Infusion antishock therapy. Anti-shock kit number one

§ Normalization of external respiration and gas exchange.

All are shown inhalations of humidified oxygen (through nasal catheters, face mask) at a rate of 4-8 l/min.

§ Anesthesia.

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

A combination of medicines is possible (in different combinations): 1 ml of 2% solutionpromedol or 1 ml omnopon , 2 ml 1% r-radiphenhydramine or 1-2 ml 2.5% solutionpipolfena , 2 ml 50% r-ra metamizole sodium (analgin), 2 ml 0.5% r-radiazepam (seduxen etc.), 10.0 ml of 20% solutionoxybutyrate sodium.

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

§ Infusion therapy.

The algorithm for using venous access: a peripheral catheter in the area of ​​intact skin, a peripheral catheter through the burned surface, central venous access through intact skin, and, last but not least, central vein catheterization through the burn wound.

Firsthours 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 with the introduction glucose-electrolyte solutions. This choice is due to the ineffectiveness of colloid preparations in the early period of burn shock. The first step is to 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 drip (ratio of crystalloids and colloids in shock I- II degree is 2 and 1 ml per 1% burn and 1 kg of body weight, with shock III-IV degrees - respectively 1.5 and 1.5 ml);

· rheopolyglucin 5-7.5 ml/kg;

· drugs hydroxyethyl starches (refortan , stabilizol) 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 entered in the first 8 hours from injury. After 8 hours, with stable hemodynamics, it is recommended to reduce the rate of infusion and start the introduction of drugs for correction. hypoproteinemia(fresh frozen plasma, serum albumin). Recommended share protein-containing solutions in the daily balance of injected fluids is from 20 to 25%.

§ Inotropic support.

Sometimes with extremely severe burn shock (or with late infusion therapy), it is impossible to maintain infusion therapy (the total volume of infusion in the first 24 hours should not exceed 4 ml / kg per 1% of the burn area) blood pressure at the perfusion level (above 80-90 mm Hg. Art.). 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 (400mg in 250ml saline) at a rate of 2-20mcg/kg/min.

§ Correction of blood hemorheology.

From the first hours, the introduction of low molecular weight heparins ( fraxiparine , clexana , fragmina) or unfragmented heparin to correct the aggregate state of the blood:

· Fraxiparine in / in 0.3 ml 1 or 2 times a day;

· Heparinwith an initial bolus of 5-10 thousand U and subsequent IV infusion at the rate of 1-2 thousand U / h (or 5-6 thousand U every 4-6 hours) under the control of APTT and platelet count.

To reduce the aggregation of blood cells, the following are used:

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

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

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

§ Organ protection.

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

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

· Vitamin C 5% solution of 250 mg 3-4 times a day;

· Polarizing Blend 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)/duck). All patients undergo bladder catheterization to control diuresis. Oh good microcirculation in the kidneys, urine output in the amount of 0.5-1.0 ml / kg / h is indicated. Methusol and ringer's 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 increase gluconeogenesis. Perftroran in 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 administration of Perfron 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 dressing is applied to the affected areas.

§ Criteria for the adequacy of the 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, an increase in body temperature, a decrease in the severity of dyspeptic disorders.

Anaphylactic shock (according to the ICD year - code T78.2) is a rapid generalized allergic reaction that directly threatens a person's life and can develop within seconds.

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

Anaphylactic shock is a very dangerous allergic reaction that threatens a person's 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 take 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 as a result of contact with microdoses of the allergen, anaphylaxis may develop. 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 a sharp, intense pain in the area of ​​​​the bite or injection. In the case of oral intake of the allergen, the pain is localized in the abdomen and in the hypochondrium.

Additional signs of the development of an anaphylactic shock clinic are:

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

Consequences of anaphylactic shock - edema

• skin itching gradually spreading throughout the body;
• a sharp drop in blood pressure;
• pallor of the skin, cyanosis of the lips and extremities;
• increased heart rate and respiration;
• delusional disorders, fear of death;
• when taken orally - loose stools, nausea, swelling of the oral mucosa, vomiting, diarrhea, swelling of the tongue;
• impaired vision and hearing;
• spasm of the larynx and bronchi, as a result of which the victim begins to suffocate;
• fainting, impaired consciousness, convulsions.

The reasons

Anaphylactic shock develops under the influence of many different factors, the main of which 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: shrimps, 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.

• Medical preparations

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: anti-tetanus, anti-rabies and anti-diphtheria;
7. Muscle relaxants: norcuron, succinylcholine, trakrium;
8. Enzymes: chymotrypsin, streptokinase, pepsin;
9. Blood substitutes: albumin, reopoliglyukin, polyglukin, stabizol, refortan;
10. Latex: disposable gloves, instruments, catheters.

Advice! Anaphylactic shock in children, which has not even taken place 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 all conceivable (and often unthinkable) ways. However, this should not be done, since the baby's immune system - in order to form normally - must encounter a variety of substances and materials that surround us in life.

All the same, it will not be possible to hide from all the dangers, but it is very easy to harm the baby with excessive care. Remember that everything is in moderation!

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

• Plants

1. Forbs: dandelion, ragweed, couch grass, wormwood, nettle, quinoa;
2. Deciduous trees: poplar, linden, birch, maple, hazel, ash;
3. Flowers: lily, rose, gladiolus, orchid, daisy, carnation;
4. Coniferous: 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 wool); as well as feathers and fluff 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 - specific antibodies are released. They cause a massive release of inflammatory factors (histamine, prostaglandins and others). Antibodies cause a massive release of inflammatory factors (histamine, prostaglandins, and others);
• Patochemical - inflammation factors spread through tissues and organs, where they provoke violations of their work;
• Pathophysiological - a violation of the normal functioning of organs and tissues can be expressed significantly, 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 - a short syncope is possible;
3. The effect of therapy is easily treatable;
4. The period of precursors is approx. (redness, itching, rash (urticaria), burning sensation all over the body, hoarseness and loss of voice with laryngeal edema, Quincke's edema of different localization).

The victim manages to describe his condition, complaining of: dizziness, severe weakness, chest pain, headache, loss of vision, lack of air, tinnitus, fear of death, numbness of the lips, fingers, tongue; as well as pain in the lower back and abdomen. Expressed pallor or cyanosis of the skin of the face. Some experience bronchospasm - exhalation is difficult, wheezing is heard at a distance. In some cases, vomiting, diarrhea and involuntary urination or defecation appear. The pulse is thready, the heart rate is increased, muffled heart sounds.

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

1. BP - reduced to 60/40;
2. Loss of consciousness - about a minute;
3. The effect of therapy is delayed, observation is required;
4. The period of precursors is about 2-5 minutes. (dizziness, pallor of the skin, urticaria, general weakness, anxiety, pain in the heart, fear, vomiting, angioedema, suffocation, sticky cold sweat, cyanosis of the lips, dilated pupils, often involuntary defecation and urination).
5. In some cases, convulsions develop - tonic and clonic, and then the victim loses consciousness. Thready pulse, tachycardia or bradycardia, muffled heart sounds. In rare cases, bleeding develops: nasal, gastrointestinal, uterine.

Severe course (malignant, fulminant)

1. AD: not defined at all;
2. Loss of consciousness: over 30 minutes;
3. Results of therapy: none;
4. period of harbingers; a matter of seconds. The victim does not have time to complain about the sensations that have arisen, losing consciousness very quickly. Emergency care for this type of anaphylactic shock must be urgent, otherwise death is inevitable. The victim has pronounced pallor, 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 wheezing. The pulse is threadlike, it is not actually palpable, heart sounds are not audible.

A recurrent or protracted course, which is characterized by recurring episodes of anaphylaxis, occurs when the allergen continues to enter the body without the knowledge of the patient

• According to clinical forms:

1. Asphyctic - 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 up to the absolute impossibility of physiological breathing);
2. Abdominal - dominated by pain in the abdomen, similar to that in acute appendicitis, as well as perforated gastric ulcer. These sensations arise due to spasm of the smooth muscles of the intestinal wall. Vomiting and diarrhea are characteristic;
3. Cerebral - swelling of the brain and its membranes develops, which manifests itself in the form of convulsions, nausea and vomiting, which does not give relief, as well as states of stupor or coma;
4. Hemodynamic - the first to appear is pain in the region of the heart, similar to that in 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, should be as quick as possible so that assistance is timely. After all, the prognosis for the patient's life will directly depend on how quickly he will be provided with first and subsequent medical care.

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

In laboratory studies, the following are determined:

• In a clinical blood test:

1. anemia (decrease in the number of red blood cells),
2. leukocytosis (an increase in the number of white blood cells),
3. eosinophilia (increased number of eosinophils).

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

• In a biochemical blood test:

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

• Plain chest x-ray shows interstitial pulmonary edema.
• ELISA detects specific Ig E and Ig G.

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

Treatment

First aid for anaphylactic shock (first aid) should be provided as follows:

• Prevent the allergen from entering the body of the victim - apply a pressure bandage over the bite, remove the sting of the insect, attach 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, by laying a blanket rolled up with a roller);

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

In anaphylactic shock, you can not lay the head of the victim on a pillow - this will reduce the blood supply to the brain

Repeat these manipulations without interruption until a pulse and breathing appear or until an ambulance arrives.

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

The actions of a nurse and a doctor in the relief of anaphylactic shock include:

• Control of vital functions - blood pressure, pulse, ECG, oxygen saturation;
• Control of airway patency - cleaning the mouth from vomiting, triple reception for the withdrawal of the lower jaw (Safara), tracheal intubation;

Note! With severe edema and spasm of the glottis, a conicotomy is indicated (performed by a doctor or paramedic - the larynx is cut between the cricoid and thyroid cartilages) or tracheotomy (strictly in a medical facility);

• The introduction of 0.1% solution of Adrenaline hydrochloride in a quantity of 1 ml (diluted with sodium chloride to 10 ml and, if the place of introduction of the allergen is known - a bite or injection) - it is chipped subcutaneously);
• Introduction (in / in or sublingually) 3-5 ml of Adrenaline solution;
• The introduction of the remaining solution of Adrenaline, dissolved in 200 ml of sodium chloride (drip, intravenously, under the control of blood pressure);

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

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

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

• Introduction with severe respiratory failure 5-10 ml of 2.4% solution of Eufillin;
• The introduction of antihistamine drugs - Suprastin, Dimedrol, Tavegil;

Note! Antihistamines for anaphylactic shock are injected, and then the patient switches to tablet forms.

• Inhalation of 40% humidified oxygen (4-7 l/min.);
• In order to avoid further redistribution of blood and the formation of acute vascular insufficiency - in / in the introduction of colloid (Gelofusin, Neoplasmagel) and crystalloid (Plasmalit, Ringer, Ringer-lactate, Sterofundin) solutions;
• The introduction of diuretics (indicated for the relief of pulmonary and cerebral edema - Furosemide, Torasemide, Mannitol).
• Appointment of anticonvulsants in the cerebral form of the disease (10-15 ml of 25% magnesium sulfate and tranquilizers - Relanium, Sibazon, GHB).

Note! Hormonal drugs and histamine blockers contribute to the relief of allergy manifestations during the first three days. But for another two weeks, the patient needs to continue desensitizing therapy.

After the acute symptoms are eliminated, the doctor will prescribe the patient treatment in intensive care or intensive care unit.

Complications and their therapy

Anaphylactic shock most often does not pass without a trace.

After relief of respiratory and heart failure, a number of symptoms may persist in the patient:

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

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

• neuritis;
• hepatitis
• vestibulopathy;
• recurrent urticaria;
• allergic myocarditis;
• diffuse damage to nerve cells (may cause the death of the patient);
• glomerulonephritis;
• angioedema;
• bronchial asthma.

Important! In case of repeated contact 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 emissions 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 provides early diagnosis and, accordingly, timely treatment:

1. treatment of allergic rhinitis,
2. eczema therapy;
3. treatment of atopic dermatitis,
4. pollinosis treatment,
5. conducting allergological tests;
6. detailed history taking;
7. putting on the title page of the medical card or medical history the names of intolerable medications;
8. carrying out tests for sensitivity to drugs before i / v or i / m administration;
9. observation after injection (from 30 min.).

• Tertiary prevention prevents relapses:

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

Medical workers must also follow a number of rules:

When treating a patient with anaphylactic shock, healthcare professionals should take into account the age of the patient when prescribing drugs.

• 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 age of the patient when prescribing drugs;
• avoid using Procaine as a diluent for antibiotics;
• patients with a history of allergies 3-5 days before the use of the prescribed drug and immediately 30 minutes before its administration - strongly recommend taking antihistamines (Semprex, Claritin, Telfast). Calcium and corticosteroids are also indicated;
• for the convenience of applying a tourniquet in case of shock, the first injection (1/10 of the usual dose) should be administered in 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 puncture the injection area with Adrenaline solution, apply cold;
• control injection sites;
• provide 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 the wards of patients with anaphylactic shock near manipulation rooms, as well as near the 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 the place of residence, monitor their registration at the dispensary.

Complete set of anti-shock first-aid kit according to SanPiN standards:

• Preparations:

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

• Expendable materials:

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

The first aid kit is supplied with instructions.

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

Fundamentals of antishock therapy and resuscitation in case of injuries

The treatment of traumatic shock and related terminal conditions is sometimes determined not so much by the availability of effective anti-shock agents, which are generally sufficient, but by the frequent need to provide assistance to victims in extremely difficult and unusual conditions (street, production, apartment, etc.). Nevertheless, despite what has been said, 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 such measures and means that will be technically the most accessible and, in their influence on the body of the victim, 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. So, in particular, to this day, discussions continue 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 dealt in part with questions of this kind, but nevertheless we consider it useful to emphasize once again that it is methodologically not entirely correct to speak of a combination of traumatic shock with various kinds of injuries. Such a situation could be discussed only if the injuries and traumatic shock developed independently of one another, i.e., were completely independent. In fact, 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 lesions have far from the same clinical manifestations, tactical maneuverability (a certain individualization of diagnostic and therapeutic measures) is undoubtedly necessary.

So, for example, in cerebral shock, in addition to conventional anti-shock therapy, ultrasound 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. surgical interventions on the urinary tract, the elimination of a shortage of circulating blood volume, the fight against secondary intestinal dysfunction, etc. With contusions of the heart-ECG, therapy similar to that of myocardial infarction. In acute blood loss - determination of the amount of blood loss, active fight against anemia, etc.

As for the adoption of 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 benefits already being carried out. At the same time, 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 at the pre-hospital stages, not to mention cases of mass injuries, it is inaccessible. Thus, when discussing the possibility of individual therapeutic solutions in traumatic shock and terminal states, one should first of all take into account the time elapsed from the moment of injury, the scene of the incident and the tactical situation. Thus, in the conditions of providing assistance by an ambulance team, in isolated cases of traumatic shock, therapeutic maneuverability is much wider than in 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 the organization of assistance to the victim, it is practically impossible to individualize therapy, since this requires additional sufficiently detailed information, the collection of which may require a large and completely unacceptable investment of time.

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

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

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

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

A schematic diagram of 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, providing access to fresh air

2. Wound closure with aseptic dressings

3. Drug complex: inside 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 the pleural cavities with 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% solution of aminophylline, 10 ml of 10% solution of calcium chloride.

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

9. With progressive hemothorax and tension pneumothorax - thoracotomy.

The basic scheme of treatment of cerebral shock is as follows.

1. Strict bed rest.

2. Prolonged craniocerebral hypothermia.

3. Oxylidine 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, it can be administered intramuscularly).

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

5. a) In case of hypertensive syndrome - intravenous administration of 10% calcium chloride solution 10 ml, 40% glucose solution 40-60 ml, 2.4% aminofillin solution 5-10 ml, 10% mannitol solution up to 300 ml, intramuscular injection 25% magnesium sulphate solution 5 ml, 1% vikasol solution 1 ml. b) in case of hypotensive syndrome, intravenous administration of isotonic sodium chloride solution and 5% glucose solution up to 500-1000 ml, hydrocortisone 25 mg.

6. Spinal punctures - medical and diagnostic.

7. In case of respiratory failure - tracheostomy, artificial or assisted ventilation of the lungs.

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, self- and mutual assistance, only paragraphs. 1-3.

MED24INFO

T. M. DARBINYAN A. A. ZVYAGIN YU. I. TSITOVSKII, ANESTHESIA AND REANIMATION AT THE STAGES OF MEDICAL EVACUATION, 1984

Antishock Therapy

Lyak G. N., 1975; Shushkov G. D., 1978]. Initially, shock was referred to in the presence of a severe injury, accompanied by a decrease in blood pressure, tachycardia, and other homeostasis disorders. 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 trauma leading to shock are different - bleeding, burns, compression 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 the course of shock is judged not only by the level of blood pressure and pulse rate, but also by the data of central and peripheral hemodynamics - stroke and minute volume of the heart, circulating blood volume, and total peripheral resistance. Indicators of the acid-base state and electrolyte composition of the blood also indicate the severity of the shock. However, with a mass admission of victims, the signs of the severity of the injury and shock that are 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 behavior of the victim will make it possible to judge the functional state of his central nervous system.

The volume of intensive care 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 the loss of circulating blood and, above all, to the loss of plasma. 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 speedy 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 for perfusion of internal organs and peripheral tissues.

Infusion in 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. With low arterial and high central venous pressure, indicating right ventricular failure, one should start with drug therapy for heart failure (intravenous calcium chloride, strophanthin and drip adrenaline at a dilution of 1:200). In addition to plasma-substituting drugs, blood or blood products (if possible) are administered intravenously, as well as solutions to correct electrolyte and acid-base disorders, drugs that stimulate the activity of the cardiovascular system.

The adequacy of antishock therapy is controlled by the activity of the cardiovascular system. The elimination of the cause that led to the development of a shock reaction (bleeding, pain, etc.), and the conduct of infusion therapy in sufficient volume increase and stabilize the level of blood pressure, reduce the pulse rate, and improve peripheral circulation. The prognosis of dealing with shock depends primarily on the possibility of eliminating the main cause of its development.

Clinical characteristics of shock. Polytrauma, in which there is a large blood loss 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 - gas exchange disorders in case of chest injury, damage to the central nervous system in case of traumatic brain injury, blood loss, etc.

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

severity of the flow distinguish 4 degrees of shock [Smolnikov V. P., Pavlova 3. P., 1967; Shraiber M. G., 1967].

1. degree of shock - blood pressure is reduced by

1. 20 mmHg Art. compared with the original (within 90-100 mm Hg. Art.) The pulse rate increases by 15 - 20 beats per minute. Consciousness is clear, but motor restlessness and pallor of the skin are noted.

1. the degree of shock is a decrease in blood pressure to 75-80 mm Hg. Art., pulse rate 120-130 beats per minute. Sharp pallor of the skin, motor restlessness or some lethargy, shortness of breath.
2. degree of shock - blood pressure within 60-65 mm Hg. Art., 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 - 30-40 mm Hg. Art. * is determined with difficulty, the pulse is up to 170-180 beats per minute. Violation of the rhythm of breathing.

Antishock therapy should be multicomponent and aimed at:

1. suppression of pathological pain impulses with the help of local anesthesia, novocaine blockades, analgesia with pentran or trilene, administration of analgesics;
2. control and maintenance of the patency of the upper respiratory tract and the restoration of spontaneous breathing or mechanical ventilation;
3. rapid compensation of blood loss by intravenous administration of blood and plasma-substituting drugs (dextran, 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 the course of shock can be judged by such quite accessible clinical signs as the level of blood pressure, pulse rate, consciousness and the adequacy of the behavior of the victim.

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 bones of the lower leg 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. Quite naturally, blood loss leads to a rapid decrease in circulating blood volume, a decrease in blood pressure and an increase in pulse rate.

With external bleeding, self-help 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 injury site. The tourniquet is applied so tightly that the pulsation in the peripheral artery is not determined. Note the time of application of the tourniquet. If within 2 hours it is not possible to make a final stop of bleeding, then the tourniquet is removed for

1. 5 min using other temporary stop methods.

Temporary arrest of venous bleeding can be achieved by tightly packing the bleeding area with sterile material and applying a pressure bandage. However, the imposition of a pressure bandage is ineffective in case of damage to arterial vessels. Bleeding can also be stopped by clamping the bleeding vessels and ligating them with ligatures. A temporary stop of bleeding is performed by the personnel of the sanitary teams in the lesion. In the first aid unit (OPM), the final stop of external bleeding is performed.

Maintaining the activity of the cardiovascular system. When a victim with bleeding enters the APM or a medical institution, the approximate amount of blood loss is determined, guided by the level of blood pressure, pulse rate, skin color, hemoglobin and hematocrit.

Pale skin, a rapid pulse, and a decrease in blood pressure during bleeding indicate significant blood loss. It has been proven that a decrease in blood pressure by 20-30 mm Hg. Art. 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 the volume of circulating blood at V3. Such a pronounced decrease in blood pressure and blood volume creates a real danger to the life of the victim and requires urgent measures to be taken to maintain the activity of the cardiovascular system and to restore

Volume of infusion therapy, ml

Decreased blood pressure by 20-30 mm Hg. st (I - II degree of shock)

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

Decreased blood pressure by 30-

(II - III degree of shock)

Polyglucin - 400 Reopoliglyukin - 400 Ringer's solution or lactasol - 500 5% glucose solution - 500 Unigroup blood or plasma - 250

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

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

Polyglukin - 800 Reopoliglyukin - 800- 1200 Ringer's solution-1000 Lactasol solution-1000 5% glucose solution-g-1000-2000

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

Establish intravenous transfusion of solutions by puncture of the veins or their catheterization, which is more preferable. The veins are punctured with needles with a large inner diameter (1-1.5 mm). With low blood pressure and collapsed veins in the APM, a venesection is performed with the introduction of plastic catheters. Insertion of catheters into peripheral veins

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

To replenish the volume of circulating blood, fast drops or streams, depending on the severity of the shock, are transfused intravenously from 1.5 to 6 liters of solutions, depending on the state 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 the central venous pressure, it is assessed by the state of the jugular 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). With low central venous pressure, transfusion therapy is carried out depending on the level of arterial pressure. We propose the following scheme for conducting infusion therapy for hypovolemic shock (Table 7).

The lower the blood pressure, the faster

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 OPM, 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 glucose solutions with insulin, 200-250 ml of 5% sodium bicarbonate solution to compensate for the base deficiency in metabolic acidosis (see Chapter III).

With an unstable level of blood pressure, 1-2 ml of mezaton, norepinephrine, adrenaline, diluted in 250-500 ml of 5% glucose solution or Ringer's solution, are injected intravenously. The transfusion of these drugs should always be started with adrenaline, as it simultaneously stimulates cardiac activity and constricts peripheral vessels. If you immediately start treating hypotension with mezaton or norepinephrine, then with myocardial weakness, the effect can be negative, since these drugs mainly constrict blood vessels and thereby increase the load on the heart.

Intravenous administration of 10% calcium chloride solution

Yes, 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. Tools for venesection: scalpel, 2 clamps, needle holder with a needle, 3-4 silk or catgut ligatures, 4-5 sterile wipes,

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

Operation technique: allocate the largest

peripheral veins - in the elbow (v. cephalic a, v. basilica), in the anatomical snuffbox or on the front surface of the ankles. The projection area of ​​the vein is treated with iodine and alcohol. The operating 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 observing sterility or with minimal compliance with it. 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 extracted vein. With a clamp, the subcutaneous tissue is bluntly stratified over the vein and it is isolated for 1-2 cm from the surrounding tissues, trying not to damage the thin wall of the vein. Then, a clamp is placed under the selected vein and two ligatures are pulled. The upper (proximal) one is stretched and with its help the vein is lifted a few millimeters, the lower (distal) one 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 the needle or catheter is inserted into the lumen of the vein, a second (proximal, upper) ligature is tied over them. 2-3 silk sutures are applied to the skin. The cannula of the needle or catheter is fixed to the skin with a separate suture and additionally with strips of adhesive tape. Then apply an aseptic bandage.

Catheterization of peripheral veins according to Seldinger. Catheterization technique: a tourniquet is applied to the lower third of the shoulder and a dotted line

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 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 the fishing line into the vein. The line is removed, and the catheter left in the vein is attached 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 because of 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 estimated length of the catheter should be determined in advance by attaching it to the forearm and shoulder of the victim so that its end reaches the site of the 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 intra-arterially or intraosseously.

Intra-arterial blood injection is indicated in terminal conditions and prolonged hypotension. Isolate the radial or posterior tibial artery. Blood is injected towards the heart at a pressure of 180-200 mm Hg. Art.

Intraosseous administration of drugs is indicated in case of impossibility of puncture of the saphenous veins, with extensive burns. A shortened Beer needle is inserted into the wing of the ilium, ankle. Solutions, including blood, blood substitutes, drugs are administered at a rate usual for intravenous infusions.

TS with modern combat lesions develops in 20-25% of the wounded. Under traumatic shock is understood as a severe form of the general reaction of the body to trauma, combat, mainly 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 medical and diagnostic measures in the system of staged treatment of the wounded with evacuation as directed.

Pathogenesis:

Acute blood loss: a decrease in BCC, a decrease in the IOC, hypotension and a decrease in tissue perfusion, accompanied by their increasing hypoxia. Blood loss exceeding 1000 ml is detected in 50%, and 1500 ml - in 35% of the wounded arriving in a state of shock. In grade III shock, massive blood loss exceeding 30% of the BCC (1500 ml) occurs in 75-90% of the wounded.

Reducing the level of systolic blood pressure: insufficient. eff. pumping function of the heart, which may be due to circulatory hypoxia of the heart muscle, contusion of the heart with a closed or open chest injury, as well as early post-traumatic endotoxemia. The decrease in blood pressure in TS is also associated with the circulatory, vascular factor.

Pathological afferent impulses.

Functional disorders associated with a specific localization of damage.

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

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

Centralization of blood circulation by increasing the tone of peripheral vessels and internal redistribution of limited BCC 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 for compensating for developing hypoxia;

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

Severity of shock	Clinical Criteria	Forecast
I degree (mild shock)	Damage of moderate severity, often isolated. General condition of moderate or severe. Moderate congestion, pallor. Heart rate = 90-100 in 1 minute, systolic blood pressure is not lower than 90 mm Hg. Art. Blood loss up to 1000 ml (20% BCC)	With timely assistance - favorable
II degree (moderate shock)	The damage is extensive, often multiple or combined. The general condition is severe. Consciousness is preserved. Severe lethargy, pallor. Heart rate 100-120 in 1 minute, systolic blood pressure 90-75 mm Hg. Blood loss up to 1500 ml (30% BCC)	Doubtful
III degree (severe shock)	Injuries are extensive, multiple or combined, often with damage to vital organs. The condition is extremely difficult. Stunning or stupor. Sharp pallor, adynamia, hyporeflexia. Heart rate 120-160 in 1 minute, weak filling, systolic blood pressure 70 - 50 mm Hg. Art. Possible anuria. Blood loss 1500-2000 ml (30-40% BCC)	Very serious or unfavorable

In the terminal state, its pre-agonal phase, agony and clinical death are distinguished. The preagonal state is characterized by the absence of a pulse in the peripheral vessels, a decrease in systolic blood pressure below 50 mm Hg. 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, 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 most sensitive to hypoxia cells of the cerebral cortex occurs, and then - biological death.

Treatment of traumatic shock should be early, comprehensive and adequate. The main objectives of treatment:

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

2) Stop ongoing external or internal bleeding.

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

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

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

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

8) Early antibiotic therapy, starting from the advanced stages of medical evacuation. Such therapy is especially indicated in the wounded with penetrating wounds of the abdomen, with open bone fractures and with extensive damage to soft tissues.

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

First 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 an immediate life threat and subsequent transportation to the next stage of evacuation. If there are indications, additional measures are taken to reliably eliminate disorders of external respiration: tracheal intubation, cricoconicotomy or tracheostomy, oxygen inhalation using standard devices, thoracocentesis with a valve device for tension pneumothorax. The tourniquet is controlled and, if possible, a temporary stop of external bleeding in the wound. Transport immobilization is corrected using standard means. Analgesics are reintroduced. With combined injuries of the musculoskeletal system, conduction blockades using local anesthetics are indicated. If there are pronounced signs of acute blood loss - the implementation of infusion or infusion-transfusion therapy in a volume of 500-1000 ml. In the presence of appropriate conditions, infusion therapy continues during further transportation. All the wounded are given tetanus toxoid, and according to indications, broad-spectrum antibiotics are used.

When rendering qualified and specialized medical care anti-shock measures must be carried out in full, which requires a sufficiently high qualification of 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 the mechanical causes of respiratory disorders - mechanical asphyxia, pneumothorax, hemothorax, paradoxical movements of the chest wall during the formation of a costal valve, aspiration of blood or vomit into the tracheobronchial tree.

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

Anesthesia by performing a segmental paravertebral or vagosympathetic blockade;

Continuous inhalation of humidified oxygen;

Intubation of the trachea and mechanical ventilation with respiratory failure of the III degree (respiratory rate of 35 or more per minute, abnormal breathing rhythms, cyanosis and sweating, feeling of lack of air).

In case of respiratory failure due to pulmonary contusions, it is required:

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

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

The use of rheologically active drugs in the mode of hemodilution (0.8 l of 5% glucose solution, 0.4 l of rheopolyglucin), antiplatelet agents (trental), direct anticoagulants (up to 20,000 IU 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 of 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 a 5% solution 3-4 times a day.

In the case of the development of adult respiratory distress syndrome or fat embolism, mechanical ventilation with increased pressure at the end of exhalation up to 5-10 cm of water takes on the leading role in the treatment of respiratory disorders. Art. apparatus of the "Phase-5" type against the background of the activities recommended for lung contusion. But at the same time, the dose of glucocorticoids increases to 30 mg / kg of body weight per day.

Restoration of the function of the circulatory system. A prerequisite for the effectiveness of intensive care measures is to stop external or internal bleeding, as well as to eliminate 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-substituting solutions with a total volume of 2-2.5 liters per day; with blood loss up to 2 liters - compensation of BCC due to erythrocyte mass and blood substitutes in a ratio of 1: 1 with a total volume of up to 3.5-4 liters per day; with blood loss exceeding 2 liters, the compensation of the BCC is carried out mainly due to the erythrocyte mass in a ratio of 2: 1 with blood substitutes, and the total volume of the injected fluid exceeds 4 liters; with blood loss exceeding 3 liters, the BCC is replenished at the expense of large doses of erythrocyte mass (in terms of blood - 3 liters or more), blood transfusion is carried out at a fast pace into two large veins, or into the aorta through the femoral artery. It must be remembered that the blood that has poured into the body cavity is subject to reinfusion (if there are no contraindications). Compensation for lost blood is most effective in the first two days. Adequate replacement of blood loss is combined with the use of drugs that stimulate the tone of peripheral vessels: 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 rate of 40-50 drops per minute.

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

Correction of the blood coagulation system is determined by the severity of the syndrome of disseminated intravascular coagulation (DIC): with DIC I degree (hypercoagulation, isocoagulation), heparin 50 U / kg 4-6 times a day, prednisolone 1.0 mg / kg 2 times a day, trental are used , reopoliglyukin; with II degree DIC (hypocoagulation without activation of fibrinolysis), heparin is used up to 30 U / kg (not more than 5000 U per day), prednisolone 1.5 mg / kg 2 times a day, albumin, plasma, rheopolyglucin, erythrocyte mass no more than 3 days conservation; with DIC of the III degree (hypocoagulation with the beginning activation of fibrinolysis), prednisolone 1.5 mg / kg 2 times a day, counterkal 60,000 units per day, albumin, plasma, erythrocyte mass of short periods of preservation, fibrinogen, gelatin, dicynone are used; with DIC IV degree (generalized fibrinolysis), prednisolone up to 1.0 g per day, counterkal 100,000 units per day, plasma, fibrinogen, albumin, gelatin, dicinone, alkaline solutions are used. In addition, a mixture is injected locally through drains into the serous cavities for 30 minutes: a 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 damage to the heart, it is necessary to limit intravenous infusion-transfusion therapy to 2-2.5 liters per day (the rest of the required volume is injected into the aorta through the femoral artery). In addition, polarizing mixtures are used as part of 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 of 0.06 % solution of corglicon or 0.5 ml of 0.05% solution of strophanthin 2-3 times a day), and with progressive heart failure, inotropic support is performed with dopmin (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 a 1% solution 2 times a day, diluted slowly). The introduction of heparin is performed subcutaneously at 5000 IU 4 times a day.

Restoration of 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 integumentary tissues and restoring external respiration by 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.

In case of encephalopathies of various origins (consequences of hypoxia, brain compression) 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 (per 250 ml of 38 units of insulin with a total volume of 500-1000 ml), reopoliglyukin or reogluman; with the development of cerebral edema, dehydration is carried out due to saluretics (lasix 60-100 mg), osmodiuretics (mannitol 1 g / kg of body weight in the form of a 6-7% solution), oncodiuretics (albumin 1 g / kg of body weight);

Complete central analgesia by intramuscular injection 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 (nicegolin) 4.0 mg 3-4 times a day intramuscularly, solcoseryl 10.0 ml intravenously drip on the first day, in the subsequent - 6 .0-8.0 ml;

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

Continuous inhalation of humidified oxygen.

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

The most important component of shock treatment is the implementation of urgent 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 hollow abdominal organs. At the same time, intensive care measures are carried out as preoperative preparation, anesthetic support of the operation itself and continue in the postoperative period.

Adequate treatment of shock is not only aimed at eliminating this formidable consequence of a severe combat injury. It lays the foundation for treatment in the post-shock period until the immediate outcome of the injury is determined. At the same time, the entire pathological process until the healing of the wounded is considered in recent years from the standpoint of concept of traumatic illness.

The concept of traumatic disease is fully implemented at the stage of specialized medical care, where the treatment of severe consequences of trauma and complications, including the rehabilitation of the wounded, is carried out depending on the location of 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 resuscitation and burn departments, ambulance workers and the Ministry of Emergency Situations must have 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 will not hurt to have such a first-aid kit in the house, while it is necessary 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 shock condition can be provoked by an allergic reaction of a person to food, a medication, contact with a cosmetic product, or an insect bite. It is almost impossible to predict in advance the likelihood of such a reaction of the body, and the huge problem of 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 this or that drug in the first-aid kit 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.
• "Dimedrol" in ampoules.
• Sodium chloride solution.
• "Eufillin" in ampoules.
• "Prednisolone" (in ampoules).
• Antihistamines.

Why do you need to inject "Adrenaline"?

This medicine can be safely called the main drug in the anti-shock kit. If we consider its use, then 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 of this, 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 goes into a state of shock. All of his 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 introduction of "Adrenaline" prevents the rapid fall in blood pressure, which is accompanied by shock conditions. Also, an injection of "Adrenaline" improves the functioning of the heart and prevents its possible stop.

"Dimedrol" - a remedy not only for insomnia

Most people who are not related to medicine mistakenly consider Diphenhydramine to be an exclusively hypnotic drug. This medicine really has a hypnotic effect, but besides this, Diphenhydramine is also an anti-shock drug. After the introduction, it dilates the blood vessels, while relieving bronchospasm. In addition, it is an antihistamine. It blocks the production of histamine and additionally suppresses the overactive activity of the central nervous system.

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

This solution is most often used in medical practice for dehydration, because after intravenous administration it is able to correct the functioning of various body systems. "Sodium chloride" is used as a detoxification drug. Also, with severe bleeding, this solution is able to raise blood pressure. With 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 the reserve capillaries, which stabilizes and greatly facilitates breathing in a state of shock.

"Prednisolone" - the closest analogue of the hormone produced by the body

"Prednisolone" is a fairly important drug in helping a patient in a state of 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 introduction, the shock state of the body subsides in a very short time. It is worth noting that this anti-shock drug is used not only for anaphylactic shock. Doctors also use it for burn, cardiogenic, intoxication, traumatic and surgical shocks.

When should anti-shock drugs be used?

The shock state of the human body can be provoked not only by anaphylaxis due to an allergic reaction. Anti-shock kit preparations are used to provide first aid in other situations, they are especially relevant in cases where there is no possibility to quickly deliver the victim to the hospital and he will have to be transported for a long time.

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

• pain shock;
• receiving a 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" (solution of ketorolac tromethamine) - is a strong pain reliever. Helps to stop severe pain in case of 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" - 25% solution of nicotinic acid. It 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 either together or separately.

Drugs that are used in critical situations in resuscitation

In a hospital setting, to assist a patient in critical condition, in addition to those already considered by us earlier, other anti-shock drugs are also used - solutions for administration:

1. "Polyglukin" is a drug that has a powerful anti-shock effect. It is used by physicians as an anti-shock drug for wounds, burns, severe injuries and serious blood loss. After intravenous administration, Polyglukin improves and activates the coronary current and restores the total volume of blood circulating in the body. Also, the drug normalizes the level of blood pressure and VD. It should be noted that its greatest anti-shock efficacy is manifested when administered together with canned 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 to reduce ascyst and eliminates swelling of the brain. A characteristic feature is that after the introduction of "Hemovinil" an increase in body temperature is often observed.
3. "Polyvinol" - a solution that is injected into / in with severe bleeding, serious injuries, burn and operational shock, which are characterized by a sharp drop in blood pressure. The drug quickly increases 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). With all its advantages, this drug is not suitable for stopping shock conditions that are accompanied by cranial injuries and cerebral hemorrhages.
4. "Gelatinol" - an 8% solution of hydrolyzed gelatin, which is administered intravenously for traumatic and burn shocks. It removes harmful and toxic substances from the body, performing a detoxification function.
5. Droperidol is a neuroleptic, antiemetic and protoshock drug. Belongs to the group of myotropic antispasmodics. Introduced intravenously with severe pain shock.
6. "Dexaven" - refers to the pharmacological group of glucocorticoids. It is administered intravenously in the event of an operational or postoperative shock. It is also used for anaphylactic and traumatic shock and angioedema. It has a pronounced anti-allergic activity and strong anti-inflammatory properties.

If the patient has 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, during dehydration, the administration of appropriate saline solutions may be an anti-shock measure.

Whole blood not always available, especially in military field conditions. In such cases, whole blood can be replaced by plasma transfusion, as 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 about 2 times before adverse complications appear. Thus, in the emergency setting, 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 unavailable. In these cases, various plasma substitutes are used, which perform the same hemodynamic functions as plasma. One of them is a dextran solution.

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

Solution to replace plasma, must contain high-molecular substances that create colloid-osmotic (oncotic) pressure. Only then will it stay 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 certain types of bacteria. For its industrial production, the method of growing a bacterial culture is used, and certain conditions for the growth of bacteria 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 toxicity substance that it is considered a reliable substitute for plasma to compensate for fluid deficiency in the body.

Sympathomimetics in shock

Sympathomimetics called drugs that reproduce the effect of sympathetic stimulation. These include norepinephrine epinephrine, as well as a large number of drugs with prolonged action.

In two cases, the development of shock 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 necessary for the treatment of anaphylactic shock, in the development of which an excess of histamine plays a leading role. Sympathomimetics have a vasoconstrictive effect, in contrast to the vasodilating effect of histamine. Thus, norepinephrine and other sympathomimetics often save the lives of shock patients.

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

Therapeutic effect changes in body position (“head lower than legs”). If during shock the pressure drops sharply, especially in hemorrhagic or neurogenic shock, it is necessary to change the position of the patient's body so that the head is lower than the legs by at least 30 cm. This significantly increases the venous return of blood to the heart and, consequently, cardiac 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 the 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 development, the problem is not a violation of blood oxygenation in the lungs, but a violation of oxygen transport by the blood after oxygenation.

The 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) it has been empirically shown that glucocorticoids often increase the force of contraction of the heart in the later stages 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.