Principles of treatment of critical conditions

Principles of treatment of critical conditionsThe most important in everyday medical practice are questions of treatment of critical States such as respiratory failure, critical circulatory failure and cardiac arrest, shock. Acute respiratory failure (ARF). Most frequent causes: injuries of the chest and respiratory organs, accompanied by fractures of the ribs, pneumo - or hemothorax, a violation of the position and mobility of the diaphragm; disorders of the Central mechanisms of regulation of respiration with injuries and brain diseases; disorders of the airway; reduced operating surface of the lung with pneumonia or atelectasis of the lung; disorders of blood circulation in a small circle (bypass surgery, the development of so-called shock lung embolism branches of the pulmonary arteries, pulmonary edema). Signs of acute respiratory failure: shortness of breath, cyanosis (not for bleeding and anemia), tachycardia, agitation, then progressive lethargy, loss of consciousness, moisture skin, purple hue, the motion of the wings of the nose, the inclusion of an auxiliary breathing muscles. In progressive respiratory failure arterial hypertension followed 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 to keep intensive care ODN. In order to diagnose the causes of ARF conduct physical and radiological examination of the chest (detection of pneumo-hydrothorax, rib fractures, pneumonia and other disorders). It is also useful to make a study of blood gas composition to determine the degree of hypoxia and hypercapnia. To determine the cause of ARF is strictly prohibited drugs administered to the patient hypnotic, sedative or antipsychotic action, as well as drugs. In the detection of pneumothorax for the treatment of ARF should drain the pleural cavity by introducing into the second intercostal space in the parasternal line of rubber or silicone drain, 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. Impaired patency of the 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 phone If the obstacle is located below the entrance to the larynx, to eliminate the obturation required bronchoscopy (preferably using fibrobronchoscopy), during which remove solid foreign body from trachea and bronchi, and in the presence of bronchial system pathological content (blood, pus, food mass) produce sanitation, ie wash (lavage) of the bronchi. The use of modern fiberoptic, allow for control of the purification of individual segments of the bronchial tree, gives the best therapeutic effect on the background of the injection ventilation. The bronchial lavage (lavage) is used when it is impossible simple extraction of the contents of bronchial lumen when they are thick mucopurulent material (for example, severe asthmatic condition). Purification of the tracheobronchial tree from the liquid Muco-purulent masses can be achieved by sucking them through a sterile catheter is introduced alternately into the right and left bronchus through an endotracheal or tracheostomy tube or through the nose (blindly). If it is impossible to apply the above measures for the restoration of the airway and the readjustment of the bronchi produce a tracheostomy. Struggle with ONE paresis or paralysis of the gastrointestinal tract, disorders of the position and mobility of the diaphragm is the introduction of a probe for evacuation of gastric contents and giving the patient an elevated position. Treatment of ARF in pulmonary edema details, see Chapter ?Diseases of the circulatory system?. In addition to drug therapy, oxygen therapy and the creation of a permanent high airway pressure(PAP), increased resistance in end-expiratory (peep), which is often effective. Developed appropriate valves and devices, in the absence of which use a simple device to oxygen inhaler or anesthetic machine. To this end expiratory tube is placed in the vessel with 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 (the breath out of the machine, blow out), which requires the flow of the gas mixture, slightly higher than the minute volume of respiration. If acute respiratory failure causes or exacerbates a sharp pain when breathing (chest trauma, acute process in the abdominal cavity), analgesic drugs can be used only after diagnosis. Must be received intercostal nerve blockade. Fractures of the ribs carry procaine blockade of the fracture site, paravertebral blockade, if the damage is more than 2 edges-vagosympathetic blockade. When oxygen patient with ARF is necessary to monitor the depth and frequency of breathing. Stop breathing or holding inhalation of oxygen indicates the presence of severe hypoxic condition requiring artificial lung ventilation (ALV). Mechanical ventilation should be initiated with gross violations of breath, signs of severe hypoxia and hypercapnia (confusion, agitation or lethargy, purple or BladeCenter color of the skin, tachycardia or bradycardia, hypertension, sometimes, on the contrary, hypotension, shortness of breath more than 40 breaths 1 min, moisture skin). Treatment of patients with advanced ARF should be an anesthesiologist - resuscitation in the 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 method of mechanical ventilation used during clinical death in the absence of the necessary technical equipment is expiratory, i.e., the injection of air exhaled by a physician, in light of the patient. To improve the airway of the patient head maximum zaprokidyvaya, lifting his chin up and bringing the lower jaw forward. Patient's mouth open, make sure that in the mouth no food masses, clusters of blood, etc. If they are, delete them and mouth clean. Then, through the handkerchief, napkin or directly grasping his mouth slightly open the patient's mouth, a hand clamped over his nose and exhales into the lungs of the patient, observing the movement of the chest. Chest wall with artificial breath should rise. You can hold your breath from the mouth to the nose, holding the patient's mouth and making the breath in the nose. The ratio of inspiratory time and pause (exhalation) should be 1:2 at a frequency of 12 to 16 in 1 minutes More effective ventilation with the help 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 ventilation available to the physician. The most effective way to maintain the airway when the ventilator is intubation of the trachea, for which necessary: laryngoscope with lighting, set an endotracheal tube with an inflatable cuff, a connecting element for connecting the endotracheal tube to the unit for ventilation. Through an endotracheal tube can be artificial ventilation expiratory way (mouth of the tube). The technique of intubation: patient is placed on his back, enter the laryngoscope blade into the mouth (leaving the language to the left of the blade) and under visual control move it to the base of the epiglottis (curved blade end is injected between the materials of the tongue and epiglottis, straight blade grasp and lift the epiglottis). Then, trying not to put pressure on the patient's teeth, they turn up the epiglottis, shifting the laryngoscope blade in up to the feet of the patient, and the field of view is the glottis. Under the control of the glottis to introduce an endotracheal tube, promoting an end in the trachea at 5-7 cm, ensuring that the inflatable cuff is hidden behind the vocal cords. The laryngoscope is removed, the tube do test-expiratory breath to make sure its correct position, then insert it in the machine. Sign of the endotracheal tube in the esophagus is no visible movement of the chest and respiratory noise in breathing, swelling of the stomach in the ongoing attempts of artificial lung ventilation. Make sure the correct distance of the tube, it is fixed to the patient's head to avoid falling or slipping in the Airways, which leads to overlapping of the lumen of the bronchus (usually the left). Avoid sick pinched 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. IVL hold one of the available methods.


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