SUDDEN DEATH

Diagnostics. Lack of consciousness and pulse in the carotid arteries, a little later - cessation of breathing.

During CPR, ECP indicates ventricular fibrillation (in 80% of cases), asystole or electromechanical dissociation (in 10-20% of cases). If it is impossible to urgently register an ECG, they are guided by the manifestations of the onset of clinical death and the reaction to CPR.

Ventricular fibrillation develops suddenly, symptoms appear sequentially: disappearance of the pulse in the carotid arteries and loss of consciousness, single tonic contraction of skeletal muscles, disturbances and respiratory arrest. The reaction to timely CPR is positive, and to cessation of CPR is a quick negative reaction.

With advanced SA or AV blockade, symptoms develop relatively gradually: confusion => motor agitation => moaning => tonic-clonic convulsions => breathing problems (MAS syndrome). When performing closed cardiac massage, there is a rapid positive effect that persists for some time after CPR is stopped.

Electromechanical dissociation in massive pulmonary embolism occurs suddenly (often at a moment of physical stress) and is manifested by cessation of breathing, absence of consciousness and pulse in the carotid arteries, and severe cyanosis of the skin of the upper half of the body. swelling of the neck veins. When CPR is started in a timely manner, signs of its effectiveness are determined.

Electromechanical dissociation during myocardial rupture, cardiac tamponade develops suddenly (often after severe anginal syndrome), without convulsive syndrome, signs of CPR effectiveness are completely absent. Hypostatic spots quickly appear on the back.

Electromechanical dissociation due to other causes (hypovolemia, hypoxia, tension pneumothorax, drug overdose, increasing cardiac tamponade) does not occur suddenly, but develops against the background of progression of the corresponding symptoms.

Urgent Care :

1. In case of ventricular fibrillation and immediate defibrillation is impossible:

Apply a precordial blow: Cover the xiphoid process with two fingers to protect it from damage. It is located at the bottom of the sternum, where the lower ribs meet, and with a sharp blow can break off and injure the liver. Apply a pericardial blow with the edge of your clenched fist slightly above the xiphoid process covered by your fingers. It looks like this: with two fingers of one hand you cover the xiphoid process, and with the fist of the other hand you strike (with the elbow of the hand directed along the victim’s torso).

After this, check the pulse in the carotid artery. If the pulse does not appear, it means that your actions are not effective.

There is no effect - immediately begin CPR, ensure defibrillation is possible as soon as possible.

2. Conduct closed cardiac massage at a frequency of 90 per minute with a compression-decompression ratio of 1:1: the active compression-decompression method (using a cardiopump) is more effective.

3. WALKING in an accessible way (the ratio of massage movements and breathing is 5:1, and when working with one doctor - 15:2), ensure the patency of the airways (throw back the head, extend the lower jaw, insert an air duct, according to indications - sanitize the airways);

Use 100% oxygen:

Intubate the trachea (no more than 30 s);

Do not interrupt cardiac massage and mechanical ventilation for more than 30 seconds.

4. Catheterize the central or peripheral vein.

5. Adrenaline 1 mg every 3 minutes of CPR (method of administration hereinafter - see note).

6. As early as possible - defibrillation 200 J;

No effect - defibrillation 300 J:

No effect - defibrillation 360 J:

No effect - see point 7.

7. Act according to the scheme: drug - cardiac massage and mechanical ventilation, after 30-60 s - defibrillation 360 J:

Lidocaine 1.5 mg/kg - defibrillation 360 J:

There is no effect - after 3 minutes, repeat the lidocaine injection at the same dose and defibrillation 360 J:

No effect - ornid 5 mg/kg - defibrillation 360 J;

There is no effect - after 5 minutes, repeat the injection of Ornid at a dose of 10 mg/kg - defibrillation 360 J;

No effect - novocainamide 1 g (up to 17 mg/kg) - defibrillation 360 J;

No effect - magnesium sulfate 2 g - defibrillation 360 J;

In pauses between shocks, perform closed cardiac massage and mechanical ventilation.

8. With asystole:

If it is impossible to accurately assess the electrical activity of the heart (do not exclude the atonic stage of ventricular fibrillation), act. as in ventricular fibrillation (items 1-7);

If asystole is confirmed in two ECG leads, perform steps. 2-5;

No effect - atropine 1 mg every 3-5 minutes until an effect is achieved or a total dose of 0.04 mg/kg is achieved;

EX as early as possible;

Correct the possible cause of asystole (hypoxia, hypo- or hyperkalemia, acidosis, drug overdose, etc.);

Administration of 240-480 mg of aminophylline may be effective.

9. With electromechanical dissociation:

Execute paragraph 2-5;

Establish and correct its possible cause (massive pulmonary embolism - see relevant recommendations: cardiac tamponade - pericardiocentesis).

10. Monitor vital functions (cardiac monitor, pulse oximeter).

11. Hospitalize after possible stabilization of the condition.

12. CPR can be stopped if:

As the procedure progressed, it became clear that CPR was not indicated:

Persistent asystole that is not amenable to medication, or multiple episodes of asystole are observed:

Using all available methods, there is no evidence that CPR is effective within 30 minutes.

13. CPR may not be started:

In the terminal stage of an incurable disease (if the futility of CPR is documented in advance);

If more than 30 minutes have passed since the cessation of blood circulation;

If the patient has previously documented refusal to perform CPR.

After defibrillation: asystole, ongoing or recurrent ventricular fibrillation, skin burn;

During mechanical ventilation: gastric overfilling with air, regurgitation, aspiration of gastric contents;

During tracheal intubation: laryngo- and bronchospasm, regurgitation, damage to the mucous membranes, teeth, esophagus;

With closed heart massage: fracture of the sternum, ribs, lung damage, tension pneumothorax;

During puncture of the subclavian vein: bleeding, puncture of the subclavian artery, lymphatic duct, air embolism, tension pneumothorax:

With intracardiac injection: administration of drugs into the myocardium, damage to the coronary arteries, hemotamponade, lung injury, pneumothorax;

Respiratory and metabolic acidosis;

Hypoxic coma.

Note. In case of ventricular fibrillation and the possibility of immediate (within 30 s) defibrillation - defibrillation 200 J, then proceed according to paragraphs. 6 and 7.

Administer all medications intravenously quickly during CPR.

When using a peripheral vein, mix the drugs with 20 ml of isotonic sodium chloride solution.

In the absence of venous access, adrenaline, atropine, lidocaine (increasing the recommended dose by 2 times) should be injected into the trachea in 10 ml of isotonic sodium chloride solution.

Intracardiac injections (with a thin needle, with strict adherence to the injection technique and control) are permissible in exceptional cases, when it is absolutely impossible to use other routes of drug administration.

Sodium bicarbonate 1 mmol/kg (4% solution - 2 ml/kg), then 0.5 mmol/kg every 5-10 minutes, used for very long CPR or in cases of hyperkalemia, acidosis, overdose of tricyclic antidepressants, hypoxic lactic acidosis preceding cessation of blood circulation ( exclusively under conditions of adequate mechanical ventilation1).

Calcium supplements are indicated only for severe initial hyperkalemia or overdose of calcium antagonists.

For treatment-resistant ventricular fibrillation, reserve drugs are amiodarone and propranolol.

In case of asystole or electromechanical dissociation after tracheal intubation and administration of drugs, if the cause cannot be eliminated, decide on cessation of resuscitation measures, taking into account the time elapsed from the onset of circulatory arrest.

CARDIOLOGICAL EMERGENCIES TACHYARHYTHMIAS

Diagnostics. Severe tachycardia, tachyarrhythmia.

Differential diagnosis- according to ECG. It is necessary to distinguish between non-paroxysmal and paroxysmal tachycardias: tachycardias with normal duration of the OK8 complex (supraventricular tachycardia, atrial fibrillation and flutter) and tachycardias with a wide 9K8 complex on the ECG (supraventricular tachycardia, fibrillation, atrial flutter with transient or permanent blockade of the P1ca bundle branch: antidromic supraventricular tachycardias and ; atrial fibrillation with IGV syndrome; ventricular tachycardia).

Urgent Care

Emergency restoration of sinus rhythm or correction of heart rate is indicated for tachyarrhythmias complicated by acute circulatory disorders, with the threat of cessation of blood circulation, or with repeated paroxysms of tachyarrhythmias with a known method of suppression. In other cases, it is necessary to provide intensive monitoring and planned treatment (emergency hospitalization).

1. If blood circulation stops, perform CPR according to the “Sudden Death” recommendations.

2. Shock or pulmonary edema (caused by tachyarrhythmia) are absolute vital indications for EIT:

Carry out oxygen therapy;

If the patient’s condition allows, then premedicate (fentanyl 0.05 mg or promedol 10 mg intravenously);

Introduce medicinal sleep (diazepam 5 mg intravenously and 2 mg every 1-2 minutes until falling asleep);

Monitor heart rate:

Carry out EIT (for atrial flutter, supraventricular tachycardia, start with 50 J; for atrial fibrillation, monomorphic ventricular tachycardia - with 100 J; for polymorphic ventricular tachycardia - with 200 J):

If the patient’s condition allows, synchronize the electrical impulse during EIT with the K wave on the ECL

Use well-moistened pads or gel;

At the moment of delivering the shock, press the electrodes firmly against the chest wall:

Apply the shock as the patient exhales;

Follow safety regulations;

There is no effect - repeat the EIT, doubling the discharge energy:

There is no effect - repeat EIT with a discharge of maximum energy;

There is no effect - administer an antiarrhythmic drug indicated for this arrhythmia (see below) and repeat EIT with a maximum energy discharge.

3. In case of clinically significant circulatory disorders (arterial hypotension, anginal pain, increasing heart failure or neurological symptoms) or in case of repeated paroxysms of arrhythmia with a known method of suppression, carry out emergency drug therapy. If there is no effect, the condition worsens (and in the cases indicated below - and as an alternative to drug treatment) - EIT (item 2).

3.1. With paroxysm of reciprocal supraventricular tachycardia:

Carotid sinus massage (or other vagal techniques);

No effect - administer ATP 10 mg intravenously with a push:

No effect - after 2 minutes ATP 20 mg intravenously in a push:

No effect - after 2 minutes verapamil 2.5-5 mg intravenously:

No effect - after 15 minutes verapamil 5-10 mg intravenously;

A combination of ATP or verapamil administration with vagal techniques may be effective:

No effect - after 20 minutes novocainamide 1000 mg (up to 17 mg/kg) intravenously at a rate of 50-100 mg/min (with a tendency to arterial hypotension - in one syringe with 0.25-0.5 ml of 1% mesatone solution or 0.1-0.2 ml of 0.2% norepinephrine solution).

3.2. For paroxysmal atrial fibrillation to restore sinus rhythm:

Novocainamide (clause 3.1);

With a high initial heart rate: first, 0.25-0.5 mg of digoxin (strophanthin) intravenously and after 30 minutes - 1000 mg of novocainamide. To reduce heart rate:

Digoxin (strophantine) 0.25-0.5 mg, or verapamil 10 mg intravenously slowly or 80 mg orally, or digoxin (strophantine) intravenously and verapamil orally, or anaprilin 20-40 mg sublingually or orally.

3.3. For paroxysmal atrial flutter:

If EIT is not possible, reduce heart rate with digoxin (strophanthin) and (or) verapamil (clause 3.2);

To restore sinus rhythm, novocainamide may be effective after preliminary administration of 0.5 mg of digoxin (strophanthin).

3.4. In case of paroxysm of atrial fibrillation against the background of IPU syndrome:

Slow intravenous novocainamide 1000 mg (up to 17 mg/kg), or ami-darone 300 mg (up to 5 mg/kg). or rhythmylene 150 mg. or aimalin 50 mg: either EIT;

Cardiac glycosides. β-adrenergic receptor blockers, calcium antagonists (verapamil, diltazem) are contraindicated!

3.5. During paroxysm of antidromic reciprocal AV tachycardia:

Intravenously slowly novocainamide, or amiodarone, or ajmaline, or rhythmylene (section 3.4).

3.6. In case of takiarigmia against the background of CVS, to reduce heart rate:

Intravenously slowly 0.25 mg of digoxin (strophantine).

3.7. With paroxysm of ventricular tachycardia:

Lidocaine 80-120 mg (1-1.5 mg/kg) and every 5 minutes 40-60 mg (0.5-0.75 mg/kg) intravenously slowly until the effect or a total dose of 3 mg/kg is reached:

No effect - EIT (item 2). or procainamide. or amiodarone (section 3.4);

No effect - EIT or magnesium sulfate 2 g intravenously very slowly:

No effect - EIT or Ornid 5 mg/kg intravenously (over 5 minutes);

No effect - EIT or after 10 minutes Ornid 10 mg/kg intravenously (over 10 minutes).

3.8. With bidirectional fusiform tachycardia.

EIT or slowly introduce 2 g of magnesium sulfate intravenously (if necessary, magnesium sulfate is reintroduced after 10 minutes).

3.9. In case of paroxysm of tachycardia of unknown origin with wide complexes 9K5 on the ECG (if there are no indications for EIT), administer lidocaine intravenously (section 3.7). no effect - ATP (clause 3.1) or EIT, no effect - novocainamide (clause 3.4) or EIT (clause 2).

4. In all cases of acute cardiac arrhythmia (except for repeated paroxysms with restored sinus rhythm), emergency hospitalization is indicated.

5. Constantly monitor heart rate and conduction.

Cessation of blood circulation (ventricular fibrillation, asystole);

MAS syndrome;

Acute heart failure (pulmonary edema, arrhythmic shock);

Arterial hypotension;

Respiratory failure when administered narcotic analgesics or diazepam;

Skin burns during EIT:

Thromboembolism after EIT.

Note. Emergency treatment of arrhythmias should be carried out only for the indications given above.

If possible, the cause of arrhythmia and its supporting factors should be influenced.

Emergency EIT with a heart rate less than 150 per minute is usually not indicated.

In case of severe tachycardia and there are no indications for urgent restoration of sinus rhythm, it is advisable to reduce heart rate.

If there are additional indications, potassium and magnesium supplements should be used before administering antiarrhythmic drugs.

For paroxysmal atrial fibrillation, the administration of 200 mg of fenkarol orally can be effective.

An accelerated (60-100 per minute) idioventricular rhythm or rhythm from the AV junction is usually a replacement, and the use of antiarrhythmic drugs in these cases is not indicated.

Emergency care for repeated, habitual paroxysms of tachyarrhythmia should be provided taking into account the effectiveness of treatment of previous paroxysms and factors that can change the patient’s response to the introduction of antiarrhythmic drugs that helped him before.

BRADYARHYTHMIAS

Diagnostics. Severe (heart rate less than 50 per minute) bradycardia.

Differential diagnosis- according to ECG. It is necessary to differentiate sinus bradycardia, SA node arrest, SA and AV blockade: distinguish AV blockade by degree and level (distal, proximal); in the presence of an implanted pacemaker, it is necessary to evaluate the effectiveness of stimulation at rest, with changes in body position and load.

Urgent Care . Intensive therapy is necessary if bradycardia (heart rate less than 50 per minute) causes MAS syndrome or its equivalents, shock, pulmonary edema, arterial hypotension, angina pain, or a progressive decrease in heart rate or an increase in ectopic ventricular activity is observed.

2. In case of MAS syndrome or bradycardia causing acute heart failure, arterial hypotension, neurological symptoms, anginal pain or with a progressive decrease in heart rate or increase in ectopic ventricular activity:

Place the patient with the lower limbs elevated at an angle of 20° (if there is no pronounced congestion in the lungs):

Carry out oxygen therapy;

If necessary (depending on the patient’s condition), closed heart massage or rhythmic tapping on the sternum (“fist rhythm”);

Administer atropine 1 mg intravenously over 3-5 minutes until the effect is achieved or a total dose of 0.04 mg/kg is achieved;

No effect - immediate endocardial percutaneous or transesophageal pacemaker:

There is no effect (or there is no possibility of ECS) - intravenous slow injection of 240-480 mg of aminophylline;

No effect - dopamine 100 mg or adrenaline 1 mg in 200 ml of 5% glucose solution intravenously; Gradually increase the infusion rate until a minimum sufficient heart rate is achieved.

3. Constantly monitor heart rate and conduction.

4. Hospitalize after possible stabilization of the condition.

Main dangers in complications:

Asystole;

Ectopic ventricular activity (up to fibrillation), including after the use of adrenaline, dopamine. atropine;

Acute heart failure (pulmonary edema, shock);

Arterial hypotension:

Anginal pain;

Impossibility or ineffectiveness of pacemaker:

Complications of endocardial pacemaker (ventricular fibrillation, right ventricular perforation);

Pain during transesophageal or percutaneous pacemaker.

UNSTABLE ANGINA

Diagnostics. The appearance of frequent or severe anginal attacks (or their equivalents) for the first time, a change in the course of previously existing angina, the resumption or appearance of angina in the first 14 days of the development of myocardial infarction, or the first appearance of anginal pain at rest.

There are risk factors for the development or clinical manifestations of coronary artery disease. Changes in the ECG, even at the height of the attack, may be vague or absent!

Differential diagnosis. In most cases - with prolonged exertional angina, acute myocardial infarction, cardialgia. extracardiac pain.

Urgent Care

1. Shown:

Nitroglycerin (tablets or aerosol 0.4-0.5 mg sublingually repeatedly);

Oxygen therapy;

Correction of blood pressure and heart rate:

Propranolol (anaprilin, inderal) 20-40 mg orally.

2. For anginal pain (depending on its severity, age and condition of the patient);

Morphine up to 10 mg or neuroleptanalgesia: fentanyl 0.05-0.1 mg or promedol 10-20 mg with 2.5-5 mg droperidol intravenously in divided doses:

In case of insufficient analgesia - 2.5 g of analgin intravenously, and in case of high blood pressure - 0.1 mg of clonidine.

5000 units of heparin intravenously. and then dropwise 1000 units/hour.

5. Hospitalize after possible stabilization of the condition. Main dangers and complications:

Acute myocardial infarction;

Acute disturbances of heart rhythm or conduction (including sudden death);

Incomplete elimination or recurrence of anginal pain;

Arterial hypotension (including drug-induced);

Acute heart failure:

Breathing disorders when administered narcotic analgesics.

Note. Emergency hospitalization is indicated, regardless of the presence of changes on the ECG, in intensive care units (wards), departments for the treatment of patients with acute myocardial infarction.

It is necessary to ensure constant monitoring of heart rate and blood pressure.

To provide emergency care (in the first hours of the disease or in case of complications), catheterization of a peripheral vein is indicated.

For recurrent anginal pain or moist rales in the lungs, nitroglycerin should be administered intravenously.

For the treatment of unstable angina, the rate of intravenous heparin administration must be selected individually, achieving a stable increase in activated partial thromboplastin time by 2 times compared with its normal value. It is much more convenient to use low molecular weight heparin enoxaparin (Clexane). 30 mg of Clexane is administered intravenously as a bolus, after which the drug is prescribed subcutaneously at 1 mg/kg 2 times a day for 3-6 days.

If traditional narcotic analgesics are not available, then 1-2 mg of butorphanol or 50-100 mg of tramadol with 5 mg of droperidol and (or) 2.5 g of analgin with 5 mg of diaepam can be prescribed intravenously slowly or in fractions.

MYOCARDIAL INFARCTION

Diagnostics. Characteristic are chest pain (or its equivalents) radiating to the left (sometimes to the right) shoulder, forearm, scapula, and neck. lower jaw, epigastric region; disturbances of heart rhythm and conduction, instability of blood pressure: the response to taking nitroglycerin is incomplete or absent. Other variants of the onset of the disease are less common: asthmatic (cardiac asthma, pulmonary edema). arrhythmic (fainting, sudden death, MAS syndrome). cerebrovascular (acute neurological symptoms), abdominal (pain in the epigastric region, nausea, vomiting), asymptomatic (weakness, vague sensations in the chest). There is a history of risk factors or signs of coronary artery disease, the appearance for the first time or a change in habitual anginal pain. Changes in the ECG (especially in the first hours) may be vague or absent! 3-10 hours after the onset of the disease - a positive test with troponin-T or I.

Differential diagnosis. In most cases - with prolonged angina, unstable angina, cardialgia. extracardiac pain. PE, acute diseases of the abdominal organs (pancreatitis, cholecystitis, etc.), dissecting aortic aneurysm.

Urgent Care

1. Shown:

Physical and emotional peace:

Nitroglycerin (tablets or aerosol 0.4-0.5 mg sublingually repeatedly);

Oxygen therapy;

Correction of blood pressure and heart rate;

Acetylsalicylic acid 0.25 g (chew);

Propranolol 20-40 mg orally.

2. For pain relief (depending on the severity of pain, the patient’s age, his condition):

Morphine up to 10 mg or neuroleptanalgesia: fentanyl 0.05-0.1 mg or promedol 10-20 mg with 2.5-5 mg droperidol intravenously in fractions;

In case of insufficient analgesia - 2.5 g of analgin intravenously, and against the background of high blood pressure - 0.1 mg of clonidine.

3. To restore coronary blood flow:

In case of transmural myocardial infarction with elevation of the 8T segment on the ECG (in the first 6, and in case of recurrent pain - up to 12 hours from the onset of the disease), administer streptokinase 1,500,000 IU intravenously over 30 minutes as early as possible:

In case of subendocardial myocardial infarction with depression of the 8T segment on the ECG (or the impossibility of thrombolytic therapy), administer 5000 units of heparin intravenously as a bolus and then drip as soon as possible.

4. Constantly monitor heart rate and conduction.

5. Hospitalize after possible stabilization of the condition.

Main dangers and complications:

Acute disturbances of heart rhythm and conduction up to sudden death (ventricular fibrillation), especially in the first hours of myocardial infarction;

Recurrence of anginal pain;

Arterial hypotension (including drug-induced);

Acute heart failure (cardiac asthma, pulmonary edema, shock);

Arterial hypotension; allergic, arrhythmic, hemorrhagic complications with the administration of streptokinase;

Breathing disorders due to the administration of narcotic analgesics;

Myocardial rupture, cardiac tamponade.

Note. To provide emergency care (in the first hours of the disease or when complications develop), catheterization of a peripheral vein is indicated.

For recurrent anginal pain or moist rales in the lungs, nitroglycerin should be administered intravenously.

If there is an increased risk of developing allergic complications, administer 30 mg of prednisolone intravenously before prescribing streptokinase. When carrying out thrombolytic therapy, ensure control of the heart rate and basic hemodynamic indicators, readiness to correct possible complications (availability of a defibrillator, ventilator).

For the treatment of subendocardial (with depression of the 8T segment and without a pathological O wave) myocardial infarction, the rate of intravenous administration of hegyurin must be selected individually, achieving a stable increase in activated partial thromboplastin time by 2 times compared with its normal value. It is much more convenient to use low molecular weight heparin enoxaparin (Clexane). 30 mg of Clexane is administered intravenously as a bolus, after which the drug is prescribed subcutaneously at 1 mg/kg 2 times a day for 3-6 days.

If traditional narcotic analgesics are not available, then 1-2 mg of butorphanol or 50-100 mg of tramadol with 5 mg of droperidol and (or) 2.5 g of analgin with 5 mg of diaepam can be prescribed intravenously slowly or in fractions.

CARDIOGENIC PULMONARY EDEMA

Diagnostics. Characteristic: suffocation, shortness of breath, worsening in a lying position, which forces patients to sit down: tachycardia, acrocyanosis. overhydration of tissues, inspiratory shortness of breath, dry wheezing, then moist rales in the lungs, copious foamy sputum, ECG changes (hypertrophy or overload of the left atrium and ventricle, blockade of the left branch of the Pua's bundle, etc.).

History of myocardial infarction, heart defect or other heart disease. hypertension, chronic heart failure.

Differential diagnosis. In most cases, cardiogenic pulmonary edema is differentiated from non-cardiogenic (with pneumonia, pancreatitis, cerebrovascular accident, chemical damage to the lungs, etc.), pulmonary embolism, and bronchial asthma.

Urgent Care

1. General activities:

Oxygen therapy;

Heparin 5000 units intravenous bolus:

Heart rate correction (if the heart rate is more than 150 per 1 min - EIT; if the heart rate is less than 50 per 1 min - ECS);

In case of excessive foam formation, defoaming (inhalation of a 33% ethyl alcohol solution or intravenously 5 ml of a 96% ethyl alcohol solution and 15 ml of a 40% glucose solution), in extremely severe (1) cases, 2 ml of a 96% ethyl alcohol solution is injected into the trachea.

2. With normal blood pressure:

Complete step 1;

Sit the patient with lower limbs down;

Nitroglycerin, tablets (preferably aerosol) 0.4-0.5 mg sublingually again after 3 minutes or up to 10 mg intravenously slowly in fractions or intravenously in 100 ml of isotonic sodium chloride solution, increasing the rate of administration from 25 mcg/min until effect by controlling blood pressure:

Diazepam up to 10 mg or morphine 3 mg intravenously in fractions until the effect is achieved or a total dose of 10 mg is reached.

3. For arterial hypertension:

Complete step 1;

Sit the patient down with lower limbs down:

Nitroglycerin, tablets (preferably aerosol) 0.4-0.5 mg under the tongue once;

Furosemide (Lasix) 40-80 mg intravenously;

Nitroglycerin intravenously (item 2) or sodium nitroprusside 30 mg in 300 ml of 5% glucose solution intravenously, gradually increasing the rate of infusion of the drug from 0.3 mcg/(kg x min) until the effect is obtained, controlling blood pressure, or pentamin to 50 mg intravenously in fractions or drips:

Intravenously up to 10 mg of diazepam or up to 10 mg of morphine (item 2).

4. In case of severe arterial hypotension:

Follow step 1:

Lay the patient down, raising the head of the bed;

Dopamine 200 mg in 400 ml of 5% glucose solution intravenously, increasing the infusion rate from 5 mcg/(kg x min) until blood pressure is stabilized at a minimum sufficient level;

If it is impossible to stabilize blood pressure, additionally prescribe norepinephrine hydrotartrate 4 mg in 200 ml of 5-10% glucose solution, increasing the infusion rate from 0.5 mcg/min until blood pressure is stabilized at a minimum sufficient level;

If blood pressure increases, accompanied by increasing pulmonary edema, additionally nitroglycerin is given intravenously (item 2);

Furosemide (Lasix) 40 mg IV after blood pressure has stabilized.

5. Monitor vital functions (cardiac monitor, pulse oximeter).

6. Hospitalize after possible stabilization of the condition. Main dangers and complications:

Fulminant form of pulmonary edema;

Airway obstruction by foam;

Respiratory depression;

Tachyarrhythmia;

Asystole;

Anginal pain:

Increased pulmonary edema with increased blood pressure.

Note. The minimum sufficient blood pressure should be understood as a systolic pressure of about 90 mmHg. Art. provided that the increase in blood pressure is accompanied by clinical signs of improved perfusion of organs and tissues.

Eufillin for cardiogenic pulmonary edema is an adjuvant and may be indicated for bronchospasm or severe bradycardia.

Glucocorticoid hormones are used only for respiratory distress syndrome (aspiration, infection, pancreatitis, inhalation of irritants, etc.).

Cardiac glycosides (strophanthin, digoxin) can be prescribed only for moderate congestive heart failure in patients with tachysystolic form of atrial fibrillation (flutter).

In aortic stenosis, hypertrophic cardiomyopathy, cardiac tamponade, nitroglycerin and other peripheral vasodilators are relatively contraindicated.

Creating positive end-expiratory pressure is effective.

To prevent recurrence of pulmonary edema in patients with chronic heart failure, ACE inhibitors (captopril) are useful. When captopril is first prescribed, treatment should begin with a test dose of 6.25 mg.

CARDIOGENIC SHOCK

Diagnostics. A marked decrease in blood pressure combined with signs of impaired blood supply to organs and tissues. Systolic blood pressure is usually below 90 mmHg. Art., pulse - below 20 mm Hg. Art. There are symptoms of deterioration in peripheral circulation (pale cyanotic moist skin, collapsed peripheral veins, decreased skin temperature of the hands and feet); a decrease in blood flow speed (the time it takes for the white spot to disappear after pressing on the nail bed or palm is more than 2 s), a decrease in diuresis (less than 20 ml/h), impaired consciousness (from mildly inhibited to the appearance of focal neurological symptoms and the development of coma).

Differential diagnosis. In most cases, true cardiogenic shock should be differentiated from its other varieties (reflex, arrhythmic, drug, with slow myocardial rupture, rupture of the septum or papillary muscles, damage to the right ventricle), as well as from pulmonary embolism, hypovolemia, internal bleeding and arterial hypotension without shock.

Urgent Care

Emergency care must be carried out in stages, quickly moving to the next stage if the previous one is ineffective.

1. In the absence of pronounced congestion in the lungs:

Place the patient with the lower limbs elevated at an angle of 20° (in case of severe congestion in the lungs - see “Pulmonary edema”):

Carry out oxygen therapy;

In case of anginal pain, carry out complete anesthesia:

Correct heart rate (paroxysmal tachyarrhythmia with a heart rate of more than 150 beats per minute is an absolute indication for EIT, acute bradycardia with a heart rate of less than 50 beats per minute is for pacemaker);

Administer heparin 5000 units intravenously.

2. In the absence of pronounced congestion in the lungs and signs of a sharp increase in central venous pressure:

Inject 200 ml of 0.9% sodium chloride solution intravenously over 10 minutes under the control of blood pressure and respiratory rate. Heart rate, auscultatory picture of the lungs and heart (if possible, control central venous pressure or wedge pressure in the pulmonary artery);

If arterial hypotension persists and there are no signs of transfusion hypervolemia, repeat fluid administration according to the same criteria;

In the absence of signs of transfusion hypervolemia (central venous pressure below 15 cm of water column), continue infusion therapy at a rate of up to 500 ml/h, monitoring these indicators every 15 minutes.

If blood pressure cannot be quickly stabilized, then proceed to the next stage.

3. Introduce dopamine 200 mg in 400 ml of 5% glucose solution intravenously, increasing the infusion rate starting from 5 mcg/(kg x min) until the minimum sufficient blood pressure is achieved;

There is no effect - additionally prescribe norepinephrine hydrotartrate 4 mg in 200 ml of 5% glucose solution intravenously, increasing the infusion rate from 0.5 mcg/min until the minimum sufficient blood pressure is achieved.

4. Monitor vital functions: cardiac monitor, pulse oximeter.

5. Hospitalize after possible stabilization of the condition.

Main dangers and complications:

Delayed diagnosis and initiation of treatment:

Inability to stabilize blood pressure:

Pulmonary edema due to increased blood pressure or intravenous fluid administration;

Tachycardia, tachyarrhythmia, ventricular fibrillation;

Asystole:

Recurrence of anginal pain:

Acute renal failure.

Note. The minimum sufficient blood pressure should be understood as a systolic pressure of about 90 mmHg. Art. when signs of improved perfusion of organs and tissues appear.

Glucocorticoid hormones are not indicated for true cardiogenic shock.

emergency angina heart attack poisoning

HYPERTENSIVE CRISES

Diagnostics. Increased blood pressure (usually acute and significant) with neurological symptoms: headache, “floaters” or blurred vision, paresthesia, “crawling” sensation, nausea, vomiting, weakness in the limbs, transient hemiparesis, aphasia, diplopia.

In neurovegetative crisis (type I crisis, adrenal): sudden onset. excitement, hyperemia and moisture of the skin. tachycardia, frequent and profuse urination, a predominant increase in systolic pressure with an increase in pulse pressure.

In the water-salt form of crisis (type II crisis, norepinephrine): gradual onset, drowsiness, adynamia, disorientation, pallor and puffiness of the face, swelling, a predominant increase in diastolic pressure with a decrease in pulse pressure.

In the convulsive form of the crisis: throbbing, bursting headache, psychomotor agitation, repeated vomiting without relief, visual disturbances, loss of consciousness, clonic-tonic convulsions.

Differential diagnosis. First of all, one should take into account the severity, form and complications of the crisis, identify crises associated with the sudden withdrawal of antihypertensive drugs (clonidine, beta-blockers, etc.), differentiate hypertensive crises from cerebrovascular accidents, diencephalic crises and crises with pheochromocytoma.

Urgent Care

1. Neurovegetative form of crisis.

1.1. For mild cases:

Nifedipine 10 mg sublingually or in drops orally every 30 minutes, or clonidine 0.15 mg sublingually. then 0.075 mg every 30 minutes until effect, or a combination of these drugs.

1.2. In severe cases.

Clonidine 0.1 mg intravenously slowly (can be combined with nifedipine 10 mg sublingually), or sodium nitroprusside 30 mg in 300 ml of 5% glucose solution intravenously, gradually increasing the rate of administration until the required blood pressure is achieved, or pentamin up to 50 mg intravenously drip or stream fractionally;

If the effect is insufficient, furosemide 40 mg intravenously.

1.3. If emotional tension persists, additionally diazepam 5-10 mg orally, intramuscularly or intravenously, or droperidol 2.5-5 mg intravenously slowly.

1.4. For persistent tachycardia, propranolol 20-40 mg orally.

2. Water-salt form of crisis.

2.1. For mild cases:

Furosemide 40-80 mg orally once and nifedipine 10 mg sublingually or in drops orally every 30 minutes until effect, or furosemide 20 mg orally once and captopril sublingually or orally 25 mg every 30-60 minutes until effect.

2.2. In severe cases.

Furosemide 20-40 mg intravenously;

Sodium nitroprusside or pentamine intravenously (section 1.2).

2.3. If neurological symptoms persist, intravenous administration of 240 mg of aminophylline may be effective.

3. Convulsive form of crisis:

Diazepam 10-20 mg intravenously slowly until seizures are eliminated; in addition, magnesium sulfate 2.5 g intravenously very slowly can be prescribed:

Sodium nitroprusside (clause 1.2) or pentamine (clause 1.2);

Furosemide 40-80 mg intravenously slowly.

4. Crises associated with sudden withdrawal of antihypertensive drugs:

Appropriate antihypertensive drug intravenously. under the tongue or orally, with severe arterial hypertension - sodium nitroprusside (section 1.2).

5. Hypertensive crisis complicated by pulmonary edema:

Nitroglycerin (preferably aerosol) 0.4-0.5 mg sublingually and immediately 10 mg in 100 ml of isotonic sodium chloride solution intravenously. increasing the rate of administration from 25 mcg/min until the effect is obtained, either sodium nitroprusside (section 1.2) or pentamine (section 1.2);

Furosemide 40-80 mg intravenously slowly;

Oxygen therapy.

6. Hypertensive crisis complicated by hemorrhagic stroke or subarachnoid hemorrhage:

For severe arterial hypertension - sodium nitroprusside (section 1.2). reduce blood pressure to values ​​higher than normal for a given patient; if neurological symptoms increase, reduce the rate of administration.

7. Hypertensive crisis complicated by anginal pain:

Nitroglycerin (preferably an aerosol) 0.4-0.5 mg sublingually and immediately 10 mg intravenously (item 5);

Pain relief is required - see “Angina”:

If the effect is insufficient, propranolol 20-40 mg orally.

8. In case of complicated course- monitor vital functions (cardiac monitor, pulse oximeter).

9. Hospitalize after possible stabilization of the condition .

Main dangers and complications:

Arterial hypotension;

Cerebrovascular accident (hemorrhagic or ischemic stroke);

Pulmonary edema;

Anginal pain, myocardial infarction;

Tachycardia.

Note. In case of acute arterial hypertension, which has not been restored to normal life, reduce blood pressure within 20-30 minutes to the usual, “working” or slightly higher values, use intravenous. route of administration of drugs whose hypotensive effect can be controlled (sodium nitroprusside, nitroglycerin).

In case of a hypertensive crisis without an immediate threat to life, reduce blood pressure gradually (over 1-2 hours).

If the course of hypertension worsens, not reaching a crisis, blood pressure must be reduced within several hours, and the main antihypertensive drugs should be prescribed orally.

In all cases, blood pressure should be reduced to the usual, “working” values.

Provide emergency care for repeated hypertensive crises of sls diets, taking into account the existing experience in treating previous ones.

When using captopril for the first time, treatment should begin with a trial dose of 6.25 mg.

The hypotensive effect of pentamine is difficult to control, so the drug can only be used in cases where an emergency reduction in blood pressure is indicated and there are no other possibilities for this. Pentamine is administered 12.5 mg intravenously in fractional doses or drops up to 50 mg.

During a crisis in patients with pheochromocytoma, raise the head of the bed. 45°; prescribe (rentolation (5 mg intravenously after 5 minutes until effect); you can use prazosin 1 mg sublingually repeatedly or sodium nitroprusside. As an auxiliary drug - droperidol 2.5-5 mg intravenously slowly. Change P-adrenergic receptor blockers only (!) after the introduction of α-adrenoreceptor blockers.

PULMONARY EMBOLISM

Diagnostics Massive pulmonary embolism is manifested by sudden cessation of blood circulation (electromechanical dissociation), or shock with severe shortness of breath, tachycardia, pallor or severe cyanosis of the skin of the upper half of the body, swelling of the jugular veins, antinoxious pain, and electrocardiographic manifestations of acute “cor pulmonale.”

Non-passive pulmonary embolism is manifested by shortness of breath, tachycardia, and arterial hypotension. signs of pulmonary infarction (pulmonary-pleural pain, cough, in some patients - with sputum stained with blood, increased body temperature, crepitating rales in the lungs).

To diagnose PE, it is important to take into account the presence of risk factors for the development of thromboembolism, such as a history of thromboembolic complications, old age, prolonged mobilization, recent surgery, heart disease, heart failure, atrial fibrillation, cancer, DVT.

Differential diagnosis. In most cases - with myocardial infarction, acute heart failure (cardiac asthma, pulmonary edema, cardiogenic shock), bronchial asthma, pneumonia, spontaneous pneumothorax.

Urgent Care

1. If blood circulation stops - CPR.

2. In case of massive pulmonary embolism with arterial hypotension:

Oxygen therapy:

Catheterization of the central or peripheral vein:

Heparin 10,000 units intravenously in a bolus, then drip at an initial rate of 1000 units/hour:

Infusion therapy (reopolyglucin, 5% glucose solution, hemodez, etc.).

3. In case of severe arterial hypotension not corrected by infusion therapy:

Dopamine, or adrenaline, intravenous drip. increasing the rate of administration until blood pressure stabilizes;

Streptokinase (250,000 IU intravenous drip over 30 minutes, then intravenous drip at a rate of 100,000 IU/hour to a total dose of 1,500,000 IU).

4. With stable blood pressure:

Oxygen therapy;

Peripheral vein catheterization;

Heparin 10,000 units intravenously as a bolus, then drip at a rate of 1000 units/hour or subcutaneously at 5000 units after 8 hours:

Eufillin 240 mg intravenously.

5. In case of recurrent pulmonary embolism, additionally prescribe 0.25 g of acetylsalicylic acid orally.

6. Monitor vital functions (cardiac monitor, pulse oximeter).

7. Hospitalize after possible stabilization of the condition.

Main dangers and complications:

Electromechanical dissociation:

Inability to stabilize blood pressure;

Increasing respiratory failure:

Recurrence of pulmonary embolism.

Note. In case of a burdened allergic history, 30 mg of predniolone is injected intravenously before prescribing sprepyukinosis.

For the treatment of pulmonary embolism, the rate of intravenous heparin administration must be selected individually, achieving a stable increase in activated partial thromboplastin time by 2 times compared with its normal value.

STROKE (ACUTE CEREBRAL CIRCULATION DISORDER)

Stroke (stroke) is a rapidly developing focal or global disorder of brain function that lasts more than 24 hours or leads to death if another genesis of the disease is excluded. Develops against the background of atherosclerosis of cerebral vessels, hypertension, their combination, or as a result of rupture of cerebral aneurysms.

Diagnostics The clinical picture depends on the nature of the process (ischemia or hemorrhage), localization (hemispheres, brainstem, cerebellum), rate of development of the process (sudden, gradual). A stroke of any origin is characterized by the presence of focal symptoms of brain damage (hemiparesis or hemiplegia, less often monoparesis and damage to the cranial nerves - facial, hypoglossal, oculomotor) and general cerebral symptoms of varying severity (headache, dizziness, nausea, vomiting, impaired consciousness).

ACVA is clinically manifested by subarachnoid or intracerebral hemorrhage (hemorrhagic stroke), or ischemic stroke.

Transient cerebrovascular accident (TCI) is a condition in which focal symptoms undergo complete regression in a period of less than 24 hours. The diagnosis is made retrospectively.

Suborocnoidal hemorrhages develop as a result of rupture of aneurysms and, less often, against the background of hypertension. Characterized by the sudden onset of a sharp headache, followed by nausea, vomiting, motor agitation, tachycardia, and sweating. With massive subarachnoid hemorrhage, depression of consciousness is usually observed. Focal symptoms are often absent.

Hemorrhagic stroke - hemorrhage into the substance of the brain; characterized by a sharp headache, vomiting, rapid (or sudden) depression of consciousness, accompanied by the appearance of severe symptoms of dysfunction of the limbs or bulbar disorders (peripheral paralysis of the muscles of the tongue, lips, soft palate, pharynx, vocal folds and epiglottis due to damage to the IX, X and XII pairs of cranial nerves or their nuclei located in the medulla oblongata). It usually develops during the day, while awake.

Ischemic stroke is a disease that leads to a decrease or cessation of blood supply to a certain part of the brain. It is characterized by a gradual (over hours or minutes) increase in focal symptoms corresponding to the affected vascular system. General cerebral symptoms are usually less pronounced. Develops more often with normal or low blood pressure, often during sleep

At the prehospital stage, differentiation of the nature of the stroke (ischemic or hemorrhagic, subarachnoid hemorrhage and its location is not required.

Differential diagnosis should be carried out with traumatic brain injury (history, presence of traces of trauma on the head) and much less often with meningoencephalitis (history, signs of a general infectious process, rash).

Urgent Care

Basic (undifferentiated) therapy includes emergency correction of vital functions - restoration of patency of the upper respiratory tract, if necessary - tracheal intubation, artificial ventilation, as well as normalization of hemodynamics and cardiac activity:

If blood pressure is significantly higher than normal values ​​- reduce it to levels slightly higher than the “working” one, usual for a given patient; if there is no information, then to a level of 180/90 mm Hg. Art.; for this use - 0.5-1 ml of a 0.01% solution of clonidine (clonidine) in 10 ml of a 0.9% solution of sodium chloride intravenously or intramuscularly or 1-2 tablets sublingually (if necessary, the administration of the drug can be repeated), or pentamin - no more than 0. 5 ml of a 5% solution intravenously at the same dilution or 0.5-1 ml intramuscularly:

As an additional remedy, you can use dibazol 5-8 ml of 1% solution intravenously or nifedipine (Corinfar, phenigidine) - 1 tablet (10 mg) sublingually;

To relieve convulsive seizures, psychomotor agitation - diazepam (Relanium, Seduxen, Sibazon) 2-4 ml intravenously with 10 ml of 0.9% sodium chloride solution slowly or intramuscularly or Rohypnol 1-2 ml intramuscularly;

If ineffective - 20% sodium hydroxybutyrate solution at the rate of 70 mg/kg body weight in a 5-10% glucose solution, slowly intravenously;

In case of repeated vomiting - Cerucal (Raglan) 2 ml intravenously in a 0.9% solution intravenously or intramuscularly:

Vitamin Wb 2 ml of 5% solution intravenously;

Droperidol 1-3 ml of 0.025% solution, taking into account the patient’s body weight;

For headaches - 2 ml of 50% analgin solution or 5 ml of baralgin intravenously or intramuscularly;

Tramal - 2 ml.

Tactics

For patients of working age, in the first hours of the disease it is mandatory to call a specialized neurological (neuro-resuscitation) team. Hospitalization on a stretcher to the neurological (neurovascular) department is indicated.

If you refuse hospitalization, call a neurologist at the clinic and, if necessary, actively visit an emergency doctor after 3-4 hours.

Patients in deep atonic coma (5-4 points on the Glasgow scale) with intractable severe breathing disorders: unstable hemodynamics, with a rapid, steady deterioration of their condition are not transportable.

Dangers and complications

Obstruction of the upper respiratory tract by vomit;

Aspiration of vomit;

Inability to normalize blood pressure:

Brain swelling;

A breakthrough of blood into the ventricles of the brain.

Note

1. Early use of antihypoxants and activators of cellular metabolism is possible (nootropil 60 ml (12 g) intravenously 2 times a day after 12 hours on the first day; Cerebrolysin 15-50 ml intravenous drip per 100-300 ml isotonic solution in 2 doses; glycine 1 tablet under the tongue ribojusin 10 ml intravenous bolus, solcoseryl 4 ml intravenous bolus, in severe cases 250 ml of 10% solution of solcoseryl intravenous drip can significantly reduce the number of irreversibly damaged cells in the ischemic zone, reduce the area of ​​perifocal edema.

2. Aminazine and propazine should be excluded from drugs prescribed for any form of stroke. These drugs sharply inhibit the functions of brain stem structures and clearly worsen the condition of patients, especially the elderly and senile.

3. Magnesium sulfate is not used for seizures and to lower blood pressure.

4. Eufillin is shown only in the first hours of a mild stroke.

5. Furosemide (Lasix) and other dehydrating drugs (mannitol, reogluman, glycerol) should not be administered at the prehospital stage. The need to prescribe dehydrating agents can only be determined in a hospital based on the results of determining plasma osmolality and sodium content in blood serum.

6. In the absence of a specialized neurological team, hospitalization in the neurological department is indicated.

7. For patients of any age with a first or repeated stroke with minor defects after previous episodes, a specialized neurological (neuro-resuscitation) team can also be called on the first day of the disease.

BRONCHASTMATIC STATUS

Bronchoasthmatic status is one of the most severe variants of the course of bronchial asthma, manifested by acute obstruction of the bronchial tree as a result of bronchiolospasm, hyperergic inflammation and swelling of the mucous membrane, hypersecretion of the glandular apparatus. The formation of the status is based on a deep blockade of beta-adrenergic receptors of the smooth muscles of the bronchi.

Diagnostics

An attack of suffocation with difficulty exhaling, increasing shortness of breath at rest, acrocyanosis, increased sweating, harsh breathing with dry scattered wheezing and subsequent formation of areas of “silent” lung, tachycardia, high blood pressure, participation of auxiliary muscles in breathing, hypoxic and hypercapnic coma. During drug therapy, resistance to sympathomimetics and other bronchodilators is revealed.

Urgent Care

Status asthmaticus is a contraindication to the use of β-agonists (adrenergic agonists) due to loss of sensitivity (lung receptors to these drugs. However, this loss of sensitivity can be overcome using nebulizer technology.

Drug therapy is based on the use of selective β2-agonists fenoterol (Beroteca) at a dose of 0.5-1.5 mg or salbutamol at a dose of 2.5-5.0 mg, or a complex drug Berodual containing fenoterol and the anticholinergic drug ipra, using the nebulizer technique -tropium bromide (Atrovent). Berodual dosage is 1-4 ml per inhalation.

In the absence of a nebulizer, these drugs are not used.

Eufillin is used in the absence of a nebulizer or in particularly severe cases when nebulizer therapy is ineffective.

Initial dose - 5.6 mg/kg body weight (10-15 ml of 2.4% solution intravenously slowly, over 5-7 minutes);

Maintenance dose - 2-3.5 ml of a 2.4% solution in fractions or drops until the patient’s clinical condition improves.

Glucocorticoid hormones - in terms of methylprednisolone 120-180 mg intravenously.

Oxygen therapy. Continuous insufflation (mask, nasal catheters) of an oxygen-air mixture with an oxygen content of 40-50%.

Heparin - 5,000-10,000 units intravenously drip with one of the plasma-substituting solutions; it is possible to use low molecular weight heparins (fraxiparine, clexane, etc.)

Contraindicated

Sedatives and antihistamines (inhibit the cough reflex, increase bronchopulmonary obstruction);

Mucolytic agents for thinning sputum:

antibiotics, sulfonamides, novocaine (have high sensitizing activity);

Calcium supplements (deepen initial hypokalemia);

Diuretics (increase initial dehydration and hemoconcentration).

In a comatose state

Urgent tracheal intubation with spontaneous breathing:

Artificial ventilation;

If necessary, perform cardiopulmonary resuscitation;

Drug therapy (see above)

Indications for tracheal intubation and mechanical ventilation:

hypoxic and hyperkalemic coma:

Cardiovascular collapse:

The number of respiratory movements is more than 50 per 1 minute. Transportation to the hospital during therapy.

CONVIVUS SYNDROME

Diagnostics

A generalized generalized convulsive seizure is characterized by the presence of tonic-clonic convulsions in the extremities, accompanied by loss of consciousness, foam at the mouth, often tongue biting, involuntary urination, and sometimes defecation. At the end of the attack, a pronounced respiratory arrhythmia is observed. Long periods of apnea are possible. At the end of the seizure, the patient is in a deep coma, the pupils are maximally dilated, without reaction to light, the skin is cyanotic, often moist.

Simple partial seizures without loss of consciousness are manifested by clonic or tonic convulsions in certain muscle groups.

Complex partial seizures (temporal lobe epilepsy or psychomotor seizures) are episodic changes in behavior when the patient loses contact with the outside world. The beginning of such seizures can be an aura (olfactory, gustatory, visual, a feeling of “already seen,” micro- or macropsia). During complex attacks, inhibition of motor activity may be observed; or smacking tubes, swallowing, walking aimlessly, picking off one’s own clothes (automatisms). At the end of the attack, amnesia is noted for the events that took place during the attack.

The equivalents of convulsive seizures manifest themselves in the form of gross disorientation, somnambulism and a prolonged twilight state, during which unconscious, severe asocial acts can be committed.

Status epilepticus is a fixed epileptic state due to a prolonged epileptic seizure or a series of seizures repeated at short intervals. Status epilepticus and frequent seizures are life-threatening conditions.

A seizure can be a manifestation of genuine (“congenital”) and symptomatic epilepsy - a consequence of previous diseases (brain trauma, cerebrovascular accident, neuroinfection, tumor, tuberculosis, syphilis, toxoplasmosis, cysticercosis, Morgagni-Adams-Stokes syndrome, ventricular fibrillation , eclampsia) and intoxication.

Differential diagnosis

At the prehospital stage, determining the cause of a seizure is often extremely difficult. Anamnesis and clinical data are of great importance. Particular caution must be exercised in relation to primarily, traumatic brain injury, acute cerebrovascular accidents, heart rhythm disturbances, eclampsia, tetanus and exogenous intoxications.

Urgent Care

1. After a single convulsive seizure - diazepam (Relanium, Seduxen, Sibazon) - 2 ml intramuscularly (as a prevention of repeated seizures).

2. With a series of convulsive seizures:

Prevention of head and torso injuries:

Relief of convulsive syndrome: diazepam (Relanium, Seduxen, Sibazon) - 2-4 ml per 10 ml of 0.9% sodium chloride solution intravenously or intramuscularly, Rohypnol 1-2 ml intramuscularly;

If there is no effect, sodium hydroxybutyrate 20% solution at the rate of 70 mg/kg body weight intravenously in a 5-10% glucose solution;

Decongestant therapy: furosemide (Lasix) 40 mg per 10-20 ml of 40% glucose or 0.9% sodium chloride solution (in patients with diabetes)

intravenously;

Relief of headaches: analgin 2 ml of 50% solution: baralgin 5 ml; Tramal 2 ml intravenously or intramuscularly.

3. Status epilepticus

Prevention of head and torso injuries;

Restoration of airway patency;

Relief of convulsive syndrome: diazepam (Relanium, Seduxen, Syabazon) _ 2-4 ml per 10 ml of 0.9% sodium chloride solution intravenously or intramuscularly, Rohypnol 1-2 ml intramuscularly;

If there is no effect, sodium hydroxybutyrate 20% solution at the rate of 70 mg/kg body weight intravenously in a 5-10% glucose solution;

If there is no effect, inhalation anesthesia with nitrous oxide mixed with oxygen (2:1).

Decongestant therapy: furosemide (Lasix) 40 mg per 10-20 ml of 40% glucose or 0.9% sodium chloride solution (in patients with diabetes) intravenously:

Headache relief:

Analgin - 2 ml of 50% solution;

- baralgin - 5 ml;

Tramal - 2 ml intravenously or intramuscularly.

According to indications:

If blood pressure increases significantly above the patient’s usual levels, use antihypertensive drugs (clonidine intravenously, intramuscularly or sublingually tablets, dibazol intravenously or intramuscularly);

For tachycardia over 100 beats/min - see “Tachyarrhythmias”:

For bradycardia less than 60 beats/min - atropine;

For hyperthermia above 38° C - analgin.

Tactics

Patients with their first seizure in their life should be hospitalized to determine its cause. In case of refusal of hospitalization with a rapid recovery of consciousness and the absence of general cerebral and focal neurological symptoms, it is recommended to urgently contact a neurologist at a local clinic. If consciousness is restored slowly, there are general cerebral and (or) focal symptoms, then a call to a specialized neurological (neuro-resuscitation) team is indicated, and in its absence, an active visit after 2-5 hours.

Intractable status epilepticus or a series of convulsive seizures is an indication to call a specialized neurological (neuro-resuscitation) team. If this is not the case, hospitalization is required.

If there is a disturbance in the activity of the heart, leading to a convulsive syndrome, appropriate therapy or calling a specialized cardiology team. In case of eclampsia, exogenous intoxication - action according to the relevant recommendations.

Main dangers and complications

Asphyxia during a seizure:

Development of acute heart failure.

Note

1. Aminazine is not an anticonvulsant.

2. Magnesium sulfate and chloral hydrate are not currently used.

3. The use of hexenal or sodium thiopental to relieve status epilepticus is possible only in the conditions of a specialized team, if conditions are available and the ability to transfer the patient to mechanical ventilation if necessary. (laryngoscope, set of endotracheal tubes, ventilator).

4. For glucalcemic convulsions, calcium gluconate (10-20 ml of a 10% solution intravenously or intramuscularly), calcium chloride (10-20 ml of a 10% solution strictly intravenously) are administered.

5. For hypokalemic convulsions, administer panangin (10 ml intravenously).

FAINTING (BRIEF LOSS OF CONSCIOUSNESS, SYNCOPE)

Diagnostics

Fainting. - short-term (usually within 10-30 s) loss of consciousness. in most cases accompanied by a decrease in postural vascular tone. Fainting is based on transient hypoxia of the brain, which occurs due to various reasons - a decrease in cardiac output. heart rhythm disturbances, reflex decrease in vascular tone, etc.

Fainting (syncope) conditions can be conditionally divided into two most common forms - vasodepressor (synonyms - vasovagal, neurogenic) fainting, which is based on a reflex decrease in postural vascular tone, and fainting associated with diseases of the heart and great vessels.

Syncope conditions have different prognostic significance depending on their genesis. Fainting associated with pathology of the cardiovascular system can be a harbinger of sudden death and requires mandatory identification of their causes and adequate treatment. It must be remembered that fainting can be the onset of a serious pathology (myocardial infarction, pulmonary embolism, etc.).

The most common clinical form is vasodepressor syncope, in which a reflex decrease in peripheral vascular tone occurs in response to external or psychogenic factors (fear, anxiety, the sight of blood, medical instruments, venous puncture, high ambient temperature, being in a stuffy room, etc. .). The development of fainting is preceded by a short prodromal period, during which weakness, nausea, ringing in the ears, yawning, darkening of the eyes, pallor, and cold sweat are noted.

If the loss of consciousness is short-term, there are no seizures. If fainting lasts more than 15-20 seconds. clonic and tonic convulsions are observed. During fainting, there is a decrease in blood pressure with bradycardia; or without it. This group also includes fainting that occurs with increased sensitivity of the carotid sinus, as well as so-called “situational” fainting - with prolonged coughing, defecation, and urination. Fainting associated with pathology of the cardiovascular system usually occurs suddenly, without a prodromal period. They are divided into two main groups - those associated with disturbances of heart rhythm and conduction and those caused by a decrease in cardiac output (aortic stenosis, hypertrophic cardiomyopathy, myxoma and spherical thrombi in the atria, myocardial infarction, pulmonary embolism, dissecting aortic aneurysm).

Differential diagnosis fainting should be carried out with epilepsy, hypoglycemia, narcolepsy, comas of various origins, diseases of the vestibular apparatus, organic pathology of the brain, hysteria.

In most cases, diagnosis can be made based on a detailed history, physical examination, and ECG recording. To confirm the vasodepressor nature of fainting, positional tests are performed (from simple orthostatic tests to the use of a special inclined table); to increase sensitivity, tests are carried out against the background of drug therapy. If these actions do not clarify the cause of fainting, then a subsequent examination in a hospital is carried out depending on the identified pathology.

In the presence of heart disease: Holter ECG monitoring, echocardiography, electrophysiological study, positional tests: if necessary, cardiac catheterization.

In the absence of heart disease: positional tests, consultation with a neurologist, psychiatrist, Holter ECG monitoring, electroencephalogram, if necessary, computed tomography of the brain, angiography.

Urgent Care

In case of fainting it is usually not required.

The patient must be placed in a horizontal position on his back:

give the lower limbs an elevated position, free the neck and chest from constricting clothing:

Patients should not be seated immediately, as this may lead to recurrence of fainting;

If the patient does not regain consciousness, it is necessary to exclude traumatic brain injury (if there was a fall) or other causes of prolonged loss of consciousness mentioned above.

If syncope is caused by a cardiac disease, emergency care may be necessary to eliminate the immediate cause of syncope - tachyarrhythmia, bradycardia, hypotension, etc. (see relevant sections).

ACUTE POISONING

Poisoning is a pathological condition caused by the action of toxic substances of exogenous origin through any route of entry into the body.

The severity of the poisoning condition is determined by the dose of the poison, the route of its intake, the exposure time, the patient’s premorbid background, complications (hypoxia, bleeding, convulsions, acute cardiovascular failure, etc.).

The prehospital doctor needs to:

Observe “toxicological alertness” (the environmental conditions in which the poisoning occurred, the presence of foreign odors may pose a danger to the ambulance team):

Find out the circumstances surrounding the poisoning (when, with what, how, how much, for what purpose) in the patient himself, if he is conscious, or in those around him;

Collect material evidence (packages of medicines, powders, syringes), biological media (vomit, urine, blood, washing water) for chemical-toxicological or forensic chemical research;

Register the main symptoms (syndromes) that the patient had before providing medical care, including mediator syndromes that are the result of strengthening or suppression of the sympathetic and parasympathetic systems (see appendix).

GENERAL ALGORITHM FOR PROVIDING EMERGENCY CARE

1. Ensure normalization of breathing and hemodynamics (perform basic cardiopulmonary resuscitation).

2. Carry out antidote therapy.

3. Stop further entry of poison into the body. 3.1. In case of inhalation poisoning, remove the victim from the contaminated atmosphere.

3.2. In case of oral poisoning, rinse the stomach, administer enteric sorbents, and give a cleansing enema. When washing the stomach or washing off poisons from the skin, use water with a temperature no higher than 18 ° C; do not carry out a reaction to neutralize the poison in the stomach! The presence of blood during gastric lavage is not a contraindication for lavage.

3.3. For cutaneous application, wash the affected area of ​​skin with an antidote solution or water.

4. Start infusion and symptomatic therapy.

5. Transport the patient to the hospital. This algorithm for providing care at the prehospital stage is applicable to all types of acute poisoning.

Diagnostics

With mild to moderate severity, anticholinergic syndrome occurs (intoxication psychosis, tachycardia, normohypotension, mydriasis). In severe cases, coma, hypotension, tachycardia, mydriasis.

Neuroleptics cause the development of orthostatic collapse, long-term persistent hypotension due to the insensitivity of the terminal vascular bed to vasopressors, extrapyramidal syndrome (muscle spasms of the chest, neck, upper shoulder girdle, protrusion of the tongue, bulging eyes), neuroleptic syndrome (hyperthermia, muscle rigidity).

Hospitalization of the patient in a horizontal position. Anticholinergics cause the development of retrograde amnesia.

Opiate poisoning

Diagnostics

Characteristic: depression of consciousness, to deep coma. development of apnea, tendency to bradycardia, injection marks on the elbows.

Emergency treatment

Pharmacological antidotes: naloxone (Narkanti) 2-4 ml of 0.5% solution intravenously until spontaneous breathing is restored: if necessary, repeat administration until mydriasis appears.

Start infusion therapy:

400.0 ml of 5-10% glucose solution intravenously;

Reopoliglucin 400.0 ml intravenous drip.

Sodium bicarbonate 300.0 ml 4% intravenous drip;

Oxygen inhalation;

If there is no effect from the administration of naloxone, perform mechanical ventilation in hyperventilation mode.

Tranquilizer poisoning (benzodiazepine group)

Diagnostics

Characteristics: drowsiness, ataxia, depression of consciousness to the point of coma 1, miosis (in case of Noxiron poisoning - mydriasis) and moderate hypotension.

Benzodiazepine tranquilizers cause deep depression of consciousness only in “mixed” poisonings, i.e. in combination with barbiturates. neuroleptics and other sedative-hypnotics.

Emergency treatment

Follow steps 1-4 of the general algorithm.

For hypotension: rheopolyglucin 400.0 ml intravenously, drip:

Barbiturate poisoning

Diagnostics

Miosis, hypersalivation, “greasy” skin, hypotension, deep depression of consciousness up to the development of coma are detected. Barbiturates cause a rapid breakdown of tissue trophism, the formation of bedsores, the development of positional compression syndrome, and pneumonia.

Urgent Care

Pharmacological antidotes (see note).

Execute point 3 of the general algorithm;

Start infusion therapy:

Sodium bicarbonate 4% 300.0, intravenous drip:

Glucose 5-10% 400.0 ml intravenous drip;

Sulphocamphocaine 2.0 ml intravenously.

Oxygen inhalation.

POISONING WITH STIMULATIVE DRUGS

These include antidepressants, psychostimulants, general tonics (tinctures, including alcoholic ginseng, eleutherococcus).

Delirium, hypertension, tachycardia, mydriasis, convulsions, cardiac arrhythmias, ischemia and myocardial infarction are determined. They cause depression of consciousness, hemodynamics and respiration after the phase of excitation and hypertension.

Poisoning occurs with adrenergic (see appendix) syndrome.

Antidepressant poisoning

Diagnostics

With a short duration of action (up to 4-6 hours), hypertension is determined. delirium. dry skin and mucous membranes, expansion of the 9K8 complex on the ECG (quinidine-like effect of tricyclic antidepressants), convulsive syndrome.

With prolonged action (more than 24 hours) - hypotension. urinary retention, coma. Always - mydriasis. dry skin, expansion of the OK8 complex on the ECG: Antidepressants. serotonin blockers: fluoxentine (Prozac), fluvoxamine (paroxetine), alone or in combination with analgesics, can cause “malignant” hyperthermia.

Urgent Care

Execute point 1 of the general algorithm. For hypertension and agitation:

Short-acting drugs with a rapid onset of effect: galantamine hydrobromide (or nivalin) 0.5% - 4.0-8.0 ml, intravenously;

Long-acting drugs: aminostigmine 0.1% - 1.0-2.0 ml intramuscularly;

In the absence of antagonists, anticonvulsants: Relanium (Seduxen), 20 mg per 20.0 ml of 40% glucose solution intravenously; or sodium hydroxybutyrate 2.0 g per - 20.0 ml of 40.0% glucose solution intravenously, slowly);

Follow step 3 of the general algorithm. Start infusion therapy:

In the absence of sodium bicarbonate - trisol (disol. hlosol) 500.0 ml intravenously, drip.

With severe arterial hypotension:

Reopoliglucin 400.0 ml intravenously, drip;

Norepinephrine 0.2% 1.0 ml (2.0) in 400 ml of 5-10% glucose solution intravenously, drip, increase the rate of administration until blood pressure stabilizes.

POISONING BY ANTI-TUBERCULOSIS DRUGS (INSONIAZIDE, FTIVAZIDE, TUBAZIDE)

Diagnostics

Characteristic: generalized convulsive syndrome, development of stunning. up to coma, metabolic acidosis. Any convulsive syndrome resistant to treatment with benzodiazepines should alert you to isoniazid poisoning.

Urgent Care

Execute point 1 of the general algorithm;

For convulsive syndrome: pyridoxine up to 10 ampoules (5 g). intravenous drip of 400 ml of 0.9% sodium chloride solution; Relanium 2.0 ml, intravenously. until the convulsive syndrome is relieved.

If there is no result, anti-depolarizing muscle relaxants (Arduan 4 mg), tracheal intubation, mechanical ventilation.

Follow step 3 of the general algorithm.

Start infusion therapy:

Sodium bicarbonate 4% 300.0 ml intravenously, drip;

Glucose 5-10% 400.0 ml intravenously, drip. For arterial hypotension: rheopolyglucin 400.0 ml intravenously. drip.

Early detoxification hemosorption is effective.

POISONING BY TOXIC ALCOHOLS (METHANOL, ETHYLENE GLYCOL, CELLOSOLV)

Diagnostics

Characteristic: the effect of intoxication, decreased visual acuity (methanol), abdominal pain (propyl alcohol; ethylene glycol, cellosolve with prolonged exposure), depression of consciousness to deep coma, decompensated metabolic acidosis.

Urgent Care

Follow step 1 of the general algorithm:

Follow step 3 of the general algorithm:

The pharmacological antidote for methanol, ethylene glycol and cellosolves is ethanol.

Initial therapy with ethanol (saturation dose per 80 kg of patient’s body weight, at the rate of 1 ml of 96% alcohol solution per 1 kg of body weight). To do this, dilute 80 ml of 96% alcohol with water and give it to drink (or administer it through a tube). If it is impossible to prescribe alcohol, 20 ml of a 96% alcohol solution is dissolved in 400 ml of a 5% glucose solution and the resulting alcoholic glucose solution is injected into a vein at a rate of 100 drops/min (or 5 ml of solution per min).

Start infusion therapy:

Sodium bicarbonate 4% 300 (400) intravenously, drip;

Acesol 400 ml intravenously, drip:

Hemodez 400 ml intravenously, drip.

When transferring the patient to the hospital, indicate the dose, time and route of administration of the ethanol solution at the prehospital stage to provide a maintenance dose of ethanol (100 mg/kg/hour).

ETHANOL POISONING

Diagnostics

Determined: depression of consciousness to deep coma, hypotension, hypoglycemia, hypothermia, cardiac arrhythmia, respiratory depression. Hypoglycemia and hypothermia lead to the development of heart rhythm disturbances. In alcoholic coma, lack of response to naloxone may be due to concomitant traumatic brain injury (subdural hematoma).

Urgent Care

Follow steps 1-3 of the general algorithm:

For depression of consciousness: naloxone 2 ml + glucose 40% 20-40 ml + thiamine 2.0 ml intravenously slowly. Start infusion therapy:

Sodium bicarbonate 4% 300-400 ml intravenous drip;

Hemodez 400 ml intravenous drip;

Sodium thiosulfate 20% 10-20 ml intravenously slowly;

Unithiol 5% 10 ml intravenously slowly;

Ascorbic acid 5 ml intravenously;

Glucose 40% 20.0 ml intravenously.

When excited: Relanium 2.0 ml intravenously slowly with 20 ml of 40% glucose solution.

Alcohol-induced withdrawal symptoms

When examining a patient at the prehospital stage, it is advisable to adhere to certain sequences and principles of emergency care for acute alcohol poisoning.

· Establish the fact of recent alcohol intake and determine its characteristics (date of last intake, binge drinking or one-time use, quantity and quality of alcohol consumed, total duration of regular alcohol intake). It is possible to adjust for the social status of the patient.

· Establish the fact of chronic alcohol intoxication and nutritional level.

· Determine the risk of developing withdrawal syndrome.

· Within the framework of toxic visceropathy, determine: the state of consciousness and mental functions, identify gross neurological disorders; stage of alcoholic liver disease, degree of liver failure; identify damage to other target organs and the degree of their functional usefulness.

· Determine the prognosis of the condition and develop a plan for observation and pharmacotherapy.

· Obviously, clarifying the patient’s “alcohol” history is aimed at determining the severity of the current acute alcohol poisoning, as well as the risk of developing alcohol withdrawal syndrome (on the 3-5th day after the last alcohol intake).

When treating acute alcohol intoxication, a set of measures is required, aimed, on the one hand, at stopping further absorption of alcohol and accelerating its elimination from the body, and on the other, at protecting and maintaining systems or functions that suffer from the effects of alcohol.

The intensity of therapy is determined both by the severity of acute alcohol intoxication and the general condition of the intoxicated person. In this case, gastric lavage is performed to remove alcohol that has not yet been absorbed, and drug therapy with detoxification agents and alcohol antagonists.

In the treatment of alcohol withdrawal the doctor takes into account the severity of the main components of the withdrawal syndrome (somato-vegetative, neurological and mental disorders). Mandatory components are vitamin and detoxification therapy.

Vitamin therapy includes parenteral administration of solutions of thiamine (Vit B1) or pyridoxine hydrochloride (Vit B6) - 5-10 ml. For severe tremor, a solution of cyanocobalamin (Vit B12) is prescribed - 2-4 ml. The simultaneous administration of various B vitamins is not recommended due to the possibility of increasing allergic reactions and their incompatibility in the same syringe. Ascorbic acid (Vit C) - up to 5 ml is administered intravenously along with plasma-substituting solutions.

Detoxification therapy includes the administration of thiol drugs - 5% unithiol solution (1 ml per 10 kg of body weight intramuscularly) or 30% sodium thiosulfate solution (up to 20 ml); hypertonic - 40% glucose - up to 20 ml, 25% magnesium sulfate (up to 20 ml), 10% calcium chloride (up to 10 ml), isotonic - 5% glucose (400-800 ml), 0.9% sodium chloride solution ( 400-800 ml) and plasma-substituting - hemodez (200-400 ml) solutions. It is also advisable to administer intravenously a 20% solution of piracetam (up to 40 ml).

These measures, according to indications, are supplemented by the relief of somato-vegetative, neurological and mental disorders.

If blood pressure increases, 2-4 ml of papaverine hydrochloride or dibazole solution is injected intramuscularly;

In case of heart rhythm disturbances, analeptics are prescribed - a solution of cordiamine (2-4 ml), camphor (up to 2 ml), potassium preparations panangin (up to 10 ml);

In case of shortness of breath, difficulty breathing, up to 10 ml of a 2.5% aminophylline solution is injected intravenously.

A reduction in dyspeptic symptoms is achieved by administering a solution of raglan (cerucal - up to 4 ml), as well as antispasmodics - baralgin (up to 10 ml), NO-ShPy (up to 5 ml). A solution of baralgin, along with a 50% solution of analgin, is also indicated to reduce the severity of headaches.

For chills and sweating, a solution of nicotinic acid (Vit PP - up to 2 ml) or a 10% solution of calcium chloride - up to 10 ml is administered.

Psychotropic drugs are used to relieve affective, psychopathic and neurosis-like disorders. Relanium (dizepam, seduxen, sibazon) is administered intramuscularly or at the end of an intravenous infusion of solutions intravenously in a dose of up to 4 ml for withdrawal states with anxiety, irritability, sleep disorders, and autonomic disorders. Nitrazepam (Eunoctin, Radedorm - up to 20 mg), phenazepam (up to 2 mg), Grandaxin (up to 600 mg) are given orally, but it must be taken into account that nitrazepam and phenazepam are best used to normalize sleep, and Grandaxin to relieve autonomic disorders.

For severe affective disorders (irritability, tendency to dysphoria, outbursts of anger), antipsychotics with a hypnotic-sedative effect are used (droperidol 0.25% - 2-4 ml).

For rudimentary visual or auditory hallucinations, paranoid mood in the structure of abstinence, 2-3 ml of a 0.5% solution of haloperidol is injected intramuscularly in combination with Relanium to reduce neurological side effects.

For severe motor restlessness, use droperidol 2-4 ml of a 0.25% solution intramuscularly or sodium hydroxybutyrate 5-10 ml of a 20% solution intravenously. Neuroleptics from the group of phenothiazines (aminazine, tizercin) and tricyclic antidepressants (amitriptyline) are contraindicated.

Therapeutic measures are carried out until signs of a clear improvement in the patient’s condition appear (reduction of somato-vegetative, neurological, mental disorders, normalization of sleep) under constant monitoring of the function of the cardiovascular or respiratory system.

Electrocardiostimulation

Electrocardiac pacing (PAC) is a method by which external electrical impulses generated by an artificial pacemaker (pacemaker) are applied to any part of the heart muscle, resulting in a contraction of the heart.

Indications for cardiac pacing

· Asystole.

· Severe bradycardia, regardless of the underlying cause.

· Atrioventricular or Sinoatrial block with Adams-Stokes-Morgagni attacks.

There are 2 types of pacing: permanent pacing and temporary pacing.

1. Permanent pacing

Permanent cardiac pacing is the implantation of an artificial pacemaker or cardioverter-defibrillator. Temporary cardiac pacing

2. Temporary cardiac pacing is necessary for severe bradyarrhythmias caused by sinus node dysfunction or AV block.

Temporary cardiac pacing can be performed using various methods. Transvenous endocardial and transesophageal pacing, as well as in some cases external percutaneous pacing, are relevant today.

Transvenous (endocardial) cardiac pacing has received especially intensive development, since it is the only effective way to “impose” an artificial rhythm on the heart in the event of severe disturbances of the systemic or regional circulation due to bradycardia. When performing it, an electrode under ECG control is inserted into the right atrium or right ventricle through the subclavian, internal jugular, ulnar or femoral veins.

Temporary transesophageal atrial pacing and transesophageal ventricular pacing (TEV) have also become widespread. TEES is used as replacement therapy for bradycardia, bradyarrhythmia, asystole and sometimes for reciprocal supraventricular arrhythmias. It is often used for diagnostic purposes. Temporary transthoracic pacing is sometimes used by emergency physicians to buy time. One electrode is inserted through a percutaneous puncture into the heart muscle, and the second is a needle installed subcutaneously.

Indications for temporary pacing

· Temporary cardiac pacing is carried out in all cases where there are indications for permanent cardiac pacing as a “bridge” to it.

· Temporary cardiac pacing is performed when immediate implantation of a pacemaker is not possible.

· Temporary cardiac pacing is performed in cases of hemodynamic instability, primarily due to Morgagni-Edams-Stokes attacks.

· Temporary cardiac pacing is carried out when there is reason to believe that bradycardia is transient (in case of myocardial infarction, the use of medications that can inhibit the formation or conduction of impulses, after cardiac surgery).

· Temporary cardiac pacing is recommended for the purpose of prevention in patients with acute myocardial infarction of the anteroseptal region of the left ventricle with blockade of the right and anterosuperior branches of the left bundle branch, due to the increased risk of developing complete atrioventricular block with asystole due to the unreliability of the ventricular pacemaker in this case.

Complications of temporary pacing

· Displacement of the electrode and impossibility (cessation) of electrical stimulation of the heart.

· Thrombophlebitis.

· Sepsis.

· Air embolism.

· Pneumothorax.

· Perforation of the heart wall.

Cardioversion-defibrillation

Cardioversion-defibrillation (electrical pulse therapy - EIT) - is a transsternal direct current of sufficient strength to cause depolarization of the entire myocardium, after which the sinoatrial node (first-order pacemaker) resumes control of the heart rhythm.

There are cardioversion and defibrillation:

1. Cardioversion - direct current exposure synchronized with the QRS complex. For various tachyarrhythmias (except ventricular fibrillation), the effect of direct current must be synchronized with the QRS complex, because If exposed to current before the peak of the T wave, ventricular fibrillation may occur.

2. Defibrillation. The impact of direct current without synchronization with the QRS complex is called defibrillation. Defibrillation is carried out in case of ventricular fibrillation, when there is no need (and no possibility) to synchronize the effects of direct current.

Indications for cardioversion-defibrillation

· Ventricular flutter and fibrillation. Electropulse therapy is the method of choice. Read more: Cardiopulmonary resuscitation at a specialized stage in the treatment of ventricular fibrillation.

· Persistent ventricular tachycardia. In the presence of impaired hemodynamics (Morgagni-Adams-Stokes attack, arterial hypotension and/or acute heart failure), defibrillation is carried out immediately, and if it is stable, after an attempt to relieve it with medications if it is ineffective.

· Supraventricular tachycardia. Electropulse therapy is performed for health reasons with progressive deterioration of hemodynamics or routinely when drug therapy is ineffective.

· Atrial fibrillation and flutter. Electropulse therapy is performed for health reasons with progressive deterioration of hemodynamics or routinely when drug therapy is ineffective.

· Electropulse therapy is more effective for tachyarrhythmias of the reentry type, less effective for tachyarrhythmias as a result of increased automaticity.

· Electropulse therapy is absolutely indicated for shock or pulmonary edema caused by tachyarrhythmia.

· Emergency electropulse therapy is usually performed in cases of severe (more than 150 per minute) tachycardia, especially in patients with acute myocardial infarction, unstable hemodynamics, persistent anginal pain, or contraindications to the use of antiarrhythmic drugs.

All ambulance teams and all departments of medical institutions must be equipped with a defibrillator, and all medical workers must be proficient in this method of resuscitation.

Methodology for cardioversion-defibrillation

In case of elective cardioversion, the patient should not eat for 6-8 hours to avoid possible aspiration.

Due to the painfulness of the procedure and the patient’s fear, general anesthesia or intravenous analgesia and sedation are used (for example, fentanyl at a dose of 1 mcg/kg, then midazolam 1-2 mg or diazepam 5-10 mg; for elderly or weakened patients - 10 mg promedol). For initial respiratory depression, non-narcotic analgesics are used.

When performing cardioversion-defibrillation, you must have the following kit on hand:

· Instrumentation for maintaining airway patency.

· Electrocardiograph.

· Ventilator.

· Medicines and solutions necessary for the procedure.

· Oxygen.

Sequence of actions when performing electrical defibrillation:

· The patient should be in a position that allows, if necessary, tracheal intubation and closed cardiac massage.

· Reliable access to the patient's vein is required.

· Turn on the power supply, turn off the defibrillator timing switch.

· Set the required charge on the scale (approximately 3 J/kg for adults, 2 J/kg for children); charge the electrodes; Lubricate the plates with gel.

· It is more convenient to work with two hand electrodes. Place the electrodes on the anterior surface of the chest:

One electrode is installed above the zone of cardiac dullness (in women - outward from the apex of the heart, outside the mammary gland), the second - under the right collarbone, and if the electrode is spinal, then under the left scapula.

Electrodes can be placed in an anteroposterior position (along the left edge of the sternum in the area of ​​the 3rd and 4th intercostal spaces and in the left subscapular region).

Electrodes can be placed in an anterolateral position (in the space between the clavicle and the 2nd intercostal space along the right edge of the sternum and above the 5th and 6th intercostal space, in the area of ​​the apex of the heart).

· To minimize electrical resistance during electric pulse therapy, the skin under the electrodes is degreased with alcohol or ether. In this case, use gauze pads well moistened with isotonic sodium chloride solution or special pastes.

· The electrodes are pressed firmly and firmly against the chest wall.

· Perform cardioversion-defibrillation.

The discharge is applied at the moment of complete exhalation of the patient.

If the type of arrhythmia and the type of defibrillator allow it, the shock is delivered after synchronization with the QRS complex on the monitor.

Immediately before applying the shock, you should make sure that the tachyarrhythmia for which electropulse therapy is being performed persists!

For supraventricular tachycardia and atrial flutter, a shock of 50 J is sufficient for the first impact. For atrial fibrillation or ventricular tachycardia, a shock of 100 J is required for the first impact.

In the case of polymorphic ventricular tachycardia or ventricular fibrillation, a shock of 200 J is used for the first impact.

If the arrhythmia persists, with each subsequent discharge the energy is doubled up to a maximum of 360 J.

The time interval between attempts should be minimal and is required only to assess the effect of defibrillation and set, if necessary, the next shock.

If 3 shocks with increasing energy do not restore the heart rhythm, then the fourth - maximum energy - is applied after the intravenous administration of an antiarrhythmic drug indicated for this type of arrhythmia.

· Immediately after electropulse therapy, the rhythm should be assessed and, if it is restored, a 12-lead ECG should be recorded.

If ventricular fibrillation continues, antiarrhythmic drugs are used to reduce the defibrillation threshold.

Lidocaine - 1.5 mg/kg intravenously, as a bolus, repeat after 3-5 minutes. In case of restoration of blood circulation, a continuous infusion of lidocaine is performed at a rate of 2-4 mg/min.

Amiodarone - 300 mg intravenously over 2-3 minutes. If there is no effect, you can repeat the intravenous administration of another 150 mg. In case of restoration of blood circulation, a continuous infusion of 1 mg/min (360 mg) is carried out in the first 6 hours, and 0.5 mg/min (540 mg) in the next 18 hours.

Procainamide - 100 mg intravenously. If necessary, the dose can be repeated after 5 minutes (up to a total dose of 17 mg/kg).

Magnesium sulfate (Cormagnesin) - 1-2 g intravenously over 5 minutes. If necessary, the administration can be repeated after 5-10 minutes. (with tachycardia of the “pirouette” type).

After administering the medicine, general resuscitation measures are carried out for 30-60 seconds, and then electrical pulse therapy is repeated.

For intractable arrhythmias or sudden cardiac death, it is recommended to alternate the administration of drugs with electrical pulse therapy according to the following scheme:

· Antiarrhythmic drug - shock 360 J - adrenaline - discharge 360 ​​J - antiarrhythmic drug - shock 360 J - adrenaline, etc.

· You can apply not 1, but 3 discharges of maximum power.

· The number of digits is not limited.

If ineffective, general resuscitation measures are resumed:

Tracheal intubation is performed.

Provide venous access.

Adrenaline is administered 1 mg every 3-5 minutes.

Increasing doses of adrenaline 1-5 mg every 3-5 minutes or intermediate doses of 2-5 mg every 3-5 minutes can be administered.

Instead of adrenaline, vasopressin 40 mg can be administered intravenously once.

·Safety rules when working with a defibrillator

Eliminate the possibility of grounding personnel (do not touch the pipes!).

Avoid the possibility of others touching the patient while the shock is being administered.

Make sure that the insulating part of the electrodes and your hands are dry.

Complications of cardioversion-defibrillation

· Post-conversion arrhythmias, and above all – ventricular fibrillation.

Ventricular fibrillation usually occurs when the shock is delivered during a vulnerable phase of the cardiac cycle. The probability of this is low (about 0.4%), however, if the patient’s condition, type of arrhythmia and technical capabilities allow, synchronization of the discharge with the R wave on the ECG should be used.

If ventricular fibrillation occurs, a second shock with an energy of 200 J is immediately applied.

Other post-conversion arrhythmias (eg, atrial and ventricular premature beats) are usually short-lived and do not require special treatment.

· Thromboembolism of the pulmonary artery and systemic circulation.

Thromboembolism more often develops in patients with thromboendocarditis and with long-term atrial fibrillation in the absence of adequate preparation with anticoagulants.

· Breathing disorders.

Breathing disorders are a consequence of inadequate premedication and analgesia.

To prevent the development of breathing disorders, complete oxygen therapy should be carried out. Often, developing respiratory depression can be managed with verbal commands. You should not try to stimulate breathing with respiratory analeptics. For severe breathing problems, intubation is indicated.

· Skin burns.

Skin burns occur due to poor contact of electrodes with the skin and the use of repeated discharges with high energy.

· Arterial hypotension.

Arterial hypotension rarely develops after cardioversion-defibrillation. Hypotension is usually mild and does not last long.

· Pulmonary edema.

Pulmonary edema rarely occurs 1-3 hours after restoration of sinus rhythm, especially in patients with long-standing atrial fibrillation.

· Changes in repolarization on the ECG.

Changes in repolarization on the ECG after cardioversion-defibrillation are multidirectional, nonspecific and can persist for several hours.

· Changes in biochemical blood test.

Increases in enzyme activity (AST, LDH, CPK) are mainly associated with the effect of cardioversion-defibrillation on skeletal muscles. The activity of MV CPK increases only with repeated high-energy discharges.

Contraindications for EIT:

1. Frequent, short-term paroxysms of AF, self-limiting or with medication.

2. Permanent form of atrial fibrillation:

More than three years old

The date is unknown.

Cardiomegaly

Frederick's syndrome

Glycoside intoxication,

TELA up to three months,

LIST OF REFERENCES USED

1. A.G. Miroshnichenko, V.V. Ruksin St. Petersburg Medical Academy of Postgraduate Education, St. Petersburg, Russia “Protocols of the diagnostic and treatment process at the prehospital stage”

2. http://smed.ru/guides/67158/#Pokazaniya_k_provedeniju_kardiversiidefibrillyacii

3. http://smed.ru/guides/67466/#_Pokazaniya_k_provedeniju_jelektrokardiostimulyacii

4. http://cardiolog.org/cardiohirurgia/50-invasive/208-vremennaja-ecs.html

5. http://www.popumed.net/study-117-13.html

Emergency conditions(accidents) - incidents that result in harm to human health or a threat to his life. An emergency is characterized by suddenness: it can happen to anyone, at any time and in any place.

People injured in an accident need immediate medical attention. If there is a doctor, paramedic or nurse nearby, turn to them for first aid. Otherwise, help should be provided by people near the victim.

The severity of the consequences of an emergency condition, and sometimes the life of the victim, depends on the timeliness and correctness of actions to provide emergency medical care, so every person must have the skills to provide first aid in emergency conditions.

The following types of emergency conditions are distinguished:

Thermal injuries;

Poisoning;

Bites from poisonous animals;

Attacks of illness;

Consequences of natural disasters;

Radiation injuries, etc.

The set of measures necessary for victims in each type of emergency condition has a number of features that must be taken into account when providing assistance to them.

4.2. First aid for sunstroke, heatstroke and fumes

Sunstroke is a lesion caused by prolonged exposure to sunlight on an unprotected head. You can also get sunstroke if you spend a long time outside on a clear day without a hat.

Heatstroke- This is excessive overheating of the entire body as a whole. Heat stroke can also happen in cloudy, hot, windless weather - during long and hard physical work, long and difficult treks, etc. Heat stroke is more likely when a person is not physically fit enough and experiences severe fatigue and thirst.

Symptoms of sunstroke and heatstroke are:

Cardiopalmus;

Redness and then paleness of the skin;

Loss of coordination;

Headache;

Noise in ears;

Dizziness;

Severe weakness and lethargy;

Decreased heart rate and breathing;

Nausea, vomiting;

Nose bleed;

Sometimes cramps and fainting.

Providing first aid for sunstroke and heatstroke should begin with transporting the victim to a place protected from heat exposure. In this case, it is necessary to lay the victim so that his head is higher than his body. After this, the victim needs to provide free access to oxygen and loosen his clothing. To cool the skin, you can wipe the victim with water and cool the head with a cold compress. The victim should be given a cold drink. In severe cases, artificial respiration is necessary.

Fainting is a short-term loss of consciousness due to insufficient blood flow to the brain. Fainting can occur from severe fright, excitement, great fatigue, as well as from significant blood loss and a number of other reasons.

When a person faints, he loses consciousness, his face turns pale and becomes covered in cold sweat, his pulse is barely palpable, his breathing slows down and is often difficult to detect.

First aid for fainting comes down to improving blood supply to the brain. To do this, the victim is laid so that his head is lower than his body, and his legs and arms are slightly raised. The victim's clothes need to be loosened and his face is sprayed with water.

It is necessary to ensure a flow of fresh air (open the window, fan the victim). To stimulate breathing, you can sniff ammonia, and to enhance the activity of the heart, when the patient regains consciousness, give hot, strong tea or coffee.

Frenzy– human carbon monoxide (CO) poisoning. Carbon monoxide is formed when fuel burns without a sufficient supply of oxygen. Carbon monoxide poisoning occurs unnoticed because the gas is odorless. Carbon monoxide poisoning causes the following symptoms:

General weakness;

Headache;

Dizziness;

Drowsiness;

Nausea, then vomiting.

In severe poisoning, disturbances in cardiac activity and breathing are observed. If the victim is not helped, death may occur.

First aid for fumes comes down to the following. First of all, the victim must be taken out of the carbon monoxide zone or the room ventilated. Then you need to apply a cold compress to the victim’s head and let him smell a cotton swab soaked in ammonia. To improve cardiac activity, the victim is given a hot drink (strong tea or coffee). Hot water bottles or mustard plasters are applied to the legs and arms. If you faint, perform artificial respiration. After which you should immediately seek medical help.

4.3. First aid for burns, frostbite and freezing

Burn- This is thermal damage to the body's integument caused by contact with hot objects or reagents. A burn is dangerous because, under the influence of high temperature, the living protein of the body coagulates, i.e., living human tissue dies. The skin is designed to protect tissues from overheating, but with prolonged exposure to the damaging factor, not only the skin, but also the skin, suffers from the burn.

but also tissues, internal organs, bones.

Burns can be classified according to a number of characteristics:

According to the source: burns from fire, hot objects, hot liquids, alkalis, acids;

By degree of damage: first, second and third degree burns;

By the size of the affected surface (as a percentage of the body surface).

With a first-degree burn, the burned area becomes slightly red, swollen, and a slight burning sensation is felt. This burn heals within 2–3 days. A second-degree burn causes redness and swelling of the skin, and blisters filled with a yellowish liquid appear on the burned area. The burn heals in 1 or 2 weeks. A third-degree burn is accompanied by necrosis of the skin, underlying muscles, and sometimes bone.

The danger of a burn depends not only on its degree, but also on the size of the damaged surface. Even a first-degree burn, if it covers half the surface of the entire body, is considered a serious illness. In this case, the victim experiences a headache, vomiting, and diarrhea. Body temperature rises. These symptoms are caused by general poisoning of the body due to the breakdown and decomposition of dead skin and tissue. With large burn surfaces, when the body is not able to remove all decay products, kidney failure may occur.

Second- and third-degree burns, if they affect a significant part of the body, can be fatal.

First aid for first and second degree burns is limited to applying a lotion of alcohol, vodka or a 1-2% solution of potassium permanganate (half a teaspoon per glass of water) to the burned area. Under no circumstances should blisters formed as a result of a burn be pierced.

If a third degree burn occurs, a dry, sterile bandage should be placed on the burned area. In this case, it is necessary to remove any remaining clothing from the burned area. These actions must be performed very carefully: first, the clothing is cut off around the affected area, then the affected area is soaked in a solution of alcohol or potassium permanganate and only then removed.

For a burn acid the affected surface must be immediately washed with running water or a 1-2% soda solution (half a teaspoon per glass of water). After this, the burn is sprinkled with crushed chalk, magnesia or tooth powder.

When exposed to particularly strong acids (for example, sulfuric acid), rinsing with water or aqueous solutions can cause secondary burns. In this case, the wound should be treated with vegetable oil.

For burns caustic alkali the affected area is washed with running water or a weak solution of acid (acetic, citric).

Frostbite- This is a thermal damage to the skin caused by severe cooling. Unprotected areas of the body are most susceptible to this type of thermal injury: ears, nose, cheeks, fingers and toes. The likelihood of frostbite increases when wearing tight shoes, dirty or wet clothes, general exhaustion of the body, and anemia.

There are four degrees of frostbite:

– I degree, in which the affected area turns pale and loses sensitivity. When the cold stops, the frostbitten area becomes bluish-red, becomes painful and swollen, and itching often appears;

– II degree, in which blisters appear on the frostbitten area after warming, the skin around the blisters has a bluish-red color;

– III degree, in which necrosis of the skin occurs. Over time, the skin dries out and a wound forms underneath;

– IV degree, in which necrosis can spread to the tissues underlying the skin.

First aid for frostbite is to restore blood circulation in the affected area. The affected area is wiped with alcohol or vodka, lightly lubricated with Vaseline or unsalted fat, and carefully rubbed with cotton wool or gauze so as not to damage the skin. You should not rub the frostbitten area with snow, as there are pieces of ice in the snow that can damage the skin and facilitate the penetration of germs.

Burns and blisters caused by frostbite are similar to burns caused by heat. Accordingly, the steps described above are repeated.

In the cold season, severe frosts and snowstorms are possible general body freezing. Its first symptom is chilliness. Then the person develops fatigue, drowsiness, the skin turns pale, the nose and lips are bluish, breathing is barely noticeable, the activity of the heart gradually weakens, and perhaps an unconscious state.

First aid in this case comes down to warming the person and restoring his blood circulation. To do this, you need to bring it into a warm room, take a warm bath, if possible, and lightly rub the frostbitten limbs with your hands from the periphery to the center until the body becomes soft and flexible. Then the victim must be put to bed, covered warmly, given hot tea or coffee and a doctor called.

However, it should be taken into account that with prolonged exposure to cold air or cold water, all human blood vessels narrow. And then, due to a sharp heating of the body, blood can hit the vessels of the brain, which can lead to a stroke. Therefore, heating a person must be done gradually.

4.4. First aid for food poisoning

Poisoning of the body can be caused by eating various low-quality foods: stale meat, jelly, sausage, fish, lactic acid products, canned food. Poisoning is also possible due to the consumption of inedible greens, wild berries, and mushrooms.

The main symptoms of poisoning are:

General weakness;

Headache;

Dizziness;

Abdominal pain;

Nausea, sometimes vomiting.

In severe cases of poisoning, loss of consciousness, weakening of cardiac activity and breathing are possible, and in the most severe cases, death.

First aid for poisoning begins with removing poisoned food from the victim’s stomach. To do this, they induce vomiting: they give him 5-6 glasses of warm salted or soda water to drink, or they insert two fingers deep into the throat and press on the root of the tongue. This cleansing of the stomach must be repeated several times. If the victim is unconscious, his head must be turned to the side so that vomit does not enter the respiratory tract.

In case of poisoning with a strong acid or alkali, you cannot induce vomiting. In such cases, the victim should be given oatmeal or flaxseed broth, starch, raw eggs, sunflower or butter.

A poisoned person should not be allowed to fall asleep. To eliminate drowsiness, you need to spray the victim with cold water or give him strong tea. If cramps occur, the body is warmed with heating pads. After providing first aid, the poisoned person must be taken to a doctor.

4.5. First aid for poisonous substances

TO toxic substances(CA) refer to chemical compounds that can affect unprotected people and animals, leading to their death or incapacitating them. The action of agents can be based on entry into the body through the respiratory system (inhalation exposure), penetration through the skin and mucous membranes (resorption) or through the gastrointestinal tract when consuming contaminated food and water. Toxic substances act in droplet-liquid form, in the form of aerosols, steam or gas.

As a rule, chemical agents are an integral part of chemical weapons. Chemical weapons are understood as military weapons whose destructive effect is based on the toxic effects of chemical agents.

The toxic substances that make up chemical weapons have a number of features. They are capable of causing mass casualties of people and animals in a short time, destroying plants, and infecting large volumes of ground air, which leads to damage to unsheltered people in the area. They can maintain their damaging effect for a long time. Delivery of such chemical agents to their destinations is carried out in several ways: with the help of chemical bombs, liquid airborne devices, aerosol generators, rockets, rockets and artillery shells and mines.

First medical aid in case of damage to the respiratory tract should be carried out in the form of self- and mutual aid or by specialized services. When providing first aid you must:

1) immediately put a gas mask on the victim (or replace a damaged gas mask with a working one) to stop the effect of the damaging factor on the respiratory system;

2) quickly administer an antidote (specific drug) to the victim using a syringe tube;

3) sanitize all exposed areas of the victim’s skin with a special liquid from an individual anti-chemical package.

The syringe tube consists of a polyethylene body onto which a cannula with an injection needle is screwed. The needle is sterile and is protected from contamination by a cap tightly placed on the cannula. The body of the syringe tube is filled with an antidote or other drug and hermetically sealed.

To administer the drug using a syringe tube, you need to perform the following steps.

1. Using the thumb and index finger of your left hand, grasp the cannula and support the body with your right hand, then turn the body clockwise until it stops.

2. Make sure there is medicine in the tube (to do this, press on the tube without removing the cap).

3. Remove the cap from the syringe, turning it slightly; Squeeze the air out of the tube by pressing it until a drop of liquid appears at the tip of the needle.

4. Insert the needle sharply (with a stabbing motion) under the skin or into the muscle, after which all the liquid contained in it is squeezed out of the tube.

5. Without unclenching your fingers on the tube, remove the needle.

When administering the antidote, it is best to inject into the buttock (upper outer quadrant), the anterolateral surface of the thigh and the outer surface of the shoulder. In an emergency situation, the antidote is administered at the site of the lesion using a syringe tube and through clothing. After the injection, you need to attach an empty syringe tube to the victim’s clothing or put it in the right pocket, which will indicate that the antidote has been administered.

Sanitary treatment of the victim's skin is carried out with liquid from an individual anti-chemical package (IPP) directly at the site of the injury, as this allows you to quickly stop exposure to toxic substances through unprotected skin. The PPI includes a flat bottle with a degasser, gauze swabs and a case (plastic bag).

When treating exposed skin with PPI, follow these steps:

1. Open the bag, take a swab from it and moisten it with the liquid from the bag.

2. Wipe the exposed skin and the outer surface of the gas mask with a swab.

3. Re-moisten the swab and wipe the edges of the collar and cuffs of clothing in contact with the skin.

It must be taken into account that the liquid from PPI is poisonous and if it gets into the eyes it can cause harm to health.

If chemical agents are sprayed using an aerosol method, the entire surface of the clothing will be contaminated. Therefore, after leaving the affected area, you should immediately take off your clothes, since the chemical agents contained on them can cause damage due to evaporation into the breathing zone and the penetration of vapors into the space under the suit.

If a nerve agent is damaged, the victim must be immediately evacuated from the source of infection to a safe area. During the evacuation of the injured, it is necessary to monitor their condition. To prevent seizures, repeated administration of the antidote is allowed.

If the affected person vomits, his head should be turned to the side and the lower part of the gas mask should be pulled back, then the gas mask should be put on again. If necessary, replace a dirty gas mask with a new one.

At subzero ambient temperatures, it is important to protect the valve box of the gas mask from freezing. To do this, cover it with a cloth and systematically warm it up.

If a suffocating agent (sarin, carbon monoxide, etc.) is affected, the victim is given artificial respiration.

4.6. First aid for a drowning person

A person cannot live without oxygen for more than 5 minutes, therefore, if he falls under water and remains there for a long time, a person can drown. The reasons for this situation may be different: cramp of the limbs when swimming in reservoirs, exhaustion of strength during long swims, etc. Water entering the victim’s mouth and nose fills the respiratory tract, and suffocation occurs. Therefore, assistance to a drowning person must be provided very quickly.

First aid to a drowning person begins with removing him to a hard surface. We especially note that the rescuer must be a good swimmer, otherwise both the drowning person and the rescuer may drown.

If a drowning person tries to stay on the surface of the water, he needs to be encouraged, throw him a lifebuoy, a pole, an oar, the end of a rope so that he can stay on the water until he is rescued.

The rescuer must be without shoes and clothes, or, in extreme cases, without outerwear. You need to swim up to a drowning person carefully, preferably from behind, so that he does not grab the rescuer by the neck or arms and pull him to the bottom.

A drowning person is taken from behind under the armpits or by the back of the head near the ears and, holding his face above the water, floats on his back to the shore. You can grab a drowning person with one hand around the waist, only from behind.

On the shore you need restore your breath victim: quickly remove his clothes; free your mouth and nose from sand, dirt, silt; remove water from the lungs and stomach. Then the following actions are performed.

1. The first aid provider kneels on one knee and places the victim stomach down on the other knee.

2. Use your hand to apply pressure on the victim’s back between the shoulder blades until foamy liquid stops flowing from his mouth.

4. When the victim regains consciousness, he needs to be warmed up by rubbing his body with a towel or covering it with heating pads.

5. To enhance cardiac activity, the victim is given strong hot tea or coffee.

6. The victim is then transported to a medical facility.

If a drowning person has fallen through the ice, then it is impossible to run to his aid on the ice when it is not strong enough, since the rescuer may also drown. You need to place a board or ladder on the ice and, approaching carefully, throw the end of a rope to the drowning person or extend a pole, oar, or stick. Then, just as carefully, you need to help him get to the shore.

4.7. First aid for bites of poisonous insects, snakes and rabid animals

In the summer, a person can be bitten by a bee, wasp, bumblebee, snake, and in some areas, a scorpion, tarantula or other poisonous insects. The wound from such bites is small and resembles a needle prick, but when bitten, poison penetrates through it, which, depending on its strength and quantity, either acts first on the area of ​​the body around the bite, or immediately causes general poisoning.

Single bites bees, wasps And bumblebees do not pose any particular danger. If there is a sting left in the wound, it must be carefully removed, and a lotion of ammonia with water or a cold compress from a solution of potassium permanganate or just cold water should be applied to the wound.

Bites poisonous snakes life-threatening. Usually snakes bite a person on the leg when he steps on them. Therefore, you should not walk barefoot in places where there are snakes.

When a snake bites, the following symptoms are observed: burning pain at the site of the bite, redness, swelling. After half an hour, the leg can almost double in volume. At the same time, signs of general poisoning appear: loss of strength, muscle weakness, dizziness, nausea, vomiting, weak pulse, and sometimes loss of consciousness.

Bites poisonous insects very dangerous. Their venom causes not only severe pain and burning at the site of the bite, but sometimes general poisoning. Symptoms resemble those of snake venom poisoning. In case of severe poisoning by the venom of the karakurt spider, death may occur within 1–2 days.

First aid for bites from poisonous snakes and insects is as follows.

1. A tourniquet or twist must be applied above the bitten area to prevent the poison from entering other parts of the body.

2. The bitten limb should be lowered and try to squeeze out the blood containing the poison from the wound.

You cannot suck blood from a wound with your mouth, as there may be scratches or broken teeth in the mouth, through which the poison will penetrate into the blood of the person providing assistance.

You can pull the blood along with the poison from the wound using a medical jar, glass or shot glass with thick edges. To do this, hold a lit splinter or cotton wool on a stick in a jar (glass or shot glass) for a few seconds and then quickly cover the wound with it.

Every victim of a snake bite or poisonous insect bite must be transported to a medical facility.

A person gets sick from the bite of a rabid dog, cat, fox, wolf or other animal. rabies. The bite site usually bleeds slightly. If your arm or leg is bitten, you need to quickly lower it and try to squeeze the blood out of the wound. If there is bleeding, the blood should not be stopped for some time. After this, the bite site is washed with boiled water, a clean bandage is applied to the wound and the patient is immediately sent to a medical facility, where the victim is given special vaccinations that will save him from the deadly disease - rabies.

It should also be remembered that you can get rabies not only from the bite of a rabid animal, but also in cases where its saliva gets on scratched skin or mucous membrane.

4.8. First aid for electric shock

Electric shock is dangerous to human life and health. High voltage current can cause instant loss of consciousness and lead to death.

The current voltage in the wires of residential premises is not so high, and if you carelessly grab a bare or poorly insulated electrical wire at home, pain and convulsive contraction of the muscles of the fingers are felt in the hand, and a small superficial burn of the upper skin may form. Such a lesion does not cause much harm to health and is not life-threatening if there is grounding in the house. If there is no grounding, then even a small current can lead to undesirable consequences.

A current of higher voltage causes convulsive contraction of the muscles of the heart, blood vessels, and respiratory organs. In such cases, a circulatory disorder occurs, a person may lose consciousness, while he suddenly turns pale, his lips turn blue, breathing becomes barely noticeable, and the pulse is difficult to palpate. In severe cases, there may be no signs of life at all (breathing, heartbeat, pulse). The so-called “imaginary death” occurs. In this case, a person can be brought back to life if he is immediately given first aid.

First aid in case of electric shock should begin with stopping the current on the victim. If a broken bare wire falls on a person, it must be reset immediately. This can be done with any object that does not conduct electricity well (a wooden stick, a glass or plastic bottle, etc.). If an accident occurs indoors, you must immediately turn off the switch, remove the plugs, or simply cut the wires.

It should be remembered that the rescuer must take the necessary measures to ensure that he himself does not suffer from the effects of electric current. To do this, when providing first aid, you need to wrap your hands in a non-conductive fabric (rubber, silk, wool), put dry rubber shoes on your feet, or stand on a stack of newspapers, books, or a dry board.

Do not grab the victim by the naked parts of the body while the current continues to affect him. When removing a victim from the wire, you should protect yourself by wrapping your hands in insulating cloth.

If the victim is unconscious, he must first be brought to his senses. To do this, you need to unbutton his clothes, sprinkle water on him, open the windows or doors and give him artificial respiration until spontaneous breathing occurs and consciousness returns. Sometimes artificial respiration has to be done continuously for 2–3 hours.

Simultaneously with artificial respiration, the victim’s body must be rubbed and warmed with heating pads. When the victim regains consciousness, he is put to bed, covered warmly and given a hot drink.

A patient struck by an electric current may have various complications, so he must be sent to the hospital.

Another possible option for the effect of electric current on a person is lightning strike, the action of which is similar to the action of an electric current of very high voltage. In some cases, the victim instantly dies from respiratory paralysis and cardiac arrest. Red stripes appear on the skin. However, being struck by lightning often results in only severe stunning. In such cases, the victim loses consciousness, his skin turns pale and cold, his pulse is barely palpable, his breathing is shallow and barely noticeable.

Saving the life of a person struck by lightning depends on the speed of providing him with first aid. The victim should immediately begin artificial respiration and continue until he begins to breathe on his own.

To prevent the effects of lightning, a number of measures must be taken during rain and thunderstorms:

During a thunderstorm, you cannot hide from the rain under a tree, as trees “attract” lightning to themselves;

During a thunderstorm, you should avoid elevated areas, as these areas are more likely to be struck by lightning;

All residential and administrative premises must be equipped with lightning rods, the purpose of which is to prevent lightning from entering the building.

4.9. Cardiopulmonary resuscitation complex. Its application and effectiveness criteria

Cardiopulmonary resuscitation is a set of measures aimed at restoring the victim’s cardiac activity and breathing when they cease (clinical death). This can happen due to electric shock, drowning, or in a number of other cases due to compression or blockage of the airways. The likelihood of a patient’s survival directly depends on the speed of use of resuscitation.

It is most effective to use special devices for artificial ventilation of the lungs, with the help of which air is blown into the lungs. In the absence of such devices, artificial ventilation of the lungs is carried out in various ways, of which the most common is the “mouth-to-mouth” method.

Mouth-to-mouth method of artificial lung ventilation. To assist the victim, it is necessary to lay him on his back so that the airways are free for air to pass through. To do this, his head needs to be tilted back as much as possible. If the victim’s jaws are strongly clenched, it is necessary to move the lower jaw forward and, pressing on the chin, open the mouth, then clean the oral cavity of saliva or vomit with a napkin and begin artificial ventilation:

1) place a napkin (handkerchief) in one layer on the victim’s open mouth;

2) hold his nose;

3) take a deep breath;

4) press your lips tightly against the victim’s lips, creating a tight seal;

5) forcefully blow air into his mouth.

Air is inhaled rhythmically 16–18 times per minute until natural breathing is restored.

For injuries to the lower jaw, artificial ventilation can be performed in another way, when air is blown through the victim’s nose. His mouth should be closed.

Artificial ventilation is stopped when reliable signs of death are established.

Other methods of artificial ventilation. With extensive wounds of the maxillofacial area, artificial ventilation of the lungs using the “mouth to mouth” or “mouth to nose” methods is impossible, so the methods of Sylvester and Kallistov are used.

During artificial ventilation of the lungs Sylvester's way the victim lies on his back, the person assisting him kneels at his head, takes both his hands by the forearms and sharply raises them, then takes them back behind him and spreads them to the sides - this is how he inhales. Then, with a reverse movement, the victim’s forearms are placed on the lower part of the chest and squeezed - this is how exhalation occurs.

With artificial ventilation of the lungs Kallistov's method The victim is placed on his stomach with his arms extended forward, his head is turned to the side, and clothing (a blanket) is placed under it. Using stretcher straps or tied with two or three trouser belts, the victim is periodically (in the rhythm of breathing) raised to a height of 10 cm and lowered. When the victim is raised as a result of straightening his chest, an inhalation occurs; when lowered due to its compression, an exhalation occurs.

Signs of cessation of cardiac activity and indirect cardiac massage. Signs of cardiac arrest are:

Lack of pulse, heartbeat;

Lack of pupil reaction to light (pupils dilated).

If these signs are identified, you should immediately begin indirect cardiac massage. For this:

1) the victim is placed on his back, on a hard, hard surface;

2) standing on the left side of him, place their palms one on top of the other on the area of ​​the lower third of the sternum;

3) with energetic rhythmic pushes 50–60 times per minute, press on the sternum, after each push releasing the hands to allow the chest to straighten. The anterior wall of the chest should shift to a depth of at least 3–4 cm.

Indirect cardiac massage is performed in combination with artificial ventilation: 4–5 compressions on the chest (as you exhale) alternate with one blowing of air into the lungs (inhalation). In this case, two or three people should provide assistance to the victim.

Artificial ventilation in combination with chest compressions is the simplest way resuscitation(revival) of a person in a state of clinical death.

Signs of the effectiveness of the measures taken are the appearance of spontaneous breathing of a person, restored complexion, the appearance of a pulse and heartbeat, as well as the return of consciousness to the patient.

After carrying out these measures, the patient must be provided with rest, he must be warmed up, given hot and sweet drinks, and, if necessary, tonics must be used.

When performing artificial ventilation of the lungs and chest compressions, elderly people should remember that bones at this age are more fragile, so movements should be gentle. For young children, indirect massage is performed by applying pressure in the sternum area not with the palms, but with the finger.

4.10. Providing medical assistance during natural disasters

Natural disaster called an emergency situation in which human casualties and material losses are possible. There are emergencies of natural (hurricanes, earthquakes, floods, etc.) and man-made (bomb explosions, accidents at enterprises) origin.

Sudden natural disasters and accidents require urgent organization of medical assistance to the affected population. Of great importance are the timely provision of first aid directly at the site of the injury (self- and mutual aid) and the evacuation of victims from the outbreak to medical institutions.

The main type of damage in natural disasters is injuries accompanied by life-threatening bleeding. Therefore, it is first necessary to take measures to stop the bleeding, and then provide symptomatic medical care to the victims.

The content of measures to provide medical assistance to the population depends on the type of natural disaster or accident. Yes, when earthquakes This means extracting victims from the rubble and providing them with medical care depending on the nature of the injury. At floods The first priority is to remove victims from the water, warm them, and stimulate cardiac and respiratory activity.

In the affected area tornado or hurricane, it is important to quickly carry out medical triage of those affected, providing assistance first to those most in need.

Injured as a result snow drifts And landslides after being removed from the snow, they warm them up, then provide them with the necessary assistance.

In outbreaks fires First of all, it is necessary to extinguish the burning clothes of the victims and apply sterile bandages to the burned surface. If people are affected by carbon monoxide, immediately remove them from areas of intense smoke.

Whenever accidents at nuclear power plants It is necessary to organize radiation reconnaissance, which will determine the levels of radioactive contamination of the territory. Food, food raw materials, and water must be subjected to radiation control.

Providing assistance to victims. If lesions occur, victims are provided with the following types of assistance:

First aid;

First medical aid;

Qualified and specialized medical care.

First medical aid is provided to those affected directly at the scene of injury by sanitary squads and sanitary posts, other units of the Russian Ministry of Emergency Situations working in the outbreak, as well as in the form of self- and mutual aid. Its main task is to save the life of the affected person and prevent possible complications. The removal of the injured to the places of loading onto transport is carried out by rescue force porters.

First medical aid to those affected is provided by medical units, medical units of military units and health care institutions that have survived in the outbreak. All these formations constitute the first stage of medical and evacuation support for the affected population. The tasks of first medical aid are to maintain the vital functions of the affected body, prevent complications and prepare it for evacuation.

Qualified and specialized medical care for those affected is provided in medical institutions.

4.11. Medical care for radiation poisoning

When providing first aid to victims of radiation contamination, it is necessary to take into account that in a contaminated area you cannot consume food, water from contaminated sources, or touch objects contaminated with radiation substances. Therefore, first of all, it is necessary to determine the procedure for preparing food and purifying water in contaminated areas (or organizing delivery from uncontaminated sources), taking into account the level of contamination of the area and the current situation.

First medical aid to victims of radiation contamination should be provided in conditions of maximum reduction of harmful effects. To do this, victims are transported to uninfected areas or to special shelters.

Initially, it is necessary to take certain actions to save the life of the victim. First of all, it is necessary to organize sanitization and partial decontamination of his clothes and shoes to prevent harmful effects on the skin and mucous membranes. To do this, wash the victim’s exposed skin with water and wipe with damp swabs, wash the eyes, and rinse the mouth. When decontaminating clothing and shoes, it is necessary to use personal protective equipment to prevent harmful effects of radioactive substances on the victim. It is also necessary to prevent contaminated dust from reaching other people.

If necessary, the victim's stomach is lavaged and absorbent agents (activated carbon, etc.) are used.

Medical prevention of radiation injuries is carried out using radioprotective agents available in an individual first aid kit.

The individual first aid kit (AI-2) contains a set of medical supplies intended for personal prevention of injuries from radioactive, toxic substances and bacterial agents. For radiation infections, the following medications contained in AI-2 are used:

– I slot – syringe tube with an analgesic;

– III nest – antibacterial agent No. 2 (in an oblong pencil case), a total of 15 tablets, which are taken after radiation exposure for gastrointestinal disorders: 7 tablets per dose on the first day and 4 tablets per dose daily for the next two days. The drug is taken to prevent infectious complications that may arise due to the weakening of the protective properties of the irradiated organism;

– IV nest – radioprotective agent No. 1 (pink pencil cases with a white lid), 12 tablets in total. Take 6 tablets simultaneously 30–60 minutes before the start of irradiation following a civil defense warning signal in order to prevent radiation damage; then 6 tablets every 4–5 hours when staying in an area contaminated with radioactive substances;

– Socket VI – radioprotective agent No. 2 (white pencil case), 10 tablets in total. Take 1 tablet daily for 10 days when consuming contaminated products;

– VII nest – antiemetic (blue pencil case), 5 tablets in total. Use 1 tablet for contusions and primary radiation reaction to prevent vomiting. For children under 8 years of age, take one-fourth of the indicated dose, for children from 8 to 15 years of age - half the dose.

The distribution of medications and instructions for their use are attached to the individual first aid kit.

The most important thing before the doctors arrive is to stop the influence of factors that worsen the well-being of the injured person. This step involves eliminating life-threatening processes, for example: stopping bleeding, overcoming asphyxia.

Determine the actual status of the patient and the nature of the disease. The following aspects will help with this:

• what are the blood pressure values?
• are bleeding wounds visible?
• the patient has a reaction of the pupils to light;
• has your heart rate changed?
• respiratory functions are preserved or not;
• how adequately a person perceives what is happening;
• whether the victim is conscious or not;
• if necessary, ensuring respiratory functions by accessing fresh air and ensuring that there are no foreign objects in the air ducts;
• carrying out non-invasive ventilation (artificial respiration using the “mouth to mouth” method);
• performing indirect (closed) in the absence of a pulse.

Quite often, the preservation of health and human life depends on the timely provision of high-quality first aid. In case of emergency, all victims, regardless of the type of illness, require competent emergency actions before the arrival of the medical team.

First aid for emergency conditions cannot always be offered by qualified doctors or paramedics. Every modern person must have the skills of pre-medical measures and know the symptoms of common diseases: the result depends on the quality and timeliness of measures, the level of knowledge, and the skills of witnesses to critical situations.

ABC Algorithm

Emergency pre-medical actions involve the implementation of a set of simple therapeutic and preventive measures directly at the scene of the tragedy or near it. First aid for emergency conditions, regardless of the nature of the illness or received, has a similar algorithm. The essence of the measures depends on the nature of the symptoms exhibited by the injured person (for example: loss of consciousness) and on the expected causes of the emergency (for example: a hypertensive crisis in arterial hypertension). Rehabilitation measures within the framework of first aid in emergency conditions are carried out according to uniform principles - the ABC algorithm: these are the first English letters denoting:

• Air (air);
• Breathing (breathing);
• Circulation (blood circulation).

A-Z A B C D E F G H I J J K L M N O P R S T U V X C CH W SCH E Y Z All sections Hereditary diseases Emergency conditions Eye diseases Children's diseases Men's diseases Venereal diseases Women's diseases Skin diseases Infectious diseases Nervous diseases Rheumatic diseases Urological diseases Endocrine diseases Immune diseases Allergic diseases Oncological diseases Diseases of the veins and lymph nodes Hair diseases Dental diseases Blood diseases Breast diseases ODS diseases and injuries Respiratory diseases Diseases of the digestive system Diseases of the heart and blood vessels Diseases of the large intestine Diseases of the ear, throat , nose Drug problems Mental disorders Speech disorders Cosmetic problems Aesthetic problems

– severe disorders of vital functions that pose a threat to the patient’s life and require emergency assistance, including using intensive care and resuscitation methods. Such critical conditions include both acute pathologies (poisoning, asphyxia, traumatic shock) and complications of long-term chronic diseases (hypertensive crisis, status asthmaticus, diabetic coma, etc.). Resuscitators of the emergency medical care service, disaster medicine, and ICU are engaged in the management of emergency conditions. However, all senior and mid-level medical workers are familiar with the basics and principles of resuscitation measures.

Life-threatening conditions vary in cause and underlying mechanism. Knowledge and consideration of the etiopathogenesis of critical life disorders are extremely important, as they allow us to build the correct algorithm for providing medical care. Depending on the damaging factor, emergency conditions are divided into three groups:

• Injuries. They occur when the body is exposed to extreme factors: thermal, chemical, mechanical, etc. They include burns, frostbite, electrical trauma, fractures, damage to internal organs and bleeding. They are recognized on the basis of external examination and assessment of basic vital processes.
• Poisoning and allergies. They develop due to inhalation, enteral, parenteral, or contact intake of poisons/allergens into the body. This group of emergency conditions includes poisoning with mushrooms, plant poisons, alcohol, psychoactive substances, chemical compounds, drug overdose, bites of poisonous snakes and insects, anaphylactic shock, etc. Visible damage in many intoxications is absent, and severe disorders occur at the cellular level.
• Diseases of internal organs. These include acute dysfunctions and states of decompensation of chronic processes (myocardial infarction, uterine bleeding, mental disorders. Symptoms that should alert relatives and those around the patient are severe weakness and lethargy, loss of consciousness, speech impairment, excessive external bleeding, pallor or cyanosis of the skin , suffocation, convulsions, repeated vomiting, severe pain.

  The strategy for treating emergency conditions consists of first aid, which can be provided to the victim by nearby people, and the actual medical measures carried out by professional doctors. First aid depends on the nature of the disorder and the patient’s condition; it may include cessation of the damaging factor, giving the patient an optimal body position (with the head or leg end raised), temporary immobilization of the limb, providing access to oxygen, applying cold or warming the patient, and applying a hemostatic tourniquet. In all cases, you should immediately call an ambulance.

  Cardiopulmonary resuscitation is continued for 30 minutes. The criterion for its effectiveness is the restoration of vital functions; in this case, after stabilization of the patient’s condition, the patient is hospitalized in a hospital for further treatment of the underlying disease. If after the specified time no signs of revival of the body appear, then resuscitation measures are stopped and biological death is declared. In the online directory “Beauty and Medicine” you will find a detailed description of emergency conditions, as well as professional recommendations for providing first aid to people in critical condition.

Article 11 Federal Law of November 21, 2011 No. 323-FZ“On the basics of protecting the health of citizens in the Russian Federation” (hereinafter referred to as Federal Law No. 323) says that in an emergency, a medical organization and a medical worker provides a citizen immediately and free of charge. Refusal to provide it is not allowed. A similar wording was in the old Fundamentals of Legislation on the Protection of Citizens’ Health in the Russian Federation (approved by the Supreme Court of the Russian Federation on July 22, 1993 N 5487-1, no longer in force on January 1, 2012), although the concept “” appeared in it. What is emergency medical care and what is its difference from the emergency form?

An attempt to isolate emergency medical care from emergency or emergency medical care that is familiar to each of us was previously made by officials of the Ministry of Health and Social Development of Russia (since May 2012 -). Therefore, since approximately 2007, we can talk about the beginning of some separation or differentiation of the concepts of “emergency” and “urgent” assistance at the legislative level.

However, in explanatory dictionaries of the Russian language there are no clear differences between these categories. Urgent - one that cannot be postponed; urgent. Emergency - urgent, extraordinary, urgent. Federal Law No. 323 put an end to this issue by approving three different forms of medical care: emergency, urgent and planned.

Emergency

Medical care provided for sudden acute diseases, conditions, exacerbation of chronic diseases that pose a threat to the patient’s life.

Urgent

Medical care provided for sudden acute diseases, conditions, exacerbation of chronic diseases without obvious signs of a threat to the patient’s life.

Planned

Medical care that is provided during preventive measures, for diseases and conditions that are not accompanied by a threat to the patient’s life, that do not require emergency and emergency medical care, and the delay of which for a certain time will not entail a deterioration in the patient’s condition, a threat to his life and health.

As you can see, emergency and emergency medical care are opposed to each other. At the moment, absolutely any medical organization is obliged to provide only emergency medical care free of charge and without delay. So are there any significant differences between the two concepts under discussion?

The main difference is that EMF occurs in cases of life threatening person, and emergency - without obvious signs of a threat to life. However, the problem is that the legislation does not clearly define which cases and conditions are considered a threat and which are not. Moreover, it is not clear what is considered a clear threat? Diseases, pathological conditions, and signs indicating a threat to life are not described. The mechanism for determining the threat is not specified. Among other things, the condition may not be life-threatening at a particular moment, but failure to provide assistance will subsequently lead to a life-threatening condition.

In view of this, a completely fair question arises: how to distinguish a situation when emergency assistance is needed, how to draw the line between emergency and emergency assistance. An excellent example of the difference between emergency and emergency care is outlined in the article by Professor A.A. Mokhov “Features of legislative regulation of the provision of emergency and emergency care in Russia”:

Sign	Medical assistance form
	Emergency	Urgent
Medical criterion	Threat to life	There is no obvious threat to life
Reason for providing assistance	The patient’s request for help (expression of will; contractual regime); treatment of other persons (lack of expression of will; legal regime)	Request by the patient (his legal representatives) for help (contractual regime)
Terms of service	Outside a medical organization (pre-hospital stage); in a medical organization (hospital stage)	Outpatient (including at home), as part of a day hospital
Person obliged to provide medical care	A doctor or paramedic, any medical professional	Medical specialist (therapist, surgeon, ophthalmologist, etc.)
Time interval	Help must be provided as quickly as possible	Assistance must be provided within a reasonable time

But unfortunately, this is also not enough. In this matter, we definitely cannot do without the participation of our “legislators”. Solving the problem is necessary not only for theory, but also for “practice”. One of the reasons, as mentioned earlier, is the obligation of each medical organization to provide emergency medical care free of charge, while emergency care can be provided on a paid basis.

It is important to note that the “image” of emergency medical care is still “collective”. One of the reasons is territorial programs of state guarantees for the free provision of medical care to citizens (hereinafter referred to as TPGG), which contain (or do not contain) various provisions regarding the procedure and conditions for the provision of EMC, emergency criteria, the procedure for reimbursement of expenses for the provision of EMC, and so on.

For example, the 2018 TPGG of the Sverdlovsk region indicates that a case of emergency medical care must meet the criteria of an emergency: suddenness, acute condition, life-threatening. Some TPGGs mention emergency criteria, referring to Order of the Ministry of Health and Social Development of the Russian Federation dated April 24, 2008 No. 194n “On approval of Medical criteria for determining the severity of harm caused to human health” (hereinafter referred to as Order No. 194n). For example, the 2018 TPGG of the Perm Territory indicates that the criterion for emergency medical care is the presence of life-threatening conditions, defined in:

• clause 6.1 of Order No. 194n (harm to health, dangerous to human life, which by its nature directly poses a threat to life, as well as harm to health that caused the development of a life-threatening condition, namely: head wound; contusion of the cervical spinal cord with disruption of it functions, etc. * );
• clause 6.2 of Order No. 194n (harm to health, dangerous to human life, causing a disorder of the vital functions of the human body, which cannot be compensated by the body on its own and usually ends in death, namely: shock of severe III - IV degree; acute, profuse or massive blood loss, etc.*).

* The full list is defined in Order No. 194n.

According to ministry officials, emergency medical care is provided if the patient’s existing pathological changes are not life-threatening. But from various regulations of the Ministry of Health and Social Development of Russia it follows that there are no significant differences between emergency and emergency medical care.

Some TPGGs indicate that the provision of emergency medical care is carried out in accordance with emergency medical care standards, approved by orders of the Russian Ministry of Health, according to conditions, syndromes, diseases. And, for example, the TPGG 2018 of the Sverdlovsk region means that emergency care is provided in outpatient, inpatient and day hospital settings in the following cases:

• when an emergency condition occurs in a patient on the territory of a medical organization (when the patient seeks medical care in a planned form, for diagnostic tests, consultations);
• when the patient self-refers or is delivered to a medical organization (as the closest one) by relatives or other persons in the event of an emergency;
• if an emergency condition occurs in a patient during treatment in a medical organization, during planned manipulations, operations, or studies.

Among other things, it is important to note that if a citizen’s health condition requires emergency medical care, the citizen’s examination and treatment measures are carried out at the place of his appeal immediately by the medical worker to whom he turned.

Unfortunately, Federal Law No. 323 contains only the analyzed concepts themselves without the criteria that “separate” these concepts. As a result, a number of problems arise, the main one of which is the difficulty of determining in practice the presence of a threat to life. As a result, there is an urgent need for a clear description of diseases and pathological conditions, signs indicating a threat to the patient’s life, with the exception of the most obvious (for example, penetrating wounds of the chest, abdominal cavity). It is unclear what the mechanism for identifying a threat should be.

Order of the Ministry of Health of Russia dated June 20, 2013 No. 388n “On approval of the Procedure for providing emergency, including specialized emergency medical care” allows us to identify some conditions that indicate a threat to life. The order states that the reason for calling an ambulance in emergency form are sudden acute diseases, conditions, exacerbations of chronic diseases that pose a threat to the patient’s life, including:

• disturbances of consciousness;
• breathing problems;
• disorders of the circulatory system;
• mental disorders accompanied by the patient’s actions that pose an immediate danger to him or others;
• pain syndrome;
• injuries of any etiology, poisoning, wounds (accompanied by life-threatening bleeding or damage to internal organs);
• thermal and chemical burns;
• bleeding of any etiology;
• childbirth, threat of miscarriage.

As you can see, this is only an approximate list, but we believe that it can be used by analogy when providing other medical care (not emergency).

However, from the analyzed acts it follows that often the conclusion about the presence of a threat to life is made either by the victim himself or by the ambulance dispatcher, based on the subjective opinion and assessment of what is happening by the person who sought help. In such a situation, both an overestimation of the danger to life and a clear underestimation of the severity of the patient’s condition are possible.

I would like to hope that the most important details will soon be more fully spelled out in the acts. At the moment, medical organizations probably still should not ignore the medical understanding of the urgency of the situation, the presence of a threat to the patient’s life and the urgency of action. In a medical organization, it is mandatory (or rather, highly recommendatory) to develop local instructions for emergency medical care on the territory of the organization, which all medical workers must be familiar with.

Article 20 of Law No. 323-FZ states that a necessary precondition for medical intervention is the giving of informed voluntary consent (hereinafter referred to as IDS) by a citizen or his legal representative for medical intervention on the basis of complete information provided by a medical worker in an accessible form about the goals and methods of providing medical care. , the associated risk, possible options for medical intervention, its consequences, as well as the expected results of medical care.

However, the situation in providing medical care in emergency form(which is also considered a medical intervention) falls within the exception. Namely, medical intervention is allowed without the consent of a person for emergency reasons to eliminate a threat to a person’s life, if the condition does not allow one to express one’s will, or if there are no legal representatives (clause 1 of part 9 of article 20 of Federal Law No. 323). The basis for disclosing medical confidentiality without the patient’s consent is similar (clause 1 of part 4 of article 13 of Federal Law No. 323).

In accordance with clause 10 of Article 83 of Federal Law No. 323, expenses associated with the provision of free emergency medical care to citizens by a medical organization, including a medical organization of the private healthcare system, are subject to reimbursement. Read about reimbursement of expenses for the provision of emergency medicine in our article: Reimbursement of expenses for the provision of free emergency medical care.

After entry into force Order of the Ministry of Health of Russia dated March 11, 2013 No. 121n“On approval of the Requirements for the organization and performance of work (services) in the provision of primary health care, specialized (including high-tech) ...” (hereinafter referred to as Order of the Ministry of Health No. 121n), many citizens have a well-founded misconception that emergency medical care must be included in the medical license. The type of medical service “emergency medical care”, subject to , is also indicated in Decree of the Government of the Russian Federation dated April 16, 2012 No. 291“On licensing of medical activities.”

However, the Ministry of Health of the Russian Federation, in its Letter No. 12-3/10/2-5338 dated July 23, 2013, gave the following explanation on this topic: “As for the work (service) for emergency medical care, this work (service) was introduced for licensing the activities of medical organizations that, in accordance with Part 7 of Article 33 of Federal Law N 323-FZ, have created units in their structure to provide emergency primary health care. In other cases of providing emergency medical care, obtaining a license providing for the performance of emergency medical care work (services) is not required.”

Thus, the type of medical service “emergency medical care” is subject to licensing only by those medical organizations in whose structure, in accordance with Article 33 of Federal Law No. 323, medical care units are created that provide the specified assistance in an emergency form.

The article uses materials from the article by A.A. Mokhov. Features of providing emergency and emergency care in Russia // Legal issues in healthcare. 2011. No. 9.

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