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Hemorrhagic shock: intensity, signs and treatment

The state of shock occurs when a sharp violation of the habitual blood circulation. This is a severe stress reaction of the body, not cope with the management of vital systems. Hemorrhagic shock causes a sudden blood loss. Since blood is the main fluid supporting metabolism in cells, this kind of pathology refers to hypovolemic states (dehydration). In ICD-10, it is regarded as “Hypovolemic shock” and is coded R57.1.

Under conditions of sudden bleeding, an unsubstituted volume of 0.5 l is accompanied by acute tissue oxygen deficiency (hypoxia).

Most often, blood loss is observed in injuries, surgical interventions, in obstetric practice during labor in women.

What mechanisms depends on the severity of shock?

In the development of pathogenesis of compensation for blood loss are important:

  • the state of the nervous regulation of vascular tone,
  • the ability of the heart to work in hypoxia,
  • blood clotting
  • environmental conditions for additional oxygen supply,
  • immunity level.

It is clear that a person with chronic diseases is less likely to suffer massive blood loss than a previously healthy one. The work of military medics in the Afghan war showed how severe the moderate blood loss for healthy fighters turns out to be in high mountains, where the air saturation with oxygen is reduced.

In humans, on average, about 5 liters of blood constantly circulates through the arterial and venous vessels. At the same time 75% is in the venous system. Therefore, the subsequent reaction depends on the speed of adaptation of the veins.

The sudden loss of 1/10 of the circulating mass makes it impossible to quickly “replenish” stocks from the depot. Venous pressure drops, leading to maximum centralization of blood circulation to support the work of the heart, lungs and brain. Such tissues as muscles, skin, intestines are recognized as “extra” by the body and are turned off from the blood supply.

During systolic contraction, the ejected volume of blood is insufficient for tissues and internal organs; it feeds only the coronary arteries. In response, endocrine protection is included in the form of increased secretion of adrenocorticotropic and antidiuretic hormones, aldosterone, renin. This allows you to retain fluid in the body, to stop the urinary function of the kidneys.

At the same time, the concentration of sodium, chloride increases, but potassium is lost.

Increased catecholamine synthesis is accompanied by vasospasm in the periphery, vascular resistance grows.

Due to the circulatory hypoxia of the tissues, acidification of the blood by accumulated slags occurs - metabolic acidosis. It contributes to the increase in the concentration of kinins, which destroy the vascular walls. The liquid part of the blood enters the interstitial space, and cellular elements accumulate in the vessels, all the conditions for increased thrombus formation are formed. There is a danger of irreversible disseminated intravascular coagulation (DIC).

The heart is trying to compensate for the necessary release of increased contractions (tachycardia), but they are not enough. Losses of potassium reduce myocardial contractility, heart failure is formed. Blood pressure drops sharply.

The cause of hemorrhagic shock is acute bleeding.

Traumatic pain shock is not always accompanied by significant blood loss. It is more characteristic of a widespread lesion surface (extensive burns, combined fractures, tissue crushing). But the combination with unresolved bleeding exacerbates the effect of damaging factors, weights the clinical course.

Hemorrhagic shock in obstetrics occurs during heavy labor, during pregnancy, in the postpartum period. Massive blood loss cause:

  • ruptures of the uterus and birth canal,
  • placenta previa
  • in the normal position of the placenta its early detachment is possible,
  • abortion,
  • hypotonia of the uterus after childbirth.

In such cases, often bleeding is combined with another pathology (injury during labor, preeclampsia, concomitant chronic diseases of the woman).

Clinical manifestations

Clinic of hemorrhagic shock is determined by the degree of impaired microcirculation, severity of cardiac and vascular insufficiency. Depending on the stage of development of pathological changes, it is customary to distinguish the stages of hemorrhagic shock:

  1. Compensation or the first stage - blood loss is no more than 15–25% of the total volume, the patient is fully conscious, he adequately answers questions, and during examination the pallor and coldness of the limb skin, weak pulse, blood pressure at the lower limits of the norm heart rate increased to 90-110 per minute.
  2. The second stage, or decompensation, in accordance with the name, symptoms of oxygen insufficiency of the brain, weak cardiac output, appear. Usually characterized by acute blood loss from 25 to 40% of the total circulating blood volume. Disruption of adaptive mechanisms is accompanied by impaired consciousness of the patient. In neurology, it is regarded as soporous, there is a retardation of thinking. There is pronounced cyanosis on the face and extremities, hands and feet are cold, the body is covered with sticky sweat. Blood pressure (BP) decreases sharply. Pulse of weak filling, characterized as “filiform”, frequency up to 140 per minute. Breathing is frequent and superficial. Urination is severely limited (up to 20 ml per hour). Such a reduction in the filtration function of the kidneys is called oliguria.
  3. The third stage is irreversible - the patient's condition is regarded as extremely difficult, requiring resuscitation. Consciousness is absent, the skin is pale, with a marble tinge, blood pressure is not detected, or only the upper level within 40–60 mmHg can be measured. Art. It is impossible to feel the pulse on the ulnar artery, with sufficiently good skills it is felt on the carotid arteries, heart sounds are deaf, tachycardia reaches 140-160 per minute.

How is blood loss determined?

In diagnosis, it is most convenient for a doctor to use objective signs of shock. The following indicators are suitable for this:

  • circulating blood volume (BCC) - determined by laboratory,
  • shock index.

Death occurs with a sharp decrease in the BCC by 60% or more.

To ascertain the severity of the patient, there is a classification associated with minimal possibilities in determining hypovolemia by laboratory and clinical signs.

These figures are not suitable for assessing the severity of shock in children. If a newborn baby’s total blood volume barely reaches 400 ml, then for him the loss of 50 ml is quite similar to 1 l in an adult. In addition, children suffer from hypovolemia much more, because they have poorly expressed compensation mechanisms.

Shock index is able to identify any medical professional. This is the ratio of the calculated heart rate to systolic pressure. Depending on the coefficient obtained, approximately the degree of shock is judged:

  • 1,0 - easy,
  • 1.5 - moderate,
  • 2.0 is heavy.

Laboratory indicators in the diagnosis should indicate the severity of anemia. For this are determined:

  • hemoglobin,
  • red blood cell count
  • hematocrit.

For the timely choice of treatment tactics and recognition of severe complications in the form of disseminated intravascular coagulation syndrome, coagulogram indicators are determined by the patient.

Diuresis control is necessary in the diagnosis of kidney damage and impaired filtration.

How to assist in the prehospital phase?

Actions on first aid on the background of the identified acute bleeding should be aimed at:

  • measures to stop bleeding,
  • prevention of hypovolemia (dehydration).

Help with hemorrhagic shock can not do without:

  • imposition of hemostatic dressings, tourniquet, limb immobilization for injuries of large vessels,
  • giving the victim a lying position, with a mild degree of shock, the victim may be in a euphoric state and inadequately assess his well-being, try to get up,
  • to compensate for the loss of fluid with the help of abundant drinking,
  • warming warm blankets, heaters.

To the scene it is necessary to call an ambulance. The life of the patient depends on the speed of action.

The algorithm of the doctor’s actions is determined by the severity of the injury and the patient’s condition:

  1. checking the effectiveness of the pressure bandage, tow, the imposition of clamps on the vessels with open wounds,
  2. installation of transfusion systems in 2 veins, if possible puncture of the subclavian vein and its catheterization,
  3. the establishment of fluid transfusion for the speedy recovery of the BCC, in the absence of Reopolyglukine or Polyglukine, normal saline solution will be suitable for the time of transportation,
  4. provision of free breathing by fixing the tongue, installing an air duct, if necessary, intubation and translation into hardware breathing or using the Ambu hand bag,
  5. anesthesia using injections of narcotic analgesics, baralgin and antihistamines, ketamine,
  6. administering corticosteroids to support blood pressure.

The ambulance must ensure that the patient is transported to the hospital as quickly as possible (with a sound signal), report by radio or telephone about the arrival of the victim for the preparedness of the staff of the emergency department.

Video about the principles of first aid in acute blood loss:

Basics of Hemorrhagic Shock Therapy

In the hospital, shock therapy is provided with a set of measures aimed at counteracting the damaging mechanisms of pathogenesis. The basis lies:

  • respecting continuity in the provision of care with the prehospital phase,
  • continuation of substitution transfusion solutions,
  • measures to permanently stop bleeding,
  • adequate use of medications, depending on the severity of the victim,
  • antioxidant therapy - inhalation of a humidified oxygen-air mixture,
  • warming the patient.

When a patient enters the intensive care unit:

  • carry out catheterization of the subclavian vein, add Polyglyukin jet injection to the drip infusion of saline,
  • arterial pressure is constantly measured, a heart rate is noted on the cardiac monitor, an amount of urine is detected in the catheter from the bladder,
  • during vein catheterization, blood is taken for urgent analysis to determine the extent of BCC loss, anemia, blood type and Rh factor,
  • after the readiness of tests and diagnostics of the moderate stage of shock, donor blood is ordered, tests for individual sensitivity, rhesus compatibility are made,
  • with a good biological sample, blood transfusion begins, in the early stages plasma, albumin or protein transfusions (protein solutions) are indicated,
  • In order to eliminate metabolic acidosis, sodium bicarbonate infusion is necessary.

What is the volume of blood to be transfused?

When blood transfusion doctors use the following rules:

  • for blood loss in 25% of the BCC, compensation is possible only with blood substitutes, not blood,
  • to newborns and small children, the total volume is half combined with the erythrocyte mass,
  • if the BCC is reduced by 35%, it is necessary to use both the erythrocyte mass and blood substitutes (1: 1),
  • the total volume of transfused liquids must be 15–20% higher than a certain blood loss,
  • If severe shock is detected with a loss of 50% of the blood, then the total volume should be twice as large, and the ratio between the erythrocyte mass and blood substitutes should be observed as 2: 1.

The indications for discontinuing a continuous infusion of blood and blood substitutes are:

  • the absence of new signs of bleeding within three to four hours of observation,
  • restoration of stable blood pressure numbers
  • the presence of permanent diuresis,
  • cardiac compensation.

If there are wounds, antibiotics are prescribed to prevent infection.

Cardiac glycosides and osmotic diuretics such as Mannitol are used very carefully when stabilizing blood pressure and there are no contraindications for ECG results.

What complications are possible with hemorrhagic shock?

The state of hemorrhagic shock is very transient, dangerously massive blood loss and death in cardiac arrest.

  • The most severe complication is the development of disseminated intravascular coagulability syndrome. It disrupts the balance of shaped elements, vascular permeability, impairs microcirculation.
  • The hypoxia of tissues most of all affects lungs, a brain, heart. This is manifested by respiratory and heart failure, mental disorders. In the lungs, the formation of a "shock lung" with hemorrhagic areas, necrosis is possible.
  • Hepatic and renal tissues react with manifestations of organ failure, impaired synthesis of coagulation factors.
  • When obstetric massive bleeding distant consequences are considered a violation of the reproductive capabilities of a woman, the appearance of endocrine pathology.

To combat hemorrhagic shock, it is necessary to maintain the constant readiness of medical personnel, to have a supply of funds and blood substitutes. The public has to be reminded of the importance of donation and the participation of the public in providing assistance.

About the causes of the dangerous state and the mechanism of its progression

The main cause of hemorrhagic shock is serious injuries leading to blood loss. Damage to blood vessels can be closed and open. The second reason for the pathological condition is severe bleeding caused by diseases of the uterus, perforation of gastric ulcers, decays of cancer in the last stages of the disease.

In gynecological patients, the following may cause shock from blood loss: rupture of the ovary, spontaneous abortion or artificial interruption of pregnancy, uterine fibroids and injuries of the genital organs, gallbladder drift.

The central link in the pathogenesis of hemorrhagic shock is a violation of the systemic circulation. The amount of circulating blood drops very quickly. Naturally, the body systems can not respond quickly to this loss.

On the nerve endings, the receptors transmit “alarming signals”, which lead to an increased heartbeat, peripheral vasospasm, respiration, followed by centralization of blood circulation, when the biological fluid begins to actively circulate through the vessels of certain internal organs. There is a further decrease in pressure, stimulation of the baroreceptors.

Gradually, all organs, with the exception of the brain and heart, cease to participate in the blood circulation. The amount of oxygen in the pulmonary system decreases as quickly as possible, which leads to inevitable death.

Manifestations and shock signs of blood loss

Medical specialists identify the main signs of hemorrhagic shock, which can be observed during its onset.

These include:

  • Dry mouth and nausea.
  • Excessive weakness and severe dizziness.
  • Darkening in the eyes and even loss of consciousness.
  • Compensatory redistribution of blood and a decrease in its amount in the muscles leads to blanching of the skin. A gray tint may appear if a person almost faints.
  • Hands and feet become wet and sticky from cold sweat.
  • Disorders of blood microcirculation in the kidneys lead to hypoxia, tubular necrosis and ischemia.
  • There is severe shortness of breath, impaired respiratory function.
  • Disturbance of heart rhythms and excessive excitement.

According to the indicated signs of shock from blood loss, medical specialists can accurately diagnose this condition. It requires the immediate detection of pathology on the symptoms, to be able to avoid death.

The main indicators of the condition of a suffering person include:

  1. The temperature and color of the epidermis.
  2. Pulse rate (may show hemorrhagic shock only when combined with other symptoms).
  3. Shock index - is considered the most informative indicator of a serious condition. This is the ratio of heart rate to systolic pressure. In a healthy person, it should not be more than 0.5.
  4. Hourly diuresis. Its gradual decrease will indicate the onset of a shock.
  5. Hematocrit. This is a test that can reveal the adequacy or inadequacy of blood circulation in the body.

First stage

This is a compensated shock, which occurs with a sharp decrease in circulating blood volume by fifteen percent. The clinical picture of the syndrome of insignificant release is dominated by such signs as moderate tachycardia and oliguria, sharp blanching of the skin, absence of arterial hypotension, or a clear decrease. Central venous pressure does not change.

Компенсированный шок может продолжаться довольно долго, если не была оказана неотложная помощь. В результате наступает прогрессирование опасного состояния.

Третья стадия

Получила название некомпенсированного или декомпенсированного обратимого шока. Кровопотеря достигает тридцати-сорока процентов. It is characterized by a significant deepening of circulatory disorders. Blood pressure is significantly reduced due to severe vascular spasm.

Additional symptoms are also highlighted:

  • Severe tachycardia and severe shortness of breath.
  • Acrocyanosis, rapid pulse, pale skin.
  • Cold sweat and lowering oliguria.
  • Sharp inhibition in human behavior.
  • Normal blood supply to the heart, kidneys, liver, lungs and intestines is gradually disrupted, which inevitably leads to tissue hypoxia.

Fourth stage

Decompensated or irreversible shock. This is the most serious condition, which in most cases is fatal. The decrease in circulating blood volume is approaching 45 percent or more. Tachycardia reaches 160 beats per minute, and the pulse is not actually felt, the patient’s mind is completely confused.

The skin becomes unnatural marble shade, that is pale in the background of well-defined blood vessels. Systolic pressure at this stage decreases to critical indicators - up to 60 mm Hg. Manifesting hyporeflexia and anuria.

Further disruption of microcirculation leads to irreversible loss of plasma, stupor and sharp coldness of the limbs. Significantly increased respiratory disorders. At the last stage of hemorrhagic shock, urgent hospitalization should be carried out in order not to lose the patient.

Help with the onset of shock

Emergency care for hemorrhagic shock should be very operational, especially if the patient's condition has reached a critical level of severity. First you need to promptly call the team of medical specialists, and then try:

  1. Stop bleeding if it is not internally. Be sure to use the harnesses, everything that you find at hand. Tie or gently clamp the wound before the ambulance arrives.
  2. Eliminate any items that you think may interfere with human breathing. Be sure to unbutton the tight collar. In case of an accident, it is advised to first remove any foreign bodies from the victim’s mouth that could get there, including vomit, fragments of teeth, if necessary. Such assistance can also be provided by a non-professional physician, who is on the scene. Try to prevent tongue dropping into the nasopharynx. All these manipulations will help a person not to suffocate and live until the arrival of professionals.
  3. If possible, give the victim anesthetic drugs of non-narcotic effect. Lexier, Tromo and Fortral will be the best fit. Note that these medicines should not affect the functioning of the respiratory and circulatory system. Also Baralgin and Analgin can help in this situation. These funds are normally combined with antihistamines.

After hospitalization: the actions of specialists

If a patient in a state of hemorrhagic shock has been successfully hospitalized, doctors will conduct a general assessment of his condition.

The parameters of respiration, blood pressure are measured, the stability of consciousness is determined. Then the doctors proceed to stop the loss of biological fluid.

This is the main measure for removing a person from shock and preventing death.

An infusion intensive therapy is required with constant simultaneous control of hourly diuresis. Such actions with therapy in two or three veins are relevant if the decrease in circulating blood volume is up to forty percent or more.

You will also need inhalation of one hundred percent oxygen through a special mask and injecting adrenaline. It can be replaced by dopamine-containing agents.

Medical specialists after hospitalization must perform the following actions:

  1. Use oxygen inhalation catheters.
  2. Introduce the catheter into the patient’s central vein to ensure free access to the vessels. With a strong loss of biological fluid, this will not be enough - you have to use the femoral vein.
  3. Next, infusion therapy begins (it was mentioned above in connection with large blood loss).
  4. Evaluation of the effectiveness of infusions and control of urination of the patient using the installed Foley catheter.
  5. Blood test.
  6. The physician should prescribe analgesics and sedatives.

In the process of first aid and treatment it is very important to determine the source of blood loss and try to alleviate the patient’s condition, stop the loss of biological fluid as much as possible at the moment.

In a different situation, the victim simply will not have a chance to live until the arrival of qualified doctors. In seventy percent of cases, patients die before the ambulance arrives

Shock index Algovera

Of great importance is the calculation of the shock index of Algover, defined as the quotient when the heart rate index is divided by the systolic pressure value. Normally, the shock index is less than 1. Depending on the degree of blood loss and the severity of shock, this can be:

  1. index from 1 to 1.1 corresponding to mild blood loss,
  2. index 1, 5 - the average degree of blood loss,
  3. index 2 - severe blood loss,
  4. Index 2.5 - extremely severe blood loss.

In addition to the Algauvera index, measurement of arterial and central venous pressure (BP and CVP), monitoring of minute or hourly diuresis, as well as the level of hemoglobin and its ratio to the hematocrit value (specific weight of erythrocyte mass of the total blood volume) helps to clarify the volume of lost blood.

The following signs indicate mild blood loss:

  1. Heart rate less than 100 beats per minute, pallor,
  2. dryness and low temperature of the skin,
  3. hematocrit from 38 to 32%, CVP from 3 to 6 mm of water column,
  4. diuresis more than 30 ml.

The moderate blood loss is manifested by more pronounced symptoms:

  1. A heart rate increase of up to 120 beats per minute
  2. excitement and restless behavior
  3. the appearance of cold sweat
  4. fall of CVP up to 3-4 cm of water column,
  5. decrease in hematocrit to 22-30%,
  6. diuresis less than 30 ml.

About severe blood loss indicate:

  1. Tachycardia more than 120 per minute
  2. drop in blood pressure below 70 mm Hg. Art., and venous - less than 3 mm of water Art.,
  3. severe pallor of the skin, accompanied by sticky sweat,
  4. anuria (lack of urine),
  5. hematocrit decrease below 22%, hemoglobin - less than 70 g / l.

The degree and stage of severity of blood loss

The severity of the clinical picture of hemorrhagic shock is determined by the volume of blood loss and, depending on this, is distributed to:

  1. I - easy
  2. II - average
  3. III - heavy
  4. IV - extremely heavy.

When I degree GSH blood loss of not more than 15% of the total. At this stage of shock development, the patient contacts, their consciousness is preserved. Pallor of the skin and mucous membranes is accompanied by an increase in pulse rate of up to 100 beats per minute, slight arterial hypotension (100 mm or higher) and oliguria (decrease in the amount of urine released).

Anxiety and excessive sweating join the symptoms of GSH of the II degree, acrocyanosis appears (cyanosis of the lips, fingers and limbs). Pulse increases to 120 beats per minute, respiratory rate to 20 per minute, blood pressure is lowered to 90-100 mm Hg. Art., growing oliguria. Lack of volume of the Central Committee grows to 30%.

During GSH III degree of blood loss reaches 40% of the BCC. Patients in a state of confused consciousness, pronounced pallor and marbling of the skin, and the pulse rate exceeds 130 beats per minute. Patients in this stage have shortness of breath (NPV up to 30 min) and oliguria (no urine excreted), and the systolic blood pressure drops below 60 mm Hg. Art.

IV degree of GSH is characterized by a deficiency in the volume of the Central Committee of more than 40% and the suppression of vital functions: lack of pulse, consciousness, and venous pressure. Patients observed areflexia, anuria, shallow breathing.

Without which no first aid can be given.

Help with hemorrhagic shock can not do without:

  1. imposition of hemostatic dressings, tourniquet, limb immobilization for injuries of large vessels,
  2. giving the victim a lying position, with a mild degree of shock, the victim may be in a euphoric state and inadequately assess his well-being, try to get up,
  3. to compensate for the loss of fluid with the help of abundant drinking,
  4. warming warm blankets, heaters.

To the scene is necessary cause «First aid". The life of the patient depends on the speed of action.

Algorithm for the provision of emergency medical care

The algorithm of the doctor’s actions is determined by the severity of the injury and the patient’s condition:

  1. checking the effectiveness of the pressure bandage, tow, the imposition of clamps on the vessels with open wounds,
  2. installation of transfusion systems in 2 veins, if possible puncture of the subclavian vein and its catheterization,
  3. the establishment of fluid transfusion for the speedy recovery of the BCC, in the absence of Reopolyglukine or Polyglukine, normal saline solution will be suitable for the time of transportation,
  4. provision of free breathing by fixing the tongue, installing an air duct, if necessary, intubation and translation into hardware breathing or using the Ambu hand bag,
  5. anesthesia using injections of narcotic analgesics, baralgin and antihistamines, ketamine,
  6. administering corticosteroids to support blood pressure.

The ambulance must ensure that the patient is transported to the hospital as quickly as possible (with a sound signal), report by radio or telephone about the arrival of the victim for the preparedness of the staff of the emergency department.

Hemorrhagic shock treatment

Intensive therapy after stopping bleeding and catheterization of veins is aimed at:

  1. Elimination of hypovolemia and restoration of circulating blood volume.
  2. Detoxification.
  3. Ensuring adequate microcirculation and cardiac output.
  4. Restoration of the initial indices of osmolarity and oxygen transport capacity of the blood.
  5. Normalization and maintenance of normal diuresis.
  6. Prevention of DIC (aggregation of erythrocytes).

To achieve these goals, the priority in infusion therapy for GSH was:

  1. HES solutions up to 1.5 liters per day and normalization of oncotic blood pressure,
  2. intravenous crystalloid solutions in a volume of up to 2 liters, until normalization of blood pressure,
  3. erythrocyte mass and other blood substitutes under the control of CVP to a hematocrit level of 32-30%,
  4. colloidal solutions (gelatins and dextrans) in a ratio of 1: 1 to the total volume of infusions,
  5. donated blood
  6. glucocorticosteroids in maximum dosages (up to 1.5 mg).

An important role in the treatment of GSH is assigned to vasodilator drugs necessary to eliminate vasospasm (papaverine, aminophylline), prevention of reperfusion syndrome, for which use alkalizing solutions, antioxidants, GHB, trental and antihistamines and proteolysis inhibitors.

Criteria for the effectiveness of treatment

Intensive therapy for GSH is carried out to the level of indicators indicating the elimination of a life-threatening condition:

  1. HELL to the level of 100/60 mm Hg. Art. and higher,
  2. Heart rate up to 100 beats per minute
  3. CVP 4 and above mm of water, Art.
  4. per minute diuresis over 1 ml, and hourly - over 60 ml,
  5. hemoglobin level 60 g / l,
  6. blood oxygen concentration of 94 -96%,
  7. protein content in blood plasma is more than 50 g / l,
  8. venous blood hematocrit 20% and above.

Possible complications

Against the background of decompensated GSH can develop:

  1. DIC - syndrome (clumping of red blood cells),
  2. reperfusion syndrome (oxygen paradox),
  3. myocardial ischemia,
  4. coma,
  5. ventricular fibrillation
  6. asystole.

Effects. A few years after massive blood loss, accompanied by GSH, endocrine pathology and chronic diseases of internal organs may develop with an outcome for disability.

20. Hazards and outcomes of bleeding.

Among the dangers of bleeding are:

• compression of an organ located in a cavity of small volume with accumulation of blood in it,

• infection of blood accumulated in tissues or in body cavities,

• compression of great vessels and nerve formation hematoma.

With blood loss, anemia develops, and with significant (heavy blood loss), death can occur. Compression of vital organs such as the brain, heart,

lung occurs when bleeding occurs in a limited cavity

- The cavity of the skull, pericardium, chest cavity.

Spilled blood infection. Any accumulation of blood outside the vessel is a good nutrient for microorganisms and can lead to the formation of a purulent process - abscess, phlegmon, suppuration of the surgical wound, purulent

Hematoma. When a large arterial vessel is wounded, blood may accumulate in the gap between the tissues - a hematoma occurs, which continues to communicate with the vessel lumen (pulsating hematoma). Over time, around this hematoma is formed

connective tissue capsule, and a pulsating hematoma turns into an enclosed aneurysm. The formation of a large hematoma can lead to compression of the great vessel and cause disruption of the blood supply to the tissues.

21. Bleeding. Characteristics of certain types of hemorrhage and bleeding.

Bleeding (hemorrhage) is the exit of blood outside the vascular bed.

external - the release of blood into the environment (hemoptysis, bleeding from the nose), internal - the release of blood in the body cavity (hemothorax, hemopreicard).

Hemorrhage is the release of blood into the tissue.

The accumulation of coagulated blood in the tissue is called hematoma, and when the tissue elements are preserved, hemorrhagic soaking (infiltration). Flat hemorrhages - hemorrhages, small dot - petechias.

22. Temporary stop bleeding.

For a temporary stop of arterial bleeding, the following types are used. I. Finger pressing of the arterial trunk.

To stop the bleeding from the main vessel by pressing it to the bone above the wound.

1) common carotid artery: pressing I with the finger or at the middle of the inner edge of the sternocleidomastoid muscle against the carotid tubercle of the transverse process of the VI cervical vertebra

2) the external maxillary artery - to the lower edge of the lower jaw (border of the posterior and middle 1/3 of the jaw).

3) temporal - in the area of ​​the temple above the ear trestle

4) subclavian - in the middle of the supraclavicular region to the tubercle of the I rib

5) shoulder - to the humerus at the inner edge of the biceps muscle

6) axillary - in the armpit to the head of the humerus

7) radial - to the radius, where the pulse is determined

8) the ulnar to the ulna

9) femoral - in the middle of the pupart ligament to the pubic bone

10) popliteal - to the middle of the popliteal fossa

11) the dorsal artery of the foot - on its dorsal surface between the outer and inner ankles

12) abdominal - fist to the spine to the left of the navel

Ii. Circular pulling limbs harness:

Rules for applying rubber band Esmarkh.

- apply a plait on a smooth fabric without folds, so as not to injure the skin,

- put a harness above the wound and as close as possible to it,

- the first turn of the stretched rubber band must stop bleeding,

- the next few turns reinforce the success achieved,

- tie loose ends or hooks,

- check the correctness of applying a tourniquet to stop bleeding and the disappearance of the pulse,

- under the bundle enclose a note indicating the time of its imposition,

- in the cold season, apply a harness for no more than 30 minutes, in a warm one for no more than 1 hour,

- if more than 1.5 hours have passed since the imposition, for 1 - 2 minutes the tourniquet should be loosened for blood flow in order to avoid necrosis, at the same time the bleeding vessel is pressed with a finger above the wound,

- for the prevention of shock - to produce immobilization of the limb,

- transportation of the patient with a tourniquet - in turn I, cover the limb in winter.

Iii. Limit flexion of the limbs in the joints.

1. The artery of the forearm is compressed when the arm is bent at the elbow joint to failure, followed by fixation. It is used for arterial bleeding from the hand and n / 3 forearm.

2. Subclavian, brachial arteries - pull both elbows with bent forearms back to a possible contact and fix.

3. Popliteal - maximum flexion of the knee (in the popliteal fossa - roller). It is used for bleeding from the arteries of the foot and n / 3 lower leg.

Iv. Overlay hemostatic clamp.

In case of arterial bleeding, the wound edges are moved apart, both ends of the artery are found and seized with sterile clips with the subsequent application of an aseptic dressing. When venous bleeding - the elevated position of the limb and a pressure bandage.

Causes of hemorrhagic shock

The basis of hemorrhagic shock is serious damage to the blood vessels. Acute leakage of fluid in the vessels means the absence of half a liter to a liter of blood, combined with a rapid decrease in the amount of circulating fluid. This situation is usually provoked by serious injuries that are accompanied by severe damage to the blood vessels. Often, hemorrhagic shock is a consequence of pathologies in gynecology: injuries during childbirth, postpartum hemorrhage, prematurely detached placenta, fetal death, ectopic pregnancy. Конечно же, сильное кровотечение может случиться после операции, когда распадается раковая опухоль, возникновении сквозного отверстия и, как следствие, желудочной язвы.

Степени тяжести

Of course, only the index index can not be regarded as absolute. Doctors see him in a complex with blood loss. The classification of types of severity of shock is called, as well as the indices, but provides for the presence of a certain volume of blood. So, a mild degree implies a shock index of 1.0-1.1 and a blood loss of 10 to 20% of volume, but not more than 1 liter. Average severity - shock index to 1.5, loss from 20 to 30% of volume, but not more than 1.5 liters. Severe - index up to 2.0, loss up to 40% or up to 2 liters. Extreme severity - index up to 2.5, loss of more than 40% or more than 2 liters.

Diagnosis of the disease

Hemorrhagic shock (ICD code 10 - R 57.1) refers to conditions similar to dehydration, which are characterized by a sharp decrease in the amount of blood that is in the body's blood vessels. The center for diagnosing symptoms of hemorrhagic shock is the determination of the amount of lost blood, the source of leakage, and its intensity.

The first is the inspection of the source of leakage of fluid from the vessels. The doctor assesses the extent of the damage. Blood can flow a pulsating stream or beat the fountain. It is important to understand that a leak occurs abruptly, in a large volume and in a short period.

How to provide first aid

The condition of the victim is very important to properly assess. Find the cause of the bleeding and eliminate it as soon as possible. Properly rendered first aid contributes to a more rapid release of the victim from the state of shock, and sometimes can even save his life.

So, let's figure out what to do with hemorrhagic shock. The first step is to localize the source of the loss. Place over the source of the leakage of blood must be tied with a bandage or a tourniquet. The tourniquet usually severely presses down the vessels and can damage them, so emergency doctors recommend using a rag or gauze bandage. Above the wound, it must be tied up tightly, wrapped with a tight bundle on top, which after 1 hour will need to be spun up gradually to avoid tissue death below the bandaged area. Further, to take any measures without doctors is not recommended. It is necessary to wait for the arrival of an ambulance and be sure to write a tight bandage on the injured time so that doctors understand how long the wound is localized from the blood supply.

Hemorrhagic shock treatment

After the arrival of the ambulance carriage, the doctors will proceed to restore the volume of fluid in the vessels. In the event of a severe leak, donated blood is infused into the patient. If the blood loss is moderate or light, then a special replenishment solution can be used - saline, blood substitute, red blood cell mass.

Action algorithm

Hemorrhagic shock is an extremely dangerous condition that threatens a person’s life and requires immediate, first-aid emergency treatment. The algorithm of rendering emergency first aid is similar regardless of the causes of acute blood loss. First of all, call an ambulance and act promptly:

Step 1. The first emergency action in providing emergency care for hemorrhagic shock is to eliminate excessive bleeding. You can stop the blood in one of the following ways:

  • strongly press the damaged artery above the injured area,
  • impose a special medical harness
  • tighten a tight bandage above the injured area.

Attention! It is imperative to record the time when the tourniquet was applied, and pass this information to the medical team.

Step 2. Make sure that the pulse is present, make sure that the respiratory functions and the airway are maintained.

Step 3. Give the injured body the correct posture on a hard, level surface. If the victim is unconscious, lay him on his side and throw his head back.

Attention! If a fracture of the cervical spine is intended, it is forbidden to move the head of the person back. Patients with a probable fracture of the hip bones are placed in the pelvis, with their legs slightly bent at the knees, spreading the limbs to the side.

Step 4. An important emergency intervention for hemorrhagic shock is to warm the patient by wrapping him with a warm blanket.

Step 5. A sterile aseptic dressing should be applied to the open wound. If venous or capillary bleeding is observed, a tightly wound wound will not bleed.

Attention! If a craniocerebral injury is suspected or an abdominal wound is injured, the use of analgesics is prohibited due to the risk of deterioration of respiratory function.

Step 6. In case of hemorrhagic shock, emergency care is carried out with constant monitoring of the blood pressure of the victim. With a sharp drop in the tonometer, you must give the victim, if he is conscious, a large amount of fluid.

Further actions should be carried out in the hospital.

Definition

Hemorrhagic shock requiring emergency care is a type of hypovolemic crisis that develops as a result of acute or massive blood loss (more than 10% of the total circulating blood volume).

To provide adequate emergency care for hemorrhagic shock, not only the volume, but also the speed of blood loss is of great importance.

Factor 1. Intensive non-abundant bleeding

The reason for the sudden sharp intensive release of blood is the complete transverse rupture of large vessels: the aorta, the upper and lower veins, and the pulmonary trunk. Although the volume of blood loss in such situations is noncritical (up to 300 ml), however, as a result of a lightning-like reduction in blood pressure, there is a complete lack of oxygen in the brain and myocardial tissues, which is fraught with a rapid onset of death. This factor is becoming the main cause of death from blood loss.

Factor 2. Slow heavy bleeding

The reason for the massive leakage of blood, in which more than 50% of the existing reservoirs are released, is open and closed injuries, and surgical intervention. Severe and extensive bleeding can be the result of serious somatic diseases, such as: perforation of a stomach ulcer or disintegration of a malignant neoplasm. Despite the impressive volumes of blood lost due to the slow speed of the process, the body manages to use compensatory mechanisms.

The main clinical signs of hemorrhagic shock, requiring urgent emergency care, are:

  • pallor of the skin, nail plates, mucous membranes,
  • hypotension,
  • increase in heart rate.

In severe situations, there is a decrease in the amount of urine excreted by the kidneys. Collapse and impaired level of consciousness to a coma can be fixed.

Causes

Hemorrhagic shock can be caused by traumatic injury, injury, spontaneous bleeding, or surgery. According to medical statistics, hemorrhagic shock in obstetrics is the largest percentage in the total mass of such shock conditions. Acute blood loss may occur in pregnant women in the following cases:

  • ectopic pregnancy, rupture of the fallopian tube,
  • premature detachment, presentation of the placenta or intimate attachment,
  • hypotension or rupture of the uterus,
  • getting amniotic fluid into the bloodstream of a pregnant woman,
  • coagulopathic uterine bleeding and DIC,
  • acute fatty liver of pregnant women.

In gynecological practice, the causes of bleeding with the subsequent occurrence of hemorrhagic shock can be:

  • ovarian apoplexy,
  • oncology,
  • septic processes that are accompanied by massive tissue necrosis,
  • traumatic injuries of the genitals.

You can learn more about hemorrhagic shock in obstetrics from this video:

In clinical practice, hemorrhagic shock becomes the result of inadequate or inadequate emergency care or medical therapy for the following diseases, conditions or manipulations:

  • pathologies that can cause a sharp dehydration of the body,
  • prolonged stay in an environment with high air temperature
  • cholera,
  • osteomyelitis,
  • sepsis,
  • uncompensated diabetes
  • intestinal obstruction and / or peritonitis,
  • oncological lesions
  • small volume and bleeding rate against the background of acute heart failure and fever,
  • during EPI or peridural anesthesia due to the use of ganglioblockers and diuretics.

Indirect factors that can cause the onset of hemorrhagic shock are:

  1. Invalid estimate of the speed and volume of bleeding,
  2. Incorrectly chosen tactics of filling up the lost volume,
  3. Late or inadequate correction in case of improper blood transfusion or in cases of bleeding, which are caused by diseases that cause a violation of its clotting,
  4. Lateness and / or the wrong choice of drugs to stop blood loss.

Development mechanism

Very simply, the pathogenesis of hemorrhagic shock can be represented by the following scheme.

If the bleeding does not stop, and the lost volume is not restored, irreversible changes occur and total cell death of all organs and systems, including the lungs and the brain. In this case, even conducting intensive infusion therapy is useless - inevitable death.

Clinical picture

The following symptoms and signs are characteristic of hemorrhagic shock:

  • general weakness
  • nausea with dry mouth
  • dizziness, darkening of the eyes, loss of consciousness,
  • blanching the skin to gray tint,
  • decrease in temperature of the limbs,
  • cold sweat,
  • reducing the formation of a normal amount of urine,
  • development of acute renal failure,
  • increase in shortness of breath, impaired respiratory rhythm,
  • the occurrence of sustained emotional arousal,
  • cyanosis of the feet, hands, ears, lips and tip of the nose,
  • increase in total swelling.

In general, the clinic manifestations of hemorrhagic shock in humans depends not only on the speed of blood loss, but also on the level of individual compensatory mechanisms that directly depend on age, constitutional composition, and concomitant aggravating factors, such as heart and lung diseases.

Children and people of advanced years, pregnant women with preeclampsia, as well as people suffering from obesity or with reduced immunity suffer more severely than other bleeding.

Version of the American Association of Surgeons

Despite the fact that the decisive role in the occurrence of hemorrhagic shock is still played by the bleeding rate, in order to estimate roughly the lost volume of circulating blood, the doctor initially relies on the most important criteria of the hemorrhagic shock clinic: pulse, blood pressure in general and systolic pressure in particular Algauver-Grover index of shock, the value of central venous pressure, as well as the clinical symptoms and signs of organ dysfunction and hemodynamic disorders.

The extremities are cold to the touch, gray.

In the horizontal position (back) blood pressure is lowered.

A sharp slowdown in the formation of urine.

Critical indicators: GARDEN 100.

Clinical signs are supplemented by: marbling of all skin integuments, cyanosis of the distal regions and lack of pulse in them, impairment of consciousness (up to a coma).

Catastrophic drop in blood pressure.

Any, even the first, severity of hemorrhagic shock is a direct indication for emergency care and intensive care.

Based on clinical signs

The following pathophysiological stages of hemorrhagic shock are distinguished, with their respective clinics:

  1. Stage of shock compensation or "centralization of blood circulation"
    • the patient is conscious, may be agitated or calm,
    • pale skin, limbs cold to the touch,
    • visually distinguishable veins - slept,
    • cold and sticky sweat profusely
    • GARDEN - normal or low, dad increased,
    • pulse is weakly filled and speeded up
    • urine formation decreases from a norm of 45–50 to 25 ml / h.
  1. Stage of decompensation or “microcirculation crisis”
    • the patient is inhibited or in a state of prostration,
    • all the skin is of marble color, and the distal sections are cyanotic,
    • shortness of breath, thirst
    • low blood pressure
    • Shock index = 1.5-2,
    • urine synthesis ceases and anuria develops,
    • DIC syndrome - in the stage of decompensation,
    • with strong pressure on the tip of the finger, the pale spot fills with blood in more than 4-5 seconds.
  1. Stage of irreversible or refractory shock
    • the accumulation of excess toxic substances,
    • death of cell structures
    • appearance of signs of polyorgan failure,
    • the lack of effect from infusion-transfusion therapy and the inability to stabilize blood pressure.

The last stage, as a rule, lasts about 12 hours, after which a lethal outcome occurs.

Attention should be paid to the fact that not every patient goes through all stages of a shock condition. The rate of passage from the first stage of hemorrhagic shock to the next depends not only on the volume and rate of blood loss, but also on the patient’s initial condition, localization and nature of the transferred damage, time of arterial hypotension, timeliness and adequacy of intensive treatment.

Urgent Care

First of all, at the pre-hospital stage, it is necessary to carry out available manipulations to temporarily stop the bleeding with any available materials. After that it is necessary to contact the resuscitation team or deliver the patient to the hospital independently.

Further, the provision of first emergency care for hemorrhagic shock should be carried out according to the rule of "3 catheters", which includes 3 stages:

  1. Provided to maintain gas exchange and airway. Set nasogastric tube. If necessary, an artificial respiration ventilator or a pressure chamber will be activated.
  2. With the help of catheters for 2-3 peripheral veins, the volume of circulating blood is replenished, which is carried out according to a special table and individual calculations. At the same time, the balance of crystalloid and colloid solutions should not be less than 1: 1, ideally 1: 2.
  3. Provides catheterization of the bladder.

After that, the necessary diagnostics and intensive care are consistently carried out according to the following algorithm:

  • Rapid analyzes that determine the level of glucose concentration in plasma and the amount of ketone bodies in the urine.
  • Preventive measures to prevent the occurrence of a hypoglycemic state and the deadly acute Wernicke encephalopathy — thiamine (100 mg) is first injected intravenously, and only after it is given a bolus of 40% glucose solution (20–40 ml, the dosage as necessary increases).
  • The use of narrow-profile antidotes - only if necessary and after special diagnostics.
  • Reduction of cerebral edema, inflammation of its membranes and reduction of intracranial pressure - an algorithm: first infusion of mannitol, then the introduction of furosemide, followed by a bolus of dexamethasone.
  • For neuroprotection, depending on the state, piracetam (drip), or glycine (per cheek), or mexidol (bolus), or semax (instillation into the nose).
  • Symptomatic therapy - warming or cooling the limbs with heaters, stopping seizures (Relanium), preventing vomiting (raglan)
  • Required continuous monitoring of ECG.

Therapeutic therapy

Actually, the treatment of hemorrhagic shock occurs after stabilization of the patient's condition. In the general scheme of maintaining and normalizing the vital activity of the organism, the following are standardly applied:

  • Vitamin C, dicynone, essliver, troksevazin - to restore and stabilize cell membranes.
  • Ganglioblockers, trental, chimes - to eliminate the effects of vasospasm.
  • Carvetin, cocarbaxylase, riboxin, actovegin, cytochrome C, mildronate, dopamine - to maintain the heart muscle.
  • Hydrocortisone, prednisone, dexamethasone - to improve the contractile work of the heart.
  • Kontrikal - to normalize the real properties and blood clotting.
  • When the values ​​of the GARDEN above 90 mm Hg. it is advisable to use droperidol - to maintain central nervous activity.

The treatment algorithm for the effects of hemorrhagic shock has long been tested, and the dosage of the above drugs is strictly regulated. Equally important is the rehabilitation period, including exercises.

In conclusion, we remind you that timely and adequate assistance for hemorrhagic shock will save not only health, but also life - if you are close to a person in such an extreme situation, make every effort to stop the bleeding and immediately call an ambulance .

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