Agony

Agony is the last stage of life before irreversible dying (practically the transition of clinical death to the biological in the event of sudden stopping of breathing and cardiac activity or the stage of natural dying from old age), characterized by a rise in the activity of compensatory mechanisms aimed at fighting the extinction of the body's vital forces. Do not confuse with the terminal state, when resuscitation can be successful, if its inefficiency also comes the agony.

Pathogenesis

Agony is treated with a different name - with death, during which the hemodynamic and respiratory disorders dominate, causing the development of hypoxia and hypovolemia, which determines the clinical picture. The duration of agony depends on the underlying pathology that caused the process. Trauma incompatible with life, especially with a primary lesion of 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.

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

Symptoms of the agony

The agony has polymorphic signs, but mainly consists of symptoms of the inhibition of vital body functions due to severe hypoxia. These include: the disappearance of pain sensitivity, loss of consciousness, mydriasis, extinction of pupillary, corneal, tendon and skin reflexes. The most important sign of the agonal syndrome is the formation of arrhythmia of breathing: Cheyne-Stokes type - intermittent, frequent, superficial or, conversely, Kussmaul type - rare, very deep and noisy with a long period of apnea. In the breath involved auxiliary musculature of the neck, shoulder girdle, trunk. The head opens with each inhalation, the mouth is wide open, the patient swallows the air, but the efficiency of breathing is up to 15% of the norm due to terminal pulmonary edema (the alveolar surfactant breaks down, they fall off from the breath, the lung capillaries empty, open alveolocapillary shunts). The exhalation muscles and the diaphragm are turned off from the breath, or their contraction occurs simultaneously with contraction of the inspiratory muscles.

The oppression of cardiac activity is the "last chord of life". After some terminal pause, the effectiveness of the heart rate increases somewhat, tachycardia appears, blood pressure rises slightly, for a short period, literally to say the last "sorry", even consciousness may recover, but this is a poor prognostic sign that resuscitation will be ineffective.

The third leading feature is the deactivation of the functions of the cerebral cortex (neocortex) and simultaneously stimulation of the subcortex and stem structures, i.e. The regulation of the functions of other systems goes to a primitive, uncoordinated, vegetative type, which determines the state of respiration and cardiac activity during the period of agony.

Additional manifestations depend on the cause that caused the agony. When dying from traumatic shock and blood loss: skin and mucous membranes waxy-pale, the nose is sharpened, the cornea shell of the eyes loses transparency, the pupils widen sharply, with hypotension a pronounced tachycardia with a slow fading of cardiac activity.

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

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

In extreme situations, agony is an indication for the cessation of resuscitation benefits, with natural dying resuscitation is not indicated at all.

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