Traumatic shock - This is a pathological condition that arises due to bloodstures and painful syndrome during injury and presents a serious threat to the patient's life. Regardless of the cause of development, it is always manifested by the same symptoms. Pathology is diagnosed on the basis of clinical signs. Urgent cessation of bleeding, anesthesia and immediate delivery of the patient to the hospital. Treatment of traumatic shock is carried out under the conditions of the intensive care unit and includes a set of measures to compensate for the disorders. The forecast depends on the severity and phase of shock, as well as the severity of the injury.
Traumatic shock is a severe condition, which is a reaction of an organism to an acute injury accompanied by severe blood loss and intense pain syndrome. It is usually developing immediately after injury and is a direct response to damage, but under certain conditions (additional traumatization) may occur after some time (4-36 hours). It is a state of threatening for the patient's life, and requires urgent treatment in the conditions of the intensive care unit.
Traumatic shock develops with all types of severe injuries, regardless of their cause, location and damage mechanism. His cause can be knife and firearms, drops from height, automotive accidents, technogenic and natural disasters, accidents in production, etc. In addition to extensive wounds with damage to soft tissues and blood vessels, as well as open and closed fractures of large bones ( Especially multiple and accompanying damage to the arteries) traumatic shock can cause extensive burns and frostbite, which are accompanied by a significant loss of plasma.
The development of traumatic shock is based on massive blood loss, expressed by pain syndrome, violation of the function of vital organs and mental stress caused by acute injury. At the same time, blood loss plays a leading role, and the influence of other factors can differ significantly. Thus, if there is damage to the sensitive zones (perineum and neck), the influence of the painful factor increases, and in the injury of the chest, the patient's condition is aggravated by a violation of the respiratory function and providing the organism with oxygen.
The launcher mechanism of traumatic shock is largely associated with the centralization of blood circulation - a state when the body sends blood to vital organs (easy, heart, liver, brain, etc.), having reducing it from less important organs and tissues (muscles, skin, fatty fiber). The brain receives signals about the lack of blood and reacts to them, stimulating the adrenal glands to throw out adrenaline and norepinephrine. These hormones act on the peripheral vessels, forcing them to narrow them. As a result, blood flows from the limbs and it becomes enough for the work of vital organs.
After some time, the mechanism begins to malfunctions. Due to the lack of oxygen, peripheral vessels are expanding, so blood flows from vital organs. At the same time, due to disorders of the tissue metabolism of peripheral vessels, they cease to respond to signals of the nervous system and the effect of hormones, so the re-narrowing of the vessels does not occur, and the "periphery" turns into a blood depot. Due to the insufficient volume of blood, the work of the heart is disturbed, which further aggravates the circulatory disorders. Arterial pressure drops. With a significant decrease in the blood pressure, the normal operation of the kidneys is disturbed, and a little later - the liver and intestinal wall. From the wall of the intestine to the blood is thrown toxins. The situation is exacerbated due to the occurrence of numerous foci of dead without oxygen of tissues and a coarse metabolic disorder.
Due to the spasm and increasing blood clotting, some of the small vessels are blocked by blood closures. This causes the development of the DVS-syndrome (disseminated intravascular coagulation syndrome), in which blood coagulation is first slowed down, and then almost disappears. When IC-syndrome, bleeding can be resumed at the injury, pathological bleeding occurs, multiple fine hemorrhages appear in the skin and internal organs. All of the above leads to a progressive deterioration of the patient's condition and is caused by death.
There are several classifications of traumatic shock depending on the causes of its development. Thus, in many Russian manuals on traumatology and orthopedics, surgical shock, endotoxin shock, shock due to fragmentation, burn, shock air wave and harness impositions. The classification of VK is widely used. Kulagina, according to which the following types of traumatic shock exist:
- Wounded traumatic shock (resulting from mechanical injury). Depending on the localization of damage, it is divided into visceral, pulmonary, cerebral, during the injury of the limbs, with multiple injury, when squeezing soft tissues.
- Operating traumatic shock.
- Hemorrhagic traumatic shock (developing with internal and outer bleeding).
- Mixed traumatic shock.
Regardless of the causes of the occurrence, traumatic shock flows into two phases: an erectile (the body is trying to compensate for the disorders) and the torpid (compensation capabilities are depleted). Taking into account the severity of the patient's condition in the trapid phase, 4 degrees of shock are distinguished:
- I (Easy). Patient pale, sometimes slightly slowed down. Consciousness is clear. Reflexes are reduced. Dyspnea, pulse up to 100 ot / min.
- II (moderate severity). The patient is sluggish, inhibited. Pulse about 140 Ud / min.
- III (heavy). Consciousness is preserved, the possibility of perception of the surrounding world is lost. Earth-gray leather, lips, nose and tips of the fingers of blue. Sticky sweat. Pulse about 160 Ud / min.
- IV (Predagonia and Agony). Consciousness is absent, the pulse is not determined.
Symptoms of traumatic shock
In the erectile phase, the patient is excited, complains of pain, can shout or moan. He is anxious and scared. Often there is aggression, resistance to examination and treatment. Pale skin, blood pressure is slightly increased. Tachycardia is noted, tachipne (respiratory increase), trembling limbs or minor twitching of individual muscles. Eyes shine, pupils are extended, a restless look. The skin is covered with cold sticky sweat. Rhythmic pulse, body temperature is normal or slightly elevated. At this stage, the organism also compensates for the disorders. Rough violations of the activities of the internal organs are absent, the DVS-syndrome is not.
With the onset of the trapid phase of traumatic shock, the patient becomes apatic, sluggish, drowy and depressive. Despite the fact that pain during this period does not decrease, the patient ceases or almost ceases to signal. He no longer screams and does not complain, it can lie silently, quietly posting, or losing consciousness at all. The reaction is absent even when manipulations in the area of damage. Arterial pressure is gradually decreasing, and the heart rate increases. The pulse on the peripheral arteries weakens, becomes filamentous, and then ceases to be determined.
The eyes of the patient dull, spawned, pupils are extended, the view is still, under the eyes of the shade. There is a pronounced pallor of the skin, cyanoticity of mucous, lips, noses and fingertips. The skin is dry and cold, the elasticity of the fabrics is reduced. Face features pointed, nasolabial folds smoothed. The body temperature is normal or low (it is also possible to increase the temperature due to the wound infection). Patient beats chills even in the warm room. Often, convulsions, involuntary selection of feces and urine, are observed.
Symptoms of intoxication are detected. The patient suffers from thirst, the language is covered, the lips baked, dry. A nausea may be observed, and in severe cases, even vomiting. Due to the progressive disorders of the kidney, the amount of urine decreases even with abundant drink. Watering dark, concentrated, with severe shock can Anuria (complete lack of urine).
Traumatic shock is diagnosed when identifying the corresponding symptoms, the presence of fresh injury or another possible cause of the occurrence of this pathology. To assess the state of the victim, periodic measurements of the pulse and blood pressure produce, laboratory studies are prescribed. The list of diagnostic procedures is determined by the pathological state, which caused the development of traumatic shock.
Treatment of traumatic shock
At the first aid stage, it is necessary to carry out a temporary stopping of bleeding (harness, tight bandage), restore the airways permeability, perform pain relief and immobilization, as well as prevent hypothermia. Move the patient should be very careful to prevent repeatance.
In the hospital at the initial stage, resuscitation-anesthesiologists carry out the suspension of saline (lactasol, ringer solution) and colloidal (REOPOLIGLUKIN, Polyglyukin, gelatinoly, etc.) of solutions. After determining the resume and blood group, the transfusion of these solutions continues in combination with blood and plasma. Provide adequate breathing using ducts, oxygen therapy, trachea intubation or IVL. Continue anesthesia. Perform the catheterization of the bladder to accurately determine the amount of urine.
Operational interventions are carried out according to life indications in the amount necessary to preserve the vital activity and prevent further exacerbation of the shock. Carry out the bleeding and processing of the Russian Academy of Sciences, blockade and immobilization of fractures, elimination of pneumothorax, etc. Assigns hormone therapy, and dehydration, apply drugs to combat brain hypoxia, adjust exchange violations.
Shock is a response of the body to the action of external aggressive stimuli, which may be accompanied by circulatory disorders, metabolism, nervous system, respiration, other vital functions of the body.
There are such reasons for shock:
1. Injuries obtained due to mechanical or chemical impact: burns, breaks, tissue disruption, limb separation, current impact (traumatic shock);
2. Concomprising injury of blood loss in large quantities (hemorrhagic shock);
3. Transfiction with incompatible blood patient in large volume;
4. Hit allergens in a sensitized medium (anaphylactic shock);
5. Necrosis extensive liver, intestines, kidneys, hearts; ischemia.
Diagnose shock in a person who has undergone a shock or injury, on the following signs:
- blurred consciousness with tachycardia;
- reduced blood pressure;
- Violated breathing
- reduced urine allocated;
- Cool and wet skin, marble or pale - cyanotic color
Clinical picture of Shoka
The clinical picture of shock differs depending on the severity of the effect of external stimuli. To correctly assess the state of the person underwent shock, and assistance to shock, several stages of this state should be distinguished:
1. Shock 1 degree. The person retains consciousness, it goes to contact, although the reactions are slightly inhibited. Pulse indicators - 90-100 beats, systolic pressure - 90mm;
2. Shock 2 degrees. The reactions in humans also injected, but he is conscious, correctly answers the asked questions, talking to a muted voice. There is a rapid surface breathing, a frequent pulse (140 beats per minute), the pressure of arterial is reduced to 90-80 mm Hg. The forecast for this shock is serious, the state requires urgent anti-deposit procedures;
3. Shock 3 degrees. In humans, the reactions are inhibited, he does not feel pain and adams. It is spoken by the patient slowly and whisper, may not be responsible for questions in general or one one. Consciousness may be absent completely. Skin covers are pale, with severe acricyanosis, covered later. The pulse near the victim is barely noticeable, it is forgiven only on the femoral and carotid arteries (usually 130-180 ° C. / min). Also observed surface and frequent breathing. Venous central pressure may be lower than zero or zero, and systolic pressure is below 70 mm Hg.
4. Shock 4 degrees are the terminal state of the body, expressed often in irreversible pathological changes - hypoxia tissues, acidosis, intoxication. The patient's condition in such a form of shock is extremely difficult and the forecast is almost always negative. The victim does not listen to the heart, he is unconscious and breathe superficially with sobs and convulsions. There is no reaction to pain, pupils are expanded. In this case, the blood pressure is 50 mm Hg, and may not be determined at all. The pulse is also minority and felt only on the main arteries. Man's skin - gray, with a characteristic marble pattern and stains similar to corpus, indicating the overall decrease in blood flow.
Types of Shock.
The shock state is classified depending on the causes of the shock. So, you can highlight:
- vascular shock (septic, neurogenic, anaphylactic shock);
- hypovolemic (anhydremic and hemorrhagic shock);
- cardiogenic shock;
- pain shock (burn, traumatic shock).
Vascular shock is a shock caused by a decrease in vascular tone. Its subspecies: septic, neurogenic, anaphylactic shock is a state with different pathogenesis. Septic shock arises due to human infection by bacterial infection (sepsis, peritonitis, gangrene process). Neurogenic shock is most often manifested after injury of a dorsal or oblong brain. Anaphylactic shock is an allergic reaction in severe form, which occurs during the first 2-25 minutes. After entering allergen to the body. Substances that can cause anaphylactic shock are plasma and plasma protein preparations, x-ray and anesthetics, other drugs.
The hypovolemic shock is caused by a sharp circulating blood deficiency, a secondary decrease in the emission of the heart, a decrease in the venous return to the heart. This shock state occurs during dehydration, loss of plasma (anhydremic shock) and blood loss - hemorrhagic shock.
Cardiogenic shock is an extremely severe condition of the heart and vessels characterized by high mortality (from 50 to 90%), and the coming due to a serious circulatory disorder. With a cardiogenic shock of the brain due to the lack of blood supply (impaired heart work, extended vessels, unable to hold blood), is experiencing a sharp lack of oxygen. Therefore, a person who is in a state of cardiogenic shock loses consciousness and most often dies.
Pain shock, as well as cardiogenic, anaphylactic shock - a common shock state arising from acute reaction to the injury (traumatic shock) or burn. Moreover, it is important to understand that the burn and traumatic shock is a variety of shock hypovolemic, because their cause is the loss of a large amount of plasma or blood (hemorrhagic shock). These may be internal and external bleeding, as well as the exudation of the plasma fluid through the baked areas of the skin during burns.
Help with shock
Helping assistance in shock It is important to understand that it is often the cause of late shock states is the wrong transportation of the victim and the provision of first aid with a shock, so the conduct of elementary rescue procedures before the arrival of the ambulance brigade is very important.
Help with shock is the following events:
1. eliminate the cause of the shock, for example, to stop the bleeding, release the cropped limbs, repay the burning clothes on the affected;
2. Check the availability of foreign items in the mouth and the nose of the victim, if necessary, remove them;
3. Check the availability of breathing, pulse, and, if necessary, carry out a heart massage, artificial respiration;
4. To follow, so that the victim lay his head on the side, so he will not choke by his own vomit, he does not stock language;
5. Install, whether the victim is in consciousness, and give it an anesthetic. It is advisable to give a patient with hot tea, but to exclude the wound of the abdomen before that;
6. Loosen clothes on the belt, chest, neck of the victim;
7. The patient must be warm or cool depending on the season;
8. The victim cannot be left alone, he can not smoke. Also, it is impossible to apply injured places to the heating places - it can provoke blood outflow from the vital organs.
Video from YouTube on the subject of Articles:Anaphylactic shock:
The hardest manifestation of an allergic reaction threatening life.Anaphylaxis
- A fast-growing allergic reaction, threatening life, often manifests itself in the form of anaphylactic shock. Literally the term "anaphylaxis" translates "against immunity". From Greek "and" -
against and "Philaxis "-
Protection or immunity. The term is first mentioned over 4,000 years ago.
- The frequency of cases of anaphylactic reactions per year in Europe 1-3 cases per 10,000 population, mortality up to 2% among all patients with anaphilaxia.
- In Russia, from all anaphylactic reactions, 4.4% is manifested by anaphylactic shock.
What is allergen ?Allergen
- This substance is mainly protein that provokes the development of an allergic reaction.
Allocate various types of allergens:
- Inhalation (aero allergens) or those that fall into the body through the respiratory tract (pollen of plants, spores of mold mushrooms, home dust, etc.);
- Food (eggs, honey, nuts, etc.);
- Insequent or allergens of insects (cockroaches, mole, moth flies, beetles, etc., are particularly dangerous allergens contained in the poison and saliva insects, such as bees, wasps, and scrutiny.);
- Allergens of animals (cats, dogs, etc.);
- Medicinal allergens (antibiotics, anesthetics, etc.);
- Professional allergens (woody, grain dust, nickel salt, formaldehyde and mn. Dr.).
Immunity condition for allergies
The state of immunity plays a decisive role in the development of an allergic reaction. In allergy, the immune function of the body has increased activity. What is manifested by an excessive reaction to enter the alien substance. Such violations in the work of the immune system are caused by a number of factors, ranging from genetic susceptibility, ending with environmental factors (contaminated ecology, etc.). An important meaning in violation of the work of the immune system has psycho-emotional conflicts, both with surrounding people and with themselves. According to psychosomatics (direction, in medicine, the influence of psychological factors on the development of diseases), allergies arise from those people who are not satisfied with the circumstances of their lives, and do not allow themselves to protest. They are forced to endure everything in themselves. They do what they do not want to force themselves to unloved but necessary affairs.
Anaphylaxia development mechanism
To understand the mechanism of development of anaphylactic shock, it is necessary to consider the main points of the development of allergic reactions.
The development of an allergic reaction can be divided into several stages:
- Sensitization or allergyization of the body. The process in which the body becomes very sensitive to the perception of a substance (allergen) and with a re-entering of such a substance in the body arises an allergic reaction. When for the first time allergen enters the body the immune system, it is recognized as an alien substance and specific proteins (immunoglobulins E, G) are produced. Which are subsequently fixed on immune cells (fat cells). Thus, after the production of such proteins, the organism becomes sensitized. That is, when allergen hit the body, an allergic reaction will occur. Sensitization or body allergyization is the result of a malfunction of the normal operation of the immune system caused by various factors. Such factors may be hereditary predisposition, long-term contact with allergen, stressful situations, etc.
- Allergic reaction. When the allergen enters the body for the second time, immune cells are immediately met, on which there are already early educated specific proteins (receptors). After contact of the allergen with such a receptor, there is an emissions from the immune cell of particular substances that run allergic reaction. One of these substances is histamine - the main substance of allergies and inflammation, which causes the extension of vessels, itching, swelling subsequently disruption of respiration, reduced blood pressure. With anaphylactic shock, the release of such substances is massive, which significantly violates the work of vital organs and systems. Such a process with anaphylactic shock without timely medical intervention is irreversible and leads to the death of the body.
Risk factors for the development of anaphylactic shock
- Age. In adults, anaphylactic reactions are more often developing on antibiotics, other medicines (anesthetics, plasma components) and beyl bites. Children are more likely to food products.
- Floor. In women, anaphylaxis is more often developed when taking Aspirin, contact with latex. Men more often anaphylaxis occurs with the bite of refamped panels (bees, wasps, hornets).
- The presence of allergic diseases (Atopic dermatitis, allergic rhinitis, etc.).
- Socio-economic status. Surprisingly, the risk of an anaphylactic reaction is higher in people with high socio-economic status.
- The development of anaphylaxis during intravenous administration of drugs is heavier than when drug use inside.
- The severity of the anaphylactic reaction affects the duration and frequency of contact with the allergen.
- The severity of anaphylactic shock can be determined by the onset of the first symptoms. The earlier the beginning of the symptoms from the moment of contact with the allergen, the harder the allergic reaction will occur.
- The presence in the life of episodes of anaphylactic reactions.
Causes of anaphylactic shock1. Drugs
- Most often anaphylaxis arises for the introduction Penicillina and other beta-lactam antibiotics (aminoglycosides, metranasal, trimethoprim, vancomycin). It is worth noting that Penicillin may be present as a pollutant in food, milk, frozen meat. Even a slight amount of penicillin in products can cause an allergic reaction.
- In second place in the frequency of the anaphylaxis, it is worth receiving Aspirin and other non-steroidal anti-inflammatory funds (NSAIDs).
- Also, the high frequency of the development of anaphylactic shock remains when using muscle relaxants (drugs relaxing), especially during operations and other surgical interventions. In addition, muscle relaxants are found in some food products, as well as part of certain cosmetics.
- It is possible to develop anaphylaxis when using anesthetics, which is more often due to operational interventions or in dental offices.
- The development of anaphylactic shock often occurs when the bite of bees, OS, especially if there are many bites at the same time. In addition, there are cases of anaphylaxis development when carrying out the so-called apitherapy, where they produce intentional slips in the bees of the pounds of patients of the body.
- The most often the anaphylactic reactions cause the following products: peanuts, nuts, fish, mollusks. Children more often cow milk, eggs, soy. Sometimes for the development of an anaphylactic reaction and allergen micrograms. In rare cases, even nutritional supplements are able to cause anaphylactic shock.
- Sometimes an anaphylactic reaction can be caused by not the product itself and not food additives, but parasites located in the product. For example: Parasites of fish (Anisakis Simplex) may cause severe anaphylactic reaction.
- The development of an anaphylactic reaction when allergen hitting allergen through the respiratory tract arises very rarely. However, in the season of dusting in patients with high sensitivity to pollen, anaphylaxis is possible.
- Cases of development of heavy allergic reactions to the introduction of vaccines from influenza, measles, rubella, tetanus, parotitis, cough are described. It is assumed that the development of reactions is associated with vaccine components, such as gelatin, neomycin.
- The cause of anaphylactic shock can be blood transfusion, but such reactions are very rare.
- Anaphylaxis caused by exercise is a rare form of anaphylactic reactions and is 2 types. The first, in which anaphylaxis occurs due to the physical activity and consumption of food or medicines. The second form occurs during exercise, regardless of food eating.
- Anaphylaxis can be a manifestation of a special disease - System Mastocytosis . The disease in which an excess amount of specific immune cells (fat cells) is formed in the body. Such cells contain a large number of biologically active substances capable of causing an allergic reaction. A number of factors as an intake of alcohol, drugs, food products, bees bites can lead to the emission of these substances from cells and cause a heavy anaphylactic reaction.
Symptoms of anaphylactic shock, photo
The first symptoms of anaphylaxis usually appear 5-30 minutes after intravenous or intramuscular admission of allergen or a few minutes to 1 hour when allergen hits the mouth. Sometimes anaphylactic shock can develop within a few seconds or arose several hours later (very rarely). It should be known that the earlier the beginning of an anaphylactic reaction after contact with the allergen, the harder it will be.
|The first signs of anaphylactic shock described by patients is:||A photo|
|Organs and systems||Symptoms and their description||A photo|
|Leather and mucous membranes||The heat, itching, rashes in the form of urticaria often arise on the skin of the inner surface of the hips, palms, soles. However, rashes may occur in any area of the body. Edema in the area of the face, neck (lips, eyelids, larynx), edema of genitalia and / or lower extremities. With a rapidly developing anaphylactic shock, skin manifestations may be absent or later. 90% of the anaphylactic reactions are accompanied by urticule and edema.|
|Respiratory system||Nasal congestion, mucous discharge from the nose, wheezes, cough, feeling of edema of the throat, difficulty breathing, witness voice. These symptoms are found in 50% of patients with anaphilaxia.|
|The cardiovascular system||Weakness, dizziness, decrease in blood pressure, pulse, chest pain, is possible loss of consciousness. The damage to the cardiovascular system is found in 30-35% of patients with anaphylactic shock.|
|Gastrointestinal||Disorders of swallowing, nausea, vomiting, diarrhea, intestinal spasms, pain in the abdomen. Violations of the GTS are found in 25-30% of patients with anaphylactic shock.|
|central nervous system||Headache, weakness, fog before eyes, cramps are possible.|
In which forms is the anaphylactic shock more often develop?
|The form||Development mechanism||External manifestations|
|Typical (most frequent)||Finding into the body of the allergens, a number of immune processes are launched, as a result of which a large number of biologically active substances (histamine, bradykin, etc.) are thrown into the blood. Mainly, it leads to the expansion of blood vessels, a decrease in blood pressure, spasm and respiratory tract. Violations rapidly increase and lead to a change in the work of all organs and systems. At the beginning of the anaphylaxis, the patient feels the heat in the body, the rashes and itching of the skin, there are edema in the field of the neck of the neck, dizziness appears, noise in the ears, nausea, difficulty breathing, the drop in blood pressure leads to a violation of consciousness, cramps are possible. Reduced pressure down to 0-10 mm.rt.st. All these symptoms are accompanied by fear of death.|
|Asphyxic form (shape with a predominance of respiratory disruption)||With this form of anaphylaxis, the symptoms of respiratory disorders come to the fore. After the allergen hit, the body feels nasal congestion, cough appears, witness voice, wheezing, feeling of edema of the throat, difficulty breathing. The spasm of larynx, bronchi, pulmonary swelling and respiratory failure increases. If during the not to take measures the patient dies from choking.|
|Gastrointestinal||With this form, the main manifestations of anaphylaxis, there will be pain in the abdomen, vomiting, diarrhea. The precursor of such a reaction may be a moletory cavity, lip edema and language. Pressure is usually not lower than 70/30 mm.rt.st.|
|Brain form||In a brain form of anaphylaxis in the picture of the manifestation of the disease, violations of the central nervous system prevail, a violation of consciousness, convulsions against the background of brain edema.|
|Anaphylaxis caused by exercise||Both separately physical activity and its combination with preliminary intake of food or medicines can cause the launch of an anaphylactic reaction up to an anaphylactic shock. It is often manifested by itching, heat, redness, urticaria, edema in the face, neck, with further progression, the gastrointestinal tract, the respiratory system is involved, there is a larynx swelling, blood pressure is sharply reduced.|
How to determine the severity of anaphylactic shock?
|Criterion||1 degree||2 degree||3 degree||4 degree|
|Arterial pressure||Below the norm by 30-40 mm.rt.st (norm 110-120 / 70-90 mm.rt.st||90-60 / 40 mm.rt and below||Systolic 60-40 mm.T.Te, diastolic can not be determined.||Not determined|
|Consciousness||In consciousness, anxiety, excitement, fear of death.||Stunning, it is possible to loss of consciousness||Possible loss of consciousness||Immediate loss of consciousness|
|Effect of anti-shock therapy||Good||Good||Treatment is little effectively||Practically absent|
First emergency care for anaphylactic shock
- Do I need to call an ambulance?
The first thing at the first signs of anaphylactic shock should be an ambulance. It should be considered the fact that there is a two-phase anaphylactic reaction. When after the resolution of the first episode of the anaphylactic reaction, in 1-72 hours the second occurs. The probability of such reactions is 20% of all patients with anaphylactic shock.Indications for hospitalization
: Absolute, with anaphylactic shock of any degree of severity.
- How to help up ambulance?
- First of all, it is necessary to remove the source of the allergen. For example, remove the sting of an insect or stop the introduction of the drug.
- The patient must be put on the back and raise his legs.
- It should be checked by the patient's consciousness, whether the questions are responsible for questions, it reacts to mechanical irritation.
- Release the respiratory tract. Rotate the head of the side and remove the mouth, mucus, foreign bodies, pull out the language (if the patient is unconscious). Next you need to make sure that the patient breathes.
- In the absence of breathing and pulse, start cardiovascular resuscitation. However, in the case of strong edema and spasm of the respiratory tract, the pulmonary ventilation before the administration of adrenaline may not be effective. Therefore, in such cases, only the indirect heart massage is applied. In the event of a pulse, the indirect heart massage is not held!
|2 inhale 30 presses on the chest, such an alternation of action during cardiopulmonary resuscitation. However, unprepared eyewitnesses can only produce an indirect heart massage until the ambulance arrival.|
- In emergency situations for opening the respiratory tract, puncture or incision of the pisteless ligament is carried out.
- In addition, if possible, arterial pressure and pulse should be measured, this will give information about the severity of the flow of anaphylactic shock. In severe cases, the pressure drops to 0-10 mm.rt.st, the pulse is frequent, barely provers, but with the timely use of medicines, everything is reversible.
Application of medicines
Three major medications that will help save your life!
At the very first symptoms of anaphylaxis, it is necessary to introduce intramuscularly 0.3 ml of 0.1% epinephrine (adrenaline), 60 mg of prednisolone or 8 mg of dexamethasone, antihistamines (suprastin, etc.).
|Preparations||In which cases to apply?||How and how much to enter?||Effects|
|Adrenalin 1 ampoule - 1 ml-0.1%||Anaphylaxis, anaphylactic shock, allergic reactions of various types, etc.||Anaphylaxis: Enter adrenaline follows at the first symptoms of anaphylaxis! In any place intramuscularly, it is possible even through clothes (preferably in the middle part of the hip from the outside or the deltoid muscle). Adults: 0.1% of the decrease of adrenaline 0.3-0.5 ml. Children: 0.1% solution of 0.01 mg / kg or 0.1-0.3 ml. With a pronounced respiratory impairment and a sharp drop in blood pressure, it is possible to enter a tongue of 0.5 ml - 0.1%, in this case the absorption of the drug occurs much faster. If there is no effect, the administration of adrenaline can be repeated every 5-10-15 minutes depending on the state of the patient. With anaphylactic shock: Doses of administration: 3-5 μg / min, for an adult 70-80 kg, to obtain an integrated effect. After administration, adrenaline is preserved in the bloodstream only 3-5 minutes. It is better to introduce the drug in the solution of intravenously drip (30-60 drops in min.): 1 ml of 0.1% Р-RA adrenaline, diluted in 0.4 liters of isotonic NaCl. Or 0.5 ml of 0.1% of the adrenaline rally, diluted with 0.02 ml of isotonic NaCl and introduce intravenously in 0.2-1 ml in an interval of 30-60 seconds. It is possible to introduce adrenaline directly into the trachea if impossible to introduce intravenously.|| |
|Syringe - pen (EPI PEN) - containing a one-time adrenaline dose (0.15-0.3 mg). The handle is created for the convenience of administration.||Anaphylaxis, anaphylactic shock.||One time is introduced into the middle part of the thigh.||See adrenaline|
|Allerjet. - Devices for administering adrenaline, containing sound instructions for use.||Anaphylaxis, anaphylactic shock.||One time is introduced into the middle part of the thigh. Fig.20||See adrenaline|
Allerjet - video Instruction :
|Hormones (hydrocortisone, prednisone, dexamethasone)||Anaphylaxis, anaphylactic shock. Allergic reactions of various types.||Hydrotisut : 0.1-1 g intravenously or intramuscularly. Children 0.01-0.1g intravenously. Dexamethasone (ampoule 1ml-4mg): Intramuscularly 4-32 mg, with a shock of 20 mg intravenously, then 3mg / kg at 24 hours. Tablets (0.5 mg) to 10-15 mg per day. Tablets: Prednisolon (5mg) 4-6 tablets, as much as possible to 100 mg per day. With anaphylactic shock 5 ampoules of 30 mg (150 mg). If it is impossible to introduce intravenously or intramuscularly, you can pour the contents of the ampoule under the tongue, holding some time until the drug sends. The effect of the drug occurs very quickly, as the drug, sucking through the sub-speaking veins, passes the liver and comes directly to vital organs.|| |
|Antihistamines||Allergic reactions of various types.||Cleptine (Tueva) - intramuscularly, 1ml- 0.1%; Supratine- 2ml-2%; DIMEDROL-1ML-1%; The combined assignment of antihistamine drugs H1 and H2-blockers gives a more pronounced effect, for example diphenhydramine and ranitidine. Preferably intravenous administration. With a slight course of anaphylaxis, you can in the form of tablets. H1 - histaginoblocators: Loratadine - 10mg cetirizin -20 mg Ebastin 10 mg Supratine 50 mg H2-histaginoblocators: Famotidin -20-40 mg Ranitidine 150-300 mg|| |
|Preparations restoring respiratory tract (Ehufillin, albuterol, metaproterol)||Pronounced bronchospasm, respiratory disorder.||Eufillin - 2.4% - 5-10 ml., Intravenously. Albuterol - intravenously for 2-5 minutes by 0.25 mg, if necessary, repeat every 15-30 minutes. If it is impossible to introduce intravenous, salbutamol in the form of an aerosol, inhalation administration.||Expansion of the respiratory tract (bronchus, bronchiole);|
How to ensure the passability of the respiratory tract at the swelling of the larynx?
In the case when breathing is impossible because of the edema of the upper respiratory tract, and the medication therapy did not help or simply do not have it, an emergency puncture (puncture) of a cryoticoidal (pisteless-shaped) bundle should be performed. This manipulation will help win the time before the arrival of specialized medical care and save lives. The puncture is a temporary measure that can provide adequate air intake into the lungs only for 30-40 minutes.Execution technique:
- Determination of an individual ligament or membrane. To do this, moving the finger through the front surface of the neck, the thyroid cartilage is determined (in men Adamovo apple), immediately under it is a desired bunch. Below the ligament is determined by another cartilage (pispene), it is located in the form of a dense ring. Thus, between two cartilage, thyroid and robust, there is a space through which it is possible to provide emergency air access to the easy. In women, this space is more convenient to determine, moving upwards at the bottom, first finding the pisteless cartilage.
- The puncture or puncture is carried out by being at hand Ideally, this is a wide puncture needle with a trocar, however, in an emergency, you can use the puncture of 5-6 needles with a big lumen or make a cross-section of the ligament. Punch, incision is performed from top to bottom at an angle of 45 degrees. The needle introduces that moment when the ability to draw air or the feeling of the failure in the syringe during the needle progress. All manipulations should be made by sterile instruments, in the absence of those sterilized on fire. The surface of the puncture should be previously treated with antiseptic, alcohol.
Treatment in hospital
Hospitalization is carried out in the intensive care unit.
The basic principles of the treatment of anaphylactic shock in hospital conditions:
- Elimination of Contact with Allergen
- Treatment of acute violations of the work of blood circulation, respiration and central nervous system. To do this, the introduction of epinephrine (adrenaline) is used 0.2 ml 0.1% with an interval of 10-15 minutes intramuscularly, if there is no response, then the drug is administered intravenously (0.1 mg in dilution 1: 1000 in 10 ml NaCl).
- Neutralization and stopping of biologically active substances (histamine, kallikrein, bradyikinin, etc.). Glucocorticoid agents (prednisolone, dexamethasone) and antihistamine Blocators N1 and H2 receptors (Supratine, Ranitidine, etc.) are introduced.
- Disinfection of the body and the replenishment of the volume of circulating blood. For this, the solutions are injected with fraud, reopolyugulukin, isotonic solution NaCl B, etc.).
- According to the testimony, the means eliminating the spasm of the respiratory tract (Ehufillin, aminoophyllin, albuterol, metaproterol), for convulsions, anticonvulsant drugs, etc.
- Maintaining vital functions of the body, resuscitation actions. Dopamine, 400 mg in 500 ml of 5% declaration solution intravenously is used to support the pressure and pump function of the heart. If necessary, the patient is transferred to the apparatus of artificial respiration.
- All patients who have suffered an anaphylactic shock are recommended to be under the supervision of a doctor at least 14-21 days, since it is possible to develop complications from the cardiovascular and urinary system.
- Be sure to conduct a general blood test, urine, ECG.
Prevention of anaphylactic shock
- Always have the necessary medicines at hand. Be able to use the automatic injector to introduce adrenaline (Epi-Pen, Allerjet).
- Try to avoid insect bites (do not wear bright clothes, do not use spirits, do not drink mature fruits on the street).
- Learn correctly, evaluate information about the components of the purchased products to avoid contact with allergens.
- If you have to eat outside the house, the patient must make sure that the dishes do not contain allergens.
- In production, contact with inhalation tons of skin allergens should be avoided.
- Patients with severe anaphylactic reaction should not be used by beta-blockers, and if necessary, must be replaced by drugs of another group.
- During diagnostic studies, radiopatruts are needed by preliminary administration of prednisolone or dexamethasone, diphenhydramina, ranitidine
Acutely developing, threatening the life pathological process, due to the effect on the body of a superproof irritant and characterized by severe violations of the activity of the central nervous system, blood circulation, respiration and metabolism (for example, pain shock).
General ideas about shock, types of shock and methods for treating shock states
Shock is defined as a state of extreme reduction in blood pressure, accompanied by a decrease in oxygen inflow to tissues and accumulation of final metabolic products. Depending on the cause of the cause, the first aid will be different and the tactics of first aid will be different, but in any case the resuscitation algorithm will require rapid accurate accurate actions. What types of shock exist and what can be done for the victim before the arrival of emergency medical care - Medaboutme will tell you about it.
Shock: Symptoms and Manifestations
The shock understands such a pathological condition, which is a consequence of decompensation of body protective systems in response to a powerful irritant factor. In fact, the human body can no longer cope with the pathological process (whether intensive pain or allergic reaction) and decompensation reaction affecting the nervous, cardiovascular, hormonal system develops. It is believed that for the first time, this condition was described by a great antique hypocratic doctor, but the term "shock" himself was proposed only in the XVIII century. From this time, the active scientific study of the shock state begins, theories that explain the development and action of shock are proposed, methods of treatment of shock are being developed.
At the moment, shock is considered within the framework of adaptation syndrome, which includes 3 stages:
After the impact of an aggressive irritant factor, the body maintains the ability to cope with the changing conditions. Perfusion (blood flow) in vital organs (brain, heart, kidneys) is maintained in sufficient volume. This stage is completely reversible.
After the impact of an aggressive irritant factor, the body already loses the ability to cope with the changing conditions. Perfusion (blood flow) in vital organs is progressively declining. This stage without timely intensive treatment is irreversible.
At this stage, even intensive therapy is not able to restore the activity of vital organs. The development of the terminal stage leads to the death of the body.
The symptoms of the shock include:
- Reduced arterial pressure
- Heart palpitations
- Reducing the selection of urine (up to its complete absence)
- Violation of the level of consciousness (characterized by a change in the period of excitation by a period of inhibition)
- Centralization of blood circulation (decrease in temperature, pallor of skin, weakness)
Types of Shock.
There are several classifications of the shock state, depending on the factors of its causing, such as hemodynamic disorders, clinical manifestations.
In more detail, we will look at all types of shock in specially designated paragraphs, here we will try to bring a general classification.
Classification by the type of hemodynamic disorders
Reduced pressure by reducing the volume of circulating blood. The reason may be: blood loss, burns, dehydration.
The heart is not able to adequately shrink and maintain a sufficient level of pressure and perfusion. The reason may be: heart failure, myocardial infarction, arrhythmia.
Reduced pressure by expanding the vascular bed with a constant amount of circulating blood. The reason may be: toxic poisoning, anaphylaxis, sepsis.
The reason may be: pulmonary artery thromboembolism, intense pneumothorax.
Acute hypoxia due to the violation of the hemoglobin structure. The reason can be: carbon monoxide poisoning
Classification by pathogenesis
- Hypovolemic shock
- Cardiogenic shock
- Neurogenic shock (damage to the nervous system, leading to the expansion of the vascular channel, as a rule, is a spinal injury)
- Anaphylactic shock (acute progressive allergic reaction)
- Traumatic shock
- Septic shock
- Infectious-toxic shock
- Combined shock (comprehensive reaction, including various pathogenesis of shock status)
The patient is conscious, the pulse is a bit more participated (~ 100 shots per minute), the pressure is slightly reduced (systolic not less than 90 mm.rt.st.), weakness, light inhibition.
The patient in consciousness, stunned, badly, the weakness is growing, the skin is pale. The frequency of heart abbreviations (up to 130 per minute) is growing, pressure drops (systolic not less than 80 mm.rt.st.), the pulse is weak. Correction of the state requires medical intervention, intensive therapy.
The patient is controlled, the consciousness is broken, the skin is pale. The pulse of the weak filling "thread-shaped" over 140 beats per minute, the blood pressure is resolved (systolic less than 70 mm.T.). Violation of urine release (up to the complete absence). The forecast without adequate therapy is unfavorable.
The level of consciousness of the patient - coma. The pulse on the peripheral arteries is not determined, blood pressure may also not be determined or is at a very low level (systolic less than 40 mm.rt.st.). No urine release. Reflexes and reactions to pain are not traced. Breathing is barely noticeable, neulty. The forecast for life in such a situation is extremely unfavorable, intensive therapy does not lead to a positive effect.
One of the most Grozny complications of allergic reactions is anaphylactic shock. It proceeds as the hypersensitivity of the immediate type and is a life-in-law. The rate of development of anaphylactic shock is quite high and ranges from a few seconds to several hours after reaction with an allergen. Any substance can act as an allergen, but most often these are medicines, food, chemicals, poisons. With a primary meeting of the body with an allergen, anaphylactic shock does not develop, but the sensitivity to this allergen increases sharply in the body. And during a re-meeting the body with an allergen, anaphylactic shock is possible.
Clinical symptoms of anaphylactic shock Next:
- A pronounced local reaction, accompanied by extensive swelling, pain, increasing temperature, redness, rash
- Itching that can take generalized
- Full blood pressure and pulse
- Quite often arises extensive respiratory edema, which can lead to patient death
With anaphylactic shock, first aid includes:
- Call an ambulance
- Tradition to the patient's horizontal position with raised legs
- Provide the influx of fresh air to the room, unzipped clothes, free the cavity of the mouth from foreign objects (chewing, dentures)
- If the anaphylactic shock developed in response to the bite of an insect or injection of the drug, then it is necessary to apply ice to the bite, and above the bite to impose a harness.
A quick medical team has drugs for the treatment of anaphylactic shock and may emerge to hospitalize the patient in the hospital.
At the stage of medical care, adrenaline is introduced, which quickly narrows the vessels and expands bronchi, increases blood pressure. Prednisolone is also introduced, which contributes to the active regression of an allergic reaction. Antihistamines (Dimedrol, Tuegyl) are antagonists of histamine, which underlies an allergic reaction. Isotonic solution is injected intravenously. Inhalation of oxygen. Symptomatic therapy is carried out. In some cases, the trachea intubation is required, with a pronounced larynx swelling, tracheostomas are performed.
As measures for the prevention of anaphylactic shock, those medicinal or food allergens should be avoided, which can provoke a shock state. In the house it is advisable to have a first-aid kit for emergency assistance, including adrenaline, prednisone or dexamethasone, isotonic solution, diphroll, eufillin, syringes and droppers, alcohol, bandage and harness.
The rapid drop in blood pressure in response to the toxins allocated by bacteria is called infectious-toxic shock. The risk group includes diseases caused by kokkoy microorganisms: pneumonia, tonsillitis, sepsis, etc. Particularly often infectious toxic shock develops against the background of reduced immunity with HIV infection, diabetes mellitus.
The main symptoms of infectious-toxic shock:
- Fever (above 390s)
- Reduced blood pressure (systolic below 90 mm.rt.)
- Violation of consciousness (depends on the severity of shock)
- Polyorgan insufficiency
Treatment of infectious-toxic shock includes:
- Treatment is carried out under the conditions of the resuscitation department
- Appointment of antibiotics (cephalosporins, aminoglycosides)
- Corticosteroid preparations (prednisolone, dexamethasone)
- Massive infusion therapy
- Heparin (the prevention of thrombosis)
- Symptomatic therapy
Infectious-toxic shock is a serious disease with a high degree of mortality, requiring immediate medical care. Also, at this type of shock there is a risk of developing the following complications:
- Syndrome in DVS (violation of the coagulation system)
- Polyorgan deficiency (renal, pulmonary, cardiac, hepatic)
- Recurner of infectious toxic shock
The forecast of the disease is relatively favorable upon the condition of timely complex treatment.
Under the cardiogenic shock, the state of dysfunction of the pump function of the left ventricle of the heart, leading to a resistant reduction in blood pressure, hypoxia and microcirculation disorders in organs and tissues. The causes of the cardiogenic shock are: arrhythmias, severe injuries of the heart muscle, leading to a violation of its integrity, acute myocardial infarction.
Several subspecies of cardiogenic shock are isolated:
Cardiogenic shock, symptoms:
- Resistant hypotension against the background of heart pathology (systolic pressure is maintained at less than 90mm.rt.st.)
- Tachycardia or bradycardia (depending on the severity of shock)
- Circulatory Centralization (Pale and Cool To Skin Skin Covers)
- Reducing urinary release
- Violation of consciousness (up to complete loss)
The severity of the manifestation of certain symptoms of cardiogenic shock on the part of the patient is influenced by the age, the presence of related pathologies, the duration of the shock, the nature and volume of the damage to the heart muscle, the timeliness of the provision of medical care.
True cardiogenic shock
The reason for this state is the death of at least 40% of the cardiomyocytes of the left ventricle of the heart. Forecast with such a type of shock is unfavorable. The remaining capable cardiomyocytes are not able to provide adequate contractual activity of the heart, leading to distinct heavy clinical manifestations of cardiogenic shock. Compensatory mechanisms for supporting blood pressure (through renin-angenetenzine-aldosterone, corticoid, sympathetic and adrenal system) are not able to compensate for the hypotension in full. There is a spasm of the vascular bed and hypercoagulation, leading to the DVS syndrome.
The reflex cardiogenic shock develops by the type of heart response to the pain caused by myocardial infarction (especially the heart attack of the back wall of the heart). The reason for the development of pathology is precisely the reflex mechanism, and not the scope of the heart muscle damage. As a reflex on pain occurs a violation of the tone of blood vessels, a decrease in blood flow to the left ventricle of the heart and as a result, a decrease in the blood volume emitted by heart. With this type of shock, the forecast is favorable, it is borne by the appointment of analgesics and infusion therapy.
Groundmogenic shock is formed due to arrhythmias and blockades of conductive pathways. The prognosis is favorable, the shock condition is fastened with the timely treatment of a heart rhythm. Grotter tachycardia, Av-blockade 2-3 degrees can lead to arrhythmogenic shock.
Hypovolemic shock develops due to a sharp decline in circulating blood. The causes of this state may come:
- Blood loss as a result of injury of trunk vessels, extensive fractures, during operational benefits, etc.
- Non-corrosive vomiting in disorders of the water and electrolyte balance
- Abundant diarrhea for some infectious diseases
- Extensive burns
- Intestinal obstruction
The degree of clinical manifestations of hypovolemic shock directly depends on the amount of lost fluid (or circulating blood volume):
As such, there are no shock symptoms, however, an insignificant thirst may be present and some increase in the pulse by 10-20 blows per minute compared with the individual norm. The state is compensated by internal reserves of the body
The feeling of thirst increases, the blood pressure decreases and the pulse rate is growing. Vertical position is felt dizziness.
Persistent hypotension (systolic pressure of 90 mm.T. and below), the pulse frequency exceeds 110 beats per minute. There is a pronounced weakness, the pallor of the skin, the selection of urine is reduced.
Violation of the level of consciousness, the pronounced pallor of the skin, the pulse on the periphery may not be felt, resistant hypotension, no urine. This condition can threaten the health and life of the patient, the intensive correction of hypovolemia is needed.
The treatment of hypovolemic shock directly proceeds from the cause of it causing. If it is bleeding, it is necessary to stop bleeding, if the infectious process is antibacterial therapy, intestinal obstruction is allowed to be operative. In addition, at all stages of treatment it is necessary to carry out massive infusion therapy in order to correct the water and electrolyte balance. For this purpose, central venous access is performed (for example, the connective vein cathetterized). Transfusion of donor blood and plasma has proven itself as a method for treating hypovolemic shock, especially in the case of a decrease in the level of hemoglobin and protein. With timely, the causes of the hypovolemic shock and the normalization of the water-electrolyte balance prediction for the patient is favorable.
Other reasons for shock
As mentioned above, the shock can also be caused by carbon monoxide poisoning. The thing is that the carbon monoxide has the ability to integrate into the hemoglobin molecule and impede oxygen transport to organs and tissues. Durchable gas is formed as a result of combustion with limited oxygen access. Such a situation occurs during fires in closed rooms. Clinical manifestations directly depend on the concentration of carbon monoxide in the air and the duration of its inhalation. The main symptoms are as follows:
- Dizziness, weakness
- Violation of consciousness
- Increased blood pressure and pulse frequency
- Nausea, vomiting
- Redness of the skin and mucous
- Convulsive syndrome
Despite the fact that blood pressure increases, hypoxia is growing in the body due to the disorder of oxygen transport to tissues. Carbon monoxide poisoning is the main cause of fire mortality. It should be remembered that the filter gas for protection against carbon monoxide should be equipped with hypocalet cartridge.
To prevent the development of shock caused by carbon monoxide poisoning, the victim is necessary:
- Remove from the focus of the propagation of carbon monoxide
- Provide access to fresh air, put the oxygen mask
- There is a special antidote from carbon monoxide "Atzizol". This drug is also possible to apply as a means of preventing carbon monoxide poisoning.
With a mild degree of poisoning of these measures, it is quite enough, but in any case it is advisable to consult a doctor. Additional methods of treatment and prophylaxis include hyperbaric oxygenation, ultraviolet irradiation, symptomatic therapy. To prevent the development of inflammatory diseases of the upper respiratory tract, it is advisable to appoint antibiotics.
Action of shock on internal organs
The effect of shock on the internal organs occurs due to a number of factors. These include decrease in blood pressure, insufficient blood supply, perfusion, organs and tissues, hypoxia, edema, disruption of acid-alkaline and water and electrolyte balance.
Each type of shock state has its own individual pathogenesis mechanisms, but in general, any shock leads to the development of hypoxia against the background of inadequate microcirculation, which is the cause of polyorgan deficiency. The effect of shock is the more dangerous than the less resistant organ to hypoxia.
For example, the brain is most sensitive to the deficiency of oxygen and suffers first in the occurrence of a shock state. This is manifested by dizziness, headache, drowsiness, intensity. Shock symptoms are progressing according to the severity of the patient's condition and may be accompanied by the loss of consciousness and the oppression of reflex activity.
The effect of shock on the internal organs has not only physiological, but also morphological character. So, if the cause of the patient's death was shock, then this condition will directly affect the internal organs. There is even a special concept of a "shock body", characterizing morphological changes that have arisen in a particular organ.
Against the background of the shock, the selection of urine is reduced, up to its complete absence, protein and erythrocytes can be observed in the urine. In the blood, the content of urea and creatinine increases. On the section, the cortical layer of such kidneys looks pale and edema. Pyramids are brown. Under the microscope, the anemia of the cortical zone, necrosis of the epithelium of the convulsion canal, swelling the interstice.
This condition is often accompanied by the development of a shock kidney within the framework of polyorganic insufficiency syndrome and is developing, as a rule, in the phase of decompensation of shock. Hepatic enzymes are growing in the blood. On the sections, the liver has a pale, yellowish tint. There is no glycogen in hepatocytes. Due to hypoxia, necrosis occurs in the central part of hepatic lobes.
In clinical literature, this condition is called a "respiratory distress of adult syndrome." Easy is notometricly filled with blood, essay is developing, multiple necrosis of lung tissue, hemorrhage form. When developing shock lungs, pneumonia always joins.
Hypoxia phenomena is also distinctly expressed in the heart. Muscular heart cells are deprived of glycogen, they develop dystrophy phenomena, lipid accumulation, necrosis foci are formed.
Multiple hemorrhages are observed in the intestines, the area of ulceration is formed in the layer of the layer. The loss of the barrier function of the intestine walls leads to the release of bacteria and their toxins, which aggravates the severity of the state of such a patient.
It should be remembered that the morphological changes described above in organs are developing in the decompensation phase and to the terminal phase. They are not purely specific, but only complement the overall picture of the action of shock on the internal organs.
Quite often you can hear or read such a term as a "pain shock". Above, we disassemble the main types of shock, according to the main classifications used in medical practice and among them pain shock will not be mentioned, what's the matter? The answer is that the pain itself does not cause a shock state. Yes, the pain in some situations occurs quite strong, sometimes painful, sometimes with a loss of consciousness, but it is not the cause of the development of shock. In case of injury, especially with extensive injury, pain always accompanies a shock state, complementing the common clinical symptoms. The term "pain shock" is used most often as synonymous with traumatic shock, and traumatic shock is a special case of hypovolemic shock, which is based on the loss of circulating blood volume. To call traumatic shock pain in principle does not take place, but in a medical conversation, such non-professional terminology is unacceptable.
Traumatic shock develops as a consequence of external excessive impact on the body (injury of any genesis, extensive burns, blowing). In the development of traumatic shock, the role of 2 types of factors play:
- Character injury (fracture, burn, stupid injury, cutting wound, electrician, etc.)
- Related conditions (patient age, hypotension duration, stress, hunger, ambient temperature, etc.)
In the development of the clinical picture of traumatic shock, 2 main phases are distinguished, which first described in detail in their writings outstanding surgeon N.I. Pies:
- Excitation (erectile)
- Brake (torpid)
During the erectile phase, the patient's overall activation, its endocrine and sympathetic systems is observed. The patient is in consciousness, reflexes are revived, it is overly worried, the pupils are somewhat expanded, the skin pale, the pulse is rapidly, the blood pressure is increased. The most often erectile phase of shock accompanies injuries of the central nervous system. This phase is observed in 1/10 of all clinical cases of traumatic shock.
During the trapid phase, the patient's overall injection is observed, with a gradual regression of activity, both from its motor activity, and in the emotional plan. Consciousness of the patient is broken, it is badly, adamissed, the skin is pale, cold to the touch, hypotension, pulse is ridiculous, surface, reduced urine release. This phase is observed in 9/10 of all clinical cases of traumatic shock.
According to the clinical picture, traumatic shock is divided into 3 degrees:
- The easy degree of shock develops, as a rule, with an isolated injury, the volume of blood loss is small and amounts to 20% of the volume of circulating blood. A man in a shock of a lightly degree is in consciousness, the pressure is slightly reduced, the pulse is rapidly, weakness is felt. The forecast in this case is favorable, anti-deposit measures are symptomatic.
- The average degree of shock develops, as a rule, with severe isolated or combined injury. The volume of blood loss is approximately 20 to 40% of the circulating blood volume. The man in shock is stunned, the skin pale, hypotension reaches a level below 90mm.rt. The pulse is rapid up to 110 beats per minute. The forecast in this case is in close relationships from concomitant conditions exacerbating the course of shock. If medical care is provided in a timely manner, the forecast for further recovery is favorable.
- A severe degree of shock is developing, as a rule, with an extensive combined injury from the injury of trunk vessels and vital organs. The person in a shock of severe ADINAMIC, the consciousness is broken, the skin of pale, reflexes are injected, the arterial systolic pressure can fall below 60mm.rt.st., the pulse is frequent, weak, may not listen to peripheral arteries, the breath of the rapid, superficial, urine does not stand out . The volume of blood loss exceeds 40% of the volume of circulating blood. The forecast in this case is not favorable.
Treatment of traumatic shock implies early diagnosis and an integrated approach. Therapeutic measures should be aimed at eliminating factors causing a shock condition, factors exacerbating the course of shock and maintaining the organism homeostasis. The first thing to be stopped during injury is painful syndrome. To achieve this, the following activities are provided:
- Careful patient transportation from the lesion focus
- Immobilization of the damaged body
- Alestruction (narcotic and nonarcotic analgesics, Novocaine blockades, anesthesia)
After anesthesia, the source of bleeding is revealed and eliminated. Bleeding can be both outdoor and internal. Stopping bleeding is temporary (overlaying the gulling bandage, harness) and the final (bandage of the vessel or its reconstruction). Blood accumulations in the cavities of the organism (abdominal, pleural) are subject to evacuation by drainage. Simultaneously with the bleeding stop, it is necessary to ensure the infusion correction of the lost liquid volume. For this, colloid, crystalloid solutions, plasma and blood components are used. With a declaring of blood pressure, the following drugs with pressor properties are used: norepinephrine, extra, Meston. Also introduced corticosteroids (Solumedrol, dexamethasone).
Respiratory failure is also an integral component in the treatment of traumatic shock. It is necessary to restore the patency of the respiratory tract, to establish adequate ventilation, eliminate pneumothorax, hemotorax, to ensure inhalation of oxygen, if it is impossible to translate the patient to artificial (IVL apparatus). The correction of homeostasis is carried out by bringing to the norm of water-electrolyte balance and the pH of equilibrium.
The main point of the final treatment of traumatic shock is the performance of operational intervention. Depending on the type of injury, the operation helps to stop the bleeding, asphyxia, restore the integrity of damaged organs and tissues, remove the accumulated blood and others. All of the above measures to combat traumatic shock are, in fact, preoperative preparation of the patient in order to output from the shock state. During the operation, it is necessary to monitor vital indicators, compensate for blood loss and hypoxia. In a state of shock, it is permissible to perform operations only on life indications (tracheostomy during asphyxia, stopping the ongoing bleeding, elimination of intense pneumothorax).
How to quickly appreciate that man is shocked
Clinical symptoms of shock is quite characteristic. It includes a violation of the level of consciousness, a resistant reduction in blood pressure, the increase in heart rate and pulse. Later, a polyorgan deficiency increases due to a violation of perfusion and hypoxia in organs and tissues.
Any shock is preceded by the reason that causes it. So, with anaphylactic shock, there is always a substance-allergen, with a cardiogenic shock - a violation of the work of the heart, etc.
At traumatic shock it is possible to assess the patient's condition by character injury.
- Easy shock: an extensive wound injury of soft tissues, a shoe fracture, legs, a closed fracture of the hip, a bearing of a foot or brush, sharp blood loss (up to 1.5 liters).
- The average degree of shock: a combination of two signs of a light shock, a fracture of the pelvis, the sharp of blood loss (up to 2 liters), the separation of the leg or the forearm, the open fracture of the hip, penetrating the wound of the chest or abdomen.
- A severe degree of shock: a combination of two signs of the average degree of shock or three signs of light shock, sharp blood loss (over 2 liters), a bearing of the thigh.
For a preliminary assessment of gravity of traumatic shock, the so-called "shock index" is used. To calculate the shock index, it is necessary to divide the heart rate (blows per minute) to the systolic blood pressure indicator (in mm.rt.st.). Under normal conditions, the index is 0.5, with a light shock ranges from 0.6 to 0.8, with an average of 0.9 to 1.2 and with severe shock exceeds 1.3.
Shock: the first thing you need to know
If suddenly such a situation happened that a person in a shock was held next to you, do not pass by. Another important rule is not to panic. Calm down, rate the situation, think than you can help. It should be remembered that a person in a shock state himself cannot help himself. Therefore, you will cause ambulance and, desirable, stay close to the arrival of physicians. In principle, this is all that you are required at this stage. You can also try to find out the cause and circumstances of the shock, eliminate the damaging factor if possible. In some cases, to stop the outer bleeding is possible by handicrafts. You should not rush to the victim and provide him with cardiovascular resuscitation, if you do not know how to do this in practice.
Treatment with shock
Sometimes you can meet such headlines as "shock treatment". Yes, such a type of treatment really exists, only it is called completely "electric shock therapy". Treatment is carried out due to electric current, not a shock state. No pathology cannot be cured by the shock state, since the shock itself is a severe pathological condition that requires medical intervention.
The confusion of terms, of course, is present and to figure out, briefly describe electrocontal therapy here (synonyms: electrosusproy or electroconvulsive therapy). This type of treatment is based on the effects of electric current on the human brain. Electric therapy is used in psychiatric practice for the treatment of schizophrenia and severe depressive disorders. This method has a narrow list of indications for use and a number of side effects.
First aid for shock
As noted above, the first assistance in shock comes down to a small list of rules that are not difficult to remember. Of course, you should consider the reason that caused shock, but the general rules are quite similar. Next will be described an exemplary algorithm for the identification of a person in shock. In principle, the most important thing is not to remain indifferent and promptly call an ambulance. It is also important not to succumb to a panic, especially shouting on a patient in a shock. It is also not recommended to beat it on the cheeks and leading to feelings is also not recommended, external aggression can only aggravate and without that serious condition of the victim. After calling ambulance, you are next to the victim. All other measures listed below in the algorithm are certainly important, but they are secondary in nature, and no one forces you to perform them.
Do not have a cardiovascular resuscitation if you have no experience. Firstly, the reason that caused a shock condition in humans is not always reliably known, especially if it is an unfamiliar man on the street. Secondly, the inept execution of cardiovascular intensive care can aggravate the severity of a person in shock.
The same situation and when the harness is applied. It is necessary to remember the basic rules for its overlay:
- The harness is superimposed on the limb above the level of bleeding
- Harness can not be imposed on a naked body, put a fragment of clothes under it
- Harness are tightened to stop arterial bleeding
- You must specify the exact time of the harness
- The harness should be well visible, warn about this ambulance
Urgent help with shock
Emergency care with shock includes:
- Anesthesia. Especially relevant at traumatic shock. Narcotic and nonarcotic analgesics are used, sometimes anesthesia is required.
- In an anaphylactic shock, the introduction of adrenaline and antihistamine preparations and glucocorticoids is necessary.
- In case of infectious toxic shock, it is necessary to choose adequate antibacterial therapy.
- Hypovolemic shock requires massive infusion therapy and eliminating the source of hypovolemia (especially if it is continuing bleeding).
- If the cardiogenic shock is caused by arrhythmia, it is prescribed anticultimitic drugs.
- In cases of combined shock, treatment is starting with the elimination of life-threatening states.
Operational benefits are produced after stabilization of the patient's hemodynamics. Except may be only operations on life indications (continued bleeding, the imposition of tracheostas at asphyxia).
Help with shock: action algorithm
An exemplary algorithm for the shock is as follows:
- Call an ambulance. Self-treatment with a developed shock is contraindicated.
- Do not leave a person in a shock of one, watch it for its condition.
- If possible, the damaging factor should be eliminated. For example, discontinue the introduction of the medication if it caused an anaphylaxis, impose a bandage or harness during outer bleeding.
- If a person in shock has no consciousness, then his head must be turned his head. This measure prevents asphyxia.
- Estate the shocking clothes, ensure the influx of fresh air into the room, free the mouth of the patient from foreign objects (chewing, dentures).
- It is necessary to prevent the patient's supercooling, cover it with a blanket or jacket.
- In case of injury, the fracture damaged part of the body must be immobilized.
- Transporting a person in shock should be carried out gently, without sharp movements.
- After the emergency arrival, let me know you have information about a person in shock. Specify the exact time of the imposition of the harness, if it was imposed.
Anaphylactic shock: first aid
When anaphylactic shock develops, the first help is as follows:
- It is necessary to immediately stop the contact of the allergen substance with the patient: no longer enter the drug that caused an anaphylaxius, impose a harness above the insect bite, impose ice on the wound.
- Call the ambulance
- Put the patient, slightly raise my legs
- Release the oral cavity from foreign objects (chewing, dentures of teeth)
- Ensure the access of oxygen into the room, unzipped the shy
- Take antihistamine drug
- Stay next to the patient before the arrival of ambulance
The ambulance brigade has drugs for the treatment of anaphylactic shock, therapeutic measures will be reduced to the following:
- The introduction of adrenaline. This drug quickly raises pressure, reduces swelling, expanding bronchi
- Introduction glucocorticoids. Preparations of this group have an antiallergic effect, increase pressure
- Introduction of antihistamine drugs.
- Eufillin contributes to the regression of the resulting spasm of bronchi
- Inhalation of oxygen reduces hypoxia phenomena
- Preparations can be reused to achieve the therapeutic effect.
Shock (from English. shock - Blow, shock) - a pathological process, developing in response to the impact of emergency stimuli and accompanied by a progressive violation of the vital functions of the nervous system, blood circulation, breathing, metabolism and some other functions. In fact, it is a breakdown of the organism compensatory reactions in response to damage.
The state of shock was first described by hippocratic. For the first time, the term "shock" was applied in 1737. LE LED. At the end of the XIX century, possible mechanisms for the development of the pathogenesis of shock were offered, among them the most popular were the following concepts:
- paralysis of nerves, innervating vessels;
- exhaustion of the vasomotor center;
- nervous kinetic disorders;
- violation of the function of the endocrine glands;
- reduction of circulating blood volume (BCC);
- Capillary stasis with violation of vessel permeability.
From a modern point of view, shock develops in accordance with the theory of Stress G. Siele. According to this theory, the excessive effect on the body causes in it specific and non-specific reactions. The first depend on the nature of the impact on the body. The second is only from the force of exposure. Non-specific reactions when influenced by a supercritical stimulus, the name of the general adaptation syndrome was obtained. The total adaptation syndrome always flows the same type, in three stages:
- The stage is compensated (reversible)
- Stage decompensated (partially reversible, is characterized by a general decrease in the body's resistance and even the death of the body)
- Stage terminal (irreversible, when no therapeutic effects may interfere with death)
Thus, shock, silly, is a manifestation Non-specific reaction The body for excessive impact.
N. I. Pirogov in the middle of the XIX century determined in the pathogenesis of the shock of the concept of erectile (excitement) and torpid (lethargy, stupor) phases.
Criteria for diagnosis
The diagnosis of "shock" is made in the presence of the patient the following signs of shock:
- reduction of blood pressure and tachycardia (in the torpid phase);
- anxiety (erectile phase by piercing) or darkening of consciousness (trapid phase on the piercing);
- Breathing disorder;
- reduction of the volume of the allocated urine;
- Cold, wet leather with pale cyanotic or marble color.
Classification of Shock
There are various ways to classify the shock, however, the classification of shock on the type of circulatory disorders is most apprehensible.
By type of circulatory disorders
This classification provides for the following types of shock:
The clinical classification divides the shock by four degrees by the degree of its gravity.
- Shock I degree. The state of the victim is compensated. Consciousness is saved, clear, patient contact, slightly slow down. Systolic blood pressure (blood pressure) exceeds 90 mm mercury pillars, pulse is more expensive, 90-100 shots per minute. The forecast is favorable.
- Shock II degree. The victim is injected, the skin is pale, the tones of the heart are muted, the pulse is frequent - up to 140 beats per minute, of weak filling, the maximum hell is reduced to 90-80 mm Hg. Art. Breathing superficial, rapid, consciousness stored. The victim answers questions correctly, speaks slowly, a quiet voice. The forecast is serious. For rescue life, anti-shock events are required.
- Shock III degree. The patient adamised, hesitated, does not respond to pain, the questions are responsible to the questions, and it is extremely slow, or not at all, says the deaf barely audible whisper. Consciousness confused or absent at all. The skin is pale, covered in cold sweat, expressed acricyanosis. Heart tones deaf. Pulse threaded - 130-180 beats per minute, determined only on large arteries (sleepy, femoral). Surface breathing, frequent. Systolic blood pressure below 70 mm mercury pillars, central venous pressure (CVD) is zero or negative. Anoururia is observed (lack of urine). The forecast is very serious.
- Shock IV degree manifests itself clinically as one of the terminal states. Heart tones are not listened to the victim unconscious, the skin of gray acquires a marble pattern with stagnant stains of the body type (a sign of a decrease in blood flow and stagnation of blood in small vessels), blue lips, blood pressure below 50 mm RT. Art., often not determined at all. The pulse is barely notice on the central arteries, Anuria. Breathing Surface, rare (sobbing, convulsive), barely noticeable, pupils are expanded, there are no reflexes and reactions to pain irritation. The forecast is almost always unfavorable.
Approximately the severity of the shock can be determined by the Alghera index, that is, in relation to the pulse to the meaning of systolic blood pressure. Normal index - 0.54; 1.0 - transitional state; 1.5 - Heavy shock.
A number of sources [one] Provides the classification of shock in accordance with the main pathogenetic mechanisms.
This classification divides shock on:
For all listed shock species, the change in hemodynamics is characteristic. Below is the comparative characteristic of hemodynamic disorders under various types of shock.
|Type of Shock||Page volume of heart||Central venous pressure||arterial pressure||Peripheral resistance|
Control and gravity of shock
The objectives of control, as well as estimates of the severity and the flow of shock are:
- identify mechanisms causing shock development;
- establish the severity of the course of shock;
- Control the effectiveness of the treatment of shock.
Small control program
Of great importance is the control of blood pressure and the study of hemodynamics.
A small control program includes the main five parameters that can be investigated in any medical department, regardless of its profile, as well as in medical transport. It:
- arterial pressure;
- Central venous pressure during central veins catheterization;
- breathing rate;
- hourly diuresis;
- Evaluation of blood flow in the skin (skin color, body temperature, blood capillaries).
Specialized control program
The specialized program for monitoring the flow of shock is carried out in resuscitation and intensive care departments.
The specialized control program is necessary in a slow or complicated course of shock. It is carried out in a specialized department (for example, in the resuscitation and intensive care unit) and includes the following studies:
- Hemodynamic studies with special techniques (blood volume, blood viscosity, blood pressure, minute volume of emissions, peripheral resistance, central venous pressure, heart function control);
- study of microcirculation and metabolic balance;
- Studies of blood coagulation system;
- study of the respiratory function;
- study of the function of urinary;
- The study of acid-alkaline state and biochemical blood indicators.
Treatment of Shock
With a non-desired shock, it is recommended to raise the foot end of the body.
Treatment of shock consists of several points:
- elimination of the reasons that caused the development of shock;
- reimbursement of the shortage of circulating blood volume (OCC), with caution during cardiogenic shock;
- oxygen therapy (inhalation of oxygen);
- therapy of acidosis;
- Therapy of vegetotropic drugs in order to cause a positive inotropic effect.
Additionally, steroid hormones, heparin and streptokinase for the prevention of microcurrent, diuretics for restoring the kidney function during normal blood pressure, artificial ventilation of the lungs are used.
This type of shock arises as a result of a rapid decrease in the volume of circulating blood, which leads to a drop in the pressure of filling the circulatory system and to a decrease in the venous return of blood in the heart. As a result, there is a violation of blood supply to organs and tissues and their ischemia.
The amount of circulating blood can quickly decrease due to the following reasons:
- blood loss;
- plasmopoter (for example, when burning, peritonitis);
- Loss of fluid (for example, with diarrhea, vomiting, abundant sweating, sugar and nonachon diabetes).
Depending on the severity of the hypovolemic shock, it is distinguished by three stages, which consistently replace each other. it
- The first stage is an immanent (compensated). At this stage there are no vicious circles.
- The second stage is progressive.
- The third stage is the stage of irreversible changes. At this stage, no modern anti-deposit facilities allow the patient from this state. At this stage, medical intervention can return arterial pressure on a short period of time to normal, but it does not stop the destructive processes in the body. Among the reasons for the irreversibility of the shock at this stage, there is a violation of homeostasis, which is accompanied by severe damage to all organs, the special value has damage to the heart.
With hypovolemic shock, many vicious circles are formed. Among them, the vicious circle is of the greatest importance, which contributes to damage to the myocardium and the vicious circle, which contributes to the insufficiency of the vasomotor center.
Vicious circle that promotes myocardial damage
Reducing the amount of circulating blood leads to a decrease in the minute volume of the heart and the fall of blood pressure. The drop in blood pressure leads to a decrease in blood circulation in the coronary arteries of the heart, which leads to a decrease in myocardial reduction. The reduction in myocardial reduction leads to an even greater decrease in the minute volume of the heart, as well as to the further fall of blood pressure. The vicious circle closes.
Vicious circle that promotes the insufficiency of the Vasomotor Center
Hypovolemia is due to a reduction in the minute emission volume (that is, a decrease in the volume of blood exhaled from the heart in one minute) and a decrease in blood pressure. This leads to a decrease in blood flow in the brain, as well as violation of the activity of the vascular (vasomotor) center. The latter is in the oblong brain. One of the consequences of the violation in the Vasomotor Center is the drop in the tone of the sympathetic nervous system. As a result, blood pressure centralization mechanisms are violated, blood pressure drops, and this, in turn, launches a violation of the cerebral circulation, which is accompanied by a large oppression of the vasomotor center.
Recently, the term "shock organ" was often used ("Shock light" and "Shock kidney"). It is in mind that the impact of a shock stimulus disrupts the function of these organs, and further disorders of the patient's body are closely related to changes in the "shock organs"  .
This term first introduced into the practice of Ashbaugh (1967) in the description of the syndrome of progressive acute respiratory failure. However, in 1944 Burford. и Burbank. described similar clinical and anatomical syndrome by calling it "Wet (wet) light" . After some time, it was found that the picture of the "shock light" occurs not only at shocks, but also in the crank-brain, thoracic, abdominal injuries, with blood loss, long-term hypotension, aspiration of acidic gastric content, massive transfusion therapy, acute renal failure increasing Decompensation of the heart, thromboembolism of the light artery. Currently, no connection was found between the length of the shock and the severity of light pathology.
Etiology and pathogenesis
Most often, the cause of the development of "shock light" is hypovolemic shock. Ischemia of many fabrics, as well as massive emissions of catecholamines lead to the flow of collagen, fat and other substances into the blood, which cause massive thrombosis. Because of this, microcirculation is disturbed. A large number of blood clots are settled on the surface of the vessels of the lungs, which is associated with the characteristics of the latter structure (long convolutions capillaries, double supply with blood, shunting). Under the action of inflammation mediators (vasoactive peptides, serotonin, histamine, kinines, foregnostin) increase the vascular permeability in the lungs, the bronchospasm develops, the release of mediators leads to a narrowing of the vessels and damage.
Syndrome "Shock Light" develops gradually, reaching its apogee, usually after 24-48 hours, the outcome is often massive (often bilateral) liga-tissue lesion. The process is clinically divided into three stages.
- The first stage (initial). The arterial hypoxemia (lack of oxygen in the blood) is dominated, the radiological picture of the lung is usually not changed (with a rare exception, when an increase in the pulmonary pattern is observed during x-ray). Cyanosis (blue skin shade) is absent. The partial oxygen pressure is sharply reduced. Auscultation reveals scattered dry wheels.
- Second stage. In the second stage, tachycardia increases, that is, the cardiac abbreviation frequency increases, Tahipne (respiratory frequency) occurs, the partial pressure of oxygen decreases even more, the psyche disorders increase, the partial pressure of carbon dioxide increases somewhat. Auscultation reveals dry, and sometimes fine-pushed wheezes. Cianoz is not expressed. Radiologically determines the decrease in the transparency of the light tissue, bilateral infiltrates appear, obscure shadows.
- Third stage. For the third stage, without special support, the body is non-visual. Cyanosis develops. X-ray is revealed to increase the number and sizes of focal shadows with their transition to drain formations and total dim dimum. The partial pressure of oxygen decreases to critical numbers.
Pathoanomatic drug kidney patient who deceased from acute renal failure.
The concept of "shock kidney" reflects the acute violation of the kidney function. In the pathogenesis, the leading role is played by the fact that a compensatory shunting of arterial blood flow occurs in direct veins of pyramids with a sharp decrease in hemodynamic volume in the region of the cortical renal layer. This is confirmed by the results of modern pathophysiological studies. [four] .
The kidneys are somewhat increased in size, swollen, the cortical layer of their small-calm, pale gray, the overlooking zone and pyramids, on the contrary, dark red. Microscopically in the first hours is determined by the anemia of the vessels of the cortex layer and the sharp hyperemia of the seaside zone and the pyramids direct veins. Rarely meet microtrombosis of capillaries Glomerul and leading capillaries.
In the future, increasing dystrophic changes in nephrothelia, covering first proximal, and then distal nephrone departments are observed.
The picture of the "shock" kidney is characterized by a clinic of progressive acute renal failure. In its development, acute renal failure under shock passes four stages:
The first stage flows at that time until the reason caused sharp renal failure. Clinical notes decreased diuresis.
Second stage (oliganuric). The most important clinical signs of the oligognomic stage of acute renal failure include:
- Oliganuria (with the development of edema);
- azotemia (smell ammonia from mouth, itching);
- an increase in the size of the kidneys, pain in the loins, a positive symptom of Pasternatsky (the appearance of red blood cells in the urine after tapping in the area of kidney projection);
- weakness, headache, muscle sticking;
- Tachycardia, expansion of heart boundaries, pericarditis;
- the dynake, stagnant wheezing in the lungs up to the interstitial edema of the lungs;
- dry mouth, anorexia, nausea, vomiting, diarrhea, cracks of the mucous membrane of the mouth and language, abdominal pain, intestinal paresis;
Third stage (recovery of diusca). Diuresis can normalize gradually or rapidly. The clinical picture of this stage is associated with arising dehydration and dielectrictime. The following features are developing:
- loss of body weight, asthenia, lethargy, inhibition, possibly infection;
- Normalization of nitrogen-excretory function.
Fourth stage (recovery). Gomeostasis indicators, as well as the kidney function comes to normal.
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- Klimiashvili A. D. Chadaev A. P. Bleeding. Blood transfusion. Blood substitutes. Shock and resuscitation. - M., "Russian State Medical University", 2006. P. 38-60
- Meerson F. Z., Prennikova M. G. Adaptation to stressful situations and physical exertion. - M., "Triada X", 2000. P. 54-60
- Puliardin G. V. Stress and pathology. - M., "Miniprint", 2002. P. 3-22
- Stolkovkov V. I. General Surgery. - M., "Medicine", 1978. P. 144-157
- Sergeev S.T. Surgery of shock processes. - M., Triada-X, 2001. P. 234-338