Hemorrhagic shock: signs, emergency care, degrees, stages and treatment. What is hemorrhagic shock

Hemorrhagic shock (HS)- this is a critical condition of the body associated with acute blood loss, resulting in a crisis of macro- and microcirculation, a syndrome of multiple organ and polysystemic insufficiency. From a pathophysiological point of view, this is a crisis of microcirculation, its inability to provide adequate tissue metabolism, satisfy the need for oxygen in tissues, energy products, remove toxic metabolic products.

organism healthy woman blood loss up to 20% of the BCC (approximately 1000 ml) can be restored due to autohemodilution and redistribution of blood in the vascular bed. With blood loss of more than 20-25%, these mechanisms can eliminate the BCC deficiency. With massive blood loss, vasoconstriction remains the leading "protective" reaction of the body, in connection with which normal or close to normal blood pressure is maintained, blood supply to the brain and heart is carried out (centralization of blood circulation), but due to weakening of blood flow in the muscles internal organs, including in the kidneys, lungs, liver.

long-term sustained vasoconstriction defensive reaction of the body, at first, for some time, it maintains blood pressure within certain limits, later, with the progression of shock and in the absence of adequate therapy, contributes to the consistent development of severe microcirculation disorders, the formation of "shock" organs and the development of acute kidney failure and other pathological conditions.

The severity and speed of disorders in HS depends on the duration of arterial hypotension, the ascending state of organs and systems. With ascending hypovolemia, short-term hypoxia during childbirth leads to shock, as it is a trigger for impaired hemostasis.

Clinic of hemorrhagic shock

HS is manifested by weakness, dizziness, nausea, dry mouth, darkening of the eyes, with increased blood loss - loss of consciousness. In connection with the compensatory redistribution of blood, its amount decreases in the muscles, the skin is manifested by pallor of the skin with a gray tint; the limbs are cold, wet. A decrease in renal blood flow is manifested by a decrease in diuresis, subsequently with impaired microcirculation in the kidneys, with the development of hypoxia, tubular necrosis. With an increase in blood loss, symptoms of respiratory failure increase: shortness of breath, respiratory rhythm disturbance, agitation, peripheral cyanosis.

There are four degrees of severity of hemorrhagic shock:

I degree severity is noted with a BCC deficit of 15%. The general condition is satisfactory, the skin is pale in color, slight tachycardia (up to 80-90 beats / min), blood pressure within 100 mm Hg, Hb 90 g / l, central venous pressure is normal.
II degree severity - BCC deficiency up to 30%. General condition of moderate severity, complaints of weakness, dizziness, darkening of the eyes, nausea, skin is pale, cold. Arterial pressure is 80-90 mm Hg, central venous pressure is below 60 mm of water column, tachycardia is up to 100-120 beats / min, diuresis is reduced, Hb is 80 g / l and below.
III degree severity occurs with a BCC deficiency of 30-40%. The general condition is severe. There is a sharp lethargy, dizziness, pale skin, acrocyanosis, blood pressure below 60-70 mm Hg, CVP drops (20-30 mm water column and below). There is hypothermia rapid pulse(130-140 beats / min), oliguria.
IV degree severity is observed with a BCC deficiency of more than 40%. The condition is very serious, consciousness is absent. Arterial pressure and central venous pressure are not determined, the pulse is noted only on the carotid arteries. Breathing is superficial, rapid, with an abnormal rhythm, mobile excitation, hyporeflexia, anuria are noted.

Treatment of hemorrhagic shock

Fast and reliable stop of bleeding, taking into account the cause of obstetric bleeding;
Replenishment of bcc and maintenance of macro-, microcirculation and adequate tissue perfusion using controlled hemodilution, blood transfusion, rheocorektoriv, glucocorticoids, etc.;
TTTVL in the mode of moderate hyperventilation with positive end-expiratory pressure (prevention of "shock lungs")
Treatment of DIC, acid-base disorders, protein and water electrolyte metabolism, correction of metabolic acidosis;
Anesthesia, therapeutic anesthesia, antihypoxic brain protection;
Maintaining adequate diuresis at 50-60 ml/hour;
Maintaining the activity of the heart, liver;

Use of antibiotics a wide range actions.

Eliminate the cause of bleeding- the main point of the treatment of HS. The choice of method to stop bleeding depends on its cause. In the treatment of HT great importance has a rate of compensation for blood loss and timely surgical treatment. GS II severity is absolute reading to promptly stop bleeding.

Infusion therapy for HS should be carried out in 2-3 veins: with blood pressure in the range of 40-50 mm Hg. the volumetric infusion rate should be 300 ml/min at a blood pressure of 70-80 mm Hg. - 150-200 ml / min with stabilization of blood pressure up to 100-110 mm Hg. infusion is carried out drip under the control of blood pressure and hourly diuresis.

The ratio of colloids and crystalloids should be 2:1. Infusion therapy includes: reopoliglyukin, volekam, erythromass, native or fresh frozen plasma (5-6 vials), albumin, Ringer-Locke solution, glucose, panangin, prednisolone, corglicon, for the correction of metabolic acidosis - 4% sodium bicarbonate solution, trisamine. At hypotensive syndrome administration of dopamine or dopamine. The volume of infusion should exceed the estimated blood loss by 60-80%, at the same time, blood transfusion is carried out in the amount of not more than 75% of blood loss with its simultaneous replacement, then delayed blood transfusion in smaller doses.

To eliminate vasospasm, after eliminating bleeding and eliminating BCC deficiency, ganglionic blockers are used with drugs that improve rheological properties blood (rheopolyglucin, trental, complamin, chimes). It is necessary to use high doses of glucocorticoids (30-50mg/kg hydrocortisone or 10-30mg/kg prednisone), diuretics, artificial ventilation lungs.

For the treatment of DIC in HS, fresh frozen plasma is used, protease inhibitors - contrical (trasylol) 60-80000 OD, Gordox 500-600000 OD. Dicynon, etamsylate, androxon reduce capillary fragility, enhance functional activity platelets. Apply cardiac glycosides, immunocorrectors, vitamins, according to indications - antibiotic therapy, anabolics (nerobol, retabolil), essentiale.

Of great importance after intensive therapy is rehabilitation therapy, therapeutic exercises.

Shock is a general non-specific reaction of the body to an excessive (in strength or duration) damaging effect. In the case of the development of hemorrhagic shock, such an impact may be an acute, timely uncompensated blood loss leading to hypovolemia. Usually, for the development of hemorrhagic shock, a decrease in BCC by more than 15-20% is necessary.

SYNONYMS

hypovolemic shock.

CLASSIFICATION

By volume of blood loss:

mild degree - a decrease in BCC by 20%;
medium degree - a decrease in BCC by 35–40%;
severe - a decrease in BCC by more than 40%.

In this case, the rate of blood loss is of decisive importance.

According to the Algover shock index (quotient from the division of heart rate by systolic blood pressure, normally it is less than 1)

Mild degree of shock - index 1.0–1.1.
The average degree is an index of 1.5.
Severe degree - index 2.
Extreme severity - index 2.5.

According to clinical signs (according to G.Ya. Ryabov).

Compensated hemorrhagic shock- moderate tachycardia, arterial hypotension is mild or absent. Detect venous hypotension, moderate shortness of breath with physical activity, oliguria, cold extremities. In terms of blood loss, this stage corresponds to a mild degree of the first classification.
Decompensated reversible hemorrhagic shock - heart rate 120–140 beats per minute, systolic blood pressure below 100 mm Hg, low pulse pressure, low CVP, shortness of breath at rest, severe oliguria (less than 20 ml per hour), pallor, cyanosis, cold sweat, restless behavior. In terms of blood loss, it usually corresponds to the average degree of the first classification.
Irreversible hemorrhagic shock. Persistent prolonged hypotension, systolic blood pressure below 60 mm Hg, heart rate over 140 beats per minute, negative CVP, severe shortness of breath, anuria, lack of consciousness. The volume of blood loss is more than 40% of the BCC.

ETIOLOGY

Basic etiological factor development of hemorrhagic shock - not timely replenished blood loss exceeding 15-20% of the BCC. In gynecological practice, this condition is most often caused by an interrupted ectopic pregnancy, especially the gap fallopian tube; the closer to the uterus there was a violation of the integrity of the tube, the higher the volume of hemoperitoneum. However, other pathological conditions can also lead to the development of massive bleeding, such as:

ovarian apoplexy;
oncological diseases;
septic processes associated with massive tissue necrosis and vascular erosion;
genital trauma.

Contributing factors are:

initial hypovolemia due to heart failure, fever, etc.;
iatrogenic hypovolemia resulting from the use of diuretics, ganglion blockers, which is a consequence of epidural and epidural anesthesia;
incorrect assessment of the volume and speed of blood loss, tactical errors in replenishment, inadequate assessment of the state of the hemostasis system and belated correction of its violations, untimely choice of means to stop bleeding, complications that arose in the process of providing medical care.

DEVELOPMENT MECHANISM

The trigger mechanism for hemorrhagic shock is acute irreversible blood loss, leading to a decrease in BCC by 15–20% or more, i.e. causing hypovolemia, in parallel to which there is a decrease in venous return and cardiac output. In response to a diverse deficiency of BCC, the sympathoadrenal system is activated, leading to spasm of capacitive vessels (arterioles and precapillaries) in all organs and systems, with the exception of the brain and heart, i.e. there is a centralization of blood circulation, which is compensatory in nature. At the same time, the processes of autohemodilution begin to develop due to the movement of fluid from the interstitium to the vascular sector and the delay in the removal of water from the body by increasing the reabsorption of it and sodium in renal tubules. However, these mechanisms cannot be guarantors of long-term stabilization of hemodynamics. In conditions of ongoing bleeding and inadequate replacement of blood loss, their depletion occurs within 30–40 minutes. Following the crisis of macrocirculation, the crisis of microcirculatory processes follows, which, due to its irreversibility, is more pronounced and life-threatening. A decisive role in this begins to play hemostasiological disorders, occurring in the form of blood DIC syndrome. As a consequence of vasoconstriction and lack of perfusion pressure, blood flow stops in most exchange vessels, which are capillaries. Platelet-fibrin thrombi are quickly formed in them, involving erythrocytes remaining in the capillaries, which are relatively quickly destroyed, supplying new portions of activators of the coagulation process. This process ends with the formation of a significant acidosis, causing a sharp increase in permeability. cell membranes and vascular wall. The sodium-potassium pump is inverted, the fluid moves first into the interstitium, and then into the cells, their massive death in all organs and tissues, including vital ones, especially those with increased hydrophilicity, such as the brain and lungs. These changes are of a total nature, have no exceptions and cannot stop on their own even with the restoration of central hemodynamics through active infusion therapy. Time is lost, the shock becomes irreversible, and the death of the body is almost inevitable.

CLINICAL PICTURE

The severity of clinical manifestations depends on the stages of development of hemorrhagic shock, the criteria for which are set out in clinical classification given in the relevant section. It should be added to the above that it is very short-sighted and dangerous to rely in the assessment of the state on the subjective feelings of the patient. It must be remembered that significant clinical manifestations of hemorrhagic shock can be detected only when it enters the second, already decompensated stage, when stable arterial hypotension becomes the leading symptom as a sign of hypovolemia and heart failure, indicating the impossibility of self-compensation of hemodynamics due to the centralization of blood circulation. In the absence of adequate assistance, especially infusion-transfusion therapy, in conditions of ongoing bleeding, shock progresses towards its irreversibility, with inevitable rapidity there is a shift in emphasis in pathogenetic processes and clinical signs from macrocirculatory problems to microcirculatory ones, which leads to the development of multiple organ and polysystemic insufficiency with the corresponding symptom complex. In addition to the above, it is important to understand that the construction of the concept of providing care on the basis of only clinical diagnostics and prognosis without carrying out appropriate laboratory and instrumental studies leads to disorientation of the medical staff and a delay in the entire medical diagnostic process.

DIFFERENTIAL DIAGNOSTIC MEASURES

It should be remembered that when there are doubts about the type of shock, the main differential diagnostic criterion that rejects its hemorrhagic nature is the proven absence of ongoing bleeding and unreplaced blood loss. However, it is necessary to keep in mind the possibility of a combination of different types of shock in one patient, as well as the simultaneous or sequential additional action of several shockogenic factors (anaphylaxis, dehydration, trauma, excessive pain stimulus, septic agent) against the background of hemorrhagic shock, which undoubtedly leads to aggravation its course and consequences.

The logic of the diagnostic process in case of suspected hemorrhagic shock, first of all, involves determining the volume of blood loss and confirming or denying the fact of ongoing bleeding and the degree of its intensity. At the same time, there is often an underestimation of the volume of blood loss and, as a result, a delay in the start of infusion-transfusion therapy, late diagnosis hemorrhagic shock, often in its already decompensated stage.

Certain assistance in diagnosing the presence of hemorrhagic shock and its stage is provided by:

the maximum possible specification of the amount of irretrievably lost blood and its correlation with the calculated BCC (in percent) and the volume of infusion therapy performed;
determination of the state of the central nervous activity, its mental and reflex components;
assessment of the condition of the skin: their color, temperature and color, the nature of the filling of the central peripheral vessels, capillary blood flow;
auscultatory and radiological assessment of the activity of the respiratory and circulatory organs;
monitoring of the main vital indicators: blood pressure, heart rate, respiratory rate, blood oxygen saturation;
calculation of the shock index (see the "Classification" section);
measurement of CVP;
control of minute and hour diuresis;
measurement of hemoglobin concentration and its correspondence to hematocrit. It should be noted that in acute blood loss, the hematocrit value may be more indicative of the volume of infusion therapy than the volume of blood lost;
study of the hemostasis system for the presence and intensity of the development of DIC of the blood, the form and stage of its course. It is fundamental to determine the presence in the blood of soluble complexes of fibrin monomers and / or fibrin degradation products (Ddimer), as well as the number of platelets, by a qualitative or quantitative method;
monitoring of the acid-base state, electrolyte and gas composition of the blood, preferably with a comparison of arterial and venous blood;
electrocardiographic control, if possible, echocardiography;
study of biochemical parameters of blood.

The synthetic and final diagnostic result of the above is an objective assessment of the severity general condition patients, the formation of a structural diagnosis and the determination of the strategy and tactics of providing medical care.

EMERGENCY ACTION AND TREATMENT

The main and most urgent action for the treatment and prevention of the progression of hemorrhagic shock, the search for the source of bleeding and its elimination should be considered. In gynecological practice, the best way to do this is surgical intervention.
The second fundamental action, which decides the issue of saving the patient's life, is the speed of recovery of the BCC. The infusion rate is determined by the most accessible indicators - blood pressure, heart rate, CVP and minute diuresis. In this case, in the case of ongoing bleeding, it should outpace the rate of outflow of blood by about 20%.
Such a rate of administration of solutions can be achieved only if there is a confident access to the central venous vessels through a large-diameter catheter. Therefore, catheterization of the subclavian or jugular vein included in the range of emergency measures.
We should not forget about the simultaneous catheterization of preferably two peripheral vessels, which are necessary for long-term strictly dosed administration of drugs, as well as the installation of a catheter into the bladder.
AT critical condition patients, close to terminal, proceed to intra-arterial injection of solutions.
All these measures are taken in order to maintain optimal oxygen consumption by tissues and maintain metabolism in them, for which prolonged artificial ventilation of the lungs with a clear maneuvering of the composition of the gas mixture and adequate anesthesia, as well as warming the patient, is very important.
The priority in the infusion therapy of hemorrhagic shock, of course, today belongs to HES solutions of 10% concentration. It is these solutions that allow you to quickly and for a sufficiently long period of time (up to 4 hours) to ensure the compensation of the BCC by increasing the oncotic pressure. With their rapid introduction, infusion therapy for shock should be started. Typically, up to 1.5 liters of HES per day are used, alternating with crystalloid (mostly glucose-free) and other colloidal solutions(dextrans, gelatins), the ratio of which in the general infusion program should be 1:1. Until now, it has not lost its significance as a starting component in the treatment of massive blood loss and hypertonic - 7-7.5% sodium chloride solution, infusion of 150-200 ml (6 ml / kg) of which, followed by the introduction of HES and crystalloids, can effectively stabilize or even restore systolic blood pressure and cardiac output. Not so long ago, an official hypertonic version of HES appeared - HyperHayes©. Its introduction in the amount of 1 liter also very actively and quickly affects blood pressure and volumetric indicators of the work of the heart, but just like with conventional HES, further infusion of a sufficient volume of liquid is necessary. All solutions should be heated to 30–35 °C.
The fight against hemorrhagic shock and its consequences also implies, depending on hemostasiological parameters and the presence of DIC, a permanent correction of the hemostasis system by transfusion of FFP and suppression of fibrinolytic and proteolytic activity of the blood (for details, see the section " DIC syndrome blood" this manual). It is important to remember that the earlier the decision on replacement therapy plasma and the more intensively it is carried out under the cover of fibrinolysis inhibitors, the faster and with less cost and consequences it is possible to transfer disturbances in the hemostasis system from acute form into chronic. You should also try to avoid technical errors when thawing and administering plasma (plasma is transfused into a stream, into a central vein and heated to 30 ° C, after each dose of plasma, 10 ml of a 10% solution of calcium chloride is injected to neutralize sodium citrate).
With regard to the introduction of erythrocyte mass or suspension, it should be borne in mind that this is not a primary measure to combat shock, because a critical decrease in the concentration of the oxygen carrier usually occurs with blood loss of more than 40% of the BCC. As a rule, erythrocyte transfusion is started after bleeding has stopped, the volume of lost blood has been replenished, and relatively reliable research results have been obtained, first of all, blood gas composition, confirming an extremely low partial pressure of oxygen. It is unacceptable to focus only on quantification hemoglobin and hematocrit. If a decision on transfusion is made, it is necessary to limit the number of injected erythrocytes to the minimum possible, postponing their further transfusion to a period more remote from blood loss, when it will be possible to objectively judge the blood composition in the central and peripheral sectors. An indisputable fact is the strict observance of all the rules for blood transfusion and technical requirements, including the need to dilute the erythrocyte mass with isotonic sodium chloride solution in a ratio of 1: 1 and the introduction after each dose of 10 ml of 10% calcium chloride solution to neutralize sodium citrate.
On average, with a loss of about 35-40% of the BCC, the volume of all infusion therapy, including blood components (1-1.5 l of FFP and about 600 ml of erythrocyte mass), subject to normalization of diuresis, per day is 250-300% of the finally established volume irrevocably lost blood.
An important issue, especially in gynecological practice, is the issue of reinfusion of blood that has flowed into abdominal cavity. Considering it from modern pathophysiological positions, it can be concluded that it is impossible to reinfuse blood by filtering it through gauze. This blood can be returned to the patient only in the form of erythrocytes washed in a special apparatus or using special filters.
To compensate for acute adrenal insufficiency, after the start of active fluid therapy, the administration of prednisolone 90–120 mg or equivalent doses of hydrocortisone, dexamethasone, or methylprednisolone is indicated. The use of these drugs must be repeated periodically until stabilization of hemodynamics is achieved.
Given the problems with perfusion of the renal tissue that occur during the shock process, it is necessary, subject to adequate replenishment of blood loss and insufficient minute and hourly diuresis (less than 50-60 ml / hour), for each liter of transfused fluid, 10-20 mg of furosemide should be administered intravenously.
The use of vasopressors, such as epinephrine, phenylephrine and their analogues, is contraindicated, especially before the replenishment of the BCC. On the other hand, the permanent use of dopamine as an agonist of dopamine receptors through a perfusor at a renal dose of 2–3 μg/(kg min) after replenishment of the main part of the BCC improves renal and mesenteric blood flow, and also contributes to the normalization of systemic hemodynamics.
Correction of the acid-base state of the blood, protein and electrolyte metabolism, no doubt, remains a necessary component of therapy throughout the entire period of treatment of hemorrhagic shock. It is important that this requires reliable data from laboratory studies, otherwise, instead of helping the patient, you can harm the already extremely stressed functioning organs and systems. Special attention attention should be paid to calcium and potassium deficiencies, as well as sodium excess, which can lead to rapid development swelling of the brain. However, the use of a 4% solution of sodium bicarbonate in an amount of 2 ml / kg will reduce metabolic acidosis until laboratory data are obtained.

Criteria for the effectiveness of assistance:

stabilization of blood pressure, heart rate at indicators that are not life-threatening and provide adequate perfusion of organs and tissues, i.e. BP not lower than 100/60 mm Hg. and heart rate 100/min;
CVP not lower than 4–6 mm of water column;
minute diuresis of at least 1 ml and hourly at least 60 ml;
blood oxygen saturation of at least 94-96%;
venous blood hemoglobin concentration not lower than 60 g/l;
venous blood hematocrit not less than 20%;
the concentration of total protein in blood plasma is not lower than 50 g/l;
stable isocoagulation of venous blood with a tendency to hypercoagulation;
the absence of sharp shifts in the acid-base state and electrolyte composition of the blood;
absence acute disorders myocardial nutrition.

BIBLIOGRAPHY
Anesthesiology and resuscitation: textbook / Ed. O.A. Valley. - M.: GEOTARMEDIA, 2002. - 552 p.
Vorobyov A.I., Gorodetsky V.M., Shulutko E.M., Vasiliev S.A. Acute massive blood loss. - M.: GEOTARMEDIA, 2001. - 176 p.
Vertkin A.L. Emergency. - M.: GEOTARMEDIA, 2003. - 368 p.
Mariino P.L. Intensive care: Per. from English. / Ed. A.I. Martynova - M.: GEOTARMedia, 1998.
Marshall V. J. Clinical biochemistry: Per. from English. - St. Petersburg: BINOM-Nevsky Dialect, 2002. - 384 p.
Litvitsky P.F. Pathophysiology: textbook in 2 volumes - M.: GEOTARMedia, 2002.
Anesthesiology and Intensive Care: A Practitioner's Handbook / Ed. ed. B.R. Gelfand. - M.: Literra, 2005. - 544 p.
Petch B., Madlener K., Sushko E. Hemostasiology. - Kyiv: Health, 2006. - 287 p.
Shifman E.M., Tikanadze A.D., Vartanov V.Ya. Infusion transfusion therapy in obstetrics. - Petrozavodsk: Intel Tech, 2001. - 304 p.

Hemorrhagic shock is essentially an abnormal loss of blood. When the volume of blood decreases sharply and by a significant amount, the body flows into stressful condition. Usually the body saturates about 5-6 liters of blood, even a slow loss of about 400 milliliters, which is usually taken from a donor, causes instant weakness,. That is why, after donating blood, to stimulate the restoration of the full volume of fluid circulating through the vessels, doctors strongly recommend drinking sweet warm tea with hematogen.

Such a reaction is provoked by slow blood loss, what can we say about the rapid loss. With a sharp loss of blood, the tone of the veins is increased, and the body is immediately plunged into shock from instant downgrade blood volume. With a decrease in the norm of blood, the body begins to function differently. More than 15% of the leakage turns on a kind of energy saving mode - the body switches power to life-supporting organs: the heart, lungs, brain, and the rest of the parts are considered secondary. There is hemorrhagic and hypovolemic shock. They are distinguished by and large only by the rate of decrease in blood volume. Hypovolemia does not provoke a catastrophic outcome, because the recovery algorithm is activated. This means that only shock during a rapid decrease in volume can be considered hemorrhagic.

Reasons for the development of hemorrhagic shock

The basis of hemorrhagic shock is serious. Acute leakage of fluid in the vessels implies the absence of half a liter to a liter of blood, combined with rapid decline amount of circulating fluid. This situation is usually provoked by serious injuries, which are accompanied by severe damage to blood vessels. Often, hemorrhagic shock is a consequence of pathologies in terms of gynecology: trauma during childbirth, postpartum hemorrhage, prematurely detached placenta, intrauterine death fetus, ectopic pregnancy. Of course, heavy bleeding can happen after surgery, when the cancerous tumor disintegrates, the occurrence of a through hole and, as a result, a gastric ulcer.

Clinical manifestations

Manifestation acute blood loss directly depends on the amount of fluid lost. Doctors distinguish three stages of hemorrhagic shock. Separation occurs in direct proportion to the volume of blood lost:

I stage. The degree to which it is still possible to compensate for the lost fluid. The victim is conscious, retains sober thinking, looks rather pale, the pulse is weakly palpable, low blood pressure and a decrease in the temperature of the extremities are observed. At the same time, the lost volume does not exceed 15–25% of the total volume. The heart muscle tries to compensate for the missing fluid with the heart rate, so the heart rate increases to 90-110 per minute;
II stage. At this stage, the normal functions of the organs are disrupted. The absence of a large volume of blood forces the body to distribute life support processes in accordance with the priority of specific organs. Observed oxygen starvation brain, the heart pumps out blood much weaker. Symptoms appear when there is a loss of 25 to 40% of the circulating blood volume. The consciousness of the victim is disturbed - the person thinks retarded. The fluid in the vessels is critically low, so the face, arms, legs are painted cyanotic, and protrudes all over the body sticky sweat. A thready pulse appears, the pressure decreases, and the heart rate reaches 140 beats. The kidneys stop filtering fluid normally, urination decreases;
III stage. This is an irreversible shock. The patient's condition is regarded as extremely critical. Consciousness is completely absent, the skin acquires a marble hue, the pressure in the arteries decreases to 60-80 millimeters of mercury or is not detected at all. Tachycardia occurs - the heart contracts up to 140-160 times per minute.

How is the degree of blood loss determined?

Doctors determine the levels of shock stages by the Algover index. This number shows the proportional ratio of the indicator of the number of contractions of the heart muscle to the indicator of the upper blood pressure. The numerical indicator of the index directly depends on the severity of the condition of the victim. Normal is within 1.0. Further, the severity of the indicator is divided by doctors into:

light, within 1.0 to 1.1;
moderate, within 1.1 to 1.5;
heavy, within 1.5 to 2.0;
critical severity, within 2.0 to 2.5.

Severity

Of course, only the index indicator cannot be considered as absolute. Doctors see it in combination with blood loss. The classification of the types of severity of shock is named in the same way as the indices, but provides for the presence of a certain volume of blood. So, mild degree assumes a shock index of 1.0-1.1 and a blood loss of 10 to 20% of the volume, but not more than 1 liter. Moderate severity - shock index up to 1.5, loss from 20 to 30% of volume, but not more than 1.5 liters. Severe degree - 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 sharp decline the amount of blood that is in. In the center of diagnosing the symptoms of hemorrhagic shock lies the determination of the amount of blood lost, the source of the leak, and its intensity.

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

How to provide first aid

The condition of the victim is very important to correctly assess. Find the cause of bleeding and eliminate it as soon as possible. Properly rendered first aid contributes to a more rapid recovery 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 locate the source of the loss. The place above the source of blood leakage must be bandaged with a bandage or tourniquet. The tourniquet usually strongly presses the vessels and can damage them, so emergency doctors recommend using a rag or gauze bandage. Over the wound, it must be tightly bandaged, wrapping a tight bundle on top, which after 1 hour will need to be untwisted a little to avoid tissue death below the bandaged place. Further, it is not recommended to take any measures without doctors. It is necessary to wait for the arrival of an ambulance and be sure to write on the victim the time of applying a tight bandage so that the doctors understand how long the wound has been localized from the blood supply.

Treatment of hemorrhagic shock

After the arrival of the ambulance, the doctors will proceed to restore the volume of fluid in the vessels. In a severe form of leakage, the patient is infused. If the blood loss is moderate or light, then a special solution for replenishment can be used - saline, blood substitute, erythrocyte mass.

Possible Complications

Hemorrhagic shock can cause quite serious complications. It all depends on the amount of fluid lost, its intensity, and the rate of localization of the source. Most complications occur due to oxygen starvation. This is damage to the mucous membrane of the lungs, mild exhaustion of the brain, damage to the functions of the brain, kidneys, and liver. In the event of a shock due to labor activity irreversible damage to the reproductive organs is possible.

So, we found out how hemorrhagic shock manifests itself, what its degrees and stages are, and how to provide first aid to the victim. If you still have questions after reading the article, then feel free to write them in the comments.

Hemorrhagic shock (HS) is associated with acute blood loss, as a result of which macro- and microcirculation is disturbed, a syndrome of multiple organ and polysystemic insufficiency develops. sharp and profuse bleeding leads to the fact that adequate tissue metabolism stops in the body. As a result, oxygen starvation of cells occurs, in addition, tissues receive less nutrients and toxic products are not excreted.

Hemorrhagic shock is associated precisely with intense bleeding, resulting in severe hemodynamic disturbances, the consequences of which may be irreversible. If the bleeding is slow, then the body has time to turn on compensation mechanisms, which can reduce the consequences of violations.

Causes and pathogenesis of hemorrhagic shock

Since hemorrhagic shock is based on heavy bleeding, only 3 possible reasons such a state:

if spontaneous bleeding occurs;
intense blood loss may occur as a result of trauma;
Surgery can be the cause of large blood loss.

In obstetrics, hemorrhagic shock is a common condition. It is the leading cause of maternal death. The state can be called:

premature detachment or placenta previa;
hypotension and atony of the uterus;
obstetric injuries of the uterus and genital tract;
ectopic pregnancy;
postpartum hemorrhage;
embolism of amniotic fluid vessels;
intrauterine fetal death.

In addition to obstetric problems, hemorrhagic shock may be accompanied by some oncological pathologies and septic processes associated with massive tissue necrosis and erosion of the vascular walls.

The pathogenesis of hemorrhagic shock will depend on many factors, but is mainly determined by the rate of blood loss and the initial state of health of the patient. The greatest danger is heavy bleeding. Slow hypovolemia, even with significant losses, will be less dangerous in its consequences.

Schematically, the state development mechanism can be described as follows:

due to acute bleeding, the volume of circulating blood (CBV) decreases;
since the process is fast, the body does not include defense mechanisms, which leads to the activation of baroreceptors and carotid sinus receptors;
receptors transmit signals to increase heart rate and respiratory movements, spasm of peripheral vessels is caused;
the next stage of the state is the centralization of blood circulation, which is accompanied by a decrease in blood pressure;
due to the centralization of blood circulation, the blood supply to organs is reduced (except for the heart and brain);
the lack of blood flow to the lungs reduces the level of oxygen in the blood, which causes imminent death.

In the pathogenesis of the condition, the main thing is to provide first aid in time, since a person’s life will depend on this.

Symptoms of the development of the disease

HS can be diagnosed in different ways. clinical manifestations. Common features such pathological condition are:

discoloration of the skin and mucous membranes;
change in the frequency of respiratory movements;
violation of the pulse;
abnormal levels of systolic and venous pressure;
change in the amount of urine produced.

Make a diagnosis based on subjective feelings the patient is extremely dangerous, since the clinic of hemorrhagic shock will depend on the severity of the condition.

When classifying the stages of HS, the volume of blood loss and hemodynamic disturbances that are caused in the body are mainly taken into account. Each stage of the disease will have its own signs:

Compensated GSh (mild degree). In the first stage, blood loss is about 10-15% of the BCC. This is approximately 700-1000 ml of blood. At this stage, the patient is contact and is conscious. Symptoms: pallor of the skin and mucous membranes, the pulse quickens (up to 100 beats per minute), there are complaints of dry mouth, severe thirst.
Decompensated HS ( average degree) is stage 2. Blood loss is up to 30% of the BCC (1-1.5 liters). The first thing you need to pay attention to when diagnosing a condition: acrocyanosis develops, the pressure drops to 90-100 mm Hg. Art., the pulse is quickened (120 beats per minute), the amount of urine excreted decreases. The patient develops anxiety, accompanied by increased sweating.
Decompensated irreversible HS (severe degree) is stage 3. At this stage, the body loses up to 40% of the blood. The patient's consciousness is often confused, the skin is very pale, and the pulse is very frequent (130 beats per minute or more). There is inhibition of actions, dizziness, frustration external respiration and cold extremities (hypothermia). Systolic pressure falls below 60 mm Hg. Art., the patient does not go to the toilet "in a small way" at all.
The most severe degree of HS is stage 4 of the condition. Blood loss is more than 40%. At this stage, there is an oppression of all vital important functions. The pulse is poorly palpable, and the pressure is not determined, the breathing is shallow, hyporeflexia develops. The severity of HSH at this stage leads to the death of the patient.

The stages of hemorrhagic shock and the classification of acute blood loss are comparable concepts.

Diagnostic methods

Due to the pronounced clinic of the condition, which is accompanied by a large loss of blood or ongoing bleeding, the diagnosis of HSH will usually not cause difficulties.

When diagnosing, it is important to know that a decrease in BCC to 10% will not cause shock. The development of a pathological condition will be observed only if more than 500 ml of blood is lost in a short period. At the same time, blood loss in the same volume, but for several weeks, will only cause the development of anemia. Symptoms of the condition will be weakness, fatigue, loss of strength.

Of great importance early diagnosis GSH. basis of positive therapeutic effect- timely first aid. How earlier man receives adequate treatment, the higher the likelihood of a full recovery and no complications.

Diagnosis of the severity of HSH is based primarily on the indication of blood pressure and the amount of blood loss. In addition, to understand the difference between the stages of the state will help additional symptoms, such as the color and temperature of the skin, shock index, pulse rate, amount of urine, hematocrit, acid-base composition of the blood. Depending on the combination of symptoms, the doctor will judge the stage of the disease and the need to provide emergency care to the patient.

Emergency care for hemorrhagic shock

Since the disease is serious and can cause irreversible complications, the patient must be given first aid correctly. It is precisely the timely provision of first aid that will affect the positive outcome of therapy. The foundations of such treatment will focus on addressing the following issues:

Emergency care for hemorrhagic shock is aimed primarily at stopping bleeding, and for this it is necessary to establish its causes. Surgery may be required for this purpose. Or the doctor may temporarily stop the bleeding using a tourniquet, bandage, or endoscopic hemostasis.
Next stage emergency treatment- restore the volume of blood (CBV), which is necessary to save the patient's life. Intravenous infusion of solutions should be at least 20% faster than the rate of ongoing bleeding. For this, the readings of blood pressure, CVP and heart rate of the patient are used.
Urgent measures for GS also include catheterization of large vessels, which is done to ensure reliable access to the bloodstream, including ensuring the necessary infusion rate.

Treatment

AT emergency situations treatment of hemorrhagic shock will include the following activities:

if necessary, it is required to provide artificial ventilation of the lungs;
the patient is shown to breathe through an oxygen mask;
at severe pain adequate anesthesia is prescribed;
with the development of hypothermia, the patient must be warmed.

After first aid The patient is assigned intensive care, which should:

eliminate hypovolemia and restore BCC;
remove toxins from the body;
ensure adequate microcirculation and cardiac output;
restore the original osmolarity and oxygen-transport abilities of the blood;
normalize diuresis.

After stabilization of the acute condition, therapy does not end. Further treatment will be directed to the elimination of complications that were caused by GSh.

SHOCK HEMORRHAGIC

Shock is a general non-specific reaction of the body to an excessive (in strength or duration) damaging effect. In the case of the development of hemorrhagic shock, such an effect may be an acute, timely uncompensated blood loss leading to hypovolemia. Usually, for the development of hemorrhagic shock, a decrease in BCC by more than 15–20% is necessary.

CLASSIFICATION

By volume of blood loss:

mild degree - a decrease in BCC by 20%;

medium degree - a decrease in BCC by 35–40%;

severe - a decrease in BCC by more than 40%.

In this case, the rate of blood loss is of decisive importance.

According to the Algover shock index (quotient from the division of heart rate by systolic blood pressure, normally it is less than 1)

Mild degree of shock - index 1.0–1.1.

The average degree is an index of 1.5.

Severe degree - index 2.

Extreme severity - index 2.5.

CLINICAL PICTURE

Stage 1(compensated shock)

blood loss is 15-25% of the BCC

consciousness is preserved

skin is pale, cold

BP is moderately low

moderate tachycardia up to 90-110 beats / min, pulse of weak filling

mild shortness of breath on exertion

oliguria

Stage 2(decompensated shock)

blood loss is 25-40% of the BCC

impaired consciousness to constipation

acrocyanosis, cold extremities

cold sweat

Systolic blood pressure below 100 mm Hg.

tachycardia 120-140 beats / min, pulse weak, thready

oliguria up to 20 ml/hour.

Stage 3(irreversible shock) is a relative concept and largely depends on the methods of resuscitation used.

consciousness is sharply oppressed to the point of complete loss

pale skin, "marbling" of the skin

systolic pressure below 60 mm Hg.

pulse is determined only on the main vessels

sharp tachycardia up to 140-160 beats / min.

DIFFERENTIAL DIAGNOSTIC MEASURES

Certain assistance in diagnosing the presence of hemorrhagic shock and its stage is provided by:

the maximum possible specification of the amount of irretrievably lost blood and its correlation with the calculated BCC (in percent) and the volume of infusion therapy performed;

determination of the state of central nervous activity, its mental and reflex components;

assessment of the condition of the skin: their color, temperature and color, the nature of the filling of the central and peripheral vessels, capillary blood flow;

monitoring of the main vital indicators: blood pressure, heart rate, respiratory rate, blood oxygen saturation;

shock index calculation

measurement of CVP;

control of minute and hour diuresis;

measurement of hemoglobin concentration and its correspondence to hematocrit.

study of biochemical parameters of blood.

EMERGENCY ACTION AND TREATMENT

the main and most urgent measure should be considered the search for the source of bleeding and its elimination

rapid recovery of the BCC. The infusion rate is determined by the most accessible indicators - blood pressure, heart rate, CVP and minute diuresis. It should outpace the outflow of blood by about 20% (HES 10% concentration; hypertonic solution sodium chloride)

artificial ventilation

plasma injection

To compensate for acute adrenal insufficiency, after the start of active infusion therapy, the administration of prednisolone, dexamethasone, or methylprednisolone is indicated.

for each liter of transfused fluid, inject 10–20 mg of furosemide intravenously.