Organization of antishock therapy. Fundamentals of antishock therapy and resuscitation in case of injuries Introduction of steroid hormones

§ Normalization of external respiration and gas exchange.

All are shown inhalations of humidified oxygen (through nasal catheters, face mask) at a rate of 4-8 l/min.

§ Anesthesia.

Pain relief is better agonists-antagonists morphine group. They have sufficient analgesic effect and do not depress breathing: nalbuphine 2 ml (10 mg in 1 ml), stadol 0.2% - 1 ml, tramadol 1 ml (50 mg). To enhance the analgesic effect and block the synthesis cyclooxygenases shown introduction ketonal as a continuous intravenous infusion (100-200 mg in 500 ml of infusion solution) for 8 hours (with a possible repetition of the infusion after 8 hours).

A combination of medicines is possible (in different combinations): 1 ml of 2% solutionpromedol or 1 ml omnopon , 2 ml 1% r-radiphenhydramine or 1-2 ml 2.5% solutionpipolfena , 2 ml 50% r-ra metamizole sodium (analgin), 2 ml 0.5% r-radiazepam (seduxen etc.), 10.0 ml of 20% solutionoxybutyrate sodium.

For neuroleptanalgesia use 1-2 ml of 0.005% solutionfentanyl with 1-2 ml of 0.25% solutiondroperidol .

§ Infusion therapy.

The algorithm for using venous access: a peripheral catheter in the area of ​​intact skin, a peripheral catheter through the burned surface, central venous access through intact skin, and, last but not least, central vein catheterization through the burn wound.

Firsthours after injury, infusion therapy is aimed at replenishing the volume of circulating blood and rehydrating the interstitial space. It is recommended to start the infusion with the introduction glucose-electrolyte solutions. This choice is due to the ineffectiveness of colloid preparations in the early period of burn shock. The first step is to use:

· solution Ringer-Locke (lactosol, acesol, disol) 5-7.5 ml/kg;

· solution glucose 5% 5-7.5 ml/kg.

Subsequently, the infusion program includes:

· polyglucin 5-7.5 ml / kg intravenously drip (ratio of crystalloids and colloids in shock I- II degree is 2 and 1 ml per 1% burn and 1 kg of body weight, with shock III-IV degrees - respectively 1.5 and 1.5 ml);

· rheopolyglucin 5-7.5 ml/kg;

· drugs hydroxyethyl starches (refortan , stabilizol) 10-20 ml/kg as an intravenous infusion.

The volume of infusion therapy on the first day can be calculated using the modified Parkland formula:

V = 2 ml × burn area (%) × body weight (kg).

About 50% of the calculated value must be entered in the first 8 hours from injury. After 8 hours, with stable hemodynamics, it is recommended to reduce the rate of infusion and start the introduction of drugs for correction hypoproteinemia(fresh frozen plasma, serum albumin). Recommended Share protein-containing solutions in the daily balance of injected fluids is from 20 to 25%.

§ Inotropic support.

Sometimes with extremely severe burn shock (or with late infusion therapy), it is impossible to maintain infusion therapy (the total volume of infusion in the first 24 hours should not exceed 4 ml / kg per 1% of the burn area) blood pressure at the perfusion level (above 80-90 mm Hg. Art.). In such cases, it is advisable to include inotropic drugs in the treatment regimen:

· Dopamineat a dose of 2-5 mcg/kg/min ("renal" dose) or 5-10 mcg/kg/min;

· dobutamine (400mg in 250ml saline) at a rate of 2-20mcg/kg/min.

§ Correction of blood hemorheology.

From the first hours, the introduction of low molecular weight heparins ( fraxiparine , clexana , fragmina) or unfragmented heparin to correct the aggregate state of the blood:

· Fraxiparine in / in 0.3 ml 1 or 2 times a day;

· Heparinwith an initial bolus of 5-10 thousand U and subsequent IV infusion at the rate of 1-2 thousand U / h (or 5-6 thousand U every 4-6 hours) under the control of APTT and platelet count.

To reduce the aggregation of blood cells, the following are used:

· Trental 200-400 mg IV drip in 400 ml of saline 1-2 times a day;

· Xanthinol nicot inat 2 ml of 15% intravenous solution 1-3 times a day;

· Actovegin 20-50 ml IV drip in 200-300 ml saline.

§ Organ protection.

To reduce the permeability of the vascular wall, it is recommended:

· Glucocorticoids (prednisolone 3 mg/kg or dexamethasone 0.5 mg/kg per day);

· Ascorbic acid 5% solution of 250 mg 3-4 times a day;

· Polarizing mixture at a dose of 5-7.5 ml / kg.

For the prevention of acute renal failure, 4% is administered sodium bicarbonate solution(3 ml sodium bicarbonate × body weight (kg)/duck). All patients undergo bladder catheterization to control diuresis. Oh good microcirculation in the kidneys, urine output in the amount of 0.5-1.0 ml / kg / h is indicated. Methusol and ringer's malate- preparations based on succinic and malic acids - can reduce posthypoxic metabolic acidosis, increase ATP synthesis, stabilize the structure and function of mitochondria, induce the synthesis of a number of proteins, prevent inhibition of glycolysis and increase gluconeogenesis. Perftroran in burn shock, it is used as a blood substitute with a gas transport function, which has hemodynamic, rheological, membrane stabilizing, cardioprotective, diuretic and sorption properties.

Dose and frequency of administration of Perfron depending on the severity of burn shock (according to E.N. Kligulenko et al., 2004)

Lesion severity index	Time of administration
	1 day	2 days	3 days
Up to 30 units	1.0-1.4 ml/kg
31-60 units	1.5-2.5 ml/kg	1.0-1.5 ml/kg	1.5-2.0 ml/kg
61-90 units	2.5-5.0 ml/kg	2.5-4.0 ml/kg	1.5-2.0 ml/kg
Over 91 units	4.0-7.0 ml/kg	2.5-5.0 ml/kg	2.5-4.0 ml/kg

§ Relief of nausea, vomiting 0.5 ml 0.1% solutionatropine .

§ Protection of the burn surface.

An aseptic dressing is applied to the affected areas.

§ Criteria for the adequacy of the therapy.

The criteria for exiting the state of shock are considered to be stabilization of hemodynamics, restoration of circulating blood volume, diuresis (at least 0.5-1.0 ml / kg / h), duration of the pale spot symptom(pressure on the nail bed - the nail bed remains pale)less than 1 second, an increase in body temperature, a decrease in the severity of dyspeptic disorders.

TS with modern combat lesions develops in 20-25% of the wounded. Under traumatic shock is understood as a severe form of the general reaction of the body to trauma, combat, mainly gunshot or explosive trauma. TS is one of the fundamental concepts and is an important component of the diagnosis of combat damage, which determines the nature of medical and diagnostic measures in the system of staged treatment of the wounded with evacuation as directed.

Pathogenesis:

Acute blood loss: a decrease in BCC, a decrease in the IOC, hypotension and a decrease in tissue perfusion, accompanied by their increasing hypoxia. Blood loss exceeding 1000 ml is detected in 50%, and 1500 ml - in 35% of the wounded arriving in a state of shock. In grade III shock, massive blood loss exceeding 30% of the BCC (1500 ml) occurs in 75-90% of the wounded.

Reducing the level of systolic blood pressure: insufficient. eff. pumping function of the heart, which may be due to circulatory hypoxia of the heart muscle, contusion of the heart with a closed or open chest injury, as well as early post-traumatic endotoxemia. The decrease in blood pressure in TS is also associated with the circulatory, vascular factor.

Pathological afferent impulses.

Functional disorders associated with a specific localization of damage.

The main natural compensatory mechanisms can be presented in the following sequence:

An increase in the minute volume of blood circulation against the background of a decrease in the volume of circulating blood due to an increase in the heart rate;

Centralization of blood circulation by increasing the tone of peripheral vessels and internal redistribution of limited BCC in the interests of organs experiencing the greatest functional load in an extreme situation;

Increasing the depth and frequency of external respiration as a mechanism for compensating for developing hypoxia;

Intensification of tissue metabolism in order to mobilize additional energy resources.

Severity of shock	Clinical Criteria	Forecast
I degree (mild shock)	Damage of moderate severity, often isolated. General condition of moderate or severe. Moderate congestion, pallor. Heart rate = 90-100 in 1 minute, systolic blood pressure is not lower than 90 mm Hg. Art. Blood loss up to 1000 ml (20% BCC)	With timely assistance - favorable
II degree (moderate shock)	The damage is extensive, often multiple or combined. The general condition is severe. Consciousness is preserved. Severe lethargy, pallor. Heart rate 100-120 in 1 minute, systolic blood pressure 90-75 mm Hg. Blood loss up to 1500 ml (30% BCC)	Doubtful
III degree (severe shock)	Injuries are extensive, multiple or combined, often with damage to vital organs. The condition is extremely difficult. Stunning or stupor. Sharp pallor, adynamia, hyporeflexia. Heart rate 120-160 in 1 minute, weak filling, systolic blood pressure 70 - 50 mm Hg. Art. Possible anuria. Blood loss 1500-2000 ml (30-40% BCC)	Very serious or unfavorable

In the terminal state, its pre-agonal phase, agony and clinical death are distinguished. The preagonal state is characterized by the absence of a pulse in the peripheral vessels, a decrease in systolic blood pressure below 50 mm Hg. Art., impaired consciousness to the level of stupor or coma, hyporeflexia, agonal breathing. During agony, pulse and blood pressure are not determined, heart sounds are muffled, consciousness is lost (deep coma), breathing is shallow, has an agonal character. Clinical death is recorded from the moment of complete cessation of breathing and cessation of cardiac activity. If it is not possible to restore and stabilize vital functions within 5-7 minutes, the death of the most sensitive to hypoxia cells of the cerebral cortex occurs, and then - biological death.

Treatment of traumatic shock should be early, comprehensive and adequate. The main objectives of treatment:

1) Elimination of the disorder of external respiration, achieved by restoring the patency of the upper respiratory tract, eliminating open pneumothorax, draining tension pneumothorax and hemothorax, restoring the chest bone frame in case of multiple fractures, oxygen inhalation or transfer to mechanical ventilation.

2) Stop ongoing external or internal bleeding.

3) Replenishment of blood loss and restoration of BCC with subsequent elimination of other factors of ineffective hemodynamics. The use of vasoactive and cardiotropic drugs is carried out according to strict indications after the replenishment of the BCC or (if necessary) in parallel with its replenishment. Infusion therapy also aims to eliminate violations of the acid-base state, osmolar, hormonal and vitamin homeostasis.

4) Termination of pathological afferent impulses from the lesions, which is achieved by the use of analgesics or adequate general anesthesia, the implementation of conductive novocaine blockades, and the immobilization of damaged body segments.

5) Performing urgent surgical interventions included in the complex of anti-shock measures and aimed at stopping bleeding, eliminating asphyxia, damage to vital organs.

6) Elimination of endotoxicosis through the use of various methods of extracorporeal and intracorporeal detoxification.

8) Early antibiotic therapy, starting from the advanced stages of medical evacuation. Such therapy is especially indicated in the wounded with penetrating wounds of the abdomen, with open bone fractures and with extensive damage to soft tissues.

9) Correction of general somatic disorders identified in the dynamics, reflecting the individual characteristics of the general reaction of the body to severe trauma.

First aid: wounded arriving in a state of shock, especially with shock of II-III severity, it is necessary to carry out a set of measures to ensure the elimination of an immediate life threat and subsequent transportation to the next stage of evacuation. If there are indications, additional measures are taken to reliably eliminate disorders of external respiration: tracheal intubation, cricoconicotomy or tracheostomy, oxygen inhalation using standard devices, thoracocentesis with a valve device for tension pneumothorax. The tourniquet is controlled and, if possible, a temporary stop of external bleeding in the wound. Transport immobilization is corrected using standard means. Analgesics are reintroduced. With combined injuries of the musculoskeletal system, conduction blockades using local anesthetics are indicated. If there are pronounced signs of acute blood loss - the implementation of infusion or infusion-transfusion therapy in a volume of 500-1000 ml. In the presence of appropriate conditions, infusion therapy continues during further transportation. All the wounded are given tetanus toxoid, and according to indications, broad-spectrum antibiotics are used.

When rendering qualified and specialized medical care anti-shock measures must be carried out in full, which requires a sufficiently high qualification of anesthesiologists, surgeons and all medical personnel.

Restoring the function of the respiratory system. An indispensable condition for the effectiveness of measures in this area of ​​anti-shock care is the elimination of the mechanical causes of respiratory disorders - mechanical asphyxia, pneumothorax, hemothorax, paradoxical movements of the chest wall during the formation of a costal valve, aspiration of blood or vomit into the tracheobronchial tree.

Along with these activities, depending on the specific indications, the following are performed:

Anesthesia by performing a segmental paravertebral or vagosympathetic blockade;

Continuous inhalation of humidified oxygen;

Tracheal intubation and mechanical ventilation with respiratory failure of the III degree (respiratory rate of 35 or more per minute, abnormal breathing rhythms, cyanosis and sweating, feeling of lack of air).

In case of respiratory failure due to pulmonary contusions, it is required:

Limiting the volume of intravenous infusion-transfusion therapy to 2-2.5 liters with switching the required additional volume to intra-aortic infusions;

Long-term multilevel analgesia through retropleural blockade (administration every 3-4 hours of 15 ml of 1% lidocaine solution through a catheter installed in the retropleural space), central analgesia with intravenous fentanyl 0.1 mg 4-6 times a day and neurovegetative blockade with intramuscular injection of droperidol 3 times a day;

The use of rheologically active drugs in the hemodilution mode (0.8 l of 5% glucose solution, 0.4 l of rheopolyglucin), antiplatelet agents (trental), direct anticoagulants (up to 20,000 IU of heparin per day), aminophylline (10.0 ml of 2.4% solution intravenously 2-3 times a day), saluretics (lasix 40-100 mg per day up to 50-60 ml of urine per hour), and with sufficient excretory function of the kidneys - osmodiuretics (mannitol 1 g / kg of body weight per day) or oncodiuretics ( albumin 1 g / kg body weight per day), as well as glucocorticoids (prednisolone 10 mg / kg body weight) and ascorbic acid 5.0 ml of a 5% solution 3-4 times a day.

In the case of the development of adult respiratory distress syndrome or fat embolism, mechanical ventilation with increased pressure at the end of exhalation up to 5-10 cm of water takes on the leading role in the treatment of respiratory disorders. Art. apparatus of the "Phase-5" type against the background of the activities recommended for lung contusion. But at the same time, the dose of glucocorticoids increases to 30 mg / kg of body weight per day.

Restoration of the function of the circulatory system. A prerequisite for the effectiveness of intensive care measures is to stop external or internal bleeding, as well as to eliminate damage and tamponade of the heart.

Subsequent compensation for blood loss is carried out based on the following principles: for blood loss up to 1 liter - crystalloid and colloid blood-substituting solutions with a total volume of 2-2.5 liters per day; with blood loss up to 2 liters - compensation of BCC due to erythrocyte mass and blood substitutes in a ratio of 1: 1 with a total volume of up to 3.5-4 liters per day; with blood loss exceeding 2 liters, the compensation of the BCC is carried out mainly due to the erythrocyte mass in a ratio of 2: 1 with blood substitutes, and the total volume of the injected fluid exceeds 4 liters; with blood loss exceeding 3 liters, the BCC is replenished at the expense of large doses of erythrocyte mass (in terms of blood - 3 liters or more), blood transfusion is carried out at a fast pace into two large veins, or into the aorta through the femoral artery. It must be remembered that the blood that has poured into the body cavity is subject to reinfusion (if there are no contraindications). Compensation for lost blood is most effective in the first two days. Adequate replacement of blood loss is combined with the use of drugs that stimulate the tone of peripheral vessels: dopmin at a dose of 10-15 mcg / kg per minute or norepinephrine at a dose of 1.0-2.0 ml of a 0.2% solution in 400.0 ml of a 5% glucose solution at a rate of 40-50 drops per minute.

Along with this, in order to stabilize hemodynamics, glucocorticoids, antiplatelet agents and rheologically active drugs are used in the doses indicated in subsection 1.

Correction of the blood coagulation system is determined by the severity of the syndrome of disseminated intravascular coagulation (DIC): with DIC I degree (hypercoagulation, isocoagulation), heparin 50 U / kg 4-6 times a day, prednisolone 1.0 mg / kg 2 times a day, trental are used , reopoliglyukin; with II degree DIC (hypocoagulation without activation of fibrinolysis), heparin is used up to 30 U / kg (not more than 5000 U per day), prednisolone 1.5 mg / kg 2 times a day, albumin, plasma, rheopolyglucin, erythrocyte mass no more than 3 days conservation; with DIC of the III degree (hypocoagulation with the beginning activation of fibrinolysis), prednisolone 1.5 mg / kg 2 times a day, counterkal 60,000 units per day, albumin, plasma, erythrocyte mass of short periods of preservation, fibrinogen, gelatin, dicynone are used; with DIC IV degree (generalized fibrinolysis), prednisolone up to 1.0 g per day, counterkal 100,000 units per day, plasma, fibrinogen, albumin, gelatin, dicinone, alkaline solutions are used. In addition, a mixture is injected locally through drains into the serous cavities for 30 minutes: a 5% solution of epsilon-aminocaproic acid 100 ml, 5.0 ml of adroxon, 400-600 units of dry thrombin.

In case of heart failure caused by damage to the heart, it is necessary to limit intravenous infusion-transfusion therapy to 2-2.5 liters per day (the rest of the required volume is injected into the aorta through the femoral artery). In addition, polarizing mixtures are used as part of the infusion media (400 ml of 10% glucose solution with the addition of 16 units of insulin, 50 ml of 10% potassium chloride solution, 10 ml of 25% magnesium sulfate solution), cardiac glycosides are administered (1 ml of 0.06 % solution of corglicon or 0.5 ml of 0.05% solution of strophanthin 2-3 times a day), and with progressive heart failure, inotropic support is performed with dopmin (10-15 mcg / kg per minute) or dobutrex (2.5-5, 0 mcg / kg per minute), as well as the introduction of nitroglycerin (1 ml of a 1% solution 2 times a day, diluted slowly). The introduction of heparin is performed subcutaneously at 5000 IU 4 times a day.

Restoration of the function of the central nervous system. Surgical assistance for wounds and head injuries at the stage of providing qualified medical care is limited to stopping external bleeding from integumentary tissues and restoring external respiration by tracheal intubation or tracheostomy. Next, preparations are made for the evacuation of the wounded to the hospital base, where surgical intervention is performed at a specialized level in an exhaustive manner.

In case of encephalopathies of various origins (consequences of hypoxia, brain compression) or excessive afferent impulses from multiple lesions, the following intensive care measures are carried out:

Infusion therapy in the mode of moderate dehydration with a total volume of up to 3 liters per day using crystalloid solutions, 30% glucose solution (per 250 ml of 38 units of insulin with a total volume of 500-1000 ml), reopoliglyukin or reogluman; with the development of cerebral edema, dehydration is carried out due to saluretics (lasix 60-100 mg), osmodiuretics (mannitol 1 g / kg of body weight in the form of a 6-7% solution), oncodiuretics (albumin 1 g / kg of body weight);

Complete central analgesia by intramuscular injection of fentanyl 0.1 mg 4-6 times a day, droperidol 5.0 mg 3-4 times a day, intravenous administration of sodium hydroxybutyrate 2.0 g 4 times a day;

Parenteral administration of the following drugs: piracetam 20% 5.0 ml 4 times a day intravenously, Sermion (nicegolin) 4.0 mg 3-4 times a day intramuscularly, solcoseryl 10.0 ml intravenously drip on the first day, in the subsequent - 6 .0-8.0 ml;

Oral administration of glutamic acid 0.5 g 3 times a day;

Continuous inhalation of humidified oxygen.

In the case of the development of early multiple organ failure, intensive care measures acquire a syndromic character.

The most important component of shock treatment is the implementation of urgent and urgent surgical interventions aimed at stopping ongoing external or internal bleeding, eliminating asphyxia, damage to the heart or other vital organs, as well as hollow abdominal organs. At the same time, intensive care measures are carried out as preoperative preparation, anesthetic support of the operation itself and continue in the postoperative period.

Adequate treatment of shock is not only aimed at eliminating this formidable consequence of a severe combat injury. It lays the foundation for treatment in the post-shock period until the immediate outcome of the injury is determined. At the same time, the entire pathological process until the healing of the wounded is considered in recent years from the standpoint of concept of traumatic illness.

The concept of traumatic disease is fully implemented at the stage of specialized medical care, where the treatment of severe consequences of trauma and complications, including the rehabilitation of the wounded, is carried out depending on the location of injuries and their nature until the final outcome.

Shock- hypocirculation syndrome with impaired tissue perfusion that occurs in response to mechanical damage and other pathological effects, as well as their immediate complications leading to decompensation of vital functions.

The volume and nature of anti-shock measures in the provision of various types of medical care.

In case of a shock injury, active anti-shock therapy should be started even if there are no pronounced clinical manifestations of shock in the first hours.

In some cases, pathogenetic and symptomatic therapy is combined (for example, intravenous infusions to correct BCC and the introduction of vasopressors when blood pressure drops below a critical level).

Stop bleeding.

Continued bleeding leads to a threatening increase in the BCC deficiency, which cannot be replenished without full hemostasis. When providing each type of medical care, within the framework of the available possibilities, hemostatic measures should be performed as quickly and fully as possible, without which all anti-shock therapy cannot be effective.

Anesthesia.

Afferent pain impulse is one of the most important links in the pathogenesis of shock. Adequate anesthesia, eliminating one of the main causes of shock, creates the preconditions for successful correction of homeostasis in developed shock, and performed early after injury - for its prevention.

Immobilization of injuries.

Maintaining mobility in the area of ​​damage leads to an increase in both pain and bleeding from damaged tissues, which, of course, can cause shock or aggravate its course. In addition to the direct fixation of the damaged area, the purpose of immobilization is also gentle transportation during the evacuation of the victims.

Maintenance of respiratory and cardiac function.

Correction of impaired homeostasis in shock requires a certain amount of time, however, a critical drop in blood pressure and respiratory depression, characteristic of decompensated shock, can quickly lead to death. And therapy, directly aimed at maintaining respiration and cardiac activity, being essentially symptomatic, allows you to buy time for pathogenetic treatment.

Elimination of the direct impact of the shockogenic factor.

This group of measures includes the release of victims from the rubble, extinguishing the flame, stopping the impact of electric current and other similar actions that do not need a separate decoding and justification of their need.

However, with massive injuries and destruction of the limbs, blood circulation often cannot be normalized until the crushed segment is amputated, the wound is treated, bleeding is stopped, and a protective aseptic dressing and immobilizing splint is applied to the treated wound.

In the composition of substances circulating in the blood with intoxication properties, toxic amines (histamine, serotonin), polypeptides (bradykinin, kallidin), prostaglandins, lysosomal enzymes, tissue metabolites (lactic acid, electrolytes, adenyl compounds, ferritin) were found. All of these substances have a direct inhibitory effect on hemodynamics, gas exchange, and thereby exacerbate the clinical manifestations of shock.

They violate antimicrobial barriers, contribute to the formation of irreversible effects of shock. Given this circumstance, indications for limb amputation in some cases are set, regardless of the presence of shock, and are considered as an element of anti-shock measures.

Therapy aimed at normalizing BCC and correcting metabolic disorders:

Infusion-transfusion therapy.

Scientifically substantiated restriction of blood transfusion is characteristic of modern transfusiology. In order to correct BCC, crystalloid and colloid solutions are widely used, as well as blood components, which are in large quantities in the arsenal of modern medicine. At the same time, the goal is not only to compensate for the bcc, but also to combat generalized dehydration of tissues and correct disturbed water and electrolyte balances.

In conditions of decompensation, it is usually necessary to control the acid-base state of the blood (pH and alkaline reserve), since instead of the expected metabolic acidosis shock is often associated with metabolic alkalosis especially 6-8 hours after injury. In this case, alkalosis occurs the more often, the later the BCC deficiency is replenished.

Correction of vascular tone.

The need to correct vascular tone is due to the fact that its value to a large extent determines not only the parameters of systemic circulation (for example, cardiac output and arterial pressure), but also the distribution of blood flows along the nutritive and shunt pathways, which significantly changes the degree of tissue oxygenation.

With prolonged spasm of peripheral vessels and the introduction of significant volumes of fluid, the use of drugs that actively reduce the total peripheral resistance, reduce the return of venous blood to the heart and thereby facilitate its work is indicated.

Hormone therapy.

The introduction of large doses (hydrocortisone - 500-1000 mg) of glucocorticoids, especially in the first minutes of treatment, has a positive inotropic effect on the heart, reduces spasm of the renal vessels and capillary permeability; eliminates the adhesive properties of blood cells; restores reduced osmolarity of intra- and extracellular fluid spaces.

In the first decades of the 20th century, the main cause of death in patients with severe trauma was primarily traumatic shock; after the Second World War, the fate of patients with polytrauma was mainly determined by diseases resulting from shock. During the Korean War, it was primarily kidney shock, later shock lung or respiratory distress syndrome in adults, and finally, nowadays, multiple organ failure. These changes in the causes of death from accidents that have occurred over the past 50 years are associated with the progress of medicine, primarily with new possibilities for the treatment of shock, and therefore in clinics in advanced countries, the main cause of death is the insufficiency of individual organs and systems or multiple organ failure.

An analysis of the lethality of patients with polytrauma indicates that the main causes of death from injuries in domestic medical institutions are still shock and blood loss, and the measures taken to effectively treat shock are insufficient. Some patients could have been saved if timely diagnosis and treatment of the patient had been organized in the first hours after hospitalization.

The main causes of mortality include inadequate equipment of the anti-shock ward, poor training and organization of work of medical personnel in the first "golden hour" after hospitalization. Cowley, back in 1971, outlined the "Golden Hour in Shock" - the period of time required for primary diagnostic and therapeutic measures. Initial diagnosis, as well as stabilization of vital signs as an initial measure, should be done within this hour to avoid prolongation of shock and thus later complications. This can only be done with the cooperation of an efficient team of specialists and with the shortest possible treatment time in a well-equipped anti-shock ward.

Shock wards have always been an integral part of the advanced military medical field facilities, which confirms the importance of these units for the successful treatment of trauma victims. In modern traumatology clinics in advanced countries, the organization of the work of anti-shock chambers is also of paramount importance (Vecei, 1992; H. Tscherne, 1997).

In medical institutions of Ukraine involved in the provision of emergency care, anti-shock wards are either absent or have lost their significance. Even in emergency hospitals providing round-the-clock emergency medical care, anti-shock wards do not meet modern requirements for such units.

Some of our specialists believe that such wards are not needed, since patients in serious condition should be sent to the operating room or intensive care unit, but this excludes the possibility of modern diagnostics, which in such cases is carried out primitively, at the level of the senses of the surgeon on duty. In addition, there are always a lot of seriously ill patients in the intensive care unit, and the hospitalization of another patient there in a state of shock does not allow the staff to give him maximum attention.

1. In advanced countries, in each clinic of traumatology (Unfallchirurgie), an anti-shock ward is open for those hospitalized in a state of shock, the doctors of which solve the following tasks: Preservation or restoration of vital functions (control of cardiovascular activity, artificial respiration, infusion and transfusion therapy);

2. Primary diagnostics (radiography, computed tomography, sonography, angiography, laboratory diagnostics);

3. Carrying out life-saving operations (intubation, drainage of the pleural cavity, venesection, emergency thoracotomy, tracheostomy).

It should be borne in mind that all activities can be carried out simultaneously, which, in turn, puts forward special requirements for the anti-shock chamber.

For example, out of 300 patients treated at the Vienna Clinic Unfallchiruigie in 1995-1998, chest x-rays in the anti-shock ward were performed in all 300 patients, sonography - 259, computed tomography of the skull - 227, chest - 120, pelvis - 78, abdomen - 119, spine - 58, angiography - 59 patients.

In the anti-shock ward of our medical institutions, primary diagnostics, except for laboratory ones, is impossible due to the lack of appropriate equipment, therefore, for diagnostic studies, a seriously ill patient must be taken through the floors and rooms where his life path may end.

In order to reduce daily mortality from injuries, we also need to take measures to improve the diagnosis and treatment of victims of injuries during the “first golden hour in shock”, which means to improve the equipment and organization of work of anti-shock wards.

The anti-shock ward should be located near the entrance to the hospital, next to the registration area and the emergency department, not far from the emergency operating room. This ensures an immediate start of treatment and prevents the patient from having to travel for a long time throughout the hospital. Here, resuscitation measures can be carried out at any time, if necessary, the patient can be taken to a nearby operating room, and then intensive therapy can be continued again to stabilize the patient's condition.

The anti-shock ward is the central room, which is adjacent to rooms for advanced diagnostics (for example, x-rays, computed tomography) and for special treatment. The room itself should have a minimum area of ​​30 m2 and a minimum height of 3 m, with the severely injured patient lying in the center of the room on a gurney with his hands free. This is necessary so that several doctors of various specialties can examine him at once. The room should be well lit and have an independent temperature control system or heating elements. Appropriate storage of clothing, valuables and bio-containing materials belonging to the patient should be ensured.

Materials and equipment required for the various procedures of team members should be openly located, well marked and kept in close proximity to those team members who may need them. The optimal equipment of the anti-shock chamber should be as follows:

1. X-ray machine, which can be used at any time of the day to conduct a study, including angiography and catheterembolization. The X-ray machine easily moves in all planes and after use is taken out in a non-working position outside the zone of activity of the resuscitators so as not to interfere with their work. Since both diagnostics and emergency therapy are required, the basic equipment also includes a sufficient number of protective aprons that are always at hand. While assisting the patient, each member of the team must work in such an apron.

X-rays for a patient with a chest injury should be taken within the first 5 minutes; even before the patient arrives, an x-ray film should lie on the table in the anti-shock ward where he enters.

2. The mobile ultrasound machine is positioned so that it can be driven to the patient. Unlike many other European countries, in Germany, large trauma centers conduct ultrasound diagnostic trauma examinations. Its advantage is that this diagnostic method is possible at any time, even in the anti-shock ward.

Ultrasound diagnosis facilitates simultaneous diagnosis and has the advantage above all that it is possible to carry out repeated examinations in the anti-shock ward and during the operation.

3. Portable Doppler ultrasound machine with battery power. Doppler echography is used in all cases when a patient with polytrauma does not have a pulse. This may be due to a weakening of the pulse in hemorrhagic shock or damage to blood vessels. If this does not form an unambiguous signal, then angiography is required.

4. Anesthesia machine and monitor.

5. Suction system.

6. Refrigerator for medicines and blood depot, which should contain a large number of canned red blood cells.

7. Thermo cabinet for heating solutions and blood. There should always be a sufficient amount of warm solutions for infusion therapy, the necessary number of systems for blood transfusion and blood substitutes at the ready. A thermal cabinet, like a refrigerator for storing medicines, should be located in each anti-shock ward.

8. Trolley with all the most important medicines and everything you need for intubation. All medicines and dressings are in easily accessible boxes in protective packaging.

9. Rack with boxes for medicines.

10. Operating lamp.

11. The computer should be in the anti-shock unit, since patients with TBI on mechanical ventilation need periodic control studies. A CT scanner may be located near the anti-shock ward, but this makes emergency diagnosis difficult.

The anti-shock chamber should be provided with oxygen, sterile instruments for venesection, Bullau drainage, subclavian vein puncture, intubation, conicotomy (tracheotomy), laparocentesis.

For effective treatment of shock and prevention of late complications, trauma team personnel should be trained to perform primary diagnosis and stabilization of vital functions within 1 hour.

A team of specialists on duty should meet a seriously injured person at the entrance to the emergency department, while the patient is treated simultaneously by several doctors and nurses, without duplicating each other, for which the methodology of providing assistance should be worked out to the smallest detail.

Thus, in order to reduce daily mortality from injuries, it is necessary to open and equip anti-shock wards at the modern level, systematically train duty teams to receive patients with severe concomitant injuries, and transfer them to a horizontal level of work. H. Tscherne (1998) recommends such a distribution of duties of the specialists on duty at the Hanover Unfallchiruigie clinic when receiving a seriously injured person with an injury.

Responsible surgeon on duty:

1. Examination, determination of the diagnostic sequence, appointment of radiography of the chest, pelvis, skull.

2. Decision on the consultation, control and management of procedures, further sequential diagnostics.

3. Continuation of diagnosis and treatment, assessment of radiographs, notification of the operating room or intensive care hospital about preparations for the patient's admission.

4. Supervision and guidance of specialists during X-ray examinations, sonography, computed tomography, preparation for surgery, performance of operations.

First duty traumatologist:

1. Venesection (great saphenous vein), transfusion of 2000 ml of Ringer's solution and 100 ml of sodium bicarbonate, determination of the need for blood and ordering of preserved blood, emergency dressings, reduction and immobilization of fractures.

2. Thoracic drainage, abdominal sonography or lavage.

3. Observation of thoracic and abdominal drainages, with an initial hemoglobin below 8.5 g%, order 5 units. blood.

Carrying out infusion therapy, controlling urine output, maintaining blood circulation, informing the operating room staff, preparing for surgery.

Receptionist:

1. Taking 35 ml of blood for laboratory testing, blood gases.

2. Control of blood circulation, recording of all introduced catheters, medicines, tests, neurological examination.

3. Accounting for the value of analyzes and recording. Conducting blood gas analysis, documentation of all activities carried out.

4. Determining the severity of the patient's condition based on the examination data. Completing patient documentation.

Doctor of the antishock ward:

1. Measurement of blood pressure, pulse rate and documentation. Reception and documentation of the events that have occurred before admission to the clinic.

2. Putting forward the idea of ​​a council, assisting in anti-shock therapy.

3. Infusion therapy, assistance with blood transfusion.

4. Assistance in anti-shock therapy, the introduction of a catheter into the femoral artery. Assistance to the anesthesiologist. Recording the volume of transfused fluid and the volume of fluid released from the bladder.

First duty nurse:

1. Removing clothes, washing and shaving the neck and shoulder area, taking blood, cross-checking for blood transfusion.

2. Assistance in performing thoracic drainage.

3. Determination of platelets and blood gases. Filling in temporary shock logging schemes.

4. Conversation with the anesthetist staff about the care and condition of the patient during 30 - 60 minutes of blood transfusion.

5. Transfer of this activity to the anesthesiologist.

Second duty nurse:

1. In the absence of an anesthesiologist - assistance in removing clothes.

2. Performing infusion therapy, applying a cuff to measure pressure, conducting continuous infusion therapy.

4. Filling in the passport part of the medical history (receiving personalities), clarifying the address, receiving valuables, warming the patient.

5. Turning on the blood warmer, monitoring infusion therapy.

6. Referral of the case to the anesthetist staff.

Anesthetist:

1. Intubation, insertion of a probe into the stomach, respiratory control, central access to a vein.

2. Control of blood circulation, recording.

3. Control of breathing, circulation.

4. Anti-shock therapy and assessment of blood circulation and urine output.

5. Continuation of antishock therapy, anesthesia.

Anesthetist:

1. Assisting with intubation, infusion therapy.

2. Determination of blood type and compatibility, measurement of central venous pressure.

3. Protocol for urination and blood transfusion, preparation of warm blood for transfusion.

4. Accompanying and assisting.

5. Warming blood, assisting in transfusion and performing transfusion.

6. Assistance in anesthesia and anti-shock therapy, preparation and warming of mattresses.

The experience of the Unfallchirurgie clinics has shown that the organization and modern equipment of the anti-shock ward, the transfer of staff work to a horizontal level makes it possible to reduce mortality from injuries.