Agony

Agony is the last stage of life before irreversible dying (practically the transition from clinical death to biological death with sudden cessation of breathing and cardiac activity or the stage of natural dying from old age), characterized by an increase in the activity of compensatory mechanisms aimed at combating the fading of the body's vital forces. Do not confuse with a terminal state, when resuscitation can be successful, if it is ineffective, agony also occurs.

Pathogenesis

Agony is interpreted by another name - at death, during which hemodynamic and respiratory disorders predominate, causing the development of hypoxia and hypovolemia, which determine the clinical picture. The duration of agony depends on the underlying pathology that caused the process. Trauma incompatible with life, especially with primary damage to the brain and other vital organs, or some acute diseases (extensive heart attack, stroke, etc.) have a very short period of several seconds, when the clinic does not have time to develop. In other cases, the agonal period can last up to several days.

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Symptoms agonies

Agony has polymorphic signs, but mainly consists of symptoms of suppression of vital functions of the body due to severe hypoxia. These include: disappearance of pain sensitivity, loss of consciousness, mydriasis, fading of pupillary, corneal, tendon and skin reflexes. The most important sign of agonal syndrome is the formation of respiratory arrhythmia: Cheyne-Stokes type - intermittent, frequent, superficial or, conversely, Kussmaul type - rare, very deep and noisy with a long period of apnea. Auxiliary muscles of the neck, shoulder girdle, trunk participate in breathing. The head is thrown back with each inhalation, the mouth is wide open, the patient seems to swallow air, but the efficiency of breathing is up to 15% of the norm due to terminal pulmonary edema (the surfactant of the alveoli is destroyed, they collapse, being excluded from breathing, the capillaries of the lung become empty, being excluded from the blood flow, alveolocapillary shunts open). The expiratory muscles and the diaphragm are excluded from breathing, or their contraction occurs simultaneously with the contraction of the inhalatory muscles.

Depression of cardiac activity is the "last chord of life". After a certain terminal pause, the effectiveness of cardiac contractions increases somewhat, tachycardia appears, arterial pressure increases somewhat, for a short period, literally to say the last "goodbye", consciousness may even be restored, but this is a bad prognostic sign, indicating that resuscitation will be ineffective.

The third leading sign is the shutdown of the functions of the cerebral cortex (neocortex) and, at the same time, the excitation of the subcortex and stem structures, i.e. the regulation of the functions of other systems switches to a primitive, uncoordinated, vegetative type, which determines the state of breathing and cardiac activity during the period of agony.

Additional manifestations depend on the cause of agony. When dying from traumatic shock and blood loss: skin and mucous membranes are waxy-pale, the nose becomes pointed, the cornea loses transparency, the pupils dilate sharply, with hypotension there is pronounced tachycardia with a slow fading of cardiac activity.

In mechanical asphyxia, at first, arterial pressure rises sharply with simultaneous bradycardia and extrasystole, the skin of the upper half of the body is sharply cyanotic, convulsions, involuntary movements, prolapse of the tongue, paralysis of the sphincters of the urethra and rectum.

When dying from heart failure: blood pressure progressively drops and tachycardia increases with a weakened pulse, severe cyanosis of the whole body, the face becomes puffy, convulsions are possible.

In extreme situations, agony is an indication for stopping resuscitation; in the case of natural dying, resuscitation is not indicated at all.

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