Principles of treatment of critical conditions

The most important in everyday medical practice is the treatment of critical conditions such as respiratory failure, critical circulatory failure and cardiac arrest, shock conditions.

Acute respiratory failure (ODN). The most common causes are: trauma of the chest and respiratory organs, accompanied by fractures of the ribs, pneumo- or hemothorax, disruption of position and mobility of the diaphragm; Disorders of the central mechanisms of breathing regulation in trauma and brain diseases; Violation of airway patency; Reduction of the functioning surface of the lungs with pneumonia or lung atelectasis; Circulatory disorders in the small circle (bypass, the development of the so-called shock lung, thromboembolism of the branches of the pulmonary arteries, pulmonary edema).

Signs of acute respiratory failure: dyspnea, cyanosis (absent from bleeding and anemia), tachycardia, agitation, then progressive inhibition, loss of consciousness, skin moisture, purple hue, movements of the wings of the nose, respiration of the auxiliary musculature. With progressive respiratory failure, hypertension is replaced by hypotension, bradycardia, arrhythmia often develop, and death occurs when cardiovascular insufficiency occurs. Resuscitative measures in the terminal phase of ODN are ineffective, therefore, timely intensive ODN therapy is especially important.

In order to diagnose the cause of ODN, a physical and radiological examination of the chest organs (detection of pneumo-, hydrothorax, rib fractures, pneumonia and other disorders) is carried out. It is also advisable to make a study of the gas composition of the blood to determine the degree of hypoxia and hypercapnia. Until the cause of ODN is clarified, it is strictly forbidden to administer to the patient drugs of hypnotics, sedatives or neuroleptic effects, as well as drugs.

If pneumothorax is detected for the treatment of ODN, the pleural cavity should be drained by inserting a rubber or silicone drainage into the second intercostal space through a parasternal line, which is connected to a suction or underwater valve. When a large amount of fluid is accumulated in the pleural cavity (hemo- or hydrothorax, pleural empyema), it is removed by puncture through a needle or trocar.

Upper airway patency disorders require immediate examination of the oral cavity and entry into the larynx with the help of a laryngoscope, releasing them from the contents and foreign bodies. If the obstacle is located below the entrance to the larynx, bronchoscopy (preferably with the help of a fibrobronchoscope) is required to eliminate obstruction, during which solid foreign bodies are removed from the trachea and bronchi, and in the presence of pathological contents (blood, pus, food masses) in the bronchial system, , T. With. Lavage of the bronchi. The use of modern fibrobronhoscopes, which allow the monitoring of individual segments of the bronchial tree under the supervision of vision, gives the best therapeutic effect against the background of injection ventilation of the lungs. Bronchial flushing (lavage) is used when it is impossible to simply suction the contents of the bronchi when there are dense mucopurulent masses in their lumen (for example, in severe asthmatic conditions). Cleansing the tracheobronchial tree from liquid mucopurulent masses can be accomplished by sucking them with a sterile catheter, alternately inserted into the right and left bronchi through the intubation or tracheostomy tube or through the nose (blindly). If it is impossible to apply the above-described measures to restore airway patency and sanitizing bronchial tubes, they produce tracheostomy.

Combating ODN in the paresis or paralysis of the gastrointestinal tract, the disruption of the position and mobility of the diaphragm consists in introducing a probe to evacuate the contents of the stomach and giving the patient an elevated position.

Treatment of ONE in case of pulmonary edema is described in detail in the chapter "Diseases of the circulatory system". In addition to medical therapy, oxygen therapy and the creation of permanent high pressure in the airways (PPD), increased end-expiratory endurance (PEEP), which often turns out to be effective. Appropriate valves and devices have been developed, in the absence of which, a simple adaptation to an oxygen inhaler or an anesthesia-respiratory apparatus is used. For this, the exhalation hose is placed in a vessel with water to a depth of 5-6 cm, the patient breathes in through the mask from the breathing apparatus bag. Breathing is carried out on a semi-open system (inhaling from the apparatus, exhaling outwards), which requires a gas mixture flow that is slightly greater than the minute volume of respiration.

If acute respiratory failure causes or aggravates severe pain during breathing (chest injury, acute process in the abdominal cavity), analgesic drugs can be used only after diagnosis. Should be performed blockade of intercostal nerves. With fractures of the ribs, Novocain blockade of the fracture site, paravertebral blockade, if more than 2 ribs are damaged, the vagosympathetic blockade.

When oxygenating a patient with ODN, it is necessary to monitor the depth and frequency of breathing. Stopping breathing or hypoventilation with inhalation of oxygen indicates a severe hypoxic condition requiring artificial ventilation (IVL).

Ventilation should be initiated with severe breathing disorders, signs of severe hypoxia and hypercapnia (confused consciousness, agitation or blocking, purple or paleocyanotic skin color, tachycardia or bradycardia, hypertension, sometimes, vice versa, hypotension, dyspnea over 40 respiratory movements per minute, Moisture of the skin).

Treatment of patients with developed ODN should be performed by an anesthesiologist - resuscitator in intensive care unit. At the pre-hospital stage, including transportation of the patient to a medical institution, intensive medical measures should be carried out, in the presence of indications - IVL. Such indications are respiratory arrest, clinical death, critical forms of ODN.

The easiest and most affordable way to carry out ventilation, used for clinical death in the absence of the necessary technical equipment, is the expiratory, that is, the injection of air exhaled by the doctor into the lungs of the patient. To improve the patency of the airways, the patient's head is thrown back as much as possible, lifting his chin up and leading his lower jaw forward. Having opened the patient's mouth, they are convinced that there are no food masses, blood accumulation in the oral cavity, etc. If they are, they are removed and the mouth cavity is wiped. Then through a handkerchief, a napkin, or directly grasp the patient's slightly open mouth with his mouth, squeeze his nose with his hand and exhale into the patient's lungs, watching the movement of the chest. The chest wall with artificial inspiration should rise. You can breath from the mouth to the nose, clamping the patient's mouth and exhaling into the nose. The ratio of inspiration and pause (expiration) should be 1: 2 at a frequency of 12-16 per 1 min.

More effective ventilation with the help of special devices, the simplest of which is an Ambu bag with a mask and an irreversible valve. Any ventilators at the doctor's disposal may also be used. The most effective way to maintain airway patency with ventilation is intubation of the trachea, which requires: a laryngoscope with a lighting device, a set of intubation tubes with inflatable cuffs, a connecting element for connecting the intubation tube to the ventilator. Through the intubation tube, it is possible to carry out artificial ventilation of the lungs with an expiratory method (mouth into the tube).

The technique of intubation of the trachea: the patient is placed on the back, the laryngoscope is inserted into the mouth (leaving the tongue to the left of the blade) and under the vision control move it to the base of the epiglottis (the curved blade is inserted between the roots of the tongue and the epiglottis, and the epiglottis is lifted directly by the straight blade). Then, trying not to press on the patient's teeth, the epiglottis is removed upward, shifting the laryngoscope blade in the direction upwards to the patient's legs, with a voice gap in the field of vision. Under the control of vision, the intubation tube is inserted into the vocal cuff, pushing its end into the trachea by 5-7 cm, making sure that the inflatable cuff disappears behind the vocal cords. The laryngoscope is removed, a test expiratory breath is made into the tube to make sure its position is correct, then connect it to the apparatus. A sign of getting the endotracheal tube into the esophagus is the absence of visible movements of the chest and respiratory noises during inspiration, bloating of the stomach with continued attempts at artificial ventilation of the lungs.

After confirming the correct standing of the tube, it is fixed to the patient's head in order to avoid falling out or slipping into the respiratory tract, which leads to overlapping of the bronchus lumen (usually the left one). In order to avoid the patient's clamped teeth, a spacer is inserted into the mouth (a folded gauze cloth 3-4 cm in diameter, the airway), which is fixed to the intubation tube.

The ventilation is performed by one of the available methods. Optimum use of special devices for automatic or manual ventilation (suitable apparatus for anesthesia, all types of respirators, including portable). In the absence of devices, ventilation is performed by an expiratory method.