Ministry of health of Ukraine

FIRST AID cardiovascular disease

1. Background:

Circulatory failure (PRS) - a syndrome of sudden and progressive vascular lesions or cardiac muscle comprising the dysregulation of vascular tone (vascular insufficiency), reducing the pumping function of the heart (heart failure), BCC and change the quality of the blood (shock and etc..), which can lead to serious complications in the parenchymal organs or death of the patient. High frequency of met and the number of deaths PRS, which occurs in children with developmental disabilities and inflammatory diseases, causes the relevance of studying this disease.

2. Specific objectives:

1. Master the list of diseases and patolohichchnyh conditions that cause cardiovascular failure.
2. Recognize the major clinical manifestations of cardiovascular disease.
3. Differentiate cardiovascular failure depending on its type and causes.
4. Interpret helper methods: ultrasound, x-ray, laboratory and biochemical analyzes, hemodynamic parameters.
5. Demonstrate the technique of vascular catheterization for Seldynherom.
6. Identify peculiarities of cardiovascular disease.
7. Justify and formulate preliminary clinical diagnosis.
8. Submit algorithm Action physician in cardiovascular disease.
9. To interpret the general principles of treatment of cardiovascular disease.
4.2. Theoretical question for the class:
1. Present a etiological structure of cardiovascular disease.
2. Pathogenesis of cardiovascular disease.
3. Know the clinical picture of cardiovascular disease.
4. Identify the principles of the use of auxiliary examination methods and interpretation of the data obtained in this pathology.
5. Directions of the treatment of cardiovascular disease.
6. Definition tactics patient recovering from cardiovascular disease.
CONTENTS TOPICS
Acute vascular insufficiency.
Syncope - a sudden and brief loss of consciousness in violation of postural tone (often accompanied by a fall) and rapid, complete and self-restoring normality. This mild form of acute cerebral vascular insufficiency, caused by hypoxia of the brain. There are faint neurogenic (vasovagal), orthostatic, symptomatic patients with chronic heart disease (the most severe).
Emergency. Easy, short fainting emergency requires. If the ECG can not be removed, and loss of consciousness accompanied by signs of death - Showing ventilator and indirect heart massage. When tahiaritmiyi - Electro Therapy (EIT). When bradyaritmiyi - enter intravenously 0,75-1,0 ml (depending on age) 0.1% solution of atropine, then intravenously 1.0 ml 0.02% solution izuprelu. Hospitalization for indication. Children age group - hospitalization is required.
Collapse - (Latin collapsus that adversity, fell) acute vascular insufficiency, characterized primarily fall in vascular tone and blood volume. This decreases the flow of venous blood to the heart, reduced cardiac output, decreases arterial and venous pressure, raised tissue perfusion and metabolism, there is hypoxia brain pryhnoblyuyutsya vital functions. Collapse develops as a complication mainly serious diseases and pathological conditions. However, it can also occur in cases where no significant abnormalities (eg, orthostatic collapse in children).
Depending on the etiological factors distinguish collapse in poisonings and acute infectious diseases (toxic collapse), acute massive blood loss (hemorrhagic collapse), while working in a low oxygen content in the air vdyhayemomu (collapse hypoxia et al.). Toxic collapse develops in acute poisoning, including Substance zahalnotoksychnoyi action (carbon monoxide, cyanide, organophosphorus substances, nitro and amidoz'yednannyamy et al.). Call collapse can a number of physical factors - current high doses of ionizing radiation, high temperature environment (with overheating, heat exhaustion). Collapse observed in some acute diseases of internal organs such as acute pancreatitis. Some allergic reactions of immediate type, such as anaphylactic shock occur with vascular disorders, typical collapse. Infectious collapse develops as a complication of meningoencephalitis, acute dysentery, acute pneumonia, botulism, viral hepatitis, toxic flu and others. intoxication due to endo-and exotoxins microorganisms.
Orthostatic collapse occurs when the rapid transition from horizontal to vertical, as well as prolonged standing due to redistribution of blood with an increase in total volume and decreased venous flow to the heart, on the basis of this condition is the lack of venous tone. Orthostatic collapse can be observed in convalescents after severe diseases in the postoperative period, with rapid evacuation of ascitic fluid or as a complication of spinal or peridural anesthesia. Orthostatic collapse often occurs in healthy children, adolescents and boys.
Hemorrhagic collapse develops acute massive blood loss (damage to blood vessels, internal bleeding), due to the rapid decrease in circulating blood volume. Such a condition can occur as a result of abundant plazmovtraty burns, fluid and electrolyte disorders on the basis of severe diarrhea, uncontrollable vomiting, irrational use of diuretics.
Possible collapse in diseases of the heart, accompanied by a sharp and rapid decrease in stroke volume (cardiac rhythm disorders, acute myocarditis, or pericarditis haemopericardium the rapid accumulation vыpota in the pericardial cavity), as well as pulmonary embolism.
The severity of symptoms depends on the collapse of the underlying disease and the degree of vascular disorders. Should also value the degree of adaptation (eg, hypoxia), age (in infants collapse occurs heavier) and emotional characteristics of the patient. Relatively mild collapse sometimes called collaptoid condition.
Features collapse in the youngest age group. In pathological conditions (dehydration, starvation, covert or overt blood loss, "sequestration" of fluid in the intestine, pleural or abdominal cavities) collapse occurs in children more difficult than in adults. In the youngest age group more often than in children over age group, the collapse develops at the toxemia and infectious diseases, which are accompanied by high fever, vomiting, diarrhea. Lowering blood pressure and impaired blood flow in the brain occur with deeper tissue hypoxia, accompanied by loss of consciousness and convulsions. Because infants alkaline reserve in the tissues is limited, violation of oxidative processes during this condition easily leads to decompensated acidosis. Lack of concentration and filtration ability of the kidneys and the rapid accumulation of metabolic products complicate therapy collapse and delayed restoration of normal vascular reactions.
Treatment. In doshpytalnomu stage can be an effective treatment only collapsing due to acute vascular insufficiency (orthostatic, infectious) in hemorrhagic collapse needs emergency hospitalization at nearest hospital, preferably surgical. An important section treat any collapse is etiologic therapy: stop the bleeding, removal of toxic substances from the body, specific antydotnaya therapy, elimination of hypoxia, giving the patient a strictly horizontal position with orthostatic collapse, immediate injection of epinephrine, desensitizing agents in anaphylactic collapse, eliminating arrhythmia and others.
The main objective of immunosuppressive therapy is to stimulate blood circulation and breathing, increased blood pressure. Increased venous flow to the heart is achieved transfusion krovozaminnyh fluids, blood plasma and other liquids as well as by affecting the peripheral circulation. Therapy with dehydration and intoxication is entering polyionic pyrogen-free solutions crystalloids (Atsesol, Disol, Hlosol, laktasola). Volume infusion in emergency treatment of 60 ml of crystalloid per 1 kg of body weight. Infusion rate - 1 ml / kg in 1 min. Infusion of colloid substitutes sharply dehydrated patients contraindicated! In hemorrhagic collapse primary importance of blood transfusion. In order to restore blood volume substitutes massive intravenous (polyglucin, dextran, gemodez etc..) Or blood carry spray or drip, also used transfusion native and dry plasma, concentrated albumin solution and protein. Less effective infusion of isotonic saline or glucose solution. Number infusion solution depends on clinical indicators, blood pressure, urine output (if need be controlled by determining hematocrit, blood volume and central venous pressure). On removal of hypotension sent as input tools excitatory vasomotor center (kordiamin, caffeine, etc.)..
Pressor agents (norepinephrine, mezatona, angiotensin, epinephrine) are shown with the express toxic, orthostatic kollasah. In hemorrhagic - they should be applied only after the restoration of blood volume, not the so-called "blank line". Pressor therapy in children should be administered cautiously. Efficiency and-blockers in peripheral vazokonstriktsiyi sufficiently studied yet.
In the treatment of collapse, not associated with peptic ulcer bleeding, apply glucocorticoids, briefly, in sufficient doses (hydrocortisone sometimes up to 1,000 milligrams or more, prednisolone from 90 to 150 milligrams, sometimes up to 600 mg intravenously or intramuscularly according to the child's age).
To eliminate metabolic acidosis in conjunction with, improving hemodynamics, used 5-8% solution of sodium bicarbonate in an amount of 100-300 ml intravenously or laktasola.
Oxygen therapy is particularly indicated in the collapse, which arose as a result of poisoning by toxins or background anaerobic infection with these forms mainly use oxygen under high pressure (hyperbaric oxygenation). In protracted course when possible development of disseminated intravascular coagulation (coagulopathy consumption) as a therapeutic agent, used heparin intravenously to 5,000 units every 4 hours (exclude internal bleeding!). For all types of collapse careful monitoring of respiratory function, possibly with the study of gas exchange parameters. With the development of respiratory failure using auxiliary mechanical ventilation.
Intensive care in the collapse is performed under general rules. To maintain adequate minute volume of blood during external cardiac massage in hypovolemia should increase the frequency of heart crushed to 100 in 1 min.
Weather. Rapid elimination of the causes that led to this condition often leads to complete recovery of hemodynamics. In severe diseases and acute poisoning prognosis often depends on the severity of the underlying disease, the degree of vascular insufficiency, age of the patient. If not effective therapy collapse may recur. Repeated collapses ill children carry heavier.

Acute heart failure.

A condition in which the heart is unable to provide blood circulation in the body, despite adequate filling of venous blood.
The nature of the process cardiogenic failure can occur in the form:
- Decompensation of varying degrees to the left or right ventricular type, or total failure;
- Arrhythmias in breach of automatism, excitability and conductivity varying degrees up to full lateral blockade;
- Cardiogenic shock.
SHOCK
Shock - sharp arisen critical condition of the body with advanced life support system failure due to acute circulatory failure, microcirculation and tissue hypoxia. This versatile circulatory-metabolic syndrome, which can evolve in pathological conditions of any cause when stress factor exceeds the compensatory ability of the organism to provide support basal homeostasis. Development of shock accompanied by severe hemodynamic, respiratory and metabolic disorders that occur separately or combine and reflect the inclusion of the cascade of compensatory-adaptive reactions necessary for adaptation to stress effects (both exogenous and endogenous). Shock - concept Polyetiological but monopatohenetychne. The biggest differences syndrome observed in early shock when etiological factors closely associated with shock pathogenic. In progress syndrome etiopathogenetical differences smoothed and shock is gradually transformed into a biological process of dying.
Since the development of the syndrome is based on the basic physiological processes, the age of anatomical and physiological characteristics of the child generate a number of differences, as in the pathogenesis of shock and in its clinical manifestations. In particular this applies to the humble (compared with adults) energy reserves of the body of the child and limited compensatory ability of the cardiovascular and respiratory systems. Are essential features of neurovegetative and humoral regulation of vital functions, which makes the "atypical" clinical manifestations of shock in children, making it difficult for its diagnosis and prognosis.
In clinical practice, using etiopathogenetical classification:
Hypovolemic shock:
- The loss of most globular volume (bleeding);
- The loss of most plasma volume (dehydration).
Cardiogenic shock:
- Due to lack of contractile myocardium;
- Arrhythmogenic shock (Braden and tachyarrhythmia).
Infectious-toxic (or septic) shock.
Anaphylaxis.
Neurogenic shock:
-Traumatic;
-Burn;
-Cold;
-Electric.
The shock caused by blood flow obstacle.
The shock caused by acute endocrine insufficiency.
Given the severity of physiological disorders, children in shock should be hospitalized in the intensive care unit, regardless of its etiology and severity.
Treatment. Transfusion therapy in emergency situations in the treatment of shock should start with tools that can quickly restore the BCC. Use of blood leads to the loss of 20 - s0 minutes of time required for the determination of blood tests for compatibility and others. By restoring the ability of BCC donated blood has advantages over colloidal plasma substitutes. In addition, when expressed shock and CBV deficit occurs microcirculation disorder - impaired capillary blood flow, caused by increased blood viscosity, aggregation of formed elements and microtromboformation, aggravated transfusion of donor blood. In this regard, starting transfusion therapy in shock, and even when hemorrhage, followed with intravenous protivoshokovym substitutes - polyglucin and dextran.
Krovozaminni fluid divided into colloidal solutions-dextran (polyglukin reopolyglukine), gelatin preparations (zhelatynol), solutions of polyvinylpyrrolidone (gemodez) saline - isotonic sodium chloride solution, Ringer-Locke laktosol; buffers - a solution of sodium bicarbonate, solution trysamyna, the solutions of sugars and polyhydric alcohols (glucose, sorbitol, fructose), protein preparations (hydrolyzed protein, amino acid solutions); drugs fat - fat emulsion (lipofundin, intralipid).
Depending on the orientation of the liquid krovozaminni classified as follows.
Hemodynamic (protyshokovi).
Low molecular-dextran - reopolyglukine.
Serednomolekulyarni-dextran - polyglukin.
-Preparations gelatin - zhelatynol.
Detoxification.
-Low molecular weight polyvinyl gemodez.
-Low molecular weight polyvinyl alcohol - polidez.
Preparations for parenteral nutrition.
-Protein hydrolyzate - casein hydrolyzate, aminopeptyd, aminokrovin hidrolizin.
-Solutions of amino acids - polyamine, mariamin, friamin.
-Fat emulsions - intralipid, lipofundin.
Sahara-and polyhydric alcohols - glucose, sorbitol, fructose.
Regulator of water and salt and acid - base status.
-Saline - isotonic sodium chloride solution
Ringer, laktosol, a solution of sodium bicarbonate, solution trysamyna.

Pulmonary edema.

On stage doshpytalnomu greatest practical interest is the development of acute heart failure with symptoms, defined as pulmonary edema. Pathological condition caused by abundant propotivannyam liquid part of blood capillaries small circle of blood circulation in the first interstitial lung tissue and then into the alveoli. With the development of alveolar edema is decreasing, kolabuvannya alveoli.
Pulmonary edema is a complication of diseases and pathological conditions:
- Diseases of the cardiovascular system, accompanied by left ventricular failure (in children frequently aortic and mitral heart defects, idiopathic cardiomyopathy, myocarditis);
- Respiratory disease (pneumonia, acute bacterial, viral, radiation, traumatic, severe tracheobronchitis, acute airway obstruction during larinhospazmi, bronchospasm, foreign bodies, mechanical asphyxia);
- Damage to the central nervous system (brain injury, brain tumor, meningitis and encephalitis, status epilepticus, inhibition of the function of the respiratory center during anesthesia, poisoning by hypnotics and psychotropic drugs);
- Endogenous and exogenous intoxication and toxic lesions (uremia, renal failure, the effect of endotoxin in severe infectious diseases, inhalation of toxic agents);
- During prolonged artificial ventilation;
- In cases involving intravascular thrombosis (postinfectious states);
- When hyperergic reaction immediate-type (anaphylactic shock, rarely - angioedema, serum sickness);
- Pulmonary thromboembolism in the system logs.
Pulmonary edema in children under 1 year - extremely rare and the causes of its development, as in older age is difficult comorbidities or complications associated with its treatment. For young children the most relevant absolute or relative hypervolemia associated with enteral or parenteral fluid volumes that exceed the capabilities of physiological adaptation. This occurs when drowning, uncontrolled flushing the stomach and intestines with plenty of water.

Treatment.

1. Treatment of the underlying disease or pathological condition that led to pulmonary edema.
2. Pathogenetic and symptomatic therapy, consisting of the following measures:
- Restoration of the airway;
- Reduction of venous blood flow to the right ventricle;
- Reduction of circulating blood volume;
- Dehydration lung;
-Reduce the hydrostatic pressure in the vessels of the small circle of blood circulation;
- Strengthening the contractile ability of the myocardium;
-Elimination of pain and acute cardiac arrhythmias;
- Correction of disorders of acid-base balance and electrolyte balance.
In the treatment of this syndrome on doshpytalnomu stage can not be assigned pathogenesis unsubstantiated treatments. Please note that children reduced vascular and cardiac mechanisms of tolerance to drugs that increase inotropic function. Thus, the appointment adrenoceptor agonists or cardiac glycosides in children more often than adults, the syndrome "losing the right-left ventricular dependence", ie excessive contractile ability of the right ventricle may increase left ventricular inotropic failure. Therefore, a child with pulmonary edema paramount importance is the establishment of conditions for pulmonary gas exchange. Resistance to exhalation or breathing out all the time - positive pressure is the method of choice. Early treatment can be assigned to oxygen through a mask. Are more effective intubation and mechanical ventilation (manual or mechanical resistance to exhalation).
To restore the airway:
- With abundant foam - aspiration (suction) foam with upper airway through a soft rubber catheter (or trachea after previous intubation or tracheostomy);
-Reducing foam in the airways using inhaled oxygen, passed through a 70-90% ethyl alcohol (in patients who are in a coma - in 30-40% alcohol) or 10% alcohol solution antyfomsilanu.
-To improve airway conductance when co bronchospasm shown in / drip 5-10 ml of 2.4% solution эufillinu (no threat of ventricular fibrillation of the heart).
To improve the supply of circulating blood, venous blood flow to the right ventricle, pulmonary dehydration:
- Peace, semisitting position patient with pants down (no kollapsu);
- The imposition of venous tourniquet on four limbs (below the tourniquet should be kept throbbing of the arteries);
-With the rapid growth of pulmonary edema after previous single / in heparin dose in age;
-Intravenous drip of peripheral vazodilyatatoriv;
-Intravenous diuretics speed: Lasix, urehit, prolonged, refractory to therapy of pulmonary edema appropriate use of osmotic diuretics (mannitol and urea) in the age dosages.
To reduce the pressure in the pulmonary capillaries, reducing blood pressure, reducing psychomotor agitation:
-Narcotic analeptics antipsychotics, adrenoblokirujushchej means ganglioplegic;
To enhance the contractile ability of the myocardium:
-Cardiac glycosides, in / or / m calcium gluconate.
To reduce alveolar-capillary permeability:
-In / entry prednisolone, hidrokartyzonu in isotonic sodium chloride solution or 5% glucose solution.
Fighting hypoxia:
-Oxygen inhalation, artificial ventilation.

Features of cardiopulmonary resuscitation in children

During sudden cardiac arrest understood clinical syndrome characterized by the disappearance of the signs of heart activity (termination ripple on femoral and carotid arteries, the lack of warm tones) and stop spontaneous breathing, loss of consciousness and dilated pupils. These symptoms are the most important diagnostic criteria of cardiac arrest, which may be provided or sudden. Cardiac arrest as provided can be observed in a terminal condition under which imply the waning life of the organism. Terminal condition may result from critical disorder of homeostasis due to illness or inability of the body to respond to an external force (trauma, hypothermia, overheating, poisoning, etc.). Cardiac arrest and cessation of blood flow may be associated with asystole, ventricular fibrillation and collapse. Cardiac arrest is always accompanied by respiratory arrest, as a sudden stop breathing associated with airway obstruction, oppression CNS or neuromuscular paralysis, it can result in cardiac arrest.
Sequence of resuscitation in children in general, similar to that in adults, but there are features. If resuscitation of adults based on the fact of the primacy of heart failure, then the child cardiac arrest - a final process of extinction of physiological functions, initiated usually respiratory insufficiency. Primary cardiac arrest in children is very rare, ventricular fibrillation and tachycardia are its causes less than 15% of cases. Many children have a relatively long phase "peredzupynky" that determines the need for early diagnosis of this phase.
Not wasting time to determine the cause of cardiac arrest or breathing, immediately begin to treat that includes the following range of activities. Lowers the head end of the bed, lifted the lower limbs, creating access to the chest and head. To ensure airway lightly throw your head back, bring up the lower jaw and produce 2 slow injection of air into the lungs of the child (1 - 1.5 seconds to 1 breath). Inspiratory volume should provide a minimum excursion of the chest. Forced air injection Visio ¬ lows directly inflating the stomach that dramatically affects the effectiveness of resuscitation! Injection is carried out by any method - "mouth to mouth", "mouth - mask" or use breathing device "bag - mask", "fur - a mask." However, infants are especially perform these manipulations:
- Should not be too throw the child's head;
- Should not compress the soft tissue chin, because it can cause airway obstruction.
If the injection of air has no effect, it is necessary to improve the airway, giving them a better anatomical position of extension of the head. If this manipulation also failed to produce the effect, it is necessary to release the airway from foreign bodies and mucus continue breathing with a frequency of 20 - 30 in 1 min.
Methods of eliminating airway obstruction caused by a foreign body, depends on the age of the child. Purification finger upper airway blind children is not recommended to use because at this point you can push the foreign body deeper. If the foreign body is visible, it can be removed using the Kelly clamp or forceps Medzhila. Clicking on the stomach is not recommended for use in children under one year, because it threatens damage to abdominal organs, especially the liver. A child at this age can help hold it in your hand in position "rider" with his head lowered below the torso. Chairman of child support hand around the lower jaw and chest. On the back between the shoulder blades quickly causing four strokes proximal part of the palm. Then the child laid on his back so that his head was below the torso throughout the reception and serve four pressing on the chest. If the child is very high, so put it on your forearm, it is placed on the hip so that his head was below the torso. After clearing the airways and restore their free terrain in the absence of spontaneous breathing begin artificial ventilation. In older children or adults with airway obstruction foreign body advise taking Heymliha - subdiafrahmalnyh series of clicks.
Emergency krykotyreotomiya - one of the support options patency respiratory tract in patients who can not get intubuvaty trachea.
Methods of indirect heart massage. Using 2 or 3 fingers of the right hand, press down on the breast at the site, located at 1.5 - 2 cm below the intersection of the sternum with nipple line. In newborns and infants clicking on the breast can be produced by placing the thumbs of both hands in a specified place obhvatyvshy palms and fingers chest. Depth sternum deflection inside ranges from 0.5 to 2.5 cm, frequency clicks at least 100 times in 1 min., The ratio of pressures and artificial respiration - 5:1. Massage hearts hold, putting the patient on a hard surface or tucked under the back child infants left arm. In newborns and infants acceptable method of asynchronous ventilation and massage without complying with pauses for breaths, which increases cardiac blood flow.
Criteria effectiveness of resuscitation - the emergence of a distinct ripple on the femoral and carotid arteries, narrowing of the pupils. It is desirable to develop emergency tracheal intubation and to provide ECG - monitoring of cardiac activity.
If the background cardiac massage and ventilation cardiac activity is not restored, then intravenously administered 0.01 mg / kg of epinephrine hydrochloride (epinefrinu), then sodium bicarbonate - 1 - 2 mg / kg. If intravenous administration is not possible, then as a last resort - ask intracardiac, sublingual or endotracheal administration. The feasibility of using drugs during resuscitation calcium being questioned. To maintain cardiac activity after its restoration injected Dopamine or Dobutamine (dobutreks) - 2 - 20 mg / kg in 1 min. When ventricular fibrillation prescribed lidocaine - 1 mg / kg intravenously, with no effect demonstrated Emergency эlektrodefibrilyatsiya (2 W / kg in 1 sec). If necessary, do it again - 3 - 5 W / kg in 1 sec.
During cardiopulmonary resuscitation important to quickly provide access to the venous bed. Central venous access is more preferred than peripheral, since there is a significant delay in the circulation of drugs introduced through a peripheral vein, although the same dose of drugs.
Intravenous access is made as follows.
Children younger than 5 years:
• first attempt - peripheral line if no success for 90 seconds - intraosseous line;
• later - the central line (femoral, internal and external jugular vein, subclavian) venesektsiya saphenous vein leg.
Children over 5 years:
• first attempt - peripheral line;
• the second attempt - the central line or venesektsiya saphenous vein leg.
All medications used during cardiopulmonary resuscitation, and all fluids, including whole blood, can be introduced intraosseous. Standard needle 16-18G, needle puncture of the spinal stiletom or bone marrow needle is injected into the anterior surface of the tibia 1-3 cm below its tuberosity. The needle is directed at an angle of 90 degrees to the medial surface of the tibia, so as not to damage the epiphysis.

Ventricular fibrillation

Ventricular fibrillation and ventricular tachycardia - unusual for children kinds circulatory arrest. Ventricular fibrillation is more common in adolescents and patients with congenital heart disease. If still there fibrillation should try to make defibryllyatsyyu soon. If the time from cardiac arrest is unknown, then as the first measure - recommended cardiopulmonary resuscitation for at least two minutes. The success of defibrillation electrode size is important and its location. Size electrode for adults - 13 cm in diameter, for older children - 8 cm for infants - 4.5 cm One electrode is placed to the right of the sternum below the clavicle, the other - below and to the left for the left nipple. Between the electrode and the skin should be a layer of cream, saline, soap.
Algorithm for treatment of the following:
- Defibrillation, three consecutive bits (4> 4> 4 J / kg);
- Adrenaline 0.01 mg / kg / in or 0.1 mg / kg endotracheal;
- Defibrillation - 4 J / kg;
- Lidocaine 1 mg / kg;
- Defibrillation - 4 J / kg;
- Adrenaline 0.1 mg / kg / v;
- Defibrillation - 4 J / kg;
- Bretylium 5 mg / kg.
Therapy that supports, is to use mechanical ventilation mode AC or positive pressure at the outlet to support Ra02 at 9.3 - 13.3 kPa (70 - 100 mm Hg) and PaCO2 within 3,7-4 kPa (28-30 mm Hg). When bradycardia injected isoproterenol - 0.05 - 1.5 mg / kg in 1 min, at its ineffectiveness use artificial pacemaker. If resuscitation lasts more than 15 minutes or doreanimatsiynyy period lasts more than 2 minutes, then carry out activities aimed at preventing brain edema. Enter Mannitol - 1 g / kg, deksazon - 1 mg / kg at intervals of 6 hours. Appropriate hyperventilation to achieve RaS02 within 3.7 kPa (28 mm Hg). Nifedipine is administered at a dose of 1 mg / kg during the first day under the control of blood pressure. Assign thiopental sodium - 3 - 5 mg / kg intravenously during con ¬ troll respiratory rate (remember the negative inotropic effect). Mandatory monitoring of vital parameters heart rate, CVP, blood pressure, body temperature. Very important control urination and state of consciousness. EEG monitoring and ECG monitoring is performed to stabilize cardiac activity and respiration.
Contraindications for resuscitation:
- Terminal states due inkurabelnoho disease.
- Severe disease and irreversible brain damage.
The question of the duration of resuscitation and stopping their children in Ukraine nowhere and never discussed. Before doctors often face the question resuscitate or not resuscitate the child, especially when the final stop before the heart was peredzupynnyy long period of intensive care and all the body's reserves are exhausted. In the world literature on this issue is also paid very little attention
Cardiopulmonary resuscitation and continued support of life in children should be part of the integration of the social system. Only such an approach can properly organize timely and complete care for patients. And this requires smooth functioning following systems:
• sanitary-educational work on the prevention of injuries in children;
• basic life support level in children (doshpytalna assistance);
• for easy and quick access to child reanimation teams;
• highly skilled support life (hospital, niche assistance);
• intensive care postreanimatsiynoyi disease in children.

Materials for self-

Situational task
Task 1. Patient A., aged 14, while trying to climb out of bed after elective surgery on varicocele, there was severe weakness, zapamorochylasya head. Loss of consciousness was not a nurse brought another doctor.
1. What is the most likely diagnosis?
2. Tactics physician in detecting the disease.
3. Etiology and pathogenesis of disease.
4. Name the main areas of treatment.
5. What features of clinical supervision for the child after recovery?
Answers:
1. Orthostatic collapse.
2. Give the patient a horizontal position when raised with gentle end.
3. Orthostatic collapse due to redistribution of blood with an increase in total volume and decreased venous flow to the heart, the basis of this condition is the lack of venous tone.
4. Treatment of the underlying disease, review cardiologist, neurologist.
5. In the absence of diseases that contribute to the occurrence of this condition, clinical supervision is not required. In the presence of organic background - clinical supervision in profile specialist.

Task 2. In patient 10, the capture of the total blood in the surgical department during the test there was a loss of consciousness for up to 5 seconds. After applying ammonia recovered consciousness immediately. The nurse brought the doctor.

1. What is the most likely diagnosis?
2. Tactics physician in detecting the disease.
3. Etiology and pathogenesis of disease.
4. Name the main areas of treatment.
5. What features of clinical supervision for the child after recovery?
Answers:
1. Dizziness.
2. Easy, short fainting emergency requires.
3. A sudden and brief loss of consciousness due to violation of postural tone.
4. Special treatment is needed.
5. In the absence of diseases that contribute to the occurrence of this condition, clinical supervision is not required. In the presence of organic background - clinical supervision in profile specialist.

Problem 3. Man K., 13 years old, is unconscious on the floor after hitting electrocution due to damage electrical wiring. The patient's severe, external respiration preserved carotid pulse is palpable.

1. What complication occurred in a patient?
2. Tactics physician in detecting the disease.
3. Etiology and pathogenesis of disease.
4. Present a method of cardiopulmonary resuscitation.
5.What features of clinical supervision for the child after recovery?
Answers:
1. Cardiac arrest.
2. Perform cardio-pulmonary resuscitation and dopravyty patient to hospital.
3. Progressive failure of livelihood due to acute circulatory failure, microcirculation and tissue hypoxia.
4. Depth sternum deflection inside ranges from 0.5 to 2.5 cm, frequency clicks at least 100 times in 1 min., The ratio of pressures and artificial respiration - 5:1. Massage hearts hold, putting the patient on a hard surface.
5. Clinical supervision by a cardiologist.

Problem 4. A patient 10 years on the beach zapamorochylasya head, increased body temperature. He lost consciousness for 5 seconds. I turned for help to the nurse.

1. What disease arose in this case?
2. Tactics physician in detecting the disease.
3. Etiology and pathogenesis of disease.
4. Name the main areas of treatment.
5. What features of clinical supervision for the child after recovery?
Answers:
1. Heat stroke, dizziness.
2. Easy, short fainting emergency requires.
3. A sudden and brief loss of consciousness due to violation of postural tone, fever due to disorder center of thermoregulation.
4. Special treatment is needed.
Problem 5. A patient 10 years old, diagnosed with acute hematogenous osteomyelitis of the right tibia deteriorated condition after administration of ceftriaxone. On examination marked coldness of the extremities, acrocyanosis, skin marbling. Patient delirious. The body temperature of 40.80 C. Also determined tachycardia, tachypnea, drop in blood pressure.
1. What complication arose in this case?
2. Tactics physician in detecting the disease.
3. Etiology and pathogenesis of disease.
4. Name the main areas of treatment.
5. What features of clinical supervision for the child after recovery?
Answers:
1. Infectious-toxic shock.
2. Replacing antibiotic immediate holding infusion therapy glucose-saline to detoxification, symptomatic therapy to stabilize hemodynamics.
3. Progressive failure support system, caused by acute circulatory failure, microcirculation and tissue hypoxia.
4. Combined treatment should vkyuchaty immobilization, rational antibiotic therapy, immunocorrection, correction fluid and electrolyte disorders, detoxification therapy and symptomatic treatment in cases of funtsiy organs and systems (treatment of multiple organ failure).
5. Clinical supervision in orthopedic, surgeon and other specialists in the presence of complications.