Many infectious diseases are caused by pathogenic bacteria that enter our body in various ways. In the process of their active life, a lot of harmful substances are released into the human body, which can cause infectious toxic shock (ITS). This condition is dangerous because its first symptoms are perceived by many as a cold. People are in no hurry to see a doctor, they try to be treated with medicines that are completely useless in this case, which further exacerbate intoxication. Meanwhile, severe pathological changes continue in the body that can lead to death. The All-Russian organization dealing with disaster medicine, together with the Profile Commission of the Ministry of He alth of the Russian Federation, developed clinical recommendations for the treatment and diagnosis of infectious-toxic shock. They are based on more than 20 years of experience and allow doctors to work clearly and quickly to save a person's life. These recommendations are focused on the occurrence of TSS in emergency situations, but all of their provisions are relevant.and in everyday life.
General definition
Toxic shock is an urgent pathological condition that requires medical attention as soon as possible. Bacteria of absolutely all kinds, having penetrated into any organ of the human body, begin to multiply rapidly. In an infected person, this process causes symptoms characteristic of each disease. At the same time, a person is poisoned by substances called exotoxins. They are secreted by bacteria in the course of their life. If you do not treat with antibiotics, the patient's condition will worsen significantly. Even death may occur.
However, you are mistaken if you think that antibiotics completely solve the problem. When bacteria are destroyed from their destroyed dead cells, individual structural components, which are called endotoxins, are released into the human body. By their nature, they are no less dangerous than exotoxins.
Both types of these substances harmful to humans, getting into the blood, cause a violation of its transport function, oxygen starvation of tissues and, as a result, severe pathologies of vital organs.
Code for toxic shock according to the ICD 10th revision - A48.3. This classification was adopted in 1989. It is the main statistical basis of he alth care in all countries of the world. The previous revision was carried out in 1975. Although almost no one now uses the outdated classification, it can still be found in some textbooks. To make it clear whatdisease in question, we note that the code for infectious-toxic shock according to the ICD 9th revision is 040.82.
This condition can occur in people of any age, from a baby to a very old man. Its occurrence is determined by the strength of the patient's immune system and the type of microbe.
In general terms, TSS can be described as a combination of a severe inflammatory process (the underlying disease) and circulatory failure.
Pathogenesis
Microbiological studies have made it possible to study in sufficient detail the pathogenesis of infectious-toxic shock. Without therapy, bacterial toxins enter the patient's blood, which destroy the cells. These toxic substances are specific to each microbe, but all are very dangerous. For example, 0.0001 mg of botulinum toxin kills a guinea pig.
With intensive antibiotic therapy, a huge amount of cytokines, adrenaline and other substances that cause spasms in arterioles and venules penetrate into the patient's blood. As a result, the blood cannot deliver oxygen and nutrients to the tissues of the organs. This leads to their ischemia (oxygen starvation) and a violation of the acid-base balance of the body as a whole (acidosis).
At the next stage, there is a release of histamine, a decrease in the sensitivity of blood vessels to adrenaline, paresis of arterioles. Clinically, in this case, blood flows out of the vessels into the intercellular space.
This process is accompanied not only by bleeding, but also by a decrease in blood in the vessels of the body (hypovolemia). It is dangerous because to her heartreturns less than required for its normal operation.
Ischemia and hypovolemia cause disruption of all systems. The patient is diagnosed with kidney failure, breathing problems, irregular heart rhythms and other dangerous symptoms.
Etiology
Infectious-toxic shock in most cases occurs in diseases accompanied by bacteremia (microbes circulate in the blood), such as leptospirosis, typhoid fever. However, it often becomes a complication of such ailments:
- Pneumonia.
- Salmonellosis.
- Dysentery.
- HIV or AIDS.
- Scarlet fever.
- Diphtheria.
Some viral diseases can also cause TSS:
- Flu.
- Chickenpox.
Also at risk are patients diagnosed with:
- Tracheitis.
- Sinusitis.
- Postpartum sepsis.
- Complicated abortion.
- Post-surgery infections.
- Closed wounds (in the nose).
- Allergic dermatitis.
- Open wounds, including burns.
Women can develop TTS from using tampons, which sometimes help S. aureus enter the vagina.
In medical practice, cases of infectious-toxic shock have been recorded when using insufficiently sterile vaginal contraceptives.
TTS can also occur in both sexes who use drugs.
Pre-shock state
There are three degrees of toxic shock, called compensated, decompensated and irreversible. However, many doctors also distinguish the fourth degree, called pre-shock or early.
This condition may have the following symptoms:
- Blood pressure is stable and pulse rate is low.
- Tachycardia.
- Headache.
- Mild nausea.
- Weakness.
- Muscle pain.
- Uncaused depression, anxiety.
- Skin is warm, only feet or hands can be cold.
- Skin color is normal.
- Some people have a fever of 39-40 degrees.
- Hemorrhages in the mucous membrane of the eye.
Shock index less than 1.0.
When such symptoms appear against the background of an infectious disease, it is necessary to call an ambulance, since it is impossible to treat toxic shock at home. The emergency assistance that the relatives of the patient should provide consists of the following actions:
- Provide fresh air into the premises.
- Remove (or unfasten) tight clothing from the patient.
- Put a heating pad under his feet and a voluminous pillow under his head.
It is important to note that even with pre-shock symptoms, hospitalization is mandatory.
First degree
It is called pronounced or compensated shock. At this stage, the patient has:
- Reducing blood pressure to critical levels.
- Weak and rapid pulse (over 100 beats per minute).
- Skin is cold and damp.
- Cyanosis.
- Inhibition of reactions.
- Apathy.
- Tachypnea. For adults, this is 20 breaths/exhalations per minute. For children - 25, for babies - 40.
Shock index is in the range of 1.0-1.4.
Medical care for second-degree toxic shock should be provided immediately. It includes activities to detoxify the body, restore normal blood circulation, ensure stable breathing and heartbeat.
Second degree
Its name is decompensated shock. The patient's condition continues to deteriorate. He has:
- Blood pressure at 70 mm. rt. Art. and below.
- High heart rate.
- General cyanosis.
- Shortness of breath.
- Sometimes jaundice or marbling can be observed.
- Oliguria.
- Some patients may experience a rash with necrosis.
The shock index is 1.5. At this stage, severe, sometimes irreversible damage to the organs occurs. Such pathologies in the central nervous system are especially dangerous. However, with timely and competent medical care, the patient can still be saved.
Third degree
This condition develops in patients who are not treated on time. It is called the late stage or irreversible shock. At the same time, in the internal organs,irreversible transformations, often incompatible with life. The toxic shock clinic at this stage:
Hypothermia (body temperature below 35 degrees).
- Skin is cold, earthy.
- Cyanosis around joints.
- Involuntary bowel movements.
- Anuria.
- Very labored breathing.
- Mask face.
- The pulse is threadlike (sometimes not audible at all).
- Loss of consciousness.
- Coma.
- Shock index above 1.5.
Note that TSS in most cases develops very quickly. In some patients, the first two stages are so fleeting that they cannot be differentiated. Therefore, there is no need to tempt fate, doubt and hope for a miracle. If the pre-shock symptoms described above occur, you must immediately call an ambulance. Remember, the third (final) stage can occur within 1 hour.
Toxic Infectious Shock in Children
In babies, as in adults, TSS occurs as a result of poisoning the body with endo- and exotoxins secreted by pathogenic microbes. Its features are in the rapid (sometimes lightning-fast) development of a decrease in blood circulation in the vessels, which leads to the death of cells in all organs. The greatest danger to children (especially infants) are staphylococci and streptococci. As a rule, babies do not yet have strong immunity, so bacterial diseases are more difficult for them.
Very often children develop infectious toxicshock in pneumonia. The lungs of young patients are very vulnerable to poisonous toxins. With the cessation of blood circulation in microvessels and capillary paresis, microembolism is observed in the alveoli, which leads to hypoxia. The child may die not from the underlying disease (in this case, pneumonia), but from suffocation.
Other dangerous diseases and conditions that can lead to TSS:
- Urticaria.
- Allergy.
- Dysbacteriosis.
- Dysentery.
- Chickenpox.
- HIV/AIDS.
- Scarlet fever.
- Diphtheria.
Parents should pay attention to the following symptoms in a child:
- Sudden rise in temperature.
- Fever.
- Small rash on hands and feet.
- Lethargy (baby like a rag) caused by a sharp drop in blood pressure.
- Marbling or other discoloration of the skin.
- Decrease in urine output (can be seen by the frequency of diaper changes).
- Vomiting, diarrhea (watery stools).
- Conjunctivitis (may not appear in all cases).
Every parent should clearly understand that it is unacceptable to self-medicate. At the slightest suspicion of infectious-toxic shock, there is only one recommendation - immediately call an ambulance. Before her arrival, the baby should be allowed to drink water at room temperature. If he has chills and icy limbs, you need to warm the child, and at a high temperature, on the contrary, remove excess (especially woolen) clothes from him. You also need to open a window in the room, providing fresh air.
IfTSS occurred during treatment with antibiotics, it is necessary to stop taking them before the doctors arrive. It is also unacceptable to give the child antipyretics and medicine "for diarrhea". At very high temperatures, you can undress the baby and wipe it with water at room temperature, put a cold compress on the forehead, which must be changed regularly.
Emergency
Due to the very rapid development of infectious-toxic shock, emergency doctors often begin to provide emergency care right on the spot.
The first action is to stabilize the breath. If necessary (the patient is not breathing), artificial lung ventilation and oxygen therapy are performed.
Further, the ambulance doctors administer intravenous vasopressors - "Norepinephrine" or "Norepinephrine" with saline. The dosage may vary, depending on the age of the patient and on his condition. Glucocorticosteroids are also administered intravenously. The most commonly used are Prednisolone or Dexamethasone. Children can be given "Metipred bolus" in the calculation - 10 mg/kg for the second degree, 20 mg/kg for the third, 30 mg/kg for the fourth.
In the intensive care unit continue to provide emergency care. Patients enter catheters into the bladder and into the subclavian vein. Constantly monitor breathing and heart function, monitor the amount of urine excreted. Patients are administered:
- Inotropic drugs (regulate heart contractions).
- Glucocorticosteroids.
- Colloid solutions (correct hemorheological disorders).
- Antithrombins.
Diagnosis
Research is carried out while the patient is in the intensive care unit. Perform the following tests:
- Biochemical blood (it is used to determine the type of pathogen, its reaction to antibiotics).
- Common urine and blood.
- Measure the amount of urine excreted per day.
- If necessary, carry out instrumental diagnostics, including ultrasound, MRI, ECG. It is needed to determine the degree of pathological changes in vital organs.
Diagnosis of toxic shock is based on clinical signs (until test results are available). Its main criteria:
- Dynamic progression of deterioration over a short period of time.
- Cyanosis.
- Acute respiratory failure.
- The appearance of cadaveric spots on the neck, torso, legs.
- Very low blood pressure (down to zero).
Treatment of toxic shock
In the intensive care unit, the patient continues to receive mechanical ventilation and oxygen therapy (using a mask or nasal catheter). Pressure is measured every 10 minutes, and when the condition stabilizes - every hour.
The amount of urine output is also regularly checked. If the indicators reach values of 0.5 ml / min. - 1.0 ml / min, this indicates the effectiveness of ongoing resuscitation.
Mandatory infusion therapy. It involves the introduction of an intravenous crystalloid solution(1.5 liters), "Albumin" or "Reopoliglyukina" (1.5-2.0 l). Doses are given for adults. For children, they are calculated per kg of weight.
To restore blood flow in the kidneys, "Dolamine" is administered. Dosage: 50 mg in 250 ml glucose 5%.
Glucocorticosteroids are administered to restore blood flow in the vessels. For those with first-degree TSS, Prednisolone is administered intravenously every 6-8 hours, and for patients with third- and second-degree shock, every 3-4 hours.
If hypercoagulation of DIC syndrome is observed, "Heparin" is administered. First, this is done in a jet, and then drip. At the same time, blood coagulation indicators must be constantly monitored.
Also, the patient is given antibiotic therapy and detoxification of the body.
After the patient is removed from ITS, intensive treatment is continued to rule out any failure (cardiac, pulmonary, renal).
Forecasts
Unfortunately, only with the first degree of infectious-toxic shock, the prognosis is favorable. If the patient was taken to the intensive care unit on time and given the necessary therapy, he is usually discharged from the hospital in a satisfactory condition after 2-3 weeks.
In the second degree of TSS, the prognosis depends on three factors:
- Professionalism of doctors.
- How strong the patient's body is.
- Which microbe caused TSS.
Approximately 40-65% of deaths are observed in the second degree.
A very small percentage of patients survive with third-degree TSS. After suffering such a severe conditionpeople need long-term rehabilitation in order to restore the functioning of the organs in which the changes have occurred.
