There are hundreds of situations in life that can cause shock. Most people associate it only with the strongest nervous shock, but this is only partly true. In medicine, there is a classification of shock that determines its pathogenesis, severity, the nature of changes in organs and methods for their elimination. For the first time this condition was characterized more than 2 thousand years ago by the famous Hippocrates, and the term "shock" was introduced into medical practice in 1737 by the Parisian surgeon Henri Ledran. The proposed article discusses in detail the causes of shock, classification, clinic, emergency care in the event of this serious condition and prognosis.
Shock Concept
From English shock can be translated as the highest shock, that is, not a disease, not a symptom and not a diagnosis. In world practice, this term is understood as the response of the body and its systems to a strong stimulus (external or internal), which disrupts the functioning of the nervous system, metabolism, respiration and blood circulation. This is what is shocking at the momentdefinition. Classification of this condition is needed to identify the causes of shock, its severity and begin effective treatment. The prognosis will be favorable only with the correct diagnosis and the immediate start of resuscitation.
Classifications
Canadian pathologist Selye identified three stages, roughly the same for all types of shock:
1. Reversible (compensated), in which the blood supply to the brain, heart, lungs and other organs is impaired, but not stopped. The prognosis for this stage is usually good.
2. Partially reversible (decompensated). At the same time, the violation of blood supply (perfusion) is significant, but with urgent and proper medical intervention, there is a chance of restoring functions.
3. Irreversible (terminal). This is the most difficult stage, in which disturbances in the body are not restored even with the strongest medical impact. The prognosis here is 95% unfavorable.
Another classification divides the partially reversible stage into 2 - subcompensation and decompensation. As a result, there are 4 of them:
- 1st compensated (easiest, with a favorable prognosis).
- 2nd subcompensated (moderate, requiring immediate resuscitation. The prognosis is controversial).
- 3rd decompensation (very severe, even with the immediate implementation of all necessary measures, the prognosis is very difficult).
- 4th irreversible (Poor prognosis).
Our famous Pirogov singled out the shockstate two-phase:
-torpid (the patient is in a daze or extremely lethargic, does not respond to combat stimuli, does not answer questions);
-erectile (the patient is extremely excited, screams, makes many uncontrolled unconscious movements).
Types of shock
Depending on the reasons that led to an imbalance in the functioning of the body's systems, there are different types of shock. Classification by indicators of circulatory disorders is as follows:
-hypovolemic;
-distributive;
-cardiogenic;
-obstructive;
-dissociative.
Classification of shock by pathogenesis is as follows:
-hypovolemic;
-traumatic;
-cardiogenic;
-septic;
-anaphylactic;
-infectious-toxic;
-neurogenic;
-combined.
Hypovolemic shock
A complicated term is easy to understand, knowing that hypovolemia is a condition when blood circulates through the vessels in a smaller volume than necessary. Reasons:
-dehydration;
-extensive burns (a lot of plasma is lost);
- adverse reactions to drugs, such as vasodilators;
- large blood loss, as a result of which the organs receive less oxygen and nutrients, that is, perfusion is disturbed.
Hypovolemic shock due to high blood loss can be considered as hemorrhagic shock. The classification of this condition is identical to that developed by Selye, and in this case the stages are determined by the numberblood not received by the organs. Shock is always a kind of protection of the body in an extreme situation. That is, it launches a series of processes that seek to preserve the activity of important organs and thereby save the life of the entire system. In particular, with blood loss, reserve blood (approximately 10% of the total volume) spills into the blood vessels from the liver and spleen. If this is not enough, the blood supply to less important parts of the body, for example, to the limbs, is reduced or stopped, so that the remaining blood is enough to perfuse the heart, brain, and lungs. The classification of shock defines these two stages as reversible and partially reversible. At the same time, if measures are taken in time, it is possible to bring a person out of a state of shock and save his life.
The body is not able to work for a long time on reserve blood and provide perfusion of some organs at the expense of others. Therefore, if you do not start resuscitation, the last (irreversible) stage begins. Vascular paralysis is observed, the pressure in them drops sharply, blood flows to the periphery, increasing the deficit of perfusion of the brain, heart and lungs to critical levels.
Dehydration
Water in the human body, depending on age and gender, from 60 to 80%. Loss of only 20% of this volume can be fatal, and losses that reach 10% cause hypovolemic shock, which in this case is considered as dehydration, meaning a decrease in the volume of blood circulating through the vessels due to highdehydration. Reasons:
-diseases leading to diarrhea, vomiting, frequent copious urination;
- lack of water (drinking) by the body in extreme conditions, for example, in extreme heat, especially during high physical exertion;
-irrational diets.
Young children and the elderly are especially likely to be dehydrated.
Classification of shock resulting from lack of water, highlights the stages:
-reversible;
-partially reversible;
-irreversible.
In addition, dehydration is divided into these three types:
1. Isotonic (loss of Na and K ions). The fluid in our body is intracellular and intercellular. With isotonic losses, caused mainly by diarrhea, a lot of potassium is excreted from the body, and sodium, which is the main cation in the interstitial fluid, passes into the cells to replenish the lost potassium in them.
2. Hypotonic, which is a consequence of isotonic. At the same time, high losses in the intercellular fluid are noted (after all, sodium has passed into the cells). The first two stages are considered reversible, since electrolyte losses can be compensated. Partially, this is possible when the patient is given plenty of fluids, especially those containing sodium ions.
3. Hypertensive, developing in cases where diarrhea is accompanied by vomiting, preventing the intake of fluid into the body orally or with an overdose of certain substances that provoke additional urination. In this case, the fluid again passes from the cells into the intercellularspace, trying to maintain osmotic pressure. Twice dehydrated cells disrupt their work and decrease in volume. Especially dangerous is a decrease in brain volume, which leads to subdural hemorrhage.
Symptoms
We looked at the classification that characterizes hypovolemic shock. The clinic of this condition, regardless of the reasons that caused it, is approximately the same. At the reversible stage, a patient who is in a supine position may not have pronounced symptoms. Signs of the beginning of a problem are:
- heart palpitations;
-slight decrease in blood pressure;
-cold moist skin on limbs (due to decreased perfusion);
- with dehydration, there is dryness of the lips, mucous membranes in the mouth, absence of tears.
In the third stage of shock, the initial symptoms become more pronounced.
Patients have:
-tachycardia;
- decrease in blood pressure values below critical;
-breathing disorder;
-oliguria;
-cold to the touch skin (not only limbs);
-marbling of the skin and / or a change in their color from normal to pale cyanotic;
-threaded pulse;
-when pressing on the fingertips, they turn pale, and the color after removing the load is restored in more than 2 seconds, set by the norm. Hemorrhagic shock has the same clinic. Classification of its stages depending on the volume of circulating inblood vessels, additionally includes features:
-at the reversible stage tachycardia up to 110 beats per minute;
-on partially reversible - tachycardia up to 140 beats/min;
- on the irreversible - heart contractions of 160 and above beats / min. In a critical position, the pulse is not heard, and the systolic pressure drops to 60 mm Hg or less. column.
When dehydrated in a state of hypovolemic shock, symptoms are added:
-dryness of mucous membranes;
-reducing the tone of the eyeballs;
-in babies, the omission of a large fontanelle.
These are all external signs, but laboratory tests are carried out to accurately determine the extent of the problem. The patient is urgently performed a biochemical blood test, set the level of hematocrit, acidosis, in difficult cases, examine the density of the plasma. In addition, doctors monitor the level of potassium, basic electrolytes, creatinine, blood urea. If conditions permit, minute and stroke volumes of the heart, as well as central venous pressure, are examined.
Traumatic shock
This type of shock is in many ways similar to hemorrhagic, but it can only be caused by external wounds (stab, gunshot, burns) or internal (rupture of tissues and organs, for example, from a strong blow). Traumatic shock is almost always accompanied by a pain syndrome that is difficult to bear, further aggravating the situation of the victim. In some sources, this is called pain shock, often leading to death. SeverityTraumatic shock is determined not so much by the amount of blood lost, but by the rate of this loss. That is, if the blood leaves the body slowly, the victim is more likely to be saved. It also aggravates the position and degree of importance of the damaged organ for the body. That is, surviving a wound in the arm will be easier than a wound in the head. These are the features of traumatic shock. The classification of this condition according to severity is as follows:
-primary shock (occurs almost instantly after being wounded);
-secondary shock (appears after the operation, removal of tourniquets, with additional stress on the victim, for example, his transportation).
In addition, two phases are observed in traumatic shock - erectile and torpid.
Erectile symptoms:
-severe pain;
-inappropriate behavior (screaming, overexcitation, anxiety, sometimes aggression);
-tremor;
-cold sweat;
-dilated pupils;
-tachycardia;
-tachypnea.
Symptoms of torpid:
- the patient becomes indifferent;
-pain is felt, but the person does not react to it;
-blood pressure drops sharply;
-eyes dim;
-appears pallor of the skin, cyanosis of the lips;
-oliguria;
- taxed tongue;
-dryness of mucous membranes;
-cold sweat does not appear, but the skin loses turgor;
- thready pulse;
- Facial features are sharpened.
Infectious-toxicshock, classification
This condition occurs due to the penetration of an infection into the body, that is, viruses and bacteria that cause severe intoxication with their activities. Most often, streptococci, staphylococci, salmonella, Pseudomonas aeruginosa are responsible for the onset of shock. They enter the body, both with the help of open wounds (postpartum sepsis, burns, operations), and without them (typhoid fever, AIDS, tracheitis, sinusitis, pneumonia, influenza and other ailments).
Pathogenic microorganisms produce superantigens that activate T-lymphocytes and other T-cells. Those, in turn, secrete cytokines, as a result of which the patient's immune system is suppressed, and a huge amount of toxins is released into his blood, causing toxic shock. The classification of this condition distinguishes three stages:
1. Reversible. At the same time, blood pressure may be normal, consciousness remains clear, the skin becomes pink or reddens. The patient is often agitated, complains of pain in the body or in the abdomen, he has diarrhea, fever, and sometimes vomiting.
2. Partly reversible. Symptoms: fever, weak pulse, tachycardia, pressure drop, the patient is lethargic, his reactions are inhibited.
3. Irreversible. Symptoms: shallow breathing, convulsions, cyanosis of the skin, weak pulse, blood pressure below critical, the patient is unconscious.
Classification of anaphylactic shock
This condition occurs when poisons from the bite of snakes, spiders, wasps enter the bodyand other living beings, from taking certain drinks and food, and from the introduction of drugs that are allergens for this patient. Most often, such a reaction is given by novocaine, penicillin, organ preparations. Shock can occur a few seconds after the allergen enters the body or after a longer time, and the earlier the reaction occurs, the worse the prognosis. There are several forms of anaphylactic shock:
-typical (there is redness at the site of the bite (prick) or pain in the abdomen, throat with oral ingestion of the allergen, lowering pressure, squeezing under the ribs, possible diarrhea or vomiting);
-hemodynamic (in the first place cardiovascular disorders);
-asphyxia (respiratory failure, suffocation);
-cerebral (disturbances in the work of the central nervous system, convulsions, loss of consciousness, respiratory arrest);
-abdominal (acute abdomen).
Treatment
Proper categorization of shocks is critical to emergency action. Emergency resuscitation care in each case has its own specifics, but the sooner it begins to be provided, the more chances the patient has. At an irreversible stage, a lethal outcome is observed in more than 90% of cases. In traumatic shock, it is important to immediately block blood loss (apply a tourniquet) and take the victim to the hospital. They carry out intravenous administration of saline and colloidal solutions, transfusion of blood, plasma, anesthetize, if necessary, connect to an artificial respiration apparatus.
In case of anaphylactic shock, adrenaline is urgently injected, in case of asphyxiaintubate the patient. Subsequently, glucocorticoids and antihistamines are administered.
In case of toxic shock, massive infusion therapy is carried out using strong antibiotics, immunomodulators, glucocorticoids, plasma.
In hypovolemic shock, the main tasks are to restore the blood supply to all organs, eliminate hypoxia, normalize blood pressure and work of the heart. In shock caused by dehydration, an additional replacement of the lost volume of fluid and all electrolytes is required.
