Ambulance protocols. Clinical recommendations (protocols) for the provision of emergency medical care

13.03.2020 -

First aid

With a neurovegetative form of a crisis, the sequence of actions:

1) inject 4–6 ml of a 1% solution of furosemide intravenously;

2) inject 6–8 ml of 0.5% dibazol solution dissolved in 10–20 ml of 5% glucose solution or 0.9% sodium chloride solution intravenously;

3) inject 1 ml of a 0.01% solution of clonidine in the same dilution intravenously;

4) inject 1–2 ml of a 0.25% solution of droperidol in the same dilution intravenously.

With a water-salt (edematous) form of a crisis:

1) inject 2–6 ml of a 1% solution of furosemide intravenously once;

2) inject 10–20 ml of a 25% solution of magnesium sulfate intravenously.

With a convulsive form of a crisis:

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

2) antihypertensive drugs and diuretics - according to indications.

In a crisis associated with a sudden cancellation (stopping taking) antihypertensive drugs: inject 1 ml of 0.01% clonidine solution diluted in 10-20 ml of 5% glucose solution or 0.9% sodium chloride solution.

Notes

1. Drugs should be administered sequentially, under the control of blood pressure;

2. In the absence of a hypotensive effect within 20–30 minutes, the presence acute violation cerebral circulation, cardiac asthma, angina pectoris requires hospitalization in a multidisciplinary hospital.

angina pectoris

Clinical manifestations s - m. Nursing in therapy.

First aid

1) stop physical activity;

2) put the patient on his back and with his legs down;

3) give him a tablet of nitroglycerin or validol under the tongue. If the pain in the heart does not stop, repeat the intake of nitroglycerin every 5 minutes (2-3 times). If there is no improvement, call a doctor. Before he arrives, proceed to the next stage;

4) in the absence of nitroglycerin, 1 tablet of nifedipine (10 mg) or molsidomine (2 mg) can be given under the tongue to the patient;

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

6) offer the patient to drink in small sips hot water or put a mustard plaster on the area of \u200b\u200bthe heart;

7) in the absence of the effect of therapy, hospitalization of the patient is indicated.

myocardial infarction

Clinical manifestations- see Nursing in Therapy.

First aid

1) lay or seat the patient, unfasten the belt and collar, provide access fresh air, complete physical and emotional peace;

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

3) give an aspirin tablet (325 or 500 mg) to drink;

4) give a propranolol 10–40 mg tablet under the tongue;

5) enter intramuscularly: 1 ml of a 2% solution of promedol + 2 ml of a 50% solution of analgin + 1 ml of a 2% solution of diphenhydramine + 0.5 ml of a 1% solution of atropine sulfate;

6) with systolic blood pressure less than 100 mm Hg. Art. it is necessary to intravenously inject 60 mg of prednisolone diluted with 10 ml of saline;

7) inject heparin 20,000 IU intravenously, and then 5,000 IU subcutaneously into the area around the navel;

8) the patient should be transported to the hospital in the supine position on a stretcher.

Pulmonary edema

Clinical manifestations

It is necessary to differentiate pulmonary edema from cardiac asthma.

1. Clinical manifestations of cardiac asthma:

1) frequent shallow breathing;

2) expiration is not difficult;

3) orthopnea position;

4) during auscultation, dry or wheezing rales.

2. Clinical manifestations of alveolar pulmonary edema:

1) suffocation, bubbling breath;

2) orthopnea;

3) pallor, cyanosis of the skin, moisture of the skin;

4) tachycardia;

5) selection a large number frothy, sometimes blood-stained sputum.

First aid

1) give the patient a sitting position, apply tourniquets or cuffs from the tonometer to lower limbs. Reassure the patient, provide fresh air;

2) inject 1 ml of a 1% solution of morphine hydrochloride dissolved in 1 ml physiological saline or in 5 ml of 10% glucose solution;

3) give nitroglycerin 0.5 mg sublingually every 15–20 minutes. (up to 3 times);

4) under the control of blood pressure, inject 40–80 mg of furosemide intravenously;

5) in case of high blood pressure, inject intravenously 1-2 ml of a 5% solution of pentamin, dissolved in 20 ml of saline, 3-5 ml with an interval of 5 minutes; 1 ml of a 0.01% solution of clonidine dissolved in 20 ml of saline;

6) establish oxygen therapy - inhalation of humidified oxygen using a mask or nasal catheter;

7) make an inhalation of oxygen moistened with 33% ethyl alcohol, or inject 2 ml of a 33% solution ethyl alcohol intravenously;

8) inject 60–90 mg of prednisolone intravenously;

9) in the absence of the effect of therapy, an increase in pulmonary edema, a fall in blood pressure, artificial ventilation lungs;

10) hospitalize the patient.

Fainting may occur when long stay in a stuffy room due to a lack of oxygen, in the presence of tight clothing that restricts breathing (corset) healthy person. Repeated fainting is a reason for a visit to the doctor in order to exclude a serious pathology.

Fainting

Clinical manifestations

1. Short-term loss of consciousness (for 10–30 s.).

2. In the anamnesis there are no indications of diseases of the cardiovascular, respiratory systems, Gastrointestinal tract, obstetric and gynecological history is not burdened.

First aid

1) give the body of the patient horizontal position(without pillow) with legs slightly raised;

2) unfasten the belt, collar, buttons;

3) spray your face and chest with cold water;

4) rub the body with dry hands - hands, feet, face;

5) let the patient inhale vapors of ammonia;

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

Bronchial asthma (attack)

Clinical manifestations- see Nursing in Therapy.

First aid

1) seat the patient, help to take a comfortable position, unfasten the collar, belt, provide emotional peace, access to fresh air;

2) distraction therapy in the form hot bath for legs (water temperature at the level of individual tolerance);

3) inject 10 ml of a 2.4% solution of aminophylline and 1–2 ml of a 1% solution of diphenhydramine (2 ml of a 2.5% solution of promethazine or 1 ml of a 2% solution of chloropyramine) intravenously;

4) carry out inhalation with an aerosol of bronchodilators;

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

asthmatic status

Clinical manifestations- see Nursing in Therapy.

First aid

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

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

3) when breathing stops - IVL;

4) administer rheopolyglucin intravenously in a volume of 1000 ml;

5) inject 10–15 ml of a 2.4% solution of aminophylline intravenously during the first 5–7 minutes, then 3–5 ml of a 2.4% solution of aminophylline intravenously by drop in infusion solution or 10 ml each 2.4 % solution of aminophylline every hour into the dropper tube;

6) administer 90 mg of prednisolone or 250 mg of hydrocortisone intravenously by bolus;

7) inject heparin up to 10,000 IU intravenously.

Notes

1. Taking sedatives, antihistamines, diuretics, calcium and sodium preparations (including saline) is contraindicated!

2. Repeated consecutive use of bronchodilators is dangerous due to the possibility of death.

Pulmonary bleeding

Clinical manifestations

Discharge of bright scarlet frothy blood from the mouth when coughing or with little or no cough.

First aid

1) calm the patient, help him take a semi-sitting position (to facilitate expectoration), forbid getting up, talking, calling a doctor;

2) on chest put an ice pack or cold compress;

3) give the patient a cold liquid to drink: a solution of table salt (1 tablespoon of salt per glass of water), nettle decoction;

4) carry out hemostatic therapy: 1-2 ml of 12.5% solution of dicynone intramuscularly or intravenously, 10 ml of 1% solution of calcium chloride intravenously, 100 ml of 5% solution of aminocaproic acid intravenously, 1-2 ml 1 % solution of vikasol intramuscularly.

If it is difficult to determine the type of coma (hypo- or hyperglycemic), first aid begins with the introduction of a concentrated glucose solution. If the coma is associated with hypoglycemia, then the victim begins to recover, skin turn pink. If there is no response, then the coma is most likely hyperglycemic. At the same time, clinical data should be taken into account.

Hypoglycemic coma

Clinical manifestations

2. The dynamics of the development of a coma:

1) feeling of hunger without thirst;

2) anxious anxiety;

3) headache;

4) increased sweating;

5) excitement;

6) stunning;

7) loss of consciousness;

8) convulsions.

3. Absence of symptoms of hyperglycemia (dry skin and mucous membranes, decreased skin turgor, softness eyeballs, the smell of acetone from the mouth).

4. Fast positive effect from intravenous administration 40% glucose solution.

First aid

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

2) if there is no effect, re-introduce 40 ml of a 40% glucose solution intravenously, as well as 10 ml of a 10% solution of calcium chloride intravenously, 0.5–1 ml of a 0.1% solution of adrenaline hydrochloride subcutaneously (in the absence of contraindications );

3) when feeling better, give sweet drinks with bread (to prevent relapse);

4) patients are subject to hospitalization:

a) at the first appeared hypoglycemic condition;

b) when hypoglycemia occurs in a public place;

c) with the ineffectiveness of emergency measures medical care.

Depending on the condition, hospitalization is carried out on a stretcher or on foot.

Hyperglycemic (diabetic) coma

Clinical manifestations

1. Diabetes in history.

2. Development of a coma:

1) lethargy, extreme fatigue;

2) loss of appetite;

3) indomitable vomiting;

4) dry skin;

6) frequent copious urination;

7) decrease in blood pressure, tachycardia, pain in the heart;

8) adynamia, drowsiness;

9) stupor, coma.

3. The skin is dry, cold, the lips are dry, chapped.

4. Tongue crimson with a dirty gray coating.

5. The smell of acetone in the exhaled air.

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

First aid

Sequencing:

1) carry out rehydration with a 0.9% sodium chloride solution intravenously at a rate of 200 ml infusion over 15 minutes. under the control of the level of blood pressure and spontaneous breathing (cerebral edema is possible with too rapid rehydration);

2) emergency hospitalization in the intensive care unit of a multidisciplinary hospital, bypassing admission department. Hospitalization is carried out on a stretcher, lying down.

Acute abdomen

Clinical manifestations

1. Abdominal pain, nausea, vomiting, dry mouth.

2. Soreness on palpation of the anterior abdominal wall.

3. Symptoms of peritoneal irritation.

4. Tongue dry, furred.

5. Subfebrile condition, hyperthermia.

First aid

Urgently deliver the patient to the surgical hospital on a stretcher, in a comfortable position for him. Pain relief, water and food intake are prohibited!

Acute abdomen and similar conditions can occur with a variety of pathologies: diseases digestive system, gynecological, infectious pathologies. Main principle first aid in these cases: cold, hunger and rest.

Gastrointestinal bleeding

Clinical manifestations

1. Paleness of the skin, mucous membranes.

2. Vomiting blood or "coffee grounds".

3. Black tarry stools or scarlet blood (for bleeding from the rectum or anus).

4. The abdomen is soft. There may be pain on palpation in the epigastric region. There are no symptoms of peritoneal irritation, the tongue is wet.

5. Tachycardia, hypotension.

6. History of peptic ulcer, oncological disease Gastrointestinal tract, cirrhosis of the liver.

First aid

1) give the patient to eat ice in small pieces;

2) with deterioration of hemodynamics, tachycardia and a decrease in blood pressure - polyglucin (rheopolyglucin) intravenously until stabilization of systolic blood pressure at the level of 100–110 mm Hg. Art.;

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

4) inject up to 5 ml of a 0.5% dopamine solution intravenously in the infusion solution with a critical drop in blood pressure that cannot be corrected by infusion therapy;

5) cardiac glycosides according to indications;

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

Renal colic

Clinical manifestations

1. Paroxysmal pain in the lower back unilateral or bilateral, radiating to the groin, scrotum, labia, anterior or inner thigh.

2. Nausea, vomiting, bloating with retention of stool and gases.

3. Dysuric disorders.

4. Motor anxiety, the patient is looking for a position in which the pain will ease or stop.

5. The abdomen is soft, slightly painful along the ureters or painless.

6. Tapping on the lower back in the kidney area is painful, the symptoms of peritoneal irritation are negative, the tongue is wet.

7. nephrolithiasis in history.

First aid

1) inject 2–5 ml of a 50% solution of analgin intramuscularly or 1 ml of a 0.1% solution of atropine sulfate subcutaneously, or 1 ml of a 0.2% solution of platifillin hydrotartrate subcutaneously;

2) put a hot heating pad on the lumbar region or (in the absence of contraindications) place the patient in a hot bath. Do not leave him alone, control general well-being, pulse, respiratory rate, blood pressure, skin color;

3) hospitalization: with a first attack, with hyperthermia, failure to stop an attack at home, with a repeated attack during the day.

Renal colic is a complication urolithiasis arising from metabolic disorders. The cause of the pain attack is the displacement of the stone and its entry into the ureters.

Anaphylactic shock

Clinical manifestations

1. Connection of the state with the introduction medicinal product, vaccines, specific food intake, etc.

2. Feeling of fear of death.

3. Feeling of lack of air, retrosternal pain, dizziness, tinnitus.

4. Nausea, vomiting.

5. Seizures.

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

7. Tachycardia, thready pulse, arrhythmia.

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

9. Coma.

First aid

Sequencing:

1) in case of shock caused by intravenous allergen medication, leave the needle in the vein and use it for emergency anti-shock therapy;

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

3) give the patient a functionally advantageous position: elevate the limbs at an angle of 15°. Turn your head to one side, in case of loss of consciousness, push the lower jaw forward, remove dentures;

4) carry out oxygen therapy with 100% oxygen;

5) inject intravenously 1 ml of a 0.1% solution of adrenaline hydrochloride diluted in 10 ml of a 0.9% solution of sodium chloride; the same dose of epinephrine hydrochloride (but without dilution) can be injected under the root of the tongue;

6) polyglucin or other infusion solution should be started to be administered by jet after stabilization of systolic blood pressure at 100 mm Hg. Art. - continue infusion therapy drip;

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

8) inject 10 ml of 10% calcium chloride solution into the infusion system;

9) in the absence of the effect of the therapy, repeat the administration of adrenaline hydrochloride or inject 1-2 ml of a 1% solution of mezaton intravenously by stream;

10) in case of bronchospasm, inject 10 ml of a 2.4% solution of aminophylline intravenously;

11) with laryngospasm and asphyxia - conicotomy;

12) if the allergen was injected intramuscularly or subcutaneously, or anaphylactic reaction arose in response to an insect bite, it is necessary to cut off the injection or bite site with 1 ml of a 0.1% solution of adrenaline hydrochloride diluted in 10 ml of a 0.9% solution of sodium chloride;

13) if the allergen entered the body by mouth, it is necessary to wash the stomach (if the patient's condition allows);

14) at convulsive syndrome inject 4–6 ml of a 0.5% solution of diazepam;

15) at clinical death perform cardiopulmonary resuscitation.

In every treatment room there must be a first aid kit available for first aid in case of anaphylactic shock. Most often anaphylactic shock develops during or after the introduction of biological products, vitamins.

Quincke's edema

Clinical manifestations

1. Communication with the allergen.

2. Itchy rash on various parts of the body.

3. Edema of the rear of the hands, feet, tongue, nasal passages, oropharynx.

4. Puffiness and cyanosis of the face and neck.

6. Mental excitement, restlessness.

First aid

Sequencing:

1) stop introducing the allergen into the body;

2) inject 2 ml of a 2.5% solution of promethazine, or 2 ml of a 2% solution of chloropyramine, or 2 ml of a 1% solution of diphenhydramine intramuscularly or intravenously;

3) administer 60–90 mg of prednisolone intravenously;

4) inject 0.3–0.5 ml of a 0.1% solution of adrenaline hydrochloride subcutaneously or, diluting the drug in 10 ml of a 0.9% solution of sodium chloride, intravenously;

5) inhalation with bronchodilators (fenoterol);

6) be ready for conicotomy;

7) to hospitalize the patient.

Appendix 20 to the order

Ministry of Health of the Republic of Belarus

13.06.006 № 484

CLINICAL PROTOCOLS for the provision of emergency medical care to the adult population

CHAPTER 1 GENERAL PROVISIONS

Protocols for the provision of emergency medical care is a list of timely, consistent, minimally sufficient diagnostic and medical measures applied on prehospital stage in a typical clinical setting.

Emergency medical care - a type of medical care provided to the sick and injured according to vital indications in conditions requiring urgent medical intervention, and carried out immediately public service ambulance, both at the scene and along the way.

The main principles of the organization of the ambulance service are the availability of this type of medical care to the population, the efficiency in work and the timeliness of the arrival of teams to the sick and injured, the completeness of the medical care provided, ensuring unhindered hospitalization in the relevant specialized healthcare organizations, as well as continuity in working with inpatient and outpatient clinics. - polyclinic health organizations.

Emergency medical care is provided in accordance with approved emergency medical protocols. The right tactical decision ensures the delivery of a sick or injured person to a specialized medical institution after providing the optimal amount of medical care in the shortest possible time, thereby preventing the development of life-threatening complications.

delivery to stationary organizations health care are subject to all sick and injured with clear signs life-threatening conditions and the threat of life-threatening complications, if no exclusion is possible pathological processes and complications requiring hospital treatment, diagnostic and therapeutic measures, as well as patients who are dangerous to others due to infectious-epidemic and psychiatric indications, suddenly

sick and injured from public places or re-applied for emergency medical care during the day.

Delivery to trauma centers is subject to victims in the absence of signs of life-threatening conditions, the forecast of their development and with fully or partially preserved ability to independent movement that do not require urgent inpatient diagnostic and therapeutic measures.

When making a call to the sick and injured with a criminal injury, aggressive patients with alcohol or drug intoxication, when there is a threat to the life and health of the patient or victim, as well as when social danger the patient (injured) himself, the ambulance team is obliged to seek help and assistance in the implementation of the medical-tactical decision in the internal affairs bodies in accordance with the established procedure.

In the provision of medical care and delivery to hospitals of patients and victims who are under investigation, trial or serving a sentence, prerequisite making a call, as well as receiving and transferring documents and valuables of patients (injured) with the participation of an ambulance team, is their escort by employees of the internal affairs bodies.

Patients arriving in a state life threatening are hospitalized directly to the intensive care unit, bypassing the emergency department.

The procedure for certifying the admission of a patient or injured person in a hospital provides for the signature of the doctor on duty (paramedic, nurse) of the emergency department in the call card of the ambulance team indicating the date and time of admission of the patient and confirmation of this signature with a stamp of the hospital admission department.

If the patient or the victim refuses from medical intervention or hospitalization to him or his accompanying persons (spouse, in his absence - to close relatives, and if it concerns a child, then to parents), medical worker ambulance in an accessible form, the possible consequences of refusal should be explained.

Refusal of a sick or injured person from medical intervention, as well as from hospitalization, indicating possible consequences recorded in medical records and signed by the patient, or the persons indicated above, as well as by the medical worker.

If the patient could not be convinced of the need for hospitalization, the emergency physician:

in a life-threatening condition of the victims associated with severe trauma, acute blood loss, poisoning, acute psychosis calls the police officers to resolve the issue of hospitalization;

in case of a life-threatening condition associated with the disease, reports the need for hospitalization and the refusal of the patient to be delivered to the hospital to the senior doctor of the operational department or the administration of the ambulance station, who decide on the need for a second visit to the patient;

transfers the active call to the outpatient clinic organization.

CHAPTER 2 SUDDEN DEATH

1. Diagnostic criteria for circulatory arrest (clinical death):

loss of consciousness; lack of pulsation on large arteries (carotid, femoral);

absence or pathological (agonal) type of breathing; dilatation of the pupils, setting them in a central position.

2. Causes of cardiac arrest:

2.1. Heart disease:

direct pacing. 2.2. Circulatory causes: hypovolemia; tension pneumothorax;

air embolism or pulmonary embolism (hereinafter PE);

vagal reflexes.

2.3. Respiratory causes: hypoxia (often causes asystole); hypercapnia.

2.4. Metabolic disorders: potassium imbalance; acute hypercalcemia; hypercatecholaminemia;

hypothermia.

2.5. Medicinal effects: direct pharmachologic effect; secondary effects.

2.6. Other reasons:

drowning; electrical injury.

3. Mechanisms sudden death:

3.1. ventricular fibrillation (in 80% of cases), asystole or electromechanical dissociation. Ventricular fibrillation develops gradually, the symptoms appear sequentially: the disappearance of the pulse on the carotid arteries, loss of consciousness, a single tonic contraction skeletal muscle, violation and cessation of breathing. response to timely cardiopulmonary resuscitation is positive, on termination of cardiopulmonary resuscitation - fast negative;

3.2. electromechanical dissociation in massive thromboembolism pulmonary artery develops suddenly (often at the time of physical exertion) and is manifested by cessation of breathing, lack of consciousness and pulse on the carotid arteries, sharp cyanosis of the upper half of the body, swelling of the cervical veins; with myocardial rupture and cardiac tamponade, it develops suddenly, usually against the background of a protracted, recurrent anginal attack. Signs of effectiveness no cardiopulmonary resuscitation. Hypostatic spots quickly appear in the underlying parts of the body.

In favor of circulatory arrest, not associated with ventricular fibrillation, data on drowning, a foreign body in the respiratory tract, and hanging speak.

4.1. Statement of the state of clinical death.

4.2. Precordial stroke.

4.3. Provide patency respiratory tract:

Safar technique (head extension, removal mandible); clean the oral cavity and oropharynx from foreign bodies, if necessary

dimity - Heimlich's maneuver; tracheal intubation;

Cricothyreotomy for permanent blockade of the upper respiratory tract.

Ambu bag through the endotracheal tube with an air-oxygen mixture.

the resuscitator's arms are straight, positioned vertically; help massage with your body weight; frequency of compressions in adults 80-100 per minute;

stop the massage only for inhalation; slightly delay the massage movements in the maxi-

small compression.

7. The ratio between IVL and VMS:

one rescuer - 2:15 (2 breaths - 15 compressions); two or more resuscitators 1:4 (1 breath - 4 compressions).

8. Provide continuous venous access.

9. The introduction of epinephrine 1 ml of a 0.18% solution in / in or endotracheally for 10 ml of a 0.9% solution of sodium chloride.

10. Recording an electrocardiogram (hereinafter - ECG) and / or cardiomonitoring

11. differentiated therapy.

immediate electrical impulse therapy (hereinafter referred to as EIT) (according to paragraph 16 of chapter 3);

if immediate EIT is not possible, apply a precordial strike and start CPR, ensure the possibility of EIT as soon as possible;

if EIT or asystole is ineffective, inject 1 ml of a 0.18% solution of epinephrine in 10 ml of a 0.9% solution of sodium chloride into the main vein (if the veins were catheterized before the resuscitation) or into a peripheral vein (through a long catheter reaching a large vein), or intracardiac followed by EIT. The introduction of epinephrine can be repeated every 3-5 minutes;

if VF persists or recurs after the above measures, intravenous lidocaine (hereinafter referred to as IV) slowly 120 mg (6 ml of a 2% solution) followed by drip administration (200-400 mg per 200 ml of 0.9% sodium chloride solution - 30- 40 drops per minute) or amiodarone according to the scheme: slowly at a dose of 300 mg (5 mg / kg) (5% -6 ml per 5% glucose) for 20 minutes, then IV drip at a rate of up to 1000-1200 mg / day;

in the absence of effect - EIT again after the introduction of lidocaine 0.5-0.75 mg / kg (2% - 2-3 ml) intravenously slowly, or against the background of the introduction of magnesium sulfate 2 g (20% solution 10 ml) intravenously in slowly;

in the absence of effect - EIT again after the introduction of lidocaine

0.5-0.75 mg/kg (2% - 2-3 ml) IV slowly;

with acidosis or prolonged resuscitation (more than 8-9 minutes) - 8.4% solution of sodium bicarbonate IV, 20 ml;

Interrupt CPR for no more than 10 seconds to administer drugs or defibrillate.

Alternate drug administration and defibrillation. 11.2. Electromechanical dissociation (hereinafter - EMD):

exclude or treat the cause (hypovolemia, hypoxia, cardiac tamponade, tension pneumothorax, drug overdose, acidosis, hypothermia, PE), diagnosis and immediate action - according to the relevant chapters;

in case of an overdose of calcium antagonists, with hyperkalemia, hypocalcemia, inject a 10% solution of calcium chloride 10 ml IV (calcium preparations are contraindicated in case of poisoning with cardiac glycosides).

11.3. Asystole: continue CPR;

inject 1 ml of a 0.18% solution of epinephrine again intravenously after 3-4 minutes;

inject atropine 1 mg (0.1% solution - 1 ml) intravenously per 10 ml of 0.9% sodium chloride solution after 3-5 minutes (until the effect or a total dose of 0.04 mg / kg is obtained);

inject sodium bicarbonate 8.4% solution of 20 ml intravenously with acidosis or prolonged resuscitation (more than 8-9 minutes);

inject a 10% solution of calcium chloride 10 ml IV in case of hyperkalemia, hypocalcemia, overdose of calcium blockers;

conduct external or internal pacing. Continue CPR activities for at least 30 minutes, constantly assess

the patient's condition (cardiomonitoring, pupil size, pulsation large arteries, chest excursion).

Termination of resuscitation is carried out in the absence of signs of cardiac activity on the ECG, against the background of the use of all possible measures for at least 30 minutes under normothermic conditions.

Refusal of resuscitation measures is possible if at least 10 minutes have passed since the moment of circulatory arrest, with signs biological death, in the terminal stage of long-term incurable diseases (documented in outpatient card), diseases of the central nervous system(hereinafter - CNS) with damage to the intellect, trauma incompatible with life.

Transportation of the patient to the department intensive care carried out after the restoration of the efficiency of cardiac activity. The main criterion is sustainable heartbeat with sufficient frequency, accompanied by a pulse in large arteries.

12. When restoring cardiac activity: do not extubate the patient;

continuation of mechanical ventilation with a breathing apparatus with inadequate breathing;

maintaining adequate blood circulation - 200 mg of dopamine (5-10 mcg / kg / min) intravenously in 400 ml of 5% glucose solution, 0.9% sodium chloride solution;

to protect the cerebral cortex, for the purpose of sedation and relief of seizures - diazepam 5-10 mg (1-2 ml of a 0.5% solution) intramuscularly or intramuscularly (hereinafter referred to as intramuscular injection).

13. Features of CPR.

All drugs during cardiopulmonary resuscitation must be administered intravenously quickly. Following the administered drugs for their delivery to the central circulation, 2030 ml of 0.9% sodium chloride solution should be administered.

In the absence of access to a vein, epinephrine, atropine, lidocaine (increasing the recommended dose by 1.5-3 times) is injected into the trachea (through an endotracheal tube or cricothyroid membrane) in 10 ml of 0.9% sodium chloride solution.

Antiarrhythmic drugs: lidocaine at the above dose or amiodarone at a dose of 300 mg (6 ml of a 5% solution) intravenously is recommended to be administered after 9-12 defibrillator discharges against the background of epinephrine administration.

Intracardiac injections (with a thin needle, with strict observance of technique) are permissible only in exceptional cases, if it is impossible to use other routes of administration medicines(in children are contraindicated).

Sodium bicarbonate 1 mmol/kg of body weight IV, then 0.5 mmol/kg every 5-10 minutes, apply for prolonged cardiopulmonary resuscitation (after 7-8 minutes after its start), with hyperkalemia, acidosis, overdose of tricyclic antidepressants , hypoxic lactic acidosis (adequate mechanical ventilation is required).

Calcium preparations do not improve the prognosis and have a damaging effect on the myocardium, therefore, the use of calcium chloride (at a dose of 2-4 mg / kg intravenously) is limited to situations of well-established situations: hyperkalemia, hypocalcemia, intoxication with calcium channel blockers.

With asystole or electromechanical dissociation, treatment options are limited. After tracheal intubation and administration every 3 minutes of epinephrine 1.8 mg (0.18% solution - 1 ml) and atropine 1 mg (0.1% solution - 1 ml) IV per 10 ml of 0.9% sodium solution chloride (until the effect or a total dose of 0.04 mg / kg is obtained), if the cause cannot be eliminated, decide on the termination of resuscitation measures, taking into account

the time elapsed from the onset of circulatory arrest (30 minutes).

CHAPTER 3 EMERGENCIES IN CARDIOLOGY

14. Tachyarrhythmias.

14.1. Supraventricular tachyarrhythmias.

14.1.1. sinus tachycardia requires emergency treatment, only if it causes angina pectoris, an increase in heart failure(hereinafter referred to as CH), arterial hypotension. First-line drugs are beta-blockers. Non-dihydropyridine potassium antagonists (verapamil) should be prescribed in cases where beta-blockers are contraindicated. It should be remembered that excessive suppression of reflex (with hypovolemia, anemia) or compensatory (with left ventricular dysfunction (hereinafter - LV)) tachycardia can lead to sharp decline blood pressure(hereinafter - AD) and aggravation of heart failure. In such cases, careful consideration should be given to the rationale for the appointment and selection of the dose of drugs.

Treatment algorithm for excessive sinus tachycardia: propranolol 2.5-5 mg IV slowly (0.1% - 2.5 - 5 ml in 0.9% sodium chloride solution) or verapamil 5-10 mg IV slowly (0.25% - 2 - 4 ml

in 0.9% sodium chloride solution) under the control of blood pressure.

14.1.2. With paroxysmal supraventricular tachycardia with narrow QRS complexes (atrial - focal or reciprocal, atrioventricular(hereinafter referred to as AV) nodal - focal or reciprocal, AV orthodromic reciprocal in the presence of an additional connection), regardless of the mechanism of cardiac arrhythmias, treatment should begin with vagal maneuvers - in this case, interruption of tachycardia or a change in AV conduction with slowing heart rate and improving hemodynamics may be observed.

Assistance algorithm:

with hemodynamically unstable tachycardia - EIT; with relatively stable hemodynamics, regardless of the type of ta-

chicardia is carried out:

massage carotid sinus(or other vagal tricks); in the absence of effect, after 2 minutes - verapamil 2.5-5 mg IV

(0.25% - 1 - 2 ml in 0.9% sodium chloride solution) under the control of blood pressure; in the absence of effect, after 15 minutes - verapamil 5-10 mg IV

(0.25% - 2 - 4 ml in 0.9% sodium chloride solution) under the control of blood pressure or immediately start with procainamide 500-1000 mg / in (10% - 5 - 10 ml

on 0.9% sodium chloride solution) at a rate of 50-100 mg / min under con-

blood pressure control (it is possible to introduce phenylephrine 1% solution in one syringe

0.1-0.3-0.5 ml).

14.1.3. Wide complex tachycardia when the nature of the expansion of the complex is unclear.

Rendering algorithm emergency care with paroxysmal tachycardia with wide complexes of unspecified origin:

14.1.3.1. with stable hemodynamics:

inject lidocaine 1-1.5 mg / kg (2% - 5-6 ml) and every 5 minutes at 0.5-0.75 mg / kg (2% - 2-3 ml) intravenously slowly until the effect or total dose 3 mg/kg; in the absence of effect - procainamide 500-1000 mg IV (10% - 5-10 ml in 0.9% sodium chloride solution) at a rate of 50-100 mg per minute

under the control of blood pressure (it is possible to introduce phenylephrine 1% solution of 0.1-0.3-0.5 ml in one syringe), against the background of the introduction of potassium preparations (10 ml of a 4% solution of potassium chloride, 10 ml of a solution of potassium and magnesium aspartate);

in the absence of effect - EIT.

14.1.3.2. with unstable hemodynamics, it is carried out immediately

Cardiac glycosides, beta-blockers, non-dihydropyridine potassium antagonists are contraindicated in patients with the unknown nature of the expansion of the QRS complex. In case of unstable hemodynamics, emergency EIT is indicated.

In the case when paroxysms with wide QRS complexes have been proven to be of a supraventricular nature, the treatment tactics depend on the cause of the expansion of the QRS complex. In paroxysmal supraventricular tachycardia with bundle branch block, treatment tactics do not differ from supraventricular tachycardia with narrow QRS complexes. If the cause of the expansion of the QRS complex cannot be precisely established, the first-line drugs are procainamide, amiodarone. With a combination of tachycardia with a decrease in LV function, amiodarone becomes the drug of choice.

14.1.4. In paroxysmal antidromic reciprocal AV tachycardia in WPW syndrome (with wide QRS complexes), procainamide is the drug of choice. Given the risk of sudden death, electrical cardioversion is indicated even in stable hemodynamics in case of failure. antiarrhythmic therapy or as an alternative to drug therapy.

Assistance algorithm:

inject procainamide 500-1000 mg IV (10% - 5 - 10 ml in 0.9% sodium chloride solution) at a rate of 50-100 mg / min under the control of blood pressure (it is possible to co-administer with phenylephrine 1% solution 0.1- 0.3-0.5 ml);

in the absence of effect - EIT.

14.1.5. With paroxysm of supraventricular tachycardia against the background of sick sinus syndrome, all antiarrhythmic drugs should be administered with extreme caution. With aggravation of sinus bradycardia - implantation of a temporary or permanent pacemaker(hereinafter referred to as EX).

To reduce the frequency of ventricular contractions and attempt to restore the rhythm, help should be provided in accordance with the following algorithm:

inject digoxin 0.25 mg (0.025% - 1 ml per 10 - 20 ml of 0.9% sodium chloride solution) intravenously slowly or verapamil 2.5-5 mg (0.25% - 1 - 2 ml per 0, 9% sodium chloride solution) in/in under the control of blood pressure;

in the absence of effect, or with an increase in circulatory failure - EIT.

14.1.6. For paroxysmal atrial fibrillation, pharmacological or electrical cardioversion is indicated for urgent indications in patients with unstable hemodynamics. Immediate electrical cardioversion in patients with paroxysmal atrial fibrillation that does not respond to attempts pharmacological treatment for a long time in the presence of the above symptoms. If the duration of atrial fibrillation is more than 72 hours or there are other contraindications to the restoration of the rhythm, hemodynamic stabilization is indicated by controlling the heart rate (hereinafter referred to as HR)

and planned restoration of rhythm.

Pharmacological or electrical cardioversion in hemodynamically stable patients is indicated for repeated paroxysms with fixed effective method restoration of rhythm in paroxysms lasting less than two days. Class 1 drugs (procainamide) should not be prescribed to patients with severe left ventricular failure. Patients after myocardial infarction should be prescribed first-class drugs in combination with beta-blockers.

Algorithm for emergency care:

inject procainamide 500-1000 mg IV (10% - 5 - 10 ml in 0.9% sodium chloride solution) at a rate of 50-100 mg / min under the control of blood pressure (it is possible to introduce 1% phenylephrine solution 0.1 in one syringe -0.3-0.5 ml), against the background of the introduction of potassium preparations (10 ml of 4% potassium chloride, 10 ml of a solution of potassium and magnesium aspartate);

administer amiodarone according to the scheme: in / in a stream slowly at a dose of 300 mg (5 mg / kg) (5% - 6 ml in / in drip per 200 ml of 5% glucose) for 20 minutes, then in / in drip at a rate up to 1000-1200 mg / day, or digoxin 0.25 mg (0.025% - 1 ml per 10 - 20 ml in 0.9% sodium chloride solution) with 10 ml of a solution of potassium and magnesium aspartate IV slowly;

Presentation description CLINICAL RECOMMENDATIONS (PROTOCOLS) FOR EMERGENCY MEDICAL CARE on slides

Classes of recommendations Class I - The recommended method of diagnosis or treatment is clearly useful and effective Class IIa - Evidence indicates more usefulness and effectiveness of the method of diagnosis or treatment Class II b - There is limited evidence on the applicability of the method of diagnosis or treatment Class III - Evidence indicates inapplicability (of uselessness or harm) of the proposed method Levels of Evidence A — Data obtained from several randomized clinical research B - Data based on one randomized trial or multiple non-randomized trials C - Data based on expert agreement, individual clinical observations, standards of care.

CLINICAL RECOMMENDATIONS (PROTOCOLS) FOR THE PROVISION OF AMBULANCE MEDICAL CARE FOR BRADYCARDIAS PROVIDING EMERGENCY CARE AT THE PRE-HOSPITAL STAGE WITH SINUS BRADYCHARDIA Examination and physical examination. Grade general condition sick. History for clarification possible cause bradycardia. Registration of pulse, blood pressure, ECG. In the absence of life-threatening symptoms and ischemic changes on the ECG, evacuation to a hospital for examination and treatment. In case of refusal of delivery to the hospital, give recommendations for further monitoring of the patient. . Classification (ICB) Sinus bradycardia. Sino-atrial blockade. artioventricular blockade. Stopping the sinus node. In the presence of life-threatening symptoms, it is necessary: Ensure airway patency, oxygen inhalation (at Spo. O 2 -95%), intravenous access. Start IV fluid transfusion (physiological sodium chloride solution). In / in enter solution of atropine 0.1% - 0.5 ml. (or at a calculated dose of 0.004 mg / kg) Carry out an emergency delivery of the patient to the hospital (in the ICU of the hospital). ICD-10 code Nosological form I 44 Atrioventricular [atrioventricular] blockade and blockade of the left bundle branch [His] I 45. 9 Conduction disorder, unspecified

CLINICAL RECOMMENDATIONS (PROTOCOLS) FOR THE PROVISION OF EMERGENCY MEDICAL CARE FOR SA-blockades Examination, physical examination of the patient. Assessment of the general condition, the presence of life-threatening symptoms. Patient history, try to determine the most probable cause bradycardia. Registration of blood pressure, pulse, ECG. Provide airway patency, oxygen inhalation, intravenous access. In / in or / m the introduction of atropine sulfate 0.1% - 0.5 ml. ECG monitoring. Emergency transfer of the patient to the hospital. In the presence of life-threatening symptoms (MES): Examination, physical examination of the patient. Assessment of the general condition, the presence of life-threatening symptoms. Patient history, try to determine the most likely cause of bradycardia. Registration of blood pressure, pulse, Spo. O 2 ECG. Start fluid infusion (physiological chloride solution sodium), intravenous administration of atropine sulfate 0.1% - 0.5 ml until the degree of blockade decreases, monitoring of ECG and cardiac activity. If myocardial infarction is suspected, the ambulance protocol for this disease should be followed. Emergency delivery of the patient to the hospital in the ICU of the hospital.

CLINICAL RECOMMENDATIONS (PROTOCOLS) FOR THE PROVISION OF EMERGENCY MEDICAL CARE FOR AV blockades Examination, physical examination of the patient. Assessment of the general condition, the presence of life-threatening symptoms. Patient history, try to determine the most likely cause of bradycardia. Registration of blood pressure, pulse, ECG. Provide airway patency, oxygen inhalation, intravenous access. In / in or / m the introduction of atropine sulfate 0.1% - 0.5 ml. ECG monitoring. Emergency transfer of the patient to the hospital. In the presence of life-threatening symptoms: Examination, physical examination of the patient. Assessment of the general condition, the presence of life-threatening symptoms. Patient history, try to determine the most likely cause of bradycardia. Registration of blood pressure, pulse, Spo. O 2 ECG. Start fluid infusion ( physiological solution sodium chloride), intravenous administration of atropine sulfate 0.1% - 0.5 ml, again 1.0 ml. ECG and cardiac monitoring. If myocardial infarction is suspected, the emergency medical care protocol for this disease should be followed. The introduction of atropine is ineffective in distal AV blockade. With the ineffectiveness of atropine, the patient is shown an emergency pacemaker.

CLINICAL RECOMMENDATIONS (PROTOCOLS) FOR THE PROVISION OF EMERGENCY MEDICAL CARE FOR AV blockades Examination, physical examination of the patient. Assessment of the general condition, the presence of life-threatening symptoms. Patient history, try to determine the most likely cause of bradycardia. Registration of blood pressure, pulse, ECG. Provide airway patency, oxygen inhalation, intravenous access. In / in or / m the introduction of atropine sulfate 0.1% - 0.5 ml. ECG monitoring. Emergency transfer of the patient to the hospital. ABOUT general profile field brigades ambulance - external or transesophageal pacemaker. Specialized mobile ambulance teams - transvenous pacemaker. If it is impossible to use the EX-, use drugs that increase the heart rate by acting on the B receptors of the heart. Adrenaline 1 ml 0.1% solution, dopamine at a calculated dose of 5-6 mcg * kg / min, IV drip in 500 ml physiological solution. In case of ineffectiveness, in / in enter solution of euphylline 2.4% - 10 ml. Access MES. Determine circulatory arrest (specify the time), ensure airway patency, record the electrical activity of the heart (ECG monitoring). Start basic CPR, provide IV access. In / in enter rr adrenaline 0.1% - 1.0 ml, with asystole. In case of bradysystole atropine sulfate 0.1% -1.0 ml, in case of ineffectiveness intravenously, enter the solution of aminophylline 2.4% - 10 ml. When restoring cardiac activity - emergency EKS All patients are shown emergency delivery to the hospital bypassing Art. OSMP

CLINICAL RECOMMENDATIONS (PROTOCOLS) ON PROVIDING EMERGENCY MEDICAL ASSISTANCE IN CARDIOGENIC SHOCK Examination, physical examination of the patient. Assessment of the general condition, the presence of life-threatening symptoms. Anamnesis of the patient Registration of blood pressure, pulse, ECG, rapid test for troponin. Lay the patient down, raise the foot end. Oxygen therapy ((with O2 saturation level of 90%.)) In the absence of stagnation in the lungs and signs of hypovolemia - rapid infusion of 200 ml of saline sodium chloride solution 200 ml in 10 minutes, May be repeated if necessary, until a total volume of 400 ml is reached To raise blood pressure - vasopressors (preferably administered through a dispenser - Dopamine at an initial rate of 2-10 mcg / kg * min. If there is no effect, the rate increases every 5 minutes to 20 -50 mcg / kg * min. The effect occurs quickly, in the first minutes, but upon termination infusion lasts 10 minutes Standard solution is prepared by adding 400 mg of dopamine to 250 ml of 0.9% sodium chloride solution, which gives a concentration of 1600 mcg per 1 ml Do not mix with alkaline solutions! stop the infusion gradually.Doses up to 5 µg/l*min improve renal blood flow, 5-10 µg/l*min provide a positive inotropic effect, over 10 µg/l*min cause vasoconstriction. pamine can increase myocardial oxygen demand. Side effects - tachycardia, cardiac arrhythmias, nausea, aggravation of myocardial ischemia. Contraindications - pheochromocytoma, life-threatening ventricular arrhythmias (ventricular fibrillation, ventricular tachycardia). - Dobutamine - 250 mg of lyophilizate is dissolved in 10 ml of 0.9% sodium chloride solution, diluted to a volume of 50 ml and added to 200 ml of 0.9% sodium chloride solution, infusion at a rate of 2.5 -10 μg / kg * min s increasing it, if necessary, by 2.5 mcg / kg * min to a maximum of 20 mcg / kg * min (without an infusion pump, start with 8-16 drops per minute). The effect develops in 1-2 minutes, when stopped, it lasts 5 minutes. Dobutamine has a distinct positive inotropic effect, it reduces vascular resistance in the pulmonary circulation, with little effect on total peripheral resistance. Emergency transfer of the patient to the hospital. Dopamine/dobutamine infusions Indication for use is cardiogenic shock with pulmonary edema. In the absence of the effect of dopamine / dobutamine, progressive hypotension with SBP<80 мм рт. ст. возможно введение адреналина (эпинефрин) в дозе 2 -4 мкг в минуту в виде инфузии или норадреналина (с учетом понимания того, что последний усугубляет вазоконстрикцию) – 0, 2 -1, 0 мкг/кг/мин. внутривенно капельно. При отеке легких после стабилизации САД выше 100 мм рт. ст. добавить внутривенно нитраты, начиная с малых доз и морфин дробно по 2 мг (последний хорош и для адекватного обезболивания) Рассмотреть необходимость назначения аспирина(250 -325 мг разжевать) и антикоагулянтов (гепарин 70 Ед на кг массы тела, не более 4000 ЕД) Тщательное мониторирование АД, ЧСС, аритмий, диуреза (катетер в мочевой пузырь желателен) Тактика: Срочная доставка в стационар и госпитализация с продолжающейся в ходе транспортировки инфузией вазопрессоров и мониторированием жизненно важный функций, желательно в стационар с наличием кардиохирургического отделения и рентгенэндоваскулярной операционной для возможной коронароангиопластики и баллонной внутриаортальной контрпульсации. Транспортировка только на носилках. МКБ 10 код Нозологическая форма R 57. 0 Кардиогенный шок

CLINICAL RECOMMENDATIONS (PROTOCOLS) FOR EMERGENCY CARE FOR ACUTE CORONARY SYNDROME WITHOUT ST SEGMENT ELEVATION Physical data Examination and physical examination. Assessment of the general condition of the patient. Changes are often missing. There may be symptoms of heart failure or hemodynamic disturbances. Electrocardiography: ECG must be taken no later than 10 minutes after the first contact with the patient. Comparison of the ECG with previously taken electrocardiograms is invaluable. Identification of any dynamics related to the ST segment and T waves in the presence of clinical signs of myocardial ischemia should be sufficient reason to interpret the situation as a manifestation of ACS and urgently hospitalize the patient. Differential diagnosis to exclude the non-coronary nature of the pain syndrome. Biomarkers: Rapid troponin testing should not be used as a guideline for management decisions in patients with typical clinical presentations and changes. ECG. Treatment Oxygen therapy at a rate of 4–8 L/min with less than 90% oxygen saturation Oral or intravenous nitrate (IV nitrate treatment is recommended in patients with recurrent angina and/or signs of heart failure. Nitroglycerin 0.5–1 mg tablets or Nitrospray ( 0.4 -0.8 mg) 2 doses under the tongue Nitroglycerin intravenously 10 ml of 0.1% solution is diluted in 100 ml of 0.9% sodium chloride solution (constant monitoring of heart rate and blood pressure is necessary, be careful when lowering systolic blood pressure<90 мм рт. ст.) При некупирующемся болевом синдроме Морфин 3 -5 (до 10) мг внутривенно с титрацией дозы, что особенно важно для пожилых, для чего препарат разводят на 10 мл физиологического раствора и повторно вводят по 2 -3 мл под контролем АД и ЧД. Аспирин 150 -300 мг без кишечно-растворимой оболочки — Клопидогрель 300 мг. 75 лет- 75 мг. Код по МКБ X Нозологические формы I 20. 0 Нестабильная стенокардия I 21. 4 Острый субэндокардиальный инфаркт миокарда I 21. 9 Острый инфаркт миокарда неуточненный

CLINICAL RECOMMENDATIONS (PROTOCOLS) FOR EMERGENCY CARE FOR NON-ST-ELEVATION ACUTE CORONARY SYNDROME (continued) tactics that involve PCI within the next 2 hours after the first contact with a healthcare worker: Refractory Urgent hospitalization in a specialized hospital where invasive intervention is possible . Already in the prehospital stage, very high-risk patients requiring urgent invasive angina (including myocardial infarction) should be identified Recurrent angina associated with ST-segment depression > 2 mm or deep negative T-wave despite intensive treatment Clinical symptoms of heart failure or hemodynamic instability (shock) Life-threatening arrhythmias (ventricular fibrillation or ventricular tachycardia) Patients with ST ACS should be immediately referred to the ICU, bypassing St. OSMP. UFH) IV 60-70 IU/kg as a bolus (max 4000 IU) followed by infusion at 12-15 IU/kg/h (max 1000 IU/h). insufficiency.Metoprolol - with severe tachycardia, preferably intravenously - 5 mg every 5 minutes for 3 injections, then after 15 minutes 25-50 mg under the control of blood pressure and heart rate. Tablet preparations can be prescribed - metoprolol 50-100 mg, in the absence of metoprolol, use bisoprolol 5-10 mg.

CLINICAL RECOMMENDATIONS (PROTOCOLS) FOR EMERGENCY CARE FOR ST-ELEVATION ACUTE CORONARY SYNDROME The diagnosis of MI is made on the basis of the following criteria: A significant increase in biomarkers of cardiomyocyte necrosis in combination with at least one of the following signs: symptoms of ischemia, episodes of ST-segment elevation on the ECG or first-time complete blockade of the left bundle branch block, the appearance of an abnormal Q wave on the ECG, the appearance of new areas of impaired local myocardial contractility, the detection of intracoronary thrombosis on angiography, or the detection of thrombosis on autopsy. 2. Cardiac death, with symptoms suggestive of myocardial ischemia and presumably new ECG changes, when necrosis biomarkers are not defined or not yet elevated. 3. Stent thrombosis, confirmed angiographically or at autopsy, in combination with signs of ischemia and a significant change in biomarkers of myocardial necrosis. Classification: Type 1. Spontaneous MI associated with ischemia during the primary coronary event (erosion, tear, rupture or dissection of the plaque). Type 2. Secondary MI associated with ischemia caused by an imbalance between myocardial oxygen demand and delivery due to coronary spasm, coronary embolism, anemia, arrhythmia, hypertension or hypotension. Type 3 Sudden coronary death, including cardiac arrest associated with symptoms of ischemia or verified coronary thrombosis on angiography or autopsy. Type 4 a. MI associated with percutaneous intervention (PCI). Type 4 b. MI associated with verified stent thrombosis. Type 5. MI associated with coronary artery bypass grafting (CABG). In the practice of an emergency physician (paramedic), type 1 infarction is most common, which is the focus of a typical algorithm for providing care for ACS with ST segment elevation. Examination, physical examination of the patient. Assessment of the general condition, the presence of life-threatening symptoms. Anamnesis of the patient Registration of blood pressure, pulse, ECG, rapid test for troponin. MK B code X Nosological forms I 21. 0 Acute transmural infarction of the anterior myocardial wall I 21. 1 Acute transmural infarction of the lower myocardial wall I 21. 2 Acute transmural myocardial infarction of other specified localizations I 21. 3 Acute transmural myocardial infarction of unspecified localization

CLINICAL RECOMMENDATIONS (PROTOCOLS) FOR EMERGENCY CARE FOR ST-ELEVATION ACUTE CORONARY SYNDROME (continued) Absolute contraindications to thrombolytic therapy: Hemorrhagic stroke or stroke of unknown origin of any age Ischemic stroke in the previous 6 months Trauma or tumors of the brain, arteriovenous malformation Major trauma/surgery/trauma of the skull within the previous 3 weeks Gastrointestinal bleeding within the previous month Established hemorrhagic disorders (excluding menses) Aortic wall dissection Puncture of an uncompressible site (including liver biopsy, lumbar puncture) in the previous 24 hours Relative contraindications: Transient ischemic attack within the previous 6 months Oral anticoagulant therapy Pregnancy or postpartum within 1 week Resistant hypertension (systolic BP >180 mmHg and/or diastolic BP >110 mmHg) Serious disease liver Infective endocarditis Exacerbation peptic ulcer Prolonged or traumatic resuscitation Thrombolysis drugs: Alteplase (tissue plasminogen activator) 15 mg IV as a bolus of 0.75 mg/kg over 30 minutes, then 0.5 mg/kg over 60 minutes IV. The total dose should not exceed 100 mg Tenecteplase - once in / in the form of a bolus, depending on body weight: 30 mg -<60 кг 35 мг — 60 -<70 кг 40 мг — 70 -<80 кг 45 мг — 80 -<90 кг 50 мг — ≥ 90 кг. Выбор лечебной тактики Как только диагноз ОКСп. ST установлен, требуется срочно определить тактику реперфузионной терапии, т. е. восстановления проходимости окклюзированной левой ножки пучка Гиса При отсутствии противопоказаний и невозможности выполнения ЧКВ в рекомендуемые сроки выполняется тромболизис (I, А), предпочтительно на догоспитальном этапе. Тромболитическая терапия проводится, если ЧКВ невозможно выполнить в течение 120 минут от момента первого контакта с медработником (I, А). Если с момента появления симптомов прошло менее 2 часов, а ЧКВ не может быть выполнено в течение 90 минут, при большом инфаркте и низком риске кровотечения должна быть проведена тромболитическая терапия (I, А). После тромболитической терапии больной направляется в центр с возможностью выполнения ЧКВ (I, А).

CLINICAL RECOMMENDATIONS (PROTOCOLS) FOR EMERGENCY CARE FOR ST-ELEVATION ACUTE CORONARY SYNDROME (continued) Other drug therapy Opioids intravenously (morphine 4-10 mg), in elderly patients should be diluted with 10 ml of saline and administered in divided doses of 2 - 3 ml. If necessary, additional doses of 2 mg are administered at intervals of 5-15 minutes until complete relief of pain). Perhaps the development of side effects: nausea and vomiting, arterial hypotension with bradycardia and respiratory depression. Antiemetics (eg, metoclopramide 5–10 mg intravenously) may be given concomitantly with opioids. Hypotension and bradycardia are usually stopped by atropine at a dose of 0.5-1 mg (total dose up to 2 mg) intravenously; Tranquilizer (Diazepam 2, 5-10 mg IV) with the appearance of severe anxiety Beta-blockers in the absence of contraindications (bradycardia, hypotension, heart failure, etc.): Metoprolol - with severe tachycardia, preferably intravenously - 5 mg every 5 minutes 3 injections, then after 15 minutes 25-50 mg under the control of blood pressure and heart rate. In the future, tablet preparations are usually prescribed. Sublingual nitrates for pain: Nitroglycerin 0.5-1 mg tablets or Nitrospray (0.4-0.8 mg). With recurrent angina pectoris and heart failure Nitroglycerin is administered intravenously under the control of blood pressure: 10 ml of a 0.1% solution is diluted in 100 ml of saline. Constant monitoring of heart rate and blood pressure is necessary, do not administer with a decrease in systolic blood pressure<90 мм рт. ст. Ингаляции кислорода (2 -4 л/мин) при наличии одышки и других признаков сердечной недостаточности Пациенты с ОКС с п. ST должны сразу направляться в ОРИТ, минуя Ст. ОСМП. Всем больным с ОКС при отсутствии противопоказаний показана двойная дезагрегантная терапия (I, A): Если планируется первичное ЧКВ: Аспирин внутрь 150 -300 мг или в/в 80 -150 мг, если прием внутрь невозможен Клопидогрель внутрь 600 мг (I, C). (Если есть возможность, предпочтительнее Прасугрель у не принимавших Клопидогрель пациентов моложе 75 лет в дозе 60 мг (I, B) или Тикагрелор в дозе 180 мг (I, B)). Если планируется тромболизис: Аспирин внутрь 150 -500 мг или в/в 250 мг, если прием внутрь невозможен Клопидогрель внутрь в нагрузочной дозе 300 мг, если возраст ≤ 75 лет Если не планируется ни тромболизис, ни ЧКВ: Аспирин внутрь 150 -500 мг Клопидогрель внутрь

CLINICAL RECOMMENDATIONS (PROTOCOLS) ON PROVIDING EMERGENCY MEDICAL CARE IN ACUTE HEART FAILURE Clinical classification. Allocate for the first time (de novo) AHF and worsening CHF. In both groups, the presence and severity of coronary artery lesions can determine the tactics of managing the patient in the initial period and during hospitalization. Initial therapy is based on the clinical profile at the time of admission to the hospital. Of the approximately 80% of AHF patients with worsening CHF, only 5-10% have severe advanced progressive HF. It is characterized by low blood pressure, kidney damage, and/or signs and symptoms refractory to standard treatment. The remaining 20% represent new-onset AHF, which can be further subdivided into variants with and without pre-existing risk of HF (hypertension, coronary artery disease), as well as without previous LV dysfunction or structural heart disease, or with the presence of organic cardiac disease (for example, reduced FV). It is important to assess AHF according to the Killip Killip I classification - the absence of congestive rales in the lungs. Killip II - congestive rales occupy less than 50% of the lung fields. Killip III - congestive rales occupy more than 50% of the lung fields (pulmonary edema). Killip IV - cardiogenic shock. Indications for delivery to the hospital. Patients diagnosed with AHF should be taken to the hospital. Transportation on a stretcher with a raised head end. Monitor heart rate and blood pressure. Treatment. Exclude or suspect ACS (if there is pain in the chest, acutely developed pulmonary edema against the background of normal or low blood pressure without paroxysmal arrhythmias, its probability increases significantly). A rapid troponin test is highly recommended. Pulse oximetry to determine and control saturation O 2. Monitoring blood pressure and heart rate. Reliable access to a peripheral vein. ECG in 12 leads 1. Intravenously - furosemide (B, 1+). If the patient has already taken loop diuretics, the dose should be 2.5 times his last daily dose. Otherwise, 40 - 200 mg. Re-enter if necessary. Control of diuresis - consider the need for bladder catheterization.

CLINICAL RECOMMENDATIONS (PROTOCOLS) FOR THE EMERGENCY CARE OF ACUTE HEART FAILURE (CONTINUED) Body weight (BW) Increase in BW precedes hospitalization, however, decrease in BW in response to therapy does not correspond to a decrease in hospitalization or mortality Heart rate pattern and rate As brady- and tachyarrhythmia may contribute to BP congestion No change or increase in BP during transition from supine to standing position or during Valsalva maneuver usually reflects relatively high LV filling pressure Jugular venous pressure Increased, jugular venous distention present Equivalent to pressure in PP. Wheezing Usually finely bubbling, symmetrical on both sides, unless the patient lies predominantly on one side, does not disappear with coughing, more in the basal regions of the lungs, associated with increased wedge pressure in the pulmonary capillaries when combined with other signs of increased filling pressure ( jugular vein pressure), but are not specific per se. Orthopnea Patients often cannot lie down when filling pressure builds up rapidly. Edema Peripheral edema, if combined only with an increase in jugular pressure, indicates the presence of right ventricular failure, which, as a rule, is accompanied by LVH. The severity of edema can be different - from a "trace" in the ankles or lower legs (+) to edema spreading to the thighs and sacrum (+++). BNP/NT pro. BNP (express tests exist) An increase of more than 100/400 pg / ml is a marker of increased filling pressure 2. At a saturation level of O 2 90% (C, 1+). 3. With severe shortness of breath, psycho-emotional arousal, anxiety, fear in the patient - intravenous opiates (morphine 4-8 mg). (Be aware of possible respiratory depression, especially in elderly patients!). To prevent nausea and vomiting, you can add 10 mg of metoclopramide intravenously. With SBP >110 mm Hg. Art: Vasodilators (nitroglycerin) - start infusion at a rate of 10 mcg per minute. , depending on the effect and tolerability, double the speed every 10 minutes. Hypotension usually limits the infusion rate. Doses >100 micrograms per minute are rarely achieved. With a positive response to therapy (reduction of dyspnea and heart rate, the number of wheezing in the lungs, pallor and moisture of the skin, adequate urine output > 100 ml per hour for the first 2 hours, improvement in Sat. O 2), continue nitroglycerin infusion and oxygen therapy and transfer the patient to hospital in the supine position on a stretcher with a raised headboard while continuing to monitor blood pressure and heart rate during transportation.

CLINICAL RECOMMENDATIONS (PROTOCOLS) FOR EMERGENCY CARE FOR ACUTE HEART FAILURE (CONTINUED E) When re-evaluating the patient's condition after starting treatment for any of the above options. If there is hypotension with SBP< 85 мм рт. ст. : остановить инфузию вазодилятатора, при наличии признаков гипоперфузии прекратить терапию бетаадреноблокаторами добавить инфузию инотропа без вазодилятирующих свойств или вазопрессора (допамин с начальной скоростью 2, 5 мкг/кг/мин. , удваивая дозу каждые 15 мин. до достижения эффекта или в зависимости от переносимости (ограничения возможны вследствие тахикардии, нарушений сердечного ритма или ишемии миокарда). Дозы более 20 мкг/кг/мин достигаются редко. Если Sp. O 2 < 90%: оксигенотерапия, рассмотреть возможность инфузии вазодилятатора (нитроглицерин), при прогрессирующем снижении Sp. O 2, неэффективности внешнего дыхания, появлении или нарастания явления спутанности сознания – интубация трахеи и переход к ИВЛ. Если диурез < 20 мл/мин: катетеризация мочевого пузыря для подтверждения низкого диуреза, увеличить дозу диуретика или добавить второй диуретик, рассмотреть возможность инфузии низких («почечных») доз допамина (2, 5 -5 мкг/кг/мин). При САД 85 -110 мм рт. ст. Вазодилятаторы не применяются. После выполнения пунктов 1 -3 провести повторную оценку состояния пациента. При улучшении (может быть постепенным, в течение 1 -2 часов) – доставка пациента в стационар по принципам, предыдущем пункте При САД < 85 мм рт. ст. или явлениях шока. Инотропы без вазодилятирующего действия – инфузия добутамина (С, 1+), начиная с 2, 5 мкг/кг/мин. , удваивая дозу каждые 15 мин. до достижения эффекта или в зависимости от переносимости (ограничения возможны вследствие тахикардии, нарушений сердечного ритма или ишемии миокарда). Дозы более 20 мкг/кг/мин достигаются редко.

CLINICAL RECOMMENDATIONS (PROTOCOLS) FOR EMERGENCY ASSISTANCE FOR TACHYCARDIAS AND TACHYARHYTHMIAS direct medical influence on sinus tachycardia is not necessary. In case of abuse of coffee, tea, smoking, it is recommended to exclude a harmful factor, if necessary, use valocardin, corvalol or sedatives (possibly in tablets: fenozepam 0.01 dissolve in the mouth) (C, 2++). In the absence of hemodynamic disorders, hospitalization is not required. The issue of hospitalization and patient management tactics is decided on the basis of the algorithm of the disease that is accompanied by sinus tachycardia. In case of unstable hemodynamics, the patient is taken to the hospital and admitted to the intensive care unit. Remember that tachycardia may be the first, and up to a certain point, the only sign of shock, blood loss, acute myocardial ischemia, pulmonary embolism, and some other conditions dangerous for the patient. Classification 1. Sinus tachycardia. 2. Supraventricular tachycardia: 2. 1 Paroxysmal supraventricular tachycardia; 2. 2 Non-paroxysmal supraventricular tachycardias. 3. Atrial fibrillation or flutter. 4. Ventricular tachycardia. ICD code -10 Nosological form I 47. 1 Supraventricular tachycardia I 47. 2 Ventricular tachycardia I 48 Atrial fibrillation and flutter

CLINICAL RECOMMENDATIONS (PROTOCOLS) FOR EMERGENCY ASSISTANCE FOR TACHYCARDIAS AND TACHYARHYTHMIAS (CONTINUED) 2. No effect - after 2 minutes ATP 10 mg IV in a push. 3. No effect - after 2 minutes verapamil 5 mg IV, slowly 4. No effect - after 15 minutes verapamil 5-10 mg IV, slowly 5. Repeat vagal techniques. 6. No effect - after 20 minutes, novocainamide, or propranolol, or propafenone, or disopyramide - as indicated above; however, in many cases, hypotension is exacerbated and the likelihood of bradycardia after restoration of sinus rhythm increases. An alternative to the repeated use of the above drugs can be the introduction of: Amiodarone (Cordarone) at a dose of 300 mg per 200 ml of saline, drip, take into account the effects on conductivity and QT duration (A, 1++). A special indication for the introduction of amiodarone is paroxysmal tachycardia in patients with ventricular pre-excitation syndromes. Procainamide (Novocainamide) is administered intravenously at a dose of 1000 mg (10.0 ml of a 10% solution, the dose can be increased to 17 mg / kg) at a rate of 50 - 100 mg / min under the control of blood pressure (with a tendency to arterial hypotension - together with 0.3 -0.5 ml of 1% phenylephrine solution (Mezaton) or 0.1 -0.2 ml of 0.2% norepinephrine solution (Norepinephrine)), (A, 1++). Propranolol is administered intravenously at a dose of 5–10 mg (5–10 ml of a 0.1% solution) per 200 ml of saline under the control of blood pressure and heart rate; with initial hypotension, its administration is undesirable even in combination with mezaton. (A, 1+). Propafenone is injected intravenously at a dose of 1 mg/kg over 3-6 minutes. (C, 2+). Disopyramide (Ritmilen) - at a dose of 15.0 ml of a 1% solution in 10 ml of saline (if novocainamide was not previously administered) (C, 2+). If there is no effect, the drugs can be administered repeatedly, already in the ambulance. An alternative to the repeated use of the above drugs can be the introduction of: Amiodarone (Cordarone) at a dose of 300 mg per 200 ml of saline, drip, take into account the effects on conductivity and QT duration (B, 2++). A special indication for the administration of amiodarone is paroxysmal tachycardia in patients with ventricular preexcitation syndromes.

CLINICAL RECOMMENDATIONS (PROTOCOLS) FOR EMERGENCY ASSISTANCE FOR TACHYCARDIAS AND TACHYARHYTHMIAS (CONTINUED) Examination and physical examination. Assessment of the general condition of the patient. Anamnesis to find out the possible cause. Registration of pulse, blood pressure, ECG. In the absence of life-threatening symptoms and ischemic changes on the ECG, evacuation to a hospital for examination and treatment. Paroxysmal supraventricular tachycardia with wide QRS complexes The tactics are somewhat different, since the ventricular nature of tachycardia cannot be completely excluded, and the possible presence of a pre-excitation syndrome imposes certain restrictions. Electrical impulse therapy (EIT) is indicated for hemodynamically significant tachycardias (A, 1++). Treatment and further tactics of patient management Verapamil is administered intravenously at a dose of 5-10 mg (2.0-4.0 ml of 2.5% solution) per 200 ml of saline under the control of blood pressure and rhythm frequency. (A, 1++). Procainamide (Novocainamide) is administered intravenously at a dose of 1000 mg (10.0 ml of a 10% solution, the dose can be increased to 17 mg / kg) per 200 ml of saline at a rate of 50-100 mg / min under the control of blood pressure (with tendencies to arterial hypotension - together with 0.3-0.5 ml of 1% phenylephrine solution (Mezaton) or 0.1-0.2 ml of 0.2% norepinephrine solution (Norepinephrine) (A, 1 ++ Amiodarone (Cordarone) at a dose of 300 mg per 200 ml of saline, drip, take into account the effects on conductivity and QT duration, which may prevent the administration of other antiarrhythmics. (B, 2+) If intravenous administration of drugs is impossible, tablet therapy is possible: Propranolol ( Anaprilin, Obzidan) 20-80 mg (A, 1++) Another B blocker can be used in a moderate dose (at the discretion of the doctor) Verapamil (Isoptin) 80-120 mg (in the absence of pre-excitation!) in combination with phenazepam (Phenazepam) 1 mg or clonazepam 1 mg (A, 1+) Or one of the previously effective antiarrhythmics doubled: Quinidine-durules 0.2 g, n rocainamide (Novocainamide) 1. 0 -1. 5 g, disopyramide (Ritmilen) 0.3 g, etacizin (Etacizin) 0.1 g, propafenone (Propanorm) 0.3 g, sotalol (Sotahexal) 80 mg). (B, 2+). Urgent delivery to the hospital and hospitalization in the intensive care unit or intensive care unit

CLINICAL RECOMMENDATIONS (PROTOCOLS) FOR EMERGENCY ASSISTANCE FOR TACHYCARDIAS AND TACHYARHYTHMIAS (CONTINUED) nye departments of hospitals. (if EIT has not been performed and there is no severe underlying disease (ICU) IN AFTER FIBRILLATION (FLINKING) AND ATRIAL FLUTTER Indications for restoring sinus rhythm at the prehospital stage: - Duration of atrial fibrillation 48 hours in combination with hemodynamic disturbance, myocardial ischemia and heart rate > 250 in 1 min Also in favor of rhythm recovery are the following circumstances: - CHF symptoms or weakness increase in the absence of sinus rhythm - Hypertrophy or severe LV dysfunction - LA size less than 50 mm - Duration of atrial fibrillation less than 1 year - Young age of the patient - Presence of a paroxysmal form of arrhythmia - Contraindications for long-term anticoagulant therapy In case of unstable hemodynamics, loss of consciousness, electrical impulse therapy (EIT, cardioversion).

CLINICAL RECOMMENDATIONS (PROTOCOLS) FOR EMERGENCY MEDICAL CARE FOR TACHYCARDIAS AND TACHYARHYTHMIAS (CONTINUED Treatment with drugs: When arresting paroxysm for up to 1 day, heparin can not be administered. Administration of amiodarone (Cordaron) at a dose of 300 mg intravenously by drop infusion into 200 ml of saline (A, 1+ +) Verapamil is administered intravenously at a dose of 5-10 mg (2.0-4.0 ml of 2.5% solution per 200 ml of saline) under the control of blood pressure and rhythm frequency (A, 1++). intravenous drip at a dose of 5-10 mg (5-10 ml of 0.1% solution) per 200 ml of saline under the control of blood pressure and heart rate (A, 1+). mg (10.0 ml of a 10% solution, the dose can be increased to 17 mg / kg) at a rate of 50-100 mg / min under the control of blood pressure (with a tendency to arterial hypotension - together with 0.3 -0.5 ml of 1% solution of phenylephrine (Mezaton) or 0.1 -0.2 ml of 0.2% solution of norepinephrine (Norepinephrine)) (B, 1+) Digoxin, strophanthin: 1 m l of the drug solution per 10 ml of saline, intravenous bolus (D, 2+). Potassium preparations: 10 ml of Panangin solution - intravenously by stream or 10 ml of 10% potassium chloride solution per 200 ml of saline solution intravenously (A, 1+). Disopyramide (Ritmilen) - at a dose of 15.0 ml of a 1% solution in 10 ml of saline. solution (if novocainamide was previously administered) (B, 2+). Tablet therapy Propranolol (Anaprilin, Obzidan) 20-80 mg (A, 1++). You can use another B-blocker in a moderate dose (at the discretion of the doctor). Verapamil (Isoptin) 80-120 mg (in the absence of pre-excitation!) in combination with phenazepam (Phenazepam) 1 mg or clonazepam 1 mg (B, 2+). Or one of the previously effective antiarrhythmics in a double dose of quinidine (Kinidin-durules) 0.2 g, procainamide (Novocainamide) 1.0 -1. 5 g, disopyramide (Ritmilen) 0.3 g, etacizin (Etacizin) 0.1 g, propafenone (Propanorm) 0.3 g, sotalol (Sotahexal) 80 mg) (B, 1+).

CLINICAL RECOMMENDATIONS (PROTOCOLS) FOR EMERGENCY CARE FOR TACHYCARDIAS AND TACHYCARDIACS (CONTINUED) resort to electrical cardioversion. Perform emergency electrical cardioversion with a 100 J discharge. In case of pulseless ventricular tachycardia, start with defibrillation with an unsynchronized discharge of 200 J. If the patient is conscious, but his condition is severe, synchronized cardioversion is used. Amiodarone IV 5 mg/kg over 10–30 min (15 mg/min) or IV 150 mg over 10 min followed by 360 mg over 6 hours (1 mg/min) and 540 mg over 18 hours (0 , 5 mg/min) in saline; the maximum total dose is 2 g in 24 hours (150 mg in 10 minutes can be added as needed) (B, 1+). Correction of electrolyte disturbances is carried out (potassium preparations: 10 ml of Panangin solution - intravenously by stream or 10 ml of 10% potassium chloride solution intravenously in 200 ml of saline, drip) (A, 1++).

CLINICAL RECOMMENDATIONS (PROTOCOL) FOR RENDERING EMERGENCY CARE IN SUDDEN CARDIAC DEATH Clinical guidelines for the provision of emergency medical care in sudden cardiac death. With ventricular fibrillation and the possibility of defibrillation in the first 3 minutes of clinical death, start with the application of an electric discharge. 2. Start carrying out deep (5 cm), frequent (at least 100 per 1 min), continuous chest compressions with a ratio of the duration of compression and decompression of 1: 1. 3. The main method of ventilation is mask (the ratio of compressions and breathing in adults is 30: 2), ensure the patency of the respiratory tract (tilt back the head, push the lower jaw forward, insert the air duct). 4. As soon as possible - defibrillation (with a monophasic pulse shape, all discharges with an energy of 360 J, with a biphasic pulse shape, the first shock with an energy of 120–200 J, subsequent - 200 J) - 2 minutes of chest compressions and mechanical ventilation - evaluation of the result; Definition. Sudden cardiac death (SCD) is an unexpected death from cardiac causes that occurs within 1 hour of the onset of symptoms in a patient with or without known heart disease. Key areas of differential diagnosis. According to the ECG during CPR, the following are diagnosed: - ventricular fibrillation; - electrical activity of the heart without a pulse; – asystole

CLINICAL RECOMMENDATIONS (PROTOCOL) FOR EMERGENCY CARE FOR SUDDEN CARDIAC DEATH (CONTINUED) MONITORING - for persistent ventricular fibrillation - second defibrillation - 2 minutes of chest compressions and mechanical ventilation - evaluation of the result ; - with persistent ventricular fibrillation - third defibrillation - 2 minutes of chest compressions and mechanical ventilation - result score 5. In case of ventricular fibrillation, EABP or asystole without interrupting chest compressions, catheterize a large peripheral vein and inject 1 mg of epinephrine (adrenaline), continue injections of epinephrine at the same dose every 3 to 5 minutes until the end of CPR. 6. In case of ventricular fibrillation without interrupting chest compressions, inject 300 mg of amiodarone (cordarone) as a bolus and perform the fourth defibrillation - 2 minutes of chest compressions and mechanical ventilation - evaluation of the result. 7. In case of persistent ventricular fibrillation, without interrupting chest compressions, with a bolus of 150 mg of amiodarone and apply the fifth electric shock - 2 minutes of chest compressions and mechanical ventilation - evaluation of the result.

CLINICAL RECOMMENDATIONS (PROTOCOL) FOR EMERGENCY CARE FOR SUDDEN CARDIAC DEATH (CONTINUED) MONITORING 8. For pulseless ventricular tachycardia, the procedure is the same. 9. Patients with fusiform ventricular tachycardia and possible hypomagnesaemia (for example, after taking diuretics) are shown intravenous administration of 2000 mg of magnesium sulfate. 10. In case of asystole or EABP: - perform steps 2, 3, 5; – check the correct connection and operation of the equipment; - try to identify and eliminate the cause of asystole or EABP: hypovolemia - infusion therapy, hypoxia - hyperventilation, acidosis - hyperventilation (sodium bicarbonate if it is possible to control CBS), tension pneumothorax - thoracocentesis, cardiac tamponade - pericardiocentesis, massive PE - thrombolytic therapy; take into account the possibility of the presence and correction of hyper- or hypokalemia, hypomagnesemia, hypothermia, poisoning; with asystole - external transcutaneous pacing. 11. Monitor vital signs (heart monitor, pulse oximeter, capnograph). 12. Hospitalize after possible stabilization of the condition; ensure that treatment (including resuscitation) is carried out in full during transportation; alert hospital staff deliver the patient directly to the intensive care unit and transfer to the anesthesiologist-resuscitator. 13. It is possible to stop resuscitation only in those cases when, when using all available methods, there are no signs of their effectiveness within 30 minutes. It should be borne in mind that it is necessary to start counting the time not from the beginning of CPR, but from the moment when it ceased to be effective, i.e. after 30 minutes of the complete absence of any electrical activity of the heart, the complete absence of consciousness and spontaneous breathing.

Note. It is advisable to start resuscitation with a precordial shock only at the very beginning (in the first 10 seconds) of clinical death, if it is impossible to apply an electric discharge in a timely manner. Drugs are administered into a large peripheral vein. In the absence of access to a vein, use intraosseous access. The endotracheal route of drug administration is not used. When issuing medical documentation (an ambulance call card, an outpatient or inpatient card, etc.), the resuscitation benefit must be described in detail, indicating the exact time for each manipulation and its result. Mistakes (13 Common CPR Mistakes). In the implementation of resuscitation, the price of any tactical or technical errors is high; the most typical of them are the following. 1. Delay with the start of CPR, loss of time for secondary diagnostic, organizational and therapeutic procedures. 2. The absence of a single leader, the presence of outsiders. 3. Incorrect technique of chest compressions, insufficient (less than 100 per 1 min) frequency and insufficient (less than 5 cm) depth of compressions. 4. Delay in the start of chest compressions, the start of resuscitation with mechanical ventilation. 5. Interruptions in chest compressions greater than 10 seconds due to seeking venous access, mechanical ventilation, repeated attempts at tracheal intubation, ECG recording, or any other reason. 6. Incorrect ventilator technique: airway patency not secured, tightness when blowing air (most often the mask does not fit snugly against the patient's face), prolonged (more than 1 s) air blowing. 7. Interruptions in the administration of epinephrine (adrenaline) exceeding 5 minutes. 8. Lack of constant monitoring of the effectiveness of chest compressions and mechanical ventilation. 9. Delayed shock delivery, improperly selected shock energy (use of insufficient energy shocks in treatment-resistant ventricular fibrillation). 10. Non-compliance with the recommended ratios between compressions and air blowing - 30: 2 with synchronous ventilation. 11. Use of lidocaine rather than amiodarone for electrically refractory ventricular fibrillation. 12. Premature termination of resuscitation. 13. Weakening of control of the patient's condition after the restoration of blood circulation.

CLINICAL RECOMMENDATIONS (PROTOCOL) ON PROVIDING EMERGENCY MEDICAL ASSISTANCE IN INCREASED ARTERIAL PRESSURE Arterial hypertension, worsening. 1. 1. With an increase in blood pressure without signs of hypersympathicotonia: - captopril (Capoten) 25 mg sublingually - if the effect is insufficient, give again after 30 minutes at the same dose 1. 2. With an increase in blood pressure and hypersympathicotonia: - moxonidine (physiotens) 0 , 4 mg sublingually; - with insufficient effect - again after 30 minutes at the same dose. 1. 3. With isolated systolic arterial hypertension: - moxonidine (physiotens) at a dose of 0.2 mg once under the tongue.

CLINICAL RECOMMENDATIONS (PROTOCOL) ON PROVIDING EMERGENCY ASSISTANCE IN INCREASED ARTERIAL PRESSURE 2. Hypertensive crisis 2. 1. GC without increased sympathetic activity: - urapidil (Ebrantil) intravenously bolus slowly at a dose of 12.5 mg; - in case of insufficient effect, repeat injections of urapidil at the same dose no earlier than after 10 minutes. 3. GK with high sympathetic activity: - clonidine 0.1 mg intravenously in a stream slowly. 4. Hypertensive crisis after discontinuation of an antihypertensive drug: - an appropriate antihypertensive drug intravenously or sublingually. 5. Hypertensive crisis and acute severe hypertensive encephalopathy (convulsive form of GC). For a controlled decrease in blood pressure: - urapidil (Ebrantil) 25 mg intravenously fractionally slowly, then drip or using an infusion pump, at a rate of 0.6-1 mg / min, select the infusion rate until the required blood pressure is reached. To eliminate convulsive syndrome: - diazepam (seduxen, relanium) 5 mg intravenously slowly until the effect or reaching a dose of 20 mg. To reduce cerebral edema: Furosemide (Lasix) 40–80 mg IV slowly.

CLINICAL RECOMMENDATIONS (PROTOCOL) ON PROVIDING EMERGENCY ASSISTANCE WITH INCREASED BLOOD PRESSURE 6. Hypertensive crisis and pulmonary edema: - nitroglycerin (nitrosprint spray) 0.4 mg under the tongue and up to 10 mg nitroglycerin (perliganite) intravenously by drip or using an infusion pump, by increasing the rate of administration until an effect is obtained under the control of blood pressure; Furosemide (Lasix) 40–80 mg IV slowly. 7. Hypertensive crisis and acute coronary syndrome: - nitroglycerin (nitrosprint spray) 0.4 mg under the tongue and up to 10 mg nitroglycerin (perlinganite) intravenously by drip or with an infusion pump, increasing the rate of administration until the effect is obtained. 8. Hypertensive crisis and stroke: - antihypertensive therapy should be carried out only in cases where diastolic pressure exceeds 120 mm Hg. Art. , seeking to reduce it by 10–15%; - as an antihypertensive agent, use intravenous administration of 12.5 mg of urapidil; if the effect is insufficient, the injection can be repeated no earlier than after 10 minutes; - with an increase in neurological symptoms in response to a decrease in blood pressure, stop antihypertensive therapy immediately

Notes. It is possible to increase the effectiveness of the main tableted antihypertensive agents (moxonidine and captopril) by using a combination of 0.4 mg of moxonidine with 40 mg of furosemide, 0.4 mg of moxonidine with 10 mg of nifedipine and 25 mg of captopril with 40 mg of furosemide. For specialized resuscitation teams, a reserve drug used only for absolute vital indications - sodium nitroprusside (niprid) is administered at a dose of 50 mg in 500 ml of 5% glucose solution intravenously, selecting the infusion rate to achieve the required blood pressure. If a dissecting aortic aneurysm is suspected, the drugs of choice are esmolol (breviblok) and sodium nitroprusside (see Aortic Dissection protocol). The crisis in pheochromocytoma is suppressed with α-blockers, for example, pratsiol sublintally or phentolamine intravenously. Second-line drugs are sodium nitroprusside and magnesium sulfate. With arterial hypertension due to the use of cocaine, amphetamines and other psychostimulants (see protocol "Acute poisoning"). Taking into account the peculiarities of the course of acute arterial hypertension, the presence of concomitant diseases and the response to ongoing therapy, it is possible to recommend specific self-help measures to the patient with a similar increase in blood pressure.

Emergency transportation of the patient to the hospital is indicated: - with GC, which could not be eliminated at the prehospital stage; - with GC with severe manifestations of acute hypertensive encephalopathy; - with complications of arterial hypertension requiring intensive care and constant medical supervision (ACS, pulmonary edema, stroke, subarachnoid hemorrhage, acute visual impairment, etc.); - with malignant arterial hypertension. In case of indications for hospitalization, after possible stabilization of the condition, take the patient to the hospital, ensure the continuation of treatment (including resuscitation) for the duration of transportation in full. Alert hospital staff. Transfer the patient to the hospital doctor. Code according to ICD-10 Nosological form I 10 Essential (primary) hypertension I 11 Hypertensive heart disease [hypertensive heart disease] I 12 Hypertensive [hypertensive] disease with primary damage to the kidneys I 13 Hypertensive [hypertensive] disease with primary heart damage and kidney I 15 Secondary hypertension

Research Institute of EMERGENCY them. prof. I. I. Dzhanelidze

CITY STATION NSR

ACTION PROTOCOLS FOR PARADISE ROOMS

EMERGENCY TEAM

St. Petersburg 2002

Web version

"AGREED" "APPROVE"

Director of NIISP Committee Chairman

them. prof. health

prof. yov administration of the governor

chief physician of the city station of the ambulance service in the city of

Editors: prof. , prof. .

Reviewers: MD, Prof., Chief Surgeon of the Committee

for Health Administration of the Governor of S.-Pb.

Doctor of Medical Sciences, Head of Scientific and Clinical

The protocol "Bronchial asthma" has been changed in the Web version.

List of abbreviations................................................... .............................................5

Memo to the SMP officer .............................................. ...................................6

Rules of personal hygiene .............................................................. ...............................7

"Golden Hour" ............................................... ................................................. ......eight

General rules for the work of the medical staff of the EMS .............................................. ........nine

Rules for dealing with aggressive patients .............................................................. ....ten

Examination of the patient .................................................................. .....................................eleven

Glasgow scale, shock index (Algover).................................................. ........12

Rules for transporting patients .............................................................. ...............thirteen

Measurement of blood pressure, critical blood pressure figures in children .............................................. ...fourteen

Pneumatic anti-shock trousers (PPSHB) ..............................................15

Rules for oxygen therapy .............................................................. .................................sixteen

Protocol: Respiratory Disorders .................................................................. ......................17

The simplest methods for restoring patency in. d.p. ...........................eighteen

Figure: restoration of patency in. d.p............................................ .nineteen

Figure: insertion of the oropharyngeal airway .............................................................20

Intubation................................................. ................................................. ........21

Conicotomy ............................................................ ................................................. ...22

Figure: conicotomy ............................................................... ................................................23

Foreign bodies c. d.p............................................ .........................................24

Figure: Heimlich maneuver .............................................. ...................25

Protocol: transport immobilization .................................................................. ..........26

Rules for anesthesia with nitrous oxide .................................................... ..............27

Clinical death .............................................................. ......................................28

Protocol: Basic Cardiopulmonary Resuscitation .................................................................29

Protocol: ventricular fibrillation.............................................. .................thirty

Rules for defibrillation .............................................................. ................31

Figure: the place of application of the electrodes during defibrillation ..... 32

Protocol: pulseless electrical activity .............................................................. 33

Protocol: asystole ............................................................... ................................................34

Active Compression-Decompression Method in CPR .................................................................35

in. d.p. upper respiratory tract

in / in intravenously

i / m intramuscularly

j joule

VT ventricular tachycardia

IVL artificial lung ventilation

kg kilogram

mmHg Art. millimeters of mercury

min. minute

ml milliliter

mg milligram

CVA is an acute cerebrovascular accident

circulating blood volume

s / c subcutaneously

p.p. transverse fingers

PPShB pneumatic anti-shock pants

rr solution

rice. picture

see see

CPR cardiopulmonary resuscitation

SMP ambulance

PE pulmonary embolism

FOS organophosphorus compounds

RR respiratory rate

TBI traumatic brain injury

HR heart rate

VF ventricular fibrillation

EABP electrical activity without pulse

REMINDER TO THE EMS EMPLOYEE

1. The appearance of the EMS service largely depends on the appearance and behavior of its personnel.

2. Clean, smart, neatly dressed, without defiant hair and makeup, the dexterous employee of the SMP inspires the trust of patients.

3. The clarity and confidence of your actions increases the trust in you and your knowledge and capabilities.

4. Never be fussy, impatient and irritable.

5. You must always be presentable, not to allow familiarity. Refer to patients only on "You".

6. Never discuss with the patient or in his presence the actions and appointments of your colleagues that are incorrect, from your point of view.

7. Remember! Smoking in the SMP car is not allowed. Drinking alcohol on the eve of duty is unacceptable.

8. Working in the SMP requires a high degree of self-discipline. What is important is loyalty to the service and the exact fulfillment of one's duties.

RULES OF PERSONAL HYGIENE

EMS teams provide assistance in a variety of conditions to patients suffering from a variety of diseases. In the interests of patients, your own health and the health of your families, you must follow the rules listed below:

1. Take a shower or bath daily.

2. Keep your hands absolutely clean. Nails should be short. Long nails for an EMS health worker are unacceptable.

3. Wash hands with soap and water before and after patient contact.

4. Wear gloves before each intended contact with the patient's blood or other body fluids.

5. Wear thick gloves in situations where thin gloves may tear.

6. If there is a threat to get dirty with blood or other biological fluids of the patient, put on an apron, and protect the mucous membranes of the mouth and eyes with a mask with goggles.

7. In case of skin contamination with blood, immediately wash the affected areas with soap and water, wipe dry and treat with a swab moistened with 70% alcohol.

12. The surfaces of stretchers, bags, etc., in case of contamination with blood, are treated with a 3% solution of chloramine.

13. When transporting patients with an open form of tuberculosis, they should wear a gauze mask.

"GOLDEN HOUR"

1. For seriously ill and injured people, the time factor is of great importance.

2. If the victim is delivered to the operating room within the first hour after injury, then the highest level of survival is achieved. This time is called the "golden hour".

3. "Golden Hour" begins the moment you get hurt, not the moment you start helping.

4. Any action at the scene should be life-saving in nature, as you lose minutes of the patient's "golden hour".

5. The fate of the patient largely depends on the efficiency and skill of your actions, since you are the first one who provides him with medical care.

6. The time spent on your arrival is just as important as the time lost due to the inconsistency of your actions at the scene. You must learn to save every minute of the helping process.

7. Rapid assistance does not mean just to quickly get to, "throw" the patient into an ambulance and also quickly deliver him to the nearest hospital.

8. You can maximize the patient's chances of survival if you provide care according to pre-thought-out tactics and sequence of actions.

GENERAL RULES OF WORK FOR EMS MEDICAL STAFF

1. The ambulance team must respond to the call within one minute after receiving it.

2. Medical personnel should have a good knowledge of the streets and passages in order to help the driver in choosing the shortest route.

3. The movement of the ambulance along the streets of the city should be fast, using special signals, but careful. We must adhere to common sense and the shortest route.

4. When parking a car closer to the scene of an accident, one must take into account the possible dangers of fire, the possibility of explosions, traffic, etc.

5. Upon arrival at the place of the call, quickly assess the situation: approximately determine the number of patients, the need for additional teams, police, firefighters, rescuers, and the way of the entrance.

6. Report the situation at the call site and the need for assistance to the doctor on duty "03".

7. If there is a delay on the call for more than 1 hour, report to the dispatcher on duty.

RULES FOR WORKING WITH AGGRESSIVE PATIENTS

Aggression is an action or gesture that indicates the possibility of violence.

Anger- an ordinary emotion that, under certain circumstances, can occur in any person.

Aggressiveness is a loss of emotional control, which can turn into violence against:

o other people;

─ inanimate objects;

the patients themselves.

Aggressiveness can be caused by a number of reasons:

Experiencing mental illness;

Experiencing drug overdose;

Experiencing alcohol or drugs;

─ abstinence;

Experiencing pain and stress.

THERE ARE NO HARD RULES FOR GIVING ASSISTANCE

AGGRESSIVE PATIENTS,

BUT THREE SHOULD BE REMEMBERED ALWAYS!!!

I. Do not give in to feelings of anger.

II. Assess the situation.

Remember! Professionalism and calm, confident behavior always inspire respect and trust the patient.

You have neither the right nor the authority to forcibly take him away when a patient refuses hospitalization.

You should not try to deal with an aggressive patient. Inform the dispatcher. If necessary, the police or psychiatric team will be sent to help you.

EXAMINATION OF THE PATIENT

1. Initial inspection(no more than 2 minutes).

Search for a cause that poses an immediate threat to life:

─ patency disorder c. d.p.;

- signs of clinical death;

─ External bleeding.

2. Secondary inspection(no more than 10 minutes).

a). Assess the patient's condition (level of consciousness according to

Glasgow scale, pulse, blood pressure, RR) on arrival, before

starting transport and arriving at the hospital.

b). Assess the size of the pupils and their reaction to light.

in). Find out the mechanism of injury. Determine the time, pro -

elapsed since the injury or onset of the disease.

─ splints for limbs (vacuum, inflatable, stair),

─ Various types of dressings.

RULES FOR ANESTHESIA WITH NITRIC OXIDE

1. Nitrous oxide is a gas in cylinders in a liquid state. At an ambient temperature below 0 ° C, inhalation of nitrous oxide is not possible.

2. The use of nitrous oxide is possible in almost all cases of pain. Alcohol intoxication is a contraindication.

3. To prevent excitation and aggravation of hypoxia in seriously ill and injured do not inhale mixtures containing more than 50% nitrous oxide. The ratio of nitrous oxide and oxygen should be 1:1.

4. Before turning on nitrous oxide, give the patient an inhalation of oxygen and give him/her 2 g (50% - 4 ml) of analgin and mgml) of diazepam.

5. When motor and speech excitation appears, reduce the concentration of N2O in the respiratory mixture.

6. Stopping N2O–O2 inhalation, initially turn off N2O and continue oxygen inhalation for another five minutes.

CLINICAL DEATH

To establish the fact of clinical death, it is enough

CLINICAL PROTOCOLS

"PROVISION OF EMERGENCY MEDICAL ASSISTANCE

with injuries"

1. This document is approved and put into effect by the Order of the Chief Emergency Physician "No. ______ dated _____ _______________ 2009

2. When developing this document, the following were used:

2.1. "Standards for the provision of emergency medical care at the pre-hospital stage" edited by professor, associate professor, approved by the congress of the ROSMP on 23., "Nevsky Dialect", St. Petersburg

2.2. "Guidelines for emergency medical care", recommended by the Ministry of Health and Social Development of the Russian Federation for doctors and paramedics providing primary health care, "GEOTAR-Media", Moscow, 2007

3. Revision of the document - 01.

Agreed

	Position
	Novosibirsk
	Chief pediatric traumatologist-orthopedist
	Chief Specialist in Ambulance

( C ) This document is the property of Novosibirsk Ambulance Station and may not be partially or completely reproduced and distributed without permission


	Application area

	Upper limb injuries
	Humerus fracture
	Shoulder dislocation
	Clavicle fracture
	Closed injuries of the elbow joint
	Fractures of the bones of the forearm

	scapula fracture
	Lower limb injuries
	hip dislocation
	hip fracture
	Closed injuries of the knee joint
	Fracture of the leg bones

	Spinal injury


	Pelvic fractures
	Algorithm of medical care for patients with spinal cord injury

1 area of use

1.1. Clinical protocols establish general requirements for the procedure for providing medical care to adults and children in terms of the type and scope of diagnostic, therapeutic and tactical measures for traumatic injuries at the stage of emergency medical care.

1.2. This document is intended for managers of substations and medical personnel of mobile ambulance teams.

2. General principles of diagnosis and emergency care for injuries

Trauma is the result of exposure to the body of external factors (mechanical, chemical, thermal, electrical, radiation), causing pathological changes in the anatomical structure and physiological functions in organs and tissues, accompanied by a local or general reaction and the risk of decompensation of vital body functions.

Tasks of the ambulance stage:

· quickly and atraumatically diagnose;

· stabilize or improve the patient's condition with life-threatening disorders;

Estimate the duration of transportation with the possibility of its implementation by a linear or specialized team.

Anamnesis (circumstances of injury)	It is necessary to determine the mechanism of injury (transport damage, falling from heights, etc.) and establish related moments(time, place, industrial or household, whether it is associated with violent criminal acts; Is it the result of a suicide attempt?). For road traffic injuries, specify -who was the victim (pedestrian, cyclist, motorcyclist, driver/passenger of a vehicle),type of vehicle and incident type (collision, overturning, running over, running over, crushing, falling, etc.). All data on the circumstances of the injury must be included in the medical documentation (Call Card, accompanying sheet), since many injuries subsequently become the subject of litigation.
Features of an objective examination	Victims are examined in the acute period, immediately after injury, against the background of pain, stress. · In some cases, emergency medical care for complications of trauma (bleeding, shock, etc.) is provided before a complete clinical diagnosis is established. · When examining the state of the musculoskeletal system, it is necessary to determine a whole group of special symptoms. · In case of polytrauma, determine the leading (dominant) damage
Initial inspection (from 30 sec to 1 min)	1. Assess the general condition according to the "ABC" algorithm. 2. Identify signs of life-threatening conditions leading to death within minutes: clinical death; coma, shock; respiratory disorders; external or internal bleeding; penetrating wounds of the neck and chest. A high risk of developing traumatic shock - with polytrauma, hip fracture, fracture of the pelvic bones. 3. Identify the signs of biological death when rendering assistance is meaningless: · maximum pupil dilation. · pallor and / or cyanosis, and / or marbling (spotting) of the skin. · decrease in body temperature. Only after the elimination of the causes leading to death in the first minutes, it is possible to proceed to the secondary examination of the victim and the provision of further assistance.
Secondary inspection (from 3 min)	If the patient is conscious: 1. Find out the complaints of the victim
Diagnostics	With fractures of both bones of the forearm, deformation of the forearm, pathological mobility, pain, crepitus of fragments are noted. With a fracture of one bone, the deformation is less pronounced, palpation can determine the place of greatest pain, and displacement of fragments is possible. There is always pain in the area of the fracture, aggravated by the load along the axis.
Urgent care	Owithout painbe 2% solutionpromedol 1 mlintravenouslyor intramuscularly or non-narcotic analgesics (2 ml of 50% analgin solution (adults) and 10 mg / kg - children). Immobilization with Kramer's splints, a scarf bandage from the upper third of the shoulder to the base of the fingers of the hand: the arm is bent at the elbow joint at a right angle.
TRANSPORTATION	In the trauma department with a suspected fracture with displacement, in other cases - in the trauma center.
3.6. Fracture of the radius in a typical location
Traumatic genesis	Falls with emphasis on the hand, direct blows, etc.
Diagnostics	Severe pain at the fracture site, with mixing of fragments, bayonet joint deformity, edema, hematoma (may be absent). Movement in the joint is sharply limited and painful. Often there is a combination with a fracture of the styloid process of the ulna.
Urgent care	Adults) and 10 mg / kg - for children, or 1 ml of 2% promedol for adults and 0.05 ml per year of life for children intravenously or intramuscularly, or Ksefokam 8 mg IV. Immobilization with a tire applied from the base of the fingers to the upper third of the shoulder.
TRANSPORTATION	To the trauma center
3.7. FRACTURE OF THE BLADE
Traumatic genesis	Direct action of force in case of transport injuries, falling from a height
Diagnostics	Movement is limited and painful. With fractures of the body and neck of the scapula, swelling is formed due to hematoma (comolli symptom)
Urgent care	Opain relief - 2 ml of 50% solution of analgin (adults) and 10 mg/kg for children,or 1 ml of 2% promedolintravenouslyor intramuscularly, or Ksefokam 8 mg IV Immobilization with a Deso bandage.
TRANSPORTATION	To the trauma center

4. lower limb injury

4.1. HIP DISTRUCTION
Traumatic genesis	They are more often found in car injuries, when the traumatic forces act along the axis of the leg bent at the knee joint with a fixed torso: when falling from a height.
Diagnostics	With posterior dislocation (more than 90% of cases) - the leg is bent at the hip and knee joints, adducted and rotated inward. When suprapubic, it is straightened, slightly retracted and rotated outward, and the head is palpable under the pupart ligament. With obturator dislocation - the leg is bent at the hip joint, abducted and rotated outward. Deformities in hip dislocations are of a fixed nature, when you try to change the position, springy resistance is felt. There is a flattening of the contours of the hip joint on the side of the injury. Hip dislocation is often associated with acetabular fractures, making it difficult to diagnose dislocation from a fracture. At the prehospital stage, it is advisable to formulate a diagnosis: fracture, dislocation in the hip joint.
Urgent care	Owithout painbe 2% solutionpromedol 1 mlfor adults and 0.05 ml per year of lifeintravenouslyor intramuscularly. Immobilization - the patient is placed on a stretcher on his back, rollers from improvised soft material are placed under the knee joints, while not changing the position in which the limb is fixed, the application of the Cramer splint from the lower back to the foot.
TRANSPORTATION
4.2. HIP FRACTURES
Traumatic genesis	Direct blows during road traffic injuries, “bumper” fractures in pedestrians, falls from heights, landslides and various accidents.
Diagnostics	Epiphyseal (fractures of the femoral neck). They are more common in people over 60 years of age. The most characteristic is the position of the extreme external rotation of the foot on the side of the lesion, the “symptom of stuck heel”. Localized pain in the hip joint. Metaphyseal fractures. They are often hammered in. Localized pain and localized soreness, increased pain in the area of the fracture when the limb is loaded along the axis. You can note the shortening of the limb. Diaphyseal fractures(most common). Large displacements of fragments are characteristic. Localized pain and tenderness in the area of the fracture, a symptom of "stuck heel". Significant swelling - hematoma. *High risk of developing traumatic shock.*
Urgent care	Owithout painbe 2% solutionpromedol 1 mlfor adults and 0.05 ml per year of lifeintravenouslyor intramuscularly. Immobilization - tires Dieterichs, Kramer, inflatable tires with fixation of 3 joints of the limb.
TRANSPORTATION	To the trauma department
4.3. CLOSED INJURIES OF THE KNEE JOINT
Traumatic genesis
Diagnostics	Pain, swelling, limitation of movement, symptom of balloting of the patella. A "click" sensation at the time of injury indicates cruciate ligament rupture, violation of its integrity confirms the pathological mobility of the joint in the anteroposterior direction. To damage the meniscus characterized by a sudden block of movements. With dislocations in the knee joint the meniscus and joint capsule are often damaged; with posterior dislocations, damage to the popliteal vessels, peroneal nerve is possible. With a fracture of the patella often there is a rupture of the lateral tendon sprain, due to which the upper fragment of the patella is displaced upward. The knee joint is enlarged in volume, there is pain in the anterior part of the joint, abrasions and hematoma are often determined there. Palpation can reveal a defect between fragments of the patella.
Urgent care	Opain relief - 2 ml of 50% solution of analgin (adults) and 10 mg/kg for children,or 1 ml of 2% promedolfor adults and 0.05 ml per year of life for childrenintravenouslyor intramuscularly. Immobilization with a Kramer splint.
TRANSPORTATION	In the trauma department. Lay the patient on his back, under the knee joint - a roller.
4.4. Fracture of the leg bones
Traumatic genesis	Falls on the knee joints during traffic accidents or from a height
Diagnostics	The occurrence of pain and swelling, localized below the knee joint. With a fracture of the condyles of the tibia, valgus deformity of the knee joint, hemarthrosis, and limitation of joint function occur. Non-displaced fractures are characterized by pain in the area of the knee joint, especially when loaded along the axis of the limb, and excessive lateral mobility of the lower leg.
Urgent care	Owithout painbe 2% solutionpromedol 1 mlfor adults and 0.05 ml per year of lifeintravenouslyor intramuscularly. Immobilization with a transport tire
TRANSPORTATION	In the trauma department for fractures with displacement, in other cases - in the trauma center.
4.5. Ankle injuries
Traumatic genesis	Domestic injuries (sudden twisting of the foot in or out, falling from a height, falling heavy objects on the foot)
Diagnostics	Sprained ankle ligaments edema develops rapidly due to hemorrhage from the inner or outer side of the joint, sharp pain during supination. On palpation under the ankles - a sharp pain. If a simultaneous sprain fracture of the fifth metatarsal bone, then a sharp pain is determined on palpation of the base of the bone. At fracture of both ankles with subluxation of the foot the joint is sharply enlarged in volume, an attempt to move causes significant pain. The foot is displaced outward, inward or backward, depending on the type of subluxation. Crepitation of fragments is felt. Palpation of the outer and inner ankles reveals soreness, often a defect between bone fragments is determined.
Urgent care	Owithout painbe 2% solutionpromedol 1 mlfor adults and 0.05 ml per year of lifeintravenouslyor intramuscular or2 ml of 50% analgin solution (adults) and 10 mg/kg for children. Immobilization with Kramer splints or inflatable splints from the knee joint to the ends of the toes
TRANSPORTATION	In the trauma department. Patients with an isolated fracture of the ankles and damage to the ligaments of the ankle joint are sent to the trauma center.

5. Spinal injury

5.1. Cervical spine injuries
Traumatic genesis	They occur with a sharp flexion or overextension of the neck, with a fall from a height, in divers, with car injuries, with a strong direct blow from behind.
Diagnostics	Characterized by sharp pain in the neck. With concomitant spinal cord injury - sensitivity disorders from mild to severe paresthesias, movement disorders (paresis, paralysis) and functions of internal organs (intestines, bladder). Conduct a minimal neurological examination: check the strength of the muscles of the upper limbs, the presence of movement in the legs, tactile and pain sensitivity on the hands and feet, find out the possibility of independent urination. The differential diagnosis is carried out with acute myositis of the cervical muscles, acute cervical radiculitis - the injury is minor or absent altogether, there is diffuse soreness in the neck muscles, the load on the head is usually painful; in the anamnesis - a cold factor.
Urgent care	Opain relief - 2 ml of 50% solution of analgin (adults) and 10 mg/kg for childrenintravenouslyor intramuscularly. Mandatory fixation of the head and neck with the help of a cervical splint (Schanz collar), after fixing the head and neck, carefully transfer to a stretcher. The patient should not be transferred to a sitting or semi-sitting state, try to tilt or turn his head.
TRANSPORTATION	In the trauma department. Transportation is gentle, careful shifting to avoid iatrogenic damage to the spinal cord.
5.2. Injuries of the thoracic and lumbar spine
Traumatic genesis	It is more often observed when falling on the back, road injuries, when falling from a height, with a sharp flexion and extension of the body.
Diagnostics	Soreness with axial load of the spine (soft pressure on the head, when lifting the head or legs, coughing, trying to sit down). *With fractures of the transverse processes of the vertebrae, pain is noted in the paravertebral points lateral to the midline by 5-8 cm; pressure on the spinous process painlessly.* Kyphotic deformity (with protrusion of the spinous process of the intact process and retraction of the damaged vertebra), tension of the long muscles of the back and local pain in the fracture zone With concomitant spinal cord injury - sensitivity disorders from mild paresthesia to severe disorders, movement disorders (paresis, paralysis) and functions of internal organs (intestines, bladder). Difficulties in diagnosis - in the absence of consciousness, brain contusion, concomitant alcohol intoxication.
Urgent care	Immobilization must be carried out on the shield at the scene. Opain relief - 2 ml of 50% solution of analgin (adults) and 10 mg/kg for children,or 1 ml of 2% promedolfor adults and 0.05 ml per year of life for childrenintravenouslyor intramuscularly.
TRANSPORTATION	Transportation is gentle in the supine position with a roller under the lower back, on the stomach (with a roller under the chest and head). Careful shifting to avoid iatrogenic damage to the spinal cord.
6. FRACTURES OF THE PELVIC BONES
Traumatic genesis	In traffic accidents, falls, when the pelvis is compressed. The most frequent unilateral fractures of the anterior pelvis. Often, this causes a violation of the continuity of the pelvic ring with damage to large vessels, nerves, internal organs (bladder, uterus, rectum)
Diagnostics	Forced position - on the back with the breeding of half-bent legs (the "frog" position). Inability to raise the heel (symptom of "stuck heel"), to sit down, and even more so to walk or stand. Swelling, hematoma and sharp pain in the fracture zone, coinciding with pain when trying to bring the wings of the pelvis closer together or apart. In case of bladder injury (more often occurs when it is full) - pain in the lower abdomen, urinary retention, the appearance of blood in the urine. Injury to the urethra - excretion of blood, impregnation of tissues with urine ("urinary infiltration"). In case of damage to the rectum - on rectal examination, blood in the stool. In case of damage to the abdominal organs - at first, symptoms of internal bleeding, followed by the addition of symptoms of inflammation of the peritoneum (the more distal the rupture of the intestinal lumen, the more aggressive the peritonitis). As a rule, pelvic fractures are accompanied by the development of traumatic shock.
Urgent care	Anesthesia with narcotic and non-narcotic analgesics (if there is no data indicating damage to internal organs) - 2-4 ml of a 50% solution of analgin (adults) and 10 mg/kg for children,or 1-2 ml of 2% promedolfor adults and 0.05-0.1 ml per year of life for childrenintravenouslyor intramuscularly. If necessary, anti-shock therapy (see "Traumatic shock"). Immobilization on a rigid stretcher in the "frog" position (roller under the knee joints).
TRANSPORTATION	On an emergency basis, in a supine position, with careful shifting.

7. ALGORITHM OF MEDICAL ASSISTANCE TO PATIENTS WITH SPINAL AND SPINAL INJURY

Ambulance protocols. Clinical recommendations (protocols) for the provision of emergency medical care

angina pectoris

myocardial infarction

Pulmonary edema

Fainting

Bronchial asthma (attack)

asthmatic status

Pulmonary bleeding

Hypoglycemic coma

Hyperglycemic (diabetic) coma

Acute abdomen

Gastrointestinal bleeding

Renal colic

Anaphylactic shock

Quincke's edema

Presentation description CLINICAL RECOMMENDATIONS (PROTOCOLS) FOR EMERGENCY MEDICAL CARE on slides

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