SHOCK

SHOCK is observed in various pathological conditions and is characterized by insufficient blood supply to tissues (decreased tissue perfusion) with impaired function of vital organs. Infringement of blood supply of tissues and organs and their functions arise as a result of collapse - acute vascular insufficiency with a drop in vascular tone, a decrease in the contractile function of the heart and a decrease in the volume of circulating blood; A number of researchers generally do not distinguish between the concepts of "shock" and "collapse." Depending on the cause that caused the shock, they distinguish: pain shock, hemorrhagic (after blood loss), hemolytic (with blood transfusion), cardiogenic (due to myocardial injury), traumatic (after severe injuries), burn (after extensive burns), infectious- Toxic, anaphylactic shock, etc.

The clinical picture of shock is caused by a critical decrease in capillary blood flow in the affected organs. The examination is characterized by the face of a patient who is in a state of shock. It is described by Hippocrates (hippocratic mask): "... The nose is sharp, the eyes are sunken, the temples are depressed, the ears are cold and tightened, the lobes of the ears are lapidated, the skin on the forehead is firm, stretched and dry, the color of the entire face is green, black or pale, or lead". Along with the marked signs (a drained earthy face, sunken eyes, pallor or cyanosis) draws attention to the patient's low position in the bed, immobility and indifference to the surrounding, barely audible, "reluctant" answers to questions. Consciousness can be preserved, but confused, apathy and drowsiness are noted. Patients complain of severe weakness, dizziness , chilliness , blurred vision, tinnitus, sometimes a sense of anguish and fear. Often, drops of cold sweat appear on the skin, the extremities are cold to the touch, with a cyanotic skin tone (the so-called peripheral signs of shock). Breathing is usually rapid, superficial, with oppression of the respiratory center due to the increasing hypoxia of the brain, apnea is possible. There is an oliguria (less than 20 ml of urine per hour) or anuria .

The greatest changes are observed from the side of the cardiovascular system: the pulse is very frequent, weak filling and tension ("filiform"). In severe cases, it can not be probed. The most important diagnostic sign and the most accurate indicator of the severity of the patient's condition is a drop in blood pressure. The maximum, and minimum, and pulse pressure decreases. About shock can be said with a decrease in systolic pressure below 90 mm Hg. Art. (In the future it decreases to 50-40 mm Hg or even not determined); The diastolic blood pressure decreases to 40 mm Hg. Art. And below. In people with previous arterial hypertension, the picture of shock can be observed even at higher BP values. A steady increase in blood pressure during repeated measurements indicates the effectiveness of the therapy.

With hypovolemic and cardiogenic shock, all the signs described are quite pronounced. With hypovolemic shock, in contrast to cardiogenic shock, there are no swollen, pulsating cervical veins. On the contrary, the veins are empty, sleeping, getting blood for puncture of the ulnar vein is difficult, and sometimes impossible. If you raise the patient's arm, you can see how the saphenous veins fall off immediately. If you then lower your hand so that it hangs from the bed down, the veins fill very slowly. With cardiogenic shock, the neck veins are filled with blood, signs of pulmonary stagnation are revealed. With infectious-toxic shock, the clinic features a fever with tremendous chills, warm, dry skin, and in far-reaching cases - strictly delineated necrosis of the skin with its rejection in the form of blisters, petechial hemorrhages and pronounced marbling of the skin. In case of anaphylactic shock, in addition to circulatory symptoms, other manifestations of anaphylaxis are noted, in particular skin and respiratory symptoms (itching, erythema, urticaria rash, Quincke's edema, bronchospasm, stridor), abdominal pain.

Differential diagnosis is performed with acute heart failure. As distinctive signs, one can note the position of the patient in bed (low in shock and half-sitting with heart failure), his appearance (with a hock hippocratic mask, pallor, marbling of the skin or gray cyanosis , with heart failure - more bluish puffy face, swollen pulsating veins , Acrocyanosis), breathing (with shock it, rapid, superficial, with heart failure - rapid and intensified, often difficult), widening the boundaries of cardiac dullness and signs of cardiac stagnation (wet wheezing in the lungs, increase and soreness of the liver) with heart failure and sharp Falling BP in shock.

Treatment of shock should comply with the requirements of emergency therapy, i.e., it is necessary to immediately use the drugs that give effect immediately after their introduction. Delay in the treatment of such a patient can lead to the development of gross violations of microcirculation, the appearance of irreversible changes in tissues and to be the immediate cause of death. Since in the mechanism of development of shock the most important role is played by lowering the tone of blood vessels and reducing the flow of blood to the heart, therapeutic measures should primarily be aimed at increasing venous and arterial tone and increasing the volume of fluid in the bloodstream.

First of all, the patient is laid horizontally, i. Without a high pillow (sometimes with raised legs) and provide oxygen therapy. The head should be turned on its side to avoid aspiration of vomit in case of vomiting; Taking medicines through the mouth, of course, is contraindicated. In shock, only intravenous infusion of drugs can benefit, since the disorder of the tissue circulation disrupts the absorption of drugs injected subcutaneously or intramuscularly, as well as taken internally. Fast infusion of liquids enlarging the volume of circulating blood is shown: colloid (for example, polyglucin) and saline solutions in order to increase blood pressure to 100 mm Hg. Art. Isotonic sodium chloride solution is quite suitable as an initial emergency therapy, but with the transfusion of very large volumes it is possible the development of pulmonary edema. In the absence of signs of heart failure, the first portion of the solution (400 ml) is injected. If the shock is caused by acute blood loss, if possible, blood is poured or blood substitutes are injected.

With cardiogenic shock, in connection with the danger of pulmonary edema, preference is given to cardiotonic and vasopressor drugs - pressor amines and digitalis preparations. With anaphylactic shock and shock, resistant to the introduction of fluids, therapy with pressor amines is also indicated.

Norepinephrine acts not only on blood vessels, but also on the heart - it strengthens and intensifies cardiac contractions. Norepinephrine is intravenously dripped at a rate of 1-8 μg / kg / min. If there is no doser, proceed as follows: 150 - 200 ml of 5% glucose solution or isotonic sodium chloride solution are poured into the dropper with 1-2 ml of 0.2% norepinephrine solution and the clamp is set so that the rate of administration is 16-20 drops per minute. By monitoring blood pressure every 10 to 15 minutes, if necessary, double the rate of administration. If the cessation for 2 to 3 minutes (with clamp) of the drug does not cause a repeated drop in pressure, you can finish the infusion while continuing to control the pressure.

Dopamine has a selective vascular effect. It causes narrowing of the vessels of the skin and muscles, but dilates the vessels of the kidneys and internal organs. Dopamine is administered intravenously drip with an initial rate of 200 μg / min. In the absence of a dispenser, the following scheme can be used: 200 mg of dopamine is diluted in 400 ml of physiological saline, the initial injection rate of 10 drops per minute, in the absence of effect, the rate of administration is gradually increased to 30 drops per minute under the control of blood pressure and diuresis.

Since the shock can be caused by various causes, along with the introduction of liquids and vasoconstrictors, measures against the further exposure of these causative factors and the development of pathogenetic mechanisms of collapse are needed. With tachyarrhythmias, the means of choice is electropulse therapy, with bradycardia, electrical stimulation of the heart. With hemorrhagic shock, activities aimed at stopping bleeding (tourniquet, tight bandage, tamponade, etc.) come to the fore. In the case of obstructive shock pathogenetic treatment is thrombolysis with pulmonary embolism, pleural cavity drainage with intense pneumothorax, pericardiocentesis with cardiac tamponade. Puncture of the pericardium can be complicated by myocardial damage with the development of hemopericardium and fatal rhythm disturbances, therefore, in the presence of absolute indications, this procedure can be performed only by a qualified specialist in a hospital.

In case of traumatic shock local anesthesia is shown (Novocaine blockade of the injury site). In case of traumatic, burn shock, when due to stress there is a lack of adrenal function, it is necessary to use prednisolone , hydrocortisone . With an infectious-toxic shock, antibiotics are prescribed. Anaphylactic shock also replenishes the circulating blood volume with saline solutions or colloidal solutions (500-1000 ml), but the main treatment is adrenaline 0.3-0.5 mg subcutaneously with repeated injections every 20 minutes, additionally using antihistamines, Glucocorticoids (hydrocortisone 125 mg intravenously every 6 hours).

All medical measures are conducted against the background of absolute rest for the patient. The patient is not transportable. Hospitalization is possible only after removal of the patient from shock or (if ineffectiveness started on the site of therapy) by a specialized ambulance, in which all the necessary medical measures are continued. In case of severe shock, immediately begin active therapy and at the same time call an intensive care unit "on yourself." The patient is subject to emergency hospitalization in the intensive care unit of a multidisciplinary hospital or a specialized department.