What is the erectile shock phase? Traumatic shock: classification, degrees, first aid algorithm. Causes and mechanisms of development of traumatic shock
Traumatic shock is a dynamic phase process, the symptomatology of which changes over time and is determined by the phase and degree of development. During shock, two phases are distinguished - erectile and torpid. The erectile phase occurs immediately after the injury and is characterized by preservation of consciousness, motor and speech excitation, and lack of a critical attitude towards one’s condition and the environment. The pain response is sharply increased. The patient's gaze is restless, his voice is muffled, his sentences are abrupt. The skin and visible mucous membranes are pale, sweating is increased. General hyperesthesia is expressed, skin and tendon reflexes are increased; the pupils are dilated, their reaction to light is increased. The pulse is usually frequent, but sometimes slow, with satisfactory filling. Blood pressure is normal or elevated.
The erectile phase of shock lasts up to 10-20 minutes, and the more pronounced the excitement during it, the more severe the torpid phase and the worse the prognosis. The transition from the erectile phase to the torpid phase usually occurs within a few minutes, and therefore it often eludes the doctor’s observation.
The torpid phase is divided into four degrees according to severity.
First degree shock ( light form) usually develops with injuries moderate severity. The victim may be slightly sluggish. The skin and visible mucous membranes are pale. Skin and tendon reflexes are reduced, muscle tremors are pronounced. The patient complains of thirst. Breathing increased to 25 beats per minute, pulse 90-100 beats per minute. Blood pressure within 100/60 mm Hg. Art.
Shock of the second degree (moderate) often occurs with severe and especially multiple injuries. More typical serious condition the victim, his lethargy, sluggish reaction to his surroundings, slow speech, quiet voice. The skin and visible mucous membranes are sharply pale, gray in color. Breathing is shallow, up to 30 per minute. Pulse up to 130 beats per minute; satisfactory or weak filling. Blood pressure is about 85/60 mm Hg. Art. Body temperature is reduced.
Third degree shock (severe) is observed with large multiple injuries and is characterized by a very severe general condition of the victim. Consciousness is preserved, but the victim is sharply inhibited, has little communication, and answers questions slowly, in a barely audible whisper. The skin and visible mucous membranes are deathly pale, gray or pale cyanotic. Shortness of breath is pronounced. Pulse 120-140 beats per minute, poor filling or thread-like, arrhythmic. Blood pressure within 60/30 mm Hg. Art. Body temperature is reduced.
Shock of the fourth degree (terminal state) is characterized by the onset of collapse, preagonal and atonal state. General state the victim is severely injured. There is no consciousness, reflexes disappear, sphincters relax. The pulse is thread-like, barely noticeable, and at times disappears completely. Systolic blood pressure is below 60 mm Hg. Art., diastolic is often not determined. Respiratory movements fade away.
The four-degree classification of the torpid phase of shock, developed by V.I. Popov, most fully reflects it clinical course and determines the treatment plan.
Clinically, it is not always possible to correctly assess the condition of the victim in the first minutes and hours after injury. Clinical signs have not yet been studied on the basis of which one could reliably judge the presence of an irreversible condition in traumatic shock. In a number of cases, when at first glance it seems that the victim is traumatic injuries complicated by shock, is already dying, rational antishock therapy makes it possible to bring the patient out of a serious condition.
Extensive frostbite can be complicated by shock, which develops immediately after the frostbitten parts of the body are warmed due to severe pain, accompanying the restoration of sensitivity of the affected tissues. General hypothermia, common in these victims, contributes to the development of shock.
Shock with extensive burns also has some features (see).
Surgical shock is distinguished by the absence of an erectile phase, as well as the fact that it can develop during an operation performed under anesthesia. The loss of pain sensitivity, and during anesthesia, also of consciousness, leads to the fact that the patient’s well-being and behavior make it difficult to diagnose shock and the latter manifests itself only in changes functional state cardiovascular and respiratory systems. In the torpid phase, when the effect of anesthesia ends, the clinical picture of surgical shock is the same as with traumatic shock.
Traumatic shock– the body’s response, which has a generalized nature, to any severe physical injury. With severe blood loss, traumatic shock is also called hemorrhagic shock.
Causes of traumatic shock.
The main triggering factors for the occurrence of traumatic shock are multiple severe combined and concomitant injuries and injuries, coupled with severe blood loss and pain syndromes, provoking a number of serious changes in the body, which are aimed at restoring and replacing lost ones, as well as maintaining basic vital functions.
The body's first response to injury is to release large quantity catecholamines such as adrenaline and norepinephrine, etc. Under the influence of the strongly pronounced biological effect of these substances, blood circulation is radically redistributed. The volume of circulating blood decreases due to massive blood loss, and therefore cannot fully ensure oxygenation of tissues and organs in the periphery due to the preserved volume of blood supply, as a result of which blood pressure drops sharply.
Catecholamines provoke peripheral vasospasm, which blocks blood circulation in the capillaries in the periphery. The condition is aggravated by low blood pressure, and metabolic acidosis develops. The largest percentage of the circulating blood supply is located in main vessels, thereby supporting vital organs such as the heart, lungs, and brain.
The described phenomenon is called “centralization of blood circulation.” It should be borne in mind that it cannot provide compensation for blood supply for a long time, so assistance to the victim must be provided as quickly as possible. In the absence of anti-shock measures, metabolic acidosis begins to move from peripheral to centralized, thereby causing multiple organ failure syndrome, which without treatment leads to death.
Phases of traumatic shock.
Traumatic shock, like any other, has two phases, following in turn one after another:
The arousal phase is erectile. It is shorter in duration than the next phase and has the following signs: restless, darting gaze, increased blood pressure, strong psycho-emotional arousal, tachycardia, hyperesthesia, tachypnea, pallor skin;
The braking phase is torpid. The first phase passes into the inhibition phase, this is evidence of the severity and intensification of shock changes. The pulse becomes threadlike, blood pressure drops to the point of collapse, and consciousness is impaired. The person is inactive and indifferent to surrounding actions.
The braking phase has four degrees of severity:
1st degree. There is a slight stupor, heart rate up to 100 beats/min, blood loss is 15-25% of the total blood volume, upper blood pressure (BP) is not less than 90-100 mm Hg. Art., diuresis is normal;
2nd degree. Obvious stupor, tachycardia develops up to 120 beats per minute, upper blood pressure is not less than 70 mm Hg. Art., urination is impaired, oliguria is noted;
3rd degree. Stupor, heart rate more than 140 beats/min, upper blood pressure not more than 60 mm Hg. Art., blood loss is more than 30% of the total blood volume, there is no urine output at all;
4th degree. Coma state, there is no pulse in the periphery, it manifests itself pathological breathing and multiple organ failure, upper blood pressure is determined to be lower than 40 mmHg, blood loss is more than 30% of the total blood volume. This condition should be regarded as terminal.
Diagnosis of traumatic shock.
When diagnosing of this disease important role plays a role in the type of injury.
Severe degrees of traumatic shock are usually observed with:
Fractures femur(open or closed splintered)
Abdominal injury combined with injury to 2 or more parenchymal organs
Contusion or fracture of the skull with traumatic brain injury
Multiple rib fractures with or without lung damage.
When diagnosing, it is extremely important to determine blood pressure and pulse indicators, because they give an idea of the severity of the shock.
In intensive care, other indicators are monitored, in particular diuresis and venous pressure, which help to build a picture pathological changes of cardio-vascular system and the severity of multiple organ failure.
Monitoring venous pressure allows us to judge whether cardiac activity is impaired, or when low rates– about the presence of ongoing bleeding.
Diuresis indicators help determine the state of kidney function.
Emergency care in case of traumatic shock.
The victim must be in horizontal position. If possible, external bleeding should be eliminated. If blood is bleeding from an artery, then a tourniquet is applied 15-20 cm above the bleeding site. Venous bleeding requires a pressure bandage on the injury site itself.
In the absence of damage to the thoracic and abdominal cavity and 1st degree of shock severity, the patient can be given warm tea, wrap in a blanket.
A 1% solution of promedol administered intravenously can eliminate pronounced pain syndrome.
If a person stops breathing, then it is necessary to do artificial respiration, in the absence of heartbeat it is necessary cardiopulmonary resuscitation, the patient must be taken to medical institution immediately.
Traumatic shock is the earliest severe complication of mechanical injury. This condition arises and develops as general reaction the body for damage and is classified as a critical condition. Traumatic shock can be defined as a life-threatening complication of severe injuries, in which the regulation of the functions of vital systems and organs is disrupted and then steadily deteriorates, causing circulatory disorders to develop, microcirculation is disrupted, resulting in hypoxia of tissues and organs.
Disruption of microcirculation in organs and tissues is that the gradient between arterioles and venules decreases with limited blood flow, a drop in blood flow velocity in capillaries and post-capillary venules, a decrease in capillary blood flow up to stasis, a decrease in the surface of functioning capillaries and limitation of transcapillary transport, an increase in blood viscosity and the occurrence of erythrocyte aggregation. This leads to a critical decrease in blood flow in the tissues, deep metabolic disorders, among which the main ones are hypoxia of tissues and organs, as well as metabolic disorders. IN clinical picture predominantly acute cardiovascular and respiratory failure.
The term “traumatic" should refer only to a certain group of reactions of the body that develop in the same way and have a common pathogenesis, and not be a collective concept that unites heterogeneous severe critical conditions of the body ( acute blood loss, severe traumatic brain injury, cardiovascular and respiratory disorders, etc.), based on secondary signs hypotension and tachycardia. Frequency of traumatic shock in patients hospitalized with different characters and localization mechanical damage, according to national statistics, is 2.5%.
Pathogenesis of traumatic shock
The pathogenesis of traumatic shock is very complex. All pathogenetic links are linked together by the neuroreflex theory of shock. According to this theory, the “starter” of traumatic shock is pain, impulses that occur during injury. In response to super-strong irritations entering the central nervous system, the function of the sympathetic-adrenal system is enhanced, which leads first to a reflex spasm, and then to atony of peripheral vessels, a decrease in the speed of blood flow in the capillaries, as a result of which increased permeability of the capillary walls develops, plasma loss occurs , the volume of circulating blood decreases and hypovolemia occurs. The heart does not receive enough blood, stroke and minute blood volume decreases. Universal stereotypical symptoms of shock, hypotension and tachycardia occur. Prolonged hypotension leads to circulatory hypoxia, which affects vital functions important organs: brain, liver, kidneys. The state of circulatory hypoxia leads to disruption of all types of metabolism, vasoparalyzing substances and other metabolites appear in the blood, which causes toxic hypoxia. As metabolic disorders progress and hypotension increases, reaching a critical level, all vital functions of the body are suppressed - a terminal state occurs.
Blood loss aggravates the course of shock and its outcome; it is an important pathogenetic link, since it itself creates hypovolemia and anemic hypoxia. However, blood loss is not the primary cause of shock. In the development of shock and its course, a certain importance is attached to the absorption of decay products of damaged tissues and bacterial toxins. An important pathogenetic link in traumatic shock is endocrine disorders. It has been established that with the development of shock, there is initially an increase in the function of the adrenal glands (hyperadrenalemia) and then their rapid depletion. In dysfunction internal organs and metabolism in traumatic shock, acidosis, azotemia, histaminemia, and imbalance of electrolytes, in particular potassium and calcium, play an important role. Thus, with traumatic shock, the development of circulatory, anemic, toxic and respiratory hypoxia occurs in combination with metabolic disorders and, in the absence or untimely appropriate therapy, leads to the gradual extinction of all vital functions of the body and, under certain unfavorable conditions, to the death of the victim. The occurrence and severity of shock depend on the severity and location of the injury, predisposing factors, effectiveness preventive measures, as well as the timing and intensity of treatment.
Most often, shock occurs with injuries to the abdomen, pelvis, chest, spine, or hip.
For the occurrence of shock and its development are of great importance predisposing factors: blood loss, mental condition, hypothermia and overheating, fasting.
Phases of traumatic shock
During shock, two phases are distinguished - erectile and torpid. In practice, the erectile phase can be observed infrequently, in only every tenth patient admitted to the hospital. medical institution in a state of shock. This is explained by the fact that it is fleeting, lasts a few minutes, is often not diagnosed and is not differentiated from excitement as a result of fear, alcohol intoxication, poisoning, mental disorders.
During the erectile phase the patient is conscious, his face is pale, his gaze is restless. Motor and speech excitation is observed. He complains of pain, often screams, is euphoric and does not realize the severity of his condition. He can jump off a stretcher or gurney. It is difficult to hold it as it offers a lot of resistance. The muscles are tense. There is general hyperesthesia, skin and tendon reflexes are increased. Breathing is rapid and uneven. The pulse is tense, blood pressure periodically rises, which is caused by the release of the “emergency hormone” - adrenaline. It is noted that the more pronounced the erectile phase of shock is, the more severe the torpid phase is usually and the worse the prognosis. Following the erectile shock phase, a phase of deep inhibition of the activity of regulatory and executive systems body - torpid phase of shock.
Torpid phase of shock clinically manifested in mental depression, indifferent attitude towards the environment, sharp decline reactions to pain with, as a rule, preserved consciousness. There is a drop in arterial and venous pressure. The pulse is rapid, weak filling. Body temperature is reduced. Breathing is frequent and shallow. Skin is cold, severe degrees Shock covered in cold sweat. Thirst is observed, and sometimes vomiting occurs, which is a bad prognostic sign.
Clinical signs of traumatic shock
Main clinical signs, on the basis of which shock is diagnosed and the degree of its severity is determined, are hemodynamic indicators: blood pressure, filling rate and pulse tension, respiratory rate and circulating blood volume. The value of these indicators lies in the simplicity of their acquisition and ease of interpretation. With a certain degree of probability, the level of blood pressure can indirectly judge the mass of circulating blood. So, a drop in blood pressure to 90 mm Hg. Art. indicates a decrease in the mass of circulating blood by half, and up to 60 mm Hg. Art. - three times. In addition, the level of blood pressure and the nature of the pulse are objective criteria for the effectiveness of the therapy.
The torpid phase of shock, according to the severity and depth of symptoms, is conventionally divided into four degrees: I, P, III and IV (terminal state). This classification is necessary for selection therapeutic tactics and determining prognosis.
Degrees of the torpid phase of traumatic shock
Shock I degree (mild). It manifests itself in a mildly expressed pallor of the skin and a slight disturbance of hemodynamics and breathing. The general condition is satisfactory, consciousness is clear. The pupils react well to light. Blood pressure is kept at 100 mmHg. Art. The pulse is rhythmic, satisfactory filling, up to 100 per minute. Body temperature is normal or slightly reduced. The mass of circulating blood decreases within 30%. Breathing is even, up to 20-22 per minute. The prognosis is favorable. Mild shock does not cause fear for the life of the victim. Rest, immobilization and pain relief are sufficient to restore body functions.
Shock II degree (moderate). It is characterized by more pronounced depression of the victim’s psyche, lethargy and pale skin are clearly expressed. Consciousness is preserved. The pupils react sluggishly to light. Maximum blood pressure 80-90 mm Hg. Art., minimum 50-60 mm Hg. Art. Pulse 120 per minute, weak filling. The volume of circulating blood decreases by 35%. Breathing is rapid and shallow. Severe hyporeflexia, hypothermia. The prognosis is serious. A favorable and unfavorable outcome is equally likely. Saving the life of a victim is only possible with immediate, vigorous, long-term complex therapy. In case of failure of compensatory mechanisms, as well as unrecognized severe injuries, transition is possible medium degree shock to severe.
Shock III degree (severe). The general condition of the victim is serious. The maximum blood pressure is below the critical level - 75 mm Hg. Art. The pulse is sharply increased, 130 per minute or more, thread-like, difficult to count. The volume of circulating blood decreases by 45% or more. Breathing is shallow and sharply rapid. The prognosis is very serious. With delayed help, irreversible forms of shock develop, in which the most vigorous therapy becomes ineffective. The irreversibility of shock can be stated in victims when, in the absence of ongoing bleeding, prolonged full complex antishock measures do not ensure a rise in blood pressure above a critical level. Severe shock can progress to stage IV - terminal state , which represents an extreme degree of inhibition of the vital functions of the body, turning into clinical death.
The terminal state is conventionally divided into three stages.
1. The pre-atonal state is characterized by severe pallor with pronounced cyanosis, absence of a pulse on the radial artery if it is present on the carotid and femoral arteries and undetectable blood pressure. Breathing is shallow and rare. Consciousness is confused or absent. Reflexes and tone skeletal muscles sharply weakened.
2. The atonal state has the same hemodynamic changes as the preagonal state, but is manifested by more severe respiratory disturbances (arrhythmic, Cheyne-Stokes), with pronounced cyanosis. Consciousness and reflexes are absent, muscle tone is sharply weakened, and the patient does not react to external influences.
3. Clinical death begins from the moment of the last breath. There is no pulse in the carotid and femoral arteries. Heart sounds are not audible. The pupils are dilated and do not react to light. There is no corneal reflex.
Shock of the III and IV degrees, if treatment is not carried out in a timely manner or is not complete enough, can end in clinical, and then biological death, characterized by the complete cessation of all vital functions of the body.
Shock index
The severity of the shock and, to some extent, the prognosis can be determined by its index. This concept refers to the ratio of heart rate to systolic pressure. If the index is less than one, that is, the pulse rate is less than the maximum blood pressure figure (for example, pulse 80 per minute, maximum blood pressure 100 mm Hg), “mild shock, the condition of the wounded is satisfactory - the prognosis is favorable. With a shock index equal to one (for example, pulse 100 per minute and blood pressure 100 mm Hg), the shock is of moderate severity. When the shock index is greater than one (for example, pulse 120 per minute, blood pressure 70 mm Hg), the shock is severe, the prognosis is threatening. Systolic pressure is a reliable diagnostic and prognostic indicator, provided that the degree of decrease in its actual and average age figures is taken into account.
Practical significance in shock, it has a level of diastolic pressure that is valuable both diagnostically and prognostically. Diastolic pressure in shock, like systolic, it has a certain critical limit - 30-40 mm Hg. Art. If it is below 30 mm Hg. Art. and there is no tendency to increase after anti-shock measures, the prognosis is most likely unfavorable.
The most accessible and widespread indicator of circulatory status is the frequency and filling of the pulse in the peripheral arteries. A very frequent, difficult to count or undetectable pulse that does not tend to slow down and fill better is a poor prognostic sign. In addition to the listed prognostic tests: shock index, level of systolic and diastolic pressure, pulse rate and filling, it is proposed to conduct a biological test for the reversibility and irreversibility of shock. This test consists of intravenously injecting the patient with a mixture consisting of 40 ml of a 40% glucose solution, 2-3 units of insulin, vitamins B1-6%, B6-5%, PP-1%o 1 ml, vitamin C 1% -5 ml and cordiamine 2 ml. If there is no reaction to the introduction of this mixture (increased blood pressure, decreased shock index, slowing and filling of the pulse), the prognosis is unfavorable. Determination of venous pressure in shock has no diagnostic or prognostic value. Knowing the level of venous pressure is only necessary to determine the need and possibility of intravenous transfusions, since it is known that venous hypertension is a direct contraindication to blood transfusions.
Traumatology and orthopedics. Yumashev G.S., 1983
Excitation phase (erectile) – excitement, euphoria, increased breathing, pulse, blood pressure is normal or low.
Torpid phase - passivity, indifference, lethargy, increased breathing, pale skin, cold sweat, Blood pressure is reduced or not determined.
"...With an arm or leg torn off, such a numb person lies motionless at the dressing station; he does not scream, does not yell, does not complain, does not understand participation in anything and does not demand anything. His body is cold, his face is pale, but, like a corpse, his gaze is motionless and turned into the distance. The pulse is like a thread, barely noticeable under the fingers and with frequent alternations. He is numb or doesn’t answer questions at all or only in a barely audible whisper to himself. Breathing is also barely noticeable. The wound and skin are almost completely insensitive, but if the large nerve hanging from the wound is irritated, then the patient with one contraction of the personal muscles reveals signs of feeling..."- wrote N.I. Pirogov (1865).
Shock severity:
I degree – mild shock: blood pressure up to 100 mm Hg, pulse up to 100 per minute, slight lethargy;
Stage II – shock of moderate severity: blood pressure is less than 100 mm Hg, but more than critical (60–70 mm), pulse is more often than 100, but less than 120 per minute, lethargy, pale skin, oliguria.
III degree – severe shock: blood pressure is below critical, pulse is more frequent, 120 per minute, anuria, cold sweat, oliguria.
IV degree – terminal shock: blood pressure is not determined, the pulse in the peripheral arteries is not palpable, preagonia.
Agony is a breathing disorder.
Clinical death - from the moment of the last breath.
Due to compensatory centralization of the circulation (ensuring sufficient blood supply to the brain, liver, kidneys, heart and intestines), blood pressure may remain above 100 mmHg. or even be at normal numbers. Therefore, the diagnosis of mild shock is made much less often than it actually is.
Signs of mild shock with “normal” blood pressure are:
the patient has multiple or combined injuries;
isolated fracture of the femur, tibia (especially with insufficient transport immobilization);
fracture of the trochanteric region in an elderly person (significant blood loss for him);
possibility of large blood loss (fracture of the pelvis, hip);
signs of peripheral circulatory disorder: pale skin, retraction of peripheral veins, coldness of the distal extremities, difference in temperature of the rectum and the back of the first toe by more than 5°C.
The concept of “mild shock” does not mobilize the surgeon for the necessary full-fledged infusion therapy.
It is advisable to distinguish two periods in the torpid phase of shock:
period of latent decompensation - blood pressure is normal, the pulse is well filled, diuresis is sufficient, there are microcirculation disorders, but we cannot yet determine them;
period of obvious decompensation - blood pressure begins to fall. In this period: moderate shock, severe shock, terminal shock.
Features of diagnosing injuries in a state of shock:
During the first minutes of contact with the patient, life-threatening disorders are identified in the following order:
assessment of breathing quality and airway patency,
presence and quality of pulse,
assessment of consciousness,
blood pressure measurement,
diagnosis of external or internal bleeding,
bladder catheterization.
Traumatic shock– acute neurogenic phase pathological process, developing under the influence of an extreme traumatic agent and characterized by the development of insufficiency peripheral circulation, hormonal imbalance, a complex of functional and metabolic disorders.
In the dynamics of traumatic shock, erectile and torpid stages are distinguished. In the case of an unfavorable course of shock, the terminal stage occurs.
Erectile stage The shock is short-lived, lasting several minutes. Outwardly it manifests itself as speech and motor restlessness, euphoria, pale skin, frequent and deep breathing, tachycardia, and a slight increase in blood pressure. At this stage, generalized excitation of the central nervous system, excessive and inadequate mobilization of all adaptive reactions aimed at eliminating the violations that have arisen. A spasm of the arterioles occurs in the vessels of the skin, muscles, intestines, liver, kidneys, i.e. organs that are less important for the survival of the body during the action of the shockogenic factor. Simultaneously with peripheral vasoconstriction, a pronounced centralization of blood circulation occurs, ensured by dilatation of the vessels of the heart, brain, and pituitary gland.
The erectile phase of shock quickly turns into a torpid phase. The transformation of the erectile stage into the torpid stage is based on a complex of mechanisms: progressive hemodynamic disorder, circulatory hypoxia leading to severe metabolic disorders, macroerg deficiency, formation of inhibitory mediators in the structures of the central nervous system, in particular GABA, prostaglandins type E, increased production of endogenous opioid neuropeptides.
Torpid phase traumatic shock is the most typical and prolonged, it can last from several hours to 2 days.
It is characterized by lethargy of the victim, adynamia, hyporeflexia, dyspnea, and oliguria. During this phase, inhibition of the activity of the central nervous system is observed.
In the development of the torpid stage of traumatic shock, in accordance with the state of hemodynamics, two phases can be distinguished - compensation and decompensation.
The compensation phase is characterized by stabilization of blood pressure, normal or even slightly reduced central venous pressure, tachycardia, absence of hypoxic changes in the myocardium (according to ECG data), absence of signs of brain hypoxia, pallor of the mucous membranes, and cold, moist skin.
The decompensation phase is characterized by a progressive decrease in IOC, a further decrease in blood pressure, the development of disseminated intravascular coagulation syndrome, microvascular refractoriness to endogenous and exogenous pressor amines, anuria, and decompensated metabolic acidosis.
The stage of decompensation is the prologue to the terminal phase of shock, which is characterized by the development irreversible changes in the body, gross disturbances of metabolic processes, mass cell death.