The conclusion drawn by English anesthesiologists and resuscitators during the Falklands campaign deserved attention and approval: improving intensive care at all stages of care for the wounded and injured is more important than finding ideal means for induction and maintenance of anesthesia, according to the Internet publication for girls and women from 14 to 35 years old.. net Hartmann's solution, hemocoel, plasma, donor blood were used as an indispensable ingredient of infusion-transfusion therapy.

In one of the hospitals of the II line (specialized care), 220 wounded were treated.

The anesthetic aid consisted in the sequential administration of atropine, thiopental sodium or ketamine, succamethonium, after which intubation was undertaken and began to supply halothane or trichloroethane mixed with air. In the process of anesthesia, pulse, blood pressure, CVP, respiration, temperature were monitored. A total of 57 liters of donor blood transfused. Not a single wounded person died.

In some cases, an epidural catheter was installed for prolonged postoperative pain relief. With repeated interventions, the use of halothane was abstained (toxic effect on the liver) and large doses of fentanyl were injected intravenously in combination with inhalation of a nitrous-oxygen mixture. For anesthesia in the postoperative period, morphine was used intravenously in small doses (up to 5 mg), and against the background of respiratory failure - pentazocine (30-60 mg); overdose, respiratory depression was treated with naloxone.

For very painful burns of hands and face, in addition to morphine, diazepam was prescribed in small doses (5 mg) to eliminate nervous excitement. Frei and Ch. Zurni (1983) summarized the experience of 3076 anesthesia in the provision of surgical care for the wounded in armed conflicts in Chad, Pakistan, Cambodia.

The requirements for the methods of anesthesia in the field, formulated by the authors, deserve attention: availability not only for anesthesiologists, but also for auxiliary personnel.; the ability to administer anesthetics intravenously and intramuscularly; quick onset of the anesthetic effect and good controllability; maintaining adequate spontaneous breathing; minimal negative effect on hemodynamics, respiration, reflex activity; full hypnotic, analgesic effect; large therapeutic range of action and low toxicity; indifference to temperature, non-flammable; the possibility of using an anesthetic both in the form of mononarcosis and in combination with other agents; no difficulties in supplying in specific field conditions.

Inhalation types of anesthesia, due to the need for the participation of experienced specialists, equipment and difficulties in supplying gases are significantly inferior to intravenous methods. To the greatest extent, ketamine meets all the formulated requirements.. With its help, an important organizational requirement is realized as quickly as possible to provide assistance to the largest number of wounded..

Under ketamine anesthesia in combination with seduxen, such types of operations as enucleation of the eye, surgical debridement of wounds, all types of interventions on the upper and lower extremities, debridement of festering wounds and burn surfaces were performed.. In a hopeless position under ketamine anesthesia, it was possible to perform urgent thoraco- and laparotomies without intubation with preserved spontaneous breathing..

In such cases, premedication was carried out with atropine (0.5 mg) and diazepam (5-10 mg) intravenously or intramuscularly.. The initial dose of ketamine was 1–2 mg / kg IV; maintenance dose - 0.5-1 mg / kg and diazepam - 5-10 mg. When administered intramuscularly, the initial dose of ketamine was 5-10 mg / kg, the maintenance dose was 2.5-5 mg / kg, diazepam was prescribed if necessary.

The drop technique of ketamine anesthesia (250 mg of ketamine and 50 mg of diazepam per 500 ml of isotonic sodium chloride solution) is easily controllable provided that 50-60 drops per minute are administered. The authors were convinced that in the absence of signs of hypovolemia in a wounded or injured person, spinal anesthesia is quite applicable (2 ml of a 4% solution of scandicaine). There were no serious complications from the use of this technique.. Ether anesthesia was used in the surgical treatment of the wounded on open terraces in Sudan.

The treatment of the wounded in Chad took place in an extremely unfavorable environment: there were no donor blood, plasma substitutes, oxygen. Ketamine saved the day. In particular, for the laparotomy, they resorted to intubation of the wounded, mechanical ventilation with room air; insufficient degree of muscle relaxation was compensated by expanding the surgical incision. A reasonable addition to general anesthesia, according to the authors, is the blockade of the nerve conductors of the extremities with a solution of local anesthetics.

However, with a large accumulation of wounded and an acute shortage of time among medical personnel, regional anesthesia was applied conditionally.. Conducting 90% of all interventions under ketamine anesthesia and having received generally satisfactory treatment results, the authors came to the conclusion that ketamine is of "

Ch. Beeking (1980) rightly emphasizes that in conditions of mass admission of the wounded and injured, the following conditions affect the provision of anesthetic care: limited technical means and narcotic drugs, the inability to use gases when it is necessary to create deep anesthesia against the background of frequent hypovolemia and shock.. The author believes that the prerequisites for the smooth course of ketamine mononarcosis in an emergency situation are the preliminary training of non-anesthetic specialists and the constant readiness of standard installations for the practical use of this anesthetic..

Bing and Fu-Jin Li (1982) used ketamine anesthesia to treat combat wounds in the field. The predominant operations were surgical debridement of wounds, removal of foreign bodies, osteosynthesis of bone fractures, transplantation of skin flaps, restoration of blood vessels and nerves, amputation of limbs and their segments. Craniotomy, thoracotomy, laparotomy were performed under the same type of anesthesia..

In 30% of all cases, ketamine mononarcosis was used, when the anesthetic was administered intravenously one to three times at a dose of 0.5-4 mg / kg (in total, 45-700 mg per anesthesia). Respiratory depression was recorded in 25% of the wounded, and vomiting was also common against the background of laryngospasm..

Complications of pain relief.

The most common causes of side effects included ketamine overdose, rapid vein injection, and “irritating” hormones..

The possibility of developing these complications was dictated by an immutable rule: during anesthesia, always have a suction device and a ventilator on hand.. The sympathomimetic effect of ketamine was recorded in 6.17% of all cases. A balanced assessment of the positive and negative properties of ketamine, the characteristics of the operation and the level of the individual threshold allows avoiding side effects..

Carmichael (1981) carried out anesthetic and resuscitation aid for the wounded, treated in the English Red Cross hospital during the fighting in Cambodia (1974-1975), Angola (1976). The medical group worked in difficult sanitary conditions: there were not enough tools, there was a constant overload, the wounded were placed on the floor.

On some days, 20-50 people were admitted to the hospital with gunshot wounds, traumatic amputations, napalm burns. One sister often provided assistance to 15 wounded in a state of shock at once.. The seriously injured and injured after the initial examination, the beginning of infusion therapy were admitted to the operating room, where the anesthesiologist introduced them to anesthesia, left them under the supervision of a nurse, and he himself proceeded to provide assistance to the next patient.

In the conditions of complete absence of donor blood, autotransfusion of the blood of the wounded was widely used, which was poured into the chest and abdominal cavities.. For anesthesia, in most cases, the usual technique was used with the sequential administration of thiopental sodium, muscle relaxants, and after intubation - the beginning of mechanical ventilation - inhalation of low concentrations of halothane. With a "

For induction anesthesia against the background of shock, ketamine is preferred instead of thiopental sodium, which does not guarantee against the occurrence of critical hypotension, cardiac arrest. In the absence of proper postoperative control, it is important to ensure the rapid awakening of patients and the restoration of protective reflexes.. The method of choice for wounds and injuries of the extremities is a combination of ketamine anesthesia and regional anesthesia. The overall mortality rate among the wounded treated with the author's participation was 25-30%.

Nirlinger et al. (1983) conducted a comparative study of the analgesic properties of ketamine for emergency pain relief in catastrophic situations. It was assumed that the drug was administered intramuscularly by medical personnel who did not have anesthetic training.. Two groups of patients who received ketamine at doses of 0.5 and 1 mg / kg underwent a detailed assessment..

In both groups, ketamine produced effective analgesia 10 minutes after administration. The hemodynamic response was the same; no negative impact on vital functions was recorded. Higher doses of ketamine turned off consciousness. For effective analgesia, its content in blood plasma is more than 100 mg / ml.. The most pronounced analgesic effect of ketamine was observed with injuries of the extremities, burns. Both doses tested were equally effective.

medbe. ru.