vital functions. Anatomical and physiological foundations of the vital functions of the body

Most doctors check your vital signs at every appointment because they are what the name implies - vital signs. The four indicators of such functions are: heart rate, blood pressure, respiratory rate and temperature. You should include regular blood pressure and temperature measurements in your prevention program, which you can easily do either at home or with your health consultant.

Heart rate

It's amazing how many people don't know how to measure their heart rate or pulse, but we think it's important that everyone knows how to apply this elementary skill. Learning to measure your heart rate is very easy and can give you a lot of information about your heart. Practitioners of Chinese medicine measure 12 different types of wrist pulses, but luckily you only need to learn how to measure just one and a simple one.

The easiest way to measure the pulse is on the wrist. Simply place the index and middle fingers of your other hand on the inside of your wrist next to your thumb. Count the beats for 20 seconds, multiply by 3 and there you have your heart rate. You might want to try it right now. You may need to feel for a pulse if you haven't already, but with a little practice, most people can find their pulse on their wrist. The most common mistake is to press hard, so touch lightly. Also in pharmacies or sports stores you can buy inexpensive heart rate monitors that are easy to use.

Armstrong, for example, has a resting heart rate of just 32 beats per minute. Men usually have a lower resting heart rate than women, but in general, you want your heart rate to be less than 84 beats per minute. The optimal heart rate is less than 70 beats per minute. If your resting heart rate is over 100, then either you are in very poor shape or you have an underlying medical problem such as heart disease, a thyroid problem, or anemia and you should see a doctor.

Blood pressure (BP)

BP is easy to measure at home with widely available automated devices. There are four categories of blood pressure:

< 120/80 мм. рт. ст. - оптимальное; от 120/80 до 130/85 мм. рт. ст. - нормальное; от 130/85 до 140/90 мм. рт. ст. - повышенное нормальное; >140/90 mm. rt. Art. - high.

Approximately 40% of Americans have blood pressure readings in the optimal range, 24% in the normal range, 13% in the elevated normal range, and 23% in the high range. Most physicians recommend medication when blood pressure is consistently above 140/90, but there are health risks anytime blood pressure is above the optimal range of 120/80. According to a study by the National Heart, Lung and Blood Institute, published in 2008, the chance of a heart attack or stroke increases significantly the higher the blood pressure. The table below illustrates the risk of cardiovascular events, such as heart attack or stroke, over a 10-year period for men and women aged 35 to 64:

Table 10-1: Risk of cardiovascular events over a 10 year period

This table shows that even elevated normal blood pressure, which does not require medical treatment, increases the risk of heart attacks by 230% in women and by 70% in men compared to optimal parameters. Weight loss, regular exercise, and reduced intake of high glycemic foods are simple and effective ways to move normal and elevated normal blood pressure closer to the optimal range.

For those whose BP remains elevated normal or even in the lower high BP range despite the implementation of the TRANSCEND program, we recommend the Seven Forests Traditional Chinese Medicine herbal formulation known as Uncaria-6, also known as Gou Teng Jiang Ya Pian. This inexpensive herbal mixture appears to work safely and effectively in many cases, with few side effects. It is widely available from acupuncturists who also practice Chinese herbal medicine.

Composition of body tissues

In addition to vital signs, it is important to know the composition of body tissues. This is a quantitative indicator of how much adipose tissue in your body and how much lean tissue, which includes everything else, such as muscles, bones and blood. You can get more information about your body's tissue composition by measuring your waist-to-hip ratio, which will tell you where your body fat is distributed. These two measurements are just as important, if not more so, than your weight on the scale. Most therapists rarely measure body composition and waist-to-hip ratio, so you may need to do this yourself.

body fat

Body fat can be divided into two main types: essential fat, which is needed for survival and reproduction, and stored fat, which serves as a store of calories. This is another example that our genetic "program" is outdated. An ancient gene, the insulin receptor gene, generally says to hold on to every calorie. It made sense thousands of years ago, but not now. Men need a minimum of 2 to 5 percent of their required body fat, and women need 10 to 12 percent. In many ways, fat behaves like any other organ in the body and plays a vital role. The necessary fat is needed to create a soft elastic layer for organs such as the heart, spleen and intestines. Almost half the weight of the brain, excluding water, is fat, and in women, fat is involved in the regulation of sex hormones such as testosterone and estrogen. In both sexes, adipose tissue secretes important hormones such as leptin, resistin, adiponectin, interleukin-6, and tumor necrosis factor alpha, which help regulate numerous metabolic processes.

As a general rule, men should keep their total body fat levels between 10 and 17 percent and women between 18 and 26 percent. Optimal percentages are at the lower end of these ranges, so men can aim for optimal body fat levels of 10 to 12 percent and women 18 to 20 percent, although trained athletes are likely to have body fat levels below these values. If you weigh 164 pounds (the average weight of an American woman in 2002) and your body fat level is 34 percent, then you are carrying 52 pounds of fat. To reach a healthier 24 percent body fat, you need to lose 22 pounds (then you would weigh 142 pounds, which is close to the average weight of American women in the 1960s).

The most accurate method of measuring body fat is underwater (hydrostatic) weighing, but you can get close results with handheld devices or scales that show both weight and body fat percentage. Some of these devices are notorious for being inaccurate, so it's a good idea to measure your body fat percentage in a doctor's office or gym on a more accurate instrument, such as an impedance meter or an underwater tank, and then compare that measurement to your home instrument to make sure that you get accurate data.

Resuscitation: basic concepts

Life and death are the two most important philosophical concepts that determine the existence of an organism and its interaction with the external environment. In the process of life of the human body, there are three states: health, illness and critical (terminal) state.

Terminal state - the critical condition of the patient, in which there is a complex of dysregulation of the vital functions of the body with characteristic general syndromes and organ disorders, poses a direct threat to life and is the initial stage of thanatogenesis.

Violation of the regulation of vital functions. There is damage not only to the central regulatory mechanisms (nervous and humoral), but also to local ones (the action of histamine, serotonin, kinins, prostaglandins, histamine, serotonin, the cAMP system).

General syndromes. Syndromes characteristic of any terminal state are observed: violation of the rheological properties of blood, metabolism, hypovolemia, coagulopathy.

Organ disorders. There is an acute functional insufficiency of the adrenal glands, lungs, brain, blood circulation, liver, kidneys, gastrointestinal tract. Each of these disorders is expressed to varying degrees, but if some specific pathology has led to the development of a terminal condition, the elements of these disorders always exist, so any terminal condition should be considered as multiple organ failure.

In a terminal state, only a "lifeline" in the form of intensive therapy and resuscitation can stop the process of thanatogenesis (physiological mechanisms of dying).

Intensive therapy - a set of methods for correcting and temporarily replacing the functions of vital organs and systems of the patient's body.

In the terminal state, the intensity of treatment is extremely high. It is necessary to constantly monitor the parameters of the main

vital systems (heart rate, blood pressure, respiratory rate, consciousness, reflexes, ECG, blood gases) and the use of complex methods of treatment that quickly replace each other or are performed simultaneously (central venous catheterization, continuous infusion therapy, intubation, mechanical ventilation, sanitation tracheobronchial tree, transfusion of components and blood products).

The most complex and intensive methods of treatment are used in cases where the process of thanatogenesis reaches its climax: the patient's heart stops. It is not only about healing, but also about revitalization.

resuscitation(revitalization of the body) - intensive therapy in case of circulatory and respiratory arrest.

The science of resuscitation deals with the study of the dying of an organism and the development of methods for its revival.

resuscitation(re- again, animare- revive) - the science of the laws of the extinction of life, the principles of revitalization of the body, the prevention and treatment of terminal conditions.

From the time of Hippocrates and until the 20th century, the opinion was true that it was necessary to fight for the life of the patient until his last breath, the last heartbeat. After the cessation of cardiac activity - in a state of clinical death - it is necessary to fight for the patient's life.

Key parameters of vital functions

In resuscitation, the time factor is extremely important, so it makes sense to simplify the examination of the patient as much as possible. In addition, to solve resuscitation problems, it is necessary to find out the fundamental changes in the vital systems of the patient's body: the central nervous system, cardiovascular and respiratory systems. The study of their condition can be divided into two groups:

Assessment at the prehospital stage (without special equipment);

Evaluation at a specialized stage.

Assessment at the prehospital stage

In resuscitation, it is necessary to determine the following parameters of the main vital systems of the body:

CNS:

The presence of consciousness and the degree of its oppression;

The state of the pupils (diameter, reaction to light);

Preservation of reflexes (the most simple - corneal).

The cardiovascular system:

Skin color;

The presence and nature of the pulse in the peripheral arteries (a. radialis);

The presence and magnitude of blood pressure;

The presence of a pulse in the central arteries (a. carotis, a. femoralis- similar to the points of their pressing during a temporary stop of bleeding);

The presence of heart sounds.

Respiratory system:

The presence of spontaneous breathing;

Frequency, rhythm and depth of breathing.

Assessment at a specialized stage

The assessment at the specialized stage includes all the parameters of the prehospital stage, but they are supplemented by the data of instrumental diagnostic methods. The most commonly used monitoring method includes:

ECG;

Study of blood gases (O 2, CO 2);

Electroencephalography;

Constant measurement of blood pressure, control of CVP;

Special diagnostic methods (finding out the cause of the development of a terminal state).

Shock

This is a serious condition of the patient, closest to the terminal, in translation shock- hit. In everyday life, we often use this term, meaning, first of all, a nervous, emotional shock. In medicine, shock is really a "blow on the patient's body", leading not only to some specific disorders in the functions of individual organs, but accompanied by general disorders, regardless of the point of application of the damaging factor. Perhaps there is not a single syndrome in medicine that mankind has been familiar with for so long. The clinical picture of shock was described by Ambroise Pare. The term "shock" when describing the symptoms of severe trauma

we introduced at the beginning of the 16th century the French doctor-consultant of the army of Louis XV Le Dran, he also proposed the simplest methods of treating shock: warming, rest, alcohol and opium. Shock must be distinguished from fainting and collapse.

Fainting- sudden short-term loss of consciousness associated with insufficient blood supply to the brain.

A decrease in cerebral blood flow during fainting is associated with a short-term spasm of cerebral vessels in response to a psycho-emotional stimulus (fear, pain, sight of blood), stuffiness, etc. Women with arterial hypotension, anemia, and an unbalanced nervous system are prone to fainting. The duration of fainting is usually from a few seconds to several minutes without any consequences in the form of disorders of the cardiovascular, respiratory and other systems.

Collapse- a rapid drop in blood pressure due to sudden cardiac weakness or a decrease in the tone of the vascular wall.

Unlike shock, in collapse, the primary reaction to various factors (bleeding, intoxication, etc.) is from the cardiovascular system, changes in which are similar to those in shock, but without pronounced changes in other organs. The elimination of the cause of the collapse leads to the rapid restoration of all body functions. In shock, unlike fainting and collapse, there is a progressive decline in all vital functions of the body. There are many definitions of shock, both general and simple, and very complex, reflecting the pathogenetic mechanisms of the process. The authors consider the following to be optimal.

Shock- an acute severe condition of the body with a progressive insufficiency of all its systems, due to a critical decrease in blood flow in the tissues.

Classification, pathogenesis

Due to the occurrence of shock, it can be traumatic (mechanical trauma, burns, cooling, electric shock, radiation injury), hemorrhagic, surgical, cardiogenic, septic, anaphylactic. It is most expedient to divide shock into types, taking into account the pathogenesis of changes occurring in the body (Fig. 8-1). From this point of view, hypovolemic, cardiogenic, septic and anaphylactic shock are distinguished. With each of these types of shock, specific changes occur.

Rice. 8-1.The main types of shock

hypovolemic shock

The circulatory system of the body consists of three main parts: the heart, blood vessels, and blood. Changes in the parameters of the activity of the heart, vascular tone and bcc determine the development of symptoms characteristic of shock. Hypovolemic shock occurs as a result of an acute loss of blood, plasma, and other body fluids. Hypovolemia (decrease in BCC) leads to a decrease in venous return and a decrease in the filling pressure of the heart, which is shown in Fig. 8-2. This, in turn, leads to a decrease in the stroke volume of the heart and a drop in blood pressure. As a result of stimulation of the sympathetic-adrenal system, the heart rate increases, vasoconstriction (increase in total peripheral resistance) and centralization of blood circulation occur. At the same time, α-adrenergic receptors of vessels innervated by n. splanchnicus, as well as the vessels of the kidneys, muscles and skin. Such a reaction of the body is quite justified, but if hypovolemia is not corrected, then due to insufficient tissue perfusion, a picture of shock occurs. Thus, hypovolemic shock is characterized by a decrease in BCC, cardiac filling pressure and cardiac output, blood pressure, and an increase in peripheral resistance.

Cardiogenic shock

The most common cause of cardiogenic shock is myocardial infarction, less often myocarditis and toxic myocardial damage. In case of violation of the pumping function of the heart, arrhythmias and other acute causes of a decrease in the efficiency of heart contractions, a decrease in the stroke volume of the heart occurs, as a result of which blood pressure decreases, and the filling pressure of the heart increases (Fig. 8-3). As a result of

Rice. 8-2.The pathogenesis of hypovolemic shock

Rice. 8-3.The pathogenesis of cardiogenic shock

stimulation of the sympathetic-adrenal system occurs, heart rate and total peripheral resistance increase. Changes are similar to those in hypovolemic shock. These are hypodynamic forms of shock. Their pathogenetic difference is only in the value of the filling pressure of the heart: in hypovolemic shock it is reduced, and in cardiogenic shock it is increased.

Septic shock

In septic shock, peripheral circulatory disorders first occur. Under the influence of bacterial toxins, short arteriovenous shunts open, through which blood rushes, bypassing the capillary network, from the arterial bed to the venous one (Fig. 8-4). With a decrease in blood flow to the capillary bed, the blood flow in the periphery is high and the total peripheral resistance is reduced. Accordingly, there is a decrease in blood pressure, a compensatory increase in the stroke volume of the heart and heart rate. This is the so-called hyperdynamic circulation response in septic shock. A decrease in blood pressure and total peripheral resistance occurs with a normal or increased stroke volume of the heart. With further development, the hyperdynamic form passes into the hypodynamic one.

Rice. 8-4.The pathogenesis of septic shock

Rice. 8-5.The pathogenesis of anaphylactic shock

Anaphylactic shock

An anaphylactic reaction is an expression of a special hypersensitivity of the body to foreign substances. The development of anaphylactic shock is based on a sharp decrease in vascular tone under the influence of histamine and other mediator substances (Fig. 8-5). Due to the expansion of the capacitive part of the vascular bed (vein), a relative decrease in the BCC occurs: there is a discrepancy between the volume of the vascular bed and the BCC. Hypovolemia leads to a decrease in blood flow to the heart and a decrease in the filling pressure of the heart. This leads to a drop in stroke volume and blood pressure. A direct violation of myocardial contractility also contributes to a decrease in the productivity of the heart. Anaphylactic shock is characterized by the absence of a pronounced reaction of the sympathetic-adrenal system, which leads to the progressive clinical development of anaphylactic shock.

Violation of microcirculation

Despite the difference in the pathogenesis of the presented forms of shock, the end of their development is a decrease in capillary blood flow. Following-

As a result, the delivery of oxygen and energy substrates, as well as the excretion of end products of metabolism, become insufficient. Hypoxia occurs, a change in the nature of metabolism from aerobic to anaerobic. Less pyruvate is included in the Krebs cycle and turns into lactate, which, along with hypoxia, leads to the development of tissue metabolic acidosis. Under the influence of acidosis, two phenomena occur, leading to a further deterioration of microcirculation during shock: shock specific dysregulation of vascular tone and violation of the rheological properties of blood. The precapillaries expand, while the postcapillaries are still narrowed (Fig. 8-6c). Blood enters the capillaries, and the outflow is impaired. There is an increase in intracapillary pressure, the plasma passes into the interstitium, which leads to a further decrease in BCC, a violation of the rheological properties of blood, and cell aggregation in the capillaries. Red blood cells stick together in "coin columns", clumps of platelets are formed. As a result of an increase in blood viscosity, an insurmountable resistance to blood flow occurs, capillary microthrombi are formed, and DIC develops. This is how the center of gravity of changes occurs during progressive shock from macrocirculation to microcirculation. Violation of the latter is characteristic of all forms of shock, regardless of the cause that caused it. It is the microcirculation disorder that is the immediate cause that threatens the life of the patient.

shock organs

Violation of cell functions, their death due to microcirculation disorders during shock can affect all cells of the body, but there are organs that are especially sensitive to shock - shock organs.

Rice. 8-6.The mechanism of microcirculation disorders in shock: a - normal; b - the initial phase of shock - vasoconstriction; c - specific dysregulation of vascular tone

us. These include, first of all, the lungs and kidneys, and secondly, the liver. At the same time, it is necessary to distinguish between changes in these organs during shock (lung during shock, kidneys and liver during shock), which disappear when the patient recovers from shock, and organ disorders associated with the destruction of tissue structures, when, after recovery from shock, insufficiency or complete loss of functions persists. organ (shock lung, shock kidneys and liver).

Mild in shock.Disturbance of absorption of oxygen and an arterial hypoxia are characteristic. If a “shock lung” occurs, then after the shock is eliminated, severe respiratory failure rapidly progresses. Patients complain of suffocation, rapid breathing. They have a decrease in the partial pressure of oxygen in the arterial blood, a decrease in the elasticity of the lung. There is an increase in p a CO 2 . In this progressive phase of shock, the “shock lung” syndrome, apparently, no longer undergoes regression: the patient dies from arterial hypoxia.

Kidneys in shock.Characterized by a sharp restriction of blood circulation with a decrease in the amount of glomerular filtrate, a violation of the concentration ability and a decrease in the amount of urine excreted. If these disorders, after the elimination of the shock, did not undergo an immediate regression, then diuresis progressively decreases, the amount of slag substances increases, a "shock kidney" occurs, the main manifestation of which is the clinical picture of acute renal failure.

Liver -central organ of metabolism, plays an important role in the course of shock. The development of a "shock liver" can be suspected when the activity of liver enzymes increases after shock relief.

Clinical picture

Main symptoms

The clinical picture of shock is quite characteristic. The main symptoms are associated with the inhibition of the vital functions of the body. Patients in a state of shock are inhibited, reluctant to make contact. The skin is pale, covered with cold sweat, acrocyanosis is often observed. Breathing is frequent, shallow. Tachycardia, decrease in blood pressure are noted. The pulse is frequent, weakly filled, and in severe cases it is barely defined (filamentous). Changes

hemodynamics - basic in shock. Against this background, there is a decrease in diuresis. The pulse and blood pressure change most dynamically during shock. In this regard, Allgover suggested using the shock index: the ratio of heart rate to the level of systolic blood pressure. Normally, it is approximately equal to 0.5, in the transition to shock it approaches 1.0, with developed shock it reaches 1.5.

Shock severity

Depending on the severity, four degrees of shock are distinguished.

Shock I degree.Consciousness is preserved, the patient is in contact, slightly inhibited. Systolic blood pressure is slightly reduced, but exceeds 90 mm Hg, the pulse is slightly quickened. The skin is pale, sometimes muscle tremors are noted.

Shock II degree.Consciousness is preserved, the patient is inhibited. The skin is pale, cold, sticky sweat, slight acrocyanosis. Systolic blood pressure 70-90 mm Hg. The pulse is speeded up to 110-120 per minute, weak filling. CVP is reduced, shallow breathing.

Shock III degree.The patient's condition is extremely serious: he is adynamic, lethargic, answers questions in monosyllables, does not respond to pain. The skin is pale, cold, with a bluish tinge. Breathing is shallow, frequent, sometimes rare. The pulse is frequent - 130-140 per minute. Systolic blood pressure 50-70 mm Hg. CVP is zero or negative, there is no diuresis.

Shock IV degree.The predagonal state is one of the critical, terminal states.

General principles of treatment

Treatment of shock largely depends on the etiological factors and pathogenesis. Often it is the elimination of the leading syndrome (stopping bleeding, elimination of the focus of infection, the elimination of an allergic agent) that is an indispensable and main factor in the fight against shock. At the same time, there are general patterns of treatment. Shock therapy can be roughly divided into three stages. But even the very first, “zero step” is considered leaving. Patients should be surrounded by attention, despite the large amount of diagnostic and therapeutic measures. The berths must be functional, accessible for the transportation of equipment. Patients must be completely undressed. The air temperature should be 23-25? C.

The general principles of shock treatment can be summarized in three steps.

Basic shock therapy (first step):

Replenishment of the BCC;

oxygen therapy;

acidosis correction.

Pharmacotherapy of shock (second stage):

- dopamine;

norepinephrine;

cardiac glycosides.

Additional therapeutic measures (third stage):

Glucocorticoids;

Heparin sodium;

Diuretics;

Mechanical circulatory support;

Cardiac surgery.

In the treatment of patients with shock, a large place is given to the diagnostic program and monitoring. On fig. Figure 8-7 shows a minimal monitoring scheme. Among the presented indicators, the most important are heart rate, blood pressure, CVP, blood gas composition and diuresis rate.

Rice. 8-7.Minimum monitoring regimen for shock

Rice. 8-8.Scheme for measuring central venous pressure

Moreover, diuresis in shock is measured not per day, as usual, but per hour or minutes, for which the bladder is catheterized without fail. With normal blood pressure, above the critical level of perfusion pressure (60 mm Hg), and with normal kidney function, the rate of urine output is more than 30 ml / h (0.5 ml / min). On fig. 8-8 shows a scheme for measuring CVP, knowledge of which is extremely important for conducting infusion therapy and replenishing BCC. Normally, the CVP is 5-15 cm of water.

It should be noted that in the treatment of shock, a clear program of action is needed, as well as a good knowledge of the pathogenesis of changes occurring in the body.

Terminal States

The main stages of the organism's dying are successively changing terminal states: pre-agonal state, agony, clinical and biological death. The main parameters of these states are presented in Table. 8-1.

Predagonal state

Predagonal state - the stage of the dying of the body, in which there is a sharp decrease in blood pressure; first tachycardia and tachypnea, then bradycardia and bradypnea; progressive depression of consciousness, electrical activity of the brain and reflexes; growth

Table 8-1.Characteristics of terminal states

depth of oxygen starvation of all organs and tissues. The IV stage of shock can be identified with the preagonal state.

Agony

Agony is the stage of dying preceding death, the last flash of vital activity. During the period of agony, the functions of the higher parts of the brain are turned off, the regulation of physiological processes is carried out by the bulbar centers and are of a primitive, disordered nature. Activation of stem formations leads to some increase in blood pressure and increased respiration, which usually has a pathological character (Kussmaul, Biot, Cheyne-Stokes respiration). The transition from the pre-agonal state to the agonal state, therefore, is primarily due to the progressive depression of the central nervous system. The agonal flash of vital activity is very short-lived and ends with the complete suppression of all vital functions - clinical death.

clinical death

Clinical death is a reversible stage of dying, “a kind of transitional state that is not yet death, but is no longer

can be called life” (V.A. Negovsky, 1986). The main difference between clinical death and the states preceding it is the absence of blood circulation and respiration, which makes redox processes in cells impossible and leads to their death and death of the organism as a whole. But death does not occur directly at the moment of cardiac arrest. Exchange processes fade away gradually. The cells of the cerebral cortex are most sensitive to hypoxia, so the duration of clinical death depends on the time that the cerebral cortex experiences in the absence of respiration and blood circulation. With its duration of 5-6 minutes, damage to most of the cells of the cerebral cortex is still reversible, which makes it possible to fully revive the body. This is due to the high plasticity of CNS cells; the functions of dead cells are taken over by others that have retained their vital activity. The duration of clinical death is affected by:

The nature of the previous dying (the more sudden and faster clinical death occurs, the longer it can be);

Ambient temperature (with hypothermia, the intensity of all types of metabolism is reduced and the duration of clinical death increases).

biological death

Biological death follows clinical death and is an irreversible state when the revival of the organism as a whole is no longer possible. This is a necrotic process in all tissues, starting with the neurons of the cerebral cortex, the necrosis of which occurs within 1 hour after the cessation of blood circulation, and then within 2 hours the cells of all internal organs die (skin necrosis occurs only after a few hours, and sometimes days ).

Reliable signs of biological death

Reliable signs of biological death are cadaveric spots, rigor mortis and cadaveric decomposition.

cadaveric spots- a kind of blue-violet or purple-violet coloration of the skin due to draining and accumulation of blood in the lower parts of the body. Their formation occurs 2-4 hours after the cessation of cardiac activity. The duration of the initial stage (hypostasis) is up to 12-14 hours: the spots disappear with pressure

vanishing, then reappear within a few seconds. Formed cadaveric spots do not disappear when pressed.

Rigor mortis - compaction and shortening of skeletal muscles, creating an obstacle to passive movements in the joints. Occurs after 2-4 hours from the moment of cardiac arrest, reaches a maximum in a day, is resolved after 3-4 days.

cadaveric decomposition - occurs at a later date, manifested by decomposition and decay of tissues. Decomposition time largely depends on environmental conditions.

Statement of biological death

The fact of the onset of biological death is established by a doctor or paramedic by the presence of reliable signs, and before they appear, by the combination of the following symptoms:

Lack of cardiac activity (no pulse on large arteries, heart sounds are not heard, there is no bioelectrical activity of the heart);

The time of the absence of cardiac activity is significantly more than 25 minutes (at normal ambient temperature);

Lack of spontaneous breathing;

The maximum expansion of the pupils and the absence of their reaction to light;

Lack of corneal reflex;

The presence of postmortem hypostasis in sloping parts of the body.

brain death

With some intracerebral pathology, as well as after resuscitation, a situation sometimes arises when the functions of the central nervous system, primarily the cerebral cortex, are completely and irreversibly lost, while cardiac activity is preserved, blood pressure is maintained or maintained by vasopressors, and breathing is provided by mechanical ventilation. This condition is called brain death (“brain death”). The diagnosis of brain death is very difficult to make. There are the following criteria:

Complete and permanent absence of consciousness;

Sustained lack of spontaneous breathing;

Disappearance of reactions to external stimuli and any kind of reflexes;

Atony of all muscles;

The disappearance of thermoregulation;

Complete and persistent absence of spontaneous and induced electrical activity of the brain (according to electroencephalogram data).

The diagnosis of brain death has implications for organ transplantation. After its ascertainment, it is possible to remove organs for transplantation to recipients. In such cases, when making a diagnosis, it is additionally necessary:

Angiography of cerebral vessels, which indicates the absence of blood flow or its level is below critical;

The conclusions of specialists (neurologist, resuscitator, forensic medical expert, as well as an official representative of the hospital), confirming brain death.

According to the legislation existing in most countries, "brain death" is equated with biological.

Resuscitation measures

Resuscitation measures are the actions of a doctor in case of clinical death, aimed at maintaining the functions of blood circulation, respiration and revitalizing the body. There are two levels of resuscitation: basic and specialized resuscitation. The success of resuscitation depends on three factors:

Early recognition of clinical death;

Start basic resuscitation immediately;

Prompt arrival of professionals and start of specialized resuscitation.

Diagnosis of clinical death

Clinical death (sudden cardiac arrest) is characterized by the following symptoms:

Loss of consciousness;

Absence of a pulse in the central arteries;

Stop breathing;

Absence of heart sounds;

Pupil dilation;

Change in skin color.

However, it should be noted that the first three signs are sufficient to ascertain clinical death and start resuscitation measures: lack of consciousness, pulse on the central arteries and

breathing. After the diagnosis is made, basic cardiopulmonary resuscitation should be started as soon as possible and, if possible, a team of professional resuscitators should be called.

Basic cardiopulmonary resuscitation

Basic cardiopulmonary resuscitation is the first stage of care, the likelihood of success depends on the timeliness of which begins. Carried out at the place of detection of the patient by the first person who owns her skills. The main stages of basic cardiopulmonary resuscitation were formulated back in the 60s of the XX century by P. Safar.

BUT - airways- Ensuring free airway patency.

AT - breathing- IVL.

FROM - circulation- indirect heart massage.

Before starting the implementation of these stages, it is necessary to lay the patient on a hard surface and give him a position on his back with raised legs to increase blood flow to the heart (lift angle 30-45? C).

Ensuring free airway patency

To ensure free patency of the respiratory tract, the following measures are taken:

1. If there are blood clots, saliva, foreign bodies, vomit in the oral cavity, it should be mechanically cleaned (the head is turned on its side to prevent aspiration).

2. The main way to restore airway patency (when the tongue is retracted, etc.) is the so-called triple technique of P. Safar (Fig. 8-9): extension of the head, protrusion of the lower jaw, opening of the mouth. In this case, head extension should be avoided if a cervical spine injury is suspected.

3. After performing the above measures, a test breath is performed according to the "mouth to mouth" type.

Artificial lung ventilation

IVL begins immediately after the restoration of the patency of the upper respiratory tract, carried out according to the type of "mouth-to-mouth" and "mouth-to-nose" (Fig. 8-10). The first method is preferable, the resuscitator takes a deep breath, covers the mouth of the victim with his lips and

Rice. 8-9.Triple reception of P. Safar: a - retraction of the tongue; b - extension of the head; c - protrusion of the lower jaw; d - mouth opening

produces exhalation. In this case, fingers should pinch the nose of the victim. In children, breathing into the mouth and nose is used at the same time. The use of air ducts greatly facilitates the procedure.

General rules of ventilation

1. The volume of injection should be about 1 liter, the frequency is about 12 times per minute. The blown air contains 15-17% oxygen and 2-4% CO 2 , which is quite enough, taking into account the dead space air, which is close in composition to atmospheric.

2. Exhalation should last at least 1.5-2 s. Increasing the duration of expiration increases its efficiency. In addition, the possibility of gastric expansion is reduced, which can lead to regurgitation and aspiration.

3. During mechanical ventilation, the patency of the airways should be constantly monitored.

4. To prevent infectious complications in the resuscitator, you can use a napkin, handkerchief, etc.

5. The main criterion for the effectiveness of mechanical ventilation: expansion of the chest when air is blown in and its collapse during passive exhalation. Swelling of the epigastric region indicates swelling of the

Rice. 8-10.Types of artificial respiration: a - mouth to mouth; b - mouth to nose; in - in the mouth and nose at the same time; g - with the help of an air duct; d - the position of the duct and its types

puddle. In this case, check the patency of the airways or change the position of the head.

6. Such mechanical ventilation is extremely tiring for the resuscitator, therefore it is advisable to switch to mechanical ventilation as soon as possible using the simplest devices of the Ambu type, which also increases the efficiency of mechanical ventilation.

Indirect (closed) heart massage

Indirect cardiac massage is also referred to as basic cardiopulmonary resuscitation and is performed in parallel with mechanical ventilation. Chest compression leads to the restoration of blood circulation due to the following mechanisms.

1. Heart pump: squeezing the heart between the sternum and the spine due to the presence of valves leads to a mechanical extrusion of blood in the right direction.

2. Chest pump: Compression causes blood to be squeezed out of the lungs and into the heart, which greatly contributes to the restoration of blood flow.

Choice of point for chest compression

Pressure on the chest should be made along the midline at the border of the lower and middle thirds of the sternum. Usually, moving the IV finger along the midline of the abdomen upwards, the resuscitator gropes for the xiphoid process of the sternum, applies another II and III to the IV finger, thus finding a compression point (Fig. 8-11).

Rice. 8-11.Choice of compression point and method of indirect massage: a - compression point; b - the position of the hands; c - massage technique

precordial beat

In sudden cardiac arrest, a precordial stroke can be an effective method. A fist from a height of 20 cm is struck twice on the chest at the point of compression. In the absence of effect, proceed to a closed heart massage.

Closed heart massage technique

The victim lies on a rigid base (to prevent the possibility of displacement of the whole body under the action of the hands of the resuscitator) with raised lower limbs (increased venous return). The resuscitator is located on the side (right or left), puts one palm on top of the other and presses on the chest with arms straightened at the elbows, touching the victim at the compression point only with the proximal part of the palm located below. This enhances the pressure effect and prevents damage to the ribs (see Figure 8-11).

Intensity and frequency of compressions. Under the action of the hands of the resuscitator, the sternum should shift by 4-5 cm, the frequency of compressions should be 80-100 per minute, the duration of pressure and pauses are approximately equal to each other.

Active "compression-decompression". Active "compression-decompression" of the chest for resuscitation has been used since 1993, but it has not yet found wide application. It is carried out using the Cardiopamp apparatus, equipped with a special suction cup and providing active artificial systole and active diastole of the heart, contributing to mechanical ventilation.

Direct (open) heart massage

Direct cardiac massage during resuscitation is rarely resorted to.

Indications

Cardiac arrest during intrathoracic or intra-abdominal (transdiaphragmatic massage) operations.

Chest trauma with suspected intrathoracic bleeding and lung injury.

Suspicion of cardiac tamponade, tension pneumothorax, pulmonary embolism.

Injury or deformity of the chest, interfering with the implementation of a closed massage.

Ineffectiveness of closed massage within a few minutes (relative indication: used in young victims, with the so-called "unjustified death", is a measure of desperation).

Technique.Produce thoracotomy in the fourth intercostal space on the left. The hand is inserted into the chest cavity, four fingers are brought under the lower surface of the heart, and the first finger is placed on its front surface and rhythmic contraction of the heart is performed. During operations inside the chest cavity, when the latter is wide open, the massage is carried out with both hands.

Combination of ventilation and cardiac massage

The order of combination of mechanical ventilation and heart massage depends on how many people are helping the victim.

Reanimating one

The resuscitator produces 2 breaths, after which - 15 chest compressions. This cycle is then repeated.

Reanimating two

One resuscitator performs mechanical ventilation, the other - an indirect heart massage. In this case, the ratio of respiratory rate and chest compressions should be 1:5. During inspiration, the second rescuer should pause the compressions to prevent gastric regurgitation. However, during massage on the background of mechanical ventilation through an endotracheal tube, such pauses are not necessary. Moreover, compression during inhalation is useful, as more blood from the lungs enters the heart and artificial circulation becomes effective.

The effectiveness of resuscitation

A prerequisite for carrying out resuscitation measures is constant monitoring of their effectiveness. Two concepts should be distinguished:

Efficiency of resuscitation;

Efficiency of artificial respiration and blood circulation.

Resuscitation efficiency

The effectiveness of resuscitation is understood as a positive result of resuscitation of the patient. Resuscitation measures are considered effective in the event of the appearance of sinus rhythm of heart contractions, restoration of blood circulation with registration of systolic blood pressure of at least 70 mm Hg, constriction of the pupils and the appearance of a reaction to light, restoration of the color of the skin and the resumption of spontaneous breathing (the latter is not necessary) .

Efficiency of artificial respiration and circulation

The effectiveness of artificial respiration and blood circulation is said when resuscitation measures have not yet led to the revival of the body (there is no independent blood circulation and respiration), but the measures taken artificially support metabolic processes in tissues and thereby lengthen the duration of clinical death. The effectiveness of artificial respiration and blood circulation is evaluated by the following indicators:

1. Constriction of the pupils.

2. The appearance of a transmission pulsation on the carotid (femoral) arteries (assessed by one resuscitator when another chest compressions are performed).

3. Change in the color of the skin (reduction of cyanosis and pallor).

With the effectiveness of artificial respiration and blood circulation, resuscitation continues until a positive effect is achieved or until the indicated signs disappear permanently, after which resuscitation can be stopped after 30 minutes.

Drug therapy in basic resuscitation

In some cases, during basic resuscitation, it is possible to use pharmacological preparations.

Routes of administration

During resuscitation, three methods of administering drugs are used:

Intravenous jet (in this case, it is desirable to administer drugs through a catheter in the subclavian vein);

Intracardiac;

Endotracheal (with tracheal intubation).

Intracardiac technique

The ventricular cavity is punctured at a point located 1-2 cm to the left of the sternum in the fourth intercostal space. This requires a needle 10-12 cm long. The needle is inserted perpendicular to the skin; a reliable sign of the needle being in the cavity of the heart is the appearance of blood in the syringe when the piston is pulled towards itself. Intracardiac administration of drugs is not currently used due to the threat of a number of complications (lung injury, etc.). This method is considered only in the historical aspect. The only exception is the intracardiac injection of epinephrine into the ventricular cavity during open heart massage using a conventional injection needle. In other cases, drugs are injected into the subclavian vein or endotracheally.

Drugs used in basic resuscitation

For several decades, epinephrine, atropine, calcium chloride, and sodium bicarbonate have been considered essential in basic cardiopulmonary resuscitation. Currently, the only universal drug used in cardiopulmonary resuscitation is epinephrine at a dose of 1 mg (endotracheally - 2 mg), it is administered as early as possible, subsequently repeating infusions every 3-5 minutes. The main effect of epinephrine during cardiopulmonary resuscitation is the redistribution of blood flow from peripheral organs and tissues to the myocardium and brain due to its α-adrenomimetic effect. Epinephrine also excites β-adrenergic structures of the myocardium and coronary vessels, increases coronary blood flow and contractility of the heart muscle. With asystole, it tones the myocardium and helps to "start" the heart. In ventricular fibrillation, it promotes the transition of small-wave fibrillation to large-wave fibrillation, which increases the efficiency of defibrillation.

The use of atropine (1 ml of a 0.1% solution), sodium bicarbonate (4% solution at a rate of 3 ml/kg of body weight), lidocaine, calcium chloride and other drugs is carried out according to indications, depending on the type of circulatory arrest and the cause that caused it. In particular, lidocaine at a dose of 1.5 mg/kg of body weight is the drug of choice for fibrillation and ventricular tachycardia.

Basic resuscitation algorithm

Taking into account the complex nature of the necessary actions in case of clinical death and their desirable speed, a number of specific

Rice. 8-12.Algorithm for basic cardiopulmonary resuscitation

nyh algorithms of actions of the resuscitator. One of them (Yu.M. Mikhailov, 1996) is shown in the diagram (Fig. 8-12).

Basics of specialized cardiopulmonary resuscitation

Specialized cardiopulmonary resuscitation is carried out by professional resuscitators using special diagnostic and treatment tools. It should be noted that specialized activities are carried out only against the background of basic cardiopulmonary resuscitation, supplement or improve it. Free airway patency, mechanical ventilation and indirect heart massage are essential and main components of all resuscitation

events. Among the ongoing additional activities in order of their implementation and significance, the following can be distinguished.

Diagnostics

By clarifying the anamnesis, as well as special diagnostic methods, the causes that caused clinical death are revealed: bleeding, electrical injury, poisoning, heart disease (myocardial infarction), pulmonary embolism, hyperkalemia, etc.

For treatment tactics, it is important to determine the type of circulatory arrest. Three mechanisms are possible:

Ventricular tachycardia or ventricular fibrillation;

asystole;

Electromechanical dissociation.

The choice of priority therapeutic measures, the result and prognosis of cardiopulmonary resuscitation depend on the correct recognition of the mechanism of circulatory arrest.

Venous access

Ensuring reliable venous access is a prerequisite for resuscitation. The most optimal - catheterization of the subclavian vein. However, catheterization itself should not delay or interfere with resuscitation. Additionally, it is possible to administer drugs into the femoral or peripheral veins.

Defibrillation

Defibrillation is one of the most important specialized resuscitation measures necessary for ventricular fibrillation and ventricular tachycardia. The powerful electric field created during defibrillation suppresses multiple sources of myocardial excitation and restores sinus rhythm. The earlier the procedure is performed, the higher the likelihood of its effectiveness. For defibrillation, a special apparatus is used - a defibrillator, the electrodes of which are placed on the patient, as shown in the diagram (Fig. 8-13).

The power of the first discharge is set to 200 J, if this discharge is ineffective, the second is 300 J, and then the third is 360 J. The interval between discharges is minimal - only in order to

Rice. 8-13.The layout of the electrodes during defibrillation

make sure on the electrocardioscope that fibrillation persists. Defibrillation can be repeated several times. At the same time, it is extremely important to observe safety precautions: the absence of contact between medical personnel and the patient's body.

Tracheal intubation

Intubation should be done as early as possible, as it provides the following benefits:

Ensuring free airway patency;

Prevention of regurgitation from the stomach with indirect heart massage;

Ensuring adequate controlled ventilation;

The possibility of simultaneous compression of the chest when blowing air into the lungs;

Ensuring the possibility of intratracheal administration of medicinal substances (drugs are diluted in 10 ml of saline and injected through a catheter distal to the end of the endotracheal tube, after which 1-2 breaths are taken; the dose of drugs is increased by 2-2.5 times compared to intravenous administration).

Medical therapy

Drug therapy is extremely diverse and largely depends on the cause of clinical death (the underlying disease). The most commonly used are atropine, antiarrhythmic

agents, calcium preparations, glucocorticoids, sodium bicarbonate, antihypoxants, means of replenishing BCC. When bleeding paramount importance is given to blood transfusion.

Brain protection

During resuscitation, cerebral ischemia always occurs. To reduce it, use the following means:

Hypothermia;

Normalization of acid-base and water-electrolyte balance;

Neurovegetative blockade (chlorpromazine, levomepromazine, diphenhydramine, etc.);

Decreased permeability of the blood-brain barrier (glucocorticoids, ascorbic acid, atropine);

Antihypoxants and antioxidants;

Drugs that improve the rheological properties of blood.

Assisted circulation

In the event of clinical death during cardiac surgery, it is possible to use a heart-lung machine. In addition, the so-called auxiliary circulation (aortic counterpulsation, etc.) is used.

Algorithm for specialized resuscitation

Specialized cardiopulmonary resuscitation is a branch of medicine, a detailed presentation of which is in special manuals.

Prognosis of resuscitation and post-resuscitation illness

The prognosis of the restoration of body functions after resuscitation is primarily associated with the prognosis of the restoration of brain functions. This prognosis is based on the duration of the absence of blood circulation, as well as on the time of appearance of signs of restoration of brain functions.

The effectiveness of resuscitation, the restoration of blood circulation and respiration do not always indicate a complete restoration of body functions. Metabolic disorders during OS-

Circulation and respiration, as well as during urgent resuscitation, lead to insufficiency of the functions of various organs (brain, heart, lungs, liver, kidneys), which develops after stabilization of the parameters of the main vital systems. The complex of changes that occur in the body after resuscitation is called “post-resuscitation disease”.

Legal and moral aspects

Indications for resuscitation

Issues on the conduct and termination of resuscitation are regulated by legislative acts. Carrying out cardiopulmonary resuscitation is indicated in all cases of sudden death, and only in the course of its implementation, the circumstances of death and contraindications to resuscitation are clarified. The exception is:

Injury incompatible with life (detachment of the head, crushing of the chest);

The presence of clear signs of biological death.

Contraindications for resuscitation

Cardiopulmonary resuscitation is not indicated in the following cases:

If death occurred against the background of the use of the full complex of intensive care indicated for this patient, and was not sudden, but associated with a disease incurable for the present level of development of medicine;

In patients with chronic diseases in the terminal stage, while the hopelessness and futility of resuscitation should be recorded in advance in the medical history; such diseases often include stage IV malignant neoplasms, severe forms of stroke, incompatible with life injuries;

If it is clearly established that more than 25 minutes have passed since the moment of cardiac arrest (at normal ambient temperature);

If patients have previously recorded their justified refusal to conduct resuscitation in the manner prescribed by law.

Termination of resuscitation

Cardiopulmonary resuscitation may be terminated in the following cases.

Assistance is provided by non-professionals - in the absence of signs of the effectiveness of artificial respiration and blood circulation within 30 minutes of resuscitation or at the direction of resuscitation specialists.

Help from professionals:

If during the course of the procedure it turned out that resuscitation was not indicated for the patient;

If resuscitation measures are not fully effective within 30 minutes;

If there are multiple cardiac arrests that are not amenable to medical influences.

Problems of euthanasia

There are two types of euthanasia: active and passive.

Active euthanasia

This is intentional compassionate mortification at the request of the patient or without it. It implies the active actions of a doctor and is otherwise called "filled syringe method". Such actions are prohibited by the laws of the vast majority of countries, they are considered as a criminal act - deliberate murder.

Passive euthanasia

Passive euthanasia is the limitation or exclusion of particularly complex medical methods, which, although they would lengthen the life of the patient at the cost of further suffering, would not save her. Otherwise, passive euthanasia is called "Delayed syringe method". Particularly relevant is the problem of passive euthanasia in the treatment of extremely severe, incurable diseases, decortication, and severe congenital malformations. The morality, humanity and expediency of such actions of doctors are still perceived by society ambiguously, in the vast majority of countries such actions are not recommended.

All types of euthanasia are prohibited in Russia.

Most doctors check vital signs every time you visit because their name fits the role - they are essential to life. There are four vital signs: heart rate, respiration, blood pressure and temperature.

An individual health and wellness program should include regular measurement of heart rate and blood pressure. You can easily take this data at home or at the doctor's.

Heart rate

It's amazing how many people don't know how to check their heart rate, or pulse, but we think it's important that everyone has this basic skill. It is very easy to learn how to check your pulse - this can provide a lot of valuable information about the state of the heart. Chinese medicine practitioners can measure 12 different types of wrist pulses, but luckily everyone only needs to know one of them, and it's easy.

The best place to check your pulse is at the wrist. Just place the index and middle fingers of one hand on the inside of the wrist of the other hand from the side of the thumb. Count the beats of the pulse for 20 seconds, multiply the resulting value by three: now you know your heart rate. Maybe you want to do it right now. It will probably take some effort

to feel for a pulse if you haven't done it before, but most people can easily find it on their wrist. A common mistake is to press too hard, so press lightly. You can also buy an inexpensive and easy-to-use heart rate monitor - they are sold in pharmacies and sports stores.

The better your fitness, the lower your resting heart rate. For example, Lance Armstrong's resting heart rate is only 32 beats per minute. This is usually lower in men than in women, but in general it is desirable that your resting heart rate be less than 84. The optimal heart rate is less than 70. If your heart rate is above 100, then either you are in very poor shape, or you have any health problems, such as heart or thyroid disease, anemia, and should see a doctor.

Arterial pressure

Blood pressure is easy to measure at home with available and inexpensive automated devices. There are four categories of blood pressure:

less than 120/80 mm Hg Art. - optimal;

120/80-130/85mmHg Art. - normal;

130/85-140/90mmHg Art. - increased normal;

more than 140/90 mm Hg. Art. - high.

Nearly 40% of Americans have optimal, 24% normal, 13% elevated normal, and 23% high blood pressure. If the pressure is significantly higher than 140/90, then most doctors recommend taking medications. Of course, every time the blood pressure rises above the optimal value of 120/80, there is a threat to health. According to a study by the National Heart, Lung, and Blood Institute published in 2008, high blood pressure significantly increases the likelihood of a heart attack or stroke. The table below shows the rates of risk for developing cardiovascular pathologies, such as heart attack or stroke, in women and men aged 35-64 over a 10-year period.

Table 10.1

RISK OF DEVELOPING CARDIOVASCULAR PATHOLOGY OVER 10 YEARS

This table shows that at high normal blood pressure, which does not even require medication, compared to the optimal range, the risk of heart attack and stroke increases by 230% in women and 70% in men. Losing weight, exercising regularly, and limiting your intake of high glycemic foods are simple and effective ways you can use to bring your normal or elevated normal blood pressure down to optimal levels.

For people whose blood pressure remains in the high-normal range, or even in the lower part of the high-pressure range, despite following the principles of the Overcoming program, we recommend taking the traditional Chinese herbal preparation Uncaria-6, manufactured by Seven Forests. This inexpensive herbal formula is safe, effective in many cases, and has few side effects. Uncaria 6 is available from most acupuncturists who practice Chinese herbal medicine.

body composition

In addition to vital signs, it is important to know your body composition. Measurement is a determination of how much of your body tissue is made up of fat and how much is made up of everything else, that is, muscle, bone, and blood. You can get more information about this by checking your waist to hip ratio, which shows the distribution of fat in your body. These two indicators are no less (if not more) important than weight. Most doctors rarely examine body composition and waist-to-hip ratio, so you probably need to do it yourself.

Fats in the body

Fats contained in the body can be divided into two main types: essential - they are necessary for the survival and operation of the reproductive system (reproduction, procreation), and fat reserves (fat depots), which serve as a storehouse of calories. This aspect also indicates that our genetic software is outdated. The insulin receptor gene in adipose tissue is the oldest one that tells you to hold on to every calorie. Thousands of years ago this mechanism was useful, but today there is no need for it. Men need a minimum of 2-5%, and women need 10-12% of essential fat. In many ways, fat behaves like any other organ in the body and performs important functions. Essential fat is needed to protect the heart, spleen and intestines. If you do not take into account water, one of the components of the brain, then most of the remaining substance will be in fat. In women, fat is involved in the exchange of sex hormones - testosterone and estrogen. In both sexes, adipose tissue secretes important hormones such as leptin, resistin, adiponectin, interleukin-6, and tumor necrosis factor-alpha, which help regulate numerous metabolic processes.

As a rule of thumb, total body fat should be 10-17% for men and 18-26% for women. Values ​​at the lower limits of these ranges can be considered optimal, so men can set a normal rate for themselves at the level of 10-12%, and women - about 18-20%. At the same time, in trained athletes, these figures are usually even lower. If you weigh 74 kg (the average weight of an American woman in 2002) and have approximately 34% body fat, that means you have a whopping 23.6 kg of body fat. To return to a healthy 24% would require losing 10 kg (then you would weigh 64 kg, which is close to the average weight of an American woman in 1960).

The most accurate method of measuring body fat is to be completely immersed in a pool of water, but you can get approximate data using portable devices or scales that show body fat in addition to weight. True, some of these devices are notorious for their inaccuracy, so it would be a good idea to measure this figure at the doctor's office or at the gym using more accurate methods, such as impedance measurements or underwater weighing, and then compare this data with those you received at home. device. Thus, it will turn out to check the accuracy of your device.

Ratio of waist circumference to hip circumference

Your health can be affected not only by body fat content, but also by its distribution. Some people (mostly women) tend to accumulate fat in the upper thighs and buttocks, which gives the figure a so-called pear shape. This body type has mostly aesthetic disadvantages, as it is associated with fewer health risks than the apple body type, which stores fat in the middle part of the body.

The accumulation of fat above the waistline - the classic "beer belly" - is more common in men, and its correct name is central obesity. This is a sign of metabolic syndrome, a major risk factor for the development of cardiovascular disease. Measuring the ratio of waist circumference to hip circumference can be considered the simplest method for diagnosing metabolic syndrome. All you need to do this test is paper or plastic tape. Measure the circumference of the abdomen at the level of the navel. Relax your stomach, do not pull it in. Then measure your hip circumference at its widest point. Now divide your waist circumference by your hip circumference and compare the resulting value with the table below.

Table 10.2

WAIST TO HIP RATIO AND HEALTH RISKS

There are 12 systems in our body. Each of them is respiratory, digestive, endocrine, etc. - has its own key indicator. Sputnik asked a preventive medicine specialist Ekaterina Stepanova talk about the most important parameters of the body, which are important to always keep under control.

1. Blood pressure (BP). For six billion of the world's population, it fluctuates between 120/80. Why - no one knows, but it is these numbers that allow us to be healthy and feel good. What is this pressure? Oxygen from the air dissolves in water and enters the blood under this pressure. This is the first important indicator of our health! A change in blood pressure is a signal of the central nervous system. This is her SOS!

2. The number of breaths. It is equal to 16 in 1 minute. This is the norm for all healthy adults at rest. It is clear that activity, as well as emotions, make their own adjustments. Any changes in this indicator signal us about problems in the respiratory system.

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3. Heart rate (HR). The norm is 78 in 1 minute. What is this number? This is the optimal rate of movement of oxygen through the blood, along with blood from the lungs to the organ.

This is an indicator of the work of our cardiovascular system, which is responsible, among other things, for regulating the speed of water in the body.

These three indicators, when they are in the physiological norm, allow us to feel good. You don't need a doctor to control them. It is worth sounding the alarm if:

• pressure deviates from the norm 120/80 - we can start to get sick and certainly feel bad. Critical can be considered numbers close to 220 or, conversely, to 40-35. This is a reason to immediately call an ambulance!
• when running, working, increased load, the number of heartbeats (HR) has gone beyond the permissible limit, then at rest within 2 minutes it should return to normal. This is how the heart works: it works for 0.5 seconds - it rests for 0.5 seconds with proper breathing. It doesn’t happen otherwise, or it happens, but not for long ...

4. Hemoglobin. The norm for women is 120-140 for men - 140-160 millimoles per liter. What is this number? This is the amount of oxygen in our body, which is at the same time and constantly. The amount of oxygen that we have enough for all our needs. And even with a margin - in which case to activate additional resources of the body. This figure should be constant, it is this amount that provides us with the quality of life.

Hemoglobin is an indicator of the hematopoietic system, including the density of blood in terms of oxygen. If the amount of hemoglobin in the blood falls, the number of respiratory movements increases. Shortness of breath appears, as a result, the number of heart contractions increases, blood pressure is disturbed and ... we are waiting for an ambulance!

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5. Bilirubin. This is an indicator of blood toxicity in terms of the number of processed dead red blood cells, since every day cells in the body are born and die. The norm is 21 micromoles per liter. It allows you to analyze the work of the digestive (liver, intestines) and excretory systems. Allows you to understand the body's ability to self-purify.

If the indicator exceeds 24 units, this indicates that the body begins to die quietly. All systems suffer - there is no life in a dirty environment.

6. Urine. Both quantity and quality are important here. Urine is a qualitative characteristic of water in the body. The physiological norm of excreted urine per day is 1.5 liters. In a healthy person, it is light straw in color, specific gravity 1020 g/l, acidity 5.5. Nothing else should be in the urine. If protein or leukocytes appear in the urine, it's time to worry, the excretory system is malfunctioning.

7. Weight. Stocks of clean water and energy in the body are regulated, including by hormones. In nature, a prime example is the camel. He tolerates multi-day hikes well, as before that he eats a hump. And the hump is fat. During exercise, fat is broken down into water and energy, so fat is the body's strategic energy store.

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Like all key indicators, weight has its health limits. For an adult, it is customary to consider the rate of his growth (-) 100 (+) (-) 5-10 kg as the norm. For example - if your height is 170 centimeters, then the maximum weight norms are from 60 to 80 kg. From birth to death, the weight should be constant according to the age scale, except in explicable situations. Since all systems (organs) adjust and serve the norm of weight, laid down by nature, and not "inflated" by us. All excess weight is overtime work for the organs, which leads to their faster wear. As a rule, everyone who drinks little and does not eat enough foods that alkalize the body is overweight.

In the case of pregnancy, the female body is under stress, so weight fluctuations after childbirth are possible, but all women know about this and help their body return to normal.

Since by nature a man and a woman perform different functions, their relationship with fat is also different. In women, the fat reserve is a depot of hormones that regulate the course of pregnancy; it performs a thermoregulatory function (protects the fetus from the cold); is a strategic reserve for mother and fetus.

For men, things are different. Excess fat most often begins to be deposited in the waist area. It is difficult to remove from the body, as it has its own characteristics. This fat, depending on the amount, can be a sign of an endocrine failure or an incipient disease. Abdominal fat (deposited in the waist area - Sputnik) accumulates estrogens - hormones that antagonize male testosterone. This weakens the male power. Normally, the male waist should be 87-92 cm.

We must not forget that with excess weight, internal organs suffer. They are also prone to obesity. Excess fat on the internal organs is one of the most toxic! The reproductive system is responsible for the constancy of weight.

8. Blood sugar. The norm is 3.5-5.5 millimoles per liter (according to WHO recommendations). This indicator determines the supply of operational energy in the body. That is for every day. Glycogen is made from sugar every day. It is needed for the energy of cells in order for the necessary chemical reactions to take place in the body. If the body is starving for several days, glycogen ends and the consumption of a strategic reserve begins. The endocrine system, including the pancreas, is responsible for the constancy of this indicator.

9. pH-acid-base balance in the blood. It is also called the concentration of the oxygen-hydrogen factor (alkali and acid). Resuscitators and cardiologists call it an indicator of the life of everything! Norm 7.43. At a value of 7.11, the point of no return comes - death! In this case, it is no longer possible to save a person. At numbers 7.41, the development of acute heart failure begins.

Unfortunately, in our country this indicator is not given the importance it deserves. In many countries, a conversation between a doctor and a patient begins with this indicator - in order to understand the conditions in which a person lives, what he eats, drinks, how active he is, the doctor must find out the so-called physiology of life.

pH balance is those strategic numbers that the body will maintain in any way. If organic (environmentally friendly) alkaline products do not come to us from the outside, then the body will take from itself the beloved (teeth, nails, bones, blood vessels, eyes, etc.) the main alkaline metals Ca, MG, Na, K , and further unpleasant development of events begins.

We are arranged in such a way that we can exist healthy only in a slightly alkaline internal environment. The whole body, all systems, but to a greater extent musculoskeletal (joints, ligaments, bones) are responsible for the constancy of this indicator.

10. Leukocytes. The norm is 4.5 thousand × 10⁹. Our white blood cells are our individual protection. Everything that has entered our body (viruses, bacteria) will be destroyed. If there is an increase in all groups of leukocytes (monocytes, eosenophils, stab) - this indicates that our security has been violated and we are at war. And the higher the number, the more serious the situation. These are our protectors! Our border control! The immune system is responsible for the constancy of our protection.

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11. Body temperature. The classical norm is 36.6 ° C. It is at this temperature that the water crystal in our body is in a stable state and provides all the processes of oxidation and reduction. If the temperature rises to 38°C and higher, the water crystal is destroyed, energy is released, which goes to fight the problem, since different life forms have different viability temperatures, the body temperature cannot be lowered below 38-38.3°C!

At a body temperature of 42°C, life is impossible, but even 35.4°C is not the best temperature, since a water crystal at such values ​​\u200b\u200bis unstable, like chemical reactions. 36.6°C is the temperature of the constancy of our chemical processes, the constancy of our life in nature! The temperature outside is 40°C, and we have 36.6°C, outside it is 50°C, we have 36.6°C, because we are healthy!

Our immune system is responsible for the constancy of our temperature. By the way, if you catch a cold and run out of your nose - that's fine. The discharge from the nose is lymph and dead white blood cells. They need to be given a way out, do not organize a cemetery of leukocytes inside yourself, for the first 2-3 days vasoconstrictor drops are not needed - let the unnecessary flow out. Of course, this will cause some inconvenience, but it will reduce intoxication and lead to a faster recovery.

12. Cholesterol (general). The norm is 6.0 millimoles per liter. This indicator determines the fat content of water as the basis of all fluids in the body. It is responsible for the functioning of the nervous system, since the shell of neurons (conductors) along which the impulse (signal) runs consists of cholesterol, and the cells of the main analyzer - the brain are partially composed of cholesterol, it is the energy reserve on which the brain works.

Summing up, I would like to say: it is desirable to keep blood pressure, heart rate and respiratory movements of the body under control every day. Once every six months, you need to be interested in how our body feels, whether it copes with life in the environment. To do this, you just need to pass tests and make the necessary measurements. If something is wrong, this is a signal that our biological machine is close to breaking down and needs service!

Salvatore Mangione, M.D.

No sounds are heard directly below the place of complete clamping of the artery (with obliteration of the lumen). As soon as the first drop of blood begins to leak from under the area of ​​compression, we hear a very distinct popping sound. This sound is heard from the moment the occluded artery is released and until the appearance of pulsation in the peripheral vessels.

N.S. Korotkov: "On the methods of studying blood pressure". Imperial Academy of Medicine. Sciences.St. Petersburg. - 1905. - 4:365.

Mankind has at least three great enemies: Fever, Famine, and War. Of these, the worst is fever.
Sir William Osler, JAMA 26:999, 1896

The four-day fever kills the old and heals the young.
Italian proverb

TRADITIONAL QUESTIONS AND ANSWERS

Assessment of vital signs is an initial and still integral part of the physical examination. Unfortunately, it is often entrusted to paramedical and even technical personnel. Nevertheless, as the name implies, the main physiological indicators carry an abundance of critical information that may require special skills and knowledge.

What are anthropometric indicators?

Weight and height are both important measurements. Unlike basic physiological indicators, anthropometric indicators are usually more stable.you and little change over time. Thus, they represent less decisive clinical information.

2. What are the main physiological parameters?

These are decisive, therefore, vital signs that must be evaluated at every examination of the patient. These are heart rate, respiratory rate, temperature and blood pressure.

PULSE

3. What is the normal heart rate?

60 - 100 beats per minute (bpm). A rate below 60 bpm is considered bradycardia, and a rate greater than 100 bpm is considered tachycardia.

4. What are the characteristics of the pulse?

This is the pulse rate. Then the rhythmicity or irregularity of the pulse is assessed. For example, rhythmic tachycardia usually occurs with sinus tachycardia, atrioventricular tachycardia re-entry, or ventricular tachycardia. In contrast, non-rhythmic tachycardia is almost always caused by atrial fibrillation. Flutter - non-rhythmic tachycardia due to variable atrioventricular blockade. A rhythmic rare pulse can also be in patients with atrioventricular blockade of the second degree, in whom the loss of a pulse beat occurs at regular intervals.

5. What is an alternating pulse?

The alternating pulse is characterized by a normal frequency and rhythm with alternating pulse waves of small and large filling. An alternating pulse is typical of congestive heart failure and is sometimes associated with electrical alternation (alternating high and low QRS complexes on the electrocardiogram (ECG), but the heart rhythm remains normal).

Rice. 2.1. Pulse alternation. Note that every second heart beat creates a lower systolic pressure. (Adapted from: Abrams J: Prim Cardiol, 1982.)

RESPIRATORY RATE AND RHYTHM

6. What information can be obtained by assessing the speed, rhythm and depth of breathing?

In doing so, you can get a lot of useful information. A meaningful assessment of these parameters may require an entire alphabetical set of terminology, often entailing a specific diagnosis. A detailed description of these terms and the pathological processes themselves is given in Chapter 13.

TEMPERATURE

7. Define fever.

Fever is body temperature above 37°C. However, it is normal for many people to reach higher body temperatures during exercise or exposure to the external environment. Thus, a true fever should be considered a temperature in the oral cavity above 37.9 ° C.

8. What is the difference between the temperature in the mouth and the rectum?

The rectal temperature is slightly higher than the temperature in the mouth. The difference is usually 0.55°C, but can be greater if the person breathes through the mouth or in cases of tachypnea (whether breathing through the mouth or through the nose). In such patients, the difference in temperature in the rectum and in the mouth averages 0.93 ° C, but can be even greater with an increase in respiratory rate. Ingestion of cold or hot substances (including cigarette smoking) shortly before the examination may cause a falsely low or falsely high temperature in the mouth.

9. What about axillary temperature?

It is very inaccurate and it is best not to rely on it.

10. How long does it take to correctly measure the temperature inmouth (under the tongue)

Approximately 3 minutes for older mercury thermometers and 1 minute for modern models.

11. What is the clinical significance of fever?

It usually indicates the presence of an infection. Fever can also be associated with inflammation (eg, some autoimmune diseases), malignancies, drug reactions, environmental conditions (eg, heat stroke), and certain metabolic and endocrine disorders (eg, Graves' disease, Addison's disease). crisis).

12. What is artificial fever?

This is a false fever caused by the patient himself (from the Latin word factitius- artificially created). The methods of inducing fever vary widely, according to the imagination and skill of the patients. Most often, just before measuring the temperature, they collect hot liquid in their mouths and hold it in it. Fever is often (but not always) detectable by measuring rectal or urine temperature immediately after urination. However, the temperature of the urine is slightly lower than the temperature in the mouth.

13. What is relapsing fever?

Relapsing fever is manifested by a series of febrile attacks lasting about 6 days and separated by temperature-free intervals of about the same duration. Relapsing fever is usually caused by an infectious process (eg, brucellosis, malaria, borreliosis, or tuberculosis), but can also occur with Hodgkin's disease or familial Mediterranean fever.

14. What is Pell-Ebstein fever?

Pel-Ebstein fever occurs in 16% of patients with Hodgkin's disease. It is characterized by episodes of fever lasting from hours to days, followed by temperature-free periods of days and sometimes even weeks. Therefore, Pell-Ebstein fever is a variant of recurrent fever. It was described in the nineteenth century by the Dutchman Peter Pehl and the German Wilhelm Ebstein. Ebstein's interests extended far beyond medicine, encompassing fine arts, literature, and history. He even wrote severalbooks about diseases of famous Germans - Luther and Schopenhauer, and honey Yiqing interpretation of the Bible.

15. What is relapsing (laxative) fever?

It is characterized by a prolonged increase in body temperature with daily fluctuations exceeding 1 ° C.

16. What is intermittent (intermittent) fever?

It is characterized by high fever for 1-2 days, followed by normal body temperature.

17. What is Charcot's intermittent fever?

A specific type of intermittent fever usually accompanied by chills, right upper quadrant pain, and jaundice. It is a consequence of periodic obstruction of the common bile duct by a stone.

18. What is hectic (wasting) fever?

Fever (from the Greek. hektikos - habitual), characterized by daily peaks of temperature increase in the daytime and often flushing of the face. It is usually seen in active tuberculosis and is a form of intermittent fever with much more extreme temperature fluctuations.

19. What is persistent or resistant fever?

Its course is not accompanied by interruptions or a noticeable decrease in temperature. Persistent fever is observed in sepsis caused by gram-negative bacteria, or in lesions of the central nervous system.

20. What is malarial fever?

21. What is an ephemeral fever?

This rise in temperature is not more than one or two days.

22. What is a rising fever?

Rising fever (from the Greek word epakmastikos - rising to a height) is characterized by a steady increase in temperature to a climax, and then its crisis or lysis decrease (crisis means a sharp decrease in temperature, and lysis is more gradual).

23. What is exanthematous fever?

Fever caused by exanthemic eruptions.

24. What is a wasting fever?

Increased body temperature after excessive and prolonged muscular exertion. It may last up to several days.

25. What is miliary fever?

Infectious fever characterized by profuse sweating and prickly heat (tiny blisters on the skin that appear when fluid is retained in the sweat glands). In the past it was usually observed during severe epidemics.

26. What is monoleptic fever?

Persistent fever, characterized by only one paroxysmal rise in temperature.

27. What is polyleptic fever?

It is a fever with two or more paroxysms. Usually observed in malaria (from the Greek words poly - multiple and lepsis - paroxysm).

28. What is undulating fever?

Undulating fever is characterized by a long undulating temperature curve. characteristic of brucellosis.

29. What is essential (idiopathic) fever?

This is a fever of unknown etiology. It manifests itself with a temperature of at least 38 ° C for 3 weeks or more without any apparent reason. In adults, fever of unknown origin is most often associated with localized infection (abscess) or disseminated infection (malaria, tuberculosis, HIV infection, endocarditis, generalized fungal infection). Less common causes of essential fever are: (1) malignant tumors (especially lymphomas, hypernephromas, hepatomas, and liver metastases); 2) autoimmune diseases (collagenoses); (3) drug reactions. Patients with drug-induced iatrogenic fever often have pulse-temperature dissociation (see below) and appear well despite high fever. They also have other signs of an allergic reaction (skin rashes and eosinophilia).

30. What is temperature-pulse dissociation?

This is an increase in temperature that does not correspond to the usual increase in heart rate. Normally, with an increase in body temperature by 1 ° C, the number of heartbeats increases by 10 beats per minute. However, the heart rate may not increase. This occurs in salmonellosis, typhoid fever, brucellosis, legionnaires' disease, mycoplasma pneumonia, and meningitis with increased intracranial pressure. The dissociation of temperature and pulse may also be iatrogenic (as in drug fever) or simply a consequence of the use of digitalis drugs or beta-blockers.

31. What is the cause of extreme hyperthermia?

Very high temperature (> 40.6 ° C) is usually caused by dysfunction of the thermoregulatory centers of the nervous system (central fever). This is observed with heat stroke, cerebrovascular accident or extensive hypoxic brain damage as a result of cardiac arrest (with clinical death). Malignant hyperthermia and neuroleptic malignant syndrome are also important causes of acute central hyperthermia (often exceeding 41.2°C). Such hyperthermia is usually not characteristic of an infectious process. The exception is infections of the central nervous system (meningitis or encephalitis).

32. What are the causes of inadequately low fever?

An increase in temperature below the expected values ​​​​is observed in chronic renal failure (especially if the fever is of uremic origin) and in patients receiving antipyretics (eg, acetaminophen) and non-steroidal anti-inflammatory drugs. Cardiovascular collapse is another important cause of inappropriately low body temperature.

33. What is hypothermia? What are its reasons?

Hypothermia is a decrease in body temperature below 37°C. However, given the normal fluctuations in temperature, a decrease in body temperature below 35 ° C is considered true hypothermia. With moderate hypothermia, body temperature drops to 23°C-32°C, while with deep hypothermia - up to 12°C - 20°C. Such temperatures cannot be measured with conventional thermometers. This requires a thermistor.

Depending on the situation, the most common cause of hypothermia is areactive sepsis or hypothermia. Other causes are cerebrovascular accidents, endocrine disorders (hypoglycemia, hypothyroidism, panhypopituitarism, adrenal insufficiency) and intoxications (drugs and alcohol). Patients who feel cold to the touch often have peripheral vasospasm.

ARTERIAL PRESSURE

34. How is blood pressure measured?

Depending on the circumstances. In practice, the standard method for measuring blood pressure is the indirect method of measurement using a pneumatic cuff of a sphygmomanometer. In this case, the pressure is determined by palpation or auscultation. However, the gold standard remains the direct measurement of blood pressure through a rigid catheter inserted intra-arterially.

35. Why is it important to accurately measure blood pressure?

Unrecognized hypertension can lead to cardiovascular disease and shorten life expectancy. Hypertension is a common medical problem affecting at least 1 in 5 adults in North America. It is easily treatable, but often does not manifest itself clinically, especially in the initial stages. Thus, only regular and accurate measurements of blood pressure can detect hypertension in time and prescribe effective therapy. There is another reason for accurately measuring blood pressure. Accidental elevation of blood pressure can cause misdiagnosis in a healthy individual, with significant economic, medical, and psychological consequences. Thus, correct and frequent ambulatory blood pressure measurements are important tools for any physician.

36. What is a sphygmomanometer?

Translated from Greek(sphygmos - pulse, manos - meager, and metron - measurement) is a device for measuring a weak pulse.

37. Who invented the sphygmomanometer?

Like many achievements of the past, the sphygmomanometer has many fathers (failures are almost always orphans). His proud parents are Frenchman Pierre Potin, Italian Scipione Riva-Rocci, Russian Nikolai Korotkov and American Harvey Cushing. Cushing was not involved in the creation of the device, but distributed it throughout North America. By the way, the mercury sphygmomanometer recently celebrated its 100th anniversary - it was invented in 1896.

38. Who carried out the first direct measurement of blood pressure and how?

The first direct measurement of blood pressure was made in England in 1733. The English botanist and chemist Stephen Haile (1677-1761) decided to sacrifice his horse to find out if "blood pressure" really existed. In his backyard, he catheterized the carotid artery of an unfortunate animal and then measured the height of the blood column rising from the carotid artery through a glass tube. Measurements continued from the moment of carotid catheterization until the death of the horse. Based on his observations, Haile concluded that the animal did indeed have something he called "blood pressure" and that this pressure differed in arteries and veins, during relaxation and contraction of the heart, and between large and small animals. He published his observations under the title"Pushes of Blood" and then moved on to more important and pleasant matters: he began to explain to housewives that the pies should be covered with upside down tea cups so that their surface does not dampen.

39. Who is Poten? What contribution did he make to blood pressure measurement?

The French physician Pierre Potin was the first to describe the gallop rhythm and later became the prototype of the great Parisian diagnostician in Proust's book."In Search of Lost Time".Potain was one of the giants of nineteenth century French medicine. In addition, he was a very interesting person. As an intern, he survived an encounter with cholera during the 1849 epidemic. He then endured even more dangerous encounters with the Prussians as a simple infantryman during the War of 1870. Potin became one of Trousseau's protégés (see below), an ardent supporter of cardiac auscultation and a compassionate educator.

He was known for answering his own questions in exams if a student could not provide an answer in time. His unique contribution to the measurement of blood pressure was a device in the form of a compressible balloon filled with air. The balloon (pear) was connected with a rubber tube to an aneroid manometer. Then the balloon was pressed against the artery until the pulse disappeared. The readings on the manometer during the disappearance of the pulse reflected the patient's systolic blood pressure.

40. Who was the first to invent a mercury sphygmomanometer?

Scipione Riva-Rocci was one of Poten's students. At first, Riva-Rocci studied and worked under the guidance of Forlanini on the idea of ​​a therapeutic pneumothorax in pulmonary tuberculosis. While studying the process of filling the pleural cavity with air at a given pressure, he became interested in non-invasive measurement of blood pressure. In 1896, at the age of 33, Riva-Rocci came up with the idea of ​​​​creating a mercury sphygmomanometer, a device close to a manometer in which pressure changes are determined by the difference in the height of the mercury column instead of the rotating needle of Potain's aneroid (or disc) manometer. This idea was very useful for medicine, but may have proved fatal for Riva-Rocci. A few years later, he died of a chronic neurological disease, possibly from a laboratory. Riva-Rocci made several improvements to Potain's instrument:

1. He suggested using the brachial instead of the radial (which made blood pressure measurements easier and more accurate).
2. He also suggested wrapping the arm with an inflatable rubber cuff; while the likelihood of overestimation of blood pressure decreased. (Later, Recklinghausen increased the width of the cuff from 5 to 13 cm).
3. To avoid errors, guidance on the use of the sphygmomanometer has been provided.
4. The device has become so simple and easy to use that it became possible to measure blood pressure right at the patient's bedside. Indeed, the perfection of his device is confirmed by the fact that after 100 years it has undergone only minor changes. Riva-Rocci was also well aware of the "white coat" effect in measuring blood pressure and was the first to describe it.

41. How did Riva-Rocci get to the United States?

Despite his merits, the Riva-Rocci sphygmomanometer could have remained an Italian secret if it were not for the visit of Harvey Cushing to Pavia in 1901. Cushing spent several days with Riva-Rocci at the Ospedal di San Matteo, made a drawing of the device, received one in gift and brought everything back to Johns Hopkins. The rest is history.

42. Who improved the method of indirect measurement of arterial pressure?

The problem with the Potain and Riva-Rocci sphygmomapometers was that they only measured systolic blood pressure (released the pulse wave after the artery was clamped). The Russian doctor Nikolai Sergeevich Korotkov came to the rescue. Korotkov accidentally stumbled upon his discovery of auscultatory blood pressure tones, as often happens in major discoveries in medicine. As a surgeon in the tsarist army, he had just completed his service during the Russo-Japanese War of 1904 and at the age of 30 arrived in St. Petersburg, where he began to study post-surgical arterio-venous fistulas in animals. Once Korotkov listened to the dog's artery while loosening the tourniquet. Suddenly he heard loud noises. Intrigued, he noticed that the sounds corresponded to the systole and diastole of the heart, and published the results of his observations in 1905. Korotkov suggested that the moments of the appearance and disappearance of pulse beats coincide with the achievement of maximum and minimum blood pressure. The article, written in Russian, did not evoke much response in Europe, but made a lot of noise in Russia, giving Korotkov an enviable reputation as a madman. Only after the article finally reached Germany (and from there England) did the auscultatory method of Korotkov replace the pulse method of Riva-Rocci and Potin. The modern method for measuring systolic and diastolic blood pressure was finally born. Korotkov was arrested during the Russian Revolution and died in 1920.

43. How to measure blood pressure using the Korotkoff method?

The American Heart Association has issued guidelines for indirect auscultatory blood pressure measurement.

Technique for measuring blood pressure _

It is necessary to explain your goals and intentions to the patient and dispel all his doubts. In addition, every effort should be made to make the patient feel at ease, including a 5-minute rest before the first blood pressure measurement. The sequential steps for measuring blood pressure in the upper extremity, both for routine examination and for monitoring purposes, should be as follows:

1. Have paper and pen ready for immediate blood pressure recording.
2. Create a quiet, calm environment for the patient (legs stand freely on the iola, the back rests on the back of the chair). The patient's bare arm should lie quietly on a regular table or other support so that the middle of the shoulder is at the level of the heart.
3. Estimate by eye or measure with a tape measure the circumference of the exposed upper arm midway between the acromion (lateral end of the scapular spine) and the olecranope (olecranon) and select an appropriately sized cuff. The bladder inside the cuff must encircle 80% of the arm of adults and 100% of the arm of children under 13 years of age. If in doubt, use a larger cuff. If you only have a cuff that is too small, this should be noted.
4. Palpate the brachial artery and position the cuff so that the middle of the inflatable bladder is over the region of the palpable arterial pulse; then wrap and secure the cuff tightly around the patient's bare arm. Do not roll up the sleeve so that it forms a tight band around the shoulder. A loose cuff will cause high blood pressure. The lower edge of the cuff should be 2 cm above the anterior cubital fossa, in which the head of the phonendoscope is placed.
5. Position the pressure gauge so that the center of the mercury column or aneroid disc is at eye level (except for angled tube models) and is clearly visible and the cuff tube is not kinked.
6. Inflate the cuff rapidly to 70 mmHg. Art. and gradually increase the pressure by 10 mm Hg, while palpating the pulse on the radial artery. Note the pressure at which the pulse disappears and then reappears when the cuff is deflated. This palpatory method provides the necessary preliminary indication of systolic pressure and ensures that the cuff is inflated to an adequate level during auscultatory blood pressure measurement. The palpation method avoids under-inflation of the cuff in patients with auscultatory dip (zone of silence) and its over-inflation at very low blood pressure.
7. Place the earphones of the stethoscope into the external auditory canals, bending them forward for a snug fit. Switch the head of the stethoscope to the low-frequency position of the stethoscope. To confirm the switch, lightly tap on the funnel of the stethoscope.
8. Place the stethoscope over the pulse of the brachial artery just above and medial to the anterior cubital fossa, but below the edge of the cuff, and hold it at this point (but do not apply too much pressure). Make sure the funnel of the stethoscope is in firm contact with the skin around its entire circumference. Sliding the funnel of the stethoscope under the edge of the cuff allows one arm to be freed, but as a result, significant extraneous noise can be heard (in any case, this is almost impossible to do when listening with a stethoscope).
9. Inflate the cuff quickly and evenly to a pressure that is 20 to 30 mmHg. Art. exceeds the pressure previously determined by palpation. Then partially open the valve and, releasing air from the cuff, reduce the pressure in it at a rate of 2 mm Hg/s, while listening for the appearance of Korotkoff sounds.
10. As the cuff depressurizes, note the reading on the pressure gauge when the repeated pulse tones first appear (Phase I), when the tones subside (Phase IV), and when they disappear (Phase V). During the period when Korotkoff sounds are heard, the cuff deflation rate should not exceed 2 mm Hg. Art. for each pulse beat, thereby compensating for both fast and slow heart rates.
11. After Korotkoff sounds are no longer audible, the cuff pressure must be reduced slowly (at least the next 10 mmHg) to ensure that no more sounds are heard. Only then can the cuff be quickly and completely deflated. The patient should be allowed to rest for at least 30 seconds.
12. Systolic (Phase I) and diastolic (Phase V) pressure readings should be recorded immediately, rounded up (upwards) by 2 mmHg. In children and in cases where tones are heard almost at the level of 0 mm Hg. st, Phase IV blood pressure is also recorded (for example: 108/65/56 mm Hg). All values ​​must be recorded with the patient's name, date, time of measurement, which arm was measured, patient position, and cuff size (if it was a custom size).
13. The measurement should be repeated no earlier than 30 seconds later and the two values ​​should be averaged. In some clinical cases, additional measurements can be taken on the same or opposite arm, in the same or different position.

Copyrighted by the American Heart Association (1993). (Adapted from:Reeves RA: Does this patient have hypertension? How to measure blood pressure. JAMA. - 1995. - 273. - C. 1211-1217).

44. When should blood pressure be measured?

It should be measured at each examination of the patient, both in the clinic and in the hospital. At each examination, you must take two or more measurements on the same arm in the supine or sitting position. Average values ​​should be reflected in the medical record. If the diastolic pressure values ​​differ by more than 5 mm Hg. Art., it is necessary to carry out additional measurements until stable indicators are obtained. At the first meeting with the patient, measure the blood pressure in both arms, and subsequently - on the arm with a higher blood pressure (it is believed that there are pathological changes in the arm with a lower pressure).

45. Where should blood pressure be measured?

At a minimum, it should be measured on both hands. The difference in systolic pressure between the two arms is more than 10-15 mm Hg. Art. considered significant. This measurement requires two independent examiners to measure simultaneously on two arms and then switch sides. You should also measure blood pressure in your legs if clinically indicated (see below).

46. ​​How is arterial hypertension diagnosed?

Hardly. In fact, there are no true blood pressure thresholds below which the risk of cardiovascular disease is minimal and above which disease tends to develop. Even minor hypertension should not be left without close attention, and systolic hypertension should not be ignored.

* Based on the average of two or more measurements taken over two or more visits after the first examination.

Adapted from the Fifth Report of the Joint National Committee on the Detection, Evaluation and Treatment of High Blood Pressure.(Reeves RA.: Does this patient have hyprtension? How to measure blood pressure. JAMA.- 1995. -213. - C.1211-1217)

Arterial hypertension is generally considered to be a level of blood pressure above which the risk of developing cardiovascular disease increases significantly. The threshold for hypertension is around (or above) 140/90 mmHg. Treatment-requiring hypertension is a level of blood pressure above which the benefits of treatment outweigh the possible negative effects. This threshold is set for persistent blood pressure values ​​(In fact, even "mild" arterial hypertension (systolic blood pressure = 140-159/> 90-99 mmHg) requires monitoring and treatment. - Note. ed.):

• systolic pressure ≥ 160 mmHg (only in the elderly) with or without increased diastolic pressure or
• diastolic pressure ≥ 90 mmHg Art. (in young and elderly patients).

Blood pressure is highly variable and often decreases over time. Thus, it is important to observe the patient for some time before making a diagnosis of hypertension (see below).

47. What factors lead to overestimation or underestimation of true arterial pressure?

During a routine outpatient examination, several factors can cause both an increase and a decrease in blood pressure. It is important to know them well.

Factors affecting the accuracy of blood pressure measurements in the doctor's office

SBP = systolic blood pressure, DBP = diastolic blood pressure. (Adapted from:Reeves RA.: Does this patient have hyprtension? How to measure blood pressure. JAMA. 273:1211 - 1217, 1995).

The following factors do not affect the measurement of blood pressure: menstruation, chronic caffeine use, instillation of mezaton (phenylephrine) into the nose, automatic cuff inflation, gender or race of the patient and examiner, the presence of a thin shirt sleeve under the cuff, the bell of a stethoscope or diaphragm, self-inflating the cuff patient, time of day and room temperature.

48. What are the most common causes of blood pressure variability?

They are usually associated with the patient, equipment, or researcher. Over time, the blood pressure of patients varies greatly. If blood pressure is measured two or more times at each patient visit, the standard deviation of blood pressure values ​​between visits is 5 to 12 mmHg. for systolic and 6 - 8 mm Hg. for diastolic. These pressure fluctuations between visits are much greater than pressure fluctuations within a single visit. Thus, the more often you meet with the patient, the more confidence in the accuracy of the diagnosis. However, when assessing the magnitude of blood pressure and clinical status, it is necessary to take into account the interval between patient visits. The Joint National Committee recommends repeating measurements once a month at initial systolic pressures of 160 - 179 mmHg. or diastolic pressure 100-109 mm Hg. (stage 2); every 2 months in stage 1, once a week in stage 3, and immediate evaluation in stage 4. In addition, arrhythmias (especially atrial fibrillation) can also cause beat-to-beat changes in cardiac output and thus increase the variability in blood pressure measurements from different researchers. The arithmetic mean of several measurements overcomes this problem.

Finally, although agreement between investigators is fairly high, clinicians may be responsible for errors. In fact, differences among researchers in 10/8 mm Hg. are quite common. Of interest, automated auscultatory monitors have slightly fewer mismatches than experienced clinicians in a control group.