Infusion antishock therapy. Anti-shock set number one

§ Normalization of external respiration and gas exchange.

Everyone is shown inhalation of humidified oxygen (through nasal catheters, face mask) at a rate of 4-8 l/min.

§ Anesthesia.

It is better to carry out anesthesia agonists-antagonists morphine group. They have sufficient analgesic effect and do not depress breathing: nalbuphine 2 ml (10 mg in 1 ml), herd 0.2% - 1 ml, tramadol 1 ml (50 mg). To enhance the analgesic effect and block synthesis cyclooxygenase introduction shown ketonal as a continuous intravenous infusion (100-200 mg in 500 ml infusion solution) for 8 hours (with a possible repeat of the infusion after 8 hours).

A combination of drugs is possible (in different combinations): 1 ml of 2% solutionpromedol or 1 ml omnopona , 2 ml 1% solutiondiphenhydramine or 1-2 ml of 2.5% solutionpipolphena , 2 ml 50% solution metamizole sodium (analgin), 2 ml 0.5% solutiondiazepam (seduxen etc.), 10.0 ml of 20% solutionhydroxybutyrate sodium.

For neuroleptanalgesia, use 1-2 ml of 0.005% solutionfentanyl with 1-2 ml of 0.25% solutiondroperidol .

§ Infusion therapy.

The algorithm for using venous access is: peripheral catheter in the area of ​​intact skin, peripheral catheter through the burned surface, central venous access through intact skin, and lastly, catheterization of the central vein through the burn wound.

For the first timehours after injury, infusion therapy is aimed at replenishing the volume of circulating blood and rehydrating the interstitial space. It is recommended to start the infusion by administering glucose-electrolyte solutions. This choice is due to the ineffectiveness of colloidal preparations in the early period of burn shock. At the first stage use:

· solution Ringer-Locke (lactosol, acesol, disol) 5-7.5 ml/kg;

· solution glucose 5% 5-7.5 ml/kg.

Subsequently, the infusion program includes:

· polyglucin 5-7.5 ml/kg intravenously (ratio of crystalloids and colloids in shock I - II degree is 2 and 1 ml per 1% burn and 1 kg of body weight, in shock III - IV degrees - 1.5 and 1.5 ml, respectively);

· rheopolyglucin 5-7.5 ml/kg;

· drugs hydroxyethyl starches (refortan , stabizol) 10-20 ml/kg as an intravenous infusion.

The volume of infusion therapy on the first day can be calculated using the modified Parkland formula:

V = 2 ml × burn area (%) × body weight (kg).

About 50% of the calculated value must be administered in the first 8 hours after injury. After 8 hours, with stable hemodynamics, it is recommended to reduce the infusion rate and begin administering drugs for correction hypoproteinemia(fresh frozen plasma, serum albumin). Recommended share protein-containing solutions in the daily balance of administered fluids ranges from 20 to 25%.

§ Inotropic support.

Sometimes, with extremely severe burn shock (or with infusion therapy started late), it is impossible to maintain blood pressure at the perfusion level (above 80-90 mm Hg. In such cases, it is advisable to include inotropic drugs in the treatment regimen:

· Dopamineat a dose of 2-5 mcg/kg/min (“renal” dose) or 5-10 mcg/kg/min;

· Dobutamine (400 mg in 250 ml saline) at a rate of 2-20 mcg/kg/min.

§ Correction of blood hemorheology.

From the first hours, the administration of low molecular weight heparins is indicated ( fraxiparine , clexane, fragmina) or unfragmented heparin to correct the aggregative state of the blood:

· Fraxiparine IV 0.3 ml 1 or 2 times a day;

· Heparinwith an initial bolus of 5-10 thousand units and subsequent intravenous infusion at the rate of 1-2 thousand units/hour (or 5-6 thousand units every 4-6 hours) under the control of aPTT and platelet count.

To reduce the aggregation of blood cells, we use:

· Trental 200-400 mg IV drip in 400 ml of saline 1-2 times a day;

· Xanthinol nicot inat 2 ml of 15% solution intravenously 1-3 times a day;

· Actovegin 20-50 ml IV drip in 200-300 ml physiological solution.

§ Organoprotection.

To reduce the permeability of the vascular wall it is recommended:

· Glucocorticoids (prednisolone 3 mg/kg or dexamethasone 0.5 mg/kg per day);

· Ascorbic acid 5% solution 250 mg 3-4 times a day;

· Polarizing mixture at a dose of 5-7.5 ml/kg.

For the prevention of acute renal failure, 4% is administered sodium bicarbonate solution(3 ml sodium bicarbonate × body weight (kg)/s duck). All patients undergo bladder catheterization to control diuresis. About good microcirculation in the kidneys says urine output in the amount of 0.5-1.0 ml/kg/h. Methuselah and ringer malate– preparations based on succinic and malic acids – can reduce posthypoxic metabolic acidosis, increase ATP synthesis, stabilize the structure and function of mitochondria, induce the synthesis of a number of proteins, prevent inhibition of glycolysis and increased gluconeogenesis. Perftroran in case of burn shock, it is used as a blood substitute with a gas transport function, which has hemodynamic, rheological, membrane stabilizing, cardioprotective, diuretic and sorption properties.

Dose and frequency of perftron administration depending on the severity of burn shock (according to E.N. Kligulenko et al., 2004)

Lesion severity index	Time of administration
	1 day	2 days	3 days
Up to 30 units	1.0-1.4 ml/kg
31-60 units	1.5-2.5 ml/kg	1.0-1.5 ml/kg	1.5-2.0 ml/kg
61-90 units	2.5-5.0 ml/kg	2.5-4.0 ml/kg	1.5-2.0 ml/kg
Over 91 units	4.0-7.0 ml/kg	2.5-5.0 ml/kg	2.5-4.0 ml/kg

§ Relief of nausea, vomiting 0.5 ml 0.1% solutionatropine .

§ Protection of the burn surface.

An aseptic bandage is applied to the affected areas.

§ Criteria for the adequacy of therapy.

The criteria for exiting the state of shock are considered to be stabilization of hemodynamics, restoration of circulating blood volume, diuresis (at least 0.5-1.0 ml/kg/h), duration of the pale spot symptom(pressure on the nail bed - the nail bed remains pale)less than 1 second, increase in body temperature, decrease in the severity of dyspeptic disorders.

Anaphylactic shock (ICD code T78.2) is a rapid generalized allergic reaction that directly threatens a person’s life and can develop within a matter of seconds.

Important! Despite the fact that the overall mortality rate during the development of anaphylactic shock does not exceed 1%, in its severe form it tends to reach a figure of 90% in the absence of emergency assistance in the first minutes.

Anaphylactic shock is a very dangerous allergic reaction that threatens human life

Therefore, this topic should be comprehensively covered. As a rule, anaphylactic reactions develop after the second or subsequent interactions with a certain substance. That is, after a single contact with the allergen it usually does not appear.

General symptoms

The development of anaphylactic shock can last for 4-5 hours, but in some cases a critical condition occurs seconds after contact with the allergen. In the formation of a shock reaction, neither the amount of the substance nor how it entered the body plays any role. Even due to contact with microdoses of an allergen, the development of anaphylaxis is possible. However, if the allergen is present in large quantities, this, of course, contributes to the worsening of the situation.

The first and most important symptom that gives reason to suspect anaphylaxis is sharp, intense pain in the area of ​​the bite or injection. In the case of oral administration of the allergen, the pain is localized in the abdomen and hypochondrium.

Additional signs of the development of clinical anaphylactic shock are:

• large tissue swelling in the area of ​​contact with the allergen;

Consequences of anaphylactic shock - swelling

• skin itching gradually spreading throughout the body;
• a sharp drop in blood pressure;
• pale skin, bluish lips and limbs;
• increased heart rate and breathing;
• delusional disorders, fear of death;
• when taking the substance orally - loose stools, nausea, swelling of the oral mucosa, vomiting, diarrhea, swelling of the tongue;
• visual and hearing impairment;
• spasm of the larynx and bronchi, as a result of which the victim begins to choke;
• fainting, disturbances of consciousness, convulsions.

Reasons

Anaphylactic shock develops under the influence of many different factors, the main ones are listed below:

• Food products

1. Flavoring additives: preservatives, a number of dyes, flavor and aroma enhancers (bisulfites, agar-agar, tartrazine, monosodium glutamate);
2. Chocolate, nuts, coffee, wine (including champagne);
3. Fruits: citrus fruits, apples, strawberries, bananas, dried fruits, berries;
4. Seafood: shrimp, crabs, oysters, crayfish, lobsters, mackerel, tuna;
5. Proteins: dairy products, beef, eggs;
6. Cereals: legumes, wheat, rye, less often - rice, corn;
7. Vegetables: celery, red tomatoes, potatoes, carrots.

Anaphylactic shock can even occur from eating vegetables such as red tomatoes or carrots

• Medicines

1. Antibacterial: penicillin and cephalosporin series, as well as sulfonamides and fluoroquinolones;
2. Non-steroidal anti-inflammatory and analgesic drugs: paracetamol, analgin, amidopyrine;
3. Hormonal drugs: progesterone, insulin, oxytocin;
4. Contrast agents: barium, iodine-containing preparations;
5. Vaccines: anti-tuberculosis, anti-hepatitis, anti-influenza;
6. Serums: antitetanus, antirabies and antidiphtheria;
7. Muscle relaxants: norcuron, succinylcholine, tracrium;
8. Enzymes: chymotrypsin, streptokinase, pepsin;
9. Blood substitutes: albumin, rheopolyglucin, polyglucin, stabizol, refortan;
10. Latex: disposable gloves, instruments, catheters.

Advice! Anaphylactic shock in children, which has not even occurred yet, but can develop in theory, sometimes becomes a real “horror story” for parents. Because of this, they try to protect the child from “possible allergens” in every conceivable (and often inconceivable) way. However, this should not be done, since the baby’s immune system - in order to develop normally - must encounter a variety of substances and materials that surround us in life.

You still won’t be able to hide from all the dangers, but you can very easily harm your baby by being too careful. Remember that moderation is good in everything!

You should not protect your child from all possible allergens in advance, because this can only harm the baby

• Plants

1. Forbs: dandelion, ragweed, wheatgrass, wormwood, nettle, quinoa;
2. Deciduous trees: poplar, linden, birch, maple, hazel, ash;
3. Flowers: lily, rose, gladiolus, orchid, daisy, carnation;
4. Conifers: fir, pine, larch, spruce;
5. Agricultural plants: sunflower, mustard, hops, sage, castor bean, clover.

• Animals

1. Helminths: pinworms, roundworms, whipworms, trichinella;
2. Biting insects: wasps, hornets, bees, ants, mosquitoes, lice, fleas, bedbugs, ticks; as well as cockroaches and flies;
3. Pets: cats, dogs, rabbits, hamsters, guinea pigs (pieces of skin or fur); as well as feathers and down of parrots, ducks, chickens, pigeons, geese.

Pathogenesis

Pathology goes through three successive stages of formation:

• Immunological - after contact of the allergen with immune cells, Ig E and Ig G are released - specific antibodies. They cause a massive release of inflammatory factors (histamine, prostaglandins and others). Antibodies cause a massive release of inflammatory factors (histamine, prostaglandins and others);
• Pathochemical – inflammatory factors spread throughout tissues and organs, where they provoke disruption of their functioning;
• Pathophysiological - disruption of the normal functioning of organs and tissues can be significantly expressed, up to the formation of an acute form of heart failure, and even in some cases - cardiac arrest.

Anaphylactic shock in children and adults occurs with the same symptoms and is classified:

• According to the severity of clinical manifestations:

1. Blood pressure – reduced to 90/60;
2. Loss of consciousness – short-term fainting is possible;
3. The effect of therapy is easy to treat;
4. The period of precursors is about min. (redness, skin itching, rash (urticaria), burning sensation throughout the body, hoarseness and loss of voice with swelling of the larynx, Quincke's edema of different localization).

The victim manages to describe his condition, complaining of: dizziness, severe weakness, chest pain, headache, decreased vision, lack of air, tinnitus, fear of death, numbness of lips, fingers, tongue; as well as pain in the lower back and abdomen. Pallor or bluishness of the facial skin is evident. Some experience bronchospasm - exhalation is difficult, wheezing can be heard from a distance. In some cases, vomiting, diarrhea and involuntary urination or defecation occur. The pulse is thread-like, the heart rate is increased, the heart sounds are muffled.

During a mild form of anaphylactic shock, a person may lose consciousness

1. Blood pressure - reduced to 60/40;
2. Loss of consciousness - near minus;
3. The effect of therapy is delayed, observation is required;
4. The period of precursors is about 2-5 minutes. (dizziness, pale skin, urticaria, general weakness, anxiety, heart pain, fear, vomiting, Quincke's edema, suffocation, sticky cold sweat, cyanosis of the lips, dilated pupils, often involuntary bowel movements and urination).
5. In some cases, convulsions develop - tonic and clonic, and then the victim loses consciousness. Thread-like pulse, tachycardia or bradycardia, dull heart sounds. In rare cases, bleeding develops: nasal, gastrointestinal, uterine.

Severe course (malignant, fulminant)

1. Blood pressure: not determined at all;
2. Loss of consciousness: over 30 minutes;
3. Treatment results: none;
4. Precursor period; in a matter of seconds. The victim does not have time to complain about the sensations that arise, losing consciousness very quickly. Emergency care for anaphylactic shock of this type must be urgent, otherwise death is inevitable. The victim is markedly pale, a foamy substance is released from the mouth, large drops of sweat are visible on the forehead, diffuse cyanosis of the skin is observed, the pupils are dilated, convulsions are characteristic - tonic and clonic, breathing with an extended exhalation is whistling. The pulse is thread-like, it is practically not palpable, heart sounds are not audible.

Recurrent or prolonged course, characterized by repeated episodes of anaphylaxis, occurs when the allergen continues to enter the body without the patient's knowledge

• According to clinical forms:

1. Asphyxial - the victim is dominated by the phenomenon of bronchospasm and symptoms of respiratory failure (difficulty breathing, shortness of breath, hoarseness), Quincke's edema often develops (the larynx can swell until physiological breathing is absolutely impossible);
2. Abdominal - pain in the abdominal area predominates, similar to that of acute appendicitis, as well as a perforated gastric ulcer. These sensations arise due to spasm of the smooth muscles of the intestinal wall. Vomiting and diarrhea are common;
3. Cerebral - swelling of the brain and its membranes develops, which manifests itself in the form of convulsions, nausea and vomiting, which does not provide relief, as well as states of stupor or coma;
4. Hemodynamic – the first to appear is pain in the area of ​​the heart, similar to that of a heart attack, as well as an extremely sharp drop in blood pressure.
5. Generalized (or typical) – observed in most cases and manifests itself in a complex of symptoms of the disease.

Diagnostics

All actions in case of anaphylactic shock, including diagnosis, must be as quickly as possible so that assistance can be provided in a timely manner. After all, the prognosis for a patient’s life will directly depend on how quickly he receives first and subsequent medical care.

Pay attention! Anaphylactic shock is a symptom complex that can often be confused with other diseases, so a detailed history will be the most important factor for making a diagnosis!

Laboratory studies determine:

• In a clinical blood test:

1. anemia (decreased number of red blood cells),
2. leukocytosis (increased number of white blood cells),
3. eosinophilia (increased number of eosinophils).

At the first signs, you should immediately consult a doctor!

• In a biochemical blood test:

1. increased liver enzymes (AST, ALT), bilirubin, alkaline phosphatase;
2. increased renal parameters (creatinine and urea);

• A plain chest x-ray shows interstitial pulmonary edema.
• Enzyme immunoassay reveals specific Ig E and Ig G.

Advice! If a patient who has suffered anaphylactic shock finds it difficult to answer, after which he feels “bad,” he will need to visit an allergist to prescribe allergy tests.

Treatment

First aid for anaphylactic shock (pre-medical aid) should be provided as follows:

• Prevent the allergen from entering the victim’s body - apply a pressure bandage over the bite, remove the insect sting, apply an ice pack to the injection or bite site, etc.;
• Call an ambulance (ideally, perform these actions in parallel);
• Lay the victim on a flat surface, raising his legs (for example, using a rolled-up blanket);

Important! There is no need to place the victim's head on a pillow, as this reduces the blood supply to the brain. Removal of dentures is recommended.

• Turn the victim's head to the side to avoid aspiration of vomit.
• Provide fresh air in the room (open windows and doors);
• Feel the pulse, check for spontaneous breathing (put a mirror to your mouth). The pulse is checked first in the wrist area, then (if it is absent) - in the arteries (carotid, femoral).
• If a pulse (or breathing) is not detected, proceed to the so-called indirect cardiac massage - for this you need to clasp your straight arms and place them between the lower and middle thirds of the victim’s sternum. Alternate 15 sharp pressures and 2 intense breaths into the victim’s nose or mouth (the “2 to 15” principle). If the activities are carried out by only one person, act according to the “1 to 4” principle.

In case of anaphylactic shock, the victim’s head should not be placed on a pillow - this will reduce blood supply to the brain

Repeat these manipulations continuously until pulse and breathing appear or until the ambulance arrives.

Important! If the victim is a child under one year old, then pressing is carried out with two fingers (second and third), and the frequency of pressing should range from 80 to 100 units/min. Older children should perform this manipulation with the palm of one hand.

The actions of the nurse and doctor when relieving anaphylactic shock include:

• Monitoring vital functions - blood pressure, pulse, ECG, oxygen saturation;
• Control of airway patency - clearing the mouth of vomit, triple maneuver to remove the lower jaw (Safara), tracheal intubation;

Pay attention! In case of severe swelling and spasm of the glottis, a conicotomy may be indicated (performed by a doctor or paramedic - the larynx is cut between the cricoid and thyroid cartilages) or tracheotomy (strictly in a healthcare facility);

• Administration of 0.1% Adrenaline hydrochloride solution in an amount of 1 ml (diluted with sodium chloride to 10 ml and, if the location of the allergen is known - a bite or injection) - it is injected subcutaneously);
• Administration (iv or sublingual) 3-5 ml of Adrenaline solution;
• Administration of the remaining solution of Adrenaline, dissolved in 200 ml of sodium chloride (drip, intravenously, under blood pressure control);

Important! The nurse should remember that when the pressure is already within normal limits, the intravenous administration of epinephrine is suspended.

• The algorithm of actions for anaphylactic shock includes, among other things, the administration of glucocorticosteroids (Dexamethasone, Prednisolone);

A patient with anaphylactic shock is under constant supervision of medical staff

• Administration for severe respiratory failure: 5-10 ml of 2.4% Eufillin solution;
• Administration of antihistamines - Suprastin, Diphenhydramine, Tavegil;

Pay attention! Antihistamines for anaphylactic shock are administered by injection, and then the patient switches to tablet forms.

• Inhalation of 40% humidified oxygen (4-7 l/min.);
• To avoid further redistribution of blood and the formation of acute vascular insufficiency - intravenous administration of colloidal (Gelofusin, Neoplasmazhel) and crystalloid (Plasmalit, Ringer, Ringer-lactate, Sterofundin) solutions;
• Administration of diuretics (indicated for the relief of pulmonary and cerebral edema - Furosemide, Torasemide, Mannitol).
• Prescription of anticonvulsants for the cerebral form of the disease (10-15 ml of 25% magnesium sulfate and tranquilizers - Relanium, Sibazon, GHB).

Pay attention! Hormonal drugs and histamine blockers help relieve allergy symptoms during the first three days. But for another two weeks the patient needs to continue desensitizing therapy.

After eliminating acute symptoms, the doctor will prescribe treatment to the patient in an intensive care unit or intensive care unit.

Complications and their therapy

Anaphylactic shock most often does not go away without a trace.

After relief of respiratory and heart failure, the patient may continue to have a number of symptoms:

• lethargy, lethargy, weakness, nausea, headaches - nootropic drugs (Piracetam, Citicoline), vasoactive drugs (Ginko biloba, Cavinton, Cinnarizine) are used;
• pain in joints, muscles, abdomen (use analgesics and antispasmodics - No-shpa, Ibuprofen);
• fever and chills (if necessary, treated with antipyretics - Nurofen);
• shortness of breath, heart pain - the use of cardiotrophic drugs (ATP, Riboxin), nitrates (Nitroglycerin, Isoket), antihypoxic drugs (Mexidol, Thiotriazolin) is recommended;
• prolonged hypotension (low blood pressure) - relieved by long-term administration of vasopressor drugs: Mezaton, Adrenaline, Dopamine, Norepinephrine;
• infiltrates at the site of contact with the allergen - hormonal ointments (Hydrocortisone, Prednisolone), ointments and gels with a resorption effect (Troxevasin, Lyoton, Heparin ointment) are prescribed locally.

Long-term observation of the patient after anaphylactic shock is mandatory, since a number of people may develop late complications requiring therapy:

• neuritis;
• hepatitis
• vestibulopathy;
• recurrent urticaria;
• allergic myocarditis;
• diffuse damage to nerve cells (can cause the patient’s death);
• glomerulonephritis;
• Quincke's edema;
• bronchial asthma.

Important! In case of repeated contacts with the allergen, the patient may develop systemic autoimmune diseases: SLE, periarteritis nodosa.

Prevention

• Primary prevention is aimed at preventing contact with the allergen:

1. getting rid of bad habits;
2. control of the production of medicines and medical products;
3. combating chemical releases into the environment;
4. a ban on the use of a number of food additives (bisulfites, tartrazine, monosodium glutamate);
5. combating the uncontrolled prescription of a large number of drugs by doctors.

• Secondary prevention ensures early diagnosis and, accordingly, timely treatment:

1. therapy for allergic rhinitis,
2. eczema therapy;
3. treatment of atopic dermatitis,
4. treatment of hay fever,
5. conducting allergy tests;
6. detailed medical history;
7. placing on the title page of the medical card or medical history the names of intolerable medications;
8. conducting sensitivity tests to drugs before intravenous or intramuscular administration;
9. observation after injection (from 30 minutes).

• Tertiary prevention prevents relapses:

1. daily shower;
2. regular wet cleaning;
3. ventilation;
4. removal of excess upholstered furniture, toys;
5. control of food intake;
6. wearing a mask and glasses during allergen blooms.

Medical workers must also follow a number of rules:

Health care providers when treating a patient with anaphylactic shock should consider the patient's age when prescribing medications.

• carefully collect anamnesis;
• do not prescribe unnecessary drugs, do not forget about their compatibility and cross-reactions;
• avoid simultaneous administration of drugs;
• take into account the patient’s age when prescribing medications;
• avoid using Procaine as a solvent for antibiotics;
• For patients with a history of allergies, 3-5 days before using the prescribed drug and immediately 30 minutes before its administration, it is strongly recommended to take antihistamines (Semprex, Claritin, Telfast). Taking calcium supplements and corticosteroids is also indicated;
• for the convenience of applying a tourniquet in case of shock, the first injection (1/10 of the usual dose) is administered into the upper part of the shoulder. In case of pathological symptoms, apply a tight tourniquet over the injection site until the pulsation below the tourniquet stops, and inject the injection area with Adrenaline solution, apply cold;
• control injection sites;
• equip treatment rooms with anti-shock first aid kits and tables with information on cross-allergic reactions when taking a number of drugs;
• exclude the location of wards of patients with anaphylactic shock near manipulation rooms, as well as near wards in which allergen drugs are used for treatment;
• indicate on medical records information about predisposition to allergies;
• after discharge, refer patients to specialists at their place of residence and monitor their registration with dispensaries.

Complete set of the anti-shock first aid kit in accordance with SanPiN standards:

• Preparations:

1. Adrenaline hydrochloride, amp., 10 pcs., 0.1% solution;
2. Prednisolone, amp., 10 pcs.;
3. Diphenhydramine, amp., 10 pcs., 1% solution;
4. Eufillin, amp., 10 pcs., 2.4% solution;
5. Sodium chloride, vial, 2 pcs. 400 ml each, 0.9% solution;
6. Reopoliglyukin, vial, 2 pcs. 400 ml each;
7. Medical alcohol, solution 70%.

• Consumables:

1. 2 IV infusion systems;
2. sterile syringes, 5 pcs. each type - 5, 10 and 20 ml;
3. gloves, 2 pairs;
4. medical tourniquet;
5. alcohol wipes;
6. sterile cotton wool – 1 pack;
7. venous catheter.

The first aid kit comes with instructions.

Advice! A first aid kit equipped in this way should be present not only in medical institutions, but also at home for patients with a family history or a predisposition to allergies.

Basics of anti-shock therapy and resuscitation for injuries

Treatment of traumatic shock and associated terminal conditions is sometimes determined not so much by the availability of effective anti-shock drugs, which are generally sufficient, but by the frequent need to provide assistance to victims in extremely difficult and unusual conditions (street, production, apartment, etc.). However, despite the above, one should always strive to ensure that anti-shock therapy and resuscitation are carried out at the highest modern level. For this, first of all, it is especially important to select measures and means that will be technically the most accessible and, in their effect on the victim’s body, would have the most rapid and effective effect.

First of all, we consider it necessary to dwell on some controversial issues related to the problem of treating traumatic shock. Thus, in particular, discussions continue to this day about the extent to which the treatment of traumatic shock should be individualized depending on the location and severity of the injury, the combination of injuries, the age of the victim, etc.

We have already partly dwelled on questions of this kind, but nevertheless we consider it useful to once again emphasize that it is methodologically not entirely correct to talk about the combination of traumatic shock with various types of damage. This situation could be discussed only if the injuries and traumatic shock developed independently of one another, that is, they were completely independent. In reality, traumatic shock is not an independent disease, but only one of the most severe variants of the course of a traumatic disease. But since different mechanisms and localizations of damage have far from the same clinical manifestations, tactical maneuverability (a certain individualization of diagnostic and therapeutic measures) is undoubtedly necessary.

For example, in case of cerebral shock, in addition to generally accepted anti-shock therapy, ultrasonic echolocation, decompressive craniotomy with emptying of epi- and subdural hematomas, unloading of the cerebrospinal fluid system by lumbar puncture, craniocerebral hypothermia, etc. are often indicated. For extensive fractures of the pelvic bones - novocaine blockades, surgical interventions on the urinary tract, eliminating the deficit in circulating blood volume, combating secondary intestinal dysfunction, etc. For heart contusions - ECG, therapy similar to that for myocardial infarction. In case of acute blood loss - determination of the amount of blood loss, active fight against anemia, etc.

As for making an appropriate tactical decision in each specific case, this becomes possible only after some relatively significant period of time after the initial examination and against the background of resuscitation aids already being carried out. It should be noted that the individual principle of treatment is ideal, but in the conditions of anti-shock therapy and resuscitation, especially in the first hours of the prehospital stages, not to mention cases of mass traumatism, it is not readily available. Thus, when discussing the possibility of individual therapeutic decisions for traumatic shock and terminal conditions, one should first of all take into account the time that has passed since the moment of injury, the location of the incident and the tactical situation. Thus, in the conditions of providing assistance by an emergency medical team, in isolated cases of traumatic shock, therapeutic maneuverability is much wider than in the case of mass injuries and a pronounced shortage of forces and means of medical care. But even in the first case, at the very beginning of organizing assistance to the victim, it is almost impossible to individualize therapy, since this requires additional sufficiently detailed information, the collection of which may require a large and completely unacceptable amount of time.

Based on the foregoing, we believe that when starting to provide medical care to victims in a state of traumatic shock, preference should be given to known standardized therapeutic measures and, already against the background of intensive treatment, certain adjustments should be made as relevant information becomes available.

Since the severity of shock can be determined clinically, a certain standardization of therapeutic agents is fundamentally possible, taking into account the phase and severity of shock.

It is less difficult to individualize the solution of tactical and therapeutic issues depending on the age of the victims. You just need to remember that in children single doses of medicinal substances should be correspondingly reduced several times. In persons over 60 years of age, treatment should begin with half the dose and only then increase if necessary.

It is also obvious that the volume of anti-shock therapy is determined by the location and nature of the existing anatomical damage and the severity of shock. Moreover, the period that has passed since the injury or the onset of shock should not affect the scope of treatment measures. As for the effectiveness of anti-shock measures, it is undoubtedly in direct connection with the amount of time lost, since a mild shock with irrational treatment and loss of time can turn into a severe one, and a severe shock can be replaced by agony and clinical death. Consequently, the heavier the patient, the more difficult it is to bring him out of shock, the more dangerous the loss of time is - the more likely the development of not only functional, but also irreversible morphological changes in vital organs and systems.

The principle scheme for the treatment of reflex pain shock is presented in Table 10.

Below is a schematic diagram of the treatment of thoracic (pleuropulmonary) shock

1. Freeing the neck, chest and abdomen from constricting clothing, ensuring access to fresh air

2. Closing wounds with aseptic dressings

3. Drug complex: orally 0.02 g of oxylidine (0.3 g of andaxin), 0.025 g of promedol, 0.25 g of analgin and 0.05 g of diphenhydramine

4. Intercostal and vagosympathetic novocaine blockades

5. Puncture or drainage of pleural cavities for tension pneumothorax

6. Oxygen inhalation

7. Intravenous administration of 60 ml of 40% glucose solution + 3 units. insulin, 1 ml of 1% solution of diphenhydramine, 2 ml of cordiamine, 2 ml of 2% solution of promedol, 1 ml of 0.1% solution of atropine, 1 ml of vitamins PP, Bi, B6, 5 ml of 5% solution of ascorbic acid, 10 ml 2 ,4% aminophylline solution, 10 ml of 10% calcium chloride solution.

8. Sanitation of the upper respiratory tract, in case of respiratory failure - tracheostomy, artificial or auxiliary ventilation

9. For progressive hemothorax and tension pneumothorax - thoracotomy.

The basic treatment plan for cerebral shock is as follows:

1. Strict bed rest.

2. Prolonged craniocerebral hypothermia.

3. Oxilidine 0.02 g (andaxin 0.3 g), promedol 0.025 g, analgin 0.25 g and diphenhydramine 0.05 g orally (in the absence of consciousness, can be administered intramuscularly).

4. Subcutaneous injection of cordiamine 2 ml, 10% caffeine solution 1 ml.

5. a) For hypertensive syndrome - intravenous administration of 10% calcium chloride solution 10 ml, 40% glucose solution 40-60 ml, 2.4% aminophylline solution 5-10 ml, 10% mannitol solution up to 300 ml, intramuscular administration 25% magnesium sulfate solution 5 ml, 1% vikasol solution 1 ml. b) for hypotensive syndrome, intravenous administration of an isotonic solution of sodium chloride and 5% glucose solution up to 500-1000 ml, hydrocortisone 25 mg.

6. Spinal punctures - therapeutic and diagnostic.

7. In case of respiratory failure - tracheostomy, artificial or auxiliary ventilation.

8. Antibacterial therapy - broad-spectrum antibiotics.

9. Surgical treatment and revision of wounds, decompressive craniotomy, removal of bone fragments, foreign bodies, etc.

Note. When providing first medical aid, self-help and mutual aid, only paragraphs 1-3.

MED24INfO

T. M. DARBINYAN A. A. ZVYAGIN Y. I. TTSITOVSKY, ANESTHESIA AND RESUSCITATION AT THE STAGES OF MEDICAL EVACUATION, 1984

Antishock therapy

Lyak G.N., 1975; Shushkov G.D., 1978]. Initially, shock was spoken of in the presence of severe trauma, accompanied by a decrease in blood pressure, tachycardia and other disturbances of homeostasis. However, at present, in addition to traumatic shock, other types are also distinguished in clinical practice - hemorrhagic, burn, tourniquet, cardiogenic shock, etc. The causes of injury leading to shock are different - bleeding, burns, compartment syndrome [ Kuzin M.I., 1959; Berkutov A. N., 1967; Tsybulyak G. N., 1975; Sologub V.K., 1979; Hardaway, 1965, 1967, 1969; Rohte, 1970].

The severity of shock is judged not only by the level of blood pressure and pulse rate, but also by data from central and peripheral hemodynamics - stroke and cardiac output, circulating blood volume, and total peripheral resistance. Indicators of the acid-base status and electrolyte composition of the blood also indicate the severity of shock. However, when there is a mass arrival of victims, the signs of the severity of the injury and shock available for determination will apparently be the level of blood pressure, heart rate, color of the skin and visible mucous membranes. The adequacy of the victim’s behavior will allow us to judge the functional state of his central nervous system.

The volume of intensive therapy depends primarily on the conditions available for its implementation, and it is aimed primarily at maintaining a satisfactory level of hemodynamics. The human body is most sensitive to loss of circulating blood and, above all, to loss of plasma. A loss of 30% of plasma is critical and leads to extremely severe

hemodynamic disorders. Traumatic, hemorrhagic and burn shock is accompanied by a decrease in the volume of circulating blood and requires its rapid replenishment with the help of infusion therapy. Intravenous transfusion of plasma-substituting solutions allows you to temporarily replenish the volume of circulating fluid, increase blood pressure and improve the conditions of perfusion of internal organs and peripheral tissues.

Infusion in case of shock should be carried out simultaneously in 2-3 veins at a fast pace. The lower the level of arterial and central venous pressure, the faster it is necessary to carry out infusion therapy. In case of low arterial and high central venous pressure, indicating right ventricular failure, one should begin with drug therapy for heart failure (intravenously administer calcium chloride, strophanthin and drip adrenaline at a dilution of 1:200). In addition to plasma-substituting drugs, blood or blood products (if possible), as well as solutions for correcting electrolyte and acid-base disorders, and drugs that stimulate the activity of the cardiovascular system are administered intravenously.

The adequacy of antishock therapy is monitored by the activity of the cardiovascular system. Elimination of the cause that led to the development of the shock reaction (bleeding, pain, etc.) and carrying out infusion therapy in sufficient volume increases and stabilizes the level of blood pressure, reduces the pulse rate, and improves peripheral circulation. The forecast for dealing with a shock depends primarily on the possibility of eliminating the main cause of its development.

Clinical characteristics of shock. Polytrauma, in which large blood loss occurs in combination with severe pain, leads to the development of traumatic shock - a variant of traumatic disease [Rozhinsky M. M. et al., 1979]. The severity of shock also depends on a number of other reasons - disturbances in gas exchange during chest injury, damage to the central nervous system during traumatic brain injury, blood loss, etc.

In addition to traumatic shock, burn and hemorrhagic shock can relatively often occur at the lesion site, in which disturbances in the functioning of the cardiovascular system predominate with a sharp decrease in the volume of circulating blood. By

the severity of the course is divided into 4 degrees of shock [Smolnikov V.P., Pavlova 3.P., 1967; Schreiber M. G., 1967].

1. degree of shock - blood pressure is reduced by

1. 20 mmHg Art. compared to the original (within 90-100 mm Hg. Art.), the pulse rate increases by 15 - 20 beats per minute. Consciousness is clear, but there is motor restlessness and pale skin.

1. the degree of shock is a decrease in blood pressure to 75-80 mm Hg. Art., pulse rate 120-130 beats per minute. Severe pallor of the skin, restlessness or some lethargy, shortness of breath.
2. degree of shock - blood pressure within 60-65 mm Hg. Art., is difficult to measure on the radial artery. Pulse up to 150 beats per minute. Cyanosis of the skin and visible mucous membranes. Cold sweat, inappropriate behavior, shortness of breath - up to 40-50 respiratory cycles per minute.
3. degree (terminal) - consciousness is absent, blood pressure is 30-40 mm Hg. Art.* difficult to determine, pulse up to 170-180 beats per minute. Breathing rhythm disturbance.

Antishock therapy should be multicomponent and aimed at:

1. suppression of pathological pain impulses using local anesthesia, novocaine blockades, analgesia with pentran or trilene, and administration of analgesics;
2. control and maintenance of patency of the upper respiratory tract and restoration of spontaneous breathing or mechanical ventilation;
3. rapid compensation of blood loss by intravenous administration of blood and plasma-substituting drugs (dex-country, crystalloid solutions).

The effectiveness of anti-shock measures, in particular the fight against hypovolemia, also depends on the timely stop of bleeding.

At the stages of medical evacuation, the severity of shock can be judged by such quite accessible clinical signs as blood pressure, pulse rate, consciousness and the adequacy of the victim’s behavior.

Stop bleeding. Bleeding occurs with injuries with damage to arterial or venous vessels, with open and closed fractures of the human musculoskeletal system. It is known that a fracture of the tibia or femur is accompanied by

is given by blood loss in a volume of up to 1.5-2 liters, and a fracture of the pelvic bones - up to 3 liters. It is quite natural that blood loss leads to a rapid decrease in circulating blood volume, a decrease in blood pressure and an increase in heart rate.

In case of external bleeding, self- and mutual assistance should be aimed at temporarily stopping the bleeding by pressing the damaged artery with a finger.

Bleeding from the vessels of the upper and lower extremities can be temporarily stopped by applying a tourniquet above the site of injury. The tourniquet is applied so tightly that pulsation in the peripheral artery is not detected. The time of application of the tourniquet is noted. If it is not possible to completely stop the bleeding within 2 hours, then the tourniquet is removed

1. 5 min using other temporary stopping methods.

Temporary cessation of venous bleeding can be accomplished by tightly packing the bleeding area with sterile material and applying a pressure bandage. However, applying a pressure bandage is ineffective when damaging arterial vessels. Bleeding can also be stopped by applying clamps to bleeding vessels and ligating them with ligatures. Temporary stoppage of bleeding is carried out by the personnel of the sanitary squads at the site of the lesion. The first aid unit (FAM) performs the final stop of external bleeding.

Maintaining the activity of the cardiovascular system. When a victim with bleeding is admitted to the emergency medical department or a medical institution, the approximate amount of blood loss is determined, based on the level of blood pressure, pulse rate, skin color, hemoglobin content and hematocrit.

Pale skin, rapid pulse and decreased blood pressure during bleeding indicate significant blood loss. It has been proven that a decrease in blood pressure by 20-30 mm Hg. Art. is associated with a decrease in circulating blood volume by 25%, and a decrease in pressure by 50-60 mm Hg. Art. - with a decrease in circulating blood volume at V3. Such a pronounced decrease in blood pressure and circulating blood volume creates a real danger to the life of the victim and requires urgent measures aimed at maintaining the activity of the cardiovascular system and recovery

Volume of infusion therapy, ml

Reducing blood pressure by 20-30 mmHg. st (I - II degree of shock)

Polyglkzhin -400 Ringer's solution or 5% glucose solution - 500

Reduced blood pressure by 30-

(II - III degree of shock)

Polyglucin - 400 Reopoliglucin - 400 Ringer's solution or lactasol - 500 5% glucose solution - 500 Single-group blood or plasma - 250

5% sodium bicarbonate solution - 500 \% potassium solution - 150

Decrease in blood pressure by 50 mm Hg or more. Art. (Ill - IV degree of shock)

Polyglucin - 800 Reopoliglucin - 800- 1200 Ringer's solution-1000 lactasol solution-1000 5% glucose solution-g-1000- 2000

5% sodium bicarbonate solution - 500-750 Single-group blood or plasma - 1000 or more \% potassium solution - 300-500

Intravenous transfusion of solutions is established using venous puncture or catheterization, which is more preferable. Veins are punctured with needles with a large internal diameter (1 -1.5 mm). In case of low blood pressure and collapsed veins, a venesection is performed in the OPM with the introduction of plastic catheters. The introduction of catheters into peripheral veins allows

continue the intravenous administration of solutions and drugs during further transportation of victims from the emergency area to a hospital in a suburban area.

To replenish the volume of circulating blood, in quick drops or in a stream, depending on the severity of the shock, 1.5 to 6 liters of solutions are transfused intravenously, depending on the condition of the myocardium, the presence or absence of right ventricular heart failure, a sign of which is an increase in central venous pressure. If it is impossible to measure central venous pressure, it is assessed by the condition of the neck veins. Swollen, swollen veins are a symptom of the development of right ventricular failure. Before starting transfusion therapy, it should be eliminated with medications (adrenaline drip, calcium chloride, etc. - see above). In case of low central venous pressure, transfusion therapy is carried out depending on the level of blood pressure. We propose the following scheme for infusion therapy for hypovolemic shock (Table 7).

The lower the blood pressure, the faster (in

1. - 3 veins) and in large volumes it is necessary to carry out infusion therapy with plasma-substituting drugs. If the tactical and medical situation allows, then a transfusion of donor blood is desirable.

In the emergency department, measures are taken to finally stop external bleeding: ligation of bleeding vessels in the wound or throughout. Drugs that support the activity of the cardiovascular system are administered intravenously - cardiac glycosides, concentrated solutions of glucose with insulin, 200-250 ml of 5% sodium bicarbonate solution to replenish the base deficiency in metabolic acidosis (see Chapter III).

If the level of blood pressure is unstable, 1-2 ml of mezatone, norepinephrine, adrenaline, diluted in 250-500 ml of 5% glucose solution or Ringer's solution, are administered intravenously. Transfusion of these drugs should always begin with adrenaline, since it simultaneously stimulates cardiac activity and constricts peripheral blood vessels. If you immediately begin treating hypotension with mezaton or norepinephrine, then if the myocardium is weak, the effect may be negative, since these drugs mainly constrict the blood vessels and thereby increase the load on the heart.

Intravenous administration of 10% calcium chlorine solution

It also stimulates the activity of the heart muscle and increases blood pressure.

Methods of infusion therapy. In patients in a state of shock of any etiology, infusion therapy is carried out for 2-3 days or more. For this purpose, catheterization of peripheral or central veins is desirable.

Venesection. Instruments for venesection: scalpel, 2 clamps, needle holder with needle, 3-4 silk or catgut ligatures, 4-5 sterile napkins,

1. 4 sterile gauze balls. It is advisable to have “vascular” scissors, a sterile towel or diaper to delimit the surgical field, and a sterile catheter for the subclavian vein with an internal diameter of 1 to 1.4 mm.

Operation technique: the largest ones are isolated

peripheral veins - in the elbow (v. cephalic a, v. basilica), in the area of ​​the anatomical snuffbox or on the anterior surface of the ankles. The area of ​​the vein projection is treated with iodine and alcohol. The surgical field is covered on all sides with a sterile towel or napkins. In special conditions, in the absence of opportunities, venesection can be done without sterility or with minimal compliance. Under local anesthesia with a 0.25% solution of novocaine (5-6 ml), a skin incision 2-3 cm long is made with a scalpel in the transverse direction relative to the projection of the isolated vein. Using a clamp, the subcutaneous tissue is bluntly separated over the vein and isolated for 1-2 cm from the surrounding tissue, being careful not to damage the thin wall of the vein. Then a clamp is placed under the isolated vein and two ligatures are pulled through. The upper (proximal) is pulled and with its help the vein is raised a few millimeters, the lower (distal) is tied. The venous wall is incised with scissors or a scalpel so that a needle with a large internal lumen or a plastic catheter with an internal diameter of 1 to 1.4 mm can be inserted into the hole. After inserting a needle or catheter into the lumen of the vein, a second (proximal, upper) ligature is tied above it. 2-3 silk sutures are placed on the skin. The cannula of the needle or catheter is fixed to the skin with a separate suture and additional strips of adhesive tape. Then an aseptic bandage is applied.

Catheterization of peripheral veins according to Seldinger. Catheterization technique: apply a tourniquet to the lower third of the shoulder and puncture

There is a well-contoured vein of the cubital fossa or another vein of the forearm. A fishing line 10-12 cm long is passed through the lumen of the needle located in the vein. Then the needle is removed from the vein, and a catheter is placed on the fishing line left in the vein. Catheter (inner diameter

1. -1.4 mm) is carried out along a fishing line into a vein. The line is removed, and the catheter, left in the vein, is secured to the skin of the forearm with a suture and strips of adhesive tape, and then connected to the system for intravenous infusion of solutions.

It should be remembered that excessive advancement of the catheter towards the heart is dangerous due to the possibility of passing it into the cavity of the right atrium. In these cases, it is sometimes possible to damage the thin wall of the right atrium with the tip of the catheter, so the expected length of the catheter should be determined in advance by applying it to the victim’s forearm and shoulder so that its end reaches the site of formation of the superior vena cava. The inner edge of the right clavicle can serve as a reference point.

Infusion therapy can also be carried out intraarterially or intraosseously.

Intra-arterial blood injection is indicated for terminal conditions and prolonged hypotension. The radial or posterior tibial artery is isolated. Blood is pumped towards the heart at a pressure of 180-200 mmHg. Art.

Intraosseous administration of drugs is indicated if it is impossible to puncture the saphenous veins or with extensive burns. A shortened Beer needle is inserted into the wing of the ilium and ankle. Solutions, including blood, blood substitutes, and medications, are administered at a rate normal for intravenous infusions.

In modern combat injuries, TS develops in 20-25% of the wounded. Under traumatic shock refers to a severe form of the body’s general reaction to trauma, combat, predominantly gunshot or explosive trauma. TS is one of the fundamental concepts and is an important component of the diagnosis of combat damage, which determines the nature of therapeutic and diagnostic measures in the system of staged treatment of the wounded with evacuation as directed.

Pathogenesis:

Acute blood loss: decreased blood volume, decreased IOC, hypotension and decreased tissue perfusion, accompanied by increasing hypoxia. Blood loss exceeding 1000 ml is detected in 50%, and 1500 ml - in 35% of wounded patients arriving in a state of shock. In case of shock of the third degree of severity, massive blood loss exceeding 30% of the blood volume (1500 ml) occurs in 75-90% of the wounded.

Decrease in systolic blood pressure: insufficient. eff. pumping function of the heart, which may be caused by circulatory hypoxia of the heart muscle, cardiac contusion due to closed or open chest trauma, as well as early post-traumatic endotoxemia. A decrease in blood pressure during TS is also associated with a circulatory, vascular factor.

Pathological afferent impulses.

Functional disorders associated with a specific location of damage.

The main natural compensatory mechanisms can be presented in the following sequence:

An increase in minute volume of blood circulation against the background of a decrease in circulating blood volume due to an increase in heart rate;

Centralization of blood circulation by increasing the tone of peripheral vessels and internal redistribution of limited blood volume in the interests of organs experiencing the greatest functional load in an extreme situation;

Increasing the depth and frequency of external respiration as a mechanism to compensate for developing hypoxia;

Intensification of tissue metabolism in order to mobilize additional energy resources.

Shock severity	Clinical criteria	Forecast
I degree (mild shock)	The damage is of moderate severity, often isolated. The general condition is moderate or severe. Moderate lethargy, pallor. Heart rate = 90-100 per minute, systolic blood pressure not lower than 90 mm Hg. Art. Blood loss up to 1000 ml (20% bcc)	If assistance is provided in a timely manner - favorable
II degree (moderate shock)	The damage is extensive, often multiple or combined. The general condition is serious. Consciousness is preserved. Severe lethargy, pallor. Heart rate 100-120 per minute, systolic blood pressure 90-75 mm Hg. Blood loss up to 1500 ml (30% bcc)	Doubtful
III degree (severe shock)	The injuries are extensive, multiple or combined, often with damage to vital organs. The condition is extremely serious. Stupor or stupor. Severe pallor, adynamia, hyporeflexia. Heart rate 120-160 per minute, weak filling, systolic blood pressure 70 - 50 mm Hg. Art. Anuria is possible. Blood loss 1500-2000 ml (30-40% bcc)	Very serious or unfavorable

In the terminal state, a distinction is made between its preagonal phase, agony and clinical death. The preagonal state is characterized by the absence of a pulse in the peripheral vessels and a decrease in systolic blood pressure below 50 mmHg. Art., impaired consciousness to the level of stupor or coma, hyporeflexia, agonal breathing. During agony, pulse and blood pressure are not determined, heart sounds are muffled, consciousness is lost (deep coma), breathing is shallow and has an agonal character. Clinical death is recorded from the moment of complete cessation of breathing and cessation of cardiac activity. If it is not possible to restore and stabilize vital functions within 5-7 minutes, the death of the cells of the cerebral cortex that are most sensitive to hypoxia occurs, and then biological death.

Treatment of traumatic shock must be early, comprehensive and adequate. Main objectives of treatment:

1) Elimination of external respiratory distress, achieved by restoring the patency of the upper respiratory tract, eliminating open pneumothorax, draining tension pneumothorax and hemothorax, restoring the bone frame of the chest in case of multiple fractures, oxygen inhalation or transfer to mechanical ventilation.

2) Stopping ongoing external or internal bleeding.

3) Replenishment of blood loss and restoration of blood volume with subsequent elimination of other factors of ineffective hemodynamics. The use of vasoactive and cardiotropic drugs is carried out according to strict indications after replenishment of blood volume or (if necessary) in parallel with its replenishment. Infusion therapy also aims to eliminate disturbances in the acid-base state, osmolar, hormonal and vitamin homeostasis.

4) Termination of pathological afferent impulses from lesions, which is achieved by the use of analgesics or adequate general anesthesia, conduction novocaine blockades, and immobilization of damaged body segments.

5) Performing emergency surgical interventions included in the complex of anti-shock measures and aimed at stopping bleeding, eliminating asphyxia, and damage to vital organs.

6) Elimination of endotoxemia through the use of various methods of extracorporeal and intracorporeal detoxification.

8) Early antibiotic therapy, starting in the advanced stages of medical evacuation. This therapy is especially indicated for patients with penetrating abdominal wounds, open bone fractures and extensive soft tissue damage.

9) Correction of general somatic disorders identified in the dynamics, reflecting the individual characteristics of the body’s general reaction to severe trauma.

First medical aid: wounded arriving in a state of shock, especially with shock of II-III severity, it is necessary to carry out a set of measures to ensure the elimination of the immediate life threat and subsequent transportation to the next stage of evacuation. If there are indications, additional measures are taken to reliably eliminate external respiratory disorders: tracheal intubation, cricoconicotomy or tracheostomy, oxygen inhalation using standard devices, thoracentesis with a valve device for tension pneumothorax. The tourniquet is controlled and, if possible, external bleeding in the wound is temporarily stopped. Transport immobilization is corrected using standard means. Analgesic drugs are reintroduced. In case of combined injuries of the musculoskeletal system, conduction blockades using local anesthetics are indicated. If there are pronounced signs of acute blood loss, perform infusion or infusion-transfusion therapy in a volume of 500-1000 ml. If appropriate conditions exist, infusion therapy continues during further transportation. All wounded are given tetanus toxoid, and broad-spectrum antibiotics are used when indicated.

When providing qualified and specialized medical care anti-shock measures must be carried out in full, which requires sufficiently highly qualified anesthesiologists, surgeons and all medical personnel.

Restoring the function of the respiratory system. An indispensable condition for the effectiveness of measures in this area of ​​anti-shock care is the elimination of mechanical causes of respiratory disorders - mechanical asphyxia, pneumothorax, hemothorax, paradoxical movements of the chest wall during the formation of the costal valve, aspiration of blood or vomit into the tracheobronchial tree.

Along with these measures, depending on specific indications, the following are performed:

Anesthesia by performing segmental paravertebral or vagosympathetic blockade;

Constant inhalation of humidified oxygen;

Tracheal intubation and mechanical ventilation for stage III respiratory failure (respiratory rate of 35 or more per minute, pathological breathing rhythms, cyanosis and sweating, feeling of lack of air).

In case of respiratory failure due to lung contusions, the following is required:

Limiting the volume of intravenous infusion-transfusion therapy to 2-2.5 l with switching the required additional volume to intra-aortic infusions;

Long-term multi-level analgesia through retropleural blockade (administration of 15 ml of 1% lidocaine solution every 3-4 hours through a catheter installed in the retropleural space), central analgesia with intravenous fentanyl 4-6 times a day, 0.1 mg, and neurovegetative blockade with intramuscular injection of droperidol 3 times a day;

The use of rheologically active drugs in hemodilution mode (0.8 l of 5% glucose solution, 0.4 l of rheopolyglucin), disaggregants (trental), direct anticoagulants (up to 20,000 units of heparin per day), aminophylline (10.0 ml of 2.4% solution intravenously 2-3 times a day), saluretics (Lasix 40-100 mg per day up to 50-60 ml of urine per hour), and with sufficient excretory function of the kidneys - osmodiuretics (mannitol 1 g/kg body weight per day) or oncodiuretics ( albumin 1 g/kg body weight per day), as well as glucocorticoids (prednisolone 10 mg/kg body weight) and ascorbic acid 5.0 ml of 5% solution 3-4 times a day.

In the event of the development of adult respiratory distress syndrome or fat embolism, mechanical ventilation with increased end-expiratory pressure up to 5-10 cmH2O takes on leading importance in the treatment of respiratory disorders. Art. with a “Phase-5” type device against the backdrop of measures recommended for lung contusion. But at the same time, the dose of glucocorticoids is increased to 30 mg/kg of body weight per day.

Restoring the function of the circulatory system. A prerequisite for the effectiveness of intensive care measures is stopping external or internal bleeding, as well as eliminating damage and tamponade of the heart.

Subsequent compensation for blood loss is carried out based on the following principles: for blood loss up to 1 liter - crystalloid and colloid blood replacement solutions with a total volume of 2-2.5 liters per day; for blood loss up to 2 liters - replacement of bcc with red blood cells and blood substitutes in a 1:1 ratio with a total volume of up to 3.5-4 liters per day; with blood loss exceeding 2 liters, the volume of blood volume is replaced mainly by red blood cells in a 2:1 ratio with blood substitutes, and the total volume of injected fluid exceeds 4 liters; when blood loss exceeds 3 liters, replenishment of the bcc is carried out using large doses of red blood cells (in terms of blood - 3 liters or more), blood transfusion is carried out at a rapid pace into two large veins, or into the aorta through the femoral artery. It must be remembered that blood spilled into the body cavity is subject to reinfusion (if there are no contraindications). Replacement of lost blood is most effective in the first two days. Adequate compensation of blood loss is combined with the use of drugs that stimulate peripheral vascular tone: dopmin at a dose of 10-15 mcg/kg per minute or norepinephrine at a dose of 1.0-2.0 ml of a 0.2% solution in 400.0 ml of a 5% glucose solution at a speed of 40-50 drops per minute.

Along with this, in order to stabilize hemodynamics, glucocorticoids, disaggregants and rheologically active drugs are used in the doses specified in subsection 1.

Correction of the blood coagulation system is determined by the severity of disseminated intravascular coagulation syndrome (DIC): for DIC of the first degree (hypercoagulation, isocoagulation), heparin 50 U/kg 4-6 times a day, prednisolone 1.0 mg/kg 2 times a day, trental are used , rheopolyglucin; for stage II DIC (hypocoagulation without activation of fibrinolysis), heparin is used up to 30 U/kg (no more than 5000 U per day), prednisolone 1.5 mg/kg 2 times a day, albumin, plasma, rheopolyglucin, red blood cell mass for no more than 3 days conservation; for DIC of the third degree (hypocoagulation with the beginning activation of fibrinolysis), prednisolone 1.5 mg/kg 2 times a day, contrical 60,000 units per day, albumin, plasma, red blood cell mass for short periods of preservation, fibrinogen, gelatin, dicinone are used; for stage IV DIC (generalized fibrinolysis), prednisolone up to 1.0 g per day, contrical 100,000 units per day, plasma, fibrinogen, albumin, gelatin, dicinone, alkaline solutions are used. In addition, a mixture is injected locally through drainages into the serous cavities for 30 minutes: 5% solution of epsilon-aminocaproic acid 100 ml, 5.0 ml of adroxon, 400-600 units of dry thrombin.

In case of heart failure caused by heart damage, it is necessary to limit intravenous infusion-transfusion therapy to 2-2.5 liters per day (the remaining required volume is injected into the aorta through the femoral artery). In addition, polarizing mixtures are used in the infusion media (400 ml of 10% glucose solution with the addition of 16 units of insulin, 50 ml of 10% potassium chloride solution, 10 ml of 25% magnesium sulfate solution), cardiac glycosides are administered (1 ml 0.06 % korglycon solution or 0.5 ml of 0.05% strophanthin solution 2-3 times a day), and for progressive heart failure, inotropic support is provided with dopamine (10-15 mcg/kg per minute) or dobutrex (2.5-5. 0 mcg/kg per minute), as well as the introduction of nitroglycerin (1 ml of 1% solution 2 times a day, diluted slowly by drip). Heparin is administered subcutaneously at 5000 units 4 times a day.

Restoring the function of the central nervous system. Surgical assistance for wounds and head injuries at the stage of providing qualified medical care is limited to stopping external bleeding from the integumentary tissue and restoring external respiration through tracheal intubation or tracheostomy. Next, preparations are made for the evacuation of the wounded to the hospital base, where surgical intervention is performed at a specialized level in an exhaustive manner.

For encephalopathies of various origins (consequences of hypoxia, compression of the brain) or excessive afferent impulses from multiple lesions, the following intensive care measures are carried out:

Infusion therapy in the mode of moderate dehydration with a total volume of up to 3 liters per day using crystalloid solutions, 30% glucose solution (38 units of insulin per 250 ml with a total volume of 500-1000 ml), rheopolyglucin or reogluman; with the development of cerebral edema, dehydration is carried out due to saluretics (Lasix 60-100 mg), osmodiuretics (mannitol 1 g/kg body weight in the form of a 6-7% solution), oncodiuretics (albumin 1 g/kg body weight);

Complete central analgesia by intramuscular administration of fentanyl 0.1 mg 4-6 times a day, droperidol 5.0 mg 3-4 times a day, intravenous administration of sodium hydroxybutyrate 2.0 g 4 times a day;

Parenteral administration of the following drugs: piracetam 20% 5.0 ml 4 times a day intravenously, sermion (nicerogoline) 4.0 mg 3-4 times a day intramuscularly, solcoseryl 10.0 ml intravenously drip on the first day, 6 days on subsequent days .0-8.0 ml;

Oral administration of glutamic acid 0.5 g 3 times a day;

Constant inhalation of humidified oxygen.

In the case of the development of early multiple organ failure, intensive care measures take on a syndromic character.

The most important component of the treatment of shock is the implementation of emergency and urgent surgical interventions aimed at stopping ongoing external or internal bleeding, eliminating asphyxia, damage to the heart or other vital organs, as well as the hollow organs of the abdomen. In this case, intensive care measures are carried out as preoperative preparation, anesthetic support for the operation itself and continue in the postoperative period.

Adequate treatment of shock is aimed not only at eliminating this terrible consequence of severe combat trauma. It lays the foundation for treatment in the post-shock period before determining the immediate outcome of the injury. At the same time, the entire pathological process until the wounded person is cured has been considered in recent years from the standpoint of concept of traumatic illness.

The concept of traumatic illness is fully realized at the stage of providing specialized medical care, where the treatment of severe consequences of injury and complications, including rehabilitation of the wounded, is carried out depending on the location of the injuries and their nature until the final outcome.

Antishock drugs are used by doctors to help patients in life-critical situations. Depending on these situations, doctors may use different drugs. In intensive care and burn departments, ambulance workers and the Ministry of Emergency Situations are required to carry anti-shock kits.

Since an unforeseen situation can happen, unfortunately, not only in the presence of doctors, every enterprise must have a first aid kit containing anti-shock drugs. We will consider a short list of them in our article below.

The need for a first aid kit for anaphylactic shock

According to the recommendation of the Ministry of Health, a first aid kit containing anti-shock therapy drugs should be available not only in every dental and surgical office, but also in any enterprise. It wouldn’t hurt to have such a first aid kit in your home, and you need to have at least minimal knowledge about how and in what cases to use its contents.

Unfortunately, medical statistics show that the number of cases of sudden anaphylactic shock is increasing every year. This state of shock can be provoked by a person’s allergic reaction to food, a medicine, contact with a cosmetic product, or an insect bite. It is almost impossible to predict in advance the likelihood of such a reaction in the body, and a huge problem with anaphylactic shock is the lightning speed of its development.

It is for this reason that a person’s life may depend on the presence of a particular drug in the medicine cabinet and understanding how to use it.

Antishock drugs: list

The Ministry of Health has approved a list of drugs that should be in every first aid kit to help with the onset of anaphylactic shock. These include:

• "Adrenaline" (0.1%) in ampoules.
• "Diphenhydramine" in ampoules.
• Sodium chloride solution.
• "Eufillin" in ampoules.
• "Prednisolone" (ampoules).
• Antihistamines.

Why do you need to inject Adrenaline?

This medicine can easily be called the main drug in the anti-shock kit. If we consider its use, it is necessary to understand that when a strong allergic reaction occurs in the human body, the hypersensitivity of immune cells is suppressed. As a result, the immune system begins to destroy not only the foreign agent (allergen), but also the cells of its own body. And when these cells begin to die, the human body falls into a state of shock. All its systems begin to work in intensive, emergency mode in order to provide the most important organs with oxygen.

An injection of “Adrenaline” (0.1%) instantly constricts blood vessels, due to which the circulation of histamine produced by the immune system is significantly reduced. In addition, the administration of Adrenaline prevents the rapid drop in blood pressure that accompanies shock states. Also, an injection of "Adrenaline" improves the functioning of the heart and prevents its possible stop.

"Diphenhydramine" is a remedy not only for insomnia

Most people not involved in medicine mistakenly consider Diphenhydramine to be exclusively a sleeping pill. This medicine does have a hypnotic effect, but in addition to this, Diphenhydramine is also an anti-shock drug. After administration, it dilates blood vessels, while relieving bronchospasm. In addition, it is an antihistamine. It blocks the production of histamine and further suppresses overactive central nervous system activity.

Why do you need sodium chloride solution in an anti-shock first aid kit?

This solution is most often used in medical practice for dehydration, since after intravenous administration it is able to correct the functioning of various body systems. "Sodium chloride" is used as a detoxification drug. Also, in case of severe bleeding, this solution can raise blood pressure. For cerebral edema, it is used as

"Eufillin" - quick help with bronchial spasm

This drug is a fairly powerful bronchodilator. In a state of shock, it helps to activate additional life support mechanisms in the body.

"Eufillin" is able to expand the bronchi and open reserve capillaries, which stabilizes and significantly facilitates breathing in a state of shock.

“Prednisolone” is the closest analogue of the hormone produced by the body

Prednisolone is a fairly important drug when helping a patient in shock. By its action, it is able to suppress the activity of immune cells that provoke cardiac arrest.

This synthetic hormone is indeed the closest analogue of the anti-shock hormone, which is independently secreted by the body in life-critical situations. After its administration, the shock state of the body subsides in a very short time. It is worth noting that this antishock drug is used not only for anaphylactic shock. Doctors also use it for burns, cardiogenic, intoxication, traumatic and surgical shocks.

In what cases is it necessary to use antishock drugs?

The shock state of the human body can be provoked not only by anaphylaxis due to an allergic reaction. Anti-shock kit drugs are used to provide first aid in other situations, they are especially relevant in cases where there is no opportunity to quickly deliver the victim to the hospital and there is a long transportation ahead.

In addition to anaphylactic shock, the following situations can provoke the human body:

• pain shock;
• receiving serious injury;
• infectious-toxic shock;
• bite of poisonous insects, snakes and animals;
• getting injured;
• drowning.

In such cases, the list of drugs in the anti-shock kit can be supplemented with the following drugs:

1. "Ketanov" (ketorolac tromethamine solution) is a strong pain reliever. Helps relieve severe pain from serious injuries.
2. Dexamethasone is a drug that is a glucocorticoid hormone. It has an active anti-shock effect and also has a pronounced anti-inflammatory effect.
3. “Cordiamin” is a 25% solution of nicotinic acid. Belongs to the pharmacological group of respiratory stimulants. It also has a stimulating effect on the brain.

Depending on the situation and the degree of criticality of the patient’s condition, doctors can use these drugs both together and separately.

Drugs that are used in critical situations in resuscitation

In a hospital setting, to provide care to a patient in critical condition, in addition to those we have already discussed earlier, other antishock drugs are used - solutions for administration:

1. "Polyglukin" is a drug that has a powerful anti-shock effect. It is used by doctors as an anti-shock drug for wounds, burns, severe injuries and serious blood loss. After IV administration, “Polyglyukin” improves and activates coronary flow and restores the total volume of blood circulating in the body. The drug also normalizes blood pressure and blood pressure levels. It is worth noting that its greatest anti-shock effectiveness occurs when administered together with preserved blood.
2. “Hemovinil” is a medicinal solution that is used for severe intoxication, traumatic and burn shock. It is often used to remove toxins from the body, as it is a strong adsorbent. Helps reduce ascysts and eliminate brain swelling. A characteristic feature is that after the administration of Hemovinyl, an increase in body temperature is often observed.
3. “Polyvinol” is a solution that is administered intravenously for severe bleeding, serious injuries, burns and surgical shock, which are characterized by a sharp drop in blood pressure. The drug quickly increases blood pressure, maintains the level of plasma circulating in the body and, if necessary, restores its volume (that is, it is used as a plasma substitute). Despite all its advantages, this drug is not suitable for relieving shock conditions that are accompanied by cranial injuries and cerebral hemorrhages.
4. “Gelatinol” is an 8% solution of hydrolyzed gelatin, which is administered intravenously for traumatic and burn shocks. Removes harmful and toxic substances from the body, performing a detoxification function.
5. "Droperidol" is a neuroleptic, antiemetic and proto-shock drug. Belongs to the group of myotropic antispasmodics. It is administered intravenously for severe painful shock.
6. "Dexaven" belongs to the pharmacological group of glucocorticoids. It is administered intravenously when surgical or postoperative shock occurs. Also used for anaphylactic and traumatic shock and angioedema. It has pronounced antiallergic activity and strong anti-inflammatory properties.

If the patient shock developed as a result of blood loss, the best treatment is whole blood transfusion. If shock has developed as a result of a decrease in plasma volume in the body, for example due to dehydration, an anti-shock measure may be the introduction of appropriate saline solutions.

Whole blood not always available, especially in military field conditions. In such cases, whole blood can be replaced by plasma transfusion, because this leads to an increase in blood volume and restoration of hemodynamics. Plasma cannot restore normal hematocrit, however, with adequate cardiac output, the human body can withstand a decrease in hematocrit by approximately 2 times before adverse complications occur. Thus, in emergency settings, it is advisable to use plasma instead of whole blood in the treatment of hemorrhagic shock, as well as hypovolemic shock of any other origin.

Sometimes blood plasma also not available. In these cases, various plasma substitutes are used, which perform the same hemodynamic functions as plasma. One of them is dextran solution.

Dextran solution as a plasma substitute. The main requirement for a plasma replacement solution is that the solution remain in the bloodstream and not filter through capillary pores into the interstitial space. In addition, the solution should not be toxic and should contain the necessary electrolytes so as not to disturb the electrolyte composition of the extracellular fluid in the body.

Solution replacing plasma, must contain high-molecular substances that create colloid-osmotic (oncotic) pressure. Only then will it linger in the bloodstream for a long time. One of the substances that meets these requirements is dextran (a specially designed polysaccharide consisting of glucose molecules). Dextran is synthesized by a certain type of bacteria. For its industrial production, a method of growing a bacterial culture is used, and certain bacterial growth conditions contribute to the synthesis of dextran of the required molecular weight. Dextran molecules of a certain size do not pass through the pores in the capillary wall, therefore, they can replace plasma proteins that create colloid-osmotic pressure.
Purified dextran is such a low-toxic substance that it is considered a reliable plasma substitute for replenishing fluid deficiency in the body.

Sympathomimetics for shock

Sympathomimetics are called drugs that reproduce the effect of sympathetic stimulation. These include norepinephrine, adrenaline, and a large number of long-acting drugs.

In two cases of shock development it is especially necessary. Firstly, with neurogenic shock, during which the sympathetic system is deeply depressed. The introduction of sympathomimetics compensates for the decrease in the activity of sympathetic nerve centers and can completely restore the functions of the circulatory system.

Secondly, sympathomimetic agents are necessary for the treatment of anaphylactic shock, in the development of which excess histamine plays a leading role. Sympathomimetics have a vasoconstrictor effect in contrast to the vasodilator effect of histamine. Thus, norepinephrine and other sympathomimetics often save the lives of shock patients.

On the other side, use of sympathomimetic drugs in hemorrhagic shock it is most often inappropriate. Hemorrhagic shock is accompanied by maximum activation of the sympathetic nervous system, as well as the circulation of large amounts of adrenaline and norepinephrine in the blood. In this case, the administration of sympathomimetic drugs does not provide an additional positive effect.

Therapeutic effect changes in body position (“head lower than feet”). If during shock the pressure drops sharply, especially with hemorrhagic or neurogenic shock, it is necessary to change the position of the patient's body so that the head is at least 30 cm lower than the legs. This significantly increases the venous return of blood to the heart and, consequently, cardiac output. ejection. The head-down position is the very first and necessary step in the treatment of many types of shock.

Oxygen therapy. Since the main damaging factor during shock is too low a level of oxygen supply to tissues, in many cases breathing pure oxygen has a beneficial effect on patients.

However, very often positive effect of oxygen therapy turns out to be much less than expected, because In most cases of shock, the problem is not a violation of blood oxygenation in the lungs, but a violation of oxygen transport by the blood after oxygenation.

Use of glucocorticoids(hormones of the adrenal cortex that control carbohydrate metabolism). Glucocorticoids are often prescribed to patients with severe shock for the following reasons: (1) glucocorticoids have been empirically shown to often increase the force of cardiac contraction late in the development of shock; (2) glucocorticoids stabilize the state of lysosomes in tissue cells and thus prevent the release of lysosomal enzymes into the cytoplasm and their subsequent destruction of cellular structures; (3) glucocorticoids support glucose metabolism in severely damaged tissue cells.