Emergency care for hemorrhagic shock: when seconds count. Providing emergency care for hemorrhagic shock

Description:

Hemorrhagic shock develops as a result of acute blood loss.

Acute blood loss is the sudden release of blood from the vascular bed. Main clinical symptoms resulting from a decrease in blood volume (hypovolemia) are pallor of the skin and visible mucous membranes, and arterial hypotension.

Symptoms:

Stage 1 (compensated shock), when blood loss is 15-25% of the bcc, the patient’s consciousness is preserved, the skin is pale, cold, blood pressure is moderately reduced, the pulse is weak, moderate tachycardia up to 90-110 beats/min.

Stage 2 (decompensated shock) is characterized by an increase in cardiovascular disorders, and the body’s compensatory mechanisms fail. Blood loss is 25-40% of the bcc, impaired consciousness to the point of soporosis, cold extremities, blood pressure is sharply reduced, tachycardia 120-140 beats/min, pulse is weak, thread-like, oliguria up to 20 ml/hour.

Stage 3 (irreversible shock) is a relative concept and largely depends on the resuscitation methods used. The patient's condition is extremely serious. Consciousness is sharply depressed to the point of complete loss, the skin is pale, the skin is marbling, systolic pressure is below 60 mmHg, the pulse is determined only on main vessels, sharp tachycardia up to 140-160 beats/min.

How express diagnostics To assess the severity of shock, the concept of shock index is used - SI - the ratio of heart rate to systolic pressure. For 1st degree shock, CI = 1 (100/100), 2nd degree shock - 1.5 (120/80), 3rd degree shock - 2 (140/70).
Hemorrhagic shock is characterized by a general severe condition of the body, insufficient blood circulation, hypoxia, metabolic disorders and organ functions. The pathogenesis of shock is based on hypotension, hypoperfusion (decreased gas exchange) and hypoxia of organs and tissues. The leading damaging factor is circulatory hypoxia.
Relatively quick loss 60% of the bcc is considered fatal for a person, blood loss of 50% of the bcc leads to a breakdown of the compensation mechanism, blood loss of 25% of the bcc is almost completely compensated by the body.

The relationship between the amount of blood loss and its clinical manifestations:

Blood loss is 10-15% of the volume of blood volume (450-500 ml), there is no hypovolemia, blood pressure is not reduced;
Blood loss 15-25% of blood volume (700-1300 ml), mild hypovolemia, blood pressure reduced by 10%, moderate tachycardia, pale skin, cold extremities;
Blood loss 25-35% of blood volume (1300-1800 ml), average degree severity of hypovolemia, blood pressure reduced to 100-90, tachycardia to 120 beats/min, pale skin, cold sweat, oliguria;
Blood loss up to 50% of the volume of blood volume (2000-2500 ml), severe hypovolemia, blood pressure reduced to 60 mm. Hg, thready pulse, absent or confused consciousness, severe pallor, cold sweat, ;
Blood loss of 60% of the blood volume is fatal.
The initial stage of hemorrhagic shock is characterized by a disorder of microcirculation due to centralization of blood circulation. The mechanism of centralization of blood circulation occurs due to acute shortage BCC due to blood loss, venous return to the heart decreases, venous return to the heart decreases, stroke volume of the heart decreases and blood pressure drops. As a result, sympathetic activity increases nervous system, there is a maximum release of catecholamines (adrenaline and norepinephrine), the heart rate increases and the total peripheral vascular resistance to blood flow increases.

On early stage shock centralization of blood circulation ensures blood flow in coronary vessels and cerebral vessels. Functional status These organs are very important for maintaining the vital functions of the body.
If there is no replenishment of the bcc and the sympathoadrenergic reaction is delayed over time, then the overall picture of shock will include negative sides vasoconstriction of the microvasculature – decreased perfusion and hypoxia of peripheral tissues, due to which centralization of blood circulation is achieved. In the absence of such a reaction, the body dies in the first minutes after blood loss from acute circulatory failure.
Main laboratory indicators in case of acute blood loss are hemoglobin, red blood cells, hematocrit (red blood cell volume, the norm for men is 44-48%, for women 38-42%). Determining the blood volume in emergency situations is difficult and associated with loss of time.

Disseminated intravascular coagulation syndrome (DIC syndrome) is a severe complication of hemorrhagic shock. The development of DIC syndrome is facilitated by disruption of microcirculation as a result of massive blood loss, trauma, shock of various etiologies, transfusion large quantities preserved blood, heavy infectious diseases and etc.
The first stage of DIC syndrome is characterized by the predominance of hypercoagulation with simultaneous activation of anticoagulant systems in patients with blood loss and trauma.
The second stage of hypercoagulation is manifested by coagulopathic bleeding, the stop and treatment of which is very difficult.
The third stage is characterized by hypercoagulation syndrome, and the development of thrombotic complications or recurrent bleeding is possible.
Both coagulopathic and hypercoagulability syndrome serve as a manifestation general process in the body - thrombohemorrhagic syndrome, the expression of which in the vascular bed is DIC - syndrome. It develops against the background of severe circulatory disorders (crisis of microcirculation) and metabolism (acidosis, accumulation of biological active substances, hypoxia).

Causes:

The cause of acute blood loss can be trauma, spontaneous bleeding, or surgery. The speed and volume of blood loss are of great importance.
With the slow loss of even large volumes of blood (1000-1500 ml), compensatory mechanisms have time to turn on, hemodynamic disturbances arise gradually and are not very serious. On the contrary, intense bleeding with loss of a smaller volume of blood leads to severe hemodynamic disturbances and, as a consequence, to hemorrhagic shock.

Treatment:

For treatment the following is prescribed:

Principles of resuscitation and intensive care in patients with acute blood loss and in a state of hemorrhagic shock at the prehospital stage are as follows:
1. Reduction or elimination of existing phenomena of acute respiratory failure (ARF), the cause of which may be aspiration of knocked out teeth, blood, vomit, cerebrospinal fluid from a fracture of the base of the skull. This complication is especially often observed in patients with confused or absent consciousness and, as a rule, is combined with retraction of the root of the tongue.
Treatment comes down to mechanical release of the mouth and oropharynx, aspiration of the contents using suction. Transportation can be carried out with an inserted airway or endotracheal tube and mechanical ventilation through them.
2. Carrying out pain relief medications, not depressing breathing and blood circulation. Of central narcotic analgesics devoid of side effects opiates, you can use Lexir, Fortral, Tramal. Non-narcotic analgesics (analgin, baralgin) can be combined with antihistamines. There are options for nitrous-oxygen analgesia, intravenous administration of subnarcotic doses of ketamine (calypsol, ketalar), but these are purely anesthetic aids that require an anesthesiologist and the necessary equipment.
3. Reduction or elimination of hemodynamic disorders, primarily hypovolemia. In the first minutes after severe injury the main cause of hypovolemia and hemodynamic disorders is blood loss. Prevention and everyone else serious violations– immediate and maximum possible elimination hypovolemia. The main therapeutic measure should be massive and rapid infusion therapy. Of course, stopping external bleeding should precede infusion therapy.
Resuscitation in case clinical death due to acute blood loss, it is carried out according to generally accepted rules.

The main task in case of acute blood loss and hemorrhagic shock at the hospital stage is to carry out a set of measures in a certain relationship and sequence. Transfusion therapy is only part of this complex and is aimed at replenishing blood volume.
In carrying out intensive care for acute blood loss, it is necessary to reliably provide continuous transfusion therapy with a rational combination of available funds. It is equally important to observe a certain stage in treatment, speed and adequacy of assistance in the most difficult situations.

As an example, the following procedure can be given:

Immediately upon admission, the patient is measured for blood pressure, pulse and respiration rates, and catheterized bladder and take into account the excreted urine, all this data is recorded;
The central or peripheral vein is catheterized, infusion therapy is started, and CVP is measured. In case of collapse, without waiting for catheterization, a jet infusion of polyglucin is started by puncture of a peripheral vein;
A jet infusion of polyglucin restores the central blood supply, and a jet infusion of saline restores diuresis;
They determine the number of red blood cells in the blood and the hemoglobin content, hematocrit, as well as the approximate amount of blood loss and what is still possible in the coming hours, and indicate required amount donated blood;
The patient's blood group and Rh status are determined. After receiving this data and donor blood, tests are carried out for individual and Rh compatibility, a biological test and blood transfusions begin;
When the central venous pressure increases above 12 cm of water column, the infusion rate is limited to rare drops;
If it is expected surgical intervention, decide on the possibility of carrying it out;
After normalization of blood circulation, support water balance and normalize hemoglobin, red blood cells, protein, etc.;
Stop continuous intravenous infusion after 3-4 hours of observation have proven: no new bleeding, stabilization of blood pressure, normal intensity of diuresis and absence of threat

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

The body of a healthy woman can restore blood loss of up to 20% of the bcc (approximately 1000 ml) due to autohemodilution and redistribution of blood in the vascular bed. With blood loss of more than 20-25%, these mechanisms can eliminate the deficit of blood volume. With massive blood loss, persistent vasoconstriction remains the body’s leading “protective” reaction, and therefore normal or close to normal blood pressure is maintained, blood supply to the brain and heart is provided (blood circulation centralization), but at the expense of weakening blood flow in the muscles of internal organs, including kidneys, lungs, liver.

Long-term stable vasoconstriction, as a protective reaction of the body at first, maintains blood pressure within certain limits for some time, and later, with the progression of shock and in the absence of adequate therapy, contributes to the consistent development of severe microcirculation disorders, the formation of “shock” organs and the development of acute renal failure and other pathological conditions.

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

Hemorrhagic Shock Clinic

GSH is manifested by weakness, dizziness, nausea, dry mouth, darkening of the eyes, and with increasing blood loss - loss of consciousness. Due to the compensatory redistribution of blood, its quantity decreases in the muscles, the skin is manifested by pallor of the skin with gray tint extremities are cold, wet. A decrease in renal blood flow is manifested by a decrease in diuresis, subsequently with impaired microcirculation in the kidneys, with the development of hypoxia, tubular necrosis. As the volume of blood loss increases, the symptoms of respiratory failure increase: shortness of breath, irregular breathing rhythm, agitation, peripheral cyanosis.

There are four degrees of severity of hemorrhagic shock:

I degree severity is observed when the BCC deficiency is 15%. General state satisfactory, pale skin, slight tachycardia (up to 80-90 beats/min), blood pressure within 100 mm Hg, HB 90 g/l, central venous pressure is normal.
II degree severity - BCC deficiency up to 30%. The general condition is moderate, complaints of weakness, dizziness, darkening of the eyes, nausea, pale and cold skin. Blood pressure 80-90 mm Hg, central venous pressure below 60 mm water column, tachycardia up to 100-120 beats / min, diuresis reduced, HB 80 g / l and below.
III degree severity occurs when the BCC deficit is 30-40%. The general condition is serious. There is severe lethargy, dizziness, pale skin, acrocyanosis, blood pressure below 60-70 mmHg, central venous pressure drops (20-30 mmHg and below). Hypothermia is observed rapid pulse(130-140 beats/min), oliguria.
IV degree severity is observed when the BCC deficiency is more than 40%. The condition is very serious, there is no consciousness. Blood pressure and central venous pressure are not determined, the pulse is noted only in the carotid arteries. Breathing is shallow, rapid, with a pathological rhythm, mobile excitation, hyporeflexia, and anuria are noted.

Treatment of hemorrhagic shock

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

Use of broad-spectrum antibiotics.

Eliminating the cause of bleeding — main point treatment of GS. The choice of method to stop bleeding depends on its cause. When treating with HT great importance has a speed of blood loss compensation and timely surgery. Grade II hepatitis is an absolute indication for surgical bleeding control.

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

The ratio of colloids and crystalloids should be 2:1. IN infusion therapy include: rheopolyglucin, volecam, erythromass, native or fresh frozen plasma (5-6 bottles), albumin, Ringer-Locke solution, glucose, panangin, prednisolone, korglykon, for the correction of metabolic acidosis - 4% sodium bicarbonate solution, trisamin. For hypotensive syndrome - administration of dopamine or dopamine. The volume of infusion should exceed the estimated blood loss by 60-80%; at the same time, blood transfusion is carried out in a volume of no more than 75% of blood loss with its simultaneous replacement, then delayed blood transfusion in smaller doses.

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

For the treatment of DIC syndrome in HS, fresh frozen plasma is used, protease inhibitors - contrical (trasylol) at 60-80,000 OD, gordox at 500-600,000 OD. Dicynone, etamsylate, androxon reduce capillary fragility and enhance the functional activity of platelets. Cardiac glycosides, immunocorrectors, vitamins are used, according to indications - antibacterial therapy, anabolics (Nerobol, Retabolil), essential.

After intensive therapy, rehabilitation therapy and therapeutic exercises are of great importance.

Hemorrhagic shock (HS) is associated with acute blood loss, as a result of which macro- and microcirculation is disrupted and a syndrome of multiple organ and multisystem failure develops. Sharp and profuse bleeding leads to the fact that adequate tissue metabolism ceases in the body. As a result, it happens oxygen starvation cells, in addition, tissues do not receive enough nutrients, and toxic products are not removed.

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

Causes and pathogenesis of hemorrhagic shock

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

if spontaneous bleeding occurs;
intense blood loss may occur as a result of injury;
Surgery may cause loss of a large volume of blood.

In obstetrics, hemorrhagic shock is a common condition. It is the leading cause of maternal mortality. The condition can be caused by:

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

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

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

Schematically, the mechanism of development of the condition can be described as follows:

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

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

Symptoms of disease development

GSH can be diagnosed using different methods. clinical manifestations. Common signs such pathological condition are:

change in color of the skin and mucous membranes;
change in respiratory rate;
pulse disturbance;
deviations from normal levels of systolic and venous pressure;
change in the volume of urine excreted.

Making a diagnosis based only on the patient’s subjective feelings is extremely dangerous, since the clinical picture of hemorrhagic shock will depend on the severity of the condition.

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

Compensated HS (mild degree). In the first stage, blood loss is about 10-15% of the blood volume. This is approximately 700-1000 ml of blood. At this stage, the patient is contactable and conscious. Symptoms: pallor of the skin and mucous membranes, the pulse quickens (up to 100 beats per minute), complaints of dry mouth and severe thirst appear.
Decompensated HS (moderate) is stage 2. Blood loss is up to 30% of the blood volume (1-1.5 l). The first thing you need to pay attention to when diagnosing the condition: acrocyanosis develops, the pressure drops to 90-100 mm Hg. Art., rapid pulse (120 beats per minute), the amount of urine excreted decreases. The patient experiences increasing anxiety, accompanied by increased sweating.
Decompensated irreversible HS (severe degree) is stage 3. At this stage, the body loses up to 40% of blood. The patient's consciousness is often confused, the skin is very pale, and the pulse is very rapid (130 beats per minute or more). There is inhibition of action, dizziness, respiratory distress and coldness of the extremities (hypothermia). Systolic pressure falls below 60 mm Hg. Art., the patient does not go to the toilet at all.
The most severe degree of HS is stage 4 of the condition. Blood loss is more than 40%. At this stage, all vital functions are suppressed. The pulse is difficult to palpate, the pressure cannot be determined, breathing is shallow, and hyporeflexia develops. The severity of HS at this stage leads to the death of the patient.

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

Diagnostic methods

Due to the pronounced clinical picture of the condition, which is accompanied by large blood loss or ongoing bleeding, diagnosing HS will usually not cause difficulties.

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

Of great importance early diagnosis GSH. The basis of positive therapeutic effect— timely first aid. The sooner a person receives adequate treatment, the higher the likelihood of a full recovery and no complications.

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

Emergency care for hemorrhagic shock

Since the disease is serious and can cause irreversible complications, the patient must be given proper first aid. Delivered exactly on time medical assistance will influence the positive outcome of therapy. The basics of such treatment will focus on addressing the following issues:

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

Treatment

IN emergency situations Treatment of hemorrhagic shock will include the following measures:

if necessary, artificial ventilation is required;
the patient is advised to breathe through an oxygen mask;
at severe pain adequate pain relief is prescribed;
If hypothermia develops, the patient must be warmed.

After first aid The patient is prescribed intensive therapy, which should:

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

Once the acute condition has stabilized, therapy does not end. Further treatment will be aimed at eliminating complications that were caused by HS.

Hemorrhagic shock is a condition associated with acute and massive blood loss. Blood loss of 1000 ml or more leads to the development of shock, which means a loss of 20% of the bcc.

Causes of hemorrhagic shock:

The causes leading to hemorrhagic shock in obstetric practice are: bleeding during pregnancy, during childbirth, in the afterbirth and postpartum periods. The most common causes of massive blood loss are: placenta previa, premature abruption of a normally located placenta, interrupted ectopic pregnancy, uterine rupture or birth canal, early uterine hypotension postpartum period.

Massive blood loss is often accompanied by a bleeding disorder (either precedes it or is a consequence).
The peculiarities of obstetric bleeding are that they are profuse, sudden and usually combined with other dangerous pathologies (preeclampsia, extragenital pathology, birth trauma, etc.).

Pathogenesis:

With any blood loss, compensatory factors are triggered first. In case of acute blood loss as a result of a decrease in blood volume, a decrease in venous return and cardiac output the sympathetic-adrenal system is activated, which leads to vascular spasm, primarily arterioles and capillaries.

In order to compensate, blood circulation is centralized, aimed at providing blood to the most important organs, as well as the redistribution of fluid in the body, its transition from tissues to the vascular bed (autohemodilution, i.e. dilution of blood due to its own fluid).
Due to the production of antidiuretic hormone, there is a general retention of fluid in the body and a decrease in diuresis. For a while, this helps to increase the BCC. These changes can be characterized as disturbances of macrocirculation.

Violations of macrocirculation lead to disturbances of microcirculation, i.e., pathological changes in the periphery. In organs that are not vital, the blood supply is sharply reduced. Due to this, blood circulation is still maintained in vital organs for some time, although at a reduced level.

Then an even more pronounced spasm of peripheral vessels occurs, which entails deterioration of microcirculation and pathological changes rheological properties blood. Tissue ischemia develops, tissue acidosis increases due to the accumulation acidic foods, metabolism is disrupted, and the picture of internal combustion engine appears.

Deterioration of hemodynamics primarily worsens the condition of the liver, kidneys, and hypothalamic-pituitary system.
There is a disturbance in water-electrolyte metabolism: the level of extracellular potassium increases. There is depression of myocardial function, its activity decreases, which leads to secondary hypovolemia (a decrease in heart function leads to a decrease in blood volume).

Permeability increases vascular wall due to acidosis and a decrease in oncotic pressure (oncotic pressure is determined by the concentration of blood protein), which leads to the transfer of fluid from the bloodstream into the cells. In this regard, the situation is getting even worse. In the absence of timely correction, a complete disruption of both macro- and microcirculation occurs, i.e., all types of metabolism. Due to severe anemia, deep hypoxia is observed. If blood loss is not replaced, cardiac arrest may occur due to severe hypovolemia.

Classification:

Stage 1 - compensated shock.
Stage 2 - decompensated reversible shock.
Stage 3 - decompensated irreversible shock.

Symptoms and stages of hemorrhagic shock:

At stage 1, or stage of compensated shock, blood loss is usually above 700 ml, but does not exceed 1200 ml, while the loss of blood volume is 15-20%. The shock index is equal to 1. The shock index is the ratio of heart rate to systolic pressure.

The woman’s consciousness is usually preserved, but she is disturbed following symptoms hemorrhagic shock - weakness, there may be dizziness, drowsiness, accompanied by yawning. The skin is pale, the extremities are cold, the veins are collapsed, which makes them difficult to puncture (therefore, a very important preventive measure is to establish contact with the vein in the presence of risk factors for bleeding in advance). Breathing is rapid, pulse is increased to 100 beats/min, blood pressure is reduced slightly, no more than 100/60 mmHg. Art. The amount of urine excreted is reduced by 2 times.

At stage 2, or the stage of decompensated reversible shock, blood loss is more than 1200 ml, but does not exceed 2000 ml, while the loss of blood volume is 20-45%, the shock index is 1.5. At this stage, symptoms are pronounced - severe weakness, lethargy, observed severe pallor, acrocyanosis, cold sweat. Breathing is rapid with rhythm disturbance. The pulse is weak, increased to 120-130 beats/min. Systolic blood pressure from 100 to 60 mm Hg. Art. Diastolic blood pressure is reduced even more significantly and may not be detected. Severe oliguria (decrease in hourly diuresis to 30 ml/h).

At stage 3, or the stage of decompensated irreversible shock, blood loss more than 2000 ml and loss of blood volume more than 45-50%. Shock index more than 1.5. Symptoms of stage 3 hemorrhagic shock - the patient is unconscious, severe pallor (marbling) of the skin. The pulse in the peripheral vessels is not detected. Heart rate 140 or more, rhythm disturbances, systolic blood pressure 60 mm Hg. Art. and lower, difficult to determine, diastolic approaches 0. Breathing is weakened, with a disturbed rhythm, anuria.

Diagnostics:

Diagnosis of blood loss and severity of hemorrhagic shock is based on external blood loss and symptoms of internal blood loss. The severity of shock is indicated by pallor and a decrease in skin temperature, a decrease in blood pressure, and an increased and weakened pulse. Vital dysfunction is observed important organs, as indicated by changes in heart rhythm, breathing, depression of consciousness, decreased diuresis, impaired coagulation factors, decreased hemoglobin, hematocrit, and protein concentration.

First aid:

The midwife is obliged to establish the cause of blood loss and, if possible, perform hemostasis, establish contact with the vein, and administer blood replacement solutions. It is necessary to urgently call a doctor or take the woman to a hospital and explain the urgency of the situation. Before the doctor arrives (before delivery to the hospital), maintain life support, provide care, and provide psychoprophylactic assistance to the woman and her relatives.

The scope of first aid is determined by the availability of medical care and the amount of blood loss. In hospitals in large cities, the medical stage begins almost immediately; after the doctor arrives, the midwife carries out his instructions. In remote areas where medical care is less available, the midwife must perform more, including surgical interventions, e.g. manual examination uterine cavity and massage of the uterus on a fist.

Treatment of hemorrhagic shock:

An indispensable condition effective assistance is to stop bleeding. Often, this requires the use of surgical treatment methods: removal of the fallopian tube if it ruptures, C-section with placenta previa, premature detachment placenta, manual examination of the uterine cavity for uterine hypotension, suturing ruptures in the birth canal. In the most severe cases Removal of the uterus is required, for example in the case of “Couveler's uterus”.

Only a doctor can perform a transsection, cesarean section, removal of the uterus, tubes, or other abdominal surgery. Anesthesia is needed to relieve pain in such operations. Therefore, if bleeding for which it is necessary abdominal operations, occur at the pre-medical level, the woman faces deadly danger. During the deployment of operational actions and after them, the drug treatment. It is necessary to maintain and restore bcc, restore macro- and microcirculation. For this purpose, hemodynamic and hemostatic agents are used, agents for correcting coagulation disorders, blood substitutes are administered, and blood transfusions are performed.

As with other types of shock, antishock therapy includes the administration of glucocorticoids, cardiac drugs, and drugs to improve the function of vital organs. In severe shock, it is used artificial ventilation lungs, with terminal states- resuscitation measures. All treatment is prescribed by an obstetrician together with an anesthesiologist-resuscitator, and in such a situation the most experienced doctors, consultants - hematologists and other specialists - are urgently involved.

Midwives and nurses carry out doctors’ orders and provide care (the success of treatment largely depends on qualified care). The midwife must know the principles of diagnosis, observation, care, treatment of hemorrhagic shock, action medicines, used for large blood loss, be able to follow the doctor’s instructions.

The basis of the treatment of hemorrhagic shock is infusion-transfusion therapy. The volume of transfused funds must exceed the volume of blood loss, the infusion rate must be effective, so it is necessary to use the veins in both arms and central veins. An optimal ratio of colloidal, crystalloid solutions and blood is required, which is determined by the doctor. The quantity and quality of transfused blood substitutes depends on the amount of blood loss, the woman’s condition, the cause of bleeding, complications that have arisen, blood counts, and surgical interventions performed.

Colloidal solutions:

Polyglucin - 6% dextran solution. It has a pronounced hemodynamic effect: it steadily increases blood volume, remains in the bloodstream for a long time, promotes fluid retention in the bloodstream, and also helps improve microcirculation.
Reopolyglucin - 10% dextran solution. It has approximately the same properties, but the hemodynamic properties are less pronounced, while the rheological properties are more pronounced. It also has detoxifying properties. When large volumes are transfused, clotting activity decreases.
Gelatinol is an 8% solution of partially split and modified gelatin, prepared in an isotonic solution of sodium chloride. It quickly increases the volume of circulating plasma, but is eliminated very quickly.

Crystalloid solutions:

Crystalloid solutions are used to replenish lost fluid, normalize disturbances in water-electrolyte metabolism and acid-base balance. For this purpose they are used isotonic solution sodium chloride, Ringer's solutions, sodium bicarbonate, glucose, lactosol, etc. Replenishment of blood loss mainly due to crystalloids leads to disturbances in coagulation factors.

Blood substitutes - blood products:

Protein preparations
Albumin is available in the form of 5%, 10%, 20% solutions, helps to increase colloid osmotic pressure, which leads to the flow of fluid from tissues into the bloodstream, and provides both hemodynamic and rheological effects, as well as detoxification. Protein is an isotonic solution of pasteurized plasma proteins (80% albumin and 20% globulin). Helps increase plasma volume and improve microcirculation.

Plasma can be dry or liquid (native)
Plasma consists of 8% protein, 2% organic and inorganic substances and 90% water. Plasma transfusion is carried out taking into account group affiliation and Rh factor. Dried plasma is diluted with saline solution.
Transfusion of blood substitutes may cause anaphylactic reactions.

Canned donor blood
In case of hemorrhagic shock, transfusion of solutions and plasma is not enough; blood transfusion is also necessary. This restores not only the volume of blood volume, but also hemostasis disorders. Canned donor blood is whole blood with the addition of an anticoagulant.

In case of hemorrhagic shock, blood is transfused that was collected no earlier than three days ago. Blood transfusions are carried out taking into account the matching group and Rh factor. It is mandatory to check the group and Rh factor, carry out compatibility tests: cold, polyglucin and biological tests. During a transfusion, it is necessary to promptly identify complications, which are indicated by chills accompanied by a rise in temperature, skin hyperemia, itchy skin, headaches, joint pain, back pain, aches, suffocation, deterioration of hemodynamic parameters and diuresis, the appearance of blood in the urine.

These manifestations are easier to notice when the woman is conscious. It is much more difficult when a woman is under anesthesia or dozing after surgery. Therefore, monitoring pulse, blood pressure, temperature, respiration, hourly diuresis, urgent analysis urine, it is necessary to monitor the color of the skin.

Red blood cell mass is more concentrated than canned blood and eliminates hypoxia to a greater extent. The principles of preparing for a transfusion are the same. As with canned blood transfusions, anaphylactic complications are possible.

Platelet mass is transfused when the platelet count decreases and the resulting clotting disorder occurs.

Medicinal purposes:

Antispasmodics are used to relieve peripheral spasm; to improve cardiac activity - cardiac glycosides; as antishock agent hydrocortisone is used; hemostatic agents are prescribed to improve microcirculation, oxygenation, and to correct coagulation disorders.

Care:

With such a severe complication, care is individual, the woman is in the operating room and then in the intensive care ward. Individual fasting, constant monitoring of pulse, blood pressure, respiratory rate, hourly diuresis, temperature, and skin condition. Monitors are used to monitor hemodynamic parameters, and an indwelling catheter is used to monitor diuresis. Used for drug administration permanent catheters, including in the subclavian vein.

A strict record of the administered solutions and medications is carried out, indicating the time (as is done in the anesthesia card). Manifestations of bleeding or hemorrhage are monitored: from the uterus and vagina, postoperative wounds, injection sites, the presence of petechiae, hemorrhages on the skin and mucous membranes. Since bleeding most often occurs during childbirth and after childbirth or requires urgent surgical intervention, the general plan of monitoring and care is appropriate to the requirements of the postpartum or postoperative period.

Complications of hemorrhagic shock:

With rapid and massive blood loss and absence adequate assistance Cardiac arrest may quickly occur. Pathological changes with massive blood loss, even after it has stopped, often associated with surgical interventions, and even with infusion and transfusion therapy, often lead to severe and even irreversible and fatal dangerous complications with hemorrhagic shock. (Complications may occur due to infusions and transfusions, massive drug therapy.)

Hypoxia occurs, caused by a sharp decrease in hemoglobin, cardiac and pulmonary failure. Respiratory failure accompanied by increased and disrupted breathing rhythm, cyanosis, hemodynamic disturbances and mental changes. Extremely heavy pulmonary failure called "shock lung". This complication causes loss of elasticity. lung tissue, hemorrhages, edema, atelectasis, hyaline membranes, which can be characterized as respiratory distress syndrome.

Liver failure (“shock liver”) may develop, renal failure(“shock kidney”), coagulation disorders, postpartum infectious complications and etc.
More long-term consequences there may be chronic diseases of vital organs and postpartum endocrine diseases. Due to the use surgical operations to control bleeding, including removal of the uterus, absolute loss is possible reproductive function.

Rehabilitation:

Restoring health after such a serious complication is lengthy and requires great effort. For physical rehabilitation a whole range of measures is required, which is prescribed by doctors. The midwife's responsibilities include monitoring the implementation of the rehabilitation program. The most important thing is to restore the function of the lungs and kidneys, since after massive blood loss and resuscitation measures the development of “shock lung” and “shock kidney” with disruption of their functions is likely.

In the event of the loss of a child, and especially the persistent loss of reproductive function, psychological support is necessary. The midwife must remember that it is necessary to maintain confidential information, especially if a woman loses her reproductive function.

Prevention:

Preventative measures are extremely important. It is much safer and more effective to pay more attention to preventive measures than to deal with the consequences of severe blood loss. If blood loss exceeds the norm, it is necessary to urgently therapeutic measures without waiting for the occurrence severe complications. The midwife, just like the doctor, is responsible for preventive work.

Prevention of hemorrhagic shock includes:

strict identification of risk factors for bleeding;
providing qualified care in an intensive maternity unit with mandatory medical supervision for women with risk factors for bleeding;
constant readiness of personnel at any stage to provide assistance with bleeding;
coordination of personnel actions;
readiness necessary medications, instruments, diagnostic and resuscitation equipment.

Hemorrhagic shock is extremely dangerous condition, threatening human life, requiring immediate pre-hospital emergency care. – similar regardless of the causes of acute blood loss. First of all, call an ambulance and act quickly:

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

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

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

Step 3. Apply to the victim's body correct posture on a hard, level surface. If the victim is unconscious, you need to lay him on his side and tilt his head back.

Attention! If a fracture of the cervical spine is suspected, it is forbidden to move the person’s head back. In patients with a probable fracture of the hip bones, the pelvis is placed with the knees slightly bent and the limbs spread to the side.

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

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

Attention! If you suspect a traumatic brain injury or if you are injured abdominal cavity the use of analgesics is prohibited due to the risk of deterioration of respiratory function.

Step 6. For hemorrhagic shock, emergency care is provided by constant monitoring above the victim's blood pressure values. At sharp drop tonometer indicators must be given to the victim if he is conscious, a large number of liquids.

Further actions must be carried out in a hospital.

Definition

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

Causes

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

Factor 1. Intense, light bleeding

The cause of a sudden, sharp, intense release of blood is a complete transverse rupture of large vessels: the aorta, upper and lower veins, and pulmonary trunk. Although the volume of blood loss in such situations is non-critical (up to 300 ml), however, as a result of a lightning-fast decrease in blood pressure, complete absence oxygen in the tissues of the brain and myocardium, which is fraught with a rapid onset fatal outcome. It is this factor that becomes the main cause of death from blood loss.

Factor 2. Slow heavy bleeding

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

Symptoms

Main clinical signs hemorrhagic shock requiring emergency pre-medical actions, are:

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

In severe situations, a decrease in the amount of urine excreted by the kidneys occurs. Collapse and disturbance in the level of consciousness to the point of coma may be recorded.