Karaganda state medical university Educational and clinical (training) center




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Ф КГМУ 4/09-11/02

ПП КГМУ 4/02

Karaganda state medical university

Educational and clinical (training) center

Guidelines for teachers

training in clinical skills training and clinical (training) center

(with using clinical cases)


Specialty: 051301 General medicine


Cipher, name: SNMP 4307


Discipline: Urgent emergency medical care


Course: V


The department of urgent and emergency medical care


Compiled by:docent A.R.Alpyssova, assistant L.S.Batirbekova
Karaganda 2011 y.



Considered at the meeting of the department accident and emergency

protocol №4 from «01»12.2011 y.


Head of the Department A.R. Alpyssova


Discussed by Methodological council of department____________________________

protocol №4 from «06»12.2011 y.


Chairman K.K. Toleubekov





Relief of a hypertensive crisis


Task 1.

Patient Inna Vasileva, 62 years old.

Reason for call: headache.

Upon arrival, SP (ambulance): complaints of severe headache, dizziness, tinnitus, nausea, vomiting, a one-time, feeling short of breath, sweating, and irritability.

From anamnesis: the patient suffers from hypertension for 10 years. Treated regularly. 2 years ago suffered a stroke on the ischemic type. Deterioration of health - in the last 5-6 hours, when they began to harass headaches, blood pressure rose to 170/100 mm Hg; for 30 min. before the arrival of the UMH (Urgent medical help) brigade, appeared shortness of breath and cough.

Objective: The general condition serious. Patient hypersthenic built, high power. Hectic. Forced situation - ortopnoe. Skin pale. Acrocyanosis. Pouring sweat. FRM (Frequency of respiratory motion)-24c 1 min. In the lungs vesicular breathing. Cardiac weakened sonority, rhythm is correct, the accent of II tone above an aorta. PS = 78 in 1min. BP = 180/110 mmHg. On the other bodies - without features.

The ECG: sinus tachycardia. Left ventricular hypertrophy. Diffuse changes in the myocardium.


Task 2.

Patient Mukashev Daniyar Abikenovich, 57 years old.

Reason for call: raising blood pressure in a patient with hypertension.

He complains to headaches, mainly in the occipital region, dizziness, a flicker of "floaters" in front of the eyes, nausea, pain in the heart of pressing nature, feeling short of breath.

From anamnesis: the first recorded increase in blood pressure 6 years ago. Treated regularly. Occasionally takes Enap 5 mg. The present deterioration - the day before, when there were headaches, dizziness, within 2-3 hours were disturbed pain in the heart of pressing nature, feeling short of breath. Caused by the SP team (ambulance).

Founded: Status of moderate severity. Several high power. Hyperemic face. FRM-18 in 1 min. In the lungs - painful. Cardiac attenuated sonorities, rhythmic accent of II tint above an aorta. FHSH-84 in 1 min. Blood pressure - 190/110 mm Hg

The ECG - sinus rhythm. Left ventricular hypertrophy. Diffuse changes in the myocardium.


Task 2.

Patient Dolgopolova Jeanne Eduardovna, 73 years old.

Reason for call: choking.

Upon arrival, the UH(Urgent help), complained to headache, mainly in the occipital region, "iron" head, dizziness, dyspnea appearance, choking, "aching" pain in the heart.

From anamnesis: the first recorded increase in blood pressure 15 years ago, did not explore, occasionally taking Adelfan. The present deterioration - in the evening - started headaches, with nothing in common. Condition has deteriorated over time - have joined heart pains, for 15 min. before the arrival of UH appeared shortness of breath, it became difficult to breathe.

In the history of life - chronic pyelonephritis, ChIDH (Chronic ischemic disease of heart).

Found: His condition was grave. The patient is excited. Trembling all over. Cyanosis nasolabial triangle, the nail plate. The skin is moist. Orthopnea. FB (frequency of breath)-23 in 1 min., Gurgling in his chest. In the lungs - mixed wet rales. Cardiac weakened sonority, FHSH-92 in 1min. BP-200/165 mmHg (Familiar figures - 150 and 100). To other organs - the hurt

The ECG: sinus tachycardia. Left ventricular hypertrophy. Displacement of the ST segment below the contour and flattening spike T.

The learning goal: to teach students the algorithm of diagnosis and relief of hypertensive crisis, and the ability of intravenous infusions and injections, a differentiated approach to emergency medical treatment in the presence of concomitant diseases.

The necessary theoretical knowledge

  • topographic anatomy of major neurovascular structures of the chest, thorax, mediastinum, diaphragm;

  • propaedeutics basis: diagnostic percussion, palpation, auscultation of the chest;

  • basics of asepsis and antisepsis;

  • concept of complicated and uncomplicated hypertensive crises;

  • Clinical pharmacology of antihypertensive drugs;

  • risk factors for hypertensive crisis;

  • pathogenetic mechanisms of development of a hypertensive crisis;

  • Classification of hypertensive crisis

  • Clinical manifestations of hypertensive crisis I and type II

  • Clinical management of hypertensive crisis

  • Indications for hospitalization


Necessary clinical skills:

1. collecting complaints, medical history

2. inspection, palpation, percussion, auscultation

3. perform venipuncture technique

4. build and implement systems for intravenous drip infusion

5. based technique of oxygen therapy with Ambu bag

The time required to parse the clinical case: 30 minutes

List of mannequins, models, visual aids, interactive computer programs: Upper limb for the measurement of blood pressure and for administration of drugs intravenously.

The list of medical products and equipment.

1. System for infusion of fluids - 8

2. Syringe with needle, disposable - 10.0 - 40.

3. Non-sterile gloves - 8 pairs

4. Alcohol or the simulator 70%

5. Gauze bandages (width of the bandage 8-10 cm) - 8.

6. Scissors - 1pc.

7. Cotton-gauze roll - 3 pcs.

8. Tray 1 pc.

9. Ampules - 16 pcs.

10. Tripod - 1 pc.

11. Tourniquet - 1 pc.

A clinical case

Patient Inna Vasileva, 62, complained to severe headaches, dizziness, tinnitus, nausea, vomiting, a one-time, feeling short of breath, sweating, and irritability.

From anamnesis: the patient suffers from hypertension for 10 years. Treated regularly. 2 years ago suffered from AIBC (acute infringement of brain circulation) on the ischemic type. Deterioration of health - in the last 5-6 hours, when they began to harass headaches, blood pressure rose to 170/100 mm Hg; for 30 min. before the arrival of the SMP brigade appeared shortness of breath and cough.

Objectively: The general condition serious. Patient hypersthenic built, high power. Hectic. Forced situation - ortopnoe. Skin pale. Acrocyanosis. Pouring sweat. FRM-24 in 1min. In the lungs vesicular breathing. Cardiac weakened sonority, rhythm is correct, the accent of II tone above an aorta. PS = 78 in 1min. BP = 180/110 mmHg. On the other bodies - without features.

Task:

1. assess the situation

2. Justify a provisional diagnosis

3. Provide emergency care


Prospective algorithm of skill:

1. Prepare your hands to work: Wash and dry your hands, wear disposable medical gloves. Wear a disposable surgical mask.

2. Rate consciousness. Check blood pressure, presence or absence of complications from cerebral infarction, kidney failure.

3. Put the patient on the couch with his feet down and head elevated 30 degrees. To reassure the patient.

4. Carry the bag with oxygen therapy Ambu.

5. To prepare for the parenteral administration of antihypertensive drugs:

6. Dial into the syringe of sodium nitroprusida rate of 5 mg / kg / min intravenously

7. Dial into the syringe pp aminophylline (10 ml 2.4% solution) intravenously

8. Dial into the syringe furosemide 40 mg intravenously.

9. Cover the patient's bare shoulder cloth or towel over the tourniquet on his arm. Determine the pulse of the radial artery.

10. Process the cubital area with a gauze ball with alcohol.

11. Pierce the skin with a needle to inject the selected parallel veins and push the needle forward, completely hiding the cut needle under the skin. Then change the direction of the needle at an angle of 45 ˚ and to puncture the vein wall.

12. Apply for a plunger and make sure to find a needle in the lumen of the vessel. In one motion to remove a tourniquet. Slowly introduce the drug into a vein, observing the patient's response and for the injection.

13. Ask the patient feels.

14. Applied to the injection site with a cotton ball with alcohol and extract accurate motion the needle from a vein.

15. Reset the syringe in a disinfectant solution.

16. Remove gloves and throw them in a disinfectant solution, wash your hands.

17. Re-measured blood pressure, heart rate monitor.

18. Clearly define the goals and objectives (Make a sequence of actions)

19. Demonstrate good communication and partnership behavior

20. Maintain a schedule of work, to feel a shared responsibility

21. Finish together work, to adequately assess its effectiveness


Materials for self-Related Activities:

1.How of the following drugs is the drug of choice for drug treatment of hypertensive crisis?

A sodium nitroprusside

B. labetalol

C. trimetafan

D. nitroglycerin

E. nifedipine

2. How of these patients most in need of urgent treatment for high blood pressure?

A 55-year-old patient (BP 180/100 mm Hg), which has resulted in drugs (diuretics), and in general feels good)

B. 85-year-old woman (blood pressure 212/110 mm Hg), not receiving treatment, complaining of headache, suffered a stroke in the past

C. 35-year-old man (BP 200/110 mm. Hg.), Suffering from fears after administration of drugs (cocaine)

D. 29-year-old woman (blood pressure 160/94 mm. Hg.) At the 30th week of pregnancy, complaining of headache, nausea

E. 50-year-old man (blood pressure 210/130 mm. Hg.), With a broken leg, but otherwise-satisfactory condition

3. Which of the following antihypertensive agents least effective when used in the elderly:

A. Inhibitors of angiotensin-converting enzyme

B. diuretics

C. beta-blockers

D. alpha-blockers

E. Calcium channel blockers


4. The criteria for a hypertensive crisis is:

A. increase in blood pressure > 159/94 mm. Hg.

B. sudden rise of blood pressure

C. appearance of headaches in combination with elevated blood pressure

D. signs of encephalopathy

E. cardiodynia


5. Which of the following characteristics is leading in the diagnosis of hypertensive crisis:

A. urinary syndrome

B. azotemia

C. Cerebral symptoms

D. cardiodynia

E. fundus changes in vascular


6. Which of the following combinations of antihypertensive drugs is preferable for hypertensive crisis, coupled with acute left ventricular failure:

A. pentamin + droperidol

B. klofellin + furosemide

C. aminophylline + Lasix

D. sodium nitroprusside + Lasix

E. klofellin + aminophylline


7. Which of the following combinations of antihypertensive drugs is preferable for hypertensive crisis with encephalopathy in combination:

A. pentamin + droperidol

B. klofellin + furosemide

C. beta-blockers + Lasix

D. aminophylline + Lasix

E. Magnesium sulfate + Lasix


8.How do most of the symptoms characteristic of renal eclampsia:

A stimulation

B. lethargy, drowsiness

C. polyuria

D. muscle weakness

E. tendency to edema


9. Which one of the most characteristic symptoms of the convulsive type of hypertensive crisis:

A loss of consciousness

B. short-term increase in blood pressure

C. convulsions

D. Rush

E. prolonged elevation of blood pressure


10. Sistolodiastolic crisis is characterized by:

A sharp increase in diastolic blood pressure

B. sharp increase in systolic blood pressure

C. a sharp increase in both systolic and diastolic blood pressure

D. sharp drop in diastolic blood pressure

C. A sharp increase in renal pressure


Criteria for assessing performance:


1. Prepared the hands to work: wash and dry your hands, put on disposable medical gloves. Put on a disposable surgical mask.

2. Appreciated unconscious. To check blood pressure, presence or absence of complications from cerebral infarction, kidney failure.

3. Put the patient on the couch with his feet down and head elevated 30 degrees. Reassure the patient.

4. Oxygen therapy conducted by Ambu sack.

5. Prepared for parenteral administration of antihypertensive drugs:

6. Typed into the syringe of sodium nitroprusida rate of 5 mg / kg / min intravenously

7. Typed into the syringe of aminophylline solution (10 ml 2.4% solution) intravenously

8. Typed into the syringe furosemide 40 mg intravenously.

9. Covered the patient's bare shoulder cloth or towel over the tourniquet on his arm. Determined the pulse of the radial artery.

10. Cubital area treated with a gauze ball with alcohol.

11. Pricked with a needle parallel to the skin for the selected vein injection needle and move forward, completely hiding the cut needle under the skin. Then changed the direction of the needle at an angle of 45 ˚ and have a puncture of the vein wall.

12. They filed for a plunger and made sure to find a needle in the lumen of the vessel. In one motion lifted tow. Slowly entered the drug into a vein, observing the patient's response and for the injection.

13. Asked the patient feels.

14. Appended to the site of injection of a cotton ball with alcohol and extracted a neat movement needle from a vein.

15. Dropped the syringe in a disinfectant solution.

16. Took off his gloves, threw them in a disinfectant solution, washed their hands.

17. Re-measured blood pressure, monitor your pulse.

18. Clearly defined goals and objectives (Compiled sequence of actions)

19. Demonstrate good communication and partnership behavior

20. Maintain a schedule of work, feel a shared responsibility

21. Finish together work, to adequately assess its effectiveness


Literature

Basic:


1. Инькова, А.Н. Неотложная кардиология : ЭКГ, клиника, лечение / Инькова, А.Н. - Ростов н/Д : Феникс, 2001. - 384 с. - (Медицина для вас)

2. Сумин С.А. Неотложные состояния : Учебное пособие / С. А. Сумин. - 7-е изд., перераб. и доп,. - М. : Мед. информ. агентство, 2010. - 960 с

3. Верткин А. Л. Скорая медицинская помощь : Учеб. пособие для мед. вузов / Верткин, Аркадий Львович. - 2-е изд., перераб. и доп. - М. : ГЭОТАР-МЕД, 2003. - 368 с.

4. Виноградов А.В. Дифференциальный диагноз внутренних болезней : учеб. пособие / А. В. Виноградов. - 3-е изд., перераб. и доп. - М. : Мед. информ. агентство, 2009. - 912 с

5. Волков В.С. Экстренная диагностика и лечение в неотложной кардиологии : руководство для врачей / В. С. Волков. - М. : Мед. информ. агентство, 2010. - 336 с. : ил

6. Джанашия П.Х. Неотложная кардиология : руководство для врачей / П. Х. Джанашия, Н. М. Шевченко, С. В. Олишевко. - М. : БИНОМ, 2008. - 296 с. : ил.

7. Джанашия П.Х. Неотложная кардиология / Джанашия, Платон Харитонович, Шевченко Н.М., Олишевко С.В. - М. : Бином, 2006. – 288с.

8. Неотложная помощь при заболеваниях внутренних органов на догоспитальном этапе : руководство для врачей / ред. В. А. Галкин. - М. : Мед. Информ

9. Неотложная помощь в практике семейного врача / ред.: М. К. Михайлов, В. Ф. Богоявленский. - 2-е изд.,испр. и доп. - Казань : Медлитература, 2008. - 656 с. - (Библиотека врача общей практики)


Additional:

1. Баргер С. И. Анализ ЭКГ в практике терапевта / Баргер, Савелий Иосифович. - М. : МарТ, 2005. - 160 с. : ил. - (Высшее медицинское образование)

2. Вебер В.Р. Неотложные состояния в практике семейного врача: : Учеб. пособие для студ.,клинич. ординаторов и врачей общей практики / Вебер, В.Р., Швецова Т.П., Швецов Д.А. - Великий Новгород : Б.и., 2005. - 282 с

3. Рациональная фармакотерапия неотложных состояний : руководство для практикующих врачей / ред.: Б. С. Брискин, А. Л. Верткин. - М. : Литтерра, 2007. - 648 с. - (Рациональная фармакотерапия : Серия руководств для практикующих врачей ; Т. XVII)

4. Струтынский А.В. Электрокардиограмма: анализ и интерпретация : Учеб. пос. / Струтынский, Андрей Вечяславович. - 6-е изд. - М. : МЕДпресс-информ, 2006. - 224 с. : ил.

5. Гайворонский И.В. Сосуды и нервы внутренних органов : учеб. пособие / И. В. Гайворонский, Г. И. Ничипорук. - СПб. : ЭЛБИ-СПб, 2009. - 56 с. : ил.

6. Клинические рекомендации.Стандарты ведения больных / ред.Баранов А.А. - М. : ГЭОТАР-Медиа, 2007. - 1376 с. - (Клинические рекомендации

7. Гребенев А.Л. Пропедевтика внутренних болезней: Учебник / Гребенев, Андрей Леонидович. - 5-е изд., перераб. и доп. - М. : Медицина, 2001. - 592 с. : ил. - (Учеб. лит. Для студ. мед. вузов)


Electronic library of educational and clinical center:


  1. 616.082 N 91

Harwood-Nuss Clinical Practice of Emergency Medicine, Book

(Клиническая практика по скорой неотложной помощи Харвуда Наса, учебник

  1. 610.8 S 61

Sim Clinic: Interactive Cases: Primary Care

(Интерактивные клинические случаи: первичная помощь)


The list of right answers for materials on self assessment

Standards of replies to the topic: "Relief of hypertensive crisis"

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Ф КГМУ 4/09-12/02

ПП КГМУ 4/02

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