Shock

Shock is a collective concept, which denotes the extreme stress stress of mechanisms, the regulation of homeostasis under various primary endogenous and exogenous effects.

Depending on the main reason, different forms of shock are distinguished, there are many of them, there is no single classification. The most popular classification is based on the etiological principle:

1. exogenous painful (traumatic, burn, with electric trauma, etc.);
2. endogenous-painful (cardiogenic, nephrogenic, abdominal, etc.);
3. humoral (blood transfusion or post-hemotransfusion, hemolytic, insulin, anaphylactic, toxic, etc.);
4. psychogenic.

[1],

Anaphylactic shock

This is a life-threatening condition that develops when the body's allergic reaction to medications (more often antibiotics, serums, radiocontrast preparations) and food products. In most cases it develops immediately, but it can be after 30-40 minutes.

The main signs that characterize the shock are: a feeling of tightness in the chest, suffocation, weakness, headache and dizziness, a feeling of heat, weakness. Characteristic of the development of Quincke's edema with respiratory depression, rapid inhibition of cardiac activity with hypotension and tachycardia, depression of consciousness down to coma. Death can come in a few minutes.

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

Hemorrhagic shock

The development of hemorrhagic shock depends on the magnitude and rate of hemorrhage. Hemorrhagic shock develops with blood loss of more than 30% BCC and causes an inevitable form with blood loss over 60% BCC, but this is with a slow blood loss and rapid recovery.

With rapid blood loss within 15-20 minutes, even 30% of BCC and slowing with its replenishment within an hour cause irreversible changes in the body. In this regard, clinicians suggest an approximate index of the reversibility of shock by skin color: a gray appearance (due to stasis of erythrocytes in capillaries) - reversible shock; white look.

Irreversible shock. Like most other forms of shock, hemorrhagic shock proceeds with the development of two stages. The erectile stage is very short, just a few minutes. Accompanied by the excitation of the patient, inadequate behavior, in most cases, aggression. Blood pressure is slightly increased.

The torpid phase of shock is accompanied by the oppression of the great, his indifference. Depending on the condition of hemodynamics and the severity of hypovolemia, 4 degrees of hemorrhagic shock are conventionally distinguished: I degree - ADS reduced to 100-90 mm Hg. Tachycardia up to 100-110 per minute; II degree - ADS decreases to 80-70 mm Hg. Tachycardia grows to 120 per minute; III degree - ADS below 70 mm Hg. Tachycardia up to 140 per minute; IV degree - ADS below 60 mm Hg. Tachycardia up to 160 per minute. Hypovolemic shock proceeds in a similar way.

Cardiogenic shock

One of the most formidable complications of myocardial infarction, characterized by disorganization of hemodynamics, its nervous and humoral regulation and impairment of vital functions.

According to the pathogenesis, four forms of shock are distinguished:

1. Reflex shock, based on pain irritation (the easiest);
2. "True" shock caused by a violation of the contractile function of the myocardium;
3. an areactive shock caused by a variety of factors (irreversible);
4. arrhythmic shock caused by atrioventricular blockade with the development of tachycardia or bradisystolic forms of arrhythmia.

Pain syndrome can be expressed sharply, weakly or not at all, especially with repeated heart attacks. Peripheral manifestations: pallor of the skin, often with an ashy-gray or cyanotic hue, cyanosis of the extremities, cold sweat, fallen veins, small and frequent, pulse, cyanosis of the mucous membranes - depend on the severity of the shock. The marble pattern of the skin with pale patches on the background of cyanosis is an extremely unfavorable prognostic factor. There may be a gastro-cardiac syndrome.

The main objective criteria for the presence and severity of cardiogenic shock are: lowering blood pressure below 90 mm Hg. Art. (in hypertensive patients with very high pressure, a shock can occur at relatively normal numbers, but the drop in blood pressure is always pronounced compared to the initial one); arrhythmia - tahisistolic (up to the atrial) or bradisystolic forms; oliguria; disruption of central and peripheral nervous system (psychomotor agitation or adynamia, confusion of consciousness without sudden inhibition or temporary loss, changes in reflexes and sensitivity).

By severity, there are 3 degrees of shock:

• 1 degree. The level of blood pressure is 85/50 - 60/40 mm Hg. Art. The duration is 3-5 hours. Pressor reaction the attraction of the hour. Peripheral manifestations are moderately expressed.
• 2 degree. The level of blood pressure is 80/50 - 40/20 mm Hg. Art. Duration 5-10 hours. Pressor reaction is slow and unstable. Peripheral manifestations are sharply expressed in 20% of patients with alveolar edema of the lungs.
• 3 degree. Blood pressure level is 60/50 and below. Duration 24-72 hours, or heart failure progresses with the development of alveolar pulmonary edema. Pressor reaction in most cases is not expressed.

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

Traumatic shock

This phase response compensatory-adaptive reaction of the body to an aggressive, predominantly painful effect of factors, the external environment, accompanied by dysfunctional, energy, regulatory disorders of the homeostasis and neurohumoral reactivity of the organism with the development of hypovolemia. A characteristic feature is the phase flow and the characteristic changes in hemodynamics that determine the severity of the shock.

The phase of the shock is determined by the following statements. The brain of each person can individually perceive only a certain amount of painful stimuli, which is called a "shock threshold", it can be low and high. The lower the shock threshold, the greater the probability of shock and the severity of developing hemodynamic changes, i.e. Degree of shock. During the period of accumulation of painful stimuli to the shock threshold, the erectile (exciting) phase of shock develops, which is accompanied by an inadequate behavior of the victim, he is excited. Behavior, as a rule, depends on the situation preceding the trauma. The victim can be well-intentioned, but can be aggressive, has a place of motor excitement, and the patient can even move on the injured limb. The skin is pale, the face is feverish, the eyes are shiny, the pupils are wide. Arterial pressure in this phase is not reduced, can be increased, there is a moderate tachycardia.

After reaching the shock threshold, a torpid (inhibition) phase of shock develops, accompanied by gradual depression of consciousness, development of hypovolemia and cardiovascular insufficiency due to blood and plasma loss. Specifically, hypovolemic syndrome and cardiovascular insufficiency (quite conditionally, since the victim's adaptive condition is specific in each case) judge the severity of traumatic shock according to the classification of the Kit. The severity of shock is determined only in the torpid phase.

• 1 degree (light shock). The general condition of the victim does not inspire fears for his life. Consciousness is preserved, but the patient is inactive and indifferent. Skin covers are pale, body temperature is somewhat lowered. The reaction of the pupils is preserved. The pulse is rhythmic; normal filling and tension, is increased to 100 per minute. Blood pressure at the level of 100/60 mm Hg. Art. Breathing is increased to 24 per minute, there is no shortness of breath. Reflexes are saved. Diuresis is normal, over 60 ml per hour.
• 2 degree (moderate shock). Consciousness is co-operative. Skin covers are pale, with a grayish hue, cold and dry. Pupils react weakly to light, reflexes are reduced. BP at 80/50 mm Hg. Art. Pulse up to 120 per minute. Breathing is increased to 28-30 per minute with shortness of breath, auscultation is weakened. Diuresis is reduced, but kept at 30 ml per minute.
• 3 degree (heavy cheek). It is accompanied by deep depression of consciousness in the form of stupor or coma. The skin is pale, with an earthy tinge. There is no pupillary reaction, a sharp decrease in reflexes or areflexia is noted peripherally. BP is reduced to 70/30 mm Hg. Art. The pulse is threadlike. There is acute respiratory failure, or it is absent, which in both cases requires artificial ventilation (IVL). Diuresis is either drastically reduced, or anuria develops.

DM Sherman (1972) proposed the introduction of an IV degree of shock (terminal synonyms: transcendental, irreversible), which in fact represents a state of clinical death. But the resuscitation measures with it are absolutely ineffective.

There are many additional criteria for determining the severity of the shock, based on laboratory and instrumental studies (the principle of the Allgäuer is the ratio of the pulse to the AD, the determination of the bcc, the lactate / pyruvate system of the creatinine index, the use of the calculated formulas for shock indices, etc.), but they are not always available do not have sufficient accuracy. We consider the clinical classification of China to be the most accessible, accurate and acceptable.

Burn shock

It is the initial stage of a burn disease. The erectile phase of burn shock is characterized by general excitation, increased blood pressure, increased respiration and pulse. Usually it lasts 2-6 hours. Then comes the torpid phase of shock. Timely and qualitative assistance to the victim can prevent "the development of the torpid phase of shock. Conversely, additional traumatization of the victim, late and unskilled help contribute to weighting the shock. In contrast to traumatic, for burn shock is characterized by a prolonged persistence of elevated blood pressure, which is explained by massive plasmapo- tumery in the edema and pronounced vascular tone and painful stimuli. Reduction of blood pressure during the shock period is an extremely unfavorable prognostic sign.

By severity, in the torpid phase, there are 3 degrees of shock.

• I degree. Light shock. Develops with superficial burns not more than 20% and at deep no more than 10%. Victims are more often quiet, less excited or euphoric. It is marked: chills, pallor, thirst, goosebumps, muscle tremors, occasionally nausea and vomiting. Breathing is not accelerated. Pulse is within 100-110 per minute. AD within normal limits. CVP is normal. The kidney function is reduced moderately, hourly diuresis over 30 ml / hour. Blood thickening is insignificant: hemoglobin is raised to 150 g / l, erythrocytes - up to 5 million in 1 μl of blood, hematocrit - up to 45-55%. BCC reduced by 10% of the norm.
• II degree. Heavy shock. It develops with burns occupying an area of more than 20% of the body surface. The condition is severe, the victims are nervous or hindered. Disturb: chills, thirst, nausea and vomiting. The skin is pale, dry, cold to the touch. Breathing is quickened. Pulse is 120-130 per minute. BP is reduced to 110-100 mm Hg. Art. BCC is reduced by 10-30%. There is an obvious thickening of the blood: hemoglobin rises to 160-220 g / l, erythrocytes - up to 5.5-6.5 million in μl of blood, hematocrit - up to 55-65%. The kidney failure is formed, hourly diuresis is less than 10ml / hour, often hematuria and proteinemia, the specific gravity of urine is significantly increased; increase the slag of blood: residual nitrogen, creatinine, urea. Due to microcirculation disturbance, tissue metabolism decreases with the development of acidosis and water-electrolyte blood changes: hyperkalaemia and hyponatremia.
• III degree. Extremely heavy shock. It develops when more than 60% of the surface of the body is affected by superficial burns or 40% deep. The state is extremely difficult, the consciousness is confused. Disturbing painful thirst, it is often uncontrollable vomiting. The skin is pale, with a marble shade, dry, their temperature is significantly reduced. Respiration is frequent, with severe shortness of breath. Blood pressure below 100 mm Hg. Art. The pulse is threadlike. BCC reduced by 20-40%, which causes a violation of blood circulation in all organs and tissues. Blood clotting is sharp: hemoglobin rises to 200-240 g / l, erythrocytes up to 6.5-7.5 million in μl of blood, hematocrit - up to 60-70%. Urine is completely absent (anuria), or it is extremely small (oliguria). The slag of blood is growing. Hepatic insufficiency develops with the growth of bilirubin and a drop in the prothrombin index.

The duration of the torpid phase of shock is from 3 to 72 hours. With a favorable outcome, which is determined by the severity of the burn and shock, the timely delivery of care, the correctness of treatment begins to restore peripheral circulation, and microcirculation, the body temperature rises, diuresis normalizes.

[13], [14], [15], [16], [17], [18], [19], [20],