It is the inadequacy of circulation at the cellular level. Dysfunction of organs and systems occurs as a result of the dysfunction of cells (SIRS: Systemic Inflammatory Response Syndrome). If emergency treatment is not given, it quickly results in death.
Clinical and laboratory findings:
- Hypotension (systolic blood pressure<90 mmHg)
- Filiform pulse
- Tachycardia (> 100/min)
- Tachypnea (>20/min)
- Hypoxemia
- Cold extremities
- Oliguria, anuria
- Conciousness changes
- Organ system dysfunctions (SIRS)
- Lactic acidosis
- Leukocytosis, leukopenia, cytopenias, diffuse intravascular coagulation
- Septic shock in the presence of fever and infection focus
- Hypovolemic shock in the presence of dry tongue and skin
- Diffuse moist crackles in both AC basals, venous Cardiogenic shock in the presence of fullness and sweaty skin, pulsus alternans, S3, S4
- Anaphylaxis shock in the presence of skin itching ±, bronchospasm, rapidly developing angioneurotic edema
- Toxic shock should be considered in the presence of a history of toxin exposure.
Types of shock:
•Septic
•Neurogenic (SSS,PSShayellow)
•Anaphylactic
•Toxic
•Inflammatory (Pancreatitis, burn, etc. .)
•Adrenal insufficiency
Clinical stages:
Initially, as tissue perfusion deteriorates, the organism develops some defense methods to protect vital organs. The aim is to prevent these organs from being affected. In the first phase, the reversible (compensated) phase, tachycardia develops due to the effort to increase it in response to the decreasing cardiac output. In this way, blood pressure can be kept at the limit. Perfusion of non-vital tissues is reduced (skin and muscles). For this reason, the skin is cold and twitching occurs in the muscles. Cardiac output decreases over time. Pulse pressure decreases. The amount of urine has decreased. Unrest has begun. In the next stage, the precautions taken by the organism become insufficient. Therefore, despite the tachycardia, cardiac output has decreased significantly. The skin takes on a mottled appearance, the amount of urine becomes oliguric/anuric. Tachypnea and a tendency to sleep occur. After a while, consciousness will turn off. k. This phase is called the decompensated phase. In addition to eliminating the current problem, organ dysfunctions must be combated. The chance of success in treatment is greatly reduced for a patient who reaches this stage. In the next stage, the person is in a coma. Cyanosis is present. There is no urine output. Tachypnea and tachycardia cannot be maintained and bradycardia and bradypnea develop after a while. Circulation is completely disrupted and the person quickly loses weight. This phase is called the irreversible phase.
The main reason for hypovolemic shock is the decrease in circulating blood volume due to dehydration. As blood pressure decreases, peripheral circulation deteriorates. Tachycardia and tachypnea occur. If early measures are not taken, death may result as a result of the clinical stages mentioned above. The most common causes are bleeding and diuretic use. It may also occur as a result of neglect in older ages.
Cardiogenic shock develops as a result of a decrease in output due to sudden deterioration in cardiac functions. The most common cause is myocardial infarction. Apart from this, arrhythmias (tachycardia, bradycardia), A-V block, heart valve disease, pericardial tamponade, myocarditis, etc. may cause cardiogenic shock. There are often signs of acute left heart failure. But it can also develop as a sudden change of consciousness or acute right heart failure.
Septic is a condition that usually progresses with high and rarely low fever and clinical signs of shock are observed as a result of an underlying organ system infection. It's called shock. It is seen in half of severe sepsis cases. Mostly the cause is gram negative microorganisms. Body temperature is >380C or <360C, heart rate is >90/min, respiratory rate is >20 or PaCo2 is <32 mmHg, and PMNL count in complete blood count is >12,000/mm3 or <4000/mm3. Newborns and the elderly, cancer patients, diabetes, chronic alcoholism, HIV positivity, immunodeprived patients, those receiving mechanical ventilation, those receiving chemotherapy/radiotherapy, neutropenic patients, those with catheters and/or prostheses, and those using intensive antibiotics are at risk for the development of sepsis and septic shock. The most common foci of infection are; intra-abdominal infections (pyelonephritis, infected ovarian cyst, PID, cholangitis, pancreatitis), urinary tract infections, skin infections (cellulitis, pressure sores), respiratory tract infections and endocrine It is arditis.
Shock neurogenic shock, which is mostly accompanied by hypotension as a result of sympathetic nervous system dysfunction as a result of central nervous system injuries, but also bradycardia, peripheral vascular pooling and decreased cardiac output (due to decreased preload). It is called.
Toxic shock should be suspected when an underlying cause cannot be found in addition to the above-mentioned findings in a patient with clinical signs of shock. Shock may develop due to any chemical exposure, food toxicity or toxins produced by microorganisms during the course of infection.
Rapidly developing adrenal insufficiency is also among the causes of shock. As a result of severe hypocorticism, hyponatremia, water and salt loss, and hypovolemia develop. Development of an acute stressful situation (infection, inflammation, trauma) may cause adrenal venous thrombosis and/or adrenal bleeding.
Treatment:
Airway, breathing and circulation must be ensured. Saline infusion should be made (very quickly if necessary, depending on dehydration), the cause should be determined and treated quickly.
Urinary output should be monitored, and an urgent cardiac evaluation should be made.
In the presence of severe hypotension, inotropic treatment (dopamine, dobutamine, etc.) should be given.
Broad-spectrum antibiotics should be preferred in the presence of a focus of infection (Beta lactam group antibiotics, broad-spectrum antibiotics). spectrum cephalosporins, carbapenems). When anaerobic infection is considered, agents effective against it should be used.
Treatment becomes difficult in the presence of disseminated intravascular coagulation (DIC). The main treatment is to eliminate the underlying condition (focus of infection). In addition, fresh frozen plasma and platelet suspension can be given in case of emergency. In the presence of disseminated intravascular coagulation, platelet suspension will help continue the cascade rather than prevent bleeding. For this reason, it can only be given when vital bleeding occurs, otherwise it has no indication. Although heparin applications are mentioned theoretically, since initially increased coagulation, then consumption, and then bleeding diathesis are blamed, it has little place in practical applications.
Se Immune therapies have been tried in recent years in peptic shock. Some of those; corticosteroids, anti-endotoxin monoclonal antibodiesE-5, HA-1A, anti-TNF antibodies and IL-1 receptor antagonists. New studies are still needed for clear results.
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