Emergency care for acute respiratory and circulatory disorders

Life sometimes brings surprises, and they are not always pleasant. We find ourselves in difficult situations or become witnesses to them. And often we are talking about the life and health of loved ones or even random people. How to act in this situation? After all, quick action and proper emergency assistance can save a person’s life. What are emergency conditions and emergency medical care, we will consider further. We will also find out what assistance should be provided in case of emergency conditions, such as respiratory arrest, heart attack and others.

Types of medical care

The medical care provided can be divided into the following types:

Emergency. It turns out that there is a threat to the patient’s life. This may be during an exacerbation of any chronic diseases or during sudden acute conditions.
Urgent. It is necessary during a period of acute chronic pathology or in the event of an accident, but there is no threat to the patient’s life.

Planned. This is the implementation of preventive and planned measures. Moreover, there is no threat to the patient’s life even if the provision of this type of assistance is delayed.

Main clinical symptoms

Sudden cardiac death

Sudden cardiac death that occurs within 1 hour after the onset of the first symptoms of the disease, or a significant deterioration in the patient’s condition against the background of a stable chronic course of the disease. There are no visible signs of violent death.

Cardiac arrest, unspecified

Sudden (without any previous symptoms) death from an unknown cause. There are no visible signs of violent death.

Clinical death

Lack of consciousness (lack of reflex responses to stimuli);
Lack of spontaneous breathing;
Absence of pulse in the carotid arteries;
ECG: ventricular fibrillation or asystole, or EMD;
No cadaveric changes.

Emergency and urgent care

Emergency and emergency medical care are very closely related to each other. Let's take a closer look at these two concepts.

In case of emergency, medical care is required. Depending on where the process occurs, in case of emergency, assistance is provided:

External processes that arise under the influence of external factors and directly affect a person’s life.
Internal processes. The result of pathological processes in the body.

Emergency care is one of the types of primary health care, provided during exacerbation of chronic diseases, in acute conditions that do not threaten the patient’s life. It can be provided either as a day hospital or on an outpatient basis.

Emergency assistance should be provided in case of injuries, poisoning, acute conditions and diseases, as well as in accidents and in situations where assistance is vital.

Emergency care must be provided in any medical institution.

First aid in emergency situations is very important.

Emergency medical care for acute mental disorders with psychomotor agitation

Emergency medical care is required for acute (including suddenly developed) mental disorders (delusions, hallucinations, psychomotor agitation, etc.), accompanied by an incorrect assessment and interpretation of what is happening, ridiculous actions, when the patient’s actions become dangerous for himself and others. Such patients should be treated by psychiatrists, and specialized psychiatric teams are assigned to provide emergency care to them at large EMS stations. However, in sparsely populated (rural) areas there are no psychiatrists and psychiatric teams, and the emergency medical services doctor is often the first to meet such patients. In addition, he sometimes has to provide emergency psychiatric care when mental disorders develop in patients with various diseases of internal organs (for example, high fever, pneumonia, myocardial infarction, etc.).

Emergency therapeutic measures are indicated only for those patients whose condition poses a threat to themselves and others, primarily in the presence of agitation and aggressiveness, suicidal behavior of the patient, a state of altered consciousness, when the patient refuses to take food and liquid, his inability to self-care, and also with the development of severe side effects of psychopharmacotherapy.

Acute mental disorders are identified primarily during a conversation with the patient, during which the tactics for managing the patient are determined. The main objectives of such a conversation determine the rules of communication with patients with acute mental disorders:

establishing initial contact;
establishing a trusting relationship between doctor and patient;
determining the diagnosis at the syndromic level;
development of a medical care plan and further tactics.

Correct psychotherapeutic tactics carried out by medical staff in relation to a patient with acute psychosis can sometimes replace drug care and, in any case, be an extremely important addition to it. The main condition that the doctor must observe is not to lose “psychiatric vigilance” for a single minute, since the patient’s behavior can change sharply at any moment (there should be no objects around him that are suitable for attack or self-harm; he should not be allowed to approach window, etc.).

In addition to examining the patient's mental state, it is necessary to assess his somatic and neurological status. On the one hand, this is necessary in order not to miss somatoneurological pathology (including traumatic brain injury, other injuries and diseases), on the other hand, it can help confirm a psychiatric diagnosis (for example, identify physical exhaustion in depression) and correctly build an emergency treatment plan .

It should be remembered that any acute psychotic state, accompanied by disorganized behavior, agitation or suicidal tendencies, can pose a threat not only to the patient, but also to others. Consequently, organizational measures are required to ensure the safety of both patients and medical personnel. During the conversation and examination, it is necessary to remain alert. If the patient is aggressive, the room should not be locked. It is better to stand or sit next to the door (so that you can quickly leave the room), placing members of the emergency medical team (medic, driver), police officers, and, in their absence, relatives on both sides of the patient.

In the event of a call to the place of residence, if the patient has locked himself in a room or apartment, the doors to this room are opened only with the consent of relatives. If relatives do not give consent to forced access to the patient, despite his clearly pathological behavior, according to their description, this fact is recorded in the medical documentation and the call is transferred to the local psychiatrist at the psychoneurological dispensary. Upon receipt of consent, the doors are opened by the patient's relatives themselves or, at their request, by other persons, including police representatives and firefighters. Police officers are obliged to provide assistance to medical workers, providing safe conditions for examining the patient. When opening the apartments of single patients, the presence of police officers, as well as representatives of the housing office, is required for subsequent sealing of the doors. Pets of hospitalized single patients are handed over to police or housing office workers, and the fact of the transfer itself is certified by an act.

If called to the workplace, the patient is examined in the premises of the medical center, and if there is none, in the administrative premises, where the patient is deprived of the opportunity to offer armed resistance.

If a patient runs away at the sight of medical workers, chasing him down the street is unacceptable in order to avoid road accidents. The responsible EMS doctor is immediately informed about the fact of the patient’s escape, who must notify the police officers about the incident.

Despite the fact that a qualified assessment of the severity of symptoms can only be given by a psychiatrist, if necessary, emergency therapeutic measures are also carried out by other clinicians, including an emergency medical technician. The general strategy when providing emergency care to a patient with a mental disorder is to ensure the safety of the patient himself (which means preventing suicide or self-harm), as well as preventing possible harm to others and medical personnel (i.e. preventing aggression).

Emergency medical care for acute mental disorders includes pharmacotherapy, physical restraint (restraining the patient), delivery to an appointment with a psychiatrist, and, if necessary, to a hospital (depending on the availability of specialized psychiatric ambulance teams). If the patient requires assistance and hospitalization, the patient's consent should be obtained. At the same time, being overwhelmed by emotions and the lack of a critical attitude towards them on the part of the patient in some acute psychopathological conditions in some cases suggests the need to provide medical care, including hospitalization, without the patient’s consent.

In accordance with the Law of the Russian Federation “On psychiatric care and guarantees of the rights of citizens during its provision” (1992), hospitalization of a patient in a psychiatric hospital without his consent or without the consent of his legal representative can be carried out if the patient’s treatment or examination is possible only in inpatient conditions, and the mental disorder itself is severe and causes:

a) immediate danger to the patient himself or others;

b) helplessness of the patient, i.e. inability to independently satisfy basic life needs;

c) significant harm to the health of the patient himself due to a deterioration in his mental state if he is left without psychiatric help.

The initial psychiatric examination and decision on the issue of hospitalization of a patient in a psychiatric hospital is the exclusive competence of a psychiatrist (Law of the Russian Federation “On Psychiatric Care...”, 1992), accordingly, a patient requiring emergency psychiatric care must be immediately examined by a psychiatrist.

Thus, a doctor of the line EMS team, if there is an obvious need to provide emergency medical care to a patient and act in his interests in accordance with the Law of the Russian Federation “Fundamentals of Legislation of the Russian Federation on the Protection of Citizens’ Health” (1993), may violate the Law of the Russian Federation “On Psychiatric Care and Guarantees of Citizens’ Rights in its provision" (1992). The most accessible way out of this situation (in the absence of an on-site specialized psychiatric service in the region) is to deliver the patient by ambulance to an appointment with a psychiatrist at a psychoneurological dispensary, and at night - to the emergency room of a hospital. However, even transporting a patient to a psychiatrist (especially in cases of developed psychomotor agitation) requires certain knowledge and skills of an emergency medical technician.

The main task of drug therapy at the prehospital stage is not the treatment of the disease itself, but the drug “preparation” of the patient, which allows one to gain time before a consultation with a psychiatrist or before hospitalization in a psychiatric hospital. The main principle of providing assistance in acute psychopathological conditions is a syndromic or even symptomatic approach.

Adequate use of psychopharmacological agents allows for rapid control of almost all acute psychopathological conditions. It must be remembered that even with seemingly effective therapy, improvement may be unstable, and the patient's behavior may again become unpredictable at any time. Accordingly, if there are indications, temporary mechanical fixation should not be neglected, especially if emergency care is provided to a patient with strong motor agitation and a sharp decrease in his criticism of his behavior. A mandatory entry is made in the medical documentation about the forms and time of application of measures of physical restraint of the patient.

As practice shows, psychomotor agitation and aggressiveness constitute the main group among all mental disorders that require emergency care. Excitement is the most common reason for calling emergency services.

In an emergency setting, states of excitement are often encountered that develop against the background of acute neurological pathology (traumatic brain injury, acute cerebrovascular accidents), exogenous poisoning (for example, organophosphorus compounds), endogenous intoxication (including infections), acute therapeutic (for example, myocardial infarction) and surgical (for example, acute pathology in the abdominal cavity) diseases, emergency conditions accompanied by loss of consciousness (stupor, shallow coma), etc. In these cases, an incorrect assessment of the somatoneurological status may delay the necessary emergency therapeutic, surgical or other assistance.

Agitation is a complex pathological condition that includes speech, mental and motor components. It can develop against a background of delusions, hallucinations, mood disorders, and be accompanied by confusion, fear and anxiety. Excitement is one of the manifestations of the disease, its “nodal” point, in which features specific to each disease appear.

At the same time, the clinical and psychopathological uniqueness of this state in various diseases is preserved only to a certain extent: the increase in excitement erases the differences between its individual types, it can become chaotic, thinking can become incoherent, affect reaches maximum intensity. Excitation can lead to significant metabolic changes, and even secondary brain hypoxia, contribute to decompensation and the development of acute disorders of the cardiovascular, respiratory and other systems.

The following forms of psychomotor agitation are distinguished.

Hallucinatory-delusional arousal is characterized by an influx of visual (enemies, animals, monsters) or auditory (threatening, accusing “voices”) hallucinations and/or delusional ideas (usually persecution or influence). Hallucinatory-delusional arousal is observed in schizophrenia, epilepsy, organic brain diseases, involutional psychosis, delirium tremens (delirium tremens) and hallucinosis. In these cases, the behavior of patients depends on the nature of the hallucinatory-delusional experiences. Patients often talk with imaginary interlocutors (“voices”), answer their questions and conduct a lively dialogue. The patient sees danger to himself in everything around him and does not always understand the meaning of what is happening to him. Such patients are emotionally tense, wary, suspicious (can be angry), and they are not left for a minute with the feeling of a threat looming over them. This condition is accompanied by anxiety and fear. Patients see danger everywhere and believe that everyone around them is against them, this encourages patients to self-defense. In defense, they try to escape, attack others, and can even (this is rarely noted) make suicidal attempts to save themselves from suffering. A type of such agitation is a delirious state.

Catatonic agitation is manifested by prolonged or paroxysmal motor restlessness, often in the form of meaningless, monotonous (stereotypical) movements. Catatonic agitation is usually observed in schizophrenia or organic diseases of the brain. Such patients are characterized by negativism (active or passive opposition to others, including meaningless resistance to implementation or complete refusal to perform any actions and movements), verbalization (speech stereotypy, a tendency to monotonously repeat the same words and phrases, often completely meaningless), echolalia (repetition of phrases or words from the statements of others), echopraxia (repetition of movements), paramimia (inconsistency of facial reactions with emotional and intellectual experience). There are “silent” and impulsive catatonic excitation. “Mute” excitement is silent, chaotic, senseless, with violent resistance to others, often with aggression and/or auto-aggression. Impulsive excitement is characterized by unexpected, outwardly unmotivated actions of patients - they suddenly jump up, run somewhere, attack others with senseless rage (they can “freeze” in a stupor for a short time and become excited again).

Hebephrenic arousal has the following leading signs: extremely mannered, absurdly foolish behavior with actions of a paradoxical and pretentious nature (patients make faces, grimace, distort words, dance, jump, tumble), accompanied by unmotivated fun and ridiculous statements.

Depressive agitation occurs due to the increase in anxiety and fear in patients against the background of low mood and the absence of motor inhibition, which is manifested by motor agitation, reaching the point of violence. Typically, such arousal is characteristic of manic-depressive psychosis and schizophrenia, but can also occur in a number of other mental disorders. Clinical manifestations of agitated depression are characterized by a combination of pronounced melancholy and anxious anxiety. Patients rush about, experience “terrible” mental anguish, express ideas of self-accusation and self-abasement. They often believe that only death will bring relief to them and those around them, and therefore the danger of suicidal acts, usually sophisticatedly and carefully prepared, is extremely high. Melancholic raptus is the highest form of depressive arousal, with the development, against a background of pronounced and acute painful melancholy and confusion, of sudden “explosions” - attacks of frantic motor excitement and despair, with an expression of horror on the face, groans, sobs, wringing of hands, throwing of patients (they cannot “ find a place for yourself"), are capable of self-harm, even suicide.

Manic excitement is accompanied by elevated mood, a desire for constant vigorous activity and speech agitation. Manic agitation is characteristic of manic-depressive psychosis, schizophrenia, organic diseases of the brain, during treatment with steroid hormones and quinine poisoning. Such patients are unreasonably cheerful, are in constant motion, experience a physical feeling of vivacity, are inexhaustible and tireless in their activities, easily make contact, take on any task, but do not complete anything. When talking, they easily switch from one topic to another without finishing the discussion of the previous one. When excitement reaches its maximum, patients cannot “sit still”; they constantly talk loudly and even scream; all attempts to calm them down remain unsuccessful. Persistent insomnia is added. During this period, a cheerful mood can be replaced by irritable anger, patients do not tolerate objections, openly express their dissatisfaction, showing violent angry and aggressive reactions with destructive actions when others try to interfere with the implementation of their plans. Patients' overestimation of their own capabilities and inability to control their actions, combined with attacks of aggressiveness, sometimes lead to dangerous actions (for example, rape, murder).

Panic (psychogenically caused) agitation represents meaningless motor agitation in the form of a so-called “motor storm.” The cause of such excitement is usually sudden strong emotional shocks from psychotraumatic situations that pose a direct threat to people's lives (transport accidents, industrial accidents, fires, earthquakes, floods, etc.). Against the background of emerging disorders of consciousness, from affectively narrowed to deep twilight states, motor excitation predominates - from monotonous to randomly chaotic. Characterized by senseless movements and actions (patients rush around, strive somewhere, run away in panic, often towards danger), do not respond to questions from others, can cause harm to themselves, and try to commit suicide. In emergency situations, when the emotion of horror and fear predominates in the crowd, one of the tasks, in addition to providing medical assistance, is to identify the “leader” (one person or group of people) creating panic and immediately remove him (them) with the help of police officers from the outbreak .

Psychopathic agitation is characteristic of psychopathy and psychopathic behavior against the background of organic brain damage. Like psychogenic, psychopathic arousal is caused by some psychological reasons, but the difference is its purposefulness. Characterized by a discrepancy between an excessively violent emotional reaction and a stimulus that is minimal in strength and quality. Such patients are extremely agitated, loud, angry, swear (often obscenely), resist examination and interview, are prone to aggressive, destructive actions, and can demonstratively injure themselves. Their anger is usually targeted against a specific person - the imaginary offender. When trying to restrain such persons, excitement increases; the content of speech (demands, threats, abuse) changes depending on the actions of others and the situation. Often psychopathic arousal is of a “theatrical” nature; patients strive to attract attention to themselves, “working for the public.” The excitation is initially targeted (realization of drive or attitude), then global, with a narrowing of consciousness, sometimes to hysterical twilight states.

Epileptic excitation occurs suddenly and is accompanied by a pronounced affect of anger, aggressive and destructive actions against the background of hallucinations and delusional experiences of a frightening nature. Occurs during twilight stupefaction, before or after convulsive seizures, with epileptic psychoses and organic diseases of the brain. Epileptic agitation usually occurs against the background of a twilight disorder of consciousness (excluding the possibility of contact with patients and the patient’s criticism of his actions) and in its intensity exceeds all other options encountered in psychiatric practice. The strength of affect is determined by vivid, frightening hallucinations with pictures of world catastrophes, raging fires, massacres; the patient hears threats, screams, moans, sees blood pouring. An extreme degree of aggressiveness (as a discharge of affect) directed at others is characteristic; serious consequences are possible (murder, injury, auto-aggression, etc.).

Fussy (senile) agitation is observed with severe atherosclerosis of cerebral vessels and atrophic processes in the brain in elderly people, often with the increase of acquired dementia (dementia). It develops gradually against the background of senile insomnia and is a manifestation of the patient’s “exciting” anxious thoughts and fears. Accompanied by aimless actions and motor restlessness (patients rush out of bed and room, fussily get ready somewhere, look for and pack things, strive to go outside, and when trying to hold them they show quite active resistance, even aggression).

The actions of the doctor of the linear EMS team on a call are shown schematically in the figure.

Typically, diagnosing psychomotor agitation does not present any particular difficulties. In these cases, it is important to assess the degree of possible aggression of the patient.

During the examination, the doctor's behavior must obey certain rules.

A dismissive, bewildering, blaming, threatening or judgmental tone of conversation may cause or increase the patient's aggression. The conversation should be conducted calmly, with reasonable persistence, non-contradiction with the patient, and compliance with his permissible demands. In some cases, the patient can be calmed down with a properly conducted conversation.
Establishing contact is facilitated by creating in the patient the impression that the doctor can take his place (“I understand that you are very nervous...”).
You should not get too close to the patient. This may be perceived as a threat.
At the same time, it is important not to give the patient the opportunity to harm the doctor. It is advisable to have employees nearby. Consideration should be given to how to protect your face, neck and head. First you need to take off your glasses, tie, necklaces, etc. During the conversation, the doctor must take care of a possible “retreat” and be closer to the door of the office or ward than the patient.

If the manifestation of psychomotor agitation is sufficiently pronounced, there may be no need to ask questions to the patient, especially if the patient behaves aggressively. In some cases (manifestation of intoxication with various substances, with traumatic brain injury, etc.), the doctor’s questions should be aimed at identifying anamnestic information important for differential diagnosis (the possibility of taking poisonous drugs, trauma, etc.).

First of all, the doctor’s attention should be directed to identifying the most characteristic symptoms of agitation - acceleration and intensification of manifestations of motor (motor) and mental (thinking, speech) anxiety.

Patients with psychomotor agitation are subject to emergency hospitalization in a specialized hospital. To do this, the psychoneurological ambulance team should be immediately called, whose doctor will determine further tactics for managing the patient.

While carrying out all the above measures, you must not give up trying to establish contact with the patient, calm him down, and explain what is happening.

Treatment

When providing assistance to an agitated patient, the main task of the EMS doctor is to ensure the safety of the patient and others. Often, to control anxiety, it is enough to create a calm environment and establish contact with the patient so that he feels safe.

For psychotic disorders (delusions, hallucinations), antipsychotic antipsychotics are used to relieve agitation. The main indication for injections of psychotropic drugs is the lack of patient consent to treatment, since the differences between tablet and injectable forms of drugs relate mainly to the speed of development of the therapeutic effect and, to a lesser extent, the level of sedation achieved. The optimal route of drug administration is intramuscular; intravenous administration of drugs is not necessary, and in some cases physically impossible.

Modern standards of therapy suggest the use of tablets (for example, risperidone, olanzapine) and injectable forms of atypical antipsychotics (for example, Rispolept Konsta) as first-line agents in all groups of patients, while traditional antipsychotics remain reserve drugs. In case of decompensation of mental illness in a somatically healthy patient, maximum doses of drugs are used to relieve agitation, if necessary. Typically, olanzapine (Zyprexa) at a dose of 5–10 mg or zuclopenthixol (Clopixol-Acufaz) at a dose of 50 mg is administered intramuscularly. The introduction of some antipsychotics (haloperidol, zuclopenthixol, olanzapine, trifluoperazine) is often accompanied by the development of extrapyramidal disorders and requires the parallel use of correctors - antiparkinsonian drugs, such as trihexyphenidyl (Cyclodol, Parkopan, Romparkin). In the absence of atypical antipsychotics, 100–150 mg (4–6 ml of a 2.5% solution) of chlorpromazine (Aminazine) or levomepromazine (Tizercin) can be administered intramuscularly. The administration of antipsychotics requires monitoring blood pressure levels due to the risk of collapse. To prevent orthostatic reactions, the use of antipsychotics in doses exceeding the minimally effective ones should be accompanied by an intramuscular injection of 2.0–4.0 ml of a 25% solution of Cordiamine (into the other buttock).

Of the tablet drugs, preference is given to risperidone (Rispolept) at a dose of 1–4 mg or clozapine (Azaleptin, Leponex), which has a strong antipsychotic and sedative effect, at a dose of up to 150 mg once.

Temporary fixation of a patient with severe agitation is allowed, subject to mandatory documentation of this procedure by the EMS doctor. In this case, the patient should be under constant supervision of medical personnel. It is important to prevent pinching of blood vessels, for which the fixing bandages must be wide enough.

According to the Law “On the Police” (1991) and the order of the Ministry of Health of the Russian Federation and the Ministry of Internal Affairs of the Russian Federation “On measures to prevent socially dangerous actions of persons suffering from mental disorders” No. 133/269 of April 30, 1997, law enforcement agencies must provide assistance to doctors in such cases.

Tranquilizers (in particular, benzodiazepines) are most effective for neurotic disorders, in particular panic attacks; their use is also recommended in cases where the diagnosis is unclear. From the group of benzodiazepines, it is optimal to use drugs with a shorter half-life and maximum anxiolytic effect, for example, lorazepam. For agitation that develops as a result of deep metabolic disorders (during intoxication, severe infection, etc.), it is also preferable to use benzodiazepine tranquilizers - diazepam at a dose of 10-30 mg (2-6 ml of 0.5% solution) or lorazepam at a dose 5–20 mg (2–8 ml of 0.25% solution). It is better not to use neuroleptics in such cases, and if necessary, the dose of the drugs should be reduced.

For agitated depression (with prolonged speech motor excitation), melancholic raptus, intramuscular administration of antidepressants with a sedative effect (in order to potentiate the calming effect), for example, amitriptyline at a dose of 40–80 mg (2–4 ml of a 2% solution) is possible. Dosages of psychotropic drugs available in injectable form and used for emergency treatment of mental disorders are shown in the table.

The drugs of choice for the treatment of psychomotor agitation are sedative neuroleptics, including in combination with diphenhydramine (Diphenhydramine) or promethazine (Diprazine, Pipolfen), or tranquilizers. Tranquilizers should be preferred in the elderly, in the presence of severe somatic diseases, severe hypotension.

Drugs are administered parenterally, but they should not be neglected when administered orally, thereby affecting the speed of onset of action of the drug.

It is necessary to adjust the doses of drugs upward if the patient has previously received psychopharmacotherapy.

Haloperidol, zuclopenthixol, olanzapine, trifluoperazine must be prescribed with a corrector - trihexyphenidyl (Cyclodol) at a dose of 2 mg.

To a greater extent, the choice of the drug used will be determined by the availability of the necessary drugs (including in the arsenal of emergency physicians) and the minimum of possible negative consequences. According to our observations (data from a large multidisciplinary hospital in a metropolis), a greater number of cases of severe side effects of therapy at the prehospital stage are associated with the prescription of incorrectly selected doses of such an available “unaccounted” tranquilizer as Phenazepam.

The doctor of the linear EMS team should know certain provisions of the Order of the Ministry of Health of the Russian Federation “On emergency psychiatric care” No. 108 of 04/08/98 in order to better navigate the management of patients with mental disorders.

Common errors:

Leaving a patient without proper observation and control over his behavior.
Underestimation of the danger of psychomotor agitation for the patient himself and those around him (including failure to attract help from police officers).
Neglect of physical restraint methods.
Confidence in the need for only intravenous administration of sedatives, excluding intramuscular and oral routes.
Non-use of correctors when administering neuroleptics that can cause side extrapyramidal disorders.

When carrying out any drug intervention, the EMS doctor must remember that doses of psychotropic drugs are selected based on the patient’s physical condition (body weight, age, concomitant somatoneurological pathology).

In addition, it should be taken into account that the use of psychotropic drugs “erases” the severity of psychopathological symptoms, which subsequently creates difficulties for the psychiatrist in making a decision on the patient’s involuntary hospitalization. Accordingly, prehospital psychopharmacological intervention is appropriate only in cases where the patient's mental state would interfere with safe transport; the exception is long-term transportation from remote locations. Specialized psychiatric teams follow the same tactics.

V. G. Moskvichev , Candidate of Medical Sciences MGMSU, NNPOSMP, Moscow

Major emergencies

Emergency conditions can be divided into several groups:

Injuries. These include:

Burns and frostbite.
Fractures.
Damage to vital organs.
Damage to blood vessels with subsequent bleeding.
Electric shock.

2. Poisoning. Damage occurs inside the body, unlike injuries, it is the result of external influences. Disruption of the functioning of internal organs in case of untimely emergency care can lead to death.

Poison can enter the body:

Through the respiratory system and mouth.
Through the skin.
Through the veins.
Through mucous membranes and through damaged skin.

Treatment emergencies include:

1. Acute conditions of internal organs:

Stroke.
Myocardial infarction.
Pulmonary edema.
Acute liver and kidney failure.
Peritonitis.

2. Anaphylactic shock.

3. Hypertensive crises.

4. Attacks of suffocation.

5. Hyperglycemia in diabetes mellitus.

Emergency conditions in pediatrics

Every pediatrician must be able to provide emergency care to a child. It may be required in case of a serious illness or accident. In childhood, a life-threatening situation can progress very quickly, since the child’s body is still developing and all processes are imperfect.

Pediatric emergencies that require medical attention:

Convulsive syndrome.
Fainting in a child.
Comatose state in a child.
Collapse in a child.
Pulmonary edema.
State of shock in a child.
Infectious fever.
Asthmatic attacks.
Croup syndrome.
Continuous vomiting.
Dehydration of the body.
Emergency conditions in diabetes mellitus.

In these cases, emergency medical services are called.

Features of providing emergency care to a child

The doctor's actions must be consistent. It must be remembered that in a child, disruption of the functioning of individual organs or the entire body occurs much faster than in an adult. Therefore, emergency conditions and emergency medical care in pediatrics require a quick response and coordinated actions.

Adults should ensure that the child remains calm and fully cooperate in collecting information about the patient's condition.

The doctor should ask the following questions:

Why did you seek emergency help?
How was the injury sustained? If it's an injury.
When did the child get sick?
How did the disease develop? How did it go?
What medications and remedies were used before the doctor arrived?

The child must be undressed for examination. The room should be at normal room temperature. In this case, the rules of asepsis must be observed when examining a child. If it is a newborn, a clean robe must be worn.

It is worth considering that in 50% of cases, when the patient is a child, the diagnosis is made by the doctor based on the information collected, and only in 30% - as a result of the examination.

At the first stage, the doctor must:

Assess the degree of impairment of the respiratory system and the functioning of the cardiovascular system. Determine the degree of need for emergency treatment measures based on vital signs.
It is necessary to check the level of consciousness, breathing, the presence of seizures and cerebral symptoms and the need for emergency measures.

It is necessary to pay attention to the following points:

How the child behaves.
Lethargic or hyperactive.
What an appetite.
Condition of the skin.
The nature of the pain, if any.

How to help children

Children, like adults, have medical emergencies. But the trouble is that children may not notice that something is wrong, and also begin to be capricious, cry, and adults may simply not believe him. This is a great danger, because timely help can save the child’s life, and if his condition suddenly worsens, call the doctor immediately. After all, the child’s body is not yet strong, and the emergency situation should be urgently eliminated.

First, calm the child so that he does not cry, push, kick, or be afraid of doctors. Describe to the doctor everything that happened as accurately, in detail and quickly as possible. Tell us what medications he was given and what he ate; perhaps the child had an allergic reaction.
Before the doctor arrives, prepare antiseptics, clean clothes and fresh air in a room with a comfortable temperature so that the child can breathe well. If you see that the condition is sharply worsening, begin resuscitation, cardiac massage, and artificial respiration. Also measure the temperature and do not let the child fall asleep until the doctor arrives.
When the doctor arrives, he will look at the functioning of the internal organs, heart function and pulse. In addition, when making a diagnosis, he will definitely ask how the child behaves, his appetite and usual behavior. Have you had any symptoms previously? Some parents do not tell the doctor everything, for various reasons, but this is strictly forbidden, because he must have a complete picture of your child’s life and activities, so tell everything as detailed and accurate as possible.

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Emergency conditions in therapy and assistance

The health care professional must be able to quickly assess emergency conditions, and emergency medical care must be provided in a timely manner. Correctly and quickly diagnosed is the key to a quick recovery.

Emergency conditions in therapy include:

Fainting. Symptoms: pale skin, skin moisture, muscle tone is reduced, tendon and skin reflexes are preserved. Blood pressure is low. There may be tachycardia or bradycardia. Fainting can be caused by the following reasons:

Failure of the cardiovascular system.
Asthma, various types of stenosis.
Brain diseases.
Epilepsy. Diabetes mellitus and other diseases.

The assistance provided is as follows:

The victim is placed on a flat surface.
Unbutton clothes and provide good air access.
You can spray water on your face and chest.
Give ammonia a whiff.
Caffeine benzoate 10% 1 ml is administered subcutaneously.

2. Myocardial infarction. Symptoms: burning, squeezing pain, similar to an angina attack. Painful attacks are wave-like, decrease, but do not stop completely. The pain gets stronger with each wave. It may radiate to the shoulder, forearm, left shoulder blade or hand. There is also a feeling of fear and loss of strength.

Providing assistance is as follows:

The first stage is pain relief. Nitroglycerin is used or Morphine or Droperidol with Fentanyl is administered intravenously.
It is recommended to chew 250-325 mg of Acetylsalicylic acid.
Blood pressure must be measured.
Then it is necessary to restore coronary blood flow.
Beta-adrenergic blockers are prescribed. During the first 4 hours.
Thrombolytic therapy is carried out in the first 6 hours.

The doctor’s task is to limit the extent of necrosis and prevent the occurrence of early complications.

It is necessary to urgently hospitalize the patient in an emergency medicine center.

3. Hypertensive crisis. Symptoms: headache, nausea, vomiting, feeling of “goose bumps” in the body, numbness of the tongue, lips, hands. Double vision, weakness, lethargy, high blood pressure.

Emergency assistance is as follows:

It is necessary to provide the patient with rest and good air access.
For type 1 crisis, take Nifedipine or Clonidine under the tongue.
For high blood pressure, intravenous Clonidine or Pentamin up to 50 mg.
If tachycardia persists, use Propranolol 20-40 mg.
For type 2 crisis, Furosemide is administered intravenously.
For convulsions, Diazepam or Magnesium sulfate is administered intravenously.

The doctor’s task is to reduce the pressure by 25% of the initial value during the first 2 hours. In case of a complicated crisis, urgent hospitalization is necessary.

4. Coma. May be of different types.

Hyperglycemic. It develops slowly and begins with weakness, drowsiness, and headache. Then nausea, vomiting appears, the feeling of thirst increases, and skin itching occurs. Then loss of consciousness.

Urgent Care:

Eliminate dehydration, hypovolemia. Sodium chloride solution is administered intravenously.
Insulin is administered intravenously.
For severe hypotension, a solution of 10% “Caffeine” is administered subcutaneously.
Oxygen therapy is administered.

Hypoglycemic. It starts off sharp. The humidity of the skin is increased, the pupils are dilated, blood pressure is reduced, the pulse is increased or normal.

Emergency assistance includes:

Ensuring complete peace.
Intravenous administration of glucose.
Correction of blood pressure.
Urgent hospitalization.

5. Acute allergic diseases. Severe diseases include: bronchial asthma and angioedema. Anaphylactic shock. Symptoms: the appearance of skin itching, excitability, increased blood pressure, feeling of heat. Then loss of consciousness and respiratory arrest, heart rhythm failure are possible.

Emergency assistance is as follows:

Place the patient so that the head is lower than the level of the legs.
Provide air access.
Clear the airways, turn your head to the side, and extend your lower jaw.
Adrenaline is administered; repeated administration is allowed after 15 minutes.
"Prednisolone" IV.
Antihistamines.
For bronchospasm, a solution of "Eufillin" is administered.
Urgent hospitalization.

6. Pulmonary edema. Symptoms: shortness of breath is pronounced. Cough with white or yellow sputum. The pulse is increased. Convulsions are possible. Breath is bubbling. Moist rales can be heard, and in severe conditions “silent lungs”

We provide emergency assistance.

The patient should be in a sitting or semi-sitting position, legs down.
Oxygen therapy is carried out with antifoam agents.
Lasix is administered intravenously in saline solution.
Steroid hormones such as Prednisolone or Dexamethasone in saline solution.
"Nitroglycerin" 1% intravenously.

Let us pay attention to emergency conditions in gynecology:

Disturbed ectopic pregnancy.
Torsion of the pedicle of an ovarian tumor.
Apoplexy of the ovary.

Let's consider providing emergency care for ovarian apoplexy:

The patient should be in a supine position, with her head raised.
Glucose and sodium chloride are administered intravenously.

It is necessary to monitor indicators:

Blood pressure.
Heart rate.
Body temperature.
Respiratory frequency.
Pulse.

Cold is applied to the lower abdomen and urgent hospitalization is indicated.

Treatment of acute coronary syndrome

First of all, this is a medical emergency. Every minute is important in providing first aid for ACS, since death can occur very quickly from the onset of a heart attack.

Short-term treatment strategies include reducing pain and improving blood flow to restore myocardial function as quickly as possible.

Long-term treatment is based on improving overall heart function, managing risk factors, and reducing the likelihood of having a heart attack. Most often, long-term therapy is performed in a hospital setting and involves a combination of medications and surgical procedures.

Medicines used to treat acute coronary syndrome:

Nitroglycerine
Antiplatelet drugs
Beta blockers
Angiotensin-converting enzyme inhibitors (ACEIs)
Angiotensin receptor blockers (ARBs)
Statins

People who call an ambulance are most often advised to take aspirin before it arrives. If medications cannot relieve problems and restore proper heart function, angioplasty combined with stenting may be required. Also, depending on the indications, coronary bypass surgery may be performed.

Video: Master class on emergency care for Acute Coronary Syndrome Pulmonary edema

First aid algorithm for patients with acute coronary syndrome

In case of suspected ACS, first aid and hospitalization of the patient are mandatory conditions for a successful outcome and the exclusion of further complications. Emergency care, as well as transportation of a patient with an acute heart attack, is carried out in a lying position with the head slightly raised.

The main stages of first aid for ACS:

Nitroglycerin is placed under the patient's tongue. This is first aid for heart failure, as well as for acute coronary syndrome. You can take the medicine every 5-10 minutes if necessary.
Acetylsalicylic acid (chewable tablet 160-325 mg) is taken in the absence of nitroglycerin.
Clopidogrel is used in cases where the patient has hypersensitivity to nitroglycerin.
Oxygen therapy . Inhalation is carried out with hydrated oxygen using a mask or nasal catheter (flow rate 4-6 l/min.). If there are no inhalation devices, it is necessary to ensure access to a sufficient amount of air to the patient. This especially applies to those cases when the attack occurred in a stuffy room.
Anesthesia with nitroglycerin is carried out under the control of blood pressure and is done intramuscularly in combination with diphenhydramine.
Morphine hydrochloride - administered intramuscularly 1% in the form of a 1:20 folic solution to relieve pain that does not go away for a long time.
Heparin (5 thousand units).

Further tactics depend on electrocardiography data and the general condition of the patient.

Treatment of NSTEMI and NSTE-ACS

If the ECG does not show typical changes, then it may be non-ST segment elevation ACS (NSTE-ACS). Patients also often suffer from “non-ST segment elevation myocardial infarction” (NSTEMI).

Treatment of unstable angina and NSTE-ACS is initially with aspirin and secondarily with an inhibitor such as clopidogrel or diacylglycerol. Heparin (low density) such as enoxaparin is also used. Trinitroglycerin and trinitroglycerol are administered intravenously if the problem persists.

A blood test is only used to check the rise of cardiac troponins over a 12-hour period. If the result is positive, then a typical coronary angiography is done urgently. It allows you to quickly detect a heart attack in a fairly short time.

If troponins are negative, exercise with a treadmill test is performed. If there is no evidence of a high ST segment on the ECG until the next morning, then angioplasty may be indicated.

Lifestyle changes

In some cases, acute coronary syndrome can be prevented. Other heart disease often leads directly to ACS, but those without cardiovascular disease can protect themselves by following healthy lifestyle habits:

a heart-healthy diet
Do not smoke , and if it is difficult for you to give up, you can try medications and consultations to give up the bad habit.
Lead an active lifestyle , that is, engage in regular physical exercise to have good physical fitness. People should aim for moderate exercise, at least 2-3 hours per week.
You need to pay attention to a number of physiological indicators , it is especially important to know your blood pressure and cholesterol levels and understand what these numbers mean and how to keep them in the optimal range.
Maintain a healthy weight , which will take the extra strain off your heart.
Drink alcohol in moderation , preferably limiting it to one or two alcoholic drinks a day, or better yet avoiding them altogether, so that there are no factors that increase blood pressure.

For people who have had problems such as a heart attack in the past, aspirin may also be recommended in addition to taking other daily medications. Aspirin contains acetylsalicylic acid, which helps prevent platelet formation and reduces the chance of another heart attack by about 22%.

Acute coronary syndrome can be prevented or treated with lifestyle changes and the right medications. This will allow you to study and work for your own pleasure in the future.

Video: Emergency care for ACS

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How are emergencies diagnosed?

It is worth noting that the diagnosis of emergency conditions should be carried out very quickly and take literally seconds or a couple of minutes. The doctor must use all his knowledge and make a diagnosis in this short period of time.

The Glasgow scale is used when it is necessary to determine impairment of consciousness. In this case they evaluate:

Opening the eyes.
Speech.
Motor reactions to painful stimulation.

When determining the depth of coma, the movement of the eyeballs is very important.

In acute respiratory failure, it is important to pay attention to:

Color of the skin.
Color of mucous membranes.
Respiration rate.
Movement during breathing of the muscles of the neck and upper shoulder girdle.
Retraction of intercostal spaces.

Shock can be cardiogenic, anaphylactic or post-traumatic. One of the criteria may be a sharp decrease in blood pressure. In case of traumatic shock, the following is determined first:

Damage to vital organs.
The amount of blood loss.
Cold extremities.
"White spot" symptom.
Decreased urine output.
Decreased blood pressure.
Violation of acid-base balance.

The organization of emergency medical care consists, first of all, in maintaining breathing and restoring blood circulation, as well as in delivering the patient to a medical facility without causing additional harm.

Emergency care algorithm

Treatment methods are individual for each patient, but the algorithm of actions in emergency conditions must be followed for each patient.

The operating principle is as follows:

Restoring normal breathing and blood circulation.
Help with bleeding is provided.
It is necessary to stop seizures of psychomotor agitation.
Anesthesia.
Elimination of disorders that contribute to disruption of the heart rhythm and its conductivity.
Carrying out infusion therapy to eliminate dehydration.
Decrease in body temperature or increase.
Carrying out antidote therapy for acute poisoning.
Enhance natural detoxification.
If necessary, enterosorption is performed.
Fixing the damaged body part.
Correct transportation.
Constant medical supervision.

How to proceed: algorithm

Emergency care for acute cerebrovascular accident should begin with calling an ambulance, even if symptoms appear for only a few minutes.

Until the doctors arrive, if the person is conscious, it is necessary to proceed according to the following scheme:

Place the patient in a position that is comfortable for him.
There must be sufficient fresh air in the room.
If a person is wearing clothes, then they should be unbuttoned, especially the shirt at the throat.
Measure the pressure.
If the upper level exceeds 220 mmHg. Art., then immediately give the patient a medicine that he takes on an ongoing basis.
Measure body temperature.
If it is 39 degrees or higher, then it is necessary to give the patient two paracetamol tablets.

You should know that you cannot use other antipyretic drugs.

If a person is unconscious, then emergency care for acute cerebrovascular accident should begin with the patient being placed on his side. If there are removable dentures in the mouth, they must be pulled out and the oral cavity freed from food debris. And the main thing is to make sure that the person is breathing.

What to do before the doctor arrives

First aid in emergency conditions consists of performing actions that are aimed at saving human life. They will also help prevent the development of possible complications. First aid in case of emergency conditions should be provided before the doctor arrives and the patient is taken to a medical facility.

Algorithm of actions:

Eliminate the factor that threatens the health and life of the patient. Assess his condition.
Take urgent measures to restore vital functions: restoring breathing, performing artificial respiration, cardiac massage, stopping bleeding, applying a bandage, and so on.
Maintain vital functions until the ambulance arrives.
Transport to the nearest medical facility.

Next, let's look at how first aid is provided in emergency situations:

Acute respiratory failure. It is necessary to perform artificial respiration “mouth to mouth” or “mouth to nose”. We tilt our head back, the lower jaw needs to be moved. Cover your nose with your fingers and take a deep breath into the victim’s mouth. You need to take 10-12 breaths.

2. Heart massage. The victim is in a supine position. We stand on the side and place our palm on top of our chest at a distance of 2-3 fingers above the lower edge of the chest. Then we apply pressure so that the chest moves by 4-5 cm. Within a minute, you need to do 60-80 pressures.

Let's consider the necessary emergency care for poisoning and injuries. Our actions in case of gas poisoning:

First of all, it is necessary to remove the person from the gas-polluted area.
Loosen tight clothing.
Assess the patient's condition. Check pulse, breathing. If the victim is unconscious, wipe his temples and give him a sniff of ammonia. If vomiting begins, it is necessary to turn the victim's head to the side.
After the victim has been brought to his senses, it is necessary to inhale pure oxygen to avoid complications.
Next, you can drink hot tea, milk or slightly alkaline water.

Help with bleeding:

Capillary bleeding is stopped by applying a tight bandage, which should not compress the limb.
We stop arterial bleeding by applying a tourniquet or squeezing the artery with a finger.

It is necessary to treat the wound with an antiseptic and contact the nearest medical facility.

Providing first aid for fractures and dislocations.

In case of an open fracture, it is necessary to stop the bleeding and apply a splint.
It is strictly forbidden to correct the position of the bones or remove fragments from the wound yourself.
Having recorded the location of the injury, the victim must be taken to the hospital.
It is also not allowed to correct a dislocation on your own; you cannot apply a warm compress.
It is necessary to apply cold or a wet towel.
Provide rest to the injured part of the body.

First aid for fractures should occur after the bleeding has stopped and breathing has normalized.

Prevention

Compliance with emergency care standards for acute cerebrovascular accident is an important condition for saving lives. But every person must understand that their own health is only in their hands. Therefore, it is necessary to undergo regular medical examination. Statistics show that only 50% of people with high blood pressure are aware of their condition. And only about 15% of patients constantly monitor their blood pressure levels.

Although in most cases, hypertension is not so difficult to recognize. Usually this is a person with increased body weight, tense facial expressions and a characteristic color of the skin on the face.

Clinic and emergency care for acute cerebrovascular accidents is something that patients and people living with them should know about. This will make it possible to respond in a timely manner to an attack.

If a person knows that he has high blood pressure, then there must be a tonometer in the house. The indicator should be checked daily in the morning and evening. Despite the fact that WHO considers hypertensive individuals whose blood pressure is equal to or higher than 140/90 mmHg. Art., you should always take into account the individual characteristics of the body. This largely applies to women. If a representative of the fairer sex has had blood pressure at 90/60 all her life, then an increase to 130/80 may already be critical.

If a hypertensive person is a smoker, then the number of cigarettes must be minimized, and it is best to give up this habit altogether.

It is allowed to consume no more than 50 ml of strong drinks or 2 glasses of dry wine per day.

You should definitely undergo a complete examination of the body to detect or ensure that there are no problems with the functioning of the heart. After 35 years, it is recommended to undergo an ECG once every 6 months.

An important factor in the development of the disease is high cholesterol in the blood, the level of which should be controlled. If there is a history of diabetes mellitus, then changes in glucose levels should be carried out on an ongoing basis. Don't forget about an active lifestyle and proper nutrition. You must try to avoid emotional turmoil.