Hemorrhagic shock - Symptoms

Symptoms of hemorrhagic shock have the following stages:

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

The stages of shock are determined based on an assessment of the complex of clinical manifestations of blood loss corresponding to pathophysiological changes in organs and tissues.

Stage 1 hemorrhagic shock (low output syndrome, or compensated shock) usually develops with blood loss approximately corresponding to 20 % of the BCC (from 15 % to 25%). At this stage, compensation for the loss of BCC is carried out due to hyperproduction of catecholamines. The clinical picture is dominated by symptoms indicating a change in cardiovascular activity of a functional nature: pale skin, desolation of the subcutaneous veins in the arms, moderate tachycardia up to 100 beats/min, moderate oliguria and venous hypotension. Arterial hypotension is absent or weakly expressed.

If the bleeding has stopped, the compensated stage of shock can continue for quite a long time. If the bleeding is not stopped, further deepening of circulatory disorders occurs, and the next stage of shock occurs.

Stage 2 of hemorrhagic shock (decompensated reversible shock) develops with blood loss corresponding to 30-35% of the BCC (from 25% to 40%). At this stage of shock, circulatory disorders worsen. Arterial pressure decreases, since high peripheral resistance due to vascular spasm does not compensate for the low cardiac output. Blood supply to the brain, heart, liver, kidneys, lungs, intestines is impaired, and, as a consequence, tissue hypoxia and a mixed form of acidosis develop, requiring correction. In the clinical picture, in addition to a drop in systolic blood pressure below 13.3 kPa (100 ml Hg) and a decrease in the amplitude of pulse pressure, there is pronounced tachycardia (120-130 beats/min), shortness of breath, acrocyanosis against the background of pale skin, cold sweat, anxiety, oliguria below 30 ml/h, muffled heart sounds, and a decrease in central venous pressure (CVP).

Stage 3 shock (decompensated irreversible shock) develops with blood loss equal to 50% of the BCC (from 40% to 60%). Its development is determined by further microcirculation disorders: capillary stasis, plasma loss, aggregation of formed elements of the blood, and increasing metabolic acidosis. Systolic blood pressure falls below critical values. The pulse quickens to 140 beats per minute and higher. Respiratory disorders intensify, extreme pallor or marbling of the skin, cold sweat, sudden coldness of the extremities, anuria, stupor, and loss of consciousness are noted. The essential signs of the terminal stage of shock are an increase in the hematocrit index and a decrease in plasma volume.

The diagnosis of hemorrhagic shock is usually not difficult, especially in the presence of external bleeding. However, early diagnosis of compensated shock, which ensures successful treatment, is sometimes overlooked by doctors due to underestimation of the existing symptoms. The severity of shock cannot be assessed based only on blood pressure figures or the amount of blood lost during external bleeding. The adequacy of hemodynamics is judged by a set of fairly simple symptoms and indicators:

• color and temperature of the skin, especially the extremities;
• pulse;
• blood pressure value;
• shock index";
• hourly diuresis;
• CVP level;
• hematocrit index;
• Blood acidity test.

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

Pulse rateserves as a simple and important indicator of the patient's condition only in comparison with other symptoms. Thus, tachycardia may indicate hypovolemia and acute heart failure. These conditions can be differentiated by measuring the central venous pressure. The assessment of arterial pressure should be approached from a similar standpoint.

A simple and fairly 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 systolic blood pressure. In healthy people, this index is 0.5, with a decrease in the BCC by 20-30% it increases to 1.0. with a loss of 30-60% of the BCC is 1.5. With a shock index of 1.0, the patient's condition is seriously alarming, and with an increase to 1.5, the patient's life is at risk.

Hourly diuresisserves as an important indicator characterizing organ blood flow. A decrease in diuresis to 30 ml indicates insufficiency of peripheral circulation, below 15 ml - indicates the approach of irreversibility of decompensated shock.

CVPis an indicator that is of significant importance in the comprehensive assessment of the patient's condition. In clinical practice, normal CVP values are 0.5-1.2 kPa (50-120 mm H2O). CVP values can be a criterion for choosing the main direction of treatment. A CVP level below 0.5 kPa (50 mm H2O) indicates severe hypovolemia, requiring immediate replenishment. If blood pressure remains low against the background of infusion therapy, then an increase in CVP over 1.4 kPa (140 mm H2O) indicates decompensation of cardiac activity and dictates the need for cardiac therapy. In the same situation, low CVP values require an increase in the volumetric infusion rate.

The hematocrit valuein combination with the above data is a good test indicating the adequacy or inadequacy of the body's blood circulation. Hematocrit in women is 43% (0.43 l/l). A decrease in the hematocrit value below 30% (0.30 l/l) is a threatening symptom, below 25% (0.25 l/l) - characterizes a severe degree of blood loss. An increase in hematocrit at stage III shock indicates the irreversibility of its course.

Definition of KOSAccording to Zinggaard-Andersen by the Astrula micromethod - a highly desirable study when bringing a patient out of a state of shock. It is known that hemorrhagic shock is characterized by metabolic acidosis, which can be combined with respiratory: plasma pH below 7.38, sodium bicarbonate concentration below 24 mmol/l, P _CO2 exceeds 6.67 kPa (50 mm Hg) with a base deficit (- BE exceeds 2.3 mmol/l). However, in the final phase of metabolic disorders, alkalosis can develop: plasma pH above 7.45 in combination with an excess of bases. The SB indicator is above 29 mmol/l, the -f- BE indicator exceeds 2.3 mmol/l.

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