History. *» *.......... 4 62
Classification.......... 4 62
Aetiology, * *.......... 4 63
Pathological anatomy..... 4 68
Clinical picture, diagnosis
and complications......... 470
Treatment and forecast......... 471
Features of traumatic shock
in field conditions. 4 73
Infectious and toxic shock. 4 74
Shock (fr. choc; English shock) — standard, fazovo the developing pathological process arising owing to the disorders of neyrogumo-ralny regulation caused by extreme influences (a mechanical injury, a burn, an electric trauma, etc.) and characterized by the sharp reduction of blood supply of fabrics disproportionate to the level of exchange processes, a hypoxia and oppression of functions of an organism. Highway is shown a wedge, the syndrome which is characterized in the most typical for it to a torpid phase by emotional block, a hypodynamia, a hyporeflexia, a hypothermia, arterial hypotension, tachycardia, dispnoe, an oliguria, etc.
In the course of Sh.'s evolution as pathological process (see) forms in the form of a number of reactions, to-rye it is possible to regard as adaptive, directed to survival of a look in general. From this point of view of Sh. it is represented such response of an organism to aggression, to-ry it is possible to refer to category of the passive protection directed to preservation of life in the conditions of extreme influence.
Ideas of Sh. as standard patol. process, but adaptive character, to-ry can arise at action of various extreme factors and to be a component of different diseases, most of domestic scientists adheres. Foreign researchers, e.g. Veyl and Choubin (M. N. of Weil, N. of Shubin, 1971), as a rule, do not discuss the general pathology of Sh. and the main attention is paid to its wedge, by manifestations, understanding as Sh. any syndrome arising in response to aggression and which is characterized by essential oppression of life activity of an organism. One researchers do not do essential distinctions between the concepts «shock» and «collapse» while others, including domestic, distinguish these concepts. Under a collapse (see) it is necessary to understand 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.
History. It is told about the general heavy changes arising in a human body at an injury in Hippocrates's «Aphorisms». In 1575 A. Paré, meaning Shch., described the serious conditions arising «during the falling from height on something rigid or at the blows causing bruises», etc.
To modern, the fr. surgeon Le H. F. Le Dran in 1737 in the book «Traite ou reflections tirees de la pratique sur les playes d'armes a feu» for the first time gave the idea of Sh. close. In 1795 a picture traumatic III. in detail described D. J. Latta.
By N. I. Pirogov, A.S. Tauber and dr * it was in detail described a wedge, a picture Sh. studying of the reasons causing it is also begun. N. I. Pirogov, V. V. Pashutin, K. Bernard, etc. attached significance in Sh.'s development, along with the strong pain stimulation promoting its development, other factors, napr, to blood loss, cooling, starvation to-rye lower body resistance to an injury * In 19 century theories of a pathogeny of Sh. were put forward, authors to-rykh tried to explain emergence of III. disorders of functions of a sympathetic nervous system, cardiovascular system, etc.
An important stage in development of a problem Sh. was studying of its pathogeny in an experiment. These researches gave big actual material. At shock disturbances of blood circulation, breath and a metabolism, change of biochemistry and morphology of blood, etc. are characteristic. Originally these researches were devoted to Sh. arising at an injury * However soon it turned out that an injury — not the only reason of development Sh, Due to the broad use in 20 century of methods of a serotherapy inf. diseases and their seroimmunity, and then and hemotransfusion it was necessary to face development of processes, in many respects similar to traumatic Sh. as on a wedge, a picture, and on some other indicators. These processes connected with an anaphylaxis, hemolysis, a toxaemia were referred further to category of a collapse.
Development of a problem Sh. became more active during World War I, the big role of a toxaemia in development of shock was revealed At this time. In days of the Great Patriotic War on its fronts various groups of researchers under the leadership of the leading surgeons of the country (H. N. Burdenko, P. A. Kupriyanov, M. N. Akhutin, etc.) the successful development of a problem Sh. promoting improvement of system of treatment of wounded was conducted.
Since 60th 20 century of a research on a problem Sh. are intensively conducted in all developed countries of the world that is caused not only by the big theoretical importance of a problem, but also its practical importance in connection with the become frequent impact on the person of various extreme factors that is caused by rapid development of the industry and transport.
Classification. To a crust, time does not exist the uniform standard classification Sh. Naiboley accurate classification on etiological, to be exact, on etiopatogenetichesky signs is. Allocate the following types of Sh.: 1) shock owing to action of disturbing factors of the environment (painful exogenous): traumatic shock at a mechanical injury, burn shock at a thermal injury (see Burns), shock at an electric trauma (see); 2) shock as a result of excessive afferent an impulse-tsii at diseases
of internals (painful endogenous): cardiogenic shock (see) at a myocardial infarction, nephrogenic shock at diseases of kidneys (see), abdominal shock at impassability of intestines (see), hepatic colic (see
Cholelithiasis), etc.; 3) the shock caused by humoral factors (close on the mechanism to a collapse), called sometimes by humoral: hemotransfusionic,
or posttransfusion, shock (see Hemotransfusion), an acute anaphylaxis (see), hemolitic, insulin, toxic (bacterial, infectious and toxic) shock and shock at traumatic toxicosis (see). Some researchers allocate psychogenic shock which, apparently, shall be carried to reactive psychoses (see).
During creation of classifications of Sh., except etiopatogenetichesky signs, it is necessary to estimate its dynamics and weight. The loudspeaker Sh. (its phase development) is defined by extent of disturbances of the major functions of an organism. The most widespread is classification of shock by weight (excepting terminal states) according to which distinguish shock of I, II and III degrees, or respectively a little shock, moderately severe shock and heavy.
Etiology. Etiol. Sh.'s factors, as well as any other patol. process, divide into the main, leading to its emergence (reason), and accompanying, exerting impact on an organism at the same time or neodnovremenno with major factors (condition). Development of shock and its subsequent current depend also on reactivity of an organism (see).
Major factors cause pov-
the rezhdeniye which is followed intensive afferent an impulse-tsiyey, including and painful (see. Extraordinary irritant). Mechanical agents of significant force refer high temperature, electric current to them, etc. These factors lead to Sh.'s development when they cause rather heavy damage. The damages of fabric elements of internals at various diseases conducting to an intensive afferent impulsation belong to endogenous painful Sh.'s reasons. The reasons of other types of Sh. close on the mechanism to a collapse, are hit in a blood channel or excess accumulation in it of the toxic or other physiologically active agents lowering a tone of vessels. Concurrent factors influence possibility of Sh. and its current. Overheating, overcooling, a hyponutrient, emotional pressure, etc. concerns to them. These factors, as a rule, change reactivity of an organism and by that promote Sh.'s development or, on the contrary, limit its manifestations. The role of reactivity of an organism in Sh.'s emergence is extremely big: disturbing factors, identical on force and time of action, at the same localization of damage in one individual can cause easy Sh., and in another — heavy, even deadly. Change of reactivity of an organism under the influence of overheating (see Overheating of an organism), the previous muscular exhaustion (see), a hyponutrient and a vitamin deficiency (see. The vitamin deficiency, Food), hypokinesias (see), i.e. the factors limiting possibilities of adaptive reactions makes heavier Sh. V current a crust, time to traumatic Sh.'s problem in connection with its wide spread occurance (damages to result of transport, first of all road, traumatism, falling about heights and other types of bruises) the greatest attention is paid.
Pathogeny. Highway as standard patol. process was created in the course of evolutionary development. Its separate elements can be observed at various classes of vertebrata, but it is most expressed at mammals and the person. According to Fayn (J. Fine, 1965), at different types of mammals does not observe basic distinctions in emergence and Sh. Eto's current is the major factor causing possibilities of its experimental studying. Still
H. N. Burdenko emphasized that Sh. should be considered not as a stage of dying and as reaction of an organism capable to live. At the highest animals the main are the active forms of protection which developed in the course of evolution and allowing to avoid action of the adverse (damaging) environmental factors (leaving from danger, fight). At their insolvency there is a set of the reactions having character passivnooboronitelny, providing to certain limits, preservation of life of the individual — shock. Sh.'s being makes braking (see) the majority of functions, development of a hypothermia (see Cooling of an organism), reduction of a metabolic cost (see the Metabolism and energy), i.e. extremely economical use of the remained reserves of an organism.
The most general manifestations of different types of III. — oppression of a physical activity, braking of specific functions, reduction of minute volume of blood, development of a hypoxia (see), implementation of energy balance it is preferential in the anaerobic way. These phenomena * if they are short, provide preservation of functions of vitals and can promote a gradual exit from - Sh., and further — to recovery. If disturbances of functions go deep, there occurs death of an organism.
Along with these general mechanisms different types of Sh. can * have the specific features. So, at extensive crushes of soft tissues the phenomena of the expressed toxicosis develop (see. Traumatic toxicosis), at burns — the phenomena of dehydration of fabrics (see Dehydration), at an electric trauma — an intensive afferent impulsation, practically lack of a loss of blood, a little expressed direct damage of fabrics. Now thanks to development of anesthesiology (see) practically so-called operational shock — a kind of traumatic shock * observed earlier during the performing extensive surgeries does not meet.
During Sh., since works of H. N. Burdenko, it is accepted to distinguish erectile and torpidnuk> phases. The erectile phase comes directly after extreme influence and is characterized by generalized excitement of c. N of page, intensification of a metabolism, strengthening of activity of nek-ry hemadens. This phase is quite short-term and is seldom observed in; wedge, practice; however its allocation as phases, in a cut form rudiments of the phenomena characteristic of the following phase — torpid, is proved by the doctrine about staging of development of nervous processes, about a dominant (see) etc. The torpid phase is characterized by the expressed braking of c. N of page, disturbance of functions of cardiovascular system, development of respiratory insufficiency and
In development traumatic III. is more distinct, than at other types of Sh., erectile and torpid phases differ. However between erectile and torpid phases it cannot be carried out a clear boundary,
i.e. already in an erectile phase there are circulator frustration, deficit of oxygen and other phenomena typical for torpid fa
zy. Nek-ry researchers, e.g. D. M. Sherman (1972), allocate
a terminal phase of traumatic Sh., distinguishing it from other terminal states.
Most of researchers consider Sh. as uniform process, however, defining a ratio of pathological and adaptive reactions in dynamics of a torpid phase, distinguish in it a number of the periods: period of disintegration of functions, period of temporary adaptation, period of a decompensation. V. K. Kulagin (1978) and other researchers on the basis of similarity of these periods gave them a bit different names — initial, the period of stabilization, final.
Most of domestic researchers came to conclusion that it is reasonable to consider traumatic Sh. as one of patol. the processes characteristic of a traumatic disease — set of all pathological and adaptive reactions arising at heavy bruises of an organizkhm from the moment of damage (onset of the illness) till its outcome (absolute or incomplete recovery, death). During a traumatic disease it is also accepted to distinguish a number of the periods: the period of acute reaction on an injury (lasts one - two days), the period of early manifestations sometimes called postshock (proceeds up to 14 days), the period of late manifestations (after 14 days), the period of rehabilitation. At the heavy course of a traumatic disease in each of these periods there can come the lethal outcome. Traumatic Sh. concerns to one of patol. the processes typical for the period of acute reaction on an injury. Along with it can develop acute blood loss (see), traumatic toxicosis, etc. Later periods of a traumatic disease are shown by development of others patol. processes (the expressed disturbances of functions of c. N of page, disorders of breath, etc.).
The main starting moments of a pathogeny of traumatic Sh. are: an intensive afferent
impulsation, blood loss, a resorption of decomposition products of the damaged fabrics, and in the subsequent — intoxication products of the broken exchange. Artificial allocation of one of these factors as the basic generated different emergence of unitary theories of shock in due time (neurogenic, krovoplazmopoter, toxemic), the Crimea succeeded a comprehensive approach to assessment of its pathogeny.
Traumatic Sh.'s development at its early stages is caused by disturbances of activity of nervous and endocrine systems. At a severe mechanical injury in a zone of damage receptors are irritated, nerve fibrils and nervous trunks, specificity to-rykh in relation to an irritant, unlike receptors are excited, it is not expressed. Damages with crush and ruptures of large nervous trunks lead to development especially heavy III. Typical traumatic Sh. usually arises at the multiple and combined damages: injuries of extremities, a breast, a stomach, a skull (see Politravm).
The irritation of nervous elements arising at an injury, character of an afferent tshulsation and spread of activation decide by force of an irritant, localization of damage, its extensiveness, intensity of a flow of impulses from bodies on the broken functions. The irritation of nervous elements long time is supported by a prelum of nerve fibrils, action on receptors of toxic products of the damaged fabrics, the broken exchange, etc.
The erectile phase Sh. is characterized by generalization of excitement that is shown by motive concern, sensitization to additional irritations. Excitement extends also to the vegetative centers that leads to emission in blood of catecholamines (see), adaptive hormones (see. The adaptation syndrome), is as a result stimulated action of the heart. the tone first of all of small arteries and partly veins raises, the metabolism amplifies.
Further development of Sh. (torpid phase) is caused by the fact that a long afferent impulsation from the place of damage and from bodies with the broken functions, and also changes of lability (see) nervous elements lead to development of the centerin braking, especially in those educations, to-rye differ in smaller lability and the flow of impulses to the Crimea is most intensive. Early the centers of braking in mezentsefalichesky area of a reticular formation, in nek-ry structures of a thalamus and spinal cord form that interferes with a flow of impulses to a cerebral cortex and promotes restriction of corticofugal influences. The phase phenomena in c. N of page are shown by changes of functions of other systems of an organism that, in turn, is reflected in a condition of nervous elements.
Nek-ry researchers, e.g.
S. P. Matua (1981), note oppression of functions of limbic structures of a brain (see. Limbic system) and release of the activating systems of a brain from under their influence, oppression of function of visual department of a cerebral cortex that is explained by preservation of activity of a reticular formation (see).
At Sh.'s development more bystry decrease in lability of a reticular formation and hypothalamus comes to light (see) in comparison with a cerebral cortex, i.e. there is a functional blockade of a reticular formation from the afferent impulsation arriving from a zone of damage and bodies with the broken functions. At the beginning of development of III. the afferent impulsation from a zone of damage increases. Extending towards the cortical analyzer, the nociceptive impulsation causes the phenomena of desynchronization, however the processes limiting carrying out impulses — hyperpolarization of internuncial neurons soon join (see. Nervous cell) and iresinapti-chesky braking.
Afferent impulses extend on the ascending ways of a spinal cord and subcrustal departments more on the party of damage. A certain asymmetry in the maintenance of mediators of a nervous system (see Mediators) on the party of damage and contralateral comes to light.
After the injury which caused shock carrying out impulses in thalamic, reticular and trunk and spinal structures is significantly slowed down. Conduction function of axons at the same time completely remains. The braking arising in a reticular formation of a brainstem leads to the functional blockade of cortical departments providing preservation of their activity. At Sh.'s deepening disorders of functions of a nervous system can be supported by disturbances of a brain blood-groove (see. Cerebral circulation) and hypoxia. Despite the known autonomy of brain circulation, ensuring sufficient blood supply of a brain it is reached only at the average ABP (not lower than 40 mm of mercury.).
Changes in reflex regulation of functions at traumatic Sh.'s development are combined with reaction of endocrine system, and first of all those closed glands, to-rye differ in speed of a hormonal response. Originally activation of gipotalamo-hypo-fizarno-adrenal system (strengthening of synthesis the ACT of, increase in products glyuko-and mineralokorti-koid, emission in blood of catecholamines, etc.), and then gradual oppression of a peripheral link of mechanisms of endocrine regulation, development of extraadrenal glucocorticoid insufficiency comes to light (see lyukokortikoidny hormones). Change function and other closed glands, in particular synthesis of antidiuretic hormone (see Vasopressin) increases that Repina is shown by arterial hypotension, a hypovolemia, increase in osmotic pressure of extracellular liquid, and also (see) at a hypoxia of kidneys that leads to release of angiotensin. Increase in content of insulin (see) in blood is noted, however at heavy traumatic Sh. there can be also an insulin insufficiency. During later periods of Sh. interrenalovy insufficiency owing to frustration of a blood-groove in adrenal glands comes to light.
According to Yu. N. Tsibin (1974), at Sh.'s development increases in the beginning, and then the maintenance of a histamine (see) in blood decreases, the content of serotonin increases (see), proteolytic activity of blood increases. The maintenance of acetylcholine (see) in blood at deep Sh. decreases. In nek-ry cases it is preceded by sharp increase in its concentration.
Changes in reflex and humoral regulation first of all affect activity of the blood circulatory system: in an erectile fazesh. increase in the ABP owing to a generalized spasm of resistive vessels of the arterial bed which resulted from activation of sympathoadrenal system and emission of catecholamines is observed. Increase in a tone of resistive vessels is combined with activation of an arteriovenous anastomosis and transition of a part of blood to a venous bed, passing capillaries that leads to increase of venous pressure, disturbance of outflow of blood from capillaries and even to their retrograde filling.
The restriction of a capillary blood-groove which is combined with stimulation of exchange processes brings already in an erectile phase to development of a hypoxia and an oxygen debt (see. Muscular work). The delay of blood in capillaries and post-capillary venules, especially internals (its deposition) which is combined with blood loss leads to bystry emergence of a hypovolemia, the cut promotes further deepening an ekstravazation of liquid. Already in an erectile phase Sh. the exception of a part of blood of active circulation is found. It is the main reason for reduction of minute volume of blood, or cordial emission, Krom is promoted by delay of a blood-groove, especially in venous department of a vascular bed and, therefore, reduction of venous return.
The changes of the general peripheric resistance of vessels compensating usually reduction of minute volume of blood at Sh. are inadequate to it, arterial hypotension, typical for it is result of it (see Hypotension arterial). Disorders of circulation at heavy III. are shown by the increasing discrepancy of changes of the general peripheric resistance to minute volume of blood. Recovery of cardiac effeciency could be the most reasonable adaptive reaction of blood circulation at disturbances of blood supply of fabrics, however this reaction is limited, and at heavy Sh. adaptation is carried out by increase of the general peripheric resistance.
Increase in the general peripheric resistance is defined not by uniform total increase in a tone of resistive vessels, and their peculiar dystonia that finds expression in centralization of blood circulation — reduction of a blood-groove in skin, muscles, digestive organs at its preservation in vitals (see Blood loss). According to centralization of blood circulation also microcirculation changes (see), disturbances a cut at Sh. are characterized by reduction of quantity of the functioning capillaries, a delay of uniform elements of blood in post-capillary venules, shunting of a blood-groove. It gives the grounds to consider that increase of the general peripheric resistance is defined not only by increase in a tone of vessels, but also a delay of blood in capillaries and venules, and also change of its rheological properties. The last is shown by tendency of uniform elements to aggregation, reduction of suspension stability of blood, increase in adhesive properties of erythrocytes (see Aggregation of erythrocytes), increase of viscosity of blood especially at small shear stresses (see Viscosity).
Development of a hypoxia is connected with circulatory disturbances at Sh. tesnykhm in the way, edges is a consequence of emergence of an oxygen debt already in an erectile phase and the restriction of transport of oxygen accompanying it as a result of disorders of circulation. In genesis of a hypoxia also reduction of oxygen capacity of blood matters (see Blood, respiratory function).
The asthma which is observed at Sh. can be considered as the adaptive reaction providing satisfactory oxygenation of an arterial blood. The fabric hypoxia developing because of restriction of utilization of oxygen owing to reduction of perfusion of fabrics with blood is compensated by additional extraction of oxygen from unit volume of blood that is shown by reduction of oxygenation of a venous blood and increase of an arteriovenous difference on oxygen. The hypoxia at Sh. is combined with a hypocapny (see). Further at easy Sh. accumulation of carbonic acid comes to light, and at heavy — decrease in its contents.
The oxygen mode of bodies at Sh. changes unequally and in many respects corresponds to disorders of circulation. Fabric elements long time keep ability to utilize oxygen, i.e. the system of respiratory enzymes is damaged far not at once.
Changes of circulation and oxygen balance considerably affect the course of exchange processes, to-rye in different bodies change also unequally. Stimulation of a catabolism of carbohydrates already in an erectile phase Sh. leads to reduction of stocks of a glycogen in fabrics and to change of ratios between glycoclastic and oxidizing phases of carbohydrate metabolism (see) therefore there are a hyperglycemia and a hyper lactacidemia. The ratio lactate/pyruvate in a torpid phase Sh. increases, the content of creatine phosphate and ATP in tissue of a brain, in muscles and a liver decreases; at the same time in muscles and a liver contents milk to - you (lactate) and inorganic phosphate increases. Stocks of a glycogen in a myocardium at Sh. also decrease, however a possibility of utilization to them milk to - you from blood at sufficient supply with oxygen long time provide functions of heart. Potential ability of mitochondrions of cells of a liver, kidneys and other bodies to synthesis of ATP at Sh. remains.
The disorders of lipidic exchange (see the Lipometabolism) which are coming to light in a torpid phase in the form of an acetonemia and acetonuria are closely accompanied by changes of carbohydrate metabolism. Changes of utilization free (not esterified) fat to - t, their intensive assimilation at the beginning of Sh. and insufficient is further one of the reasons of power deficit. Reserves of lipoproteids, phospholipids, the general cholesterol decrease.
Disturbances of protein metabolism (see. A nitrogen metabolism) at Sh. are shown by increase in amount of nonprotein nitrogen of blood at the expense of nitrogen of polypeptides, reduction of amount of serum protein at the expense of albumine, a nek-eye increase of a2-globulins in blood. As a result of disturbances of exchange in an organism acid products of incomplete metabolism collect that leads to development of metabolic (metabolic) acidosis, then carbonic acid collects and there is a gaseous acidosis (see).
Changes of a metabolism and disturbance of secretory processes cause deviations in ionic composition of plasma. For III. the gilokaliyemiya (see), and also gradual equalizing of ion concentration in cells and extracellular liquid is typical.
Changes of internal environment of an organism essentially affect excitability of nervous elements, permeability of cellular membranes and a vascular wall. The last in combination with changes of oncotic and osmotic balance between fabrics and a blood plasma, and also with reduction of intravascular hydrostatic pressure conducts to an ekstravazation of liquid and development of fabric hypostases (see Hypostasis).
Circulatory disturbances, hypoxia and changes of a metabolism lead to disturbances of functions of most bodies. Functions of various bodies at Sh. suffer in different degree that is explained by an originality of circulatory disturbances (its centralization) and various depth of a hypoxia. Long safety at Sh. of satisfactory blood supply of a brain and heart leads to maintenance of their functions that is shown by preservation of consciousness and the speech at their some inferiority.
Sokratitelny function of a myocardium in development of Sh. long remains significantly not broken; this results from the fact that supply with its blood owing to centralization of blood circulation suffers a little. Use by a myocardium as energy resources milk and pyroracemic to - the t which are formed in other bodies is a lot of, provides its sokratitelny ability. At emergence of disturbances of sokratitelny function of a myocardium of the phenomenon of Sh. quickly progress. In the 70th 20 century nek-ry researchers found in blood of patients at heavy Sh. the substance oppressing sokratitelny function of a myocardium (a factor of a depression of a myocardium), fiziol. value to-rogo in many respects remains not clear. As for changes of bioelectric activity of heart at III., along with increase of cordial reductions emergence of high teeth 7\decrease in a segment of ST and a deviation of an electrical axis of heart comes to light to the right. It can be regarded as result of disorders of the central regulation and gip-e rk and l of an iyemiya.
In a crust, time much attention is paid to dysfunctions of lungs at III. Earlier was considered that at Sh. there is a hypoxia of circulator type, and an asthma should be considered as reaction to a hypoxia. In lungs in the conditions of the reduced minute volume of blood even at heavy Sh., according to S. A. Seleznyov (1973), there is a sufficient saturation of blood oxygen, close to normal — to 95 — 98% of oxyhemoglobin. Only in terminal phase III. can come to light patol. types of breath of Cheyn — Stokes (see Cheyn — Stokes breath) or Kussmaulya (see Kussmaul breath), but they demonstrate already disturbance of excitability of a respiratory center.
At traumatic Sh. if there are no direct damages of system of external respiration and patol. processes in a respiratory organs, the arterial gipoksekhmiya which is the main indicator of respiratory insufficiency (see; meets seldom. Its development is more often it is characteristic of the postshock period; it is shown by increase in intensity of external respiration with the progressing decrease in its efficiency. It is caused by disturbances of alveolar ventilation as a result of reduction of a pliability of pulmonary fabric (hypostasis), development of atelectases, changes ventilating perfu the hot relations, shunting of a blood-groove. These phenomena of postshock respiratory insufficiency in a crust, time define as «a respiratory distress», «congestive atelectases», «a shock lung», etc. Proximate causes and mechanisms of postshock respiratory insufficiency are not established yet. In development of this complication oppression of the centers of regulation of breath, hypoperfusion of lungs blood, stagnation and release from them physiologically active agents, an inactivation of surfactant (see), effects of a metabolic acidosis, and also aspiration of acid gastric contents, consecutive infection can play an important role. In a pathogeny of postshock respiratory insufficiency such phenomena as an overload of an organism liquids, colloid crystalloid - ny an imbalance of blood, long artificial ventilation of the lungs, high content of oxygen in the inhaled mixes,
the researchers arising at an intensive care of Sh. Nek-rye, e.g. Lillikhey can play an important role (R. Page of Lillehei, 1962), attached great value in Sh.'s pathogeny, especially to its irreversibility, injury of intestines (see), to a widespread hemorrhagic necrosis of his mucous membrane. In an experiment on dogs features of reactivity of vessels of intestines are revealed. At the severe mechanical injuries which are followed by development of III., clear frustration of a blood-groove in a submucosal layer of intestines are found. Motive function went. - kish. a path at III. also it is broken, but at the same time absorption of a number of substances, including glucose, salts, water, remains.
With Sh.'s development functions of a liver are considerably broken. Right after an injury the liver is exempted from the deposited glycogen and loses ability to its synthesis, proteinaceous and synthetic and barrier functions of a liver are broken. These changes are substantially caused by frustration of a hepatic blood-groove: reduction
of total amount of perfusion of a liver blood, shunting of a blood-groove at the level of a microcirculator bed that leads to development of the expressed hypoxia, despite transition of a liver to preferential arterial blood supply. Share of an arterial blood-groove in blood supply of a liver in a torpid phase III. makes, according to S. A. Seleznyov (1971), apprx. 60% (it is normal of 20 — 25%), however and it does not prevent development of a hypoxia.
At III. secretory function of kidneys is considerably broken. An oliguria (see) is so typical symptom of III., that nek-ry researchers consider it one of the main criteria during the definition of its weight. Reduction of an uropoiesis in kidneys at Sh. is caused by hl. obr. sharp restriction of filtering of primary urine in balls and, to a lesser extent, changes of a reabsorption. Filtering is broken owing to sharp frustration of a blood-groove in cortical substance of kidneys. In a torpid phase III. the ratio between blood supply cortical and marrow of kidneys becomes equal about 1:1 (instead of 9:1. normal) that is caused as reduction of size of perfused pressure as a result of arterial hypotension, and increase in resistance of cortical vessels owing to neuroendocrinal influences.
At assessment of weight of III. much attention is paid to searches of criteria of its irreversibility. «Irreversibility of shock» — a concept conditional. It is possible to allocate two types of irreversibility of III.: because of
damages incompatible with life (absolute irreversibility) and owing to insufficient efficiency of modern therapeutic actions (relative irreversibility). At different times development of irreversibility of III. connected with disturbance of functions of this or that body. So, I. R. Petrov, G. of III. Vasadze (1972) the main role in its development was assigned to disturbances of functions of c. N of page though further it became clear that the brain and heart at Sh. a long time do not suffer as a result of centralization of blood circulation. V. K. Kulagin (1978) allocated brain and somatic type of irreversibility of Sh.: in the first case irreversibility is caused by sharp disturbances of functions of a brain, in the second — functions of other bodies. If in development of the irreversible phenomena at the injury which is followed by Sh. not to consider a role of direct damage of bodies, it is possible to assume that their long ischemia (see) which is followed by development of a necrosis in those bodies to-rye in the conditions of centralization of blood circulation leads to really irreversible imputations in fabrics are worse supplied with oxygen (centrolobular necroses of a liver, necrotic changes in cortical substance of kidneys, in mucous and under-slilistom a layer of intestines).
At a severe mechanical injury to a half of victims, according to P. N. Petrov (1980), have injuries of a skull and a brain of different degree. At a combination of a craniocereberal injury (see) with the extracranial shockogenic injury which is followed by shock of the I degree, the symptomatology of a craniocereberal injury is regarded as symptomatology of the isolated craniocereberal injury. At a combination of a cherepnomozgovy injury of a brain to the extracranial shockogenic injury which is followed by shock of the II—III degree, symptoms of injury of a brain are regarded as typical for heavier, than the available actually craniocereberal injury. So, damage of diencephalic structures of a brain is shown by emergence of reactions of giperergichesky character that masks development traumatic III., and the injury of structures of an average and myelencephalon is characterized by aggravation of the frustration typical for III., what is caused by direct damage from the udodvigatelny center.
The wedge, picture of a craniocereberal injury against the background of traumatic Sh. is shown not clearly therefore for diagnosis the great value is gained by tool methods of a research, in particular an electroencephalography (see). According to EEG, of damages of diencephalic department of a brain polyrhythm with dominance the theta waves, strengthening of the synchronizing influences from frontal areas at functional loads are characteristic, and of damage of structures of an average and a myelencephalon — rough changes of bioelectric activity of diffusion character with highly - amplitude delta rhythms.
At a combination of a severe cherepnomozgovy injury to extracranial damages the erectile phase Sh. is extended, and in a torpid phase circulatory disturbances quickly progress, the period of temporary adaptation of a torpid phase is significantly shortened.
Damages of bodies of a thorax significantly influence development of III. (plevropulmonalny shock). They are characterized by the expressed frustration of external respiration (its depth, frequency, volume). In these cases, and especially during the developing of pheumothorax (see) and a hemothorax (see), ratios between alveolar ventilation and perfusion of lungs blood therefore other its types join a circulator hypoxia, characteristic of Sh., are broken, the hypercapnia develops (see). At injuries of a thorax the closed injuries of heart are possible; at the same time the minute volume of blood sharply decreases that aggravates characteristic of III. frustration of a hemodynamics.
At the combined injuries injuries of a liver are frequent (see), to-rykh the massive bleedings which are aggravating a hypovolemia, typical for it, at Sh.'s development and even more reducing the minute volume of blood result. Injuries of a pancreas (see) and development of traumatic pancreatitis (see) also make heavier Sh. Prichinami's current of it formation of physiologically active agents, disturbances in coagulant system of blood (see) resulting from a giperfermen-temiya are. At injury of intestines (see) there can be both considerable bleedings, and the frustration of a blood-groove in abdominal organs which are followed by a venous plethora and switching off of a part of blood from active circulation. It leads to reduction of minute volume of blood and aggravation of the circulatory disturbances characteristic of traumatic Highway. Similarly influence Sh.'s development in the period of priming reaction of an organism on a travkhma of injury of kidneys (see), followed by usually considerable hemorrhages in retroperitoneal cellulose.
To traumatic III. it is quite close on mechanisms of development of Sh., arising at an electric trauma (see). When at action of current there is no fibrillation of ventricles of heart, III. it is characterized expressed, but a short erectile phase and the subsequent long torpid. A starting pathogenetic factor of this type of Sh. is the irritation current of receptors and nervous trunks leading to an initial vasospasm and redistribution of a blood-groove. As a result there are typical circulatory disturbances — reduction of minute volume of blood, arterial hypotension, disorders of breath and disbolism joining them.
The burn Sh. arising at extensive thermal damages — burns (see), on mechanisms of development is close to traumatic since the leading role in its pathogeny belongs to irritation of extensive receptor zones and damage of fabric elements. The burn injury is resulted by the massive afferent impulsation from the center of damage leading to emergence of excitement, and then development of the centers of braking in c. N of page. It in a complex with changes of endocrine regulation leads to the hemodynamic and exchange disturbances characteristic of Highway. Great value in disturbances of blood circulation and a metabolism at burns dehydration of fabrics owing to frustration of water exchange, the pachemia and change of its rheological properties towards increase in dynamic viscosity, intoxication decomposition products of the damaged fabrics have, renal failures. Because of increase of viscosity of blood and quite high tone of resistive vessels of the ABP at burn III; it is long does not decrease that considerably distinguishes it from other views of Highway. These factors typical for a burn disease, essentially define its wedge, a picture in an early stage, for a cut development of Highway is characteristic.
The cardiogenic shock (see) arising at an extensive myocardial infarction. it is characterized by initial considerable decrease in minute volume of blood owing to weakening of sokratitelny function of the myocardium caused by frustration of a trophicity. In cardiogenic Sh.'s development the known role is played by also intensive afferent impulsation from a zone of damage. Venous return at the same time changes disproportionately that can lead to disturbances of blood circulation in a small circle and in combination with other factors — to a fluid lungs.
Hemorrhagic III., caused by considerable acute blood loss (see) as a separate type of III. it is allocated not with all researchers. Domestic researchers, e.g.
V. B. Koziner (1973), describe not Sh. more often, and acute blood loss, considering it as independent patol. process typical for the early period of a traumatic disease. At long circulatory disturbances as a result of the hypovolemia caused by blood loss at a fabric hypoxia and disbolism there can be changes of a tone of vessels of a micro circulator bed typical for Sh. Eto gives the grounds to regard late stages of heavy blood loss as a kind of Highway.
The acute anaphylaxis (see) arising at effect of antigens on a sensibilized organism differs from other types of Sh. in the fact that a releaser in its pathogeny is reaction antigen — an antibody, as a result a cut proteases of blood are activated, a histamine from mast cells, the serotonin and other vasoactive substances causing primary dilatation of resistive vessels, decrease in the general peripheric resistance and as a result of it arterial hypotension are released.
Hemotransfusionic (posttransfusion) shock is close to an acute anaphylaxis (see Hemotransfusion), the main mechanism to-rogo is the interaction of antigens of the alien erythrocytes incompatible on the VO system A with antibodies of blood serum which is followed by agglutination of erythrocytes and hemolysis (see), and also the release of vasoactive substances leading to dilatation of vessels, development of circulatory disturbances and a hypoxia on the same type as at anaphylactic Highway. Blockade of vessels of a microcirculator bed at the expense of obturation of their gleam the agglutinated erythrocytes, and also damage and irritation of an epithelium of nek-ry parenchymatous bodies (kidneys, a liver) products of hemolysis can have a certain value.
To relatives on a pathogeny to this type of Sh. septic (toxi-infectious) shock is, to-ry in essence is a collapse. It arises at action on an organism of bacterial toxins. As a result of dystonia of vessels of a microcirculator bed under the influence of toxic factors the blood stream through capillaries is broken, a part of blood is shunted through an arteriolovenu-lyarny anastomosis, resistance of a vascular bed decreases, there is arterial hypotension, the hypoxia of fabrics develops. Toxins exert also direct impact on assimilation by cells of various fabrics of oxygen and on exchange processes in them.
The similar phenomena are observed at serious exogenous poisoning (ekzotoksichesky shock) and the endogenous intoxications arising at extensive necroses, frustration of a metabolism, disturbances of anti-toxic function of a liver, etc. (endotoxic shock).
Pilot models of shock
carry the traumatic Sh. reproduced on Kennon's way (drawing a standard mechanical injury of soft tissues of one or both hips) To the main pilot models of Sh. On the mechanism Sh. arising at a prelum of soft tissues of hips of animals special tisochka with the devices dosing degree of a prelum is similar. For the nek-ry purposes, in particular for primary analysis of efficiency of antishock means, reproduce shock across Nobl — to Kollip for what small animals (rats, mice) are placed in the rotating drums with the set speed of rotation. Depending on speed and the number of rotations there is a multiple mechanical injury of various degrees of severity which is followed by Highway.
For the analysis of a role of an afferent impul-sation in Sh.'s pathogeny use irritation of large nervous trunks or extensive receptor zones the electric current which is not damaging fabric with the set parameters (force, frequency of following of impulses).
Hemorrhagic shock is reproduced by massive blood loss or blood loss up to the certain size ABP with the subsequent maintenance by its fractional bloodlettings or reinfusions of the produced blood. Sometimes use the special devices allowing to support automatically set size ABP during certain time to this purpose. This model Sh. allows to investigate value of circulator frustration, patterns of disbolism in a pathogeny of III.
For identification of a role of humoral factors in Sh.'s development reproduce the processes which are characterized by deep circulatory disturbances, way of introduction of high doses of peptone, endotoxins, etc.
Pathological anatomy. The main pathoanatomical signs of Sh. consider liquid state of blood in vessels of a corpse, the disseminated intravascular coagulation (DIC) with a hemorrhagic syndrome, deposition of blood in vessels of a microcirculator bed, shunting of a blood-groove, bystry mobilization of a glycogen from fabric depots and circulator and hypoxemic damages of bodies.
A phenomenon of liquid state of cadaveric blood owing to a posthumous fibrinolysis (see) is a sign of sudden death of any etiology. It is considered to be that liquid state of cadaveric blood at Sh. is a consequence of a consumption coagulopathy, i.e. uses of all blood-coagulation factors (see. Coagulant system of blood) in the course of DVS in microcircus-lyatornom a bed. However detection of insignificant quantity of microblood clots during the opening, especially at separate types of Sh., forces to assume that at Sh. the fibrinolysis owing to ekstrvkhmalny increase in activity of anticoagulative system is observed. Therefore the wedge, a phase of a fibrinosis can not be implemented in microthrombosis, i.e. in DVS. It does not exclude that a part of microblood clots can lyse during lifetime of the patient and even posthumously. In a crust, time numerous data on DVS at different types of III appeared. This syndrome really meets considerably more often at the diseases complicated by Sh. Odnako its scales and prevalence are not identical at different types of Sh. Chashche it is found at bacterial III., is more rare at cardiogenic.
Deposition of blood in a microcirculator bed easily comes to light macroscopically on an uneven krovenapolneniye of internals and signs of a hypovolemia: «empty» heart, trace amount of blood in large venous vessels that corresponds to one of conducting a wedge, Sh.'s signs — insufficiency of inflow of blood to heart and small cordial emission. It is much more difficult to define clinically and even on opening selective deposition of blood in a certain system, napr, portal. At Sh. the weight of a liver and spleen never considerably increases therefore it is impossible to explain a decrease from a system blood-groove of 2 — 3 l of blood with deposition it in these bodies. It is not possible to find also, as a rule, deposition of blood in any body by means of microscopic examination.
Shunting of a blood-groove — the important sign of Sh. characteristic first of all of kidneys, a liver and lungs. At a pathoanatomical research it is difficult to establish shunting of a blood-groove in internals. Only in kidneys at Sh. come to light pallor of cortical substance at a sharp plethora of a yuk-stamedullyarny zone and pyramids. However this gross appearance is characteristic not of all types of Sh. Vozmozhno that signs of shunting of a pulmonary blood-groove are the numerous microatelectases and intersticial hypostasis found at Sh. in lungs.
Bystry mobilization of glikogenovy depots of an organism, in particular the accelerated emission of a glycogen from a liver is characteristic of Sh. On this basis A. V. Rusakov (1946) suggested to use for pathoanatomical diagnosis of Sh. qualitative biochemical test on a glycogen. In the next years for these purposes used methods of quantitative definition of a glycogen in tissue of a liver. At the same time it turned out that emergence of the light (shock)
hepatocytes described by N. A. Kra-evsky is caused by bystry disappearance of a glycogen from cytoplasm with the subsequent fatty dystrophy of a cell. In a crust, time it is established that by means of a biochemical research of cadaveric blood it is possible to find the disturbances of lipidic and protein metabolism inherent to heavy Sh. which are shown an acetonemia and an azotemia.
Describing disturbances of blood circulation at III., pathologists use the concepts «hyperemia», «sladzh», «staz», «thrombosis». At a hyperemia (see) an expanded gleam of a vessel it is filled with the erythrocytes which are freely located among plasma, walls of vessels are not changed and keep ability to emigration. Sladzh — pasting of erythrocytes in units; at the same time between dense the gleam filled with plasma and freely located uniform elements of blood remains the unit of erythrocytes and a vascular wall. At full filling of a gleam of a vessel it is almost impossible to distinguish sladzh from a staz. Electronic microscopically dense adhesion of erythrocytes, however with preservation of covers and borders between them is characteristic of a sladzh. In a raster microscope between separate erythrocytes it is possible to find peculiar Moscow teak contacts. Staz — a stop of a blood-groove, at a cut an expanded gleam of a vessel is filled with the deformed erythrocytes, plasma is not enough, a diaiye-misinformation is absent, the endothelium which bulked up. At a long staz partial hemolysis of erythrocytes is observed, as a rule. Owing to an exit of plasma blood-coagulation factors in interstitial fabric blood clots are not formed, however loss of separate fibers of fibrin is possible.
Massive internal injuries, a skeleton, soft tissues are characteristic of traumatic Sh., liquid state of blood in vessels, moderate manifestations of DVS, lack of any selectivity in dystrophic changes of internals, the general circulator hypoxia, intersticial hypostasis of parenchymatous bodies, etc. is frequent in various combinations (see Politravm). The severe shockogenic injury is, as a rule, combined with more or less massive blood loss.
Are characteristic of hemorrhagic Sh. or traumatic Sh.'s combination to blood loss also uneven plethora of internals — a plethora of one bodies, napr, lungs and a liver, and an anemia of others, napr, kidneys. At the same time in kidneys pallor of cortical substance and a sharp hyperemia of a yukstamedullyarny zone and marrow — a shock kidney are noted (see. Renal failure). At noncompensated hemorrhagic Sh. when transfusion therapy for any reasons was not carried out, on opening signs of a hypovolemia are noted.
Widespread DVS with preferential defeat of arterioles and capillaries of vitals is characteristic of bacterial (endotoksi-chesky) Sh., and for its nek-ry options — preferential defeat went. - kish. path and lungs. Thrombosis of microvessels of kidneys, adrenal glands and an adenohypophysis is, as a rule, shown macroscopically in the form of the centers of a necrosis (see) that creates a specific picture of bacterial shock.
At an acute anaphylaxis (see) lungs preferential are surprised. In them intersticial and alveolar hypostasis, and also widespread hemorrhages in a parenchyma are noted. Also asphyxial option of the most acute anaphylactic Sh. which is shown sharp hypostasis of a mucous membrane of a throat with a stenosis of respiratory tracts and morfol is known. a picture of asphyxia (see).
Existence of deep and widespread burns of skin is characteristic of burn Sh., the pachemia, manifestations of DVS is preferential in microvessels went. - kish. path, pancreas and gall bladder.
Patomorfol. manifestations of cardiogenic shock the scantiest also come to light, as a rule, in a torpid phase, at the irreversible Sh. proceeding as hypovolemic. On opening the uniform capillary and venous plethora, in other cases — signs of sudden death is found (see. Sudden death, t. 29, additional materials): a venous plethora
of internals, overflow by liquid blood of large venous trunks, dot and spotty hemorrhages under serous covers, a fluid lungs.
At heterotransfusion (hemolitic) Sh. damage of kidneys with development of an acute renal failure is noted (see).
Shock — a concept kliniko-anatomic therefore its pathoanatomical diagnosis shall not be based only on results morfol. researches, and furthermore on the basis of any one sign, napr, a shock lung (see Lungs, pathological anatomy). Only in rare instances of the hidden or clinically reduced operational Sh. under anesthetic, napr, at the hidden gemotransfuznoyny conflict, the diagnosis can be established on the basis morfol. signs of a hemoglobinuric nephrosis (see Kidneys, pathological anatomy) and an acute renal failure.
The pathoanatomical picture Sh. can be considerably changed as a result of an intensive care. However the diagnostic difficulties arising at the same time should not be exaggerated. Highway most often is a phase of a basic disease. Therefore if death comes from Sh., i.e. during the most acute period of a disease, then on opening almost all signs of frustration of a hemodynamics are found. At irreversible forms of hemorrhagic Sh., despite massive hemotransfusions, microscopic signs of shunting of blood in kidneys remain. When death comes on 3 — the 4th days or later, after elimination of a depressed case, its reason, obviously, not Sh., but its effects is, on to-rye complications of a basic disease and inadequate therapy accumulate. In a similar situation the attempt to find pathoanatomical changes, characteristic of Sh., is usually unsuccessful.
In a crust, time in medical literature the concept «shock body» was approved. Generally it assumes a shock lung and a shock kidney. In the beginning this concept was based on nek-ry morphological (kliniko-anatomic) features or selectivity of defeat of body at Sh. a certain etiology, and also primary defeat of body which served as the reason of Highway. Many researchers, disregarding morfol. Sh.'s specifics, apply the concept «shock body» at any defeat of body which is followed its acute and sometimes by irreversible functional insufficiency including and shock genesis. Thus, the term «shock body» practically gained independent value, not always equivalent to the concept «shock».
Nek-ry researchers use the concept «shock cell», meaning by it structural and biochemical disturbances of a cell at Sh. Sushchnost of these changes in a crust, time is well-known: bystry utilization of a glycogen, decrease of the activity of enzymes of a tricarbonic acid cycle (see. Tricarboxylic acids a cycle) with single-step activation of enzymes of a cycle of anaerobic glycolysis, dystrophic-nekroti-cheskiye changes. However it must be kept in mind that as approaching subcellular and molecular level specifics of III., and consequently, and diagnostic value of the found changes more and more is lost.
Clinical picture, diagnosis and complications. Wedge, the picture ILL is defined by its phase and extent of development. The erectile phase coming directly behind an injury is characterized by speech and motive excitement at preservation of consciousness, lack of the critical relation to the state and to a surrounding situation, increase of pulse and breath, increase in the ABP. At victims with the severe mechanical injuries which are followed by Sh. at receipt in a hospital the developed torpid phase Sh is usually observed. The classical description of this phase belongs to N. I. Pirogov: «With the torn-off leg or a hand lies such okochenely on dressing point not movably; he does not shout, does not cry out, does not complain, does not take part in anything and demands nothing; his body is cold, the person is pale, as at a corpse; the look is not mobile and turned afar; pulse — as a thread, is swept hardly up under a finger and with frequent peremezhka. Okochenely either does not answer questions at all, or only about himself slightly audible whisper; breath is also hardly perceptible. The wound and skin are almost not sensitive at all; but if the sore nerve hanging from a wound something is angry, then the patient with one easy reduction of personal muscles finds a sign of feelings. Sometimes this state passes in several hours from the use of stimulants; sometimes it proceeds without change to death... Okochenely did not faint absolutely, it not that does not understand the suffering at all, he as if all plunged into it as though calmed down and stiffened in it».
Sh.'s diagnosis at a pre-hospital stage comes down to approximate assessment of character and weight of damages, the general condition of the patient and extent of disturbances of functions of the major systems of an organism in size ABP, pulse rate, character and a respiration rate, reaction of pupils, etc. Great value in assessment and the characteristic of III. belongs to its gradation on severity in relation to a torpid phase. In a crust, time three-sedate classification is the most accepted (excepting terminal states) Keith, the cut is the basis one sign — the size of the systolic ABP. On this classification distinguish shock of the I degree (easy) when the general condition of the victim does not inspire fears for his life. Consciousness is kept, but the patient malokontakten. Skin and mucous membranes pale. Body temperature is a little lowered. Pupils react to light. Pulse is rhythmical, speeded a little up. Systolic ABP of 100 — 90 mm of mercury., diastolic — apprx. 60 mm of mercury. Breath is speeded up. Reflexes are weakened.
At shock of the II (moderately severe) degree consciousness is kept, but obscured. Skin is cold, a pale face, a look it is not mobile, pupils poorly react to light. Pulse is frequent, weak filling. Systolic ABP of 85 — 75 mm of mercury., diastolic — apprx. 50 mm of mercury. The breath which is speeded up, weakened. Reflexes are slowed down.
At shock of the III degree (heavy) consciousness is confused. Skin pale or cyanotic, is covered with a clammy sweat. Pupils do not react to light. Pulse is frequent, threadlike. Systolic ABP of 70 mm of mercury. below, diastolic — apprx. 30 mm of mercury. Breath is weakened or periodic.
Unreliability of one criterion for assessment of weight of III. induced researchers to search of other parameters. Quite successful was Allgever's principle — definition of weight of Sh. on the relation of pulse rate to the size of the systolic ABP. Normal it is equal 0,5 — 0,6, at shock of the I degree — apprx. 0,8, at shock of the II degree —
0,9 — 1,2, at shock of the III degree — 1,3 and above.
At the end of 60 — the 70th 20 century the tendency to searches of methods of parametrical multifactorial assessment of weight of Sh. and forecasting of its current and outcomes was defined. In the USSR a number of formulas and nomograms is developed for assessment of weight of damages and forecasting of duration and Sh.'s outcome at optimum treatment.
As additional criteria of weight of Sh. and assessment of disturbance of life activity of an organism criteria can be used, to-rye reflect conditions of function of the most affected systems, first of all blood circulations. Scoping of the circulating blood is important (see Blood circulation), a cut it can be carried out by an isotope method with separate assessment of globular volume and volume of the circulating plasma. Other methods of scoping of the circulating blood (on gemato-kritny and to other indicators) yield unreliable results because of impossibility to determine time which passed after blood loss and owing to changes of indicators under the influence of quickly begun infusional therapy. Determination of minute volume of blood (see Blood circulation) at victims allows to reveal different types of disturbance of blood circulation: hyper perfused when the minute volume of blood exceeds usual sizes (apprx. 5 l/min), and giioper-fusional. These types, apparently, depend not only on disturbances of blood circulation, but also on character of a ratio of transfusion and vasoactive therapy. An important indicator is the size of the central venous pressure (see. Blood pressure). Increase in its St. 15 — 20 cm w.g. confirms
redundancy of transfusions or development of cordial weakness.
Due to assessment of circulatory disturbances diagnosis of bleeding is important (see). Unsuccessfulness of transfusion therapy shall suggest an idea of the proceeding bleeding. The diagnosis of bleeding in a pleural cavity at injuries of a thorax is established on the basis of data of a physical research, a X-ray analysis or by means of a puncture of a pleural cavity. At suspicion of bleeding in an abdominal cavity resort to a paracentesis abdominis and introduction of the «rummaging» catheter (see L aparotsen-tez). Availability of blood in an abdominal cavity is the indication to the emergency laparotomy (see).
With disturbances of blood circulation at III. respiratory insufficiency of an organism is closely interfaced. Indicators of disturbance of the ventilyatsi-onno-perfused relations are undervoltage of oxygen in an arterial blood lower than 70 mm of mercury. or saturation of hemoglobin oxygen is less than 80% also increase in tension of carbon dioxide gas in an arterial blood of St. 50 — 60 mm of mercury.; decrease it to 32 — 28 mm of mercury. is a sign to a hyperventilation (see. Respiratory insufficiency). The hypocapny can lead to developing of arrhythmia of heart because of ratio distortions of extracellular and intracellular potassium, to development of a hypoxia of a brain in connection with a vasospasm (see the Hypoxia), to deepening of arterial hypotension. Special attention to diagnosis of frustration of external respiration shall be paid at injuries of a thorax (multiple fractures of edges, development of pheumothorax, first of all valve). In Sh.'s diagnosis
assessment of function of kidneys is important, edges it can be broken considerably as a result of disorders of filtering in the glomerular device owing to arterial hypotension. Decrease in the ABP to 70 — 60 mm of mercury. leads to the termination of filtering less. Development of insufficiency of function of kidneys can be suspected when at recovery of size of the system ABP proportional increase in a diuresis is not observed (see). Increase of amount of nonprotein nitrogen of blood, decrease in specific weight of urine is also confirmation of a renal failure. For control of a diuresis at the victims who are in Sh.'s condition amounts of urine take hourly measurement. A critical level of a diuresis are 50 ml at 1 o'clock.
At assessment of weight of a current of Sh. define extent of metabolic disturbances, to-rye arise right after an injury because of circulator frustration, changes of the oxygen mode, disorders of neuroendocrinal regulation. Especially large role is played by the disorders of carbohydrate metabolism which are shown excess formation of a lactate. The maintenance of a lactate in blood can reach 24,3 — 30,6 mg of % (2,7 — 3,4 mmol/l), it is normal
of 9 — 16 mg of % (0,99 — 1,77 mmol/l). Nek-ry researchers, e.g. Veyl, Choubin (M. N. of Weil, N. of Shubin,
1971), consider that it is not obligatory to determine the size of a ratio lactate/pyruvate if saturation of an arterial blood oxygen rather steadily. As Sh. is shown by increase of processes of a catabolism, including catabolism of proteins, definition creatine - a creatinine index can be important at shock:
creatine - f-creatinine
— 1 — —-. By data
creatinine Yu, N. Tsibina and G. D. Shushkov
(1974), at a lung of III. it reaches
1,5, and at heavy — 2,0 and above
(is normal — 1,0).
Owing to restriction of heat production, introduction of a large amount of solutions temperature of the mixed venous blood at victims decreases to 31 — 30 °. Its definition, napr, by means of the thermoprobe entered into a venous bed or in a different way, can have diagnostic and predictive value.
A number of researchers recommends to apply various tests to assessment of weight of Sh. and definition of a functional condition of the vital systems. So, lack of pressor reaction to intra arterial forcing of blood or on intravenous administration of solution of noradrenaline can be considered as the evidence of irreversible changes in the blood circulatory system.
Sh.'s weight can significantly change depending on reactivity of an organism (see). So, the alcoholic intoxication leading to change of functions of c. the N of page, can mask a current of III. and even to promote removal of victims from Sh. at heavy damages, however in the postshock period of a traumatic disease these victims perish much more often from different complications.
Sh.'s current significantly depends on age of the victim. So, at newborn children even small injuries can lead to development of the metabolism expressed Sh. Boley a high level in children, lead imperfection of adaptive reactions to more bystry development of an oxygen debt. Highway for a short time becomes heavier. Hemodynamic frustration at Sh. at children are more difficultly liquidated, the ABP is long can remain unstable. At children the hypocapny and acidosis of metabolic type easily develop.
At persons pozhily and senile age of III. proceeds also hard, especially if it is combined with massive blood loss. Quite often owing to an idiopathic hypertensia arterial hypotension, characteristic of Sh., at them does not come to light. At elderly persons secretory function of kidneys is considerably broken — there is an anury more often. Functions of other bodies are also broken.
On Sh.'s current the undoubted mark is left by conditions, in to-rykh was traumatized. III. during natural disasters (see) can heavier proceed.
After removal from III. — in the postshock period — can develop patol. processes, frequency and character to-rykh depend on weight of the postponed Sh. (they arise after heavy III twice more often., than after a lung). The most frequent complications of the gyustshokovy period are different inflammatory processes: a pneumo
niya (see), peritonitis (see), suppuration of wounds (see Wounds, wounds), etc.; many of them are caused by opportunistic flora. One of the factors contributing to development inf. complications in the postshock period, the tranzi-even immunosuppression is (see Yim-mu nodepressivny states): oppression of system of mononuclear phagocytes (see) and polymorphonuclear leukocytes (to development of complications weakening of a chemotaxis of these leukocytes, reduction of content of cationic protein in their lysosomes precedes). Extent of oppression of an immune response depends on weight of an injury.
From complications in the postshock period, according to M. P. Gvozdev with sotr. (1979), 2 — 5% of the victims who transferred easy for III perish., and the St. 40% which transferred heavy III.
Treatment and forecast. Sh.'s therapy begins with assistance on site of incident, as a rule, crews of emergency medical service (see Emergency medical service). For achievement of the maximum succession in assistance to victims at pre-hospital and hospital stages in 1958 in Leningrad, and then and in other large cities of the USSR the specialized reanimatologichesky (antishock) crews providing the due volume of medical aid on high professional level were created. The further antishock assistance is carried out in the specialized intensive care unit (see).
The main objectives of rendering medical aid at a pre-hospital stage are: prevention of development of III. at heavy damages; elimination of the phenomena, life-threatening the victim at already developed Sh.; bystry and safe transportation of the victim in a hospital.
To lay down. to the events held at a pre-hospital stage belong: 1) anesthesia of places of changes by administration of novocaine (see Anesthesia local) and an immobilization transport tires (see Splintage]); 2) introduction of analgetics, and at heavy Sh. — an anesthesia (see) nitrous oxide or retilany; 3) at serious condition intravenous infusions of 250 — 1000 ml of plasma substituting solutions, introduction cardiovascular (Cordiaminum, korglyukon) and antihistamines; 4) introduction of glucocorticoids in high doses; 5) carrying out oxygenotherapy. If necessary make a temporary stop of outside bleeding (see), recover passability of upper respiratory tracts, carry out an intubation (see) or a tracheostomy (see), apply aseptic bandages wounds and occlusive bandages at open pheumothorax. At an asystolia carry out an outside cardiac massage (see) or an electric defibrillation (see) in combination with artificial ventilation of the lungs (see. Artificial respiration). After performance of the specified urgent actions providing a possibility of transportation of the victim he is brought in a specialized hospital. Along the line continue to give him necessary help.
Prevention of III. on site incidents and during the transportation of the victim consists in the prevention of emergence of additional damages and restriction of an afferent impulsation. For this purpose the victim who got a severe injury is stacked on a special board (it is necessary to exclude a repeated rearrangement), immobilize the damaged parts of a body (see the Immobilization), carry out appropriate anesthesia, and also other antishock actions even to emergence of symptoms of shock.
Assistance to victims provides as much as possible bystry assessment of weight of his state in a hospital, napr, by results of definition of the most informative indicators of blood circulation and breath, and also reflexes. At shock of the I degree the basic is the prevention of its deepening. For this purpose provide to the victim the maximum rest, carry out blockade of ways of carrying out afferent impulses (see. Novocainic blockade), set the due oxygen mode, liquidate a hypovolemia introduction of 200 — 500 ml of plasma substituting solutions (to
i of an ormalization of size ABP). At the same time enter glucocorticoid hormones, and also kardiotropny means and vitamins.
An important antishock action is the urgent operative measure which is carried out according to vital indications (the proceeding internal bleeding, the expressed disorders of breath which are not giving in to conservative therapy, intracranial hematomas, ruptures of internals, etc.). It is reasonable to refrain from the operations which are not connected with vital indications before removal of the victim from Sh. (e.g., it is necessary to postpone operation on a blood vessel if the reliable temporary stop of bleeding is possible). Exception short-term and a little traumatic interventions, napr make, cuts at a mephitic gangrene, removal of an impractical part of the extremity keeping on rags of soft tissues (so-called transport amputation).
Treatment at shock of II and III degrees is directed to recovery of functions of a nervous system, elimination of circulatory disturbances and breath, correction of disbolism, ionic balance and acid-base equilibrium. Actions begin usually with administration of crystalloid solutions and, whenever possible quickly, massive infusions of blood and blood-substituting liquids in one or several veins (see. Infusional therapy, Hemotransfusion). If at this ABP higher than 70 mm of mercury do not rise., forcing of blood in an artery is shown. At shock of the I degree the total amount of infusions makes 1000 — 1500 ml (liquids), at shock
11 degrees — 2000 — 2500 ml (of them to 30% of blood), and at shock of the III degree — 3500 — 5000 ml (of them to 35% of blood). T ransfuzionno-infuzion-
ny therapy depending on degree of III. carry out with different intensity. So, the first 3 hours at shock of the I degree enter 200 ml of liquids at 1 o'clock, then more slowly; at shock of the II degree — 350 ml at 1 o'clock; at shock of the III degree — 500-GOO ml at 1 o'clock.
For transfusion use odes-nogruppnuyu donor blood, Erie-trotsitnuyu the weight, dry plasma, albumine, reinfusion of previously filtered blood which streamed in a pleural or abdominal cavity (is sometimes possible at internal bleedings). It is useful to supplement infusional therapy with administration of isogenic blood serum. At use of colloid plasma substituting solutions (Polyglucinum, reopoliglyukin, etc.) their quantity, according to IO. Et al. (1977), V4 of total amount of infusions shall not exceed N. Qi bin, other part is the share of crystalloids. For improvement of rheological properties of blood it is reasonable to use hemodilution (see), at the same time the gematokritny number shall not be less than 30%. Transfusions and infusions carry out under control of hemodynamic indicators and first of all size ABP and the central venous pressure (increase in the central venous pressure of St. 15 cm w.g. confirms redundancy of infusions).
At removal from heavy Sh. use vasoactive drugs. However use of such drugs as noradrenaline and a phenylephine hydrochloride, it is necessary to consider as the last resort directed to the prevention of a life-threatening circulatory disturbance. In a crust, time in Sh.'s therapy use vazodilatator (al-fa-blockers or beta stimulators) for expansion of resistive vessels more often; arterial hypotension is stopped increase in minute volume of blood at the expense of additional transfusions.
For cardiac activation drugs of direct action are recommended (e.g., strophanthin, Korglykonum), to-rye improve utilization of oxygen and promote digestion of glucose.
Elimination of respiratory insufficiency provides first of all recovery of passability of upper respiratory tracts, inhalation of air-oxygen mix at the sufficient volume of ventilation (6 — 8 l! mines). At the sharp respiratory depression which is followed by reduction of its minute volume and also in the presence of obstacles in lower parts of upper respiratory tracts the intubation and transfer of the victim into an artificial respiration in conditions mio is necessary for a relaxation (see M iorelaksan-you). The long artificial respiration is carried out by volume respirators in the mode of a moderate hyperventilation. From upper respiratory tracts during the carrying out an artificial respiration apply an intubation to reduction of volume of dead space, the prevention of possible aspiration of slime from an oral cavity or contents of a stomach, restriction of influence of reflexes, and according to special indications — a tracheostomy. The artificial respiration is carried out kislorodnovozdushny mix (2: 3) under control of indicators of tension of oxygen and carbonic acid in blood.
The essential moment of antishock therapy is correction of functions of a nervous system and anesthesia that is carried out by use of drugs of local and resorptive action. The local anesthesia is reached by an immobilization and no*vokainovy blockade. In a hospital the transport immobilization is replaced with a constant only after definition of weight of Sh., the prevention of its deepening and performing effective anesthesia. For providing a constant immobilization use the extra focal osteosynthesis (see) which is carried out by means of special devices (see Distrak-tsionno-kompressionnye devices). Usually apply novocainic blockade, Promedolum to anesthesia (intravenously 0,5 — 1 ml of 2% of solution), fentanyl, nitrous oxide in mix with oxygen in a proportion 1: 1 or 2:1. At easy Sh. or after removal from heavy Sh. for the purpose of anesthesia intravenously of drops - but hydroxybutyrate of sodium and viadril (at severe forms of Sh. or in diagnostically not clear cases use of these drugs in connection with duration of their action can be dangerous) enter. Besides, use a neyroleptanalgeziya (see). However danger of decrease in the ABP at introduction, e.g., of Droperidolum limits its use.
For the emergency anesthesia and at operative measures at patients with traumatic Sh., especially against the background of not filled blood loss and arterial hypotension, widely apply Ketaminum (Ketalorum) — anesthetic of short action with the expressed analgesic effect. It is entered in a dose up to 2 mg/kg intravenously, to children — 5 — 10 mg/kg intramusculary (in rare instances drug causes respiratory depression, but gag and guttural reflexes, a tone of cross-striped muscles remain). As Ketaminum promotes raising of the ABP, it is applied in case of need urgent operation against the background of not filled blood loss (including and to a stop of bleeding). This property of drug allows to begin an anesthesia, to transfer the victim to artificial ventilation of the lungs and further to carry out full infusional therapy. Ketaminum is applied both for introduction, and to the main anesthesia. Ketaminum is contraindicated at a severe cherepnomozgovy injury when substantial increase of intracranial and spinal pressure is not excluded.
For recovery of the regulating function of gipotalamo-gipofizar-but-adrenal system usually appoint high doses of corticosteroids.
For the purpose of correction of metabolic disturbances, especially energy balance, enter glucose (60 — 100 ml of 40% of solution, on each 4 g of glucose add 1 PIECE of insulin). Hormonal (glucocorticoid) therapy renders also positive metabolic effect — leads to stimulation of formation of carbohydrates at the expense of a gluconeogenesis (see Glycolysis). It is also reasonable to appoint redoxons and Vkh in view of their positive influence on exchange and regenerative processes.
The important place in Sh.'s therapy is taken by correction of acid-base equilibrium (see) and ionic balance (see the Water salt metabolism). Elimination of a metabolic acidosis (see) is promoted by intravenous drop administration of 3% of solution of hydrosodium carbonate under control of indicators of acid-base equilibrium. Disturbance of exchange of electrolytes, generally sodium - potassium balance, is compensated by administration of solution of calcium chloride (the antagonist of potassium) and sodium chloride. Correction of ionic balance is carried out under control of content of potassium, sodium and chlorides of blood.
At massive damages of soft tissues hold disintoxication events (see. Disintoxication therapy), what is reached by stimulation of a diuresis, injection of large amounts of isotonic solution of sodium chloride, Ringer's solution — Locke, 5% of solution of glucose (to 2 — 3 l a day). For stimulation of a diuresis Mannitolum (300 ml of 15% of solution) under control of an hourly diuresis and the central venous pressure can be used. At changes of these indicators it is possible to suspect development of hypostases; in such cases apply the furosemide limiting a reabsorption in the canalicular device of kidneys and stimulating a renal blood stream.
At heavy III., despite carrying out all complex of the described therapy, there can come the cardiac standstill and the termination of breath (clinical death) demanding immediate holding resuscitation actions (see Resuscitation). Recovery of cordial activity (in case of a cardiac standstill) at Sh. — more complex challenge, than at its stop during operations, at acute blood loss or even acute asphyxia; it is explained by steady stress of adaptive reactions in development of Sh. and their exhaustion.
The forecast for life of the patient depends on the reasons which caused Sh., weights of shock, extent of oppression of the vital functions of an organism, timeliness and efficiency of the held events.
Features of traumatic shock in field conditions
Traumatic Sh. at wounded is characterized by a number of features that gave the grounds a nek-eye to researchers to call it wound, military and wound or voyennotravmatichesky shock.
Emotional and mental overstrain during conducting combat operations, the sleep debt and irregular food, long overheating, thirst and dehydration in hot season, overcooling and a high expense of energy resources cause ultimate strain of all functional systems, especially devices of their regulation and first of all c in the winter. N of page. The bleeding and blood loss arising after wound, disorders of breath or functions of vitals even more strengthen tension of regulatory systems and life support systems that against the background of adverse effects of a fighting situation leads to bystry exhaustion of energy resources and failure of compensation — the torpid phase of traumatic Highway develops.
Defective or untimely rendering the first medical aid, the long, sometimes connected with big inconveniences carrying out from the battlefield, long transportation of wounded on the advanced stages of medical evacuation on military roads promote bystry progressing and deepening of the arisen frustration of a hemostasis, heavier current of traumatic Highway.
Numerous factors exert impact on the frequency and traumatic Sh.'s weight in field conditions, among to-rykh importance have terms of carrying out from the battlefield and assistance, the nature of a fighting injury; quality, content and terms of rendering the first medical aid; delivery periods and conditions of evacuation of wounded (see Evacuation medical) on stages of medical evacuation (see); operating conditions of medical aid stations, terms and quality of rendering the first medical assistance (see) and the qualified medical care (see). According to
S. I. Banaytis (1948), during the Great Patriotic War in regimental medical aid station (see) shock was registered at 2 — 7% of wounded, and in divisional medical aid station (see. Medical and sanitary batal-it) — already at 5 — 11% of wounded.
Considerable fluctuations of frequency of traumatic Sh. could not be put into dependence on the nature of fighting pathology as during the conducted researches firearms aboutthe tivnik practically did not change. According to
S. I. Banaytis (1948), more low frequency of traumatic Sh. was recorded on those directions of the front where the first medical aid was the fullest, and terms of carrying out and delivery of wounded to stages of medical aid — shorter. Traumatic Sh.'s frequency depended preferential on the size of sanitary losses (see) and the delivery periods of wounded connected with it in regimental and divisional medical points. Increase dignity. losses steadily involved lengthening of delivery periods. So, according to N. A. Eremin (1943), shock of the I—II degree made 68% of all cases of Sh. at the wounded brought in a divisional first-aid post during the period to 6 hours from the moment of wound, 62,3% — at the wounded brought to 12 hours and 40,4% — at the wounded brought to 24 hours, and respectively shock of the III degree made 32% at the wounded brought to 6 hours, 37,7% — to
12 hours and 59,6% — at the wounded brought to 24 hours I.e. weight of shock depending on delivery periods in proportion grew.
Frequency of emergence of Sh. at wounds of various localization considerably fluctuates that depends on the nature of wounds and their early complications. At a combination of wounds of a skull to wounds of other localizations the frequency and Sh.'s weight depend preferential on the nature of wounds of extracranial localization. During the Great Patriotic War at wounds of upper extremities of Sh. it is stated in 1,9% of cases, and at wounds of the lower extremities — in 7,8%. The timely stop of bleeding and an immobilization the elementary receptions promoted elimination or weakening of action of the main shockogenic factors therefore Sh.'s current at wounds of extremities was more favorable. At the getting wounds of a breast which were not followed by open pheumothorax and a hemothorax, Sh. was observed at 20 — 25% of wounded. At the wounds of a breast which were followed by the open or valve pheumothorax expressed by a hemothorax, Sh.'s frequency reached 50% of cases. It was caused not only by extensiveness of damage of fabrics and blood loss, but also sharp disturbance of breath owing to fall of a lung on the party of damage and more bystry increase of a hypoxia. At the getting wounds of a stomach (see) traumatic III. it was observed at 23,3 — 65% of wounded. The main shockogenic factors at wound of a stomach are pain and blood loss. Besides, at damage of hollow bodies outpouring in a free abdominal cavity of gastric or intestinal contents causes sharp irritation of in-teroretseptor of a peritoneum, and then and intoxication of an organism in process of development of peritonitis (see) * Thereof traumatic Sh. at wounds of a stomach proceeds especially hard. At the multiple and combined damages traumatic Sh. is characterized by the heaviest manifestations and bystry exhaustion of regulatory systems and bodies of life support. It is connected with simultaneous damage of several anatomic areas of a body, injury of vitals, massive blood loss (outside and internal bleeding), excessive painful impulses.
At use of new types of weapon a dignity. losses will be characterized by significant increase in specific weight of heavy damages and. therefore, increase of frequency traumatic Sh. Tak. according to nek-ry researchers, e.g. Pikkart (K.-N. of Pi-ckart, 1979), in modern wars Sh.'s frequency can reach 20 — 30% of total number of wounded. And change of a pathogeny and a wedge, pictures of traumatic Highway is possible. This results from the fact that influence of the pathogenetic factors of traumatic Sh. characteristic of a mechanical injury (neurogenic, blood loss, disorders of breath, intoxication), can be combined with a contusion (see) internals, ionizing radiation (see), burns (see) or with a combination of these defeats (see. The combined defeats). Therefore wedge, manifestations traumatic III. can vary owing to dominance of symptoms, e.g. a radial illness (see) or poisonings (see). In war using modern types of weapon a role of the first medical aid in the battlefield, the carrying out of wounded and their timely delivery in medical institutions, the full first medical and qualified aid will become particularly important.
Prevention and Sh.'s treatment in the battlefield and in regimental medical aid station include the following events: early use of analgetics, blockade of field of damage by anesthetic, reliable transport immobilization, imposing of protective primary bandage; fight against bleeding and blood loss that is reached by a temporary stop of bleeding, injection of plasma substituting solutions, the most bystry evacuation of wounded on stages of rendering the qualified medical aid; elimination of disturbance of external respiration (clarification of an oral cavity and nasopharynx from slime and foreign bodys, elimination of tension valve pneumothorax, closing with an occlusive bandage of a wound of open pheumothorax, the prevention of retraction of language at an injury of a skull or changes of a mandible); use of the hormonal drugs promoting elimination of endocrine disturbances.
In medical and sanitary battalion (separate medical group) the antishock therapy providing permanent removal of the victim from state of shock and creation of conditions for its possible evacuation on the subsequent stages of medical evacuation shall be carried out in full. Such antishock actions include: maintenance of active lung ventilation; effective anesthesia; fight against hemodynamic disturbances and a hypovolemia by a stop of bleeding, completion of deficit of the circulating blood, liquids of an organism and electrolytes, normalization of water-salt balance; maintenance or recovery of blood circulation by means of a direct or indirect cardiac massage; operative measures; fight against hypostasis of a brain and hyperthermia, recovery of a diuresis.
Infectious and toxic shock
Infectious and toxic (toxi-infectious) Sh. most often is caused by gram-negative bacteria — meningokokk (see. Meningococcal infection), salmonellas (see the Salmonella), shigellas (see), colibacillus (see), iyersiniya (cm, Iyersinioz, Plague); approximately in 1/3 cases gram-positive microbes — staphylococcus (cm *), streptococci (see), pneumococci are infektsionnotoksichesky (ekzotoksichesky) Sh.'s reason (see). In a crust, time infectious and toxic HL, especially at children and persons at advanced and senile age, against the background of hron. inflammatory processes is caused by Proteus more often (see Proteus), klebsiyellam (see Klebsiella), a pyocyanic stick (see), an aerobakter, bacteroids (see t * 20, additional materials). It can develop at bacterial, virus, rickettsial (see the Sapropyra epidemic), spirochetotic and even fungus diseases. Infectious and toxic shock makes more than 1/3 all Sh.'s cases, conceding on frequency cardiogenic and hypovolemic to III., however a lethality at it higher; usually it exceeds 50%.
The crucial role in infectious and toxic Sh.'s pathogeny is assigned to bacterial toxins (see), preferential to endotoxin (en-dotoksichesky Sh.). Endotoxins in a wedge. to practice and on experimental endotoxic Sh.'s model are capable to influence directly a tone of regional vessels, causing opening of short arteriovenous shunts and considerably slowing down a capillary blood stream that leads to disorders of microcirculation (see). At the same time they stimulate allocation of the catecholamines (see) strengthening a spasm of arterioles and venules, which are slowing down a blood stream and leading to deposition and sequestration of blood in a capillary network. The progressing, quite often fulminant development of infectious and toxic HL is explained by the immune mechanism to a specific gipa to a rch vstvitet nost
to endotoxin with activation of system of a complement (see). Complement activation leads to accumulation of the vasoactive substances increasing permeability of vessels and causing killing including leukocytes and thrombocytes. Endotoxins strengthen a blood coagulation, influencing preferential suck-disto-platelet mechanisms of a hemostasis (see. Coagulant system of blood). The disseminated intravascular blood coagulation — the essential pathophysiological mechanism infectious and toxic III. The essential part in its progressing is assigned to activation of kinin-kallikrein system (see Kininy\and also to reduction of oxygen consumption by cells under the influence of bacterial toxins. During an initial stage of infektsionnotoksichesky Sh. at decrease in peripheric vascular resistance and the ABP compensatory increase in a stroke output of heart and heart rate (a hyper dynamic phase) is observed. Further at the increasing deficit of volume of blood and heart failure there comes the hypodynamic phase. At the continuing disturbance of microcirculation, reduction of venous return of blood and cordial emission the ABP falls, the hypoxia, acidosis amplifies, irreversible changes of a metabolism, death of cells and fabrics are observed.
The wedge, infectious and toxic Sh.'s picture is characterized by a combination of symptomatology of acute vascular insufficiency and generalized inf. process. At infectious diseases (see) infectious and toxic Sh. most often develops in 1 — 2 days of a disease. Early and its constant signs are the expressed fever, fervescence to 40 °. B cases of later development precede it gektichesky or remittiruyushchy type of temperature reaction (see Fever), repeated oznoba, plentiful sweating. At the same time the headache amplifies, confusion of consciousness, vomiting, spasms, a hyperesthesia, motive excitement appears. At the expressed hyper dynamic phase (the compensated Sh.) extremities of patients remain warm, the hyperemia of the person and an upper half of a trunk is noted, breath becomes frequent, tachycardia to 110 — 120 blows in 1 min. is combined with good filling of pulse and minor change of the ABP. At infectious and toxic Sh.'s progressing and transition it in a sublump-pensirovannuyu degree are noted a black-out up to development of coma (see Côme), pallor of skin, a Crocq's disease, marble coloring of skin. The fever and a hyperemia are replaced by decrease in body temperature, is frequent with critical falling to subnormal figures, a brush and foot become pale cyanochroic, cold, wet. Pulse reaches 160 blows in 1 min., becomes weak, arrhythmic, the ABP quickly falls, hemorrhages on skin and mucous quite often appear, gastric bleedings (dekompensiro-bathing Sh.) are possible. At infectious and toxic Sh. lungs and kidneys most suffer. At a «shock» lung acute respiratory insufficiency, shunting in a small circle of blood circulation is noted, at rentgenol. a research — the lowered transparency of pulmonary fabric and existence of mosaic shadows. The picture of a «shock» kidney is characterized by the progressing acute renal failure (see).
Idiosyncrasies of infectious and toxic Sh. at children is big expressiveness of the general intoxication, defeat of c. N of page, dispeptic frustration (repeated vomiting, a diarrhea, strengthening of a vermicular movement of intestines, emergence of pains in an upper part of a stomach), existence of hemorrhagic rash.
The infectious and toxic Sh. caused by gram-negative bacteria proceeds heavier and gives higher lethality, than the infectious and toxic Sh. caused by gram-positive bacteria, at Krom longer time remains adequate vascular perfusion.
Infectious and toxic Sh.'s diagnosis is based on characteristic clinical laboratory changes. At children and persons of advanced and senile age at a heavy current generalized inf. processes diagnosis causes considerable difficulties.
At laboratory researches at patients the anoxemia, a metabolic acidosis, increase in concentration of a lactate in blood, an azotemia (see), a hyponatremia (see), a hypoalbuminemia, signs of the disseminated intravascular blood coagulation decides on infectious and toxic Sh. (see. Hemorrhagic diathesis).
Treatment shall be complex and is directed both on etiological, and to pathogenetic factors. For the purpose of recovery of a hemodynamics treatment should be begun with intravenous administration of crystalloid and colloid solutions (preference is given to a reopoliglyukin and Haemodesum). Intravenous infusion of 5% of the solution of the albumine improving rheological properties of blood and promoting recovery of permeability of capillaries is shown. From crystalloid drugs preference is given to polyionic solutions, to-rye it is necessary to pour with extra care under control of the central venous pressure at wet brain (see Hypostasis and swelling of a brain), «шоковохм» easy, an acute renal failure. Apply antibiotics of a broad spectrum of activity. It is necessary to consider that therapy by massive doses of antibiotics can promote death of a large number of bacteria that purpose of corticosteroids in a daily dose to 30 mg/kg is followed by increase in amount of the endotoxin circulating in blood and infectious and toxic Sh. Pokazano's progressing (in terms of Prednisolonum), to-rye possess pharmakodina-michesky action. Besides, enter inhibitors of proteases (Contrykal, Gordoxum, trasshgol). At inefficiency of blood-substituting liquids patients are given simpatomnme-tics (a dopamine, Isoproterenolum). At infectious and toxic III., caused by stafilokokka, widely apply specific immunoglobulin (see) and blood plasma. The expressed respiratory insufficiency against the background of a «shock» lung demands carrying out artificial ventilation of the lungs; at development of the disseminated intravascular coagulation apply heparin, the frozen blood plasma; at an acute renal failure — an artificial diuresis, a hemodialysis.
The forecast is especially adverse at subcompensated and the compensated Sh., in cases when he is called a gramotritsatel by ny bacteria, children of the first year have lives, persons 60 years from an eo-putstvuyushchikhma diseases of sulfurs - are more senior, than dechno-vascular system, kidneys, a liver, disturbance of the immune status of an organism.
Infectious and toxic Sh.'s prevention consists in early diagnosis and timely carrying out an intensive care at tyazhelokhm the course of infectious diseases.
See also Acute anaphylaxis; Cardiogenic shock; Burns; Hemotransfusion, reactions and complications.
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