A. Western medical diagnosis of the disease name: shock
Definition: Shock is a clinical syndrome caused by multiple strong pathogenic factors acting on the body, causing acute circulatory failure, and characterized by ischemia and hypoxia of vital organs or impaired utilization of tissue oxygen and nutrients, and progressive development of pathophysiological processes, resulting in inadequate microcirculatory perfusion and cellular metabolic disorders as the main manifestations. Shock belongs to the “syncope” in Chinese medicine, which refers to a type of disease caused by internal trapping of evil toxins, or internal injury to dirty qi, or loss of essence and blood, resulting in the reversal of qi and blood and depletion of positive qi. The clinical manifestations of syncope, syncope and corporeal syncope due to blood loss, asthma, death of yin, death of yang and external evil are similar to those of shock.
Etiology and pathology
1.Western medical etiology: Although different causes of shock have their own characteristics, but all have the common pathological characteristics of a sharp decrease in tissue and organ perfusion and insufficient effective circulating blood volume. And with the heart pump function, blood volume, vascular diastolic function, microcirculatory status and blood rheology and other pathological changes are closely related. When the damaging factors of shock act on the body, a series of compensatory mechanisms are initiated under the stress response of the organism. Catecholamines are released in large quantities, hypothalamus synthesis and release of vasopressin increase, endothelin and thromboxane A2 increase at the same time, causing small blood vessels to contract and peripheral resistance increases, as a way to maintain blood pressure and ensure the perfusion of blood flow to the heart and brain. At the same time, the levels of aldosterone and antidiuretic hormone increase, leading to water and sodium retention to supplement the blood volume deficit. Thus there may be no significant decrease in blood pressure early in shock, or only a transient decrease. Due to the redistribution of blood, the blood perfusion of the heart and brain is maintained, and this period is the compensatory period of shock. If the primary cause and the pathological changes initiated during this period cannot be removed or terminated, the microcirculatory self-regulation mechanism will be lost, and the blood perfusion to the major vital organs will not be sustained, resulting in persistent hypotension, further decrease of effective circulating blood volume, increase of blood viscosity in the microcirculation, slower blood flow, and even “mud” stagnation. Organ dysfunction intensifies.
After shock enters the bruising ischemic phase, the blood is in a hypercoagulable state, and diffuse intravascular coagulation can occur. Subsequently, due to the depletion of coagulation factors, fibrinolytic activity and bleeding, called the microcirculatory failure period, exacerbated the damage to the functional structure of organs, and promote the damage to organ function, and eventually become irreversible shock due to multi-organ failure.
In conclusion, shock is an acute systemic inflammatory syndrome mediated by multiple pathogenic factors, which severely damages the cardiovascular system and leads to a group of syndromes of acute microcirculatory disorders and failure. Microcirculatory disorders are present throughout the pathological process of shock, and the final result is a reduction in microcirculatory blood perfusion to the vital organs of the body, but its recovery is later than the return of blood pressure.
2.TCM etiology and pathogenesis
(1) Internal trapping of evil toxins: external evil toxins, internal trapping, resulting in the disconnection of yin and yang qi, qi reversal, positive qi dissipation, yin exhaustion and yang loss.
(2) internal injury of dirty qi: urgent deficiency of dirty qi, or long-standing illness, or severe pain of trauma, depletion of positive qi, rebellion of qi and blood, all lead to internal injury of the organs. Qi rebellion, Ying and Wei can not, the pulse does not work, lifting and lowering want to rest then gas stand alone dangerous, gas and blood does not pass then in and out of the abolition, and finally lead to the God machine extinguished, there are yin and Yang from the decision of the momentum.
(3) blood loss and loss of fluid: a large amount of blood loss is followed by blood loss; violent vomiting and diarrhea, or sweating and vomiting too much, fluid loss and injury, yang is lost with yin, resulting in the extinction of yin and yang.
Clinical manifestations: Initial irritability and restlessness, indifference and depression in the middle and late stages, unresponsiveness, or blurred consciousness, disorders, coma, but there are also people with clear consciousness. Appearance may show pale or grayish skin of mouth and lips and whole body, cyanosis and cold extremities, or wet and cold body, mucous sweat, superficial vein atrophy, emaciated and painful face, feeling dizzy, thirsty, cold, etc. Skin capillary filling test may appear pale, recovery time is significantly prolonged, pulse is weak, pulse rate is increased. Blood pressure may not fall in early shock, or diastolic blood pressure may be slightly increased, or the pulse pressure difference may be reduced, and in the middle and late stages blood pressure may gradually fall to undetectable. Urine output decreases to no urine. Various changes of MOF can be seen in the late stage.
V. Laboratory tests
1, cardiovascular testing: electrocardiogram, cardiac enzyme profile, D-dimer, observation of acute myocardial infarction, myocardial ischemia, arrhythmia, pulmonary artery embolism, etc.
2.Imaging: bedside chest X-ray, echocardiography and Doppler examination to observe the presence of pneumothorax, pulmonary artery embolism, pericardial tamponade, aortic coarctation aneurysm, acute myocardial infarction, cardiac rupture, valvular insufficiency and pleural effusion, etc.
3. Blood tests: In acute systemic inflammatory response syndrome, total white blood cells and neutrophils are elevated, the nucleus is left-shifted, and there are toxic granules and nuclear degeneration in the white blood cells. Significant decrease in red blood cells and erythrocyte pressure product suggests blood loss, and conversely, if the erythrocyte pressure product of terminal blood is greater than that of central venous blood, it is due to blood concentration with severe dehydration and plasma loss.
4, coagulation function examination: platelets, fibrinogen decreased, international standard ratio (INR), prothrombin time, prothrombin time, partial prothrombin time prolonged, plasma fisetin paraconglutination test positive, and increased serum fibrin degradation products, etc., can indicate DIC.
5, biochemical tests: liver and kidney function, blood gas analysis, electrolytes, osmolality, blood sugar, ketone bodies, lactate and other tests to observe liver, kidney, adrenal function, water and electrolytes, acid-base imbalance and metabolic status.
6.Pathogenetic examination: blood, urine, sputum bacterial culture can be done.
7, other tests: according to the different etiology of shock for specific tests.
8.Central venous pressure (CVP) measurement: it can indicate the lack of effective circulatory volume and the increase of cardiac load or not.
9. Hemodynamic testing: Pulmonary capillary wedge pressure (PCWP), cardiac output (CO) and cardiac index (CI) can be observed to determine the effect of shock on cardiac function and guide treatment.
10. Microcirculation examination: It can indirectly respond to the microcirculation perfusion status of the nail bed at the fingertips through SPO2.
VI. Diagnosis and differential diagnosis
1.Diagnostic points
All types of shock have hypotension, poor microcirculatory perfusion, sympathetic nerve compensatory hyperactivity and other major clinical manifestations, so as the basis for clinical diagnosis.
(1) There is an etiology that induces shock.
(2) Abnormal consciousness.
(3) Fine pulse count, >100 beats/minute or not palpable.
(4) Inadequate perfusion of the peripheral circulation: wet and cold extremities, positive skin acupressure sign at the sternal area (refill time after pressure >2 seconds), skin pattern, pale or cyanotic mucous membranes, etc.; urine output <30 ml/h or urinary closure.
(5) Systolic blood pressure <80mmHg.
(6) Pulse pressure <20mmHg.
(7) In case of pre-existing hypertension, systolic blood pressure decreased by 30% from the original level.
If the above item (1), two of (2) (3) (4) and one of (5) (6) (7) are met, shock can be diagnosed.
2.Differential diagnosis
(1) Differential diagnosis of various types of shock: septic shock has bacterial, viral and other signs of infection and toxin damage to the heart, brain, kidney and other organs. However, electrocardiogram usually does not have the evolution of acute myocardial infarction, blood routine examination often has the total number of white blood cells and neutrophils increased, there are toxic particles appear, blood culture helps to determine the causative agent, horseshoe crab test helps to diagnose endotoxin shock; anaphylaxis has a history of allergen exposure and allergy history, the onset of acute, rapid appearance of laryngeal edema and signs of cardiopulmonary damage; hypovolemic shock has a history of massive blood loss or fluid loss. Hypovolemic shock has a history of massive blood or fluid loss. In hypovolemic shock, there is a history of massive blood loss or fluid loss, with a significant decrease in red blood cell count and hemoglobin; in massive fluid loss, there may be an increase in red blood cell pressure; in neurogenic shock, there is a history of high lumbar anesthesia, a history of brain and spinal cord injury, and there may be corresponding neurological localization signs on physical examination, with a poor prognosis.
(2) Diseases similar to cardiogenic shock Diabetic ketoacidosis, often with a history of diabetes and infections, improper diet and discontinuation of blood glucose control drugs and other triggers, clinical signs such as deep and rapid breathing, ketone odor, increased heart rate, decreased blood pressure, and impaired consciousness. Blood glucose is often >16.7 mmol/L, and blood and urine ketone bodies are strongly positive; acute hemorrhagic necrotizing pancreatitis, mostly with a history of high-fat satiety, hypertriglyceridemia and pancreatitis, can suddenly appear in shock within a few hours of onset. There may be obvious gastrointestinal symptoms and signs of peritoneal irritation, significant increase in serum amylase and lipase, electrocardiogram may show transient Q waves, ST segment abnormalities but myocardial enzymes almost no change.
3, Chinese medicine class evidence to distinguish: syncope and stroke, epilepsy, summer syncope, round syncope, there are similarities, but also differences. Similarities: syncope, stroke, epilepsy, summer syncope all have the symptom of sudden coma, syncope and ascariasis both have the characteristics of hand and foot syncope. Differences: Stroke can be seen in coma with distorted mouth and eyes and hemiplegia, and there are many sequelae after waking up. Epilepsy can be seen as coma with twitching of limbs, salivation at the mouth, or abnormal screams, and after waking up, a normal person. The syncope is manifested as coma with pale face, cold extremities, no distorted mouth and eyes, hand and foot paralysis, no limb twitching and other symptoms. The summer syncope occurs in the summer heat season, mostly seen in people who have been exposed to the hot sun for a long time, or who have been working in a high temperature room, feel the summer heat, heat depression and gas reversal, blocking the qi flow, blocking the clear orifices and suddenly syncope, and see dizziness and headache, chest tightness and body heat, flushed face, or delirium and other symptoms; roundworm syncope is due to roundworms twisted into a mass, blocking the intestine, retrograde into the stomach, stomach gas reversal, drill air and scurry, into the bile duct, resulting in severe pain in the abdomen, pressed with The result is severe pain in the stomach and abdomen, with obstruction in the intestine, and even vomiting of roundworms and cold sweat in the limbs.
VII. Treatment
1. Treatment principles. The main contradiction should be grasped according to different etiologies and comprehensive measures should be taken to correct hemodynamic disorders, control capillary leakage, restore blood perfusion of tissue vessels, improve cell function and metabolism, and protect the function of important organs. The comprehensive measures are basically similar, such as keeping the airway unobstructed, giving oxygen, opening venous channels to replenish blood volume, correcting acidosis, etc. At the same time, we should take targeted treatment according to different causes of shock.
2.Western medical treatment. The basic measures should be immediate hemodynamic and vital signs monitoring, oxygen administration, blood volume replenishment, correction of acidosis. Anti-inflammatory, anti-toxic and vasoactive drugs are applied according to the different nature of shock.
3.Chinese medicine treatment
Septic shock
(1) Pulmonary source of desperate evidence
Symptoms: high fever, coughing and shortness of breath, sore throat and coughing blood, or coughing pink blood, black face, red-red or purple-red tongue, yellow moss, smooth or rapid pulse. Treatment: Cool the blood and detoxify the toxin, clear the luo and nurture yin. Radix: Rhizoma Rhizoma Dihuang Tang combined with Yin Qiao San, plus or minus. Rhinoceros horn, Dihuang, Paeonia lactiflora, Dampi, Jinyinhua, Forsythia, Temperate bamboo leaf, Thornbush, Burdock, Peppermint, Temperate tempeh, Radix Platycodon, Licorice.
(2) Heat syncope from the internal organs
Symptoms: redness of the face and eyes, coldness of the extremities, or even coldness of the whole body, dizziness, lack of bowel movements, red urine, fullness of the chest and abdomen, or even refusal to press, preference for cool drinks, red and vivid tongue, yellow and dry coating, sunken pulse. Treatment: Drain heat from the internal organs and urgently lower the Yin. Remedy: Dacheng Tang plus or minus. Raw rhubarb, mangosteen, citrus aurantium and thick park.
(3) Urgent evidence of all three jiao
Symptoms: great heat, great thirst, fullness and hard pain in the chest, diaphragm and abdomen, constipation, red tongue, golden yellow or scorched coating, slippery pulse. Treatment: Open the lungs and intestines, and resuscitate kidney water. Radicals: Xiao Cheng Qi Tang combined with Xiao Shen Che Tang, plus or minus. Raw rhubarb, Citrus aurantium, thick park, Huanglian, made hemihsia, whole raspberry.
(4) Evidence of Qi-Yin depletion
Symptoms: Heart tremor, strong tongue and dizziness, pinching the air and feeling the bed, red-red and dry tongue, large deficient pulse that wants to disperse. Treatment: Nourish yin essence, astringent sweating and submergence of yang. Treatment: Nourish Yin essence, regulate sweating and submerge Yang.
(5) Cold in three yin evidence
Symptoms: no actual heat in the transmitting channels, i.e. fear of cold, syncope of the limbs, abdominal pain and diarrhea, trembling and no thirst, blue lips and white face, sunken and weak pulse. Treatment: Warming the middle and dispersing cold, returning Yang to save the rebellion. Direction: Warming the middle and dispersing cold, returning Yang to save the rebellion. Ginseng, Radix et Rhizoma ginseng, Radix ginger, Glycyrrhiza glabra. Ginseng and Fructus injection or ginseng and wheat injection or diluted intravenous drip can be applied.
Cardiogenic shock
(1) Evidence of Yang Qi wanting to escape
Symptoms: Violent cold rides on the heart, severe pain without sound, the extremities convulsion, depression and dizziness, cold sweat like oil, pale face, fear of cold and curled up, blue lips and nails, pale tongue with white fur, and weak pulse to die. Treatment: Support Yang to save rebellion and benefit Qi to consolidate detachment. Radicals: Hui Yang Rescue Tang with addition and reduction. Citrus aurantium, Hou Pei. Can be applied to ginseng and sorbit injection or ginseng and wheat injection or astragalus injection after dilution and intravenous drip.
(2) Evidence of deficiency of organs and yin exhaustion
Symptoms: faintness and irritability, body heat and dry mouth, chest pain like burning, sweating profusely, yellow urine, thirst for cold drinks, red, vivid and dry tongue, deficient pulse. Treatment: To astringent Yin and save fluid, and to urgently consolidate the true essence. Direction: To astringent the yin and save the fluid, and urgently consolidate the true essence. Ginseng, maitong, wu wei zi. It can be applied to raw pulse injection or ginseng and wheat injection after dilution and intravenous drip.
(3) Blood stasis and Qi loss
Symptoms: chest pain through the back, blue and purple extremities, panic, cool sweat, panting and breath, purple and dark tongue, petechiae, and knotted pulse. Treatment: To resolve blood stasis and clear the ligaments, and tonify Qi to fix the detachment. Blood Mansion and Blood Stasis Soup with Addition and Reduction. Radix Angelicae Sinensis, Radix et Rhizoma Dioscoreae, Peach kernel, Safflower, Glycyrrhiza glabra, Citrus aurantium, Radix Paeoniae Alba, Radix et Rhizoma Chai Hu, Rhizoma Ligustici Chuanxiong, Radix Platycodon grandiflorum, Radix Achyranthes spp. It can be diluted with Blood Seton injection or Langshangtuan or Danshen injection and injected intravenously.
(4) Evidence of yin exhaustion and yang detachment
Symptoms: Eyes closed and mouth open, sweating like oil, faintness of mind and limbs, snoring and breath, hands spreading and lips green, tongue curled and not moving, two stools left behind, pulse sunken and weak. Treatment: Urgently consolidate the vital yang and quickly converge the true yin. Radicals: Ginseng and Radix-Arhizoma combined with Si Wei Tang, plus or minus. Ginseng, Radix et Rhizoma, Radix ginger, Glycyrrhiza glabra. Or use Doshen Tang to take an urgent decoction. Ginseng and Radix injection or ginseng and wheat injection or astragalus injection can be applied after dilution and intravenous drip.
VIII. Prognosis
Depends on the following factors.
1.Response to treatment If the patient is conscious and quiet after treatment, the limbs are warm, cyanosis disappears, urine output increases, blood pressure regains and pulse pressure widens, the prognosis is good.
2. the prognosis is better if the primary foci of infection can be completely cleared or controlled
3, the prognosis of those with severe acidosis and hyperlactatemia is poor, and the death rate of those with DIC or multi-organ failure is also high.
4, there are serious primary underlying diseases, such as leukemia, lymphoma or other malignant tumors, shock is difficult to reverse the prognosis of other diseases, such as diabetes, liver stiffness, heart disease, etc..
Nine, Chinese medical care: after the consciousness to maintain emotional stability, avoid mental tension, diet should be light.