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Shock

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EMERGENCY MANAGEMENT

EMERGENCY MANAGEMENT

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  • 1. Shock : Pathophysiology Causes & Management Dr.Anil Haripriya Assistant Professor Surgery NHDC & RC
  • 2. Introduction
    • “ Rude unhinging of machinery of life’
        • Gross
    • Inadequate delivery of oxygen and nutrients to maintain normal tissue and cellular function
    • Clinically accompanied by hypotension
    • MAP < 60 mmHg in a previously normotensive person
  • 3. Types of Shock
    • Hypovolemic
    • Vasodilatory (Septic)
    • Neurogenic
    • Cardiogenic
    • Obstructive
    • Traumatic
  • 4. Pathophysiology
    • Physiologic response to hypovolemia directed
    • at preservation of perfusion to vital organs
    • - Increase cardiac contractility & peripheral vascular tone via ANS
    • - Hormonal response to preserve salt & water
    • - Change in local micro circulation to regulate
    • regional blood flow
  • 5. Neuroendocrine response
    • Mediated via baro & chemo receptors which stimulates ANS & HPA axis
    • release of epinephrine & norepinephrine
  • 6. Hormonal response Hypothalamus Hyperglycemia Lypolysis Gluconeogenesis Glycogenolysis Cortisol ACTH CRH
  • 7. Hormonal response
    • Stimulation of renin angiotensin system
    • Release of ADH to conserve salt &
    • water
  • 8. Cellular response
    • Inadequate delivery of oxygen & substrates
    • leads to in oxidative phosphorylation & ATP
    • generation
    • Anaerobic respiration leads to lactic acidosis
  • 9. Cellular response
    • Na+,K+ ATP ase activity decrease leading to
    • accumulation of Na+ & leak of K+
    • Cellular gene expression for HSP,VEGF,NO
    • synthase & cytokines is also increased
  • 10. Hypovolemic shock
    • M/C form of shock
    • Due to loss of blood, plasma, extravascular
    • sequestration
    • C/f and severity depends upon amount of volume lost
  • 11. Hypovolemic shock
    • Causes
    • - Trauma
    • - Severe dehydration
    • - Burns
    • - Intestinal obstruction
    • - Perforation peritonitis
  • 12. Hypovolemic shock
    • Phases
    • - Compenseted
    • - Decompenseted
    • - Irreversible
  • 13. Hypovolemic shock Same + Hypotension Mental status deterioration Same + Tachycardia Tachypnoea Oliguria Postural -hypotension Cold extremities CRT Diaphoresis Anxiety Severe(>40%) Moderate(20-40%) Mild (<20%)
  • 14. Cardiogenic shock
    • Circulatory pump failure in setting of adequate vascular volume
    • Sustained hypotension SBP < 90 mm Hg for at least 30 minutes
      • CI < 2.2 L/min/m 2
      • PAWP >15mmHg
    • Surgical importance in patients with chest trauma for
      • Tamponade
      • Tension pneumothorax
  • 15. Cardiogenic shock
    • Chest pain
    • Hypotension
    • Arrhythmias
    • Beck’s triad
  • 16. Vasodilatory shock
    • Characterised by peripheral vasodilatation with hypotension & resistance to T/t with vasopressors
    • Causes
    • - Septic shock
    • - Hypoxic lactic acidosis
    • - CO poisoning
    • - terminal stage of cardiogenic & hemorrhagic shock
  • 17. Septic shock
    • Manifestation of excessive & inflammatory response of endogenous immune mechanism
    • Sepsis is SIRS with established focus of infection
    • Septic shock - severe sepsis unresponsive to continuous fluid infusion and inotropes
  • 18. Septic shock Gram –ve bacilli LPS+CD14 TNF IL-1 IL-6/IL-8 NO/PAF
  • 19. Neurogenic shock
    • tissue perfusion as a result of loss of vasomotor tone to peripheral arterial beds
    • Secondary to spinal cord injury from vertebral #
    • - Hypotension with bradycardia
    • Warm extremities
    • Motor and sensory deficit
  • 20. Management
    • Initially empirical
    • Air way secured + oxygenation
    • Two wide bore lines
    • I.V. fluids NS/BSS
    • Catheterisation
    • Insertion of central venous catheter
    • Hb, CBC, Blood sugar, urea, creatinine, electrolytes
    • ABG
  • 21. Hypovolemic shock
    • I.V. fluid NS/RL 2-3 liters over 15-30 min
    • If hemodynamic instability persist then start blood transfusion & control on going heamorrhage
    • Ionotropic like
    • Dopamine 5-10microgms/Kg/min
    • Dobutamine 2-20microgms/Kg/min
  • 22. Cardiogenic shock
    • Conformation of diagnosis by ECG & ECHO
    • Intubation & mechanical ventilation often required
    • Avoid fluid overload
    • Ionotropic support preferably Dobutamine 2-20microgms/Kg/min
    • USG guided pericardiocentesis
  • 23. Neurogenic shock
    • Restoration of intravascular volume by crystalloids
    • Vasoconstrictor
    • Dopamine > 10microgms/Kg/min
    • Phenylephrine 0.2-2.9microgms/Kg/min
  • 24. Septic shock
    • Culture of body fluids
    • Infuse BSS 500 cc/15min monitor SBP/CVP
    • Repeat if CVP 8-12mmHg
    • Goal to have a MAP of 65 mmHg & P < 120/min
    • If hemodynamic instability persists start vasopressor preferrably Norepinephrine 0.02-0.25microgms/Kg/min
    • Broad spectrum antibiotic given
  • 25. Aims of resuscitation
    • CVP of 8-12 mmHg/ PCWP 8-12 mmHg
    • MAP of > 65 mmHg
    • Urine output of 0.5ml/Kg/hr
    • Hb of 7-9 gm%
    • CI of > 4.2 L/Kg/m 2 of BSA
  • 26. End Points of resuscitation
    • Resuscitation complete when oxygen debt repaid,tissue acidosis corrected & aerobic metabolism restored
    • Systemic Parameters
    • Lactate
    • Base deficit
    • Tissue Parameters
    • Gastric tonometery
    • Near infrared spectroscopy
  • 27. Conclusion
    • Early recognition of warning signs and diagnosis in the reversible phase important for successful management of shock
    • Hypovolemia and sepsis account for majority of shock in surgical patients
    • Principles of initial resuscitation same irrespective of type of shock
    • Ultimate treatment of underlying cause forms cornerstone of management