EMERGENCY AID IN ACCIDENTS

Shock is a serious condition that results from exposure to extreme factors, and leads to a rapid progressive reduction in tissue perfusion and therefore failure of all organs. Shock inhibits cardiovascular, respiratory and renal functions and hampers microcirculation and metabolism. Depending on the causative agent shock is classified astraumatic, hypovolaemic, cardiogenic and septic.

Traumatic shock is the commonest and results from severe injuries. It is often associated with intractable bleeding, severe pain and intoxication due to absorption of products of decay from ischaemic tissues. Bleeding plays an dramatic role in traumatic shock. It is not only the amount of blood lost but also the rate of bleeding which is of significance. In gradual blood loss a 20-30% reduction in circulating blood volume does not lead to a marked fall in blood pressure. On the contrary, in rapid bleeding the decreased circulating blood volume by 30% can be fatal. Thus reduced circulating blood volume (hypovolaemia) and microcirculatory deficiency are the mainstays in pathogenesis of traumatic shock.

Shock evolves two stages: erective and torpid.

Erective phase is very short and follows immediately the exposure to trauma, which causes increased sympathetic nervous activity: pallor of the skin, tachycardia, hypertension, and agitation.

The torpid phase is characterised by semicon-sciousness or even confusion, hypotension and thready pulse. The torpid phase is divided into four degrees.

• Degree 1. The patient is conscious and able toanswer the physician's questions but is a bit confused. Systolic blood pressure falls to as low as 90 mm Hg with mild tachycardia. The skin is pale and tremor is sometimes evident. On pressing the nail bed blood flow is restores rather slowly.

• Degree 2. The patient is confused. The skin is cool and pale, with diaphoresis. Cyanosis of the nail beds is pronounced, on pressing the nail bed blood flow restores very slowly. Systolic blood pressure falls below 90 mm Hg, pulse is weak and rapid (110-120 beats per minute). Central venous pressure is reduced. Breathing is shallow.

• Degree 3. The patient's condition is critical: he/ she is semiconscious, drowsy and can hardly answer the physician's questions, and does not react to pain. The skin is cold and bluish-pale.

Pulse is as fast as 130-140 beats per minute. Breathing is shallow, fast or sometimes rare. Systolic blood pressure is as low as 50-70 mm Hg. Central venous pressure falls to zero or even becomes negative. Urine production ceases.

• Degree 4. The patient is in a preagonal state: the skin and mucus membranes are bluish-pale, breathing is shallow and fast, pulse is rapid and very weak, systolic blood pressure falls to as low as 50 mm Hg.

First aid to the patient in shock before admittance to hospital includes the following:

1) bleeding control;

2) clearing the airway and ensuring adequate pulmonary ventilation;

3) pain relief;

4) transfusion therapy;

5) immobilization of fracture sites;

6) appropriate transportation.

Severe traumatic shock usually results in inadequate pulmonary ventilation due to aspiration of vomitus, blood or a foreign body. In such cases the first thing to do is to turn the patient's head aside and clean the mouth. Then the head is tilted backwards and the lower jaw pulled forward. An airway or an S- tube can then be used.

External bleeding requires immediate control with a tourniquet, tight bandaging, pressing on the bleeding vessel or the application of the vascular clamps on the bleeding vessel in the wound.

In intractable internal bleeding, the patient must be hospitalised immediately for surgery.

Bleeding control and transfusion therapy should be performed simultaneously. Dextran solutions (polyglucin, reopolyglucin), partially splited gelatine (gelatinol) are usually preferred for nutritional support. Similarly, crystalloids (Ringer's solution, normal saline, lactasol) or 5% glucose can be used. If intravenous fluids that increase the circulating blood volume are unavailable, the patient should be placed in the Trendelenburg's position, i.e. the one with the table tilted head down, the patient being prevented from slipping off by shoulder, or preferably pelvic, supports, and by having the legs hang over the end of the table).

Before transportation analgesia should be provided and splint applied. The analgesics that can be used include morphine, omnopon, promedol, lexyl, and droperidol. It is noteworthy that morphine, omnopon and promedol can suppress respiration, thus they must be used cautiously, especially in patients with chest injuries and the elderly. Lexyl or droperidol is a better choice in such cases. A mask connected to the anaesthetic machine can also be used to provide analgesia. Nitrous oxide and oxygen in the ratio of 1: 1 or 2: 1 are mostly used.

In traumatic shock non-narcotic analgesics (e.g. 4-5 ml 50% analgin) can also be effective. Equally, such tranquilizers as 1-2 ml 0, 5% seduxen (Biazepam) in doses of 1-2 ml of 0, 5% solution may also be acceptable. As diminished peripheral circulation impedes absorption of drugs, in shock they should be given intravenously.

Immobilization of injured limbs with splint should be provided as early. Correct transportation of the injured patient is of great importance. Improper transportation augments pain reaction, which, in turn, worsens shock. A conscious patient is put supine on the stretcher to be transported, while an unconscious one should be placed on his/her side carefully monitored to prevent airway obstruction (e.g. the tongue from falling back, vomitus or blood from entering the airway). In nasal or oral cavity injury resulting in bleeding before transportation have the patient lie prone, with his/her head turned aside. When the tongue obstructs trachea, an airway must be used.

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