Dangerous shock conditions. Traumatic shock: classification, degrees, first aid algorithm Description of shock

The term "shock", meaning a blow, shock, shock in English and French, was accidentally introduced in 1743 by a now unknown translator into English language books by Louis XV's army consultant Le Dran to describe the condition of patients after gunshot injury. Until now, this term is widely used to describe emotional state a person when exposed to unexpected, extremely strong mental factors without implying specific damage to organs or physiological disorders. Applied to clinical medicine, shock means a critical condition characterized by a sharp decrease in organ perfusion, hypoxia and metabolic disorders. This syndrome is manifested by arterial hypotension, acidosis and rapidly progressive deterioration in the functions of vital body systems. Without adequate treatment, shock quickly leads to death.

Acute short-term hemodynamic disturbances can be a transient episode when there is a violation of vascular tone, reflexively caused by sudden pain, fear, the sight of blood, stuffiness or overheating, as well as cardiac arrhythmia or orthostatic hypotension due to anemia or hypotension. This episode is called collapse and in most cases resolves on its own without treatment. Due to a transient decrease in blood supply to the brain, it may develop fainting- short-term loss of consciousness, which is often preceded by neuro-vegetative symptoms: muscle weakness, sweating, dizziness, nausea, darkening of the eyes and tinnitus. Characterized by pallor, low blood pressure, bradycardia or tachycardia. The same thing can happen in healthy people at high temperature environment, since heat stress leads to a significant dilation of skin vessels and a decrease in diastolic blood pressure. Longer hemodynamic disorders always pose a danger to the body.

Causesshock

Shock occurs when the body is exposed to super-strong irritants and can develop as a result of various diseases, injuries and pathological conditions. Depending on the cause, hemorrhagic, traumatic, burn, cardiogenic, septic, anaphylactic, blood transfusion, neurogenic and other types of shock are distinguished. There may also be mixed forms shock caused by a combination of several reasons. Taking into account the pathogenesis of changes occurring in the body and requiring certain specific therapeutic measures There are four main types of shock

Hypovolemic shock occurs with a significant decrease in blood volume as a result of massive bleeding or dehydration and is manifested by a sharp decrease in venous return of blood to the heart and severe peripheral vasoconstriction.

Cardiogenic shock occurs with a sharp decrease in cardiac output due to impaired myocardial contractility or acute morphological changes in the heart valves and interventricular septum. It develops with normal bcc and is manifested by overflow of the venous bed and pulmonary circulation.

Redistribution shock manifested by vasodilation, a decrease in total peripheral resistance, venous return of blood to the heart and an increase in the permeability of the capillary wall.

Extracardiac obstructive shock occurs due to a sudden obstruction to blood flow. Cardiac output drops sharply despite normal blood volume, myocardial contractility and vascular tone.

Pathogenesis of shock

Shock is based on generalized perfusion disorders, leading to hypoxia of organs and tissues and disorders of cellular metabolism ( rice. 15.2.). Systemic circulatory disorders are a consequence of decreased cardiac output (CO) and changes in vascular resistance.

Primary physiological disorders that reduce effective tissue perfusion are hypovolemia, heart failure, impaired vascular tone, and obstruction of large vessels. With the acute development of these conditions, a “mediator storm” develops in the body with the activation of neuro-humoral systems, the release into the systemic circulation of large quantities of hormones and pro-inflammatory cytokines, affecting vascular tone, vascular wall permeability and CO. In this case, the perfusion of organs and tissues is sharply disrupted. Acute severe hemodynamic disorders, regardless of the reasons that caused them, lead to the same type of pathological picture. Serious disturbances of central hemodynamics, capillary circulation and critical disruption of tissue perfusion with tissue hypoxia, cell damage and organ dysfunction develop.

Hemodynamic disorders

Low CO is an early feature of many types of shock, except for redistribution shock, in which initial stages cardiac output may even be increased. CO depends on the strength and frequency of myocardial contractions, venous blood return (preload) and peripheral vascular resistance (afterload). The main reasons for a decrease in CO during shock are hypovolemia, deterioration in the pumping function of the heart and increased arteriolar tone. The physiological characteristics of various types of shock are presented in table 15.2.

In response to a decrease in blood pressure, the activation of adaptive systems increases. First there is a reflex activation of the sympathetic nervous system, and then the synthesis of catecholamines in the adrenal glands increases. The content of norepinephrine in plasma increases 5-10 times, and the level of adrenaline increases 50-100 times. This enhances the contractile function of the myocardium, increases cardiac activity and causes a selective narrowing of the peripheral and visceral venous and arterial beds. Subsequent activation of the renin-angiotensin mechanism leads to even more pronounced vasoconstriction and the release of aldosterone, which retains salt and water. The release of antidiuretic hormone reduces urine volume and increases its concentration.

In shock, peripheral vasospasm develops unevenly and is especially pronounced in the skin and organs abdominal cavity and the kidneys, where the most pronounced reduction in blood flow occurs. Pale and cool skin observed during examination and pallor of the intestine with weakened pulse in the mesenteric vessels visible during surgery are clear signs of peripheral vasospasm.

Constriction of the blood vessels of the heart and brain occurs to a much lesser extent compared to other zones, and these organs are provided with blood longer than others due to a sharp limitation of the blood supply to other organs and tissues. The metabolic rates of the heart and brain are high, and their reserves of energy substrates are extremely low, so these organs do not tolerate prolonged ischemia. To provide immediate vital needs important organs- brain and heart and is primarily aimed at neuroendocrine compensation of the patient in shock. Sufficient blood flow in these organs is maintained by additional autoregulatory mechanisms until arterial pressure exceeds 70 mm Hg. Art.

Centralization of blood circulation- biologically appropriate compensatory reaction. In the initial period, it saves the patient’s life. It is important to remember that initial shock reactions are adaptation reactions of the body aimed at survival in critical conditions, but beyond a certain limit, they begin to be pathological in nature, leading to irreversible damage to tissues and organs. Centralization of blood circulation, which persists for several hours, along with protection of the brain and heart, is fraught with a mortal danger, although more distant. This danger lies in the deterioration of microcirculation, hypoxia and metabolic disorders in organs and tissues.

Correction of central hemodynamic disturbances during shock includes intensive infusion therapy aimed at increasing blood volume, the use of drugs that affect vascular tone and myocardial contractility. Only in case of cardiogenic shock is massive infusion therapy contraindicated.

Violations mmicrocirculation and tissue perfusion

The microvasculature (arterioles, capillaries and venules) is the most important link in the circulatory system in the pathophysiology of shock. It is at this level that delivery to organs and tissues occurs. nutrients and oxygen, and metabolic products are also removed.

The developing spasm of arterioles and precapillary sphincters during shock leads to a significant decrease in the number of functioning capillaries and a slowdown in the speed of blood flow in the perfused capillaries, ischemia and tissue hypoxia. Further deterioration of tissue perfusion may be associated with secondary capillary pathology. The accumulation of hydrogen ions, lactate and other products of anaerobic metabolism leads to a decrease in the tone of arterioles and precapillary sphincters and an even greater decrease in systemic blood pressure. In this case, the venules remain narrowed. Under these conditions, the capillaries become overfilled with blood, and albumin and the liquid part of the blood intensively leave the vascular bed through pores in the walls of the capillaries (“capillary leak syndrome”). Thickening of blood in the microcirculatory bed leads to an increase in blood viscosity, while the adhesion of activated leukocytes to endothelial cells increases, red blood cells and other formed elements of blood stick together and form large aggregates, peculiar plugs, which further worsen microcirculation until the development of sludge syndrome.

Vessels blocked by the accumulation of blood cells are switched off from the bloodstream. The so-called “pathological deposition” develops, which further reduces the BCC and its oxygen capacity and reduces the venous return of blood to the heart and, as a result, causes a drop in CO and a further deterioration in tissue perfusion. Acidosis, in addition, reduces the sensitivity of blood vessels to catecholamines, preventing their vasoconstrictor effect and leads to atony of the venules. Thus, a vicious circle is closed. A change in the ratio of the tone of the precapillary sphincters and venules is considered a decisive factor in the development of the irreversible phase of shock.

An inevitable consequence of slowing capillary blood flow is the development of hypercoagulation syndrome. This leads to disseminated intravascular thrombus formation, which not only increases capillary circulation disorders, but also causes the development of focal necrosis and multiple organ failure.

Ischemic damage to vital tissues consistently leads to secondary damage that maintains and aggravates the shock state. The resulting vicious circle can lead to a fatal outcome.

Clinical manifestations of impaired tissue perfusion are cold, moist, pale cyanotic or marbled skin, prolongation of capillary refill time over 2 seconds, temperature gradient over 3 °C, oliguria (urination less than 25 ml/hour). To determine the capillary refill time, squeeze the tip of the nail plate or the pad of the toe or hand for 2 seconds and measure the time during which the pale area regains its pink color. In healthy people this happens immediately. In case of deterioration of microcirculation, pallor persists long time. Such microcirculation disorders are nonspecific and are a constant component of any type of shock, and the degree of their severity determines the severity and prognosis of shock. The principles of treatment of microcirculation disorders are also not specific and practically do not differ for all types of shock: elimination of vasoconstriction, hemodilution, anticoagulant therapy, disaggregant therapy.

Metabolic disorders

Under conditions of reduced perfusion of the capillary bed, adequate delivery of nutrients to tissues is not ensured, which leads to metabolic disorders, dysfunction of cell membranes and cell damage. Carbohydrate, protein, and fat metabolism are disrupted, and the utilization of normal energy sources - glucose and fatty acids - is sharply inhibited. In this case, pronounced catabolism of muscle protein occurs.

The most important metabolic disorders in shock are the destruction of glycogen, a decrease in dephosphorylation of glucose in the cytoplasm, a decrease in energy production in mitochondria, disruption of the sodium-potassium pump of the cell membrane with the development of hyperkalemia, which can cause atrial fibrillation and cardiac arrest.

The increase in plasma levels of adrenaline, cortisol, glucagon that develops during shock and the suppression of insulin secretion affect the metabolism in the cell by changes in the use of substrates and protein synthesis. These effects include increased metabolic rate, increased glycogenolysis and gluconeogenesis. A decrease in tissue glucose utilization is almost always accompanied by hyperglycemia. In turn, hyperglycemia can lead to a decrease in oxygen transport, disruption of water-electrolyte homeostasis and glycosylation of protein molecules with a decrease in their functional activity. Significant additional damaging effects of stress hyperglycemia during shock contribute to the deepening of organ dysfunction and require timely correction while maintaining normoglycemia.

Against the background of increasing hypoxia, oxidation processes in tissues are disrupted, their metabolism proceeds along the anaerobic pathway. At the same time, acidic metabolic products are formed in significant quantities, and metabolic acidosis develops. The criterion for metabolic dysfunction is a blood pH level below 7.3, a base deficiency exceeding 5.0 mEq/L and an increase in the concentration of lactic acid in the blood above 2 mEq/L.

An important role in the pathogenesis of shock belongs to the disturbance of calcium metabolism, which intensively penetrates into the cytoplasm of cells. Elevated intracellular calcium levels increase the inflammatory response, leading to intense synthesis of potent mediators of the systemic inflammatory response (SIR). Inflammatory mediators play a significant role in the clinical manifestations and progression of shock, as well as in the development of subsequent complications. Increased production and systemic distribution of these mediators can lead to irreversible cell damage and high mortality. The use of calcium channel blockers improves survival in patients with various types shock.

The action of pro-inflammatory cytokines is accompanied by the release of lysosomal enzymes and free peroxide radicals, which cause further damage - “sick cell syndrome”. Hyperglycemia and an increase in the concentration of soluble products of glycolysis, lipolysis and proteolysis lead to the development of hyperosmolarity of the interstitial fluid, which causes the transition of intracellular fluid into the interstitial space, dehydration of cells and further deterioration of their functioning. Thus, cell membrane dysfunction may represent a common pathophysiological pathway various reasons shock. Although the exact mechanisms of cell membrane dysfunction are unclear, The best way eliminating metabolic disorders and preventing the irreversibility of shock - rapid restoration of bcc.

Inflammatory mediators produced during cellular damage contribute to further disruption of perfusion, which further damages cells within the microvasculature. Thus, a vicious circle is completed - impaired perfusion leads to cell damage with the development of systemic inflammatory response syndrome, which in turn further worsens tissue perfusion and cell metabolism. When these excessive systemic responses persist for a long time, become autonomous and cannot be reversed, multiple organ failure syndrome develops.

In the development of these changes, the leading role belongs to tumor necrosis factor (TNF), interlekins (IL-1, IL-6, IL-8), platelet activating factor (PAF), leukotrienes (B4, C4, D4, E4), thromboxane A2, prostaglandins (E2, E12), prostacyclin, interferon gamma. Simultaneous and multidirectional action etiological factors and activated mediators in shock leads to endothelial damage, disruption of vascular tone, vascular permeability and organ dysfunction.

Persistence or progression of shock may result from either ongoing perfusion defects, cellular damage, or a combination of both. Since oxygen is the most labile vital substrate, its inadequate delivery by the circulatory system forms the basis of the pathogenesis of shock, and timely restoration of tissue perfusion and oxygenation often completely stops the progression of shock.

Thus, the pathogenesis of shock is based on deep and progressive disorders of hemodynamics, oxygen transport, humoral regulation and metabolism. The interrelation of these disorders can lead to the formation of a vicious circle with complete depletion of the body’s adaptive capabilities. Preventing the development of this vicious circle and restoring the body's autoregulatory mechanisms is the main task of intensive care for patients with shock.

Stages of shock

Shock is a dynamic process that begins with the action of the aggression factor, which leads to systemic circulatory disorders, and, as the disorders progress, ends with irreversible damage to organs and death of the patient. Efficiency of compensatory mechanisms, degree clinical manifestations and the reversibility of the changes that occur make it possible to distinguish a number of successive stages in the development of shock.

Preshock stage

Shock is usually preceded by a moderate decrease in systolic blood pressure, not exceeding 20 mm Hg. Art. from normal (or 40 mm Hg if the patient has arterial hypertension), which stimulates the baroreceptors of the carotid sinus and aortic arch and activates the compensatory mechanisms of the circulatory system. Tissue perfusion is not significantly affected and cellular metabolism remains aerobic. If the influence of the aggression factor ceases, then compensatory mechanisms can restore homeostasis without any therapeutic measures.

Early (reversible) stage of shock

This stage of shock is characterized by a decrease in systolic blood pressure below 90 mmHg. Art. , severe tachycardia, shortness of breath, oliguria and cold clammy skin. At this stage, compensatory mechanisms are independently unable to maintain adequate CO and satisfy the oxygen needs of organs and tissues. Metabolism becomes anaerobic, tissue acidosis develops, and signs of organ dysfunction appear. An important criterion for this phase of shock is the reversibility of the resulting changes in hemodynamics, metabolism and organ functions and a fairly rapid regression of developed disorders under the influence of adequate therapy.

Intermediate (progressive) stage of shock

This is a life-threatening critical situation with a systolic blood pressure level below 80 mmHg. Art. and pronounced but reversible organ dysfunction with immediate intensive treatment. This requires artificial pulmonary ventilation (ALV) and the use of adrenergic drugs. medicines to correct hemodynamic disorders and eliminate organ hypoxia. Prolonged deep hypotension leads to generalized cellular hypoxia and critical disruption of biochemical processes, which quickly become irreversible. It is on the effectiveness of therapy during the first so-called "golden hour" the patient's life depends.

Refractory (irreversible) stage of shock

This stage is characterized by severe disorders of central and peripheral hemodynamics, cell death and multiple organ failure. Intensive therapy is ineffective, even if the etiological causes are eliminated and blood pressure temporarily increases. Progressive multiorgan dysfunction usually leads to irreversible organ damage and death.

Diagnostic tests and monitoring for shock

Shock does not leave time for an orderly collection of information and clarification of the diagnosis before starting treatment. Systolic blood pressure during shock is most often below 80 mmHg. Art. , but shock is sometimes diagnosed at higher systolic blood pressure, if present Clinical signs a sharp deterioration in organ perfusion: cold skin covered with sticky sweat, changes mental status from confusion to coma, oligo- or anuria and insufficient refill of skin capillaries. Rapid breathing during shock usually indicates hypoxia, metabolic acidosis and hyperthermia, and hypoventilation indicates depression respiratory center or increased intracranial pressure.

Diagnostic tests for shock also include a clinical blood test, determination of electrolytes, creatinine, blood clotting parameters, blood group and Rh factor, arterial blood gases, electrocardiography, echocardiography, radiography chest. Only carefully collected and correctly interpreted data helps make the right decisions.

Monitoring is a system for monitoring the vital functions of the body, capable of quickly notifying about the occurrence of threatening situations. This allows you to start treatment on time and prevent the development of complications. To monitor the effectiveness of shock treatment, monitoring of hemodynamic parameters, heart, lung and kidney activity is indicated. The number of controlled parameters must be reasonable. Monitoring for shock must necessarily include recording of the following indicators:

• Blood pressure, using intra-arterial measurement if necessary;
• heart rate (HR);
• intensity and depth of breathing;
• central venous pressure (CVP);
• stall pressure in pulmonary artery(DZLA) with severe shock and unknown reason shock;
• diuresis;
• blood gases and plasma electrolytes.

To approximate the severity of shock, you can calculate the Algover-Burri index, or, as it is also called, the shock index - the ratio of the pulse rate per minute to the value of systolic blood pressure. And the higher this indicator, the greater the danger to the patient’s life. The lack of ability to monitor any of the listed indicators makes it difficult right choice therapy and increases the risk of developing iatrogenic complications.

Central venous pressure

Low central venous pressure is an indirect criterion of absolute or indirect hypovolemia, and its rise above 12 cm of water. Art. indicates heart failure. Measuring central venous pressure and assessing its response to a low fluid load helps to select a fluid therapy regimen and determine the appropriateness of inotropic support. Initially, the patient is given a test dose of liquid over 10 minutes: 200 ml at an initial CVP below 8 cm aq. Art. ; 100 ml - with a central venous pressure within 8-10 cm aq. Art. ; 50 ml - with a central venous pressure above 10 cm aq. Art. The reaction is assessed based on the rule “5 and 2 cm aq. Art. ": if the central venous pressure increases by more than 5 cm, the infusion is stopped and the question of the advisability of inotropic support is decided, since such an increase indicates a breakdown of the Frank-Starling contractility regulation mechanism and indicates heart failure. If the increase in central venous pressure is less than 2 cm water. Art. - this indicates hypovolemia and is an indication for further intensive fluid resuscitation without the need for inotropic therapy. Increase in central venous pressure in the range of 2 and 5 cm aq. Art. requires further infusion therapy under the control of hemodynamic parameters.

It must be emphasized that CVP is an unreliable indicator of left ventricular function, since it depends primarily on the condition of the right ventricle, which may differ from the condition of the left. More objective and broader information about the condition of the heart and lungs is provided by monitoring hemodynamics in the pulmonary circulation. Without its use, the hemodynamic profile of a patient with shock is incorrectly assessed in more than a third of cases. The main indication for catheterization of the pulmonary artery in shock is an increase in central venous pressure during infusion therapy. The response to the introduction of a small volume of fluid when monitoring hemodynamics in the pulmonary circulation is assessed according to the rule “7 and 3 mm Hg. Art. "

Hemodynamic monitoring in the pulmonary circulation

Invasive monitoring of blood circulation in the pulmonary circulation is performed using a catheter installed in the pulmonary artery. For this purpose, a catheter with a floating balloon at the end (Swan-Gans) is usually used, which allows you to measure a number of parameters:

• pressure in the right atrium, right ventricle, pulmonary artery and pulmonary artery, which reflects the filling pressure of the left ventricle;
• SV by thermodilution method;
• partial pressure of oxygen and oxygen saturation of hemoglobin in mixed venous blood.

Determination of these parameters significantly expands the possibilities of monitoring and assessing the effectiveness of hemodynamic therapy. The resulting indicators allow:

• differentiate cardiogenic and non-cardiogenic pulmonary edema, identify pulmonary embolism and rupture of the mitral valve leaflets;
• assess the BCC and condition of cardio-vascular system in cases where empirical treatment is ineffective or involves increased risk;
• adjust the volume and rate of fluid infusion, doses of inotropic and vasodilator drugs, and the value of positive end-expiratory pressure during mechanical ventilation.

Decreased oxygen saturation of mixed venous blood is always an early indicator of inadequate cardiac output.

Diuresis

A decrease in diuresis is the first objective sign of a decrease in blood volume. Patients with shock must have a permanent urinary catheter to control the volume and rate of urination. When carrying out infusion therapy, diuresis should be at least 50 ml/hour. At drunkenness shock can occur without oliguria, since ethanol inhibits the secretion of antidiuretic hormone.

Shock – pathological change functions of the vital systems of the body, in which there is a violation of breathing and circulation. This condition was first described by Hippocrates, but the medical term appeared only in the mid-18th century. Since various diseases can lead to the development of shock, for a long time scientists proposed a large number of theories of its origin. However, none of them explained all the mechanisms. It has now been established that the basis of shock is arterial hypotension, which occurs when the volume of circulating blood decreases, cardiac output and general peripheral vascular resistance decrease, or when fluid is redistributed in the body.

Manifestations of shock

Symptoms of shock are largely determined by the cause that led to its appearance, but there are also common features this pathological condition:

• impaired consciousness, which can manifest itself as agitation or depression;
• decrease in blood pressure from minor to critical;
• an increase in heart rate, which is a manifestation of a compensatory reaction;
• centralization of blood circulation, in which spasm of peripheral vessels occurs, with the exception of the renal, cerebral and coronary;
• pallor, marbling and cyanosis of the skin;
• rapid shallow breathing, which occurs when increasing metabolic acidosis;
• change in body temperature, usually it is low, but during an infectious process it is increased;
• the pupils are usually dilated, the reaction to light is slow;
• in particularly severe situations, generalized convulsions, involuntary urination and defecation develop.

There are also specific manifestations of shock. For example, when exposed to an allergen, bronchospasm develops and the patient begins to choke; with blood loss, a person experiences a pronounced feeling of thirst, and with myocardial infarction, chest pain.

Degrees of shock

Depending on the severity of shock, there are four degrees of its manifestations:

1. Compensated. At the same time, the patient’s condition is relatively satisfactory, the function of the systems is preserved. He is conscious, systolic blood pressure is reduced, but exceeds 90 mm Hg, pulse is about 100 per minute.
2. Subcompensated. Violation is noted. The patient's reactions are inhibited and he is lethargic. The skin is pale and moist. The heart rate reaches 140-150 per minute, breathing is shallow. The condition requires prompt medical intervention.
3. Decompensated. The level of consciousness is reduced, the patient is very inhibited and reacts poorly to external stimuli, does not answer questions or answers in one word. In addition to pallor, there is marbling of the skin due to impaired microcirculation, as well as cyanosis of the fingertips and lips. The pulse can only be determined in the central vessels (carotid, femoral artery); it exceeds 150 per minute. Systolic blood pressure is often below 60 mmHg. A malfunction appears internal organs(kidneys, intestines).
4. Terminal (irreversible). The patient is usually unconscious, breathing is shallow, and the pulse is not palpable. By the usual method, using a tonometer, pressure is often not determined, and heart sounds are muffled. But blue spots appear on the skin in places where venous blood accumulates, similar to cadaveric ones. Reflexes, including pain, are absent, the eyes are motionless, the pupil is dilated. The prognosis is extremely unfavorable.

To determine the severity of the condition, you can use the Algover shock index, which is obtained by dividing the heart rate by the systolic blood pressure. Normally it is 0.5, with the 1st degree -1, with the second -1.5.

Types of shock

Depending on the immediate cause, there are several types of shock:

1. Traumatic shock, arising as a result of external influence. In this case, the integrity of some tissues is violated and pain occurs.
2. Hypovolemic (hemorrhagic) shock develops when the volume of circulating blood decreases due to bleeding.
3. Cardiogenic shock is a complication various diseases heart (, tamponade, rupture of aneurysm), in which the ejection fraction of the left ventricle sharply decreases, as a result of which arterial hypotension develops.
4. Infectious-toxic (septic) shock is characterized by a pronounced decrease in peripheral vascular resistance and an increase in the permeability of their walls. As a result, a redistribution of the liquid part of the blood occurs, which accumulates in the interstitial space.
5. develops as an allergic reaction in response to intravenous exposure to a substance (injection, insect bite). In this case, histamine is released into the blood and blood vessels dilate, which is accompanied by a decrease in pressure.

There are other types of shock that include different symptoms. For example, burn shock develops as a result of injury and hypovolemia due to large losses of fluid through the wound surface.

Help with shock

Every person should be able to provide first aid for shock, since in most situations minutes count:

1. The most important thing to do is to try to eliminate the cause that caused the pathological condition. For example, if there is bleeding, you need to clamp the arteries above the injury site. And when an insect bites you, try to prevent the poison from spreading.
2. In all cases, with the exception of cardiogenic shock, it is advisable to elevate the victim's legs above his head. This will help improve blood flow to the brain.
3. In cases of extensive injuries and suspected spinal injuries, it is not recommended to move the patient until the ambulance arrives.
4. To replenish fluid loss, you can give the patient a drink, preferably warm, water, as it will be absorbed faster in the stomach.
5. If a person has severe painful sensations, he can take an analgesic, but it is not advisable to use sedatives, since this will change clinical picture diseases.

In cases of shock, emergency doctors use either intravenous solutions or vasoconstrictors (dopamine, adrenaline). The choice depends on the specific situation and is determined by a combination of various factors. Medication and surgery shock directly depends on its type. Thus, in case of hemorrhagic shock, it is urgent to replenish the volume of circulating blood, and in case of anaphylactic shock, antihistamines and vasoconstrictors must be administered. The victim must be urgently transported to specialized hospital, where treatment will be carried out under the monitoring of vital signs.

The prognosis for shock depends on its type and degree, as well as the timeliness of assistance. With mild manifestations and adequate therapy, recovery almost always occurs, while with decompensated shock there is a high probability of death, despite the efforts of doctors.

symptom complex of life disorders important functions organism, arising as a result of a discrepancy between tissue blood flow and the metabolic need of tissues.

During the development of shock main task the body is to maintain adequate blood flow to vital organs (heart and brain). Therefore, initially, vasoconstriction occurs in other organs and tissues, thus achieving centralization of blood circulation. Such prolonged narrowing of blood vessels over time leads to the development of ischemia - a decrease in blood supply to an organ or tissue that occurs due to a weakening or cessation of arterial blood flow. This leads to the production of biologically active substances, contributing to an increase in vascular permeability, which ultimately leads to vasodilation. As a result, the body’s protective adaptive mechanism—centralization of blood circulation—is disrupted, which entails serious consequences.

According to pathogenesis they distinguish the following types shock:

• hypovolemic;
• traumatic;
• cardiogenic;
• infectious-toxic;
• anaphylactic;
• septic;
• neurogenic;
• combined (contains all pathogenetic elements of various shocks).

The consequences of shock depend on the cause that led to the development of this condition. For example, shock can lead to complications such as failure of a number of internal organs, swelling of the lungs and brain. Such dire consequences can lead to death, so shock requires increased attention.

Symptoms

In case of shock, you can pay attention to appearance patient. Such a person has pale and cold-to-the-touch skin. The exception is septic and anaphylactic shock, in which the skin is warm at the beginning of development, but then it does not differ in any way from the characteristics of other types of shock. General weakness, dizziness, and nausea are pronounced. Excitement may develop, followed by lethargy or coma. Blood pressure decreases significantly, which poses a certain danger. As a result, the stroke volume of blood required to supply organs and tissues with oxygen is reduced. Therefore, tachycardia occurs - an increase in the number of heart contractions. In addition, the appearance of oligoanuria is noted, which means a sharp decline amount of urine excreted.

With traumatic shock, patients complain of severe pain caused by the injury. Anaphylactic shock is accompanied by shortness of breath, which occurs due to bronchospasm. Significant blood loss can also lead to the development of shock, in which case attention is drawn to internal or external bleeding. In septic shock, elevated body temperature is detected, which is difficult to control by taking antipyretic drugs.

Diagnostics

For some time, the state of shock may go unnoticed, since there is no specific symptom indicating exclusively the development of shock. Therefore, it is important to evaluate all the symptoms the patient has and analyze the situation individually in each case. To diagnose shock, it is necessary to identify signs of insufficient blood circulation to tissues, as well as to detect the inclusion of compensatory mechanisms of the body.

First of all, attention is paid to the patient’s appearance. The skin is often cold to the touch and has a pale appearance. Cyanosis (bluish discoloration of the skin and/or visible mucous membranes) may be detected. To confirm hypotension, blood pressure is measured. Patients complain of general weakness, dizziness, nausea, palpitations, and the amount of urine excreted sharply decreases.

It is important to quickly compare all the symptoms, make the correct diagnosis and begin appropriate treatment.

Treatment

Shock is emergency, which can lead to irreversible consequences. Therefore, it is extremely important to provide timely medical assistance. Before specialists arrive, people nearby should take first aid measures. First, you need to give the person a horizontal position with the leg end raised. Such actions help to increase venous return to the heart, which leads to an increase in stroke volume of the heart. During shock, the heart can no longer cope with the stroke volume of blood required to deliver the required amount of oxygen to the tissues. A horizontal position with elevated legs, although it does not completely compensate for the insufficiency of the stroke volume of the heart, but helps to improve this condition.

Medical care consists of infusion therapy and the administration of drugs whose action is aimed at narrowing blood vessels. Infusion therapy is based on the introduction of various solutions of a certain volume and concentration into the bloodstream to fill the vascular bed.

The use of medications that constrict blood vessels is necessary to maintain blood pressure.

In case of breathing problems, oxygen therapy or mechanical ventilation is used.

These general measures are aimed at combating the pathogenesis of shock; there is also symptomatic treatment, different for each type of shock. For example, in case of traumatic shock, it is necessary to administer painkillers, immobilize fractures, or apply a sterile dressing to the wound. Cardiogenic shock requires treatment of the cause contributing to the development of shock. Hypovolemic shock is often associated with blood loss, so it is important to understand that without eliminating the cause, that is, stopping the bleeding (application of a tourniquet, pressure bandage, squeezing a vessel in the wound, etc.), general measures will not have the desired effect. Septic shock is accompanied by fever, therefore, antipyretic drugs are used as symptomatic treatment, and to eliminate the cause itself, they are prescribed antibacterial drugs. When treating anaphylactic shock, it is important to prevent delayed systemic manifestations; for this purpose, glucocorticosteroids and antihistamines. It is also necessary to stop the phenomenon of bronchospasm.

Medicines

When shock develops, it is important to provide access to a vein as quickly as possible, preferably not to one, but to several at once. This is necessary to start infusion therapy, as well as administer drugs directly into the bloodstream. Infusion therapy influences the main links of pathogenesis. It is able to maintain an optimal level of BCC (circulating blood volume), which leads to stabilization of hemodynamics, improves microcirculation, thereby increasing the delivery of oxygen to tissues, and improves metabolism in cells.

Infusion solutions used for shock include:

• crystalloids (isotonic NaCl solution, Ringer's solution, glucose solutions, mannitol, sorbitol);
• colloids (hemodez, polydesis, polyoxidin, polyglucin, rheopolyglucin).

Usually a combination of crystalloid and colloid solutions is used. This tactic allows you to replenish the volume of circulating blood, and also regulates the balance of intracellular and interstitial fluids. The choice of volume and ratio of crystalloid and colloid solutions depends on each clinical case, which has its own characteristics.

Of the drugs that cause narrowing of the lumen of blood vessels, the main one is adrenaline. Intravenous administration promotes the accumulation of the required concentration of the drug directly in the blood, which leads to the most rapid manifestation of the effect than with other methods of administration. Dobutamine and dopamine also have this effect. Their effect begins approximately 5 minutes after intravenous administration and lasts about 10 minutes.

Folk remedies

Shock of various etiologies requires exclusively medical care, no recipes folk remedies are not able to improve the patient's condition. Therefore, it is important not to waste precious time, but to immediately call specialists who will provide necessary help and will save you from possible irreversible consequences. While waiting for the ambulance team to arrive, you should follow the first aid measures that were described earlier (put the person in a horizontal position with the leg end raised, warm the body). Not only the effectiveness of treatment, but also a person’s life depends on correct actions!

The information is for reference only and is not a guide to action. Do not self-medicate. At the first symptoms of the disease, consult a doctor.

Shock (English - blow, push)- an acute, life-threatening pathological process that occurs under the influence of a very strong irritant for the body and is characterized by disorders of the central and peripheral circulation with a sharp decrease in blood supply to vital organs. This leads to severe disturbances in cellular metabolism, resulting in changes or loss of normal cell function, and in extreme cases, cell death.

ETIOLOGY AND PATHOGENESIS

Many diseases potentially contribute to the development of shock and the following main groups of causes of its occurrence can be distinguished:

1. Primary decrease in circulating blood volume (hypovolemic shock) - with bleeding, dehydration, loss of plasma due to burns.
2. Impaired peripheral hemodynamics (redistribution or vasogenic shock) - sepsis, anaphylaxis, intoxication, acute adrenal insufficiency, neurogenic shock, traumatic shock.
3. Primary heart failure (cardiogenic shock) - with arrhythmias, myocarditis, acute left ventricular failure, myocardial infarction.
4. Obstruction of venous blood flow or cardiac output (obstructive shock) - in diseases of the pericardium, tension pneumothorax, pulmonary embolism, fat and air embolism, etc.

The essence of shock is a disruption of gas exchange between blood and tissues, followed by hypoxia and microcirculation disorders. The main pathogenetic links of shock are caused by hypovolemia, cardiovascular failure, disruption of tissue circulation as a result of changes in capillary and post-capillary resistance, blood shunting, capillary stasis with aggregation cellular elements blood (sludge syndrome), increased permeability of the vascular wall and blood rejection. Impaired tissue perfusion negatively affects all organs and systems, but the central nervous system is especially sensitive to hypoxia.

DIAGNOSTICS

United generally accepted classification There is no shock in pediatrics. More often, the origin, phase of development, clinical picture and severity of shock are taken into account.

By origin they distinguish hemorrhagic, dehydration (anhydremic), burn, septic, toxic, anaphylactic, traumatic, endogenous pain, neurogenic, endocrine in acute adrenal insufficiency, cardiogenic, pleuropulmonary, post-transfusion shocks, etc.

According to the phases of development of peripheral circulatory disorders, the following are indicated:

• early (compensated) phase
• phase of pronounced shock c) late (decompensated) phase of shock.

According to the severity, shock can be classified as mild, moderate, or severe. Techniques that allow one to assess, first of all, the state of the cardiovascular system and the type of hemodynamics come to the fore in diagnosing shock of any etiology. As the degree of shock increases, heart rate progressively increases (1st degree - by 20-40%, 2nd degree - by 40-60%, 3rd degree - by 60-100% or more compared to the norm) and decreases blood pressure (1st degree - decreases pulse pressure, 2nd degree - the value of systolic blood pressure drops to 60-80 mmHg, the phenomenon of “continuous tone” is characteristic, 3rd degree - systolic blood pressure is less than 60 mmHg or not determined).

Shock of any etiology has a phased development of peripheral circulatory disorders, at the same time, their severity and duration can be very diverse.

The early (compensated) phase of shock is clinically manifested in a child by tachycardia with normal or slightly elevated blood pressure, pale skin, cold extremities, acrocyanosis, slight tachypnea, and normal diuresis. The child is conscious, states of anxiety and psychomotor excitability are possible, reflexes are strengthened.

The phase of pronounced (subcompensated) shock is characterized by a violation of the child’s consciousness in the form of lethargy, muffledness, weakened reflexes, a significant decrease in blood pressure (60-80 mm Hg), severe tachycardia up to 150% of the age norm, severe pallor and acrocyanosis of the skin, thread-like pulse , more pronounced superficial tachypnea, hypothermia, oliguria.

The late (decompensated) phase of shock is characterized by an extremely severe condition, impaired consciousness up to the development of coma, pallor of the skin with an earthy tint or widespread cyanosis of the skin and mucous membranes, hypostasis, a critical decrease in blood pressure or its uncertainty (less than 60 mm Hg), thread-like pulse or its absence on peripheral vessels, arrhythmic breathing, anuria. With further progression of the process, the clinical picture of an atonal state (terminal stage) develops.

Sometimes the early phase of shock is very short-lived ( severe forms anaphylactic shock, fulminant form of infectious-toxic shock with meningococcal infection, etc.). And therefore the condition is diagnosed in the phase of severe or decompensated shock. The early phase can manifest itself quite fully and for a long time with the vascular origin of shock, less so in the presence of primary hypovolemia.

It is always necessary to pay attention to the possibility of circulatory decompensation: progressive pallor of the skin and mucous membranes, cold sticky sweat, cold extremities, positive test capillary filling (after pressing on the fingernail, the color is normally restored after 2 s, and with a positive test - more than 3 s, indicating a violation of peripheral circulation) or a positive symptom of a “pale spot” (more than 2 s), progressive arterial hypotension, increased shock Algover index (the ratio of pulse rate to systolic pressure, which normally does not exceed 1 in children over 5 years of age and 1.5 in children under 5 years of age), a progressive decrease in diuresis.

With severe insufficiency of perfusion, multiple organ failure can form - simultaneous or sequential damage to the vital systems of the body (“shock organs” - the central nervous system, lungs, kidneys, adrenal glands, heart, intestines, etc.).

FIRST AID FOR SHOCK

1. Place the patient in a horizontal position with the lower limbs raised.
2. Ensure patency of the upper respiratory tract- delete foreign bodies from the oropharynx, throw back the head, remove the lower jaw, open the mouth, set up the supply of humidified, heated 100% oxygen through a breathing mask or nasal catheter.
3. If possible, reduce or eliminate the effect of a developmentally significant shock factor:

• for anaphylaxis: stop administering medications; remove the insect sting; above the injection or bite site, apply a tourniquet for up to 25 minutes, inject the injection site or lesion with 0.3-0.5 ml of a 0.1% solution of adrenaline in 3-5 ml of saline, cover the injection site with ice for 10-15 minutes, when if the allergen enters through the mouth, if the patient’s condition allows, rinse the stomach, give a laxative, do a cleansing enema, if allergens get into the nose or eyes, rinse with running water;
• in case of bleeding, stop external bleeding using tamponade, bandages, hemostatic clamps, clamping of large arteries, a tourniquet with recording the time of its application;
• in case of traumatic pain syndrome: immobilization; analgesia intravenously, intramuscularly with a 50% analgin solution at a dose of 0.1 ml/year of life or even, if necessary, with a 1% solution of promedol at a dose of 0.1 ml/year of life, inhalation anesthesia - with nitric oxide mixed with oxygen (2 :1 or 1:1), or intramuscularly or intravenously by administration of 2-4 mg/kg Kalip-Sol;
• for tension pneumothorax - pleural puncture.

4. Catheterization of central or peripheral veins for intensive infusion therapy, starting with the introduction of crystalloids in a volume of 10-20 ml / kg (Ringer's solutions, 0.9% sodium chloride) and colloids (reopolyglucin, polyglucin, 5% albumin, Gecodez, gelatinol , Gelofusin). The choice of drugs, their ratio, volume of infusion and rate of administration of solutions is determined by the pathogenetic variant of shock and the nature of the underlying disease. For shock, intravenous infusions are carried out until the patient recovers from this state, or until minimal signs of congestion appear in the small or big circle blood circulation To prevent excessive administration of solutions, central venous pressure is constantly monitored (normally its value in mm H2O is equal to 30/35 + 5 x number of years of life). If it is low, the infusion continues, if it is high, it stops. Monitoring blood pressure and diuresis is also mandatory.

5. In the presence of acute adrenal insufficiency, hormones are prescribed:

Hydrocortisone 10-40 mg/kg/day;
or prednisolone 2-10 mg/kg/day, with half the first dose daily dose, and the other half - evenly throughout the day.

6. In case of hypoglycemia, administer a 20-40% glucose solution at a dose of 2 ml/kg intravenously.
7. In case of refractory arterial hypotension and in the presence of metabolic acidosis, its correction is with a 4% solution of sodium bicarbonate at a dose of 2 ml/kg under the control of the acid-base state.
8. Symptomatic therapy(sedatives, anticonvulsants, antipyretics, antihistamines, hemostatics, antiplatelet agents, etc.)..
9. If necessary, comprehensive resuscitation support.

Patients with manifestations of shock should be hospitalized in the intensive care unit, where, taking into account the etiopathogenesis, the clinic will carry out further conservative or surgical treatment.

Anaphylactic shock

Anaphylactic shock- the most severe manifestation allergic reaction immediate type, which occurs upon the introduction of an allergen against the background of sensitization of the body and is characterized by severe disturbances of blood circulation, breathing, and central nervous system activity and is truly life-threatening.

Causally significant allergens for the development of arterial shock in children may be:

• medications (antibiotics, sulfonamides, local anesthetics, X-ray contrast agents, antipyretics, heparin, streptokinase, Asparaginase, plasma substitutes - dextran, gelatin)
• foreign proteins (vaccines, serums, donor blood, plasma)
• allergen extracts for diagnosis and treatment;
• poison of insects, snakes;
• some food products(citrus fruits, nuts, etc.);
• chemical compounds;
• plant pollen;
• cooling the body.

On the frequency and time of development arterial shock influences the route of introduction of the allergen into the body. In the case of parenteral administration of the allergen, AS is observed more often. Particularly dangerous via the route of administration medication, although the development of AS is quite possible with any option for the entry of drugs into the child’s body.

DIAGNOSTICS

Arterial shock develops quickly, within the first 30 minutes (maximum up to 4 hours) from the moment of contact with the allergen, and the severity of the shock does not depend on the dose of the allergen. In severe cases, collapse develops at the moment of contact with the allergen.

There are five clinical forms arterial shock:

1. Asphyxial (asthmatoid) variant- weakness appears and increases, a feeling of constriction in the chest, lack of air, persistent cough, throbbing headache, pain in the heart area, fear. The skin is sharply pale, then cyanotic. Foaming at the mouth, suffocation, expiratory shortness of breath with wheezing on exhalation. Possible development angioedema face and other parts of the body. In the future, with the progression of respiratory failure and the addition of symptoms of acute adrenal insufficiency, death may occur.

2. Hemodynamic (cardiac-vascular) variant- weakness, tinnitus, heavy sweating, anginal pain in the heart area appear and increase. Pallor of the skin and acrocyanosis increase. Blood pressure drops progressively, the pulse is threadlike, heart sounds are sharply weakened, cardiac arrhythmias, loss of consciousness and convulsions are possible within a few minutes. A lethal outcome can occur with an increase in cardiovascular insufficiency.

3. Cerebral variant- focal neurological and cerebral symptoms rapidly increase.

4. Abdominal option- spastic diffuse abdominal pain, nausea, vomiting, diarrhea, gastrointestinal bleeding.

5. Mixed option.

A state of shock, or shock, is an acute, sudden disturbance of blood circulation in the organs and tissues of the body. Cells do not receive the oxygen and nutrients necessary for their existence. The result is hypoxia. This condition disrupts the vital functions of the body and threatens human life. Therefore, in a state of shock, the victim needs emergency medical care.

The condition of a person in shock can rapidly deteriorate. Therefore, before the ambulance arrives, you need to provide first aid to the victim. Perhaps this will save a person's life. How to distinguish a state of shock in a person, what first aid is needed, what are the symptoms of shock - we will talk to you about this very important topic today:

How does shock manifest in a person? Symptoms of the condition

Let us immediately note that the nature of the shock is always different. For example, anaphylactic - can affect an allergy sufferer from one insect bite. People suffering from heart disease, in particular myocardial infarction, may develop cardiogenic shock. With weakened immune system, from the penetration of toxic substances into the body, septicemia can develop, and if a serious injury occurs, traumatic shock occurs.

There are several stages of shock. At the initial stage, the person is noticeably excited. This prevents him from adequately assessing his surroundings. Blood pressure does not change significantly.

Excitement gives way to lethargy, depression, and apathy. The patient is conscious, can speak, and answer questions. Breathing becomes shallow, blood pressure decreases. Due to slow blood circulation, skin, mucous membranes turn pale.

Next, a further decrease in blood pressure occurs, tachycardia appears, and the normal function of the respiratory system is disrupted. The skin is cold and pale. The pulse is weak but rapid. Does not exceed 120 beats. min. There is a sharp reduction in urine output.

The most severe condition is stage III shock. Characterized by the following symptoms: extreme pallor, bluish skin, cold sweat, rapid breathing. The pulse is frequent (more than 120 beats per minute), thread-like, palpable only in the largest arteries. Blood pressure drops sharply to 70 mmHg and below.

Because of acute intoxication, when the body begins to be poisoned by its own waste products, characteristic spots appear on the skin. At this stage, the patient may lose consciousness.

In a severe state of shock, the patient does not respond to pain, is unable to move, and cannot answer questions. At this stage, anuria is observed, a condition in which urination is almost completely absent. Dysfunction of some internal organs occurs, in particular the liver and kidneys.

Of course, each case is individual. The state of shock, the symptoms of which we are considering today, can manifest itself in different ways, depending on the type of shock, its severity, age, general condition health of the patient. However, the main signs we discussed above are usually similar.

How is a person’s state of shock corrected? First aid

To help a person, and in some cases save his life, each of us needs to have first aid skills. For example, you need to be able to perform artificial respiration (you can find a description of the technique on our website).

So you can do the following:

First of all, calm down yourself and call ambulance. When calling, clearly explain what happened and what condition the patient is in.

Then check the patient's breathing and, if necessary, perform artificial respiration.

If the person is conscious and there are no visible injuries to the head, back or limbs, place him on his back, raising his legs slightly above his body position (30 - 50 cm). You can’t raise your head, so don’t put a pillow on it.

If there is injury to the limbs, there is no need to elevate the legs. This will cause severe pain. If the back is injured, the victim should not be touched. It should be left in the same position. Just bandage wounds and abrasions, if any. This concerns traumatic shock.

For other types of this pathological condition, provide the patient with warmth, unbutton buttons, hooks, and belts on clothing, allowing him to breathe freely. Perform artificial respiration if necessary.

If there is excessive salivation or vomiting, turn the patient's head to the side to prevent him from choking on the vomit.

Monitor vital signs until emergency services arrive. Measure your pulse, breathing rate, and blood pressure.

Further necessary assistance will be provided by the called team of doctors. If necessary, resuscitation measures will be provided in an ambulance on the way to the hospital.