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Shock sinai - copy

  1. 1. SHOCKSHOCK PresentsPresents byby S. VimalaS. Vimala
  2. 2. SHOCKSHOCK DefinitionDefinition::  Acute wide spread impaired tissueAcute wide spread impaired tissue perfusionperfusion  Circulatory collapse which leads toCirculatory collapse which leads to hypoperfusion & hypoxiahypoperfusion & hypoxia  Cellular, metabolic andCellular, metabolic and hemodynamic disarrangementshemodynamic disarrangements occuroccur
  3. 3. ShockShock  Shock is defined as inadequateShock is defined as inadequate perfusion to the tissues of the bodyperfusion to the tissues of the body  The body isn’t getting enoughThe body isn’t getting enough oxygen or nutrients to feed itself.oxygen or nutrients to feed itself.  There are different types of shockThere are different types of shock and though they are all similar, theyand though they are all similar, they act upon the body in different ways.act upon the body in different ways.
  4. 4. Clinical Manifestations:Clinical Manifestations: of Shockof Shock  Differ according with the stageDiffer according with the stage  Try to improve tissue perfusion:Try to improve tissue perfusion: Depends on how much O2 isDepends on how much O2 is availableavailable  If it is transported to the tissuesIf it is transported to the tissues  If they are able to use it.If they are able to use it.
  5. 5. Clinical Manifestations:Clinical Manifestations: of Shockof Shock This is affected by: Hb level,This is affected by: Hb level, cardiac output and pulmonary gascardiac output and pulmonary gas exchangeexchange Hb and cardiac output are going toHb and cardiac output are going to depend on the HR, preload,depend on the HR, preload, afterload and contractilityafterload and contractility
  6. 6. How does it happen?How does it happen?  Shock is a process that happens on aShock is a process that happens on a cellular level.cellular level.  Most forms of shock are caused byMost forms of shock are caused by inadequate delivery, which meansinadequate delivery, which means the body doesn’t have the adequatethe body doesn’t have the adequate amounts of oxygen or nutrients itamounts of oxygen or nutrients it needs to surviveneeds to survive
  7. 7. How does it happen?How does it happen?  Some are caused bySome are caused by inadequate utilization,inadequate utilization, meaning the body has what itmeaning the body has what it needs to survive, it justneeds to survive, it just doesn’t know how to use it.doesn’t know how to use it.  Shock, if not quicklyShock, if not quickly recognized and rapidlyrecognized and rapidly reversed, will be fatal.reversed, will be fatal.
  8. 8. ShockShock  CausesCauses::  Decrease volume or loss ofDecrease volume or loss of intravascular volume (Hypovolemic)intravascular volume (Hypovolemic)  Decrease cardiac output or ImpairedDecrease cardiac output or Impaired myocardial function (Cardiogenic)myocardial function (Cardiogenic)  Maldistribution of intravascularMaldistribution of intravascular volume (Distributive)volume (Distributive)
  9. 9. Maldistribution of intravascularMaldistribution of intravascular volume (Distributive)volume (Distributive)  Severe antibody antigen reactionSevere antibody antigen reaction (Anaphylactic)(Anaphylactic)  Loss of sympathetic toneLoss of sympathetic tone (Neurogenic)(Neurogenic)  Microorganisms invading bodyMicroorganisms invading body systems (Septic)systems (Septic)
  10. 10. The Four (4) Stages of ShockThe Four (4) Stages of Shock  Initial StageInitial Stage:: ↓↓ cardiac output,cardiac output, impaired tissue perfusion.impaired tissue perfusion. As blood supply to tissuesAs blood supply to tissues ↓↓  aerobic metabolism for a shortaerobic metabolism for a short periodperiod  anaerobic metabolism toanaerobic metabolism to get some energyget some energy byproducts arebyproducts are producedproduced acid lactic formationacid lactic formation  cellular damagecellular damage
  11. 11. Initial StageInitial Stage ↓ COCO ↓↓ ↓ ↓↓ ↓↓ ↓↓ Impaired tissue PerfusionImpaired tissue Perfusion ↓↓ ↓↓ ↓↓ ↓↓ Anaerobic MetabolismAnaerobic Metabolism ↓↓ ↓↓ ↓↓ ↓↓ Lactic acidemiaLactic acidemia ↓↓ ↓↓ ↓↓ ↓↓ Cellular damageCellular damage
  12. 12. STAGES OF SHOCKSTAGES OF SHOCK Stage of CompensationStage of Compensation  Stage of Compensation (sympatheticStage of Compensation (sympathetic activatesactivates  cool, pupils dilated etc)cool, pupils dilated etc)  Pathway:Pathway: • Decreased cardiac output leads toDecreased cardiac output leads to reflex sympathetic stimulationreflex sympathetic stimulation causing increase HR and peripheralcausing increase HR and peripheral vasoconstrictionvasoconstriction
  13. 13. STAGES OF SHOCKSTAGES OF SHOCK Stage of CompensationStage of Compensation  PathwayPathway  BP rises and skin is cold and clammyBP rises and skin is cold and clammy due to peripheral vasoconstrictiondue to peripheral vasoconstriction  Urine output drops (oliguria) due toUrine output drops (oliguria) due to renal artery vasoconstrictionrenal artery vasoconstriction
  14. 14. Stage Of CompensationStage Of Compensation cont.cont.  Compensatory StageCompensatory Stage: the body is: the body is trying to improve the tissue perfusion.trying to improve the tissue perfusion. The sympathetic NSThe sympathetic NS  Neural,Neural, hormonal & chemical responses.hormonal & chemical responses.  NeuralNeural::  ↑↑ HR,HR, ↑↑ heart contractility, arterialheart contractility, arterial and venous vasoconstrictionand venous vasoconstriction  blood is going to be shunted toblood is going to be shunted to the body organsthe body organs
  15. 15. Stage Of CompensationStage Of Compensation cont.cont.  HormonalHormonal::  Renin responseRenin response  angiotensin IIangiotensin II  AldosteroneAldosterone  ADH this is going toADH this is going to retain H2O and Naretain H2O and Na  Anterior pituitaryAnterior pituitary ↑↑ ACTHACTH  adrenocortex is stimulatedadrenocortex is stimulated glucocorticoidsglucocorticoids  ↑↑ glucoseglucose  Adrenal medulla stimulationAdrenal medulla stimulation  epinephrine & norepinephineepinephrine & norepinephine
  16. 16. Stage Of CompensationStage Of Compensation cont.cont.  ChemicallyChemically::  Epinephrine causes an increase inEpinephrine causes an increase in HR/Cardiac contractility andHR/Cardiac contractility and therefore tissue perfusiontherefore tissue perfusion  Norephrine causes arterialNorephrine causes arterial vasocontriction and shunts bloodvasocontriction and shunts blood away from non vital organs to vitalaway from non vital organs to vital organs.organs.  The response of the Pt is toThe response of the Pt is to hyperventilatehyperventilate ∴∴ it tries to do is toit tries to do is to neutralize the lactic acidosisneutralize the lactic acidosis
  17. 17. Stage Of CompensationStage Of Compensation cont.cont. NeurologicNeurologic ↓ ↓↓ ↓↓ ↓↓ Sympathetic ChemoreceptorsSympathetic Chemoreceptors ↓↓ ↓↓ ↓↓ ↓↓ ↓↓ ↓↓ VasoconstrictionVasoconstriction ↑↑ HRHR ↑↑Rate/DepthRate/Depth Contractility RespirationContractility Respiration ↓↓ ↓↓ ↓↓ Shunting ofShunting of ↑↑ COCO BloodBlood ↓↓PaCo2PaCo2 TissueTissue Perfusion RespiratoryPerfusion Respiratory AlkalosisAlkalosis
  18. 18. Stage Of CompensationStage Of Compensation cont.cont. EndocrineEndocrine ↓↓ ↓↓ ↓↓ ↓↓ RAS ACTHRAS ACTH ↓↓ ↓↓ ↓↓ ↓↓ ↓↓ ↓↓ VasoconstrictionVasoconstriction GlucorticoidGlucorticoid Na+ and H2Na+ and H2 ↓↓ ↓↓ retentionretention ↑↑ SerumSerum GlucoseGlucose
  19. 19. Stage of ProgressionStage of Progression  Progressive StageProgressive Stage: the: the compensatory mechanisms arecompensatory mechanisms are starting to failstarting to fail  Na & K pump and the cellularNa & K pump and the cellular membranes failmembranes fail  cellular deathcellular death (rupture) and then every system in the(rupture) and then every system in the body is affectedbody is affected  Cardiac: PtCardiac: Pt  ventricular failureventricular failure  NeurologicallyNeurologically  cerebralcerebral hypoperfusionhypoperfusion  Thermoregulation failureThermoregulation failure
  20. 20. Stage of Progression cont.Stage of Progression cont.  ComaComa  PulmonaryPulmonary  Acute respiratory failureAcute respiratory failure  Renal: ATN, renal vasoconstriction, renalRenal: ATN, renal vasoconstriction, renal hypoperfusionhypoperfusion  Disseminated Intravascular CoagulationDisseminated Intravascular Coagulation (DIC)(DIC)  GI: gram-negative bacteria enter into theGI: gram-negative bacteria enter into the systemsystem  Hepatic & pancreatic failureHepatic & pancreatic failure
  21. 21. Stage of Impaired PerfusionStage of Impaired Perfusion (Progressive Shock)(Progressive Shock)  Pathway:Pathway:  Prolonged vasoconstriction causesProlonged vasoconstriction causes irreversible ischemic injury. Adverseirreversible ischemic injury. Adverse effects that occur as a direct consequenceeffects that occur as a direct consequence of decreased perfusion:of decreased perfusion:  Anaerobic metabolism of glucoseAnaerobic metabolism of glucose  lacticlactic acidosisacidosis  Cell necrosis as in ATNCell necrosis as in ATN  acute renalacute renal failurefailure
  22. 22. Stage of Impaired PerfusionStage of Impaired Perfusion (Progressive Shock)(Progressive Shock)  Acute alveolar damageAcute alveolar damage  intra-alveolarintra-alveolar edema, hemorrhage and formation of aedema, hemorrhage and formation of a hyaline-fibrin membrane (Shock Lung)hyaline-fibrin membrane (Shock Lung) ARDSARDS  Anoxic necrosis of liverAnoxic necrosis of liver  Nutmeg LiverNutmeg Liver  Ischemic necrosis of intestinesIschemic necrosis of intestines  releaserelease of bacterial toxinsof bacterial toxins  worsening shockworsening shock
  23. 23. Stage of DecompensationStage of Decompensation  Pathway:Pathway:  Hypoxia and acidosisHypoxia and acidosis  failure of reflexfailure of reflex (sympathetic) peripheral vasoconstriction(sympathetic) peripheral vasoconstriction (vasodilation)(vasodilation)  progressive hypotensionprogressive hypotension until perfusion of heart and brain reachuntil perfusion of heart and brain reach critical levelscritical levels  Prognosis for Shock depends upon causePrognosis for Shock depends upon cause and stage at which treatment is begunand stage at which treatment is begun
  24. 24. Stage of DecompensationStage of Decompensation Initial StageInitial Stage ↓ ↓↓ ↓↓ ↓↓ Compensatory StageCompensatory Stage ↓↓ ↓↓ ↓↓ ↓↓ Compensatory mechanism begin to failCompensatory mechanism begin to fail ↓↓ ↓↓ ↓↓ ↓↓ Some irreversible cellular damageSome irreversible cellular damage
  25. 25. Stage of DecompensationStage of Decompensation  The shock cycle begins to perpetuateThe shock cycle begins to perpetuate itselfitself  BP and blood flow can not be maintainedBP and blood flow can not be maintained  Anaerobic metabolism cannot sustainAnaerobic metabolism cannot sustain cellular activitycellular activity  Irreversible cellular damage occursIrreversible cellular damage occurs  Organ dysfunction appearsOrgan dysfunction appears
  26. 26. Stage of DecompensationStage of Decompensation
  27. 27. Refractory StageRefractory Stage  Refractory StageRefractory Stage: Irreversible: Irreversible  MODSMODS multiple organmultiple organ dysfunction syndromedysfunction syndrome  RenalRenal  hepatichepatic  pulmonarypulmonary  cardiaccardiac
  28. 28. Critical Care NursingCritical Care Nursing  You live by the motto "to be right isYou live by the motto "to be right is only half the battle, to convince theonly half the battle, to convince the doctor is more difficult."doctor is more difficult."
  29. 29. Types of shock:Types of shock:  HypovolemicHypovolemic:: Circulating or intravascularCirculating or intravascular volume lossvolume loss  HemmorhagicHemmorhagic  CardiogenicCardiogenic: inability of the heart to pump: inability of the heart to pump  DistributiveDistributive: maldistribution of circulating: maldistribution of circulating blood volumeblood volume  SepticSeptic  AnaphylacticAnaphylactic  Neurogenic: loss of sympathetic toneNeurogenic: loss of sympathetic tone
  30. 30. TYPES OF SHOCKTYPES OF SHOCK  Hypovolemic – decreased volume inHypovolemic – decreased volume in circulation due to:circulation due to: Severe hemorrhageSevere hemorrhage GI lossesGI losses Losses secondary to wound ofLosses secondary to wound of surgerysurgery BurnsBurns
  31. 31. Hypovolemic ShockHypovolemic Shock  This is fluid loss in theThis is fluid loss in the intravascular space.intravascular space.  It is the most common due to GIIt is the most common due to GI bleeding, trauma.bleeding, trauma.  Two types:Two types: Absolute and RelativeAbsolute and Relative
  32. 32. Hypovolemic ShockHypovolemic Shock  AbsoluteAbsolute: due to trauma, surgery: due to trauma, surgery of GI system (esophageal varices).of GI system (esophageal varices).  Blood, plasmaBlood, plasma ↑↑ lossloss  External loss of fluidExternal loss of fluid
  33. 33. Hypovolemic ShockHypovolemic Shock  RelativeRelative: rupture of spleen, arterial: rupture of spleen, arterial dissection, sepsis, hyponatremia,dissection, sepsis, hyponatremia, internal injuries that cause a shiftinternal injuries that cause a shift from the intravascularfrom the intravascular  extravascular compartmentsextravascular compartments  Loss on intravascular integrityLoss on intravascular integrity  ↑↑ capillary permeabilitycapillary permeability
  34. 34. Hypovolemic ShockHypovolemic Shock  PathologyPathology:: ↓↓ of venous returnof venous return ∴∴ ↓↓ preload (stroke volume & cardiacpreload (stroke volume & cardiac output) = Inadequate tissueoutput) = Inadequate tissue perfusionperfusion  Initially pt losses about a 15%,Initially pt losses about a 15%, which is about 750 mlwhich is about 750 ml  At 40% or greater::::: BIG TROUBLEAt 40% or greater::::: BIG TROUBLE
  35. 35. Hypovolemic ShockHypovolemic Shock  During theDuring the compensatory stagecompensatory stage wewe want to maintain cardiac outputwant to maintain cardiac output  ↓↓ Cardiac output = tachycardia,Cardiac output = tachycardia, pulse narrows,pulse narrows, ↑↑ diastolic pressure,diastolic pressure, tachypneatachypnea  ABGs reveal a respiratory alkalosis &ABGs reveal a respiratory alkalosis & hypoxemiahypoxemia
  36. 36. Hypovolemic ShockHypovolemic Shock  ↓↓ Urinary outputUrinary output  Skin is pale, cool, delayed capillarySkin is pale, cool, delayed capillary refillrefill  Jugulars are collapse (flat)Jugulars are collapse (flat)  Neurological: change in LOCNeurological: change in LOC
  37. 37. Hypovolemic ShockHypovolemic Shock  In theIn the progressive stageprogressive stage we arewe are going to see a 1500 – 2000 ml lossgoing to see a 1500 – 2000 ml loss  ↑↑ HR, myocardial ischemiaHR, myocardial ischemia ∴∴somesome arrhythmiasarrhythmias  ABGsABGs  metabolic acidosismetabolic acidosis ∴∴ PCO2PCO2 ↑↑, Bicarbonate, Bicarbonate ↓↓ and PaO2and PaO2 ↓↓
  38. 38. Hypovolemic ShockHypovolemic Shock  PtPt  acute renal failure where BUNacute renal failure where BUN and creatinineand creatinine ↑↑  When the organs start failing we areWhen the organs start failing we are going to see the pt becomesgoing to see the pt becomes hypotensive probably we have tohypotensive probably we have to administer dopamine, vasopressinadminister dopamine, vasopressin
  39. 39. Hypovolemic ShockHypovolemic Shock  In theIn the RefactoryRefactory we are going towe are going to seesee ↑↑ 2000 ml loss2000 ml loss  Severe tachycardia and thenSevere tachycardia and then bradycardiabradycardia  ↓↓ Preload (right atrial pressure) RAPPreload (right atrial pressure) RAP = CVP= CVP ↓↓  ↓↓ Stroke volumeStroke volume ↓↓ tissue perfusiontissue perfusion  ↑↑ AfterloadAfterload  ↑↑ SVR (systemicSVR (systemic vascular resistance)vascular resistance)
  40. 40. Hypovolemic ShockHypovolemic Shock  ManagementManagement  Prevent and correct the fluid lossPrevent and correct the fluid loss  Restore tissue perfusionRestore tissue perfusion  2 peripheral accesses Large2 peripheral accesses Large bore IV’sbore IV’s  Triple lumen catheterTriple lumen catheter (femoral or(femoral or jugular))jugular))  Administer appropriate fluidsAdminister appropriate fluids
  41. 41. Hypovolemic ShockHypovolemic Shock  Hypovolemic ShockHypovolemic Shock is similar tois similar to hemorrhagic shock.hemorrhagic shock.  The difference is the patient is losingThe difference is the patient is losing body fluid rather than blood.body fluid rather than blood.  This body fluid is water and/orThis body fluid is water and/or plasma.plasma.
  42. 42. Hypovolemic ShockHypovolemic Shock  This thickens the blood making itThis thickens the blood making it difficult for the heart to put outdifficult for the heart to put out enough volume to meet the demandsenough volume to meet the demands of the body.of the body.  The most common causes ofThe most common causes of hypovolemic shock are severehypovolemic shock are severe dehydration and severe burns.dehydration and severe burns.
  43. 43. Hypovolemic ShockHypovolemic Shock  Signs and symptoms are the same asSigns and symptoms are the same as hemorrhagic shock, but include:hemorrhagic shock, but include:  Collapsed veins in the extremities andCollapsed veins in the extremities and neck,neck,  Poor skin turgorPoor skin turgor  Concentrated, dark, strong smelling urine.Concentrated, dark, strong smelling urine.
  44. 44. Hemorrhagic ShockHemorrhagic Shock  Hemorrhagic ShockHemorrhagic Shock is whenis when the body is losing bloodthe body is losing blood volume.volume.  When it loses this volume, theWhen it loses this volume, the red blood cells which carry thered blood cells which carry the oxygen are depletedoxygen are depleted
  45. 45. Hemmorhagic ShockHemmorhagic Shock  The blood loss may be causedThe blood loss may be caused from a traumatic source, andfrom a traumatic source, and may be quite obvious becausemay be quite obvious because there is a copious amount ofthere is a copious amount of blood around the body;blood around the body;  i.e. GSW’s , stab wounds,i.e. GSW’s , stab wounds, large lacerations,large lacerations, amputations,etc.amputations,etc.
  46. 46. Hemmorhagic ShockHemmorhagic Shock  The traumatic source may also beThe traumatic source may also be from blunt trauma where the injuryfrom blunt trauma where the injury is an organ that has torn oris an organ that has torn or ruptured.ruptured.  This can be the result of being hitThis can be the result of being hit with a blunt object like a baseballwith a blunt object like a baseball bat, slamming into the steeringbat, slamming into the steering wheel in a vehicle crash or fallingwheel in a vehicle crash or falling any distance.any distance.
  47. 47. Hemmorhagic ShockHemmorhagic Shock  The solid organs of the body areThe solid organs of the body are the organs that usually tear orthe organs that usually tear or rupture from an impact.rupture from an impact.  The solid organs in the abdomenThe solid organs in the abdomen are the liver and kidneys, spleenare the liver and kidneys, spleen (LUQ, under the rib cage), and(LUQ, under the rib cage), and appendix (RLQ).appendix (RLQ).
  48. 48. Hemmorhagic ShockHemmorhagic Shock  With a blunt trauma injury, theWith a blunt trauma injury, the patient is losing blood inside theirpatient is losing blood inside their body.body.  A person can bleed into three areasA person can bleed into three areas of their body: the chest cavity, theof their body: the chest cavity, the abdominal cavity, and into bothabdominal cavity, and into both thighsthighs  e.g. bilateral femure.g. bilateral femur fractures.fractures.
  49. 49. Hemmorhagic ShockHemmorhagic Shock  Hemmorhagic shock can also beHemmorhagic shock can also be caused from an atraumatic bleedcaused from an atraumatic bleed commonly caused from bleedingcommonly caused from bleeding ulcers.ulcers.
  50. 50. Hemmorhagic ShockHemmorhagic Shock  Signs and symptoms withSigns and symptoms with hemorrhagic shock are what mosthemorrhagic shock are what most people think of as shock:people think of as shock:  low blood pressure (systolic belowlow blood pressure (systolic below 100),100),  high pulse rate (above 120), andhigh pulse rate (above 120), and  rapid respiratory rate (greater thanrapid respiratory rate (greater than 32),32),  the skin will be pale or cyanotic,the skin will be pale or cyanotic, cold and sweaty.cold and sweaty.
  51. 51. Cardiogenic ShockCardiogenic Shock
  52. 52. TYPES OF SHOCKTYPES OF SHOCK  CardiogenicCardiogenic : A form of shock: A form of shock resulting from the heart’s failureresulting from the heart’s failure to inadequately pump inadequately pump blood.  This results in inadequateThis results in inadequate delivery of oxygenated blood todelivery of oxygenated blood to the periphery, there tissuethe periphery, there tissue perfusion is also inadequate.perfusion is also inadequate.
  53. 53. Cardiogenic ShockCardiogenic Shock  Cardiogenic ShockCardiogenic Shock may resultmay result from many different etiologies:from many different etiologies:  Ventricular Ischemia caused byVentricular Ischemia caused by Acute MIAcute MI Open Heart SurgeryOpen Heart Surgery ***** These are the most***** These are the most common ******common ******
  54. 54. Cardiogenic ShockCardiogenic Shock  Structural DefectsStructural Defects Papillary muscle rupturePapillary muscle rupture CardiomyopathyCardiomyopathy Pulmonary EmbolusPulmonary Embolus  DysrhymthmiasDysrhymthmias Affect normal circulationAffect normal circulation
  55. 55. Cardiogenic ShockCardiogenic Shock  Signs and symptoms includeSigns and symptoms include chest painschest pains shortness of breath with increasedshortness of breath with increased raterate cool, clammy skincool, clammy skin pale or cyanotic colorpale or cyanotic color
  56. 56. Cardiogenic ShockCardiogenic Shock Coarse rales in the lungsCoarse rales in the lungs Cardiac dysrhythmiasCardiac dysrhythmias HypotensionHypotension tachycardiatachycardia
  57. 57. Cardiogenic ShockCardiogenic Shock ↓↓ CO/CICO/CI ↑↑ PA and PAWPPA and PAWP ↑↑ SVRSVR ↑ Cardiac EnzymesCardiac Enzymes ↓↓UOUO
  58. 58. Ineffective Pumping of Blood Failure toFailure to eject bloodeject blood fromfrom ventriclesventricles ↓↓ IncreasedIncreased PulmonaryPulmonary PressuresPressures ↓↓ PulmonaryPulmonary CongestionCongestion ↓↓ HypoxemiaHypoxemiaInadequate tissue perfusion ↓ S V ↓ C O Pathophysiology
  59. 59. Cardiogenic ShockCardiogenic Shock  Treat Underlying cause:Treat Underlying cause: Thrombolytics,angioplasty,Thrombolytics,angioplasty, surgery,antiarrhythmics,electricalsurgery,antiarrhythmics,electrical therapytherapy  ↑↑ Pumping effectivenessPumping effectiveness Vasodilators, diurectics, inotropes,Vasodilators, diurectics, inotropes, mechanical devicesmechanical devices
  60. 60. Cardiogenic ShockCardiogenic Shock  Improve tissue perfusion O2, activityImprove tissue perfusion O2, activity restriction,analgesics, sedativesrestriction,analgesics, sedatives  Monitor hemodynamics, enzymes,Monitor hemodynamics, enzymes, electrolytes, I&O, ABG’s, ECGelectrolytes, I&O, ABG’s, ECG
  61. 61. (Distributive shock)(Distributive shock) Anaphylactic ShockAnaphylactic Shock  Severe hypersensitive reactionSevere hypersensitive reaction which leads to (antigen –which leads to (antigen – antibody) response.antibody) response. ∴∴  ↓↓ Tissue perfusion and shockTissue perfusion and shock syndrome occurs as asyndrome occurs as a consequenceconsequence
  62. 62. Distributive ShockDistributive Shock Anaphylactic ShockAnaphylactic Shock  Risk factorsRisk factors  Food allergiesFood allergies  InsulinInsulin  VaccinesVaccines  DrugsDrugs  Venoms (snakes, spiders etc)Venoms (snakes, spiders etc)  Blood transfusionsBlood transfusions  Environmental agentsEnvironmental agents  LatexLatex
  63. 63. Distributive ShockDistributive Shock Anaphylactic ShockAnaphylactic Shock  It is an Ig E or non Ig E mediatedIt is an Ig E or non Ig E mediated responseresponse  ↑↑ Capillary permeabilityCapillary permeability  BronchoconstrictionBronchoconstriction  Excessive mucous productionExcessive mucous production  Coronary vasoconstrictionCoronary vasoconstriction  InflammationInflammation  Cutaneous skin reactionsCutaneous skin reactions  Constriction of intestinal wall, bladder &Constriction of intestinal wall, bladder & uterusuterus
  64. 64. Exposure Antigen – Antibody response Increased Capillary Permeability↓ Circulating volume ↓ Decrease CO ↓ Inadequate Tissue perfusion Vasodilation Pathophysiology
  65. 65. Anaphylactic ShockAnaphylactic Shock  Treatment:Treatment:  Maintain adequate airwayMaintain adequate airway Consider mechanical ventilationConsider mechanical ventilation  CirculationCirculation  insert large bore IV –give fluidsinsert large bore IV –give fluids  Medications-Medications- epinephrine, antihistamines,epinephrine, antihistamines, bronchodilators, steroidsbronchodilators, steroids  Educate patientEducate patient
  66. 66. Distributive ShockDistributive Shock Anaphylactic ShockAnaphylactic Shock  It starts 15 – 30 minutes withIt starts 15 – 30 minutes with generalized itching, redness andgeneralized itching, redness and angioedema.angioedema.  Give epinephrineGive epinephrine  most prominentmost prominent actions are on the heart, producing aactions are on the heart, producing a rapid rise in blood pressure, increasedrapid rise in blood pressure, increased strength of ventricular contraction,strength of ventricular contraction, increase in the heart rate, andincrease in the heart rate, and constriction of the arterioles in the skinconstriction of the arterioles in the skin and mucosa.and mucosa.
  67. 67. Distributive ShockDistributive Shock Anaphylactic ShockAnaphylactic Shock  Epinephrine relaxes the smoothEpinephrine relaxes the smooth muscles of the bronchi.muscles of the bronchi.  It elevates the blood sugar level byIt elevates the blood sugar level by increasing hydrolysis of glycogen toincreasing hydrolysis of glycogen to glucose in the liver, and at the sameglucose in the liver, and at the same time begins the breakdown of lipidstime begins the breakdown of lipids in fat fat cells.  Epinephrine has a suppressive effectEpinephrine has a suppressive effect on the adaptive immune system.on the adaptive immune system.
  68. 68. Distributive ShockDistributive Shock Anaphylactic ShockAnaphylactic Shock  EpinephrineEpinephrine  It is the drug of choice inIt is the drug of choice in anaphylaxis.anaphylaxis.  Dose: 0.1 mg/Kg of a 1:10000 dose,Dose: 0.1 mg/Kg of a 1:10000 dose, usually given IV in 3 – 5 minutesusually given IV in 3 – 5 minutes push.push.  If pt is intubated we can put it downIf pt is intubated we can put it down the tube.the tube.
  69. 69. Neurogenic ShockNeurogenic Shock  Neurogenic – rare occurrenceNeurogenic – rare occurrence resulting from loss sympathetic toneresulting from loss sympathetic tone and is caused by an injury of theand is caused by an injury of the spinal cord above T6.spinal cord above T6.  Loss or suppression of sympatheticLoss or suppression of sympathetic tone, the onset is between minutestone, the onset is between minutes but can last for days, weeks orbut can last for days, weeks or months, depending on the causemonths, depending on the cause
  70. 70. Neurogenic ShockNeurogenic Shock (Distributive shock)(Distributive shock)  S/SS/S  ↓↓ BPBP  BradycardiaBradycardia  Skin warm & drySkin warm & dry  Determine the cause to treat itDetermine the cause to treat it
  71. 71. Neurogenic ShockNeurogenic Shock  Signs and symptoms:Signs and symptoms:  low blood pressure,low blood pressure,  increased respiratory rate,increased respiratory rate,  diaphragmatic breathingdiaphragmatic breathing (quadriplegia (total loss of sensation(quadriplegia (total loss of sensation and movement from the neckand movement from the neck down).down).  Rarely is neurogenic shockRarely is neurogenic shock reversible.reversible.
  72. 72. Neurogenic ShockNeurogenic Shock (Distributive shock)(Distributive shock)  Risk FactorsRisk Factors  Spinal cord injuries above the levelSpinal cord injuries above the level of T6of T6  Spinal anestheticSpinal anesthetic  Emotional stressEmotional stress  Pts with intractable painPts with intractable pain  Pts with CN system dysfunctionPts with CN system dysfunction
  73. 73. Neurogenic ShockNeurogenic Shock (Distributive shock)(Distributive shock)  PathologyPathology  When we loss sympathetic tone weWhen we loss sympathetic tone we have:have:  Massive peripheral dilatationMassive peripheral dilatation  Impaired thermal regulationImpaired thermal regulation
  74. 74. Neurogenic ShockNeurogenic Shock (Distributive shock)(Distributive shock)  Arterial and venous vasodilatationArterial and venous vasodilatation  ↓↓ Venous returnVenous return ∴∴ ↓↓ preloadpreload  ↓↓ CVPCVP  ↓↓ Arterial returnArterial return ∴∴ ↓↓ afterloadafterload  ↓↓ BPBP ∴∴  ↓↓ SVR systemic vascular resistanceSVR systemic vascular resistance
  75. 75. Loss of sympathetic tone Loss of thermoregulation Massive Vasodilation ↓ CO Inadequate Tissue Perfusion Bradycardia Pathophysiology
  76. 76. Septic ShockSeptic Shock  Septic Shock – Secondary toSeptic Shock – Secondary to gram negative sepsis due togram negative sepsis due to endotoxemia causing directendotoxemia causing direct toxic vessel injurytoxic vessel injury  Pathway:Vasodilatation leadsPathway:Vasodilatation leads to peripheral pooling andto peripheral pooling and relative hypovolemia andrelative hypovolemia and decreased perfusiondecreased perfusion
  77. 77. Septic ShockSeptic Shock  Septic ShockSeptic Shock is when an infectionis when an infection has invaded the body and causes thehas invaded the body and causes the cells to be unable to utilize oxygencells to be unable to utilize oxygen and nutrients.and nutrients.  Often intense intravenous antibioticOften intense intravenous antibiotic therapy is required and even thentherapy is required and even then may not be effective.may not be effective.
  78. 78. PathologyPathology  Gram-negatives release endotoxinsGram-negatives release endotoxins from their cell membrane as they lysefrom their cell membrane as they lyse and die. Gram-positive bacteria releaseand die. Gram-positive bacteria release exotoxins throughout their life span.exotoxins throughout their life span.  These toxins trigger the release ofThese toxins trigger the release of cytokines (proteins release by cells tocytokines (proteins release by cells to signal other cells) such as tumorsignal other cells) such as tumor necrosis factor and the interleukins.necrosis factor and the interleukins.  They also activate phagocytic cells asThey also activate phagocytic cells as the macrophages.the macrophages.
  79. 79. PathologyPathology  Microorganism invades the CNS &Microorganism invades the CNS & endocrinal systemendocrinal system  Sympathetic nervous system is stimulatedSympathetic nervous system is stimulated and release ACTH (epinephrine &and release ACTH (epinephrine & norepinephine, glucocorticoids,norepinephine, glucocorticoids, aldosterone, glucagons and renin)aldosterone, glucagons and renin)  afterafter releaserelease  hypermetabolic statehypermetabolic state  massivemassive peripheral dilatation, form of microemboli,peripheral dilatation, form of microemboli, selective vasoconstriction &selective vasoconstriction & ↑↑ capillarycapillary membranemembrane ∴∴ ↓↓ tissue perfusion,tissue perfusion, ↓↓ cellularcellular perfusionperfusion  acid lactic as a result ofacid lactic as a result of metabolic metabolismmetabolic metabolism
  80. 80. PathologyPathology  These complex chemical reactionsThese complex chemical reactions lead to multiple system effectslead to multiple system effects  MODSMODS  Microorganism invasionMicroorganism invasion  inflammatory immune responseinflammatory immune response  endothelium damageendothelium damage cellularcellular hypoxiahypoxia
  81. 81. Septic ShockSeptic Shock (Distributive shock)(Distributive shock)  Most frequentMost frequent  Maldistribution of blood flow (someMaldistribution of blood flow (some areasareas ↓↓ perfusion and on othersperfusion and on others ↑↑ the perfusion)the perfusion)  Increased blood will occur to theIncreased blood will occur to the heart, brain, liver and adrenalheart, brain, liver and adrenal glands.glands.  At the same time there’ll be aAt the same time there’ll be a decrease in blood to the skin, lungs,decrease in blood to the skin, lungs, kidneys and viscera.kidneys and viscera.
  82. 82. Septic ShockSeptic Shock (Distributive shock)(Distributive shock)  It is a sepsis-induced shock withIt is a sepsis-induced shock with hypotension despite adequate fluidhypotension despite adequate fluid replacement that producereplacement that produce • Mortality rate > 45% depending on theMortality rate > 45% depending on the population agepopulation age  Primary source is gram-negative &Primary source is gram-negative & positive bacteria , aerobes andpositive bacteria , aerobes and anaerobes, fungi or viral.anaerobes, fungi or viral.  Gram-negatives are more frequentGram-negatives are more frequent
  83. 83. Septic ShockSeptic Shock (Distributive shock)(Distributive shock)  Risk FactorsRisk Factors  DiabetesDiabetes  MalnutritionMalnutrition  Alcohol abuseAlcohol abuse  CirrhosisCirrhosis  Respiratory infectionsRespiratory infections  HemorrhageHemorrhage  CancerCancer  SurgerySurgery
  84. 84. Septic ShockSeptic Shock (Distributive shock)(Distributive shock)  Risk FactorsRisk Factors  Traumatic injuries with peritonealTraumatic injuries with peritoneal contaminationcontamination  BurnsBurns  Prolonged IV cannulationProlonged IV cannulation  AbscessesAbscesses  Multiple blood transfusionsMultiple blood transfusions
  85. 85. Septic ShockSeptic Shock  2 types: Exogenous and2 types: Exogenous and EndogenousEndogenous  ExogenousExogenous (hospitals)(hospitals)  EndogenousEndogenous (skin, GI track,(skin, GI track, respiratory & GU, catheters, EGT,respiratory & GU, catheters, EGT, ETT)ETT)
  86. 86. Septic ShockSeptic Shock  Intrinsically: age of pt andIntrinsically: age of pt and comorbiditiescomorbidities  Extrinsically: Drug therapy, fluidExtrinsically: Drug therapy, fluid therapy and surgerytherapy and surgery  Similar to toxic shock syndromeSimilar to toxic shock syndrome (tampons(tampons  gram-positives causedgram-positives caused by staphylococcus aureus)by staphylococcus aureus)
  87. 87. Septic ShockSeptic Shock (Distributive shock)(Distributive shock)  Venous system dilateVenous system dilate  ↓↓ preloadpreload both in right and left ventriclesboth in right and left ventricles ∴∴  ↓↓ RVPRVP  ↓↓ afterload,afterload, ↓↓ SVR,SVR, ↓↓ BPBP
  88. 88. Septic ShockSeptic Shock  Signs and symptoms include: inSigns and symptoms include: in early stages, high blood pressure,early stages, high blood pressure, high pulse rate and high respiratoryhigh pulse rate and high respiratory rate, fever, chills, and sweats.rate, fever, chills, and sweats.  In late stages, the opposite, lowIn late stages, the opposite, low blood pressure, low pulse rate, lowblood pressure, low pulse rate, low respiratory rate and low bodyrespiratory rate and low body temperature.temperature.
  89. 89. Three StagesThree Stages have been identifiedhave been identified  EarlyEarly  HyperdynamicHyperdynamic  Compensated stage:Compensated stage:
  90. 90. StagesStages  EarlyEarly  TachycardiaTachycardia  ↑↑ Cardiac indexCardiac index  Skin warm and flushedSkin warm and flushed  Normal BPNormal BP
  91. 91. StagesStages  Hyperdynamic stageHyperdynamic stage  As shock progressesAs shock progresses  Diastolic BPDiastolic BP ↓↓  Pulse widensPulse widens  Peripheral pulses are boundingPeripheral pulses are bounding  Temperature can be normal,Temperature can be normal, elevated or below normalelevated or below normal
  92. 92. StagesStages  Late Hyperdynamic, uncompensatedLate Hyperdynamic, uncompensated  Widespread organ dysfunction beginsWidespread organ dysfunction begins to occurto occur  BPBP ↓↓  hypotensionhypotension  ↑↑ Peripheral edema is more evidentPeripheral edema is more evident  Labored TachypneaLabored Tachypnea  CracklesCrackles ∴∴ pulmonary interstitialpulmonary interstitial edemaedema  Sputum copious, pink and frothySputum copious, pink and frothy
  93. 93. StagesStages  Late septic shockLate septic shock  BPBP ↓↓ 90 mmHg90 mmHg  Cold extremitiesCold extremities  MODSMODS  ↓↓ Urinary outputUrinary output  Abdominal distentionAbdominal distention  Absence of BSAbsence of BS  Bleeding from invasive linesBleeding from invasive lines  Disseminated intravascularDisseminated intravascular coagulation (DIC)coagulation (DIC)
  94. 94. StagesStages  Late septic shockLate septic shock  MODSMODS  PetechiaePetechiae  Cardiac dysrhythmiasCardiac dysrhythmias  ABGs:you will see hypoxemia,ABGs:you will see hypoxemia, hypercapniahypercapnia  Metabolic acidosis (Lactic acidosis)Metabolic acidosis (Lactic acidosis)  COMACOMA
  95. 95. StagesStages  Shift to left of WBC (later)Shift to left of WBC (later)  ↑↑ of glucose and the pt develops anof glucose and the pt develops an insulin resistanceinsulin resistance  Obtain blood cultures right away,Obtain blood cultures right away, then initiate broad-spectrumthen initiate broad-spectrum antibiotics, when results of theantibiotics, when results of the cultures return adjust the antibiotics.cultures return adjust the antibiotics.
  96. 96. TreatmentTreatment  Triple antibioticsTriple antibiotics  Without the right antibioticWithout the right antibiotic ↑↑ endotoxinsendotoxins ∴∴ aggravates the caseaggravates the case  Drugs:Drugs:  Vasoconstrictors (dopamine orVasoconstrictors (dopamine or norepinephrine (Levophed))norepinephrine (Levophed))  Platelet aggregated antagonistPlatelet aggregated antagonist ((Aspirin and NSAIDs *non-steroidal anti-Aspirin and NSAIDs *non-steroidal anti- inflammatory drugs):inflammatory drugs):  Steroids shownSteroids shown nono benefitbenefit
  97. 97. Post TestPost Test
  98. 98. Shock SyndromesShock Syndromes  1. True or False: Regardless of the1. True or False: Regardless of the cause, Shock means inadequatecause, Shock means inadequate tissue perfusion.tissue perfusion.
  99. 99. TRUETRUE
  100. 100.  List down the complication of shockList down the complication of shock
  101. 101. The EndThe End