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Types of shock

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					SHOCK
DEFINITION

     Inadequate delivery of oxygen and
substrates to meet the metabolic needs of the
tissues.

 Prompt diagnosis is essential, as the prognosis
depend on severity and duration.
Pathophysiology…
Types of shock

  Hypovolaemic
  Cardiogenic
  Septic
  Anaphylactic
  Vasovagal
  Neurogenic
Hypovolaemic shock
Causes
    Hemorrhage

    Non haemorrhagic
         Burns
         Diarrhea
         Vomiting
         Intestinal obstruction
         Peritonitis
         Urinary loss(DM)
Hypovolaemic shock
   4 classes

   Depends on
        % of total blood volume loss
        Associated symptoms & signs
           Classes of hypovolaemic shock…
% Loss of   Pulse     Systolic   Pulse p    Capillary Respiration   CNS       Urine
Circulating rate      P                     refill                            output
blood
volume

<15%        Normal    Normal     Normal     Normal    Normal        Normal    >30ml/hr

15 – 30%    >100      Normal     Reduced    Delayed   Mild          Anxious   20 –
                                                      tachynpnea              30ml/hr
30 – 40%    >120      Reduced Reduced       Delayed   Marked        Confused 10 –
            Weak                                      tachypnea              20ml/hr
>40%        >140      Very       Markedly   Absent    Marked        Lethargic <10ml/hr
            Thready   low        reduced              tachypnea
Management…
  ABC approach
  High flow O2 via face mask.
  2 large bore iv cannulae.
  Take blood for FBC, SE, grouping &
   cross matching.
  Crystalloids or colloids for initial
   resuscitation.
  Identify site of bleeding, and take
   necessary actions to arrest it.
Management cont….
  - Inform the blood bank, OT, Anesthetist
  - Blood O-ve - for very urgent cases
    Group specific - for urgent cases
    Fully cross matched - if there is time

  - All IV fluids should properly warm before
   giving to the patient
    Because hypothermia (<35oC) – high motility

 Aggressive fluid resuscitation- increased bleeding
Anaphylactic shock
Anaphylactic shock
 -   Ig E mediated Type I hypersensitivity
     reaction to an antigen
 -   Release of histamine & serotonin from
     mast cells & basophils
 -   Common causative agents -
                    Drugs
                    Radio –contrast media
                    Blood products
 Presentation


     - Cardiovascular collapse
     - Erythema
     - Bronchospasm
     - Angioedema
     - Rash
     - Urticaria
     Anaphylactic shock- management
   Immediate
     - Stop administration of any potential triggering agent.

     - Check ABC
     - Call for help
     - Maintain the airway & give 100% O2
     - Lay the patient flat & legs up
     - Adrenaline (1:1000) 0.5 - 1ml IM, repeat every 5-
       10min
     - IV fluids (crystalloids or colloids)
 Subsequent   management

  - Hydrocortisone – 100mg - 300mg iv

  - Antihistamines – chlorpheniramine 10mg iv

  - Check ABG - consider NaHCO3 if acidotic

  - Consider bronchodilators if bronchospasms
Septic shock
Septic shock
-   Severe sepsis & arterial hypotension
    refractory to fluid resuscitation.
-   Due to infection mainly with gram
    negative organisms.
   Clinical features

      Fever with chills and rigors or hypothermia
      Hypotension
      Tachypnoea, tachycardia
      Nausea and vomiting
      Vasodilatation, warm peripheries
      Bounding pulse

     With a history suggestive of infection
Diagnosis

 Full Blood Count with Differential count
 Platelet count
 Sepsis Screen
    ◦ Cultures - blood, urine, sputum – prior to antibiotics
 Basic chemistry – serum bilirubin, serum lactate,
  renal function tests
 Coagulation screen
Management…
   Fluid Resuscitation
      Crystalloids or colloids
      Target CVP - >8mmHg


 Vasopressors
      Maintain MAP >65 mmHg
      Noradrenalin
      Add Dobutamine if cardiac dysfunction
Management cont…
     Antibiotics

      ◦ Start with broad spectrum antibiotics
        empirically, adjust according to sensitivity.

      ◦ Duration 7-10 days
Septic shock management cont…

      Low dose Steroids

      ◦ Hypotension respond poorly to fluids/ Vasopressors
         Hydrocortisone 200 - 300mg/day x 7d

      Blood

      ◦ IF HB% <7g/dl
Cardiogenic shock
Cardiogenic shock
  Causes
   ◦   MI
   ◦   Arrhythmia
   ◦   Valvular heart disease
   ◦   Tension pneumothorax
   ◦   Cardiac tamponade
   ◦   Cardiac contusion
   ◦   Cardiomyopathies
   ◦   Pulmonary Embolism
Cardiogenic shock management
     Management depends on the cause
        General measures are
          Give high flow O2
          Put patient on cardiac monitoring
          An ECG
          Send blood for
                ABG
                FBC
                Cardiac enzymes
                BU & SE
          Urgent echocardiogram
          Chest x ray
          Catheterize the pt and monitor UOP
Management cont…
   Further management depends on the cause

     Arrhythmias       - Anti arrhythmatics

      MI               - GTN, Heparin or Streptokinase,
                        Aspirin.

      Fluid overload   - Diuretics (Frusemide 40mg iv)

      Tension pneumothorax - Needle thoracotomy,
                             IC tubes

      Cardiac tamponade - Emergency pericardiocentesis
                          Emergency thoracotomy
                          Aggressive fluid resuscitation
Shock management…other measures
     DVT prophylaxis
        - LMWH
        - Mechanical prophylaxis devices


     Stress ulcer prophylaxis
        - H2 receptor blockers or proton pump inhibitors


     Renal replacement therapy
        - Intermittent haemodialysis
        - Continuous veno-venous haemofiltration
Neurogenic Shock
    Traumatic or pharmacological blockage of
     the sympathetic nervous system causes
     dilation of arterioles and capacitance veins
     leading to relative hypovolaemia and
     hypotension
Vasovagal shock
    Pooling of blood in larger vascular
     reservoirs(limb muscles) and dilation of
     splanchnic arterioles lead reduced venous
     return to heart causing low cardiac output.

				
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posted:1/6/2012
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