Acute vascular insufficiency in children

Vascular insufficiency is a clinical syndrome, in which there is a discrepancy between bcc and the volume of the vascular bed. In this regard, vascular insufficiency can arise due to a decrease in BCC (hypovolemic, or circulatory, type of vascular insufficiency) and due to the increase in the volume of the vascular bed (vascular type of vascular insufficiency), and as a result of a combination of these factors (combined type of vascular insufficiency) .

Acute vascular insufficiency manifests itself in the form of various variants of syncope, in the form of collapse and shock.

[1], [2], [3], [4], [5], [6], [7], [8]

Child fainting

Fainting (Latin syncope) is a sudden short-term loss of consciousness caused by transient ischemia of the brain.

Children have different types of syncope. They differ from each other by etiological factors and pathogenetic mechanisms. However, there are similar pathogenetic changes, chief among which is the sudden onset of acute cerebral hypoxia. The development of such an attack is based on a mismatch in the functioning of its integrative systems, which causes a disruption in the interaction of psychovegetative, somatic and endocrine-humoral mechanisms that provide universal adaptive responses.

[9], [10], [11], [12]

Classification of syncope

• Neurogenic syncope:
  • vasodepressor (simple, vasovagal);
  • psychogenic;
  • sino-carotid;
  • orthostatic;
  • nocturnal;
  • tussive;
  • hyperventilation;
  • reflex.
• Somatogenic (symptomatic) syncope:
  • cardiogenic;
  • hypoglycemic;
  • hypovolemic;
  • anemic;
  • respiratory.
• Medicinal syncope.

[13], [14], [15], [16], [17]

Symptoms of fainting

The clinical manifestations of various variants of syncope are similar.

• Periods of development of a syncope: a presyncope (hypothyroidism), a period of loss of consciousness and a post-fainting condition (recovery period).
• Pre-condition. Its duration is usually from a few seconds to 2 minutes. There is dizziness, nausea, a feeling of lack of air, general discomfort, growing weakness, feelings of anxiety and fear, noise or ringing in the ears, darkening in the eyes, unpleasant sensations in the heart and abdomen, palpitations. The skin becomes pale, wet and cold.
• The period of loss of consciousness can last from a few seconds (with a slight fainting) to several minutes (with a deep fainting). During this period, when examining the patients, they reveal a sharp pallor of the skin, expressed muscular hypotonia, a weak rare pulse, shallow breathing, arterial hypotension, dilated pupils with reduced response to light. Possible clonic and tonic convulsions, involuntary urination.
• Recovery period. Children quickly regain consciousness. After fainting, anxiety, fear, adynamia, weakness, shortness of breath, tachycardia remain for a while.

Emergency care in syncope

In case of fainting, it is necessary to lay the child horizontally, lifting the legs at an angle of 40-50 ".At the same time, you should unbuckle the collar, loosen the belt, provide fresh air. You can sprinkle the child's face with cold water, letting in a couple of ammonia.

With prolonged fainting, a 10% solution of caffeine (0.1 ml per year of life) or niketamide (0.1 ml per year of life) is recommended to be administered subcutaneously. If the expressed arterial hypotension is maintained, then 1% solution of phenylephrine (0.1 ml per year of life) is administered intravenously.

With pronounced vagotonia (a decrease in diastolic blood pressure to 20-30 mm Hg, a decrease in the pulse by more than 30% of its age norm), 0.1% solution of atropine is calculated from the calculation of 0.05-0.1 ml per year of life.

If fainting is caused by a hypoglycemic condition, then a 20% dextrose solution should be administered intravenously in a volume of 20-40 ml (2 ml / kg), if hypovolemic, then infusion therapy is given.

With cardiogenic syncope, measures are taken to increase cardiac output, eliminate life-threatening cardiac arrhythmias.

[18]

Collapse in the child

Collapse (Latin collapsus - weakened, fallen) is one of the forms of acute vascular insufficiency, caused by a sharp decrease in vascular tone and a decrease in BCC. At a collapse arterial and venous pressure decreases, there is a hypoxia of a brain, functions of the vital organs are oppressed. At the heart of the pathogenesis of collapse is an increase in the volume of the vascular bed and a decrease in BCC (a combined type of vascular insufficiency). In children, the collapse most often occurs in acute infectious diseases and exogenous poisoning, severe hypoxic conditions, acute adrenal insufficiency.

[19], [20], [21], [22], [23], [24]

Symptoms of collapse

Clinical variants of collapse. In pediatrics, it is customary to distinguish sympathy-cotonical, vagotonic and paralytic collapse.

• Sympaticotonic collapse occurs with hypovolemia. Associated, as a rule, with exsicosis or blood loss. At the same time, there is a compensatory increase in activity of the sympathetic-adrenal system, arterioles spasm and centralization of blood circulation (hypovolemic type of vascular insufficiency). Characteristic pallor and dryness of the skin, as well as mucous membranes, rapid reduction in body weight, coldness of the hands and feet, tachycardia; facial features become sharpened. In children, the systolic blood pressure is predominantly reduced, the pulse BP decreases drastically.
• Vagotonic collapse most often occurs with edema of the brain of an infectious-toxic or other origin, which is accompanied by increased intracranial pressure and activation of the parasympathetic part of the autonomic nervous system. This in turn causes vasodilation, an increase in the volume of the vascular bed (vascular type of vascular insufficiency). Clinically, with the vagotonic collapse, marbling of the skin with a grayish-cyanotic shade, acrocyanosis, bradycardia arise. Reveal red spilled dermographism. The blood pressure is sharply reduced, especially diastolic, in connection with which the pulse BP is increased.
• Paralytic collapse occurs as a result of the development of metabolic acidosis, the accumulation of toxic metabolites, biogenic amines, bacterial toxins that cause damage to receptors of blood vessels. In this case, children have a sharp drop in blood pressure, pulse becomes threadlike, tachycardia develops, signs of hypoxia of the brain with oppression of consciousness. Blue-purple spots on the skin may appear.

Unconditional help in case of collapse

The child is given a horizontal position with raised legs, provides free patency of the respiratory tract, and fresh air. At the same time, the child should be warmed with warm warmers and hot tea.

The leading role in the treatment of collapse is played by infusion-transfusion therapy, which achieves a correspondence between BCC and the volume of the vascular bed. In case of bleeding, the erythrocyte mass is transfused, with dehydration, the infusion of crystalloids (0.9% solution of sodium chloride, Ringer's solution, disol, 5% and 10% dextrose solution, etc.), colloidal plasma substitutes (most often dextran derivatives). In addition, plasma transfusion, 5% and 10% albumin solution can be performed.

Treatment depending on the clinical variant of the collapse

• Sympathicotonic collapse. Against the backdrop of infusion therapy prescribe drugs that relieve the spasm of precapillary arterioles (ganglioblokatory, papaverine, bendazole, drotaverin), which are administered intramuscularly. When the BCC is restored, CVP is normalized, cardiac output increases, blood pressure rises and urination significantly increases. If oliguria is preserved, then one can think of adherence to renal failure.
• Vagotonic and paralytic collapse. The main focus is on the restoration of BCC. For infusion therapy to maintain bcc, rheopolyglucin (10 ml / kg per hour), 0.9% sodium chloride solution, Ringer's solution and 5-10% dextrose solution (10 ml / kg per hour) or hydroxyethyl starch can be used. The latter are prescribed to children only older than 10 years, since it can cause anaphylactic reactions. With a heavy collapse, the rate of introduction of plasma-substituting liquids can be increased. In this case, it is expedient to introduce an initial shock dose of crystalloids from the calculation of 10 ml / kg for 10 min, as in the case of shock, and to administer intravenously at a rate of 1 ml / kgmin) until the vital organs function. At the same time intravenously administered prednisolone up to 5 mg / kg, hydrocortisone to 10-20 mg / kg, especially with infectious toxicosis, since hydrocortisone may have a direct antitoxic effect, binding toxins. In addition, can use dexamethasone from the calculation of 0.2-0.5 mg / kg. With the preservation of arterial hypotension against the background of the infusion therapy, it is advisable to administer 1% phenylephrine solution intravenously, 0.5-1 μg / kghmin intravenously, 0.2% solution of norepinephrine from 0.5-1 μg / kg hmin) to the central vein control of blood pressure. In less severe cases, phenylephrine can be administered subcutaneously, and in the absence of "Infusomat" it can be administered as a 1% solution intravenously drip (0.1 ml per year of life in 50 ml of a 5% solution of dextrose) at a rate of 10-30 drops per minute under control blood pressure. Norepinephrine is recommended for use in the treatment of septic shock. However, in connection with pronounced vasoconstriction, its use is severely limited, as the side effects of the treatment may be gangrene of the limb, necrosis and ulceration of large sections of tissues when its solution enters the subcutaneous fatty tissue. With the introduction of small doses (less than 2 μg / min), the drug has a cardiostimulating effect through the activation of beta adrenoreceptors. The addition of low doses of dopamine (1 μg / kg per minute) helps to reduce vasoconstriction and maintain renal blood flow when norepinephrine is introduced. In the treatment of collapse, dopamine can be used in cardiostimulating (8-10 μg / kg per minute) or vasoconstrictive (12-15 μg / kg per minute) doses.