Stomatolog y

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10.10 A Traumatic Shock

It is well known from a long-time praxis that isolated injuries of the facial skeleton, the teeth and soft tissues do not usually evoke a traumatic shock. This complication may appear, however, with combined injuries or poly-traumas.

The definition

The term shock designates a severe, general hemodynamic and metabolic disorder caused by insufficient blood supplies. Three basic parts of the blood circulation are affected during the shock:

  • loss of circulation

  • defects in permeability of vessels

  • heart output decrease

The result is a decrease of the nutritional blood supply to the vital tissues and hypoxia. Insufficient removal of metabolites from tissues causes an acidosis. Irreversible damages to important organs originate from a developing shock: “shock kidneys”, “shock lungs”.
Causes of a shock

Hypovolaemic shock:

  • hemorrhagic: blood losses, low damage of tissues

  • traumatic: large damage of tissues

  • burns related: losses of plasma

  • dehydration related: losses of water (diarrhea, vomiting)

Other types of shocks: cardiogenic, septic, anaphylactic.
Stages of a shock

The first stage - compensation

Independently of a shock causes, the volume of circulating blood changes (macrocirculation), as well as specific shock-related changes of circulation inside blood vessels (microcirculation). At the first stage, the organism protects itself by a sympathetic-adrenergic reaction, releasing of catecholamines and excitation of adrenal cortex, in order to maintain homeostasis. Excitation of alpha-receptors of sympathetic nerves leads to closure of pre- and post-capillary sphincters which causes decrease of blood supply to organs depending on the degree of their alpha-adrenergic innervation (splanchnic organs, kidneys, liver, skin). On the other hand, coronary and brain circulations remain unaffected - centralization of circulation. The vital organs continue to be supplied with nutrients.

The second stage - decentralization of circulation

After the first stage, a shock deepens and without a compensation, serious metabolic malfunctions occur, tissue hypoxia and acidosis (lactate, ketoacids) increase, damages of cell membranes are caused by failure of the sodium-potassium pump (retention of Na+ and losses of K+). Decentralization of circulation appears, blood flows into the interstices after an initial peripheral spasm. Microcirculation specific changes also happen, characteristic by hemo-concentration, platelets sticking together, increasing blood viscosity, formation of thrombi, defects of DIC (disseminated intravascular coagulation) and appearance of consumptive coagulopathies.

A decompensated shock originates at this stage!
Therapy of a shock

A sudden loss of blood requires an adequate replacement. During the first stage, the blood volume is compensated for by replacement solutions, expanders, full blood, infusions, sugars, or salts. It is imperative to prevent any further blood losses (stop bleeding). A sufficient breathing and/or artificial ventilation of lungs (including also intubation) has to be ensured.

Therapy by medication: pain relief, vegetative blockers, corticoids, cardiotonics, prophylaxis of kidneys failure, occasionally a dialysis. A specific therapy is applied for particular types of shocks.

10.11 Polytraumas

A polytrauma is a clinical unit that means a short equivalent for the term “multiple injuries with an immediate damage to a vital organ, followed by failures of vital functions”.

The term “polytrauma” has to be understood as an accidental injury of several anatomic systems of an organism, the general state of organism, not a simple addition of individual wounds of various seriousness and extent. The course of an illness depends not only on the degree of damage to individual organs, but also on significant participation of systems, whose anatomical damages would be totally diminutive. Moreover, the injury influences pathologically also systems that are not directly affected by a trauma. The prototypes of polytraumas have become road accidents. By their nature, polytraumas do not allow for an immediate treatment of all injured parts. The dominant nature of injuries to vital organs require other wounds to wait for attention. Statistical analyses show occurrence of serious injuries of maxillo-facial area with a consequent affection of the middle facial third, in cases of polytraumas. Such injuries are combined with brain damages of various degree (88%), defects of lower (25%) and upper limbs (24%). Chest injuries occur at 15% of cases, damages of the spinal chord, abdomen and pelvis happen less frequently.

The treatment strategy is based on a five-step therapeutic plan:

  1. reanimation

  2. the first surgical phase (life-saving activities)

  3. phase of an active awaiting - to stabilize a patient’s condition

  4. the second surgical phase (final treatment)

  5. recovery and rehabilitation phase

Treatment of combined injuries of the facial area should assure the following:

At first, all attention has to be paid to making the airways free (releasing of stuck tongue, foreign object inside the mouth, mucous scraps and coagula). If the airways cannot be freed, breathing has to be enabled by tracheotomy or by a long-term intubation.

The second phase consists of treatments directed towards bleeding control and suturing situationally soft tissues. In cases of defective wounds, these are sutured by “enwreathing”. No long-term actions may be undertaken (such as osteosynthesis), bone fragments are fixed temporarily mainly by fixtures and dental splints.

The phase of stabilization of the general patient’s condition does not mean a period of a physician’s inactivity. A definite therapy and further treatments should be planned. An inter-disciplinary collaboration helps to specify a diagnosis and get all technical tools ready. A sufficient fixation of bone fragments has to be provided during the awaiting phase. Care should be also taken about the oral cavity, damaged soft tissues and patient’s diet.

A rigid inter-maxillary fixation with the aid of dental splints belongs among the basic methods of treatment of maxillo-facial injuries. In cases of polytraumas is the firm intermaxillary fixation undesirable for the following reasons: it does not allow for intubation by mouth, draining from airways is difficult, lung ventilation is worsened, food intake, introduction of a stomach probe and the oral hygiene are troublesome. During the final treatment of fractures of jawbones, it is necessary to use such methods of osteosynthesis that do not require intermaxillary fixation (such as minisplints). Besides taking care of injuries at the last phase of therapy, a complex stomatological treatment should be done. An active rehabilitation is very important as well. Secondary surgeries take place during this phase, as well as necessary corrections in order to achieve optimal results of the treatment and to minimize permanent consequences of an injury.

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