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All people experience bleeding throughout their lives. Hemorrhage is a condition in which blood flows from a damaged vessel. Most often, capillary bleeding occurs, which the body usually copes with on its own. Venous and arterial bleeding is life-threatening and requires medical attention. But the most insidious are internal bleeding, which is difficult to identify.

It is important to be able to distinguish between types of bleeding and to know their main characteristics in order to provide first aid in a timely manner and save a person's life. After all, misdiagnosis or violation of the rules for stopping bleeding can cost the victim his life.

What types of bleeding are there, what are the main signs of external and internal hemorrhages, what are the actions when providing the first medical care (PMP) - you will learn about this and much more later in the article.

Classification of bleeding

Hemorrhages are divided into different types, this is necessary to save time and to more easily determine the treatment plan. Indeed, thanks to prompt diagnostics, you will not only save your life, but also minimize blood loss.

General classification of types of bleeding:

• Depending on where the blood was shed:
  • External - a type of bleeding that is in contact with the external environment;
  • Internal - blood is poured into one of the body cavities;
• Depending on the damaged vessel:
  • - capillaries are damaged;
  • - the integrity of the veins is broken;
  • - blood flows from the arteries;
  • Mixed - different vessels are damaged;

• Depending on the body cavity into which the blood flows:
  • Bleeding into the free abdominal cavity;
  • Blood runs out in internal organs;
  • Hemorrhage into the stomach or intestines;
• Depending on the amount of blood loss:
  • I degree - the victim has lost about 5% of the blood;
  • II degree - loss of up to 15% of fluid;
  • III degree - the volume of blood loss is up to 30%;
  • Grade VI - I lost 30% of my blood or more wounds.

The most dangerous for life are III and VI degrees of blood loss. Next, we will consider in detail the characteristics of various and at the same time the most common and dangerous species bleeding.

Capillary

Most often, it is capillary hemorrhage that occurs. This is external bleeding, which is considered not life-threatening, unless the wound area is too large or the patient has low blood clotting. In other cases, the blood independently ceases to flow out of the vessels, since a blood clot forms in its lumen, which clogs it.

Capillary bleeding occurs due to any traumatic injury that compromises the integrity of the skin.

As a result of the injury, blood of a bright scarlet color evenly flows out of the damaged capillaries (the smallest blood vessels). The liquid flows out slowly and evenly, there is no pulsation, since the pressure in the vessels is minimal. The amount of blood loss is also insignificant.

First aid for capillary bleeding consists in disinfecting the wound and applying a tight bandage.

In addition, a cold compress can be applied to the damaged area. Hospitalization is usually unnecessary for capillary bleeding.

Venous

Venous hemorrhage is characterized by a violation of the integrity of the veins that are located under the skin or between the muscles. As a result of superficial or deep injury, blood flows from the vessels.

Symptoms of venous hemorrhage:

• Blood of a dark burgundy hue flows out of the vessels, a subtle ripple may be present;
• The hemorrhage is strong enough and is manifested by a constant flow of blood from the damaged vessel;
• By pressing on the area under the wound, bleeding is reduced.

Venous bleeding is life threatening, because in the absence of timely medical care, the victim can die from profuse blood loss. In rare cases, the body can cope with such a hemorrhage, and therefore it is not recommended to hesitate in stopping it.

If the superficial veins are damaged, the hemorrhage is less intense, and if the integrity of the deep vessels is disturbed, profuse blood loss is observed (profuse bleeding).

With venous bleeding, the victim can die not only from massive blood loss, but also from air embolism. After damage to a large vein, air bubbles clog its lumen at the moment of inhalation. When the air reaches the heart, it blocks the access of blood to important organs, as a result, a person can die.

Arterial

Arteries are large vessels that lie deep in soft tissues... They transport blood to all important organs. If the integrity of the vessel is violated, blood begins to flow out of its lumen.

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Arterial bleeding is rare. Most often, injury occurs as a result of a knife, gunshot or mine-explosive wound. This dangerous damage threatens human life, because the blood loss is large enough.

If you do not provide assistance to the victim with arterial bleeding within 3 minutes after the injury, he will die from exsanguination.

It is easiest to identify arterial hemorrhage, for this, pay attention to the following signs:

• The blood is bright red;
• The blood does not run out, but pulsates from the wound;
• The bleeding is very severe;
• Blood does not stop even after being pressed under or over the wound;
• The wound is localized at the site of the intended passage of the artery.

Intense arterial hemorrhage rapidly provokes profuse blood loss and shock... If the vessel ruptures completely, the victim can die from exsanguination of the body in just 1 minute. That is why arterial bleeding requires prompt first aid. A tourniquet is most often used to stop the blood.

What are the main signs of external bleeding you now know, then we will consider what to do if the hemorrhage has occurred inside the body.

Internal

This type of hemorrhage is the most insidious, since, unlike external bleeding, it has no obvious symptoms. They appear when a person has already lost a lot of blood.

Internal hemorrhage is a condition characterized by bleeding into one of the body cavities due to vascular damage.

It is possible to identify bleeding at an early stage by the following signs:

• The victim feels weak, he is drawn to sleep;
• Discomfort or pain in the abdomen;
• Blood pressure drops for no reason;
• The pulse quickens;
• The skin turns pale;
• Pain appears when the victim tries to stand up, which disappears when he takes a half-sitting position.

Types of internal bleeding occur as a result of penetrating wounds of the abdomen, lower back, rib fractures, stab and gunshot injuries. As a result, internal organs are injured, due to which the integrity of their vessels is disrupted and bleeding begins. As a result, blood accumulates in the abdominal cavity, chest, permeates the wounded organs or subcutaneous fatty tissue (hematoma).

The intensity of internal bleeding is different, that is, they can develop quickly or increase for several days after injury. The severity of such hemorrhages depends on the size of the injury to a particular organ.

In most cases, the spleen is damaged, a little less often the liver. A single-stage rupture of an organ provokes instant and rapid bleeding, and a two-stage rupture provokes a hematoma inside the organ, which ruptures over time, and the victim's condition deteriorates sharply.

Gastrointestinal

This type of hemorrhage is most often a complication of diseases of the digestive tract (for example, stomach and duodenal ulcers). Blood accumulates in the stomach or intestines and does not come into contact with air.

It is important to detect the symptoms of gastrointestinal hemorrhage in time in order to transport the victim to a medical facility.

Gastrointestinal hemorrhage symptoms:

• The patient feels weak, dizzy;
• The pulse quickens, and the pressure decreases;
• The skin turns pale;
• There are bouts of vomiting mixed with blood;
• Thin, bloody stool or thick black stool.

The main reasons for such a complication are ulcers, oncological diseases, various necrotic processes on the inner lining of the gastrointestinal tract, etc. Patients who know their diagnosis should be prepared for such situations in order to go to the hospital on time.

First aid for different types of hemorrhage

It is important to be able to carry out differential diagnostics in order to determine the type of bleeding in time and provide competent first aid.

General rules to follow for any bleeding:

• If symptoms of bleeding occur, the injured person is settled on his back;
• The person providing assistance must observe that the victim is conscious, periodically check his pulse and pressure;

• Treat the wound antiseptic solution (hydrogen peroxide) and stop the bleeding with a pressure bandage;
• Apply a cold compress to the damaged area;
• Then the victim is transported to a medical facility.

The above actions will not harm a person with any type of bleeding.

Detailed tactics of actions for different types of bleeding are presented in the table:

Type of hemorrhage	Procedure for temporarily stopping hemorrhage (first aid)	Procedure for the final stop of bleeding (medical assistance)
Capillary	Treat the wound surface with an antiseptic; Cover the wound with a tight bandage (dry or soaked in peroxide).	Sew up the wound if necessary.
Venous	Carry out all the steps as for capillary hemorrhage; Apply a pressure bandage to the wound, while you need to capture the area above and below the wound (10 cm each).	If the superficial vessels are damaged, then they are bandaged, and the wound is sutured; If deep veins are damaged, then the defect in the vessel and the wound are sutured.
Arterial	Perform the activities that are described in the first two cases; Press the bleeding vessel over the wound with your fingers or fist; Insert a tampon soaked in hydrogen peroxide into the wound; Apply a tourniquet to the finger pressure site.	The damaged vessel is sutured or prosthetic, the wound is sutured.
Internal (including gastrointestinal)	General first aid measures are carried out.	Doctors inject hemostatic drugs; Infusion therapy to replenish blood volume; Medical supervision; Surgery if bleeding continues.

The above measures will help stop the hemorrhage and save the victim.

Harness imposition rules

This method of stopping the blood is used for severe venous or arterial hemorrhages.

To correctly apply the tourniquet, follow these steps:

It is important to be able to distinguish between different types of bleeding in order to competently provide first aid to the victim.

It is important to strictly follow the rules of first aid, so as not to worsen the condition of the wounded. By remembering even the basic rules, you can save a person's life.

Acute blood loss is a one-stage or rapid blood loss in the volume of one tenth of its entire circulation. This phenomenon is very dangerous for human health and life, since significant changes occur in the human body associated with hypoxia in its tissues and the nervous system.

The emergence of acute blood loss syndrome is noted in the case of significant blood loss, more than half a liter. Blood flows out of the body into the external space through skin lesions, as a result of wounds and injuries, due to fractures, cuts, rupture of blood vessels.

Bleeding can be latent and be directed deep into the hollow organs, which have communication with the external environment. We are talking about the intestines, stomach, bladder, trachea and uterus. In addition, nosebleeds may occur.

Internal bleeding is the flow of blood masses into the internal spaces of closed cavities. In this case, we are talking about the cranial cavity, abdominal cavity, pericardial cavity and chest. Until the volume of blood loss becomes critical, such bleeding may be latent.

Acute blood loss: classification

Acute blood loss is a syndrome that occurs as a response to a decrease in the total volume of blood circulating in the body.

It is not difficult to diagnose external bleeding, while internal bleeding can be difficult to diagnose. Especially in cases where it is not accompanied by pain. If in the case of internal bleeding, blood loss is not observed more than 15% of the total circulation, the clinical manifestations in this case will not be pronounced and may be limited to tachycardia and shortness of breath, as well as a state close to fainting.

Arterial bleeding is considered the most dangerous of all types. In such cases, blood flows out of the injured arteries and at the same time it can pulsate or beat in a stream. The color of the blood is bright scarlet. It is necessary in such situations to immediately take some action, since the situation may result in the death of the patient from a large amount of blood lost by him.

With venous bleeding, the blood is dark and flows slowly from the wound. If the damaged veins are small, the bleeding can be stopped spontaneously without taking action to stop it.

Bleeding capillary or parenchymal may have a bleeding feature of the entire damaged surface of the skin, while this can occur in case of damage to internal organs.

Mixed bleeding may also occur, accompanied by the loss of a large amount of blood.

Signs of acute blood loss

With acute blood loss, the body is exsanguinated due to a sharp decrease in the total volume of circulating blood. First of all, the heart and brain suffer from this.

Acute blood loss may cause the victim headache, noises in the head, as well as feelings of weakness, ringing in the ears, thirst, drowsiness, blurred vision, fear and general anxiety. In addition, fainting and loss of consciousness are possible.

With a decrease in the total volume of blood circulating in the body, blood pressure decreases, while in the body its protective mechanisms are activated.

It should be noted that as a result of the fall blood pressure the following signs are noted:

• the integuments of the skin and mucous membranes turn pale, which is evidence of a spasm of peripheral vessels;
• attacks of tachycardia are noted as a compensatory reaction of the heart;
• shortness of breath occurs as a result of the struggle of the respiratory system with a lack of oxygen

All these signs indicate acute blood loss, but heart rate and blood pressure indicators are not enough to judge their value. Tests are required to determine clinical blood data, such as hemoglobin and hematocrit values, as well as data on the number of red blood cells in the blood.

The cause of acute blood loss

Acute blood loss can be caused by various reasons... These include various injuries, damage to external and internal organs, as well as their diseases, the consequence of improperly performed surgical interventions and profusely flowing menstruation in women.

It is very important to replenish the loss of blood in a timely manner, since blood plays an important role in the body, performing the function of maintaining homeostasis. The transport function of the circulatory system ensures the distribution of gases and their constant exchange between the systems of the body, as well as the exchange of plastic and energy materials and the regulation of hormonal levels. In addition, due to the buffering function of the blood, the maintenance of the acidic balance, as well as the balance, osmotic and electrolyte, is ensured. Maintaining the proper level of homeostasis is ensured by the immune function of the blood. Maintaining a delicate balance between the coagulation and anti-coagulation systems ensures a fluid state of the blood.

Pathogenesis of acute blood loss

In acute blood loss, irritation of the receptors of the veins takes place, which causes a persistent venous spasm. At the same time, there are no significant hemodynamic disturbances. In case of loss of at least one liter of blood, irritation occurs not only of the venous receptors, but also of the alpha receptors of the arteries. At the same time, the sympathetic nervous system is excited and the neurohumoral reaction is stimulated, there is a release of hormones by the adrenal cortex. At the same time, the amount of adrenaline exceeds the permissible threshold hundreds of times.

The action of catecholamines causes a spasm of the capillaries, and subsequently larger vessels are also subject to spasm. The contractile function of the myocardium is stimulated and tachycardia develops. There are contractions of the spleen and liver, blood is thrown into the vascular bed. In the lung cavity, the arteriovenous shunts open. Everything that has just been listed helps to supply blood to all the most important organs for three hours, to maintain hemoglobin at the proper level, as well as pressure in the arteries. In the future, there is a depletion of neuro-reflex mechanisms, angiospasm is replaced by vasodilation. There is a decrease in blood flow in all vessels, there is stasis of erythrocytes. The metabolic process in tissues is increasingly disturbed, and metabolic acidosis develops. Thus, a complete picture of hypovolemia and hemorrhagic shock is formed.

Acute blood loss: treatment

In case of acute blood loss, the most important thing is to stop the cut from the victim as quickly as possible. If external bleeding occurs, apply a pressure bandage, a hemostatic tourniquet, or conduct a tight wound tamponade. This will help prevent further blood loss and assist the surgeon in diagnosing the patient's condition and choosing the means for further treatment.

First aid for acute blood loss

A pressure bandage can be applied in case of damage to small vessels, as well as, if necessary, stop venous bleeding. When applying a bandage or dressing bag, a certain effort must be applied in order to achieve a higher quality of blood arrest. You can use tampons, gauze dressings, and napkins. A tourniquet can be considered as a pressure bandage, which is used to eliminate the consequences of neck injuries, accompanied by damage to large vessels. In this case, pressure should be applied only to damaged vessels located on one side of the neck. Those located on the other side of it must be protected by the imposition of materials at hand.

As an option for providing first aid for acute blood loss, pressing the injured area with a finger, be it capillary or venous bleeding, can be considered. The method is simple and ensures the cessation of blood flow to a specific place. In some situations, you can press the damaged artery to the wound with your fingers. This method can only have a temporary effect.

Acute blood loss therapy

The main method of therapy for acute blood loss is to restore the volume of lost blood through transfusion. It should be understood that blood should be transfused in a volume that exceeds the volume of lost blood. The physiological point of view provides for the use of erythrocyte-containing means of early storage, which are capable of providing the effect of transporting gases by erythrocytes, which is their main task.

When transfusing blood, ensure that safety measures are observed regarding the penetration of infection into the blood. It is imperative to conduct an examination of the transfused blood for the presence of viruses and pathogenic bacteria, including HIV.

Complications of acute blood loss

The main complication of acute blood loss is shock. With hemorrhagic shock, there is a disruption in the functioning of the main life support systems of the body, which develops in response to acute blood loss. Hemorrhagic shock can develop as a form of hypovolemic shock. In this case, there is a progressive hypoxia, which occurs for the reason that the lungs cannot transfer a sufficient amount of oxygen into the blood and it cannot be delivered by the blood to the tissues and assimilated by them.

As a result, there is a violation of the process of gas exchange in the lungs, they are poorly supplied with oxygen. This happens against the background of a decrease in the total volume of circulating blood in the body and the occurrence of oxygen starvation of internal organs. This requires an urgent implementation of a complex of measures for resuscitation and intensive therapy. Late initiation of treatment for acute blood loss is associated with the occurrence of irreversible changes in the body associated with impaired blood circulation and metabolic disorders in the body.

CHAPTER 11 INFECTIOUS COMPLICATIONS OF COMBAT SURGICAL INJURIES

CHAPTER 20 COMBAT CHEST INJURY. TORACOABDOMINAL Wounds

CHAPTER 7 BLEEDING AND BLOOD LOSS. INFUSION-TRANSFUSION THERAPY. PREPARATION AND TRANSFUSION OF BLOOD IN WAR

CHAPTER 7 BLEEDING AND BLOOD LOSS. INFUSION-TRANSFUSION THERAPY. PREPARATION AND TRANSFUSION OF BLOOD IN WAR

Fighting bleeding from wounds is one of the main and oldest problems in military surgery. The world's first blood transfusion in a military field was carried out S.P. Kolomninduring the Russian-Turkish War (1877-1878). The importance of quickly replenishing blood loss in the wounded was proven during the First World War ( W. Cannon), at the same time the first blood transfusions were performed taking into account group compatibility ( D. Crail). During the Second World War and in subsequent local wars, ITT was widely used at the stages of medical evacuation ( V.N. Shamov, S.P. Kaleko, A.V. Chechetkin).

7.1. SIGNIFICANCE OF THE PROBLEM AND TYPES OF BLEEDING

Bleeding is the most common consequence of combat injuries resulting from injury blood vessels.

In case of damage to the main vessel bleedingthreatens the life of the wounded, and therefore is designated as life-threatening consequence of injury... After intense or prolonged bleeding develops blood losswhich pathogenetically represents typical pathological process , and clinically - injury or trauma consequences syndrome ... With intense bleeding, blood loss develops faster. Clinical manifestations of blood loss in most cases occur when the wounded loses 20% or more of the volume of circulating blood (BCC), which is indicated in the diagnosis as acute blood loss... When the amount of acute blood loss exceeds 30% of the BCC, it is designated as acute massive blood loss... Acute blood loss of more than 60% of the BCC is practically irreversible.

Acute blood loss is the cause of death for 50% of those killed on the battlefield and 30% of the wounded who died at the advanced stages of medical evacuation (A.A.Vasiliev, V.L. Bialik). Wherein half of the death toll from acute blood loss could have been saved with the timely and correct application of methods for temporarily stopping bleeding .

Classification of bleeding(Fig. 7.1) takes into account the type of damaged vessel, as well as the time and place of bleeding. By the type of damaged vessel, arterial, venous, mixed (arteriovenous) and capillary (parenchymal) bleeding are distinguished. Arterial bleedinglook like a pulsating stream of scarlet blood. Profuse bleeding from the main artery leads to death within a few minutes.

Fig. 7.1Classification of bleeding in wounds and trauma

However, with a narrow and long wound channel, bleeding can be minimal, because the damaged artery is compressed by a tense hematoma. Venous bleedingare characterized by a slower filling of the wound with blood, which has a characteristic dark cherry color. When large venous trunks are damaged, blood loss can be quite significant, although venous bleeding is more often less life-threatening. Gunshot wounds to blood vessels in most cases damage both arteries and veins, causing mixedbleeding. Capillary bleedingoccur with any injury, but pose a danger only in case of disorders of the hemostasis system (acute radiation sickness, disseminated intravascular coagulation syndrome (DIC), blood diseases, overdose of anticoagulants). Parenchymal bleeding when internal organs are injured (liver, spleen, kidneys, pancreas, lungs) can also be life-threatening.

Primary bleedingoccur when blood vessels are damaged. Secondary bleedingdevelop at a later date and may be early(ejection of a blood clot from the lumen of the vessel, loss of a poorly fixed temporary intravascular prosthesis, defects of the vascular suture, rupture of the vessel wall with incomplete damage) and late- with the development of a wound infection (melting of a thrombus, arrosion of the artery wall, suppuration of a pulsating hematoma). Secondary bleeding can be repeated if stopping them has been ineffective.

Depending on the localization, they differ outdoorand internal(intracavitary and interstitial) bleeding. Internal bleeding is much more difficult to diagnose and more severe in its pathophysiological consequences than external bleeding, even when it comes to equivalent volumes. For example, significant intrapleural bleeding is dangerous not only for blood loss; it can also cause severe hemodynamic disturbances due to compression of the mediastinal organs. Even small hemorrhages traumatic etiology into the pericardial cavity or under the lining of the brain cause severe disturbances in life (cardiac tamponade, intracranial hematomas), which are fatal. Tension subfascial hematoma can compress the artery with the development of limb ischemia.

7.2. PATHOPHYSIOLOGY, CLINIC, METHODS FOR DETERMINING BLOOD LOSS VALUE

When acute blood loss occurs, the BCC decreases and, accordingly, the return of venous blood to the heart; deteriorates coronary blood flow. Impaired blood supply to the myocardium adversely affects its contractile function and heart performance. In the next few seconds after the onset of severe bleeding, the tone of the sympathetic nervous system due to central impulses and the release of adrenal hormones into the bloodstream - adrenaline and norepinephrine. Due to such a sympathicotonic reaction, a widespread spasm of peripheral vessels (arterioles and venules) develops. This defensive reaction is called "Centralization of blood circulation"since blood is mobilized from the peripheral parts of the body (skin, subcutaneous tissue, muscles, internal organs of the abdomen).

Blood mobilized from the periphery enters the central vessels and maintains the blood supply to the brain and heart - organs that cannot tolerate hypoxia. However, a prolonged spasm of peripheral vessels causes ischemia of cellular structures. In order to maintain the vitality of the organism, cell metabolism switches to the anaerobic pathway of energy production with the formation of lactic, pyruvic acids and other metabolites. Metabolic acidosis develops, which has a sharply negative effect on the function of vital important organs.

Arterial hypotension and widespread peripheral vasospasm during rapid bleeding control and early infusion-transfusion therapy (ITT) are usually treatable. However, long periods of massive exsanguination (over 1.5-2 hours) are inevitably accompanied by profound disturbances of the peripheral circulation and morphological damage to cellular structures, which become irreversible. Thus, hemodynamic disorders in acute massive blood loss have two stages: at the first they are reversible, at the second - a fatal outcome is inevitable.

Other neuroendocrine changes also play an important role in the formation of a complex pathophysiological response of the body to acute blood loss. The increased production of antidiuretic hormone leads to a decrease in urine output and, accordingly, to fluid retention in the body. This causes blood thinning (hemodilution), which also has a compensatory orientation. However, the role of hemodilution in maintaining the BCC, in comparison with the centralization of blood circulation, is much more modest if we consider that a relatively small amount of intercellular fluid (about 200 ml) is attracted into the circulation in 1 hour.

The decisive role in cardiac arrest in acute blood loss belongs critical hypovolemia- i.e. a significant and rapid decrease in the amount (volume) of blood in the bloodstream. Of great importance in ensuring cardiac activity is the amount of blood flowing into the chambers of the heart (venous return). A significant decrease in the venous return of blood to the heart causes asystole against the background of high hemoglobin and hematocrit values, satisfactory oxygen content in the blood. This death mechanism is called empty heart arrest.

Classification of acute blood loss in the wounded.In terms of severity, four degrees of acute blood loss differ, each of which is characterized by a certain complex of clinical symptoms. The degree of blood loss is measured as a percentage of the blood volume, because Measured in absolute units (milliliters, liters), blood loss for wounded of small stature and body weight may be significant, and for large - medium and even small.

The clinical signs of blood loss depend on the amount of blood lost.

With mild blood lossthe BCC deficiency is 10-20% (approximately 500-1000 ml), which has little effect on the condition of the wounded. The skin and mucous membranes are pink or pale. The main hemodynamic parameters are stable: the pulse can increase up to 100 beats / min, the SBP is normal or decreases at least 90-100 mm Hg. With blood loss moderate bCC deficiency is 20-40% (approximately 1000-2000 ml). A clinical picture of grade II shock develops (pallor of the skin, cyanosis of the lips and sub-nail beds; palms and feet are cold; the skin of the trunk is covered with large drops of cold sweat; the wounded is restless). Pulse 100-120 beats / min, SBP level - 85-75 mm Hg. The kidneys produce only a small amount of urine, and oliguria develops. With severe blood lossbCC deficiency - 40-60% (2000-3000 ml). Grade III shock with a fall in systolic blood pressure to 70 mm Hg clinically develops. and below, with an increase in heart rate up to 140 beats / min or more. The skin acquires a sharp pallor with a grayish-cyanotic tint, covered with drops of cold, sticky sweat. Cyanosis of the lips and subungual beds appears. Consciousness is depressed to the point of stunning or even stupor. The kidneys completely stop producing urine (oliguria turns into anuria). Extremely severe blood lossaccompanies a deficiency of more than 60% BCC (more than 3000 ml). The picture of the terminal state is clinically determined: the disappearance of the pulse in the peripheral arteries; heart rate can be determined only on the carotid or femoral arteries (140-160 beats / min, arrhythmia); BP is not determined. Consciousness is lost to sopor. The skin is sharply pale, cold to the touch, moist. The lips and subungual beds are gray.

Determination of the amount of blood lossplays an important role in providing emergency care wounded. In military field conditions for this purpose, the simplest and most quickly implemented techniques are used:

According to the localization of injury, the volume of damaged tissues, general clinical signs of blood loss, hemodynamic parameters (systolic blood pressure level);

According to the concentration indicators of blood (specific gravity, hematocrit, hemoglobin, erythrocytes).

There is a close correlation between the volume of lost blood and the level of systolic blood pressure, which makes it possible to roughly estimate the magnitude of acute blood loss. However, when assessing the amount of blood loss by the value of systolic blood pressure and clinical signs of traumatic shock, it is important to remember about the action of blood loss compensation mechanisms that can keep blood pressure close to normal with significant exsanguination (up to 20% BCC or about 1000 ml). A further increase in the volume of blood loss is already accompanied by the development of a shock clinic.

Reliable information about the estimated volume of blood loss is obtained by determining the main indicators of "red blood" - hemoglobin concentration, hematocrit; the number of erythrocytes. The most rapidly determined indicator is the relative density of blood.

Method for determining the relative density of blood according to G.A. Barash-kovu is very simple and requires only advance preparation of a set of glass jars with solutions of copper sulfate of different densities - from 1.040 to 1.060. The blood of the wounded is drawn into a pipette and sequentially dripped into jars with a solution of copper sulfate, which has a blue color. If a drop of blood floats up, the specific gravity of the blood is less; if it sinks, then it is more than the density of the solution. If the drop hangs in the center, the specific gravity of the blood is equal to the figure written on the jar with the solution.

blood density (due to its dilution) are no longer so informative. In addition, with a large loss of fluid in a hot climate (as was the case during the war in Afghanistan), the decrease in the level of relative blood density in the wounded may also not correspond to the real volume of lost blood.

It is important to remember that blood loss can occur not only with injuries, but also with a closed injury. Experience shows that based on the assessment of clinical data ("pool of blood" on a stretcher, wet dressings), doctors tend to overestimate the degree of external blood loss, but underestimate the amount of blood loss in interstitial bleeding, for example, with bone fractures. So, in a wounded person with a fracture of the hip, blood loss can reach 1-1.5 liters, and with unstable fractures of the pelvis even 2-3 liters, often causing death.

7.3. PRINCIPLES OF TREATMENT OF ACUTE BLOOD LOSS

The main thing for saving the life of the wounded from acute blood loss is fast and reliable stop of ongoing bleeding... Methods of temporary and final hemostasis for injuries of blood vessels of various localization are discussed in the relevant sections of the book.

The most important component of salvaging injured people with ongoing internal bleeding is emergency surgery to stop bleeding... In case of external bleeding, temporary hemostasis is first provided (pressure bandage, tight wound tamponade, hemostatic tourniquet, etc.) in order to prevent further blood loss, as well as to expand the surgeon's ability to diagnose wounds and select the priority of surgical interventions.

Tactics of infusion-transfusion therapy in the woundedis based on the existing ideas about the pathophysiological mechanisms of blood loss and the possibilities of modern transfusiology. The tasks of quantitative (volume of infusion-transfusion therapy) and qualitative (used blood components and blood-substituting solutions) replenish blood loss are distinguished.

Table 7.2. shows the approximate volumes of infusion and transfusion agents used in the course of replenishing acute blood loss.

Table 7.2.Content of infusion-transfusion therapy for acute blood loss in the wounded (on the first day after injury)

Light blood loss up to 10% of the BCC (about 0.5 liters), as a rule, is independently compensated by the body of the wounded. With blood loss up to 20% of the BCC (about 1.0 l), an infusion of plasma substitutes with a total volume of 2.0-2.5 liters per day is indicated. Transfusion of blood components is required only when the amount of blood loss exceeds 30% of the BCC (1.5 L). With blood loss of up to 40% of the BCC (2.0 l), the deficiency of the BCC is compensated for by blood components and plasma substitutes in a ratio of 1: 2 with a total volume of up to 3.5-4.0 liters per day. With a blood loss of more than 40% of the BCC (2.0 l), the deficiency of the BCC is compensated for by blood components and plasma substitutes in a ratio of 2: 1, and the total volume of injected fluid should exceed 4.0 liters.

The greatest difficulty is the treatment of severe and extremely severe blood loss (40-60% of the BCC). As you know, a decisive role in cardiac arrest in case of profuse bleeding and

acute blood loss belongs critical hypovolemia- i.e. a sharp decrease in the amount (volume) of blood in the bloodstream.

It is necessary to restore the intravascular fluid volume as soon as possible to avoid stopping the "empty heart". For this purpose, at least two peripheral veins (if possible, into the central vein: subclavian, femoral), the plasma substitute solution is injected under pressure using a rubber balloon. When providing SCS for quick replenishment of the BCC in wounded with massive blood loss, the abdominal aorta is catheterized (through one of the femoral arteries).

The infusion rate in severe blood loss should reach 250 ml / min, and in critical situations, approach 400-500 ml / min.If irreversible changes have not occurred in the body of the wounded as a result of deep prolonged exsanguination, then in response to an active infusion of plasma substitutes, systolic blood pressure begins to be determined in a few minutes. After another 10-15 minutes, the level of "relative safety" of systolic blood pressure is reached (approximately 70 mm Hg). In the meantime, the process of determining the AB0 and Rh factor blood groups is being completed, pre-transfusion tests are performed (tests for individual compatibility and biological test), and jet blood transfusion begins.

Concerning the qualitative aspect of the initial infusion-transfusion therapy of acute blood loss , then the following provisions are of fundamental importance.

The main thing in acute massive blood loss (more than 30% of the BCC) is the rapid replenishment of the volume of lost fluid, therefore, any available plasma substitute should be administered. If possible, it is better to start with the infusion of crystalloid solutions with a smaller amount side effects (ringer lactate, lactasol, 0.9% sodium chloride solution, 5% glucose solution, mafusol). Colloidal plasma substitutes ( polyglucin, macrodexand others), due to the large size of the molecules, have a pronounced vollemic effect (i.e., they stay in the bloodstream for a longer time). This is of value in military field conditions with prolonged evacuation of the wounded. However, it should be borne in mind that they also have a number of negative features - pronounced anaphylactogenic properties (up to the development of anaphylactic shock); the ability to cause non-specific

Agglutination of erythrocytes, which interferes with the determination of the blood group; activation of fibrinolysis with the threat of uncontrolled bleeding. Therefore, the maximum amount of polyglucin administered per day should not exceed 1200 ml. Promising colloidal solutions are preparations based on hydroxyethylated starch, devoid of the listed disadvantages: refortan, stabizol, voluven, infukoland etc.). Rheologically active colloidal plasma substitutes ( reopo-liglukin, reogluman) in the initial phase of replenishing blood loss, it is inappropriate and even dangerous to use. When these plasma substitutes are administered to a wounded with acute blood loss, difficult to stop parenchymal bleeding may develop. Therefore, they are used in a later period, when the replacement of blood loss is mostly completed, but peripheral circulatory disorders persist. Effective remedy to eliminate violations of hemostasis (hypocoagulation) with bleeding is fresh frozen plasma, which contains at least 70% of coagulation factors and their inhibitors. However, defrosting and preparing for direct transfusion of freshly frozen plasma requires 30-45 minutes, which should be taken into account if it is necessary to use it urgently. A promising low volume hypertonic infusion conceptintended for the initial stage of blood loss replacement. Concentrated (7.5%) sodium chloride solution infused into a vein at the rate of 4 ml / kg of the wounded body weight (on average 300-400 ml of solution) has a pronounced hemodynamic effect. With the subsequent administration of polyglucin, the stabilization of hemodynamics increases even more. This is due to an increase in the osmotic gradient between the blood and the intercellular space, as well as the beneficial effect of the drug on the vascular endothelium. At present, 3 and 5% of wounded with acute blood loss are already used abroad. sodium chloride solutions, and preparations of 7.5% sodium chloride solution continue to undergo clinical trials. In general, the use of a hypertonic saline solution in combination with colloidal solutions is of great interest for use at the stages of medical evacuation.

Blood transfusionand its components are produced in a larger volume, the greater the amount of blood loss. At the same time, from a physiological point of view, it is preferable to use erythrocyte-containing products of early shelf lifesince their erythrocytes, immediately after transfusion, begin to perform their main function - transporting gases. With long periods of storage, erythrocytes have a reduced gas transport function, and after transfusion, a certain time is required for its recovery.

The main requirement for the use of transfusions of donor blood and its components in acute blood loss is ensuring infectious safety (all transfusion drugs should be tested for HIV, viral hepatitis B and C, syphilis). Indications for transfusion of certain blood components are determined by the presence in the wounded of a deficiency of the corresponding blood function, which is not eliminated by the reserve capabilities of the body and creates a threat of death. In the absence of blood components of the required group in a medical institution, canned blood is used, prepared from emergency reserve donors.

It is advisable to start transfusion therapy after temporary or definitive hemostasis achieved surgically... Ideally, replenishment of blood loss by blood transfusion should begin as early as possible and generally end in the next few hours - after reaching a safe hematocrit level (0.28-0.30). The later the blood loss is compensated, the more blood transfusion funds are required for this, and with the development of a refractory state, any blood transfusions are already ineffective.

Reinfusion of blood.In case of injuries of large blood vessels, organs of the chest and abdomen during operations, the surgeon can detect a significant amount of blood poured out due to internal bleeding in the body cavity. Immediately after stopping the ongoing bleeding, such blood must be collected using special devices (Cell-Saver) or polymer reinfusion devices. The simplest system for collecting blood during surgery consists of a tip, two polymer tubes, a rubber stopper with two leads (for connecting with tubes to the tip and aspirator), an electric aspirator, sterile 500 ml glass bottles for blood. In the absence of devices and devices for reinfusion, the blood poured into the cavity can be collected

scoop into a sterile container, add heparin, filter through eight layers of gauze (or special filters) and return the wounded to the circulation. In view of the potential for bacterial contamination, a broad-spectrum antibiotic is added to the reinfused autologous blood.

Contraindications to blood reinfusion- hemolysis, contamination with the contents of hollow organs, blood infection (late operation, the phenomenon of peritonitis).

Use of "artificial blood"- that is, true blood substitutes capable of transporting oxygen (polymerized hemoglobin solution gelenpole, blood substitute based on

Table 7.3.General characteristics of standard blood transfusion agents and plasma substitutes

perfluorocarbon compounds perftoran) - when replenishing acute blood loss in wounded, it is limited by the high cost of manufacturing and the complexity of use in the field. Nevertheless, in the future, the use of artificial blood preparations in the wounded is very promising due to the possibility of long - up to 3 years - storage times at ordinary temperatures (hemoglobin preparations) with no danger of infection transmission and the threat of incompatibility with the recipient's blood.

The main criterion for the adequacy of blood loss replacement it is not the fact of infusion of the exact volume of certain media that should be considered, but, first of all, the body's response to the therapy. To favorable signs in the dynamics of treatment include: restoration of consciousness, warming and pink color of the integument, the disappearance of cyanosis and sticky sweat, a decrease in heart rate less than 100 beats / min, normalization of blood pressure. This clinical picture should correspond to an increase in the hematocrit value to a level of at least 28-30%.

To carry out ITT at the stages of medical evacuation, accepted for supply (standard) g emotransfusion drugsand plasma substitutes(Table 7.3).

7.4. ORGANIZATION OF BLOOD SUPPLY

FIELD THERAPEUTIC AND PREVENTIVE

INSTITUTIONS

The system of surgical care for the wounded in war can function only on the basis of a well-established supply of blood, blood transfusion means, and infusion solutions. Calculations show that in a large-scale war, only one front-line operation will require at least 20 tons of blood, its preparations and blood substitutes to provide surgical aid to the wounded.

To ensure the supply of blood to the field medical institutions as part of the medical service of the RF Ministry of Defense there is a special transfusiology service ... It is headed by the Chief Transfusiologist of the Ministry of Defense, to whom the medical officers responsible for the supply of blood and blood substitutes are subordinate. Research Department - Center for Blood and Tissue at Military Medical Academy is the organizational, methodological, educational and scientific-production center of the blood service of the Ministry of Defense of the Russian Federation.

Blood and blood substitute supply system in large-scale warproceeds from the basic provision that most of the blood transfusion funds will be received from the rear of the country [institutes and blood transfusion stations (SPK) of the Ministry of Health of the Russian Federation], the rest is procured from donors from the 2nd echelon of the rear of the front - reserve units, rear groups , convalescent contingents of HPHLR. At the same time, for the procurement of 100 liters of canned blood, 250-300 donors will be needed with the amount of donated blood from 250 to 450 ml.

In the modern structure of the military medical service of the front, there are special institutions for the collection of blood from donors and the supply of medical institutions. The most powerful of these is the Frontline Blood Procurement Squad (OZK). The OZK is entrusted with the tasks of storing canned blood, making its preparations, as well as receiving blood and plasma coming from the rear of the country, delivering blood and its components to medical institutions. The OZK front has a capacity of 100 l / day for the collection of preserved blood, including the production of components from 50% of the prepared blood.

SPKthat are available in each GBF are designed to perform the same tasks, but on a smaller scale. Their daily rate the collected blood is 20 liters.

SPK military districtswith the beginning of the war, they also begin to actively collect blood from donors. Their daily rate depends on the letter assigned: A - 100 l / day, B - 75 l / day, C - 50 l / day.

Autonomous preparation of donor blood (5-50 l / day) is also carried out departments of collection and blood transfusionlarge hospitals (VG central subordination, OVG). In the garrison VG and medb organized non-standard blood collection and transfusion points (NPZPK), whose duties include the procurement of 3-5 l / day of canned blood.

Even during the Great Patriotic War, the so-called two-stage blood collection system for the wounded ... The essence of this system is the separation of long and complex process blood preservation in 2 stages.

1st stageincludes industrial production of special sterile dishes (vials, polymer containers) with a preservative solution and is carried out on the basis of powerful institutions of the blood service.

2nd stage- taking blood from donors into ready-made vessels with a preservative solution - performed at blood collection points. The two-stage method allows for mass harvesting of blood in the field. It ensures wide decentralization of blood procurement, eliminating the need for long-term transportation of blood over long distances, expands the possibilities of transfusion of fresh blood and its components, and makes blood transfusion more accessible to medical institutions of the military district.

Organization of blood supply in modern local wars

depends on the scale of hostilities, the specifics of the theater of operations and the state's capabilities for material support of troops. So, in armed conflicts with the participation of US troops, blood supply was carried out mainly through centralized supplies of blood components, incl. cryopreserved (the war in Vietnam 1964-1973, in Afghanistan and Iraq 2001 - up to now). During the military operations of the USSR in Afghanistan (1979-1989), less expensive technologies were used - an autonomous decentralized preparation of "warm" donor blood as the wounded arrived. At the same time, centralized supplies of blood plasma preparations (dry plasma, albumin, protein) were practiced. Reinfusion of blood has become widespread, especially for chest wounds (used in 40-60% of the wounded). The organization of the provision of blood transfusion agents during counterterrorist operations in North Kazakhstan (1994 -19 9 6, 1999 -2 0 02) was performed taking into account the fundamental provisions of modern transfusiology to limit indications for transfusion of canned blood in favor of the use of its components. Therefore, the main option for the supply of blood has become the centralized supply of donor blood components (from the SEC of the North Caucasian Military District and central institutions). If blood transfusion was necessary for health reasons and the absence of blood components of the required group and Rh affiliation, blood was taken from emergency reserve donors from among military personnel of military units not directly participating in combat operations.

To important questions blood supply to hospitals include: organization of rapid blood delivery; storage at a strictly defined temperature (from +4 to +6? C); careful control over the settling process and rejection of questionable ampoules and containers. For long-distance delivery of donated blood

air transport is used as the fastest and least traumatic for blood corpuscles. The transportation and storage of canned blood and its preparations should be carried out in movable refrigeration units, refrigerators or insulated containers. In field conditions, adapted cold rooms - cellars, wells, dugouts - are used for storing blood and its preparations. Of particular importance is the organization of careful control over the quality of blood and its preparations, their timely rejection in case of unsuitability. For storage and quality control of blood, 4 separate racks are equipped:

To settle the delivered blood (18-24 hours);

For settled blood suitable for transfusion;

For "doubtful" blood;

For the rejected, i.e. unfit for blood transfusion. Criteria for good quality canned bloodserve: the absence of hemolysis, signs of infection, the presence of macro-clots, leakage of the blockage.

Tinned blood is considered suitable for transfusion within 21 days of storage. The laboratory confirms the absence of a direct reaction to bilirubin, syphilis, HIV, hepatitis B, C and other vector-borne infections. Transfusion of bacterially decomposed blood is especially dangerous. Transfusion of even a small amount of such blood (40-50 ml) can cause fatal bacterial toxic shock. The "doubtful" category includes blood, which does not acquire sufficient transparency on the second day; then the observation period is extended to 48 hours.

Deserve solid learning and strict adherence in any most urgent situation technical rules for blood transfusion... The doctor performing the blood transfusion is obliged to personally verify its good quality. It is necessary to make sure of the tightness of the package, correct certification, permissible shelf life, absence of hemolysis, clots and flakes. The doctor personally determines the group ABO and Rhesus blood belonging to the donor and recipient, conducts pre-transfusion tests (tests for individual compatibility and biological test).

The most serious complication of transfusion of incompatible blood is blood transfusion shock... It is manifested by the occurrence of pain in the lumbar region, the appearance of a sharp pallor

and cyanosis of the face; tachycardia, arterial hypotension develops. Then vomiting appears; loss of consciousness; acute hepatic renal failure develops. From the first signs of shock - the blood transfusion is stopped. Crystalloids are poured in, the body is alkalized (200 ml of 4% sodium bicarbonate solution), 75-100 mg of prednisolone or up to 1250 mg of hydrocortisone is injected, diuresis is forced... As a rule, the wounded is transferred to the ventilator mode. In the future, exchange blood transfusions may be required, and with the development of anuria, hemodialysis.

The wounded can die of blood loss

with normal hemoglobin and five

millions of red blood cells.

Doliotti,1940

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

CLASSIFICATION OF BLOOD LOSS

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

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

By localization, the following types of bleeding are distinguished.

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

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

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

External bleeding is easy to diagnose. They accompany surgical operations, injuries with damage to the outer covers 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 diagnostic and tactical group of bleeding. Moreover, intracavitary bleeding (pleural and abdominal cavities, joints) is characterized by defibrinating and non-coagulability of the outflowing blood, and interstitial (hematoma, hemorrhagic infiltration) - the inability to determine the volume of blood loss and often lack of signs.

Mixed bleeding is a type of internal bleeding. In such cases, bleeding into a hollow organ (more 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 external. Depending on the localization of the source, bleeding is also distinguished 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 3-5th day). They are caused by mechanical detachment of a thrombus as a result of an increase in blood pressure or elimination of vascular spasm.

Secondary late bleeding occur, as a rule, with suppuration of wounds and are dangerous in that they can cause the development of circulatory decompensation even with insignificant volume of 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 the se volume, the speed with which the blood leaves the vascular bed, and the compensatory capabilities of the organism ("initial background").

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

The rate of blood loss determines certain clinical signs behold.

With a slow loss of even very large blood volumes, significantly exceeding the BCC (hemoptysis, melena, hematuria, hemobilia, etc.), the clinical picture may not appear, hemodynamic disorders develop gradually and rarely reach a critical level, sometimes pronounced and persistent hydremia is noted. accompanied by a decrease in hematocrit, hemoglobin content and the number of erythrocytes; 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 possibility of a hydraemic reaction (up to 20-50 ml / min or more), compensation can be provided only by a hemodynamic mechanism, which is manifested by a corresponding clinical symptom complex. In this case, circulatory decompensation develops in connection with 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 heart injury, rupture of an aortic aneurysm, instantaneous polytrauma), death can occur from cardiac arrest in the first minutes ("empty" heart).

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

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

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 hollow, jugular, portal veins, severe blood loss is characteristic. Its clinical signs are not as critical as with fulminant. However, with acute blood loss, hypotension and impaired consciousness develop rapidly, within 10-15 minutes, which requires stopping bleeding by any method available in this case.

Moderate blood loss 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 rate (moderate) and on the volume of blood loss.

Typical surgical blood loss, the amount of which depends on the duration of the operation and does not exceed 5-7% of the BCC per hour on average, are 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 due to the pathology that causes them, and due to the development of chronic anemia, which is difficult to correct with antianemic drugs and fractional blood transfusions.

It is very difficult to determine the volumetric blood loss rate. Even knowing the duration of bleeding and the total volume of blood flowed out, only the average volumetric velocity can be calculated, while bleeding is almost never uniform throughout 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 substitution therapy.

A very important factor that determines the compensatory capabilities of the body in acute blood loss is the initial state of the body. Prolonged fasting, including in connection with 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 disease; burns; deep anesthesia; long-term use of hormonal and vasoactive drugs; extensive sympathetic blockade with epidural anesthesia is not 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 definition 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 measuring the BCC and its components.

THE INFLUENCE OF BLOOD LOSS ON THE BODY

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

Sympathoadrenal stimulation accompanying acute hypovolemia is aimed at maintaining the required level of blood circulation in the vital organs, which are the brain and heart. As a result of this stimulation, adrenaline and other mediators of the sympathetic nervous system enter the general bloodstream, their vasoconstrictor effect is mediated in areas rich in alpha-adrenergic receptors. In this case, the hemodynamic reaction manifests itself already in the first minutes of blood loss by a reduction in the capacitive section of the venous system (mainly the portal circulation system), which 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 (2-3 times), entering this initial stage into the bloodstream, contributes to the necessary increase in cardiac output (MRV) due to both moderate tachycardia (up to 90-100 beats / mi) and regional dilatation of the arterial vessels of the brain, heart and lungs, which somewhat reduces the total value of peripheral vascular resistance (OPS) ... 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 hypovolism, and also if the volume of blood loss exceeds 15-20% of the BCC, the venomotor compensation mechanism is insufficient, blood flow to the heart decreases, which leads to more pronounced sympathoadrenal stimulation and the implementation of mechanisms aimed at delaying fluid 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 absorption processes under the influence of aldosterone and antidiuretic hormone, which are released simultaneously with catecholamines. The capacity of the vascular bed decreases due to the 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. The result is a "centralization" of blood circulation. In this case, the local regulation of blood flow, providing regional functioning and metabolism, is replaced by a general one aimed at maintaining the required level of metabolism in the organs that determine the preservation of life. Vascular active substances, acting on the myogenic elements of peripheral vessels, increase the resistance to blood flow at the level of arterioles and precapillary sphincters, which is accompanied by an increase in OPS and, 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 dilation) and maintenance of the required blood pressure. An increase in resistance at the inlet to the capillaries leads to a decrease in the hydrostatic transcapillary pressure and the emergence of another compensatory mechanism - a hydraemic reaction, i.e., an excessive flow of fluid from the interstitial space into the capillary network. Gydremic compensation of 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 the 3rd - 6th hour and then it is set on average at the level of 30-40 ml / h) and not can provide the necessary correction of the BCC in case of rapid blood loss.

The positive effects of centralization of blood circulation can be completely leveled in the subsequent 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 normal or even somewhat elevated level only due to tachycardia, OPS increases sharply, but the type of hemodynamics becomes eukinetic and thereby creates the illusion of relative well-being, supported by the stability of systolic blood pressure. Meanwhile, mean arterial and diastolic pressure increases 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, with the generalization of the process becomes pathological and contributes to the emergence of irreversibility. In other words, compensation in the macrocirculation system is achieved through decompensation in the microcirculation system.

With an increase in the volume of blood loss up to 30-50% of the BCC, a prolonged 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, naturally, in 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, a decrease in CVP is an early initial sign of decompensation, which is ahead of BP indicators. In general, a reversible shock is characterized by a decrease in all indicators of central hemodynamics, with the exception of the minute ejection, which remains at a normal or subnormal level due to critical tachycardia (140-160 / min). This is how reversible shock differs from irreversible shock. In the initial stage of shock, the OPS is still increased, and then rapidly decreases.

Irreversible shock is a continuation of reversible and a consequence of uncorrected 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 drop in all hemodynamic parameters (Fig. 1).

Disturbances of microcirculation in acute blood loss are secondary and occur if the 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 constituent elements and proteins are lost in acute blood loss in proportion to the amount 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 hemoglobin level of blood and hematocrit, the number of erythrocytes and the content of total protein begin to decrease only with a rapid loss of 40-50% of the BCC or more. At the same time, there is a clear dynamics of such changes in the post-hemorrhagic period (Fig. 4): the maximum decrease 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 available 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, that is, the volume of blood lost during trauma, external bleeding, surgery, postoperative period,

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

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, linen, the rate of blood flow into the wound is based on the surgeon's experience and knowledge of the main average values \u200b\u200bof 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 blood hypo- or hyperchromia. In the first case, due to the lower intensity of blood staining of the surgical material and the wound (especially with hemoglobin less than 60 g / l), the actual blood loss is always greater than the expected one and not underestimation is a danger in anemic patients. In the second case, the amount of blood loss is overestimated, which may lead to an unjustified prescription of blood transfusion.

Weighing the patient before and after the operation on a special table-scales allows 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, wound, and during breathing. However, it is difficult to take into account the “pure” blood loss, as well as the overall fluid balance, if the operation is prolonged and if multicomponent infusion therapy is performed, solutions are used for irrigation and washing of wounds and cavities.

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

All varieties of the 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 recording 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 pouring out of the cavities (peritoneal, pleural) and cystic formations... In addition, with the same total mass of blood, the loss of its liquid part and formed elements is different in different patients. Finally, blood on non-standard surgical clothes (sheets, gowns, etc.) dries up rather quickly and is taken into account, as a rule, only by a rough visual estimate.

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

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

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

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

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

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

Determination of blood loss during small operations by counting the number of erythrocytes 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 discharged into one basin containing 1 liter of saline 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.

Determination of blood loss by measuring changes in the electrical conductivity of a dielectric solution (distilled water) when a certain amount of blood enters it is based on the constancy of its electrolyte composition. Diagram of a device that automatically determines the amount of blood loss. Since distilled water does not conduct an electric current, when the electrical circuit is closed in the initial position, the galvanometer needle (graduated in ml of blood loss) will remain in the zero position. If an operating material moistened with blood (electrolyte) gets into the tank, it 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 of the method is its vulnerability in the event of an electrolyte imbalance, which is quite realistic in conditions of massive blood loss and centralization of blood circulation. This reality also arises during the infusion therapy of blood loss, unthinkable without the use of electrolyte solutions. Despite the fact that the author has provided for appropriate amendments for electrolytes introduced from the outside, the device has not entered mass production.

Tables of average blood loss enable the physician to tentatively determine the amount of possible blood loss during typical operations without complications. For atypical or complicated operations, this technique is unacceptable due to the large percentage of error. At the same time, the indicators presented in the tables, not only the average losses, but also the possible (observed) maximum limits of their fluctuations allow the novice surgeon to tune in to a more realistic attitude to blood loss during "standard" operations.

Among the indirect methods, one should not forget an approximate assessment of the amount of blood loss by determining the size of the wound by placing a hand on it ("palm rule"). 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 makes it possible, both at the scene of the incident, at the prehospital stage, and upon admission of the victim to the hospital, to determine the program of first aid and subsequent therapy.

CLINIC AND DIAGNOSTICS OF BLOOD LOSS

Bleeding in surgical practice is a common occurrence, and if blood is poured out, diagnosis and treatment tactics are not difficult. Due to the ability to quickly stop bleeding, the risk of developing hemorrhagic shock arises only when 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 obvious only when "sudden" signs of hypovolemia appear (severe weakness, dizziness, ringing in the ears, flashing flies in front of the eyes, unmotivated fainting, difficulty breathing , pallor, sweating, cooling of the distal extremities). However, it should be borne in mind that such symptoms are a consequence of pronounced compensation of blood loss, the volume of which by this time can reach 30-50% of the BCC, since 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 GN Tsibulyak, 1976), which develops with a significant deficiency of the 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 advisable.

In the initial, adaptive (adaptive) stage, clinical manifestations are scarce - only a slight increase in pulse and respiration is detected, the minute cardiac output, decreases, without going beyond the normal range, OPS, that is, in the aggregate, a hyperkinetic type of blood circulation develops on the part of the central hemodynamics. Most often, such changes are not recorded or are explained by stress, that is, in fact, at this stage the person is still healthy, and if the BCC deficiency does not increase, all deviations spontaneously normalize, and physiological equilibrium sets in. Such dynamics is typical for blood loss not exceeding 5-15% of the BCC. With greater blood loss or insufficient physiological adaptation (patients with concomitant circulatory and respiratory pathologies, elderly patients, children under 3 years of age, etc.), disorders of homeostatic functions arise, "including" 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 the centralization of blood circulation are quite characteristic. Systolic blood pressure (SD) is within the normal range or slightly increased (by 10-30 mm Hg); diastolic (DD) and average (SD) are increased, and the degree of this increase correlates with the degree of vasoconstriction. Stroke volume (SV) is naturally reduced. At the same time, the MSV is maintained at the level of the previous stage, which is ensured by increasing tachycardia. The peripheral venous pressure is increased, while the central one remains within the normal range. Peripheral circulation is impaired. As a result, the skin and visible mucous membranes turn pale (a sign, first of all, of vascular spasm, not anemia), the symptom “ white spot»Becomes positive (after pressing on the skin in the area of \u200b\u200bthe back of the hand, the bleeding spot disappears slowly, longer than 10 s), the temperature of the skin decreases - it is cold to the touch, dry. The difference between the temperature in the axillary and rectal region increases to 2-3 ° C. Capillaroscopically reveals the initial elements of intravascular aggregation and an increase in the number of "plasma" capillaries that do not contain erythrocytes. Indicators of red blood do not go beyond normal fluctuations. There are tendencies to hypercoagulability, moderate hypoalbuminism, compensated metabolic acidosis. Diuresis decreases to 20-30 ml / h (0.3-0.5 ml per minute). Despite the deficiency of the BCC, superficial veins can be successfully punctured. Consciousness remains, however, the patient has anxiety, anxiety, sometimes - excitement, rapid breathing; moderate thirst.

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

The compensatory-adaptive mechanisms are biologically determined by the volumes of blood loss that are not life-threatening. Therefore, with an acute deficit of the BCC of more than 30-50%, they turn out to be untenable, which is accompanied by inappropriate prolonged and, as a result, pathological centralization or decompensation of blood circulation. Decompensation with blood loss is usually called hemorrhagic shock.

Diagnosis of hemorrhagic shock in the presence of an established fact of bleeding is not particularly difficult. The main clinical manifestation arterial hypotension serves this condition. 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, a drop in diabetes mellitus and DD is noted. MSV is at the lower limit of the norm and tends to decrease further. Tachycardia increases to the limit values \u200b\u200b(140-160 / min). Venous pressure (both CVP and PVP) is steadily decreasing and can reach 0. DD, SDP and OPS are falling evenly, which is a reflection of initial signs vascular collapse. The orthostatic instability of blood pressure increases - patients become very sensitive to changes in body position. The hypokineticity of 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 aggregation of cells 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. The body temperature decreases even more (temperature gradient is more than 3 ° C); against the background of pallor, acrocyanosis appears. Dull heart sounds; systolic murmur is often heard. ECG - signs diffuse changes and myocardial ischemia. Shortness of breath becomes constant, the respiratory rate reaches 40-50 per minute; the appearance of periodic respiration of the Kussmaul type (respiration of a "driven animal") is possible. The symptoms of "shock" lung are determined. Oliguria is replaced by anuria. Intestinal peristalsis, as a rule, is absent (a drop in the electrokinetic potential of pacemaker membranes). With fulminant blood loss, blood concentration indices do not change or decrease slightly; with a longer duration, and especially in combination with infusion therapy, they decrease, but rarely reach critical figures (1/3 of the norm). In connection with liver dysfunctions, toxins and "medium molecules" accumulate in the blood, hypoproteinemia and protein imbalance increase. Metabolic acidosis becomes uncompensated, combined with respiratory acidosis. The symptoms of DIC syndrome are growing and are determined by laboratory and clinical symptoms.

"Irreversible" shock differs from "reversible" only in the depth of impairment, the duration of decompensation (more than 12 hours) and the progression of multiple organ failure. Central hemodynamic indices are not determined. There is no consciousness. Possible tonic-clonic generalized convulsions, hypoxic cardiac arrest.

A significantly more difficult diagnostic problem is blood loss without signs of external bleeding (for example, with closed injury breast and abdomen, ectopic pregnancy, duodenal ulcer, etc.). V.D.Bratus writes about this quite emotionally (1989):

“... Whenever, a short time after a sudden abundant bloody vomiting, a patient is brought to the emergency room of the surgical department, whose pale face is covered with cold sticky sweat, shiny eyes with dilated pupils look attentively and pleadingly at the doctor, in the latter, first of all, and tormenting questions constantly arise: what is the nature of the profuse bleeding that has arisen? What was the immediate cause of its occurrence? Is the bleeding still continuing, and if it stopped, then what is the real threat of its renewal? ... "

Indeed, the emergence of the classical triad of hypovolemia (arterial hypotension, frequent and low pulse, cold wet skin) indicates hemorrhagic shock, when quick and vigorous action is required.

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

GENERAL PRINCIPLES OF ACUTE BLOOD LOSS THERAPY

Therapy for acute blood loss is based on 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 the bleeding;

Determination of the stage of compensation of blood loss;

Final hemostasis and elimination of the BCC deficiency;

Stabilization of central hemodynamics;

Diagnostics and correction of the consequences of hypovolemia;

Monitoring the effectiveness of therapy.

The diagnosis should be made as soon as possible, but treatment 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 treatment tactics. If it starts at the first, subclinical, stage, the effect is usually positive, it is possible to avoid the development of overcompensation and major complications. In the early stage of the centralization of blood circulation, when the process has not yet reached its culminating generalization, the main efforts should be directed 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 uncontrollable collapse can develop. At this stage, rheological hemocorrectors are used, hemodilution is appropriate, correction of organ disorders, DIC syndrome is necessary. The stages of hemorrhagic shock require multicomponent replacement therapy using modern methods of intensive therapy and resuscitation.

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

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

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 steadily eliminate hypovolsmia. This is dictated by the fact that hypoxia even with fatal blood loss develops due to circulatory rather than hemic insufficiency. In addition, whole donor blood (even fresh) has such a "set" of drawbacks that transfusion of large amounts of it causes serious, purely fatal complications. The choice of blood substitutes and their combination with blood are 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) in combination with crystalloids (Ringer's solution, lactasol, quartasol) in a ratio of 1: 2 are shown ...

At 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 ICS 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 decreases 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 in the first place is also the appointment of colloidal and crystalloid solutions in a 1: 1 ratio. The most effective colloids are rheopolyglucin, albumin. Due to the relatively lower antishock activity, plasma can only be an addition to the infusion after hemodynamic stabilization at a safe level. One should not get carried away with the infusion 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, of peripheral circulation. Otherwise, the red blood cells will not be able to fulfill their primary function of carrying oxygen and the infusion will be useless at best.

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

It is inappropriate to use glucose solutions to replenish the BCC with blood loss. The latter quickly moves into the intracellular sector, without significantly increasing the BCC. At the same time, a negative role is played by the cellular hyperhydration developing due to the introduction of large amounts of glucose.

Correction of the BCC deficiency is carried out mainly by intravenous infusion. 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 at the same time, including central veins. Puncture and catheterization of one of the central veins is a prerequisite for effective (and controlled) treatment of acute blood loss.

Replacement of moderate blood loss (including the operating room) can be achieved by infusion into one vein if the lumen of the needle or catheter is about 2 mm. This diameter allows, if necessary, injecting a crystalloid solution into a vein 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"

From time immemorial, blood has attracted the attention of an observant person. Life was identified with her, and the development of medicine and the triumphant 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 differing in the relative constancy of its composition, performs the most important diverse functions that ensure the normal vital activity of the organism.

BLOOD TRANSFUSION METHODS

The main and most widely used method is indirect blood transfusion into peripheral or central veins. For transfusion, canned whole blood, erythrocyte mass or washed erythrocytes are used, depending on the infusion program. This program is drawn up 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 allows you to achieve different rates of transfusion (drip, jet) and is not inferior in efficiency to other methods (intra-arterial, intraosseous), 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 they are not available, “reusable” systems made 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 the arterial trunks. At the same time, with a shallow drop in vascular tone positive effect can be achieved with the help of vasopressors, and in the case of total decompensation of blood circulation, intra-arterial injection is ineffective or gives only a short-term effect.

Intraosseous 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 direct blood transfusion from a donor to a recipient without stabilization or conservation. So can only be given intravenously whole blood... This method does not provide for the use of filters during transfusion, which significantly increases the risk of small blood clots in 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.

Direct blood transfusion is now considered a compulsory therapeutic measure... It is carried out only in an extreme situation - with the development of sudden massive blood loss, in the absence of large quantities of erythrocytes, fresh frozen plasma, cryoprecipitate in the doctor's arsenal. Instead of direct blood transfusion, freshly prepared "warm" blood can be transfused.

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

Exchange transfusion is understood to mean "complete" or partial removal of blood from the bloodstream, replacing it with the same or slightly more donated 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 the BCC. The purpose of such a transfusion is to remove toxic substances circulating in the blood from the blood. For partial replacement, use 2-6 liters of blood.

For exchange transfusion, you can use blood with a shelf life of no more than 5 days, but freshly prepared blood is preferable. Moreover, you must carefully follow all the rules for preventing incompatibility.

Exchange blood transfusions are carried out in two ways - continuous and intermittent. In the first case, bloodletting and blood transfusion are performed simultaneously, making sure that the amount of blood injected corresponds to the amount of blood removed. 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 injected with a slight excess. The number of bloodletings and the volume of exfused blood depend on the patient's condition 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 permissible. With a 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 consistency between the volumes of blood withdrawn and injected (50-75 ml / min). A higher rate of it can cause the phenomena of citrate shock. If polyglucin is used, 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 infused into any vein by venipuncture or venesection.

Autohemotransfusion is one of the promising methods of infusion therapy, which consists in the transfusion of a 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 their 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 are not so pronounced in freshly preserved autologous blood and, most importantly, can be destroyed in the bloodstream if blood is taken and returned to the patient immediately or during the first six hours.

Autohemotransfusion is indicated for patients with a rare blood group, if it is impossible to select 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 poettransfusion complications during transfusion of donor blood and erythrocytes. Recently, autohemotransfusion has become more widely used in operations with relatively low volume of blood loss in order to reduce the thrombogenic hazard resulting from hemodilution arising 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, unfortunately, this method is rarely used in clinical practice. This is explained, firstly, by the fact that the preliminary blood sampling from the patient and its stabilization must be carried out under strictly aseptic conditions (in the blood transfusion department, operating room, in a clean dressing room) by personnel who are not engaged in servicing surgical patients, which is not always possible. (Ideally, autohemotransfusion should be carried out by a special team or in a hospital department of blood transfusion.) Secondly, the limiting point in relation to the use of autohemotransfusion is that only a small volume of blood (250-400 ml) can be exfused at a time and the patient can be operated 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).

In practical medicine, more preference is given to the so-called iitraoperative hemodilution method. It consists in one-step blood sampling from the patient in the operating room immediately before the surgical intervention. 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 the infusion of blood substitutes (lactasol, Ringer's solution), blood is taken (up to 800-1200 ml) into standard vials with preservative or heparin (1000 IU per 500 ml of blood), replacing it with one and a half or two times the volume of Ringer's solution with rheopolyglucin or 10% albumin solution in a ratio of 3-4: 1. The return of autologous blood begins from the moment of the final surgical hemostasis. Infusion rate is dictated by hemodynamic parameters. All blood should be returned to the patient within the first postoperative day. Correctly applied technique causes moderate hemodilution, which favorably affects the peripheral circulation; reducing the absolute loss of cellular elements and blood proteins; as a rule, normalization of hemostasis parameters; significantly better than with transfusion of the same volumes of donor blood, the course of the postoperative period; eliminates the need for any serological studies and tests for compatibility, as well as additional infusions of canned donor blood.

For intraoperative hemodilution, a doctor and a nurse who are familiar with this technique are specially allocated (if the staff is not trained, it is better to use donor blood!). When performing this technique, sterile blood collection systems, vials with hemo-preservative, heparin, accessories for puncture of a peripheral vein or venesection are required.

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

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

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

In elective surgery, it is necessary to reconsider the attitude to the problem of irreversible blood loss as a fatal inevitability - with many surgical operationsaccompanied 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 for operations on the organs of the chest, on the spine, osteoplastic operations in the orthopedic clinic.

In the postoperative period, it is possible to reinfuse the blood released on the first day through the drains (subsequently, for such reinfusion, the discharge from the drain 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 drawn.

The simplest and least traumatic for blood cells is a method consisting in 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 bottles with a capacity of 250 and 500 ml, containing respectively 50 and 100 ml of one of the standard hemo-preservatives or 500 and 1000 U 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 the collection and filtration of blood, 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 taking blood deep in the wound and directly from the operating field. It is carried out using aspiration systems. However, this method is used much less frequently than the first, because blood from the operating 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 slightly more injured when taken.

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 hypocoagulation stage of the DIC syndrome.

Reinfusion of blood is contraindicated if the period of its presence in the cavity exceeds 24 hours, or hemolysis of erythrocytes is detected, or blood is 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 bacteria per se, but blood altered as a result of microbial contamination. This is confirmed by reports of good outcomes during reinfusion of blood infected with intestinal contents with life-threatening blood loss. Therefore, without in any way ignoring contraindications, it should be remembered that they can become relative if reinfusion is the only possible measure of help for life-threatening blood loss.

In the postoperative period, reinfusion is usually indicated in chest surgery, when bleeding through the drains can be quite significant and usually requires hemocorrection, and donor blood transfusion is undesirable. The peculiarity of reinfusion in such cases is as follows. Blood, accumulating in the pleural cavity, is defibrinated and does not clot, 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 washing them in physiological sodium chloride solution.

Complications and reactions of blood transfusion

Complications during 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, a deviation from the rules is a violation of the order of arrangement of standard sera or erythrocytes in racks and their application to a plate, an incorrect ratio of the amount of serum and erythrocytes, failure to observe the time required for the reaction (5 min), failure to conduct a control reaction with the group serum ABo (IV), fouling or the use of wet pipettes, plates, sticks, use of poor quality standards, for example, serum with an expired (insufficiently active) or contaminated or partially dried serum that can cause a nonspecific agglutination reaction, etc. These deviations and 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 determining the blood group 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 weak agglutinability of the erythrocytes of the patient's blood (in the presence of these two reasons, agglutination may not appear at all at the same time, for example, inactive serum of the Bα group (111) does not agglutinate with erythrocytes group Aβ (II), if the agglutinability 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 whose agglutinating ability checked and meets the requirements of the instructions);

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

c) at a high temperature (above 25 ° C) of the ambient air, for example, in hot weather (to avoid this error, the reaction should be performed on a chilled plate).

2. The person who determines the blood group believes that agglutination has occurred, while it is actually absent. This error can occur if:

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

b) the tested erythrocytes give the phenomenon of auto- or panagglutination (in order to avoid this error, it is impossible to allow the determination of blood groups at temperatures below 15 ° C and it is imperative to use standard serum of the ABo (V) group;

c) a poor-quality serum is used, giving nonspecific agglutination (to avoid this error, it is necessary to tightly seal open ampoules with serum with cotton wool or adhesive plaster, however, in this case, you cannot use a serum that is cloudy or with signs of drying out);

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; to avoid this error, you need to periodically shake the plate on which the determination is made);

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; 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 drawn about the blood group if the order of the standards in the stand or plate is confused.

In all cases of an unclear or doubtful result, it is necessary to re-determine the blood group using standard sera of other series, as well as in a cross-over manner.

Errors in determining the Rh factor can be caused by:

a) the use of anti-rhesus serum without taking into account the group belonging of the blood (in order to avoid this error, the rhesus belonging should always be determined only after determining the blood system group A VO);

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

c) a change in the temperature regime (in laboratory studies by the method of conglutination or agglutination in a saline medium, the temperature should be in the range 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 (when dry) assessment of the result.

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

Air embolism may occur if the transfusion system is not properly filled, and especially if the pumping method is used. This formidable complication develops due to the ingress of air through the bloodstream into the right heart and then into the lungs. It manifests itself as sudden shortness of breath, anxiety, rapidly increasing facial cyanosis and acrocyanosis, tachycardia and heart rhythm disturbances, a sharp decrease in blood pressure (due to acute hypoxic coronary 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 transfusion of blood and its components, it is strictly forbidden to use any pressure equipment, and should be transfused only with disposable plastic systems. Already only if there is a suspicion of an air embolism, it is necessary to immediately begin cardiopulmonary resuscitation (chest compressions, mechanical ventilation using 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 the infusion of rheopolyglucin or lactasol should be started). The choice of further measures depends on the effect of the 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 dropper filter 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, embolization and thrombosis of small branches of the pulmonary artery most often occurs 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; usually the body temperature 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 hyper-kapnia.

In case of violation of the permeability of the vessel wall or damage to it, bleeding begins. In this case, blood can flow out of a vessel or into the body, or out through wounds on the skin or natural openings: nose, mouth, vagina, anus. The classification of bleeding is rather complicated and is divided depending on the time and causes of its occurrence, the type of damaged vessel, the rate of development, the volume of lost blood, and the severity.

Causes

There are two main causes of bleeding: as a result of trauma and due to internal pathological processes, that is, they are traumatic and atraumatic (or pathological).

Traumatic

They arise as a result of exposure to traumatic factors that exceed the characteristics of vascular strength. In this case, mechanical damage to the vascular wall occurs. This is the most common reason bleeding.

Atraumatic

Can start without any provoking factor. Occur in the following cases:

• in case of pathological processes occurring in the body: ulceration, necrosis, destruction of the vascular wall, for example, with the decay of a tumor, inflammation, peritonitis and others;
• with increased permeability of the vessel wall at the microscopic level, which can happen with diseases such as hemorrhagic vasculitis, vitamin C deficiency, scarlet fever, uremia, sepsis and others.

The bleeding process depends to a large extent on the state of the coagulation system. By themselves, disturbances in her work cannot be the cause of bleeding, but they significantly worsen the situation. If a small vessel is damaged with a normally functioning hemostasis system, significant blood loss does not occur and the blood quickly stops. If, for example, the process of thrombus formation is disturbed in the body, then even a minor injury can result in death from blood loss. An example of a disease in which the hemostasis process is impaired is hemophilia.

Classifications

IN medical practice accepted several classifications of bleeding for different reasons.

Anatomical

Bleeding in this case is divided by the type of damaged vessel:

1. Capillary. They occur when small veins, arteries, capillaries are damaged. Usually not massive, bleeding, as a rule, is the entire damaged surface (in the form of a mesh).
2. Venous. They are characterized by a continuous stream of dark blood. The speed depends on the diameter of the vein: the larger it is, the faster it flows out. Bleeding from the cervical veins is the most dangerous because there is a possibility of developing an air embolism.
3. Arterial. The rate is often high; the amount of blood lost depends on the diameter of the vessel and the type of injury. Scarlet blood flows out under pressure, usually in a pulsating stream.
4. Parenchymal... Occur when damage to organs such as the liver, lungs, kidneys, spleen, which are called parenchymal. These bleeding is capillary, but due to the anatomical features of these organs, they are dangerous.
5. Mixed. In this case, all types of vessels bleed simultaneously.

By the time of occurrence

According to this classification, there are two types: primary and secondary bleeding:

• Primary - begin immediately after damage to the vessel.
• Secondary - occur some time after the injury. They are divided into two more types: early (within three days from the moment of injury, after pushing a thrombus out of the damaged vessel) and late (three days after injury, usually due to the development of purulent inflammatory processes).

In relation to the external environment

According to this classification, bleeding is divided into several types:

• External - blood flows from an ulcer or wound located on the surface of the body, so they are easily diagnosed.
• Internal - arise in organs, their cavities, tissues. They are divided into strip (blood is poured into the articular, pleural, abdominal, pericardial cavities) and interstitial (blood is poured into the tissue and forms hematomas). Accumulations of blood that have poured into a cavity or tissue are called hemorrhages in medicine. There are several types: petechiae, ecchymosis, bruising, hematoma, vibitses.
• Hidden - do not have pronounced signs, according to some classifications they are internal.

By flow type

There are two types:

• Acute - blood flows out within a short time.
• Chronic - characterized by the duration of bleeding, while there is a gradual release of blood in small portions. The duration of bleeding is typical for diseases such as hemorrhoids, stomach ulcers, malignant tumors, uterine fibroma and others.

By severity

There are several classifications on this basis. Most often, four degrees of severity are distinguished:

• Mild - blood loss ranges from 10 to 12%, or from 500 to 700 ml.
• Medium - from 16 to 20%, or up to 1400 ml.
• Severe - from 20 to 30%, or from 1500 to 2000 ml.
• Massive - blood loss over 30%, or more than 2000 ml.

This classification of bleeding is very important. Assessment of the severity helps to determine the nature of the circulatory disorder and the risk of blood loss for a person. Knowing the severity is necessary in order to correctly prescribe treatment and choose the tactics of blood transfusion.

Severe bleeding can be fatal, and usually death in this case is due to acute cardiovascular failure. Sometimes the cause of death can be the loss of its functions by the blood (transfer of gases, nutrients, metabolic products).

The outcome of bleeding is determined by the rate and volume of blood loss. A loss of more than 40% is considered incompatible with life. In chronic processes, a person can lose blood no less and have a low level of red blood cells, but at the same time live and work. When assessing the severity, consider:

• general state patient (initial anemia, shock, cardiovascular failure, exhaustion of the body);
• his gender;
• age.

In case of bleeding, the wound must be treated with an antiseptic and a pressure bandage applied; an unwound bandage can be used as a tampon

Help with bleeding

Violation of the integrity of tissues and blood vessels is not uncommon, so everyone should know what to do when bleeding. Correctly rendered first aid can save a person's life.

Capillary

This slight bleeding usually stops on its own quickly. In some cases, a bandage is required. Before bandaging, the wound must be treated with an antiseptic solution.

Venous

This bleeding differs in that the dark blood flows in a stream. If possible, the victim is placed in such a way that the damaged area is above the level of the heart.

For moderate bleeding, tamponing and a tight bandage will suffice. A rolled up bandage can be used as a tampon.

With severe bleeding, a tourniquet is required below the injury site. If the blood stops, then the help was provided correctly.

With arterial bleeding, immediate blood arrest is required, which is usually done by pressing the damaged vessel against the nearest bone so that its lumen is completely closed

Arterial

Differs in scarlet blood gushing with a fountain. If medium-sized vessels are damaged, then tight bandaging may be sufficient. If a large artery is damaged, a tourniquet will be required, after which the patient must be taken to the hospital for treatment as soon as possible. Before that, you need to do the following:

1. Lay the victim so that the wound is higher than the heart.
2. To stop the blood before applying the tourniquet, press the damaged artery with your finger.
3. Now you need to apply a tourniquet above the wound site. It can be replaced with any suitable item at hand: belt, towel, rope, etc.
4. The tourniquet cannot be kept for more than an hour and a half. Therefore, if a person could not be delivered to a medical facility during this time, you need to press the artery with your finger, remove the tourniquet for five minutes, and then apply it again, but slightly higher than the last time.

The tourniquet cannot be applied for more than an hour and a half, so it is imperative to attach a note in which to indicate the time of its application

Internal

It is difficult to independently recognize such bleeding, but if there is a suspicion of it, then the following must be done:

1. The victim should take a half-sitting or lying position, while placing a pillow under his feet.
2. If bleeding in the stomach is suspected, a person should not drink or eat, you can only rinse your mouth with cool water.
3. Cold should be applied to the site of the alleged bleeding. This can be, for example, a bottle of water, under which you need to place a piece of cloth.

Blood arrest methods

Stopping blood is spontaneous and artificial. The second, in turn, is divided into temporary and final. Before the victim is taken to a medical facility for treatment, the following methods of temporary stopping are used:

1. The easiest and most affordable way is tamponade and dressing... It is effective for bleeding from veins, capillaries and small arteries. Using a tampon and a pressure bandage, the lumen of the vessel is reduced, which leads to the formation of a blood clot.
2. Pressing the vessel with your finger necessary when immediate arrest of blood from the artery is needed. The vessel is pressed against the nearby bones above the wound, in case of damage to the cervical arteries - below the wound. To perform this technique, you need to make an effort so that the lumen of the artery is completely closed. Carotid artery pressed against the tubercle of the transverse process of the sixth cervical vertebra, the subclavian - to the first rib at a point above the clavicle, the femur - to the pubic bone, the humerus - to humerus (its inner surface), axillary - to the head of the humerus in the armpit.
3. The most reliable way is to apply a tourniquet. Due to its simplicity and availability, it is widely used. Despite some drawbacks, it fully justifies itself when providing first aid for injured limbs. If applied correctly, bleeding will stop immediately. When working with a tourniquet, certain rules must be followed in order to avoid the negative consequences of squeezing a limb. It must be remembered that it should be applied only to the lining and for no more than 1.5 hours, and in winter no more than an hour. It should be clearly visible, so a piece of bandage is tied to it. Be sure to attach a note in which to write the time of the application of the tourniquet.
4. Another well-known and quite effective method is limb flexion... You need to bend it all the way to the joint (knee, elbow, hip), which is located above the wound, and then fix it with bandaging.

For the final stop of the blood, the patient is taken to the hospital, where he will be treated further. The final methods include the following:

• suturing;
• tamponade if it is impossible to suture the vessel;
• embolization - the introduction of an air bubble into the vessel and its fixation at the site of injury;
• local administration of hemocoagulants (substances for blood clotting of artificial or natural origin).

Conclusion

Bleeding can be life-threatening, so you need to learn to distinguish between their types and be able to properly provide first aid, on which a person's life can depend. Even a temporary stopping of blood before the patient is taken to hospital for treatment can be decisive.