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Treatment of hemorrhagic shock at the stages of medical evacuation

/. Primary medical care in the focus of destruction: temporary arrest of bleeding,temporary immobilization, anesthesia with analgetics in syrettes, application of occlusive dressing in open pneumothorax, removal of mechanical asphyxia, a careful transportation (to avoid superfluous rearrangements).

2. Primary physician 's care: control of proper arrest of bleeding and application of occlusive dressing, as far as posssible — a carrying out of novocaine blockade, transfusion of hypertonic-and-hyperoncotic solutions (7.5% NaCl solution, plasma substitutes (refortan, stabizol) and plasma, repeated administration of analgetics and cardio-vascular agents.

3. Qualified and specialized aid:

I. Hemostasis. Taking a decision about operation in order to arrest
hemorrhage, in spite of significant decrease of operative risk owing to
anesthesiologic provision and corrective therapy, represents certain difficulties:
it is necessary to assess as far as the operation will remove the main
pathogenetic factor in development of shock, and a choice of anesthesia is
important, from the point of vew of prevention of irreversible shock.

They consider that a deepening of narcosis exerts unfavorable effect upon hemodynamics. In already developed shock a surface anesthesia is more sparing. Up to now, the problem of choice of anesthetics for anesthesiologic provision of operations in patients with hemorrhagic shock remains debatable. A preference is given to intra-venous anesthesia with ketamine and diprivan in combination with inhalation anesthetic — nitrous oxide. As for ensuring a proper respiration during operation, a preference is always given to APV.

II. Replenishment of VCB (Table 22) — transfusion therapy is one of the
basic elements in the treatment of shock. It must be made taking into account
stages of shock.

If shock is compensated and Ht is no less than 0.3, hemotransfusion is not indicated.

The dosage and rate of administration of plasma substitutes and solutions for infusion therapy are defined by the levels of AP and CVP.

Salt solutions leave rapidly vascular bed, worsen a transport of oxygen by blood, at the expense of hemodilution, and increase the danger of arising hemolysis. Therefore, their application in cases of severe shock must be limited, except 7.5% NaCl solution that is infused by the so-called "small volumes" (by 50 ml).

A replenishment of VCB deficit, primarily, with colloid solutions is fraught with development of cardiac overload.

In order to eliminate critical hypovolemia (CVP is equal to zero, AP is not defined), an infusion of solutions at the rate of 400-500 ml/min into 2-3 veins is needed.

Table 22 Scheme of replenishment of VCB by Reissigi

Therapy is considered as adequate if one succeeds in measuring AP in 10 min. A replenishment of VCB is to be continued until the upper boundary of CVP norm (10-12 cm water column) is achieved. The optimal rate of infusion of solutions at this stage makes up 20 ml/min. If after the infusion of 250 ml of solution for 15 min CVP increases by 5 cm of water column, it points to the possibility of cardiac overload and demands a slowing down or discontinuation of transfusion.

In normovolemic patients the infusion of 200ml NaCl isotonic solution or colloid solution produces an elevation of CVP that returns rapidly to the norm. If this does not occur and CVP remains elevated, in case of need in further infusion, it is carried out with observation of the rule "5-2":

— in CVP > 8, but < 14 cm water column, a 10-min load is carried out with 200 ml isotonic solution;

— in CVP > 14 cm water column a load makes up 50 ml;

— if as a result of load, CVP elevates by more than 5 cm, — infusion is discontinued;

— if as a result of load, the rise makes up < 5, but > 2 cm water column — the infusion is suspended;

— if CVP increases by less than 2 cm water column — the infuson is continued under further control of CVP.

On the background of replenishment of lost VCB a sympathomimetic agent of choice is dopamin. Its initial dose should not exceed 200 mg/kg/min. In replenished VCB the place of sympathomimetics is gradually taken by vasodilating agents contributing to a restoration of microcirculation.

Therapy of acidosis — 4% soda, trisamine — 200-250 ml/hour.

A program of component infusion-transfusion therapy of blood loss is given in Table 23.

The main tasks of infusion therapy in hemorrhagic shock:

— replenishment of VCB, restoration of hemodynamics, elimination of microcirculatory disorders;

— increase or restoration of oxygen-transport function of blood at the expense of introduction of packed red cells, perftoran.

According to L.V. Usenko's findings (2000), perftoran decreases a degree of shock expression at the expense of lowering the excitation of stress-realizing systems (sympathoadrenal, histamine-reactive), decrease of total peripheral resistance, improvement of microcirculation that leads to the protection from hypoxia of the liver and kidneys (organoprotective effect), activation of gas transport function of blood, increase of hemoglobin oxygen capacity and facilitating its dissociation. Perftoran (PF) is indicated:

Table 23 Assessment of needs in liquid in hemorrhagic shock (in accordance with G.M. Susla et al., 1999)

a) as a component of infusion-transfusion therapy from the 2-nd level of blood substitution 2-4 ml/kg, the 3-rd level — 4-7 ml/kg, the 4-th — 7-10 ml/kg, the 5-th—10-15 ml/kg.

b) at the prehospital level up to the arrest of bleeding with surgical methods — 4-15 ml/kg.

c) after the arrest of bleeding in the intra- and postoperative periods.
Application of perftoran gives the possibility to decrease total lethality by

5-35% and frequency of postoperative complications by 12.5%, to reduce a volume of infused blood or packed red cells 1.5 times.

Effect of perftoran increases in carrying out an oxygen therapy with content of 40-60% oxygen in the inhaled mixture for 24 hours after its infusion, as well as the use of hyperbaric oxygenation (0.8-1.25 atm for 1.5 hour).

Criteria of control of the adequacy of infusion-transfusion therapy in hemorrhagic shock:

1) Ht 0.25-0.3;

2) Factors of blood coagulation > 30% of the norm;

3) Hb 75 — 100 g/1;

4) Thrombocytes > 50000 in mm³.

A qualitative composition of the media for infusion therapy of hemorrhagic shock is constantly revised. At present, a chief attention is paid to the use of crystalloids, as well as synthetic and natural colloids. Of the synthetic oies they apply gelatinol, dextrans and hydroxyethylstarches, and of natural — albumin, plasma.

In the treatment of hemorrhagic shock a role of gas exchange normalization is great, it is implemented by means of oxygen inhalation through nasal catheters, masks of apparatuses and even via endotracheal tube with APV, as well as elimination of consequencies of compensatory reactions, and firs: of all, hepatic and renal insufficiency.

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