Toxic syndrome

Toxic syndrome (toxicosis with exsicosis and neurotoxicosis).

Etiology. Most often occurs in gastrointestinal diseases of infectious nature (colienteritis, secondary toxicosis in dysentery, salmonella, staphylococcal enteritis). Toxic syndrome can develop in some hereditary metabolic diseases (intolerance of disaccharides, renal tubular acidosis, lactic acidosis, adrenogenital syndrome with loss of salt, hypoapdosteronism).

Pathogenesis. Initial intoxication, dehydration (loss of water and salts with vomiting and liquid stool), hemodynamic disorders (various types of vascular collapse). Insufficiency of blood circulation leads to damage of all systems and organs of the child, to the violation of tissue respiration and exhaustion of the energy resources of the organism and serves as an immediate threat to the life of the patient.

Clinical picture. Toxicosis is characterized by oppression of the child's reactions to external stimuli. After a short period of excitement, consciousness is disturbed to a varying degree: somnolence, co-infection, coma. The most important manifestation of toxicosis are cardiovascular disorders, as evidenced by a gray-earthy skin tone, cold extremities, a frequent pulse of weak filling. Increased at the beginning of the toxicosis of AD in the future falls. Dimensions of relative and absolute cardiac dullness are reduced, heart sounds are deaf. In the lungs - the phenomena of toxic emphysema. In connection with the violation of pulmonary circulation, there appear small wet rales. The most important sign are disorders of metabolism, the main one of which should be considered exsicosis (dehydration). It is characterized by certain quantitative and qualitative characteristics. Initial clinical manifestations of exsicosis (dry skin and mucous membranes, sunken a large fontanel and eyeballs, decreased tissue turgor) are detected with a loss of 6-8% of the original mass. Deficiency of 10% of mass, as a rule, is associated with pronounced exciticosis, and with a loss of 15% of body weight, severe exsicosis develops.

Depending on the prevalence of water and salt losses, there is a distinction between salt deficiency exsicosis, "pure" or water-deficient exciticosis, and isotonic dehydration. Hypotonic dehydration is noted during vomiting and liquid stool, characterized by a sharp insufficiency of the peripheral circulation. Almost constant is potassium deficiency syndrome. Its signs: 1) persistent inhibition, depression, from which the child can not be withdrawn even with the help of intravenous drips, if the loss of potassium is not compensated; 2) muscle hypotension and hyporeflexia; 3) violation of breathing (weakness of respiratory muscles); 4) widening the boundaries of cardiac dullness, tachycardia, arterial hypotension, lengthening of the interval (QT and inversion of the T wave on the ECG; 5) intestinal paresis, flatulence; 6) a violation of the concentration ability of the kidneys (renal water loss). In hypertensive dehydration (water-deficient excitosis), the child is nervous, restless. The temperature is often high. Tension of the occipital muscles, convulsions are noted. Peripheral blood circulation remains satisfactory for a long time, the pulse is frequent, but good filling, blood pressure is increased. With isotonic dehydration (isotonic exsicosis) there is a combination of signs of the described options; Prognostically, it is more favorable.

Treatment. The child is prescribed a drink of 5% glucose solution and Ringer's solution for 1-2 teaspoons every 5-10 minutes. A good effect can be obtained with the early appointment of Moro carrot soup (500 g of carrots pour water to 1 liter, cook for 2 hours, then double-rub through a sieve, bring the volume to 1 liter, boil for 10 minutes and bottled). Then, fractional feeding with expressed milk (maternal or donor) is prescribed for 10 ml every 2 hours, continuing with the introduction of Moro soup, glucose-saline solutions. In the following, 10-15 ml of milk are added daily to each feeding, and with a significant decrease in the severity of the toxicosis the child is allowed to apply to the breast.

Assign antibiotics that act on gram-negative flora, levomycetin, polymyxin, with staphylococcal enteritis - erythromycin, broad-spectrum antibiotics - ampicillin, etc. Rehydration therapy: iv injection of plasma or its substitutes at a rate of 5-10 ml / kg. After this, a drip IV infusion is introduced for a solution that is uniform for all types of exsicosis: isotonic (0.85%) sodium chloride solution and 5% glucose solution in a ratio of 1: 2. When the overall clinical and biochemical picture becomes clear, the quality composition of the fluids changes.

With water-deficient exsicosis, the total amount of isotonic sodium chloride solution is reduced so that it is not more than 1/4 of the total volume of injected fluids. With salt deficiency, the isotonic sodium chloride solution is administered at a rate of up to 100 ml / (kg-day). Pronounced acidosis (large breathing of the Kussmaul type) requires replacing half of the total amount of isotonic sodium chloride solution (about 50 ml / kg) with 0.25% sodium bicarbonate solution. At the phenomena of potassium deficiency it is administered at the rate of 100-200 mg / kg for 5-6 days in the form of 0.3% potassium chloride solution at 30-50 ml / kg, prescribed for drinking. For parenteral administration, a 1.1% solution of potassium chloride is used in a 10-20% glucose solution at a rate of 3-4 ml / (kg-day), preferably under ECG control. Early elimination of potassium deficiencies, fruit juices, vegetable broths, carrot mixes . The total amount of fluid injected into the child and parenterally is determined by the degree of water deficiency (10% of body weight), the daily requirement of the child in water (about 80 ml / kg), the loss of water after the start of treatment. A child weighing 6 kg should thus receive 600 ml (10% mass) + (6 X 80) = 1080 ml of liquid. Parenterally, without significant cardiovascular overload, about 80% of the total daily amount of fluid can be administered. Subcutaneous, intragastric and other infusion methods do not eliminate the main threat to life - insufficiency of peripheral circulation. Corticosteroids (hydrocortazone) are used to accelerate the rehydration. They are especially shown at a collapse (prednisolone on 1 mg / kg). It is advisable to administer them in the first half of the day for 5-6 days. The dose of the drug is gradually reduced during this course.

In a number of cases (with child excitation, persistent vomiting), it is possible to use aminazine at a rate of 2 mg / (kg-day) in 4 doses or in / m (should not be used in coma, vascular collapse, toxic-septic state).

Neurotoxic syndrome. The leading importance in pathogenesis is the direct toxic effect of toxins on the central nervous system, microcirculation disorders, resulting in cerebral edema, necrosis, diapedemic hemorrhages. The syndrome can be observed in dysentery, influenza, respiratory viral diseases, meningitis, meningoencephalitis, staphylococcal and other infections.

The most important sign of a neurotoxic syndrome is the absence or weak manifestation of the phenomena of exsicosis. Characteristic disorders of consciousness of various degrees up to coma, general generalized tonic and clonic convulsions against a background of muscular hypertension, disorders of thermoregulation and heat production (hyperthermia), hyperventilation, violation of cardiac activity (coronary insufficiency, tachycardia up to 200 strokes per 1 min or more, shift of the ST interval ECG), circulatory disorders of the "centralization" type, when high blood pressure is combined with a decrease in pulse amplitude, impaired renal function, osmoregulation-hyperelectrolithy disorder, fluid retention in tissues. In most cases, a sudden beginning is characteristic; Vomiting, liquid stupas, dehydration with gastrointestinal diseases are joined later.

Treatment. Abrupt excitation of the patient, absence of the effect of the therapy is the basis for the appointment of neuroplagic drugs (contraindicated in the case of vascular collapse with symptoms of diffuse CNS inhibition). Aminazine (or propazine) is administered in combination with pipolfen [in the form of 2.5% w / w solutions at the rate of 2-4 mg / (kg-day)] of each drug. Neuroplegic drugs are also used in conjunction with dimedrol, suprastin. Their various combinations are included in the composition of the lytic mixtures. A mixture consisting of a daily dose of aminazine, pipolpene, 0.2 ml of a 1% solution of promedol and a 0.25-0.5% solution of novocain in an amount twice that of aminazine and pipolpene combined is widely used. Some authors also recommend phenobarbital for 2-3 mg / (kg-day).

In order to eliminate hyperthermia, a 1% solution of amidopyrine in 0.5 ml / kg (or 4% solution of 0.1 ml / kg) with 50% solution of analgin (0.1 ml per year of life) is shown in / m. With a sharp pallor to relieve the spasm of peripheral vessels, baby skin is gently rubbed with 70% alcohol until redness. With persistent hyperthermia, active cooling measures are taken: exposing the child, blowing the skin with a fan, wrapping with diapers moistened with room temperature water; Cold to the head and large vessels; IV infusion chilled to 4 g. With 20% glucose solution; Siphon enema with an isotonic solution of sodium chloride at room temperature, washing the stomach with water at a temperature of 18 ° C (and even 4-5 ° C) for 7-10 minutes. Body temperature should not fall below 37.5 g. C. In severe condition in / in or / m and simultaneously inside enter corticosteroids at the rate: prednisopone-1 2 mg / (kg-day), hydrocortisone - 3-5 mg / (kg-day). With the syndrome of Waterhouse-Frideriksen (acute adynamia, loss of consciousness, deafness of the heart tones, tachycardia, vomiting, dryness of the mucous membranes and skin, loose stools, hemorrhages), immediately enter into / in 20-50 mg hydrocortisone (for the / m administration is also prescribed High doses - 50 mg), prescribe DOCA, adrenaline.

To dehydrate IV infusion of 10-20% glucose solutions, plasma at a rate of 10-20 ml / kg in the ratio of 2: 1, 3: 1 in combination with drugs of diuretic action. A fast diuretic effect is exerted by furosemide (Lasix), which is prescribed to children inside or in / m at a dose of 1-3 mg / kg / day and even 3-5 mg / kg / day at 2-3 hours IV. Edema of the lungs (in an ampoule in 2 ml of solution contains 20 mg of the drug). If necessary, the administration can be repeated after 20 minutes. Subsequent administrations are given either in / m or inside. The drug is contraindicated in renal failure with anuria, renal coma, hypoelectrolithy. Strong diuretics are diacarb, mannitol (5 ml / kg 10% w / w solution) and urea (5-10 ml of 30% solution intravenously); Contraindicated in renal and hepatic insufficiency. The introduction is carried out under strict control of diuresis.

It is advisable to control the value of the osmotic pressure of the blood plasma by cryoscopy.

Assign iv administration of 10% calcium chloride solution to 0.5-1 ml per year of life or 10% calcium gluconate solution per 1 ml per year of life in order to reduce permeability of the vascular wall and diuretic action. To dehydrate into the stomach through the probe, glycerol is added at a rate of 3-4 ml / (kg-day).

Apply nonspecific detoxification therapy: low-molecular-weight plasma substitutes (neocompensane, hemodez, reopolyglucin - 10-15 ml / kg), glucose-saline solutions in / in the drip (with the insertion of a catheter into the subclavian vein - through the catheter). The total amount of fluid initially does not exceed 100-300 ml, depending on the age; Further calculation is carried out taking into account the general condition of the patient on the basis of strictly controlled diuresis with constant addition as the elimination of hyperhydration is 15% of the volume of the allocated urine. The liquid is injected at a rate of 4 to 6 drops per minute. Drip administration of solutions should be especially cautious in newborns because of the propensity to form edema.

In addition to neocompensan, 10% glucose solution, saline solutions in a ratio of 3: 1, add to the dropper diuretic drugs, antibiotics, cardiac drugs, sodium hydrogencarbonate, antihistamines, vitamins, etc. With less toxic toxicity, solutions in the amount of 100-200 ml in Depending on age, administered 2 times a day without the addition of diuretics; The role of osmotic components is performed by plasma colloids - 20-40% solutions (20 ml).

To achieve anticonvulsant, hypotensive and sedative effect, magnesium sulfate is given (injected in / m as a 25% solution at the rate of 0.2 ml / kg), then in / m or / in a 0.5% solution of seduksen (child 1 year - 0.5-1 ml). When convulsive syndrome (see) lead appropriate therapy.

The phenomena of cardiovascular insufficiency serve as a direct indication for the introduction of cardiac glycosides: 0.1-0.2 ml of a 0.05% solution of strophantin in / 1-2 times per day in 10 ml of 20% glucose solution: 0.1-0, 3 ml of 0.06% solution of Korglikon IV in slowly in 10 ml of 20% solution of glucose and cocarboxylase (25-50 mg once a day). With moderate manifestations of heart failure, digoxin is prescribed [initially at a saturation dose of 0.05 mg / (kg-day) given every 8 hours, i.e., 3 times for 1-2 days of treatment, and then in a maintenance dose equal to 1 / 5 saturation doses].

When a paralytic collapse threatens, drip IV infusions of plasma, 10% glucose solution and isotonic sodium chloride solution or Ringer's solution are shown. In connection with the possibility of hyperlectrolysis, the amount of saline solutions should not exceed 1/4 of the total volume of the injected fluid in order to avoid the growth of edema and swelling of the brain.

With hemorrhagic syndrome, inside or in / to inject 10% calcium chloride solution, rutin in combination with large doses (up to 500-1000 mg) of ascorbic acid, vikasol (inside or in / m), a positive effect gives hormones.

Antibiotics of a wide spectrum of action are shown at suspicion on an intestinal infection-levomitsetin, polymiksin, etc. At a flu enter an influenza gamma globulin. An obligatory element of the complex therapy of neurotoxic syndrome is the introduction of vitamins, especially C and B group.

The prognosis is serious.

Prevention: early diagnosis and treatment of the underlying disease.