified by at least 3 signatures (mesestra, nurse, doctor on duty).

5. All bedding from the bed of the deceased is given for disinfection. The bed, bedside table are wiped with a 5% solution of chloramine B, the bedside vessel is soaked in a 5% solution of chloramine B.

6. During the day, it is not customary to place newly admitted patients on the bed where the patient has recently died.

7. It is necessary to report the death of the patient to the hospital emergency department, to the relatives of the deceased, and in the absence of relatives, as well as in case of sudden death, the cause of which is not clear enough - to the police department.

Topic 11. Wounds and wound healing. Wound definition and wound symptomatology. Types of wounds. The concept of single, multiple, combined and combined wounds. Phases of the course of the wound process. Types of wound healing. Principles of first aid for wounds. Primary surgical treatment of wounds, its types. Secondary surgical treatment. Wound closure by skin grafting.

Purulent wounds primary and secondary. General and local signs of suppuration of the wound. Treatment of a purulent wound depending on the phase of the course of the wound process. The use of proteolytic enzymes. Additional methods of treatment of purulent wounds.

Topic 12. General disorders of life in a surgical patient. Clinical assessment of the general condition of patients. Types of general disorders of the body in surgical patients: terminal conditions, shock, acute blood loss, acute respiratory failure, acute heart failure, dysfunction of the digestive tract, acute renal failure, hemorheological disorders, endogenous intoxication. Glasgow coma scale.

Types, symptoms and diagnosis of terminal states: pre-agony, agony, clinical death. Signs of biological death. First aid in case of cessation of breathing and circulation. Criteria for the effectiveness of revitalization. Monitor control systems. Indications for termination of cardiopulmonary resuscitation.

Shock - causes, pathogenesis, clinical picture, diagnosis, phases and stages of surgical shock. First aid for shock. Complex therapy of shock. Criteria for success in treating shock. Prevention of operational shock. The concept of shocks of another etiology: hemorrhagic shock, cardiogenic shock, anaphylactic shock, septic shock. Intensive care of the consequences of acute and chronic blood loss. The concept of hypoventilation. Diagnosis of insufficiency of the function of external respiration. Equipment for artificial lung ventilation (IVL). Indications for conducting and conducting IVL. Tracheostomy, tracheostomy care. Diagnosis and intensive therapy of disorders of the motor-evacuation function of the digestive tract. Diagnosis of the main syndromes of violation of the water-electrolyte and acid-base state. Principles of drawing up a corrective program. Intensive therapy of disorders of the coagulation system. Diagnosis and intensive therapy of exogenous intoxications. Parenteral nutrition as a component of intensive care.

Topic 13. Mechanical injury. Fractures and dislocations. The concept of trauma. Types of injuries and classification of injuries. The concept of isolated, multiple, combined and combined injuries. Medical prevention of traumatism. Complications and dangers of injuries: immediate, immediate and late. General principles for the diagnosis of traumatic injuries, first aid and treatment. Nonspecific and specific prevention of infectious complications.

Mechanical trauma. Types of mechanical trauma: closed (subcutaneous) and open (wounds). Closed mechanical injuries of soft tissues: bruises, sprains and ruptures (subcutaneous), concussions and compression, prolonged compression syndrome. First aid and treatment of closed soft tissue injuries.

Types of mechanical damage to tendons, bones and joints. Torn ligaments and tendons. Traumatic dislocations. Joint bruises, Hemarthrosis, First aid and treatment. Bone fractures. Classification. Clinical symptoms of fractures. Fundamentals of X-ray diagnostics of dislocations and fractures. The concept of fracture healing. The process of bone formation. First aid for closed and open fractures. Complications of traumatic fractures: shock, fat embolism, acute blood loss, development of infection and their prevention. First aid for spinal fractures with and without spinal cord injury. First aid "for fractures of the pelvis with and without damage to the pelvic organs. Transport immobilization - goals, objectives and principles. Types of transport immobilization. Standard splints. Principles of fracture treatment: reposition, immobilization, surgical treatment. The concept of plaster bandages. Gypsum. The basic rules for applying plaster casts The main types of plaster casts Tools and techniques for removing plaster casts Complications in the treatment of fractures The concept of orthopedics and prosthetics.

The concept of traumatic brain injury, classification. The main dangers of head injuries that pose a threat to the life of patients. Tasks of first aid in case of head injury. Measures for their implementation. Features of transportation of patients.

Types of chest injuries: open, closed, with and without damage to the bone base of the chest, with and without damage to internal organs, unilateral and bilateral. The concept of pneumothorax. Types of pneumothorax: open, closed, valvular (tense) external and internal. First aid and features of transportation for tension pneumothorax, hemoptysis, foreign bodies of the lungs, open and closed injuries of the lungs, heart and main vessels. Features of gunshot wounds of the chest, first aid, transportation of the victim.

Abdominal injuries with and without violation of the integrity of the abdominal wall, abdominal organs and retroperitoneal space. First aid tasks for abdominal trauma. Features of first aid and transportation in case of prolapse of abdominal organs into the wound. Features of gunshot wounds of the abdomen. Complications of traumatic injuries of the abdomen: acute anemia, peritonitis.

Features of medical tactics in outpatient settings.

Topic 14. Thermal, chemical and radiation damage. Electrical injury. Combustiology is a branch of surgery that studies thermal injuries and their consequences.

Burns. Burn classification. Recognition of the depth of burns. Determination of the area of the burn. Prognostic methods for determining the severity of burns.

First aid for burns. Primary surgical treatment of the burn surface: anesthesia, asepsis, surgical technique. Methods of treatment of local treatment of burns.: open, closed, mixed. Skin transplant. Antimicrobial therapy (sulfonamides, antibiotics, sera). Outpatient treatment of burns: indications, contraindications, methods. Restorative and plastic surgery of post-burn cicatricial deformities.

Burn disease: 4 periods of its development and course. General principles of infusion therapy for various periods of burn disease, enteral nutrition and patient care.

Types of radiation burns. Features of first aid for radiation burns. Phases of local manifestations of radiation burns. Treatment of radiation burns (first aid and further treatment).

Cold injury. Types of cold injury: common - freezing and chilling; local - frostbite. Prevention of cold injury in peacetime and wartime. Symptoms of freezing and chills, first aid for them and further treatment.

Classification of frostbite by degrees. Clinical course of frostbite: pre-reactive and reactive periods of the disease.

First aid for frostbite in the pre-reactive period. General and local treatment of frostbite in the reactive period, depending on the degree of damage. 0 "general complex therapy for victims of cold injury. Prevention of tetanus and purulent infection, nutrition and care.

Electrical injury. The effect of electric current on the human body. The concept of electropathology. Local and general effect of electric current. First aid for electrical injury. Features of further examination and treatment of local and general pathology. Lightning strikes. Local and general manifestations. First aid.

Chemical burns. Exposure to caustic chemicals on fabrics. Features of local manifestation. First aid for chemical burns of the skin, oral cavity, esophagus, stomach. Complications and consequences of burns of the esophagus.

Features of medical tactics in outpatient settings.

Topic 15. Fundamentals of purulent-septic surgery. General questions of surgical infection. The concept of surgical infection. Classification of surgical infection: acute and chronic purulent (aerobic), acute anaerobic, acute and chronic specific. The concept of mixed infection.

Local and general manifestations of purulent-septic diseases. Purulent-resorptive fever. Features of asepsis in purulent-septic surgery. Modern principles of prevention and treatment of purulent diseases. Local non-operative and surgical treatment. General principles of the technique of surgical interventions. Modern methods of treatment of purulent focus and methods of postoperative management. General treatment for purulent diseases: rational antibiotic therapy, immunotherapy, complex infusion therapy, hormone and enzyme therapy, symptomatic therapy.

Acute aerobic surgical infection . main pathogens. Ways of infection. The pathogenesis of purulent inflammation. Stages of development of purulent-inflammatory diseases. Classification of acute purulent diseases. local manifestations.

Chronic aerobic surgical infection. Reasons for development. Features of manifestation. Complications: amyloidosis, wound depletion.

Acute anaerobic surgical infection. The concept of clostridial and non-clostridial anaerobic infection. main pathogens. Conditions and factors contributing to the occurrence of anaerobic gangrene and phlegmon. incubation period. clinical forms. Comprehensive prevention and treatment of clostridial anaerobic infection. The use of hyperbaric oxygen therapy. Prevention of nosocomial spread of anaerobic infection.

Place of non-clostridial anaerobic infection in the general structure of surgical infection. Pathogens. Endogenous anaerobic infection. Frequency of anaerobic non-clostridial infection. The most characteristic clinical signs: local and general. Prevention and treatment (local and general) of anaerobic surgical infection.

Topic 16. Acute purulent nonspecific infection. Purulent surgery of the skin and subcutaneous tissue. Types of purulent skin diseases: acne, ostiofolliculitis, folliculitis, furuncle and furunculosis, carbuncle, hydradenitis, erysipelas, erysipeloid, peri-wound pyoderma. Clinic, features of the course and treatment. Types of purulent-inflammatory diseases of the subcutaneous tissue: abscess, cellulitis, phlegmon. Clinic, diagnostics, local and general treatment. Possible complications. Purulent diseases of the lymphatic and blood vessels.

Purulent surgery of the hand. The concept of panaritium. Types of panaritium. Furuncles and carbuncles of the hand. Purulent tendovaginitis. Purulent inflammation of the palm. Purulent inflammation of the back of the hand. Special types of panaritium. Principles of diagnosis and treatment (local and general). Prevention of purulent diseases of the hand.

Purulent surgery of cellular spaces . Phlegmon of the neck. Axillary and subpectoral phlegmon. Subfascial and intermuscular phlegmon of the extremities. Phlegmon of the foot. Purulent mediastinitis. Purulent processes in the tissue of the retroperitoneal space and pelvis. Purulent paranephritis. Purulent and chronic acute paraproctitis. Causes, symptoms, diagnosis, principles of local and general treatment.

Purulent surgery of glandular organs. Purulent parotitis. Predisposing factors, clinical signs, methods of prevention and treatment.

Acute and chronic purulent mastitis. Symptoms, prevention, treatment of acute lactational postpartum mastitis.

Purulent diseases of other glandular organs (pancreatitis, prostatitis, etc.).

Purulent surgery of serous cavities. Introduction to the etiology, clinical manifestations and principles of treatment of purulent meningitis and brain abscesses. Acute purulent pleurisy and pleural empyema. Pericarditis. Purulent diseases of the lungs: abscess and gangrene of the lung, chronic suppurative diseases of the lungs. General ideas about the causes, symptoms, diagnosis and treatment (conservative and operative).

Purulent diseases of the peritoneum and abdominal organs. Acute peritonitis. Classification. Etiology and pathogenesis. Symptomatology and diagnosis. General disorders in the body in acute peritonitis. Principles of treatment. First aid for acute surgical diseases of the abdominal organs.