Clinical protocols “Providing emergency medical care for injuries. Clinical guidelines (protocols) for the provision of emergency medical care Emergency medical care protocols

Research Institute of Ambulance named after. prof. I. I. DZHANELIDZE

CITY SMP STATION

ACTION PROTOCOLS FOR PHYSICAL SERVES

EMERGENCY MEDICAL CLIPS

St. Petersburg 2002

Web version

“AGREED” “APPROVED”

Director of NIISP Committee Chairman

them. prof. on healthcare

prof. ev the governor's administration

chief physician of the city emergency medical service station in the city.

Editors: prof. , prof. .

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

on health care of the administration of the governor of St.-Petersburg.

Doctor of Medical Sciences, Head of Scientific and Clinical

In the Web version, the “Bronchial asthma” protocol has been changed.

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

Memo to EMS employee................................................................... ...................................6

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

“Golden hour” .................................................... ........................................................ ......8

General rules for the work of emergency medical personnel.................................................... ........9

Rules for working with aggressive patients................................................................. ....10

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

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

Rules for transporting patients........................................................ ...............13

Blood pressure measurement, critical blood pressure figures in children.................................................... ...14

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

Rules of oxygen therapy................................................... .................................16

Protocol: breathing disorders................................................................. ...........................17

The simplest methods for restoring patency c. d.p. ...........................18

Figure: restoration of patency c. d.p......................................................... .19

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

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

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

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

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

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

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

Rules for pain relief with nitrous oxide .................................................... ...............27

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

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

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

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

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

Protocol: electrical activity without pulse.................................................... 33

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

Method of active compression-decompression in CPR....................................................35

V. d.p. upper respiratory tract

IV intravenously

IM intramuscularly

joule

VT ventricular tachycardia

IVL artificial ventilation of the lungs

kg kilogram

mmHg Art. millimeters of mercury

min. minute

ml milliliter

mg milligram

ACVA acute cerebrovascular accident

BCC volume of circulating blood

s/c subcutaneously

p.p. cross fingers

PPSHB pneumatic anti-shock trousers

solution

rice. drawing

see look

CPR cardiopulmonary resuscitation

SMP emergency medical care

PE pulmonary embolism

FOS organophosphorus compounds

RR respiratory rate

TBI traumatic brain injury

Heart rate heart rate

VF ventricular fibrillation

EABP electrical activity without pulse

MEMO FOR EMS EMPLOYEES

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

2. A clean, smart, neatly dressed, without provocative hairstyle or makeup, a dexterous EMS employee inspires the trust of patients.

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

4. Never be fussy, impatient and irritable.

5. You should always be personable and avoid familiarity. Address patients using “you” only.

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

7. Remember! Smoking in an ambulance vehicle is not permitted. Drinking alcohol on the eve of duty is unacceptable.

8. Working in an emergency medical service requires a high degree of self-discipline. Loyalty to service and accurate fulfillment of one’s duties are important.

RULES OF PERSONAL HYGIENE

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

1. Take a shower or bath daily.

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

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

4. Before each intended contact with the patient's blood or other biological fluids, put on gloves.

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

6. If there is a risk of becoming contaminated with the patient’s blood or other biological fluids, put on an apron and protect the mucous membranes of the mouth and eyes with a mask and goggles.

7. If the skin is contaminated with blood, immediately wash the affected areas with soap and water, wipe dry and treat with a swab moistened with 70% alcohol.

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

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

"GOLDEN HOUR"

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

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

3. The golden hour begins when the injury occurs, not when you begin to provide care.

4. Any actions at the scene must be life-saving in nature, since you are losing minutes of the patient’s “golden hour”.

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

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

7. Providing assistance quickly does not mean just getting there quickly, “throwing” the patient into an ambulance and also quickly delivering him to the nearest hospital.

8. You can ensure the patient’s maximum chance of survival if you provide assistance according to pre-planned tactics and sequence of actions.

GENERAL RULES FOR THE WORK OF EMS MEDICAL PERSONNEL

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

2. Medical personnel must know the streets and passages well in order to help the driver choose the shortest route.

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

4. When parking a car closer to the scene of the incident, it is necessary to take into account the possible dangers of fire, the possibility of explosions, traffic, etc.

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

6. Report the situation at the scene of the call and the need for assistance to the doctor on duty “03”.

7. If the call is delayed for more than 1 hour, report to the duty dispatcher.

RULES FOR WORKING WITH AGGRESSIVE PATIENTS

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

Anger- a common emotion that, under certain circumstances, can arise in any person.

Aggressiveness is a loss of emotional control, which can result in violence directed against:

---------------- other people;

---------------- inanimate objects;

- the patients themselves.

Aggressiveness may be caused by a number of reasons:

mental illnesses;

---------------- overdose of drugs;

alcohol or drugs;

----------------abstinence;

---------------- pain and stress.

THERE ARE NO STRICT RULES FOR PROVIDING HELP

FOR AGGRESSIVE PATIENTS,

BUT THREE YOU MUST ALWAYS REMEMBER!!!

I. Do not give in to feelings of anger.

II. Assess the situation.

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

If a patient refuses hospitalization, you have neither the right nor the authority to forcibly take him away.

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

EXAMINATION OF THE PATIENT

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

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

obstruction of patency c. d.p.;

---------------- signs of clinical death;

External bleeding.

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

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

Glasgow scale, pulse, blood pressure, respiratory rate) upon arrival, before

beginning of transportation and arriving at the hospital.

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

V). Find out the mechanism of injury. Determine the time, about -

starting from the moment of injury or the onset of the disease.

・limb splints (vacuum, inflatable, stair splints),

---------------- various types of dressings.

RULES FOR PAIN RELIEF WITH NITRIC OXIDE

1. Nitrous oxide is a gas found in cylinders in a liquid state. At ambient temperatures below 0°C, inhalation of nitrous oxide is impossible.

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

3. To prevent agitation and worsening hypoxia in seriously ill and injured patients do not inhale a mixture containing more than 50% nitrous oxide. The ratio of nitrous oxide and oxygen should be 1:1.

4. Before turning on the nitrous oxide, inhale oxygen to the patient and administer 2 g (50% - 4 ml) of analgin and mgml) diazepam intravenously.

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

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

CLINICAL DEATH

To establish the fact of clinical death, it is enough

Research Institute of Ambulance named after. prof. I.I. DZHANELIDZE

CITY SMP STATION

Mikhailov Yu.M., Nalitov V.N.

ACTION PROTOCOLS FOR PHYSICAL SERVES

EMERGENCY MEDICAL CLIPS

St. Petersburg 2002 Web - version

BBK 54.10 M69

UDC 614.88 + 614.25 (083.76)

Nalitov V.N. chief physician of the city emergency medical service station in 1996-2000.

Editors: prof. B. G. Apanasenko, prof. V. I. Kovalchuk.

Reviewers: A. E. Borisov, MD, Prof., Chief Surgeon of the Health Committee of the Administration of the Governor of St. Petersburg. N. B. Perepech, Doctor of Medical Sciences, Head of Scientific and Clinical

Department of Emergency Cardiology, Research Institute of Cardiology, Ministry of Health of the Russian Federation.

The book discusses the main issues of providing emergency care for conditions that are most often encountered by EMS paramedics, as well as the rules of behavior and action in various situations. A unified style, strict structuring and algorithmization, logic, accuracy and clarity of presentation will help overcome difficulties in memorizing material. Action protocols provide clear guidelines for providing care at the prehospital stage and will help improve the skills of paramedics.

For paramedics at EMS stations.

Computer layout and preparation of the original layout Mikhailov Yu. M.


List of abbreviations................................................... ...........................................
Memo to EMS employee................................................................... ...................................
Rules of personal hygiene........................................................ ......................................
“Golden hour” .................................................... ........................................................ ......
General rules for the work of emergency medical personnel.................................................... ........
Rules for working with aggressive patients................................................................. ....
Examination of the patient........................................................ ....................................
Glasgow scale, shock index (Algover) .................................................... ........
Rules for transporting patients........................................................ ...............
Blood pressure measurement, critical blood pressure figures in children.................................................... ...
Pneumatic anti-shock trousers (PPShB)............................................
Rules of oxygen therapy................................................... ...................................
Protocol: breathing disorders................................................................. ...........................
The simplest methods for restoring the patency of the airway. ...........................
Figure: restoration of patency of the v.d.p.................................................. .......
Figure: insertion of the oropharyngeal airway....................................................
Intubation................................................. ........................................................ ........
Conicotomy........................................................ ........................................................ ...
Figure: conicotomy................................................... ........................................
Foreign bodies i.d.p.................................................... ........................................................
Figure: Heimlich maneuver ............................................... ...................
Protocol: transport immobilization.................................................... ..........
Rules for pain relief with nitrous oxide.................................................... ..............
Clinical death........................................................ ...........................................
Protocol: Basic Cardiopulmonary Resuscitation....................................................
Protocol: ventricular fibrillation.................................................... .............
Rules for defibrillation................................................................... ................
Figure: place of application of electrodes during defibrillation.....
Protocol: electrical activity without pulse....................................................
Protocol: asystole................................................... ...........................................
Method of active compression-decompression in CPR....................................................
CPR in pediatrics................................................................... ...................................................
Pediatric CPR chart. ........................................................ ...............................
Rules for stopping and refusing to perform CPR....................................................
Protocol: declaration of biological death.................................................... ..
Shock................................................. ........................................................ ...............
Protocol: hypovolemic shock.................................................... ....................
Plasma replacement solutions................................................................... ...........................
Protocol: anaphylactic shock. ........................................................ ................
Protocol: infectious-toxic shock for meningococcemia...................
Protocol: cardiogenic shock.................................................... ............................
Protocol: acute myocardial infarction.................................................... .............

Protocol: heart pain
Figure: basic CPR algorithm.................................................... ....................
Protocol: rhythm disturbance (bradycardia) .................................................... .........
Protocol: rhythm disturbances (tachycardia) .................................................... ..........
Protocol: cardiac asthma, pulmonary edema.................................................... ...............
Protocol: attack of bronchial asthma.................................................... ............
Protocol: hypertensive crisis.................................................... .......................
Protocol: seizure. ........................................................ .............
Protocol: ONMK................................................... ...................................................
Protocol: comas................................................... ........................................................ .
Protocol: preeclampsia, eclampsia.................................................... ...............
Protocol: childbirth................................................... ........................................................ .
Protocol: newborn................................................... ................................
Drawing: newborn................................................... ...................................
Apgar score................................................... ........................................................ ....
Protocol: fever in children.................................................. ...............................
Protocol: chest injury.................................................... .......................
Protocol: cardiac tamponade.................................................... ...............................
Protocol: tension pneumothorax. ........................................................ ........
Figure: pleural puncture for tension pneumothorax...................
Protocol: abdominal trauma............................................................ ...............
Protocol: TBI................................................... ........................................................ .
Protocol: spinal injury.................................................... ........................
Protocol: limb injury.................................................... ...........................
Protocol: avulsions of limb segments subject to replantation........
Protocol: long-term crush syndrome....................................................
Protocol: eye injury.................................................... ....................................
Protocol: burns. ........................................................ ...........................................
Figure: rule of nines for determining the area of burns.................................
Protocol: chemical burns.................................................... ............................
Protocol: frostbite................................................................... ....................................
Protocol: general hypothermia (hypothermia) ............................................... .
Protocol: electric shock.................................................................... ...............
Protocol: drowning...................................................... ...........................................
Protocol: strangulation asphyxia. ........................................................ ........
Protocol: poisoning................................................... .........................................
Rules for gastric lavage................................................................... ...........................
Working in an outbreak with a large number of victims. ...................................
Rules for the work of EMS personnel during civil unrest.................................
Working in a hotbed of particularly dangerous infection.................................................................... ..............
Damage from ionizing radiation................................................................... ..........
Medicines........................................................ .......................	89, 90, 91, 92, 93, 94
Bibliography................................................ ............................................

g gram

l liter

	millimeters of mercury

	milliliter
	milligram
	acute cerebrovascular accident
	circulating blood volume
	subcutaneously
	cross fingers
	pneumatic anti-shock pants



	cardiopulmonary resuscitation
	emergency
	pulmonary embolism
	organophosphorus compounds
	breathing rate
	traumatic brain injury
	heart rate
	ventricular fibrillation
	electrical activity without pulse

MEMO FOR EMS EMPLOYEES

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

2. A clean, smart, neatly dressed, without provocative hairstyle or makeup, a dexterous EMS employee inspires the trust of patients.

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

4. Never be fussy, impatient or irritable.

5. You should always be personable and avoid over-familiarity. Address patients using “you” only.

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

7. Remember! Smoking in an ambulance vehicle is not permitted. Drinking alcohol on the eve of duty is unacceptable.

8. Working in an emergency medical service requires a high degree of self-discipline. Loyalty to service and accurate fulfillment of one’s duties are important.

RULES OF PERSONAL HYGIENE

Emergency medical services teams provide care in a variety of settings to patients suffering from a variety of diseases. In the interests of your patients, your own health and the health of your families, you must follow the rules listed below:

1. Take a shower or bath daily.

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

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

4. Before each intended contact with the patient's blood or other body fluids, put on gloves.

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

6. If there is a risk of becoming contaminated with the patient’s blood or other biological fluids, wear an apron and protect the mucous membranes of the mouth and eyes with a mask and goggles.

7. If the skin is contaminated with blood, immediately wash the affected areas with soap and water, wipe dry and treat with a swab moistened with 70% alcohol.

8. If you are injured by an injection needle or glass, let the blood drain from the wound, rinse with running water, disinfect the skin around the wound with 70% alcohol, treat the edges of the wound with iodine, and apply a bandage.

9. If blood gets on the mucous membrane of the eyes or nose, you must immediately rinse them with water, and then 30% sodium sulfacyl solution.

10. If blood gets into the oral cavity, rinse the mouth with 70% alcohol.

11. Store blood-stained materials in a separate plastic bag. Used gloves are treated with a 6% hydrogen peroxide solution.

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

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

"GOLDEN HOUR"

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

2. If the victim is taken to the operating room within the first hour after injury, the highest survival rate is achieved. This time is called the "golden hour".

3. The “golden hour” begins from the moment of injury,

A not from the moment you begin to provide assistance.

4. Any actions at the scene must be life-saving in nature, since you are losing minutes of the patient’s “golden hour.”

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

6. The time it takes you to arrive is just as important as the time you waste due to inconsistency of your actions at the scene of the incident. You must learn to save every minute of the care process.

7. Providing quick assistance does not mean just getting there quickly, “throwing” the patient into an ambulance and also quickly delivering him to the nearest hospital.

8. You can ensure the patient's maximum chance of survival if you provide assistance according to pre-planned tactics and sequence of actions.

GENERAL RULES FOR THE WORK OF EMS MEDICAL PERSONNEL

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

2. Medical personnel must know the streets and passages well in order to help the driver choose the shortest route.

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

4. When parking a car closer to the scene of the incident, it is necessary to take into account the possible dangers of fire, the possibility of explosions, traffic, etc.

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

6. Report the situation at the scene of the call and the need for assistance to the doctor on duty “03”.

7. If the call is delayed for more than 1 hour, report to the duty dispatcher.

RULES FOR WORKING WITH AGGRESSIVE PATIENTS

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

Anger is a common emotion that can arise in any person under certain circumstances. Aggression is a loss of emotional control, which can result in violence directed against:

other people; inanimate objects; the patients themselves.

Aggression can be caused by a number of reasons: mental illness; drug overdose; alcohol or drugs; withdrawal symptoms; pain and stress.

THERE ARE NO STRONG RULES FOR PROVIDING HELP TO AGGRESSIVE PATIENTS,

BUT THREE YOU MUST ALWAYS REMEMBER!!!

I. Don't give in to feelings of anger.

II. Assess the situation.

III. Always remain polite.

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

If a patient refuses hospitalization, you have neither the right nor the authority to forcibly take him away.

You should not try to deal with an aggressive patient. Inform the dispatcher. If necessary, they will send you

V help the police or a psychiatric team.

10 -

Description of the presentation CLINICAL GUIDELINES (PROTOCOLS) FOR PROVIDING EMERGENCY MEDICAL CARE on slides

Classes of Recommendations Class I - The recommended diagnostic or treatment method is clearly useful and effective Class IIa - Available evidence strongly suggests the usefulness and effectiveness of the diagnostic or treatment method Class II b - There is limited evidence of the applicability of the diagnostic or treatment method Class III - Available evidence suggests inapplicability (futility or harm) of the proposed method Levels of evidence A - Data are based on several randomized clinical trials B - Data are based on the results of one randomized trial or several non-randomized studies C - Data are based on expert agreement, individual clinical observations, and standards of care.

CLINICAL GUIDELINES (PROTOCOLS) FOR PROVIDING EMERGENCY MEDICAL CARE FOR BRADYCARDIA PROVIDING EMERGENCY MEDICAL CARE AT THE PREHOSPITAL STAGE FOR SINUS BRADYCARDIA Examination and physical examination. Assessment of the patient's general condition. History to determine the possible cause of bradycardia. Registration of pulse, blood pressure, ECG. In the absence of life-threatening symptoms and ischemic changes on the ECG, evacuation to the hospital for examination and treatment. If you refuse delivery to the hospital, give recommendations for further monitoring of the patient. . Classification (ICD) Sinus bradycardia. Sinoatrial blockades. Artioventricular blockades. Stopping the sinus node. In the presence of life-threatening symptoms, it is necessary to: Ensure airway patency, oxygen inhalation (at Spo. O 2 -95%), intravenous access. Start IV fluid transfusion (saline sodium chloride solution). Inject a solution of atropine 0.1% - 0.5 ml intravenously. (or at a calculated dose of 0.004 mg/kg) Carry out emergency delivery of the patient to the hospital (to the hospital ICU). ICD-10 code Nosological form I 44 Atrioventricular [atrioventricular] block and left bundle branch block [His] I 45. 9 Conduction disorder, unspecified

CLINICAL GUIDELINES (PROTOCOLS) FOR PROVIDING EMERGENCY MEDICAL CARE FOR CA blockades Examination, physical examination of the patient. Assessment of general condition, presence of life-threatening symptoms. History of the patient, try to determine the most likely cause of bradycardia. Registration of blood pressure, pulse, ECG. Ensure airway patency, oxygen inhalation, intravenous access. IV or IM administration of atropine sulfate 0.1% - 0.5 ml. ECG monitoring. Emergency delivery of the patient to the hospital. In the presence of life-threatening symptoms (MES): Examination, physical examination of the patient. Assessment of general condition, presence of life-threatening symptoms. History of the patient, try to determine the most likely cause of bradycardia. Registration of blood pressure, pulse, Spo. O 2 ECG. Start fluid infusion (physiological solution of sodium chloride), intravenous administration of atropine sulfate 0.1% - 0.5 ml until the degree of blockade decreases, monitor ECG and cardiac activity. If myocardial infarction is suspected, follow the emergency medical care protocol for this disease. Emergency delivery of the patient to the hospital in the intensive care unit of the hospital.

CLINICAL GUIDELINES (PROTOCOLS) FOR PROVIDING EMERGENCY MEDICAL CARE FOR AV blockages Examination, physical examination of the patient. Assessment of general condition, presence of life-threatening symptoms. History of the patient, try to determine the most likely cause of bradycardia. Registration of blood pressure, pulse, ECG. Ensure airway patency, oxygen inhalation, intravenous access. IV or IM administration of atropine sulfate 0.1% - 0.5 ml. ECG monitoring. Emergency delivery of the patient to the hospital. In the presence of life-threatening symptoms: Examination, physical examination of the patient. Assessment of general condition, presence of life-threatening symptoms. History of the patient, try to determine the most likely cause of bradycardia. Registration of blood pressure, pulse, Spo. O 2 ECG. Start fluid infusion (physiological solution of sodium chloride), intravenous administration of atropine sulfate 0.1% - 0.5 ml, again 1.0 ml. ECG and cardiac monitoring. If myocardial infarction is suspected, follow the emergency medical care protocol for this disease. Atropine administration is ineffective for distal AV blocks. If atropine is ineffective, the patient is indicated for emergency ECS.

CLINICAL GUIDELINES (PROTOCOLS) FOR PROVIDING EMERGENCY MEDICAL CARE FOR AV blockages Examination, physical examination of the patient. Assessment of general condition, presence of life-threatening symptoms. History of the patient, try to determine the most likely cause of bradycardia. Registration of blood pressure, pulse, ECG. Ensure airway patency, oxygen inhalation, intravenous access. IV or IM administration of atropine sulfate 0.1% - 0.5 ml. ECG monitoring. Emergency delivery of the patient to the hospital. OB general field ambulance teams - external or transesophageal pacemaker. Specialized mobile emergency medical teams - transvenous pacemaker. If it is impossible to use a pacemaker, use drugs that increase heart rate by acting on the B receptors of the heart. Adrenaline 1 ml of 0.1% solution, dopamine at an estimated dose of 5-6 mcg*kg/min, IV drip in 500 ml of physiological solution. If IV is ineffective, administer aminophylline solution 2.4% - 10 ml. MES attack. Determine circulatory arrest (indicate the time), ensure airway patency, record the electrical activity of the heart (ECG monitoring). Start basic CPR and provide IV access. Inject intravenously a solution of adrenaline 0.1% - 1.0 ml, for asystole. For bradysystole, atropine sulfate 0.1% -1.0 ml; if ineffective, administer aminophylline solution 2.4% - 10 ml intravenously. If cardiac activity is restored, an emergency pacemaker is required. All patients are advised to undergo emergency delivery to the hospital bypassing St. OSMP

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

CLINICAL GUIDELINES (PROTOCOLS) FOR PROVIDING EMERGENCY MEDICAL CARE IN ACUTE NON-ST SEGMENT Elevation CORONARY SYNDROME Physical data Examination and physical examination. Assessment of the patient's general condition. There is often no change. There may be symptoms of heart failure or hemodynamic disturbances. Electrocardiography: An ECG must be taken no later than 10 minutes after the first contact with the patient. Comparison of the ECG with previously taken electrocardiograms is invaluable. Identification of any dynamics related to the ST segment and T waves in the presence of clinical signs of myocardial ischemia should be sufficient grounds to interpret the situation as a manifestation of ACS and urgently hospitalize the patient. Differential diagnosis to exclude the non-coronarogenic nature of the pain syndrome. Biomarkers: You should not rely on the results of rapid troponin assessment when deciding on management tactics in patients with typical clinical manifestations and changes. ECG. Treatment Oxygen therapy at a rate of 4-8 l/min when oxygen saturation is less than 90% Oral or intravenous nitrates (intravenous nitrate treatment is recommended in patients with recurrent angina and/or signs of heart failure. Nitroglycerin 0.5-1 mg tablets or Nitrospray ( 0.4 -0.8 mg) 2 doses sublingually Nitroglycerin intravenously 10 ml of 0.1% solution diluted in 100 ml of 0.9% sodium chloride solution (constant monitoring of heart rate and blood pressure is required, be careful when reducing systolic blood pressure<90 мм рт. ст.) При некупирующемся болевом синдроме Морфин 3 -5 (до 10) мг внутривенно с титрацией дозы, что особенно важно для пожилых, для чего препарат разводят на 10 мл физиологического раствора и повторно вводят по 2 -3 мл под контролем АД и ЧД. Аспирин 150 -300 мг без кишечно-растворимой оболочки — Клопидогрель 300 мг. 75 лет- 75 мг. Код по МКБ X Нозологические формы I 20. 0 Нестабильная стенокардия I 21. 4 Острый субэндокардиальный инфаркт миокарда I 21. 9 Острый инфаркт миокарда неуточненный

CLINICAL GUIDELINES (PROTOCOLS) FOR PROVIDING EMERGENCY MEDICAL CARE IN ACUTE CORONARY SYNDROME WITHOUT ST SEGMENT Elevation (continued) tactics involving PCI within the next 2 hours after the first contact with a medical professional: Refractory Urgent hospitalization in a specialized hospital where invasive intervention is possible . Already in the prehospital phase, patients at very high risk who require urgent invasive angina (including myocardial infarction) should be identified Recurrent angina associated with ST segment depression > 2 mm or deep negative T wave, despite intensive treatment Clinical symptoms of heart failure or hemodynamic instability (shock) Life-threatening arrhythmias (ventricular fibrillation or ventricular tachycardia Patients with BP ACS should be immediately sent to the ICU, bypassing Art. OSMP When presenting the material, the classes of recommendations and levels of evidence proposed by the ACC/AHA and used in the Russian recommendations are used. Unfractionated heparin ( UFH) intravenously 60 -70 IU/kg as a bolus (maximum 4000 IU), followed by an infusion of 12 -15 IU/kg/h (maximum 1000 IU/h). Beta-blockers. In the presence of tachycardia or hypertension without signs of cardiac insufficiency Metoprolol - in case of severe tachycardia, preferably intravenously - 5 mg every 5 minutes for 3 injections, then after 15 minutes 25-50 mg under the control of blood pressure and heart rate. Tablet drugs can be prescribed - metoprolol 50 - 100 mg, in the absence of Metoprolol, use Bisoprolol 5 -10 mg.

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

Clinical recommendations (protocols) for the provision of ambulance in acute coronary syndrome with the rise of the ST segment (continuation) Absolute contraindications to thrombolytic therapy: hemorrhagic stroke or stroke of unknown origin ischemic stroke in the previous 6 months of trauma or brain tumor, arterio-venous malformation Major trauma/surgery/cranial trauma within the previous 3 weeks Gastrointestinal bleeding within the previous month Established bleeding disorders (excluding menses) Aortic dissection Non-compressible puncture (including liver biopsy, lumbar puncture) in the previous 24 hours Relative contraindications: Transient ischemic attack within the previous 6 months Oral anticoagulant therapy Pregnancy or postpartum status within 1 week Resistant hypertension (systolic blood pressure >180 mmHg and/or diastolic blood pressure >110 mmHg) Severe liver disease Infectious endocarditis Exacerbation of peptic ulcer Prolonged or traumatic resuscitation Drugs for thrombolysis: Alteplase (tissue plasminogen activator) 15 mg IV as a bolus of 0.75 mg/kg over 30 minutes, then 0.5 mg/kg over 60 min i.v. The total dose should not exceed 100 mg Tenecteplase - once intravenously as a bolus depending on body weight: 30 mg -<60 кг 35 мг — 60 -<70 кг 40 мг — 70 -<80 кг 45 мг — 80 -<90 кг 50 мг — ≥ 90 кг. Выбор лечебной тактики Как только диагноз ОКСп. ST установлен, требуется срочно определить тактику реперфузионной терапии, т. е. восстановления проходимости окклюзированной левой ножки пучка Гиса При отсутствии противопоказаний и невозможности выполнения ЧКВ в рекомендуемые сроки выполняется тромболизис (I, А), предпочтительно на догоспитальном этапе. Тромболитическая терапия проводится, если ЧКВ невозможно выполнить в течение 120 минут от момента первого контакта с медработником (I, А). Если с момента появления симптомов прошло менее 2 часов, а ЧКВ не может быть выполнено в течение 90 минут, при большом инфаркте и низком риске кровотечения должна быть проведена тромболитическая терапия (I, А). После тромболитической терапии больной направляется в центр с возможностью выполнения ЧКВ (I, А).

CLINICAL GUIDELINES (PROTOCOLS) FOR PROVIDING EMERGENCY MEDICAL CARE IN ACUTE CORONARY SYNDROME WITH ST SEGMENT ELEVATION (continued) Other drug therapy Opioids intravenously (morphine 4 -10 mg), in elderly patients, must be diluted in 10 ml of saline and administered in 2 - 3 ml. If necessary, additional doses of 2 mg are administered at intervals of 5-15 minutes until pain is completely relieved). Side effects may develop: nausea and vomiting, arterial hypotension with bradycardia and respiratory depression. Antiemetics (eg, metoclopramide 5-10 mg intravenously) can be administered concomitantly with opioids. Hypotension and bradycardia are usually treated with atropine at a dose of 0.5-1 mg (total dose up to 2 mg) intravenously; Tranquilizer (Diazepam 2.5 -10 mg IV) in case of severe anxiety Beta blockers in the absence of contraindications (bradycardia, hypotension, heart failure, etc.): Metoprolol - for severe tachycardia, preferably intravenously - 5 mg every 5 minutes 3 injections, then after 15 minutes 25-50 mg under the control of blood pressure and heart rate. In the future, tablet drugs are usually prescribed. Nitrates for pain sublingually: Nitroglycerin 0.5-1 mg in tablets or Nitrospray (0.4-0.8 mg). For recurrent angina and heart failure, Nitroglycerin is administered intravenously under blood pressure control: 10 ml of a 0.1% solution is diluted in 100 ml of saline. Constant monitoring of heart rate and blood pressure is necessary, do not administer if systolic blood pressure decreases<90 мм рт. ст. Ингаляции кислорода (2 -4 л/мин) при наличии одышки и других признаков сердечной недостаточности Пациенты с ОКС с п. ST должны сразу направляться в ОРИТ, минуя Ст. ОСМП. Всем больным с ОКС при отсутствии противопоказаний показана двойная дезагрегантная терапия (I, A): Если планируется первичное ЧКВ: Аспирин внутрь 150 -300 мг или в/в 80 -150 мг, если прием внутрь невозможен Клопидогрель внутрь 600 мг (I, C). (Если есть возможность, предпочтительнее Прасугрель у не принимавших Клопидогрель пациентов моложе 75 лет в дозе 60 мг (I, B) или Тикагрелор в дозе 180 мг (I, B)). Если планируется тромболизис: Аспирин внутрь 150 -500 мг или в/в 250 мг, если прием внутрь невозможен Клопидогрель внутрь в нагрузочной дозе 300 мг, если возраст ≤ 75 лет Если не планируется ни тромболизис, ни ЧКВ: Аспирин внутрь 150 -500 мг Клопидогрель внутрь

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

CLINICAL GUIDELINES (PROTOCOLS) FOR PROVIDING EMERGENCY MEDICAL CARE IN ACUTE HEART FAILURE (CONTINUED) Body weight (BW) An increase in BW precedes hospitalization, however, a decrease in BW in response to therapy does not correspond with a decrease in the frequency of hospitalization or mortality The nature and frequency of the heart rate How Brady- and tachyarrhythmia can contribute to the development of BP stagnation. No change or increase in BP during the transition from a supine to a standing position or during a Valsalva maneuver usually reflects a relatively high LV filling pressure. Jugular venous pressure is increased, there is distension of the jugular veins. Equivalent to pressure in the PP. Wheezing As a rule, fine-bubbling, symmetrical on both sides, unless the patient lies predominantly on one side, does not disappear with coughing, is more pronounced in the basal parts of the lungs, is associated with increased wedge pressure in the pulmonary capillaries when combined with other signs of increased filling pressure ( jugular venous pressure), but are not specific in themselves Orthopnea Patients are often unable to remain in a supine position when filling pressures rapidly increase. Edema Peripheral edema, if combined only with an increase in jugular pressure, indicates the presence of right ventricular failure, which is usually accompanied by left ventricular failure. The severity of edema can vary - from a “trace” in the area of the ankles or legs (+) to edema spreading to the hips and sacrum (+++). BNP/NT-pro. BNP (there are express tests) An increase of more than 100/400 pg/ml is a marker of increased filling pressure 2. At a oxygen saturation level of 90% (C, 1+). 3. In case of severe shortness of breath, psycho-emotional agitation, anxiety, and a feeling of fear in the patient, intravenous opiates (morphine 4-8 mg). (Be aware of possible respiratory depression, especially in elderly patients!). Metoclopramide 10 mg IV can be added to prevent nausea and vomiting. With SBP >110 mm Hg. st: Vasodilators (nitroglycerin) - start infusion at a rate of 10 mcg per minute. , depending on effect and tolerance, double speed every 10 minutes. Hypotension usually limits acceleration of infusion. Doses >100 mcg per minute are rarely achieved. If there is a positive response to therapy (decrease in shortness of breath and heart rate, the number of wheezes in the lungs, pallor and moisture of the skin, adequate diuresis > 100 ml per hour in the first 2 hours, improvement in Sat. O 2), continue nitroglycerin infusion and oxygen therapy and transport the patient to hospital in a lying position on a stretcher with the head of the bed raised, with monitoring of blood pressure and heart rate continuing during transportation.

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

CLINICAL GUIDELINES (PROTOCOLS) FOR PROVIDING EMERGENCY MEDICAL CARE FOR TACHYCARDIAS AND TACHYARHYTHMIAS Diagnostic examination - collect anamnesis, - examine the patient, - measure pulse and blood pressure, - take an ECG to identify the possible cause of sinus tachycardia Treatment and further tactics of patient management As a rule, in There is no need for a direct drug effect on sinus tachycardia. If you abuse coffee, tea, or smoking, recommend eliminating the harmful factor; if necessary, use Valocardine, Corvalol or sedatives (possibly in tablets: phenozepam 0.01 dissolve in the mouth) (C, 2++). In the absence of hemodynamic disorders, hospitalization is not required. The issue of hospitalization and patient management tactics is decided on the basis of the algorithm of the disease that is accompanied by sinus tachycardia. If hemodynamics are unstable, the patient is taken to the hospital and admitted to the intensive care unit. Remember that tachycardia can be the first, and up to a certain point, the only sign of shock, blood loss, acute myocardial ischemia, pulmonary embolism and some other conditions dangerous to the patient. Classification 1. Sinus tachycardia. 2. Supraventricular tachycardia: 2. 1 Paroxysmal supraventricular tachycardia; 2. 2 Non-paroxysmal supraventricular tachycardia. 3. Atrial fibrillation or flutter. 4. Ventricular tachycardia. ICD code -10 Nosological form I 47. 1 Supraventricular tachycardia I 47. 2 Ventricular tachycardia I 48 Atrial fibrillation and flutter

CLINICAL GUIDELINES (PROTOCOLS) FOR PROVIDING EMERGENCY MEDICAL CARE FOR TACHYCARDIAS AND TACHYARHYTHMIAS (CONTINUED) Recommended administration regimen 1. Sodium adenosine triphosphate (ATP) 5 -10 mg IV in a push. 2. No effect - after 2 minutes ATP 10 mg IV in a push. 3. No effect - after 2 minutes verapamil 5 mg IV, slowly 4. No effect - after 15 minutes verapamil 5 -10 mg IV, slowly 5. Repeat vagal techniques. 6. No effect - after 20 minutes, novocainamide, or propranolol, or propafenone, or disopyramide - as indicated above; in many cases, hypotension is aggravated and the likelihood of bradycardia after restoration of sinus rhythm increases. An alternative to repeated use of the above drugs can be the administration of: Amiodarone (Cordarone) at a dose of 300 mg per 200 ml of saline, drip, taking into account the effect on conductivity and QT duration (A, 1++). A special indication for the administration of amiodarone is paroxysm of tachycardia in patients with ventricular pre-excitation syndromes. Procainamide (Novocainamide) is administered intravenously in a dose of 1000 mg (10.0 ml of 10% solution, the dose can be increased to 17 mg/kg) at a rate of 50 - 100 mg/min under blood pressure control (with a tendency to arterial hypotension - together with 0.3-0.5 ml of 1% phenylephrine solution (Mezaton) or 0.1-0.2 ml of 0.2% norepinephrine solution (Norepinephrine)), (A, 1++). Propranolol is administered intravenously in a dose of 5-10 mg (5-10 ml of 0.1% solution) per 200 ml of saline under the control of blood pressure and heart rate; in case of initial hypotension, its administration is undesirable even in combination with mezatone. (A, 1+). Propafenone is administered intravenously in a bolus at a dose of 1 mg/kg over 3-6 minutes. (C, 2+). Disopyramide (Ritmilen) - at a dose of 15.0 ml of 1% solution in 10 ml of saline (if novocainamide was previously administered) (C, 2+). If there is no effect, the drugs can be re-administered in the ambulance. An alternative to repeated use of the above drugs can be the administration of: Amiodarone (Cordarone) at a dose of 300 mg per 200 ml of saline, drip, taking into account the effect on conductivity and QT duration (B, 2++). A special indication for the administration of amiodarone is paroxysm of tachycardia in patients with ventricular preexcitation syndromes

CLINICAL GUIDELINES (PROTOCOLS) FOR PROVIDING EMERGENCY MEDICAL CARE FOR TACHYCARDIAS AND TACHYARHYTHMIAS (CONTINUED) Examination and physical examination. Assessment of the patient's general condition. History to determine possible cause. Registration of pulse, blood pressure, ECG. In the absence of life-threatening symptoms and ischemic changes on the ECG, evacuation to the hospital for examination and treatment. Paroxysmal supraventricular tachycardia with wide QRS complexes The tactics are somewhat different, since the ventricular nature of tachycardia cannot be completely excluded, and the possible presence of pre-excitation syndrome imposes certain restrictions. Electrical pulse therapy (EPT) is indicated for hemodynamically significant tachycardias (A, 1++). Treatment and further tactics of patient management Verapamil is administered intravenously in a dose of 5-10 mg (2.0-4.0 ml of 2.5% solution) per 200 ml of saline under the control of blood pressure and rhythm frequency. (A, 1++). Procainamide (Novocainamide) is administered intravenously at a dose of 1000 mg (10.0 ml of 10% solution, the dose can be increased to 17 mg/kg) per 200 ml of physiological solution at a rate of 50 -100 mg/min under blood pressure control (with tendencies to arterial hypotension - together with 0.3 -0.5 ml of 1% phenylephrine solution (Mezaton) or 0.1 -0.2 ml of 0.2% norepinephrine solution (Norepinephrine) (A, 1++ Amiodarone (Cordarone) at a dose of 300 mg per 200 ml of saline, dropwise, take into account the effect on conductivity and QT duration, which may interfere with the administration of other antiarrhythmics. (B, 2+) If intravenous administration of drugs is not possible, tablet therapy is possible: Propranolol ( Anaprilin, Obzidan) 20 -80 mg (A, 1++) Can be another blocker in a moderate dose (at the discretion of the doctor) Verapamil (Isoptin) 80 -120 mg (in the absence of pre-excitation!) in combination with phenazepam (Phenazepam) 1 mg or clonazepam 1 mg (A, 1+).Or one of the previously effective antiarrhythmics in double form: Kinidin-durules 0.2 g, procainamide (Novocainamide) 1.0 -1. 5 g, disopyramide (Ritmilen) 0.3 g, etacizin (Etacizin) 0.1 g, propafenone (Propanorm) 0.3 g, sotalol (Sotahexal) 80 mg). (B, 2+). Urgent delivery to hospital and hospitalization in the intensive care unit or intensive care unit

CLINICAL GUIDELINES (PROTOCOLS) FOR PROVIDING EMERGENCY MEDICAL CARE FOR TACHYCARDIAS AND TACHYARHYTHMIAS (CONTINUED) Diagnostic examination - collect anamnesis, - examine the patient, - measure the pulse and blood pressure, - take an ECG Paroxysms of atrial fibrillation, atrial flutter are taken to the hospital and hospitalized in a specialized ny hospital departments. (if EIT has not been performed and there is no severe underlying illness (ICU) IN FIBRILLATION (FIBRILLATION) AND ATRIAL FLUTTER Indications for restoration of sinus rhythm at the prehospital stage: - Duration of atrial fibrillation 48 hours in combination with hemodynamic disturbances, myocardial ischemia and heart rate > 250 per 1 min Also in favor of restoring the rhythm are the following circumstances: - Symptoms of CHF or weakness increase in the absence of sinus rhythm - Hypertrophy or severe dysfunction of the LV - LA size less than 50 mm - Duration of atrial fibrillation less than 1 year - Young age of the patient - Presence of a paroxysmal form of arrhythmia - Contraindications for long-term anticoagulant therapy: In case of unstable hemodynamics, loss of consciousness - electrical impulse therapy (EIT, cardioversion).

CLINICAL GUIDELINES (PROTOCOLS) FOR PROVIDING EMERGENCY MEDICAL CARE FOR TACHYCARDIAS AND TACHYARHYTHMIAS (CONTINUED Treatment with drugs: When stopping paroxysm for up to 1 day, heparin can not be administered. Administration of amiodarone (Cordarone) at a dose of 300 mg intravenously in 200 ml of physiological solution (A, 1+ +) Verapamil is administered intravenously in a dose of 5-10 mg (2.0-4.0 ml of 2.5% solution per 200 ml of saline) under the control of blood pressure and rhythm frequency (A, 1++).Propranolol is administered IV drip at a dose of 5-10 mg (5-10 ml of 0.1% solution) per 200 ml of physiological solution under the control of blood pressure and heart rate (A, 1+).Procainamide (Novocainamide) is administered IV drip at a dose of 1000 mg (10.0 ml of 10% solution, the dose can be increased to 17 mg/kg) at a rate of 50 -100 mg/min under blood pressure control (with a tendency to arterial hypotension - together with 0.3 -0.5 ml of 1% solution of phenylephrine (Mezaton) or 0.1 -0.2 ml of 0.2% solution of norepinephrine (Noradrenaline) (B, 1+). Digoxin, strophanthin: 1 ml of drug solution per 10 ml of physiological solution, intravenously jet (D, 2+). Potassium preparations: 10 ml of panangin solution - intravenously by stream or 10 ml of 10% solution of potassium chloride per 200 ml of physiological solution by intravenous drip (A, 1+). Disopyramide (Ritmilen) - in a dose of 15.0 ml of 1% solution in 10 ml of saline. solution (if novocainamide was previously administered) (B, 2+). Tablet therapy Propranolol (Anaprilin, Obzidan) 20 -80 mg (A, 1++). You can use another B-blocker in a moderate dose (at the doctor's discretion). Verapamil (Isoptin) 80-120 mg (in the absence of pre-excitation!) in combination with phenazepam (Phenazepam) 1 mg or clonazepam 1 mg (B, 2+). Or one of the previously effective antiarrhythmics in a double dose of quinidine (Kinidin-durules) 0.2 g, procainamide (Novocainamide) 1.0 -1. 5 g, disopyramide (Ritmilen) 0.3 g, etacizin (Etacizin) 0.1 g, propafenone (Propanorm) 0.3 g, sotalol (Sotahexal) 80 mg) (B, 1+).

CLINICAL GUIDELINES (PROTOCOLS) FOR PROVIDING EMERGENCY MEDICAL CARE FOR TACHYCARDIAS AND TACHYARHYTHMIAS (CONTINUED) Diagnostic examination - collect anamnesis, - examine the patient, - measure pulse and blood pressure, - take an ECG PAROXYSMAL VENTRICULAR TACHYCARDIA If the condition unstable, then immediately resort to electrical cardioversion. Emergency electrical cardioversion is performed with a discharge of 100 J. In case of pulseless ventricular tachycardia, they begin with defibrillation with a non-synchronized discharge of 200 J. If the patient is conscious, but his condition is severe, synchronized cardioversion is used. Amiodarone 5 mg/kg IV over 10–30 minutes (15 mg/min) or IV 150 mg over 10 minutes, followed by infusion of 360 mg over 6 hours (1 mg/min) and 540 mg over 18 hours (0 , 5 mg/min) in saline; the maximum total dose is 2 g per 24 hours (you can add 150 mg per 10 minutes as needed) (B, 1+). Correction of electrolyte disturbances is carried out (potassium preparations: 10 ml of panangin solution - intravenously in a stream or 10 ml of a 10% solution of potassium chloride intravenously per 200 ml of physiological solution, drip) (A, 1++).

CLINICAL GUIDELINES (PROTOCOL) FOR PROVIDING AMBULANCE MEDICAL CARE IN SUDDEN CARDIAC DEATH Clinical guidelines for providing emergency medical care in case of sudden cardiac death. In case of ventricular fibrillation and the possibility of defibrillation in the first 3 minutes of clinical death, begin with the application of an electrical discharge. 2. Start deep (5 cm), frequent (at least 100 per 1 min), continuous chest compressions with a ratio of the duration of compression and decompression of 1: 1. 3. The main method of mechanical ventilation is mask (the ratio of compressions and breathing in adults is 30: 2), ensure airway patency (throw back the head, push the lower jaw forward, insert the air duct). 4. As early as possible - defibrillation (with a monophasic pulse form, all discharges with an energy of 360 J, with a biphasic pulse form, the first discharge with an energy of 120–200 J, subsequent ones - 200 J) - 2 minutes of chest compressions and mechanical ventilation - assessment of the result; Definition. Sudden cardiac death (SCD) is an unexpected death from cardiac causes that occurs within 1 hour of the onset of symptoms in a patient with or without known cardiac disease. Key points in differential diagnosis. According to ECG data, during CPR the following is diagnosed: – ventricular fibrillation; – electrical activity of the heart without a pulse; – asystole

CLINICAL GUIDELINES (PROTOCOL) FOR PROVIDING AMBULANCE MEDICAL CARE FOR SUDDEN CARDIAC DEATH (CONTINUED) MONITORATION – with persistent ventricular fibrillation - second defibrillation - 2 minutes of chest compressions and mechanical ventilation - outcome assessment ; – if ventricular fibrillation persists - third defibrillation - 2 minutes of chest compressions and mechanical ventilation - outcome assessment 5. For ventricular fibrillation, EABP or asystole, without interrupting chest compressions, catheterize a large peripheral vein and inject 1 mg of epinephrine (adrenaline), continue epinephrine injections in the same dose every 3–5 minutes until the end of CPR. 6. In case of ventricular fibrillation, without interrupting chest compressions, administer 300 mg of amiodarone (cordarone) as a bolus and perform the fourth defibrillation - 2 minutes of chest compressions and mechanical ventilation - evaluation of the result. 7. If ventricular fibrillation persists, without interrupting chest compressions, administer a bolus of 150 mg amiodarone and apply a fifth electrical shock - 2 minutes of chest compressions and mechanical ventilation - evaluate the result.

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

Note. It is advisable to begin resuscitation measures with a precordial stroke only at the very beginning (in the first 10 seconds) of clinical death, if it is impossible to timely apply an electric discharge. Medicines are administered into a large peripheral vein. If there is no access to a vein, use intraosseous access. The endotracheal route of drug administration is not used. When preparing medical documentation (EMS call cards, outpatient or inpatient cards, etc.), the resuscitation aid must be described in detail, indicating the exact time of each manipulation and its result. Errors (13 common mistakes when performing CPR). When carrying out resuscitation measures, the cost of any tactical or technical errors is high; the most typical of them are the following. 1. Delay in starting CPR, loss of time on secondary diagnostic, organizational and treatment procedures. 2. Absence of a single leader, presence of outsiders. 3. Incorrect technique of chest compressions, insufficient (less than 100 per 1 min) frequency and insufficient (less than 5 cm) depth of compressions. 4. Delay in the start of chest compressions, the start of resuscitation measures with mechanical ventilation. 5. Interruptions in chest compressions exceeding 10 seconds due to the search for venous access, mechanical ventilation, repeated attempts at tracheal intubation, ECG recording or any other reasons. 6. Incorrect mechanical ventilation technique: airway patency, tightness during air injection are not ensured (most often the mask does not fit tightly to the patient’s face), prolonged (more than 1 s) air injection. 7. Interruptions in the administration of epinephrine (adrenaline) exceeding 5 minutes. 8. Lack of constant monitoring of the effectiveness of chest compressions and mechanical ventilation. 9. Delay in application of an electrical discharge, incorrectly selected discharge energy (use of insufficient energy discharges for treatment-resistant ventricular fibrillation). 10. Failure to comply with the recommended ratios between compressions and air injection - 30: 2 with synchronous ventilation. 11. Use of lidocaine rather than amiodarone for shock-resistant ventricular fibrillation. 12. Premature cessation of resuscitation measures. 13. Weakening control of the patient’s condition after restoration of blood circulation.

CLINICAL GUIDELINES (PROTOCOL) FOR PROVIDING EMERGENCY MEDICAL CARE FOR INCREASED BLOOD PRESSURE Arterial hypertension, worsening. 0 , 4 mg sublingually; – if the effect is insufficient - again after 30 minutes at the same dose. 1. 3. For isolated systolic arterial hypertension: – moxonidine (Physiotens) in a dose of 0.2 mg once sublingually.

CLINICAL GUIDELINES (PROTOCOL) FOR PROVIDING EMERGENCY MEDICAL CARE FOR INCREASED BLOOD PRESSURE 2. Hypertensive crisis 2. 1. GK without increasing sympathetic activity: – urapidil (Ebrantil) intravenously in a slow stream at a dose of 12.5 mg; – if the effect is insufficient, repeat injections of urapidil in the same dose no earlier than after 10 minutes. 3. GK with high sympathetic activity: – clonidine 0.1 mg intravenously in a slow stream. 4. Hypertensive crisis after discontinuation of an antihypertensive drug: – appropriate antihypertensive drug intravenously or sublingually. 5. Hypertensive crisis and acute severe hypertensive encephalopathy (convulsive form of GC). For a controlled decrease in blood pressure: – urapidil (Ebrantil) 25 mg intravenously in slow fractions, then drip or using an infusion pump, at a rate of 0.6–1 mg/min, adjust the infusion rate until the required blood pressure is achieved. To eliminate convulsive syndrome: – diazepam (Seduxen, Relanium) 5 mg intravenously slowly until the effect is achieved or a dose of 20 mg is reached. To reduce cerebral edema: – furosemide (Lasix) 40–80 mg intravenously slowly.

CLINICAL GUIDELINES (PROTOCOL) FOR PROVIDING AMBULANCE MEDICAL CARE IN CASE OF INCREASED BLOOD PRESSURE 6. Hypertensive crisis and pulmonary edema: – nitroglycerin (nitrosprint spray) 0.4 mg sublingually and up to 10 mg nitroglycerin (perliganitis) intravenously drip or using an infusion pump , increasing the rate of administration until the effect is achieved under blood pressure control; – furosemide (Lasix) 40–80 mg intravenously slowly. 7. Hypertensive crisis and acute coronary syndrome: – nitroglycerin (nitrosprint spray) 0.4 mg sublingually and up to 10 mg of nitroglycerin (perlinganite) intravenously by drip or using an infusion pump, increasing the rate of administration until the effect is obtained. 8. Hypertensive crisis and stroke: – antihypertensive therapy should be carried out only in cases where diastolic pressure exceeds 120 mmHg. Art. , trying to reduce it by 10–15%; – use intravenous administration of 12.5 mg of urapidil as an antihypertensive agent; if the effect is insufficient, the injection can be repeated no earlier than after 10 minutes; – if neurological symptoms increase in response to a decrease in blood pressure, immediately stop antihypertensive therapy

Notes The effectiveness of the main tablet antihypertensive drugs (moxonidine and captopril) can be increased by using combinations of 0.4 mg moxonidine with 40 mg furosemide, 0.4 mg moxonidine with 10 mg nifedipine and 25 mg captopril with 40 mg furosemide. For specialized resuscitation teams, a reserve drug used only for absolute life-saving indications - sodium nitroprusside (niprid) is administered at a dose of 50 mg in 500 ml of a 5% glucose solution intravenously, adjusting the infusion rate to achieve the required blood pressure. If a dissecting aortic aneurysm is suspected, the drugs of choice are esmolol (breviblok) and sodium nitroprusside (see protocol “Aortic dissection”). The crisis in pheochromocytoma is suppressed with the help of α-blockers, for example, sublinval pratsiol or intravenous phentolamine. Second-line drugs are sodium nitroprusside and magnesium sulfate. For arterial hypertension due to the use of cocaine, amphetamines and other psychostimulants (see protocol “Acute poisoning”). Taking into account the characteristics of the course of acute arterial hypertension, the presence of concomitant diseases and the response to therapy, specific self-help measures can be recommended to the patient with a similar increase in blood pressure.

Emergency transportation of the patient to the hospital is indicated: – for HA that could not be eliminated at the prehospital stage; – in case of GC with severe manifestations of acute hypertensive encephalopathy; – for complications of arterial hypertension that require intensive therapy and constant medical supervision (ACS, pulmonary edema, stroke, subarachnoid hemorrhage, acute visual impairment, etc.); – with malignant arterial hypertension. If there are indications for hospitalization, after possible stabilization of the patient’s condition, deliver the patient to the hospital and ensure continuation of treatment (including resuscitation measures) in full during transportation. Warn hospital staff. Transfer the patient to the hospital doctor. ICD-10 code Nosological form I 10 Essential (primary) hypertension I 11 Hypertensive heart disease [hypertensive disease with predominant damage to the heart] I 12 Hypertensive [hypertensive] disease with predominant damage to the kidneys I 13 Hypertensive [hypertensive] disease with predominant damage to the heart and kidney I 15 Secondary hypertension

Appendix 20 to the order

Ministry of Health of the Republic of Belarus

13.06.006 № 484

CLINICAL PROTOCOLS for providing emergency medical care to adults

CHAPTER 1 GENERAL PROVISIONS

Emergency medical care protocols are a list of timely, consistent, minimally sufficient diagnostic and therapeutic measures used at the prehospital stage in a typical clinical situation.

Emergency medical care is a type of medical care provided to sick and injured people for life-saving reasons in conditions requiring urgent medical intervention, and is carried out immediately by the state emergency medical service, both at the scene of the incident and along the route.

The main principles of organizing an emergency medical service are the availability of this type of medical care to the population, efficiency in work and timely arrival of teams to the sick and injured, the completeness of the medical care provided, ensuring unhindered hospitalization in the relevant specialized healthcare organizations, as well as continuity in work with inpatients and outpatients - polyclinic healthcare organizations.

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

All patients and victims with obvious signs of life-threatening conditions and the threat of developing life-threatening complications are subject to delivery to inpatient healthcare organizations, if it is impossible to exclude pathological processes and complications requiring inpatient treatment, diagnostic and therapeutic measures, as well as patients who pose a danger to others by infectious-epidemic and psychiatric indications, suddenly

sick and injured people from public places or who repeatedly sought emergency medical care within 24 hours.

Victims are subject to delivery to trauma centers in the absence of signs of life-threatening conditions, the prognosis of their development and with the ability to move independently fully or partially preserved, who do not require urgent inpatient diagnostic and treatment measures.

When making a call to patients and victims with criminal trauma, aggressive patients with alcohol or drug intoxication, when there is a threat to the life and health of the patient or victim, as well as in the social danger of the patient (victim), the emergency medical team is obliged to seek help and assistance in the implementation of treatment and tactical decisions to the internal affairs bodies in accordance with the established procedure.

When providing medical care and delivering patients and victims to hospitals who are under investigation, in court or serving a sentence, a mandatory condition for fulfilling the call, as well as receiving and transferring documents and valuables of patients (victims) with the participation of an emergency medical team is that they must be accompanied by employees of internal affairs bodies business

Patients admitted in a life-threatening condition are hospitalized directly in intensive care units, bypassing emergency departments.

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

If a patient or injured person refuses medical intervention or hospitalization, he or accompanying persons (spouse, in his absence - close relatives, and if this concerns a child, then parents), an emergency medical worker must explain in an accessible form the possible consequences of the refusal.

The refusal of a patient or victim from medical intervention, as well as from hospitalization, indicating the possible consequences, is recorded in the medical documentation and signed by the patient, or the persons indicated above, as well as a medical professional.

If the patient cannot be convinced of the need for hospitalization, the emergency doctor:

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

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

transfers an active call to an outpatient clinic.

CHAPTER 2 SUDDEN DEATH

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

loss of consciousness; absence of pulsation in large arteries (carotid, femoral);

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

2. Causes of cardiac arrest:

2.1. Heart diseases:

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

air embolism or pulmonary embolism (hereinafter referred to as PE);

vagal reflexes.

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

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

hypothermia.

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

2.6. Other reasons:

drowning; electrical injury.

3. Mechanisms of sudden death:

3.1. ventricular fibrillation (in 80% of cases), asystole or electromechanical dissociation. Ventricular fibrillation develops gradually, symptoms appear sequentially: disappearance of the pulse in the carotid arteries, loss of consciousness, single tonic contraction of skeletal muscles, disturbance and cessation of breathing. Response to timely cardiopulmonary resuscitation is positive, for cessation of cardiopulmonary resuscitation - rapid negative;

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

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

4.1. Statement of clinical death.

4.2. Precordial beat.

4.3. Ensure airway patency:

Safar maneuver (head extension, lower jaw extension); clean the oral cavity and oropharynx from foreign bodies, if necessary

Dimosti - Heimlich maneuver; tracheal intubation;

cricothyroidotomy for unremovable blockage of the upper respiratory tract.

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

The resuscitator’s arms are straight and positioned vertically; assist the massage with your body weight; compression frequency in adults is 80-100 per minute;

stop the massage only to inhale; slightly delay the massage movements in the maximum position

low compression.

7. The relationship between mechanical ventilation and VMS:

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

8. Provide permanent venous access.

9. Administration of epinephrine 1 ml of 0.18% solution intravenously or endotracheally in 10 ml of 0.9% sodium chloride solution.

10. Recording an electrocardiogram (hereinafter referred to as ECG) and/or cardiac monitoring

11. Differentiated therapy.

immediate implementation of electrical pulse therapy (hereinafter referred to as EIT) (according to paragraph 16 of Chapter 3);

if immediate EIT is not possible, apply a precordial blow and begin CPR, ensuring the possibility of performing EIT as quickly as possible;

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

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

if there is no effect, EIT is repeated after the administration of lidocaine 0.5-0.75 mg/kg (2% - 2-3 ml) slowly intravenously, or against the background of the administration of magnesium sulfate 2 g (20% solution 10 ml) i.v. c slowly;

if there is no effect, repeat EIT after lidocaine administration

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

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

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

Alternate between drug administration and defibrillation. 11.2. Electromechanical dissociation (hereinafter referred to as EMD):

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

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

11.3. Asystole: continue CPR;

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

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

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

administer 10% calcium chloride solution 10 ml intravenously for hyperkalemia, hypocalcemia, overdose of calcium blockers;

carry out external or internal cardiac stimulation. Continue CPR activities for at least 30 minutes, constantly assessing

the patient’s condition (cardiac monitoring, pupil size, pulsation of large arteries, chest excursion).

Cessation of resuscitation measures is carried out in the absence of signs of cardiac activity on the ECG, while using all possible measures for at least 30 minutes under normothermia.

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

The patient is transported to the intensive care unit after the efficiency of cardiac activity has been restored. The main criterion is a stable heart rhythm with a sufficient frequency, accompanied by a pulse in the large arteries.

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

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

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

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

13. Features of CPR.

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

If there is no access to a vein, epinephrine, atropine, lidocaine (increasing the recommended dose by 1.5-3 times) should be injected into the trachea (through an endotracheal tube or cricothyroid membrane) in 10 ml of 0.9% sodium chloride solution.

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

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

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

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

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

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

CHAPTER 3 EMERGENCIES IN CARDIOLOGY

14. Tachyarrhythmias.

14.1. Supraventricular tachyarrhythmias.

14.1.1. Sinus tachycardia requires emergency treatment only if it causes angina or worsening heart failure(hereinafter referred to as HF), arterial hypotension. First-line drugs are beta-blockers. Non-dihydropyridine potassium antagonists (verapamil) should be prescribed in cases where beta-blockers are contraindicated. It should be remembered that excessive suppression of reflex (with hypovolemia, anemia) or compensatory (with dysfunction of the left ventricle (hereinafter referred to as LV)) tachycardia can lead to a sharp decrease in blood pressure (hereinafter referred to as blood pressure) and worsening heart failure. In such cases, you should be careful in justifying the prescription and selecting the dose of drugs.

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

on 0.9% sodium chloride solution) under blood pressure control.

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

Algorithm for providing assistance:

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

Hicardia is performed:

carotid sinus massage (or other vagal techniques); if there is no effect, after 2 minutes - verapamil 2.5-5 mg IV

(0.25% - 1 - 2 ml in 0.9% sodium chloride solution) under blood pressure control; if there is no effect, after 15 minutes - verapamil 5-10 mg IV

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

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

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

0.1-0.3-0.5 ml).

14.1.3. Tachycardia with wide complexes, when the nature of the expansion of the complex is unclear.

Algorithm for providing emergency care for paroxysmal tachycardia with broad complexes of unspecified origin:

14.1.3.1. with stable hemodynamics:

administer lidocaine 1-1.5 mg/kg (2% - 5-6 ml) and every 5 minutes 0.5-0.75 mg/kg (2% - 2-3 ml) IV slowly until effect or total dose 3 mg/kg; if there is no effect - procainamide 500-1000 mg IV (10% - 5 - 10 ml in 0.9% sodium chloride solution) at a rate of 50-100 mg per minute

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

if there is no effect - EIT.

14.1.3.2. in case of unstable hemodynamics it is carried out immediately

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

In cases where paroxysms with wide QRS complexes are proven to be of a supraventricular nature, treatment tactics depend on the cause of the widening of the QRS complex. For paroxysmal supraventricular tachycardia with bundle branch block, treatment tactics do not differ from supraventricular tachycardia with narrow QRS complexes. If the cause of the widening of the QRS complex cannot be accurately determined, the first-line drugs are procainamide and amiodarone. When tachycardia is combined with decreased LV function, amiodarone becomes the drug of choice.

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

Algorithm for providing assistance:

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

if there is no effect - EIT.

14.1.5. In case of paroxysm of supraventricular tachycardia against the background of sick sinus syndrome, all antiarrhythmic drugs should be prescribed with extreme caution. If sinus bradycardia worsens, implantation of a temporary or permanent pacemaker(hereinafter referred to as EX).

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

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

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

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

And planned rhythm restoration.

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

Algorithm for providing emergency care:

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

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