Classification of shock, definition of the concept
In life there can be hundreds of situations that cancause shock. Most people associate it only with a severe nervous shock, but this is only partly true. In medicine, there is a classification of shock, determining its pathogenesis, severity, the nature of changes in organs and methods for their elimination. For the first time this condition was described more than 2 thousand years ago by the famous Hippocrates, and the term "shock" in medical practice was introduced in 1737 by the Parisian surgeon Henri Ledrand. The proposed article details the causes of shock, classification, clinic, emergency care in the event of this severe condition and predictions.
The concept of shock
With English shock can be translated asthe highest shock, that is, not 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 work of the nervous system, metabolism, respiration and circulation is disturbed. Here such at the moment has a shock definition. Classification of this condition is needed to identify the causes of shock, the degree of its severity and begin effective treatment. The prognosis will be favorable only with the proper diagnosis and the immediate beginning of resuscitation.
Canadian pathologist Selye identified three stages, approximately the same for all types of shock:
1.Possible (compensated), in which the blood supply to the brain, heart, lungs and other organs is broken, but not stopped. Forecast at this stage, as a rule, favorable.
2. Partially reversible (decompensated). In this case, the violation of blood supply (perfusion) is significant, but with urgent and correct medical intervention there is a chance of restoration of functions.
3. Irreversible (terminal). This is the most difficult stage, in which disturbances in the body are not restored even with the strongest medical effect. The outlook here is 95% unfavorable.
Another classification separates the partially reversible stage into 2 - subcompensation and decompensation. As a result, they are 4:
- 1st compensated (the easiest, having a favorable prognosis).
- 2nd subcompensated (moderate, requiring immediate resuscitation.) The prognosis is controversial.
- 3rd decompensational (very severe, even with the immediate implementation of all necessary measures, the forecast is very complicated).
- 4th irreversible (prognosis unfavorable).
Our famous Pirogov identified two phases in the shock state:
-total (the patient is dazed or extremely weak, does not respond to combat irritants, does not answer questions);
-Erectile (the patient is extremely excited, screams, makes many uncontrolled unconscious movements).
Types of shock
Depending on the reasons that led to an imbalance in the functioning of the body's systems, there are different types of shock. Classification of the indicators of circulatory disorders is as follows:
The classification of shock by pathogenesis is as follows:
A complex term is easy to understand, knowing that hypovolemia is a condition where blood circulates in blood vessels in smaller volumes than needed. Causes:
Extensive burns (lots of plasma are lost);
-additional reactions to drugs, for example, vasodilating;
-larger blood loss, as a result of which the organs lack oxygen and nutrients, that is, perfusion is disturbed.
Hypovolemic shock due to highblood loss can be regarded as a hemorrhagic shock. The classification of this state is identical to that developed by Selye, and at the same time the stages are determined by the number of lost organs of blood. Shock is always a kind of protection of the body in an extreme situation. That is, it launches a number 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 in blood vessels, reserve blood spills out (approximately 10% of the total volume) from the liver and spleen. If this is not enough, the supply of blood to less important parts of the body, for example, to the extremities, is reduced or stopped, so that the remaining blood is sufficient for perfusion of the heart, brain and lungs. The classification of shock determines these two stages, as reversible and partially reversible. At the same time if time to take action, you can take a person out of shock and save his life.
Long work on reserve blood and provideperfusion of some organs at the expense of others the body is not able. Therefore, if you do not start resuscitation, the last (irreversible) stage begins. Paralysis of the vessels is observed, the pressure in them sharply decreases, the blood flows to the periphery, increasing to critical markers the deficiency of perfusion of the brain, heart and lungs.
Water in the human body, depending on the age andfloor, from 60 to 80%. Loss of only 20% of this volume can become lethal, and losses of up to 10% cause hypovolemic shock, which in this case is considered as a dehydration, meaning a decrease in the volume of blood circulating through blood vessels due to high dehydration. Causes:
- diseases that lead to diarrhea, vomiting, frequent profuse urination;
-Interpreting the body of water (nedopivanie) in extreme conditions, for example, in extreme heat, especially at high physical exertion;
- unreasonable diets.
Especially the probability of dehydration in young children and the elderly is especially high.
Classification of the shock resulting from a lack of water, distinguishes the stages:
is partially reversible;
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 excreted from the body, and sodium, which is the main cation in the intercellular fluid, goes inside the cells to make up for lost potassium.
2.Hypotonic, which is the consequence of isotonic. In this case, 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 losses can be compensated. Part of this can be done by giving the patient a copious drink, especially containing sodium ions.
3.Hypertonic, which develops in cases when 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 liquid again from the cells passes into the intercellular space, trying to maintain the osmotic pressure. Twice dehydrated cells disrupt their work and decrease in volume. Especially dangerous is the decrease in brain volume, which leads to subdural hemorrhage.
We examined what a characterizinghypovolemic shock classification. The clinic for this condition, regardless of the reasons that caused it, is approximately the same. At the reversible stage in a patient in a recumbent position, pronounced symptomatology may be absent. Signs of the beginning of the problem are:
-small decrease in blood pressure;
cold, damp skin on the limbs (due to reduced perfusion);
-if dehydration, drying of the lips, mucous in the mouth, absence of tears.
In the third stage of shock, the initial symptoms become more pronounced.
Patients are noted:
-reduction of blood pressure values below critical;
- Disturbance of breathing;
- cold to the touch skin (not only limbs);
- marbling of the skin and / or changing their color from normal to pale-cyanotic;
-When pressing on the fingertips, theypale, and color after removal of the load is restored in more than 2 seconds put in the norm. The hemorrhagic shock also has the same clinic. The classification of its stages, depending on the volume of blood circulating in blood vessels, additionally includes the characteristics:
In a reversible stage tachycardia up to 110 beats per minute;
- on a partially reversible - tachycardia up to 140 beats / min;
-on irreversible - heartbeat 160 and more beats / min. In the critical position, the pulse is not audible, and the systolic pressure drops to 60 or less mm Hg. column.
With dehydration in a state of hypovolemic shock, symptoms are added:
-highness of mucous membranes;
- Reducing the tone of eyeballs;
Infants dropping a large fontanel.
These are all external signs, but to be precisedetermine the extent of the problem, conduct laboratory tests. The patient immediately perform a biochemical blood test, establish a level of hematocrit, acidosis, in complex cases, investigate the plasma density. In addition, doctors monitor the level of potassium, basic electrolytes, creatinine, urea blood. If conditions permit, minute and shock volumes of the heart, as well as central venous pressure, are examined.
This type of shock is similar in many respects tohemorrhagic, but its cause can be only external wounds (stabbed, cut, gunshot, burns) or internal (rupture of tissues and organs, for example, from a strong blow). Traumatic shock is almost always accompanied by a hard-to-bear pain syndrome, further exacerbating the situation of the victim. In some sources, this is called a pain shock, often leading to death. The degree of severity of traumatic shock is determined not so much by the amount of blood lost as by the rate of this loss. That is, if the blood leaves the body slowly, the victim has more chances to be saved. It also aggravates the position and severity of the damaged organ for the body. That is, surviving a wound in the arm will be easier than with a wound in the head. Here such features have a traumatic shock. The classification of this state in terms of severity is as follows:
Primary shock (occurs almost immediately after injury);
-second shock (appears after the operation, removal of harnesses, with additional loads on the victim, for example, his transportation).
In addition, with traumatic shock, there are two phases - erectile and torpid.
Symptoms of erectile:
-Inadequate behavior (screaming, overexcitation, anxiety, sometimes aggression);
Symptoms of torpid:
- The patient becomes indifferent;
-been felt, but the person does not react to it;
-Arterial pressure is sharply reduced;
-powers skin, cyanosis of the lips;
-existence of language;
-highness of mucous membranes;
- cold sweat does not protrude, but the skin loses the turgor;
- the pulse is threadlike;
The faces of the face are sharpened.
Infectious-toxic shock, classification
This condition occurs for a reasonpenetration into the body of infection, that is, viruses and bacteria, which cause their activity with strong intoxication. Most often, blame for the onset of shock is streptococci, staphylococcus, salmonella, Pseudomonas aeruginosa. They enter the body, both with the help of open wounds (postpartum sepsis, burns, surgery), and without them (typhoid fever, AIDS, tracheitis, sinusitis, pneumonia, influenza and other ailments).
Pathogenic microorganisms produceSuperantigens, which 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 is released into his blood. The classification of this state distinguishes three stages:
1. Convertible. At the same time, blood pressure can be normal, the mind remains clear, the skin becomes pink or reddens. The patient is often excited, complains of pain in the body or in the abdomen, he has diarrhea, fever, 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, convulsions, cyanosis of the skin, the pulse is palpable, the arterial pressure is below critical, the patient is unconscious.
Classification of anaphylactic shock
Such a state occurs whenthe body of poisons from the bite of snakes, spiders, wasps and other living things, from taking certain drinks and food, and from administering drugs that are allergens to the patient. Most often this reaction is given by novocaine, penicillin, organopreparations. Shock may occur a few seconds after the ingestion of an allergen or after a longer time, and the earlier the reaction occurred, the worse the prognosis. There are several forms of anaphylactic shock:
-typical (redness occurs at the site of the bite (prick) or abdominal pain, throat with oral ingestion of the allergen, lowering of pressure, squeezing under the ribs, diarrhea or vomiting is possible);
- hemodynamic (in the first place cardiovascular disorders);
- Asphyxia (respiratory failure, suffocation);
- cerebral (violations in the work of the central nervous system, seizures, loss of consciousness, stopping breathing);
-Abdominal (acute abdomen).
To take emergency measures is extremely importantcorrect classification of shocks. Emergency emergency care in each case has its own specifics, but the sooner it begins to turn out, the patient has more chances. With an irreversible stage, lethal 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. There, intravenous saline and colloidal solutions are administered, blood transfusion, plasma, anesthetize, if necessary, connect to an artificial respiration apparatus.
With anaphylactic shock, adrenaline is urgently administered, with asphyxia intubating the patient. In the future, glucocorticoids and antihistamines are administered.
In toxic shock, massive infusion therapy is performed with the help of strong antibiotics, immunomodulators, glucocorticoids, and plasma.
With hypovolemic shock, the main tasksis the restoration of blood supply to all organs, the elimination of hypoxia, the normalization of pressure and the work of the heart. In the case of shock caused by dehydration, the recovery of the lost volume of fluid and all electrolytes is additionally required.