mmHg.
- Cerebral ischemia causes a huge stimulation of sympathetic activity leading to vasoconstriction and increased heart rate.
2.1.4. Liver:
- Hepatocellular necrosis caused by anemia contributes to multisystemic failure syndrome.
organ
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- Liver dysfunction favors the development of metabolic acidosis due to
lactate defect
2.1.5. Kidney:
Glomerular filtration rate is reduced due to:
- Reduced blood flow to the kidneys.
- Blood flow to the renal medulla is greater than to the renal cortex. The effects of angiotensin and aldosterone increase the reabsorption of water and salt to compensate for the loss of body fluids. If shock persists, organic kidney failure will occur.
2.1.6. Lungs:
There is no marked change in gas exchange in the early stages of hypovolemic shock; lung parenchymal damage occurs only in some cases of severe shock.
2.1.7. Intestines:
- Hypoxia causes mucosal ischemia leading to mucosal barrier dysfunction.
- Reperfusion after resuscitation causes accumulation of oxidants leading to cell damage.
cell
- Intestinal bacteria and endotoxins translocate through the intestinal wall and enter the
blood stream causing sepsis
2.2. Response in extracellular fluid:
- Reducing circulating fluid volume will reduce hydrostatic pressure in the blood vessels.
- When there is a lot of blood loss, the fluid in the interstitial space not only enters the blood vessels but also enters the cells, causing an increase in intracellular fluid and cell edema in a displacement manner.
- Thus, the cyclic redistribution occurs in two places:
2.2.1. At the agency level:
- Reduced blood flow in the skin to non-core organs such as skin, kidneys, and internal organs.
- Increases blood flow to organs such as the heart and brain.
2.2.2. In microcirculation:
- Capillary constriction.
- Reduce fluid retention in the microcirculation area.
- Cellular edema obstructs blood vessels.
- Lack of oxygen in tissue cells and organs.
3. Cellular response:
- Na goes into the cell and K goes out of the cell, leading to cell edema.
- Cellular metabolism becomes anaerobic because lack of oxygen becomes acidosis
chemical
4. Diagnosis:
4.1. Clinical:
4.1.1. Early symptoms:
- The earliest symptoms of shock are rapid heart rate and vasoconstriction of the skin.
- Therefore, when a patient has a rapid heart rate after trauma with signs of cold extremities, he or she must be considered to be in shock. The heart rate is rapid when:
+ Pulse over 100 times/minute in the patient.
+ Pulse over 120 beats/minute in school-age children.
+ Pulse rate above 140-160 beats/minute in young children. In the elderly, heart rate may not be fast due to the heart's limited response to catecholamines.
4.1.2. Typical symptoms:
- Fast or very fast heart rate.
- Decreased arterial blood pressure is also a reliable sign but usually does not occur early.
- Arterial blood pressure is also an early sign, but at this time a significant amount of blood has been lost and the compensatory mechanism has been affected.
- Cold limbs with purple veins indicate reduced circulation to nourish the skin.
- Oliguria is a good sign of volume depletion.
- Rapid breathing indicates tissue hypoxia Pa024.
- Sweating due to increased catecholamine secretion.
- Thirst is very common when the patient is conscious.
- Pale skin and mucous membranes in cases of severe anemia.
- Anxiety, lethargy, agitation when blood flow to the brain has decreased significantly.
4.2. Paraclinical:
- Low hematocrit or hemoglobin is very specific in hemorrhagic shock but often appears too late.
- Blood lactate concentration increases when there is cellular hypoxia.
- Central venous pressure is important in the diagnosis, treatment and monitoring of shock.
4.3. Level:
The division of shock into many levels is to emphasize the early symptoms of considering the clinical manifestations of shock. Shock can be divided into 4 levels based on the amount of blood loss.
5. Treatment principles:
5.1. Principles of treatment of traumatic shock
+ First aid is one step ahead to replenish circulating volume, ensure breathing, and reduce pain to prevent shock.
+ Step by step find the cause of traumatic shock to handle appropriately
+ prioritize urgent surgeries to save patients' lives
5.2. Tasks to be done in emergency trauma shock
+ Record pulse, respiratory rate and arterial blood pressure in medical records
+ Take venous blood to test Hematocrit, hemoglobin, blood type, blood formula
+ Blood urea test, blood electrolytes
+ Place the patient in a low head position.
+ Place an intravenous line into a large vein.
+ Place a bladder catheter to monitor urine output and collect urine for testing.
+ Take arterial blood to measure pH, PaC02, Pa02.
+ Record in patient monitoring sheet. Test results and monitoring results.
+ Ensure upper respiratory tract circulation
+ Treatment of disorders caused by traumatic shock.
5.3. Resuscitation treatment for traumatic shock requires
5.3.1. Comprehensive medical examination and treatment planning:
This is very important and requires an experienced surgeon. Systematic examination. Many doctors have missed the patient's injuries, so shock treatment is ineffective.
- Experience shows that it is difficult to diagnose and easy to miss lesions, especially in cases with multiple combined lesions.
- After examining the patient, doctors must have a diagnosis and a specific surgical plan if surgical intervention is required.
5.3. 2. Ensure good breathing:
- Because shock leads to lack of oxygen in the tissues, the first thing to do in treatment is to bring oxygen naturally to the patient.
- Clear the upper respiratory tract, remove foreign objects, suction fluids such as blood, vomit...
- Some complicated cases require special treatment such as tracheostomy and mechanical ventilation.
5.3.3. Ensure good circulation:
- Prepare a good line for monitoring and resuscitation in critically ill patients, it is necessary to establish 2-3 intravenous lines.
- Measure central venous pressure. This blood pressure is a good indicator to assess myocardial activity and circulatory volume. Combined with arterial blood pressure and hourly urine output, cardiac output can be indirectly assessed for resuscitation:
+ If central venous pressure is low. Low arterial blood pressure is due to loss of circulating volume, then fluid must be administered.
+ If central venous pressure is high. Arterial blood pressure is low, there are two possibilities: either the patient has heart failure and needs cardiac support medication. If the patient has pneumothorax or mediastinal emphysema, which means the heart is compressed, timely drainage is needed.
- Infusion:
+ The first to mention is HAES solution - Steril is a solution purified from
cornstarch, it replaces the plasma volume with its own volume, and is stable for 6-8 hours. It improves microcirculation. HAES - Steril has no electrical charge when infused it increases the negative charge, causing the blood cells to separate from each other. Thus avoiding the phenomenon of red blood cell aggregation.
+ Isotonic Ringer's lactate: is a solution with a composition similar to extracellular fluid, so it is good for treating shock.
Infuse with a volume equal to 5% of the patient's body weight and then test the Hematocrit.
If the Hematocrit is between 30 - 35%, no blood transfusion is required. Most patients are stable.
+ Sodium chloride 9%o solution: this solution is also used in the treatment of shock. Because after an electrical shock, the exchange of Na+ increases and the body's need for salt also increases. Because Na+ and H20 are attracted to the tissue around the blood vessels, between the collagen cells and the substrate. Therefore, using Sodium chloride 9%o has the same value as Ringer's Lactate.
+ Dexuan solution: Dextran 40,000 also known as infuloll 40 (Germany) is used in the late stage of shock. Because they have the effect of preventing cells from sticking together. This increases circulation through capillaries, drawing water from the intercellular space into the blood vessels, thereby increasing circulating volume.
+ In addition, other solutions are also used in anti-shock: such as coconut water which is widely used in the Southern earthquake field and some Southeast Asian countries. Darrow and Hartman solutions are also used...
- Transmission speed:
If the central venous pressure is low, infuse quickly. When it reaches 8cm H20, infuse slowly. If it is > 12cm H20, infuse very slowly. In addition, it also depends on the urine output to produce 1ml of urine per minute.
+ Blood transfusion: it is best to transfuse the same blood group and fresh blood. Nowadays, with technical means, it is possible to measure the patient's remaining blood volume (Vc) and thereby determine the amount of blood loss.
Vm = (Pkg X 70ml) - Vc
Vm: blood volume Vc: remaining blood volume P: is body weight
Thus, the amount of blood and fluid to be transfused is: Vt = 0.05 X p + Vm
Vt: total amount of blood and fluid to be transfused. 0.05 XP: amount of fluid to be transfused.
Vm: amount of blood to be transfused.
+ Heart medication -
Once the amount of circulation has been compensated but the arterial blood pressure is still low and the venous blood pressure is still high, the heart must be checked. If the heart fails, the heart must be supported with an average dose of Uabaine, Strophantine 1/4 -1/2 mg Cedieanide: 0.4 mg Digoxin 0.5 mg. These drugs should be used as a mandatory principle for elderly patients, patients with pre-existing heart disease. If the patient still does not improve after using these drugs, drugs that release Adrenaline such as: Isuprel, Dopamine can be used to dilate the blood vessels, making the heart beat stronger, increasing the need for oxygen of the heart muscle. Adrenaline and Noadrenaline should absolutely not be used to treat traumatic shock, hemorrhagic shock because they increase vasoconstriction, increasing tissue hypoxia.
5.3.4. Ensure good kidney function
- Place a bladder catheter to monitor urine output every hour, each hour must achieve 60ml of urine.
- Replenish circulating volume and use diuretics when necessary.
- Only give diuretics when arterial blood pressure is close to normal but the patient has no urine or little urine.
- Furosemide (lasix) starting dose is 20mg, usually after 20-30 minutes the patient will urinate a lot. If the patient urinates less, double the dose every 1 hour until urine output reaches 60ml/hour. However, only inject a maximum of 4 times (15 tubes = 300mg)
- Matitol 20% 150ml intravenous infusion rate 80 drops/minute. Dosage not to exceed 300ml/24 hours.
- Peritoneal dialysis, hemodialysis.
5.3.5. Pain relief for patients
Pain control is no less important than blood transfusion and fluid infusion. Blocking the injured limb and administering appropriate pain-relieving sedatives for each patient.
To avoid diagnostic errors. Avoid anything that causes additional pain to the patient.
5.3.6. Antibacterial
In shock, the body's resistance is reduced, so it is necessary to actively prevent infection, use antibiotics appropriately, use strong doses of broad-spectrum antibiotics from the beginning and use the full dose. It is best to choose antibiotics based on the antibiogram.
5.3.7. Treatment of acid-base disorders and coagulation disorders
In shock, there is often metabolic acidosis. The more severe the shock, the more severe the metabolic acidosis. It is necessary to adjust when pH = 7.3, base excess (BE) = 3. Commonly used solutions are:
- 7.4% or 5% Sodium Bicarbonate Solution is calculated as follows: Vml of 7.4% Sodium Bicarbonate Solution = (BE) X Pkg/3
If it is a 5% solution = (BE) xPkg/ 3 . P: is body weight = kg
- THAM solution: Vm of 0.3M THAM solution = BE X p
- Regulate blood clotting disorders.
EACA dose 2g injected into the blood vessel if the disorder persists, add 2g each time, total dose not to exceed 24g/24 hours until bleeding completely stops.
Heparin 20 - 50 units intravenously every 4-6 hours until the ethanol and protamine sulfate alcohol tests return negative.
+ Use of metabolic drugs
Vitamin C and Vitamin Bj support the oxidation-reduction process, so they are very good for shock.
Dosage of Vitamin C is 2 - 5g mixed in 250ml of 5% Glucose, intravenous drip 20 - 30 drops/minute.
Vitamin B100 - 200mg dose by intravenous drip
5.4. Surgical treatment: Surgery to resolve the cause of shock
- If it is a ruptured solid organ such as a ruptured liver, spleen, or torn large blood vessels or a heart wound, resuscitation and surgery must be performed at the same time.
- If the fracture is a large bone, resuscitation should be performed and surgery should be performed after the patient is truly stable.
IV. References:
1. Bui Van Ninh (2001), surgical symptomatology, Medical Publishing House, Ho Chi Minh City branch.
2. Aiexander H Raymond (1993).Shock.Advance tranma life support, American College surgccn Cuiion 5J,edition (75-110).
3. Anderson w Robut-Shock. In Sabiston Textbook of Surgery