Emergency Management of Circulatory Collapse - An Insight

Introduction

Circulatory collapse is a clinical syndrome characterized by hypotension, peripheral vasoconstriction, and loss of consciousness, resulting in circulatory failure. This is due to low cardiac output followed by hypoperfusion of vital organs such as the brain, lungs, and the kidneys.

How Does Circulatory Collapse Occur?

The accompaniment of circulatory failure is shock and syncope-

• Shock: Shock is a clinical condition when the heart fails to meet the adequate blood supply demands of various organs. This makes the cells and organs nutrient and oxygen deficient. This leads to multiple organ dysfunction or failure. Shock requires immediate medical assistance. Causes of shock include heart attack, heart failure, severe allergic reactions, medicines that reduce blood pressure, dehydration (loss of fluid from the body), infection, etc. Symptoms include dizziness, chest pain, anxiety, profuse sweating, decreased urine output, bluish lips, pale-colored skin, etc. Shock can be classified into the following categories:

• Cardiogenic Shock - It occurs due to cardiac issues. It occurs when the heart cannot supply enough oxygen and nutrients to various organs. In this type of shock, either side of the heart is affected, or pulmonary circulation is involved. The most common causes are acute myocardial infarction, pericardial effusion, progressive myocarditis, acute valvular disease, tachyarrhythmias, and acute pulmonary embolism.

• Hypovolemic Shock - It occurs due to reduced blood volume due to external or internal loss of fluid. This can result in multiple organ failures. If a body loses more than one-fifth of its blood, it is in hypovolemic shock. Causes of hypovolemic shock include hemorrhage (blood loss) after an injury that can be external due to cuts and wounds or internal to the bowel or body cavity. Burns, diarrhea, and vomiting can also cause blood and fluid loss.

• Anaphylactic Shock - This type of serious allergic reaction results in anaphylactic shock. When a person's body reacts to an allergen (chemical to which a person is allergic), such as any drug or venom, allergic reactions are produced in the body. The body releases histamine and other substances in response to this reaction.

• Septic Shock - This is a type of shock caused due to infection in the entire body leading to decreased blood pressure. Anaphylactic shock-causing bacteria are staphylococcus aureus, fungi, and sometimes viruses release toxins leading to tissue damage. The body produces a huge inflammatory response that also results in organ damage. Patients with immunocompromised conditions such as diabetes, acquired immunodeficiency syndrome (AIDS), and leukemia are severely affected by this.

• Syncope: Syncope is a sudden transient loss of consciousness. This is a temporary condition that gets reversed soon. This is due to reduced blood flow to the brain. It occurred due to low blood pressure and decreased blood flow to the brain. It can be classified as:

  • Vasovagal Syncope - Vasovagal syncope is the most common type of syncope, which occurs when the body fails to deal with fluctuating blood pressure. It is also known as neurocardiogenic syncope as it is associated with the brain, heart, or both.

  • Postural or Orthostatic Syncope - Postural or orthostatic syncope occurs due to a falling in blood pressure on a change in position like incase of standing up.

  • Cardiac Syncope - Cardiac syncope is associated with a cardiac condition such as a valve defect.

  • Situational Syncope - Situational syncope occurs only in certain situations, such as anxiety, and fear.

  • Neurologic Syncope - Neurologic syncope occurs if a person has a neurologic condition such as a seizure.

How Is Circulatory Collapse Managed?

• The first and foremost thing to be done is to maintain the hemodynamics (dynamics of blood) of the patient. Till the time a patient reaches the hospital starts, cardiac resuscitation or CPR (cardiopulmonary resuscitation). This is a life-saving procedure given to someone who experiences shortness of breath or becomes unconscious. A person is revived from unconsciousness by resuscitation, that is, chest compressions and mouth-to-mouth breathing. 30 chest compressions are advised with two breaths in two minutes. Once the patient reaches the hospital, finding out the underlying cause, clotting factors, should be administered immediately in case of hypovolemic shock or bleeding. In case of septic shock, remove the underlying cause and administer antibiotics and thrombolysis for pulmonary embolism.

• Check for Vitals - Checks for the vitals of the patient. Monitoring of ABCs (airway, breathing, and circulation) is to be done.

• Oxygen Inhalation or Ventilatory Support - Oxygen is to be administered immediately as all the organs become oxygen deficient. Monitoring of oxygen is to be done by blood gas monitoring.

• Administration of Fluids - It should be started as it is beneficial in any type of shock. Cardiogenic acute edema results in decreased intravascular volume, and hypovolemia to substitute the fluid loss.

• Hypotension - In case of hypotension or low blood pressure, the vasopressor agent is administered. If hypotension persists even after the administration of fluids, a vasopressor is indicated. In case of low cardiac output also, vasopressors are suggested. The drug of choice in vasopressors is norepinephrine for maintaining blood pressure and increasing cardiac output dopamine (inotropic agent), and dobutamine can be administered.

• Vasopressin (Antidiuretic hormone-ADH) - The rationale for using a low dose of vasopressin in septic shock includes the relative deficiency of vasopressin in late shock and increased sensitivity of systemic circulation to the vasopressor effect of vasopressin. It also potentiates the vasopressor effects of catecholamines and activates cortisol production.

• Steroid Therapy - Corticosteroid therapy is also considered in septic shock.

• Management of Complications - Corrections of metabolic acidosis with sodium bicarbonate pH is less than 7.2. In case of renal failure, antibiotics are given to control sepsis, vasoactive substances, and fluid therapy. Nutritional support is also given.

Conclusion

This article gives details of circulatory collapse and its management in emergencies through various means. Cardiovascular diseases are often life-threatening conditions that could result in shock, syncope, or apparent death. Therefore they require extra care and handling, especially in the case of immunocompromised patients. Managing cardiovascular collapse can be difficult if a person is too far from the hospital. In such cases, the first aid to be given is resuscitation which is a life-saving procedure. Resuscitation might bring some people back to consciousness or from apparent death. Further treatment of circulatory collapse is done on the basis of an underlying cause. Vasoactive agents are very important in the treatment of cardiovascular collapse.