Principles of treatment of critical states
Most importance in daily medical practice are questions of treatment of critical states such as:
respiratory failure, critical circulatory failure and cardiac arrest, a state of shock.
Acute respiratory failure (ARF). The most common causes are: trauma of the chest and respiratory organs, accompanied by fractures of the ribs, pneumo-or hemothorax, a violation of the provisions and the mobility of the diaphragm;
disorders of the central mechanisms of breathing control in case of injuries and diseases of the brain; violation of the airway, a reduction of a functioning surface of the lungs in pneumonia or atelectasis, pulmonary circulation disorders in the disk (bypass surgery, the development of so-called shock lung, pulmonary thromboembolism of the branches of the arteries, pulmonary edema).
Signs of acute respiratory failure: dyspnea, cyanosis (not of bleeding and anemia), tachycardia, agitation, and then progressing lethargy, loss of consciousness, the humidity of the skin, the purple tint them, the movement of the wings of the nose, the inclusion of auxiliary breathing muscles. In progressive respiratory failure hypertension is replaced by hypotension, often develop bradycardia, arrhythmia, and with symptoms of cardiovascular disease death occurs. Resuscitation in the terminal phase of the ODN are ineffective, so it is especially important the timely intensive care ODN.
In order to diagnose the causes of ARF conduct physical and radiological examination of the chest (pneumo-detection, hydrothorax, rib fractures, pneumonia and other disorders). It is also advisable to make a study of blood gas composition to determine the degree of hypoxia and hypercapnia. Prior to clarify the cause of ARF is strictly forbidden to introduce drugs to the patient sleeping pills, sedative or neuroleptic action, as well as drugs.
In detecting pneumothorax for the treatment of ARF should drain the pleural cavity by introducing into the second intercostal space in parasternal line of rubber or silicone drainage, which is connected to the suction valve or underwater. When large amounts of fluid in the pleural cavity (hemo-or hydrothorax, empyema), it is removed by aspiration through a needle or trocar.
Violations of the patency of upper airway requires immediate inspection of the oral cavity and the entrance to the larynx through the laryngoscope, the release of their content, and foreign bodies. If the obstruction is below the entrance to the larynx, to eliminate the obstruction is required bronchoscopy (preferably with FBS), during which remove solid foreign bodies from the trachea and bronchi, and the presence in the bronchial system of pathological content (blood, pus, edible weight) produce sanitation , ie,. lavage (lavage) bronchus. Using modern FBS to allow under the control of purification of individual segments of the bronchial tree, gives the best therapeutic effect on the background of the injection ventilation. Bronchial lavage (lavage) can not be used for simple content sucking bronchus, when in their lumen are thick muco-purulent masses (eg, severe asthma states). Purification of the tracheobronchial tree from liquid muco-purulent masses can be accomplished by sucking them through a sterile catheter, administered alternately in right and left bronchus through the tracheal or tracheostomy tube or through the nose (blindly). When it is impossible to apply the above measures for the restoration of the airway and the readjustment of the bronchi produce a tracheostomy.
Fighting ODN paresis or paralysis of the gastrointestinal tract, the violation of a provision and mobility of the diaphragm is the introduction of the probe for the evacuation of stomach contents and giving the patient an elevated position.
In addition to drug therapy, oxygen therapy and the need for a permanent high airway pressure, (PAP), increased resistance in end-expiratory (PEEP), which often proves to be effective. Develop appropriate valves and devices, in the absence of which use a simple device to oxygen inhaler or anesthesia-breathing apparatus. To this end expiratory tube is placed in a container of water to a depth of 5-6 cm, making the patient breathe through the mask of the breathing bag apparatus. Hold your breath for a half-open system (inspiration from the apparatus, exhale to the outside), which requires a flow of gas mixture, a few more than the minute volume of respiration.
If acute respiratory failure causes or exacerbates a sharp pain when breathing (chest injuries, acute process in the abdominal cavity), analgesic drugs can be used only after diagnosis. Must be received intercostal nerve blockade. With broken ribs carry the fracture site procaine blockade, paravertebral blockade is damaged more than 2 edges, vagosimpaticheskuyu blockade.
When oxygen patient with ARF should monitor the depth and breath rate. Apnea or hypoventilation during inhalation of oxygen indicates the presence of severe hypoxic condition requiring artificial ventilation (AV).
Mechanical ventilation should be initiated for gross violations of breath, signs of severe hypoxia and hypercapnia (confusion, agitation or retardation, or blednotsianotichny crimson color, tachycardia or bradycardia, hypertension, sometimes, on the contrary, hypotension, shortness of breath more than 40 breaths in 1 min, moisture of the skin).
Treatment of patients with the development of ARF should be made an anesthesiologist - resuscitation in the intensive care unit and intensive care. Prehospital, including transportation of the patient in hospital, it is necessary to conduct intensive therapeutic measures, if indicated - AV. These indications are respiratory failure, clinical death, critical forms of ARF.
The simplest and most affordable way of mechanical ventilation used during clinical death in the absence of necessary technical equipment is expiratory, ie, the injection of air exhaled by a physician, a patient in the lungs. To improve the airway as the patient throws back her head, lifting his chin up and driving forward the lower jaw. Patient's mouth open, make sure that the mouth is not food of the masses, clusters of blood, etc. If they are, they should be removed, and mouth clean. Then, through a handkerchief, napkin or directly grasping his mouth slightly open mouth patient, a hand clamped over his nose and exhales into the lungs the patient, observing the movement of the thorax. Chest wall during artificial inspiration should rise. You can spend your breath from the mouth to the nose, pinching the patient's mouth and making the breath in your nose. Ratio of inspiratory time and pause (expiratory) should be 1:2 at a frequency of 12-16 in 1 min.
More effective ventilation by means of special devices, the simplest of which is the Ambu bag with mask and uni-directional valve. Can also be applied to any apparatus for the IVL available to the physician.
The most effective way to maintain the airway during mechanical ventilation is tracheal intubation, for which you need: a laryngoscope with a lighting device, a set of intubation tubes with inflatable cuffs, a connecting element for connecting the endotracheal tube to the apparatus for artificial ventilation. Through the tracheal tube can be carried out mechanical ventilation expiratory way (mouth of the tube).
Technology tracheal intubation: the patient laid on his back, introducing the laryngoscope blade in her mouth (leaving the tongue to the left of the blade) and under the control of move it to the base of the epiglottis (curved blade end of the input between the tongue and epiglottis, straight blade grasp and lift the epiglottis). Then, trying not to put pressure on the teeth of a patient, they turn up the epiglottis, displacing the laryngoscope blade in the upward direction at the feet of the patient, while in the field of view is glottis. Under the control of the glottis in the tracheal tube is introduced, promoting an end to it in the trachea for 5-7 cm, ensuring that the inflatable cuff is hidden behind the vocal cords. Laryngoscope is removed, the tube test-expiratory breath to make sure its correct position, then connected it to the unit. Sign of hitting the endotracheal tube into the esophagus is no visible movement of the chest and respiratory noise in breathing, swelling of the stomach in the ongoing attempts to mechanical ventilation.
After verifying the correct distance the tube, it is fixed to the patient's head in order to avoid falling or slipping into the airways, which leads to overlapping of the lumen of the bronchus (usually the left). To avoid Pinched sick tube teeth in the mouth enter the spacer (folded gauze with a diameter of 3-4 cm, air), which is fixed to the endotracheal tube.
ALV hold one of the available methods. Optimal use of special devices for automatic or manual ventilation (suitable devices for anesthesia, all kinds of respirators, including portable). In the absence of the ventilator expiratory hold method.