Wstrząs hipowolemiczny to reakcja wywołana nagłym, znacznym zmniejszeniem objętości płynów fizjologicznych w łożysku naczyń krwionośnych. Jedną z odmian wstrząsu hipowolemicznego jest wstrząs oparzeniowy. Jak wygląda patogeneza tej reakcji, jakie są jej objawy i jak przebiega terapia?
Patogeneza wstrząsu oparzeniowego
Wstrząs oparzeniowy jest następstwem głębokiego uszkodzenia tkanek na skutek rozległego urazu oparzeniowego. W wyniku oparzenia do krwiobiegu uwalniane są w znacznym stężeniu kininy (histamina, bradykinina, serotonina) oraz mediatory zapalne (tromboksany, prostacykliny, prostaglandyny, leukotrieny). Doprowadza to do uszkodzenia śródbłonka i w konsekwencji do przemieszczenia płynów pomiędzy poszczególnymi przestrzeniami płynowymi. Osocze przedostaje się zarówno do tkanek uszkodzonych w wyniku oparzenia, jak i tkanek zdrowych. Na skutek tych procesów ilość płynu w łożysku naczyniowym gwałtownie się zmniejsza, a w konsekwencji dochodzi do wstrząsu oparzeniowego.
Objawy wstrząsu oparzeniowego
Wśród objawów wstrząsu oparzeniowego wymienia się: obniżenie ciśnienia tętniczego krwi, słabo wyczuwalny puls, tachykardię, ogólne osłabienie, nasilone pragnienie, skąpomocz, przyspieszony i płytki oddech, dreszcze i zimne poty, a także objawy ze strony OUN: pobudzenie, poczucie zagrożenia, splątanie, senność, utratę przytomności.
Leczenie wstrząsu oparzeniowego
Leczenie wstrząsu oparzeniowego polega na wczesnym wdrożeniu intensywnej płynoterapii (z wykorzystaniem metod resuscytacji płynowej). Płynoterapia ma na celu utrzymanie wypełnienia łożyska naczyniowego płynem.
Pacjentom z rozległymi oparzeniami przetacza się w znacznych ilościach krystaloidy (samodzielnie wg reguły Parkland lub w połączeniu z koloidami – wg reguły Evans, Brook), stężone roztwory chlorku sodu (reguła Monafo) lub świeżo mrożone osocze (zgodnie z regułą Slatera).
Eksperci zwracają jednak uwagę, że podawanie koloidów i preparatów białkowych jest niewskazane w okresie pierwszych 8-12 godzin po oparzeniu. Koloidy i białka osocza egzogennego mogą przenikać przez ściany naczyń do przestrzeni pozanaczyniowej, czego skutkiem może być pogłębienie objawów wstrząsu i konwersja głębokości oparzenia. Z tego powodu można je stosować dopiero po 8 godzinach od wystąpienia urazu oparzeniowego.
U pacjenta, u którego doszło do wstrząsu, należy monitorować godzinowe wydalanie moczu, a także stężenie w osoczu: jonów sodu i potasu, mocznika, kreatyniny, glukozy i białka. Parametry te powinny być wskazaniem do kontrolowania przebiegu płynoterapii.
Źródła: Ł. Dróżdż, R. Mądry, J. Strużyna, „Wstrząs oparzeniowy, diagnostyka, monitorowanie i leczenie płynowe ciężkich oparzeń – nowe spojrzenie”, „Wiadomości Lekarskie” 2011, tom LXIV, nr 4, s. 288-293.
Przeczytaj także: Pierwsza pomoc przy oparzeniach dróg oddechowych
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