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SHOCKSHOCK Objectives: Objectives: at the end of this at the end of this lecture you would be able to :lecture you would be able to :1- define shock1- define shock2- recognize types of shock and their causes2- recognize types of shock and their causes3- correlate pathophysiologic changes with 3- correlate pathophysiologic changes with clinical features .clinical features .4- know the broad lines of monitoring and 4- know the broad lines of monitoring and
treatment of shock patientstreatment of shock patients . .
ShockShock A physiological state characterized A physiological state characterized by a significant, systemic reduction by a significant, systemic reduction in tissue perfusion, resulting in in tissue perfusion, resulting in decreased tissue oxygen delivery and decreased tissue oxygen delivery and insufficient removal of cellular insufficient removal of cellular metabolic products, resulting in metabolic products, resulting in tissue injury.tissue injury.
Shock is not a synonym to hypotensionShock is not a synonym to hypotension!!
SHOCK
Definition: SHOCK is an acute circulatory failure, characterized by dysfunction of the microcirculation , inadequate blood flow to vital organs and inability of the body cell mass to metabolize the nutrients normally.
What are the functions of the What are the functions of the cardio-vascular systemcardio-vascular system ? ?
Definition of ShockDefinition of Shock
Cellular levelCellular level : :
Reduction of mitochondrial oxygenReduction of mitochondrial oxygen
Anaerobic glycolysis of ATPAnaerobic glycolysis of ATP
Accumulation of pyruvate Accumulation of pyruvate Lactatic AcidosisLactatic Acidosis
SHOCK Classification of Shock
A- Classification of Shock by CausesA- Classification of Shock by Causes
(1) Hypovolemic shock (1) Hypovolemic shock
(2) (2) Cardiogenic shockCardiogenic shock(3) (3) Neurogenic shockNeurogenic shock(4) Anaphylactic shock(4) Anaphylactic shock(5) Septic shock(5) Septic shock
BB. . Classification of Shock according to Classification of Shock according to hemodynamic changes:hemodynamic changes:
⑴⑴Hypodynamic Shock: Cardiac Output Hypodynamic Shock: Cardiac Output , ,
Vascular ResistaceVascular Resistace,,
Cold Skin;Cold Skin;
⑵ ⑵ Hyperdynamic Shock: Cardiac Output Hyperdynamic Shock: Cardiac Output ,,
Vascular Resistace Vascular Resistace ,,
Warm Skin;Warm Skin;
Metabolic Disturbances
Inadequate Blood Flow
Circulatory Failure
Different kind of Reason
Special Clinical Syndrome
Low blood flow
Skin,fat,skeletal
muscls,kidney,intestines
Heart,brain normal or
Systemic pathophysiologic responces of Shock
Redistribution of blood flow
Etiology & Hemodynamic Etiology & Hemodynamic Changes in ShockChanges in Shock
Etiology of Etiology of shockshock
exampleexampleCVPCVPCOCOSVRSVRVO2VO2 satsat
preloadpreloadhypovolemichypovolemiclowlowlowlowhighhighlowlow
contractilitycontractilitycardiogeniccardiogenichighhighlowlowhighhighlowlow
afterloadafterloaddistributivedistributive
Etiology & Hemodynamic Changes Etiology & Hemodynamic Changes in Shock (Afterload)in Shock (Afterload)
ETIOLOGY ETIOLOGY OF SHOCKOF SHOCK
EXAMPLEEXAMPLECVPCVPCOCOSVRSVRVO2 SATVO2 SAT
AFTERLOADAFTERLOADDISTRIBUTIVEDISTRIBUTIVE
HyperdynamicHyperdynamic
SepticSeptic
Low/HighLow/HighHighHighLowLowHighHigh
Hypodynamic Hypodynamic SepticSeptic
Low/HighLow/HighLowLowHighHighLow/HighLow/High
NeurogenicNeurogenicLowLowLowLowLowLowLowLow
AnaphylacticAnaphylacticLowLowLowLowLowLowLowLow
Hypovolemic ShockHypovolemic ShockDecreased preloadDecreased preload→→small ventricular end-small ventricular end-diastolic volumes diastolic volumes →→inadequate cardiac inadequate cardiac generation of pressure and flowgeneration of pressure and flowCausesCauses::
-- -- bleeding: trauma, GI bleeding, ruptured bleeding: trauma, GI bleeding, ruptured aneurysms, hemorrhagic pancreatitisaneurysms, hemorrhagic pancreatitis
-- -- protracted vomiting or diarrheaprotracted vomiting or diarrhea -- -- adrenal insufficiency; diabetes insipidusadrenal insufficiency; diabetes insipidus
-- -- dehydrationdehydration -- -- third spacing: intestinal obstruction, third spacing: intestinal obstruction,
pancreatitis, cirrhosispancreatitis, cirrhosis
Classes of acute hemorrhageClasses of acute hemorrhage Class IClass IClass IIClass IIClass IIIClass IIIClass IVClass IV
Blood Blood lossloss
< <750750 cc cc 0-15%0-15%
750-1500750-1500 15-30%15-30%
1500-1500-20002000
30-40%30-40%
> > 2000cc2000cc>>40%40%
HRHRNormalNormal
PPPPNormalNormal
BPBPNormalNormalNormalNormal
UOPUOPNormalNormalNormalNormalDecreasedDecreasedNegligibleNegligible
MentalMentalNormalNormalAnxiousAnxiousConfusedConfusedLethargicLethargic
FluidFluidCrystalloidCrystalloidCrystalloidCrystalloidCrys+bloodCrys+bloodCrys+bloodCrys+blood
*ATLS; 2004. 70kg male
Signs & Symptoms:Signs & Symptoms: Hypotension, Tachycardia, Hypotension, Tachycardia, change, Oliguria, Deminished Pulseschange, Oliguria, Deminished Pulses..
MarkersMarkers: monitor urine output UOP, central : monitor urine output UOP, central venous pressure CVP, blood pressure BP, heart venous pressure CVP, blood pressure BP, heart rate HR, hemaocrit Hct, mental state MS, rate HR, hemaocrit Hct, mental state MS, cardiac outputCO, lactic acid and pulmonary cardiac outputCO, lactic acid and pulmonary capillary wedge pressurePCWPcapillary wedge pressurePCWP
TreatmentTreatment: IVF (crystalloid), Trasfusion: IVF (crystalloid), Trasfusion, ,
Stem ongoing Blood LossStem ongoing Blood Loss
TRUE OR FALSE ?TRUE OR FALSE ?The earliest sign of hypovolemic The earliest sign of hypovolemic
shock is hypotensionshock is hypotension. .
TRUE OR FALSETRUE OR FALSEIn early stage of hypovolemic In early stage of hypovolemic shock the skin would be warm shock the skin would be warm
due to vaso-dilationdue to vaso-dilation. .
Septic/InflammatorySeptic/Inflammatory ShockShockThis type is due to infection/sepsis: G(-/+ ) This type is due to infection/sepsis: G(-/+ ) speticemia, pneumonia, peritonitis, meningitis, speticemia, pneumonia, peritonitis, meningitis, cholangitis, pyelonephritis, necrotic tissue, cholangitis, pyelonephritis, necrotic tissue, pancreatitis, wet gangrene, toxic shock pancreatitis, wet gangrene, toxic shock syndrome, etc. syndrome, etc. MechanismMechanism:: It is due to release of inflammatory mediators It is due to release of inflammatory mediators which leads to which leads to 1-Disruption of the microvascular endothelium 1-Disruption of the microvascular endothelium 2-Cutaneous arteriolar dilation and 2-Cutaneous arteriolar dilation and sequestration of blood in cutaneous venules and sequestration of blood in cutaneous venules and small veinssmall veins
Signs: Signs: EarlyEarly– warm with vasodilation (hyper dynamic – warm with vasodilation (hyper dynamic circulation), often adequate urine output, fever and circulation), often adequate urine output, fever and tachypnea.tachypnea. LateLate--- vasoconstriction, hypotension, oliguria, - vasoconstriction, hypotension, oliguria, altered mental status (hypodynamic circulation).altered mental status (hypodynamic circulation).Findings: Findings: EarlyEarly : : hyperglycemia, respiratory alkalosis, hyperglycemia, respiratory alkalosis, hemoconcentration, WBC typically normal or low.hemoconcentration, WBC typically normal or low. LateLate : Leukocytosis, lactic acidosis : Leukocytosis, lactic acidosis VeryLate :VeryLate :Disseminated Intravascular Coagulation & Disseminated Intravascular Coagulation &
Multi-Organ System FailureMulti-Organ System Failure . .
TreatmentTreatment : : Intravenous fluid IVF, Blood Intravenous fluid IVF, Blood transfusion, antibiotics, Drainage (ie transfusion, antibiotics, Drainage (ie
abscess) vasopressor agentsabscess) vasopressor agents. .
TRUE OR FALSE TRUE OR FALSE In hyperdynamic state of septic In hyperdynamic state of septic shock there is rapid washout of shock there is rapid washout of
metabolites because of increased metabolites because of increased blood supply to the tissuesblood supply to the tissues
Cardiogenic ShockCardiogenic ShockMechanismMechanism: Intrinsic abnormality of heart : Intrinsic abnormality of heart →→ inability to deliver blood into the vascular inability to deliver blood into the vascular tree with adequate powertree with adequate powerCausesCauses::
11 . .Cardiomyopathies: myocardial ischemia, Cardiomyopathies: myocardial ischemia, myocardial infarction, cardiomyopathy, myocardial infarction, cardiomyopathy, myocardiditis, myocardial contusionmyocardiditis, myocardial contusion
22 - -Mechanical: cardiac valvular insufficiency, Mechanical: cardiac valvular insufficiency, papillary muscle rupture, septal defects, papillary muscle rupture, septal defects, aortic stenosisaortic stenosis
33 - -Arrythmias: bradyarrythmias (heart Arrythmias: bradyarrythmias (heart block), tachyarrythmias (atrial block), tachyarrythmias (atrial fibrillation, atrial flutter, ventricular fibrillation, atrial flutter, ventricular fibrillation) fibrillation) 4- Obstructive disorders: pulmonary 4- Obstructive disorders: pulmonary embolism PE, tension peneumothorax, embolism PE, tension peneumothorax, pericardial tamponade, constrictive pericardial tamponade, constrictive pericaditis, severe pulmonary pericaditis, severe pulmonary hypertensionhypertension
Signs and symptoms : Dyspnea, rales, gallop, low Signs and symptoms : Dyspnea, rales, gallop, low BP, oliguriaBP, oliguria
Monitor/findings: CXR pulmonary venous Monitor/findings: CXR pulmonary venous congestion, elevated CVP, Low COcongestion, elevated CVP, Low CO..
Treatment : this will be according to cause egTreatment : this will be according to cause eg
Congestive heart failure CHF– diuretics & Congestive heart failure CHF– diuretics & vasodilators +/- pressorsvasodilators +/- pressors..
Left ventricular LV failure – pressors , Left ventricular LV failure – pressors , decrease afterload, intraaortic ballon pump & decrease afterload, intraaortic ballon pump &
ventricular assist deviceventricular assist device . .
Neurogenic ShockMechanism: Loss of autonomic innervation of the cardiovascular system (arterioles, venules, small veins, including the heart)Causes:
*Spinal cord injury*Regional anesthesia
*Drugs *Neurological disorders
Characterized by loss of vascular Characterized by loss of vascular tone & reflexes.tone & reflexes.Signs: Hypotension, Signs: Hypotension, Bradycardia, Accompanying Bradycardia, Accompanying Neurological deficits. Neurological deficits. Treatment : IVF, vasoactive Treatment : IVF, vasoactive medications if refractorymedications if refractory
Anaphylactic shockAnaphylactic shock::
This type occurs due to binding of a foreign This type occurs due to binding of a foreign antigen to immunogloin E (IGE) on the antigen to immunogloin E (IGE) on the mast cells and basophils , releasing large mast cells and basophils , releasing large amounts of amounts of histaminehistamine and and SRS-ASRS-A ( slow- ( slow-release substance-anaphylaxis) which will release substance-anaphylaxis) which will produce bronchospasm , laryngeal edema produce bronchospasm , laryngeal edema and respiratory distress with hypoxia , and respiratory distress with hypoxia , massive vasodilatation hypotension and massive vasodilatation hypotension and shock.This type occurs on exposure to shock.This type occurs on exposure to penicillinpenicillin , , anestheticanesthetic drugsdrugs , , serumserum injectionsinjections and and stingsstings. .
Monitoring of shock
1-General monitoring
Heart rateBreathing
Monitoring of shock
22 .. Colour and Colour and temprature of skin temprature of skin
Monitoring of shock
3 . BP Systolic Pressure was
lower than 12kPa(90mmHg)
4. Urina
Oliguria
Special monitoring Special monitoring
1.CVP 5-10cmH1.CVP 5-10cmH22O O CVP<5cmHCVP<5cmH22O Inadequecy of blood volumeO Inadequecy of blood volume CVP>12cmHCVP>12cmH22O Cardiac dysfunctionO Cardiac dysfunction 2.Lung arterial pressure2.Lung arterial pressure 3.Cardiac output3.Cardiac output 4.Blood gas PO4.Blood gas PO22 75-100mmHg75-100mmHg PcoPco22 40mmHg 40mmHg PH 7.35—7.45PH 7.35—7.45 5.Coagulation test5.Coagulation test
Monitoring of shock
Treatment of the shockPosition of Body 30 。
TRUE OR FALSE TRUE OR FALSE * shock in intestinal obstruction * shock in intestinal obstruction
is multifactorialis multifactorial . .