I r i n e u T a d e u V e l a s c o *
C lin ic a i a n d th e ra p e u tic a sp e c ts o f th e sta te o f sh o c k
S
h o c k is s e e n a s a s e q u e n c e o f e v e n ts in itia te d b y a n a g g r e s s iv e f a c to r ( h y p o v o lu m e tr ic tr a u ln a , b u r n s , s e p s is ) f o llo w e d b y a e n d o c r in e r e s p o n s e ( r e le a s e o f A C T H , a d r e n a lin e , v a s o p r e s s in ) a n d a f a ilu r e in th e m a in te n a n c e ln e c h a n is m o f h o m e o s ta s is a t th e h e m o d y n a ln ic le v e I , w ith a d e c r e a s e in e f f e c tiv e tis s u e p e r f u s io n . T h is le a d s to c e llu la r is c h e m ia a n d to th e r e le a s e o f c y to k in in s ( a f a c to r in tu m o r a l in te r le u c in a s n e c r o s is1 ,6 a n d 8 , n itr ic o x id e a n d e n d o th e lin s ) w h ic h r e s u lt in a s y s te m ic in f la m ln a to r y p r o c e s s , w h ic h , if n o t c o n tr o lle d in tiI n e , b e c o ln e s ir r e v e r s ib le . T h e tr e a tm e n t its e lf c a n a c c e n tu a te th e in f la m m a to r y p r o c e s s , w h ic h is c a lle d , r e p e r f u s io n le s io n .
T h e d ia g n o s tic is c lin ic a I , in s tr u m e n ta l a n d la b o r a to r ia l, a n d th e o b je c tiv e s o f tr e a tm e n t a r e :
• to p r e v e n t th e a g g r e s s iv ~ f a c to r s ( a p u b lic h e a th ln e a s u r e ) ;
• to r e p la c e th e lo s t v o lu m e in a c c o r d a n c e w ith th e ty p e o f a g g r e s s io n ;
• to m o n ito r th e e n d o c r in a l r e s p o n s e , a n d b e f o r e th e f a c t to tr y to m o d u la te th e r e le a s e o f c a te c h o la m in e s a n d v a s o p r e s s in ;
• to th e Í ln p r o v e th e e f f e c tiv e tis s u e p e r f u s io n ; • to m o d u la te
the
r e le a s e o f c y to k in in s a n d ; • to ln in in liz e th e in f la m m a to r y p r o c e s s a n dr e p e r f u s io n le s io n s .
I n th e r e p la c e m e n t o f v o J u ln e , a h y p e r to n ic s o lu tio n o f s o d iu m c h lo r id e ( N a C L ) 7 .5 % h a s b e e n s h o w n to h a v e g r e a t p o te n tia l b e c a u s e it:
• is lo w c o s t a n d r a p id ly p o r ta b le to th e a g g r e s s io n s ite ; • c a u s e s r a p id h e m o d y n a m ic im p r o v e m e n t;
• im p r o v e s a ll- o v e r tis s u e e d e m a ;
• im p r o v e s tis s u e p e r f u s io n th r o u g h v o lu m ic e x p a n s io n a n d a d e c r e a s e in th e e n d o te lio e d e ln a o f m ic r o c ir c u la tio n ;
* F u l l p r o f e s s o r o f l h e E m e r g e n c y M e d i c i n e Di s c i p l i n e , F a c u l t y o f M e d i c i n e - Un i v e r s i t y o f S ã o P a u l o .
V E L A S C O , !.T . - C lin ic a i a n d th e ra p e u tic a s p e c ts o f th e s ta te o f s h o c k
• m o d u la te s th e e x c e s s iv e r e le a s e o f v a s o p r e s s in a n d ; • in d ic a te s ( s u g g e s ts ) a ln o d u la tio n o f th e
in f la m m a to r y r e s p o n s e
I n v o lu n 1 e tr ic r e p la c e ln e n t w ith w h a te v e r e x p a n d e r , w e ln u s t a s s o c ia te v a s o a c tiv e d r u g s if a n a v e r a g e P A o f >
6 0 ln H g is n o t m a in ta in e d . T h e n e x t s te p is to lllo n ito r th e p a tie n t a n d tr y to a c h ie v e a c a r d ia c r a te a b o v e 2 .2 in c a r d io g e n ic s h o c k , a n d a b o v e 4 .0 - 4 .5 in s e p s is a n d h y p o v o le m ia .
A s to th e m e d ia to r s in v o lv e d , in s e p s is a b a c te r ia l e n d o to x in c a n p r o v o k e a n in c r e a s e in T N F a n d in te r le u c in a s 1 ,6 a n d 8 , w h ic h in tu r n r e le a s e n itr ic o x id e a n d c a u s e a r te r ia l v a s o d ila tio n . T h e u s e o f I llo n o c lo n a l a n tib o d ie s a g a in s t e n d o to x in o r ta u r o lid in d o e s n o t lo w e r lllo r ta lity in s e p s is . O n th e o th e r h a n d , th e u s e o f th e a n ti-T N F a n tib o d y in c r e a s e s s u r v iv a l in s e p s is .
T h e u s e o f n - m e til a r g in in , w h ic h r e d u c e s th e r e le a s e o f n itr ic o x id e , s till r e q u ir e s I n o r e c o n c lu s iv e te s ts a s to its b e n e f its in s e p s is . T h e in h a la to r y u s e o f n itr ic o x id e s h o w s a n im p r o v e m e n t in th e r a tio p e r f u s io n - v e n tila tio n .
I n th e c o n tr o l o f a p a tie n t in s h o c k , it is iln p o r ta n t to I llo n ito r th e r e g io n a l f lo w d is tr ib u tio n a n d e v e n tu a l o r g a n ic f a ilu r e s ( r e n a l a n d h e p a tic in s u f f ic ie n c ie s , I lle n ta l c o n f u s io n a n d C I U D ) . T h e la c ta te a n d th e in tr a lllu c o s a l p H , a n d th e e n Z Y llle s a n d p r o te in s o f th e a f f e c te d o r g a n s c o u ld b e u s e f u l in f o llo w in g th e p a tie n t.
S O ln e p r o c e d u r e s .in c a r d ia c s h o c k in a c u te llly o c a r d ia l in f a r c tio n d e s e r v e c o n s id e r a tio n , s u c h a s a n g io p la s tia a n e l r e v a s c u la r iz a tio n th r o u g h m e d ic a tio n o r s u r g e r y .
I n c o n c lu s io n , it I llU S t b e s tr e s s e d th a t d e s p ite th e s o p h is tic a tio n o f th e p r o p e d e u tic s , n e w I lle d i'c a tio n s a n e l llle c h a n is m s in th e tr e a tm e n t o f s h o c k , n o th in g . s u b s titu te s th e p h y s ic ia n b e in g c o n s ta n tly a t th e p a tie n t's s id e , k n o w in g h o w to in te r p r e t th e s ig n if ic a n c e o f s Y ln p to llls ( m e n ta l c o n f u s io n , p a le n e s s , s w e a tin e s s , ta c h y c a r d ia , c y a n o s is , b a s e s te r to r , P V C , e tc .) f o r th e s u c c e s s o f th e th e r a p y .
