Overview
Elderly shock is a syndrome in which the organism suffers from a disorder of neurohumoral factors and acute microcirculatory disorders caused by various pathogenic factors, resulting in insufficient blood perfusion to tissues and organs, cell damage and organ malfunction. Clinical manifestations of shock early patient agitation, unwilling to answer questions or polyglot, later turned to expression of indifference, unresponsive, indicating that the shock has entered the period of loss of compensation, serious confusion and even deep coma. Elderly people often have cerebral arteriosclerosis, poor tolerance of brain tissue to ischemia and hypoxia, pale and cold skin, prolonged skin pressure pallor, decreased blood pressure, increased pulse rate up to 100 times/min or more, very little urine, or even no urine, shallow respiration, respiratory depression and other symptoms.
Etiology
1. Hypovolemic shock
Insufficient blood volume due to severe water loss or massive blood loss, such as bleeding, vomiting, diarrhea, massive burns, bone fracture and so on.
2. Traumatic shock
Shock caused by trauma resulting in massive loss of blood and plasma, coupled with the involvement of central nervous system trauma factors.
3. Infectious shock
Caused by pathogenic microorganisms including bacteria, viruses, rickettsiae, protozoa, fungi and other infections and their metabolites (endotoxin, exotoxin, etc.).
4. Cardiogenic shock
Caused by various cardiovascular diseases resulting in myocardial contractility, cardiac ejection disorders or blood flow disorders in large vessels leading to severe pump failure.
5. Anaphylaxis
Caused by allergen antibody reaction. Cardiogenic shock, infectious shock and hypovolemic shock are more common in the elderly.
Symptoms
1. Mental status
The mental state of the patient often reflects the perfusion status of brain tissue. In the early stage of shock, the patient is agitated, unwilling to answer questions or talk too much, and later turns to have indifferent expression and slow reaction, which indicates that the shock has entered the stage of loss of compensation, and in serious cases, the patient is confused or even in deep coma. Older people often have cerebral arteriosclerosis, the brain tissue to ischemia and hypoxia tolerance is poor, early consciousness disorder can occur, sometimes become the first symptom of shock in the elderly.
2. Skin changes
The color and temperature of the skin often reflect the blood perfusion of the body surface. The small blood vessels of the skin contract to make the skin pale and cold, and the time of skin paleness is prolonged by finger-pressure, and the time of re-filling is slow after pressure (>2s). Sympathetic excitation makes sweat glands hypersecretion, so the performance of the skin wet and cold.
3. Rapid pulse
Often occurs before the drop in blood pressure, is the body’s compensatory response to the decrease in circulation performance. Pulse rate increases up to 100 times/min or more, even if the blood pressure is not low at this time, should still be alert to the occurrence of shock, the pulse becomes weak, reflecting the contraction of small peripheral arteries, peripheral vascular resistance increases, cardiac blood volume drops. The elderly often have sinus node degenerative lesions and functional insufficiency, sometimes even if shock has occurred, but the pulse rate does not increase.
4. Decrease in blood pressure
It is an important indicator for the diagnosis of shock, but in the early stage of shock, due to the body’s compensatory mechanism, sympathetic excitation, so that the peripheral small arteries contract, so that the systolic blood pressure is maintained within the normal range. Peripheral vascular resistance increases, the diastolic blood pressure on the contrary has increased, resulting in a smaller pulse pressure, when the pulse pressure ≤ 20mmHg, it should be considered that shock has occurred. Systolic blood pressure falling to 80mmHg or below is one of the diagnostic conditions for shock. Although the blood pressure of the elderly or patients with pre-existing hypertension is within the normal standard range, it does not negate the existence of shock. At this time should be based on the changes in blood pressure to determine, such as systolic blood pressure decreased by up to 30% of the original, combined with other manifestations should still be judged the existence of shock.
5. Changes in urine output
Urine volume is an indicator reflecting renal blood flow, early mild shock, urine volume can be normal, blood pressure as low as 80/50mmHg, renal blood flow decreases, vascular resistance increases, urine volume begins to decrease, blood pressure to 50/0mmHg, renal blood flow almost stops, urine volume is very small, or even no urine. Later shock due to the occurrence of acute renal insufficiency can also lead to anuria. Increased urine output in elderly shock patients sometimes does not mean that the renal function is good, on the contrary, it may be a manifestation of reduced concentration function.
6. Respiratory changes
Early shock patients often have hyperventilation, which may be the body to ischemia hypoxia compensation performance. In infectious shock, bacterial endotoxin directly affects the respiratory center is another reason. In this case, blood gas analysis results often show respiratory alkalosis. With the development of shock, metabolic acidosis occurs in the body, and the respiratory performance is deep and fast. Elderly people may have respiratory acidosis because they often have emphysema and pulmonary insufficiency, which can make their breathing shallow and respiratory depression.
Examination
1. Hematologic examination
Blood routine, hematocrit, platelet count, prothrombin time and fibrinogen concentration should be measured if there is bleeding tendency or shock has lasted more than 12 hours.
2.Bacteriologic examination
Bacteriologic examination should be carried out according to the condition of patients with infectious shock or other causes of shock combined with infection.
3. Biochemical examination
(1) Lactate concentration measurement reflects the degree of hypoxia in microcirculation disordered tissue cells, and also suggests the severity of acidemia. The normal value is 0.5~1.5mmol/L.
(2) Electrolytes, such as blood K +, Na +, Cl -, Mg2 +, etc. may appear disturbed.
(3) Blood transaminase, lactate dehydrogenase, creatine phosphokinase, urea nitrogen, creatinine and so on.
(4) Blood gas analysis: Shock itself and concomitant or combined cardiopulmonary insufficiency often have hypoxemia and respiratory and metabolic double or triple acid-base imbalance, and blood gas analysis is helpful for accurate diagnosis, guidance of treatment and prognosis judgment.
4. Electrocardiogram and electrocardiogram monitoring
5. Chest X-ray examination
Diagnosis
Based on the history, clinical symptoms and signs, plus blood pressure changes, the diagnosis is not difficult.
Treatment
1. Hypovolemic shock
Loss of blood volume is directly caused by various reasons (e.g. trauma, blood loss, dehydration, etc.), and circulating blood volume decreases abruptly, resulting in lower cardiac output and insufficient perfusion of tissue cells. Rapidly determining the causes of blood loss and dehydration and eliminating them in time prior to treatment, as well as rapidly replenishing the blood volume at an early stage, is the key to treatment.
2.Infectious shock
In addition to hypovolemia and myocardial infarction, infection is the third common cause of shock. Infectious shock can be caused by a variety of pathogenic bacteria and their toxins.
If a localized abscess is found, it should be promptly drained and removed; appropriate antibiotics should be selected. Antibiotics should be applied early and in sufficient quantity, and broad-spectrum antibiotics that are effective against both gram-negative and gram-positive bacteria are usually used first. The first dose should be given intravenously as a shock dose, persist for 3 to 5 days, and change the drug as appropriate when it is ineffective.
Infectious shock, although there is no obvious blood loss, fluid loss, but due to the shock of peripheral vascular diastolic changes, capillary bed volume expansion, capillary permeability increases, as well as cardiac function is inhibited, so that the effective circulating blood volume is reduced and tissue perfusion is insufficient, so the treatment of the first should still be intravenous rehydration, generally the first to give physiological saline or glucose saline drip. If the blood pressure does not rise, low molecular dextrose anhydride can be input, also can consider replenishment of plasma or whole blood, should be replenished within 24 hours 2000 ~ 2500 ml. After replenishment of fluids, such as the performance of the urine volume of > 40 ml / hour, skin elasticity recovery, tongue wet, blood pressure and mental recovery, that is to say, replenishment of fluids initially reached a satisfactory level.
3. Anaphylactic shock
(1) Immediately cut off the allergen.
(2) Immediate use of epinephrine, the drug can make the dilated blood vessel contraction, spasm of smooth muscle diastole, rapid relief of shock symptoms. The dose should be small for the elderly, and the efficacy and possible cardiovascular side effects, such as elevated blood pressure and serious arrhythmia, should be closely observed.
(3) Adrenocorticotropic hormone can inhibit the immune response, reduce vascular permeability, stabilize cell lysosomal membranes and prevent the release of various enzymes.
(4) Relieve bronchospasm: Aminophylline can be used for intravenous infusion.
(5) Supplementary blood volume: use crystal liquid or plasma substitute low molecular dextrose, etc..
(6) Vasoconstrictor drugs: m-hydroxylamine added to glucose solution IV.
(7) Keep the airway open: tracheal intubation and mechanical ventilation if necessary.
(8) Immediately perform cardiopulmonary brain resuscitation in cardiac arrest.