L'état de choc

L'état de choc

1.   Définition

Un choc circulatoire est un tableau clinique traduisant un état d'insuffisance circulatoire aiguë généralisée. Quelle que soit la cause du choc, les cellules ne disposent plus de la quantité suffisante d'oxygène nécessaire à leur fonctionnement. Même en cas de survie, la souffrance cellulaire se complique souvent de défaillance d'organes.

2.   Tableau clinique.

Hypotension artérielle : avec tension artérielle systolique inférieure a 90 mmHg et/ou tension artérielle moyenne inférieure à 70 mmHg. Mais il faut bien avoir à l'esprit que la tension artérielle est un chiffre relatif et qu'il faut prendre en compte les pathologies associées du patient, notamment l'hypertension artérielle.
Altération de la perfusion d'organes : 
Une oligurie inférieure à 20 ml/mn est le témoin d'une chute du débit sanguin rénal. Encore faut-il que le patient soit sondé.
En cas d'atteinte du système nerveux central, le patient présente un tableau qui peut aller d'une confusion modérée avec somnolence à la franche encéphalopathie.
Au niveau de la peau, il existe souvent une vasoconstriction cutanée avec marbrures, peau froide et cyanose périphérique.

3.   Tableau biologique

L'augmentation des lactates artériels témoigne d'un mauvais état circulatoire et d'un métabolisme anaérobie. Il y a alors un déséquilibre entre les besoins et les apports en oxygène aux cellules. Il en résulte une hypoxie cellulaire qui se traduit par un métabolisme anaérobie.

4.  Les complications des états de choc.

- Les troubles de la coagulation
Un tableau de CIVD
Une thrombopénie isolée

- Un OAP lésionnel dans le cadre d'un SDRA
Le patient présente une dyspnée plus ou moins sévère.
La radiographie pulmonaire montre des infiltrats bilatéraux diffus.
La gazométrie sanguine montre une hypoxémie importante.
Le rapport PaO2/FiO2 est inférieur à 200mmHg.
Si on dispose d'une sonde de Swan-Ganz la Pcap est inférieure à 18 mmHg.

- Une insuffisance rénale
La diminution de la perfusion rénale est responsable d'oligurie. L'insuffisance rénale aiguë par nécrose tubulaire peut persister plusieurs semaines voire définitivement.

- Les altérations des tests hépatiques
Il y a une hyperbilirubinémie sans cholestase. Une cytolyse modérée est fréquente.

- Les altérations de la conscience
La ponction lombaire donne un LCR normal
La tomodensitométrie est normale
L'EEG montre une dysrythmie lente diffuse


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