I.Ya. HORBACHEVSKY TERNOPIL STATE MEDICAL UNIVERSITY Disaster medicine and military medicine department

1. I.Ya. HORBACHEVSKY TERNOPIL STATE MEDICAL UNIVERSITYDisaster medicine and military medicine department Lecture 2 Cardiac, pulmonary and cerebral reanimation at pre-hospital stage

2. Three stages of ABC-reanimation. Algorithm of its realization by one and two medical men. Testimony to defibrillation and technique of its execution. Cardiac shock of feature of clinical dynamics, first aid. Acute respiratory insufficiency. Reasons of origin, types of hypoxia, degrees of heaviness. Medicinal therapy. Treatment of post-reanimating illness.

3. First aid at the terminal states. • Concept about the terminal states, purpose and task the first medical aid, first-aid and medical rescue.

4. General principles, legal, organizational, medical and deontological features of giving the first aid in extraordinary situation. Algorithm of primary inspection of the patient in the place of event.

5. BASIC CONCEPTS in REANIMATOLOGY • Reanimatology is science about the revival of organism, which studies etiology, pathogenesis, diagnostics and treatment of the terminal states. • A reanimation (abroad widespread is a term of rescucitation) is a process of replacement and proceeding in the functions of organism by the leadthrough of the special reanimation measures. It is proposed by V.Negovsky (1975). To these measures a pneumocardial reanimation belongs in particular (CLR).

6. Clinical death -| it is the state which circulation of blood and spontaneous breathing absent in the conditions of, but there yet were irrecurent changes in the human brain, when it is yet possible to return a patient to life without a clinically meaningful neurological deficit.

7. Why does attention apply exactly on a cerebrum? It is a structure of organism, which most sensible to the hypoxia or anoxia (clinical death), and in tissue of which above all things in case of stopping of circulation of blood there are irreversible changes. Maximally this period can last 3-б min, except of some states, above all things hypothermias, when vitability of cortex can be restored and through the greater interval of time.

8. Biological death is consisting of irreversible changes above all things of CNS, when to life turning a man is impossible. To the clinical signs of biological death take drying out and dimness of cornea, of a corpse spots and of a corpse окоченіння.

9. Such concepts utillize in rescucitation, as a decortication (social death) is death of cortex (when somatic functions can recommence almost in full, but the function of cortex does not recommence) a that decerebration is death of cerebrum. • By the clinical signs of decortication ñ absence of свідо­мості and purchased reflexes. There is a timber-toe by the dead bark of the brain on condition of valuable supervision can live yet long time. To set the exact diagnosis of decortication heavily, as there are events, when after the protracted comma a man came to consciousness.

10. A decerebration arises up after more protracted total ischemia of brain (20 min and anymore), sometimes can develop on a background a decortication in the case of progress of іschemical-reperfusion defeats.

11. The clinical signs of death of cerebrum is absence of electric activity of cerebrum during ЕЕG-decay, atony, areflexy, hypothermia, bradicardia, arterial hypotension, absence of the independent breathing. The vital functions of organism at decerebrationmay be supported of short duration time due to the leadthrough of AB and support of circulation of blood. Such organism can be utillized as a donor for transplantation of organs.

12. On condition of primary stop of circulation of blood the spontaneous rhythmic breathing stopping is not later than in 1 min as a result of exhaustion of respiratory center. But the terminal types of breathing are possible: Cheyn-Stoks, Biott, breathing by Husping. • After the stop of heart a man loses consciousness already through 10-15 sdue to exhaustion of power substrates in the brain, first of all glucosum.

13. MOST WIDESPREAD REASONS OF UNEFFECTIVE CIRCULATION OF BLOOD MYOCARDIAC ISCHEMIA A myocardial ischemia more frequent all arises up as a result of violation of circulation of blood in coronarias (embolism, spasm). The extreme display of ischemia is a sharp heart attack of myocardium. As a result of complete absence of delivery oxygen there is a sharp deficit of power substrates to cardiac cells, above all things ATP.

14. Activity of cells membrane pumps and canals, foremost Na+, K+ and Ca++ is violated. The result of it is an accumulation in the myocardium Na and Ca with development of intracellular edema, there is a considerable intracellular deficit of K+. The finished goods of metabolism accumulate in myocardium, foremost C02 and lactat which results in heavy intracellular acidosis.

15. It does not follow to forget that the damage of cardiac cells (and also tissues of brain and other tissues of an organism) takes a place and after proceeding in perfusion, is the so-called syndrome of reperfusion. Its damaging factors are active free radicals (above all things, oxygen – super-oxides, peroxides, ions of hydroxide, peroxinitrate) on a background diminishing of activity of the antioxidant system.

16. Reflex stop of heart • Takes a place foremost as a result of n.vagus reflexes (from an eye is reflex of Ashner, trachea, carotis areas, root of lights, stomach, uterus). It should be noted that usually the stop of cardiac activity arises up on a background a myocardial ischemia, intact myocardium in default of hypoxia (it can be respiratory hypoxia, ischemia and others like that) quickly «avoids» influence of n.vagus.

17. TYPES OF STOP OF the HEART Fibrillation of ventricles The most widespread type of uneffective circulation of blood in позалікарняних terms is all of to 2/3 cases. Reason of фібриляції of ventricles is violation of leadthrough of impulses on myocardium of передсердь and ventricles, and also increase of excitability of myocardium. To the factors which are instrumental in the origin of фібриляції of ventricles, take intracellular hypokaiemia, total cooling of organism, mechanical irritations, during implementation of diagnostic and medical manipulations.

18. During fibrillation of ventricles there is a desynchronization of reductions of myo-fibriles myocardium with the loss of pumping function of the heart. On EKG fibrillation of ventricles shows up alike on a wave the curve of differentamplitude in default of auricle and gastric complexes.

19. Unpulsive gastric tachycardia • The most widespread type of uneffective circulation of blood is in the conditions of permanent establishment. At unpulsive gastric tachycardia , without regard to frequent reduction of ventricles, the retractiveness of myocardium is considerably mionectic, that is accompanied uneffective circulation of blood.

20. Asystole • Practical absence of electric and mechanical activity of myocardium. On EKG appears as an almost straight line • The most frequent reason of asystole is ischemic heart (IKHS) trouble, it can develop on a background fibrilation of ventricles which are an unfavorable prognostic sign.

21. Electromechanic dissociation (EMD) and bradiarythmia with the uneffective mechanical activity of heart • At the transferred states electric activity of heart is stored, but it is not accompanied effective reductions of myocardium. On EKG discover typical and off type gastric complexes with a different rhythm. off type gastric complexes at electromechanical dissociation

22. Diagnostics of uneffective circulation of blood • The element of pneumocardial reanimation is very important. On timely diagnostics of stop of circulation of blood a prognosis depends often. • If in the conditions of permanent establishment cardio-monitoring is conducted a patient during the stop of circulation of blood, on a monitor or on EKG find out the characteristic signs of stop of circulation of blood.

23. But more frequent all uneffective circulation of blood is diagnosed only after clinical signs. To them absence of pulse belongs, foremost, on central arteries (sleepy and thigh). The method of research of pulse is resulted the way of palpation. Research of pulse by means of palpation on a. carotis

24. To the early signs of unefficiency of circulation of blood paralytic mydriasis belongs also: at raising of overhead eyelid a pupil remains wide and irresponsive on light

25. Research of pulse by palpation and estimation of the state of pupil it is possible to perform simultaneously. • As already marked higher, the obligatory signs of uneffective circulation is absence of consciousness and rhythmic independent breathing. • Such symptoms, as cyanosys of skin, absence of tones of heart during auscultation, to the pulse on peripheral arteries, unnecessarily are the signs of stop of heart, but can be those symptoms which need immediate estimation of the state of circulation.

26. PNEUMOCARDIAL REANIMATION • Complex of measures which are executed during the leadthrough of CPR, it is possible to divide on three basic groups: • base sustentation - after the English letters of ABC: • A (airway ореn) providing of communicating of respiratory tracts • B (breeth) artificial respiration • C (сirculation) a massage of heart

27. Must be conducted any man which is alongside; • subsequent methods of CPR, the purpose of which is proceeding in independent circulation of blood for a patient: electric дефібриляція, medicinal therapy; • stabilizing of basic vitally important functions of organism sick, above all things it touches activity of cerebrum, heart and vessels, intensive therapy.

28. If a patient is in the swoon state (absence of reaction on asking and mechanical irritation), it is necessary to perform the followings actions: • To cause the brigade of medical first-aid, if there is possibility (it is better) - reanimation brigade.

29. Immediately to begin the leadthrough of reanimation measures: • 1) to provide communicating of respiratory tracts; • 2) to check up the presence of the independent breathing; • 3) if the independent breathing absents is a leadthrough of AB; • 4) to define a pulse on a carotid; if during 5 secto discover the pulse is impossible - immediately to begin the non-direct massage of the heart. • Reanimation specialized measures in obedience to algorithms are performed by reanimation brigade.

30. Providing of communicating of respiratory tracts • A patient at stop of circulation of blood has a presence of extraneous bodies reasons of violation of communicating of respiratory tracts in the cavity of mouth and swallow; supra-larynx and the root of tongue is recovered included in a larynx Violation of communicating of overhead respiratory tracts in event of stopping of circulation of blood

31. For providing of communicating of respiratory tracts of patient inlay on a hardeven surface, lying on the back. After it oral cavity of patient with a gauze tampon, serviette or handkerchief, release a finger from blood, vomit the masses, extraneous bodies (dentures and others like that). For the leadthrough of rest room of oral cavity it is possible to apply an aspirator.

32. The next stage is providing of communicating of larynx. As a result of that a tongue is anatomically related to the lower jaw, it is necessary to show out a lower jaw how it is indicated on a figure Variants of leading-out of lower jaw for proceeding in communicating of overhead respiratory tracts

33. All of medical workers must own this reception. More simple and less effective, but made to order to application unmedical personnel, there is a reception of filling up of the head. • For this purpose reanimator lays the palm of one hand on the brow of patient, and доло­ню of other hand underlays under a neck and unbends the head simultaneous motion of both hands (triple reception by Safar).

34. More professional methods of providing of communicating of respiratory tracts is intubation of trachea, use of laringeal mask or combined air-tube - combitube Laringeal mask

35. Intubation of trachea is the most reliable method of providing of communicating of respiratory tracts, but it must do it professional which will be able to execute manipulation in short period (30-40 s).

36. Urgent methods of artificial ventilation of lights • The methods of AB can be divided into 2 groups: inciter and expiration. Unfortunately, the inciter methods of AB, which almost reproduce the physiology mechanism of the spontaneous breathing, did not find the wide use in clinical practice through some inconveniences and difficult equipment for their leadthrough.

37. Today most widespread are expiration methods of AB (due to insufflation of gas mixture to lights), from urgent methods it above all things method «mouth to the mouth», which consists in insufflation of air in the respiratory tracts of patient under time of breathing out reanimator. For this purpose reanimator destroys the lower jaw of patient up to the top, whereupon densely takes by his lips the lip of patient and does exhalation, but necessarily here stops up the nose of patient.

38. If the leadthrough of AB is uneffective (what absence of excursion of thorax testifies to), it is needed to suspect the presence of extraneous body in lower respiratory tracts (below vocal connection). At that rate it follows to use reception by Geymlikh – under-diaphragmatic shove

39. MAINTENANCE OF CIRCULATION OF BLOOD • Except for providing of adequate receipt of oxygen in teethridges, it is needed to provide artificial circulation of blood. On condition of uneffective spontaneous circulation apply the indirect (external) and direct (internal) massage of heart to that end.-

40. A method is based on the compression of ventricles of heart between sternum and and column. Circulation the leadthrough of the external massage of heart provided due to two mechanisms: to the effect of pectoral pump and direct compression of ventricles of heart, that is why more expedient would be to talk about the massage of thorax. Indirect massage of heart

41. Reanimator becomes from one side from a patient, places basis of one palm on middle part of sternum approximately on 2 fingers higher from to basis of sworden out-growth and along brest-bone disposes the second palm. • Then by direct hands, not bending them in elbow joints (it saves forces), reanimator executes pressure on sternum on a depth 4-6 sm for adults.

42. For children method of leadthrough of indirect massage of heart some other. It consists in pressure one or by two fingers on sternum with frequency for children junior in 1 over 100 times per 1 min. • The skilled conducted is closed the massage of heart enables keeping of systole BP at the level of 60-80 mm of Hg, although diastole BPleaves at low level which diminishes coronal and cerebral perfusion considerably, and it worsens a prognosis considerably.

43. Reasons of unefficiency of the closed massage of heart can be hypovolemy, hemopericarditis, anatomic defects of thorax. • It should be remembered that during the leadthrough of the closed massage of heart it is impossible to do the protracted (over 5-10 s) pauses.

44. Many thanks!