Presentation on the topic of terminal conditions. Presentation on life expectancy "terminal conditions". Conceptually, the dynamics of dying are represented by a chain of pathophysiological events

28.01.2024

Terminal state is a critical level of dysfunction with a catastrophic drop in blood pressure, profound disturbances in gas exchange and metabolism. During the provision of surgical care and intensive therapy, acute development of extreme respiratory and circulatory disorders with severe, rapidly progressing cerebral hypoxia is possible.

The second feature of the dying process is a general pathophysiological mechanism that occurs regardless of the cause of dying - one or another form of hypoxia, which, as dying progresses, becomes mixed with a predominance of circulatory disorders, often combined with hypercapnia. The cause of the disease largely determines the course of the dying process and the sequence of extinction functions of organs and systems (respiration, blood circulation, central nervous system). If the heart is initially affected, then in the process of dying, the phenomena of heart failure prevail, followed by damage to the function of external respiration and the central nervous system. The second feature of the dying process is a general pathophysiological mechanism that occurs regardless of the cause of dying - one or another form of hypoxia, which, as dying progresses, becomes mixed with a predominance of circulatory disorders, often combined with hypercapnia. The cause of the disease largely determines the course of the dying process and the sequence of extinction functions of organs and systems (respiration, blood circulation, central nervous system). If the heart is initially affected, then in the process of dying, the phenomena of heart failure prevail, followed by damage to the function of external respiration and the central nervous system.

Clinical picture: preagonal state General lethargy Impaired consciousness up to stupor or coma Hyporeflexia Decrease in systolic blood pressure below 50 mm Hg Pulse in the peripheral arteries is absent, but palpated in the carotid and femoral arteries Severe shortness of breath Cyanosis or pallor of the skin General lethargy Impaired consciousness up to to stupor or coma Hyporeflexia Decrease in systolic blood pressure below 50 mm Hg Pulse in the peripheral arteries is absent, but palpable in the carotid and femoral arteries Severe shortness of breath Cyanosis or pallor of the skin

Terminal pause This transition period lasts from 5-10 seconds to 3-4 minutes and is characterized by the fact that after tachypnea the patient experiences apnea, cardiovascular activity sharply worsens, and conjunctival and corneal reflexes disappear. It is believed that the terminal pause occurs as a result of the predominance of the parasympathetic nervous system over the sympathetic nervous system under hypoxic conditions.

Clinical death Recorded from the moment of complete cessation of breathing and cessation of cardiac activity. If it is not possible to restore and stabilize vital functions within 5–7 minutes, then the death of the cells of the cerebral cortex that are most sensitive to hypoxia occurs, and then biological death.

Primary clinical signs Clearly identified in the first 10–15 seconds from the moment of circulatory arrest Sudden loss of consciousness Disappearance of the pulse in the main arteries Clonic and tonic convulsions Clearly identified in the first 10–15 seconds from the moment of circulatory arrest Sudden loss of consciousness Disappearance of the pulse in the main arteries Clonic and tonic convulsions

Symptom complex of clinical death * lack of consciousness, blood circulation and breathing * areflexia * lack of pulsation in large arteries * adynamia or small-amplitude convulsions * dilated pupils that do not respond to light * cyanosis of the skin and mucous membranes with an earthy tint * lack of consciousness, blood circulation and breathing * areflexia * absence pulsations in large arteries * adynamia or small-amplitude convulsions * dilated pupils that do not respond to light * cyanosis of the skin and mucous membranes with an earthy tint

Basic life support. 1. Restoration of airway patency. 2. Artificial maintenance of respiration. 3. Artificial maintenance of blood circulation. The goal is emergency oxygenation, the resumption of blood circulation sufficiently saturated with oxygen, primarily in the basins of the cerebral and coronary arteries

Ensuring patency of the upper respiratory tract Throwing back the head with hyperextension of the neck Bringing forward the lower jaw Using a breathing tube (nasal or oral S-shaped airway) Intubation of the trachea (in an operating room or intensive care ward)

Preparing for artificial respiration: push the lower jaw forward (a), then move the fingers to the chin and, pulling it down, open the mouth; with the second hand placed on the forehead, tilt the head back (b). Preparation for artificial respiration: push the lower jaw forward (a), then move the fingers to the chin and, pulling it down, open the mouth; with the second hand placed on the forehead, tilt the head back (b).

Place of contact of the arm and sternum Place of contact of the arm and sternum Position of the patient and those providing assistance during chest compressions. Scheme of indirect cardiac massage: a - laying hands on the sternum b - pressing on the sternum a - laying hands on the sternum b - pressing on the sternum

Stage 2 Further life support. Stages: Drug therapy. Electrocardiography or electrocardioscopy. Defibrillation Goal: restoration of spontaneous circulation, consolidation of the success of revival, if it is achieved and spontaneous circulation is restored as a result of the pumping function of the patient’s myocardium.

Below is the dosage of some medications used for CPR Adrenaline - 1 ml of 0.1% solution (1 mg) every 3-5 minutes. until clinical effect is obtained. Each dose is accompanied by the introduction of 20 ml of saline solution. Norepinephrine – 2 ml of 0.2% solution, diluted in 400 ml of saline solution. Atropine – 1.0 ml of 0.1% solution every 3-5 minutes. until the effect is obtained, but not more than 3 mg. Lidocaine (for extrasystole) - initial dose mg (1-1.5 mg/kg).

INDICATIONS AND CONTRAINDICATIONS FOR CPR Lack of consciousness, breathing, pulse in the carotid arteries, dilated pupils, lack of reaction of the pupils to light; Unconscious state, rare, weak, thread-like pulse, shallow, rare, fading breathing.

Criteria for ending CPR: establishing the irreversibility of brain damage; Long-term lack of restoration of spontaneous circulation; Clinical indicators of the effectiveness of resuscitation measures; · the appearance of pulsation in large vessels - the carotid, femoral and ulnar arteries. -· systolic blood pressure not lower than 60 mmHg. -· constriction of the pupils -· pinking of the skin and visible mucous membranes -· registration of cardiac complexes on the ECG

Definition: Terminal states are extreme
states close to the border of life and
deaths, transition from life to death.
!!! All terminal states are reversible
(subject to timely, correct
carrying out resuscitation measures);
possible at all stages of dying
revival.

Conceptually, the dynamics of dying are represented by a chain of pathophysiological events

Asystole or ventricular fibrillation,
circulatory arrest - progressive
brain dysfunction, loss
consciousness (within a few seconds) -"
pupil dilation (20-30sec) - stop
breathing - preagony, terminal pause,
agony - clinical death.
The diagnosis should be established within 8-10
seconds

There are 4 types of terminal conditions (stages of dying):

, To
which is equivalent to stage IV
torpid shock;
terminal pause;
agony;
clinical death.

Preagonal state (preagony)

General motor excitation (excitation phase).
Progressive disturbances of consciousness - lethargy,
confusion, lack of consciousness. The skin is pale, with
earthy tint. The nail bed is bluish; after clicking on
nail blood flow is not restored for a long time. Pulse
frequent, barely countable on the carotid and femoral arteries; then
slow (bradycardia). Blood pressure is progressive
decreases (a short-term slight rise is possible at first),
soon not determined. Breathing is initially rapid (tachypnea),
then slow (bradypnea), infrequent, convulsive, arrhythmic.
Reflexes are not evoked. Skeletal muscle tone is extremely reduced.
Body temperature is sharply reduced. Skin-rectal temperature
gradient more than 160C. Anuria. With rapid dying possible
short-term convulsions (decerebrate type), loss
consciousness, motor excitement.
At the end of preagonia there is a decrease in the degree of excitation
respiratory center - a terminal pause occurs.

Preagonal state (preagony)

Terminal pause (primary anoxic apnea).

Lasts from a few seconds to 3-4 minutes.
There is no breathing. Pulse is sharply slow
(bradycardia), determined only on
carotid, femoral arteries. The ECG shows atrioventricular rhythm. Pupil reaction to
light and corneal reflexes disappear,
the width of the pupils increases.
Ends with restoration of activity
respiratory center (since due to
increasing hypoxia inhibitory vagal
the reflex disappears) and turns into agony.

Agony

Characterized by a final short flash
life activity.
With short agony, short-term
restoration of consciousness, some increase in frequency. pulse
(determined on the carotid and femoral arteries). Heart sounds
deaf. Possible slight increase in blood pressure
pressure; then it drops sharply and is no longer detectable.
Corneal reflexes may initially be partially restored,
then they fade away. Possible increased electrical activity
brain, then fall.
Pathological breathing. There are two types of breathing:
convulsive, large amplitude, with a short maximum
inhalation and rapid full exhalation, frequency 2 - 6 per 1 min;
weak, rare, superficial, small amplitude. Agony
ends with the last breath (last contraction
heart) and progresses to clinical death.

Clinical death

Boundary state of transition from extinction
life to biological death. Arises
immediately after termination
blood circulation and respiration.
Clinical death state
characterized by a complete cessation of all
external manifestations of life activity,
however, even in the most vulnerable tissues
(brain) irreversible conditions have not yet occurred
changes.

Clinical death

The stage of clinical death is characterized
the fact that an already dead person can still be
bring back to life by restarting the mechanisms
breathing and blood circulation.
Under normal room conditions
the duration of this period is
6-8 minutes, which is determined by the time in
the course of which can be fully
restore the functions of the cerebral cortex.

!!! Terminating the terminal process
serves as biological death, which is
irreversible condition when revival
organism as a whole is impossible.

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Classification Preagonal state Terminal pause Agony Clinical death

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Agony Consciousness is lost (deep coma) Pulse and blood pressure cannot be determined Heart sounds are muffled Breathing is superficial, agonal.

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Primary clinical signs Clearly identified in the first 10–15 seconds after circulatory arrest Sudden loss of consciousness Disappearance of pulse in the main arteries Clonic and tonic convulsions

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Symptom complex of clinical death * lack of consciousness, blood circulation and breathing * areflexia * absence of pulsation in large arteries * adynamia or small-amplitude convulsions * dilated pupils that do not respond to light * cyanosis of the skin and mucous membranes with an earthy tint

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Basic life support. Restoration of airway patency. Artificial maintenance of respiration. Artificial maintenance of blood circulation. The goal is emergency oxygenation, the resumption of blood circulation sufficiently saturated with oxygen, primarily in the basins of the cerebral and coronary arteries

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closed airways open airways The position of the patient's head during artificial ventilation of the lungs using the mouth-to-mouth or mouth-to-nose method.

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Mechanical ventilation Expiratory methods: mouth to mouth, mouth to nose, mouth to air duct Various breathing devices: Ambu bag, ventilators

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Artificial ventilation of the lungs using the mouth-to-nose method. Artificial ventilation of the lungs using the mouth-to-mouth method.

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Maintaining blood circulation Outside the operating room - closed cardiac massage In the operating room, especially when the chest is opened, open cardiac massage During laparotomy - cardiac massage through the diaphragm.

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The place of contact between the arm and the sternum. The position of the patient and the person providing assistance during chest compressions. Scheme of indirect cardiac massage: a - laying hands on the sternum b - pressing on the sternum

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Types of terminal states Predagonal state Terminal pause (not always noted) Agony Clinical death

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Preagonal state Consciousness is depressed or absent. The skin is pale or cyanotic. Blood pressure decreases to zero. The pulse is preserved in the carotid and femoral arteries. Breathing is bradyform. The severity of the condition is explained by increasing oxygen deprivation and severe metabolic disorders.

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Terminal pause Terminal pause does not always happen. After vagotomy it is absent. Respiratory cessation, periods of asystole 1-15 seconds.

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Agony The precursor to death. The regulatory function of the higher parts of the brain ceases. The bulbar centers control vital processes.

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Clinical death The activity of the heart and breathing ceases, but there are still no irreversible changes in the organs and systems. On average, the duration is no more than 5-6 minutes, depending on the ambient temperature, atm. pressure, etc.

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3 types of circulatory arrest 1. Asystole - cessation of contractions of the atria and ventricles (complete blockade, irritation of the vagus nerves, exhaustion, endocrine diseases, etc.). 2. Ventricular fibrillation - discoordination in myocardial contraction. 3. Myocardial atony - loss of muscle tone (hypoxia, blood loss, shock).

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3 types of cessation of respiratory activity Hypoxia. Hypercapnia. Hypocapnia - respiratory alkalosis.

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Signs of clinical death Coma are dilated pupils and lack of reaction to light. Apnea is the absence of breathing movements. Asystole is the absence of a pulse in the carotid arteries. Time factors play a huge role in this condition, so it is necessary to strive to perform an EEG, ECG, acid-base balance is not necessary, but we must move on to resuscitation methods.

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Methods of revitalization Air way open - restore airway patency. Breathe por victim - start mechanical ventilation. Circulation his blood - start cardiac massage.

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ABC rules 1. Unbend the cervical spine, remove the lower jaw (Fig. 23,24), empty the oral cavity and pharynx, air duct - ventilation (Fig. 25,26). 2. a) external (external) - compression of the chest. b) blowing air into the lungs.

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Methods of performing mechanical ventilation: ventilation through an S-shaped air duct. Ventilation through a gauze bandage (1-2 layers) or a handkerchief. Mouth-to-mouth ventilation 10-12 per minute (count 4-5). Mouth-to-nose ventilation.

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Methods for restoring cardiac activity 1. Indirect cardiac massage. After 2-3 breaths, strike with your fist in the heart area and then massage between the sternum and spine, 1:5 ratio of massage to ventilation.

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2. Drug stimulation. Repeats every 5 minutes. Adrenergic agonists - adrenaline 1.0 0.1% + 10.0 physical. solution intravenously, intravenously until a clinical effect is obtained. Antiarrhythmic drugs - lidocaine 80-120 mg. Sodium bicarbonate 2 ml 1% per 1 kg. Magnesium sulfate 1-2 g in 100 ml of 5% glucose. Atropine 1.0 0.1% solution. Calcium chloride 10% - 10.0

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3. Electropulse therapy 200J, 200-300, 360, 2500 V, 3500 V. Resuscitation benefits are not provided to patients who have injuries incompatible with life, who are in the terminal stage of incurable diseases, or cancer patients with metastases.

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Types of shock Hypovolemic (posthemorrhagic, burn - these are varieties) shock. Cardiogenic shock. Vascular shock (septic and anaphylactic).

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Clinical signs of shock are cold, moist, pale cyanotic or marbled skin; sharply slowed blood flow of the nail bed; darkened consciousness; dipnea; oiguria; thycardia; decrease in blood and pulse pressure.

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Pathogenetic classification, main clinical symptoms and compensatory mechanisms of hypovolemic shock (according to G.A. Ryabov, 1979)

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Shock control criteria Shock index is the ratio of heart rate to systolic pressure (P.G. Bryusov, 1985). Normal value SI = 60/120 = 0.5 With shock I stage. (blood loss 15-25% of the bcc) SI = 1(100/100) In case of shock, stage II. (blood loss 25-45% of bcc) SI = 1.5 (120/80) In case of shock III degree. (blood loss more than 50% of blood volume) SI = ” (140/70)

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Principles of treatment of hypovolemic shock Immediate stop of bleeding, adequate pain relief. Catheterization of the subclavian vein and adequate infusion therapy. Relief of signs of acute respiratory failure. Constant supply of oxygen in the inhaled mixture in an amount of 35-45%. Relief of signs of acute heart failure. Bladder catheterization

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Infusion therapy program depending on blood loss (V.A. Klimansky, A.Ya.Rudaev, 1984)

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Principles of treatment of septic shock Elimination of signs of acute respiratory failure and acute respiratory failure, transfer to mechanical ventilation according to indications. Normalization of central hemodynamic parameters by using intravenous infusions of dextrans, crystalloids, glucose under the control of central venous pressure and hourly diuresis. Correction of basic indicators of acid-base balance and water-electrolyte balance. Preventive treatment of pulmonary distress syndrome, which is inevitable for this pathology. Antibacterial therapy (preferably bacteriostatic drugs). Relief of DIC syndrome. Treatment of the allergic component of the disease by prescribing glucocorticoids. Sanitation of the source of infection. Symptomatic therapy.

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Principles of treatment of anaphylactic shock Resuscitation measures if indicated. If possible, eliminate contact with the allergen, although this is not always possible. If this is not possible, use a tourniquet above the injection site of the allergen or inject the injection site with a diluted solution of adrenaline. IV jet infusion therapy under the control of central venous pressure and hourly diuresis. Slowly intravenously 1 ml of 0.1% adrenaline solution + 20.0 saline. solution (can be done under the tongue). Relief of bronchospasm, slow intravenous administration of 5-10 ml of 2.4% aminophylline solution. The administration of glucocorticoids is indicated as desensitizing drugs and stabilizers of cell membranes. When using prednisolone, the dose should be 90-120 mg. At the same time, hydrocortisone 125-250 mg is prescribed, which has the ability to retain sodium and water in the body.

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Criteria for successful treatment of shock: Restoration of blood volume and elimination of hypovolemia. Restoration of UOS, MOS. Elimination of microcirculation disorders.

Description of the presentation by individual slides:

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Terminal states. First resuscitation aid. Performed by the teacher of the Municipal Budgetary Educational Institution “Security School in the village of Dubovka” Alexey Vladimirovich Golodnov

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Terminal states are the borderline states of the body between life and death, the last stages of life. In this case, a characteristic five-link chain of events can be identified: shock, pre-agony, terminal pause, agony, clinical death (the last four links develop over a period of time not exceeding 8-9 minutes). In all terminal conditions, full recovery is possible. In practical situations, you most often have to deal with first resuscitation care in case of clinical death. This assistance is of great importance, since immediately after clinical death irreversible biological death occurs. Clinical death is characterized by five main signs: 1. Lack of consciousness. 2. Lack of breathing. 3. Absence of pulse in the carotid or femoral arteries. 4. Pupil dilation. 5. Lack of pupil reaction to light.

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Stages of first resuscitation aid. Resuscitation is the revival of a dying person, bringing him out of a state of clinical death, and preventing the occurrence of biological death. The purpose of resuscitation is to save the life of a person as a social subject, a full-fledged member of society. Objectives of resuscitation: *prevention of death, support, restoration of brain functions; *removing the body from terminal conditions; *preventing their return (relapse); *preventing or limiting the number of possible complications; *reducing the severity of their course.

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There are five stages of first resuscitation. 1. Diagnostic - solves five questions, whether a person is alive or dead; sick or healthy (being intoxicated); whether he is in a state of clinical death or in severe shock; what kind of medical care does the victim need or is not subject to treatment at all.

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Diagnostic stage. Determination of the state of consciousness, reaction to external influences (shake the shoulder, call out) There is a reaction There is no reaction If necessary, position the victim more comfortably; exclude the possibility of blockage of the respiratory tract, provide first aid, call for help. Check the condition of the cervical vertebrae. Rule out fractures, fracture-dislocations of the vertebrae, neck and head injuries. Clear the airways; throw back your head, push your lower jaw forward; if necessary, remove foreign bodies. Call for help. Stop external bleeding. Call an ambulance. Check the victim’s breathing by the sound, sensation of air escaping, by the rise of the anterior chest wall during inhalation. Breathing is preserved. Breathing is sharply weakened. Breathing is absent. Check for the presence of blood circulation: by pulse in the carotid artery; according to the condition of the pupils Carry out artificial ventilation of the lungs Blood circulation is preserved Blood circulation is absent There is no breathing. There is no blood circulation Carry out a full cycle of resuscitation

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Preparatory and initial stages. Preparatory stage Initial stage Place the victim on a rigid base (on the floor, on the ground, etc.) on his back (stretch his arms along the body) Throw back the victim’s head Loosen the collar and belt. Release your bra. The mouth is open The mouth is closed Open the mouth using one of the following methods: - bilateral grip of the lower jaw, - anterior grip of the lower jaw, - lateral grip of the lower jaw. Check airway patency. Absent Preserved Restore airway patency

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Resuscitation stage. Artificial pulmonary ventilation External cardiac massage Oral methods Precardinal blow before external cardiac massage at the beginning of each cycle Mouth to mouth Mouth to nose Mouth to mouth and nose in children, frequency of ventilation - 20-24 per 1 minute Non-pause ventilation: 3-5(6 ) breaths at the fastest possible pace, without pauses. Inhalation volume – 400-500 ml Inhalation cycle: ventilation frequency – 8 per 1 minute; inhalation time no more than 1 s. Checking the effectiveness of the measures taken by checking the pulse on the carotid artery, the condition of the pupils. If there is no effect. Cycles of external cardiac massage: frequency of shocks – 100 per 1 minute; depth of sternum deflection – 4-5 cm. Resuscitation ratio (ventilation + external cardiac massage) With one rescuer – 2:15 With two rescuers – 1:5 For children – 1:4 In all cases, ensuring constant monitoring of the victim’s condition and the effectiveness of resuscitation with adjustments

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