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 . .