Shock (French Choc - blow, push, shock) - Acutely developing, life-threatening pathological process, characterized by progressive decrease in tissue perfusion, severe disorders of the central nervous system, blood circulation, respiration and metabolism.
Infectious - toxic shock (ITSH) -one of the types of shock is a consequence of massive bacteremia and toxemia
1. Gram-negative bacteria (meningococcus, Proteus, E. coli, Klebsiella), gram-positive (staphylococcus, streptococcus, pneumococcus), their associations.
2. Less commonly, other pathogens: viruses, spirochetes, fungi, rickettsia.
The development of ITS is characteristic of hypertoxic forms of meningococcal infection. The peculiarity of gram-negative shock caused by meningococcus is an extraordinary, compared with gram-positive shock, speed of development of the process, leading to death within a few hours from the onset of the disease.
Despite the extremely rapid onset of ITSH, there is a certain phase nature in the development of the processes taking place, corresponding to different degrees of ITSH. There are three degrees ITSH:
ITS I degree (compensated. shock or warm normotonium phase): the patient’s condition is severe. Consciousness is preserved, euphoria, excitement and motor restlessness, hyperreflexia are noted, and in infants, infrequently - convulsive readiness. Chills, central hyperthermia. The face is pink, but the skin is pale, the extremities are cold, cyanosis of the lips and nail plates. Mild tachycardia, tachypnea, hyperpnea, normal or elevated blood pressure. Diuresis is normal or slightly reduced. CVP normal or reduced. ICE I degree (hypercoagulation). Compensated metabolic acidosis.
ITS II degree (subcompensated shock or phase of warm hypotension): the patient's condition is very serious. Excitement is replaced by inhibition. The child is lethargic, consciousness is impaired. Temperature is normal or subnormal. The skin is pale, with a grayish tinge, cold, moist, acrocyanosis, Gvedal symptom (“white spots”, in norm - 5-6 seconds). Expressed tachycardia, tachypnea, weak pulse, heart sounds deaf. Blood pressure is reduced, but above the critical (60-70 mm / Hg), CVP is reduced. Oligoanuria. ICE II degree. Metabolic acidosis.
ITS III degree (decompensated shock or cold hypotension phase): the condition is extremely serious, consciousness is absent in most cases. The skin is cyanotic, cold, total cyanosis, venous stasis type "dead spots". Sharply positive symptom of Gualala. Hypothermia. Pulse is thready or undetermined, shortness of breath, tachycardia. HELL below critical (60/20 mm / Hg) or not determined, does not respond to an increase in BCC. Anuria. ICE III degree. Decompensated metabolic acidosis. Possible development of pulmonary edema, toxic cerebral edema, metabolic myo- and endocarditis. Death occurs within 6-48 hours from the onset of the disease.
Early diagnostic signs of meningococcal infection:
1. The most acute beginning, often with the indication of the hour of the disease.
2. Sharp pallor of skin, cold extremities.
3. The discrepancy between the severity of the child’s condition and objective data.
Adverse prognostic signs of hypertoxic form of meningococcal infection:
1. Early age - up to 1 year.
2. The rapid increase in hemorrhagic drain rash with necrotic component.
3. The preferred location of the rash on the face and torso, eyelids, auricles.
4. Low blood pressure, poorly amenable to hormone correction.
6. Lack of meningitis.
7. Leukopenia and thrombocytopenia.
The appearance of any (!) Rash in combination with severe, rapidly increasing intoxication, should alarm the physician in relation to meningococcemia.
If meningococcemia is suspected, treatment is started immediately, because the minutes play a role in the outcome of the disease!
During the initial examination and before transportation, it is necessary to check and note in the direction: the frequency and quality of the pulse, the level of blood pressure, the degree of consciousness disorder, meningeal symptoms, diuresis (when the patient had urinated the last time).
ITSH treatment is aimed at:
1. Restoration of hemodynamics,
2. Improving microcirculation,
3. Treatment of DIC - syndrome.
Without recovery of hemodynamics, the patient cannot be transported! Hospitalization in the intensive care unit of an infectious diseases hospital, after carrying out urgent measures. If possible, it is necessary to inform the emergency room or resuscitation specialists about the transportation of a heavy patient.
1. Lay the patient in a horizontal position.
2. To provide free passability of the upper respiratory tract, to give humidified oxygen through a mask or nasal catheter.
3. Provide access to the peripheral vein.
4. Conduct continuous dynamic observation and recording of temperature, blood pressure, pulse, respiration, and consciousness.
Recommendations for the treatment of patients with meningococcemia at the prehospital stage:
meningococcemia without ITSH:
- the introduction of a lytic mixture: analgin 50% - 0.1 ml / year of life + papaverine 1% - 0.3 ml / year of life + novocaine 0.25% - 1.0 ml,
- prednisone 2 mg kg in m or in in,
- chloramphenicol sodium succinate 25 mg kg, in in, in m,
meningococcemia with ITSH I degree:
- the introduction of a lytic mixture,
- hydrocortisone 20 mg kg + prednisone 5 mg kg in in,
- solution of sodium chloride 0.9%, Ringer-Locke solution - 10.0 ml kg hour, per ,
- chloramphenicol sodium succinate in a single dose of 25 mg kg of weight, per ,
meningococcemia with ITSH II degree:
- hydrocortisone 30 mg kg + prednisone 10 mg kg, in c. In the absence of effect, repeat in the same dose after 30 minutes,
- c / v administration: sodium chloride solution 0.9%, Ringer-Locke solution 20 ml / kg, in the absence of effect - repeated administration in the previous dose after the end of the infusion,
- with continued hypotension against the background of continued infusion therapy - administration of vasopressors: dopamine - 5-10 μg / kg / min or norepinephrine 0.02% - 0.1-0.5 μg / kg / min in a separate vein,
- chloramphenicol sodium succinate,
meningococcemia with ITSH Grade III:
- hydrocortisone 50 - 70 mg / kg + prednisone 15 - 20 mg / kg, per c. In the absence of effect, repeat in the same dose after 30 minutes,
- v v introduction: sodium chloride 0.9%, Ringer-Locke solution 20 ml / kg, in the absence of effect after the end of the infusion - administration in a dose of 40.0 ml / kg,
- use of hydroxyethyl starch preparations of 15 - 20 ml / kg (HAES - steril),
- against the background of the continuation of infusion therapy - the introduction of vazopressorov: dopamine 10-15 mg / kg / min or norepinephrine 0.02% - 0.1 - 0.5 mg / kg / min in a separate vein,
Infectious toxic shock in pneumonia
Pneumonia is an infectious lung disease in which the alveoli are affected (thin-walled vesicles that saturate the blood with oxygen). The cause for the occurrence of pneumonia can serve as a number of pathogens - intracellular parasites, fungi, bacteria, viruses. Different types of pneumonia have their own characteristics. Often, it develops as a complication after illness - flu, cold, bronchitis.
Infectious toxic shock is a very serious complication of acute pneumonia (most often bilateral). All patients with this complication must necessarily be in the intensive care unit, where they will receive the necessary medical care, and monitor the work of the vital functions of the body. This complication is quite dangerous and can even lead to death (the probability of mortality is 30-50%).
Infectious toxic shock develops during severe pneumonia, with severe infiltration of lung tissue. It acts as a reflection of the extreme degree of intoxication characteristic of any pneumonia. The beginning infectious shock can be identified by several early signs, which include hyperventilation and cerebral dysfunction causing respiratory alkalosis, manifested in the form of lethargy or anxiety.
These early symptoms very often do not attract special attention, which does not allow for the timely diagnosis of the disease and significantly worsens the prognosis. With the development of the disease, shortness of breath increases, tachycardia increases, arterial hypotension, and sometimes a tendency to hypertension, pallor of the extremities can also be observed. The skin becomes dry and warm (the so-called "warm shock"). The treatment of patients with infectious toxic shock is based on appropriate therapy and constant registration of clinical data.
Expert Editor: Pavel Alexandrovich Mochalov | D.M.N. general practitioner
Education: Moscow Medical Institute. I. M. Sechenov, specialty - “Medicine” in 1991, in 1993 “Occupational diseases”, in 1996 “Therapy”.
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