V. Reference basis of action

Method of conducting of infiltration anaesthesia of skin

At first by a thin needle a «lemon crust» is done due to vnutrikognogo introduction of anestetika. Then – the layer introduction 0,25 % solution of novocaine. On principle of tight creeping infiltrata, that spreads on fastsialnim and aponevroticheskim cases, we continue a similar infiltration of fabrics, that are found below.

Method of conducting of explorer anaesthesia on Oberstu-Lukashevichu

In the basis of finger naladivayut plait. Distalnee than plait, from a back surface, a needle is entered with a 2-5 ml syringe, filled anestetikom. By introduction of solution of anestetika a skin is anaesthetized that hypodermic cellulose of this area. Then, conducting a needle on the lateralnim sides of basic phalanx of finger, athwart his surfaces, bring anestetik into a podkognogirovuyu cellulose and anaesthetize the nerves of finger in this place. For both sides, as a rule, use 5-8 ml 1 % solution of novocaine.

VI. System of teaching tasks for verification of eventual level of knowledges.

Situation tasks.

Sick L., 37 years, works of mine, entered clinic concerning пахвово-scrotum hernia. Three years are ill. During the last three months the hernia was twice hurt, however the restriction quickly has passed single-handed. Operative medical treatment is shown. It is definite, that expediently to execute the operation under the local anaesthetizing. Hallmarked on a sensitiveness to novocaine, the result of which is considered as sharply positive. Whether possible implementation of interference under the local anaesthetizing?

Answer: Implementation of operation it is possible under the local anaesthetizing, as an allergic giperergichnaya reaction of organism behaves to novocaine only. Consequently, it is necessary to find anestetik, which the allergic displays of organism of patient will not be present to .

Sick, 43 years, a driver complains on pain in an epigastralnom area, heartburn, loss of mass of body, seasonal intensification of disease. It is ill 8 years ulcerous illness of duodenum. In connection with intensification, during a month treated oneself in the gastroenterology separation without the expressed effect. It is translated in surgical permanent establishment. On the second days after hospitalization the abundant bloody vomiting began suddenly . The diagnosed bleeding from a duodenal ulcer, deficit of volume of circulatory blood 1,5 litres, composition of blood is not changed, the deficit of vnekletochnoy liquid is not present. The conducted conservative gemostaticheskaya therapy. Bleeding is stopped. After days the decline of quantity of red corpuscles and haemoglobin in bloods, insignificant deficit OTSK is definite, deficit of intertissue liquid to 18%. What factors affected its redistribution, that provides constancy of composition of blood and water spaces of organism of man? In the case of operative interference or possible resection of stomach under local anaesthesia by infiltration of his svyazochnogo vehicle on all perimeter? What the N.I. Pirogova study about the case structure of fabrics consists in?

Answer: Krovopoterya which arose up, and stipulated the OTSK deficit the redistribution of liquid of interstitsialnih spaces by moving of her in an of the circulatory system river-bed. Constancy of water spaces of organism and volume of blood, even with other factors, is provided by constancy of osmotic and onkoticheskogo pressures in them. The resection of stomach is possible under local anaesthesia by infiltration on the perimeter of dublikaturi parietalnoy peritoneum which creates a svyazochniy vehicle and case of stomach. Forcing in the cases of anestetik, it is possible to obtain the shutdown of sensitiveness on his extent, in what and the value of the study N.I consists. Pirogova. However it is better to execute such operation under anesthesia.

A patient 35 years, seamstress, entered clinic concerning chronic paraproktita. At the inspection other diseases are not exposed. Protipokazan to the operation it is not. Carving of svisha is shown. The executed spinal-cerebral anaesthesia at the level of L lV-V 1% by solution of sovkaina. What anatomic educations are passed by a needle in the area of spine, between the L IV-V vertebrae, to be before included in a spinal-cerebral channel? Why is it impossible to conduct spinal-cerebral anaesthesia at a level higher than the D-XII vertebra?

Answer: In the process of implementation of spinal-cerebral anaesthesia a punktsionnaya needle passes through a skin, hypodermic cellulose, megostistie copulas, yellow copula, hard brain-tunic. Spinal-cerebral anaesthesia higher the XII pectoral vertebra is not conducted, as a diaphragm and proper megdurebernie muscles is turned off from breathing. The stop of breathing can come.

Patient with, acted with complaints on pain in the area of the left podmishechnoy cavity, general weakness, indisposition, rise of temperature of body to 38 degrees. Considers itself a patient about 24 hours, when pain in the area of the left podmishechnoy cavity appeared . At examination in this area infiltrat is determined by sizes 3х2 see. Skin round him giperemirovana, are present signs of flyuktuatsii. What testimonies to operative interference? What type of local anaesthesia will you offer?

Answer: at a patient absolute testimonies to operative medical treatment – sharp festering surgical disease (abscess). The shown infiltration anaesthesia on Vishnevskomu.

Sick T., entered proktologicheskoe separation with complaints about pain in the area of anus, which increases during the act of defecation, festering excretions near a rectum, general weakness. At outward examination in 2 sm. from an anal edge, on 9 hours the outward opening of svisha is determined, by a diameter to 0,2 mm At finger research of rectum in area of back kripti is determined internal opening of svisha. Palpatsiya of her is sickly. Motion of svisha of transfinkterniy. DIAGNOSIS: Back transsfinkterniy rectal svish. Surgical medical treatment is shown - deleting of svisha on the first method of Gabrial. What type of local anaesthesia must be applied?

Answer: pains the shown spinal anaesthesia.

A patient with entered surgical to the separation with a diagnosis: abscess of posleoperatsionnogo scar of front abdominal wall, the state after taking of ileostomi in. At examination in the right half of stomach, in the area of posleoperatsionnogo scar, dense moderately sickly infiltrat is determined 10х15 sm with softening influence in a center. Under local infiltration anaesthesia, opening of abscess is done. During conducting of anaesthesia by a mistake a 10% solution of lidokaina was used, as a result at a patient there was the picture of the sharp poisoning. What will be clinical picture of display of poisoning by the anaesthetic matter?

Answer: Dizziness, nausea, weakness, death-damp, frequent pulse of the weak filling, decline of arterial pressure.

Patient with L., entered clinic with complaints on pain in the area of anus, selection of bright red blood from a rectum during the act of defecation. At finger research of rectum megascopic internal haemorrhoidal knots are determined. On 6 o'clock of conditional clock-face - chronic crack of anal channel with kaleznimi edges, long to 1 sm. In the planned order a patient is operated. For anaesthetizing epiduralno-sakralnaya anaesthesia is used. In 15 minutes, after the beginning of operation, a patient suddenly lost consciousness, there were cramps. What it is necessary to take measures for the fight against complication which arose up?

Answer: It is necessary to enter cardiac facilities, glucose, poliglyukin. For the removal of cramps in a rectum barbiturati is entered. Necessary inhalation by oxygen.

At Sick N., on the third days after appendektomii, the displays of intestinal impassability appeared, it is possible spaechnogo geneza. For differential diagnostics there is the shown paranefralnaya novocaine blockade. Where to execute punktsiyu, how to enter anestetik?

Answer: Punktsiya at the level of bisector of corner between long muscles and costal arc, conducting of needle without a blood and liquid to feeling of failure.

At sick N., 28 years, with the hypodermic whitlow of middle phalanx of the ІІ finger of right brush the temperature of body to 38о rose S. Poyavilas pulsating pain, edema of finger. What your tactic? Choose the type of anaesthetizing.

Answer: at a patient there is the sharp festering disease of finger of brush – whitlow. Coming from that the state of patient became worse, it follows to consider that at a patient the stage of abstsedirovaniya this disease. To the patient the shown urgent operative interference – opening and drenirovanie of abscess. The operation needs to be conducted under anaesthesia on Oberstu-Lukashevichu.

Patient To., 74 years, entered clinic on the first-aid concerning the hurt right-side inguinal hernia. It is ill concomitant illnesses: by bronchial asthma, saccharine diabetes. What your actions? What type of anaesthetizing you use and why? What concentration of solution of novocaine will you apply in this case?

Answer: the hurt inguinal hernia is a testimony to the exigent surgical operation. As a patient declining years, with the present heavy concomitant diseases, common anaesthetizing to him contra-indicated. By the method of anaesthetizing it is needed to choose local anaesthesia, namely – periduralnuyu.

After successful implementation of operation of apendektomii concerning sharp flegmonoznogo appendicitis (under infiltatsionnoy anaesthesia) at a patient the hyperemia, dermatitis, appeared in 3 hours, edema of fabrics in the area of operative interference, signs of serdechno-sosudistogo collapse (pallor, sticky death-damp, drop in the temperature of extremities, sharp decline of arterial pressure). About development, what complication it is possible to think? Appoint medical treatment.

Answer: the symptoms of poisoning to local anestetikom developed at a patient. For getting a patient out of this state we appoint antihistaminic, cardiac, anaesthetic preparations.

To sick N., 67 years, spinal anaesthesia for amputation of the left lower extremity was conducted (concerning a moist gangrene). During conducting of anaesthesia of patient began to grumble about a stuffiness, lost consciousness. Skin covers of steel of tsianotichnimi, HELL went down to 80/60 to mm of rt item What complication arose up at a patient?

Answer: a patient has the allergic reaction on introduction of local anestetika. It is needed quickly to stop introduction of preparation, to enter antihistaminic, cardiac, anaesthetic preparations. In the case of stop of breathing or heart to conduct reanimation measures on current methods.

At a patient with P., 23 years, pregnancy is diagnosed 20 weeks, hypodermic abscess of right buttock. What medical treatment to appoint as a patient? How to anaesthetize a patient?

Answer: at a patient sharp festering surgical disease – abscess. To her the shown urgent operative interference – opening, drenirovanie of abscess. As a patient is pregnant, it serves by contra-indication for conducting of the common anaesthetizing (intravenous anesthesia). Therefore the operation needs to be conducted under infiltration anaesthesia on Vishnevskomu.

After DTP there is the driver of machine without consciousness, very pale. In 40 minutes the brigade of first-aid of signs of breaks of bones did not expose. On a forehead there is a cone-shaped haematoma. HELL 80/50 mm of rt st; pulse 144 ud/min. A stomach is soft, takes part in the act of breathing. At palpatsii of ribs – krepitatsiya on a right middle-clavicular line. Breathing frequency 27 for a 1 minute. What threatening complication can develop at a patient? How profilaktirovat him?

Answer: a patient has the massive breaks of ribs. There can be plevro-pulmonalniy shock. With the purpose of his prophylaxis, a patient needs to execute a vago-simpaticheskuyu blockade on Vishnevskomu.

In a surgical cabinet the victim is delivered with the sword-cut of lower third of right shoulder measuring 3х0,5 sm, which he got during a fight in the street (after a trauma passed 18 hours). What help it is necessary to give to the patient in permanent establishment? What method of local anaesthesia will you offer for anaesthetizing?

Answer: a patient needs to conduct primary surgical treatment of wound. The blockade of humeral interlacement on Kulen-Kampfu will be the best method of the local anaesthetizing.