Terminal illness are pathologies that are characterized by a critical level of impairment of vital activity, gross changes in gas exchange, hemodynamics and metabolism. The process is irreversible without resuscitation. The main clinical manifestations are centralization of blood flow, a pathological type of breathing, a decrease in blood pressure up to undetectable, depression or complete loss of consciousness, pallor and marbling of the skin, cold sweat, cardiac arrhythmia. They are diagnosed according to the available clinical picture during a physical examination. Specific treatment — resuscitation measures, which consist in ventilating, infusion of cardiotonic drugs, glucocorticosteroids, colloidal and crystalloid infusion solutions.
R57 Shock, not classified elsewhere
Terminal illness (TI) are the initial stage of dying. They arise as the finale of life in old age, the outcome of an incurable disease, the result of an accident. It is more often detected in patients of intensive care units and intensive care units. The rate of development increases in direct proportion to the stage. Death occurs most quickly in weakened patients, with fever and accelerated metabolism. The main pathogenetic factor is progressive hypoxia, which is accompanied by the transition of metabolic processes to anaerobic glycolysis. Compensatory systems are activated, which causes the depletion of internal reserves. The duration of the states varies from a few minutes to 1-2 days.
There are many factors of vehicle development. These include all types of diseases that lead to the death of the patient, as well as natural age-related changes. A deep pathogenetic factor is considered to be a critical decrease in blood perfusion, oxygen starvation, violation of metabolic processes, accumulation of pathological metabolic products in the body. Terminal illness occur in the following cases:
- Old age. Over the years, the human body undergoes destructive changes. Natural death, preceded by a short period of dying, occurs at the age of 80-100 years against the background of senile degradation of the myocardium, weakening of the functional ability of the heart, cachexia and dehydration. Such processes are considered normal, resuscitation is extremely rare.
- Severe somatic diseases. About 80% of cardiac arrest cases are caused by diffuse coronary artery disease, malignant ventricular tachyarrhythmias, ventricular fibrillation and other cardiological pathology. Heart diseases can develop independently or have a secondary nature. In addition, terminal illness are the result of oncological processes, multiple organ failure, generalized infections and ACVA.
- Traumatic injuries. Critical disorders of vital activity occur when the central nervous system (brain and spinal cord), lungs and abdominal organs are affected. With combined injuries, they can develop in the first minutes. Limited damage leads to a vehicle after a certain period of time, more often 3-4 days. This is due to the development of wound infection, depletion of compensatory mechanisms, dehydration (burns), necrosis. Hemorrhagic shock, which is formed with a large volume of blood loss and a sharp decrease in CBV, is considered separately.
- Mechanical asphyxia. Occurs in drowning, strangulation, strangulation, obstruction of the respiratory tract by foreign bodies. Asphyxia is more common among children of preschool and primary school age. It is relatively easy to stop when the pathogenetic factor is eliminated. In some cases, it does not require resuscitation. The condition stabilizes after the restoration of normal gas exchange in the lungs.
- Congenital nonviability. It occurs among premature infants born at the gestation period of 5-7 months. It is caused by the immaturity of the internal systems of the body, the inability of the child to exist outside the uterus. The survival rate among such children is low. It is necessary to be placed in a cuvez, providing complex and long-term resuscitation measures.
Terminal illness are formed at the moment of transformation of pathogenesis into thanatogenesis. This happens against the background of depletion of protective resources, after which reactions aimed at maintaining vital activity acquire a killing character. Hyperventilation, characteristic of many pathological processes, leads to respiratory alkalosis and deterioration of cerebral blood flow. Centralization of blood circulation causes changes in the rheological properties of blood, reducing its total volume.
Reactions of the hemostatic type are transformed into disseminated intravascular coagulation, in which there is increased thrombosis, followed by bleeding. The functional capacity of organs is reduced, decompensation of acid-base and electrolyte balance is revealed, inactivation of enzyme systems is observed. Energy production decreases, there is a violation of the transmission of nerve impulses in synapses, a disorder of innervation of all body systems, which ends in cardiac arrest.
Critical situations are classified depending on the type of changes present, the depth of damage to vital body systems, and the expected chances of saving the patient. The division is conditional, since the transformations occurring are similar in most thanatogenic processes. There are seven main types of vehicles:
- Shock of the IV degree. It occurs against the background of circulatory dysfunction, is manifested by a sharp deterioration in tissue perfusion, proceeds with the involvement of several organs and systems. One of the main signs is the centralization of vascular activity. It develops with acute blood loss, cardiac catastrophes, thyrotoxic crisis, adrenogenital syndrome, dehydration, intoxication of various origins, generalized infectious processes and allergic reactions.
- Terminal coma. There are multiple disorders in the body, there is a profound depression of the central nervous system, brain stem structures. Usually, multiple organ failure is detected. Without artificial life support, clinical death occurs very quickly, and then biological death.
- Collapse. One of the varieties of coronary insufficiency. It is manifested by a sharp decrease in vascular tone, a decline in the peripheral blood network, a decrease in the volume of circulating blood and cardiac output. In the absence of help, it quickly leads to hypoxia of the brain, depression of most functions of the human body, bradycardia. It can occur with acute infections, intoxication, insulin overdose, hypotensive agents and ganglioblockers, abdominal and heart diseases. Non—canceling collapse is the cause of circulatory arrest.
- Preagonal state. It is characterized by a rapid and steady increase in pathological changes: a decrease in perfusion, a weakening of breathing, depression of consciousness. The duration of the period depends on the cause that caused it. With blood loss, the bill goes for hours, with incurable chronic diseases — for a day. In case of death from electric shock or injuries incompatible with life (head crushing, volumetric damage to the heart), it is not observed.
- Terminal pause. It is a breath retention that can last from 2 to 4 minutes. During it, the patient has a sharp bradycardia or reversible asystole, undetectable blood pressure, areflexia and adynamia. It may be mistaken for the onset of clinical death.
- Agony. The last outbreak of vital activity of the body. There is a short-term recovery of coronary activity and respiration, a slight increase in blood pressure, enlightenment of consciousness for a few minutes. It is not considered a sign of improvement, without resuscitation, it always ends with the death of the patient. It is possible to stop such phenomena only if they were provoked by an avoidable factor. Agonal episodes in chronic patients are practically not amenable to correction.
- Clinical death. It is considered a transitional period between life and death. It is reversible with the timely start of recovery measures. It is accompanied by respiratory and circulatory arrest, lack of consciousness, pulse in the peripheral and central arteries. It proceeds for 3-5 minutes, after which the changes in the central nervous system become irreversible. With deep hypothermia, it is possible to restore vital activity in 30-40 minutes.
All conditions of this group manifest a similar clinical picture. The patient has hypotension, tachycardia, as the pathology deepens, turning into bradycardia, signs of centralization of blood circulation: pallor, grayness or cyanosis of the skin, the appearance of stagnant spots. At the initial stage, reflexes may persist. Increased convulsive readiness is revealed. Breathing is rapid and deepened, with the inclusion of the neck, shoulder girdle, bottom of the oral cavity, anterior abdominal wall and intercostal muscles in the process. Exhalation is active.
As the process progresses, depression of the respiratory center develops. Respiratory movements slow down, are reduced. The breaths are shallow, rare, insufficient for a full exchange of gases in the lungs. In case of shocks and terminal coma, hemodynamics is maintained with the help of cardiotonics. Independent life activity is impossible. Consciousness, as a rule, is absent. Normal reflexes gradually fade away, replaced by pathological ones. During the period of agony, the pulse and blood pressure at the periphery are not determined. Palpation-detectable cardiac arrhythmias are detected. When clinical death occurs, breathing, consciousness and blood circulation are absent. Tissue and cellular metabolism are partially preserved. Reflexes of any type, there is no reaction to pain.
The conclusion about the need for rescue measures is made on the basis of the clinical picture. Attending physician — resuscitator-anesthesiologist. The consultation of a cardiologist and specialists involved in the therapy of the underlying disease that provoked the deterioration is shown. The data obtained during the physical examination is sufficient to establish the type and severity of the pathology. To clarify the depth of changes and determine the tactics of further management of the patient, hardware and laboratory methods of examination can be used:
- Physical methods. During the examination, the patient’s respiratory rate is revealed to be >36 or < 8 per minute, heart rate >130-140 or < 40 beats. The systolic blood pressure level is less than 80 mmHg, SpO2<90%. The heart tones are muted, the rhythm is uneven. Korotkov’s tones may not be heard when measuring blood pressure by a mechanical device.
- Laboratory methods. The greatest diagnostic value is the study of blood for ABB, the content of gases and electrolytes. There is a decrease in pH below 7.35, and more often 7.29, the level of peripheral pO2 < 10 mm, central (in the blood flowing from the brain) — < 10-12 mm Hg. column. The pCO2 index exceeds 50 mmHg.
- Hardware methods. The main method of hardware examination is the use of an anesthesiological monitor. The device allows you to monitor vital signs online: blood pressure, saturation, heart rate, breathing. If necessary, direct measurement of blood pressure using an intraarterial catheter (invasive tonometry) is practiced. To determine the causes that provoked terminal illness, computed tomography, laparoscopy, radiography, scintigraphy, etc. are used. The choice of method depends on the main diagnosis.
Treatment is carried out using a number of medical and hardware techniques. To replenish the CBV, an infusion of 400-800 ml of colloidal solutions, including reopoliglyukin and volute, is indicated. Hemodynamic stabilization is achieved by long-term continuous administration of vasopressors: dopamine, norepinephrine. To stop the pathological clotting, heparin is recommended. Suppression of inadequate immune responses is carried out at the expense of hormonal agents.
To enhance the effect of medications, calcium chloride or gluconate is used. Restoration of neuromuscular conduction is performed with the help of proserin. Correction of acid-base balance requires infusion of sodium bicarbonate at a dose of 200-400 mg. The restoration of the salt balance is carried out using solutions of trisol, acesol, disol. Intravenous administration of diuretics is indicated for the elimination of toxic metabolites. With convulsions – muscle relaxants of curare-like action, benzodiazepines.
Hardware support consists in carrying out artificial ventilation of the lungs. Modern technology makes it possible to adjust the ratio of gases in such a way as to avoid the development of respiratory acidosis, providing adequate oxygenation. For the delivery of pressor amines, injectomats are used — devices that allow for several hours or days to inject a strictly dosed amount of the drug. Intracardiac conduction blockages may require the installation of a pacemaker. In order to relieve the effects of hypoxia at the stage of recovery, hyperbaric oxygenation is prescribed.
Prognosis and prevention
Terminal illness have an unfavorable prognosis. Up to 75-80% of patients die. In the absence of specialized care, mortality reaches 100%. To prevent such situations, careful monitoring of the condition of patients in intensive care units, daily laboratory blood testing, monitoring of the function of external respiration and cardiac activity is necessary. All existing deviations should be corrected at an early stage. Diseases potentially capable of leading to terminal illness are subject to control. The patient must undergo regular examination, monitor his health, follow the doctor’s recommendations.