Traumatic shock
Traumatic shock caused by trauma is called a serious condition, accompanied by severe disturbances of functions of vital organs, especially the circulatory and respiratory system. Similar clinical manifestations of state can occur when heavy blood loss, not associated with trauma (hemorrhagic shock), in allergic reactions, intoxication. Large losses of plasma and other fluids from diarrhea, vomiting, debilitating, extensive burns, acute pancreatitis, peritonitis, intestinal obstruction and other causes the development of serious disorders, called gipovolemichaskim shock, leading pathogenesis of which is a decrease in blood volume (CBV).
Condition similar to hypovolemic shock can occur without external and internal fluid loss as a result of a dramatic expansion of the vascular bed, which develops relative hypovolemia (mismatch normal bcc dramatically increased the volume of vascular bed). This is typical for the pathogenesis of some forms of toxic, allergic, neurogenic shock.
The clinical picture of all these shocks (or shokopodobnyh) states have many common features: pale skin and mucous membranes, cold skin, anxiety, shortness of breath, frequent small pulse, blood pressure reduction, reduction of BCC, cardiac output, poor blood supply to peripheral tissues.
In the pathogenesis of shock and shokopodobnyh states are important compensatory responses to blood loss, hypovolaemia. These include increased vascular tone of the venous system and the tone of the arterioles, the development of so-called centralization of circulation, with a circulation in the brain and the heart is not broken. In other organs and tissues of blood flow decreases, which leads to oxygen starvation of kidney, liver, intestine peripheral tissues. Hypovolemia is compensated by hemodilution - inflow of fluid from the bloodstream introduced sudistogo-space. This condition is defined as the stage of relative compensation. It is observed with a decrease in BCC by 20-25% (800-1200 ml of blood loss). If treatment is not conducted against the background of vasoconstriction begins shunting blood from arterioles to venules, bypassing the capillaries. Due to hypoxia dilate capacitance microvessels. Clinically it is manifested severe general condition: blood pressure falls below 80 mm Hg. Art. , Increasing tachycardia, decreased cardiac output, decreased urination, progressive cooling and blanching of the skin, cyanosis. When reducing the BCC by 30-40% (blood loss 1500-2000 ml) begins initial decompensation, but with proper treatment process is reversible.
In the stage of decompensation, which develops with decreasing BCC by 50% or more (for bleeding - loss of 2500 ml), there is a weakening of the tone of the arterioles, further enlargement of venules and capillaries, slowing blood flow, and then complete stasis of blood in the aggregation of blood cells, increasing the viscosity blood in vivo formation of microthrombi. Arising as a result of enhanced bleeding tissue causes suspected disseminated intravascular thrombus formation, is often a symptom of irreversible changes in the body. The clinical picture at this stage of shock is characterized by the deterioration of the patient, a progressive decrease in blood pressure, increasing tachycardia, further decrease in the bcc, cardiac output, central venous pressure. Integuments acquire a marble color, sometimes with a stagnant spots such as cadaver, urination ceases. This condition is rarely cured. However, intensive therapy should be carried out in full as accurately diagnose the state of irreversible shock is impossible.
If the blood loss, acute hypovolemia major damaging factor is the violation of perfusion and oxygen supply of tissues, then in the pathogenesis of severe traumatic shock leading role played by abnormal impulses from areas of damage. In severe forms of infectious toxic shock condition of patients is compounded by factors of intoxication, early metabolic disorders. Severity of the condition in this case exacerbated the phenomenon of irreversibility of shock may develop earlier.
Emergency medical activities in the treatment of various forms of shock in principle similar to, and should include measures to address the acute disturbance of circulation and respiration. Other methods of intensive therapy is carried out taking into account the causes of shock, the peculiarities of its pathogenesis and related disorders.
Treatment of traumatic, hemorrhagic and hypovolemic shock
should include: intense infusion-transfusion therapy, if necessary, to stop bleeding, elimination of acute respiratory failure (in severe stages of shock, or in the presence of injuries and diseases that cause acute respiratory failure), the elimination or suppression of pain and other pathological impulse, holding the pathogenetic drug therapy, the use of modern methods vneorgannoy detoxification, in particular plasmapheresis.
Intensive multimodality therapy with early start allows her to prevent the development of irreversible shock.
Procedure physician assisting a patient in a state of shock, the next one.
1. Stop bleeding. For external bleeding, it is stopped by plugging the wound, the imposition of a pressure bandage or a clamp on the bleeding vessel and pressing of it for out of the wound. The use of tourniquet is permissible only if it is impossible to stop arterial bleeding listed methods.
Transporting a patient in a state of shock, especially hemorrhagic, only carry out on a stretcher during the ongoing infusion therapy, which in severe shock hold D two veins, general anesthesia (optimally - through the inhalation of a mixture of nitrous oxide with oxygen in the ratios 1:1,2:1 ) and mandatory immobilization of limb fractures, in violation of breath hold AV.
2. ODN treatment is performed according to the recommendations made above. The special role played by the timely diagnosis of pneumothorax (particularly stress) at which the ADU can not be eliminated without an immediate drainage of the pleural cavity. Prehospital easiest way to perform a drainage by puncture of the pleural cavity of a thick needle (such as Dufour), which immediately translates into the open air block and creates the conditions for effective ventilation. With growing evidence of asphyxia may occur in the immediate tracheostomy.
3. Intensive infusion-transfusion therapy (Iitti) at critical violations hemodynamics is the leading method for correcting acute hypovolemia. Patient is placed horizontally or slightly downy head, low blood pressure should lift his legs. The dotted line or kateteriziruyut peripheral vein and begin infusion of plasma-solution at a rapid pace. In-patient treatment of choice is the catheterization of central veins (internal jugular, subclavian, femoral)
allows you to monitor central venous pressure (CVP) and quickly massive infusion fluid. Prehospital this method is rarely used due to its complexity and the risk of complications.
Infuziruemoy fluid volume and speed of its introduction should be significant. Drip infusion in the treatment of critical illness circulatory shock are virtually useless. Infusion volume should be much larger deficit BCC, since we make up for not only the lack of intravascular fluid and tissue water loss as water moves into the bloodstream as a result of a compensatory response to hypovolemia. In the first hours of treatment, especially if it was started late, in severe shock may require infusion at a rate of 2.4 l / h. This volume should be administered under the supervision of central venous pressure (CVP), a rapid rise which is a sign of developing heart failure.
If the blood pressure and central venous pressure remains low, then increase infusion rate, holding her in 2-3 veins simultaneously.
Protivoshokovym effective action has all the plasma-solutions, among which are: crystalloid solutions (5% glucose, 0.85% sodium chloride solution, electrolyte mixtures of Ringer's solution, Ringer-Locke and others); colloidal polysaccharides (polyglukin, reopoliglyukin) , gelatin (zhelatinol), protein blood products (fresh frozen plasma, albumin).
In conducting intensive infusion-transfusion therapy in prehospital be combined crystalloid and colloid solutions at a ratio of 1:1,2:1, including patients with severe blood loss. In a hospital such patients continue infusion plasma substitutes, combining them with transfusions of red blood cells. In this case, transfused red blood cells should not exceed 40-50% of bites into the liquid, and the total number of preserved red blood cells should not exceed 1000 ml for an adult to avoid the development of complications (massive transfusion syndrome, intoxication, citrate). Transfusion of whole blood is shown only in the absence of single-group erythrocytes, reducing the level of hemoglobin below 80 grams per liter. Should be included in the infusion therapy drugs that increase the oncotic pressure of blood, including high efficiency has albumin. Number poliglyukina should not exceed 10 ml / kg, since large amounts can disrupt gemokoagupyatsiyu.
If you burn shock fluid therapy should include plasma and blood, because when it develops significant plazmopoterya. In addition, you need a full-fledged long-term pain relief and interventions that reduce plazmopoteryu burn surface.
Infusion therapy is carried out to stabilize the systolic blood pressure by figures of 90-100 mm Hg. Art. and central venous pressure - with figures of 50-100 mm of water. Art. Achieving a satisfactory rate of urination (more than 20 ml / h) is an indicator of recovery of peripheral blood.
When an infusion therapy, despite satisfactory blood pressure, the patient remains sharply pale skin is cold to the touch, urination is less than 20 ml / h, or missing, then the shortfall after intravascular fluid begin a set of measures to normalize the blood flow in peripheral tissues and microcirculatory bed . It includes the introduction of vasodilators on the background of the continuing infusion with continued monitoring of hemodynamic parameters. Removing the effects of centralization of blood flow and vascular spasm can be carried out after the shortfall BCC, slowly introducing one of the antipsychotic, antispasmodic or ganglioblokiruyuschih drugs. Fast and controllable effect is the introduction of 0,25% solution of novocaine. Vasodilating action has droperidol and diazepam (seduksen). In the hospital also used nitrites (nitroglycerin, nitroprusside) and ganglion blocking (pentamine, gigrony). All vasodilator and antispasmodic agents are slow (drip into a large dilution) for continuous monitoring of hemodynamic parameters. When exacerbating hypotension increases the rate of infusion, while slowing the rate of introduction of vasodilators. Ongoing therapy can be considered effective if a patient with stable systolic blood pressure 90-100 mm Hg. Art. occurs porozovenie and warming the skin begins urination at more than 20 ml / h.
Conducting fluid therapy may present great difficulties in the development of patient events of heart failure (a syndrome of low cardiac output). Treatment of this condition is considered in the section on myocardial infarction. In acute heart failure in patients on various forms of shock common to use a drip of low doses of catecholamines. In this case, an ampoule of adrenaline (1 mg) was diluted in 200-500 ml of fluid and injected at a rate at which does not increase heart rate and other hemodynamic parameters (BP, CVP, and others) are improving.
Widely used in the treatment of acute circulatory failure in shock are corticosteroids. They are administered intravenously or fractional drip primarily to increase the sensitivity of adrenergic receptors to endogenous and exogenous catecholamines.
In shock therapy to prevent progression of disseminated intravascular coagulation sometimes assigned heparin (under the skin of the stomach or intravenously) under the control clotting time (no more than 15 min) and other indices of coagulation. Uncontrolled appointment of heparin is dangerous.
In allergic (anaphylactic) shock, as well as reflex neurogenic shock is characterized first and foremost a violation of vascular tone and a significant increase in the capacity of the vascular bed. Relative hypovolemia occurs as a result of discrepancies bcc dramatically increased the volume of intravascular pathology. The complex of urgent measures should include infusion therapy, the introduction of corticosteroids and vasoactive substances (ephedrine, epinephrine, dopamine). In allergic (anaphylactic) shock is also used antihistamines (suprastin, diphenhydramine, etc.) that can enhance hypotension. Therefore, they should be administered on a background infusion started treatment, corticosteroids and calcium supplements (10 ml 10% solution of chloride or calcium gluconate), which reduce the impaired permeability of vascular walls.
The volume of infusion therapy is determined by the reaction and the patient's condition. If urination was restored, CVP does not exceed normal values, then to maintain hemodynamics can be applied a large infusion volume, sometimes at 3-4 times the amount of recorded losses.
In the course of infusion therapy must be:
- Continuously monitor central venous pressure, blood pressure, pulse rate, the state of the lungs (pulmonary edema threatening);
, Carefully measure the exterior of fluid loss (blood loss, diuresis, gastric loss of vomiting, intestinal losses with diarrhea);
-Take into account the internal loss of intravascular fluid in the next most common conditions: multiple trauma (bruising in the soft tissues), hemoperitoneum, hemothorax, gastrointestinal bleeding, acute pancreatitis (plazmopoterya vzabryushinnom space), ileus (plazmopoterya into the lumen of the intestine).
4. Anaesthesia in a state of shock to the presence of pain. It should be remembered that regional or general analgesia with low numbers of blood pressure and unmet hypovolemia can lead to increased hypotension and deterioration of the patient. Therefore, early treatment of conductors, local anesthesia, general analgesia, antihistamines, and the introduction of antipsychotic drugs should be undertaken only under the protection of infusion therapy. It is helpful to give preference to local or block anesthesia (injection of local anesthetic into the fracture, nerve blocks and textures, futlyarnye blockade, epidural anesthesia).
General analgesia conduct narcotic analgesics (morphine, promedol, fentanyl) for mandatory control of respiration and hemodynamics. A good analgesic effect also makes intravenous analgin, inhalation general analgesia with nitrous oxide (with oxygen).
5. Great importance in the treatment of shock are detoxification activities. Extracorporeal detoxication (plasmapheresis, hemosorbtion, limfosorbtsiya, hemodialysis, ultragemofiltratsiya) is effective as at ekzotoksikozah (poisonings poisonous substances), and during endotoxemia (infectious and septic shock, multiple organ failure). Extracorporeal detoxification methods should be applied in a timely manner in patients with severe infectious and inflammatory diseases, sepsis, along with general non-specific measures to restore the impaired circulation and respiration. Conducting detoxification therapy is desirable to carry out in the ICU (intensive care). In severe poisoning, accompanied by the typical shock disorder, conduct an intensive general anti shock therapy in combination with specific measures, including the introduction of antidotes, the use of hemosorption etc.
