COLLAPSE (Latin collapsus which weakened, fell) — sharply developing vascular insufficiency which is characterized first of all by falling of a vascular tone, and also acute reduction of volume of the circulating blood. At the same time there is a reduction of inflow of a venous blood to heart, decrease in cordial emission, falling of arterial and venous pressure, perfusion of fabrics and a metabolism are broken, there is a hypoxia of a brain, the vital functions of an organism are oppressed. To. develops as a complication, is more often at a serious illness and patol, states.
The doctrine about To. arose in connection with development of ideas of insufficiency blood circulations (see). Wedge, picture K. it was described long before introduction of this term. So, S. P. Botkin (1883), in connection with the death of the patient from a typhoid, presented a full picture to lectures inf. To., having called this state intoxication of a body. I. P. Pavlov (1894) paid attention to special genesis To., having noted that it is not connected with weakness of heart, and depends on reduction of volume of the circulating blood. Considerable development the doctrine about To. received in works of G. F. Lang, N. D. Strazhesko, I. R. Petrov, V. A. Negovsky and other domestic scientists.
The standard definition To. it is not developed. The greatest disagreements exist on whether it is necessary to consider To. and shock independent states or to consider them only as the different periods same patol, process i.e. whether to consider «shock» and «collapse» synonyms. The last point of view is accepted English and an amer. authors who consider that both terms designate identical patol of a state, prefer to use the term «shock». Fr. researchers sometimes oppose To. at inf. disease to shock of a traumatic origin.
G.F. Lang, I. R. Petrov, V. I. Popov, E. I. Chazov and other domestic authors, as a rule, differentiate the concepts «shock» and «collapse». Quite often these terms nevertheless mix up.
An etiology and classification
Due to the distinctions in understanding patofiziol, mechanisms K., possible domination of this or that patofiziol, the mechanism, and also a variety nozol, forms of diseases, at which To. can develop, the accurate standard classification of forms K. it is not developed. In a wedge, interests it is reasonable to distinguish forms K. depending on etiol, factors. Most often To. develops at intoxications of an organism and acute inf. diseases. At acute massive blood loss develops so-called hemorrhagic To., during the work in the conditions of the lowered oxygen content in inhaled air — hypoxemic K. Inogda K. can arise also without essential patol, deviations (e.g., orthostatic To. at children).
Allocate toxic To., which arises at acute poisonings (see), including the prof. of character, substances of all-toxic action (carbon monoxide, cyanides, organophosphorous substances, nitro - and amidoconnections, etc.). To cause development To. a number of physical factors — influence of electric current, high doses of radiation, high temperature of the environment (can during the overheating, a thermal shock) at which regulation of function of vessels is broken.
To. it is observed at some acute diseases of internals — at peritonitis, acute pancreatitis that it is connected with endogenous intoxication, and also at an acute duodenitis, erosive gastritis, etc. Some allergic reactions of immediate type, e.g. acute anaphylaxis (see), proceed with the vascular disorders typical for K.
Infektsionny K. develops as a complication acute heavy inf. diseases: encephalomeningitis, belly and sapropyra, acute dysentery, pneumonia, botulism, malignant anthrax, viral hepatitis, toxic flu, etc. Intoxication endo-and exotoxins of microorganisms, preferential influencing c is the reason of such complication. N of page or on receptors pre-and post-capillaries.
Hypoxemic To. can arise in the conditions of the lowered tension of oxygen in inhaled air, especially in combination with the lowered barometric pressure. At the same time insufficiency of adaptive reactions of an organism is a proximate cause of circulator disturbances to hypoxias (see), the cardiovascular system influencing directly or indirectly via the receptor device on the vasculomotor centers. To development To. in these conditions can promote and hypocapny (see) because of a hyperventilation, leading to a trichangiectasia and vessels and, therefore, to deposition and reduction of volume of the circulating blood.
Orthostatic To., arising upon bystry transition from horizontal position in vertical, and also at long standing, it is caused by redistribution of blood with increase in total amount of a venous bed and decrease in inflow to heart; insufficiency of a venous tone is the cornerstone of this state. Orthostatic To. it can be observed at convalescents after a serious illness and a long bed rest, at some diseases of an endocrine and nervous system (a myelosyringosis, encephalitis, tumors of hemadens, a nervous system, etc.), in the postoperative period, at bystry evacuation of ascitic liquid or as a result of spinal or peridural anesthesia. Iatrogenic orthostatic To. sometimes arises at misapplication of neuroleptics, ganglioblokator, adrenoblockers, sympatholytics, etc. At pilots and astronauts orthostatic To. it can be caused by the redistribution of blood connected with action of forces of acceleration; at the same time blood from vessels of an upper part of a trunk and head moves to vessels of abdominal organs and lower extremities, causing a hypoxia of a brain. Orthostatic To. it is quite often observed at almost healthy children, teenagers and young men.
Severe form compressed-air disease (see) can be followed To., which is connected with accumulation of gas in a right ventricle of heart.
One of frequent forms is hemorrhagic To., developing at acute massive blood loss (an injury, wound of vessels, internal bleeding owing to a rupture of aneurism of a vessel, an arrosion of a vessel in the field of stomach ulcer, etc.). To. at to blood loss (see) develops as a result of bystry reduction of volume of the circulating blood. The same state can arise owing to a plentiful plazmopotera at a burn, water and electrolytic frustration at heavy diarrhea, pernicious vomitings, irrational use of diuretics.
To. it can be observed at the heart diseases which are followed by sharp and bystry reduction of a stroke output (a myocardial infarction, disturbances of a cordial rhythm, acute myocarditis, a hemopericardium or a pericardis with bystry accumulation of an exudate in a cavity of a pericardium), and also at thromboembolisms of pulmonary arteries. The acute cardiovascular insufficiency developing at these states is described by nek-ry authors not as To., and as a so-called syndrome of small emission, manifestation to-rogo are especially characteristic for cardiogenic shock (see).
Some authors call reflex To., observed at patients in the period of stenocardia or an anginous attack at a myocardial infarction. I. R. Petrov (1966) and a number of authors allocate a syndrome To. at shock, considering that the terminal phase of heavy shock is characterized by the phenomena To.
can Conditionally be allocated two main mechanisms of development To., which are often combined. One mechanism consists in falling of a tone of arterioles and veins as a result of influence inf., toxic, physical, allergic and other factors directly on a vascular wall, a vasomotor center and on vascular receptors (a sinocarotid zone, an aortic arch, etc.). At insufficiency of compensatory mechanisms decrease in peripheric vascular resistance (paresis of vessels) leads to patol, to increase in capacity of a vascular bed, reduction of volume of the circulating blood with its deposition in some vascular areas, to reduction of a venous inflow to heart, increase of a cordial rhythm, falling of the ABP.
Other mechanism is connected directly with a bystry degrowth of the circulating blood (e.g., at a massive krovo-and a plazmopoter when it surpasses compensatory opportunities of an organism). The reflex spasms of small vessels, and also increase of a cordial rhythm arising in response to it under the influence of the increased emission in blood catecholamines (see) can be insufficient for preservation of datum level of the ABP. Reduction of volume of the circulating blood reduces return of blood to heart on veins of a big circle of blood circulation and respectively cordial emission, breaks system microcirculation (see), blood accumulates in capillaries, the ABP falls. The hypoxia of circulator type develops (see. Hypoxia ), metabolic acidosis (see) and other disturbances. The hypoxia and acidosis lead it to damage of a vascular wall, increase permeability (see). Loss of a tone of precapillary sphincters and easing of their sensitivity to angiotonic substances develops against the background of preservation of a tone of the post-capillary sphincters steadier against acidosis. In the conditions of a hyperpermeability of capillaries it promotes transition of water and electrolytes from blood in intercellular spaces. Rheological properties are broken, there is hypercoagulation of blood and patol, aggregation of erythrocytes and thrombocytes, conditions for formation of micro blood clots are created.
In a pathogeny inf. To. increase in permeability of walls of vessels with escaping them liquid and electrolytes, reduction of volume of the circulating blood, and also considerable dehydration as a result of plentiful sweating play especially important role. Sharp rise in body temperature causes excitement, and then braking of the respiratory and vasculomotor centers. At generalized meningococcal, pneumococcal and other infection and development on 2 — the 8th days of myocarditis or an allergic mioperikardit delivery function of heart decreases, filling of arteries and inflow of blood to fabrics decreases.
In development To. always also reflex mechanisms take part.
At long, torpid, a current To. as a result of a hypoxia and disturbances of exchange vasoactive substances are released, at the same time vazodilatator prevail: acetylcholine (see), histamine (see), kinina (see), prostaglandins (see) fabric metabolites are also formed — lactic acid (see), adenosine and its derivatives (see. Adenozinfosforny acids ), having hypotensive effect. The histamine and histamine-like substances, milk to - that increase vascular permeability. A role of kinin and prostaglandins in a pathogeny To. it is not found out. Wilhelm (D. Wilhelm, 1971) points to the high content of kinin in plasma at experimental toxic To., explaining it with influence of the formed complexes endotoxin — an antibody. High activity of kinin in plasma is noted at irreversible hemorrhagic To. and at patients with orthostatic To. The progressing changes connected with a hypoxia inevitably lead to dysfunction of a brain, deepening of regulatory and hemodynamic frustration (see. Hemodynamics ).
Pathoanatomical changes at To. are studied insufficiently; most often they are defined by a basic disease, at Krom there is K. Neredko the changes inherent to ischemia of bodies are noted morfol (see. Ischemia ). To number specific morfol, signs hemorrhagic To., distinguishing it from traumatic shock, I. V. Davydovsky refers fluidifying of blood, decrease in a hemoglobin content, pallor, dryness of fabrics with reduction of contents in them of a lymph, weight reduction of bodies, lack of a fluid lungs.
A clinical picture
the Clinical picture at To. various origin it is generally similar. To. develops more often sharply, suddenly.
At all forms K. consciousness of the patient is kept, but he is indifferent to surrounding, quite often complains of feeling of melancholy and depression, of dizziness, easing of sight, a sonitus, thirst. Integuments turn pale, the mucous membrane of lips, a tip of a nose, fingers of hands and legs get a cyanochroic shade. Turgor of fabrics decreases, skin can become marble, the person of earthy color, becomes covered by a cold clammy sweat, language dry. Body temperature is often lowered, patients complain of cold and a chill. The shallow breathing which is speeded up more rare slowed down. Despite an asthma, patients do not test suffocation. Pulse is small, soft, speeded up, more rare slowed down, weak filling, often wrong, on beam arteries sometimes is defined hardly or is absent. By the ABP it is lowered, sometimes systolic the ABP goes down to 70 — 60 mm of mercury. and even below, however in an initial stage To. at persons with the previous hypertensia of the ABP can remain at the level close to normal. Diastolic pressure also decreases. Superficial veins are fallen down, the speed of a blood-groove, peripheral and central venous pressure go down. In the presence of heart failure on right ventricular type the central venous pressure can remain on datum level or decrease slightly; the volume of the circulating blood decreases. From heart dullness of tones, arrhythmia (premature ventricular contraction, atrial fibrillation, etc.), an embryocardia is noted.
On an ECG — the signs of insufficiency of a coronary blood-groove and other changes having secondary character and caused most often by reduction of a venous inflow and connected with this disturbance of the central hemodynamics, and sometimes and infectious and toxic damage of a myocardium (see. Myocardial dystrophy ). Disturbance of sokratitelny action of the heart can lead to further decrease in cordial emission and the progressing disturbance of a hemodynamics. The oliguria, nausea and vomiting (after drink), an azotemia, a pachemia, increase in the oxygen content in a venous blood owing to shunting of a blood-groove, a metabolic acidosis are almost constantly noted.
Weight of manifestations To. depends on weight of a basic disease and extent of vascular frustration. Extent of adaptation (e.g., to a hypoxia), age matters also (at elderly people and children of early age To. proceeds heavier) and emotional features of the patient etc. Rather easy degree To. sometimes call a kollaptoidny state.
Depending on the basic disease which caused To., the wedge, a picture can gain some specific features. So, e.g., at To., caused blood loss, instead of oppression of the psychological sphere excitement is quite often observed in the beginning, sweating often sharply decreases. The phenomena To. at toxic defeats, peritonitis, acute pancreatitis are most often combined with symptoms of the general heavy intoxication. For orthostatic To. are characteristic suddenness (often against the background of good health) and rather easy current; and for stopping orthostatic To., especially at teenagers and young men, usually happens to provide enough rest (in strictly horizontal position of the patient), warming and inhalation of spirit of ammonia.
Inf. To. develops more often in time of critical decrease in body temperature; it occurs in different terms, napr, at a sapropyra usually on 12 — the 14th day of a disease, especially during spasmodic decrease in temperature (on 2 — 4 °), more often in the morning. The patient very much weakens, lies not movably, is apathetic, answers questions slowly, quietly; complains of a fever, thirst. The person becomes a pale earthy shade, a lip cyanotic; features are pointed, eyes sink down, pupils are expanded, extremities cold, muscles are relaxed. After falloff of body temperature a forehead, temples, sometimes all body it is covered with a cold clammy sweat. Body temperature at measurement in an axillary pole sometimes decreases to 35 °; the gradient of rectal and skin temperature increases. Pulse is frequent, weak. ABP and a diuresis are reduced.
Current inf. To. it is burdened dehydration of an organism (see), hypoxia (see), edges is complicated by pulmonary hypertensia, a decompensated metabolic acidosis, a respiratory alkalosis and a hypopotassemia. At loss of a large amount of water with an emetic masses and excrements at food toxicoinfections, salmonellosises, acute dysentery, cholera volume extracellular, including intersticial and intravascular, liquids decreases. Blood is condensed, its viscosity, density, an index of a hematocrit, content of crude protein of plasma increases. The volume of the circulating blood sharply decreases. The venous inflow and cordial emission decreases. According to biomicroscopy of a conjunctiva of an eye, the quantity of the functioning capillaries decreases, there are arteriolovenulyarny anastomosis, a pendulum blood stream and staz in venules and capillaries with a diameter less than 25 microns
With signs of aggregation of uniform elements of blood. The ratio of diameters of arterioles and venules makes 1: 5 (norm 1: 2,5). At inf. diseases To. lasts of several minutes to 6 — 8 hours (more often 2 — 3 hours).
During the deepening To. pulse becomes threadlike; it is almost impossible to define the ABP, breath becomes frequent. Consciousness of the patient is gradually darkened, reaction of pupils sluggish, is observed a tremor of hands, myotonia of the person and hands are possible. Sometimes the phenomena To. accrue very quickly; features are sharply pointed, consciousness is darkened, pupils extend, reflexes disappear and at the accruing weakening of cordial activity arises agony (see).
Death at To. is caused by a fabric hypoxia, intoxication, disbolism owing to exhaustion of energy resources of a brain.
Diagnosis in the presence of characteristic a wedge, pictures taking into account data of the anamnesis is usually not complicated. Researches of volume of the circulating blood, cordial emission, the central venous pressure, gematokritny and other indicators can add idea of character and weight To., what is necessary for the choice etiol, and pathogenetic therapy.
Differential diagnosis carry out with a faint, for to-rogo the short-term loss of consciousness with disappearance of sensitivity, and with shock is characteristic, at Krom there are deeper hemodynamic disturbances, defeat of c. N of page, etc. Difficulties in diagnosis can arise at To. at elderly people, developing against the background of the pneumonia proceeding with scanty symptomatology and also at a poisoning with barbiturates and antihypertensives. Sometimes difficult happens to differentiate To. and cardiogenic shock; at cardiogenic shock, unlike To., in emergence of hemodynamic disturbances an important role is played by damage of heart.
At development To. the intensive care directed to elimination of the reason which caused To is always necessary., or on weakening of its action. Indispensable conditions of efficiency of therapy are its immediate beginning, ensuring rest and warming of the patient. Therapy is most important etiol: to it to lay down. to actions depending on the reason To. belong a stop bleedings (see), removal of toxicants from an organism (see. Disintoxication therapy ), specific antidotal therapy, elimination of a hypoxia, giving to the patient of strictly horizontal position at orthostatic To., immediate administration of adrenaline, the desensibilizing means (see) at anaphylactic To., elimination of arrhythmia of heart etc.
The main objective of pathogenetic therapy is stimulation of blood circulation and breath, increase in the ABP. Increase in a venous inflow to heart is reached by a transfusion blood-substituting liquids (see), a blood plasma and other liquids, and also the means influencing peripheric circulation. Therapy at dehydration and intoxication is performed by administration of polyionic depyrogenized solutions of crystalloids (Acesolum, disalt, hlosol, laktasol). The volume of infusion at emergency treatment makes 60 ml of solution of crystalloid on 1 kg of body weight. Speed of infusion is 1 ml/kg in 1 min. Infusion of colloid blood substitutes by sharply dehydrated patient is contraindicated. At hemorrhagic To, hemotransfusions have paramount value; for the purpose of recovery of volume of the circulating blood massive intravenous administration of blood substitutes (Polyglucinum, reopoliglyukin, Haemodesum, etc.) or blood carry out struyno or kapelno. Reopoliglyukin exerts beneficial effect on microcirculation), Haemodesum (solution of low-molecular polyvinylpirrolidone) possesses preferential disintoxication action. Also transfusions of native and dry plasma, konts are effective in recovery of volume of the circulating blood. solution of albumine and protein. Injections of isotopic salt solutions or solution of glucose are less reliable. The amount of infusional solution is defined a wedge, and at an opportunity is controlled by indicators, the ABP level, a condition of a diuresis by means of definition of a hematocrit, volume of the circulating blood and the central venous pressure. Also introduction of the means exciting the vasculomotor center (Cordiaminum, caffeine, camphor, etc.)* is directed to elimination of hypotension.
Angiotonic drugs (noradrenaline, phenylephine hydrochloride, angiotensin, adrenaline, etc.) are shown at expressed toxic, orthostatic, reflex To. At hemorrhagic To. it is reasonable to apply them only after recovery of volume of blood, but not at a so-called empty bed. If the ABP in response to administration of sympathomimetic amines does not raise, it is necessary to think of existence expressed peripheral vasoconstriction and high peripheric resistance; in these cases further use of sympathomimetic amines can worsen a condition of the patient only. Therefore angiotonic therapy should be applied carefully. Efficiency of a-adrenoblockers for elimination of peripheral vasoconstriction sufficiently is not studied yet.
At treatment To., not connected with ulcer bleeding, the glucocorticoids applied quickly in sufficient doses are effective (a hydrocortisone, sometimes to 1000 mg and more, Prednisolonum from 90 to 150 mg, sometimes to 600 mg intravenously or intramusculary).
For elimination of a metabolic acidosis along with the means improving a hemodynamics 5 — 8% solution of hydrosodium carbonate in number of 100 — 300 ml kapelno intravenously or solution laktasol are used. At a combination To. to heart failure essential value gets use of cardiac glycosides, active treatment of acute frustration of a cordial rhythm and conductivity.
The oxygenotherapy is especially shown at To., resulted from poisoning with carbon monoxide or against the background of a mephitic gangrene; at these forms use of oxygen under supertension is more preferable (see. Hyperbaric oxygenation ). At a long current To., when development of multiple intravascular coagulation is possible (consumption coagulopathy), in quality to lay down. means apply heparin intravenously kapelno to 5000 PIECES each 4 hours (to exclude a possibility of internal bleeding!).
If To. developed against the background of a heavy inf. diseases, warm the patient, carefully laying over hot-water bottles, legs shall be raised. The body and extremities can be pounded camphoric or divorced alcohol. Specific medicamentous therapy is carried out depending on the basic infectious disease.
For desintoxication and recovery of volume of the circulating blood at inf. To. infusion of colloid blood substitutes is sometimes applied.
At all types To. careful control of function of breath is necessary, at an opportunity — with a research of indicators of gas exchange. At development of respiratory insufficiency assisted ventilation of lungs is applied (see. Artificial respiration ).
The resuscitation help at To. it appears by the general rules (see. Resuscitation ). According to E. A. Luzhnikov (1977), for maintenance of adequate minute volume of blood at an outside cardiac massage in the conditions of a hypovolemia it is necessary to increase the frequency of prelums of heart to 100 in 1 min.
Features of a collapse at children
It is possible to allocate two main reasons To. at children and teenagers: strong emotional disorders (emotional To.) and long motionless standing or too bystry transition from horizontal to vertical position (orthostatic To.). At children, especially at teenage age, these forms K. are observed more often than at adults that it is connected with underdevelopment of regulatory and compensatory mechanisms of cardiovascular system, first of all peripheral vessels. Orthostatic and emotional To. it is quite often observed also at youthful age and it is connected with a disproportion of growth, relative immaturity and imperfection of nervous and hormonal regulation of vascular reactions.
To. at patol, states (dehydration, starvation, the hidden or explicit blood loss, «sequestration» of liquid in intestines, pleural or belly cavities) proceeds heavier, than at adults. More often than at adults, To. develops at toxicoses and inf. the diseases which are followed by high temperature, vomiting, a diarrhea. According to E. Kerpel-Froniusha, at small children three times less water is the share of a surface unit of a body, than at adults therefore the fluid loss at them occurs quicker, bringing to expressed a wedge, to displays of dehydration of an organism. Decrease in the ABP and disturbance of a blood-groove in a brain proceed with deeper fabric hypoxia, are followed by a loss of consciousness and spasms. As at children of early age the alkaline reserve in fabrics is limited, disturbance of oxidizing processes in time To. easily leads to a decompensated acidosis. Insufficient concentration and filtrational ability of kidneys p bystry accumulation of products of metabolism complicate therapy To. also detain recovery of normal vascular reactions.
Diagnosis To. at small children it is complicated because it is impossible to find out feelings of the patient, and systolic the ABP at children even in normal conditions can not exceed 80 mm of mercury. The most characteristic for To. at the child it is possible to consider a complex of symptoms: easing of sonority of cardiac sounds, decrease in pulse waves at measurement of the ABP, the general adynamia, weakness, pallor or spottiness of an integument, the accruing tachycardia.
Therapy orthostatic and emotional To., as a rule, does not demand medicamentous appointments; it is enough to put the patient horizontally without pillow and to raise legs higher than the level of heart, to undo clothes. Fresh air, steam inhalation of spirit of ammonia has favorable effect. Only at deep and resistant To. with decrease in the systolic ABP lower than 70 mm of mercury. intramuscular or intravenous administration of vascular analeptics (caffeine, ephedrine, a phenylephine hydrochloride) in age dosages is shown. At To. owing to blood loss and at inf. diseases the same actions, as at adults, with prescription of medicines in age dosages are shown.
Bystry elimination of the reason which caused To. (orthostatic, hypoxemic, reflex, hemorrhagic), often leads to a complete recovery of a hemodynamics both at adults, and at children. At a serious illness and acute poisonings the forecast often depends on expressiveness of a basic disease, degree of vascular insufficiency, age of the patient. At insufficiently effective therapy To. can recur. Repeated To. patients transfer heavier, and they are one of the main reasons for a lethal outcome of a basic disease.
In hard cases when the basic disease accepts irreversible character and to lay down. actions are inefficient, the vascular disorders connected with To., progress, there are irreversible changes of c. the N of page leading to a lethal outcome.
Prevention such complication, as To., consists in intensive treatment of a basic disease, constant overseeing by the patients who are in a serious and moderately severe condition; in this respect plays a special role monitor observation (see). It is important to consider features of a pharmacodynamics of pharmaceuticals (ganglioblokator, neuroleptics, hypotensive and diuretics, barbiturates, etc.), allergol. the anamnesis and individual sensitivity to a nek-eye to pharmaceuticals and alimentary factors. Need an explanation teachers and trainers about inadmissibility of long motionless standing of children and teenagers on rulers, collecting, sports constructions etc.
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Of K. Alekseev; B. B. Bulychev, B. B. Maleev (inf.), B. M. Balagin, S. I, Denisov-Nikolsky (ped.).