Shock is caused by the sharp decline of effective circulating blood volume and serious insufficient blood perfusion of tissues, which leads to functional, metabolic and structural damage of important life organs.Common types of shock includeHemorrhagic shock、Burn shock、Traumatic shock、Septic shock、Anaphylactic shock、Cardiogenic shock、Neurogenic shockEtc.Shock can be caused by many factors, including severe blood loss, extensive burns, severe infection with severe circulatory disorders, and extensive myocardial infarction.
The clinical manifestations of shock are different in different periods: in the microcirculation ischemia period, the patient's face is pale, the limbs are cold and wet, and the pulse pressure is reduced;In the stage of microcirculatory congestion, blood pressure and pulse pressure decreased progressively, renal blood flow was seriously insufficient, and skin and mucosa were cyanotic or mottled;In the stage of microcirculation failure, intractable hypotension occurs in circulatory failure, which is often accompanied byDisseminated intravascular coagulation(DIC) and other serious complications.
The treatment of shock is mainly to actively deal with the cause of disease. It needs to stabilize vital signs, ensure microcirculation perfusion of important organs, improve cell metabolism, and pay attention to the prevention and treatment of complications.It may be necessary to carry out infusion treatment, or use vasoactive drugs, as well as corresponding treatment for specific causes, such as antibiotic treatment, blood transfusion, thrombolysis treatment, etc.
The prognosis of shock is related to the specific type, etiology, timely treatment and other factors.Some refractory shock develops to advanced stage, which may cause systemic shockOrgan failureAnd other serious complications, even fatal.Therefore, if there are risk factors that may develop into shock, such as massive hemorrhage, serious infection, extensive burns, etc., you should go to the hospital in time.
TCM disease name
shock
Foreign name
shock
Visiting department
Emergency Department
Multiple population
There is no evidence of evidence-based medicine to support that the disease is likely to occur in a certain population
Common causes
Severe blood and fluid loss, infection, trauma, extensive burn, allergy, cardiac dysfunction, strong nerve stimulation
common symptom
Pale face, wet and cold limbs, cold sweat, fast pulse, fast heart rate, low blood pressure, apathy, even coma
Related drugs
Dobutamine, norepinephrine, epinephrine or dopamine, vasopressin, etc
Shock is mainly caused by various strong pathogenic factors acting on the body, causing tissue perfusion disorder.
lose blood
It is commonly seen in trauma bleeding, gastric ulcer bleeding, esophageal vein bleedingectopic pregnancy, postpartum hemorrhage, DIC, etc.Whether shock occurs depends on the amount and speed of blood loss. When rapid and massive blood loss occurs, the amount of blood loss exceeds 15%~25% of the total amount of blood, which will lead to shock.
Fluid loss
It is commonly seen in severe vomiting, diarrhea, intestinal obstruction, sweating and polyuria in diabetes.Shock caused by the sharp decrease of effective circulating blood volume due to fluid loss was formerly called collapse.
burn
Large area burn leads to burn shock, which is due to the loss of plasma due to massive leakage of burn, the reduction of effective circulating blood volume, and insufficient tissue perfusion.In the early stage, it is related to pain and low blood volume, and in the late stage, it often develops into septic shock due to secondary infection.
Infected
Severe infection of pathogenic microorganisms such as bacteria, viruses, fungi and rickettsia can lead to septic shock.
Septic shock is a special subtype of sepsis, which is accompanied by severe circulatory disorder and abnormal cell function and metabolismSepsisIn the case of full fluid resuscitation, vasoconstrictors are still needed to maintain the mean arterial pressure above 65mmHg, and the serum lactic acid level is higher than 2mmol/L (18mg/dl).
trauma
Severe trauma can lead to severe pain, massive blood loss and fluid loss, and tissue necrosis, leading to traumatic shock.
Cardiac dysfunction
Large area acutemiocardial infarction、Acute myocarditis, rupture of ventricular aneurysm, serious arrhythmia and other cardiac diseases, cardiac tamponade, pulmonary embolism, tension pneumothorax and other extracardiac obstructive diseases that can affect blood flow and cardiac ejection function, can lead to a sharp reduction in cardiac output and a serious shortage of effective circulating blood volume, resulting in shock. The former is called cardiogenic shock, and the latter is called extracardiac obstructive shock.
allergy
Some people with allergic constitution may suffer from type I hypersensitivity reaction after injecting certain drugs (such as penicillin), serum preparations or vaccines, or even eating certain foods or contacting certain objects (such as pollen), which may cause shock, called anaphylactic shock.
Intense nerve stimulation
Severe pain, spinal cord injury, high spinal cord anesthesia, and excessive central sedatives can inhibit the sympathetic vasoconstriction function, expand the resistance vessels, increase the volume of the vascular bed, and cause shock due to relatively insufficient effective circulating blood volume, which is called neurogenic shock.
Microcirculatory perfusion of this type of shock is normal and the prognosis is good. Generally, it can heal itself without treatment.
symptom
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According to the characteristics of microcirculation changes at different stages of shock, it can be divided into the following three stages: microcirculation ischemia, microcirculation congestion, and microcirculation failure.
Patients at different periods have different manifestations.In severe cases, it will be accompanied by various metabolic and functional disorders of the body.
Typical symptoms
Ischemic phase of microcirculation
It is also called early shock, shock compensation period and ischemic hypoxia period.The main manifestations of the patient are pale face, wet and cold limbs, cold sweat, fast pulse, decreased pulse pressure, decreased urine output, and restlessness.Generally, they are conscious, and their blood pressure can drop suddenly (such as massive blood loss) or slightly, or even rise normally or slightly due to compensatory action, but their pulse pressure is significantly reduced.Therefore, whether the blood pressure drops or not cannot be taken as an indicator to judge early shock.
Microcirculatory congestion stage
It is also called reversible shock decompensation period, shock progression period, microcirculatory congestion hypoxia period.
The main manifestations of patients are:
The blood pressure and pulse pressure decrease progressively. The blood pressure often drops significantly, the pulse is thin, and the vein collapses;
Renal blood flow is seriously insufficient, oliguria or even anuria;
Microcirculatory congestion increases deoxyhemoglobin, causing cyanosis or flecks in the skin and mucosa.
Microcirculation Failure Stage
It is also called refractory period, DIC period and irreversible period.Patients with microcirculation failure mainly have the following manifestations.
Circulatory failure
There is obstinate hypotension, which can not even be measured, and it is difficult to recover with vasopressors;
Heart sounds are low and weak, and the pulse is weak and fast, even cannot be touched;
Central venous pressure decreased;
Superficial vein collapse makes intravenous infusion very difficult.
Concurrent DIC
It is often accompanied by disseminated intravascular coagulation (DIC), anemia, subcutaneous ecchymosis, and punctate bleeding.
Failure of important organs
The dysfunction of heart, brain, lung, liver, kidney and other important organs is aggravated, and dyspnea, oliguria or anuria may occur;
The clinical manifestations of multiple organ dysfunction or multiple organ failure, such as confusion or even coma, occur.
Accompanying symptoms
Shock is often accompanied by various metabolic and functional disorders of the body.
Substance metabolism disorder
During shock, the material metabolism changes generally show that oxygen consumption decreases, glycolysis increases, glycogen, fat and protein catabolism increases, and anabolism decreases.
Patients often present with transient hyperglycemia and diabetes, increased free fatty acids and ketones in blood, increased plasma amino acid content, increased urinary nitrogen excretion, and negative nitrogen balance.
water-electrolyte disorders and acid-base imbalance
Patients often present with metabolic acidosis, respiratory alkalosis, and hyperkalemia.
Organ dysfunction
During shock, due to microcirculation dysfunction and systemic inflammatory response syndrome, lung, kidney, liver, gastrointestinal, heart, brain and other organs are often damaged, even leading to multiple organ dysfunction syndrome or multiple organ failure.
Medical treatment
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Pay close attention to the patient's condition changes during the illness, and go to the hospital in time when blood pressure drops, heart rate is too fast, limbs are wet and cold, or there are major bleeding, serious infection, extensive burns and other factors that lead to shock.
Doctors make diagnosis according to clinical manifestations, past medical history, physical examination and necessary laboratory and imaging examinations.
Red blood cell count and hemoglobin determination are helpful to the diagnosis of hemorrhagic shock, while white blood cell count and classification are important diagnostic criteria for septic shock.
Routine urination and stool
Routine urine test can determine the cause of shock and its impact on renal function;Routine stool examination is valuable in judging infectious and hemorrhagic shock.
Blood biochemical examination and blood gas analysis
Blood pH, alkali residue, etc.: it can help doctors understand the degree of acidosis in patients with shock.
Urea nitrogen and creatinine: help doctors understand the renal function of patients in shock and judge whether there is upper gastrointestinal bleeding.
Liver function: it is helpful to understand the impact of shock on liver function.
Myocardial injury markers: help judge the impact of shock on myocardial metabolism and diagnose cardiogenic shock.
Electrolyte: understand the electrolyte balance disorder during shock.
Blood lactate, central vein or mixed vein oxygen saturation, etc.: evaluate and monitor the changes of systemic perfusion indexes during shock.
Outflow and coagulation function test
It is helpful to judge the progress of shock and whether DIC occurs.
Supplementary Examination
The cause of shock can be determined by bedside cardiopulmonary ultrasound, chest X-ray, electrocardiogram, head chest abdominal CT, etc.
Hemodynamic monitoring: such as monitoring central venous pressure, pulmonary artery wedge pressure, cardiac output, etc., can help to determine the cause of shock, understand the state of cardiac function, and guide treatment.
Shock often manifests as hypotension, but hypotension is not always shock.It is generally believed that adult blood pressure below 90/60mmHg is considered as hypotension.Hypotension patients generally have no organic disease, normal heart rate, normal skin and mucosa color, and normal urine volume, which is a benign physiological state.
The cause of shock needs to be further identified, and different treatment methods will be adopted according to different causes.To determine the level of cardiac output, whether the circulatory capacity is sufficient, whether the lungs are clean, and other issues through perfect examination, to distinguish the cause of shock according to the characteristics of hemodynamics, so as to help determine further treatment plans.
treatment
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The treatment of shock is mainly to actively deal with the causes. First, stabilize the vital signs, ensure the microcirculation perfusion of important organs and improve cell metabolism, while paying attention to the prevention and treatment of complications.
General treatment
Calm down, take oxygen, fast, reduce moving;
ECG, blood pressure, pulse oxygen saturation and respiratory monitoring, blood routine examination, blood gas analysis and biochemical examination, ECG, chest film, central venous pressure and other examinations were performed;
Open venous access, detain deep venous catheter and conduct hemodynamic monitoring if necessary;
All causes and types of shock are accompanied by absolute and/or relative circulatory insufficiency.
Therefore, before the application of vasoactive drugs, active infusion treatment is needed to correct the possible low blood volume.
Unless the clinical manifestations strongly suggest that the ventricular filling pressure is significantly increased (usually including cardiogenic shock and obvious pulmonary edema), rapid fluid replacement can be performed at the beginning of shock treatment.
Rational use of vasoactive drugs
If proper blood pressure cannot be maintained by actively adjusting the circulating volume, vasoactive drugs, including pressor and/orCardiotonic。
The vasoactive drugs selected are different according to different types of shock.In cardiogenic shock, drugs with β - adrenergic receptor excitatory effect (such as dobutamine) should be selected, while in distributive shock and obstructive shock, drugs with α - receptor excitatory effect (such as norepinephrine, epinephrine or dopamine) or other kinds of vasopressors (such as vasopressin) should be selected.
Correct lactic acid poisoning
The treatment of lactic acidosis associated with shock remains controversial.
The proper treatment of lactic acidosis should be to improve the liver and systemic perfusion, thereby eliminating anaerobic metabolism and promoting the liver to clear accumulated lactic acid.If the above treatment is invalid, when the blood pH value is less than 7.1, sodium bicarbonate can be considered for infusion.
surgical treatment
The disease generally does not require surgical treatment.
Other treatments
Etiological treatment
Although supportive treatment is essential to maintain the life of patients, the key to completely reverse shock is etiological treatment.
Etiological treatment varies according to the type and cause of shock:
When septic shock occurs, it is necessary to actively search for the infectious focus and conduct proper drainage, supplemented by correct antibiotic treatment;
Hemorrhagic shock should be actively stopped and transfused;
Acute myocardial infarction needs vascular reconstruction as far as possible;
Large area pulmonary embolism with obstructive shock needs thrombolytic therapy;
Pericardiocentesis and drainage must be performed during pericardial tamponade.
recovery
The initial treatment of shock should follow the general principles of resuscitation.Since many shock patients are accompanied by trauma and/or disturbance of consciousness, it is necessary to ensure the patient's ventilation status.This may require endotracheal intubation and/or mechanical ventilation.
Pain control
Some patients may need pain relief treatment due to their illness.Analgesic treatment can not only relieve pain, but also reduce the oxygen consumption of the whole body.
prognosis
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The prognosis of shock is mostly good, and most patients can recover completely.Some refractory shock develops to the late stage, causing systemic organ failure and other complications, often leading to death of patients.
complication
The main complication was microcirculation failure.
