Patient With Shock

8/13/2019 Patient With Shock

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DR I. K. OWUSU

PATIENT IN SHOCK


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What is Shock?

Shock is a physiologic state characterized by

a significant reduction of systemic tissue

perfusion,

resulting in decreased oxygen delivery tothe tissues.

This creates an imbalance between oxygen

delivery and oxygen consumption.

Prolonged oxygen deprivation leads to cellular

hypoxia and derangement of critical

biochemical processes at the cellular level,

which can progress to the systemic level andif untreated, to death.


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What is Shock? contd

In shock, cardiac output may be high (sepsis) orlow (eg cardiogenic shock)

The common factor is failure of tissue oxygen

delivery and/or utilisation


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Epidemiology

Mortality

Septic shock 35-40% (1

month mortality)Cardiogenic shock 60-90%

Hypovolemic shock

variable/mechanism


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Effects of Shock contd

The effects of oxygen deprivation are initiallyreversible, but rapidly become irreversible.

The result is

sequential cell death,end-organ damage,

multi-system organ failure, and

death.

This highlights the importance of prompt

recognition and reversal of shock


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Hypovolaemic (Low-volume

shock)

Occurs from excssive loss of blood orfluid leading to circulatory instability:

Heamorrhage may be internal eg

upper GIT bleeding, rupturedanuerysm or external .eg bleeding

from laceration

Fluid loss - e.g. diarrhea, vomiting,burns, third spacing, iatrogenic


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Septic Shock (Vasodilative

shock)

Septic shock is brought on byinfection from certain bacteria that

release a chemical mediators which

affects the proper functioning of the

blood vessels. Vascular tone is

reduced leading to vasodilatation

and pooling of blood into the

vascular system.


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Anaphylactic/Allergic shock

(Vasodilative shock)

Anaphylactic shock occurs whenthere is sudden release of

histamine and other chemical

mediators in response to injection of

a particular foreign substance, as in

the case of an insect sting or certain

medications.

This leads to reduction in vascular

tone, vasodilatation and pooling of


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Cardiogenic Shock

This results from any circumstance that severelyaffects the pumping action of the heart. These

include:

Acute myocardial infarction

Heart failure eg from dilated cardiomyopathy

Arrythmia

Pulmonary embolism

Pericardial tamponade

Cardio-depressant drugs (drugs with negative

ionotopic effects), such as

Beta-blockers

Calcium channel blockers


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Neurogenic shock

Manifested by fainting ,

occurs when the regulating

capacity of the nervoussystem is impaired by severe

pain, profound fright, or other

overwhelming stimulus.


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Clinical presentation

Depends upon the severity and speed of onset ofcause and the physiologic reserve of the host

Systolic BP < 90 mmHg with features of reduced

organ perfusion.


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Clinical Presentation

Clinical presentation varies with type and cause,

but there are features in common

Hypotension (SBP


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Assessment

Should be rapid

If patient can speak, take a brief focused history

If not, assess the patient whilst questioning

relatives


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Check immediately

Airway competence

Breathing

Circulation-pulse rate, rhythm, volume &

character


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Obtain the following

12-lead ECG

Chest X-ray

Arterial blood gas analysis

Urgent biochemistry: BUE, glucose, Calcium FBC If sepsis is suspected, blood C/S


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Treatment

Manage the emergency

Determine the underlying cause

Definitive management or support


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Manage the emergency Control airway and breathing Maximize oxygen delivery

Establish good peripheral IV access

If significant bradycardia, give atropine 0.5-1 mg IV

and refer to Cardiologist for a possible pacing If the patient is not in cardiogenic shock,

Give rapid IV fluid challenge (eg normal saline)

If the BP remains low (


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Determine the Cause

Often obvious based on history

Trauma most often hypovolemic (hemorrhagic)

Postoperative most often hypovolemic(hemorrhagic or third spacing)

Debilitated hospitalized pts most often septic

Must evaluate all pts for risk factors for MI and

consider cardiogenic

Consider distributive (spinal) shock in trauma


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Definitive Management

Hypovolemic Fluid resuscitate (blood or

crystalloid) and control ongoing loss

Cardiogenic - Restore blood pressure(chemical and mechanical) and prevent

ongoing cardiac death

Vasodilatory/Dilatstributive Fluidresuscitate, pressors for maintenance,

immediate antibiotic control for infection,

etc

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Patient With Shock