POSSIBILITY OF IMPROVEMENT OF RENDERING EMERGENCY MEDICAL SERVICE FOR PATIENTS WITH TRAUMATIC SHOCK
Kabanov City Clinical Hospital No.1,
Omsk State Medical University, Omsk, Russia
Considering the position of the modern critical care medicine, patients with traumatic shock should receive the urgent surgical treatment [1]. Therefore, it is important to use the algorithmic complex emergent care at the prehospital and hospital stages with possibility of fast etiopathogetenic treatment for improving outcomes [2]. However the problem of fluid load from perspectives of its efficiency, continuity and safety remains unsolved, despite the fact of the properly developed and effective algorithmic complex medical care for patients with traumatic shock [3].
Therefore, the objective of the study was to define the main organizational and tactical priorities when rendering algorithmic complex emergency medical service for patient with serious traumatic shock at the prehospital and hospital stages for realization of its optimization.
MATERIALS AND METHODS
The study presented the outcomes of a simple blinded randomized clinical cohort prospective study (envelopes technique) of 75 patients with traumatic shock of degree 3 who were distributed into groups according to the type of infusion therapy at the prehospital and hospital stages (the table 1). The inclusion criteria were: 1) age of the patients from 18 to 40; 2) acute initiation of a disease; 3) absent narcotic or alcohol intoxication; 4) hospital admission within the first hour after disease onset. The exclusion criteria were: 1) concurrent sub- and decompensated chronic renal, hepatic, cardiac or pulmonary pathology; 2) previous oncologic pathology; 3) previous hormonal and chemical therapy; 4) diabetes mellitus of types 1-2; 5) terminal state; 6) participation in other study; 7) allergic responses to hemodynamic colloid solutions on the basis of 4 % modified gelatin and 6 % HES. Traumatic shock of degree 3 was diagnosed before hospital admission (before initiation of infusion therapy) in presence of history of injuries and on the basis of the following signs: disordered consciousness (Glasgow Coma Scale), systolic arterial pressure (SAP, mm Hg), diastolic arterial pressure (DAP, mm Hg), mean arterial pressure (MAP, mm Hg), heart rate (HR, min-1), shock index (SI) and body temperature (T, °C) (the table 2).
Table 1. The variants of infusion therapy, the gender and age composition, locations of injuries, main values of organizational and tactical priorities of arrangement of emergency medical aid for patients in the groups I, II and III
|
Patient groups, infusion therapy program, age (years), gender, n (%) |
Injuries location |
Time from initiation of anti-shock measures before hospital admission (min) |
Time from hospital admission to initiation of surgical treatment |
Time from initiation of surgical treatment to bleeding arrest (min) |
|
Group I (0.9% NaCl + 6% HES 200/0.5 in ratio 1.3/1), n = 25; mean age – 27.2 ± 1.9; men, n = 15 (60%); women, n = 10 (40%) |
Fracture of pelvic bones + fracture of femoral bone +closed abdominal injury with injuries to spleen, mesentery and liver (n = 15, 60%). Fracture of femoral and tibial bones + closed abdominal injury with injuries to spleen, mesentery and liver (n = 10, 40%) |
57.1 ± 0.2 |
8.6 ± 1.1 |
33.4 ± 2.8 |
|
Group II (0.9% NaCl + 4% MG in ratio 1/3), n = 25; mean age – 27.5 ± 2.1; men, n = 16 (64%); women, n = 9 (36%) |
Pelvic fracture + femoral bone fracture + closed abdominal injury (injuries to spleen, mesentery and liver), n = 13 (52%). Fracture of femoral + fibular and tibial bones + closed abdominal injury (injuries to spleen, mesentery and liver), n = 12 (48%). |
56.9 ± 0.4 |
8.7 ± 1.2 |
34.1 ± 1.3 |
|
Group III (isotonic sterofundin + 4% MG in ratio 1/3), n = 25; mean age – 26.9 ± 1.8; men, n = 15 (60%), women, n = 10 (40%)
|
Pelvic fracture + femoral bone fracture + closed abdominal injury (injuries to spleen, mesentery and liver), n = 14 (56%). Fracture of femoral and fibular and tibial bones + closed abdominal injury (injuries to spleen, mesentery and liver), n = 11 (44%) |
56.7 ± 0.5 |
8.8 ± 1.3 |
33.3 ± 3.1 |
Note: No statistically significant differences were found in the table (Kruskal-Wallis ANOVA, p > 0.05).
Table 2. The values of systemic hemodynamics, GCS and body temperature in patients at prehospital stage, Me (Ql; Qh)
|
Index |
Groups |
||
|
I (n = 25) |
II (n = 25) |
III (n = 25) |
|
|
HR, min-1 |
137.9 (130; 144) |
140.9 (136; 145) |
141.7 (136; 146) |
|
AP syst., mm Hg |
48.1 (42; 53) |
47.9 (44; 51) |
47.2 (43; 51) |
|
AP diast., mm Hg |
21.4 (18; 25) |
21.8 (18; 24) |
21.6 (18; 25) |
|
SAP, mm Hg |
32.3 (30; 34) |
32.2 (29; 34) |
32.5 (30; 34) |
|
SI, c.u. |
2.9 (2.8; 3) |
3.1 (3; 3,2) |
3.1 (3; 3,2) |
|
GCS, points |
7.9 (7; 8) |
7.8 (7; 8) |
7.9 (7; 8) |
|
Т, °С |
35.9 (35.8; 36) |
35.9 (35.9; 36) |
35.9 (35.9; 36) |
Note: No statistically significant intergroup differences were found (Kruskal-Wallis ANOVA, p > 0.05). Me (Ql; Qh) – median (upper and lower quartiles).
The patients with traumatic shock received the prehospital care according to the following algorithm:
Temporary arrest of bleeding;
Central vein catheter for carrying out the infusion therapy (crystalloids and colloids);
Multimodal analgesia for arresting pain impulse from the injury site;
Use of ά1 и β2 adrenomimetric agents for purposeful correction of systemic hemodynamics in absence of effect from volemic load;
Moistened oxygen inhalation; for progressing symptoms of acute respiratory (respiratory rate > 40 or < 10) or cerebral (GCS < 8) insufficiency – tracheal intubation and ALV;
Transport immobilization;
Transportation of patients in horizontal position;
A telephone message to the specialized surgery hospital made by emergency physician to duty surgeon, traumatologist or intensivist, with presenting the information about patient’s general condition (shock degree and approximate blood loss according to shock index);
Rapid transportation to a specialized medical facility.
Therefore, all patients received prehospital multimodal analgesia (narcotic or non-narcotic analgetics), infusion therapy with the catheter in the central (subclavicular or jugular) vein, inotropic and vascular support with dopamine (5 µg/kg of body mass per minute). Artificial lung ventilation with Chirolog Paravent PAT (Chirana, Slovakia) was initiated for all patients after tracheal intubation.
At the hospital stage all patients were immediately admitted to the surgery room for realization of urgent surgical care with continuing the anti-shock therapy, which was initiated at the prehospital stage. At the same time, the diagnostic examinations were conducted (plain X-ray of chest, abdominal organs, skull, pelvis and injured extremities, ultrasonic abdominal examination, laparoscopy, biochemical data, hemostasis parameters, general blood and urine analysis, blood group and Rh factor testing).
The surgical treatment was conducted with total intravenous (fentanyl + ketamine + sibazon) anesthesia with muscle relaxants in conditions of ALV with air-oxygen mixture. The surgical treatment was conducted for all patients (n = 75), its volume depended on injury location (the table 1). After it the patients were admitted to the intensive care unit (ICU) for infusion, antibacterial, respiratory and symptomatic therapy. The blood loss degree (hospital and prehospital) was estimated on the basis of shock index, clinical symptoms and estimation of external blood loss volume (the table 3). Within the first 24 hours all patients received the therapy for anemia and consumption coagulopathy according to the common criteria with transfusion of single-group plasma and packed red blood cells [4]. During the subsequent two days, the transfusion therapy was conducted according to coagulation hemostasis parameters, hemoglobin and hematocrit. The hemodynamic monitor MEC 1200 (Mindray, China) was used for estimating SAP, DAP, MAP, HR and body temperature (T, °C) at the prehospital stage. Capillary blood oxygen saturation was measured with the pulse oximeter MD 300 from the same manufacturer. SAP, DAP, MAP, heart rate and body temperature were registered with the hemodynamic monitor ICARD (Chirana, Slovakia) at the hospital stage. Tetrapolar rheography was used for measuring the central hemodynamic parameters: heart rate (HR, min-1), stroke volume (SV, ml), cardiac minute output (CMO, l), cardiac index (CI, l/min./m2), total peripheral vascular resistance (TPVR, dyn×cm×sec.-5), circulating blood volume (CBV, l). The automatic hematological analyzer Hemolux 19 (Mindray, China) was used for measuring hemoglobin level (g/l) and platelet count (109/l). Lactate in venous blood serum was measured with the biochemical analyzer Huma Laser 2000 (Human, Germany). Endothelin-1 (E-1, fmol/l), Willebrand factor (WF, %) and activated partial thromboplastin time (APTT, sec.) were measured. The electrolytic composition of venous blood serum (potassium, natrium, chloride, ionized calcium (mmol/l)) was estimated with the analyzer Easy Lyte (Medica, USA). MT-5 (NPP Burevestnik, Russia) was used for estimating the plasma and urine osmolarity (mOsm/l). SOFA was used for estimating the time course and intensity of organ system dysfunctions.
Table 3. Blood loss volume and infusion-transfusion therapy in patients with traumatic shock during 1 day (М ± m)
|
Values, ml |
Группы / Groups |
||
|
I (n = 25) |
II (n = 25) |
III (n = 25) |
|
|
Blood loss at prehospital stage |
2810 ± 225 |
2869 ± 221 |
2905 ± 215 |
|
Crystalloids |
822 ± 25 |
438 ± 22 |
441 ± 21* |
|
Colloids |
822 ± 42 |
1316 ± 58 |
1352 ± 49 |
|
Total volume |
1645 ± 250 |
1755 ± 242 |
1767 ± 235 |
|
Blood loss at hospital stage |
464 ± 35 |
436 ± 39 |
411 ± 38 |
|
Total blood loss |
3274 ± 121 |
3305 ± 161 |
3317 ± 152 |
|
Crystalloids |
2123 ± 39 |
989 ± 31 |
1035 ± 35 |
|
Colloids |
1620 ± 48 |
2888 ± 50 |
2960 ± 55 |
|
Packed red cells |
1524 ± 22 |
1509 ± 29 |
1528 ± 30 |
|
Plasma |
2872 ± 67 |
2530 ± 56 |
2486 ± 49 |
|
Total volume of ITT |
9786 ± 111 |
9883 ± 108 |
9805 ± 103 |
Note: * – differences in comparison with 1st group are statistically significant with p < 0.05 (Student's test for paired comparison of independent samples).
The examinations were conducted at the moment of ICU admission, 12 hours after it, and within the following 3 days. Estimation of efficiency of algorithmic complex urgent medical care at the prehospital and hospital stages was estimated according to prehospital, 24-hour and three-day mortality. The systemic statistical analysis was conducted with ANOVA, Freedman non-parametrical test, Kruskall-Wallis, Wilcoxon and Mann-Whitney tests, c2test and Spearman correlation analysis with obligatory estimation of statistical significance (p < 0.05) [5] and Statistica 6 (Statsoft, USA, 1999) and MedCalc 7.6.0.0.
The study was conducted with approval from the bioethical committee of Kabanov City Clinical Hospital No.1 and corresponded to the ethical standards of Helsinki Declaration – Ethical Principles for Medical Research with Human Subjects 2000 and the Rules for Clinical Practice in the Russian Federation confirmed by the Order of Russian Health Ministry, June 19, 2003, No.266.
RESULTS
According to the table 2, there were not any reliable differences between the values which were used for confirmation of shock and its severity that confirmed their basic equivalence. The use of algorithmic complex urgent medical care at the prehospital and hospital stages was efficient in all examined groups and was confirmed by the values of prehospital mortality and 24-hour hospital mortality (the table 4). At the moment of ICU admission all patients demonstrated the hypodynamic type of blood circulation that was confirmed by cardiac output supported by intense tachycardia and vascular spasm (the table 5). The main factor of low cardiac minute output was deficiency of CBV caused by massive blood loss and endothelial insufficiency that was indicated by the parameters of vascular endothelial dysfunction (the table 5).
Already at the moment of admission, the patients demonstrated some evident hemostasis disorders (the table 5) determined by acute massive blood loss (the table 3). The intensive care promoted the positive influence on the examined parameters in the patients of all groups (the table 5). In its return, the comparative analysis demonstrated the statistically significant difference in dynamic changes of lactate in the patients of the groups 1 and 3 and 1 and 2 (the table 5). Also the comparative analysis identified some reliable differences in SV and CMO in the patients of the group 1 as compared to the group 2 and 3 (the table 5). Moreover, the comparative analysis identified the increased plasma and urine osmolarity in the group 1 as compared to the group 3 (the table 5). All these facts testified the insufficiency of the available type of blood circulation in the group 1 and determined the use of inotropic and vascular support within 74.2 ± 2.3 hours that differed from the similar time in the groups 2 and 3 (48.1 ± 2.4 and 47.3 ± 2.1 hours correspondingly).
Table 4. The values of mortality and comparative analysis during 3 days
|
Patient groups |
Mortality rates, n (%) |
|
Prehospital stage |
|
|
Group I (n = 25) |
0 (0 %) |
|
Group II (n = 25) |
0 (0 %) |
|
Group III (n = 25) |
0 (0 %) |
|
Hospital stage |
|
|
Group I (n = 25) |
0 (0 %) |
|
Group II (n = 25) |
0 (0 %) |
|
Group III (n = 25) |
0 (0 %) |
|
Within 3 days |
|
|
Group I (n = 25) |
3 (12 %) |
|
Group II (n = 25) |
1 (4 %) |
|
Group III (n = 25) |
1 (4 %) |
|
Comparison of groups |
Results of comparison |
|
Group I / Group II |
c2 = 0.11; p = 0.95 |
|
Group I / Group III |
c2 = 0.11; p = 0.95 |
|
Group II / Group III |
c2 = 0.00; p = 1.0 |
Note: No statistically significant differences were found (критерий χ2, p > 0.05).
Table 5. The comparative analysis of instrumental and laboratory data, Me (Ql; Qh) – median (upper and lower quartiles)
|
Values |
Upon admission to ICU |
72 hours after admission to ICU |
||||
|
Group I |
Group II |
Group III |
Group I |
Group II |
Group III |
|
|
HR, min-1 |
131 (128; 131) |
112.5 (101; 117)^ |
113 (102; 116)^ |
89 (89; 90)* |
90 (89; 91)* |
90 (89; 91)* |
|
SD, ml |
35 (34; 36) |
36 (35; 37) |
36 (34; 37) |
69 (67; 72)* |
75 (74; 78)*^ |
75 (74; 77)*^ |
|
CO, l/min |
4.5 (4.4; 4.7) |
4 (3,9; 4,1) |
4 (3.9; 4.1) |
6.1 (6.0; 6.4)* |
6.6 (6.5; 6.9)*^ |
6.7 (6.6; 6.9)*^ |
|
TPVR, dyn×s×cm-5) |
2797 (2558; 2896) |
2767 (2588; 2829) |
2767 (2585; 2828) |
1565 (1518; 1593)* |
1478 (1457; 1498)*^ |
1476 (1455; 1496)*^ |
|
TBV, l |
1.98 (1.97; 2.15) |
1.96 (1.94; 2) |
1.97 (1.94; 2.00) |
4.48 (4.47; 4.55)* |
4.52 (4.49; 4.55)* |
4.51 (4.48; 4.5)* |
|
Platelets, 109/l |
125 (125; 126) |
122.1 (114; 130) |
123.7 (117; 132) |
171 (163; 186)* |
186.8 (182.1; 214.3)*^ |
185.7 (183.4; 212.1)*^ |
|
APTT, sec. |
58 (57; 59) |
48 (46; 50)^ |
49 (47; 51)^ |
48 (47; 48)* |
32 (31; 34)*^ |
32 (29; 34)*^ |
|
E-1, fmol/l |
1.7 (1.6; 1.8) |
1.6 (1.5; 1.7) |
1.6 (1.5; 1.7) |
1 (0.9; 1.1)* |
0.5 (0.4; 0.6)*^ |
0.4 (0.3; 0.5)*^ |
|
EF, % |
193.4 (190.4; 196.7) |
192.1 (189.8; 195.7) |
191.7 (190.2; 196.8) |
164.8 (162.1; 165.6)* |
103.4 (100.7; 108.6)*^ |
100.8 (99.7; 104.3)*^ |
|
Hemoglobin, g/l |
56 (52; 58) |
57 (53; 59) |
57 (53; 58) |
86 (85; 87)* |
89 (88; 91)* |
89 (88; 91)* |
|
Lactate, mmol/l |
4 (3.9; 4.1) |
4.1 (3.9; 4.2) |
4 (3.9; 4.1) |
2.6 (2.5; 2.7)* |
2 (2; 2.1)*^ |
2 (2; 2)*^ |
|
Potassium, mmol/l |
3.9 (3.7; 4.1) |
3.9 (3.8; 4) |
3,9 (3,7; 4.1) |
3.3 (3.2; 3.4)* |
3.3 (3.3; 3.4)* |
3.9 (3.8; 4.2)^ |
|
Chloride, mmol/l |
95 (94; 96) |
95 (94; 96) |
94 (94; 95) |
111 (110; 112)* |
111 (111; 111)* |
97 (96; 98)^ |
|
Natrium, mmol/l |
136 (135; 137) |
136 (136; 138) |
136 (135; 137) |
144 (143; 145)* |
144 (144; 144)* |
139 (139; 140)^ |
|
Ionized calcium, mmol/l |
0.5 (0.32; 0.73) |
0.6 (0.43; 0.78) |
0.9 (0.8; 1)^ |
0.71 (0.69; 0.72) |
0.74 (0.72; 0.76)* |
1.21 (1.2; 1.22)*^ |
|
Plasma osmolarity, mOsm/l |
288 (284; 291) |
287 (283; 290) |
286 (282; 289) |
306 (303; 309)* |
305 (301; 308)* |
281 (279; 283)^ |
|
Urine osmolarity, mOsm/l |
0 (0; 0) |
0 (0; 0) |
0 (0; 0) |
1341 (1318; 1357)* |
1303 (1291; 1317)*^ |
1225 (1214; 1237)*^ |
|
Diuresis, ml |
0 (0; 0) |
0 (0; 0) |
0 (0; 0) |
1500 (1400; 1600)* |
1500 (1400; 1600)* |
1300 (1100; 1450)*^ |
|
Inotropic and vascular support with dopamine |
8.9 (8; 10) |
8.5 (8; 9) |
8.4 (8; 9) |
3.7 (3; 4)* |
0 (0; 0)*^ |
0 (0; 0)*^ |
Note: * – the differences are statistically significant as compared to the previous period, with p < 0.05 (Wilcoxon's test); ^ – the differences are statistically significant as compared to the group I, with p < 0.05 (Mann-Whitney test).
During the whole follow-up, the patients of the group 1 (as compared to the groups 2 and 3) demonstrated some reliable differences in plasma levels of E-1 and WF (the table 5). During all three days the patients of the group 1 demonstrated the disorders of plasma hemostasis that was confirmed by increasing APTT (the table 5) with significant difference from the groups 2 and 3. During the whole follow-up, the patients of the group 1 (as compared to the group 3) demonstrated some changes in electrolytic composition of plasma with statistically significant increase in levels of natrium and chloride ions and in decreasing potassium and calcium ions (the table 5). The infusion therapy demonstrated a positive influence on the volemic and hemodynamic status that promoted shock involution at the end of the second day (the table 5).
However the patients of the group 2 demonstrated the evident decrease in calcium ions (the table 5) as compared to the group 3 at the moment of admission. Also the patients of the group 2 demonstrated the statistically significant increase in the serum levels of natrium and chloride ions (the table 5) as compared to the identical data in the group 3 on the second day. Moreover, the patients of the group 2 demonstrated the significant decrease in plasma levels of potassium ions (the table 5) as compared to the group 3. The infusion therapy in the group 3 made the efficient influence on the systemic hemodynamics parameters (the table 5). It promoted the shock regression in the end of the second day. During the whole period of the follow-up, the patients of the group 3 demonstrated the positive time trends of the hemostasis parameters without changes in osmolarity and electrolytic composition of blood plasma (the table 5).
DISCUSSION
The used algorithms of complex urgent medical care at the prehospital and hospital stages were equally efficient in all groups. It was confirmed by absence of lethal outcomes and 24-hour mortality. It was explained by the fact that the used algorithms promoted the minimization of time from initiation of the anti-shock measures before hospital admission to beginning of the surgical treatment and hemorrhage arrest, i.e. at the moment of initiation of ethiopathogenetic (surgical and anti-shock) therapy, which has the highest efficiency in traumatic shock [1]. The similar efficiency of the used prehospital and hospital algorithms was indirectly confirmed by absence of any statistical differences in ICU admission.
However the conducted variants of volemic load in the group 2 and 3 (as compared to the fluid provision program for the groups 1 and 2) determined the reliably early correction of acute cardiovascular insufficiency and cancellation of inotropic and vascular support. It determined the statistically significant intensity of MODS (SOFA = 7.4 (6; 8)) in the group 1 as compared to the groups 2 (SOFA = 4.5 (3; 5))) and the group 3 (SOFA = 4.4 (3; 5)). The high efficiency of the variants of volemic replacement in relation to MODS correction in the groups 2 and 3 was determined by 4 % MG colloid solution, which has the significantly higher daily dose (in contrast to 6 % HES) as compared to the fluid provision program in the group 1. This circumstance allows adhering to the principle of continuity of infusion therapy program in patients with severe traumatic shock at the prehospital and hospital stages, with use of the optimal ratio of crystalloids and colloids for efficient removal of blood circulation disorders [3]. It also was confirmed by the comparative analysis that showed the reliable difference in the prehospital volume of introduced colloid solutions in the group 1 as compared to the groups 2 and 3 (the table 3).
Also the comparative analysis (the table 3) identified the significant difference in the volume of introduced crystalloid solutions at the prehospital and hospital stages in the patients of the group 1 as compared to the groups 2 and 3. The lower volumes of colloid solutions with high volemic activity and the higher volumes of crystalloid solutions in the infusion program for the patients of the group 1 was the determining factor of late correction of MODS. It testified that the infusion therapy programs were more efficient for correcting the hemodynamic disorders in the patients of the groups 2 and 3 as compared to the volemic load in the group 1. The insufficiency of the available type of blood circulation in the group 1 was confirmed by the increasing values of tissue hypoperfusion and endothelial dysfunction.
Actually, the high plasma level of E-1, which was probably caused by hypercatecholaminemia, ischemia and hypoxia, is able both to make the direct constrictive influence of the vessels [6] (confirmed by high TPVR in the group 1) and induce MODS by means of direct toxic influence on the cardiac muscle [7]. In its turn, the serum level of WF can increase in endothelial stimulation and, moreover, in its activation and injury [6]. Moreover, severe hemocirculatory disorders and, as result, mixed hypoxia are the factors making the negative influence on the endothelial cells with discharge of systemic inflammatory response mediators releasing [6] that worsens the endothelial dysfunction and leads to progressive worsening volemic status [7]. Hyperlactataemia and high level of chloride ions could independently produce the high vascular permeability [8] and could cause the development of relative hypovolemia [7, 9].
During the whole follow-up period, the patients of the group 1 (in contrast to the group 3) demonstrated the higher levels of chloride ions. The important thing was the decrease in plasma ionized calcium in the group 1 that was at the same time as plasma hemostasis disorders. Possibly, it was associated with necessity of adequate plasma levels of calcium ions [10, 11]. The evident disorders of plasma hemostasis were confirmed by the fact that the volume of introduced fresh frozen single-group plasma was higher by 11.9 % than the similar volume in the group 2 and by 13.4 % higher than the same volume in the group 3 (the table 3). The statistically significant decrease in contents of calcium ions was noted in the group 2 as compared to the group 3. But in contrast to the group 1, the decrease in ionized calcium levels in the group 2 did not influence on plasma hemostasis. It was confirmed by the comparative analysis that did not identify any significant difference in plasma hemostasis in the group 2 as compared to the group 3.
This position testified that 4 % MG colloid solution made the lower negative influence on the plasma hemostasis parameters in the patients with severe traumatic shock as compared to 6 % HES 200/0.5 colloid solution in the infusion therapy program. The infusion program with 0.9 % sodium chloride promoted the evident increase in plasma levels of sodium ions and decreasing levels of potassium ions in the patients of the groups 1 and 2 as compared to the group 3. The increase in the plasma levels of sodium ions determined the increase in plasma osmolarity in the groups 1 and 2 in comparison with the identical index in the group 3 that was confirmed by identified reliable correlation relationships between plasma osmolarity and levels of sodium ions (r = 0.45, р = 0.04; r = 0.46, р = 0.04). The efficiency of 4 % MG colloid solution in the infusion program for the patients with severe traumatic shock was confirmed by the mortality rate during the whole period of the follow-up (the table 4). At the same time, none of the used variants of the infusion therapy for the treatment of degree 3 traumatic shock showed any significant advantage in mortality (the table 4).
CONCLUSION
1. The main organizational and tactical priorities of algorithmic complex urgent medical care for patients with severe traumatic shock are: 1) time from initiation of anti-shock measures to hospital admission (not more than 57 minutes); 2) time from hospital admission to beginning of surgical treatment (not more than 9 minutes); 3) time from beginning of surgical treatment to hemorrhage arrest (not more than 34 minutes).
2. At the hospital stage, the diagnostic and curative measures (surgical arrest of bleeding, skeletal traction, anti-shock therapy) for patients with traumatic shock are necessary to perform simultaneously in the surgery room.
3. Optimization of algorithmic complex urgent medical care for patients with severe traumatic shock at the prehospital and hospital stages is possible only by means of improvement in the infusion therapy program.
4. The maximal clinical effect of infusion therapy as one of the key methods of intensive care within the limits of algorithmic urgent medical care in patients with severe traumatic shock is achieved with obligatory adherence to the continuity principle for such type of treatment at the prehospital and hospital stages.
5. The use of isotonic sterofundin and 4 % MG provides the efficient elimination of circulatory disorders and endothelial insufficiency, do not cause any negative changes in hemostasis, osmolarity and electrolytic composition of blood plasma in contrast to other variants of volemic replacement (0.9 % sodium chloride + 6 % HES 200/0.5 and 0.9 % sodium chloride + 4 % MG) for patients with severe traumatic shock at the prehospital and hospital stages.
6. As compared to 0.9 % sodium chloride + 6 % HES 200/0.5, the prehospital and hospital use of isotonic sterofundin and 4 % MG gives 40.3 % decreasing the intensity of multiple dysfunction syndrome in patients with degree 3 traumatic shock 8 % decreasing the mortality.
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