RESUSCITATION (Latin re-the prefix meaning repetition, resuming, + animatio revival; synonym resussitation) — a complex of the actions directed to recovery of the died-away or dying away vital signs of an organism.
Now traditional idea of R. of an organism considerably extended. Refer to resuscitation actions now not only recovery of action of the heart and breath after clinical death, but also the measures directed to prevention of clinical death, and also artificial management of functions of breath, activity of kidneys, metabolic processes, etc. Depending on character of the main actions directed to revival of an organism distinguish cardiopulmonary, cordial, respiratory R. K resuscitation the actions applied until a cardiac standstill, napr, recovery of passability of upper respiratory tracts at sudden asphyxia can be carried.
Abroad insufficiently reasonably combine concepts resuscitation and an intensive care.
The river includes a complex of actions; the main are artificial ventilation of the lungs — IVL (see. Artificial respiration ), recovery of blood supply of a brain, a cut is provided direct or indirect cardiac massage (see), electric defibrillation (see), and also some other, including and medicinal therapy. The river can be limited also to any one action — e.g., and adequate breath is recovered by immediate recovery of passability of upper respiratory tracts at acute asphyxia when activity of a respiratory center did not manage to stop yet spontaneously at once after elimination of obstruction of upper respiratory tracts, or electric cardiac defibrillation at acute emergence of fibrillation of ventricles at the patient who is on monipgorny observation (see). The impulse of electric current passed through heart in the first 10 — 20 sec. after a stop of blood circulation can stop fibrillation, and rhythmical action of the heart and breath in the subsequent are recovered spontaneously. At the development of a full cross heart block and very slow rhythm of reduction of its ventricles which is not providing fabric with necessary amount of oxygenic blood cardiostimulation (see) belongs to resuscitation actions since with its help recover the blood circulation providing life activity of an organism. After clinical death of R. it cannot be limited only to methods of recovery of cordial activity and breath; in the postresuscitatic period (see below) for a complete recovery of all functions of an organism, and first of all functions of c. the N of page, is required use of methods intensive care (see). Thus, R. is not only temporary substitution and recovery of the vital functions of an organism, but also the subsequent management of them until until the full-fledged autoregulyation is recovered.
Methods P. began to develop quickly from 40th 20 century, however attempts of revival of the died person were made by people since ancient times what rock drawings confirm, the age to-rykh is estimated in the millennia. In 2 century BC in Ancient Greece Asklepiad applied tracheotomy at the abscess of a throat threatening with suffocation. Hippocrates's works, A. Tsels in the area patol. physiology of breath promoted development of respiratory resuscitation. In 16 century Paratseljs for the purpose of recovery of the dying-away breath inserted into a mouth saved a tube, connecting it to bellows forcing air, and A. Vezaly (1543) in detail described the observations about inflating of lungs of an animal through the straw inserted into a trachea. In the same experiences he established that the termination of an artificial respiration leads to gradual weakening of cordial activity and to a cardiac standstill, to-ruyu can prevent resuming of an artificial respiration. In 1775 J. Gunter recommended to carry out an artificial respiration by bellows for assistance during the drowning. The intubation of a trachea for respiratory R. of newborns was offered I Drink (V. Pugh) in 1754, and in 1788. Whale (Ch. To. Kite) designed an endotracheal tube for respiratory R. of adults. Methods of manual artificial ventilation of the lungs began to be used later, than methods of ventilation by means of bellows. For the first time manual artificial ventilation of the lungs was described in 1833. The hall (M. of Hall), and Sylvester's way (H. R. Silvester, 1858) and others, offered a bit later, were widely used almost to the middle of 20 century
R. of heart lagged behind R. of breath more than for the millennium. Described ventricular fibrillation of heart in 16 century. And. Vezaly, and U. Garvey on pigeons excited the stopped action of the heart in an experiment, touching it with a finger. The direct cardiac massage on a dog for the first time was shown in 1874 by Schiff (M. of Schiff), and the Norwegian doctor Igelsrud (To. Igel-srud) in 1901 for the first time successfully carried out revival of a human body by means of this method. In 1892 F. Maass described successful R. of two children by means of an indirect cardiac massage. However then the indirect cardiac massage was not applied up to 1960 when the American scientists Kouvenkhoven (W. Century of Kouwenho-ven), J. R. Jude and G. G. Knickerbocker implemented it in pre-hospital clinical practice again. The electric defibrillation was for the first time shown in 1899 Mr. of J. L. Prevost, and chemical by means of potassium chloride — D'Alluen (M. to d'Hal-luin) in 1904. Many Russian scientists, and first of all P. V. Posnikov, S. G. Zybelin who described in 1766 a technique of an artificial respiration from a mouth in a mouth, E. O. Mukhin, A. M. Filomafitsky, and then A. A. Kulyabko, N. P. Nravkov, F. A. Andreyev, S. I. Chechulin, S. S. Bryu-honenko, etc., the works made an essential contribution to studying of a problem of revival of an organism.
In the USSR formation of resuscitation and improvement of its methods are inseparably linked with activity of V. A. Negovsky and his pupils. Basic elements of the complex method of resuscitation offered by V. A. Negovsky are IVL and intra arterial forcing of blood. This method was already applied to rescue of wounded during the Great Patriotic War. The powerful contribution to studying of fibrillation of ventricles of heart and development of perfect methods of a defibrillation were brought by N. L. Gurvich.
the Indication to R.'s carrying out is the sudden termination of cordial activity (as a result of an acute disorder of coronary circulation, a reflex cardiac standstill at patients during operative measures, defeat with electric current, etc.) and breath (as a result of a suffocation, aspiration of foreign bodys, slime or emetic masses, drowning, defeat by a lightning or electric current, overdoses of pharmaceuticals, etc.).
Clinical experience showed what the most successful R. happens when the cardiac massage is begun immediately after the termination of independent cordial activity or within the first 3 minutes of clinical death. Cases of revival after more long terms of clinical death (over 8 min.) with the subsequent full recovery of functions of a brain are extremely rare and known as casuistic. Nevertheless existence even of single similar observations does reasonable and obligatory actions for revival and at so long terms of clinical death. If duration of the last is authentically unknown, resuscitation actions shall be begun and can be stopped only after on the course of their carrying out there is obvious their hopelessness.
The time factor is the Ruble defining for success. Therefore in one and all situations R. shall be begun in the minimum terms after emergence of indications. This requirement is strictly obligatory. Immediately begun indirect cardiac massage any trained person who even does not have considerable experience of carrying out R. can create more full-fledged blood stream in an organism of the recovered patient, than the massage which is carried out by the specialist, but begun 3 — 4 minutes later after approach of clinical death.
Statistical data show that at approach of sudden death at patients with various disturbances of coronary circulation, including and with myocardial infarction (see), but the being in specialized cardiological intensive care units under monitor observation, efficiency of an electric defibrillation (see), an indirect cardiac massage (see), artificial ventilation of the lungs and other resuscitation actions happens very high, reaching 96%. On the contrary, at approach of sudden death at the same category of the patients who are out of the intensive care unit and furthermore in extra hospital conditions, R.'s efficiency does not exceed several percent. It is explained most often by absence in close proximity to the victim of the persons owning receptions of primary cardiopulmonary River. All types of resuscitation actions and an intensive care at a pre-hospital stage are provided by crew of emergency medical service (whenever possible specialized).
If duration of clinical death is small, dying was not long and exhausting compensatory opportunities of an organism, resuscitation events are held competently, in full and there are no irreversible injuries of vitals, then recovery of cordial activity happens within several minutes and even seconds after R. Inogd's beginning the fibrillation of ventricles of heart which led to the termination of blood circulation is not eliminated with one or several categories of a defibrillator though the cardiac massage is carried out effectively. In such cases resuscitation events should be held until it is possible to eliminate fibrillation of ventricles and to prevent its repeated emergence. At emergence of signs of an inefficient blood-groove (lack of a pulsation of carotid arteries, synchronous with a rhythm of massage, the maximum expansion of pupils, absence or disappearance of the independent respiratory movements which appeared at the first stages P.) and impossibility of their bystry elimination, further carrying out R. becomes unpromising.
At obviously big term of clinical death (more than 8 min.), and also existence at the patient of irreversible injuries of vitals of R. it is not necessary to carry out.
Effective carrying out an artificial respiration — expiratory (from a mouth in a mouth or in a nose) — is impossible without preliminary recovery and constant control of passability of upper respiratory tracts. At retraction of language it is recovered by the maximum zaprokidyvaniye of the head of the patient back or by means of the special air ducts entered into an oral cavity. If these receptions are inefficient and free passing of air in upper respiratory tracts is absent, then aspiration can be the cause of impassability foreign body (see). Also aspiration of emetic masses, especially at patients with the confused consciousness or being in coma is possible. Effective methods itself and mutual assistance, directed to extraction of foreign bodys from upper respiratory tracts are developed (see St. Foreign bodys ).
During the carrying out an expiratory artificial respiration (tsvetn. fig. 5) giving help after each inflation of air in a mouth or a nose to the victim monitors the movements of his thorax. Lack of movements of a thorax noticeable approximately testifies to the inefficiency of an artificial respiration caused by impassability of upper respiratory tracts as a result of not eliminated retraction of language, existence of a foreign body in upper respiratory tracts, lack of tightness in the «lungs giving help — lungs of the victim» system, the insufficient volume of the blown air. The specified causes shall be immediately removed. Increase in efficiency of expiratory breath is promoted by use of the special air ducts interfering retraction of language and providing good tightness during an artificial respiration, and also allowing to carry out it without touching directly a mouth or a nose of the victim (tsvetn. fig. 6).
Efficiency of the blood-groove created by indirect cardiac massage (see), periodically control (at least once in 1 min.) by definition of a pulsation of the general carotid artery of the victim, the cut and compliance to a rhythm of massage indicates existence recovery of a blood-groove on the main arteries of the head. Narrowing of pupils soon after the beginning of a cardiac massage is the second favorable sign of the recovered cerebral circulation. The third sign of efficiency of a cardiac massage is emergence in the victim of independent breaths. Efficiency of a cardiac massage is provided with the correct application of force of hands massing strictly on the lower half of a breast and the shift of a breast towards a backbone not less than on 4 — 6 cm that promotes emptying of cavities of ventricles of heart (tsvetn. fig. 9). The rhythm of massage shall provide to 60 compression of heart in 1 min. for a sufficient volume blood-groove.
Lack of effect of an indirect cardiac massage can depend on an atony of a myocardium owing to the late beginning of the cordial River. At an atony of a myocardium the ventricles of heart compressed from the outside do not recover spontaneously the initial volume and are not filled sufficiently with blood from veins. Massage of such «empty» heart cannot provide a sufficient blood stream. It is possible to diagnose an atony of a myocardium about a nek-swarm degree of probability on lack of signs of an effective blood-groove, despite, apparently, correct carrying out a cardiac massage within about one minute. For fight against an atony of a myocardium use endocardiac introduction (by means of the syringe with a long needle) 1 ml of 0,1% of solution of Adrenalinum hydrochloricum and (or) 5 ml of 10% of solution of calcium chloride. If R. is made in hospital and the patient had a kateterizirovana an upper vena cava through subclavial or internal jugular veins earlier (see. Catheterization of veins puncture ), it is reasonable to enter these pharmaceuticals through a catheter.
The direct transthoracic cardiac massage run by one or two hands (tsvetn. fig. 11 and 12), provides more effective blood stream, than an indirect cardiac massage, allows to control directly a tone of a myocardium and to take immediate measures to its medicamentous increase. However due to the need of a thoracotomy the direct cardiac massage in a crust, time is applied only in cases of a cardiac standstill during operations on bodies of a chest cavity.
During cardiopulmonary R.'s carrying out there can be sharp bradycardia (see), edges interferes with recovery of an adequate blood-groove. In such cases apply 0,1% solution of atropine; for elimination of the metabolic acidosis (see) which is naturally developing in time of clinical death use 4,5 — 8,4% solution of hydrosodium carbonate. The dosage of drug in each case is individual and is defined by indicators acid-base equilibrium (see).
The hypoxia of a myocardium is the most frequent reason of fibrillation of ventricles and if it proceeds is long, then the electric defibrillation is inefficient. Therefore the electric defibrillation (see) shall be made during the first 20 — 30 sec. after emergence of fibrillation of ventricles (see. Arrhythmias of heart ), so far the myocardium still has a necessary reserve of oxygen. If fibrillation is eliminated in these terms (1 — 2 a stage of fibrillation according to an ECG), then ability of heart to reduction is recovered. The preliminary cardiac massage and an artificial respiration is not required to be carried out in such cases. The defibrillation which is carried out to later terms (3 — the 5th stages of fibrillation according to an ECG), can only eliminate fibrillation, but will not lead to resuming of rhythmical cordial activity. Preliminary carrying out in such cases of an indirect cardiac massage and an artificial respiration allows to recover circulation of oxygenic blood but to coronary arteries and energy resources of a myocardium. After that the defibrillation becomes reasonable and effective. Endocardiac administration of solutions of Adrenalinum hydrochloricum and Calcii chloridum (as well as at an atony of a myocardium) promotes more bystry transition of fibrillation from 3 — the 5th stage in 1 — the 2nd stage.
For an electric defibrillation (tsvetn. fig. 13) apply defibrillators (see. Defibrillation ), the best samples to-rykh were created in our country in V. A. Negovsky's laboratory. In the conditions of a hospital and intensive care unit (see) as well as in working conditions of specialized crews of emergency medical service, for carrying out IVL use air ducts and an intubation of a trachea (see. Intubation ). IVL is carried out by means of portable (the RD-10 type, Ambu) and stationary respiratory devices. In our country stationary volume respirators of the RO-3, RO-5, RO-6 type are the most widespread. For carrying out an indirect cardiac massage the automatic machines massagers working at electrical energy or energy of compressed gas are created (most often — oxygen). Modern intensive care units are equipped with the watching systems — monitor observation (see) behind function of vitals and systems.
The forecast of recovery of functions of a brain after the cardiopulmonary R. which is carried out in connection with clinical death is based on a complex nevrol. symptoms, to-rye are found during the broken consciousness. Various scales of a coma based on clinical (a scale of Glasgow), kliniko-physiological (Shakhnovich's scale) signs gained distribution. The most informative for establishment of the favorable forecast of a coma are opening of eyes in response to a sound and pain, implementation of instructions, lack of a mydriasis, hypomyotonia, disturbances of breath. After clinical death from the subsequent cardiopulmonary R. in some cases against the background of the carried-out IVL and the recovered cordial activity owing to hypostasis and the termination of blood circulation comes death of a brain (see). The main criterion for its recognition is the termination of reflex activity of a brainstem — the termination of own breath, lack of reaction of pupils to light, an immovability of eyeglobes, lack of a gag reflex, reflexes from a trachea, okulovestibulyarny and okulotsefalichesky reflexes, an atony, an areflexia.
The postresuscitatic period
the Postresuscitatic period — the period after resuscitation and recovery of activity of cardiovascular system and breath, during to-rogo develops postresuscitatic pathology of various bodies and systems, the so-called postresuscitatic disease described for the first time by V. A. Negovsky (1979). The postresuscitatic period proceeds at a favorable current on average apprx. 5 days.
According to V. A. Negovsky and sotr. (1970), based on the analysis of results of treatment of 1539 patients with massive blood loss, an injury and the phenomena of shock, in the postresuscitatic period the following 3 stages — of temporary stabilization of functions, a repeated aggravation of symptoms and a stage of normalization of functions are traced.
The stage of temporary stabilization of functions develops at the correct treatment in 10 — 12 hours after resuscitation. The general condition of patients improves regardless of the further forecast, the ABP is stabilized. At the same time at massive blood loss, despite its compensation, the hypovolemia — deficit of volume of the circulating blood to 30% remains (see. Oligemiya ), the hypoproteinemia — the content of crude protein in a blood plasma is lower than 60 g/l (see. Proteinemia ), anemia — hemoglobin is lower than 100 g/l. Disturbances peripheral are noted blood circulations (see), a circulator and anemic hypoxia (see), surplus of nedookislenny products of exchange — strengthening of a lactate and organic to - t in a blood plasma by 1,5 — 2 times (see. Acidosis ) at normal pH. Are characteristic also active removal of potassium with urine and accumulation of sodium, development of functional oligurias (see) or anuries (see) owing to deficit of water in an organism and disturbances of blood circulation in kidneys. The hypocoagulation typical for the first hours after resuscitation, is replaced by normalization of coagulating properties of blood or the beginning hypercoagulation. Treatment of patients during this period shall be directed to correction of noted disturbances homeostasis (see). For this purpose continue IVL and infusional therapy, exercise control of the central venous pressure and volume of the circulating blood, an hourly diuresis, a system hemodynamics, peripheric circulation, biochemical composition of blood and urine.
The stage of a repeated aggravation of symptoms of patients begins at the end of the first — the beginning of second day. In addition to deterioration in the general state, the arterial anoxemia develops (decrease in partial pressure of oxygen in an arterial blood — Rao2 lower than 80 mm of mercury., saturation of an arterial blood oxygen — SaO2 is lower than 92%). At the same time hypercoagulation accrues; joins the remaining circulator, anemic hypoxia also hypoxemic (see. Hypoxia .)
According to a number of researchers, disturbance of exchange of gases in lungs owing to change of a ratio a ventilation/blood stream — increase by 2 — 2,5 times of an alveoloarterialny gradient on oxygen, reliable increase of physiological «dead» space, true venous shunting in lungs is the main reason for development of the last. Releaser of disturbances gas exchange (see) primary circulator disturbances in vessels of a small circle are: embolization by microblood clots and drops of fat from vessels of a big circle of blood circulation, formation of microblood clots in lungs, and also disturbances of exchange in tissue of lungs. The listed reasons already in this stage can lead to development of acute pulmonary insufficiency — to «a shock lung» (see. Respiratory insufficiency ). At a long hypovolemia development of «a shock kidney» is possible (see. Renal failure ). Deepening of a hypoxia against the background of the remaining hypovolemia, disturbances of peripheric circulation leads to strengthening glycolysis (see), activation of removal of potassium from an organism, deterioration in water and electrolytic balance and development in some cases metabolic alkalosis (see). The main objective of treatment during this period along with symptomatic therapy is correction of acute renal and pulmonary failure. Maintenance of gas exchange on datum level is promoted also by elimination of hypercoagulation. In this phase recommend to appoint anticoagulants — heparin, fibrinolysin, a streptokpnaza, antiagregant (acetilsalicylic to - that, reopoliglyukin).
At an adverse current postresuscitatic for about 3 periods — the 5th days progress a hypoxia and disturbances of functions of various bodies and systems. The shift of curve dissociation of hemoglobin joins a circulator, anemic, hypoxemic hypoxia to the left, i.e. affinity of hemoglobin to oxygen increases. One of the reasons of it is decrease in concentration in erythrocytes of organic phosphates, hl. obr. 2,3-difosfogli-tserinovoy to - you. The wedge, the picture characteristic of «a shock kidney», «a shock lung» develops. Inflammatory and purulent complications — suppuration of wounds join, pneumonia (see), peritonitis (see), generalization of an infection (see. Sepsis ). At a long hypoxia hallucinations (see), speech and motive excitement, the noncritical relation to a surrounding, state, psychoses are quite often observed. A basis to lay down. tactics are made by treatment of complications against the background of correction of a hypoxia and other disturbances of a homeostasis. The timely beginning and the correct carrying out long IVL is especially important. At the same time carry out pathogenetic therapy: appoint anticoagulants, hold the events directed to normalization of rheological properties of blood and microcirculation, korrigirut water and electrolytic disturbances, fill a metabolic cost of an organism (the parenteral or mixed food).
In the remote period after R. at 71% of the patients who transferred clinical death or massive blood loss with hypotension psychoneurological disturbances develop, to-rye can arise in 3 — 4 months after R., progress within 6 — 12 months and remain within 2 — 3 years and more. Are most often observed a neurotic syndrome (see. Neurasthenia ) and neurocirculatory dystonia (see). There are also focal damages of various parts of the nervous system which are shown trunk and cerebellar frustration, a pyramidal syndrome.
Prevention of disturbances of functions of a brain and other bodies in the early postresuscitatic period depends on that, how fast and the hypoxia is effectively eliminated. At the same time traditional dehydrating and diuretics it is necessary to appoint only according to strict indications. In the first 5 — 7 days of the postresuscitatic period the neurogenic stimulators which are often applied to acceleration of an exit of patients from a coma are contraindicated. After an extract from a hospital the patients who transferred cardiopulmonary R. within 6 — 12 months shall be under observation of the neuropathologist. Creation of the guarding mode, out-patient use of the means improving metabolic processes and blood circulation in a brain, fortifying therapy is recommended; since the second month after an extract — use of easy psychogogic means (acephen, Encephabolum). The specified scheme of treatment reduces duration of a readaptation, and sometimes promotes full regress psikhonevrol. disturbances within 3 — 9 months or prevents their emergence.
Most carefully the current of the postresuscitatic period in the first 6 — 9 hours at revival after clinical death is studied on animals. At the same time three early stages of the postresuscitatic period — giperdinamiche-Skye, a stage of relative stabilization of functions and a hypodynamic stage are established.
The hyper dynamic stage proceeds 20 — 40 min. after revival. Are characteristic hypertensia in vessels of a small circle of blood circulation of it, build-up of pressure in cardial cavities, an aorta and disturbance of action of the heart (acute insufficiency of a myocardium). The minute volume of blood circulation comes nearer to normal or at tachycardia exceeds it by 1,5 — 2 times. The general peripheric resistance normal or is lowered. Hyper perfusion of coronary arteries, vessels of a brain, the lower extremities, sometimes kidneys are characteristic. The hyper dynamic form of blood circulation is combined with a hyperventilation, a hypocapny. Oxygen consumption by an organism increases by 40 — 60% though oxygen consumption by a brain decreases. Metabolic disturbances are sharply expressed. There are an acidemia, a giperfer-mentemiya, a toxaemia, hypercoagulation along with activation of a fibrinolysis, the wedge, a picture of the disseminated intravascular coagulation Can develop, the hypermetabolism occurs against the background of increase in total activity of catecholamines of blood twice and more, strengthening of glucocorticoids, thyroid hormones, decrease in level of insulin, activity of androgens, estrogen. During this period recovery of functions of c begins. N of page, confirmed by means of EEG: at first there is an electric activity of a reticular formation, then certain areas of a cerebral cortex and subcrustal educations.
The stage of relative stabilization of functions is observed at the end of the 1st — the beginning of the 2nd hour after revival at a favorable current of the postresuscitatic period. There occurs relative normalization of functions of heart, compensation of a metabolic acidosis, recovery of electric activity of a cerebral cortex.
The hypodynamic stage begins in 2 — 3 hours; after resuscitation also proceeds till 6 — 9 o'clock. Development of a syndrome of small cordial emission, reduction of inflow of blood to the right departments of heart is characteristic of it. At steadily normal ABP the stroke output of heart decreases to 26 — 27% of initial, the minute volume of blood circulation decreases, work of a left ventricle increases approximately twice, the general peripheric resistance increases by 2 — 2,6 times. On this background the regional blood stream in muscles of extremities (decreases by 35%), in kidneys (for 26%), in a brain (for 50%). Oxygen consumption by a brain, kidneys becomes normal or increases. There is an increase in utilization of oxygen fabrics (increase in arteriovenous distinction on oxygen due to decrease in partial pressure of oxygen in a venous blood — PvO 2 and saturation of a venous blood oxygen — SvO 2 ). On this background electric activity of a cerebral cortex is normalized. At the same time the hyperventilation, a hypocapny increases and the respiratory alkalosis, often dekompensirovanny develops. Surplus of nedookislenny products of exchange in a blood plasma remains (increase in the sum organic to - t by 1,5 — 2 times). The long combination of a syndrome of small cordial emission to a hypocapny quite often leads to repeated development or deepening of a circulator hypoxia.
Resuscitation and an intensive care of newborns
Resuscitation and an intensive care of newborns with the broken functions of an organism at the birth or with manifestation of these disturbances is carried out to the next few hours and days of life in maternity home (see). A number of urgent actions (intravenous and intra arterial administration of pharmaceuticals through vessels of an umbilical cord, an indirect cardiac massage, release of respiratory tracts from slime, IVL by means of a mask) shall be able to see to arrival of resuscitation crew not only to lay down. doctor, but also midwife (tsvetn. fig. 7, 8 and 10).
In process childbirth (see) at careful overseeing by a state fruit (see), rather correct assessment of a condition of the woman in labor (a complication of pregnancy and childbirth) in a certain measure can predict their outcome for the child and in advance to be prepared for resuscitation actions if the birth of the child in asphyxia is expected.
The first actions (release of respiratory tracts from slime, several artificial breaths by means of a mask, administration of the medicines which are in advance gathered in the syringe, an indirect cardiac massage) can be held right after the birth of the child. For the subsequent resuscitation actions it is necessary to prepare the special place in physiological and observation departments where shall be a little table (better with continuous heating), a locker for pharmaceuticals and tools, the respiratory equipment. It is possible to attach a vessel for infusional therapy to this little table, over a table establish a shadowless lamp. Put the roller that the newborn could give the necessary situation for carrying out an intubation on a little table. In a locker there have to be sterile a vessel with system for drop intravascular injection, tubes (air ducts) and the laryngoscope; surely it is necessary to have masks for carrying out IVL. Also there have to be on call pharmaceuticals: 5% solution of hydrosodium carbonate (a period of validity no more than 2 days), 10 and 20% solutions of glucose for intravenous administration, solutions of an Euphyllinum, Adrenalinum hydrochloricum, Prednisolonum, GOMK, respiratory analeptics — Cordiaminum, etimizol, analeptical mix of Kudrin (caffeine of benzoate of 0,01 mg, Corazolum of 0,01 mg, strychnine of nitrate of 0,00005 mg, picrotoxin of 0,00005 mg and the water distilled to 1 ml). The question of use of analeptics is disputable. V. A. Negovsky and some other researchers consider them contraindicated in these conditions.
The indication for R. and an intensive care of the newborn are asphyxia (see Asphyxia of a fruit and the newborn), a craniocereberal birth trauma (see), a syndrome of respiratory frustration (see. Distress syndrome ), post-hypoxemic complications (see. Hypoxia ).
Right after the birth to differentiate preferential hypoxemic or traumatic (local) defeat of c. N of page it is quite difficult. Allows to specify the diagnosis careful nevrol. a research (see. Birth trauma ). At preferential hypoxemic defeat of c. N of page at newborns focal nevrol. the symptomatology, as a rule, does not come to light, the syndrome of oppression of c prevails more often. N of page. At nek-ry children increase in neuroreflex irritability is noted: motive concern, a tremor of extremities, a moderate fleksorny muscular hypertension, strengthening of reflexes of oral automatism (see Reflexes pathological). Occasionally the non-constant nystagmus (see), periodically meeting can be observed squint (see). At newborns with dominance of a traumatic component (extensive subdural, subarachnoidal and intraventricular hemorrhages) at the birth vascular shock with the expressed pallor of skin and hyper excitability comes to light. Newborns quickly become uneasy, they have a tremor of extremities, sometimes asymmetric, a shriek. It is reasonable to make a spinal puncture for differential diagnosis with tsitol. research of liquid, ultrasound examination of a skull and transillumination (see).
It is necessary to estimate weight of asphyxia of the newborn on a scale Apgar (see. Apgar method ), and degree of respiratory insufficiency, especially at premature newborns, on Silvermen's scale — Andersen, edges is based on assessment on points of signs of respiratory retraction: at retraction of intercostal spaces with an abdominal respiration during a breath — 1 point, at retraction of the lower intercostal muscles — 2 points, retraction of a xiphoidal shoot — 3, at the movement of wings of a nose with a breath — 4, at an exhalation with noise (grumble) - 5 points; the fortune of the healthy child is estimated in 0 points.
In total patol. conditions of newborns are followed by dysfunction of breath, cardiovascular system, metabolism and therefore R. represents a complex of the actions directed to elimination of a hypoxia and >metabolic disturbances, and also to normalization of cordial activity, blood circulation, a likvorodinamika of a brain, microcirculation. The main indications to R. and an intensive care of newborns and methods of carrying out — see the table.
Resuscitation is contraindicated at incompatible with life and not korrigiruyemy in the surgical way congenital and hereditary anomalies, the diagnosed extensive hematencephalons.
According to V. A. Negovsky, at R.'s carrying out first of all adequate supply of an organism with oxygen by means of IVL for which carrying out the devices RD-1, DP-5, Vit-I, Lada (can be used see shall be provided. Artificial respiration ). After IVL supply of the newborn with oxygen can be carried out by means of hyperbaric oxygenation, napr, according to the scheme offered by B. D. Bayborodov: rise in pressure of oxygen to 2 at — 1 min., a saturation 2 at — 5 — 10 min., a decompression up to the pressure of 0,5 at — 15 min., a saturation with a pressure of oxygen of 0,5 at — 1,5 hours. The session of hyperbaric oxygenation continues 1,5 — 2 hours.
For the purpose of elimination of excessive acidosis usually use 5% solution of hydrosodium carbonate. Its quantity is calculated depending on surplus of the bases in whole capillary blood — BE (English bases excess) — on a formula: BE-0,3 of body weight in. If together with gidrokarbo-naty sodium enter cocarboxylase, then the amount of alkaline solution should be reduced by 5 ml. Hydrosodium carbonate at slight asphyxia can be entered, to especially full-term children, without preliminary definition of indicators of acid-base balance (see) depending on body weight at the birth (to 300Q of g, from 3000 to 4000 g, St. 4000 g respectively on 10, 15», 20 - ml)-. At heavy asphyxia enter hydrosodium carbonate 5 ml more than that dose, edges corresponds to body weight at slight asphyxia.
In a complex to lay down. actions infusional therapy since it improves rheological properties of blood shall be surely included, eliminating microcirculator disturbances. In the first days of life optimum amount of the entered liquid on 1 kg of body weight of the full-term child are 30 — 40 ml, premature — 70 — 80 ml.
All resuscitation events should be held under control of such key parameters as a respiration rate and its conductivity in lower parts of lungs, heart rate, the ABP, a hematocrit. Reasonablly also in dynamics to define gas structure, pCO2, pO2, indicators of acid-base equilibrium, to carry out electroencephalography (see), reoeitsefalografiya (see), electrocardiography (see). The most objective indicators of adequacy of external respiration are pCO2 and pO2. So, pO2 can be defined constantly by the electrodes located on skin or entered vnutrikozhno.
The question of duration of resuscitation is debatable and extremely delicate. E.g., on. to opinion of H. N. Rasstrigina (1978), at the termination of cordial activity in 4 — 5 min. prior to the birth of the child and at failure of recovery it the first 8 — 10 min. R. should be stopped. If in the presence of serdtsebiyeniye in the course of IVL independent breath is absent within 10 — 15 min., then it is also necessary to refuse further attempts of resuscitation. On this matter many years V. A. Negovsky holds the same opinion. However this point of view is disputable and demands further specification.
The question of transfer of the newborns who were born in asphyxia and with a birth trauma from a maternity home in children's hospitals should be solved strictly individually. During the transportation of the child it is reasonable to place in couveuse (see) and to transport in specially equipped car. In cases of accession of infectious and septic diseases or surgical complications of newborns, irrespective of age, urgently transfer to surgical or somatic departments of pathology of newborns at children's multi-field hospitals. At identification nevrol. the disturbances demanding long and special correction newborn on 7 — the 10th day of life (taking into account transportability) is sent to specialized departments for children with defeat of c. N of page. Newborns, the state to-rykh was compensated for this term without deviations in somatic and nevrol. the status, discharge from children's departments of a maternity home under observation of the local pediatrician and children's neuropathologist.
The Reanimatologichesky help in the center of mass defeat and at stages of medical evacuation
At mass defeat R.'s restriction in comparison with its volume made in peace time is inevitable. In the center of mass defeat and in the battlefield only the simplest means and methods allowing to reduce life-threatening disturbances of breath and blood circulation can be used. Heavy respiratory frustration during the next period after defeat can be more often caused by an injury of a skull or thorax. At a cherepnomozgovy injury with a loss of consciousness language can sink down, in an oral cavity slime, blood p emetic masses accumulate. In these cases disturbance of passability of upper respiratory tracts can be eliminated as it should be first aid (see) way of a toilet of an oral part of a throat, the subsequent promotion of a mandible forward and maximum zaprokidyvaniye of the head back. After recovery of free breath the victim is given the fixed side situation. At sharply expressed disturbance of breath which resulted from an injury of a thorax, struck give a semi-sitting position. The artificial respiration and in the battlefield can seldom be applied by methods of companies in a mouth and a mouth in a nose in the center of defeat. It is connected with the fact that the termination of breath after defeat usually demonstrates in the nearest future extremely heavy, damage incompatible with life. Use of IVL (see. Artificial respiration ) it is justified when the main reason which caused the termination of breath is removed (extraction from water, from under blockages).
Dangerous disturbances of blood circulation in the center of defeat can be caused by big blood loss, at a cut the timely and correct applying a tourniquet is important (see. Plait styptic ) or compressing bandage (see). At sharply expressed display of anemia (pallor of skin, a low pulse) the victim is given situation with the raised lower extremities and a basin that increases inflow of blood to heart and improves a system hemodynamics.
During the rendering pre-medical help (see), in addition to urgent measures, for struck, being in a terminal state, use of a pneumo-oxygenator, air duct, the manual device for IVL, nek-ry cardiovascular means is provided. At sharply expressed pain syndrome introduction subcutaneously or intramusculary 1 ml of 1% of solution of morphine of a hydrochloride is possible.
During the rendering the first medical assistance (see) carry out urgent measures in wider volume. But acute management at a big flow struck appears preferential that from them, at to-rykh find dangerous disturbances breath (see) and blood circulations (see). At heavy disorders of breath the doctor first of all controls passability of respiratory tracts and if necessary undertakes measures for the purpose of its improvement (suction of contents from upper respiratory tracts, introduction of an air duct, underrunning of language with the subsequent fixing of a ligature to clothes of struck). At the disturbance of passability of deep departments of respiratory tracts causing asphyxia or creating danger of its development it is necessary to carry out an intubation of a trachea (see. Intubation ) or tracheostomy (see). Against the background of asphyxia the intubation is possible without preliminary anesthesia or after single irrigation of a mucous membrane of a throat and a root of language a mestnoanesteziruyushchy sredetv.
At intense pheumothorax (see) it is recommended to carry out a pleurocentesis (see) a thick short needle, to suck away through it air and to leave a needle for evacuation under rykhlo the applied bandage. More effective is drainage (see) a pleural cavity a plastic tube to dia. 4 — 6 mm, to-ruyu it is necessary to enter at a thoracocentesis or through a trocar, fixing to skin a seam and on the distal end mounting the valve (a finger of a rubber glove with a cut).
At the same time in cases of extremely heavy respiratory insufficiency (see) it is recommended to use pneumo-oxygenators and to carry out IVL by the manual or automatic device. Long carrying out IVL at a big flow struck is impossible, this method is shown when it is possible to count on bystry recovery of effective spontaneous breath. Hypotonia at severe wounds is the indication for transfusion of blood-substituting liquids (see).
For reduction of pain intravenously it is necessary to enter drugs (morphine a hydrochloride or Promedolum) in combination with a neuroleptic (isopromethazine or Phenazepamum), to carry out novocainic blockade of field of damage (see. Novocainic blockade ).
At stages of the qualified medical care (see) and specialized medical care (see) The river should be seen off in the departments of anesthesiology and resuscitation developing one or two chambers of an intensive care. Department shall be equipped with special sets, technical means for oxygen and inhalation therapy, devices IVL and an inhalation anesthesia.
At a stage of the qualified medical aid can need R. wounded and burned in state of shock or struck a therapeutic profile. At a stage of the specialized surgical help an intensive care and R. it is necessary to carry out hl. obr. heavy postoperative wounded.
The most important components of an intensive care — intravenous administration of liquid, use of cardiotonic and sosudoaktivny means, holding the actions directed to improvement of gas exchange, correction of heavy disturbances of metabolism and internal environment of an organism. Infusional therapy varies in considerable limits in the quantitative and qualitative relations depending on whether it serves the purposes of compensation of big blood loss, desintoxication or parenteral food. At much struck, being in a terminal state, it gains universal purpose.
Improvement of external respiration can be generally reached by performing oxygen therapy (see), maintenance of passability of respiratory tracts, reduction of the pain complicating breath, elimination of pheumothorax. IVL which is the difficult method demanding constant and attentive control it is necessary to undertake according to strict indications.
At struck, it is long being in a terminal state, there can be expressed metabolic frustration. At the same time correction of breath and blood circulation has major importance. The therapy directed to reduction is reasonable acidosis (see), completion of a metabolic cost and correction water salt metabolism (see). Hemotransfusion and its components at the stopped bleeding shall prizvoditsya according to indications. At considerable intoxications (see) important to lay down. a factor is the artificial diuresis.
Resuscitation actions at various terminal states — see also articles devoted to individual diseases and morbid conditions, e.g. Asphyxia , Stroke , Myocardial infarction , Collapse , Coma , Peritonitis , Shock etc.
Table. The main indications to resuscitation and an intensive care of the newborn and methods of their carrying out
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B. H. Semenov; E. S. Zolotokrylina (postresuscitatic period), G. M. Savelyev (resuscitation and intensive care of newborns), B. S. Uvarov (soldier.).