Girgiza (hanzari)

**Shock,** shine yanayin rashin isasshen jini zuwa kyallen jikin jiki sakamakon matsalolin da ke tattare da tsarin jini.Alamun farko na girgiza na iya haɗawa da rauni, saurin bugun zuciya, saurin numfashi, gumi, damuwa, da ƙãra ƙishirwa. Wannan na iya biyo bayan rikicewa, rashin sani, ko kama zuciya, yayin da rikitarwa ke daɗa muni. 

Shock ya kasu kashi huɗu manyan nau'o'i bisa tushen dalili: hypovolemic, cardiogenic, obstructive, da kuma rarrabawar girgiza. Hypovolemic shock, wanda kuma aka sani da ƙaramar ƙara girgiza, na iya kasancewa daga zub da jini, gudawa, ko amai.  Girgizar zuciya na iya zama saboda bugun zuciya ko raunin zuciya . Matsanancin girgiza na iya kasancewa saboda tamponade na zuciya ko tashin hankali pneumothorax. Rarraba girgiza na iya zama saboda sepsis, anaphylaxis, rauni ga igiyar kashin baya na sama, ko wasu abubuwan da suka wuce kima.

Sakamakon ganewar asali gabaɗaya ya dogara ne akan haɗakar alamomi, gwajin jiki, da gwaje-gwajen dakin gwaje-gwaje.  Ragewar bugun bugun jini ( systolic blood pressure in diastolic blood pressure ) ko saurin bugun zuciya yana haifar da damuwa.  Adadin zuciya wanda aka raba ta hanyar hawan jini na systolic, wanda aka sani da alamar girgiza (SI), na sama da 0.8 yana goyan bayan ganewar asali fiye da ƙananan hawan jini ko saurin bugun zuciya a keɓe. 

Maganin firgita ya dogara ne akan abin da zai iya haifar da dalili.  Ya kamata a kafa hanyar iska ta bude da isasshen numfashi .Ya kamata adakatar da duk wani jubar jini mai gudana, wanda zai iya buƙatar tiyata ko embolization.Ruwan ciki, kamar lactate na Ringer ko cushe jajayen ƙwayoyin jini, ana yawan ba da su. Ƙoƙarin kiyaye yanayin zafin jiki na yau da kullun yana da mahimmanci. Vasopressors na iya zama da amfani a wasu lokuta. Shock abu ne na kowa kuma yana da babban haɗarin mutuwa. A Amurka kimanin mutane miliyan 1.2 ne ke halartar dakin gaggawa a kowace shekara tare da kaduwa kuma hadarinsu na mutuwa yana tsakanin 20 zuwa 50%. 

## Alamomi
Gabatarwar girgiza yana canzawa, tare da wasu mutane suna da ƙananan alamomi kamar rudani da rauni.  Yayin da alamun gabaɗaya ga kowane nau'in girgiza sune ƙarancin hawan jini, raguwar fitowar fitsari, da rikicewa, waɗannan ƙila ba koyaushe suke kasancewa ba. Yayin da bugun zuciya mai sauri ya kasance na kowa, wadanda ke kan β-blockers, wadanda ke da wasanni, kuma a cikin 30% na lokuta na wadanda ke da damuwa saboda zubar da jini na ciki, bugun zuciya na iya zama al'ada ko jinkirin.  Ƙayyadaddun ƙananan nau'o'in girgiza na iya samun ƙarin alamun bayyanar.

Busassun mucous membrane, rage turgor fata, dogon capillary cika lokaci, rauni na gefe bugun jini, da sanyi extremities iya zama farkon alamun firgita.

### Kananan kara

Hypovolemic shock shine mafi yawan nau'in firgita kuma vana faruwa ne ta
dalilin rashin isasshen karar zagayawa.Mafi yawan abin da ke haifar da girgiza hypovolemic shine zubar jini (na ciki ko na waje); amma, amai da gudawa sun fi zama sanadin vara. Sauran abubuwan da ke haifarwa sun hada da konewa, da yawan zubar fitsari saboda ketoacidosis mai ciwon
sukari da insipidus na ciwon sukari. 

Alamomi da alamun girgiza hypovolemic
sun hada da: 

. Saurin bugun jini mai rauni, mai rauni saboda raguwar kwararar jini hade da
tachycardia 

• Cool fata saboda vasoconstriction da
karfafa vasoconstriction

Sauri da numfashi mara zurfi saboda
tsarin juvayi mai tausayi da acidosis 

. Hypothermia saboda raguwar turare da
kafewar gumi 

. Kishirwa da bushewar baki, saboda
raguwar ruwa 

.Cold da mottled fata (livedo reticularis), musamman ma extremities, saboda rashin
isashen turaren fata.

Za'a iya kididdige tsananin girgizar jini akan sikelin 1-4 akan alamun jiki. Ma'anar girgiza (karashin bugun zuciya da aka raba ta hanyar hawan jini na systolic) shine mafi karfin hasashen tasirin asarar jini five da
bugun zuciya da hawan jini kadai. [5]. Wannan dangantaka ba ta da kyau a cikin
zubar jini da ke da alaka da ciki[12].

### Cardiogenic

Ciwon zuciya na cardiogenic yana faruwa ne sakamakon gazawar zuciya wajen yin famfo yadda ya kamata. [7] Wannan na iya zama saboda lalacewa ga tsokar zuciya, mafi yawan lokuta daga babban ciwon zuciya. Sauran abubuwan da ke haifar da girgiza cardiogenic sun hada da dysrhythmias, cardiomyopathy/ myocarditis, congestive heart failure (CHF), ciwon zuciya na zuciya, ko matsalolin cututtukan zuciya na valvular. [10]

Alamomin girgiza cardiogenic sun hada da: 

.Rarrabewar jijiyoyin jugular saboda
karuwar matsi na jugular venous

. bugun jini mai rauni ko babu

. Kauyen zuciya mara kyau, sau da yawa saurin 
bugun zuciya

. Pulsus paradoxus idan akwai tamponade

. Rage hawan ini

. Karancin numfashi, saboda cunkoson huhu

### Mai hanawa

Tashin hankali wani nau'i ne na girgiza da ke da alaka da toshewar jiki na manyan
tasoshin magudanar jini ko na huhu. [13] Sharuɗɗa da yawa na iya haifar da wannan
nau'in girgiza.

. Tamponade na zuciya[10] wanda ruwa a cikin pericardium ke hana shigar jini cikin
zuciya (dawowar venous). 

. Kunkarar pericarditis, wanda pericardium yana raguwa kuma ya taurare, yana kama da gabatarwa.

.Tashin hankali na pneumothorax[10] Ta hanyar karuwar matsa lamba na intrathoracic, ana hana kwararar jini zuwa
zuciya (dawowar venous).

.Ciwon huhu shine sakamakon abin da ya far na thromboembolic a cikin jini na huhu kuma yana hana dawowar jini zuwa zuciya.

. Aortic stenosis yana hana wurare dabam dabam ta hanyar toshe hanyar fita ta
ventricular

.Hypertrophic sub-aortic stenosis shine tsoka mai kauri mai kauri da yawa wanda
ke mamaye fili mai fita.

.Ciwon ciki da aka bayyana a matsayin karuwa a matsa lamba na ciki zuwa> 20
mmHg tare da tabarbarewar gabbai. [14]
Kara yawan matsa lamba na ciki na iya zamama saboda sepsis da mummunan rauni na ciki. Wannan karin matsi yana rage kwararar jini zuwa zuciya, ta yadda zai rage kwararar jini zuwa jiki da haifar da alamu da alamun firgita [15].

Yawancin alamun girgiza mai hanawa suna kama da girgizar zuciya, duk da haka jiyya sun bambanta. Alamomin abin girgiza sun hada da: . Kauyen zuciya mara kyau, sau da yawa
saurin bugun zuciya.

. Rage hawan jini.

.Cool, clammy, mottled fata, sau da yawa saboda kananan hawan jini da
vasoconstriction.

. Rage fitar fitsari.

### Mai Rarrabawa

Rarrabar damuwa shine karancin hawan
jini saboda faduwar jijiyoyin jini a cikin jiki. [7][17] Ana iya haifar da wannan ta hanyar kamuwa da cuta ta tsarin (septic shock), mummunan rashin lafivar jiki (anaphylaxis), ko raunin kashin baya
(neurogenic shock).

. Septic shock shine mafi yawan sanadin girgizar rarrabawa. [10] Yana faruwa ne ta hanyar kamuwa da cuta mai yawa wanda ke haifar da vasodilation wanda ke haifar da hypotension. Septic shock na iya hafar da kwayar cutar Gram korau kamar (a tsakanin wasu) Escherichia coli, nau'in Proteus, Klebsiella pneumoniae (wadanda ke da endotoxin a saman su wanda ke hafar da mummunan tasirin biochemical, immunological da lokaci-lokaci na jijiyoyin jijiyoyin jiki wadanda ke cutar da jiki), da sauransu. Gram-positive cocci, irin su
pneumococci da streptococci, da wasu

fungi da kuma Gram-positive kwayoyin guba. Septic shock kuma ya hada da wasu abubuwa na girgiza cardiogenic. A cikin
1992, Kwamitin Taron Yarjejeniyar ACCP / SCCM ya ayyana rawar jiki: "... Jigilar jini da ke haifar da sepsis (gudanar jini na systolic <90 mmHg ko raguwar 40 mmHg daga asali) duk da isassun farfadowar ruwa tare da kasancewar rashin daidaituwa na perfusion wanda ke haifar da hauhawar jini. na iya hadawa, amma ba'a iyakance ga: lactic acidosis, oliguria, ko babban canji a
yanayin tunani.

. Babban bayyanar cututtuka na septic shock shine saboda yawan sakin histamine wanda ke hafar da tsangwama na jijiyoyin jini. Mutanen da ke da bugun jini suma za
su iya zama tabbatacce ga ma'aunin SIRS. Mafi yawan varda da magani ga wadannan marasa lafiya shine farkon ganewar alamun bayyanar cututtuka, da kuma fara
gudanar da maganin kwayoyin cuta masu yawa 

a da kwayoyin cuta.[19]
Alamomin cutar bugun jini sun hada da: 
. Kauyen zuciya mara kyau, sau da yawa saurin bugun zuciya . Rage hawan jini . Rage fitar fitsari
. Canjin vanayin tunani . Anaphylactic shock yana haifar da mummunan halayen anaphylactic zuwa alerji, antigen, magani, ko furotin na waje wanda ke haifar da sakin histamine wanda ke hafar da vasodilation mai yaduwa, yana haifar da hauhawar lini da habaka habakar capillary.

Alamun yawanci suna faruwa bayan bayyanar da allergen kuma suna iya
hadawa da: .Canje-canjen fata, kamar amya, itching,
flushing, da kumburi.
. Haushi da rashin numfashi.
. Ciwon ciki, gudawa, da amai. Hasken haske, rudani, ciwon kai, asarar Sani.

.Babban raunin da ya faru na kashin baya na iya hafar da girgizar neurogenic, wanda aka fi sani da shi azaman juzu'in girgizar rarrabawa. [20] Alamun alamomin sun hada da jinkirin bugun zuciya saboda asarar sautin tausayi na zuciva da dumin fata saboda faduwar jijiyoyin jini. [20] (Wannan kalmar na iya rikicewa tare da girgiza kashin baya wanda shine asarar aikin da za'a iya dawo da shi na kashin baya bayan rauni kuma baya nufin rashin zaman lafiya
na hemodynamic.)

## Sanadi
Shock shine karshen gama gari na vawancin yanayin kiwon lafiya. [10] Girgizar da ta haifar da mummunar rashin lafiyar da ake kira anaphylactic shock, gigin da ke haifar da rashin ruwa mai tsanani ko asarar jini ana kiransa hypovolemic shock, girgiza da ke haifar da sepsis da ake kira septic
shock, da dai sauransu Shock kanta yanayi ne ne 

e mai hadarin gaske a sakamakon haka. na raguwar zagawar jiki.[22] Ana iya raba shi zuwa manyan nau'ikan kamar haka: hypovolemic, distributive, cardiogenic, da hanawa.[23]. Ana amfani da yan karin rarrabuwa lokaci-lokaci, kamar girgizar
endocrinologic. [10]

## Pathophysiology

Akwai matakai hudu na girgiza. Shock wani yanayi ne mai rikitarwa kuma mai ci gaba, kuma babu wani canji kwatsam daga mataki daya zuwa na gaba[24]. A matakin salula, girgiza shine tsarin bukatar iskar oxygen ya zama mafi girma fiye da samar da iskar oxygen.[7]

Dayan mahimman hatsarori na firgita shi ne cewa vana ci gaba ta hanyar madaidaicin ra'ayi. Rashin karancin jini yana hafar da lalacewar salula, wanda ke
haifar da amsa mai kumburi don Kara 

yawan jini zuwa yankin da aka shafa. Yawanci, wannan yana haifar da matakin samar da jini don dacewa da bukatar nama don abubuwan gina jiki. To sai dai idan aka samu isassun bukatu a was wuraren, hakan na iva hana was wuraren samun isashshen wadataccen wadataccen abinci,
wanda daga nan sai a fara neman karin. Wannan yana haifar da habakar casca koyaushehe.

### Na farko

A lokacin matakin farko (Mataki na 1),
yanayin hawan jini yana haifar da hypoxia. Saboda rashin iskar oxygen, sel suna yin fermentation na lactic acid. Tun da iskar oxygen, mai karbar wutar lantarki ta karshe a cikin sarkar sufuri na lantarki, ba ta da yawa, wanna yana jinkirta shigar da pyruvate cikin zagaye na Krebs, wanda ya haifar da tarawa. An canza pyruvate mai tarawa zuwa lactate (lactic acid) ta hanyar
lactate dehydrogenase. Lactate na tarawa yana haifar da lactic acidosis.

### Ramuwa

Matakin ramawa (Mataki na 2) yana siffanta shi da jiki yana amfani da hanyoyin ilimin lissafin jiki, gami da hanyoyin jijiyoyi, hormonal, da sinadarai, a kokarin juyawa yanayin. Sakamakon acidosis, mutum zai fara yin iska don kawar da jikin carbon dioxide (CO2). CO2 a kaikaice yana aiki don daidaita jini, don haka jiki yayi kokarin komawa zuwa acid-base homeostasis ta
hanyar cire wannan wakili na acidifying. Baroreceptors a cikin arteries gano hypotension sakamakon babban adadin jini da ake juva zuwa kyallen takarda mai nisa, kuma suna hafar da sakin epinephrine da
norepinephrine.

Rashin jini zuwa tsarin koda vana haifar da halayyar karancin samar da fitsari. Koyaya, tasirin renin-angiotensin axis yana daukar
lokaci kuma ba su da mahimmanci ga t

saka-tsak in 

n gida na girgiza kai tsaye.

### Mai ci gaba
Matakin ci gaba (mataki na 3) yana haifar da idan ba a sami nasarar magance abin da ke haifar da girgiza ba. A wannan mataki,
hanvoyin ramawa sun fara lalacewa. Sakamakon raguwar rubar sel a cikin jiki, ions sodium suna habaka a cikin sararin cikin salula yayin da ions potassium ke fitowa. Saboda rashin iskar oxygen, numfashin salula yana raguwa kuma anaerobic metabolism ya mamaye. Yayin da metabolism na anaerobic ke ci gaba da ci gaba, tsokar jijiya mai santsi da santsin jijiyoyin jini suna shakata ta vadda jini ya kasance a cikin capillaries. [18] Saboda wannan, matsin lamba na hydrostatic zai karu kuma, tare da sakin histamine, zai haifar da zubar da ruwa da furotin a cikin kyallen da ke kewaye. Yayin da wannan ruwa ya bace, kaddamarwar jini da danko
yana karuwa, yana hafar da sludging na

micro-circulation. Dadewar vasoconstriction kuma zai haifar da lalacewa ga mahimman gabobin saboda raguwar turare. [18] Idan hanji ya zama ischemic ischemic, kwayoyin cuta na iya shiga cikin magudanar jini, wanda hakan zai haifar da kara rikitarwa na girgiza
endotoxic. [6][18]

### Refractory
A mataki na refractory (mataki na 4), mahimman gabobin sun gaza kuma ba za a iya jujjuya firgicin ba. Lalacewar kwakwalwa da mutuwar tantanin halitta suna faruwa, kuma mutuwa za ta faru nan da nan. Daya daga cikin dalilan farko da girgiza ba zai iya jurewa ba a wannan lokacin shine yawancin ATP na salula (tushen makamashi na asali don sel) an lalata su zuwa adenosine a cikin rashin iskar oxygen a matsayin mai karbar
lantarki a cikin matrix na mitochondrial. Adenosine cikin sauki vana watsawa daga cikin in membranes na salula zuwa cikin ruwa na waje, yana habaka vasodilation na capillary, sannan kuma ya zama uric acid. Domin sel na iva samar da adenosine ne kawai a kusan kashi 2% a jimillar bukatun tantanin halitta a cikin awa daya, ko da maido da iskar oxygen ba shi da amfani a wannan lokacin domin babu adenosine
zuwa phosphorylate zuwa ATP.[6]

## Bincike
Ganewar firgita yawanci ya dogara ne akan hadakar alamomi, gwajin jiki, da gwaje- gwajen dakin gwaje-gwaje. Yawancin alamu da alamun ba su da mahimmanci ko kebance ga girgiza, don haka yawancin kayan aikin yanke shawara na asibiti an kirkira su don gano girgiza a farkon matakin.[25] Babban mataki na zato ya
zama dole don dacewa da ganewar girgiza.

Canjin farko da aka gani a cikin firgici shine
kara yawan fitarwar zuciya sannan kuma

raguwar haduwar iskar oxygen jikewa (Smv02) kamar yadda aka auna a cikin
jijiyar huhu ta hanyar catheter na huhu. [26] Jikewar iskar oxygen ta tsakiya (Scv02) kamar yadda aka auna ta hanyar layin tsakiya yana da alaka da Smv02 kuma yana da saukin siye. Idan girgiza ya ci gaba da habaka metabolism na anaerobic zai fara faruwa tare da karuwar lactic acid na jini a sakamakon haka. Yayin da yawancin gwaje- gwajen dakin gwaje-gwaje yawanci ana yin su, babu wani gwajin da ko dai ya yi ko ya kebe cutar. X-ray na kirji ko duban dan tayi na sashen gaggawa na iya zama da amfani
don tantance matsayin girma.[7)[8]

## Manazarta