Collapse – sharply developing vascular insufficiency which is followed by decrease in a tone of the blood course and relative reduction of OTsK. It is shown by sharp deterioration in a state, dizziness, tachycardia, hypotonia. In hard cases consciousness loss is possible. It is diagnosed on the basis of clinical yielded and results of a tonometriya on Korotkov's method. Specific treatment includes or caffeine under skin, infusions of crystallites, lying situation with the raised foot end. After restoration of consciousness hospitalization for performing differential diagnostics and definition of the reasons of a pathological state is shown.
Kollaptoidny state (vascular insufficiency) – pathology which suddenly arises against the background of existence of chronic or sharp diseases of cardiovascular system, other diseases. It is more often diagnosed for the patients inclined to hypotonia, at a myocardial infarction, total blockade of intracardial conductivity, ventricular arrhythmias. On pathogenesis and clinical signs reminds shock. Differs from it in lack of the characteristic pathophysiological phenomena at initial stages – changes of pH, considerable deterioration in fabric perfusion and violation of work of internals do not come to light. Collapse duration usually does not exceed 1 hour, a state of shock can remain during longer period.
Regulation of a vascular tone is carried out by means of three mechanisms: local, humoral and nervous. The nervous mechanism consists in stimulation of a wall of a vessel fibers of sympathetic and parasympathetic nervous system. The humoral way is implemented at the expense of ions of sodium and calcium, vazopressorny hormones (adrenaline, antidiuretic hormone, an aldosteron). Local regulation assumes emergence of the centers of an ektopiya directly in a vascular wall which cages have ability to generation of own electric impulses. The blood network of skeletal muscles is regulated in mainly nervous way therefore any states at which activity of the sosudodvigatelny center of a brain is suppressed can become the reasons of a collapse. The main etiofaktor are:
- Infectious processes. Lead the heavy infections which are followed by the expressed intoxication to development of vascular insufficiency. Most often the collapse arises at krupozny pneumonia, sepsis, peritonitis, meningitis and an encephalomeningitis, a typhoid, focal inflammatory diseases of TsNS (brain abscess).
- Exogenous intoxications. Pathology comes to light at poisoning with the fosfororganichesky connections, carbon monoxide, medicines capable to influence a vascular tone (clonidine, kapoteny, ebrantily). Besides, the collapse can develop under the influence of medicines for local anesthesia at their epiduralny or peridural introduction.
- Heart diseases. The sharp myocardial infarction is the most common cause. Kollaptoidny states can be also found against the background of malformations of heart, decrease in sokratitelny ability of a myocardium, takhi-or bradiaritmiya, malfunction sinus knot (the driver of a rhythm), refusals of atrioventricular connection (AV-blockade 3 degrees) from diskoordinatsiy work of auricles and ventricles.
- Injuries. The main reason for vascular insufficiency at injuries – the large volume of blood loss. At the same time not relative, but the actual reduction of OTsK due to physical loss of liquid is observed. In the absence of a profuzny gemorragiya falling of a vascular tone becomes reaction to severe pain that meets at children and patients with high tactile sensitivity more often.
The expressed discrepancy of capacity of vascular network and OTsK is the cornerstone of pathogenesis of kollaptoidny states. The extended arteries do not create necessary resistance that HELL leads to sharp decrease. The phenomenon can arise at toxic defeat of the sosudodvigatelny center, violation of operation of the receptor device of large arteries and veins, inability of heart to provide the necessary volume of emission of blood, insufficient amount of liquid in blood system. Falling of arterial pressure leads to weakening of perfusion of gases in fabrics, to insufficient intake of oxygen in cages, ischemia of a brain and internals because of discrepancy of metabolic requirements of a body and level of its supply O2.
Division is made by the etiologichesky principle. There are 14 kinds of a collapse: infectious and toxic, pancreatic, cardiogenic, hemorrhagic and so forth. As at all types of pathology the same events of first aid are held, similar classification has no essential practical value. Systematization on development stages is more urgent:
- Simpatotonichesky stage. Compensatory reactions are expressed. The spasm of small capillaries, blood circulation centralization, emission of catecholamines is observed. Arterial pressure keeps normal or slightly rises. Duration does not exceed several minutes therefore pathology is seldom diagnosed in this stage.
- Vagotonichesky stage. There is a partial decompensation, expansion and arteriovenozny anastomoz comes to light. Blood is deposited in the capillary course. There are symptoms of hypotonia, blood supply of skeletal muscles worsens. Duration of the period makes 5-15 minutes depending on compensatory opportunities of an organism.
- Paralytic stage. The full decompensation of a state connected with exhaustion of mechanisms of regulation of blood circulation. Passive expansion of capillaries, visible signs of vascular stagnation on skin, consciousness oppression is noted. The hypoxia of bodies of the central nervous system develops. In the absence of the help violation of a warm rhythm and a lethal outcome is possible.
The clinical picture developing at sharp vascular insufficiency changes in process of progressing of a disease. The Simpatotonichesky stage is characterized by psychomotor excitement, concern, increase in a muscular tone. The patient is active, but not completely realizes the actions, cannot quietly sit or lie even at the request of medical staff, rushes about in a bed. Integuments pale or marble, extremities cold, increase in heart rate is noted.
At a vagotonichesky stage of the patient it is slowed down. Answers questions slowly, in monosyllables, does not understand an essence of the speech turned to it. The muscular tone decreases, physical activity disappears. Skin pale or gray , lobes of ears, lips, mucous membranes get a bluish shade. HELL moderately decreases, there is bradycardia or tachycardia. Pulse is defined poorly, has insufficient filling and tension. The glomerular filtration decreases that becomes the oliguriya reason. Breath is noisy, speeded up. Nausea, dizziness, vomiting, the expressed weakness joins.
At a paralytic collapse there is a consciousness loss, reflexes disappear skin (plantar, belly) and bulbarny (palatal, glotatelny). Skin is covered with blue-crimson spots that testifies to capillary stagnation. Breath is rare, periodic as Cheyna-Stokes. ChSS is slowed down to 40-50 beats per minute and less. Pulse is threadlike, HELL falls to critical figures. Early stages are sometimes stopped without medical intervention, due to compensatory and adaptive reactions. At a final stage of pathology the independent reduction of symptomatology is not observed.
The main danger at a collapse violation of a blood-groove in a brain with development of ischemia is considered. At a long course of disease it becomes the reason of dementia, dysfunction of the internals innervated by the central nervous system. At vomiting against the background of unconsciousness or a sopor there is a risk of inhalation of gastric contents. Hydrochloric acid in airways causes a burn of a trachea, bronchial tubes, lungs. There is aspiration pneumonia which is badly giving in to treatment. Lack of the immediate help at the third stage leads to formation of the expressed metabolic violations, disorder of work of receptor systems and death of the patient. A complication of successful resuscitation in such cases is the post-resuscitation disease.
Diagnosis of a collapse is performed by the health worker who appeared the first on the scene: in ORIT – the doctor the intensivist, in a therapeutic hospital – the therapist (the cardiologist, the gastroenterologist, the nephrologist, etc.), in surgical office – the surgeon. If pathology developed out of MPI, the preliminary diagnosis is exposed by crew of emergency medical service according to survey. Additional methods are appointed in medical institution for the purpose of differential diagnostics. The collapse is distinguished from a coma of any etiology, a faint, shock. Use the following techniques:
- Fizikalnoye. The doctor finds the clinical symptoms of hypotonia, absence or oppression of consciousness remaining within 2-5 and more minutes. Smaller time of unconsciousness with its subsequent restoration is characteristic of a faint. By results of a tonometriya HELL lower than 90/50. Symptoms of an injury of the head, including focal symptomatology, no.
- Hardware. It is made after stabilization of haemo dynamics for definition of the reasons of a collapse. Carrying out KT of the head (a tumor, focal inflammatory processes) is shown, to KT of an abdominal cavity (pancreatitis, cholelithiasis, mechanical damages). In the presence of coronary pains ultrasonography of heart (expansion of cameras, congenital defects), an electrocardiography (symptoms of ischemia, myocardial infarction) is carried out. Suspicion of vascular disorders is confirmed by means of the color Doppler mapping allowing to establish degree of passability of arteries and venous vessels.
- Laboratory. During laboratory inspection determine sugar level in blood for an exception hypo - or a hyperglycemia. Decrease in concentration of hemoglobin is found. Inflammatory processes lead to the increase in SOE expressed to a leykotsitoz, sometimes – to increase in concentration of C-jet protein. At long hypotonia the shift of a hydrogen indicator in the sour party, decrease in concentration of electrolytes in plasma is possible.
Treatment of a collapse
The patient in a condition of a collapse is stacked on a horizontal surface with slightly raised legs. At vomiting the head is turned so that separated freely flew down outside, but did not get into airways. VDP clear two fingers which are wrapped up by a gauze tampon or a pure fabric napkin. The list of further therapeutic actions depends on a collapse stage:
- Simpatotoniya stage. The procedures directed to knocking over of a vascular spasm are shown. Intramuscularly enter a papaverine, , but-shpu. For prevention of hypotonia and stabilization of haemo dynamics use steroid hormones (dexamethasone, Prednisolonum). Statement of a peripheral venous catheter, control of arterial pressure and the general condition of the patient is recommended.
- Vagotoniya and paralytic stage. For restoration of OTsK carry out infusions of kristalloidny solutions to which if necessary add cardiotonic means. For prevention of aspiration of gastric contents at a pre-hospital stage establish to the patient an air duct or a laringealny mask. Once enter glucocorticosteroids in the dose corresponding to age of the patient, , caffeine. Pathological breath is the indication for transfer to IVL.
Hospitalization is performed in intensive care unit of the nearest profile MPI. In a hospital medical actions continue, inspection during which the pathology reasons are defined is appointed. Support of the vital functions of an organism is provided: breath, warm activity, work of kidneys. The therapy directed to elimination of the reasons of a kollaptoidny attack is carried out.
Forecast and prevention
As pathology develops at a decompensation of a serious illness, the forecast often adverse. Directly vascular insufficiency is rather easily stopped, however at preservation of its prime cause attacks arise again. Not stopped collapse leads of the patient to death. Prevention consists in timely treatment of the pathologies capable to lead to sharp falling of a vascular tone. Competently picked up therapy of cardiac diseases, timely prescription of antibiotics at bacterial infections, a full-fledged detoxication at poisonings and a hemostasis at injuries allow to prevent a collapse in 90% of cases.