THE LOCAL (TOPICAL)

ANESTHESIA
Today 50% of the surgical operations are performed under
the local anesthesia.
Indications: are determined with its advantages:
Prolonged preoperative preparation of patient isn’t necessary;
It may be used with success, when narcosis is contraindicated;
Patient doesn’t need intensive supervision, as after the
narcosis;
It is useful in outpatient’s department;
It may be used with favorable results, when patient is very
old, week, with respiratory and cardiovascular insufficiency
when intubation narcosis may be more dangerous for patient’s
life, than surgical intervention.
 THE LOCAL (TOPICAL)
ANESTHESIA
Contraindications:
1. Intolerance (individual) of the anesthetic drugs, as a result of
individual hypersensitivity;
2. Age less than 10 years;
3. Psychological (mental) disturbance – excitement;
4. Local presence of inflammatory process and scars, which makes
impossible to perform infiltration anesthesia;
5. Continuing internal hemorrhage which needs the urgent
operation in aim to control the bleeding.
It is necessary to explain to the patient, that consciousness, tactile
and deep sensitivity, but not pain will be maintained during the
operation. Before the operation injection of Promedol, Suprastin
(Dimedrol), Maxigan (Baralgin) and Droperidol must be done in
aim to reduce neuropsychological stress.
 THE LOCAL (TOPICAL)
ANESTHESIA
Einhorn in 1905 introduced the Procaine (Novocain)
into the surgical practice.
A.Vishnewsky improved the anesthetic liquid:
Novocain - 2.5g, sodium chloride - 5g, potassium chloride
- 0.075g, calcium chloride -0.125g, distilled water - 1000ml
and 1:100 - diluted adrenaline (epinephrine) - 2ml.
Duration of local anesthesia with 0.5% or 0.25% sol. of
Novocain is up to 1.5h. Novocain is easily destroyed in
the blood serum, liver and has no accumulative action. It
is necessary to introduce 2g of this preparation (400ml of
0.5% sol. or 800ml 0.25% sol.) per each hour of operation.
 Preparations, used for topical anestesia

Efficacy in Toxic characteristic in

Concentration
Preparation comparison with comparison with Types of anesthesia
%
Novocain Novocain
Novocain
/Procain, allocain, - - 0.25-0.5-1-2 Superficial; Infiltration;
aminocain/
Intravenous;Conductive; Spinal;
5-10-20
Peridural
Lydocain
4 times 2 times 0.25-0.5-1-2 Superficial; Infiltration;
/Xilocain, Lignocain/
10 Intravenous;Conductive; Epidural
Sovcain
20 times 20 times 0.5-1 Spinal
/Optocain, Percain/
Dicain
15 times 10 times 0.25-0.5-1-2-3 Superficial, Peridural
/Anetain, Pantocain/
Trimecain /Mesocain/ 3 times 1.5 times 0.25-0.5-1-2 Conductive, Infiltration
Zcegnocain
/salt of Novocain and - - 0.25-0.5-1-2-3 Infiltration, Conductive, Peridural
cellulose glycolic acid/
Corticain
- - 1-2 Infiltration, Regional, Peridural
/Ultracain/
 THE LOCAL (TOPICAL)
ANESTHESIA
Periods of action of local anesthetics are divided on following
parts:
1. Administration of the local anesthesia preparation;
2. Period of waiting lasts 5-6 min in case of infiltration anesthesia
by A.Vishnewsky and 10 min in case of conductive anesthesia.
During this period anesthetic drug acts on the receptors and
nervous trunks;
3. Period of complete anesthesia lasts 1-2h.It is necessary to
repeat injections if this time in not enough to perform the
operation. Local anesthesia provides loss of sense of pain but not
reflexes and motor activity in case if the thick nervous trunks and
plexus;
4. Period of restoration of sensitivity: pain, which occurs in this
period must be arrested by means of narcotic analgesics, cold
(local hypothermia) and elevated position of the operated region.
 THE LOCAL (TOPICAL)
ANESTHESIA
Complications of local anesthesia includes poisoning with preparation
for local anesthesia, allergy, broncho- and laryngospasm are more
frequent if Cocaine, Dicain, Sovcain were used.
3 stages of poisoning with local anesthesia remedies are
distinguished:
I stage (light) - typical symptoms are: cold sweat, weakness, dizziness,
tachycardia with weak pulse, nausea, dispnea, dilatation of pupils;
II stage (moderate) - motoric excitement, hallucinations, fear,
delirium, tremor, cramps;
III stage (grave) - small, rapid, arrhythmic, sometimes slow (30 per
min) pulse, dilation of pupil’s, interrupted respiration, loss of
consciousness, paralysis of breathing center and death.
Treatment: Oxygenation, sodium bromide i.v., chloral hydrate per
rectum, artificial lung ventilation, transfusion of blood (after
exfussion) and blood substituents.
 METHODS OF LOCAL
ANESTHESIA
Classification:
1. by coating;
2. by irrigation;
3. by infiltration;
4. regional:
5. Conductive anesthesia:
a. of neural trunks (endoneural, perineural);
b. of neural plexus;
c. of neural nodules (paravertebral);
d. Spinal (subarachnoidal);
e. Peridural (epidural);
f. Intravenous;
g. Intra-arterial;
h. Intraosseous.
 METHODS OF LOCAL
ANESTHESIA
1. Anesthesia by coating (2. irrigation) is widely accepted in ophthalmology,
urology, otorhinolaryngology by the help of 1-10% sol. of Cocaine, Novocain (5-
10%), Dicain (0.25-3%), Sovcain (0.1%). For the broncho- and esophagoscopy is used
Dicain (0.5%) or Novocain (5-10%);
2. Infiltration anesthesia was introduced by Orlov (1887). Recklus (1889) and
Schleich (1891). In the very beginning of infiltration anesthesia it is necessary to
make “intradermal bleb of local anesthesia“ (cutis limonarium or cutis anserina)
with thin needle in aim to make anesthesia of the skin along the whole length of
the incision /fig. 38/. Then subcutaneous fatty tissue, fascia, aponeurosis, muscles
and other tissues (more deep layers) must be infiltrated. It is very useful to infiltrate
margins of operative area (field) to form rhomb (rhomboid anesthesia) or make
circular ”case “ anesthesia of the extremity (when limb amputation is designed).
A.Vishnewsky worked out the anesthesia with low concentration Novocain solution
which was injected under the pressure along fascias and muscles cases. Infiltration
must be performed “layer by layer” and surgeon must use scalpel and syringe with
Novocain in turn (method of “tight creeper infiltrate”). The positive side of this
method is low toxicity of the anesthetic and absence of reabsorptive action (as big
amount of Novocain is poured out after the incision), easy dissection of a tissues
after hydropreparation with solution of anesthetic.
Fig 38. Intradermal bleb of local anesthesia
 METHODS OF LOCAL ANESTHESIA
3. Regional anesthesia:
a. Conductive anesthesia is based on interruption of
nervous impulse passing through the nervous fiber with
the help of intra- or perineural injection of anesthetic
solutions (usually 1-2% of Novocain). It is widely used in
the stomatological practice (extraction of tooth) during
thoracic operations (symphatic trunk, vagus nerve, celiac
nerve blocking) for the operations on fingers. Conductive
anesthesia of the fingers by Oberst-Lukashevich: at the
basis of the finger tourniquet must be applied and after
that into both lateral sides 2-3ml of 1-2% solution of
Novocain must be injected deeply up to the bone /fig. 39/.
Intercostal anesthesia is used against the pain in case of
ribs fracture.
Fig 39. Conductive anesthesia of the fingers by
Oberst-Lukashevich
 METHODS OF LOCAL
ANESTHESIA
After the anesthesia of the skin, tip of the needle must be
inserted to the fractured rib on few centimetres from the site
of fracture in the direction to the backbone (spine). 3-5ml of
1-2% sol. of Novocain must be injected perineurally under
the lower margin of the rib, after that with the same needle
2-3ml 1-2% sol. of Novocain must be injected to the upper
border of the rib /fig. 40/. Anesthesia of the brachial plexus
by Kullenkamph is in use, when the operations on the
upper extremity is performed. After the skin anesthesia the
long needle must be inserted laterally from the subclavian
artery pulsation,1cm above the clavicle, from the upper
margin of 1st rib in the direction of spinous processes of 1st
and 2nd thoracic vertebra and reach to the brachial plexus
/fig. 41/ (at this moment the patient feels shooting pain).
Fig 40. Intercostal anesthesia
Fig 41. Brachial plexus anesthesia
 METHODS OF LOCAL
ANESTHESIA
After being sure, that there is no blood in the needle (the tip
of the needle is not dislocated inside of the blood vessel) it
is necessary to inject 30-35ml of 1% sol. of Lidocain.
Anesthesia starts after 10-15min and lasts 2-6h. Intra-
abdominal anesthesia of celiac nervs by Braun must be used
as addition to the local infiltration anesthesia during the
gastric resection. Surgeon must dislocate second finger of
his left hand between the aorta and inferior vena cava above
the locus of celiac artery exit from the aorta, behind of the
minor omentum. The tip of the needle must reach the body
of the 12th thoracic vertebra and surgeon must inject 50-70ml
of 0.5% sol. of Novocain. The anesthetic covers the plexus
solaris, begins to act after 5-10min and it’s action lasts 1.5-h.
 METHODS OF LOCAL
ANESTHESIA
b. Nerve blocks with Novocain are designed for the prophylaxis
of traumatic shock and as a background for infiltrative anesthesia:
1. Circular (case) block of the shoulder: after the skin anesthesia
with long needle must punctured fascia bicipitalis, biceps until
the tip of the needle reaches the brachium bone. It is necessary to
fill the fascial case of biceps with 50-60ml of 0.25% sol. of
Novocain. The same should be repeated with fascial case of
triceps muscle;
2. Circular block of forearm: it is necessary to introduce into the
fascial cases of flexor and extensor muscles in the middle third of
the forearm 60-80ml of 0.25% sol. of Novocain in each fascial case;
3. Circular block of the thigh: the needle must be inserted from
the front surface in the middle third of the thigh down to the
femur with subsequent injection of 150-180ml of 0.25% sol. of
Novocain /fig. 42/;
Fig 42. Circular block of the thigh
 METHODS OF LOCAL
ANESTHESIA
4. Circular case block of the lower leg (shank): into the fascial case of flexor
and extensor muscles should be injected 80-100ml of 0,25% sol. of Novocain
in each one;
5. Retromammar block is useful for the treatment of initial stage of mastitis
and as component of local anesthesia for performing of sectoral resection
and opening of an abscess. It is necessary to inject 50ml at 0.25% Novocain
sol. at the basis of the mammary gland from 3-points (summary dose
150ml) /fig. 43/;
6. Cervical vagosymphatic block is very important for the prophylaxis and
treatment of pleuropulmonar shock. Patient is on the supine position with
the torus under the neck, head is turned to the opposite side and arm is
pulled down. On the crossing point of the sternocleidomastoid and external
jugular vein after the skin anesthesia and displacement of this muscle and
carotid vessels forward and medially with 2nd finger of left hand 40-50ml of
25% sol. of Novocain must be injected in the direction of anterior surface of
the cervical vertebras. Horner’s symptom (pupil’s dilation at the side of
block) appears if the manipulation was done correctly;
Fig 43. Retromammar block
 METHODS OF LOCAL
ANESTHESIA
7. Lumbar (paranephral) block is useful in case of
haemotransfusion shock, intestinal paralysis and as a
background for local anesthesia for the operations on the
lumbar region and retroperitoneal space. Patients position on
the healthy side with the torus under the loins. The leg,
dislocated on upper side is straightened, lower one is bended in
the knee-joint. The point of puncture is dislocated on the
bisector of the angle, formed with the 12th rib and m.erector
spina, on the 1-1,5cm from the angle. Needle, inserted
perpendicularely to skin gets into the paranephrium /fig. 44/,
after the passing through the lumbar fascia. It is necessary to
inject 60-80ml of 0.25% sol. of Novocain in each side after
checking the content of syringe (“no drop of blood and no drop
of liquid from the needle “ – as A.Vishnewsky told);
Fig 44. Lumbar (paranephral) block
 METHODS OF LOCAL
ANESTHESIA
7. Intravenous anesthesia. Indications: operations on the
limbs (surgical treatment of the wounds, reposition of the
fractured fragments and dislocations, arthrotomy). Method is
based on the local diffusion and action of Novocain, injected
into the vein of the extremity, isolated with the applying of
tourniquet from other parts of body. With the help of the
venepunction or venesection 150-200ml (for the upper
extremity) or 200-250ml (for the lower extremity) of 0.25%
Novocain sol. must be injected into the superficial fore-arm
or cubital veins or v.saphena magna or v.saphena parva.
Arterial blood supply must be renewed after the operation
by loosening and removing of tourniquet (not too quickly)
/fig. 45/;
Fig 45. Intravenous anesthesia
 METHODS OF LOCAL
ANESTHESIA
9. Intracostal anesthesia is the variation of the intravenous
local anesthesia as the Novocain, injected into the bone,
gets into the venous system. The limb must be isolated
from the circulation system by applying of the elastic
bandage or cuff of the sphygmomanometer. Novocain must
be injected into the humeral epicondylus, olecranon and
bones of hand (100-150ml of 0.25% sol. of Novocain) in case
of operation on the upper limb and into the epicondyles of
femur and medial and lateral condyles of shank (shin) (150-
200ml and 100-150ml of Novocain) in case of the operations
of the lower extremity. It is preferable to introduce 2ml of
Coffein, before removing of the tourniquet.
 SPINAL (SUBARACHNOID)
ANESTHESIA
Spinal anesthesia belongs to the conductive type of anesthesia. It was
worked out in 1899 by August Bier. This method is based on the injection of
1.5-2ml 5% Novocain sol. (hyperbaric, heavy solution) or 0.3-1.0ml of 1%
Sovcain (hypobaric, light solution) into the subarachnoid space by the help
of special needle and its action on the roots of the spinal cord.
Indications of spinal anesthesia: operations on the organs, dislocated below
the diaphragm (stomach, bowels, liver and bile ducts, spleen, pelvic organs,
lower extremities).
Contraindications of spinal anesthesia: are divided into two groups:
Absolute: the situations with direct danger for patient’s life in case of spinal
anesthesia-marked shock, low blood pressure, abscesses of the skin in the
point of puncture, deformation of backbone, diseases of central nervous
system, uncorrected coagulopathy;
Relative: cardiac insufficiency (decompensation), cachexia, adipositas
(morbid obesity) chronic pathologic processes of backbone, marked
hypotension (max. blood pressure 100mm Hg) or hypertension.
 SPINAL (SUBARACHNOID)
ANESTHESIA
Techniques: it is necessary to have 2-5ml graduated syringe and fine (narrow) border, 10-12 cm in length
/fig. 46/ needle with stylet. It is preferable to have 1-2ml syringe for Sovcain injection. Patient is sitting or
lying on the operative table with the spine to the surgeon /fig. 47, 48/, hands are put on the abdomen, chin
to the chest. Spine is flexed. Skin must be cleaned ,as before surgical operation .Iodine must be washed out
by alcohol. Lines for precise topical orientation:
1. The line, which connects upper points of iliac bone dissects the spinous processes of the 4 th lumbar
vertebra (Jacob’s line /fig. 47/);
2. The line, which connects lower angles of scapulas, passes on the spinous process of 7 th thoracic vertebra;
3. Spinous processus of 7th cervical vertebrae (vertebra prominence) is always easy to palpate. The point of
puncture must be infiltrated (skin and space between spinous processes) with 3-5ml of 0.5% sol. of
Novocain .The tip of the needle passes the following layers, before the surgeon receives the cerebrospinal
liquor /fig. 49/:
4. Skin, subcutaneous fatty tissue;
5. Fascia lumbodorsalis (f.thoracolumbalis);
6. Ligamentum supraspinatum;
7. Ligamentum interspinatum;
8. Ligamentum flavum;
9. Plexus venosus vertebralis interni;
10. Dura mater;
11. Aracnhoidea spinalis.
Fig 46. Spinal puncture with the needle
Fig 47. Patients sitting position and
determination Jacob’s line
Fig 48. Patients lying position for the spinal
puncture
Fig 49. Layers of tissues , which must be
punctured
 SPINAL (SUBARACHNOID)
ANESTHESIA
After the injection of abovementioned anesthetics,
the needle must be removed, skin - covered with
iodine and patched. Patient must be put on the
operation table with elevated position of the head
(the chin must be pressed to chest) if 5% (heavy or
hyperbaric) sol. of Novocain was injected and
lowered position on 15º of the head, if 1% sol. of
Sovcain (light or hypobaric) was injected in aim to
avoid spreading of the anesthetic drug to the
direction of medulla oblongata which may cause the
bulbar paralysis /fig. 50/.
Fig 50. Directions of spreading hyper-, iso-
and hypobaric anesthetics
 SPINAL (SUBARACHNOID)
ANESTHESIA
Course of spinal anesthesia:
I stage: Patient feels warmth in the lower extremity, disappearance of pain
and then temperature and tactile sensitivity. This stage lasts 3-20 min.
Sometimes tactile sense disappears later. At first, sense disappears in the
region of perineum, then in the legs and upper parts to the injection level.
Skin and tendineous reflexes disappears together with sense. In I stage
muscle relaxation happens, which turns into paraplegia. Arterial
hypotension also is typical. Some patients with high level of anesthesia –
diaphragmatic type of respiration occurs;
II stage: Complete anesthesia and muscle relaxation starts 10-15min after
the injection and lasts 45-80min (for Novocain) and 2.5-3.5h (for Sovcain);
III stage: Restoration of movement, sense and reflexes. It lasts usually 20-
30min and goes in reverse turn in comparison with I stage (eg, at first
restores the tactile and then pain sense).
SPINAL (SUBARACHNOID)
ANESTHESIA
Complications of spinal anesthesia: are divided on 3 groups:
1. Complications which occur during performing of spinal anesthesia-
breaking of needle hemorrhage from venous plexus, injury of spinal chord
(above-LII), absence of anesthesia in 3-5% of cases (leakage of anesthetic
from subdural into the epidural space). It is dangerous to make lumbar
puncture above the 12th thoracic vertebra. That’s why majority of surgeons
doesn’t do it. Typical point of puncture is between L-3-4 and L-2-3;
 SPINAL (SUBARACHNOID)
ANESTHESIA
2. Complications during the course of the spinal anesthesia:
a) Marked depression of blood pressure (in 1-2 % of cases). The reason of this
complication is block of sympathetic part of the vegetative nervous system,
myorelaxation and blood accumulation in the dilated vessels. It is very
dangerous complication. It accompanies spreading of the anesthetic up to the
medulla oblongata. Prophylaxis of those complications is the preventive
subcutaneous injection of 5% - 1.0 ml Ephedrine, 20-30 min. before anesthesia
and correct position of the head. In some cases emergency blood transfusion
is necessary;
b) Vomiting: in most cases has reflex background, but it is dangerous if it is
accompanied with respiratory disturbances and hypertension (paralysis of
bulbar centers). Vasotonic, cardiotonic drugs, blood transfusion, artificial
pulmonary ventilation, Lobelin injection, oxygenation are needed;
c) Respiratory standstill (apnea): occurs if the anesthetic reaches the level of
clavicles. Diaphragmatic type of respiration happens before it. The treatment
is artificial pulmonary ventilation and respiratory analeptic drugs.
 SPINAL (SUBARACHNOID)
ANESTHESIA
3. Late complications of the spinal anesthesia:
a) Purulent meningitis is very rare complication and is the
result microbial contamination during the puncture;
b) Paralysis (paraparesis, paraplegia, paralysis of n.peroneus
or n.oculomotorius) has transitory nature and disappears after
1.5-2 months. Paralysis of n.oculomotorius is accompanied
with squint (strabismus) and seeing double (diplopia). It may
be explained with local aseptic meningitis in the area of routs of
those nerves. Patients recovers in 2-3 months;
c) Headache (cephalalgia, cerebralgia) is most common
complication of spinal anesthesia. Some times it is
accompanied with dizziness (vertigo, giddiness), vomiting,
nausea and ataxia.
 SPINAL (SUBARACHNOID)
ANESTHESIA
This complication may have following reasons:
1) Irritation of the soft cerebral membranes with iodine (this
reason is not too acceptable).
2) Disturbance of the pressure of cerebrospinal liquor,
especially after the puncture with thick needle.
Treatment of this situation has empiric character, as the
reason of headache is unknown (horizontal position of the body,
Amidopyrin, Coffein, i.v. hexamethylenetetramine (Urotropin)
and antibiotics);
d) Meningism is irritation of the dura mater (headache, nausea,
vomiting, falling asleep, bradicardia, muscular rigidity of
posterior muscles of neck, fever, cerebrospinal liquor
hypertension) must be treated with infusion of 40% sol. of
glucose, 40% sol. of Urotropin and antibiotics.
 PERIDURAL (EPIDURAL)
ANESTHESIA
The method was worked out by Pageut (1920) and Dogliotti (1925),
and is based on the injection of Dicain into the epidural space, which
is dislocated between the periosteum of vertebra (lamina externa) and
dura mater (lamina interna), lasts from the coccyx up to the foramen
occipitale and filled with friable fatty tissue. The epidural space has
no connections with subarachnoid space and cisterns of brain.
Preparation of Dicain’s 0.3% solution: 33ml sterile isotonic 0.9%
sol. of sodium chloride) must be boiled in the neutral glass during 1.5-
2min. In the hot (not boiling) saline must be dissolved 0.1g powder of
Dicain and warm up to the point of boiling (but not to boil, as it
decreases anesthetic characteristics of the drug).6-7 drops of 0.1% sol.
of Epinephrine must be added in this (cool) solution before
anesthesia. Today less toxic drugs Trimecain (3%-60-80ml) or 0.75%
20ml Lidocain are in use.
 PERIDURAL (EPIDURAL)
ANESTHESIA
Position of patient’s body is the same as during the spinal anesthesia. Point
of puncture must be choiced with following rule:
a) For intra-abdominal and gynecological operations between L1-L2 or L2-L3;
b) For vaginal operations between L3-L4 or L4-L5;
c) For operations on kidneys, urether and prostate - T10-T11 or T11-T12;
d) For the operations on stomach and biliary tract - T8-T9 or T9-T10.
Length of the needle must be 6cm, thickness - not more then 1mm. It is
necessary to connect the syringe, filled with saline and air bubble inside to
the needle after it’s insertion on 2cm of depth. It is impossible to inject this
solution until the tip of the needle perforates the yellow ligament
(lig.flavum) and gets into the epidural space, where solution may be injected
very easily without pressure /fig. 51/. After disconnection of the syringe
from the needle, surgeon mustn’t receive cerebrospinal. Appearance of the
cerebrospinal fluid from the needle shows, that it gets into the subarachnoid
space and epidural anesthesia couldn’t be performed.
Fig 51. Peridural (epidural) puncture
 PERIDURAL (EPIDURAL)
ANESTHESIA
If the puncture was done correctly, 5ml Dicain must be injected.
If there is no anesthesia of lower extremities, loins and abdomen
after 5min, next 5ml of Dicain could be injected. After 5min interval
(in case of absence of anesthesia) next 5ml (III portion) of Dicain
must be injected and following (last IV portion), also after 5min. 20
ml of Dicain (dilution 3:1000) is enough to get good anesthesia for
the middle height patient. For very tall persons 25ml of 0.3% Dicain
is necessary and only 15ml for week patients with depletion and
hypotension. 3% solution of Trimecain (60-80ml) and 0.75% solution
of Lidocain (20 ml) may be used for epidural anesthesia.
After the injection patient must be placed on the operative table
in the horizontal position .Epidural anesthesia starts 30-40min after
the first portion of Dicain and lasts 3-5h.It may be accompanied
with ether narcosis(15-25g of ether), intravenous anesthesia (5-10ml
of 10% sol. of Hexenal) or local anesthesia with Novocain, in case, if
the complete epidural anesthesia wasn’t reached
 PERIDURAL (EPIDURAL)
ANESTHESIA
If first 5ml of Dicain was injected erroneously in subarachnoid
space, we will receive very quick (in 5min) spinal anesthesia of lower
limbs and it may be used as spinal anesthesia without adding of
anesthetic, as dose more, than 5ml of 3% Dicain is toxic.
Indications of epidural anesthesia: Traumatologic and orthopedic
operations on the lower extremities, abdominal and pelvic organs,
elderness, cardiovascular, respiratory and metabolic disturbances
(adipositas, diabetes). It is very useful in postoperative period if the
fine lumen catheter was left for fractional introduction of anesthetic
drug.
Contraindications: are same as for spinal anesthesia.
Complications: hypotension, dispnea, nausea, vomiting, cramps, no
effect of anesthesia (in 5-10% of cases), what can be explained with
existence of septs in the peridural space, which limits the spreading of
the anesthetic drug.
RESUSCITATION, INTENSIVE
THERAPY
Resuscitation is the complex of measures in aim to
reanimate the organism, maintain the action of
cardiovascular, respiratory, central nervous systems
and metabolism.
Critical conditions:
Collapse;
Coma;
Syncope, fainting;
Shock;
Poisoning;
Drowning.
 RESUSCITATION,
INTENSIVE THERAPY
Terminal States:
Preagonal state;
Agonal state;
Clinical death.
Collapse: is blood pressure fall as a result of sudden cardiac weakness, or decreased
tonus of blood vessels.
Types of Collapse:
Hemorrhagic;
Hypoxemic (hypoxic);
Septic;
Carcinogenic collapse/shock;
Orthostatic.
Pancreatic collapse/shock;
Semeran-Siemianowsky’s paroxysmal collapse;
Toxic;
Circulatory.
 RESUSCITATION,
INTENSIVE THERAPY
Clinical signs of collapse: sudden pallor, small and rapid
(sometimes-thread-like) pulse, low blood pressure, shallow
and infrequent breathing, cool sweat, cool extremities, low
temperature of the body, consciousness is confused or lost
(in case of shock it is retained). Clinical signs of collapse
and shock are very similar, but in case of collapse initial
alterations are in cardiovascular system and in the nervous
system in case of shock.
Treatment: includes removal of reasons, which caused
cardiovascular weakness (blood loss, intoxication), blood
transfusion, infusion of hemocorrectors, Coffein,
Cordiamin, Strophantin;
 RESUSCITATION, INTENSIVE
THERAPY
Coma: is the unconsciousness, areactive state, getting out from which is impossible by the
stimulation. There is no simple defense reflexes, in the case of deep coma.
Types of coma:
Apoplectic;
Asthmatic;
Hemolytic;
Hyperthermal;
Hypoglycemic;
Hypocorticoid/Adrenal;
Hypoxic/Anoxic;
Alimentary-dystrophic;
Diabetic;
Hepatic;
Respiratory/Hypoxic;
Thyreotoxic;
Eclamptic;
Epileptic.
Treatment: should be etiopathogenic and include removal of reasons of coma,
normalization of the cardiovascular, respiratory, nervous and metabolic damages.
 RESUSCITATION,
INTENSIVE THERAPY
Syncope, Faint (Lypothimia): is the sudden losing of
consciousness for a short time, caused with
transitory ischemia of the brain as a reason of
hypoxemia or decreased blood supply of the brain.
If the patient has fainted, doctor must be sure
that there is no injury of the skull. It is necessary to
put the patient down, unbutton the clothes, place the
patient’s head lower than the rest of the body,
elevate the legs, let him inhale ammonia spirit, give
him strong tea or coffee with cognac, injections of
Coffein, Cordiamin.
 RESUSCITATION,
INTENSIVE THERAPY
Shock: the term “shock” was introduced in medical
practice in 1737 by French surgeon Anri Le Dran.
P.Savenko determined shock as a grave alteration of
central nervous system in 1834. N.Pirogov made
classic description of clinical picture of shock and
distinguished two phases of shock: a) Erectile b)
Torpid. Shock is defined as a critical condition of the
organism with marked depression of functions of
central nervous system, cardiovascular insufficiency,
disturbance of microcirculation and hypoxia of
tissues. It is polietiologic pathology.
 RESUSCITATION,
INTENSIVE THERAPY
Classification of Shock:
1. Traumatic shock:
a) Mechanical traumas (wounds, fractures of the bones, compression of the
tissues);
b) Burn (thermal, chemical);
c) Cold;
d) Electric.
2. Hemorrhagic (hypovolemic) shock caused by:
a) Bleeding (hemorrhage) and acute blood loss;
b) Acute disturbance of the water balance of the organism-dehydration (exicosis).
3. Bacteriemic (infective-toxic or septic) - as a result of grave purulent
processes;
4. Anaphylactic shock;
5. Cardiogenic shock (myocardial infarction, acute cardiac insufficiency).
 RESUSCITATION,
INTENSIVE THERAPY
Most important starting mechanisms of the shock are:
vasodilatation, hypovolemia, decrease heart output and
microcirculatory disturbance, aggregation of erythrocytes as “coin
pillar”, increase blood viscosity, intracapillary blood clotting
(microthrombosis of capillaries), disturbances of acid-base balance
(metabolic acidosis) increased blood plasma creatinine and blood
serum urea nitrogen, decreased synthesis of corticosteroids, blood
circulation disturbance in visceral organs (shocked lung, kidney,
liver). So, principal, initial pathogenetic factors of the shock are:
1) decreased volume of circulating blood (hemorrhagic,
hypovolemic shock);
2) Vasodilatation-increased volume of blood vessel’s, bed
redistribution of blood (anaphylactic, septic shock);
3) Disturbance of cardiac activity with decreased cardiac output.
 RESUSCITATION, INTENSIVE
THERAPY
All those factors cause capillary circulation damage,
hypoxia and metabolic disturbances in tissues and organs.
Factors, which promote the development of shock: avitaminosis,
tuberculosis, hypo- and dysproteinemia, cachexia, anemia,
cold, nervous stress, incomplete transport immobilization and
anesthesia during operation, ionizing radiation.
Theories of Etiopathogenesis of shock:
Toxic (Quenu);
Vasomotor (Crile);
Acapnic (Henderson);
Blood and plasma loss (Blelock);
Sympathetic-adrenal depletion (H.Selye);
Neuro-reflector (I.Pavlov).
 RESUSCITATION,
INTENSIVE THERAPY
Assessment of the phases and the degree of the shock:
phases of the shock (according to N.Pirogov):
1. Erectile phase of the shock is very short, occurs at
once after the trauma and is characterized with the
hypertonus of sympathetic-adrenal system (skin
integument and visible mucous membranes are pale,
pulse-rapid, blood pressure-elevated, patient is
excited, cries, asks to help him);
2. Torpid phase patient is depressed, low blood
pressure thread-like pulse.
 RESUSCITATION,
INTENSIVE THERAPY
Shock of I degree: consciousness is retained (a little depressed), systolic
blood pressure is decreased down to 90mmHg, pulse is a little, rapid, skin
is pale, muscular tremor, circulation restores slowly after the compression
and decompression of the nail.
Shock of II degree: patient is depressed, pallor, viscous sweat, cyanosis of
the nails is marked (circulation restores very slowly) systolic blood pressure
90-70mm.Hg, pulse-weak, rapid, 110-120 per min, central venous pressure
is decreased, shallow breathing.
III degree Shock: patient’s condition is grave, he is adynamic, very
depressed, clouded consciousness, no reaction on pain, skin-cold, pale with
cyanotic color, breathing is accelerated, shallow, sometimes-infrequent
(bradipnea), pulse 130-140,systolic blood pressure 70-50mm Hg, central
venous pressure 0 or negative, no excretion of urine (anuria).
Shock of IV degree: means the preagonal state, arterial blood pressure less,
than 50 mm Hg, skin and mucosa arepale, pulse - rapid, weak, breathing
superficial.
 RESUSCITATION, INTENSIVE
THERAPY
Monitoring of the patients with shock: it is necessary to determine general condition
of the patient, pulse, arterial blood pressure, respiration (frequency, depth, rhythm),
diuresis, central venous pressure, p O2 and p CO2 and Algover’s index of shock
(correlation of pulse and arterial blood pressure). Normally Algover’s index is equal
60 pulse beat/min = 0.5
120 mmHg
Conversion from the early stage to the marked shock:
100 pulse beats/min = 1.0
100 mm Hg
Developed shock 120 pulse beats/min = 1.5
80 mm Hg
As high is above-mentioned index, as worse is prognosis. It is possible to calculate
the blood loss, following to this index.
If Algover’s index is 1, blood loss compose 20-30% of volume of circulating blood.
If Algover’s index is more than 1, blood loss reaches 30-50% of volume of
circulating blood.
TREATMENT OF THE SHOCK

The first aid (before hospitalization) includes:

Control of bleeding;
Adequate pulmonary ventilation;
Anesthesia;
Transfusion and infusion therapy;
Immobilization in case of fractures;
Transportation in adequate region.
 THE PATHOGENIC TREATMENT
OF SHOCK
1. The removal of the reason, caused the shock;
2. Restoration of blood vessel’s tonus;
3. Substitution of the circulatory blood volume;
4. Normalization of capillary circulation (microcirculation);
5. Removal of hypoxemia and hypoxia of tissues;
6. Treatment of renal, hepatic, respiratory and other
complications of shock;
7. Recovery of metabolic disturbances.
For correction of hypovolemia, it is preferable to use
hemocorrectors (blood substitute liquids) with homodynamic
(anti shock) action- Macrodex (Polyglukin), Rheomacrodex
(Rheopoliglucin), Gelofusin (Gelatinol), crystalloid solutions are
also useful, Trisamin (trisbupher) or 4% solution of sodium
bicarbonate for the removal of acidosis.
 THE PATHOGENIC
TREATMENT OF SHOCK
Morphine hydrochloride, Omnopon (Pantopon), Promedol
(trimeperidine hydrochloride), Phentanil, Pentazocin (Lexir)
may be used for the anesthesia, with monitoring of respiration
(narcotic analgesics can decrease the respiratory center activity).
Trancvilizators: Seduxen (diazepam) 0.5%- 1-2 ml is also useful.
As peripheral blood circulation is damaged, all preparations
must be administrated intravenously, not i.m.
S-shape airway tubes must be used for adequate respiration,
if patient is in unconsciousness condition. Good transport
immobilization, local anesthesia, Novocain block (vago-
sympathetic, paranephral, paravertebral and intercostal) must
be discussed as prophylaxis of shock. For the restoration of
blood vessel's tonus, dopamine (Dobutrex) sol. is very useful,
so as glucocorticoid hormones (prednizollone, hydrocortisone).
 THE PATHOGENIC
TREATMENT OF SHOCK
Hemorrhagic Shock: see “Bleeding”;
Burns Shock: see “Burns”;
Anaphylactic Shock is based on the immediate
reaction antigen - antibody, which happens in the
organism with allergic (hypersensitive) state. It is
very frequent after the infusion of protein-
containing blood substitute liquids, immune
drugs, antibiotics and iodine-containing
antiseptics among the patients with bronchial
asthma, drug-induced dermatitis.
 THE PATHOGENIC
TREATMENT OF SHOCK
Types of anaphylactic shock are:
Cardiovascular type with tachycardia, cardiac arrhythmia, atrial and
ventricular fibrillation, hypotension and acute cardiac insufficiency;
Respiratory type : respiratory insufficiency, dyspnea (shortness of breath,
breathlessness), cyanosis, whistling (stridor) breathing with moist râles in
the lungs, swelling of the lungs, larynx and epiglottis;
Cerebral type : with hypoxia, swelling of brain, coma with local signs of
CNS alteration. Anaphylactic shock is divided in to 4 stages following its
gravity.
I stage (slight): itching of the skin, rashes, headache and vertigo;
II stage (moderate): Quincke’s swelling, tachycardia, hypotension,
increased Algover’s index joints to the abovementioned symptoms;
III stage (grave): unconsciousness, acute cardiovascular and respiratory
insufficiency;
IV stage (very grave): Unconsciousness, grave cardiovascular insufficiency
(no pulse on periphery, low blood pressure).
 THE PATHOGENIC
TREATMENT OF SHOCK
Treatment of the anaphylactic shock:
1) Restoration of circulation (Ephedrine, Adrenaline,
Noradrenalin, Dopamine);
2) Substitution of circulation blood mass (colloid solutions,
Rheomacrodex, Gelofusin);
3) Antihistamine drugs (Dimedrol, Suprastin, Tavegil);
4) Glucocorticoids (Dexamethazon, Prednizollon,
Hydrocortisone);
5) Calcium chloride or gluconate (10% -10.0 ml);
6) Inactivation of antigen (e.g. inactivation of the penicillin wit
penicillinaza or β-lactamaza).
Prophylaxis: careful collection of allergic history, performing of
allergic tests, using of antihistamine and glucocorticoid drugs.
 THE PATHOGENIC
TREATMENT OF SHOCK
Drowning: for the drowned person the duration of clinical
death is reduced until 3 min. Drowned person spends all his
stocks of oxygen, because of enormous intensive muscular
movements.
It is necessary to start artificial pulmonary ventilation and
indirect (external) cardiac massage (in case of cardiac arrest)
as soon as possible in the boat or on the beach. One must not
waist the time on removal of water from the lower airways. It
is necessary to empty the stomach by the help of compression
of the epigastrium with the hand after that the body of the
patient is turned on the side. It is necessary to remove the
mucus, slime (salt) and sand from mouth and nose in aim to
establish adequate airway and perform urgent artificial
respiration by mouth to mouth.
 THE PATHOGENIC
TREATMENT OF SHOCK
In case of drowning in the fresh water, which has low osmollarity
than blood, it will easily be absorbed from alveoli into the blood. That’s
why it is not necessary to waist the time on removal of the water from the
trachea and bronchus.
In case of drowning in salt (3,5- 4%) water, liquid part of the blood
(plasma) passes into the upper airways and trachea and bronchus could
be filled with foam and liquid, which prevents to performing of artificial
pulmonary ventilation. This liquid foam partially could be removed by
the help of placement of the upper part of the body and the head lower
than the rest part of the body.
In the case of the drowning in the cold water, effect of hypothermia
occurs and resuscitation may be successful after the stay of patient’s body
under the water during 20 min and more.
All patients must be transported into the resuscitation department after
the successfully performed first aid.
 TERMINAL STATES
Preagonal state: patient is depressed, clouded or confused
consciousness, pallor, acrocyanosis, eye reflexes-retained,
no pulse, or thread-like pulse, low blood pressure (60- 70
mm Hg) or it is impossible to determine it.
Agonal state: Unconsciousness, thread pulse or no pulse, no
blood pressure, areflexia (absence of a reflex), pulse may be
palpated only on the carotic arteries, heart sounds are dull,
bradicardia, irregular, agonal (terminal) breathing (gasp).
Clinical death: starts after cardiac arrest and respiratory
standstill and lasts 5-6 minutes (according to V.Negovsky,
1969). In this period anaerobic glycolysis occurs. After 5-6
minutes unreversable processes in the brain cause the
biological death.
 TERMINAL STATES
The reasons of the cardiac arrest may be:
Myocardial infarction;
Obstruction of upper airways with foreign body;
Reflectory cardiac failure;
Wound of heart;
Anaphylactic shock;
Electric trauma;
Drowning;
Grave metabolic disturbances (hyperkaliemia,
metabolic acidosis).
 TERMINAL STATES
The clinical signs of cardiac arrest:
Absence of the pulse on the carotic artery;
Pupil’s dilation, no reaction to light;
Respiratory standstill (apnea, respiratory arrest);
Unconsciousness;
Pallor, sometimes-cyanosis;
Absence of pulse on peripheral arteries;
Absence of the blood pressure;
Absence of the heart sounds.
 TERMINAL STATES
Absolute signs of the cardiac arrest:
Absence of the pulse on the carotic artery;
Respiratory arrest;
Dilation of pupils, no reaction on light;
Resuscitation measures must be started
immediately in case of presence of those
symptoms.
 TERMINAL STATES
Cardiopulmonary Resuscitation (principal methods of
resuscitation).
It includes 4 stages of reanimation:
Providing an adequate airway;
Artificial pulmonary ventilation (artificial respiration);
Cardiac massage (1,2 and 3 stages, see “General
anesthesia”);
Differential diagnosis, drug therapy, heart defibrillation
must be performed by the physicians in the reanimobiles
or in the resuscitation departments (electrocardiography,
intracardial drug administration, defibrillation).
 Efficacy in comparison with Toxic characteristic in Concentration
Preparation Types of anesthesia
Novocain comparison with Novocain %

Novocain
/Procain, allocain, - - 0.25-0.5-1-2 Superficial; Infiltration;
aminocain/

Intravenous;Conductive;
5-10-20
Spinal; Peridural

Lydocain
4 times 2 times 0.25-0.5-1-2 Superficial; Infiltration;
/Xilocain, Lignocain/

Intravenous;Conductive;
10
Epidural

Sovcain
20 times 20 times 0.5-1 Spinal
/Optocain, Percain/

Dicain
15 times 10 times 0.25-0.5-1-2-3 Superficial, Peridural
/Anetain, Pantocain/

Trimecain /Mesocain/ 3 times 1.5 times 0.25-0.5-1-2 Conductive, Infiltration

Zcegnocain
Infiltration, Conductive,
/salt of Novocain and - - 0.25-0.5-1-2-3
Peridural
cellulose glycolic acid/

Corticain Infiltration, Regional,

- - 1-2
/Ultracain/ Peridural