Method for early therapy of hemorrhagic shock of ii, iii degree

FIELD: medicine, first aid, anesthesiology, resuscitation, surgery.

SUBSTANCE: along with conventional medicinal preparations applied to treat shock one should introduce crystalloids into central vein in certain sequence: 7.5% and 0.9%-sodium chloride solution, 5%-glucose solution, and, also, infucol and similar-group plasma; after stabilizing arterial pressure one should introduce, additionally, either mildronate, or dalargin at certain dosages. The present innovation enables to restore the volume of extracellular liquid in the shortest period of time at decreased volume of infusion that, in its turn, favors to remove shock and prevent other possible further complications.

EFFECT: higher efficiency.

3 ex

 

The invention relates to medicine, namely to provide emergency medical care, anesthesiology and intensive care and surgery, can be used for early treatment of hemorrhagic shock.

Known early therapy of hemorrhagic shock (M. V., Miroshnichenko A.G. guidelines for physicians ambulance. // SPb.: Nevsky Dialect. - 2001.- P.114-116). The essence of therapy is to stop the bleeding, the filling volume of circulating blood, normalization of metabolic processes, oxygen. Infusion therapy is recommended to start with the introduction of colloidal solutions. Preference is given polyglycine or 10% solution HAES-steril, then enter reopoliglyukin, relational and crystalloid solutions.

In shock I degree - poliglyukin 400 ml or 10% solution of HAES-steril 500 ml crystalloid solution - 500 ml

When the shock of II degree - poliglyukin 800 ml, 10% solution HAES-steril 500-1000 ml crystalloid solutions - 1000 ml.

When the shock of the III degree - poliglyukin 800 ml, reopoliglyukin 400 ml, relational 400 ml, 10% solution HAES-steril 500-1000 ml crystalloid solutions - 1000 ml.

Hormone therapy - up to 300 mg of prednisone or other corticosteroids in appropriate doses.

For normalization of metabolic processes - kokarboksilaza (100-150 mg), cytochrome C (10-30 mg), sodium oxybutyrate, glucose with insulin, calcium chloride 0% solution of 5-10 ml

Correction of metabolic acidosis 5% solution of sodium bicarbonate (3 ml/kg). With the development of respiratory failure with acute respiratory failure requires respiratory therapy.

According to some authors (Shirokov D.M., Som SV, Polushin US an Objective assessment of the severity of gunshot wounds. // Anesthesiology and resuscitation. - 1998. No. 2. - P.8-11)in patients with wounds and injuries accompanied by shock, the most common complications are sepsis, organ failure, resulting in 50% lethal.

Known early therapy of hemorrhagic shock does not always lead to a positive effect, because it does not account for disorders of microcirculation, and the volume of infusion therapy is focused on indices of Central hemodynamics. This can not affect the further course of pathological changes and mortality rates in these patients (Kartavenko VI, Pogodin A.I., Shabanov A.K. Intensive therapy for severe combined trauma. //VIII all-Russian Congress of anesthesiology and resuscitation. The abstracts. - Omsk. - 2002. - P.142).

The task of the invention is to increase the effectiveness of early treatment of hemorrhagic shock.

The task reach due to the fact that the patient is first injected with 7.5% Rast is the PR of sodium chloride, dalargin or Mildronate, contrical (gordox), heparin, ascorbic acid, vitamin B6, Riboxin, first in the Central veins of 7.5% sodium chloride 200-300 ml, dalargin 0,001-0,003 g or systolic blood pressure below 90 mm Hg - Mildronate 10% - 5-6 ml, then under the control of the Central venous pressure injected with 0.9% sodium chloride 400-800 ml 5% glucose solution 400-800 ml insulin 6-12 UNITS and potassium chloride 4% solution - 20-30 ml, calcium chloride 10% solution of 8-10 ml magnesium sulfate 25% solution of 4-6 ml of 0.9% sodium chloride 400 - 800 ml contrical (gordochom) 20-40 thousand UNITS, infocol 500-800 ml, single-group plasma 600 - 800 ml, heparin 3000-4000 IU intravenous bolus of 0.9% sodium chloride 20 ml, and then injected into a peripheral vein ascorbic acid 5% - 4-6 ml intravenous bolus of 40% glucose solution 15 ml, Riboxin 8-10 ml intravenous bolus of 0.9% sodium chloride 10 ml, vitamin B61-2 ml intravenous bolus of 20 ml of 0.9% solution of sodium chloride, in Central vein continue the introduction of a 20% glucose solution 300-400 ml insulin 20-26 UNITS that are single-group blood transfusion of erythrocyte mass 400-600 ml, with unstable hemodynamics continue intravenous 0.9% sodium chloride solution with infusion of dopamine 5-10 mg/kg/min, and after stabilization of hemodynamic parameters, for which recchi volume of circulating blood, dalargin administered intramuscularly in a dose of 0.001-0.003 g 2 times a day, or the patient Mildronate 5-6 ml of 10% solution intravenously to 15 ml of 0.9% sodium chloride 1 times a day for 10-14 days and pentamin 5% solution of 0.3 - 0.5 ml intramuscularly 3 times a day for 3-5 days.

The method is carried out:

The patient with hemorrhagic shock in the Central veins of 7.5% sodium chloride 200-300 ml, dalargin 0,001-0,003 g or systolic blood pressure below 90 mm Hg - Mildronate 10% - 5-6 ml, then under the control of the Central venous pressure injected with 0.9% sodium chloride 400-800 ml 5% glucose solution 400-800 ml insulin 6-12 UNITS and potassium chloride 4% solution - 20-30 ml, calcium chloride 10% solution of 8-10 ml magnesium sulfate 25% solution of 4-6 ml of 0.9% sodium chloride 400 - 800 ml the contrical (gordochom) 20-40 thousand UNITS, infocol 500-800 ml, single-group plasma 600-800 ml, heparin 3000-4000 IU intravenous bolus of 0.9% sodium chloride 20 ml, and then injected into a peripheral vein ascorbic acid 5% - 4-6 ml intravenous bolus of 40% glucose solution 15 ml, Riboxin 8-10 ml intravenous bolus of 0.9% sodium chloride 10 ml, vitamin B61-2 ml intravenous bolus of 20 ml of 0.9% solution of sodium chloride, in Central vein continue the introduction of a 20% glucose solution 300-400 ml insulin 20-26 UNITS, carry out a blood transfusion single-group, eritria the ary mass 400-600 ml, in unstable hemodynamics continue intravenous 0.9% sodium chloride solution with infusion of dopamine 5-10 mg/kg/min, and after stabilization of hemodynamic parameters, correction of volume of circulating blood, dalargin administered intramuscularly in a dose of 0.001-0.003 g 2 times a day, or the patient Mildronate 5-6 ml of 10% solution intravenously to 15 ml of 0.9% sodium chloride 1 times a day for 10-14 days and pentamin 5% solution of 0.3-0.5 ml intramuscularly 3 times a day for 3-5 days.

The use of a 7.5% solution of sodium chloride allows faster to compensate for the loss of extracellular fluid, thus the smaller infusion, to eliminate arterial hypotension, restore cardiac output, improve capillary perfusion.

The use of dalargin allows to normalize microcirculation and lymph flow in the damage zone, causes a sedative and analgesic effect.

Introduction mildronata improves metabolic processes, due to the stimulation charitynavigator of fatty acid metabolism and activation of glucose metabolism, regulation of cellular immunity. Mildronate corrects organ disorders in ischemic conditions and adrenergic effects, has a cardioprotective effect.

Contrical (gordox) reduces the activity of the proteolytic enzyme is in, the increase which has taken place in many critical conditions.

Blood loss in the first hours there is an increase in coagulation properties of blood, heparin, introduced in this period, allows to normalize the coagulation system also has an immunosuppressive effect and improves coronary blood flow.

The use of ascorbic acid allows you to adjust the oxidation-vostanovlenie processes, carbohydrate metabolism, clotting of the blood, promotes tissue regeneration, normalization of the capillary permeability, and in combination with b vitamins, has a stress-protective effect.

Riboxin, as a precursor to adenosine triphosphate, regulates carbohydrate metabolism, stimulates the synthesis of nucleotides, has antihypoxic effect, increases the energy balance of a myocardium, improves coronary blood flow.

The use of blood loss as infusion therapy crystalloid solutions allows you to quickly compensate for the loss of interstitial fluid, in combination with blood transfusions has a good effect in this pathology (Malyshev E Intensive therapy. Reanimation. First aid. - M.: Medicine. - 2000. - S-198), avoids many of the complications caused by the introduction of a large volume of colloidal solutions (Likhachev E.A., yanchyn, Y.M. Liciniacarvalheiro and hemorrhagic shocks prehospital hypertonic solution of sodium chloride. // Actual problems of emergency medical care for urgent conditions and prospects of their development. Proceedings of the first part. - Novokuznetsk. -1994. - S-72).

Pentamin improves peripheral circulation, oxygenation of tissues, improves metabolic processes in tissues by influencing the trophic function of the nervous system, in small doses does not cause hypotension, has a stress-protective effect (Nazarov I.P. Extended ganglioplegic in anesthesiology and surgery. - Krasnoyarsk. - 1999. - Ñ.38-56).

Clinical example 1. Patient B. 27 years has been a household injury: incised wound to the right forearm. At the time of inspection of patient contact, adequate. Clear consciousness. Pale skin, a symptom of pale spots = 1 C. vesicular Breathing, wheezing no, NPV - 20 per minute. Heart tones are clear, rhythmic, pulse, sufficient filling. Heart rate was 108 beats/min, BP-100/60 mm Hg, saturation of blood (SaO2) - 94%, shock index (SHI) is 1.1. The patient complains of dry mouth, weakness, dizziness. The patient was introduced to 200.0 ml of a 7.5% solution of sodium chloride, dalargin 0,001 intravenous bolus of 20 ml of 0.9% solution of sodium chloride. After injection, the patient noted improvement. Objectively: the skin is pink, normal humidity. Symptom pale spots < 1 C, heart rate of 98 beats/min, BP - 120/80 MRTT, SaO2- 99%, CHI - 0,7, NPV - 18 per minute. Patient diagnosed with Incised wound to the right forearm, hemorrhagic shock 1 degree.

Produced primary debridement, suturing the damaged vessel.

The patient received fluid resuscitation with 0.9% solution of sodium chloride (400 ml 5% glucose solution 400 ml insulin 6 UNITS, 4% solution of potassium chloride 20 ml, 10% solution of calcium chloride 8 ml, 25% solution of magnesium sulfate 4 ml of 0.9% solution of sodium chloride (400 ml contrical 20 thousand UNITS. Intravenous bolus the patient was administered ascorbic acid 5% 4 ml 20 ml 40% glucose solution, Riboxin 9 ml intravenous bolus of 10 ml of 0.9% solution of sodium chloride, vitamin B61 ml intravenous bolus of 20 ml of 0.9% solution of sodium chloride. Within 10 days the patient received dalargin 0.001 g intramuscularly 2 times a day, pentamin 0.5 ml of 5% solution intramuscularly 3 times a day for 3 days, antibiotic therapy. The healing of joints primary intention, the patient was discharged from hospital in satisfactory condition for 5 days.

Clinical example 2. Patient C. 42 years have received criminal injury: stab wound in the stomach. During the inspection: a serious condition, consciousness - stun 1-2 degrees, the skin pale, cool, acrocyanosis, wet. Symptom pale spots =2 C. vesicular Breathing, wheezing no. NPV - 22 min. The heart is by the tones are muffled, rhythmic. Pulse weak filling. AD - 75/30 mm Hg, heart rate is 115 beats/min, SaO2- 91%, CHI - 1,5, Central venous pressure (CVP) - 15 mm Vogt

Was diagnosed with Stab wounds of the anterior abdominal wall, penetrating into the abdominal cavity with damage to internal organs. Hemorrhagic shock 2 degrees.

The patient is entered into the Central vein of 250 ml of 7.5% sodium chloride/drip, 5 ml of 10% solution mildronata/jet 15 ml of 0.9% solution of sodium chloride. Then therapy was continued with the introduction of 0.9% solution of sodium chloride (400 ml) and 5% glucose solution 200 ml was conducted respiratory support (inhalation O2with FiO2=0,3).

After injection of a hypertonic solution of sodium chloride and mildronata the patient noted improvement objectively: the skin is pink, moist, symptom pale spots = 1, AD - 110/60 mmHg, heart rate 100 beats/min, SaO2- 98%, CHI - 0,9, CVP 30 mm Vogt, NPV - 20 per minute.

When receiving the diagnosis was confirmed. Intraoperatively revealed liver damage, hemoperitoneum, injury to the bowel. Final hemostasis, reinfuse blood.

Therapy continued for introduction into the Central vein 200 ml of 0.9% sodium chloride solution, 600 ml of 5% glucose solution with 9 UNITS of insulin, 25 ml of 4% solution of potassium chloride, 9 ml of 10% solution of calcium chloride, 5 ml of 25% solution of magnesium sulfate,600 ml of 0.9% solution of sodium chloride with 30 thousand contrical ED, infocol 500 ml, single-group plasma 600 ml heparin 3000 IU intravenous bolus of 0.9% sodium chloride 20 ml, then into a peripheral vein was injected ascorbic acid 5% - 5 ml intravenous bolus of 40% glucose solution 15 ml, Riboxin 9 ml intravenous bolus of 0.9% sodium chloride 10 ml, vitamin B61.5 ml intravenous bolus of 20 ml of 0.9% solution of sodium chloride, in Central vein continued the introduction of a 20% glucose solution 300 ml insulin, 20 UNITS were single-group blood transfusion of erythrocyte mass 400 ml.

After stabilization of hemodynamic parameters, correction of volume of circulating blood, the patient received Mildronate 5 ml of 10% solution intravenously to 15 ml of 0.9% sodium chloride 1 time a day for 10 days and pentamin 5% solution of 0.4 ml for 4 days, antibiotic therapy. After 18 days the patient was discharged in good condition.

Clinical example 3. Patient, 50 years of age have received criminal injury: penetrating stab wound in the stomach. At the time of inspection in contact almost does not enter. A serious condition, consciousness is disturbed by type spoor. Pale skin, cyanosis, dry, cold, symptom pale spots >3 C. In the lungs, the breath is held, all fields, hard, no wheezing. NPV 26 per minute. Heart tones are deaf, single extrasystoles, pulse on peripheral artery the x is not defined. HELL 60/30 mm Hg, heart rate of 122 beats/min, SaO2- 88%, CHI - 2,03, CVP negative. Was diagnosed with stab wounds of the anterior abdominal wall, penetrating into the abdominal cavity with damage to internal organs. Hemorrhagic shock 3 degrees.

The patient through a Central vein put 300 ml of 7.5% sodium chloride/drip, 6 ml of 10% solution mildronata/jet 15 ml of 0.9% solution of sodium chloride. Then the treatment was continued by the introduction of crystalloid solutions were placed in 0.9% sodium chloride solution, 400 ml of 5% glucose solution 400 ml connectivity inotropic stimulation in a dose dopamine 5 mcg/kg/min, was performed respiratory support (inhalation O2with FiO2or = 0.6). After this therapy objectively: the skin is pale pink, the symptom pale spots = 1, BP - 90/60 mm Hg, heart rate is 110 beats/min, SaO2- 97%, CHI - 1,2, NPV - 20 per minute, CVP - 20 mm Vogt Intraoperatively revealed liver damage, hemoperitoneum, injury to the kidney and intestine. Final hemostasis, reinfuse blood.

Therapy was continued by introduction into the Central vein under the control of the CVP 0.9% solution of sodium chloride (400 ml 5% glucose solution (800 ml) with insulin 12 UNITS and potassium chloride 4% solution 30 ml, calcium chloride 10% solution - 10 ml magnesium sulfate 25% solution of 6 ml of 0.9% solution of sodium chloride (800 ml) with contrical 40 thousand UNITS, infocol 800 ml single-group plasma 800 ml, heparin 4000 IU intravenous bolus of 0.9% sodium chloride 20 ml, then into a peripheral vein was injected ascorbic acid 5% - 6 ml intravenous bolus of 40% glucose solution 15 ml, vitamin b62 ml intravenous bolus of 20 ml of 0.9% solution of sodium chloride, in Central vein continued the introduction of a 20% glucose solution 400 ml insulin 26 UNITS were single-group blood transfusion of erythrocyte mass of 600 ml, and after stabilization of hemodynamic parameters, correction of the BCC, the patient received Mildronate 6 ml of 10% solution intravenously to 15 ml of 0.9% sodium chloride 1 time a day for 14 days and pentamin 5% solution of 0.3 ml for 5 days antibiotic therapy.

The postoperative course was uneventful. After 30 days the patient was discharged in satisfactory condition.

The proposed method early treatment of hemorrhagic shock can improve the effectiveness of treatment in these patients and prevent further complications.

How early therapy of hemorrhagic shock II and III, including the introduction of crystalloids and colloids, a 5%solution of glucose with insulin, potassium chloride, calcium chloride, magnesium sulfate, red cell mass, single-group blood, 20%glucose solution with insulin, the introduction of a 0.9%solution of sodium chloride with Ingushetian 5-10 mcg/kg/min, wherein the patient is additionally administered a 7.5%solution of sodium chloride, dalargin or Mildronate, contrical, heparin, ascorbic acid, vitamin b6, Riboxin, pentamin, and infusion therapy is mainly crystalloid solutions, first in the Central veins of 7.5%solution of sodium chloride 200-300 ml, dalargin 0,001-0,003 g or systolic blood pressure below 90 mm Hg - Mildronate 10%5 - 6 ml, then under the control of the Central venous pressure injected with 0.9%solution of sodium chloride 400-800 ml 5%glucose solution 400 - 800 ml insulin 6-12 UNITS and potassium chloride 4%aqueous solution of 20-30 ml, calcium chloride 10%aqueous solution of 8-10 ml magnesium sulfate 25%aqueous solution of 4-6 ml of 0.9%solution of sodium chloride (400 - 800 ml contrical 20-40 thousand UNITS, infocol 500-800 ml, single-group plasma 600-800 ml, heparin 3000-4000 IU intravenous bolus of 0.9%sodium chloride solution 20 ml, and then injected into a peripheral vein ascorbic acid 5%4-6 ml intravenous bolus of 40%glucose solution 15 ml, Riboxin 8-10 ml intravenous bolus of 0.9%sodium chloride 10 ml, vitamin B61-2 ml intravenous bolus of 20 ml of 0.9%solution of sodium chloride, in Central vein continue the introduction of a 20%glucose solution 300-400 ml insulin 20-26 UNITS, carry out a blood transfusion single-group erythrocyte is nuclear biological chemical (NBC weight 400-600 ml, in unstable hemodynamics continue intravenous administration of 0.9%sodium chloride solution with infusion of dopamine 5-10 mcg/kg/min, and after stabilization of hemodynamic parameters, correction of volume of circulating blood, dalargin administered intramuscularly in a dose of 0.001-0.003 g 2 times a day, or the patient Mildronate 5-6 ml of 10%solution intravenously to 15 ml of 0.9%sodium chloride 1 times a day for 10-14 days and pentamin 5%solution of 0.3-0.5 ml intramuscularly 3 times a day for 3-5 days.



 

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