Classification of acute blood loss. Acute blood loss

The materials are published for review and are not a prescription for treatment! We recommend that you contact a hematologist at your healthcare facility!

Every person sometimes faces such a problem as blood loss. In a small amount, it does not pose a threat, but if the permissible limit is exceeded, appropriate measures must be taken urgently to eliminate the consequences of the injury.

Every person from time to time faces the problem of bleeding of one kind or another. The amount of blood loss can be insignificant and not pose any threat to health. With massive bleeding, minutes count, so you need to know how to deal with them.

In general, every person knows the external signs of blood loss. But a wound on the body and traces of blood are far from everything. Sometimes bleeding goes unnoticed or is not taken seriously enough. Pay attention to common signs:

• pallor;
• cold sweat;
• cardiopalmus;
• nausea;
• flies before eyes;
• tinnitus;
• thirst;
• clouding of consciousness.

These symptoms may be harbingers of hemorrhagic shock that has developed with heavy bleeding.

Let us consider in more detail the features of different categories of blood loss and how dangerous each of them is.

Types of blood loss

In medical practice, there are several criteria for classifying blood loss. Consider their main types. First of all, the following bleeding is distinguished:

• capillary;
• venous;
• arterial;
• parenchymal.

Important: the most dangerous are arterial and parenchymal (internal) types.

The classification also implies the division into such groups:

• Acute blood loss. One-time loss of blood in a significant amount.
• Chronic. Minor bleeding, often hidden, lasting for a long time.
• massive. Loss of a large volume of blood, drop in blood pressure.

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Separate types are distinguished, depending on what cause caused the bleeding:

• Traumatic - with damage to tissues and blood vessels.
• Pathological - pathologies circulatory system, internal organs, diseases and tumors.

Severity

The greater the severity of blood loss, the more serious its consequences. There are such degrees:

• Light. Lost less than a quarter of the total volume of circulating blood, the condition is stable.
• Medium. Abundant blood loss, on average 30-40%, hospitalization is required.
• Severe degree. From 40%, poses a serious threat to life.

The degrees of acute blood loss are also characterized by the severity of hemorrhagic shock:

1. 1 - lost about 500 ml of blood;
2. 2 - about 1000 ml;
3. 3 - 2 liters or more.

Table: Classification by severity

According to the reversibility criterion, the following phases of the shock state are distinguished:

• compensated reversible;
• decompensated irreversible;
• irreversible.

But how to determine the amount of lost blood? There are such ways of determining:

• by general symptoms and type of bleeding;
• weighing bandages with blood;
• weighing the patient;
• laboratory tests.

What to do with severe bleeding?

To prevent hemorrhagic shock syndrome and other complications, it is important to provide assistance to the victim correctly and in a timely manner. With blood loss, the consequences can range from temporary weakness and anemia to organ failure and death. Death occurs when blood loss exceeds 70% of the BCC.

First aid

First aid for bleeding is to reduce the intensity of blood loss and its complete cessation. For minor injuries, it is enough to apply a sterile bandage.

If we are talking about heavy venous bleeding, you will need a tight bandage and further help from doctors. With arterial bleeding, you can not do without a tourniquet, with which the artery is clamped.

With internal bleeding, a person should be provided with complete rest, you can apply cold to the damaged area. It is necessary to immediately call an ambulance, and before they arrive, provide the person with plenty of drink and keep him conscious.

Table: First aid for different types of bleeding

The hospital determines the amount of blood loss, and based on the data, further treatment is prescribed. With significant risks, infusion therapy is used, that is, transfusion of blood or its individual components.

Arterial bleeding is deadly if first aid is not provided in a timely manner. Many people who find themselves in this situation simply do not know how to help. Consider the intricacies of first aid, applying a tourniquet for arterial bleeding.

The wounded may die from blood loss

with normal hemoglobin and five

millions of red blood cells.

Doliotti, 1940

Acute blood loss is a complex of compensatory-adaptive reactions of the body that develop in response to a primary decrease in the volume of circulating blood and are manifested by characteristic clinical signs. Among the reasons for the development of terminal conditions, acute blood loss is one of the first places in trauma, internal bleeding, surgical interventions ah etc.

CLASSIFICATION OF BLOOD LOSS

The classification of blood loss is based on the nature of different types of bleeding, the degree of severity and resistance of the body.

Types of bleeding differ in the localization of its source and the time of occurrence.

According to localization, the following types of bleeding are distinguished.

Arterial bleeding is the most dangerous, especially in case of damage to the main vessels. With such bleeding, if help is not provided immediately (a tourniquet, pressure on the vessel, etc.), even relatively small amounts of blood loss (500-800 ml) can lead to circulatory decompensation and death. The blood is usually scarlet (with severe hypoventilation it has the color of venous blood), flows out in a pulsating stream (with hypotension, terminal state- does not pulsate).

Venous bleeding is usually profuse but may stop spontaneously. In such cases, blood flows out in a continuous stream, quickly filling the wound, which requires active surgical hemostasis. The relatively slow rate of blood loss also determines the longer stability of hemodynamics - failure of compensation occurs more often with a loss of 30-50% of the BCC.

Parenchymal (capillary) bleeding is essentially venous and poses a threat in case of extensive damage to the parenchyma of the lungs, liver, kidneys, spleen and pancreas or severe hemostasis disorders. Particularly dangerous are internal bleeding from parenchymal organs.

External bleeding is easily diagnosed. They accompany surgical operations, injuries with damage to the outer integument of the body and limbs (penetrating wounds of the chest and abdomen can be combined with damage to internal organs).

Internal bleeding is the most difficult group of bleeding in diagnostic and tactical terms. Moreover, intracavitary bleeding (pleural and abdominal cavities, joints) are distinguished by defibrination and non-coagulability of the outflowing blood, and interstitial bleeding (hematoma, hemorrhagic infiltration) - the impossibility of determining the volume of blood loss and often the absence of signs.

Mixed bleeding is a type of internal bleeding. In such cases, bleeding into a hollow organ (often into the organs of the gastrointestinal tract) first manifests itself as internal and, in the absence of a clinic of hypovolemia or a corresponding syndrome of organ disease, causes diagnostic errors, then, when melena, hematuria, etc. appear, it becomes obvious externally. Depending on the localization of the source, there are also bleeding pulmonary, esophageal, gastric, intestinal, renal, uterine, etc.

According to the time of occurrence of bleeding, there are primary and secondary.

Primary bleeding occurs immediately after damage to the vessel.

Secondary bleeding can be early and late.

Early bleeding occurs in the first hours or days after injury (especially often on the 3rd-5th day). Their cause is the mechanical separation of a thrombus as a result of an increase in blood pressure or the elimination of vascular spasm.

Secondary late bleeding occurs, as a rule, with suppuration of wounds and is dangerous in that it can cause the development of circulatory decompensation even with insignificant blood loss. Secondary bleeding also includes bleeding associated with blood clotting disorders. The most common cause is the development of generalized intravascular coagulation or improper anticoagulant therapy.

The degree of resistance to blood loss depends on its volume, the speed with which the blood leaves the vascular bed, and the compensatory capabilities of the organism ("initial background").

Depending on the amount of blood loss, there are light (15-25% BCC), medium (25-35%), severe (35-50%) and massive (more than 50% BCC) blood loss.

The rate of blood loss determines certain clinical signs of ce.

With a slow loss of even very large volumes of blood, significantly exceeding the BCC (hemoptysis, melena, hematuria, hemobilia, etc.), the clinical picture may not manifest itself, hemodynamic disorders develop gradually and rarely reach a critical level, pronounced and persistent hydremia is sometimes noted, accompanied by a decrease in hematocrit, hemoglobin content and the number of red blood cells; acute hypoxia, as a rule, is not accompanied, i.e. the patient is in a state of stable compensation, which is based on compensatory hemodilution. Only a sudden acceleration of bleeding or the occurrence of a purulent-septic complication leads to rapid decompensation.

In case of blood loss at a rate significantly exceeding the capabilities of the hydremic reaction (up to 20-50 ml / min and more), compensation can be provided only by the hemodynamic mechanism, which is manifested by the corresponding clinical symptom complex. In this case, circulatory decompensation develops due to a sharp decrease in the effective volume of circulating blood and, to a lesser extent, depends on the total volume of blood loss.

So, with bleeding at a rate of up to 100-300 ml / min (for example, with a wound to the heart, rupture of an aortic aneurysm, simultaneous polytrauma), death can occur from cardiac arrest in the very first minutes ("empty" heart).

According to the rate of blood loss, several characteristic types can be distinguished.

Lightning-fast (usually massive) blood loss occurs when the heart and great vessels are damaged during surgery, with injuries and certain diseases (rupture of an aneurysm, etc.). Clinically, they are manifested by a sharp drop in blood pressure, a mild arrhythmic pulse, pallor with a grayish tint, retraction eyeballs(palpation they become soft), loss of consciousness, cardiac arrest. The whole clinic develops within a few minutes and in out-of-hospital conditions, as a rule, ends in death. In a medical institution, an attempt to save the patient consists in the immediate surgical stop of bleeding against the background of resuscitation.

Acute blood loss accompanies damage to large arteries or veins in the same situations as fulminant ones.

In particular, with bleeding from the carotid, iliac, femoral arteries or from the vena cava, jugular, portal veins, severe blood loss is characteristic. Its clinical signs are not as critical as with lightning. However, in acute blood loss, hypotension and impaired consciousness develop quickly, within 10-15 minutes, which requires stopping the bleeding by any method available in this case.

blood loss moderate occurs with damage to vessels of a relatively smaller caliber (limbs, mesentery, parenchymal organs). The severity of clinical manifestations in this case depends equally on the speed (moderate) and on the volume of blood loss.

Ordinary surgical blood loss, the magnitude of which depends on the duration of the operation and does not exceed 5-7% of the BCC per hour on average, is subacute. The same group should include blood loss associated with increased bleeding of the surgical wound due to the development of consumption coagulopathy (stages 2-3 of the DIC syndrome).

Chronic oozing blood loss erosive gastritis, hemobilia, hemorrhoids, granulating burn wounds, etc.) are the least dangerous, because they are rarely accompanied by circulatory disorders. However, they exhaust patients both in connection with the pathology that causes them, and because of the development chronic anemia, difficult to correct with antianemic drugs and fractional blood transfusions.

It is very difficult to determine the volumetric rate of blood loss. Even knowing the duration of bleeding and the total volume of blood flowing out, one can only calculate the average volumetric velocity, while bleeding is almost never uniform during the entire period of injury or surgery. Nevertheless, such a calculation, if possible, should always be done, since this allows you to clarify the correctness of the replacement therapy being carried out.

A very important factor determining the compensatory capabilities of the body in acute blood loss is the initial state of the body. Prolonged fasting, including due to organ pathology digestive system; physical fatigue; psychological exhaustion; hyperthermia; endogenous (purulent-septic complications) or exogenous (poisoning) intoxication; dehydration; previous (even small) blood loss; anemia; early postoperative period; postresuscitation illness; burns; deep anesthesia; long-term use of hormonal and vasoactive drugs; extensive sympathetic blockade during epidural anesthesia is far from a complete list of conditions that increase the body's sensitivity to blood loss and weaken its natural physiological compensation mechanisms.

Thus, only a comprehensive assessment makes it possible to obtain a more or less satisfactory determination of the severity of blood loss. According to A. I. Gorbashko (1982), the most stable indicator of the degree of blood loss is the deficit of globular blood volume (GO), which, of course, requires measurement of BCC and its components.

IMPACT OF BLOOD LOSS ON THE ORGANISM

The macrocirculation system (central hemodynamics) in acute blood loss changes quite characteristically.

Sympathoadrenal stimulation that accompanies acute hypovolemia is aimed at maintaining the necessary level of blood circulation in the vital organs, which are the brain and heart. As a result of this stimulation, adrenaline and other sympathetic mediators enter the general circulation. nervous system, their vasoconstrictive action is mediated in areas rich in alpha-adrenergic receptors. At the same time, the hemodynamic reaction is manifested already in the first minutes of blood loss by a reduction in the capacitive part of the venous system (mainly the portal circulation system), which in an initially healthy person provides compensation for up to 10-15% of the BCC deficiency with virtually no changes in cardiac output and blood pressure. Moreover, a slight increase in the level of catecholamines (by 2-3 times), entering the bloodstream at this initial stage, contributes to the necessary increase in cardiac output (MCV) due to both moderate tachycardia (up to 90-100 bpm) and regional dilatation of the arterial vessels of the brain, heart and lungs, which somewhat reduces the total value of peripheral vascular resistance (OPC). As a result, a hyperkinetic type of blood circulation develops, which determines the good compensatory capabilities of the body and the likelihood of a positive prognosis.

If bleeding occurs in a patient with initial but compensated hypovolemia, and also if the volume of blood loss exceeds 15-20% of the BCC, the venomotor mechanism of compensation is insufficient, blood flow to the heart decreases, which leads to more pronounced sympathoadrenal stimulation and the implementation of mechanisms aimed at delaying fluids in the body and a more significant decrease in the capacity of the vascular bed. Fluid retention is provided by a decrease in natriuresis and an increase in the processes of reabsorption under the influence of aldosterone and antidiuretic hormone, released simultaneously with catecholamines. The capacity of the vascular bed decreases due to regional redistribution of blood flow under the influence of catecholamines, the concentration of which increases by 1-2 orders of magnitude and reaches the level necessary to influence the resistance vessels. As a result, "centralization" of blood circulation occurs. At the same time, local regulation of blood flow, which ensures regional functioning and metabolism, is replaced by a general one, aimed at maintaining the necessary level of metabolism in the organs that determine the preservation of life. Vascularly active substances, acting on the myogenic elements of the peripheral vessels, increase the resistance to blood flow at the level of arterioles and precapillary sphincters, which is accompanied by an increase in the peripheral blood pressure and, all other things being equal, an increase in the residual volume of the heart. Even with a reduced intensity of blood flow, this mechanism contributes to the normalization of cardiac activity (preservation of tonogenic dilatation) and maintaining the required level of blood pressure. An increase in resistance at the entrance to the capillaries causes a decrease in hydrostatic transcapillary pressure and the emergence of another compensatory mechanism - a hydremic reaction, i.e., an excess flow of fluid from the interstitial space into the capillary network. Hydremic compensation for blood loss is quite long (up to 48-72 hours). During this time, up to 2 liters or more of fluid can enter the vascular bed. However, the volumetric rate of hydremia is low (in the first 2 hours - up to 90-120 ml / h; decreases to 40-60 ml / h at 3 - 6 hours and then sets on average at the level of 30-40 ml / h) and does not can provide the necessary correction of BCC in case of rapid blood loss.

The positive effects of centralization of blood circulation can be completely offset in the future by developing microcirculation deficiency and functional insufficiency of "peripheral" but vital organs (kidneys, liver, lungs) due to total shunting of blood flow. In the stage of centralized circulation, the stroke volume begins to decrease, the minute output is maintained at a normal or even somewhat elevated level only due to tachycardia, OPS increases sharply, but the type of hemodynamics becomes eukinetic and thus creates the illusion of relative well-being, supported by the stability of systolic blood pressure. Meanwhile, mean arterial and diastolic pressure rises and reflects the degree of increase in vascular tone. Thus, the centralization of blood circulation, being, of course, an expedient compensatory reaction of the circulatory system, becomes pathological when the process is generalized and contributes to the emergence of irreversibility. In other words, compensation in the macrocirculation system is achieved by decompensation in the microcirculation system.

With an increase in blood loss to 30-50% of the BCC, a long period of centralization of blood circulation, or with an initially weakened background, decompensation develops - hemorrhagic shock. This process can be divided into two stages: reversible and irreversible. They differ only in some indicators of central hemodynamics and, of course, in the outcome.

At the stage of reversible shock, arterial hypotension arises and increases, the lower limit of which (for systolic pressure) should be considered 60-70 mm Hg. Art. At the same time, an early initial sign of decompensation, ahead of blood pressure indicators, is a decrease in CVP. In general, a reversible shock is characterized by a decrease in all indicators of central hemodynamics, with the exception of a minute ejection, which remains at normal or sub normal level due to critical tachycardia (140-160/min). This is how a reversible shock differs from an irreversible one. In the initial stage of shock, the OPS is still increased, and then quickly falls.

Irreversible shock is a continuation of the reversible and the result of uncorrectable decompensation of the central and peripheral circulation, the development of multiple organ failure, and deep energy depletion of the body. It is characterized by unresponsiveness and a steady decline in all hemodynamic parameters (Fig. 1).

Microcirculation disorders in acute blood loss are secondary and occur if centralization of blood circulation develops. Prolonged sympathoadrenal stimulation leads to a predominant vasoconstrictor response of precapillary sphincters and shunting of blood flow through arteriovenous anastomoses. This sharply reduces the intensity of the flow of blood and oxygen into the capillaries and immediately affects the nature of metabolic processes -

Blood - its formed elements and proteins are lost during acute blood loss in proportion to the magnitude of the latter. However, in normal clinical practice, it is very difficult to determine this deficit, because in the first 24 hours, when the process of natural (hydremia) or artificial (infusion therapy) blood thinning is still small, the concentration indicators practically do not change. The level of blood hemoglobin and hematocrit, the number of erythrocytes and the content of total protein begin to decrease only with a rapid loss of 40-50% of BCC or more. At the same time, there is a clear dynamics of such changes in the posthemorrhagic period (Fig. 4): maximum reduction on the 2-4th day, followed by recovery to the initial level on the 10-28th day.

METHODS FOR DETERMINING BLOOD LOSS

There are many methods for determining blood loss, but this fact itself speaks of their imperfection. Indeed, sufficiently accurate methods are complex and therefore not widely used, while accessible and simple ones have a number of serious drawbacks or give a large percentage of error.

All methods can be divided into two groups:

Direct or indirect determination of "external" blood loss, i.e. the volume of blood lost during trauma, external bleeding, surgery, in postoperative period,

Determination of "internal" blood loss, based on the assessment of individual compensatory mechanisms, BCC deficiency or the general resistance of the body to hypovolemia.

External blood loss can be determined by the following methods.

A visual assessment of the amount of blood loss by the degree of blood staining of the surgical material, underwear, the rate of blood flow into the wound is based on the experience of the surgeon and knowledge of the main average values ​​of blood loss during operations most often performed with his participation. However, even for experienced surgeons in the case of atypical operations, the error with this method of determination can be very large (2-3 or more times compared to the actual value). Another, more common cause of the error is hypo- or hyperchromia of the blood. In the first case, due to the lower intensity of blood staining of the surgical material and the wound (especially when hemoglobin is less than 60 g/l), the actual blood loss is always greater than the expected one and, if not underestimated, is dangerous in anemic patients. In the second case, the amount of blood loss is overestimated, which may lead to an unjustified appointment of a blood transfusion.

Weighing the patient before and after surgery on a special table-scale allows you to take into account not only the volume of blood loss, but also the loss of fluid during evaporation from the surface of the body, wounds, and breathing. However, it is difficult to take into account “net” blood loss, as well as the overall fluid balance, if the operation is long and if multicomponent infusion therapy is performed, solutions are used for irrigation and washing of the wound and cavities.

Weighing surgical material and underwear is one of the simplest methods. It does not require special equipment (it is enough to have dial scales), it can be used in any operating room, it makes it possible to determine blood loss step by step with the help of even junior medical personnel.

All varieties of the weight (gravimetric) method give an error in the range of 3-15%, which is quite acceptable for practical purposes. The main disadvantages of the method are the difficulty of accurately accounting for the mass of solutions used during the operation (for washing wounds, anesthesia, etc.), as well as the complete impossibility of determining the volume of tissue fluid or fluids flowing from cavities (peritoneal, pleural) and cystic formations. In addition, with the same total mass of blood, the loss of its liquid part and formed elements in different patients is different. Finally, blood on non-standard surgical linen (sheets, gowns, etc.) dries out rather quickly and is taken into account, as a rule, only by an approximate visual assessment.

Since the blood contains a colored substance - hemoglobin, its determination is possible using colorimetry. The fundamental basis of the colorimetric method is the determination of the total amount of hemoglobin lost by the patient with blood. The method for determining blood loss is quite simple.

A basin with tap water (5 or 10 liters, depending on the expected volume of blood loss; for children, the volume can be 1-2 liters) is placed at the operating table, where all the material moistened with blood is dumped during the operation. When stirred, the erythrocytes quickly (within 20-30 s) are hemolyzed, and the solution acquires the properties of a true one, which makes it possible to take a sample from it at any time to determine the concentration of hemoglobin. The latter can be performed both directly in the operating room using a hemometer, and in the laboratory using one or another express method. Knowing the concentration of hemoglobig in the input and blood of the patient, calculations are made.

Since the calculation by the formula requires a certain amount of time, a table is used, with the help of which the amount of blood loss is determined from known values ​​within a few seconds. The average error of the method is ± 3-8%.

This technique greatly simplifies and makes the use of devices with microprocessor devices more modern and reliable. One of the simplest foreign devices is a block of a washing device (where bloody material is placed with a certain amount of water) with a photocolorimeter that automatically calculates and indicates the amount of blood loss.

Compared to weighing methods, the colorimetric method is less dependent on unaccounted for volumes of liquids. Indeed, with a volume of water in the pelvis equal to 5 liters, an unaccounted volume of even 1 liter will give an error not exceeding 20%, which is ± 200 ml for a blood loss of 1000 ml and does not significantly change the treatment tactics. In addition, the method makes it possible to obtain the total amount of blood loss for each moment of the study. In general, this variant of the colorimetric method is preferable to weighing methods, especially for medical institutions with a limited number of employees working simultaneously in the operating room.

Determining the amount of blood loss by collecting blood into a measuring vessel directly or using an aspiration system is sometimes performed during blood reinfusion in case of injuries, ectopic pregnancy; in thoracic, vascular surgery, spine and brain surgery. The basis of the error and inconvenience of this technique is the need for strict accounting of the fluids used during the operation, as well as increased evaporation of water during continuous continuous operation of the aspirator. It is possible that the expansion of indications for reinfusion of autologous blood, including blood collected during surgical interventions, will make it possible to technically improve this method.

The determination of blood loss during minor operations by counting the number of red blood cells in the blood lost by the patient is carried out according to the following method. Before the operation, the number of erythrocytes in 1 mm 3 of the patient's blood is determined. During the operation, all material with blood is dumped into one basin containing 1 liter of physiological sodium chloride solution. After the operation, the contents of the pelvis are thoroughly mixed and the number of erythrocytes in 1 mm 3 of the solution is determined.

The determination of blood loss by measuring changes in the electrical conductivity of a dielectric solution (distilled water) when one or another amount of blood enters it is based on the constancy of its electrolyte composition. Scheme of a device that automatically determines the amount of blood loss. Since distilled water does not conduct electricity, when the electrical circuit is closed in its original position, the galvanometer needle (graded in ml of blood loss) will remain in the zero position. The entry of surgical material moistened with blood (electrolyte) into the tank will create conditions for the passage of current, and the arrow will deviate by an amount corresponding to the volume of blood loss. A significant disadvantage method is its vulnerability in the event of electrolyte imbalance, which is quite realistic in conditions of massive blood loss and centralization of blood circulation. This reality also arises during infusion therapy of blood loss, which is unthinkable without the use of electrolyte solutions. Despite the fact that the author provided appropriate corrections for electrolytes introduced from outside, the device was not put into serial production.

Tables of average blood loss give the doctor the opportunity to tentatively predetermine the amount of probable blood loss during typical operations that occur without complications. With atypical or complicated operations, this technique is unacceptable due to the large percentage of errors. At the same time, the indicators presented in the tables of not only average losses, but also the possible (observed) maximum limits of their fluctuations allow the novice surgeon to tune in to a more realistic attitude towards blood loss during "standard" operations.

Among the indirect methods, one should not forget the approximate assessment of the amount of blood loss by determining the size of the wound by placing the hand on it ("rule of the palm"). The area occupied by one brush corresponds to a volume of about 500 ml (10% BCC), 2-3-20%, 3-5-40%, over 5-50% and more. Such an assessment allows both at the scene of the incident, at prehospital stage, and upon admission of the victim to the hospital, determine the program for first aid and subsequent therapy.

CLINIC AND DIAGNOSIS OF BLOOD LOSS

Bleeding in surgical practice is a common occurrence, and if the blood is poured out, the diagnosis and treatment tactics are not difficult. In connection with the ability to quickly stop bleeding, the risk of developing hemorrhagic shock occurs only if the heart and large vessels are damaged. With closed injuries, internal bleeding, the symptoms of blood loss are not immediately determined; the doctor's attention is focused on the formulation and formulation of the diagnosis, the fact of blood loss as the main link in pathogenesis is relegated to the background and becomes apparent only when "sudden" signs of hypovolemia appear (severe weakness, dizziness, ringing in the ears, flies before the eyes, unmotivated fainting, difficulty breathing , pallor, sweating, cold distal extremities). However, it must be taken into account that such symptoms are a consequence of a pronounced compensation for blood loss, the volume of which by this time can reach 30-50% of the BCC, because less blood loss in an initially healthy person is not clinically manifested.

In fact, the symptom complex "acute blood loss" is a clinical reflection of circulatory hypoxia (or "hypovolemic hypocirculation", according to G. N. Tsibulyak, 1976), which develops with a significant deficiency of BCC or primary weakness of adaptive and compensatory mechanisms.

Since acute blood loss is a distinctly staged process, a consistent assessment of clinical signs is appropriate.

In the initial, adaptive (adaptive) stage, clinical manifestations are scarce - only a slight increase in heart rate and respiration are detected, cardiac output increases slightly, OPS decreases without going beyond the normal range, i.e., in aggregate, a hyperkinetic type of blood circulation develops from the side of central hemodynamics . Most often, such changes are not fixed or are explained by stress, i.e., in fact, at this stage the person is still healthy, and if the BCC deficiency does not increase, all deviations spontaneously normalize, physiological balance sets in. Such dynamics is typical for blood loss not exceeding 5-15% of the BCC. With greater blood loss or insufficiency of physiological adaptation (patients with concomitant pathology of blood circulation and respiration, elderly patients, children under 3 years old, etc.), homeostatic function disorders occur, “switching on” more powerful compensation mechanisms, in particular, “centralization” of blood circulation. Therefore, clinical manifestations at this stage characterize not the amount of blood loss, but the severity of compensation.

Signs of centralization of blood circulation are quite characteristic. systolic arterial pressure(SD) is within the normal range or slightly increased (by 10-30 mm Hg); diastolic (DD) and mean (SDD) are elevated, and the degree of this increase correlates with the degree of vasoconstriction. Stroke volume (SV) is naturally reduced. At the same time, MSV is maintained at the level of the previous stage, which is provided by increasing tachycardia. Peripheral venous pressure is increased, and the central one remains within the normal range. Peripheral circulation is disturbed. As a result, the skin and visible mucous membranes turn pale (a sign primarily of vascular spasm, and not anemia), a symptom of " white spot» becomes positive (after pressing on the skin in the rear of the hand, the bleeding spot disappears slowly, longer than 10 s), the skin temperature decreases - it is cold to the touch, dry. The difference between the temperature in the axillary region and the rectal region increases to 2-3 ° C. Capillaroscopically, the initial elements of intravascular aggregation and an increase in the number of "plasma" capillaries that do not contain erythrocytes are detected. Red blood values ​​do not go beyond normal fluctuations. Tendencies to hypercoagulation, moderate hypoalbuminsmia, and compensated metabolic acidosis are noted. Diuresis decreases to 20-30 ml/h (0.3-0.5 ml per minute). Despite the BCC deficiency, superficial veins can be successfully punctured. Consciousness is preserved, but the patient has anxiety, anxiety, sometimes excitement, increased breathing; moderate thirst.

With prolonged centralization (more than 6-8 hours), urination stops, short-term fainting may occur, especially when standing up (orthostatic instability of blood pressure).

Compensatory-adaptive mechanisms are biologically determined by non-life-threatening volumes of blood loss. Therefore, with an acute BCC deficiency of more than 30-50%, they turn out to be ineffective, which is accompanied by an inappropriately long and, as a result, pathological centralization or decompensation of blood circulation. Decompensation with blood loss is commonly referred to as hemorrhagic shock.

Diagnosis of hemorrhagic shock in the presence of an established fact of bleeding is not particularly difficult. The main clinical manifestation of this condition is arterial hypotension. The rate of fall in blood pressure depends on the rate of blood loss and the degree of stability of the circulatory system.

In the stage of "reversible" shock, there is a decrease in DM and DD. MSV is at the lower limit of normal and tends to further decrease. Tachycardia increases to limit values ​​(140-160/min). Venous pressure (both CVP and PVD) steadily decreases and can reach 0. DD, DDD and OPS evenly fall, which is a reflection of the initial signs of vascular collapse. Orthostatic instability of blood pressure increases - patients become very sensitive to changes in body position. Hypokinetic blood circulation develops and increases. In the skin and other peripheral vascular zones, along with spasmodic and "empty" vessels, there are more and more dilated capillaries with signs of total cell aggregation and cessation of blood flow, which is clinically accompanied by the appearance of "marbling" of the skin, first on the limbs, and then on body. Body temperature decreases even more (temperature gradient - more than 3 ° C); acrocyanosis appears against the background of pallor. Heart sounds are muffled; systolic murmur is often heard. ECG signs diffuse changes and myocardial ischemia. Shortness of breath becomes constant, the respiratory rate reaches 40-50 per 1 min; the appearance of periodic breathing of the Kussmaul type (breathing of the “driven beast”) is possible. The symptoms of a "shock" lung are determined. Oliguria is replaced by anuria. Intestinal peristalsis, as a rule, is absent (drop in the electrokinetic potential of pacemaker membranes). With lightning-fast blood loss, blood concentrations do not change or decrease slightly; with a longer, and especially in combination with infusion therapy, they decrease, but rarely reach critical numbers (1/3 of the norm). In connection with violations of liver functions, toxins and “middle molecules” accumulate in the blood, hypoproteinemia and protein imbalance increase. Metabolic acidosis becomes uncompensated, combined with respiratory acidosis. The symptoms of DIC syndrome increase and are determined laboratory and clinically.

"Irreversible" shock differs from "reversible" only in the depth of disturbances, the duration of decompensation (more than 12 hours) and the progression of multiple organ failure. Indicators of central hemodynamics are not determined. Consciousness is absent. Generalized tonic-clonic convulsions, hypoxic cardiac arrest are possible.

A much more difficult problem in terms of diagnostics is blood loss without signs of external bleeding (for example, with a closed injury of the chest and abdomen, ectopic pregnancy, duodenal ulcer, etc.). V. D. Bratus (1989) writes quite emotionally about this:

"... Whenever through a short time after a sudden profuse hematemesis, a patient is delivered to the emergency room of the surgical department, whose pale face is covered with cold sticky sweat, shining eyes with dilated pupils look attentively and imploringly at the doctor, the latter, first of all and relentlessly, has painful questions: what is the nature of the resulting profuse bleeding? What was the immediate cause of its occurrence? Does the bleeding still continue, and if it has stopped, what is the real threat of its resumption?...”

Indeed, the appearance of the classic triad of hypovolemia (arterial hypotension, frequent and small pulse, cold wet skin) already indicates hemorrhagic shock, when quick and vigorous action is needed.

To determine the source of internal bleeding, endoscopic and radiological (scanning, tomography) diagnostic methods are currently widely used, which make it possible to make a topical diagnosis with a high degree of certainty. In the clinical aspect, in addition to general signs of hypovolemia, centralization of blood circulation and shock, one should be aware of the symptoms most characteristic of each type of internal bleeding (esophageal, gastric, pulmonary, uterine, etc.).

GENERAL PRINCIPLES OF THERAPY FOR ACUTE BLOOD LOSS

The therapy of acute blood loss is built according to the stage of its compensation, and the algorithm of the treatment program consists of the following components:

Establishing the diagnosis of "acute blood loss" and the nature of bleeding;

Determining the stage of compensation for blood loss;

Final hemostasis and elimination of BCC deficiency;

Stabilization of central hemodynamics;

Diagnosis and correction of the consequences of hypovolemia;

Monitoring the effectiveness of therapy.

The diagnosis should be established as soon as possible, but therapeutic measures should be started even if bleeding is suspected, because the time factor in these situations is extremely important. It is especially important to identify ongoing internal bleeding with all available diagnostic methods.

The stage of development or compensation of blood loss determines the entire tactics of treatment. If it starts at the first, subclinical, stage, the effect is usually positive, it is possible to avoid the development of hypercompensation and major complications. In the early stage of circulatory centralization, when the process has not yet reached its culminating generalization, the main efforts should be aimed at reducing or eliminating centralization. At the same time, in its late stage after the onset of multiple organ failure, artificial decentralization is not only ineffective, but also dangerous, since uncontrolled collapse can develop. At this stage, rheological hemocorrectors are used, hemodilution is appropriate, correction of organ disorders, DIC syndrome is necessary. Stages of hemorrhagic shock require multicomponent replacement therapy using modern methods intensive care and resuscitation.

Hemostasis is a prerequisite for the effectiveness of infusion therapy for blood loss. Immediate stopping of bleeding by any method suitable for a particular case (application of a tourniquet, tamponade, pressure bandage, clamping of the vessel throughout, application of a hemostatic clamp) is carried out at the prehospital stage, and the final hemostasis is performed in the dressing room or operating room of the hospital.

The elimination of BCC deficiency is the basis of the infusion program for the treatment of acute blood loss. The doctor who is given such a task needs to decide what, how and how much to transfuse.

When choosing a drug, it should be borne in mind that at present, even with massive acute blood loss, the first infusion agent is not blood, but blood substitutes that can quickly and steadfastly eliminate hypovolemia. This is dictated by the fact that hypoxia, even with lethal blood loss, develops as a result of circulatory rather than hemic insufficiency. In addition, whole donated blood (even fresh) has such a "set" of shortcomings that the transfusion of large amounts of it causes serious, purely fatal complications. The choice of blood substitutes and their combination with blood is determined by the stage of compensation for blood loss.

With compensated blood loss without manifestations of centralization of blood circulation (i.e., with blood loss up to 15-20% of the BCC), infusions of colloidal blood substitutes (polyglucin, blood plasma) are indicated in combination with crystalloids (Ringer's solution, lactasol, quartasol) in a ratio of 1: 2 .

In the stage of centralization of blood circulation, blood substitutes are used that have a rheological effect (rheopolyglucin with albumin, lactasol in various combinations). With concomitant DIC syndrome, as well as for its prevention, early use of fresh frozen plasma (up to 500-800 ml / day) is recommended. Whole blood is not transfused. Erythrocyte mass is indicated when the level of hemoglobin in the blood drops to 70-80 g / l (the total volume of erythrocyte-containing solutions is up to 1/3 of the volume of blood loss).

Hemorrhagic shock strongly dictates the need for active infusion therapy, and the appointment of colloid and crystalloid solutions in a 1:1 ratio is also in the first place. The most effective colloids are rheopolyglukin, albumin. Due to the relatively lower anti-shock activity, plasma can only be an addition to infusion after stabilization of hemodynamics at a safe level. You should not get carried away with infusions of large volumes of blood substitutes in order to quickly “normalize” blood pressure. If intravenous administration of 800-1000 ml of any blood substitute at a rate of 50-100 ml / min does not lead to a change (increase) in blood pressure, then there is a pronounced pathological deposition and a further increase in the volumetric infusion rate is inappropriate. In this case, without stopping the infusion of blood substitutes, vasopressors (dopamine up to 5 μg / kgmin, etc.) or glucocorticoids (hydrocortisone up to 1.5-2 g / day, etc.) are used. As in the previous stages, repeated infusions of fresh frozen plasma (up to 400-600 ml 2-4 times a day) are pathogenetically justified.

Hemorrhagic shock usually develops with massive blood loss, when a deficiency of erythrocytes leads to a deterioration in the gas transport function of the blood and there is a need for appropriate correction. The method of choice is the transfusion of erythrocyte mass or washed erythrocytes, but only after stabilization of hemodynamics and, preferably, peripheral circulation. Otherwise, the red blood cells will not be able to perform their primary function of carrying oxygen and the infusion will be useless at best.

Of the complex blood substitutes, rheogluman is very effective. Its use is advisable in the stage of centralization of blood circulation and in the initial period of hemorrhagic shock.

It is not advisable to use glucose solutions to replenish the BCC in case of blood loss. The latter quickly moves to the intracellular sector, without significantly increasing the BCC. At the same time, cellular overhydration, which develops as a result of the introduction of large amounts of glucose, plays a negative role.

Correction of BCC deficiency is carried out mainly by intravenous infusions. This method is technically simple. Infusions by this method are made into the largest, capacitive, reservoir and, therefore, have a direct effect on venous return, especially if several veins are used simultaneously, including the central veins. Puncture and catheterization of one of the central veins is a necessary condition for effective (and controlled) therapy of acute blood loss.

Compensation for moderate blood loss (including the operating room) can be provided by infusion into one vein if the lumen of the needle or catheter is about 2 mm. This diameter allows, if necessary, to inject into the vein a crystalloid solution at a rate of more than 100 ml/min, a colloid - up to 30-40 ml/min, which is sufficient for the primary correction of sudden massive bleeding.

BLOOD TRANSFUSION

Blood, you need to know, is a very special juice.

Goethe, Faust

Since time immemorial, blood has attracted the attention of the observant person. Life was identified with it, and the development of medicine and the victorious march of hemotherapy in the second half of the 20th century. only reinforced this view. Indeed, blood, being a mobile internal environment of the body and at the same time distinguished by a relative constancy of composition, performs the most important diverse functions that ensure the normal functioning of the body.

BLOOD TRANSFUSION METHODS

The main and most widely used method is indirect blood transfusion into peripheral or central veins. For transfusion, canned whole blood, red blood cells or washed red blood cells are used, depending on the infusion program. This program is compiled by a doctor based on an assessment of the nature and dynamics of the pathological process (the severity of anemia, the state of peripheral and central hemodynamics, the amount of BCC deficiency, etc.) and the main properties of the infusion drug.

Intravenous infusion makes it possible to achieve different transfusion rates (drip, jet) and is not inferior to other methods (intra-arterial, intraosseous) in efficiency, especially in cases where central veins are used or transfusion is performed simultaneously into several veins.

Blood transfusion should be carried out using disposable plastic systems. However, if these are not available, "reusable" systems manufactured directly in the hospital can be used.

The method of intra-arterial transfusion is currently practically not used, since it is technically more complicated than intravenous, and can cause serious complications associated with damage and thrombosis of arterial trunks. At the same time, with a shallow drop in vascular tone, a positive effect can be achieved with the help of vasopressors, and in the case of total circulatory decompensation, intra-arterial injection is ineffective or gives only a short-term effect.

The intraosseous method of blood transfusion is not a competitor for intravenous, but can be used when there is no access to veins, in children, with burns, etc.

Direct blood transfusion is a method of directly transfusing blood from a donor to a recipient without stabilizing or preserving it. So only whole blood can be transfused intravenously. This method does not provide for the use of filters during transfusion, which significantly increases the risk of small thrombi entering the recipient's bloodstream, which inevitably form in the transfusion system, and this is fraught with the development of thromboembolism of small branches of the pulmonary artery.

Currently, direct blood transfusion is considered as a forced therapeutic measure. It is carried out only in an extreme situation - with the development of sudden massive blood loss, in the absence of large amounts of red blood cells, fresh frozen plasma, cryoprecipitate in the doctor's arsenal. Instead of a direct blood transfusion, you can resort to a transfusion of freshly prepared "warm" blood.

The method of exchange transfusion of blood (blood replacement operation - 03K) can be used if it is necessary to carry out emergency detoxification (in case of exogenous poisoning with hemolytic poisons, methemoglobin formation, hemotransfusion shock, in severe forms hemolytic disease newborns, etc.) and there is no way to apply modern, more effective and less dangerous methods(hemo- or lymphosorption, plasmapheresis, hemodialysis, peritoneal dialysis, forced diuresis, etc.).

By exchange transfusion is meant the "complete" or partial removal of blood from the bloodstream with its replacement with the same or a slightly larger amount of donor blood. For a "complete" exchange transfusion in an adult, 10-15 liters of whole donor blood is required, that is, 2-3 times more in volume than BCC. The purpose of such a transfusion is to remove toxic substances circulating in the blood. For partial replacement, 2-6 liters of blood are used.

For exchange transfusion, blood with a shelf life of no more than 5 days can be used, but freshly prepared is preferable. Moreover, it is necessary to carefully observe all the rules for preventing incompatibility.

Exchange transfusions of blood are carried out in two ways - continuous and intermittent. In the first case, bloodletting and blood transfusion are performed at the same time, making sure that the amount of blood infused corresponds to the amount withdrawn. In the second case, one vein is used, alternating bloodletting with transfusion.

The operation of exchange blood transfusion begins with bloodletting (50-100 ml), after which donor blood is infused with a slight excess. The number of phlebotomies and the volume of exfused blood depend on the condition of the patient and on the level of blood pressure. If the maximum blood pressure is not lower than 100 mm Hg. Art., bloodletting up to 300-400 ml is acceptable. At lower blood pressure (not lower than 90 mm Hg), the volume of a single bloodletting should not exceed 150-200 ml. The average rate of transfusion should ensure the correspondence between the volumes of withdrawn and injected blood (50-75 ml/min). A higher rate of it can cause the phenomena of citrate shock. In the case of the use of polyglucin, the initial volume of bloodletting can be increased by 2-3 times.

Bloodletting is performed from a large vein through a needle or catheter, or by exposure and puncture of the radial artery. Blood is poured into any vein by venipuncture or venesection.

Autohemotransfusion is one of the promising methods of infusion therapy, which consists in transfusing the patient's own blood. This eliminates the risk of complications associated with group and Rh incompatibility of donor blood, the transfer of infectious and viral diseases(syphilis, hepatitis, AIDS, etc.), alloimmunization, with the development of homologous blood syndrome. In addition, the cellular elements of one's own blood take root faster and better, are functionally more complete than donor ones. It should also be emphasized that microaggregates formed when using any methods of blood preservation in freshly preserved autologous blood are not so pronounced and, most importantly, can be destroyed in the bloodstream if blood is taken and returned to the patient immediately or within the first six hours.

Autotransfusion is indicated for patients with rare group blood, if it is impossible to find a donor, during surgical interventions in patients with impaired liver and kidney functions, if a large blood loss is predicted, which significantly increases the risk of transfusion complications during transfusion of donor blood and erythrocytes. Recently, autohemotransfusion has become more widely carried out even with relatively small volume of blood loss operations in order to reduce the thrombogenic risk as a result of hemodilution that occurs after blood exfusion.

Autohemotransfusion is contraindicated in severe inflammatory processes, sepsis, severe liver and kidney damage, as well as pancytopenia. It is absolutely contraindicated in pediatric practice.

The technique of autohemotransfusion does not differ from that of blood sampling from donors and is relatively simple. However, this method is rarely used in clinical practice. This is explained, firstly, by the fact that preliminary blood sampling from the patient and its stabilization must be carried out under strictly aseptic conditions (in the blood transfusion unit, operating room, in a clean dressing room) by personnel not involved in servicing surgical patients, which is not always possible. (Ideally, autotransfusion should be performed by a special team or in a hospital blood transfusion unit.) Secondly, a constraint in relation to the use of autotransfusion is that only a small volume of blood (250-400 ml) can be exfused at a time and the patient can be operated on after this. not earlier than in 5-7 days. (and if you need to prepare 1000 ml of blood or more, then the time is delayed for several weeks).

AT practical medicine more preference is given to the method of so-called intraoperative hemodilution. It consists in a single-stage blood sampling from a patient in the operating room immediately before surgery. Moreover, the patient is taken to the operating room in advance, and after introducing him into anesthesia from another peripheral (less often central) vein, necessarily under the "cover" of infusion of blood substitutes (lactasol, Ringer's solution), blood is taken (up to 800-1200 ml) into standard vials with preservative or heparin (1000 units per 500 ml of blood), replacing it with one and a half or two times the volume of Ringer's solution with reopoliglyukin or 10% albumin solution in a ratio of 3-4:1. Return of autologous blood begins from the moment of final surgical hemostasis. The rate of infusion is dictated by hemodynamic parameters. All blood should be returned to the patient during the first postoperative day. A correctly applied technique causes moderate hemodilution, which favorably affects the peripheral circulation; reduction of the absolute loss of cellular elements and blood proteins; as a rule, the normalization of hemostasis; significantly better than with the transfusion of the same volumes of donor blood, the course of the postoperative period; eliminates the need for any serological and compatibility tests, as well as additional infusions of canned donor blood.

For intraoperative hemodilution, a doctor and nurse who know this technique (if the staff is not trained, it is better to use donated blood!). This technique requires sterile blood collection systems, vials of hemopreservative, heparin, accessories for peripheral vein puncture or venesection.

The method of preliminary sampling of autoplasma (plasmapheresis) with its subsequent freezing and use during surgery also deserves special attention, which makes it possible to compensate for a deficiency of up to 20-25% of the BCC without the use of donor blood.

A variety of autohemotransfusion is reinfusion, or reverse blood transfusion. If certain conditions are required when using the preliminary blood sampling method, then reinfusion can be performed for most surgical interventions, both urgent and elective. Reinfusion has gained particular value at the present time, when it has become clear what dangers the patient is exposed to when transfusing donor blood and what it costs the state in material terms. The results of numerous studies have shown that the blood pouring into the serous cavity or wound (if not bacterially contaminated) is almost identical to the blood circulating in the body. She is always "at hand" with the surgeon. Its volume is approximately equal to the amount of blood loss. The transfusion of such blood is safe and economical, and it eliminates the complications associated with the transfusion of massive doses of canned donor blood.

In urgent surgical situations, blood should be reinfused from the pleural cavity (with closed and penetrating wounds chest with damage to the heart, lungs, arterial and venous vessels), from abdominal cavity(with ruptures of the spleen, liver injuries, damage to blood vessels and diaphragm, ectopic pregnancy); with combined thoracoabdominal wounds without damage to hollow organs (primarily the intestines); during urgent operations on the vessels of the extremities.

In elective surgery, it is necessary to reconsider the attitude to the problem of irretrievable blood loss as a fatal inevitability - in many surgical operations accompanied by large blood loss, it is possible not to drain the surgical field with tampons, but to aspirate blood from the wound and reinfuse it if the latter is not contaminated with pus or intestinal contents. This is especially true of operations on the organs of the chest, on the spine, osteoplastic operations in an orthopedic clinic.

In the postoperative period, it is possible to reinfuse the blood released on the first day through the drains (subsequently, for such a reinfusion, the discharge from the drainage must be centrifuged, and the erythrocytes must be washed from the exudate).

There are 2 main methods of reinfusion, which differ in the way blood is taken.

The simplest and least traumatic for blood cells is the method of scooping it out of the pleural cavity or peritoneum using a previously prepared and sterilized scoop, glass, glass jar. The collected blood is filtered by gravity through 8 layers of sterile gauze into a Bobrov jar or into 250 and 500 ml vials containing, respectively, 50 and 100 ml of one of the standard hemopreservatives or 500 and 1000 IU of heparin. This blood is reinfused to the patient directly during the operation or in the immediate postoperative period. To exclude possible hemolysis, it is recommended that, starting blood sampling and filtration, centrifugation of the sample taken into the test tube is recommended. Pink plasma above the erythrocyte layer indicates the presence of hemolysis. Such blood cannot be reinfused.

The second method is more convenient for blood sampling in the depth of the wound and directly from the surgical field. It is carried out with the help of aspiration systems. However, this method is used much less frequently than the first, because the blood from the surgical field, regardless of the volume lost, is currently not used, with rare exceptions. Meanwhile, this blood is similar to the blood that collects in the cavities, but its cellular elements are somewhat more traumatized during sampling.

Reinfusion of autologous blood can be performed without any samples and serological studies, at a given volumetric rate. With massive reinfusions, one should take into account the increased fibrinolytic activity of autologous blood, which can be dangerous in the hypocoagulable stage of the DIC syndrome.

Reinfusion of blood is contraindicated if the period of its stay in the cavity exceeds 24 hours or hemolysis of erythrocytes is detected or blood has poured into the cavity containing pus or intestinal contents. At the same time, it is known that reinfusion increases the body's resistance to infection and the danger is not the bacteria themselves, but the blood altered as a result of microbial contamination. This is confirmed by reports of good outcomes in reinfusions of blood infected with intestinal contents in life-threatening blood loss. Therefore, without in any way ignoring contraindications, it should be remembered that they can become relative in the event that reinfusion is the only possible measure to help with life threatening hemorrhage.

In the postoperative period, reinfusion is usually indicated in surgery of the chest cavity, when bleeding through the drains can be quite significant and usually requires hemocorrection, and transfusion of donor blood is undesirable. The peculiarity of reinfusion in such cases is as follows. Blood, accumulating in the pleural cavity, is defibrinated and does not coagulate, that is, it does not require stabilization. In the first 3-6 hours after surgery, the drainage blood contains a small amount of pleural exudate. It can be infused immediately as it accumulates. In the next 6-18 hours, the drainage extravasate retains the properties of blood serum and has an admixture of formed elements. Reinfusion of the latter is possible only after their washing in physiological sodium chloride solution.

COMPLICATIONS AND REACTIONS DURING BLOOD TRANSFUSION

Complications in blood transfusion may arise due to errors and technical errors, may be due to the properties of the transfused blood, as well as the immunological incompatibility of the blood of the donor and recipient.

Errors can occur due to careless documentation, failure to follow instructions, incorrect assessment of the agglutination reaction.

When determining blood groups of the ABO system, deviations from the rules are a violation of the order of arrangement of standard sera or erythrocytes in racks and their application to the plate, the wrong ratio of the amount of serum and erythrocytes, non-compliance with the time required for the reaction (5 min), failure to conduct a control reaction with the serum of the group ABo(IV), contamination or use of wet pipettes, plates, sticks, use of poor quality standards, such as serum with expired validity (not active enough) or contaminated or partially dried serum, which can cause a non-specific agglutination reaction, etc. These deviations and the errors associated with them can lead to an incorrect assessment of the result of the reaction as a whole and in each individual drop, which may be as follows .

1. The person who determines the blood type believes that agglutination has not occurred, while it actually is or should appear. This happens:

a) when agglutination begins late or is weakly expressed, which may be due to the low activity of standard sera or the weak agglutination of the blood erythrocytes of the subject (in the presence of these two reasons, agglutination may not appear at all at the same time, for example, low-active serum of the Bα (111) group does not give agglutination with erythrocytes group Aβ (II), if the agglutination of the latter is low; in order to avoid this error, it is necessary to observe the course of the reaction for at least 5 minutes and especially carefully for those drops in which agglutination has not yet occurred; in addition, only active sera should be used, the agglutinating ability of which checked and complies with the requirements of the instructions);

b) with an excess of blood, if too large a drop of it is taken (to avoid this error, it is necessary to observe the ratio of the volumes of the tested blood and standard serum or standard erythrocytes and tested serum approximately 1:10);

c) at high temperature(above 25°C) ambient air, e.g. in hot weather (to avoid this error, the reaction should be carried out on a chilled plate).

2. The person who determines the blood type believes that agglutination has occurred, while in fact it is absent. This error may occur if:

a) the erythrocytes of the tested blood are folded into "money columns", which can be mistaken for agglutinates with the naked eye (to avoid this error, it is necessary to add isotonic sodium chloride solution to them and subsequently shake the plate, which, as a rule, destroys the "money columns") ;

b) the tested erythrocytes show the phenomenon of auto- or pan-agglutination (in order to avoid this error, it is impossible to determine blood groups at temperatures below 15 ° C and it is imperative to use standard sera of the ABo (V) group;

c) low-quality serum is used, giving non-specific agglutination (to avoid this error, it is necessary to tightly cork open ampoules with serum with cotton wool or adhesive tape, however, in this case, cloudy serum or with signs of drying should not be used);

d) the mixture of erythrocytes and serum is not shaken (in this case, erythrocytes, settling to the bottom, form separate clusters that can simulate agglutination; in order to avoid this error, it is necessary to periodically shake the plate on which the determination is carried out);

e) observation is carried out for too long - more than 5 minutes (in this case, the mixture of erythrocytes and serum begins to dry out and granularity appears on its periphery, which simulates agglutination; in order to avoid this error, the observation time should not exceed 5 minutes).

However, even with a correct assessment of the reaction in each individual drop, an erroneous conclusion can be made about the blood group, if the order of the standards in a stand or on a plate is confused.

In all cases of indistinct or questionable results, it is necessary to re-determine the blood group using standard sera from other series, as well as by a cross method.

Errors in determining the Rh factor can be caused by:

a) the use of anti-Rhesus serum without taking into account the blood group (to avoid this mistake, Rh-affiliation should always be determined only after determining the blood group of the A BO system);

b) the wrong ratio of serum and erythrocyte volumes (the basic rule should be observed: erythrocytes should always be several times less than serum);

c) a change in the temperature regime (at laboratory research by the method of conglutination or agglutination in a salt medium, the temperature should be within the limits of 46-48 ° C and 37 ° C, respectively);

d) adding a drop of isotonic sodium chloride solution (causes dilution and a decrease in serum activity);

e) early (up to 10 minutes) or late (drying) evaluation of the result.

Technical errors are rare these days. However, they can lead to serious, sometimes fatal complications.

An air embolism can occur if the blood transfusion system is not properly filled, and especially when using the blood pumping method. This formidable complication develops as a result of air entering through the bloodstream into the right heart and then into the lungs. It is manifested by sudden shortness of breath, anxiety, rapidly increasing cyanosis of the face and acrocyanosis, tachycardia and cardiac arrhythmia, a sharp decrease in blood pressure (due to acute hypoxic coronary artery bypass grafting). Sometimes a characteristic "purr" can be heard over the heart. Massive air embolism leads to lightning death.

In order to prevent air embolism during the transfusion of blood and its components, it is strictly forbidden to use any injection equipment, and it should be transfused only with disposable plastic systems. Even if an air embolism is suspected, cardiopulmonary resuscitation should be started immediately ( indirect massage heart, ventilation by the "mouth to mouth" method), in no case removing the needle (or catheter) from the vein so that infusion and drug therapy(naturally, the blood transfusion system should be replaced and infusion of rheopolyglucin or lactasol should be started). The choice of further measures depends on the effect of primary resuscitation.

Pulmonary embolism (PE) is also a very serious complication. Its main cause may be the ingress of an embolus (blood clot) into various vessels of the small circle (the trunk of the pulmonary artery, its main or small branches) and their acute occlusion. Large emboli, if there is a filter dropper in the transfusion system, cannot enter the patient's venous system. Their source can be either thrombophlebitis, stagnation of blood in the veins of the lower extremities, etc. of the patient himself, or blood clots that form directly in the puncture needle (or catheter). Therefore, most often there is embolization and thrombosis of small branches of the pulmonary artery and the clinical picture does not develop as rapidly as it happens with embolism of the main trunk or main branches: anxiety, shortness of breath, chest pain, tachycardia, moderate arterial hypertension appear; body temperature usually rises, hemoptysis is possible; X-ray may reveal infarction-pneumonia or interstitial pulmonary edema. Any form of PE, including small branches, is always accompanied by acute respiratory failure, manifested by increased respiration, hypoxemia and hypercapnia.

Bleeding always poses a serious threat to the life of the victim. This is due to the fact that a sufficient volume of circulating blood (CBV) is necessary condition circulation. In turn, the adequacy of blood circulation is a necessary condition for maintaining the vital activity of the human body, since its violation leads to the loss of all those diverse and complex functions that blood performs.

Depending on the person's body weight and age, a certain amount of blood circulates in the human bloodstream (on average, from 2.5 to 5 liters). One of the main tasks of surgery is to stop bleeding.

Bleeding is the outflow of blood from blood vessels in violation of their integrity or permeability.

Hemorrhage is the outflow of blood from damaged vessels into tissues or body cavities.

Bleeding of any origin requires the adoption of emergency measures to stop it.

shock bleeding vessel ligation

Classification of bleeding

I. Due to the occurrence:

• 1. Traumatic - occur when a blood vessel is mechanically damaged as a result of an injury.
• 2. Pathological - arise as a result of any disease (non-traumatic).
• a) arrosine bleeding - occurs as a result of corroding the vascular wall of any pathological process.

For example: ulcer, suppuration, tumor decay.

b) neurotrophic bleeding - develop as a result of a malnutrition of the vascular wall or a violation of metabolic processes in it.

For example: bedsores, measles, rubella, scarlet fever, scurvy - vitamin C deficiency and others.

c) hypocoagulation bleeding - due to a violation of blood coagulation processes.

For example: hemophilia, Werlhof's disease, cirrhosis of the liver, DIC - syndrome, overdose of anticoagulants.

II. According to the type of bleeding vessel:

• 1. Arterial bleeding - the outflow of blood from a damaged artery - is characterized by a massive ejection of bright red blood in the form of a fountain, it flows out quickly, in a pulsating stream. The color of blood is bright red due to oxygen saturation. If large arteries or the aorta are damaged, most of the circulating blood can flow out within a few minutes, and blood loss incompatible with life will occur.
• 2. Venous bleeding - the outflow of blood from a damaged vein - is characterized by a slow flow of blood of a dark cherry color. It is characterized by a continuous flow of blood from a damaged vessel due to low pressure in the veins and is not life-threatening for the victim. The exception is the large veins of the chest and abdominal cavity. Injuries to the large veins of the neck and chest are dangerous due to the possibility of air embolism.
• 3. Capillary bleeding - outflow of blood from the smallest blood vessels - capillaries. Such bleeding is observed with shallow cuts and abrasions of the skin, muscles, mucous membranes, bones. This bleeding usually stops on its own. Its duration increases significantly with reduced blood clotting.
• 4. Parenchymal - outflow of blood in case of damage to the parenchymal organs - the liver, spleen, kidneys and lung. These bleedings are similar to capillary ones, but more dangerous than them, since the vessels of these organs do not collapse due to anatomical structure stroma of the organ, there is profuse bleeding, which requires emergency care.
• 5. Mixed bleeding - this bleeding combines the signs of two or more of the above.

III. In connection with the external environment.

• 1. External bleeding - blood is poured directly into the external environment, onto the surface of the human body through its defect skin.
• 2. Internal bleeding - the most diverse in nature and complex in diagnostic and tactical terms. Blood is poured into the lumen of hollow organs, into tissues or into the internal cavities of the body. They are dangerous by compression of vital organs. Internal bleeding is divided into:
  • a) obvious internal bleeding - blood is poured into the internal cavities and then goes out into the external environment. For example: bleeding into the lumen of the gastrointestinal tract, pulmonary, uterine, urological bleeding.
  • b) latent internal bleeding - blood is poured into closed cavities that do not have communication with the external environment. Bleeding in some cavities received special names:
    • - in the pleural cavity - hemothorax (hemothoraks);
    • - in the abdominal cavity - hemoperitoneum (hemoperitoneum);
    • - in the pericardial cavity - hemopericardium (hemopericardium);
    • - in the joint cavity - hemarthrosis (hemarthrosis).

A feature of bleeding into the serous cavities is that fibrin is deposited on the serous cover, so the outflowing blood becomes defibrinated and usually does not clot.

Latent bleeding is characterized by the absence of obvious signs of bleeding. They can be interstitial, intestinal, intraosseous, or hemorrhages can impregnate tissues (hemorrhagic infiltration occurs), or form accumulations of outflowing blood in the form of a hematoma. They can be identified by special research methods.

The blood accumulated between the tissues forms artificial cavities, which are called hematomas - intermuscular hematomas, retroperitoneal hematomas, mediastinal hematomas. Very often in clinical practice there are subcutaneous hematomas - bruises that do not entail any serious consequences.

IV. By the time of occurrence:

• 1. Primary bleeding - begins immediately after exposure to a traumatic factor.
• 2. Secondary bleeding - occur after a certain period of time after the primary bleeding stops and are divided into:
  • a) secondary early bleeding - occur from several hours to 4-5 days after the primary bleeding stops, as a result of the ligature slipping from the vessel or washing out of the thrombus due to increased blood pressure.
  • b) late secondary bleeding - develop in a purulent wound as a result of erosion (arrosion) of a thrombus or vascular wall by pus after more than five days.

V. By duration:

• 1. Acute bleeding - the outflow of blood is observed for a short period of time.
• 2. Chronic bleeding - prolonged, persistent bleeding, usually in small portions.

VI. By clinical manifestation and localization:

• - hemoptysis - hemopneic;
• - bloody vomiting - hematemesis;
• - uterine bleeding - metrorrhagia;
• - bleeding into the urinary cavitary system - hematuria;
• - bleeding into the abdominal cavity - hemoperitoneum;
• - bleeding into the lumen of the gastrointestinal tract - tarry stools - melena;
• - epistaxis - epistaxis.

VII. According to the severity of blood loss:

• 1. I degree - mild - blood loss is 500 - 700 ml. blood (BCC is reduced by 10-12%);
• 2. II degree - medium - blood loss is 1000-1500 ml. blood (BCC is reduced by 15-20%);
• 3. III degree - severe - blood loss is 1500-2000 ml. blood (BCC is reduced by 20-30%);
• 4. IV degree - blood loss is more than 2000 ml. blood (BCC is reduced by more than 30%).
• 3. Clinical manifestations of bleeding

The manifestation of symptoms and their severity depend on the intensity of bleeding, the magnitude and speed of blood loss.

Subjective symptoms appear with significant blood loss, but they can also occur with a relatively small blood loss that occurred quickly, at the same time.

Victims complain of: increasing general weakness, dizziness, tinnitus, darkening in the eyes and flickering of "flies" before the eyes, headache and pain in the heart area, dry mouth, thirst, suffocation, nausea.

Such complaints of the victim are the result of a violation of the blood circulation of the brain and internal organs.

Objective symptoms can be detected when examining the victim: drowsiness and lethargy, sometimes there is some agitation, pallor of the skin and mucous membranes, frequent pulse of weak filling, rapid breathing (shortness of breath), in severe cases, Chain-Stokes breathing, decrease in arterial and venous pressure, loss consciousness. Local symptoms are different. With external bleeding, local symptoms are bright and easily identified. With internal bleeding, they are less pronounced and sometimes difficult to determine.

There are three degrees of blood loss:

Mild blood loss - heart rate - 90-100 beats per minute, blood pressure - 110/70 mm. rt. Art., hemoglobin and hematocrit remain unchanged, BCC is reduced by 20%.

The average degree of blood loss - pulse up to 120 - 130 beats per minute, blood pressure 90/60 mm. rt. Art., Ht-0.23.

Severe degree of blood loss - there is a sharp pallor of the mucous membranes and skin, cyanosis of the lips, severe shortness of breath, very weak pulse, heart rate - 140-160 beats per minute, hemoglobin level decreases to 60 g / l or more, hemotacrit rate up to 20%, BCC is reduced by 30-40%.

The body can independently compensate for the loss of blood no more than 25% of the BCC due to protective reactions, but on condition that the bleeding is stopped.

To assess the severity of the victim's condition and the amount of blood loss, the Altgover shock index is used - the ratio of the pulse to the systolic pressure (PS / BP). Normally, it is equal to - 0.5.

For example:

I degree - PS / BP \u003d 100/100 \u003d 1 \u003d 1 l. (deficit of BCC 20%).

II degree - PS/BP=120/80=1.5=1.5l. (deficit of BCC 30%).

III degree - PS/BP=140/70=2=2l. (deficit of BCC 40%).

In addition to the severity of blood loss, clinical manifestations depend on:

• - gender (women tolerate blood loss more easily than men);
• - age (the clinic is less pronounced in middle-aged people than in children and the elderly);
• - from the initial state of the victim (the condition worsens with initial anemia, debilitating diseases, starvation, traumatic long-term operations).
• 4. Possible Complications bleeding

The most common bleeding complications are:

• 1. Acute anemia, which develops with a loss of blood from 1 to 1.5 liters.
• 2. Hemorrhagic shock, in which there are severe violations microcirculation, respiration and multiple organ failure develops. Hemorrhagic shock requires emergency resuscitation and intensive care.
• 3. Compression of organs and tissues with outflowing blood - compression of the brain, cardiac tamponade.
• 4. Air embolism, which can endanger the life of the victim.
• 5. Coagulopathic complications - a violation in the blood coagulation system.

The outcome of bleeding is more favorable, the sooner it is stopped.

5. The concept of hemostasis. Ways to temporarily and permanently stop bleeding

Stop bleeding - hemostasis.

To stop bleeding, temporary (preliminary) and final methods are used.

I. Ways to temporarily stop bleeding.

Temporary stop of bleeding is carried out in order to provide emergency care to the victim at the pre-hospital stage and is carried out within the time period necessary to take measures for the final stop of bleeding.

It is carried out with bleeding from arteries and large veins. With bleeding from small arteries, veins and capillaries, measures to temporarily stop bleeding can lead to a final one.

Temporary stop of external bleeding is possible in the following ways:

• 1. Giving the damaged part of the body an elevated position;
• 2. Pressing the bleeding vessel in the wound with a finger;
• 3. Pressing the damaged artery above the site of bleeding (throughout);
• 4. Pressing the bleeding vessel in the wound with a pressure bandage;
• 5. Clamping of the artery by fixing the limb in the position of maximum flexion or overextension of it in the joint;
• 6. Clamping of the artery by applying a tourniquet;
• 7. Applying a hemostatic clamp in the wound;
• 8. Tight tamponade of the wound or cavity with a dressing.

II. Methods for the final stop of bleeding.

The final stop of bleeding is carried out by a doctor in a hospital. Almost all victims with injuries are subject to surgical treatment. With external bleeding, primary surgical treatment of the wound is more often performed.

With internal and hidden external bleeding, more complex operations: thoracotomy - opening of the pleural cavity, laparotomy - opening of the abdominal cavity.

Methods for the final stop of bleeding:

With external bleeding, mainly mechanical methods of stopping are used, with internal bleeding - if surgery is not performed - physical, chemical, biological and combined.

Mechanical methods:

• 1. Ligation of the vessel in the wound. To do this, a hemostatic clamp is applied to the bleeding vessel, after which the vessel is tied up.
• 2. Vessel ligation throughout (Gunter's method) is used when it is impossible to detect the ends of the vessel in the wound, as well as in secondary bleeding, when the arrosive vessel is in the inflammatory infiltrate. For this purpose, an incision is made above the injury site, based on topographic anatomical data, the artery is detected and ligated.
• 3. Twisting the vessel, previously captured with a hemostatic forceps, then suturing and ligating along with the surrounding tissues.
• 4. Clipping of bleeding vessels with metal clips. It is used in cases where the bleeding vessel is difficult or impossible to tie. This method is widely used in laparo- and thoracoscopic operations, neurosurgery.
• 5. Artificial vascular embolization. It is used for pulmonary, gastrointestinal bleeding and bleeding of cerebral vessels.
• 6. Vascular suture can be performed manually and mechanically.
• 7. Vessel sealing. This method of hemostasis is used for bleeding from the vessels of the cancellous bone. Sealing of vessels is performed with a sterile paste, which is rubbed into the bleeding surface of the cancellous bone. The paste consists of 5 parts of paraffin, 5 parts of wax and 1 part of Vaseline.

Physical methods:

• 1. Application of hot saline. In case of diffuse bleeding from a bone wound, a parenchymal organ, wipes moistened with hot (75°C) isotonic sodium chloride solution are applied.
• 2. Local application of cold. Under the influence of cold, a spasm of small blood vessels occurs, blood flow to the wound decreases, which contributes to vascular thrombosis and stop bleeding. Ice packs are applied to the postoperative wound, subcutaneous hematomas, the abdomen with gastrointestinal bleeding and give the patient pieces of ice for swallowing.
• 3. Diathermocoagulation. It is used to stop bleeding from damaged vessels of subcutaneous adipose tissue, muscles, small vessels, parenchymal organs.
• 4. Laser photocoagulation. Focused in the form of a beam of quantum electron waves, laser radiation dissects tissues and simultaneously coagulates small vessels of parenchymal organs.
• 5. Cryosurgery. It is used in operations with extensive blood circulation. The method consists in local freezing of tissues and promotes hemostasis.

Chemical methods:

The method is based on the use of vasoconstrictor and blood clotting agents.

• - Vasoconstrictor drugs - adrenaline, dopanin, pituitrin.
• - Means that increase blood coagulation include: calcium chloride 10% -10 ml., Epsilon - aminocaproic acid, calcium gluconate, hydrogen peroxide 3%.
• - Means that reduce the permeability of the vascular wall: rutin, ascorbic acid, ascorutin, dicynone, etamsylate.

Biological methods:

• 1. Tomponade of a bleeding wound with the patient's own tissues.
• 2. Intravenous use hemostatic agents of biological origin.

Used: transfusion of whole blood, plasma, platelet mass, fibrinogen, antihemophilic plasma, the use of fibrinolysis inhibitors (kontrykal, vikasol).

Bleeding is defined as the penetration of blood outside the vascular bed, which occurs either when the walls of blood vessels are damaged or when their permeability is impaired. A number of conditions are accompanied by bleeding, which is physiological if the blood loss does not exceed certain values. These are menstrual bleeding and blood loss in the postpartum period. The causes of pathological bleeding are very diverse. Changes in vascular permeability are observed in such diseases and pathological conditions like sepsis, scurvy, the last stages of chronic kidney failure, hemorrhagic vasculitis. In addition to the mechanical causes of vascular destruction due to injuries, the integrity of the vessels can be impaired due to hemodynamic factors and changes in the mechanical properties of the vascular wall itself: hypertension against the background of systemic atherosclerosis, aneurysm rupture. The destruction of the vessel wall can occur as a result of a pathological destructive process: tissue necrosis, tumor decay, purulent fusion, specific inflammatory processes (tuberculosis, etc.).

There are several classifications of bleeding.

Looks like a bleeding vessel.

1. Arterial.

2. Venous.

3. Arteriovenous.

4. Capillary.

5. Parenchymal.

According to the clinical picture.

1. External (blood from the vessel enters the external environment).

2. Internal (blood leaking from the vessel is located in the tissues (with hemorrhages, hematomas), hollow organs or body cavities).

3. Hidden (without a clear clinical picture).

For internal bleeding, there is an additional classification.

1. Leaks of blood in the tissue:

1) hemorrhages in the tissues (blood flows into the tissues in such a way that they cannot be separated morphologically. The so-called impregnation occurs);

2) subcutaneous (bruising);

3) submucosal;

4) subarachnoid;

5) subserous.

2. Hematomas (massive outflow of blood into the tissues). They can be removed with a puncture.

According to the morphological picture.

1. Interstitial (blood spreads through interstitial spaces).

2. Interstitial (blood outflow occurs with tissue destruction and cavity formation).

According to clinical manifestations.

1. Pulsating hematomas (in case of communication between the hematoma cavity and the arterial trunk).

2. Non-pulsating hematomas.

Allocate also intracavitary bleeding.

1. Blood outflows into the natural cavities of the body:

1) abdominal (hemoperitoneum);

2) the cavity of the heart bag (hemopericardium);

3) pleural cavity (hemothorax);

4) joint cavity (hemarthrosis).

2. Blood outflows into hollow organs: gastrointestinal tract (GIT), urinary tract, etc.

The rate of bleeding.

1. Acute (from large vessels, a large amount of blood is lost within minutes).

2. Acute (within an hour).

3. Subacute (during the day).

4. Chronic (within weeks, months, years).

By the time of occurrence.

1. Primary.

2. Secondary.

Pathological classification.

1. Bleeding resulting from mechanical destruction of the walls of blood vessels, as well as from thermal lesions.

2. Arrosive bleeding arising from the destruction of the vessel wall by a pathological process (tumor decay, bedsores, purulent fusion, etc.).

3. Diapedetic bleeding (in violation of the permeability of blood vessels).

Blood performs a number of important functions in the body, which are mainly reduced to maintaining homeostasis. Thanks to the transport function of blood in the body, a constant exchange of gases, plastic and energy materials becomes possible, hormonal regulation, etc. is carried out. The buffer function of blood is to maintain acid-base balance, electrolyte and osmotic balance. immune function also aimed at maintaining homeostasis. Finally, due to the delicate balance between the coagulation and anticoagulation systems of the blood, its liquid state is maintained.

bleeding clinic consists of local (due to the outflow of blood into the external environment or into tissues and organs) and general signs of blood loss.

Symptoms of acute blood loss- this is a unifying clinical sign for all types of bleeding. The severity of these symptoms and the body's response to blood loss depend on many factors (see below). Fatal blood loss is considered to be such a volume of blood loss when a person loses half of all circulating blood. But this is not an absolute statement. The second important factor that determines the body's response to blood loss is its rate, that is, the rate at which a person loses blood. With bleeding from a large arterial trunk, death can occur even with smaller volumes of blood loss. This is due to the fact that the compensatory reactions of the body do not have time to work at the proper level, for example, with chronic blood loss in volume. General clinical manifestations of acute blood loss are the same for all bleeding. There are complaints of dizziness, weakness, thirst, flies before the eyes, drowsiness. The skin is pale, with a high rate of bleeding, cold sweat can be observed. Orthostatic collapse, development of syncope are frequent. An objective examination reveals tachycardia, a decrease in blood pressure, and a pulse of small filling. With the development of hemorrhagic shock, diuresis decreases. In the analysis of red blood, there is a decrease in hemoglobin, hematocrit and the number of red blood cells. But a change in these indicators is observed only with the development of hemodilution and in the first hours after blood loss is not very informative. The severity of clinical manifestations of blood loss depends on the rate of bleeding.

There are several severity of acute blood loss.

1. With a shortage of circulating blood volume (BCC) of 5-10%. The general condition is relatively satisfactory, there is an increase in the pulse, but it is of sufficient filling. Arterial pressure (BP) is normal. When examining blood, hemoglobin is more than 80 g / l. On capillaroscopy, the state of microcirculation is satisfactory: on a pink background, fast blood flow, at least 3-4 loops.

2. With a deficit of BCC up to 15%. General condition of moderate severity. There is tachycardia up to 110 in 1 min. Systolic blood pressure drops to 80 mm Hg. Art. In the analysis of red blood, a decrease in hemoglobin from 80 to 60 g / l. Capillaroscopy reveals fast blood flow, but on a pale background.

3. With a deficit of BCC up to 30%. General serious condition of the patient. The pulse is threadlike, with a frequency of 120 beats per minute. Arterial pressure drops to 60 mm Hg. Art. With capillaroscopy, a pale background, slowing of blood flow, 1-2 loops.

4. With a BCC deficit of more than 30%. The patient is in a very serious, often agonal condition. Pulse and blood pressure peripheral arteries missing.

It is possible to clearly determine from which vessel blood flows only when external bleeding. As a rule, with external bleeding, diagnosis is not difficult. When the arteries are damaged, the blood is poured into the external environment in a strong pulsating jet. Scarlet blood. This is a very dangerous condition, since arterial bleeding quickly leads to critical anemia of the patient.

Venous bleeding, as a rule, is characterized by a constant outflow of blood of a dark color. But sometimes (when large venous trunks are injured), there may be diagnostic errors, since transmission pulsation of the blood is possible. Venous bleeding is dangerous with the possible development of an air embolism (with low central venous pressure (CVP)). At capillary bleeding there is a constant outflow of blood from the entire surface of the damaged tissue (like dew). Especially severe are capillary bleedings that occur when traumatizing parenchymal organs (kidneys, liver, spleen, lungs). This is due to the structural features of the capillary network in these organs. Bleeding in this case is very difficult to stop, and during surgery on these organs it becomes a serious problem.

With various types internal bleeding the clinic is different and not as obvious as with external ones.

Methods for determining the volume of blood loss

There is a technique for estimating the amount of blood loss by clinical signs(see Ch. "Clinic of acute blood loss").

Libov's method is used for surgical interventions. The amount of blood lost by patients during the intervention is defined as 57% of the mass of all gauze pads and balls used.

Method for determining blood loss by specific gravity of blood (according to Van Slyke). The specific gravity of blood is determined using a set of test tubes containing a solution of copper sulphate in various dilutions. The analyzed blood is successively dripped into the solutions. The specific gravity of the dilution in which the drop does not sink and lingers for some time is considered equal to the specific gravity of blood. The volume of blood loss is determined by the formula:

Vcr \u003d 37 x (1.065 - x),

where Vkr is the volume of blood loss,

x - a certain specific gravity of blood, as well as according to the Borovsky formula, taking into account the value of hematocrit and blood viscosity.

This formula is slightly different for men and women.

DCCm \u003d 1000 x V + 60 x Ht - 6700;

DCCzh \u003d 1000 x V + 60 x Ht - 6060,

where DCKm is the deficiency of circulating blood for men,

DCC - deficiency of circulating blood for women,

V - blood viscosity,

Ht - hematocrit.

The only drawback of this formula can be considered a certain inaccuracy of the quantities determined with its help in early period after blood loss, when compensatory blood dilution (hemodilution) has not yet occurred. As a result, there is an underestimation of blood loss.

The body of an adult contains approximately 70-80 ml/kg of blood, and not all of it is in constant circulation. 20% of the blood is in the depot (liver, spleen). The circulating volume is blood that is not in the vessels of the depositing organs, and most of it is contained in the veins. 15% of the whole blood of the body is constantly in the arterial system, 7-9% is distributed in the capillaries, the rest is deposited in the venous system.

Since blood performs homeostatic functions in the body, all physiological mechanisms are aimed at preventing violations of its functioning.

The human body is quite resistant to blood loss. There are both systemic and local mechanisms to stop bleeding spontaneously. Local mechanisms include the reactions of the damaged vessel, which are due to both its mechanical properties (due to the elastic properties of the vascular wall, it contracts and closes the lumen of the vessel with intima screwing in) and vasomotor reactions (reflex spasm of the vessel in response to damage). Common mechanisms include coagulation and vascular-platelet mechanisms of hemostasis. When the vessel is damaged, the processes of platelet aggregation and the formation of fibrin clots are triggered. Due to these mechanisms, a thrombus is formed, which closes the lumen of the vessel and prevents further bleeding.

All mechanisms are aimed at maintaining central hemodynamics. To this end, the body tries to maintain the volume of circulating blood by activating the following mechanisms: blood is ejected from the depot organs, blood flow slows down, and blood pressure decreases. In parallel, blood flow is maintained mainly along main vessels(with priority blood supply to vital organs - the heart and brain). When the mechanism of centralization of blood supply is turned on, microcirculation is seriously affected, and blood flow disturbances in the microcirculatory bed begin long before clinically detectable signs of macrocirculation disorders (it should be borne in mind that blood pressure can be normal with a loss of up to 20% of BCC). Violation of capillary blood flow leads to disruption of the blood supply to the parenchyma of organs, the development of hypoxia and dystrophic processes in it. An adequate indicator of the state of microcirculation is such a clinical indicator as the debit-hour of urine.

The general reaction to bleeding according to Gulyaev proceeds in four phases. These are protective (until the bleeding stops), compensatory (centralization of blood flow), reparative (hemodilution due to the movement of tissue fluid and lymph into the bloodstream) and regenerative (restoration of normal hematocrit due to regeneration of formed elements) phases.

Temporary stopping methods.

1. Finger pressure (mainly for arterial bleeding). A method to stop bleeding immediately. Lets buy time. Unfortunately, stopping bleeding with this method is extremely short-lived. Places of digital pressure of the arteries:

1) carotid artery. The inner edge of the sternocleidomastoid muscle is at the level of the upper edge of the thyroid cartilage. The artery is pressed against the carotid tubercle on the transverse process of the VI cervical vertebra;

2) subclavian artery. Poorly amenable to finger pressure, therefore, it is possible to achieve blood flow restriction through it by moving the arm as far back as possible in the shoulder joint;

3) axillary artery. Presses into the armpit humerus. The approximate place of pressing is along the front border of hair growth;

4) brachial artery. Presses against the shoulder bone. The approximate place of pressing is the inner surface of the shoulder;

5) femoral artery. Presses against the pubic bone. The approximate place of pressing is the border between the middle and inner thirds of the inguinal ligament.

2. Maximum flexion of the limb in the joint with the roller (arterial) using:

1) pressure bandage (for venous, capillary bleeding);

2) tourniquet. It is applied proximal to the wound site for arterial bleeding, distally for venous bleeding. Using a tourniquet for arterial bleeding, it can be applied for a maximum of 1.5 hours. If after this time the need for its use persists, it is dissolved for 15-20 minutes and then applied again, but to another place;

3) clamping on the vessel in the wound (with arterial or venous bleeding);

4) temporary arthroplasty (with arterial bleeding in the absence of an opportunity for an adequate final stop in the near future). Effective only with mandatory heparinization of the patient;

5) exposure to cold (with capillary bleeding).

Final stop methods.

1. Ligation of the vessel in the wound.

2. Ligation of the vessel throughout.

3. Vascular suture.

4. Vascular transplantation.

5. Vessel embolization.

6. Vessel prosthesis (the previous methods are used for damage to large vessels that remain to stop bleeding, mainly from small arterial trunks).

7. Laser coagulation.

8. Diathermocoagulation.

In the presence of massive bleeding occurring with serious disorders in the hemostasis system (DIC, consumption coagulopathy, etc.), the listed methods of stopping bleeding may not be enough, sometimes additional therapeutic measures are required to correct them.

Biochemical methods effects on the hemostasis system.

1. Methods affecting the body as a whole:

1) transfusion of blood components;

2) platelet mass, fibrinogen intravenously;

3) cryoprecipitate intravenously;

4) aminocaproic acid parenterally and enterally (as one of the methods of hemostasis in gastric bleeding, especially erosive gastritis).

2. Methods of local influence. They are used in operations that involve damage to the tissue of parenchymal organs and are accompanied by capillary bleeding that is difficult to stop:

1) tamponade of the wound with a muscle or omentum;

2) hemostatic sponge;

3) fibrin film.

Bleeding (haemorrhagia) - outflow of blood from blood vessels in case of damage or violation of the permeability of their walls.

The loss of blood poses an immediate threat to the life of the victim, and his fate depends on immediate measures to stop the bleeding.

Classification of bleeding

I. Depending on the cause of occurrence:

a) mechanical damage, rupture of blood vessels (haemorrhagia per rhexin);

b) arrosive bleeding (haemorrhagia per diabrosin);

c) diapedetic bleeding (haemorrhagia per diapedesin);

d) violation chemical composition blood, changes in the coagulation and anticoagulation system of the blood.

II. Depending on the type of bleeding vessel:

a) arterial;

b) arteriovenous;

c) venous;

d) capillary;

e) parenchymal.

III. In relation to the external environment and clinical manifestations:

a) external;

b) internal;

c) hidden.

IV. By time of occurrence:

a) primary;

b) secondary.

Mechanical damage vessels can occur with open and closed injuries (ruptures, wounds), burns, frostbite.

Arrosive bleeding arise when the integrity of the vascular wall is violated due to the germination of the tumor and its decay, when the vessel is destroyed by spreading ulceration in the case of necrosis, destructive inflammation, etc.

Diapedetic bleeding arise due to increased permeability of small vessels (capillaries, venules, arterioles), observed in a number of diseases: beriberi C, hemorrhagic vasculitis (Schoenlein-Genoch disease), uremia, sepsis, scarlet fever, smallpox, phosphorus poisoning, etc. This state of the vessels is due to molecular, physical and chemical changes in their wall.

The possibility of bleeding is determined by the condition blood coagulation system. In violation of blood coagulation, massive blood loss is possible if even small vessels are damaged.

Hemophilia and Werlhof's disease are diseases accompanied by disorders of the blood coagulation system. At hemophilia(hereditary disease) there are defective specific clotting factors in plasma: factor VIII (hemophilia A) or factor IX (hemophilia B). The disease is manifested by increased bleeding. The slightest injury can lead to massive bleeding that is difficult to stop. At Werlhof's disease(thrombocytopenic purpura) reduced platelet count in the blood.

Severe changes in the blood coagulation system are observed with disseminated intravascular coagulation syndrome(DIC). The formation of multiple clots and blood clots in the vessels leads to the depletion of blood coagulation factors, which causes a violation of its coagulation, hypocoagulation and bleeding: tissue bleeding during surgery, gastrointestinal, uterine bleeding, hemorrhages in the skin, subcutaneous tissue at the injection site, at the site of palpation . The causes of DIC can be shock, sepsis, massive traumatic injuries, multiple fractures, traumatic toxicosis (crush syndrome), massive blood transfusions, massive bleeding, etc.

Disturbances in the blood coagulation system and, as a result, bleeding can be caused by the action of certain medicinal substances. The use of indirect anticoagulants (ethyl biscumacetate, acenocoumarol, phenindione, etc.), which disrupt the synthesis of blood coagulation factors VII, IX, X in the liver, as well as sodium heparin, which has a direct effect on the process of thrombosis, fibrinolytic drugs (streptokinase, streptodecase etc.), leads to a violation in the blood coagulation system. Drugs such as phenylbutazone, acetylsalicylic acid, can increase bleeding due to impaired platelet function.

Bleeding due to clotting disorders includes cholemic bleeding. It has long been observed that in patients with jaundice

blood clotting is disturbed and both spontaneous bleeding (bleeding into the muscles, skin, internal organs, nosebleeds) and increased tissue bleeding during surgery and in the postoperative period can occur. The cause of changes in the blood coagulation system is a decrease in the synthesis of coagulation factors V, VII, IX, X, XIII in the liver due to impaired absorption of vitamin K.

To increase blood clotting, plasma transfusions, cryoprecipitate, and the introduction of vitamin K are used.

The nature of bleeding is determined by the type of damaged vessel.

For arterial bleeding blood of scarlet color beats with a pulsating jet. The larger the vessel, the stronger the jet and the greater the volume of blood lost per unit time.

For venous bleeding the outflow of blood is constant, only when the damaged vein is located next to a large artery, transmission pulsation is possible, as a result of which the blood stream will be intermittent. If large veins in the chest area are damaged, the impulse of the heart is transmitted to the blood stream or the suction effect of the chest is influenced (when inhaling, bleeding slows down, while exhaling it intensifies). Only at high venous pressure, for example, when varicose veins of the esophagus rupture, does a jet flow of blood occur. In case of damage to large veins of the neck or subclavian vein it is possible to develop severe complications and even death due to air embolism. This is due to the negative pressure in these veins that occurs during inspiration, and the possible entry of air through the damaged vessel wall. Venous blood is dark in color.

capillary bleeding mixed, there is an outflow of arterial and venous blood. In this case, the entire wound surface bleeds, after removal of the outflowing blood, the surface is again covered with blood.

Parenchymal bleeding are observed when parenchymal organs are damaged: the liver, spleen, kidneys, lungs, etc. They are essentially capillary, but they are more massive, difficult to stop and more dangerous due to the anatomical features of the structure of the vessels of these organs.

For external bleeding blood is shed into the environment.

Internal bleeding can occur both in the cavity and in the tissue. Hemorrhages in tissue occur by impregnation of the latter with blood with the formation of swelling. The size of the hemorrhage

be different, depending on the caliber of the damaged vessel, the duration of bleeding, the state of the blood coagulation system. The blood poured into the tissue imbibes (impregnates) the interstitial cracks, coagulates and gradually resolves. Massive hemorrhages may be accompanied by tissue stratification with the formation of an artificial cavity filled with blood, - hematomas. The resulting hematoma can resolve, or a connective tissue capsule forms around it, and the hematoma turns into a cyst. When microorganisms penetrate into the hematoma, the latter suppurates. Unresolved hematomas can grow into connective tissue and calcify.

Bleeding is of particular importance. into the serous cavities- pleural, abdominal. Such bleeding is massive due to the fact that it rarely stops spontaneously. This is due to the fact that the blood that has poured into the serous cavities loses its ability to coagulate, and the walls of these cavities do not create a mechanical obstacle to the blood flowing from the vessels. In the pleural cavities, in addition, a suction effect is created due to the negative pressure. Blood clotting is disturbed due to the loss of fibrin from the blood, which is deposited on the serous cover, while the process of thrombus formation is disturbed.

To hidden include bleeding without clinical signs. As an example, clinically not manifested bleeding from stomach ulcers and duodenum. Such bleeding can be detected only by a laboratory method - a study of feces for occult blood. Undetected long-term occult bleeding can lead to the development of anemia.

Primarybleeding occurs immediately after damage to the vessel, secondary- after a certain period of time after the primary bleeding stops.

Factors that determine the volume of blood loss and the outcome of bleeding

The cause of death in blood loss is the loss of the functional properties of blood (transfer of oxygen, carbon dioxide, nutrients, metabolic products, detoxification function, etc.) and impaired blood circulation (acute vascular insufficiency - hemorrhagic shock). The outcome of bleeding is determined by a number of factors, but volume and rate of blood loss: rapid blood loss of about a third of the BCC is life-threatening, acute blood loss is absolutely fatal.

a loss of about half of the BCC. Under other unfavorable circumstances, the death of the patient may also occur with the loss of less than a third of the BCC.

The rate and volume of blood loss depend on the nature and type of the damaged vessel. The most rapid blood loss occurs when arteries are damaged, especially large ones. When arteries are injured, edge damage to the vessel is more dangerous than its complete transverse rupture, since in the latter case the damaged vessel contracts, the inner membrane is screwed inward, the possibility of thrombosis is greater and the probability of self-stopping of bleeding is higher. With marginal damage, the artery does not contract - it gapes, bleeding can continue for a long time. Naturally, in the latter case, the volume of blood loss may be higher. Arterial bleeding is more dangerous than venous, capillary or parenchymal bleeding. The volume of blood loss is also affected by disturbances in the coagulation and anticoagulation system of the blood.

As a result of blood loss importance It has general state organism. Healthy people tolerate blood loss more easily. Not favorable conditions occur with traumatic shock, previous (initial) anemia, debilitating diseases, starvation, traumatic long-term operations, cardiac insufficiency, disorders in the blood coagulation system.

The outcome of blood loss depends on the rapid adaptation of the body to blood loss. Thus, ceteris paribus, blood loss is easier to tolerate and faster adapted to it by women and donors, since blood loss during menstruation or constant donation create favorable conditions for compensating various systems, primarily cardiovascular, for blood loss.

The reaction of the body to blood loss depends on the environmental conditions in which the victim is located. Hypothermia, like overheating, adversely affects the body's adaptability to blood loss.

Factors such as age and sex of the victims, also play a role in the outcome of blood loss. As already mentioned, women tolerate blood loss more easily than men. Children and the elderly have a hard time with blood loss. In children, this is due to the anatomical and physiological characteristics of the body. So, for a newborn, the loss of even a few milliliters of blood is dangerous. In the elderly due to age-related changes in the heart, blood vessels (atherosclerosis), the adaptation of the cardiovascular system to blood loss is much lower than in young people.

Localization of bleeding

Even with minor bleeding, there may be a danger to the life of the victim, which is determined by the role of the organ into which the hemorrhage occurred. So, a slight hemorrhage in the substance of the brain can be extremely dangerous due to damage to vital centers. Hemorrhages in the subdural, epidural, subarachnoid spaces of the skull, even small in volume, can lead to compression of the brain and disruption of its functions, although the amount of blood loss does not affect the state of blood circulation. Hemorrhages in the heart sac, which in themselves, given the small amount of blood loss, are not dangerous, can lead to the death of the victim due to compression and cardiac arrest due to his tamponade.

ACUTE BLOOD LOSS

The risk of blood loss is associated with the development of hemorrhagic shock, the severity of which is determined by the intensity, duration of bleeding and the amount of blood lost. A rapid loss of 30% of the BCC leads to acute anemia, cerebral hypoxia and may result in the death of the patient. With a slight but prolonged bleeding, the hemodynamics change little, and the patient can live even if the hemoglobin level drops to 20 g / l. A decrease in BCC will lead to a decrease in venous pressure and cardiac output. In response to this, catecholamines are released by the adrenal glands, which leads to vasospasm, resulting in a decrease in vascular capacity and thereby maintaining hemodynamics at a safe level.

Acute blood loss due to a decrease in BCC can lead to hemorrhagic shock, the development of which is possible with blood loss equal to 20-30% of BCC. Shock is based on disorders of central and peripheral hemodynamics due to hypovolemia. With severe massive blood loss as a result of hemodynamic disorders, capillary paresis occurs, decentralization of blood flow, and shock can go into an irreversible stage. If arterial hypotension lasts more than 12 hours, complex therapy ineffective, multiple organ failure occurs.

With an increase in blood loss, acidosis develops, sharp disturbances occur in the microcirculation system, and erythrocyte aggregation occurs in the capillaries. Oliguria (a decrease in the amount of urine) at first has a reflex character, in the stage of decompensation it

passes into anuria, which develops as a result of impaired renal blood flow.

Signs of blood loss: pallor and moisture of the skin, a haggard face, frequent and small pulse, increased respiration, in severe cases, Cheyne-Stokes breathing, lowering of CVP and blood pressure. Subjective symptoms: dizziness, dry mouth, thirst, nausea, darkening of the eyes, increasing weakness. However, with a slow flow of blood, the clinical manifestations may not correspond to the amount of blood lost.

It is important to determine the amount of blood loss, which, along with stopping bleeding, is of decisive importance for the choice of therapeutic tactics.

The content of erythrocytes, hemoglobin (Hb), hematocrit (Ht) must be determined immediately upon admission of the patient and the study should be repeated in the future. These indicators in the first hours with severe bleeding do not objectively reflect the amount of blood loss, since autohemodilution occurs later (it is most pronounced after 1.5-2 days). The most valuable indicators are Ht and relative blood density, which reflect the ratio between blood cells and plasma. With a relative density of 1.057-1.054, Hb 65-62 g/l, Ht 40-44, blood loss is up to 500 ml, with a relative density of 1.049-1.044, Hb 53-38 g/l, Ht 30-23 - more than 1000 ml.

A decrease in CVP in dynamics indicates an insufficient blood flow to the heart due to a decrease in BCC. CVP is measured in the superior or inferior vena cava using a catheter inserted into the cubital or great saphenous vein of the thigh. The most informative method for determining the amount of blood loss is to determine the deficiency of the BCC and its components: the volume of circulating plasma, the volume of formed elements - the globular volume. The research methodology is based on the introduction of a certain amount of indicators (Evans blue dye, radioisotopes, etc.) into the vascular bed. The volume of circulating plasma is determined by the concentration of the indicator diluted in the blood; taking into account the hematocrit, with the help of tables, BCC and globular volume are calculated. Proper indicators of BCC and its components are found according to the tables, which indicate the body weight and sex of patients. By the difference between due and actual indicators, the deficit of BCC, globular volume, volume of circulating plasma, that is, the amount of blood loss, is determined.

It should be borne in mind that it is necessary to judge the amount of blood loss primarily by clinical signs, as well as by the totality of laboratory data.

Depending on the volume of outflowing blood and the level of decrease in BCC, four degrees of severity of blood loss:

I - mild degree: loss of 500-700 ml of blood (decrease in BCC by 10-15%);

II - medium degree: loss of 1000-1500 ml of blood (decrease in BCC

by 15-20%);

III - severe degree: loss of 1500-2000 ml of blood (decrease in BCC

by 20-30%);

IV degree - massive blood loss: loss of more than 2000 ml of blood (decrease in BCC by more than 30%).

Clinical signs observed with blood loss, allow you to determine its degree. At the I degree of blood loss, there are no pronounced clinical signs. With the II degree of blood loss, the pulse is up to 100 per minute, the blood pressure drops to 90 mm Hg, the skin is pale, the extremities are cold to the touch. With severe blood loss (III degree), the patient's restless behavior, cyanosis, pallor of the skin and visible mucous membranes, increased respiration, and "cold" sweat are noted. The pulse reaches 120 per minute, blood pressure is lowered to 70 mm Hg. The amount of separated urine is reduced - oliguria. With massive blood loss (IV degree), the patient is inhibited, is in a state of stupor, there is a sharp pallor of the skin, acrocyanosis, anuria (cessation of urination). The pulse on the peripheral vessels is weak, threadlike or not detected at all, with a frequency of up to 130-140 per minute or more, blood pressure is lowered to 30 mm Hg. and below.

Timely started treatment can prevent the development of hemorrhagic shock, so it should be started as quickly as possible. In case of severe blood loss, they immediately begin to administer blood-substituting fluids, the use of which is based on the fact that the loss of plasma and, consequently, a decrease in BCC are much more difficult for the body than the loss of red blood cells. Albumin, protein, dextran [cf. they say weight 50,000-70,000] are well kept in the bloodstream. If necessary, crystalloid solutions can be used, but it should be remembered that they quickly leave the vascular bed. Low molecular weight dextrans (dextran [cf. mol. weight 30,000-40,000]) replenish the volume of intravascular fluid, improve microcirculation and blood rheology. Transfusion of blood products is necessary when the hemoglobin level drops below 80 g / l and the hematocrit index is less than 30. In severe acute blood loss, treatment begins with a jet infusion into one, two or three veins and only after the SBP rises above 80 mm Hg. switch to drip.

To eliminate anemia, erythrocyte mass infusions are used, it is more expedient to administer it after the infusion of blood substitutes, as this improves capillary blood flow and reduces the deposition of blood cells.

Replenishment of blood loss

With a deficiency of BCC up to 15%, the volume of the infusion medium is 800-1000 ml (crystalloids 80% + colloids 20%) - 100% in relation to the deficit.

With blood loss of 15-25% of the BCC, the transfusion volume is 150% deficit - 1500-2300 ml, the ratio of crystalloids, colloids and plasma is 4:4:2.

With blood loss of 25-35% of the BCC, the replacement volume is 180-220% - 2700-4000 ml (crystalloids 30% + colloids 20%, plasma 30%, erythrocyte mass 20%).

With a BCC deficiency of more than 35%, the volume of transfusion is 220% - 4000-6000 ml (crystalloids 20% + colloids 30%, plasma 25%, erythrocyte mass - 25%).

Transfusions of blood products are indicated for blood loss exceeding 35-40% of the BCC, when both anemia and hypoproteinemia occur. Acidosis is corrected by the administration of sodium bicarbonate, trometamol (see. Blood transfusion). The use of drugs that increase vascular tone (vasoconstrictor agents) is contraindicated until the blood volume is fully restored, as they aggravate hypoxia. On the contrary, glucocorticoids improve myocardial function and reduce spasm of peripheral vessels. Oxygen therapy, hyperbaric oxygen therapy, used after bleeding has stopped, are shown.

EXTERNAL AND INTERNAL BLEEDING

external bleeding

The main sign of a wound is external bleeding. The color of the blood in this case is different: scarlet - with arterial bleeding, dark cherry - with venous bleeding. Bleeding not only from the aorta, but also from the femoral or axillary artery can lead to death within a few minutes after injury. Damage to large veins can also quickly cause death. With damage to the large veins of the neck and chest, such dangerous complication like an air embolism. This complication develops as a result

air entering through a wound in a vein (into the right parts of the heart, and then into the pulmonary artery) and blockage of its large or small branches.

internal bleeding

With traumatic injury or the development of a pathological process in the area of ​​the vessel, internal bleeding occurs. Recognizing such bleeding is more difficult than external bleeding. Clinical picture consists of common symptoms caused by blood loss, and local signs depending on the location of the source of bleeding. In acutely developed anemia (for example, a disturbed ectopic pregnancy or rupture of the spleen capsule in the presence of a subcapsular hematoma), pallor of the skin and visible mucous membranes, darkening of the eyes, dizziness, thirst, drowsiness, and fainting may occur. The pulse is frequent - 120-140 per minute, blood pressure is lowered. With slow bleeding, signs of blood loss develop gradually.

Bleeding into the lumen of hollow organs

If bleeding occurs into the lumen of hollow organs and blood flows out through natural openings, it is difficult to determine the source of such bleeding. Thus, the release of blood through the mouth may be due to bleeding from the lungs, trachea, pharynx, esophagus, stomach, duodenum. Therefore, the color and condition of the outflowing blood matter: foamy scarlet blood is a sign of pulmonary bleeding, vomiting of "coffee grounds" - gastric or duodenal. Black tarry stools (melena) are a sign of bleeding from the upper gastrointestinal tract, discharge of scarlet blood from the rectum - bleeding from the sigmoid or rectum. Hematuria is a sign of bleeding from the kidney or urinary tract.

Taking into account the expected localization of bleeding, to identify its source, choose special methods research: gastric probing and digital examination of the rectum, endoscopic methods, for example, bronchoscopy - for lung diseases, esophagogastroduodeno-, sigmoidoscopy and colonoscopy - for gastrointestinal bleeding, cystoscopy - for lesions of the urinary system, etc. Great importance have ultrasound, x-ray and radioisotope research methods, especially to determine hidden bleeding occurring with minor

or unusual manifestations. The essence of the radioisotope method is that the radionuclide (usually a colloidal solution of gold) is administered intravenously, while together with the outflowing blood it accumulates in the tissues, cavity or lumen of the internal organs. An increase in radioactivity at the site of damage is detected by radiometry.

Bleeding into closed cavities

More difficult is the diagnosis of bleeding in closed body cavities: the cranial cavity, spinal canal, chest and abdominal cavities, pericardium, joint cavity. These bleedings are characterized by certain signs of fluid accumulation in the cavity and general symptoms of blood loss.

Hemoperitoneum

Accumulation of blood in the abdominal cavity - hemoperitoneum (haemoperitoneum)- associated with injury closed injury abdomen, damage to parenchymal organs (liver, spleen), vessels of the mesentery, violation of ectopic pregnancy, rupture of the ovary, eruption or slipping of the ligature applied to the vessels of the mesentery or omentum, etc.

Against the background of blood loss, local signs are determined. The abdomen is limitedly involved in breathing, painful, soft, sometimes a slight muscular defense is determined, symptoms of peritoneal irritation are mild. In sloping areas of the abdomen, dullness of percussion sound is detected (with an accumulation of about 1000 ml of blood), percussion is painful, in women a protrusion of the posterior vaginal fornix can be observed, which is determined during vaginal examination. Patients with suspected hemoperitoneum need strict observation, determining the dynamics of hemoglobin and hematocrit levels; a rapid drop in these indicators confirms the presence of bleeding. It should be remembered that with simultaneous rupture of a hollow organ, local signs of bleeding will be masked by symptoms of developing peritonitis.

To clarify the diagnosis, puncture of the abdominal cavity using a "groping" catheter, laparoscopy, and puncture of the posterior vaginal fornix are of great importance. When the diagnosis is established, an emergency operation is indicated - laparotomy with a revision of the abdominal organs and stopping bleeding.

Hemothorax

Accumulation of blood in the pleural cavity - hemothorax (haemothorax)- due to bleeding due to trauma to the chest and lungs, including the operating room, a complication of a number of diseases of the lungs and pleura (tuberculosis, tumors, etc.). Significant bleeding is observed when the intercostal and internal thoracic arteries are damaged. There are small, medium and large (total) hemothorax. With a small hemothorax, blood usually fills only the sinuses of the pleural cavity, with an average it reaches the angle of the scapula, with a total hemothorax it occupies the entire pleural cavity. The blood in the pleural cavity, with the exception of cases of severe and massive bleeding, does not coagulate, since there are anticoagulant substances in the blood flowing from the lung.

The clinical picture of hemothorax depends on the intensity of bleeding, compression and displacement of the lungs and mediastinum. In severe cases, the patient's anxiety, chest pain, shortness of breath, pallor and cyanosis of the skin, cough, sometimes with blood, increased heart rate and lowering blood pressure are noted. During percussion, a dull sound is determined, voice trembling and breathing are weakened. The degree of anemia depends on the amount of blood loss. Due to aseptic inflammation of the pleura (hemopleurisy), serous fluid also enters the pleural cavity. When a hemothorax is infected from a damaged bronchus or lung, a severe complication develops - purulent pleurisy. The diagnosis of hemothorax is confirmed by X-ray data and pleural puncture. Treatment of small and medium hemothorax is carried out by pleural punctures, with the development of a large hemothorax, an emergency thoracotomy with ligation of the vessel or suturing of the lung wound is indicated.

Hemopericardium

Most common cause of hemopericardium (haemopericardium)- accumulation of blood in the pericardial sac - bleeding with wounds and closed injuries of the heart and pericardium, less often - with rupture of an aneurysm of the heart, myocardial abscesses, sepsis, etc. The accumulation of 400-500 ml of blood in the pericardium threatens the patient's life. The patient's anxiety, pain in the region of the heart, frightened facial expression, shortness of breath, tachycardia, frequent weak filling of the pulse are noted. BP is lowered. Displacement or disappearance of a cardiac impulse, expansion of the boundaries of cardiac dullness, deafness of heart sounds are revealed. With an increase in the amount of blood in the pericardium, a dangerous complication occurs - cardiac tamponade.

If hemopericardium is suspected, a diagnostic puncture is performed. With the slow development of hemopericardium, a small accumulation of blood, it is possible to conduct conservative treatment(rest, cold, pericardial puncture); in severe cases, an emergency operation is performed and the causes of bleeding are eliminated.

Accumulation of blood in the cranial cavity

Accumulation of blood in the cranial cavity (haemocranion), observed more often due to trauma, leads to the appearance of cerebral and focal neurological symptoms.

Hemarthrosis

Hemarthrosis (haemarthrosis)- accumulation of blood in the joint cavity due to bleeding that occurred during closed or open joint injuries (fractures, dislocations, etc.), hemophilia, scurvy and a number of other diseases. With significant bleeding, the functions of the joint are limited, its contours are smoothed, fluctuation is determined, and if the knee joint is damaged, the patella ballots. To clarify the diagnosis and exclude bone damage, an X-ray examination is performed.

Joint puncture is both diagnostic and therapeutic manipulation.

interstitial bleeding

Interstitial bleeding causes hematomas, sometimes of considerable size. For example, with a fracture of the femur, the amount of blood released can exceed 500 ml. The most dangerous are hematomas that form during rupture and crushing of large main vessels. In cases where the hematoma communicates with the lumen of the artery, the so-called pulsating hematoma develops, and later, with the formation of a capsule, a false aneurysm is formed. Along with the general symptoms of acute anemia, two main features are characteristic of a pulsating hematoma: a pulsation over the swelling, synchronous with heart contractions, and a blowing systolic murmur when auscultated. The limb in case of damage to the main artery is in a state of ischemia, pale, cold to the touch, there are violations of sensitivity, the pulse in the distal parts of the artery is not determined. In such cases, an emergency operation is indicated to restore the blood supply to the limb.

Interstitial bleeding can lead to impregnation (imbibition) of tissues with blood. This type of internal bleeding is called hemorrhage. Hemorrhage can occur in the muscles, fatty tissue, brain, heart, kidney, etc.

Hemorrhages are not significant in volume, but can lead to serious consequences (for example, hemorrhage into the substance of the brain).

INFLUENCE OF BLOOD LOSS ON THE ORGANISM. PROTECTIVE COMPENSATOR REACTIONS

Developed posthemorrhagic hypovolemia leads to circulatory disorders in the body. As a result, protective and compensatory processes are activated, aimed at restoring the correspondence between the BCC and the capacity of the vascular bed, thereby the body ensures the maintenance of blood circulation by adaptive reactions. These reactions include three main mechanisms.

1. Reducing the volume of the vascular bed by increasing the tone of the veins (venospasm) and peripheral arterioles (arteriolospasm).

2. Compensation for the lost part of the BCC due to autohemodilution due to the movement of the intercellular fluid into the bloodstream and the release of blood from the depot.

3. Compensatory reaction of life support organs (heart, lungs, brain).

Veno- and arteriolospasm is based on the reflex reaction of baro- and chemoreceptors of vessels, stimulation of the sympathetic-adrenal system. An increase in the tone of the veins compensates for the loss of BCC up to 10-15%. Vessels of the skin, kidneys, liver, abdominal cavity undergo vasoconstriction, while the vessels of the brain, heart, lungs remain unchanged, which ensures the maintenance of blood circulation in these vital organs (centralization of blood circulation).

The movement of tissue fluid into the vascular bed occurs quickly. So, within a few hours, a liquid transition in a volume of up to 10-15% of the BCC is possible, and up to 5-7 liters of liquid can move in 1.5-2 days. The influx of tissue fluid does not allow to fully restore the lost blood, since it does not contain formed elements and is characterized by a low protein content. Hemodilution occurs (dilution, blood thinning).

developed tachycardia, due to the influence of the sympathetic-adrenal system, allows you to maintain the minute volume of the heart

ca at a normal level. Hyperventilation provides adequate gas exchange, which is very important in conditions of hypoxia caused by a low level of hemoglobin in the blood and circulatory disorders.

Activation due to hypovolemia of the secretion of the pituitary antidiuretic hormone and aldosterone causes an increase in reabsorption in the kidneys and a delay in the body of sodium and chlorine ions. developed oliguria reduces the excretion of fluid from the body, thereby maintaining the level of volemia.

Such a compensatory reaction cannot last for a long time, the developed state of vascular resistance leads to a breakdown in compensation. Hypoxia of the liver, kidneys, subcutaneous tissue causes serious metabolic disturbances.

The progression of disorders in the body is due to slugging (gluing) of erythrocytes in the capillaries due to their spasm and slowing of blood flow, as well as increasing tissue hypoxia. In metabolism, anaerobic processes prevail over aerobic ones, and tissue acidosis increases. Such disorders of tissue metabolism and microcirculation lead to multiple organ failure: glomerular filtration decreases or stops in the kidneys and oliguria or anuria develops, necrotic processes occur in the liver, contractility of the heart decreases due to myocardial damage, interstitial edema develops in the lungs with impaired gas exchange through the lungs. capillary membrane ("shock lung").

Thus, even with stopped bleeding, blood loss leads to serious changes in all vital systems of the body, which makes it necessary to use a wide variety of means and methods of treatment, the main among which is the replacement of blood loss, and the earlier it is performed, the better for the patient.

STOP BLEEDING

Bleeding from small arteries and veins, as well as from capillaries, in most cases stops spontaneously. Rarely there is an independent stop of bleeding from large vessels.

One of the important defense systems of the body is the blood coagulation system. Spontaneous hemostasis in some cases, it allows the body to cope with bleeding on its own.

Hemostasis- a complex biochemical and biophysical process in which a blood vessel and surrounding tissues, thrombosis,

bocytes and plasma factors of the blood coagulation and anticoagulation system.

The contraction of the smooth muscle cells of the vessel leads to vasoconstriction, in the area of ​​damage to the vessels, the disturbed endothelium creates a surface, a place for the formation of a thrombus. Changes in hemodynamics, slowing of blood flow make the process of thrombosis possible, and the thromboplastin of the damaged vessel and surrounding tissues (tissue thromboplastin) takes part in the process of blood clotting. Changes in the electrical potential of the damaged vessel, exposure of collagen, accumulation of active biochemical substances (glycoproteins, von Willebrand factor, calcium ions, thrombospandin, etc.) ensure adhesion (sticking) of platelets to the exposed collagen of the vessel wall. Adhering platelets create conditions for platelet aggregation - a complex biochemical process involving epinephrine, ADP, thrombin with the formation of arachidonic acid, prostaglandins, thromboxane and other substances. Aggregated platelets, together with thrombin and fibrin, form a platelet clot - a surface for subsequent thrombosis with the participation of the blood coagulation system.

In the 1st phase, clotting occurs with the participation of plasma factors (VIII, IX, XI, XII Hageman factor) and blood platelets - blood thromboplastin is formed. The latter, together with tissue thromboplastin, in the presence of Ca 2 + ions, converts prothrombin into thrombin (2nd phase of coagulation), and thrombin, in the presence of factor XIII, converts fibrinogen into fibrin polymer (3rd phase). The process of clot formation ends with the retraction of the latter with the formation of a thrombus. This ensures hemostasis, and bleeding from small vessels reliably stops. The whole process of thrombus formation occurs very quickly - within 3-5 minutes, and processes such as platelet adhesion, the transition of prothrombin to thrombin, and the formation of fibrin take a few seconds.

Continued bleeding, if the body has not coped with it on its own, is an indication for a temporary stop of bleeding.

Methods for temporarily stopping bleeding

Tourniquet application

The most reliable method is the application of a tourniquet, but it is used mainly in the limbs.

Rice. 28.Applying a tourniquet: a - preparation for applying a tourniquet; b - the beginning of the overlay; c - fixation of the first round; d - final view after applying the tourniquet.

The hemostatic tourniquet is a rubber band 1.5 m long, ending with a metal chain on one side and a hook on the other. With established arterial bleeding, a tourniquet is applied proximal to the injury site.

The intended area of ​​application of the tourniquet is wrapped with a soft material (towel, sheet, etc.), i.e. create a soft pad. The tourniquet is stretched, applied closer to the chain or hook, and 2-3 rounds are made with a tourniquet, subsequent turns are applied, stretching the tourniquet. Then the hook is attached to the chain (Fig. 28). Be sure to indicate the time of applying the tourniquet, since the compression of the artery by it is longer than 2 hours per day. lower limb and 1.5 hours at the top is fraught with the development of necrosis of the limb. The control of the correct application of the tourniquet is the cessation of bleeding, the disappearance of the pulsation of the peripherally located arteries and light

Rice. 29.The imposition of an army tourniquet.

"waxy" pallor of the skin of the limb. If the transportation of the wounded takes more than 1.5-2 hours, the tourniquet should be periodically removed for a short time (10-15 minutes) until the arterial blood flow is restored. In this case, the damaged vessel is pressed down with a tupfer in the wound or the artery is pressed with fingers. Then the tourniquet is applied again, slightly above or below the place where it was located.

Subsequently, if necessary, the procedure for removing the tourniquet is repeated: in winter - after 30 minutes, in summer - after 50-60 minutes.

To stop bleeding, a special military tourniquet or an impromptu twist can be used (Fig. 29).

The application of a tourniquet on the neck (with bleeding from the carotid artery) with a strap or through the armpit on the healthy side is rarely resorted to. You can use the Cramer splint applied to the healthy half of the neck, which serves as a frame (Fig. 30). A tourniquet is pulled over it, which presses down on the gauze roller and squeezes the vessels on one side. In the absence of a tire, you can use the opposite hand as a frame - it is placed on the head and bandaged. The imposition of a tourniquet to compress the abdominal aorta is dangerous because injury to the internal organs can occur.

Rice. thirty.The imposition of a tourniquet on the neck.

Tourniquet application for bleeding from the femoral and axillary arteries is shown in Fig. 31.

After the tourniquet is applied, the limb is immobilized transport bus, in the cold season, the limb is wrapped to avoid frostbite. Then, after the introduction of analgesics, the victim with a tourniquet is quickly transported to the clinic in the supine position.

Rough and prolonged compression of tissues with a tourniquet can lead to paresis and paralysis of the limb due to both traumatic damage to the nerve trunks and ischemic neuritis that develops as a result of oxygen starvation. The lack of oxygen in the tissues located distally to the applied tourniquet creates favorable conditions for the development of anaerobic gas infection, i.e. for bacterial growth,

multiplying without oxygen. Given the risk of developing severe complications, it is better to temporarily stop bleeding by applying a pneumatic cuff to the proximal part of the limb. In this case, the pressure in the cuff should be slightly higher than the blood pressure.

Finger artery pressure

Finger pressure of the artery during correct execution leads to the cessation of bleeding, but it is short-lived, since it is difficult to continue pressing the vessel for more than 15-20 minutes. Pressing the artery is carried out in those areas where the arteries are located superficially and near the bone: carotid artery - transverse process C IV, subclavian - rib I, humerus - the region of the inner surface of the humerus, femoral artery - pubic bone (Fig. 32, 33) . The pressing of the brachial and femoral arteries is good, worse - the carotid.

Rice. 32.Places of pressure of arteries for a temporary stop of bleeding.

Rice. 33.Finger pressure on the carotid (a), facial (b), temporal (c), subclavian (d), brachial (e), axillary (f), femoral (g) arteries to temporarily stop bleeding.

It is even more difficult to press the subclavian artery due to its location (behind the collarbone). Therefore, in case of bleeding from the subclavian and axillary arteries, it is better to fix the arm by moving it as far back as possible. This causes compression of the subclavian artery between the clavicle and the first rib. Finger pressing of the artery is especially important in preparation for the application of a tourniquet or its change, and also as a technique for amputation of a limb.

Flexion of the limb at the joint

Flexion of the limb in the joint is effective provided that the arm bent to failure is fixed in elbow joint with bleeding from the

Rice. 34.Temporary stop of bleeding from the arteries by maximum flexion: a - from femoral artery; b - from the popliteal; in - from the shoulder and elbow.

dov of the forearm or hand, and the legs - in the knee joint with bleeding from the vessels of the lower leg or foot. In case of high injuries of the femoral artery that are inaccessible to the application of a tourniquet, the thigh should be fixed to the stomach with maximum flexion of the limb in the knee and hip joints (Fig. 34).

Wound tamponade and pressure dressing

Wound tamponade and application of a pressure bandage with immobilization under the condition of an elevated position of the limb are good method temporary stop of bleeding from veins and small arteries, from soft tissues covering the bones of the skull, elbow and knee joints. For tight tamponade, a gauze pad is inserted into the wound, filling it tightly, and then fixed with a pressure bandage. Tight tamponade is contraindicated for injuries in the area of ​​the popliteal fossa, since in these cases gangrene of the limb often develops. Pressure with a weight (sandbag) or in combination with cooling (ice pack) is used for interstitial bleeding, and is also often used as a method of preventing postoperative hematomas.

Pressing the vessel in the wound with fingers

Pressing the vessel in the wound with fingers is carried out in emergency situations, sometimes during surgery. For this purpose, the doctor quickly puts on a sterile glove or treats the hand with alcohol, iodine and presses or compresses the vessel in the wound, stopping the bleeding.

Applying a hemostat

In case of bleeding from damaged deeply located vessels of the proximal parts of the limb, abdominal cavity, chest, when the methods of temporary stopping of bleeding listed above cannot be applied, a hemostatic clamp is applied to the bleeding vessel in the wound. To avoid injury to nearby formations (nerves), you must first try to stop the bleeding by pressing the vessel with your fingers, and then apply a clamp directly to the bleeding vessel, after draining the wound from the blood.

Temporary vascular bypass

Temporary shunting of a vessel is a way to restore blood circulation in case of damage to large arterial vessels. A densely elastic tube is inserted into both ends of the damaged artery, and the ends of the vessel are fixed on the tube with ligatures. This temporary shunt restores arterial circulation. The shunt can function from several hours to several days, until the possibility of a final stop of bleeding appears.

Methods for the final stop of bleeding

Methods for the final stop of bleeding are divided into four groups: 1) mechanical, 2) physical, 3) chemical and biological, 4) combined.

Mechanical Methods Ligation of a vessel in a wound

Bandaging a vessel in a wound is the most reliable way to stop bleeding. For its implementation, the central and peripheral ends of the bleeding vessel are isolated, captured with hemostatic clamps and tied up (Fig. 35).

Vessel ligation throughout

Ligation of the vessel throughout is used if it is impossible to detect the ends of the bleeding vessel in the wound (for example, when the external and internal wounds are injured). carotid arteries), as well as with secondary cro-

Rice. 35.Methods for the final stop of bleeding from the vessel: a - ligation; b - electrocoagulation; c - ligation and crossing of the vessel at a distance; d - ligation of the vessel throughout; e - chipping of the vessel.

inflows, when the arrosated vessel is located in the thickness of the inflammatory infiltrate. In such cases, focusing on topographic anatomical data, they find, expose and tie up the vessel outside the wound. However, this method does not guarantee the cessation of bleeding from the peripheral end of the damaged artery and collaterals.

If it is impossible to isolate the ends of the vessel, the vessel is ligated together with the surrounding soft tissues. If the vessel is captured by the clamp, but it is not possible to bandage it, it is necessary to leave the clamp in the wound for a long time - up to 8-12 days, until reliable thrombosis of the vessel occurs.

Torsion of the vessel

Damaged vessels of small caliber can be grasped with a hemostatic forceps and rotational movements can be used to twist the vessel.

Tamponade of the wound

Sometimes, in the presence of small wounds and damage to small-caliber vessels, tamponade of the wound can be performed. Tampons are used dry or moistened with an antiseptic solution. Typical examples of stopping bleeding are anterior and posterior nasal tamponade in epistaxis, uterine tamponade in uterine bleeding.

clipping

For bleeding from vessels that are difficult or impossible to bandage, clipping is used - clamping the vessels with silver metal clips. After the final stop of the internal

For ripple bleeding, a part of the organ is removed (for example, gastric resection with a bleeding ulcer) or the entire organ (splenectomy in case of rupture of the spleen). Sometimes special sutures are applied, for example, to the edge of a damaged liver.

Artificial vascular embolization

At present, methods of artificial vascular embolization have been developed and introduced to stop pulmonary, gastrointestinal bleeding and bleeding from bronchial arteries, cerebral vessels. Under X-ray control, a catheter is inserted into the bleeding vessel, and emboli are placed along it, closing the lumen of the vessel, thereby stopping the bleeding. Balls made of synthetic polymeric materials (silicone, polystyrene), gelatin are used as emboli. Thrombus formation occurs at the site of embolization.

Vascular suture

The main indication for the imposition of a vascular suture is the need to restore the patency of the main arteries. The vascular suture must be highly airtight and meet the following requirements: it must not interfere with the blood flow (no constriction or turbulence), there must be as little suture material as possible in the lumen of the vessel. There are manual and mechanical seams (Fig. 36).

Rice. 36.Vascular sutures. a - single nodal (according to Carrel): b - single U-shaped; in - continuous twisting; g - continuous U-shaped; d - mechanical.

Manual vascular suture is applied using atraumatic needles. An end-to-end connection is ideal. A circular vascular suture can be applied using tantalum staples, Donetsk rings. The mechanical seam is quite perfect and does not narrow the lumen of the vessel.

A lateral vascular suture is applied with a tangential injury to the vessel. After application, the suture is strengthened with the help of fascia or muscle.

Patches made from biological material

If there is a large defect in the wall resulting from injury or surgery (for example, after removal of the tumor), patches from biological material (fascia, vein walls, muscles) are used. More often, an autovein is chosen (a large saphenous vein of the thigh or a superficial vein of the forearm).

transplants

As grafts in vascular surgery, auto- and allografts of arteries or veins are used, prostheses made of synthetic materials are widely used. Reconstruction is performed by applying end-to-end anastomoses or by suturing the graft.

Physical Methods

Thermal methods of stopping bleeding are based on the ability of high temperatures to coagulate proteins and on the ability of low temperatures to cause vasospasm. These methods are of great importance for combating bleeding during surgery. In case of diffuse bleeding from a bone wound, wipes soaked in hot isotonic sodium chloride solution are applied to it. Applying an ice pack for subcutaneous hematomas, swallowing pieces of ice for gastric bleeding are widely used in surgery.

Diathermocoagulation

Diathermocoagulation, based on the use of high frequency alternating current, is the main thermal method for stopping bleeding. It is widely used for bleeding from damaged vessels of subcutaneous fat and muscle, from small vessels of the brain. The main condition for the use of diathermocoagulation is the dryness of the wound, and when it is carried out, tissues should not be brought to charring, since this in itself can cause bleeding.

Laser

A laser (electron radiation focused in the form of a beam) is used to stop bleeding in patients with gastric bleeding (ulcer), in people with increased bleeding (hemophilia), and during oncological operations.

Cryosurgery

Cryosurgery - surgical methods treatment with local application cold during operations on richly vascularized organs (brain, liver, kidneys), especially when removing tumors. Local tissue freezing can be performed without any damage to healthy cells surrounding the area of ​​cryonecrosis.

Chemical and biological methods

Hemostatic agents are divided into resorptive and local action. Resorptive action develops when a substance enters the blood, local action develops when it comes into direct contact with bleeding tissues.

Substances of general resorptive action

Hemostatic substances of general resorptive action are widely used for internal bleeding. The most effective direct transfusion of blood products, plasma, platelet mass, fibrinogen, prothrombin complex, antihemophilic globulin, cryoprecipitate, etc. These drugs are effective for bleeding associated with congenital or secondary insufficiency individual blood coagulation factors in a number of diseases ( pernicious anemia, leukemia, hemophilia, etc.).

Fibrinogen is obtained from donor plasma. It is used for hypo-, afibrinogenemia, profuse bleeding of a different nature, with a substitution purpose.

Currently widely used fibrinolysis inhibitors, having the ability to lower the fibrinolytic activity of the blood. Bleeding associated with an increase in the latter is observed during operations on the lungs, heart, prostate gland, with cirrhosis of the liver, septic conditions, transfusion of large doses of blood. Both biological antifibrinolytic drugs (for example, aprotinin) and synthetic ones (aminocaproic acid, aminomethylbenzoic acid) are used.

Etamzilat- drugs that accelerate the formation of thromboplastin, they normalize the permeability of the vascular wall, improve microcirculation. Rutoside, ascorbic acid are used as agents that normalize the permeability of the vascular wall.

menadione sodium bisulfite - a synthetic water-soluble analogue of vitamin K. As a therapeutic agent, it is used for bleeding associated with a decrease in the content of prothrombin in the blood. Shown at acute hepatitis and obstructive jaundice, parenchymal and capillary bleeding after injuries and surgical interventions, gastrointestinal bleeding, peptic ulcer, hemorrhoidal and prolonged nosebleeds.

The process of converting prothrombin to thrombin requires a very small amount of calcium ions, which are usually already present in the blood. Therefore, the use of calcium preparations as a hemostatic agent is advisable only in the case of transfusion of massive doses of citrated blood, because when calcium interacts with citrate, the latter loses its anticoagulant properties.

Substances of local action

Local hemostatic agents are widely used. With parenchymal bleeding from a liver wound, a kind of biological tampon is used - muscle tissue or omentum in the form of a free flap or flap on a leg. Of particular importance in surgery is the use of a fibrin film, a biological antiseptic swab, and a hemostatic collagen sponge. Hemostatic and gelatin sponges, a biological antiseptic tampon are used to stop capillary and parenchymal bleeding from bones, muscles, parenchymal organs, for tamponade of the sinuses of the dura mater.

Thrombin - a drug obtained from the blood plasma of donors, promotes the transition of fibrinogen to fibrin. The drug is effective in capillary and parenchymal bleeding of various origins. Before use, it is dissolved in isotonic sodium chloride solution. Sterile gauze wipes or a hemostatic sponge are impregnated with a solution of the drug, which are applied to the bleeding surface. The use of thrombin is contraindicated for bleeding from large vessels, since the development of widespread thrombosis with a fatal outcome is possible.

Combined Methods

To enhance the effect of hemostasis, various methods of stopping bleeding are sometimes combined. The most common are wrapping with muscle tissue or lubricating the vascular suture with glue, the simultaneous use of various types of sutures, biological swabs, etc., for parenchymal bleeding.

For the treatment of patients with DIC, it is important to eliminate the cause that caused it, restore the BCC, take measures to eliminate renal failure, and normalize hemostasis - the introduction of sodium heparin and (stream) native or fresh frozen plasma, platelet mass; if necessary apply IVL.

To stop bleeding caused by the action of drugs, native or fresh frozen plasma is used, with an overdose of indirect anticoagulants - menadione sodium bisulfite (vitamin K), with an overdose of sodium heparin - protamine sulfate, for inactivation of fibrinolytic drugs - aminocaproic acid, aprotinin.

To stop bleeding in patients with hemophilia, cryoprecipitate, antihemophilic plasma, native plasma, native donor plasma, freshly citrated blood, direct blood transfusions are used.

SECONDARY BLEEDING

Secondary bleeding may be early(in the first 3 days) and late- after a long period of time after injury (from 3 to several days, weeks). The division into early and late is determined by the causes of secondary bleeding (as a rule, they differ in the time of manifestation). The cause of early secondary bleeding is a violation of the rules for the final stop of bleeding: insufficient control of hemostasis during surgery or surgical treatment of the wound, poorly tied ligatures on the vessels. An increase in blood pressure after surgery (if the patient or wounded person is operated on under reduced pressure), shock, hemorrhagic anemia, controlled arterial hypotension, when blood clots can be pushed out of large or small vessels, slipping of ligatures can lead to bleeding.

The cause of both early and late secondary bleeding can be disorders in the coagulation or anticoagulation system of the blood (hemophilia, sepsis, cholemia, etc.), careless change of

viscous, tampons, drainages, in which the separation of a blood clot and the appearance of bleeding are possible.

The main causes of secondary bleeding are purulent-inflammatory complications in the wound, the development of necrosis, which can lead to melting of blood clots. The cause of late bleeding can also be bedsores of blood vessels with pressure on them from bone or metal fragments, drainage. The resulting necrosis of the vessel wall can lead to its rupture and bleeding.

Secondary bleeding, as well as primary, can be arterial, venous, capillary, parenchymal, as well as external and internal.

The severity of the patient's condition is determined by the volume of blood loss, depends on the caliber and nature of the damage to the vessel. Secondary bleeding is more severe in terms of its effect on the body than primary ones, since it occurs against the background of a condition after a previous blood loss (due to primary bleeding or surgery). Therefore, in secondary bleeding, the severity of the patient's condition does not correspond to the volume of blood loss.

The clinical picture of secondary bleeding consists of general and local symptoms, as with primary bleeding. With external bleeding, first of all, wetting of the bandage is observed: bright red blood - with arterial bleeding, dark - with venous bleeding. Bleeding into a wound closed with sutures leads to the formation of a hematoma, which is accompanied by the appearance of pain, a feeling of fullness in the wound, and swelling.

For internal secondary bleeding, first of all, general signs of blood loss are characteristic: increasing weakness, pallor of the skin, an increase in the frequency and decrease in the filling of the pulse, and a decrease in blood pressure. According to laboratory studies, there is a decrease in the concentration of hemoglobin and hematocrit. Local symptoms are determined by the localization of the hemorrhage: hemoperitoneum, hemothorax, hemopericardium. With bleeding into the gastrointestinal tract, hematemesis or vomiting of “coffee grounds”, blood-stained stools, and melena are possible.

Stop secondary bleeding

The principles of stopping secondary bleeding are the same as for primary bleeding. If secondary bleeding is detected, urgent measures are taken to temporarily stop it using the same

methods and means, as in the case of primary bleeding - the application of a tourniquet, finger pressure of the vessel, pressure bandage, tamponing. With massive bleeding from the wound, it is temporarily stopped by one of the methods, and then the sutures are removed and a thorough revision of the wound is carried out. A clamp is applied to the bleeding vessel, then ligated. In case of capillary bleeding in the wound, it is tightly packed with a gauze swab or a hemostatic sponge.

Ligation of a bleeding vessel in a purulent wound is unreliable due to the likelihood of recurrence of bleeding due to the progression of the purulent-necrotic process. In such situations, apply ligation of the vessel throughout within healthy tissues. To do this, the vessel is exposed from the additional reserve more proximal, outside the place of its damage, and a ligature is applied. With the final stop of secondary bleeding, the general condition of the patient should be taken into account and it should be done after the patient is removed from hemorrhagic shock. For this purpose, transfusion of blood, anti-shock blood substitutes is carried out.

With established secondary bleeding into the abdominal, pleural cavities, gastrointestinal tract, when a temporary stop is impossible due to the anatomical features of the location of the bleeding vessel, despite the severity of the patient's condition, the presence of shock, an emergency operation is indicated - relaparotomy, rethoracotomy. Surgical intervention to stop bleeding and anti-shock measures are carried out simultaneously.

During the operation, the source of bleeding is determined and its final stop is carried out - ligation, stitching, ligation of the vessel along with surrounding tissues, suturing the bleeding parenchyma of the organ - the liver, ovary, etc. The blood that has poured into the serous cavities, if it is not contaminated with the contents of the gastrointestinal a path and since bleeding there has passed no more than 24 h, collect, filter and pour in to the patient (blood reinfusion). After the final stop of bleeding, replenishment of blood loss and antishock therapy are continued.

Mechanical methods are combined with chemical and biological means to stop bleeding. If the cause of bleeding was a violation of the activity of the blood coagulation or anticoagulation system, special factors are used to increase the blood coagulation system or reduce the activity of the anticoagulant system: plasma cryoprecipitate, antihemophilic factor, fibrinogen, platelet mass, aminocaproic acid, etc.

Preventionsecondary bleeding are the following highlights.

1. Careful final stop of primary bleeding in case of vascular damage and during any surgical intervention. Before suturing the wound, the area of ​​surgical intervention must be carefully examined (checking hemostasis). If there is no confidence in the complete stop of bleeding, additional methods are carried out - ligation, electrocoagulation of the vessel, the use of a hemostatic sponge. Only with complete hemostasis, the operation is completed by suturing the wound.

2. Careful conduct of the primary surgical treatment wounds, removal of foreign bodies - freely lying bone fragments, metal foreign bodies (shell fragments, bullets, shots, etc.).

3. Prevention of purulent complications from the wound: scrupulous observance of the rules of asepsis and antisepsis during surgery, antibiotic therapy.

4. Drainage of wounds, cavities, taking into account the topography of the vessels, in order to prevent the formation of bedsores in their walls, erosion.

5. Study before each planned operation of the state of the coagulation and anticoagulation system of the patient's blood: clotting time, bleeding time, prothrombin level, platelet count. If these indicators change, as well as patients with an unfavorable history of increased bleeding or suffering from blood diseases, jaundice, a detailed coagulogram is necessary. In case of violations in the state of the blood coagulation system, purposeful preoperative preparation is carried out to normalize or improve its condition. Monitoring the state of hemocoagulation in these patients, who are threatened in terms of secondary bleeding, is carried out systematically in the postoperative period.