Acute blood loss. Symptoms of acute and slow blood loss. Clinical characteristics of acute blood loss Physiology and not so

By type: traumatic (wound, operating room), pathological (during a disease, pathological process), artificial (exfusion, therapeutic bloodletting).

According to the speed of development: acute, subacute, chronic.

By volume: small - from 5 to 10% bcc (0.5 l); average - from 10 to 20% of the bcc (0.5-1.0 l); large - from 21 to 40% of the bcc (1.0-2.0 l); massive - from 41 to 70% bcc (2.0-3.5 l); fatal - more than 70% of the blood volume (more than 3.5 l).

According to the severity and possibility of developing shock: mild (deficiency of bcc 10-20%, globular volume up to 30%), no shock; moderate (BCC deficit 21-30%, globular volume 30-45%), shock develops with prolonged hypovolemia; severe (BCC deficit 31-40%, globular volume 46-60%), shock is inevitable; extremely severe (BCC deficit more than 40%, globular volume more than 60%), shock, terminal state

According to the degree of compensation: Period I - compensation (BCC deficit up to 10%);

Period II - relative compensation (BCC deficit up to 20%); Period III - compensation violations (BCC deficit 30%-40%); IV period - decompensation (BCC deficit more than 40%)

11.3. Diagnosis of bleeding and blood loss

Acute external bleeding is diagnosed quite clearly and, with timely assistance, is successfully stopped. The danger comes from injuries to large arteries and veins, as well as parenchymal organs. It is difficult to diagnose internal and secondary bleeding.

Internal bleeding is recognized by tracing the course of the wound canal, using auscultation and percussion of the chest and abdomen, by puncture, thoracentesis, laparocentesis and x-ray examination methods. General clinical signs of blood loss are of great importance in diagnosis:

weakness, drowsiness, dizziness, yawning, pale and cold skin and mucous membranes, shortness of breath, rapid and weak pulse, decreased blood pressure, impaired consciousness. However, the calculation of the amount of blood loss plays a decisive role.

The clinical picture does not always correspond to the amount of blood lost, especially in young people who have preserved the body’s adaptive capabilities. Sensitivity to blood loss increases with overheating or hypothermia, fatigue, injury, and ionizing radiation.

11.4. Determining the amount of blood loss

Determining the amount of blood loss in the field presents certain difficulties, since there is no sufficiently informative and fast method for accurately measuring it, and the doctor has to be guided by a combination of clinical signs and laboratory data.

In military field surgery, 4 groups of methods are used for this purpose:

1. According to the location of the injury and the volume of damaged tissue.

2. According to hemodynamic parameters (“shock index”, systolic blood pressure).

3. According to blood concentration indicators (hematocrit, hemoglobin content).

4. By changing the BCC.

When providing assistance to a victim, you can roughly determine the amount of blood loss by the location of the injury: in case of severe trauma to the chest it is 1.5-2.5 l, in the abdomen - up to 2 l, in case of multiple fractures of the pelvic bones - 2.5-3.5 l, open hip fracture - 1, more than 40%)

11.3. Diagnosis of bleeding and blood loss

Acute external bleeding is diagnosed quite clearly and, with timely assistance, is successfully stopped. The danger comes from injuries to large arteries and veins, as well as parenchymal organs. It is difficult to diagnose internal and secondary bleeding.

Internal bleeding is recognized by tracing the course of the wound canal, using auscultation and percussion of the chest and abdomen, by puncture, thoracentesis, laparocentesis and X-ray into 4 groups:

1. Small wounds - the damage surface is smaller than the surface of the palm. Blood loss is equal to 10% of the blood volume.

2. Medium-sized wounds - the damage surface does not exceed the area of ​​2 palms. Blood loss up to 30% of blood volume.

3. Large wounds - the surface is larger than the area of ​​3 palms, but does not exceed the area of ​​5 palms. Average blood loss is about 40% of the blood volume.

4. Wounds of very large sizes - the surface is larger than the area of ​​5 palms. Blood loss is about 50% of the blood volume.

In any conditions, it is possible to determine the amount of blood loss using hemodynamic indicators - the shock index. Despite criticism of the use of blood pressure as a criterion for the severity of blood loss, it, together with heart rate, has and will continue to be used in the advanced stages of evacuation. Essentially, these are the first important objective indicators that make it possible to roughly determine not only the severity of the wounded person’s condition, but also the amount of blood lost.

The shock index is the ratio of heart rate to systolic blood pressure. Normally, this figure is 0.5. Each subsequent increase by 0.1 corresponds to a loss of 0.2 liters of blood, or 4% of the bcc. An increase in this indicator to 1.0 corresponds to a loss of 1 liter of blood (20% of the bcc), to 1.5 ~ 1.5 l (30% of the bcc), to 2 - 2 l (40% of the bcc).

This method has proven to be informative in acute situations, but it allows for an underestimation of the true amount of blood loss by 15%. The method should not be used in cases of slow bleeding. To simplify calculations, a nomogram was developed based on the shock index (Table 11.1). In it, for the main values ​​of the index, the volumes of blood loss are determined in absolute figures in the wounded of 3 weight categories, and also the corresponding values ​​are given as a percentage of the proper blood volume, which is 7% of body weight for men and 6.5% for women. These data make it possible to roughly calculate the amount of blood loss in any wounded person. The indicators of systolic blood pressure are given as purely approximate, allowing an approximate estimate of blood loss. This bloodless method for determining acute blood loss can be used in the advanced stages of medical evacuation, especially in emergency situations with mass casualties.

Among the methods of the 3rd group, it is most recommended to determine the amount of blood loss based on the specific gravity (relative density) of blood using G.A.’s nomogram. Barashkova. However, the method produces a significant percentage of errors, underestimating the amount of blood loss by almost half in an acute situation. The magnitude of the error decreases as autohemodilution progresses.

It is more appropriate to use hematocrit or hemoglobin content in calculations. The most widely used is the Moore hematocrit method, represented by the following formula:

K P = O C K d x Gt d -gt f

where KP is blood loss, l; OTsKd - due OTsK; Gt d - the proper hematocrit, which is 45% in men and 42% in women; GTF is the actual hematocrit determined in the affected person after stopping bleeding and stabilization of hemodynamics. In this formula, instead of hematocrit, you can use hemoglobin content, considering a level of 150 g/l.

To simplify calculations, you can use the nomogram (Fig. 11.1). The nomogram is calculated for wounded 4 weight categories from 50 to 80 kg. After comparing the hematocrit and body weight indicators, we find the desired value. Straight radial lines connect the rounded values ​​of the listed indicators, between which, if necessary, intermediate values ​​can be distinguished.

Bleeding(haemorragia: synonym hemorrhage) - intravital leakage of blood from a blood vessel when the permeability of its wall is damaged or impaired.

Classification of bleeding

Depending on the symptom underlying the classification, the following types of bleeding are distinguished:

I. Due to the occurrence:

1). Mechanical bleeding(h. per rhexin) - bleeding caused by a violation of the integrity of blood vessels during trauma, including combat damage or surgery.

2). Arrosive bleeding(h. per diabrosin) - bleeding that occurs when the integrity of the vessel wall is violated due to tumor germination and disintegration, when the vessel is destroyed by ongoing ulceration during necrosis, a destructive process.

3). Diapedetic bleeding(h. per diapedesin) - bleeding that occurs without violating the integrity of the vascular wall, due to increased permeability of small vessels caused by molecular and physicochemical changes in their wall, in a number of diseases (sepsis, scarlet fever, scurvy, hemorrhagic vasculitis, phosphorus poisoning and etc.).

The possibility of bleeding is determined by the state of the blood coagulation system. In this regard, they distinguish:

- fibrinolytic bleeding(h. fibrinolytica) - due to a blood clotting disorder caused by an increase in its fibrinolytic activity;

- cholemic bleeding(h. cholaemica) - caused by a decrease in blood clotting during cholemia.

II. By type of bleeding vessel (anatomical classification):

1). Arterial bleeding(h. arterialis)- bleeding from a damaged artery.

2). Venous bleeding(h. venosa)- bleeding from a damaged vein.

3). Capillary bleeding(h.capillaris) - bleeding from capillaries, in which blood oozes evenly over the entire surface of damaged tissue.

4). Parenchymal bleeding(h. parenchymatosa) - capillary bleeding from the parenchyma of any internal organ.

5). Mixed bleeding(h. mixta) - bleeding occurring simultaneously from arteries, veins and capillaries.

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

1). External bleeding(h. extema) - bleeding from a wound or ulcer directly onto the surface of the body.

2). Internal bleeding(h.intema) - bleeding into tissues, organs or body cavities.

3). Hidden bleeding(h. occuta) - bleeding that does not have pronounced clinical manifestations.

In turn, internal bleeding can be divided into:

a) Internal cavity bleeding(h. cavalis) - bleeding into the abdominal, pleural or pericardial cavity, as well as into the joint cavity.

b) Interstitial bleeding(h. interstitialis) - bleeding into the thickness of tissues with their diffuse imbibition, dissection and hematoma formation.

The accumulation of blood spilled from a vessel in the tissues or cavities of the body is called hemorrhage(haemorrhagia).

Ecchymosis(ecchymosis) - extensive hemorrhage into the skin or mucous membrane.

Petechia(petechia, synonym: pinpoint hemorrhage) - a spot on the skin or mucous membrane with a diameter of 1-2 mm, caused by capillary bleeding.

Vibice(vibices, synonym: linear purple spots) - hemorrhagic spots in the form of stripes.

Bruise(suffusio, syn. bruise) - hemorrhage into the thickness of the skin or mucous membrane.

Hematoma(haematoma, synonym: bloody tumor) - a limited accumulation of blood in tissues with the formation of a cavity containing liquid or coagulated blood.

60. Classification of bleeding. By etiology:

Traumatic - occurs as a result of a traumatic effect on organs and tissues that exceeds their strength characteristics. In case of traumatic bleeding under the influence external factors An acute disruption of the structure of the vascular network at the site of the lesion develops.

Pathological - is a consequence of pathophysiological processes occurring in the patient’s body. It may be caused by a malfunction of any of the components of the cardiovascular and blood coagulation systems. This type of bleeding develops with minimal provoking influence or without it at all.

By time:

Primary - bleeding occurs immediately after damage to blood vessels (capillaries).

Secondary early - occurs soon after the final stop of bleeding, more often as a result of lack of control over hemostasis during surgery.

Secondary later - occurs as a result of destruction of the blood wall. Bleeding is difficult to stop.

By volume:

Lung 10-15% of circulating blood volume (CBV), up to 500 ml, hematocrit more than 30%

Average 16-20% of blood volume, from 500 to 1000 ml, hematocrit more than 25%

Severe 21-30% of bcc, from 1000 to 1500 ml, hematocrit less than 25%

Massive >30% bcc, more than 1500 ml

Lethal >50-60% of blood volume, more than 2500-3000 ml

Absolutely lethal >60% of blood volume, more than 3000-3500 ml

61. Criteria for assessing the severity of bleeding

Classification of the severity of blood loss, based both on clinical criteria (level of consciousness, signs of peripheral circulation, blood pressure, heart rate, respiratory rate, orthostatic hypotension, diuresis), and on fundamental indicators of the red blood picture - hemoglobin and hematocrit values ​​(Gostishchev V.K., Evseev M.A., 2005). The classification distinguishes 4 degrees of severity of acute blood loss:

I degree (mild blood loss)- characteristic clinical symptoms absent, orthostatic tachycardia is possible, hemoglobin level is above 100 g/l, hematocrit is at least 40%. BCC deficit up to 15%.

II degree (moderate blood loss)- orthostatic hypotension with a decrease in blood pressure by more than 15 mm Hg. and orthostatic tachycardia with an increase in heart rate by more than 20 per minute, hemoglobin level in the range of 80-100 g/l, hematocrit in the range of 30-40%. BCC deficit is 15-25%.

III degree (severe blood loss)- signs of peripheral dyscirculation (distal limbs are cold to the touch, pronounced pallor of the skin and mucous membranes), hypotension (BP 80-100 mm Hg), tachycardia (heart rate more than 100 per minute), tachypnea (RR more than 25 per minute) , phenomena of orthostatic collapse, diuresis is reduced (less than 20 ml/h), hemoglobin level is within 60-80 g/l, hematocrit is within 20-30%. BCC deficit is 25-35%.

IV degree (extreme blood loss)- impaired consciousness, profound hypotension (BP less than 80 mm Hg), severe tachycardia (heart rate more than 120 per minute) and tachypnea (respiratory rate more than 30 per minute), signs of peripheral dyscirculation, anuria; hemoglobin level is below 60 g/l, hematocrit - 20%. BCC deficit is more than 35%.

The classification is based on the most significant clinical symptoms that reflect the body’s response to blood loss. Determining the level of hemoglobin and hematocrit also seems to be very important in assessing the severity of blood loss, especially in grades III and IV, since in such a situation the hemic component of posthemorrhagic hypoxia becomes very significant. In addition, the hemoglobin level is still the decisive criterion for red blood cell transfusion.

It should be noted that the period from the appearance of the first symptoms of bleeding, and even more so from its actual onset to hospitalization, which is usually at least a day, makes the hemoglobin and hematocrit indicators quite realistic due to the hemodilution that has had time to develop. If clinical criteria do not correspond to hemoglobin and hematocrit, the severity of blood loss should be assessed based on the indicators that are most different from normal values.

The proposed classification of the severity of blood loss seems acceptable and convenient for emergency surgery clinics for at least two reasons. Firstly, assessing blood loss does not require complex special studies. Secondly, determination of blood loss immediately in the emergency department allows, according to indications, to begin infusion therapy and hospitalize the patient in the intensive care unit.

Bleeding (haemorrhagia) - leakage of blood from blood vessels due to damage or disruption of the permeability of their walls.

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 blood coagulation and anticoagulation systems.

II. Taking into account 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 blood vessels can occur with open and closed injuries (ruptures, wounds), burns, frostbite.

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

Diapedetic bleeding arise as a result of increased permeability of small vessels (capillaries, venules, arterioles), observed in a number of diseases: vitamin deficiency C, hemorrhagic vasculitis (Henoch-Schönlein disease), uremia, sepsis, scarlet fever, smallpox, phosphorus poisoning, etc. This condition of the vessels is due to molecular, physicochemical changes in their wall.

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

Diseases accompanied by disorders of the blood coagulation system include hemophilia and Werlhof's disease. At hemophilia(hereditary disease) the plasma contains defective specific coagulation factors: 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) the content of platelets in the blood is reduced.

Severe changes in the blood coagulation system are observed when disseminated intravascular coagulation syndrome(DIC syndrome). The formation of multiple clots and thrombi in the vessels leads to the depletion of blood clotting 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. Use of anticoagulants indirect action(ethyl biscoumacetate, acenocoumarol, phenindione, etc.), which disrupt the synthesis of blood clotting factors VII, IX, X in the liver, as well as sodium heparin, which has a direct effect on the process of thrombus formation, fibrinolytic drugs (streptokinase, streptodecase, etc.) , leads to disturbances in the blood coagulation system. Drugs such as phenylbutazone and acetylsalicylic acid can increase bleeding by impairing platelet function.

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

blood clotting is impaired and spontaneous bleeding can occur (bleeding into muscles, skin, internal organs, nosebleeds), as well as increased tissue bleeding during surgery and during surgery. postoperative period. 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, transfusions of plasma, cryoprecipitate, and administration of vitamin K are used.

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

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

For venous bleeding the flow of blood is constant, only when the damaged vein is located next to a large artery is transmission pulsation possible, as a result of which the blood stream will be intermittent. If large veins in the chest area are damaged, a heart impulse is transmitted to the blood stream or a suction effect is exerted. chest(when you inhale, the bleeding slows down, when you exhale, it intensifies). Only with high venous pressure, for example, when varicose veins of the esophagus rupture, does a jet of blood occur. If large veins of the neck or subclavian vein are damaged, severe complications and even death may develop due to air embolism. This occurs due to the negative pressure in these veins that occurs during inhalation 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. At the same time everything bleeds wound surface, after removing the spilled blood, the surface becomes covered with blood again.

Parenchymal bleeding are observed when parenchymal organs are damaged: liver, spleen, kidneys, lungs, etc. They are essentially capillary, but they can be 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 poured into the external 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 may

be different, which depends on the caliber of the damaged vessel, the duration of bleeding, and the state of the blood coagulation system. The blood poured into the tissue imbibes (impregnates) the intertissue gaps, coagulates and gradually resolves. Massive hemorrhages may be accompanied by tissue dissection 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 the hematoma, the latter suppurates. Unresolved hematomas can grow with connective tissue and become calcified.

Bleeding occupies a special place 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 blood 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 pouring out of the vessels. In addition, a suction effect is created in the pleural cavities due to negative pressure. Blood clotting is impaired due to the loss of fibrin from the blood, which is deposited on the serous surface, and the process of thrombus formation is disrupted.

TO hidden include bleeding without clinical signs. As an example, clinically silent bleeding from stomach ulcers and duodenum. Such bleeding can only be detected by a laboratory method - testing stool for occult blood. Undiagnosed, long-term hidden bleeding can lead to the development of anemia.

Primarybleeding occurs immediately after damage to the vessel, secondary- after some period of time after the primary bleeding has stopped.

Factors determining the volume of blood loss and the outcome of bleeding

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

loss, amounting to about half of the bcc. Under other unfavorable circumstances, the patient's death may occur with a loss of less than a third of the blood volume.

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, marginal damage to the vessel is more dangerous than its complete transverse rupture, since in the latter case the damaged vessel contracts, the inner lining is screwed inward, the possibility of thrombus formation is greater and the likelihood of spontaneous stopping of bleeding is higher. With marginal damage, the artery does not contract - it gapes, and 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 blood coagulation and anticoagulation systems.

In the outcome of blood loss, it is important general state body. Healthy people tolerate blood loss more easily. Unfavorable conditions arise when traumatic shock, previous (initial) anemia, debilitating diseases, fasting, traumatic long-term operations, cardiac failure, disorders of the blood coagulation system.

The outcome of blood loss depends on the body's rapid adaptation to blood loss. Thus, all other things being equal, blood loss is more easily tolerated and women and donors adapt to it more quickly, since blood loss during menstruation or constant donation creates favorable conditions for compensation of various systems, primarily the cardiovascular system, for blood loss.

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

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

Localization of bleeding

Even with minor bleeding, there can be a danger to the life of the victim, which is determined by the role of the organ into which the hemorrhage occurred. Thus, a minor hemorrhage into 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 volume of blood loss does not affect the state of blood circulation. Hemorrhages into 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 tamponade.

ACUTE BLOOD LOSS

The danger 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 volume of blood lost. A rapid loss of 30% of the bcc leads to acute anemia, brain hypoxia and can result in the death of the patient. With minor but prolonged bleeding, hemodynamics change little, and the patient can live even if the hemoglobin level decreases to 20 g/l. A decrease in blood volume will lead to a decrease in venous pressure and cardiac output. In response to this, the adrenal glands release catecholamines, 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 blood volume can lead to hemorrhagic shock, the development of which is possible with blood loss equal to 20-30% of blood volume. Shock is based on disorders of central and peripheral hemodynamics due to hypovolemia. In case of severe massive blood loss as a result of hemodynamic disorder, capillary paresis occurs, blood flow decentralization occurs, and shock can progress to an irreversible stage. If arterial hypotension continues for more than 12 hours, complex therapy is ineffective, multiple organ failure occurs.

With increasing blood loss, acidosis develops, sudden disturbances occur in the microcirculatory system, and aggregation of red blood cells occurs in the capillaries. Oliguria (decreased amount of urine) initially has a reflex character; in the stage of decompensation it

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

Signs of blood loss: pale and moist skin, haggard face, rapid and small pulse, increased breathing, in severe cases, Cheyne-Stokes breathing, decreased central venous pressure and blood pressure. Subjective symptoms: dizziness, dry mouth, thirst, nausea, darkening of the eyes, increasing weakness. However, if bleeding is slow, 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 crucial for choosing treatment tactics.

The content of red blood cells, hemoglobin (Hb), hematocrit (Ht) must be determined immediately upon admission of the patient and the study must be repeated in the future. These indicators in the first hours of severe bleeding do not objectively reflect the amount of blood loss, since autohemodilution occurs later (it is maximally expressed after 1.5-2 days). The most valuable indicators are Ht and relative blood density, which reflect the relationship between the formed elements of blood 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 central venous pressure over time indicates insufficient blood flow to the heart due to a decrease in blood volume. CVP is measured in the superior or inferior vena cava using a catheter inserted into the ulnar or greater saphenous vein of the thigh. Most informative method Establishing the amount of blood loss is to determine the deficiency of bcc and its components: the volume of circulating plasma, the volume of formed elements - globular volume. The research technique 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, the bcc and globular volume are calculated using tables. The proper indicators of blood volume and its components are found from tables that indicate the body weight and gender of the patients. Based on the difference between the expected 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 the amount of blood loss must be judged primarily by clinical signs, as well as based on the totality of laboratory data.

Depending on the volume of blood shed and the level of decrease in BCC, they are divided into four degrees of severity of blood loss:

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

II - moderate degree: loss of 1000-1500 ml of blood (decrease in blood volume

by 15-20%);

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

by 20-30%);

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

Clinical signs observed during blood loss help determine its degree. With grade I blood loss, there are no pronounced clinical signs. With stage II blood loss, the pulse is up to 100 per minute, blood pressure drops to 90 mm Hg, the skin is pale, the limbs are cold to the touch. In case of severe blood loss ( III degree) the patient's restless behavior, cyanosis, pallor are noted skin and visible mucous membranes, increased breathing, “cold” sweat. The pulse reaches 120 per minute, blood pressure is reduced to 70 mm Hg. The amount of urine discharge is reduced - oliguria. With massive blood loss (IV degree), the patient is inhibited, in a state of stupor, severe pallor of the skin, acrocyanosis, and anuria (cessation of urination) are noted. The pulse in the peripheral vessels is weak, thread-like or not detected at all, with a frequency of up to 130-140 per minute or more, blood pressure is reduced to 30 mm Hg. and below.

Timely start 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 replacement fluids, the use of which is based on the fact that the loss of plasma and, consequently, a decrease in blood volume is tolerated by the body much more difficultly than the loss of red blood cells. Albumin, protein, dextran [cf. they say weight 50,000-70,000] are well retained in the bloodstream. If necessary, crystalloid solutions can be used, but remember that they quickly leave the vascular bed. Low molecular weight dextrans (dextran [average molecular weight 30,000-40,000]) replenish the volume of intravascular fluid, improve microcirculation and rheological properties of blood. Transfusion of blood products is necessary when the hemoglobin level decreases below 80 g/l and the hematocrit is less than 30. In case of 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 infusion.

To eliminate anemia, infusions of red blood cells are used; it is more advisable 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 deficiency.

With blood loss of 15-25% of the bcc, the volume of transfusion is 150% of the 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 volume of replenishment is 180-220% - 2700-4000 ml (crystalloids 30% + colloids 20%, plasma 30%, erythrocyte mass 20%).

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

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

EXTERNAL AND INTERNAL BLEEDING

External bleeding

The main sign of a wound is external bleeding. The color of the blood can be 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. If large veins of the neck and chest are damaged, this may happen dangerous complication like an air embolism. This complication develops as a result

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

Internal bleeding

In case of traumatic injury or development pathological process Internal bleeding occurs in the area of ​​the vessel. 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 case of acutely developed anemia (for example, a disturbed ectopic pregnancy or rupture of the splenic capsule in the presence of a subcapsular hematoma), pallor of the skin and visible mucous membranes, darkening in the eyes, dizziness, thirst, drowsiness are observed, and fainting may occur. The pulse is frequent - 120-140 per minute, blood pressure is low. 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, the source of such bleeding is difficult to determine. Thus, the release of blood through the mouth can be caused by bleeding from the lungs, trachea, pharynx, esophagus, stomach, duodenum. Therefore, the color and condition of the gushing blood matter: frothy scarlet blood is a sign of pulmonary hemorrhage, vomiting “coffee grounds” is a sign of gastric or duodenal hemorrhage. Black, tarry stools (melena) are a sign of upper tract bleeding. 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, special research methods are chosen to identify its source: 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 damage to the urinary system, etc. Great importance have ultrasound, X-ray and radioisotope research methods, especially to determine hidden bleeding that occurs with minor

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

Bleeding into closed cavities

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

Hemoperitoneum

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

Against the background of blood loss, local signs are determined. The abdomen participates in breathing to a limited extent, is painful, soft, sometimes slight muscle protection is detected, and symptoms of peritoneal irritation are mild. In sloping areas of the abdomen, dullness of percussion sound is detected (with the accumulation of about 1000 ml of blood), percussion is painful, in women one can observe protrusion of the posterior vaginal fornix, which is determined during vaginal examination. Patients with suspected hemoperitoneum need strict monitoring, 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 the symptoms of developing peritonitis.

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

Hemothorax

Accumulation of blood in the pleural cavity - hemothorax (haemothorax)- caused by bleeding due to trauma to the chest and lungs, including the operating room, as a complication of a number of diseases of the lungs and pleura (tuberculosis, tumors, etc.). Significant bleeding is observed when the intercostal and internal mammary 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 a medium hemothorax, it reaches the angle of the scapula; with a total hemothorax, it occupies the entire pleural cavity. Blood in the pleural cavity, except in cases of severe and massive bleeding, does not clot, since the blood flowing from the lung contains anticoagulant substances.

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 decreased blood pressure are noted. Percussion reveals a dull sound, vocal tremors and breathing are weakened. The degree of anemia depends on the amount of blood loss. Due to aseptic inflammation of the pleura (hemopleuritis), serous fluid also enters the pleural cavity. When hemothorax becomes infected from a damaged bronchus or lung, a serious complication develops - purulent pleurisy. The diagnosis of hemothorax is confirmed by X-ray examination and pleural puncture. Treatment of small and medium hemothorax is carried out pleural punctures If a large hemothorax develops, an emergency thoracotomy with ligation of the vessel or suturing of a lung wound is indicated.

Hemopericardium

Most common reason hemopericardium (haemopericardium)- accumulation of blood in the pericardial sac - bleeding during injury and closed injuries of the heart and pericardium, less often - with rupture of a cardiac aneurysm, myocardial abscesses, sepsis, etc. Accumulation of 400-500 ml of blood in the pericardium threatens the life of the patient. The patient's anxiety, pain in the heart area, a frightened facial expression, shortness of breath, tachycardia, and a rapid, weak pulse are noted. Blood pressure is low. The displacement or disappearance of the cardiac impulse, expansion of the boundaries of cardiac dullness, and dullness of heart sounds are detected. When the amount of blood in the pericardium increases, a dangerous complication occurs - cardiac tamponade.

If hemopericardium is suspected, a diagnostic puncture is performed. With slow development of the hemopericardium and a small accumulation of blood, it is possible to carry out conservative treatment(rest, cold, pericardial puncture); in severe cases, emergency surgery 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 injury, leads to the appearance of general cerebral and focal neurological symptoms.

Hemarthrosis

Hemarthrosis (haemarthrosis)- accumulation of blood in the joint cavity due to bleeding resulting from closed or open joint injuries (fractures, dislocations, etc.), hemophilia, scurvy and a number of other diseases. If there is 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 balls out. To clarify the diagnosis and exclude bone damage, an X-ray examination is performed.

Joint puncture is both a diagnostic and therapeutic procedure.

Interstitial bleeding

Interstitial bleeding causes formation hematomas, sometimes of considerable size. For example, when a femur is fractured, the amount of blood released may exceed 500 ml. The most dangerous are hematomas that form when large major vessels rupture and crush. In cases where the hematoma communicates with the lumen of the artery, a so-called pulsating hematoma develops, and later, when a capsule is formed, a false aneurysm is formed. Along with the general symptoms of acute anemia, a pulsating hematoma is characterized by two main signs: pulsation over the swelling synchronous with heart contractions and a blowing systolic murmur during auscultation. If the main artery is damaged, the limb is in a state of ischemia, pale, cold to the touch, there are sensory disturbances, the pulse in the distal parts of the artery is not detected. In such cases, emergency surgery is indicated to restore blood supply to the limb.

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

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

INFLUENCE OF BLOOD LOSS ON THE BODY. PROTECTIVE COMPENSATORY 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, through adaptive reactions, ensures the maintenance of blood circulation. These reactions involve three main mechanisms.

1. Reducing the volume of the vascular bed due to increased 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 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 blood vessels, stimulation of the sympathetic-adrenal system. An increase in venous tone compensates for the loss of blood volume up to 10-15%. The vessels of the skin, kidneys, liver, and abdominal cavity undergo vasoconstriction, while the vessels of the brain, heart, and lungs remain unchanged, which ensures the maintenance of blood circulation in these vital areas. important organs (centralization of blood circulation).

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

Developed tachycardia, caused by the influence of the sympatheticoadrenal system, allows you to maintain cardiac output

tsa on normal level. Hyperventilation ensures adequate gas exchange, which is very important in conditions of hypoxia caused by a low level of hemoglobin in the blood and poor circulation.

Activation due to hypovolemia of the secretion of antidiuretic hormone of the pituitary gland and aldosterone causes an increase in reabsorption in the kidneys and retention of sodium and chlorine ions in the body. Developed oliguria reduces the removal of fluid from the body, thereby maintaining the level of volume.

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

The progression of disorders in the body is due to sludge (sticking together) of red blood cells 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, the contractility of the heart decreases due to myocardial damage, interstitial edema develops in the lungs with impaired gas exchange through the pulmonary - 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 one of which is replenishment 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 does bleeding from large vessels stop spontaneously.

One of the body's important defense systems 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 blood vessel and surrounding tissues, thrombus

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

Contraction of the smooth muscle cells of the vessel leads to vasoconstriction; in the area of ​​vascular damage, the damaged endothelium creates a surface, a place for the formation of a blood clot. Changes in hemodynamics and slowing of blood flow make the process of thrombus formation possible, and thromboplastin of the damaged vessel and surrounding tissues (tissue thromboplastin) takes part in the process of blood clotting. A change 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. Adherent 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 thrombus formation with the participation of the blood coagulation system.

In the 1st phase, coagulation 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 its retraction with the formation of a thrombus. This ensures hemostasis and reliably stops bleeding from small vessels. The entire process of thrombosis occurs very quickly - within 3-5 minutes, and processes such as platelet adhesion, the transition of prothrombin to thrombin, and fibrin formation take several seconds.

Continued bleeding if the body cannot cope with it on its own is an indication for temporarily stopping the bleeding.

Methods for temporarily stopping bleeding

Application of a tourniquet

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

Rice. 28.Application of a tourniquet: a - preparation for application of a tourniquet; b - beginning of overlay; c - fixation of the first round; d - final view after applying a 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. If arterial bleeding is established, a tourniquet is applied proximal to the site of injury.

The intended area of ​​application of the tourniquet is wrapped in soft material (towel, sheet, etc.), i.e. create a soft pad. The tourniquet is stretched, applied closer to the chain or hook and made into a tourniquet for 2-3 rounds, subsequent turns are applied, stretching the tourniquet. The hook is then attached to the chain (Fig. 28). Be sure to indicate the time of application of the tourniquet, since it compresses the artery for more than 2 hours. lower limb and 1.5 hours on the upper one is fraught with the development of limb necrosis. Control of the correct application of the tourniquet is the cessation of bleeding, the disappearance of pulsation of peripherally located arteries and lung

Rice. 29.Application of a military tourniquet.

“waxy” pallor of the skin of the limb. If transporting a wounded person takes more than 1.5-2 hours, you should periodically a short time(10-15 min) remove the tourniquet until arterial blood flow is restored. In this case, the damaged vessel is pressed with a tamper in the wound or finger pressure is applied to the artery. Then the tourniquet is applied again, slightly higher or lower than 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 army tourniquet or an improvised twist can be used (Fig. 29).

Applying a tourniquet to the neck (in case of bleeding from the carotid artery) with a bar or through the armpit on the healthy side is rarely resorted to. You can use a Kramer splint applied to the healthy half of the neck, which serves as a frame (Fig. 30). A tourniquet is pulled over it, which presses the gauze roller and compresses the vessels on one side. If there is no splint, you can use the opposite hand as a frame - it is placed on the head and bandaged. Applying a tourniquet for compression abdominal aorta It is dangerous because injury to internal organs may occur.

Rice. thirty.Applying a tourniquet to the neck.

Applying a tourniquet for bleeding from the femoral and axillary arteries shown in Fig. 31.

After applying a tourniquet, the limb is immobilized transport bus, in the cold season, the limb is wrapped to prevent frostbite. Then, after the administration of analgesics, the victim with a tourniquet is quickly transported to the clinic in a lying position.

Rough and prolonged compression tissue 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 distal to the applied tourniquet creates favorable conditions for the development of gas anaerobic infection, i.e. for the growth of bacteria,

multiplying without oxygen. Considering 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 slightly exceed blood pressure.

Finger pressure on the artery

Finger pressing the artery for a long time, when performed correctly, 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. The artery is pressed in those areas where the arteries are located superficially and near the bone: carotid artery - transverse process of C IV, subclavian - 1st rib, humerus - area of ​​the inner surface of the humerus, femoral artery - pubic bone (Fig. 32, 33) . Pressing the brachial and femoral arteries works well, but worse - the carotid artery.

Rice. 32.Places where arteries are pressed to temporarily stop bleeding.

Rice. 33.Finger pressure of 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 compress the subclavian artery due to its location (behind the collarbone). Therefore, when bleeding from the subclavian and axillary arteries, it is better to fix the arm by moving it back as far as possible. In this case, compression of the subclavian artery occurs between the collarbone and the first rib. Finger pressure on the artery is especially important in preparation for applying a tourniquet or changing it, as well as as a technique for amputating a limb.

Flexion of a limb at a joint

Flexion of a limb at a joint is effective provided that the arm bent to failure is fixed in elbow joint when bleeding from a vessel

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

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

Wound tamponade and application of a pressure bandage

Wound tamponade and application of a pressure bandage with immobilization provided the limb is in an elevated position 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 a tight tamponade, a gauze swab is inserted into the wound, filling it tightly, and then fixed with a pressure bandage. Tight tamponade is contraindicated for wounds in the popliteal fossa, since in these cases gangrene of the limb often develops. Pressure with a weight (sand bag) 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 your 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 squeezes the vessel in the wound, stopping the bleeding.

Applying a hemostatic clamp

In case of bleeding from damaged deep-lying vessels of the proximal parts of the limb, abdominal cavity, chest, when the above methods of temporarily stopping bleeding cannot be applied, apply a hemostatic clamp 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, having previously dried the wound from the blood.

Temporary vessel bypass

Temporary vessel bypass is a method of restoring blood circulation when large arterial vessels are damaged. A dense elastic tube is inserted into both ends of the damaged artery and the ends of the vessel are fixed to the tube with ligatures. This temporary shunt restores arterial circulation. The shunt can function from several hours to several days until it is possible to finally stop the bleeding.

Methods for definitively stopping bleeding

Methods for finally stopping 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

Ligation of a vessel in a wound is the most reliable way to stop bleeding. To carry it out, the central and peripheral ends of the bleeding vessel are isolated, grabbed with hemostatic clamps and bandaged (Fig. 35).

Ligation of the vessel throughout

Ligation of the vessel along its length is used if it is impossible to detect the ends of the bleeding vessel in the wound (for example, when wounding the external and internal carotid arteries), as well as with secondary blood

Rice. 35.Methods for finally stopping bleeding from a vessel: a - applying a ligature; b - electrocoagulation; c - ligation and intersection of the vessel at a distance; d - ligation of the vessel along its length; d - puncture of the vessel.

flows, when the arrozed vessel is located in the thickness of the inflammatory infiltrate. In such cases, focusing on topographic-anatomical data, the vessel is found, exposed and bandaged 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, ligate the vessel together with the surrounding soft tissues. If a vessel is captured by a clamp, but it is not possible to bandage it, you have to leave the clamp in the wound for a long time - up to 8-12 days, until reliable thrombosis of the vessel occurs.

Twisting the vessel

Damaged small-caliber vessels can be grabbed with a hemostatic clamp and the vessel can be twisted using rotational movements.

Wound tamponade

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

In case of ripple bleeding, part of an organ is removed (for example, resection of the stomach with a bleeding ulcer) or the entire organ (splenectomy for rupture of the spleen). Sometimes they impose special seams, for example, on the edge of a damaged liver.

Artificial vascular embolization

Currently, artificial vascular embolization methods have been developed and implemented to stop pulmonary, gastrointestinal bleeding and bleeding from bronchial arteries and 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) and gelatin are used as emboli. At the site of embolization, a thrombus subsequently forms.

Vascular suture

The main indication for applying a vascular suture is the need to restore the patency of the main arteries. The vascular suture must be highly sealed and meet the following requirements: it must not disrupt the blood flow (no narrowing or turbulence), and 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; c - continuous wrapping; g - continuous U-shaped; d - mechanical.

The vascular suture is applied manually using atraumatic needles. The ideal is to connect the vessel end to end. A circular vascular suture can be applied using tantalum staples and Donetsk rings. The mechanical suture is quite perfect and does not narrow the lumen of the vessel.

A lateral vascular suture is applied when there is a tangential wound to a vessel. After application, the suture is strengthened with fascia or muscle.

Patches from biological material

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

Transplants

Auto- and allografts of arteries or veins are used as grafts in vascular surgery; prostheses made of synthetic materials are widely used. Reconstruction is performed by applying end-to-end anastomoses or suturing a graft.

Physical methods

Thermal methods of stopping bleeding are based on the ability of high temperatures to coagulate proteins and the ability low temperatures cause vasospasm. These methods are of great importance to combat bleeding during surgery. In case of diffuse bleeding from a bone wound, wipes soaked in a hot isotonic sodium chloride solution are applied to it. Applying an ice pack for subcutaneous hematomas and 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 of stopping bleeding. It is widely used for bleeding from damaged vessels of subcutaneous fatty tissue and muscle, and 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, the tissue should not be charred, as this in itself can cause bleeding.

Laser

Laser (electron radiation focused in the form of a beam) is used to stop bleeding in patients with gastric bleeding (ulcers), 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 agents. The resorptive effect develops when the substance enters the blood, while the local effect develops when it comes into direct contact with bleeding tissues.

Substances with general resorptive action

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

Fibrinogen is obtained from donor plasma. Used for hypo-, afibrinogenemia, profuse bleeding of other nature, for replacement purposes.

Currently widely used fibrinolysis inhibitors, having the ability to reduce the fibrinolytic activity of the blood. Bleeding associated with an increase in the latter is observed during operations on the lungs, heart, prostate gland, liver cirrhosis, 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 and improve microcirculation. Rutoside and 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. How remedy used for bleeding associated with a decrease in prothrombin levels in the blood. Indicated for acute hepatitis and obstructive jaundice, parenchymal and capillary bleeding after wounds and surgical interventions, gastrointestinal bleeding, peptic ulcer, hemorrhoidal and prolonged nosebleeds.

The process of converting prothrombin into 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 anticoagulating properties.

Substances of local action

Local hemostatic agents are widely used. In case of 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 a pedicle flap. Special meaning in surgery it uses fibrin film, biological antiseptic tampon, hemostatic collagen sponge. Hemostatic and gelatin sponges, biological antiseptic tampon are used to stop capillary and parenchymal bleeding from bones, muscles, parenchymal organs, and for tamponade of the dural sinuses.

Thrombin is a drug obtained from donor blood plasma that promotes the transition of fibrinogen to fibrin. The drug is effective for capillary and parenchymal bleeding of various origins. Before use, it is dissolved in an isotonic sodium chloride solution. Sterile gauze pads or a hemostatic sponge are impregnated with the drug solution and 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 smearing the vascular suture with glue, simultaneous use for parenchymal bleeding various types sutures, biological tampons, etc.

For the treatment of patients with DIC syndrome, it is important to eliminate the cause that caused it, restore the blood volume, and carry out measures to eliminate renal failure, as well as normalization of hemostasis - administration of sodium heparin and (boost) native or fresh frozen plasma, platelet mass; If necessary, use mechanical ventilation.

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

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

SECONDARY BLEEDINGS

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 a wound, loosely tied ligatures on the vessels. Bleeding can be caused by increased blood pressure after surgery (if the patient or wounded person is operated on with low blood pressure), shock, hemorrhagic anemia, controlled arterial hypotension, when blood clots can be pushed out of large or small vessels, or ligatures may slip.

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

bandages, tampons, drainages, which may cause a blood clot to break off and cause bleeding.

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

Secondary bleeding, like primary bleeding, 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 and depends on the caliber and nature of the damage to the vessel. Secondary bleeding has a more severe impact on the body than primary bleeding, as it occurs against the background of a condition after previous blood loss (due to primary bleeding or surgery). Therefore, with secondary bleeding, the severity of the patient’s condition does not correspond to the amount of blood loss.

The clinical picture of secondary bleeding consists of general and local symptoms, as with primary bleeding. In case of external bleeding, the first thing to observe is the soaking of the bandage: bright red blood for arterial bleeding, dark blood for venous bleeding. Bleeding into a wound closed with sutures leads to the formation of a hematoma, which is accompanied by pain, a feeling of fullness in the wound, and swelling.

Internal secondary bleeding is characterized primarily by general signs blood loss: increasing weakness, pallor of the skin, increased frequency and decreased filling of the pulse, decreased blood pressure. According to laboratory studies, there is a decrease in hemoglobin concentration and hematocrit. Local symptoms are determined by the location of the hemorrhage: hemoperitoneum, hemothorax, hemopericardium. Bleeding into the gastrointestinal tract may result in bloody or coffee-ground vomiting, bloody stools, and melena.

Stopping secondary bleeding

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

methods and remedies as for primary bleeding - application of a tourniquet, finger pressure of the vessel, pressure bandage, tamponing. In case of massive bleeding from the wound, it is temporarily stopped using one of the methods, and then the sutures are removed and a thorough inspection of the wound is carried out. A clamp is applied to the bleeding vessel and 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 purulent wound unreliable due to the likelihood of recurrent bleeding due to the progression of the purulent-necrotic process. In such situations use ligation of the vessel along within healthy tissues. To do this, from the additional reserve, the vessel is exposed proximally, outside the site of its damage, and a ligature is applied. When finally stopping secondary bleeding, the general condition of the patient should be taken into account and should be done after the patient has been recovered from hemorrhagic shock. For this purpose, blood transfusions and blood substitutes with anti-shock action are performed.

In case of established secondary bleeding in the abdominal, pleural cavities, or gastrointestinal tract, when temporary stopping 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, emergency surgery 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, suturing, ligation of the vessel along with surrounding tissues, suturing the bleeding parenchyma of the organ - liver, ovary, etc. Blood poured into the serous cavities, if it is not contaminated with the contents of the gastrointestinal tract and no more than 24 hours have passed since the bleeding, collect, filter and infuse into the patient (blood reinfusion). After the bleeding has completely stopped, blood loss replacement and anti-shock therapy are continued.

Mechanical methods are combined with chemical and biological means of stopping 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 decrease the activity of the anticoagulation system: plasma cryoprecipitate, antihemophilic factor, fibrinogen, platelet mass, aminocaproic acid, etc.

Preventionsecondary bleeding are the following main points.

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

2. Careful initial surgical treatment of wounds, removal of foreign bodies - loose bone fragments, metal foreign bodies (shell fragments, bullets, shot, etc.).

3. Prevention of purulent complications from the wound: scrupulous adherence to the rules of asepsis and antisepsis during surgery, antibacterial therapy.

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

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