General rules of medical care after seriously ill patients

Very important is making of the bed and control of bed linen condition. The mattresses of the patients, who suffer from fecal and urinary incontinence, are covered with rubber sheets. The bed sheet should be carefully straightened (no folds) and the ends of the bed sheet should be tucked in under the mattress. The folds on the bed sheet cause discomfort and can lead to bedsores.

If bedsores emerge they can be accompanied by secondary purulent or saprogenic infection. Prophylaxis of bedsores includes constant control of bed condition, bed linen and patient’s underwear, straightening folds. Also special rubber circles can be used; they are placed under that body parts are which under constant pressure (e.g., sacral bone). The circle must not be completely inflated so that it can change its form when the patient moves. The patient’s position in bed must be systematically changed 8-10 times a day.

During the first stage of bedsores (appearance of red or bluish-red spots without clear boundaries) the skin should be smeared with one of the solutions: 10% camphor solution, 1% spirit solution of salicylic acid, 5-10% spirit solution of iodine, 1% spirit solution of brilliant green or a mixture of half 70% ethyl alcohol half water.

In case vesicles appear (the second stage of bedsores) they must be smeared with 1-2% spirit solution of brilliant green or 5-10% solution of potassium permanganate; the skin surrounding the vesicles – 10% solution of camphor or a mixture of half 70% ethyl alcohol half water.

If the vesicles start to burst and form ulcers (the third stage of bedsores) it is necessary to apply ointment dressing with 1% chloramphenicol emulsion, etc.

During the fourth stage of bedsores (necrosis of skin, subcutaneous tissue and other soft tissues) surgical procedures are used – removal of dead tissues and clearing the wound. Then the wound is treated with 0,5% solution of potassium permanganate; if there is pus the wound is washed with 3% solution of hydrogen peroxide or 0,5% solution of potassium permanganate, etc. The surface of the bedsores is covered with aseptic bandage.

Bed linen and underwear must be changed at least once in ten days and if necessary much more frequently. If the patient has urinary incontinence the linen and underwear must be changed after each urination. If the patient is lying he must be provided with a bedpan (in Russian medical slang “duck”). After emptying the bedpan it must be washed with hot water and disinfected in 12% solution of chloride (chlorinated) lime or 3% solution of chloramine B.

In cases with seriously ill patients their skin should be sponged down with one of antiseptic solution: 10% solution of camphor, 1% spirit solution of salicylic acid, or a mixture of half 70% ethyl alcohol half water, etc. Before the sponging the patient should be placed on a rubber sheet. The sequence of actions: dip the sponge in antiseptics solution, then wipe the neck, chest, arms, belly, back and legs. To wipe the back the patient should be turned first to the right side, then to the left. The skin in the area of genitals and perineum must be daily smeared using swabs dipped in weak solution of potassium permanganate or warm water.

No less than once a week it is required to clip the patient’s nails, removing the dirt under them. The eyes are treated if there are any secretions that glue together eyelashes and eyelids. Using swabs dipped in 2% solution of boric acid first we wet the dried secretions on the eyes and then carefully remove them. After that the eye conjunctiva is washed with boiled water or isotonic solution of sodium chloride. The oral cavity of seriously ill patients is washed using the Janet’s syringe or rubber syringe (colonic bulb) with 0,5% solution of sodium hydrocarbonate, isotonic solution of sodium chloride or weak solution of potassium permanganate. To prevent liquid from getting into respiratory tracts the patient is should be half sitting with his head bent forward or, if he is lying, with his head turned to one side. To help the liquid flow out of the oral cavity the angle of mouth is slightly pulled aside using spatula.

Seriously ill patients often develop terminal stage – borderline condition between life and death. Clinical dynamics of dying is represented by a chain of pathological processes: heart activity stops; blood circulation stops; brain functioning disorder; loss of consciousness (for 1-2 sec); pupil dilation (20-30 sec); breathing stops; preagonal condition; terminal pause; agony; clinical death.

In preagonal condition the patient has mental confusion, the skin is pale and cyanotic tint, the pulse can be detected only on carotid and femoral arteries, the pulse is thready; there is tachycardia. Systolic arterial pressure is less than 70 mm of mercury. The breathing is frequent, shallow (hypopnoea).

Terminal pause. It is characterized by temporary extinction of cortex of cerebrum, extinction of respiratory center, heart; arterial pressure falls to zero point, breathing stops (this period lasts from 10 sec to 4 min); usually it is followed by the agonal breathing.

Agony. It is characterized by deep and rare respiratory movements. The patient is as if trying to grasp the air with open mouth, but the breathing is ineffective, because the inhalation and exhalation muscles contract simultaneously. The heart temporarily increases its activity, maximal arterial pressure can reach 100 mm of mercury. Quite often the consciousness becomes clear. After that the patient’s condition worsens and the result is clinical death.

Clinical death

The condition of the organism during several minutes after breathing and blood circulation stopped, when all the visible signs of life activity disappear, but there are still no irreversible changes in the tissues. This period is a reversible stage of dying. Signs of clinical death: complete loss of consciousness and reflexes (including corneal reflex); the change of the colour of the skin and visible mucous coats; significant pupil dilation; absence of cardiac beat and breathing; convulsions; uncontrolled urination, defecation; body temperature decrease. The condition of clinical death last from 4 to 6 minutes. If the patient had some serious illness that time shortens to 1-2 min. It should be remembered that the time during which it is still possible to restore brain functions is 3-4 min, maximally 5-6 min. Reanimation activities must be started as soon as possible, best before the development of cardiac asystole and complete respiratory standstill – in that case the chances of efficient and favourable results are higher. In medical practice there are a number of cases of successful restoration of cardiac and respiratory activity of patients after 6-7 min of clinical death.

Access for air. Can be achieved if the left hand is placed under the neck in supination position, the right hand is on the forehead. With a strong movement the head should be extended. In this case the neck is stretched, the tongue rises and moves from the back of the throat, so the obstacle is removed from the air passage. Using fingers or aspirator (suction unit/device/pump) all the foreign objects are removed from the mouth and throat.

Restoring breathing. In case of need for artificial respiration mouth-to-mouth (“kiss of life”) the person’s head should be maximally thrown back and a hand is placed under the neck. Then using the thumb and index finger of the other hand the nostrils are pressed together. Then open your mouth wide, take a deep breath and pressing your mouth to the person’s mouth exhale.

Remember! Lung ventilation is effective if you see the rising and falling of the chest; feel the resistance of the person’s lung when they extend; hear the sound of air passing during exhaling.

Restoring blood circulation.

Is done by means of closed-chest cardiac massage.

Contra-indications to closed-chest cardiac massage: penetrating chest wound; massive air embolism, pneumothorax, cardiac tamponade.

Massage technique. Most convenient position for a person is lying on his back, on a hard surface (floor, table, ground, etc.). Medical worker should be on the left side, on his knees or standing if the person is lying on a table. The medical worker unties the waist and the collar of the shirt, takes of the tie of the sick person. The palm of the right hand is placed on the lower third of the breastbone, perpendicular to its axis. The base of the hand must be 1,5-2,5 cm higher than the xiphoid process (xiphisternum). The palm of the left hand is placed on the back of the right hand at an angle of 90⁰. The base of the left hand must be perpendicular to the base of the right hand. Both hands and the fingers are maximally extended.

The push with both hands should be sharp (using body weight), providing 3-4 cm shifting of sternum, and if the chest is broad then 5-6 cm.

After the push the chest should straighten up, the hands are not removed from the chest, but they do not obstruct it from straightening.

Cardiac massage should be combined with artificial lung ventilation. The pressing of the chest is done during the exhaling of the sick person.

Remember! External cardiac massage is effective if after each pressing on the chest there is pulse on carotid artery; each pressing on the chest leads to new types of electrocardiographic artifacts. The sick person’s pupils react to light with constriction.

The closed-chest cardiac massage is done with 60 pushes per minute, after each 5^th push – one inhaling (5:1).

When there are no sign of effect of the reanimation measures after 30 min from the beginning it can be supposed that the brain is severely damaged and there is no point to go on.

Biological death.

It is an irreversible stop of the organism’s life activities that follow clinical death.

The death can only be certified by the doctor. He writes down in the patient’s history the day, hour and minute of death.

Signs of biological death:

1) Absence of heartbeat, pulse, breathing, pupils’ reaction to light;

2) Turbidity and drying of the cornea;

3) When the eye is pressed the pupil deforms and resemblea cat’s eye (“cat’s eye” symptom);

4) Cooling of the body and appearance of livores mortis (death spot);

5) Postmortem rigidity. This undeniable sign of death appears after 2-4 hours after death.