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SHOCK

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SHOCK is observed in various pathological conditions and is characterized by insufficient blood supply to the tissues (a decrease in tissue perfusion) with impaired function of vital organs. Impaired blood supply to 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 circulating blood volume; A number of researchers generally do not distinguish between the concepts of "shock" and "collapse." Depending on the cause of the shock, there are: painful shock, hemorrhagic (after blood loss), hemolytic (through transfusion of other group blood), 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 the critical decrease in capillary blood flow in the affected organs. On examination, the patient’s face is in a state of shock. It is described by the Hippocrates (Hippocratic Mask): “... The nose is sharp, sunken eyes, depressed temples, ears cold and strained, earlobes otvorochennye, 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 haggling, sallow 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, marked apathy and drowsiness. Patients complain of severe weakness, dizziness , chilliness, impaired vision, tinnitus, and sometimes a feeling of anguish and fear. Often there are drops of cold sweat on the skin, the extremities are cold to the touch, with a cyanotic shade of the skin (the so-called peripheral signs of shock). Breathing is usually rapid, shallow, and if the function of the respiratory center is inhibited due to increasing hypoxia of the brain, apnea is possible. There is oliguria (less than 20 ml of urine per hour) or anuria .

The greatest changes are observed on the part of the cardiovascular system: the pulse is very frequent, weak filling and voltage ("filamentary"). In severe cases, it can not be felt. 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 maximum and minimum pulse pressure is decreasing. It is possible to speak about shock at a decrease in systolic pressure below 90 mm Hg. Art. (hereinafter, it decreases to 50–40 mmHg or is not even determined); diastolic blood pressure is reduced to 40 mm Hg. Art. and below. In individuals with previous arterial hypertension, a picture of shock can also be observed at higher BP levels. A steady increase in blood pressure during repeated measurements indicates the effectiveness of the therapy.

In hypovolemic and cardiogenic shock, all the described symptoms are quite pronounced. In hypovolemic shock, in contrast to the cardiogenic shock, there are no swollen, pulsating cervical veins. On the contrary, the veins are empty, collapsed, to get blood when puncture the ulnar vein is difficult and sometimes impossible. If you raise the hand of the patient, you can see how immediately saphenous veins fall. If you then lower the arm so that it hangs down from the bed, the veins fill up very slowly. In cardiogenic shock, the neck veins are filled with blood, signs of pulmonary stagnation are identified. In case of infectious-toxic shock, the clinic's features are fever with stunning chills, warm, dry skin, and in advanced cases - strictly defined skin necrosis with blister rejection, petechial hemorrhages and pronounced marbling of the skin. In anaphylactic shock, in addition to circulatory symptoms, there are other manifestations of anaphylaxis, in particular, skin and respiratory symptoms (itching, erythema, urticarial rash, angioedema, bronchospasm, stridor), abdominal pain.

The differential diagnosis is carried out with acute heart failure. As distinctive signs, the patient’s position in bed can be noted (low with shock and half-sitting with heart failure), his appearance (with a hippocrates 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.

Treatment of shock should meet the requirements of emergency treatment, i.e. it is necessary to immediately apply the means that give the 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 the tissues and be the direct cause of death. Since in the mechanism of development of shock, the most important role is played by a decrease in vascular tone and a decrease in blood flow to the heart, therapeutic measures should first of all be aimed at increasing venous and arterial tone and increasing the volume of fluid in the bloodstream.

First of all, the patient is placed 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 vomitus in case of vomiting; taking medication by mouth is naturally contraindicated. In shock, only intravenous infusion of drugs can be beneficial, since a disorder of tissue blood circulation disrupts the absorption of medicinal substances, administered subcutaneously or intramuscularly, as well as taken orally. Rapid infusion of liquids that increase the volume of circulating blood: colloid (eg, polyglucin) and saline solutions in order to increase blood pressure to 100 mm Hg. Art. An isotonic solution of sodium chloride is quite suitable as an initial emergency treatment, but when transfusing very large volumes of it, pulmonary edema may develop. In the absence of signs of heart failure, the first portion of the solution (400 ml) is injected in a jet. If shock is caused by acute blood loss, if possible, blood is transfused or blood-substituting fluids are injected.

In case of cardiogenic shock, due to the risk of pulmonary edema, preference is given to cardiotonic and vasopressor agents - pressor amines and digitalis preparations. In anaphylactic shock and shock resistant to the introduction of fluids, pressor amines therapy is also indicated.

Norepinephrine acts not only on the vessels, but also on the heart - it strengthens and speeds up the heartbeat. Norepinephrine is administered intravenously at a rate of 1-8 mg / kg / min. In the absence of a dispenser, they act as follows: 150-200 ml of 5% glucose solution or an isotonic sodium chloride solution with 1-2 ml of 0.2% norepinephrine solution is poured into the dropper and the clamp is set so that the injection rate is 16-20 drops per minute. Controlling blood pressure every 10 to 15 minutes, if necessary, double the rate of injection. If stopping for 2 to 3 minutes (using a clamp) of the drug administration does not cause a repeated drop in pressure, you can finish the infusion by continuing to control the pressure.

Dopamine has a selective vascular effect. It causes a 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 μg / min. In the absence of a dispenser, the following scheme can be used: 200 mg of dopamine is diluted in 400 ml of saline, the initial injection rate of 10 drops per minute, with no effect, the injection rate is gradually increased to 30 drops per minute under the control of blood pressure and diuresis.

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

In traumatic shock, local anesthesia is shown (novocainic blockade of the injury site). In traumatic, burn shock, when due to stress there is a lack of adrenal function, it is necessary to use prednisone , hydrocortisone . In case of an infectious-toxic shock, antibiotics are prescribed. In anaphylactic shock, the circulating blood volume is also filled with saline solutions 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 therapeutic measures are carried out against the background of absolute peace for the patient. The patient is not transportable. Hospitalization is possible only after removing the patient from shock or (with the ineffectiveness of the treatment started at the Place of therapy) a specialized ambulance, in which all necessary medical measures are continued. In the case of severe shock, you should immediately begin active therapy and at the same time call the intensive care team "on yourself." The patient is subject to emergency hospitalization in the intensive care unit of a multidisciplinary hospital or a specialized unit.