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SHOCK

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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. Violation of the blood supply to tissues and organs and their functions arise as a result of collapse - acute vascular insufficiency with a decrease 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 do not distinguish between the concepts of “shock” and “collapse”. Depending on the cause of the shock, they distinguish: pain shock, hemorrhagic (after blood loss), hemolytic (due to transfusion of different blood types), cardiogenic (due to myocardial damage), traumatic (after severe injuries), burn (after extensive burns), infectious toxic, anaphylactic shock, etc.

The clinical picture of shock is due to a critical decrease in capillary blood flow in the affected organs. On examination, the face of a patient in a state of shock is characteristic. It is also described by Hippocrates (a hippocratic mask): “... The nose is sharp, the eyes are hollow, the temples are depressed, the ears are cold and tight, the earlobes are flap, the skin on the forehead is firm, stretched and dry, the whole complexion is green, black or pale, or lead". Along with the noted symptoms (a haggard, earthy face, sunken eyes, pallor or cyanosis), the patient's low position in bed, immobility and indifference to the environment, barely audible, “reluctant” answers to questions draw attention. Consciousness can be maintained, but confused, apathy and drowsiness are noted. Patients complain of severe weakness, dizziness , coldness, blurred vision, tinnitus, sometimes a feeling of longing and fear. Drops of cold sweat often appear on the skin, limbs cold to the touch, with a cyanotic skin tone (the so-called peripheral signs of shock). Respiration is usually quicker, shallow, with inhibition of the function of the respiratory center due to increasing hypoxia of the brain, apnea is possible. Oliguria (less than 20 ml of urine per hour) or anuria is noted.

The greatest changes are observed on the part of the cardiovascular system: the pulse is very frequent, weak filling and tension ("threadlike"). In severe cases, it is not possible to test it. The most important diagnostic sign and the most accurate indicator of the severity of the patient's condition is a drop in blood pressure. Both the maximum, and minimum, and pulse pressure are reduced. Shock can be said with a decrease in systolic pressure below 90 mm Hg. Art. (in the future, it decreases to 50 - 40 mm RT. Art. or is not even determined); diastolic blood pressure is reduced to 40 mm RT. Art. and below. In people with previous arterial hypertension, a shock pattern can also be observed with higher blood pressure. A steady increase in blood pressure during repeated measurements indicates the effectiveness of the therapy.

With hypovolemic and cardiogenic shock, all the described symptoms are quite pronounced. With hypovolemic shock, in contrast to cardiogenic, there are no swollen, pulsating cervical veins. On the contrary, the veins are empty, asleep, it is difficult, and sometimes impossible, to receive blood during puncture of the ulnar vein. If you raise the patient’s hand, you can see how saphenous veins immediately fall. If you then lower your arm so that it hangs down from the bed, the veins fill up very slowly. With cardiogenic shock, the cervical veins are filled with blood, signs of pulmonary stagnation are detected. In case of an infectious-toxic shock, the clinic features a fever with tremendous chills, warm, dry skin, and in advanced cases, strictly outlined skin necrosis with rejection in the form of blisters, petechial hemorrhages and severe marbling of the skin. In 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.

The differential diagnosis is carried out with acute heart failure. As distinctive signs, one can note the patient’s position in bed (low with shock and half-sitting with heart failure), his appearance (with a cheek hippocratic mask, pallor, marbling of the skin or gray cyanosis , with heart failure - more often a bluish puffy face, swollen pulsating veins , acrocyanosis), respiration (if it is a shock, tachycardia, surface, in heart failure - increased and rapid, often shortness) expanding the boundaries of cardiac dullness and signs of cardiac standstill (wet rips in the lung, liver enlargement and tenderness) in heart failure and sudden drop in blood pressure during shock.

The treatment of shock should comply with the requirements of emergency therapy, i.e., it is necessary to immediately use means that give an effect immediately after their introduction. Delay in the treatment of such a patient can lead to the development of gross disturbances in microcirculation, the appearance of irreversible changes in the tissues and can be a direct cause of death. Since a decrease in vascular tone and a decrease in blood flow to the heart play a major role in the mechanism of shock development, 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.e. 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; oral medication is naturally contraindicated. In shock, only intravenous infusion of drugs can be beneficial, since a disorder of tissue circulation disrupts the absorption of drugs administered subcutaneously or intramuscularly, as well as taken orally. A rapid infusion of fluids that increase the volume of circulating blood is shown: colloidal (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 treatment, but with transfusion of very large volumes it is possible to develop pulmonary edema. In the absence of signs of heart failure, the first portion of the solution (400 ml) is administered jet. If the shock is caused by acute blood loss, blood transfusion is possible, or blood-replacing fluids are administered.

With cardiogenic shock, in connection with the danger of pulmonary edema, cardiotonic and vasopressor agents - pressor amines and digitalis preparations are preferred. 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 - strengthens and speeds up heart contractions. Norepinephrine is administered intravenously at a rate of 1-8 μg / kg / min. In the absence of a dispenser, proceed as follows: 150-200 ml of a 5% glucose solution or isotonic sodium chloride solution is poured into a dropper with 1-2 ml of a 0.2% solution of norepinephrine and the clamp is set so that the injection rate is 16-20 drops per minute. Monitoring blood pressure every 10 to 15 minutes, if necessary, double the rate of administration. If the cessation of administration of the drug for 2 to 3 minutes (with a clamp) does not cause a repeated drop in pressure, you can end 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 at an initial rate of 200 mcg / 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 administration rate is gradually increased to 30 drops per minute under the control of blood pressure and urine output.

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

In case of traumatic shock, local anesthesia is indicated (novocaine blockade of the injury site). In case of traumatic, burn shock, when adrenal insufficiency arises due to stress, it is necessary to use prednisone , hydrocortisone . With infectious toxic shock, antibiotics are prescribed. In anaphylactic shock, the volume of circulating blood is also replenished with saline or colloidal solutions (500-1000 ml), but the main treatment is adrenaline at a dose of 0.3-0.5 mg subcutaneously with repeated injections every 20 minutes, antihistamines are additionally used, glucocorticoids (hydrocortisone 125 mg intravenously every 6 hours).

All medical measures are carried out against the background of absolute rest for the patient. The patient is not transportable. Hospitalization is possible only after the patient has been taken out of shock or (with the ineffectiveness started at the treatment site) a specialized ambulance, in which all necessary medical measures are continued. In case of severe shock, active therapy should immediately begin and at the same time call an intensive care team. The patient is subject to emergency hospitalization in the intensive care unit of a multidisciplinary hospital or a specialized department.