Unloading ICC is done by improving the pump function LV and
reduction
blood flow to the heart. The increase in pump function by improving
myocardial contractility and reduced preload is achieved by
reduce blood pressure, PR.
advisable to intravenous nitroglycerin in the form of a continuous infusion,
until
not achieved the effect of reducing blood pressure, wedge pressure LA, an increase
cardiac output and decrease central venous pressure.
After infusion prescribed nitrates inside. ACE:
Capoten 6-25 mg every 8 hours, enalapril 5-20 mg 2 times a day.
Pulmonary edema ( NL ) - a clinical syndrome of acute left-ventricular
failure,
due to increased hydration of the lung tissue and reduction of their functional
opportunities.
In cardiology NL is often a complication of AHF and CHF. Range of diseases
cardiovascular system and lungs is quite wide: OIBS, Hibbs, arterial
hypertension (EAH,
SAG), myocarditis and cardiomyopathy, heart defects, pulmonary hypertension.
Current data giperkateholaminemiya increases PR and creates
difficulties
work LV . Tachycardia, a decrease in diastolic filling time
LV , peripheral
vasoconstriction increases the pressure in the LP. Uhudshaetsya blood flow in
pulmonary veins. Increased venous inflow to the RV and pulmonary blood circulation.
main reason for the increase of hydrostatic pressure in the pulmonary capillaries
is
impairment of LV contractile function , that is accompanied
an increase in diastolic
volume / DD LV .
2. Etiology
most frequent causes of pulmonary edema are:
1) cardiac:
- arterial hypertension;
- aortic, mitral heart defects;
- unstable angina, myocardial infarction;
- myocarditis, cardiomyopathy;
- cardiac arrhythmia;
2) nekardialnye:
- transfusion hypervolemia;
- hypoproteinemia <25 g / l;
- kidney, liver failure;
- anaphylactic shock, septic;
- acute pancreatitis, fat embolism;
- severe chest injuries;
- pulmonary embolism, hemorrhagic shock;
- severe pneumonia, foreign body VAR;
- drowning;
- gassing;
- head trauma, stroke;
- NL on height;
3) the introduction of medications with negative inotropic action
vasotonic
funds.
3. Classification of hemodynamic mechanisms of heart failure
1. LVSD.
arises during the initial myocardial damage - at cardiosclerosis /
atherosclerotic, postinfarction / myocarditis, dilated cardiomyopathy.
2. Systolic overload LV - Overload
pressure in hypertension and aortic stenosis.
3. Diastolic overload LV - this is volume overload - when
failure KLA,
MC, VSD, an open arterial canal.
4. Diastolic failure - decrease left ventricular filling with
hypertrophic
cardiomyopathy, hypertensive heart without ventricular dilatation, stenosis, MC
constrictive pericarditis.
5. High cardiac output with hyperthyroidism, anemia, obesity, cirrhosis
liver.
6. Violation of water-electrolyte metabolism with hormonal, metabolic
violations.
4. Pathogenesis
The lungs healthy person at rest is up to 600 ml of blood. This volume
can be increased by 3 times, and then in bottles ICC begins to rise
hydrostatic pressure. The main force that holds the blood in the pulmonary
capillaries and not allowing its liquid part extend beyond the vascular
channel is a colloid osmotic pressure. Due to the sharp decline
contractile function LV (sometimes LP) for a satisfactory function of the pancreas
hydrostatic pressure in the pulmonary capillaries is greater than 30 mm Hg. Art. and
transudation is the liquid part of blood into the interstitial space
lung tissue. The mucous membrane of the bronchial tubes swell, and in the lumen of the alveoli
accumulated fluid.
parallel baroreceptors are activated sympathoadrenal system. Increase
concentrations of catecholamines causes peripheral vasoconstriction, which
increases blood flow to the ICC, raising pressure on the weakened left ventricle .
increase preload increases myocardial oxygen demand and
depress myocardial contractile function. Vicious circle.
5. Treatment of pulmonary edema (NL)
Beginning with a performance of urgent universal activities:
1. Restoration of the airway.
In severe respiratory failure with acidosis and hypotension -
endotracheal intubation.
2. Oxygen - inhalation of 100% humidified oxygen through a nasal
cannula or a mask method.
3. With copious foam is foam breaking: inhalation
oxygen at 96 0 solution of ethyl alcohol. In exceptional
cases - the introduction of two ml of 30% alcohol solution into the trachea or intravenously, 5 ml of 96 *
alcohol with 15 ml of 5% glucose solution.
6. NL hypertension
When hypertension occurs systolic overload LV .
Treatment
1. Urgent universal event.
2. Sit down with the patient's legs.
3. Nitroglycerin sublingually or intravenously. In severe NL -
sodium nitropassside, 30 mg dissolved in 300 ml of physiological
sodium chloride solution. To protect from light bottle is placed in a black bag.
The initial rate of introduction of 6 drops / min (30 micrograms), with an increase every 15 minutes. on
10 drops / min to decrease BP with at least 90 mm Hg. Art. against the background
stabilization of the patient.
4. Ganglioplegic pentamine 1-2 ml of 5% solution in 20 - ti ml physiological
solution
fractional intravenous bolus of 3-5 ml with an interval of 5-10 minutes under
BP control -
every 2-3 minutes - on the other hand.
5. In severe hypertension and mild clinical manifestations NL - clonidine
1 ml 0.01%
solution intravenously.
6. Droperidol 2-4 ml 0.25% solution or diazepam 10 mg, or morphine to 10
mg intravenously.
7. NL normal blood pressure (BP)
1. Implementation of urgent universal events.
2. Sit down with the patient's legs to reduce venous return. C
For the same purpose may be sanctioned harness on proximal 3 limbs.
Compression ratio should correspond to an intermediate value between
diastolic and systolic pressure. Bundles are superimposed on the 15 cm below
the groin area and 9 cm below the shoulder. Every 15-20 minutes, one of the bundles
necessary to remove and apply it to the free limb. Method
contraindicated in the presence of thrombophlebitis and varicose veins.
3. To reduce the venous return of blood and reducing preload -
1 tablet of nitroglycerin 0.5 mg sublingually every 5 minutes or by intravenous
infusion of 10 mg under the control of blood pressure. Reduce by 10-15%, but lower BP with <100
mm Hg. Art.
Can - izoket 0.1% solution of 20-40 mg in 15 ml saline
intravenously for 10 minutes. Perlinganit 20-40 mg per 200 ml of physiological
solution intravenously to reduce blood pressure by 15 mmHg. Art. or improvement
state.
4. To unload the ICC - diuretics. Lasix 40-80 mg intravenously at
for 1-2 minutes. With no effect - to repeat the introduction of 1 hour,
of 80 - 160 mg. Diuretic effect develops within a few minutes and
lasts 2-3 hours with up to 2 liters of urine that is accompanied by
decrease in plasma volume and an increase in colloid osmotic pressure due to
blood clots. The latter facilitates the transition edema fluid into the vascular
channel, reduce pulmonary blood flow and reduce pulmonary artery pressure.
Necessary to avoid hypotension below 90 mm Hg. Art. Not recommended
use
osmotic diuretics as the first phase of its action, they can
increase the BCC, which increases the load on the ICC and may contribute to
progression NL .
5. To normalize the emotional status, relief of pain,
eliminate giperkateholemii and hyperventilation administered morphine 1 ml of 1% solution
10 ml saline by slow intravenous injection of 2 ml of the mixture
every 7-10 minutes under the control of the BH, AD.
Droperidol 2 ml 0.25% solution in 10 ml of saline or diazepam
2 ml 0.5% solution in 10 ml of saline. 1 hour later: repeat
Lasix 80 - 160 mg intravenously, izoket intravenously.
6 Prednisone 90-120 mg intravenously - eliminates the sharply increased
permeability of vascular walls and other barriers in the pulmonary interstitium.
8. OL at moderate hypotension (BP with = 90 mm Hg. Art.)
1. Urgent universal event.
2. Lay the patient, raising his head.
3. Dobutamine (dobutreks): 250 mg dissolved in 250 ml
saline. The dasg selectively stimulates b - A -
receptors in the myocardium without peripheral vasodilation. Initial dose - 2,5 - 10
ug / kg / min. Increase the dose of 2.5 mg / kg / min to achieve the effect.
The maximum dose - 40 mg / kg / min maintenance - 10 mg / kg / min.
Avoid contact with the dasg under the skin. dasg is incompatible with alkaline
and alcohol-containing solutions.
Side effects:
- tachycardia;
- a sharp increase in blood pressure;
- GEN;
- phlebitis;
- anginal pain.
4. Furosemide 40 mg intravenously after stabilization of blood pressure.
9. NL with severe arterial hypotension (BP with <80
- 70 mm Hg. Art.)
1. Urgent universal event.
2. Lay the patient, raising his head.
3. Dopamine 200 mg diluted in 250 ml of saline or 5%
glucose solution. In small doses, up to 3 mg / kg / min of the dasg stimulates
postsynaptic dopaminergic receptors, resulting in an
dilatation of the renal and mesenteric vessels, increased diuresis, excretion of Na. In
large doses - 3.10 mg / kg / min - stimulates a and
b - A - receptors, and consequently increases the contractility of NE, growth
HR uvelivaet coronary blood flow and PR. This positive inotropic
action by increasing E costs.
Initial dose 5.10 mg / kg / min increased by 5-10 mg, if necessary -
20-50
ug / kg / min. Limit: heart rate greater than or equal to 110, Action
fades after 3-5 minutes.
Side effects:
- tachycardia extrasystole;
- shortness of breath;
- angina;
- headaches;
- nausea, vomiting;
- necrosis at the injection site.
4. If increased blood pressure accompanied by a rise NL - in addition
intravenous nitroglycerin.
5. Lasix 40 mg intravenously after stabilization of blood pressure.
10. OL heart rhythm disturbances
1. When tachyarrhythmias - cardioversion. Antiarrhythmic medication therapy
less than shown due to negative inotropic and hypotensive action
Most antiarrhythmic dasgs. With care administered lidokain
intravenously 100 mg per 1minutu novokainamid or 10 ml of 10% solution with 0.2
mezatona ml in 10 ml of saline under the control of blood pressure and heart rate.
2. If bradyarrhythmia - pacing. When it is impossible:
intravenously
atropine bolus of 1 ml 0.1% solution or 1 ml alupent 0.05 * solution in 20 ml
physiological
solution under the control of blood pressure and heart rate.
11. NL with mitral stenosis (diastolic failure)
1 Promedol 2% 1.0 ml intravenously.
2 Lasix 80-120 mg intravenously.
3 aminophylline 2.4% 10 ml in 10,0 Tee ml of saline intravenously
jet.
4 Strophanthin 0,05% 0,5 ml in 10.0 ml of saline intravenously
jet.
5 oxygen and ethyl alcohol 96 *
Table 1
interval of dasg administration | name dasgs | dosages | Dosing | Note |
Through 30 minutes | droperidol | 0,25% 2 - 6.0 ml | intravenously |
|
Through 60 minutes | Lasix | 80 - 120 mg | intravenously |
|
Pentamino | 5% 1.0 ml in 10.0 ml physiological | intravenously | ||
Through 2:00 | droperidol | 0,25% 2,0 ml | intravenously |
|
Promedol | 2% 1.0 ml | intravenously |
12. NL with CNS (stroke)
1. Lasix 80-120 mg intravenously.
2. Aminophylline 2.4% 10 - 20,0 ml in 10,0 Tee ml saline
intravenously.
3. Droperidol 0.25% - 2.0 ml intravenously.
4. Strophanthin 0,05% 0,5 ml in 10.0 ml of saline intravenously
jet
if MA and CHF .
5. Reopoliglyukin 400.0 ml intravenously.
6. Pentamine 5% 1.0 ml intravenous infusion in hypertension.
7. Fentanyl 0.005% -1.0 ml intravenously, can not be in violation of breath.
60 minutes - mannitol 30 - 60 g in 200 - 400,0 distilled water.
13. The method of positive end-expiratory pressure
Increases anti-filtration pressure in the alveoli and making the transition to
They transudate from the capillaries of the ICC. In addition, breathing with resistance to
exhalation reduces venous blood return to the heart and relieves the ICC.
To implement the method of patient exhale through a tube lowered to
6 - 8 cm of water. This creates a positive expiratory pressure of 1 to 5
cm of water.
ventilation in positive pressure mode can be achieved by the establishment at the end
exhalation using a bag or mechanical ventilator / hand-operated pressure / 5 - 6
cm water column.
14. Criteria for relief NL and transportability of patient
1. Reducing breathlessness at least 22 min.
2. The disappearance of frothy sputum.
3. The disappearance of moist rales over the front surface of the lungs.
4. Decrease cyanosis.
5. The absence of recurrence NL when transferring a patient into a horizontal
position.
6. Stable hemodynamics: BP, HR.
Minsk. September 20 04g.