Traumatic shock - causes and stages. Algorithm for emergency care for injuries and traumatic shock

Traumatic shock- a severe, life-threatening pathological condition that occurs during severe injuries, such as pelvic fractures, severe gunshot wounds, traumatic brain injury, abdominal trauma with damage to internal organs, operations, and large loss of blood.

The main factors causing this type of shock- severe pain irritation and loss of large volumes of blood.

Causes and mechanisms of development of traumatic shock.

The cause of traumatic shock is the rapid loss of a large volume of blood or plasma. Moreover, this loss does not have to be in the form of obvious (external) or hidden (internal) bleeding - a shock state can also be caused by massive exudation of plasma through the burned surface of the skin during burns,

What is important for the development of traumatic shock is not so much the absolute amount of blood loss as the rate of blood loss. With rapid blood loss, the body has less time to adjust and adjust, and shock is more likely to develop. Therefore, shock is more likely when large arteries, such as the femoral artery, are injured.

Severe pain, as well as neuropsychic stress associated with injury, undoubtedly play a role in the development of the shock state (although they are not its main cause), and aggravate the severity of shock.

The outcome of severe shock without treatment is usually death.

Symptoms of shock.

Traumatic shock usually goes through two phases in its development, the so-called “erectile” shock phase and the “torpid” phase. In patients with low compensatory capabilities of the body, the erectile phase of shock may be absent or very short (measured in minutes) and shock begins to develop immediately from the torpid phase

Erectile shock phase

At the initial stage, the victim often feels severe pain and signals it using the means available to him: screaming, moaning, words, facial expressions, gestures.

In the first, erectile, phase of shock, the patient is excited, scared, and anxious. Often aggressive. Resists examination and treatment attempts. He may thrash about, scream in pain, moan, cry, complain of pain, ask or demand analgesics, drugs.

In this phase, the body’s compensatory capabilities have not yet been exhausted, and blood pressure is often even elevated compared to the norm (as a reaction to pain and stress). At the same time it is celebrated spasm of skin vessels - pallor, worsening as bleeding continues and/or shock progresses. Observed rapid heartbeat(tachycardia), rapid breathing (tachypnea), fear of death, cold sticky sweat(such sweat is usually odorless), tremor(trembling) or small muscle twitches. The pupils are dilated (reaction to pain), the eyes are shiny. Restless look, doesn't stop at anything. Body temperature may be slightly elevated(37-38 C) even in the absence of signs of wound infection - simply as a result of stress, the release of catecholamines and increased basal metabolism. The pulse remains satisfactory and rhythmic.

Torpid phase of shock

In this phase, the patient in most cases stops screaming, moaning, crying, thrashing about in pain, does not ask for anything, does not demand anything. He is lethargic, lethargic, apathetic, drowsy, depressed, and may lie in complete prostration or lose consciousness. Sometimes the victim may only make a faint moan. This behavior is caused by a state of shock. However, the pain does not decrease. Blood pressure decreases, sometimes to critically low numbers or is not determined at all when measured in peripheral vessels. Severe tachycardia. Pain sensitivity is absent or sharply reduced. He does not respond to any manipulation in the wound area. He either doesn’t answer questions or answers barely audibly. Convulsions may occur. Involuntary release of urine and feces often occurs.

The eyes of a patient with torpid shock dim, lose their shine, look sunken, and shadows appear under the eyes. The pupils are dilated. The gaze is motionless and directed into the distance. Body temperature can be normal, increased (wound infection) or slightly decreased to 35.0-36.0 ° C (“energy depletion” of tissues), chills even in the warm season. Attracts attention severe pallor of patients, cyanosis (cyanotic) lips and other mucous membranes.

Intoxication phenomena are noted: the lips are dry, parched, the tongue is heavily coated, the patient is tormented by constant strong thirst and nausea. Vomiting may occur, which is a poor prognostic sign. There is a development shock kidney syndrome- despite thirst and the copious amounts of drink given for it, the patient has little urine and it is highly concentrated and dark. In severe shock, the patient may not have any urine at all. Syndrome "shock lung"- despite rapid breathing and intensive work of the lungs, the supply of oxygen to tissues remains ineffective due to vasospasm and low levels of hemoglobin in the blood.

The skin of a patient with torpid shock is cold, dry (there is no longer cold sweat - there is nothing to sweat with due to the large loss of fluid during bleeding), tissue turgor (elasticity) is reduced. Sharpening facial features, smoothing nasolabial folds. The saphenous veins are collapsed. The pulse is weak, poorly filled, may be thread-like or not detectable at all. The faster and weaker the pulse, the more severe the shock.

First aid for shock

You should try to stop the bleeding as best and completely as possible: press the bleeding large vessel with your finger above the site of injury, apply a pressure bandage (for venous or capillary bleeding) or a tourniquet (for arterial bleeding), pack the open wound with tampons with 3% hydrogen peroxide (which has a hemostatic effect). If there is a hemostatic sponge or other means for quickly stopping bleeding that are suitable for use by a non-specialist, they should be used.

As a non-specialist, you should not try to remove a knife, splinter, etc. - manipulations of this kind can cause severe bleeding, pain and aggravate shock. Do not reposition internal organs that have prolapsed (intestinal loops, omentum, etc.). It is recommended to apply a clean antiseptic cloth to the fallen parts and constantly moisten it so that the insides do not dry out. Do not be afraid, such manipulations are painless for the patient.

In cold weather, a patient with shock should be covered warmly(without covering your face), but do not overheat (optimal temperature +25 °C) and deliver to a warm room or heated car interior as soon as possible(patients with shock are very sensitive to hypothermia). It is very important to give the patient plenty of water (often, but in small portions - sips, so as not to vomit or increase nausea). It is better to drink from a spoon (because the victim himself is unlikely to be able to drink on his own). Moreover, you need to drink more than the patient himself wants or asks for (as much as he physically can drink). You need to start drinking before the development of thirst and signs of intoxication such as dry lips and a coated tongue. In this case, it is better to drink not with plain water, but with a special water-salt solution containing all the salts necessary for the body (the kind that is used for diarrhea - such as Regidron or Ringer's solution). You can drink it with sweet strong tea or coffee, juice, compote, mineral water, or simply plain water salted to the concentration of saline solution.

Remember! Under no circumstances should you feed or give water to a victim with any injuries to the abdominal cavity! If the patient has a wound or injury to the abdomen, then he is only allowed to wet his lips with a damp cotton swab. It is also not recommended to give food or drink to a victim with head and/or neck injuries, as his swallowing functions may be impaired. Under no circumstances should you put anything into the mouth of an unconscious or semi-conscious victim!

Fractures and dislocations must be carefully immobilized on splints(any suitable boards) to reduce pain and prevent tiny pieces of tissue (bone marrow, adipose tissue) from entering the bloodstream, which can trigger the development of disseminated intravascular coagulation syndrome during shock.

A patient with shock should be transported to the nearest hospital as quickly as possible, but at the same time exercise reasonable caution and try not to shake the car on the road, so as not to increase pain, provoke resumption of bleeding and aggravate shock. Do not shift the victim unless absolutely necessary, as any transportation causes additional suffering to the patient.

If possible, pain relief that is accessible to non-specialists should be provided - apply cold to the wound(ice pack or cold water) give 1-2 tablets of any of the non-narcotic analgesics such as analgin, aspirin available on hand(reduces blood clotting) or, better yet, inject a non-narcotic analgesic.

If possible, relief from neuropsychic stress (which also aggravates shock) that is accessible to a non-specialist should be provided: giving 1-2 tablets of any available tranquilizer or 40-50 drops of Corvalol, Valocordin, or a small amount of strong alcoholic drink. But alcohol can be used only in extreme cases, and only if the person tolerates it well! Since it can worsen the patient's condition.

Try to calm the victim. The emotional state of patients is of no small importance in the fight against shock. Do not be offended by a patient who behaves aggressively towards others. Remember that in a state of shock a person is not aware of his actions, so correct and most importantly friendly communication with the victim is of great importance!

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2016

Other early complications of trauma (T79.8), Early complication of trauma, unspecified (T79.9), Traumatic shock (T79.4)

Emergency medicine

General information

Brief description

Approved
Joint Commission on Healthcare Quality
Ministry of Health and Social Development of the Republic of Kazakhstan
dated June 23, 2016
Protocol No. 5

Traumatic shock- an acutely developing and life-threatening condition that occurs as a result of exposure to severe mechanical trauma on the body.
Traumatic shock- this is the first stage of a severe form of the acute period of a traumatic disease with a peculiar neuro-reflex and vascular reaction of the body, leading to profound disorders of blood circulation, breathing, metabolism, and the functions of the endocrine glands.

ICD-10 codes

Date of protocol development/revision: 2007/2016.

Protocol users: doctors of all specialties, nursing staff.

Level of Evidence Scale (Table 1):

A	A high-quality meta-analysis, systematic review of RCTs, or large RCTs with a very low probability (++) of bias, the results of which can be generalized to an appropriate population.
IN	High-quality (++) systematic review of cohort or case-control studies or High-quality (++) cohort or case-control studies with very low risk of bias or RCTs with low (+) risk of bias, the results of which can be generalized to an appropriate population .
WITH	Cohort or case-control study or controlled trial without randomization with low risk of bias (+). The results of which can be generalized to the relevant population or RCTs with very low or low risk of bias (++ or +), the results of which cannot be directly generalized to the relevant population.
D	Case series or uncontrolled study or expert opinion.

Classification

Classification

According to the course of traumatic shock:
Primary - develops at the moment or immediately after injury;
· secondary - develops delayed, often several hours after injury.

Classification of the severity of traumatic shock according to Keith(Table 2):

Degree gravity shock	Level systole BP mm. Hg Art.	Frequency pulse in 1 min	Index Allgower*	Volume blood loss (exemplary)
I easy	100-90	80-90	0,8	1 liter
II Wed. gravity	85-75	90-110	0,9-1,2	1-1.5 liters
III heavy	70 or less	120 or more	1.3 or more	2 or more

*Determination of the shock index may be incorrect if systolic blood pressure is below 50 mm. Hg Art., with severe traumatic brain injury accompanied by bradycardia, with heart rhythm disturbances, in persons with an increased level of “working blood pressure”. In these situations, it is advisable to rely not only on the level of systolic blood pressure, but also on the volume of traumatic injuries.

Stages of traumatic shock:
· compensated - there are all signs of shock, with a sufficient level of blood pressure, the body is able to fight;
· decompensated - there are all signs of shock and hypotension is pronounced;
· refractory shock - all therapy is unsuccessful.

Risk factors:
· rapid blood loss;
· overwork;
· cooling or overheating;
· fasting;
· repeated injuries (transportation);
· combined injuries with mutual aggravation.

There are two phases in the development of traumatic shock:
· erectile phase;
· torpid phase.

Classification of traumatic shock in children (according to G.K. Bairov):

I slight shock: observed with injuries of the musculoskeletal system, blunt abdominal trauma. For several hours after the injury, the victim persistently retains the clinical picture of shock in the stage of centralization of blood circulation. The effect of therapy appears within 2 hours.
Clinic: psychomotor agitation or inhibition, systolic blood pressure within the normal range for this age group, intense pulse, tachycardia, decreased pulse pressure, pale skin, they are cold to the touch, cyanotic tint of mucous membranes and nails. Reduction of circulating blood volume by 25%. Respiratory alkalosis, metabolic acidosis;

II medium-heavy: extensive soft tissue damage with significant crushing, damage to the pelvic bones, traumatic amputation, fractured ribs, pulmonary contusion, isolated damage to the abdominal organs. After some time from the moment of injury, a transition occurs from the stage of centralization of blood circulation to the transitional stage. After therapy, the effect is observed within 2 hours, but a wave-like deterioration of the condition is possible.
Clinic: lethargy, decreased systolic blood pressure, pulse rate more than 150% of the age norm, poor filling. Shortness of breath, pale skin, decrease in circulating blood volume by 35-45%;

III heavy: multiple injuries to the chest and pelvis organs, traumatic amputation, bleeding from large vessels. Within 1 hour after injury, decentralization of blood circulation develops. The effect of the therapy appears after 2 hours or does not appear at all.
Clinic: lethargy. Systolic blood pressure is 60% lower than the age norm. Tachycardia, thready pulse. The skin is pale cyanotic in color. Breathing is shallow and frequent. Reduction in circulating blood volume by 45% of normal. Bleeding tissue. Anuria;

IVterminal: signs of preterminal (agonal) and terminal states.

Diagnostics (outpatient clinic)

OUTPATIENT DIAGNOSTICS

Diagnostic criteria

Complaints:
· pain in the area of impact of the traumatic agent;
· dizziness;
darkening of the eyes;
· heartbeat;
· nausea;
· dry mouth.

Anamnesis: mechanical injury that led to traumatic shock.

Physical examination:
· assessment of the general condition of the patient: The general condition of the patient, as a rule, varies from moderate to extremely severe. Severe pain often leads to traumatic shock. Patients are restless. Sometimes there is a disturbance of consciousness, up to coma. The psyche is inhibited, with the transition to depression;
· appearance of the patient: pale or pale gray face, acrocyanosis, cold sticky sweat, cold extremities, decreased temperature;
· examination of the state of the cardiovascular system: frequent weak pulse, decreased arterial and venous pressure, collapsed saphenous veins;
· examination of the respiratory system: increased and weakened breathing;
· examination of the condition of the abdominal organs: characteristic features in the presence of damage to the internal organs of the abdomen and retroperitoneal space;
· examination of the condition of the musculoskeletal system: the presence of damage to the bone frame is typical (fracture of the pelvic bones, fractures of tubular bones, avulsions and crushing of the distal part of one limb, multiple fractures of the ribs, etc.).

Laboratory research: No.

Measuring blood pressure - lowering blood pressure.

Diagnostic algorithm

Diagnostics (hospital)

DIAGNOSTICS AT THE INPATIENT LEVEL

Diagnostic criteria at the hospital level:
Complaints and medical history: see outpatient level.
Physical examination: see outpatient level.

Laboratory research:
· general blood test (if there are signs of bleeding, anemia is possible (decrease in hemoglobin, red blood cells);
· general urinalysis (there may be no changes);
· biochemical blood test (possibly increased transaminases and C-reactive protein. Abdominal trauma is characterized by increased bilirubin and amylase);
· blood gases (changes are possible if the function of external respiration is impaired, a decrease in the oxygen level is less than 80 mm Hg, an increase in CO2 is more than 44 mm Hg);
· coagulogram (there may be no changes, but with the development of coagulopathy, changes characteristic of intravascular coagulation syndrome are possible);
Determination of blood group and Rhesus affiliation.

Instrumental studies:
· blood pressure measurement;
· general radiography of the skull, pelvis, limbs, chest and abdominal organs in two projections - determining the presence of bone pathology;
· ultrasound examination of the pleural and abdominal cavities - in the presence of hemorrhage or hemoperitoneum, fluid is determined in the pleural and abdominal cavity on the affected side;
· measurement of central venous pressure - a sharp decrease is observed with massive blood loss;
· diagnostic laparoscopy and thoracoscopy - allows you to clarify the nature, localization;
· bronchoscopy (in case of combined injury, scarlet blood flows from the bronchus when the lung is damaged. Damage to the trachea and bronchi can be visualized);
· ECG (tachycardia, signs of hypoxia, myocardial damage);
· CT, MRI (the most informative research methods allow you to most accurately determine the location and nature of the damage).

Diagnostic algorithm: see outpatient level.

List of main diagnostic measures:
· general radiography of the skull, pelvis, limbs, chest and abdominal organs in two projections;
· Ultrasound examination of the pleural and abdominal cavities;
· measurement of central venous pressure;
· laparoscopy
· thoracoscopy;
· bronchoscopy;
· CT;
· MRI.

List of additional diagnostic measures:
general blood test;
general urine analysis;
· biochemical blood test: (depending on the clinical situation);
· ECG.

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Treatment

Drugs (active ingredients) used in treatment

Treatment (outpatient clinic)

OUTPATIENT TREATMENT

Treatment tactics

Non-drug treatment:
· assess the severity of the patient’s condition (it is necessary to focus on the patient’s complaints, level of consciousness, color and moisture of the skin, pattern of breathing and pulse, blood pressure level);
· ensure patency of the upper respiratory tract (if necessary, mechanical ventilation);
· stop external bleeding. At the prehospital stage, it is carried out using temporary methods (tight tamponade, application of a pressure bandage, digital pressure directly in the wound or distal to it, application of a tourniquet, etc.). Continuing internal bleeding at the prehospital stage is almost impossible to stop, so the actions of the emergency doctor should be aimed at the speedy, careful delivery of the patient to the hospital;
· lay the patient down with the leg end raised by 10-45%, Trendelenburg position;
· application of bandages, transport immobilization (after administration of analgesics!), with tension pneumothorax - pleural puncture, with open pneumothorax - transfer to closed. (Attention! Foreign bodies are not removed from wounds, prolapsed internal organs are not reset!);
· delivery to the hospital with monitoring of heart rate, respiration, blood pressure. If tissue perfusion is insufficient, the use of a pulse oximeter is ineffective.

Drug treatment:
oxygen inhalation;
· maintain or provide venous access - venous catheterization;
· interrupt shockogenic impulses (adequate pain relief):
Diazepam [A] 0.5% 2-4 ml + Tramadol [A] 5% 1-2 ml;
Diazepam [A] 0.5% 2-4 ml + Trimeperidine [A] 1% 1ml;
Diazepam [A] 0.5% 2-4 ml + Fentanyl [B] 0.005% 2 ml.
For children:
from 1 year Tramadol [A] 5% 1-2 mg/kg;
trimeperidine [A] 1% is not prescribed until 1 year of age, then 0.1 ml/year of life, Fentanyl [B] 0.005% 0.05 mg/kg.

Normalization of blood volume, correction of metabolic disorders:
for undetectable blood pressure, the infusion rate should be 250-500 ml per minute. A 6% dextran solution [C] is administered intravenously.
If possible, preference is given to 10% or 6% solutions of hydroxyethyl starch [A]. No more than 1 liter of such solutions can be poured at a time. Signs of the adequacy of infusion therapy are that after 5-7 minutes the first signs of detectable blood pressure appear, which in the next 15 minutes increase to a critical level (SBP 90 mm Hg).
For mild to moderate shock, preference is given to crystalloid solutions, the volume of which should be higher than the volume of lost blood, since they quickly leave the vascular bed. Introduce 0.9% sodium chloride solution [B], 5% glucose solution [B], polyionic solutions - disol [B] or trisol [B] or acesol [B].
If infusion therapy is ineffective, 200 mg of dopamine [C] is administered for every 400 ml of crystalloid solution at a rate of 8-10 drops per minute (up to a SBP level of 80-90 mmHg). Attention! The use of vasopressors (dopamine) in traumatic shock without compensated blood loss is considered a gross therapeutic error, as this can lead to even greater disruption of microcirculation and increased metabolic disorders. In order to increase the venous return of blood to the heart and stabilize cell membranes, up to 250 mg of prednisolone is administered intravenously at a time. For children, infusion therapy is carried out with crystalloid solutions of 0.9% sodium chloride solution [B] in a dose of 10-20 ml/kg. Prednisolone [A] is administered according to the age-specific dose (2-3 mg/kg).

List of essential medicines:
· oxygen (medical gas);
Diazepam 0.5%; [A]
tramadol 5%; [A]
trimeperidine 1%; [A]
fentanyl 0.005%; [IN]
· dopamine 4%; [WITH]
Prednisolone 30 mg; [A]
· sodium chloride 0.9% [B].

List of additional medicines:
· Hydroxyethyl starch 6%. [A]

Algorithm of actions in emergency situations

Other types of treatment: No.

Indications for consultation with specialists:
· consultation with specialists in the presence of concomitant pathology.

Preventive measures:
· timely and effective stopping of bleeding in order to reduce the decrease in blood volume;
· timely and effective interruption of shockogenic impulses in order to reduce the risk of developing traumatic shock due to the pain component;
· effective immobilization to reduce the risk of secondary injuries during transportation and reduce pain.

stabilization of blood pressure;
stopping bleeding;
· improvement of the patient's condition.

Treatment (inpatient)

INPATIENT TREATMENT

Treatment strategy: see outpatient level.
Surgical intervention: no.
Other treatments: no.

Indications for specialist consultation: see outpatient level.

Indications for transfer to the intensive care unit:
· admission of the victim in a state of unresolved traumatic shock at the emergency room stage;
· secondarily developed traumatic shock while the victim was in a specialized department of the hospital, as well as after carrying out diagnostic and treatment procedures.

Indicators of treatment effectiveness: see outpatient level.

Hospitalization

Indications for planned hospitalization: none.

Indications for emergency hospitalization: emergency hospitalization is indicated in all cases for injuries accompanied by traumatic shock. In case of stabilization of the patient and relief of shock, hospitalization in a specialized department, in case of instability of hemodynamics and the condition of the victim - in the nearest hospital after an urgent call.

Information

Sources and literature

Minutes of meetings of the Joint Commission on the Quality of Medical Services of the Ministry of Health of the Republic of Kazakhstan, 2016
1. 1) National ambulance manual. Vertkin A.L. Moscow 2012; 2) Clinical Practice Guidelines. Trauma/ Pre-hospital trauma by-pass. Version February 2015. Queensland Government. 3) Algorithms of action for a doctor in the St. Petersburg emergency medical service. Afanasyev V.V., Biderman F.I., Bichun F.B., St. Petersburg 2009; 4) Recommendations for the provision of emergency medical care in the Russian Federation. Ed. Miroshnichenko A.G., Ruksina V.V. St. Petersburg, 2006; 5) Guide to emergency medical care. Bagnenko S.F., Vertkin A.L., Miroshnichenko A.G., Khabutia M.Sh. GEOTAR-Media, 2006

Information

Abbreviations used in the protocol:

HELL	-	blood pressure
Road accident	-	traffic accident
mechanical ventilation	-	artificial ventilation
CT	-	computed tomography
ICD	-	International Classification of Diseases
MRI	-	magnetic resonance imaging
OKS	-	acute coronary syndrome
BCC	-	circulating blood volume
GARDEN	-	systolic blood pressure
CPR	-	cardiopulmonary resuscitation
CVP	-	central venous pressure
Heart rate	-	heart rate

List of protocol developers:
1) Nurila Amangalievna Maltabarova - Candidate of Medical Sciences at Astana Medical University JSC, Professor of the Department of Emergency Care and Anesthesiology, Reanimatology, Member of the International Association of Scientists, Teachers and Specialists, Member of the Federation of Anesthesiologists-Resuscitators of the Republic of Kazakhstan.
2) Sarkulova Zhanslu Nukinovna - Doctor of Medical Sciences, Professor, RSE at the West Kazakhstan State Medical University named after Marat Ospanov, head of the department of emergency medical care, anesthesiology and resuscitation with neurosurgery, chairman of the branch of the Federation of Anesthesiologists-Resuscitators of the Republic of Kazakhstan in the Aktobe region
3) Alpysova Aigul Rakhmanberlinovna - Candidate of Medical Sciences, RSE at the Karaganda State Medical University, head of the department of ambulance and emergency medical care No. 1, associate professor, member of the Union of Independent Experts.
4) Alexey Ivanovich Kokoshko - Candidate of Medical Sciences, JSC "Astana Medical University", Associate Professor of the Department of Emergency Care and Anesthesiology, Reanimatology, member of the International Association of Scientists, Teachers and Specialists, member of the Federation of Anesthesiologists-Resuscitators of the Republic of Kazakhstan.
5) Akhilbekov Nurlan Salimovich - RSE at the Republican Air Ambulance Center, Deputy Director for Strategic Development.
6) Grab Alexander Vasilyevich - GKP at the RVC "City Children's Hospital No. 1" Health Department of the city of Astana, head of the department of resuscitation and intensive care, member of the Federation of Anesthesiologists and Resuscitators of the Republic of Kazakhstan.
7) Boris Valerievich Sartaev - RSE at the Republican Medical Aviation Center, doctor of the mobile air ambulance team.
8) Dyusembayeva Nazigul Kuandykovna - Candidate of Medical Sciences, Astana Medical University JSC, head of the department of general and clinical pharmacology.

Conflict of interest: absent.

List of reviewers: Sagimbayev Askar Alimzhanovich - Doctor of Medical Sciences, Professor of JSC National Center for Neurosurgery, Head of the Quality Management and Patient Safety Department of the Quality Control Department.

Conditions for reviewing the protocol: review of the protocol 3 years after its publication and from the date of its entry into force or if new methods with a level of evidence are available.

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Update: December 2018

The word “shock” has become entrenched in modern culture as a feeling of surprise, outrage, or other similar emotion. However, its true meaning is of a completely different nature. This medical term originated in the early 18th century thanks to the famous surgeon James Latta. Since that time, doctors have widely used it in specialized literature and case histories.

Shock is a serious condition in which a sharp drop in pressure occurs, a change in consciousness, and disturbances occur in various organs (kidneys, brain, liver and others). There are a large number of reasons that can lead to this pathology. One of them is a severe injury, for example, separation or crushing of an arm/leg; deep wound with bleeding; fracture of the femur. In this case, the shock is called traumatic.

Reasons for development

The occurrence of this condition is associated with two main factors - pain and blood loss. The more pronounced they are, the worse the health and prognosis for the victim will be. The patient does not realize the presence of a threat to life and cannot even provide first aid to himself. This is precisely why this pathology is especially dangerous.

Any severe injury can cause extreme pain, which is extremely difficult for a person to cope with on his own. How does the body react to this? He is trying to reduce the perception of unpleasant sensations and save his life. The brain almost completely suppresses the functioning of pain receptors and increases the heart rate, increases blood pressure and activates the respiratory system. This requires a huge amount of energy, the supply of which is quickly depleted.

Scheme

After the disappearance of energy resources, consciousness slows down, pressure drops, but the heart continues to work with all its might. Despite this, blood does not circulate well through the vessels, which is why most tissues lack oxygen and nutrients. The kidneys begin to suffer first, and then the functions of all other organs are disrupted.

The following factors can further worsen the prognosis:

Blood loss. Reducing the amount of blood circulating through the vessels will lead to a greater drop in pressure in a short period of time. Often, severe blood loss with the development of a state of shock is the cause of death;
Crash syndrome. The softening or crushing of tissues leads to their necrosis. Dead tissues are the strongest toxins for the body, which, when released into the blood, poison the victim and worsen his well-being;
Blood poisoning/sepsis. The presence of a contaminated wound (due to a gunshot wound, when wounded by a dirty object, after soil gets on the wound, etc.) is a risk of dangerous bacteria entering the blood. Their reproduction and active life can lead to abundant release of toxins and disruption of the functions of various tissues;
Body condition. The body's defense systems and ability to adapt vary from person to person. Any shock is a great danger for children, the elderly, people with severe chronic illness or with persistently weakened immunity.

The state of shock develops rapidly, it disrupts the functioning of the entire body and often ends in death. Only timely treatment can improve the prognosis and increase the victim’s chances of life. And in order to provide it, it is necessary to promptly recognize the first signs of traumatic shock and call an ambulance (ambulance) team.

Symptoms

All the diverse manifestations of pathology can be reduced to 5 main signs that reflect the work of the whole organism. If a person has a serious injury and these symptoms, the likelihood of a state of shock is extremely high. In this case, you should not hesitate to provide first aid.

Typical clinical manifestations include:

Change of consciousness

In most cases, consciousness goes through 2 stages during the development of this state. On the first ( erectile), the person is very excited, his behavior is inappropriate, his thoughts “jump” and do not have a logical connection. As a rule, it does not last long - from a few minutes to 1-2 hours. After this comes the second stage ( torpid), in which the victim’s behavior changes significantly. He becomes:

Apathetic. Everything that happens around a person practically does not bother him. The patient may not respond or respond poorly to verbal appeals, pats on the cheeks, changes in the environment and other stimuli;
Adynamic. The victim does not change his body position or tries extremely sluggishly to make any movement;
Emotionless. If the patient’s speech is preserved, he communicates in monosyllables, without intonation or facial expressions, and is absolutely indifferent.

These two stages have one thing in common – the inability to adequately assess the presence of serious damage to oneself and a threat to one’s life. Therefore, he needs the help of people around him to call a doctor.

Increase in the number of heart contractions (HR)

Until the last minute of life, the heart muscle tries to maintain sufficient blood pressure and blood supply to vital organs. That is why the heart rate can increase significantly - in some patients it can reach 150 or more beats/minute, with the norm being up to 90 beats/min.

Breathing problems

Since most tissues lack oxygen, the body tries to increase its supply from the environment. This leads to an increase in breathing rate and it becomes shallow. With a significant deterioration in health, it is compared to the “breath of a hunted animal.”

Reduced blood pressure (BP)

The main criterion of pathology. If, against the background of a severe injury, the numbers on the tonometer drop to 90/70 mmHg. and less - this can be considered the first sign of vascular dysfunction. The more pronounced the drop in blood pressure, the worse the prognosis for the patient. If the lower pressure figure drops to 40 mm Hg, the kidneys stop working and acute renal failure occurs. It is dangerous due to the accumulation of toxins (creatinine, urea, uric acid) and the development of severe uremic coma/urosepsis.

Metabolic disorder

The manifestations of this syndrome are quite difficult to detect in the victim, however, it is it that often leads to death. Since almost all tissues experience energy deficiency, their work is disrupted. Sometimes these changes become irreversible and lead to failure of various organs of the hematopoietic, digestive and immune systems, and kidneys.

Classification

How to determine how dangerous a person’s condition is and roughly navigate treatment tactics? For this purpose, doctors have developed degrees that differ in the level of blood pressure, heart rate, degree of depression of consciousness and breathing. These parameters can be quickly and fairly accurately assessed in any setting, which makes determining the degree a fairly simple process.

The modern classification according to Keith is presented below:

I (mild) Depressed, however, the patient makes contact. Answers briefly, unemotionally, with virtually no facial expressions. Shallow, frequent (20-30 breaths per minute), easily identified. Up to 9090-10070-80

Degrees	Degree of consciousness	Breathing changes	Heart rate (bpm)	Blood pressure (mm.Hg)
Degrees	Degree of consciousness	Breathing changes	Heart rate (bpm)	Syst. (top on the tonometer)	Diast. (lower on the tonometer)
I (light)	Oppressed, however, the patient makes contact. He answers briefly, without emotion, with virtually no facial expressions.	Shallow, frequent (20-30 breaths per minute), easily identified.	Up to 90	90-100	70-80
II (moderate)	The victim responds only to a strong stimulus (loud voice, pat on the face, etc.). Contact is difficult.	Very superficial, respiratory rate more than 30.	90-119	70-80	50-60
III (severe)	The patient is unconscious or in complete apathy. He does not respond to any stimuli. The pupils practically do not constrict in the light.	Breathing is almost imperceptible, very shallow.	More than 120	Less than 70	Less than 40

In old monographs, doctors additionally identified IV or extremely severe degree, but at present, this is considered inappropriate. IV degree is pre-agony and the beginning of dying, when any ongoing treatment becomes useless. It is possible to achieve a significant effect from therapy only in the first 3 stages of the pathology.

Additionally, doctors divide traumatic shock into 3 stages, depending on the presence of symptoms and the body's response to treatment. This classification also helps to preliminarily assess the threat to life and the likely prognosis.

Stage I (compensated). The patient maintains normal/high blood pressure, but there are typical signs of pathology;

II (decompensated). In addition to a pronounced decrease in pressure, dysfunction of various organs (kidneys, heart, lungs and others) may occur. The body responds to the treatment and with the correct algorithm of assistance, it is possible to save the life of the victim;

III (refractory). At this stage, any therapeutic measures are ineffective - the vessels cannot maintain the necessary blood pressure, and the work of the heart is not stimulated by pharmaceuticals. In the vast majority of cases, refractory shock ends in death.

It is quite difficult to predict in advance which stage a patient will develop - it depends on a large number of factors, including the condition of the body, the severity of injuries and the volume of treatment measures.

First aid

What determines whether a person will survive or die when this pathology develops? Scientists have proven that the timeliness of first aid for traumatic shock is of greatest importance. If it is provided promptly and the victim is taken to the hospital within an hour, the likelihood of death is significantly reduced.

We list the actions that can be performed to help the patient:

Call an ambulance. This point is of fundamental importance - the sooner the doctor begins full treatment, the higher the patient’s chances of recovery. If the injury occurred in a hard-to-reach area where there is no ambulance station, it is recommended to independently transport the person to the nearest hospital (or emergency room);
Check airway patency. Any algorithm for helping with shock must include this point. To do this, you need to tilt the victim’s head back, push the lower jaw forward and examine the oral cavity. If there is vomit or any foreign bodies, they need to be removed. When the tongue retracts, it is necessary to pull it forward and attach it to the lower lip. You can use a regular pin for this;
Stop the bleeding, if available. A deep wound, open fracture or crushed limb often causes severe blood loss. If this process is not stopped quickly, the person will lose a large amount of blood, which often causes death. In the vast majority of cases, such bleeding occurs from a large arterial vessel.
Applying a tourniquet above the injury site is the best thing you can do when providing first aid. If the wound is located on the leg, then it is applied to the upper third of the thigh, on top of clothing. If the arm is injured - on the upper part of the shoulder. To tighten the vessel, you can use any available materials: a belt, a strong belt, a strong rope, etc. The main criterion for a correct tourniquet is stopping the bleeding. A note should be placed under the tourniquet indicating the time it was applied.
Anesthetize. In a car first aid kit, a woman's handbag or at the nearest pharmacy you can often find various painkillers: Paracetamol, Analgin, Citramon, Ketorol, Meloxicam, Pentalgin and others. It is recommended to give the victim 1-2 tablets of any of the drugs with a similar effect. This will reduce the symptoms somewhat;
Immobilize the affected limb. A fracture, a tourniquet, a deep wound, a severe injury - this is not a complete list of conditions in which it is necessary to immobilize an arm or leg. To do this, you can use strong materials at hand (boards, steel pipes, a strong tree branch, etc.) and a bandage.

There are many nuances to applying splints, but the main thing is to effectively immobilize the limb in a physiological position for it and not injure it. The arm must be bent at the elbow joint by 90 degrees and “wound” to the body. The leg should be straight at the hip and knee joints.

If the injury is located on the torso, it is somewhat more difficult to provide quality assistance. It is also necessary to call an ambulance team and anesthetize the victim. But to stop bleeding, it is recommended to apply a tight pressure bandage. If possible, apply a thick cotton pad to the wound site to increase pressure on the vessels.

What not to do if you are in shock

Without a specific purpose, disturb the victim, change the position of his body, or independently try to bring him out of his stupor;
Use a large number of tablets (or any other dosage forms) with an analgesic effect (more than 3). An overdose of these drugs can worsen the patient’s well-being, cause gastric bleeding or severe intoxication;
If there is any object in the wound, you should not try to remove it yourself - doctors in the surgical hospital will deal with this;
Keep the tourniquet on the limb for more than 60 minutes. If there is a need to stop bleeding for more than 1 hour, it is necessary to weaken it for 5-7 minutes. This will partially restore tissue metabolism and prevent the occurrence of gangrene.

Treatment

All victims in a state of shock must be hospitalized in the intensive care unit of the nearest hospital. If possible, emergency teams try to place such patients in multidisciplinary surgical hospitals, where all the necessary diagnostics and required specialists are available. Treatment of such patients is one of the most difficult tasks, since disorders occur in almost all tissues.

The treatment process includes a huge number of procedures that are aimed at restoring the functions of the body. Simplified, they can be divided into the following groups:

Complete pain relief. Despite the fact that the doctor/paramedic administers some of the necessary drugs while still in the ambulance, in the hospital doctors supplement analgesic therapy. If surgery is necessary, the patient may be placed under full anesthesia. It should be noted that the fight against pain is one of the most important points in anti-shock therapy, since this sensation is the main cause of pathology;
Restoring airway patency. The need for this procedure is determined by the patient's condition. In case of breathing disorders, insufficient oxygen inhalation or damage to the trachea, the person is connected to an artificial respiration apparatus (abbreviated as ventilator). In some cases, this requires making an incision in the neck and installing a special tube (tracheostomy);
Stop bleeding. The faster the blood leaves the vessels - the lower the blood pressure drops - the more the body suffers. If this pathological chain is interrupted and normal blood flow is restored, the patient's chances of survival are significantly increased;
Maintaining adequate blood flow. In order for blood to move through the vessels and nourish the tissues, a certain level of blood pressure and a sufficient amount of blood itself is necessary. Doctors help restore hemodynamics by transfusion of plasma-substituting solutions and special medications that stimulate the cardiovascular system (Dobutamine, Norepinephrine, Adrenaline, etc.);
Restoring normal metabolism. While the organs are in “oxygen starvation,” metabolic disorders occur in them. To correct metabolic disorders, doctors can use glucose-saline solutions; vitamins B1, B6, PP and C; albumin solution and other medicinal measures.

If the above goals are successfully achieved, a person’s life ceases to be at risk. For further treatment, he is transferred to the ICU (intensive care ward) or to a regular inpatient department of the hospital. In this case, it is quite difficult to talk about the timing of treatment. It can range from 2-3 weeks to several months, depending on the severity of the condition.

Complications

Shock after an accident, disaster, attack or any other trauma is scary not only because of its symptoms, but also because of its complications. At the same time, a person becomes vulnerable to various microbes, the risk of blockage of blood vessels by blood clots in the body increases tenfold, and the function of the renal epithelium may be irreversibly impaired. Often, people die not from shock symptoms, but due to the development of severe bacterial infections or damage to internal organs.

Sepsis

This is a common and dangerous complication that occurs in every third patient admitted to the intensive care unit after injury. Even with the modern level of medicine, about 15% of patients with this diagnosis do not survive, despite the joint efforts of doctors of various specialties.

Sepsis occurs when a large number of microbes enter the human bloodstream. Normally, blood is completely sterile - it should not contain any bacteria. Therefore, their appearance leads to a strong inflammatory reaction throughout the body. The patient's temperature rises to 39 o C and higher, purulent foci appear in various organs, which can disrupt their functioning. Often this complication leads to changes in consciousness, breathing and normal tissue metabolism.

TELA

Damage to tissues and the vascular wall causes the formation of blood clots, which try to close the formed defect. Typically, this protective mechanism helps the body stop bleeding only from small wounds. In other cases, the process of thrombus formation poses a danger to the person himself. It is also necessary to remember that due to low blood pressure and prolonged lying down, systemic stagnation of blood occurs. This can lead to “clumping” of cells in the vessels and increase the risk of pulmonary embolism.

Pulmonary embolism (or PE for short) occurs when the normal state of the blood changes and blood clots enter the lungs. The outcome depends on the size of the pathological particles and the timeliness of the treatment. With simultaneous blockage of both pulmonary arteries, death is inevitable. If only the smallest branches of the vessel are obstructed, the only manifestation of PE may be a dry cough. In other cases, special blood thinning therapy or angiosurgical intervention is necessary to save life.

Hospital pneumonia

Despite thorough disinfection, in any hospital there is a small percentage of microbes that have developed resistance to various antiseptics. This could be Pseudomonas aeruginosa, resistant staphylococcus, influenza bacillus and others. The main targets for these bacteria are patients with weakened immune systems, including shock patients in intensive care units.

Hospital pneumonia ranks first among complications caused by hospital flora. Despite resistance to most antibiotics, this lung disease is mostly treatable with backup drugs. However, pneumonia that develops against the background of shock is always a serious complication that worsens the prognosis for a person.

Acute kidney failure/chronic kidney disease (AKI and CKD)

The kidneys are the first organ to suffer from low arterial pressure. For them to work, a diastolic (lower) blood pressure of more than 40 mmHg is required. If it crosses this line, acute kidney failure begins. This pathology is manifested by the cessation of urine production, the accumulation of toxins in the blood (creatinine, urea, uric acid) and the general serious condition of the person. If intoxication with the listed poisons is not eliminated in a short time and urine production is not restored, there is a high probability of developing urosepsis, uremic coma and death.

However, even with successful treatment of acute renal failure, kidney tissue can become damaged enough to cause chronic kidney disease to develop. This is a pathology in which the organ’s ability to filter blood and eliminate toxic substances deteriorates. It is almost impossible to cure completely, but proper therapy can slow or stop the progression of CKD.

Laryngeal stenosis

Very often, a shock patient needs to be connected to a breathing apparatus or undergo a tracheostomy. Thanks to these procedures, it is possible to save his life in case of impaired breathing, however, they also have long-term complications. The most common of these is laryngeal stenosis. This is a narrowing of one of the sections of the upper respiratory tract, which develops after the removal of foreign bodies. As a rule, it occurs after 3-4 weeks and is manifested by breathing problems, hoarseness and a strong “wheezing” cough.

Severe laryngeal stenosis is treated surgically. With timely diagnosis of the pathology and the normal state of the body, the prognosis for this complication is almost always favorable.

Shock is one of the most severe pathologies that can occur after serious injuries. Its symptoms and complications often lead to the death of the victim or the development of disability. To reduce the likelihood of an unfavorable outcome, it is necessary to provide first aid correctly and transport the person to the hospital as soon as possible. At the medical institution, doctors will carry out the necessary anti-shock measures and try to minimize the likelihood of adverse consequences.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Archive - Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2007 (Order No. 764)

Traumatic shock (T79.4)

General information

Brief description

Traumatic shock- an acutely developing and life-threatening condition that occurs as a result of exposure to severe mechanical trauma on the body.

Traumatic shock is the first stage of a severe form of the acute period of a traumatic disease with a peculiar neuro-reflex and vascular reaction of the body, leading to profound disorders of blood circulation, breathing, metabolism, and the functions of the endocrine glands.

The triggering mechanisms of traumatic shock are pain and excessive (afferent) impulses, acute massive blood loss, trauma to vital organs, mental shock.

Protocol code: E-024 "Traumatic Shock"
Profile: emergency medical care

Purpose of the stage: restoration of the function of all vital systems and organs

ICD-10 code(s):

T79.4 Traumatic shock

Excluded:

Shock (caused by):

Obstetric (O75.1)

Anaphylactic

NOS (T78.2)

Due to:

Pathological reaction to food (T78.0)

Adequately prescribed and correctly administered medicinal product (T88.6)

Serum reactions (T80.5)

Anesthesia (T88.2)

Caused by electric current (T75.4)

Non-traumatic NCD (R57.-)

Against lightning (T75.0)

Postoperative (T81.1)

Accompanying abortion, ectopic or molar pregnancy (O00-O07, O08.3)

T79.8 Other early complications of trauma

T79.9 Early complication of trauma, unspecified

Classification

According to the course of traumatic shock:

1. Primary - develops at the time of or immediately after injury.

2. Secondary - develops delayed, often several hours after injury.

Stages of traumatic shock:

1. Compensated - there are all signs of shock, with a sufficient level of blood pressure, the body is able to fight.

3. Refractory shock - all therapy is unsuccessful.

Severity of traumatic shock:

Shock 1st degree - SBP 100-90 mm Hg, pulse 90-100 per minute, satisfactory filling.

Shock 2 degrees - SBP 90-70 mm Hg, pulse 110-130 per minute, weak filling.

Shock 3rd degree - SBP 70-60 mm Hg, pulse 120-160 per minute, very weak filling (thread-like).

Shock 4 degrees - blood pressure is not determined, pulse is not determined.

Risk factors and groups

1. Rapid blood loss.

2. Overwork.

3. Cooling or overheating.

4. Fasting.

5. Repeated injuries (transportation).

6. Penetrating radiation and burns, that is, combined injuries with mutual aggravation.

Diagnostics

Diagnostic criteria: the presence of mechanical injury, clinical signs of blood loss, decreased blood pressure, tachycardia.

Characteristic symptoms of shock:

Cold, damp, pale cyanotic or marbled skin;

Sharply slowed blood flow of the nail bed;

Darkened consciousness;

Dyspnea;

Oliguria;

Tachycardia;

Decrease in blood and pulse pressure.

An objective clinical examination reveals

There are two phases in the development of traumatic shock.

Erectile stage occurs immediately after injury and is characterized by pronounced psychomotor agitation of the patient against the background of centralized blood circulation. The behavior of patients may be inappropriate; they rush around, scream, make erratic movements, are euphoric, disoriented, and resist examination and assistance. Getting in touch with them can sometimes be extremely difficult. Blood pressure may be normal or close to normal. There may be various breathing disorders, the nature of which is determined by the type of injury. This phase is short-lived and by the time assistance is provided it may change to a torpid one or stop.

For torpid phase characterized by blackouts, stupor and the development of a coma as an extreme degree of brain hypoxia caused by disturbances of the central circulation, decreased blood pressure, soft, rapid pulse, pale skin. At this prehospital stage, the emergency physician should rely on blood pressure levels and try to determine the amount of blood loss.

Determination of the volume of blood loss is based on the ratio of pulse rate to systolic blood pressure (S/SBP).

In case of shock 1 degree (blood loss 15-25% of the bcc - 1-1.2 l) SI = 1 (100/100).

In case of shock 2 degrees (blood loss 25-45% of the bcc - 1.5-2 l) SI = 1.5 (120/80).

In case of shock 3 degrees (blood loss more than 50% of the bcc - more than 2.5 l) SI = 2 (140/70).

When estimating the volume of blood loss, one can proceed from known data on the dependence of blood loss on the nature of the injury. So, with a fracture of the ankle in an adult, blood loss does not exceed 250 ml, with a fracture of the shoulder, blood loss ranges from 300 to 500 ml, of the lower leg - 300-350 ml, hips - 500-1000 ml, pelvis - 2500-3000 ml, with multiple fractures or In a combined injury, blood loss can reach 3000-4000 ml.

Taking into account the capabilities of the prehospital stage, it is possible to compare different degrees of shock and their inherent clinical signs.

Shock 1st degree(mild shock) is characterized by blood pressure 90-100/60 mmHg. and pulse 90-100 beats/min. (SI=1), which can be satisfactorily filled. Usually the victim is somewhat inhibited, but easily makes contact and reacts to pain; the skin and visible mucous membranes are often pale, but sometimes have a normal color. Breathing is rapid, but in the absence of concomitant vomiting and aspiration of vomit, there is no respiratory failure. It occurs against the background of a closed fracture of the femur, a combined fracture of the femur and tibia, and a mild fracture of the pelvis with other similar skeletal injuries.

Shock 2 degrees(moderate shock) is accompanied by a decrease in blood pressure to 80-75 mm Hg, and the heart rate increases to 100-120 beats/min. (SI=1.5). Severe skin pallor, cyanosis, adynamia, and lethargy are observed. Occurs with multiple fractures of long tubular bones, multiple fractures of ribs, severe fractures of the pelvic bones, etc.

Shock 3 degrees(severe shock) is characterized by a decrease in blood pressure to 60 mm Hg. (but may be lower), the heart rate increases to 130-140 beats/min. Heart sounds become very muffled. The patient is deeply inhibited, indifferent to his surroundings, the skin is pale, with pronounced cyanosis and an earthy tint. Develops with multiple concomitant or combined trauma, damage to the skeleton, large muscle masses and internal organs, chest, skull and burns.

With further deterioration of the patient's condition, a terminal condition may develop - grade 4 shock.

List of main diagnostic measures:

1. Collection of complaints, medical history, general therapeutic.

2. Visual examination, general therapeutic.

3. Measurement of blood pressure in peripheral arteries.

4. Pulse examination.

5. Heart rate measurement.

6. Respiration rate measurement.

7. General therapeutic palpation.

8. General therapeutic percussion.

9. General therapeutic auscultation.

10. Registration, interpretation and description of the electrocardiogram.

11. Studies of the sensory and motor spheres in pathologies of the central nervous system.

List of additional diagnostic measures:

1. Pulse oximetry.

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Treatment

Tactics of medical care

Treatment algorithm for traumatic shock

General activities:

1. Assess the severity of the patient’s condition (it is necessary to focus on the patient’s complaints, level of consciousness, color and moisture of the skin, breathing and pulse patterns, blood pressure level).

2. Provide measures aimed at stopping bleeding.

3. Interrupt shockogenic impulses (adequate pain relief).

4. Normalization of BCC.

5. Correction of metabolic disorders.

6. In other cases:

Lay the patient down with the leg end elevated by 10-45%, Trendelenburg position;

Ensure patency of the upper respiratory tract and oxygen access (if necessary, mechanical ventilation).

Specific events:

1. Stopping external bleeding at the prehospital stage is carried out using temporary methods (tight tamponade, application of a pressure bandage, digital pressure directly in the wound or distal to it, application of a tourniquet, etc.).

Continuing internal bleeding at the prehospital stage is almost impossible to stop, so the actions of the emergency physician should be aimed at the speedy, careful delivery of the patient to the hospital.

2. Pain relief:

Option 1 - intravenous administration of 0.5 ml of a 0.1% solution of atropine, 2 ml of a 1% solution of diphenhydramine (diphenhydramine), 2 ml of a 0.5% solution of diazepam (Relanium, Seduxen), then slowly 0.8-1 ml 5% ketamine solution (Calipsol).

In case of severe traumatic brain injury, do not administer ketamine!

2nd option - intravenous administration of 0.5 ml of 0.1% atropine solution, 2-3 ml of 0.5% diazepam solution (Relanium, Seduxen) and 2 ml of 0.005% fentanyl solution.

In case of shock accompanied by ARF, intravenously administer sodium hydroxybutyrate 80-100 mg/kg in combination with 2 ml of 0.005% fentanyl solution or 1 ml of 5% ketamine solution in 10-20 ml of isotonic solution of 0.9% sodium chloride or 5% glucose.

3. Transport immobilization.

4. Replenishment of blood loss.
For undetectable blood pressure, the infusion rate should be 250-500 ml per minute. A 6% solution of polyglucin is administered intravenously. If possible, preference is given to 10% or 6% solutions of hydroxyethyl starch (stabizol, refortan, HAES-steril). No more than 1 liter of such solutions can be poured at a time. Signs of the adequacy of infusion therapy are that after 5-7 minutes the first signs of detectable blood pressure appear, which in the next 15 minutes increase to a critical level (SBP 90 mm Hg).

For mild to moderate shock, preference is given to crystalloid solutions, the volume of which should be higher than the volume of lost blood, since they quickly leave the vascular bed. Introduce 0.9% sodium chloride solution, 5% glucose solution, polyionic solutions - disol, trisol, acesol.

In order to gain time if it is impossible to carry out infusion therapy, it is advisable to use intravenous administration of dopamine - 200 mg in 400 ml of 5% glucose solution at a rate of 8-10 drops/min.

3. *Dopamine 200 mg per 400 ml

4. *Pentastarch (refortan) 500 ml, fl.

5. *Pentastarch (stabizol) 500 ml, fl.

* - drugs included in the list of essential (vital) medicines.

Information

Sources and literature

Protocols for diagnosis and treatment of diseases of the Ministry of Health of the Republic of Kazakhstan (Order No. 764 of December 28, 2007)
1. 1. Clinical recommendations based on evidence-based medicine: Trans. from English / Ed. Yu.L. Shevchenko, I.N. Denisova, V.I. Kulakova, R.M. Khaitova. 2nd ed., rev. - M.: GEOTAR-MED, 2002. - 1248 p.: ill. 2. Guide for emergency physicians / Ed. V.A. Mikhailovich, A.G. Miroshnichenko - 3rd edition, revised and expanded - St. Petersburg: BINOM. Knowledge Laboratory, 2005.-704p. 3. Management tactics and emergency medical care in emergency conditions. Guide for doctors./ A.L. Vertkin - Astana, 2004.-392 p. 4. Birtanov E.A., Novikov S.V., Akshalova D.Z. Development of clinical guidelines and diagnostic and treatment protocols taking into account modern requirements. Methodological recommendations. Almaty, 2006, 44 p. 5. Order of the Minister of Health of the Republic of Kazakhstan dated December 22, 2004 No. 883 “On approval of the List of essential (vital) medicines.” 6. Order of the Minister of Health of the Republic of Kazakhstan dated November 30, 2005 No. 542 “On introducing amendments and additions to the order of the Ministry of Health of the Republic of Kazakhstan dated December 7, 2004 No. 854 “On approval of the Instructions for the formation of the List of essential (vital) medicines.”

Information

Head of the Department of Emergency and Emergency Medical Care, Internal Medicine No. 2, Kazakh National Medical University named after. S.D. Asfendiyarova - Doctor of Medical Sciences, Professor Turlanov K.M.

Employees of the Department of Ambulance and Emergency Medical Care, Internal Medicine No. 2 of the Kazakh National Medical University named after. S.D. Asfendiyarova: candidate of medical sciences, associate professor Vodnev V.P.; candidate of medical sciences, associate professor Dyusembayev B.K.; Candidate of Medical Sciences, Associate Professor Akhmetova G.D.; candidate of medical sciences, associate professor Bedelbaeva G.G.; Almukhambetov M.K.; Lozhkin A.A.; Madenov N.N.

Head of the Department of Emergency Medicine of the Almaty State Institute for Advanced Medical Studies - Candidate of Medical Sciences, Associate Professor Rakhimbaev R.S.

Employees of the Department of Emergency Medicine of the Almaty State Institute for Advanced Medical Studies: candidate of medical sciences, associate professor Silachev Yu.Ya.; Volkova N.V.; Khairulin R.Z.; Sedenko V.A.

Attached files

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In medicine, there are a number of pathologies that develop very quickly, sometimes instantly, threaten the life of the victim and require emergency assistance in the first minutes, since delay can lead to irreversible consequences. Traumatic (painful) shock is one of these conditions; from the name it is obvious that its development is preceded by a mechanical injury, and the injury is very severe or extensive.

Causes of traumatic shock

Various injuries can lead to this life-threatening condition: fracture of the pelvic bones, damage to other large bones and blood vessels, severe gunshot and knife wounds, head injuries, abdominal injuries with damage to internal organs, extensive burns, crush injuries, polytrauma in an accident, falls from a height and etc. People most often receive such severe injuries in some extreme situations.

Development mechanism

The mechanism of development of this pathology is quite complex; it can be compared to a chain reaction, where the previous process triggers and aggravates the next one. Two factors play a major role in the development of traumatic shock: rapid blood loss (if any) and severe pain. And sometimes it's hard to tell which one is leading.

When you receive a serious injury accompanied by severe pain, a signal is sent to the brain, which is a super-strong irritant for it. In response to this signal, a powerful release of the stress hormone, adrenaline, occurs. This first leads to spasm of small vessels, and then their atony develops. As a result, a very large volume of blood, which is “stuck” in small capillaries, is turned off from the circulation. The overall volume of blood flow drops, and the heart, brain, lungs, liver and other organs experience a lack of circulation.

Subsequent signals from the brain, “requiring” an additional release of hormones that constrict blood vessels in order to increase blood pressure, lead to the depletion of the body’s compensatory capabilities. Tissues under conditions of hypoxia (lack of oxygen due to impaired blood supply) accumulate various substances that lead to intoxication of the body.

If the mechanism of injury involves damage to blood vessels, especially large ones, then this doubly aggravates the situation, since disturbances in blood flow will develop much faster. The faster the blood loss occurs, the more severe the person’s condition and the less chance of a favorable outcome, since in such extreme conditions the body will not have time to adapt and turn on compensatory mechanisms.

Sometimes, with mild or moderate shock, its development may stop spontaneously. This means that the body was still able to compensate for the pathological processes described above. However, such a victim still requires serious emergency medical care.

Symptoms of traumatic shock

During this pathology, two stages are distinguished: erectile and torpid.

The erectile stage for many victims lasts a few minutes, and sometimes less. Severe pain and fear make them very agitated, the person may scream, moan, cry, may become aggressive and resist help. Victims experience unnatural paleness of the skin, cold sticky sweat, rapid breathing and heart palpitations. The more active and inappropriate a person’s behavior is during the erectile stage of traumatic shock, the more severe the torpid stage will be.
The torpid stage usually occurs very quickly. Patients stop screaming, move actively, and become lethargic or lose consciousness. This does not mean that they stop feeling pain, it’s just that the body no longer has the strength to signal it. That is why, even if the patient is unconscious, all manipulations must be performed extremely carefully.

Patients may experience chills, the skin becomes even more pale, and cyanosis (blueness) of the lips and mucous membranes is observed. The victim’s blood pressure decreases, the pulse is weak, sometimes barely palpable, and at the same time accelerated. Subsequently, disturbances in the functioning of internal organs develop: (decreased urine output or absence), pulmonary, hepatic, etc.

Severity of pain shock

Depending on the severity of symptoms, there are 4 degrees of severity of the torpid stage of shock. The classification is based on the patient’s hemodynamic state and is necessary to determine treatment tactics and prognosis.

I degree of shock (mild)

The patient's condition is satisfactory, consciousness is clear, not inhibited, he clearly understands speech addressed to him and adequately answers questions. Hemodynamic parameters are stable: blood pressure does not fall below 100 mm Hg. Art., the pulse is clearly palpable, rhythmic, frequency does not exceed 100 beats per minute. Breathing is even, slightly faster, up to 22 times per minute. Mild traumatic shock often accompanies fractures of large bones without damage to large blood vessels. The prognosis in such cases is usually favorable; the victim requires immobilization of the injured limb, pain relief (often with the use of narcotic analgesics) and infusion therapy, selected by a doctor.

II degree of shock (medium)

The patient experiences depression of consciousness, he may be inhibited, and does not immediately understand speech addressed to him. In order to get an answer, you need to ask the same question several times. There is pallor of the skin and acrocyanosis (blueness of the extremities). Hemodynamics are seriously impaired, blood pressure does not rise above 80-90 mmHg. Art., the pulse is weak, its frequency exceeds 110-120 beats. per minute. Breathing is rapid and shallow. The prognosis for the victim is very serious; in the absence of necessary assistance, the next stage of shock may develop.

III degree of shock (severe)

The victim is in stupor or unconscious, practically does not react to stimuli, the skin is pale and cold. Blood pressure drops below 75 mmHg. Art., the pulse is difficult to determine only in large arteries, the beat frequency is more than 130 beats per minute. The prognosis in this situation is unfavorable, especially when the therapy and the absence of bleeding fail to raise blood pressure.

IV degree of shock (terminal)

The patient is unconscious, the pressure is below 50 mm Hg. Art. or not detected at all, the pulse cannot be felt. Victims diagnosed with this stage of traumatic shock rarely survive.

First aid for traumatic shock

Traumatic shock is a condition that requires emergency medical care, provided with special equipment and a wide range of drugs. But first aid provided on the spot by a person who happens to be nearby is extremely important and can save the victim’s life. There are many cases where people who received non-fatal injuries died precisely from shock.

If you find a victim, you must immediately call an ambulance.
You cannot remove fragments, a knife or other objects from the wound; sometimes they “block” the vessels and their removal can lead to increased bleeding and additional trauma to the victim.
Also, you should not try to remove the remains of clothing from a person who has received a burn.

Stop bleeding

The first thing to do in such a situation is, if any. This can be done using a tourniquet, a pressure bandage, tamponade of an open wound; a belt, scarf, rope, etc. are suitable as improvised means.

A tourniquet is applied only in case of arterial bleeding, when the blood “spouts like a fountain” or flows out in a pulsating stream from the wound. It must be applied above the wound site, placing a towel, bandage, and clothing under it (you cannot apply tourniquets directly to the skin). The time of application of the tourniquet must be recorded; this is very important for those who will provide further assistance to the victim. The fact that the tourniquet is applied correctly is indicated by stopping bleeding and the disappearance of pulsation of the vessels below the application site.

The time the tourniquet is continuously on the limb should not exceed 40 minutes; after this time, it must be loosened for 15 minutes, then tightened again.

Venous or massive capillary bleeding is stopped with a pressure bandage or wound tamponade; the injured limb must be elevated. Unlike arterial bleeding, with venous bleeding, very dark blood flows out of the damaged vessel slowly.

Allowing breathing

It is necessary to unfasten or remove clothing that may restrict the chest and neck, and remove foreign objects from the oral cavity. If the victim is unconscious, you need to turn your head to the side and fix your tongue to prevent vomit from entering the respiratory tract and causing the tongue to retract.

If there is no breathing or pulse, artificial respiration and chest compressions must be started.

Warming the victim

Even in warm weather, with traumatic shock, a person may begin to feel chills, so he must be warmed with a blanket, clothing or any other available means. This is especially true in the cold season, since hypothermia aggravates the victim’s condition.

Anesthesia

It is unlikely that many of us will have an ampoule of analgin or other painkiller and a syringe in our bag in order to administer the drug at least intramuscularly. In case of traumatic shock, if the victim is conscious, he can be given an analgin tablet, and it should not be swallowed, but placed under the tongue until completely absorbed. This is only possible if the person is conscious.