Infusion therapy of traumatic shock
Background. Analysis of all deaths due to military trauma (MT) over the last decade revealed that 1/4 of them could have been prevented. Up to 90 % of these deaths are related to blood loss. Trauma induces acute endogenous coagulopathy within a few minutes in 25 % of patients, which quadruples mortality. The main feature of MT is its combined nature, because in explosive injuries the local action of the explosion is combined with shrapnel wounds and distant damage to organs, and the wound canal goes through several anatomical parts of the body. In case of concomitant injuries, there are several sources of pain impulses, there is a deep endotoxicosis and impaired function of damaged organs. Under MT conditions, it is difficult to determine the nature of the shock due to a combination of hemorrhagic and traumatic shock. Uncontrolled post-traumatic bleeding is the leading cause of preventable death.
Objective. To describe infusion therapy (IT) of shock.
Materials and methods. Analysis of literature data on this issue.
Results and discussion. In approximately 1/3 of hospitalized patients with trauma, the bleeding is coagulopathic. The severity of coagulopathy is determined by the influence of environmental factors, metabolic disorders, therapeutic strategy, the presence of brain and liver injuries, individual characteristics of the patient, the trauma and shock, hemodilution coagulopathy. The primary task of managing a patient with trauma is to eliminate the so-called lethal triad (hypothermia, acidosis, coagulopathy) and ensure perfusion of vital organs. Damage Control Resuscitation (DRC) is a systemic approach to the treatment of severe injuries that combines a resuscitation strategy with a range of surgical techniques from the moment of injury till the end of the treatment. DRC is aimed at blood loss minimization, maximization of tissue oxygenation, and optimization of outcomes. Surgeries performed as part of the DRC approach include an incision from the xiphoid process to the pubis with evacuation of blood and clots from the abdominal cavity, thorough examination and termination of all bleedings. Damaged parenchymal organs are completely resected. Damaged intestine is resected and connected with clips without anastomosis formation. Damaged vessels are ligated. The abdominal cavity is closed with a sterile bandage, but not sutured. After 1-2 days, tampons are removed, anastomoses are formed, and all non-viable tissues are removed. As for examinations, magnetic resonance imaging is the gold standard for assessing the severity of the injury and detecting extraperitoneal bleeding. In patients with closed abdominal trauma, hypotension, or an unknown mechanism of trauma, a rapid ultrasound examination is indicated to look for blood at potential sites of its accumulation. In the treatment of injuries with bleeding and shock, IT is of great importance. Its principles include the restriction of crystalloids use, the use of blood products in the optimal ratio of blood and plasma, and hypotension until the final surgical hemostasis. Reosorbilact (“Yuria-Pharm”) has properties close to an ideal infusion solution. The efficacy of Reosorbilact in shock was demonstrated in a multicenter Rheo-STAT study. In traumatic shock, infusion of 800 ml of Reosorbilact does not affect the coagulation hemostasis system. Instead, administration of a similar volume of 0.9 % NaCl is accompanied by a tendency to hypercoagulation, and 500 ml of hydroxyethyl starch – by hypocoagulation. Reosorbilact has a pronounced rapid hemodynamic effect. The target hemoglobin level in patients with trauma and bleeding is 70-90 g/L. Intravenous iron preparations (Sufer, “Yuria-Pharm”) can be used for its correction. Prehospital plasma transfusion is recommended to normalize coagulogram parameters. Tranexamic acid (Sangera, “Yuria-Pharm”) should be administered to patients with bleeding within 3 hours of injury. The first dose should be given at the prehospital stage of care. The pleiotropic effects of Sangera include antifibrinolytic, anti-allergic and anti-inflammatory. In addition, Sangera 2-3 times lowers the threshold of pain sensitivity. Another recommended component of comprehensive treatment of bleeding is the introduction of calcium chloride. Recombinant activated coagulation factor VII is not recommended for routine administration and is prescribed only when other measures are ineffective. It is recommended to urgently discontinue vitamin K antagonists and use appropriate antidotes. Pulmonary embolism is the third most common cause of death among patients with polytrauma who survived the third day. It is recommended to initiate the pharmacological thromboprophylaxis within 24 hours of bleeding control being achieved.
Conclusions. 1. A significant proportion of preventable deaths are related to blood loss. 2. The primary task of managing a patient with trauma is to eliminate the lethal triad (hypothermia, acidosis, coagulopathy) and ensure perfusion of vital organs. 3. In the treatment of injuries with bleeding and shock, IT is of great importance. 4. Tranexamic acid should be administered to bleeding patients within 3 hours of injury.
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