In life, hundreds of situations can happen that can cause shock. Most people associate it only with a severe nervous shock, but this is only partially true. In medicine, there is a classification of shock, which determines its pathogenesis, severity, the nature of changes in organs and methods for their elimination. For the first time this state was described more than 2 thousand years ago by the famous Hippocrates, and the Paris surgeon Henri Ledran introduced the term “shock” into medical practice in 1737. This article discusses in detail the causes of shock, classification, clinic, emergency care in the event of this serious condition and forecasts.
Shock concept
From English shock can be translated as the highest shock, that is, in no way a disease, not a symptom and not a diagnosis. In world practice, this term is understood as the response of the organism and its systems to a strong stimulus (external or internal), in which the nervous system, metabolism, respiration and blood circulation are disturbed. Here it is at the moment has a shock definition. Classification of this condition is needed to identify the causes of shock, its severity and begin effective treatment. The prognosis will be favorable only with the correct diagnosis and the immediate start of resuscitation.
Classifications
Canadian pathologist Selye identified three stages, approximately the same for all types of shock:
1. Reversible (compensated), in which the blood supply to the brain, heart, lungs and other organs is disturbed, but not stopped. The prognosis at this stage is usually favorable.
2. Partially reversible (decompensated). In this case, the violation of blood supply (perfusion) is significant, but with urgent and proper medical intervention there is a chance of restoration of functions.
3. Irreversible (terminal). This is the most difficult stage in which disorders in the body cannot be restored even with the strongest medical effect. The forecast here is 95% unfavorable.
Another classification divides the partially reversible stage into 2 - subcompensation and decompensation. As a result, they get 4:
- 1st compensated (the lightest, having a favorable prognosis).
- 2nd subcompensated (moderate, requiring immediate resuscitation. Forecast controversial).
- 3rd decompensation (very difficult, even with the immediate implementation of all necessary measures, the forecast is very difficult).
- 4th irreversible (unfavorable prognosis).
Our famous Pirogov singled out two phases in a state of shock:
torpid (the patient is numb or extremely lethargic, does not respond to combat stimuli, does not answer questions);
- erectile (the patient is extremely excited, screaming, makes many uncontrolled unconscious movements).
Types of shock
Depending on the causes of the imbalance in the functioning of the body systems, there are different types of shock. The classification according to the indicators of circulatory disturbance is as follows:
hypovolemic;
-distributive;
cardiogenic;
obstructive;
-dissociative.
The classification of shock by pathogenesis is as follows:
hypovolemic;
-traumatic;
cardiogenic;
-septic;
-anaphylactic;
-infectious toxic;
neurogenic;
-combined.
Hypovolemic shock
It is easy to understand the complex term, knowing that hypovolemia is a condition when blood circulates through the vessels in a smaller volume than necessary. Causes:
-dehydration;
- extensive burns (a lot of plasma is lost);
- adverse reactions to drugs, for example, vasodilators;
- large blood loss, as a result of which the organs receive less oxygen and nutrients, that is, perfusion is impaired.
Hypovolemic shock due to high blood loss can be considered as hemorrhagic shock. The classification of this condition is identical to that developed by Selye, and in this case the stages are determined by the amount of blood that is not received by the organs. Shock is always a kind of defense of the body in an extreme situation. That is, he starts a series of processes that seek to preserve the activity of important organs and thereby save the life of the entire system. In particular, with blood loss, reserve blood (approximately 10% of the total volume) from the liver and spleen is spilled into the blood vessels. If this is not enough, the flow of blood to the less important sections to maintain the body, for example, to the extremities, is reduced or stopped, so that the remaining blood is enough to perfuse the heart, brain and lungs. The shock classification defines these two stages as reversible and partially reversible. Moreover, if measures are taken in time, it is possible to remove a person from a shock state and save his life.
The body is not able to work for a long time on reserve blood and ensure perfusion of some organs at the expense of others. Therefore, if you do not start resuscitation measures, the last (irreversible) stage begins. Vascular paralysis is observed, the pressure in them sharply decreases, blood flows to the periphery, increasing the deficiency of perfusion of the brain, heart and lungs to critical points.
Dehydration
Water in the human body, depending on age and gender, from 60 to 80%. A loss of only 20% of this volume can be fatal, and losses of up to 10% cause hypovolemic shock, which in this case is considered as dehydration shock, which means a decrease in the volume of blood circulating through the vessels due to high dehydration. Causes:
- Diseases leading to diarrhea, vomiting, frequent excessive urination;
-non-receipt by the body of water (under-drowning) in extreme conditions, for example, in extreme heat, especially with high physical exertion;
unreasonable diets.
Particularly high probability of dehydration in young children and the elderly.
The classification of shock resulting from a lack of water distinguishes the stages:
-reversible;
-partially reversible;
irreversible.
In addition, dehydration is divided into three types:
1. Isotonic (loss of Na and K ions). The fluid in our body is intracellular and intercellular. With isotonic losses caused mainly by diarrhea, a lot of potassium is eliminated from the body, and sodium, which is the main cation in the intercellular fluid, passes into the cells to replenish the lost potassium in them.
2. Hypotonic, which is a consequence of isotonic. At the same time, there are high losses in the intercellular fluid (after all, sodium has passed into the cells). The first two stages are considered reversible, since electrolyte loss compensation is possible. This is partially successful in providing the patient with a plentiful drink, especially containing sodium ions.
3. Hypertensive, developing in cases where diarrhea is accompanied by vomiting, preventing the flow of fluid into the body orally or with an overdose of certain substances that provoke additional urination. In this case, the fluid again from the cells passes into the intercellular space, trying to maintain the osmotic pressure. Double-dehydrated cells disrupt their work and decrease in volume. Especially dangerous is a decrease in brain volume, which leads to subdural hemorrhage.
Symptoms
We examined what classification characterizing hypovolemic shock exists. The clinic of this condition, regardless of the reasons that caused it, is approximately the same. At a reversible stage in a patient in a supine position, pronounced symptoms may be absent. Signs of the onset of the problem are:
- heart palpitations;
-a slight decrease in blood pressure;
-cold wet skin on the limbs (due to a decrease in perfusion);
-when dehydration is observed drying of the lips, mucous membranes in the mouth, the absence of tears.
In the third stage of shock, the initial symptoms become more pronounced.
In patients noted:
-tachycardia;
-decrease in blood pressure values below critical;
violation of breathing;
-oliguria;
- skin cold to the touch (not only limbs);
Marble skin and / or a change in their color from normal to pale cyanotic;
threadlike pulse ;
-when pressing on the tips of the fingers, they fade, and the color after unloading is restored in more than 2 seconds, set at the norm. The same clinic has hemorrhagic shock. The classification of its stages, depending on the volume of blood circulating in the blood vessels, additionally includes the following characteristics:
- at a reversible stage, tachycardia up to 110 beats per minute;
-on partially reversible - tachycardia up to 140 beats / min;
-on irreversible - heart rate of 160 and above beats / min. In a critical position, the pulse is not heard, and the systolic pressure drops to 60 mm or less. column.
With dehydration in a state of hypovolemic shock, symptoms are added:
dry mucous membranes;
- decrease in tone of eyeballs;
in infants, omission of a large fontanel.
These are all external signs, but in order to accurately determine the extent of the problem, laboratory tests are carried out. A patient undergoes a biochemical blood test, the hematocrit level, acidosis are established, and in complex cases, the plasma density is examined. In addition, doctors monitor the level of potassium, basic electrolytes, creatinine, blood urea. If conditions allow, the minute and stroke volumes of the heart, as well as central venous pressure, are examined.
Traumatic shock
In many ways, this type of shock is similar to hemorrhagic, but its cause can only be external wounds (stab-cut, gunshot, burns) or internal (rupture of tissues and organs, for example, from a strong blow). Traumatic shock is almost always accompanied by difficult to endure pain syndrome, further exacerbating the position of the victim. In some sources, this is called a pain shock, often leading to death. The severity of the traumatic shock is determined not so much by the amount of blood lost, but by the rate of this loss. That is, if the blood leaves the body slowly, the victim is more likely to escape. It also exacerbates the position and importance of the damaged organ for the body. That is, surviving a wound in the arm will be easier than with a wound to the head. These are the traumatic shock features. The severity of this condition is as follows:
primary shock (occurs almost instantly after injury);
-secondary shock (appears after the operation, removing the tourniquets, with additional loads on the victim, for example, transporting him).
In addition, with traumatic shock, two phases are observed - erectile and torpid.
Symptoms of erectile dysfunction:
-strong pain;
Inappropriate behavior (screaming, overexcitation, anxiety, sometimes aggression);
-tremor;
-cold sweat;
- dilated pupils;
-tachycardia;
-tahypnea.
Symptoms of torpid:
- the patient becomes indifferent;
- the pain is felt, but the person does not respond to it;
arterial pressure decreases sharply;
- eyes grow dull;
- pallor of the skin, cyanosis of the lips;
-oliguria;
-language of the language;
dry mucous membranes;
-cold sweat does not protrude, but the skin loses turgor;
- pulse is threadlike;
- facial features are sharpened.
Infectious toxic shock, classification
This condition occurs due to the penetration of infection into the body, that is, viruses and bacteria, which cause severe intoxication with their activity. Most often, the onset of shock streptococci, staphylococci, salmonella, Pseudomonas aeruginosa. They enter the body, both with open wounds (postpartum sepsis, burns, operations), and without them (typhoid fever, AIDS, tracheitis, sinusitis, pneumonia, flu and other ailments).
Pathogenic microorganisms produce superantigens that activate T-lymphocytes and other T-cells. Those, in turn, secrete cytokines, as a result of which the patient’s immune system is suppressed, and a huge amount of toxins that cause toxic shock are released into his blood. Classification of this condition distinguishes three stages:
1.Reversible. In this case, blood pressure may be normal, consciousness remains clear, the skin becomes pink or red. The patient is often excited, complains of pain in the body or abdomen, he has diarrhea, fever, and sometimes vomiting.
2. Partially reversible. Symptoms: fever, weak pulse, tachycardia, decreased pressure, the patient is sluggish, his reactions are inhibited.
3. Irreversible. Symptoms: shallow breathing, cramps, blueness of the skin, the pulse is palpated weakly, blood pressure is lower than critical, the patient is unconscious.
Classification of Anaphylactic Shock
This condition occurs when poisons from the bite of snakes, spiders, wasps and other living things get into the body, from taking certain drinks and food, and from the administration of drugs that are allergens for this patient. Most often, such a reaction is produced by novocaine, penicillin, organ preparations. Shock can occur a few seconds after ingestion of an allergen or after a longer time, and the sooner the reaction occurred, the worse the prognosis. There are several forms of the course of anaphylactic shock :
-typical (there is redness at the site of a bite (injection) or pain in the abdomen, throat with an oral exposure to an allergen, lowering pressure, squeezing under the ribs, diarrhea or vomiting is possible);
hemodynamic (in the first place cardiovascular disorders);
Asphyxia (respiratory failure, suffocation);
- cerebral (disorders in the central nervous system, convulsions, loss of consciousness, respiratory arrest);
abdominal (acute abdomen).
Treatment
For emergency measures, the correct classification of shocks is crucial. Emergency resuscitation care in each case has its own specifics, but the sooner it begins to be provided, the patient has more chances. With an irreversible stage, a fatal outcome is observed in more than 90% of cases. In case of traumatic shock, it is important to immediately block blood loss (apply a tourniquet) and deliver the victim to the hospital. They carry out intravenous administration of saline and colloidal solutions, transfusion of blood, plasma, anesthetize, if necessary, connect to an artificial respiration apparatus.
With anaphylactic shock, adrenaline is urgently administered, with asphyxiation, the patient is intubated. Subsequently, glucocorticoids and antihistamines are administered.
In toxic shock, massive infusion therapy is performed using strong antibiotics, immunomodulators, glucocorticoids, and plasma.
With hypovolemic shock, the main tasks are to restore blood supply to all organs, eliminate hypoxia, normalize blood pressure and heart function. With shock caused by dehydration, the renewal of the lost volume of fluid and all electrolytes is additionally required.