Hemorrhagic shock: symptoms

Symptoms of hemorrhagic shock have the following stages:

• Stage I - compensated shock;
• II stage - decompensated reversible shock;
• III stage - irreversible shock.

Stages of shock are determined on the basis of evaluation of a complex of clinical manifestations of blood loss, corresponding to pathophysiological changes in organs and tissues.

Stage 1 hemorrhagic shock (small-shot syndrome, or compensated shock) usually develops with blood loss approximately corresponding to 20 % BCC (15 % to 25%). In this stage, compensation for the loss of bcc. Is carried out due to hyperproduction of catecholamines. The clinical picture is dominated by symptoms that indicate a change in cardiovascular activity of a functional nature: pallor of the skin, desolation of the subcutaneous veins on the hands, moderate tachycardia to 100 beats / min, moderate oliguria and venous hypotension. Arterial hypotension is absent or mild.

If the bleeding has stopped, then the compensated stage of the shock can last quite a long time. With unsettled bleeding, there is further deepening of circulatory disorders, and the next stage of shock comes.

Stage 2 hemorrhagic shock (decompensated reversible shock) develops with blood loss corresponding to 30-35% BCC (from 25% to 40%). In this stage of shock there is a deepening of circulatory disorders. Reduced blood pressure, as high peripheral resistance due to spasm of blood vessels does not compensate for small cardiac output. The blood supply to the brain, heart, liver, kidneys, lungs, intestines is broken, and as a result, tissue hypoxia and a mixed form of acidosis, which require correction, develop. In the clinical picture, in addition to the fall in systolic blood pressure below 13.3 kPa (100 ml of mercury) and a decrease in the pulse pressure amplitude, there is a pronounced tachycardia (120-130 beats / min), dyspnea, acrocyanosis against the background of pale skin, cold perspiration, anxiety, oliguria below 30 ml / h, deafness of cardiac tones, reduction in central venous pressure (CVP).

Stage 3 shock (decompensated irreversible shock) develops with a blood loss of 50% BCC (40% to 60%). Its development is determined by a further violation of microcirculation: capillarostasis, loss of plasma, aggregation of blood elements, increase in metabolic acidosis. Systolic blood pressure drops below critical figures. The pulse speeds up to 140 beats / min and more. The disorders of external respiration are amplified, extreme paleness or marbling of the skin is noted, cold sweat, a sharp cooling of the limbs, anuria, stupor, loss of consciousness. Significant signs of the terminal stage of shock are an increase in the hematocrit and a decrease in the plasma volume.

The diagnosis of hemorrhagic shock usually does not present great difficulties, especially in the presence of external bleeding. However, early diagnosis of compensated shock, which ensures the success of treatment, is sometimes seen by doctors because of underestimation of the existing symptoms. You can not assess the severity of the shock, based only on the numbers of blood pressure or the amount of blood lost in external bleeding. The adequacy of hemodynamics is judged by a complex of fairly simple symptoms and indices:

• color and temperature of the skin, especially the limbs;
• pulse;
• the value of blood pressure;
• shock index ";
• hourly diuresis;
• level of CVP;
• hematocrit;
• COC blood.

The color and temperature of the skin are the parameters of the peripheral blood flow: warm and pink skin, pink color of the nail bed, even with reduced blood pressure figures, indicate good peripheral blood flow; cold pale skin with normal and even slightly elevated figures of blood pressure indicates centralization; blood circulation and violation of peripheral blood flow; marbling of the skin and acrocyanosis - this is already a consequence of a profound violation of peripheral circulation, vascular paresis, the approaching irreversibility of the condition.

The pulse rate serves as a simple and important indicator of the patient's condition only in comparison with other symptoms. Thus, tachycardia can indicate hypovolemia and acute heart failure. Differentiate these states by measuring the CVP. From such positions, one should also approach the evaluation of blood pressure.

A simple and rather informative indicator of the degree of hypovolemia in hemorrhagic shock is the so-called shock index - the ratio of the pulse rate per minute to the value of systolic blood pressure. In healthy people, this index corresponds to 0.5, with a decrease in the bcc by 20-30%, it increases to 1.0. With a loss of 30-60%, the bcc is 1.5. With a shock index of 1.0. The patient's condition causes serious fears, and if the patient is raised to 1.5, the patient's life is threatened.

Hourly diuresis is an important indicator that characterizes the organ blood flow. Decrease in urine output to 30 ml indicates peripheral circulatory failure, below 15 ml - indicates the irreversibility of decompensated shock approach.

CVP is an indicator that is essential in a comprehensive assessment of the patient's condition. In clinical practice, the normal CVP figures are 0.5-1.2 kPa (50-120 mm H2O). The figures of CVP can be a criterion for choosing the main direction of treatment. The level of CVP below 0.5 kPa (50 mmHg) indicates a pronounced hypovolemia requiring immediate replenishment. If the blood pressure continues to be low against the background of the infusion therapy, the increase in CVP above 1.4 kPa (140 mm H2O) indicates cardiac decompensation and dictates the need for cardiac therapy. In the same situation, low CVP numbers prescribe an increase in the volumetric infusion rate.

The hematocrit indicator in combination with the above data is a good test, indicating the adequacy or inadequacy of the blood circulation of the body. Hematocrit in women is 43% (0.43 l / l). Decrease in hematocrit index less than 30% (0.30 l / l) is a menacing symptom, below 25% (0.25 l / l) - characterizes a severe degree of blood loss. The increase in hematocrit in the III stage of shock indicates the irreversibility of its course.

The determination of CBS by Singgaard-Andersen by the microl method Astrula is a highly desirable test when the patient is removed from a state of shock. It is known that for hemorrhagic shock metabolic acidosis is characteristic. Which can be combined with respiratory: the pH of the plasma is below 7.38, the concentration of sodium bicarbonate is below 24 mmol / L, the P _CO2 value is greater than 6.67 kPa (50 mmHg) with base deficiency (- BE exceeds 2.3 mmol / l). However, in the final phase of metabolic disorders, alkalosis can develop: the pH of the plasma is above 7.45 in combination with an excess of bases. The SB index is above 29 mmol / l, the -f-BE index exceeds 2.3 mmol / l.

[1], [2], [3]