Traumatic shock - causes and stages. Algorithm for emergency care for injuries and traumatic shock. Traumatic shock: causes, clinical picture, emergency care The final phase of traumatic shock is accompanied by

The content of the article

Concept definition traumatic shock causes great difficulty. I. K. Akhuibaev and G. L. Frenkel (1960) found 119 definitions of shock in the world literature. The remark of L. Delogers (1962) (according to Y. Shuteu, 1981) is fair: “Shock is easier to recognize than to describe and easier to describe than to define it.” To illustrate, here are some definitions of shock.
Dillon: "Shock is a violent attack on life." True (S. Vernon, 1970): shock is "a general response to a stimulus that the body recognizes as potentially lethal." Hadvey (R. Hardaway, 1966): shock is "inappropriate capillary perfusion."
According to the majority of researchers who have studied shock, none of these definitions fully describes the concept of shock. Therefore, we restrict ourselves to the definitions of traumatic shock, which are given by domestic authors. M. N. Akhutin (1942): “Shock is a kind of inhibition of all vital functions of the body, arising in connection with a severe injury or other similar harmful factors affecting the sick or wounded.” A. A. Vishnevsky, M. I. Schreiber (1975): "Traumatic shock is the body's response to severe mechanical injury or burns." Traumatic shock is commonly understood as a violation of the body's vital functions resulting from the action of an emergency (mechanical) stimulus.
The frequency and severity of traumatic shock increases with each war, depending on the severity of the injuries. With gunshot wounds with modern weapons, 8-10% of the total number of wounded can be expected to develop traumatic shock. When using nuclear missile weapons, traumatic shock can occur in 25-30% of those affected.

Etiology of traumatic shock

The pathogenesis of traumatic shock

Traumatic Shock Clinic

Classification of traumatic shock

Treatment of traumatic shock

First aid

First aid (MPB)

First aid (MPP)

Final treatment

A rapidly developing condition against the background of a severe injury, which poses a direct threat to human life, is commonly called traumatic shock. As it already becomes clear from the name itself, the cause of its development is severe mechanical damage, unbearable pain. It is necessary to act in such a situation immediately, since any delay in the provision of first aid can cost the patient's life.

Causes of traumatic shock

The cause may be injuries of a severe degree of development - fractures of the hip bones, gunshot or stab wounds, rupture of large blood vessels, burns, damage to internal organs. These can be injuries to the most sensitive parts of the human body, such as the neck or perineum, or vital organs. The basis of their occurrence, as a rule, are extreme situations.

note

Very often, pain shock develops when large arteries are injured, where there is a rapid loss of blood, and the body does not have time to adapt to new conditions.

Traumatic shock: pathogenesis

The principle of development of this pathology lies in a chain reaction of traumatic conditions that have serious consequences for the patient's health and are aggravated one after another in stages.

With intense, unbearable pain and high blood loss, a signal is sent to our brain, which provokes its strong irritation. The brain abruptly releases a large amount of adrenaline, such an amount is not typical for normal human life, and this disrupts the functioning of various systems.

With severe bleeding there is a spasm of small vessels, for the first time it helps to save part of the blood. Our body cannot maintain such a state for a long time, subsequently the blood vessels expand again and blood loss increases.

In the event of a closed injury the mechanism of action is similar. Due to the secreted hormones, the vessels block the outflow of blood and this condition no longer carries a protective reaction, but, on the contrary, is the basis for the development of traumatic shock. Subsequently, a significant volume of blood is retained, there is a lack of blood supply to the heart, respiratory system, hematopoietic system, brain and others.

In the future, intoxication of the body occurs, vital systems fail one after another, and necrosis of the tissue of internal organs occurs from a lack of oxygen. In the absence of first aid, all this leads to death.

The development of traumatic shock against the background of an injury with intense blood loss is considered the most severe.

In some cases, the recovery of the body with mild and moderate pain shock can occur on its own, although such a patient should also be given first aid.

Symptoms and stages of traumatic shock

Symptoms of traumatic shock are pronounced and depend on the stage.

stage 1 - erectile

Lasts from 1 to several minutes. The resulting injury and unbearable pain provoke an atypical condition in the patient, he can cry, scream, be extremely agitated and even resist assistance. The skin becomes pale, sticky sweat appears, the rhythm of breathing and heartbeat is disturbed.

note

At this stage, it is already possible to judge the intensity of the manifested pain shock, the brighter it is, the stronger and faster the subsequent stage of shock will manifest itself.

Stage 2 - torpid

Has a rapid development. The patient's condition changes dramatically and becomes inhibited, consciousness is lost. However, the patient still feels pain, and first aid manipulations should be carried out with extreme caution.

The skin becomes even paler, cyanosis of the mucous membranes develops, the pressure drops sharply, the pulse is barely palpable. The next stage will be the development of dysfunction of internal organs.

Degrees of development of traumatic shock

Symptoms of the torpid stage can have different intensity and severity, depending on this, the degree of development of pain shock is distinguished.

1 degree

Satisfactory condition, clear consciousness, the patient clearly understands what is happening and answers questions. Hemodynamic parameters are stable. Slightly rapid breathing and pulse may occur. It often occurs with fractures of large bones. Light traumatic shock has a favorable prognosis. The patient should be assisted in accordance with the injury, give analgesics and be taken to the hospital for treatment.

2 degree

It is noted by the patient's inhibition, he can answer the question for a long time and does not immediately understand when he is being addressed. The skin is pale, the limbs may become bluish. Arterial pressure is reduced, the pulse is frequent, but weak. Lack of proper assistance can provoke the development of the next degree of shock.

3 degree

The patient is unconscious or in a state of stupor, there is practically no reaction to stimuli, pallor of the skin. A sharp drop in blood pressure, the pulse is frequent, but weakly palpable even on large vessels. The prognosis for this condition is unfavorable, especially if the ongoing procedures do not bring positive dynamics.

4 degree

Fainting, no pulse, extremely low or no blood pressure. The survival rate for this condition is minimal.

Treatment

The main principle of treatment in the development of traumatic shock is immediate action to normalize the patient's state of health.

First aid for traumatic shock should be carried out immediately, take clear and decisive action.

First aid for traumatic shock

What kind of actions are necessary is determined by the type of injury and the cause of the development of traumatic shock, the final decision comes according to the actual circumstances. If you witness the development of a pain shock in a person, it is recommended to immediately take the following actions:

A tourniquet is used for arterial bleeding (blood spurts out), superimposed above the wound. It can be used continuously for no more than 40 minutes, then it should be loosened for 15 minutes. When the tourniquet is properly applied, the bleeding stops. In other cases of damage, a pressure gauze bandage or tampon is applied.

• Provide free air access. Remove or unfasten constricting clothing and accessories, remove foreign objects from the respiratory passages. The unconscious patient should be placed on their side.
• warming procedures. As we already know, traumatic shock can manifest itself in the form of blanching and coldness of the extremities, in which case the patient should be covered or additional heat should be provided.
• Painkillers. The ideal option in this case would be an intramuscular injection of analgesics.. In an extreme situation, try to give the patient an analgin tablet sublingually (under the tongue - for speedy action).
• Transportation. Depending on the injuries and their location, it is necessary to determine the method of transporting the patient. Transportation should be done only when waiting for medical attention can take a very long time.

Forbidden!

• Disturb and excite the patient, make him move!
• Transfer or move the patient from

Update: December 2018

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

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

Reasons for development

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

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

Scheme

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

The following factors can further worsen the prognosis:

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

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

Symptoms

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

Typical clinical manifestations include:

Change of consciousness

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

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

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

Increase in the number of heartbeats (HR)

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

Respiratory failure

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

Lowering blood pressure (BP)

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

Metabolic disorder

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

Classification

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

The modern classification according to Keith is presented below:

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

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

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

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

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

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

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

First aid

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

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

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

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

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

What not to do when shocked

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

Treatment

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

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

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

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

Complications

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

Sepsis

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

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

TELA

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

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

hospital pneumonia

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

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

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

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

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

Stenosis of the larynx

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

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

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

Treatment of an already developed traumatic shock should be early, successive and complex. Of decisive importance in assisting a victim in a state of shock is the time factor: the sooner assistance is provided, the more favorable the outcome.

In organizational terms, it is advisable to divide the provision of assistance with shock in peacetime into the following stages: the scene of the incident, the ambulance, and the hospital.

Preventive anti-shock measures are carried out at the scene of the incident, and in cases of terminal conditions and clinical death, a set of measures for resuscitation (see Resuscitation of the body).

The main task of ambulance workers is the fastest delivery of the victim to the hospital, where there are conditions for providing assistance in full. In specially equipped machines, in addition to these measures, it is possible to use oxygen therapy, anesthesia with nitrous oxide, intravenous and intra-arterial administration of blood-substituting and anti-shock fluids, dressing wounds, tracheostomy, and artificial respiration.

In a hospital, shock therapy should be pathogenetic and differentiated depending on the phase and degree of shock, the nature of the injury, and the individual characteristics of the victim's body. In addition to the general condition of the victim at the time of the examination, it is necessary to take into account the mechanism of injury, the nature and severity of the injuries.

There are several groups of anti-shock measures.
1. Pain relief measures: the fight against pain is carried out by using drugs administered intravenously and narcotic drugs (nitrous oxide with oxygen in a ratio of 1: 1), by introducing a 2% solution of novocaine into the hematoma in an amount of 10-30 ml with closed fractures.

In case of pleuropulmonary shock, a vagosympathetic (cervical) blockade is indicated (see Novocaine Blockade), in abdominal shock - cervical and pararenal, in shock caused by fractures of the pelvic bones - blockade according to Shkolnikov.

Novocaine blockade is indicated in any phase of shock and with any degree of its severity. Radical elimination of the source of pain impulses is achieved by appropriate surgical intervention - surgical treatment of the wound, reposition and fixation of bone fragments in case of fracture, restoration of integrity or removal of the damaged organ. However, it is often more advantageous to postpone the provision of prompt assistance until the victim is out of shock. With crushing of tissues and with crush syndrome, the damaged part of the body must be covered with ice. A tourniquet is a source of painful irritation, so it is necessary to remove it and make a final stop of bleeding as soon as possible. The removal of the tourniquet, if it is not performed under anesthesia, should be preceded by a circular novocaine blockade of the limb above the tourniquet.

2. Measures aimed at combating circulatory disorders. A powerful remedy for shock of the first and second degree is drip and jet intravenous blood transfusion (see) and anti-shock liquids under the control of venous pressure. In shock of the third and fourth degree, blood pressure under the influence of intravenous infusions in some cases increases slightly and does not increase for a short time or at all. Intravenous transfusion of large doses of blood can even worsen the patient's condition due to overload of the right heart, a symptom of which is increased venous pressure. If the victim has a systolic blood pressure below 60 mm Hg. Art. or as a result of a jet intravenous transfusion of 500 ml of blood, systolic blood pressure does not rise to 60-70 mm, then you should switch to intra-arterial infusion of blood or anti-shock fluid at a pressure of 200 mm Hg. Art., in fractional doses of 40-50 ml every 3-5 minutes, up to 250 ml in total.

To stabilize hemodynamics in traumatic shock, blood substitutes are also used - polyglucin, polyvinal, polyvinylpyrrolidone, which have a persistent pressor effect. They can be used both intravenously and intraarterially.

Medicinal substances that stimulate the central nervous system and blood circulation are widely used (camphor oil, corazole, cordiamine, caffeine, strychnine, etc.), and adrenomimetic substances (adrenaline, ephedrine, norepinephrine, etc.). Medicinal substances (except camphor oil) in traumatic shock of the third and fourth degree, it is advisable to administer intravenously, since absorption from the subcutaneous tissue and muscles in such patients is sharply slowed down. Substances that increase vascular tone, it is advisable to enter only if the bloodstream is full, as can be judged by the level of venous pressure. When myocardial fibrillation occurs, a defibrillator is used. In case of cardiac arrest, an indirect heart massage is indicated.

3. Measures aimed at combating respiratory disorders. To eliminate hypoxia while maintaining active breathing, oxygen is supplied through the mask of the anesthesia machine in the form of an oxygen-air humidified mixture with an oxygen content of up to 50%. In case of violation of active breathing, first of all, it is necessary to make sure that the airway is patent. After that, intubation is performed and mechanical artificial respiration is established (see) using devices or a bag of an anesthesia machine. The endotracheal tube can be in the glottis for no more than six hours. If during this time active breathing is not restored, then the imposition of a tracheostomy and the continuation of mechanical artificial respiration through the tracheostomy are shown. In cases of accumulation of fluid in the respiratory tract, it is necessary to periodically suction from the bronchi with the introduction of a solution of soda and antibiotics into the tracheostomy at the same time with a total volume of not more than 3-5 ml. Mechanical artificial respiration for some types of injuries (traumatic brain injury, multiple fractures of the ribs) is used for many hours and days. In the event of pathological respiration, lobelin and korkonium are administered intravenously.

4. Activities that normalize metabolism. In the room where assistance is provided to a patient in a state of traumatic shock, it should be warm, but the air temperature should not exceed 20-22 °. Increased heating of the patient leads to the expansion of capillaries in the periphery, which contributes to a drop in blood pressure.

In connection with a sharp imbalance of vitamins in shock, ascorbic acid, nicotinic acid, vitamins of the B complex should be administered. To eliminate acidosis in shock, oral administration of sodium citrate, intravenous administration of 300-400 ml of 4.5% sodium bicarbonate solution is indicated.

In connection with the dysfunction of the endocrine system in shock, the use of deoxycorticosterone acetate, ACTH, pituitrin, norepinephrine is indicated.

20065 0

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

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

Traumatic shock II degree characterized by inhibition of the wounded, severe pallor of the skin, a significant violation of hemodynamics. Arterial pressure drops to 85–75 mm Hg, pulse quickens to 110–120 beats/min. With the failure of compensatory mechanisms, as well as with unrecognized severe injuries in the late stages of assistance, the severity of traumatic shock increases.

Traumatic shock III degree usually occurs with severe combined or multiple injuries (injuries), often accompanied by significant blood loss (the average blood loss in grade III shock reaches 3000 ml, while in grade I shock it does not exceed 1000 ml). The skin acquires a pale gray color with a cyanotic tint. The path is greatly accelerated (up to 140 beats / min), sometimes even filiform. Blood pressure drops below 70 mm Hg. Breathing is shallow and rapid. Restoration of vital functions in grade III shock presents significant difficulties and requires the use of a complex set of anti-shock measures, often combined with urgent surgical interventions.

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

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

1 Predagonal state characterized no pulse in the radial arteries in the presence of it on the carotid and femoral arteries and not determined by the usual method of blood pressure.

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

3. Clinical death begins with the last breath and cardiac arrest. Clinical signs of life in the wounded are completely absent. However, metabolic processes in the brain tissue continue for an average of 5–7 minutes. The allocation of clinical death as a separate form of a serious condition of the wounded is advisable, since in cases where the wounded person does not have injuries incompatible with life, this condition can be reversible with the rapid application of resuscitation measures.

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

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

Gumanenko E.K.

Military field surgery