Intravenous blood transfusion

Intravenous is the main route of blood infusion. Most often, puncture of the vein of the elbow or subclavian vein is used, less often they resort to venesection. For puncture of the vein of the elbow bend, a rubber tourniquet is applied to the lower third of the shoulder, the operating field is treated with alcohol or an alcoholic solution of iodine and isolated with sterile linen. Only the veins are squeezed with a tourniquet (the arteries are passable), and when the fingers are squeezed into a fist and the muscles of the forearm are contracted, they are well contoured.

The Dufo needle is taken with the fingers for the pavilion or put on a syringe, pierced the skin, subcutaneous tissue, the needle is advanced several (about 1 cm) in the subcutaneous tissue above the vein, its front wall is pierced and then advanced through the vein. The appearance of a stream of blood from the needle when the vein wall is punctured indicates a correctly performed vein puncture. 3-5 ml of blood is taken from the vein for the control determination of the recipient's blood group and testing for compatibility. The tourniquet is then removed and a system for infusing a fluid, such as isotonic sodium chloride solution, is attached to the needle to prevent needle thrombosis. The needle is fixed to the skin with a strip of adhesive plaster.

After determining the blood group according to the AB0 system and the Rh factor, conducting a test for compatibility, connect the blood transfusion system and begin the transfusion.

When it is impossible to puncture superficial veins (collapsed veins in shock, pronounced obesity), venesection is performed. The operating field is treated with alcohol or an alcoholic solution of iodine, isolated with sterile surgical linen. The incision site is infiltrated with 0.25% procaine solution. A tourniquet is applied to the limb without squeezing the arteries. The skin, subcutaneous tissue are dissected and a vein is isolated with tweezers. Two ligatures are brought under it, while the peripheral one serves as a holder. Pulling the vein by the holder, it is punctured with a needle towards the center or the wall is cut with scissors, the needle is inserted and fixed with a central ligature. A blood transfusion system is connected to the needle, 2-3 sutures are applied to the skin.

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At the end of the transfusion, when about 20 ml of blood remains in the system, the system is clamped and disconnected, and the needle is removed. The puncture or venesection site is lubricated with an alcohol solution of iodine and a pressure bandage is applied.

In cases where a long (several days) transfusion of solutions, blood and its components is assumed, a puncture of the subclavian or external jugular vein is performed, a special catheter is introduced into the lumen of the vein, which can be in it for a long time (up to 1 month), and to it at if necessary, connect a system for blood transfusion or other transfusion media.

Intra-arterial blood transfusion Indications: a state of clinical death (respiratory and cardiac arrest) caused by massive massive blood loss; severe traumatic shock with a long-term decrease in SBP to 60 mm Hg, ineffectiveness of intravenous blood transfusions.

The therapeutic effect of intra-arterial transfusion is determined by reflex stimulation of cardiovascular activity and the restoration of blood flow through the coronary vessels. To achieve the effect, blood is injected at a rate of 200-250 ml for 1.5-2 minutes under a pressure of 200 mm Hg, with the restoration of cardiac activity, the pressure is reduced to 120 mm Hg, and with a clearly defined pulse, they switch to intravenous infusion blood; when the systolic blood pressure is stabilized at 90100 mm Hg. the needle is removed from the artery.

The system for intra-arterial blood transfusion is similar to that for intravenous administration, with the exception that a Richardson balloon is connected to a long needle inserted into the vial for air injection, connected through a T-piece to a pressure gauge (Fig. 40). The artery is punctured through the skin with a Dufo needle or arteriosection is performed.

Figure: 40. System for intra-arterial blood transfusion. THE BASIC ACTIONS OF THE DOCTOR AND THE SEQUENCE OF THEIR PERFORMANCE FOR BLOOD TRANSFUSION

Blood transfusion is a serious operation to transplant human living tissue. This method of treatment is widespread in clinical practice. Blood transfusion is used by doctors of various specialties: surgeons, obstetricians-gynecologists, traumatologists, therapists, etc.

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Achievements of modern science, in particular transfusiology, make it possible to prevent complications in blood transfusion, which, unfortunately, still occur and sometimes even end in the death of the recipient. The cause of complications is errors in blood transfusion, which are caused by insufficient knowledge of the basics of transfusion or violation of the rules of blood transfusion technique at various stages. These include incorrect determination of indications and contraindications for transfusion, erroneous determination of group or Rh-affiliation, incorrect testing of the individual compatibility of donor and recipient blood, etc. Success is determined by scrupulous, competent implementation of the rules and reasonable consistent actions of the doctor during blood transfusion.

Determination of indications for blood transfusion

Blood transfusion is a serious intervention for a patient, and the indications for it must be justified. If it is possible to provide effective treatment for a patient without blood transfusion or there is no confidence that it will benefit the patient, it is better to refuse transfusion. Indications for blood transfusion are determined by the pursued goal: reimbursement of the missing volume of blood or its individual components, increase in the activity of the blood coagulation system during bleeding. The absolute indications are acute blood loss, shock, bleeding, severe anemia, severe traumatic surgeries, including those with artificial circulation. Indications for transfusion of blood and its components are anemia of various origins, blood diseases, purulent-inflammatory diseases, and severe intoxication.

Preparing a patient for blood transfusion

In a patient admitted to a surgical hospital, the blood group and the Rh factor are determined. A study of the cardiovascular, respiratory, and urinary systems is carried out in order to identify contraindications to blood transfusion. A general blood test is done 1-2 days before the transfusion; before the blood transfusion, the patient must empty the bladder and intestines. Transfusion is best done in the morning on an empty stomach or after a light breakfast. Evaluation of the suitability of canned blood and its components for transfusion

Before transfusion, determine the suitability of blood for transfusion (Fig. 41, see color incl.): Check the integrity of the package, expiration date, blood storage mode (possible freezing, overheating). It is most advisable to transfuse blood with a shelf life of no more than 5-7 days, since with an extension of the shelf life, biochemical and morphological changes occur in the blood, which reduce its positive properties. When macroscopic assessment of blood should have three layers. At the bottom is a red layer of erythrocytes, then a thin layer of leukocytes, and on top is a transparent, slightly yellowish plasma. Signs of unsuitable blood are red or pink staining of plasma (hemolysis), the appearance of flakes in it, turbidity, the presence of a film on the plasma surface (signs of blood infection), clots (blood coagulation). In case of urgent transfusion of unstable blood, part of it is poured into a test tube and centrifuged. Pink staining of plasma indicates hemolysis. When transfusing frozen blood components, blood packs are quickly heated to 38 ° C, then the erythrocytes are washed from the used cryoprotectant (glycerol - for erythrocytes, dimethyl sulfoxide - for leukocytes and platelets).

Testing for compatibility

To determine individual compatibility, 3-5 ml of blood is taken from a vein into a test tube and, after centrifugation or settling, one large drop of serum is applied to a plate or plate. A drop of donor's blood is applied nearby in a ratio of 5: 1 - 10: 1, stirred with a corner of a glass slide or a glass rod and observed for 5 minutes, after which a drop of isotonic sodium chloride solution is added and the result is assessed by the presence or absence of agglutination. The absence of agglutination indicates the group compatibility of the donor's and recipient's blood, its presence indicates incompatibility (Fig. 42, see color incl.). A test for individual compatibility should be carried out with each vial of transfused blood. Group blood compatibility is schematically shown in Fig. 43. Figure: 43. Compatibility of blood groups (scheme).

Determination of blood compatibility by the Rh factor is carried out in the case of an unfavorable transfusion history (post-transfusion reactions with

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blood transfusions in the past, Rh-conflict pregnancy, miscarriages), in critical situations when it is impossible to determine the Rh-factor of the recipient's blood, and in the case of forced transfusion of Rh-positive blood to a patient with an unknown Rh-factor.

Blood is taken from the recipient's vein, as well as to determine individual (group) compatibility, and centrifuged. A centrifuge or other glass tube with a capacity of at least 10 ml is used for research. The use of plastic tubes and smaller tubes makes it difficult to evaluate the results. On the test tube, you must indicate the surname, initials, blood group of the patient, surname, initials, blood group of the donor and the number of the container with blood.

On the wall of the test tube with a pipette apply 2 drops of the patient's serum, 1 drop of donor blood, 1 drop of 33% dextran solution [cf. pier weight 50,000-70,000], then the test tube is tilted almost to a horizontal position and slowly rotated for 3 minutes so that its contents spread along the walls (this makes the reaction more pronounced). Then add 2-3 ml of isotonic sodium chloride solution to the test tube and mix by inverting the test tube 2-3 times to the horizontal level (do not shake!).

Turning the test tube over, look through it at a light or fluorescent lamp. If the contents of the test tube remain uniformly colored and there are no signs of agglutination, the liquid slightly opalescent when turned over, which means that the donor's blood is compatible with the patient's blood, and there are no isoimmune antibodies in it.

If agglutination of erythrocytes is observed in the test tube in the form of a suspension of small or large lumps against the background of a clear or completely discolored liquid, then the donor's blood is incompatible with the patient's blood and cannot be transfused (Fig. 44, see color incl.).

This test simultaneously allows you to determine the compatibility of blood in the presence of other isoimmune antibodies (Kell, Lutheran, Kidd, etc.), in fact, it can be considered universal for determining the compatibility of blood in the presence of isoimmune sensitization in the recipient.

In cases where true agglutination is detected during tests for group compatibility according to the AB0 or ​​Rh factor system, an individual selection of donor blood at the blood transfusion station is required. If the patient's condition requires an emergency blood transfusion, it is selected from the available supply - of the same name in the group and Rh-factor, without waiting for the results of the study and blood flow from the transfusion station. With blood from each vial and serum of the recipient, a test for group compatibility is carried out according to the AB0 system and the Rh factor. If there is no agglutination, this blood can be transfused to the patient, starting the transfusion with a biological sample. If agglutination is detected in samples for group and Rh-belonging with the same blood from all vials from the available blood supply, the latter cannot be transfused,

Having received blood from the transfusion station, it is necessary to perform a control determination of its blood group and Rh-factor in the vial, as well as tests for group and Rh compatibility. Only if the group and resuspendency of the blood of the donor and the patient coincide and there is no agglutination in the samples for group compatibility according to the AB0 system and the Rh factor, you can start blood transfusion, starting with a biological sample. Classification of bleeding I. Depending on the cause of the occurrence:

a) mechanical damage, rupture of blood vessels (haemorrhagia per rhexin);

b) arrosive bleeding (haemorrhagia per diabrosin);

c) diapedetic bleeding (haemorrhagia per diapedesin);

d) violation of the chemical composition of the blood, changes in the coagulation and anticoagulation system of the blood.

II. Taking into account the type of the bleeding vessel:

a) arterial;

b) arteriovenous;

c) venous;

d) capillary;

e) parenchymal.

III. In relation to the external environment and clinical manifestations:

a) external;

b) internal;

c) hidden.

IV. By the time of occurrence:

a) primary;

b) secondary.

he nature of bleeding is determined by the type of damaged vessel.

With arterial bleeding , scarlet blood beats in a pulsating stream. The larger the vessel, the stronger the stream and the greater the volume of blood lost per unit of time.

With venous bleeding the outflow of blood is constant, only when the damaged vein is located next to a large artery is transmission pulsation possible, as a result of which the blood stream will be intermittent. When large veins in the chest area are damaged, a pulse of the heart is transmitted to the blood stream or the suction effect of the chest is influenced (when you inhale, bleeding slows down, when you exhale, it increases). Only at high venous pressure, for example, when the varicose veins of the esophagus rupture, there is a jet outflow of blood. In case of damage to the large veins of the neck or the subclavian vein, severe complications and even death due to air embolism may develop. This is due to the negative pressure in these veins, which occurs during inhalation, and the possible flow of air through the damaged vessel wall. Venous blood is dark in color.

Capillary bleeding is mixed, arterial and venous blood flows out. In this case, the entire wound surface bleeds, after removal of the outflowing blood, the surface is again covered with blood.

Parenchymal bleeding is observed when the parenchymal organs are damaged: liver, spleen, kidneys, lungs, etc. They are essentially capillary, but they are more massive, difficult to stop and more dangerous due to the anatomical features of the structure of the vessels of these organs.

Methods for temporarily stopping bleeding

Harness overlay

The most reliable method is a tourniquet, but it is mainly used in the limbs.Figure: 28. Application of a tourniquet: a - preparation for the imposition of a tourniquet; b - start of overlay; c - fixing the first round; d - the final view after the application of the tourniquet.

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The hemostatic tourniquet is a 1.5 m long rubber band, ending on one side with a metal chain and on the other with a hook. With established arterial bleeding, a tourniquet is applied proximal to the injury site.

The proposed area of ​​application of the tourniquet is wrapped in a soft material (towel, sheet, etc.), i.e. create a soft pad. The tourniquet is stretched, applied closer to the chain or hook and made with a tourniquet of 2-3 rounds, subsequent turns are applied, stretching the tourniquet. Then the hook is attached to the chain (fig. 28). Be sure to indicate the time of application of the tourniquet, since the compression of the artery by it for more than 2 hours on the lower limb and 1.5 hours on the upper limb is fraught with the development of limb necrosis. The control of the correct application of the tourniquet is the cessation of bleeding, the disappearance of pulsation of the peripherally located arteries and a slight "waxy" pallor of the skin of the limb. If the transportation of the wounded takes more than 1.5-2 hours, the tourniquet should be periodically removed for a short time (10-15 minutes) until the arterial blood flow is restored. In this case, the damaged vessel is pressed down with a swab in the wound or finger pressure of the artery is performed. Then the tourniquet is applied again, slightly above or below the place where it was. Figure: 29. The imposition of an army harness.

Subsequently, if necessary, the procedure for removing the tourniquet is repeated: in winter - after 30 minutes, in summer after 50-60 minutes.

To stop bleeding, a special army tourniquet or an impromptu twist can be used (Fig. 29).

The application of a tourniquet on the neck (with bleeding from the carotid artery) with a bar or through the armpit on the healthy side is rarely resorted to. You can use the Cramer splint applied to the healthy half of the neck, which serves as a frame (Fig. 30). A tourniquet is pulled over it, which presses the gauze roller and squeezes the vessels from one side. In the absence of a tire, you can use the opposite hand as a frame - it is placed on the head and bandaged. The imposition of a tourniquet to compress the abdominal aorta is dangerous because injury to internal organs can occur.

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Figure: 30. Application of a tourniquet on the neck.Figure: 31 . The imposition of a tourniquet in case of damage to the femoral (a) and axillary (b) arteries

The application of a tourniquet for bleeding from the femoral and axillary arteries is shown in Fig. 31.

After the application of the tourniquet, the limb is immobilized with a transport tire; in the cold season, the limb is wrapped in order to avoid frostbite. Then, after the administration of analgesics, the victim with a tourniquet is quickly transported to the clinic in a supine position.

Rough and prolonged compression of tissues with a tourniquet can lead to paresis and paralysis of the limb due to both traumatic damage to the nerve trunks and ischemic neuritis, which develops as a result of oxygen starvation. The lack of oxygen in the tissues located distal to the imposed tourniquet creates a fertile ground for the development of anaerobic gas infection, i.e. for the growth of bacteria that multiply without oxygen. Given the risk of severe complications, it is better to temporarily stop bleeding by applying a pneumatic cuff to the proximal part of the limb. In this case, the pressure in the cuff should slightly exceed the blood pressure.

Finger pressure of an artery

Finger pressing of the artery throughout, if done correctly, leads to the cessation of bleeding, but it is short-lived, since it is difficult to continue pressing the vessel for more than 15-20 minutes. The artery is pressed in those areas where the arteries are located superficially and near the bone: the carotid artery is the transverse process C 6 , the subclavian is the I rib, the humerus is the area of ​​the inner surface of the humerus

femoral artery - pubic bone (Fig. 32, 33). It is good to press the brachial and femoral arteries, worse - the carotid.

It is even more difficult to compress the subclavian artery due to its location (behind the collarbone). Therefore, when bleeding from the subclavian and axillary arteries, it is better to fix the arm by placing it back as much as possible. In this case, the subclavian artery is squeezed between the clavicle and the 1st rib. Finger pressing of the artery is especially important in preparation for the application of a tourniquet or its change, and also as a technique for limb amputation. Figure: 32. Places of pressing of the arteries for the temporary stop of bleeding.Figure: 33. Finger pressing of the carotid (a), facial (b), temporal (c), subclavian (d), brachial (e), axillary (f), femoral (g) arteries for temporary stop

bleeding.

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Flexion of the limb in the joint

Flexion of the limb in the joint is effective if the arm bent to failure is fixed in the elbow joint during bleeding from the vessels of the forearm or hand, and the legs - in the knee joint during bleeding from the vessels of the leg or foot. With high lesions of the femoral artery, inaccessible to the application of a tourniquet, the thigh should be fixed to the abdomen with maximum flexion of the limb in the knee and hip joints (Fig. 34).Figure: 34. Temporary arrest of bleeding from arteries by maximum flexion: a - from the femoral artery; b - from the popliteal; c - from the shoulder and elbow.

Tamponade the wound and apply a pressure bandage

Tamponade of the wound and the immobilization of a pressure bandage, provided that the limb is elevated, is a good method of temporarily stopping bleeding from veins and small arteries, from the soft tissues covering the bones of the skull, elbow and knee joints. For a tight tamponade, a gauze swab is inserted into the wound, filling it tightly, and then fixed with a pressure bandage. Tight tamponade is contraindicated for injuries in the popliteal fossa, since in these cases gangrene of the limb often develops. Pressure with a load (sandbag) or in combination with cooling (ice bladder) is used for interstitial bleeding, and is also often used as a method of preventing postoperative hematomas.

Pressing the vessel in the wound with fingers

Pressing the vessel in the wound with fingers is carried out in emergency situations, sometimes during surgery. For this purpose, the doctor quickly puts on a sterile glove or treats the hand with alcohol, iodine and presses or squeezes the vessel in the wound, stopping the bleeding.

Applying a hemostat

In case of bleeding from damaged deeply located vessels of the proximal parts of the limb, abdominal cavity, chest, when the above methods of temporarily stopping bleeding cannot be applied, a hemostatic clamp is applied to the bleeding vessel in the wound. To avoid injury to nearby formations (nerves), you must first try to stop the bleeding by pressing the vessel with your fingers, and then apply a clamp directly to the bleeding vessel, after draining the wound from the blood.

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Temporary vessel bypass

Temporary bypass grafting is a way to restore blood circulation in case of damage to large arterial vessels. A tight-elastic tube is inserted into both ends of the damaged artery and the ends of the vessel are fixed on the tube with ligatures. With this temporary shunt, arterial circulation is restored. The shunt can function from several hours to several days, until the possibility of final stopping the bleeding appears.

Methods for permanent control of bleeding

Methods for the final stop of bleeding are divided into four groups: 1) mechanical, 2) physical, 3) chemical and biological, 4) combined.

Terminal states

There are three types of terminal states: preagonal state, agony, clinical death.

• Preagonal state. The patient is inhibited, there is severe shortness of breath, the skin is pale, cyanotic, blood pressure is low (60-70 mm Hg) or not determined at all, the pulse is weak and frequent.

• Agony. The deep stage of the dying process, in which there is no consciousness, the pulse is threadlike or disappears altogether, blood pressure is not determined. Breathing is shallow, rapid, convulsive or significantly slowed down.

• Clinical death occurs immediately after the cessation of breathing and blood circulation. This is a kind of transitional state from life to death, lasting 3-5 minutes. The main metabolic processes are sharply reduced and in the absence of oxygen are carried out due to anaerobic glycolysis. After 5-6 minutes, irreversible phenomena develop, primarily in the central nervous system, and true, or biological, death occurs.

Cardiac arrest can be sudden or gradual - against the background of a long-term chronic illness, in the latter case it is preceded by a preagonal state and agony. The causes of sudden cardiac arrest are myocardial infarction, blockage (obstruction) of the upper respiratory tract by foreign bodies, reflex cardiac arrest, heart injury, anaphylactic shock, electrical trauma, drowning, severe metabolic disorders (hyperkalemia, metabolic acidosis).

Signs of cardiac arrest, i.e. the onset of clinical death:

1) lack of pulse in the carotid artery;

2) dilation of the pupils with the absence of their response to light;

3) respiratory arrest;

4) lack of consciousness;

5) pallor, less often cyanosis of the skin;

6) lack of pulse in the peripheral arteries;

7) absence of blood pressure;

8) lack of heart sounds.

The time to diagnose clinical death should be as short as possible.

Absolute signs: no pulse in the carotid artery, respiratory arrest, dilated pupils with no reaction to light. If these signs are present, resuscitation should be started immediately.

Cardiopulmonary resuscitation

There are four stages of cardiopulmonary resuscitation:

I - restoration of airway patency;

II - mechanical ventilation;

III - heart massage;

IV - differential diagnosis, drug therapy, cardiac defibrillation.

The first three stages can be carried out in an out-of-hospital setting, and not necessarily by medical personnel, by persons with the appropriate resuscitation skills. Stage IV is carried out by doctors of ambulance and intensive care units.

Stage I - airway restoration

The cause of impaired airway patency can be mucus, sputum, vomit, blood, foreign bodies, tongue retraction.

The victim or patient must be laid on his back on a hard surface, turning his head to one side, open his mouth with crossed fingers I and II of the left hand and clean the oral cavity with a handkerchief (napkin) wound around II or III finger of the right hand (Fig. 22). Then the head must be turned straight and thrown back as much as possible. In this case, one hand is located under the neck, the other on the forehead, fixing the head. When the head is thrown back, the lower jaw is pushed back together with the root of the tongue, as a result the patency of the airways is restored (Fig. 23). To eliminate their obstruction, air ducts are also used (Fig. 24).

Stage II - mechanical ventilation At the first stages, cardiopulmonary resuscitation is carried out by mouth-to-mouth, mouth-to-nose and mouth-to-mouth and nose methods (Fig. Figure: 22 . Removal of mucus and foreign contents from the oral cavity and pharynxFigure: 23. Tongue sinking (a) and its elimination by throwing the head back (b) or pushing the lower jaw (c, d).Figure: 24. Prevention of mechanical asphyxiation by means of an air duct.

Figure: 25. Artificial ventilation of the lungs: a - from mouth to mouth; b - from mouth to nose; c - from mouth to mouth and nose; d - through the air duct.

To conduct artificial respiration from mouth to mouth, the assisting person stands to the side of the victim (and if he is lying on the ground, he kneels), puts one hand under the neck, puts the other on the forehead, throws his head back as much as possible, and clamps the wings of the nose with fingers I and II , takes a breath and, pressing his mouth tightly to the victim's mouth, makes a sharp exhalation. Then it is removed until the patient performs a passive exhalation. The volume of the blown air is from 500 to 700 ml. Respiratory rate - 12-18 per minute. The control of the correctness of artificial respiration is an excursion of the chest - swelling during inhalation and collapse during exhalation.

In case of traumatic injuries of the lower jaw or if the jaws are tightly clenched, it is recommended to perform mechanical ventilation from the mouth to the nose. To do this, putting a hand on the victim's forehead, throw his head back, grab the lower jaw with the other hand and press it tightly against the upper jaw, closing his mouth. Lips capture the victim's nose and exhale. In newborns, mechanical ventilation is performed from mouth to mouth and nose. The child's head is thrown back. With his mouth, the resuscitator covers the child's mouth and nose and inflates. The respiratory volume of the newborn is 30 ml, the respiratory rate is 25-30 per minute.

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Ventilation using the described methods must be carried out through gauze or a handkerchief to prevent infection of the respiratory tract of the caregiver. The ventilator can use an S-shaped tube (airway). The tube is curved, keeps the root of the tongue from sinking and thereby prevents airway obstruction. The tube is inserted into the oral cavity with the curved end up, sliding along the lower edge of the upper jaw. At the level of the tongue root, it is rotated around the axis by 180 °. The cuff of the tube tightly covers the victim's mouth, and his nose is pinched with his fingers. Breathing is carried out through the free lumen of the tube

(see Fig. 25, d).

Ventilation can also be performed with a face mask with an Ambu bag. Having fixed the victim's head in a thrown back position, a mask is applied to his face, covering his mouth and nose. The narrow nose of the mask is held with a thumb, the lower jaw is lifted up with three fingers (III, IV, V). The second finger fixes the lower part of the mask. Inhale is performed by rhythmic squeezing of the bag with the free hand, passive exhalation is carried out through a special valve into the atmosphere. Oxygen can be supplied to the bag.

Stage III - heart massage

Compression of the heart artificially creates cardiac output and maintains blood circulation in the body. At the same time, blood circulation of vital organs is restored: brain, heart, lungs, liver, kidneys. The effectiveness of artificial respiration and blood circulation is determined by the narrowing of the pupils, the presence of pulsation in the carotid and femoral arteries with compression of the chest and heart, a decrease in pallor and cyanoticity of the skin. Distinguish between indirect (closed) and

direct (open) heart massage.

At the prehospital stage, as a rule, an indirect massage is performed , in which the heart is squeezed between the sternum and the spine. Manipulation is carried out by placing the patient on a hard surface or placing a shield under his chest. The palms are placed one on top of the other at right angles, placing them on the lower third of the sternum and retreating upward from the point of attachment of the xiphoid process to the sternum by 2 cm (Fig. 26). Pressing on the sternum with an effort equal to 8-9 kg, it is shifted to the spine by 4-5 cm. The heart massage is carried out continuously by rhythmic pressure on the sternum with straightened arms at a frequency of 60 per minute.

In children under 10 years of age, heart massage is performed with one hand with a frequency of 80 pressures

per minute. In newborns, external heart massage is performed with two (II and III) fingers, placing them parallel to the sagittal plane of the sternum. Pressing frequency - 120

per minute.

Direct heart massage is used for operations on the chest, multiple rib fractures, chest deformities and ineffective indirect massage. To carry out a direct massage of the heart, the chest is opened in the fourth intercostal space on the left. The hand is inserted into the chest cavity, four fingers are brought under the lower surface of the heart, the thumb is placed on its front surface. Massage is performed by rhythmic heart compression. For operations where the chest is wide open, heart massage can be performed with two hands. With cardiac tamponade, the pericardium should be opened.

Resuscitation measures can be carried out by one or two people (Fig. 27). If one person is helping, he stands to the side of the victim. After

to establish a diagnosis of cardiac arrest, cleanse the mouth and produce 4 blows into the lungs by mouth-to-mouth or mouth-to-nose methods. Then 15 pressures on the sternum are successively alternated with 2 blows into the lungs.Figure: 26. Indirect cardiac massage.Figure: 27. Cardiopulmonary resuscitation performed by one (a) and two (b) persons.

If resuscitation is carried out by two people, one of them performs a heart massage, the other - mechanical ventilation. The ratio between mechanical ventilation and closed massage is 1: 5, i.e. one blowing into the lungs is carried out every 5 pressures on the sternum.

Conductive ventilation controls the correctness of the heart massage by the presence of pulsation on the carotid artery, and also monitors the state of the pupils. Resuscitators periodically change places.

Resuscitation measures in newborns are carried out by one person, who successively alternates 3 injections into the lungs and 15 pressures on the sternum.

Effective resuscitation is considered when the resumption of independent heart contractions, pupil constriction and the appearance of their reaction to light, restoration of skin color and blood pressure level not lower than 70 mm Hg. Resuming spontaneous breathing is not necessary.

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The resuscitator should periodically monitor the condition of the pupils. Every 2-3 minutes it is necessary to stop the heart massage in order to determine the appearance of independent heart contractions by the pulse on the carotid artery. From this moment on, heart massage is stopped and mechanical ventilation is continued. The indication for the termination of resuscitation measures in case of their ineffectiveness are clear signs of biological death.

The stages of cardiopulmonary resuscitation (restoration of airway patency, mechanical ventilation, chest compressions) are taught to the broad masses of the population - schoolchildren, industrial workers, students, employees of special services (police, traffic police, fire brigade, water rescue services), nurses ...

Stage IV - differential diagnosis, drug therapy, cardiac defibrillation

The fourth stage is carried out only by specialist doctors in the intensive care unit or intensive care unit. At this stage, such complex manipulations are performed as an ECG study, intravenous or intracardiac administration of drugs: 0.1% epinephrine solution - 1 ml in 10 ml of 0.9% sodium chloride solution; 10% calcium chloride solution - 10 ml; 2% sodium bicarbonate solution - 20 ml. It is permissible to administer epinephrine endotracheally (through an endotracheal tube or by puncturing the trachea) due to the high absorption capacity of the tracheal mucosa.

In case of large-wave fibrillation recorded by a cardioscope or electrocardiograph, defibrillation is performed (current power - starting from 3 kW).

LOCAL ANESTHESIA

Local anesthesia - reversible elimination of pain sensitivity in

a certain part of the body, caused by the action of special medicines.

Currently, about 50% of surgical operations are performed under local anesthesia.

Indications for local anesthesia are determined by its advantages: no special long-term preoperative preparation is required; it can be used in cases where there are contraindications to anesthesia; the patient does not need constant postoperative observation, as after anesthesia. Surgeries are performed on an outpatient basis under local anesthesia. Local anesthesia is indicated in cases where the operation under intubation anesthesia is associated with a great risk to the patient's life. This group of patients includes elderly and senile persons, emaciated, suffering from respiratory and cardiovascular insufficiency. In these cases, anesthesia can be more dangerous than the operation itself.

Contraindications for local anesthesia:

1) intolerance to patients with anesthetics due to increased individual sensitivity;

2) age is less than 10 years;

3) the presence of mental disorders, increased nervous excitability in patients;

4) the presence of inflammatory or cicatricial changes in tissues that impede the performance of infiltration anesthesia;

5) ongoing internal bleeding, which requires urgent surgery to stop.

The main drugs for local anesthesia and their properties are shown in table. 1.

Table 1. Pharmacological characteristics of local anesthetics.

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In general preparation for the operation, the patient is introduced to the peculiarities of local anesthesia: consciousness, tactile and deep sensitivity are preserved, but there is no feeling of pain. This is psychological preparation. Before the operation, premedication is performed (injections of solutions of trimeperidine, atropine, droperidol), tranquilizers are prescribed to patients with a labile nervous system a few days before the operation.