The last stage of dying is called agony. The agonal state is characterized by the fact that compensatory mechanisms begin to work actively. This is a struggle with the extinction of the last vital forces of the body.
Terminal states
Irreversible changes in brain tissue that begin due to hypoxia and changes in acid-base balance are called terminal conditions. They are characterized by the fact that the functions of the body are dying away, but this does not happen simultaneously, but gradually. Therefore, in some cases, doctors can restore them using resuscitation measures.
The following points are referred to terminal states:
- severe shock (we are talking about a shock condition of IV degree);
- coma of the IV degree (it is also called beyond);
- collapse;
- predagonia;
- cessation of respiratory movements - terminal pause;
- agony;
- clinical death.
Agony as a stage of a terminal state is characterized by the fact that all vital functions are suppressed in a patient, although he can still be helped. But this can be done in cases where the body has not yet exhausted its capabilities. For example, you can restore vitality if death occurs as a result of blood loss, shock, or asphyxiation.
All diseases are classified according to the ICD. The agonal state is assigned to code R57. This is a shock that is not defined in other sections. Under this code, a number of thermal conditions are determined in the ICD, including predagony, agony, and clinical death.
Predagonia
Problems begin with disruption of the central nervous system. The patient falls into an unconscious state. In some cases, consciousness persists, but it is confused. In this case, blood pressure drops significantly - it can drop below 60 mm Hg. Art. In parallel with this, the pulse quickens, it becomes threadlike. It can be felt only on the femoral and carotid arteries, on the peripheral it is absent.
Breathing in a state of pre-agony is superficial, it is difficult. The skin of the patient turns pale. The agonal state can begin immediately after the end of this period or after the so-called thermal pause.
The duration of this period directly depends on the reasons that caused the onset of this pathological process. If the patient has a sudden cardiac arrest, then this period is practically absent. But blood loss, respiratory failure, traumatic shock can cause the development of a predagonal state, which will last several hours.
Terminal pause
The pre-agonal and agonal state is not always inextricable. For example, with blood loss in most cases, there is a so-called transition period - a terminal pause. It can last from 5 seconds to 4 minutes. It is characterized by a sudden cessation of breathing. Bradycardia begins. This is a condition in which the heart rate decreases markedly, in some cases asystole occurs. This is called cardiac arrest. The pupils stop responding to light, they expand, reflexes disappear.
In this state, the bioelectrical activity disappears on the electroencephalogram, and ectopic pulses appear on it. In the process of a terminal pause, glycolytic processes are strengthened, and oxidative ones are inhibited.
State of agony
Due to a sharp lack of oxygen, which occurs in a state of pre-agony and a terminal pause, all body functions are suppressed. Its main symptom is respiratory failure.
The agonal state is characterized by the absence of pain sensitivity, the extinction of the main reflexes (pupil, skin, tendon, corneal). Ultimately, the activity of the heart also stops. This process may vary depending on what caused the death.
With various types of death, the duration of agony can vary significantly. For example, traumatic shock or blood loss leads to the fact that the last stage of dying can last from 2 to 20 minutes. With mechanical asphyxiation (asphyxiation), it will be no more than 10 minutes. With cardiac arrest, agonal breathing can persist for 10 minutes even after the circulation stops.
The most prolonged agony is observed at death resulting from prolonged intoxication. It can be with peritonitis, sepsis, cancer cachexia. As a rule, in these cases there is no terminal pause. And the agony itself can last several hours. In some cases, it lasts up to three days.
Characteristic clinical picture
In the initial pores, many brain structures are activated. The patient's pupils dilate, the pulse may intensify, and motor excitement appears. Vascular spasm can lead to high blood pressure. If this condition lasts a long time, then hypoxia intensifies. As a result, the subcortical structures of the brain are activated - and this leads to an increase in the excitement of the dying. This is manifested by convulsions, involuntary emptying of the intestines and bladder.
In parallel, the agonal state of the patient is characterized by the fact that the volume of blood in the veins decreases, which returns to the heart muscle. This situation occurs due to the fact that the total volume of blood is distributed over the peripheral vessels. This makes it difficult to properly determine the pressure. The pulse can be felt in the carotid arteries, heart sounds are not heard.
Agony breathing
It can become weak with small amplitude movements. But sometimes patients sharply inhale and exhale. In a minute they can make from 2 to 6 such respiratory movements. Before dying, the muscles of the entire trunk and neck are involved in the process. Outwardly, it seems that such breathing is very effective. After all, the patient inhales fully and completely releases all the air. But in fact, such breathing in an agonal state allows very weak ventilation of the lungs. The air volume does not exceed 15% of normal.
Unconsciously, with each breath, the patient throws back his head, his mouth opens wide. From the side it seems as if he is trying to swallow the maximum amount of air.
But the agonal state is accompanied by terminal pulmonary edema. This is due to the fact that the patient is in a state of acute hypoxia, in which the permeability of the capillary walls is increased. In addition, the rate of blood circulation in the lungs is significantly reduced, microcirculation processes are disturbed.
ICD definition
Knowing that all diseases are determined by the international classification of diseases (ICD), many are interested in the code of agonal conditions. They are listed in section R00-R99. Here are collected all the symptoms and signs, as well as deviations from the norm, which were not included in other sections. Subgroup R50-R69 contains common signs and symptoms.
R57 unites all types of shocks not classified in other headings. Among them are thermal conditions. But it is worth noting separately, if death occurs from any other causes, then there are separate types of classification for this. R57 includes a sudden stop in circulation and respiration, which occurred under the influence of external or internal factors. In this case, clinical death will also apply to this section.
Therefore, we must understand the reasons due to which the agonal state developed. ICD 10 suggests that it is important to determine blood pressure to determine thermal signs. If it is above 70 mm RT. Art., then the vital organs are in relative safety. But when it falls below the level of 50 mm RT. Art. the processes of dying off begin, primarily the heart muscle and brain are affected.
The signs described in the heading
Medical classification allows you to accurately determine the signs that diagnose the thermal and agonal state. The ICD 10 R57 code indicates that the following symptoms are observed:
- general inhibition;
- impaired consciousness;
- pressure drop below 50 mm RT. st .;
- the appearance of severe shortness of breath;
- lack of pulse in the peripheral arteries.
Other clinical signs of agony are also noted. Following them are signs of clinical death. It belongs to the same section as the agonal state. The ICD code R57 defines all the symptoms that a doctor needs to know in order to determine the extinction of life.
Clinical death
Primary symptoms occur within 10 seconds after the circulation stops. The patient loses consciousness, his pulse disappears even on the main arteries, convulsions begin.
Secondary symptoms may begin in a period of 20-60 seconds:
- pupils stop responding to light;
- breathing stops;
- face skin turns earthy gray;
- the muscles relax, including the sphincters.
As a result, involuntary bowel movements and urination may begin.
Resuscitation measures
You should be aware that thermal conditions, which include agony and the final stage - clinical death, are considered reversible. The body can be helped to overcome this condition if it has not yet exhausted all of its functional capabilities. For example, it is possible to do this when dying from asphyxiation, blood loss or traumatic shock.
Resuscitation methods include indirect heart massage and artificial respiration. The person who provides such assistance may be misled by the patient's independent respiratory movements and signs of irregular cardiac activity. Continuing to do resuscitation measures is necessary until the person is removed from the state of agony until the state is completely stabilized.
If these measures are not enough, then muscle relaxants can be used and tracheal intubation can be performed. If this is not possible, then do artificial ventilation of the lungs from the mouth to the nose or mouth. In cases where thermal pulmonary edema has already begun, intubation is indispensable.
In some cases, against the background of indirect cardiac massage, the agonal state continues. Its signs are ventricular fibrillation of this organ. In this case, it is necessary to use an electrodefibrillator. It is also important to carry out intra-arterial transfusion of blood and the necessary plasma-replacement fluids, if dying occurs as a result of blood loss, traumatic shock.
Condition after resuscitation
Thanks to timely and complete measures taken to restore the vital activity of the patient, it is often possible to eliminate the agonal state. After this, the patient needs long-term observation and intensive care. The need for these measures remains even if the cause of the indicated thermal state has been quickly eliminated. After all, the body of such a patient is prone to a repetition of the development of agony.
It is important to fully eliminate hypoxia, circulatory disorders and metabolic disorders. It is necessary to prevent the possible development of septic and purulent complications. Ventilation and transfusion therapy should continue until all signs of respiratory failure have been eliminated and the volume of circulating blood has returned to normal.
Animal agony
Our smaller brothers also have situations when they are on the border between life and death. The agonal state of the animal according to clinical signs is not particularly different from what happens in a similar situation with a person.
Experiments on rats showed that after stopping their heart, brain activity increased by 30 seconds. At the same time, high-frequency waves emanating from it became more frequent, neurotransmitters stood out. This was possible to establish thanks to the assessment of brain activity using an electroencephalograph and an electrocardiograph. Death in rats was caused by suffocation.
By the way, scientists explain the visions that people who have experienced clinical death like to explain with this brain activity. They attribute this only to the febrile activity of this organ.