6. Therapy of traumatic shock depending on the stage of hemodynamic disturbance Stage of centralization of blood circulation: 1) stopping external bleeding; 2) alcohol-vocaine (trimecaine) blockade of the fracture area or nerve trunks throughout; 3) immobilization

Pathogenesis of traumatic shock Etiopathogenetic factors of traumatic shock include excessive afferentation, blood loss, acute respiratory failure, and toxemia. It is not without reason that it is believed that traumatic shock is a collective name for various

General principles treatment of traumatic shock Intensive therapy of traumatic shock should be early, comprehensive and individual. However, at the first stages of treatment of the wounded in a state of traumatic shock, a complex of pathogenetically based

Complex therapy of shock Complex differentiated therapy of traumatic shock is carried out at the stage of providing qualified surgical care where in the state medical institutions there is a department of anesthesiology and resuscitation, which deploys two

Traumatic shock develops as a result of traumatic injury various organs and parts of the body, accompanied by pain, blood loss, which appear during severe mechanical damage, poisoning due to absorption of decay products from ischemic tissues. Factors predisposing to the development of shock and aggravating its course are hypothermia or overheating, intoxication, starvation, and overwork.

Severe injuries are the third leading cause of death in adults after cardiovascular diseases And malignant neoplasms. Causes of injury include motor vehicle accidents, fall injuries, and rail injuries. Medical statistics show that in Lately More often, polytraumas are recorded - injuries with damage to several areas. They are distinguished by severe violations of the vital functions of the body, and primarily by circulatory and respiratory disorders.

In the pathogenesis of traumatic shock, an important place belongs to blood and plasma loss, which accompanies almost all traumatic injuries. As a result of injury, vascular damage occurs and the permeability of vascular membranes increases, which leads to the accumulation of large volumes of blood and plasma in the area of ​​injury. And the severity of the victim’s condition largely depends not only on the volume of blood lost, but also on the rate of bleeding. Thus, blood pressure remains at the values ​​​​that were before the injury if bleeding occurs at a slow rate and the blood volume decreases by 20%. At high speed bleeding, a loss of circulating blood of 30% can lead to the death of the victim. A decrease in the volume of circulating blood - hypovolemia - leads to an increase in the production of adrenaline and norepinephrine, which have direct action on capillary circulation. As a result of their influence, the precapillary sphincters close and the postcapillary sphincters expand. Impaired microcirculation causes disruptions in the metabolic process, resulting in the release of large amounts of lactic acid and its accumulation in the blood. A significantly increased amount of under-oxidized products leads to the development of acidosis, which in turn contributes to the development of new circulatory disorders and a further decrease in circulating blood volume. A low volume of circulating blood cannot provide sufficient blood supply to vital organs, which include primarily the brain, liver, kidneys, and brain. Their functions are limited, resulting in the development of irreversible morphological changes.

During traumatic shock, two phases can be traced:

Erectile, which occurs immediately after injury. During this period, the consciousness of the victim or patient is preserved, motor and speech agitation, and lack of a critical attitude towards oneself and the environment are noted; the skin and mucous membranes are pale, sweating is increased, the pupils are dilated and react well to light; blood pressure remains normal or may increase, and the pulse quickens. The duration of the erectile shock phase is 10-20 minutes, during this time the patient’s condition worsens and enters the second phase;

The course of the torpid phase of traumatic shock is characterized by a decrease in blood pressure and the development of severe lethargy. The change in the condition of the victim or patient occurs gradually. To assess the patient’s condition during the torpid phase of shock, it is customary to focus on indicators of the level of systolic blood pressure.

I degree- 90-100 mHg. Art.; in this case, the condition of the victim or patient remains relatively satisfactory and is characterized by pallor of the skin and visible mucous membranes, muscle tremors; the victim’s consciousness is preserved or slightly inhibited; pulse up to 100 beats per minute, number of respirations up to 25 per minute.

II degree- 85-75 mm Hg. Art.; the victim’s condition is characterized by clearly expressed retardation of consciousness; pale skin, cold sticky sweat, decreased body temperature are noted; the pulse is increased - up to 110-120 beats per minute, breathing is shallow - up to 30 times per minute.

III degree- pressure below 70 mm Hg. Art., often develops with multiple severe traumatic injuries. The victim’s consciousness is greatly inhibited, he remains indifferent to his surroundings and his condition; does not respond to pain; the skin and mucous membranes are pale, with a grayish tint; cold sweat; pulse - up to 150 beats per minute, breathing is shallow, frequent or, conversely, rare; consciousness is darkened, pulse and blood pressure are not determined, breathing is rare, shallow, diaphragmatic.

Without the provision of timely and qualified medical care, the torpid phase ends in a terminal condition, which completes the process of development of severe traumatic shock and, as a rule, leads to the death of the victim.

Main clinical signs. Traumatic shock is characterized by inhibited consciousness; pale skin color with a bluish tint; impaired blood supply, in which the nail bed becomes cyanotic; when pressed with a finger, the blood flow is not restored for a long time; the veins of the neck and limbs are not filled and sometimes become invisible; breathing rate increases and becomes more than 20 times per minute; pulse rate increases to 100 beats per minute or higher; systolic pressure drops to 100 mmHg. Art. and below; there is a sharp cooling of the extremities. All these symptoms are evidence that a redistribution of blood flow occurs in the body, which leads to disruption of homeostasis and metabolic changes, becomes a threat to the life of the patient or injured. The likelihood of restoration of impaired functions depends on the duration and severity of shock.

Shock is a dynamic process, and without treatment or with delayed medical care, its milder forms become severe and even extremely severe with the development of irreversible changes. Therefore the main principle successful treatment traumatic shock in victims is to provide comprehensive assistance, including identifying violations of the vital functions of the victim’s body and carrying out measures aimed at eliminating life-threatening conditions.

Emergency assistance at prehospital stage includes the following steps.

Restoration of airway patency. When providing first aid to a victim, it should be remembered that the most common cause leading to deterioration of the victim’s condition is acute respiratory failure resulting from aspiration of vomit, foreign bodies, blood and cerebrospinal fluid. Traumatic brain injuries almost always involve aspiration. Acute respiratory failure develops when multiple fractures ribs as a result of hemopneumothorax and severe pain. In this case, the victim develops hypercapnia and hypoxia, which aggravate the phenomenon of shock, sometimes causing death due to suffocation. Therefore, the first task of the person providing assistance is to restore the airway.

Respiratory failure, which appears as a result of suffocation due to retraction of the tongue or severe aspiration, is caused by the general anxiety of the victim, severe cyanosis, sweating, retraction of the chest and neck muscles during inspiration, hoarse and arrhythmic breathing. In this case, the person providing assistance must ensure the patency of the upper respiratory tract for the victim. In this case, he should tilt the victim’s head back, move the lower jaw forward and aspirate the contents of the upper respiratory tract.

Intravenous infusions of plasma-substituting solutions, if possible, are carried out simultaneously with measures to restore normal ventilation of the lungs, and depending on the size of the injury and the amount of blood loss, a puncture of one or two veins is performed and an intravenous infusion of solutions is started. The goal of infusion therapy is to compensate for the deficit in circulating blood volume. The indication for starting the infusion of plasma replacement solutions is a decrease in systolic blood pressure below 90 mmHg. Art. In this case, to replenish the volume of circulating blood, the following volume-replacing solutions are usually used: synthetic colloids - polyglucin, polydes, gelatinol, rheopolyglucin; crystalloids - Ringer's solution, lactasol, isotonic sodium chloride solution; salt-free solutions - 5% glucose solution.

If it is impossible to use infusion therapy at the prehospital stage in case of blood loss, the victim is placed in a lying position with the head end down; in the absence of injuries to the upper and lower limbs they are given vertical position, which will help increase the central volume of circulating blood. In critical situations, in the absence of the possibility of infusion therapy, administration of vasoconstrictors to increase blood pressure.

Stopping external bleeding, which is carried out by applying a tight bandage, hemostatic clamp or tourniquet, packing the wound, etc. Stopping bleeding contributes to more effective infusion therapy. Prompt hospitalization is necessary if the victim has internal bleeding, signs of which are pale skin covered with cold sweat: rapid pulse and low blood pressure.

Anesthesia should be performed before removing the victim from under heavy objects, placing him on a stretcher, before applying transport immobilization, and carried out only after all measures have been taken to restore vital functions, which include sanitation of the respiratory tract, administration of solutions in case of large blood loss, and stopping bleeding.

Under the condition of fast (up to 1 hour) transportation, mask anesthesia using AP-1, Trintal devices and the use of methoxyflurane and local anesthesia with novocaine and trimecaine.

During long-term transportation (more than 1 hour), narcotic and non-narcotic analgesics, they are also used in cases accurate diagnosis(for example, limb amputation). Since absorption from tissues is impaired in the acute period of severe injury, drugs analgesic effect administered intravenously, slowly, under the control of breathing and hemodynamics.

Immobilization: transportation and removal (removal) of the victim from the scene and, if possible, rapid hospitalization.

Fixation of injured limbs prevents the appearance of pain that intensifies the phenomena of shock, and is indicated in all necessary cases regardless of the condition of the victim. Standards are being established transport tires.

Placing the victim on a stretcher for transportation plays no less important role upon his rescue. In this case, the victim is placed in such a way as to avoid aspiration of the respiratory tract with vomit, blood, etc. The conscious victim should be placed on his back. A patient who is unconscious should not place a pillow under his head, since in such a position it is possible to close the airways with the tongue with reduced pressure. muscle tone. If the patient or victim is conscious, he is placed on his back. Otherwise, you must remember that with reduced muscle tone, the tongue closes the airways, so you should not place a pillow or other objects under the victim’s head. In addition, in this position, a bent neck can cause kinking of the airways, and if vomiting occurs, vomit will easily enter the airways. If there is bleeding from the nose or mouth of a victim lying on his back, the flowing blood and stomach contents will freely enter the airways and close their lumen. This is a very important point in transporting a victim, since according to statistics, approximately a quarter of all victims of accidents die in the first minutes due to aspiration of the respiratory tract and incorrect position during transportation. And if in this case the victim survives in the first hours, then in most cases later he develops post-aspiration pneumonia, which is difficult to treat. Therefore, to avoid similar complications In such cases, it is recommended to lay the victim on his stomach and ensure that his head is turned to the side. This position will facilitate the outflow of blood from the nose and mouth, in addition, the tongue will not interfere free breathing the victim.

Positioning the victim on his side with his head turned to his side will also help avoid aspiration of the airway and tongue retraction. But to prevent the victim from turning onto his back or face down, the leg on which he lies should be bent in knee joint: in this position it will serve as support for the victim. When transporting a victim, it should be borne in mind that if the chest is injured, in order to facilitate breathing, it is better to lay the victim down, lifting him up. top part bodies; if the ribs are fractured, the victim should be laid on the damaged side, and then the body weight will act like a splint, preventing painful movements of the ribs when breathing.

When transporting a victim from the scene of an accident, the person providing assistance must remember that his task is to prevent the shock from deepening, to reduce the severity of hemodynamic and respiratory disorders, which pose the greatest danger to the life of the victim.

First aid for shock

Shock is the body's general reaction to an emergency (trauma, allergy). Clinical manifestations: spicy cardiovascular failure and necessarily - multiple organ failure.

The main link in the pathogenesis of traumatic shock is disorders caused by injury to tissue blood flow. Trauma leads to disruption of the integrity of blood vessels and blood loss, which is a trigger for shock. There is a deficit of circulating blood volume (CBV), bleeding (ischemia) of organs. At the same time, in order to support the right level blood circulation in vital important organs(brain, heart, lungs, kidneys, liver) at the expense of others (skin, intestines, etc.), compensatory mechanisms are activated, i.e. blood flow is redistributed. This is called centralization of blood circulation, due to which the functioning of vital organs is maintained for some time.

The next compensation mechanism is tachycardia, which increases the passage of blood through the organs.

But after some time, compensatory reactions take on a pathological character. At the level of microcirculation (arterioles, venules, capillaries), the tone of the capillaries and venules decreases; blood collects (pathologically deposits) in the venules, which is equivalent to repeated blood loss, since the area of ​​the venules is huge. Then the capillaries also lose their tone, they do not stretch, they fill with blood, it stagnates, which causes massive microthrombi to form - the basis for hemocoagulation disorders. There is a violation of the patency of the capillary wall, plasma leakage, and blood again flows in place of this plasma. This is an irreversible, terminal phase of shock, capillary tone is not restored, and cardiovascular failure progresses.

In other organs during shock, changes due to decreased blood supply (hypoperfusion) are secondary. Functional activity The central nervous system is preserved, but complex functions are impaired as the brain is ischemic.

Shock is accompanied by respiratory failure, as there is hypoperfusion of blood in the lungs. Tachypnea and hyperpnea begin as a result of hypoxia. The so-called non-respiratory functions of the lungs (filtering, detoxification, hematopoietic) suffer; blood circulation in the alveoli is disrupted and the so-called “shock lung” occurs - interstitial edema. In the kidneys, a decrease in diuresis is initially observed, then acute renal failure, “shock kidney”, since the kidney is very sensitive to hypoxia.

Thus, multiple organ failure quickly develops, and without taking urgent anti-shock measures, death occurs.

Shock clinic. In the initial period, excitement is often observed, the patient is euphoric, and does not realize the severity of his condition. This is the erectile phase and is usually short. Then comes the torpid phase: the victim becomes inhibited, lethargic, and apathetic. Consciousness is preserved until the terminal stage. The skin is pale and covered in cold sweat. For an ambulance paramedic, the most convenient way to roughly determine blood loss is by systolic blood pressure (SBP).

1. If SBP is 100 mm Hg, blood loss is no more than 500 ml.

2. If SBP is 90-100 mm Hg. Art. - up to 1 l.

3. If SBP is 70-80 mm Hg. Art. - up to 2 l.

4. If SBP is less than 70 mm Hg. Art. - more than 2 l.

Shock of the first degree - there may be no obvious hemodynamic disturbances, blood pressure is not reduced, the pulse is not increased.

Second degree shock - systolic pressure reduced to 90-100 mm Hg. Art., the pulse is rapid, the skin becomes pale, and the peripheral veins collapse.

III degree shock is a serious condition. SBP 60-70 mm Hg. Art., pulse increased to 120 per minute, weak filling. Severe pallor of the skin, cold sweat.

IV degree shock is an extremely serious condition. Consciousness is confused at first, then fades away. Against the background of pale skin, cyanosis and a spotted pattern occurs. SBP 60 mm Hg. Tachycardia 140-160 per minute, pulse is determined only at large vessels.

General principles of shock treatment:

1. Early treatment, as shock lasts 12-24 hours.

2. Etiopathogenetic treatment, i.e. treatment depending on the cause, severity, course of shock.

3. Complex treatment.

4. Differentiated treatment.

Urgent Care

1. Ensuring airway patency:

Slightly tilting the head back;

Removing mucus, pathological secretions or foreign bodies from the oropharynx;

Maintaining patency of the upper respiratory tract using an airway.

2. Breathing control. Carry out an excursion of the chest and abdomen. If there is no breathing - urgently artificial respiration"mouth to mouth", "mouth to nose" or using portable breathing apparatus.

3. Control of blood circulation. Check the pulse in the large arteries (carotid, femoral, brachial). If there is no pulse - urgently indirect massage hearts.

4. Providing venous access and starting infusion therapy.

For hypovolemic shock, isotonic sodium chloride solution or Ringer's solution is administered. If hemodynamics do not stabilize, then ongoing bleeding can be assumed (hemothorax, ruptures). parenchymal organs, fracture of the pelvic bones).

5. Stopping external bleeding.

6. Pain relief (promedol).

7. Immobilization for injuries of the limbs and spine.

8. Stopping the intake of allergen during anaphylactic shock.

In case of traumatic shock, first of all, it is necessary to stop the bleeding (if possible) by applying tourniquets, tight bandages, tamponade, applying clamps to the bleeding vessel, etc.

In shock I-II degrees shown intravenous infusion 400-800 ml of polyglucin, which is especially appropriate for preventing the deepening of shock when transporting over long distances is necessary.

In shock I-III degrees after transfusion of 400 ml of polyglucin, 500 ml of Ringer's solution or 5% glucose solution should be transfused, and then resume the infusion of polyglucin. Add 60 to 120 ml of prednisolone or 125-250 ml of hydrocortisone to the solutions. In case of severe injury, infusion into two veins is advisable.

Along with infusions, pain relief should be carried out in the form of local anesthesia with a 0.25-0.5% solution of novocaine in the area of ​​fractures; if there is no damage to internal organs, or skull injuries, solutions of promedol 2% - 1.0-2.0, omnopon 2% - 1-2 ml or morphine 1% - 1-2 ml are administered intravenously.

In case of shock of III-IV degree, anesthesia should be performed only after transfusion of 400-800 ml of polyglucin or rheopolyglucin. Hormones are also administered: prednisolone (90-180 ml), dexamethasone (6-8 ml), hydrocortisone (250 ml).

You should not try to quickly raise blood pressure. The administration of pressor amines (mesaton, norepinephrine, etc.) is contraindicated.

For all types of shock, oxygen is inhaled. If the patient’s condition is extremely serious and there is a long distance to be transported, especially in rural areas, there is no need to rush. It is advisable to at least partially compensate for blood loss (BCB), carry out reliable immobilization, and stabilize hemodynamics if possible.

By systolic blood pressure level and severity clinical symptoms traumatic shock is divided into three degrees of severity, followed by a new qualitative category - next form serious condition of the wounded - terminal condition.

Traumatic shock I degree most often occurs as a result of isolated wounds or trauma. It is manifested by pallor of the skin and minor hemodynamic disturbances. Systolic blood pressure is maintained at 90-100 mmHg and is not accompanied by high tachycardia (pulse up to 100 beats/min).

Traumatic shock II degree characterized by lethargy of the wounded person, severe pallor of the skin, and significant hemodynamic impairment. Blood pressure drops to 85–75 mmHg, pulse increases to 110–120 beats/min. If compensatory mechanisms fail, as well as with unrecognized severe injuries in the later stages of assistance, the severity of traumatic shock increases.

Traumatic shock III degree usually occurs with severe combined or multiple wounds (traumas), often accompanied by significant blood loss ( average value blood loss in case of shock of the third degree reaches 3000 ml, while in case of shock of the first degree it does not exceed 1000 ml). The skin becomes pale gray in color with a cyanotic tint. The path is greatly accelerated (up to 140 beats/min), and can even be thread-like. Blood pressure drops below 70 mmHg. Breathing is shallow and rapid. Restoring vital functions in grade III shock presents significant difficulties and requires the use of a complex set of anti-shock measures, often combined with emergency surgical interventions.

Prolonged hypotension with a decrease in blood pressure to 70–60 mm Hg is accompanied by a decrease in diuresis, profound metabolic disorders and can lead to irreversible changes in vital organs and systems of the body. In this regard, the indicated level of blood pressure is usually called “critical”.

Untimely elimination of the causes that support and deepen traumatic shock prevents the restoration of vital functions of the body and third degree shock can develop into terminal state , which is an extreme degree of suppression of vital functions, turning into clinical death. Terminal state develops in three stages.

1 Pre-agonal state characterized lack of pulse on radial arteries if it is present on the carotid and femoral arteries and blood pressure not determined by the usual method.

2 Agonal state has the same features as preagonal, but combined with respiratory disorders (arrhythmic breathing of the Cheyne-Stokes type, severe cyanosis, etc.) and loss of consciousness.

3. Clinical death begins from the moment of the last breath and cardiac arrest. Clinical signs The wounded man has no life at all. However metabolic processes in brain tissue lasts on average another 5–7 minutes. Selection clinical death as separate form the serious condition of the wounded is advisable, since in cases where the wounded does not have injuries incompatible with life, this condition can be reversible with the rapid application of resuscitation measures.

It should be emphasized that resuscitation measures undertaken in the first 3–5 minutes, it is possible to achieve complete restoration of the vital functions of the body, while resuscitation. carried out at a later date, can lead to the restoration of only somatic functions (blood circulation, breathing, etc.) in the absence of restoration of the functions of the central nervous system. These changes can be irreversible, resulting in permanent disability (defects of intelligence, speech, spastic contractures, etc.) - “a disease of a revitalized organism.” The term “resuscitation” should not be understood narrowly as the “revival” of the body, but as a set of measures aimed at restoring and maintaining the vital functions of the body.

The irreversible condition is characterized by a complex of signs: complete loss of consciousness and all types of reflexes, absence of spontaneous breathing, heart contractions, absence of brain biocurrents on the electroencephalogram (“bioelectric silence”). Biological death is stated only when these signs cannot be resuscitated for 30-50 minutes.

Gumanenko E.K.

Military field surgery