Military Review

Traumatic triad of death. Acidemia and coagulopathy

39
Traumatic triad of death. Acidemia and coagulopathy

About hypothermia, which is part of the triad, you can read here.


The article is for informational purposes and tries to explain complex processes in as simple a language as possible. You will not determine acidosis or coagulopathy “by eye”, but knowing how it works, what causes it and what consequences it has, you may have a slightly better chance of holding the victim until help arrives. "He who is warned is armed" - folk wisdom.

Hypovolemic shock (from Latin hypo - lower, volume - volume) is a pathological condition caused by a rapid decrease in the volume of circulating blood.

Accompanied by changes in the cardiovascular system and acute metabolic disorders: a decrease in stroke volume and filling of the ventricles of the heart, deterioration of tissue perfusion (blood supply in natural conditions), tissue hypoxia (decrease in the level of oxygen supply) and metabolic acidosis (arterial blood pH disorders).

Hypovolemic shock is a compensatory mechanism designed to ensure normal blood supply to internal organs in conditions of insufficient blood volume. With the loss of a large volume of blood, compensation is ineffective, hypovolemic shock begins to play a destructive role, pathological changes are aggravated and lead to the death of the patient.

Reasons for the development of hypovolemic shock:

1) irretrievable loss of blood during bleeding;
2) irretrievable loss of plasma and plasma-like fluid in trauma and pathological conditions. Characteristic of extensive burns;
3) deposition (accumulation) of a large amount of blood in the capillaries. It is observed with injuries and some infectious diseases;
4) loss of a large amount of isotonic fluid during vomiting and diarrhea.

With a decrease in the volume of blood in the body, baroreceptors are irritated and an additional portion of blood is released into the general bloodstream, which is stored in the bones, liver and spleen. If this is not enough, the body tries to save the brain, heart and lungs first of all. Peripheral vessels narrow, and active blood circulation continues only in the vital organs.

If it is not possible to compensate for the lack of blood further, centralization intensifies even more, and the spasm of peripheral vessels increases.

Further, due to the depletion of the compensatory mechanism, the spasm is replaced by paralysis of the vascular wall and a sharp expansion of the vessels. As a result, a significant part of the circulating blood goes to the peripheral regions, which leads to aggravation of circulatory failure of vital organs. These processes are accompanied by gross violations of all types of tissue metabolism.

The main signs of hypovolemic shock are a progressive increase in heart rate (tachycardia), a decrease in blood pressure (hypotension), pale skin, nausea, dizziness, and impaired consciousness.

Metabolic acidosis or acidemia


In simple terms, this is an acid-base disorder that is manifested by depression of the myocardium, the respiratory center and a decrease in sensitivity to catecholamines (for example, neurotransmitters such as adrenaline, norepinephrine, dopamine or dopamine).

It is diagnosed on the basis of the results of a laboratory study of indicators of acid-base balance (acid-base state). Specific treatment is infusion (slow administration of a substance, most often intravenously) buffer solutions (a solution with a stable concentration of hydrogen ions).

With acidosis, the activity of biologically significant proteins changes due to the shift of acid-base balance to the acidic side. Develops with shocks of any origin. When the cause of the failure is eliminated, the normal state of the internal environment is restored without medical intervention. Severe acidosis requires urgent treatment in the intensive care unit.

Acidemia occurs with increased or decreased excretion of acids by the body, as well as increased excretion of alkaline components of the blood. There are the following types of this state:

· Lactic acidosis. Occurs when the processes of glucose oxidation in the muscles increase. Severe forms of lactic acidosis occur in patients with severe tissue hypoxia, respiratory failure, and a decrease in systolic blood pressure below 70 mm Hg. Art. Acidification does not require correction and disappears on its own soon after muscle relaxation.

Ketoacidosis. They occur in diabetes mellitus, chronic and acute renal failure, alcohol poisoning, methyl alcohol, ethylene glycol, salicylates, impaired excretory function of the liver.

· Loss of grounds. It occurs in a number of diseases of the gastrointestinal tract: prolonged diarrhea, intestinal fistulas, intestinal derivation of urine.

Severe metabolic acidosis at the terminal stage causes depression of the respiratory center. Hyperventilation is replaced by weak shallow breathing. Brain hypoxia develops, leading to loss of consciousness and coma. The activity of the kidneys, liver is disturbed, multiple organ failure occurs. Disturbance of neuromuscular conduction progresses, which causes a disorder in the activity of all body systems. Initially, atrial arrhythmias spread to the ventricles. Fibrillation of the latter is observed, clinical death is diagnosed.

Diagnosis of metabolic acidosis is carried out by an anesthesiologist-resuscitator.

coagulopathy


Roughly speaking, this is a blood disease associated with the ability of blood to clot. Either hypercoagulation and the formation of blood clots inside the blood vessels begin, preventing the free flow of blood, or hypocoagulation and a decrease in the ability of blood to clot with the appearance of a tendency to repeated bleeding and hemorrhage.

The main mechanism of violations of blood properties is an imbalance in the coagulation and anticoagulation systems.

Hypercoagulable syndromes are characterized by a high risk of thrombosis. Clinical manifestations may be completely absent, then coagulopathy is diagnosed only in the laboratory. In other cases, there is rapid blood clotting with minor injuries, thrombosis of venous catheters and needles during blood sampling.

Hypocoagulation syndrome is accompanied by increased bleeding. Bleeding of the capillary type is manifested by the formation of petechiae (a small (1-2 mm) red or purple spot on the skin or conjunctiva, caused by minor bleeding from ruptured capillary blood vessels) and ecchymosis (bleeding into the skin or mucous membrane, the diameter of which is usually greater than 3 mm) on skin, nosebleeds, sometimes - intracerebral hemorrhages.

The traditionally accepted replacement of lost volume with large amounts of crystalloid solutions (to regulate pH and regulate water-electrolyte metabolism) and red cell mass leads to clotting disorders due to dilution, lack of clotting factors and hypothermia.

In particular, hypothermia has adverse effects on enzymes associated with the coagulation cascade and on platelet function.

With the development of coagulopathy, surgical attempts to stop such non-mechanical bleeding, especially from the liver and retroperitoneal space, are usually unsuccessful. Patients with extensive trauma during any major surgery develop coagulopathy after stopping the main sources of bleeding.

Hematologists, hemostasiologists, cardiologists, immunologists, phlebologists and other doctors, who are usually found in hospitals in the rear, and not on the front lines, take part in the diagnosis of coagulopathy.

Conclusions


Despite the specificity of the topic raised and its complexity for the perception of an ordinary person, certain conclusions can be drawn.

First, as with most disease-related cases, preventing the development of the condition is the primary tool in dealing with it.

Secondly, the development of a worsening condition is not always associated with any “bright event”, for example, a gunshot wound. Banal significant hypothermia or severe diarrhea can cause the development of conditions that worsen the situation due to the inability to cope with the cause normally.

Thirdly, it is critical to always have radio communication and the ability to carry out medical and evacuation measures. At the stage of stopping massive bleeding история does not end, but only begins. For the provision of first aid according to any of the protocols, evacuation should follow, and how much time you have for this directly depends on the literacy of the actions.

Fourthly, a person who has read such "abstruse" texts, or a medical instructor, will not always be able to be nearby. In this situation, the obligation to provide assistance will lie with you, and it will be too late to regret ignorance.
Author:
39 comments
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  1. O. Bender
    O. Bender 24 October 2022 06: 29
    +12
    I didn’t understand what to do. Except as a hospital, the author didn’t provide options. It’s a pity there is no resuscitation at the front end, and it’s not clear which drugs to use. With a quick and large loss of blood, only a tourniquet and a hemostat, if you have time. You can't always use painkillers yourself.
    1. Doctor
      Doctor 24 October 2022 09: 26
      +9
      I didn’t understand what to do. Except as a hospital, the author didn’t provide options. It’s a pity there is no resuscitation at the front end, and it’s not clear which drugs to use. With a quick and large loss of blood, only a tourniquet and a hemostat, if you have time. You can't always use painkillers yourself.

      I translate into human. laughing

      When a person loses a lot of blood (more than 1,5 liters), the body tries to maintain the life of the main organs - the brain, heart and lungs.
      Blood begins to circulate between these three organs, and oxygen starvation occurs in other tissues.
      To survive, the cells of other organs start biochemical reactions that take place without oxygen. But during these reactions, acids accumulate in them - a general "acidification" of the body occurs. This is called acidosis.
      pH is an indicator of the degree of acidity. The norm is 7,35 - 7,45. Below - acidosis, above - alkalosis (reverse process, alkalization).
      pH 6,8 and below - death.

      There is only one salvation - to put a dropper as soon as possible and pour a lot of liquid into a vein. Lost a liter of blood - you need to pour 2 liters of water (roughly). Then the blood with oxygen (albeit diluted with water) will reach the peripheral organs.
      1. Simple
        Simple 24 October 2022 10: 44
        +1
        the body tries to keep the main organs alive


        The key word here is "trying" because. everyone's limits are different.

        As long as the body of one person with the same lesions will redirect the internal bloodlines, while being conscious, the brain of another individual can already receive the irreversible consequences of oxygen starvation.
        And what's the point of instructions if there was no comrade nearby who could stop the blood loss, not to mention a dropper.
        1. Doctor
          Doctor 24 October 2022 11: 39
          +5
          The key word here is "trying" because. everyone's limits are different.

          As long as the body of one person with the same lesions will redirect the internal bloodlines, while being conscious, the brain of another individual can already receive the irreversible consequences of oxygen starvation.
          And what's the point of instructions if there was no comrade nearby who could stop the blood loss, not to mention a dropper.

          Organisms on the front line are about the same. The question is the volume and speed of blood loss. This question was studied back in Auschwitz. wink

          The more blood loss, the lower blood pressure (little fluid in the vessels), more frequent pulse and breathing (the body tries to quickly pump the rest of the blood and catch up with oxygen), paler and colder skin (blood leaves the tissues to the brain and lungs), less urine ( little fluid).
          If more than 2 liters, the brain is already lacking, first lethargy, then the body switches the brain to an economical mode of operation (disconnects from external stimuli).

          The dependency is something like this:

      2. O. Bender
        O. Bender 24 October 2022 10: 57
        +3
        Ok, thank you, live forever and learn. But again, the question is what to pour in and where to get it.
        1. Doctor
          Doctor 24 October 2022 12: 39
          +7
          Ok, thank you, live forever and learn. But again, the question is what to pour in and where to get it.

          There are two approaches.

          US - pour in a lot of water (sterile naturally) with mineral additives. These solutions are called crystalloids. Examples: saline (0,9% common salt solution), glucose 5,10% (sugar in water), various combinations of other salts (disol, trisol, acesol, sterofundin, etc.). For the battlefield, Americans have packages of up to 3 liters at once with a dropper and a valve to prevent air from entering. Entered the vein, put under the patient and drove. The solution is squeezed out under the weight of the body.

          European - to introduce the so-called. colloid solutions. This is water with the addition of large starch molecules. Examples: gelofusine, voluven. These solutions raise the pressure faster but are less physiological.

          Competent special forces carry with them a bottle of colloid and a dropper per person, in ordinary troops it should begin with a company orderly (already a doctor, ideally a paramedic).
          1. decimalegio
            decimalegio 25 October 2022 14: 06
            +2
            Thanks for the info. Interesting. I always like to have information about different approaches to the same problem. hi
      3. Thrifty
        Thrifty 24 October 2022 12: 15
        +1
        Arzt- but will not excess water in the blood lead to the impossibility of blood clotting normally? Wouldn't it turn out, on the contrary, some pathology of the blood, such as leukemia? Maybe, instead of water or plasma, use some weak chemicals or solutions?
        1. Doctor
          Doctor 24 October 2022 12: 49
          +7
          Arzt- but will not excess water in the blood lead to the impossibility of blood clotting normally? Wouldn't it turn out, on the contrary, some pathology of the blood, such as leukemia? Maybe, instead of water or plasma, use some weak chemicals or solutions?

          Until then, things won't get done. First of all, it is necessary to prevent acidosis, for this it is necessary to prevent the centralization of blood circulation, as they say, to prevent the periphery from "closing". This is where the acidification process begins. The pH can drop to critical in an hour or so.

          Therefore, the main thing:
          1. Immediately stop ANY bleeding, even peripheral. Do not forget that they can hurt again and then everything is summed up.
          2. Start intravenous infusion as soon as possible.

          As for blood coagulation factors (platelets in the first place), for this you need to pour donor plasma or thrombus suspension. And before that, it must be prepared (by blood type). And before transfusion - defrost (and not quickly, but according to technology). Karoch, only at the hospital level.

          Although the medical services of some armed forces did this in the Second World War at the level of a battalion first-aid post. laughing



          PS By water, I mean just different salt solutions. But they do not have clotting factors, only plasma or thrombus suspension.
          Leukemia is an excess of white blood cells (protective blood cells). It happens with leukemia (blood cancer).
      4. fif21
        fif21 24 October 2022 19: 39
        +2
        Quote: Arzt
        I translate into human.

        You need to write in human. fool
        Bleeding - capillary, venous, arterial, parenchymal (of internal organs). Venous - dark blood, arterial - scarlet blood.
        Stop capillary - sterile dressing. Stopping venous, arterial - tourniquet, twisting. The tourniquet application time is an hour in winter, 1,5 hours in summer, but not more than 2 hours.
        Loosening the tourniquet after 60 minutes in summer and 30 minutes in winter for 15 minutes with a transfer of 3-5 cm higher. We look at the presence - no bleeding.
        With a venous tourniquet, you can not use it (coagulated blood itself will clog the damaged vein, if the blood is poorly clotting, the tourniquet is used), a tight sterile bandage. Arterial, only tourniquet. If the bleeding has stopped, a tourniquet is removed, the twist is removed, the bandage is not touched. The hardest part is internal bleeding. And be sure to specify the overlay time. Everything else does not apply to first aid. Evacuation - as soon as possible. The sooner the wounded falls into the hands of doctors, the greater the chance of survival. Therefore, it is important to sort the wounded - someone on the table, and who can wait. That's what the "pill" taught us recourse
      5. decimalegio
        decimalegio 25 October 2022 14: 00
        +1
        Thank you for translating into an understandable language even for those who have not graduated from medicine. Now I can close my mouth, opened in amazement at what I read. belay
  2. Dmitry Ivanov_8
    Dmitry Ivanov_8 24 October 2022 08: 03
    +9
    Judging by the video of the wounded with amputations, not a damn thing in our army do not know how to use tourniquets. There was already a srach on YouTube in the comments: which is better - the Esmarch tourniquet or the NATO turnstile. So, all are equally bad if you do not know how to impose them correctly. Pictures of how to properly apply a tourniquet / tourniquet during bleeding, in my opinion, were in the USSR textbook for grade 9 in biology. And yes, a tourniquet can also be applied to the carotid artery :) Surprised? Google the picture for how to do it.
    Z.Y. I am writing from my couch from the intern's room of the X-ray endovascular and vascular surgery department ... As for the rest, these are common truths for any doctor. Restoration of BCC and relief of shock.
    1. Archimedos
      Archimedos 24 October 2022 11: 36
      +8
      Well, even in the Soviet encyclopedia there were sections on first aid, how to apply tourniquets, how to stop bleeding, and so on and so forth. Soviet education was good, but let the indignant defenders of modernity eat me up. And in the book on anatomy there was a paragraph devoted to this. And how they drove us to the NVP ... mmm, how they drove us ... Tsimes!
    2. Bingo
      Bingo 24 October 2022 17: 31
      -1
      Quote: Dmitry Ivanov_8
      Pictures of how to properly apply a tourniquet / tourniquet during bleeding, in my opinion, were in the USSR textbook for grade 9 in biology.

      You just can’t learn how to apply a tourniquet from pictures, and in general, only someone who has applied it more than once can correctly apply a tourniquet ... Not as a reproach, you just probably know for sure that therapists can know and know how, they even taught on mannequins and on classmates .. But as a result, the nerve is squeezed - like two fingers. And the turnstile is somewhat more difficult than Esmarch. In the same place, only the first two rounds are tight, and all those who have completed first aid courses are stretched until the last round, and there a pancake from the nerve remains, a classic mistake.
  3. Dmitry Ivanov_8
    Dmitry Ivanov_8 24 October 2022 08: 07
    +2
    I will quote the author:
    Patients with extensive trauma during any major surgery develop coagulopathy after stopping the main sources of bleeding.

    It's called DVS.
    1. Bingo
      Bingo 24 October 2022 10: 44
      +3
      And information about him, as far as I remember, is not recommended for distribution, otherwise they will read too much and heal themselves. That is why the medical libraries of the USSR / RF were closed. In Jerome Klapka Jerome, "Three in a Boat" it is well described how the patient found all the sores in himself, except for puerperal fever
  4. Aviator_
    Aviator_ 24 October 2022 08: 44
    +4
    Interesting note. It should be more accessible, at least in the final part - the timing of the withdrawal from the shock, etc.
  5. APASUS
    APASUS 24 October 2022 09: 00
    +3
    Fifthly: The training of the mobilized must take place properly. The theoretical and practical parts must be completed in full.
    It is worth paying attention to the field of military medicine, equipment, training of field medicine personnel. Equipment and modern equipment.
  6. Doctor
    Doctor 24 October 2022 09: 16
    +3
    Coagulopathy, stroke volume, blood pH, catecholamines, isotonic fluid....
    Valery, an ordinary person will read such an article as in Persian - with a dictionary. laughing

    It should be easier - and people reach out.
    1. Ka-52
      Ka-52 24 October 2022 10: 45
      +6
      the author was too carried away by the description of the phenomenon and the symptomatology of the processes. From the point of view of applied medicine - stupid knowledge. The author expressed the whole result of this article in only one suitable phrase:
      Thirdly, it is critical to always have radio communication and the ability to carry out medical and evacuation measures. At the stage of stopping massive bleeding, the story does not end, but only begins. For the provision of first aid according to any of the protocols, evacuation should follow, and how much time you have for this directly depends on the literacy of the actions.

      but for the most part, this is a no-brainer. In general, an incomprehensible article is not clear why request
      1. minus
        minus 24 October 2022 19: 16
        0
        An article for the sake of an article. Judging by the publications, just another "expert *
    2. Doccor18
      Doccor18 24 October 2022 13: 01
      +2
      Quote: Arzt
      It should be easier - and people reach out.

      The key.
      It is better, blindfolded, to be able to find a tourniquet in your (and colleague's) first-aid kit and, in the prone position, apply it correctly and quickly than to read about
      intestinal diversion of urine.
  7. Bingo
    Bingo 24 October 2022 10: 33
    +5
    Well, here the author got carried away. This is the case when the level of the orderly / nurse does not roll. The paramedic can still make a preliminary diagnosis ... Although what am I talking about? If the client is rinsed to a really significant loss of fluid, then he will be sent from the front line, he is not combat-ready, there should be such a rinse ... That anyone who has not even heard of medicine will suspect dysentery. The blood loss is such that blood is thrown out of the depot - Christmas trees, you don’t even have to pour a liter there, there is also a direct road to the hospital, and everyone knows everyone there anyway ...
    In short, an extra article on VO.
    The author, it would be better if the technique for determining bleeding, venous-arterial-capillary, well, the basics about, for example, parenchymal and the basics of dressings were described, it will be more useful for people. What will a non-medic take out of the article? What if a person has plopped down and does not move his hands - does he need to go to the hospital? And no one will guess...
    You, as I understand it, decided to make a series of articles from the category of medlikbez? Well, here you need less theory, more practice, so that you live at least to the orderly
  8. Mikhail3
    Mikhail3 24 October 2022 11: 38
    +1
    In this situation, the obligation to provide assistance will lie with you, and it will be too late to regret ignorance.
    Completely, yat, I agree! Where are the recommendations on what to do?
  9. Knell wardenheart
    Knell wardenheart 24 October 2022 19: 14
    +2
    Immobilization, warming, moderate warm drinking and (possibly) a dropper with saline, standard painkillers (in addition to stopping bleeding, a tourniquet, bandaging) - these are all the measures that a person of the level of "everyman" can do in such a case (and of course evacuation how to stabilize condition and if there is anything). A bunch of abstruse terms are unlikely to help here, although thanks to the Author for describing in detail the mechanism for the development of collapse. This is not too much to know.

    Otherwise, the average person will not have available means of providing more assistance and / or the right to provide it. This requires mass courses, and I'm surprised that so far no one has scratched the surface of organizing something similar, at least in a televised format.
    1. fif21
      fif21 24 October 2022 21: 55
      0
      Quote: Knell Wardenheart
      (possibly) a dropper with saline, standard painkillers (in addition to stopping bleeding, a tourniquet, bandaging) - that's all the measures that a person of the "everyman" level can do in such a case

      Dropper? Not every nurse can get into a vein. hi
      1. Dmitry Ivanov_8
        Dmitry Ivanov_8 24 October 2022 22: 42
        0
        Last Saturday, a patient was brought in with angina pectoris, so the "squirrels" put an "armour" (also green - max diameter) in the brachial artery. So they can!
        1. marswell
          marswell 24 October 2022 23: 05
          +1
          armor, and even green, it’s actually what and with what they eat it
          1. Doctor
            Doctor 26 October 2022 16: 59
            0
            armor, and even green, it’s actually what and with what they eat it

            Catheter for peripheral veins. Now they don’t put needles anymore, he pricked and left a soft catheter in the vein, you can move your hand, it won’t pierce the wall.


            Sizes - depending on the color, green is one of the most popular.

            1. marswell
              marswell 26 October 2022 20: 05
              +1
              wow thanks!!! I'll know - a mechanic by life and education - but all the same, I and my son and our dog faced this in life. And for my youngest son, at the age of six months, this little thing practically saved his life!
      2. Bolt cutter
        Bolt cutter 24 October 2022 22: 59
        +1
        Not every nurse can get into a vein.
        For such cases, experienced drug addicts are preferable. laughing .
        1. Doctor
          Doctor 26 October 2022 16: 54
          +2
          Not every nurse can get into a vein.
          For such cases, experienced drug addicts are preferable to laughing.

          Yeah. The killers are already there, they are sniping, it remains to call junkies to the medical service)). laughing
  10. cpls22
    cpls22 25 October 2022 14: 32
    +1
    Further, due to the depletion of the compensatory mechanism, the spasm is replaced by paralysis of the vascular wall and a sharp expansion of the vessels. As a result, a significant part of the circulating blood goes to the peripheral regions, which leads to aggravation of circulatory failure of vital organs.

    Whether this sharp expansion of vessels is followed by a loss of consciousness?
    And if so, what follows what?
    1. Doctor
      Doctor 26 October 2022 17: 09
      0
      Further, due to the depletion of the compensatory mechanism, the spasm is replaced by paralysis of the vascular wall and a sharp expansion of the vessels. As a result, a significant part of the circulating blood goes to the peripheral regions, which leads to aggravation of circulatory failure of vital organs.

      Whether this sharp expansion of vessels is followed by a loss of consciousness?
      And if so, what follows what?

      Oppression of consciousness is a defense mechanism. With a lack of oxygen, the brain turns off external stimuli in order to switch to a more economical mode of operation.
      Blood (erythrocytes, in particular) carries oxygen, so the more blood loss, the deeper the depression of consciousness, up to a complete loss (coma).

      Degrees of oppression of consciousness:



      PS By the way, despite the fact that the weight of the brain is about 2% of the total body weight, it consumes 15% of the volume of circulating blood. It is in a calm state. And in excited and all 30%.
      And half of all glucose produced by the body. hi
      1. cpls22
        cpls22 26 October 2022 22: 21
        +1
        But what about the numerous filmed episodes, when a doctor or medical instructor persuades the wounded man not to turn off, constantly pulling him so that he speaks to him while remaining conscious? Is it not in order to delay the moment of a sharp expansion of blood vessels, and to prolong the action of the compensatory mechanism? If so, it would be nice to mention this in the article as a recommendation ..
        1. Doctor
          Doctor 27 October 2022 09: 18
          0
          But what about the numerous filmed episodes, when a doctor or medical instructor persuades the wounded man not to turn off, constantly pulling him so that he speaks to him while remaining conscious? Is it not in order to delay the moment of a sharp expansion of blood vessels, and to prolong the action of the compensatory mechanism? If so, it would be nice to mention this in the article as a recommendation ..

          Forget about this "vasodilatation". The medical instructor pulls so that the unconscious patient does not suffocate. In patients in a coma, in the supine position, the tissues of the oropharynx relax and block the airways. Or a foreign body, vomit, etc. During the Nord-Ost terrorist attack, most of the dead simply suffocated in their sleep.



          A pin was inserted into the IPP of the USSR SA sample. In a patient in a coma, the tongue was pierced with a pin and pinned to the shoulder. Tough but effective. laughing
          1. cpls22
            cpls22 27 October 2022 10: 06
            +1
            I see. Thanks. In the light of the story with the pin, the idiom is perceived in a completely different way - "tongue on the shoulder").
            Or did she go from there?
            1. Doctor
              Doctor 27 October 2022 11: 11
              0
              I see. Thanks. In the light of the story with the pin, the idiom is perceived in a completely different way - "tongue on the shoulder").
              Or did she go from there?

              Surely, this is a highly specialized topic. Most people know about the air duct, but it must be controlled so that it does not fall out, and even with a massive influx of coma (for example, a chemical attack), you will not get enough air ducts for everyone. And the pin is always in the IPP.
  11. Eule
    Eule 4 November 2022 09: 59
    0
    It is difficult and incomprehensible to a person with a non-core education, who has one and a half doctors in the family. (mother is a prosthetist in limbs, dad of the last girlfriend is a traumatologist and pathologist with the right forensic medical examination). But for paramedics, this is probably a very useful text.
    I really want to read about the differences in the Soviet and Reich / NATO sorting of the wounded. I understand that the topic is very slippery, but if there are more wounded than able to help, then healthy people should know who can be saved and who should not be wasted time instead of helping those who can be helped.