Collapse is an acutely developing vascular insufficiency, accompanied by a decrease in the tone of the bloodstream and a relative decrease in CBV. It is manifested by a sharp deterioration of the condition, dizziness, tachycardia, hypotension. In severe cases, loss of consciousness is possible. It is diagnosed on the basis of clinical data and the results of tonometry. Specific treatment includes cordiamine or caffeine under the skin, infusions of crystalloids, a supine position with a raised leg end. After the restoration of consciousness, hospitalization is indicated for differential diagnosis and determination of the causes of the pathological condition.
ICD 10
R55 Fainting [syncope] and collapse
General information
A collaptoid condition (vascular insufficiency) is a pathology that suddenly occurs against the background of the presence of chronic or acute diseases of the cardiovascular system, other diseases. It is more often diagnosed in patients prone to hypotension, with myocardial infarction, total blockade of intracardiac conduction, ventricular arrhythmias. The pathogenesis and clinical signs resemble shock. It differs from it in the absence of characteristic pathophysiological phenomena at the initial stages – pH changes, significant deterioration of tissue perfusion and disruption of internal organs are not detected. The duration of the collapse usually does not exceed 1 hour, the shock state may persist for a longer period of time.
Causes
Regulation of vascular tone is carried out using three mechanisms: local, humoral and nervous. The nervous mechanism consists in stimulating the vessel wall with fibers of the sympathetic and parasympathetic nervous system. The humoral method is implemented due to sodium and calcium ions, vasopressor hormones (adrenaline, vasopressin, aldosterone). Local regulation presupposes the appearance of foci of ectopia directly in the vascular wall, the cells of which have the ability to generate their own electrical impulses. The circulatory network of skeletal muscles is regulated mainly in a nervous way, therefore, any conditions in which the activity of the vasomotor center of the brain is suppressed can become the causes of collapse. The main etiofactors are:
- Infectious processes. Severe infections accompanied by severe intoxication lead to the development of vascular insufficiency. Most often, collapse occurs with croup pneumonia, sepsis, peritonitis, meningitis and meningoencephalitis, typhoid fever, focal inflammatory diseases of the central nervous system (brain abscess).
- Exogenous intoxication. Pathology is detected by poisoning with organophosphorus compounds, carbon monoxide, drugs that can affect vascular tone (clofelin, kapoten, ebrantil). In addition, collapse can develop under the influence of drugs for local anesthesia with their epidural or peridural administration.
- Heart diseases. The most common cause is acute myocardial infarction. Collaptoid conditions can also be detected against the background of heart malformations, decreased myocardial contractility, tachyarrhythmia or bradiarrhythmia, dysfunction of the sinus-atrial node (rhythm driver), atrioventricular junction failures (AV block of the 3rd degree) with discoordination of the atria and ventricles.
- Injuries. The main cause of vascular insufficiency in injuries is a large amount of blood loss. At the same time, there is not a relative, but an actual decrease in CBV due to the physical loss of fluid. In the absence of profuse hemorrhage, a drop in vascular tone becomes a reaction to severe pain, which is more common in children and patients with high tactile sensitivity.
Pathogenesis
The pathogenesis of collaptoid conditions is based on a pronounced discrepancy between the capacity of the vascular network and the CBV. Dilated arteries do not create the necessary resistance, which leads to a sharp decrease in blood pressure. The phenomenon can occur with a toxic lesion of the vasomotor center, disruption of the receptor apparatus of large arteries and veins, the inability of the heart to provide the necessary volume of blood release, insufficient amount of fluid in the circulatory system. A drop in blood pressure leads to a weakening of perfusion of gases in tissues, insufficient oxygen supply to cells, ischemia of the brain and internal organs due to the discrepancy between the metabolic needs of the body and the level of its supply of O2.
Classification
The separation is carried out according to the etiological principle. There are 14 types of collapse: infectious-toxic, pancreatic, cardiogenic, hemorrhagic, etc. Since the same first aid measures are carried out for all types of pathology, such a classification has no significant practical significance. Systematization by stages of development is more relevant:
- Sympathotonic stage. Compensatory reactions are expressed. There is a spasm of small capillaries, centralization of blood circulation, release of catecholamines. Blood pressure is kept normal or rises slightly. The duration does not exceed several minutes, so pathology is rarely diagnosed at this stage.
- Vagotonic stage. Partial decompensation occurs, expansion of arterioles and arteriovenous anastomoses is detected. Blood is deposited in the capillary bed. There are signs of hypotension, the blood supply to skeletal muscles worsens. The duration of the period is 5-15 minutes, depending on the compensatory capabilities of the body.
- Paralytic stage. Complete decompensation of the condition associated with depletion of the mechanisms of regulation of blood circulation. There is a passive expansion of capillaries, visible signs of vascular stagnation on the skin, depression of consciousness. Hypoxia of the organs of the central nervous system develops. In the absence of help, cardiac arrhythmia and death may occur.
Symptoms
The clinical picture that develops in acute vascular insufficiency changes as the disease progresses. The sympathotonic stage is characterized by psychomotor agitation, anxiety, increased muscle tone. The patient is active, but is not fully aware of his actions, cannot sit or lie still even at the request of the medical staff, rushes in bed. The skin is pale or marbled, the limbs are cold, there is an increase in heart rate.
At the vagotonic stage, the patient is inhibited. He answers questions slowly, in monosyllables, does not understand the essence of the speech addressed to him. Muscle tone decreases, motor activity disappears. The skin is pale or gray-cyanotic, earlobes, lips, mucous membranes acquire a bluish hue. Blood pressure decreases moderately, bradycardia or tachycardia occurs. The pulse is poorly detected, has insufficient filling and tension. Glomerular filtration decreases, which causes oliguria. Breathing is noisy, rapid. Nausea, dizziness, vomiting, pronounced weakness are added.
With paralytic collapse, loss of consciousness occurs, skin (plantar, abdominal) and bulbar (palatal, swallowing) reflexes disappear. The skin is covered with blue-purple spots, which indicates capillary stagnation. Breathing is rare, periodic in the Cheyne-Stokes type. Heart rate slows down to 40-50 beats per minute or less. Pulse is thready, blood pressure drops to critical figures. The early stages are sometimes stopped without medical intervention, due to compensatory and adaptive reactions. At the final stage of pathology, there is no independent reduction of symptoms.
Complications
The main danger in collapse is considered to be a violation of blood flow in the brain with the development of ischemia. With a prolonged course of the disease, this becomes the cause of dementia, a violation of the function of internal organs innervated by the central nervous system. When vomiting against the background of unconsciousness or constipation, there is a risk of inhaling gastric contents. Hydrochloric acid in the respiratory tract causes a burn of the trachea, bronchi, lungs. Aspiration pneumonia occurs, which is difficult to treat. The lack of immediate help at the third stage leads to the formation of pronounced metabolic disorders, disruption of the receptor systems and death of the patient. A complication of successful resuscitation in such cases is post-resuscitation disease.
Diagnostics
The diagnosis of collapse is carried out by a medical worker who was the first on the scene: in the ICU – an anesthesiologist- resuscitator, in a therapeutic hospital – a therapist (cardiologist, gastroenterologist, nephrologist, etc.), in the surgical department – a surgeon. If the pathology has developed outside the medical facility, a preliminary diagnosis is made by the ambulance team according to the examination data. Additional methods are prescribed in a medical institution for the purpose of differential diagnosis. Collapse is distinguished from coma of any etiology, fainting, shock. The following techniques are used:
- Physical. The doctor detects clinical signs of hypotension, absence or depression of consciousness, persisting for 2-5 minutes or more. A shorter period of unconsciousness with its subsequent recovery is characteristic of fainting. According to the results of blood pressure tonometry below 90/50. There are no signs of head trauma, including focal symptoms.
- Hardware. It is performed after hemodynamic stabilization to determine the causes of collapse. brain CT (tumors, focal inflammatory processes), CT of the abdominal cavity (pancreatitis, cholelithiasis, mechanical damage) are shown. In the presence of coronary pains, ultrasound of the heart is performed (expansion of chambers, congenital malformations), electrocardiography (signs of ischemia, myocardial infarction). The suspicion of vascular disorders is confirmed with the help of color Doppler mapping, which allows to determine the degree of patency of arteries and venous vessels.
- Laboratory. During a laboratory examination, the blood sugar level is determined to exclude hypo- or hyperglycemia. A decrease in the concentration of hemoglobin is detected. Inflammatory processes lead to an increase in ESR, pronounced leukocytosis, and sometimes an increase in the concentration of C–reactive protein. With prolonged hypotension, it is possible to shift the hydrogen index to the acidic side, a decrease in the concentration of electrolytes in plasma.
Emergency care
The patient in a state of collapse is placed on a horizontal surface with slightly raised legs. When vomiting, the head is turned so that the discharge flows freely outwards, and does not enter the respiratory tract. URT is cleaned with two fingers wrapped with a gauze swab or a clean cloth napkin. The list of further therapeutic measures depends on the stage of collapse:
- The stage of sympathotonia. Procedures aimed at relieving vascular spasm are shown. Papaverine, dibazole, and no-shpu are injected intramuscularly. Steroid hormones (dexamethasone, prednisone) are used to prevent hypotension and stabilize hemodynamics. It is recommended to install a peripheral venous catheter, monitor blood pressure and the general condition of the patient.
- Vagotonia and the paralytic stage. To restore the CBV, infusions of crystalloid solutions are carried out, to which, if necessary, cardiotonic agents are added. To prevent aspiration of gastric contents at the prehospital stage, an air duct or a laryngeal mask is installed for the patient. Glucocorticosteroids are administered once at a dose appropriate to the patient’s age, cordiamine, caffeine. Pathological breathing is an indication for the transfer to a ventilator.
Hospitalization is carried out in the intensive care unit of the nearest specialized medical facility. In the hospital, medical measures are continuing, an examination is prescribed, during which the causes of pathology are determined. It provides support for vital functions of the body: respiration, cardiac activity, kidney function. Therapy is carried out aimed at eliminating the causes of a collaptoid attack.
Prognosis and prevention
Since pathology develops during decompensation of severe diseases, the prognosis is often unfavorable. Vascular insufficiency itself is relatively easy to stop, however, if its root cause persists, seizures occur again. An uncoupling collapse leads to the death of the patient. Prevention consists in the timely treatment of pathologies that can lead to a sharp drop in vascular tone. Well-chosen therapy of heart diseases, timely administration of antibiotics for bacterial infections, complete detoxification for poisoning and hemostasis for injuries can prevent collapse in 90% of cases.