Traumatic shock

Description:

Traumatic shock — heavy, life-threatening the patient, the morbid condition arising at severe injuries, such as changes of pelvic bones, severe gunshot wounds, a craniocereberal injury, a stomach injury with an internal injury, operations, a big loss of blood. On a pathogeny traumatic shock corresponds to hypovolemic. The major factors causing this type of shock — strong pain stimulation and loss of large volumes of blood.

Symptoms of Traumatic shock:

Traumatic shock usually passes two phases, a so-called "erectile" phase of shock and a "torpid" phase in the development. Patients with low compensatory opportunities of an organism can are absent or have very short (to be measured for minutes) erectile phase of shock and shock begins to develop from a torpid phase, for example at very severe injury or wound (traumatic separations and crush of extremities at the level of a hip, the getting wounds of an abdominal and chest cavity with wound of internals, a severe craniocereberal injury) which are followed by blood loss and crush of soft tissues at once. Such damages usually lead to shock of extreme weight. In this case the person at once faints because of excessively strong painful signal with which the brain is simply not able to cope and "is as if switched off".

Erectile phase of shock. The victim at the initial stage often feels severe pain and signals about it means available to it: shout, groan, words, mimicry, gestures. In the first, erectile, a phase of shock of the patient it is excited, scared, disturbing. It is often aggressive. Resists inspection, treatment attempts. He can rush about, shout from pain, groan, cry, complain of pain, ask or demand analgetics, drugs.

In this phase compensatory opportunities of an organism are not exhausted yet, and arterial pressure often is even increased in comparison with norm (as reaction to pain and stress). The spasmodermia — the pallor amplifying in process of continuation of bleeding and/or progressing of shock is at the same time noted. The cardiopalmus (tachycardia), hurried breathing (tachypnea), fear of death, a cold clammy sweat (such sweat, as a rule, has no smell), a tremor (trembling) or small twitchings of muscles is observed. Pupils are expanded (reaction to pain), eyes shine. The look is uneasy, does not stop on anything. Body temperature can be slightly increased (37-38 C) even for lack of signs of infection of a wound — just as result of a stress, emission of catecholamines and the raised standard metabolism. Pulse keeps satisfactory filling, rhythm. There are no signs of development of the IDCS, a syndrome of "a shock kidney", "a shock lung". Integuments usually cold (vasospasm).

Torpid phase of shock. In this phase of the patient in most cases ceases to shout, groan, cry, rush about from pain, asks nothing, does not demand. It is slowed down, sluggish, apathetic, sleepy, depressive, can lie in complete prostration or faint. Sometimes the victim can publish only weak groan. Such behavior is caused by a depressed case. At the same time pain does not decrease. Arterial pressure decreases, sometimes to critically low figures or is not defined at measurement on peripheral vessels at all. The expressed tachycardia. Painful sensitivity is absent or is sharply reduced. Around a wound it does not react to any manipulations. Either does not answer questions, or answers it is hardly heard. Spasms can be observed. Often there is an involuntary release of urine and a calla.

The patient's eyes with torpid shock grow dull, tarnish, look sunk down, shadows under eyes appear. Pupils are expanded. The look is not mobile and directed afar. Body temperature can be normal, raised (accession of a wound fever) or a little lowered to 35.0-36.0 °C ("power exhaustion" of fabrics), a fever even in warm season. Sharp pallor of patients, cyanosis (tsianotichnost) of lips and other mucous attracts attention. Low level of hemoglobin, a hematocrit and erythrocytes in blood.

Intoxication phenomena are noted: lips are dry, baked, language is laid strongly over, the patient is tormented by constant strong thirst, nausea. Vomiting can be observed that is a bad predictive sign. Development of a syndrome of "a shock kidney" — despite thirst and the plentiful drink given in its occasion is observed, the patient of urine has not enough and it strongly concentrated, dark. At heavy shock of urine at the patient can not be in general. The syndrome of "a shock lung" — despite hurried breathing and hard work of lungs, supply of fabrics with oxygen remains inefficient because of a vasospasm and the low level of hemoglobin in blood.

Skin at the patient with torpid shock cold, dry (there is no cold sweat any more — there is nothing to sweat because of big loss of liquid at bleeding), turgor (elasticity) of fabrics is reduced. Point of features, smoothing of nasolabial folds. The saphenas which are fallen down. The low pulse, bad filling, can be threadlike or not be defined at all. The pulse is more often and weaker, the shock is heavier.

Abnormal liver functions are noted (as the liver receives less blood too and tests air hunger). If the patient with traumatic shock survives, then in several days (usually easy) yellowness of integuments as result of increase in level of bilirubin in blood and disturbances of bilirubin binding function of a liver can appear.

Reasons of Traumatic shock:

Absolute value of blood loss, how many blood loss speed is important for development of traumatic shock not so much. At bystry blood loss the organism has less time to adapt and adapt, and development of shock is more probable. Therefore shock is more probable at wound of large arteries, for example, of femoral.
Severe pain, and also the psychological stress connected with an injury undoubtedly play a role in development of a depressed case (though are not its main reason), and aggravate weight of shock.
The factors leading to development of traumatic shock or aggravating it are also injuries with damage of especially sensitive zones (a crotch, a neck) and vitals (for example, wound in a thorax, changes ребёр with dysfunction of external respiration, a craniocereberal injury). In similar cases weight of shock is defined by the blood loss size, intensity of a pain syndrome, the nature of an injury and degree of safety of function of vitals.
Shock can be primary (early) which arises directly after an injury and is direct reaction to an injury. Secondary (late) shock arises 4-24 hours later after an injury and even later, is frequent as a result of additional traumatization of the victim (when transporting, cooling, the renewed bleeding, an extremity banner with a plait, from rough manipulations at delivery of health care, etc.). A frequent kind of secondary shock is postoperative shock at wounded. Under the influence of additional traumatization also a shock recurrence at victims, usually within 24-36 hours is possible. Quite often shock develops after removal of a plait from an extremity.

Treatment of Traumatic shock:

It is necessary to try as it is possible to stop better and more stoutly bleeding: to press a finger the bleeding large vessel above the place of damage, to apply a compressing bandage (at venous or capillary bleeding) or burn down (at arterial bleeding), to plug an open wound tampons from 3% the hydrogen peroxide (having styptic effect). If there is an absorbable gelatin sponge or other means for a bystry stop of bleeding, suitable for use by the nonspecialist — it is necessary to use them. At low (or unknown) arterial pressure it is not necessary to give to the victim "cordial" drugs: nitroglycerine, Corvalol, motherwort and other: one of them will be useless, and others can sharply reduce already lowered pressure.

Does not follow, being a nonspecialist, to try to take a knife, a splinter, etc. — manipulations such can cause severe bleeding, pain and to aggravate shock. Do not set into place the internals (intestines loops, an epiploon etc.) which dropped out outside. It is recommended to impose pure antiseptic fabric on the dropped-out parts and to constantly moisten it that interiors did not dry. Be not afraid, for the patient such manipulations are painless.

In cold weather of the patient with shock it is necessary to cover heat (without covering the face), but not to overheat (optimum temperature of +25 °C) and to deliver as soon as possible to the warm room or the warmed car interior (patients with shock are very sensitive to overcooling). Very important plentifully (frequent, but in the small portions — drafts that did not pull out or did not strengthen nausea) to give to drink to the patient. It is better to give to drink from a spoon (because the victim will be hardly capable to drink independently). And it is necessary to give to drink more, than the patient himself wants or asks (so much how many he can physically drink). To begin to give to drink it is necessary even before development of thirst and symptoms of intoxication like dry lips and an oblozhennost of language. At the same time it is better to give to drink not simple water, but the special aqueous salt solution containing all salts necessary for an organism (it what feed a liquid at a diarrhea — like Regidron or Ringer's solution). It is possible to give to drink sweet strong tea or coffee, juice, compote, mineral water or the usual water which is simply added some salt to concentration of physical solution. Remember! Do not feed at all and do not give to drink to the victim with any injuries of an abdominal cavity! If the patient has a wound or an injury of a stomach, then it is only allowed to it urinate lips a wet cotton plug. Also the victim is not recommended to allow to eat and drink with injuries of the head and/or neck as at him swallowing functions can be broken. Do not give anything in a mouth to the victim in an unconscious or semi-conscious state at all!

Fractures, dislocations need to be immobilized carefully on tires (any suitable boards or branches) to reduce an oxycinesia and to prevent hit in blood of the smallest pieces of fabric (marrow, fatty tissue) which can provoke development of the IDCS at shock.

The patient with shock should be transported in the next hospital as soon as possible, but at the same time to observe reasonable care and to try not to shake the car on the road not to strengthen pain, not to provoke resuming of bleeding and not to aggravate shock. Do not shift the victim without emergency as any movements inflict on the patient additional suffering.

Whenever possible it is necessary to provide anesthesia available to the nonspecialist — to sprinkle a little "freezing" or to put to a wound cold (a bubble with ice or cold water), to give 1 — 2 tablets of any of disposed non-narcotic analgesics of type of analginum, aspirin, a ketorolak (provided that the patient on them has no allergy) or, in case of vomiting, to make an injection of non-narcotic analgesic. It is preferable to give non-narcotic analgesic more powerfully.

Introduction of narcotic analgetics by the nonspecialist at shock, in addition to possible legal problems, can be just dangerous: will cause respiratory depression, further falling of arterial pressure or strengthening of slackness and block in the patient. It is possible to enter narcotic analgetics only if you precisely know that you do, and are sure that you do not do harm. At the same time it is not necessary to use morphine (it strongly reduces arterial pressure and strongly breath oppresses, stronger than other drugs causes drowsiness and block). At shock from narcotic analgetics are optimum not reducing and even the butorfanol drugs raising the ABP (морадол, стадол), a nalbufin (нубаин), a tramadol (tramat). At severe pain Promedolum can be used (is in the syringe tubes of "military" first-aid sets). If you do an injection, then it is necessary to choose for it such place on a body, access to which demands less movements from the victim: more often it is an upper third of a shoulder (between elbow and humeral joints, is closer to humeral).

Whenever possible it is necessary to provide removal available to the nonspecialist nervously — a mental stress (which aggravates shock too): giving 1 — 2 tablets of any available benzodiazepine tranquilizer or a small amount of strong alcoholic drink. But alcohol can be applied only in extreme cases and that under a condition if the person normally transfers it! As it can worsen a condition of the patient.

Try to calm the victim. The emotional condition of patients has important value in fight against shock. Do not take offense at the patient who behaves aggressively in relation to people around. Remember that in state of shock of people does not give the report to the actions therefore is of great importance assured (without panic) and benevolent communication with the victim.