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Shock B. Mladosievicova
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Page 1: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Shock

B. Mladosievicova

Page 2: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Definition

State of acute generalized circulatory failure causing inadequate tissue perfusion

Page 3: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

The effects of shock are initially reversible,

but rapidly become irreversible, resulting

in multiorgan failure (MOF) and death

Page 4: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Shock left untreated may be

fatal.

It must be recognized and

treated immediately

Page 5: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Shock at cellular level

• oxygen delivery to the cells is not sufficient to sustain cellular activity

• the central role of microcirculation in providing oxygen to the cells

Page 6: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Microcirculatory dysfunction leads to

• dysfunction of cell membranes, breakdown of cellular metabolism

• Reduced oxygen and nutrients delivery in cells – LA – decreased cellular pH- release of strong enzymes, RMO – loss of cell integrity – loss of cells in brain, heart– irreversibility of shock

Page 7: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...
Page 8: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Finfer SR,

NEJM 2013

Page 9: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Activating hematologic system

Page 10: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Activating CVS

Page 11: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Activating renal system

Page 12: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...
Page 13: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

5/11/2017 10

Hypovolemic Shock

Hemorrhagic/Traumatic

Blood (external, internal)

Fluid (GIT,kidneys...)

Plasma - burn

increased: Hb, Ht, plasma proteins -

from haemoconcentration

Page 14: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

The most common causes of HS

External blood loss: penetrating trauma, GI bleeding disorders

Internal blood loss: organ injury, abd. aortic aneurysma

Page 15: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Hypovolemic shock -phases

• Compensation (latent)

• Decompensation

• Irreversible

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Compensatory period able to compensate blood loss to 20%

• Releasing of catecholamines

• Constriction of arteriols and veins, shift of blood to arterial region

• Centralisation of blood to heart and brain from splanchnic tissues, skin, kidneys (activation of RAAS – retention of Na, water, increased osmolality, releasing of ADH - oliguria), decreased HP, higher oncotic pressure in capillaries

Page 17: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Hypoperfusion – ischemic triggers releasing of

TNF-alpha, IL-1,IL-2,IL-6,IL-8. Metabolites of arachidonic acids,

lysosomal ee,, vasoactive mediators (k, h, s)

Page 18: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Decompensation

• If centralisation longer than 1-2 hours

• If blood loss is more than 20-30%

• METABOLIC FAILURE OF CELLS - MA

Page 19: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Blood loss BP(mmHg) Heart rate (bpm) Diuresis 10-15% normal normal normal

15-30% <100 > 100 oliguria

30-40% < 90 > 120 anuria

Shock starts when

systolic BP<100 and heart rate >100

Page 20: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Hypovolemic = decreased circulating volume

hypotension (rapid 25% volume loss)

rapid pulse (measurable on a. radialis means 90 SBP,

only on a.carotis 70 SBP)

Compression of nail (more than 5 s – means

hypoperfusion)

tachypnea

anxiety

irritability

Page 21: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

• reduced level of consciousness - apathy

- coma

• oliguria - urine production less than 400ml/d

• cool skin, pale, thirst, hypothermia

Page 22: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Blood loss

• Closed femoral fracture 300-2000 mL

• Closed costal fracture 150 mL pre each

• Closed fracture of tibie 500 mL

• Open wound 10x10 cm 500 mL

• Haemothorax 2000mL

• State of circulation is modified by fear, cold, pain!!!

Page 23: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Cardiogenic shock

is a life-threatening condition that occurs in

response to reduced cardiac output in the

presence of adequate intravascular volume

and results in tissue hypoxia

Page 24: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Cardiogenic shock

hypoperfusion is usually associated with

increased central venous pressure,

hepatomegaly can be clinically apparent

Page 25: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...
Page 26: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

CARDIOGENIC SHOCK - MI (7% of pts),

heart failure,

arrhythmias

Decreased contractility- reduced cardiac output –

decreased coronary perfusion- further ischemia- necrosis

SBP <90 mm Hg persistent more than 30 min.

urine output < 20 ml/HOUR

peripheral vasoconstriction – oliguria, cool ext.,pale skin...

impaired mental status

ECG, invasive haemodyn. monitoring

Page 27: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Spiral of cardiogenic shock

Page 28: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Management of PTS with cardiogenic shock

- improving myocardial contractility (inotropy –

dopamine…)

- decreasing afterload (vasodilators)

- increasing myocardial oxygen supply

- decreasing “ “ demand

- correcting hypoxia, met. acidosis

- diuretics

- mechanical assist devices – intraaortic ballon pump

reduction of pain, anxiety

Page 29: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

5/11/2017 12

Obstructive Shock

Massive pulmonary

Embolism

Cardiac Tamponade

Dissecting of aorta or

aneurysma

Aortic stenosis

Page 30: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

11/24/2016 11

Distributive Shock

caused by loss of vasomotor controlvolume remains unchaged, vascular bed

enlarges, CO is high

Septic (mainly – LPS of G negative bact. -

peritonitis, abscess, pneumonia) ATB

Anaphylactic (massive Ag-Ab reactions

no more than 1-2 hours after exposure)

EPINEPHRIN

Neurogenic (sympathetic tone loss –

vasodilation- decreased venous return –

hypotension, bradycardia) ATROPINE

Page 31: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

S SEPTIC SHOCK

M (sepsis + hypotension)

- SEPSIS -

systemic inflammatory response syndrome (SIRS)

induced by infection – old definition

Sepsis should be defined as life-threatening organ

dysfunction caused by a dysregulated host response to

infection. For clinical operationalization, organ dysfunction

can be represented by an increase in the Sequential [Sepsis-

related] Organ Failure Assessment (SOFA) score of 2

points or more, which is associated with an in-hospital

mortality greater than 10%.

Page 32: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Septic shock

• a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone.

• trauma, surgical pts

• DM

• malignancies (+ immunosupressive therapy)

• cirrhosis

• urinary tract, GI infections

• newborns

• in the elderly

Page 33: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

SIRS (at least 2 signs)

• > 38°C or <36°C

• tachycardia > 90 bpm

• tachypnoe > 20/min or PaCO2 < 4.3 kPa

• Le > 12 x 109/l or < 4 x 109/l

Page 34: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Infectious Noninfectious

bacterial diabetic complications cholecystitis pneumonia urogenital meningitis etc.

acute intestinal ischemia pancreatitis autoimunne diseases burns aspiration drug reactions cocain/amphetamine MI

Causes of SIRS

Page 35: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Septic shock develops in less than one half of patients with bacteremia. It occurs in about 40% of those patients with gramnegative bacteremia and about 20% of patients with Staphylococcus aureus bacteremia.

Page 36: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Septic shock

• Fever

• Chills

• Sweating

• Altered mental status

- Anxiety

- Agitation

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Page 38: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

• Head and neck infections - earache, sore throat, sinus pain or congestion, nasal congestion or exudate, swollen

lymph glands • Chest and pulmonary infections - cough (productive),

pleuritic chest pain, dyspnea

• Abdominal and GI infections - abdominal pain, nausea, vomiting, diarrhea • Pelvic and genitourinary infections - pelvic or flank pain,

vaginal or urethral discharge, dysuria, frequency, urgency • Bone and soft tissue infections - focal pain or tenderness,

focal erythema, edema

Page 39: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Management of pts with clinical

signs and symptoms

Ventilation Infusion Pump function

Page 40: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

COMPLICATIONS OF SHOCK

IF PERFUSION PRESSURE IS < 50 mm Hg

BRAIN DEATH

FOCAL MYOCARDIAL NECROSIS, HF

CONGESTION OF SPLEEN

STRESS ULCERS IN STOMACH

VASODILATION AND SPLANCHNIC POOLING

NECROSIS OF INTESTINE

ACUTE TUBULAR NECROSIS OF KIDNEY

NECROSIS OF LIVER

ADULT RESPIRATORY DISTRESS SYNDROME (ARDS)

FEVER

Page 41: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Practice questions

What is the first sign of a shock?

What is the most common type of shock in

ICU?

Page 42: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Syncope

• a transient, self-limited loss of consciousness [with an inability to maintain postural tone that is followed by spontaneous recovery.

• It excludes seizures, coma, shock, or other states of altered consciousness.

• Most causes of syncope are benign • In a small subset - several serious heart

conditions, such as bradycardia, tachycardia or blood flow obstruction (e.g. valvular defect), can also cause syncope

Page 43: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

50% of the population may experience

a syncopal event during their lifetime

Page 44: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Syncope (fainting)

rapid drop in blood pressure or heart rate

Page 45: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Prior syncope symptoms

• faintness, dizziness, or light-headedness, vertigo, weakness, diaphoresis, epigastric discomfort, nausea, blurred or faded vision, pallor, or paresthesias

• Red flag symptoms - Exertional onset, chest pain, dyspnea, low back pain, palpitations, headache focal neurologic deficits, diplopia, ataxia, or dysarthria

Page 46: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Treatment

depends on the cause or precipitant of the syncope: • Situational syncope – neurally mediated – vasovagal -

patient education regarding the condition • Orthostatic syncope - Patient education;,

mineralocorticoids, and other drugs (eg, midodrine); elimination of drugs associated with hypotension; intentional oral fluid consumptionadditional therapy in the form of thromboembolic disease (TED) stockings

• Cardiac arrhythmic syncope - Antiarrhythmic drugs or pacemaker placement

• Cardiac mechanical syncope – if valvular disease is present, surgical correction

Page 47: Prezentace aplikace PowerPoint · Prezentace aplikace PowerPoint Author: LF UK Created Date: 5/1/2020 1:13:22 PM ...

Hypotension (< 100/60)

Cardiac (Low Output) Vascular origins

Arrhythmias

Structural

Disease

Hypovolemia

Systemic

Vasodilation

Obstructive

• pulmonary

embolism

• bradycardia

• tachycardia

• fibrillation

• valvular disease

• ischemic heart disease

• pericardial disease

• cardiac tamponade

• congenital disease

• obstructive

cardiomyopathy

• dilated cardiomyopathy

• primary pulmonary

• hypertension

• hemorrhage

• diarrhea

• dehydration

• orthostatic

volume shifts

• drugs (diuretics)

• sepsis

• anaphylaxis

• neurogenic

• autonomic dysfunction

• drugs


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