RESUSCITATION PATHOLOGY — the traumatic and not traumatic complications arising during the performing resuscitation and an intensive care of terminal states. Sometimes Genitive («a postresuscitatic disease») is a proximate cause of death, pushing aside the basic disease which was the cause for performing resuscitation and an intensive care on a background.
Complications of resuscitation are generally connected with surgical manipulations (a cardiocentesis, a puncture and catheterization of veins, a tracheostomy, etc.) or with hypoxemic damages of bodies and fabrics, to-rye can develop in the result of successful resuscitation. Difficulties of definition of a role of resuscitation actions in thanatogenesis (see) are caused by masking of signs of the basic patol. process by effects of resuscitation, complications of resuscitation actions.
Pathologist and court. - the medical expert shall approach with extra care assessment of tanato-genetic value of traumatic complications of resuscitation and an intensive care as they most often are not a cause of death, but the reason of inefficiency of resuscitation.
Despite the znachrggelny number of the works devoted to complications of resuscitation and an intensive care still does not exist a little ratsionalnorr classifications of these complications. Ya. L. Rapoport (1966) who offered the term «resuscitation pathology» allocates the «resuscitation traumatology» combining traumatic complications of resuscitation from this general concept. Many resuscitators suggest to allocate in a separate nosological form the hypoxemic damages of a brain arising after successful resuscitation under the name «reanimatsionno the caused encephalopathies», «anoxic encephalopathy», «post-anoxic encephalopathy».
Refer damages at massage and a cardiocentesis, catheterization of large veins to the traumatic complications arising in connection with manipulations on heart; in connection with manipulations on a respiratory organs — complications of an intubation of a trachea, a tracheostomy, the artificial ventilation of the lungs (AVL). Complications of transfusion therapy (an acute cardiomegaly, an air embolism, fibrinferments and embolisms, posttransfusion shock, citrate intoxication, the pyrogenic reactions, a syndrome of massive transfusions, etc.), complications belong to not traumatic complications at a detoxication of an organism (a gastric lavage, intestinal dialysis, a hemodialysis, peritoneal dialysis, etc.); complications of hyperbaric oxygenation, and also osmotic nephrosis during the use of methods of an artificial diuresis and septic complications at catheterization of veins. So-called diseases of a brisk organism are especially allocated: post-anoxic encephalopathy, cardiopulmonary syndrome, hepatonephric syndrome, gastroenteric syndrome, post-anoxic endocrinopathy.
Damages at a direct cardiac massage to a look ranenrrya the walls of heart, coronary arteries, large sosudrtsty trunks easy were observed during excessive interest in resuscitation when torakotomrgya it was made in unsterile conditions, napr, in the ambulance car at a lack of technical means and weak qualification of resuscitation crew. Now straight line cardiac massage (see) it is made only in the conditions of a surgical hospital if the cardiac standstill came during an operative measure on a chest cavity.
The damages coming at a direct cardiac massage are documented on opening by existence in an epicardium, in the thickness of a myocardium of front and back walls of a left ventricle and in an interventricular partition of multiple hemorrhages with expanding and stratification of muscle fibers and the subsequent their disintegration and a lysis. Microscopically in 8 — 10 hours in a circle of the damaged muscle fibers emigration of polymorphonuclear leukocytes is observed. The large centers of a necrosis of a myocardium meet seldom. As a rule, such centers are connected with the secondary circulatory disturbances which arose not only because of an injury, but also owing to a reduction of a blood-groove in the recovery period.
Effects of a direct cardiac massage in the myocardium are liquidated on average in 30 days after resuscitation, and adhesive pericardis (see) it is found also in 3 — 6 months. At disturbance of an asepsis during a direct cardiac massage the purulent pericardis and abscesses of a myocardium develop.
Damages at an indirect cardiac massage come both in bones of a thorax, and in internals.
Fractures of bones thorax (see) are noted on section material rather often, preferential in the senior age groups. It is necessary to notice that at the existing technique it is almost impossible to avoid changes even at the qualified carrying out an indirect cardiac massage as for maintenance of adequate blood circulation it is necessary to squeeze heart between a breast and a backbone in beat to 60 pushes in 1 min. At rigid, in particular so-called barrel-shaped, a thorax effective squeezing of heart is possible only in case of a fracture of edges. The fractures of edges which are observed at the same time as rrravit, multiple, bilateral, subperiostal, are localized on rrarasternalny and average and clavicular linrshchm. The II—VI edges on both sides are most often injured. Approximately in 20% of cases fractures of edges are combined with cross fractures of a breast in average or its lower third.
The strength loss of bones caused by their age reorganization or patol. process, promotes emergence of widespread damages. In a zone of a change, as a rule, there are small hemorrhages, and at fractures of a breast — small hematomas of cellulose of a front mediastinum.
It is natural that fractures of bones of a thorax make heavier development of a basic disease and slow down recovery processes in the postresuscitatic period.
Internal injuries at an indirect cardiac massage meet much less often than bone damages. In rare instances fragments of edges break off a parietal pleura. Ruptures of the capsule of a liver and spleen are slightly more often observed, to-rye can be isolated or get into a parenchyma of body. In a circle of cracks there are hemorrhages, and sometimes and hemoperitoneum (see). At a long and intensive indirect cardiac massage at patients of young age resuscitation injuries of a liver can be followed massive (to 2 l) by a hemoperitoneum.
At an indirect cardiac massage walls of a stomach are quite often damaged. These damages are similar to those, to-rye arise at Mallori's syndrome — Weiss (see. Mallori — Weiss a syndrome ) — various depth radial cracks of a mucous membrane of cardial department with distribution on small curvature and a body of a stomach. Ruptures of walls of a stomach can seldom be observed. Crack initiation of a mucous membrane, on-vidrshomu, is connected with sharp build-up of pressure in a stomach. On opening usually find this or that quantity in these cases (but no more than 100 — 150 ml) the liquid blood in a stomach which was not in time to move to intestines.
Damages at catheterization of large veins meet often, generally in unsuccessful attempts of catheterization of a subclavial vein. So, cases of a rupture of a subclavial vein at its puncturation are known for a thick needle on Seldingera (see. Catheterization of veins puncture , Seldingera method ). These damages are followed by hemorrhage in cellulose mediastinums (see) or bleeding in a pleural cavity (see. Hemothorax ), to-rye can remain unnoticed against the background of the general serious condition of the patient.
The casuistry of complications of catheterization of veins is various. Separations of intravenous pieces of a catheter owing to the insufficient durability of material are described, in particular, from to-rogo it it is made. The scrap of a catheter is brought by a blood flow in a cavity of a right ventricle and can cause an embolism pulmonary artery (see). Large scraps can be, apparently, a long time in the curtailed state in a cavity of a right ventricle, worsening its sokratitelny function. In the absence of sufficient experience the catheter is entered, passing a vein or through all its walls in a pleural cavity. Besides, and at successful introduction of a catheter «depth» of catheterization (length of its intravenous part) is not always controlled, at the same time the end of a catheter quite often reaches a cardial cavity, injuring the three-leaved valve.
Damages at a cardiocentesis can be caused, e.g., by the aspirating needle entered, passing heart, in a mediastinum and tissue of lungs. Administration of solution of Calcii chloridum possessing, as we know, necrotizing action can be made not in a cardial cavity, and in thickness of a wall of ventricles, an interventricular or interatrial partition and is especially frequent to the area of an atrioventricular node that not only does not promote recovery of cordial activity, but makes it in general impossible owing to medicamentous destruction of the main driver of a ventricular rhythm. Also anguishes of a myocardium by an aspirating needle — a linear form of damage, the hearts arising at repeated «starts» owing to «sawing» of the reduced muscle about a tip of a needle are observed at its insufficiently deep introduction. At the same time in case of unsuccessful «start» of heart arises hemopericardium (see) of no more than 50 — 100 ml. Less often the amount of blood in a pericardium can reach 250 — 300 ml with development of a haemo tamponade (see. Cardiac tamponade ), what happens at repeated «starts» of heart p cannot but affect efficiency of resuscitation. It is important to note that even more considerable hemopericardium (to 400 ml) is sometimes formed after a cardiocentesis for the purpose of intrakardialny administration of medicines.
Complications of an intubation of a trachea are observed at disturbance of the technology of introduction of an endotracheal tube. In these cases drinks, a gullet are possible its introduction to a gullet, damage of an epiglottis, a thyroid cartilage, false and true phonatory bands. Are observed as small anguishes of a mucous membrane with hemorrhage on peripheries, and more rough defects of walls up to their complete separation. At long intubations (see), in particular during the use of the tubes made from not enough elastic materials development of decubituses and ulcerations of a mucous membrane of a trachea is noted. They are, as a rule, infected that is followed superficial or deep ulcer and necrotic and diphtheritic tracheitis (see). Inflammatory process in a trachea can be limited to a zone of damages or gain widespread character up to development of bronchial pneumonia (see. Pneumonia ).
Complications of a tracheostomy are much more various, than complications of an intubation of a trachea. Therefore resort to a tracheostomy only according to strict indications when long IVJI is supposed. According to aggregated data large world the statistician, complications of a tracheostomy meet in 20% and more. All complications of a tracheostomy can be divided conditionally on noninfectious and infectious. The first are connected, generally with technical defects of the technology of operation or use of rough metal cannulas, the pressurizing cuffs, etc., come to light, as a rule, soon after operation and demand immediate elimination in order to avoid asphyxia. In most cases such complications develop during the imposing of the lower tracheostoma with a section more than two cartilaginous rings (see. Tracheostomy ). At an imperfect hemostasis massive bleedings from edges of an operational wound with heavy gem-aspiration already soon after operation are possible. Wrong introduction of a cannula to cellulose of a front mediastinum and as the inevitable investigation of it, development of massive emphysema of a front mediastinum is described (see. Pneumomediastinum ), pheumothorax (see) and compression atelectasis (see). However, heavy emphysema of a mediastinum and hypodermic cellulose is not so a rare complication of the lower tracheostomy and in cases of the correct introduction of a tube to a trachea. It is promoted abundance of a friable fatty tissue in the field of jugular cutting of a breast and insufficient sealing of edges of a tracheostomy opening.
Long stay in a trachea of the tracheostomy tube which is, in essence, a foreign body leads to constant traumatization of edges of a wound, an ulceration of a mucous membrane and development of limited or diffusion ulcer and necrotic tracheitis. It is promoted by microbic impurity of edges of a wound and a possibility of introduction of an exogenous infection at long IVL, and also use of the heavy metal cannulas and the rough pressurizing cuffs putting the constant injuring pressure upon walls of a trachea. Especially often dekubitalny ulcers are formed at the lower end of a tracheostomy tube having the greatest mobility. Dekubitalny ulcers can get on all thickness of a wall of a trachea, baring cartilaginous rings, to-rye in the subsequent are exposed to a necrosis and sequestration. Inflammatory process can pass to surrounding fabrics with development of phlegmon of paratracheal cellulose and purulent thyroiditis (see).
Further owing to scarring of ulcer defects the stenosis of a trachea can develop (see. Tracheostenosis ), demanding operational treatment. However the similar outcome necrotic - ulcer tracheitis should be considered rather favorable. Deep ulcer defects conceal in themselves threat of the secondary profuse bleeding caused by an arrosion of large vascular trunks, adjacent to a tracheostoma. Such bleedings arise usually in a week after a tracheostomy.
The insufficient toilet of a tracheostomy cannula throughout the period of existence of a tracheostoma can bring to asphyxia (see) owing to closing of a respiratory opening that is more often observed not at IVL, and at spontaneous breath. During the change of a cannula and sanitation of a trachea the reflex cardiac standstill is possible.
Complications of artificial ventilation laid down - to and x include also the complications of an intubation of a trachea and a trakheostokhmiya described above, and also the nek-ry defeats of a parenchyma of lungs connected with hardware breath.
Being one of the main technical achievements of resuscitation, IVL demands strict indications to use, and also constant control of gas composition of blood for a right choice of key parameters of hardware ventilation: volume of ventilation, synchronization of spontaneous breath with the device, quality of respiratory mix. The wrong choice of volume of ventilation and desynchronization of IVL with spontaneous breath can lead to a heavy barotrauma (see. Barotrauma ) lungs owing to sharp increase in intra pulmonary pressure with restretching of alveoluses, their gaps, violent and intersticial emphysema of lungs (see), hemorrhages in a parenchyma of lungs. These changes or in itself, or through a number of the subsequent complications (diffusion and focal alveolites, bronchial pneumonia, focal atelectases) cause development in the postresuscitatic period of the progressing hypoxemic hypoxias (see).
Inflammatory diseases of a trachea, bronchial tubes and lungs are the most frequent and terrible complication of WILLOWS of L. Among etiol. factors golden staphylococcus, a streptococcus and gram-negative sticks meet more often, i.e. all that bacterial flora, edges is the most frequent reason of development of surgical sepsis. Endogenous flora, vegetans on mucous membranes of upper airways and skin of the patient can be a source of infection. However the exogenous intra-hospital infection caused by disturbances of the technology of sterilization of devices IVL, a dressing material, trakheostomny cannulas, bed linen, etc., and also an insufficient toilet of skin in a circle of a tracheostoma has the prevailing value, apparently. Therefore particularly important become the most strict observance in the intensive care unit corresponding a dignity. mode and timely holding hygienic actions.
Inflammatory damages of lungs first have, as a rule, the nature of the melkoochagovy bronchial pneumonia taking one or several alveolar courses; at the same time nearby bronchial tubes can be intact. Later, owing to merge of small inflammatory focuses, bronchial pneumonia gains macrofocal character with possible abscessing.
The atelectasis of lungs is not less rare complication, than bronchial pneumonia. Moreover, primary kollabirovaniye of tissue of lung owing to hypoventilation or its complete cessation often is the cornerstone of pneumonia. Most often at WILLOWS of L are observed small - and macrofocal atelectases, a fascinating 1 — 2 segment of a lung, or the lamellar subpleural atelectases of zadnenizhny departments developing in a zone of gipostaz. Such atelectases have no independent tanatologichesky value. In their pathogeny it is necessary to consider many factors: obturation of a bronchial tree slime and a cellular detritis, disturbances of a hemodynamics as a result of thrombosis of vessels of a microcirculator bed, destruction surfactant (see) owing to the damaging effect of gas mixture, a reflex spasm of bronchioles.
Complications of transfusion therapy make the greatest on the frequency and a variety group of not traumatic complications of resuscitation. Value of this fact is aggravated with the fact that transfusion therapy of terminal states takes the leading place in system of resuscitation actions. Terminal states with inherent to them a diskorrelyation of exchange processes and chaos in system of a homeostasis are optimum field of activity of a transfuziolog. At the same time the aspiration to purposeful intervention in internal environment of an organism is accompanied by a number of the dangers involving various complications. If in the relation hemotransfusions (see) indications and contraindications are developed rather accurately, it cannot be told about other transfusion environments applied in a wedge, practice still.
Complications of the perfusions applied in treatment of terminal states to improvement microcirculation (see) way of normalization of rheological properties of blood (degree of a condensation, viscosity, adhesive properties of thrombocytes, etc.), are observed also quite often. Managed applied at the same time hemodilution (see) assumes thin regulation of water-salt balance, inadequate correction to-rogo is shown in a form hypo-or an overhydratation.
Complications of parenteral food divide on nonspecific and specific. From among nonspecific complications at parenteral food special danger is constituted fibrinferments (see), embolisms (see), heavy pyrogenic reactions (see. Fever ), caused by the pyrogenic substances of the proteinaceous and nonprotein nature, etc. Those treat specific complications, to-rye are connected with side effects of effect of the substances applied to parenteral food, or products of their disintegration in an organism of the recipient. Proteins and protein hydrolyzates cause anaphylactoid reactions (see), the concentrated solutions of glucose — hyperglycemia (see), glycosuria (see) and osmotic diuresis (see), at Krom electrolytes, in particular potassium can be lost that is fraught with disturbance of conductivity in a myocardium. Isotonic 5% solution of glucose can fill daily energy needs of an organism at introduction it in very large number (to 12 — 15 l a day) that threatens with an overhydratation, in particular in pediatric practice.
From the fatty emulsions applied in the power purposes gained distribution intralipid, at prolonged use to-rogo disturbances of the hemopoietic function can be observed marrow (see), coagulant system of blood (see), functions liver (see). During the use of fatty emulsions it must be kept in mind a possibility of a fatty embolism of lungs and a brain.
These side effects can burden a condition of the patient therefore demand additional correction. They seldom in itself lead to a lethal outcome, but in some cases have essential value in a thanatogenesis, though are disguised both by manifestations of a basic disease, and hypoxemic changes of the terminal period. It is necessary to refer to number of such most adverse side effects first of all osmotic action of the majority of drugs of a power row and disturbances of vodnoelektrolitny balance connected with it.
At a transfusion of giperosmolyarny solutions of glucose, urea, a dextran, a reopoliglyukin, etc. development of an osmotic (mannitolovy) nephrosis — a peculiar defeat of an epithelium of gyrose tubules of kidneys is possible. Osmotic nephrosis — the inevitable investigation of the artificial diuresis applied to fight against an overhydratation (see. Renal failure ).
Septic thrombophlebitis can arise at transfusion therapy with prolonged use of plastic catheters. As a result of mechanical traumatization of an endothelium of vessels of delay of a blood-groove in a zone of finding of a catheter at first thrombosis, and in case of infection of trombotichesky masses — septic arises a catheter, chemical influence of the poured solutions which are especially concentrated and also thrombophlebitis (see) and sepsis (see). A source of infection can be as ekzo-, and endogenous flora, however practically to establish it can be difficult. Septic thrombophlebitis arises when constant catheterization is applied at patients with purulent processes: peritonitis, an empyema of a pleura, the suppurated decubituses, etc. This complication does the forecast of a basic disease, as a rule, remediless, however is diagnosed clinically seldom since most often develops at patients with a heavy current of a basic disease.
Complications of the forced detoxication of an organism are observed at treatment of various exogenous intoxications (see), caused poisonings (see) various chemical substances. These methods find more and more broad application also as a measure of disintoxication therapy (see) at the diseases which are characterized by heavy endointoxication, purulent peritonitis, a heavy pancreatonecrosis, a chronic and acute renal failure, etc. From methods of an artificial detoxication of an organism in clinic were widely adopted peritoneal dialysis (see), hemodialysis (see), detoksikatsioniy hemosorption (see) and limfosorbtion (see).
At numerous hours-long peritoneal dialysis there are reactive changes of a peritoneum and danger of development peritonitis (see) owing to pollution of dialysis fluids. Real danger is constituted also by the gi-pergpdratation of the extracellular sector of an organism demanding strict correction of water-salt balance.
Among the complications developing sometimes during the carrying out an extracorporal hemodialysis it is necessary to mention the heavy collapses up to a cardiac standstill interfaced to disturbances of electrolytic balance and sudden reorganization of a hemodynamics. Special danger is constituted by the septic complications caused by hl. obr. difficulties of sterilization and cleaning of the device artificial kidney (see), and also threat of infection of the constant arteriovenous shunt («shunt sepsis»). During the passing of blood through system of an artificial kidney the erythrocytolysis with the haemoglobinaemia which is quite often exceeding concentration (100 — 150 mg of %), threshold for the renal filter, that brings to is possible haemoglobinuria (see).
At detoksikatsionny hemosorption a number of the serious complications caused first of all by impact of a sorbent on uniform elements of blood is possible. The majority of sorbents along with toxicants besieges and destroys thrombocytes owing to what thrombocytopenia and symptoms of hemorrhagic diathesis connected with it (develops see. Hemorrhagic diathesis ), sometimes with diapedetic bleeding in an abdominal cavity (in number of 300 — 500 ml). Danger of such bleedings sharply increases if hemosorption is made in the postoperative period.
Complications of a limfosorbtion can be caused both by the operation (bleeding), and dehydration of the extracellular sector of an organism connected with a fluid loss and the substances dissolved in it. At the bystry expiration of a lymph heavy gemodinamnchesky disturbances up to a collapse are possible.
Complications of hyperbaric oxygenation draw attention of doctors because this method finds more and more broad application at treatment of patients with acute and chronic hypoxemic conditions, thermal burns, gas gangrene, craniocereberal injury, occlusion of vessels of extremities, etc. Along with huge advantage hyperbaric oxygenation (see) it must be kept in mind a possibility of the serious complications caused by oxygen intoxication (see. Oxygen therapy ).
Injuries of the central nervous system are observed almost in each case of effective resuscitation and lives of the patient are one of the main reasons for death within the next week.
Post-anoxic encephalopathy (synonym: postresuscitatic encephalopathy, anoxic encephalopathy) can develop generally in the remote period after successful resuscitation.
Macroscopically easy and average degrees of post-anoxic encephalopathy do not come to light on opening or are shown in a look hypostasis and swelling of a brain (see). Histologically at the same time find the widespread ischemic damages of ganglionic cells which are coming to an end in 1 — 2 days with their full necrosis with the subsequent destruction of myelin fibers of white matter of a brain. Damages of neurocytes are preferential observed in bark of big hemispheres, a cerebellum (pear-shaped neurocytes), and also extra-cortical zones of gray matter. Thus, postresuscitatic encephalopathy of easy and average degree from positions of the general pathology does not represent essentially new phenomenon as it is about anoxic damages of the neurocytes which are well studied by neurohistologists. However in connection with development of the resuscitation considerably prolonging a condition of a hypoxia, these defeats have more various character and meet more often. Most of victims of this group perish in the remote period after resuscitation from bronchial pneumonia, cordial and a pulmonary heart.
The resistant decerebration coming in the course of resuscitation, as a rule, is incompatible with life as it is followed by disturbance of vegetative functions. If to the patient who is in a condition of decerebration, but at safe function of heart, it is long IVL is carried out, then the heavy changes of a brain defined as «a respiratory brain» (see can develop. Death of a brain ). Pathoanatomical «the respiratory brain» is characterized by the following types of defeat: 1) diffusion and focal damages of a cerebral cortex; 2) partial necroses (heart attacks) of tissue of brain; 3) symmetric necrosis of subcrustal nodes; 4) total necrosis of a brain.
Macroscopically diffusion and focal changes are shown by the hypostasis or swelling of substance of a brain which are coming to the end dislocation of a brain (see). Histologically at the same time find the large centers of loss of neurocytes in the same zones, as at encephalopathy of easy and average degree. Clinically these defeats proceed g the phenomena of decerebration of this or that degree and come to an end with cardiac death in 2 — 3 and more weeks, on an extent to-rykh the patient is on IVL. As a rule, such defeats of c. N of page arise when blood circulation is not resumed up to 3 — 4 min. after primary cardiac standstill. If «start» of the stopped heart is carried out in later terms, then for the next 3 — 4 days of stay of the patient on IVL the symmetric necrosis of subcrustal nodes and heart attacks of a brain which are clinically shown the resistant and going deep symptoms of decerebration develop. At the same time against the background of intensive dehydrational care the centers of a necrosis of a brain are not exposed to fluidifying as in usual conditions, and gain the nature of coagulative (dry) heart attacks. Microscopically in a brain widespread disorders of microcirculation in the form of a staz of the erythrocytes and thrombosis taking larger arterial trunks are found.
The total necrosis of a brain can develop the patients who are in a condition of decerebration with undisturbed function of heart, exposed to IVL have more than 3 days. Clinically it is shown by symptoms areflexias (see), disturbance of breath (see. Respiratory insufficiency ), disappearance of bioelectric activity of a brain (see. Elektroentsefalografiya ), decrease in a brain blood-groove at adequate cordial activity and the ABP steady level. Macroscopically substance of a brain takes a form of the unstructured grayish semi-fluid gruel concluded in a meninx. Histologically in upper parts of a spinal cord and in tissue of a brain on border with an adenohypophysis find leukocytic reaction, to-ruyu estimate as manifestations of demarcation.
The total necrosis of a brain arises not only after a long cardiac standstill, but also after the strokes which are followed by paralysis of a respiratory center at undisturbed function of heart. In a pathogeny of a necrosis sharp increase matters intracranial pressure (see) with full switching off of an intracerebral blood-groove owing to its shunting on ekstrakra-nialny vessels. At a total necrosis of a brain full loss of mechanisms of master control is observed by a hemodynamics therefore extreme instability of the ABP is noted that the energy and electrolytic balance forces to resort constantly to the help of pressor amines and to parenteral administration of solutions, corrective. At the same time vospalitelnoekssudativny processes (pneumonia, purulent peritonitis) proceed clinically asymptomatically and have no patomorfol. features. Against the background of decerebration in connection with disorders of microcirculation there can be ruptured ulcers of a stomach and duodenum, to-rye it is not necessary to connect pathogenetic with the disease which was a reason for River.
Cardiopulmonary syndrome. The progressing insufficiency of heart in the postresuscitatic period, as a rule, is combined with damage of the upper airways and lungs which are sharply burdening function of heart not only owing to prolongation of a ventilating hypoxia but also in connection with creation of additional obstacles to a blood-groove in a small circle of blood circulation. Therefore during the next period after successful R. in the absence of severe damages of a brain cardiopulmonary insufficiency most often is a proximate cause of death.
Pathology of heart depends on whether only respiratory resuscitation concerning paralysis of breath (was carried out at undisturbed function of heart) or carried out cordial resuscitation concerning primary cardiac standstill. Changes of a myocardium at long IVL consist of hypoxemic damages like melkoochagovy fatty dystrophy and a myolysis of separate cardiomyocytes of ventricles of heart.
Pathology of a myocardium after cordial resuscitation is caused by many factors: 1) changes, with to-rymi connected primary cardiac standstill; 2) type of resuscitation (direct or indirect cardiac massage, electric defibrillation); 3) the changes caused by a circulatory unefficiency in the postresuscitatic period; 4) the complications of infectious and inflammatory character connected with damages of lungs and complications of resuscitation actions.
Experience shows that the period of a hypoxia of a myocardium caused by clinical death happens so short that practically it can be not considered in the analysis of structural changes of a myocardium. It is difficult to find also klinikoanatomichesky features of development of a basic disease, napr, a myocardial infarction, in the cases complicated by a cardiac standstill. Considerably traumatic effects of an indirect cardiac massage make heavier the forecast of a myocardial infarction. The electric defibrillation causes the minimum changes of cardiomyocytes.
The changes of a myocardium caused by a circulatory unefficiency and a ventilating hypoxia in the recovery period develop from focal proteinaceous dystrophy (see) and fatty dystrophy (see) owing to disturbances of metabolism.
Pathology of upper respiratory tracts and lungs in the postresuscitatic period is defined by traumatic and not traumatic complications of resuscitation. Exudative pleurisy (see) and pheumothorax (see), quite often complicating multiple fractures of edges and bronchial pneumonia (see. Pneumonia ), sometimes demand surgical treatment. Against the background of delay of a blood-groove in small branches of a pulmonary artery and veins the numerous blood clots interfering elimination of atelectases and bronkhopnevmoniya are formed. Destruction and reorganization of an aerogematichesky barrier sharply reduce efficiency of spontaneous breath and are a reason for long IVL. At a favorable outcome further owing to insufficient drainage function of bronchial tubes the centers of atelectases and bronkhopnevmonichesky focuses quite often are exposed to the organization that leads to development of diffusion and focal pneumosclerosis (see) and bronchiectasias (see), getting a chronic current.
Pechenochno - a renal syndrome. Damages of a liver and kidneys meet together with post-anoxic encephalopathy and cardiopulmonary insufficiency more often. Independent value has this syndrome seldom since tolerance of a liver and kidneys to a lack of oxygen is much higher, than other vitals.
Experimental and the wedge, researches demonstrate that during the first hours the postresuscitatic period considerable disturbances of blood circulation and stagnation of blood in portal system, disorders of microcirculation and shunting of a blood-groove in kidneys are noted. At the same time protein synthesis and a bile production in a liver decrease, secretory function of kidneys is broken (see. Gepatorenalny syndrome ). By means of histologic and histochemical methods in a liver decrease of the activity of oxidation-reduction enzymes, diffusion and focal proteinaceous and fatty dystrophy, and also a necrobiosis of separate hepatocytes come to light. The vein thrombosis of portal system and extensive necroses of a liver meet seldom. Dystrophic changes of a liver in process of recovery of a hemodynamics within the first month are exposed to involution. By this time functional indicators of a liver are normalized.
Morfol. changes of kidneys consist of the circulatory disturbances inherent to the terminal period which is quite often proceeding, as we know, in the form of shock reaction. In the early postresuscitatic period of a circulatory disturbance are supported by weakness of sokratitelny function of a myocardium therefore dystrophic changes a nefroteliya can go deep even more. However in most cases these changes are reversible. The widespread necrotic nephrosis which is coming to an end with an acute renal failure develops seldom. The similar outcome, apparently, is possible only at far come forms of background diseases of kidneys — nephrosclerosis (see), chronic pyelonephritis (see), hydronephrosis (see), etc.
Acute renal (hepatonephric) failure in the postresuscitatic period arises only in case of influence of accessory disturbing factors, napr, clinically hidden hemotransfusionic conflict. But more often such factors are a heavy myolysis and myoglobinuria (see), the trunks caused by an extensive necrosis of muscles and extremities.
The post-anoxic gastroenteropathy is rather rare complication of the postresuscitatic period. Acute erosion and stomach ulcers and a duodenum are described, to-rye can be followed gastrointestinal bleeding (see) and perforation (see). Owing to disorders of microcirculation development of focal necroses of a small bowel with perforation and purulent peritonitis is possible (see). These complications clinically, as a rule, are not diagnosed since arise against the background of a heavy current of the postresuscitatic period caused by damage of other vitals. For the same reasons the necrosis of a small bowel with the perforation which happened several hours prior to cardiac death usually has no independent value in a thanatogenesis.
Post-anoxic endocrinopathy. During the first period of a terminal state of any etiology there is a compensatory simpatoadrenergichesky reaction caused by sharp activation in the conditions of a hypoxia of system a hypothalamus — a hypophysis — bark of adrenal glands. Function and other hemadens, napr, thyroid amplifies. At the same time function of hemadens in the recovery period is characterized by disharmony owing to disturbance or full loss of the central mechanisms of neyroendo-krrshny regulation that in the most expressed form is peculiar to a condition of post-anoxic encephalopathy.
The excessive functional load on adrenal glands on condition of their insufficient blood supply leads to considerable exhaustion of cortical substance that demands medicamentous correction of glucocorticoid insufficiency.
The prevention of complications of resuscitation is one of urgent tasks modern resuscitation (see). Further improvement is demanded by a method of an indirect cardiac massage, about the Crimea the majority of injuries of a thorax, and also bodies of chest and belly cavities is connected. Elimination of the not traumatic complications arising at resuscitation connected with transfusion therapy, parenteral food, methods of a detoxication of an organism, etc. requires further improvement of control methods of biochemical parameters of a homeostasis and the volume of the circulating blood.
The specialization of resuscitation actions which is carried out in a crust, time and creation on this basis in corresponding is intended to serve the prevention of development of the complications arising at resuscitation to lay down. institutions of specialized reanimatologichesky departments, napr, cardiological, nephrological, neurologic, etc. (see. Intensive care unit ).
However the possibility of development of complications does not belittle value of the resuscitation measures more and more widely applied in connection with improvement of knowledge of terminal states and also receptions and technical means of fight against them. Timely and skillfully carried out they serve as the only measure of rescue of life in appropriate cases that defines a special role of the prevention of resuscitation pathology.
See also Resuscitation .
Bibliography: B. D. mosquitoes, L at - N and to about in E. A. and Sh and I. I semolina. Surgical methods of treatment of acute poisonings, M., 1981; Luzhniki E. A., D and and e in V. N. and F and r with about in N. N. Fundamentals of resuscitation at acute poisonings, M., 1977; It in with to and y V. A. Urgent problems of resuscitation, M., 1971; N. K. Residents of Perm. Bases of resuscitation pathology. M, 1979, bibliogr.; N. K. residents of Perm and to 3 them and on L. N. Acute renal failure, M., 1982.
N. K. Permyakov.