Clinical manifestations

First aid

With a neareetative form of chisosis, the sequence of actions:

1) to introduce 4-6 ml of 1% furosemide solution intravenously;

2) introduce 6-8 ml of 0.5% solution of dibazole dissolved in 10-20 ml of 5% glucose solution or 0.9% sodium chloride solution, intravenously;

3) introduce 1 ml of 0.01% clofelin solution in the same dilution intravenously;

4) introduce 1-2 ml of 0.25% droperidol solution in the same dilution intravenously.

With water-salt (empty) form of chisosis:

1) enter 2-6 ml of 1% furosemide solution intravenously once;

2) to introduce 10-20 ml of a 25% magnesium solution of sulfate intravenously.

With convulsive form of chisosis:

1) introduce intravenously 2-6 ml of 0.5% diazepam solution divorced in 10 ml of 5% glucose solution or 0.9% sodium chloride solution;

2) hypotensive drugs and diuretics - according to the testimony.

With a crisis associated with a sudden cancellation (termination of admission) of hypotensive drugs: to introduce 1 ml of 0.01% clofelin solution, divorced in 10-20 ml of a 5% glucose solution or a 0.9% sodium solution of chloride.

Notes

1. To enter drugs should be sequentially, under the control of blood pressure;

2. In the absence of a hypotensive effect for 20-30 minutes, the presence of an acute violation of cerebral circulation, cardiac asthma, angina is required hospitalization into a multidisciplinary hospital.

Angina

Clinical manifestationss - m. Nursing in therapy.

First aid

1) stop physical load;

2) to put a patient with a support on the back and with lowered legs;

3) under the tongue to give it a nitroglycerin or validol tablet. If the heartache does not stop, repeat the reception of nitroglycerin every 5 minutes (2-3 times). If the improvement has not come, call a doctor. Before it arrives to go to the next stage;

4) in the absence of nitroglycerin, it is possible to give under the patient with 1 tablet of nifedipine (10 mg) or Molidomin (2 mg);

5) give a drink aspirin tablet (325 or 500 mg);

6) Suggest a patient to drink with small sips hot water or put a mustarder on the heart;

7) In the absence of the effect of therapy, the hospitalization of the patient is shown.

Myocardial infarction

Clinical manifestations - See the nursing case in therapy.

First aid

1) to put or sit down the patient, unbutton the belt and collar, provide fresh air access, full physical and emotional peace;

2) with systolic blood pressure at least 100 mm Hg. Art. and heart rate greater than 50 in 1 min give a nitroglycerin tablet under the interval of 5 minutes. (but not more than 3 times);

3) give a drink of aspirin tablet (325 or 500 mg);

4) to give a tablet of propranolol 10-40 mg under the tongue;

5) introduce intramuscularly: 1 ml of 2% propellane solution + 2 ml of 50% analgin solution + 1 ml of 2% diploma solution + 0.5 ml of 1% sulfate atropine solution;

6) with systolic blood pressure less than 100 mm Hg. Art. It is necessary to intravenously to introduce 60 mg of prednisolone in dilution with 10 ml of saline;

7) introduce heparin 20,000 units intravenously, and then - 5000 units subcutaneously into the zone around the navel;

8) Transport the patient to the hospital follows the position lying on the stretcher.

Pulmonary edema

Clinical manifestations

It is necessary to differentiate swelling of the lungs from cardiac asthma.

1. Clinical manifestations of cardiac asthma:

1) frequent surface breathing;

2) exhalation is not difficult;

3) the position of orthopne

4) with auscultation dry or whistling wheels.

2. Clinical manifestations of alveolar edema of the lungs:

1) choking, bubbling;

2) orthopne

3) pallor, skin sinusiness, humidity of skin;

4) tachycardia;

5) Isolation of a large number of foamy, sometimes colored sputums.

First aid

1) Give a sideling position, impose harnesses or cuffs from a tonometer to the lower limbs. Reassure the patient to ensure fresh air;

2) introduce 1 ml of the 1% mortar solution of hydrochloride dissolved in 1 ml of physiological solution or in 5 ml of 10% glucose solution;

3) give nitroglycerin at 0.5 mg under the tongue every 15-20 minutes. (up to 3 times);

4) under the control of blood pressure to introduce 40-80 mg of furosemide intravenously;

5) with high blood pressure introduce intravenous 1-2 ml of a 5% pentamine solution dissolved in 20 ml of physiological solution, 3-5 ml with an interval of 5 minutes; 1 ml of 0.01% clofelin solution dissolved in 20 ml of saline;

6) to establish oxygen therapy - inhalation of hydrated oxygen with a mask or nasal catheter;

7) make the inhalation of oxygen, moistened with 33% ethyl alcohol, or introduce 2 ml of 33% solution ethyl alcohol intravenously;

8) to introduce 60-90 mg of prednisolone intravenously;

9) in the absence of the effect of therapy, the growth of pulmonary edema, the adhesive adhesion is shown artificial ventilation of the lungs;

10) hospitalize the patient.

Syncoon may occur during a long stay in the stuffy room due to lack of oxygen, if there is a tight, shining the breath of clothing (corset) in a healthy person. Repeating fainting are a reason for a visit to the doctor in order to exclude serious pathology.

Fainting

Clinical manifestations

1. Short-term loss of consciousness (10-30 p.).

2. In history, there are no indications of diseases of cardiovascular, respiratory systems, gastrointestinal tract, not an obstetric and gynecological history.

First aid

1) give the body with a sick horizontal position (without a pillow) with a bit raised legs;

2) unbutton the belt, collar, buttons;

3) spray face and chest with cold water;

4) to lose the body with dry hands - hands, legs, face;

5) give the patient to breathe a pair of ammonia alcohol;

6) intramuscularly or subcutaneously introduce 1 ml of a 10% caffeine solution, intramuscularly 1-2 ml of a 25% solution of Cordiamine.

Bronchial asthma (attack)

Clinical manifestations - See the nursing case in therapy.

First aid

1) put a patient, help take a comfortable position, unbutton collar, belt, provide emotional peace, fresh air access;

2) distracting therapy in the form of a hot foot bath (water temperature at the level of individual tolerance);

3) introduce 10 ml of 2.4% solution of euphilline and 1-2 ml of 1% diploma solution (2 ml of 2.5% solution of the promethazine or 1 ml of 2% chloropiramine solution) intravenously;

4) to carry out inhalation by aerosol of broncholists;

5) with hormone-dependent form bronchial asthma And information from the patient about the violation of the hormone therapy rate to introduce prednisolone in the dose and with the method of administration corresponding to the main course of treatment.

Astmatic status

Clinical manifestations - See the nursing case in therapy.

First aid

1) calm the patient, help take a convenient position, provide fresh air access;

2) oxygen therapy with a mixture of oxygen with atmospheric air;

3) when stopping the breath - IVL;

4) introduce refooliglukin intravenously drip in the volume of 1000 ml;

5) introduce 10-15 ml of 2.4% solution of euphilline intravenously during the first 5-7 minutes, then 3-5 ml of 2.4% solution of EUFILIN intravenously drip in an infusion solution or 10 ml of 2.4 % Euphillin solution every hour in a dropper tube;

6) introduce 90 mg of prednisone or 250 mg of hydrocortisone intravenously;

7) introduce heparin to 10,000 units intravenously.

Notes

1. Receiving sedative, antihistamine, diuretic products, calcium and sodium preparations (including saline) contraindicated!

2. Multiple consistent use of bronchoditics is dangerous due to the possibility of fatal outcome.

Lonantic bleeding

Clinical manifestations

Isolation of bright scarlet blood blood from mouth during coughing or practically without coughing jolts.

First aid

1) calm the patient, help him take a half-time position (to relieve an expectoration), prohibit getting up, talking, call a doctor;

2) to the chest put a bubble with ice or cold compress;

3) to give a patient to drink cold liquid: a solution of a cooking salt (1 tbsp. L salt on a glass of water), decoction of nettle;

4) to carry out hemostatic therapy: 1-2 ml of 12.5% \u200b\u200bdicinone solution intramuscularly or intravenously, 10 ml of 1% calcium solution intravenously, 100 ml of 5% solution of aminocaproic acid intravenously drip, 1-2 ml 1 % Vikasol solution intramuscularly.

In case of difficulty determining the type of coma (hypo-or hyperglycemic), the first help is beginning with the introduction of a concentrated solution of glucose. If a coma is connected with hypoglycemia, then the victim begins to recover, skin covers pink. If there is no response, then the coma is most likely hyperglycemic. At the same time, clinical data should be taken into account.

Hyogolcemic Coma

Clinical manifestations

2. Dynamics of the development of a comatose state:

1) feeling of hunger without thirst;

2) anxious concern;

3) headache;

4) increased sweating;

5) excitement;

6) overweight;

7) loss of consciousness;

8) cramps.

3. No symptoms of hyperglycemia (dry skin and mucous membranes, reduction of the leather turgora, the softness of eyeballs, the smell of acetone from the mouth).

4. The rapid positive effect of intravenous administration of a 40% glucose solution.

First aid

1) enter intravenously inkjet 40-60 ml of 40% glucose solution;

2) In the absence of effect, re-introduce 40 ml of a 40% glucose solution intravenously, as well as 10 ml of a 10% calcium solution of chloride intravenously, 0.5-1 ml of 0.1% solution of adrenaline hydrochloride subcutaneously (in the absence of contraindications );

3) when improving well-being, give sweet drinks with bread (to prevent recurrence);

4) Patients are subject to hospitalization:

a) with the first arising hypoglycemic state;

b) in the event of hypoglycemia in a public place;

c) with the ineffectiveness of emergence of emergency medical care.

Depending on the state, hospitalization is carried out on stretchers or on foot.

Hyperglycemic (diabetic) coma

Clinical manifestations

1. Sugar diabetes a history.

2. The development of a comatose state:

1) lethargy, extreme fatigue;

2) loss of appetite;

3) indomitable vomiting;

4) dry skin;

6) frequent abundant urination;

7) decreased blood pressure, tachycardia, heart pain;

8) Adamina, drowsiness;

9) Sportor, coma.

3. Dry skin, cold, dry lips, cracked.

4. Raspberry language with a dirty gray raid.

5. The smell of acetone in exhaled air.

6. Sharply reduced tone of eyeballs (soft to the touch).

First aid

Sequencing:

1) to rehydrate with a 0.9% sodium solution of chloride intravenously drip at a rate of administration 200 ml in 15 minutes. under the control of the level of blood pressure and independent respiration (the brain swelling is possible with too fast rehydration);

2) Emergency hospitalization in the resuscitation department of a multidisciplinary hospital, bypassing the reception office. Hospitalization is carried out on stretchers, lying.

Acute belly

Clinical manifestations

1. Pain in the stomach, nausea, vomiting, dry mouth.

2. Painting with palpation of the front abdominal wall.

3. Symptoms of irritation of peritoneum.

4. Language is dry, covered.

5. Subfebrile, hyperthermia.

First aid

Actually deliver a patient into a surgical hospital on stretchers, in a convenient position for it. Anesthesia, water and food intake are prohibited!

Acute belly and similar states may occur with a variety of pathology: diseases digestive system, gynecological, infectious pathologies. The main principle of first aid in these cases: cold, hunger and peace.

Gastrointestinal bleeding

Clinical manifestations

1. The pallor of the skin, mucousse.

2. Vomiting with blood or "coffee grounding".

3. Black tar eyed chair or volatile blood (with bleeding from the rectum or rear pass).

4. Soft belly. There may be soreness when palpation in the epigastric area. Abdominal irritation symptoms are missing, wet language.

5. Tachycardia, hypotension.

6. In anamnesis - ulcerative disease, oncological disease gasts, liver cirrhosis.

First aid

1) give the patient there are ice with small pieces;

2) with a deterioration of hemodynamics, tachycardia and decreased blood pressure - polyglyukine (REOPOLIGLUKIN) intravenously before stabilizing systolic blood pressure at 100-110 mm Hg. Art.;

3) introduce 60-120 mg of prednisone (125-250 mg of hydrocortisone) - add to infusion solution;

4) introduce up to 5 ml of 0.5% dopamine solution intravenously drip in an infusion solution at a critical drop of blood pressure, not amenable to correction of infusion therapy;

5) cardiac glycosides according to indications;

6) Emergency delivery to a surgical hospital lying on a stretcher with a lowered head end.

Renal colic

Clinical manifestations

1. Top-like pains in the lower back one or two-sided, irradiate in groin, scrotum, sexual lip, the front or inner surface of the hip.

2. Nausea, vomiting, bloating with a stool delay and gases.

3. Dysuric disorders.

4. Motor anxiety, the patient is looking for a posture at which pain will be reduced or will cease.

5. The stomach is soft, slightly painful in the course of the ureters or painless.

6. Pickup sickness sickness painfully, peritonean irritation symptoms Negative, wet language.

7. Renal disease in history.

First aid

1) to introduce 2-5 ml of the 50% analgin solution intramuscularly or 1 ml of 0.1% solution of atropine sulfate subcutaneously, or 1 ml of 0.2% solution of hydrotathe platoofillin subcutaneously;

2) to put a hot heater or (in the absence of contraindications) to put the patient in the hot bath. Do not leave it alone, control overall well-being, pulse, chdd, blood pressure, color of skin;

3) Hospitalization: with the first appearance for the first time, with hyperthermia, the unsuccessful binding of the attack at home, with a re-attack during the day.

Renal colic is a complication of a urolithiasis that occurred during metabolic disorders. The cause of the painful attack is the displacement of the stone and its hit in the ureters.

Anaphylactic shock

Clinical manifestations

1. The connection of the state with the introduction of the drug, vaccine, a reception of specific food, etc.

2. Feeling fear of death.

3. Feeling of lack of air, stubborn pain, dizziness, noise in the ears.

4. Nausea, vomiting.

5. Causes.

6. Sharp pallor, cold sticky sweat, urticaria, swelling of soft tissues.

7. Tachycardia, threaded pulse, arrhythmia.

8. Sharp hypotension, diastolic blood pressure is not determined.

9. Comath state.

First aid

Sequencing:

1) with a shock caused by the introduction of intravenously drug-allergen, the needle is left in Vienna and use it for emergency anti-shock therapy;

2) immediately stop the introduction medicinal substancewhich caused the development of anaphylactic shock;

3) Give a patient a functionally advantageous position: limbs raise at an angle of 15 °. Rotate the head, with the loss of consciousness to put forward low jaw, remove dental prostheses;

4) to carry out oxygen therapy with 100% oxygen;

5) introduce intravenously 1 ml of 0.1% solution of the adrenaline hydrochloride, divorced in 10 ml of 0.9% sodium chloride solution; the same dose of adrenaline hydrochloride (but without dilution) can be administered under the root of the language;

6) Polyglyukin or other infusion solution to begin to introduce inkid after stabilization of systolic blood pressure per 100 mm Hg. Art. - continue the infusion therapy drip;

7) introduce 90-120 mg of prednisone (125-250 mg of hydrocortisone) into the infusion system;

8) introduce 10 ml of a 10% calcium solution chloride into an infusion system;

9) in the absence of an effect from the treatment carried out, repeat the administration of hydrochloride adrenaline or introduce 1-2 ml of 1% mesaton solution intravenously inkjet;

10) at bronchospasm to introduce 10 ml of a 2.4% solution of euphilline intravenously;

11) during laryingospasm and asphyxia - conicotomy;

12) If the allergen was introduced intramuscularly or subcutaneously or an anaphylactic reaction arose in response to the insect bite, it is necessary to comply with the place of injection or bite 1 ml of 0.1% solution of adrenaline hydrochloride, diluted in 10 ml of 0.9% sodium chloride solution ;

13) If Allergen entered the body orally, it is necessary to rinse the stomach (if the patient's condition allows);

14) under convulsive syndrome introduce 4-6 ml of 0.5% diazepam solution;

15) for clinical death Conduct cardiovascular resuscitation.

In each procedural office, it must be in stock a first-aid kit to provide first aid for anaphylactic shock. The most often anaphylactic shock is developing during or after the introduction of biological preparations, vitamins.

Sweet Qincke

Clinical manifestations

1. Communication with an allergen.

2. Itchy rash at different parts of the body.

3. The edema of the rear of the brushes, stop, tongue, nasal moves, oroglotka.

4. Wildness and cianoz face and neck.

6. Mental excitement, motor anxiety.

First aid

Sequencing:

1) stop introducing allergen to the body;

2) introduce 2 ml of a 2.5% solution of the promethazine, or 2 ml of a 2% solution of chloropyramine, or 2 ml of a 1% solution of DIMEDROL intramuscularly or intravenously;

3) to introduce 60-90 mg of prednisolone intravenously;

4) to introduce 0.3-0.5 ml of a 0.1% solution of adrenaline hydrochloride subcutaneously or, dilute the preparation in 10 ml of a 0.9% sodium solution of chloride, intravenously;

5) to carry out inhalation with bronchoditics (phenoterol);

6) be ready for conforming;

7) hospitalize the patient.

Algorithms for the provision of first medical care during urgent states

FAINTING
Fainting - a fit of a short-term loss of consciousness due to the transient brain ischemia associated with the weakening of cardiac activity and the acute violation of the regulation vascular tone. Depending on the severity of factors contributing to the violation of the cerebral circulation.
Allocate: brain, heart, reflex and hysterical types of trimming states.
Stages of faint development.
1. Harppinger (before snowstanding condition). Clinical manifestations: discomfort, dizziness, noise in the ears, lack of air, the appearance of cold sweat, numbness of fingertips. It lasts from 5 seconds to 2 minutes.
2. Violation of consciousness (actual faint). Clinic: loss of consciousness lasting from 5 seconds to 1 minute, accompanied by pallhery, reduced muscle tone, expansion of pupils, weak response to light. Surface breathing, bradypognoe. Pulse labile, more often bradycardia to 40 - 50 per minute, systolic blood pressure decreases to 50 - 60 mm. RT. Art. With deep fainting, convulsions are possible.
3. Post-clean (recovery) period. Clinic: It is properly oriented in space and time, a pallor, rapid breathing, labile pulse and low blood pressure can be maintained.

2. Unbutton collar.
3. Provide fresh air access.
4. Wipe the face with a wet cloth or irrigating cold water.
5. Inhalation of the vapor of ammonium alcohol (reflex stimulation of respiratory and vessels).
With the ineffectiveness of the listed events:
6. Caffeine 2.0 V / V or V / m.
7. Cordiamine 2.0 V / m.
8. Atropine (in bradycardia) 0.1% - 0.5 p / k.
9. When leaving a fainting condition, continue dental manipulations with the adoption of measures to prophylaxize relapse: treatment is carried out with a horizontal position of a patient with adequate premedication and with sufficient anesthesia.

COLLAPSE
Collapse is a severe form of vascular failure (reduction of the vascular tone), manifested by a decrease in blood pressure, the expansion of venous vessels, a decrease in the volume of circulating blood and the accumulation of it in the blood depot - liver capillary, spleen.
Clinical picture: a sharp deterioration in the overall state, the pronounced pallor of the skin, dizziness, chills, cold sweat, sharp decrease in blood pressure, frequent and weak pulse, frequent, surface breathing. Peripheral veins are inserted, the walls are falling down, which makes it difficult to perform venopunction. Patients retain consciousness (with fainting patients lose consciousness), but indifferent to what is happening. Collapse can be a symptom of such severe pathological processes as myocardial infarction, anaphylactic shock, bleeding.

Algorithm of therapeutic events
1. Patient give a horizontal position.
2. Ensure the influx of fresh air.
3. Prednisolone 60-90 mg in / c.
4. Norainerenaline 0.2% - 1 ml of V / B by 0.89% solution of sodium chloride.
5. Meston 1% - 1 ml in / in (to increase the venous tone).
6. Corglukol 0.06% - 1.0 V / in slowly 0.89% sodium chloride solution.
7. Polyglyukine 400.0 V / in a drip, 5% glucose solution in / in drip 500.0.

HYPERTENSIVE CRISIS
Hypertensive crisis is a sudden rapid increase in blood pressure, accompanied by clinical symptoms from the organs of targets (more often than brain, retina, heart, kidneys, gastrointestinal tract, etc.).
Clinical picture. Sharp headaches, dizziness, ears, often accompanied by nausea and vomiting. Violation of sight (grid or fog before eyes). The patient is excited. At the same time, there is a trembling of hands, sweating, sharp redness of the skin of the face. Pulse is tense, blood pressure is increased by 60-80 mm.rt.st. Compared to normal. During the crime, angina attacks may occur, an acute violation of cerebral circulation.

Algorithm of therapeutic events
1. Intravenously in one syringe: Dibazole 1% - 4.0 ml with papaverine 1% - 2.0 ml (slow).
2. With a serious flow: Clofelin 75 μg under the tongue.
3. Intravenously laziks 1% - 4.0 ml on a physiological solution.
4. Anaprilin 20 mg (with pronounced tachycardia) under the tongue.
5. Sedatives - Elenium inside 1-2 tablets.
6. Hospitalization.

It is necessary to constantly monitor blood pressure!

ANAPHYLACTIC SHOCK
Typical form of medicinal anaphylactic shock (LASH).
The patient is acute a state of discomfort with uncertain sensations. There is a fear of death or a state of internal anxiety. There is nausea, sometimes vomiting, cough. Patients complain of harsh weakness, feeling of tingling and itching the skin of the face, hands, head; Feeling of blood tide to the head, face, feeling of chest or gravity chest; The appearance of pain in the field of the heart, the difficulty of breathing or the inability to do exhale, for dizziness or headache. The disorder of consciousness occurs in the terminal phase of shock and is accompanied by violations of speech contact with patients. Complaints arise immediately after receiving a drug.
Clinical picture of LASH: hyperemia of skin or pallor and cyanosis, edema of the face, abundant sweating. Breathing noisy, tachipne. Most patients develop motor anxiety. Midship is noted, the reaction of pupils into light is weakened. Pulse frequent, sharply loosened on peripheral arteries. Hell decreases quickly, in severe cases, diastolic pressure is not determined. A shortness of breath appears, difficulty breathing. Subsequently, the clinical picture of the pulmonary edema is developing.
Depending on the severity of the flow and time of the development of symptoms (from the moment of the introduction of the antigen), the lightning (1-2 minutes) is distinguished, heavy (after 5-7 minutes), moderate severity (up to 30 minutes) shape of the shock. The shorter time from the administration of the drug to the occurrence of the clinic, the hardest shock flows, and the less chances for the prosperous outcome of treatment.

Algorithm of therapeutic events
Urgently provide access to Vienna.
1. Stop the introduction of the medicine that caused anaphylactic shock. Call an "on yourself" by the ambulance brigade.
2. Put the patient, lift the lower limbs. If the patient is unconscious, turn your head on the side, push the lower jaw. Inhalation of hydrated oxygen. Lung ventilation.
3. Intravenously introduce 0.5 ml of 0.1% adrenaline solution in 5 ml of isotonic sodium chloride solution. With the difficulty of venopunction, adrenaline is injected into the root of the tongue, perhaps intraterably (puncture of the trachea below the thyroid cartilage through a conical ligament).
4. Prednisolone 90-120 mg V / c.
5. Dimedrol solution 2% - 2.0 or Supratine solution 2% - 2.0, or a solution of diprage 2.5% - 2.0 V / c.
6. Cardiac glycosides according to the testimony.
7. When obstruction of the respiratory tract - oxygen therapy, 2.4% EUFILIN solution of 10 ml in / in fiz.
8. If necessary, endotracheal intubation.
9. Hospitalization of the patient. Identification of allergies.

Toxic reactions to anesthetics

Clinical picture. Anxiety, tachycardia, dizziness and weakness. Cyanosis, muscle tremor, chills, convulsions. Nausea, sometimes vomiting. Respiratory disorder, decreased blood pressure, collapse.

Algorithm of therapeutic events
1. Give a sick horizontal position.
2. Fresh air. Give breathe a couple of ammonia alcohol.
3. Caffeine 2 ml p / k.
4. Cordiamine 2 ml n / k.
5. In the oppression of breathing - oxygen, artificial respiration (according to indications).
6. Adrenaline 0.1% - 1.0 ml on the physical in / c.
7. Prednisolone 60-90 mg V / c.
8. TAVEGIL, Supratin, Dimedrol.
9. Cardiac glycosides (according to indications).

Stenokard attack

Stenokard attack - Paroxism of pain or other unpleasant sensations (heaviness, compression, pressure, burning) in the heart area duration from 2-5 to 30 minutes with characteristic irradiation (in the left shoulder, neck, left blade, lower jaw) caused by the excess of myocardium intake In oxygen over its admission.
Provoking the attack of the angina increase arterial pressure, psycho-emotional tension, which always takes place before and during the treatment of a dentist's doctor.

Algorithm of therapeutic events
1. Termination of dental intervention, peace, fresh air access, free breathing.
2. Nitroglycerin in tablets or capsules (capsule to greet) 0.5 mg under the tongue every 5-10 minutes (only 3 mg under the control of AD).
3. If the attack is stopped, the recommendations of the outpatient surveillance of the cardiologist. The resumption of dental benefits - to stabilize the state.
4. If the attack is not stopped: barallgan 5-10 ml or analgin 50% - 2 ml in / in or in / m.
5. In the absence of the effect - a challenge of ambulance and hospitalization team.

Acute myocardial infarction.

The acute myocardial infarction is the ischemic necrosis of the heart muscle, resulting from an acute inconsistency between the need of a portion of myocardium in oxygen and its delivery according to the relevant coronary artery.
Clinic. The most characteristic clinical symptom is pain that is more often localized in the region of the heart behind the sternum, less often captures the entire front surface of the chest. Irradiate B. left, shoulder, shovel, inter-documenny space. Pain is usually waveled: it is strengthened, it weakens, it continues from several hours to several days. Objectively marked the pallor of the skin, cyanosis lips, increased sweating, decreased blood pressure. Most patients have heart rhythm (tachycardia, extrasystole, cleaning arrhythmia).

Algorithm of therapeutic events

1. Urgent cessation of intervention, peace, fresh air access.
2. Call a cardiac ambulance brigade.
3. With systolic blood pressure; 100 mm.rt.st. Under 0.5 mg nitroglycerin in tablets every 10 minutes (total dose of 3 mg).
4. Mandatory relief of pain syndrome: Baralgin 5 ml or analgin 50% - 2 ml in / in or in / m.
5. Inhalation of oxygen through a mask.
6. Papaverin 2% - 2.0 ml in / m.
7. Eufillin 2.4% - 10 ml per nat. R-re / c.
8. Relanium or Seduksen 0.5% - 2 ml
9. Hospitalization.

Clinical death

Clinic. Loss of consciousness. No pulse and heart tones. Stop breathing. Pallor and sinusiness of the skin and mucous membranes, no bleeding from the operating wound (tooth hole). Expansion of pupils. The respiratory stop is usually preceded by a heart stop (in the absence of breathing, the pulse is preserved on carotid arteries and pupils are not expanded), which is taken into account when resuscitation.

Algorithm of therapeutic events
Resuscitation:
1. To put on the floor or couch, throw back the head, push the jaw.
2. Clean the respiratory tract.
3. Enter the air duct, carry out artificial ventilation of the lungs and the outer heart massage.
When resuscitation by one person in the ratio: 2 inhalation on 15 sander of the sternum ;;
When resuscitation together in the ratio: 1 breath on 5 soreness of the sternum.;
It takes into account that the frequency of artificial respiration is 12-18 per minute, and the frequency of artificial blood circulation is 80-100 per minute. Artificial ventilation of the lungs and the outer massage of the heart is carried out before the "resuscitation" arrival.
During resuscitation, all drugs are administered only intravenously, intracardular (adrenaline preferably - interphoneal). After 5-10 minutes of injection repeat.
1. Adrenaline 0.1% - 0.5 ml in breeding 5 ml. Phys. Enormous solution or glucose (preferable - inter-tech).
2. Lidocaine 2% - 5 ml (1 mg per kg of weight) V / B, intracardiac.
3. Prednisolone 120-150 mg (2-4 mg per kg of weight) V / B, intracardiac.
4. Sodium bicarbonate 4% - 200 ml in / c.
5. Ascorbic acid is 5% - 3-5 ml in / c.
6. Cold to the head.
7. Laziks according to the testimony of 40-80 mg (2-4 ampoules) in / c.
Resuscitation is carried out taking into account the available asistolis or fibrillation, for which the data of electrocardiography is necessary. When diagnosing fibrillation, a defibrillator is applied (if the latter is available), preferably prior to medication therapy.
In practice, all listed events are held simultaneously.

SUDDEN DEATH

Diagnostics. The absence of consciousness and pulse on carotid arteries, a little later - the cessation of breathing.

In the process of conducting the ECP, the ventricular fibrillation (in 80% of cases), asistolia or electromechanical dissociation (in 10-20% of cases). If it is impossible for emergency registration, ECG is focused on the manifestations of the beginning of clinical death and the response to the SLR.

The fibrillation of ventricles is developing suddenly, the symptoms appear consistently: the disappearance of the pulse on carotid arteries and the loss of consciousness of the one-time tonic reduction of skeletal muscles of the violations and the stop of breathing. The reaction to the timely survey is positive, the termination of the SLR is fast negative.

With a far-closed sa- or av-blockade, symptoms develop relatively gradually: acknowledgment of consciousness \u003d\u003e Motor excitation \u003d\u003e moan \u003d\u003e Tonic-clonic cramps \u003d\u003e respiratory disorders (MAS syndrome). When conducting a closed heart massage - a quick positive effect, which remains some time after the termination of the SLR.

Electromechanical dissociation with a massive TELE arises suddenly (often at the time of physical stress) and is manifested by the cessation of respiration, the absence of consciousness and pulse on carotid arteries, sharp cyanosis of the skin of the upper half of the body. swelling of the cervical veins. Upon timely early election, signs of its effectiveness are determined.

Electromechanical dissociation when the myocardial break, the Heart Tamponade is developing suddenly (often after severe anginal syndrome), without convulsive syndrome, there are no signs of the effectiveness of the SLR completely. On the back quickly appear hypostatic stains.

Electromechanical dissociation due to other reasons (hypovolemia, hypoxia, intense pneumothorax, overdose of drugs, increasing heart tamponade) does not occur suddenly, but develops against the background of the progression of the corresponding symptoms.

Urgent Care :

1. When fibrillation of ventricles and the impossibility of immediate defibrillation:

Apply a precondition shot: Cover the swordeephoid process with two fingers to protect it from damage. It is located at the bottom of the sternum, where the lower ribs converge, and maybe with a sharp impact break and injure the liver. Apply the edge of the palm slim into the fist a little higher with the fingers of the sword-shaped pericardial blow. It looks like this: two fingers of one hand are covering the Movie-shaped process, and put the other hand with a fist (at the same time elbow hands, directed along the injury body).

After that, check the pulse on the carotid artery. If the pulse does not appear, then your actions are not effective.

There is no effect - to immediately start the CLP, as soon as possible to ensure the possibility of defibrillation.

2. The closed heart massage is carried out with a frequency of 90 in 1 min with a compression ratio of decompression 1: 1: a method of active compression-decompression (using cardiopamp) is more efficient.

3. Walking in an affordable way (the ratio of massage movements and respiration is 5: 1. And when operating one doctor - 15: 2), ensure the passability of the respiratory tract (to throw off the head, pull out the lower jaw, introduce the air duct, by testimony - to sanitize the respiratory tract);

Use 100% oxygen:

Intubate the trachea (no more than 30 seconds);

Do not interrupt the heart massage and IVL more than 30 s.

4. Catheterize a central or peripheral vein.

5. Adrenaline for 1 mg every 3 min hold of the CPR (the method of administration here and continue - see Note).

6. As soon as possible - Defibrillation 200 J;

No effect - Defibrillation 300 J:

No Effect - Defibrillation 360 J:

No effect - see paragraph 7.

7. Act according to the scheme: the drug - Heart and IVL massage, after 30-60 C - Defibrillation 360 J:

Lidocaine 1.5 mg / kg - Defibrillation 360 J:

No effect - after 3 minutes, repeat the injection of lidocaine in the same dose and defibrillation of 360 J:

No effect - Ornid 5 mg / kg - Defibrillation 360 J;

No effect - after 5 minutes, repeat the injection of the ornide at a dose of 10 mg / kg - Defibrillation of 360 J;

No effect - Novocainamide 1 g (up to 17 mg / kg) - Defibrillation 360 J;

No effect - magnesium sulfate 2 g - Defibrillation 360 J;

In pauses between discharges to carry out a closed heart massage and IVL.

8. When asystolia:

If it is impossible to accurately assess the electrical activity of the heart (do not exclude the atonic stage of ventricular fibrillation) - to act. As with ventricular fibrillation (PP. 1-7);

If the asistolia is confirmed in two leaders of the ECG - execute PP. 2-5;

No effect - atropine after 3-5 minutes of 1 mg before obtaining the effect or achieve a total dose of 0.04 mg / kg;

Ex as early as possible;

Correction possible cause asistolia (hypoxia, hypo-or hypercalemia, acidosis, overdose of drugs, etc.);

The introduction of 240-480 mg of euphilline can be effective.

9. With electromechanical dissociation:

Perform PP. 2-5;

Install and adjust its possible cause (massive tel - see the relevant recommendations: Heart Tamponade - Perica-Diocentsis).

10. Monitor vital functions (cardiomonitor. Pul Coximeter).

11. Hospitalize after possible status stabilization.

12. The SLR can be discontinued if:

In the course of carrying out, it turned out that the SLR is not shown:

There is a resistant asystoly, non-drugic effects, or repeated asistolis episodes:

When using all available methods, there are no signs of the effectiveness of the CPR for 30 minutes.

13. The SLR can not start:

In the terminal stage of the incurable disease (if the expectancy of the CPR is documented in advance);

If more than 30 minutes have passed since the cessation of blood circulation;

With a previously documented failure of the patient from the CL.

After defibrillation: ashistolia, continuing or recurrent ventricular fibrillation, skin burns;

With IVL: air stomach overflow, regurgitation, aspiration of gastric content;

In the intubation of the trachea: laryngo- and bronchospasm, regurg Гетити, damage to the mucous membranes, teeth, esophagus;

With a closed massage of the heart: a fracture of breasts, ribs, lung damage, intense pneumothorax;

When puncture of a subclavian vein: bleeding, puncture of a subclavian artery, lymphatic duct, an air embolism, intense pneumothorax:

With intracardiac injection: the introduction of drugs into myocardium, damage coronary arteries, hemotamponada, wounded lung, pneumothorax;

Respiratory and metabolic acidosis;

Hypoxic coma.

Note. With ventricular fibrillation and the possibility of introducing immediate (within 30 seconds) defibrillation - Defibrillation 200 J, further act according to PP. 6 and 7.

All drugs during the election introduce intravenously quickly.

When using peripheral veins, drugs are mixed with 20 ml of isotonic sodium chloride solution.

With absence venous access Adrenaline, Atropine, Lidocaine (increasing the recommended dose 2 times) to enter into a trachea in 10 ml of isotonic sodium sodium solution.

Intricultural injections (thin needle, with strict compliance with the technique of administration and control) are permissible in the well-minded cases, with absolute inability to use other ways to administer drugs.

Sodium bicarbonate 1 mmol / kg (4% solution - 2 ml / kg), then 0.5 mmol / kg each 5-10 min. It is used to apply with a very long election or at the cessation of blood circulation of hypercalemia, acidosis, overdose of tricyclic antidepressants, hypoxic lactoacidosis ( Is-faithfully in the conditions of adequate IVL1).

Calcium preparations are shown only with severe initial hypercalemia or an overdose of calcium antagonists.

With resistant to the treatment of ventricular fibrillation, drug reserves - amiodarone and propranolol.

When asystolia or electromechanical dissociation after the intubation of the trachea and administration of drugs, if the reason cannot be eliminated, to solve the issue of termination of resuscitation measures, taking into account the time spent on the start of the circulatory stop.

Emergency cardiac states Tahiaritimia

Diagnostics. Pronounced tachycardia, tahiaritium.

Differential diagnosis - ECG. Non-paroxysmal and paroxysmal tachycardia should be distinguished: tachycardia with a normal duration of the OK8 complex (tachycardia, flickering and fluttering) and tachycardia with a wide range of 9k8 on ECG (supertoday tachycardia, flickering, atrial fluttering with a transient or constant blockade P1A beam legs: antidrome tachycardia ; atrial flicker with syndrome ^ p \\ y; ventricular tachycardia).

Urgent Care

Emergency recovery of sinus rhythm or CHEG correction is shown in tachyarhyrahythmias complicated by an acute circulatory impairment, in the threat of cessation of blood circulation or with repeated paroxysms of tachiartimia with a known suppression method. In other cases it is necessary to ensure intensive observation and planned treatment (emergency hospitalization).

1. When the blood circulation is discontinued - the SLR on the recommendations of the "sudden death".

2. Shock or pulmonary swelling (caused by tachiaritium) are absolute life testimony to the Eit:

Carry out oxygen therapy;

If the patient's condition allows, to carry out premedication (hairdryer 0.05 mg, or promidal 10 mg intravenously);

Introduce into drug sleep (diazepam 5 mg intravenously and 2 mg every 1-2 minutes to fall asleep);

Carding heart rate:

Conduct an EIT (with the atrodium fluttering, navel idle tachycardia to start with 50 J; when the atrium is flickering, the monomorphic gastric tachycardia - from 100 J; when polymorphic ventricular tachycardia - with 200 J):

If the patient's condition is allowed to synchronize the electrical pulse with an EIT with a token to another

Use good moistened gaskets or gel;

At the time of applying the discharge with force to press electrodes to the chest wall:

Apply a discharge at the time of the patient's exhalation;

Comply with safety regulations;

No effect - repeat the Eit, doublening the discharge energy:

There is no effect - repeat the email by the discharge of maximum energy;

There is no effect - to introduce an antiarrhythmic drug, shown in this arrhythmia (see below), and repeat the detection of maximum energy.

3. With a clinically significant circulatory impairment (arterial hypotension. Angic pain, increasing heart failure or neurological symptoms) either during recurrence of arrhythmias with a known method of suppression - carry out urgent drug therapy. In the absence of effect, deterioration of the state (and in the following cases - and as an alternative medical treatment) - Eit (p. 2).

3.1. With paroxysm reciprocal religion tachycardia:

Massage of carotid sinus (or other vagazines we);

No effect - Introduce ATP 10 mg intravenously by the impetus:

No effect - after 2 min ATP 20 mg intravenously shock:

No effect - after 2 min Verapamil 2.5-5 mg intravenously:

No effect - after 15 min, verapamil 5-10 mg intravenously;

A combination of ATP or verapamil with vagus receptions can be effective:

No effect - after 20 minutes, Novocainamide 1000 mg (up to 17 mg / kg) intravenously at a speed of 50-100 mg / min (with a trend towards arterial hypo-tenment - in one syringe with 0.25-0.5 ml of 1% mesaton solution or 0.1-0.2 ml of a 0.2% solution of norepinephrine).

3.2. With paroxysm atrial flickering to restore sinus rhythm:

Novocainamide (p. 3.1);

With high source CSH: first, intravenously 0.25-0.5 mg of digoxin (stroofine) and after 30 minutes - 1000 mg of Novocainamide. To reduce the CSG:

Digoxin (Stroofantine) 0.25-0.5 mg, or verapamil 10 mg intravenously slowly or 80 mg inside or digoxin (stroofantine) intravenously and verapamil inside or anaprilin 20-40 mg under the tongue or inside.

3.3. With paroxysm atrial trembles:

If the EIT is impossible - the decrease in the CSG with the help of digoxin (stanfantine) and (or) verapamila (clause 3.2);

To restore the sinus rhythm, new-canemita may be effective after the preliminary administration of 0.5 mg of digoxin (stanfantine).

3.4. With paroxysm atrial flickering against the background of IPU syndrome:

Intravenously slowly novocainamide 1000 mg (up to 17 mg / kg), or AMI-Odrons 300 mg (up to 5 mg / kg). or rhythmilene 150 mg. or AIMALIN 50 mg: either an EIT;

Heart glycosides. Blockers of P-adrenoreceptors, calcium antagonists (verapamil, diltcase) are contraindicated!

3.5. With paroxysm antidrometreciproknyav-tachycardia:

Intravenously slowly novocainamide, or amiodarone, or aimalin, or rhythmilene (p. 3.4).

3.6. In case of takiaricpmia on the background of the smbudscence of the decline in CSG:

Intravenously slowly 0.25 mg of digoxin (Tina Stroofan).

3.7. With ventricular tachycardia paroxysm:

Lidocaine 80-120 mg (1-1.5 mg / kg) and every 5 min to 40-60 mg (0.5-0.75 mg / kg) intravenously slowly to the effect or achieve a total dose of 3 mg / kg:

No effect - EIT (p. 2). or Novocainamide. either amiodarone (p. 3.4);

No effect - Eit or magnesium sulfate 2 g intravenously very slowly:

No effect - an orinide of 5 mg / kg intravenous (for 5 minutes);

There is no effect - an in either after 10 minutes ornid 10 mg / kg intravenously (within 10 minutes).

3.8. With bidirectional spindle-shaped tachycardia.

Eit either intravenously slowly introduce 2 g of sulfate magnesium (with magnesium, sulfate is administered repeated after 10 minutes).

3.9. In the paroxysm of tachycardia of unclear genes with wide complexes 9K5 per ECG (if there is no reading to the EIT) to introduce intravenously lidocaine (clause 3.7). There is no effect - ATP (p. 3.1) or an EIT, there is no effect - Novocainamide (p. 3.4) or an EIT (p. 2).

4. In all cases of acute heart rate disorders (except for repeated paroxysis with restored sinus rhythm), emergency hospitalization is shown.

5. Constantly control cardiac rhythm and conductivity.

Termination of blood circulation (ventricular fibrillation, asistolia);

Mas syndrome;

Acute heart failure (pulmonary edema, arrhythmic shock);

Arterial hypotension;

Breathing disorder with the introduction of narcotic analgesics or diazepam;

Skin burns when conducting an Eit:

Thromboembolism after the Eit.

Note. Urgent treatment of arrhythmia should be carried out only by the indications above.

If possible, the cause of the development of arrhythmia and supporting its factors should be affected.

Emergency EIT with CHG less than 150 in 1 min is not usually shown.

With pronounced tachycardia and the absence of indications for urgent restoration of sinus rhythm it is advisable to reduce the CSU.

In the presence of additional indications Before the introduction of antiarrhythmic drugs, potassium and magnesium preparations should be applied.

With paroxysm of atrial flication, 200 mg of phencarol inside can be effectively effective.

The accelerated (60-100 in 1 min) idioventricular rhythm or rhythm of the AV-compound is usually replacing, and the use of antiarrhythmic agents in these cases is not shown.

Ensuring urgent assistance in repeated, usual paroxysms of tachyarhythmias should be taking into account the effectiveness of the treatment of previous paroxysms and factors that can change the patient's reaction to the introduction of antiarrhythmic agents that helped him earlier.

Bradiarhythmia

Diagnostics. Pronounced (CSS less than 50 in 1 min) Bradycardia.

Differential diagnosis - ECG. It should be differentiated sinusovoy bradycardia, stop by the CA node, sa- and av-blockade: distinguish between the AV-blockade in the degree and the level (distal, proximal); In the presence of an implanted electrocardiotimulator, it is necessary to estimate the effectiveness of stimulation at rest when changing the position of the body and load.

Urgent Care . Intensive therapy is necessary if bradycardia (CSS less than 50 in 1 min) causes MAS or its equivalents, shock, pulmonary edema, arterial hypotension, an anginal pain, or a progressive decrease in heart rate or an increase in ectopic ventricular activity is observed.

2. In case of either bradycardia syndrome, caused by acute heart failure, arterial hypotension, neurological symptoms, anginal pain or with a progressive decrease in heart rate or an increase in ectopic ventricular activity:

Put the patient with raised at an angle of 20 ° by lower limbs (if there is no pronounced stagnation in the lungs):

Carry out oxygen therapy;

If necessary (depending on the state of the patient) - a closed heart massage or rhythmic harvesting on the sternum ("fist rhythm");

Introduce atropine after 3-5 minutes to 1 mg intravenously until the effect or achieve a total dose of 0.04 mg / kg;

No effect - immediate endocardial percutaneous or percussive ex:

There is no effect (or there is no possibility of conducting ex) - intravenous slow jet introduction 240-480 mg of euphilline;

No effect - dopamine 100 mg or adrenaline 1 mg in 200 ml of 5% glucose solution intravenously; Gradually increase the infusion rate until the minimal heart rate is achieved.

3. Constantly control cardiac rhythm and conductivity.

4. Hospitalize after possible status stabilization.

Basic hazards in complications:

Asistolia;

Ectopic ventricular activity (up to fibrillation), including after applying adrenaline, dopamine. Atropine;

Acute heart failure (lung swells, shock);

Arterial hypotension:

Anginal pain;

The inability to conduct or ineffectiveness ex:

Complications of endocardial ex (fibrillation of ventricles, perforation of the right ventricle);

Paints when carrying out perchive or percutaneous ex.

Unstable angina

Diagnostics. The emergence of frequent or severe anginal attacks (or their equivalents) for the first time, change in the flow of the previously occurred angina, the resumption or appearance of angina in the first 14 days of the development of myocardial infarction or the appearance of for the first time angiosky pain alone.

There are risk factors for development or clinical manifestations HebS. Changes to ECG, even at the height of the attack, can be uncertain or absent!

Differential diagnosis. In most cases, with a tightened stress angina, acute myocardial infarction, cardiacriages. extracardial pain.

Urgent Care

1. Showing:

Nitroglycerin (tablets or aerosol of 0.4-0.5 mg under the tongue again);

Oxygen therapy;

Correction of arterial pressure and cardiac rhythm:

Propranolol (Anaprilin, Inderal) 20-40 mg inside.

2. with anginal pain (depending on its severity, age and patient state);

Morphine up to 10 mg or neuroleptanalgesia: fentanyl 0.05-0.1 mg or Promedol 10-20 mg with 2.5-5 mg of dropneridol intravenously fractional:

With insufficient analgesia - intravenously 2.5 g of analgin, and with an increased arterial pressure - 0.1 mg of clonidine.

5000 UZHPARIN intravenously jet. And then drip 1000 units / h.

5. Hospitalize after possible status stabilization. Basic hazards and complications:

Acute myocardial infarction;

Acute heart rate disorders or conductivity (up to sudden death);

Incomplete elimination or recurrence of anginal pain;

Arterial hypotension (including medicinal);

Acute heart failure:

Breathing disorders with the introduction of narcotic analgesics.

Note. Emergency hospitalization is shown, regardless of the presence of changes to the ECG, in blocks (chambers) of intensive therapy, departments for the treatment of patients with acute myocardial infarction.

It is necessary to ensure permanent control over the heart rate and arterial pressure.

For rendering emergency care (In the first hours of the disease or with complications), the catheterization of the peripheral vein is shown.

An accounting angiosky pain or wet chrys in the lungs of nitroglycerin should be administered intravenously drip.

For the treatment of unstable angina, the rate of intravenous administration of heparin must be selected individually, achieving a stable increase in activated partial thromboplastin time 2 times compared with its normal value. It is much more convenient to use low molecular weight heparin ENOCAPARIN (Kleksan). 30 mg of glasses are administered intravenously inkjano, after which the drug is prescribed subcutaneously to 1 mg / kg 2 times a day for 3-6 days.

If traditional narcotic analgesics are absent, then 1-2 mg of beamfanola or 50-100 mg of tramadol with 5 mg of dropidol and (or) 2.5 g of analgin from 5mg diasipelais intravenously slowly or fractional is possible.

Myocardial infarction

Diagnostics. Characterized by the prudent pain (or its equivalents) with irradiation in the left (sometimes and right) shoulder, forearm, shovel, neck. lower jaw, nasty region; Disturbance of heart rate and conductivity, unstable of arterial pressure: the reaction to the reception of nitroglycerin is incomplete or absent. Less often, other options for the start of the disease are observed: asthmagic (cardiac asthma, pulmonary edema). Arrhythmic (fainting, sudden death, MAS syndrome). Cerebrovascular (acute neurological symptoms), abdominal (pain in the silent region, nausea, vomiting), small-axipput (weakness, indefinite sensations in the chest). In history - risk factors or signs of IBS, the appearance of for the first time or change of familiar anhylic pain. Changes to ECG (especially in the first hours) may be uncertain or absent! After 3-10 hours from the beginning of the disease - a positive test with troponin-T or I.

Differential diagnosis. In most cases, with the protracted angina, unstable angina, cardialgias. extracardial pain. Tel, acute organs of organs abdominal cavity (Pancreatitis, cholecystitis, etc.), aggravating aortic aneurysm.

Urgent Care

1. Showing:

Physical and emotional rest:

Nitroglycerin (tablets or aerosol of 0.4-0.5 mg under the tongue again);

Oxygen therapy;

Correction of arterial pressure and heart rhythm;

Acetylsalicylic acid 0.25 g (december);

Propranolol 20-40 mg inside.

2. For anesthesia (depending on the severity of pain, the age of the patient, its state):

Morphine up to 10 mg or neuroleptanalgesia: Fentanyl 0.05-0.1 mg or Promedol 10-20 mg with 2.5-5 mg of droperidol intravenously fractionally;

With insufficient analgesia - intravenously 2.5 g of analgin, and against the background of an increased blood pressure - 0.1 mg of klonidin.

3. To restore coronary blood flow:

For transmural infarct Myocardial with a lifting segment 8t per ECG (in the first 6, and with a recurrent pain - up to 12 hours from the beginning of the disease) as early as possible to introduce streptokinase 1,500,000 I intravenously drip in 30 minutes:

With the sub-endocardial myocardial infarction with the depression of the segment 8t on the ECG (or the impossibility of trombolytic therapy) as early as possible to introduce 5,000 units of heparin intravenously, and then drip.

4. Constantly control cardiac rhythm and conductivity.

5. Hospitalize after possible status stabilization.

Basic hazards and complications:

Acute violations of heart rhythm and conductivity up to sudden death (ventricular fibrillation), especially in the first hours of the myocardial infarction;

Recurrence of anginal pain;

Arterial hypotension (including medication);

Acute heart failure (cardiac asthma, pulmonary swelling, shock);

Arterial hypotension; allergic, arrhythmic, hemorrhagic complications with the introduction of streptocinase;

Breathing disorders with the introduction of narcotic analgesics;

Miocardial break, heart tamponade.

Note. To provide emergency care (in the first hours of the disease or in the development of complications), the catheterization of the peripheral vein is shown.

In case of recurrent angino pain or wet chirks in the lungs of nitroglycerin, intravenously drip.

With increased risk of developing allergic complications before appointing streptocinase, introduce intravenously 30 mg of prednisolone. When carrying out blood-blooded therapy to ensure control over the heart rhythm and the main indicators of hemodynamics, readiness for correction possible complications (The presence of a defibrillator, an IVL apparatus).

For the treatment of subendocardial (with the depression of the segment 8t and without pathological teeth, the myocardial infarction, the speed of intravenous administration of Geguri-on must be selected individually, achieving a stable increase in activated partial thromboplastin time by 2 times compared with its normal value. It is much more convenient to use low molecular weight heparin ENOCAPARIN (Kleksan). 30 mg of glasses are introduced intravenously, after which the drug is prescribed subcutaneously to 1 mg / kg 2 times a day for 3-6 days.

If traditional narcotic analgesics are absent, then 1-2 mg of beamfanola or 50-100 mg of tramadol with 5 mg of dropidol and (or) 2.5 g of analgin from 5 mg of diaspeam intravenously slowly or fractional is possible.

Cardiogenic swelling of the lungs

Diagnostics. Characteristics are characteristic: suffocity, shortness of breath, increasing in the position lying, which forces patients to sit down: tachycardia, acricyanosis. Hi-injectation of fabrics, inspiratory shortness of breath, dry whistling, then wet wets in the lungs, abundant frothy wet, changes to ECG (hypertrophy or overload of the left atrium and ventricle, the blockade of the left leg of the beam Puah and others).

A history of myocardial infarction, vice or other heart disease. Hypertensive disease, chronic heart failure.

Differential diagnosis. In most cases, the cardiogenic swelling of the lungs is differentiated from non-ordogenic (with pneumonia, pancreatitis, violation of cerebral circulation, chemical damage to the lungs, etc.), Tel, bronchial asthma.

Urgent Care

1. Common events:

Oxygen therapy;

Heparin 5000 U intravenously insertion:

CHSS correction (with CSG more than 150 in 1 min - Eit. At CHG less than 50 in 1 min - ex);

With abundant formation of foam - defoaming (inhalation of a 33% solution of ethyl alcohol either intravenously 5 ml of 96% solution of ethyl alcohol and 15 ml of 40% glucose solution), in extremely heavy (1) cases in the trachea, 2 ml of 96% of ethyl alcohol solution are injected into the trachea.

2. In normal arterial pressure:

Perform p. 1;

Sat the patient with lowered lower limbs;

Nitroglycerin, tablets (better aerosol) 0.4-0.5 mg under 3 min or up to 10 mg intravenously slowly fractionally or intravenously drip in 100 ml of isotonic sodium chloride solution, increasing the rate of introduction from 25 μg / min to receiving Effect controlling blood pressure:

Diazepams up to 10 mg or morphine 3 mg intravenously fractionally to the effect or achieve a total dose of 10 mg.

3. Ply arterial hypertension:

Perform p. 1;

Sour the patient with lowered lower limbs:

Nitroglycerin, tablets (better aerosol) 0.4-0.5 mg under the tongue once;

Furosemid (Laziks) 40-80 mg intravenously;

Nitroglycerin intravenously (p. 2) or sodium nitroprusside 30 mg in 300 ml of 5% glucose solution insidely drip, gradually increasing the infusion rate of the drug from 0.3 μg / (kg x min) before receiving the effect, controlling blood pressure, or pentamin to 50 mg intravenously fractionally or drip:

Intravenously up to 10 mg of diazepam or up to 10 mg of morphine (p. 2).

4. With a pronounced arterial hypotension:

Perform paragraph 1:

Put the patient, raising the headboard;

Dopamine 200 mg in 400 ml of 5% glucose solution intravenously drip, increasing the infusion rate from 5 μg / (kg x min) before stabilizing blood pressure at the minimum sufficient level;

If it is impossible to stabilize blood pressure - to additionally assign norepinephrine hydrothatrate 4 mg in 200 ml of 5-10% glucose solution, increasing the infusion rate from 0.5 μg / min to the stabilization of blood pressure at the minimum sufficient level;

With an increase in blood pressure, accompanied by increasing pulmonary edema, is additionally nitroglycerin intravenously drip (p. 2);

Furosemide (Laziks) 40 mg intravenously after the stabilization of blood pressure.

5. Monitor vital functions (cardiomonitor. Pul-Soximeter).

6. Hospitalize after possible status stabilization. Basic hazards and complications:

Lightning form of pulmonary edema;

Obstruction of the respiratory tract of foam;

Depression of breathing;

Tahiaritmia;

Asistolia;

Angic pain:

The increase in pulmonary edema with an increase in blood pressure.

Note. Under the minimum sufficient arterial pressure, systolic pressure of about 90 mm Hg should be understood. Art. Provided that the increase in blood pressure is accompanied by clinical signs of improving the perfusion of organs and tissues.

Eufillin with a cardiogenic pulmonary edema is an auxiliary means and can be shown in bronchospasm or severe bradycardia.

Glucocorticoid hormones are used only in respiratory disk syndrome (aspiration, infection, pancreatitis, inhalation of irritating substances, etc.).

Cardiac glycosides (stroofantine, digoxin) can only be appointed with moderate congestive heart failure in patients with a tachiisistol-holy form of flicker (treputania) atrial.

With aortic stenosis, hypertrophic cardiomotopathy, tamponade of the heart of nitroglycerin and other peripheral veauilators relatively contraindicated.

Effectively creating a positive pressure at the end of the exhalation.

Inhibitors of ACE (captopril) are useful for preventing recurrence of pulmonary edema in patients with chronic heart failure. At the first purpose of the adjustment, the treatment began to start with a test dose of 6.25 mg.

Cardiogenic shock

Diagnostics. A pronounced decline in blood pressure in combination with signs of violation of blood supply to organs and tissues. Systolic blood pressure is usually below 90 mm Hg. Art., pulse - below 20 mm Hg. Art. The symptoms of the deterioration of peripheral blood circulation are noted (pale cyanotic wet skin, sleeping peripheral veins, reducing the skin temperature of the brushes and stop); Reducing the rate of blood flow (the time of the white spot after pressing on the nail bed or palm - more than 2 c), a decrease in diurea (less than 20 ml / h), a violation of consciousness (from light-intensive ™ to the emergence of focal neurological symptoms and coma development).

Differential diagnosis. In most cases, a true cardiogenic shock should be differentiated from its species (reflex, arrhythmic, drugs, with a slow member of the myocardial break, breaking partition or papillary muscles, damage to the right ventricle), as well as from TEL, hypovolemia, internal bleeding and arterial hypotension without shock.

Urgent Care

Emergency care must be carried out in stages, quickly moving to the next stage with the ineffectiveness of the previous one.

1. In the absence of pronounced stagnation in the lungs:

To lay the patient with raised under the dill of 20 ° by the bottom limbs (with a pronounced embroidery in the lungs - see "Elevation of the Lungs"):

Carry out oxygen therapy;

With anginal pain hold full-fledged anesthesia:

CHSS correction (paroxysmal tachiaritium from heart rate more than 150 blows in 1 min - an absolute reading to the EIT, the sharp bradycar dius with the CHG of less than 50 blows in 1 min - to ex);

Enter Heparin 5000 U intravenously inkjet.

2. In the absence of pronounced stagnation in the lungs and signs of a sharp increase in CVD:

200 ml of 0.9% sodium chloride solution to introduce intravenously drip in 10 minutes under blood pressure control, respiratory frequency. Heart rate, auscultatory pattern of lungs and hearts (whenever possible control FAVD or junction pressure in the pulmonary artery);

Under the preserving arterial hypotension and the absence of signs of transfusion hypervolemia - repeat the introduction of fluid on the same criteria;

In the absence of signs of transfusion hypervolemia (CVD below 15 cm of water. Art.) Infusion therapy to continue at a speed of up to 500 ml / h, controlling the indicated indicators every 15 minutes.

If the blood pressure is not quickly stabilized, then go to the next step.

3. introduce dopamine 200 mg in 400 ml of a 5% glucose solution intravenously drip, increasing the infusion rate from 5 μg / (kg x min) to achieve minimally sufficient blood pressure;

There is no effect - additionally appoint norepinephrine hydrothatrate 4 mg in 200 ml of 5% glucose solution intravenously drip, increasing the rate of infusion from 0.5 μg / min to the achievement of minimally sufficient blood pressure.

4. Monitor vital functions: Cardiomonitor, Pulse oximeter.

5. Hospitalize after possible stabilization from standing.

Basic hazards and complications:

Undime diagnosis and start of treatment:

Inability to stabilize blood pressure:

Pulmonary edema with an increase in blood pressure or intravenous injection of fluid;

Tachycardia, Tahiaritimia, ventricular fibrillation;

Asistolia:

Recurney of anginal pain:

Acute renal failure.

Note. Under the minimum sufficient arterial pressure should be understood as systolic pressure of about 90 mm. Art. When signs of improving perfusion of organs and tissues.

Glucocorpshkoid hormones with true cardiogenic shock are not shown.

emergency angina infarction poisoning

Hypertensive crisis

Diagnostics. Increased blood pressure (more often east and significant) with neurological symptoms: headache, "flies" or paddle in front of the eyes, paresthesia, a feeling of "crawling goosebumps", nausea, vomiting, weakness in limbs, transient hemipreps, aphasia, diplopia.

With a neareegetative crisis (type I, adrenal crisis): a sudden beginning. Excitation, hyperemia and skin moisture. Tachycardia, rapid and abundant urination, preferential increase in systolic pressure with an increase in pulse.

With a water-salt form of a crisis (type II crisis, non-affected): gradual start, drowsiness, adamopery, disorientation, pallor and endlessness of the face, swelling, preferential increase in diastolic pressure with a decrease in the bullets of the owl.

With a convulsive form of a crisis: pulsating, sawing headache, psychomotor arousal, multiple vomiting without facilitating, disorder of vision, loss of consciousness, clonic-tonic convulsions.

Differential diagnosis. First of all, the severity, shape and complications of the crisis should be taken into account, to allocate crises associated with the sudden abolition of hypotensive agents (clonidine, p-adrenobloclockers, etc.), differentiate hypertensive crises from violation of cerebral circulation, diancephal crises and crises at the peuochromocytoma.

Urgent Care

1. Nearegetive form of chisosis.

1.1. With a netwent:

Nifedipine is 10 mg under the tongue or drops inside every 30 min, or clonidine 0.15 mg under the tongue. Then 0.075 mg every 30 minutes to the effect, or the combination of these drugs.

1.2. With severe flow.

Clonidine 0.1 mg intravenously slowly (can be in combination with 10 mg of Ni-Fedipine under the tongue), or sodium nitroprusside 30 mg in 300 ml of 5% glucose solution intravenously drip, gradually increasing the rate of administration until the necessary blood pressure is reduced, or pentamine to 50 mg intravenously drip either stroke fractionally;

With insufficient effect - furosemid 40 mg intravenously.

1.3. With persisted emotional, voltage additionally di-amzepams 5-10 mg inside, intramuscularly or intravenously or droperidol 2.5-5 mg intravenously slowly.

1.4. With continued tachycardia, propranolol is 20-40 mg inside.

2. Water-salt form of chisosis.

2.1. With a netwent:

Furosemide 40-80 mg inside once and nifedipine in 10 mg under the tongue or drops inside every 30 minutes to the effect or a furosemid 20 mg inside once and captoped under the tongue or inside 25 mg every 30-60 minutes to effect.

2.2. With severe flow.

Furosemid 20-40 mg intravenously;

Sodium nitroprusside or pentamine intravenously (p. 1.2).

2.3. With preserving neurological symptoms can be effectively intravenous administration 240 mg of Euphillin.

3. The convulsive form of the crisis:

Diazepam 10-20 mg intravenously slowly before eliminating seizures, it is additionally possible to prescribe magnesium sulfate 2.5 g intravenously very slowly:

Sodium nitroprusside (p. 1.2) or pentamine (p. 1.2);

Furosemide 40-80 mg intravenously slowly.

4. Crimi associated with sudden cancellation of hypotensive drugs:

The corresponding hypotensive drug intravenously. Under the tongue or inside, with sharply pronounced arterial hypertension - sodium nitroprusside (p. 1.2).

5. Hypertensive crisis, complicated by eleven swelling:

Nitroglycerin (better aerosol) 0.4-0.5 mg under the tongue and immediately 10 mg in 100 ml of isotonic sodium solution chloride intravenously drip. Increasing the rate of administration from 25 μg / min to the effect of the effect, either the NTR Nitroprusside (§ 1.2), or pentamine (clause 1.2);

Furosemid 40-80 mg intravenously slowly;

Oxigenotherapy.

6. Hypertempics crisis complicated by hemorrhagic stroke or subarachnoidal hemorrhage:

With severely pronounced arterial hypertension - sodium nitroprusside (p. 1.2). Blood pressure reduce to values \u200b\u200bexceeding the usual in this patient, when the neurological symptoms enhance the speed of administration.

7. Hypertensive crisis complicated by anginal pain:

Nitroglycerin (better aerosol) 0.4-0.5 mg under the tongue and immediately 10 mg intravenously drip (paragraph 5);

Be sure to anesthesia - see "angina region":

In case of insufficient effect - propranolol 20-40 mg inside.

8. With complicated current - monitor vital functions (cardiomonitor, pulse oximeter).

9. Hospitalize after possible status stabilization .

Basic hazards and complications:

Arterial hypotension;

Brain circulation impairment (hemorrhagic or ischemic stroke);

Pulmonary edema;

Anginal pain, myocardial infarction;

Tachycardia.

Note. With acute arterial hypertension, fuses of the devoid of life, blood pressure reduce for 20-30 minutes to the usual, "workers" or several more high valuesUse intravenous. The path of administration of drugs, the hypotensive effect of which can be monitored (sodium nitroprusside, nitroglycerin.).

With a hypertensive crisis without a direct threat to life, blood pressure decreases gradually (for 1-2 hours).

With a deterioration of the flow hypertensive diseasenot reaching a criste, blood pressure is necessary to reduce for several hours, the main hypuncizivs to appoint inside.

In all cases, blood pressure should be reduced to the usual, "workers" of values.

Implement urgent assistance in repeated hypertensive crises of SLS-diets, taking into account the experience of treating previous ones.

When you first use, therapy treatment must be started with a test dose of 6.25 mg.

The hypotensive effect of the pentamine is difficult to control, therefore the drug is permissible only in the plys when the emergency decrease in blood pressure is shown and there are no other features for this. Pentamine is administered by 12.5 mg intravenously fractionally or drip up to 50 mg.

When crisping in patients with a peochromocytoy, raise the headboard on the bed. 45 °; Prescribe (X-ray (5 mg intravenously 5 minutes to effect.); Prazozin can be used for 1 mg under the tongue re-either sodium nitroprusside. As an auxiliary drug - Droperidol 2.5-5 mg intravenously slowly. Floor-figures R-adrenoreceptors exchangers Only (!) After the introduction of A-blood-reorpector blockers.

PULMONARY EMBOLISM

Diagnostics The massive TEL is manifested by a sudden cessation of the circulation of electromechanical dissociation), or shock with pronounced shortness of breath, tachycardia, pallhery or sharp cyanosis of the skin of the upper half of the body, swelling of the cervical veins, antine-like pain, electrocardiographic manifestations of a sharp "pulmonary heart."

Hggossinous Tel is manifested by shortness of breath, tachycardia, arterial hypotension. Signs of the lung infarction (pulmonary-plenural pain, cough, in part of patients - with sputum, painted with blood, increasing body temperature, creating wheezing in the lungs).

To diagnose TELA, it is important to take into account the presence of such risk factors for the development of thromboembolism, as thromboembolic complications in history, elderly age, long-term mobilization, recent surgical intervention, heart rate, heart failure, flicculative arrhythmia, oncological diseases, TGV.

Differential diagnosis. In most cases, with myocardial infarction, acute heart failure (cardiac asthma, pulmonary edema, cardiogenic shock), bronchial asthma, pneumonia spontaneous pneumothorax.

Urgent Care

1. When the blood circulation is discontinued - the SLR.

2. With a massive tel with arterial hypotension:

Oxygen therapy:

Catheterization of central or peripheral veins:

Heparin 10 000 U intravenously inkjet, then drip at the initial speed of 1000 UR / H:

Infusion therapy (Reopolyglyukin, 5% glucose solution, hemodez, etc.).

3. With severe arterial hypotension, not corrected infusion therapy:

Dopamine, or adrenaline intravenously drip. increasing the rate of administration to the stabilization of blood pressure;

Streptocinase (250,000 meters intravenously for 30 minutes. Next intravenously drip at a rate of 100,000 and h to the total dose of 1,500,000 me).

4. With stable arterial pressure:

Oxygen therapy;

Catheterization of peripheral veins;

Heparin 10,000 units intravenously, then drip at a speed of 1000 units or subcutaneously 5000 units after 8 hours:

Eufillin 240 mg intravenously.

5. With the recurrent flow of TEL, to additionally assign inside 0.25 g of acetylsalicylic acid.

6. Monitor vital functions (cardiomonitor, bulletsimeter).

7. Hospitalize after possible status stabilization.

Basic hazards and complications:

Electromechanical dissociation:

The inability to stabilize blood pressure;

Growing respiratory failure:

Recurrent TEL.

Note. With a burdened allergic history before appointing Schtreyukinosis, 30 mg of prenailolone is introduced intravenously.

For the treatment of TEL, the rate of intravenous administration of heparin must be selected individually, achieving a stable increase in activated partial thromboplastin time 2 times compared with its normal value.

STROKE (Acute brainwater impairment)

Stroke (ONMK) is a rapidly developing focal or global violation of the brain function, which is located more than 24 hours or leading to death with the exclusion of other genesis of the disease. Developed against the background of atherosclerosis of the brain vessels, hypertension, their combinations or as a result of the ripper of the aneurysm of the brain vessels.

Diagnostics The clinical picture depends on the nature of the process (ischemia or hemorrhage), localization (hemisphere, trunk, cerebellum), the pace of development of the process (sudden, gradual). For stroke any genesis, the presence of focal symptoms of brain lesion (hemipreples or hemipilegia, less often monopares and lesions of the cranial nerves - facial, sub-public, gladation) and general-selling symptoms various degrees severity (headache, dizziness, nausea, vomiting, violation of consciousness).

OnMK clinically manifests a subarachnoidal or intraindose hemorrhage (Hemorrhagic stroke), or ischemic stroke.

The transient violation of the cerebral circulation (PNMK) is a condition in which the focal symptoms are subjected to full regression for a period of less than 24 hours. The diagnosis is made retrospectively.

Saboroknoidol hemorrhages are developing as a result of a ripper aneurysm and less often against the background of hypertension. A characteristic sudden appearance of a sharp headache, following her nausea, vomiting, motor excitement, tachycardia, sweating. In case of massive subarachno-idle hemorrhage, it is usually oppressed by consciousness. The focal symptoms are more often absent.

Hemorrhagic stroke - hemorrhage in the brain substance; Silent headache, vomiting, fast (or sudden) depression of consciousness, accompanied by the appearance of pronounced symptoms of impaired limbs or bulbar disorders (peripheral paralysis of the muscles of the tongue, lips, soft sky, pharynx, voice folds, and the epiglotes due to the defeat of the IX, X and XII pairs of cranial nerves or their nuclei located in oblong brain). Usually develops during the day during wakefulness.

Ischemic stroke is a disease that leads to a decrease or termination of the blood supply to a certain brain department. It is characterized by the gradual (for hours or minutes) by the increase in focal symptoms corresponding to the affected vascular basin, general-selling symptoms are usually less pronounced. Develops more often at normal or low arterial pressure, often during sleep

On the chipboard The differentiation of the character of a stroke (ischemic or hemorrhagic, subarachnoid hemorrhage and its localization is not required.

Differential diagnosis should be carried out with a cranial and brain injury (history, the presence of traces of injury on the head) and significantly less often with meningoencephalitis (history, signs of the general infection process, rash).

Urgent Care

The basic (undifferentiated) therapy includes an emergency correction of vital functions - restoration of the upper respiratory tract, if necessary, intubation of the trachea, artificial ventilation of the lungs, as well as the normalization of hemodynamics and cardiac activity:

When arterial pressure is significantly higher than normal values \u200b\u200b- reduced it to indicators, somewhat exceeding the "working", habitual for a given patient, if there is no information - then to the level of 180/90 mm RT. Art.; To do this, use - 0.5-1 ml of 0.01% of the clonidine solution (clofelin) in 10 ml of 0.9% sodium solution of chloride intravenously or intramuscularly or 1-2 sublingual tablets (if necessary, the introduction of the drug can be repeated), or pentamine - no more than 0, 5 ml of a 5% solution intravenously with the same dilution or 0.5-1 ml intramuscularly:

Dibazole 5-8 ml of 1% solution of intravenously or nifedipine (Corinthar, Penigidine) - 1 tablet (10 mg) sublingual can be used as an additional tool.

To relieve convulsive seizures, psychomotor excitation - diazepams (relaignation, sysksen, sybazon) 2-4 ml intravenously with a 10 ml of 0.9% sodium solution of chloride slow or intramuscularly or rogpnol 1-2 ml intramuscularly;

With ineffectiveness - 20% sodium solution of oxybutirate at the rate of 70 mg / kg body weight by 5-10% glucose solution intravenously slowly;

In the case of re-vomiting - Cerukal (reglan) 2 ml intravenously by 0.9% solution intravenously or intramuscularly:

Vitamin BB 2 ml of 5% solution intravenously;

Droperidol 1-3 ml of 0.025% solution, taking into account the mass of the patient's body;

With headaches - 2 ml of 50% of the analgin solution or 5 ml of baraghi-on intravenously or intramuscularly;

Tramal - 2 ml.

Tactics

To patients of working age in the first hours of the disease, the challenge of a specialized neurological (neuroreanimation) brigade is required. The hospitalization on stretchers in neurological (neuro-vascular) is shown.

When refusing hospitalization - the challenge of the neurologist of the polyclinic and, if necessary, an active visit to the doctor's emergency care after 3-4 hours.

Non-transportable patients in a deep atonic coma (5-4 points on the Glasgow scale) with non-compatible harsh respiration disorders: unstable hemodynamics, with a rapid, steady deterioration of the state.

Hazards and complications

Obstruction of the upper respiratory tract by vomit masses;

Aspiration of vomit;

Inability to normalize blood pressure:

Brain swelling;

Blood breakthrough in cerebral ventricles.

Note

1. It is possible to early use of antihypoxants and cellular metabolism activators (nootropyl 60 ml (12 g) intravenously 2 times a day after 12 hours in the first day; cerebrolysine 15-50 ml intravenously drip at 100-300 ml of isotone solution in 2 reception; glycine 1 Tab. Table RiboSyn 10ml is in virtually bolus, alcoholic 4 ml intravenously, in severe cases, 250 ml of a 10% solister solution intravenously drip absolutely to significantly reduce the amount of irreversible damaged cells in the ischemia zone, reduce the peripocal edema zone.

2. Aminazine and suspension must be excluded from the means appointed with any form of stroke. These drugs abruptly oppress the functions of the stem structures of the brain and clearly worsen the state of patients, especially the elderly and old age.

3. Magnesium sulfate does not apply under convulsive syndrome and to reduce blood pressure.

4. Eufillin by show only in the first hours of the easily flowing stroke.

5. Furosemid (Laziks) and other dehydrating drugs (Mannitol, Luman, Glieceol's rogue) can not be administered in a prehospital stage. The need to prescribe dehydration funds can be determined only in the hospital according to the results of the determination of plasma osmolality and sodium content in blood serum.

6. In the absence of a specialized neurological brigade, hospitalization in the neurological department is shown.

7. To the patients of any age with first or repeated ONMK with minor defects after previously transferred episodes, a specialized neurological (neuroreanimative) brigade may also be caused in the first day of the disease.

Bronchoastmatic status

The bronchoastmapic status is one of the most difficult versions of the flow of bronchial asthma, manifested by acute obstruction of the bronchial tree as a result of bronchio-acid, hypergic inflammation and edema of the mucous membrane, hypersecretion of the ferrous apparatus. The formation of status is based on a deep blockade of R-adrenoreceptors of the smooth muscles of the bronchi.

Diagnostics

The attack of suffocation with a difficult exhalation, an increasing shortness of breath in peace, acricyanosis, increased sweating, hard breathing with dry scattered wheezes and the subsequent formation of sections of the "silent" light, tachycardia, high blood pressure, participation in the breathing of auxiliary muscles, hypoxic and hypercapnic coma. When conducting medication therapy, resistance to sympathomimetics and other bronchophytes are revealed.

Urgent Care

Asthmatic status is a contraindication to the use of P-agonists (adrenomimetics) due to loss of sensitivity (lung receptors to these drugs. However, this loss of sensitivity can be overcome using nebulizer technology.

Medical therapy is based on the use of selective P2-agonists of phenoterol (BEROTEK) using nebulizer (Berretk) in a dose of 0.5-1.5 mg or salbutamol at a dose of 2.5-5.0 mg or a complex preparation of Berodala containing phenoterol and anticholinergic drug Ipra -Tropium bromide (atrovant). Dosage berodual - 1-4 ml per inhalation.

In the absence of a nebulaner, these drugs do not apply.

Eufillin is used in the absence of a nebulizer or in particularly severe cases in the ineffectiveness of nebulizer therapy.

The initial dose is 5.6 mg / kg of body weight (10-15 ml of 2.4% of the solution in the inspirate slowly, for 5-7 minutes);

Supporting dose - 2-3.5 ml of 2.4% solution fractionally or drip to improving the clinical condition of the patient.

Glucocorticoid hormones - in terms of methylprednisolone 120-180 mg intravenously inkjet.

Oxygen therapy. Continuous insufflation (mask, nasal catheters) oxygen-air mixture with an oxygen content of 40-50%.

Heparin - 5,000-10,000 units intravenously drip with one of the plasma-substituting solutions; It is possible to use low molecular weight heparins (fraxipart, kleksan, etc.)

Contraindicated

Sedative and antihistamines (inhibit cough reflex, enhance the bronchopulmonary obstruction);

Mulitatic means for wet wet:

antibiotics, sulfonamides, novocaine (possess high sensitizing activity);

Calcium preparations (deepen the initial hypokalemia);

Diuretics (increase the initial dehydration and hemoconcent-ration).

During comatose state

Trachea urgent intubation with spontaneous breathing:

Artificial ventilation of the lungs;

If necessary - cardiovary and pulmonary resuscitation;

Medical therapy (see above)

Indications for intubation trachea and IVL:

hypoxic and hypercalemic coma:

Cardiovascular collapse:

The number of respiratory movements over 50 in 1 min. Transportation to the hospital against the background of therapy.

Convulsive syndrome

Diagnostics

A generalized common convulsive fit is characterized by the presence of tonic-clonic convulsions in the limbs accompanied by the loss of consciousness, foam at the mouth, often a bite of language, involuntary urination, sometimes defecation. At the end of the seizure there is a sharply pronounced breathing arrhythmia. Possible long periods of apnea. At the end of the fear of the patient is in deep coma, the pupils are maximally expanded, without reaction to light, the skin is cyanotic, often wet.

Simple partial convulsive seizures without losing consciousness are manifested by clonic or tonic convulsions in certain muscle groups.

Complex partial seizures (temporal epilepsy or psychomotor seizures) - episodic behavior changes when the patient loses contact with the outside world. The beginning of such seizures may be aura (olfactory, taste, visual, sensation of "already seen", micro or macrobia). During complex seizures, the engine activity can be braked; Either swinging tubes, swallowing, aimless walking, rich in our own clothes (automates). At the end of the attack, amnesia is noted on the events that occurred during an attack.

Equivalents of convulsive seizures are manifested in the form of coarse disorientation, somnambulism and a long twilight state, during which unconscious severe asocial deeds may be performed.

Epileptic status is a fixed epileptic state due to a long epileptic seal or a series of seizures that are repeated through short time intervals. Epileptic status and frequently repetitive convulsive seizures are life-threatening conditions.

The convulsive fit can be a manifestation of the generic ("congenital") and symptomatic epilepsy - consequence of transferred diseases (brain injury, brainwater disorder, neuro-infection, tumor, tuberculosis, syphilis, toxoplasmosis, cysticercosis, Morgali-Adams-Stokes syndril, ventricular fibrillation , eclampsia) and intoxication.

Differential diagnosis

At the cooking stage, the clarification of the cause of a convulsive fidge is often extremely difficult. A history and clinical data are of great importance. It is necessary to exercise a particular alertness regarding. First of all, the acute brain injury, acute violations of cerebral circulation, heart rate disorders, eclampsia, tetanus and exogenous intoxication.

Urgent Care

1. After a single convulsive seizure - diazepam (relaignation, sysksen, sybazone) - 2 ml intramuscularly (as the prevention of repeated seizures).

2. With a series of convulsive seizures:

Prevention of traumatization of the head and body:

Saving convulsive syndrome: diazepam (relagnium, syshuxen, sybazon) - 2-4 ml per 10 ml of 0.9% sodium solution of chloride intravenously or intramuscularly, Rogpnol 1-2 ml intramuscularly;

In the absence of effect - sodium oxybutirate 20% solution at the rate of 70 mg / kg body weight intravenously by 5-10% glucose solution;

Anti-ease therapy: Furosemide (Laziks) 40 mg per 10-20 ml of 40% glucose or 0.9% sodium chloride solution (in patients diabetes)

intravenously;

Cutting headaches: analgin 2 ml of 50% solution: 5 ml barallgan; Tramal 2 ml intravenously or intramuscularly.

3. Epileptic status

Warning traumatization of the head and body;

Restoration of airways;

Saving convulsive syndrome: diazepams (relaignation, sysksen, scabazon) _ 2-4 ml per 10 ml of 0.9% sodium solution of chloride intravenously or intramuscularly, Rogpnol 1-2 ml intramuscularly;

In the absence of effect - sodium oxybutirate 20% solution at the rate of 70 mg / kg body weight intravenously by 5-10% glucose solution;

In the absence of an effect - inhalation anesthesia Zaku nitrogen in a mixture with oxygen (2: 1).

Anti-ease therapy: Furosemid (Laziks) 40 mg per 10-20 ml of 40% glucose or 0.9% sodium solution chloride (in patients with diabetes mellitus) intravenously:

Cutting headaches:

Analgin - 2 ml of 50% solution;

- Baratgin - 5 ml;

Tramal - 2 ml intravenously or intramuscularly.

According to the testimony:

With an increase in blood pressure, hypotensive preparations (clofelin intravenous, intramuscularly or pills sublingual, dibazol intravenously or intramuscularly) are significantly higher for the patient.

For tachycardia Over 100 Ud / min - see "Takhiaritmia":

In bradycardia less than 60 UD / min - atropine;

With hyperthermia Over 38 ° C - analgin.

Tactics

Patients with the first in the life of a convulsive fit should be hospitalized to clarify its cause. In case of refusal to hospitalize fast recovery The consciousness and absence of general-selling and focal neurological symptoms are recommended urgent appeal to the neurologist of the polyclinic at the place of residence. If the consciousness is restored slowly, there is a total and (or) focal symptoms, the challenge of a specialized neurological (neuro-resuscitation) brigade is shown, and in its absence - an active visit after 2-5 hours.

An unknown epileptic status or a series of convulsive seizures is an indication of the challenge of a specialized neurological (neuroreanimation) brigade. In the absence of such - hospitalization.

In violation of the activity of the heart, led to a convulsive syndrome, is the appropriate therapy or a challenge of a specialized cardiological brigade. At eclampsia, exogenous intoxication - action on the relevant recommendations.

Basic hazards and complications

Asphyxia during the seal:

Development of acute heart failure.

Note

1. Aminazine is not an anticonvulsant.

2. Magnesium sulfate and chloralhydrate are currently not applied.

3. The use of hexenal or sodium thiopental to relieve epileptic status is possible only under a specialized brigade, if there are conditions and the ability to translate the patient to the IVL if necessary. (laryngoscope, set of endotracheal tubes, device for IVL).

4. Calcium glucoonate (10-20 ml of a 10% solution intravenously or intramuscularly), calcium chloride (10-20 ml of 10% solution of strictly intravenously is injected with glukealcymic seizures.

5. Panangin (10 ml intravenous) is introduced at hypokalemic sevors.

FAINTING (Short-term loss of consciousness, syncope)

Diagnostics

Fainting. - Short-term (usually within 10-30 seconds) loss of consciousness. In most cases, accompanied by a decrease in postural vascular tone. The fainting is based on transient brain hypoxia, resulting from various reasons - reduction of cardiac output. Heart rhythm disorders, reflex reduction of vascular tone, etc.

Syncical (synicopal) states can be divided into two most common forms - vasodepressor (synonyms - vasodigal. Neurogenic) fainting, based on the reflex reduction in postural vascular tone, and fainting associated with heart disease and trunk vessels.

Syncopal states have different prognostic significance depending on their genesis. The fainting associated with the pathology of the cardiovascular system may be precursors of sudden death and require the mandatory detection of their causes and adequate treatment. It must be remembered that fainting can be the debut of severe pathology (myocardial infarction, TEL, etc.).

The most frequent clinical form is a vasopressor fainting, in which a reflex reduction of peripheral vascular tone is occurring in response to external or psychogenic factors (fear, excitement, blood type, medical instruments, vein puncture. High ambient temperature, stay in a stuffy room, etc. .). The development of fainting is preceded by a short long period, during which weakness, nausea, ringing in the ears, yawning, darkening in the eyes, pallor, cold sweat.

If the loss of consciousness is short-term - convulsion is not noted. If fainting lasts more than 15-20 s. Clonic and tonic convulsions are noted. During the faint, the blood pressure decreases with bradycardia; Or without it. The same group includes fainting, arising from the increased sensitivity of the carotid sinus, as well as the so-called "situational" fainting - with a long cough, defecation, urination. The fainting associated with the pathology of the cardiovascular system usually occurs suddenly, without a long period. They are divided into two main groups - related heart rate impaired and conduction and reduced heart rate (stenosis of the aorta's mouth. Hypertrophic cardiomyopathy, mixoma and spherrophic clomes in atria, myocardial infarction, tel, sparking aortic aneurysm).

Differential diagnosis The fainting must be carried out with epilepsy, hypoglycemia, narcolepsy, commen of various genesis, diseases of the vestibular apparatus, organic brain pathology, hysteria.

In most cases, the diagnosis can be established on the basis of detailed anamnesis, physical examination and ECG registration. To confirm the vasodepressor nature of the fainting, there are positional samples (from simple orthostatic before using a special inclined table), to increase the sensitivity of the sample are carried out against the background of medication therapy. If the specified actions do not find out the cause of the fainting, then the subsequent examination in the hospital is carried out depending on the detected pathology.

In the presence of heart disease: Holter monitoring of ECG, echocardiography, electrophysiological research, positional samples: If necessary, the catheterization of the heart.

In the absence of heart disease: positional samples, consultation of the neuropathologist, psychiatrist, Halter monitoring ECG, electroencephalogram, if necessary, computer tomography of the brain, angiography.

Urgent Care

With fainting usually not required.

The patient must be put in a horizontal position on the back:

posted by lower limbs an elevated position, free from shy clothes and chest:

Do not immediately plant patients, as this can lead to a revision of fainting;

If the patient does not come into consciousness, it is necessary to exclude the crank-brain injury (if there was a fall) or other causes of the long loss of the consciousness mentioned above.

If the faint is caused by a cardiac disease, urgent assistance may be necessary to eliminate the immediate cause of fainting - tachyarhythmias, bradycardia, hypotension, etc. (see the relevant sections).

Acute poisoning

Poisoning - pathological conditions caused by the action of toxic substances of exogenous origin in any ways of their admission to the body.

The severity of the state in poisoning is due to the dose of poison, through its receipt, the exposure time, the premorbid background of the patient, complications (hypoxia, bleeding, convulsive syndrome, acute cardiovascular failure, etc.).

The doctor of the dog phase is necessary:

Observe the "toxicological alertness" (environmental conditions in which poisoning occurred, the presence of extraneous odors may be dangerous to the ambulance brigade):

Find out the circumstances accompanying poisoning (when, as, how much, for what purpose) in the patient himself, if he is in consciousness or surrounding persons;

Collect material evidence (packaging of drugs, powders, syringes), biosrials (vomit, urine, blood, washing water) for chemical and toxicological or judicial and chemical research;

Register the main symptoms (syndromes), which were in a patient before providing medical care, including mediator syndromes that are the result of strengthening or inhibition of sympathetic and parasympathetic systems (see Attachment).

General algorithm for emergency care

1. Ensure the normalization of breathing and hemodynamics (to carry out the basic cardiovascular resuscitation).

2. Conduct antidote therapy.

3. Stop further entering the body into the body. 3.1. With inhalation poisoning - remove the victim from an infected atmosphere.

3.2. With oral poisoning - rinse the stomach, enter entero sorbents, put the cleansing enema. When washing the stomach or washing of poisons from the skin, use water with a temperature not higher than 18 ° C, the reaction of neutralization of poison in the stomach does not conduct! The presence of blood when washing the stomach is not a contraindication for washing.

3.3. When the cavity applique is to wash the affected area of \u200b\u200bthe skin with antidote or water.

4. Start the conduct of infusion and symptomatic therapy.

5. Transport patient to the hospital. This algorithm for assistance in the pre-hospital stage is applicable to all types of acute poisoning.

Diagnostics

With mild and moderate severity, anticholinergic syndrome (intoxication psychosis, tachycardia, normogypotensia, mydriasis) occurs. With severe coma, hypotension, tachycardia, mydriasis.

Neuroleptics cause the development of an orthostatic collapse, a long-term resistant hypotension, due to the insensitivity of the terminal department of the vascular bed to vazopressors, an extrapyramidal syndrome (armor of the chest muscles, neck, upper shoulder belt, protrusion of the tongue, pucheglasie), neuroleptic syndrome (hyperthermia, muscle rigidity).

Hospitalization of the patient in a horizontal position. Cholinolites cause the development of retrograde amnesia.

Opiatami poisoning

Diagnostics

Characteristic: inhibition of consciousness, to a deep coma. Development of apnea, tendency to bradycardia, traces of injection on elbow bends.

Emergency therapy

Pharmacological antidots: Naloxone (drugs) 2-4 ml of 0.5% solution intravenously, before the restoration of spontaneous breathing: if necessary, Introduction to repeat before the appearance of mydriasis.

Start infusion therapy:

400.0 ml of 5-10% glucose solution intravenously drip;

Reopolyglyukin 400.0 ml intravenously drip.

Sodium bicarbonate 300.0 ml 4% intravenously drip;

Inhalation of oxygen;

In the absence of an effect from the introduction of Naloxone - to carry out an IVL in the hyperventilation mode.

Tranquilizer poisoning (Benzodiazepine group)

Diagnostics

Characteristic: drowsiness, ataxia, oppression of consciousness to coma 1, miosis (with non-zirona poisoning - mydriasis) and moderate hypotension.

Tranquilizers of benzodiazepine series cause a deep oppression of consciousness only in "mixture" poisoning, i.e. in combination with barbiturate mi. Neuroleptics and other sedative hypnotic means.

Emergency therapy

Perform paragraphs 1-4 of the general algorithm.

In hypotension: Reopolyglyukin 400.0 ml intravenously, drip:

Barbiturati poisoning

Diagnostics

MIOs, hypersiviation, "solidity" of the skin cover, hypotension, deep depression of consciousness up to coma develops are determined. Barbiturates cause a rapid tissue trophy disorder, forming breakdown, the development of positional compression syndrome, pneumonium.

Urgent Care

Pharmacological antidots (see Note).

Perform paragraph 3 of the general algorithm;

Start infusion therapy:

Sodium bicarbonate 4% 300.0, intravenously drip:

Glucose 5-10% 400.0 ml intravenously drip;

Sulfocamphocain 2.0 ml intravenously.

Inhalation of oxygen.

Poisoning of stimulating effects

These include antidepressants, psychostimulators, generalonizing agents (tincture, including alcohol ginseng, eleutherococcus).

Defined, delirium, hypertension, tachycardia, mydriasis, convulsions, heart rhythm disorders, ischemia and myocardial infarction. Consciousness, hemodynamics and respiration are oppressed after the excitation phase and hyper-tenys.

Poisoning proceed with adrenergic (see Appendix), syndrome.

Antidepressant poisoning

Diagnostics

With a short time (up to 4-6 hours), hypertension is determined. Delia. dryness of the skin and mucous membranes, expansion of the 9k8 complex on the ECG (quinido-like action of tricyclic antide-pressants), convulsive syndrome.

With long-term action (more than 24 hours) - hypotension. Urine delay, coma. Always - mydriasis. dry skin, expansion of the OK8 complex on ECG: antidepressants. Serotonino blockers: fluofacentine (PRESS), fluoroxamine (paroxetine) independently, or in the combination of analgesic can cause "malignant" hyperthermia.

Urgent Care

Perform paragraph 1 of the general algorithm. With hypertension and excitation:

Preparations short action, with a quickly upcoming effect: Ga Lantamine Hydrobromide (or Nivalin) 0.5% - 4.0-8.0 ml, intravenously;

Preparations long action: aminostigmine 0.1% - 1.0-2.0 ml intramuscularly;

In the absence of antagonists - anticonvulsant means: relagnium (sadocent), 20 mg at - 20.0 ml of 40% glucose solution intravenously; or sodium oxybutirate 2.0 g per - 20.0 ml of 40.0% solution of glucose intravenously, slowly);

Perform paragraph 3 of the general algorithm. Start infusion therapy:

In the absence of sodium bicarbonate - Trisole (Dzer. Gloss), 500.0 ml intravenously, drip.

With pronounced arterial hypotension:

Reopolyglyukin 400.0 ml intravenously, drip;

Noraderenalin 0.2% 1.0 ml (2.0) in 400 ml of 5-10% solution of glucose intravenously, drip, increase the speed of administration before stabilization of blood pressure.

Poisoning with tuberculosis drugs (Isoniazid. Film, tubazid)

Diagnostics

Characteristic: generalized convulsive syndrome, the development of stunning. Up to coma, metabolic acidosis. Any convulsive syndrome, resistant to the treatment of benzodiazepines, should be alarmed by isoniazide poisoning.

Urgent Care

Perform paragraph 1 of the general algorithm;

With convulsive syndrome: pyridoxine up to 10 ampoules (5 g). intravenously drip at 400 ml of 0.9% sodium chloride solution; Relanyium 2.0 ml, intravenously. Before relieving convulsive syndrome.

In the absence of the result, the muscle relaxants of the antide-polarizing action (Ardaun 4 mg), the intubation of the trachea, IVL.

Perform paragraph 3 of the general algorithm.

Start info-band therapy:

Sodium bicarbonate 4% 300.0 ml intravenously, drip;

Glucose 5-10% 400.0 ml intravenously, drip. In the arterial hypotension: Reopolyglyukin 400.0 ml intravenously. drip.

Early detoxification hemosorption is effective.

Poisoning toxic alcohols (Methanol, ethylene glycol. Accoselities)

Diagnostics

Characteristic: Effect of intoxication, reduction of visual acuity (methanol), abdominal pain (propyl alcohol; ethylene glycol, accoselity with long exposure), depression of consciousness to a deep coma, decompensated metabolic acidosis.

Urgent Care

Perform paragraph 1 of the general algorithm:

Perform paragraph 3 of the general algorithm:

Pharmacological antidote of methanol, ethylene glycol and accoselves is ethanol.

Initial therapy with ethanol (dose of saturation of 80 kg of body weight of the patient, at the rate of 1 ml of 96% alcohol solution per 1 kg of body weight). For this, 80 ml of 96% of alcohol dilute with water ingredients, give a drink (or enter through the probe). If the alcohol is not possible, a 20 ml of 96% alcohol solution is dissolved in 400 ml of a 5% glucose solution and the alcohol solution obtained glucose is introduced into vein at a rate of 100 drops / min (or 5 ml of solution in min).

Start infusion therapy:

Sodium bicarbonate 4% 300 (400) intravenously, drip;

Azesol 400 ml intravenously, drip:

Hemodez 400 ml intravenously, drip.

When transferring a patient to the hospital to indicate a dose, time and path of administration of ethanol solution at the prehospital stage to ensure the supporting dose of ethanol (100 mg / kg / h).

Ethanol poisoning

Diagnostics

Defined: the oppression of consciousness to the deep coma, hypotension, hypoglycemia, hypothermia, violation of the heart rhythm, respiratory oppression. Hypoglycemia, hypothermia lead to the development of heart rhythm disorders. With an alcoholic coma, the lack of a reaction to Naloxon may be a consequence of a concomitant traumatic brain injury (subdural hematoma).

Urgent Care

Perform paragraphs 1-3 of the total algorithm:

In the oppression of consciousness: Naloxone 2 ml + glucose 40% 20-40 ml + thiamine 2.0 ml intravenously slowly. Start infusion therapy:

Sodium bicarbonate 4% 300-400 ml intravenously drip;

Hemodez 400 ml intravenously drip;

Sodium thiosulfate 20% 10-20 ml intravenously slowly;

Unitiol 5% 10 ml intravenously slowly;

Ascorbic acid 5 ml intravenously;

Glucose 40% 20.0 ml intravenously.

When excited: Relanium 2.0 ml intravenously slowly by 20 ml of 40% glucose solution.

Abstineent status caused by alcohol

When examining the patient in the prehospital stage it is advisable to adhere to certain sequences and the principles of emergency care in acute alcohol poisoning.

· Set the fact of recent alcohol intake and determine its characteristics (the date of the last reception, a winding or one-time reception, the quantity and quality of the drunk, the total duration of the regular alcohol). Amendments to the social status of the patient are possible.

· Install the fact of chronic alcoholic intoxication, Power supply.

· Determine the risk of cancellation syndrome.

· In the framework of toxic whischopathy to determine: the state of consciousness and mental functions, identify gross neurological disorders; Stage of alcohol liver disease, degree of liver failure; To identify the defeat of other target organs and the degree of their functional fullness.

· Determine the state forecast and develop an observation plan and pharmacotherapy.

· Obviously, the clarification of the "alcoholic" history of the patient is to determine the severity of the current acute alcohol poisoning, as well as the risk of developing alcohol cancellation syndrome (for the 3-5 days from the moment of the last alcohol intake).

In the treatment of acute alcohol intoxication, a set of measures aimed at one hand, on the termination of further absorption of alcohol and the accelerated elimination of it from the body, and on the other, to protect and maintain systems or functions suffering from the effects of alcohol.

The intensity of therapy is defined as the severity of acute alcohol intoxication and the general state of the oxane. At the same time, the stomach washing is carried out in order to remove not yet attempted alcohol, and drug therapy with disinfectants and alcohol antagonists.

In the treatment of alcohol abstinence The doctor takes into account the severity of the main components of the abstinence syndrome (somato-vegetative, neurological and mental disorders). Mandatory components are vitamin and disintellation therapy.

Vitaminotherapy includes parenteral administration of thiamine solutions (VIT B1) or pyridoxine hydrochloride (VIT B6) - 5-10 ml. With pronounced tremor, a solution of cyancobalamina is prescribed (VIT B12) - 2-4 ml. The simultaneous introduction of various vitamins of the group is not recommended, due to the possibility of enhancing allergic reactions and their incompatibility in one syringe. Ascorbic acid (VIT C) - up to 5 ml is introduced intravenously together with plasma-substituting solutions.

Disinfection therapy includes the introduction of thic drugs - 5% of the system of unitiola (1 ml by 10 kg of body weight intramuscularly) or 30% sodium solution of thiosulfate (up to 20 ml); hypertensive - 40% glucose - up to 20 ml, 25% sulfate magnesia (up to 20 ml), 10% calcium chloride (up to 10 ml), isotonic - 5% glucose (400-800 ml), 0.9% sodium chloride solution (sodium 400-800 ml) and plasma-substituting - hemodez (200-400 ml) solutions. It is also advisable, also, intravenous administration of a 20% piracetam solution (up to 40 ml).

These testimony activities are complemented by the relief of somato-vegetative, neurological and mental disorders.

With an increase in blood pressure, a 2-4 ml of the hydrochloride or dibazole hydrochloride or dibazole solution is injected intramuscularly;

In case of violation of the heart rhythm, analeptics are prescribed - a solution of Cordiamine (2-4 ml), camphor (up to 2 ml), potassium preparations Panangin (up to 10 ml);

When breathing, breathing is intravenously introduced to 10 ml of 2.5% of the solution of euphilline.

The reduction in dyspeptic phenomena is achieved by the introduction of the regulated solution (Cerukhala - up to 4 ml), as well as spasmalgets - barallin (up to 10 ml), but-shts (up to 5 ml). The baralginium solution along with a 50% an anal phase solution is shown, also, to reduce the severity of headaches.

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