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8/7/2019 PKI 5002 SHOCK
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SHOCK
IN MULTIPLE INJURY
PKI 5002
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Definition
Acute circulatory failure with inadequate tissue
perfusion resulting in generalized tissue
hypoxia.
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Homeostasis
Adequate cellularoxygenationdependson
Red celloxygenation
Oxygendeliverytoalveoli
Oxygenexchange with blood
Red celldeliverytotissues
Adequateperfusion
Bloodvolume
Cardiac output Hb levels
Distance between capillariesand cells
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Pathophysiology
Inadequatetissueperfusion causes:
Generalized cellular hypoxia
Shiftfromaerobic toanaerobic metabolism
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Aerobic Metabolism
METABOLISM
6 O2
GLUCOSE
6 CO2
6 H2O
36 ATP
HEAT (417 kcal)
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Anaerobic Metabolism
METABOLISMGLUCOSE
2 LACTIC ACID
2 ATP
HEAT (32 kcal)
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CONSEQUENCE OF ANAEROBIC
METABOLISM
Inadequate cellular
Oxygendelivery
Inadequat
eenergy
productionAnaerobic
metabolism
Lactic acid
production
Metabolic
acidosisCellDeathMetabolic
failure
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The three essential patterns of circulatory
shock
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SHOCK SYNDROMES
Hypovolaemic Shock
blood VOLUME problem
Cardiogenic Shock
blood PUMP problem
Distributive Shock
blood VESSEL problem
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Hypovolemic Shock
= Low Volume
Aetiology:
Internalorexternalfluidloss
Intracellularandextracellular compartment
Most common causes:
Haemorrhage
Dehydration (non-haemorrhagic)
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Pathophysiology Hypovolaemic Shock
Decreased intravascular volume
Decreasedvenousreturn
Decreasedventricularfilling
Decreasedstrokevolume
Decreased CO
Inadequate tissue perfusion!!!!
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Signsofseverity
Grade 1
Uptoabout 15% lossofeffective bloodvolume
(~750mlinanaverageadult whoisassumedto
havea bloodvolumeof5 liters)
Thisleadstoamildrestingtachycardia
Usually,no changesinBP,pulsepressure,orrespiratoryrateoccur.
Adelayin capillaryrefilloflongerthan 3 secondscorrespondstoavolumelossofapproximately10%.
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Cont
Grade 2
Between 15-30% lossofbloodvolume
750-1500ml amoderatetachycardia (rate >100 beatsper
minute),tachypnoea,decreaseinpulsepressure,
cool clammyskinand begintonarrow thepulse
pressure. Thetimetakenforthe capillariestorefillafter 5
secondsofpressure will beextended.
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cont
Grade 3
30 - 40% lossofeffective bloodvolume
1500 - 2000 ml the compensatorymechanisms begintofail
hypotensionandtachycardia
low urineoutput (
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cont
Grade4
At40-50% lossofbloodvolume
2000 -2500 ml
Symptomsincludethefollowing:markedtachycardia,
decreasedsystolic BP,narrowedpulsepressure (or
immeasurablediastolic pressure),markedlydecreased (or
no) urinaryoutput,depressedmentalstatus (orlossof
consciousness),and coldandpaleskin. Thisamountofhemorrhageisimmediatelylife
threatening.
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Management hypovolaemic shock
Hemorrhage control
Restorevolume
Optimizeoxygendelivery
Enough circulatingred cell
Red celloxygenation
Red celldelivery
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Fluid Resuscitation
Crystalloids
Such assodium chloride (0.9%) or
La
ctated
Ringers
solution
(Hartmann's
solution
)
Dextrosesolutions which containfree waterare
lesseffectiveatre-establishing circulatingvolume
andpromote hyperglycemia.
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cont
Colloids
Forexample,polysaccharide (Dextran),polygeline(Haemaccel),succinylated gelatin (Gelofusine) and
hetastarch (Hespan). Much moreexpensivethan crystalloidsolutions
Combination
colloidsand crystalloids
Blood Essentialinsevere hemorrhagic shock,oftenpre-
warmedandrapidlyinfused
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Cardiogenic Shock
Theimpairedabilityofthe hearttopump
blood
Pumpfailureoftherightorleftventricle
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Etiology Cardiogenic Shock
Pump Failure
Acute M I
CHF
Bradyarrhythmias
Tachyarrhythmias
Cardiomyopathy
ObstructiveObstructive
(Mechanical flow
obstruction)
Tension
pneumothorax
Pulmonaryembolism
Cardiac tamponade
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Pathophysiology Cardiogenic Shock
Decreased SVDecreased CO
DecreasedBP
Decreasedtissueperfusion!!!!
Inadequatesystolicemptying
Increased LV fillingpressure(preload)
Increased LApressure
Increasedpulmonarycapillarypressure
Pulmonaryinterstitial &intraalveolar oedema!!!!
Impaired pumping
ability of LV
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Management Cardiogenic Shock
Goals:
Treatreversible
causes
Protect ischaemicmyocardium
Improvetissue
perfusion
Treatment is aimed at :
Earlyassessment &
treatment!!!
Optimizingpump by:
Increasingmyocardial O2delivery
Maximizing CO
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DISTRIBUTIVE SHOCK
Vasogenic
Septic
Anaphylactic
Acuteadrenal
insufficiency
NeurogenicNeurogenic (Lossofsympathetic
tone)
Spinal cordinjuryabove T6
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Anaphylactic Shock
Resultsfrom widespreadsystemic allergic
reactiontoanantigen
LIFETHR
EAT
EN
ING
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Pathophysiology Anaphylactic Shock
Antigenexposure
Bodystimulatedtoproduce IgE antibodiesspecifictoantigen
drugs, bites, contrast, blood, colloid,foods,vaccines,latex
Reexposure toantigen
IgE bindstomast cellsand basophils
Causes histaminerelease
Anaphylactic response
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Anaphylactic Response
Vasodilatation
Increasedvascularpermeability
Bronchoconstriction
Increasedmucusproduction
Increasedinflammatorymediators
recruitmenttositesofantigeninteraction
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ManagementAnaphylactic Shock
Earlyrecognition,treataggressively
Stopsuspecteddrug
Maintainairway:give 100% O2 Layflat & elevatefeet IV Adrenaline
Fluidresuscitation
Antihistamines
Corticosteroids
Bronchodilators
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DIAGNOSIS OF SHOCK
Based clinicallyonthepresenceofatleast 2 offollowing4 criteria
Hypotension
SBP < 90 mmHgor
MAP < 60 mmHgor
SBPq >40 mmHgfrom baseline
Oliguria < 0.25 ml/kg/hour
Cold, clammyskinand/or cloudysensorium
Metabolic acidosis
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EXPOSURE
Exposepatient
Quick surveyfrom headtotoe
Donotforgetpatients back Logrollif? C-spineinjury
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PRIMARY SURVEY
Ask thepatientdirectly
How areyou?
Ifpatientgivesameaningfulanswer:
The brainisreasonablyfunctional
Thereisanintactairway
Ventilationisoccurring
Circulationispresent
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SECONDARY SURVEY
Further history
Head-to-toe & front-to-back examination
Lab tests:ABG, clottingstudies,andetc
X-rayeverythingthat hurts
CT scan,onlyifstable
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RESUSCITATION
ENDPOINTS
Restorationofnormalvitalsigns
Adequate Urineoutput(0.5 - 1.0 ml/kg/hr) Adequate Cardiac Index Normalizationof
OxygendeliveryDO2I Normal Serum Lactatelevels
Bloodlactate < 4mmol/l
Basedeficit-3 to +3mmol/l
CVP = 15 mmHg
These endpoints
represent normalhemodynamicparameters in
adults.