Hemorrhagic shock (GSH). Degrees, clinic, treatment

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

The body of a healthy woman krovopoterju to 20% BCC (approximately 1000 ml) can restore due to autohemodilution and redistribution of blood in the vascular channel. With blood loss of more than 20-25%, these mechanisms can eliminate the deficit of BCC. With massive blood loss, the vasoconstriction stance remains the leading "protective" reaction of the body, in connection with which the normal or close blood pressure is maintained, the blood supply of the brain and heart (blood circulation centralization) is realized, but due to the weakening of the blood flow in the muscles of internal organs, including kidney, lung, liver.

Long-term stable vasoconstriction, as a protective reaction of the body first, maintains arterial pressure within certain limits for some time, further, 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 renal failure and other pathological conditions.

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

Clinic of hemorrhagic shock

GSH is manifested by weakness, dizziness, nausea, dry mouth, darkening of the eyes, increased blood loss - loss of consciousness. In connection with compensatory redistribution of blood, its amount decreases in muscles, the skin shows a paleness of skin with a gray shade of the extremity of the cold, moist. Reduction of renal blood flow is manifested by a decrease in diuresis, subsequently with impaired microcirculation in the kidneys, with the development of ischemia, hypoxia, tubular necrosis. With an increase in the volume of blood loss, the symptoms of respiratory failure increase: dyspnea, rhythm of breathing, excitation, peripheral cyanosis.

There are four degrees of severity of hemorrhagic shock:

  • I degree severity is noted with a deficit of BCC 15%. The general condition is satisfactory, the skin is pale, insignificant tachycardia (up to 80-90 beats per minute) BP within 100 mm Hg, HB 90 g /L, central venous pressure is normal.

  • II degree severity - BCC deficit to 30%. The general condition of moderate severity, complaints of weakness, dizziness, darkening in the eyes, nausea, skin pale, cold. Arterial pressure 80-90 mm Hg, central venous pressure below 60 mm of water, tachycardia to 100-120 beats /min, diuresis is lower, Hv 80 g /l and lower.

  • III degree Gravity occurs when the deficit of bcc is 30-40%. The general condition is severe. There is a sharp inhibition, dizziness, pale skin, acrocyanosis, blood pressure below 60-70 mm Hg, CVP falls (20-30 mm of water and below). There is a hypothermia, a frequent pulse (130-140 beats /min), oliguria.

  • IV degree The severity is observed when the deficit of bcc is more than 40%. The condition is very heavy, there is no consciousness. Arterial pressure and central venous pressure is not determined, the pulse is noted only on the carotid arteries. Breathing shallow, rapid, with a pathological rhythm, mobile excitement, hyporeflexia, anuria observed.

  • Treatment of hemorrhagic shock

  • Rapid and reliable stopping of bleeding, taking into account the cause of obstetric hemorrhages;

  • Replenishment of BCC and maintenance of macro-, microcirculation and adequate tissue perfusion using controlled hemodilution, blood transfusion, reocorrecting, glucocorticoids, etc .;

  • TTTVL in the mode of moderate hyperventilation with positive end-expiratory pressure (prophylaxis of "shock lungs")

  • Treatment of ICE, acid-base disturbances, protein and water-electrolyte metabolism, correction of metabolic acidosis;

  • Anesthesia, medical anesthesia, antihypoxic defense of the brain;

  • Maintaining an adequate diuresis at a level of 50-60 ml /h;

  • Maintaining the activity of the heart, liver;

  • The use of broad-spectrum antibiotics.

    Elimination of the cause of bleeding - the main point of treatment GSH. The choice of method for stopping bleeding depends on its cause. In the treatment of HT, great importance is the rate of compensation for blood loss and timely surgical treatment. GSH II severity is an absolute indication for an operative stop of bleeding.

    Infusion therapy with GSH should be performed in 2-3 veins: with blood pressure within 40-50 mm Hg. the volume infusion rate should be 300 ml /min with blood pressure 70-80 mm Hg. - 150-200 ml /min with stabilization of blood pressure to 100-110 mm Hg. infusion is carried out drip under the control of blood pressure and hourly urine output.

    The ratio of colloid and crystalloid should be 2: 1. Infusion therapy includes: reopoliglyukin, volekam, erythromassa, native or fresh-frozen plasma (5-6 vials), albumin, Ringer-Locka solution, glucose, panangin, prednisolone, korglikon, 4% sodium hydrogen carbonate solution, trisamine for correction of metabolic acidosis. When hypotensive syndrome - the introduction of dopamine or dopamine. The volume of infusion should exceed the estimated blood loss by 60-80%, while hemotransfusion is carried out in the volume of no more than 75% of blood loss in its one-stage replacement, then delayed blood transfusion in smaller doses.

    To eliminate vasospasm, after eliminating bleeding and eliminating the deficit of bcc, ganglion blockers are used with drugs that improve the rheological properties of blood (rheopolyglucin, trental, komplin, kurantil). It is necessary to use for GSH glucocorticoids in large doses (30-50 mg /kg hydrocortisone or 10-30 mg /kg prednisolone), diuretics, use artificial ventilation.

    For the treatment of DIC-syndrome with GSH apply fresh frozen plasma, inhibitors of proteases - kontrikal (trasilol) to 60-80000 OD, gordoks 500-600000 OD. Dicinone, etamzilate, androxon reduce the fragility of capillaries, enhance the functional activity of platelets. Apply cardiac glycosides, immunocorrectors, vitamins, according to indications - antibacterial therapy, anabolics (nerobol, retabolil), Essentiale.

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