Shock
Table of Contents
Shock
Con il termineshocksi intende una sindrome dainsufficienza micro e macro-circolatoria acutaa patogenesi multifattoriale, ad evoluzione progressiva, solo inizialmente reversibile, caratterizzata da una perfusione tissutale inadeguata rispetto ai fabbisogni metabolici.E’ una sindrome pericolosa per la vita, in cui l’organismo si trova in una situazione di ipossia cellulare e tissutale che porta a morte cellulare e a disfunzione organica.Gli effetti dello shock sono reversibili solo nella fase inizialee un ritardo nella diagnosi e/o nell’inizio del trattamento o portare a una situazione irreversibile di multiple-organ-failure MOF) e a morte del paziente.
Patogenesi
la patogenesi è da ricercarsi in un’ alterazione del trasporto e/o del consumo di ossigeno e nel suo inadeguato utilizzo a livello cellulare e tissutale. La manifestazione più frequente è l’ipotensione (pressione arteriosa sistolica < 90 mmHg o pressione arteriosa media PAM < 60 mmHg).
Nello stato di shock si evidenziano delle dinamiche patogenetiche fondamentali come ad esempio:
- Ischemia: severa compromissione della perfusione efficace a livello cellulare sistemico.
- Ipossia: severa sofferenza cellulare sistemica a causa di uno sbilanciamento tra trasporto e richiesta di O2.
- Alterazionedel metabolismo ossidativo a livello mitocondriale.
- Alterazionedel funzionamento delle pompe di membrana. e acidosi intracellulare con accumulo di CO2.
- Disfunzioned’organo correlata ai mediatori della risposta infiammatoria sistemica e danno da riperfusione con liberazione dei radicali liberi dell’ossigeno.
Tutto ciò può portare ad un’ insufficienza multiorgano e a morte del paziente.
Classificazione
- Shock ipovolemicoda insufficienza del volume ematico circolante: lo stato di shock compare se la volemia si riduce bruscamente del 20% o oltre.
- Shock cardiogeno:si manifesta quando la portata cardiaca scende al di sotto dei valori minimi necessari a mantenere la funzione degli organi vitali. La grave riduzione della portata cardiaca può essere causata da un grave infarto con perdita funzionale di almeno il 40% della massa miocardica (che rimane la causa più frequente di shock cardiogeno), da una grave miocardite o cardiomiopatia oppure da una complicanza acuta meccanica, come rottura del setto interventricolare, di un muscolo papillare, di corde tendinee o della parete libera del ventricolo sinistro.
- Shock settico:è dovuto a modificazioni del microcircolo provocate da tossine batteriche, spesso nelle sepsi da gram-negativi. Alla vasocostrizione iniziale, succede una fase di atonia con dilatazione dell’arteriola e occlusione venulare, che determina una stasi circolatoria responsabile della caduta della portata cardiaca.
- Shock neurogenocon interessamento del sistema nervoso centrale. Lo shock è dovuto ad un’atonia venosa che provoca una stasi e, secondariamente, una diminuzione del flusso cardiaco, da cui l’ipotensione arteriosa.
- Shock anafilatticorisulta dalla combinazione di una sostanza antigenica e dell’anticorpo corrispondenze che provoca una reazione vasoplegica con insufficienza del microcircolo. L’allergene in causa nella maggior parte dei casi è una sostanza somministrata per iniezione (siero eterologo, farmaco, mezzo di contrasto, ecc..).
Prognosi
Lo stato di shock, non trattato è in genere è fatale. La sua prognosi dipende dalla natura dell’aggressione iniziale e dalla precocità del trattamento. L’età avanzata, il coma, l’acidosi metabolica grave e lo shock cardiogeno hanno una prognosi molto infausta. Lo stato di shock può complicarsi in ogni momento con anuria, polmone da shock, coagulopatia intravascolare disseminata.
Terapia
- Mettere sempre il paziente in posizione antishock.La posizione antishock, o posizione di Trendelenburg si realizza ponendo l’infortunato disteso al suolo, in posizione supina, inclinato di 20-30° con il capo a terra senza cuscino, con il bacino leggermente rialzato (per esempio con un cuscino) e gli arti inferiori sollevati.
- Analgesici e sedativi: la morfina viene somministrata in caso di dolore forte per esempio nell’infarto del miocardio acuto, purché non vi sia depressione respiratoria. I sedativi devono essere impiegati solo in caso di necessità assoluta.
- Ossigeno: bisogna mantenere la permeabilità delle vie aeree con l’ossigeno. l’ossigeno viene somministrato con maschera, sonda nasale o ventilazione assistita dopo intubazione, se necessario, sotto controllo delle emogasanalisi arteriosa.
- Correzione dell’ ipovolemia: in caso di emorragia grave, bisogna preparare due e tre vie venose, di cui una centrale che consente anche la misura della pressione venosa centrale o la pressione polmonare capillare di punta. La quantità di liquidi da somministrare e la loro qualità dipendono dalla stima delle perdite, dallo stato clinico del malato, dai parametri emodinamici ed alla loro evoluzione.
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