Asthmatic attack – a state of suffocation caused by spasm of the bronchi and violation of their patency. It occurs when the balance between the parasympathetic and sympathetic parts of the autonomic nervous system is disturbed. Due to pathological irritation of the branches of the vagus nerve, excessive impulse is generated, which causes a contraction of the smooth muscles of the bronchi. Narrowing their lumen, and excessive secretion and swelling of the mucous membrane violate bronchial patency.
- Asthma Attack Treatment
- Intensive therapy of asthmatic status
- Traumatic injuries of the chest
- “Coronary Cafe Syndrome”
- Laryngeal mask, its application
The causes of the attack may be allergic, neurogenic or endocrine factors. A symptom of asthma is an asthma attack that begins with a dry cough. These attacks occur suddenly, the patient takes a forced position – sitting. Orthopnea helps the musculature of the chest, abdomen, and the shoulder girdle to participate in the act of breathing. At a distance, you can hear wheezing dry wheezes. The patient takes a short breath, after which the elongated exhalation immediately follows difficulties. A very disturbing sign is the absence of phlegm. With complete obturation of the bronchi, the syndrome of the “mute lung” develops: the breathing is uneven, and zones of “silence” of the lungs or whole particles are identified in auscultation. In patients, hypoxia, hypercapnia with subsequent loss of consciousness increases.
Asthma Attack Treatment
In most cases, an attack of bronchial asthma can be stopped with the inhalation of an asthmatic aerosol (or its analogs), by using 1-2 tablets. theophedrine or antastmans, subcutaneous administration of 0.5-1 ml of a 0.1% solution of epinephrine hydrochloride, 1 ml of a 5% solution of ephedrine, intravenously – 10 ml of a 2.4% solution of euphyllin diluted in 10 ml of isotonic sodium chloride solution.
A prolonged attack of bronchial asthma (or a series of frequent), does not lend itself to standard therapy with beta-adrenomimetics, xanthines and glucocorticoids, is regarded as an asthmatic status. At the heart of its occurrence are bronchiolospasm, inflammatory and edematous processes of the mucous membrane of the tracheobronchial tree and a violation of the evacuation capacity of the ciliary epithelium, which lining the bronchi. Due to hyperventilation, patients lose significantly more water through the lungs; there is drying out of the mucosa of the tracheobronchial tree. The sputum becomes dense, viscous, ceases to stand out when coughing and blocks the lumen of small bronchi, bronchioles, which become impassable for air.
There are two forms of asthmatic status : anaphylactic and metabolic. Allergic and immunological reactions are the basis of the development of the anaphylactic form. It can occur after the use of drugs (antibiotics, enzymes, acetylsalicylic acid, etc.) and flows very rapidly. The metabolic form of the asthmatic status is caused by the dizmetabolic reactions; this can be facilitated by long-term use of sympathomimetics ( asthmopent, ephedrine, alupent, etc.).
The asthmatic status proceeds in stages . 1 stage of relative compensation. The patients are cyanotic, restless, in a sitting position. There is pronounced expiratory dyspnea with a respiratory rate of 26-40 per minute, tachycardia to 120 per minute and, in the vast majority of patients, hypertension. In the lungs dry scattered wheeze with prolonged exhalation and “mosaic” breathing are heard.
2 stage of decompensation. The general condition of patients is severe or very severe. They are exhausted, sometimes agitated and aggressive. The skin is cyanotic, moist. Dyspnea increases to 60 per minute, breathing is superficial, noisy at a distance and abruptly weakened by auscultatory, often signs of “mute lung”. Tachycardia (120-140 beats per minute), hypotension (system AO – up to 80 mmHg), hypoxemia and hypercapnia (respiratory and metabolic acidosis).
Stage 3 – hypoxic coma. The general condition is extremely difficult. Sick of consciousness, sometimes there are cramps. The skin is cyanotic-gray, covered with sticky sweat. Pupils are wide, reflexes or suppressed, or pathological. Breathing more than 60 per minute (sometimes abruptly slowed down), auscultatory – not bugged; pulse rate more than 140 per minute, blood pressure is reduced to critical values. Biochemical blood tests indicate a mixed acidosis of decompensated degree (pH <7.2) with gross disturbances of homeostasis. Acute pulmonary heart disease can lead to death.
Adjust inhalation of moistened oxygen; if possible, add 20-30% helium to the respiratory mixture;
- Provide cardiomonitoring control. It should be remembered that ventricular fibrillation is one of the possible causes of death of a patient with asthmatic status;
- Carry out infusion therapy. It is necessary to pour solutions (crystalloids, 5% glucose solution, polarizing mixture, rheopolyglucin, etc.) heated to 30-32 ° C into catheterized peripheral or central veins. With pronounced symptoms of dehydration, the volume of infusions should reach 5-7 liters per day. In the presence of metabolic acidosis, 4% sodium hydrogen carbonate solution (100-150 ml) is prescribed;
- Apply hormonal therapy hydrocortisone (150-200 mg every 2-3 hours), rn prednisolone (60 mg every 4-6 hours.), P-n dexamethasone (8-16 mg every 6 hours. )
- Introduce antispasmodic, antihistamines and sedatives (2.4% solution of euphyllin 10 ml, 2% solution of 2 ml 2 ml, 2% solution of dimedrol 1 ml, 0.5% solution of sibazone 2-4 ml or 20% solution of sodium oxybutyrate, 10-20 ml each: administered intravenously drip;
- When the signs of heart failure increase, cardiotrophic middles are prescribed (cardiac glycosides: 0.5 ml of 0.05% solution of strophanthin in isotonic p-no sodium chloride, intravenously);
- In some cases, as a means of immediate action, it is possible to conduct therapeutic fluorotane-dioxide-oxygen anesthesia, which eliminates spasm of the bronchi and improves oxygenation of the body;
- In the absence of the effect of drug therapy and worsening of the general condition of the patient, intubate and carry out artificial ventilation of the lungs.
Indications for mechanical ventilation of the lungs with asthmatic status:
– Loss of consciousness;
– Hypotension (blood pressure <70 mm Hg);
– Tachycardia (heart rate> 140 beats Min);
– CO2> 60 mm Hg. at .; PO2 <60 mm Hg. Art. Blood pH <7.25.
In these cases, the patient is treated with medical anesthesia (fluorotane-oxygen) and performs sanative bronchoscopy or tracheobronchial lavage (washing the bronchi with a heated isotonic solution of sodium chloride, 50-100 ml, followed by its suction with a catheter, in total for the session use up to 1.5 liters of solution ). Carrying out the lavage, change the position of the patient’s body, setting the catheter alternately in different bronchi so as to clear them as much as possible from the mucous plugs.
- Important importance is given to rational antibacterial therapy, elimination of allergic factors, treatment of concomitant somatic diseases, timely administration of adequate infusion and inhalation therapy, can prevent the occurrence of asthmatic status.
Numerous fractures of the ribs, especially the “final ones,” lead to disruption of the respiratory biomechanics. Clinically, one can observe a decrease in the excursion of the thorax, the westing of its individual parts and asymmetric movements during breathing. In patients, a decrease in the respiratory volume, cyanosis of the skin and mucous membrane, destabilization of central hemodynamics, disturbance of microcirculation, and disorders of consciousness are noted.
Fractures of the ribs may be accompanied by hemo- or pneumothorax. One of the terrible complications is intense pneumothorax, in which hypoxia is expressed and the displacement of the mediastinal organs can quickly lead to the death of the patient.
The medical worker in such patients should conduct the methods of examination available to him: external examination, palpation, auscultation of the lungs and their percussion; laboratory and instrumental diagnostics. Particular attention deserves patients who are delivered in an unconscious state.
“Coronary Cafe Syndrome”
This is a syndrome of acute sudden asphyxia, which occurs when a foreign body enters the vocal cavity and overlaps its lumen.
The reason for it is a violation of the biomechanics of swallowing and breathing. The victim, who talked to him briskly during the meal, suddenly, interrupting the speech in mid-sentence, jumps to his feet. He tries to breathe in air, but vigorous efforts prove futile. Hands convulsively embrace the neck, which the victim releases with desperate movement from clothes, tearing it. The face turns blue, swells, and horror appears in your eyes. After 3-4 minutes the victim loses consciousness, falls. Cramps develop. Pulse, at first frequent, intense, quickly weakens. Attempts to breathe become less pronounced. There are involuntary urination and defecation, convulsions stop, pupils widen and clinical death occurs.
So, with acute total obstruction of the glottis by a foreign body, it is possible to distinguish such periods of tanatogenesis:
- 1-st – patient in consciousness, is on his feet (2 – 4 min);
- 2 nd – the period of loss of consciousness and development of seizures (2 – 3 min);
- 3rd – the period of clinical death. It takes place from 5 to 10 minutes.
Urgent care. In the first period, a doctor, nurse or anyone familiar with the basics of resuscitation should try to implement Heimlich’s reception. To do this, the reanimator goes behind the victim’s back and covers the lower sections of his chest with his hands, winding his hands in the epigastric region. He orders the victim to exhale vigorously, and at this time he squeezes his chest with his hands and sharply bends his body anteriorly and downward.
This method allows creating a high pressure in the trachea of the victim, so that the exhaled air pushes the foreign body out of the vocal cords to the outside. If an unsuccessful attempt or loss of consciousness (the second period), to save the life of the victim can only immediate conicotomy (dissection of the thyroid-cricoid ligament).
Method of conicotomy. Reanimator puts under the shoulders of the injured roller, maximally unbending his neck. In the presence of convulsions, he asks those present to hold the victim’s chest. Then, tightly grasping the first and third fingers of the left hand, the thyroid cartilage, “slides” along them with the index finger down to the semilunar depression, which divides the thyroid and cricoid cartilage. At this point, the thickness of the membrane together with the skin is a few millimeters. This allows you to pierce it with an improvised piercing-cutting object (kitchen knife).
Squeezing the blade of the knife with the fingers of the right hand so that its tip protrudes no more than 1 cm, the Reanimator on the nail of the index finger of the left hand pierces – cuts the ligaments. To prevent the cartilage from closing into the created fistula, insert a tube (for example, the body of a ball-point pen). With a clear implementation of the conicotomy takes a little time (up to a minute), which allows saving the life of the patient.
If the victim is in a state of clinical death (the third period of dying), immediately perform a conicotomy and conduct cardiopulmonary resuscitation according to general rules. Artificial ventilation is provided by blowing air through a conical tube.
Specialized care consists in direct laryngoscopy and, under the control of vision, removal of a foreign body with the help of special forceps. If necessary, in hospital conditions, such patients undergo a sanative bronchoscopy or impose a tracheostomy.
This sudden abnormal closure of the vocal cords, which is manifested by a sharp difficulty or inability to breathe. Laryngospasm arises from a pathological reflex with excessive irritation of the branches of the vagus nerve.
The cause of laryngospasm are traumatic manipulations and operations in the field of reflexogenic zones (vocal cords, bifurcation of the trachea, epiglottis, eyeballs, peritoneal mesentery, rectal cossette, periosteum). The irritation of the vocal cords in the case of droplets of saliva, food particles, acidic gastric contents, water, chemical (acid pairs) and thermal (open flame) stimuli, allergic reaction in patients, especially Vagotonics, are frequent causes of laryngospasm.
Laryngospasm may be partial or complete. In both cases, it manifests itself by the sudden occurrence of inspiratory suffocation. The patient strives to breathe: the respiratory muscles are actively contracting, the intercostal spaces are retracted, the jugular notch, the supraclavicular fossa. With partial laryngospasm, a small amount of air penetrates through loosely compressed vocal cords, which, hesitantly, cause a sound resembling a rooster cry. For total laryngospasm, aphonia is characteristic. Within a few minutes the patient develops cyanosis, tachycardia, blood pressure rises; In the future, under the influence of hypoxia, consciousness is lost, reflexes are suppressed. In some cases, the striated muscle of the larynx relaxes, which leads to the unauthorized elimination of laryngospasm.
- to adjust the oxygenation system through the mask of the respiratory apparatus, since the increase in hypoxia worsens the patient’s condition and promotes the transition of partial laryngospasm to total;
- immediately stop the action of the stimulus on the reflexogenic zone (if an operation is being performed, stop it);
- Enter intravenously solutions of atropine sulfate (at the rate 0.01 mg / kg of mass), eufillina (2.4% – 5-10 ml, diluting it twice with sodium chloride solution). In the presence of allergies, chemical or thermal damage to the vocal cords – to introduce solutions of antihistamine middens (2.5% solution of pifolen – 2 ml) and glucocorticoids (prednisolone solution 60 – 90 mg).
• inhalation of bronchodilators (salbutamol);
• re-introduction of the above-mentioned middens;
• with partial laryngospasm, perform artificial ventilation of the lungs with large volumes of oxygen through the mask of the respiratory apparatus;
• in the absence of the effect of the previous treatment – to inject intravenously muscle relaxants of depolarizing action (2% solution of dithilin – 10 ml), and, after waiting for complete relaxation of the muscles, under the control of direct laryngoscopy, intubate the patient (it is advisable to turn off consciousness beforehand, on ketamine);
• In the absence of conditions for intubation of the trachea and the emergence of a life threat (pronounced bradycardia, fainting, lowering blood pressure more than 70 mm Hg, generalized seizures), it is necessary to immediately carry out conicotomy and inject oxygen through the tube inserted into the trachea;
• in the diagnosis of clinical death – immediately carry out cardiopulmonary resuscitation in accordance with generally accepted rules.
This acute violation of the function of external respiration, caused by the closing of the smooth muscles of the small bronchi. It can be partial or complete. The causes of bronchiolospasm and drug treatment are the same as in laryngospasm. However, the introduction of muscle relaxants does not eliminate bronchiolospasm, conicotomy is also ineffective. Unfortunately, with total bronchiolospasm, death is almost inevitable.
It is very important to use preventive premedication with the introduction of peripheral M-cholinolytics (atropine sulphate solution at the rate of 0.01 mg / kg) when performing manipulations on the reflexogenic zones. This will prevent the overexcitation of the parasympathetic nervous system and the appearance of pathological reflexes.
Laryngeal (throat) mask is an elastic plastic tube with a masked obturator in the proximal part. This outstanding medical invention of recent years is becoming increasingly popular among emergency medicine workers.
Indication : provision in patients with patency of the upper respiratory tract and artificial ventilation, and if necessary, anesthesia, in the absence of a laryngoscope and the impossibility of intubation of the trachea.
Necessary equipment : neck masks of various sizes, rotor-expander, clamp with gauze napkins, aspirator, 10 ml syringe.
Method of application . Clean the mouth and throat of the victim from the contents (saliva, blood, vomit) with an aspirator and gauze napkins on the clamps. If necessary (trisme) use a rotor expander.
The Savior (doctor, nurse, paramedic) is located in front of the victim, facing him. Fingers of the left hand opens his mouth to him (if necessary, he uses a rotator for this purpose). In his right hand he takes a laryngeal mask, capturing the proximal tube with the index and middle fingers (at the obturator). Having directed it cavity to the teeth of the lower jaw of the patient, the savior carefully switches the mask through the mouthpiece. On the back of the tongue, he pushes it as deep as possible into the throat.
As soon as the mask ceases to advance, the savior inflates her obturator with air using a syringe through a special valve-type catheter. In this case, the mask tightly obturates the throat cavity. The proximal end of the tube (its lumen) is located at the entrance to the trachea, in front of the epiglottis. Distal – protrudes from the oral cavity outward. To him, if necessary, you can attach the respiratory circuit of the ventilator.
On the channel of laryngeal masks, if necessary, a small diameter intubation tube can be inserted into the trachea (intubate the patient).
Indications : obstruction of the upper respiratory tract in tumors, stenoses of the larynx, etc .; the need for prolonged artificial ventilation of the lungs and the rehabilitation of the tracheobronchial tree in patients with disturbed functions of external respiration.
Necessary equipment :
- a set of tracheostomy tubes,
- suture and dressing material,
- antiseptic solutions,
- electric pump,
- Breathe-helping machine,
- middling anesthesia.
Method of conducting . Tracheostomy is an operation that is performed under operating conditions (preferably after preliminary introduction of the patient into anesthesia and, ideally, after intubation of the trachea.) Depending on the choice of the site of the incision, the neck is distinguished by the upper, middle and lower tracheostomy.
After the treatment of the operating field in aseptic conditions, the surgeon fixes the larynx with fingers and strictly on the middle line of the neck, starting under the action of the thyroid cartilage, makes a cut, 4-5 cm long. It dissects the skin, subcutaneous fatty tissue and aponeurosis, then bluntly dissects the cartilage cartilage and acute crochet pulls it to the top and forward. On the lower edge of it makes a cross-section of the fascia, which covers the isthmus of the thyroid gland. Then pulling it down with a dull crochet.
The naked trachea pierces and raises with a single-tooth crochet and dissects two of its rings. In the section introduces the expander of the Tissue and inserts a tracheostomy tube between his jaws. In some cases, to insert the tube into the trachea, you can cut out the oval hole. The diameter of the hole should not be more than a third of the diameter of the trachea. On the skin, 2-3 sutures are applied, aseptic bandage.