SHOCK - Yola

SHOCK - Yola

SHOCK M K ALAM MS;FRCS ILOs At the end of this presentation students will be able to: Describe the different types of shock. Understand the pathophysiology of different types of shock.

Explain the effect of shock on different organs. Discuss the management of each type of shock. Introduction Definition: A state of inadequate delivery of oxygen and nutrients to maintain normal tissue and cellular function. Untreated results in anaerobic metabolism, tissue acidosis & cellular dysfunction leading to multi organ dysfunction and death.

Types of Shock Hypovolemic. Septic. Cardiogenic. Anaphylactic. Neurogenic. Hypovolemic Shock (HS) Most common type in surgical practice. Reduction in intravascular volume. o

Blood loss: Trauma, GI bleeding, ruptured aneurysm o Plasma loss: Burn o Water & electrolytes loss: Diarrhoea, vomiting

Easily correctable. Hypovolemic Shock- pathophysiology Catecholamines release- adrenal medulla, sympathetic nerve endings. AT II- renin-angiotensin system. Tachycardia, vasoconstriction. Increased myocardial contractility attempting to maintain CO. Later CO. Maintains blood flow to vital organs- brain, heart & muscle. Diverts blood from non-vital organs- skin (pale, cold, prolonged capillary refill), gut

Classes of hemorrhagic shock Class I Class II Class III Class IV Blood loss Up to 750

(ml) 750- 1500 1500- 2000 > 2000 Pulse <100

>100 >120 >140 BP Normal

Normal/low normal Decreased Decreased Established hemorrhagic Shock Tachycardia Vasoconstriction Decreased cardiac output

Narrow pulse pressure (increased diastolic pressure) Decreased blood flow Septic Shock (SS) Sepsis induced hypotension (systolic < 90 mmHg). Disturbance in O delivery and O consumption. Gram positive (52%), Gram negative (38%) infections. Common sites of infection: Lung (50-70%), abdomen (20-25%), urinary tract (5-7%), skin.

Septic Shock- pathophysiology Infection- triggers cytokines (TNF-, IL 1-) mediated pro-) mediated proinflammatory response. Peripheral vasodilatation (NO), redistribution of blood flow. Increased cardiac output (CO)- High output state. Warm well perfused periphery, low diastolic BP, wide pulse pressure. Septic Shock- pathophysiology If septic state persists: vascular permeability (endothelial dysfunction), loss of intravascular volume. Ventricular dysfunction affects CO.

Peripheral perfusion falls- now indistinguishable from hypovolemia. Microthrombi formation within microcirculation. Microcirculatory dysfunction impairs O delivery to cells. Mitochondrial dysfunction impairs O utilization within cell. Cardiogenic Shock (CS) Causes: Myocardial infarction, arrhythmias, valve dysfunction, massive pulmonary embolism, cardiac tamponade and tension pneumothorax.

A pump failure: Heart unable maintain adequate cardiac output to meet metabolic requirements. Low output state. Normal circulating volume. Anaphylactic Shock (AS) Severe systemic reaction to an allergen. Drugs (antibiotics, dextran, radiological contrasts), food (peanuts, shellfish, dairy) insect stings and latex. Release of vasoactive mediators from basophil & mast cells

(histamine, kinins, prostaglandins) . Reaction mostly mediated by IgE, IgG, or complement. Shock: Vasodilatation, intravascular volume redistribution, capillary leak and reduced CO. Neurogenic Shock (NS) Injury to spinal cord (cervical, thoracic), high spinal anaesthesia. Disruption of sympathetic efferent.

Loss of vasomotor tone- profound vasodilatation, fall in peripheral vascular resistance. loss of cardiac stimulation (T1-4). Loss of sweat gland innervation- anhydrosis. Hypotension, bradycardia, dry & warm periphery Microcirculation in shock Microcirculation: Arterioles, capillaries & venules Early HS & CS: Arteriolar vasoconstriction fall in capillary hydrostatic pressure

shift of interstitial space fluid to intravascular space to maintain intravascular volume. SS: Disruption of microcirculation & activation of coagulation, DIC Shock uncorrected: Accumulation of lactic acid, CO, endothelium factors pre-capillary vasodilatation. Pooling of blood in capillary bed, capillary permeability leading to loss of fluid into interstitial space. Increased viscosity, platelet aggregation, microthrombi formation.

Cellular function in shock Anaerobic metabolism - accumulation of lactic acid O extraction initially, continued O supply results fall in its use. Anaerobic glycolysis generating only 2 moles of ATP vs 38 in normal state. Intracellular accumulation of Na leads to cell swelling. Disruption of protein synthesis, lysosomal & mitochondrial damage due to fall in pH (due to lactic acidosis) Less ATP supply leads to cell dysfunction, ultimately cell death. Effects of shock on organs function

CVS: coronary blood flow myocardial ischemia CO. Widespread endothelial activation microcirculatory dysfunction. RS: Tachypnoea Pulmonary edema (cardiogenic shock) Acute lung injury hypoxia. Effects of shock on organs function CNS: Restless, confusion, coma GIT: Splanchnic hypoperfusion breakdown of gut

mucosal barrier bact./bact. wall content entry into circulation SIRS Renal: Hypoperfusion oliguria anuria Acute renal failure: urea, creatinine, K& metabolic acidosis. Management- general principles Identification & treatment of underlying cause. Like most emergencies- ABC approach. Admission to HDU or ICU Adequate O delivery: Maintaining airway,

high flow O delivery (10-15L/ min) Pulse oximetry, frequent ABG Intubation & ventilatory support. Hypovolemic shock o Blood loss*: Trauma, GI bleeding, ruptured aneurysm o Plasma loss: Burn o Water & electrolytes loss: Diarrhoea, vomiting *

Commonest cause in surgical practice. Indicators of hypovolemic shock Tachycardia*

Agitation Tachypnea Sweating Cool extremities Collapsed neck veins Weak peripheral pulse Decreased pulse pressure Hypotension Oliguria

Low CVP Management of HS Hemorrhage: Arrest external bleeding Fluid resuscitation- Two wide bore (14-16 gauge) peripheral venous access. Crystalloid infusion- titrated to clinical response. PRBCs: Life threatening/ continued bleeding. Diagnosis & treatment: Bleeding source ,?other causes, specific treatment. Invasive monitoring: CVP, PAWP, acid-base status Vasopressor & inotropes- little role Urine output monitoring- Foley catheter

Management Parameters of improvement: Reduction in tachycardia. Increasing blood pressure. Improving peripheral perfusion. Improving urine output. CVP rise Management- septic shock Crystalloid infusion ( target CVP 8 mmHg).

Urine output: 0.5 ml/kg/hr. Vasopressors (noradrenaline):Persistent hypotension, after volume restoration Serum lactate: Monitor tissue perfusion. Identification of underlying infection: History, examination & investigations Treatment of infection: IV antibiotics (empirical, post-culture), Radiological / Surgical intervention. PCD- intra-abdominal abscess Management of cardiogenic Shock Myocardial infarction- commonest cause.

Tension pneumothorax, traumatic cardiac tamponade- trauma. Hypotension, cool and mottled skin, depressed mental status, tachycardia, and diminished pulses, dysrhythmia. Distended neck veins , Raised CVP. ECG, echocardiography, CXR,ABG, CK-MB, troponin. Maintenance of adequate oxygenation. Judicious fluid administration to avoid fluid overload. Cardiology consultation. Thoracocenteasis, pericardiocentesis in trauma. Management of neurogenic shock

Acute spinal cord injury: Bradycardia, hypotension, cardiac dysrhythmias, reduced cardiac output, and decreased peripheral vascular resistance. Airway secured, adequate ventilation. Fluid resuscitation to restore intravascular volume. Administration of vasopressor. Management of anaphylactic shock Stop administration of causative agent. Maintain airway, give 100% O. Adrenaline 0.5-1 mg (0.5-1 ml 1:1000) IM.

IV crystalloid. 2nd line: Antihistamine- chlorphenamine 120 mg slow IV or Hydrocortisone 200 mg IV Thank you!

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