Acute vascular insufficiency in children

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

Acute vascular insufficiency manifests itself in the form of various types of fainting, collapse and shock.

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Fainting in a child

Fainting (Latin: syncope) is a sudden, short-term loss of consciousness caused by transient cerebral ischemia.

Children experience various types of fainting. They differ from each other in etiological factors and pathogenetic mechanisms. However, there are similar pathogenetic changes, the main one of which is considered to be a sudden attack of acute hypoxia of the brain. The development of such an attack is based on the mismatch of the functioning of its integrative systems, which causes a disruption in the interaction of psychovegetative, somatic and endocrine-humoral mechanisms that ensure universal adaptive reactions.

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Classification of syncope

• Neurogenic syncope:
  • vasodepressor (simple, vasovagal);
  • psychogenic;
  • sinus-carotid;
  • orthostatic;
  • nocturic;
  • tussive;
  • hyperventilation;
  • reflex.
• Somatogenic (symptomatic) syncope:
  • cardiogenic;
  • hypoglycemic;
  • hypovolemic;
  • anemic;
  • respiratory.
• Drug-induced fainting.

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Symptoms of Fainting

The clinical manifestations of various types of fainting are similar.

• Periods of development of fainting: pre-fainting state (hypothymia), period of loss of consciousness and post-fainting state (recovery period).
• Pre-fainting condition. Its duration usually ranges from a few seconds to 2 minutes. There is dizziness, nausea, a feeling of shortness of breath, general discomfort, increasing weakness, a feeling of anxiety and fear, noise or ringing in the ears, darkening of the eyes, unpleasant sensations in the heart and abdomen, palpitations. The skin becomes pale, damp and cold.
• The period of loss of consciousness may last from several seconds (with mild fainting) to several minutes (with deep fainting). During this period, examination of patients reveals a sharp pallor of the skin, pronounced muscle hypotonia, a weak, rare pulse, shallow breathing, arterial hypotension, dilated pupils with a reduced reaction to light. Clonic and tonic convulsions and involuntary urination are possible.
• Recovery period. Children quickly regain consciousness. After fainting, anxiety, fear, adynamia, weakness, shortness of breath, tachycardia persist for some time.

First aid for fainting

In case of fainting, it is necessary to lay the child horizontally, raising the legs at an angle of 40-50". At the same time, you should unbutton the collar, loosen the belt, provide access to fresh air. You can sprinkle the child's face with cold water, let him inhale ammonia vapors.

In case of prolonged fainting, it is recommended to administer a 10% caffeine solution (0.1 ml per year of life) or nikethamide (0.1 ml per year of life) subcutaneously. If severe arterial hypotension persists, then a 1% phenylephrine solution (0.1 ml per year of life) is prescribed intravenously by jet stream.

In case of severe vagotonia (decrease in diastolic blood pressure to 20-30 mm Hg, decrease in pulse rate by more than 30% of its age norm), a 0.1% solution of atropine is prescribed at a rate 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 due to a hypovolemic condition, then infusion therapy is performed.

In case of cardiogenic syncope, measures are taken to increase cardiac output and eliminate life-threatening cardiac arrhythmias.

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Collapse in a 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 the BCC. During collapse, arterial and venous pressure decreases, hypoxia of the brain occurs, and the functions of vital organs are suppressed. The pathogenesis of collapse is based on an increase in the volume of the vascular bed and a decrease in the BCC (a combined type of vascular insufficiency). In children, collapse most often occurs with acute infectious diseases and exogenous poisoning, severe hypoxic conditions, and acute adrenal insufficiency.

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Symptoms of collapse

Clinical variants of collapse. In pediatrics, it is common to distinguish between sympathetic-cotonic, vagotonic and paralytic collapse.

• Sympathicotonic collapse occurs with hypovolemia, usually associated with exsicosis or blood loss. In this case, there is a compensatory increase in the activity of the sympathetic-adrenal system, spasm of arterioles and centralization of blood circulation (hypovolemic type of vascular insufficiency). Characteristic are pallor and dryness of the skin, as well as mucous membranes, rapid weight loss, cold hands and feet, tachycardia; facial features become sharper. In children, systolic blood pressure mainly decreases, pulse blood pressure decreases sharply.
• Vagotonic collapse most often occurs with cerebral edema of infectious-toxic or other origin, which is accompanied by increased intracranial pressure and activation of the parasympathetic division 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, vagotonic collapse is characterized by mottling of the skin with a grayish-cyanotic tint, acrocyanosis, and bradycardia. Red diffuse dermographism is revealed. Blood pressure is sharply reduced, especially diastolic, due to which pulse blood pressure is increased.
• Paralytic collapse occurs as a result of the development of metabolic acidosis, accumulation of toxic metabolites, biogenic amines, bacterial toxins, causing damage to vascular receptors. In this case, children's blood pressure drops sharply, the pulse becomes threadlike, tachycardia occurs, signs of cerebral hypoxia with depression of consciousness. Blue-purple spots on the skin may appear.

Emergency care for collapse

The child is placed in a horizontal position with raised legs, free air passage and fresh air flow are ensured. At the same time, the child should be warmed up with hot water bottles and hot tea.

The leading role in the treatment of collapse is played by infusion-transfusion therapy, with the help of which the correspondence between the BCC and the volume of the vascular bed is achieved. In case of bleeding, red blood cell mass is transfused, in case of dehydration - infusion of crystalloids (0.9% sodium chloride solution, 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 collapse

• Sympathicotonic collapse. Against the background of infusion therapy, drugs are prescribed that relieve spasm of precapillary arterioles (ganglionic blockers, papaverine, bendazole, drotaverine), which are administered intramuscularly. With the restoration of the BCC, the central venous pressure is normalized, cardiac output increases, blood pressure rises, and urine output increases significantly. If oliguria persists, then one can think about the addition of renal failure.
• Vagotonic and paralytic collapse. The main attention is paid to the restoration of the circulating blood volume. For infusion therapy to maintain the circulating blood volume, 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 is prescribed only to children over 10 years of age, as it can cause anaphylactic reactions. In severe collapse, the rate of administration of plasma-substituting fluids can be increased. In this case, it is advisable to administer an initial shock dose of crystalloids at the rate of 10 ml/kg over 10 minutes, as in shock, and carry out intravenous administration at a rate of 1 ml/kg x min) until the functions of vital organs are stabilized. At the same time, prednisolone up to 5 mg/kg, hydrocortisone up to 10-20 mg/kg are administered intravenously, especially in case of infectious toxicosis, since hydrocortisone may have a direct antitoxic effect by binding toxins. In addition, dexamethasone can be used at a rate of 0.2-0.5 mg/kg. If arterial hypotension persists during infusion therapy, it is advisable to administer 1% phenylephrine solution at a rate of 0.5-1 mcg/kg x min intravenously, 0.2% norepinephrine solution at a rate of 0.5-1 mcg/kg x min into the central vein under the control of arterial pressure. In less severe cases, phenylephrine can be administered subcutaneously, and if Infusomat is not available, it can be administered as a 1% solution intravenously by drip (0.1 ml per year of life in 50 ml of 5% dextrose solution) at a rate of 10-30 drops per minute under the control of arterial pressure. Norepinephrine is recommended for use in the treatment of septic shock. However, due to severe vasoconstriction, its use is significantly limited, since side effects of treatment can include gangrene of the limb, necrosis and ulceration of large areas of tissue when its solution enters the subcutaneous fat. When administered in small doses (less than 2 mcg / min), the drug has a cardiostimulating effect through the activation of beta-adrenergic receptors. The addition of low doses of dopamine (1 mcg / kg per minute) helps to reduce vasoconstriction and maintain renal blood flow against the background of norepinephrine administration. In the treatment of collapse, dopamine can be used in cardiostimulating (8-10 mcg/kg per minute) or vasoconstrictor (12-15 mcg/kg per minute) doses.