ADDITIONAL CIRCULATION AND HBO IN COMPLEX REANIMATION AT TRAUMATIC SHOCK.

Practical recommendations.

Despite the most contemporaneous therapy lethality from traumatic shock is too large.

The progress can be achieved only in complex treating using, in particular, additional extracorporal circulation. It reduced violations of circulation and respiration improves metabolism.

A 15-years experience is gathered in Voronezh Medical Institution in treating of traumatic shock by means of additional circulation (AC).

Here is a brief systematization of it for practical use.

Treating of traumatic shock before clinical deposition.

A success of treating shock (III-IV degree) is probable, especially when begun in early stage; only the special anti-shock and reanimatologist groups of emergency medical service. These are to be equipped with special facilities including corresponding specialists; medicines; respiratory machine; defibrillator; special pumps; etc.

The primary should be support and normalization of respiration by means of transfusions to prevent lowering of pressure below 80 mm.

Catheterisation and puncture of thoracic vein with polyglucin and hormones; isotonic to blood solutions should prevent from dehydration and violations of microcirculations. Simultaneously the external bleeding is to be interrupted.

Anesthesia should be done, but here are some specifications: many anasthesics (morphine; panthonon; aminasin)can cause the central nervous system with severe violation of compensatory systems.

The interveinal solutions of analgesics (1 - 2 ml of 1% solution of dymedrol or 2,5% pipolphen) are desirable; sodium oxybutirat; fentanil and seduxen (1 - 2 ml in vein). Novocain blockades can be used only after partial recreation of circulation (up to 80 - 90 mm.); here should be noted, that novocain can leave the tissue and condenses in blood, renewing of lowering of arterial pressure.

Transportation would be done only after immobilization by means of Diedrich's or Cramer's transportation splint.

Treating of traumatic shock in clinic with use of additional circulation and HBO.

Transfusion therapy is the principle measure in clinic for it restores circulation and diminishing of hypotension. Here additional circulation with extracorporal oxygenation (ACE) are useful.  ACE can treat multiple skeletal trauma of extremities of III - IV degree; predagonia; sharp bleedings.

Such patients would be operated with permanent transfusion therapy by mean of catheterisation of thoracic vein with sodium oxybutirat; cetamin;  fentanil and seduxen. Later intubation and IVL are done in regime of moderate hyperventilation.

The respiratoric violations always follow the shock; sequentially ventilation is compulsory.

Anesthesia and IVL diminish acidosis; stabilizes arterial pressure; prepares to the operation. After the pressure improves the figure of 70 mm., premedication of anesthesia is done (injection in vein of 0,5 - 0,8 0,1% solution of atropine. The optimal introductive anesthesia is in-vein injection of sodium oxybutirat, fentanil and seduxen. That combination can lessen the reduction period. Injection of sodium oxybutirat is also indicated to protect the cerebrum from hypoxia, that is caused by capability of oxybutirat to protect the high level of energy in cerebral mitochondria with active respiration and phosphorilation.

After total curarisation the intubation as injection of short-active relaxants (listenon, myorelaxin, etc.). To avoid the strengthening of hypoxia and exclude the larynx reflecting effects, intubatuion would follow the oxygenation. In case the "complete stomach" effect the Sellic method or probe injection would be used. After intubation for anesthesia nitrous oxide and oxygen (1 : 2 or 1 : 1) are used.

Besides the AIK is terminated by means of peripheral vascularity. Oxygenated blood is injected into femoral artery. The time of procedure would be no more than 10 - 15 min.

Additional circulation is made on ISL - 3; ISL - 4; AIK - 5M facilities. They would be permanently sterilized and prepared for use. The sterilization is done as usual: autoclaving for 1,5 hour at 120 C; combined facility is fooled with dioxin solution (1 : 3000) for 45 - 60 min. and then is cleaned with physiologic salt solution.

The sterilization would be done each three days with bacteriologic control.

AIK is fooled with fresh citrate blood. In extra cases the mix of plasma with albumin or protein can be used; the blood is added then when the perfusion. The heparinisation - 1,5 - 2 mg/kg of body. The artificial hemiphilia is controlled by testing of coagulability.

The body's intermedia would be controlled too.

The perfusion index would be selected individually: from 35 to 50 ml/kg*min; hemodilution - 20 - 30%.

The body immediately responds with improvement of arterial pressure from 40 - 60 mm. to 95 - 100 mm.; AC quickly diminishes hypovolemic changes: improves the volume of circulating blood; normalizes OCK and Ht.

Extracorporal perfusion can also normalize the CVD - index, improving the inlet of heart and squeezability of myocard. The hemoglobin of arterial and venose blood is satisfied with oxygen; the partial pressure of carbon dioxide is also normalized as well as "terminal" index of acid-alkaline balance and electrolytic balance of blood. The dynamics of organic acids approves the abilities of additional circulation: their concentration lessens and approximates to normal one. The kidney function improves.

Steady normalization of hemodynamics, respiration, acid-alkaline balance, electrolytic balance  after AC comes on the third day.

The function of liver normalizes much later; but still it comes sooner than when the AC is excluded.

Additional circulation with Extracorporal oxygenation provides the efficiency of anti shock activities.

Significant normalization of hemodynamics, respiration, acid-alkaline balance, electrolytic balance permits to operate the patient more soon. The operations on wounds after digging up the extremities; opened crashes; amputations with shock of III - IV degree can be held immediately after the normalization and stabilization of arterial pressure at 90 - 100 mm. Hemodynamics transgressions do not arrive. All these operations are to be held no later than all compensatory function is released. Besides the operation assists to avoid the penetration of pathologic pulsation into cerebrum.

Anesthesia would be done by means of nitrous oxide and oxygen (2 : 1) and fentanil injections each 20 - 30 min.

Artificial ventilation of lung would be done with respiratory facility "OR - 5" and "Phase" in regime of moderate hyperventilation and control of acid-alkaline balance and gaseous composition.

AC is desirable in terminal period to avoid the unreversable changes caused by arterial hypotension and hypoxia.

Artificial ventilation of lung would be prolonged together with anesthesia for 2 - 4 hours after operation. It can improve the oxygenation of arterial blood; lessens the loading of respiratory muscles with sequent economy in assimilation of oxygen.

AC can effectively treat circulation and respiration. Other pathologies require the prolongation of complex therapy for 5 - 7 days; but this is another kind of therapy: the correction of water-electrical violations; normalization of micro circulation after renovation of circulation; Improvement of reology of blood; hemodilution; oxygenotherapy; parenthral food. The infusion of proteins (plasma, albumin, amino peptide, etc.) is of great importance in complex therapy.  This improves the level of proteins in body and besides improve arterial pressure, reducing hemodynamic violations and hypoxia. In hard cases the direct infusion of blood is indicated as well as mix of blood substitute with little-molecular peptides (repoliglucin, hemodes, neocompensan). Antihistamines, calcium gluconat, ascorbic acid and corticosteroids are injected to restore the penetration of vessels.

The violations of lysosomes and intercellar enzymes are treated with calol, trasiol, contrical.  Glucose (10% solution) and vitamins B1, B6, B12, C, PP, K, ATP and cocarboxilase improve enzyme reactions.

Acidose is treated with sodium bicarbonate; the use of alkalines is recommended if pH index is less than 7,24. It is known that acidose can change to alkolose; the treating of acid-alkaline balance changes are adequate transfusion therapy; diminishing of shortage of water and early reparation of peripheral circulation.  Violation of electrolyte's balance needs the injection of hypertensional glucosal solutions with insulin.

Hepatic and renal deficiency caused by circulation shortage, cerebral inflation and other pathologies require adequate pathogenic therapy. The hepatic therapy includes 500 ml of 10% glucose  with insulin twice a day; vitamins B, C, glucocortiroids and proteins; after sharp period - include syrenar, B15, linolic acid.

The renal therapy includes polyglucin, reopolyglucin, mannitol, glucose-novocain mix. In sharp renal deficiency - hemodialisis (with AC if pressure is little).  tissue respiration is treated byinjections of 5000 - 10000 units of heparin in muscles 4 times a day beginning from 2 - 3 day. The application of AC improves the efficiency of therapy of shock twice.

Mechanical damages can cause also respiratory violations, hypoxia. The oxygenotherapy is a method of its treating; its abilities improve in case of HBO.

HBO would be included on 2 - 3 day after the operation. "Oka - MT" chambers are used with pressure of 1AT, for 1 hour, once a day, 6 procedures in course.

The combination of AC and HBO permit efficiently and quickly normalization of circulation, respiration, acid-alkali balance. HBO can also help to avoid shock of the lung; pneumonia; healing of wounds; hypercoagulation diminishes. AC causes hydrodynamical assistance from arterial part of capillars.  Artificial hemodilution and heparinisation improve the reology of blood and peripheral circulation; the circulation and metabolism in liver and intestine; reduces the synthesis of active vascular substances.

Acceleration of delivery of oxygen and deletion of intermediately oxygenated substances assists the healing of patient; the system of homeostasis is normalized after its primary tension or shortage. Complex therapy of hard traumatic shock would include: perfusion and transfusional therapy with AC; complex anesthesia and operation; HBO would be added soon after operational reanimation. This can be surely recommended for Centers of reanimation.