Local fractional hypothermia according to the Agapkin method. “It would be interesting to make a space suit for diving into the Mariana Trench. Complications and their prevention

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Artificial hypothermia is the deliberate cooling of the human body used in medicine. This type of hypothermia is carried out to slow down metabolic processes in the body, increase resistance to injury and oxygen starvation.

Artificial hypothermia can be general and local, as well as moderate (when body temperature drops to 32 - 27.9 degrees) and deep (human body temperature is 20 degrees and below). In medicine, moderate hypothermia is widely used.

Indications for artificial hypothermia

Artificial hypothermia is widely used in surgery and traumatology. There are times when it is necessary to slow down all the biochemical processes occurring in the body in order to provide assistance and recovery to the patient.

Indications for artificial hypothermia are:

Methods of hypothermia

Methods of artificial hypothermia are:

• physical;
• Chemical;
• Combined (a combination of physical and chemical methods). This method allows you to effectively reduce body temperature to 24 degrees, and at the same time increase the resistance of brain cells in conditions of oxygen starvation.

The physical methods of cooling the human body include:

The chemical method is based on the use of drugs that help reduce body temperature by acting on various departments of thermoregulation.

The following groups of chemicals are distinguished:

• Influencing the central nervous system, or rather the center of thermoregulation. The action of these drugs leads to a decrease in heat production and increased heat transfer by the body. These include substances for general anesthesia and neurotropic agents;
• Muscle relaxants. These drugs lead to a significant relaxation of the skeletal muscles. At the same time, the production of heat by the muscle mass decreases, and its return to the environment increases;
• Antagonists of thyroid hormones. These thyroid hormones are actively involved in the process of heat production. When they are oppressed, heat transfer will prevail over the production of heat by the body;
• Adrenolytic agents. They cause the expansion of peripheral vessels, that is, those located closer to the surface of the body. Due to this, heat transfer is significantly increased.

Devices for artificial hypothermia

Artificial cooling of the human body (general and local) is carried out using special devices.

Apparatus for artificial hypothermia is a device that:

• Cools the body;
• Controls body temperature and reagent;
• Maintains a certain body temperature that has been set.

Most artificial hypothermia devices work both for cooling and warming the patient.

The principle of operation of devices for artificial hypothermia can be considered using the example of the Hypotherm-3 device.

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The device for local hypothermia consists of:

Thus, the cooling of the body, its section or a certain internal organ is carried out by continuous cooling of the coolant, which, entering the cooling device, lowers the temperature of the tissues and organ. In this case, the coolant itself is heated and requires re-cooling in the heat exchanger chamber and is again sent to the cooling device.

Features of local hypothermia

Local artificial hypothermia is a decrease in body temperature in a certain part of the body or organ. It is carried out to reduce metabolic processes and increase resistance to oxygen starvation of tissues.

In the case of local artificial hypothermia, complications arising after general hypothermia are excluded.

Local artificial hypothermia is widely used in the following areas of medicine: Gynecology, Neurosurgery, Resuscitation, Surgery, Urology, Transplantology.

Hypothermia of the stomach

Indications for gastric cooling are:

• Severe gastric bleeding against the background of hemorrhagic inflammation of the gastric mucosa, as well as gastric ulcer and / or duodenal ulcer;
• Severe course of acute pancreatitis (to relieve inflammation).

With local hypothermia of the stomach, a number of changes occur:

• Motility of the stomach is sharply reduced or absent;
• The blood flow in the walls of the organ is significantly reduced;
• The production of hydrochloric acid is suppressed;
• The activity of gastric juice is sharply reduced;
• Decreased production and activity of pancreatic juice.

Artificial cooling of the stomach is carried out in 2 ways:

Kidney cooling

Indications for conducting controlled hypothermia of the kidney are conditions in which the organ will be in conditions of acute hypoxia (oxygen starvation) for a long time.

Kidney hypothermia is prescribed in case of:

• Transplantation (organ transplant operation) of the kidney;
• Removal of multiple and / or large stones from their pack;
• Operation on large renal vessels;
• Kidney operation;
• Removal of one of the poles of the organ.

Local hypothermia of the kidney is carried out by 2 methods:

Hypothermia of the prostate

Artificial prostate hypothermia is used to improve hemostasis during an operation to remove an adenoma (benign tumor).

Blood loss during prostate surgery is significantly reduced after hypothermia, and bleeding is accelerated.

The decrease in blood loss is associated with vasospasm under the influence of low temperature.

Prostate cooling methods:

• Washing the bladder with cold saline or furatsilin;
• Cooling of the rectum with rectal coolers and elastic tubes. In this case, water cooled to 1 degree circulates in a closed space (in a cooling device) and does not come into contact with the intestinal mucosa;
• Exposure to cold from the suprapubic region (for example, an ice pack).

With local cooling of the prostate, the need for oxygen and nutrition in its tissues decreases.

Artificial cooling of the heart

Artificial hypothermia of the heart is called cold cardioplegia.

Cardiac cooling is carried out in order to:

• A sharp slowdown in metabolic processes;
• Decreased sensitivity of the myocardium to conditions of oxygen starvation.

Hypothermia of the heart is achieved in the following ways:

Cranio-cerebral hypothermia

Artificial cooling of the brain through the outer tissues of the head.

Artificial hypothermia of the brain is used:

• In resuscitation, in order to avoid the occurrence of cerebral edema, as well as with edema that has already occurred;
• In cardiac surgery during heart surgery for congenital or acquired defects, lesions of the aorta.

Methods of cranio-cerebral hypothermia are varied:

The last two methods are ineffective, as they do not achieve the desired result.

When using the apparatus "Kholod-2F" there is an effective decrease in the temperature of the cerebral cortex to 30 degrees.

This method is based on the jet cooling method. The cooling agent is distilled water. It is poured into the apparatus in a volume of 7 liters. The water temperature should be 2 degrees.

A helmet in the form of a hemisphere is put on the head of a person. The helmet has holes through which cooled water enters at a right angle to the surface of the scalp.

The device "Cholod-2F" is used:

• During the operation. It also allows you to urgently cool the brain during the operation, without interrupting its course;
• In the postoperative period to prevent the development of complications, for the purpose of resuscitation.

The device "Kholod-2F" is able to maintain the desired temperature in the coolant and on the surface of the head, to control body temperature.

To determine the temperature of the brain during artificial cooling, it is necessary to measure the temperature inside the external auditory canal.

Hypothermia in newborns

The first use of hypothermia in neonates dates back to the late 1950s. Already at that time, there was a positive trend in the general cooling of newborns with asphyxia: the number of stillborns decreased, the condition of children with deep hypoxia improved, and there was no delay in psycho-physical development.

For general cooling in the 60s, Aminazine with Diprozol was used that were administered to the child. Then he was left undressed at room temperature. At the same time, the restoration of the functioning of the cardiac, respiratory and nervous systems is noted.

In modern medicine, general cooling of infants is not used due to inconvenience and imperfection. Preference is given to local cooling of the head.

Indications for cranio-cerebral hypothermia in newborns:

• Severe asphyxia. Apgar score no more than 4 points without a tendency to improve in the next 10-15 minutes;
• Birth trauma to the head;
• Severe operative delivery (currently extremely rare, as caesarean section is used).

Use 2 methods of local head cooling in newborns:

• Irrigation of the scalp of the child with running water, the temperature of which should be no more than 12 and not less than 10 degrees. Cooling can be achieved using this method quite quickly, in 10 to 20 minutes;
• Using a helmet made of polyethylene tubes. Chilled water, the temperature of which is 5 degrees, continuously circulates in the tubes.

A child may experience a neurovegetative reaction to cooling; to eliminate it, drugs Aminazine, Droperidol, Sodium hydroxybutyrate solution are used.

It should be noted that local hypothermia in newborns is always accompanied by general hypothermia. Body temperature drops to 34 - 32 degrees.

After hypothermia, there is a restoration of all vital functions, an improvement in the state of both physical and neurological.

2)* a, b, e, f, g;

3) c, d, h, i;

5) a, b, d.
064. Surgical sepsis is characterized by: a) weak dependence on the characteristics of the primary focus of infection; b) always accompanied by persistent bacteremia; c) high incidence of gram-negative septic shock; d) high frequency of development of secondary septicopyemic foci in gram-negative sepsis; e) weak dependence of the specificity of the clinical picture on the type of pathogen; f) high incidence of multiple organ dysfunction syndrome. Choose the correct combination of answers:
1) a, b, c;

5) * c, e, f.
065. Septic level of bacterial contamination of wounds is (microbial bodies per 1 g of tissue):
1)* 10 5 -10 6 ;

5) more than 10 9 .
066. Choose the correct definition of sepsis (adapted from the Consent Conference, Atlanta, 1992). Sepsis is a combination of:
1) periodic or persistent bacteremia with an unsanitized focus of infection;

2) persistent bacteremia with multiple organ dysfunction syndrome;

3) * systemic response to inflammation with the presence of a focus of infection;

4) systemic inflammatory response syndrome with purulent-resorptive fever;

5) recurrent or persistent bacteremia, focus of infection and multiple organ dysfunction syndrome.
067. Early symptoms of anaerobic infection are: a) high body temperature; b) inadequate behavior of the patient; c) arching pains in the wound; d) swelling of wound tissues; e) frequent weak pulse. Choose the correct combination of answers:
1) a, b, c;

2) b, c, d, e;

3) a, b, c, d;

4) a, c, d, e;

5)* everything is correct.
068. Local signs of an infectious wound process caused by non-clostridial anaerobic microflora include: a) gray wound tissues; b) copious amount of dirty-gray, brown discharge; c) absence of necrosis; d) abundance of necrotic tissues; e) the presence of bright pink granulations; e) accumulation of gas in soft tissues. Choose the correct combination of answers:
1)* a, b, d;

4) a, b, e, f;

5) everything is correct.
069. In the complex treatment of gas gangrene, the following are used: a) excision of necrotic tissues; b) the widest possible dissection of tissues; c) antibacterial monotherapy; d) detoxification infusion therapy; e) hyperbaric oxygen therapy; f) antibacterial combination therapy; g) muscle relaxants + mechanical ventilation. Choose the correct combination of answers:
1)* a, b, d, e, f;

5) everything is correct.
070. Treatment of tetanus includes: a) tetanus toxoid globulin; b) tetanus toxoid; c) anti-tetanus serum; d) tranquilizers and barbiturates; e) muscle relaxants; e) IVL. Choose the correct combination of answers:
1) a, b, c, d;

2) c, d, e, f;

5)* everything is correct.
071. A necessary condition for wound healing by primary intention is: a) the presence of foci of necrosis and hematomas in the wound; b) contact of the edges of the wound; c) maintaining the viability of the edges of the wound; d) a small area of ​​damage; e) bacterial contamination of the wound tissues is above a critical level. Choose the correct combination of answers:
1) a, c;

5) everything is correct.
072. For local treatment of purulent wounds in the inflammation phase, the following are used: a) fat-soluble ointments; b) proteolytic enzymes; c) water-soluble ointments; d) washing with antiseptics; e) immunization. Choose the correct combination of answers:
1) a, b;

5) a, d, e.
073. In what terms is it necessary to perform the primary treatment of a wound in a patient delivered in a state of severe shock?
1) immediately upon admission;

2) * immediately after removing the patient from shock;

3) 2 hours after admission;

4) the next day;

5) after blood transfusion.
074. What manipulations are performed during the primary surgical treatment of a wound? a) excision of the edges of the wound; b) stop bleeding; c) removal of foreign bodies from the wound; d) washing the wound with antibiotics; e) excision of the bottom of the wound; e) excision of the walls of the wound. Choose the correct combination of answers:
1) a, c, d, e;

2)* a, b, c, e, f;

3) b, c, d, e;

4) a, b, d, e;

5) everything is correct.
075. General predisposing non-microbial factors of postoperative wound suppuration include: a) advanced age; b) cachexia of the patient; c) taking hormones and immunosuppressants; d) trauma to the edges of the wound with a tool, underwear. Choose the correct combination of answers:
1) a, c;

5) b, d.
076. The critical level of contamination of the wound tissue is (microbial bodies per 1 g of tissue):
1) 102-103;

5) 108-109.
077. Gunshot wounds are characterized by: a) the presence of an inlet smaller than the outlet; b) the presence of a destruction zone; c) the presence of a zone of bruising and necrosis; d) the presence of a zone of molecular shaking; e) the presence of a burn zone; e) asepsis of the wound channel. Choose the correct combination of answers:
1) b, c, e;

3) a, b, e, f;

4)* a, b, c, d;

5) everything is correct.
078. There are the following types of wound healing: a) by secondary resorption of hematoma; b) by biological adhesion of tissues; c) secondary intention; d) primary tension; e) under a bandage; e) under a plaster splint; g) under the scab. Choose the correct combination of answers:
1) a, b, e;

5) everything is correct.
079. The use of local hypothermia in the postoperative period contributes to:
1) cryodestruction of microbial bodies;

2) * stop capillary bleeding;

3) fast adhesion of wound edges;

4) prevention of divergence of the edges of the wound;

5) prevention of thrombosis and embolism.
080. On the basis of what data in the first hours after a thermal injury can a deep burn be assumed? a) pain sensitivity is preserved; b) there is no pain sensitivity; c) there is swelling of unaffected surrounding tissues; d) there is no edema; e) during thermography, there is a decrease in heat transfer. Choose the correct combination of answers:
1) a, b, e;

3) * b, c, e;

5) b, e.
081. Burn disease develops: a) with superficial burns up to 10% of the body area; b) with burns over 15% of the body area; c) with burns of at least 20% of the body area; d) with deep burns from 5 to 10% of the body area; e) with burns of 10% of the body area; f) with burns of at least 30% of the body area. Choose the correct combination of answers:
1) a, d;

5) e.
082. What periods are distinguished during a burn disease and what is their sequence? a) acute burn toxemia; b) dehydration phase; c) burn shock; d) septicotoxemia; e) hydration phase; e) convalescence. Choose the correct combination of answers:
1) a, c, b, d;

2) b, c, e, f;

3)* a, c, d, f;

5) a, c, d, f.
083. The most effective element of first aid at the scene for burns of I-II degree of severity limited in area (up to 10% of the body surface) is:
1) lubrication of the burnt surface with vaseline oil;

2) application of a dry aseptic dressing;

3) applying a bandage with an antiseptic solution;

4) * cooling the burnt area for 8-10 minutes with running cold water;

5) the use of a fat-soluble ointment.
084. Frostbite of what degree is characterized by necrotic damage to the surface layer of the skin without damage to the growth layer and restoration of destroyed skin elements in 1-2 weeks?
1) frostbite I degree;

2) * frostbite II degree;

3) frostbite III degree;

4) frostbite III-IV degree;

5) frostbite IV degree.
085. What measures should be taken in the treatment of frostbite in the pre-reactive period? a) warming the affected area of ​​the body in water; b) warming the supercooled part of the body with warm air; c) warming the supercooled part of the body by rubbing; d) complete isolation of the supercooled area of ​​the body from external thermal effects; e) the use of vasodilators; e) the introduction of warm infusion solutions; g) novocaine blockade. Choose the correct combination of answers:
1) a, e, f;

3) * d, e, f;

5) b, e, f.
086. What pathological processes are important in the development of trophic ulcers? a) chronic disorders of blood and lymph circulation; b) traumatic effects; c) diseases of the nervous system; d) metabolic disorders; e) systemic diseases; e) infectious diseases; g) tumors. Choose the correct combination of answers:
1) a, b, e, f;

2) b, d, f, g;

5)* everything is correct.
087. Formation of bedsores is facilitated by: a) compression of tissues with a plaster bandage; b) long stay of the endotracheal tube in the trachea; c) prolonged stay of drainage in the abdominal cavity; d) compression of tissues during prolonged lying position of the patient; e) violation of innervation in spinal cord injury; f) prolonged pressure of the stone on the wall of the gallbladder. Choose the correct combination of answers:
1) a, b, c;

5)* everything is correct.
088. Preoperative preparation for emergency surgery includes: a) hygienic treatment of the skin in the area of ​​operation; b) shaving the surgical field; c) sanitation of the oral cavity; d) carrying out infusion therapy; e) cleansing enema; e) spirometry; g) performing an ECG. Choose the correct combination of answers:
1) a, b, c;

4) a, b, c, f;

5) c, e, f.
089. When should the skin be shaved before a planned operation?
1) before admission to the hospital;

2) one day before the operation;

3) in the evening before the operation;

4) * in the morning on the day of surgery;

5) immediately before the start of the operation on the operating table.
090. What methods of prevention of wound infection should be applied before a planned operation? a) breathing exercises; b) activation of the patient; c) desensitization of the body; d) sanitation of the oral cavity; e) change of linen of the patient; f) hygienic shower; g) stimulation of diuresis; h) treatment of the surgical field. Choose the correct combination of answers:
1) a, d, e, h;

5) * d, e, f, h.
091. The tasks of the preoperative period include: a) assessment of operational and anesthetic risk; b) determining the urgency of the operation; c) establishing a diagnosis; d) determination of indications for surgery; e) identification of the state of vital organs and systems; f) determining the nature of the transaction; g) preparing the patient for surgery. Choose the correct combination of answers:
1) b, d, e;

5)* everything is correct.
092. What diseases require urgent operations? a) stomach cancer; b) perforated stomach ulcer; c) acute appendicitis; d) malignant lung tumor; e) strangulated inguinal hernia; e) shoulder lipoma. Choose the correct combination of answers:
1) * b, c, e;

5) a, d.
093. Specify the stages of a surgical operation: a) surgical access; b) placing the patient on the operating table; c) prompt reception; d) stop bleeding; e) suturing the wound. Choose the correct combination of answers:
1) a, b, c;

2)* a, c, e;

3) a, c, d, e;

5) everything is correct.
094. Contraindications for urgent surgery for widespread peritonitis are: a) fresh myocardial infarction; b) severe traumatic shock in concomitant trauma; c) the agonal state of the patient; d) early postoperative period; e) there are no contraindications. Choose the correct combination of answers:
1) a, b, c;

5) d.
095. Radical operation is:
1) * an operation that claims to be a complete cure;

2) an operation that completely excludes the possibility of a return of the main source of the disease;

3) excision of the tumor within healthy tissues;

4) removal of the affected organ and blockade of metastasis pathways;

5) intervention aimed at the complete elimination of the manifestations of the disease.
096. On the first day after surgery, the following complications are more common: a) external bleeding; b) eventration; c) formation of a hematoma in the wound; d) rhythm disturbance and cardiac arrest; e) suppuration of the wound. Choose the correct combination of answers:
1) a, b, c;

3)* a, c, d;

5) everything is correct.
097. The catabolic phase of the postoperative state of the patient is characterized by: a) activation of the sympathetic-adrenal system; b) an increase in blood glucose levels; c) increased breakdown of adipose tissue; d) an increase in the vital capacity of the lungs; e) decrease in diuresis. Choose the correct combination of answers:
1) a, b, c;

4)* a, b, c, e;

5) everything is correct.
098. The development of pneumonia in the postoperative period is facilitated by: a) old age; b) hypoventilation of the lungs during surgery; c) features of the diet; d) inadequate pain relief after surgery; e) long horizontal position; f) oxygen inhalation; g) intravenous administration of antibiotics; h) breathing exercises; i) chronic heart failure. Choose the correct combination of answers:
1) a, b, c, d, e;

2) b, e, f, g;

3) b, g, h, i;

4)* a, b, d, e, i;

5) a, b, d, f, i.
099. Prevention of deep vein thrombosis after surgery includes: a) antibiotic therapy; b) bandaging of a limb; c) prolonged bed rest after surgery; d) early activation of patients after surgery; e) the use of anticoagulants. Choose the correct combination of answers:
1) a, b;

4) * b, d, e;

5) a, c, e.
100. The anabolic phase of the course of postoperative disease is characterized by: a) restoration of muscle mass; b) protein lysis and accumulation of their decay products; c) activation of the hormonal system; d) restoration of nitrogen balance; e) the intake of exogenous energy that exceeds the needs of the body. Choose the correct combination of answers:
1)* a, d, e;

5) a, b, c.
Anesthesiology, resuscitation, intensive care
001. Operational stress is:
1) biological defense processes in response to surgical trauma;

2) * biological processes of protection on a complex of various influences: fear, excitement, pain, the effect of anesthesia, the formation of wounds and trauma to body tissues, blood loss, etc.;

3) biological processes of protection only for pain (pain relief is not a stress factor);

4) biological processes of protection, occurs only at the beginning of the operation and ends after its completion;

5) biological processes of protection against injury and blood loss.
002. Adequate protection of the patient's body from operational stress is possible if the component of general anesthesia is observed. Choose the right combination of general anesthesia components:
1) deep sleep with the addition of narcotic analgesics;

2) * switching off consciousness, neurovegetative protection, analgesia and muscle relaxation;

3) switching off consciousness and muscle relaxation;

4) the state of neurolepsy and analgesia;

5) anesthesia, muscle relaxation and neurovegetative protection.
003. Before planned and emergency surgical interventions, patients are given premedication. What are the main goals of premedication:
1) analgesia and prevention of vagal reactions;

2) neurovegetative stabilization, prevention of vagal reflexes, elimination of fear of surgery;

3) creating a background of analgesia, parasympatholytic action, neurovegetative protection;

4) * removal of psycho-emotional stress, neurovegetative stabilization, analgesia and potentiation of anesthetics, prevention of vagal reactions;

5) psycho-emotional stabilization, suppression of the secretion of bronchial glands, prevention of respiratory disorders.
004. It is known that the goals of premedication are: sedation and neurovegetative inhibition, analgesia, prevention and elimination of unwanted reflex reactions. Choose from the following combinations of drugs the most effective and successful combination that would provide an analytical and sedative effect:
1) * diazepam (midazolam, dormicum), fentanyl (promedol);

2) diazepam, droperidol;

3) chlorpromazine, diphenhydramine;

4) norphine, barbiturates;

5) analgin, clonidine.

Medical hibernation is a method of controlled decrease in the temperature of the body or its organs in order to reduce the intensity of metabolism, the level of functions of tissues, organs and their physiological systems, and increase their resistance to hypoxia.

With deep cooling of the body, metabolic processes are inhibited, and the need for oxygen in tissues decreases. This feature of oxygen metabolism, in particular the brain, is taken into account by surgeons during operations on various organs under artificial hypothermia under conditions of a significant decrease or even temporary cessation of blood circulation, which is called operations on dry organs (heart, blood vessels, brain, other organs). Usually, anesthesiologists are guided by the temperature in the rectum in the range of 28-30 ° C, but if necessary, it is possible to create a deeper hypothermia (thermolysis, according to Labori, a specialist in medical hibernation) using machine artificial circulation, muscle relaxants, metabolic inhibitors and other manipulations. For general cooling of the body, liquids with a temperature of +2 to -12 ° C are used, circulating in special "cold" suits worn on the patient, or "cold" blankets that cover them. In a number of cases, local hypothermia is used, for example, of the head, with the help of a special helmet worn on the patient's head, pierced with thermo-tubes through which coolant circulates.

In order to eliminate or reduce the pronounced adaptive reactions of the body in response to hypothermia, to limit the stress response, the patient is given anesthesia before the start of cooling and is injected with muscle relaxants and neuroplegic substances (lytic cocktail). Taken together, these manipulations provide a gradual decrease in general and cellular metabolism, oxygen consumption by cells, the release of carbon dioxide and other metabolites, and prevent disturbances in acid-base balance, imbalance of ions and water in tissues.

The benefits of medical hibernation are that

Life-threatening violations of the functions of the cerebral cortex and reflex activity of the nervous system are not observed,

excitability, conductivity decrease and the automation of the pacemaker cells of the conduction system of the heart is limited,

sinus bradycardia develops

Decreased cardiac output and stroke volume

Decreased arterial blood pressure

Functional activity and the level of metabolism in the organs and tissues of the body are inhibited.

Locally controlled hypothermia of individual organs and tissues (brain, kidneys, stomach, liver, prostate, and others) is used when it is necessary to perform surgical interventions or other therapeutic manipulations on them: correction of blood flow, plastic processes, metabolism and other purposes.

A very important and still not fully resolved problem is the withdrawal of the patient from the state of artificial hypothermia. If this state is deep enough and continues for a relatively long time, significant changes in almost all types of metabolism occur in the body. Their normalization in the process of removing the body from hypothermia is an important aspect of the application of this method in medicine.

Hypothermic conditions include conditions characterized by a decrease in body temperature below normal. Their development is based on the breakdown of thermoregulation mechanisms that ensure the optimal thermal regime of the body. There are cooling of the body (actually hypothermia) and controlled (artificial) hypothermia, or medical hibernation.

Hypothermia

Hypothermia - a typical form of heat metabolism disorders - occurs as a result of the effect on the body of a low ambient temperature and / or a significant decrease in heat production in it.

Hypothermia is characterized by a violation (disruption) of the mechanisms of thermoregulation and is manifested by a decrease in body temperature below normal.

Etiology

The reasons development of body cooling are diverse.

Low ambient temperature (water, air, surrounding objects, etc.) is the most common cause of hypothermia. It is important that the development of hypothermia is possible not only at negative (below 0 °C), but also at positive external temperatures. It has been shown that a decrease in body temperature (in the rectum) to 25 ° C is already life-threatening; up to 20 °C, - as a rule, irreversible; up to 17–18 ° C - usually fatal.

The statistics of mortality from cooling is indicative. Hypothermia and death of a person during cooling is observed at air temperatures from +10 °C to 0 °C in about 18%; from 0 °C to -4 °C in 31%; -5 °C to -12 °C at 30%; from -13 °C to -25 °C in 17%; from -26 °C to -43 °C in 4%. It can be seen that the maximum mortality rate during hypothermia is in the air temperature range from +10 °C to –12 °C. Consequently, a person in the conditions of existence on Earth is constantly in the potential danger of cooling.

Extensive muscle paralysis and / or a decrease in their mass (for example, with their malnutrition or dystrophy). This can be caused by trauma or destruction (for example, postischemic, as a result of syringomyelia or other pathological processes) of the spinal cord, damage to the nerve trunks that innervate the striated muscles, as well as some other factors (for example, Ca 2+ deficiency in muscles, muscle relaxants) .

Metabolic disorders and / or decrease in the efficiency of exothermic metabolic processes. Such conditions can develop with adrenal insufficiency, leading (among other changes) to a deficiency in the body of catecholamines; with severe hypothyroid conditions; with injuries and dystrophic processes in the area of ​​the centers of the sympathetic nervous system of the hypothalamus.

The extreme degree of exhaustion of the body.

In the last three cases, hypothermia develops under the condition of a low external temperature.

Risk factors body cooling.

Increased air humidity. This significantly reduces its thermal insulation properties and increases heat loss, mainly through conduction and convection.

High air velocity. The wind contributes to the rapid cooling of the body due to a decrease in the thermal insulation properties of the air.

Excessive moisture content or clothes getting wet. This reduces its thermal insulation properties.

Getting into cold water. Water is about 4 times more heat-consuming and 25 times more thermally conductive than air. In this regard, freezing in water can be observed at a relatively high temperature: at a water temperature of +15 ° C, a person remains viable for no more than 6 hours, at +1 ° C - about 0.5 hours. Intensive heat loss occurs mainly by convection and conduction.

Prolonged fasting, physical fatigue, alcohol intoxication, as well as various diseases, injuries and extreme conditions. These and a number of other factors reduce the body's resistance to cold.

Types of acute cooling

Depending on the time of death of a person under the influence of cold, there are three types of acute cooling that causes hypothermia:

Acute, in which a person dies within the first 60 minutes (when staying in water at temperatures from 0 ° C to +10 ° C or under the action of a damp cold wind).

Subacute, in which death is observed before the expiration of the fourth hour of being in cold, moist air and wind.

Slow when death occurs after the fourth hour of exposure to cold air (wind) even with clothing or body protection from the wind.

The pathogenesis of hypothermia

The development of hypothermia is a staged process. Its formation is based on a more or less prolonged overvoltage and, in the end, the breakdown of the body's thermoregulation mechanisms. In this regard, in hypothermia, two stages of its development are distinguished: 1) compensation (adaptation) and 2) decompensation (deadaptation). Some authors distinguish the final stage of hypothermia - freezing.

Stage of compensation

The compensation stage is characterized by the activation of emergency adaptive reactions aimed at reducing heat transfer and increasing heat production.

The development mechanism of the compensation stage includes:

† change in the behavior of the individual, aimed at leaving the conditions in which the low ambient temperature operates (for example, leaving a cold room, using warm clothes, heaters, etc.).

† Decrease in the efficiency of heat transfer is achieved due to the reduction and cessation of sweating, narrowing of the arterial vessels of the skin and muscles, and therefore blood circulation in them is significantly reduced.

† activation of heat production by increasing blood flow in the internal organs and increasing muscle contractile thermogenesis.

- inclusion of a stress reaction (an excited state of the victim, an increase in the electrical activity of thermoregulation centers, an increase in the secretion of liberins in the neurons of the hypothalamus, in pituitary adenocytes - ACTH and TSH, in the adrenal medulla - catecholamines, and in their cortex - corticosteroids, in the thyroid gland - thyroid hormones .

Due to the complex of these changes, although the body temperature decreases, it still does not go beyond the lower limit of the norm. Temperature homeostasis of the body is maintained.

The above changes significantly modify the function of organs and physiological systems of the body: tachycardia develops, blood pressure and cardiac output increase, respiratory rate increases, and the number of red blood cells in the blood increases.

These and some other changes create conditions for the activation of metabolic reactions, as evidenced by a decrease in the glycogen content in the liver and muscles, an increase in GPA and FFA, and an increase in oxygen consumption by tissues.

The intensification of metabolic processes is combined with an increased release of energy in the form of heat and prevents the body from cooling.

If the causative factor continues to act, then compensatory reactions may become insufficient. At the same time, the temperature of not only the integumentary tissues of the body decreases, but also its internal organs, including the brain. The latter leads to disorders of the central mechanisms of thermoregulation, discoordination and inefficiency of heat production processes - their decompensation develops.

Stage of decompensation

The stage of decompensation (deadaptation) of thermoregulation processes is the result of the disruption of the central mechanisms of heat exchange regulation (Fig. 6–12).

Rice. 6–12. The main pathogenic factors of hypothermia at the stage of decompensation of the body's thermoregulation system.

At the stage of decompensation, body temperature falls below normal levels (in the rectum it drops to 35 ° C and below) and continues to decrease further. Temperature homeostasis of the body is disturbed: the body becomes poikilothermic.

Cause development of the decompensation stage: increasing inhibition of the activity of the cortical and subcortical structures of the brain, including the centers of thermoregulation. The latter causes the inefficiency of heat production reactions and the continued loss of heat by the body.

Pathogenesis

† Violation of the mechanisms of neuroendocrine regulation of metabolism and the functioning of tissues, organs and their systems.

† Disorganization of the functions of tissues and organs.

† Inhibition of metabolic processes in tissues. The degree of disorders of function and metabolism directly depends on the degree and duration of the decrease in body temperature.

Manifestations

† Circulatory disorders:

‡ decrease in cardiac output, both due to a decrease in the force of contraction and due to heart rate - up to 40 per minute;

‡ decrease in blood pressure,

‡ increase in blood viscosity.

† Violations of microcirculation (up to the development of stasis):

‡ slowing down of blood flow in the vessels of the microvasculature,

‡ increased blood flow through arteriolo-venular shunts,

‡ Significant reduction in capillary blood supply.

† Increasing the permeability of the walls of microvessels for inorganic and organic compounds. This is the result of impaired blood circulation in the tissues, the formation and release of BAS in them, the development of hypoxia and acidosis. An increase in the permeability of the walls of blood vessels leads to the loss of protein from the blood, mainly albumin (hypoalbuminemia). Fluid exits the vascular bed into the tissues.

† Development of edema. In this regard, blood viscosity increases even more, which aggravates microcirculation disorders and contributes to the development of sludge and blood clots.

† Local foci of ischemia in tissues and organs are the result of these changes.

- Discoordination and decompensation of functions and metabolism in tissues and organs (bradycardia, followed by episodes of tachycardia; cardiac arrhythmias, arterial hypotension, decrease in cardiac output, decrease in the frequency to 8-10 per minute and the depth of respiratory movements; cessation of cold muscle trembling, decrease in oxygen tension in tissues, a drop in its consumption in cells, a decrease in the glycogen content in the liver and muscles).

† Mixed hypoxia:

‡ circulatory (as a result of a decrease in cardiac output, impaired blood flow in the vessels of the microvasculature),

‡ respiratory (due to a decrease in the volume of pulmonary ventilation),

‡ blood (as a result of blood clotting, adhesion, aggregation and lysis of erythrocytes, impaired dissociation of HbO 2 in tissues;

‡ tissue (due to cold suppression of activity and damage to tissue respiration enzymes).

† Increasing acidosis, imbalance of ions in the cells and in the interstitial fluid.

† Suppression of metabolism, reduced oxygen consumption by tissues, disruption of the energy supply of cells.

† Formation of vicious circles that potentiate the development of hypothermia and disorders of the body's vital functions (Fig. 6–13).

Rice. 6–13. The main vicious circles at the stage of decompensation of the thermoregulation system during hypothermia.

‡ metabolic vicious circle. A decrease in tissue temperature in combination with hypoxia inhibits the course of metabolic reactions. It is known that a decrease in body temperature by 10 °C reduces the rate of biochemical reactions by 2–3 times (this pattern is described as a temperature coefficient van't Hoffa - Q 10). The suppression of the intensity of metabolism is accompanied by a decrease in the release of free energy in the form of heat. As a result, the body temperature drops even more, which additionally suppresses the intensity of metabolism, etc.

‡ vascular vicious circle. The increasing decrease in body temperature during cooling is accompanied by the expansion of arterial vessels (according to the neuromyoparalytic mechanism) of the skin, mucous membranes, and subcutaneous tissue. This phenomenon is observed at a body temperature of 33–30 °C. The expansion of skin vessels and the influx of warm blood to them from organs and tissues accelerates the process of heat loss by the body. As a result, the body temperature drops even more, blood vessels expand even more, heat is lost, etc.

‡ Nervously‑muscular vicious circle. Progressive hypothermia causes a decrease in the excitability of nerve centers, including those that control muscle tone and contraction. As a result, such a powerful mechanism of heat production as muscle contractile thermogenesis is turned off. As a result, the body temperature is intensively reduced, which further suppresses neuromuscular excitability, myogenic thermogenesis, etc.

‡ The pathogenesis of hypothermia may include other vicious circles that potentiate its development.

† The deepening of hypothermia causes inhibition of the functions of the first cortical, and subsequently the subcortical nerve centers. In this regard, patients develop hypodynamia, apathy and drowsiness, which can end in coma. In this regard, the stages of hypothermic "sleep" or coma are often distinguished as a separate stage of hypothermia.

† When the body leaves the hypothermic state, subsequently, the victims often develop inflammatory processes - pneumonia, pleurisy, acute respiratory diseases, cystitis, etc. These and other conditions are the result of a decrease in the effectiveness of the IBN system. Often there are signs of trophic disorders, psychoses, neurotic conditions, psychasthenia.

With an increase in the action of the cooling factor, freezing and death of the body occurs.

† Immediate causes of death in severe hypothermia: cardiac arrest and respiratory arrest. Both the first and the second are to a greater extent the result of cold depression of the vasomotor and respiratory bulbar centers.

† The reason for the termination of the contractile function of the heart is the development of fibrillation (more often) or its asystole (less often).

† With predominant cooling of the spinal region (in conditions of prolonged exposure to cold water or on ice), death is often preceded by collapse. Its development is the result of cold inhibition of the spinal vascular centers.

† Hypothermia usually occurs when the rectal temperature falls below 25–20°C.

† Those who died under conditions of hypothermia show signs of venous plethora of the vessels of the internal organs, the brain and spinal cord; small and large focal hemorrhages in them; pulmonary edema; depletion of glycogen stores in the liver, skeletal muscles, myocardium.

Principles of treatment and prevention of hypothermia

Treatment hypothermia is built taking into account the degree of decrease in body temperature and the severity of disorders of the body's vital functions.

At the stage of compensation victims need mainly to stop external cooling and warm the body (in a warm bath, heating pads, dry warm clothes, warm drinks). In this case, the body temperature and the vital activity of the organism usually normalize on their own, since the mechanisms of thermoregulation are preserved.

At the stage of decompensation hypothermia requires intensive comprehensive medical care. It is based on three principles: etiotropic, pathogenetic and symptomatic.

Etiotropic principle includes:

Measures to stop the action of the cooling factor and warm the body. The victim is immediately transferred to a warm room, dressed and warmed. The most effective warming in the bath (with immersion of the whole body). At the same time, it is necessary to avoid warming the head because of the danger of aggravating brain hypoxia (due to increased metabolism in it under conditions of limited oxygen delivery).

Active warming of the body is stopped at a temperature in the rectum of 33–34 ° C in order to avoid the development of a hyperthermic state. The latter is quite probable, since the adequate function of the body's thermoregulation system has not yet been restored in the victim. Warming is advisable to carry out under conditions of surface anesthesia, muscle relaxation and mechanical ventilation. This allows you to eliminate the protective reactions of the body, in this case, excessive, to the cold (in particular, muscle stiffness, their trembling) and thereby reduce oxygen consumption, as well as reduce the effects of tissue hypoxia. Warming gives a greater effect if, along with the external one, methods of warming the internal organs and tissues are used (through the rectum, stomach, lungs).

pathogenetic principle includes:

Restoration of effective blood circulation and respiration. For this purpose, it is necessary to free the airways (from mucus, sunken tongue) and carry out auxiliary or mechanical ventilation with air or gas mixtures with a high oxygen content. If at the same time the activity of the heart is not restored, then its indirect massage is performed, and, if possible, defibrillation. It must be remembered that defibrillation of the heart at a body temperature below 29 ° C may be ineffective.

Correction of KShchR, balance of ions and liquid. For this purpose, balanced salt and buffer solutions (for example, sodium bicarbonate), solutions of polyglucin and rheopolyglucin are used.

Elimination of glucose deficiency in the body. This is achieved by introducing its solutions of different concentrations in combination with insulin, as well as vitamins.

With blood loss, blood, plasma and plasma substitutes are transfused.

Symptomatic treatment aimed at eliminating changes in the body that aggravate the condition of the victim. Concerning:

Apply means that prevent swelling of the brain, lungs and other organs;

Eliminate arterial hypotension,

normalize diuresis,

Eliminate severe headache;

In the presence of frostbite, complications and concomitant diseases, they are treated.

Prevention body cooling and hypothermia includes a set of measures.

Use of dry warm clothes and shoes.

Proper organization of work and rest in the cold season.

Organization of heating points, provision of hot meals.

Medical control over the participants of winter hostilities, exercises, sports competitions.

Prohibition of alcohol intake before a long stay in the cold.

Hardening of the body and acclimatization of a person to environmental conditions are of great importance.

medical hibernation

Controlled (artificial) hypothermia is used in medicine in two varieties: general and local.

General controlled hypothermia

Application area

Performing operations in conditions of a significant decrease or even temporary cessation of blood circulation. This was called operations on the so-called "dry" organs: the heart, brain and some others.

The most widely general artificial hibernation is used in operations on the heart to eliminate defects in its valves and walls, as well as on large vessels, which requires stopping blood flow.

Advantages

A significant increase in the stability and survival of cells and tissues under hypoxic conditions at low temperatures. This makes it possible to disconnect the organ from the blood supply for several minutes, followed by the restoration of its vital activity and adequate functioning.

Temperature range

† Hypothermia is usually used with rectal temperature lowered to 30–28°C. If long-term manipulations are necessary, a deeper hypothermia is created using a heart-lung machine, muscle relaxants, metabolic inhibitors, and other influences. When carrying out long operations (several tens of minutes) on "dry" organs, "deep" hypothermia (below 28 ° C) is performed, artificial blood circulation and breathing apparatuses are used, as well as special schemes for the administration of drugs and anesthesia.

† Most often, for general body cooling, a liquid with a temperature of +2–12 ° C is used, circulating in special “cold” suits worn on patients or in “cold” blankets that cover them. Additionally, containers with ice and air cooling of the patient's skin are also used.

Medical preparation

In order to eliminate or reduce the severity of the adaptive reactions of the body in response to a decrease in its temperature, as well as to turn off the stress reaction, immediately before the start of cooling, the patient is given general anesthesia, neuroplegic substances, muscle relaxants are administered in various combinations and doses. Taken together, these effects provide a significant reduction in metabolism in cells, their oxygen consumption, the formation of carbon dioxide and metabolites, prevent violations of the acid-base balance, imbalance of ions and water in tissues.

Effects of medical hibernation

For hypothermia 30–28 °C (rectal)

- there are no vitally dangerous changes in the function of the cerebral cortex and reflex activity of the nervous system;

- reduced excitability, conductivity and automatism of the myocardium;

† develops sinus bradycardia,

- decrease in stroke and minute output of the heart,

† lowering blood pressure,

† reduced functional activity and metabolic rate in organs and tissues.

Local controlled hypothermia

Local controlled hypothermia of individual organs or tissues (brain, kidneys, stomach, liver, prostate, etc.) is used if it is necessary to perform surgical interventions or other therapeutic manipulations on them: correction of blood flow, plastic processes, metabolism, drug efficiency, etc.

Hypothermia (as a method) is an artificial decrease in the temperature of the body (or part of the body) by cooling. It is used as an independent or auxiliary remedy. There are local (local) and general hypothermia.

Local hypothermia of the stomach is performed using a special apparatus LGZH-1 for bleeding ulcers of the duodenum, less often the stomach, erosive and a number of inflammatory diseases (for example,). The patient is introduced through a probe with a thin-walled balloon shaped like a stomach. Coolant (50% alcohol t° 4-5°) enters the cylinder, constantly circulating through the apparatus. The duration of hypothermia is 3-4 hours. At the same time, blood is transfused. Local hypothermia of the brain is performed using the Hypotherm apparatus, from which a stream of cold water or chilled air flows around the scalp. It is used for severe cerebral edema (trauma, impaired blood supply to the brain). The duration of hypothermia is 2-4 hours; at the same time, simultaneous infusion of intravenous hypertonic solution, plasma is shown. Local hypothermia of the extremities is used as an anesthetic for amputations in seriously ill patients. The limb is covered with ice bags, having previously applied (for, for 2-3 hours; for, for 1-2 hours).

General hypothermia is used in operations requiring a temporary cessation of blood circulation (operations on the open - "dry" -, operations with, etc.). With a decrease in body temperature to 25 °, it is possible to stop blood circulation for 10-15 minutes, with cooling below 20 ° - for 45 minutes. and even more. Hypothermia is obtained in two ways.
1. External cooling (bath t ° 3-5 °, wrapping with bags of ice, devices - hypotherms in the form of, consisting of a system of tubes through which cold circulates). The patient is given endotracheal anesthesia with muscular and controlled breathing. Upon reaching the depth (see Anesthesia) the patient is placed in a cold bath. Control the temperature in the esophagus or a special thermometer. For 30-60 min. the temperature drops to 32-30°. The patient is taken out of the bath, wiped and laid on. Within 30 min. the temperature continues to decrease independently by 2-5 °. Muscle trembling at the beginning of cooling is removed by an additional injection of a relaxant.

After the end of the operation, putting a sticker on the wound, the patient is placed in a bath at t° 40-45° and warmed up to t° 33-35°, then transferred to the bed, covered with a blanket. Then it rises on its own. Hypothermia reduces the sensitivity of tissues to oxygen starvation, which allows the brain to tolerate a decrease in blood circulation without harm.

The general rules for hypothermia with a machine or with ice packs are the same.

2. Extracorporeal (external) cooling; blood is taken from the patient's vein through a system of tubes to a cooling apparatus, and then poured into a large artery.

Hypothermia below 20° requires artificial circulation (see). The main danger of hypothermia is cardiac fibrillation. The frequency of this complication increases with a decrease in temperature below 28 °. If cardiac fibrillation occurs, defibrillation should be performed (see).

Hypothermia (from the Greek hypo - lower and therme - warmth; a synonym for general cooling) - an artificial decrease in body temperature, achieved under anesthesia, with the help of physical influence (cold water, ice, chilled air, etc.). Hypothermia reduces the body's need for oxygen, increases its resistance to hypoxia (see), reduces or even eliminates the danger of temporary cerebral ischemia. Hypothermia is indicated during surgical interventions on a "dry" heart, during which it is turned off for 10 minutes. or longer (cerebral ischemia without hypothermia is tolerated without dangerous consequences only for 3 minutes), during operations requiring aortic clamping and turning off blood flow through the pulmonary artery. In neurosurgery, hypothermia is used in operations for cerebral aneurysms and brain tumors. Hypothermia proved to be effective in thyroid storm. In patients with severe thyrotoxicosis and a significant increase in the level of metabolic processes, it is advisable to use moderate hypothermia in combination with neurovegetative blockade and endotracheal anesthesia. Hypothermia is also used during major operations in seriously ill patients whose compensatory forces are depleted before surgery (I. S. Zhorov). In the postoperative period, hypothermia is indicated for hypoxic cerebral edema, intoxication, and CNS injuries (A.P. Kolesov).

The combination of anesthesia (see) with hypothermia is the most complex, technically difficult type of combined anesthesia. At the same time, the risk of severe complications forces one to resort to hypothermia only when the danger due to the severity of the patient's condition or the complexity of the intervention exceeds the risk associated with hypothermia itself.

Hypothermia can be general and local. With local hypothermia according to Allen, the limb, tied with a tourniquet, is covered with crushed ice (as it melts, a new one is added). After 60-150 min. the temperature of the cooled tissues drops to 6-8 °, which reduces their need for oxygen and causes an analgesic effect. In elderly patients in serious condition, the use of local hypothermia in amputations for atherosclerotic or diabetic gangrene has been very effective.

With general hypothermia, endotracheal anesthesia is required, which provides the possibility of controlled breathing and the use of muscle relaxants (see). Changes during general cooling are cyclic (phase) in nature. The 1st phase of hypothermia - "adrenergic" - is characterized by a decrease in the temperature of the heart and esophagus to 34 ° (initial, or mild, hypothermia). Under the influence of the release of adrenaline, arterial and venous pressure rises, the pulse and respiration become more frequent, and the arteriovenous difference in the oxygen content increases. Hyperglycemia, hyperkalemia, increased intake into the blood and thyroxine are noted.

The 2nd phase occurs when the temperature drops to 28° (moderate hypothermia). At the end of this phase, there is a significant inhibition of all body functions. Muscle stiffness, a drop in arterial and venous pressure are noted, the pulse slows down to 40 beats, cardiac output and arteriovenous difference (arteriolization of venous blood) decrease, and intracranial pressure decreases. Endocrine functions are suppressed. The patient loses consciousness. Doses of narcotic substances from this point on should be significantly reduced, it is even recommended to switch to 100% oxygen insufflation. In this phase, you can turn off the heart for a period of 10 minutes.

The 3rd phase, which occurs when cooling below 28 °, is characterized by complete depletion of the endocrine functions of the pituitary, thyroid and adrenal glands. The stiffness of the muscles is replaced by their relaxation. Heart fibrillation often occurs, threatening death, but if you maintain a superficial level of anesthesia, then at a temperature not lower than 21 °, neither respiratory nor cardiovascular reflexes will disappear, although they will gradually decrease. T. M. Darbinyan distinguishes the cooling phase of the body from 27 ° to 20 ° as intermediate hypothermia.

Deep hypothermia should be considered cooling below 20°C, which requires the use of extracorporeal circulation devices. Drew, Keen and Benazon (S. E. Drew, G. Keen, D. B. Benazon) proved that at t ° 13 ° cerebral ischemia is tolerated for 45 minutes. with full subsequent restoration of all functions. S. A. Kolesnikov et al. cooled down to 9-15.6° with circulatory arrest for 7-45 min. However, clinical experience with deep hypothermia is still limited. Mortality with it is still very high due to the often developing decortication syndrome.

The final stage of hypothermia is the warming period. With it, the prevalence of oxygen supply to the tissues over its consumption should be ensured. Active slow rewarming (warm water, warm air, diathermy, etc.) is recommended, combined with sufficient anesthesia.

In the initial phase of hypothermia, the body responds to a decrease in temperature with shivering, and oxygen consumption does not decrease, but, on the contrary, increases by 2-7 times. Curarization with non-depolarizing relaxants in combination with shallow anesthesia is successfully used to suppress this reaction. When trembling occurs, intravenous administration of 10-25 mg of chlorpromazine and 20 mg of promedol is recommended.

Respiratory failure that occurs during hypothermia leads to acidosis, and acidosis and myocardial hypoxia provoke cardiac fibrillation. Hyperventilation is recommended to combat respiratory acidosis. With the onset of fibrillation, defibrillation with a capacitor discharge is most effective (V. A. Negovsky, N. L. Gurvich).

To improve coronary circulation, it is advisable to compress the thoracic aorta (see Revitalization of the body).

To achieve hypothermia, external cooling methods, cooling of body cavities and extracorporeal circulation are used. Cooling is controlled by thermometry in the rectum or esophagus (with a special thermometer).

External cooling is achieved by wrapping the patient with ice packs, immersion in a bath of water at t ° 3-5 °, wrapping in a blanket, through which cold water is passed through the tubes. For external cooling, special refrigerators are most convenient, for example, the Avtogipotherm apparatus (Swedish production).

With any method of external cooling, it is necessary to stop it when the temperature of the blood circulating through the cooled superficial tissues drops by 2/3 of the planned cooling: after cooling is completed, the temperature continues to fall, and, if this is not taken into account, its decrease will exceed the set level of hypothermia.

Hypothermia by the method of cooling cavities - washing the opened chest with cold water (1954), introducing a balloon with ice water circulating in it into the stomach cavity, etc. - has not received sufficient distribution. With extracorporeal cooling, venous blood from the vena cava enters the refrigeration system, and then returns to the body through the femoral artery. A. A. Vishnevsky and T. M. Darbinyan et al. developed a method of combined regional perfusion of the brain and heart, which makes it possible to operate on an open heart under conditions of moderate hypothermia for 9-29 minutes. The method of regional hypothermia of the head with the help of external cooling, due to the speed and ease of implementation, began to be used in a set of resuscitation measures (see Revitalization of the body).