The The organization of emergency organization of emergency

care in an care in an epidemic outbreakepidemic outbreak

Prepared by:Prepared by:C.m.s., assistant professor C.m.s., assistant professor

of outpatient therapy of outpatient therapy and emergency medical and emergency medical

emergency KGMUemergency KGMUA.R. AlpyssovaA.R. Alpyssova

The purpose of the lectureThe purpose of the lecture

► After completing the lecture, students should be After completing the lecture, students should be

guided in the organization of emergency care in an guided in the organization of emergency care in an

epidemic outbreak.epidemic outbreak.

The plan of the lectureThe plan of the lecture

► Infection-toxic shockInfection-toxic shock► Meningococcal infection.Meningococcal infection.► Hypovolemic shock in acute intestinal infectionsHypovolemic shock in acute intestinal infections► Tetanus, botulism, a severe flu complicationsTetanus, botulism, a severe flu complications► Diphtheria, whooping cough, croupDiphtheria, whooping cough, croup► Acute liver failureAcute liver failure► Acute renal failureAcute renal failure► MalariaMalaria

► Emergency Physician must distinguish Emergency Physician must distinguish three groups of severely ill with infectious three groups of severely ill with infectious diseases:diseases:

► 1) patients, treatment success is determined 1) patients, treatment success is determined by pre-hospital resuscitation (toxic by pre-hospital resuscitation (toxic shock in meningococcal infection, hypovolemic shock in meningococcal infection, hypovolemic shock in cholera and nutritional diseases);shock in cholera and nutritional diseases);

► 2) patients in critical 2) patients in critical condition requiring immediate condition requiring immediate hospitalization in an intensive care unit of an hospitalization in an intensive care unit of an infectious hospital, emergency care on site at the infectious hospital, emergency care on site at the same time to spend in case of same time to spend in case of delay in hospitalization or over-expressed delay in hospitalization or over-expressed violations of the (in botulism, complicated forms violations of the (in botulism, complicated forms of influenza, etc.);of influenza, etc.);

► 3) patients in whom there is a threat of critical 3) patients in whom there is a threat of critical states, patients in this group are also in need of states, patients in this group are also in need of urgent hospitalization.urgent hospitalization.

► Having established the diagnosis Having established the diagnosis of infectious diseases, emergency doctor should of infectious diseases, emergency doctor should decide on further tactics of the patient - the need decide on further tactics of the patient - the need for emergency hospitalization or treatment at for emergency hospitalization or treatment at home to transfer the call to the local clinic, the home to transfer the call to the local clinic, the patient must also enroll in epidbyuro city.patient must also enroll in epidbyuro city.

► First two groups of patients in need of First two groups of patients in need of immediate hospitalization in the intensive care immediate hospitalization in the intensive care unit of a hospital infection.unit of a hospital infection.

► The third group of patients with a note about the The third group of patients with a note about the threat of immediate state can be brought to the threat of immediate state can be brought to the emergency department.emergency department.

► At the same time a doctor decides on the amount At the same time a doctor decides on the amount of remedial measures to be carried out on pre-of remedial measures to be carried out on pre-hospital emergencies.hospital emergencies.

Infection-toxic shockInfection-toxic shock► From emergency conditions that occur in From emergency conditions that occur in

infectious diseases, the most common is toxic infectious diseases, the most common is toxic shock, which can cause death due shock, which can cause death due to delayed diagnosis and therapy.to delayed diagnosis and therapy.

► Some of the infections for which the incidence Some of the infections for which the incidence of shock is mainly determined by mortality of shock is mainly determined by mortality rate, primarily include meningokokktsemi or menirate, primarily include meningokokktsemi or meningococcal sepsis.ngococcal sepsis.

► The development of shock and described in other The development of shock and described in other infectious diseases (typhus and typhoid fever, infectious diseases (typhus and typhoid fever, influenza, salmonella, dysentery, anthrax, etc.).influenza, salmonella, dysentery, anthrax, etc.).

► Allocate 3 degrees of shock:Allocate 3 degrees of shock:► 1 - Compensation;1 - Compensation;► II - subcompensation;II - subcompensation;► III-decompensation.III-decompensation.

► Compensated for (I degree) shock Compensated for (I degree) shock is characterized by is characterized by high fever, agitation, anxiety, mental distress, dyspnea, high fever, agitation, anxiety, mental distress, dyspnea, and tachycardia, inappropriate magnitude increase in body and tachycardia, inappropriate magnitude increase in body temperature on the background of a temperature on the background of a pronounced symptom of infectious disease.pronounced symptom of infectious disease.

► In this release the following triad In this release the following triad of symptoms ("prodrome shock"): impaired consciousness, of symptoms ("prodrome shock"): impaired consciousness, hyperventilation, and the presence of foci of infection in hyperventilation, and the presence of foci of infection in the body.the body.

► Subcompensated (II degree) shock Subcompensated (II degree) shock is characterized is characterized by lethargy, depression, and blanching of the skin, the by lethargy, depression, and blanching of the skin, the appearance of cyanosis, tachycardia, oliguria, acidosis, appearance of cyanosis, tachycardia, oliguria, acidosis, decreased body temperature.decreased body temperature.

► Uncompensated (III degree)Uncompensated (III degree) is characterized  is characterized by cyanosis, shock, hypothermia, anuria, a violation of by cyanosis, shock, hypothermia, anuria, a violation of consciousness. Pulse thready with, difficult to define, consciousness. Pulse thready with, difficult to define, cardiac deaf, low blood pressure (50 / cardiac deaf, low blood pressure (50 / 0 mm Hg. or not defined).0 mm Hg. or not defined).

► Develop pronounced decompensated metabolic acidosis, Develop pronounced decompensated metabolic acidosis, profound intoxication, secondary irreversible disorder in profound intoxication, secondary irreversible disorder in the organs.the organs.

Meningococcal infection.Meningococcal infection.► Generalized forms of meningococcal infection Generalized forms of meningococcal infection

(meningokokktsemiya, meningitis) require emergency pre-(meningokokktsemiya, meningitis) require emergency pre-hospital in connection with the development ITSH andhospital in connection with the development ITSH and cerebral cerebral edema.edema.

► Meningococcal sepsis is characterized by a very rapidly Meningococcal sepsis is characterized by a very rapidly progressive disease onset. The body temperature rises to 39-progressive disease onset. The body temperature rises to 39-420S for I-th day, accompanied by a fever, she later reduced 420S for I-th day, accompanied by a fever, she later reduced to subfebrial and in shock - to normal and subnormalto subfebrial and in shock - to normal and subnormal values. Along with marked fever headache, muscle aches, values. Along with marked fever headache, muscle aches, vomiting, tachycardia.vomiting, tachycardia. Blood pressure early in the Blood pressure early in the disease increases, then decreases. Decreaseddisease increases, then decreases. Decreased urination, small urination, small children can diarrhea. The most constant and striking diagnostic children can diarrhea. The most constant and striking diagnostic feature of meningococcal sepsis - exanthema. Skin feature of meningococcal sepsis - exanthema. Skin rashes occur within hours ofrashes occur within hours of onset. Typical petechiasis irregular star-shaped with onset. Typical petechiasis irregular star-shaped with a single large hemorrhages.a single large hemorrhages. The The preferential localization of - limbs, torso, buttocks. The preferential localization of - limbs, torso, buttocks. The rash initially notrash initially not abundant, a few hours may abundant, a few hours may become generalized.become generalized.

► When fulminant meningokokktsemii rash becomes flush witWhen fulminant meningokokktsemii rash becomes flush with the nature of the formation of large purple-tsianotic spots h the nature of the formation of large purple-tsianotic spots (colored purple ink), which can quickly necrosis.(colored purple ink), which can quickly necrosis.

► Hemorrhagic rash - a metastasis of Hemorrhagic rash - a metastasis of meningococcal sepsis, and the more intensemeningococcal sepsis, and the more intense meningokokktsemiya, the more rash.meningokokktsemiya, the more rash.

► Hemorrhage, defined on all mucous membranes lining Hemorrhage, defined on all mucous membranes lining the trachea, bronchi, gastrointestinal tract, in the the trachea, bronchi, gastrointestinal tract, in the parenchyma of various organs.parenchyma of various organs.

► Originating in the adrenal glands, hemorrhages cause the Originating in the adrenal glands, hemorrhages cause the development of acute adrenal insufficiency (Waterhouse-development of acute adrenal insufficiency (Waterhouse-Friderichsen syndrome).Friderichsen syndrome).

► Patients are anxious, excited, quite often, especially in Patients are anxious, excited, quite often, especially in children, experiencedchildren, experienced convulsions, vomiting occurs, blood convulsions, vomiting occurs, blood pressure has been steadily declining.pressure has been steadily declining.

► Expressed as a rule, meningeal syndrome.Expressed as a rule, meningeal syndrome.► Fast, lightning progressive course of shock Fast, lightning progressive course of shock

in meningococcal sepsis (1-2 days) with in meningococcal sepsis (1-2 days) with severe hemorrhagic syndrome and possible bleeding in severe hemorrhagic syndrome and possible bleeding in the adrenal glandsthe adrenal glands requires immediate diagnosis of the requires immediate diagnosis of the disease, selection stages (degrees) shockdisease, selection stages (degrees) shock and and immediate therapeutic measures.immediate therapeutic measures.

► In order to avoid diagnostic errors ambulance In order to avoid diagnostic errors ambulance surgeon must remember that in the presence surgeon must remember that in the presence of haemorrhagic rash in a patient diagnosed with the of haemorrhagic rash in a patient diagnosed with the choice is always achoice is always a meningococcal sepsis.meningococcal sepsis.

► The risks of overThe risks of over diagnosis is not, on the diagnosis is not, on the contrary, any statement of misdiagnosis of contrary, any statement of misdiagnosis of hemorrhagic diathesis.hemorrhagic diathesis.

► Tactics emergency doctor in meningococcemia is to Tactics emergency doctor in meningococcemia is to provide complex emergencyprovide complex emergency treatment treatment measures, contents of which depend on the measures, contents of which depend on the severity of infectious-toxic shock, severity of infectious-toxic shock, and subsequent hospitalization in an intensive care and subsequent hospitalization in an intensive care unit of an infectiousunit of an infectious hospital.hospital.

Intensive therapy. I degree of shock.Intensive therapy. I degree of shock. ► When hyperthermia (t body above 39,5-40 ° C) When hyperthermia (t body above 39,5-40 ° C)

- Antipyretics:- Antipyretics:- Analgin (50% solution) for adults - 2 ml for children - Analgin (50% solution) for adults - 2 ml for children - 0.1 ml at 1 year of age;- 0.1 ml at 1 year of age;- Diphenhydramine (1% solution) for adults - 2 ml for - Diphenhydramine (1% solution) for adults - 2 ml for children under 1 year - 0.1 ml per month of life after 1 children under 1 year - 0.1 ml per month of life after 1 year - 1-2 ml depending on age;year - 1-2 ml depending on age;- Prednisolone (2 mg / kg) or hydrocortisone (10-- Prednisolone (2 mg / kg) or hydrocortisone (10-20 mg / kg) intravenously or20 mg / kg) intravenously or intramuscularly;intramuscularly;- Reopoligljukin gemodez or 10 ml / kg intravenously;- Reopoligljukin gemodez or 10 ml / kg intravenously;- Chloramphenicol succinate (chloramphenicol) (25 mg / - Chloramphenicol succinate (chloramphenicol) (25 mg / kg intramuscularly orkg intramuscularly or intravenously) intravenously) or penicillin (50 000 IU / kg intramuscularly) - single or penicillin (50 000 IU / kg intramuscularly) - single dose.dose.

► In the excitation and convulsions:In the excitation and convulsions:- Relanium (0.5% solution) for adults - 2-4 ml for - Relanium (0.5% solution) for adults - 2-4 ml for children under 6 months - 0.3-0.4ml, from 6 months to children under 6 months - 0.3-0.4ml, from 6 months to 2 years - 0.5 ml, over 2 years - 1-2 ml intravenously or2 years - 0.5 ml, over 2 years - 1-2 ml intravenously or intramuscularly;intramuscularly;- Magnesium sulfate (25% solution) for adults - 10-- Magnesium sulfate (25% solution) for adults - 10-15 ml for children - 1 ml to 1 year of age by 15 ml for children - 1 ml to 1 year of age by intramuscular injection.intramuscular injection.

IIII degree of shock:degree of shock: - Hydrocortisone (50 mg / kg), or deksazon (2 mg / kg) - Hydrocortisone (50 mg / kg), or deksazon (2 mg / kg)

or prednisolone (10 mg / kg) intravenously;or prednisolone (10 mg / kg) intravenously;- Reopoligliukin adults - 400 ml, the children - 10 ml / - Reopoligliukin adults - 400 ml, the children - 10 ml / kg intravenously or albumin(5% solution) for adults - kg intravenously or albumin(5% solution) for adults - 200 ml, the children - 10 ml / kg intravenously;200 ml, the children - 10 ml / kg intravenously;- Levomitsitin succinate (25 mg / kg) intravenously.- Levomitsitin succinate (25 mg / kg) intravenously.

► In the absence of effects on hormones and plasma In the absence of effects on hormones and plasma substitutes:substitutes:- Dopamine 5 ml (200 mg) per 200 ml of 10% - Dopamine 5 ml (200 mg) per 200 ml of 10% glucose intravenously (18 drops / min) with the glucose intravenously (18 drops / min) with the introduction of regulation to stabilize blood pressure.introduction of regulation to stabilize blood pressure.

► When convulsions:When convulsions:- Relanium (0.5% solution) for adults - 2-4 ml for children - Relanium (0.5% solution) for adults - 2-4 ml for children under 6 months - 0.3-0.4ml, from 6 months to 2 years -under 6 months - 0.3-0.4ml, from 6 months to 2 years -0,5-1 ml, over 2 years - 1 - 2 ml intravenously or 0,5-1 ml, over 2 years - 1 - 2 ml intravenously or intramuscularly;intramuscularly;- Sodium hydroxybutyrate (20% solution) for adults - 10-- Sodium hydroxybutyrate (20% solution) for adults - 10-20 ml for children (5% solution) - 100 mg / 20 ml for children (5% solution) - 100 mg / kg intravenously or intramuscularly.kg intravenously or intramuscularly.

IIIIII degree of shockdegree of shock::

- Hydrocortisone (75 mg / kg), or de- Hydrocortisone (75 mg / kg), or deссsazon (4 mg / sazon (4 mg / kg) or prednisolone (20 mg / kg) intravenously;kg) or prednisolone (20 mg / kg) intravenously;- Reopoligljukin adults - 400 ml or polyglukin - - Reopoligljukin adults - 400 ml or polyglukin - 500 ml intravenously, the children -10-15 ml / kg;500 ml intravenously, the children -10-15 ml / kg;- Albumin (5% solution) for adults - 200 ml, the - Albumin (5% solution) for adults - 200 ml, the children - 10 ml / kg intravenously,children - 10 ml / kg intravenously, then drip.then drip.

► With no effect - dopamine 5 ml (200 mg) in 200 ml of With no effect - dopamine 5 ml (200 mg) in 200 ml of 10% glucose solution10% glucose solution intravenously to stabilize blood intravenously to stabilize blood pressure.pressure.

► Chloramphenicol succinate (25 mg / Chloramphenicol succinate (25 mg / kg) intravenously with meningitis andkg) intravenously with meningitis and meningococcal sepsis.meningococcal sepsis.

► Swelling of the brain:Swelling of the brain:- Lasix (1-2 mg / - Lasix (1-2 mg / kg) intravenously or vnutrimmyshechno;kg) intravenously or vnutrimmyshechno;- Dexamethasone (1 mg / kg) or prednisolone (2-- Dexamethasone (1 mg / kg) or prednisolone (2-5 mg / kg) intramuscularly or intravenously.5 mg / kg) intramuscularly or intravenously.

► In the excitation and convulsions:In the excitation and convulsions:- Relanium (0.5% solution) for adults - 2-4 ml for - Relanium (0.5% solution) for adults - 2-4 ml for children under 6 months - 0.3-0.5ml, from 7 months children under 6 months - 0.3-0.5ml, from 7 months to 2 years - 0.5-1 ml, over 2 years - 1 - 2 ml;to 2 years - 0.5-1 ml, over 2 years - 1 - 2 ml;- Sodium hydroxybutyrate 20% solution for adults - Sodium hydroxybutyrate 20% solution for adults - 20 ml intravenously, children(5% solution) - - 20 ml intravenously, children(5% solution) - 100 mg / kg;100 mg / kg;- Chloramphenicol succinate (25 mg / - Chloramphenicol succinate (25 mg / kg) intravenously or intramuscularly.kg) intravenously or intramuscularly.

► Compulsory hospitalization in intensive care unit Compulsory hospitalization in intensive care unit of a hospital infection after theseof a hospital infection after these events.events.

Hypovolemic shock in acute intestinal infectionsHypovolemic shock in acute intestinal infections► Emergency Conditions due to dehydration syndrome Emergency Conditions due to dehydration syndrome

in infectious diseases,in infectious diseases, usually develop acute intestinal usually develop acute intestinal infection (foodborne diseases, includinginfection (foodborne diseases, including gastrointestinal forms of salmonellosis, staphylococcal gastrointestinal forms of salmonellosis, staphylococcal intoxication, gastroenteritisintoxication, gastroenteritis of different etiologies, of different etiologies, cholera, etc.).cholera, etc.).

► Depending on the amount of fluid lost by Depending on the amount of fluid lost by the distinguishedthe distinguished          4 degrees of dehydration4 degrees of dehydration. Prehospital data to . Prehospital data to determine the degree of dehydration to focus on the determine the degree of dehydration to focus on the collection of clinicalcollection of clinical..

► When I degree of dehydration observed thirst, dry When I degree of dehydration observed thirst, dry mouth, cyanosis of lips, dry skin,mouth, cyanosis of lips, dry skin, stool 3-10 times a day.stool 3-10 times a day.

► In the II degree observedIn the II degree observed stools 10-20 stools 10-20 times a times a day, vomiting 10 times. In this caseday, vomiting 10 times. In this case there is dryness of there is dryness of the skin, mucous membranes, cyanosis of lips unstable, the skin, mucous membranes, cyanosis of lips unstable, fingersfingers and feet, thirst, leg cramps, hoarseness, shortness and feet, thirst, leg cramps, hoarseness, shortness of breath, decreased skin turgor, tachycardia, drop in of breath, decreased skin turgor, tachycardia, drop in blood pressure, reduced urine output up to anuria.blood pressure, reduced urine output up to anuria. Body Body temperature is normal.temperature is normal.

► When III degree of dehydrationWhen III degree of dehydration lost a large amount  lost a large amount of liquid stools and vomiting are very common (more than of liquid stools and vomiting are very common (more than 20 times a day). The above symptoms become more 20 times a day). The above symptoms become more pronounced: sharpened features, the pronounced: sharpened features, the eyeballs sink ("sunglasses"), skinfold not cracked down for eyeballs sink ("sunglasses"), skinfold not cracked down for 2-3 minutes, there is considerable shortness of 2-3 minutes, there is considerable shortness of breath, pulse and blood pressure are not determined.breath, pulse and blood pressure are not determined.

► In the IV degree of dehydration (algidnoy) In the IV degree of dehydration (algidnoy) body body temperature falls below normal(35,1-35,6 temperature falls below normal(35,1-35,6 ° C), cyanosis becomes generalized. Tonic ° C), cyanosis becomes generalized. Tonic convulsions. Anuria.convulsions. Anuria.     In dehydration grade IV there are all symptoms      In dehydration grade IV there are all symptoms of dehydration develop secondary changes in the of dehydration develop secondary changes in the major body systems.major body systems.     During algida no chair, vomiting stops, which can lead      During algida no chair, vomiting stops, which can lead to diagnostic errors.to diagnostic errors.

► Hospitalization of patients with severe and complicated Hospitalization of patients with severe and complicated forms of acute intestinal infections is required.forms of acute intestinal infections is required.

► An urgent therapeutic activity An urgent therapeutic activity in in patients with primary gipovolemic shock ispatients with primary gipovolemic shock is rehydration.rehydration.

► Rehydration is carried out by means of intravenous injection Rehydration is carried out by means of intravenous injection of an emergencyof an emergency water-electrolytic solutions water-electrolytic solutions (Trisol, isotonic NaCl solution, etc.).(Trisol, isotonic NaCl solution, etc.).

► The total amount required for initial rehydration, infusion of The total amount required for initial rehydration, infusion of funds is determined by the degree of dehydration.funds is determined by the degree of dehydration.

► Before rehydration should wash out the stomach with water or Before rehydration should wash out the stomach with water or 2% sodium2% sodium bicarbonate, as gagging not oporozh-t stomach.bicarbonate, as gagging not oporozh-t stomach.

► Gastric lavage is manifestedGastric lavage is manifested only be used in the only be used in the diagnosis and certainty that the patient has no heart attacks diagnosis and certainty that the patient has no heart attacks or acute surgical diseases of the abdominal cavity.or acute surgical diseases of the abdominal cavity.

► If the patient is conscious and can be liquid inside, it is useful at If the patient is conscious and can be liquid inside, it is useful at any stage (at home, in hospital) to begin oral rehydration.any stage (at home, in hospital) to begin oral rehydration.

► For this purpose, a solution containing 20 g glucose, 3.5 g NaCl, For this purpose, a solution containing 20 g glucose, 3.5 g NaCl, 2,5 g of sodium bicarbonate, 1.5 g KCl in 1 liter of boiled water.2,5 g of sodium bicarbonate, 1.5 g KCl in 1 liter of boiled water.

► The solution is given slowly, in small amounts to avoid vomiting.The solution is given slowly, in small amounts to avoid vomiting.► At home, the glucose can be replaced by eating sugar, NaCl At home, the glucose can be replaced by eating sugar, NaCl

- sodium chloride, and Na bicarbonate - baking soda.- sodium chloride, and Na bicarbonate - baking soda.

► Patients with I dehydration can restrict the introduction Patients with I dehydration can restrict the introduction of fluids orally.of fluids orally.

► In the II degree of dehydration is In the II degree of dehydration is administered intravenously at 100 ml / min,administered intravenously at 100 ml / min, crystalloid solutions in the volume of 3-4 liters.crystalloid solutions in the volume of 3-4 liters.

► Further correction of violations of water-salt should be Further correction of violations of water-salt should be carried out by intravenous drip infusion in an carried out by intravenous drip infusion in an amount equal to the losses.amount equal to the losses.

► In patients with III and IV rehydration dehydration is the In patients with III and IV rehydration dehydration is the nature of critical carenature of critical care benefits.benefits.

► Infusions (atsesol, hlosol, Trisol) pre-Infusions (atsesol, hlosol, Trisol) pre-hospital administered at up to 120 ml / min (5-7 x 1-hospital administered at up to 120 ml / min (5-7 x 1-1.5 h).1.5 h).

► The total volume of infusion administered for the first The total volume of infusion administered for the first 3-5 days of treatment may range from 20 to 60 liters.3-5 days of treatment may range from 20 to 60 liters.

► Pressor amines, cardiovascular drugs in patients Pressor amines, cardiovascular drugs in patients with syndrome of dehydration are not shown.with syndrome of dehydration are not shown.

► Antibiotics do not play a decisive role in the fight Antibiotics do not play a decisive role in the fight against cholera, salmonellosisagainst cholera, salmonellosis and foodborne diseases, and foodborne diseases, and therefore the pre-hospital emergency medical and therefore the pre-hospital emergency medical evacuation if not appointed.evacuation if not appointed.

► Extremely important epidemiologic and Extremely important epidemiologic and clinical significance of pathological clinical significance of pathological material fence (faeces, vomitus, contaminated linen), material fence (faeces, vomitus, contaminated linen), as well as the alleged objectsas well as the alleged objects of transmission (water, of transmission (water, food and other objects of the environment) as soon food and other objects of the environment) as soon as the detection of the patient.as the detection of the patient.

► Sampling using sterile orSampling using sterile or washed by boiled washed by boiled water  dishes.water  dishes.

► Material take glass Material take glass or wooden sticks or sterile spoons boiled, placed in a or wooden sticks or sterile spoons boiled, placed in a glass jar or in a sterile tube, closed glass jar or in a sterile tube, closed with impermeable stoppers.with impermeable stoppers.

► For the sampling of material in patients with For the sampling of material in patients with severe gastroenteritis, you can use a severe gastroenteritis, you can use a rubber catheter, one end of which is introduced into rubber catheter, one end of which is introduced into the rectum and the other is lowered into the tube.the rectum and the other is lowered into the tube.

► Any material to be transported to the Any material to be transported to the laboratory hospital.laboratory hospital.

► In the direction of bacteriological testing indicates the In the direction of bacteriological testing indicates the name, first name the patient, name of the material, name, first name the patient, name of the material, the diagnosis, the date and time of sampling.the diagnosis, the date and time of sampling.

► Treatment of children in the first two years of Treatment of children in the first two years of life with acute intestinal infections with life with acute intestinal infections with exsicosis (hypovolemic shock) has features that exsicosis (hypovolemic shock) has features that require registration for a favorable outcome.require registration for a favorable outcome.

► Exsicosis in this case - soledefitsitny or isotonic.Exsicosis in this case - soledefitsitny or isotonic.► The clinical picture of hypovolemic shock, The clinical picture of hypovolemic shock, I degree I degree

(5% loss of initial body weight) is characterized by (5% loss of initial body weight) is characterized by thirst, infrequent diarrhea and vomiting, restlessness.thirst, infrequent diarrhea and vomiting, restlessness.

► In the II degree In the II degree (loss of 5 to 10% of body weight) (loss of 5 to 10% of body weight) appears disorders of hemodynamics, marked dryness of appears disorders of hemodynamics, marked dryness of the skin and mucous membranes, sunken fontanel large, the skin and mucous membranes, sunken fontanel large, poor tissue turgor, tachycardia, drop in blood pressure.poor tissue turgor, tachycardia, drop in blood pressure.

► In the III degreeIn the III degree of dehydration (loss of more than 10%  of dehydration (loss of more than 10% of body weight) the child is in soporose state, there of body weight) the child is in soporose state, there are shortness of breath, acrocyanosis, anuria.are shortness of breath, acrocyanosis, anuria.

► It should be noted that the It should be noted that the children quickly comes decompensation, often children quickly comes decompensation, often associated with fever, general toxic phenomena are associated with fever, general toxic phenomena are always observed neurological disorders due to brain always observed neurological disorders due to brain edema in the background of dehydration and shock, with edema in the background of dehydration and shock, with his characteristic hemodynamic disturbances.his characteristic hemodynamic disturbances.

► Prehospital in II and III degree of dehydration necessary Prehospital in II and III degree of dehydration necessary to carry out urgent remedial measures.to carry out urgent remedial measures.

► When I degree of dehydration for children ages 1 year When I degree of dehydration for children ages 1 year to 5 years imposed 75-140ml / kg, 6-10 years - 75-to 5 years imposed 75-140ml / kg, 6-10 years - 75-125 ml / kg of fluid per day, respectively, at the II 125 ml / kg of fluid per day, respectively, at the II degree -160-180 ml  / kg and 120 ml / kg, III degree degree -160-180 ml  / kg and 120 ml / kg, III degree - 220-175 ml / kg and 130 ml / kg of crystalloid infusion.- 220-175 ml / kg and 130 ml / kg of crystalloid infusion.

► If the patient's body weight accurately known, If the patient's body weight accurately known, the approximate calculation is made on the II degree of the approximate calculation is made on the II degree of shock.shock.

► It is important to bear in mind that if you have It is important to bear in mind that if you have diarrhea, and in particular with cholera, children, unlike diarrhea, and in particular with cholera, children, unlike adults, are losing more and less potassium adults, are losing more and less potassium ions - sodium in children along with this rapidly ions - sodium in children along with this rapidly developing hypoglycemia.developing hypoglycemia.

► The infusion rate in children The infusion rate in children should be considerably less than that of adults: 30 ml should be considerably less than that of adults: 30 ml /kg body weight in the first hour of /kg body weight in the first hour of administration, subsequent - 10-20 ml / kg.administration, subsequent - 10-20 ml / kg.

► E.K. Tsybulkin (1987) recommends that children E.K. Tsybulkin (1987) recommends that children with stage II-III "angidremic" shock to carry out with stage II-III "angidremic" shock to carry out emergency measures in the following sequence:emergency measures in the following sequence:

► 1) to ensure reliable access to the venous bed, early 1) to ensure reliable access to the venous bed, early childhood - venesection;childhood - venesection;

► 2) correction of metabolic acidosis and osmolarity of 2) correction of metabolic acidosis and osmolarity of plasma jet administration of sodium bicarbonate;plasma jet administration of sodium bicarbonate;

► 3) transfusion reopoliglyukina zhelatinolya or a dose 3) transfusion reopoliglyukina zhelatinolya or a dose of 10 ml / kg at 10 ml / min to increase blood of 10 ml / kg at 10 ml / min to increase blood pressure.pressure.

► If you have seizures before transportation you must If you have seizures before transportation you must enter relanium or sodium hydroxybutyrate.enter relanium or sodium hydroxybutyrate.

► These recommendations are important to do with These recommendations are important to do with the prevalence of toxicity in children.the prevalence of toxicity in children.

► In case of a exsicosis preference should be In case of a exsicosis preference should be given glucose saline.given glucose saline.

► Among the urgent measures in children, unlike Among the urgent measures in children, unlike adults, include antibiotics - recommended pre-adults, include antibiotics - recommended pre-hospital parenteral chloramphenicol succinate introdhospital parenteral chloramphenicol succinate introduce a dose of 20 mg / kg.uce a dose of 20 mg / kg.

Acute respiratory insufficiencyAcute respiratory insufficiency► ARI (Acute respiratory ARI (Acute respiratory

insufficiency) can accompany many infectious insufficiency) can accompany many infectious diseases, and worn as a vent, and parenchymal in diseases, and worn as a vent, and parenchymal in nature.nature.

► ARI violation occurs when the airway as a result of ARI violation occurs when the airway as a result of acute process in the larynx (diphtheria, acute process in the larynx (diphtheria, viral croup) or laryngospasm (rabies, tetanus).viral croup) or laryngospasm (rabies, tetanus).

► ARI ventilation character with paralysis of respiratory ARI ventilation character with paralysis of respiratory muscles is observed in patients with botulism, polio.muscles is observed in patients with botulism, polio.

TetanusTetanus► The development of the leading symptoms of the The development of the leading symptoms of the

disease caused by the action disease caused by the action tetanospazmina, which together with the blood and tetanospazmina, which together with the blood and possibly in peripheral nerves up the spinal cord possibly in peripheral nerves up the spinal cord and medulla oblongata and reticular formation and and medulla oblongata and reticular formation and affects the motor centers.affects the motor centers.

► Toxin relieves inhibitory Toxin relieves inhibitory influence neurons polisinaptich's neural circuits in motor influence neurons polisinaptich's neural circuits in motor neurons, because of the lack of inhibition of motor neurons, because of the lack of inhibition of motor neurons arise in constant currents of neurons arise in constant currents of д-вия д-вия not coordinated, and continually come to the muscles.not coordinated, and continually come to the muscles.

► There are a tonic muscle tension and frequent clonic There are a tonic muscle tension and frequent clonic seizures in response to any stimulus.seizures in response to any stimulus.

► Not exclude the possibility of direct Not exclude the possibility of direct effects on tetanospazmina neuromuscular synapses.effects on tetanospazmina neuromuscular synapses.

► Hitting the medulla oblongata, tetanospazmin alter the Hitting the medulla oblongata, tetanospazmin alter the activity of the respiratory center, may act on activity of the respiratory center, may act on the conducting system of the heart.the conducting system of the heart.

► Violated thermoregulation, metabolism, hypoxic acidosis Violated thermoregulation, metabolism, hypoxic acidosis develop tissue changes.develop tissue changes.

► Death usually occurs due to respiratory paralysis or from Death usually occurs due to respiratory paralysis or from asphyxia occurring during the tonic convulsions.asphyxia occurring during the tonic convulsions.

► The incubation approach of tetanus lasts from 1 day to 1 The incubation approach of tetanus lasts from 1 day to 1 month and very rare -more of this period (usually 7-10 days).month and very rare -more of this period (usually 7-10 days).

► As a rule, the severity of disease correlates with the time of As a rule, the severity of disease correlates with the time of incubation approach - the shorter the incubation, the incubation approach - the shorter the incubation, the harder the disease.harder the disease.

► At the beginning of the disease may occur prodrom.At the beginning of the disease may occur prodrom. of phenomena in the form of general weakness, sweating, of phenomena in the form of general weakness, sweating, paresthesia in the wound, muscle tension around it.paresthesia in the wound, muscle tension around it.

► The first characteristic symptom is trismus - a The first characteristic symptom is trismus - a convulsive strain of masticatory muscles, muscle convulsive strain of masticatory muscles, muscle strain appears later face a change in its expression (sardonic strain appears later face a change in its expression (sardonic smile).smile).

► Later tonic tension grabs the back muscles, chest, abdomen, Later tonic tension grabs the back muscles, chest, abdomen, extremities.extremities.

► Appear severe muscle pains.Appear severe muscle pains.► The body of a patient can take a variety of position, most The body of a patient can take a variety of position, most

often occurs crowding the head with an arched arching of the often occurs crowding the head with an arched arching of the spine (opisthotonus).spine (opisthotonus).

► Against the background of tonic tension in the Against the background of tonic tension in the muscles of small external stimuli(light, a breath of air, the muscles of small external stimuli(light, a breath of air, the sound, rustling, etc.) having seizures clonic convulsions which sound, rustling, etc.) having seizures clonic convulsions which follow one after the other.follow one after the other.

► Duration of seizures, their frequency determines the severity of Duration of seizures, their frequency determines the severity of the disease.the disease.

► Patient consciousness is preserved.Patient consciousness is preserved.► Body temperature is usually increased.Body temperature is usually increased.► Characterized sweating, Characterized sweating,

severe tachycardia, especially during an attack of severe tachycardia, especially during an attack of convulsions.convulsions.

► Urine and feces is difficult.Urine and feces is difficult.► In the event of seizures of respiratory In the event of seizures of respiratory

muscles and diaphragm, there are signs of muscles and diaphragm, there are signs of choking, laryngeal spasm, during which the patient may choking, laryngeal spasm, during which the patient may die of asphyxia.die of asphyxia.

► Very hard proceeds neonatal tetanus - mortality is 80-Very hard proceeds neonatal tetanus - mortality is 80-100%.100%.

► Gateway for neonatal tetanus is usually umbilical Gateway for neonatal tetanus is usually umbilical wound in its sterile processing or contamination of the wound in its sterile processing or contamination of the ground.ground.

► Development of neonatal tetanus observed in the first Development of neonatal tetanus observed in the first days after birth.days after birth.

► Death occurs in 3 to 4 days after infection and usually Death occurs in 3 to 4 days after infection and usually on 7-8th day after birth.on 7-8th day after birth.

► Between the date of onset and day of death is from 1 to Between the date of onset and day of death is from 1 to 14 days, but more often - 2-3 days.14 days, but more often - 2-3 days.

► The first signs of illness: the child becomes restless, The first signs of illness: the child becomes restless, does not open his mouth, can not suck because does not open his mouth, can not suck because of spasms of masticatory muscles.of spasms of masticatory muscles.

► The skin on his forehead wrinkled, his The skin on his forehead wrinkled, his eyelids closed, her lips compressed, mouth eyelids closed, her lips compressed, mouth corners are lowered - the equivalent of a corners are lowered - the equivalent of a sardonic smile.sardonic smile.

► Following this, there are convulsive Following this, there are convulsive seizures, muscle rigidity comes from the seizures, muscle rigidity comes from the general opisthotonos; tonic convulsions are general opisthotonos; tonic convulsions are accompanied by fever.accompanied by fever.

► Contact with the child, the noise contributed frequent Contact with the child, the noise contributed frequent attacks of tonic seizures.attacks of tonic seizures.

► Tendon reflexes were increased.Tendon reflexes were increased.► During the seizure of respiratory During the seizure of respiratory

muscles and diaphragm child can die of asphyxia.muscles and diaphragm child can die of asphyxia.

► Tactics emergency doctorTactics emergency doctor is primarily  is primarily to organize a safe hospital stay.to organize a safe hospital stay.

► You must You must call for hospitalization resuscitation transport call for hospitalization resuscitation transport (ambulance) with respiratory equipment and tools (ambulance) with respiratory equipment and tools necessary for the treatment of tetanus.necessary for the treatment of tetanus.

► Evacuation of the patient to a specialized Evacuation of the patient to a specialized hospital to go with the resuscitation.hospital to go with the resuscitation.

► Treatment should begin immediately, even at Treatment should begin immediately, even at the prehospital stage.the prehospital stage.

► Use anti tetanus serum in a dose of 100 000 Use anti tetanus serum in a dose of 100 000 IU intramuscularly with pre-desensitization.IU intramuscularly with pre-desensitization.

► Parallel to impose anti tetanus toxoid in 0.5-1 ml.Parallel to impose anti tetanus toxoid in 0.5-1 ml.► These drugs is not in the bag emergency These drugs is not in the bag emergency

doctor, but they must be entered in the doctor, but they must be entered in the trauma section or in the emergency room hospital.trauma section or in the emergency room hospital.

► Each of the drugs is injected by different needles to Each of the drugs is injected by different needles to different parts of the body.different parts of the body.

► With frequent andWith frequent and severe convulsions with respiratory disorders administered large severe convulsions with respiratory disorders administered large doses of drugs neyroplegic in combination with intramuscular doses of drugs neyroplegic in combination with intramuscular injection ofinjection of barbiturates.barbiturates.

► Recommended for adults neyroplegic mixture contains 2.5% Recommended for adults neyroplegic mixture contains 2.5% solution of chlorpromazine - 2 ml, 2% solution of chlorpromazine - 2 ml, 2% solution omnopona (or promedola) - 1 ml 2% solutionsolution omnopona (or promedola) - 1 ml 2% solution dimedrola -dimedrola -1 ml, 0.05% scopolamine solution - 0.5 ml.1 ml, 0.05% scopolamine solution - 0.5 ml.

► It is advisable to follow the hospital to introduce this mixture 4-5 It is advisable to follow the hospital to introduce this mixture 4-5 times a day in combination with barbiturates (2 g / day).times a day in combination with barbiturates (2 g / day).

► Children under 1 year are 0.5% solution relanium - 0.5 ml over - 1 Children under 1 year are 0.5% solution relanium - 0.5 ml over - 1 to 2 ml, Nato 2 ml, Na hydroxybutyrate (0.5 ml / kg), short-hydroxybutyrate (0.5 ml / kg), short-acting barbiturate (hexenal 1% solution - 15 mg / kg, acting barbiturate (hexenal 1% solution - 15 mg / kg, chlorpromazine 2.5% solution-0, 02 ml / kg).chlorpromazine 2.5% solution-0, 02 ml / kg).

► You can use a single dose of penicillin 30 000 units / You can use a single dose of penicillin 30 000 units / kg, tetracycline 5 mg / kg chloramphenicol succinate or 20 mg / kg, tetracycline 5 mg / kg chloramphenicol succinate or 20 mg / kgkg

► In the treatment of very severe tetanus with muscle In the treatment of very severe tetanus with muscle relaxation requires transfer of a patient on long-term mechanical relaxation requires transfer of a patient on long-term mechanical ventilation.ventilation.

► To do this, carry out a tracheotomy, and as soon as possible, To do this, carry out a tracheotomy, and as soon as possible, because increase the frequency and duration of attacks creates because increase the frequency and duration of attacks creates great difficulties for intubation and tracheotomy, and great difficulties for intubation and tracheotomy, and often share it impossible.often share it impossible.

► Introduction miorel- santo eliminates the need for the Introduction miorel- santo eliminates the need for the appointment of other anticonvulsive funds.appointment of other anticonvulsive funds.

BotulismBotulism► Botulism in the mechanism of transfer refers to a Botulism in the mechanism of transfer refers to a

group of intestinal infections.group of intestinal infections.► The disease is often characterized by severe, due The disease is often characterized by severe, due

to damage to the nervoussystem and to damage to the nervoussystem and the development of the ABI.the development of the ABI.

► The causative agent of The causative agent of botulism - S1.botulinumbotulism - S1.botulinum - produces  - produces a powerful exotoxin, depending on the antigenic a powerful exotoxin, depending on the antigenic structure which distinguish 6 types of Clostridium: A, structure which distinguish 6 types of Clostridium: A, B,C, D, E, F.B,C, D, E, F.

► Each type of toxin can be neutralized only by Each type of toxin can be neutralized only by homologous antiserum.homologous antiserum.

► Once in the body with contaminated food, he has a Once in the body with contaminated food, he has a particular tropism for the nervous system.particular tropism for the nervous system.

► The toxin acts on the motor cells of the spinal cord The toxin acts on the motor cells of the spinal cord and medulla oblongata, inhibits the transmission and medulla oblongata, inhibits the transmission of neuromuscular impulses that clinically impaired, spof neuromuscular impulses that clinically impaired, speech and swallowing and breathing due to central and eech and swallowing and breathing due to central and peripheral lesions of intercostal and peripheral lesions of intercostal and diaphragmatic muscles.diaphragmatic muscles.

► The incubation period The incubation period for botulism lasts from for botulism lasts from several hours to 15 days.several hours to 15 days.

► Short incubation period, usually portends a severe Short incubation period, usually portends a severe course of illness because of the massive revenues of course of illness because of the massive revenues of toxin in the body.toxin in the body.

► The disease begins gradually, nausea, The disease begins gradually, nausea, vomiting, sometimes diarrhea, which is due vomiting, sometimes diarrhea, which is due to paresis of the intestine is quickly replaced to paresis of the intestine is quickly replaced by constipation.by constipation.

► Body temperature is usually normal in this case.Body temperature is usually normal in this case.► After 12-24 hours of onset neurological After 12-24 hours of onset neurological

symptoms occur: blurred vision, diplopia, ptosis.symptoms occur: blurred vision, diplopia, ptosis.► Eye symptoms - early and characteristic feature Eye symptoms - early and characteristic feature

of botulism.of botulism.► On examination revealed dilated On examination revealed dilated

pupils, their sluggish reaction to light the horizontal pupils, their sluggish reaction to light the horizontal and vertical nystagmus and vertical nystagmus (Ophthalmoplegic syndrome).(Ophthalmoplegic syndrome).

► Because of paresis and paralysis of the larynx, Because of paresis and paralysis of the larynx, pharynx, soft palate observeddysphagia, dysphonia, pharynx, soft palate observeddysphagia, dysphonia, dysarthria (disfagic syndrome), there paresis neck, dysarthria (disfagic syndrome), there paresis neck, pper extremities.pper extremities.

► In severe cases develop paresis and paralysis of In severe cases develop paresis and paralysis of respiratory muscles.respiratory muscles.

► In children, there is a similar clinical picture.In children, there is a similar clinical picture.► There have constipation and urinary retention.There have constipation and urinary retention.► Symptoms of botulism in infants is of special Symptoms of botulism in infants is of special

features: muscle weakness, impaired features: muscle weakness, impaired sucking, swallowing, ptosis, mydriasis and ophthalmopsucking, swallowing, ptosis, mydriasis and ophthalmoplegia on the background of a normal body legia on the background of a normal body temperature and unchanged cerebrospinal fluidtemperature and unchanged cerebrospinal fluid

► Due to the fact that the efficacy of therapeutic Due to the fact that the efficacy of therapeutic measures is largely dependent on the timing of their measures is largely dependent on the timing of their implementation, early diagnosis is of particular implementation, early diagnosis is of particular importance.importance.

► Most important are the Most important are the identification and ophthalmoplegic disfagic identification and ophthalmoplegic disfagic syndromes, weakness of skeletal muscle at normal syndromes, weakness of skeletal muscle at normal body temperature and the absence of diarrhea.body temperature and the absence of diarrhea.

► Important epidemiological history: the group of Important epidemiological history: the group of disease in people who ate the disease in people who ate the same product (usually canned food, dried fish, same product (usually canned food, dried fish, meats, juice, home-made).meats, juice, home-made).

► When the diagnosis the doctor must take the When the diagnosis the doctor must take the vomit and food products in sterile jars and tubes.vomit and food products in sterile jars and tubes.

► The material should be immediately transported to The material should be immediately transported to the laboratory, since botulinum toxin is quickly the laboratory, since botulinum toxin is quickly destroyed.destroyed.

► The need for emergency care when botulism is The need for emergency care when botulism is caused not only the severity of the patient, but also caused not only the severity of the patient, but also the uncertainty of the forecast.the uncertainty of the forecast.

► There have been cases of sudden deaths There have been cases of sudden deaths from paralytic syndrome intensified with the end from paralytic syndrome intensified with the end result of asphyxia, even in severe illness.result of asphyxia, even in severe illness.

► All patients with botulism be hospitalized in an All patients with botulism be hospitalized in an infectious hospital.infectious hospital.

► The main objectives The main objectives of emergency of emergency in botulism include elimination, in botulism include elimination, binding and elimination of toxins from the body, as binding and elimination of toxins from the body, as well as the maintenance of respiratory and well as the maintenance of respiratory and cardiovascular systems.cardiovascular systems.

► Respiratory failure in botulism increases in cases of Respiratory failure in botulism increases in cases of paresis or paralysis of the accession of the paresis or paralysis of the accession of the muscles of the pharynx and larynx, which muscles of the pharynx and larynx, which contributes to deterioration of the airway, the contributes to deterioration of the airway, the development of aspiration pneumonia and development of aspiration pneumonia and atelectasis.atelectasis.

► Sometimes, the immediate cause of death Sometimes, the immediate cause of death may be sudden cardiac arrest.may be sudden cardiac arrest.

► Immediate measures:Immediate measures:- Immediate gastric lavage through a thick tube, - Immediate gastric lavage through a thick tube, first with boiled water (for sampling to determine first with boiled water (for sampling to determine the toxin), and then 2% sodium bicarbonate (to the toxin), and then 2% sodium bicarbonate (to neutralize located in the gastrointestinal tract of neutralize located in the gastrointestinal tract of botulinum toxin);botulinum toxin);- Saline laxative (30 g MgSO4 in two cups of water);- Saline laxative (30 g MgSO4 in two cups of water);- Excessive drinking and frequent stimulation of - Excessive drinking and frequent stimulation of diuresis (gipotiazid, Lasix or other diuretics).diuresis (gipotiazid, Lasix or other diuretics).

► For delays in hospital along with these activities, starting For delays in hospital along with these activities, starting with the receptionist-patient should be with the receptionist-patient should be given antibotulinum antitoxic serum as the most effective given antibotulinum antitoxic serum as the most effective method for rapid neutralization of circulating toxin in the method for rapid neutralization of circulating toxin in the body.body.

► Prior to establishing the type of botulinum toxin is Prior to establishing the type of botulinum toxin is administered intramuscularly, preferably intravenously (in administered intramuscularly, preferably intravenously (in severe disease with afaq, aphonia, respiratory severe disease with afaq, aphonia, respiratory disorders) polyvalent serum types A, C and E in doses up disorders) polyvalent serum types A, C and E in doses up to 15 000 IU, Type B- 5,000 IU.to 15 000 IU, Type B- 5,000 IU.

► The best therapy is effective in the most severe course The best therapy is effective in the most severe course of botulism is achieved with of botulism is achieved with intravenous antibotulinum serum.intravenous antibotulinum serum.

► Seriously ill prehospital held non-specific infusion-Seriously ill prehospital held non-specific infusion-therapy disintoxication with forced diuresis.therapy disintoxication with forced diuresis.

► Enter also Neostigmine (0.05% solution) for adults of 2 Enter also Neostigmine (0.05% solution) for adults of 2 ml / m or subcutaneously, children under the age of 10 ml / m or subcutaneously, children under the age of 10 years - 0.02 ml / kg.years - 0.02 ml / kg.

► If ABI is due mainly bulbar paralysis, then as urgent If ABI is due mainly bulbar paralysis, then as urgent measures at any stage of the patient may measures at any stage of the patient may require intubation or tracheostomy and mechanical require intubation or tracheostomy and mechanical ventilation.ventilation.

SSevere complicated influenzaevere complicated influenza► The severity of the clinical course of disease in this The severity of the clinical course of disease in this

case is due to specificcase is due to specific influenza toxicity, additional influenza toxicity, additional bacterial complications (mainly pneumonia), the bacterial complications (mainly pneumonia), the exacerbation of underlying chronic diseases exacerbation of underlying chronic diseases and functional disorders of vital organs.and functional disorders of vital organs.

► Among the syndromes requiring emergency Among the syndromes requiring emergency treatment for the flu, are the majortreatment for the flu, are the major toxic toxic shock, ABI, cerebral edema, pulmonary edema.shock, ABI, cerebral edema, pulmonary edema.

► Signs of severe influenza are hyperthermia, severe Signs of severe influenza are hyperthermia, severe headache, repeated vomiting, fainting, headache, repeated vomiting, fainting, nosebleeds, bloody sputum, convulsive syndrome.nosebleeds, bloody sputum, convulsive syndrome.

► All patients with severe and complicated forms All patients with severe and complicated forms of influenza are subject to of influenza are subject to compulsory admission. Influenza in patients with compulsory admission. Influenza in patients with severe concomitant diseases, exacerbation severe concomitant diseases, exacerbation of chronic diseases, especially in the elderly, is also of chronic diseases, especially in the elderly, is also a reason fora reason for hospitalization.hospitalization.

► Emergency Treatment Prehospital conducted taking into Emergency Treatment Prehospital conducted taking into account the prevalence of a syndrome.account the prevalence of a syndrome.

► At the same regardless of the duration of At the same regardless of the duration of influenza illness is administered immune influenza illness is administered immune globulin (5 ml intramuscularly) and prednisolone (2 mg / globulin (5 ml intramuscularly) and prednisolone (2 mg / kg intramuscularly).kg intramuscularly).

► In the absence of influenza immunoglobulin can be In the absence of influenza immunoglobulin can be used for measles or the donorused for measles or the donor immunoglobulin.immunoglobulin.

► Usually after the administration of Usually after the administration of immunoglobulin through 4-6 h reduced body immunoglobulin through 4-6 h reduced body temperature, decreased symptoms of intoxication, the temperature, decreased symptoms of intoxication, the patient's conditionpatient's condition improves.improves.

► If not, it is recommended the reintroduction of the drug If not, it is recommended the reintroduction of the drug in the same dose. Childrenin the same dose. Children immunoglobulin is immunoglobulin is administered at a dose of 1-3 ml, depending on age.administered at a dose of 1-3 ml, depending on age.

► The presence of hyperthermia - a base for intramuscular The presence of hyperthermia - a base for intramuscular injection with analgininjection with analgin adimedrolom.adimedrolom.

► The antiviral drug rimantadine is most effective in the The antiviral drug rimantadine is most effective in the treatment of influenza caused by virus type treatment of influenza caused by virus type A, and only in the first three days of illness onset.A, and only in the first three days of illness onset.

► It is prescribed for adults of 0.05 g 3 times daily for 3 It is prescribed for adults of 0.05 g 3 times daily for 3 daysdays

► The presence in patients with severe influenza ABI with The presence in patients with severe influenza ABI with shortness of breath, acrocyanosis, rhythm shortness of breath, acrocyanosis, rhythm disturbances of breathing, chest pain, aphonia may be disturbances of breathing, chest pain, aphonia may be due todue to a hemorrhagic pulmonary edema, and early a hemorrhagic pulmonary edema, and early development of viral and bacterialdevelopment of viral and bacterial pneumonias focal or pneumonias focal or equity with a hemorrhagic equity with a hemorrhagic component, diffuse bronchiolitis.component, diffuse bronchiolitis.

► Among the most dangerous agents of Among the most dangerous agents of bacterial complications includebacterial complications include Staphylococcus aureus, Staphylococcus aureus, which causes in association with respiratory viruseswhich causes in association with respiratory viruses massive inflammatory foci of early destruction of the massive inflammatory foci of early destruction of the lungs.lungs.

► In addition, the severe pathology of the lungs may be In addition, the severe pathology of the lungs may be caused by caused by E. coliE. coli,, Pseudomonas aeruginosa, as well Pseudomonas aeruginosa, as well as non-clostridial anaerobes.as non-clostridial anaerobes.

► Very severe condition of patients as a Very severe condition of patients as a result of ABI and infectious-toxic shockresult of ABI and infectious-toxic shock requires emergency treatment to be carried requires emergency treatment to be carried out starting from the pre-hospitalout starting from the pre-hospital phase.phase.

► Lack of capacity verification of the etiology Lack of capacity verification of the etiology of emergency bronchiolitis and pneumonia and a of emergency bronchiolitis and pneumonia and a greater likelihood of staphylococcal greater likelihood of staphylococcal infection obliged to include in the infection obliged to include in the complex treatment of semi-synthetic complex treatment of semi-synthetic penicillins (oxacillin or methicillin in a single dose penicillins (oxacillin or methicillin in a single dose of 25-30 mg / kg) in combination with gentamicin (1-of 25-30 mg / kg) in combination with gentamicin (1-2mg/kg) orcephalosporins (30 mg / kg) in 2mg/kg) orcephalosporins (30 mg / kg) in combination with gentamicin (1.2 mg / kg).combination with gentamicin (1.2 mg / kg).

► You can use carbenicillin, tetraolean, erythromycin, You can use carbenicillin, tetraolean, erythromycin, doxycycline (Vibramycin) and other antibiotics.doxycycline (Vibramycin) and other antibiotics.

► Detoxification is carried out Detoxification is carried out using gemodeza, reopoliglyukin.using gemodeza, reopoliglyukin.

► Swelling of the brain or lungs intravenous Lasix (40-Swelling of the brain or lungs intravenous Lasix (40-80 mg for children - 1 mg / kg).80 mg for children - 1 mg / kg).

► In a severe influenza may develop a hemorrhagic In a severe influenza may develop a hemorrhagic syndrome in the form of epistaxis, hemoptysis, syndrome in the form of epistaxis, hemoptysis, vomiting with blood.vomiting with blood.

► Such patients show pre-hospital administration Such patients show pre-hospital administration of calcium gluconate, ascorbic acid, vikasola.of calcium gluconate, ascorbic acid, vikasola.

► Particularly noteworthy are sick, especially children, with Particularly noteworthy are sick, especially children, with symptoms neurotoxicosis,symptoms neurotoxicosis, with the pathology of the with the pathology of the lungs, hemorrhagic syndrome and other organ disorders.lungs, hemorrhagic syndrome and other organ disorders.

► Such patients simultaneously with the means of specific Such patients simultaneously with the means of specific therapy shows an urgenttherapy shows an urgent pathogenetic therapy aimed at pathogenetic therapy aimed at eliminating the excitement increased convulsive eliminating the excitement increased convulsive readiness or seizures.readiness or seizures.

► For deexcitation is used lytic mixture: 2.5% solution of For deexcitation is used lytic mixture: 2.5% solution of chlorpromazine, 1% solutionchlorpromazine, 1% solution dimedrol, 0.5% solution in dimedrol, 0.5% solution in age age ккelanium doses described above.elanium doses described above.

► Droperidol is used as a 0.25% solution of 0.25-0.3 ml / kg Droperidol is used as a 0.25% solution of 0.25-0.3 ml / kg intramuscularly orintramuscularly or intravenously.intravenously.

► It is advisable It is advisable to introduce aminophylline (2.4% solution) 0.1 ml / kg for to introduce aminophylline (2.4% solution) 0.1 ml / kg for children under 1 year of 0.05-0.1 ml / kg - for children children under 1 year of 0.05-0.1 ml / kg - for children older than 1 year, 5-10 ml - in the adult 5-10 older than 1 year, 5-10 ml - in the adult 5-10 ml 10% glucose solution.ml 10% glucose solution.

► Polisyyndrome pathology that occurs in Polisyyndrome pathology that occurs in severe influenza requires a great deal of individualization severe influenza requires a great deal of individualization of therapy, emergency pre-hospital, integrated approach, of therapy, emergency pre-hospital, integrated approach, becausebecause it can serve as a guarantee of a it can serve as a guarantee of a favorable outcome.favorable outcome.

DiphtheriaDiphtheria► Increased incidence of diphtheria, the emergence in Increased incidence of diphtheria, the emergence in

1992-1996. epidemic, mostly among adults, has 1992-1996. epidemic, mostly among adults, has set new challenges for doctors treating emergency set new challenges for doctors treating emergency conditions, developing in patients with conditions, developing in patients with severe toxic forms of diphtheria, characterized by a severe toxic forms of diphtheria, characterized by a total defeat for the tracheobronchial tree.total defeat for the tracheobronchial tree.

► The most common forms The most common forms of diphtheria diphtheria are mouth, pharynx, nose of diphtheria diphtheria are mouth, pharynx, nose and throat.and throat.

► On the areas covered stratified On the areas covered stratified epithelium (mouth), exotoxin diphtheria bacilli leads epithelium (mouth), exotoxin diphtheria bacilli leads to the formation of a to the formation of a dense, hard film withdrawn (difteritic inflammation).dense, hard film withdrawn (difteritic inflammation).

► On mucous membranes, coated one-On mucous membranes, coated one-layer epithelium (larynx, trachea), the film is easily layer epithelium (larynx, trachea), the film is easily removed (lobar inflammation).removed (lobar inflammation).

► A characteristic feature of toxic diphtheria of the A characteristic feature of toxic diphtheria of the pharynx and throat is swelling of pharynx and throat is swelling of cervical tissue or submandibular lymph nodes.cervical tissue or submandibular lymph nodes.

► Gipertoxic diphtheria is characterized by Gipertoxic diphtheria is characterized by sudden rapid onset, fever of 40 ° C, sudden rapid onset, fever of 40 ° C, repeated vomiting, disturbance of repeated vomiting, disturbance of consciousness, seizures.consciousness, seizures.

► Raids from tonsillectomy quickly spread to Raids from tonsillectomy quickly spread to the pharynx, larynx, cervical edema the pharynx, larynx, cervical edema progresses fiber.progresses fiber.

► In the most severe toxic diphtheria death can occur In the most severe toxic diphtheria death can occur already at the 2-5th day of illness due to the already at the 2-5th day of illness due to the development of infectious-toxic shock.development of infectious-toxic shock.

► Sudden deaths are observed in cases of Sudden deaths are observed in cases of severe myocarditis.severe myocarditis.

► The latter may be early - at 1-week and later - on the The latter may be early - at 1-week and later - on the 2nd and 4th week of illness onset and are 2nd and 4th week of illness onset and are accompanied by phenomena of severe heart failure.accompanied by phenomena of severe heart failure.

► Among the specific complications of diphtheria in a Among the specific complications of diphtheria in a timely manner undiagnosed throat, developing for 2 timely manner undiagnosed throat, developing for 2 to 4 weeks of illness, should be made polyradiculitis.to 4 weeks of illness, should be made polyradiculitis.

► The threat of death during the development of The threat of death during the development of severe diphtheria polyradiculoneuritis associated with severe diphtheria polyradiculoneuritis associated with damage to the nerves that innervate damage to the nerves that innervate the larynx,respiratory muscles and diaphragm, and heart.the larynx,respiratory muscles and diaphragm, and heart.

► Deaths may occur during the period of maximum Deaths may occur during the period of maximum development of symptoms polyradiculoneuritis (6-development of symptoms polyradiculoneuritis (6-8th week of the onset of the disease) with symptoms 8th week of the onset of the disease) with symptoms of ABI.of ABI.

► Typically, a complication occurs in patients, observed by Typically, a complication occurs in patients, observed by a physician with angina misdiagnosis and therefore did a physician with angina misdiagnosis and therefore did not receive diphtheria serum.not receive diphtheria serum.

► Diphtheria in such patients is Diphtheria in such patients is established retrospectively by the nature of established retrospectively by the nature of complications (paresis, and paralysis of the soft complications (paresis, and paralysis of the soft palate, polyradiculitis).palate, polyradiculitis).

► Mortality rates for diphtheria croup is Mortality rates for diphtheria croup is associated with asphyxia.associated with asphyxia.

► Forecast worsens when combined with Forecast worsens when combined with toxic diphtheria croup throat.toxic diphtheria croup throat.

There are There are three stages of diphtheria croup:three stages of diphtheria croup: ► Stage I Stage I (Stage lobar cough). There (Stage lobar cough). There

are rough "barking" cough, hoarseness.are rough "barking" cough, hoarseness.► Stage IIStage II (stage of stenosis). There have  (stage of stenosis). There have

been loud "sawing" the breath, aphonia, been loud "sawing" the breath, aphonia, participation in the act of participation in the act of breathing support muscles, inspiratory dyspnea.breathing support muscles, inspiratory dyspnea.

► Stage IIIStage III (stage of asphyxia). Join the signs of  (stage of asphyxia). Join the signs of oxygen deficiency with marked excitement, passing oxygen deficiency with marked excitement, passing into drowsiness, coma. Skin pallor, cyanosis, cold into drowsiness, coma. Skin pallor, cyanosis, cold sweat, tachycardia, signs of circulatory failure.sweat, tachycardia, signs of circulatory failure.

► Viral croup, diphtheria, in contrast Viral croup, diphtheria, in contrast to croup, develops, usually sudden, bypassing to croup, develops, usually sudden, bypassing the I, and sometimes stage II.the I, and sometimes stage II.

► With the purpose of treatment is applied high-With the purpose of treatment is applied high-purified hyperimmune horse serum "Diaferm."purified hyperimmune horse serum "Diaferm."

Principles of treatment of diphtheria serum:Principles of treatment of diphtheria serum:

► I. The objective is I. The objective is to maximize its early introduction, especially in patients to maximize its early introduction, especially in patients with toxic and hypertoxic diphtheria.with toxic and hypertoxic diphtheria.

► The optimal timing of the introduction of The optimal timing of the introduction of serum warning death, are considered the first hours of the serum warning death, are considered the first hours of the disease.disease.

► 2. Doses for administration are determined by the 2. Doses for administration are determined by the serum form of diphtheria(localized - 10-serum form of diphtheria(localized - 10-15 thousand AE, widespread - 50-100 thousand AE, toxic - 15 thousand AE, widespread - 50-100 thousand AE, toxic - 100-500 thousand AE).100-500 thousand AE).

► In the later stages of treatment the initial dose of In the later stages of treatment the initial dose of serum increases.serum increases.

► When diphtheria croup initial dose of serum in stage I - 15-When diphtheria croup initial dose of serum in stage I - 15-20 thousand AE, stage II- 30-50 thousand AU, and stage III - 20 thousand AE, stage II- 30-50 thousand AU, and stage III - 50-100 thousand AE.50-100 thousand AE.

► Complex pathogenetic therapy is conducted in Complex pathogenetic therapy is conducted in acute toxic diphtheria II and III level, with hypertoxic form.acute toxic diphtheria II and III level, with hypertoxic form.

► Its purpose - detoxification, the compensation of Its purpose - detoxification, the compensation of hemodynamic disturbances, swelling of the brain hemodynamic disturbances, swelling of the brain and adrenal insufficiency.and adrenal insufficiency.

► However, any therapeutic interventions can be effective However, any therapeutic interventions can be effective only with the simultaneous neutralization of diphtheria only with the simultaneous neutralization of diphtheria toxin, diphtheria serum to specific doses of the form of toxin, diphtheria serum to specific doses of the form of the disease.the disease.

► The onset of croup asfiksic stage is an indication The onset of croup asfiksic stage is an indication for intubation.for intubation.

► With With localized croup shows prolonged nasopharyngeal intubatilocalized croup shows prolonged nasopharyngeal intubation with plastictubes, in on with plastictubes, in advanced croup (diphtheria larynx and trachea) is advanced croup (diphtheria larynx and trachea) is required tracheotomy, followed by required tracheotomy, followed by removal elektroots. fibrinous films of the larynx, trachea removal elektroots. fibrinous films of the larynx, trachea and bronchi.and bronchi.

► Due to frequent complications Due to frequent complications of pneumonia, croup appropriate early use of antibiotics.of pneumonia, croup appropriate early use of antibiotics.

► Prehospital Emergency Physician must correctly establish Prehospital Emergency Physician must correctly establish the diagnosis of diphtheria, specify the form of location the diagnosis of diphtheria, specify the form of location (mouth, pharynx, nose, throat, etc.), according to the (mouth, pharynx, nose, throat, etc.), according to the severity (localized, toxic, its extent - I, II, severity (localized, toxic, its extent - I, II, III), select complications(toxic shock, myocarditis), the III), select complications(toxic shock, myocarditis), the stage of diphtheria larynx (catarrhal, stenotic, asfiksic).stage of diphtheria larynx (catarrhal, stenotic, asfiksic).

► Pathogenetic treatment of hyperthermia, an infectious-Pathogenetic treatment of hyperthermia, an infectious-toxic shock, ABI is the pre-hospital medication listed toxic shock, ABI is the pre-hospital medication listed above.above.

► Diphtheria serum on prehospital subject to immediate Diphtheria serum on prehospital subject to immediate hospitalization is not entered.hospitalization is not entered.

► The slowing of hospitalization for any reason in the The slowing of hospitalization for any reason in the presence of toxic diphtheria of the presence of toxic diphtheria of the pharynx, diphtheria croup I-II degree requires the pharynx, diphtheria croup I-II degree requires the introduction of diphtheria serum, corticosteroids, introduction of diphtheria serum, corticosteroids, and infusion solutions in the following sequenceand infusion solutions in the following sequence

- Intravenous injection of 2-5 mg / kg of prednisolone of - Intravenous injection of 2-5 mg / kg of prednisolone of 10-20 mg / kg10-20 mg / kg gidrokorti-zone, with no effect this dose is gidrokorti-zone, with no effect this dose is administered repeatedly at 20-30 ';administered repeatedly at 20-30 ';- The introduction of diphtheria serum to begin on 0.1 ml - The introduction of diphtheria serum to begin on 0.1 ml of a 3-fold every 10 min,of a 3-fold every 10 min, subcutaneously administered 30 subcutaneously administered 30 minutes remaining dose (200-300 thousand AE);minutes remaining dose (200-300 thousand AE);- Begin intravenous reopoliglyukin or 5% glucose - Begin intravenous reopoliglyukin or 5% glucose solution 10 ml / kg;solution 10 ml / kg;- Introduce a chloramphenicol succinate 25 mg / kg.- Introduce a chloramphenicol succinate 25 mg / kg.

► With signs of severe ABI - endotracheal With signs of severe ABI - endotracheal intubation or tracheostomy.intubation or tracheostomy.

► Based on analysis of the diphtheria epidemic of 1991-Based on analysis of the diphtheria epidemic of 1991-1995. have been supplemented and expanded our data on the 1995. have been supplemented and expanded our data on the urgent conditions in diphtheria and how to treat urgent conditions in diphtheria and how to treat them. In 154 patients who died of diphtheria, have been them. In 154 patients who died of diphtheria, have been clarified the cause of death and emergency conditions.clarified the cause of death and emergency conditions.

► Causes of death for patients were:Causes of death for patients were:- Asphyxia - 42.8%;- Asphyxia - 42.8%;- Myocarditis - 21.4%;- Myocarditis - 21.4%;- Myocarditis, and respiratory insufficiency - 21.4%;- Myocarditis, and respiratory insufficiency - 21.4%;- Polyneuropathy - 14.4%.- Polyneuropathy - 14.4%.

► The main cause of deaths from diphtheria was ABI (asphyxia), The main cause of deaths from diphtheria was ABI (asphyxia), alone or in combination with myocarditis.alone or in combination with myocarditis.

► The defeat of the respiratory tract and lungs in toxic, toxic The defeat of the respiratory tract and lungs in toxic, toxic and hemorrhagic formsand hemorrhagic forms of of combined diphtheria oropharynx in patients who died was combined diphtheria oropharynx in patients who died was characterized by:characterized by:- Discirculatory disorders with serous-hemorrhagic edema of - Discirculatory disorders with serous-hemorrhagic edema of the larynx andthe larynx and trachea, which simulated a major diphtheria, trachea, which simulated a major diphtheria, and in essence is an acute swelling of and in essence is an acute swelling of the throat and demanded adequate approaches to therapy;the throat and demanded adequate approaches to therapy;- Diphtheria croup localized with the presence of films only in - Diphtheria croup localized with the presence of films only in the larynx according to the autopsy and morphological studies the larynx according to the autopsy and morphological studies have not been observed.have not been observed.

► Characteristic is the rapid and early dissemination of films on Characteristic is the rapid and early dissemination of films on the tracheo-bronchialthe tracheo-bronchial tree with the development tree with the development of tracheobronchitis and bronchiolitis withof tracheobronchitis and bronchiolitis with broncho-obturation of broncho-obturation of bronchi fibrinous films with partial necrosis of their walls.bronchi fibrinous films with partial necrosis of their walls.

► Characteristic is the rapid and early dissemination of films on Characteristic is the rapid and early dissemination of films on the tracheo-bronchialtree with the development the tracheo-bronchialtree with the development of tracheobronchitis and bronchiolitis with broncho-obturation of of tracheobronchitis and bronchiolitis with broncho-obturation of bronchi fibrinous films with partial necrosis of their walls.bronchi fibrinous films with partial necrosis of their walls.Noted the presence of both traheobronhiolita and broncho-Noted the presence of both traheobronhiolita and broncho-bronchiolitis;bronchiolitis;- Diphtheritic pneumonia and pleuropneumonia was - Diphtheritic pneumonia and pleuropneumonia was first identified in conjunctionfirst identified in conjunction with pathomorphology, characterized by the presence with pathomorphology, characterized by the presence of fibrinous films in the bronchioles of of fibrinous films in the bronchioles of focal fibrinous exudate around the bronchioles and alveoli with a focal fibrinous exudate around the bronchioles and alveoli with a large number of corynebacteria.large number of corynebacteria.

► Bronchopneumonia were localized predominantly in the Bronchopneumonia were localized predominantly in the basal segments of the paracentral and lungs.basal segments of the paracentral and lungs.

► In some patients was accompanied by In some patients was accompanied by a serous pneumonia and pleurisy seroplastic with lots a serous pneumonia and pleurisy seroplastic with lots of corynebacteria in exudates.of corynebacteria in exudates.

Whooping coughWhooping cough► Severe bouts of coughing in children older than 2 Severe bouts of coughing in children older than 2

years may facilitate codeine -0,001-0,0075 g per reception, years may facilitate codeine -0,001-0,0075 g per reception, depending on age.depending on age.

► In adults, use codeine dose 0.01-In adults, use codeine dose 0.01-0.02 g ingestion or phenobarbital 0.05 g, 2 times 0.02 g ingestion or phenobarbital 0.05 g, 2 times a day in medicine.a day in medicine.

► Children who, after coughing constantly vomiting occurs, Children who, after coughing constantly vomiting occurs, designate 0.6% solution of designate 0.6% solution of atropine in 90% ethanol solution, 1-2 drops 4 times daily atropine in 90% ethanol solution, 1-2 drops 4 times daily before meals, atropine reduces vomiting but had little before meals, atropine reduces vomiting but had little effect on cough (a drop of solution contained 0.2 mg of effect on cough (a drop of solution contained 0.2 mg of atropine).atropine).

► Sometimes it is very effective method of Sometimes it is very effective method of chlorpromazine (chlorpromazine) in a dose of 0.5-1 mg / kg chlorpromazine (chlorpromazine) in a dose of 0.5-1 mg / kg 3 times a day.3 times a day.

► Study of broad-spectrum antibiotics has shown that Study of broad-spectrum antibiotics has shown that they can take a permanent place in the treatment they can take a permanent place in the treatment of whooping cough, at least, to prevent lung infections.of whooping cough, at least, to prevent lung infections.

► In catarrhal conditions, while in small In catarrhal conditions, while in small children - prophylactically administeredchildren - prophylactically administered erythromycin.erythromycin.

► In this case, cotrimoxazole and amoxicillin are less In this case, cotrimoxazole and amoxicillin are less effective.effective.

► Pneumonia complicating whooping cough, is always Pneumonia complicating whooping cough, is always accompanied by atelectasis accompanied by atelectasis and requires similar treatment with antibiotics and requires similar treatment with antibiotics and active physiotherapy.and active physiotherapy.

► Convulsions with whooping cough can be caused Convulsions with whooping cough can be caused by hypoxia, intracranial hemorrhage, by hypoxia, intracranial hemorrhage, or encephalopathy.or encephalopathy.

► Bout with whooping cough apnea usually occurs in Bout with whooping cough apnea usually occurs in children younger than 6 monthschildren younger than 6 months after the onset of after the onset of coughing.coughing.

► The body is pale or cyanotic, decreased muscle The body is pale or cyanotic, decreased muscle tone, possible convulsions.tone, possible convulsions.

► In severe cases a day are 12 such attacks.In severe cases a day are 12 such attacks.► For each child under the age of 1 year from severe For each child under the age of 1 year from severe

attacks of coughing with whooping cough, and for attacks of coughing with whooping cough, and for every child under the age of 6 months regardless every child under the age of 6 months regardless of the severity of seizures should be closely of the severity of seizures should be closely monitored during bouts of coughing.monitored during bouts of coughing.

► Ready to be electric pumps and an oxygen inhaler.Ready to be electric pumps and an oxygen inhaler.

Methods of treatment, you can use to quickly stop Methods of treatment, you can use to quickly stop the attack of apnea:the attack of apnea:1. Child is placed face down on the right 1. Child is placed face down on the right forearm and hand so that his legs huggedforearm and hand so that his legs hugged elbow area.elbow area.

► The index finger of right hand, entering it into The index finger of right hand, entering it into the baby's mouth, push forwardthe baby's mouth, push forward tounge.tounge.

► From the top left hand of the child is fixed to the From the top left hand of the child is fixed to the back.back.2. Hold your finger protruding tongue of the child, 2. Hold your finger protruding tongue of the child, producing artificial respiration by raising and producing artificial respiration by raising and lowering a child from a vertical to a horizontal lowering a child from a vertical to a horizontal position and vice versa.position and vice versa. Omitting Omitting the child breathe easier at the expense of pressure the child breathe easier at the expense of pressure on the back of his left hand.on the back of his left hand.3. If necessary, produce oxygen inhalation through a 3. If necessary, produce oxygen inhalation through a nasal catheter and remove thenasal catheter and remove the mucus by suction.mucus by suction.

CroupCroup► Hoarseness, cough (barking), Hoarseness, cough (barking),

and stridor are symptoms of croup. In most cases, and stridor are symptoms of croup. In most cases, croup is of infectious origin, most often the cause of croup is of infectious origin, most often the cause of this infection is parainfluenza virus 1.this infection is parainfluenza virus 1.

► Is divided Is divided into four clinical stages of croup.into four clinical stages of croup.► Stage I. Stage I. Hoarseness, sometimes progressing up Hoarseness, sometimes progressing up

to aphonia, barking cough, to aphonia, barking cough, inspiratory stridor appearance only with inspiratory stridor appearance only with exertion, stridor at rest is missing; fever.exertion, stridor at rest is missing; fever.

► Stage II.Stage II. Permanent stridor, indrawing on  Permanent stridor, indrawing on inspiration of the lower intercostal spacesand soft inspiration of the lower intercostal spacesand soft tissues of neck, part of the auxiliary muscles of tissues of neck, part of the auxiliary muscles of respiration, shortness of breath increases respiration, shortness of breath increases significantly with load.significantly with load.

► Stage III.Stage III. Signs of hypoxia and (or) delay of carbon  Signs of hypoxia and (or) delay of carbon dioxide: anxiety, agitation, sweating and shortness dioxide: anxiety, agitation, sweating and shortness of breath.of breath.

► Stage IV.Stage IV. Apnea, periodic or permanent, respiratory  Apnea, periodic or permanent, respiratory depression.depression.

TreatmentTreatment► Only patients with stage I of croup can be safely treated Only patients with stage I of croup can be safely treated

at home; II stage IV to beat home; II stage IV to be progressive over a few hours.progressive over a few hours.► Excluding the patient's diphtheria, place it in a tent Excluding the patient's diphtheria, place it in a tent

with humidified oxygen andwith humidified oxygen and assign (ren) Amoxicillin 125 assign (ren) Amoxicillin 125 mg every 8 hoursmg every 8 hours

► With laryngitis, caused by H.influenzae, mandatory use of With laryngitis, caused by H.influenzae, mandatory use of antibiotics.antibiotics.

► But now, when the vast majority of croup is caused by a But now, when the vast majority of croup is caused by a viral infection, sensuous to antibiotics, it is better to viral infection, sensuous to antibiotics, it is better to avoid potentially toxic drugs.avoid potentially toxic drugs.

► When symptoms of hypoxia (III cent.) Baby start When symptoms of hypoxia (III cent.) Baby start to inhale humidified O2, injectedto inhale humidified O2, injected intramuscularly, 40 intramuscularly, 40 mg of prednisolone and carefully observe the state.mg of prednisolone and carefully observe the state.

► After the introduction After the introduction of steroids may prompt improvement, in this of steroids may prompt improvement, in this case, continue to impose steroids in much smaller case, continue to impose steroids in much smaller doses over the next 2-3 days.doses over the next 2-3 days.

► Patients with stage IV croup patients with stage III Patients with stage IV croup patients with stage III disease, not responding totreatment konservennoe is disease, not responding totreatment konservennoe is required tracheotomy.required tracheotomy.

► Apply sedation in patients with croup dangerous, in the III Apply sedation in patients with croup dangerous, in the III century. When anxiety is a symptom of hypoxia, the use century. When anxiety is a symptom of hypoxia, the use of sedatives can not.of sedatives can not.

► Sometimes restless children in the II stage of croup can be Sometimes restless children in the II stage of croup can be given by mouth chloral hydrate (100 mg in children under 1 year given by mouth chloral hydrate (100 mg in children under 1 year old, 500 mg for children aged 5 years),but only if there is the old, 500 mg for children aged 5 years),but only if there is the possibility of persistently monitor the condition of the child.possibility of persistently monitor the condition of the child.

► Acute epiglottitis can cause death in the first 24 hours of the Acute epiglottitis can cause death in the first 24 hours of the disease. This is a raredisease. This is a rare and severe form of croup, in which and severe form of croup, in which the epiglottis is red and swollen appearance,the epiglottis is red and swollen appearance, marked shortness of marked shortness of breath and increasing stridor, as well as symptoms ofbreath and increasing stridor, as well as symptoms of toxemia caused by H. Influenzae, which is sure to be found in the toxemia caused by H. Influenzae, which is sure to be found in the blood and swabs from the throat.blood and swabs from the throat.

► When therapy is administered large doses When therapy is administered large doses of chloramphenicol (chloramphenicol)by mouth of chloramphenicol (chloramphenicol)by mouth or intravenously (but not by intramuscular injection) in or intravenously (but not by intramuscular injection) in combination with an emergency naso tracheal intubation of the combination with an emergency naso tracheal intubation of the trachea.trachea.

► This manipulation is safer than a tracheotomy, and it This manipulation is safer than a tracheotomy, and it must conduct a timely manner without delay.must conduct a timely manner without delay.

► Patients with paralysis of the diaphragm and (or) the intercostal Patients with paralysis of the diaphragm and (or) the intercostal muscles can be treated with a tank respirator, or cabinet type, muscles can be treated with a tank respirator, or cabinet type, provided that they have not violated swallowing and does not provided that they have not violated swallowing and does not accumulate outside the secret parts of the bronchial tree.accumulate outside the secret parts of the bronchial tree.

► If any suspicion of swallowing disturbances, If any suspicion of swallowing disturbances, delayed secretion in the throat or the delayed secretion in the throat or the bronchi must intubate the patient and attach to bronchi must intubate the patient and attach to the respirator through an endotracheal tube as the respirator through an endotracheal tube as long as there is no tracheotomy performed with the long as there is no tracheotomy performed with the introduction of a tracheostomy tube into the introduction of a tracheostomy tube into the trachea with the cuff.trachea with the cuff.

► After tracheotomy continues skillful ventilation with inAfter tracheotomy continues skillful ventilation with intermittent positive pressure on inspiration.termittent positive pressure on inspiration.

► Treatment of such patients is best done in a Treatment of such patients is best done in a specialized respiratory center.specialized respiratory center.

► Basic principles of management of patients Basic principles of management of patients who carried mechanical ventilation, are who carried mechanical ventilation, are the prevention of pneumonia by turning the patient on the prevention of pneumonia by turning the patient on his side every 2 hours, intensive chest his side every 2 hours, intensive chest physiotherapy, aspiration of secretion from the physiotherapy, aspiration of secretion from the bronchi, maintainingbronchi, maintaining tightness of the cuff, as well as in tightness of the cuff, as well as in monitoring the adequacy of ventilation inmonitoring the adequacy of ventilation in respiratory minute volume, frequency heart respiratory minute volume, frequency heart rate, blood pressure and RaSO2.rate, blood pressure and RaSO2.

► Treatment of patients with respiratory failure on the Treatment of patients with respiratory failure on the basis of destruction of lung tissue discussed above.basis of destruction of lung tissue discussed above.

Acute liver failure (ARF)Acute liver failure (ARF)► Development ARF observed in viral hepatitis (acute, Development ARF observed in viral hepatitis (acute,

chronic), cirrhosis of the liver.chronic), cirrhosis of the liver.► Acute liver failure Acute liver failure - a syndrome, which are the main - a syndrome, which are the main

features of encephalopathy, hemorrhagic syndrome, often features of encephalopathy, hemorrhagic syndrome, often - the smell of liver, progressive jaundice, reducing the - the smell of liver, progressive jaundice, reducing the size of the liver.size of the liver.

► Morphological substrate of acute liver failure is a Morphological substrate of acute liver failure is a diffuse degenerative changes of diffuse degenerative changes of hepatocytes or massive necrosis of the liver.hepatocytes or massive necrosis of the liver.

► In acute viral hepatitis leading cause of death of In acute viral hepatitis leading cause of death of patients is a massive liver necrosis.patients is a massive liver necrosis.

► Such forms of the disease called fulminant (lightning, Such forms of the disease called fulminant (lightning, malignant).malignant).

► However, the mortality rate in acute However, the mortality rate in acute hepatitis, primarily hepatitis B and C or mixed-hepatitis, primarily hepatitis B and C or mixed-aetiology, is 0.8-1.2%.aetiology, is 0.8-1.2%.

► A much greater problem is the severe form of chronic A much greater problem is the severe form of chronic viral hepatitis, especially in the stage of cirrhosis, in viral hepatitis, especially in the stage of cirrhosis, in which mortality is 8-10%.which mortality is 8-10%.

► In order to reduce the formation of toxins in the gut, In order to reduce the formation of toxins in the gut, including phenols, mercaptans, ammonia, including phenols, mercaptans, ammonia, and appropriate suppression of intestinal autoflora oral and appropriate suppression of intestinal autoflora oral administration of metronidazole, ciprofloxacin.administration of metronidazole, ciprofloxacin.

► Bowel with lactulose (30-50 ml of syrup per day).Bowel with lactulose (30-50 ml of syrup per day).► To reduce the inhibitory processes in the To reduce the inhibitory processes in the

CNS using nakom (or levodopa), restoring CNS using nakom (or levodopa), restoring the exchange of neurotransmitters (norepinephrine) to the exchange of neurotransmitters (norepinephrine) to reduce the swelling of the brain shows corticosteroids.reduce the swelling of the brain shows corticosteroids.

► Deserves special attention antiviral therapy - high Deserves special attention antiviral therapy - high doses of appointment doses of appointment tsimevena, adeninarabinozina, zeyfeksa (lamivudine), tsimevena, adeninarabinozina, zeyfeksa (lamivudine), interferons.interferons.

► This issue needs further discussion and study - the This issue needs further discussion and study - the duration of appointments, the dose determined by the duration of appointments, the dose determined by the level of viral replication, as well as the level of viral replication, as well as the above factors tend to provoke.above factors tend to provoke.

► The indications for emergency The indications for emergency hospitalization and treatment is a severe form of hospitalization and treatment is a severe form of viral hepatitis with increased risk of acute liver viral hepatitis with increased risk of acute liver failure.failure.

► The main clinical criteria for such status The main clinical criteria for such status - pronounced symptoms of intoxication(headache, - pronounced symptoms of intoxication(headache, dizziness, nausea, repeated vomiting, severe weakness), dizziness, nausea, repeated vomiting, severe weakness), andand hemorrhagic phenomena.hemorrhagic phenomena.

► The degree of severity of jaundice does not matter, The degree of severity of jaundice does not matter, because even in darker skinbecause even in darker skin may ikterichnost severe and extremely severe course of may ikterichnost severe and extremely severe course of hepatitis.hepatitis.

► Severe form of viral Severe form of viral hepatitis syndrome OPechN divided into four hepatitis syndrome OPechN divided into four stages;stages;- Precoma 1 - Precoma 1 - short-term shutdown of - short-term shutdown of consciousness, severe fatigue emotional consciousness, severe fatigue emotional lability, sleep rhythm disturbance, autonomic lability, sleep rhythm disturbance, autonomic dysfunction, tremor, or absent, mild ordysfunction, tremor, or absent, mild or pronounced, small size of the pronounced, small size of the liver, jaundice and observed hemorrhagic syndrome, liver, jaundice and observed hemorrhagic syndrome, which manifests itself often gastrointestinal bleeding;which manifests itself often gastrointestinal bleeding;- Precoma 2 - Precoma 2 - confused consciousness, there - confused consciousness, there is soporose state, patients are disoriented, you may is soporose state, patients are disoriented, you may experience psychomotor agitation, tremors, pronounced;experience psychomotor agitation, tremors, pronounced;

► - Coma 1 - Coma 1 (initial coma) - there is (initial coma) - there is no consciousness; preserved response to strong no consciousness; preserved response to strong stimuli, the size of the liver are reduced down to the stimuli, the size of the liver are reduced down to the "emptiness" in the right upper quadrant, may "emptiness" in the right upper quadrant, may experience convulsions, abnormal reflexes;experience convulsions, abnormal reflexes;

► - 2 coma (deep coma) - 2 coma (deep coma) - lack of consciousness, are- lack of consciousness, are flexia, the immediate causes of death in patients may flexia, the immediate causes of death in patients may be swelling of the brain, massive bleeding and septic be swelling of the brain, massive bleeding and septic complications.complications.

► Standard. treatment of patients with symptoms of viral Standard. treatment of patients with symptoms of viral hepatitis OPechN failurehepatitis OPechN failure includes a includes a set of pathogenic investigated in many centers Hepatitis.set of pathogenic investigated in many centers Hepatitis.

► The complex includes the infusion detoxication The complex includes the infusion detoxication therapy with elements of forcedtherapy with elements of forced diuresis, corticosteroids (2-5 mg / kg of diuresis, corticosteroids (2-5 mg / kg of prednisone or equivalent doses of other drugs), protease prednisone or equivalent doses of other drugs), protease inhibitors, vitamins, and is poorly absorbed in the gut with inhibitors, vitamins, and is poorly absorbed in the gut with antibiotics (to suppress the intestinal flora), oxygen antibiotics (to suppress the intestinal flora), oxygen therapy and a number of othertherapy and a number of other well-well-known medical activities.known medical activities.

► When you use the so-called standard therapy based When you use the so-called standard therapy based on controlled hemodilution in the complex therapeutic on controlled hemodilution in the complex therapeutic measures recommended include drugs such as albumin, measures recommended include drugs such as albumin, mannitol, levodopa, cytochrome C.mannitol, levodopa, cytochrome C.

► As a special treatment using exchange As a special treatment using exchange transfusion, hyperbaric oxygenation,transfusion, hyperbaric oxygenation, plasmasorption, plasmapheresis, hemosorption, plasmasorption, plasmapheresis, hemosorption, ultraviolet irradiation of blood, etc.ultraviolet irradiation of blood, etc.

► The success of acute care patients The success of acute care patients with precoma and coma depends on the timingwith precoma and coma depends on the timing of of its delivery, as in the stage of deep its delivery, as in the stage of deep coma mortality reaches 90-95%.coma mortality reaches 90-95%.

► This indicates the need for early diagnosis This indicates the need for early diagnosis of acute liver failure (stage precoma 1) of acute liver failure (stage precoma 1) and immediate hospitalization.and immediate hospitalization.

► Emergency hospitalization in the intensive care Emergency hospitalization in the intensive care unit and intensive care hospitalunit and intensive care hospital with a diagnosis with a diagnosis of infectious hepatitis with acute liver failure in of infectious hepatitis with acute liver failure in the stage of comathe stage of coma precoma 1-2 precoma 1-2 or 2.1 will gradually implement a program or 2.1 will gradually implement a program of comprehensive standard therapy and of comprehensive standard therapy and special treatments that would allow reduction special treatments that would allow reduction in mortality.in mortality.

Tactics emergency doctor:Tactics emergency doctor:► 1 The diagnosis, assessment of severity of the condition and safety 1 The diagnosis, assessment of severity of the condition and safety

of vital functions.of vital functions.Patients with precoma and coma may be taken into the Patients with precoma and coma may be taken into the compartment (chamber)of an infectious hospital resuscitation.compartment (chamber)of an infectious hospital resuscitation.Patients with severe viral hepatitis in the absence of manifest signs Patients with severe viral hepatitis in the absence of manifest signs of hepaticcoma precoma and should be considered of hepaticcoma precoma and should be considered as endangered group.as endangered group.They also require urgent admission to placement in department They also require urgent admission to placement in department (ward), intensive care unit.(ward), intensive care unit.2 Infusion therapy with the introduction of glucocorticoid 2 Infusion therapy with the introduction of glucocorticoid hormones (in the absencehormones (in the absence of hypovolemia and the possibility of hypovolemia and the possibility of emergency hospitalization) is not required.of emergency hospitalization) is not required.3 If you have agitation and signs of cerebral edema, which 3 If you have agitation and signs of cerebral edema, which often complicates the course of acute liver often complicates the course of acute liver failure, urgent measures any phase of treatment, includingfailure, urgent measures any phase of treatment, including pre-pre-hospital, are intravenously 2 ml 0.1% solution of Lasix (a child -hospital, are intravenously 2 ml 0.1% solution of Lasix (a child -0.1 ml / kg body weight), 0.25 ml / kg droperidol (0.25% solution) 0.1 ml / kg body weight), 0.25 ml / kg droperidol (0.25% solution) and 100 mg / kg of sodiumand 100 mg / kg of sodium hydroxybutyrate (20% in hydroxybutyrate (20% in solution intravenously).solution intravenously).

►

► It should be noted that hepatic coma is not a It should be noted that hepatic coma is not a contraindication to transport a patientcontraindication to transport a patient to a to a hospital accompanied by a doctor.hospital accompanied by a doctor.

► The correct approach to the emergency The correct approach to the emergency room physician assessment of severity ofroom physician assessment of severity of patient diagnosis, proper treatment can provide patient diagnosis, proper treatment can provide the necessary tactics of the patient, the necessary tactics of the patient, early intensive monitoring and treatment.early intensive monitoring and treatment.

Acute renal failureAcute renal failure

► ARF developed in cases involving infectious-ARF developed in cases involving infectious-toxic and hypovolemic shock in septictoxic and hypovolemic shock in septic forms forms of infections, malignant malaria, haemorrhagic fever with of infections, malignant malaria, haemorrhagic fever with renal syndrome (HFRS), leptospirosis.renal syndrome (HFRS), leptospirosis.

► For every infectious disease has features of the disease with its For every infectious disease has features of the disease with its inherent clinicalinherent clinical symptom.symptom.

► However, the presence of acute renal failure and determine However, the presence of acute renal failure and determine the common clinicalthe common clinical manifestations that develop in a certain manifestations that develop in a certain sequence.sequence.

► In the pathogenesis of acute renal failure in infectious In the pathogenesis of acute renal failure in infectious diseases are the leading rolediseases are the leading role of circulatory disturbances in the of circulatory disturbances in the kidney, hypoxia and edema of the interstitialkidney, hypoxia and edema of the interstitial tissue that violate tissue that violate the cross-tubules.the cross-tubules.

► This can result in the centralization of blood flow observed in This can result in the centralization of blood flow observed in infectious-toxic shock,infectious-toxic shock, or liquid part of or liquid part of blood loss during hypovolemic shock (circulatory anuria).blood loss during hypovolemic shock (circulatory anuria).

► Its pathogenesis is important, Its pathogenesis is important, and DIC syndrome in kidney capillariesmikrotrombirovaniemand DIC syndrome in kidney capillariesmikrotrombirovaniem

► With infectious diseases such as HFRS, leptospirosis, malaria, are With infectious diseases such as HFRS, leptospirosis, malaria, are significantsignificant disseminated extravascular coagulation, extravascular hemolysis disseminated extravascular coagulation, extravascular hemolysis with anemia andwith anemia and thrombocytopenia and metastasis-thrombocytopenia and metastasis-s agents in tubular epithelium.s agents in tubular epithelium.

► Pathologic substrate of the renal form of destruction of the Pathologic substrate of the renal form of destruction of the epithelium is Montubules, in advanced cases - tubular necrosis.epithelium is Montubules, in advanced cases - tubular necrosis.

► Clinically, this translates into the development of acute nephrotic Clinically, this translates into the development of acute nephrotic syndrome, manifested by proteinuria, edema, anuria.syndrome, manifested by proteinuria, edema, anuria.

► During acute renal failure are four stages: initial, oligoanuric,During acute renal failure are four stages: initial, oligoanuric, poliuric, recovery.poliuric, recovery.

► The main symptoms of it should be recalled for diagnosis of The main symptoms of it should be recalled for diagnosis of this serious conditionthis serious condition predominantly found in the competence of predominantly found in the competence of the emergency doctor.the emergency doctor.

► In the early stages are marked fever, symptoms of In the early stages are marked fever, symptoms of intoxication, hemorrhagicintoxication, hemorrhagic diathesis, and other diathesis, and other clinical manifestations of the disease, in which there is acute renal clinical manifestations of the disease, in which there is acute renal failure.failure.

► At this stage, urine output decreased slightly.At this stage, urine output decreased slightly.► In the second stage oligoanur diuresis decreases up to In the second stage oligoanur diuresis decreases up to

complete anuria.complete anuria.

► Body temperature is Body temperature is normal, and can subfebrilitet, pronounced hemorrhaginormal, and can subfebrilitet, pronounced hemorrhagicc syndrome.syndrome.

► Reveal a profound violation of water-electrolyte Reveal a profound violation of water-electrolyte metabolism and CBS, acidosis, hyperkalemia, metabolism and CBS, acidosis, hyperkalemia, hyponatremia, hypocalcemia and chloropenia, as well hyponatremia, hypocalcemia and chloropenia, as well as anemia, leukocytosis, increased ESR.as anemia, leukocytosis, increased ESR.

► Significantly increased urea and creatinine in the Significantly increased urea and creatinine in the blood, the patients' dyspepticblood, the patients' dyspeptic symptoms, nausea, symptoms, nausea, vomiting, dry mouth, abdominal pain and lower back,vomiting, dry mouth, abdominal pain and lower back, stomatitis, enterocolitis, respiratory rhythm is stomatitis, enterocolitis, respiratory rhythm is disturbed.disturbed.

► When there is severe overWhen there is severe over hydration first interstitial and then alveolar pulmonary hydration first interstitial and then alveolar pulmonary edema.edema.

► The ECG - signs of myocardial hypoxia, arrhythmias, The ECG - signs of myocardial hypoxia, arrhythmias, manifestations ofmanifestations of hyperkalemia.hyperkalemia.

► Body temperature is during this period even Body temperature is during this period even with advanced disease often is normal.with advanced disease often is normal.

► It is very characteristic CNS: headache, drowsiness, It is very characteristic CNS: headache, drowsiness, convulsions, coma.convulsions, coma.

► In the recovery stage of In the recovery stage of diuresis appears polyuria with low density of diuresis appears polyuria with low density of urine. Markedweakness, dizziness, and urine. Markedweakness, dizziness, and nausea. Detected hypokalemia, hyponatremia,nausea. Detected hypokalemia, hyponatremia, chloropenia.chloropenia.

► Often azotemia increases in the early Often azotemia increases in the early days poliurich stage, and only indays poliurich stage, and only in subsequent figures of subsequent figures of urea and creatinine decreased to normal values.urea and creatinine decreased to normal values.

► Long remain anemia, and thrombocytopenia.Long remain anemia, and thrombocytopenia.► In the stage of recovery shows signs of functional In the stage of recovery shows signs of functional

impairment of kidneys and other organs.impairment of kidneys and other organs.► Tactics emergency Tactics emergency

doctor is in immediate hospitalization in an intensive doctor is in immediate hospitalization in an intensive care unitcare unit hospital infection, indicating nosological hospital infection, indicating nosological diagnosis, which caused acute renal failure.diagnosis, which caused acute renal failure.

► It should be borne in mind HFRS symptomatology: an It should be borne in mind HFRS symptomatology: an acute onset of high fever, acute onset of high fever, hemorrhagic rash, abdominal pain in the lumbar hemorrhagic rash, abdominal pain in the lumbar region, the presence of myalgia.region, the presence of myalgia.

MalariaMalaria► Is a serious problem for the physician joint Is a serious problem for the physician joint

venture in connection with the growth "imported" malaria, venture in connection with the growth "imported" malaria, including tropical and, with the possible deaths.including tropical and, with the possible deaths.

► Assume the presence of malaria in febrile patients should Assume the presence of malaria in febrile patients should be applying for med.help in the following cases:be applying for med.help in the following cases:- Preceded by the patient stays in tropical countries and other - Preceded by the patient stays in tropical countries and other disadvantaged areas in malaria-during. last 2 years;disadvantaged areas in malaria-during. last 2 years;- If there is a history of malaria during the same time;- If there is a history of malaria during the same time;- Blood transfusion within 3 months before illness;- Blood transfusion within 3 months before illness;- In diseases with ongoing periodic rises in body - In diseases with ongoing periodic rises in body temperature, although carried out in temperature, although carried out in accordance with established diagnosis of treatment.accordance with established diagnosis of treatment.

► Patients should be gospitirovat in infectious hospital.Patients should be gospitirovat in infectious hospital.► Upon cancellation of the hospital immediately use blood Upon cancellation of the hospital immediately use blood

for malaria parasites and to start treatment, for which a for malaria parasites and to start treatment, for which a physician joint venture must be for the physician joint venture must be for the fence installation and supply of paints antimalaria drugs.fence installation and supply of paints antimalaria drugs.

► When serving on malaria from each patient should be When serving on malaria from each patient should be cooked for at least 3 drops of thick and thin smear.cooked for at least 3 drops of thick and thin smear.

► Standard acute treatment of uncomplicated forms of Standard acute treatment of uncomplicated forms of malaria with chloroquine(hingaminom, delagilom) at a malaria with chloroquine(hingaminom, delagilom) at a daily dose: children under 1 year - 0.05 g, from 1 to 6 daily dose: children under 1 year - 0.05 g, from 1 to 6 years old - 0,125 grams, from 7 to 10 years - 0.25 g, 10 years old - 0,125 grams, from 7 to 10 years - 0.25 g, 10 to 15 years - 0.5 g and adult - 1 yearto 15 years - 0.5 g and adult - 1 year

► The drug is taken after a meal, drunk plenty of water.The drug is taken after a meal, drunk plenty of water.► This is followed by a call to the clinic.This is followed by a call to the clinic.► Emergency conditions arise mainly in tropical cerebral Emergency conditions arise mainly in tropical cerebral

malaria, as well as gemoglobinuriy fever.malaria, as well as gemoglobinuriy fever.► Cerebral (comatose) malaria was observed in non-Cerebral (comatose) malaria was observed in non-

immune persons from endemic malaria areas.immune persons from endemic malaria areas.► The incubation period for falciparum malaria is The incubation period for falciparum malaria is

short, and therefore the patient or short, and therefore the patient or his relatives informed of their stay in foreign countrieshis relatives informed of their stay in foreign countries

► The clinical picture The clinical picture of malaria is comatose characteristics: disease of malaria is comatose characteristics: disease begins acutely with a fever up to 39,5-40 "C, with begins acutely with a fever up to 39,5-40 "C, with typical malaria triad: onset chills, fever, sweat.typical malaria triad: onset chills, fever, sweat.

► Against this background, in the early days of the Against this background, in the early days of the disease appears severe neurological disease appears severe neurological symptoms: painful headache, vomiting, psychomotor symptoms: painful headache, vomiting, psychomotor agitation, diplopia, anisocoria, agitation, diplopia, anisocoria, nystagmus, meningeal signs, seizures, stupor and coma.nystagmus, meningeal signs, seizures, stupor and coma.

► Often there are sub ikterichnost sclera Often there are sub ikterichnost sclera and skin, gepatolienalny syndrome.and skin, gepatolienalny syndrome.

► Blood pressure decreased, urine output decreases, it is Blood pressure decreased, urine output decreases, it is possible anuria.possible anuria.

► Crucial to the diagnosis Crucial to the diagnosis of malaria is comatose parasitological survey - detection of malaria is comatose parasitological survey - detection of the malaria parasite in the blood.of the malaria parasite in the blood.

► However, the presence of characteristic clinical However, the presence of characteristic clinical and epidemiological history is grounds and epidemiological history is grounds for immediate emergency treatment, starting with for immediate emergency treatment, starting with the pre-hospital phase.the pre-hospital phase.

► The sequence of events is as follows: blood samples for analysis, The sequence of events is as follows: blood samples for analysis, intravenousintravenous administration of 400 administration of 400 ml reopoliglyukin adult (children - 10 ml / kg), 5-10 ml of 5% ml reopoliglyukin adult (children - 10 ml / kg), 5-10 ml of 5% solution delagila (children - 0.2 ml / kg) - 5 mg / kg of solution delagila (children - 0.2 ml / kg) - 5 mg / kg of prednisolone, 60-80 mg of 1% solution Lasix (children - 0.1 ml / prednisolone, 60-80 mg of 1% solution Lasix (children - 0.1 ml / kg) - 5 ml 0.25% solution kg) - 5 ml 0.25% solution of droperidolintravenously or intramuscularly (children - 0.1 ml / of droperidolintravenously or intramuscularly (children - 0.1 ml / kg) or 2-4 ml of 0.5% seduksenasolution (children - 0.1 ml / kgkg) or 2-4 ml of 0.5% seduksenasolution (children - 0.1 ml / kg

► In countries where the dominant drug resistance falciparum In countries where the dominant drug resistance falciparum malaria, quinine is the drug of choice.malaria, quinine is the drug of choice.

► In the course of malignant malaria, quinine injected deep into the In the course of malignant malaria, quinine injected deep into the subcutaneous tissue in one day at a dose of 2 g (4 ml 25% subcutaneous tissue in one day at a dose of 2 g (4 ml 25% solution or 2 ml of 50% solution of quinine), twice with solution or 2 ml of 50% solution of quinine), twice with an interval between injections of 6-8 hoursan interval between injections of 6-8 hours

► In severe cases, make the first injection intravenously, by In severe cases, make the first injection intravenously, by introducing 0.5 g of quinine.introducing 0.5 g of quinine.

► To do this, 1 ml of 50% solution is diluted to 20 ml of 40% glucose To do this, 1 ml of 50% solution is diluted to 20 ml of 40% glucose solution and 20 ml 0.85% solution of NaCl.solution and 20 ml 0.85% solution of NaCl.

► Immediately after the intravenous infusion administered 0.5 g Immediately after the intravenous infusion administered 0.5 g (1 ml 50% solution)of quinine in the subcutaneous tissue.(1 ml 50% solution)of quinine in the subcutaneous tissue.

► The rest number of quinine (1 g) was administered The rest number of quinine (1 g) was administered subcutaneously at 6-8h.subcutaneously at 6-8h.

► Gemoglobinuriynaya fever is actually a Gemoglobinuriynaya fever is actually a complication of drug therapy, rather than the complication of drug therapy, rather than the severity of the malaria.severity of the malaria.

► Syndrome manifested acute renal failure and Syndrome manifested acute renal failure and severe general toxicity.severe general toxicity.

► It occurs as a result of massive hemolysis due to It occurs as a result of massive hemolysis due to lack of red blood cells in the enzyme glucose-6-lack of red blood cells in the enzyme glucose-6-phosphate dehydrogenase in patients treated phosphate dehydrogenase in patients treated with certain antimalarial with certain antimalarial drugs (quinine), sulfonamides, antipyretic (aspirindrugs (quinine), sulfonamides, antipyretic (aspirin).).

► In connection with massive hemolysis in the blood In connection with massive hemolysis in the blood to a large amount of hemoglobin, which is the to a large amount of hemoglobin, which is the cause of intoxication syndrome and acute renal cause of intoxication syndrome and acute renal failure.failure.

► Arrester at gemoglobinuriynoy fever is caused Arrester at gemoglobinuriynoy fever is caused by blockage of hemoglobin derivatives renal by blockage of hemoglobin derivatives renal tubules.tubules.

► In patients with falciparum malaria may have an In patients with falciparum malaria may have an additional value of renal vesselsadditional value of renal vessels occlusion parasites occlusion parasites and erythrocytes.and erythrocytes.

► Whatever the cause of acute renal Whatever the cause of acute renal failure have always been a violation of renalμ-circulation, failure have always been a violation of renalμ-circulation, swelling of the interstitial tissue, and metabolic acidosis.swelling of the interstitial tissue, and metabolic acidosis.

► With malaria complicated by acute renal failure, is subject With malaria complicated by acute renal failure, is subject to immediate hospitalization in the intensive care unit to immediate hospitalization in the intensive care unit of a hospital.of a hospital.

► Coma is not a contraindication for hospitalization.Coma is not a contraindication for hospitalization.► At the first sign of fever gemoglobinuriynoy (degradation, At the first sign of fever gemoglobinuriynoy (degradation,

dark brown urine, jaundice), you must immediately cancel dark brown urine, jaundice), you must immediately cancel the drugs that cause hemolysis (quinine, the drugs that cause hemolysis (quinine, sulfonamides, aspirin, etc.).sulfonamides, aspirin, etc.).

► As a means As a means of antimalarial treatment administered hingamin (delagil)of antimalarial treatment administered hingamin (delagil)..

► Showing plenty of drink, in / vennoe administration of 5% Showing plenty of drink, in / vennoe administration of 5% glucose solution, Ringer'sValium, laktasola with glucose solution, Ringer'sValium, laktasola with simultaneous stimulation of diuresis (Lasix, simultaneous stimulation of diuresis (Lasix, mannitol).Positive detoxification effect is mannitol).Positive detoxification effect is given glucocorticoids.given glucocorticoids.

► In conclusion, one should pay attention to the In conclusion, one should pay attention to the features and fast dynamics offeatures and fast dynamics of syndromes requiring emergency pre-syndromes requiring emergency pre-hospital treatment of patients with infectious hospital treatment of patients with infectious diseases.diseases.

► These features are due primarily to inherent each These features are due primarily to inherent each nosological form of clinical andnosological form of clinical and pathogenetic manifestations, as well pathogenetic manifestations, as well as age and premorbid factors that mightas age and premorbid factors that might account to account to determine the success of medical tactics.determine the success of medical tactics.

► It should be recalled that the causative It should be recalled that the causative factor (causative agent) always has afactor (causative agent) always has a leading role - leading role - both for the development of a medical emergency, both for the development of a medical emergency, and for its furtherand for its further progression or death.progression or death.

► This is oblige to the nosological diagnosis with the This is oblige to the nosological diagnosis with the release of the syndrome, a life-release of the syndrome, a life-threatening patient, and conducting etiologic and threatening patient, and conducting etiologic and pathogenetic emergency treatment.pathogenetic emergency treatment.

► Acting on the agent and neutralizing the toxins, we Acting on the agent and neutralizing the toxins, we reduce the intensity of thereduce the intensity of the constant constant "impulses" coming from the pathological focus."impulses" coming from the pathological focus.

► The need for urgent, immediate adjuvant therapy The need for urgent, immediate adjuvant therapy in the establishment of the in the establishment of the disease and syndrome, requiring intensive disease and syndrome, requiring intensive care benefits, due to the possibility ofcare benefits, due to the possibility of lightning and hypertoxic forms of infections in lightning and hypertoxic forms of infections in which prehospital tactics ofwhich prehospital tactics of the the patient determines the likelihood of recovery.patient determines the likelihood of recovery.

► Material provision of emergency pre-Material provision of emergency pre-hospital treatment of infectious diseases must be hospital treatment of infectious diseases must be provided not only during epidemics, but also provided not only during epidemics, but also in mezhepidemic time, with sporadic incidence.in mezhepidemic time, with sporadic incidence.

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