Types of shock. Pain, cardiogenic, hypovolemic, infectious toxic shock. General principles of emergency care in shock.

Shock is a general reaction of the body to superstrong, such as pain, irritation. It is characterized by severe disorders of the functions of vital organs, nervous and endocrine systems. Shock is accompanied by severe circulatory, respiratory and metabolic disorders. There are a number of shock classifications.. 

Types of shock.

Depending on the development mechanism, shock is divided into several main types:

– hypovolemic (dehydration, blood loss);
– cardiogenic (with severe impairment of cardiac function);
– redistributive (in case of circulatory disorders);
– pain (with trauma, myocardial infarction).

Also, shock is determined for the reasons that provoked its development:

– traumatic (due to extensive injuries or burns, the leading causative factor is pain);
– Anaphylactic, which is the most severe allergic reaction to certain substances in contact with the body;
– cardiogenic (develops as one of the most serious complications of myocardial infarction);
– hypovolemic (with infectious diseases with repeated vomiting and diarrhea, with overheating, blood loss);
– septic, or infectious toxic (for severe infectious diseases);
– combined (combines several causal factors and development mechanisms at once).

Pain shock.

Pain shock is caused by pain that exceeds the individual pain threshold in strength. It is more often observed with multiple traumatic injuries or extensive burns. Symptoms of shock are divided into phases and stages. In the initial phase of the (erectile) traumatic shock, the victim has arousal, pallor of the skin of the face, a restless look and an inadequate assessment of the severity of his condition.

There is also increased motor activity: he jumps up, tends to go somewhere, and it can be difficult to keep him. Then, as the second phase of shock (torpid) occurs, a depressed mental state, complete indifference to the environment, a decrease or complete absence of a painful reaction develop against the background of preserved consciousness. The face remains pale, its features are sharpened, the skin of the whole body is cold to the touch and covered with a sticky sweat. The patient’s breathing becomes much quicker and superficial, the victim is thirsty, and often vomiting occurs. With different types of shock, the torpid phase varies mainly in duration. It can be divided into 4 stages.

Shock of the I degree (easy).

The general condition of the victim is satisfactory, accompanied by mild inhibition. The pulse rate is 90-100 beats per minute, its filling is satisfactory. Systolic (maximum) blood pressure is 95–100 mm Hg. Art. or a little higher. Body temperature remains within normal limits or slightly reduced.

Shock II degree (moderate).

The inhibition of the victim is clearly expressed, the skin is pale, body temperature decreases. Systolic (maximum) blood pressure is 90–75 mmHg. Art., and the pulse – 110-130 beats per minute (weak filling and voltage, changing). Breathing is noted superficial, rapid.

Shock of the III degree (heavy).

Systolic (maximum) blood pressure below 75 mm Hg. Art., pulse – 120-160 beats per minute, filiform, weak filling. This stage of shock is considered critical..

Shock of the IV degree (it is called a predagonal state).

Blood pressure is not determined, and the pulse can be detected only on large vessels (carotid arteries). Patient’s breathing is very rare, superficial.

Cardiogenic shock.

Cardiogenic shock is one of the most serious and life-threatening complications of a myocardial infarction and severe heart rhythm and conduction disturbances. This type of shock can develop during a period of severe pain in the region of the heart and is characterized at first by extremely sharply arising weakness, pallor of the skin and blueness of the lips. In addition, the patient has cold extremities, cold, sticky sweat covering the whole body, and often – loss of consciousness. Systolic blood pressure drops below 90 mm Hg. Art., and the pulse pressure is below 20 mm RT. st.

Hypovolemic shock.

Hypovolemic shock develops as a result of a relative or absolute decrease in the volume of fluid circulating in the body. This leads to insufficient filling of the ventricles of the heart, a decrease in stroke volume of the heart and, as a result, to a significant reduction in cardiac output. In some cases, the victim helps the inclusion of such a compensatory mechanism, such as increased heart rate. A fairly common cause of the development of hypovolemic shock is significant loss of blood as a result of extensive injuries or damage to large blood vessels. In this case, we are talking about hemorrhagic shock.

In the mechanism of development of this type of shock, the most important is actually significant blood loss, which leads to a sharp drop in blood pressure. Compensatory processes, such as spasm of small blood vessels, exacerbate the pathological process, as they inevitably lead to impaired microcirculation and, as a consequence, to systemic oxygen deficiency and acidosis.

The accumulation in various organs and tissues of unoxidized substances causes intoxication of the body. Repeated vomiting and diarrhea in infectious diseases also lead to a decrease in the volume of circulating blood and a drop in blood pressure. Factors predisposing to the development of shock are: significant loss of blood, hypothermia, physical fatigue, mental trauma, hunger, hypovitaminosis.

Infectious Toxic Shock.

This type of shock is the most serious complication of infectious diseases and a direct consequence of the exposure of the pathogen toxin to the body. There is a pronounced centralization of blood circulation, in connection with which most of the blood is practically unused, accumulates in peripheral tissues. The result of this is a violation of microcirculation and tissue oxygen starvation. Another feature of infectious toxic shock is a significant deterioration in the blood supply to the myocardium, which soon leads to a pronounced decrease in blood pressure. For this type of shock, the patient’s appearance is characteristic – microcirculation disorders give the skin marbling.

General principles of emergency care in shock.

The basis of all anti-shock measures is the timely provision of medical care at all stages of the victim’s movement: at the scene of the incident, on the way to the hospital, directly in it. The main principles of anti-shock measures at the scene of the incident are to conduct an extensive range of actions, the order of fulfillment of which depends on the specific situation, namely:

1) elimination of the action of the traumatic agent;
2) stopping bleeding;
3) careful handling of the victim;
4) giving him a position that alleviates the condition or prevents additional injuries;
5) release from tightening clothes;
6) closing wounds with aseptic dressings;
7) anesthesia;
8) the use of sedatives;
9) improving the activity of the respiratory system and blood circulation.

In emergency care for shock, stopping bleeding and pain relief are priority. It should be remembered that the transfer of victims, as well as their transportation, must be careful. Patients should be disposed of in medical transport, taking into account the convenience of resuscitation. Anesthesia in shock is achieved by the introduction of neurotropic drugs and analgesics. The earlier it is started, the weaker the pain syndrome, which, in turn, increases the effectiveness of anti-shock therapy. Therefore, after stopping massive bleeding, before performing immobilization, dressing the wound and laying the victim, it is necessary to anesthetize.

For this purpose, 1-2 ml of a 1% solution of promedol diluted in 20 ml of a 0.5% solution of novocaine, or 0.5 ml of a 0.005% solution of fentanyl diluted in 20 ml of a 0.5% solution of novocaine or in 20 ml is injected intravenously. 5% glucose solution. Intramuscularly, analgesics are administered without a solvent (1-2 ml of a 1% solution of promedol, 1-2 ml of tram). The use of other narcotic analgesics is contraindicated, as they cause inhibition of the respiratory and vasomotor centers. Also, with injuries of the abdomen with suspected damage to internal organs, the administration of fentanyl is contraindicated.

It is not allowed to use alcohol-containing liquids in emergency care in shock, as they can cause increased bleeding, which will lead to a decrease in blood pressure and inhibition of the functions of the central nervous system. It is always necessary to remember that in case of shock conditions a spasm of peripheral blood vessels occurs, therefore, the administration of drugs is carried out intravenously, and in the absence of access to the vein – intramuscularly.

Local anesthesia and cooling of the damaged part of the body have a good analgesic effect. Local anesthesia is carried out with a solution of novocaine, which is injected into the area of ​​damage or wound (within intact tissues). With extensive crushing of tissues, bleeding from internal organs, increasing swelling of the tissues, it is advisable to supplement local anesthesia with local exposure to dry cold. Cooling not only enhances the analgesic effect of novocaine, but also has a pronounced bacteriostatic and bactericidal action.

In order to relieve excitement and enhance the analgesic effect, it is advisable to use antihistamines, such as diphenhydramine and promethazine. To stimulate the respiratory and circulatory functions, the patient is given a respiratory analeptic – 25% cordiamine solution in a volume of 1 ml. At the time of the injury, the victim may be in a state of clinical death. Therefore, when cardiac activity and breathing stop, regardless of the reasons that caused them, they immediately begin resuscitation measures – mechanical ventilation of the lungs and heart massage. Resuscitation measures are considered effective only if the victim has spontaneous breathing and a heartbeat..

When providing emergency care at the stage of transportation, the patient is given intravenous infusions of large-molecular plasma substitutes that do not require special storage conditions. Polyglukin and other large-molecular solutions, due to their osmotic properties, cause a rapid influx of tissue fluid into the blood and thereby increase the mass of blood circulating in the body. With large blood loss, transfusion of the affected blood plasma is possible.

Upon receipt of the victim in a medical institution, the correctness of immobilization, the timing of the application of a hemostatic tourniquet are checked. In the event of the arrival of such victims, the bleeding is stopped first. In case of limb injuries, a case block according to Vishnevsky is carried out above the site of damage. Repeated administration of promedol is permissible only 5 hours after its initial administration. At the same time, they begin to inhale oxygen to the victim.

A good effect in anti-shock treatment is the inhalation of a mixture of nitrous oxide and oxygen in a ratio of 1: 1 or 2: 1 using anesthesia machines. In addition, to achieve a good neurotropic effect, cardiac drugs: cordiamine and caffeine should be used. Caffeine stimulates the function of the respiratory and vasomotor centers of the brain and thereby speeds up and enhances myocardial contractions, improves coronary and cerebral blood circulation, and increases blood pressure. Contraindications to the use of caffeine are only uncontrolled bleeding, severe spasm of peripheral vessels and increased heart rate.

Cordiamine improves the activity of the central nervous system, stimulates respiration and blood circulation. In optimal dosages, it helps to increase blood pressure and enhance heart function. In severe injuries, when severe disturbances in external respiration and progressive oxygen starvation (respiratory hypoxia) occur, these phenomena are exacerbated by circulatory disorders and blood loss characteristic of shock – circulatory and anemic hypoxia develop.

In case of unexpressed respiratory failure, antihypoxic measures can be limited by the release of the victim from tightening clothes and the supply of a clean air stream or a moistened mixture of oxygen with air for inhalation. These activities are necessarily combined with stimulation of blood circulation. In cases of acute respiratory failure, if necessary, a tracheostomy is indicated. It consists in creating an artificial fistula that allows air to enter the trachea through an opening on the surface of the neck. A tracheostomy tube is inserted into it. In emergency situations, any hollow object can replace it..

If the tracheostomy and the toilet of the respiratory tract do not eliminate acute respiratory failure, treatment measures are supplemented by mechanical ventilation. The latter not only helps to reduce or eliminate respiratory hypoxia, but also eliminates congestion in the pulmonary circulation and at the same time stimulates the respiratory center of the brain.

Emerging metabolic disturbances are most pronounced in severe shock. Therefore, the complex of anti-shock therapy and resuscitation, regardless of the causes of the serious condition of the victim, includes drugs of metabolic effect, which primarily include water-soluble vitamins (B1, B6, C, PP), 40% glucose solution, insulin, hydrocortisone or its analogue prednisone.

As a result of metabolic disorders in the body, redox processes are upset, requiring the inclusion of anti-shock therapy and resuscitation of blood alkalizing agents. It is most convenient to use 4–5% solutions of sodium bicarbonate or bicarbonate, which are administered intravenously in a dose of up to 300 ml. Transfusion of blood, plasma and some plasma substitutes – an integral part of anti-shock therapy.

Based on Quick Help in Emergencies.
Kashin S.P..

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