Lectures

Lectures 3.

 

General questions traumatology. Traumatism. Sprains, broken bones.
Desmurgy.
Shock. Therapy of shock.

 

General questions traumatology.

Injuries (Greek trauma, traumatos, wound, injury)-set injuries incurred in a particular population for a limited period of time and are associated with different types of human activity. Depending on conditions and where injury happened distinguish injuries: industrial (manufacturing), agriculture, transport, sports, household, military and children.

This distribution allows to define a group of people to discover the cause and the conditions in which it originated, to identify and carry out preventive measures.

Injury or travmoyunazyvayut sudden, momentary effect on the human external factors (mechanical, thermal, chemical, radiation and other things) that causes the organs and tissues of the anatomical and physiological changes that are accompanied by local and general reactions.

Worldwide, injury is considered a priority health issue. Deaths from injury is the third place among the causes of death. It is not only medical but also a social problem as dying, usually people of working age.

In the first place instructure injuries are road traffic accidents, in which, in most cases, there are massive polytrauma often accompanied by internal bleeding. It is important that a body damaged by fire damaged the vessel as quickly and efficiently provided first aid and transported the patient to a specialized department.

It is believed that the blood loss of 700 ml has no effect on the overall condition of the victim and hemodynamic parameters. In most cases, this condition continues until one hour after the injury and started bleeding. Therefore, this time called “golden hour”.

Accordingly, the objective of the first pre-medical and medical care on site traffic and transportnoyipryhody prytransportuvanni is to ensure all measures to stabilize hemodynamics and extension of time “golden hour” by centralizing circulation (decrease blood circulation to the periphery of the body to redistribute it to the vital organs (heart, lungs, brain)).

This is achieved by introducing a large number of substitutes by bandaging the limbs or the use of antishock suit type “Chestnut” (Russia), which is squeezing small vessels, with the saved trunk bleeds provides transition 1.5-2 liters of his own blood to vital organs: heart, lungs, kidneys, brain.

This allows for hemorrhagic shock reduced mortality from 77 to 26%. However, equally important is the time to help since the delivery of the patient to the hospital for the surgery and the final stop bleeding. The most optimal time is half an hour ago, this time called “platinum half an hour.” *

Thus, if multiple trauma with internal bleeding skilled care will be provided within 90 minutes, the probability of survival of the victim is high. However, the remoteness of hospitals, lack of communication, inability to provide competent assistance at the scene, the complexity of diagnosis significantly reduces the survival rate of victims.

There are the following types of injuries:

I. Depending on the conditions that caused the injury:

injury outside work: transport (road, rail, tram, etc.), street (with pedestrian movement);

household, sport.

Injury industrial nature (industrial and agricultural).

intentional injuries (military-related suicide).

II. By the nature of damaging factors: mechanical, thermal, chemical, surgical, radiation and others.

III. The nature of damage:

 – Closed (without damage to the skin and mucous membranes): slaughter (contusio), stretching (distorsio), gap (ruptura), sprains (luxatio), fractures (fractura);,

– Open (with damage to the skin and mucous membranes) wounds (vulnus);

– Penetrating into the cavity (with damage to the peritoneum, pleura, synovium, etc.);

– Penetrating into the cavity (without damage bar’yernyhobolonok);

– Single (damage only one body, one area);

– Multiple (damage to multiple body parts);

combined, polytrauma (injury of several organs);

– Combined (a combination of mechanical damage from radiation, chemicals and others.

IV. In place of application travmuvalnoyi forces: direct (pathological changes occur at the site of application of force) and indirect (damage occurring in the area remote from the area of ​​application of force).

V. By the time of: acute (occurring immediately after one-stage action travyuvalnoho factor) and chronic (resulting from prolonged,

or repeated exposure travmuvalnoho factor (bursitis, epicondylitis, etc.).

Any injury is accompanied by both local and general changes in the body.

The local manifestations belongs pain, change in shape, color, and mucosal integrity of the skin, dysfunction of the damaged organ.

By general reaction body should include dizziness, collapse, shock.

The severity of damage depends on many factors:

– Physical characteristics travmuvalnoho factor (shape, texture);

– Anatomical and physiological features of tissues and organs injured;

– The pathological state of tissues and organs at the time of injury;

– Conditions which are injured.

Slaughter

This damage tissues and organs without violating the integrity of the skin and mucous membranes, resulting in quick and short diyitravmuvalnoho factor. Diagnosis slaughter can be spotted only after exclusion of serious injuries (fractures, ruptured internal organs, etc.).

Pathologists changes at slaughter depends on the fault location, general condition, the patient’s age and other circumstances. It comes traumatic tissue edema, hemorrhage, or hematoma (usually at slaughter meat muscles).

The patient notes pain of varying intensity, swelling, bleeding and dysfunction. Pain at the time of injury is sharp, intense and depends on the location of slaughter. Often the pain initially decreases, and after 1 -2 hours increased, due growth traumatic edema. Most pain is trauma periosteum, shin bones, reproductive organs, large nerve trunks.

Swelling occurs due to permeation of tissues with blood, lymph, serous fluid exudate due to aseptic inflammation. its value depends on the density of the slaughter and subcutaneous fat.

Hemorrhage at the surface faces appear in the first few minutes, or hours after injury, with red color. In 5-6 days the color changes to blue-purple that caused the transition of oxyhemoglobin to reduced hemoglobin. At 10-12 days gets hemorrhage green (reduced hemoglobin turns into verdohemohromohen) and later – yellow (formed biliverdyn then-bilirubin).

Function body with small faces do not suffer. Severe dysfunction occurs in massive hemorrhages in the muscles, joints and more.

Treatment involves slaughter anesthesia (chloroethyl) in the first 2-3 days – immobilization of the injured area, blending bubble pack ice by applying bandages wheecessary anesthetic.

For large hematomas and hemarthrosis spend puncture with subsequent imposition compressive dressings. From 2-3 days prescribed thermal and elektroprotsedury aimed at resolution of hemorrhage: compresses, baths, UHF, eletroforez with potassium iodide, lidasa, himotrypsynom with 12 days – physiotherapy

 

Strain

 

This soft tissue damage that occurs when the force in the form of rods, without violating the anatomical continuity of tissues. Due to external influences articular surface temporarily diverge beyond the physiological norm, and the joint capsule, ligaments and muscles ukrepitelnye not damaged.

Often there is a sprain ankle joint. It is accompanied by swelling in the joints. Hemorrhage in the early days is hardly noticeable, and 3-4 days appears bluish-purplish spots. Movements in the joint limited and painful. Pain during exercise per axle limbs missing.

To impose joint compressive bandage and provide functional peace limb. In the first two days of applying cold, then – heat treatments.

 

Gap

 

Gap is damaged soft tissue FAST force as thrust, which exceeds the force of resistance anatomical tissues. Observed rupture of ligaments, muscles, fascia, tendons, blood vessels, nerve trunks.

The most common connection breaks ankle, knee and radial-carpal joints. If the gap is accompanied by damage to the ligaments of the joint capsule there is a hemarthrosis. This is especially true for kolinnohb joint, due to damage to the lateral and cruciate ligament and meniscus. Contours joint smoothed surrounding tissue increases in volume, flexion and extension of the joint limited and quite painful.

Muscle rupture may be partial or complete. Often there is a gap abdominal muscles and extensor extremities. In the area of ​​the gap there is pain on palpation, with full fracture defect appears damaged muscle. Further, due to hematoma occurs tumor formation. Typically there is partial or complete absence of muscle function.

We provide peace of limbs and fix it in the position of closest approach of broken sections of muscles by immobilization transport or fixed (plaster) bus. In the early days of the prescribed cold, further heat-treatments. When complete rupture recommended surgical treatment – stitching the torn muscles, followed by immobilization of the limb for 14-15 days.

 

Prolonged compression syndrome

 

Syndrome of prolonged compression (crush syndrome, traumatic toxemia, positional compression syndrome) – a pathological condition caused by prolonged (4-8 hours) compression of the soft tissues of the extremities, which is based on ischemic necrosis of muscle toxicity products necrosis with development hepato-renal failure. The longer is a compression body part, the heavier the course of this syndrome. In 81% of cases damaged limbs, especially the lower.

Classification prolonged compression syndrome:

I. Types of compression: compression point and squash.

II. By localization: head, chest, abdomen, pelvis, and extremities.

III. In combination: internal organs, bones and joints, major vessels and nerves.

IV. The degree of severity: mild, moderate and severe.

V. During the period of clinical course:

Time-compression;

-Postkompresiynyy period: early (first three days), intermediate (4-18 days) and late (more than 18 days).

VI. Combined damage:

prolonged compression syndrome + burn;

prolonged compression syndrome + frostbite;

prolonged compression syndrome + radiation damage;

prolonged compression syndrome + poisoning and other possible their

combination.

VII. In developed complications:

Disease-organs and systems (myocardial infarction, pneumonia, peritonitis, etc..)

Acute ischemia-damaged limbs;

Purulent-septic complications.

In the pathogenesis of the syndrome prolonged compression are the most important three factors:

-Painful stimulation;

-Traumatic toxemia due to suction products rozpadutkanyn primarily myoglobin, which blocks the renal tubules andleads to acute renal failure;

-Plasma and blood loss arising masyvnohonabryaku pressed areas of the body or limbs.

In the clinical course of three periods:

-Period increase in edema and circulatory failure, yakyytryvaye 1-3 days;

-Period of acute renal failure (with 3 days and lasts 9 12dib);

-Recovery period.

In the first period, immediately after the release of limb patients note pain, limitation of movement, weakness and nausea. Within a few hours increases swelling limbs. In patients with increased heart rate, decreased blood pressure, increased body temperature. On examination the limb initially observed pale skin and hemorrhage. After 30-40 minutes limb swells, increases in volume, the skin becomes uneven bahryanotsynyuvatoho color bubble appear with serous-hemorrhagic content. Fabrics limb palpation thick, resembling wood. Movement joints are impossible. Ripple peripheral arteries is not defined, disappear all kinds of sensitivity.

Gradually decreasing hourly and daily urine (up to 50-70 ml per day), the latter becomes lacquer red or dark brown color. In the period of acute renal failure patients feel better, but oliguria increases and becomes anuria, which may

cause death of the patient. With the development of acute renal failure patients subject to hemodialysis (artificial kidney).

Providing first aid performed before full release compressed limbs or the victim. Perform resuscitation on the system ABC, fired limb and immediately hold her tight bandaging or elastic gauze bandage. Higher compression is impose hemostatic tourniquet. Conduct transport immobilization, limb levy ice pack or cold water. Enter the means heart, analgesics, give drink 50-100 ml of alcohol. In the ambulance carried Continuous IV administration protivoshokovym liquids: Refortan, stabizolu, dextran and others.

 

Dislocations

 

Dislocation (luxatio) – called displacement of the articular surfaces of one or more bones in violation of their anatomical location and damage the integrity of the capsular ligaments, joint and surrounding tissue. When the articular surface of the face is not fully complete dislocation, if the stored partial contact of this dislocation is incomplete or subluxation. Most sprains happen in the shoulder and hip joints.

 

а                                                           б

The appearance of the victim in the dislocation of the shoulder (a) and hip joint (b).

 

There sprains: traumatic, pathological (diseases that cause destruction of capsule-ligament apparatus and articular surfaces (tumors, inflammation)); congenital dislocation;

 

 

conventional (with a large stretch ligaments and improper treatment);

old – time nevpravleni.

The name given by name dislocation displaced distal bone. Thus, the dislocation of the shoulder joint is called a shoulder dislocation in the hip, thigh, etc.

If the damage or jamming nerve trunks called dislocation complicated. Dislocation of the shoulder usually occurs in the fall on the assigned arm and hip dislocation is more common in accidents in passengers due to the sudden collision car.

When dislocation occurs pronounced pain in the following days decreases; disappear active and passive movements in the joint. Terms limb is forced, it rotated, deformed joints, sinks, head bone is absent in the joint and defined elsewhere (such as in the groin). Relative limb length decreases, the absolute – no change. In passive joints in the joint marked resilience dislocated bone. When shoulder dislocation victim tries to maintain a healthy arm damaged, and if cant torso towards damage.

 

 

First Aid is to immobilize the limb, bandage, deodora injected analgesics, topically applied cold. The patient was sent to the hospital. Reduction of dislocation doctor performs after preliminary X-ray examination.

For reduction of dislocation doctor need 1 -2 assistants. Depending on the type of dislocation and its location, there are certain tricks reduction: by Kocher, with Dzhanelidze by Hippocrates.

After ending shoulder dislocation reduction fix plaster splints or bandage deodora for 15-20 days, after which the prescribed thermal treatments and therapeutic exercises.

 

Fractures

 

Fracture (fractura) – a partial or complete disruption of the integrity of the bone under the influence of high-speed power. Fractures are congenital (occurring during fetal development) and acquired (resulting from the mechanical factors). Fractures that occur during childbirth attributed to acquired (obstetrics). There are more pathological fractures that occur in diseases of bone (osteomyelitis, tumor, cyst).

The frequency of fractures of the upper limbs occur in 50% of cases, the lower extremities – in 31%, pelvis and spine – 12% cherepav 6%, other – 1%. ‘

On the mechanism of fractures divided: compression fractures (compression) fractures from bending;

 

 

 

fractures from twisting (torsion, helical, spiral) blocks – detached fragment of bone at the site of attachment of tendons and muscles.

Given the extent of damage Fractures are divided into complete and incomplete. The latter include crack – oxide fracture type “green branches”, which mainly occur in children.

In relation to the axis of the plane of the fracture bone distinguished:-transverse-fracture line perpendicular to the axis of the bone, buck-fracture line parallel to the axis of the bone; hand – fracture line is directed obliquely to the axis;

– Helical or spiral;

– splinter.

There are single and multiple fractures. If the damage splinter adjacent organs fractures are divided into uncomplicated and complicated.

While maintaining the integrity of the skin is called closed fractures, the damage it – open.

In most cases, fractures involving displacement of primary fragments: side, the length, angle and rotary.

In addition, there may be a secondary displacement of fragments during transportation, rearrangement injured due to muscle strain or reliance on the injured limb. Localization distinguish diaphyseal fractures, when damaged, the middle part of the tubular bone (diaphysis) and epiphyseal (intraarticular), when damaged, the pineal gland, which has a sponge-like structure.

On examination, the victim must pay attention to its position it. When injuries are usually forced position because the patient healthy limb trying to reduce the load on the damaged or elected position, which relax the muscles of the trunk in fractures of the spine and pelvis.

 

Fig. Different types of fractures, depending on the initial displacement of bone fragments..

 

 

 

Fig. Radiographic features of fracture

 

There are absolute (characteristic only for fractures) and relative (may occur with other injuries) signs of fractures.

 

Absolute signs:

deformity of limbs in the zone of fracture, crepitus bone fragments in friction with one another; absolute shortened limbs, abnormal mobility in the area of ​​the fracture.

The presence of only one of these characteristics confirms the diagnosis of fracture. Relative signs: pain in the area of ​​the fracture, which increases with the axial load on the bone, the presence of hematoma, edema and swelling of tissues in the zone of fracture, limb dysfunction. Fractures may be complicated by bleeding, traumatic shoyum, fat embolism. In open fractures external bleeding, and when closed – the blood forms a hematoma at the fracture site and in the surrounding tissues.

For the treatment of lower extremity there fractures traction with special tires Belera (Fig. 36) and skeletal traction system (Fig. 37).

Fig. 36. Tires Belera

 

Traumatic shock – the general reaction to the great damage that manifests inhibition of vital functions due to the profound changes at the level of microcirculation and occurrence of hypoxia, manifested cardiovascular, respiratory, endocrine failure and profound disorders of the nervous system. Fat embolism caused by getting fat, bone marrow in large vascular or pulmonary circulation.

To clarify the diagnosis and identify the nature of the displacement of bone fragments conduct radiography in two orthogonal projections.

Fig. 37. Skeletal traction

First Aid with mechanical trauma

The main objectives of aid are:

Termination damage factors and interventions to improve or restore cardiac activity and respiration, temporary stop bleeding, blending and aseptic immobilization bandages.

Organizing and providing favorable conditions for the transport of the victim to the medical facility. The main requirement in assisting traumatized, especially with polytrauma, which often occurs in accidents, no harm to the victim!

After the release of the victim or of his body from damaging subject to a survey traumatized SAMPLE, where:

S (sign and symptoms) – complaints symptoms;

A (allergies) – the presence of allergies to medications the means;

M (medication) – drugs that can accept up to incident;

P (past / present medical history) – transferred and existing disease;

L (last meal or oral intake) – the last meal;

E (events before the empergency) – events before and during the event mechanism of injury that subject. Then carry out a detailed examination of the victim under the DRABCDE:

D (dranger) – overview of the scene;

R (response) – level of consciousness;

A (airway) – airways;

B (breathing) – breathing;

C (circulation) – circulation (pulse, blood pressure);

D (disability) – a brief neurological examination;

E (exspose) – exposure of damaged body parts. In case of violation of respiratory and cardiac activity should start resuscitation. Day clarify the state of mind of the victim examined by the AVPU:

A (alert) – consciousness is preserved;

V (voice) – responds to voice;

P (pain) – responds to pain;

U (unresponsive) – no reaction.

If the victim in mind and requires resuscitation, it is necessary to clarify the complaints and symptoms PQRST:

P (provokes) – that provokes symptoms

Q (quatity) – that improves or worsens the symptoms

R (region) – localization or irradiation of pain

S (severity) – severity of complaints (10 point scale)

T (time) – when started, when the action stopped traumatic force

If the victim abruptly broken or absent breath, stepped into cardiac arrest immediately begin resuscitation phases ABC for S.Safarom. Other stages of resuscitation performing medical resuscitation teams in cars and offices. Patients with multiple injuries, especially poterpshi in traffic accidents often have characteristic damage. The driver in a frontal collision the car may have a horizontal wound on the head from a mirror, a reflection of the front of the chest from the steering wheel with a broken rib and sternum, and vertical knee wound, sometimes combined with a high fracture shin bones from hitting the dashboard. Not excluded in the absence of head restraints, fracture of the cervical spine. As passengers – damage whiplash, concussion infarction, lung damage (breaks) of the liver, spleen, posterior hip dislocation in the hip joint. Recognition of damage difficult in unconscious and confused patients. Under these conditions rightly guided by the general rule: when the damage found in two separate remote locations (eg, head and lower limb) then there is a high likelihood of injury in the middle of the body, the abdominal organs: liver, spleen, intestine, kidney, ureters. Fracture of the pelvis are gaps urethra and bladder, especially when it was crowded at the time of injury.

Securing the airway is an important point and it is carried out directly in the evacuation of the victim from the car or from under travmuvalnyh debris. From the cab of the truck poterpshoho carefully extracted and, in the absence of vertebral fractures, body, limbs, put it on his right shoulder, right hand grasping the leg, and the left hand (Fig. 38). When pulling out the victim’s car together, one taking him on the arm, and the second captures the tibia and femur.

To ensure the airway, preventing asphyxia vomit poterpshoho placed on the left side, as shown in Fig. 39.

Patients undressing. To remove clothing and shoes should be under the general rules. Primarily remove clothes from healthy limb, and then – with the damaged. If it is difficult to remove clothing and there is a need to process the wound to stop the bleeding, then cut the clothes better.

Transport victim to ambulances or other transport is dependent on the condition of the victim.

Moving with support – the hand of the victim accused the neck of those who help and support for the wrist.

 

Fig.38. Pulling the victim of trucks and cars

 

 

 

 

Fig. 39. Turn the patient on the left side to prevent asphyxia vomit

 

Moving on hand – take the victim to the hands and one hand covering the torso, another plant under the knee. The victim covers his neck that he endures.

Carry on the back – the victim is on his back who carries arms and clinging to shoulder.

 

Transferring a patient in half-sitting position. One person covered under the hands of the victim from behind, the other is between the legs of the victim and takes the hand of his thigh.

 

Fig. 40. “Lock-seat” to transfer victims

 

 

Moving two people with “lock”. The victim sits on a “seat” and includes hands on the shoulders of those who provide assistance ( (Fig. 40).

 

Moving on stretchers. Burden is in all departments of hospitals and ambulances. To conclude nanoshi at large polytraumas to three.

Transportation victim. After restore breathing, stop bleeding conduct immobilization of the injured parts of the body or limbs. Best of health to transport cars, airplanes, helicopters. It is important to take care that the victim was protected from external factors: cold, rain, snow, possible overheating. In freight transport better transport victims on the bottom body, in the car – in the back seat or in the front, with a reclined back, locking the victim’s belt.

 

TRANSPORT and therapeutic immobilization

 

Transport immobilization is conducted to provide skilled medical care during transport the victim to a hospital. it is conducted not only in fractures and dislocations or suspected them, but also for large damage soft tissue wounds.

 

Fig. 41. Transport immobilization of the various types of fractures

 

In most cases, immobilization is improvised. Use the handy tools or healthy parts of the body: the damage to her feet pribintovyvayut healthy, injured arm pribintovyvayut to the body or used clothing, belts, boards (Fig. 41).

 

Transportation imobilizatsiyni tires are divided into two groups: fixation and distraction. By fixation tires include mesh back Filberha and Kramer (Fig. 42). They are durable, easily modeled on any area of ​​the body. Tires Cramer are two sizes: 60×10 110×10 sm. These tires are used primarily to immobilize the humerus, forearm, hands, legs and feet.

When applied mesh tire previously modeled it on the healthy limb of the victim, the third person or by itself (Fig. 43).

 

 

 

Fig. 42. Tires Cramer and Filberha

 

 

Tire Cramer for fixing the head.

 

 

Fig. 43. Modeling tires Cramer

 

Fractures of the humerus tire should start from the inner edge of the blade healthy side, go along the outer surface of bent (90 °) of the elbow resulted hand and end on finger.

 

 

Shin better fixating three tires, one modeled on the back of the leg and foot from the toes to the middle third of the thigh, the other two are fixed on either side of the tibia, while plantar flexing portion in the form of stirrups for better fixation of ankle joint. If the damage neck with mesh tires made “helmet”.

In mesh tire used cardboard, plywood or plastic materials.

For immobilization of limbs using vacuum tires. They come in three types: Type I – for additions and forearm, II type – for feet and legs, III-type for knee.

 

Distraction tire Diterihsa (Fig.44.) Used in hip fractures and hip joint. It consists of four parts plantar, internal, external with chopsticks-twist with lace and sliding bars with stops at the top and straps for fixing to the torso and hips.

 

 

 

Fig. 44. Distraction tire Diterihsa

 

Tire usually impose over clothes and shoes. By foot pribintovyvayut pidoshvovu of tires having fastening strap and two loops for attaching exterior and interior trims. The inner part of the tire (inner loop) placed on the inner thigh, groin vpyrayut transmitting lower end through the loop foot so that its end is speaking from her 8-10 cm

 

 

The outer contour of the fix so that it began from inguinal hollow and reach the foot passes through the outer loop soles and performed at 8-10 cm below it. End of the inside of the bend angle of 90 ° and inserted into the groove of the outer contour. Tire fixed on the trunk and thigh straps-locks. End of fixed circular passages bandage. Power from the “sole” carried through the fixing hole in the hinge of the inner loop and using sticks, twists spend pulling the lower limb. With simultaneous fractures ankle, foot and thigh bones – tire Diterihsa impose impossible.

 

Basic principles and rules of transport immobilization

Tyres have to capture two joints (above and below the fracture), and sometimes – and three (fractures hip – hip, knee, ankle, shoulder fractures, shoulder, elbow and wrist).

When immobilizing the limb to give it a physiological position or a position in which the least injured limb. In open fractures reposition fragments do not carry, and impose a sterile bandage and the limb is fixed in the position in which it is located.

When applied to the body wire tires to put cotton-gauze pads and more. DRI closed fractures tires impose on clothes

While shifting the victim or nosh on a stretcher injured limb support assistant.

Poorly executed immobilization may harm the victim: yes fracture may be open, cause massive bleeding due to damage to blood vessels bone fragments. Transport immobilization of fractures of the bones of shoulder girdle and upper extremities. Clavicular fractures – in inguinal put hollow shaft with wool or clothing with the size of a fist and can hold immobilization – Dezo dressing, cross dressing with two shoulder joints (Fig. 45).

 

 

 

 

 

 

 

 

 

Fig. 45. Transport

immobilization of fractures

clavicle

 

 

Fractures of the humerus in the upper third, arm bent at the elbow at 60 ° so that the tassel fell on his shoulder healthy side in inguinal fossa put shaft and fix it into the chest through a healthy shoulder. Forearm hung on squares and fixation shoulder to the chest. Diaphysis fracture shoulder immobilization conduct tire Cramer, simulate it in inguinal fossa put roller bandages and fix the tire. Fractures in the elbow joint tire grabs his shoulder and comes to the metacarpophalangeal joints. With no standard means of shoulder fractures using improvised tires with branches, pieces of boards, umbrellas, automobile pump. This immobilization spend two tires (Fig. 46).

 

Fig. 46. Improvised

immobilization tires on

the upper limb ‘

 

Forearm fracture using Cramer splint or Filberha with mandatory locking elbow and wrist joints, before transporting the patient is injected or given pain relievers.

Transport immobilization with lesions of the spine and pelvis. When spinal injuries and fractures almost always a traumatic shock and dysfunction of the pelvic organs. Therefore, reliable immobilization and careful transportation is the key to further the patient and his treatment.

 

 

So the victim injected anesthetic and heart means. Transportation is best handled ambulance on a stretcher solid, makeshift shield or in the back of the truck (Fig. 47).

 

Fig. 47. Stretcher for transporting a patient with a fracture of the spine

 

When investing victim caot prevent displacement of the spine. Fracture of the cervical spine immobilization is cotton-gauze roller or tire Yelanskoho. Victim transported on the back of the upturned head and platen throat. Fracture of thoracic and spinal spine or pelvis victim lay on his back with a roller under your knees.

With an open fracture of the spine transported on the stomach. In recent years, used to transport victims with fractures of the spine immobilization vacuum tire (Fig. 48).

Fig. 48 immobilization vacuum tire

 

Transport immobilization of fractures of the lower extremities. At the turn of the thigh, hip and knee joints used standard splint Diterihsa.

 

In its absence can use splint Cramer interconnected. they impose on the outer, inner and posterior surface of the limb. Immobilization three joints required.

Splint improvised from boards fractures leg

 

Improvised splinting for fractures of the hip performed improvised means (skis, poles), and in case of their absence can prybyntuvaty injured limb to healthy.

When fractures shin used splint Cramer, creating a stillness in the knee and ankle joints. Recently, the use of pneumatic splints.

 

Therapeutic immobilization

The largest spread was immobilization with gypsum bandages

 

Fig. 50. Stages of preparation gypsum bandage

Gypsum (deep fried at 140 ° C calcium sulfate) is a fine powder that is mixed with water has the ability to quickly harden. On air plaster absorbs moisture, so it is stored in a tightly sealed boxes and factory made plaster bandages in a plastic-sealed packages. Plaster bandages are wide (23 sm), medium (17 sm) and narrow (10 cm). their length of less than 3 meters. To check the quality of gypsum there are a few samples:

            -Gypsum powder compressed in his fist. If it’s good quality, topislya roztyskannya fist he crumbles when bad-is in the form of lumps.

-Equal servings of plaster and water mix on a plate. The resulting mass mayezastyhnuty after 5-6 min., While pressing fingers nerozchavlyuvatys on its surface should not serve water.

-Gypsum and water mixed in a 1:1 ratio and produce a ball that after 7-10 min. hardens. When this ball drop from a height of one

meter, it should not break.

For slow freezing, gypsum diluted with cold water to speed-kneaded in a warm (35-40 ° C). Plaster bandages can prepare yourself, rubbing powder gypsum bandage. Soak the plaster bandages or splints (several layers of bandages certain length and width) hold true. Dry bandage take two hands on the edges and placed on the surface of the water, bandage yourself get stuck in the water. Wheo longer stand vesicles air – Gypsum zmochyvsya. In summing bandage fingers of both hands and gently grip the sides to remove excess water (Fig. 50). Then either put the plaster on the body, or form Longuet foot.

All casts are divided into: circular, cutting-removable; vikonchasti; prosthetic; tire; lonhetni; lonhetno-circular; torakobrahialni; koksytni; honitni; corsets; beds (Fig. 51).

When applied cast follow the rules:

-Extremity or the relevant part of the body provide physiological abofunktsionalnoho starting position;

-Limb should support all tassel, not fingers;

-Except for the damaged body part immobilization subject dvasusidnihsuhloby;

 -If the plaster cast applied to the substrate, then this metykrasche use non-absorbent cotton that impose on

Bone performances;

-When applied bandages to cover every move of the previous round. To change the direction of the course of the tour, you caot go too plaster bandage it pruned from the opposite side and straightened;

– Bandage should not compress tissue and not be too loose, after dressing overlap check if it does not compress the main vessels (cyanosis, edema, cold, numbness, lack of pulsation).

 

Different types of gypsum bandages on the lower limb

 

For overlapping gypsum are special instrumentes: extension table, pelvis, apparatus for applying corsets. Read the casts by mechanical or electrical saws for plaster, scissors, scalpels, cutter Shtill.

Desmurgy.

 

Desmurgy (from the Greek words desmos – bunch, dressing, ergon-action) – the doctrine of dressings, principles and rules of the overlay.

Under the bandage understand the complex tools that are used to protect wounds pathologically altered skin from exposure to various environmental factors. In the narrow sense of dressing is a means to secure or retain wound dressings. The process of imposing it on the wound is called racking.

Bandager – complex and demanding procedure. Wrong imposed bandage can cause serious complications and have the same negative effects as poorly executed operation. There are certain requirements as to the very bandages in general and the rules regarding its imposition. Any band should:

possible to carry out its mission, to ensure physiological conditions for the functioning of the body or body;

be not too free, but not too tight (except for special bandages), does not infringe blood and limfrobih, be comfortable for the victim, not to cause psychological discomfort, have aesthetic appearance.

For a clearer understanding of the purpose and application of bandages, they allocate (classified) according to the material functionality, stages of care. Functional bandages causes vybirpevnoho material and stage of care (first aid, doshpytalnyy Hospital and stages) determine the form of tools for racking.

Depending on the type of material distinguish the following groups of dressings:

– Soft bandage: bandage with gauze, bandages, fabric, gauze-kleolni, plastyrni with film-forming aerosols.

– Solid dressings, or that harden: tire (hard) bands of various materials (wood, metal, plastic), bandages with plaster, starch, new polymeric materials (fibrohlas, resin) in the process overlay are solid. By functionality is divided into protective bandages, fixing, compressing, hemostatic, occlusion, immobilization, adjustment and bandages to extract.

With protective bandages covering wound surface of the wound and other damage to the body surface. Apply gauze or cloth bandages, lypkoplastyr, film-forming aerosols.

With record locking bandages bandages in the area of ​​its imposition. To apply this patch, adhesive substances, elastic tubular bandages.

Appointment of compressive bandages – maintain uniform pressure on a certain area of ​​the body. These bands are superimposed on areas where there is no threat of respiratory function (neck) or blood flow (inguinal area). For this purpose lypkoplastyr (with umbilical hernia in an infant), elastic bandage (on the joints, limbs), ointment preparations (zinc-gelatin bandage dressing in diseases of the veins of the lower extremities.

Haemostatic dressings are designed to stop bleeding from a wound (mainly capillary or arterial doshpytalnomu on stage). This is achieved by using special materials (hemostatic sponge, gauze, fibrynoutvoryuvalni plate type «Tachocomb» ^ or elastic pressing the space bleeding or trunk vessels (eg, temporal artery).

Occlusal (airtight) dressings are used mainly for doshpytalnomu stage in penetrating wounds of the chest to prevent pneumothorax. For this purpose, individual or standard dressing (IPP), or any material that is not breathable.

Adjustment dressings designed to create pressure on a certain part of the body to change its location or form. To do this, use substances that harden (casts boots with clubfoot) Pavlik stirrup leather.

Immobilization bandages used for property injured limb or its fragment to prevent the development of complications (shock, hemorrhage, displacement of fragments, etc.).. To do this, use tire dressings: wood, plywood (tire Diterihsa) wire (staircases splint Cramer), metal (standard splint) and plastics (pneumatic tires and splints).

Bandages to extract used in Hospital stage in the hospital. Most of them are complex structures made of metal, wood or wire (eg, compression-distraction apparatus Ilizarov).

V.Kazitskyy, M.Korzh in 1986 proposed a classification of soft dressings:

I. Defensiveness

II. Reinforcement.

III. Special.

standard, individual dressing (IPP), dressing pack (PP), sterile bandages, cotton-gauze pads sterile, cotton-gauze strip, contour bandage suspensory, rubber sealed bandage Belov;

Custom: economical, zinc-gelatin; bandage, suspensory; lypkoplastyrna, hermetyzuvalna, pov’yazkana buttocks Zhyude bandage, fixation on limb Wedge pillow.

Rules bandager

Authority (limb segment), which is superimposed bandage should be at chest level person who performs ligation and damaged part of the body of the victim should be as available for ligation. Authority (limb segment), which is superimposed band should be at the time of imposition in that same position in which it will be located after ligation in the treatment or transportation. This situation should be functionally convenient. Muscles patient (especially limbs) should be as relaxed. In case of damage to extremities dressings should be used to support or assistive devices.

– During blending dressings to prevent the occurrence of secondary complications in the damaged organ or limb segment due to displacement of fragments of bones, their vascular compression or nerve trunks, further microbial contamination of wounds and more.

– Ligation should start at the top of (peripheral) edge toward broader (proximal) to better retention bandage and its consolidation

– Tours bandage imposed with a constant and uniform tension dlyaunyknennya folds and constrictions.

– Typically, bandage left to right (against clockwise). This head bandage should be right ruts, beginning of bandage – on the left.

– When applied dressings (except crawling) each subsequent round should cover the previous round by 1/2 or 2/3 of the width of the bandage. If bandage over – at the end of the previous bandage enclose, beginning of a new circular confirms progress and continue bandaging.

– End bandage reinforce stitching thread or break his end by 10-30 sm in length, crisscross each other, encircles around the desired segment and tie a knot on the side opposite to the site of injury or English pin fixed to one of the neighboring tours.

Errors in imposing soft bandages

If bandage imposed tight, it may be bluish, swelling of the skin, reducing the temperature of the distal limb discomfort, throbbing pain may worsen bleeding from the wound, which is located below the overlay bandage (the phenomenon of venous tourniquet). Sometimes it can develop neuritis, necrosis or gangrene of individual sections of the limb. When transporting the victim with loss of consciousness winter, frostbite can occur distal extremity. In the case of the above complications bandage partially cut.

When wrapping limbs some tours bandage may be placed too tightly, others – not tight bandage so easily becomes uninhabitable. This bandage is better to replace. Integrity headbands easily broken if not taken first fixing tours. This bandage should pidbyntuvaty and then flash rounds bandage threads.

With little tension bandage dressing can quickly spovzty. Its better to replace.

The main types of bandage bandages

Any band consists of simple strokes bandage. At the beginning and end of bandaging impose fixing circular tours bandage.

 

Circular (Circular) bandage (fasciacircularis) (Fig. 1) consists of several circular turns of bandage imposed at the same place, completely covering all the previous rounds. This bandage is placed upon the body, whose shape is similar to the cylinder (head, shoulder, lower third of the tibia, phalanges, radial-carpal joint).

Spiral bandage (fasciaspiralis) (Fig. 2) is applied if necessary wrap large area of ​​the body. This bandage impose upward, first – 2-3 circular tour, and then they are sent obliquely upwards on the basis that each subsequent round is closed 2/3 the width of the previous one. Typically, such a bandage put on the body parts that have a cylindrical shape (trunk, shoulder, lower leg and forearm).

Fig.1. Circular bandage                                              Fig.2. Spiral bandage

With varying thickness segments of the limb (leg, thigh, forearm, shoulder) achieve a proper fit bandage impossible because spiral bandage to apply with excesses. In place of inconsistencies round bandage and a surface that bandage to hold the bottom edge of bandage first finger left hand and right hand do bend towards you at 180 °. This top of the bandage becomes lower and lower – upper. Progress continues to place the bandage fixing the first finger of the previous round. In the next round the bend bandage repeat. Excesses bandage should be on one line, preferably on the side of the injury. Excesses bandage to perform until the bandage part of the body that has the shape of a cone.

  Creeping bandage (fasciaserpences) resembles a spiral (Fig. 3).

Fig.3.  Creeping bandage

 

 

After Fixing tours bandage impose helical so that its tours are not touched. Intervals mizhturamy bandage should roughly match the width of the bandage. Creeping dressing is less robust than a spiral, so it is used for temporary holding dressings on limbs if they are damaged to a significant extent.

 

Characterization of individual groups of soft dressings

Soft dressings are very diverse. The most common of these are protective and fixing. Type of protective dressings depends on the nature and scope of damage conditions blending dressings, duration of stay in the body. Depending on the type of dressings and how to fix the body distinguish Glue, scarves, praschepodibni, contour, bandages and mesh-tubular bandages.

Adhesive bandages. Finely sliced, chopped, torn, clogged wounds, abrasions, scratches can protect adhesive bandages.

To this end, apply glue BF-6, both alone and in combination with antibiotics or monomycin levomitsetinom (levoplast), glue number 88 with erythromycin and others. After 5 minutes of applying the adhesive to the wound and surrounding skin film is formed, which can protect the wound from infection 3-4 days. It is washed with water, does not interfere with and promotes wound epithelization. Glue is applied to the wound only in the absence of bleeding, as in this case, the film builds tissue content increases pain and the film quickly becomes unusable. In addition, the skin around the wound should be dry and clean, with no signs of inflammation in the wound and around the zone of injury.

Dressings can be fixed to the edges of the skin using kleolu, Kolodiy, lypkoplastyru, special medical adhesives.

Kleol factory preparation consisting of 40 parts of rosin, 33 parts 96% ethanol, 15 parts ether and 1 part oil. The wound is closed in several layers of gauze wipes. Around them on a narrow strip of skin layer impose kleolu. Gauze, which in size slightly larger than the area of ​​wound dressing, in a strained applied to the deposited layer kleolu and kept in this position for 2-3 minutes. Napkin firmly attached to the skin and reliably captures povyazku on the wound. After removing the label remains kleolu removed from the skin swab is soaked in ether.

Kolody – a volatile liquid that is a mixture of ether, ethanol and cellulose nitrate. Technology blending kolodiyevoyi dressing is the same as kleolovoyi. Kolody dries slightly charge the skin, so it can cause the patient discomfort.

In modern terms kleolova and kolodiyeva bandages when administering first aid practically applied and have historical and theoretical interest.

Leykoplastyrni bandages. Plasters – a strip of fabric that is coated on one side with a special glue. Plasters produced in the form of coils of different sizes. Adhesive side of the adhesive plaster is sterile and can be imposed directly on the wound. Strips of plaster can be applied on top of the dressing and fix it to the skin. Leykoplastyrni headbands are very comfortable wheecessary nontraumatic bring together the wound edges.

To close small wounds, abrasions used bactericidal patch, which comes in special packaging. At the center of the surface

patch to be glued, is a porous material soaked in antiseptic substance.

 

Overlay wound dressings plaster bactericidal

This patches is very small pores, which helps to prevent the skin irritation does not affect the healing process of wounds. Note itso prolonged exposure to skin lypkoplastyru cause any skin irritation (dermatitis).

 

Film-forming aerozoli.Taki aerosols obtained by mixing the film-forming composition of Freon. Mixture filled glass or metal cans with lids spray. Clicking on the head spray liquid trickle out from a container. The solvent evaporates quickly and within a few seconds on the skin formed elastic protective film. Aerosol film affects the microflora of wounds and prevents “their secondary infection because it contains antibacterial broad-spectrum antibiotics.

Bumetol (butyl methacrylate polymer Methacrylic acid + + linetol) – one of the most common film-forming aerosols. Tape does not prevent evaporation vody and aeration skin because it has tiny pores through which does not get an infection. The pharmaceutical industry produces protyopikovi wound healing and aerosol medications, Livian, Vinizol, Levovinizol, Oksytsyklozol. These drugs include antibiotics (chloramphenicol succinate, oxytetracycline hydrochloride), antiseptics (citral, tsyminal), anti-inflammatory and wound-healing agents (prednisolone, vinilin, linetol, vitamin D3), etc.

Film-forming aerosols are easy to apply, quickly create a protective film does not require special training, can be widely used in the provision of self-help and mutual aid. Especially indicated aerosol application tapes at risk of postoperative infection stitches secretions from the fistula, urine, feces, and others. Protective film well kept on the skin, does not cause discomfort in patients and is waterproof. In the pharmaceutical market in Ukraine can be found such drugs – Plastbutol (Hungary) Akuhol (Czech Republic), Nobekutan (Sweden), Likvidoplast (Germany), etc.

The protective film is also formed when applied to a wound or a mixture of liquid Novikov Cherniak.

Synthetic adhesive compositions are often used to prepare the surgical field: sticky tape circ (Operating Aseptic Film Adhesive). This film has a polymer base thickness of about thirty microns on one side of which bears a special polymer adhesive that is selective stickiness to the skin. Before using fabric skin degreased and treated with antiseptic solution. Sterile forceps pull the film from the package and remove the paper. Sticky layer stretched film imposes on dry land operative field and carefully from the center to the periphery of the pad grind it to the skin. Then through the film perform operational section. After surgery, the film is removed. This operating wound securely isolated from the surrounding skin

Bandana headbands. These headbands imposed by a piece of cloth that is cut or folded in a right triangle-kerchief. Medical industry standard produces scarves for providing first aid size 135x100x100 cm, which is pressed a cube dimensions 5x3x3 sm One or more scarves can apply a bandage to secure any area of ​​the body (Fig. 5).

For blending scarf dressing on the upper extremity, forearm placed in the middle of scarves so that bouquet was situated near the edge of the headscarf (base). One end (back of arm) is carried on top of a healthy shoulder, the second – above the damaged shoulder, and bind them together so that the forearms squares were bent at right angles. The third end with some tension encircles around the shoulder and fixed by pins to the front of the headscarf.

 

Fig.5. Overlay scarf bandages on various parts of the body.

 

Sling dressing. Imposing For this type of dressings required wide bandage or strip of cotton cloth length 75-80 sm strip with both ends cut in the longitudinal direction so that the central part remained uncut in length, which is necessary to close the area damage . This uncut portion impose in the transverse direction to the wound site, incised end crisscross and connect the upper with the lower ends. Most of these bands are superimposed on different parts of the head (Fig. 6).

 

 

Fig.6. sling bandage

a-oose                                      b – on the chin

 

Bandages bandages. Bint – a strip of gauze length 5-7 m, which skatana in a roll. Produced bandages different widths: narrow (up to 5 sm)-for bandager clusters on fingers and feet, medium (7-10 sm) – for bandages on forearm, brush, head, neck, leg, foot, wide ( 15-20 sm) – for dressings on the chest, abdomen, thigh, pelvis, shoulder joint, shoulder. Standard bandages are sterile (tightly packed in provoschenyy paper) and sterile (plain paper wrapped in bundles).

Gauze bandage easily takes the form of the body, which bandage. Swathe bandage to create uniform pressure on the fabric and functional body or limb peace.

 

The bandages on his head and neck

 

Bandage “Hippocratic cap” (Fig. 76), which covers the scalp, given time is mostly historical value as poorly recorded and easily slips. Therefore, in practice BANDAGES prefer “cap” and “bridle”.

 

The bandage “cap” imposed following chyanom (Fig. 7B). Segment bandage length of one meter impose symmetrically on the crown. The ends of the bandage loosely hanging on both sides of the head. At the level of the eyebrows and occipital hill impose first circular coil at the ends that hang freely, on each successive development make a loop around the free end, then bandage lead through the neck to the other side of the head, which again make revolution around the free end, and bandage running across the forehead to the other side. Each subsequent round gradually shifted towards the crown until such time as the bandage is not shielding the entire surface of the scalp. Loose ends tied under the chin.

 

Fig.7. Bandages on his head: a – return б – “cap Hippocrates’ в -” cap “г -” bridle “, d – Neapolitan, е-in one eye; ж – in both eyes, з – cross bandage oeck .

 

Bandage “bridle”, except the scalp, also closes the side surface of the face, chin, temples and forehead (Fig. 7g). its start with 2-3 circular tour through the forehead and neck, and then drained his ear and transferred to the rear, and then – to the right and front of the neck, then drive on the left cheek vertically up front ear. Make the desired number of vertical tour, covering the crown and nape, then bandage again spend behind the ear on the occipital area, neck, making horizontal tours for fixation.

 

Union bandage used to stop bleeding from the temporal artery. Impose it with a double-headed bandage. Wrapping begin with whiskey healthy side in the horizontal plane. At the site of injury do decussation (to increase pressure on the wound often placed under the bandage cotton-gauze ball), and then drive bandage perpendicular to the first round (in the frontal plane). Again hold both heads through healthy temple to lesions crosse roblyattam and bandage in the horizontal plane.

 

Bandage on one eye. If your right eye bandage, bandage held in his right hand and, on the contrary, if the left eye bandaging head bandage shift in the left hand and keep the bandage from right to left. The first imposes a circular tour around the head. The following turns are over the ear healthy side and under the ear from damage (Fig. 7th).

Dressings communication in both eyes begin to apply just like a bandage on one eye. Then go through the nuchal hump on the other side under the ear, then lead up, closing the other eye. Tours crisscross bandage over the bridge of the nose. The bandage complete circular tour around the head. Ears are left open (Fig. 7zh).

 

The bandage on one or both ears is the same as dressing on one or both eyes, but close ear on the affected side and leave open the eye. You can also follow bandage “bridle”, closing the ear.

 

Bandages on the chest, abdomen and pelvis

Chest, upper and middle abdomen can safely close spiral bandage Shylovtseva or crosswise bandage (Fig. 8).

To prevent bias simple spiral bandage placed on the bottom half of the abdomen, it is fixed to the femur by spicate dressing. Impose it as follows: the last tour of the back area leading through the ilium, is sent down to the front of the thigh and perform circular tour around it, then bandage directed obliquely upwards on the anterior surface of the stomach to the upper border of the bandage, which serve several circular tour .

Then make another tour that captures bandage the thigh: his lead on the back obliquely down to the ilium, and then through the groin to the thigh. Bandage fix circular tour, transfer it to the anterior abdominal wall, where complete bandage several overlapping spiral rounds.

 

 

 

Fig.8. Bandages on the chest: a – spiral b – dressing Shylovtseva в – cross bandage

 

Bandage on inguinal area

Inguinal area most conveniently close spicate bandage (Fig. 9a). Bandage fix circular round belly. If you need to close the right groin, bandage are from left to right, and left – right to left. The next tour is oblique – after entering the lumbar region of his directing obliquely down over sacrum, buttocks and the greater trochanter of the femur, remove the front of the thigh, then bandage impose obliquely down the outside inwards, looking around the thigh behind the front surface to lonnogo joints and through the iliac area on the opposite side of the lumbar region. Then impose the required number turivpo go first oblique tour with some of their displacement. To create spicate bandage oblique tours can be combined with circular, allowing securely close the lower abdomen, buttocks, groin and upper third of the thigh. Finish bandage circular rounds on the stomach.

Fig.9. Bandages on the inguinal area and perineum: a – spicate, б, в – cross bandage on the perineum.

 

Bandage on perineum

This bandage impose follows (fig.9 б,в): bandage fix two circular rounds on his stomach, then impose vosmerkoobraznaya bandage from the crossroads of the perineum. Circular tour becomes slanting through the right groin in the crotch, back-through the left buttock area to the left iliac bone, then through the left groin and perineum on the right buttock area to the right iliac bone. For durability headbands vosmerkoobraznaya tours should combine with circularly around the abdomen.

 

Bandages on upper limb

Upper limb has a complex configuration, so dressing on it are very different and each includes a combination of different types of bandages.

 

On fingers brush can impose two kinds of dressings.

Recurrent bandage on finger (Fig. 10a). Originally impose several sharivbynta turn – on the back and on the palmar surface of the finger, which record the circular round at the base and then screw-up nail phalanx. Shape final bandage overlapping spiral upward tours. Fix bandage at the base of the finger. Similar bandage can be applied to all fingers and tassel – bandage “glove”.

Spiral bandage on finger (Fig. 106) is superimposed narrow bandage. A few rounds of circular bandage record in the area of ​​the wrist. When wrapping the right brush tours impose left to right, left – right to left. From wrist bandage carried obliquely to dorsum additions to the base of the finger. Then impose two spiral downward rounds to nail phalanx, then-upward spiral bandage to the base of the finger. Bandage deduce through interfinger span on back of the hand to the wrist, where his record circular tour. Consistently moving the other fingers and repeating the above steps, you can put a bandage on all his fingers – “glove”.

 

 

Fig.10. Bandages on fingers: A – reverse b – spiral, в – “glove”.

 

Spicate bandage on I finger and begins with fixing the bandage on the wrist, then bandage are obliquely through the back surface of the brush and thumb and turn through the back of the hand to the radial-carpal joint. Further, these tours are repeated cross several times successively shifting crosse bandages on his fingers to his foundation. Fix bandage on the wrist.

 

Bandage on tassel and radial-carpal joint is a combination of circular and cross dressings. Impose a few circular tours on areas of the radial-ulnaris joint, back of the hand through the bandage conducted through 1st interfinger interval on the palmar surface of brush and put a few circular tours tassel. Bandage return via the rear hand on the forearm. Cross tours repeated several times with weave their grazing the surface of the brush. Bandage fixed circular rounds in the area of ​​the wrist joint. Forearms can safely close as spiral bandage (Fig. 10c).

Spicate bandage on tassel

 

The bandage on the elbow impose bending arms at the elbow angle of 90 ° (Fig. 12). Bandaging several rounds of fixed circular shoulder just above the joint, and then perform cross bandage, which converges with the crossing of tours in the area cubital fossa. Recent tours covering the ulnar bone. Fix circular bandage round the shoulders.

 

Spicate bandage on the shoulder joint. (Figure 13.) On the shoulder near the inguinal fossa impose three circular tours. With inguinal fossa begin the fourth, leading him up obliquely on the outer surface of the shoulder on his back and then around the chest before this tour. Fifth round bandage lead through the area shoulder joint, slightly covering the previous round, obliquely down around the shoulder and through the inguinal fossa on the anterior surface of the shoulder joint, which goes into the next round, similar to the fourth. Consistently shift tours bandage, completely cover the area joint.

 

The bandage Dezo used for fixing the entire upper extremity (Fig. 14a). Before her laying in the inguinal area set light cotton-gauze roller, hand pressed against the body and bend at the elbow at 90 °.

Fig.12. Bandage on the forearm and “Turtle” bandage on elbow joint area.

 

Fig.13. Bandage on the shoulder joint and upper limb

 

After this circular rounds fix shoulder to chest, from healthy to diseased side. With the inguinal cavity healthy hand bandage spend the anterior surface of the chest on the sore shoulder, transferred back lowered to the elbow, picked up the elbow, forearm and tassel and return the bandage in the inguinal area. Then spend obliquely round the back at shoulder sick hands, transferred forward to the elbow, bend around it and back to back to inguinal cavity healthy side. These tours are repeated several times and finish their horizontal circular bandaging.

Fig.14. Bandages Dezo (a) and Velpo (b).

 

The bandage Velpo often used after shoulder dislocation reduction (Fig. 14 b). Tassels patient hands put a healthy shoulder. Bandage circular rounds from the patient side, gradually locking arm to the torso. Then keep bandage in inguinal cavity healthy side and the back obliquely to the patient’s shoulder. After this is down round the outside of the shoulder, elbow and envelopes obliquely upwards to hold the healthy inguinal basin. These tours are conducted several times before recording the limbs.

 

Bandages on the lower limb

Bandage on I finger begins with fixing bandage several rounds at circular pits tibia (Fig. 15). Next tour conducted by the rear foot and 1 st finger, closing it completely. Bandage impose a finger upward spiral bandage to his base, then bandage deduce through interdigital interval on the dorsum of the foot and fixed circular tour to the shin.

Recurrent bandage on the distal foot. Fix circular bandage several rounds of the tibia, remove it on the dorsum of the foot, throw over your fingers and close the sole of the foot, where the bandage bend and return to the back surface.

A few rounds pivoting cover the entire distal foot, then these tours confirms an upward spiral bandage. Bandage confirms circular rounds of the tibia (Fig. 16).

 

 

Fig.15. Spiral bandage on I finger at foot

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 16. Bandages on foot:       a – return                                                          b – spicate                                                                                в – cross bandage.

 

 

Bandage on the whole foot. Bandaging circular rounds fix the tibia and close the side of the foot circular rounds (tension) through the heel and toes. These tours are fixed upward spiral bandage from the toes to the tibia (Fig. 16 б).

 

Cross bandage for ankle joint. On the leg bones in the area in the direction from left to right impose several circular tours. From inside ankle bandage transferred on the dorsum of the foot to its outer edge, looking around at the cross around the foot and through the back surface leading to the outer ankle, and then – around the shin. These crossing tours repeated several times. Bandage fix the tibia (Fig. 16 в).

 

Fig. 17. Turtle bandage on foot.

 

Turtle bandage on the heel area (Fig. 17). Starting two circular tours through the heel and the front surface of the ankle joint. Impose the following tours that diverge alternately above and below the joint. These tours reinforce progress bandage around the heel area, then cross bandage on his ankle joint.

 

 

 

ACUTE circulatory failure. SHOCK

 

Shock – a clinical syndrome that results from excessive stimulation of endogenous or exogenous factors and is characterized by impaired hemodynamics and metabolism, which leads to the discrepancy between the need for tissue oxygen and its revenues.

 

The main clinical manifestation of shock is an acute heart failure, which develops as a result of depletion of the compensatory mechanisms of the body.

 

Despite the diversity shokohennyh factors and pathogenetic mechanisms of shock is the result of a violation of capillary perfusion and oxygen supply to the tissues due to a critical reduction in their blood.

 

There are forms of shock:

 

1. Hypovolemic;

 – Bleeding;

– Traumatic;

– Burn;

– Dehidratatsiyyyy.

 

2. Distributive (redistributive):

– Anaphylactic;

– Infectious-toxic (septic);

– Neurogenic;

– Endocrine.

 

3. Cardiogenic:

– Reflex;

– A real cardiogenic;

– Areaktyvnyy;

– Arrhythmogenic.

 

4. Obstructive.

 

Hypovolemic shock

 

Hypovolemic shock resulting from primary reduction BCC (absolute hypovolemia) due to blood loss, plazmovtratu or general dehydration.

 

 Hemorrhagic shock

 

Hemorrhagic shock develops due to acute blood loss and crisis accompanied by micro-and makrotsyrkulyatsiyi may be followed by the development of the syndrome of systemic failure of many organs (multiple organ failure).

 

The pathogenesis of hemorrhagic shock is acute blood loss, leading to a decrease in CBV, thus decreasing venous return and reduced CO. This leads to ischemia and release of adrenal catecholamines. Stimulation of a-adrenergic receptors causes vascular spasm of arterioles and venules, the output of blood from the depot (spleen, blood vessels of the skin, kidneys). Developed compensatory circulatory centralization aimed at yidtry mana perfusion of vital organs especially the brain and heart. P-adrenoceptor stimulation increases myocardial contractility, therefore, increases the heart rate, which allows time to hold AT na baseline. In addition, expanding bronchioles and decreases airway resistance, which facilitates external breathing. With the increase in bleeding compensatory changes caot resist progressive decrease CO, which reduces perfusion and ischemia of various organs and tissues, including kidney, liver, intestines, skin, etc.. Renal ischemia causes activation of the renin-angiotensin system, which is accompanied by increased production of vasopressin (ADH), an increase in arteriolar spasm, increased ZPOS and increases the load on the myocardium.

 

Violation of cellular metabolism causes activation of cytokines and complement fractions which forms part of the membrane damaging complex, resulting in damage to cell membranes and blood vascular endothelial trombonlastyn emissions, and increased permeability of the vascular wall All these changes are taking place against the background of activation of arachidonic acid metabolism and the formation of prostaglandins, leukotrienes , thromboxane.

 

Arachidonic acid is a part of cell membranes, under the influence of phospholipase A2 released.

 

Metabolites of arachidonic acid actively influence pa microcirculation. Yes, thromboxane A2 causes spasm microvasculature and stimulates platelet aggregation. Prostacyclin dilates blood vessels and is an active inhibitor of platelet aggregation. Prostaglandin E2 dilates, F2a – narrows. Leukotrienes C4, D4 and E4 in 1000 – 5000 times greater than the effect of histamine pas permeability of blood vessels and cause them to spasm. Result of changes in micro-vessels is out of fluid from the vascular bed and decreased plasma volume. In the bloodstream are all prerequisites for subsequent cascade reaction intravascular coagulation and progression of DIC.

 

These and other pathophysiological processes exacerbate damage to cell membranes and release of “fragments” of protein molecules that have miokardiodepresyvnu action, closing the vicious circle.

 

Formation sudynoaktyvnyh metabolites with prolonged tissue hypoxia caused to vasodilatation and a sharp drop in AT, which is often difficult to correct.

 

Level AT <50 mm Hg. century. leads to disruption of surfactant synthesis, causing alveoli begin spadatysya, disrupting alveolar ventilation and diffusion of gases through the alveolar-capillary membrane, increasing hypoxemia.

 

By reducing blood flow in peripheral vessels and hypotension tissue begin to actively consume oxygen from venous capillaries, resulting in increased arteriovenous oxygen content difference and for some time maintained its normal flow to tissues. Subsequently, the oxygen supply to the tissues decreases and increases tissue hypoxia. After opening of arteriovenous shunts bulk blood rushes through the shunt, which makes absolutely ineffective tissue perfusion.

 

So after acute blood loss in the absence of timely correction is complete disorder macro-and microcirculation disorders of all kinds of metabolic and enzymatic systems, functions of all organs. The syndrome of systemic failure, leading to death of the organism.

 

Clinic hemorrhagic shock largely depends not only on the amount of blood loss, but also on its speed and capacity of compensatory systems.

 

Diagnosis is based on clinical presentation: pale skin, cold and damp to the touch, inadequate behavior (excitement or depression), often soft pulse, decreased AT and CVP. Refinement of the diagnosis should be carried out in parallel with the urgent antishock measures: process is progressing rapidly, and therapeutic options are exhausted quickly. An important, but often a late sign of shock is to reduce systolic blood pressure.

 

Because compensatory responses even in case of decrease CBV by 15 – 25% and CO by 50% AT is withiormal limits. In such cases should focus na other clinical symptoms: pallor, cold moist skin, tachycardia, oligouriya. AT level can be set only on condition monitoring.

 

American College of Surgeons installed 4 classes bleeding depending on the amount of blood loss and clinical signs.

 

Class I. The volume of blood loss 15% of BCC and less. Clinical manifestations may not be available or there is only tachycardia at rest, especially in the sitting position. Such orthostatic tachycardia (increased heart rate at 20 for 1 min) showing the transition from a horizontal to a vertical position of the patient.

 

Class II. Blood loss 20-25% BCC. The main clinical symptom – orthostatic hypotension: lower systolic AT least 15 mm Hg. century. during the transition from horizontal to vertical. In the supine position AT may be normal or slightly reduced. Diuresis saved.

 

Class III. Blood loss 30-40% of BCC, hypotension in position pas back oligoanuria (urine output <400 ml per day).

 

Class IV. Blood loss of more than 40% of BCC, significant hypotension (<60 mm Hg. Century.) Possible impairment of consciousness.

 

In the clinical course of shock determine erectile and torpid phase.

 

Erectile phase. Significant psychomotor agitation pas background centralization of circulation. Possible inadequate behavior: patient fussing can scream randomly moving resists examination and treatment. Establish contact with him sometimes extremely difficult. AT may be normal, but tissue blood flow is disrupted due to its centralization. Erectile phase is short-lived and rare.

 

In torpid phase are four degrees of severity, which is determined by the shock index Alhovera-Burr (Allgower-Burry) (ratio of heart rate to systolic AT). In a normal heart rate for 60 per Ihv and AT systolic 120 mm Hg. century. it is 0.5 – 0.54.

 

As one of the leading pathogenesis of vasospasm is mikrotsyrkulya-Thorpe bed, an indicator of the spasm, and hence the severity of shock is a symptom of white spots. This symptom is considered positive when pressing the PA distal phalanx of the thumb brush nail bed is pale and his original color is restored more than 2 seconds.

 

The clinical course and severity of hemorrhagic shock divided into compensated, subcompensated, decompensated (reversible and irreversible) (Table 1).

 

Recently, to determine the severity of shock and predicting its consequences than clinical signs and shock index laktatpoyi determine the level of acid in the blood plasma. At the level of sodium lactate to 2 mmol / l survival is about 80%, and more than 8 mmol / l – 5 to 8%.

 

Intensive therapy is based on the following main principles;

 

– Immediate cessation of bleeding;

 

– Speedy recovery BCC, adequate time and volume;

 

– Therapy, adequate severity and patofiziolohichyo justified.

 

Lead specific component of intensive care is to stop the bleeding. Methods depend on the cause, volume, speed and severity of the bleeding patient.

 

Restoring BCC and of infusion therapy – earlier the better. From the rate of recovery of CBV and effective perfusion of organs and tissues mainly depends on the outcome and the probability of survival of the patient. Rate of infusion therapy determined by the degree of severity. Depending on the amount of blood loss and the severity of mobilizing 01.03 veins. To carry out catheterization subclavian or internal jugular vein by Seldynherom or venesektsiyi followed by constant control of CVP (as one indicator of the effectiveness of infusion therapy).

 

TABLE 1. Clinical manifestations of hemorrhagic shock, depending on the degree of severity tion and volume

Bleeding

 

 

 

If shock 3 -4 century. optimal rate of infusion therapy is 250 – 300 ml / min.

 

Blood loss up to 800 ml infusion compensate colloidal and crystalloid solutions volume 1 200 – 1 500 ml, 800 to 1000 ml – alternately or simultaneously with plasma substitutes (drugs hidroksietylkrohmalyu – stabizol, Refortan), low-or serednomolekulyarnymy dextran (reopolyglukine) drugs gelatin (zhelatynol, zhelafuzyn, zhelazol) of 5 – 6 ml / kg resustsytatsiynoyu (Latin resustytutio ~ revival) mixture (reopolyglukine or albumin 10% + 7.5% sodium chloride solution at a ratio of 1:1 – 5 ml / kg) and crystalloid solutions – from 10 to 12 ml / kg. Saline solutions while creating a reserve interstitial fluid, which prevents the development of intracellular exsicosis, causing efficient natural reactions involving compensation of blood loss.

 

Hemorrhage volume 1000-1500 ml compensate not only colloidal and crystalloid solutions, but blood transfusion, and in terms of the relationship between infusion therapy solutions and erythrocytes environments should be less than 3: 1. This erythrocytes have not exceed 40% of this fluid, and the total number of cans of red blood cells should not exceed 1000 ml for an adult to avoid the development of complications (massive transfusions syndrome, intoxication sodium citrate). Dose of saline solution should be increased to 15 ml / kg. What started later and that therapeutic measures larger deficit BCC, the more total dose of infusion therapy exceed blood loss. It is advisable to exceed the average blood loss of 150 – 200%, if necessary – to 300%.

 

Recently, much attention to the issue of autotransfusion, the most appropriate and safe method that does not cause immune disorders. Before elective surgery if the patient’s condition allows, should procure 350 – 500 ml of his blood. According need blood transfusion during surgery it is administered intravenously, must use special filters on the system for transfusion.

 

If during emergency surgery blood poured into the abdominal or thoracic cavity and not damaged hollow bodies, conduct blood reinfusion this previously gathered it in sterile containers by aspirator or special vehicles – selseyveriv (cell seyver).

 

Proper BCC calculated based on patient weight. For women it is 60 ml / kg for men – 70 ml / kg, and for pregnant women – 75 ml / kg.

 

In cases catastrophically poor performance hemodyyamiky best substitutes is one that you can start typing immediately. Usually infusion therapy begins with the introduction of crystalloid and colloid solutions. Surround effect Plasma solutions depends primarily on their osmolarity, relative density and viscosity.

 

Infusion therapy is carried out to stabilize the systolic pressure at 90-100 mm Hg. century. and CVP – 50 – 100 mm of water. century restoration indicator peripheral circulation also satisfactory rate of urination (more than 20 ml / h).

 

If during the infusion therapy, despite satisfactory CVP and AT, the patient remains sharply pale skin – cold, urine – less than 20 ml / h or completely terminated, after correction of intravascular fluid deficit starting set of measures to normalize blood circulation in peripheral tissues and microvasculature: introduction vasodilators on background infusion therapy by continuous hemodynamic monitoring.

 

Eliminating effects of centralization and circulatory vasospasm can be made only after correcting the deficit BCC, slowly introducing nitrite or nevroleytyky. In the hospital often used nitrites (nitroglycerin, sodium nitroprusside). These funds are administered drip slowly into large dilution for continuous monitoring hemodypamiky. If deepen hypotension increase infusion rate by slowing simultaneously with oxygen vasodilators.

 

Along with the restoration of BCC aimed at normalization of SOS and adequate tissue perfusion, perform correction of metabolic disorders.

 

Volume of fluid transfusion in hemorrhagic shock depends not only on the BCC, but also on the level of AT, CVP and urine output. If normalized CVP, but AT is low, you should think about the possibility GNS. In such cases it is advisable to introduce vehicles with inotropic effect.

 

Increased myocardial contractility seen in cases where after eliminating the deficit BCC SOS and ZPOS remain low. In such cases, myocardial contractility stimulating introduction agonists, corticosteroids and glucagon.

 

Dopamine is a precursor noradrepalinu as well-and p-adrenomimeticheskoe action. In addition, the human body is the dopaminergic эetseptory through which realized its effects. In small doses – 1 – 2 mg / (kg • min) – Dopamine enhances kidney and mesentery vessels, almost without changing heart rate and AT.

 

Dose 2 – 10 mg / (kg-min) leads predominantly p-adrenomimeticheskoe effect, increasing CO without significant changes ZPOS more than S mg / (kg • min) – a-adrepomi-metychnu action – significant spasm of peripheral vessels, including and lung.

 

Normally dopamine begin to enter from 2 – 6 mg / (kg • min), gradually increasing the dose to achieve the desired effect. The maximum dose is 5 – 20 mg / (kg-min).

 

Also significant inotropic effect of dopamine is dobutamine, which exudes mainly on p1-adrenergic receptors, which is cardiotonic effect. In addition, Dobutamine has weak p2-adrenomimetychyi properties – slight vasodilatation. Reducing ZPOS and improvement of the heart lead to lower both the pre-and afterload. However, as a rule, heart rate remained essentially unchanged. The usual rate of administration of the drug – from 5 to 15 mg / (kg-min) of the requirements may be increased to 40 mg / (kg • min). Compared with dopaminergic Dobutamine has more cardiotonic activity and less likely to cause ventricular fibrillation.

 

Insertion of solutions is best handled by syringe pump, allowing precisely regulate the speed of administration of the drug. If not, you can enter medications under the scheme. Proper speed drug x mg / min. We dissolve the drug x mg in 250 ml of compatible infusion medium (isotonic sodium chloride or Ringer’s solution) and administered at 15 drops. / Min.

 

Epinephrine hydrochloride – sympatho-mimetic mainly p-adrenomimeticheskoe action. It is used only by the failure of other means. Enter strictly intravenous drip of 1 mg with 500 ml of 0.9% sodium chloride. The initial dose for adults – 1 mg / min. Introducing fractional solution to achieve the desired hemodynamic effect (dose epinephrine hydrochloride 2 – 10 micrograms / min).

 

Norepinephrine – natural catecholamines, which has ss-adrenergic (vasospasm) and moderate p-adrenergic (inotropic) effect. Calling spasm of the arteries, including the kidneys and intestines, Norepinephrine, usually leads to dysfunction of these organs.

 

In response to norepinephrine input pa CO can both increase and decrease, depending on the level ZPOS, the functional state of the left ventricle and reflex effects of carotid sinus baroreceptors. It increases myocardial oxygen demand and therefore contraindicated in patients with concomitant coronary artery disease.

 

Impose drug by continuous intravenous infusion. To 250 ml of isotonic sodium chloride added 4 mg or 8 mg norepinephrine norepinephrine gidrotartrata (in 1 ml of solution contains 16 mg or 32 mg of norepinephrine norepinephrine dytartratu).

 

Recently in complex intensive therapy in cases of left ventricular failure using amrynon that has a distinct district adrepomimetychyyy and small-and adrenomimeticheskoe effect clinically manifested in the increase CO by a slight increase in heart rate. Amrynon inhibits phosphodiesterase, increases cAMP content and free calcium ions in the cells of the myocardium. This increases myocardial contractility and simultaneously dilate arterioles and veins Do. Introduction of the drug should begin with bolus dose 0.75 – 1.5 mg / kg for C – 5 min, and then continue the infusion at a rate of 5 – 10 mg / (kg-min). Amrynon contraindicated in patients with thrombocytopenia: may cause destruction of platelets.

 

For cardiotonic effect of glucagon can be used, especially if concomitant hypoglycemia. It pancreatic hormone involved in the regulation of blood glucose levels, has a mild and fast transient inotropic effect is not associated with stimulation of adrenergic receptors. It improves the atrio-ventricular conduction, reduces ZPOS, slightly increases the heart rate. Because glucagon is effective in cases of shock, complicated by acidosis and bradycardia. The drug can be combined with p-agonists and cardiac glycosides. The introduction begins with bolus doses of 1-5 mg, and then impose an intravenous drip at a rate 1-20 mg / h, pre-dissolved in 0.9% sodium chloride.

 

Property corticosteroids stabilize hemodynamics is widely used in cases of heart failure and shock. In large doses (AOR mg / kg per day) for hydrocortisone do they Membranestabilizing effect by inhibiting phospholipase A2. In addition, hlio-kokortykoyidy in such doses reduces ZPOS by expanding blood vessels, reducing afterload on the myocardium and improving tissue perfusion. Stabilizing cell and lysosomal membranes, corticosteroids prevent the release of proteolytic enzymes, which is the phase of decompensation, yryvodyachy to activate the kinin system.

 

         Lack of oxygen in tissues due to microcirculation disturbances leads to the development of metabolic acidosis, which initially has a hidden character and turns after stabilization of hemodynamics improved tissue perfusion due to leaching nedookysnenyh Me tabolizmu products in the vascular bed (“vymyvnyy” acidosis). Therefore, conducting a comprehensive treatment of hemorrhagic shock, to explore KOS years be tions and adjust it.

 

To reduce the permeability of the vascular wall and the regulation of intracellular redox processes intravenous ascorbic acid -10 – 20 ml of 5% solution.

 

To stabilize membranes used inhibitors of proteolytic enzymes: kontrikal, gordoks, trasylol others. For this very purpose in the early stages of shock, wheo significant violations makrotsyrkulyatsiyi, justified the cautious use of calcium channel blockers (verapamil, izoptyn, finoptyn).

 

Cardiac glycosides should introduce cautiously and only with signs of heart failure, controlled ECG and background: the adjusted level of potassium in blood plasma,

 

 

Traumatic shock

 

Etiology and pathogenesis. One of the main causes of traumatic shock is the trauma that among the causes of mortality is one of the first places (about thirty%). Traumatic shock is caused by fractures, damage to internal organs, soft tissue crushing, massive hemorrhage, internal and external bleeding.

 

Big traumatic injuries are almost always accompanied by massive blood loss. In closed fractures can roughly determine the amount of blood loss, based on the fact that fractures tibia in leg tissues can accumulate about 800 ml of blood, femur – 1500, and pelvic bones – up to 2000 ml (Fig. 6).

 

Quick careful medical examination enables to estimate the extent, nature and volume of blood loss.

 

Fig. 6. Estimated volume of blood loss in closed fractures

 

 

Definition localization helps to diagnose injury internal bleeding: stupid injury in the liver may be accompanied by rupture; lumbar – margin renal legs; inferior parts of the chest to the left – rupture of the spleen.

 

Hard patient’s condition except hypovolemia related to blood loss caused by too complex factors specific to injury – pain and toxemia.

 

In general, the pathogenesis of traumatic shock is the same as hemorrhagic, traumatic shock that develops as a result of interaction of the following factors:

 

1) pain;

2) decrease in CBV and contractile ability of the myocardium, which determines the occurrence of the syndrome of small ejection;

3) disturbance of microcirculation due to the syndrome of small emission sludge-phenomenon, and aggregation of blood cells that clog the capillary network;

4) Violation of pulmonary gas exchange and hypoxia that develops as a result of pulmonary microcirculation disorders, bypass the lungs, worsening function of alveolar-capillary membrane, forming shock lung syndrome;

5) violation of tissue gas exchange by reducing the volume of tissue blood flow, shunting and shifting oxyhemoglobin dissociation curve due to acidosis;

6) changes in metabolism toward anaerobic path with the formation of excess lactate and other organic acids;

7) activation of kinin systems of the body and cellular proteolysis;

8) of “shock kidney” (prerenal oliguria and renal) as a consequence of renal hypoperfusion, renal epithelial lesions and obstruction of seminiferous tubules and hyaline casts pigment consisting of myoglobin;

9) dysfunction of other organs (brain, liver, adrenal gland, intestine);

10) generalization of infection and especially of the intestinal flora;

11) the development of DIC;

12) Disorder water-salt metabolism and protein balance.

 

Clinic of traumatic shock is almost indistinguishable from the clinic hemorrhagic, except that patients complain of pain in the injured areas, and may experience external damage tissue.

 

The main goal of intensive therapy of traumatic shock is the elimination of disorders of vital functions.

 

1. Stop the bleeding. External bleeding stop plugging wounds, bandages or overlapping squeeze clamp pas damaged vessel, and pressing the arteries outside the wound. Apply a tourniquet is permissible only if it is impossible to stop arterial bleeding mentioned methods.

 

2. Providing free airway and eliminate MLA. Significant role of timely diagnosis of pneumothorax (especially busy) when the MLA caot be eliminated without immediate thoracostomy. In dohospitalpomu easiest stage to perform a puncture drainage of the pleural cavity thick needle (type Quatuor) that immediately turns tense pneumothorax to an open and create conditions for effective ventilation.

 

3. Intensive infusion-transfusion therapy for critical hemodynamic disorders are the leading method of correction of acute hypovolemia. Tactics of infusion therapy and correction of metabolic disorders is not very different from the one carried out in cases of hemorrhagic shock.

 

4. Fighting pain is intravenous analgesics (promedol, morphine hydrochloride, ketanov, diclofenac sodium, etc.).

 

The use of narcotic analgesics is contraindicated in respiratory disorders, reducing the AT to a critical level and below on suspicion of damage to internal organs of the abdominal cavity, and in cases of traumatic brain injury. If necessary, carry out general anesthesia (optimally – inhalation mixture dinitrogen oxide and oxygen in a ratio of 1: 1 or 2: 1) and mandatory immobilization of the limb in cases of fracture. For this very purpose showerve block local anesthetic agents (procaine • – 0,25 – 0,5% solution of lidocaine hydrochloride -0,25-0,5% solution).

 

5. Transporting patients in stage shock only carry on a stretcher by simultaneous infusion therapy. Victims as possible transported in Trendelenburg position (raise foot end nosh, take the pillow from under the head).

 

6. Moderate warming victims (to prevent dangerous overheating!). In the absence of a warm room, especially during the evacuation, warming reach zakutuvannyam in blankets and heaters taxation (wet clothes, linens, shoes removed).

 

A special place among the causes of traumatic shock occupy traumatic injuries: multiple trauma, fat embolism syndrome and long crush (crush syndrome).

 

 

Burn shock

 

Burn shock develops in cases of common thermal, chemical, electrical and radiation damage to the skin ihlybshe placed tissues. Depending on the area and depth of burn is a violation of hemodynamics, including microcirculation, fluid and electrolyte metabolism, renal function, digestive system and psycho disorders.

 

Burn shock can be regarded as a kind of traumatic hypovolemic shock, but it has significant differences determined by massive fluid movement and impaired water areas with the development of long-term swelling Chaumes primarily in the area of thermal damage. Out of fluid from the vascular bed to the interstitial space occurs within 12-18 hours or more, so AT reduction in burn shock occurs immediately after injury, unlike traumatic, and the level of AT is not the first indicator to assess its severity. In addition, burn shock compared with traumatic has a longer duration.

 

Hypovolemia increases the severity and duration of poor circulation, especially microcirculation. In the first hours after the burn severity of the patient associated with pain and emotional stress, which is the trigger neuroendocrine responses. Initial reaction occurs at the level of spinal nerve reflex arc of sympathetic nervous system stimulation and release of catecholamines in vascular adrenal glands, which is spasm of blood vessels, increased ZPOS, centralization of circulation and leads to tissue hypoxia and acidosis. These effects are compounded along with respiratory dysfunction (decrease K, VC), which reduces the SaO2 and oxygenation of tissues, nedookysnenyh accumulation of metabolic products, the development of respiratory and metabolic acidosis. Simultaneously, brief increase in SOS and CO, increase AT, as with increasing hypovolemia begin to decline.

 

All affected tissues produce or release a variety of inflammatory mediators (kinins, histamine, thromboxane, cytokines) that increase the permeability of the capillary walls in the area of ​​burn wounds, and in distant organs – targets. Particularly aggressive marked leukotrienes C4, D4, E4, and interleukin-6, which cause the development of hypovolemia by different mechanisms.

 

Thus, the major pathogenic steps in the development of burn shock include:

 

1. Go vnutrishposudynnoyi fluid to interstitial space due to increased permeability of the vascular wall.

 

2. Penetration of fluid from the extracellular space to the intracellular due to dysfunction of cell membranes.

 

3. Increased swelling in the area of ​​tissue damage through enhanced transfer fluid to it, due to increased osmotic pressure in the affected tissues.

 

4. The increase in protein content and, therefore, oncotic pressure iyterstytsiypomu space that is active transition had fluid from blood vessels.

 

The main clinical manifestations of burn shock: hemodynamic disturbances (rapid pulse, decreased AT), low body temperature, oliguria, anuria, hematuria, dyspnea, thirst, nausea, vomiting, flatulence, gastrointestinal bleeding, psychomotor agitation, increase in hemoglobin, hematocrit and erythrocyte hemolysis, decreased CBV, raO2, acidosis, hyponatremia, hyperkalemia, increased coagulation and blood viscosity, hypoproteinemia and dysproteinemia, azotemia.

 

Overall reaction to thermal injury with the possibility of developing adverse outcome with burns over 15 – 20% of the body surface. To predict the effects of care can use rule BECAUSE age + total lesion area (%). If the amount is about 100 or more, the weather is questionable.

 

All these changes occur within 6 – 8 hours after injury because earlier start measures to prevent them or correct them, the more likely a favorable course of burn disease.

 

Depending on the depth, size, clinical manifestations of burn damage are four degrees of severity of burn shock.

I – develops in young and middle-age with a history of unencumbered with burns 15 – 20% of the body surface. If the damage is mostly superficial, patients feel pain in places of custody. Pulse rate – about 90 per 1 min. AT slightly elevated or normal. Breathing is not broken. Hourly urine output is reduced. If infusion therapy with no or begin after 6 – 8 hours after injury may occur oliguria and moderate hemokontsentratsiya.

 

II (moderate) – develops with burns 21-40% of body surface. Lassitude, weakness, tachycardia around 100 – 110 beats / min. AT begins to decline. Feeling thirsty, dyspeptic symptoms, possible intestinal paresis. Oliguria (urine output provide the use of drugs). Expressed hemokontsentratsiya – hematocrit 0.55 l / l, hypothermia. From the first hours after injury – mild metabolic acidosis with respiratory compensation.

 

III (severe) – develops in cases of damage about 60% of the body surface. Rapid growth retardation, adinamii saved by consciousness. Significant tachycardia (120 beats / min). AT is stable only under conditions of infusion therapy and the use of cardiotonic agents. Often there is vomiting, intestinal paresis, acute expansion of the stomach. Oliguria less than 20 ml / h, dark-colored urine (diuresis provide only the use of diuretics). Hematocrit> 0.65 l / l. From the first hours after injury – mild metabolic acidosis with respiratory compensation.

 

IV (very severe). The condition of patients is very difficult. After 1-3 h after injury mind becomes confused, lethargy, sopor. Pulse thready, AT with the first hour after injury is reduced to 80 mm Hg. century. and below (against introduction cardiotonic, hormonal and other means). Breathing shallow. Often relentless vomiting, vomit color “coffee grounds.” Paresis intestines. Urine in the first portion of the characteristics of micro-and gross hematuria, then dark brown with sediment. Quickly comes anuria. Hemokontsentratsiya after 2 – 3 h after injury, hematocrit exceed 0.70 l / l. Accrues hyperkalemia and mixed decompensated acidosis. Hypothermia.

 

Intensive care. The main objectives:

 

– Compensation of fluid volume that is lost;

– Support proper BCC;

– Normalization CBS;

– Restoration of normal levels of electrolytes and plasma proteins;

– An increase in perfusion of organs and tissues. In these tasks is dominated iyfuziyno-transfusion therapy directed pas renovation deficit BCC, fundamentally important is the infusion rate and composition of the infusion, due to time since burn.

 

Usually guided by the following rules. In the first 24 h infusion conducting electrolyte solutions (such as Ringer-lactate) at the rate of volume;

 

V = 4-t-S,

 

where m – weight, kg, 5 – the area affected body surface%.

 

Infusion rate by the following algorithm: 50% daily amount iyfuziyishh impose solutions during the first 8 h following 25% – for 8 h, 25% for 8 hours. Colloids in the first 16-24 hours is not injected.

 

To replenish the deficit BCC using 0.9% sodium chloride with 5% glucose solution. For each liter of solution that is injected, add 20 mmol / l potassium chloride saved by diuresis. Colloids (svizhozamorozhepa blood plasma or albumin) enter 24 h after burn for 8 hours.

 

The introduction of a large number of electrolyte solutions in the first hours after injury provides rapid filling of the venous vasculature (venous lockup) that provides adequate CO, intensifying the exchange of tissue fluid through increased limfoutvorennya and lymphatic drainage in the tissues with impaired microcirculation.

 

Mistake is the use of the first children of Judah after burn injuries vysokomo-molecular dextrans: high viscosity, low rate of excretion from the body, which deepens impaired lymphatic drainage.

 

Correcting protein deficiency, protein level should be maintained above 60 g / L, since its level below 50 g / l causes irreversible changes in the body. The amino acid mixture for parenteral nutrition in the acute phase of burn disease use impractical.

 

Correction CBS desirable to carry out, given the results of his research in blood, the impossibility – should focus na reaction urine.

 

For normalization of renal function after adequate replenishment volume of extracellular and intravascular fluid administered aminophylline (5 – 10 ml of 2.4% solution every 4-6 hours), if necessary – osmodiuretics (mannitol 1 – 1.5 g / kg as a 5 10% solution). For this purpose, you can also enter sorbilakt – 200 ml of 20% solution of 2 – 3 times a day. Diuresis supports no less than 50 ml / hr.

 

Correction aggregation of blood in burn shock involves the use of anticoagulants of direct action (such as heparin – 20000-40000 IU / day). Reducing the aggregation of blood cells reach the application of Antiplatelet (kuraptyl, treptal, ksaytynolu pikotypat). For normalization of used complex vitamins, ascorbic acid, cytochrome C, mildronat, antioxidants (tocopherol acetate). If necessary, Cardiac glycosides, injected dopamine – a rate of 2.5 – 10 mg / (kg-min).

 

To eliminate vasospasm of the first hours after the burn using antispasmodic drugs (Nospanum, baralgin, platifillin gidrotartrata). Be sure to use glucocorticoids (1 mg / kg prednisolone), protease inhibitors (gordoks, kontrikal) at the highest dose.

 

Droperidol should be used with caution: the deficit BCC can cause a sharp decline in AT.

 

For anesthesia used narcotic analgesics: ketanov, diclofenac.

 

To prevent infectious complications in the second period prescribed broad-spectrum antibiotics, preferably in the form of intravenous infusion.

 

From the first days after the burn begin actively combating intestinal paresis, using conventional circuit stimulation, including cleansing enemas 2-3 times a day.

 

Criteria for the effectiveness of patient withdrawal from the state of burn shock include: restoration of adequate awareness stabilization of the central and peripheral hemodynamics (SG> 3 L / (min • m2); AT • – over 110/70 mm Hg. Cent.), Normalization of breathing (SaO2> 90%) recovery of renal function (urine output of at least 1 ml / (kg • h), achieving hemodilution (Ht 33 – 38%), total protein> 60 g / l.

 

 

Dehydration shock

 

A variant of hypovolemic shock is dehydration, which is mainly in cases of significant loss of isotonic fluids (diarrhea, fistulas – duodenal, bile, small intestine, stomach – intense vomiting). A classic example of a significant loss of water and electrolytes (Na +, K *, DG, NHS) is an acute Vibrio enteritis and gastroenteritis.

 

The key element in the pathogenesis of this type of shock is isotonic dehydration. Severe diarrhea and vomiting leading to fluid loss along with plenty of electrolytes.

 

Dehydration cells is accompanied by the release of these K +. Loss of alkaline intestinal contents and circulatory disorders causing metabolic acidosis, CNS intoxication and dehydration lead to impaired consciousness, plasma volume decreases significantly, starts thickening of the blood – hematocrit increases, developing dehydration shock typical of his impaired both central and peripheral hemodynamics: reduced AT, increasing tachycardia, spadayutsya peripheral vein.

 

The main directions of emergency intensive care are:

 

– Fast rehydration of the body;

– Restoration of the central and peripheral hemodynamics;

– Correction of electrolyte deficiency.

After catheterization venous rehydration spend with speeds up to 100 ml / min isotonic saline with the addition of derivative hidroksietylkrohmalyu or dextran.

 

 

 

Anaphylaxis

 

Anaphylaxis is the type of allergic reaction of immediate type in response to a combination of fixed antigen on the cell membrane antibodies. Accompanied by impaired circulation and metabolism.

 

Antigens may be of different origin, but most often it is the substance of proteiature (immune serum, vaccines, etc.).

 

Anaphylaxis can be caused by the use of drugs (penicillin and its analogs, streptomycin, thiamine, amidopirina, aspirin, novocaine, iodine-containing radiopaque substance) of skin testing and the performance hyposensitization therapy (using allergens), errors during blood transfusion, blood products, etc.. In the development of anaphylactic reactions or dose or route of administration of allergen not play a decisive role, however big dose of it increases the severity and the duration of shock. Speed ​​of anaphylaxis can vary, from a few seconds or minutes to 2 hours or more of the contact with the allergen.

 

Before the appointment of any drug allergy doctor must consider history, including hereditary, that is the best prevention of anaphylactic shock.

 

Pathogenesis. Antigens in combination with antibodies damage the cell membrane, release of biologically active substances – serotonin and histamine from basophilic granulocytes (mast cells labrotsyty, mast cells, etc.), activate the kinin system (bradykinin). This increases the permeability of the capillary walls, dilates blood vessels, tissue edema. Expansion of peripheral vessels leading to deposition of blood, relative hypovolemia and collapse. However, slow reacting substance and histamine cause bronhiolospazm that combined with amplification secretion leads to obstruction of the small airways. In cases of acute laryngeal edema possible asphyxia. With the delay in starting treatment anaphylactic shock can cause hypoxic brain damage and encephalopathy.

 

Clinic. Depending on the dominance of clinical symptoms distinguish the following types of anaphylactic shock:

 

– Cardiac (dominated by signs of cardiovascular activity);

– Broncho-pulmonary (asfiktychnyy) (dominated by acute respiratory failure);

– Gastrointestinal (abdominal) (dominated by signs of dysfunction of the abdominal cavity);

– Cerebral (CNS symptoms predominate);

– Skin (urticaria) (swelling, rash on the background of hemodynamic disorder).

 

Depending on the course distinguish these options anaphylaxis: acute malignant, benign chronic, recurrent, abortive.

 

Developed clinical picture of anaphylaxis may be preceded by symptoms of organ or system through which an allergen enters the body, such as when antigen from food, systemic disorders may be preceded by nausea, vomiting, crampy abdominal pain, diarrhea, injection site may hives occur in cases of inhalation intake – feeling chest tightness, hoarseness, stridoroznym breathing.

 

Intensive care:

1. Stopping the further introduction of allergen (eg, drug) when signs of anaphylaxis. If the drug is introduced in limb proximal to the place of his administration to impose a venous tourniquet and place Introduction drugged solution of epinephrine hydrochloride (1: 10 000).

 

2. Monitoring and ensuring the airway. In cases of violation due to retraction of the tongue during blackouts to apply triple reception Safar, if possible – to enter the air duct or to tracheal intubation. In case of violation of the airway due to edema of the pharynx and larynx to quickly intubuvaty trachea. In case of failure or complications during intubation should perform konikotomiyu. After restoring airway spend breathing 100% oxygen.

 

3. Introduction epinephrine hydrochloride inhibits the release of inflammatory mediators basophilic granulocytes due to activation and increased concentrations of intracellular cAMP (anaphylaxis when its concentration in cells dramatically decreases). Adrenaline also reduces bronhiolospazm increases ZPSO and diastolic AT, helping to improve coronary circulation. The drug must be entered intravenous infusion at a dose of 0.5 – 1 mg diluted 1: 10 000. The inability of intravenous epinephrine hydrochloride can be administered vputrishnotrahealno through endotracheal tube or by percutaneous puncture of the trachea. If injection of epinephrine hydrochloride and correction of hypovolemia infusioot eliminate hypotension, expedient gradual infusion of norepinephrine (4 – 8 micrograms / min) or dopamine (3 – 6 mg / (kg • min)).

 

4. Of infusion therapy, which is necessary to eliminate hypovolemia, restoring perfusion of organs and tissues, as well as delivery to them of oxygen. Putting in such cases only crystalloid solutions is inefficient because in anaphylactic shock fluid quickly turns to extravascular space. By kompeksu infusion therapy should definitely enter colloidal solutions.

 

5. Introduction aminophylline (especially in cases of bronchopulmonary type shock). The drug blocks phosphodiesterase, which promotes intracellular degradation of cAMP, blocking the release of biologically active substances basophilic granulocytes, expands the bronchi. Impose aminophylline intravenously at a dose of 5 – 6 mg / kg for 20 minutes followed by infusion needs with speed 0,2-0,9 mg / (kg-h).

 

6. Corticosteroids, which inhibit the activity of phospholipase A2 and potentiate the effect of agonists on cells – effectors anaphylaxis, blood vessels and bronchi. In addition, they reduce the permeability of the vascular wall. Effects of corticosteroids is not found in the first few minutes of anaphylaxis, they prevent more remote effects of anaphylactic reactions. This effective dose is 100 – 1000 mg hydrocortisone with repeated doses in 4 – 6 hours during the day.

 

7. Putting usually means antihistamines that block NO-receptors, reducing the adverse effect of histamine.

 

 

Infectious-toxic shock

 

Etiology and pathogenesis. Triggering factor for infectious-toxic (septic) shock is exo-or endotoxins bacteria. Inherent hypotension refractory to correction BCC, and significant tissue perfusion with the development of lactic acidosis, oliguria, respiratory failure and mental health disorders.

 

Pathophysiological factors are exogenous and endogenous mediators involved in the inflammatory response.

 

Pathogenesis endotoksychnoho shock

 

It is believed that in the pathogenesis of Gram-positive and Gram-negative infectious-toxic shock are some features, but in general, these forms are almost identical with the phases of the course.

 

Phase effects of endotoxin. The bacteria enters the body, release of endotoxin lipopolysaccharide (LPS), which binds to serum protein, forming LPS-associated protein. This complex binds to the surface cell receptor CD14 in macrophages and leukocytes limorfpoyadernyh activates these cells and causes the production of cytokines – the phase of activation. In parallel, activated complement system, accompanied by the elaboration anafilotoksyniv S3A and S5a that cause vasodilatation and increased permeability of the vascular wall, stimulates platelet aggregation by platelet activating factor (PAF – platelet activity factor), which activates as cytokines. Today found 40 kinds of cytokines. In the pathogenesis of infectious-toxic shock and sepsis greatest role proinflammatory cytokines tumor necrosis factor (TNF – tumor necrosis factor), interleukin (IL) -1, -6, -8 and interferon.

 

Along with these processes is the activation of factor XII (Hageman), which stimulates the conversion prekalikreyinu to kallikrein, bradykinin formation and promotes the development of DIC.

 

Cascade formed inflammatory mediators (cytokines, interleukins, TNF, PAF) effect oeutrophils and endothelial cells of blood vessel walls, leading to activation of arachidonic acid metabolism and accumulation of its derivatives (eicosanoids), production of toxic oxygen metabolites increase NO, kinins, histamine , endothelin, endorphins, coagulation factors and other mediators of sepsis – mediator phase. All these substances have a vasodilator effect, promote aggregation of blood cells and the formation mikroemboles.

 

Gradually the body develops an inflammatory reaction associated with hyper TNF, IL, prostaglandins, which reduce the inherent activity of monocytes and increased formation of IL-10, IL-1RA – imunoparalichu phase. The accumulation of vasoactive metabolites (prostacyclin, histamine, bradykinip, NO) leads to a decrease in vascular tone and thus to arterial hypotension and a simultaneous increase in CO. Later in spout metabolites oppression of myocardial contractility, along with microcirculatory disorders leads to the syndrome of systemic failure.

 

Primarily affects the lungs – the main target organs. The main cause of lung function is endothelial damage TNF, PAF, interleukin, thromboxane A2 (increased permeability of blood vessels, adhesion peytrofilnyh granulocytes, platelets, formation mikrotrombov). This leads to the development and deepening of existing RDSD hypoxia. Violation of intestinal microcirculation lead to nekrotyzatsiyi epithelium of the villi, accompanied by translocation of bacteria and endotoxin from the gut lumen to the mesenteric lymph vessels and portal hepatic vein. If the liver caot cope with the increased barrier function, the bacteria and endotoxins to enter systemic circulation, closing a vicious cycle that often leads to death of the victim – the final phase.

 

Clinic. The key symptom to diagnose infectious-toxic shock is a fever that occurs under the influence of inflammatory mediators, especially prostaglandin E2. Unlike other forms of skin shock in these patients warm, normal color, but a symptom of white spots positive. Typical signs of progression iyfektsiyno-toxic shock is limited to areas of necrosis of skin, layer it in the form of blisters, petechiae, much marbling.

 

Respiratory disorders in the early stage of shock manifest hyperventilation leading to respiratory alkalosis and muscle depletion. Hyperventilation caused by the direct action of endotoxin on the respiratory center, hyperthermia, and the development of metabolic acidosis.

 

Cardio-vascular system in the initial stage is a reduction ZPOS and hypotension concomitant increased CO (hyperdynamic phase). Further CO decreases and hypotension progressing (hypodynamic phase).

 

In the later stages of shock joins kidney failure (oliguria, etc.).

 

In the liver, reduced production of protein, endogenous heparin and prothrombin. In cases of liver damage occurs hyperbilirubinemia. Sometimes developing necrotizing pancreatitis. All these changes are taking place against a background of progressive DIC.

High concentration of proteolytic enzymes in the blood and guts on the background of stagnation of blood in the mesenteric system is the most common cause of erosive lesions of the mucous membrane of the alimentary canal and gastrointestinal bleeding.

 

It is also possible central nervous system dysfunction with varying degrees of confusion (disorientation, psychosis, etc.).

 

In laboratory studies of blood revealed leukocytosis or leukopenia, lymphopenia, thrombocytopenia and decrease other indicators of hemostasis.

 

Basic principles of intensive care:

 

– Surgical rehabilitation of the infection (septic focus);

– Support for adequate ventilation and gas exchange;

– Correction of hemodynamic disorders: inotropic therapy, adequate infusion therapy (for continuous hemodynamic monitoring);

– Timely and effective correction of metabolism (at constant laboratory control);

– Antymediatorna and immunomodulatory therapy;

– Antibiotic therapy (at constant microbiological control).

 

Crucial in the treatment of patients with sepsis and toxic shock ipfektsiyno-surgical rehabilitation has septic focus. Even short-term success in treatment is not an indication for withdrawal surgery because septic focus will be to maintain a high level endotoksynemiyi that stimulates neurotransmitter cascade process.

 

One of the important places in the complex treatment takes antibiotic therapy. In most cases, agents septic process is Gram-positive and Gram-negative bacteria. Antibiotic therapy is better to exercise when known pathogen. You need to microbiological examination of blood, urine, trachea and content scraping with a wound surface.

 

To determine the microorganism from blood cultures consistently taken from vein 3 blood samples. In the first sample than bacteria circulating in the blood, giving rise also microorganisms contained in the skin, in the second and third (control) – only bacteria that circulate in the blood. Getting the final result, which determines the type of microorganism and its sensitivity to various antibiotics, take some time.

 

Effective treatment is essential earliest start empirical antibiotic therapy, especially in patients with impaired immunity, appointing you consider the following factors:

 

– Diseases against which there was infection, and initial immune status of the patient;

– Sensitivity of microorganisms to antibiotics;

– Pharmacokinetic properties of the antibiotic;

– Efficiency ratio cost / effect.

 

In cases of sepsis and toxic shock-iyfektsiyno often empirically prescribed combination cephalosporin, 3rd generation (eg, ceftriaxone, cefotaxime, tseftatyzym) with aminoglycosides (amikacin sulfate) or derivatives of fluoroquinolones. These combinations have high activity against many microorganisms. Ceftriaxone has a great half-life, and it can be applied once a day, antibiotics with a short period papivvyvedennya (cefotaxime, tseftatyzym etc.). Need to enter a few times a day. Before antibiotics should be the identification of flora microscopic examination and its sensitivity to them bacteriological method.

 

In cases of resistant infections has recently successfully used tiyepam (imipenem, cilastatin). For suspected gram-positive flora effectively use vancomycin.

 

After receiving the results of biological research and antybiotykohramy antibiotic regime change accordingly. It is desirable to appoint monotherapy antibiotic with a narrow spectrum of activity.

 

In the course of antibiotic treatment is necessary to consider the possibility of deterioration of the patient by type of reaction Jarisch-Hertsheymera (Jarisch – Herxchei-mer) in connection with endotoksynemiyeyu conditioned by antibiotics, which increases due to the death of bacteria and endotoxin release. Discontinue administration of antibiotic that caused this reaction should not be. Along with antibacterial treatment to conduct maintenance sympathomimetics directed pas stabilization AT.

 

Intensive care patients with iyfektsiyno-toxic shock should also be directed towards the elimination and prevention of respiratory failure RDSD. In severe cases, the background of progressive syndrome of systemic failure of the need to urgently address the issue of the transfer of the patient to the ventilator. It should be guided by the severity indices MLA (raO2 <60 mm Hg. Century. Breathing oxygen and PaCO2 ^ 60 mm Hg. Cent.). Respiratory therapy should be conducted under the rules PTKV that improves gas exchange during RDSD.

 

The primary measure to restore adequate perfusion of organs and tissues correction BCC, first fluid is injected at 50 ml / min for 15 -20 minutes, and then in a normal pace, according to the hemodynamic, respiratory, urine output and so on. The optimum ratio of crystalloids and dextrans 2:1. Use dekstrapiv allows quickly eliminate hypovolemia, maintain colloidal osmotic pressure of blood plasma.

 

If after normalization BCC blood pressure is low, you must enter a vasoconstrictor. If CAT is 60 mm Hg. century. and below, shows the use of dobutamine at 2 – 15 mg / (kg • min). In the same cases, especially against the background of oliguria, expedient introduction of dopamine at low doses (1-Zmkh / (kg-min)), which increases blood flow to the kidneys, mesenteric, cerebral and coronary vessels, and in a dose of 5 – 10 mg / (kg-min) improves myocardial contractility and OCs. If organized events do not reach steady increase AT, it is appropriate to enter gidrotartrata norepinephrine (0.05 – 0.3 mg / (kg • min)), in the extreme case of epinephrine hydrochloride (0,15-0,3 mg / (kg • min )). It should be noted thatin patients with septic shock may decrease the sensitivity of adrenergic receptors, so the introduction agonists may be effective. In such cases it is advisable to introduce drugs with positive inotropic effects, which increase the CO,-amrynon (bolus dose of 1.5 – 2 mg / kg maintenance – 10 mg / (kg-min)).

 

Immunomodulatory and antymediatorna therapy based on current knowledge of the pathogenesis of infectious-toxic shock and sepsis and is very promising. Expedient is the introduction of pentoxifylline (Trental), which inhibits the formation of TNF and prevents violation permeability of the wall of blood vessels in the lungs.

 

Perspective is the use of inhibitors of NO – syytetazy L-NAME, which helps eliminate NO induced vasodilatation and improve hemodynamics. A similar effect was obtained with intravenous methylene blue (2 mg / kg for 60 – 90 min), which inhibits guanylate cyclase by which NO affects vascular wall. To prevent peroxidation, prescribe antioxidants: tocopherol, ceruloplasmin, retinol, carotene, acetylcysteine, glutathione.

 

Given the role of p-endorphin in the pathogenesis of infectious-toxic shock shown entering naloxone (2 mg intravenously with 5% glucose rozchshyui for thirty minutes).

 

Regarding the use of glucocorticoids: in the treatment of shock, there is no conclusive evidence of their effectiveness, nor that they inhibit phospholipase A2, stabilizing cell membranes. The use of glucocorticoids is justified by the low efficiency of the complex hemodynamic therapy.

 

It is expedient to use prostaglandin inhibitors (aspirin, ibuprofen). Proved the application of glutamic acid, which normalizes metabolism in the intestinal villi, strengthening the intestinal wall and thus suppressing bacterial translocation.

 

 

Cardiogenic shock

 

Pathogenesis. The basis of cardiogenic shock is to reduce the pumping function of the heart (usually occurs in myocardial infarction), resulting in significantly reduced CO and growing lack both central and peripheral blood flow. Significant role in reducing CO plays a raised tension in the region of myocardial infarction and perifocal zone (during systole observed protrusion affected area of ​​the myocardium, which reduces CO).

 

In cardiogenic shock, as well as in hemorrhagic, CO compensated by initial vasoconstriction, and then there is the selective deposition of blood in the veins and internal organs.

 

Clinical signs of cardiogenic shock in patients with acute myocardial infarction pa:

 

– Reduction of AT to 80 mm Hg. century. the normal AT and 80 mm Hg. century. the high AT;

– Reduction of pulse pressure;

– Cold, pale with cyanotic tinge skin and mucous membranes;

– Oligo-or anuria;

– Metabolic acidosis with a shift buffer bases <-10 mmol / l;

– Impairment of consciousness (stupor or psychomotor agitation).

 

Pathophysiological basis of these features are primarily CO and a significant decrease sympathoadrenal response to this decline. Disorders of consciousness – a manifestation of cerebral hypoxia. Kardiohenpyy shock can complicate heart surgery, the course of myocardial infarction, terminal stages of aortic stenosis, cardiac arrhythmias, etc.. For EI Chazov, distinguish these types kardiohenpoho shock:

 

1. Reflex – in pain, accompanied by a decrease in vascular tone due to the fact that myocardial ischemia reflexly reduces typical shock response – a spasm of peripheral vessels.

 

This is the easiest form kardiohenpoho shock: diuresis saved extremities warm skin, bradycardia.

 

2. This (true) – develops in cases of widespread myocardial infarction, left ventricular myocardium and asynerhiyi unaffected. Any damage to much of the left ventricular cardiogenic shock develops in 80% of cases, 25 – 50% – at 12, less than 25% – 7% of cases. Reducing SOS and CO through the carotid sinus baroreceptor and aortic causes spasm of arterioles and compensatory increase AT. However, in some cases, reflexes and coronary ischemia reduces spasm of peripheral vessels.

 

Weather genuine cardiogenic shock compounded in the case of chronic lung disease with respiratory failure. However, even in healthy lungs acute myocardial infarction accompanied by hypoxemia due to shunting of blood in the lungs.

 

3. Areaktyvnyy – true cardiogenic shock unresponsive to medical therapy.

 

4. Arrhythmogenic – often occurs in cases of acute myocardial infarction, when conditions are favorable for the occurrence of arrhythmias. Severe arrhythmia impairs coronary blood flow, causing a heart attack spread. For severe bradycardia reduced CO, and less time with tachycardia diastole and decreases cardiac filling, reduced coronary blood flow while increasing myocardial oxygen demand.

 

Actually arrhythmogenic kardiohenpyy shock can develop not only in patients with myocardial infarction, but also in cardiac arrhythmias (paroxysmal tachycardia) and others.

 

Intensive treatment in cardiogenic shock conduct complex. First of all, it should be aimed at stabilizing hemodynamics. its essential elements are: elimination of pain, arrhythmia, increased AT, to prevent a decrease in coronary and cerebral blood flow.

 

Prehospital conduct the following activities:

 

1. As soon as start of thrombolytic therapy. Tissue plasminogen activator aktylize administered by the accelerated regimen: 15 mg intravenous bolus, then 50 mg intravenously for thirty minutes and the last 35 mg – for 1 h. In patients weighing up to 65 kg total dose should not exceed 1.5 mg / kg. Streptokinase at a dose of 1.5 million units dissolved in 200 ml of isotonic sodium chloride or glucose administered intravenously for 45 – 60 min.

 

2. To reduce pain vnutrishpovenno injected analgin (Iml 50% solution), diphenhydramine (1 ml of 1% solution), Promethazine (1 ml of 2% solution). Effect apalhetykiv narcotic drugs and antihistamines increase intravenous fentanyl (1 – 2 ml of 0.005% solution) with droperidol (1 ml of 0.25% solution). If you have a history of asthma and contraindications for administration feytanilu instead promedol injected (1 ml of 2% solution). Best analgesics remains morphine hydrochloride (1 ml of 1% solution), which in addition to analgesia reduces ZPOS reduces blood flow to the heart and its work, and myocardial oxygen demand.

 

3. By reducing AT to 80 mm Hg. century. starting intravenous drip of dopamine or dobutamine at 5 – 10 mg / (kg • min).

 

4. A mask anesthesia and breathing apparatus or through nasal catheters spend 100% oxygen inhalation.

 

In case of sudden cessation of circulation immediately begin SLTSR.

 

At the hospital stage conduct the following activities:

 

1. Patients with cardiogenic shock admitted directly to the intensive care unit, where provide continuous monitoring of ECG and inhalation of 100% oxygen moistened. Severe arrhythmia eliminate drugs or electric pulse therapy.

 

2. Kateteryzuyut central or peripheral vein, measuring CVP, injected vnutrishnovenpo polarizing mixture (10% glucose with insulin and potassium chloride and magnesium sulfate).

 

3. For the safety of pain, including activities conducted in the prehospital phase, injected narcotic analgesics, spend neyroleptanalgezii (1-2 ml of 0.005% solution of fentanyl and 1 – 2 ml of 0.25% solution of droperidol). Particular attention is paid to the state of ventilation (fentanyl depresses respiration).

 

4. If hypotension continues intravenous drip of dopamine or dobutamine, supporting AT systolic of 100 mm Hg. century. Sometimes AT measurement by Korotkoff may be inaccurate, which requires measurement of CAT after radial artery catheterization.

 

5. By lowering CVP below 6 cm of water. century. pour Ringer-lactate reopolyglukine. By increasing CVP more than 12 cm of water. century. infuziypu therapy limiting and in parallel with dopamine infusion administered nitroglycerin or sodium nitroprusside.

 

6. Spend anticoagulant and fibrinolytic therapy: heparin – 10 000 units intravenously, followed by 10,000 units subcutaneously every 4 hours or intravenously at 1 000 – 1 200 U / h under constant control of blood clotting time and performance coagulogram. Especially effective in the early hours is the introduction of thrombolytic intravenously for 5 – 6 hours.

 

In cases of severe kardiohenic shock is a risk of DIC, what prevents anticoagulant therapy.

 

7. Shall adjust CBS sodium bicarbonate (at pH <7).

 

8. By moving testimony to the ventilator.

 

Relatively easy to treat patients with cardiogenic shock reflex: just eliminate pain and increase vascular tone.

 

In cases of true cardiogenic shock efficacy of drug therapy is low: cardiac glycosides are ineffective, not confirmed the positive effect of glucocorticoids in massive doses. B-agonists, including izoprotenolol, while increasing productivity hearts, but also increase myocardial oxygen demand. Effective in such cases is Dobutamine or dopamine.

 

At the same time proved the feasibility of the method of intra-aortic balloon kontrapulsatsiya that gives immediate positive results in 80% of cases. The indications for this method are: reduction of CI below 2.2 L (min • m2) wedge pressure (measured catheter Swann – Ganz) in the pulmonary artery> 25 mm Hg. century.; AT <80 mm Hg. century. Be sure to remove fibrillation, which in itself can cause arytmoheyyyy cardiogenic shock. Paroxysmal tachycardia and atrial flutter eliminate electric pulse therapy (cardioversion). it is performed under combined anesthesia: inhalation dinitrogen oxide and oxygen (1: 1) with simultaneous intravenous diazepam (10 mg) and ketamine hydrochloride (2 mg / kg). It is advisable to use a defibrillator with kardiosynhronizatorom (defibrillator discharge 4.5 – 5 kV).

 

In case of ventricular tachycardia in a patient is peredterminalnomu condition and the inability to cease its jet intravenous introduction CORDARONE or lidocaine hydrochloride (1 to 2 mg / kg) used cardioversion.

 

Drug therapy in the case of premature ventricular contractions is intravenous CORDARONE (1.5 – 2 mg / kg) or lidocaine hydrochloride: first bolus of 1 ml / kg, then drip at a rate of 4 mg / min for thirty minutes, then 2 mg / min for 2 hours and 1 mg / min. Antiarrhythmic drugs themselves may worsen hemodynamics: Inderal – reduces myocardial contractility, novokainamid – enhances conduction disturbances.

 

When supraventricular arrhythmias, extrasystoles and tachyarrhythmias in the vein slowly injected 2 ml of 0.25% solution of verapamil. When reflex kardiohenomu shock sinus bradycardia is an indication for intravenous mlO.1 0.5-1% solution of atropine sulfate.

 

Patients with acute myocardial infarction may threaten complete atrioventricular block with development of severe bradiarytmichnoho shock or cardiac arrest. Incomplete blockade is accompanied by increased activity of ectopic foci and the occurrence of arrhythmias.

 

For atrioventricular block, characteristic for myocardial posterior wall of the heart, the method of choice is a temporary transvenozna elektrokardiostymulyatsiya.

 

Prophylactic administration endocardial electrode is indicated in cases of: a) atrioventricular block I – II degree and myocardial infarction anterior wall of the heart, b) atrioventricular block III-IV degree without hemodynamic disorders and frequency of contractions of the ventricles at least 45 for 1 min.

 

Auther – doc. L.Yu. Ivashchuk