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УЖМБС 2018, 3(5): 242–246
https://doi.org/10.26693/jmbs03.05.242
Medicine. Reviews

Forensic Medical Aspects of Complications and Lesions of Target Organs with Hemorrhagic Shock

Pavliukovych O. V.
Abstract

Hemorrhagic shock develops as a result of acute hemorrhage. Acute blood loss is the sudden blood outlet. The main clinical symptoms of the resulting decrease in circulating blood volume (CBV) (hypovolemia) are the pallor of the skin and visible mucous membranes, tachycardia and arterial hypotension. The cause of acute blood loss can be trauma, spontaneous bleeding, and surgery. The speed and volume of blood loss are of great importance. With a slow loss of even large amounts of blood (1000-1500 ml) compensatory mechanisms manage to turn on, hemodynamic disorders appear gradually and are not very serious. On the contrary, intensive bleeding with loss of a smaller volume of blood leads to severe hemodynamic disorders and, as a result, to hemorrhagic shock. The following stages of hemorrhagic shock are distinguished: Stage 1 (compensated shock), when blood loss is 15-25% CBV, the patient's consciousness is preserved, the skin is pale, cold, the blood pressure is moderately reduced, there is pulse of weak filling, moderate tachycardia to 90-110 beats / min. Stage 2 (decompensated shock) is characterized by an increase in cardiovascular disorders; the compensatory mechanisms of the organism are disrupted. The blood loss is 25-40% CBV, impaired consciousness before sopor, acrocyanosis, cold extremities, blood pressure sharply reduced, tachycardia 120-140 beats / min, pulse weak and thread, dyspnea, oliguria up to 20 ml / hour. Stage 3 (irreversible shock) is a relative term and largely depends on the resuscitation methods used. The patient's condition is extremely difficult. Conscience is sharply depressed until complete loss, the skin is pale, the "marbling" of the skin, systolic pressure is below 60 mm Hg, the pulse is determined only on the main vessels, a sharp tachycardia up to 140-160 beats / min. As an express diagnosis of the severity of shock, the concept of a shock index (SHI) is used – the ratio of the heart rate to the magnitude of the systolic pressure. At a shock of the 1st degree SHI = 1 (100/100); at a shock of the 2nd degree it is 1.5 (120/80), the shock of the 3rd degrees SHI=2 (140/70). Hemorrhagic shock is characterized by a general severe condition of the body, insufficient circulation of blood, hypoxia, metabolism violation and organs function. Hypotension, hypoperfusion (decrease in gas exchange) and hypoxia of organs and tissues are at the heart of the shock pathogenesis. The leading damaging factor is circulatory hypoxia. Relatively fast loss of 60% of CBV is considered deadly for a person, blood loss of 50% of CBV leads to failure of compensation mechanism, blood loss of 25% of CBV is almost completely compensated by the body. The ratio of the hemorrhage magnitude and its clinical manifestations: Blood loss 10-15% CBV (450-500 ml), there is no hypovolemia, BP is not lowered; Blood loss 15-25% CBV (700-1300 ml), mild hypovolemia, blood pressure lowered by 10%, mild tachycardia, pallor of the skin, cold extremities; Blood loss 25-35% CBV (1300-1800 ml), moderate severity of hypovolemia, blood pressure lowered to 100-90, tachycardia up to 120 beats / min, pallor of the skin, cold sweat, oliguria; Blood loss to 50% CBV (2000-2500 ml), severe degree of hypovolemia, blood pressure lowered to 60 mm Hg, pulse threadlike, unconscious or confused, sharp pallor, cold sweat, anuria; The blood loss of 60% of CBV is fatal.

Keywords: hemorrhagic shock, shock index, shock organs, forensic medical diagnostics

Full text: PDF (Ukr) 220K

References
  1. Sokolov VA. Dorozhno-transportnye travmy: rukovodstvo dlya vrachey. Moskva, 2009. 176 s. [Russian]
  2. Saveleva GM, Kulakov VY, Stryzhakov AN. Akusherstvo. 2000. 816 s. [Russian]
  3. Abdulmajeed Al Drees, Mahmoud Salah Khalil, Mona Soliman. Histological and Immunohistochemical Basis of the Effect of Aminoguanidine on Renal Changes Associated with Hemorrhagic Shock in a Rat Model. Acta Histochem Cytochem. 2017 Feb 28; 50 (1): 11–9. https://www.ncbi.nlm.nih.gov/pmc/articles/5374099. https://www.ncbi.nlm.nih.gov/pubmed/28386146. https://doi.org/10.1267/ahc.16025
  4. Ates E, Yalcin AU, Yilmaz S, Koken T, Tokyol C. Protective effect of erythropoietin on renal ischemia and reperfusion injury. ANZ J Surg. 2005; 75: 1100–5. https://doi.org/10.1111/j.1445-2197.2005.03612.x
  5. Bjerkvig CK, Strandenes G, Eliassen HS, Spinella PC, Fosse TK, Cap AP, et al. "Blood failure" time to view blood as an organ: how oxygen debt contributes to blood failure and its implications for remote damage control resuscitation. Transfusion. 2016 Apr; 56 Suppl 2: S182-9. https://doi.org/10.1111/trf.13500
  6. Bond RF, Johnson G. Vascular adrenergic interactions during hemorrhagic shock. Fed Proc. 1985; 44: 281-9. https://www.ncbi.nlm.nih.gov/pubmed/3967773
  7. Heemskerk S, Masereeuw R, Russel FGM, Pickkers P. Selective iNOS inhibition for the treatment of sepsis-induced acute kidney injury. Nat Rev Nephrol. 2009; 5: 629–40. https://www.ncbi.nlm.nih.gov/pubmed/19786992. https://doi.org/10.1038/nrneph.2009.155
  8. Langeland H, Lyng O, Aadahl P, Skjærvold NK. The coherence of macrocirculation, microcirculation, and tissue metabolic response during nontraumatic hemorrhagic shock in swine. Physiol Rep. 2017 Apr; 5(7): pii: e13216. https://www.ncbi.nlm.nih.gov/pubmed/28400499. https://www.ncbi.nlm.nih.gov/pmc/articles/5392510. https://doi.org/10.14814/phy2.13216
  9. Lee MY, Yang DK, Kim SJ. Alterations of Mg2+ After Hemorrhagic Shock. Biol Trace Elem Res. 2017 No v;180 (1): 120-126. https://www.ncbi.nlm.nih.gov/pubmed/28315119. https://doi.org/10.1007/s12011-017-0994-2. doi: 10.1007/s12011-017-0994-2
  10. Riha GM, Kunio NR, Van PY, Kremenevskiy I, Anderson R, Hamilton GJ, Differding JA, Schreiber MA. Uncontrolled hemorrhagic shock results in a hypercoagulable state modulated by initial fluid resuscitation regimens. J Trauma Acute Care Surg. 2013 Jul; 75 (1):129-34. https://www.ncbi.nlm.nih.gov/pubmed/23940856. https://doi.org/10.1097/TA.0b013e3182984a9b
  11. Rossaint R, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Gordini G, et al. Key issues in advanced bleeding care in trauma. Shock. 2006; 26: 322–31. https://www.ncbi.nlm.nih.gov/pubmed/16980877. https://doi.org/10.1097/01.shk.0000225403.15722.e9
  12. Star RA. Treatment of acute renal failure. Kidney Int. 1998; 54: 1817–31. https://www.ncbi.nlm.nih.gov/pubmed/9853246. https://doi.org/10.1046/j.1523-1755.1998.00210.x
  13. Thadhani R, Pascual M, Bonventre JV. Acute renal failure. N Engl J Med. 1996; 334: 1448–60. https://www.ncbi.nlm.nih.gov/pubmed/8618585. https://doi.org/10.1056/NEJM199605303342207
  14. van Bommel J, Siegemund M, Henny ChP, Ince C. Heart, kidney and intestine have different tolerances for anemia. Transl Res. 2008; 151: 110–7. https://www.ncbi.nlm.nih.gov/pubmed/18201678. https://doi.org/10.1016/j.trsl.2007.11.001
  15. Vollmer С, Weber AP M, Wallenfang M, Hoffmann T, Mettler‐Altmann T, Truse R, et al. Melatonin pretreatment improves gastric mucosal blood flow and maintains intestinal barrier function during hemorrhagic shock in dogs. Microcirculation. 2017 May; 24 (4). https://www.ncbi.nlm.nih.gov/pubmed/28316127. https://doi.org/10.1111/micc.12345
  16. Wang Y, Yan J, Xi L, Qian Z, Wang Z, Yang L. Protective effect of crocetin on hemorrhagic shock-induced acute renal failure in rats. Shock. 2012; 38: 63–7. https://www.ncbi.nlm.nih.gov/pubmed/22576007. https://doi.org/10.1097/SHK.0b013e3182596ec4
  17. Warke VG, Nambiar MP, Krishnan S, Tenbrock K, Geller DA, Koritschoner NP, et al. Transcriptional activation of the human inducible nitric-oxide synthase promoter by Krüppel-like factor 6. J Biol Chem. 2003; 278: 14812-9. https://www.ncbi.nlm.nih.gov/pubmed/12590140. https://doi.org/10.1074/jbc.M300787200
  18. White NJ, Ward KR, Pati S, Strandenes G, Cap AP. Hemorrhagic blood failure: Oxygen debt, coagulopathy and endothelial damage. J Trauma Acute Care Surg. 2017 Jun; 82 (6S Suppl 1): S41-S49. https://www.ncbi.nlm.nih.gov/pubmed/28328671. https://www.ncbi.nlm.nih.gov/pmc/articles/5488798. [Available on 2018-06-01]. https://doi.org/10.1097/TA.0000000000001436
  19. Wu CY, Yeh YC, Chien CT, Chao A, Sun WZ, Cheng YJ. Laser speckle contrast imaging for assessing microcirculatory changes in multiple splanchnic organs and the gracilis muscle during hemorrhagic shock and fluid resuscitation. Microvasc Res. 2015 Sep; 101: 55-61. https://www.ncbi.nlm.nih.gov/pubmed/26093177. https://doi.org/10.1016/j.mvr.2015.06.003
  20. Zager RA. Adenine nucleotide changes in kidney, liver, and small intestine during different forms of ischemic injury. Circ Res. 1991; 68; 185–96. https://www.ncbi.nlm.nih.gov/pubmed/1984861. https://doi.org/10.1161/01.RES.68.1.185
  21. Zhao G, Wu W, Feng QM, Sun J. Evaluation of the clinical effect of small-volume resuscitation on uncontrolled hemorrhagic shock in emergency. Ther Clin Risk Manag. 2017 Mar 27; 13: 387-92. https://www.ncbi.nlm.nih.gov/pubmed/28392701. https://www.ncbi.nlm.nih.gov/pmc/articles/5375637. https://doi.org/10.2147/TCRM.S132950