TOXIC SYNDROME at children (Greek toxikos the employee for greasing of arrows, i.e. poisonous; a syndrome) — the morbid condition at children of early age developing in response to the influence of the infectious agent which is characterized by damage of the central nervous system, disturbance of peripheral microcirculation, a metabolism, and also disorder of function of many bodies and systems of an organism.
T. page at children it was for the first time described in 1826 by J. Parrish and the wedge, pictures with manifestations of a cholera algid is called children's cholera in connection with similarity (see. Cholera ). Later the term «toxicosis» was entered, the Crimea began to designate the serious condition at children which is followed by considerable disturbances of water and electrolytic exchange and damage of the central nervous system. G. N. Speransky allocated intestinal and parenteral forms of toxicosis. M. G. Danilevich described the toxicosis caused by specific microbic toxin (primary), and the toxicosis connected with exchange disturbances (secondary). Levesk (J. Levesque, 1955) entered the term «neyrotokspkoz» into a wedge, practice, the Crimea called the toxicosis proceeding without dehydration and which was followed by heavy disturbances from c. N of page E. Kerpel-Froniush (1964) allocated toxicosis with dominance of the phenomena of dehydration, a hyperthermia, a hyperventilation and primary heart failure.
Yu. E. Veltishchev in 1967 detailed the concept «toxicosis with eksikozy» and described stages of this form T. page — irritativny and soporous and adynamic, and also connected with T. page toksiko-septic and toksiko-dystrophic states. A. V. Papayan and E. K. Tsybulkin (1979) suggested to allocate during T. page the periods of the generalized (preferential nonspecific) and localized (preferential specific) reactions.
Depending on expressiveness of these or those symptoms distinguish two clinical forms T. page: neurotoxicosis and toxicosis with ekspkozy. Neurotoxicosis is characterized by primary toxic defeat central and the autonomic nervous system, a cut becomes a releaser in development of T. page.
Toxicosis with ekspkozy — the state which is shown intoxication (see), dehydration (see. Dehydration of an organism ), hemodynamic frustration (see the Hemodynamics). Toxicosis with eksikozy is quite often preceded by neurotoxicosis. Depending on type of dehydration toxicosis with eksikozy subdivide into toxicosis with a water scarce eksikoz (intracellular hypertensive dehydration), toxicosis with a soledefitsitny eksikoz (extracellular hypotonic dehydration), toxicosis with an isotonic eksikoz (the general isotonic dehydration).
Prichina T. of page usually happens any inf. the disease, is more often than a virus or bacterial etiology, and also multi-infection. To development of T. the page at early children's age are promoted by anatomo-physiological features of an organism, hypersensitivity to a contagium, an adverse premorbidal background, the previous sensitization.
Initial mechanisms of development of T. pages are defeats of c. the N of page and vessels caused by tropism of viruses and bacterial toxins. Degree and the nature of these defeats define further weight of metabolic disturbances. At immediate effect inf. a factor on c. the N the village and especially diencephalic area is observed strengthening of functional activity of system a hypothalamus — a hypophysis — adrenal glands (see. Adrenocorticotropic hormone , Gipotalamo-gipofizarnaya system ) and sympathoadrenal system (see). The spasm of precapillary arterioles and precapillary sphincters develops. Centralization of blood circulation forms (see. Blood loss ), at the first stage protective character, and with development patol has edges. process is replaced by decentralization and patol. deposition of blood in a microcirculator bed. The last along with the increasing permeability of vessels, migration of liquid in fabric, loss of water through went. - kish. the path and through lungs promotes decrease in volume of the circulating blood. At the same time its rheological properties change, viscosity increases, aggregation of erythrocytes amplifies. Integrity of an endothelial layer of walls of blood vessels in system of microcirculation is broken that leads to activation of hemocoagulation, emergence of the disseminated intravascular blood coagulation (see. Hemorrhagic diathesis ). One of the leading links in a pathogeny of T. the page becomes a hypoxia of the mixed type (see. Hypoxia ), promoting development of a metabolic acidosis (see) and leading to disturbance of processes biol. oxidations. The main way of obtaining energy is anaerobic glycolysis, power insufficiency develops (see the Metabolism and energy at children, t. 20, additional materials), as a result a cut cells of a neuroglia, cellular structures of system of mononuclear phagocytes (see), the carrying-out system of heart and erythrocytes suffer. Strengthening of peroxide oxidation of lipids and decrease in anti-oxidizing activity of plasma, the changes of phospholipidic structure of cellular membranes which are followed by disturbance of activity potassium sodium pompe and redistributions of ions between a cell and the extracellular environment lead to hypostasis of a cell.
At a pathoanatomical research find numerous melkoochagovy hemorrhages in lungs, a pleura, a pericardium and an epicardium, expansion and a plethora of vessels of a soft meninx, a nek-ry smoothness of furrows and crinkles, flabbiness of tissue of brain. At gistol. a research of various bodies narrowing and expansion of blood vessels, their uneven krovenapolneniye and perivascular hypostasis, disturbance of an endothelium of vessels of a microcirculator bed, hypostasis and a loosening of muscular and connective tissue covers, perivascular hemorrhages, staz and blood clots are defined (is more often in small vessels of a brain and lungs). Dystrophic changes of nervous cells, fatty and proteinaceous dystrophy of parenchymatous bodies, especially a liver and kidneys are noted (see. Dystrophy of cells and fabrics ).
The clinical picture
the Clinical picture depends on a form T. page. The sudden beginning, excitement with the subsequent disturbance of consciousness is characteristic of neurotoxicosis, up to a coma (see). Generalized tonic and clonic spasms against the background of the expressed hypomyotonia, a hyperthermia as a result of disorder of thermal control and heat production, disorder of breath (frequent deep breath, a hyperventilation), coronary insufficiency, increase in the ABP, reduction of pulse amplitude, a renal failure (an oliguria, an anury) are observed.
Frustration of osmoregulation, dominance of a hyperelectrolytemia, a delay of liquid in fabrics lead to wet brain (see Hypostasis and swelling of a brain) and lungs (see the Fluid lungs). Steady progressing of process at neurotoxicosis can lead to death. At the same time symptoms of the disease which became the reason of T. pages, are so poorly expressed that its diagnosis is extremely complicated.
Toxicosis with eksikozy develops more often gradually, as a result of the considerable not filled losses of water and electrolytes arising generally at a diarrhea and vomiting. A wedge, manifestations depend on type and degree of dehydration (see Dehydration of an organism), weight of a state — on extent of frustration of peripheric circulation. As a result of a fluid loss and reduction of volume of the circulating blood there is (in some cases for 50%) a falling of minute volume of blood (see. Blood circulation ). Reduction of speed of a blood-groove, reduction of saturation of blood oxygen leads to a congestive anoxia (see the Hypoxia), and reduction of volume of the circulating blood for 40% — to bystry development of often irreversible circulatory unefficiency (see). Disturbances of a hemodynamics are followed by development of a noncompensated metabolic acidosis and functional insufficiency of kidneys. The Gipokaliyemichesky state is shown by a depression, a hypomyotonia and decrease in reflexes, change of the motor function of intestines leading to development of dynamic intestinal impassability (see Impassability of intestines).
Rehydration therapy is carried out taking into account a form T. page and nature of disturbances of vodnosolevy exchange. Its duration depends on a condition of the child. At neurotoxicosis the volume of the liquid entered parenterally shall not exceed the daily need for this age. The ratio of salt and electrolyte-deficient solutions is equal 1:2 — 3, colloid and crystalloid — 1:3. Infusional therapy (see) should be begun with low - or middlemolecular blood substitutes (see. Blood-substituting liquids ). Enter glucose, do not appoint solutions of potassium in the first days. At parenteral administration of liquid at the same time apply diuretics (see) - At toxicosis with eksikozy the volume of the entered liquid is defined by daily age need of the child for liquid and the deficit of water and salts resulting from a disease. The ratio of salt and electrolyte-deficient solutions depends on the nature of dehydration. Proteinaceous and colloid solutions shall make 1/3 — 1/4 part of total amount of parenterally entered liquid. Compensation of deficit of potassium is necessary. Parenteral administration of liquids is carried out at constant control of key parameters of a homeostasis (an indicator of a hematocrit, content of sodium and potassium in plasma, pH of blood, etc.). Rehydration therapy includes also obligatory administration of solutions of glucose and fatty emulsions.
At T. page for the purpose of elimination patol. influences of a gipersimpatikoto-niya appoint antipsychotic (aminazine, Droperidolum) and antihistaminic (Pipolphenum, Dimedrol) means; for the purpose of decrease in a tone of peripheral vessels apply the means which are directly influencing smooth muscles of a vascular wall (a papaverine, Dibazolum, an Euphyllinum, nicotinic to - that, etc.), and also drugs of adrenosim-patolitichesky action (Pentaminum, petrolhexonium, phentolamine). A contraindication to use of vasodilators are arterial hypotension and a collapse.
For improvement of rheological properties of blood and the prevention of a syndrome of the disseminated intravascular coagulation appoint reopoliglyukin and Dipiridamolum (curantyl). At development of a syndrome of the disseminated intravascular coagulation apply heparin, inhibitors of proteases (Contrykal), and also carry out correction of deficit of blood-coagulation factors by plasma transfusion or trombotsitny weight.
For the purpose of elimination of a hypoxia recover function of external respiration, carry out treatment by oxygen, and also apply pharmakol. the means reducing the need of an organism for oxygen. For this purpose use the drugs promoting activation of a pentozny cycle (glucose, drugs of potassium, insulin) and also Seduxenum, hydroxybutyrate of sodium, coenzymes participating in oxidizing decarboxylation of gshrovinogradny acid — pyridoxal phosphate and lipoic to - that. For protection biol. membranes enter Contrykal, heparin, isopromethazine (Pipolphenum), Seduxenum, and also bioantioxidant (tocopherol acetate). Steroid hormones (Prednisolonum, hydrocortisone) apply as means of replacement therapy within 5 — 7 days. At the same time carry out treatment of the disease which caused T. page
the Forecast, Prevention
the Forecast at timely treatment favorable.
Prevention consists in increase in body resistance, the organization of the correct mode and vskarmlrshaniye of children.
At emergence in the child of dispeptic frustration and signs intestinal inf. diseases from first days it is necessary to carry out a peroral regidratation (administration of glyukozosolevy solutions).
Bibliography: Veltishchev Yu. E. Water salt metabolism of the child, M., 1967; Diagnosis and treatment of medical emergencies at children, under the editorship of S. Ya. Doletsky, M., 1977; Dysentery — colitis — salmonel-leza at children of early age, under the editorship of M. G. Danilevich, page 47, JI., 1949; To e r-p e l - F r about N and at with E. Patologiya and clinic of a water salt metabolism, the lane with Wenger., Budapest, 1964; L and about r and And. Regulation of exchange processes, the lane with fr., M., 1970; P and p and I am a N A. V. and Tsybulkin E. K. Acute toxicoses at early children's age, L., 1979; Speransky G. N. Dysentery at children of early age, in book: Vopr. prevention and treatment of dysentery, under the editorship of I. M. Berkovich, etc., page 183, M., 1952; Levesque J. Traitement des diarr-hees du noutrisson, P., 1955; Parrish J. Remarks on the prophylactic treatment of cholera infantum, N. Amer. med. surg. J., v. 2, p. 68, 1826.
BB. E. Veltishchev, L. V. Granova.