Bleeding and acute blood loss. Blood loss: types, definition, acceptable values, hemorrhagic shock and its stages, therapy. Symptoms and diagnosis of acute blood loss

The average amount of blood in the body of an adult is 6-8% of the total mass, or 65-80 ml of blood per 1 kg of body weight, and in the body of a child - 8-9%. That is, the average blood volume in an adult man is 5000-6000 ml. Violation of the total blood volume in the direction of decrease is called hypovolemia, an increase in blood volume compared to the norm is called hypervolemia

Acute blood loss develops when a large vessel is damaged, when there is a very rapid drop in blood pressure to almost zero. This condition is noted with a complete transverse rupture of the aorta, superior or inferior veins, and pulmonary trunk. The volume of blood loss is insignificant (250-300 ml), but due to a sharp, almost instantaneous drop in blood pressure, anoxia of the brain and myocardium develops, which leads to death. The morphological picture consists of signs of acute death, an insignificant amount of blood in the body cavities, damage to a large vessel and a specific feature - Minakov's spots. With acute blood loss, exsanguination of internal organs is not observed. With massive blood loss, a relatively slow outflow of blood from damaged vessels occurs. In this case, the body loses about 50-60% of the available blood. Within a few tens of minutes, a gradual drop in blood pressure occurs. At the same time, the morphological picture is quite specific. "Marble" skin, pale, limited, insular cadaveric spots that appear later than in other types of acute death. Internal organs are pale, dull, dry. A large amount of poured blood in the form of bundles (up to 1500-2500 ml) is found in the body cavities or at the scene of the incident. With internal bleeding, large enough blood volumes are required to soak the soft tissue around the lesions.

The clinical picture of blood loss does not always correspond to the amount of blood lost. With a slow flow of blood, the clinical picture may be blurry, and some symptoms may be absent altogether. The severity of the condition is determined primarily on the basis of the clinical picture. With very large blood loss, and especially with rapid blood flow, compensatory mechanisms may be insufficient or not have time to turn on. In this case, hemodynamics progressively deteriorate as a result of a vicious circle. Blood loss reduces oxygen transport, which leads to a decrease in oxygen consumption by tissues and the accumulation of oxygen debt, as a result of oxygen starvation of the central nervous system, the contractile function of the myocardium is weakened, the IOC decreases, which, in turn, further impairs oxygen transport. If this vicious circle is not broken, then the increasing disturbances lead to death. Increase sensitivity to blood loss, overwork, hypothermia or overheating, the season (in the hot season, blood loss is worse tolerated), trauma, shock, ionizing radiation, concomitant diseases. Age and gender matter: women are more resistant to blood loss than men; newborns, infants and the elderly are very sensitive to blood loss.

Blood loss is a deficiency in the volume of circulating blood. There are only two types of blood loss - latent and massive. Latent blood loss is a deficiency of erythrocytes and hemoglobin, the deficiency of plasma is compensated by the body as a result of the phenomenon of hemodilution. Massive blood loss is a shortage of circulating blood volume, leading to dysfunction of the cardiovascular system. The terms "latent and massive blood loss" are not clinical (referring to the patient), they are academic (physiology and pathophysiology of blood circulation) educational terms. Clinical terms: (diagnosis) posthemorrhagic iron deficiency anemia corresponds to latent blood loss and the diagnosis hemorrhagic shock - massive blood loss... As a result of chronic latent blood loss, you can lose up to 70% of red blood cells and hemoglobin and save life. As a result of acute massive blood loss, you can die, losing only 10% (0.5 l) of the BCC. 20% (1L) often leads to death. 30% (1.5 L) of the BCC is absolutely fatal blood loss, if not compensated. Massive blood loss is any blood loss in excess of 5% of the blood volume. The volume of blood taken from a donor is the boundary between latent and massive blood loss, that is, between that to which the body does not respond, and that which can cause collapse and shock.

Low blood loss (less than 0.5 l) 0.5-10% BCC. Such blood loss is tolerated by a healthy body without consequences and the manifestation of any clinical symptoms. There is no hypovolemia, blood pressure is not reduced, pulse is within normal limits, slight fatigue, skin is warm and moist, has a normal shade, clear consciousness.
Medium (0.5-1.0 L) 11-20% BCC. Mild hypovolemia, blood pressure reduced by 10%, moderate tachycardia, pallor of the skin, coldness of the extremities, the pulse is slightly increased, breathing is rapid without disturbing the rhythm, nausea, dizziness, dry mouth, possible fainting, twitching of individual muscles, severe weakness, weakness, slow reaction to others.
Large (1.0-2.0 L) 21-40% BCC. Average severity of hypovolemia, blood pressure reduced to 100-90 mm Hg. Art., severe tachycardia up to 120 beats / min, breathing is very rapid (tachypnea
Massive (2.0-3.5 L) 41-70% BCC. Severe hypovolemia, blood pressure reduced to 60 mm Hg, sharp tachycardia up to 140-160 beats / min, threadlike pulse up to 150 beats / min, it is not palpable on peripheral vessels, on the main arteries it is determined much longer, the patient's absolute indifference to the environment environment, delirium, consciousness is absent or confused, a sharp deathly pallor, sometimes a bluish-gray skin tone, "goose bumps", cold sweat, anuria, Cheyne-Stokes type breathing, convulsions may occur, the face is sunken, its features are pointed, sunken dull eyes , a blank look.
Fatal (more than 3.5 liters) more than 70% of the BCC. Such blood loss is fatal for a person. Terminal state (pre-agony or agony), coma, blood pressure below 60 mm Hg. Art., may not be detected at all, bradycardia from 2 to 10 beats / min, agonal breathing, superficial, barely noticeable, skin dry, cold, characteristic "marbling" of the skin, disappearance of pulse, convulsions, involuntary discharge of urine and feces, dilated pupils , further agony and death develop.

4 question basic requirements when performing blood transfusion

The main task in the treatment of hemorrhagic shock is to eliminate hypovolemia and improve microcirculation. From the first stages of treatment, it is necessary to establish a jet transfusion of fluids (saline, 5% glucose solution) to prevent reflex cardiac arrest - empty heart syndrome.

Immediate stopping of bleeding is possible only when the source of bleeding is available without anesthesia and everything that accompanies a more or less extensive operation. In most cases, patients with hemorrhagic shock have to be prepared for surgery by injecting various plasma-substituting solutions and even blood transfusions into the vein and continue this treatment during and after surgery and stopping bleeding.

Infusion therapy aimed at eliminating hypovolemia is carried out under the control of central venous pressure, blood pressure, cardiac output, total peripheral vascular resistance and hourly urine output. For replacement therapy in the treatment of blood loss, combinations of plasma substitutes and canned blood preparations are used, based on the volume of blood loss.

For the correction of hypovolemia, blood substitutes of hemodynamic action are widely used: dextran preparations (rheopolyglucin

Polyglyukin), gelatin solutions (gelatinol), hydroxyethyl starch (refortan

In general, all pathological changes that develop in acute blood loss should be considered as compensatory and adaptive. Their essence can be expressed in one sentence. The body, responding to blood loss, mobilizes all organs and systems to ensure its vital functions in these conditions.

The main starting point in the chain of pathogenetic shifts observed in bleeding is a decrease in the BCC (hypovolemia). Acute hypovolemia is a powerful stress on the body. It is she who launches neurovegetative and endocrine reactions, the result of which are changes in the main life support systems of the body (central hemodynamics, microcirculation, external respiration, morphological composition of blood, systems for ensuring general and tissue metabolism, general nonspecific reactivity of the body and immunogenesis).

To understand the processes occurring in the body, one should recall the components of the BCC and the normal distribution of blood in the body.

80% of the blood is in the vascular bed, 20% in the parchymal organs. The venous vessels contain 70-80% of the circulating blood, 15-20% in the arteries and only 5-7.5% in the capillaries. 40-45% of the BCC are formed elements, 55-60% plasma.

In response to a decrease in the BCC, compensatory reactions are activated, aimed at its immediate restoration, and only after this, the mechanisms that correct the quality of blood are triggered. Compensatory mechanisms are included in all functional systems of the body. At the beginning, the tone of the sympathetic system increases, the secretion of catecholamines increases. As a result, changes occur in the circulatory system.

Circulatory system. In response to blood loss in the circulatory system, the following mechanisms are triggered.

A decrease in the BCC leads to a decrease in blood pressure. As a result of irritation of the baro-, chemo-, volumoreceptors of the heart and large vessels, vascular reflex reactions develop. At the same time, the sympatho-adrenal system is stimulated. As a result, the following processes develop.

1. Venospasm.

Venous spasm develops initially. Veins have a well-developed motor mechanism, which makes it possible to quickly adapt the capacity of the venous system to the changed blood volume. As indicated, the veins contain 70-80% BCC. Due to venous spasm, venous return to the heart remains the same, CVP is within normal limits. However, if blood loss continues and reaches 10%, this compensatory mechanism no longer ensures the preservation of the value of venous return and it decreases.

2. Tachycardia.

A decrease in venous return leads to a decrease in cardiac output. Compensation for these shifts is carried out by increasing the heart rate. During this period, an increase in tachycardia is characteristic. Therefore, the minute volume of the heart remains at the same level for a long time. A decrease in venous return to 25-30% is no longer compensated by an increase in heart rate. Low output syndrome (decreased cardiac output) develops. To maintain adequate blood flow, the next compensation mechanism begins to work - peripheral vasoconstriction.

3. Peripheral vasoconstriction.

Due to peripheral arteriolospasm, the pressure is maintained above the critical level. First of all, the arterioles of the skin, abdominal cavity and kidneys are narrowed. Cerebral and coronary arteries are not exposed to vasoconstriction. The phenomenon is developing - the centralization of blood circulation ”. Peripheral vasoconstriction

This is a transitional stage from compensatory reactions to pathological ones.

4. Centralization of blood circulation.

Due to the centralization of blood circulation in the brain, lungs and heart, adequate blood flow is provided to support the vital functions of these organs.

In addition to the reaction of the vascular bed, other compensatory mechanisms are also triggered.

5. Inflow of tissue fluid.

A consequence of the compensatory restructuring of hemodynamics is a decrease in the hydrostatic pressure in the capillaries. This leads to the transition of the intercellular fluid into the vascular bed. Thanks to this mechanism, the BCC can increase up to 10-15%. The influx of fluid leads to hemodelution. The developing hemodelution improves the rheological properties of blood and promotes the leaching of red blood cells from the depot, increasing the number of circulating red blood cells and the oxygen capacity of the blood.

b.Oligouria.

One of the reactions to developing hypovolemia is fluid retention in the body. In the kidneys, water reabsorption and retention of sodium and chloride ions increase. Oliguria develops.

Thus, all compensatory reactions are aimed at eliminating the discrepancy between the volume of circulating blood and the capacity of the vascular bed.

Other systems also take part in compensatory reactions.

Respiratory system. In response to blood loss, the body responds by developing hyperventilation, which increases venous return to the heart. Inhalation increases the filling of the right ventricle and pulmonary vessels. Pulsus paradoxus can be detected, reflecting changes in hemodynamics depending on respiratory movements.

The blood system. The mechanisms of erythropoiesis are included. New erythrocytes, including insufficiently mature erythrocytes, enter the bloodstream. The coagulation system responds with hypercoagulation.

The ongoing bleeding cannot be indefinitely compensated for by the adaptive reactions of the organism. The increasing blood loss leads to the progression of hypovolemia, a decrease in cardiac output, a violation of the rheological properties of blood, and its sequestration. A vicious hypovolemic circle is formed.

Decentralization of blood circulation.

The centralization of blood circulation leads to a decrease in blood flow in many organs (liver, kidneys, etc.). As a result, acidosis develops in the tissues, which leads to the expansion of the capillaries and the sequestration of blood in them. Sequestration leads to a decrease in the BCC by

10% or more, which leads to the loss of effective BCC and uncontrolled hypotension.

Violation of the rheological properties of blood.

Disturbances of microcirculation in tissues are accompanied by local hemoconcentration, blood stasis, intravascular aggregation of corpuscles ("sludge" of corpuscles). These disorders lead to blockage of capillaries, which enhances blood sequestration.

Metabolic disorders.

Pathological changes in hemodynamics, microcirculation and rheological properties of blood lead to impaired perfusion and tissue hypoxia. The exchange in tissues becomes anaerobic. Metabolic acidosis develops, which in turn aggravates microcirculation disorders and organ function. Changes affect all organs and systems, Multiple organ failure develops.

Hemorrhagic shock

Massive blood loss in the later stages leads to the development of hemorrhagic shock. Hemorrhagic shock is multiple organ failure resulting from non-compensated or untimely compensated blood loss. It is customary to distinguish three stages of hemorrhagic shock:

Stage 1 - compensated reversible shock

Stage 2 - decompensated reversible shock

Stage 3 - irreversible shock.

Compensated shock - the volume of blood loss is compensated by changes in cardiovascular activity of a functional nature.

Uncompensated shock - deep circulatory disorders are noted, reactions of the cardiovascular system of a functional nature cannot maintain central hemodynamics and blood pressure, decentralization of blood flow develops.

Irreversible hemorrhagic shock - deeper circulatory disorders are noted, which are irreversible, multiple organ failure is aggravated.

CHAPTER 11 INFECTIOUS COMPLICATIONS OF COMBAT SURGICAL INJURIES

CHAPTER 20 COMBAT CHEST INJURY. TORACOABDOMINAL INJURIES

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

Combating 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. Kolomnin during 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 World War II 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 wounds caused by damage to blood vessels.

In case of damage to the main vessel bleeding threatens the life of the wounded, and therefore is designated as life-threatening consequence of injury... After intense or prolonged bleeding develops blood loss, which pathogenetically represents typical pathological process , and clinically - injury or trauma sequelae 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 circulating blood volume (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 the damaged vessel, as well as the time and place of bleeding. By the type of the damaged vessel, arterial, venous, mixed (arterio-venous) and capillary (parenchymal) bleeding are distinguished. Arterial bleeding have the appearance of a pulsating stream of scarlet blood. Profuse bleeding from the main artery leads to death within a few minutes.

Rice. 7.1 Classification 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 bleeding 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 very significant, although venous bleeding is more often less life-threatening. In most cases, gunshot wounds to blood vessels damage both arteries and veins, causing mixed bleeding. Capillary bleeding occur with any injury, but are dangerous only in case of violations 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 bleeding occur when blood vessels are damaged. Secondary bleeding develop 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 outdoor and internal(intracavitary and interstitial) bleeding. Internal bleeding is much more difficult to diagnose and more severe in its pathophysiological consequences than external bleeding, even if we are talking about 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 of traumatic etiology in the pericardial cavity or under the lining of the brain cause severe disabilities (cardiac tamponade, intracranial hematomas) that threaten death. Tense 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. Violation of the 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 sharply increases due to central impulses and the release of adrenal hormones - adrenaline and norepinephrine - into the bloodstream. Due to this 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 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 organs.

Arterial hypotension and widespread peripheral vasospasm during rapid control of bleeding and early infusion-transfusion therapy (ITT) are usually treatable. However, long periods of massive exsanguination (over 1.5-2 hours) are inevitably accompanied by deep disturbances of 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 shifts 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, given 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 to 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, and a 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 are distinguished, 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 loss 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 moderate blood loss 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 loss BCC deficiency - 40-60% (2000-3000 ml). Grade III shock develops clinically with a fall in systolic blood pressure to 70 mm Hg. and below, 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 the production of urine (oliguria turns into anuria). Extremely severe blood loss accompanies 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. Lips and subungual beds are gray.

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

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

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" - the concentration of hemoglobin, the value of hematocrit; the number of red blood cells. The most rapidly determined indicator is the relative density of blood.

Methods for Determining the Relative Blood Density 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, 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 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 becoming the cause of 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 the salvation of injured 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 wounded is 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) replenishment of blood loss are distinguished.

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

Table 7.2. The 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 of up to 20% 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 using blood components and plasma substitutes in a 1: 2 ratio 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 using 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 difficulties are presented by 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 prevent the empty heart from stopping. 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 long-term exsanguination, then in response to the 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 fewer side effects ( ringer lactate, lactasol, 0.9% sodium chloride solution, 5% glucose solution, mafusol). Colloidal plasma substitutes ( polyglucin, macrodex and 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, infukol and etc.). Rheologically active colloidal plasma substitutes ( reopo-liglukin, reogluman) in the initial phase of replenishing blood loss, it is impractical and even dangerous to use. With the introduction of these plasma substitutes to the 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. An effective remedy for eliminating hemostasis disorders (hypocoagulation) with bleeding is fresh frozen plasma which contains at least 70% of coagulation factors and their inhibitors. However, defrosting and preparation for direct transfusion of fresh frozen plasma requires 30-45 minutes, which should be taken into account if it is necessary to use it urgently. Noteworthy is the promising low volume hypertonic infusion concept, intended for the initial stage of replenishing blood loss. Concentrated (7.5%) sodium chloride solution, jet infused into a vein at the rate of 4 ml / kg of body weight of the wounded (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 in the stages of medical evacuation.

Blood transfusion and 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 life since their erythrocytes, immediately after transfusion, begin to perform their main function - the transportation of 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 of a deficiency of the corresponding blood function in the wounded, 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 permanent hemostasis achieved by surgery. Ideally, replenishment of blood loss by blood transfusion should begin as early as possible and generally be completed 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 that has 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 carrying 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 the 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 normal temperatures (hemoglobin preparations) with no danger of transmission of infections 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 integuments, disappearance of cyanosis and sticky sweat, 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, adopted for supply (standard) g emotransfusion agents and 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 field medical institutions, there is a special transfusiological 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. The research department - the center of blood and tissues at the 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 war proceeds 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 HPGLR. At the same time, for the procurement of 100 liters of canned blood, 250-300 donors will be needed with the amount of blood donated 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 procurement of canned blood, including the production of components from 50% of the harvested blood.

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

SEC of military districts with 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 transfusion large hospitals (VG central subordination, OVG). In the garrison VG and medb are organized non-standard blood collection and transfusion points (NPZPK), whose duties include the procurement of 3-5 l / day of canned blood.

Back in the years of the Great Patriotic War, the so-called two-stage blood collection system for the wounded ... The essence of this system consists in dividing the long and complex process of blood preservation into 2 stages.

1st stage includes industrial production of special sterile utensils (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 - is performed at blood collection points. The two-stage method allows for mass harvesting of blood in the field. It provides 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 for medical institutions of the military district.

Organization of blood supply in modern local wars

depends on the scale of hostilities, the characteristics of the theater of military operations and the state's capabilities for material support of the 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 (Vietnam War 1964-1973, Afghanistan and Iraq 2001 - up to now). During the hostilities of the USSR in Afghanistan (1979-1989), less costly 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) 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 supplying 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 Rhesus 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 "dubious" blood;

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

Canned 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 a fatal bacterial-toxic shock. The "doubtful" category includes blood, which does not acquire sufficient transparency even 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, the correct certification, the permissible shelf life, the 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 incompatible blood transfusion 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 - 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 person is transferred to the mechanical ventilation mode. In the future, exchange transfusions of blood may be required, and with the development of anuria, hemodialysis.

Blood loss I Blood loss

a pathological process caused by damage to blood vessels and loss of part of the blood and characterized by a number of pathological and adaptive reactions.

At K. there is a spasm of interlobular arteries and afferent arterioles of the glomeruli of the kidneys. When blood pressure drops to 60-50 mmHg st... renal decreases by 30%, decreases, at 40 mmHg st... and below it ceases altogether. Slowdown of renal blood flow and impaired filtration are observed for several days after the transferred K. If a large blood loss was replaced incompletely or with a delay, there is a risk of developing acute renal failure . Hepatic blood flow as a result of K. decreases in parallel with the fall in cardiac output.

Hypoxia at K. is mainly of character; the degree of its severity depends on hemodynamic disturbances (see.Circulation) . In severe K., due to a strong decrease in IOC, the delivery and consumption of oxygen by tissues decreases, and a severe one develops, in which c.ns. primarily suffers. tissues leads to the accumulation in the body of under-oxidized metabolic products and to acidosis, which in the initial stages of K. is compensated. With deepening K., an uncompensated metabolic develops with a decrease in pH in venous blood to 7.0-7.05, in arterial blood - to 7.17-7.20 and a decrease in alkaline reserves. In the terminal stage To. Acidosis of venous blood is combined with arterial alkalosis (see.Alkalosis) .

Coagulation of blood in K. is accelerated, despite a decrease in the number of platelets and the content of fibrinogen. Simultaneously activated. At the same time, changes in the components of the coagulation system are of great importance: their aggregation, consumption of prothrombin, thrombin, the content of coagulation factor VIII, and the content of antihemophilic globulin decrease. Tissue thromboplastin enters with the interstitial fluid, and the antiheparin factor from the destroyed erythrocytes (see Blood coagulation (Blood coagulation system)) . Changes in the hemostatic system persist for several days, when the total blood clotting time has already returned to normal.

The clinical picture of K. does not always correspond to the amount of lost blood. Young people have a loss of 500 ml, even 1000 ml blood does not cause significant hemodynamic changes. In donors, for example, only a transient increase in heart rate is observed, rarely. It is possible to roughly classify the severity of K. by reducing the BCC. Moderate degree K. - loss of less than 30% of the circulating blood volume, massive - more than 30%, fatal - more than 50%, absolutely fatal - more than 60%, if emergency care is not provided by resuscitators. In conditions of rapid development, K., for example, when the main vessels are injured, can occur with a much smaller volume of blood that has poured out. Increase to K., hypothermia or, trauma, ionizing, concomitant diseases. Age also matters: women are more hardy to K. than men; very sensitive to K. newborns, infants and the elderly. The severity of the condition is determined primarily on the basis of the clinical picture. With a very large K., and especially with a rapid flow of blood, compensatory mechanisms may be insufficient or do not have time to turn on. In this case, hemodynamics progressively deteriorate as a result of a vicious circle. K. reduces the transport of oxygen, which leads to a decrease in oxygen consumption by tissues and the accumulation of oxygen debt, as a result of oxygen starvation of the central scientific center. the contractile function of the myocardium is weakened, the IOC falls, which, in turn, further impairs the transport of oxygen. If this one is not severed, then the increasing disturbances lead to death.

With insufficient compensatory mechanisms and with a prolonged decrease in blood pressure, acute K. goes into an irreversible state (shock), which lasts for hours. In severe cases, K. may appear Thrombohemorrhagic syndrome , due to the combination of slowed blood flow in the capillaries with an increased content of procoagulants in the blood. An irreversible state as a result of prolonged K. in many respects differs from acute K. and approaches the terminal stage of shock of another origin (see.Traumatic shock) .

In all who have undergone K., acute posthemorrhagic is noted. It is more pronounced with significant K., insufficient treatment. Its first signs - a decrease in the amount of hemoglobin and an increase in the breakdown of erythrocytes (both their own and those introduced during blood transfusion) - appears after 24 h after K. and lasts for 5-7 days.

For significant K., pale, moist with a grayish tinge, pale mucous membranes, sunken, sunken eyes, frequent weak, decreased arterial and, more frequent, in severe cases periodic - of the Cheyne-Stokes type are characteristic. Weakness, darkening of the eyes, dry mouth, severe, nausea, darkening or loss of consciousness are noted. With a slow loss of blood, even significant K. can proceed with vaguely expressed both objective and subjective symptoms.

Treatment for K. begins in parallel or immediately after carrying out measures aimed at stopping bleeding. A means to eliminate hypoxia is the transfusion of a compatible erythrocyte mass in combination with blood substitutes. In severe K., one should begin (before the selection of the erythrocyte mass) with the infusion of blood substitutes. In all cases, red blood cell transfusion is necessary when the hemoglobin content falls below 80 g / l and a hematocrit number less than 30. In acute K., treatment begins with a jet infusion of blood substitutes or erythrocyte mass and after an increase in blood pressure above 80 mmHg st... and improving the patient's condition switch to drip injection of erythrocyte mass. With increased bleeding and hypotension, which cannot be corrected by conventional methods, direct from the donor is shown, which gives a more pronounced effect even with a smaller infusion volume. With prolonged hypotension, it is often ineffective, it is supplemented with drugs that normalize impaired neuroendocrine regulation, microcirculation and (cardiovascular drugs, vitamins, antihypoxants, etc.). The introduction of heparin and fibrinolysin (in severe cases and with late treatment started) prevents the appearance of thrombohemorrhagic syndrome.

The dose of infusion solutions administered depends on the patient's condition. Approximate norms of the ratio of the volumes of erythrocyte mass and blood substitutes, depending on the severity, are practically accepted: with a loss of up to 1.5 l blood is injected only or blood substitutes, with a loss of up to 2.5-3.0 l blood - erythrocyte mass and blood substitutes in accordance with 1: 1, over 3 l - respectively 3: 1.

The prognosis depends on the general condition of the patient, the amount of blood lost and, especially, on the time of initiation of treatment. With early and vigorous treatment, even very severe K., accompanied by loss of consciousness, severe respiratory rhythm disorder, extremely low blood pressure ends in complete recovery. Restoration of vital functions is possible even with the onset of clinical death (see Terminal conditions) . The later the treatment is started, the worse. The prognosis worsens, but does not become hopeless if the heart rhythm is disturbed. With the timely start of treatment, the sinus rhythm is restored. After the restoration of hemodynamics, the indicators of acid-base balance are normalized. A poor prognostic sign is the change of acidosis by alkalosis on the second day after replacement of severe blood loss. K., even of moderate severity, but treated with a delay, can go into an irreversible state, especially if it develops. A sign of successful treatment is the disappearance of generalized vasospasm (warming and pinking of the skin, absence of sweating, normalization of systolic and especially diastolic pressure).

Bibliography: Agranenko V.A. and Skachilova N.N. Hemotransfusion reactions and complications, M., 1986; Wagner E.A. and others. Infusion-transfusion acute blood loss, M., 1986; Gorbashko A.I. and treatment of blood loss, L., 1982; Klimayskiy V.A. and Rudaev Ya.A. Transfusion therapy for surgical diseases, M., 1984; Kochetygov N.I. with blood loss and shock, L., 1984; Transfusiology manual, ed. OK. Gavrilova, M., 1980.

II Blood loss

loss of blood by the body as a result of bleeding or bloodletting.

Decompensated blood loss- significant K., leading to a sharp decrease in the volume of circulating blood and acute hypoxia of the brain.

1. Small medical encyclopedia. - M .: Medical encyclopedia. 1991-96 2. First aid. - M .: Great Russian Encyclopedia. 1994 3. Encyclopedic Dictionary of Medical Terms. - M .: Soviet encyclopedia. - 1982-1984.

See what "Blood loss" is in other dictionaries:

Blood loss ... Spelling dictionary-reference

The state of the body that occurs after bleeding, characterized by the development of a number of adaptive and pathological reactions. Blood loss is classified: by type: traumatic (wound, operating), pathological (in case of a disease, ... ... Emergency Dictionary

A pathological process that develops as a result of bleeding and is characterized by a complex of pathological and adaptive reactions to a decrease in circulating blood volume (BCC) and hypoxia caused by a decrease in blood oxygen transport. ... ... Wikipedia

Loss of blood by the body as a result of bleeding or bloodletting ... Comprehensive Medical Dictionary

blood loss- blood loss, and ... Russian spelling dictionary

blood loss- blood loss / rya, and ... Together. Apart. Hyphened.

blood loss- shelter / about / on / ter / i ... Morphemic-spelling dictionary

Significant K., leading to a sharp decrease in the volume of circulating blood and acute hypoxia of the brain ... Comprehensive Medical Dictionary

I Childbirth Childbirth (partus) is a physiological process of expulsion from the uterus of the fetus, amniotic fluid and placenta (placenta, membranes, umbilical cord) after the fetus reaches viability. Viable Fetus, as a rule, becomes after 28 weeks. ... ... Medical encyclopedia

Syndrome that occurs with severe trauma; characterized by a critical decrease in blood flow in tissues (hypoperfusion) and is accompanied by clinically pronounced circulatory and respiratory disorders. Pathogenesis. The leading pathophysiological mechanism ... ... Medical encyclopedia

Etiology and pathogenesis... Acute blood loss can be primarily of traumatic origin when more or less large-caliber vessels are injured. It may also depend on the destruction of the vessel by one or another pathological process: rupture of the tube during an ectopic pregnancy, bleeding from a stomach or duodenal ulcer, from varicose veins of the lower esophagus with atrophic cirrhosis of the liver, from varicose veins of hemorrhoidal veins. Pulmonary bleeding in a patient with tuberculosis, intestinal bleeding with typhoid fever can also be very profuse and sudden and cause more or less anemia.

Even a simple enumeration of blood loss, different in its etiology, suggests that the clinical picture, course, and therapy will be different depending on the general condition of the patient before the onset of bleeding: a healthy person who was injured, a woman who was previously healthy after a tube ruptured in an ectopic pregnancy , a patient with a stomach ulcer, who did not know about his illness before, will react in the same way in case of sudden gastric bleeding. Otherwise, patients with cirrhosis, typhoid fever or tuberculosis will suffer blood loss. The underlying disease determines the background, on which the further course of anemia largely depends.

Acute blood loss of up to 0.5 liters in a healthy, not old average weight person causes short-term, mild symptoms: slight weakness, dizziness. The day-to-day experience of blood transfusion institutions - donating blood by donors - confirms this observation. The loss of 700 ml of blood or more causes more pronounced symptoms. It is believed that blood loss in excess of 50-65% of blood, or more than 4-4.5% of body weight, is certainly fatal.

In acute blood loss, death occurs with less blood flowing out. In any case, the acute loss of more than a third of the blood causes fainting, collapse and even death.

The speed of blood flow matters. The loss of even 2 liters of blood, occurring within 24 hours, is still compatible with life (according to Ferrata).

The degree of anemization, the speed of restoration of the normal blood composition depend not only on the amount of blood loss, but also on the nature of the injury and the presence or absence of infection. In cases of the addition of anaerobic infection in the wounded, the most pronounced and persistent anemia is observed, since increased hemolysis due to anaerobic infection is added to the anemia from blood loss. These wounded have a particularly high reticulocytosis, yellowness of the integument.

Observations during the war over the course of acute anemia in the wounded refined our knowledge about the pathogenesis of the main symptoms of acute anemia and about the compensatory mechanisms developing in this case.

Bleeding from a damaged vessel stops as a result of the convergence of the edges of the injured vessel due to its reflex contraction, due to the formation of a blood clot in the affected area. NI Pirogov drew attention to important factors contributing to stopping bleeding: the "pressure" of blood in the artery decreases, blood filling and blood pressure in the wounded vessel, the direction of the blood stream changes. Blood is directed along other, "roundabout" routes.

As a result of the depletion of blood plasma in proteins and a drop in the number of cellular elements, the viscosity of the blood decreases, and its turnover is accelerated. Due to the decrease in the amount of blood, the arteries and veins contract. The permeability of the vascular membranes increases, which enhances the flow of fluid from the tissues into the vessels. Added to this is the flow of blood from blood depots (liver, spleen, etc.). All of these mechanisms improve blood circulation and oxygen supply to tissues.

In acute anemia, the mass of circulating blood decreases. There comes a depletion of blood erythrocytes, oxygen carriers. Minute blood volume decreases. Oxygen starvation of the body occurs as a result of a decrease in the oxygen capacity of the blood and often acutely developing circulatory failure.

The serious condition and death in acute bleeding mainly depend not on the loss of a large number of oxygen carriers - erythrocytes, but on the weakening of blood circulation due to the depletion of the vascular system with blood. Oxygen starvation in acute blood loss is of the hematogenous-circulatory type.

One of the factors that compensate for the consequences of anemia is also an increase in the coefficient of oxygen utilization by tissues.

VV Pashutin and his students were also involved in the study of gas exchange in acute anemia. MF Kandaratskiy already in his dissertation of 1888 showed that at high degrees of anemia gas exchange does not change.

According to MF Kandaratsky, 27% of the total amount of blood is sufficient for the minimum manifestation of life. The normal amount of blood allows the body to meet the need for maximum work.

As IR Petrov has shown, with large blood loss, cells of the cerebral cortex and cerebellum are especially sensitive to the lack of oxygen. Oxygen starvation explains the initial excitation and later inhibition of the function of the cerebral hemispheres.

In the development of the entire clinical picture of anemia and compensatory-adaptive reactions of the body, the nervous system is of great importance.

Even NI Pirogov drew attention to the influence of emotional excitement on the strength of bleeding: "Fear, which leads to bleeding in the wounded, also prevents blood from stopping and often serves to return it." From this, Pirogov concluded and pointed out that "the doctor must first of all morally calm the patient down."

In the clinic we had to observe a patient whose regeneration was inhibited after a nervous shock.

Bone marrow is activated under the influence of blood loss. With large blood loss, the yellow bone marrow of the tubular bones temporarily turns into an active one - red. The foci of erythropoiesis sharply increase in it. Puncture of the bone marrow reveals large accumulations of erythroblasts. The number of erythroblasts in the bone marrow reaches enormous sizes. Erythropoiesis in it often predominates over leukopoiesis.

In some cases, the regeneration of blood after blood loss can be delayed due to a number of reasons, of which it is necessary to isolate malnutrition.

Pathological anatomy... In the section with early death of the patient, we find pallor of organs, low filling of the heart and blood vessels with blood. The spleen is small. The heart muscle is pale (cloudy swelling, fatty infiltration). Minor hemorrhages under the endocardium and epicardium.

Symptoms... With acute massive blood loss, the patient becomes as pale as a sheet, as with a fatal fright. Irreversible muscle weakness sets in. In severe cases, complete or partial loss of consciousness occurs, shortness of breath with deep breathing, muscle twitching, nausea, vomiting, yawning (brain anemia), and sometimes hiccups. Cold sweat usually comes out. The pulse is fast, barely perceptible, the blood pressure is sharply lowered. There is a complete clinical picture of shock.

If the patient recovers from shock, if he does not die from profuse blood loss, then, having regained consciousness, he complains of thirst. He drinks if they give him a drink, and again falls into oblivion. The general condition gradually improves, the pulse appears, the blood pressure rises.

The life of the body, its blood circulation are possible only with a certain amount of fluid in the bloodstream. Following the loss of blood, the blood reservoirs (spleen, skin and other erythrocyte depots) are immediately emptied, fluid from the tissues, lymph, enters the blood. Hence the main symptom is clear - thirst.

Temperature after acute bleeding usually does not rise. Small increases for 1-2 days are sometimes observed after bleeding into the gastrointestinal tract (for example, with bleeding from a stomach ulcer and duodenal ulcer). Temperature rises to higher numbers occur with hemorrhage in muscles and serous cavities (pleura, peritoneum).

The pallor of the integument depends on a decrease in the amount of blood - oligemia - and on the contraction of the skin vessels, which occurs reflexively and reduces the capacity of the bloodstream. It is clear that at the first moment after blood loss, blood of more or less the same composition will flow along a reduced channel, oligemia is observed in the literal sense of the word. In the study of blood during this period, the number of erythrocytes, hemoglobin and the usual color indicator typical for the patient before blood loss is found. These indicators can be even greater than before blood loss: on the one hand, with the indicated decrease in the bloodstream, the blood can thicken, on the other, blood richer in formed elements enters the vessels from the released blood matter. In addition, as indicated above, when the vessels contract, more plasma is squeezed out of them than the formed elements (the latter occupy the central part of the "blood cylinder").

Anemia stimulates the functions of the hematopoietic organs, so the bone marrow begins to produce red blood cells with more energy and throw them into the blood. In this regard, in the subsequent period, the composition of erythrocytes changes. With increased production and ejection into the blood of erythrocytes inferior in terms of saturation with hemoglobin, the latter are paler than normal (oligochromia), of various sizes (anisocytosis) and various forms (poikilocytosis). The size of erythrocytes after bleeding increases slightly (shift of the Price-Jones curve to the right). In the peripheral blood, younger red blood cells appear that have not yet completely lost their basophilia, polychromatophiles. The percentage of reticulocytes rises significantly. As a rule, polychromatophilia and an increase in the number of reticulocytes develop in parallel, being an expression of enhanced regeneration and increased influx of young erythrocytes into the peripheral blood. The resistance of erythrocytes to hypotonic solutions of sodium chloride first decreases for a short time, and then increases due to the release of younger elements into the peripheral blood. Erythroblasts may appear. The color indicator decreases during this period.

The rate of restoration of the normal blood composition depends on the amount of lost blood, on whether the bleeding continues or not, on the patient's age, on the state of his health to blood loss, on the main suffering that caused the blood loss, and, most importantly, on the timeliness and expediency of therapy.

The normal number of red blood cells is restored most quickly. The amount of hemoglobin increases more slowly. The color indicator gradually returns to normal.

After a large blood loss in a previously healthy person, the normal number of red blood cells is restored in 30-40 days, hemoglobin - in 40-55 days.

In case of anemia from blood loss, especially after wounds, it is important to set the time elapsed after the injury and blood loss. So, according to Yu. I. Dymshits, 1-2 days after a penetrating wound of the chest, accompanied by hemorrhage into the pleural cavity, in 2/3 of cases less than 3.5 million erythrocytes per 1 mm3 are determined. Anemia is hypochromic: in 2/3 of cases, the color indicator is less than 0.7. But after 6 days, the number of erythrocytes below 3.5 million in 1 mm3 is observed in less than 1/6 of cases (in 13 out of 69 examined).

Following the bleeding that has occurred, moderate neutrophilic leukocytosis (12,000-15,000 leukocytes per mm3) usually occurs, and the number of platelets increases and blood clotting increases within 10 minutes).

The percentage of reticulocytes in the bone marrow significantly increases. Forsel believed that the degree of reticulocytosis is the most subtle indicator of the regenerative capacity of the bone marrow.

Treatment... With acute onset of anemia, therapeutic intervention should be urgent. The body suffers from a lack of blood and fluid that must be replenished immediately. It is clear that the most effective remedy when blood loss is significant is blood transfusion.

Blood transfusion is achieved by replenishing the body's lost fluid and nutrient material, irritating the bone marrow, enhancing its functions, hemostatic action, and introducing full-fledged erythrocytes and fibrin enzyme. Usually 200-250 ml of blood or more massive doses are transfused. With continued bleeding, the dose of re-transfused blood is reduced to 150-200 ml.

In the conditions of a combat injury in shock with blood loss, 500 ml of blood is injected. If necessary, this dose is increased to 1-1.5 liters. Before blood transfusion, all measures are taken to stop bleeding.

In case of bleeding, transfusion of fresh and preserved blood gives the same result. If necessary, it facilitates further surgery (for stomach ulcers, ectopic pregnancy). Blood transfusion is indicated for bleeding from a typhoid ulcer and is contraindicated if the bleeding is due to a ruptured aortic aneurysm. In case of bleeding from the lungs in patients with tuberculosis, blood transfusion does not give clear results and is usually not used. To stop bleeding, blood plasma infusion into a vein is successfully used.

According to L. G. Bogomolova, it is possible to use dry plasma obtained by drying at a low temperature and dissolved before infusion in distilled sterile water.

Applied physiological solution of sodium chloride (0.9%) and various mixtures of salt solutions are not blood substitutes. Significantly better results are obtained when saline mixtures are injected into the vein, to which are added colloids related to the given organism.

The introduction of blood-substituting fluids and blood into the vein must be done slowly. The required infusion rate is 400 ml for 15 minutes with a healthy heart and healthy vascular system. In case of circulatory disorders, it is necessary to apply the drip method of administration. Failure to follow these rules can be a source of unwanted infusion reactions and complications.

In later periods, the main method of treatment is the use of iron. Arsenic is a good help.

In addition, bed rest, good nutrition with a sufficient content of vitamins, in particular vitamin C, is necessary.

Methods of stopping bleeding, which were used in the past by Russian folk medicine, are of interest. It was recommended to drink juice of raw carrots and radishes when