Clinical death – the reversible stage of dying coming at the time of the termination of warm and respiratory activity. It is characterized by lack of consciousness, pulse on the central arteries and thorax excursions, expansion of pupils. It is diagnosed according to the data obtained during survey, a palpation of a carotid, listening of warm tones and pulmonary noise. An objective symptom of cardiac arrest is melkovolnovy fibrillation of auricles or the isoline on the ECG. Specific treatment – actions of primary warm and pulmonary resuscitation, transfer of the patient to IVL, hospitalization to ORIT.
The Clinical Death (CD) – the initial stage of death of an organism proceeding for 5-6 minutes. During this period exchange processes in fabrics are sharply slowed down, however do not stop completely due to anaerobic glycolysis. Then in a cerebral cortex and internals there occur the irreversible changes making revival of the victim impossible. Duration of a state depends on a number of factors. At a low temperature of air it increases, at high – decreases. Also how the patient died matters. Sudden death against the background of relative stability extends the reversible period, slow exhaustion of an organism at incurable diseases – reduces.
Reasons of clinical death
It is possible to carry all diseases and injuries leading to death of the patient to number of the factors causing KS. This list does not include accidents at which the body of the victim sustains considerable damage, incompatible with life (the razmozzheny heads, combustion on fire, a dekapitation and so forth). Division of the reasons into two big groups – connected and not connected with direct damage of a cardiac muscle is standard:
- Kardialnye. Primary violations of sokratitelny ability of a myocardium caused by sharp coronary pathology or influence of cardiotoxic substances. Provoke mechanical damage of kardialny muscular layers, a tamponada, violations to work of the carrying-out system and sinus knot. The stop of blood circulation can arise against the background of a sharp myocardial infarction, an electrolytic imbalance, arrhythmias, endocarditises, a rupture of aneurism of an aorta, an ischemic disease.
- Nekardialnye. The states which are followed by development of the expressed hypoxia enter into this group: drowning, suffocation, obstruction of airways and sharp respiratory insufficiency, shocks of any origin, embolism, reflex reactions, defeats by electric current, poisonings with cardiotoxic poisons and endotoxins. Fibrillation with the subsequent cardiac arrest can take place at the wrong introduction of warm glycosides, medicines of potassium, antiaritmik, barbiturates. The high risk is noted at patients with poisoning with phosphoorganic compounds.
After respiratory standstill and blood circulation in an organism destructive processes begin to develop quickly. All fabrics experience oxygen starvation that leads to their destruction. Are most sensitive to a hypoxia of a cell of bark of big hemispheres, perishing through several tens of seconds from the moment of the termination of a blood-groove. In case of a decortication and death of a brain even successful resuscitation actions do not lead to a complete recovery. The body continues to live, however brain activity is absent.
At a stop of a blood-groove the curtailing system of blood becomes more active, in vessels microblood clots are formed. In blood toxic products of disintegration of fabrics are allocated, metabolic acidosis develops. pH of the internal environment decreases to 7 and below. A long absence of blood circulation become the reason of irreversible changes and biological death. Successful resuscitation terminates in restoration of kardialny activity, a metabolic storm, developing of a post-resuscitation disease. The last is formed because of the postponed ischemia, thrombosis of capillary network of internals, considerable homeostatic shifts.
Symptoms of clinical death
It is characterized by three main signs: lack of effective warm reductions, breath and consciousness. An undoubted symptom are all three signs which are present at the patient at the same time. KS against the background of the kept consciousness or heartbeat is not diagnosed. Independent residual breath (gasping) can remain for 30 seconds after a blood-groove stop. The first minutes separate inefficient reductions of a myocardium which lead to emergence of weak pulse pushes are possible. Their frequency usually does not exceed 2-5 times a minute.
Refer lack of a muscular tone, reflexes, movements, unnatural position of a body of the victim to number of secondary signs. Skin is pale, an earthy shade. Arterial pressure is not defined. In 90 seconds there is an expansion of pupils to diameter more than 5 mm without reaction to light. Features are pointed (Hippocrates's mask). The similar clinical picture has no special diagnostic value in the presence of the main signs therefore inspection is performed in the course of the resuscitation actions, but not before their beginning.
The main complication – transition of clinical death in biological. It finally occurs in 10-12 minutes from the moment of cardiac arrest. If it was succeeded to restore blood circulation and breath, but clinical death prior to treatment proceeded more than 5-7 minutes, death of a brain or partial violation of its functions is possible. The last is shown in the form of neurologic frustration, post-hypoxemic encephalopathy. In the early period at the patient the post-resuscitation disease which can result in polyorgan insufficiency, endotoxicosis and a secondary asistoliya develops. The risk of development of complications increases in proportion to time spent in the conditions of a blood circulation stop.
Clinical death easily is determined by external symptoms. If pathology develops in the conditions of medical institution, apply additional equipment rooms and laboratory ways. It is necessary for definition of efficiency of the held resuscitation events, for assessment of weight of a hypoxia and violations of acid-base balance. All diagnostic manipulations are carried out in parallel with work on restoration of a warm rhythm. For confirmation of the diagnosis and control of efficiency of the taken measures use the following types of researches:
- Fizikalnye. Are the main method. At survey find characteristic signs of KS. At an auskultation coronary tones are not listened, respiratory noise in lungs are absent. Existence of pulse out of ORIT is defined by pressing on area of a projection of a carotid. Probing of pushes on peripheral vessels has no diagnostic value as at agonalny and shock states they can disappear long before the termination of warm activity. Existence or lack of breath is estimated visually, on the movements of a thorax. The test by means of a mirror or the suspended thread is inexpedient to be carried out as it demands extra time. HELL is not defined. Tonometriya out of ORIT is carried out only in the presence of two and more reanimators.
- Tool. The main way of tool diagnostics – an electrocardiography. It is necessary to consider that the isoline corresponding to full cardiac arrest is registered not always. In many cases separate fibers continue to be reduced randomly, without providing a blood-groove. On the ECG the similar phenomena are expressed in a small sinuosity (amplitude less than 0.25 mV). Accurate ventricular complexes on a film are absent.
- Laboratory. Are appointed only at successful resuscitation actions. Researches KShchS, electrolytic balance, biochemical indicators are considered as the main. In blood metabolic acidosis, the increased content of sodium, potassium, proteins and products of disintegration of fabrics is found. Concentration of platelets and factors of folding is reduced, there are hypocoagulation phenomena.
Treatment of clinical death
Restoration of the vital functions of the patient is carried out by means of basic and specialized resuscitation actions. They have to be begun as soon as possible, ideally no later than 15 seconds which passed from a blood circulation stop. It allows to prevent a decortication and neurologic pathology, to reduce weight of a post-resuscitation disease. The measures which did not lead to restoration of a rhythm for 40 minutes from the last electric activity are considered unsuccessful. Resuscitation is not shown to the patients who died owing to documentary confirmed, is long the proceeding incurable disease (oncology). Enters the list of the measures directed to renewal of warm reductions and breath:
- Basic complex. Usually is implemented out of MPI. The victim is stacked on a firm plain surface, throw back the head, under shoulders put the roller made of improvised material (a bag, a jacket). The lower jaw is pushed forward, the fingers which are wrapped up by fabric clear airways of slime, emetic masses, delete the available foreign matters, sets of false teeth. Carry out indirect massage of heart in combination with an artificial respiration of companies to a mouth. The ratio of compressions and breaths has to make 15:2 respectively irrespective of quantity of reanimators. Massage speed – 100-120 pushes/minute. After restoration of pulse of the patient stack sideways, control his state before arrival of physicians. Clinical death can repeat.
- Specialized complex. It is carried out in the conditions of ORIT or the car of SMP. For providing an excursion of lungs of the patient intubirut and connect to device . Alternative option – use of a bag of Ambu. The laringialny or front mask can be applied to noninvasive ventilation. If nonremovable impassability of airways became the reason, the konikotomiya or a trakheostomiya with installation of a hollow tube is shown. Indirect massage is carried out manually or kardiopampy. The last facilitates work of experts and does an action to more effective. In the presence of fibrillation restoration of a rhythm is made by means of a defibrillator (electropulse therapy). The 150, 200, 360 J categories are used. on bipolar devices.
- Medicamentous grant. During the resuscitation actions to the patient carry out intravenous administration of adrenaline, a mezaton, atropine, chloride calcium. For maintenance HELL after restoration of a rhythm via the syringe pump is given by pressor amines. The hydrocarbonate in the form of infusion is applied to correction of metabolic acidosis sodium. Increase in OTsK is reached at the expense of colloidal solutions – a reopoliglyukin, etc. Correction of electrolytic balance is implemented taking into account information obtained during the laboratory research. Salt solutions can be appointed: , , disalt, physiological solution of sodium of chloride. Right after recovery of work of heart the antiarrhytmic medicines, antioxidants, antigipoksant, means improving microcirculation are shown.
Actions during which at the patient the sinusovy rhythm was restored are considered as effective, systolic arterial pressure was established at the level of 70 mm of mercury. or above, ChSS keeps within 60-110 blows. The clinical picture demonstrates renewal of blood supply of fabrics. There is a narrowing of pupils, restoration of their reaction to a light irritant. Skin color comes back to norm. Emergence of independent breath or immediate return of consciousness right after resuscitation happens seldom.
Forecast and prevention
Clinical death has the adverse forecast. Even at the short period of the absent blood circulation the risk of damage of the central nervous system is high. Weight of consequences increases in proportion to time which passed from the moment of development of pathology prior to work of reanimators. If this period made more than 5 minutes, the possibility of a decortication and post-hypoxemic encephalopathy repeatedly increases. At an asistoliya more than 10-15 minutes chances of resumption of work of a myocardium sharply decrease. The cerebral cortex with guarantee is damaged.
Hospitalization and constant observation of patients with high risk of warm death is among specific preventive actions. Along with it the therapy directed to recovery of normal work of cardiovascular system is carried out. The experts working in MPI have to follow carefully dosages and rules of introduction of cardiotoxic medicines. A nonspecific measure of prevention is the observance of safety measures in all spheres of life allowing to reduce risk of drowning, a travmatization, the asphyxia resulting from accident.