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

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

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

Causes and mechanisms of development of traumatic shock.

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

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

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

The outcome of severe shock without treatment is usually death.

Shock symptoms.

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

Erectile phase of shock

The victim at the initial stage often feels severe pain and signals it with the means available to him: screaming, groaning, words, facial expressions, gestures.

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

In this phase, the body's compensatory capabilities have not yet been exhausted, and blood pressure is often elevated compared to the norm (as a reaction to pain and stress). At the same time spasm of skin vessels - pallor, increasing as bleeding continues and/or progression of shock. Observed cardiopalmus(tachycardia), rapid breathing (tachypnea), fear of death, cold clammy sweat(this sweat is usually odorless) tremor(trembling) or small muscle twitches. The pupils are dilated (reaction to pain), the eyes shine. The look is restless, does not stop at anything. Body temperature may be slightly elevated(37-38 C) even in the absence of signs of infection of the wound - simply as a result of stress, the release of catecholamines and increased basal metabolism. The pulse maintains a satisfactory filling, rhythm.

Torpid shock phase

In this phase, the patient in most cases stops screaming, moaning, crying, thrashing about in pain, does not ask for anything, does not demand. He is lethargic, lethargic, lethargic, drowsy, depressed, may lie in complete prostration or lose consciousness. Sometimes the victim can only make a weak groan. This behavior is due to the state of shock. In this case, pain does not decrease. Blood pressure decreases, sometimes to critically low numbers or is not detected at all when measured on peripheral vessels. Severe tachycardia. Pain sensitivity is absent or sharply reduced. He does not respond to any manipulations in the wound area. Either does not answer questions, or answers barely audibly. Seizures may occur. Involuntary excretion of urine and feces often occurs.

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

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

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

First aid (first aid) for shock

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

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

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

Remember! In no case do not feed or drink the victim with any damage to the abdominal cavity! If the patient has a wound or injury to the abdomen, then he is only allowed to wet his lips with a damp cotton swab. It is also not recommended to give food and drink to the victim with injuries to the head and / or neck, as swallowing functions may be impaired. Never give anything by mouth to an unconscious or semi-conscious victim!

Fractures, dislocations must be carefully immobilized on tires(any suitable boards) to reduce pain and prevent tiny pieces of tissue (bone marrow, adipose tissue) from entering the bloodstream, which can provoke the development of DIC in shock.

A patient in shock should be transported to the nearest hospital as soon as possible, but at the same time, exercise reasonable care and try not to shake the car along the road, so as not to increase pain, provoke renewed bleeding and exacerbate shock. Do not transfer the victim unless absolutely necessary, as any transportation causes additional suffering to the patient.

If possible, pain relief should be provided to a non-specialist - apply cold to the wound(ice pack or cold water) give 1-2 tablets of any of the available non-narcotic analgesics such as analgin, aspirin(reduces blood clotting) or, better, an injection of a non-narcotic analgesic.

If possible, it is necessary to ensure that the removal of neuropsychic stress (which also exacerbates shock) is available to a non-specialist: giving 1-2 tablets of any available tranquilizer or 40-50 drops of Corvalol, Valocordin, or a small amount of strong alcohol. But alcohol can be used only in extreme cases, and then on condition that a person tolerates it normally! Since it can worsen the patient's condition.

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

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

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

emergency medicine

general information

Short description

Approved
Joint Commission on the quality of medical services
Ministry of Health and Social Development of the Republic of Kazakhstan
dated June 23, 2016
Protocol #5

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

ICD-10 codes

Date of development/revision of the protocol: 2007/2016.

Protocol Users: doctors of all specialties, paramedical personnel.

Level of Evidence Scale (Table 1):

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

Classification

Classification

In the course of traumatic shock:
primary - develops at the moment or immediately after the injury;
secondary - develops delayed, often several hours after the injury.

Keith classification of severity of traumatic shock(table 2):

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

*Determination of the shock index may be incorrect when systolic blood pressure is below 50 mm. rt. Art., with severe traumatic brain injury, accompanied by bradycardia, with cardiac arrhythmias, in persons with an elevated level of "working blood pressure". In these situations, it is advisable to rely not only on the level of systolic blood pressure, but also on the amount of traumatic injuries.

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

Risk factors:
Rapid blood loss
overwork;
cooling or overheating;
fasting;
repeated injuries (transportation);
Combined injuries with mutual burdening.

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

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

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

II moderate: extensive damage to soft tissues with significant crush, damage to the pelvic bones, traumatic amputation, fracture of the ribs, contusion of the lungs, isolated damage to the abdominal organs. After some time from the moment of injury, there is a transition from the stage of centralization of blood circulation to the transitional one. After the therapy, the effect is observed within 2 hours, however, a wave-like worsening of the condition is possible.
Clinic: lethargy, decreased systolic blood pressure, pulse rate more than 150% of the age norm, weak filling. Shortness of breath, pallor of the skin, a decrease in the volume of circulating blood by 35-45%;

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

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

Diagnostics (outpatient clinic)

DIAGNOSTICS AT OUTPATIENT LEVEL

Diagnostic criteria

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

Anamnesis: mechanical injury that led to traumatic shock.

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

Laboratory research: no.

Measurement of blood pressure - lowering blood pressure.

Diagnostic algorithm

Diagnostics (hospital)

DIAGNOSTICS AT THE STATIONARY LEVEL

Diagnostic criteria at the hospital level:
Complaints and anamnesis: see outpatient level.
Physical examination: see ambulatory level.

Laboratory research:
Complete blood count (if there are signs of bleeding, anemia is possible (decrease in hemoglobin, red blood cells);
urinalysis (may not change);
Biochemical blood test (possible increase in transaminases, C-reactive protein. Abdominal injury is characterized by an increase in bilirubin, amylase);
blood gases (possible changes in violation of the function of external respiration, a decrease in oxygen levels less than 80 mm Hg, an increase in CO2 more than 44 mm Hg);
coagulogram (there may be no changes, but with the development of coagulopathy, changes characteristic of the intravascular coagulation syndrome are possible);
determination of blood group and Rh affiliation.

Instrumental research:
measurement of blood pressure;
Plain radiography of the skull, pelvis, limbs, chest and abdominal organs in two projections - determination of the presence of bone pathology;
Ultrasound examination of the pleural and abdominal cavities - in the presence of hemothorax or hemoperitoneum, fluid is determined in the pleural and abdominal cavities on the side of the lesion;
measurement of CVP - a sharp decrease is observed with massive blood loss;
Diagnostic laparoscopy and thoracoscopy - allows you to clarify the nature, localization;
Bronchoscopy (in case of combined trauma, the flow of scarlet blood from the bronchus in case of damage to the lung. Damage to the trachea and bronchi can be visualized);
ECG (tachycardia, signs of hypoxia, myocardial damage);
CT, MRI (the most informative research methods, allow you to most accurately determine the location, nature of the damage).

Diagnostic algorithm: see ambulatory level.

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

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

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Treatment

Drugs (active substances) used in the treatment

Treatment (ambulatory)

TREATMENT AT OUTPATIENT LEVEL

Treatment tactics

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

Medical treatment:
oxygen inhalation;
Maintain or provide venous access - venous catheterization;
· interrupt shockogenic impulses (adequate analgesia):
Diazepam [A] 0.5% 2-4 ml + Tramadol [A] 5% 1-2 ml;
Diazepam [A] 0.5% 2-4 ml + Trimeperidine [A] 1% 1 ml;
Diazepam [A] 0.5% 2-4 ml + Fentanyl [B] 0.005% 2 ml.
Children:
from 1 year Tramadol [A] 5% 1-2 mg/kg;
trimeperidine [A] 1% up to 1 year is not prescribed, then 0.1 ml / year of life, Fentanyl [B] 0.005% 0.05 mg / kg.

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

List of essential medicines:
oxygen (medical gas);
diazepam 0.5%; [BUT]
tramadol 5%; [BUT]
trimeperidine 1%; [BUT]
fentanyl 0.005%; [AT]
dopamine 4%; [FROM]
prednisolone 30 mg; [BUT]
Sodium chloride 0.9% [B].

List of additional medicines:
hydroxyethyl starch 6%. [BUT]

Algorithm of actions in emergency situations

Other types of treatment: no.

Indications for expert advice:
consultation of narrow specialists in the presence of concomitant pathology.

Preventive actions:
timely and effective stop of bleeding, in order to reduce the decrease in BCC;
timely and effective interruption of shockogenic impulses in order to reduce the risk of developing traumatic shock due to the pain component;
effective immobilization to reduce the risk of secondary injuries during transportation and reduce pain.

stabilization of blood pressure;
stop bleeding;
improvement in the patient's condition.

Treatment (hospital)

TREATMENT AT THE STATIONARY LEVEL

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

Indications for specialist consultation: see outpatient level.

Indications for transfer to the intensive care unit and resuscitation:
Receipt of the victim in a state of non-stopped traumatic shock at the stage of emergency rest;
Secondary developed traumatic shock during the stay of the victim in the specialized department of the hospital, as well as after the treatment and diagnostic procedures.

Treatment effectiveness indicators: see ambulatory level.

Hospitalization

Indications for planned hospitalization: no.

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

Information

Sources and literature

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

Information

Abbreviations used in the protocol:

HELL	-	arterial pressure
car accident	-	traffic accident
IVL	-	artificial lung ventilation
CT	-	CT scan
ICD	-	International Classification of Diseases
MRI	-	Magnetic resonance imaging
OKS	-	acute coronary syndrome
BCC	-	circulating blood volume
GARDEN	-	systolic blood pressure
CPR	-	cardiopulmonary resuscitation
CVP	-	central venous pressure
heart rate	-	heart rate

List of protocol developers:
1) Maltabarova Nurila Amangalievna - Candidate of Medical Sciences of JSC "Astana Medical University", Professor of the Department of Emergency Medicine and Anesthesiology, Resuscitation, Member of the International Association of Scientists, Teachers and Specialists, Member of the Federation of Anesthesiologists-Resuscitators of the Republic of Kazakhstan.
2) Sarkulova Zhanslu Nukinovna - Doctor of Medical Sciences, Professor, RSE on REM "Marat Ospanov West Kazakhstan State Medical University", Head of the Department of Emergency Medical Care, Anesthesiology and Resuscitation with Neurosurgery, Chairman of the branch of the Federation of Anesthesiologists-Resuscitators of the Republic of Kazakhstan in Aktobe region
3) Alpysova Aigul Rakhmanberlinovna - Candidate of Medical Sciences, RSE on REM "Karaganda State Medical University", Head of the Department of Emergency and Emergency Medical Care No. 1, Associate Professor, member of the "Union of Independent Experts".
4) Kokoshko Aleksey Ivanovich - Candidate of Medical Sciences, JSC "Astana Medical University", Associate Professor of the Department of Emergency Emergency Care and Anesthesiology, Resuscitation, Member of the International Association of Scientists, Teachers and Specialists, Member of the Federation of Anesthesiologists-Resuscitators of the Republic of Kazakhstan.
5) Akhilbekov Nurlan Salimovich - RSE on REM "Republican Center for Air Ambulance" Deputy Director for Strategic Development.
6) Grab Alexander Vasilyevich - State Enterprise on the REM "City Children's Hospital No. 1" Health Department of the city of Astana, head of the resuscitation and intensive care unit, member of the Federation of Anesthesiologists-Resuscitators of the Republic of Kazakhstan.
7) Sartaev Boris Valerievich - RSE on REM "Republican Center for Air Ambulance", doctor of the mobile brigade of air ambulance.
8) Dyusembayeva Nazigul Kuandykovna - Candidate of Medical Sciences, JSC "Astana Medical University", Head of the Department of General and Clinical Pharmacology.

Conflict of interests: missing.

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

Conditions for revision of the protocol: revision of the protocol 3 years after its publication and from the date of its entry into force or in the presence of new methods with a level of evidence.

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Update: December 2018

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

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

Reasons for development

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

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

Scheme

After the disappearance of energy resources, the consciousness slows down, the pressure drops, but the heart continues to work with all its might. Despite this, the blood circulates poorly through the vessels, which is why most of the tissues lack oxygen and nutrients. The kidneys are the first to suffer, and then the functions of all other organs are disrupted.

The following factors can further worsen the prognosis:

blood loss. A decrease in the amount of blood circulating through the vessels will lead to a greater drop in pressure in a short period of time. Often severe blood loss with the development of shock is the cause of death;
Crash Syndrome. Crushing or crushing of tissues leads to their necrosis. Dead tissues are the strongest toxins for the body, which, when released into the blood, poison the victim and worsen his well-being;
Blood poisoning/sepsis. The presence of a contaminated wound (due to a gunshot wound, when wounded with a dirty object, after contact with the ground on the wound, etc.) is the risk of dangerous bacteria entering the blood. Their reproduction and active life can lead to abundant release of toxins and disruption of the functions of various tissues;
Body condition. Protective systems and the body's ability to adapt are not the same in different individuals. Any shock is a great danger for children, the elderly, people with a severe chronic disease or with a persistent decrease in immunity.

The state of shock develops rapidly, it disrupts the work of the whole organism and often ends in death. Only timely treatment can improve the prognosis and increase the chances of the victim to live. And in order to provide it, it is necessary to recognize the first signs of traumatic shock in a timely manner and call an ambulance team (ambulance).

Symptoms

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

Typical clinical manifestations include:

Change of consciousness

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

apathetic. Everything that happens around a person, he practically does not care. The patient may not respond or respond poorly to verbal appeals, pats on the cheeks, changes in the environment and other irritants;
dynamic. The victim does not change the position of the body or is extremely sluggish trying to make any movement;
Emotionless. If the patient's speech is preserved, he communicates in monosyllables, without intonations and facial expressions, absolutely indifferent.

One thing unites these two stages - the inability to adequately assess the presence of serious damage and a threat to one's life. Therefore, he needs the help of people around him to call the doctor.

Increase in the number of heartbeats (HR)

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

Respiratory failure

Since most tissues lack oxygen, the body tries to increase its supply from the environment. This leads to an increase in the frequency of breathing, it becomes superficial. With a significant deterioration in well-being, it is compared with the "breath of a hunted animal."

Lowering blood pressure (BP)

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

Metabolic disorder

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

Classification

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

The modern classification according to Keith is presented below:

I (light) Oppressed, however, the patient makes contact. Answers briefly, emotionally, there is practically no facial expressions. Shallow, frequent (20-30 breaths per minute), easily determined. Up to 9090-10070-80

Degrees	degree of consciousness	Breathing changes	Heart rate (bpm)	BP (mm Hg)
Degrees	degree of consciousness	Breathing changes	Heart rate (bpm)	Syst. (upper on the tonometer)	diast. (lower on the tonometer)
I (light)	Oppressed, however, the patient makes contact. He answers briefly, without emotion, there is practically no facial expressions.	Shallow, frequent (20-30 breaths per minute), easily determined.	Up to 90	90-100	70-80
II (moderate)	The victim responds only to a strong stimulus (loud voice, patting on the face, etc.). Contact is difficult.	Very superficial, respiratory rate over 30.	90-119	70-80	50-60
III (heavy)	The patient is unconscious or in complete apathy. He does not respond to any stimuli. Pupils practically do not narrow in the light.	Breathing is almost imperceptible, very shallow.	Over 120	Less than 70	Less than 40

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

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

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

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

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

Predicting in advance which stage a patient will develop is quite difficult - it depends on a large number of factors, including the state of the body, the severity of injuries and the volume of therapeutic measures.

First aid

What determines whether a person will survive or die with the development of this pathology? Scientists have proved that the most important is the timeliness of first aid for traumatic shock. If it is provided in the near future and the victim is taken to the hospital within an hour, the likelihood of death is significantly reduced.

Here are some steps you can take to help the patient:

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

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

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

What not to do when shocked

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

Treatment

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

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

Complete pain relief. Despite the fact that the doctor / paramedic administers some of the necessary drugs while still in the ambulance, in the hospital, doctors supplement analgesic therapy. If necessary, the operation, the patient can be immersed in full anesthesia. It should be noted that the fight against pain is one of the most important moments in antishock therapy, since this sensation is the main cause of the pathology;
Restoration of patency of the respiratory tract. The need for this procedure is determined by the condition of the patient. In case of violations of the act of breathing, insufficient inhalation of oxygen or damage to the trachea, a person is connected to an artificial respiration apparatus (abbreviated as ventilator). In some cases, this requires an incision in the neck with the installation of a special tube (tracheostomy);
Stop bleeding. The faster the blood leaves the vessels - the lower the blood pressure drops - the more the body suffers. If this pathological chain is interrupted and normal blood flow is restored, the patient's chances of survival are significantly increased;
Maintaining adequate blood flow. In order for blood to move through the vessels and nourish the tissues, a certain level of blood pressure and a sufficient amount of blood itself are required. Transfusion of plasma-substituting solutions and special drugs that stimulate the cardiovascular system (Dobutamine, Norepinephrine, Adrenaline, etc.) help doctors restore hemodynamics to doctors;
Restoration of normal metabolism. While the organs are in "oxygen starvation", metabolic disorders occur in them. To correct metabolic disorders, doctors may use glucose-salt solutions; vitamins B 1, B 6, PP and C; albumin solution and other medical measures.

With the successful achievement of these goals, human life ceases to be in danger. For further treatment, he is transferred to the ICU (intensive care unit) or to a regular hospital inpatient department. It is rather difficult to speak about the terms of treatment in this case. It can range from 2-3 weeks to several months, depending on the severity of the condition.

Complications

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

Sepsis

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

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

TELA

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

Pulmonary embolism (or PE for short) occurs when there is a change in the normal state of the blood and blood clots enter the lungs. The outcome depends on the size of the pathological particles and the timeliness of the treatment. With simultaneous blockage of both pulmonary arteries, a fatal outcome is inevitable. With obstruction of only the smallest branches of the vessel, the only manifestation of PE may be a dry cough. In other cases, to save life, it is necessary to carry out special therapy that thins the blood, or angiosurgical intervention.

hospital pneumonia

Despite thorough disinfection, in any hospital there is a small percentage of microbes that have formed resistance to various antiseptics. It can be Pseudomonas aeruginosa, resistant staphylococcus aureus, influenza bacillus and others. The main target for these bacteria are immunocompromised patients, including shock patients in intensive care units.

Hospital pneumonia is in the first place among the complications caused by hospital flora. Although resistant to most antibiotics, this lung lesion is largely treatable with reserve drugs. However, pneumonia that develops against the background of shock is always a serious complication that worsens the prognosis for a person.

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

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

However, even with successful treatment of acute renal failure, kidney tissue can be damaged enough to develop chronic kidney disease. This is a pathology in which the ability of an organ to filter blood and remove toxic substances worsens. It is almost impossible to completely recover from it, but the right therapy can slow or stop the progression of CKD.

Stenosis of the larynx

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

Treatment of severe stenosis of the larynx is carried out surgically. With timely diagnosis of pathology and the normal state of the body, the prognosis for this complication is almost always favorable.

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

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

Traumatic shock (T79.4)

general information

Short description

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

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

Triggers of traumatic shock are pain and excessive (afferent) impulses, acute massive blood loss, traumatization of vital organs, mental shock.

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

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

Code (codes) according to ICD-10:

T79.4 Traumatic shock

Ruled out:

Shock (caused):

Obstetric (O75.1)

Anaphylactic

NOS (T78.2)

Due to:

Pathological reaction to food (T78.0)

Adequately prescribed and correctly administered drug (T88.6)

Serum reactions (T80.5)

Anesthesia (T88.2)

Electrical induced (T75.4)

Non-traumatic NKD (R57.-)

From being struck by lightning (T75.0)

Postoperative (T81.1)

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

T79.8 Other early complications of trauma

T79.9 Early complication of injury, unspecified

Classification

In the course of traumatic shock:

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

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

Stages of traumatic shock:

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

3. Refractory shock - all ongoing therapy is unsuccessful.

The severity of traumatic shock:

Shock 1 degree - GARDEN 100-90 mm Hg, pulse 90-100 in 1 minute, satisfactory filling.

Shock of the 2nd degree - GARDEN 90-70 mm Hg, pulse 110-130 per 1 minute, weak filling.

Shock 3rd degree - GARDEN 70-60 mm Hg, pulse 120-160 per 1 minute, very weak filling (filamentous).

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

Factors and risk groups

1. Rapid blood loss.

2. Overwork.

3. Cooling or overheating.

4. Fasting.

5. Repeated injuries (transportation).

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

Diagnostics

Diagnostic criteria: the presence of mechanical trauma, clinical signs of blood loss, decrease in blood pressure, tachycardia.

Typical symptoms of shock:

Cold, moist, pale cyanotic or marbled skin;

Sharply slowed blood flow of the nail bed;

Darkened consciousness;

dyspnea;

Oliguria;

Tachycardia;

Decrease in arterial and pulse pressure.

An objective clinical examination reveals

There are two phases in the development of traumatic shock.

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

For torpid phase characterized by darkening of consciousness, stupor and the development of a coma as an extreme degree of cerebral hypoxia caused by disorders of the central circulation, a decrease in blood pressure, a soft, frequent pulse, pale skin. At this stage, at the prehospital stage, the emergency physician should rely on the level of blood pressure and try to determine the amount of blood loss.

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

With shock 1 tbsp (blood loss 15-25% of the BCC - 1-1.2 l) SI = 1 (100/100).

With shock 2 tbsp (blood loss 25-45% of the BCC - 1.5-2 l) SI = 1.5 (120/80).

With shock 3 tbsp (blood loss of more than 50% of the BCC - more than 2.5 l) SI = 2 (140/70).

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

Given the possibilities of the prehospital stage, it is possible to compare different degrees of shock and their clinical signs.

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

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

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

With further aggravation of the patient's condition, a terminal condition may develop - shock of the 4th degree.

List of main diagnostic measures:

1. Collection of complaints, anamnesis, general therapeutic.

2. Visual examination, general therapeutic.

3. Measurement of blood pressure in the peripheral arteries.

4. Study of the pulse.

5. Heart rate measurement.

6. Measurement of respiratory rate.

7. General therapeutic palpation.

8. General therapeutic percussion.

9. General therapeutic auscultation.

10. Registration, interpretation and description of the electrocardiogram.

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

List of additional diagnostic measures:

1. Pulse oximetry.

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Treatment

Medical care tactics

Traumatic shock treatment algorithm

General activities:

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

2. Provide measures to stop bleeding.

3. Interrupt shockogenic impulses (adequate anesthesia).

4. Normalization of BCC.

5. Correction of metabolic disorders.

6. In other cases:

Lay the patient with a raised foot end by 10-45%, Trendelenburg position;

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

Specific activities:

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

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

2. Pain relief:

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

In severe traumatic brain injury - do not administer ketamine!

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

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

3. Transport immobilization.

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

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

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

3. *Dopamine 200 mg per 400 ml

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

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

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

Information

Sources and literature

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

Information

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

Employees of the Department of Emergency and Emergency Medical Care, Internal Medicine No. 2 of the Kazakh National Medical University. S.D. Asfendiyarova: Candidate of Medical Sciences, Associate Professor Vodnev V.P.; Candidate of Medical Sciences, Associate Professor Dyusembaev B.K.; Candidate of Medical Sciences, Associate Professor Akhmetova G.D.; Candidate of Medical Sciences, Associate Professor Bedelbayeva G.G.; Almukhambetov M.K.; Lozhkin A.A.; Madenov N.N.

Head of the Department of Emergency Medicine of the Almaty State Institute for the Improvement of Doctors - Ph.D., Associate Professor Rakhimbaev R.S.

Employees of the Department of Emergency Medicine of the Almaty State Institute for the Improvement of Doctors: Candidate of Medical Sciences, Associate Professor Silachev Yu.Ya.; Volkova N.V.; Khairulin R.Z.; Sedenko V.A.

Attached files

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

Causes of traumatic shock

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

Development mechanism

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

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

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

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

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

Symptoms of traumatic shock

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

The erectile stage in many victims lasts a few minutes, and sometimes less. Severe pain and fear make them very agitated, the person may scream, moan, cry, may become aggressive and resist help. The victims have an unnatural pallor of the skin, cold sticky sweat, rapid breathing and palpitations. The more active and inadequate the behavior of a person during the erectile stage of traumatic shock, the more difficult the torpid one will proceed.
The torpid stage usually comes on very quickly. Patients stop screaming, move actively, lethargy or loss of consciousness occurs. This does not mean that they stop feeling pain, just that the body no longer has the strength to signal it. That is why even if the patient is unconscious, all manipulations must be performed very carefully.

Chills may appear in patients, the skin becomes even more pale, cyanosis (cyanosis) of the lips and mucous membranes is observed. The blood pressure of the victim decreases, the pulse is weak, sometimes barely palpable, and at the same time it is quickened. In the future, disturbances in the functioning of internal organs develop: (reduction in urine output or its absence), pulmonary, hepatic, etc.

The severity of pain shock

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

I degree of shock (mild)

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

II degree of shock (medium)

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

III degree of shock (severe)

The victim is in a stupor or unconscious, practically does not react to irritants, the skin is pale, cold. Blood pressure falls below 75 mm Hg. Art., the pulse is hardly determined only on large arteries, the frequency of strokes is more than 130 beats per minute. The prognosis in this situation is unfavorable, especially when, against the background of ongoing therapy and in the absence of bleeding, it is not possible to raise blood pressure.

IV degree of shock (terminal)

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

First aid for traumatic shock

Traumatic shock is a medical emergency with specialized equipment and a wide range of medications. But the first aid provided on the spot by a person who happened to be nearby is extremely important and can save the victim's life. There are many cases when people who received non-fatal injuries died precisely from shock.

If an injured person is found, an ambulance should be called immediately.
It is impossible to remove splinters, a knife or other objects from the wound, sometimes they “block” the vessels and their removal can lead to increased bleeding and additional trauma to the victim.
Also, you should not try to remove the remnants of clothing from a person who has received a burn.

Stop bleeding

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

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

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

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

Making breathing possible

It is necessary to unfasten or remove clothing that can constrain the chest and neck, remove foreign objects from the oral cavity. If the victim is unconscious, you need to turn your head to the side and fix the tongue in order to exclude the possibility of vomit entering the respiratory tract and retraction of the tongue.

In the absence of breathing and pulse, it is necessary to start artificial respiration and chest compressions.

Warming the victim

Even in warm weather, with traumatic shock, a person may begin to feel chills, so it is necessary to warm him with a blanket, clothing, or any other available means. This is especially true in the cold season, since hypothermia aggravates the condition of the victim.

Anesthesia

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