Traumatic shock

Traumatic shock develops as a result of traumatic injury of various organs and parts of the body, accompanied by pain, blood loss, which occur with severe mechanical damage, poisoning due to the absorption of decomposition products from ischemic tissues. Predisposing to the development of shock and aggravating factors are supercooling or overheating, intoxication, starvation, overwork.

Severe injuries rank third among causes of adult mortality after cardiovascular disease and malignant neoplasms. The causes of injuries include road accidents, injuries from falling from a height, rail injuries. Medical statistics show that recently polytrauma - trauma with damage to several areas is more often recorded. They are characterized by severe impairment of vital body functions, and primarily by circulatory and respiratory disorders.

In the pathogenesis of traumatic shock, an important place belongs to blood and plasma loss, which is accompanied by almost all traumatic injuries. As a result of injury, vascular damage occurs and the permeability of vascular membranes increases, which leads to the accumulation of large volumes of blood and plasma in the area of ​​trauma. And the severity of the condition of the victim largely depends not only on the volume of lost blood, but also on the rate of bleeding. Thus, blood pressure is maintained at values ​​that were before injury in the event that bleeding occurs at a slow rate and the blood volume is reduced by 20%.With a high bleeding rate, the loss of circulating blood by 30% can lead to the death of the victim. Reducing the volume of circulating blood - hypovolemia - leads to an increase in the production of adrenaline and norepinephrine, which have a direct effect on the capillary circulation. As a result of their action, precapillary sphincters are closed and postcapillary dilates. Disturbed microcirculation causes malfunctions in the process of metabolism, resulting in the release of a large amount of lactic acid and its accumulation in the blood. A significantly increased number of under-oxidized products leads to the development of acidosis, which in turn contributes to the development of new circulatory disorders and a further decrease in the volume of circulating blood. A low volume of circulating blood can not provide sufficient supply of blood to vital organs, which include, first of all, the brain, liver, kidneys, brain. Their functions are limited, as a result of which irreversible morphological changes develop.

During the traumatic shock, two phases can be traced:

• erectile, which occurs immediately after the injury. During this period, the consciousness of the injured or sick person persists, motor and speech arousal is noted, the absence of a critical attitude towards oneself and the environment;skin and mucous membranes are pale, perspiration is strengthened, pupils are dilated and respond well to light;The arterial pressure while keeps normal or can rise, the pulse becomes fast. The duration of the erectile phase of the shock is 10-20 minutes, during which time the patient's condition worsens and passes into the second phase;

• The course of the torpid phase of traumatic shock is characterized by a decrease in blood pressure and development of severe inhibition. The change in the condition of the victim or the patient occurs gradually. To assess the patient's state during the torpid phase of shock, it is customary to focus on the systolic blood pressure level indicators.

I degree - 90-100 m Hg.p.while the condition of the victim or patient remains relatively satisfactory and is characterized by pallor of the skin and visible mucous membranes, muscle tremor;the victim's consciousness is preserved or slightly inhibited;pulse to 100 beats per minute, the number of breaths to 25 per minute.

II degree - 85-75 mmHg.p.the condition of the victim is characterized by a distinctly expressed inhibition of consciousness;marked pale skin, cold sticky sweat, lower body temperature;the pulse is increased - up to 110-120 beats per minute, the respiration is superficial - up to 30 times per minute.

III degree - pressure below 70 mm Hg.st., often develops with multiple severe traumatic injuries. The consciousness of the victim is greatly inhibited, he remains indifferent to his surroundings and his condition;does not respond to pain;skin and mucous membranes are pale, with a grayish tinge;cold sweat;pulse - up to 150 beats per minute, breathing shallow, frequent or, on the contrary, rare;consciousness is darkened, pulse and arterial pressure are not determined, breathing is rare, superficial, diaphragmatic.

Without timely and qualified medical care, the torpid phase ends with a terminal condition that completes the development of severe traumatic shock and, as a rule, leads to the death of the victim. Basic clinical signs. Traumatic shock is characterized by inhibited consciousness;pale with a cyanotic shade of skin color;disturbed blood supply, in which the nail bed becomes cyanotic, when the finger is pressed, the blood flow is not restored for a long time;the veins of the neck and limbs are not filled and sometimes become invisible;the frequency of breathing becomes more frequent and becomes more than 20 times a minute;the pulse rate is increased to 100 beats per minute and higher;systolic pressure drops to 100 mm Hg. Art.and below;there is a sharp cooling of the extremities. All these symptoms are evidence that the body is redistributing blood flow, which leads to disruption of homeostasis and metabolic changes, becomes a threat to the life of the patient or the victim. The probability of restoration of impaired functions depends on the duration and severity of the shock.

Shock is a dynamic process, and without treatment or with the late provision of medical care, its lighter forms pass into severe and even into the category of extremely severe ones with the development of irreversible changes. Therefore, the main principle of successful treatment of traumatic shock among victims is to provide assistance in a complex that includes the detection of violations of the vital functions of the affected person and the carrying out of activities whose purpose is to eliminate life-threatening conditions.

First aid at the prehospital stage includes the following steps.

• Restoration of airway patency. When providing first aid to the victim, it should be remembered that the most frequent cause leading to worsening of the patient's condition is acute respiratory failure caused by aspiration of vomit, foreign bodies, blood and cerebrospinal fluid. Craniocerebral injuries are almost always accompanied by aspiration. Acute respiratory failure develops with multiple fractures of the ribs as a result of hemopneumothorax and severe pain syndrome. In this case, the sufferer develops hypercapnia and hypoxia, which aggravate the phenomenon of shock, sometimes causing death due to suffocation. Therefore, the first task of the caregiver is to restore airway patency.

Respiratory failure resulting from asphyxiation with tongue or severe aspiration due to general anxiety, severe cyanosis, sweating, chest and chest abnormalities, neck muscles during inspiration, hoarse and arrhythmic breathing. In this case, the caregiver must provide the affected person with the patency of the upper respiratory tract. In this case, he should throw the victim's head back, pull the lower jaw forward and aspirate the contents of the upper respiratory tract.

• Intravenous infusions of plasma-substituting solutions are carried out, if possible, simultaneously with the measures for restoring normal ventilation of the lungs, depending on the size of the trauma and the volume of blood loss, one or two veins are punctured and intravenous infusion of solutions begins. The purpose of infusion therapy is to compensate for the circulating blood volume deficit. Indications for the beginning of infusion of plasma-substituting solutions is a decrease in systolic blood pressure below 90 mm Hg. Art. In this case, to replenish the volume of circulating blood, the following volume-substituting solutions are usually used: synthetic colloids - polyglucin, polydes, gelatin, rheopolyglucin;crystalloids - Ringer's solution, lactasol, isotonic sodium chloride solution;salt-free solutions - 5% glucose solution.

If it is not possible to apply the infusion therapy at the prehospital stage, the victim is placed in a prone position with the head lowered in case of blood loss;in the absence of wounds of the upper and lower extremities they are given a vertical position, which will help to increase the central volume of the circulating blood. In critical situations, in the absence of the possibility of conducting infusion therapy, the administration of vasoconstrictive agents is indicated with the aim of increasing blood pressure.

• Stopping of external bleeding, which is performed by imposing a tight bandage, hemostatic clamp or tourniquet, plugging a wound, etc. Stopping bleeding promotes more effective delivery of infusion therapy. Rapid hospitalization is necessary if the victim has internal bleeding, the signs of which are pale skin covered with cold sweat: frequent pulse and low blood pressure.

• Anesthesia should be performed before removing the victim from heavy objects, shifting to a stretcher, before applying transport immobilization, and only after carrying out all activities for the restoration of vital functions, which include the sanitation of the airways, the administration of solutions with large blood loss, stoppingbleeding.

Provided rapid( up to 1 hour) transportation using mask anesthesia with AP-1, Trantal and methoxyflurane and local anesthesia with novocaine and trimecaine.

For prolonged transport( more than 1 hour), narcotic and non-narcotic analgesics are used, and they are also used in cases of an accurate diagnosis( eg limb amputation).Since in the acute period of severe trauma, absorption from tissues is disrupted, analgesic drug preparations are administered intravenously, slowly, under the control of respiration and hemodynamics.

• Immobilization: transportation and removal( removal) of the victim from the scene and, if possible, fast hospitalization.

Fixation of damaged limbs prevents the appearance of pains that enhance shock phenomena and is indicated in all necessary cases regardless of the condition of the victim. Establishment of standard transport buses.

Stacking the victim on a stretcher for transportation plays an equally important role in his rescue. In this case, the victim is laid in such a way as to avoid aspiration of the respiratory tract with vomit masses, blood, etc. The victim, who is conscious, should be put on his back. A patient who is unconscious should not put a pillow under his head, since in such a situation, it is possible to close the respiratory tract with tongue with reduced muscle tone. If sick or injured in consciousness, he is laid on his back. Otherwise, it must be remembered that with reduced muscle tone, the tongue closes the airways, so do not put a pillow or other objects under the victim's head. In addition, in this situation, the bent neck can cause an inflection of the airways, and when vomiting occurs, vomit will freely enter the respiratory tract. When bleeding from the nose or mouth, lying down on the back of the victim, the draining blood and the contents of the stomach will freely enter the respiratory tract and close their lumen. This is a very important point in the transportation of the victim, because according to statistics, about a quarter of all casualties die in the first minutes due to aspiration of the airways and an incorrect transport position. And if in this case the victim survives in the first hours, then in the future, in the majority of cases, he develops postaspiremental pneumonia, which is difficult to treat. Therefore, to avoid such complications, the victim in such cases is recommended to be laid on the stomach and to watch that his head was turned to the side. This situation will promote the outflow of blood from the nose and mouth outward, in addition, the tongue will not interfere with the free breathing of the victim.

The position of the victim lying on his side with his head turned on his side will also help to avoid aspiration of the airways and tongue twisting. But, so that the victim could not turn on his back or down the face, the leg on which he lies should be bent at the knee joint: in this position it will serve as support for the injured person. When transporting the victim, it should be borne in mind that when injuring the chest to facilitate breathing, the victim should be better placed by lifting the upper body;when the ribs are broken, the injured person should be laid on the damaged side, and then the mass of the body will act as a tire, which prevents the painful movements of the ribs during breathing.

While engaged in transporting the victim from the scene, the caretaker should remember that his task is not to allow a deepening of the shock, to reduce the severity of hemodynamic and respiratory disorders, which are the greatest danger for the life of the victim.

Shock is the general reaction of the body to extreme effects( trauma, allergy).Clinical manifestations: acute cardiovascular insufficiency and necessarily - polyorganic insufficiency.

The main link in the pathogenesis of traumatic shock are disorders caused by trauma to tissue blood flow. Trauma leads to a violation of the integrity of blood vessels, blood loss, which is the trigger mechanism of shock. There is a shortage of circulating blood( BCC), bleeding( ischemia) of the organs. At the same time, to maintain the blood circulation in vital organs( brain, heart, lungs, kidneys, liver) at the required level due to others( skin, intestines, etc.), compensatory mechanisms are activated, i.e.there is a redistribution of blood flow. This is called centralization of blood circulation, due to which the work of vital organs is supported for some time.

The next mechanism of compensation is tachycardia, which increases the passage of blood through the organs.

But after a while compensatory reactions take the character of pathological. At the level of microcirculation( arterioles, venules, capillaries), the tone of capillaries, venules decreases, blood collects( pathologically deposited) in venules, which is equivalent to repeated blood loss, since the venule area is huge. Further, the tone and capillaries lose, they do not expand, fill with blood, stagnation occurs, which causes mass microthrombi - the basis for the violation of hemocoagulation. There is a violation of the patency of the capillary wall, the leakage of plasma, the place of this plasma again receives blood. This is an irreversible, terminal phase of shock, the tone of the capillaries is not restored, cardiovascular failure is progressing.

In other organs with shock, changes due to decreased blood supply( hypoperfusion) are secondary. The functional activity of the central nervous system is preserved, but complex functions as the brain is ischemic are violated.

Shock is accompanied by a violation of breathing, as there is hypoperfusion with the blood of the lungs. Tachypnea begins, hyperpnoea as a result of hypoxia. Suffer from the so-called non-respiratory functions of the lungs( filtering, detoxification, hematopoiesis), blood circulation is disturbed in the alveoli and so-called "shock lung" - interstitial edema. In the kidneys, a decrease in diuresis is first observed, then there is an acute renal failure, a "shock kidney", since the kidney is very sensitive to hypoxia.

Thus, quickly formed polyorganism deficiency, and without taking urgent anti-shock measures, death occurs.

Clinic of shock. In the initial period, often observed excitation, the patient is euphoric, does not realize the severity of his condition. This is the erectile phase, it is usually short. Then comes the torpid phase: the victim becomes inhibited, languid, apathetic. Consciousness is preserved until the terminal stage. Skin pale, covered with cold sweat. For the paramedic of the "First Aid" the most convenient way is an approximate determination of blood loss by the value of systolic blood pressure( SBP).

1. If SBP is 100 mmHg, blood loss is not more than 500 ml.

2. If the SBP is 90-100 mmHg, Art.- up to 1 liter.

3. If the SBP is 70-80 mmHg, Art.- up to 2 liters.

4. If the SBP is less than 70 mmHg, Art.- more than 2 liters.

Shock I degree - obvious violations of hemodynamics may not be, blood pressure is not reduced, the pulse is not frequent.

Shock II degree - systolic pressure reduced to 90 100 mm Hg. The pulse is rapid, the pallor of the skin is developing, the peripheral veins are falling.

Shock III degree - the condition is heavy. SBP 60-70 mm Hg. The pulse rate is increased to 120 per minute, weak filling. Sharp pallor of the skin, cold sweat.

Shock IV degree - the condition is extremely difficult. Consciousness is confused at first, then fades. Against the background of the pallor of the skin, there is cyanosis, a mottled pattern. SBP 60 mmHgTachycardia 140-160 per minute, the pulse is determined only on large vessels.

General principles of shock treatment:

1. Early treatment, since the shock lasts 12-24 hours.

2. Etiopathogenetic treatment, i.e.treatment depending on the cause, severity, course of shock.

3. Complex treatment.

4. Differentiated treatment.

Emergency care

1. Providing airway patency:

• easy tipping head back;

• removal of mucus, pathological secretions or foreign bodies from the oropharynx;

• maintenance of patency of the upper respiratory tract with airway.

2. Control of breathing. Exercise on a tour of the chest and abdomen. In the absence of breathing - urgently artificial respiration "mouth to mouth", "mouth to nose" or using portable breathing apparatus.

3. Control of blood circulation. Check pulse on large arteries( carotid, femoral, brachial).In the absence of a pulse, an immediate, indirect massage of the heart.

4. Provision of venous access and initiation of infusion therapy.

For hypovolemic shock, an isotonic sodium chloride solution or Ringer's solution is administered. If hemodynamics does not stabilize, then it can be assumed that bleeding continues( hemothorax, ruptures of parenchymal organs, fracture of pelvic bones).

5. Stopping external bleeding.

6. Anesthesia( promedol).

7. Immobilization with injuries of limbs, spine.

8. Termination of the receipt of an allergen in anaphylactic shock.

In case of traumatic shock, first of all, it is necessary to stop the bleeding( if possible) by applying tourniquets, tight bandages, tamponade, applying clamps to a bleeding vessel, etc.

In shock of I-II degree, intravenous infusion of 400-800 ml of polyglucin is indicated, which is particularly advisablefor the prevention of deepening of shock when transportation is necessary over long distances.

For I-III degree shock, after transfusion of 400 ml of polyglucin, 500 ml of Ringer's solution or 5% glucose solution should be poured, and then the polyglucin infusion should be resumed. In solutions, 60 to 120 ml of prednisolone or 125 to 250 ml of hydrocortisone are added. In severe trauma, infusion into two veins is advisable.

Along with infusions, anesthesia should be performed in the form of local anesthesia with a 0.25-0.5% solution of novocain in the fracture region;if there is no damage to the internal organs, trauma to the skull intravenously injected solutions promedola 2% - 1.0-2.0, omnipo 2% - 1-2 ml or morphine 1% - 1-2 ml.

With shock III-IV degree, anesthesia should be performed only after transfusion 400-800 ml of polyglucin or reopolyglucin. Enter hormones: prednisolone( 90-180 ml), dexamethasone( 6-8 ml), hydrocortisone( 250 ml).

Do not try to quickly raise blood pressure. Contraindicated the introduction of pressor amines( mezaton, noradrenaline, etc.).

For all types of shock, oxygen inhalations are produced. If the patient's condition is extremely difficult and transportation to a large distance, especially in rural areas, should not be rushed. It is advisable to at least partially replace blood loss( BCC), conduct reliable immobilization, stabilize hemodynamics as much as possible.