Treatment of traumatic shock. Traumatic shock - causes and stages. Algorithm for providing emergency care for injuries and traumatic shock Traumatic shock causes stages symptoms help

— life-threatening a person has a serious condition that occurs as a reaction to an acute injury, which is accompanied by large blood loss and intense pain.

Shock appears at the moment of receiving a traumatic effect in case of pelvic fractures, gunshot, traumatic brain injuries, severe injuries internal organs, in all cases associated with large blood loss.

Traumatic shock is considered a companion to all serious injuries, regardless of their causes. Sometimes it can occur after some time due to additional trauma.

In any case, traumatic shock is a very dangerous phenomenon, posing a threat to human life, requiring immediate recovery in intensive care.

Classification and degrees

Depending on the cause of the injury, types of traumatic shock are classified as:

• Surgical;
• Endotoxin;
• Shock resulting from a burn;
• Shock resulting from fragmentation;
• Shock from the impact of the shock wave;
• Shock received when applying a tourniquet.

According to the classification of V.K. Kulagin there are such types of traumatic shock:

• Operating;
• Wound (appears as a result mechanical impact, can be visceral, cerebral, pulmonary, occurs with multiple injuries, sudden compression of soft tissues);
• Mixed traumatic;
• Hemorrhagic (develops as a result of bleeding of any nature).

Regardless of the causes of shock, it goes through two phases - erectile (excitation) and torpid (inhibition).

1. Eriktilnaya.

This phase occurs at the moment of traumatic impact on a person with simultaneous sharp excitement nervous system manifested in excitement, anxiety, fear.

The victim remains conscious, but underestimates the complexity of his situation. He can answer questions adequately, but has impaired orientation in space and time.

The phase is characterized by pale human skin, rapid breathing, and severe tachycardia.

Mobilization stress in this phase varies in duration; shock can last from several minutes to hours. Moreover, with severe trauma, it sometimes does not manifest itself in any way.

And too short an erectile phase often precedes a more heavy current shock in the future.

1. Torpid phase.

Accompanied by a certain inhibition due to inhibition of the activity of the main organs (nervous system, heart, kidneys, lungs, liver).

Circulatory failure increases. The victim becomes pale. His skin has a gray tint, sometimes a marble pattern, indicating poor blood supply, stagnation in the blood vessels, and he breaks out in cold sweat.

The limbs in the torpid phase become cold, and breathing becomes rapid and shallow.

The torpid phase is characterized by 4 degrees, which indicate the severity of the condition.

1. First degree.

Considered easy. In this condition, the victim has a clear consciousness, pale skin, shortness of breath, slight lethargy, the pulse reaches 100 beats/min., the pressure in the arteries is 90-100 mm Hg. Art.

1. Second degree.

It's a shock moderate severity. It is characterized by a decrease in pressure to 80 mm Hg. Art., pulse reaches 140 beats/min. The person has severe lethargy, lethargy, and shallow breathing.

1. Third degree.

An extremely serious condition of a person in shock, who is in a confused state of consciousness or has completely lost it.

The skin becomes sallow gray in color, and the fingertips, nose and lips become bluish. The pulse becomes thread-like and increases to 160 beats/min. The man is covered in sticky sweat.

1. Fourth degree.

The victim is in agony. Shock of this degree is characterized by a complete absence of pulse and consciousness.

The pulse is barely palpable or completely imperceptible. The skin has grey colour, and the lips become bluish and do not respond to pain.

The prognosis is most often unfavorable. The pressure becomes less than 50 mm Hg. Art.

Causes and mechanism of development

To the causes state of shock in humans can include participation in various types of disasters, transport accidents, various injuries, and industrial injuries. Shock is possible due to large loss of plasma during burns and frostbite.

The basis of such shock is significant blood loss, pain factor, stressful mental state during acute injury and disorders important functions body.

The most significant cause is blood loss, the influence of other factors depends on which organ is affected.

Causes of traumatic shock include:

• Severe injuries (traumatic);
• Loss of large amounts of blood, plasma, fluid (hypovolemic);
• Allergy from medicines and insect bites, poisonous snakes (anaphylactic);
• Reaction to purulent inflammation(septic);
• Blood incompatible with the body during transfusion (hemotransfusion);
• Instant cardiac abnormalities (cardiogenic).

The mechanism of traumatic shock is triggered when a situation arises with a lack of blood in the body. Blood is directed to the most important organs (brain and heart), leaving less important vessels of the skin and muscles without blood due to their narrowing during pain.

Poor blood circulation causes internal organs to starve due to lack of oxygen, as a result of which their functions and metabolism are disrupted.

Blood circulation in tissues decreases and blood pressure decreases, as a result of which the kidneys begin to fail, then the liver and intestines.

The mechanism for the development of DIC syndrome is triggered due to clogging of small vessels with blood clots. As a result, the blood stops clotting, DIC syndrome causes large losses of blood in the body, which can be fatal.

Symptoms and signs

Since traumatic shock goes through two phases - excitation and inhibition, its signs are somewhat different.

A sign of a shock state in the erectile phase can be called excessive arousal of a person, his complaints of pain, anxiety, and a frightened state. He may become aggressive, scream, moan, but at the same time resist attempts to examine and treat him. He looks pale.

Symptoms of shock include small twitching of some muscles, trembling of limbs, rapid and weak breathing.

This stage is also characterized by dilated pupils, sticky sweat, and several elevated temperature. However, the body is still coping with the disturbances that have arisen.

A sign of traumatic shock in the event of a severe injury is the loss of consciousness of the victim, which occurs as a result of a strong pain signal, which is impossible to cope with; the brain turns off.

When the inhibition phase begins, the victim becomes overwhelmed by apathy, drowsiness, lethargy, and indifference. He no longer expresses any emotions, does not even react to manipulations with injured areas of the body.

Signs of the torpid phase of shock are cyanosis of the lips, nose, fingertips, and dilated pupils.

Dry and cold skin, pointed facial features with smoothed nasolabial folds are also considered signs of severe traumatic shock.

Blood pressure drops to levels dangerous to health, with a simultaneous weakening of the pulse in the peripheral arteries, which becomes thread-like and subsequently cannot be determined.

The victim’s state of chills does not go away even in the warmth, convulsions occur, and involuntary discharge of urine and feces is possible.

The temperature is normal, but with shock caused by a wound infection, it rises.

There are also signs of intoxication, which manifest themselves in a coated tongue, parched and dry lips, and suffering from thirst. Possible result severe shock will result in nausea and vomiting.

During this phase of shock, kidney function is disrupted, causing the amount of urine excreted to be significantly reduced. It becomes dark and concentrated, and in the case of the last stage of torpid shock, anuria (lack of urine) may occur.

Some patients have low compensatory capabilities, so the erectile phase may be missed or take only a few minutes. After which the torpid phase immediately begins severe form. Most often this happens with severe injuries to the head, abdominal and chest cavities with large loss of blood.

First aid

The further state of a person after traumatic shock and even his future destiny is directly dependent on the speed of reaction of others.

Assistance activities:

1. Urgently stop the bleeding using a tourniquet, bandage or wound tamponade. The main measure for traumatic shock is to stop bleeding, as well as eliminate the causes that provoked the shock.
2. Ensure increased access of air into the victim’s lungs by freeing him from tight clothing and positioning him in such a way as to prevent foreign bodies and liquids from entering the respiratory tract.
3. If there are injuries on the body of the injured person that can complicate the course of shock, then measures should be taken to close the wounds with a bandage or use means of transport immobilization for fractures.
4. Wrap the victim in warm clothes to avoid hypothermia, which worsens the state of shock. This is especially true for children and the cold season.
5. You can give the patient a little vodka or cognac, drink plenty of water with salt dissolved in it and baking soda. Even if a person doesn't feel severe pain, and this happens with shock, painkillers should be used, for example, analgin, maxigan, baralgin.
6. Call urgently ambulance or deliver the patient to the nearest medical facility yourself, it is better if it is a multidisciplinary hospital with an intensive care unit.
7. Transport on a stretcher as calm as possible. If blood loss continues, place the person with the legs elevated and the end of the stretcher lowered near the head.

If the victim is in unconscious or he is vomiting, he should be laid on his side.

In overcoming a state of shock, it is important not to leave the victim unattended and to instill in him confidence in a positive outcome.

It is important to follow 5 basic rules when providing emergency care:

• Reduced pain;
• Provide plenty of fluids for the victim;
• Warming the patient;
• Providing peace and quiet to the victim;
• Urgent delivery to a medical facility.

In case of traumatic shock it is prohibited:

• Leave the victim unattended;
• Carry the victim unless absolutely necessary. If transfer is unavoidable, it must be done carefully to avoid causing additional injuries;
• If the limbs are damaged, you cannot straighten them yourself, otherwise you can provoke an increase in pain and the degree of traumatic shock;
• Do not apply splints to injured limbs without achieving a reduction in blood loss. This can deepen the patient's state of shock and even cause his death.

Treatment

Upon admission to the hospital, recovery from the state of shock begins with the transfusion of solutions (saline and colloidal). The first group includes Ringer's solution and Lactosol. Colloidal solutions are represented by gelatinol, rheopolyglucin and polyglucin.

RCHR ( Republican Center healthcare development of the Ministry of Health of the Republic of Kazakhstan)
Version: Archive - Clinical protocols Ministry of Health of the Republic of Kazakhstan - 2007 (Order No. 764)

Traumatic shock (T79.4)

general information

Short description

Traumatic shock- an acutely developing and life-threatening condition that occurs as a result of exposure to severe mechanical trauma on the body.

Traumatic shock is the first stage of severe form acute period a traumatic disease with a peculiar neuro-reflex and vascular reaction of the body, leading to profound disorders of blood circulation, breathing, metabolism, and the functions of the endocrine glands.

The triggering mechanisms of traumatic shock are pain and excessive (afferent) impulses, acute massive blood loss, trauma to life important organs, mental shock.

Protocol code: E-024 "Traumatic Shock"
Profile: emergency

Purpose of the stage: restoration of the function of all vital systems and organs

ICD-10 code(s):

T79.4 Traumatic shock

Excluded:

Shock (caused by):

Obstetric (O75.1)

Anaphylactic

NOS (T78.2)

Due to:

Pathological reaction to food (T78.0)

Adequately prescribed and correctly administered medicinal product (T88.6)

Serum reactions (T80.5)

Anesthesia (T88.2)

Summoned electric shock(T75.4)

Non-traumatic NCD (R57.-)

Against lightning (T75.0)

Postoperative (T81.1)

Accompanying abortion, ectopic or molar pregnancy (O00-O07, O08.3)

T79.8 Other early complications of trauma

T79.9 Early complication of trauma, unspecified

Classification

According to the course of traumatic shock:

1. Primary - develops at the time of or immediately after injury.

2. Secondary - develops delayed, often several hours after injury.

Stages of traumatic shock:

1. Compensated - there are all signs of shock, with a sufficient level of blood pressure, the body is able to fight.

3. Refractory shock - all therapy is unsuccessful.

Severity of traumatic shock:

Shock 1st degree - SBP 100-90 mm Hg, pulse 90-100 per minute, satisfactory filling.

Shock 2 degrees - SBP 90-70 mm Hg, pulse 110-130 per minute, weak filling.

Shock 3rd degree - SBP 70-60 mm Hg, pulse 120-160 per minute, very weak filling (thread-like).

Shock 4 degrees - blood pressure is not determined, pulse is not determined.

Risk factors and groups

1. Rapid blood loss.

2. Overwork.

3. Cooling or overheating.

4. Fasting.

5. Repeated injuries (transportation).

6. Penetrating radiation and burns, that is, combined injuries with mutual aggravation.

Diagnostics

Diagnostic criteria: presence of mechanical trauma, clinical signs of blood loss, decrease blood pressure, tachycardia.

Characteristic symptoms shock:

Cold, damp, pale cyanotic or marbled skin;

Sharply slowed blood flow of the nail bed;

Darkened consciousness;

Dyspnea;

Oliguria;

Tachycardia;

Decrease in blood and pulse pressure.

An objective clinical examination reveals

There are two phases in the development of traumatic shock.

Erectile stage occurs immediately after injury and is characterized by pronounced psychomotor agitation of the patient against the background of centralized blood circulation. The behavior of patients may be inappropriate; they rush about, scream, make erratic movements, are euphoric, disoriented, and resist examination and assistance. Getting in touch with them can sometimes be extremely difficult. Blood pressure may be normal or close to normal. Can be various disorders breathing, the nature of which is determined by the type of injury. This phase is short-lived and by the time assistance is provided it may change to a torpid one or stop.

For torpid phase characterized by blackouts, stupor and the development of a coma as an extreme degree of brain hypoxia caused by disturbances of the central circulation, decreased blood pressure, soft, rapid pulse, pale skin. At this stage on prehospital stage The emergency physician should rely on blood pressure levels and try to determine the amount of blood loss.

Determination of the volume of blood loss is based on the ratio of pulse rate to systolic blood pressure (S/SBP).

In case of shock 1 degree (blood loss 15-25% of the bcc - 1-1.2 l) SI = 1 (100/100).

In case of shock 2 degrees (blood loss 25-45% of the bcc - 1.5-2 l) SI = 1.5 (120/80).

In case of shock 3 degrees (blood loss more than 50% of the bcc - more than 2.5 l) SI = 2 (140/70).

When estimating the volume of blood loss, one can proceed from known data on the dependence of blood loss on the nature of the injury. Thus, with a fracture of the ankle in an adult, blood loss does not exceed 250 ml, with a fracture of the shoulder, blood loss ranges from 300 to 500 ml, of the lower leg - 300-350 ml, hips - 500-1000 ml, pelvis - 2500-3000 ml, with multiple fractures or In a combined injury, blood loss can reach 3000-4000 ml.

Taking into account the capabilities of the prehospital stage, it is possible to compare various degrees shock and their inherent clinical signs.

Shock 1st degree(mild shock) is characterized by blood pressure 90-100/60 mm Hg. and pulse 90-100 beats/min. (SI=1), which can be satisfactorily filled. Usually the victim is somewhat inhibited, but easily makes contact and reacts to pain; the skin and visible mucous membranes are often pale, but sometimes have a normal color. Breathing is rapid, but in the absence of concomitant vomiting and aspiration of vomit respiratory failure No. It occurs against the background of a closed fracture of the femur, a combined fracture of the femur and tibia, and a mild fracture of the pelvis with other similar skeletal injuries.

Shock 2 degrees(moderate shock) is accompanied by a decrease in blood pressure to 80-75 mm Hg, and the heart rate increases to 100-120 beats/min. (SI=1.5). Severe skin pallor, cyanosis, adynamia, and lethargy are observed. Occurs with multiple fractures of long tubular bones, multiple fractures of the ribs, severe fractures of the pelvic bones, etc.

Shock 3 degrees(severe shock) is characterized by a decrease in blood pressure to 60 mm Hg. (but may be lower), the heart rate increases to 130-140 beats/min. Heart sounds become very muffled. The patient is deeply inhibited, indifferent to his surroundings, the skin is pale, with pronounced cyanosis and an earthy tint. Develops with multiple concomitant or combined trauma, damage to the skeleton, large muscle masses and internal organs, chest, skulls and burns.

With further deterioration of the patient's condition, a terminal condition may develop - grade 4 shock.

List of main diagnostic measures:

1. Collection of complaints, medical history, general therapeutic.

2. Visual examination, general therapeutic.

3. Measurement of blood pressure in peripheral arteries.

4. Pulse examination.

5. Heart rate measurement.

6. Respiration rate measurement.

7. General therapeutic palpation.

8. General therapeutic percussion.

9. General therapeutic auscultation.

10. Registration, interpretation and description of the electrocardiogram.

11. Studies of the sensory and motor spheres in pathologies of the central nervous system.

List of additional diagnostic measures:

1. Pulse oximetry.

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Treatment

Tactics of rendering medical care

Treatment algorithm for traumatic shock

General activities:

1. Assess the severity of the patient’s condition (it is necessary to focus on the patient’s complaints, level of consciousness, color and humidity skin, breathing and pulse patterns, blood pressure levels).

2. Provide measures aimed at stopping bleeding.

3. Interrupt shockogenic impulses (adequate pain relief).

4. Normalization of BCC.

5. Correction of metabolic disorders.

6. In other cases:

Lay the patient down with the leg end elevated by 10-45%, Trendelenburg position;

Ensure patency of the upper respiratory tract and access to oxygen (ventilation if necessary).

Specific events:

1. Stopping external bleeding at the prehospital stage is carried out using temporary methods (tight tamponade, application of a pressure bandage, digital pressure directly in the wound or distal to it, application of a tourniquet, etc.).

Ongoing internal bleeding it is almost impossible to stop at the prehospital stage, therefore the actions of the emergency doctor should be aimed at the speedy, careful delivery of the patient to the hospital.

2. Pain relief:

1st option - intravenous administration 0.5 ml of 0.1% atropine solution, 2 ml of 1% diphenhydramine solution (diphenhydramine), 2 ml of 0.5% diazepam solution (Relanium, Seduxen), then slowly 0.8-1 ml of 5% ketamine solution (calypsol) .

In case of severe traumatic brain injury, do not administer ketamine!

2nd option - intravenous administration of 0.5 ml of 0.1% atropine solution, 2-3 ml of 0.5% diazepam solution (Relanium, Seduxen) and 2 ml of 0.005% fentanyl solution.

For shock accompanied by ARF, intravenously administer sodium hydroxybutyrate 80-100 mg/kg in combination with 2 ml of 0.005% fentanyl solution or 1 ml of 5% ketamine solution in 10-20 ml isotonic solution 0.9% sodium chloride or 5% glucose.

3. Transport immobilization.

4. Replenishment of blood loss.
For undetectable blood pressure, the infusion rate should be 250-500 ml per minute. A 6% solution of polyglucin is administered intravenously. If possible, preference is given to 10% or 6% solutions of hydroxyethyl starch (stabizol, refortan, HAES-steril). No more than 1 liter of such solutions can be poured at a time. Signs of the adequacy of infusion therapy are that after 5-7 minutes the first signs of detectable blood pressure appear, which in the next 15 minutes increase to a critical level (SBP 90 mm Hg).

In case of mild shock and medium degree, preference is given to crystalloid solutions, the volume of which should be higher than the volume of lost blood, since they quickly leave the vascular bed. Introduce 0.9% sodium chloride solution, 5% glucose solution, polyionic solutions - disol, trisol, acesol.

In order to gain time if it is impossible to carry out infusion therapy, it is advisable to use intravenous administration of dopamine - 200 mg in 400 ml of 5% glucose solution at a rate of 8-10 drops/min.

3. *Dopamine 200 mg per 400 ml

4. *Pentastarch (refortan) 500 ml, fl.

5. *Pentastarch (stabizol) 500 ml, fl.

* - drugs included in the list of essential (vital) medicines.

Information

Sources and literature

1. Protocols for diagnosis and treatment of diseases of the Ministry of Health of the Republic of Kazakhstan (Order No. 764 of December 28, 2007)
   1. 1. Clinical guidelines based on evidence-based medicine: Per. from English / Ed. Yu.L. Shevchenko, I.N. Denisova, V.I. Kulakova, R.M. Khaitova. 2nd ed., rev. - M.: GEOTAR-MED, 2002. - 1248 p.: ill. 2. Guide for emergency physicians / Ed. V.A. Mikhailovich, A.G. Miroshnichenko - 3rd edition, revised and expanded - St. Petersburg: BINOM. Knowledge Laboratory, 2005.-704p. 3. Management tactics and emergency medical care in emergency conditions. Guide for doctors./ A.L. Vertkin - Astana, 2004.-392 p. 4. Birtanov E.A., Novikov S.V., Akshalova D.Z. Development of clinical guidelines and diagnostic and treatment protocols taking into account modern requirements. Guidelines. Almaty, 2006, 44 p. 5. Order of the Minister of Health of the Republic of Kazakhstan dated December 22, 2004 No. 883 “On approval of the List of essential (vital) medicines.” 6. Order of the Minister of Health of the Republic of Kazakhstan dated November 30, 2005 No. 542 “On introducing amendments and additions to the order of the Ministry of Health of the Republic of Kazakhstan dated December 7, 2004 No. 854 “On approval of the Instructions for the formation of the List of essential (vital) medicines.”

Information

Head of the Department of Ambulance and Emergency Medical Care, Internal Medicine No. 2 of the Kazakh National medical university them. S.D. Asfendiyarova - Doctor of Medical Sciences, Professor Turlanov K.M.

Employees of the Department of Ambulance and Emergency Medical Care, Internal Medicine No. 2 of the Kazakh National Medical University named after. S.D. Asfendiyarova: candidate of medical sciences, associate professor Vodnev V.P.; candidate of medical sciences, associate professor Dyusembayev B.K.; Candidate of Medical Sciences, Associate Professor Akhmetova G.D.; candidate of medical sciences, associate professor Bedelbaeva G.G.; Almukhambetov M.K.; Lozhkin A.A.; Madenov N.N.

Head of the department emergency medicine Almaty State Institute for Advanced Training of Physicians - Candidate of Medical Sciences, Associate Professor Rakhimbaev R.S.

Employees of the Department of Emergency Medicine of the Almaty State Institute for Advanced Medical Studies: Candidate of Medical Sciences, Associate Professor Silachev Yu.Ya.; Volkova N.V.; Khairulin R.Z.; Sedenko V.A.

Attached files

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One of the deadly conditions of the human body that requires immediate action is traumatic shock. Let's consider what traumatic shock is and what emergency care should be provided for this condition.

Definition and causes of traumatic shock

Traumatic shock is a syndrome that is a severe pathological condition that threatens life. It occurs as a result of severe injuries to various parts of the body and organs:

• pelvic bone fractures;
• traumatic brain injury;
• severe gunshot wounds;
• extensive;
• damage to internal organs due to abdominal trauma;
• severe blood loss;
• surgical interventions etc.

Factors predisposing to the development of traumatic shock and aggravating its course are:

• hypothermia or overheating;
• intoxication;
• overwork;
• starvation.

Mechanism of development of traumatic shock

The main factors in the development of traumatic shock are:

• massive blood loss;
• expressed pain syndrome;
• disruption of vital organs;
• mental stress caused by trauma.

Rapid and massive blood loss, as well as plasma loss, lead to a sharp reduction in circulating blood volume. As a result, blood pressure decreases, oxygen delivery is disrupted and nutrients in the tissue, tissue hypoxia develops.

As a result, toxic substances accumulate in tissues and metabolic acidosis develops. Lack of glucose and other nutrients leads to increased breakdown of fats and protein catabolism.

The brain, receiving signals about a lack of blood, stimulates the synthesis of hormones that cause peripheral vessels to constrict. As a result, blood flows away from the limbs, and there is enough of it for vital organs. But soon such a compensatory mechanism begins to malfunction.

Degrees (phases) of traumatic shock

There are two phases of traumatic shock, characterized by different symptoms.

Erectile phase

On at this stage the victim is excited and anxious state, experiences strong pain sensations and signals them to everyone accessible ways: shouting, facial expressions, gestures, etc. At the same time, he can be aggressive and resist attempts to provide assistance and examination.

There is pallor of the skin, increased blood pressure, tachycardia, increased breathing, and trembling of the limbs. At this stage, the body is still able to compensate for the violations.

Torpid phase

In this phase, the victim becomes lethargic, apathetic, depressed, and experiences drowsiness. Painful sensations do not subside, but he stops signaling about them. Blood pressure begins to decrease and heart rate increases. The pulse gradually weakens and then becomes undetectable.

There is marked pallor and dryness of the skin, cyanosis, which become obvious (thirst, nausea, etc.). The amount of urine decreases even with drinking plenty of fluids.

Emergency care for traumatic shock

The main stages of first aid for traumatic shock are as follows:

20065 0

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

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

Traumatic shock II degree characterized by lethargy of the wounded person, severe pallor of the skin, and significant hemodynamic impairment. Blood pressure drops to 85–75 mmHg, pulse increases to 110–120 beats/min. If compensatory mechanisms fail, as well as with unrecognized severe injuries in the later stages of assistance, the severity of traumatic shock increases.

Traumatic shock III degree usually occurs with severe combined or multiple wounds (traumas), 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 becomes pale gray in color with a cyanotic tint. The path is greatly accelerated (up to 140 beats/min), and can even be thread-like. Blood pressure drops below 70 mmHg. Breathing is shallow and rapid. Restoring vital functions in grade III shock presents significant difficulties and requires the use of a complex set of anti-shock measures, often combined with emergency surgical interventions.

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

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

1 Pre-agonal state characterized absence of pulse in the radial arteries if it is present on the carotid and femoral arteries and blood pressure not determined by the usual method.

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

3. Clinical death begins from the moment of the last breath and cardiac arrest. The wounded man has no clinical signs of life at all. However metabolic processes in brain tissue lasts on average another 5–7 minutes. Selection clinical death in the form of a separate form of the serious condition of the wounded is advisable, since in cases where the wounded does not have injuries incompatible with life, this condition can be reversible with the rapid application of resuscitation measures.

It should be emphasized that with resuscitation measures taken in the first 3–5 minutes, it is possible to achieve full recovery vital functions of the body, while resuscitation. carried out over late dates, can lead to the restoration of only somatic functions (blood circulation, breathing, etc.) in the absence of restoration of the functions of the central nervous system. These changes can be irreversible, resulting in permanent disability (defects of intelligence, speech, spastic contractures, etc.) - “a disease of a revitalized organism.” The term “resuscitation” should not be understood narrowly as the “revival” 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 cannot be resuscitated for 30-50 minutes.

Gumanenko E.K.

Military field surgery

is a pathological condition that occurs as a result of blood loss and pain due to injury and poses a serious threat to the patient’s life. Regardless of the cause of development, it always manifests itself with the same symptoms. Pathology is diagnosed based on clinical signs. Urgent stoppage of bleeding, anesthesia and immediate delivery of the patient to the hospital are necessary. Treatment of traumatic shock is carried out in conditions intensive care unit and includes a set of measures to compensate for violations that have occurred. The prognosis depends on the severity and phase of shock, as well as the severity of the injury that caused it.

ICD-10

T79.4

General information

Traumatic shock - serious condition, which is the body’s response to acute injury, accompanied by severe blood loss and intense pain. It usually develops immediately after injury and is an immediate reaction to damage, but under certain conditions (additional trauma) it can occur after some time (4-36 hours). Is a condition that poses a threat to the patient’s life and requires urgent treatment in the intensive care unit.

Causes

Traumatic shock develops with all types of severe injuries, regardless of their cause, location and mechanism of injury. It can be caused by knife and gunshot wounds, falls from a height, car crashes, man-made and natural disasters, industrial accidents, etc. In addition to extensive wounds with damage to soft tissues and blood vessels, as well as open and closed fractures of large bones (especially multiple and accompanied by damage to the arteries), traumatic shock can cause extensive burns and frostbite, which are accompanied by significant loss of plasma.

The development of traumatic shock is based on massive blood loss, severe pain, dysfunction of vital organs and mental stress caused by acute injury. In this case, blood loss plays a leading role, and the influence of other factors can vary significantly. Thus, if sensitive areas (perineum and neck) are damaged, the influence of the pain factor increases, and if the chest is injured, the patient’s condition is aggravated by impaired breathing function and oxygen supply to the body.

Pathogenesis

The triggering mechanism of traumatic shock is largely associated with the centralization of blood circulation - a state when the body directs blood to vital organs (lungs, heart, liver, brain, etc.), diverting it from less important organs and tissues (muscles, skin, fatty tissue). The brain receives signals about a lack of blood and reacts to them by stimulating the adrenal glands to release adrenaline and norepinephrine. These hormones act on peripheral blood vessels, causing them to constrict. As a result, blood flows away from the extremities and there is enough of it for the functioning of vital organs.

After some time, the mechanism begins to malfunction. Due to the lack of oxygen, peripheral vessels dilate, causing blood to flow away from vital organs. At the same time, due to disturbances in tissue metabolism, the walls of peripheral vessels stop responding to signals from the nervous system and the action of hormones, so re-narrowing of blood vessels does not occur, and the “periphery” turns into a blood depot. Due to insufficient blood volume, the heart's function is impaired, which further aggravates circulatory problems. Blood pressure drops. With a significant decrease in blood pressure, normal operation kidneys, and a little later - the liver and intestinal wall. Toxins are released from the intestinal wall into the blood. The situation is aggravated due to the occurrence of numerous foci of dead tissue without oxygen and severe metabolic disorders.

Due to spasm and increased blood clotting, some small vessels become clogged with blood clots. This causes the development of DIC syndrome (disseminated intravascular coagulation syndrome), in which blood clotting first slows down and then practically disappears. With DIC, bleeding may resume at the site of injury, pathological bleeding occurs, and multiple small hemorrhages appear in the skin and internal organs. All of the above leads to a progressive deterioration of the patient’s condition and becomes the cause fatal outcome.

Classification

There are several classifications of traumatic shock depending on the causes of its development. Thus, in many Russian manuals on traumatology and orthopedics, surgical shock, endotoxin shock, shock due to crushing, burns, the action of a shock air wave and the application of a tourniquet are distinguished. The classification of V.K. is widely used. Kulagin, according to which there are the following types of traumatic shock:

• Wound traumatic shock (arising due to mechanical trauma). Depending on the location of the injury, it is divided into visceral, pulmonary, cerebral, with trauma to the extremities, with multiple trauma, with compression of soft tissues.
• Operational traumatic shock.
• Hemorrhagic traumatic shock (developing with internal and external bleeding).
• Mixed traumatic shock.

Regardless of the causes of occurrence, traumatic shock occurs in two phases: erectile (the body tries to compensate for the violations that have arisen) and torpid (compensatory capabilities are depleted). Taking into account the severity of the patient’s condition in the torpid phase, 4 degrees of shock are distinguished:

• I (light). The patient is pale and sometimes a little lethargic. Consciousness is clear. Reflexes are reduced. Shortness of breath, pulse up to 100 beats/min.
• II (moderate). The patient is lethargic and lethargic. Pulse is about 140 beats/min.
• III (severe). Consciousness is preserved, the ability to perceive the surrounding world is lost. The skin is earthy gray, the lips, nose and fingertips are bluish. Sticky sweat. Pulse is about 160 beats/min.
• IV (preagonia and agony). There is no consciousness, the pulse is not detected.

Symptoms of traumatic shock

During the erectile phase, the patient is excited, complains of pain, and may scream or moan. He is anxious and scared. Aggression and resistance to examination and treatment are often observed. The skin is pale, blood pressure is slightly elevated. There is tachycardia, tachypnea (increased breathing), tremors of the limbs or small twitches individual muscles. The eyes shine, the pupils are dilated, the look is restless. The skin is covered with cold, sticky sweat. The pulse is rhythmic, body temperature is normal or slightly elevated. At this stage, the body is still compensating for the disturbances that have arisen. There are no gross disturbances in the functioning of internal organs, no disseminated intravascular coagulation syndrome.

With the onset of the torpid phase of traumatic shock, the patient becomes apathetic, lethargic, drowsy and depressed. Despite the fact that the pain does not decrease during this period, the patient stops or almost stops signaling about it. He no longer screams or complains; he can lie silently, moaning quietly, or even lose consciousness. There is no reaction even with manipulations in the area of ​​damage. Blood pressure gradually decreases and heart rate increases. The pulse in the peripheral arteries weakens, becomes thread-like, and then becomes undetectable.

The patient's eyes are dull, sunken, the pupils are dilated, the gaze is motionless, there are shadows under the eyes. There is marked pallor of the skin, cyanotic mucous membranes, lips, nose and fingertips. The skin is dry and cold, tissue elasticity is reduced. Facial features are sharpened, nasolabial folds are smoothed. Body temperature is normal or low (temperature may also increase due to wound infection). The patient gets chills even in a warm room. Convulsions and involuntary release of feces and urine are often observed.

Symptoms of intoxication are revealed. The patient suffers from thirst, his tongue is coated, his lips are parched and dry. Nausea and, in severe cases, even vomiting may occur. Due to progressive impairment of kidney function, the amount of urine decreases even with heavy drinking. Urine is dark, concentrated, with severe shock anuria is possible ( complete absence urine).

Diagnostics

Traumatic shock is diagnosed when appropriate symptoms are identified, a fresh injury or other possible reason the occurrence of this pathology. To assess the condition of the victim, periodic measurements of pulse and blood pressure are carried out, and laboratory research. Scroll diagnostic procedures determined by the pathological condition that caused the development of traumatic shock.

Treatment of traumatic shock

At the first aid stage, it is necessary to temporarily stop bleeding (tourniquet, tight bandage), restore airway patency, perform anesthesia and immobilization, and also prevent hypothermia. The patient should be moved very carefully to prevent re-traumatization.

In the hospital, at the initial stage, resuscitators-anesthesiologists transfuse saline (lactasol, Ringer's solution) and colloid (reopolyglucin, polyglucin, gelatinol, etc.) solutions. After determining the rhesus and blood group, the transfusion of these solutions in combination with blood and plasma is continued. Provide adequate breathing using airways, oxygen therapy, tracheal intubation, or mechanical ventilation. Pain relief is continued. Bladder catheterization is performed to accurately determine the amount of urine.

Surgical interventions are carried out according to vital indications in the amount necessary to preserve vital functions and prevent further aggravation of shock. They stop bleeding and treat wounds, block and immobilize fractures, eliminate pneumothorax, etc. Prescribe hormone therapy and dehydration, use drugs to combat cerebral hypoxia, and correct metabolic disorders.