Shock: manifestations and symptoms, degrees and types, emergency care. State of shock

Shock is a pathological change in the functions of the vital systems of the body, in which there is a violation of breathing and circulation. This condition was first described by Hippocrates, but the medical term appeared only in the mid-18th century. Since various diseases can lead to the development of shock, for a long time scientists have proposed a large number of theories of its occurrence. However, none of them explained all the mechanisms. It has now been established that the basis of shock is arterial hypotension, which occurs when the volume of circulating blood decreases, cardiac output and general peripheral vascular resistance decrease, or when fluid is redistributed in the body.

Manifestations of shock

The symptoms of shock are largely determined by the cause that led to its appearance, but there are also common features of this pathological condition:

• impaired consciousness, which can manifest itself as agitation or depression;
• decrease in blood pressure from minor to critical;
• an increase in heart rate, which is a manifestation of a compensatory reaction;
• centralization of blood circulation, in which spasm of peripheral vessels occurs, with the exception of the renal, cerebral and coronary;
• pallor, marbling and cyanosis of the skin;
• rapid shallow breathing that occurs with increasing metabolic acidosis;
• change in body temperature, usually it is low, but during an infectious process it is increased;
• the pupils are usually dilated, the reaction to light is slow;
• in particularly severe situations, generalized convulsions, involuntary urination and defecation develop.

There are also specific manifestations of shock. For example, when exposed to an allergen, bronchospasm develops and the patient begins to choke; with blood loss, a person experiences a pronounced feeling of thirst, and with myocardial infarction, chest pain.

Degrees of shock

Depending on the severity of shock, there are four degrees of its manifestations:

1. Compensated. At the same time, the patient’s condition is relatively satisfactory, the function of the systems is preserved. He is conscious, systolic blood pressure is reduced, but exceeds 90 mm Hg, pulse is about 100 per minute.
2. Subcompensated. Violation is noted. The patient's reactions are inhibited and he is lethargic. The skin is pale and moist. The heart rate reaches 140-150 per minute, breathing is shallow. The condition requires prompt medical intervention.
3. Decompensated. The level of consciousness is reduced, the patient is very inhibited and reacts poorly to external stimuli, does not answer questions or answers in one word. In addition to pallor, there is marbling of the skin due to impaired microcirculation, as well as cyanosis of the fingertips and lips. The pulse can only be determined in the central vessels (carotid, femoral artery); it exceeds 150 per minute. Systolic blood pressure is often below 60 mmHg. There is a disruption in the functioning of internal organs (kidneys, intestines).
4. Terminal (irreversible). The patient is usually unconscious, breathing is shallow, and the pulse is not palpable. By the usual method, using a tonometer, pressure is often not determined, and heart sounds are muffled. But blue spots appear on the skin in places where venous blood accumulates, similar to cadaveric ones. Reflexes, including pain, are absent, the eyes are motionless, the pupil is dilated. The prognosis is extremely unfavorable.

To determine the severity of the condition, you can use the Algover shock index, which is obtained by dividing the heart rate by the systolic blood pressure. Normally it is 0.5, with the 1st degree -1, with the second -1.5.

Types of shock

Depending on the immediate cause, there are several types of shock:

1. Traumatic shock resulting from external influence. In this case, the integrity of some tissues is violated and pain occurs.
2. Hypovolemic (hemorrhagic) shock develops when the volume of circulating blood decreases due to bleeding.
3. Cardiogenic shock is a complication of various heart diseases (tamponade, aneurysm rupture), in which the ejection fraction of the left ventricle sharply decreases, resulting in the development of arterial hypotension.
4. Infectious-toxic (septic) shock is characterized by a pronounced decrease in peripheral vascular resistance and an increase in the permeability of their walls. As a result, a redistribution of the liquid part of the blood occurs, which accumulates in the interstitial space.
5. develops as an allergic reaction in response to intravenous exposure to a substance (injection, insect bite). In this case, histamine is released into the blood and blood vessels dilate, which is accompanied by a decrease in pressure.

There are other types of shock that include different symptoms. For example, burn shock develops as a result of injury and hypovolemia due to large losses of fluid through the wound surface.

Help with shock

Every person should be able to provide first aid for shock, since in most situations minutes count:

1. The most important thing to do is to try to eliminate the cause that caused the pathological condition. For example, if there is bleeding, you need to clamp the arteries above the injury site. And when an insect bites you, try to prevent the poison from spreading.
2. In all cases, with the exception of cardiogenic shock, it is advisable to elevate the victim's legs above his head. This will help improve blood flow to the brain.
3. In cases of extensive injuries and suspected spinal injuries, it is not recommended to move the patient until the ambulance arrives.
4. To replenish fluid loss, you can give the patient a drink, preferably warm, water, as it will be absorbed faster in the stomach.
5. If a person has severe pain, he can take an analgesic, but it is not advisable to use sedatives, since this will change the clinical picture of the disease.

In cases of shock, emergency doctors use either intravenous solutions or vasoconstrictors (dopamine, adrenaline). The choice depends on the specific situation and is determined by a combination of various factors. Medical and surgical treatment of shock directly depends on its type. Thus, in case of hemorrhagic shock, it is urgent to replenish the volume of circulating blood, and in case of anaphylactic shock, antihistamines and vasoconstrictors must be administered. The victim must be urgently taken to a specialized hospital, where treatment will be carried out under the monitoring of vital signs.

The prognosis for shock depends on its type and degree, as well as the timeliness of assistance. With mild manifestations and adequate therapy, recovery almost always occurs, while with decompensated shock there is a high probability of death, despite the efforts of doctors.

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The state of shock is a complex phenomenon that occurs as a reaction to severe damage or injury, which relates to almost all internal organs and systems of the body. The circulatory organs are mainly affected.

The main signs of shock are:

Sharp pain;

Blood intoxication, accompanied by an increase in body temperature;

Opening of bleeding;

Cooling the body.

One of the causes of shock is toxicosis caused by prolonged compression or trauma of soft tissues. Kidney failure develops due to damage to the epithelial layer of the kidneys and closure of the renal tubules. Conclusions can be drawn about the power of the shock state in case of kidney damage based on a small amount of urine or its complete absence, even if blood pressure is normal.

The state of shock after a severe burn is characterized by a significant decrease in the mass of circulating blood due to the fact that blood plasma escapes through the damaged skin.

The first stage of shock is characterized by an extreme degree of agitation of the victim, his inability to understand the severity of the condition and the injuries received. At the next stage of development of the shock state, the victim’s reaction is inhibited, the person becomes apathetic. Consciousness is maintained throughout all stages of the shock state. The skin and mucous membranes become pale.

In the first stage of shock, blood pressure and heart rate do not change.

During the second stage of shock, blood pressure drops significantly, the heart begins to beat faster, the pallor of the skin and visible mucous membranes increases, and the peripheral circulatory system is less active.

In the third stage of shock, an extremely serious condition is observed. Blood pressure is greatly reduced, the heart beats very quickly, and the pulse is characterized by weak filling. At this stage of shock, severe pale skin and cold perspiration are observed. With the further development of the shock state, consciousness begins to leave the victim. Spots begin to appear on pale skin. The pulse can only be determined in the main arteries.

When treating shock, the same techniques are used as in the case of shock of hemorrhagic origin. In case of shock, it is extremely important to provide first aid to the victim before the ambulance arrives.

Firstly, it is necessary to restore the normal patency of the air passages, that is, normalize the position of the tongue, if it is stuck, use mouth-to-mouth breathing. After this, it is necessary to restore normal blood circulation with the help of intensive closed massage of the heart muscle, clamping of blood vessels, intravenous injections of the drug polyglucin and sodium bicarbonate.

In addition to the above measures, it is necessary:

Apply sterile dressings to open injuries;

Fix fractures if present;

Properly position the victim;

If the chest is injured, place the victim in a sitting position;

When a traumatic brain injury occurs, the victim is given a semi-sitting position;

If an abdominal injury occurs, the victim must be laid horizontally;

Injections of antispasmodics are performed if necessary;

If necessary, it is necessary to raise the victim’s legs to an elevated position;

Fixation of bone fragments in open fractures;

Warming actions to prevent hypothermia of the victim;

Give the victim as much to drink as possible, if the stomach is not damaged and there is no vomiting;

Take the victim to the hospital as soon as possible.

Before using the medications listed on the website, consult your doctor.

There are several different types of shock that every doctor may encounter in his or her practice.

Hemorrhagic shock

Since hemorrhagic shock is very common and requires the use of donor blood components, it is discussed separately in chapter b.

Cardiovascular shock

Cardiogenic shock is caused by a violation of the pumping function of the heart. The cause is myocardial infarction or severe myocarditis. BCC usually does not change. The inability of the heart to pump blood leads to increased hydrostatic pressure in the pulmonary artery (increased PAWP) and large veins (increased CVP). Transfusion of infusion solutions may aggravate the severity of the condition by reducing cardiac output or causing pulmonary edema.

Inotropic drugs (adrenaline, dobutamine).

Vasodilators, by reducing peripheral vascular resistance, increase cardiac output. In addition, vasodilators, by increasing the capacity of the vascular bed, reduce the effective blood volume

Diuretics remove excess sodium and water.

Elimination of arrhythmias.

Standard measures taken for myocardial infarction (for example, prescribing aspirin).

Septic shock

Septic shock develops as a result of vasodilation caused by the release into the bloodstream of inflammatory mediators (endotoxins, tumor necrosis factor, interleukin-6, etc.) - These mediators act on the walls of blood vessels indirectly through nitric oxide. In severe cases, vasodilation is combined with impaired pumping function of the heart. Treatment of septic shock consists of a balanced use of vasoconstrictors and infusion solutions under the control of invasive circulatory monitoring. Other aspects of management of septic shock:

It is necessary to identify the source and causative agent of the infection. Blood, urine, wound discharge, used dressings, etc. are sent to the microbiological laboratory for culture. etc.

Antibiotics are prescribed and abscesses are drained.

Due to vasodilation and increased capillary permeability, hypovolemia often develops.

The release of toxins can lead to myocardial depression requiring the administration of inotropes (as in the treatment of cardiogenic shock, see above).

There is a risk of acute adrenal insufficiency, in the event of which hydrocortisone is indicated at a dose of 25 mg every 6 hours.

Anaphylactic shock

Anaphylactic shock is caused by a foreign protein or drug, the entry of which into the body leads to a sudden sharp release of inflammatory mediators. The permeability of capillaries sharply increases, which entails a massive movement of fluid from the bloodstream into the extracellular space, leading to hypovolemia. In addition, total vasodilation develops. These changes can progress very quickly, posing a serious threat to life. Some symptoms of anaphylactic shock are presented in Table 11.

You should immediately administer 0.5 mg of adrenaline IM. If necessary, adrenaline is reintroduced. There is usually a large loss of fluid into the skin and other tissues, coupled with total vasodilation, which may require large volumes of infusion solutions.

Other measures:

Hydrocortisone (100 mg) and antihistamines (chlorpheniramine 10 mg) to reduce anaphylaxis, although the effectiveness of these drugs has not been proven.

For laryngeal edema, tracheal intubation or tracheostomy is indicated.

For wheezing in the lungs - β-adrenergic agonists.

Early tracheal intubation for bronchospasm resistant to β-adrenergic agonists.

Table 11. Some symptoms of anaphylaxis

Description:

Shock (from the English shock - blow, shock) is a pathological process that develops in response to exposure to extreme irritants and is accompanied by a progressive disruption of the vital functions of the nervous system, blood circulation, respiration, metabolism and some other functions. Essentially, this is a breakdown of the body’s compensatory reactions in response to damage.

Symptoms:

Diagnosis criteria:
The diagnosis of shock is made when the patient has the following signs of shock:

      * decrease in blood pressure and (during the torpid phase);
      * anxiety (erectile phase according to Pirogov) or blackout (torpid phase according to Pirogov);
      * breathing disorder;
      * decrease in the volume of urine excreted;
      * cold, damp skin with a pale cyanotic or marbled color.
According to the type of circulatory disorders, the classification provides for the following types of shock:

      * redistributive (distributive);
      * obstructive.

The clinical classification divides shock into four degrees according to its severity.

      * I degree shock. The victim's condition is compensated. Consciousness is preserved, clear, the patient is communicative, slightly inhibited. Systolic blood pressure (BP) exceeds 90 mmHg, the pulse is rapid, 90–100 beats per minute. The prognosis is favorable.
      * Second degree shock. The victim is lethargic, the skin is pale, the heart sounds are muffled, the pulse is frequent - up to 140 beats per minute, the filling is weak, the maximum blood pressure is reduced to 90-80 mm Hg. Art. Breathing is shallow, rapid, consciousness is preserved. The victim answers questions correctly, speaks slowly, in a quiet voice. The prognosis is serious. To save a life, anti-shock measures are required.
      * III degree shock. The patient is adynamic, inhibited, does not respond to pain, answers questions in monosyllables and extremely slowly or does not answer at all, speaks in a dull, barely audible whisper. Consciousness is confused or absent altogether. The skin is pale, covered with cold sweat, expressed. Heart sounds are muffled. The pulse is thread-like - 130–180 beats per minute, detected only in large arteries (carotid, femoral). Breathing is shallow and frequent. Systolic blood pressure is below 70 mmHg, central venous pressure (CVP) is zero or negative. Observed (absence of urine). The prognosis is very serious.
      * IV degree shock manifests itself clinically as one of the terminal conditions. Heart sounds are not heard, the victim is unconscious, the gray skin acquires a marble pattern with stagnant spots like cadaveric ones (a sign of decreased blood supply and stagnation of blood in small vessels), bluish lips, blood pressure below 50 mm Hg. Art., is often not determined at all. The pulse is barely noticeable in the central arteries, anuria. Breathing is shallow, rare (sobbling, convulsive), barely noticeable, the pupils are dilated, there are no reflexes or reactions to painful stimulation. The prognosis is almost always unfavorable.

Approximately the severity of shock can be determined by the Algover index, that is, by the ratio of the pulse to the value of systolic blood pressure. Normal index - 0.54; 1.0 - transition state; 1.5 - severe shock.

Causes:

From a modern point of view, shock develops in accordance with G. Selye’s theory of stress. According to this theory, excessive exposure to the body causes specific and nonspecific reactions in it. The first ones depend on the nature of the effect on the body. The second - only from the force of influence. Nonspecific reactions when exposed to a super-strong stimulus are called general adaptation syndrome. General adaptation syndrome always occurs in the same way, in three stages:

   1. stage of mobilization (anxiety), caused by primary damage and reaction to it;
   2. stage of resistance, characterized by maximum tension of protective mechanisms;
   3. stage of exhaustion, that is, a violation of adaptive mechanisms leading to the development of “adaptation disease”.

Thus, shock, according to Selye, is a manifestation of a nonspecific reaction of the body to excessive exposure.

N.I. Pirogov in the middle of the 19th century defined the concepts of erectile (excitement) and torpid (lethargy, numbness) phases in the pathogenesis of shock.

A number of sources provide a classification of shock in accordance with the main pathogenetic mechanisms.

This classification divides shock into:

      * hypovolemic;
      * cardiogenic;
      * traumatic;
      * septic or infectious-toxic;
      * anaphylactic;
      * neurogenic;
      * combined (combine elements of various shocks).

Treatment:

For treatment the following is prescribed:

Treatment of shock consists of several points:

   1. eliminating the causes that caused the development of shock;
   2. compensation for the deficit in circulating blood volume (CBV), with caution in case of cardiogenic shock;
   3. oxygen therapy (oxygen inhalation);
   4. therapy for acidosis;
   5. therapy with vegetotropic drugs in order to cause a positive inotropic effect.

Additionally, steroid hormones, heparin and streptokinase are used to prevent microthrombosis, diuretics to restore kidney function with normal blood pressure, and artificial ventilation.